Harrington Rod Instrumentation Research Articles

Thoracic Cage Deformity Correction in Patients with Lenke Type 1 Adolescent Idiopathic Scoliosis.

Whether the thoracic cage deformity in adolescent idiopathic scoliosis (AIS) can be sufficiently treated with vertebral derotation alone, has been quite controversial. Our aim is to control the hypothesis that the rib cage deformity (RCD) may be adequately corrected when only vertebral derotation is applied. We studied retrospectively patients treated for AIS with posterior spinal fusion without costoplasty. The RCD was assessed on lateral radiographs by rib index (RI). The correction of RI after surgery was calculated. Of the 103 patients that were finally included in our study, 29 patients (22 females and 7 males; mean age, 14.5 ± 2.1 years) represented Group A (Harrington rod instrumentation - no derotation), while 74 patients (61 females and 13 males; mean age, 14.1 ± 2.4 years) were operated with either a full pedicle screw system or a hybrid construct with hooks and pedicle screws (Group B-derotation). RI was significantly corrected after surgery in both groups. RI was significantly greater in Group A after surgery. Whatsoever, the correction of RI, thereby the RCD correction, did not significantly differ among groups. In conclusion, it cannot be suggested by the present study that vertebral derotation alone can offer an absolute correction of the deformity of the thoracic cage in patients with Lenke Type 1 AIS, and it seems also that the development of RCD may not exclusively result from the spinal deformity, thus questions can be further raised regarding scoliogeny per se.

No Significant Radiological Signs of Adult Spinal Deformity Progression after a Mean of 11 Years of Follow-Up Following Harrington Rod Instrumentation Removal and Watchful Waiting.

The study aimed to assess long-term radiological outcomes in patients from our institution who were primarily treated for adolescent idiopathic scoliosis with surgical correction using Harrington rod (HR) instrumentation, and afterward with watchful waiting of residual spinal deformity after HR removal, whereby no patient consented to spinal deformity correction. A single-institution case series of 12 patients was retrospectively evaluated. Preoperative and most recent post-instrumentation removal radiographic measurements were compared, along with baseline characteristics. The average age of patients (all females) at the time of HR instrumentation removal was 38 ± 10 years (median 40, range 19-54). The mean follow-up from the HR instrumentation implantation to the HR instrumentation removal was 21 ± 10 years (median 25, range 2-37), with a further mean of 11 ± 10 years (median 7, range 2-36) of follow-up following HR instrumentation removal and watchful waiting. No significant change in radiological parameters was observed: LL (p = 0.504), TK (p = 0.164), PT (p = 0.165), SS (p = 0.129), PI (p = 0.174), PI-LL (p = 0.291), SVA (p = 0.233), C7-CSVL (p = 0.387), SSA (p = 0.894), TPA (p = 0.121), and coronal Cobb angle (proximal (p = 0.538), main thoracic (p = 0.136), and lumbar (p = 0.413)). No significant change in coronal or sagittal parameters was observed in this single-institution long-term radiological outcome study of adults following HR instrumentation removal and watchful waiting of residual spinal deformity.

Serum metal ion levels in adolescent idiopathic scoliosis (AIS) patients 25years after treated with Harrington rod instrumentation or bracing.

Surgical instrumentation in children with adolescent idiopathic scoliosis (AIS) is performed early in life and the implants are left in situ for the rest of the patient's life. Concern has been raised regarding persistent elevated levels of serum metal ions, but only a few studies on the topic have been published. The aim of this study was to compare the levels of serum metal ions in patients with AIS treated with either Harrington rod instrumentation or bracing. AIS patients treated with Boston brace (BB) or posterior spinal fusion with Harrington rod instrumentation (HR) from 1983 to 1990 were requested to return to clinic. One hundred fifty-nine (73%) of 219 patients were available for follow-up of whom 115 agreed to have a blood draw. The proportion of patients who agreed to have a blood draw were similar in the BB (48 of 100, 48%) and HR (67 of 115, 60%, p = 0.085) groups. None of the surgical patients had their implants removed; mean age at follow-up (BB: 43.2 years vs HR: 43.5 years, p = 0.566) and mean length of follow-up (BB: 26.5 years vs HR: 24.5 years). Mean chromium serum levels were similar between the BB (2.7nmol/L) and the HR (2.9nmol/L, p = 0.827). Mean Cobalt serum levels were also similar between the BB (2.6nmol/L) and the HR (2.8nmol/L, p = 0.200). Serum metal ions were similar in AIS patients treated with bracing or Harrington rod instrumentation 25years after initiation of treatment.

Rib Hump Deformity Correction in Patients with Adolescent Idiopathic Scoliosis: A Comparison of Three Spinal Fusion Systems.

The aim of the present study is to control the hypothesis that the rib hump deformity can be adequately corrected when applying vertebral derotation. We retrospectively studied patients treated with full pedicle screw systems (group A), hybrid constructs (group B), and Harrington rod instrumentation (group C). No costoplasties were performed in the patients included in our study. Derotation was applied in groups A and B. The rib hump deformity was assessed on lateral radiographic studies by rib index (RI). Of the 72 patients that were finally included in our study, 30 patients (24 females and 6 males; mean age, 14.5 ± 2.2 years) were treated with a full pedicle screw system, 23 patients (19 females and 4 males; mean age, 13.8 ± 1.9 years) were treated with a hybrid construct, and 19 patients (16 females and 3 males; mean age, 14.3 ± 2 years) received the Harrington rod instrumentation. In all groups RI was significantly corrected after surgery. Before surgery no difference in RI was found among groups; however, after surgery RI was found significantly higher in group C as compared to groups A and B. The between-group analysis revealed that the correction of RI, and thereby the rib hump deformity correction, did not significantly differ among the three patient groups. In conclusion, it cannot be suggested based on the present study that vertebral derotation alone can offer an adequate correction of the rib hump deformity. Further, the development of rib cage deformity and its degree of interdependence with the scoliotic spinal deformity has to be further investigated and assessed, as it seems that it may not necessarily result directly from the primary vertebral deformity.

Revision Strategies for Harrington Rod Instrumentation: Radiographic Outcomes and Complications.

Study Design:Retrospective case series.Objective:The purpose of this study is to evaluate the clinical and radiographic outcomes following revision surgery following Harrington rod instrumentation.Methods:Patients who underwent revision surgery with a minimum of 1-year follow-up for flatback syndrome following Harrington rod instrumentation for adolescent idiopathic scoliosis were identified from a multicenter dataset. Baseline demographics and intraoperative information were obtained. Preoperative, initial postoperative, and most recent spinopelvic parameters were compared. Postoperative complications and reoperations were subsequently evaluated.Results:A total of 41 patients met the inclusion criteria with an average follow-up of 27.7 months. Overall, 14 patients (34.1%) underwent a combined anterior-posterior fusion, and 27 (65.9%) underwent an osteotomy for correction. Preoperatively, the most common lower instrumented vertebra (LIV) was at L3 and L4 (61%), whereas 85% had a LIV to the pelvis after revision. The mean preoperative pelvic incidence–lumbar lordosis mismatch and C7 sagittal vertical axis were 23.7° and 89.6 mm. This was corrected to 8.1° and 28.9 mm and maintained to 9.04° and 34.4 mm at latest follow-up. Complications included deep wound infection (12.2%), durotomy (14.6%), implant related failures (14.6%), and temporary neurologic deficits (22.0%). Eight patients underwent further revision surgery at an average of 7.4 months after initial revision.Conclusions:There are multiple surgical techniques to address symptomatic flatback syndrome in patients with previous Harrington rod instrumentation for adolescent idiopathic scoliosis. At an average of 27.7 months follow-up, pelvic incidence–lumbar lordosis mismatch and C7 sagittal vertical axis can be successfully corrected and maintained. However, complication and reoperation rates remain high.

P97. Correlation of UIV and cervical spine surgery to functional outcomes in AIS: a minimum 40-years follow-up

BACKGROUND CONTEXT The long-term impact of Harrington rod instrumentation for AIS and the impact of UIV and future cervical spine fusion on patient reported outcomes is not known. PURPOSE To assess whether cervical spine surgery and high UIV can negatively impact patient reported outcomes in AIS patients. STUDY DESIGN/SETTING Observational. PATIENT SAMPLE We identified 318 patients treated with Harrington instrumentation and fusion between 1961 and 1978. OUTCOME MEASURES Patients were contacted for patient reported outcomes: NDI, SRS-7, PROMIS Physical Function (PF), PROMIS Depression (D), PROMIS Pain Interference (PI). METHODS Bivariate and multivariate analyses were used to compare outcome measures based on UIV and future cervical fusion. RESULTS Fifty-six patients with an average follow-up of 49 years (range 40 - 57) and average age of 64 (range 53 to 73) completed the patient reported outcomes. Four (7%) had T2 UIV, 3 (5%) had T3 UIV, 12 (21%) had T4 UIV, 15 (27%) had T5 UIV, 14 (25%) had T6 UIV, 3 (5%) had T7 UIV, 1 (2%) had T8 UIV, 1 (2%) had T9 UIV and 3 (5%) had T10 UIV. Two patients underwent cervical fusion (3.6%). In patients without cervical spine surgery, those with UIV of T5 and higher had average NDI of 14.6 (p=0.09) and SRS-7 of 22.8 (p=0.45) compared to patients of UIV T6 and below having 10.2 and 22.9. Patients without cervical spine surgery with UIV of T5 and higher had average PROMIS PF (p=0.21) of 43.5, PROMIS D (p=0.24) of 49 and PROMIS PI (p=0.17) of 55.6 compared to UIV T6 and below having 45.5, 51.8 and 53.9. Patients with cervical spine fusion had mean NDI of 23 as compared to NDI of 11.9 in patients without cervical fusion (p=0.09). CONCLUSIONS In long-term follow-up, AIS patients who underwent fusion with UIV of T5 and higher did not have worse outcomes as compared to patients with UIV of T6 and below. Long term follow-up of patients undergoing Harrington Rod Instrumentation (avg. 49 years) did not show a correlation on patient reported outcomes based on UIV and future cervical spine surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Fifteen to twenty-five year functional outcomes of twenty-two patients treated with posterior Cotrel-Dubousset type instrumentation: a limited but detailed review of outcomes.

BackgroundLong-term outcomes of patients undergoing extensive fusions for adolescent idiopathic scoliosis (AIS) have conflicting results. Moskowitz found uninstrumented scoliosis fusion patients had similar back pain as a normal age matched population. Recently, long-term outcomes of patients with Harrington rod instrumentation were reviewed and found similar functional outcome scores to non-scoliosis patients, with trending toward worse outcomes when fusions extended to L4. Our study examined long-term functional outcomes of patients treated with Cotrel-Dubousset (CD) instrumentation and determined whether distal level of instrumented fusion (L4 and L5) correlate with increased back pain or lower functional level.MethodsRetrospective review of AIS surgeries from 1986 to 1996 was undertaken. Patient demographics and surgical data were collected via case-note audit. Patients were contacted and asked to complete a series of functional outcome questionnaires including visual analog scales (VAS) for pain, Short-Form 36 (SF-36), Scoliosis Research Society 22 (SRS-22) and Oswestry Disability Index (ODI) for function. ANOVA technique categorically compared outcome scores to most distal levels of fusion. Linear regression compared patient reported outcomes to time elapsed since surgery. Statistical significance was p < 0.05.ResultsOne hundred twelve patients were identified, 50 patients were contacted, and 22 agreed to participation and completed a full assessment. Follow-up time since surgery ranged from 15 to 26 years and age ranged from 30 to 43 years. Six patients reported daily VAS back pain of ≥5; with a mean of 2.5. Back pain was not associated with level of distal fusion (p = 0.92). ODI was 15.36, with six patients' ODI >20. No relationship was shown between ODI and distal level of fusion (p = 0.72). SF-36 and SRS 22 values were also not related to distal level of instrumentation. Patient reported VAS back pain scores (r2 = 0.18, p = 0.05), ODI (r2 = 0.09, p = 0.17), and SF-36 and SRS-22 were not worse in patients with longer follow-up over time. Back pain and certain functional score subcategories of the SF-36 and SRS-22 trended toward improved results over time.ConclusionsMost patients who underwent multi-segment spinal fixation appeared to do well long-term, with minimal back pain. Lowest instrumented segment did not appear to be associated with increased back pain after 15 to 25 years follow-up.

Adolescent Idiopathic Scoliosis

The effective treatment of adolescent idiopathic scoliosis (AIS) is predicted on timely detection and appropriate intervention. School screening programs have resulted in a reduced incidence of advanced curvature upon referral. Studies of the natural history of AIS demonstrate that a number of factors are of predictive value in assigning risk for progressive curvature and subsequent deformity and/or morbidity. These are age at time of diagnosis, stage of skeletal maturity, and magnitude and pattern of curvature. The options in treating AIS are observation, orthosis, and operation. Spinal orthoses are designed to arrest the progression of curvature during skeletal maturation. Newer brace designs and protocols facilitate compliance with long-term bracing and may reduce the incidence of curves requiring operative intervention. The goal in scoliosis surgery is to reduce curvature and to create a stable framework on which vertebral fusion can occur. Technical advances have yielded a number of instrumentation options for achieving this goal. Basic technical comparisons are made among of prototypes of posterior spinal instrumentation. The newest of these, Cotrel-Dubousset, may supplant Harrington rod instrumentation as the preferred standard in the operative treatment of AIS.

Health-related quality-of-life in adolescent idiopathic scoliosis patients 25years after treatment.

BackgroundSince 1962 to the mid eighties the Harrington Rod instrumentation was the Golden standard for surgical treatment of Adolescent Idiopathic Scoliosis (AIS). The Boston braces were introduced in the 1970´s and are still used as a conservative treatment, for curves less than 40°. Very few long-term studies exists, focusing on the health related quality of life. The purpose of this study was to evaluate the long-term health related outcome, in a cohort of AIS patients, treated 25 years ago.Method219 consecutive patients treated with Boston brace (Brace) or posterior spinal fusion (PSF) using Harrington- DDT instrumentation between 1983 and 1990 at Rigshospitalet Copenhagen, were invited to participate in a long-term evaluation study. A validated Danish version of the Scoliosis Research Society 22R (SRS22R) and Short Form-36 (SF36v1) were administrated to the patients two weeks before the clinical and radiological examination.Results159 (72,6 %) patients participated in the clinical follow up and questionnaires, 11 patients participated only in the questionnaires, 8 emigrated, 4 were excluded due to progressive neurological disease and 2 were deceased. The total follow up was 170 patients (83 %), and the average follow up was 24.5 years (22–30 years).SRS22R domain scores were within the range described as normal for the general population with no statistical difference between the groups except in the Satisfaction domain, where the PSF group had better scores than the braced group.The SF36 PCS and MCS scores in both AIS cohorts were similar to the scores for the general population.ConclusionHRQOLs, as measured by the SRS22R and SF-36, of adult AIS patients treated with Boston brace or PSF during adolescence were similar to the general population. No clinical progression of the deformity has been detected during the 25-year follow up period. The PSF group had a small but statistically significant higher score in the Satisfaction domain compared to the braced group.Trial registrationS-20110025 Regional Committees on Health Research Ethics for Southern Denmark.

Classification of adolescent idiopathic scoliosis (AIS)

In 1983 Howard King presented his classification system for adolescent idiopathic scoliosis (AIS) based on the experience with Harrington rod instrumentation. Curves were divided into five types and guidelines and recommendations for which levels should be instrumented were given to preserve motion as much as possible. As segmental instrumentation systems began to gain favor over the Harrington rods this system failed and led to the development of a new classification system which was presented by Lawrence Lenke in 2001. In order to define a curve type by the Lenke classification, one must identify the curve type, the lumbar modifier and, for the first time in any classification system for scoliosis, the sagittal profile was also included. The Lenke classification showed higher inter and intra-reliability compared to the King classification. It also provided a better and more reliable tool to assist surgeons in choosing the best method of treatment for each curve pattern. Although the Lenke classification is more comprehensive and reliable than the King classification it is still far from perfect. It does not address the rotational component of the deformity. New technologies which provide three-dimensional (3D) reconstruction of the spine may serve as a basis for a truly 3D classification of scoliosis and for new therapeutic concepts.

Neuraxial Blockade in Patients with Preexisting Spinal Stenosis, Lumbar Disk Disease, or Prior Spine Surgery

Patients with spinal canal pathology, including spinal stenosis and lumbar disk disease, are often not considered candidates for neuraxial blockade because of the risk of exacerbating preexisting neurologic deficits or developing new neurologic dysfunction. In contrast, a history of spine surgery is thought to increase the likelihood of difficult or unsuccessful block. In this retrospective study we investigated the risk of neurologic complications and block efficacy in patients with preexisting spinal canal pathology, with or without a history of spine surgery, after neuraxial anesthesia. During the 15-year study period, all patients with a history of spinal stenosis or lumbar radiculopathy undergoing a neuraxial technique were studied. Patient demographics, preoperative neurologic diagnoses and neurologic findings at the time of surgery/neuraxial block, details of the neuraxial block including technique (spinal vs. epidural, single injection vs. continuous), injectate, technical complications (paresthesia elicitation, bloody needle/catheter placement, inability to advance catheter, accidental dural puncture), and block success were noted. New or progressive neurologic deficits were identified. All patients were followed until resolution or last date of evaluation. There were 937 patients included, 207 (22%) of whom had undergone spinal surgery. A history of spinal stenosis was present in 187 (20%), lumbar radiculopathy in 570 (61%), and peripheral neuropathy in 210 (22%) patients; 180 patients (19%) had multiple neurologic diagnoses. A majority of patients had active but stable neurologic symptoms at the time of surgery. Overall block success was 97.2%. A history of spine surgery did not affect the success rate or frequency of technical complications. Ten (1.1%; 95% confidence interval [CI] 0.5%-2.0%) patients experienced new deficits or worsening of existing symptoms. Three (1.4%) complications occurred in patients with a history of spinal surgery, and the remaining 7 (1.0%) in patients without prior surgical decompression or stabilization (P = NS). Although an orthopedic procedure was not a risk factor, in 5 of the 6 patients in which the surgery was a unilateral lower extremity procedure, the postoperative deficit involved the operative side. Likewise, in both patients undergoing bilateral orthopedic procedures who developed bilateral deficits, the outcome was worse on the previously affected side. A surgical cause was presumed to be the primary etiology in 4 (40%) of 10 patients. The primary etiology of the remaining 6 (60%) complications was judged to be nonsurgical (including anesthetic-related factors). The presence of a preoperative diagnosis of compressive radiculopathy (P = 0.0495) or multiple neurologic diagnoses (P = 0.005) increased the risk of neurologic complications postoperatively. We conclude that patients with preexisting spinal canal pathology have a higher incidence of neurologic complications after neuraxial blockade (1.1%; 95% CI 0.5%-2.0%) than that previously reported for patients without such underlying pathology. However, in the absence of a control group of surgical patients with similar anatomic pathology undergoing general anesthesia, we cannot determine whether the higher incidence of neurologic injury is secondary to the surgical procedure, the anesthetic technique, the natural history of spinal pathology, or a combination of factors and the relative contributions of each.

Differential diagnosis of back pain in adult operated scoliosis patients

Back pain in adult operated scoliosis patients is a usually a major postoperative problem which has to be differentially diagnosed from a number of pathologies. The infection, immediate or delayed infection after elective spinal instrumentation and fusion is the principal postoperative problem for the patient and the surgeon. Surgical treatment is mandated in the majority of these cases, with the use of antibiotic treatment as well. Pseudarthrosis of the fusion is another major problem which needs surgical treatment as well. Some of the hardware problems that may occur are loosening, failure, inappropriate placement, prominence of hardware posteriorly or allergic reaction to it. Adjacent disc disease that is disc failure above or below fusion is a follow up problem appearing after some time postoperatively. Progression of curve after fusion can also happen and is connected to post op deterioration. Spinal balance problems, (trunk imbalance after fusion) create a serious disability to the patient. Flat back syndrome (mainly back pain after Harrington rod instrumentation for idiopathic scoliosis) also creates severe low back pain and disability. Thoracic (rib-cage) problems, rib pain after thoracoplasty and donor graft site pain (complications of iliac crest bone grafting in spine surgery) can appear postoperatively as well.

Modern scoliosis techniques: the use of thoracic pedicle screws for the correction of spinal deformity

The surgical treatment of scoliosis continues to evolve from its infancy in the late 1950s with Harrington rod instrumentation to the segmental thoracic pedicle screw constructs that are now being used. Thoracic pedicle screw fixation provides true segmental correction but also has some inherent disadvantages. Ideally, scoliosis treatment should correct sagittal, coronal and transverse or axial planes with rigid fixation minimizing fusion levels. The primary advantage of thoracic pedicle screws when compared with other constructs appears to be improved coronal correction, decreased pseudarthrosis rates, lower implant failure rates, three-column fixation, and the ability to correct the scoliotic deformity in all three planes. Potential disadvantages of all thoracic screw constructs involve the lordosing effect of posterior instrumentation systems that may significantly decrease thoracic kyphosis. Multiple screw placement techniques range from an all free-hand technique to image guidance. The free-hand technique with a straight-forward trajectory has been shown to have favorable pullout strength and insertional torque compared with the anatomic technique. Recent literature also has demonstrated that thoracic pedicle screws are so effective that they may replace the need for anterior surgery in adult scoliosis surgery. With proper technique placement, thoracic pedicle screws are safe and can provide maximal clinical efficacy. A review of thoracic pedicle anatomy, surgical techniques and segmental fixation constructs is provided in this review.

Selective fusion in adolescent idiopathic scoliosis

Selective fusion in adolescent idiopathic scoliosis

TREATMENT OF PATIENTS WITH GRADE III–IV THORACOLUMBAR SCOLIOSIS AFTER PRIOR SURGERY BY HARRINGTON METHOD

Objective. To analyze the results of idiopathic scoliosis correction with instrumentation developed by the authors in patients previously operated by the Harrington method. Material and Methods. Ten patients of 14–31 years of age with grade III–IV scoliotic deformity previously operated by the Harrington method were reoperated with universal endocorrector. The reasons for repeat surgery included a fracture of Harrington rod, insufficient correction of scoliotic deformity, perforation of the vertebral arch by distractor hook, and the trunk imbalance. All patients underwent simultaneous two-stage surgery involving distractor removal and scoliosis correction with universal endocorrector. The follow-up period was 6–24 months. Results. Mean correction in rod fracture group was 61.08 % without complications, in undercorrection group (mean correction 27.24 %) it achieved 63.39 %. In the group of patients with vertebra arch penetration and pain syndrome the mean correction by universal endocorrector was 34.29 % with 100 % reduction of pain. During the 6–24 months follow- up there were no correction loss or neurologic and septic complications in operated patients. Conclusions. The new instrumentation provides greater correction (1.8 times) of scoliotic deformity than Harrington rod instrumentation. It is successfully used in repeat surgery and equally effective both in adolescent and in adult scoliosis.

Scoliosis treatment using spinal manipulation and the Pettibon Weighting System™: a summary of 3 atypical presentations

BackgroundGiven the relative lack of treatment options for mild to moderate scoliosis, when the Cobb angle measurements fall below the 25–30° range, conservative manual therapies for scoliosis treatment have been increasingly investigated in recent years. In this case series, we present 3 specific cases of scoliosis.Case presentationPatient presentation, examination, intervention and outcomes are detailed for each case. The types of scoliosis presented here are left thoracic, idiopathic scoliosis after Harrington rod instrumentation, and a left thoracic scoliosis secondary to Scheuermann's Kyphosis.Each case carries its own clinical significance, in relation to clinical presentation. The first patient presented for chiropractic treatment with a 35° thoracic dextroscoliosis 18 years following Harrington Rod instrumentation and fusion. The second patient presented with a 22° thoracic levoscoliosis and concomitant Scheuermann's Disease. Finally, the third case summarizes the treatment of a patient with a primary 37° idiopathic thoracic levoscoliosis. Each patient was treated with a novel active rehabilitation program for varying lengths of time, including spinal manipulation and a patented external head and body weighting system. Following a course of treatment, consisting of clinic and home care treatments, post-treatment radiographs and examinations were conducted. Improvement in symptoms and daily function was obtained in all 3 cases. Concerning Cobb angle measurements, there was an apparent reduction in Cobb angle of 13°, 8°, and 16° over a maximum of 12 weeks of treatment.ConclusionAlthough mild to moderate reductions in Cobb angle measurements were achieved in these cases, these improvements may not be related to the symptomatic and functional improvements. The lack of a control also includes the possibility of a placebo effect. However, this study adds to the growing body of literature investigating methods by which mild to moderate cases of scoliosis can be treated conservatively. Further investigation is necessary to determine whether curve reduction and/or manipulation and/or placebo was responsible for the symptomatic and functional improvements noted in these cases.

Surgical Treatment for Scoliosis in Marfan Syndrome

Review of results of patients with Marfan syndrome treated with instrumented posterior fusion alone for scoliosis. To analyze the results of surgical treatment for scoliosis in Marfan syndrome. Few studies have been reported in the literature on surgical treatment for scoliosis in Marfan syndrome, analyzing long-term results of posterior instrumented fusion. Twenty-three patients with Marfan syndrome with a mean age of 17 years (range, 11-31 years) were treated surgically from 1982 to 1995 for scoliosis, using a posterior instrumented fusion alone (Harrington rod with sublaminar wires in the first 16 cases, and a more recent hybrid instrumentation in the remaining 7 cases). All of the patients received a long posterior instrumented fusion, including 12.3 levels on average (range, 9-17), extending the fusion area to vertebrae that were neutral and stable in both coronal and sagittal planes before surgery. Patients were analyzed as two different groups (Group 1 and Group 2) according to the different posterior instrumentations employed: Group 1 included 16 patients treated by the Harrington distraction rod technique with sublaminar wires, while Group 2 included 7 patients treated using more recent hybrid instrumentations. Presentation features, complications, and results were analyzed. At a minimum follow-up of 7 years (maximum, 18 years), all 23 patients were reviewed. The mean age was 26.8 years (range, 20-38 years). The average preoperative scoliosis value of 69.91 degrees was initially corrected to 38.17 degrees, averaged 40.89 degrees 1 year after surgery, and was finally equal to 44.09 degrees at the last follow-up. Differences in terms of scoliosis correction achieved with different instrumentations (Groups 1 and 2) did not reach statistical significance. In Group 2 patients, the percentage of postoperative correction was slightly lower (44.23%) than that of Group 1 (46.55%) but remained more stable at the last follow-up (40.97% vs. 36.38% of Group 1). There were 11 complications in 10 of the 23 patients (43.4%); two complications occurred in 1 patient. Intraoperatively, dural tears occurred in 2 cases (8.6%). Pseudarthrosis with instrumentation failure in 2 cases (8.6%) required revision surgery. Five (21.7%) distal hook dislodgements with moderate loss of scoliosis correction, 1 (4.3%) mild loss of correction without instrumentation failure, and 1 asymptomatic cervicothoracic junctional kyphosis. did not require surgery. All complications occurred among the 16 Group 1 patients, treated using the Harrington rod instrumentation with sublaminar wires. These results seemed to demonstrate that a satisfactory stabilization of scoliosis can be achieved by posterior instrumentation alone in patients with Marfan syndrome. Instrumented posterior fusion should be extended to include vertebrae that are neutral and stable in both coronal and sagittal planes before surgery, in order to ensure stabilization of the deformity and reduce the risks of decompensation of the spine.

Recurrent Vomiting Following Harrington Rod Instrumentation of the Spine

Recurrent Vomiting Following Harrington Rod Instrumentation 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

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. 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. 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. 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. 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. 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.

The Migration of a Harrington Rod After Cervical Fusion

A patient was treated for an anterior dislocation of C4 on C5 with an open reduction and Harrington rod hook fixation. The compression rod dislodged and migrated through the foramen magnum into the cerebellum 4 years later. This case represents an unusual complication of Harrington rod instrumentation in the cervical spine.