Measurement accuracy in congenital scoliosis.

BACKGROUND: The accuracy of measurement of curves in idiopathic scoliosis has been extensively studied; however, we know of only one article in the literature concerning the accuracy of measurement of curves in congenital scoliosis. That article stated that intraobserver variability was +/- 9.6 degrees and interobserver variability was +/- 11.8 degrees. METHODS: Sixty-nine curves in fifty patients with congenital scoliosis were measured on two separate occasions by seven different observers with varying experience in curve measurement. RESULTS: Mean intraobserver variance ranged from 1.9 degrees to 5.0 degrees, with an average of 2.8 degrees (95% confidence limit, +/- 3 degrees) for the seven observers. The interobserver variance was 3.35 degrees (95% confidence limit, 7.86 degrees). CONCLUSIONS: It is possible to measure curves in congenital scoliosis with much greater accuracy than previously reported. In the clinical situation in which a skilled observer can measure two radiographs at the same time, an accuracy of +/- 3 degrees can be expected 95% of the time.

Extension of fusions to the pelvis in idiopathic scoliosis.

STUDY DESIGN: Retrospective study of patients after extension of previous scoliosis fusions to the pelvis. OBJECTIVE: To determine whether modern instrumentation and surgical techniques provide for increased fusion rates with fewer complications. SUMMARY OF BACKGROUND DATA: Traditionally, long fusions to the pelvis in adults with idiopathic scoliosis have resulted in high complication rates, including pseudarthrosis. METHODS: The hospital and clinic charts of 41 patients (40 female, 1 male) were reviewed 41 months (range: 24-116) after surgery for extension to the pelvis of previous scoliosis fusions. Thirty-nine of 41 had a combined anteroposterior fusion extension; two had posterior extension only. In 37 of 41 patients, Cotrel-Dubousset (CD) instrumentation was used; in two, Isola (Acromed Corp., Cleveland, OH), in one, TSRH; (Sofamor-Danek, Memphis, TN), and in one, Synergy (Cross Medical Products, Columbus, OH). Parameters analyzed were fusion rate, sagittal and coronal balance, lumbar lordosis, length of fusion extension, and distal fixation method. RESULTS: Complications were seen in 30 of 41 patients. The pseudarthrosis rate was 37% (15/41) and was significantly related to the method of distal posterior fixation. With sacral fixation only, the rate was 53% (8/15), with iliac fixation only 42% (3/7), and with both iliac and sacral fixation 21% (4/19; P < 0.05). This was not correlated with fusion rate, and the length of fusion extension did not affect the pseudarthrosis rate or sagittal balance. CONCLUSION: When fixed to the ilium and sacrum, modern instrumentation appears capable of maintaining sagittal balance with lower rates of pseudarthrosis when previous scoliosis fusions are extended to the pelvis. The complication rate remains significant.

Breast cancer mortality after diagnostic radiography: findings from the U.S. Scoliosis Cohort Study.

STUDY DESIGN: A retrospective cohort study was conducted in 5573 female patients with scoliosis who were referred for treatment at 14 orthopedic medical centers in the United States. Patients were less than 20 years of age at diagnosis which occurred between 1912 and 1965. OBJECTIVES: To evaluate patterns in breast cancer mortality among women with scoliosis, with special emphasis on risk associated with diagnostic radiograph exposures. SUMMARY OF BACKGROUND DATA: A pilot study of 1030 women with scoliosis revealed a nearly twofold statistically significant increased risk for incident breast cancer. Although based on only 11 cases, findings were consistent with radiation as a causative factor. METHODS: Medical records were reviewed for information on personal characteristics and scoliosis history. Diagnostic radiograph exposures were tabulated based on review of radiographs, radiology reports in the medical records, radiograph jackets, and radiology log books. Radiation doses were estimated for individual examinations. The mortality rate of the cohort through January 1, 1997, was determined by using state and national vital statistics records and was compared with that of women in the general U. S. population. RESULTS: Nearly 138,000 radiographic examinations were recorded. The average number of examinations per patient was 24.7 (range, 0-618); mean estimated cumulative radiation dose to the breast was 10.8 cGy (range, 0-170). After excluding patients with missing information, 5466 patients were included in breast cancer mortality analyses. Their mean age at diagnosis was 10.6 years and average length of follow-up was 40.1 years. There were 77 breast cancer deaths observed compared with the 45.6 deaths expected on the basis of U.S. mortality rates (standardized mortality ratio [SMR] = 1.69; 95% confidence interval [CI] = 1.3-2.1). Risk increased significantly with increasing number of radiograph exposures and with cumulative radiation dose. The unadjusted excess relative risk per Gy was 5.4 (95% CI = 1.2-14.1); when analyses were restricted to patients who had undergone at least one radiographic examination, the risk estimate was 2.7 (95% CI = -0. 2-9.3). CONCLUSIONS: These data suggest that exposure to multiple diagnostic radiographic examinations during childhood and adolescence may increase the risk of breast cancer among women with scoliosis; however, potential confounding between radiation dose and severity of disease and thus with reproductive history may explain some of the increased risk observed.

Postoperative deep wound infection in adults after posterior lumbosacral spine fusion with instrumentation: incidence and management.

The authors reviewed 817 instrumented lumbosacral fusions in adults and found an incidence of 3.2% deep wound infections. The primary focus of this study was the management of these infections, with particular attention to whether the implants needed to be removed. A consulting infectious disease specialist indicated that an acute infection of a low back fusion wound could not be healed without removal of the metallic implants. This opinion was in contrast to the authors' daily experience and prompted this study. The authors identified and reviewed 817 cases of instrumented posterior lumbosacral arthrodeses in adults. A detailed analysis of any case with a deep wound infection was performed and yielded and infection rate of 3.2% (26 patients). Of these, 24 achieved a clean, closed wound without removal of instrumentation through a protocol of aggressive debridement and secondary closure. Instrumentation removal is not necessary to obtain a clean, closed wound using an aggressive approach with early diagnosis, vigorous debridement in the operative room under general anesthesia, delayed primary or secondary closure, and appropriate antibiotic coverage.

The spine in diastrophic dysplasia. The surgical arthrodesis of thoracic and lumbar deformities in 21 patients.

STUDY DESIGN: Retrospective chart and radiographic film review. OBJECTIVES: To discern the deformity problems in diastrophic dysplasia and to report our results in surgical treatment. SUMMARY OF BACKGROUND DATA: Due to the rarity of the problem, the literature is very scanty as to the indications for surgery or the best technique. METHODS: Analysis of radiographic film for scoliosis, kyphosis, lordosis, and decompensation before surgery, after surgery, and at follow-up. Analysis of charts for complications and problems. RESULTS: The most common deformity pattern was a double thoracic kyphosis (79 degrees/97 degrees) with a true kyphosis at the junction of the two scolioses (101 degrees). Combined anterior-posterior arthrodesis gave the best results. CONCLUSIONS: Very severe deformity can occur in children with diastrophic dysplasia, even at a young age. Prompt anterior-posterior arthrodesis can prevent catastrophic deformity.

Complications associated with pedicle screws.

BACKGROUND: The safety and the effectiveness of pedicle-screw instrumentation in the spine have been questioned despite its use worldwide to enhance stabilization of the spine. This review was performed to answer questions about the technique of insertion and the nature and etiology of complications directly attributable to the screws. METHODS: We performed a retrospective review of all of the pedicle-screw procedures that were done by us from January 1, 1984, to December 31, 1993. We inserted 4790 screws during 915 operative procedures on 875 patients; 668 (76.3 percent) of the patients had a lumbosacral arthrodesis. The mean duration of follow-up was three years (range, two to five years). The accuracy of screw placement was assessed on intraoperative, immediate postoperative, and follow-up radiographs with use of a technique that was developed by one of us (F. D.); this technique has yet to be validated to determine the prevalence of various types of error. RESULTS: Of the 4790 screws, 4548 (94.9 percent) had been inserted within the pedicle and the vertebral body. One hundred and thirty-four (2.8 percent) of the screws had perforated the anterior cortex, and this was the most common type of perforation. One hundred and fifteen (2.4 percent) of the screws were associated with complications that could be ascribed to the use of pedicle screws. The most common problem was late-onset discomfort or pain related to a pseudarthrosis or perhaps to the screws; this problem was associated with 1102 (23.0 percent) of the screws, used in 222 (24.3 percent) of the procedures. The symptoms necessitated removal of the instrumentation with or without repair of the pseudarthrosis. A pseudarthrosis was found during forty-six (20.7 percent) of the 222 procedures. Irritation of a nerve root occurred after nine procedures (1.0 percent) and was caused by eleven screws (0.2 percent); it was more commonly caused by medially placed screws. Three patients had residual neurological weakness despite removal of the screws. Twenty-five screws (0.5 percent), used in twenty procedures (2.2 percent), broke. The screws that broke were of an early design. A pseudarthrosis was found in thirteen of twenty patients who had broken screws. Sixteen of the twenty patients had an exploration; three of them were found to have a solid fusion, and thirteen were found to have a pseudarthrosis. The remaining four patients had evidence of a solid fusion on radiographs and had no pain. CONCLUSIONS: There are few problems associated with the insertion of screws, provided that the surgeon is experienced and adheres to the principles and details of the operative technique. Our review revealed a low rate of postoperative complications related to pedicle screws. The problem of late-onset pain may be related to the implants or to the stiffness of the construct; however, it is difficult to accurately identify its exact etiology.

Congenital spine deformities: scoliosis, kyphosis, and lordosis.

By definition, congenital spine deformities-scoliosis, kyphosis, and lordosis-are due to abnormal vertebral development. Thus, affected children tend to have a curvature noted much earlier in life than typical patients with idiopathic scoliosis. This early development of the deformity has resulted in a tendency for the young child with congenital deformities to receive less than optimal care. These curves must not be allowed to progress. In many cases, early fusion is necessary, which is preferable to allowing severe curves to develop.

A King type II curve pattern treated with selective thoracic fusion: case report with 44-year follow-up.

The optimal surgical treatment of the King-Moe type II thoracic curve pattern is controversial. The issue of postoperative "decompensation" has arisen in conjunction with the use of third-generation instrumentation systems. This report presents the 44-year clinical and radiographic follow-up of a patient with a type II scoliosis treated with uninstrumented selective thoracic fusion using the criteria of King and Moe. The caudal extent of the fusion was defined by proper identification of the neutral and stable vertebra. At final follow-up, the patient remained well balanced and essentially pain free. Her level of function was "above average" for her age, as per SF-36 evaluation.

Congenital scoliosis with posterior spinal arthrodesis T2-L3 at age 3 years with 41-year follow-up. A case report.

STUDY DESIGN: A case report. OBJECTIVES: To document the long-term effects of early fusion for progressive congenital scoliosis. SUMMARY OF BACKGROUND DATA: There is concern about fusion at an early age causing torso shortening and possible crankshaft phenomenon. METHODS: A review of medical and radiologic records. RESULTS: A 3-year old girl with progressive congenital scoliosis had posterior spinal arthrodesis in 1955. A pseudarthrosis was repaired at age 4, and at age 8 she had an osteotomy of the fusion mass because of bending of the fusion mass. In a follow-up 41 years after fusion, she has no back pain and no history of pulmonary problems. Despite the long fusion at a young age, her torso-to-leg ratio was remarkably good. The thoracic lordosis had improved to a normal thoracic kyphosis. CONCLUSION: Early arthrodesis was life saving and caused no long-term problems. Because significant spinal growth has occurred by age 3, no adverse effects on torso-leg ratio with an early long arthrodesis, and in addition the crankshaft phenomenon is rare in congenital scoliosis.

Coronal and sagittal balance in surgically treated adolescent idiopathic scoliosis with the King II curve pattern. A review of 67 consecutive cases having selective thoracic arthrodesis.

STUDY DESIGN: A retrospective study by an independent observer of a consecutive series of 67 cases of adolescent idiopathic scoliosis presenting with a King II curve pattern. OBJECTIVES: To demonstrate the validity of a selective thoracic fusion as a treatment of King II curves with special attention to immediate postoperative and long-term trunk balance in the coronal and sagittal planes. SUMMARY OF THE BACKGROUND DATA: The literature has been fairly controversial in terms of the recommended treatment of King II curve patterns in adolescent idiopathic scoliosis. The main confusion appears to be whether the thoracic curve alone or both curves should be instrumented and fused. METHODS: Sixty-seven patients were identified as having had a selective posterior thoracic spine fusion with instrumentation between 1961 and 1994. None of these cases had a fusion of the lumbar spine. Preoperative radiographs were analyzed for determination of the appropriate fusion level using the criteria of the stable and neutral vertebra. Follow-up radiographs were evaluated for balance in the coronal and sagittal planes using the central sacral line on posteroanterior radiograph and the C7 sacral promontory line on lateral film. RESULTS: At 2-year or greater follow-up, the unfused lumbar curve remained equal to or less than the corrected thoracic curve in 63 patients (94%). No patient required extension of fusion. Frontal plane balance analysis showed that 47 of the 67 patients had the T1 plumb line within 2 cm of the midline for an average decompensation of 8.7 mm. In no patient was the loss of balance greater than 3.8 cm. Sagittal plane balance analysis showed that only one patient had inferior junctional kyphosis greater than 10 degrees. This did not require extension of fusion. There were no cases of superior junctional kyphosis. CONCLUSIONS: The concept of selective thoracic fusion in the King II curve pattern appears to be valid. These findings suggest that arthrodesis of the lumbar spine can be avoided when this pattern is properly diagnosed and appropriately treated. Proper identification of the stable and neutral vertebra and of the appropriate level of fusion are important to achieve good postoperative balance. Successful preservation of lumbar motion segments is important to long-term satisfactory outcome in adolescent idiopathic scoliosis.

Adult spinal deformity and respiratory failure. Surgical results in 35 patients.

STUDY DESIGN: Retrospective chart and complementary study review. OBJECTIVES: To describe the features of adult patients with spinal deformity and respiratory failure and to analyze the results of surgical treatment. SUMMARY OF BACKGROUND DATA: Many authors have studied the relation between spinal deformities and cardiorespiratory failure, but there exists little information about the benefits of reconstructive surgery in severely compromised patients. METHODS: The charts and complementary studies of 35 adult patients surgically treated between January 1, 1978, and December 31, 1994, were reviewed. The patients were 18 years old or older (average age, 36 years). They had spinal deformity of any etiology with respiratory insufficiency as evidenced by vital capacity of less than 60% of predictive normal, PaO2 less than 80 mm Hg, or PaCO2 more than 45 mm Hg. All had reconstructive spinal surgery in an attempt to improve their respiratory problem. RESULTS: Seven patients died within the first postoperative year, and one patient was lost to follow-up at 6 months. The other 27 patients had a mean follow-up time of 72 months. The 34 patients were divided into three groups: good, fair, and poor evolution. The patients in the good evolution group had a better preoperative general condition, had more correction of their deformities, had more improvement in their respiratory function, and had fewer complications than those in the other groups. The patients in the poor evolution group were older, had more cardiac problems, and had less correction at surgery. CONCLUSION: The results of surgery varied from extremely good to extremely bad. The seven patients who died within the first year had no benefit, but the 27 others did very well, usually gaining significant improvement of their respiratory function. Because the alternative to surgical correction is death, this study shows that, under the right circumstances, correction of spinal deformity and, therefore, correction of respiratory function can be life-saving.

The treatment of progressive kyphoscoliosis in camptomelic dysplasia.

STUDY DESIGN: This study evaluated the different forms of treatment of camptomelic dysplasia, a rare form of short-limbed dwarfism. OBJECTIVES: To determine the most efficacious form of management of spinal deformities in camptomelic dysplasia. SUMMARY OF BACKGROUND DATA: The literature on treatment of spinal deformities in camptomelic dysplasia is sparse. One report advocates aggressive surgical treatment to prevent curve progression and prevent already compromised respiratory function. METHODS: Eight patients with camptomelic dysplasia and progressive spinal deformity underwent a retrospective chart and radiographic review by an independent observer. Follow-up averaged 3 years and 9 months. RESULTS: Five of eight patients initially were treated with bracing and six of eight patients eventually required surgery. Average initial kyphosis was 114 degrees and scoliosis 61 degrees, compared with 99 degrees kyphosis and 52 degrees scoliosis at follow-up. Complications included pseudarthrosis (50%) and neurologic problems (33%). CONCLUSIONS: The authors advocate anterior/posterior uninstrumented fusion and halo cast immobilization postoperatively to prevent curve progression and avoid the potentially fatal sequelae associated with this disorder.