Polysegmental lumbar posterior wedge osteotomies for correction of kyphosis in ankylosing spondylitis.

Between 1984 and 1993 we treated 21 consecutive patients who had progressive thoracic kyphosis due to ankylosing spondylitis by polysegmental posterior lumbar wedge osteotomies. In 19 patients we used the Universal Spinal Instrumentation System and in the last 2 patients the H-frame. The average correction in 20 of 21 patients at follow-up was 25.6 degrees (range 0 degrees-52 degrees), with a mean segmental correction of 9.5 degrees and a mean loss of correction after operation of 10.7 degrees (range 0 degrees-36 degrees). There were no fatal complications, but in one patient no correction could be obtained during surgery and another patient was reoperated due to lack of correction. Breaking out of screws through the pedicle during compressive correction was seen in seven patients. Implant failure, such as breakage of the threaded rods and/or loosening of the junction between the pedicle screw and the rod, occurred in 9 out of 21 patients. Two patients required reoperation at long-term follow-up. Five out of seven deep wound infections required removal of the implant. Polysegmental lumbar wedge osteotomies for correction of progressive thoracic kyphosis in ankylosing spondylitis is only recommended in patients at a mild stage of the disease with mobile discs and in combination with strong instrumentation.

[One hundred years of orthopedics in the Netherlands. IV. Spinal abnormalities]. / Honderd jaar orthopedie in Nederland. IV. Wervelkolomaandoeningen.

In recent years there has been spectacular progress in the approach to various disorders of the spinal column. Owing to improved methods of osteosynthesis there is no longer so much need for long periods of postoperative bed rest. Of all the scolioses, idiopathic scoliosis is most common. The vast majority of these cases are not clinically significant. What is seen in the remaining cases if left untreated is a progression in the curvature during growth. Progressive idiopathic scoliosis can be effectively treated using conservative methods. Screening at school is an important part of this process. If the curvature proves progressive and skeletal growth is not complete a brace can be prescribed. Use of this strategy and form of treatment can avoid progression of the curvature and development of serious deformities. This conservative therapy has markedly reduced the need for corrective surgery. Scheuermann's disease is characterized by a fixed dorsal thoracic kyphosis. Progressive Scheuermann's kyphosis can be effectively treated using a brace. The majority of fractures of the vertebral bodies can be treated conservatively. However, serious fractures normally require surgical intervention. In the industrialised Western world, low back pain is a major health problem and the foremost cause of disability and unfitness for work. Low back pain caused by degenerative disease of the spinal column should be treated using a multidisciplinary approach. The development of advanced operative techniques and osteosynthesis methods has made it possible to treat metastases of the spine surgically. The effects of this treatment on the quality of life are encouraging.

Anterior instrumentation of the spine in thoracic and thoracolumbar fractures: the single rod versus the double rod Slot-Zielke device.

STUDY DESIGN: This retrospective study analyzed the clinical and radiologic results of two groups of patients with unstable burst fractures of the thoracolumbar spine treated with anterior decompression, reduction of the kyphotic deformity, and stabilization by grafting and instrumentation. OBJECTIVE: To compare the results regarding loss of correction of two groups of patients treated with two different configurations of the same instrumentation, the so-called "Slot-Zielke" device. SUMMARY OF BACKGROUND DATA: Decompression of burst fractures and reduction of kyphotic deformity are facilitated by the anterior approach to the spine. The maintenance of reduction depends on the strength of the grafting material and on the rigidity of the internal fixation. METHOD: Forty consecutive patients with spine fractures underwent surgery for anterior decompression, reduction of kyphotic deformity, and stabilization by grafting and instrumentation. The first group of 25 patients (Group A) received a single rod "Slot-Zielke" device as an implant. The second group of 15 patients (Group B) received a double rod "Slot-Zielke" device. Before and at least 2 years after surgery, the kyphotic angle between the vertebrae above and below the fracture was measured. RESULTS: The clinical results at follow-up evaluation were similar between the groups. In Group A, 60% of the cases had a loss of correction of 5 degrees or more (least square mean, 5.64 degrees; range, 0-23 degrees). In Group B, the loss of correction in all cases was less than 5 degrees (least square mean, 1.60 degrees; range, 0-4 degrees). The difference between the average of both groups was highly significant (P = 0.014). CONCLUSION: The double rod instrumentation performs significantly better regarding loss of correction compared with the single rod instrumentation.

Correction of idiopathic scoliosis using the H-frame system.

To determine the effectiveness of posterior H-frame instrumentation for the surgical treatment of idiopathic scoliosis, 36 patients were studied. The patients underwent surgery between 1989 and 1993 and were evaluated for curve correction, hump correction, vertebral rotation, fusion level and complications. Average age at surgery was 19 years. Duration of follow-up averaged 2.5 years. Mean primary curve correction in patients with a King type I curve was 44.8% (n = 4) and in patients with a type II curve 67.3% (n = 9). Patients with King type III (n = 17) and IV (n = 6) curves achieved respective mean curve corrections of 67.8% and 63.9%. During follow-up there was a mean correction loss of 0.8% in type I, 5.4% in type II, 10.1% in type III and 2.4% in type IV curves. No significant derotation of the primary curves was noted. Rib hump correction and rotational changes of the unfused compensatory curves were significant. Fusion levels extended beyond L2 in six cases. Major neurological problems did not occur. Pseudoarthrosis developed in one patient and imbalance in two patients. The H-frame system satisfactorily achieves curve and rib hump correction with little correction loss.

Rip hump correction and rotation of the lumbar spine after selective thoracic fusion.

In this study a series of 32 patients with idiopathic scoliosis, managed with selective thoracic fusion, was reviewed. Classified according to King and instrumented with the H-frame, the patients were evaluated for curve correction, rib hump correction and postoperative shift in lumbar rotation. Age and follow-up average 19.4 and 2.4 years, respectively. The 32 patients had an average primary and lumbar curve correction of, respectively, 66% (6.0% correction loss) and 53% (3.4% correction loss). The respective values for postoperative rib hump correction and shift in apical lumbar rotation averaged 8 degrees and 9.4 degrees in type II King curves 4.4 degrees and 3.5 degrees in type III and 11 degrees and -5 degrees in Type IV. Significant differences were noted between the curve types in rib hump correction and shift in lumbar rotation. The study showed that en bloc postoperative rotation of the compensatory lumbar segment, directed towards the rib hump, positively influences rib hump correction. This en bloc rotation of the unfused lumbar segments is induced by the correcting forces applied by the instrumentation. The unfused lumbar spine of a patient with a King type II curve shows a larger lumbar rotation shift and subsequent rib hump correction than that of a patient with a King type III curve. Together with factors such as lateral angulation, rib-vertebra angles and structural limitations, the rotational dynamics of the unfused lumbar spine seem to form an important component in the under-standing and surgical management of scoliosis.

Closing-wedge posterior osteotomy for ankylosing spondylitis. Partial corporectomy and transpedicular fixation in 22 cases.

From 1990 to 1993 we treated 22 consecutive patients who had progressive spinal kyphosis due to ankylosing spondylitis by a closing-wedge posterior vertebral osteotomy with partial corporectomy of L4 and transpedicular fixation. The average correction was 32 degrees (24 to 52) with a mean loss of correction after operation of 2.7 degrees (0 to 13). The average operating time was 185 minutes (135 to 240) and blood loss was 2500 ml (1200 to 5000). The osteotomy corrected all patients sufficiently to allow them to see ahead and their posture was improved. There were no fatal complications, but in two cases there was failure of the instrumentation and one patient needed reoperation for nerve compression. Two deep wound infections required removal of the implant and six patients had superficial skin infections under the plaster. The use of a circoelectric bed and intermittent prone lying eliminated this problem.

Treatment of spinal deformity in myelomeningocele: a retrospective study in four hospitals.

Correction of spinal deformities in patients with myelomeningoceles (mmc) is notoriously complicated. To identify the deformity, frequency, gravity and complications of treatment a retrospective study was carried out on 61 patients from four hospitals. 45 patients had neurological defect above L3 and were wheelchair-bound. The indications for surgery were progressive disturbance in sitting balance, pain and pressure sores. Two types of spinal deformity were identified; scoliosis (often thoraco-lumbar or double major curves) and kyphosis (usually angular and lumbar). The mean age at operation was 12 years 8 months (2y 6m-19y 7m). Several operative procedures were used; posterior, anterior and circumferential fusion, and resection of the kyphosis. 52 solid fusions were achieved with variable correction at the cost of many complications such as excessive blood loss (2), post-operative pressure sores (15), failure of instrumentation (15), deep infection (11), and death following a CSF leak (1). 4 patients died from unrelated causes. Only 16 patients had no complications. The type and severity of scoliosis and kyphosis, operative technique, results and complications were correlated to identify the risks and define the optimal surgical technique for each type of spinal deformity in mmc.

Current methods of dorsal spine fusion with pedical screws and presentation of a new method for treatment of fractures and low back instability.

A new instrumentation system, the H-frame system, has been developed for dorsal fusion in scoliosis, spinal fractures and degenerative low back problems. The basis is a prelinked slotted H-frame with two rods of 6-mm diameter with 5-cm threaded ends. There are 4 different lengths, solid in the middle and threaded at the ends. Connection with hooks and/or pedical screws is easy and stable. A slotted system using special conical nuts to grasp these hooks or screws tightly prevents loosening. For low back fusion in degenerative disease the slightly lordotic H-frame is connected to 4 screws. If needed, a sublaminar Luque wire may be added in between. Correction in lordosis with distraction or compression is possible. The fixation is very rigid in all directions with a minimum of implant material. For thoracolumbar fresh fractures 2 pedical screws are placed above and 2 screws below the fracture area, and an H-frame is inserted with one end fixed below and one end above the opposite side of the other rod. Because of the rotary section in the H-frame, the apparatus may be repositioned simply by pushing the frame with the two other screws under control of the H-frame cross-link connection. Distraction and correction of kyphosis is achieved with this simple movement at the same time. The total stable fixation needs no after-treatment. The method may also be used for scoliosis with a combination of hooks, screws and wires. Experience is still very limited. The apparatus has been used in the lumbar spine in more than 10 cases with over 6 months follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Osteotomy for kyphosis in ankylosing spondylitis.

Twenty-two patients suffering from progressive kyphosis due to ankylosing spondylitis underwent one or more lumbar osteotomies during 1957-1983. The primary thoracic kyphosis was 80 degrees (45 degrees-155 degrees). The mean correction obtained by one level osteotomy was 44 degrees (30 degrees-60 degrees). The mean loss of correction after 3 years was 5 degrees. The use of internal fixation reduced the loss of correction from 9 degrees to 1 degree, also allowing ambulatory after-care and a shorter period of immobilization in plaster or jackets. We had no fatal and relatively few non-fatal complications; three cases of retrograde ejaculation were observed however. All the patients reported subjective respiratory improvement.

Multiple pterygium syndrome. A report of two unrelated cases.

Clinical description as well as differential diagnosis are presented of two unrelated patients with the so-called Multiple Pterygium Syndrome. In literature pathological alterations of muscle structures in some patients have been described. In our two patients no evidence was found for a neuromuscular disease, nor for a disease state of the central nervous system.