There is believed to be a correlation between congenital idiopathic scoliosis and congenital heart disease (CHD). Clinical and cardiological data was recorded for 3538 adolescents suffering from CHD. Data collected included the type of scoliosis; the direction of the curve; the Cobb angle; the number of curves and the presence or not of previous corrective cardiac surgery. Over 30% of the study group were found to suffer from scoliosis and a positive correlation with specific syndromes was also identified. The mean age of the patients was 34.0 +/− 14.0 years. The maximum Cobb angle was 107 degrees while the median was 7.6 degreees. Scoliosis was present in 37/188 (19.7%) was Eisenmenger syndrome (with R-L shunt) and 60/158= 38% with complex cardiac anatomy. There were also 20/103= 19.4% patients with univentricular (Fontan) circulation. Scoliosis was not necessarily related to previous corrective cardiac surgery, contrary to the current assumption in the literature. The hypothesis of common genetic pathway defects expressed both in cardiovascular and musculoskeletal organogenesis was raised and the TGF-beta pathway involvement is speculated.
In this study we aimed to retrospectively assess the local experience by reviewing patients, treated over the last 10 years, in whom scoliosis has been established, by means of MR imaging, to be associated with a cord syrinx.
The syrinx was treated surgically in 10 patients, with 80% of these achieving either deformity arrest, or no longer requiring surgical deformity correction. In the 2 patients from the same subset who did undergo deformity correction there was no neurological sequelae. Of the conservatively managed syrinxes, deformity correction with intraoperative cord monitoring was nevertheless undertaken in 31%, all without neurological sequelae. In just 4 patients (of 69%) who did not proceed to deformity correction, surgery was precluded by the inherent risks in the presence of an untreated syrinx.
Introduction: Given the timing and nature of adolescent-onset idiopathic scoliosis (AIS), this progressively deforming condition is highly likely to have a significant psychosocial impact. Body image dissatisfaction is a frequent finding in AIS patients, which is of concern, as there is a well-documented causative link between body image disturbance and the formation of disordered eating behaviour, reflected in the theoretical models for this area of psychopathology. However, although AIS patients have frequently been observed to exhibit disturbed body image, there has been no previous attempt to assess indications of disordered eating behaviour. Given the prevalence of AIS in adolescent females and the possible medical consequences of disordered eating, this study aimed to investigate whether AIS patients have an increased likelihood of low body weight. Methods and Results: Patients were recruited over a four month period from the regional scoliosis out-patient clinic at St James’ University Hospital; 44 female scoliosis patients participated, with a mean age of 16 (range 13 to 19). All those meeting the inclusion criteria (diagnosed with AIS, not diagnosed with any other serious medical condition), and attending clinic over the data collection period were asked to participate. Weight, height, and BMI (weight (kg)/height(m)2) measurements taken from AIS participants were compared to age and gender-adjusted normative data. No uncoiling correction was made for the scoliosis in terms of body height. The International Classification of Diseases (ICD-10) body mass criterion for eating pathology was used to determine how many AIS participants were within the range considered eating disordered. Independent-sample t-tests revealed that, when compared to the normative data, the AIS group did not differ significantly in terms of height (p=0.646). However, they were significantly lighter (p<
0.001), and had significantly lower BMI scores (p<
0.001); 25% of the sample had a BMI score within the range considered anorectic. Of these low-BMI patients, the mean index score was 15.6 (range 12.9–17.5). The mean weight was 40.25 kg (6st 4lbs), with a range from 31.5 to 49 kg (4st 13lbs – 7st 11lbs). The body mass data for this low-BMI group, both in terms of range and severity, is not within ‘normal’ body shape variation, and would not be expected in healthy adolescent females. Conclusion: The relationship between a diagnosis of AIS and low body weight may indicate disordered eating behaviour and is thus a cause for considerable concern. This is of particular relevance in the light of the well-established relationship between eating psychopathology and osteoporosis, which may result if disordered eating produces a reduced peak bone mass. Organic health consequences may need to be added to a matter previously considered to be one of cosmetic deformation.
We investigate the hypothesis that normal spinal shape is genetically determined raising the possibility that individuals with scoliosis may inherit an ‘at risk’ spinal shape leading to the clustering of scoliosis within families. A large scale study of spinal topography (Quantec system) in straight-backed sibling pairs of schoolchildren was undertaken. All children had no family or past history of spinal pathology and passed a modified Adams forward bend test. 223 sibling pairs were scanned including 28 heterozygote and 11 homozygote pairs. Control groups were constructed by breaking the sibling pair and replacing the removed sibling with an age, sex matched, unrelated counterpart. A sagittal spine line was extracted and analysed using principal component analysis to produce four scores accounting for 97.5% of the cumulative variation in shape. The scores were analysed by intraclass correlation coefficients (ICC). The results for the second score were:- All sibling groups showed greater correlation of sagittal profile for the second principal component than unrelated controls. Significant correlations in shape were seen for both twin groups where no correlation was seen with controls. A significant correlation was observed in same sex pairings. This work suggests that some elements of spinal profile may be familial but also shows correlation with sex. Both of these observations may be important in the aetiology of idiopathic scoliosis.
Many authors recommend surgery to remove retropulsed bone fragments from the canal in burst fractures to 'decompress' the spinal canal. We believe, however, that neurological damage occurs at the moment of injury when the anatomy is most distorted, and is not due to impingement in the resting positions observed afterwards. We studied 20 consecutive patients admitted to our spinal injuries unit over a two-year period with a T12 or L1 burst fracture. There was no correlation between bony or canal disruption and the degree of neurological compromise sustained but there was a significant correlation between the energy of the injury (as gauged by the Injury Severity Score) and the neurological status (p <
0.001). This suggests that neurological injury occurs at the time of trauma rather than being a result of pressure from fragments in the canal afterwards and questions the need to operate simply to remove these fragments.
We present a method of visualising spinal deformities in three dimensions using conventional radiographs and computer graphics. The shape of the spinal column can be determined from the anteroposterior and lateral radiographs and displayed in any projection. In patients with adolescent idiopathic scoliosis, the fundamental lesion, an abnormal lordosis, can be demonstrated without the need for additional views. The method is applicable to other spinal deformities and may help to elucidate their three-dimensional shape.
A new method of recording the three-dimensional anatomy of the proximal femur from a single anteroposterior radiograph is described. This technique shows that in Perthes' disease the femoral head and neck are in significant anteversion and true varus. This anatomical configuration may be important in the pathogenesis and treatment of this disorder.
We have developed a simple technique for demonstrating the sagittal profile of each rotated level of a scoliotic spine and used it to determine the patterns of lordosis and kyphosis in each of six clinical types of idiopathic scoliosis. The currently accepted classification of scoliosis is inaccurate and a modification is proposed. The three main types of scoliosis were shown to have sagittal profiles distinctly different from each other and from normal. Single structural curves had short lordotic sections at their apices, limited above and below by kyphosis. Double curves showed longer lordotic sections limited only by one area of kyphosis. Lordosis throughout the thoracic and lumbar spine was associated with triple curve patterns. The biomechanical effects of the abnormal sagittal profiles provide a simple explanation for the genesis and progression of the different types of scoliosis, and the recognition of the pattern of the sagittal abnormalities permits treatment to be designed on a sound anatomical basis for individual cases.
Late-onset idiopathic scoliosis is associated with a rib hump in the thoracic region, and surgery is indicated when this deformity becomes unacceptable. Fifty patients with this deformity were treated by the Leeds procedure, which consists of segmental wiring to a kyphotically-contoured square-ended Harrington rod; this procedure not only derotates the spine but restores the natural thoracic kyphosis, thus avoiding subsequent buckling. All patients were followed up for a minimum of two years. Forty-two of these, who had a pre-operative Cobb angle of less than 60 degrees, were treated by one-stage instrumentation and fusion, while the remaining eight with greater curves underwent preliminary anterior multiple discectomy to provide flexibility with shortening. Postoperative loss of correction was not observed and there were no neurological complications.
Progressive structural scoliosis in growing rabbits has been produced. Tethering the thoracic spine into the form of an asymmetric lordosis produces a slowly progressive structural scoliosis by purely mechanical means. The addition of a contralateral release of the paraspinal muscles leads to a very progressive deformity with early cardiorespiratory failure. This release, however, was performed with an electric soldering iron and subsequent study showed that in those animals with severe progressive deformity there was localised spinal cord damage. We suggest that it is this neural damage and not the muscle release which leads to rapid progression. The clinical implications are important in that neurological dysfunction seems to render the spinal column less able to resist mechanical buckling and may be the crucial factor differentiating severely progressive from more benign curves.
A radiological study of 50 patients with thoracic Scheuermann's disease revealed two types of lateral spinal curvature. A total of 43 lateral curves was present in 35 of the patients. Thirteen were apical at the same level as the Scheuermann's kyphosis and were due to vertebral-body wedging in the coronal plane; these curves had a mean Cobb angle of 15 degrees, occurred with equal prevalence in boys and girls and were directed equally to right and left. Thirty curves occurred in regions of compensatory lordosis (mean 5.6 degrees) situated above or, more commonly, below the Scheuermann's kyphosis. These scolioses had a mean Cobb angle of 16 degrees, were more often convex to the right than to the left and were significantly more prevalent in girls than in boys. The presence of these kyphoses and scolioses in the same spine, separated by only a few vertebrae, emphasises the importance of the sagittal plane in idiopathic spinal deformities and strongly suggests that idiopathic scoliosis and Scheuermann's disease share a common pathological process.
A study of 130 scoliotic children with curves measuring 10 degrees or more has been performed in order to elucidate the importance of stature, growth and development. Girls with adolescent idiopathic curves measuring 15 degrees or more were taller than girls with smaller idiopathic curves and taller than those whose scoliosis was secondary to leg-length inequality (pelvic tilt scoliosis). No differences were observed as regards growth velocity or development. The increased standing height may be genetic but the uncoiling effect of the normal kyphosis to give a flat lateral profile is a more likely cause. The familial trend in idiopathic scoliosis may therefore be explained by the genetically determined shape of the spine in the median (sagittal) plane.
Eleven articulated scoliotic spines were examined radiographically and morphometrically. Measurement of the curve on anteroposterior radiographs of the specimens gave a mean Cobb angle of 70 degrees, though true anteroposterior radiographs of the deformity revealed a mean Cobb angle of 99 degrees (41% greater). Lateral radiographs gave the erroneous impression that there was a mean kyphosis of 41 degrees while true lateral projections revealed a mean apical lordosis of 14 degrees. Morphometric measurements confirmed the presence of a lordosis at bony level, the apical vertebral bodies being significantly taller anteriorly (P less than 0.02). There were significant correlations (P less than 0.01) between the true size of the lateral scoliosis, the amount of axial rotation and the size of the apical lordosis. This study illustrates the three-dimensional nature of the deformity in scoliosis and its property of changing in character and magnitude according to the plane of radiographic projection.
A clinical, cadaveric, biomechanical and radiological investigation of the pathogenesis of idiopathic scoliosis indicates that biplanar asymmetry is the essential lesion. Many normal children have coronal plane asymmetry (an inconsequential lateral curvature of the spine), and certainly all have vertebral body asymmetry in the transverse plane, but when median plane asymmetry (flattening or more usually reversal of the normal thoracic kyphosis at the apex of the scoliosis) is superimposed during growth, a progressive idiopathic scoliosis occurs. Idiopathic kyphoscoliosis cannot and does not exist, from the mildest cases in the community to the most severe cases in pathology museums. Median plane asymmetry is crucial for progression and the lateral profile of the spine must be carefully scrutinised. Increased anterior vertebral height at the apex of the curve with posterior end-plate irregularity characterises the median plane asymmetry and suggests that idiopathic scoliosis is the reverse of Scheuermann's disease.
This paper describes the relationship between post-myelographic symptoms and the timing of a subsequent spinal operation. A prospective study was performed comparing the post-operative symptoms of patients who underwent discectomy within 48 hours of myelography (Group 1) with those of patients who underwent discectomy at least seven days after myelography (Group 2). After myelography there was no statistical difference in the incidence of nausea and headache in the two groups. However, after operation the incidence of headache and nausea was significantly greater in patients who underwent early discectomy. The incidence of urinary retention was significantly greater in Group 1 at 24 hours after operation but not at 48 and 72 hours. We conclude that the temptation to perform discectomy shortly after myelography should be resisted until at least one week has elapsed between the two procedures, except in emergency situations.
The scaphoid fracture is commonest in young men in the age group 15 to 29 years, who have the highest incidence of non-union, take the longest time to unite, lose more time from work, and spend the longest time as outpatients. A union rate of 95 per cent can be achieved using standard simple treatment. All but a few fractures are visible on the first radiograph, and failure of visualisation at this stage is not associated with a bad outcome. The postero-anterior and semipronated views are the most important to scrutinise. Crank-handle injuries have a particularly bad prognosis when they produce a transverse fracture of the waist of the scaphoid. Poor prognostic factors are displacement during treatment, the fracture line becoming increasingly more obvious, and the presence of early cystic change. The severity of trauma is an important factor to elicit from the history.
Sixty patients with congenital deformities of the spine were operated upon in the past fifteen years using a two-stage procedure. In the fifty patients with scoliosis half of the deformities were due to hemivertebrae and half to unilateral bars. The average correction of the deformity was 47 per cent. Early neurological signs observed in two patients with a diastematomyelia resolved. Of the ten patients with kyphosis nine had neurological signs of impending paraplegia and one was completely paraplegic before operation; all improved markedly. Posterior spinal fusion alone in the rapidly progressing congenital deformity may not prevent further progression, particularly in those cases iwth unilateral bars. Anterior resection of the vertebral body with later posterior fusion with Harrington instrumentation is safe and effective.
Standardised radiographs of the weight-bearing foot were analysed in fifty young patients undergoing osteotomy of the first metatarsal for hallux valgus. True metatarsus primus varus was not found more frequently than in a control series. The intermetatarsal angle was significantly greater in affected feet compared with controls. The structural abnormality in hallux valgus in the young is therefore due to a valgus disposition of the second and subsequent metatarsals, rather than varus inclination of the first metatarsal.
Congenital spinal extradural cysts are rare and may be the cause of acute paraplegia. In their clinical features they closely resemble acute transverse myelitis. Immediate decompression of the spinal cord and removal of the cyst may lead to restoration of normal function. Myelography differentiates these two conditions by showing a cyst in communication with the spinal canal. This investigation must be mandatory.
Sixteen severely haemophilic patients have undergone arthrodesis of one joint of the lower limb in the period 1966 to 1976. There have been nine arthrodeses of the knee and seven of the ankle. The follow-up period was from nine months to eight years. The arthrodeses were secured by internal fixation. The method was not without complications, but a satisfactory bony union resulted in all cases without further surgical intervention.
With the aim of controlling pain after Keller's operation, a solution of a long-acting local anaesthetic was instilled into the field before closure in a series of thirty patients. In a controlled prospective trial this simple technique by itself proved to be significantly better than either foot block at the ankle or the usual analgesics and was free from local or systemic complications.
The results of ten excision arthroplasties of the elbow for rheumatoid disease are described. The operation may afford good relief of pain and a useful increase both of hinge motion and of forearm rotation. Instability is not a serious problem unless the patient has to bear weight on crutches. To increase stability after arthroplasty it appears that Kirschner wire fixation is advisable as well as a plaster cast. For advanced rheumatoid disease unilateral excision arthroplasty has a definite value, especially for patients confined to a wheelchair.
