The surgical management of Scheuermann's disease.

Thirty patients of a group of 39 patients with Scheuermann's kyphosis who underwent posterior spine fusion using large-diameter Harrington compression instrumentation were reviewed with a mean follow-up of 71.8 months. The mean curve before surgery was 71.5, and at follow-up, 37.7. The mean loss of correction at review was 6. This procedure was effective in adults with a fixed deformity as long as no anterior bony bridging existed. The authors believe that posterior Harrington instrumentation and spine fusion offer excellent correction of deformity at long-term follow-up without the added morbidity of a second procedure.

Long-term lumbar facet joint changes in spinal fracture patients treated with Harrington rods.

Reports in the literature have questioned the practice of using Harrington distraction rods spanning unfused spinal segments for internal fixation of the fractured thoracolumbar spine. However, the long-term incidence of facet joint osteoarthritis has not been reported. This is the report on a retrospective analysis of 20 of these patients with an average follow-up period of 8.0 years. Eighty-five percent of the patients received a classification of good to excellent regarding back pain and 90% returned to their preinjury occupation. Of significance, of 75 lumbar facets traversed by rods but not fused, only two were classified as "closed" or autofused. It remains to be seen if some pedicular systems are superior to this technique in trained hands. However, multisegmental instrumentation with unisegmental fusion is possible without obtaining the severe osteoarthritic changes that animal studies have demonstrated.

Thoracolumbar fractures in ankylosing spondylitis. High-risk injuries.

Ankylosing spondylitis may affect the spine segmentally or diffusely. Because all the ligaments become ossified in the involved areas, fractures that occur through this involved segment traverse both bone and ligaments, producing an extremely unstable situation similar to a shearing type of fracture. With a pre-existing severe kyphosis, it may be dangerous to turn the patient to a supine position, because this opens up the fracture and can cause neurologic complications. The radiologic assessment of the spine in ankylosing spondylitis is difficult because the bone is frequently osteoporotic and the disc spaces are poorly outlined. Minor displacements should be looked for, as well as discontinuity of ossified ligaments (especially the interspinous ligaments). Of the seven patients reported in this series, six had fractures undiagnosed at the time of the preliminary examination. Therefore, patients known to have ankylosing spondylitis should be counseled regarding the possibility of a fracture, and if pain persists after an injury, they should be thoroughly investigated radiologically to rule out a potentially serious problem. Reduction of the displacement and stabilization is best achieved with a Luque rectangular rod system, and laminectomy is not indicated.

A contoured anterior spinal fixation plate.

There is a need for a specifically designed plate for anterior fixation of the vertebral bodies, contoured to fit closely around the lateral aspect of the spine and wide enough to allow multiple options for placement of at least three screws in each vertebra. The large-diameter cancellous screws should penetrate the opposite cortex. Existing bone plates are inadequate, because they are too narrow and do not allow positioning of more than two screws in each vertebra. The Biomedical Engineering Department of the National Research Council of Canada designed and tested the plate described in this article, with particular attention to providing smooth surfaces to prevent vascular complications. Three lengths of plates have been developed and are used in the area from T11 to L5, with a specific tapered plate for the L5 area to prevent contact with the overlying iliac vessels. This device should be used for stabilization following corpectomy for tumor, decompression of burst fractures, severe disc degeneration, pseudarthrosis, and the multiply operated back.

Acute thoracolumbar burst fractures in the absence of neurologic deficit. A comparison between operative and nonoperative treatment.

The treatment of thoracolumbar burst fractures in the absence of neurologic deficit remains controversial. The present study is a retrospective analysis of 52 of these acute burst fractures among 104 cases of thoracolumbar burst fractures treated either operatively or nonoperatively. Results are expressed in terms of neurologic function, pain, work status, and complications. All patients who had surgical treatment and no unrelated disability returned to full-time work. Twenty-five percent of the patients treated nonoperatively were unable to return to work full time. Of the patients in the nonoperative group, 17% developed neurologic problems. Prophylactic stabilization and fusion of acute burst fractures without neurologic deficit have significant advantages over conservative management.

Spinal epidural lipomatosis: a complication of glucocorticoid therapy.

A 21-year-old woman receiving prolonged high dosage glucocorticoids developed spinal cord compression due to excessive accumulation of epidural fat. Computerized tomographic scanning confirmed the diagnosis and revealed a peculiar pattern of spinal cord displacement which we believe to be unique to compression by fat. Laminectomy did not afford relief, possibly because of prolonged neural compression or because of compression at a higher spinal level. Although an unusual complication of Cushing's syndrome, epidural lipomatosis should be considered when such a patient develops symptoms of spinal cord or cauda equina compression.

Scoliogenic osteoblastoma of the posterior end of the rib. A case report.

True back pain is uncommon in children and adolescents. The authors report a case of scoliosis associated to osteoblastoma in a very unusual site--the rib. This particular location was reviewed in the literature and appears to have an incidence of 0.41% as compared with osteoid osteomas and osteoblastomas in general. The case reported was a 14-year-old girl presenting with a 32 degree scoliosis that reduced to 9 degrees after excision of the lesion. The authors recommend personal review of bone scans as poor communication between the orthopedic surgeon and the isotope expert may make an osteoblastoma be interpreted as a radiographic artifact.

Nonstandard vertebral rotation in scoliosis screening patients. Its prevalence and relation to the clinical deformity.

A total of 6,321 school children were screened using Moiré topography in Ottawa in 1979. Analyses of 400 roentgenograms showed that 39% had rotation of a nonstandard variety. The most common type was rotation extending beyond the end vertebra by more than one level. Seven percent had rotation to the opposite side of the major curve; 4% showed asymmetry due to isolated vertebral rotation without any lateral curve. The correlation of the Moiré hump to the area of the lateral curve and vertebral rotation is recorded.

Moiré topography in scoliosis screening.

Moiré topography, a simple technique for three-dimensional quantitation, was used to provide interference fringe photographs of the human back with sufficient accuracy to be used for detecting children with asymmetry due to scoliosis. Experimental equipment, built and tested at the National Research Council of Canada, was used in a pilot screening program, involving 1100 children from the 10 to 12 year age group. Each child was examined clinically by the bending test and photographed by the moiré method. All subjects with positive bending tests, asymmetrical fringe patterns or both were submitted to radiographic examination and the results correlated. The moiré technique disclosed 94% of the cases which were found to be positive by X-ray examination, while the bending test disclosed only 46%. The percentages of false positive results were approximately the same for the 2 screening methods.

A transverse loading system applied to a modified Harrington instrumentation.

Observations using standard Harrington Instrumentation revealed that while maximal distractive forces are applied it is possible to produce further correction of spinal deformity by applying a lateral force. Modifications to the standard Harrington Instrumentation by applying a transverse loading system have been made in order to produce this added correction. The transverse load is applied as nearly as possible in the same plane as the bearing points of hooks, i.e., below the axis of the rods. Transverse loading helps to reduce the distance from the apex of the curve to the midline, thereby producing a more stable spine as well as providing additional support on the convex side. The system is ideal for flexible curves with little kyphosis. Photogrammetry reveals that there was no significant rotation occurring after the application of the transverse load. To date, Instrumentation has been used in 10 patients with success.