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.

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.

Titanium-mesh block replacement of the intervertebral disk.

A prospective clinical trial was conducted involving patients with prolapsed lumbar intervertebral disk proven myelographically, who had anterior diskectomy and disk replacement with a titanium-mesh block implant. A pilot study was done in 1971 on six patients. In this trial, 28 patients were operated on with informed consent. Twenty-three had a minimum of five years' follow-up study. There were 14 men and boys, and nine women and girls. The average follow-up period was eight years and four months (range, five to 12 years three months). The average age at operation was 36 years four months (range, 13-66 years). Symptomatic improvement were divided into three groups. Sixteen patients were in Group 1, three in Group 2, and three in Group 3. Flexion-extension radiographs showed 14 patients with no movement between the vertebral bodies adjacent to the operated disk, five with minimal movement, and four with definite movement. At the implant-bone interface, no radiolucent zone was seen in 18 patients, and a definite radiolucent zone was seen in five. Twenty implants were intact, three implants had developed a crack, and three were deformed. There were no complications. The titanium-mesh block implant is an effective substitute for autogenous bone grafting in interbody fusion.

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)

Avascular necrosis of the dens: a follow-up study.

In order to determine the long-term consequences of avascular necrosis of the dens following halo-pelvic traction, 83 patients who had had their halo-pelvic apparatus removed at least five years previously were studied. Avascular necrosis of the dens was found in 31 patients (37%) within one year of removal of the apparatus, but after a minimum of five years the early bony changes had resolved and there was no evidence of atlantoaxial instability. However, 19% of patients who had had avascular necrosis had moderate or severe neck symptoms.

Surgical treatment of scoliosis following poliomyelitis. A review of one hundred and ten cases.

We reviewed the cases of 110 patients with paralytic scoliosis due to poliomyelitis who were operated on. In the lumbar region, anterior Dwyer instrumentation with posterior fusion gave excellent correction of scoliosis and pelvic obliquity. In the more rigid thoracic curves, combined anterior Dwyer instrumentation and posterior fusion gave better results than posterior fusion alone, but had more morbidity. Long c-shaped curves benefited more from a combined anterior Dwyer procedure at the apex of the curve and long posterior Harrington instrumentation. Traction was found to be of use only in rigid curves and in those larger than 80 degrees. With combined anterior and posterior fusion, there was a pseudarthrosis rate of 7 per cent in lumbar curves, none in thoracic curves, and 12.5 per cent in long c-shaped curves. The pseudarthrosis rate rose to more than 25 per cent in patients who had a posterior fusion alone.

Congenital hip dislocation and dysplasia in Southern Chinese.

In 1975 we carried out a survey in Hong Kong to locate Chinese children with congenital dislocation of the hip. Analysis of the available records between 1960 and 1975 gave an observed incidence which was at least 10 times less than found in Caucasians. The age and sex distribution, radiographic findings and the left-sided predominance were similar to Caucasians with congenital dislocation of the hip. However, unlike Caucasian children, the Chinese presented with dislocation and not dysplasia. The mothers of children with congenital dislocation of the hip were compared with a control group with normal children to assess their use of the "Hong Kong" position, in which the children are carried on the back of their mother with their hips in a position of wide abduction. Since only half of the children in either group were carried in this manner, other factors must be responsible for the low incidence of congenital dislocation of the hip in southern Chinese.

Anterior spinal fusion or deranged lumbar intervertebral disc.

Ninety-seven patients who underwent anterior interbody fusion for lumbar disc derangement were examined two to 15 years after the operation. Complete relief of back pain was obtained in 60% and of sciatica in 85%; marked improvement of back pain was obtained in 29% and of sciatica in 10%. The fusion rate was 63% and was only slightly correlated with symptomatic improvement. Many complications were encountered, most of which were transient.

The cervical spine after halo-pelvic traction. An analysis of the complications of 83 patients.

This retrospective study assesses the complications affecting the cervical spine after halo-pelvic traction in 83 patients who were followed up for a minimum of five years. Forty-four patients (53 per cent) had significant cervical complications such as radiological degenerative changes, avascular necrosis of the dens, loss of movement, pain or spontaneous fusion. The most important predisposing factors were a long period in the halo-pelvic apparatus, tuberculous kyphosis, stiffness of the spinal deformity and an age of 15 years or more at the time of application.

The pattern of deep-vein thrombosis and clinical course of a group of Hong Kong Chinese patients following hip surgery for fracture of the proximal femur.

In a prospective study of deep-vein thrombosis following hip surgery for fractures of the proximal femur, 45 Hong Kong Chinese patients were examined by bilateral functional ascending phlebography 7 to 28 days postfracture and 5 to 15 days post-surgery. In 14 patients, the phlebography was repeated 10 to 32 days later. The patients were followed for 27 to 32 months. The phlebographic pattern of the venous thrombi were analyzed, and the clinical course of the patients was presented. Despite the fact that the overall incidence of deep-vein thrombosis in this group of Chinese patients was similar to that reported in the West, clinical pulmonary embolism was not observed. The study suggested a difference in the distribution, pattern and probably the natural history of the venous thrombi among the Chinese when compared with the Western series.

Membranous bodies in the myelin sheath of Schwann cells.

Electron microscopy of muscle biopsies of patients with paralytic scoliosis and tuberculosis of spines reveals membranous bodies in the myelin sheath of Schwann cells. On the basis of this morphological pattern and indirect biochemical evidence, it is suggested that these bodies were formed by abnormal myelin metabolism.

The incidence of deep vein thrombosis in Hong Kong Chinese after hip surgery for fracture of the proximal femur.

Fifty-three Hong Kong Chinese patients with fractures of the proximal femur have been studied after hip surgery using functional ascending phlebograms for evaluating deep vein thrombosis. There was an incidence of deep vein thrombosis of 53.1 per cent in the fractured limbs and 14.3 per cent in the uninjured limbs. The majority of thrombi (84.6 per cent) were located in the calf. No clinical or fatal pulmonary embolism was observed.

Viscoelastic behavior of tissue in leg lengthening by distraction.

The leg lengthening distraction procedure was analyzed with objectives of understanding complications which arise due to overstretching, establishing guidelines to the optimum distraction rates and the frequency of distraction, and, determining the final amount of leg lengthening. An electronic recording system was devised to provide continuous monitoring of the tractive load resulting from distraction of the leg during the elongation procedure. The mechanical behavior patterns of the involved stretched tissues domonstrate time-dependent viscoelastic effects during distraction. During a leg lenthening procedure it is desirable to establish, if possible, a regular pattern of distraction early in the process. If it is necessary in the course of treatment to reduce the distraction rate for clinical reasons, then it is preferable to keep the same number of distraction events but reduce the distraction amount. Distract at equally spaced time intervals to obtain repetitive load cycles and thereby reduce peak values of load and maintain similar stress relaxation patterns for each instantaneous load increase. The total amount of lengthening depends on the characteristics of each individual leg length discrepancy and the physical properties of each distracted tissue.