The effect of age on the change in deformity after anterior débridement surgery for tuberculosis of the spine.

STUDY DESIGN: This article evaluates how an immature spine responds to anterior débridement surgery (without bone grafting) for spinal tuberculosis during growth and development. Sixty-three patients were studied, 29 of whom were children aged 10 years or less at the time of surgery, whereas the remaining 34 subjects were adults. These patients were the subject of the Medical Research Council Working Party's prospective study, started in Hong Kong in the mid-1960s. OBJECTIVES: To evaluate how an immature spine responds to débridement surgery for tuberculosis, during growth and development, to determine whether there are differences in the longitudinal pattern of deformity between children and adults, and to determine the influence of disproportionate spinal growth on the progression of deformity in children. SUMMARY OF BACKGROUND DATA: All patients were followed prospectively for a mean period of 19.6 years after débridement surgery. The mean age at surgery for children (n = 29) was 4.3 years and for adults (n = 34) 35.3 years. METHODS: The kyphos and deformity angles were measured from lateral spinal radiographs obtained at preoperative evaluation and postoperatively at 6 months, 1 year, 5 years, and at final follow-up evaluation using an electronic digitizer. RESULTS: The results showed that the longitudinal pattern of changes in the mean kyphos and deformity angles in young children presented a picture slightly different from that in adults. The mean angles were increased at the 6-month and at 1-year evaluations after débridement surgery in both groups. Afterward, in children there was some spontaneous correction in these mean angles, whereas in adults these angles showed variation according to the site of lesion during the follow-up years. Statistical analysis according to the site of spinal lesion showed that in thoracic tuberculosis, there was an increase in kyphos and deformity angles at the 6-months postoperative evaluation (more in children than in adults). There were no significant changes in these angles from the 1-year to the final follow-up evaluations. In thoracolumbar tuberculosis, there were significant increases in kyphos and deformity angles at the 6-month postoperative evaluation, and thereafter adults did not show any significant change until final follow-up examination, whereas children showed a tendency toward spontaneous correction, although this finding was not statistically significant. In lumbar tuberculosis, there was an equal tendency toward spontaneous correction in children and adults from 1 postoperative year onward. CONCLUSIONS: The authors could find no evidence of disproportionate posterior spinal growth, which has been suspected in the past to be a factor involved in contributing to progression of kyphotic deformity after anterior débridement surgery for spinal tuberculosis.

Duration of antituberculosis chemotherapy in conjunction with radical surgery in the management of spinal tuberculosis.

STUDY DESIGN: The effectiveness of duration of antituberculous chemotherapy in conjunction with radical surgery for tuberculosis of the spine is reported. One hundred fourteen patients were followed prospectively for a mean period of 14.6 years after radical resection of the tuberculous lesion and reconstruction of the resultant gap with bone graft. OBJECTIVE: To evaluate the efficacy of short-course antituberculous chemotherapy in relation to the standard 18-month chemotherapy in conjunction with radical surgery for tuberculosis of the spine. SUMMARY OF BACKGROUND DATA: One hundred fourteen patients who were subjects of the Medical Research Council's (London, UK) prospective study underwent radical resection of the lesion and anterior arthrodesis of the spine. These patients received 6, 9, and 18 months of antituberculous chemotherapy. Those who received 6- and 9-month chemotherapy received streptomycin, rifampicin, and isoniazid. Streptomycin was given for the first 3 months, and the other two drugs were continued for 6 or 9 months. Those who received 18 months of chemotherapy were given streptomycin (first 3 months), sodium para-aminosalicylic acid, and isoniazid. METHODS: These patients were followed longitudinally, and at each visit, clinical and radiologic data were collected at 1-month intervals up to 3 months postoperatively, at 3-month intervals to 30 months postoperatively, at 6-month intervals up to 5 years postoperatively, and at 12-month intervals to the conclusion of study (minimum, 10 years). For assessment of spinal deformity, the "deformity angle" was measured on lateral spinal radiographs obtained at each visit. RESULTS: Six-month, 9-month, and 18-month chemotherapeutic regimens in association with radical surgery produced similar clinical results with no recurrence or reactivation of tuberculosis. The changes in deformity angles at final follow-up evaluation compared with 6-month postoperative values were not statistically significantly different in the groups who underwent 6 months, 9 months, and 18 months of chemotherapy. CONCLUSIONS: The authors' findings show that a 6-month chemotherapeutic regimen combined with surgical excision and bone grafting is adequate for management of tuberculosis of the spine, as it produced clinical and radiologic results comparable with the 18-month chemotherapeutic regimen.

Increased limb lengths in patients with shortened spines due to tuberculosis in early childhood.

STUDY DESIGN: The spine and limb lengths of 26 patients who had a severe spinal deformity due to tuberculosis in childhood were measured and compared with similar data from 79 normal adult volunteers. OBJECTIVES: The aim of the study was to assess whether there are any compensatory growth mechanisms present in patients who had stunted spinal growth in childhood. SUMMARY OF BACKGROUND DATA: Previous studies have documented increased leg lengths in patients with adolescent idiopathic scoliosis who have had spinal fusions done. The aim of this study was to ascertain if this response was unique to scoliosis or was a more general response to the interruption of normal spine growth. METHODS: The standing height, spine height, leg length, and upper limb length were measured in 26 adults with stunted spinal growth due to tuberculosis of the spine contracted in early childhood, and compared with similar measurements in 79 normal volunteers. RESULTS: The patients with spinal deformity due to tuberculosis had significantly shorter mean standing and spine heights compared to the volunteers. However, the mean leg length of these patients was 19.4 mm longer than the volunteers and their mean upper limb length was 18.9 mm longer than the volunteers. These differences were statistically significant. CONCLUSION: Patients whose spinal growth was stunted due to disease in childhood have longer legs and upper limbs than healthy people. A compensatory stimulatory growth mechanism may be responsible for this. This has implications for the whole gamut of childhood spinal disorders that result in stunted spinal growth.

Relation of spinal and thoracic cage deformities and their flexibilities with altered pulmonary functions in adolescent idiopathic scoliosis.

STUDY DESIGN: Seventy patients (average age, 13.8 years) with adolescent idiopathic right thoracic scoliosis had full assessment of pulmonary functions and radiographic evaluation of spinal and thoracic cage deformities and their flexibilities. OBJECTIVES: To determine how measurements of spinal and thoracic cage deformities related to pulmonary function. SUMMARY OF BACKGROUND DATA: Pulmonary functions have been evaluated in relation to lateral curvature of the spine in most of the published studies. Scoliosis is a three-dimensional deformity. There is a need to evaluate these changes in pulmonary functions, reflecting not only spinal curvature but also rotational deformity, thoracic cage deformity, and their flexibilities. METHODS: Radiographic measurements obtained from anteroposterior and lateral standing and anteroposterior supine bending radiographs included lateral curvature, vertebral rotation, kyphosis, maximum sternovertebral distance, and apical rib-vertebral angles. Using previous measurements, the flexibility of the curve, vertebral rotation, and rib-vertebral angle were calculated. A pulmonary function assessment was performed using a computerized pulmonary function system (5000V; Gould, Dayton, Ohio). We analyzed pulmonary functions in relation to deformity. RESULTS: Measurements reflecting spinal deformities obtained from anteroposterior radiographs, such as Cobb angle, vertebral rotation, and vertebral rotation flexibility, were significantly correlated with the percent of predicted values of vital capacity and forced vital capacity, whereas kyphosis measured from lateral radiographs was significantly correlated with absolute values of residual volume, total lung capacity, functional residual capacity, and forced expiratory flow from 25-75% of the forced vital capacity (FEF25-75). Of the measurements reflecting thoracic cage deformity obtained from anteroposterior radiographs, rib-vertebral angle asymmetry (measured from supine bending radiographs) showed significant correlation with the percent of predicted values of vital capacity, forced vital capacity, and functional residual capacity, whereas the sternovertebral distance that was measured from lateral radiographs correlated significantly with absolute values of vital capacity, total lung capacity, forced vital capacity, and FEF25-75. CONCLUSIONS: Deformities in coronal and transverse plane influence changes in pulmonary functions expressed as the percent of predicted values, whereas sagittal plane deformities influence mainly those absolute volumes in which residual volume is a component. It is suggested that rotational flexibility combined with other deformities could be evaluated in future studies on prediction of pulmonary function from the measurements of the deformity.

New prognostic factors to predict the final outcome of brace treatment in adolescent idiopathic scoliosis.

STUDY DESIGN: Eighty-five patients with adolescent idiopathic scoliosis treated with Milwaukee or thoracolumbosacral orthoses at The Duchess of Kent Children's Hospital were studied longitudinally at 4-6-month intervals until maturity for spinal curvature and vertebral rotation, or until termination of brace treatment for persons who experienced brace failure who went on to have surgery. OBJECTIVES: To identify radiologic features so that it may be possible to predict outcome of brace treatment early on. SUMMARY OF BACKGROUND DATA: The structural curve with poor flexibility and large rotational prominence have been found to be associated with poor prognosis for brace treatment. However, early response to bracing for spinal deformity and its relationship to final outcome of brace treatment in a longitudinal study is not available in the literature. METHODS: Vertebral rotation and Cobb angles measured from anteroposterior radiographs of the spine obtained before bracing and 1-2 months after bracing were found valuable for prediction. Changes in post-brace Cobb angle and vertebral rotation were considered as an increase or reduction only when there was an increase or reduction of minimum 5 degrees or more from their prebrace measurements. RESULTS: Those patients who showed increase in vertebral rotation and/or in Cobb angle after brace application were shown to have progression of curves leading to brace failure in 93% of patients, and 79% of these required surgery. The patients with no change in both vertebral rotation and Cobb angle after bracing often experienced brace failure (69%). Two patients (15%) required surgery. The results show that reduction of both Cobb angle and vertebral rotation after application of a brace is a prognostic indicator for a good outcome (97%), and no patients required surgery. Most of the patients with lumbar scoliosis (91%) showed such reductions. CONCLUSION: The findings show a strong association between changes in vertebral rotation and the Cobb angle after application of a brace and the final outcome. Reduction in both is indicative of a good outcome, whereas increase in one or both indicates brace failure.

Increased femoral neck-shaft angles in adolescent idiopathic scoliosis.

STUDY DESIGN: Ninety-four females from Southern China, 61 with adolescent idiopathic scoliosis and 33 normal subjects, were evaluated for femoral neck shaft angles and associated asymmetry between the hips. For statistical analysis, the groups were divided into adolescent and adult, and the scoliosis group was further divided into sub-groups according to the type of spinal curvature. OBJECTIVES: To evaluate femoral neck-shaft angle and asymmetry between the hips, and their relation to adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Recently published studies have suggested there is an association between asymmetry of the hip and lower limb and the curvature in AIS. In this study, femoral neck-shaft angle in patients with adolescent idiopathic scoliosis and in normal subjects was evaluated. METHODS: Femoral neck-shaft angles of both hips and lateral spinal curvature (using Cobb's method) were measured from standard standing anteroposterior radiographs of the pelvis, including upper femora and spine. Methods of measuring femoral neck-shaft angles were evaluated in an intra- and inter-observer study and were found to be accurate. RESULTS: Patients with scoliosis had highly significantly greater femoral neck-shaft angles of both hips compared with normal subjects. In normal subjects, the femoral neck-shaft angle difference between the hips (asymmetry) was not statistically significant. This asymmetry in the scoliosis group also was not statistically significant when the results were analyzed upon grouping them all together, irrespective of curve pattern. CONCLUSION: Our new findings show that patients with scoliosis have abnormally increased femoral neck-shaft angles, and the asymmetry is characteristic and significantly different from that of normal subjects. Moreover, increased femoral neck-shaft angle is related to type and side of spinal curvature.

Evaluation of deformities and pulmonary function in adolescent idiopathic right thoracic scoliosis.

Seventy patients with adolescent idiopathic right thoracic scoliosis had full assessment of their pulmonary function using a computerised pulmonary function system. Their mean age at evaluation was 13.8 years. The following measurements were obtained from anteroposterior and lateral standing and antero-posterior supine bending radiographs: lateral curvature, vertebral rotation, kyphosis, maximum sterno-vertebral distance and apical rib-vertebral angles. Using the above measurements, the flexibility of curve, vertebral rotation and rib-vertebral angle asymmetry were calculated. Patients were classified into three groups on the basis of their predicted vital capacity, to determine whether radiological features of deformity can help identify patients with compromised pulmonary function. The mean Cobb angle and vertebral rotation for the 70 patients were 50 degrees (range 35-100 degrees) and 22 degrees (range 1-44 degrees) respectively. The mean flexibility of curve and vertebral rotation were 52% and 49% respectively. Mean thoracic kyphosis was 25 degrees, ranging from -7 to 55 degrees. Of the patients with Cobb angle less than 90 degrees, 71% had vital capacity less than 80% of predicted values, and of these, 18% had marked compromise of vital capacity (less than 60% of predicted values). Mean values of Cobb angle, vertebral rotational flexibility, kyphosis, rib-vertebral angle asymmetry (in standing as well as supine bending radiographs) differed significantly between patients with more than 80% of predicted vital capacity and those with 60% or less of predicted values. Radiological features indicative of better pulmonary function were: rotational flexibility exceeding 55%, rib-vertebral angle asymmetry (standing) less than 25 degrees and kyphosis greater than 15 degrees. Two deformity parameters--that give a better prediction of pulmonary function than the widely used Cobb angle, vertebral rotational flexibility and rib-vertebral angle asymmetry--were identified in this study.

Vertebral growth after posterior spinal fusion for idiopathic scoliosis in skeletally immature adolescents. The effect of growth on spinal deformity.

We studied 29 girls and one boy with adolescent idiopathic scoliosis who were at Risser grade 0 at the time of posterior spinal fusion and were followed until maturity (mean 7.8 years). We used serial radiographs to measure the ratio of disc to vertebral height in the fused segments and to detect differential anterior spinal growth and assess its effect on scoliosis, vertebral rotation, kyphosis, and rib-vertebral-angle difference (RVAD). From one year after surgery to the latest review, the percentage anterior disc height decreased by nearly one-half and the percentage posterior disc height by nearly one-third in the fused segments (p < 0.001). There was a 4 degree increase in mean Cobb angle (p < 0.001), 11 patients (37%) having an increase of between 6 degrees and 10 degrees. There was a significant increase in mean apical rotation by 2 degrees (p = 0.003), and four patients (13%) had an increase of between 6 degrees and 16 degrees. There was little change in kyphosis. There was an increase in mean RVAD by 4 degrees (p = 0.003), seven patients (23%) showing a reduction by 1 degree to 7 degrees, and 11 (37%) increases of between 6 degrees and 16 degrees. Spinal growth occurs after posterior fusion in adolescents who are skeletally immature, as a result of continued anterior vertebral growth. There is some progression of scoliosis, vertebral rotation, and RVAD, but little change in kyphosis. The increase in deformity is not enough to warrant the use of combined anterior and posterior fusion. The findings are relevant to the management of progressive curves, the timing and extent of surgery, and the prognosis for progression of deformity in this group of patients.

Effect of spinal fusion on growth of the spine and lower limbs in girls with adolescent idiopathic scoliosis: a longitudinal study.

Two-hundred thirty-eight Southern Chinese girls, aged 10 to 14 years, treated previously for adolescent idiopathic scoliosis were studied longitudinally from the commencement of their treatment until maturity. Their standing, sitting, and suprasternal heights were measured at each follow-up visit, and their lower limb, head-neck, and spinal lengths were calculated. The results in 113 girls treated by posterior spinal fusion and Harrington instrumentation were compared with those of 125 girls who were treated with a brace. At maturity, the mean standing height of girls who underwent spinal fusion was not significantly different from that of patients treated with a brace. The fusion group had significantly shorter spinal lengths (p = 0.001), but significantly greater leg lengths (p = 0.001) compared to those of the brace group. Their arm lengths were similar, however. The girls who underwent spinal fusion had progressively increasing leg/arm ratios postoperatively from bone age 14-15 years onward compared to those treated with a brace, which indicated disproportionately longer legs in the girls who had spinal fusion. These findings suggest that spinal fusion performed on the girls with adolescent idiopathic scoliosis did retard the longitudinal growth of the spine. The standing height was unaffected, however, as the loss in spinal length was compensated by an increase in leg length.

Bone mineral density in ankylosing spondylitis. DEXA comparison of control subjects with mild and advanced cases.

We have used dual-energy X-ray absorptiometry to measure bone mineral density (BMD) in patients with ankylosing spondylitis comparing 41 healthy control subjects and 33 patients with either mild or advanced ankylosing spondylitis. A Norland XR-28 bone densitometer was used to measure the BMD of the lumbar spine and that of the head, trunk, arms, femoral neck, Ward's triangle, legs, pelvis, and total body. Mild ankylosing spondylitis was defined as that showing no or incipient syndesmophytes between L1 and L5 vertebrae: we studied 16 men of mean age 37 years and six women of mean age 37 years. Advanced ankylosing spondylitis, in 11 men of mean age 42 years, showed a bamboo spine with bridging syndesmophytes across all disc spaces between L1 and L5. The mean BMD of the lumbar spine was significantly different in the patients and control subjects of the same sex (0.01 < p < 0.05, analysis of variance), being significantly reduced compared with control subjects in mild disease (0.001 < p < 0.01, t-test) and significantly increased in advanced disease over control subjects (0.01 < p < 0.05; t-test) and over patients with mild disease (0.001 < p < 0.01; t-test). The relevance of these findings to the aetiology and pathogenesis of spinal deformities and other complications in ankylosing spondylitis is discussed.

Deterioration of operative correction in dystrophic spinal neurofibromatosis.

STUDY DESIGN: Of 28 patients with dystrophic spinal deformity resulting from neurofibromatosis who were treated surgically since 1968, 25 were studied regarding the outcome of spinal deformity at a mean follow-up of 9.7 years after surgery (mean age at follow-up, 21.5 years). OBJECTIVES: This study sought factors that contribute to curve deterioration despite successful spinal fusion for dystrophic spinal deformity in patients with neurofibromatosis. SUMMARY OF BACKGROUND DATA/METHODS: All patients had the following radiographs: standing anteroposterior and lateral, lateral bending, flexion and extension views of the spine, and radiographs of both tibiae. Patients who had large peripheral neurofibromata or evidence of long-bone deformity at other sites had radiographs of these anatomic regions. Spinal radiographs obtained pre-operatively, 6-12 months post-operatively, and at final follow-up were measured for spinal curvatures, vertebral height, and vertebral and disc wedging. RESULTS: For analysis, the patients were divided into three groups according to deformity: 1) scoliosis, 2) ky-phoscoliosis (with kyphosis > 50 degrees) and 3) hyperkyphosis (with kyphosis > 50 degrees and sharply angulated over three vertebrae). Mean deterioration was: scoliotic group, 12 degrees (range, 0 degree-52 degrees); kyphoscoliotic group, 7 degrees (range, 0 degree-35 degrees); hyperkyphosis group, 38 degrees (range, 20 degrees-60 degrees). All patients in the latter group had anterior and posterior spinal fusion. CONCLUSION: Spinal deformity in these patients tended to progress despite the achievement of spine arthrodesis in those with hyperkyphosis and short curves. The study shows that vertebral subluxation, disc wedging, and peripheral skeletal dystrophy are additional prognostic features that predict the progression of deformity after arthrodesis of the spine.

Pulmonary functions in congenital scoliosis.

STUDY DESIGN: Thirty-six patients with congenital scoliosis underwent full clinical and radiologic evaluation of their deformity and their full pulmonary functions. OBJECTIVES: This study observed pulmonary functions in congenital scoliosis in detail, evaluated pulmonary functions in nonsurgically treated patients, and established whether, in surgically treated patients, there are any differences between those with multiple thoracic anomalies and those with lumbar or one of two thoracic anomalies. SUMMARY OF BACKGROUND DATA: Eighty-six of our patients in both groups (surgically and nonsurgically treated) showed abnormal increases in residual volumes, indicating a restrictive pattern of lung function. The results of their pulmonary functions were analyzed using predicted values to eliminate age affect. METHODS: Pulmonary functions were assessed using the Gould 5000IV Computerized Pulmonary Function System. RESULTS: Overall, mean total lung capacity was 89% of predicted value, and mean vital capacity and forced vital capacity were 74% of predicted value. The mean residual volume was significantly increased, being 154% of predicted value. Nonsurgically treated patients showed normal total lung capacity (mean 99.8% of predicted value); this mean value was 82% of predicted value in surgically treated patients. CONCLUSION: Vital capacity was found to be significantly reduced in surgically treated patients (68% of predicted value), especially in those patients who had multiple thoracic anomalies. We believe that children with congenital scoliosis due to multiple anomalies should be operated on at an early age before deformity is too severe.

Surgical management of spinal tuberculosis in adults. Hong Kong operation compared with debridement surgery for short and long term outcome of deformity.

Of 112 patients who were subjects of the Medical Research Council's prospective study, 105 (94%) were involved in a longitudinal study follow-up for a mean of 15.3 years postoperatively. Seventy-one patients had radical resection of the tuberculous lesion and bone grafting, and the remaining 34 were treated with debridement surgery at a mean age of 36.7 and 35.3 years, respectively. All these patients were aged 18 years or older at the time of surgery. The kyphosis and deformity angles were measured on lateral spinal radiographs using an electronic digitizer. The results can be summarized as follows: (1) Neurologic recovery in both radical and debridement surgical groups were equally good and no patient had pain two years after surgery. There was no incidence of reactivation or recurrence of tuberculosis in either surgical group. (2) At the six-month postoperative evaluation, patients who had radical surgery showed marginal correction in deformity, whereas those who were treated with debridement showed deterioration in both kyphosis and deformity angles. There was a statistically significant difference between the two surgical groups for the mean changes in kyphosis and deformity angles at the six-month postoperative evaluation compared with their preoperative evaluation. (3) The mean difference for kyphosis and deformity angles at final follow-up evaluation from the patients' six-month postoperative measurements were not statistically significantly different between the two surgical groups. (4) Forty percent of patients showed an improvement in deformity angle by 5 degrees or more after radical surgery at the six-months postoperative evaluation, whereas 53% of patients showed deterioration after debridement surgery. (5) All patients with tuberculosis of the lumbar spine treated with radical surgery had normal lordosis in the lumbar spine at final follow-up evaluation, compared with only 63% of patients after debridement surgery. Correction achieved after surgery at the six-month evaluation was practically maintained up to final follow-up evaluation. Radical resection and bone grafting provided better correction of deformity than did debridement surgery.

The effect of age on the change in deformity after radical resection and anterior arthrodesis for tuberculosis of the spine.

We compared the long-term changes in spinal deformity after a radical operation for tuberculosis of the spine in thirty-three children who were ten years old or younger at the time of the operation with those of seventy-one adult patients who were at least eighteen years old at the time of the operation. The spinal deformity was measured with use of the angles of kyphosis and deformity as assessed on lateral spinal radiographs made preoperatively and postoperatively at six months, one year, and five years and at the most recent follow-up evaluation (at a mean of fifteen years). We detected no significant difference in the mean angles of kyphosis and deformity between the children and the adults postoperatively at any follow-up evaluation; thus, we found that growth of the posterior portion of the spine does not contribute to the progression of deformity after a radical anterior procedure. The children who had tuberculosis of the thoracic spine had much better correction than the adults at the six-month follow-up examination. This correction was maintained. However, there were no such differences in the correction of the deformity between the adults and the children who had tuberculosis of the thoracolumbar or the lumbar spine. Our findings clearly show that a short anterior spinal arthrodesis done at an early age was not associated with progression of deformity during growth and development in our patients. The longitudinal pattern of changes in deformity was similar in the children and the adults, and there was no evidence of disproportionate posterior spinal growth contributing to the progression of deformity after anterior spinal arthrodesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Longitudinal changes in spinal deformity after anterior spinal surgery for tuberculosis of the spine in adults. A comparative analysis between radical and debridement surgery.

Of 112 patients who entered the Medical Research Council's prospective study on the surgical management of spinal tuberculosis, 105 were available for review at a mean follow-up of 15.3 years postoperatively. All these patients were age 18 years or more at the time of surgery. Seventy-one patients had radical surgery; the remaining 34 underwent debridement surgery. The longitudinal changes in spinal deformity were evaluated using kyphus and deformity angles from lateral spinal radiographs obtained at preoperative evaluation, postoperatively at 6 months, 1 year, and 5 years, and at final follow-up. The mean kyphos and deformity angles showed correction after radical surgery at 6 months' evaluation; thereafter there were minimal variations up to final follow-up. Those who underwent debridement surgery showed an increase in these angles at 6 months postoperative evaluation; thereafter there were practically no changes in thoracic and thoracolumbar tuberculosis, whereas in lumbar tuberculosis there was spontaneous correction from 1 year post-surgery onward. The changes in mean kyphos and deformity angles at 6 months postoperative evaluation from their preoperative values were significantly different between the two surgical groups, where radical surgery produced better correction. Thus, the choice of surgery--radical or debridement--is important in determining the fate of spinal deformity in the management of tuberculosis of the spine.

Spinal deformity after childhood surgery for tuberculosis of the spine. A comparison of radical surgery and debridement.

We have reviewed 80 children who were involved in the Medical Research Council (UK) trial of surgical treatment for tuberculosis of the spine in Hong Kong. Radical surgery or debridement had been performed at mean ages of 7.6 years (n = 47) and 5.1 years (n = 33) respectively. The patients were followed up to skeletal maturity (mean 17 years). Spinal deformity was measured on lateral radiographs taken preoperatively, at six months, one year, five years and at final follow-up. Radical surgery and grafting produced a reduction in kyphos and deformity angles at six months; this correction was maintained during the growth period. By contrast, after debridement surgery there was an increase in deformity at six months, with a tendency to some spontaneous correction during the growth period. There were statistically significant differences between angles for the radical and debridement groups only at six months postoperatively, but the changes during later follow-up were similar in the radical and debridement groups. Our findings highlight the importance of the surgical correction of deformity, and provide no evidence to suggest that disproportionate posterior spinal growth contributes to progression of deformity after anterior spinal fusion in children.

17-year prospective study of surgical management of spinal tuberculosis in children. Hong Kong operation compared with debridement surgery for short- and long-term outcome of deformity.

A comparative analysis of the short and long-term results of two surgical procedures, radical excision or debridement, for the management of spinal tuberculosis in children is reported. Eighty children (47 treated with radical surgery and 33 with debridement) were prospectively studied and followed to maturity (mean follow-up, 17 years postoperatively). The kyphus and deformity angles were measured from lateral spinal radiographs using an electronic digitizer. The results can be summarized as follows: 1) Long-term clinical outcome of the two surgical procedures were equally good for recovery of neurologic deficit and relief of pain. There was no incidence of reactivation and/or recurrence of tuberculous lesion in either group; 2) The mean changes in kyphus and deformity angles at the 6-month postoperative evaluation compared to their preoperative value were significantly different for the two surgical groups. There was an overall correction in these angles after radical surgery, whereas there was a deterioration after debridement surgery; 3) There were no significant differences in the changes in kyphus or deformity angles at final follow-up from their 6-month postoperative measurements between the two surgical groups; 4) The majority of children (56%) showed an improvement in deformity angle of 5 degrees or more after radical surgery at the 6-month postoperative evaluation, whereas 69% of children showed deterioration after debridement surgery; 5) At final follow-up in lumbar tuberculosis, 60% of patients in the debridement group had 10 degrees or more kyphus angle, whereas only one patient in the radical group had a kyphotic lumbar spine due to graft failure.(ABSTRACT TRUNCATED AT 250 WORDS)

New methods of measuring vertebral rotation from computed tomographic scans. An intraobserver and interobserver study on girls with scoliosis.

The purpose of this study was to search for constant and reliable reference points on the computed tomographic scans of scoliotic spines to measure vertebral rotation. Several methods using different sets of reference points on computed tomographic scans were tested for reliability. Two methods that gave minimum variation between the readings are presented here with interobserver and intraobserver reliability on 17 girls with adolescent idiopathic scoliosis. The selection of reference points for the two methods were as follows: In method 1, the vertebral rotation was an angle formed by two lines; one, a line joining the junction of the inner surfaces of two laminae and the midpoint of the posterior surface of the vertebral body and second, the vertical plane of the computed tomographic machine. In method 2, three datum points were marked; one at the junction of the inner surfaces of the laminae, and the other, one each at the junction of the inner surfaces of the lamina and the pedicle. A line bisecting this angle is drawn by the computer and the vertebral rotation was an angle between this line and the vertical plane. The 95% confidence intervals of these two methods for intraobserver variation were between 1.2 to 4.4 degrees. There was no significant difference between the readings obtained by each observer except on three occasions for observer 1. When these methods were tested for interobserver reliability, method 1 showed significant statistical differences between the readings obtained by the two observers. However, the readings obtained using method 2 were not significantly different between the two observers (95% confidence intervals = 3.2 to 5.8 degrees).(ABSTRACT TRUNCATED AT 250 WORDS)

Split tibialis posterior transfer for equinovarus deformity in cerebral palsy. Long-term results of a new surgical procedure.

We report the results of a new surgical procedure for spastic equinovarus deformity due to cerebral palsy. This is the transfer of the anterior half of the split tibialis posterior to the dorsum of the foot through the interosseous membrane. We performed the operation on 23 feet in 18 children. All patients were assessed before operation and at follow-up at a mean of 8.4 years postoperatively. Using the criteria of Kling et al (1985), excellent results were obtained in 14 feet, good results in eight, and a poor result in only one.