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PubMed2001

Medical complications in scoliosis surgery.

Several medical complications can occur after scoliosis surgery in children and adolescents. They include the syndrome of inappropriate antidiuretic hormone; pancreatitis; cholelithiasis; superior mesenteric artery syndrome; ileus; pnemothorax; hemothorax; chylothorax; and fat embolism. This review focuses on the pathophysiology, diagnosis, and treatment of the various conditions that occur after correction of spinal deformity. Attention is given to recent literature specifically related to scoliosis surgery. Surgical complications like urinary tract infection, wound infection, and hardware failure will not be addressed.

Adolescent↗
PubMed2004

Factors determining the final outcome of treatment of idiopathic scoliosis with the Boston brace: a longitudinal study.

This study tries to determine factors influencing the final outcome of treatment of idiopathic scoliosis with the Boston brace and to compare the results with the natural history. One hundred and fifty-one patients, 130 girls and 21 boys, treated between 1982 and 1991, were reviewed. A series of continuous and categorical variables were measured, allowing for the construction of a multiple regression equation. Continuous variables were age at discovery of the curve, time of interval between discovery and treatment and age at the beginning of treatment. Furthermore age of menarche, duration of treatment, duration of weaning and age and time of follow-up were noted. Continuous numerical variables were the Cobb angle, the apical vertebral rotation, and the Risser stage. Categorical variables consisted of the results of a questionnaire and the King's classification of the curve. Good results are achieved in older children, with low Cobb angles and advanced maturity, who are, however, the very ones not expected to progress, as also indicated in studies on natural history. Brace treatment seems not to alter the natural history in general, and especially not in the older child; this is the case from age 12 years and Risser stage 2 onwards. In the younger child, a brace is probably still indicated, because it has been proved that a scoliosis is more prone to progress and that a possible positive result can still not be ruled out, as long as randomized control trials are not conducted.

Adolescent↗
PubMed2002

Bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema following intubation with a double-lumen endotracheal tube for thoracoscopic anterior spinal release and fusion in a patient with idiopathic scoliosis.

Recently, thoracoscopic approaches to the spine have taken on greater clinical applications in the treatment of spinal deformity with generally good results. However, the steep learning curve must be ascended by the surgeon and may lead to complications early in one's experience. There also exists a learning curve for the anesthesiologist to become adept at obtaining single lung ventilation and managing this throughout the operative procedure. We report a case of an 11-year-old patient with severe scoliosis who developed air in both chest cavities, mediastinum, peritoneum, retroperitoneum, and subcutaneous tissue after intubation with a double-lumen endotracheal tube. The patient remained hemodynamically stable throughout this period, and bilateral chest tubes were placed. The patient remained on the ventilator for 24 hours and was extubated without sequelae. Complications from a thoracoscopic approach to the spine for deformity are most often attributed to the learning curve of the surgeon; however, the entire operative team becomes exposed to the challenges of performing this procedure. This report documents a life-threatening complication of air throughout the chest, mediastinum, abdomen, and subcutaneous tissues in a patient with severe scoliosis.

Child↗
PubMed2002

Outcomes in surgical treatment of "idiopathic-like" scoliosis associated with syringomyelia.

Patients with "idiopathic-like" spinal deformities associated with syringomyelia were retrospectively reviewed. Ten patients had surgical stabilization of their curvatures with at least a 2-year follow-up, and an additional five patients were evaluated for deformity pattern with <2 years of follow-up. Paralytic curve patterns, scoliosis associated with spina bifida, congenital scoliosis, or other associated syndromes were discarded. All 10 patients with surgery who were followed for an average of 46 months lost 10 degrees correction above, through, or below the instrumented segments. A total of 50% lost correction through the instrumented segments. Anterior fusion stabilized the instrumented portion of the spine better than posterior instrumentation alone. Eighty percent of the 15 patients had thoracic kyphosis >40 degrees. Only one patient was lordoscoliotic. Syringomyelia deformities tend to be kyphoscoliotic in 80% of cases and behave more like paralytic curvatures postoperatively. MRI is recommended for apparent idiopathic scoliotic curvatures that are kyphoscoliotic and not lordoscoliotic.

Adolescent↗
PubMed2003

Selection of fusion levels in scoliosis surgery.

Fusion levels are selected with the goal of having a balanced physiologic spine on the postoperative films. We have proposed an algorithm for selecting fusion levels based on the King-Moe scoliosis classification scheme and the flexibility of a compensatory curve. We propose the acronym TEAMS as a pneumonic. Curve type defines the region of the spine to be fused. The ends of the Cobb measurement around the region are the temporary endpoints. The endpoints are extended to avoid an apex due to the sagittal or frontal planes. The mobile disc is defined at the caudal end of the fusion area. Finally, the bending films, traction films, or intraoperative films are used to define the stable zone of Harrington that must contain the ends of the fusion mass. This scheme yields a simple, easily taught algorithm that results in reproducible endpoints for scoliosis fusion.

Adolescent↗
PubMed2003

The use of postoperative subcutaneous closed suction drainage after posterior spinal fusion in adolescents with idiopathic scoliosis.

BACKGROUND The purpose of this prospective study was to assess the impact of closed suction drainage on transfusion requirements, frequency of dressing changes, and wound healing following posterior spinal fusion in adolescents with idiopathic scoliosis. METHODS Thirty patients were randomly assigned to one of two groups: drain or no drain. Although the group with drains received more postoperative autologous blood transfusions than the group with no drains (0.88 vs 0.5 unit), the difference was not statistically significant (P = 0.2131). In the undrained group, 58% of the patients had moderate to completely saturated dressings on the second postoperative day compared with only 17% of patients in the drained group. Three of 12 patients in the undrained group demonstrated a wound complication rate compared with no complications in the drained group. CONCLUSION In conclusion, subcutaneous closed suction drainage can improve immediate postoperative wound care without significantly increasing blood loss and transfusion requirements for patients undergoing surgery for idiopathic scoliosis.

Adolescent↗
PubMed2003

Posterior releasing techniques for idiopathic scoliosis: microscopic discectomy and transverse process resection: a technical note.

The authors describe techniques and preliminary results of two releasing procedures for idiopathic scoliosis, which can be performed concomitantly in the same stage of posterior instrumentation surgery. The transpedicular microscopic discectomy and transverse process resection were clinically applied for adolescent idiopathic scoliosis. Twelve patients were divided into three groups at random: Group A patients underwent no release, group B patients underwent transverse process resection, and group C patients underwent microscopic discectomy of three discs and transverse process resection, in combination. All patients were operated on with derotation procedure with Cotrel-Dubousset instrumentation simultaneously after each releasing procedure. The outcomes-curve correction, disc wedge angle, and rotational changes-were evaluated 12 months postoperatively. The mean correction rate of the Cobb angle in group C (78%) was higher than in groups A (54%) and B (64%). Correction of the disc wedge angle was also higher in group C compared with groups A and B. The authors conclude that microscopic discectomy appeared to be an effective releasing method for thoracic curve and that further investigation is necessary for accurate evaluation of the transverse process resection.

Adolescent↗
PubMed2003

Prediction of Cobb angle in idiopathic adolescent scoliosis.

We did a prospective study of 291 children and adolescents with idiopathic scoliosis to identify possible correlations between clinical (scoliometer value, age, height) and radiographic (Cobb angle, Nash-Moe rotation, Risser iliac apophysis classification) parameters to predict the curve angle. There was a statistically significant correlation between thoracic, thoracolumbar, and lumbar scoliometer values and the thoracic, thoracolumbar, and lumbar Cobb angles, respectively (Pearson's r-0.685, 0.572, and 0.677, respectively). There was a statistically significant correlation between Cobb angle in the thoracic, thoracolumbar, and lumbar spine and the patients' age and height. Mathematical formulas that predict the Cobb angle of thoracic, thoracolumbar, and lumbar scoliosis using the scoliometer measurements are reported.

Adolescent↗
PubMed2003

Proximal kyphosis after short posterior fusion for thoracolumbar scoliosis.

Thoracolumbar idiopathic scoliosis usually is treated by anterior spinal fusion. However, short posterior spinal fusion that includes only the structural curve has been tried in a limited number of patients. The fusion may end cranially in the lower thoracic region and cause an increase in sagittal decompensation at the proximal junction. From July 1989 to July 1998, 14 patients were treated with thoracolumbar idiopathic scoliosis by short posterior spinal fusion. The lateral radiographs were evaluated preoperatively, immediately postoperative, and during followup. The focal kyphotic angle was used to examine the changes in focal sagittal alignment. A 10 degrees progression was defined as the radiographic criterion for the development of junctional kyphosis. Proximal junctional kyphosis occurred in six of the 14 patients, in which one patient needed revision surgery. In all six patients, the average preoperative lumbar lordosis was greater than 35 degrees, and decreased more than 10 degrees during surgery. In the five patients with a focal kyphotic angle larger than 10 degrees, four had proximal junctional kyphosis develop. According to the current findings, short posterior spinal fusion can be done only if the focal kyphotic angle proximal to the fusion is less than 10 degrees, and the lumbar lordosis must be preserved carefully during surgery.

Adolescent↗
PubMed2006

Postural control in patients with severe idiopathic scoliosis: a prospective study.

Thirty-one patients with severe adolescent idiopathic scoliosis were evaluated preoperatively by computerized dynamic posturography. Curve type, magnitude and spine balance were measured radiographically. In four girls, a very mild vestibular dysfunction was observed on the sensory organization analysis, and three of them had a horizontal shift of more than 2 cm; a disbalance was observed in only three other patients among the 27 patients with normal posturography. These results suggest that abnormalities in the sensory systems are not involved in the etiology of severe adolescent idiopathic scoliosis. The vestibular dysfunction detected in the four patients was most probably the result of disbalance and not the cause of the disease.

Adolescent↗
PubMedDate not supplied

Rapid progression of scoliosis following insertion of intrathecal baclofen pump.

Placement of an intrathecal baclofen pump is a common treatment of spasticity in cerebral palsy patients. Though effective, the hardware is prone to malfunction, and multiple revisions are often necessary. Additional complications have also been described, including infection and drug toxicity or withdrawal. The authors report another complication of intrathecal baclofen therapy: accelerated progression of scoliosis after pump insertion. A retrospective chart review was performed on four patients who showed accelerated scoliotic progression after intrathecal baclofen pump insertion for treatment of spasticity. Cobb angles were measured from preoperative and postoperative radiographs to determine the rate of scoliotic degeneration both before and after pump insertion. Although there may not be a direct correlation between intrathecal baclofen and scoliosis, the authors consider the issue important enough to warrant discussion with any patient considering intrathecal baclofen.

Adult↗
PubMedDate not supplied

Characteristics of congenital scoliosis in a mouse model.

Pregnant mice were exposed to 600 ppm of carbon monoxide on gestation day 9. The carbon monoxide exposure produced 38 spinal anomalies in 17 offspring with congenital scoliosis. Microcomputer tomography improved the identification of spinal anomalies and detected more affected animals, as compared when magnified radiographs were used. The curves were measured and ranged from mild to moderate at an age that corresponds to childhood and, on average, remained at the range of mild to moderate through near-maturity. The group of mice with congenital anomalies near maturity contained severe curves. The bone mineral density (BMD) determined by microcomputer tomography in the mice with congenital scoliosis was the same as that in the controls. The cervical spine BMD was higher than the thoracic BMD, which was higher than the lumbar region in the controls and affected animals. The BMD was highest in the apex of the congenital curves in the animals that were near maturity. This relationship was not seen in the younger mice with congenital curves. Histology revealed growth rates in the hemivertebrae, which, over the last half of the growth period measured, had one-third less growth than the adjacent vertebrae. The hemivertebrae were wedged, but the adjacent disks were not.

Animals↗
PubMedDate not supplied

Spinal surgery in children with idiopathic and neuromuscular scoliosis. What's the difference?

We compared children who were hospitalized for the management of idiopathic scoliosis (IS) and neuromuscular scoliosis (NMS) via analysis of the 2000 Healthcare Cost and Utilization Project Kid Inpatient Database. Children with NMS had longer lengths of stay (9.2 vs. 6.1 days, P < 0.001), higher total charges (66,953 US dollars vs. 47,463 US dollars, P < 0.001), more diagnoses (6.3 vs. 2.5, P < 0.001), and more total procedures (4.2 vs. 3.0, P < 0.001) than did children with IS. Children with NMS more frequently developed pneumonia (3.5% vs. 0.7%, P < 0.001), respiratory failure (24.1% vs. 9.2%, P < 0.001), urinary tract infections (5.3% vs. 0.7%, P < 0.001), and surgical wound infections (1.3% vs. 0.3%, P < 0.001). Overall, 1570 children with NMS underwent spinal surgery, totaling to 105 US dollars million in hospital charges and 14,444 hospital days. We conclude that children with NMS experience significantly more complicated and costly hospitalizations than do children with IS. These results may add information on preoperative care, surgical decision-making, discussions of informed consent, and the provision of anticipatory guidance for children and their caregivers.

Adolescent↗
PubMed2003

Boston brace correction in idiopathic scoliosis: a biomechanical study.

STUDY DESIGN: To analyze Boston brace biomechanics, pressure measurements and finite element simulations were done on 12 adolescent idiopathic scoliosis patients. OBJECTIVES: The aim was to analyze the Boston brace effectiveness using a finite element model and experimental measurements. SUMMARY OF BACKGROUND DATA: There are not very many biomechanical studies of Boston brace effectiveness, and its biomechanical action is not completely understood. METHODS: This study was performed on 12 girls with scoliosis treated with the Boston brace system. The experimental protocol was composed of the acquisition of two sets of multiplanar radiographs with and without brace followed by the pressure acquisition at the brace-torso interface. A personalized finite element modeling of the trunk was generated from the 3D reconstruction of the patient's geometry. The brace treatment was simulated by the application of equivalent forces calculated from the pressure measurements. RESULTS: Two Boston brace force patterns were defined from the pressure measurements. The first one consisted of high right thoracic forces of 31-113 N, lumbar forces less than 47 N, and included a left thoracic extension working as a counter pad. The second one consisted of low thoracic forces less than 20 N, lumbar forces up to 70 N, without left thoracic extension. The simulations showed that the passive forces only produced a coronal Cobb angle correction up to 9 degrees, whereas real correction was up to 16 degrees. CONCLUSION: High thoracic pads reduced more effectively both thoracic and lumbar scoliotic curves than lumbar pads only. The study suggests that mechanisms other than brace pads produce correction and contribute to the force equilibrium within the brace.

Adolescent↗
PubMed2003

Back pain and function 22 years after brace treatment for adolescent idiopathic scoliosis: a case-control study-part I.

STUDY DESIGN: A consecutive series of patients with adolescent idiopathic scoliosis and brace-treated (BT) between 1968 and 1977 before age 21 years (BT: n = 127; 122 females and 5 males) were followed-up at least 20 years after completion of the treatment. OBJECTIVES: To determine the long-term outcome in terms of back pain and function in patients BT for adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Few reports on long-term outcome of back pain and function have previously been presented for consecutive groups of these patients. MATERIALS AND METHODS: One hundred ten (87%) BT patients were reexamined as part of an unbiased personal follow-up. This included a clinical examination, evaluation of curve size (Cobb method), and degenerative findings in full standing frontal and lateral radiographs. Validated questionnaires in terms of general and disease-specific quality-of-life aspects as well as present back and pain symptoms were used. One hundred nine had complete follow-up. An age- and sex-matched control group of 100 persons was randomly selected and subjected to the same examinations. RESULTS: The deterioration of the curves was a mean of 7.9 degrees for all curves, excluding the only patient who underwent operation after 4 years (increase = 27 degrees). The patients had significantly more degenerative disc changes than the controls. Lumbar and thoracic back pain, although mild (2.7 on visual analogue scale), was significantly more frequent among the patients than the controls (75 vs. 47%, P = 0.0050 and 35.8 vs. 22.0%, P = 0.033, respectively). Only 24% of the patients admitted daily pain and analgesics were sparsely used. The patients had a slightly, but significantly, worse back function as measured by the Oswestry Disability Index (9.2 vs. 4.8, P = 0.0012) and general function score (7.7 vs. 4.2, P = 0.0006), but general health-related quality of life was not affected. No differences could be seen in sociodemographic variables between the groups, except for having ever been on sick leave because of the back (38% vs. 19%, P = 0.0036). Furthermore, no differences could be found between patients with different curve types (single thoracic, n = 50; lumbar, n = 19; double curves, n = 40). No correlation could be found between pain and its localization and curve size, an increase of at least 10 degrees since end of treatment, curve type, degenerative changes on any of the two lowest lumbar disc levels, body mass index, or smoking. CONCLUSIONS: More than 20 years after brace treatment for AIS, minimal pain and no dysfunction occurred compared with normal controls. Compared with surgically treated patients with a mean end result similar to this group, no significant differences were found except that BT patients experience more affective components of their pain.

Adolescent↗
PubMed2003

Analysis of patient and parent assessment of deformity in idiopathic scoliosis using the Walter Reed Visual Assessment Scale.

OBJECTIVES: This study evaluates the Walter Reed Visual Assessment Scale (WRVAS) compared with clinical parameters and written descriptions of the deformity from idiopathic scoliosis patients and their parents. SUMMARY OF BACKGROUND DATA: The WRVAS demonstrates seven visible aspects of spinal deformity in an analogue scale. Higher scores reflect worsening deformity. MATERIALS AND METHODS: The WRVAS was administered to 182 idiopathic scoliosis patients at four centers in conjunction with open-ended questions about patients' and their parents' perceptions of their spinal deformity. The open-ended responses were categorized as either "deformity noted" or "no deformity noted." RESULTS: WRVAS scores strongly correlate with curve magnitude (P = 0.01) and clearly differentiates curves of 30 degrees or more from lesser curves. Among treatment groups, patients with surgery recommended had significantly higher scores than that of other patients. The instrument differentiated those noting no deformity from those noting a deformity. The correlation between patients' and parents' scores was high (Spearman's rho = 0.8). When a deformity was noted, parents gave higher scores than did their children for rib prominence, shoulder level, scapular rotation, and the total score, but not for the other dimensions. CONCLUSIONS: Increasing scores of the WRVAS are strongly correlated with curve magnitude lending construct validity to this type of assessment tool. Patients with "surgery recommended" report more visible deformity on the scale than observed, braced, and postoperative patients, supporting the hypothesis that surgery improves the perceived appearance. Parents perceive more deformity of the ribs and shoulders more than did the patients, but other aspects of the deformity are identified equally. WRVAS scores correlate significantly with curve magnitude and treatment. Parents and patients have similar scores, but with parents perceiving more deformity of the ribs and shoulders than patients.

Adolescent↗
PubMed2003

The objective measurement of spinal orthosis use for the treatment of adolescent idiopathic scoliosis.

STUDY DESIGN: Technology development and prospective study. OBJECTIVES: Develop instrumentation for discrete, reliable, and objective measurement of brace use patterns between routine follow-ups and without patient involvement. BACKGROUND DATA: To understand spinal bracing efficacy and clinical effectiveness in the conservative treatment of adolescent idiopathic scoliosis, it is essential to measure and record such confounding variables as spinal physiology, force distribution, and compliance. Historically, compliance was measured using patient interviews, pad/strap forces, or temperature. These measurements were subjective, limited to laboratory or short-term monitoring only, required patient intervention, or lacked date/time recording. METHODS: Custom-fitted nonperforated thoracic lumbar sacral orthoses were instrumented with discrete data loggers to measure and record temperature at the skin-brace interface at 16-minute date/time-stamped intervals for up to 88-day periods without patient involvement. Ten female patients (age 15 years, SD 1.2) with adolescent idiopathic scoliosis who had spinal bracing as part of their treatment regimen took part in the study over 14 months, SD 4.5 months. RESULTS: Compliance with the treatment regimen ranged from 8% to 90%, average 65%. Patients tended to overestimate their compliance by 150% (SD 50%). There was no significant difference between weekday and weekend compliance but wear patterns differed. Night wear was significantly greater than day wear (P < 0.01). Patients with very good compliance only removed their brace for washing or exercise periods, but where poor compliance was evident, the brace was only worn sporadically during the day. CONCLUSIONS: Temperature provides a clear signal of the time in brace and can be used for long-term data logging using discrete instrumentation, providing a tool to help identify and understand the reasons behind poor compliance.

Adolescent↗
PubMed2003

Primary thoracolumbar scoliosis in pinealectomized chickens.

STUDY DESIGN: This study examines the gross anatomic changes in the chicken spine after pinealectomy and was undertaken because initial observation suggested that the pattern of curve development appears to be different from that reported in the literature. OBJECTIVE: To characterize the spinal deformity in chickens after pinealectomy. SUMMARY OF BACKGROUND DATA: The most common curve pattern seen after pinealectomy in chickens is said to be thoracic curves with structural changes and rotation. This is based largely on radiographic observations and forms the basis of the claim that chicken and human adolescent idiopathic scoliosis are similar. METHOD: Thirty-five chickens were divided into 2 groups, a pinealectomy group (n = 25) and a control group with no surgery performed (n = 10). The spines were harvested at 3 months of age and examined visually, by radiographs and computed tomography scans. RESULTS: Thirteen out of 25 (52%) of the pinealectomized chickens developed scoliosis. In contrast to previous studies, all the curves were located at the thoracolumbar junction with the apex at either T7 or L1. Structural changes including apical vertebral wedging, lordosis (mean of 14.3 degrees ), and rotation (mean of 14 degrees ) were seen in all cases. Pelvic wing deformity was seen in all cases and significantly contributed to the posterior rotational hump. CONCLUSION: The primary curve in these chickens is at the thoracolumbar junction. Previous reports of curve pattern based on radiographic findings would not have identified these as the thoracolumbar junction is obscured by the bony pelvis and heavy musculature. The finding of pelvic wing deformity has not been previously reported, and raises the question as to whether these curves are secondary to asymmetric muscle pull.

Animals↗