Biomedical subjects
Publications and source records attributed to R B Winter.
The congenital variant of the unipapillary kidney is associated with an abnormal contralateral kidney and frequently with anomalies of other systems as well. An additional case is presented and a review of the literature is discussed.
A case of recurrent spinal astrocytoma is presented 25 years following initial biopsy and radiation therapy. Extensive laminectomy was performed when the patient was 20 months old. Three years later the patient became paraplegic as the result of progressive severe kyphosis. Late recurrence of tumor was marked by pain onset. In addition to treating the tumor, extensive spinal reconstruction was required to control the kyphosis.
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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.
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In a retrospective review of the cases of thirteen skeletally immature children and adolescents (four to eighteen years old) with instability of the upper part of the cervical spine (occiput to fifth cervical vertebra), we determined the efficacy of posterior arthrodesis and halo-cast immobilization in the management of this condition. The patients were divided into two groups: those with congenital vertebral anomalies alone (fusion or structural defects, or both) and those with cervical anomalies and systemic disorders (dwarfism, juvenile rheumatoid arthritis, Down syndrome, and cerebral palsy). Two patterns of instability were found: instabilities at intervertebral joints adjacent to vertebral fusions, and instabilities located in vertebral defects. For all patients treatment included a posterior arthrodesis with external immobilization by a halo cast, and in two patients internal fixation with wire was also used. Solid arthrodesis was obtained in the twelve patients who were treated with autogenous grafts (iliac cancellous bone in eleven and rib bone in one), and a non-union developed in a child who was treated with bank-bone rib segments. Posterior cervical arthrodesis with wire fixation carries some risk of neural injury and often is not applicable in children with anomalous vertebrae. Spine fusion using delicate exposure, decortication using an air-drill, and placement of autogenous cancellous iliac grafts with external immobilization by a halo cast minimizes the risk of neural damage and is a reliable way to obtain a solid arthrodesis.
In selected patients a method of rod insertion without fusion combined with use of a full-time external orthotic support, e.g., the Milwaukee brace, is effective. The orthopedic surgeon confronted with young children who have curves that do not respond to conservative treatment alone or in which bracing is contraindicated should find this procedure particularly suitable. The method allows for the expression of full growth potential while maintaining curve correction.
Double-stranded cDNA from the maturation (or A2) protein gene of the RNA bacteriophage Q beta has been cloned such that its expression is regulated by the E. coli lac promoter/operator. Induction of the A2 clone is lethal to the host. The basis of this lethality is cell lysis, which is correlated with synthesis of the A2 protein. No other major proteins appear to be made from the A2 gene when inducer is added. Plasmid-derived A2 protein specifically complements infecting Q beta A2 amber mutants. Lysis activity is abolished in clones that synthesize truncated or internally deleted A2 polypeptides ranging from 10% to 95% of the length of wild-type protein. We conclude that host lysis is promoted by the maturation protein itself, rather than by a separate lysis protein. The A2 protein probably allows for the release of progeny Q beta phage particles following normal infection.
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Adult scoliosis is a complex and difficult area of modern orthopaedics. Thanks to modern techniques of both operative and nonoperative care, treatment is now possible for problems thought of as impossible only a few years ago. Most adult scoliosis problems require a great depth of evaluation and decision making before arriving at the best form of treatment. Failure to do these necessary steps can lead to monumental problems. Nonoperative treatment of painful curves is best done with orthotics and not with physiotherapy. The operative procedure of choice for most patients is posterior instrumentation and fusion, striving for stabilization and pain improvement, not dramatic curve or cosmetic change. Pain is usually significantly improved but is almost never totally eliminated. Special procedures, such as anterior correction and fusion as well as combined anterior and posterior procedures, are appropriate only for very special problems. The complication rate for adult scoliosis surgery is far higher than for children and adolescents and usually increases with age. Surgeons should not attempt treatment of adults until thoroughly competent in the treatment of adolescent scoliosis.
From the material and data reviewed in our study of 405 patients, it appears that postoperative correction of the thoracic spine approximately equals the correction noted on preoperative side-bending roentgenograms. Selective thoracic fusion can be safely performed on a Type-II curve of less than 80 degrees, but care must be taken to use the vertebra that is neutral and stable so that the lower level of the fusion is centered over the sacrum. The lumbar curve spontaneously corrects to balance the thoracic curve when selective thoracic fusion is performed and the lower level of fusion is properly selected. In Type-III, IV, and V thoracic curves the lower level of fusion should be centered over the sacrum to achieve a balanced, stable spine.
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Two cases are presented, both males with severe total spondylolisthesis and both with Marfan's syndrome. One was treated by decompression and posterolateral fusion and the other by decompression, posterolateral fusion, reduction by halo-femoral traction, and then anterior fusion. Both had excellent results in terms of pain relief and relief of severe hamstring tightness. One patient subsequently died of a dissecting aneurysm. A relationship between Marfan's syndrome and spondylolisthesis is strongly suggested.
The spines of forty patients with myelomeningocele and paralytic scoliosis were surgically stabilized at the Twin Cities Scoliosis Center between 1960 and 1979. Treatment with posterior spine fusion and Harrington instrumentation extending to the sacrum, combined with anterior fusion using either Dwyer or Zielke instrumentation, gave the best results, correcting scoliosis by an average of 45 degrees (comparing preoperative values with those at the last visit), lordosis by an average of 20 degrees, torso decompensation by an average of 5.7 centimeters, and pelvic obliquity by an average of 7 degrees. This combined fusion method reduced the rate of pseudarthrosis to 23 per cent (compared with 46 per cent when only posterior fusion and instrumentation were used). Prophylactic antibodies (selected on the basis of preoperative cultures of urine) reduced the infection rate to 8 per cent. Posterior fusion or anterior fusion alone was inadequate, even with instrumentation. Early mobilization wearing a bivalved polypropylene body jacket minimized osteoporosis, pressure sores, and social isolation. Unsolved technical problems remain, however, especially in relation to obtaining fusion across the lumbosacral joint.
We reviewed the results of spinal arthrodesis for congenital spinal deformity in forty-nine patients who were younger than five years old. The minimum follow-up was five years, and eleven patients had completed their growth. Posterior arthrodesis alone was found to be effective in most scoliotic patients. There was minimum bending of the fusion mass in most patients, almost no creation of lordosis, and minimum effect on torso-lower limb relationships. For congenital kyphosis, posterior arthrodesis was highly effective, giving better eventual correction than when both anterior and posterior arthrodesis was done.
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Anterior strut-grafting was used in forty-eight patients to treat structural kyphosis of the thoracic and lumbar spine. Forty patients had a combined anterior and posterior arthrodesis. Kyphosis was corrected from an average of 93 degrees preoperatively to an average of 59 degrees at follow-up. Eight patients underwent anterior cord decompression, five of whom showed improvement of neural function at follow-up. Ten patients had a loss of correction averaging 19 degrees. In four patients a pseudarthrosis developed at the strut graft-vertebral body junction. The strut graft fractured in five of nine patients in whom the graft was four centimeters or more from the apical vertebra. Complications were frequent, but for the most part they were thought to have been preventable. Anterior strut-grafting appears to be a valid and logical technique for managing structural kyphosis.
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