The surgical treatment of congenital kyphosis.

STUDY DESIGN: Retrospective study with clinical and radiologic evaluation of 15 patients with congenital kyphosis or kyphoscoliosis who underwent anterior instrumented spinal fusion for posterolateral or posterior hemivertebra (HV). The management of congenital kyphosis has been described in the literature using a variety of techniques. The presentation of patients at diagnosis is discussed. The question of when to begin treatment is reviewed. The pitfalls in the management and how to avoid these are discussed. The different published techniques are reviewed. We present our own techniques and our results of treatment of congenital kyphosis in very young children. OBJECTIVE: To evaluate the safety and efficacy of early surgical anterior instrumented fusion with partial preservation of the HV in the treatment of progressive congenital kyphosis in children below the age of 3. We discuss the management of patients presenting with neurologic compromise. We aim to systematically review the literature and to present our own experience in the management of these deformities, so that the issues common to treating physicians may be explored. SUMMARY OF BACKGROUND DATA: A variety of treatments have been described in the literature for the treatment of congenital kyphosis due to HV. We report the results of our technique. METHODS: Between 1997 and 2005 we have treated 15 consecutive patients with progressive congenital kyphosis with anterior instrumented fusion and strut grafting. Thirteen patients had a single posterolateral HV and 2 patients had a single posterior HV. Of the 15 patients in the study, 5 were girls and 10 boys. Mean age at surgery was 22 months (range, 8-33). Mean follow-up period was 6.8 years. Thirteen HV were located in the thoracolumbar junction (T10-L2) and 2 in the thoracic spine. RESULTS: The average operating time of procedure was 150 minutes (range, 130-210 minutes). The average blood loss was 180 mL (range, 100-330 mL), equivalent to a mean external blood volume loss of 15% (range, 11%-24%).Preoperative segmental Cobb angle averaging 34 degrees at last follow-up. Compensatory coronal cranial and caudal curves were corrected by 50%. The angle of segmental kyphosis averaged 39 degrees (range, 20 degrees-80 degrees) before surgery and 21 degrees (range, 11 degrees-40 degrees) at last follow-up. This represents a 43% of improvement of the segmental kyphosis, and a 64% of improvement of the segmental scoliosis at last follow-up. One case with initial kyphosis of 80 degrees continued to progress and required revision anterior and posterior surgery. There were no neurologic complications.

Congenital spinal deformity: a comprehensive assessment at presentation.

STUDY DESIGN: A series of 126 consecutive patients with congenital spinal deformity is presented. OBJECTIVE: To assess the incidence of intraspinal anomaly and other organic defects associated with different types of spine deformity at presentation. SUMMARY OF BACKGROUND DATA: A high incidence of intraspinal abnormalities and other organ defects is reported in relation to congenital spine deformity. The prevalence of these problems with different types of deformities is to be determined. METHODS: All patients had MRI, echocardiography, renal ultrasound, and a thorough clinical assessment. RESULTS: Intraspinal abnormalities were found in 47 patients (37%). These abnormalities were significantly more common in patients with congenital kyphosis ( = 0.0048), and in those with scoliosis resulting from mixed and segmentation defects. Scoliosis patients with cervical and thoracic hemivertebrae had significantly more intraspinal abnormalities ( = 0.0253) than those with lumbar hemivertebrae. In 64 (55%) patients other organic defects were found. These defects were more common in patients with congenital scoliosis resulting from mixed defects ( = 0.002). Cardiac defects were detected in 26% and urogenital anomalies in 21% of the patients. CONCLUSIONS: Magnetic resonance imaging and echocardiography should be an essential part in the evaluation of patients with congenital spinal deformity, and special attention should be paid to patients with segmentation abnormalities, mixed defects, and kyphosis.

Anterior instrumented fusion for thoracolumbar kyphosis in mucopolysaccharidosis.

STUDY DESIGN: A case series of seven children who had a thoracolumbar gibbus related to mucopolysaccharidosis treated with anterior instrumentation were reported retrospectively. OBJECTIVE: To describe a new technique for treating progressive thoracolumbar kyphosis in children with mucopolysaccharidosis. SUMMARY OF BACKGROUND DATA: Management of this condition is not well represented in the literature. Isolated reports on the surgical management of this disorder appear, but there is no previous report of correction performed anteriorly. METHODS: Seven patients underwent anterior instrumentation for correction of a thoracolumbar gibbus not arrested by brace treatment. Preoperative kyphosis ranged from 42 degrees to 64 degrees (average, 52.5 degrees ). Data on all seven patients were collected prospectively. The technique and its principles are described. RESULTS: A good correction of the kyphosis was obtained, with postoperative angles of 3 degrees to 29 degrees (average, 15 degrees ), and maintained through the follow-up period. There were no complications from the procedure. CONCLUSION: Anterior instrumented correction and fusion of the spine is effective in treating thoracolumbar kyphosis associated with mucopolysaccharidosis.

Spondylolisthesis in osteogenesis imperfecta due to pedicle elongation: report of two cases.

STUDY DESIGN: Two cases of spondylolisthesis due to severe elongation of pedicles in osteogenesis imperfecta are reported. OBJECTIVE: To describe an unusual type of spondylolisthesis and its successful management. SUMMARY OF BACKGROUND DATA: Spondylolisthesis is known to occur in osteogenesis imperfecta. Reports in the literature are few. Pedicle elongation resulting in spondylolisthesis has only been reported once. There is no report of a successful treatment of this type of spondylolisthesis resulting from pedicle elongation. METHOD: Two adolescent girls suffering from osteogenesis imperfecta presented with lower back pain and thoracic scoliosis. One of them had high-grade spondylolisthesis of L3-L4, L4-L5, and L5-S1, with a thoracic scoliosis. She was treated with anterior interbody fusion L3 to sacrum without instrumentation. Later, progression of her scoliosis required combined anterior and posterior instrumented fusion T1 to L1. The other girl presented with L5 spondylolisthesis and thoracic scoliosis. She has back pain as well as neurologic symptoms in her legs and is waiting for surgery. RESULTS: At the 3-year follow-up the operated patient is symptom-free from her spine and there has been no progression of either deformity. CONCLUSION: High-grade spondylolisthesis due to elongation of pedicle in osteogenesis imperfecta is uncommon. Anterior interbody fusion of all the involved motion segments has produced good pain relief and arrested deformity progression at the 3-year follow-up.

Spinal cord monitoring in neuromuscular scoliosis.

This article reviews the use of spinal cord monitoring in neuromuscular scoliosis, a condition having a higher incidence of true positive results than idiopathic scoliosis. While somatosensory cortical evoked potentials (SCEP) are unreliable, somatosensory spinal evoked potentials (SSEP) are possible to obtain in most cases and a method using an epidural electrode is described. The '50% rule' is satisfactory having good specificity and sensitivity with it rare for post-operative paralysis to have occurred undetected. The spinal cord in these cases appears to have increased susceptibility particularly during the passage of sublaminar wires with the incidence of complications reduced using modern instrumentation.

Blood loss in Duchenne muscular dystrophy: vascular smooth muscle dysfunction?

Patients with Duchenne muscular dystrophy (DMD) tend to bleed more during surgery than do patients with other conditions. A retrospective analysis of blood loss after spinal surgery for scoliosis was therefore undertaken in 102 patients undergoing surgery in the senior author's unit. These included 48 patients with DMD, 26 patients with spinal muscular atrophy, and a miscellaneous group of 28 other patients most of whom had idiopathic scoliosis. For each patient the age at surgery, estimated blood volume, duration of operation, Cobb angle, and number of vertebrae fused were recorded and compared. Expression of dystrophin in skeletal muscle and the underlying gene mutation were also determined. The estimated blood loss in patients with DMD was significantly higher than that in patients with spinal muscular atrophy undergoing the same or similar procedure (P < 0.005) and was also significantly greater than that of the third group, which consisted mostly of patients with idiopathic scoliosis (P < 0.0005). Blood loss in the patient group with DMD showed a significant relationship with duration of surgery (P < 0.05). As most patients expressed no dystrophin, this did not correlate with the estimated blood loss. There was also no correlation between the estimated blood loss and the type of gene mutation found causing DMD. The authors' previous observations confirm the increased blood loss in patients with DMD who undergo scoliosis surgery. Because children with DMD lack dystrophin in all muscle types, including smooth muscle, the excessive blood loss may be because of a poor vascular smooth muscle vaso-constrictive response due to a lack of dystrophin.

Spinal growth and a histologic evaluation of the Risser grade in idiopathic scoliosis.

STUDY DESIGN: Thirty-four patients with idiopathic scoliosis who underwent anterior spinal surgery as part of the correction of spinal deformity were studied prospectively. Superior and inferior endplates were harvested and examined histologically for evidence of residual growth activity. This was then correlated with Risser grades, chronologic age, and pubertal status. OBJECTIVES: To clarify the correlation between Risser grade and vertebral endplate growth potential in patients with idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: The importance of longitudinal spinal growth in patients with idiopathic scoliosis and its correlation with curve progression and the crankshaft phenomenon after posterior fusion are well recognized. The Risser grade, which shows the extent of excursion of the iliac apophysis on serial plain radiographs, is commonly used to estimate residual spinal growth. However, the correlation between the Risser grade and vertebral endplate growth potential in patients with idiopathic scoliosis remains unclear. METHODS: Superior and inferior endplates were harvested from these patients and examined histologically for evidence of residual growth. This was correlated with Risser grade, chronologic age, and pubertal status. RESULTS: Risser Grade 5 was found to be the only indicator of cessation of vertebral growth in idiopathic scoliosis. Of the 14 patients with Risser Grade 4, 10 showed significant growth activity in the vertebral endplates. The reliability of Risser Grade 4 increases when combined with chronologic age and time since menarche in female patients. CONCLUSIONS: The crankshaft phenomenon is reported to occur only in patients with Risser Grade 2 or less, particularly those with open triradiate cartilages. Our findings of significant endplate growth activity, even in patients with Risser Grade 4, make it unlikely that the crankshaft phenomenon is caused purely by longitudinal spinal growth.

Langerhans' cell histiocytosis of the spine: use of MRI in guiding biopsy.

The MRI features of two cases of spinal Langerhans' cell histiocytosis with multilevel involvement are presented in which MRI was of help in differentiating active from inactive healing lesions by the demonstration of signal changes in the vertebral body marrow of the active lesion, manifest as low signal intensity on T1-weighted sequences and high signal intensity on T2-weighted sequences. This distinction could not be made by plain radiography or bone scintigraphy. In cases where biopsy is required for diagnosis, MRI is recommended to guide the biopsy towards levels suggestive of active involvement.

Spinal cord monitoring in operations for neuromuscular scoliosis.

We reviewed retrospectively the role of monitoring of somatosensory spinal evoked potentials (SSEP) in 99 patients with neuromuscular scoliosis who had had operative correction with Luque-Galveston rods and sublaminar wiring. Our findings showed that SSEP monitoring was useful and that a 50% decrease in the amplitude of the trace optimised both sensitivity and specificity. The detection of true-positive results was higher than in cases of idiopathic scoliosis, but the method was less sensitive and specific and there were more false-negative results. In contrast with the findings in idiopathic scoliosis, recovery of the trace was associated with a 50% to 60% risk of neurological impairment. Only one permanent injury occurred during the use of this technique, and any temporary impairment resolved within two months.

Multiple guide wire technique for removal of the short distal fragment of a fractured intramedullary nail.

A method of removing a short distal fragment of a fractured intramedullary nail, using impacted olive-tipped guide wires, is described. We have used this technique with success when there has been a very short segment of nail left distally. This method gives improved grip and control of alignment of the nail fragment during extraction.

Cyclical micromovement and fracture healing.

We studied 56 patients with fractures of the tibial shaft in a multicentre prospective randomised trial of three methods of external fixation. Group I was treated with a fixator which was unlocked at 4 to 6 weeks to allow free axial compression (axial dynamisation) with weight-bearing. Group II was treated with a fixator that was similarly unlocked at 4 to 6 weeks but included a small silicone spring which on weight-bearing could be compressed by up to 2 mm. this spring returns to its original length on cessation of weight-bearing thus allowing cycles of motion of up to 2 mm. Group III had a spring fixator like group II, but it was unlocked from the start to allow cyclical micromovement as soon as weight-bearing began. Fracture healing was monitored by the measurement of fracture stiffness. We defined healing as achieving a stiffness of 15 Nm per degree. The mean time was 14.1 weeks in group I, 15.9 weeks in group II, and 19.3 weeks in group III. The difference between groups was statistically significant (p = 0.004). The 95% confidence intervals for the average delay in healing with early cyclical micromovement (group III) as compared with later axial dynamisation (group I) was 1.8 to 8.7 weeks. The healing time in patients whose cyclical micromovement was delayed for 4 to 6 weeks (group II) was between these two extremes, but the differences from either of the other groups could have been due to patient selection. In the patients who completed the full trial, there were pin-track infections in over 60% of those in the cyclical micromovement groups compared with 20% in the axial dynamisation group (p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Syringomyelia. A potential risk factor in scoliosis surgery.

STUDY DESIGN: An 18-year-old patient with "idiopathic" adolescent scoliosis is presented. A thoracic syrinx was detected as an incidental finding during magnetic resonance imaging of the spine. OBJECTIVES: Syringomyelia may be a risk factor for neurologic injury during correction of scoliosis, and in these cases, spinal cord monitoring may be of particular value. BACKGROUND DATA: Spinal distraction and instrumentation carry a risk of neurologic damage in patients with scoliosis and associated syringomyelia. Syringomyelia is a cause of scoliosis, and although neurologic problems are the usual symptom, scoliosis may be the only sign at initial examination. A higher risk of neurologic injury has been reported in corrective surgical treatment of patients with syringomyelia. The mechanism of cord damage is unclear. Monitoring of spinal cord function is recommended to detect intraoperative neurological injury, which may be reversed on removing distraction and implants. RESULTS: Intraoperative somatosensory-evoked potential (SSEP) spinal cord monitoring detected possible cord damage during outrigger distraction. Reduction of distraction led to a recovery of SSEPs and a satisfactory operative outcome. CONCLUSION: Syringomyelia may be a risk factor for neurologic injury during correction of scoliosis, and SSEP spinal cord monitoring may identify and prevent intraoperative spinal cord injury.

Pin placement in pelvic external fixation.

Early external fixation of major pelvic fractures reduces haemorrhage and mortality. The best site and method for pin placement remains unresolved. The superior iliac crest is biomechanically disadvantageous and hinders access to the abdomen. Low pin placement between the anterior iliac spines has been proposed as a better solution. A case-controlled study was performed on cadavers using a jig designed to place external fixator pins accurately in the pelvis; the study tested the safety of pin placement and the mechanical strength of the two placement sites. The results showed that pins could be placed safely using this method and that low placement in cadaveric bone is as strong as that of the conventional placement.

Hazard of ionizing radiation to trauma surgeons: reducing the risk.

A study aimed to establish the level of radiation exposure to orthopaedic surgeons involved in the care of injured patients; parts of the body most at risk, and to establishing whether surgeon control of X-ray image intensification reduced the risk. This was conducted on five orthopaedic surgeons regularly involved in musculoskeletal care. Radiation dosage (in millisieverts (mSv) to the body, neck, eyes and hands, was measured by means of dosimeters applied to these areas, before and after surgeon-controlled use of X-ray image intensification. Although all doses measured were within current safety guidelines (1.25 mSv total body dose/month, 3.75 mSv eye dose/month and 12.5 mSv extremity dose/month), the hands were most at risk (maximum recorded dosage 3.95 mSv/month). Control by the surgeons of X-ray image intensification significantly reduced exposure of the hands (P < 0.05).

Unrecognised joint penetration in treatment of femoral neck fractures.

Screw devices used to treat fractures of the femoral neck are usually positioned under image-intensifier control, using anteroposterior and lateral views. The volume projected by these views is over 27% larger than the femoral head; the tips of screws so placed may be outside the femoral head. This can be avoided by placement within the central two-thirds of the head: we have designed a template which can confirm safe placement.

Case report of an unusual cause of low back pain. Intervertebral diskitis caused by Eikenella corrodens.

A 42-year-old man suffered from low back pain caused by intervertebral diskitis. The condition was diagnosed on plain roentgenogram and computed tomography scans. The infected area was biopsied and grew Eikenella corrodens, a gram-negative anaerobic rod, which grows slowly only after culture on blood agar in 5-10% carbon dioxide. This is the first reported case of E. corrodens intervertebral diskitis causing acute low back pain. Recognition of this organism in this condition emphasizes the importance of aerobic and anaerobic cultures of infected disks. The organism has unusual antibiotic sensitivities. The infection, once appropriately treated, responded rapidly.

Anterior dislocation of the shoulder: a simple method of reduction.

An effective method for reducing anterior dislocation of the glenohumeral joint which does not require either sedation or traction is described. The patient performs the manoeuvre. A series of 32 consecutive patients were treated by this method. Easy reduction was achieved in 72 per cent, with no complications and patients spent less than half as long in the accident and emergency department as when it is not successful. We recommend this simple technique as a first method of reduction in patients presenting to accident and emergency departments.

Remanipulation or external fixation after slipped Colles' fractures? An anatomical study.

A series of 50 consecutive patients with Colles' fractures which redisplaced after reduction underwent either remanipulation and a plaster cast or remanipulation and external fixation. The external fixator group achieved a significantly better anatomical result than simple remanipulation and replastering. Where plaster immobilization has failed, external fixation gives a better anatomical result than remanipulation and replastering.