Francis Denis

From a retrospective study of 412 thoracolumbar injuries, the author introduces the concept of middle column or middle osteoligamentous complex between the traditionally recognized posterior ligamentous complex and the anterior longitudinal ligament. This middle column is formed by the posterior wall of the vertebral body, the posterior longitudinal ligament and posterior annulus fibrosus. The third column appears crucial, as the mode of its failure correlates both with the type of spinal fracture and with its neurological injury. Spinal injuries were subdivided into minor and major. Minor injuries are represented by fractures of transverse processes, facets, pars interarticularis, and spinous process. Major spinal injuries are classified into four different categories: compression fractures, burst fractures, seat-belt-type injuries, and fracture dislocations. These four well-recognized injuries have been studied carefully in clinical terms as well as on roentgenograms and computerized axial tomograms. They were then subdivided into subtypes demonstrating the very wide spectrums of these four entities. The correlation between the three-column system, the classification, the stability, and the therapeutic indications are presented.

Sacral fractures, often undiagnosed and untreated, frequently result in neurologic symptoms and deficits to the lower extremities and urinary, rectal, and sexual dysfunctions. These same neurologic problems often remain the major chronic sequelae after the more obvious pelvic trauma lesion has healed. Specific treatments aimed at neurologic problems are available and may allow the patient functional recovery. This is illustrated by anatomic observations on the sacrum in 39 cadavers showing the relationship among sacral nerve roots within their foramina. These observations were valuable for a retrospective study of 236 consecutive patients with sacral fractures in a series of 776 patients with pelvic injuries. A new classification of sacral fractures evolved from this study and provided a better understanding of the mechanisms responsible for the associated neurologic symptoms. The classification is based on the direction, location, and level of sacral fractures. Three different zones were identified as having characteristic clinical presentations: Zone I, the region of the ala, was occasionally associated with partial damage to the fifth lumbar root. Zone II, the region of the sacral foramina, is frequently associated with sciatica but rarely with bladder dysfunction. Zone III, the region of the central sacral canal, is frequently associated with saddle anesthesia and loss of sphincter function. Routine pelvic roentgenograms were almost useless in identifying the pathologic process in sacral injuries with neurologic symptoms. Ferguson views, tomograms, and particularly computed tomography scans were crucial for understanding these injuries. Cystometrography was most helpful in positively identifying fractures causing neurogenic bladders. Cystometrograms should be ordered routinely in Zone III injuries. Preliminary observations suggest that surgical decompression permitted significantly better neurologic recovery than nonsurgical methods.

A retrospective review of 1223 thoracic and lumbar anterior spinal fusions was performed from 1969 through 1992.To document the incidence and specific types of perspective complications related to anterior spinal fusions.Despite the increased use of anterior spinal surgery, there has been little documentation of the specific types and frequencies of the complications associated with its use.All Minnesota Spine Center patients age 18 years or older who had anterior spinal fusions between the levels of T1 and S1 from August 1969 to June 1992 were reviewed for the occurrence of perioperative complications. Surgical approach and technique and associated comorbidity was recorded.The risk of a complication was increased for patients over age 60 years, for women, and for patients with multiple preexisting health problems. Serious complications, such as death (0.3%), paraplegia (0.2%), and deep wound infection (0.6%) were rare. The complication rate for complications that were directly attributed to the anterior spinal surgery was 11.5%.Anterior spinal fusion surgery is a safe procedure and can be used with confidence when the nature of a patient's spinal disorder dictates its use. Complications are often approach specific.

The safety and the effectiveness of pedicle-screw instrumentation in the spine have been questioned despite its use worldwide to enhance stabilization of the spine. This review was performed to answer questions about the technique of insertion and the nature and etiology of complications directly attributable to the screws.We performed a retrospective review of all of the pedicle-screw procedures that were done by us from January 1, 1984, to December 31, 1993. We inserted 4790 screws during 915 operative procedures on 875 patients; 668 (76.3 percent) of the patients had a lumbosacral arthrodesis. The mean duration of follow-up was three years (range, two to five years). The accuracy of screw placement was assessed on intraoperative, immediate postoperative, and follow-up radiographs with use of a technique that was developed by one of us (F. D.); this technique has yet to be validated to determine the prevalence of various types of error.Of the 4790 screws, 4548 (94.9 percent) had been inserted within the pedicle and the vertebral body. One hundred and thirty-four (2.8 percent) of the screws had perforated the anterior cortex, and this was the most common type of perforation. One hundred and fifteen (2.4 percent) of the screws were associated with complications that could be ascribed to the use of pedicle screws. The most common problem was late-onset discomfort or pain related to a pseudarthrosis or perhaps to the screws; this problem was associated with 1102 (23.0 percent) of the screws, used in 222 (24.3 percent) of the procedures. The symptoms necessitated removal of the instrumentation with or without repair of the pseudarthrosis. A pseudarthrosis was found during forty-six (20.7 percent) of the 222 procedures. Irritation of a nerve root occurred after nine procedures (1.0 percent) and was caused by eleven screws (0.2 percent); it was more commonly caused by medially placed screws. Three patients had residual neurological weakness despite removal of the screws. Twenty-five screws (0.5 percent), used in twenty procedures (2.2 percent), broke. The screws that broke were of an early design. A pseudarthrosis was found in thirteen of twenty patients who had broken screws. Sixteen of the twenty patients had an exploration; three of them were found to have a solid fusion, and thirteen were found to have a pseudarthrosis. The remaining four patients had evidence of a solid fusion on radiographs and had no pain.There are few problems associated with the insertion of screws, provided that the surgeon is experienced and adheres to the principles and details of the operative technique. Our review revealed a low rate of postoperative complications related to pedicle screws. The problem of late-onset pain may be related to the implants or to the stiffness of the construct; however, it is difficult to accurately identify its exact etiology.

This article is a presentation of the concept of the three-column spine. The concept evolved from a retrospective review of 412 thoracolumbar spine injuries and observations on spinal instability. The posterior column consists of what Holdsworth described as the posterior ligamentous complex. The middle column includes the posterior longitudinal ligament, posterior annulus fibrosus, and posterior wall of the vertebral body. The anterior column consists of the anterior vertebral body, anterior annulus fibrosus, and anterior longitudinal ligament. Major spinal injuries are classified into four different categories, all definable in terms of the degree of involvement of each of the three columns. Each type is defined also in terms of its pathomechanics, roentgenograms, and computerized axial tomograms, as well as in terms of its particular stability. The compression fracture is basically stress failure of the anterior column with an intact middle column. The burst fracture indicates failure under compression of both the anterior and middle columns. The seat-belt-type spinal fracture is the result of failure of the posterior and middle columns under tension with an intact anterior hinge. In fracture-dislocations, the structure of all three columns fails from forces acting to various degrees from one or another direction.

Sacral fractures, often undiagnosed and untreated, frequently result in neurologic symptoms and deficits to the lower extremities and urinary, rectal, and sexual dysfunctions. These same neurologic problems often remain the major chronic sequelae after the more obvious pelvic trauma lesion has healed. Specific treatments aimed at neurologic problems are available and may allow the patient functional recovery. This is illustrated by anatomic observations on the sacrum in 39 cadavers showing the relationship among sacral nerve roots within their foramina. These observations were valuable for a retrospective study of 236 consecutive patients with sacral fractures in a series of 776 patients with pelvic injuries. A new classification of sacral fractures evolved from this study and provided a better understanding of the mechanisms responsible for the associated neurologic symptoms. The classification is based on the direction, location, and level of sacral fractures. Three different zones were identified as having characteristic clinical presentations: Zone I, the region of the ala, was occasionally associated with partial damage to the fifth lumbar root. Zone II, the region of the sacral foramina, is frequently associated with sciatica but rarely with bladder dysfunction. Zone III, the region of the central sacral canal, is frequently associated with saddle anesthesia and loss of sphincter function. Routine pelvic roentgenograms were almost useless in identifying the pathologic process in sacral injuries with neurologic symptoms. Ferguson views, tomograms, and particularly computed tomography scans were crucial for understanding these injuries. Cystometrography was most helpful in positively identifying fractures causing neurogenic bladders. Cystometrograms should be ordered routinely in Zone III injuries. Preliminary observations suggest that surgical decompression permitted significantly better neurologic recovery than nonsurgical methods.

The treatment of thoracolumbar burst fractures in the absence of neurologic deficit remains controversial. The present study is a retrospective analysis of 52 of these acute burst fractures among 104 cases of thoracolumbar burst fractures treated either operatively or nonoperatively. Results are expressed in terms of neurologic function, pain, work status, and complications. All patients who had surgical treatment and no unrelated disability returned to full-time work. Twenty-five percent of the patients treated nonoperatively were unable to return to work full time. Of the patients in the nonoperative group, 17% developed neurologic problems. Prophylactic stabilization and fusion of acute burst fractures without neurologic deficit have significant advantages over conservative management.

Background context Degenerative de novo scoliosis is commonly present in older adult patients with spinal pain. The degenerative process including disc bulging, facet arthritis, and ligamentum flavum hypertrophy contributes to the appearance of symptoms of spinal stenosis in these patients. Purpose The etiology, prevalence, biomechanics, classification, symptomatology, and treatment of degenerative lumbar scoliosis in association with spinal stenosis are reviewed. Study design Review study. Methods Retrospective analysis of studies focused on all parameters concerning degenerative scoliosis associated with stenosis. Results There is a variety of treatment methods of degenerative scoliosis based on symptomatology and radiologic measurements of scoliosis and stenosis. Satisfactory clinical results reported in relevant retrospective studies after operative treatment range from 83% to 96% but with increased percentage of complications. An algorithm for operative treatment corresponding to a newly proposed classification system of degenerative lumbar scoliosis with associated canal stenosis is presented. Conclusions There is an increasing prevalence of degenerative scoliosis in the aged population. Even though the exact percentage of patients with symptomatology of spinal stenosis is not known, the main goal is to provide pain relief and improved functional lifestyle with minimum intervention.

The authors reviewed 817 instrumented lumbosacral fusions in adults and found an incidence of 3.2% deep wound infections. The primary focus of this study was the management of these infections, with particular attention to whether the implants needed to be removed. A consulting infectious disease specialist indicated that an acute infection of a low back fusion wound could not be healed without removal of the metallic implants. This opinion was in contrast to the authors' daily experience and prompted this study. The authors identified and reviewed 817 cases of instrumented posterior lumbosacral arthrodeses in adults. A detailed analysis of any case with a deep wound infection was performed and yielded and infection rate of 3.2% (26 patients). Of these, 24 achieved a clean, closed wound without removal of instrumentation through a protocol of aggressive debridement and secondary closure. Instrumentation removal is not necessary to obtain a clean, closed wound using an aggressive approach with early diagnosis, vigorous debridement in the operative room under general anesthesia, delayed primary or secondary closure, and appropriate antibiotic coverage.

In Brief Study Design. This study prospectively evaluated the health related quality of life (HRQOL) of 73 adults presenting with scoliosis at a single institution, as related to their spinal (C7 plumbline) and global (gravity line) balance. Objective. To assess the influence of sagittal and coronal balance on HRQOL in adult scoliosis. Summary of Background Data. Many surgeons believe that achieving adequate spinal balance is important in the management of adult spinal deformity, but the evidence supporting this concept remains limited. A previous study has found weak correlations between sagittal spinal balance and HRQOL in adult spinal deformity, but this finding has never been confirmed independently. In addition, although the use of the gravity line is gaining interest in the evaluation of global balance, it remains unknown if this parameter is associated with HRQOL. Methods. During a 1-year period, 73 consecutive new patients presenting with unoperated adult scoliosis and requiring full spine standing radiographs were evaluated using a force plate in order to simultaneously assess the gravity line. All patients also completed the Oswestry Disability Index (ODI) questionnaire to assess the HRQOL. Spinal balance was evaluated from the C7 plumbline and global balance from the gravity line, respectively. C7 plumbline and gravity line were both assessed with respect to the posterosuperior corner of the S1 vertebral body and central sacral vertebral line in the sagittal and coronal plane, respectively. C7 plumbline and gravity line, as well as their relative position, were correlated with the ODI, using Spearman coefficients. Results. Sagittal spinal (C7 plumbline) and global (gravity line) balance, as well as their relative position were significantly related to the ODI. A poor ODI (>34) was associated with a sagittal C7 plumbline greater than 6 cm, a sagittal gravity line greater than 6 cm, and a C7 plumbline in front of the gravity line. Correlations between coronal balance and the ODI were not statistically significant. Conclusion. Sagittal spinal and global balance was strongly related to the ODI in adults with scoliosis. The observed correlation coefficients were higher than those reported in the only previous study suggesting the detrimental association of positive sagittal balance on ODI in adult spinal deformity. Coronal spinal and global balance did not influence the ODI in the current study cohort. Thisstudy underlines the relevance of C7 plumbline and gravity line in the evaluation of spinal and global balance, and lends further support to the philosophy of achieving adequate sagittal balance in the management of adult spinal deformity, especially in patients older than 50 years old with degenerative scoliosis. Spinal and global balance was evaluated prospectively in 73 adults with scoliosis. Sagittal spinal and global balance was strongly related to the quality of life, as opposed to coronal spinal and global balance, supporting the importance of achieving adequate sagittal balance in the treatment of adult spinal deformity.

In Brief Study Design. Retrospective case review at a single center. Objective. To analyze the incidence and risk factors associated with proximal junctional kyphosis (PJK) and distal junctional kyphosis (DJK) in patients undergoing instrumented spinal fusion for Scheuermann kyphosis. Summary of Background Data. Previously reported risk factors for junctional kyphosis include improper end vertebrae selection, curve correction greater than 50%, or excessive junctional soft tissue dissection. Methods. Clinical and radiographic data on 67 patients (mean age 37) from a single center treated with instrumented fusion for Scheuermann kyphosis were reviewed. All patients had complete radiographic data with a minimum 5-year follow-up (mean: 73 months). Abnormal PJK was defined by a proximal junctional angle greater than 10° and at least 10° greater than the corresponding preoperative measurement. DJK was similarly defined between the caudal endplate of the lower instrumented vertebra to the caudal endplate that was 1 vertebra below. Results. The incidence of PJK as defined above was seen in 20 patients (30%). The development of PJK was associated with failure to incorporate the proximal end vertebra (15 patients), disruption of junctional ligamentum flavum (3 patients), or combination of both (2 patients). The most common cause of inappropriate end vertebra selection was poor visualization of the upper thoracic vertebra. DJK occurred in 8 patients (12%) and 7 of them had fusion short of including the first lordotic disc. Conclusion. The incidence of PJK can be minimized by the appropriate selection of the upper end vertebra to be fused and avoiding disruption of the junctional ligamentum flavum. The development of DJK can be minimized by incorporation of the first lordotic disc into the fusion construct. An analysis of 67 surgically treated patients with Scheuermann kyphosis (mean follow-up: 73 months) revealed proximal junctional kyphosis in 30% and related either to too short a fusion, or disruption of the posterior ligament complex. Distal junctional kyphosis was seen in 12% and was related to failure in incorporating the first lordotic disc.

Sixty-eight patients with neuromuscular spine deformity were treated by posterior spine fusion with Luque-Galveston instrumentation between 1982 and 1986. The minimum follow-up was 4 years. Diagnoses included cerebral palsy in 34 patients and other neuromuscular diseases in another 34 patients. The average age was 14 years. Twenty patients also had anterior spine fusion without instrumentation. Preoperatively the average scoliosis was 73 degrees and this was corrected to 33 degrees at final follow-up. The subgroup having anterior discectomy and fusion had a more severe scoliosis and pelvic obliquity, but the percent of correction was similar to that of the group with posterior reconstruction only. Twenty-four patients who had an associated significant sagittal plane deformity were corrected to a physiologic curvature. A postoperative thoracolumbosacral orthosis was used in 27 patients, and a molded seating orthosis was used in 18. Although the rate of complications was high (62%), most of them were minor. Instrumentation problems occurred in 14 patients (21%), only 4 of them having broken rods. There were no broken wires. Pseudarthrosis occurred in seven patients (10%). Three patients had minor neurologic deficits, all transient. The "windshield-wiper" sign was defined as any radiolucency of 2 mm or greater. Twenty-six patients had this sign at follow-up, and this group had a higher percentage of complications, but the existence of this sign did not necessarily indicate a problem.

In Brief Study Design. A retrospective study of complications with minimal 5-year follow-up of 50 adults with scoliosis with fusion from T10 or higher to S1. Objectives. To document the perioperative and long-term complications and instrumentation problems, and to attempt to determine variables which may influence these problems. It is not a study of curve correction, balance, or functional outcome. Summary of Background Data. Several previous studies from this and other centers have shown a relatively high complication rate for this select group of patients. Various fusion techniques (anterior, posterior, autograft, allograft), various instrumentation techniques, and various immobilization techniques have created confusion as to the best methodology to employ. Minimal 2-year follow-ups have been standard, but longer follow-ups have shown additional problems. Methods. The study cohort consisted of 50 adult patients from a single center who had undergone corrective scoliosis surgery from T10 or higher to the sacrum and who had at least a 5-year minimum follow-up. The mean age was 54 years (range, 18–72), and the mean follow-up was 9.7 years (range, 5–26). All radiographs, office charts, and hospital charts were combed by an independent investigator for complications, which were divided into major and minor, as well as early, intermediate and late. The curvature values and corrections were the subject of a different article, and were not included in this study. Results. There were no deaths or spinal cord injuries. Six patients had nerve root complications, 4 of which totally recovered. Pseudarthrosis was seen in 24% of the patients, only 25% of which were detected within the 2-year follow-up period. Pseudarthrosis was most common at the lumbosacral level. There was no statistical difference in the pseudarthrosis rate between patients with sacral-only fixation versus iliac fixation. Painful implants requiring removal were noted in 11 of the 50 patients. Conclusion. Long fusions to the sacrum in adults with scoliosis continue to have a high complication rate. As compared to the original publications in the 1980s (Kostuik and Hall, Spine 1983;8:489–500; Balderston et al, Spine 1986;11:824–9) the more recent articles have shown a reduction, but not elimination of the pseudarthrosis problem using segmental instrumentation and anterior fusion of the lumbar spine coupled with structural interbody grafting at L4–L5 and L5–S1. Two-year follow-up is inadequate as pseudarthrosis and painful implants often are detected later. Only 3 of the 12 patients with pseudarthrosis were detected within the first 2 years after surgery. A group of 50 adult patients having long fusion to the sacrum for scoliosis were studied as to intraoperative, postoperative, and long-term complications. There were no deaths or spinal cord injuries, but pseudarthrosis was seen in 24%, often late.

Forty-six patients who had a neuromuscular spinal deformity were treated with arthrodesis and Luque segmental spinal instrumentation and were followed for an average of three years. Twenty-two patients had cerebral palsy and twenty-four had another neuromuscular disease. In thirty-nine patients, the arthrodesis was extended to the sacrum. Eleven patients who had severe scoliosis as well as pelvic obliquity and decompensation of the torso had a combined anterior and posterior arthrodesis; the other thirty-five patients had a one-stage posterior procedure. Preoperatively, the average scoliosis was 74 degrees; this was corrected to 39 degrees at follow-up. Final corrections were similar for scoliosis and were better for pelvic obliquity and decompensation of the torso in patients who had combined anterior and posterior arthrodesis. The results for scoliosis and pelvic obliquity in patients who had a spastic deformity were similar to the results in patients who had a flaccid deformity. Correction of decompensation of the torso was better in patients who had a spastic deformity. Postoperatively, a brace was used in half of the patients in each group; this did not appear to affect the amount of correction in either group, although the result may have been influenced by the selection process. The rate of complications was 48 per cent. Pseudarthrosis occurred in three patients (6.5 per cent). There were no major neurological deficits related to the correction or to the use of sublaminar wires. Three patients died, one in the immediate postoperative period and the other two at eighteen months and four years after the original procedure, due to causes unrelated to the operation.

The findings in seventy-one patients who had previously untreated spinal deformities associated with dystrophic changes and who had neurofibromatosis were reviewed to identify the risk factors for progression of the curve as well as the natural history of the dystrophic changes and curve patterns. Four different types of curves were evaluated. Two of them had the most severe progression: (1) kyphoscoliosis with angular kyphosis (gibbus) and marked dystrophic changes and (2) so-called kyphosing scoliosis (a scoliosis that has so much rotation [90 degrees] that progression is evident only on the lateral roentgenogram) with a round kyphosis. Risk factors for substantial progression of the curve were an early age of onset, a high Cobb angle at the first examination, an abnormal kyphosis, vertebral scalloping, severe rotation at the apex of the curve, location of the apex of the curve in the middle to caudal thoracic area, penciling of one rib or more on the concave side or on both sides of the curve, and penciling of four ribs or more.

The results of anterior and posterior excision or wedge resection of a hemivertebra and arthrodesis of the spine were reviewed retrospectively for thirty-seven patients. The degree of correction that was obtained and maintained, the balance and alignment of the trunk, changes in pelvic obliquity, and associated complications were evaluated. The average age at the time of the operation was twelve years (range, six months to forty-two years). The average duration of follow-up was six years (range, two to nineteen years). The resection was at the mid-thoracic level in six patients, at the thoracolumbar level in nine, at the mid-lumbar level in seven, and at the lumbosacral level in seventeen. (Two patients had an excision of a hemivertebra at two levels.) Instrumentation was used in twenty-eight patients. Postoperatively, all patients were managed with a body cast, with a unilateral or bilateral pantaloon extension, for four to six months. The instrumentation allowed early walking and the use of a unilateral rather than a bilateral pantaloon extension. The index curve (the curve containing the hemivertebra) averaged 54 degrees (range, 18 to 132 degrees) preoperatively, 33 degrees (range, 0 to 105 degrees) postoperatively, and 35 degrees (range, 0 to 110 degrees) at the most recent follow-up evaluation. A measurable improvement in balance was achieved and maintained in nineteen patients. Pelvic obliquity did not change appreciably, as it was related primarily to limb-length inequality in this series. Complications included a temporary nerve-root lesion in seven patients, a permanent neurological deficit involving the first sacral nerve root in one patient, a pseudarthrosis in three patients, and a wound infection in three patients. Six patients had extension of the arthrodesis to include additional vertebrae.

The authors examined factors affecting fusion rate in the surgical treatment of 89 consecutive adult patients with spondylolisthesis. Two factors significantly improved fusion rate: combined anterior and posterior fusion and rigid postoperative immobilization in the cast. In 65 patients with isthmic spondylolisthesis, the fusion rate was raised from 70% when posterior fusion alone was used to 88% when combined anterior and posterior fusion was used. In 20 patients with degenerative spondylolisthesis, frequent use of combined anterior and posterior fusion contributed to a high overall fusion rate of 95%. Among patients with isthmic spondylolisthesis, postoperative cast immobilization resulted in a higher fusion rate of 90% compared with a fusion rate of 63% obtained after brace immobilization.

Summary: Thirteen patients with progressive congenital scoliosis due to hemivertebrae or hemivertebrae associated with other spinal anomalies were treated by convex anterior and posterior hemiarthrodesis and hemiepiphysiodesis. The average curve prior to operation was 46°, average age was 3 years 6 months, and average followup was 6 years 6 months. One patient failed because of an inadequate length of anterior surgery which was success fully salvaged by further surgery. Twelve patients were successes: Seven had only cessation of the progressive curve, and five had progressive curve improvement ≤ 5° due to the arrested convex and persistent concave growth. This procedure is a valuable treatment modality for selected patients with congenital scoliosis.

Abundant data are available for direct anterior/posterior spine fusion (APF) and some for transforaminal lumbar interbody fusion (TLIF), but only few studies from one institution compares the two techniques. One-hundred and thirty-three patients were retrospectively analyzed, 68 having APF and 65 having TLIF. All patients had symptomatic disc degeneration of the lumbar spine. Only those with one or two-level surgeries were included. Clinical chart and radiologic reviews were done, fusion solidity assessed, and functional outcomes determined by pre- and postoperative SF-36 and postoperative Oswestry Disability Index (ODI), and a satisfaction questionnaire. The minimum follow-up was 24 months. The mean operating room time and hospital length of stay were less in the TLIF group. The blood loss was slightly less in the TLIF group (409 vs. 480 cc.). Intra-operative complications were higher in the APF group, mostly due to vein lacerations in the anterior retroperitoneal approach. Postoperative complications were higher in the TLIF group due to graft material extruding against the nerve root or wound drainage. The pseudarthrosis rate was statistically equal (APF 17.6% and TLIF 23.1%) and was higher than most published reports. Significant improvements were noted in both groups for the SF-36 questionnaires. The mean ODI scores at follow-up were 33.5 for the APF and 39.5 for the TLIF group. The patient satisfaction rate was equal for the two groups.

Summary: A retrospective review of 25 patients with scoliosis secondary to syringomyelia was conducted. All patients had large syrinxes, but only 10 patients had abnormal neurologic findings, suggesting that subtle neurologic findings in patients with scoliosis should not be underestimated and supporting liberal use of magnetic resonance imaging (MRI). The results of three approaches to the care of these patients were reviewed: passive observation, bracing, and spinal fusion. Curves progressed ≥5° in patients aged <10 years who were observed, but in children aged >10 years, curves progressed ≥10°. Curves responded well to bracing, but correction was not maintained out of brace for patients with progressive and/or severe curves. Good correction was achieved safely during operation.

Twelve patients sustained a shear fracture–dislocation of their thoracic or lumbar spines by a hyperextension mechanism of injury. Ten male and two female patients were injured; their average age was 29 years (range, 22 months to 56 years). Ten fracture–dislocations occurred in the thoracic spine, one at the thoracolumbar junction, and one in the lumbar spine. Eleven patients had complete paraplegia, and one had incomplete paraplegia at the time of injury. Dural tears were found in six of the patients. Eleven patients were treated by posterior spinal fusion with instrumentation, and one was treated with a brace. Three patients were treated with Harrington distraction rods alone, six had Harrington distraction rods supplemented with a midline Harrington compression rod or interspinous wiring, and two were treated with Cotrel–Dubousset instrumentation. No patient was lost to follow–up. The average length of follow–up was 3.5 years (range, 1–9 years). Six of the patients treated with Cotrel–Dubousset instrumentation or Harrington distraction rods supplemented with either a midline compression rod or interspinous wiring healed anatomically; two patients developed pseudarthroses. None of the patients treated with Harrington distraction rods alone healed in an anatomic position. The use of Harrington distraction rods alone was associated with overdistraction and nonanatomic alignment of the spine. The disruption of the anterior stabilizing structures of the spine associated with hyperextension injuries necessitates the use of instrumentation that can stabilize the spine and prevent overdistraction. This injury can be successfully treated with Cotrel–Dubousset or Harrington distraction rods supplemented with either a midline compression rod or interspinous wiring.

The authors reviewed 246 idiopathic scoliosis patients with the upper thoracic curve of more than 20$$. Group I (138 patients) had positive T1 tilt and a Spiral fusion which was extended over both the upper and lower thoracic curve with the diagnosis of double thoracic curve. Group II (43 patients) had positive T1 tilt, but the fusion was limited to the lower thoracic curve. Group III (65 patients) had negative or neutral T1 tilt and the fusion was limited to the lower thoracic curve. The average age at operation was 15.9 years (range, 11,2–35 years) and the average length of follow-up was 4.8 years (range, 2–29.5 years). Positive T1 tilt did not correlate well with left shoulder elevation contrary to previous reports, The upper thoracic curve was more rigid than the lower curve in all groups and the lumbar curve was significantly more flexible than the upper and lower thoracic curves in all groups (P< 0.05). No significant difference in the flexibility of the upper thoracic curve was found between the groups regardless of the direction of T1 tilt, When only the lower curve was fused (groups II and III), progression of the upper thoracic curve was less than 5$$ and spontaneous correction of the unfused upper curve occurred in the majority of the cases following the supine bending study. Correction and fusion on the lower curve (groups II and III aggravated shoulder imbalance of all patients with left shoulder elevation. Based on the findings of this study, the authors proposed that the diagnosis of idiopathic double thoracic patterns should be limited to those patterns which require fusion of bath the upper and lower curves. This pattern of idiopathic scoliosis includes double thoracic curves with left shoulder elevation and/or a rigid upper thoracic curve.

Study Design. A retrospective study by an independent observer of a consecutive series of 67 cases of adolescent idiopathic scoliosis presenting with a King II curve pattern. Objectives. To demonstrate the validity of a selective thoracic fusion as a treatment of King II curves with special attention to immediate postoperative and long-term trunk balance in the coronal and sagittal planes. Summary of the Background Data. The literature has been fairly controversial in terms of the recommended treatment of King II curve patterns in adolescent idiopathic scoliosis. The main confusion appears to be whether the thoracic curve alone or both curves should be instrumented and fused. Methods. Sixty-seven patients were identified as having had a selective posterior thoracic spine fusion with instrumentation between 1961 and 1994. None of these cases had a fusion of the lumbar spine. Preoperative radiographs were analyzed for determination of the appropriate fusion level using the criteria of the stable and neutral vertebra. Follow-up radiographs were evaluated for balance in the coronal and sagittal planes using the central sacral line on posteroanterior radiograph and the C7 sacral promontory line on lateral film. Results. At 2-year or greater follow-up, the unfused lumbar curve remained equal to or less than the corrected thoracic curve in 63 patients (94%). No patient required extension of fusion. Frontal plane balance analysis showed that 47 of the 67 patients had the T1 plumb line within 2 cm of the midline for an average decompensation of 8.7 mm. In no patient was the loss of balance greater than 3.8 cm. Sagittal plane balance analysis showed that only one patient had inferior junctional kyphosis greater than 10°. This did not require extension of fusion. There were no cases of superior junctional kyphosis. Conclusions. The concept of selective thoracic fusion in the King II curve pattern appears to be valid. These findings suggest that arthrodesis of the lumbar spine can be avoided when this pattern is properly diagnosed and appropriately treated. Proper identification of the stable and neutral vertebra and of the appropriate level of fusion are important to achieve good postoperative balance. Successful preservation of lumbar motion segments is important to long-term satisfactory outcome in adolescent idiopathic scoliosis.

Between 1973 and 1993, a heterogeneous group of 67 children with progressive scoliosis entered a program of incremental-distraction spinal instrumentation without fusion supplemented by full-time external orthotic support. Over the course of treatment, curve magnitude improved from an average of 67 degrees at initial instrumentation to 47 degrees at definitive fusion. For all patients, curve response tended to decline with consecutive procedures. The measured growth of the instrumented but unfused spinal segments averaged 3.1 cm over a mean treatment period of 3.1 years. The results of our study suggest that spinal instrumentation without fusion can control progressive scoliosis in a majority of children while allowing normalized growth of instrumented spinal segments. The mean duration of treatment and ultimate gain in spinal length are constrained by progressive structural changes that alter curve response to incremental distraction. Despite these limitations, spinal instrumentation without fusion may provide a reasonable management alternative when individualized among these difficult patients.

Lateral, posterolateral, posterior, and end plate bulges in the intervertebral disks of 14 fresh human cadaver lumbar motion segments were measured. Loads were applied in compression of up to 800 N; and in right lateral bending, extension, flexion, and torsion of up to 12 Nm. Mean disk bulges up to 2.7 mm were found. Disk bulges differed little after fluid injection or after posterior element removal.

From the Twin Cities Spine Center, Minneapolis, MN. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint requests to Robert B. Winter, MD, Twin Cities Spine Center, 913 East 26th Street, Suite 600, Minneapolis, MN 55404-4515; E-mail: [email protected]

Study Design. An independent retrospective review of 37 patients undergoing 39 anteroposterior lumbar fusions for lumbar pseudarthrosis repair between 1984 and 1990. Objectives. To evaluate radiographically and functionally the results of the combined anteroposterior fusion for the management of symptomatic lumbar pseudarthrosis, and to assess risk factors for functional failure after the procedure. Summary of Background Data. Most reported techniques of pseudarthrosis repair involve posterior fusion with no instrumentation, posterior fusion with instrumentation, or anterior fusion alone. The results of lumbar pseudarthrosis repair are poor. Fusion rates range from 30% to 70%, with only a 30% to 50% rate of functional success. Methods. Thirty-nine procedures were assessed in 37 patients. The outcomes were assessed radiographically (solid fusion vs. pseudarthrosis) and functionally (success vs. failure). Radiographs were assessed at follow-up examination for consolidation of fusion anteriorly and posteriorly. Functional outcome was graded by using multiple instruments, including data from chart review and the follow-up outcome questionnaire. A functional failure score that took into account 10 items was developed. Results. In this patient population (37 patients, 59% with a smoking history, 71% with compensation or legal claims), there was a 10% pseudarthrosis rate. Pseudarthrosis was defined when one or more levels were involved and when it occurred anteriorly and posteriorly. In 12 patients (35%), the outcome was rated as functional failure. The presence of one or more abnormal neurologic findings and significant narcotic use before surgery significantly increased the chance of a patient’s outcome being functional failure. Workmen’s Compensation or legal status before surgery also increased the chance of functional failure, though this correlation was not statistically significant. Conclusions. A combined anterior and posterior approach for the management of symptomatic lumbar pseudarthrosis is a viable alternative to posterior fusion alone. In fact, this procedure affords a higher fusion rate based on radiographic assessment. Functional failure rates may be decreased by using caution for those patients using narcotics regularly before surgery or in those with unexplained preoperative neurologic abnormal findings.

The medical records and radiographs of forty-two adolescents (twenty-three male and nineteen female) who had had a posterolateral spinal arthrodesis for spondylolisthesis between 1950 and 1986 were reviewed to assess the long-term outcome of this form of treatment. The average age of the patients at the time of the operation was fourteen years (range, seven years and nine months to seventeen years and eleven months). The duration of the clinical and radiographic follow-up ranged from two years to twenty-seven years and seven months. All patients had an in situ arthrodesis of the involved vertebrae. Eighteen patients had no additional intervention, and twenty-four patients had reduction and application of a cast. Use of the cast led to a decrease in sagittal translation of more than 5 per cent in eighteen patients and a decrease in lumbosacral kyphosis (the slip angle) of more than 5 degrees in fourteen patients. Of the patients who did not have a cast, eight had an increase in sagittal translation of more than 5 per cent and ten had an increase in lumbosacral kyphosis of more than 5 degrees. There were no neurological problems at the time of the initial operation or after the reduction maneuver. At the most recent clinical follow-up examination, thirty-eight patients had no complaints of low-back pain or any restriction of work-related or recreational activities. Persistent low-back pain and pain in the lower extremities limited the activities of the remaining four patients, two of whom had another operation to alleviate these symptoms.

We performed a prospective study of 317 patients in order to determine the prevalence of deep venous thrombosis after reconstructive operations on the spine; 126 of the patients were examined with duplex ultrasound assessments of the lower extremities to ensure that no asymptomatic thrombi were being missed. Thigh-high stockings and sequential pneumatic compression of the lower extremities were used, in all patients, for prophylaxis against venous thrombosis. No antiplatelet agents or anticoagulant medications were administered. There was no evidence of thrombosis on any of the duplex ultrasound studies. Subsequently, venous thrombosis developed and was treated successfully in one of the 126 tested patients and in one of the 191 untested patients, and a fatal pulmonary embolus developed in one of the untested patients. The over-all clinical prevalence of thrombotic complications was 0.9 per cent (three complications in 317 patients). All three of the patients who had clinical evidence of thrombosis had had an anterior lumbar procedure because of a degenerative disorder or trauma; however, we could not prove that this approach or these diagnoses were significant risk factors for thrombosis (p < 0.05). While it is possible that some thrombi may have escaped both clinical and ultrasonic detection, such thrombi apparently were not enough of a danger to warrant the use of intensive prophylactic procedures that are associated with more risk. On the basis of this prospective study, therefore, we think that routine screening for the detection of asymptomatic thrombosis in patients who have had a procedure on the spine is unwarranted.

Adult patients with scoliosis often have back pain, but that pain may or may not be due to the curvature. A careful history, physical examination, routine radiographic examination, and, on some occasions, specialized radiographs, CT, myelography, discography, and facet joint injection will help the physician or surgeon separate out those pain syndromes owing to the curvature versus those not owing to the curvature. Only after these critical evaluations have been done can a decent decision be made as to the area of the spine to be treated, either surgically or nonsurgically.

Three hundred and fifty-two patients had a one-stage posterior spinal arthrodesis between 1960 and 1984 using one of four types of instrumentation: a Harrington distraction rod, Harrington distraction and compression rods, Harrington distraction and compression rods with a device for transverse traction, and a Harrington distraction rod with sublaminar wires. All of the patients were female (age-range, eleven to nineteen years), and all had idiopathic scoliosis with a single right or double thoracic curve. The minimum length of follow-up was two years. No significant difference was found among the four groups relative to the amount of correction that was obtained at operation or maintained two years after operation. An average of 13.5 per cent of correction was lost during follow-up in the patients who were treated with postoperative immobilization, and an average of 27 per cent was lost in the patients who were treated with sublaminar wires without immobilization. The use of a straight Harrington rod reduced normal thoracic kyphosis, the addition of a compression rod corrected hyperkyphosis, and the use of a rod with sublaminar wires corrected thoracic hypokyphosis or thoracic lordosis.

This is a retrospective review of 129 consecutive anterior lumbar revision surgeries in 108 patients. It is a single-center, multi-surgeon study.To determine occurrence rates and risk factors for perioperative complications in revision anterior lumbar fusion surgery.Although complication rates from large series of primary anterior fusion procedures have been reported, reports of complication rates for revision anterior fusion procedures are relatively rare. Concern exists chiefly about the risk to vascular and visceral structures because of scar tissue formation from the original anterior exposure.This was a retrospective review of 129 consecutive anterior revision lumbar surgeries in 108 patients operated between 1998 and 2003. There were 40 men and 68 women. The age of patients ranged from 25 to 83 (average 50.6 years). Patients were excluded if surgery was for tumor or infection. Patients were divided into 2 groups; those with revision surgery at the same level and those with revision surgery at an adjacent level. Outcome measures included all perioperative complications. Statistical analysis included Student t test and nonparametric sign-rank.The number of surgical levels treated for revision was similar between the 2 groups (1 level 69%; 2 levels 19%; 3 or more levels 12%). Revision cases at the same operative level had a higher overall complication rate (42%) compared with extensions (20%; P = 0.007). This difference was primarily because of vein lacerations (23.7% vs. 3.6%, P = 0.002). There were 2 ureteral problems, both successfully salvaged. There were no arterial injuries or deaths.Complication rates for revision lumbar surgery in this series were 3 to 5 times higher than reported for primary lumbar exposures. Complication rates were significantly higher for revision anterior lumbar fusions at the same segment, which were typically in the lower lumbar spine, compared with cases involving extensions, which were typically in the upper lumbar spine.

This is a retrospective review of clinical records for evidence of paraplegia specifically resulting from segmental vessel ligation during anterior spinal surgery.To determine the precise risk rate, and to potentially identify risk factors.Although many authors have alluded to this risk, the exact risk rate and risk factors have never been identified.All patients having an anterior approach involving T1-L3 were reviewed. The two reviewers were not involved in any of the surgeries. The 1197 cases were consecutive from 1967 to 1991.There were no paralyses.There would appear to be virtually no risk to segmental vessel ligation provided: 1) vessel ligation is unilateral, 2) done on the convexity of a scoliosis, 3) ligated at midvertebral body level, and 4) hypotensive anesthesia is avoided. Soft clamping with somatosensory-evoked potential monitoring does not appear justified.

Study Design. Retrospective chart and radiographic reviews were conducted. Objective. To identify the incidence of and any possible risk factors for the crankshaft phenomenon after posterior spinal arthrodesis for congenital scoliosis. Summary of Background Data. Studies have shown the crankshaft problem to be common after posterior arthrodesis for infantile and juvenile idiopathic scoliosis, but the few reports available show it to be much less common for congenital scoliosis. Methods. This study chose children fused before the pubertal growth spurt, all classified as Risser 0 and with open triradiate cartilages. These children were followed to the end of their growth (mean follow-up period 12 years). Several measurement parameters were used for evaluation. Results. The crankshaft problem, measured as a Cobb angle increase of more than 10°, was seen in 15% of the 54 patients. There was a positive correlation with earlier surgery and larger (>50°) curves. No other positive correlations could be identified. Conclusions. Crankshafting was observed in 15% of the patients, more often with larger curves and earlier fusions.

Four patients who had multisegmental ankylosis of the thoracic and lumbar spine due to diffuse idiopathic skeletal hyperostosis sustained a hyperextension fracture-dislocation. The patients had a mean age of sixty-four years (range, fifty-eight to sixty-nine years); all four patients were men. All injuries occurred between the seventh and eleventh thoracic vertebrae. All patients had intact neurological function at the time of admission to the hospital. Three patients were managed with posterior spinal arthrodesis with Cotrel-Dubousset segmental instrumentation; one patient was managed non-operatively with a molded thoracolumbosacral orthosis. At a minimum duration of follow-up of twenty-two months (mean, twenty-seven months), the three patients who had been managed operatively had healing of the fracture with anatomical alignment of the spine and without postoperative complications. The one patient who had been managed non-operatively with a brace had severe neurological deterioration and non-anatomical alignment of the spine.

A retrospective review with statistical correlations of 112 patients having both scoliosis and syringomyelia was performed.To determine whether there were significant correlations between the type of scoliosis, location of the syrinx, size of the syrinx, clinical manifestation of the syrinx, and associated lesions such as cord tethering and Chiari malformation (Chiari I or Arnold-Chiari II).The coexistence of scoliosis and syringomyelia has been described previously, but these detailed correlations have had minimal attention.All patients at the center with scoliosis of any type plus a syrinx had a detailed chart and radiologic review coupled with detailed statistical analysis.Scoliosis and syringomyelia were seen in four diagnoses: myelomeningocele, myelomeningocele with congenital scoliosis, congenital scoliosis, and scoliosis with neither congenital anomalies nor myelomeningocele. Chiari malformation and cord tethering appear to have a major relation to scoliosis with syringomyelia.Anomalies of the spinal cord or spinal column coexisting with lesions of the central nervous system have significant effects on the syrinx and scoliosis. There is a significant relation between the most caudal level of the syrinx and the locations of the scoliosis.

Posterior dural lacerations associated with lumbar burst fractures are caused by impaction of the dural sac into the vertical lamina fracture. Neural elements may be extruded outside of the dura and become entrapped in the lamina fracture. This diagnosis must be made before surgery and is based on the patient's clinical presentation, the fracture pattern, and the radiographic findings. Entrapped neural elements can be successfully extracted from the lamina fracture by an opening laminoplasty of the posterior neural arch. Patients with lumbar burst fractures and radiographic evidence of posterior displacement of the neural elements in the lamina fracture should undergo posterior exploration of the spinal canal, extraction of cauda equina neural elements, and repair of the dural laceration before any spinal reduction maneuver.

Retrospective radiographic analysis of the potential role the lumbosacral hemicurve has on adolescent idiopathic scoliosis coronal trunk imbalance.To determine if the lumbosacral hemicurve predisposes adolescent idiopathic scoliosis to coronal decompensation preoperatively and postoperatively.Although coronal decompensation remains a clinical problem in adolescent idiopathic scoliosis, the literature regarding the role of potential intrinsic structural properties of the lumbosacral hemicurve is sparse.Fifty patients with adolescent idiopathic scoliosis were used to measure several potential parameters predisposing to coronal decompensation including lumbosacral hemicurve magnitude and flexibility, sacral and iliac obliquity.Overall, 84% (42/50) demonstrated preoperative decompensation. A more rigid lumbosacral hemicurve was significantly related to preoperative coronal decompensation in the combined and the King I groups. Preoperatively, significant correlation with decompensation was observed for sacral and iliac obliquity in the King I group and for iliac obliquity in the combined group. Postoperatively, coronal decompensation remained significantly correlated to sacral obliquity in the combined group and King I groups. Iliac obliquity was significantly related to postoperative decompensation in the combined group.The lumbosacral hemicurve represents an important structure predisposing to left coronal plane imbalance in adolescent idiopathic scoliosis that includes a large left lumbar curve as a component of the curve pattern. "At-risk" signs for persistent postoperative coronal decompensation include iliac and sacral obliquity noted on the preoperative standing full-length radiographs.

Retrospective study of patients after extension of previous scoliosis fusions to the pelvis.To determine whether modern instrumentation and surgical techniques provide for increased fusion rates with fewer complications.Traditionally, long fusions to the pelvis in adults with idiopathic scoliosis have resulted in high complication rates, including pseudarthrosis.The hospital and clinic charts of 41 patients (40 female, 1 male) were reviewed 41 months (range: 24-116) after surgery for extension to the pelvis of previous scoliosis fusions. Thirty-nine of 41 had a combined anteroposterior fusion extension; two had posterior extension only. In 37 of 41 patients, Cotrel-Dubousset (CD) instrumentation was used; in two, Isola (Acromed Corp., Cleveland, OH), in one, TSRH; (Sofamor-Danek, Memphis, TN), and in one, Synergy (Cross Medical Products, Columbus, OH). Parameters analyzed were fusion rate, sagittal and coronal balance, lumbar lordosis, length of fusion extension, and distal fixation method.Complications were seen in 30 of 41 patients. The pseudarthrosis rate was 37% (15/41) and was significantly related to the method of distal posterior fixation. With sacral fixation only, the rate was 53% (8/15), with iliac fixation only 42% (3/7), and with both iliac and sacral fixation 21% (4/19; P < 0.05). This was not correlated with fusion rate, and the length of fusion extension did not affect the pseudarthrosis rate or sagittal balance.When fixed to the ilium and sacrum, modern instrumentation appears capable of maintaining sagittal balance with lower rates of pseudarthrosis when previous scoliosis fusions are extended to the pelvis. The complication rate remains significant.

Summary Thirty-two pediatric patients with severe restrictive lung disease identified with vital capacities <40% of predicted, who had undergone major reconstructive spine surgery, were reviewed. There were 18 boys and 14 girls, the mean age was 13 years (range, 7-17), and the mean vital capacity was 31% of predicted (range, 16-39%). Fifty-four procedures were performed, 13 posterior only, one of which was staged, and 19 anterior and posterior procedures, of which 15 were staged and four were sequential. The incidence of pulmonary complications (pneumonia, reintubation, pneumothorax, respiratory arrest, or the need for tracheostomy) was 19% (six patients), and only three patients required tracheostomy. The surgical and perioperative mortality rate was zero. Patients who had a thoracotomy or a thoracoabdominal approach had a significantly higher number of pulmonary complications. The use of preoperative decreased vital capacity as a measure of inoperability excludes the young patient most in need of surgical intervention. With improved preoperative, intraoperative, and postoperative techniques, careful monitoring, and the cooperation of pediatric pulmonologists and intensivists, reconstructive spine surgery can be performed in the pediatric patient with severe decreased vital capacity with very acceptable morbidity and mortality.

In a prospective survey of severe open tibial fractures, the incidence of serious complications with relatively rigid one- or two-plane unilateral fixator frames was considerably lower than with internal fixation by plates and screws. Unilateral configurations that contain rigid components provide better wound access than bilateral frames and interfere less with knee and ankle motion; they allow unencumbered partial and even full weight-bearing. This increases comfort and mobility and may have a positive effect on fracture healing. No standard formula exists, however, for the application of an optimal unilateral frame. The clinical and mechanical demands of each patient and injury must be considered individually.

Communication between physicians and surgeons interested in spinal deformities depends upon an accurate and universally accepted language. Our language concerning the description and measurement of a curvature in the coronal plane (scoliosis) seems well understood and widely accepted, but that is not true of the description and measurement of a curve in the sagittal plane, especially thoracic kyphosis. PROBLEM No. 1: THORACIC KYPHOSIS, WHAT IS NORMAL? The universally accepted measurement of scoliosis is the Cobb system, which states that a curvature is measured from the end vertebrae of the curve, the end vertebrae being defined as those most tilted from the horizontal on an upright radiograph. The measurement of thoracic kyphosis is confusing, as some authors routinely measure T2-T12, T4-T12, or T5-T12, even though these may not be the maximally tilted vertebrae. Other authors use the maximally tilted vertebrae, whatever these might be. This discrepancy in measurement technique leads to confusion as to what is “normal” and to exactly what is being reported. Inability to accurately define the uppermost maximally tilted vertebra can lead to improper selection of the upper end vertebra for fusion in Scheuermann kyphosis. For example, Propst-Proctor and Bleck1 measured 104 normal children using T5-T12 as the end points in all subjects. The mean kyphosis was 27 degrees, ranging from 21 to 33 degrees. On the other hand, Boseker et al2 measured 121 normal children using the maximally tilted vertebrae (“true kyphosis” technique) and found a mean kyphosis of 33 degrees, ranging from 25 to 42 degrees (1 SD) and 20 to 50 degrees (2 SD). There were 4 children with kyphosis between 15 and 19 degrees and 4 between 51 and 54 degrees, these 8 lying outside the 2 SD range. These authors found the maximally tilted vertebrae to be T2-T12 in 49%, T2-L1 in 13%, T2-T11 in 10%, T1-T12 in 10%, T3-T12 in 7%, and “other” in 11%. This is the only study of which we are aware that accurately defined the various end vertebrae (Fig. 1).FIGURE 1.: The data from the article by Boseker et al2 shows a classic bell-curve distribution.Takemitsu et al3 measured 519 Japanese children, 253 boys and 266 girls, using the maximally tilted end vertebrae (true kyphosis) technique. They found similar measurements in girls and boys and noted a small increase in the mean kyphosis during growth. Boys increased from a mean of 35 degrees (±10 degrees for 1 SD) at ages 6 to 11 years to a mean of 41 degrees (±11 degrees for 1 SD) at ages 13 to 16 years. Girls increased from a mean 29 degrees to a mean 41 degrees for the same time periods. These large ranges of normal were emphasized in the French study of adults by Stagnara et al.4 The mean kyphosis in their study was 37 degrees, but with a range from 7 to 63 degrees. In their conclusion, they recommended avoiding the words normal or “abnormal.” Bernhardt and Bridwell5 studied 102 normal children, 55 females and 47 males. They noted that thoracic kyphosis usually began at T1 or T2 and found the mean kyphosis to be 36 degrees, ranging from 9 to 53 degrees (±10 degrees for 1 SD). Mac-Thiong et al6 measured 180 children aged 4 to 18 years using the T2-T12 vertebrae. The mean thoracic kyphosis was 43 degrees (±10.4 degrees for 1 SD), range 34 to 54 degrees. In summary of the above studies, when the kyphosis is measured from the upper thoracic vertebrae (not the T5-T12 kyphosis), the mean thoracic kyphosis in children and adolescents ranged from 332 to 43 degrees,6 with very large ranges and SDs. As is shown in Figure 1, these are classic bell-curve distributions where the extremes are difficult to define. Certainly anything from 15 to 50 degrees can be considered normal, and even 15 to 55 degrees could be justified. The old statement found in many texts, and as recently as a 2004 Instructional Course Lecture by Betz,7 that normal is from 20 to 40 degrees is not justifiable. Adding to the confusion was a commercial monograph “Radiographic Measurement Manual,” published by Medtronic Corp and authored by O'Brien et al,8 wherein it states (p. 87) under Adult Deformity “thoracic kyphosis is measured from the cephalad endplate of T2 to the caudal endplate of T12.” However, later on the same page, it states “the maximal measured kyphosis is measured from the upper endplate of the most cephalad vertebra within the kyphotic curve to the lower endplate of the most caudal vertebra.” On page 65, under “Adolescent Idiopathic Scoliosis,” it states “thoracic kyphosis is measured from the upper (cranial) endplate of T2 to the lower (caudal) endplate of T12 using the Cobb method.” From the above discussion, it is seen that this measurement may be measuring the true kyphosis in half the cases. PROBLEM No. 2: HOW DO WE TAKE A GOOD RADIOGRAPH? Why has the T5-T12 area been used in some studies? It would seem that the chief reason was the difficulty in visualizing the T1-T4 area on chest radiographs9 or older spine radiographs. With careful attention to patient positioning and radiologic techniques, decent visualization of the upper thoracic spine can be achieved. When one takes a lateral standing radiograph with the arms at the side, the humeral shafts can overlie the spine, preventing good measurement. To get around this issue, the arms need to be positioned forward out of the way. When a subject simply lifts the arms forward from the body, it induces lumbar hyperlordosis and distorts overall sagittal alignment. To avoid this, 2 techniques have been developed. In the paper by Boseker et al,2 the authors describe testing different positions and finding that the best technique was to have the patient standing in a relaxed posture with the arms forward 90 degrees to the torso and resting on a pole or ladder in a relaxed posture (Fig. 2). Some radiographs are somewhat indistinct in the T1-T4 area and the endplates are not adequately seen for a good measurement. This problem can often be overcome by “recreating” the contour by drawing a line along the anterior and posterior vertebral body cortices, the “best fit line.” Once this has been carried out, then perpendiculars to that line can be used to measure the kyphosis (unpublished data by F. Takeuchi and F. Denis) (Figs. 3, 4).FIGURE 2.: A lateral standing radiograph of a 33-year-old woman with Scheuermann disease. Note that all vertebrae in the upper thoracic spine can be well seen. The arms are forward, resting on a support. Her true kyphosis is 75 degrees and corrected to 48 degrees on a supine hyperextension film.FIGURE 3.: A lateral standing radiograph in which the upper thoracic vertebral endplates are not well seen, but the kyphosis can be measured by reconstructing the spinal contours using the anterior and/or posterior vertebral body cortices (Tekeuchi and Denis technique).FIGURE 4.: A lateral standing radiograph of an adolescent boy with a high thoracic kyphosis secondary to a laminectomy for a spinal cord tumor. Note that with good technique and centering the beam more proximally, excellent visualization of both the thoracic kyphosis and cervical lordosis is seen.Vedantam et al10,11 also tested various arm positions and recommended a 30-degree unsupported forward arm position, noting that a 90-degree forward unsupported arm position created lumbar hyperlordosis. They reported a mean thoracic kyphosis as measured from T3-T12 of 38 degrees. More recently Faro et al12 and Horton et al13 described the “clavicular” position, wherein the patient stands with the arms crossed over the chest and the fists against the opposite clavicle. Both the Boseker/Moe technique and the clavicular technique give a good view of the upper thoracic spine and avoid lumbar hyperlordosis. PROBLEM No. 3: HOW DO WE EVALUATE CORRECTION? When dealing with scoliosis correction, we typically describe the percentage correction on the basis of the pretreatment curve value against the follow-up value (pre−post/pre×100). When a 60-degree scoliosis is corrected to 30 degrees, there is a 50% correction. This is all based on the normal spine having a 0 lateral curvature. A scoliosis correction from 60 to 0 degrees would be a 100% correction. Kyphosis is a totally different problem. As a 0 degree final treatment would be a significantly pathologic thoracic flatback, we need to avoid a percentage correction mentality. As the goal of treatment, whether by bracing or surgery, is to achieve a normal sagittal alignment, we need to express our results in those terms, that is, did we achieve or not a significant number of degrees of correction, and did the patient end up with a normal thoracic kyphosis. Thus, if a patient with Scheuermann kyphosis of 80 degrees has corrective surgery and ends up at 40 degrees, we should not state there has been a 50% correction, but rather that a “full” correction to a normal status has been achieved. We want to know both the number of degrees of correction achieved and whether the patient ended up in the normal range, but the percentage correction is not relevant. With the controversy as to what is the normal range of thoracic kyphosis (15 to 50 degrees or 15 to 55 degrees), it may be best to only state the degrees of correction and not use the term “normal kyphosis.” CONCLUSIONS When we wish to document the true thoracic kyphosis in a subject, the optimal radiograph is taken in the standing position with the arms forward at 90 degrees and resting on a support or in the clavicular position. The kyphosis can then be measured from the uppermost tilted vertebra to the lowermost tilted vertebra, whatever these may be. When we report our results of treatment, we must avoid using “percentage correction” like we do for scoliosis. We need to know the number of degrees of correction and the final number of degrees of the kyphosis. We might also state whether or not the kyphosis was corrected into the normal range, but that is fraught with difficulty considering the huge range of normal.

Anterior interbody fusion has previously been demonstrated to increase neuroforaminal height in a cadaveric model using cages. No prior study has prospectively assessed the relative change in magnetic resonance imaging (MRI) demonstrated neuroforaminal dimensions at the index and supradjacent levels, after anterior interbody fusion with a corticocancellous allograft in a series of patients without posterior decompression. The objective of this study was to determine how much foraminal dimension can be increased with indirect foraminal decompression alone via anterior interbody fusion, and to determine the effect of anterior lumbar interbody fusion on the dimensions of the supradjacent neuroforamina.A prospective study comparing pre- and postoperative neuroforaminal dimensions on MRI scan among 26 consecutive patients undergoing anterior lumbar interbody fusion without posterior decompression was performed. We studies 26 consecutive patients (50 index levels) that had undergone anterior interbody fusion followed by posterior pedicle screw fixation without distraction or foraminotomy. We used preoperative and postoperative MRI imaging to assess the foraminal dimensions at each operated level on which the lumbar spine had been operated. The relative indirect foraminal decompression achieved was calculated. The foraminal dimension of the 26 supradjacent untreated levels was measured pre- and postoperatively to serve as a control and to determine any effects after anterior interbody fusion.In this study, 8 patients underwent 1 level fusion (L5-S1), 12 patients had 2 levels (L4-S1) and 6 patients had 3 levels (L3-S1). The average increase in foraminal dimension was 43.3% (p < 0.05)-19.2% for L3-4, 57.1% for L4-5, and 40.1% for L5-S1. Mean pre- and postoperative supradjacent neuroforaminal dimension measurements were 125.84 mm(2) and 124.89 mm(2), respectively. No significant difference was noted (p > 0.05).Anterior interbody fusion with a coriticocancellous allograft can significantly increase neuroforaminal dimension even in the absence of formal posterior distraction or foraminotomy; anterior interbody fusion with a coriticocancellous allograft has little effect on supradjacent neuroforaminal dimensions.

Study Design. Retrospective chart and radiologic analysis. Objectives. To analyze the value and risks of neurosurgical procedures for syringomyelia and of fusion procedures for scoliosis. Summary of Background Data. There are few reports on the benefit of neurosurgical procedures on scoliosis, as well as the risk of fusion procedures on scoliosis related to syringomyelia. Methods. The 105 patients who had both scoliosis and syringomyelia were subdivided into three groups: (I) 59 patients without congenital scoliosis or myelomeningocele, (II) 20 patients with congenital scoliosis and syringomyelia, and (III) 26 patients with myelomeningocele and syringomyelia. The study evaluated: (1) The effect of either suboccipital craniectomy or direct shunting on the syrinx, the curvature, and the neurologic status; (2) the neurologic risk of scoliosis fusion surgery; and (3) the curve status after fusion surgery. Results. In Group I (patients without congenital scoliosis or myelomeningocele), suboccipital craniectomy resulted in curve improvement in seven, worsening in three, and no change in two, whereas direct syrinx shunting gave curve improvement in none, curve worsening in six, and no change in two. In Groups II and III, no patient had curve improvement after neurosurgery. Group III had the highest rate of subsequent neurosurgery (50%). The subsequent neurosurgery was nearly always suboccipital craniectomy or detethering of the cord. Three of 38 patients (8%) had neurologic worsening when scoliosis fusion surgery was done without previous syrinx decompression. Conclusions. In patients without myelomeningocele or congenital scoliosis, but with Arnold-Chiari malformation and syringomyelia, suboccipital craniectomy gave the best chance for syrinx reduction and scoliosis improvement, particularly in children younger than 10 years. Syrinx shunting improved none of the scolioses. For syrinxes in patients with congenital scoliosis or myelomeningocele, neither neurosurgical procedure resulted in curve improvement, as other causes of scoliosis (vertebra anomalies, paralysis) remained untreated. Patients with myelomeningocele require a multipronged surgical approach to address all causes of syrinx, thus minimizing the potential need for repeat neurosurgery. Scoliosis correction without prior syrinx decompression carries a high neurologic risk.

Abstract Background The lack of a widely available scoring system for cervical degenerative spondylosis encouraged the authors to establish and validate a systematic quantitative radiographic index. Materials and methods This study included intraobserver and interobserver reliability testing among three reviewers with different years of experience. Each observer independently scored four cervical radiographs of 48 patients at separate intervals, and statistical analysis of the grading was performed. Results There was high intraobserver and interobserver reliability between the two experienced observers. There was fair reliability between the less experienced observer and the more experienced observers. Conclusions The cervical degenerative index appears to be a reliable and reproducible radiographic assessment of cervical spondylosis. The index will have direct applicability for longitudinal study of cervical spondylosis and may be clinically relevant as well.

This article describes some of the basic techniques using the Cotrel-Dubousset instrumentation in idiopathic scoliosis. Multiple illustrations will allow the reader to visualize the rationale behind the technique and to become familiar with some of its intricate details.

Objective. The purpose is to define the origin of radiculopathy of patients with degenerative lumbar scoliosis-stenosis and to assess the correlation between percentage of initial radicular leg pain relief with selective nerve root injections and lateral canal dimensions.

Study Design. Retrospective chart and complementary study review. Objectives. To describe the features of adult patients with spinal deformity and respiratory failure and to analyze the results of surgical treatment. Summary of Background Data. Many authors have studied the relation between spinal deformities and cardiorespiratory failure, but there exists little information about the benefits of reconstructive surgery in severely compromised patients. Methods. The charts and complementary studies of 35 adult patients surgically treated between January 1, 1978, and December 31, 1994, were reviewed. The patients were 18 years old or older (average age, 36 years). They had spinal deformity of any etiology with respiratory insufficiency as evidenced by vital capacity of less than 60% of predictive normal, PaO2 less than 80 mm Hg, or PaCO2 more than 45 mm Hg. All had reconstructive spinal surgery in an attempt to improve their respiratory problem. Results. Seven patients died within the first postoperative year, and one patient was lost to follow-up at 6 months. The other 27 patients had a mean follow-up time of 72 months. The 34 patients were divided into three groups: good, fair, and poor evolution. The patients in the good evolution group had a better preoperative general condition, had more correction of their deformities, had more improvement in their respiratory function, and had fewer complications than those in the other groups. The patients in the poor evolution group were older, had more cardiac problems, and had less correction at surgery. Conclusion. The results of surgery varied from extremely good to extremely bad. The seven patients who died within the first year had no benefit, but the 27 others did very well, usually gaining significant improvement of their respiratory function. Because the alternative to surgical correction is death, this study shows that, under the right circumstances, correction of spinal deformity and, therefore, correction of respiratory function can be life-saving.

Objective The objective of this study is to evaluate the effectiveness of a specific methodology for plain radiographic assessment of lumbar pedicle screw position. Purpose To evaluate the effectiveness of using orthogonal plain radiographs and a systematic method of interpretation, developed by the senior author, in assessing the placement of lumbar and lumbosacral pedicle screws. Study Design This was an adult cadaver study of the accuracy of using plain radiographs or computed tomography to assess pedicle screw position. Plain radiographs were performed and compared with computed tomography (CT) scans. Gross anatomic dissections were performed to directly confirm screw position. Variables, including screw material, radiographic view, and screw dimensions, were assessed for their effect on the ability of physicians to determine pedicle screw position. Multiple readers were included in the study, including 1 spine Fellow, 3 experienced orthopedic spine surgeons, and 1 neuroradiologist. Methods Five adult cadaveric spines were instrumented with titanium pedicle screws from L1 to S1. Screws were placed outside the confines of the pedicle in all 4 quadrants or within the pedicle using a Latin-Square design. Each cadaver was imaged with orthogonal radiographs and high-resolution CT scans. The spines were then reimaged after the instrumentation was replaced with stainless steel screws placed in the identical position. Finally, each spine was dissected to assess the exact position of the screws. Images were read in a blinded fashion by 1 spine fellow, 2 staff surgeons, and a staff radiologist. The results were compared with the known screw positions at dissection. Results In total, 120 pedicle screws were placed, 44 (38%) outside the confines of the pedicle. Sensitivity, defined as the percent of the misplaced screws that were correctly identified, was similar across the 3 diagnostic tests, but markedly improved when all CT formats were considered together. Similarly, specificity, defined as the percent of screws correctly read as being placed within the pedicle, was independent of radiographic examination. Sensitivity of the radiographic technique was 70.1% and specificity was 83.0%, whereas sensitivity for CT scans was 84.7% and specificity was 89.7%. There was an observed association with anatomic level, with a consistently less accuracy in detecting screw position at L1 with plain x-ray (P=0.001). Additionally, correct position of stainless steel screws was more difficult to detect as compared with titanium (P=0.033) using either x-rays or CT. Other variables examined, such as screw length and screw diameter, did not have an effect on the ability to read the positioning. Conclusions CT scans, often considered the “gold standard” for clinical assessment of pedicle screw placement, have limitations when validated with gross anatomical dissection. The described systematic method for evaluating pedicle screw placement using orthogonal plain radiographs attained accuracy comparable to high-resolution CT scans.

Prospective and retrospective outcome analysis following arthrodesis for adult isthmic spondylolisthesis in 31 patients.To examine whether or not patients having such surgery have a functional improvement in their lives.The literature is full of articles concerning adolescent spondylolisthesis, the union rate for adult spondylolisthesis, the ability to reduce deformities, and the outcome of surgery for degenerative spondylolisthesis, but very scant on the postoperative functional outcome of adults with isthmic spondylolisthesis.Functional outcome was analyzed by both preoperative and postoperative SF-36 questionnaires and by four additional functional questionnaires at follow-up.Statistically significant improvement was seen in six of the eight SF-36 scales. Fifty-five percent of the patients scored in the normal range at follow-up compared with none before surgery.Significant functional improvement was seen following surgical arthrodesis of the painful segments in adults with isthmic spondylolisthesis (P = 0.001). This study further confirms that such surgery is appropriate for patients failing adequate nonoperative treatment.

Study Design Retrospective comparative study of 2 approaches to multilevel fusion for cervical spondylosis in consecutive patients at a single institution. Objective To provide justification for a concomitant posterior approach in multilevel cervical fusion for spondylosis by demonstrating decreased pseudarthrosis and reoperation rates. Summary of Background Data Among the factors that affect cervical rates is the number of levels, such that increasing the number of levels leads to lower fusion rates. Because of this, modifications have been sought to improve union in multilevel procedures. One option is an antero-posterior (AP) approach or circumferential arthrodesis. Methods Seventy-eight consecutive patients who underwent multilevel cervical fusion at a single institution and with minimum 2-year follow-up data were divided into an anterior-only group (anterior: n=55), and an AP group (AP: n=23). Union was assessed by surgical exploration, computerized tomography scan, and flexion-extension radiographs. The groups were compared in terms of pseudarthrosis rates and reoperation rates. Results Using χ2 analysis, there was a significant difference in pseudarthrosis rates (anterior 38% vs. AP 0%; P<0.001), and reoperation rate for pseudarthrosis (anterior 22% vs. AP 0%; P=0.01). There were no differences in overall (anterior 36% vs. AP 30%; P=0.62) and early (anterior 15% vs. AP 26%; P=0.13) reoperation rates, but late reoperations were increased in the anterior group (24% vs. AP 4%; P=0.043). Conclusions A concomitant posterior fusion significantly reduced the incidence of pseudarthrosis (0% vs. 38%) and pseudarthrosis-related reoperations (0% vs. 22%) compared with traditional anterior-only fusion. However, this did not translate to a difference in overall reoperation rates. The majority of reoperations in the AP group (86%) were performed within 6 months, whereas those in the anterior-only group (65%) were performed later, which was generally when a pseudarthrosis became evident.

A retrospective review was performed to determine “crankshaft” prevalence in 86 immature patients who underwent posterior spinal fusion for idiopathic scoliosis. Tanner stage, chronologic age, bone age, and epiphyseal status were used as maturity indicators. Overall, 62 (72%) patients progressed≤10°, 18 (21%) patients progressed 11-15°, and six (7%) patients progressed ≥16° in the coronal plane. Tanner I patients with open triradiate cartilage had the highest rate of crankshaft occurrence; nine (75%) of 12 patients progressed >10° (p < 0.05). Fifty-two percent of Tanner I, 26% of Tanner II, 11% of Tanner III, and no Tanner IV patients progressed >10° (p < 0.05). Cobb angle increases of >10° occurred in 54% of patients with open triradiate cartilage(p < 0.05) and in 48% of patients with open capital femoral epiphyses (p < 0.05). Anterior and posterior spinal fusion should be considered in prepubertal (Tanner I) patients with open triradiate cartilage.

A study documenting major complications encountered in revision procedures for lumbar cage pseudoarthrosis.To document the perioperative complications associated with revision surgery for threaded cylindrical cage pseudoarthrosis.Pseudoarthrosis after cylindrical cage placement manifests as persistent or recurrent pain and disability after surgery. Revision strategies include isolated posterior stabilization and posterior bone grafting, versus circumferential revision where an attempt is made to remove the cages anteriorly, followed by posterior stabilization and fusion. Potential complications associated with these revision procedures have not been adequately documented in the past.Forty-seven consecutive patients with the diagnosis of cylindrical cage pseudoarthrosis were surgically treated with either a circumferential revision (AP) or an isolated posterior instrumented fusion (P). All intraoperative and postoperative complications were documented. Radiographic interbody fusion rates and preoperative and postoperative visual analog scale (VAS) scores were documented.Three of the AP patients, all with anterior cage placement at L5-S1, had iliac vein lacerations requiring repair. A fourth patient had a ureteral injury requiring subsequent nephrectomy. Three patients who underwent circumferential revision and 2 patients who had an isolated posterior procedure had postoperative complications, including 2 infections (1 AP and 1 P), 1 radiculopathy (P), and 2 patients with prolonged ileus (both AP). There was a statistically significant decrease in overall VAS scores postoperatively for the 2 groups using the paired t test (P<0.0001). There was no difference in either the preoperative (P=0.22) or 2-year postoperative (P=0.30) VAS scores between the AP and P groups [rank-sum (Mann-Whitney) t tests]. Interbody fusion was achieved in 79% (30 of 38 levels) in the AP group. The interbody fusion rate was 37% (8 of 22) for the P group.Circumferential revision including cage removal, structural allograft placement, and posterior stabilization is associated with increased perioperative complications. Although an anterior approach showed increased interbody fusion rates, this technique did not lead to more superior clinical outcomes based on VAS scores. It remains to be shown by larger prospective studies if there is a true difference in outcome between these 2 groups that will justify the increased perioperative morbidity associated with attempted cage removal.

The case histories of 11 patients (five adults and six children) who presented with scoliosis after multiple rib resection for several disorders were reviewed. All 11 cases developed scoliosis with the convexity directed toward the side of the rib resection. The natural history of the scoliosis was progressive, and the younger the age at the time of rib resection, the more severe the progression. The rate of progression was greatest during the first 10 years after rib resection. The five patients who presented as adults were treated in several ways, only one requiring spine fusion. However, five of the six children required spine fusion to prevent progression of scoliosis.

Summary: The purpose of this study was to document the medical and surgical complications of anterior spine surgery in children and to identify risk factors for complications. A retrospective chart review was conducted of 599 anterior procedures (24 anterior only, 300 staged anterior/posterior, 175 combined anterior/posterior procedures) performed between 1967 and 1991. Major complications occurred in 7.5% of procedures and minor complications in 33%. Risk factors for major complications were age >14 years, male gender, kyphotic curve type, curve sizes >100°, vital capacity <40% of predicted, and use of thoracotomy. Risk factors for minor complications were age >14 years, curves >100°, vital capacity <40% of predicted, and use of a staged procedure. Multivariate analyses of risk factors identified age >14 years and curves >100° as the most significant risk factors for major complications and age >14 years for minor complications. We concluded that anterior spinal surgery can be performed in children with an acceptable level of risk and that referral for surgery before 14 years of age and before the curve size progresses will significantly reduce the risk of complications.

A retrospective review was performed to determine "crankshaft" prevalence in 86 immature patients who underwent posterior spinal fusion for idiopathic scoliosis. Tanner stage, chronologic age, bone age, and epiphyseal status were used as maturity indicators. Overall, 62 (72%) patients progressed < or = 10 degrees, 18 (21%) patients progressed 11-15 degrees, and six (7%) patients progressed > or = 16 degrees in the coronal plane. Tanner I patients with open triradiate cartilage had the highest rate of crankshaft occurrence; nine (75%) of 12 patients progressed >10 degrees (p < 0.05). Fifty-two percent of Tanner I, 26% of Tanner II, 11% of Tanner III, and no Tanner IV patients progressed >10 degrees (p < 0.05). Cobb angle increases of >10 degrees degrees occurred in 54% of patients with open triradiate cartilage (p < 0.05) and in 48% of patients with open capital femoral epiphyses (p < 0.05). Anterior and posterior spinal fusion should be considered in prepubertal (Tanner I) patients with open triradiate cartilage.

The importance of the double thoracic (King V) curve lies in the need for the patient to have a balanced connection. None of us wishes to produce a decompensated trunk patient as the result of our surgical efforts. To recognize the curve pattern, one should read carefully the classic article by King et al.3 To select the proper technique of management, one should read the new work by Lee et al,4 which discusses subtleties not described in the previous article. At our center, we favor balanced correction so that the result is two curves of equal value, level shoulders, absence of an ugly trapezius area prominence, a vertical and well-centered torso, and a normal sagittal contour. Overcorrection of the right thoracic curve must be avoided.

The purpose of this study was to document the medical and surgical complications of anterior spine surgery in children and to identify risk factors for complications. A retrospective chart review was conducted of 599 anterior procedures (24 anterior only, 300 staged anterior/posterior, 175 combined anterior/posterior procedures) performed between 1967 and 1991. Major complications occurred in 7.5% of procedures and minor complications in 33%. Risk factors for major complications were age > 14 years, male gender, kyphotic curve type, curve sizes > 100 degrees, vital capacity < 40% of predicted, and use of thoracotomy. Risk factors for minor complications were age > 14 years, curves > 100 degrees, vital capacity < 40% of predicted, and use of a staged procedure. Multivariate analyses of risk factors identified age > 14 years and curves > 100 degrees as the most significant risk factors for major complications and age > 14 years for minor complications. We concluded that anterior spinal surgery can be performed in children with an acceptable level of risk and that referral for surgery before 14 years of age and before the curve size progresses will significantly reduce the risk of complications.

This is a retrospective clinical and roentgenographic study of two different types of instrumentation used in the treatment of thoracic and lumbar spinal fractures. Dual square-ended distraction rods contoured into lordosis produced improved results when compared with round-ended distraction rods in terms of both the degree of reduction obtained on the operating table and preventing recollapse of the fracture in the ensuing month. The importance of restoring lordosis was more apparent in the thoracolumbar junction and lumbar spine than in the thoracic region.

HYPOTHESIS: The rate of adjacent segment degeneration following lumbar fusion is not well known. This project aimed to gather basic epidemiologic outcomes related to the rate of adjacent segment degeneration requiring extension of fusions with minimum 10 year follow-up.

Thirty-two pediatric patients with severe restrictive lung disease identified with vital capacities < 40% of predicted, who had undergone major reconstructive spine surgery, were reviewed. There were 18 boys and 14 girls, the mean age was 13 years (range, 7-17), and the mean vital capacity was 31% of predicted (range, 16-39%). Fifty-four procedures were performed, 13 posterior only, one of which was staged, and 19 anterior and posterior procedures, of which 15 were staged and four were sequential. The incidence of pulmonary complications (pneumonia, reintubation, pneumothorax, respiratory arrest, or the need for tracheostomy) was 19% (six patients), and only three patients required tracheostomy. The surgical and perioperative mortality rate was zero. Patients who had a thoracotomy or a thoracoabdominal approach had a significantly higher number of pulmonary complications. The use of preoperative decreased vital capacity as a measure of inoperability excludes the young patient most in need of surgical intervention. With improved preoperative, intraoperative, and postoperative techniques, careful monitoring, and the cooperation of pediatric pulmonologists and intensivists, reconstructive spine surgery can be performed in the pediatric patient with severe decreased vital capacity with very acceptable morbidity and mortality.

Letters| December 09 2008 Peritonitis during Continuous Ambulatory Peritoneal Dialysis: Treatment with Pefloxacin: First Results and Pharmacokinetics Subject Area: Nephrology M. Benzakour; M. Benzakour aHome Dialysis Unit and Search for other works by this author on: This Site PubMed Google Scholar C. Lagarde; C. Lagarde aHome Dialysis Unit and Search for other works by this author on: This Site PubMed Google Scholar D. Benevent; D. Benevent aHome Dialysis Unit and Search for other works by this author on: This Site PubMed Google Scholar M. Mounier; M. Mounier bService de Bactériologie-Virologie, Limoges, France Search for other works by this author on: This Site PubMed Google Scholar F. Denis F. Denis bService de Bactériologie-Virologie, Limoges, France Search for other works by this author on: This Site PubMed Google Scholar Nephron (1988) 50 (2): 175–176. https://doi.org/10.1159/000185152 Article history Published Online: December 09 2008 Content Tools Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn Email Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation M. Benzakour, C. Lagarde, D. Benevent, M. Mounier, F. Denis; Peritonitis during Continuous Ambulatory Peritoneal Dialysis: Treatment with Pefloxacin: First Results and Pharmacokinetics. Nephron 1 February 1988; 50 (2): 175–176. https://doi.org/10.1159/000185152 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll JournalsNephron Search Advanced Search This content is only available via PDF. 1988Copyright / Drug Dosage / DisclaimerCopyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements. Article PDF first page preview Close Modal You do not currently have access to this content.

True back pain is uncommon in children and adolescents. The authors report a case of scoliosls associated to osteoblastoma in a very unusual site—the rib. This particular location was reviewed in the literature and appears to have an incidence of 0.41% as compared with osteold osteomas and osteoblastomas in general. The case reported was a 14-year-old girl presenting with a 32 degree scoliosls that reduced to 9 degrees after excision of the lesion. The authors recommend personal review of bone scans as poor communication between the orthopedic surgeon and the isotope expert may make an osteoblastoma be interpreted as a radiographic artifact.

Study Design. A retrospective review with statistical correlations of 112 patients having both scoliosis and syringomyelia was performed. Objective. To determine whether there were significant correlations between the type of scoliosis, location of the syrinx, size of the syrinx, clinical manifestation of the syrinx, and associated lesions such as cord tethering and Chiari malformation (Chiari I or Arnold–Chiari II). Summary of Background Data. The coexistence of scoliosis and syringomyelia has been described previously, but these detailed correlations have had minimal attention. Methods. All patients at the center with scoliosis of any type plus a syrinx had a detailed chart and radiologic review coupled with detailed statistical analysis. Results. Scoliosis and syringomyelia were seen in four diagnoses: myelomeningocele, myelomeningocele with congenital scoliosis, congenital scoliosis, and scoliosis with neither congenital anomalies nor myelomeningocele. Chiari malformation and cord tethering appear to have a major relation to scoliosis with syringomyelia. Conclusions. Anomalies of the spinal cord or spinal column coexisting with lesions of the central nervous system have significant effects on the syrinx and scoliosis. There is a significant relation between the most caudal level of the syrinx and the locations of the scoliosis.

Anterior approaches for scoliosis are now frequent. Versatility in exposure is such that any segment may be approached from either side without significant difficulty or morbidity. Anterior spine surgery is an addition to the modern armamentarium by improving correction, insuring fusions, and allowing better alignment of the scoliotic spine. In the 1990s, scoliosis patients are beneficiaries of innovators of safe and sound anterior spine surgical practice.

Three patients sustained a lateral distraction injury to the thoracic or lumbar spine. These injuries were associated with multiple fractures of the ribs and extremities as well as with thoracic and abdominal visceral injuries. No patient had an injury to the spinal cord or cauda equina. The injuries to the spine were successfully treated with open reduction of the unilateral subluxation of the facet joint and with internal fixation with Harrington instrumentation. Fusion was achieved with the spine in anatomical alignment, without any complications, in all three patients.

Study Design. Retrospective chart and radiographic reviews were conducted. Objective. To identify the incidence of and any possible risk factors for the crankshaft phenomenon after posterior spinal arthrodesis for congenital scoliosis. Summary of Background Data. Studies have shown the crankshaft problem to be common after posterior arthrodesis for infantile and juvenile idiopathic scoliosis, but the few reports available show it to be much less common for congenital scoliosis. Methods. This study chose children fused before the pubertal growth spurt, all classified as Risser 0 and with open triradiate cartilages. These children were followed to the end of their growth (mean follow-up period 12 years). Several measurement parameters were used for evaluation. Results. The crankshaft problem, measured as a Cobb angle increase of more than 10°, was seen in 15% of the 54 patients. There was a positive correlation with earlier surgery and larger (>50°) curves. No other positive correlations could be identified. Conclusions. Crankshafting was observed in 15% of the patients, more often with larger curves and earlier fusions.

BACKGROUND CONTEXT: Pedicle subtraction (PSO) and Smith Peterson (SPO) osteotomies are commonly used surgical techniques in the correction of spinal deformities, in particular the correction of sagittal plane deformity. This study compares the radiographic profile and outcomes in 151 such osteotomies, the largest series comparing 2 techniques from a single institution.

BACKGROUND CONTEXT: Pedicle subtraction (PSO) and Smith Peterson (SPO) osteotomies are commonly used surgical techniques in the correction of spinal deformities, in particular the correction of sagittal plane deformity. In this study, we compared the complications in 151 such osteotomy procedures.

Orthopaedic Surgeon in Charge of the Spine Service, St. Paul-Ramsey Medical Center; Assistant Professor of Orthopaedic Surgery, University of Minnesota; Staff on Spine Service, Gillette Children's Hospital.

Pefloxacin was used as monotherapy in 15 cases of peritonitis occurring in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Antibiotic administration was made intravenously on day 1 (800 mg) and from day 2 to day 4 (400 mg/day), then orally during 10 days (400 mg/day). The dosage of 400 mg gave a mean serum concentration peak (11.2 mg/l) and valley (5.4 mg/l) on the second day and a mean dialysate level of 5 mg/l. The last mean serum concentration (J14) were 5.5 mg/l (peak) and 2.5 mg/l (valley) and the mean dialysate level was 2.6 mg/l. Ten of these patients were cured. We explained pefloxacin therapy failure in two cases by resistant strains (S. sanguis and S. bovis), in one case by an acquired resistance during treatment (S. epidermidis), in an other case by catheter contamination; and in the last case, clinical failure occur despite good sensitivity with in vitro-test (Acinetobacter).

A study was performed to investigate the intraperitoneal penetration of Imipenem/cilastatin into inflammatory peritoneal fluid. Six patients undergoing abdominal surgery (acute peritonitis), were treated with Imipenem/cilastatin (4 perfusions of 0.5 g/day) during 5 days after the intervention. Plasma samples were obtained on day 1 and 4 at the pic and at the valley; peritoneal samples were obtained every days for 4 days, 1, 3 and 6 hours after the end of a perfusion. The samples were immediately stabilised following the manufacturer instructions and quick freezed at -80 degrees C. Dosages were performed using a microbiological assay. The mean peritoneal levels are above the MIC 90 of the more frequent bacteria which cause infection in abdominal surgery. Moreover none of the patients showed relapse of infection or complication during this treatment.

Study Design. Prospective and retrospective outcome analysis following arthrodesis for adult isthmic spondylolisthesis in 31 patients. Objective. To examine whether or not patients having such surgery have a functional improvement in their lives. Summary of Background Data. The literature is full of articles concerning adolescent spondylolisthesis, the union rate for adult spondylolisthesis, the ability to reduce deformities, and the outcome of surgery for degenerative spondylolisthesis, but very scant on the postoperative functional outcome of adults with isthmic spondylolisthesis. Methods. Functional outcome was analyzed by both preoperative and postoperative SF-36 questionnaires and by four additional functional questionnaires at follow-up. Results. Statistically significant improvement was seen in six of the eight SF-36 scales. Fifty-five percent of the patients scored in the normal range at follow-up compared with none before surgery. Conclusion. Significant functional improvement was seen following surgical arthrodesis of the painful segments in adults with isthmic spondylolisthesis (P = 0.001). This study further confirms that such surgery is appropriate for patients failing adequate nonoperative treatment.

Study Design. Retrospective chart and radiologic analysis. Objectives. To analyze the value and risks of neurosurgical procedures for syringomyelia and of fusion procedures for scoliosis. Summary of Background Data. There are few reports on the benefit of neurosurgical procedures on scoliosis, as well as the risk of fusion procedures on scoliosis related to syringomyelia. Methods. The 105 patients who had both scoliosis and syringomyelia were subdivided into three groups: (I) 59 patients without congenital scoliosis or myelomeningocele, (II) 20 patients with congenital scoliosis and syringomyelia, and (III) 26 patients with myelomeningocele and syringomyelia. The study evaluated: (1) The effect of either suboccipital craniectomy or direct shunting on the syrinx, the curvature, and the neurologic status; (2) the neurologic risk of scoliosis fusion surgery; and (3) the curve status after fusion surgery. Results. In Group I (patients without congenital scoliosis or myelomeningocele), suboccipital craniectomy resulted in curve improvement in seven, worsening in three, and no change in two, whereas direct syrinx shunting gave curve improvement in none, curve worsening in six, and no change in two. In Groups II and III, no patient had curve improvement after neurosurgery. Group III had the highest rate of subsequent neurosurgery (50%). The subsequent neurosurgery was nearly always suboccipital craniectomy or detethering of the cord. Three of 38 patients (8%) had neurologic worsening when scoliosis fusion surgery was done without previous syrinx decompression. Conclusions. In patients without myelomeningocele or congenital scoliosis, but with Arnold-Chiari malformation and syringomyelia, suboccipital craniectomy gave the best chance for syrinx reduction and scoliosis improvement, particularly in children younger than 10 years. Syrinx shunting improved none of the scolioses. For syrinxes in patients with congenital scoliosis or myelomeningocele, neither neurosurgical procedure resulted in curve improvement, as other causes of scoliosis (vertebra anomalies, paralysis) remained untreated. Patients with myelomeningocele require a multipronged surgical approach to address all causes of syrinx, thus minimizing the potential need for repeat neurosurgery. Scoliosis correction without prior syrinx decompression carries a high neurologic risk.

The importance of the double thoracic (King V) curve lies in the need for the patient to have a balanced connection. None of us wishes to produce a decompensated trunk patient as the result of our surgical efforts. To recognize the curve pattern, one should read carefully the classic article by King et al. To select the proper technique of management, one should read the new work by Lee et al, which discusses subtleties not described in the previous article. At our center, we favor balanced correction so that the result is two curves of equal value, level shoulders, absence of an ugly trapezius area prominence, a vertical and well-centered torso, and a normal sagittal contour. Over-correction of the right thoracic curve must be avoided.

Purpose of study: The goal was to investigate the pattern of pain in patients with scoliosis (SC) associated with syringomyelia (SM). Methods used: A total of 119 patients with SC associated with SM were investigated. Mean follow-up was 11.8 years. of findings: SM-related pain occurred in 70 of 119 patients (59%) at presentation, at the average age of 18.1 years (range, 3.1 to 47.6 years). Backache, headache and neck pain were the most common types of pain in 47.1%, 32.9% and 28.6% of patients, respectively. The presence and severity of an ACM had a significant correlation with the presence of headache (p = .027). Likewise, headache was also more common among patients with MM (p = .032). In only 23 cases (19.3%) pain was present at time of diagnosis of SC. In 47 cases (39.5%) SM-related pain occurred after the time of diagnosis of SC, at an average of 11.7 ± 9.7 years (range, 0.1 to 44.5 years). Pain alone or together with neurological symptoms were the main indications for magnetic resonance imaging in 12 and 28 patients, respectively. Among 70 patients with pain, 32 cases still had some pain at late follow-up. No significant correlation between size of syrinx and the presence of pain existed (p > .05). The only relationship between the location of syrinx and type of pain was that presence of leg pain correlated with a lower located syrinx (p < .05). Relationship between findings and existing knowledge: The vast majority of patients who present with idiopathic scoliosis do not have associated pain. Little is known about the pain patterns in patients with scoliosis and syringomyelia. Our study describes the onset and pattern of pain in the population of patients with both scoliosis and syringomyelia. Overall significance of findings: Syringomyelia should be considered as a differential diagnosis in patients with scoliosis with pain. Most patients had some pain at late follow-up despite treatment. Leg pain was found mainly in patients with terminal syrinxes. No correlation between syrinx size and pain existed. Disclosures: No disclosures. Conflict of interest: No conflicts.

BACKGROUND CONTEXT: Thoracic pedicle screw placement has become a commonly used technique in spinal deformity, fractures and other pathologies. The techniques commonly used for intra-operative assessment of placement of thoracic pedicle screws are plain radiographs and image intensifier. A systematic technique has been reported by Choma and Denis et al in the luimbar spine but not in the thoracic spine.

BACKGROUND CONTEXT: Although most surgeons believe that adequate balance is important in the treatment of spinal deformity, there is no strong evidence supporting that concept. Only one group has found weak correlations between sagittal spinal balance and quality of life in patients with adult spinal deformity, but this finding has never been confirmed in another study. In addition, while the use of the gravity line is gaining interest in the evaluation of global balance, it remains unknown if this parameter is associated with quality of life.

This is a case report describing the injury sustained by a 36-year-old man injured in a motorcycle crash who sustained a fracture dislocation of L2 upon L3, associated with a split in the lamina of L3. His neurologic lesion was T12 ASIA B: with a motor score of 52 but with preservation of sensory function (sensory score 96) in most parts of his lower extremities. He also suffered a lower extremity fracture. Imaging of the spine is presented showing a multiplanar fracture associated with translation and with a defect in the lamina that may be seen in certain AO type B or type C fractures, that may entrap the lumbar spinal nerve roots. Discussants of this case comment on the classification and clinical significance of this fracture pattern. and present their operative approaches, both for management of this particular fracture pattern and for any associated dural tear. The issues of steroid use and the place of rehabilitation are also discussed.

Methods Ninety-three consecutive patients (average age sixty-eight years) with degenerative de novo scoliosis (74% lumbar, 26% thoracolumbar; average curve 24 degrees) were retrospectively studied in terms of presenting symptomatology. For those patients with ipsilateral radicular symptoms, plain radiographs and MRI at presentation were reviewed. Radiographic measurements included major and lumbosacral curve Cobb angle. Computerized measurements of MRI included minimum subarticular height and foramen cross-sectional area of the nerve root that was injected. The patient's reported response from the nerve root injections was rated poor, good and excellent ( 70% of relief). Correlation between MRI measurements and response from the steroid injections were done with the Pearson's test.

The intraocular distribution of fosfomycin was studied in 32 patients undergoing cataract surgery and in 8 rabbits after experimental infection of one eye by Staphylococcus aureus. Concentrations found 1 to 6 hours after termination of a 4 g fosfomycin infusion ranged from 14 to 18.8 mg/l in the aqueous humor and 8 to 12.5 mg/l in the vitreous body. These levels are higher than the MICs for 80 to 90% of the bacteria responsible for endophthalmitis. In each rabbit, the fosfomycin concentration in the infected eye as compared to the healthy eye was increased 2.5 to 5--fold for the aqueous humor and 4.9 to 19.2--fold for the vitreous body. Fosfomycin, in association with a third generation cephalosporin (ceftriaxone) or one of the new quinolones (pefloxacin) can be recommended for the prevention or early treatment of endophthalmitis.

BACKGROUND CONTEXT: Previously reported risk factors for junctional kyphosis include inappropriate end vertebrae selection, curve correction >50%, or excessive junctional soft tissue dissection.

HYPOTHESIS: At the present time there is no universally accepted radiologic assessment method for determining pseudoarthrosis after cervical spine fusion surgery. The use of plain radiographs is used widely in clinical research, although little information is known on the true validity. The purpose of this prospective study was to assess inter- and intra-rater variability for fusion status assessment using CT and X-rays.

Department of Orthopaedics, University of Texas Health Science Center at San Antonio, San Antonio, Texas

Peritonitis is one of the most serious complication concerning patients under continuous ambulatory peritoneal dialysis (CAPD). A Staphylococcus (aureus, epidermidis) is the causative pathogen in nearly 60% of cases. This prompted a study of vancomycin, a potent antistaphylococcal agent (MIC less than or equal to 3 micrograms/ml) in 13 patients with peritonitis. Vancomycin was used as single drug therapy. Kinetics were studied after a single injection of 1 g into the dialysate bag. Serum and peritoneal concentrations exceeding 3-4 micrograms/ml were found to persist for four days; half-life was 62.3 and 54.8 h in the dialysate and serum respectively. Peritoneum to serum diffusion varied widely across individuals. In 15% of patients, serum concentration exceeded the potentially ototoxic level (80 micrograms/ml) for a few hours.

The authors report a double study comparing the conventional chest radiograph and digitalised images. The first study was to visualise normal mediastinal structures (the contour of the posterior mediastinum, the azygo-oesophageal recess, the bronchial sub-segments, intermediate, carina, trachea) and showed a superiority of the digitalised image. The second study was on the recognition of radiological abnormalities in lung cancer which showed no precise superiority of the digitalised image in the mediastinum (bronchial tumour, adenopathies) and a current deficiency at the pleuro-parenchymal level (pulmonary nodules, atelectasis pleural effusion). This double study presents parallel results to those obtained by the anglosaxon authors on different prototypes in whom the technology and possibilities were different. The principles, the advantages and the limits of these prototypes were described and in conclusion a chosen technique for the medium term is proposed by the authors.

s Presented at the Sixth Annual Meeting of the Orthopaedic Trauma Association: Toronto, Canada, November 7–10, 1990: PDF Only