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PubMed1993

The results of surgical treatment for adult scoliosis.

This study was done to define and characterize those adult patients with scoliosis who will have problems of pain and/or progression leading to a surgical procedure and to review the results of these surgical procedures. The authors reviewed the cases of 49 adult patients who had undergone surgical treatment for scoliosis (average follow-up, 34 months; range, 24-140 months). The patients were categorized according to age, which allowed analysis of the data comparing age and the incidence and level of pain, age versus the degree of curvature, and age versus the incidence of progression. The relative incidence of pain and progression as indications for surgery were found to vary with respect to age. In the younger groups, progression was more often the indication for surgery than in the older groups. The younger groups also had larger curves than did the older groups, on average. The degree of pain was not found to correlate with the magnitude of the deformity. Surgical complications occurred in 20 patients; however, 14 of these were minor complications during the perioperative period, which did not result in any sequelae. Surgical treatment can be done with a relatively low serious complication rate and good results in terms of pain relief and reasonable correction of the deformity.

Adult↗
PubMed1993

A statistical comparison between natural history of idiopathic scoliosis and brace treatment in skeletally immature adolescent girls.

Thirty-two adolescent girls braced for late onset idiopathic scoliosis at Children's Hospital, Boston were compared with thirty-two untreated girls from Our Lady's Hospital for Sick Children, Dublin, Ireland paired on the basis of curve size and site and age at diagnosis. All were Risser 0 at diagnosis. Study period for the braced group was from brace initiation to part-time brace wearing and, for the controls, from diagnosis to last review. There was no statistically significant difference between the groups on any parameter of curve progression. This study raises questions about the efficacy of spinal orthoses in modifying the natural history of late-onset idiopathic scoliosis and removes the ethical problems inherent in a prospective trial in which the only treatment permitted to the control group is surgery.

Adolescent↗
PubMed1993

Quantifying the cosmetic defect of adolescent idiopathic scoliosis.

Cosmesis is important in the treatment of adolescent idiopathic scoliosis patients. The aim of this study was to quantify the cosmetic defect using parameters of the ISIS (Oxford Metrics Ltd., Oxford, England) scan. Ten nonmedical judges scored photographs of 100 adolescent idiopathic scoliosis patients based on cosmetic criteria. This Cosmetic Spinal Score proved to be a reliable figure. The Cosmetic Spinal Score was then compared with ISIS parameters and the Cobb angle. An equation based on ISIS parameters was developed, which could predict Cosmetic Spinal Score with sufficient reproducibility to have a useful clinical application. Bracing reduced the rib hump but not enough to improve the cosmetic appearance. Spinal fusion and Harrington instrumentation improved all measured parameters influencing physical appearance.

Adolescent↗
PubMed1993

Pattern of asymmetry of paraspinal muscle size in adolescent idiopathic scoliosis examined by real-time ultrasound imaging. A preliminary study.

The symmetry of lumbar multifidus size was examined in 20 patients with adolescent idiopathic scoliosis, aged 12-19 years. With the subject prone, bilateral real-time ultrasound images were obtained at the level of the 4th lumbar vertebra. Cross-sectional area and linear (horizontal and vertical) measurements were made using on-screen calipers. A pattern of asymmetry of lumbar multifidus cross-sectional area was shown to exist for the different curve types. The cross-sectional area was smaller (P < 0.0001) on the opposite side to the convexity of a primary thoracic curve, and on the convex side of a lumbar or thoracolumbar curve. The combined linear measurements (multiplied) correlated with cross-sectional area (r = 0.95) and could therefore be used for rapid clinical assessment of multifidus size. These preliminary findings provide a basis for further investigation of the role of the musculature in the pathogenesis of adolescent idiopathic scoliosis.

Adolescent↗
PubMed1993

Analysis of the upper thoracic curve in surgically treated idiopathic scoliosis. A new concept of the double thoracic curve pattern.

The authors reviewed 246 idiopathic scoliosis patients with the upper thoracic curve of more than 20 degrees. Group I (138 patients) had positive T1 tilt and a spinal fusion which was extended over both the upper and lower thoracic curve with the diagnosis of double thoracic curve. Group II (43 patients) had positive T1 tilt, but the fusion was limited to the lower thoracic curve. Group III (65 patients) had negative or neutral T1 tilt and the fusion was limited to the lower thoracic curve. The average age at operation was 15.9 years (range, 11.2-35 years) and the average length of follow-up was 4.8 years (range, 2-29.5 years). Positive T1 tilt did not correlate well with left shoulder elevation contrary to previous reports. The upper thoracic curve was more rigid than the lower curve in all groups and the lumbar curve was significantly more flexible than the upper and lower thoracic curves in all groups (P < 0.05). No significant difference in the flexibility of the upper thoracic curve was found between the groups regardless of the direction of T1 tilt. When only the lower curve was fused (groups II and III), progression of the upper thoracic curve was less than 5 degrees, and spontaneous correction of the unfused upper curve occurred in the majority of the cases following the supine bending study. Correction and fusion on the lower curve (groups II and III) aggravated shoulder imbalance of all patients with left shoulder elevation. Based on the findings of this study, the authors proposed that the diagnosis of idiopathic double thoracic patterns should be limited to those patterns which require fusion of both the upper and lower curves. This pattern of idiopathic scoliosis includes double thoracic curves with left shoulder elevation and/or a rigid upper thoracic curve.

Adolescent↗
PubMed1993

Efficacy of spinal cord monitoring in neuromuscular scoliosis.

Somatosensory cortical evoked potentials (SCEPs) monitoring in neuromuscular scoliosis surgery was evaluated in a large consecutive series of spinal reconstructions to define its role in the detection and prevention of spinal cord injury; 141 procedures in 101 patients were evaluated. In 28% a reliable tracing could not be obtained. Two postoperative neurologic deficits were missed by SCEP monitoring. Diagnosis (Duchenne muscular dystrophy and polio) was the only significant factor found to correlate with a reliable tracing. The use of sublaminar wires was associated with a higher rate of change in tracing. Transient changes were common. SCEPs are unreliable and nonspecific in neuromuscular scoliosis surgery and are not efficatious in preventing or detecting spinal cord injury when used alone. Adjunctive techniques using epidural and MEPs must be studied in these patients.

Adolescent↗
PubMed1993

Three-dimensional spinal deformity in scoliosis associated with cerebral palsy and with progressive muscular dystrophy.

The authors analyzed lateral deviation, anteroposterior deformity, and rotation of the spinal column of 11 patients with scoliosis associated with cerebral palsy (CP) and 11 patients with progressive muscular dystrophy (PMD). There was a correlation between the magnitude of Cobb angle and that of the vertebral rotation in scoliosis associated with both CP and PMD, but the ratio of spinal rotation to Cobb angle in the former was lower than that in the latter. The magnitudes of thoracic kyphosis and of lumbar lordosis were not correlated with Cobb angle in either group, but the sagittal plane deformity in the CP patients was less severe than that in the PMD patients, and the latter demonstrated kyphosis of the lumbar spine and lordosis of the thoracic spine.

Adolescent↗
PubMed1994

Comparison of Zielke ventral derotation system and Cotrel-Dubousset instrumentation in the treatment of idiopathic lumbar and thoracolumbar scoliosis.

There has been much controversy, in the surgical treatment of idiopathic thoracolumbar and lumbar scoliosis, about whether anterior or posterior instrumentation produced a better result. This study compared the Zielke ventral derotation system (VDS) and Cotrel-Dubousset instrumentation (CDI) in the correction of frontal, sagittal, and rotational deformity, and defined the advantage and disadvantage of each instrument in idiopathic thoracolumbar and lumbar scoliosis. The ventral derotation system was used in 20 patients (VDS group) and Cotrel-Dubousset instrumentation was used in 20 patients (CDI group). The average age of VDS group patients at the time of surgery was 16.7 years, and that of CDI group patients was 18.5 years. The average length of follow up was 48 and 25 months, respectively. In frontal curve correction, the VDS group showed a 77% correction, and the CDI group a 63% correction (P > 0.05). In rotational deformity correction, the VDS group showed a 42% correction, and the CDI group a 16% correction (P < 0.05). There were six decompensations in the VDS group, and three in the CDI group. Two decompensations of the VDS group were corrected with posterior CDI. There was one pseudarthrosis in the VDS group, with no significant symptoms. There were two instrumentation problems in each group, with no adverse effects on curve correction and maintenance. In conclusion, the ventral derotation system showed more powerful frontal and rotational correction, and can be effective even in more rigid or larger curves. Cotrel-Dubousset instrumentation, however, maintained physiologic sagittal alignment, was performed using a less invasive posterior approach, and had broader indication because it could be extended upward or downward to the compensatory curves.

Adolescent↗
PubMed1994

The Ste-Justine Adolescent Idiopathic Scoliosis Cohort Study. Part I: Description of the study.

OBJECTIVES: This study determined the impact of adolescent idiopathic scoliosis (AIS) on health and well being in adulthood by comparing AIS subjects, more than 10 years after referral, to non-AIS subjects according to perceived health status, physical activity, fitness, reproductive health, respiratory condition, and back and neck pain. This paper describes the cohort, the design of the study, and response rates. STUDY DESIGN: The study was designed as a comparative retrospective cohort study. A total of 2,092 patients referred for AIS to Ste-Justine Hospital, Montreal, Quebec, between 1960 and 1979 were identified. A population-based control group was selected in 1989-90 by randomly telephoning persons in Quebec. The control group was approximately frequency-matched to the AIS cohort according to age group and broad geographic region of current residence. METHODS: Patients with adolescent idiopathic scoliosis were traced, and a self-administered questionnaire was sent by post in 1989 to subjects whose addresses were found. Identical questionnaires were sent to subjects in the control group. RESULTS: Seventy-one percent of the cohort (1,476 subjects) returned questionnaires in 1989. Subjects who did not respond to the questionnaires were similar to those who did complete the questionnaires on a number of key factors, except that lower response rates were observed for subjects with scoliotic curves under 20 degrees. The control group consisted of 1,755 subjects (55% response rate). It was similar to the general Quebec population and to the AIS cohort on a number of important sociodemographic factors. CONCLUSION: Comparisons on health outcomes between the two study groups should not be affected by differential patterns of selection or response.

Adolescent↗
PubMed1994

Recognition and treatment of the proximal thoracic curve in adolescent idiopathic scoliosis treated with Cotrel-Dubousset instrumentation.

STUDY DESIGN: A retrospective radiographic and clinical review of a consecutive series of patients with adolescent idiopathic scoliosis (AIS) instrumented/fused with Cotrel-Dubousset instrumentation (CDI) was undertaken. OBJECTIVE: The authors determined criteria when the upper thoracic curve should be instrumented/fused in AIS treated with CDI and assessed the results of surgical treatment. SUMMARY OF BACKGROUND DATA: Failure to recognize and include the upper left thoracic curve in the instrumentation/fusion of a lower right thoracic idiopathic scoliosis may produce shoulder imbalance and coronal decompensation. Patients with an elevated left shoulder clinically or a positive T1 tilt radiographically usually require instrumentation/fusion of the proximal thoracic curve. However, the upper left thoracic curve may be structural and require inclusion in the instrumentation/fusion when the shoulders clinically are level or even if the right shoulder is elevated preoperatively when using CDI. METHODS: The authors compared 27 patients with AIS with structural upper thoracic curves that were instrumented with CDI to T2 (Group I) to 27 patients with King Type III curves treated with CDI that did not have the upper thoracic curve instrumented/fused (Group II). RESULTS: The distinguishing Group I preoperative criteria indicating a structural upper thoracic curve included a proximal thoracic curve greater than 30 degrees that corrected to no better than 20 degrees on sidebending; > or = Grade I rotation or > or = 1 cm translation present at the apex of this curve; any elevation of the left shoulder or tilt of T1 into the concavity of the upper thoracic curve; or when the transitional vertebra between the two curves is at T6 or below. CONCLUSIONS: When these aforementioned criteria are present and surgical correction with CDI is planned, we recommend extending the instrumentation up to T2 to produce level shoulders and maintain coronal balance.

Adolescent↗
PubMed1994

Neurophysiologic detection of a unilateral motor deficit occurring during the noncritical phase of scoliosis surgery.

STUDY DESIGN: A four-path neurophysiologic monitoring system was designed for spinal cord monitoring during spinal surgery. It was used mainly during scoliosis surgery. OBJECTIVE: To evaluate the efficacy of this technique. METHODS: Sensory and motor pathways were continuously monitored bilaterally from skin incision to awakening, with independent evaluation of the right and left pathways for each modality. RESULTS: This monitoring technique detected a transient unilateral motor deficit that occurred during the dissection phase of spinal surgery for scoliosis before any instrumentation or mobilization of the spine.

Adolescent↗
PubMed1995

New prognostic factors to predict the final outcome of brace treatment in adolescent idiopathic scoliosis.

STUDY DESIGN: Eighty-five patients with adolescent idiopathic scoliosis treated with Milwaukee or thoracolumbosacral orthoses at The Duchess of Kent Children's Hospital were studied longitudinally at 4-6-month intervals until maturity for spinal curvature and vertebral rotation, or until termination of brace treatment for persons who experienced brace failure who went on to have surgery. OBJECTIVES: To identify radiologic features so that it may be possible to predict outcome of brace treatment early on. SUMMARY OF BACKGROUND DATA: The structural curve with poor flexibility and large rotational prominence have been found to be associated with poor prognosis for brace treatment. However, early response to bracing for spinal deformity and its relationship to final outcome of brace treatment in a longitudinal study is not available in the literature. METHODS: Vertebral rotation and Cobb angles measured from anteroposterior radiographs of the spine obtained before bracing and 1-2 months after bracing were found valuable for prediction. Changes in post-brace Cobb angle and vertebral rotation were considered as an increase or reduction only when there was an increase or reduction of minimum 5 degrees or more from their prebrace measurements. RESULTS: Those patients who showed increase in vertebral rotation and/or in Cobb angle after brace application were shown to have progression of curves leading to brace failure in 93% of patients, and 79% of these required surgery. The patients with no change in both vertebral rotation and Cobb angle after bracing often experienced brace failure (69%). Two patients (15%) required surgery. The results show that reduction of both Cobb angle and vertebral rotation after application of a brace is a prognostic indicator for a good outcome (97%), and no patients required surgery. Most of the patients with lumbar scoliosis (91%) showed such reductions. CONCLUSION: The findings show a strong association between changes in vertebral rotation and the Cobb angle after application of a brace and the final outcome. Reduction in both is indicative of a good outcome, whereas increase in one or both indicates brace failure.

Adolescent↗
PubMed1995

Relation of spinal and thoracic cage deformities and their flexibilities with altered pulmonary functions in adolescent idiopathic scoliosis.

STUDY DESIGN: Seventy patients (average age, 13.8 years) with adolescent idiopathic right thoracic scoliosis had full assessment of pulmonary functions and radiographic evaluation of spinal and thoracic cage deformities and their flexibilities. OBJECTIVES: To determine how measurements of spinal and thoracic cage deformities related to pulmonary function. SUMMARY OF BACKGROUND DATA: Pulmonary functions have been evaluated in relation to lateral curvature of the spine in most of the published studies. Scoliosis is a three-dimensional deformity. There is a need to evaluate these changes in pulmonary functions, reflecting not only spinal curvature but also rotational deformity, thoracic cage deformity, and their flexibilities. METHODS: Radiographic measurements obtained from anteroposterior and lateral standing and anteroposterior supine bending radiographs included lateral curvature, vertebral rotation, kyphosis, maximum sternovertebral distance, and apical rib-vertebral angles. Using previous measurements, the flexibility of the curve, vertebral rotation, and rib-vertebral angle were calculated. A pulmonary function assessment was performed using a computerized pulmonary function system (5000V; Gould, Dayton, Ohio). We analyzed pulmonary functions in relation to deformity. RESULTS: Measurements reflecting spinal deformities obtained from anteroposterior radiographs, such as Cobb angle, vertebral rotation, and vertebral rotation flexibility, were significantly correlated with the percent of predicted values of vital capacity and forced vital capacity, whereas kyphosis measured from lateral radiographs was significantly correlated with absolute values of residual volume, total lung capacity, functional residual capacity, and forced expiratory flow from 25-75% of the forced vital capacity (FEF25-75). Of the measurements reflecting thoracic cage deformity obtained from anteroposterior radiographs, rib-vertebral angle asymmetry (measured from supine bending radiographs) showed significant correlation with the percent of predicted values of vital capacity, forced vital capacity, and functional residual capacity, whereas the sternovertebral distance that was measured from lateral radiographs correlated significantly with absolute values of vital capacity, total lung capacity, forced vital capacity, and FEF25-75. CONCLUSIONS: Deformities in coronal and transverse plane influence changes in pulmonary functions expressed as the percent of predicted values, whereas sagittal plane deformities influence mainly those absolute volumes in which residual volume is a component. It is suggested that rotational flexibility combined with other deformities could be evaluated in future studies on prediction of pulmonary function from the measurements of the deformity.

Adolescent↗
PubMed1995

Comparison between preoperative and postoperative three-dimensional reconstructions of idiopathic scoliosis with the Cotrel-Dubousset procedure.

STUDY DESIGN: Pre- and postoperative three-dimensional reconstructions of the spine and rib cage were done and compared in a group of adolescents with idiopathic scoliosis. OBJECTIVE: Changes in the shape of the thoracic spine and rib cage induced by the Cotrel-Dubousset instrumentation and procedure were documented. SUMMARY OF BACKGROUND DATA: Although many authors have reported significant curve improvement in the frontal plane, attempts to document derotation of the spine have shown only limited correction of apical vertebral rotation. METHODS: Three-dimensional reconstructions were obtained pre- and postoperatively using a stereoradiographic technique in a group of 37 adolescents with idiopathic scoliosis. Several geometrical indices of the spine and rib cage were compared using Student t tests. RESULTS: The curve correction averaged 50% in the frontal plane and 24% in the plane of maximum curvature, while normal thoracic kyphosis was maintained in the sagittal plane. The orientation of the plane of maximum curvature was shifted very significantly toward the sagittal plane, indicating en bloc movement of the thoracic spine and three-dimensional correction of the deformity. A small but significant change in vertebral axial rotation and rib hump was found and improvement in the overall orientation of the ribs was documented. CONCLUSIONS: The Cotrel-Dubousset instrumentation and procedure are effective in producing three-dimensional improvement of the thoracic spine by en bloc relocation of the instrumented spine rather than by vertebral axial derotation.

Adolescent↗
PubMed1996

Inappropriate secretion of antidiuretic hormone in postoperative scoliosis patients: the role of fluid management.

STUDY DESIGN: The present study examined the hypothesis that hypotonic saline therapy before surgery was a major factor in the development of the syndrome of inappropriate antidiuretic hormone secretion. OBJECTIVES: The influence of fluid therapy and its relationship to the syndrome of inappropriate antidiuretic hormone secretion was studied by measuring patient electrolyte and osmolar responses at given times after surgery. SUMMARY OF BACKGROUND DATA: Mild renal dysfunction and increased plasma antidiuretic hormone occurs after surgery. Occurrence of the syndrome of inappropriate secretion of antidiuretic hormone after spine surgery is rare. The development of the syndrome of inappropriate secretion hormone after surgery may be related to hypotonic fluid replacement during and after surgery. METHODS: Twelve patients undergoing surgery for correction of idiopathic scoliosis were assigned randomly to two groups. The control group (five patients) was given isotonic saline, and the trial group (seven patients) was given hypotonic saline. RESULTS: The trial group developed syndrome of inappropriate antidiuretic hormone secretion with a significant decrease in serum sodium and osmolarity. The control group did not develop syndrome of inappropriate antidiuretic hormone secretion. CONCLUSIONS: Hypotonic saline therapy predisposes to the development of syndrome of inappropriate antidiuretic hormone secretion, whereas isotonic saline protects patients from syndrome of inappropriate antidiuretic hormone secretion when undergoing surgery for scoliosis.

Adolescent↗
PubMed1996

Convex spinal epiphysiodesis in the management of progressive infantile idiopathic scoliosis.

STUDY DESIGN: Retrospective review of patient records with current clinical and radiographic assessment. OBJECTIVE: To evaluate the long-term result of anterior and posterior convex spinal growth arrest, with or without instrumentation, in managing infantile idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: There were 12 male and 10 female patients studied, with a mean follow-up period of 10 years, 9 months. The mean Cobb angle before surgery was 65 degrees. All had a rib vertebral angle difference more than 20 degrees. The mean age at surgery was 6 years. Nine patients had epiphysiodesis alone; nine patients also underwent Harrington instrumentation simultaneously, and four underwent Harrington instrumentation 2-4 years later. METHOD: Clinical evaluation and sequential measurements of Cobb angle were done. RESULTS: The epiphysiodesis-only group had a mean preoperative Cobb angle of 72 degrees, mean progression of curves of +12 degrees, and mean rate of progression of +2.5 degrees per year: the group's postoperative figures were 92 degrees, +15 degrees, and +3 degrees per year, respectively. The epiphysiodesis and late Harrington rod group had a mean preoperative Cobb angle of 56 degrees, mean progression of +12 degrees, and a mean rate of progression of +5 degrees per year; the group's postoperative Cobb angle averaged 62 degrees, progression +6 degrees, and rate of progression +1 degree per year. The epiphysiodesis with simultaneous Harrington rod group had a preoperative mean Cobb angle of 60 degrees, mean progression of +18 degrees, and mean rate of progression of +6 degrees per years. After surgery, these improved to 58 degrees, correction of 2 degrees, and rate of correction of 0.5 degree per year. CONCLUSION: Combined anterior and posterior convex spinal growth arrest alone does not prevent progression of deformity in infantile idiopathic scoliosis. The addition of posterior instrumentation can slow or arrest deformity progression but not reverse it.

Bone Nails↗
PubMed1996

Spinal shortening in scoliosis surgery, A case with transitory paraplegia.

STUDY DESIGN: A case involving a 16-year-old patient with idiopathic adolescent double-major scoliosis is presented. The curve was so rigid that a shortening surgery was done to reduce neurologic risk. OBJECTIVE: To advise surgeons who are considering this kind of surgical procedure to reduce the neurologic risk involved in correcting scoliosis, may be more dangerous than other, more traditional modes. SUMMARY OF BACKGROUND DATE: The two-stage procedure for anterior resection of a vertebral body followed by posterior resection and fusion by shortening the spine with instrumentation has been reported to be a safe and effective method of correcting deformities and other spinal pathologies. METHODS: Surgical treatment consisted of two anterior approaches, thoracic lumbotomy and thoracofrenolumbotomy, in which all the discs between 75 and L4 and the vertebral body of T8 were resected, followed by a posterior resection. In the third surgery (posterior resection) a full T8 vertebrectomy was completed, and the gap between the adjacent vertebrae was closed. Then a traditional CD configuration with rod rotation was used, and a thoracoplasty of the rib hump was done. RESULTS: During the intraoperative wake-up test, the patient did not move her inferior extremities, and it was necessary to partially reverse the shortening of the gap produced by the vertebrectomy. The preoperative and postoperative curves measured 90 degrees/86 degrees and 25 degrees/27 degrees, respectively. CONCLUSIONS: This procedure appears to be more dangerous than traditional surgery. Partial vertebrectomy as a closing wedge osteotomy of the convexity may be a less risky procedure. The practice of not using bone graft in the intervertebral spaces does not seem to contribute to spinal shortening and increases the pseudoartosis risk.

Adolescent↗
PubMed1997

Spinal intraosseous arteriovenous malformation as a cause of juvenile scoliosis. A case report.

STUDY DESIGN: A case report. OBJECTIVES: To report and discuss an unusual case of scoliosis resulting from an arterial malformation of the spine. SUMMARY OF BACKGROUND DATA: This is a report of clinical manifestation, physical findings, computed tomography scan, magnetic resonance imaging, bone scan, and results after surgery in an 8-year-old boy with a painful scoliosis resulting from an intraosseous arteriovenous malformation of the spine. METHODS: Radiographs, computed tomography scan, magnetic resonance imaging, and bone scans were studied and oriented us to the diagnosis of scoliotic attitude secondary to a benign-appearing tumor in the right lamina of L4. Surgery was performed through a posterior midline approach to remove the lesion en bloc. Postoperative treatment was performed with a Boston orthosis. RESULTS: Final pathology reports diagnosed an intraosseous arteriovenous malformation. After 32 months, the boy had no pain, and scoliotic attitude diminished despite radiographs still showing a single 10 degrees right lumbar curve. CONCLUSIONS: Primary intraosseous arteriovenous malformations are rare. This case shows the scarce specificity of clinical findings, radiology, and bone scan in the diagnosis of these lesions when they are localized in vertebral territory. Surgical excision of the lesion relieves pain but does not completely correct the scoliotic attitude.

Arteriovenous Malformations↗