Surgical Correction Of Scoliosis Research Articles

SURGICAL TREATMENT OF PATIENTS WITH SPINAL DEFORMITIES WITH SHORTENING OF THE LOWER LIMB

Determination of the optimal diagnostic and treatment strategy in patients with scoliosis and having an anatomic shortening of the lower limb. Surgical correction of scoliosis held 8 to patients with lower limb shortening caused by congenital dislocation of the hip (n = 3), anatomic shortening of the lower extremities due to the hip (n = 1), the shin bone (n = 4). Shortening before correction and fixation of scoliosis ranged from 6 to 14 cm, after surgery on the spine has been reduced by 2-4 cm achieved reduction or removal of pelvic obliquity. The second stage, after 8-12 months, performed surgery to address shortening of the lower extremity. Osteotomy of the femur with the imposition of a spoke - rod device held 4 tibial osteotomy with the imposition of external fixation device Spoke - and 4 patients and in the subsequent limb lengthening was performed by compression-distraction osteosynthesis. After the dorsal stabilization and fixation of the spine scoliosis correction averaged 64% (from 76 to 27 degrees), the value of breast/thoracolumbar kyphosis after surgery failed to bring to the physiological (average 43 degrees). Misalignment of the pelvis is reduced by 67% (from 24 to 8 degrees), which reduced the shortening of the lower limb by an average of 3 cm (compensation relative shortening by reducing or eliminating the distortion of the pelvis). Further compensation shortening held on the second stage of treatment, representing an osteotomy and subsequent elongation of the femur or tibia bones by transosseous compression-distraction osteosynthesis by Ilizarov. Multi-stage treatment reduced the degree of spinal deformity, to normalize the balance of the body, restore the function of distance without the use of orthotic devices and means of support.

Revision of surgical correction of scoliosis in pediatric patients affected by neuromuscular pathology using Unit Rod instrumentation

The purpose of this study is to present a large consecutive series of pediatric patients affected by neuromuscular scoliosis treated with Unit Rod instrumentation. Retrospective review of 160 children treated with Unit Rod instrumentation between 2003 and 2010. This review analyzed complications, radiographic outcome, time surgery, average blood loss, hospital staying and functional outcome of patients and parents after surgery. The follow-up of 80 patients is at more than 5 years. Scoliosis was corrected from a mean of 56° range 21° to 76° Cobb (68 %). Pelvic obliquity was corrected from a mean of 24° to 5° (74 %). Major complications are not related to the technique but to the pathology. Unit Rod instrumentation is a common standard technique, is considerably less expensive than the other system, and remains a good indication for the treatment of the spinal deformity in children affected by neuromuscular disease.

Radionuclide Evaluation of Pulmonary Perfusion in Patients with Severe Thoracic Scoliosis Before and After Surgery

The purpose of the study was to evaluate the influence of severe scoliosis surgical correction upon pulmonary microcirculation. The study included 8 patients aged 12— 27 years with severe thoracic scoliosis. Angle deformity by Cobb ranged from 80 to 140° (mean 120.4°). Deformity correction and fixation was performed on the concave side of thorax using multilevel CotrelDubousset instrumentation (CDI) and elevating thoracoplasty (ET). Perfusion radionuclide pulmonary scintigraphy was performed prior to, 3 months and 1 year after surgery. Analysis of pulmonary scintigrams included both the qualitative (visual) and quantitative assessments. Besides, examination of external respiration function (spirometry and spirography) was performed. Mean postoperative Cobb angle made up 67.4°. No loss of correction was noted. Prior to surgical intervention pulmonary scintigrams showed deformation of lung fields, displacement along the vertical axis towards opposite to curvature side, decreased perfusion in the zone of intercostal retraction on the concave side of thorax. Postoperatively restoration of vertical axis, increase of lungs size and improvement of perfusion were observed. Mean vital lung capacity increased from 1510 (540-2280) to 2090 (640-3010) ml. Thus, combined application of CDI and ET enabled to perform adequate correction of severe thoracic scoliosis as well as to improve pulmonary microcirculation and radionuclide perfusion scintigraphy was a highly informative method for the evaluation of lung condition.

Posterior Spinal Fusion in Children With Flaccid Neuromuscular Scoliosis

Noninvasive intermittent positive pressure ventilatory assistance/support (NIV) can permit long-term survival for patients with no autonomous ability to breathe. Its role was explored in the perioperative management of children with flaccid neuromuscular scoliosis. Vital capacity (VC), peak cough flow, and the extent of ventilator dependence were documented before and after surgical correction of scoliosis for children with Duchenne muscular dystrophy (DMD) and spinal muscular atrophy (SMA) with VCs as low as 2%. All patients and their caretakers were trained in NIV and mechanically assisted coughing preoperatively. Postoperatively, all were extubated using a specific protocol irrespective of their extent of ventilator dependence. Thirty-four children (16 DMD, 18 SMA) underwent posterior spinal arthrodesis for scoliosis at 11.7 (range, 6.6 to 16.6 y) years of age. The Cobb angle decreased from a mean 66 (range, 20 to 135 degrees) to 16 (range, 10 to 51 degrees) degrees. Fifteen patients (5 DMD, 10 SMA) had preoperative VC<40% of normal. All were extubated successfully by postoperative day 3 despite 14 failing preextubation and postextubation spontaneous breathing trials and requiring continuous NIV for up to 21 days after extubation. None had postoperative respiratory complications or required reintubation or readmission for pulmonary issues for at least 6 months postoperatively. Noninvasive positive pressure ventilator support is an alternative to invasive airway intubation in the perioperative management of children with flaccid neuromuscular scoliosis. Level IV-case series.

Intraoperative spinal cord monitoring during the surgical correction of scoliosis due to cerebral palsy and other neuromuscular disorders

Patients with neuromuscular scoliosis are at increased risk of neurological deficit post-operatively, but are a difficult population on whom to perform neurophysiological monitoring. We look here at a 7-year sample of our practice in the monitoring of neuromuscular patients. A retrospective chart review was performed for 109 patients who underwent correction of neuromuscular scoliosis within our institution between 2005 and 2011. Of 109 patients who were identified, intraoperative monitoring was attempted in 66 cases. In eight cases (13 %), no reliable monitoring could be achieved and was therefore abandoned. On nine occasions, there was a significant drop in at least one modality intraoperatively. None of these nine suffered any clinically observable neurological deficit post-operatively. Of the 109 patients, 2 had clinically detectable deficits post-operatively, both of whom had undergone normal intraoperative monitoring. The two patients with observable deficit had their instrumentation left in situ after discussion with them and/or parents. Spinal cord monitoring in this population is possible but potentially unreliable. Surgeons will need to carefully consider the use of monitoring in their management of this challenging population.

Intrathecal morphine reduces blood loss during idiopathic scoliosis surgery: retrospective study of 256 pediatric cases

This retrospective cohort study was designed to assess the impact of intrathecal morphine compared with no intrathecal morphine on blood loss and on hemodynamic stability during surgery for pediatric idiopathic scoliosis correction. A retrospective review was done of 256 anesthetic charts who underwent scoliosis surgery between January 1993 and February 2012 by the same orthopedic surgeon. 128 patients were operated on before 2003 without intrathecal morphine (NITM group) and 128 were treated later on with intrathecal morphine (ITM group).Primary endpoints were a 20% decrease in blood loss in the ITM group and hemodynamic stability. Both groups were similar for age, girl/boy ratio, weight and duration of surgery. Blood loss was significantly greater in the NITM group: 1793.1±964.3ml vs 655.8±323.0ml (P<0.0001). Overall mean decrease in blood loss was 63.4% between the NITM group and the ITM group. A significantly (P<0.0001) greater number of patients from the NITM group (122) received blood transfusions as compared to the ITM group (30). The volume of blood transfused per patient was significantly greater in the NITM group (701.4±492.5ml) than in the ITM group (293.7±170.9ml) (P<0.0001). Heart rate was stable intra-operatively in both groups. Variation in blood pressure >20% of baseline occurred more frequently in the NITM group (28.1%) than in the ITM group (14.8%) (P=0.01). These data demonstrate that intrathecal morphine in pediatric surgical scoliosis correction significantly decreases intra-operative blood loss and transfusions and enhances blood pressure stability.

RETROSPECTIVE ANALYSIS OF INTRAOPERATIVE BLOOD LOSS DURING SURGERY FOR IDIOPATHIC SCOLIOSIS

Objective. To perform quantitative assessment of intraoperative blood loss volume and severity during stages of idiopathic scoliosis surgical correction. Material and Methods. Data of intraoperative blood loss during stages of surgical correction of idiopathic scoliosis were analyzed in 1241 operated patients. Multi-stage surgical interventions were performed in 581 (46.8 %) patients, posterior fusion - in 660 (53.2 %), and multilevel corrective vertebrectomy - in 72 (12.4 %) patients. Two methods of general anesthesia were used: TIVA with propofol, fentanyl, tracrium, and with inhaled sevoflurane, fentanyl, and tracrium. Volumes of intraoperative blood loss were assessed at main stages of surgery. Results. Total intraoperative blood loss during multistage surgical treatment with segmental hook instrumentation was 967.4 ± 43.6 ml, and with hybrid instrumentation - 1135.9 ± 139.5 ml. Blood loss during posterior only fusion procedure was 865.5 ± 40.1 ml with segmental hook instrumentation, and 1049.9 ± 75.5 ml with hybrid instrumentation. Multilevel vertebrectomy was associated with maximum intraoperative blood loss of 1242.9 ± 121.8 ml. Conclusion. Intraoperative blood loss during surgical correction of idiopathic scoliosis varies considerably and averages from 20.0 to 40.0 % of the circulatory blood volume. The duration of surgical intervention is the main proved factor influencing the volume of blood loss. Hir. Pozvonoc. 2012;(2):70-78.

Convex Short Length Rib Resection in Thoracic Adolescent Idiopathic Scoliosis

Although it brings satisfactory rib hump correction, concomitant thoracoplasty with surgical correction of scoliosis decreases pulmonary function values. To achieve satisfactory rib hump correction and avoid impairment to pulmonary function, we design a new kind of thoracoplasty-convex short length rib resection (CSLRR). This study is to evaluate the effect and outcome of CSLRR in conjunction with pedicle screw instrumentation. Seventy patients with thoracic adolescent idiopathic scoliosis treated by pedicle screw instrumentation were retrospectively analyzed after a minimum follow-up of 2 years. Patients were divided into 3 groups: C-T group (conventional thoracoplasty, n =20), N-T group (no thoracoplasty, n=24), and CSLRR group (n=26). Patients were evaluated for height of rib hump, deformity correction, balance, pulmonary function, and complications. The correction rates of hump height were 74.1% in the C-T group, 47.1% in the N-T group, and 63.2% in the CSLRR group, respectively. The CSLRR group showed significantly better correction of rib hump than the N-T group. In thoracic hypokyphosis correction, the CSLRR group was superior to the N-T group with statistical significance. There were no significant differences in proximal thoracic, main thoracic and lumbar Cobb angle, coronal and sagittal balance, and lumbar lordosis at the final follow-up among 3 groups. Three months after the operation, both absolute values and percent-predicted values of forced vital capacity and forced expiratory volume in 1 second in the N-T group and CSLRR group were better than that in the C-T group. Two years after the operation, absolute values of forced vital capacity and forced expiratory volume in 1 second in the N-T group and CSLRR group were better than that in the C-T group. There were 2 hemothorax in the C-T group and 1 pleural effusion in the CSLRR group. CSLRR showed significantly better rib hump and thoracic hypokyphosis correction without pulmonary function compromise in the treatment of thoracic adolescent idiopathic scoliosis with pedicle screw instrumentation. Therapeutic-level IV retrospective study.

Changes in Health-Related Quality of Life After Spinal Fusion and Scoliosis Correction in Patients With Cerebral Palsy

The literature is scarce on the impact of spinal fusion for scoliosis in patients with cerebral palsy (CP) regarding the health-related quality of life (HRQL). The purpose of this study was to evaluate the outcome of surgical scoliosis correction measured by the subjective change in the HRQL and the objective radiologic changes. Factors that could influence the subjective outcome were examined to investigate their correlation to the results of HRQL. A retrospective review of 50 consecutive patients with CP, who had spinal fusion for scoliosis with minimal 2-year follow-up was carried out. Radiographic data were obtained from preoperative, postoperative, and last follow-up examinations. The assessment of the HRQL was done through a modified version of the "Caregiver Priorities and Child Health Index of Life with Disabilities" questionnaire, assessed by the caregivers of the patients. There was a significant improvement (P = 0.001) of HRQL after the operation. The satisfaction rate of the patients with the outcome of the operation was 91.7%. There was an average of 64.3% scoliosis correction, 57.7% pelvic tilt correction, 53% improvement of apical vertebral rotation, and 67.2% improvement of apical vertebral translation. At the last follow-up, the average scoliosis angle was 32.0 degrees and pelvic tilt was 8.8 degrees. Weak but not significant correlation between the amount of scoliosis correction and the subjective change in the HRQL could be established (R = 0.321, P = 0.078). No correlation between the occurrence of complications and changes in the HRQL (P = 0.122) or the satisfaction rate with the outcome of the operation (P = 0.764) was found. Extension of spinal fusion to sacropelvis had no influence on the occurrence of complications (P = 0.42) or on the changes in HRQL (P = 0.71). Life quality improved after surgical scoliosis correction in patients with CP. There is a high satisfaction rate of patients and their caregivers. Subjective changes in HRQL after the operation do not correlate with objective radiographic changes brought about by the operation, which indicates that the present operation indications and achieved correction are adequate to achieve an improvement of the subjective HRQL in this patient group. Therapeutic level IV, retrospective study.

A rare case of anterior thoracic myelomeningocele with scoliosis—case report and review of the literature

Background context Spinal deformities associated with spinal dysraphism are a challenging problem. Myelomeningocele has been reported in the lumbar spine. However, it is rare in the thoracic spine. Purpose The purpose of the report was to heighten the awareness of the rare presentation of the myelomeningocele in the thoracic spine and the ability to correct the scoliosis without debulking the lesion. Study design This is a clinical case report and literature review. Methods We report a 13-year-old girl presented with complaints of back pain, difficulty in breathing, and easy fatigability. On examination, she had a thoracolumbar scoliosis, weakness of the right ankle dorsiflexors, and impaired sensation over the L5 dermatome of the right lower limb. Radiographic examination revealed a 128° thoracolumbar scoliosis with congenital hemivertebra at T6–T9, block vertebrae of T4 and T5, and intrathoracic myelomeningocele. She underwent an anterior closing wedge osteotomy and posterior correction of scoliosis without removal of the sac. Results Four-year postoperative follow-up is uneventful. To date, our patient is the first patient who had scoliosis correction surgery for the rare presentation of a myelomeningocele in the thoracic spine without removal of the sac. Conclusions To the best of our knowledge, this is the only case of anterior thoracic myelomeningocele with scoliosis in the literature who had undergone a surgical correction of the scoliosis with osteotomy without removal of the sac. Although rare, these curves are well amenable to surgical correction of scoliosis, thereby improving endurance and functional lung capacity.

Diagnosis and Treatmentof Diastematomyelia in Children

Objective. To analyze neurological status of patients, radiological presentation of disease, and an incidence rate of diasematomyelia’s association with skin and musculoskeletal disorders. Material and Methods. The study included 20 patients with diastematomyelia aged from 1 to 18 years. Diagnosis was based on a case history, clinical examinations, spine radiography in coronal and sagittal planes, CT (20 cases), CT myelography (1 case), MRI (20 cases), and neurophysiological study (electroneuromyography of lower extremities). Septum resection was indicated in 17 children. Results. All patients had cutaneous changes along the midline of the back such as hypertrichosis, hemangiomas, and dermal sinuses. Neurological symptoms were noted in 17 patients: lower paraparesis in 11, urinary incontinence in 2, monoparesis in 4, and pyramidal insufficiency in 2 patients. Three patients did not show any neurological deficit. Orthopedic examination revealed spinal deformities of various degrees of severity. Conclusion. Resection of the septum in patients with diastematomyelia should be the first stage of surgical scoliosis correction and precede orthopedic correction of low extremity deformity. Patients having neither neurological deficit no orthopedic deterioration should be followed up, and in case of pathological symptoms augmenting or elecroneuromiography changing a question of surgical treatment should be regarded.

Surgical correction of scoliosis: Numerical analysis and optimization of the procedure

AbstractA previously developed model is used to numerically simulate real clinical cases of the surgical correction of scoliosis. This model consists of one‐dimensional finite elements with spatial deformation in which (i) the column is represented by its axis; (ii) the vertebrae are assumed to be rigid; and (iii) the deformability of the column is concentrated in springs that connect the successive rigid elements. The metallic rods used for the surgical correction are modeled by beam elements with linear elastic behavior. To obtain the forces at the connections between the metallic rods and the vertebrae geometrically, non‐linear finite element analyses are performed. The tightening sequence determines the magnitude of the forces applied to the patient column, and it is desirable to keep those forces as small as possible. In this study, a Genetic Algorithm optimization is applied to this model in order to determine the sequence that minimizes the corrective forces applied during the surgery. This amounts to find the optimal permutation of integers 1, …, n, n being the number of vertebrae involved. As such, we are faced with a combinatorial optimization problem isomorph to the Traveling Salesman Problem. The fitness evaluation requires one computing intensive Finite Element Analysis per candidate solution and, thus, a parallel implementation of the Genetic Algorithm is developed. Copyright © 2010 John Wiley &amp; Sons, Ltd.

Adult thoracolumbar or lumbar scoliosis with Chiari malformation and syringomyelia: a retrospective study of correction and fusion strategies

Retrospective case series. To study the correction and fusion strategies for adult thoracolumbar or lumbar scoliosis with Chiari malformation and syringomyelia by using posterior pedicle screw instrumentation (PPSI). Surgical intervention for Chiari malformation and syringomyelia before surgical correction of scoliosis has been reported; however, there are no clinical trials for the PPSI-based correction and fusion procedures used in these patients. From 2002 to 2009, 13 adult patients (mean age, 34.9 years) suffering from thoracolumbar or lumbar scoliosis with Chiari malformation and syringomyelia underwent correction and fusion by using PPSI. Preoperative, postoperative, and final follow-up coronary Cobb angle, correction rate, pelvic obliquity (PO), apical vertebral rotation (AVR), apical vertebral translation (AVT), trunk shift (TS), sagittal thoracic kyphosis angle, and lumbar lordosis angle were analyzed on radiographs. The preoperative and postoperative mean coronary Cobb angle was from 46.8° to 9.2°, correction rate was 80.7%, PO from 9.9° to 3.2°, AVR from 1.9° to 0.3°, AVT from 3.6 to 0.8 cm, TS from 16.8 to 1.6 cm, sagittal thoracic kyphosis angle from 18.2° to 23.5°, and lumbar lordosis angle was from 37.4° to 41.8°. The mean follow-up period was 35.2 months (range, 24-50 months). There were no obvious pseudoarticulations or loss of correction and trunk equilibrium at the final follow-up; no aggravation of the original neural symptoms or new irreversible neural injury was observed. In patients with mild or moderate adult thoracolumbar or lumbar scoliosis with Chiari malformation and syringomyelia, the correction and fusion by using PPSI can yield a satisfactory clinical effect.

Multimodal Perioperative Management of Scoliosis Surgical Correction

Multimodal Perioperative Management of Scoliosis Surgical Correction

Intraoperative Three Dimensional Correction During In Situ Contouring Surgery by Using a Numerical Model

A numerical study was conducted by simulating in situ contouring (ISC) surgery. To quantify intraoperative correction during ISC surgery. Surgical techniques correcting scoliosis, like the ISC one, lead to a complex 3-dimensional correction of the spine. Using motion analysis devices to analyze the effect of intraoperative surgical maneuvers was tedious and limited the study to the kinematics of exposed vertebrae. An alternative method consisted in simulating the surgical gestures. However, proposed models were based on rigid instrumentations, and focused attention on specific gestures of the rod-rotation and the distraction techniques through operator-dependent simulations. This study included 10 patients with severe idiopathic scoliosis treated by ISC surgery. From a patient-specific finite-element model (T1-L5 and pelvis), all main steps of the ISC surgery were automatically simulated. A specific algorithm was developed to determine the sequences of bending maneuvers according to the rod shapes chosen by the surgeon. The accuracy of the automated surgery simulation was assessed regarding the virtual postoperative spinal configuration and postoperative clinical data. For each maneuver, vertebral kinematics was computed as well as the evolution of various clinical parameters. The bending maneuvers of both the first and the second rods provided complementary effects inside, but also outside the fused spinal area. These main maneuvers combined the intraoperative spinal corrections induced by maneuvers specific to the rod-rotation surgery. The automated patient-specific simulation of ISC surgery may improve the understanding of the main mechanisms involved in the scoliosis surgical correction.

Hemodynamic Status in Patients Undergoing Surgical Correction of Severe Scoliosis under Different variants of Anesthetic Protection

Objective. To study the laws of hemodynamic changes in patients undergoing staged surgical correction of severe scoliosis ander with different variants of anesthetic protection. Material and Methods. Non-invasive monitoring of basic parameters of central and peripheral hemodynamics by impedance cardiography was performed in 59 patients with severe scoliosis undergoing surgery under anesthetic protection with different hypnotic components of general anesthesia. Results. It was defined that main factors determining the patient’s hemodynamic status during surgical scoliosis correction were the following: intraoperative position, duration of exposure, and intensity of cardiodepressive and vasodilative effects of drugs used for anesthetic protection. The study has shown that inhalation anesthesia with sevoran in comparison with total intravenous anesthesia with propofol is associated with more adverse hydration status of the lungs, which increases the risk of respiratory and pulmonary-cardiac insufficiency. Conclusion. Non-invasive impedance cardiography for the real time assessing the hemodynamic state of patients may appear to be crucial in selection of anesthesia components.

Tonsillar ectopia in idiopathic scoliosis: does it play a role in the pathogenesis and prognosis or is it only an incidental finding?

BackgroundThere is an ongoing controversy about the significance of tonsillar ectopia among patients with idiopathic scoliosis (IS).AimTo find out if tonsillar ectopia occurs more frequently among patients with IS and if it plays any etiological or prognostic role in IS.Study designRetrospective study.MethodsRetrospective analysis of 155 consecutive spine MRIs (79 patients with IS and 76 controls; aged 7-25 years; 55% were female) with regard to the position of the cerebellar tonsils in relation to foramen magnum and the sagittal diameter of foramen magnum. All images were evaluated independently by two neuroradiologists. Interobserver and intraobserver reliability analysis was performed by calculation of κ-value, intraclass correlation coefficient, and systematic and random errors. The occurrence of tonsillar ectopia among patients with IS and controls was estimated and the association of tonsillar ectopia with different predictors has been tested. Statistical significance was set to P ≤ 0.05.ResultsThe interobserver and intraobserver agreement with regard to the occurrence of tonsillar ectopia was almost perfect (κ 0.84 and 0.89, respectively). Tonsillar ectopia was found in 37% of patients with IS compared with 13% among controls (p < 0.001 and odds ratio of 3.8, 95% CI 1.7-8.5). The occurrence of tonsillar ectopia was not associated with the severity of scoliotic deformity (p = 0.85), or rapid progression of scoliosis (p = 0.76). Neurological deficit occurs twice as frequently in patients with tonsillar ectopia as in those with no tonsillar ectopia. Two of five patients with tonsillar ectopia showed improvement of their neurological deficit after the surgical correction of scoliosis.ConclusionAs tonsillar ectopia is significantly more frequent among patients with IS and may exhibit some prognostic utility in patients with neurological deficit, we forward the hypothesis that tonsillar ectopia may play a role in the development of the deformity in some patients with IS. However, occurrence of tonsillar ectopia among 13% of controls precludes stating a definitive role of tonsillar ectopia in the pathogenesis of IS. Some patients with IS, tonsillar ectopia and neurological deficit showed neurological improvement following the surgical correction of scoliosis.

Three-Dimensional Quasi-Direct-Current Plasma Immersion Ion Implantation Into Biomedical Nickel–Titanium Shape Memory Alloy Rod

Near-equiatomic NiTi S-shape rods of 400 mm long, which are used for surgical correction of scoliosis, are treated by nitrogen plasma immersion ion implantation (PIII) to reduce leaching of harmful Ni ions into the human body. To accomplish this purpose, a TiN barrier is created by PIII on the S-shape bars using different experimental setups. Our results reveal that the special quasi-direct-current PIII process can improve the efficacy of the process. In this technique, the reliability is improved by using a grounded Al housing and stainless steel mesh surrounding the specimen. The color uniformity is improved, and the maximum applicable voltage can be increased with reduced arcing and minimal changes in the shape memory effects of the materials.

Scoliosis in Duchenne’s muscular dystrophy: a changing trend in surgical management

A non-randomised retrospective study to compare the results of surgical correction of scoliosis in Duchenne's muscular dystrophy (DMD) patients using three different instrumentation systems-Sublaminar instrumentation system (Group A), a hybrid of sublaminar and pedicle screw systems (Group B) and pedicle screw system alone (Group C). Between 1993 and 2003, 43 patients with DMD underwent posterior spinal fusion and instrumentation. Group A (n = 19) had sublaminar instrumentation system, Group B (n = 13) had a hybrid construct and Group C (n = 11) was treated with pedicle system. The mean blood loss in Group A was 4.1 l, 3.2 l in Group B and 2.5 l in Group C. Average operating times in Group A, B and C were 300, 274 and 234 min, respectively. Mean pre-operative, post-operative and final Cobb angle in Group A was 50.05 +/- 15.46 degrees , 15.68 +/- 11.23 degrees and 21.57 +/- 11.63 degrees , Group B was 17.76 +/- 8.50 degrees , 3.61 +/- 2.53 degrees and 6.69 +/- 4.19 degrees and Group C was 25.81 +/- 9.94 degrees , 5.45 +/- 3.88 degrees , 8.90 +/- 5.82 degrees , respectively. Flexibility index or the potential correction calculated from bending radiographs were 60 +/- 6.33, 70 +/- 4.65 and 67 +/- 6.79% for Group A, Group B and Group C respectively. The percentage correction achieved was 72.5 +/- 14.5% in Group A, 82 +/- 6% in Group B and 82 +/- 8% in Group C. The difference between percentage correction achieved and the flexibility index was 12.45 +/- 8.22, 12.05 +/- 1.3 and 15.00 +/- 1.21% in Group A, B and C, respectively The percentage loss of correction in Cobb angles at final follow-up in Group A, B and C was 12.5 +/- 3.5, 16.5 +/- 1. and 12.5 +/- 2.5%, respectively. Complications seen in Group A were three cases of wound infection and two cases of implant failure; Group B had a single case of implant failure and Group C had one patient with wound infection and one case with a partial screw pull out. Early surgery and smaller curve corrections appears to be the current trend in the management of scoliosis in DMD. This has been possible due to early curve detection and surgery thus having the advantage of less post-operative respiratory complications and stay in paediatric intensive care. Also, early surgery avoids development of pelvic deformity and extension of instrumentation to the pelvis thereby reducing blood loss. This trend reflects the advent of newer and safer instrumentation systems, advanced techniques in anaesthesia and cord monitoring. Sublaminar instrumentation system group had increased operating times and blood loss compared to both the hybrid and pedicle screw instrumentation systems due to increased bleeding from epidural vessels and pelvic instrumentation. Overall, the three instrumentation constructs appear to provide and maintain an optimal degree of correction at medium to long term follow up but the advantages of lesser blood loss and surgical time without the need for pelvic fixation seem to swing the verdict in favour of the pedicle screw system.

Optimization of Analgesia in the Emergence Period after the Surgical Correction of Scoliosis

The problem of postoperative analgesia has been attracting scrupulous attention for many years. The consequences of inadequate treatment for pain are highly significant in terms of physical or emotional injury. Objective: to optimize analgesia in the emergence period after the surgical correction of scoliosis. Subjects and methods. A total of 64 patients divided into groups by the mode of analgesia were examined. The parameters of hemodynamics, cardiointervalography, and the scores of pain, the therapy of which involved perfalgan at the final stage of anesthesia met the criteria for adequate analgesia. Results. Increased pain sensation was observed at the emergence stage in the group of patients where fentanyl administration was routinely stopped 30 minutes before the end of surgery. To prevent the intractable pain syndrome, therapy should be initiated at once when it occurs and preventive analgesia should be initiated in predictable pain (such as elective surgical intervention). The preemptive administration of perfalgan at the final stage of anesthesia with a controlled intravenous anesthetic (diprivan) prevented the development of intensive pain sensations after extubation, failed to prolong the emergence period, and made reversal of anesthesia and transportation of patients to a unit comfortable and less painful. Key words: analgesia, scoliosis, perfalgan.