Comment on "A proposal for a surgical classification of pediatric lumbosacral spondylolisthesis based on current literature" (Jean-Marc Mac-Thiong, Hubert Labelle).
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Biomedical subjects
Dietrich Schlenzka
Publications and source records attributed to Dietrich Schlenzka.
Long-term outcome after posterolateral, anterior, and circumferential fusion for high-grade isthmic spondylolisthesis in children and adolescents: magnetic resonance imaging findings after average of 17-year follow-up.
STUDY DESIGN: A cross-sectional study to evaluate the long-term result of posterolateral (PLF), anterior (AF), and circumferential fusion (CF) for isthmic spondylolisthesis. OBJECTIVES: To assess the long-term effects of PLF, AF, or CF for high-grade isthmic spondylolisthesis on lumbar spine in children and adolescents by using MRI. SUMMARY OF BACKGROUND DATA: Short- and mid-term clinical and plain radiographic results of isthmic spondylolisthesis and of PLF, AF, and CF in severe slip are well documented. The long-term effect of the fusion on soft tissues, on the intervertebral discs inside and above fusion in particular, is, however, unclear. METHODS: Between 1977 and 1991, PLF (n = 21), AF (n = 22), or CF (n = 24) was performed on 67 patients (42 females, 25 males) with high-grade (slip > or =50%) isthmic spondylolisthesis. The average age of patients at the time of operation was 14.4 (range, 8.9-19.6) years. Clinical, spinal mobility and trunk strength in addition to MRI and plain radiograph examinations were performed on these patients after an average follow-up time of 17.3 years (range, 10.7-26.0 years). RESULTS: Three (14%) patients in the PLF and AF groups, but none in the CF group, reported back pain often or very often at rest. The mean Oswestry Disability Index (ODI) was 9.7 (range, 0-62) in the PLF, 8.1 (0-32) in the AF, and 2.3 (0-14) in the CF group (P < 0.05). The mean slip before surgery was 66% (range, 50%-100%) and at the last follow-up visit 66% (range, 26%-106%). Disc degeneration was most common in the PLF group (P = 0.0014) and inside the fusion and in the lowest moving intervertebral disc spaces in all subgroups. Only 1 patient had an asymptomatic prolapse. In MR images, none of the patients had lumbar central canal stenosis inside or above the fusion. In contrast, the spinal canal was wide at the spondylolysis and spondylolisthesis level in 23 (34%) patients. Of the patients, 19 (28%) patients (32 neural foramens) had severe narrowing of the neural foramen with impingement of the nerve root. No patients had clinically confirmed L5 nerve root symptoms. Muscle degeneration was found in 29 (43%) of patients. Longer fusion and muscle degeneration, but not disc degeneration, were associated with lower performance in spinal mobility and trunk-strength measurement tests. CONCLUSIONS: The clinical outcome was best in the CF group as measured by ODI. Degenerative changes were most commonly found at the level of the slip and above the fusion level. The prevalence of disc prolapses was low. Spinal fusion for isthmic spondylolysis is not associated with central canal stenosis above the fusion. Radiologic nerve root stenosis was common but asymptomatic. Mild muscle atrophy was common.
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Results of brace treatment of adolescent idiopathic scoliosis in boys compared with girls: a retrospective study of 102 patients treated with the Boston brace.
The aim of the study was to compare the results of brace treatment of adolescent idiopathic scoliosis (AIS) in male patients with matched female patients and to assess the effectiveness of bracing of boys in AIS and to discuss the results with published data. Between 1987 and 1995, 51 consecutive male patients with AIS were treated with the Boston brace. The patients were advised to wear the brace 23 h/day. The medical records of all patients were reviewed. Cobb angles and Risser signs were measured before bracing, in brace, at brace discontinuation and at final follow-up. Everyone of 51 male patients was compared with a female patient who was treated by the same method and matched by Risser sign, curve pattern, curve magnitude and duration of treatment and follow-up time. Compliance with brace was noted at every visit. Fourteen boys had worn the brace only during nighttime or occasionally and were considered non-compliant. Only compliant patients with treatment period > 1 year and follow-up > 1 year after treatment were accepted for the analyses of effectiveness of brace treatment and its prognostic factors. Thirty-three boys met these inclusion criteria. Bracing was considered to have a failure if > 5 degrees progression occurred or if surgery was performed. At the final follow-up study progression > 5 degrees was found in 16/51 (31.4%) of male patients. Corresponding figures of female patients were 11/51 (21.6%), respectively. In compliant boys progression > 5 degrees occurred in 6/33 boys compared with 9/33 girls. The association between risk of progression and correction% in brace was statistically significant. The overall results of brace treatment of idiopathic scoliosis in male patients were inferior compared with matched females. One reason for inferior overall results in boys was poor compliance with brace wear. However, brace treatment in AIS may be recommended with the same principles in both genders.
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Treatment of severe spondylolisthesis in adolescence with reduction or fusion in situ: long-term clinical, radiologic, and functional outcome.
STUDY DESIGN: Retrospective follow-up study with two cohorts: one treated with reduction and the other with fusion in situ. OBJECTIVE: To assess the long-term effects of reduction versus fusion in situ on lumbar spine in children and adolescents with severe L5 isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA: Severe isthmic spondylolisthesis is commonly treated with fusion in situ, but modern surgical techniques and instrumentation permit the reduction of a severely slipped fifth lumbar vertebra. Advocates of one or another of these procedures present different claims to defend their choice. However, to our knowledge, no long-term results of the reduction maneuver exist. METHODS: Between 1983 and 1991, 22 adolescents with severe (more than 60%) slip were treated surgically. In 11 of them, reduction was performed with a Magerl/Dick transpedicular device, followed by fusion posteriorly from L4 or L5 to S1 and anteriorly from L5 to S1. In the others, fusion was performed in situ posteriorly from L4 (n = 7) or L5 (n = 4) to S1 and anteriorly from L5 to S1. The average age of patients at surgery was 14.7 years (range 10.7-18.5). Radiographs obtained before surgery, after surgery, and at the final follow-up evaluation were assessed for quality of fusion. In addition, magnetic resonance imaging was obtained at the last follow-up visit. Average follow-up time was 14.8 years (range 11.6-18.7). Physical examination, spinal mobility, and nondynamometric trunk strength measurements were used to assess, and Oswestry Disability Index and Scoliosis Research Society scores were used to calculate outcome at the last follow-up visit. RESULTS: In the reduction group, mean Oswestry Disability Index was 7.2 (range 0-20) and in the fusion in situ group, was 1.6 (range 0-4) (P = 0.0096). The Scoliosis Research Society total score averaged 90.0 (range 39-107) in the reduction group and 103.9 (range 93-120) in the fusion in situ group (P = 0.046). At the last follow-up evaluation, mean vertebral slip had decreased from the preoperative value of 90% to 57% in the reduction group but remained the same (80% vs. 78%) in the fusion in situ group (P = 0.04 and 0.013, respectively, for preoperative and postoperative comparison). On magnetic resonance imaging, disc degeneration above the fusion was more common in the reduction group (P = 0.004). None of the patients had spinal stenosis above the fusion. Nerve root canal impingement at the L5-S1 level was more common in the fusion in situ group (P = 0.03), but all patients were free of L5 nerve root symptoms. There was no difference in spinal mobility or trunk strength measurements between the groups. CONCLUSIONS: The fusion in situ group seems to perform better in almost all clinical parameters measured. These findings suggest that fusion in situ should be considered as a method of choice in severe L5 isthmic spondylolisthesis.
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Direct repair for treatment of symptomatic spondylolysis and low-grade isthmic spondylolisthesis in young patients: no benefit in comparison to segmental fusion after a mean follow-up of 14.8 years.
The aim of the present study was to assess the long-term clinical, functional, and radiographic outcome of direct repair of spondylolysis using cerclage wire fixation according to Scott in young patients with symptomatic spondylolysis or low-grade isthmic spondylolisthesis as compared to the outcome after uninstrumented posterolateral in situ fusion. Twenty-five out of 28 patients of the direct repair group (89%) and 23 out of 28 of the fusion group (82%) were available for follow-up examination. The assessment by independent observers included a structured interview (Oswestry questionnaire [ODI], visual analogue scale, SRS questionnaire), a clinical examination, functional testing, plain radiography, and MRI. The groups were comparable as to the mean age at operation (18.2 vs. 16.2 years.), the follow-up time (14.8 vs. 15.0 years), and the amount of preoperative slip (7.2 vs. 13.1%). The mean ODI and SRS total scores were significantly better in the fusion group (4.3 [0-16] and 96 [57-117]) as compared to the direct repair group (11.4[0-52] and 87[53-107]; P=0.02 and P=0.011, respectively). In functional testing, both groups reached normal values for abdominal and back muscle strength. The lumbar spine flexion and extension ROM was decreased in both groups showing no statistical difference between the groups. Significant progressive narrowing of the olisthetic disc was detected on the plain radiographs after direct repair. On the flexion-extension radiographs, in the direct repair group, the mobility in the lytic/olisthetic segment was decreased in comparison to normal values from the literature. The mobility at the level above the operated segment was decreased in the direct repair group as compared to the fusion group (P=0.057). On T2-weighted MR images in the direct repair group, the signal intensity of the disc below the affected vertebra was decreased in 17/23 (74%) patients. There was no difference between the groups in the nucleus signal intensity of the adjacent disc above the operated segment. No association between the disc degeneration on MRI and the outcome of the patients could be established. In the direct repair group the following complications were seen: transient nerve root irritation (2), superficial infection (1), UTI (1); in the fusion group the complications were: subcutaneous seroma (2) and UTI (1). There were six re-operations, cerclage removal(4), conversion into segmental fusion(2) in the direct repair group, and one re-operation, instrumented respondylodesis, in the fusion group. In conclusion, the results of direct repair of the spondylolysis using cerclage wire fixation according to Scott were very satisfactory in 76% of the patients after a mean follow-up of 14.8 years. After direct repair, the ODI deteriorated with time leading to a clinically moderate but statistically significant difference in favour of segmental fusion. Lumbar spine mobility was decreased after direct repair. Secondary segmental instability above the spinal fusion was not detected. The procedure does not seem to be capable of preventing the olisthetic disc from degeneration. The theoretical benefits of direct repair could not be proven.
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Effectiveness of the Providence nighttime bracing in adolescent idiopathic scoliosis: a comparative study of 36 female patients.
The aim of the study was to assess the results of treatment of adolescent idiopathic scoliosis (AIS) with the Providence nighttime brace at 1.8 years after discontinuation of bracing. A total of 36 consecutive female patients with an average Cobb angle of 28.4 degrees and an apex below T 10 were studied prospectively. For comparisons, 36 matched patients treated with the Boston full-time brace were studied retrospectively. With the Providence night brace an average of 92% for brace correction of the primary curve was achieved and during follow-up progression of the curve >5 degrees occurred in 27% of the patients. In the control group of the Boston full-time brace patients, brace correction was 50% and the progression of the major curve occurred in 22% of the patients. We conclude that the Providence night brace may be recommended for the treatment of AIS with curves less than 35 degrees in lumbar and thoracolumbar cases.
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Posterolateral, anterior, or circumferential fusion in situ for high-grade spondylolisthesis in young patients: a long-term evaluation using the Scoliosis Research Society questionnaire.
STUDY DESIGN: A retrospective, comparative follow-up study. OBJECTIVE: To compare clinical and radiographic outcomes after posterolateral, anterior, or circumferential fusion in situ for high-grade spondylolisthesis in children and adolescents. SUMMARY OF BACKGROUND DATA: Controversial opinions still exist about the surgical treatment of severe isthmic spondylolisthesis. There are no long-term comparative studies of different fusion in situ techniques in these patients. METHODS: A total of 21 patients treated using posterolateral, 23 using anterior, and 26 using the circumferential fusion technique without instrumentation for high-grade isthmic spondylolisthesis (>or=50% slip) participated. Their mean age at surgery was 14.4 years (range 8.0-19.6). The follow-up rate was 84% after a mean of 17.2 years (range 10.7-26.0). Radiographs were obtained before surgery, at 2-year follow-up, and at final follow-up. The Scoliosis Research Society (SRS) and Oswestry Disability Index questionnaires were completed, and a physical examination was performed at the final follow-up visit. RESULTS: Progression of lumbosacral kyphosis (>or=10 degrees ) was found in 9 (43%), 3 (13%), and 3 (12%) patients of the posterolateral, anterior, and circumferential fusion groups, respectively (P = 0.017). The SRS total score averaged 89.7 (range 56-105) in the posterolateral, 93.2 (range 66-114) in the anterior, and 100.0 (range 71-117) in the circumferential fusion groups (P = 0.021). Patients in the circumferential fusion group had better values for pain (P = 0.023) and function from back condition domains (P = 0.079) than patients in the posterolateral or anterior groups. The Oswestry Disability Index averaged 9.7 (range 0-62) in the posterolateral, 8.9 (range 0-32) in the anterior, and 3.0 (range 0-16) in the circumferential fusion groups (P = 0.035). CONCLUSIONS: Circumferential fusion provided significantly better long-term clinical, radiographic, and SRS total score than posterolateral or anterior fusion for high-grade isthmic spondylolisthesis.
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No correlation between patient outcome and abnormal lumbar MRI findings 21 years after posterior or posterolateral fusion for isthmic spondylolisthesis in children and adolescents.
Between 1977 and 1987, posterior (n=29) or posterolateral (n=73) fusion was performed for mild to moderate (slip <50%) isthmic spondylolisthesis on 102 patients (46 females, 56 males). The patients' average age at the time of operation was 15.9 (range, 8.1-19.8) years. Clinical (physical examination and Oswestry disability index (ODI)) and radiological (MRI and plain radiographs) examinations were performed on these patients after an average follow-up time of 21.0 (range, 26.2-15.1) years. In the radiographs, the mean slip preoperatively was 27% (range, 5-50%) and at the last follow-up visit 26% (range, 5-78%). Inside the fusion, there were a total of 148 intervertebral discs, 121 (82%) of them had decreased signal intensity in T2-weighted MR images and 113 (76%) were narrowed. Above the fusion level, 27 (27%) discs were speckled and 27 (27%) were black; 21 (21%) intervertebral disc spaces were narrowed. Two levels above the fusion level the numbers were 8 (8%), 16 (16%) and 16 (16%), respectively. Six (6%) patients had a prolapse. Degenerative facet joint hypertrophy above fusion was seen at 80 (79%) of the levels studied. When compared to healthy subjects higher frequency of disc and facet joint degeneration was found. In MR images, none of the patients had lumbar spinal stenosis inside or above the fusion. Narrowing of one or both of the neural foramina at the level of the L5-S1 interververtebral disc was noted in 32 (31%) patients. Seventeen (17%) of the patients had, usually mild, muscular atrophy of the psoas and 33 (32%) of the paraspinal muscles. There was no difference in frequency of abnormal MRI findings between patients (n=93) with ODI 20 or less compared with patients (n=9) with ODI more than 20. In situ fusion due to isthmic spondylolsthesis at adolescence is associated with moderate degenerative changes in the lumbar spine during a 20-year follow-up. Changes were most commonly found at the level of the spondylolisthesis and above fusion level. Neural foramina stenosis seems to be associated with spondylolisthesis and its severity to severity of the slip. Muscle atrophy tended to be mild. However, there was no correlation between patient outcome (ODI) and abnormal lumbar MRI findings.
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Scheuermann's kyphosis: surgical management.
Indications for surgery in Scheuermann disease are not well codified and remain rare, as the natural history of the disease is in most cases benign. In the immature adolescent, conservative treatment, such as bracing or casting, can be tried for moderate curves. For larger curves, or in the adult, conservative treatment is usually not effective, and surgery can be considered. Such indications are mostly cosmetic for large curves above 75 degrees. Pain over the deformity or in the low back may represent another surgical indication, especially in the adult group. The question of anterior release or straight posterior fusion has become more of an actuality with the advent of powerful, third-generation stiff segmental instrumentation. However, the long-term results of a modern, posterior-only instrumentation fusion are not known. Concern about loss of correction, late pseudarthrosis or the need to remove instrumentation for infected hardware or due to late pain at the operative site must make us careful about choosing this method. Very rigid and large curves still require an anterior release, either done in a conventional or mini-open fashion, or through video-assisted thoracoscopic surgery. The extent of the posterior instrumentation has now been better defined. One must fuse the whole Cobb angle without hypercorrection and stop distally, above the first lordotic disc, to avoid sagittal decompensation. New approaches such as short anterior fusion with bone-on-bone techniques and pedicle substraction osteotomies have not yet been reported in the literature as having been used for treating Scheuermann's kyphosis. These should be considered experimental.
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Does gender affect outcome of surgery in adolescent idiopathic scoliosis?
STUDY DESIGN: A retrospective follow-up study comparing 2 matched groups. OBJECTIVE: To compare long-term results of operative treatment of adolescent idiopathic scoliosis (AIS) between males and females matched for age, curve magnitude and type, and the instrumentation used. SUMMARY OF BACKGROUND DATA: It has been suggested that in AIS, the spine is more rigid in males than in females, because brace treatment fails to halt progression of the curves in males. However, there are no studies comparing the results of surgical treatment of AIS between males and females. METHODS: Thirty male and female pairs were matched for age (+/-1 year), major curve magnitude (+/-5 degrees), curve type according to the King classification, and the instrumentation used (Harrington in 11 pairs, Cotrel-Dubousset in 9 pairs, and Universal Spine System in 10 pairs). The mean age at the time of operation was 16.2 +/- 2.6 years for the males and 15.5 +/- 2.3 years for the females. The mean follow-up times were 14.3 years (range 6.7-23.0 years) and 14.1 year (range 6.4-23.7 years), respectively. Radiographs were obtained presurgery and after surgery, at the 2-year follow-up assessment, and at the final follow-up visit. In addition, a physical examination was performed, and the Scoliosis Research Society (SRS) questionnaire was completed. Spine mobility and nondynamometric trunk strength were measured at the final follow-up visit. RESULTS: Before surgery, the mean Cobb angle of the thoracic curve was 55 degrees (range 42-83 degrees) in the males and 56 degrees (range 43-80 degrees) in the females. In bending radiographs, the major curve reduced significantly more in females than in males (P = 0.027). The mean angles of the thoracic and lumbar curves were similar at all follow-up visits. The final correction of the thoracic curves was 30% (range -19-65%) in the males and 33% (range -7-71%) in the females (not significant). No significant difference was observed in thoracic kyphosis or lumbar lordosis between the study groups at the final follow-up. The total SRS questionnaire score averaged 96 (range 66-113) in the males and 95 (range 75-108) in the females. None of the males and 2 of the females reported back pain often or very often in the questionnaire. Nondynamometric trunk strength measurements corresponded with reference values, on average, and were similar in both groups. Abnormal trunk side bending tended to be more common in the males than in the females (43% vs. 23%, P = 0.10, not significant). CONCLUSIONS: Curves in males appear to be more rigid than in females with AIS. However, posterior surgery for AIS provides similar short and long-term results in males and females.
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Scoliosis research society outcome instrument in evaluation of long-term surgical results in spondylolysis and low-grade isthmic spondylolisthesis in young patients.
STUDY DESIGN: A retrospective follow-up study of low-grade (slip < or = 50%) isthmic spondylolisthesis after posterior or posterolateral fusion in young patients. OBJECTIVE: To evaluate the usefulness of the Scoliosis Research Society questionnaire and compare it with Oswestry Disability Index and radiographic parameters in patients with isthmic spondylolisthesis. SUMMARY OF BACKGROUND DATA: A few studies have examined long-term patient outcome using validated questionnaires or compared it with radiographic parameters after surgery for isthmic spondylolisthesis in young patients. The Scoliosis Research Society questionnaire provides patient-oriented information on back pain, cosmetic aspects, patient satisfaction, and level of activity and might therefore be suitable for evaluation of surgical outcome after isthmic spondylolisthesis in young patients. However, there are no studies assessing the usefulness of the Scoliosis Research Society questionnaire for these patients. METHODS: One hundred and eight patients treated at a mean (range) age of 15.9 (range, 8.1-19.8) years with posterior (n = 29) or posterolateral (n = 79) in situ fusion for isthmic spondylolisthesis participated in the present study. The follow-up rate was 83% after a mean of 20.8 (range, 15.1-25.9) years. The mean age at follow-up observation was 36.7 years. Radiographs were obtained before surgery, at 2-year follow-up observation, and at final follow-up review. The Scoliosis Research Society and Oswestry Disability Index questionnaires were completed, and a physical examination was performed at the final follow-up visit. RESULTS: Nonunion after primary operation was found in 10 (34%) patients after posterior fusion and in 10 (13%) patients after posterolateral fusion (P = 0.0017). The mean (range) anterior slip was 25.2% (0-50%) before surgery and 24.2% (0-78%) at final follow-up observation. Lumbosacral kyphosis increased significantly during the follow-up period. The Scoliosis Research Society questionnaire yielded a total of 94.0 (range, 44-114) points. On the Scoliosis Research Society questionnaire, 14 (14%) patients reported back pain often or very often at rest. The Oswestry Disability Index scores averaged 8.2 (range, 0-68). There was a significant correlation between the Scoliosis Research Society total score and the Oswestry Disability Index. The percentage slip showed significant inverse correlations with the scores for appearance in clothes, attractiveness, and self image (Scoliosis Research Society questions 5, 14, and 15). CONCLUSIONS: Long-term clinical and radiographic outcomes after posterolateral fusion of low-grade spondylolisthesis were satisfactory. Cosmetic aspects of this deformity should be included as one of the outcome measurements, since cosmetic questions on the Scoliosis Research Society questionnaire showed inverse correlations between the amount of slip at final follow-up observation. The Scoliosis Research Society questionnaire could be used as a primary patient-oriented outcome tool after back surgery in young patients.
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Cotrel-Dubousset (CD) or Universal Spine System (USS) instrumentation in adolescent idiopathic scoliosis (AIS): comparison of midterm clinical, functional, and radiologic outcomes.
STUDY DESIGN: A retrospective comparison of the clinical, radiologic, and functional results of Cotrell-Dubousset (CD) and Universal Spine System (USS) instrumentation for adolescent idiopathic scoliosis (AIS). OBJECTIVES: To establish whether there are any differences in outcome between the 2 instrumentation systems. SUMMARY OF BACKGROUND DATA: CD is the first complex posterior double rod instrumentation system to provide multiple hook fixation. USS instrumentation permits the use of rod translation instead of rod rotation, the option to secure pedicle hooks with fixation screws, and the option to use transpedicular screws in the lower thoracic and lumbar spine. Midterm and long-term results of USS instrumentation are lacking. METHODS: Fifty-seven (mean age, 28 years at follow up) patients treated with CD instrumentation and 55 (mean age, 23 years at follow up) patients treated with USS instrumentation for AIS participated in the study. The average follow-up rate was 80% and time 13.0 years for the CD group, and 95% and 7.8 years for the USS group. Radiographs were obtained before surgery, at 2-year follow up, and at final follow up. Additionally, a physical examination was performed by 2 independent observers, and the Scoliosis Research Society (SRS) questionnaire was completed; spinal mobility and nondynamometric trunk strength were measured at the final follow-up visit. RESULTS.: The mean Cobb angle of the instrumented thoracic curve was before surgery 55 degrees (range, 36-83 degrees for the CD and 52 degrees (range, 35-85 degrees) for the USS group. The mean number of instrumented vertebrae was 9.9 (range, 7-12) in the CD and 9.8 (range, 6-12) in the USS group. At final follow up, the mean angles were 32 degrees (range, 13-63 degrees) for the CD group and 29 degrees (range, 9-63 degrees) for the USS group (not significant). No significant difference was observed in thoracic kyphosis or lumbar lordosis between the study groups at final follow up. In the SRS questionnaire, the total score averaged 97 for the CD and 101 for the USS groups, respectively. In the questionnaire, 6 (11%) patients in the CD group, but none in the USS group, reported having low back pain often or very often at rest. No correlation was found between the Cobb angle of the thoracic or lumbar curves at follow up and the total score or back pain indexes of this questionnaire. Nondynamometric trunk strength measurements corresponded with age- and sex-adjusted reference values, on average, but patients in the CD group performed significantly better in the squatting test (P = 0.021) and patients in the USS group performed better in trunk side bending (P = 0.004). Complications were recorded in 15 (26%) patients in the CD and in 13 (24%) patients in the USS group (not significant). CONCLUSIONS: The midterm radiologic and functional outcomes were quite similar in both groups as were the SRS scores. The patients performed, on average, as well as did the reference population in nondynamometric trunk strength measurements. Intraoperative and late complications were similar in both groups.
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Implant removal for late-developing infection after instrumented posterior spinal fusion for scoliosis: reinstrumentation reduces loss of correction. A retrospective analysis of 45 cases.
A retrospective follow-up study of patients who, having undergone instrumented posterior spinal fusion for scoliosis, experienced late infection and then underwent either implant removal alone or implant removal and instrumented refusion. We conducted this study to determine whether it is possible to avoid loss of correction by a single-stage implant removal and reinstrumentation procedure. There have been a few reports of late-appearing infections after spinal instrumentation. Implant bulk, metallurgic reactions, and contamination with low-virulence microorganisms have been suggested as possible etiologic factors. The clinical symptoms include pain, swelling, redness, and spontaneous drainage of fluid. Complete instrumentation removal and systemic antibiotics is usually curative. We retrospectively reviewed 45 patients who underwent instrumented posterior spinal fusion for scoliosis and experienced development of late infections and, after a mean of 3 years after the initial procedure, either underwent implant removal alone [ n=35, instrumentation removal (HR) group] or additionally underwent reinstrumentation and fusion [ n=10, reinstrumentation and fusion (RI&F) group]. Three patients were reinstrumented 1.5 years after instrumentation removal, and seven underwent a one-stage rod removal and reinstrumentation/refusion procedure. Allergic predisposition, protracted postoperative fever, and pseudarthrosis appear to increase the risk of late-developing infection after posterior spinal fusion. All wounds in both groups healed uneventfully. Preoperative radiographic Cobb measurements showed no statistically significant between-group differences. At follow-up, however, outcome was clearly better in the RI&F group: Loss of correction was significantly smaller in reinstrumented patients. Thus, the thoracic Cobb angle was 28+/-16 degrees (range 0-55 degrees ) in the RI&F group versus 42+/-15 degrees (21-80 degrees ) in the HR group, and the lumbar Cobb angle was 22+/-11 degrees (10-36 degrees ) in the RI&F group versus 29+/-12 degrees (13-54 degrees ) in the HR group. The results of our study demonstrate that wound healing is usually uneventful after instrumentation removal for late infection, also when patients undergo instrumented refusion in a one-stage procedure. Reinstrumentation appears to achieve permanent correction of scoliosis.
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Three-dimensional stabilization provided by the external spinal fixator compared to two internal fixation devices: a biomechanical in vitro flexibility study.
We performed an in vitro study to investigate the stabilization (i.e. motion reduction) provided by the external spinal fixator (ESF), and to compare the three configurations of the ESF with two internal fixation techniques. Six human cadaveric lumbar spine specimens (L3-S1) were subjected to multidirectional flexibility testing in six configurations: (1) intact, (2) ESF in neutral, (3) ESF in distraction, (4) ESF in compression, (5) translaminar facet screw fixation, and (6) internal transpedicular fixation. Both the ESF and the internal fixation systems stabilized the specimens from L4 to S1. In each testing configuration, pure bending moments of flexion-extension, bilateral axial rotation, and bilateral lateral bending were applied to the uppermost vertebra stepwise to a maximum of 10 Nm. The rigid body motion between the vertebrae was measured using an optoelectronic camera system, and custom software was used to calculate the intervertebral rotations. For each applied motion in all testing configurations, the total range of motion (ROM) of L4-S1 is reported. All three ESF configurations stabilized the spine significantly when compared to the intact specimen. The ESF in compression provided significantly more stabilization in flexion-extension than the two other ESF configurations, but no other significant differences were found between the three ESF modes. In flexion-extension the ESF stabilized the spine significantly when compared with the two internal fixation devices. Only in bilateral lateral bending was the ESF inferior to internal transpedicular fixation in providing stabilization. The results of the present study suggest that the ESF provides a high degree of stabilization for preoperative assessment of selected low back pain patients. Whether other non-mechanical factors affect the pain relief experienced by the patients remains unknown.
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Body mass index and slipped capital femoral epiphysis.
Body mass index (BMI) as a predictor of slipped capital femoral epiphysis (SCFE) was studied. A total of 26 adolescent patients had complete annual height and weight measurements taken from birth to onset of slippage. These values were compared with those of the normal adolescent population. Patients with SCFE showed statistically higher BMI during growth than normal developing children. BMI gives more accurate data on body build than height and weight alone and may be a useful tool for evaluating risk factors in SCFE.
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Harrington and Cotrel-Dubousset instrumentation in adolescent idiopathic scoliosis. Long-term functional and radiographic outcomes.
BACKGROUND: Previous studies have shown that the long-term clinical outcome does not correlate with the radiographic outcome in patients treated with Harrington instrumentation for adolescent idiopathic scoliosis. Cotrel-Dubousset instrumentation has been reported to provide better correction radiographically, but it is unclear whether it provides better long-term clinical or functional outcomes. We are not aware of any long-term studies comparing Harrington and Cotrel-Dubousset instrumentation. METHODS: Seventy-eight patients in whom adolescent idiopathic scoliosis was treated with Harrington instrumentation and fifty-seven in whom it was treated with Cotrel-Dubousset instrumentation participated in this study. The mean duration of follow-up was 20.8 years for the Harrington instrumentation group and 13.0 years for the Cotrel-Dubousset instrumentation group. The mean age at the time of follow-up was thirty-six years and twenty-eight years, respectively. Radiographs were made preoperatively and at the two-year and final follow-up examinations. The Scoliosis Research Society questionnaire was completed, a physical examination was performed, and spinal mobility and non-dynamometric trunk strength were measured at the final follow-up visit. RESULTS: The mean preoperative Cobb angle of the thoracic curves was 53 degrees in the Harrington instrumentation group and 55 degrees in the Cotrel-Dubousset instrumentation group. The mean numbers of vertebrae included in the instrumentation were 10.7 and 9.9, respectively. At the two-year follow-up evaluation, the mean postoperative Cobb angles were 38 degrees and 25 degrees, respectively (p < 0.0001). At the final follow-up evaluation, the mean angles were 45 degrees and 32 degrees (p < 0.0001). No significant difference in thoracic kyphosis or lumbar lordosis was observed between the study groups at the final follow-up evaluation. The average score on the Scoliosis Research Society questionnaire was 97 points in both groups. Measurements of non-dynamometric trunk strength corresponded with age and sex-adjusted reference values, on the average, but patients with Cotrel-Dubousset instrumentation performed significantly better in the squatting test (p = 0.010). Abnormal lumbar extension and trunk side-bending were significantly more common in the Harrington instrumentation group (p = 0.050 and p = 0.0061, respectively). Complications were recorded for nine (12%) of the patients treated with Harrington instrumentation and fifteen (26%) of those treated with Cotrel-Dubousset instrumentation (p = 0.027). CONCLUSIONS: Cotrel-Dubousset instrumentation yielded better long-term functional and radiographic outcomes in patients with adolescent idiopathic scoliosis than did Harrington instrumentation. However, complications were more common in the Cotrel-Dubousset instrumentation group.
Adolescent↗
Is there a connection between the clinical response after an external fixation test or a subsequent lumbar fusion and the pre-test intervertebral kinematics?
STUDY DESIGN: Evaluation of a possible correlation of clinical symptoms of chronic low back pain (LBP) patients before and after application of external spinal fixation (ESF) with three-dimensional motion patterns. OBJECTIVE: To determine whether the intervertebral kinematics in chronic LBP patients correlate with pain relief after stabilization of the suspected painful segments. SUMMARY OF BACKGROUND DATA: Chronic LBP is a complex clinical entity with mechanical, biochemical, and psychosocial components. Although clinically controversial, ESF has been shown to reduce intervertebral motion, and thus, it provides a mechanism to investigate the mechanical aspect of LBP. METHODS: Thirty-four chronic LBP patients were tested with ESF of the suspected painful segments. The subjective pain relief experienced by the patients during the test and 2 years after spinal fusion surgery was determined, along with the Oswestry Disability Index. Before removal of ESF, the three-dimensional intervertebral kinematics of the painful segments (specifically range of motion, coupling patterns, and motion asymmetries) were analyzed with a precision optoelectronic camera system during active trunk motions. A series of linear correlations were performed between the clinical measures and the motion parameters. RESULTS: The subjective pain relief during the ESF test was nominally, but not significantly, associated with lateral bending asymmetry ( = 0.22) and "abnormal" axial rotation-lateral bending coupling ( = 0.13). The improvement in the Oswestry Disability Index both post-test and at 2 years after lumbar fusion surgery was significantly correlated with the extension range of motion ( = 0.049 and = 0.036, respectively) and the extension-to-flexion range of motion ratio ( = 0.035 and = 0.044, respectively). CONCLUSIONS: The "abnormal" motion patterns of chronic LBP patients did not correlate with subjective pain relief after ESF of the suspected symptomatic levels or with the midterm outcome of subsequent lumbar fusion surgery. The results suggest that preserved motion of the symptomatic segments before surgery is positively correlated with the clinical result of the subsequent spinal fusion in case of a positive ESF test result.
Adult↗