Chylothorax--a rare complication after anterior and posterior spinal correction. Report on six cases.

The authors observed six cases of chylothorax of 2,000 operations for spinal deformities performed in the past 5 years: in one case of VDS, two Harrington operations, and three anterior strut graft operations. Chylothorax resulted from direct injury to the lymphatic system in four cases of anterior spinal surgery. One of the Harrington cases had a previous history of spontaneous chylothorax that had been managed surgically. The other cases of chylothorax observed after a Harrington operation was bilateral and probably caused by the central venous catheter. All cases were treated conservatively, and the duration of the chylothorax varied from 1 to 18 days.

Results of surgical correction of kyphotic deformities of the spine in ankylosing spondylitis on the basis of the modified arthritis impact measurement scales.

STUDY DESIGN: This is a retrospective study of patient outcome in ankylosing spondylitis patients with fixed kyphotic deformities of the spine who underwent reconstructive surgery. OBJECTIVES: To measure the multidimensional effects of reconstructive spinal osteotomy in this patient group with a questionnaire-based instrument. SUMMARY OF BACKGROUND DATA: Between 1979 and 1988, 175 ankylosing spondylitis patients underwent operative treatment for fixed flexion deformities of the spine. One hundred forty-eight of these patients answered the questionnaire correctly and were included in the study. The others either died or were lost to follow-up. METHODS: The modified Arthritis Impact Measurement Scales with eight scales and 60 items plus six additional summative questions were administered at a mean follow-up period of 4.8 years (range, 2-10 years). The modified Arthritis Impact Measurement Scale measures eight scales--mobility, physical, household, daily, social activity, pain, anxiety, and depression. The Wilcoxon and chi-square test were used for analysis. RESULTS: Forty-seven of 60 items showed significant improvement of activity levels or status. Only two items showed a significant impairment of function. Of the patients, 88.4% were very satisfied with the result of the operation; 60.9% were able to return to work. Age, sex, and type of surgical technique did not influence the results. CONCLUSIONS: The modified Arthritis Impact Measurement Scales approach shows excellent overall improvement of health status after surgery, proving the worth of reconstructive surgery in ankylosing spondylitis patients with fixed kyphotic deformities of the spine.

Effects of the combined VDS-Zielke and Harrington operation on the frontal rib cage deformity of double major curves in idiopathic scoliosis.

STUDY DESIGN: This study analyzed the changes in the frontal plane of the deformed lower rib cage and the scoliosis-related alterations on the spine in patients with double major curve-pattern idiopathic scoliosis. OBJECTIVES: The results obtained preoperatively, after the Zielke operation, postoperatively after the Harrington instrumentation, and at the follow-up evaluation were compared to investigate which changes of the elements of the rib cage deformity are caused by each of the two instrumentations. SUMMARY OF BACKGROUND DATA: Previously, Wojcik reported on the effects of a Zielke operation on the lower rib in mild S-shaped idiopathic scoliosis. No previous data exist regarding the lower rib cage deformities in severe idiopathic double major-pattern scoliosis and their changes after combined VDS-Zielke and Harrington instrumentation. METHODS: Fifteen patients who underwent the staged Zielke operation followed by Harrington rod instrumentation were followed-up for an average period of 31.1 months. The methods used in our study included Cobb angle and a segmental analysis (T7-T12) of each of convex and concave rib-vertebra angles, rib-vertebra angle differences, vertebral rotation, and vertebral tilt. RESULTS: In this series, the apical convex ribs showed an increased droop preoperatively compared with the concave apical ribs. The VDS-Zielke operation corrected the lumbar scoliosis in an average of 63% of patients, whereas the thoracic scoliosis showed an immediate spontaneous correction of 30%. The VDS-Zielke operation also produced a significant correlation of the scoliosis-related vertebral tilt (T10-T12), derotated the lumbar vertebrae and the T12 vertebra significantly, elevated the "mobile" concave ribs, and increased the droop of the lower (T11, T12) "mobile" convex ribs. The Harrington instrumentation did not change the vertebral rotation, the vertebral tilt, the convex rib-vertebra angle, or the L4 obliquity, but significantly changed the apical concave rib-vertebra angle. The combined Zielke-Harrington instrumentation reduced the thoracic kyphosis and the thoracolumbar junction-kyphosis significantly, whereas the lumbar lordosis remained practically unchanged. CONCLUSIONS: Only the anterior VDS-Zielke instrumentation significantly corrects severe spinal deformities, elevates the three lower ribs on the concavity, and increases the droop of the two lower ribs on the convexity in the severe idiopathic double major curve-pattern scoliosis combined operated (Zielke-Harrington). Therefore, the Harrington instrumentation should have only limited use in cosmetic scoliosis surgery and should be replaced with posterior multi-hook instrumentation with a derotation effect.

Stabilization of the lumbosacral spine in postlaminectomy syndromes. Technique and 2-year results.

A 2-year follow-up study is presented using transpedicular stabilization with USIS (Universal Spinal Instrumentation System) and dorsoventral fusion for failed back syndrome. Eighty-four % excellent and good results at 3 to 6 months have decreased to 56% at 1 to 2 years. Complications are few if the anatomic landmarks are respected. Many psychological and social factors also modify the final outcome of salvage surgical procedures. Only the relief of pain determined our subjective evaluation by the patient himself, without regard to sensory or motor deficiencies.

[Ventral derotation spondylodesis. Results of treatment of cases of idiopathic lumbar scoliosis (author's (author's transl)]. / Ventrale Derotationsspondylodese. Behandlungsergebnisse bei Idiopathischen Lumbalskoliosen.

Of nearly 300 VDS operations, performed at the German Scoliosis Center, the first 50 cases have been analysed. Their follow-up was conducted over a period of two years minimally. Patients with lumbar scoliosis and double major curves will be analysed in detail separately. In suitable cases use of the ventral derotation spondylodesis offers considerable advantages as compared to other methods. Bending tests are decisive for determining the fusion area. Rotation and obliquity of the third or fourth lumbar vertebra are of critical importance. The author considers the Harrington operation no longer justified in those cases in which ventral derotation spondylodesis can be successfully used. Furthermore, the Dwyer procedure has to be considered obsolete.

[Experience with lateral electric surface stimulation in the treatment of progressive idiopathic scoliosis]. / Erfahrungen mit der lateralen elektrischen Oberflächenstimulation bei der Behandlung der progredienten idiopathischen Skoliose.

Due to incorrect use of nomenclature, scolioses are incorrectly classified in the paper by Altekruse and Heine. The angle measurement is inaccurate and does not correspond to Cobb's measuring method. The accuracy of the scientific statement and its value can be derived from this. The results of treatment obtained by Altekruse and Heine were improvement in or standstill of the scoliosis in 80% of the cases and progression in over 17%. This corresponds to the "Natural History of Scoliosis:" 5 to 25% of juvenile scolioses (age 3 to 10 years according to Drummont) are progressive, the figure for adolescent scolioses being lower. Therefore, electrostimulation is used to 70-80% in cases requiring no treatment, where there is no progression, in which there are no structural changes or which should be classified as malposture, in which spontaneous remission usually occurs or which remain stationary. In scolioses of over 25 degrees, with proven progression and structural changes, and possibly also with positive family history, electrostimulation fails. As in almost all papers published to date, Altekruse and Heine's paper disregards the behavior of the sagittal curvature of the spine under electrostimulation. We demonstrate in two cases that electrostimulation can have a considerable pathologic effect, causing lordosis. Since, on the basis of recently adopted opinions, there is reason to believe that there is a causal connection between lordosis and the pathogenesis of scoliosis, it must be assumed that in such cases electrostimulation incites or aggravates the development of scoliosis or is at least potentially capable of doing so. At any rate, in the two cases in which it was demonstrated that electrostimulation caused lordosis, the scoliosis was significantly aggravated, so that in these cases at least it must be assumed that the method has a health-damaging effect. Electrostimulation is a cost factor which does not seem justifiable today, with economy an obligation. The cost of using it in a mere 100 cases would be sufficient to pay for proper screening of all the children in one school year in the Federal Republic. Children who are really at risk could be given effective treatment. In Sweden, this has resulted in 60% of the scoliosis operations previously required in populations of the same size no longer being necessary.

[Corrective surgery for kyphosis in bekhterev's disease - indication, technique, results (author's transl)]. / Korrekturoperation bei Bechterew-Kyphose Indikation, Technik, Ergebnisse.

14 patients suffering from Bechterew's disease with a marked kyphotic deformity of their spine have been subject to extension osteotomy. Follow-up of 12 patients ranges from 7 to 33 months. Results have been good in 10 and satisfactory in 2 cases. Increase in body length has been between 2 to maximally 26 cm. Surgical procedure, results and complications have been demonstrated. Possibility of early spondylodesis in Bechterew's disease for elimination of pain and avoidance of progressing deformity is discussed.

[First results of the Luque operation (author's transl)]. / Erste Ergebnisse der operation nach Luque. Vorläufiger Bericht über 12 Fälle.

The first 12 patients operated according to the method of Luque (segmental spinal wiring) at the German Scoliosis Center, have been subject to a preliminary assessment. Results of the Luque operation are superior to those of other procedures in specially selected cases. Most important advantage of the Luque operation is the instant post operative stability. For this reason the procedure for operating deformities of the spinal column in cases of neuromuscular diseases and collapsing spine of paraplegic patients is especially advisable. Dangers and risks of this novel technic are pointed out.

[Surgical treatment of unstable, therapy-resistant and painful lumbosacral joints by distracting decompressive posterolateral spondylodesis over the divided sacral bar according to Zielke's method (author's transl)]. / Zur operativen Behandlung des instabilen, therapieresistent schmerzhaften lumbosakralen Scharniers durch distrahierend- dekomprimeierende, posterolaterale Spondylodese über den geteilten Sakralstabaufbau nach Zielke.

Here the procedure of the distracting decompressive fusion over the divided sacral bar which Zielke developed 8 years ago is being described. This procedure was applied in over 150 cases. In a follow-up only one pseudarthrosis was found in the area of L5/S1. 70% of the previously pensioned patients could at least be partially rehabilitated. 32 patients were asked of their opinion with a questionnaire. Only 2 patients (6%) assessed the operation results with "bad". Indication is in all instabilities of the lumbosacral joint. The problem of the multi-operated back can be largely solved through the possibilities of this procedure.

[A 10-year follow-up of the Harrington operation in congenital scoliosis and scoliosis due to poliomyelitis and neurofibromatosis]. / 10-Jahresverläufe nach Harrington-Operation bei kongenitalen, Poliomyelitis- und Neurofibromatose-Skoliosen.

From 1972 through 1976 40 patients with congenital scoliosis, scoliosis in neurofibromatosis and scoliosis following poliomyelitis underwent posterior spine fusion using Harrington instrumentation. Follow up was 10 years or more with an average of 12 years. 63 percent of all patients showed a curve of more than 90 degrees before operation. The different types of scolioses revealed characteristical results according to their etiology during long time follow up. Concerning long time reduction of curve the best results were obtained in patients following poliomyelitis. Patients with congenital and neurofibromatous scoliosis showed loss of correction 2 and 5 years postoperatively.

[Stabilization of the lumbosacral segment by distracting posterolateral spondylodesis using the Zielke divided sacral strut. Analysis of 400 cases based on indications, results and cause of errors]. / Stabilisierung des lumbosakralen Abschnittes durch distrahierende posterolaterale Spondylodese über den geteilten Sakralstabaufbau nach Zielke. Analyse von 400 Fällen hinsichtlich der Indikation, der Ergebnisse und der Ursache von Fehlergebnissen.

Out of 400 patients who underwent posterolateral or purely dorsal spondylodesis of the lumbosacral joint with a divided sacral strut or sacral knee using distracting Harrington struts, a total of 68.5% were free of complaints--100% in cases of fractures and destruction, spondylarthroses and osteochrondroses, 73% in cases of spondylolyses with and without spondylolistheses, and only 49% among the so-called "failed-back" patients who had already undergone one or more previous operations. Where results were poor, particularly in the group of failed-back patients, when surgical error, pseudarthroses, or inadequacies of instruments were ruled out, it could be assumed in approximately 80% of the cases that these patients simultaneously had a pension claim under review or had attempted to institute proceedings at a social insurance tribunal. In such cases the goal of treatment desired by the surgeon, i.e., pain-free stability, cannot be the aim of the patients. Freedom from pain means ability to work, and loss of the pension or the pension litigation. It is almost endemic among these patients to put the blame on the same exogenous mechanisms, as far as both time and cause are concerned, in order to obtain certification of their inability to work. The suspicion that they use the operation to prove the severity of their disability is in many cases justified. The high incidence of psychosocial problems is at least a partial explanation of why the measures we took in our efforts to improve the results of surgery failed. We changed the position of the patient, extended the duration of hospitalization, revised our implantation method, verified plasters and braces. To no avail. Essentially, the result of surgery was influenced by four factors: the number of previous operations, drug and alcohol abuse, pseudarthrosis, and simultaneous pension claims. In 1983 and 1984 the number of patients without pain soared. Basically, this is probably due to the fact that in the light of the results of this investigation, more stringent criteria were applied with regard to the selection of patients. If the patient has a claim against a social insurance institution, a private insurer, or physicians who have treated him/her previously (!!!) we refuse to operate. It is unlikely that these patients will be pain-free before the proceedings in question are terminated. This much we have learned from this analysis.(ABSTRACT TRUNCATED AT 400 WORDS)

[Comparison of the effects of lordosis on the thoracic spine using the Milwaukee and Gschwend brace in scoliosis and kyphosis]. / Vergleich der Lordosierungseffekte an der Brustwirbelsäule durch Verwendung des Milwaukee- und des Gschwend-Korsettes bei Skoliosen und Kyphosen.

64 patients in Milwaukee-Brace and 32 patients in Gschwend-Brace have been assessed for creating lordosis of the thoracic spine. In both types of braces induction of lordosis can be observed although there did not seem to exist a directly proportionate relationship towards the period of treatment. The degree of correction in the thoracic spine depends on the kyphosis at the onset of treatment. In marked kyphosis exceeding 60 degrees or corresponding kyphotic components in scoliosis the Milwaukee-Brace is preferred over against the Gschwend-Brace. In a pure kyphosis with minimal scoliotic curve the Gschwend-Brace remains the treatment of choice.

[10-year results following surgery of idiopathic scoliosis using the Harrington technique (work by the "Conference of German-language Spinal Surgeons)]. / 10-Jahresresultate bei nach Harrington operierten idiopathischen Skoliosen (Arbeit der "Konferenz deutschsprachiger Wirbelsäulen-Chirurgen").

From 1972 through 1976 90 patients with idiopathic scoliosis underwent posterior spine fusion using Harrington instrumentation. Follow up was 10 years or more with an average of 12 years. The most frequent and most serious complications occurred in adults with scoliotic deformities of more than 90 degrees. Vital capacity of adults improved more than 20 percent. In young patients with low grade scoliotic spines a better immediate postoperative correction was achieved. There was also a higher loss of correction later on in this group. Thus in the long term follow up there was no correlation between magnitude of the preoperative curve and postoperative correction.

[Transversal loading system in addition to the Harrington instruments (author's transl)]. / Korrigierender Querstabilisator nach Cotrel--Eine interessante Ergänzung des Harrington-Systems

With the transversal loading system, constructed by Cotrel, a new possibility for operative spine correction is given to the surgeon.

[Results of surgical management of scoliosis and kyphoscoliosis in adults (author's transl)]. / Ergebnisse operativer Skoliosen- und Kyphoskoliosen-behandlung beim Adoleszenten über 18 Jahre und beim Erwachsenen

Report about 60 operated scoliosis and kyphoscoliosis experienced at adults above 18 years. After separating the patients into male and female groups, age and localisation the most severe preoperative findings which make the operative treatment more difficult, will be described. Much impact will be put on pre-operative respiratoric and cardial impairment. The evaluation of scoliosis in adults will be proofed by examples. The operative technique, whose basis is the Harrington instrumentation in the modification by Stagnara, will be described also. 72 operative treatments have been necessary at 60 patients. In many cases rip-resections and dorsal osteotomies of the spine have been done. In oposition to the correction results of 46.2% on scoliosis and 56.5% on kyphoscoliosis there is one pulmonary embolism ending deadly and one irreversible paraplegia.

The neurological risk of Harrington procedures (author's transl). / Das neurologische Risiko der Harrington-Operation

250 corrective operations using the Harrington implants have been performed. 160 served as a basis for the evaluation of the neurological risks, particulary the risks of spinal cord lesions. The intra- and postoperative damage has been analyzed. The results and therapeutic conclusions are recorded.

[Osteoporosis and halo traction in scoliosis patients (author's transl)]. / Osteoporose und Halo-Extension bei Skoliosekranken. Eine histologische und biochemische Studie.

In 54 patients who underwent halo traction for an average of 80 days each, there was no laboratory evidence of any change in calcium metabolism. Histologically, there were slight but significant bony changes after termination of halo traction treatment, principally "low-turnover" osteoporosis, which was possibly more prevalent in female patients. Where a slight osteoporosis already existed prior to halo traction, it generally became more severe. The study seems to show that no relationship exists between the etiology of scolioses and the development of osteoporosis. It proves that in respect of the development of osteoporosis also, permanent halo traction is not a neutral procedure.

[Long-term follow-up of lung function and standing height following scoliosis surgery in children and adolescents]. / Langzeitverläufe von Lungenfunktion und Stehgrösse nach Skolioseoperationen bei Kindern und Jugendlichen.

Previous investigations have reported conflicting results on the development of lung function and body height after operative correction of scoliosis at young age. Partly the number of patients or the duration of observation were relatively small. 120 patients were followed for at least 10 years (10-14, average 12 years) after surgical correction of scoliosis at the age of 18.2 +/- 6.8 years. Standing height and vital capacity were measured 1, 2, 5 and 10 years after operation. Height was expressed as percentile for age and vital capacity as % expected for actual height. The primary diagnoses were idiopathic scoliosis (n = 84, average Cobb angle 90 degrees), congenital scoliosis (n = 20, 83 degrees), poliomyelitis (n = 10, 128 degrees), neurofibromatosis (n = 6, 101 degrees). We found an initial decrease in lung function after 1 year, which was probably due to post-operative immobilization and increased by the gain in body height achieved by the operation. During the rest of the observation period a significant (p less than 0.05) increase of vital capacity (% of expected for actual height) was observed. The gain was maximal for idiopathic scoliosis (+6%). In congenital scoliosis body height %ile and relative vital capacity appeared fixed at the preoperative level. Interestingly patients with an initial vital capacity below 50% expected (n = 29) or preoperative Cobb angle above 90 degrees showed the best results. They also lacked the initial deterioration of lung function in the first postoperative year and had a significant gain of vital capacity (+14%) over 10 years.(ABSTRACT TRUNCATED AT 250 WORDS)