Convex spinal epiphysiodesis in the management of progressive infantile idiopathic scoliosis.

STUDY DESIGN: Retrospective review of patient records with current clinical and radiographic assessment. OBJECTIVE: To evaluate the long-term result of anterior and posterior convex spinal growth arrest, with or without instrumentation, in managing infantile idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: There were 12 male and 10 female patients studied, with a mean follow-up period of 10 years, 9 months. The mean Cobb angle before surgery was 65 degrees. All had a rib vertebral angle difference more than 20 degrees. The mean age at surgery was 6 years. Nine patients had epiphysiodesis alone; nine patients also underwent Harrington instrumentation simultaneously, and four underwent Harrington instrumentation 2-4 years later. METHOD: Clinical evaluation and sequential measurements of Cobb angle were done. RESULTS: The epiphysiodesis-only group had a mean preoperative Cobb angle of 72 degrees, mean progression of curves of +12 degrees, and mean rate of progression of +2.5 degrees per year: the group's postoperative figures were 92 degrees, +15 degrees, and +3 degrees per year, respectively. The epiphysiodesis and late Harrington rod group had a mean preoperative Cobb angle of 56 degrees, mean progression of +12 degrees, and a mean rate of progression of +5 degrees per year; the group's postoperative Cobb angle averaged 62 degrees, progression +6 degrees, and rate of progression +1 degree per year. The epiphysiodesis with simultaneous Harrington rod group had a preoperative mean Cobb angle of 60 degrees, mean progression of +18 degrees, and mean rate of progression of +6 degrees per years. After surgery, these improved to 58 degrees, correction of 2 degrees, and rate of correction of 0.5 degree per year. CONCLUSION: Combined anterior and posterior convex spinal growth arrest alone does not prevent progression of deformity in infantile idiopathic scoliosis. The addition of posterior instrumentation can slow or arrest deformity progression but not reverse it.

Long-term results of combined anterior and posterior convex epiphysiodesis for congenital scoliosis due to hemivertebrae.

STUDY DESIGN: Retrospective review of patient records with recent clinical and radiologic assessment. OBJECTIVE: To evaluate the long-term result of anterior and posterior convex ephiphysiodesis in the management of congenital scoliosis resulting from fully segmented nonincarcerated hemivertebra. SUMMARY OF BACKGROUND DATA: Thirty patients (16 male/14 female patients) were reviewed. Follow-up was a minimum of 3 years (average, 8 years 10 months; range, 3-22.5 years). Nineteen patients were skeletally mature, and the mean age of the remaining 11 was 11.75 years. METHOD: Clinical evaluation and sequential measurements of Cobb angle was made independently by two observers. RESULTS: Compared with preoperative values, the rate of change in Cobb angle was reversed in 23 patients, arrested or slowed in five patients, and unchanged or progressed in two patients. The annual rate of change in Cobb angle was +1.9 degrees before surgery and -1.2 degrees after surgery, a difference of 3.1 degrees. This is highly statistically significant (P < 0.001). Total correction in Cobb angle correlates with age at time of surgery (P < 0.03). The rate of correction in Cobb angle after surgery correlates with the total correction achieved (P < 0.001) and with age at time of surgery (P < 0.05). The greater correction is achieved when surgery is performed at a young age. The preoperative rate of increase in Cobb angle does not correlate with correction (P < 0.76). The site of the hemivertebrae influenced final outcome with best results in the lumbar spine. CONCLUSION: Combined anterior and posterior convex epiphysiodesis is a reliable method for the correction of deformity resulting from hemivertebrae.

Long-term results of convex epiphysiodesis for congenital scoliosis.

The objective of this study was to evaluate the long term outcome of combined anterior and posterior convex spinal epiphysiodesis in the treatment of congenital scoliosis. The study covered 53 patients (27 male, 26 female) with a minimum follow up period from surgery of 3 years (mean 8.8 years, range 3-22.5 years). Of these, 34 were skeletally mature when reviewed. Clinical assessment and sequential measurement of Cobb angles were used to chart the course of the deformity following surgery. The types of vertebral anomalies encountered were: 4 unsegmented bars, 7 unsegmented bars with hemivertebrae, 30 hemivertebrae (of which 2 were double hemivertebrae) and 12 complex (unclassifiable) patterns. The severe types were concentrated in the thoracic spine. Results are presented with reference to the type and site of anomaly and to the age of the patient at the time of surgery. Where deformity was due to an unsegmented bar (with or without hemivertebra) the rate of change of Cobb angle was slowed, but not reversed, following surgery. For the complex anomalies there was a reduction in the rate of progression of deformity following surgery, however, the final Cobb angle still increased from a mean of 61 degrees to 70 degrees. In contrast, the rate of progression reversed or slowed in 97% of the hemivertebra patients following surgery, producing a change in mean Cobb angle from 41 degrees pre-operatively to 35 degrees post-operatively. For each type of anomaly the correction achieved was greater where the surgery was performed at a younger age. Final outcome was influenced by the site of anomaly, with a better correction being achieved in the lumbar than the thoracic spine. In conclusion, we feel that convex epiphysiodesis has an important role in the surgical management of congenital scoliosis and, for hemivertebrae in particular, it can produce significant correction of deformity.

Growth modification in the treatment of scoliosis.

Structural deformities, of which scoliosis is a notable example, imply a skeletal length discrepancy which may involve all three dimensions. Once the deformity is established, secondary mechanisms come into action. Physiological treatment concerns modifying spinal growth and the convex side can be retarded, the concave side stimulated, the neurocentral physis arrested to correct rotation, and the forces acting along the ribs can be altered. Thus stapling, epiphysiodesis, posterior fusion, combined convex side epiphysiodesis, and convex side posterior fusion, convex side tether, costodesis, and concave side rib head excision have all been tried. Of these, combined anterior and posterior fusion of the convexity is the most effective, particularly for congenital hemivertebrae without rotation.

Pseudarthrosis following treatment of idiopathic scoliosis by Harrington instrumentation and fusion without added bone.

A retrospective review was conducted to assess the incidence of pseudarthrosis among 381 patients who had surgical treatment of idiopathic scoliosis by Harrington distraction rod and posterior fusion without added bone. In 260 patients where the lowest level of fusion was at or above the third lumbar vertebra, there were no cases of pseudarthrosis. In the remaining 121 patients with fusion extending below the third lumbar level, there were eight cases, an incidence of 6.6%, for an overall incidence of 2.5%.

Long-term follow-up evaluation of screw-and-graft fusion of the lumbar spine.

The long-term results of 134 screw-and-graft fusions of the lumbar spine for treatment of chronic low-back pain with or without acute sciatic nerve symptoms were observed for over 16 years. Clinically, the results were excellent or good in 80% of patients at a mean review interval of nine years. There were no differences in success rates between single-level L4/5 and lumbosacral fusion or two-level fusions. Ninety-seven percent of patients returned to their previous occupation within six months. Screw-and-graft fusion is recommended as an effective method of treatment in management of selected cases of intractable low back pain.

Greater trochanteric pain syndrome. A report of 15 cases.

Fifteen patients with identical symptoms of pain and tenderness at the tip of the greater trochanter are reviewed. Diagnosis by the referring doctor was usually osteoarthritis of the hip or sciatica, but localised tenderness and pain on resisted abduction were the only clinical signs. Radiographs were usually normal. Most cases were relieved by one or more local steroid injections. This disorder has much in common with tennis elbow, golfer's elbow, coccydynia and policeman's heel. We suggest that all these conditions may be traction syndromes.

Growth arrest for progressive scoliosis. Combined anterior and posterior fusion of the convexity.

A review is presented of 13 young patients with congenital scoliosis who were treated by epiphysiodesis of part of the vertebral bodies combined with posterior fusion, both on the convex side; the plan was to arrest growth on the convexity which, combined with growth of the concave side, would result in progressive correction of the curve. The first patient was operated on at the age of four years and has now reached skeletal maturity with complete correction of her curve. Several others, still growing, are showing progressive correction. Only three curves, in which kyphosis was more severe than scoliosis, have deteriorated since operation. Although full assessment must await skeletal maturity of all the patients, this approach appears to have sufficient potential to justify an early report.

Acetabular floor thickening and femoral head enlargement in congenital dislocation of the hip: lateral displacement of femoral head.

The thickness of the acetabular floor and the horizontal diameter of the femoral head often appear enlarged on X-ray films of congenitally dislocated hips, particularly in the later stages. These distances were, therefore, measured and compared with the normal side in 49 strictly unilateral cases. Increased floor thickness was an early change and usually persisted, often in spite of a satisfactory reduction. Increased head diameter was detectable later and these two features together increased the distance between the centre of the femoral head and the midline of the body. This lateral displacement, even when the head is well covered, increases abductor effort and force transmitted to the femoral head on weight bearing and may have an adverse effect on the joint's long term future.

A short-term follow-up of patients with mild scoliosis.

Thirty patients with mild idiopathic scoliosis were reviewed between 7 and 17 years after spinal maturity. These patients were not treated surgically because they were cosmetically acceptable, and unlikely to progress further. Standardised radiographs taken at spinal maturity and at review were comparable, so any change represented true progression in a fully mature spine. There was an increase of lateral curvature in 60 per cent of the patients; this was small and always under 10 degrees. No change was seen in rotation. Lateral curves over 30 degrees, with rotation of 25 degrees or more, were found to be almost twice as likely to progress. It is suggested that caution should be exercised in leaving these curves untreated, and follow-up into early adult life is advisable.

The natural history of scoliosis in myelodysplasia.

Two hundred and fifty cases of myelodysplasia were reviewed in relation to spinal deformity. Approximately half of the children had, or were expected to develop, curves severe enough to need operations and only 10 per cent maintained completely undeformed spines. The most frequent deformity was scoliosis which could be subdivided into congenital and developmental types. The latter was of mixed aetiology, neuromuscular imbalance and asymmetry of the neural arch both contributing, while in some cases no causative factors could be identified. The best early indicator that developmental scoliosis was likely to appear was a high segmental level of both the neurological deficit and the neural arch defect. Deformity was very unlikely to start after the age of nine years.

Treatment of scoliosis by posterior fusion, Harrington instrumentation and early walking.

One hundred and three patients with scoliosis treated by posterior fusion and Harrington instrumentation are reviewed. The fusion technique described does not require added bone. Walking in a localiser plaster is encouraged as soon as the wound is healed, usually two weeks after operation. The results compare satisfactorily with others published. It is concluded that added bone is not necessary unless neural arch defects are present, and that early walking is advantageous and without risk to the correction.