Repair of a pseudarthrosis of the lumbar spine. A functional outcome study.

Eighty-six patients had a total of eighty-eight primary attempts at repair of a pseudarthrosis that had developed after a localized arthrodesis in the lumbar spine. A follow-up questionnaire was sent to all patients at a mean of fifty-one months (range, twenty-five to seventy-eight months) after the operation; seventy-two patients (84 percent) completed to questionnaire. A solid fusion was ultimately achieved after the treatment of eighty-one (94 percent) of the eighty-six pseudarthroses for which radiographic data were available. With the numbers available, we could find no significant association between a solid fusion and the patient's age, gender, body-mass index, return to work, or outcome score. Despite the high rate of fusion after the index repair and subsequent procedures, only nineteen (26 percent) of the seventy-two patients who completed the questionnaire eventually had a good or excellent outcome. Seven (10 percent) had an excellent result (90 to 100 points), twelve (17 percent) had a good result (70 to 89 points), fourteen (19 percent) had a fair result (50 to 69 points), and thirty-nine (54 percent) had a poor result (less than 50 points). Nevertheless, fifty-one patients (71 percent) reported that the operation led to some improvement, and fifty-five (76 percent) said that they would have the operation again if the circumstances were similar to those before the repair of the pseudarthrosis. Thirty-four of the seventy-two patients were smokers and thirty-eight were non-smokers at the time of the operation. There was a negative linear association between the outcome scores and the number of pack-years (p = 0.02). Cessation of smoking before the operation positively affected the outcome; the patients who had stopped smoking had a mean outcome score of 65 points, compared with 45 points for those who had not stopped (p = 0.03). Patients who had stopped smoking were also more likely to return to work full time (p < 0.001). At the latest follow-up evaluation, twenty of the seventy-two patients had returned to full-time employment. Patients who had been receiving Workers' Compensation at the time of the operation generally did poorly on the outcome questionnaire, but, with the numbers available, they did not have a significantly different rate of solid fusion than patients who had not been receiving Workers' Compensation. Also, the outcome score and the rate of fusion were nor significantly affected by age or by obesity.

Osteogenesis imperfecta. Radiographic classification, natural history, and treatment of spinal deformities.

The natural history of the radiographic changes associated with osteogenesis imperfecta was recorded for sixty-four patients. Detailed clinical data regarding spinal deformities were available for forty-three patients. The patients could be placed in six well defined groups on the basis of a cluster of radiographic changes. The radiographic criteria used to classify patients who had osteogenesis imperfecta included the shape, dimensions, and appearance of the long bones; the presence of a trefoil pelvis and protrusio acetabuli; and the shape of the vertebrae. Patients can be classified more accurately if the dynamic nature of the radiographic changes is appreciated. Patients who had Type-A disease, a mild form of osteogenesis imperfecta, maintained the contours of the vertebrae. Most had straight long bones except for five patients who had mild bowing. Patients who had Type-B disease had bowed long bones with wide cortices. The pelvis had a normal contour. The vertebral bodies were biconcave, and kyphosis and scoliosis developed. Patients who had Type-C disease had thin, bowed long bones, and protrusio acetabuli developed around the age of ten years. Patients who had Type-D disease had the same findings as those who had Type-C disease, with the additional finding of cystic changes around the knee by the age of five years. The physes closed early, and the cysts disappeared around the age of fifteen. Patients who had Type-C or D disease had development of severe spinal deformities. Patients who had Type-E disease were totally dependent functionally, and spinal deformities developed at a very early age. The long bones appeared to have no cortex. Patients who had Type-F disease had complete disruption of the ribs, which was incompatible with survival. The natural history of scoliosis in the patients who had Type-B, C, D, or E disease was one of progression of the curve. Bracing used in the treatment of scoliosis in one patient who had Type-E disease and five patients who had Type-C disease was unsuccessful. Arthrodesis of the spine prevented progression of the spinal deformities in patients who had Type-A disease, but the results of the operation were variable in the remaining types of the disease.

The spine in osteogenesis imperfecta.

The natural history and treatment of spinal deformity is presented in light of the radiographic severity of the disease. The radiographic findings are grouped according to the changes over time and are prognostically significant for ambulation, spinal deformity, and life span.

Resection of heterotopic ossification in the adult with head trauma.

Lesions of heterotopic ossification were excised from thirty-seven joints in twenty-three adults who had had injuries to the brain. The lesions were excised from twenty-three elbows, twelve hips, and two shoulders. Patients were retrospectively divided into five categories according to the neural residua (cognitive and physical deficits). The patients in Class I (minimum cognitive and physical disability) and patients in Class II (minimum cognitive disability and moderate physical disability) who had fair or good selective control of the affected extremity had the best prognosis for maintaining the range of motion resulting from resecting the lesion and improving function postoperatively. They also had a low incidence of recurrence of the lesion. Seven of the nine elbows and eight of the eight hips in patients in these classes had successful results. All three of the patients in Class V (severe cognitive and physical deficits) who had a lesion of the hip and all eight of the patients in Class V with poor selective control had a poor result. In the twenty-five joints for which adequate follow-up radiographs were available to determine if the lesion recurred, fourteen recurrences were identified (56 per cent). Eleven of these patients were considered to have a poor result. Nine of the fourteen recurrences occurred in patients in Class V. Radiographic evidence of the maturity of the lesion and a normal level of alkaline phosphatase were of limited importance in predicting a low rate of recurrence. The over-all complications included four superficial infections and no instances of osteomyelitis.(ABSTRACT TRUNCATED AT 250 WORDS)