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.     

Longitudinal changes in trunkal balance after selective fusion of King II curves in adolescent idiopathic scoliosis

STUDY DESIGN: A retrospective study was performed on the longitudinal changes of the trunkal balance in King II curves treated with selective posterior fusion of the thoracic curve. OBJECTIVES: To determine the effect of selective fusion on the coronal and sagittal plane balance in King II adolescent idiopathic scoliosis by analyzing the changes in shoulder level, pelvic tilt, trunk shift, centering of fusion mass, changes in the T11-L1 sagittal angle, and behavior of the unfused lumbar curve and its correlation with the end level of fusion. SUMMARY OF BACKGROUND DATA: It has been shown that selective fusion of the thoracic curve in a King II curve is associated with good results and arrest of lumbar curve progression in selected cases. Detailed quantitative analysis of the longitudinal changes and correlation between various clinical and radiologic parameters was not readily available in the literature. METHODS: This study investigated 24 patients with King II adolescent idiopathic scoliosis treated with Harrington rod and segmental spinous processes wiring in a 10-year period with follow-up periods of 3 to 8 years. Clinical and radiologic parameters were analyzed longitudinally during the preoperative and immediate postoperative period, then at 6 months, 1 year, 3 years, and final follow-up assessment. RESULTS: Progressive improvement in the trunk shift to within 2 cm of the center sacral line together with progressive leveling and stabilization of the shoulder and pelvic tilt was noted during the first year after surgery. Gradual movement of the Harrington rod toward the center sacral line assuming a "straight rod sign" with a rod to center line distance of less than 1 cm was found in 90% of the cases. Improvement of the sagittal alignment with no significant residual junctional kyphosis also was found. The unfused lumbar curve improved in both the coronal and sagittal plane and did not show any further progression. Patients whose lower end level of fusion was at T12 had a better percentage of lumbar curve correction than those that ended at L1. CONCLUSIONS: Selective thoracic fusion for King II idiopathic scoliosis curve can achieve acceptable coronal and sagittal plane balance of the spine. The rod to centersacral line distance is a helpful parameter in assessing the results and prognosis of surgically treated patients.     

Late complications of displaced thoracolumbar fusion instrumentation presenting as new pain in individuals with spinal cord injury

BACKGROUND: Harrington rods and more modern thoracolumbar posterior fusion with segmental instrumentation have been used successfully for decades in individuals with scoliosis or spinal cord injury (SCI). However, late complications of these instrumentations specifically presenting as new, localized pain in individuals with SCI have not been previously reported. Displacement of the hooks and the rods can cause significant back pain that may require hardware removal. METHODS: Two case reports illustrate thoracolumbar fusion rod removal because of displaced hooks with protruding rods and associated pain. RESULTS: Both of the individuals experienced back pain caused by proximal hook displacement. There was no neurologic deterioration. The proximal portions of the rods were sawed off and the displaced hooks and the rods were removed. CONCLUSIONS: These cases illustrate the importance of clarifying different types of pain experienced by individuals with SCI and the importance of diagnosing the cause of pain accurately.     

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.     

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.     

Coronal decompensation produced by Cotrel-Dubousset "derotation" maneuver for idiopathic right thoracic scoliosis

From 1985 to 1987, 82 patients with idiopathic scoliosis followed 12 to 44 months underwent selective fusion and correction of their right thoracic curves by Cotrel-Dubousset instrumentation using the "derotation" maneuver. Preoperative, postoperative, and follow-up standing anteroposterior roentgenograms of the spine were analyzed. For curves in which there was deviation from the midline (plumb line) and rotation of the lumbar segments, an increased incidence of decompensation was produced after surgery, when posterior Cotrel-Dubousset instrumentation and fusion were carried to the "stable" vertebra with one rod bend and hook alignment on the left sided derotation rod. Previous guidelines established for selective fusion with conventional posterior instrumentation (Harrington or Luque rods) may not be applicable to derotation with Cotrel-Dubousset instrumentation.     

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.     

Effect of posterior spinal fusion on spinal balance in idiopathic scoliosis

We analyzed the influence of posterior spinal fusion with Harrington rod instrumentation on spinal balance in 85 patients with primary thoracic curve patterns. Utilizing roentgenographic techniques of measurement, spinal decompensation was improved measurably in 64% of the patients, and lateral trunk shift improved in 82% of the patients with preoperative alterations of spinal balance.     

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.     

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.     

Anaesthetic management of vaginal delivery in a woman with Friedreich's ataxia complicated by cardiomyopathy and scoliosis

We report the anaesthetic management of vaginal delivery in a woman with Friedreich's ataxia, who had hypertrophic cardiomyopathy and had previously undergone thoracic spinal fusion with Harrington rod fixation. Combined spinal-epidural analgesia was used. Options for the anaesthetic management of labour and delivery are discussed.     

Adolescent idiopathic scoliosis treated by Harrington-rod distraction and fusion

One hundred and thirty-three patients who had adolescent idiopathic scoliosis were treated by insertion of a single Harrington distraction rod and spinal fusion. Postoperative immobilization consisted of six months in a below-the-shoulder cast. The mean preoperative curve was 50 degrees, with a range of 30 to 110 degrees. The mean final curve was 35 degrees, with a range of 19 to 63 degrees. There were no neurological injuries and no deep wound infections. Twelve patients required further surgery for complications, all of which were treated successfully. The duration of follow-up ranged from twenty-four to seventy-two months. At final follow-up, all patients had resumed their normal preoperative activities without limitations.     

Surgical treatment of late-onset idiopathic thoracic scoliosis. The Leeds procedure

Late-onset idiopathic scoliosis is associated with a rib hump in the thoracic region, and surgery is indicated when this deformity becomes unacceptable. Fifty patients with this deformity were treated by the Leeds procedure, which consists of segmental wiring to a kyphotically-contoured square-ended Harrington rod; this procedure not only derotates the spine but restores the natural thoracic kyphosis, thus avoiding subsequent buckling. All patients were followed up for a minimum of two years. Forty-two of these, who had a pre-operative Cobb angle of less than 60 degrees, were treated by one-stage instrumentation and fusion, while the remaining eight with greater curves underwent preliminary anterior multiple discectomy to provide flexibility with shortening. Postoperative loss of correction was not observed and there were no neurological complications.     

Evaluation of the role of concave rib osteotomies in the correction of thoracic scoliosis

The role of concave rib osteotomies was studied in a series of 25 patients with right thoracic idiopathic scoliosis who underwent Harrington distraction instrumentation and segmental sublaminar wiring of the thoracic curve. Group I had ten patients with rigid curves who had instrumentation, fusion, and segmental concave rib osteotomies. Group II had 15 patients with flexible curves who underwent instrumentation and fusion alone. Preoperative side bending curve reduction averaged 23% in Group I and 49% in Group II. Postoperative correction was similar in both groups with Group I achieving 60% (+/- 10%) overall correction and Group II, 57% (+/- 8%). Group I underwent 56% further reduction from side bending compared with Group II's 12% reduction. It was concluded that if preoperative side bending correction was below 35% of standing curve, curve correction comparable to flexible cases could be achieved through multiple concave rib osteotomies. Neurologic risk was not increased, but there was increased pulmonary morbidity of 30%.     

The role of Harrington instrumentation and posterior spine fusion in the management of adolescent idiopathic scoliosis

The Harrington instrumentation system was the first widely used, internationally accepted internal fixation system for the correction of idiopathic scoliosis when combined with a spinal arthrodesis. It has been generally available to the orthopedic surgeon for more than 25 years, and therefore its capabilities and limitations have been identified through this long experience. Its implantation requires minimal invasion of the spinal canal and is associated with a low (less than 0.5 per cent) incidence of neurologic complications. It provides predictable correction of spinal deformity with little subsequent loss of correction. When compared with other newer, more complex internal fixation systems for spinal deformities, the Harrington system has a shorter, less difficult "learning curve"; requires less operating time and blood loss to insert; implants a smaller mass of metal; and in some cases costs substantially less for the implant system. The Harrington system has an extremely low incidence of hook dislodgment and pseudoarthrosis formation in single thoracic curves, being reported as near zero for these curves in two recently published series. Conversely, there are some disadvantages to the Harrington system when compared with other types of fixation. It has limited ability to provide sagittal plane control. It does not effectively and predictably derotate the spine. A recent study showed that at an average of 4 years postoperatively, nearly two thirds of the patients had an actual increase in their rib prominence. The pseudoarthrosis rate is high, up to 4 per cent, in the thoracolumbar and lumbar spine. Hook dislodgment approaches 3 per cent when used below the thoracic region. Another disadvantage is the necessity for postoperative external support. As a result, the Harrington system remains an excellent means of treating single and double thoracic idiopathic curves in a safe and predictable manner, while admittedly having limited derotation and sagittal plane control. Other systems that are more sophisticated at segmental fixation of the spine appear to be more appropriate for scoliotic deformities requiring fusion of the thoracolumbar or lumbar spine and those associated with significant sagittal plane deformities.     

Sci Clinical Research and The American Paraplegia Society At 50 Years

Abstract

Background: Harrington rods and more modern thoracolumbar posterior fusion with segmental instrumentation have been used successfully for decades in individuals with scoliosis or spinal cord injury(SCI). However, late complications of these instrumentations specifically presenting as new, localized pain inindividuals with SCI have not been previously reported. Displacement of the hooks and the rods can causesignificant back pain that may require hardware removal.

Methods: Two case reports illustrate thoracolumbar fusion rod removal because of displaced hooks withprotruding rods and associated pain.

Results: Both of the individuals experienced back pain caused by proximal hook displacement. There wasno neurologic deterioration. The proximal portions of the rods were sawed off and the displaced hooks andthe rods were removed.

Conclusions: These cases illustrate the importance of clarifying different types of pain experienced byindividuals with SCI and the importance of diagnosing the cause of pain accurately.     

Spinal cord compression caused by the rod of a Harrington instrumentation device: A late complication in scoliosis surgery

We report a unique complication caused by the rod of a Harrington instrumentation device, which resulted in spinal stenosis and myelopathy. A literature review revealed no previous causes of direct spinal cord impingement caused by the rod of a Harrington device. In this case, years after the initial operation, the rod penetrated the lamina at the junction between a thoracic and a lumbar curve, causing spinal stenosis and myelopathy. We conclude that regular control of the position of the device and awareness of possible late neurological complications are necessary to identify such complications as early as possible.     

Dwyer instrumentation of the spine

The evolution of the Dwyer procedure during the past 10 years has enabled us to better define the indications and contraindications for the procedure. The role of the Dwyer procedure in the treatment of thoracolumbar or lumbar curves in both the adolescent and the adult has been found to be significant. When combined with Harrington rod instrumentation it can be used for either paralytic curves, curves associated with pelvic obliquity, or curves in which posterior elements are absent.     

Damage analysis of the Harrington rod fracture after scoliosis operation

Fracture of the distraction rod is one of the complications following operative treatment of scoliosis by the device of Harrington. It is reported to occur in about 7% of cases. We found this complication twice in our own number of 41 patients during a follow up period of 1 to 4 years. The rods had broken 18 and 23 months after operation, but we never saw a breakage in the 1st postoperative year during the time of cast fixation. The fracture surfaces of each rod were examined under the scanning electron microscope. In one case a fatigue fracture with two beginnings at the opposite sides of the rod was found in combination with a forced fracture in the middle. The number of alterations of load from the beginning of the fracture to the complete breakage was about 10,000. The X-ray showed a loss of correction in the curve of 20 degrees with a pseudoarthrosis visible in the fusion. In the other case a typical pure fatigue fracture was seen 23 months after the operation with 18,000 alterations of load. The X-ray showed only a slight loss of correction of less than 5 degrees and no pseudoarthrosis was visable, neither in the X-ray nor in the operative exploration of the fusion. The breakage of the distraction rod results not only from a pseudoarthrosis but also from other explained facts of the procedure. Further treatment depends on a proven pseudoarthrosis.