Submuscular Isola rod with or without limited apical fusion in the management of severe spinal deformities in young children: preliminary report.

STUDY DESIGN: Retrospective review of the results of submuscular rod placement with and without limited apical fusion for the treatment of severe spinal deformities in young children. OBJECTIVES: To determine the success of this method for controlling severe deformities while allowing for spinal growth and to compare this method with previously reported results. SUMMARY OF BACKGROUND DATA: A variety of methods for controlling scoliosis in young children have been reported, but complications including spontaneous fusion, loss of correction, instrumentation failure, and limited spinal growth are common. METHODS: The cases of 29 young children with progressive scoliosis or kyphoscoliosis as a result of a variety of diagnoses treated with a submuscular Isola rod and a postoperative orthosis were retrospectively reviewed. Eleven patients also had a short anterior and posterior apical fusion or convex hemiepiphysiodesis to aid in correction and stabilization of their deformity. The remaining 18 patients had a submuscular rod only. RESULTS: The mean age at surgery was 6.7 years (range, 1-11 years). The initial preoperative mean magnitude of the major curve was 66 degrees (range, 42-112 degrees ). After surgery this decreased to a mean of 38 degrees (range, 16-70 degrees ). The most recent radiographs demonstrated a mean 47 degrees curve (range, 28-79 degrees ). The mean number of lengthenings per patient has been two (range, 0-5). Nine patients have reached a suitable age and have been converted to a posterior spinal fusion and segmental spinal instrumentation. Nine complications have occurred in seven patients (24%). These included five hook displacements and three rod breakages. These were treated by hook reinsertion and rod exchange or sleeve and a repeat lengthening. There was one superficial infection treated medically. CONCLUSION: This technique is useful in the management of severe spinal deformities in young children who have either failed, or have a contraindication to, orthotic management. Complications are relatively frequent but well tolerated.

Growth and development of the pediatric cervical spine documented radiographically.

BACKGROUND: The radiographic anatomy of the cervical spine in children is complex and can be difficult to interpret. The present study was undertaken to document radiographically the growth and development of the cervical spine in a prospective, longitudinal manner and to establish standard radiographic measurements on the basis of findings in patients who were followed serially from the age of three months until skeletal maturity. METHODS: The radiographic resources of the Cleveland Study of Normal Growth and Development (Bolton-Brush Collection, Cleveland, Ohio) were reviewed. From this large database, we identified fifty boys and forty-six girls who had a sufficient number of radiographs of the cervical spine for inclusion in our study. With use of a computerized image analyzer, the growth and development of the atlantodens interval, the diameter of the spinal canal, the Torg ratio, the height and width of the second through fifth cervical vertebral bodies, the height of the dens, and the ossification of the first cervical vertebra were assessed on serial radiographs made from the age of three months until skeletal maturity. RESULTS: Serial measurements of the atlantodens interval, the anteroposterior diameter of the cervical canal, the height and anteroposterior width of the cervical vertebral bodies, and the height of the dens, made in normal, healthy children from the age of three months to fifteen years, are presented in tabular and graphic forms. The median Torg ratio was 1.47 for both males and females primarily, and it reached values of 1.06 for males and 1.10 for females by maturity. The anterior arch of the first cervical vertebra had ossified in 33% of the children by the age of three months and in 81% of the children by the age of one year. Closure of the synchondroses was completed in all children by the age of three years. CONCLUSIONS: The measurements presented in the current study are important because they are the first, as far as we know, to document the radiographic parameters of the cervical spine in children who were followed longitudinally from before the age of three years through the course of growth and development until skeletal maturity.

Vertebral alterations in Scheuermann's kyphosis.

In a cadaver-derived skeletal collection of 1,384 thoracolumbar spinal columns, 103 (7.4%) individuals with vertebral changes of Scheuermann's kyphosis were identified. Anterior extension of the vertebral specimens was noted in 94% of affected specimens. No evidence of osteoporosis was noted by single-photon absorptiometric analysis in the affected sample compared with a normal control group. Biopsy specimens from two immature patients obtained at surgery suggested disorganized endochondral ossification similar to that noted in Blount's disease. It was concluded that increased pressure on the anterior margin of the centrum is responsible for histologic and morphologic changes of Scheurermann's kyphosis.

Anterior extension of the thoracic vertebral bodies in Scheuermann's kyphosis. An anatomic study.

Changes consistent with Scheuermann's kyphosis were noted in 103 specimens (7.4%) of a sample of 1,384 thoracic spines in the Hamann-Todd collection of human skeletons. In 94% of the affected vertebrae, a distinct anterior elongation of the vertebral centrum was present. This anterior extension was composed of mature cancellous bone and was morphologically and roentgenographically different from marginal osteophyte formation. It was not present in any vertebrae of a control group of 50 unaffected spines. Associated findings included vertebral wedging and Schmorl's nodes.

Effects of halothane, enflurane, and isoflurane in nitrous oxide on multilevel somatosensory evoked potentials.

The effects of halothane, enflurane, and isoflurane were studied at 0.5, 0.75, and 1 MAC in 60% N2O on subcortical sensory evoked potentials recorded at the popliteal fossa (PF), the spine (L-3, C-6) and on cortical potentials recorded at the scalp (SC) following bilateral posterior tibial nerve stimulations at the ankle in 28 patients undergoing scoliosis surgery. Latencies and amplitudes of the resulting potentials at each level were compared with postinduction control values. With increasing MAC, latency and amplitude changes seen at C6 (subcortical) were also compared with those at SC (cortical). Increasing the concentrations of each agent resulted in a graded increase in latency and a graded decrease in amplitude, at all levels. At SC each increase in MAC with each agent resulted in an increase in latency (P less than 0.05) and a decrease in amplitude (P less than 0.005), respectively. The increases in SC latency at 0.75, 1 MAC were larger than the increase in latency at C-6 (P less than 0.005) and the decreases in SC amplitudes at 0.5, 0.75 and 1 MAC were greater than the decrease in amplitude at C-6 (P less than 0.01). Halothane, enflurane, and isoflurane in 60% N2O altered subcortical potentials less than cortical potentials. Enflurane and isoflurane at 0.5, 0.75, and 1 MAC, and halothane at 0.5, 0.75 MAC maintained subcortical and cortical potentials that were adequate for evaluation. However, 1 MAC of halothane suppressed cortical potentials but maintained subcortical potentials. Subcortical C-6 potential may serve as an additional monitor.

Relationship of iliac crest maturation to skeletal and chronologic age.

Risser's sign, a measure of the excursion of the iliac crest apophysis, has been used to estimate remaining skeletal growth. We used the Brush-Bolton Collection to correlate iliac crest excursion with other roentgenographic standards of skeletal age. Iliac crest excursion was measured using Risser's technique. We were able to determine mean chronologic and skeletal ages for each Risser stage for boys and girls. The state of maturation of the iliac crest apophysis, together with clinical observations of secondary sexual maturation, permit an accurate assessment of skeletal maturation without the need for wrist and hand roentgenograms.

Vertebral body and posterior element morphology: the normal spine in middle life.

Multiple morphologic parameters were studied in 50 normal adult vertebral columns ranging in age from 20 to 40 years at the time of death. Posterior element morphology is highly variable and largely unpredictable. Minimum pedicle diameters ranged from 1.8 mm at T6 to 6.4 mm at L5, and did not correlate with any more readily measured vertebral dimensions. Penetration of 5 mm screw threads through pedicle cortex can be expected to occur routinely in the lower thoracic spine, and in a lesser but significant number of lumbar vertebrae.

Posterior spinal fusion in scoliosis: computer-assisted tomography and biomechanics of the fusion mass.

Thirty patients who had posterior vertebral fusion for scoliosis, performed without metallic implants, were examined using computer-assisted tomography to study the configuration of the evolving fusion mass. It was observed that the deposition of bone followed lines of force, according to Wolff's Law. The greatest amounts of bone at the apex of the curve on the concave side indicate that flexion-compression forces are greater at this point. Further, it was observed that usually the fusion mass, seen in section, has a hollow "box-section" shape, which means that a resorption of unstressed central bone occurs. The hypothesis that the torsional forces are the predominant forces acting on the scoliotic spine can explain the characteristic "box-section" of the CT scans obtained.

Roentgenographic parameters of the normal infant hip.

Multiple parameters of hip development were analyzed in 100 children at 3, 6, 9, and 12 months. The acetabular index decreased from 25 degrees in girls and 22 degrees in boys at 3 months to 18 and 19 degrees, respectively, at 24 months. H distance did not vary with age or sex, but D distance increased with increasing age. Measurement of the medial gap was found to be highly variable. Asynchronous appearance of the secondary ossification centers occurred in eight children and was not associated with subsequent abnormal hip joint development. The true acetabular teardrop is not consistently present in these age ranges. The center edge angle increases with age. Shenton's line was difficult to measure and not reproducible.

Adult idiopathic scoliosis treated by anterior and posterior spinal fusion.

Twenty-six adults, ranging in age from nineteen to fifty-eight years old, were treated for idiopathic scoliosis by two-stage anterior and posterior spinal fusion. The goals of the combined procedure were to increase correction of the curve and decrease the rate of pseudarthrosis. Preoperatively, the major curves measured an average of 83 degrees, and on the best side-bend they averaged 59 degrees, a 29 per cent degree of flexibility. At the time of discharge from the hospital the curves had improved to an average of 44 degrees, a correction of the preoperative curve of 39 degrees or 47 per cent. At an average length of follow-up of forty-nine months, the major curves measured an average of 50 degrees, a 41 per cent correction compared with the initial curves. Twenty-three of the major curves were better than when they were measured on the preoperative radiograph of the best side-bend, by an average of 15 degrees, but eight curves were either the same or worse. No patient had pseudarthrosis or permanent neurological injury. It is our conclusion that a two-stage anterior and posterior fusion is of value for the treatment of the adult who has a rigid curve that requires maximum correction to allow the head, shoulders, and torso to be centered over the pelvis. We do not recommend the use of instrumentation for the anterior fusion as this did not increase the correction of the curve in this series of patients.

Effects of halothane, enflurane, and isoflurane on somatosensory evoked potentials during nitrous oxide anesthesia.

The effects of 0.5, 0.75, and 1 MAC of halothane, enflurane, and isoflurane in 60% nitrous oxide on somatosensory cortical evoked potentials were studied in 30 patients undergoing corrective surgery for scoliosis. The evoked potentials were averaged at the scalp from the electroencephalogram following repeated bilateral posterior tibial nerve stimulation at the ankle. Latencies and amplitudes of the resulting potentials were measured and compared with the post-induction control values. Graded increase in latencies and graded decrease in amplitudes were found with increasing concentrations of all the three agents (P less than 0.05), confirming that the effects were dose related. Reductions in amplitudes were more marked than increase in latencies. The authors conclude that, during nitrous oxide-based anesthesia, enflurane, and isoflurane resulted in less alteration of somatosensory cortical evoked potentials than halothane. In conjunction with 60% nitrous oxide, 0.5 and 0.75 MAC of halothane, 0.5, 0.75, and 1.0 MAC of isoflurane and enflurane, respectively, were found to be compatible with the generation of waves adequate for evaluation.

Efficacy and safety of sequential treatment with parenteral sulbactam/ampicillin and oral sultamicillin for skeletal infections in children.

Nine children with osteomyelitis and/or septic arthritis were treated sequentially with parenteral sulbactam/ampicillin and oral sultamicillin. Causative pathogens were identified in six cases; all were susceptible to the combination of ampicillin and sulbactam. The mean duration of parenteral therapy was 7.1 days (6-11 days), and the average hospital stay was 10.3 days (6-18 days). Peak serum bactericidal titers of greater than or equal to 1:8 were achieved in all patients during parenteral therapy; only one child receiving oral therapy did not achieve a titer of greater than or equal to 1:4. At follow-up, all of the children were cured clinically and there was no evidence of relapse. Adverse reactions to oral therapy were minimal. The regimen of parenteral sulbactam/ampicillin and oral sultamicillin used sequentially is effective and safe for the treatment of skeletal infections in children. The use of this approach significantly reduced the duration of hospitalization.

DUI offenders presenting with positive blood alcohol levels at presentencing evaluation.

Breathalyzer tests were administered to 500 DUI offenders on the day that they arrived for their scheduled presentencing psychosocial evaluations. Positive blood alcohol levels were found in 132 (26.4%) of the offenders. The persons with positive blood alcohol levels were more likely to be diagnosed as having alcoholism disorders, had higher blood alcohol levels at the times of their arrests, complained of more severe symptoms attributable to excessive alcohol use and drank more than those who did not have positive blood alcohol levels.

Segmental spinal instrumentation in idiopathic scoliosis. A preliminary report.

Eighty-six patients with idiopathic scoliosis who underwent a posterior spinal fusion using sublaminar segmental spinal instrumentation were analyzed retrospectively. There were two operative groups: group 1, 66 patients who had Harrington rod instrumentation and segmental wiring, and group 2, 20 patients who had Luque rod instrumentation. The clinical and radiographic data of the two groups were similar except for the passage of more sublaminar wires and increased intraoperative blood loss in group 2. Twenty intraoperative or postoperative complications occurred in 19 patients (22%) including 14 neurologic complications. Three patients (3%) had major spinal cord injuries, while 11 patients (13%) had transient sensory changes. There was no significant difference in the incidence of neurologic complications between group 1 or group 2. The remaining intraoperative complications were due either to anesthesia, positioning during surgery, or technique (dural tear). Late complications occurred in two patients in group 1 only: one each with rod breakage and hook displacement. Only one patient (1%) has required additional surgery. Our results indicate that although segmental instrumentation can be beneficial in idiopathic scoliosis, the incidence of complications, primarily neurologic, will be higher than expected. The major reason appears to be surgeon inexperience with passage of sublaminar wires. As experience increases, the incidence of complications declines and becomes comparable with conventional Harrington rod instrumentation alone.

Nuclear magnetic resonance imaging in Legg-Calvé-Perthes disease.

We employed nuclear magnetic resonance imaging in the evaluation of fourteen children with Legg-Calvé-Perthes disease, and found that it accurately identified infarction of the femoral head and, with appropriate techniques, could produce an arthrogram-like image of the hip without the use of ionizing radiation or injection of a contrast agent. Partial saturation-recovery and inversion-recovery pulse sequences with two-dimensional Fourier transformation produced the best results. Nuclear magnetic resonance scanning provides a noninvasive method for the study of the contours of the hip joint, and may give clearer insight into the pathophysiology of infarction and revascularization.

Personality characteristics and drinking patterns of high-risk drivers never apprehended for driving while intoxicated.

In a study of 124 high-risk drivers, almost 50% of the drives had a severe problem with alcohol and were driving without a valid license. The findings indicate that high-risk drivers, not identified as drinking drivers, are as potentially a threat to public health as those individuals arrested for driving while intoxicated. It is recommended that intervention programs for high-risk drivers cannot ignore alcohol education and, where appropriate, alcohol treatment as an identifiable programmatic strategy.

Evaluation of latamoxef as initial therapy of bone and joint infections in childhood.

The efficacy and pharmacokinetics of latamoxef were evaluated during initial therapy of bacteriologically proven bone and joint infections in children. Pharmacokinetic evaluation revealed no significant difference in latamoxef biodisposition after the first dose or at steady state. Peak serum concentrations exceeded 140 mg/l and 8-hour trough concentrations averaged 6.5 mg/l. The patients were infected with a variety of gram-positive and gram-negative pathogens. All were sensitive to readily achievable serum concentrations of latamoxef; moreover, the serum concentration remained above the MIC of the most resistant organism for at least 7 h after each dose. All patients responded favorably to initial therapy and there have been no relapses in more than 2 years of clinical follow-up.