Weight distribution in the sitting position in patients with paralytic scoliosis: pre- and postoperative evaluation.

Patients with paralytic scoliosis spend most of their time in the sitting position. The spinal deformity, pelvic obliquity and uneven weight distribution on the seating surface necessitates frequent seating adaptations in the wheelchair. In this prospective study, 45 wheelchair-bound patients were evaluated preoperatively and 43 postoperatively. The pre- and postoperative evaluation was done by an independent observer. Surgical correction was performed between 1993 and 1996. Assessments included sitting balance on a box; number of seating supports in the wheelchair; weight distribution on the seating surface, measured with a computerized EMED system; Cobb angle; hip dislocation; mediolateral translation of T1 and of the apex vertebra with reference to a perpendicular line drawn upwards from the spinal process of S1; and pelvic obliquity from a line drawn between the most proximal points in the iliac crests. X-rays for the measurement of Cobb angle and pelvic obliquity were performed in sitting position. Reference values for normal weight distribution on the seating surface were obtained for 27 normal subjects and revealed a mean value of 59% of weight supported on one side. A stepwise regression analysis on the preoperative results showed that pelvic obliquity and thoracolumbar/lumbar spinal imbalance explained weight distribution on the seating surface (R(2)=0.45). There were significant improvements in all variables except in sitting balance and imbalance of T1, 1 year postoperatively. When dividing the material into two subgroups, the results showed no significant difference in any of the assessed parameters of the scoliosis, pelvic obliquity, or sitting position between individuals with even (50-59% on one side) and those with uneven (60-100% on one side) weight distribution postoperatively. The results of the assessment showed a significant improvement after surgical correction, but the majority still had pelvic obliquity and uneven weight distribution in a sitting position. The weight distribution on the seating surface preoperatively was explained by thoracolumbar/lumbar spinal imbalance and pelvic obliquity, with R(2)= 0.45. There were no significant differences in any variables in comparisons between individuals with even weight distribution and those with uneven weight distribution. For the group with even weight distribution, however, the mean pelvic obliquity was 6 degrees and in the group with uneven weight distribution the mean pelvic obliquity was 12 degrees. Attention to seating surface and adjustment of seating position is needed for patients with paralytic scoliosis.

Vertebral hydatid cyst infection (Echinococcus granulosus): a case report.

Spinal echinococcosis is a rare but serious condition. Within bone tissue hydatid cysts enlarge by daughter cyst formation. The value of drug treatment in bone echinococcosis is questionable. The aim of surgery is therefore removal of all the cysts. The best way to achieve this is at the first operation early in the progress of the disease. An anterior or circumferential approach is generally required to give the necessary accessibility. Owing to diffuse spread of the infection within the bone and the canal, recurrence is common. If neurological deterioration occurs, reintervention is necessary.

Development of an instrument for clinical evaluation after surgery for neuromuscular scoliosis.

Surgical treatment for neuromuscular scoliosis is effective for most patients. Although those afflicted constitute a heterogeneous group, the aim of surgical treatment is approximately the same for all patients: a spine balanced in the coronal and sagittal planes over a level pelvis. Surgery results in a more stable and straighter spine, which should in turn improve performance in different activities. Previous evaluations of surgery for neuromuscular scoliosis reported in the literature have focused primarily on Cobb angles; there are very few studies dealing with the ability to perform various activities. A new tool for evaluation was developed in several steps, starting with a telephone interview with patients who had undergone surgery and a literature search. The evaluation instrument was then developed, followed by a pilot study and validation of new parts of the instrument. The instrument focuses on performance components and on activity performance. Eight items are evaluated before and after surgery. These data are complemented by a questionnaire administered to the patient or relatives at follow-up. The new parts of the instrument were developed specifically for patients with neuromuscular scoliosis, and the data obtained have been shown to have a high correlation with established measures of activities of daily living of daily living). They should therefore provide us with useful information concerning functional gains as a result of surgery as well as the effect of surgery on activity performance.

Long-term results of Harrington instrumentation in idiopathic scoliosis.

The long-term effect of Harrington instrumentation was investigated using posteroanterior radiographs and computed tomographic measurements preoperatively, postoperatively, and at a mean follow-up at 10.8 years in 33 patients with idiopathic scoliosis. No patient was lost from long-term follow-up. At follow-up, the mean Cobb angle was improved by 23.7 (40%) compared with the preoperative findings. The rotation of the apical vertebra was increased significantly. The rib hump, the translation of the apical vertebra, and the sagittal diameter of the thoracic cage were unchanged. At follow-up, the mean thoracic kyphosis was 17.3, and lumbar lordosis was 22.0. This study demonstrated that the long-term effect of Harrington instrumentation was limited to an improved Cobb angle; no correction of the rotational or sagittal deformities were achieved.

Long-term results of Boston brace treatment on vertebral rotation in idiopathic scoliosis.

The long-term effect of Boston brace treatment was investigated by computed tomography measurements before treatment, after bracing, and at mean follow-up at 8.5 years in 25 patients with idiopathic scoliosis. At follow-up, the pretreatment Cobb angle, the vertebral rotation, the rib hump, and the translation of the apical vertebra were not significantly changed. The sagittal diameter of the thoracic cage was significantly decreased at follow-up. The current study demonstrates that the Boston brace does not improve, but prevents progression of vertebral rotation, translation, rib hump, and Cobb angle in idiopathic scoliosis. The reduced sagittal diameter is noteworthy and may be of importance for cosmesis and pulmonary function.

Urethral catheterization in spinal surgery: a randomized prospective study.

In a prospective randomized study the effect of the use of an intraoperative indwelling urethral catheter (IUC) on urinary complications was investigated in patients undergoing spinal fusion. Two groups were formed; 16 patients received an intraoperative IUC and 16 patients had no intraoperative catheter (NC). All patients were, if necessary, intermittently catheterized in the postoperative period. Seven of the patients in the IUC group had positive cultures, defined as > or = 100,000 CFU/ml, compared with two patients in the NC group (n.s.). Another four patients in the NC group had cultures > or =10000 CFU/ml. Thirteen patients in the IUC group and 14 patients in the NC group had positive dip slides. The largest received urine volume in each patient at one intermittent catheterization did not differ significantly between the groups. However, in three patients in the NC group the volumes exceeded 1000 ml. Thus, irrespective of treatment dip slides showed bacteriuria in 84% of the patients. Perioperative indwelling catheters do not seem to cause many more infection complications than no bladder drainage during surgery, and the advantages of reduced risk of bladder distension injury and more accurate monitoring of fluid balance suggest their use.

The symmetry of the breasts in normal and scoliotic girls.

Mammary asymmetry was estimated visually by different investigators in three series of scoliotic girls and in three control groups. The breasts of each girl were classified as being equal in size or as being obviously different in size, note being made of which breast was the larger. Breast asymmetry was significantly more common among the scoliotic than the normal girls. Moreover, the left breast was significantly more often larger in the scoliotic series of girls. On the other hand, there was no significant difference in the frequency of breast asymmetry in respect of the classifications according to curve type (right convex thoracic vs. other types) and to Cobb angle (35 degrees or less vs. more than 35 degrees).

The thermal emission from the skin and the vascularity of the breasts in normal and scoliotic girls.

The vascularity of the breasts was examined by thermographic and diaphanographic methods in normal and scoliotic girls. The thermal emission from the skin registered with an AGA Thermovision 750 camera (Stockholm, Sweden) on black and white Polaroid film was evaluated visually by 10 independent observers. No significant differences between the thermal images of the left and the right breast were found in the control or scoliotic groups or in girls with a right convex thoracic curve, nor was there any significant difference between the groups in this respect. Image analysis of diaphanograms of the breasts using the GOP 300 system showed a significantly greater vascularity of the left breast than of the right, both in the scoliotic series as a whole and in the subgroup with a right convex thoracic curve, but not for the reference group. The vascularity of the left breast but not of the right one was significantly greater for the girls with a right convex thoracic curve than for the control group. The results of the diaphanographic study confirm earlier observations and together provide substantial evidence that unilateral stimulation of rib growth due to a greater vascularity of the left breast and the underlying costosternal junctions might be one initiating factor in the development of right convex thoracic idiopathic scoliosis in adolescent girls.

The length and ash weight of the ribs of normal and scoliotic persons.

The length and ash weight of ribs were studied in cadaveric specimens from 10 women and eight men with normal spines and from 15 women with scoliosis, six of them with idiopathic right convex thoracic curves. In each case, three rib pairs were removed, those from the scoliotic women corresponding to the apex and the suprajacent and subjacent vertebrae, and those from the normal male and female subjects usually being the 7th-9th. Between the female and the male control groups, there was a significant difference in rib length asymmetry, expressed as the mean of the left minus right difference for the three rib pairs for each person. The difference in ash weight was not significant. There was a significant mean difference in rib length asymmetry between the six patients with right convex thoracic idiopathic scoliosis (concave minus convex rib) and the group of normal females (left minus right rib). Ash weight displayed no significant differences. In five of the six patients with right convex thoracic scoliosis the left ribs of the three examined pairs were on average longer than the right ribs, but the difference was not significant.

Isotope scanning with Tc99m-MDP of the spine and the costosternal junctions of patients with idiopathic scoliosis.

Bone scanning of the thoracolumbar spine and the anterior thorax was performed in 7 girls with recently diagnosed progressive thoracic idiopathic scoliosis. A reference group consisted of a group of 8 patients submitted to bone scanning for other reasons. In all 7 girls composing the scoliosis group the isotope uptake by the vertex vertebra, the 2 vertebrae above and the 2 below was homogeneous, with no areas of abnormally increased uptake. In 5 of these patients where quantitative studies were performed there was no significant difference in uptake between the vertex and the other 4 vertebrae. Nor did the 2 groups differ significantly as regards the left-right difference in uptake by the costosternal junctions. The results of this investigation confirm the observation in a preliminary study that there was no disturbance of spinal growth during the early stage of development of idiopathic thoracic scoliosis. However, the results do not support a tentative conclusion drawn on the basis of the preliminary study--namely, that the development of spinal deformity in idiopathic scoliosis might be ascribed to asymmetric longitudinal rib growth, reflected in asymmetric isotope uptake by the paired costosternal junctions. It is questionable however, whether scintigraphic scanning can provide an accurate procedure for quantitative measurement of skeletal growth of the ribs, especially in scoliotic patients.

Anthropometric data relating to normal and scoliotic Scandinavian girls.

The increase in height and weight and the age at the menarche have been determined in girls with idiopathic scoliosis and in age-matched normal girls. The scoliotic girls were classified according to the position of the curve. The menarche was found to occur significantly later in girls with either a thoracolumbar or a double primary curve than in the control group; it was also significantly later in those two groups combined than in the girls with a right convex thoracic curve. At the time of the menarche, the girls with a thoracolumbar or a double primary curve were significantly taller than those in the control group. The girls with a double primary curve, and these together with girls with a thoracolumbar curve, were also significantly taller than those with a right convex thoracic curve. Those in the control group were significantly heavier, and in some age groups significantly taller, than children born during the period 1953-1958 and providing earlier Swedish research data. The average age at the menarche did not differ from that for a normal population for this country. The observed differences between the group with a right convex thoracic curve and that with a thoracolumbar or a double primary curve indicate that the pathomechanism, and even the etiology, may vary with the form of idiopathic scoliosis.

Scoliosis. Experimental and clinical studies.

The hypothesis, advanced on the basis of experimental and clinical observations, that asymmetric growth of the ribs may be the primary cause of the thoracospinal deformity at least in some cases of right convex, thoracic, idiopathic scoliosis finds further support in the results of the anthropometric studies referred to below. There is also the possibility that asymmetric growth and more pronounced vascularization of the often larger breast may stimulate enough longitudinal growth at the underlying costosternal cartilage to upset the balance of forces acting on the normal spine. Muscular and other mechanical forces might be responsible for the further development of the deformity. Whether the data and evidence in this article will ultimately support or advance the hypothesis presented above remains to be seen. However, this hypothesis and the observations reported to date would seem to be capable of explaining the main characteristics of at least some cases of thoracic idiopathic scoliosis, i.e., the predominance in girls, the occurrence in the teens, and the predominant right convexity.