Edward H. Simmons

Incidence and severity of back pain in adult idiopathic scoliosis.

Incidence of back pain in a referred and followed group of 197 adults with idiopathic scoliosis and in a comparable control group of 180 adults without known spinal deformity was the same. Severity of pain, however, was greater in scoliotic patients. The clinical course of back pain in adults without spinal deformity and in scoliotics was different: 64% improvement in adults without scoliosis versus 83% persistence and progression in adults with scoliosis. Fifty-one percent of adult scoliotics (101 patients) had significant pain. Pain increased with age and degree of scoliotic curvature (P < 0.0005). Patients with major lumbar curves had more pain. Major complaint was frequently below major deformity. Compensatory lumbosacral fractional curves were most painful and disabling. Pain comes mainly from concavity of curves and includes discogenic, facet joint, and radicular origins. Surgery significantly reduced pain (P < 0.0001); conservative therapy did not. Eighty-three percent of surgical patients had sufficient pain relief to make surgery worthwhile at five years average follow-up.

Spinal stenosis with scoliosis

A retrospective review was carried out on 40 patients who met the criteria of 1) having a significant lumbar scoliosis associated with spinal stenosis, with symptoms of neurogenic claudication; and 2) having been treated with posterior decompression and pedicular screw fixation techniques. The average age of the patients was 61.5 years (range, 38–77 years), and 25 of the 40 patients were female. Eighty-eight percent of the patients had significant back pain in addition to lower extremity pain. All patients had pedicular screw fixation at all levels. Zielke instrumentation was used in 24 patients, Cotrel-Dubousset instrumentation in 8 patients, and Texas Scottish Rite Hospital instrumentation in the remaining 8 patients. After surgery, there was marked improvement in regard to pain status: 34 patients (83%) had severe pain before surgery, with 38 patients (93%) reporting mild or no pain at follow-up. Average length of follow-up was 44 months (range, 24–61 months). There were no deaths and no instrument-related failures or pseudarthroses noted in this series. A mean correction of the deformity of 19° was obtained. Average scoliosis was 37° before surgery and 18° at follow-up.

Coronal and sagittal plane spinal deformities correlating with back pain and pulmonary function in adult idiopathic scoliosis

One hundred one referred adult patients (ages 20-63; mean, 36 years) with painful idiopathic scoliosis were evaluated. None. had prior surgical treatment. Severity of pain was graded and localized over radiographic deformities in the coronal and sagittal planes. Radiographic changes in primary as well as full and fractional compensatory curves were studied. Degrees of scoliosis, percent correction on side bending, vertebral body rotation at curve apex, spinal balance, and lateral olisthesis in the coronal plane, degenerative disc disease, and other degenerative changes in all curves were measured and graded in both the coronal and sagittal planes. Lordosis and kyphosis were measured on all standing sagittal radiographs. Forty-one patients had pulmonary function studies. Multiple variable statistical analysis (Spearman correlation coefficients) of the data found fractional lumbosacral curves most painful and disabling. Scoliosis greater than 40° and kyphosis greater than 50° correlated with increasing pain and decreasing forced vital capacity. Reduction in forced vital capacity also correlated with curve rigidity. Rotation correlated closely with degrees of scoliosis (r=0.70; P<0.0001) and had the highest correlation with pain (r=0.59; P<0.0001) of all radiographic findings and deformities studied.

Thirty-six years experience of cervical extension osteotomy in ankylosing spondylitis: techniques and outcomes.

Study Design. A retrospective review of the cervical extension osteotomy in the past 36 years for the treatment of flexion deformity of patients with ankylosing spondylitis was conducted. Objectives. To review the conventional and current surgical techniques of cervical extension osteotomy in ankylosing spondylitis and to evaluate the clinical outcomes. Summary of Background Data. Cervical osteotomy is a challenging procedure in the correction of flexion deformity in ankylosing spondylitis. Some authors prefer using general anesthesia and prone position for their surgery, and some, including the authors, use the sitting position. Methods. A review of 131 cases of cervical spine osteotomy was carried out. The accumulation of 131 cases was classified into two phases: 114 cases from 1967 to 1997 (conventional technique group) by our senior author and 17 cases from 1997 to 2003 (current technique group) by our first author. Patient follow-up was obtained by a combination of retrospective chart review and telephone interview by 2 independent physicians. The flexion deformity was measured before surgery and after surgery using chin-brow to vertical angle. Results. There were 114 patients in the conventional group and 17 patients in the current group. The average preoperative and postoperative angle was 56° and 4°, respectively, in the conventional group and 49° and 12°, respectively, in the current group. Conclusions. The sitting position with local anesthesia is safe and allows for correction of deformity in a controlled manner. The increased lateral resection area reduces the possibility of nerve root impingement and provides ample room for the spinal cord. The cranial halo can also be adjusted after surgery to modify the head/neck position and can be adjusted to alleviate any C8 nerve root impingement. The procedure demands great attention to detail to minimize risk.

The results of surgical treatment for adult scoliosis.

This study was done to define and characterize those adult patients with scoliosis who will have problems of pain and/or progression leading to a surgical procedure and to review the results of these surgical procedures. The authors reviewed the cases of 49 adult patients who had undergone surgical treatment for scoliosis (average follow-up, 34 months; range, 24-140 months). The patients were categorized according to age, which allowed analysis of the data comparing age and the incidence and level of pain, age versus the degree of curvature, and age versus the incidence of progression. The relative incidence of pain and progression as indications for surgery were found to vary with respect to age. In the younger groups, progression was more often the indication for surgery than in the older groups. The Younger groups also had larger curves than did the older groups, on average. The degree of pain was not found to correlate with the magnitude of the deformity. Surgical Complications occurred in 20 patients; however, 14 of these were minor complications during the perioperative period, which did result in any sequelae. Surgical treatment can be done with a relatively low serious complication rate and good results in terms of pain relief and reasonable correction of the deformity.

The management of nerve root entrapment syndromes associated with the collapsing scoliosis of idiopathic lumbar and thoracolumbar curves

From 1969 through 1978, 30 adults presented with painful idiopathic scoliosis and associated radicular symptoms. Fifteen had major thoracolumbar curves and 15 had major lumbar curves. Ten (33%) had physical findings of nerve root entrapment, 4 having two roots entrapped. Root entrapments in the sciatic distribution were most common and arose on the side opposite the major curve, coming from the concavity of compensatory lumbosacral curves (7 of 9 patients). Root entrapment in a femoral nerve distribution came from the concavity of the major curve (1 patient). Whether in a major or compensatory curve, entrapments usually arise in the concavity (8 of 10 patients). Mechanisms of root entrapment vary, but foraminal compression and pedicular kinking were most common. When major deforming curves are corrected fairly completely, most nerve root entrapments are relieved; sciatic entrapments are decompressed by spontaneous straightening of the lumbosacral curve. Dwyer instrumentation and fusion has been the most effective method of surgical management in carefully selected cases.

Evidence from Cadavers Suggestive of Entrapment of Fifth Lumbar Spinal Nerves by Lumbosacral Ligaments

Lumbosacral spines from 51 geriatric-age cadavers (25 men and 26 women) were examined both grossly and under the dissecting microscope for evidence of compression of fifth lumbar spinal nerves by their respective lumbosacral ligaments. These ligaments were found to extend from the transverse process and body of L5 to the ala of the sacrum in 97% of the specimens, and from the transverse process and body of L5 to the promontory of the sacrum in 3% of the specimens. Anterior primary rami of the fifth lumbar spinal nerve were observed to be compressed in 11% (11 of 102) of the specimens examined grossly and under the dissecting microscope. Histologic evidence of chronic compression, as suggested by perineurial and endoneurial fibrosis, peripheral thinning of myelin sheaths, or subjective evidence of a shift in fiber diameter to a population of smaller size fibers was found, deep to the lumbosacral ligament, in three of the 11 nerves judged to be compressed. The information derived is of interest to the clinician whose patient presents with L5 root signs and a myelogram, discogram, and computed tomographic scan which do not show any abnormality. The possibility of extraforaminal compression must be considered as a possible source of the clinical signs.

Intradural connections between adjacent cervical spinal roots.

It is not always possible to localize the level of cervical pathology accurately on the basis of clinical signs and symptoms. Intradural intersegmental connections between sensory rootlets occur frequently in the cervical region and have been shown to be clinically and surgically significant. Similar connections between motor rootlets also have been noticed, but their incidence was not reported. Fifty-four human cervical spines were dissected to investigate the incidence of both types of connections. Fifty-three of the 54 specimens had posterior rootlet connections, and nine of the 54 had anterior connections. The preponderant pattern (85%) was for a peripheral dorsal or ventral rootlet to join the central portion of the next rostral or caudal root, and for the two to pass together into the spinal cord. Six distinct patterns were recognized, and a classification system is proposed. These connections may provide a pathway for overlap of sensory dermatomes and motor innervation of the neck and upper extremity. Our observations imply that when a cervical nerve root is injured, small segments of an adjacent root may be equally affected, and the process may be clinically localized one segment higher or lower than it actually is.

Intervertebral disc herniation in the adolescent.

Twenty-nine patients between 14 and 20 years of age underwent surgical treatment for intervertebral disc herniation over a 10-year period. Trauma was a significant factor in 59%. Back pain was a major complaint in all cases, and all but one had significant sciatic distress. Typical painful, restricted forward flexion was found in 22 cases. All patients had definite signs of nerve root tension. Nerve compression signs were present in 41%. Myelography was done in all cases, and discography was performed on 22 patients to aid in diagnosis and planning of definitive treatment. Twenty-three patients were followed over an average of 5.3 years. Excellent or good results were found in 89%. One patient required a further surgical procedure. Analyzing 12 procedures performed at the L5-S1 level demonstrated excellent results, in all patients undergoing lumbosacral fusion combined with discotomy at this level in the presence of a normal L4–5 discogram.

Muscle disease as a cause of kyphotic deformity in ankylosing spondylitis

The effects of ankylosing spondylitis on skeletal muscle were investigated in nine consecutive patients referred for correction of severe spinal deformity. Enzymatic studies (creatinine phosphokinase, aldolose), electromyography, and paraspinal muscle biopsy were performed. The enzyme studies and electromyography yielded only variable results, but muscle biopsy uniformly demonstrated evidence of severe skeletal muscle disease. Small, scattered, sharp angular fibers were present in all specimens along with atrophy of Type I and Type II muscle fibers. Core or targetoid fibers were present in all but one patient. These findings suggest that muscle disease may be present in all ankylosing spondylitis patients with spinal flexion deformity