The correlation of idiopathic lumbar scoliosis and lumbar lordosis

A definite correlation exists between the presence of idiopathic lumbar scoliosis and hyperlordosis of the lumbar spine. Present data do not reveal whether hyperlordosis constitutes an element which makes a "spine at risk" for developing scoliosis. However, the presence of an extreme lordosis suggests that in any comprehensive plan of treatment of idiopathic lumbar scoliosis, provision should be made for correction of severe deformities of the lumbar spine.     

Prevalence of adolescent idiopathic scoliosis in Hungary

An attempt of PCS was performed for the first time in Japan. Eighteen hundred twenty-six preschool and school children were examined and the result was compared with other studies (physician's auscultation and PCG). The time requirement for a single child is approximately 1.5 min. in primary school. It took longer time in kindergarten. The heart murmur detection rate is high and the sensitivity is fairly good, although it is not so good as well-trained physician's heart murmur detection rate. PCS is not perfect, but is fairly good tool for screening. It can be used only by technician. PCS may be able to save the physician's time.     

Relation between adolescent idiopathic scoliosis and morphologic somatotypes

STUDY DESIGN: A prospective and controlled comparative study. OBJECTIVES: To verify the difference in morphologic appearance between a group of adolescents with progressive adolescent idiopathic scoliosis and a control group of normal adolescents. SUMMARY OF BACKGROUND DATA: In a previous retrospective study, the possibility of a relation between progressive adolescent idiopathic scoliosis and specific morphotypes was demonstrated. METHODS: Fifty-two adolescent girls with progressive adolescent idiopathic scoliosis were compared with an age-matched control group of 62 unaffected girls using a classification technique based on morphologic somatotypes. Morphotypes were evaluated with standardized pre-established criteria based on Sheldon's technique. RESULTS: Patients with progressive adolescent idiopathic scoliosis showed significantly less mesomorphism (mean value of 0.88 +/- 0.51) than control girls (mean value of 1.72 +/- 0.52). CONCLUSION: Adolescent girls with progressive adolescent idiopathic scoliosis have a morphologic somatotype that is different from the normal adolescent population. Subjects with progressive adolescent idiopathic scoliosis are significantly less mesomorphic than control girls. This observation may be of value as a predictive factor for early identification of subjects with adolescent idiopathic scoliosis at greater risk of progression.     

Morphologic discrimination among healthy subjects and patients with progressive and nonprogressive adolescent idiopathic scoliosis

STUDY DESIGN: A prospective and controlled comparative study. OBJECTIVES: To identify variables that would allow discrimination among patients with progressive adolescent idiopathic scoliosis, patients with nonprogressive adolescent idiopathic scoliosis, and control subjects. SUMMARY OF BACKGROUND DATA: In a previous study, the correlation was demonstrated between morphologic somatotypes and adolescent idiopathic scoliosis. METHODS: One hundred forty-six subjects were evaluated anthropometrically and were classified according to their morphologic somatotype. Of these subjects, 52 were adolescent girls with progressive idiopathic scoliosis, whereas 32 girls had nonprogressive idiopathic scoliosis. The control group was composed of 62 healthy adolescent girls. Somatotype values for ectomorphism, mesomorphism, and endomorphism were obtained according to a technique based on Sheldon's method, and 77 anthropometric measurements of segments of the thorax, head, and limbs were taken. RESULTS: The discriminant analysis realized on a subset of 18 variables allowed the correct identification of each subject's group in 84% of the cases. CONCLUSIONS: It is possible to differentiate healthy adolescent subjects, patients with nonprogressive adolescent idiopathic scoliosis, and patients with progressive idiopathic scoliosis by using anthropometric measurements and morphologic classification. These findings may be useful in the early detection of children at risk for progression of scoliosis and may allow earlier application of treatment methods without waiting for a significant increase in the curve.     

A comparison of radiographic and electrogoniometric angles in adolescent idiopathic scoliosis

STUDY DESIGN: This was a cross-sectional study of a consecutive group of adolescent patients presenting to a scoliosis clinic for routine assessment or monitoring of their scoliosis, excluding postsurgical patients. SUMMARY OF BACKGROUND DATA: In vitro studies suggested electrogoniometry could be useful in the evaluation of scoliosis. No prior in vitro study had been performed. OBJECTIVES: To determine the reliability and validity of an electrogoniometric instrument, the Metrecom Skeletal Analysis System, in assessing adolescent idiopathic scoliosis. METHODS: Thirty-one patients were examined, radiographed, and scanned with the Metrecom Skeletal Analysis System twice by two different examiners. The magnitudes of the curves derived from the Metrecom Skeletal Analysis System scans were compared with each other and with the Cobb angles measured from standing radiographs. RESULTS: The intraclass correlation coefficient (a measure of agreement, ranging from 0 to 1, where 1 represents complete agreement) for the intraexaminer reliability of the Metrecom Skeletal Analysis System ranged from 0.71 to 0.83. The interexaminer reliability intraclass correlation coefficient of the Metrecom Skeletal Analysis System was 0.58, with a mean difference between examiners of 5.5 degrees (SD = 5 degrees), and limits of agreement (mean difference +/-2 SD) ranging from -4.5 degrees to 15.6 degrees. The Metrecom Skeletal Analysis System and the radiographically derived Cobb angle correlation was 0.64, but the mean difference between the methods was 3.7 degrees (SD = 11.1), with limits of agreement from 18.4 degrees to 25.9 degrees. CONCLUSION: The Metrecom Skeletal Analysis System does not provide sufficient clinical precision to substitute for the Cobb angle measured from spinal radiographic measurements in the management of adolescents with scoliosis.     

The lordotic effect of the OSI frame on operative adolescent idiopathic scoliosis patients

STUDY DESIGN: A prospective evaluation of adolescent idiopathic scoliosis patients undergoing operative treatment on the Orthopedic Systems Incorporated (OSI; Jackson) frame. OBJECTIVES: To investigate prospectively thoracic, thoracolumbar, and lumbar sagittal alignments in patients with adolescent idiopathic scoliosis who undergo an instrumented posterior spinal fusion on the OSI frame. SUMMARY OF BACKGROUND DATA: In several studies, it has been shown that patient positioning on various operative frames is an important component of ultimate lumbar sagittal alignment. However, these studies have all concentrated on the lumbar spine, and no sagittal plane alignment data in adolescent idiopathic scoliosis patients have been reported in the thoracic and thoracolumbar junction as it relates to intraoperative positioning, correction maneuvers and correlative postoperative results. METHODS: Thirty-nine patients with operative adolescent idiopathic scoliosis treated with an instrumented posterior spinal fusion on the OSI frame were prospectively evaluated. Standing preoperative, intraoperative, and postoperative long-cassette lateral radiographs were reviewed with regional and segmental Cobb measurements of the thoracic, thoracolumbar junction, and lumbar spine obtained. RESULTS: Thoracic kyphosis (T1-T12) measured +34 degrees before surgery, +28 degrees during surgery, and +30 degrees after surgery, Thus, a statistically significant decrease was noted in thoracic kyphosis secondary to prone positioning on the OSI frame ( P < 0.05). Thoracolumbar spine measurements from T10 to L2 also showed a lordotic trend from +2 degrees before surgery, to -4 degrees during surgery, to -8 degrees after surgery, which was also statistically significant (P < 0.05). Total lumbar lordosis from T12 to S1 remained relatively unchanged from -60 degrees before surgery, to -59 degrees during surgery, to -60 degrees after surgery. However, segmental lumbar lordosis measured from T12 to the lowest instrumented vertebra showed a statistically significant increase in lordosis from -17 degrees before surgery, to -19 degrees during surgery, to -23 degrees after surgery (P < 0.05). Those patients in whom lumbar pedicle screws were used (vs. hooks alone) had the greatest increase in lumbar instrumented lordosis. CONCLUSIONS: Performing adolescent idiopathic scoliosis correction on the OSI frame tends to decrease thoracic kyphosis, increase thoracolumbar lordosis, and increase segmental instrumented lumbar lordosis, while it maintains total lumbar lordosis.     

The Milwaukee brace for the treatment of adolescent idiopathic scoliosis. A review of one thousand and twenty patients

We reviewed the medical records and roentgenograms of 1020 patients who had been managed for adolescent idiopathic scoliosis, between January 1954 and December 1979, with a Milwaukee brace; we wished to determine whether use of the brace had effectively altered the natural history of the disease. The findings were considered with respect to a previous study of 727 children who had had comparable curves and had not initially been managed with the brace but had been followed for progression of the curve, during the same time-span as that in the current study. Of those 727 patients, 558 (77 percent) had no progression of the curve. The average age of the 1020 patients at the time that treatment with the brace was begun was thirteen and one-half years (range, ten to seventeen years). None of the patients had received any other treatment, and all had been managed only by the physicians participating in this study. In both the current and the earlier series, the outcome was considered a failure if the curve had increased 5 degrees or more; in the patients in the current study, who were managed with the brace, the outcome was also considered a failure if operative intervention had been needed. Of the 1020 patients in the current series, 229 (22 percent) had operative intervention; this rate was higher in the patients who had a curve of more than 30 degrees at the time of bracing and in those who had a Risser sign of 0 or 1. The 791 remaining patients, who were managed with the brace only, had a mild improvement of 1 to 4 degrees at the time that use of the brace was discontinued (the difference being within the margin of error of measurement). With respect to curves of between 20 and 39 degrees, the rate of failure was lower in the current series of patients who had been managed with the brace than in the earlier series of patients who had not been thus managed but had been followed for progression. Progression of the curve was found to be related to the pattern and magnitude of the curve; the age of the patient at the time of presentation; the Risser sign; and, in girls, the menarchal status. We recommend that immature adolescents who have a curve of more than 25 degrees and a Risser sign of 0 be managed with a brace immediately, rather than after progression has been documented.     

Halm-Zielke instrumentation for primary stable anterior scoliosis surgery: operative technique and 2-year results in ten consecutive adolescent idiopathic scoliosis patients within a prospective clinical trial

OBJECTIVE: To determine the efficacy and safety of a new continence procedure, tension-free vaginal tape (TVT) placement for surgical treatment of stress urinary incontinence in women. STUDY DESIGN: Eighty-three women with demonstrable stress urinary incontinence underwent a nonrandomized, prospective study using the TVT procedure. The procedure was previously described by Ulmsten et al. In the present study, instead of local anesthesia, epidural blockade with 20 mL of 2% xylocaine was used. Preoperatively the patients were evaluated with a one-hour pad test, full urodynamic testing using either a double-lumen catheter or microtip transducer catheter and were instructed to maintain an one-week baseline urinary diary one week before and two months after the operation. Another one-hour pad test and complete urodynamic evaluation using microtip transducer catheters were offered to 20 patients postoperatively. The period of follow-up ranged from 3 to 18 months. RESULTS: Thirteen women were excluded for various reasons; thus, 70 subjects were enrolled in the study. The urodynamic diagnosis of the 83 women revealed that 71 had genuine stress incontinence, 11 had mixed incontinence and 1 was normal. Mean operation time was 29 minutes (range, 20-51) and mean hospital stay 3 days (range, 2-8). Three bladder perforations occurred intraoperatively. No patients had intraoperative bleeding > 300 mL, but 11 (16%) had blood loss > 200 mL, necessitating an indwelling catheter and vaginal tamponade. No evidence of defect healing or rejection of the tape occurred. Urine leakage observed on the pad test was significantly reduced from a mean of 63 g (range, 10-213) before to a mean of 5 g (range, 0-42) after surgery. The objective cure rate was 83%, and the subjective rate was 87%. CONCLUSION: Although the follow-up period was short, the TVT procedure seemed to be a safe and effective method for the treatment of stress urinary incontinence.     

Genetics of idiopathic scoliosis

To define the luminal agent(s) responsible for the reduction of nephron filtration rate following increases of loop of Henle flow rate early proximal flow rate (EPFR) during loop perfusion with 17 different salt solutions were compared to the non-perfused tubules. During orthograde microperfusions a reduction of EPFR as indication of a feedback response was noted with a number of monovalent Cl- and Br- salts (LiCl, KCl, NaCl, RbCl, CsCl, NH4Cl, choline Cl, NaBr, KBr), with Na+ salts except Na acetate (NaHCO3, NaNO3, NaF, NaI, NaSCN), and with CaCl2 and MgCl2. These latter 2 solutions where used in a concentration of 70 mM while all other solutions had a concentration of 140 mM. During retrograde perfusion from the distal to the proximal end of the loop of Henle EPFR fell significantly with Cl- and Br- salts with percentage changes of EPFR ranging from -8.0 to -44.3%. In contrast, Cl- free salts and Cl- salts of divalent cations were associated with percentage changes of EPFR ranging from +7.1 to -6.2%, significance being reached only during perfusion with NaSCN. When furosemide (5 x 10(-4) M) was added to NaBr or KBr a feedback response was not observed. During orthograde perfusion with NaNO3 distal Cl- concentrations were 44.2 +/- 5.08, mM (mean +/- S.E.) at a perfusion rate of 10 nl/min and 59.1 +/- 3.93 mM at a rate of 40 nl/min. CaCl2 perfusion induced a marked elevation of distal Cl- concentrations to levels higher than 140 mM. Loop chloride handling was normal during RbCl perfusion. The magnitude of the feedback response during retrograde perfusion was not changed by lowering NaCl concentration from 140 to 60 mM, but fell when NaCl concentration was further reduced. In contrast to orthograde perfusions it was insensitive to changes in flow rate. Our results are compatible with the thesis that feedback responses depend critically upon the rate of Cl- transport probably across the macula densa cells. Br- ions can replace Cl- because they appear to share a common transport pathway which can be inhibited with furosemide. Unspecificity of feedback responses during orthograde microperfusions is due to presence of Cl- ions in the macula densa region even when solutions are initially Cl- free. Cl- salts of divalent cations do not elicit a feedback response because Cl- transport is severely curtailed.     

Ganglioneuroma of the thoracic spine presenting as adolescent idiopathic scoliosis: a case report

Total coumarins of Fructus Cnidii (TCFC), 5 g.kg-1 by intragastric gavage, 6 d/wk, x 7 wk, was effective for prevention of bone loss in ovariectomized (OVX) rats. In comparison to aging control rats, the proximal tibia of placebo-treated OVX rats were characterized by an increase in eroded perimeter (+298%), label perimeter (+77%), osteoid perimeter (+47%), mineral apposition rate (+32%) and bone formation rate (+130%). These changes indicated a high bone turnover in OVX rats leading to a rapid bone loss (-44%) in proximal tibial metaphysis. In contrast, the TCFC-treated OVX rats showed an increase of cancellous bone area (+41%) compared with placebo-treated OVX rats and decrease in all the above indices of bone turnover to near aging control levels except that of the osteoid area (+88%) which was higher than that in aging control, but mineralization lag time did not show significant changes. The results suggested that the TCFC inhibited the high bone turnover and reversed the bone loss at early menopausal stage.     

Transpedicular fixation with Zielke instrumentation in the treatment of thoracolumbar and lumbar injuries

STUDY DESIGN: Sixty-five patients who underwent transpedicular fixation for thoracolumbar and lumbar injuries were studied for type of injury, the severity of paralysis, the degree of postoperative correction, and instrumentation failures. OBJECTIVES: To evaluate the surgical approaches and the selection of instrumentation to determine indications for using the transpedicular fixation procedure. SUMMARY OF BACKGROUND DATA: Various transpedicular fixation devices have been used for different type of injuries, and satisfactory postoperative results were not obtained in some studies. METHODS: Forty patients had burst fractures, 19 had fracture dislocations, and six had chance-type fractures. An anterior decompression procedure was used for most cases of burst fracture and some cases of fracture dislocation where anterior compression factors were present. The Zielke or modified Zielke system was used as an internal fixator for posterior segmental fixation. RESULTS: No patient had neurologic deterioration after surgery. Twenty of 28 patients with incomplete lesions improved postoperatively according to Frankel grades. The instrumentation failed in only one patient, in whom a nonunion developed. CONCLUSION: With transpedicular fixation, it is possible to provide solid internal fixation that is circumscribed to the injured vertebral segments. The elasticity of the Zielke rod makes it an excellent transpedicular fixation device because it is easily attached and reduction is easily performed. Anterior decompression with fusion needs to be used with transpedicular fixation in the treatment of injuries (especially burst fractures).     

New anterior instrumentation for the management of thoracolumbar and lumbar scoliosis. Application of the Kaneda two-rod system

STUDY DESIGN: The Kaneda multisegmental instrumentation is a new anterior two-rod system for the correction of thoracolumbar and lumbar spine deformities. This system consists of a vertebral plate and two vertebral screws for individual vertebral bodies and two semirigid rods to interconnect the vertebral screws. Clinical results of 25 thoracolumbar and lumbar scoliosis patients treated with this new instrumentation were analyzed. OBJECTIVES: To evaluate the efficacy of the new anterior instrumentation in correction and stabilization of thoracolumbar and lumbar scoliosis. SUMMARY OF BACKGROUND DATA: Since Dwyer first introduced the concept of anterior spinal instrumentation and fusion for scoliosis, anterior surgery has gradually gained acceptance. In 1976, a useful modification for the anterior spinal instrumentation, which reportedly provided means of lordosation and vertebral body derotation, was described. However, some authors reported a high tendency of the implant breakage, loss of correction, progression of the kyphosis, and pseudoarthrosis as the major complications. To overcome the disadvantages of Zielke instrumentation, the authors have developed a new anterior spinal instrumentation (two-rod system) for the management of thoracolumbar and lumbar scoliosis. METHODS: Anterior correction and fusion using Kaneda multisegmental instrumentation was performed in 25 patients with thoracolumbar or lumbar scoliosis. The average follow-up period was 3 years, 1 month (range, 2 years to 4 years, 7 months). There were 20 patients with idiopathic scoliosis (13 adolescents and seven adults) and five patients with other types of scoliosis, including congenital and other etiologies. All patients had correction of scoliosis by fusion within the major curve, and for 16 of the 25 patients, the most distal end vertebra was not included in the fusion (short fusion). Radiographic evaluations were performed to analyze frontal and sagittal alignments of the spine. RESULTS: The average correction rate of scoliosis was 83%. Over the instrumented levels, the correction rate was 90%. Preoperative kyphosis of the instrumented levels of 7 degrees was corrected to 9 degrees of lordosis. Sagittal lordosis of the lumbosacral area beneath the fused segments averaged 51 degrees before surgery and was reduced to 34 degrees after surgery. The trunk shift was improved from 25 mm before surgery to 4 mm at final follow-up evaluation. The average improvement in the lower end vertebra tilt-angle was 97% in those patients whose lower end vertebra was included in the fusion and 83% in patients whose lower end vertebra was not included in the fusion. Apical vertebral rotation showed an average correction rate of 86%. At final follow-up evaluation, all patients demonstrated solid fusion without implant-related complications. There was 1.5 degrees of frontal plane and 1.5 degrees of sagittal plane correction loss within the instrumented area at final follow-up evaluation. CONCLUSIONS: New anterior two-rod system showed excellent correction of the frontal curvature and sagittal alignment with extremely high correction capability of rotational deformities. Furthermore, correction of thoracolumbar kyphosis to physiologic lordosis was achieved. This system provides flexibility of the implant for smooth application to the deformed spine and overall rigidity to correct the deformity and maintain the fixation without a significant loss of correction or implant failure compared with conventional one-rod instrumentation systems in anterior scoliosis correction.     

Nighttime bracing for adolescent idiopathic scoliosis with the Charleston Bending Brace: long-term follow-up

We report long-term experience with the Charleston Bending Brace for treatment of adolescent idiopathic scoliosis. This brace holds the patient in maximal side-bending correction and is worn at nighttime only. Patients included in this prospective multicenter study met all of the following criteria: skeletal immaturity (Risser 0, 1, or 2), curvature >25 degrees before bracing, no prior treatment, and >1-year follow-up since completion of bracing (skeletal maturity or progression to surgery). All curves were monitored and reported. There were 149 structural curves in 98 patients. Sixty-five (66%) patients showed improvement or <5 degrees change in curvature. Seventeen (17%) patients progressed to the point of requiring surgery for their scoliosis. Based on these long-term results and improvement of the natural history of adolescent idiopathic scoliosis, continued use of the Charleston Bending Brace is justified.     

Treatment of idiopathic scoliosis in children

This is an update on the surgical and orthopedic management of scoliosis in children. After a review of the biomechanical factors underlying the scoliotic deformity in the three dimensions, methods and indications of conservative treatment combining physiotherapy and full-time or part-time bracing are discussed. Development of new segmental spinal instrumentation devices has modified the surgical treatment of scoliosis by allowing three-dimensional correction of deformities and obviating the need for postoperative immobilization in a cast or corset. Results of conservative treatment are analyzed in an original series of 56 children with progressive scoliosis treated when the angulation was still under 30 degrees. Mean follow-up since the end of treatment is 14 years. Results show that proper conservative treatment arrests progression and modifies the natural history of scoliosis. Outcome after surgical treatment is analyzed in an original and recent series composed of the 50 first children who had posterior surgery with the new Cotrel-Dubousset instrumentation. Results of anterior surgery (V.D.S. instrumentation), which is still indicated in some cases, are analyzed in an older series of 18 cases. When the deformities are too severe to allow conservative treatment, short segment fusion effectively corrects the scoliosis and reliably provides good cosmetic and functional results.     

Surgical treatment of lumbar spinal stenosis in the elderly

148 elderly patients, aged 70 years or more, diagnosed as having lumbar spinal stenosis, were operated upon at our institution during 1983 to 1995. Totally 161 operative procedures were performed. We analysed retrospectively the results of the surgical treatment. The most frequently performed procedure was multisegmental laminectomy, in 32% interlaminar fenestration and laminotomy were done. In 9 cases fusion was indicated, two of them being secondary operations. The mean hospital stay was 11 days. The morbidity was 6%, and there was one fatality (0.6%). The outcome was determined according to the six-grade classification proposed by Pappas and Sonntag [25]. Overall, in 91% of cases satisfactory-to-excellent results could be achieved. We conclude, that in elderly patients with symptomatic lumbar spinal stenosis, with no evidence of instability, decompressive surgery without stabilisation can be done in the majority of patients with low morbidity and high expectation of clinical improvement.     

Changes in the unfused lumbar spine in patients with idiopathic scoliosis. A 5- to 9-year assessment after cotrel-dubousset instrumentation

STUDY DESIGN: Postoperative changes in the lumbar spine were studied retrospectively in patients with adolescent idiopathic scoliosis who had been treated with Cotrel-Dubousset instrumentation. OBJECTIVE: To examine middle-term changes in the unfused lumbar segments below an instrumented scoliosis fusion. SUMMARY OF BACKGROUND DATA: Scoliosis fusion by the Harrington method is known to be associated with a flat back in the fused area and subsequent degenerative changes in the segments below the fusion. No data have yet been published concerning a segmental instrumentation system. PATIENTS AND METHODS: Thirty patients with idiopathic scoliosis, between the ages of 14 and 22 years at the time of surgery, were observed for 5-9 years after surgery. Activity, pain, complications, and 21 radiographic parameters were assessed. RESULTS: The prevalence of low back pain increased from 3% before surgery to 20% at the final follow-up visit, although in none of the patients was the pain so severe that specific treatment was required. Radiographically, uninstrumented lumbar segments generally were realigned successfully in the frontal plane. Analyses in the sagittal plane revealed tendencies to a gradual increase in lumbar lordosis, anterior-upward tilting of the lowest instrumented vertebra, and posterior shift of the sagittal spinal balance. During the follow-up period, seven patients (23%) developed degenerative changes, including mild junctional kyphosis, retrolisthesis, narrowing of disc spaces, or osteophytes. CONCLUSION: Whereas the overall clinical and radiographic results of surgery were satisfactory, the unfused lumbar segments required careful surveillance, especially in the sagittal plane.