John B. Emans

A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis

With use of data culled from twenty studies, members of the Prevalence and Natural History Committee of the Scoliosis Research Society conducted a meta-analysis of 1910 patients who had been managed with bracing (1459 patients), lateral electrical surface stimulation (322 patients), or observation (129 patients) because of idiopathic scoliosis. Three variables—the type of treatment, the level of maturity, and the criterion for failure—were analyzed to determine which had the greatest impact on the outcome. We also examined the effect of the type of brace that was used and the duration of bracing on the success of treatment. The number of failures of treatment in each study was determined by calculating the total number of patients who had unacceptable progression of the curve (as defined in the study), who could not comply with or tolerate treatment, or who had an operation. The percentage of patients who completed a given course of treatment without failure, adjusted for the sample sizes of the studies in which that treatment was used, yielded the weighted mean proportion of success for that treatment. The weighted mean proportion of success was 0.39 for lateral electrical surface stimulation, 0.49 for observation only, 0.60 for bracing for eight hours per day, 0.62 for bracing for sixteen hours per day, and 0.93 for bracing for twenty-three hours per day. The twenty-three-hour regimens were significantly more successful than any other treatment (p < 0.0001). The difference between the eight and sixteen-hour regimens was not significant, with the numbers available. Although lateral electrical surface stimulation was associated with a lower weighted mean proportion of success than observation only, the difference was not significant, with the numbers available. This meta-analysis demonstrates the effectiveness of bracing for the treatment of idiopathic scoliosis. The weighted mean proportion of success for the six types of braces included in this review was 0.92, with the highest proportion (0.99) achieved with the Milwaukee brace. We found that use of the Milwaukee brace or another thoracolumbosacral orthosis for twenty-three hours per day effectively halted progression of the curve. Bracing for eight or sixteen hours per day was found to be significantly less effective than bracing for twenty-three hours per day (p < 0.0001).

The Boston bracing system for idiopathic scoliosis. Follow-up results in 295 patients.

A total of 295 patients treated with the Boston bracing system with follow-up of at least 1 year after completion of bracing are reviewed. Pre-brace curves ranged from 20–59° Cobb. Mean age at brace initiation was 13.2 years with a mean treatment time of 2.9 years and mean follow-up of 1.4 years. Mean best in-brace correction averaged 50% with correction averaging 23% at the initiation of weaning from the brace. By the time of brace discontinuance, average curve correction was 15%. At follow-up, average correction was 11 %. A comparison of follow-up with pre-brace values of major curves showed that 49% were unchanged ± 5 °, 39% achieved final correction of 5–15°, 4% achieved final correction of 15° or more, 4% of patients lost 5–15°, and 3% lost more than 15° by the time of follow-up. Eleven percent of patients underwent surgery during the period of bracing; 1% had surgery during follow-up period. Correction and control of major curves with apexes below T8 and above L2 were best. A strong correlation between best, or initial in-brace correction, and follow-up correction was noted. Young age at the initiation of bracing and higher degrees of pre-brace curvature increased the incidence of surgery. Those curves that had corrected most at the end of bracing were most at risk for loss of correction after bracing. Partial compliance with brace wear appeared as effective as full-time wear. Boston braces without superstructure appeared to be as effective as braces with superstructure for curves with apexes below T7.

The treatment of spine and chest wall deformities with fused ribs by expansion thoracostomy and insertion of vertical expandable prosthetic titanium rib: growth of thoracic spine and improvement of lung volumes.

Study Design. Prospective clinical trial of vertical expandable prosthetic titanium rib (VEPTR) in patients with combined spine and chest wall deformity with scoliosis and fused ribs. Objective. Report the efficacy and safety of expansion thoracostomy and VEPTR surgery in the treatment of thoracic insufficiency syndrome (TIS) associated with fused ribs. Summary of Background Data. Traditional attitudes toward early-onset combined chest and spine deformity assume that thoracic deformity is best controlled by treatment directed at spine deformity, often involving early spinal arthrodesis. Campbell and others have heightened awareness of the interrelationship between lung, chest, and spine development during growth and characterized TIS as the inability of the thorax to support normal respiration or lung growth. Expansion thoracostomy and VEPTR insertion was developed to directly control both spine and chest wall deformity during growth, while permitting continued vertebral column and chest growth at an early stage. Methods. Multidisciplinary evaluation of children with combined spine and chest wall deformity included pediatric pulmonologist, thoracic, and orthopedic surgeon evaluations. One or more opening wedge expansion thoracostomies and placement of VEPTR devices were performed as described by Campbell, with repeated device lengthenings during growth. Parameters measured included Cobb angle, length of thoracic spine, CT-derived lung volumes, and in older children pulmonary function tests. Results. Thirty-one patients with fused ribs and TIS were treated, 4 of whom had undergone prior spinal arthrodesis at other institutions with continued progression of deformity. In 30 patients, the spinal deformity was controlled and growth continued in the thoracic spine during treatment at rates similar to normals. Increased volume of the constricted hemithorax and total lung volumes obtained during expansion thoracostomy were maintained at follow-up. Complications included device migration, infection, and brachial plexus palsy. Conclusions. Expansion thoracostomy and VEPTR insertion with serial lengthening may be the preferred treatment for young children with chest wall deformity and scoliosis associated with fused ribs but requires multidisciplinary care and attention to details of soft tissue management. When indicated, surgical intervention with VEPTR can be considered early in growth, before deformity is severe, since spinal growth will continue with treatment.

Lumbar pedicle screws Versus hooks : Results in double major curves in adolescent idiopathic scoliosis

Study Design. A retrospective assessment of the effectiveness of lumbar pedicle screws versus laminar hooks in lumbar curve correction with double major curves in adolescent idiopathic scoliosis. Objective. To determine if pedicle screw fixation of the lumbar spine has any advantage compared with multiple laminar hook instrumentation in the treatment of double major curves in adolescent idiopathic scoliosis. Summary of Background Data. Although hooks have been used most commonly, pedicle screws may offer advantages in correction and maintenance of reduction of the lumbar curve in adolescent idiopathic scoliosis. Methods. A consecutive series of 39 patients with double major curves underwent thoracic and lumbar instrumentation by a single surgeon. Lumbar pedicle screws and hooks were used in 20 patients (Group S) and in 19 patients only lumbar hooks were used (Group H). Thoracic Cotrel-Dubousset instrumentation with hooks was the same in both groups. Preoperative age, gender, bracing, and Cobb angles were similar in both groups. Preoperative, 1-month postoperative, and latest follow-up standing posteroanterior and lateral spine radiographs were blinded to the surgeon and lumbar instrumentation covered to hide its identity. Measurements included Cobb angles, preoperative flexibility, lumbar and thoracic apical vertebral deviation, and reduction of lateral tilt and lateral displacement of the first free lumbar vertebra below the instrumentation. Percent correction, maintenance of correction at follow-up, and total levels fused were calculated. Results. The mean follow-up was 3.5 years (range, 2-8 years), which was similar for Groups H and S. Pedicle screws appear to offer some advantage in lumbar curve correction, maintenance of correction, and correction of the uninstrumented spine below the fusion when compared with the use of hooks alone. Horizontalization of the first free lumbar vertebra below the instrumentation (percent correction of tilt: 62% screws vs. 11% hooks; P = 0.0003), residual tilt (8° screws vs. 17° hooks; P = 0.004), and loss of horizontalization at follow-up (5% screws vs. 26% hooks) were dramatically better for the group using screws. Lumbar curve correction (72% screws vs. 60% hooks; P = 0.026), loss of lumbar curve correction (5% screws vs. 13% hooks), and correction of lateral apical vertebral deviation (2.2-cm screws vs. 1.5-cm hooks or 63% vs. 31%; P = 0.013) were better when screws were used. There was no significant difference in loss of correction of the thoracic curves (35% vs. 37%) or any difference in loss of correction of lateral displacement of the thoracic apical vertebra (12% vs. 14%). There was no difference in total levels fused, operative blood loss, operative time, or ultimate patient outcome. No patients in either group had spinal imbalance at latest follow-up. There were no complications related to pedicle screw placement. Two cases of transient postoperative superior mesenteric artery syndrome (duodenal obstruction by the superior mesenteric artery) in the pedicle screw group are attributed to acute correction of the lumbar scoliosis and thoracolumbar kyphosis with resultant lordosis at the thoracolumbar junction. Conclusions. Lumbar pedicle screws may offer greater lumbar curve correction, better maintenance of correction, and greater correction of the uninstrumented spine below double major curves. No complications were associated with the placement of pedicle screws.

Neurovascular injury and displacement in type III supracondylar humerus fractures.

Summary From July 1987 to January 1991, 59 consecutive type III supracondylar humerus fractures in children were identified at Childrens Hospital, Boston. Twenty-nine patients (49%) had evidence of neurovascular compromise. The median nerve was involved in 15 (52%) of these patients and was associated with posterolateral displacement in 87% of cases. The radial nerve was involved in eight (28%) of these patients and was associated with posteromedial displacement in every case. Injuries to the brachial artery occurred in 11 (38%) of these patients and was associated with posterolateral displacement in 64% and posteromedial displacement in 36% of cases. We conclude that posterolateral displacement in type III supracondylar humerus fractures is strongly associated with median nerve injuries. Posteromedial displacement is responsible for injuries to the radial nerve in virtually every instance. Brachial artery injuries may occur with either type of displacement. Neurovascular injury is higher than previously reported in these fractures.

Lateral entry compared with medial and lateral entry pin fixation for completely displaced supracondylar humeral fractures in children. A randomized clinical trial.

BACKGROUND Closed reduction and percutaneous pin fixation is the treatment of choice for completely displaced (type-III) extension supracondylar fractures of the humerus in children, although controversy persists regarding the optimal pin-fixation technique. The purpose of this study was to compare the efficacy of lateral entry pin fixation with that of medial and lateral entry pin fixation for the operative treatment of completely displaced extension supracondylar fractures of the humerus in children. METHODS This prospective, randomized clinical trial had sufficient power to detect a 10% difference in the rate of loss of reduction between the two groups. The techniques of lateral entry and medial and lateral entry pin fixation were standardized in terms of the pin location, the pin size, the incision and position of the elbow used for medial pin placement, and the postoperative course. The primary study end points were a major loss of reduction and iatrogenic ulnar nerve injury. Secondary study end points included radiographic measurements, clinical alignment, Flynn grade, elbow range of motion, function, and complications. RESULTS The lateral entry group (twenty-eight patients) and the medial and lateral entry group (twenty-four patients) were similar in terms of mean age, sex distribution, and preoperative displacement, comminution, and associated neurovascular status. No patient in either group had a major loss of reduction. There was no significant difference between the rates of mild loss of reduction, which occurred in six of the twenty-eight patients treated with lateral entry and one of the twenty-four treated with medial and lateral entry (p = 0.107). There were no cases of iatrogenic ulnar nerve injury in either group. There were also no significant differences (p > 0.05) between groups with respect to the Baumann angle, change in the Baumann angle, humerocapitellar angle, change in the humerocapitellar angle, Flynn grade, carrying angle, elbow flexion, elbow extension, total elbow range of motion, return to function, or complications. CONCLUSIONS With use of the specific techniques employed in this study, both lateral entry pin fixation and medial and lateral entry pin fixation are effective in the treatment of completely displaced (type-III) extension supracondylar fractures of the humerus in children. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Childhood scoliosis: clinical indications for magnetic resonance imaging.

We retrospectively reviewed the magnetic resonance imaging studies that had been made for ninety-five patients who had idiopathic scoliosis. We wished to determine if we could identify any criteria that should be met before these studies are performed. The study group included thirty-one male patients and sixty-four female patients. The average age at the time of the imaging study was thirteen years (range, one to twenty-eight years). The average curve was 41 degrees (range, 11 to 95 degrees). Fourteen patients were seen to have an intraspinal abnormality on the imaging study: twelve had a syrinx, one had a syrinx and an astrocytoma of the spinal cord, and one had dural ectasia. Five of the eight patients who were less than eleven years old and who had a left thoracic curve had an intraspinal abnormality on the imaging study, but this combination of factors did not indicate the need for operative intervention. Four of the intraspinal abnormalities in the fourteen patients necessitated neurosurgical intervention; if the criteria for obtaining the imaging study had been restricted to neck pain and headache--particularly with exertion--and neurological findings such as ataxia, weakness, and a cavus foot, these abnormalities would have been diagnosed.

Management of vascular injuries in displaced supracondylar humerus fractures without arteriography.

One hundred forty-three displaced (type III) supracondylar fractures of the humerus in children were treated over a 5.5-year period with 17 (11.9%) having signs of vascular impairment at the time of presentation. Rapid reduction and Kirschner wire stabilization without arteriogram was performed in each case. In three cases in which satisfactory blood supply to the hand was not present after reduction, circulation was restored after exploration of the brachial artery revealed two intimal tears and one arterial entrapment. The remaining 14 patients were normal at follow-up with no late vascular compromise. Based on these findings, we feel prereduction arteriography is not indicated in this injury.

A statistical comparison between natural history of idiopathic scoliosis and brace treatment in skeletally immature adolescent girls.

Thirty-two adolescent girls braced for late onset idiopathic scoliosis at Childrens Hospital, Boston were compared with thirty-two untreated girls from Our Ladys Hospital for Sick Children, Dublin, Ireland paired on the basis of curve size and site and age at diagnosis. All were Risser 0 at diagnosis. Study period for the braced group was from brace initiation to part-time brace wearing and, for the controls, from diagnosis to last review. There was no statistically significant difference between the groups on any parameter of curve progression. This study raises questions about the efficacy of spinal orthoses in modifying the natural history of late-onset idiopathic scoliosis and removes the ethical problems inherent in a prospective trial in which the only treatment permitted to the control group is surgery.

Non-Neurologic Complications Following Surgery for Adolescent Idiopathic Scoliosis

BACKGROUND The reported prevalence of non-neurologic complications following corrective surgery for adolescent idiopathic scoliosis ranges from 0% to 10%. However, most studies were retrospective evaluations of treatment techniques and did not focus solely on complications. The purpose of this study was to determine the prevalence of non-neurologic complications following surgery for adolescent idiopathic scoliosis and to identify preoperative and operative factors that can increase this risk. METHODS The demographic data, medical and surgical histories, and prevalence of non-neurologic complications were reviewed in a prospective cohort of 702 patients who had undergone corrective surgery for adolescent idiopathic scoliosis and were consecutively enrolled in a multicenter database. RESULTS There were 556 female and 146 male patients. The mean age at the time of surgery was 14.25 years (range, eight to eighteen years). Five hundred and twenty-three patients had only posterior spinal surgery, 105 had only anterior spinal surgery, and seventy-four had a combined anterior and posterior procedure. There was a total of 108 complications in eighty-one patients, for an overall prevalence of 15.4%. There were ten respiratory complications (1.42%), six cases of excessive bleeding (0.85%), five wound infections (0.71%), and five cases of wound hematoma, seroma, or dehiscence (0.71%). Five patients, two with an early infection and three with late failure of the implant, required a reoperation. Factors that did not correlate with an increased prevalence of complications were age, body mass index, presence of cardiac or respiratory disease, previous surgery, pulmonary function, surgical approach, number of levels fused, graft material, use of a diaphragmatic incision, Lenke curve type, or region of the major curve. Although the number of patients with renal disease was small, these patients were 7.90 times more likely to have a non-neurologic complication. Increased blood loss as well as prolonged operative and anesthesia times were associated with a higher prevalence of non-neurologic complications. CONCLUSIONS The prevalence of non-neurologic postoperative complications following surgery for correction of adolescent idiopathic scoliosis in this study was 15.4%. The few factors noted to significantly increase the rate of complications include a history of renal disease, increased operative blood loss, prolonged posterior surgery time, and prolonged anesthesia time.