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PubMed2004

Progression of scoliosis after spinal fusion in Duchenne's muscular dystrophy.

A consecutive series of 85 patients with Duchenne's muscular dystrophy who underwent spinal fusion over a period of 16 years was followed up with regard to the progression of the scoliosis and pelvic obliquity. Of 74 patients with adequate radiographic follow-up, 55 were instrumented with the Luque single-unit rod system and 19 with the Isola pedicle screw system; seven were instrumented to L3/4, 42 to L5, 15 to S1 and 10 to the pelvis with intrailiac rods. The mean period of follow-up was 49 months (SD 22) before and 47 months (SD 24) after operation. There was one peri-operative death and three cases of failure of hardware. The mean improvement in the Cobb angle was 26 degrees and in pelvic obliquity, 9.2 degrees. Fusion to L3/4 achieved a poorer correction of both curves while intrapelvic rods, achieved and maintained the best correction of pelvic obliquity. Fusion to S1 did not provide any benefit over more proximal fusion excluding the sacrum, with regard to correction and maintenance of both angles. The Isola system appeared to provide and maintain a slightly better correction of the Cobb angle.

Adolescent↗
PubMed1986

Biomechanics of lumbosacral spinal fusion in combined compression-torsion loads.

The current study investigates the stabilizing effects of three different types of spinal fusion to the juxta-free motion segments and to the fused segment of the lumbosacral spine under combined compression-torsion loads. Sixteen fresh human cadaver lumbosacral spines were tested under a simulated physiologic loading condition. The relative movements of the motion segments, as well as the angular rotations and the center of rotation were then computed and analyzed. The average torsional stiffness of the unfused three-motion segment was found to be 2.35 nm/degree. After fusion, the torsional stiffness did not increase significantly. Under the compression-torsional load, the anterior and bilateral-lateral fusions provided adequate stabilizing effect on the fused segment. The posterior fusion provided the least amount of stabilizing effect. These findings are similar to the results of the compression-bending experiment. Whereas the compression-bending loads produced significantly increased stress at the juxta-free segments, the compression-torsional loads did not produce any significant amount of increase in torsional stress at the juxta-free segments.

Biomechanical Phenomena↗
PubMed1996

Management of postoperative wound infection in posterior spinal fusion with instrumentation.

Successful treatment of an infection depends first on prompt diagnosis. Management of postoperative wound infections after spinal fusion with instrumentation often presents therapeutic difficulties. This study reviews a total of 28 wound infections. An infection rate of early infection with 3.6% and late infection with 1.9% was noted. The treatment of wound infection depends on the appearance of infection. In early wound infection, it is not always necessary to remove the instrumentation, if a successful suction-irrigation system was inserted. In late wound infection, we removed the hardware in all cases. No evidence of pyogenic infection was presented. Additionally, intravenous antibiotics were used after the antibiogram.

Adult↗
PubMed1989

The syndrome of inappropriate antidiuretic hormone secretion and its effect on blood indices following spinal fusion.

Red blood cell indices in four adolescent and preadolescent patients with documented inappropriate antidiuretic hormone secretion (SIADH) following spinal fusion were examined for evidence of dilution. The blood indices in these preoperative patients demonstrated evidence of dilution on both the intracellular and extracellular levels. The major factors causing these dilutional effects were elevated ADH, intravenous fluid overloading, and mobilization of "third space" fluids. It appears that extracellular dilution secondary to these factors results in spuriously low blood indices (namely, hemoglobin, hematocrit, and red blood cells) during the postoperative period. These findings suggest that an awareness of SIADH and avoiding intravenous fluid overloads by accurately managing intraoperative and postoperative fluids will decrease the dilutional effects observed on blood indices and perhaps save patients from unwarranted transfusions.

Adolescent↗
PubMed1990

Postoperative pulmonary complications in children with neuromuscular scoliosis who underwent posterior spinal fusion.

Children with neuromuscular scoliosis may develop restrictive pulmonary disease, with substantially lower than normal predicted lung function. Posterior spinal fusion (PSF) is often used to slow down this rapid deterioration of pulmonary function. Postoperatively, these patients frequently develop pulmonary complications. In this retrospective study of 38 patients with neuromuscular scoliosis who underwent PSF, the preoperative vital capacity was related to postoperative pulmonary complications and need for postoperative ventilatory assistance. In two patients who developed postoperative atelectasis and pulmonary edema, the preoperative vital capacity was 44% of that predicted. In six patients who developed atelectasis only, it was 49.2%. In the remaining 30 patients who developed no postoperative pulmonary complications, the average was 64.6%. Low preoperative vital capacity was also shown to correlate with the need for longer postoperative ventilatory assistance. The preoperative vital capacity is an important prognostic parameter in evaluating postoperative pulmonary recovery.

Adolescent↗
PubMed1994

A comprehensive study of physical parameters, biomechanical properties, and statistical correlations of iliac crest bone wedges used in spinal fusion surgery. III. Multivariable regression analysis and practical formulas for strength prediction.

Iliac crest wedges are commonly used in spinal fusion procedures and must be capable of withstanding considerable mechanical stress during the healing process. Physical parameters, mechanical properties, correlations among physical parameters, and correlations of mechanical properties versus physical parameters have been presented by the authors in companion papers. In this study, mathematical formulas have been developed, using multi-variable regression analysis, which permit calculation of the axial load-bearing capacity and compressive strength of a wedge, provided donor age, cortical bone cross-sectional area, total cross-sectional area, and wedge "width" are available. The formulas proposed are simple, easy to use, and provide acceptable accuracy. For the predicted load-bearing capacity, experimentally determined data illustrated that 59% of the calculated values had either less than 10% error or their predicted values were smaller than the observed values, 75% of the calculated values had either less than 20% error or their predicted values were smaller than the observed values. Similar accuracies were estimated for calculation of compressive strengths. Charts are generated from the established formulas, which permit a visual determination of load-bearing capacity and compressive strength of a wedge.

Aging↗
PubMed1990

The efficacy of direct current electrical stimulation to enhance canine spinal fusions.

A prospective experimental study was devised to examine the effect of direct current electrical stimulation on the healing of lumbar spinal fusions. Twelve mongrel dogs had posterior facet fusion bilaterally at L1-L2 and L4-L5. A direct current electrical stimulator was placed through each facet fusion. One-half of the electrodes were functional, while the remainder served as controls. Two animals were killed at two and four weeks, and four animals were killed at six and 12 weeks, postoperatively. Each facet fusion was evaluated using high-resolution roentgenograms and routine histology. In the two-, four-, and six-week specimens, there was little difference in the roentgenographic or histologic appearance of the control and stimulated fusions. However, by 12 weeks, all eight stimulated facet joints showed roentgenographic and histologic evidence of solid bony fusion, but none of the eight control facet joints demonstrated osseous bridging of the fusion site. The results of this study suggest that direct current electrical stimulation appears to enhance the bony union of facet fusions in the canine lumbar spine.

Animals↗
PubMed1998

Biologic enhancement of spinal fusion.

Scientific advances in the past decade have generated considerable clinical interest in developing biologic tools that may ultimately enhance spinal fusion. This article reviews the current understanding of each of these and other fusion-enhancing tools with particular attention to the results of in vivo animal experimentation and, where available, objective clinical data.

Bone Matrix↗
PubMed1995

Administrative databases' complication coding in anterior spinal fusion procedures. What does it mean?

STUDY DESIGN: A review of a cohort of 310 consecutive patients who underwent anterior spinal fusion was performed to evaluate the accuracy of hospital ICD-9-CM complication coding. OBJECTIVES: To better understand the clinical significance of conclusions suggested by studies that rely on electronic administrative databases for their data source. SUMMARY OF BACKGROUND DATA: Despite their availability, there have been no studies to date that have evaluated the accuracy of ICD-9-CM administrative databases as they relate to the actual clinical experience in spinal procedures. METHODS: A physician and a research technician independently reviewed the primary medical records for the occurrence of complications. This data was compared with the hospital-acquired ICD-9-CM coded complications. RESULTS: The physician reviewer identified 152 complications in 119 patients, with 32 different types of complications. The research abstracter identified 175 complications in 130 patients, with 34 different types of complications identified. Hospital ICD-9-CM coding identified 105 complications in 80 patients, including only 11 different ICD-9-CM codes. Overall, 27% of ICD-9-CM complication codes were listed as "unspecified or unclassified complications, reactions, or misadventures," and contained no meaningful clinical information. Cardiac and pulmonary complications were over-estimated and wound infections and genitourinary and gastrointestinal complications were underestimated by ICD-9-CM coding. CONCLUSIONS: Studies of complications of spinal procedures using data derived from hospital ICD-9-CM complication codes may be intrinsically flawed because the data available to researchers from these electronic databases may be inaccurate.

Adolescent↗
PubMed1992

Fibrillar collagen-biphasic calcium phosphate composite as a bone graft substitute for spinal fusion.

The osteoconductive capacity of fibrillar collagen-biphasic calcium phosphate composition was compared to autogenous bone in a canine spinal fusion model. All animals underwent a standard intervertebral body fusion (L2-L4) with rigid internal fixation and received either autogenous bone alone or a mixture of the ceramic and autogenous bone (3:1) as the graft material. Animals were followed for 12 months and the quality of fusion in each animal assessed by biomechanical testing and histological analysis. The fused L2-L4 segment of each dog was embedded in bone cement and mounted in a specially designed mechanical tester for testing in flexion, extension, and side bending. Overall, the mean rigidity of the fusion mass was not significantly different between the two groups [10.5 +/- 4.1 (SD) for autogenous bone vs. 11.3 +/- 1.7 for the ceramic plus autogenous bone, p greater than 0.05]. Similar findings were obtained for mean bending moment, compressive load, angular deformation, and energy absorbed for the two groups. Histological analysis was performed on transverse nondecalcified specimens. Quantitation of bone ingrowth using back-scattered electron imaging disclosed no significant differences in the amount of new bone formed at the graft site between autogenous bone and the ceramic plus autogenous bone recipients (23.4 +/- 10% vs. 25.8 +/- 8.8%) when correction for the autogenous bone volumes was performed. Light microscopic analysis of toluidine blue-stained transverse sections demonstrated new bone growth around and through the ceramic bone graft material. These results suggest that use of a collagen-biphasic calcium phosphate ceramic and autogenous bone mixture (3:1) provides a suitable osteoconductive alternative to the use of autogenous bone and results in the formation of a mechanically competent fusion mass not significantly different from that obtained with autogenous bone alone.

Animals↗
PubMed1997

Spinal fusion using a vascularized fibular bone graft for a patient with cervical kyphosis due to neurofibromatosis.

We performed an anterior spinal fusion using a vascularized fibular bone graft combined with posterior fusion for a patient with severe cervical kyphosis due to neurofibromatosis. The kyphosis was corrected from 85 degrees preoperatively to 38 degrees postoperatively. A vascularized fibular bone graft is a useful surgical procedure in selected patients to obtain successful bony union.

Adolescent↗
PubMedDate not supplied

Spinal fusions to the sacrum in adults with scoliosis.

Forty-five skeletally mature patients averaging 44.3 years of age had spinal fusions which extended to the sacrum for pain and/or progression of their scoliosis. The primary diagnosis was idiopathic scoliosis in 35 patients, congenital scoliosis in two patients, and paralytic scoliosis in eight patients. A single curve pattern was present in 41 patients and the remainder had double primary curves. Thirty-eight patients had single stage procedures and 35 of these were done posteriorly. There was an evolution in the type of posterior instrumentation used over the 12 years. Thirty-five patients (78%) had at least one significant postsurgical complication. Thirteen of 22 patients with loss of lordosis required corrective osteotomies. Other complications included pseudoarthrosis in ten patients and neurologic complications in five patients, four of which had complete recovery. Twenty-five patients required a total of 51 subsequent surgical procedures. Despite a 51% initially poor result and a high complication rate, the final results were good or fair in 93% of the patients. This change was primarily the result of successful subsequent surgical procedures for correction of loss of lordosis and pseudoarthrosis. The adult scoliosis patient should be fused to the sacrum only if the lumbosacral disc is clearly a source of pain or the degree of pelvic obliquity makes it necessary in the paralytic curve. Every effort must be made to carefully preserve the patient's lumbar lordosis. Better results were obtained by using segmental spinal fixation in the form of sublaminar wiring of double Luque rods.

Adult↗
PubMed2002

[Application of bispectral index (BIS) monitoring to anesthetic management of posterior spinal fusion in a patient with Duchenne muscular dystrophy].

A 12-year-old boy with Duchenne muscular dystrophy underwent posterior spinal fusion for progressive scoliosis. Preoperative evaluation was focused on respiratory function as well as cardiac function, which revealed markedly reduced respiratory reserve (FVC 0.77 l, %FVC 25.9%, FEV1.0 0.48 l, %FEV1.0 62%) and well-preserved biventricular function. A possible association between malignant hyperthermia and Duchenne muscular dystrophy has been documented. Thus anesthesia was administered without triggering agents. Propofol and fentanyl were used for induction and maintenance of anesthesia, and the patient was ventilated with O2-nitrous oxide mixture. The anesthesia machine, prepared by using a disposable circuit and fresh CO2-absorbent and disconnecting the vaporizers, was flushed with O2 at a rate of 10 l.min-1 for 20 minutes before use. A small dose of vecuronium was administered while monitoring the train-of-four ratio. The bispectral index (BIS) was utilized to optimize the depth of anesthesia so that the wake-up test could be performed promptly on surgeon's request while avoiding the intraoperative awareness. The BIS was helpful in continuously assessing the wakening process. BIS increased from 40's to 80's in 15 minutes after discontinuation of propofol and nitrous oxide during the test. The patient was kept under close observation postoperatively without any sign of malignant hyperthermia.

Anesthesia, General↗
PubMed1999

Use of allograft bone for posterior spinal fusion in idiopathic scoliosis.

Eighty-seven adolescents with idiopathic scoliosis (77 female and 10 male patients) who underwent posterior spinal fusion with instrumentation using only allograft bone for graft material were evaluated retrospectively. The average age at surgery was 14 years 3 months. Each patient had a minimum 2-year followup, with an average of 3 years 5 months followup. The average preoperative curve was 59 degrees thoracic (range, 31 degrees-90 degrees) and 52 degrees lumbar (range, 21 degrees-65 degrees). At followup, the thoracic curve measured an average of 35 degrees and the lumbar curve measured an average of 34 degrees. The average loss of correction from the immediate postoperative period until last followup was 6.5 degrees or 11% in the thoracic curve and 10 degrees or 19% in the lumbar curve. There were seven reoperations; one of these reoperations involved repair of a pseudarthrosis. There was one clinical infection. The typical patient had a 2-ounce allograft at an average cost of $800. The patients' average loss of correction, complication rate, and reoperation rate compare favorably with results reported in other series using autograft bone. The authors of this study showed the ability of allograft bone to produce reliable results with a satisfactory outcome. The potential advantages of using allograft must be weighed against the potential disadvantages before recommending its routine use.

Adolescent↗
PubMed2005

Long-term outcome of laminoplasty for cervical myelopathy due to disc herniation: a comparative study of laminoplasty and anterior spinal fusion.

STUDY DESIGN: A retrospective study was conducted. OBJECTIVE: To compare the long-term outcomes after laminoplasty and anterior spinal fusion (ASF) for cervical myelopathy secondary to disc herniation. SUMMARY OF BACKGROUND DATA: There have been no reports of long-term comparative studies of laminoplasty and ASF for cervical myelopathy due to disc herniation. METHODS: Of 21 patients who underwent ASF only between 1984 and 1987, 15 were followed up. Of 22 patients who underwent laminoplasty only between 1987 and 1994, 18 were followed up. There were no significant differences in preoperative prognostic factors between the 2 groups. Average follow-up was 15 years in the ASF group and 10 years in the laminoplasty group. Neurologic and radiologic results were examined. RESULTS: Laminoplasty and ASF provided equal neurologic improvement. In the ASF group, additional surgery was required for bone graft complications in 2 patients and for adjacent spondylosis in 1. In the laminoplasty group, one patient had C5 palsy, and intractable axial pain developed in 5 patients after surgery, but no patients needed additional surgery. CONCLUSIONS: Because the 2 procedures provided the same neurologic improvement, the risks of bone graft complication with ASF must be weighed against the risks of chronic neck pain associated with laminoplasty for determining the best technique. Therefore, because our present surgical strategy for cervical myelopathy due to disc herniation, laminoplasty is the procedure of choice except for a patient with single level disc herniation without developmental canal stenosis, who is considered to be a good candidate for ASF.

Bone Transplantation↗
PubMedDate not supplied

Circumferential fusion of the lumbar and lumbosacral spine. Comparison of two techniques of anterior spinal fusion.

Thirty-two patients with therapy-resistant low-back pain and justified indication for fusion were divided into two groups: 16 patients were treated with anterior fusion of the lumbosacral spine, with insertion of tricortical bone grafts of the iliac crest, and 16 patients with insertion of a fibular peg. Additional dorsal fusion of the same segments was performed. Comparison of the two techniques of circumferential fusion of the lumbosacral joint reveals comparable clinical results. A marked difference in roentgenographical criteria such as disk height, retrolisthesis, and anterior osteophytes in the adjacent segment between the two techniques was noted at the time of follow-up evaluation after 89 months and motivated the authors to abandon the fibular-peg technique.

Adolescent↗
PubMed1996

The effect of fibrin sealant on spinal fusions using allograft in dogs.

STUDY DESIGN: This study investigated the use of Tisseel (immuno [Canada], Toronto, Ontario) as an adjunct to allograft spinal fusion. Thirteen mongrel, dogs were fused bilaterally with morcellized graft from a separate dog. OBJECTIVES: To evaluate whether fibrin sealant had an effect on bone volume of fusion mass in allograft fusions of the spine. SUMMARY OF BACKGROUND DATA: Fibrin sealant has been promoted for use in many orthopedic applications. There is controversy about its effectiveness in augmenting bone graft healing. However, some surgeons make routine use of the sealant in augmentation of bone grafting procedures. METHODS: To test the usefulness of this material in augmenting allograft fusions, the authors carried out bilateral posterolateral fusions in 13 mongrel dogs. At surgery, 15 cm3 of allograft was placed into a posterolateral position at the L5-L6 region on both sides of the spine. Fibrin sealant (Tisseel) was allocated randomly to one side only. Fusion mass was tested 6 months after the initial operation by computed tomographic scan imaging and mechanical testing. RESULTS: A significantly smaller bone volume mass, as illustrated by computed tomographic measurement, was seen on the Tisseel side (P = 0.03). Biomechanical testing indicated that there was a trend for the Tisseel side to be stiffer than the untreated side, particularly at lower weights, but statistical significance was not achieved. Computed tomographic volumetric analysis showed that Tisseel-treated allograft led to a significantly smaller fusion volume. CONCLUSIONS: This study refutes the belief that Tisseel is a good material for accomplishing or augmenting intervertebral arthrodesis. Fibrin sealant significantly retards allograft fusion mass formation in dogs.

Animals↗
PubMed1982

Anaesthetic considerations in patients with muscular dystrophy undergoing spinal fusion and Harrington rod insertion.

Charts of nine patients with Duchenne and one with Becker's muscular dystrophy who had undergone spinal fusion and Harrington rod insertion for scoliosis were reviewed retrospectively. The mean age was 15 years and mean angle of scoliosis was 69 degrees. Preoperative pulmonary function studies showed a restrictive defect with a mean vital capacity of 1.3 +/- 0.69 litres, 35 +/- 20 per cent of predicted value, 33 +/- 20 ml . kg-1 and a mean inspiratory capacity of 0.99 +/- 0.5 litres, 23 +/- 13 ml . kg-1. There were no anaesthetic complications during operation and obstructive cardiomyopathy, hyperpyrexia, hyperkalaemia and rhabdomyolysis were not problems. Succinylcholine was avoided. One patient developed an arrhythmia postoperatively and one patient whose postoperative problems included tracheostomy, pneumonia and sepsis could not be weaned from the ventilator and died 11 weeks after operation. As assessing risk and survival of the operation depends on objective pulmonary function, a vital capacity of at least 20 ml . kg-1 in the range of 30 per cent of predicted volume with an inspiratory capacity of at least 15 ml . kg-1 would appear to be adequate in patients with muscular dystrophy requiring Harrington rod insertion. Other factors including the rapidity of progression of the muscular disease, other respiratory and cardiovascular problems, and disease such as obesity should also be considered.

Adolescent↗