JBJS | The Safety and Efficacy of Isola-Galveston Instrumentation and Arthrodesis in the Treatment of Neuromuscular Spinal Deformities*†

The Journal of Bone & Joint Surgery, Volume 82, Issue 4

Articles | April 01, 2000

The Safety and Efficacy of Isola-Galveston Instrumentation and Arthrodesis in the Treatment of Neuromuscular Spinal Deformities*†

Muharrem Yazici, M.D.‡; Marc A. Asher, M.D.§; James W. Hardacker, M.D.#

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Investigation performed at the University of Kansas Medical Center, Kansas City, Kansas
*One or more of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. In addition, benefits have been or will be directed to a research fund, foundation, educational institution, or other nonprofit organization with which one or more of the authors is associated. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was DePuy AcroMed Corporation, Raynham, Massachusetts.
†Read at the Annual Meeting of the Scoliosis Research Society, Asheville, North Carolina, September 15, 1995.
‡Hacettepe University, Faculty of Medicine, Orthopaedics, Sihhiye, Ankara 06100, Turkey.
Â§Section of Orthopedics, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, Kansas 66160-7387. E-mail address: masher@kumc.edu.
#The Spine Institute, 5299 James Court, Carmel, Indiana 46033.

The Journal of Bone & Joint Surgery. 2000; 82:524-524

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Abstract

Background: Implant systems that realign and stabilize a deformed spine continue to evolve. The purpose of the study of this case series was to determine the safety and effectiveness of a system designed to integrate hook, wire, screw, and post anchors for the treatment of a wide spectrum of neuromuscular disorders associated with pelvic deformity or the potential for deformity.

Methods: Forty-seven consecutive patients who had a spinal deformity that was due to cerebral palsy or an upper motor-neuron cerebral palsy-like disease (thirty-one patients), myelomeningocele (nine), Duchenne muscular dystrophy (four), or other disorders (three) were managed with Isola-Galveston instrumentation and arthrodesis. The average age at the time of the operation was fourteen years and three months (range, five years and four months to twenty-three years and nine months). Eight patients (17 percent) had an additional anterior discectomy and arthrodesis without instrumentation, and three (6 percent) had an additional decancellation eggshell osteotomy. The forty-seven patients were followed for an average of forty-seven months (range, twenty-four to 100 months). The complications were tabulated to assess the safety of the procedure, and the correction of each deformity was calculated to determine the efficacy.

Results: There were no deaths, acute wound infections, or serious neurological problems. Reoperation was necessary in five patients (11 percent). One reoperation was performed because of a delayed deep wound infection; one, because of delayed sterile drainage; and one, for a pseudarthrosis repair. The remaining two reoperations were done for removal of an implant because the cephalad portion had become prominent. In addition to the pseudarthrosis that required a reoperation, there were three possible pseudarthroses that did not require a reoperation (overall prevalence of pseudarthrosis, 9 percent). Postoperative bracing was used for eleven patients (23 percent); it did not influence the rate of pseudarthrosis or possible pseudarthrosis.

The average preoperative scoliosis of 70 degrees was corrected to 24 degrees (a 66 percent correction) at the time of the latest follow-up, and the average preoperative pelvic obliquity of 27 degrees was corrected to 5 degrees (an 81 percent correction). A survey of the patients, parents, and caregivers indicated that 96 percent of them were satisfied or very satisfied with the result of the operation.

Conclusions: Isola-Galveston instrumentation seems as safe and effective as other types of instrumentation that have been studied in comparable series in the literature. Isola-Galveston instrumentation is probably more effective for the correction of pelvic obliquity and the maintenance of correction. Only a posterior procedure is used, and the instrumentation appears to decrease the need for an additional anterior approach. Spinal hook, wire, screw, and post anchors have been successfully integrated into one posterior spinal implant system.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Patients, especially children, with a neuromuscular disorder are at an increased risk for the development of progressive spinal deformity. Because bracing or seating modification is difficult and the effect of such strategies on the progression of the curve is questionable^{14-16,18,44,65}, effective treatment of a severe neuromuscular spinal deformity currently involves surgical instrumentation and arthrodesis^{1-3,11,14-16,18,28,32,35,36,44,49,51,52,54,55,63-67}.

The selection of patients for the procedure is based on several variables that are much harder to measure than the severity of the deformity; these variables include the effect of the deformity on the patient's functional status and the resultant pain as well as the safety and efficacy of the surgical procedure^10,66. The uncertainty involved in patient selection underscores the need for safe and effective surgical instrumentation and arthrodesis. Sometimes the operation should be done when the need for it is barely apparent to the patient and the family, as in the case of Duchenne muscular dystrophy^34,39,65, whereas at other times only a large deformity can justify the resulting trade-offs, such as a stiff spine⁵⁷.

The introduction of sublaminar segmental wire fixation by Luque and Cardoso⁴⁶, in 1977, and of intrailiac (Galveston) posts by Allen and Ferguson¹, in 1982, improved the results considerably compared with those associated with Harrington instrumentation, used either alone^16,64 or in combination with an anterior procedure with or without Dwyer^19,28 or Zielke⁶⁶ instrumentation. The Luque-Galveston procedure has become the standard of care for patients with neuromuscular disease who have spinal and pelvic deformities severe enough to warrant an operation^11,14,35.

Our goal has been to increase the versatility and range of Luque-Galveston instrumentation in order to make deformities, such as hyperlordosis and multiple curves, and diseases and lesions, such as an internal disc disorder, tumor, and pelvic fracture, more approachable. To accomplish this, fixation with hooks and pedicle screws was integrated with wire fixation; adjustable, rigid connections were developed; and the dimensions were standardized. Because the first implant resembled a butterfly, the system was named Isola, a butterfly species⁵.

The purpose of the present study was to determine whether Isola-Galveston instrumentation is safe and effective for patients with a neuromuscular spinal deformity requiring arthrodesis extending to the pelvis.

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Fig. 1:: Photograph showing the closed hook design features, which include variable throat heights and drop-entry placement. The variable throat heights allow precise placement on the transverse process, lamina, and facet, thereby minimizing intrusion into the spinal canal. The drop-entry feature, whereby the hook shoe-to-rod angle decreases from 15 to 5 degrees with set-screw tightening, eases placement of the hook and firmly secures the hook against the bone surface. These features decrease profile, limit inventory, and lower dependence on open connections, which are inherently larger and more complex.

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Fig. 2-A:: Photographs showing the v-groove concept, in which a rod with a larger diameter is forced into a hemisphere with a smaller diameter as the connection is secured (Fig. 2-A). The hollow-ground concept provides space in the middle of the connector body to accommodate three-point contact, with the set-screw posteriorly and the outer rims of the hook anteriorly with either straight or curved rods (Fig. 2-B).

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Fig. 2-B::

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Fig. 3-A:: Figs. 3-A through 3-E: Photographs demonstrating the six-degrees-of-freedom motion possible with the slotted screw-to-rod connection. This variable-position connection facilitates connection of an anatomically contoured rod to a deformed spine and realignment of the spine to the rod.
Fig. 3-A: Vertical and mediolateral translation.

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Fig. 3-B:: Anteroposterior translation.

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Fig. 3-C:: Coronal plane angulation.

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Fig. 3-D:: Sagittal plane angulation.

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Fig. 3-E:: Transverse plane angulation.

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Fig. 4-A:: Figs. 4-A and 4-B: Case 12, a man with progressive scoliosis and pelvic obliquity who was managed when he was twenty years and two months old.
Fig. 4-A: Preoperative anteroposterior radiograph made with the patient sitting. (Reprinted, with permission, from: Asher, M. A.; Strippgen, W. E.; Heinig, C. F.; and Carson, W. L.: Isola instrumentation. In The Pediatric Spine: Principles and Practice, edited by S. L. Weinstein. Vol. 2, p. 1646. New York, Raven Press, 1994.)

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Fig. 4-B: Anteroposterior radiograph, made at four years and three months postoperatively with the patient sitting, showing maintenance of the correction.

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Fig. 5-A:: Figs. 5-A through 5-D: Case 31, a boy with kyphoscoliosis and pelvic flexion who was managed when he was fourteen years and eight months old. (Reprinted, with permission, from: Asher, M.: Isola spinal instrumentation: an update focusing on realignment and versatility. In Spine: State of the Art Reviews. Vol. 8, p. 380. Philadelphia, Hanley and Belfus, 1994.)
Figs. 5-A and 5-B: Anteroposterior and lateral radiographs made four months postoperatively with the patient sitting.

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Fig. 5-B::

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Fig. 5-C:: Anteroposterior and lateral radiographs, made twenty-six months after the operation with the patient sitting, showing good correction of the deformity and integration of the hook, wire, and screw anchors.

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Fig. 5-D::

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: TABLE IData on the Patients

*The ambulatory status was graded according to a modification of the system of the Rancho Los Amigos Hospital^38,44, with 1 = community ambulator, 2 = household or physical therapy ambulator, 3 = independent sitter, 4 = dependent sitter, and 5 = nonsitter or bedridden.†The patient was considered to have preoperative scoliosis if it was at least 30 degrees. The thoracic curve is listed first. The small curve is considered compensatory.‡The patient was considered to have preoperative pelvic obliquity if it was at least 10 degrees.§Kyphosis or lordosis if it was abnormally large or small.#The patient had a reversal of pelvic obliquity from +10 to -4 degrees.**Thoracolumbar kyphosis.††The percent correction is in parentheses.‡‡Lumbar kyphosis.

Case	Gender, Age(yrs. + mos.)	Weight(kg)	Diagnosis	Ambulatory Status* (grade)		Scoliosis† (degrees)			Pelvic Obliquity (degrees)			Abnormal Kyphosis (degrees)			Abnormal Lordosis (degrees)
Preop.	Postop.	Preop.	Postop.	Latest Follow-up	Preop.‡	Postop.	Latest Follow-up	Preop.§	Postop.	Latest Follow-up	Preop.	Postop.	Latest Follow-up
1	F, 12 + 6	31	Cerebral palsy-like dis.	4	3	80	20	45	17	6	14	-	-	-	10	56	55
2	F, 9 + 0	19	Cerebral palsy-like dis.	4	3	70	15	21	29	0	0	70	60	40	-	-	-
3	F, 12 + 2	18	Cerebral palsy-like dis.	4	3	79	21	29	32	10	-4#	5	20	25	-	-	-
4	F, 9 + 7	23	Cerebral palsy-like dis.	4	3	95	38	45	41	15	10	39**	58	71	-	54	70
5	M, 17 + 0	28	Cerebral palsy-like dis.	4	3	107	68	87	30	22	10	-	-	-	-	-	-
						114	68	75
6	F, 12 + 4	23	Cerebral palsy	4	3	46	6	13	24	12	5	70	61	58	-	-	-
7	M, 22 + 2	28	Cerebral palsy-like dis.	4	3	105	26	26	46	9	3	0	37	35	11	54	52
8	M, 13 + 6	39	Cerebral palsy-like dis.	4	3	60	26	20	23	12	8	120*	56	73	-	-	-
9	M, 5 + 4	17	Cerebral palsy	4	3	79	18	16	14	7	25	34**	23	12	-	42	20
10	M, 16 + 6	34	Cerebral palsy-like dis.	4	3	37	9	14	11	5	0	106**	51	60	-	36	39
11	M, 8 + 11	24	Cerebral palsy-like dis.	4	3	84	26	36	20	0	8	-	-	-	-	-	-
12	M, 20 + 2	40	Cerebral palsy	4	3	38	13	23	40	9	8	-	-	-	-	-	-
						98	33	34
13	F, 14 + 6	36	Cerebral palsy-like dis.	4	3	-	-	-	-	-	-	88	46	51	-	-	-
14	F, 10 + 0	17	Cerebral palsy-like dis.	4	3	35	7	11	-	-	-	61	51	34	-	-	-
15	F, 15 + 4	25	Cerebral palsy	4	3	33	17	19	19	7	5	79	51	67	-	-	-
16	F, 22 + 2	38	Cerebral palsy-like dis.	4	3	40	20	14	20	10	2	90	63	68	80	65	58
17	F, 14 + 5	34	Cerebral palsy-like dis.	4	3	35	0	0	32	0	0	22	22	25	127	42	48
18	M, 10 + 6	19	Cerebral palsy-like dis.	4	3	75	12	22	15	0	2	-	-	-	-	-	-
19	M, 14 + 4	35	Cerebral palsy-like dis.	4	3	40	21	27	-	-	-	55**	40	36	-	37	34
20	F, 21 + 2	29	Cerebral palsy-like dis.	4	3	63	19	26	29	0	5	-	-	-	-	-	-
21	F, 15 + 1	30	Cerebral palsy-like dis.	4	3	92	17	18	48	9	7	-	-	-	-	-	-
22	M, 13 + 9	45	Cerebral palsy-like dis.	2	2	38	4	0	30	1	5	84	33	20	-	-	-
						70	18	18
23	M, 20 + 8	30	Cerebral palsy-like dis.	4	3	115	67	94	37	24	15	-	-	-	-	-	-
						139	81	91
24	M, 10 + 0	36	Cerebral palsy-like dis.	4	3	33	15	14	24	0	0	71	26	38	-	-	-
						92	12	15
25	M, 14 + 11	31	Cerebral palsy-like dis.	4	3	37	6	3	21	2	0	-	-	-	-	-	-
						86	20	14
26	F, 14 + 2	31	Cerebral palsy	2	2	59	10	20	20	0	0	-	-	-	126	64	64
27	F, 17 + 3	34	Cerebral palsy	4	3	33	21	14	31	6	0	-	-	-	-	-	-
						68	20	9
28	F, 13 + 11	20	Cerebral palsy-like dis.	2	2	92	34	39	38	7	2	-	-	-	-	-	-
29	F, 16 + 8	20	Cerebral palsy-like dis.	4	3	52	21	17	45	0	4	85**	22	29	-	-	-
						96	39	48
30	M, 9 + 3	28	Cerebral palsy-like dis.	4	3	88	20	23	29	3	0	2	24	26	-	-	-
31	M, 14 + 8	41	Cerebral palsy	4	3	47	24	26	-	-	-	97**	27	34	-	50	51
						64	26	28
Avg. for cerebral palsy or cerebral palsy-like disease††	14 + 3	29
Major curves (n = 30)						74	23 (69)	27 (64)	28	7 (75)	5 (82)
Compensatory curves (n = 9)						56	27 (52)	31 (45)
32	F, 17 + 4	45	Myelomeningocele	3	3	55	32	33	29	15	26	15	26	56	-	-	-
						59	35	45
33	M, 16 + 4	30	Myelomeningocele	4	3	86	40	35	37	5	4	20	38	40	8	40	34
34	F, 11 + 0	22	Myelomeningocele	4	3	50	14	24	30	2	0	63	50	75	-	-	-
						61	6	9
35	M, 15 + 1	24	Myelomeningocele	2	1	45	19	10	25	5	0	116**	50	70	-	50	38
						56	15	7
36	F, 10 + 0	18	Myelomeningocele	2	2	30	12	11	17	0	0	24	37	23	115	40	42
37	F, 12 + 2	40	Myelomeningocele	4	3	30	0	0	19	3	7	-	-	-	-	-	-
						62	21	18
38	F, 11 + 0	67	Myelomeningocele	4	3	60	13	13	12	4	10	-	-	-	-	-	-
39	F, 10 + 2	34	Myelomeningocele	4	3	-	-	-	-	-	-	78	20	15	-	-	-
40	M, 19 + 8	39	Myelomeningocele	4	3	60	5	9	27	9	0	67	39	26	-	-	-
Avg. for myelo- meningocele	13 + 8	35
Major curves (n = 8)						59	18 (69)	18 (69)	25	5 (80)	6 (76)
Compensatory curves (n = 4)						45	16 (64)	17 (62)
41	M, 15 + 7	68	Duchenne musc. dystrophy	4	3	30	20	15	26	0	0	16	18	17	23	52	57
						90	23	18
42	M, 12 + 10	45	Duchenne musc. dystrophy	4	3	39	11	10	19	2	0	15	12	18	-	-	-
						54	13	10
43	M, 14 + 5	50	Duchenne musc. dystrophy	4	3	75	16	16	24	0	4	6	10	7	-	-	-
44	M, 12 + 9	50	Duchenne musc. dystrophy	4	3	30	19	15	17	0	3	15	22	35	20	38	41
						37	11	11
Avg. for Duchenne musc. dystrophy‡‡	13 + 11	53
Major curves (n = 4)						64	16 (75)	14 (78)
Compensatory curves (n = 3)						33	17 (48)	13 (61)	22	1 (95)	2 (91)
45	F, 9 + 0n	29	Spinal musc. atrophy	4	3	46	10	18	35	10	10	19	30	38	-	-	-
						79	11	15
46	F, 23 + 9	60	Myopathy	1	1	55	20	15	-	-	-	-	-	-	94	49	39
47	M, 18 + 0	39	Nonfamilial dysautonomia	1	1	72	15	30	13	3	10	-	-	-	-	-	-

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: TABLE IData on the Patients

Case	Gender, Age(yrs. + mos.)	Weight(kg)	Diagnosis	Ambulatory Status* (grade)		Scoliosis† (degrees)			Pelvic Obliquity (degrees)			Abnormal Kyphosis (degrees)			Abnormal Lordosis (degrees)
Preop.	Postop.	Preop.	Postop.	Latest Follow-up	Preop.‡	Postop.	Latest Follow-up	Preop.§	Postop.	Latest Follow-up	Preop.	Postop.	Latest Follow-up
1	F, 12 + 6	31	Cerebral palsy-like dis.	4	3	80	20	45	17	6	14	-	-	-	10	56	55
2	F, 9 + 0	19	Cerebral palsy-like dis.	4	3	70	15	21	29	0	0	70	60	40	-	-	-
3	F, 12 + 2	18	Cerebral palsy-like dis.	4	3	79	21	29	32	10	-4#	5	20	25	-	-	-
4	F, 9 + 7	23	Cerebral palsy-like dis.	4	3	95	38	45	41	15	10	39**	58	71	-	54	70
5	M, 17 + 0	28	Cerebral palsy-like dis.	4	3	107	68	87	30	22	10	-	-	-	-	-	-
						114	68	75
6	F, 12 + 4	23	Cerebral palsy	4	3	46	6	13	24	12	5	70	61	58	-	-	-
7	M, 22 + 2	28	Cerebral palsy-like dis.	4	3	105	26	26	46	9	3	0	37	35	11	54	52
8	M, 13 + 6	39	Cerebral palsy-like dis.	4	3	60	26	20	23	12	8	120*	56	73	-	-	-
9	M, 5 + 4	17	Cerebral palsy	4	3	79	18	16	14	7	25	34**	23	12	-	42	20
10	M, 16 + 6	34	Cerebral palsy-like dis.	4	3	37	9	14	11	5	0	106**	51	60	-	36	39
11	M, 8 + 11	24	Cerebral palsy-like dis.	4	3	84	26	36	20	0	8	-	-	-	-	-	-
12	M, 20 + 2	40	Cerebral palsy	4	3	38	13	23	40	9	8	-	-	-	-	-	-
						98	33	34
13	F, 14 + 6	36	Cerebral palsy-like dis.	4	3	-	-	-	-	-	-	88	46	51	-	-	-
14	F, 10 + 0	17	Cerebral palsy-like dis.	4	3	35	7	11	-	-	-	61	51	34	-	-	-
15	F, 15 + 4	25	Cerebral palsy	4	3	33	17	19	19	7	5	79	51	67	-	-	-
16	F, 22 + 2	38	Cerebral palsy-like dis.	4	3	40	20	14	20	10	2	90	63	68	80	65	58
17	F, 14 + 5	34	Cerebral palsy-like dis.	4	3	35	0	0	32	0	0	22	22	25	127	42	48
18	M, 10 + 6	19	Cerebral palsy-like dis.	4	3	75	12	22	15	0	2	-	-	-	-	-	-
19	M, 14 + 4	35	Cerebral palsy-like dis.	4	3	40	21	27	-	-	-	55**	40	36	-	37	34
20	F, 21 + 2	29	Cerebral palsy-like dis.	4	3	63	19	26	29	0	5	-	-	-	-	-	-
21	F, 15 + 1	30	Cerebral palsy-like dis.	4	3	92	17	18	48	9	7	-	-	-	-	-	-
22	M, 13 + 9	45	Cerebral palsy-like dis.	2	2	38	4	0	30	1	5	84	33	20	-	-	-
						70	18	18
23	M, 20 + 8	30	Cerebral palsy-like dis.	4	3	115	67	94	37	24	15	-	-	-	-	-	-
						139	81	91
24	M, 10 + 0	36	Cerebral palsy-like dis.	4	3	33	15	14	24	0	0	71	26	38	-	-	-
						92	12	15
25	M, 14 + 11	31	Cerebral palsy-like dis.	4	3	37	6	3	21	2	0	-	-	-	-	-	-
						86	20	14
26	F, 14 + 2	31	Cerebral palsy	2	2	59	10	20	20	0	0	-	-	-	126	64	64
27	F, 17 + 3	34	Cerebral palsy	4	3	33	21	14	31	6	0	-	-	-	-	-	-
						68	20	9
28	F, 13 + 11	20	Cerebral palsy-like dis.	2	2	92	34	39	38	7	2	-	-	-	-	-	-
29	F, 16 + 8	20	Cerebral palsy-like dis.	4	3	52	21	17	45	0	4	85**	22	29	-	-	-
						96	39	48
30	M, 9 + 3	28	Cerebral palsy-like dis.	4	3	88	20	23	29	3	0	2	24	26	-	-	-
31	M, 14 + 8	41	Cerebral palsy	4	3	47	24	26	-	-	-	97**	27	34	-	50	51
						64	26	28
Avg. for cerebral palsy or cerebral palsy-like disease††	14 + 3	29
Major curves (n = 30)						74	23 (69)	27 (64)	28	7 (75)	5 (82)
Compensatory curves (n = 9)						56	27 (52)	31 (45)
32	F, 17 + 4	45	Myelomeningocele	3	3	55	32	33	29	15	26	15	26	56	-	-	-
						59	35	45
33	M, 16 + 4	30	Myelomeningocele	4	3	86	40	35	37	5	4	20	38	40	8	40	34
34	F, 11 + 0	22	Myelomeningocele	4	3	50	14	24	30	2	0	63	50	75	-	-	-
						61	6	9
35	M, 15 + 1	24	Myelomeningocele	2	1	45	19	10	25	5	0	116**	50	70	-	50	38
						56	15	7
36	F, 10 + 0	18	Myelomeningocele	2	2	30	12	11	17	0	0	24	37	23	115	40	42
37	F, 12 + 2	40	Myelomeningocele	4	3	30	0	0	19	3	7	-	-	-	-	-	-
						62	21	18
38	F, 11 + 0	67	Myelomeningocele	4	3	60	13	13	12	4	10	-	-	-	-	-	-
39	F, 10 + 2	34	Myelomeningocele	4	3	-	-	-	-	-	-	78	20	15	-	-	-
40	M, 19 + 8	39	Myelomeningocele	4	3	60	5	9	27	9	0	67	39	26	-	-	-
Avg. for myelo- meningocele	13 + 8	35
Major curves (n = 8)						59	18 (69)	18 (69)	25	5 (80)	6 (76)
Compensatory curves (n = 4)						45	16 (64)	17 (62)
41	M, 15 + 7	68	Duchenne musc. dystrophy	4	3	30	20	15	26	0	0	16	18	17	23	52	57
						90	23	18
42	M, 12 + 10	45	Duchenne musc. dystrophy	4	3	39	11	10	19	2	0	15	12	18	-	-	-
						54	13	10
43	M, 14 + 5	50	Duchenne musc. dystrophy	4	3	75	16	16	24	0	4	6	10	7	-	-	-
44	M, 12 + 9	50	Duchenne musc. dystrophy	4	3	30	19	15	17	0	3	15	22	35	20	38	41
						37	11	11
Avg. for Duchenne musc. dystrophy‡‡	13 + 11	53
Major curves (n = 4)						64	16 (75)	14 (78)
Compensatory curves (n = 3)						33	17 (48)	13 (61)	22	1 (95)	2 (91)
45	F, 9 + 0n	29	Spinal musc. atrophy	4	3	46	10	18	35	10	10	19	30	38	-	-	-
						79	11	15
46	F, 23 + 9	60	Myopathy	1	1	55	20	15	-	-	-	-	-	-	94	49	39
47	M, 18 + 0	39	Nonfamilial dysautonomia	1	1	72	15	30	13	3	10	-	-	-	-	-	-

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: TABLE IIOperative and Outcome Data

Case	Additional Procedures	Est. Blood Loss (ml)		Durat. of Op. (mins.)		Durat. of Follow-up(mos.)	Satisfaction	Pseudarthrosis		Implant-Related Problems
Post. Proc.	Ant. Proc.	Post. Proc.	Ant. Proc.	Possible	Definite
1	No	500		410		68	Satis.	Yes		Rod and wire breakage
2	No	1250		392		72	Satis.
3	No	700		385		94	Satis.
4	No	800		465		43	Very satis.
5	No	750		475		47	Satis.
6	No	600		555		51	Very satis.
7	Ant. arthrod.	1200		510	365	40	Very satis.
8	No	1500		540		48	Very satis.
9	No	1000		400		98	Very satis.
10	No	350		420		38	Very satis.
11	No	800		375		35	Satis.
12	No	1800		470		51	Very satis.
13	No	850		510		50	Satis.
14	No	500		390		55	Very satis.
15	No	900		570		31	Satis.
16	No	1500		510		49	Satis.
17	Ant. arthrod.	1400	600	490	360	44	Neither satis. nor unsatis.
18	No	900		415		82	Neither satis. nor unsatis.
19	Eggshell osteot.	1000		660		38	Very satis.
20	No	1000		470		36	Very satis.
21	No	2500		435		30	Satis.
22	No	1500		450		24	Very satis.
23	No	4000		625		60	Very satis.	Yes		Rod breakage bilat.
24	No	900		410		36	Very satis.
25	No	1000		415		36	Satis.
26	No	2200		405		26	Satis.
27	No	1300		480		32	Satis.
28	No	600		480		32	Satis.
29	Eggshell osteot.	1400		555		27	Very satis.
30	No	1200		480		27	Very satis.
31	Eggshell osteot.	2500		540		26	Very satis.			Trans. connect. breakage
Avg. for cerebral palsy or cerebral palsy-like disease		1239	600	474	363	46
32	Post. interbody arthrod.; lipoma excision	1950		675		56	Satis.	Yes		Rod breakage bilat.; trans. connect. and wire breakage
33	Ant. arthrod. and detethering	1600		400	285	33	Very satis.			Trans. connect. and wire breakage
34	Ant. arthrod. and detethering	1800		370	340	60	Very satis.		Yes
35	Ant. arthrod. and detethering	300	850	555	420	49	Died from renal failure			Wire breakage
36	Ant. arthrod.	250	750	280	445	54	Very satis.
37	No	1100		540		24	Very satis.
38	No	250		375		32	Very satis.
39	Post. osteot.	1200		300		29	Satis.
40	Post. interbody arthrod. and osteot.	1700		680		60	Very satis.
Avg. for myelomeningocele		1128	800	464	373	44
41	No	1500		530		64	Very satis.
42	No	2150		370		48	Very satis.
43	No	2500		390		25	Satis.
44	No	3000		525		36	Satis.
Avg. for Duchenne musc. dystrophy		2288		454		43
45	No	500		375		100	Satis.
46	Ant. arthrod.	2500	900	500	310	28	Very satis.
47	Ant. arthrod. and post. osteot.	5000	250	780	395	69	Satis.

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: TABLE IIOperative and Outcome Data

Case	Additional Procedures	Est. Blood Loss (ml)		Durat. of Op. (mins.)		Durat. of Follow-up(mos.)	Satisfaction	Pseudarthrosis		Implant-Related Problems
Post. Proc.	Ant. Proc.	Post. Proc.	Ant. Proc.	Possible	Definite
1	No	500		410		68	Satis.	Yes		Rod and wire breakage
2	No	1250		392		72	Satis.
3	No	700		385		94	Satis.
4	No	800		465		43	Very satis.
5	No	750		475		47	Satis.
6	No	600		555		51	Very satis.
7	Ant. arthrod.	1200		510	365	40	Very satis.
8	No	1500		540		48	Very satis.
9	No	1000		400		98	Very satis.
10	No	350		420		38	Very satis.
11	No	800		375		35	Satis.
12	No	1800		470		51	Very satis.
13	No	850		510		50	Satis.
14	No	500		390		55	Very satis.
15	No	900		570		31	Satis.
16	No	1500		510		49	Satis.
17	Ant. arthrod.	1400	600	490	360	44	Neither satis. nor unsatis.
18	No	900		415		82	Neither satis. nor unsatis.
19	Eggshell osteot.	1000		660		38	Very satis.
20	No	1000		470		36	Very satis.
21	No	2500		435		30	Satis.
22	No	1500		450		24	Very satis.
23	No	4000		625		60	Very satis.	Yes		Rod breakage bilat.
24	No	900		410		36	Very satis.
25	No	1000		415		36	Satis.
26	No	2200		405		26	Satis.
27	No	1300		480		32	Satis.
28	No	600		480		32	Satis.
29	Eggshell osteot.	1400		555		27	Very satis.
30	No	1200		480		27	Very satis.
31	Eggshell osteot.	2500		540		26	Very satis.			Trans. connect. breakage
Avg. for cerebral palsy or cerebral palsy-like disease		1239	600	474	363	46
32	Post. interbody arthrod.; lipoma excision	1950		675		56	Satis.	Yes		Rod breakage bilat.; trans. connect. and wire breakage
33	Ant. arthrod. and detethering	1600		400	285	33	Very satis.			Trans. connect. and wire breakage
34	Ant. arthrod. and detethering	1800		370	340	60	Very satis.		Yes
35	Ant. arthrod. and detethering	300	850	555	420	49	Died from renal failure			Wire breakage
36	Ant. arthrod.	250	750	280	445	54	Very satis.
37	No	1100		540		24	Very satis.
38	No	250		375		32	Very satis.
39	Post. osteot.	1200		300		29	Satis.
40	Post. interbody arthrod. and osteot.	1700		680		60	Very satis.
Avg. for myelomeningocele		1128	800	464	373	44
41	No	1500		530		64	Very satis.
42	No	2150		370		48	Very satis.
43	No	2500		390		25	Satis.
44	No	3000		525		36	Satis.
Avg. for Duchenne musc. dystrophy		2288		454		43
45	No	500		375		100	Satis.
46	Ant. arthrod.	2500	900	500	310	28	Very satis.
47	Ant. arthrod. and post. osteot.	5000	250	780	395	69	Satis.

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: TABLE IIIComparison of Operative Series of Patients (Reported Since 1982) with Neuromuscular Spinal Deformity Managed with Instrumentation and Arthrodesis to the Pelvis and Followed for a Minimum of One Year

*NA = not available.Minimum duration of follow-up. The average duration was not reported.Skin graft to repair wound dehiscence.Â§Percent correction of preoperative curve at time of latest follow-up.#Calculated from the data in the study.**No patient in the study by Neustadt et al. had hyperlordosis.

	Study*
Maloney et al.⁵¹(1990)	Gau et al.³⁵(1991)	Neustadt et al.⁵⁴(1992)	Present Study
Type of instrumentation	Unit rod	Luque-Galveston	Cotrel-Dubousset	Isola-Galveston
No. of patients (M/F)	10 (7/3)	68 (40/28)	18 (7/11)	47 (23/24)
No. (percent) of patients who had neuropathic disorder	8	58 (85)	16	42 (89)
Avg. age (range) (yrs.+ mos.)	15 (8 to 19)	14 + 8 (9 to 38)	19 + 2 (NA)	14 + 3 (5 + 4 to 23 + 9)
No. (percent) of anterior procedures	9	20 (29)	8	8 (17)
Avg. duration of posterior procedures (mins.)	361	295	252	473
Avg. estimated blood loss during posterior procedures (ml)	2400	NA	1945	1324
Avg. hospital stay (days)	27	NA	14	16
No. (percent) of patients managed with bracing	NA	45 (66)	7	11 (23)
Avg. duration of follow-up (range) (mos.)	48 (19 to 60)	48	27 (24 to 40)	47 (24 to 100)
No. (percent) of patients who had deep wound infection	0	2 (3)	0	0
No. (percent) of patients who had delayed wound infection	0	NA	NA	1 (2)
No. (percent) of patients who had pseudarthrosis	0	7 (10)	0	4 (9)
No. (percent) of patients who had reoperation	1	5 (7)	1	5 (11)
Scoliosis
Avg. magnitude (preop./postop./latest follow-up) (degrees)	86/21/NA	73/NA/33	70/38/41	70/21/24
Avg. correction (percent)	76	55	41Â§	70/66
Pelvic obliquity
Avg. magnitude (preop./postop./latest follow-up) (degrees)	41/7/NA	17/NA/8	19#/12#/NA	27/6/5
Avg. correction (percent)	84	53	37	78/81
Avg. hyperlordosis (preop./postop./latest follow-up) (degrees)	NA	-102/NA/-59	**	-108/-52/-50

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	Study*
Maloney et al.⁵¹(1990)	Gau et al.³⁵(1991)	Neustadt et al.⁵⁴(1992)	Present Study
Type of instrumentation	Unit rod	Luque-Galveston	Cotrel-Dubousset	Isola-Galveston
No. of patients (M/F)	10 (7/3)	68 (40/28)	18 (7/11)	47 (23/24)
No. (percent) of patients who had neuropathic disorder	8	58 (85)	16	42 (89)
Avg. age (range) (yrs.+ mos.)	15 (8 to 19)	14 + 8 (9 to 38)	19 + 2 (NA)	14 + 3 (5 + 4 to 23 + 9)
No. (percent) of anterior procedures	9	20 (29)	8	8 (17)
Avg. duration of posterior procedures (mins.)	361	295	252	473
Avg. estimated blood loss during posterior procedures (ml)	2400	NA	1945	1324
Avg. hospital stay (days)	27	NA	14	16
No. (percent) of patients managed with bracing	NA	45 (66)	7	11 (23)
Avg. duration of follow-up (range) (mos.)	48 (19 to 60)	48	27 (24 to 40)	47 (24 to 100)
No. (percent) of patients who had deep wound infection	0	2 (3)	0	0
No. (percent) of patients who had delayed wound infection	0	NA	NA	1 (2)
No. (percent) of patients who had pseudarthrosis	0	7 (10)	0	4 (9)
No. (percent) of patients who had reoperation	1	5 (7)	1	5 (11)
Scoliosis
Avg. magnitude (preop./postop./latest follow-up) (degrees)	86/21/NA	73/NA/33	70/38/41	70/21/24
Avg. correction (percent)	76	55	41Â§	70/66
Pelvic obliquity
Avg. magnitude (preop./postop./latest follow-up) (degrees)	41/7/NA	17/NA/8	19#/12#/NA	27/6/5
Avg. correction (percent)	84	53	37	78/81
Avg. hyperlordosis (preop./postop./latest follow-up) (degrees)	NA	-102/NA/-59	**	-108/-52/-50

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

From March 1989 through February 1993, sixty-seven consecutive patients with a neuromuscular spinal deformity were treated surgically with Isola instrumentation. Twenty patients (30 percent) in whom the most caudad level of instrumentation and arthrodesis was cephalad to the pelvis were not included in this study. The remaining forty-seven patients (70 percent) who had Isola-Galveston instrumentation and arthrodesis performed by the senior author (M. A. A.) are the subject of this report.

The indication for the operation was either a deformity that had affected the ability to sit continuously, breathe, eat, remain comfortable, or maintain the integrity of the skin surface involved in sitting, or one that could be predicted, on the basis of the natural history of the disease, to progress to the point that these functions would be affected. The indications for extending the use of instrumentation into the pelvis were a structural deformity that extended into the pelvis or the likelihood of a future spinal and pelvic deformity.

The indications for an additional anterior procedure without instrumentation were hyperkyphosis or hyperlordosis that was not corrected on corrective cross-table lateral radiographs; absent posterior elements, as seen, for example, in patients who have myelomeningocele; or stiff scoliotic curves (those having both less than 25 percent flexibility and a residual curve of at least 35 degrees with bending), as determined with use of lateral-bending radiographs made with the patient supine. The principal contraindication to an anterior procedure was decreased pulmonary function that was of clinical concern, as seen mainly in patients who have Duchenne muscular dystrophy.

The hospital and office charts and radiographs of all patients were reviewed. The curves in the coronal and the sagittal plane (preoperatively, postoperatively, and at the time of the latest follow-up), the fusion status, and the complications were studied. Of the forty-seven patients, nine had incomplete data and were asked to return for a follow-up examination. No patient was lost to follow-up.

Walking ability and functional capacity were evaluated preoperatively and postoperatively according to the classification system of the Rancho Los Amigos Hospital³⁸, as modified by Lonstein and Akbarnia⁴⁴. Scoliosis, kyphosis, lordosis, and pelvic obliquity were measured on thirty-six-inch (ninety-one-centimeter) radiographs, made with the patient standing or sitting according to the functional status, before the operation, after the operation, and at the time of the latest follow-up. While recognizing that there are differences of opinion, we defined abnormal alignment in the sagittal plane as thoracolumbar kyphosis of any degree, thoracic hyperkyphosis of 55 degrees or more and hypokyphosis of 25 degrees or less, lumbar hyperlordosis of 70 degrees or more and hypolordosis of 25 degrees or less, and lumbar kyphosis (a positive angulation from the twelfth thoracic vertebra to the sacrum). Pelvic obliquity was determined as the angle between a horizontal line across the top of the pelvis to a right angle from a vertical gravity reference line passing through the first sacral vertebra. The patient was considered to have balance in the coronal plane when the first thoracic vertebra was laterally offset from the midsacral gravity reference line by twenty millimeters or less.

Preoperative anteroposterior right and left-side-bending radiographs were made with the patient supine and actively bending, if possible, or with the spine passively bent if active bending was not possible. To assess a deformity in the sagittal plane, a cross-table lateral radiograph was made with a bolster under the kyphosis apex (for hyperkyphosis) or with the patient in a tucked position with maximum flexion of the hips (for hyperlordosis).

Routine thirty-six-inch (ninety-one-centimeter) anteroposterior or posteroanterior and lateral radiographs were used to determine the success of the arthrodesis. Patients who had a visible pseudarthrosis line were considered to have a pseudarthrosis, and those who had implant breakage and a loss of correction of 11 degrees or more were considered to have a possible pseudarthrosis.

At the time of the latest follow-up, the width of a radiolucent space between the pelvic rod and the iliac bone (the windshield-wiper sign) was measured and graded. Grade 1 indicated that there was no radiolucent space; grade 2, that the space was less than one millimeter wide; grade 3, that it was one to two millimeters wide; and grade 4, that it was more than two millimeters wide.

The patient, parents who were actively involved in the care of the patient, and caregivers, or two or more of these individuals, were interviewed and asked to complete an outcome questionnaire indicating whether they considered the outcome of the surgery to be very satisfactory, satisfactory, neither satisfactory nor unsatisfactory, unsatisfactory, or very unsatisfactory.

Design of the Implant

Three principal design features unique to Isola instrumentation (DePuy AcroMed, Raynham, Massachusetts) are the deliberate integration of hooks and pedicle screws with wire anchors (defined as the spinal implant component that directly attaches to the spine); the v-groove, hollow-ground connections; and the slotted connectors. (The terminology related to the implant conforms to recently adopted standards of the American Society for Testing Materials⁴, with additional definitions supplied as needed. Also, during the period of the study, the screws that were available were bone screws. Since October 1998, they became available as pedicle screws, and the indications on the label include spondylolisthesis, scoliosis, fracture, dislocation, tumor, kyphosis, and a previously failed arthrodesis.)

Pedicle screws are more stable than sublaminar wires and may be used when posterior elements are absent⁵⁹. Screws and hooks also intrude into the canal less than wires do. Wires remain valuable anchors because they have a low profile, are adjustable, have a low cost, and lend themselves to segmental fixation. However, the integration of sublaminar wires into the construct is potentially dangerous because the hook blade may subluxate into the spinal canal when the wire is tightened⁶⁰. A feature of the design that addresses this danger is the variable throat-height hook, which allows a surgeon to choose the hook that most closely semicircles the part of the bone to which it is affixed. This feature allows 10 degrees of angulation when the set-screw is loose, thus easing placement (Fig. 1).

When multiple components are used, the connection sites between these components are heavily loaded if the implant system is intrinsically stable, and thus these sites are at risk for fretting corrosion. These connections must be as rigid as possible while retaining the smallest possible profile. Our response to this design need is the v-groove, hollow-ground connection. The rod is pushed by the set-screw into a space slightly smaller in diameter than the rod (Fig. 2-A), and a recess or hollow-ground area is placed in the center of the connector body to accommodate three-point contact in the sagittal plane (Fig. 2-B).

To enable a deformed spine to accommodate to an anatomically contoured rod, the slotted connector was developed (Fig. 3-A,Fig. 3-B,Fig. 3-C,Fig. 3-D,and Fig. 3-E). It allows for preliminary connection of the deformed spine to the anatomically contoured rod, manipulation of the spine to better align it with the rod, and accommodation (if necessary) for a mismatch of any residual spinal deformity to the anatomically contoured rod.

Operative Technique

The posterior surface of the spinous processes, laminae, facet joints, and transverse processes were carefully prepared for instrumentation and arthrodesis by thorough subperiosteal dissection with use of electrocautery and by removal of the capsule of the facet joint as well as removal of the interspinous ligament. Hook anchors generally were used in the thoracic spine; wire anchors, in the thoracolumbar spine; and screw anchors, in the lumbar spine. Following placement of the implant anchors, facet arthrodesis, decortication, and grafting were done before placement of the rod.

The underlying principle of realignment was to bring the deformed spine to the anatomically contoured rods. Because of the wide variety of deformity configurations, different instrumentation sequences were utilized^5,8,15. However, the basic principle determining the sequence depended on where the initial correcting load needed to be applied. For kyphotic (flexion) deformities, the initial corrective load was at the end of the deformity. This load was applied by means of a foundation, defined as an assembly of at least two anchors and one or two rods that is stable and strong enough to accept corrective loads and to resist deforming loads without dislodgment of the anchors or plastic deformation of the rod. Through application of a cantilever corrective load (that is, one that has support at one end) to the rod or rods, their unattached ends are brought to the anchorage at the opposite end. In the thoracic spine, hook claws, with one hook placed around the cephalad surface of the transverse process and the other around the caudad edge of the inferior facet process, fail at about 350 newtons in osteoporotic human specimens²². Thoracic foundations consisting of instrumentation spanning four vertebral levels could be expected to withstand a posterior translation load of approximately 1300 newtons (292 pounds) before failing. Intrailiac posts have been shown to provide strong, if not the strongest, fixation to the pelvis^23,48. A pelvic foundation consisting of two intrailiac post anchors and two screw anchors in the first sacral vertebra withstands a load of 150 to 200 newton-meters (111 to 148 pound-feet) before failing in an experimental model⁴⁸.

To increase the stability and strength of the construct, a transverse connection was added, near the ends of the construct, as the construct was developed^6,40 (Fig. 4-A and Fig. 4-B).

For hyperlordotic or hypokyphotic (extension) deformities, a posterior apex translational load was applied first, and the sequence began on the concave side of the scoliosis.

When double scoliosis was the principal deformity (Fig. 5-A,Fig. 5-B,Fig. 5-C, and Fig. 5-D), the instrumentation sequence was initiated on the convex side of the thoracolumbar curve, similar to the sequence used for double idiopathic scoliosis. Instrumentation was then added on the concave side, with the cephalad rod connected side-to-side to the intrailiac post (Galveston) anchorage. The thoracolumbar apex vertebrae were then translated with sublaminar wires to this concave rod. The convex intrailiac post was then added, connecting the rod portion to the caudad end of the convex longitudinal rod and applying compression as necessary to level the pelvis. Finally, the concave overlapping rods were distracted as necessary to complete pelvic leveling.

Prophylaxis against infection included intravenous administration of an antibody and wound management. Twenty-five milligrams of cefazolin per kilogram of body weight was given intravenously after the induction of the anesthesia, and this was followed by intravenous administration of the same dose over the first one to three hours of the procedure. A repeat dose was given every six hours for twenty-four to forty-eight hours. Wound management included frequent irrigation with saline solution, soft-tissue dè¡²idement as necessary, and irrigation before closure with one to three liters of saline solution with 300,000 units of bacitracin and 1,200,000 units of polymyxin B sulfate. Twenty-nine patients had a subcutaneous Hemovac drain placed in the wound because a fluid-tight, deep fascial closure could not be achieved.

Study Group

All patients were examined, and the clinical records, including radiographs, were reviewed at an average of forty-seven months (range, twenty-four to 100 months) postoperatively (Table I and Table II).

Thirty-one patients had cerebral palsy or cerebral palsy-like upper-motor-neuron disease; nine, myelomeningocele; four, Duchenne muscular dystrophy; and one each, myopathy, nonfamilial dysautonomia, and spinal muscular atrophy. Of the thirty-one patients with cerebral palsy, seven (Cases 1, 8, 13, 16, 17, 19, and 21) were profoundly retarded and were institutionalized. Four patients (Cases 30, 39, 40, and 47) had had an average of two previous instrumentation procedures.

The average age at the time of the operation was fourteen years and three months (range, five years and four months to twenty-three years and nine months), and the average weight was thirty-three kilograms (range, seventeen to sixty-eight kilograms).

Thirty-nine of the forty-seven patients had posterior instrumentation and arthrodesis only, and eight also had anterior arthrodesis without instrumentation. Five procedures (Cases 17, 35, 36, 46, and 47) were staged, and three (Cases 7, 33, and 34) were sequential; the indication for staging was an anterior, posterior, or anterior and posterior procedure that was anticipated to be of long duration. The indications for an anterior procedure were lumbar hyperlordosis in three patients (Cases 17, 36, and 46), congenitally absent posterior elements at many levels in two (Cases 33 and 34), stiff scoliosis in two (Cases 7 and 47), and thoracolumbar hyperkyphosis in one (Case 35). One patient (Case 47) had had multiple previous arthrodeses of the spine. Neither pelvic obliquity nor the magnitude of truncal imbalance, in and of itself, was considered to be an indication for an additional anterior procedure. In the eight patients who had anterior discectomy and arthrodesis, an average of six vertebral segments (range, four to nine vertebral segments), usually the apex disc space and the two cephalad and two caudad disc spaces, were arthrodesed anteriorly. At the time of the posterior instrumentation and arthrodesis, three patients (Cases 33, 34, and 35) of the eight who had anterior arthrodesis without instrumentation also had release of the tethered spinal cord.

Six of the thirty-nine patients who had posterior instrumentation and arthrodesis that was not combined with anterior arthrodesis without instrumentation had supplemental sequential procedures. Four procedures were for realignment and included a posterior osteotomy in one patient (Case 39) and a decancellation eggshell osteotomy^25,45,68 in three (Cases 19, 29, and 31). The indication for this alternative supplemental anterior procedure without instrumentation was a kyphotic (flexion) deformity confined to a few segments. Two patients (Cases 32 and 40), who both had myelomeningocele, had transforaminal interbody arthrodesis, and one (Case 32) had excision of a lipoma as well.

Seven patients were functional ambulators; two of them were classified as community ambulators and five, as household ambulators. The indications for instrumentation into the pelvis were hyperlordosis in three patients (Cases 26, 36, and 46), pelvic obliquity in three (Cases 22, 28, and 47), and pelvic flexion and obliquity in one (Case 35).

An average of sixteen vertebral segments (range, eleven to eighteen vertebral segments) were arthrodesed posteriorly. In forty-six patients, freeze-dried corticocancellous or cancellous allograft (American Red Cross, Tulsa, Oklahoma, or Osteotech, Shrewsbury, New Jersey) was used⁷⁰. Additional autograft was used in five of these patients: bone resulting from the osteotomy was used in three patients (Cases 19, 40, and 47) and bone obtained from the posterior iliac crest was used in two patients (Cases 32 and 37) with myelomeningocele who had a posterior procedure only. In one patient (Case 39), ample autograft bone was available following kyphectomy. Thirty-four patients had insertion of 6.35-millimeter rods; nine patients, 4.76-millimeter rods; and four patients, a combination of the two sizes. A combination of rods was inserted in the patients who were not large enough to accommodate two 6.35-millimeter rods.

For the thirty-nine patients who had a posterior procedure only, the average duration of the operation was 473 minutes (range, 300 to 680 minutes) and the average estimated blood loss was 1324 milliliters (range, 250 to 4000 milliliters). For the five patients (Cases 17, 35, 36, 46, and 47) who had a staged procedure, the average duration of the anterior procedure was 386 minutes (range, 310 to 445 minutes) and that of the posterior procedure was 521 minutes (range, 280 to 780 minutes). The average estimated blood loss was 670 milliliters (range, 250 to 900 milliliters) for the anterior procedure and 1890 milliliters (range, 250 to 5000 milliliters) for the posterior procedure. For the three patients (Cases 7, 33, and 34) who had a sequential procedure, the average duration of the anterior procedure was 330 minutes (285, 340, and 365 minutes) and that of the posterior procedure was 427 minutes (370, 400, and 510 minutes). The estimated blood loss for the entire sequential procedure was 1533 milliliters (1200, 1600, and 1800 milliliters).

The average postoperative hospital stay was thirteen days (range, five to thirty-one days) for the thirty-nine patients who had a posterior procedure only, twenty-four days (range, sixteen to thirty days) for the five patients who had a staged procedure, and twenty-three days (thirteen, fourteen, and forty-two days) for the three patients who had a sequential prodecure.

Eleven patients were managed with postoperative bracing. Nine of them had the operation in the first half of the series (1989 through 1990). The use of postoperative bracing did not prevent the occurrence of pseudarthrosis or possible pseudarthrosis in two patients. Bracing was used initially as a precaution, but the practice was discontinued as we gained experience and confidence with the techniques. The patients were all returned to their preoperative functional status, with respect to sitting or walking, while still in the hospital.

Results

Introduction | Materials and Methods | Results | Discussion | References

Safety of the Procedure

To determine the safety of the procedure, we studied the complications.

Reoperation

Five patients (11 percent) had a reoperation: three patients had one reoperation and two patients had two reoperations, as will be described.

Deaths

There were no deaths in the perioperative or postoperative period related to the spine surgery. One patient (Case 35) who had myelomeningocele died from acute renal failure four years after surgical treatment.

Neurological Complications

There were no major neurological deficits. Neurapraxia of the fifth lumbar nerve developed in one patient (Case 47), who had nonfamilial dysautonomia; the neurapraxia was completely resolved five months postoperatively.

Infection

No patient had an acute deep wound infection. Two patients had a superficial wound infection that resolved without additional sequelae after local wound care and treatment with antibiotics.

A delayed deep wound infection developed in one patient (Case 47), who had nonfamilial dysautonomia, at thirty-four months postoperatively. He had had two prior attempts at instrumentation and arthrodesis. Cultures of tissue revealed light growth of coagulase-negative Staphylococcus and Propionibacterium. The infection initially responded to soft-tissue dè¡²idement, removal of one bypass connector, and intravenous administration of one gram of vancomycin every twelve hours for four weeks followed by 500 milligrams of amoxicillin administered orally every four hours for two months. Salvage of the implant was attempted because of the known tendency of the deformity to increase. However, drainage recurred, and complete removal of the implant and dè¡²idement was performed thirty-eight months postoperatively. The fusion was solid. Intraoperative culture revealed coagulase-negative Staphylococcus. Postoperatively, the patient received 160 milligrams of trimethoprim and 800 milligrams of sulfamethoxazole orally every four hours for four months. This choice of antibiotic was influenced by social factors, including the fact that the patient lived in a group home in a small town that was remote from his family. The wound healed per primam, but it broke down at one site nineteen weeks postoperatively. At the time of the latest follow-up (five years and nine months after the Isola-Galveston procedures and two years and nine months after removal of the implant), the wound had healed without sign of infection and the spine remained fused. The standing imbalance had increased because of progressive dislocation of the right hip.

Pseudarthrosis

A definite pseudarthrosis developed in one patient (Case 34) with myelomeningocele who had been treated for kyphoscoliosis with a sequential anterior arthrodesis from the first lumbar vertebra to the sacrum and with posterior Isola-Galveston instrumentation and arthrodesis to the third thoracic vertebra with use of allograft. Spinous-process button-wires were used at the top of the instrumentation. Although no breakage of the implant occurred, pseudarthrosis and hyperkyphosis developed cephalad to the site of the anterior arthrodesis. A revision, involving the placement of a hook-and-wire-based cantilever foundation cephalad and an arthrodesis, was performed eleven months postoperatively. The outcome was found to be successful at ninety-six months after the revision.

Three patients had a possible pseudarthrosis. One patient (Case 1) with cerebral palsy-like disease lost 25 degrees of the correction of the scoliosis and 8 degrees of the correction of the pelvic obliquity and had unilateral rod and wire breakage. This patient had not had an anterior procedure with the index operation. The clinical outcome at sixty-eight months after the procedure was satisfactory, and revision was not necessary. Another patient (Case 32), with myelomeningocele, lost 10 degrees of the correction of the scoliosis and 11 degrees of the correction of the pelvic obliquity. She had had posterior interbody arthrodesis of the fourth and fifth lumbar vertebrae with nonstructural autograft with the index operation. There was bilateral rod, caudad transverse connector, and wire breakage. The patient did not complain about her back, and she and her parents rated the outcome of the operation as satisfactory at fifty-six months postoperatively. In the third patient (Case 23), a twenty-year-old man with Pelizaeus-Merzbacher syndrome, both 6.35-millimeter rods broke between sixteen and thirty-four months after the procedure, and the scoliotic curves increased 27 degrees (from 67 to 94 degrees) and 10 degrees (from 81 to 91 degrees). He had no pain, and he and his mother, who was also his caregiver, rated the outcome of his operation as very satisfactory. Allograft alone had been used in two patients (Cases 1 and 23), who had a possible pseudarthrosis, and a combination of autograft and allograft had been used in one (Case 32). None required revision.

Definite or possible pseudarthrosis developed in three of the nine patients in whom 4.76-millimeter rods had been used bilaterally, and possible pseudarthrosis developed in one (3 percent) of the thirty-four patients in whom 6.35-millimeter rods had been used bilaterally. Thus, the rate of definite or possible pseudarthrosis in the group that had the 4.76-millimeter rods was much higher than that in the group with the 6.35-millimeter rods.

Implant-Related Complications

Perioperatively, the distal tip of the iliac post protruded posteriorly from the ilium in one patient (Case 42). During the postoperative period, the iliac post cut out of the ilium in one patient (Case 47). Neither implant needed to be revised because of the breakage.

Implant breakage occurred in six patients. Rod breakage was detected bilaterally in two patients (Cases 23 and 32) and unilaterally in one (Case 1). Sublaminar wires broke in four patients, and transverse connectors broke in three. No pedicle screws broke.

Five patients needed revision of the implant. In addition to the three patients (Cases 34, 41, and 47) already described, two patients (Cases 2 and 18) had partial removal of the implant because its cephalad portion had become prominent. In both patients, spinous-process wires had been used for anchorage at the cephalad end vertebra.

Six patients previously had had a pelvic procedure, either a pelvic osteotomy for the treatment of hip dysplasia or the harvesting of bone graft from the posterior iliac crest. Two patients subsequently had a pelvic osteotomy for the treatment of hip dysplasia after the index procedure. No difficulties were encountered during either the placement of the Galveston anchor or the pelvic osteotomy.

Increase in the Deformity

Postoperatively, the kyphosis was increased 10 degrees or more in seven patients. Five of them (Cases 1, 8, 32, 34, and 35) had spinous-process wire anchors only at the cephalad vertebra with instrumentation, one (Case 4) had down-going transverse-process hooks only, and one (Case 37), who had myelomeningocele and hip extension contractures, had instrumentation that stopped at the seventh thoracic vertebra.

At least 11 degrees of the correction of either the scoliosis or the pelvic obliquity was lost in four patients despite solid posterior fusion and no rod breakage. The crankshaft phenomenon³¹, defined as growth of the anterior column following fusion of the posterior column, occurred in two patients: one (Case 9), a five-year-old boy with cerebral palsy, had an increase in pelvic obliquity from 7 degrees postoperatively to 25 degrees at eight years and two months after the operation, and the other (Case 3), a twelve-year-old girl with cerebral palsy-like disease, had an increase in pelvic obliquity from +10 degrees postoperatively to -4 degrees at seven years and ten months. Neither patient had any pedicle screws in the construct. The third patient (Case 5), a seventeen-year-old boy with cerebral palsy-like disease, had residual scoliosis of 68 degrees that progressed to 87 degrees during a period of three years and eleven months. He also did not have anchorage with pedicle screws. The fourth patient (Case 47), an eighteen-year-old boy with nonfamilial dysautonomia who had had two previous failed operations, had progression of scoliosis from 15 degrees postoperatively to 30 degrees at five years and nine months despite anterior fusion, pedicle-screw fixation posteriorly, and proven solid fusion at the time that the implant was removed because of a delayed deep wound infection.

Windshield-Wiper Sign

At the time of the latest follow-up, the average grade for the windshield-wiper sign was 2.5. The windshield-wiper sign did not appear to be influenced by time, as it was grade 3.1 at less than thirty-six months and grade 2.1 at greater than thirty-six months of follow-up; by the ability to walk, as it was grade 3.1 for patients who could walk and grade 2.3 for patients who could not walk; by the type of intrailiac anchors, as it was grade 2.5 for patients who had the posts and grade 2.7 for those who had screws; or by the use of sacral screws, as it was grade 2.4 for those managed without a sacral screw or screws and grade 3.3 for those managed with sacral screws.

Medical Complications

Nine patients who had had only a posterior procedure had pulmonary problems, including pulmonary edema, atelectasis, pneumonia, pneumothorax, tracheitis, and pleural effusion, which prolonged their postoperative stay by an average of nine days. Two of them (Cases 43 and 44) had Duchenne muscular dystrophy, and seven (Cases 2, 8, 11, 14, 18, 21, and 24) had cerebral palsy-like disease. Two patients (Cases 18 and 24) required a tracheostomy, which was permanent in one of them (Case 18). One patient (Case 7) who had a sequential procedure had pneumonia, mucus plugging, and pancreatitis, which prolonged his stay.

Efficacy of the Procedure

Preoperatively, forty-five of the patients had a major (larger) scoliotic curve of at least 30 degrees, and the average preoperative magnitude of the major scoliotic curve in the series as a whole was 70 degrees (range, 30 to 139 degrees). The curves were corrected to an average of 21 degrees (range, 0 to 81 degrees) postoperatively (average correction, 70 percent), and the average correction was maintained at 24 degrees (range, 0 to 91 degrees) at the time of the latest follow-up (average correction, 66 percent).

Seventeen patients had a compensatory (additional), scoliosis of 30 degrees or greater preoperatively. The average preoperative compensatory scoliosis was 49 degrees (range, 30 to 115 degrees), and the curves were corrected to an average of 21 degrees (range, 0 to 68 degrees) postoperatively (average correction, 57 percent). The correction was maintained at an average of 24 degrees (range, 0 to 94 degrees) at the time of the latest follow-up (average correction, 51 percent).

Forty-one patients had a pelvic obliquity of greater than 10 degrees preoperatively. The pelvic obliquity averaged 27 degrees (range, 11 to 48 degrees) preoperatively and 6 degrees (range, 0 to 24 degrees) postoperatively, which was an average correction of 78 percent. At the time of the latest follow-up, the average pelvic obliquity was 5 degrees (range, 0 to 26 degrees), an average correction of 81 percent.

In the coronal plane, the average preoperative spinal balance (that is, the amount by which the first thoracic vertebra was offset laterally from the midsacral gravity line) was forty-two millimeters (range, zero to 188 millimeters). The spinal balance averaged eighteen millimeters (range, zero to seventy-eight millimeters) postoperatively and thirty millimeters (range, zero to 130 millimeters) at the time of the latest follow-up. Twenty-two of the thirty-four patients in whom the spine was off-balance by more than twenty millimeters preoperatively had balance in the coronal plane after the operation, and three patients who had spinal balance preoperatively did not have balance postoperatively.

Thirty-four patients had a total of forty-one deformities in the sagittal plane: two patients (Cases 13 and 39) had a pure deformity in the sagittal plane, and thirty-two had a complex three-planar deformity. Of the thirty-four patients, seven (Cases 4, 9, 10, 19, 29, 31, and 35) had thoracolumbar junction kyphosis, which averaged 76 degrees (range, 34 to 116 degrees) preoperatively. Postoperatively, the thoracic kyphosis averaged 39 degrees (range, 22 to 58 degrees) and the lumbar lordosis averaged 44 degrees (range, 36 to 54 degrees). At the latest follow-up examination, the thoracic kyphosis averaged 45 degrees (range, 12 to 71 degrees) and the lumbar lordosis averaged 44 degrees (range, 20 to 70 degrees).

Twelve patients (Cases 3, 7, 17, 30, 32, 33, 36, 41, 42, 43, 44, and 45) had thoracic hypokyphosis, which averaged 13 degrees (range, 0 to 24 degrees) preoperatively, 25 degrees (range, 10 to 38 degrees) postoperatively, and 29 degrees (range, 7 to 56 degrees) at the time of the latest follow-up.

Eleven patients (Cases 2, 6, 8, 13, 14, 15, 16, 22, 24, 34, and 40) had an average thoracic hyperkyphosis deformity of 78 degrees (range, 61 to 120 degrees) preoperatively, which was corrected to 49 degrees (range, 26 to 63 degrees) postoperatively and was an average of 50 degrees (range, 20 to 75 degrees) at the time of the latest follow-up.

Five patients (Cases 16, 17, 26, 36, and 46) had an average lumbar hyperlordosis deformity of 108 degrees (range, 80 to 127 degrees) preoperatively, which was corrected to 52 degrees (range, 40 to 65 degrees) of lordosis postoperatively and was an average of 50 degrees (range, 39 to 64 degrees) of lordosis at the latest follow-up evaluation.

Five patients (Cases 1, 7, 33, 41, and 44) who had a lumbar hypolordosis deformity (average, 14 degrees; range, 8 to 23 degrees) preoperatively had an average of 48 degrees (range, 38 to 56 degrees) of lordosis postoperatively and 48 degrees (range, 34 to 57 degrees) of lordosis at the latest follow-up examination.

One patient (Case 39) had a lumbar kyphosis of 78 degrees preoperatively, which corrected to 20 degrees postoperatively and was 15 degrees at the time of the latest follow-up.

Satisfaction of the Patient, Parents, or Caregivers

The questionnaire was completed for forty-six of the forty-seven patients, either by the patients themselves or by actively involved parents or caregivers. One patient died from acute renal failure four years after the procedure. The outcome was rated as very satisfactory for twenty-five patients, satisfactory for nineteen, and neither satisfactory nor unsatisfactory for two. Thus, 96 percent of the patients (or their parents or caregivers) were very satisfied or satisfied, and there were no unsatisfied or very unsatisfied ratings.

Preoperatively, thirty-nine patients were classified, according to the system of the Rancho Los Amigos Hospital³⁸ as modified by Lonstein and Akbarnia⁴⁴, as dependent sitters; one, as an independent sitter; five, as household or physical therapy ambulators; and two, as community ambulators. Postoperatively, no patient experienced functional loss.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The present study was conducted to determine whether the Isola-Galveston system was at least as safe and effective as other implant systems in the treatment of neuromuscular spinal deformities of various etiologies that require instrumentation and arthrodesis of the pelvis.

Our results were compared with those of series published since 1982, when Luque-Galveston instrumentation was introduced¹. To be included in the comparison, the series had to be limited to patients who had neuromuscular disorders involving various etiologies, had arthrodesis to the pelvis, and had been followed for a minimum of one year. Three investigations met these criteria: one study (sixty-eight patients) involved Luque-Galveston instrumentation³⁵, one (ten patients) involved the unit-rod modification of Luque-Galveston instrumentation⁵¹, and one (eighteen patients) involved Cotrel-Dubousset instrumentation⁵⁴ (Table III). Many studies were reviewed but did not meet the inclusion criteria^{12,13,17,20,29,32,33,36,49,55,56,63}.

With respect to safety, we found that the major complications in the three series were comparable and the rate of complications was low. The number of reoperations was slightly higher for the Isola-Galveston instrumentation, with a rate of 11 percent (five of forty-seven) compared with one of ten, 7 percent (five of sixty-eight), and one of eighteen for the others. Two of the five reoperations in the present series were performed because the cephalad part of the implant had become prominent, in patients in whom the spinous-process wires had been used as the cephalad anchors. We now know that spinous-process wires are not reliable anchors for the top of these constructs.

An anterior procedure was used less frequently in the group that had Isola-Galveston instrumentation, but the posterior procedure took longer. This could be a reflection of several factors, including the placement of more anchors, the performance of the procedure on the anterior aspect of the spinal vertebra by means of a transpedicular approach, the learning curve associated with the evolution of the system, and an inherently slow primary surgeon. Even so, blood loss from the posterior procedure was less in the Isola-Galveston group, and the hospital stay was similar to that in the other series. Although we would never deny the benefits of an anterior procedure when needed, it does add to the overall complexity of the treatment experience^31,33,37,52.

With respect to the efficacy of the procedure, we found that the average 66 percent correction of the scoliosis (46 degrees [amount of correction] divided by 70 degrees [average preoperative scoliosis]) in the Isola-Galveston group was better than the correction in either of the comparable series for which follow-up data were provided; the average correction was 55 percent (40 degrees divided by 73 degrees) for the group that had Luque-Galveston instrumentation and 41 percent (29 degrees divided by 70 degrees) for the group that had Cotrel-Dubousset instrumentation. The percent correction, in and of itself, is probably not as important as the magnitude of the residual curve. However, to justify an operation for most patients with a neuromuscular spinal deformity, with the exception of those who have Duchenne muscular dystrophy, curves are usually at least 60 degrees at the time of the procedure. On the basis of experimental⁴⁰ and clinical⁶² studies, it appears that the postoperative curve should be less than approximately 35 degrees in order to reliably prevent progression.

The correction of pelvic obliquity was much better in the present series than in the series involving Cotrel-Dubousset or Luque-Galveston instrumentation, and it was comparable with that in the series involving unit-rod instrumentation, in which nine of the ten patients had an anterior procedure. Furthermore, the correction of the pelvic obliquity was maintained over time. A study by Drummond et al. on the distribution of sitting-surface pressure in paraplegic patients showed higher-than-normal pressures associated with unbalanced scoliosis, pelvic obliquity, and loss of physiological lordosis³⁰. They concluded that pelvic obliquity should be completely corrected and ample lordosis should be retained at the time of spinal arthrodesis.

Correction of hyperlordosis in the present investigation was comparable with the correction in the series involving the Luque-Galveston instrumentation³⁵; the other two series apparently did not include patients who had hyperlordosis, a condition that we and others¹⁴ believe is particularly difficult to correct.

The 9 percent combined occurrence of definite and possible pseudarthrosis is comparable with that in the other series, in which rates of 0, 0, and 10 percent were reported. Pseudarthrosis appeared to be associated with three-sixteenth-inch (4.76-millimeter) rods, and we recommend that bilateral quarter-inch (6.35-millimeter) rods be used whenever possible, which is almost always the case. A factor that should not be forgotten is the underlying importance of a thorough arthrodesis technique, including exposure, decortication, and ample bone graft. There is now ample support for the use of allograft in arthrodeses for neuromuscular spinal deformity^17,47,53,70.

With respect to the construct, we had no mechanical problems with the caudad foundation, which always included bilateral intrailiac posts. We had some mechanical problems with the cephalad fixation, anchors, or foundation.

The kyphosis increased at least 10 degrees postoperatively in ten patients, and the reasons for the increase were clear in eight. Spinous-process wires had been used at the cephalad end in five patients, only down-going transverse-process hooks had been used in two patients, and the instrumentation stopped at the seventh thoracic vertebra in one patient with increased preoperative kyphosis and hip extension contractures. On the basis of this experience, as well as our experiment showing that either intrasegmental transverse process-facet or transverse process-pedicle hook claws are stiffer than sublaminar wires²², we recommend at least one intrasegmental hook-claw for the cephalad foundation. Virtually all patients with a neuromuscular spinal deformity should have an arthrodesis that extends at least to the third thoracic vertebra and preferably to the second^18,35. An exception is a patient with myelomeningocele who has hypokyphosis.

A loss of correction of a scoliotic curve or pelvic obliquity of 11 degrees or more was encountered in four patients; the loss was most likely related to the crankshaft phenomenon in two of them. Neither patient had pedicle screws in the constructs. We now recommend that at least two pedicle screws be included in the lumbar portion of these constructs, as recent experimental⁴² and clinical²¹ data have suggested that the crankshaft mechanism can be prevented with use of pedicle-screw anchorage.

The delayed deep wound infection and the delayed sterile drainage in our series raised a possible concern about the construct. Comparable series did not include data on the presence or absence of these complications. Delayed deep wound infection⁵⁸ and sterile drainage⁶⁹ have been reported with more complex implant systems. However, in one study, Kaplan-Meier analysis at six years did not reveal any substantial differences in the prevalence of these complications among Harrington, Cotrel-Dubousset, and Isola instrumentation in patients who had idiopathic scoliosis²⁷. Nevertheless, we believe that fretting corrosion is a concern, albeit a small one, and we recognize that the connections must be as strong as possible by design and usage and that the assemblage of the constructs must be performed with as little disruption to the oxide coating as possible.

A common concern about the Galveston procedure is the bridging of the sacroiliac joints with instrumentation, particularly in patients who are able to walk. In this series, none of the seven patients who could walk preoperatively had impairment of walking during the follow-up period. No intrailiac posts or screws were removed because of pain. This finding confirms our belief and that shared by others that the pelvis should be included in the arthrodesis if there is a deformity or instability and that the intrailiac posts do not result in long-term sacroiliac problems⁶¹. Our experience has shown that as long as normal alignment is obtained in the sagittal plane, walking is not impaired.

We recommend that, during application of the instrumentation, the sacroiliac joints be stabilized through mild compression of the joint, thereby further approximating the interdigitating surface undulations of the sacroiliac joints. Introduction of joint-deforming loads, in particular distraction and rotation, should be avoided.

The windshield-wiper sign is not thought to be related to implant failure or pseudarthrosis and, if anything, it decreases after solid fusion occurs, thereby decreasing lumbosacral motion³⁵. Our findings confirmed this observation. Use of posts or screws as intrailiac implants did not seem to affect the grade of radiolucency.

Finally, a successful outcome of an operation for spinal deformity secondary to neuromuscular disease is considered to be beneficial by most patients or their principal caregivers^9,26,43. An exception may be a profoundly retarded, institutionalized patient with cerebral palsy⁴¹, but even such patients are probably more comfortable²⁴. Furthermore, the degree of a deformity is associated with functional decline and occurrence of decubiti⁵⁰.

In conclusion, we believe that Isola-Galveston instrumentation can be used as safely and effectively as other instrumentation. In addition, it is probably more effective for the correction of pelvic obliquity and the maintenance of correction than are other types of instrumentation for patients in whom only a posterior approach is used.

References

Introduction | Materials and Methods | Results | Discussion | References

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Luque, E. R., and Cardoso, A.: Treatment of scoliosis without arthrodesis or external support, preliminary report. Orthop. Trans., 1: 37-38, 1977.

McCarthy, R. E.; Peek, R. D.; Morrissy, R. T.; and Hough, A. J.: Allograft bone in spinal fusion for paralytic scoliosis. J Bone Joint Surg, 68-A: 370-375, March 1986.

McCord, D. H.; Cunningham, B. W.; Shono, Y.; Myers, J. J.; and McAfee, P. C.: Biomechanical analysis of lumbosacral fixation. Spine, 17(8S): S235-S243, 1992.

McMaster, M. J.: Anterior and posterior instrumentation and fusion of thoracolumbar scoliosis due to myelomeningocele. J Bone Joint Surg, 69-B(1): 20-25, 1987.

Majd, M. E.; Muldowny, D. S.; and Holt, R. T.: Natural history of scoliosis in the institutionalized adult cerebral palsy population. Spine, 22: 1461-1466, 1997.

Maloney, W. J.; Rinsky, L. A.; and Gamble, J. G.: Simultaneous correction of pelvic obliquity, frontal plane, and sagittal plane deformities in neuromuscular scoliosis using a unit rod with segmental sublaminar wires: a preliminary report. J. Pediat. Orthop., 10: 742-749, 1990.

Miller, A.; Temple, T.; and Miller, F.: Impact of orthoses on the rate of scoliosis progression in children with cerebral palsy. J. Pediat. Orthop., 16: 332-335, 1996.

Montgomery, D. M.; Aronson, D. D.; Lee, C. L.; and LaMont, R. L.: Posterior spinal fusion: allograft versus autograft bone. J. Spinal Disord., 3: 370-375, 1990.

Neustadt, J. B.; Shufflebarger, H. L.; and Cammisa, F. P.: Spinal fusions to the pelvis augmented by Cotrel-Dubousset instrumentation for neuromuscular scoliosis. J. Pediat. Orthop., 12: 465-469, 1992.

O'Brien, T.; Akmakjian, J.; Ogin, G.; and Eilert, R.: Comparison of one-stage versus two-stage anterior/posterior spinal fusion for neuromuscular scoliosis. J. Pediat. Orthop., 12: 610-615, 1992.

Rawlins, B. A.; Winter, R. B.; Lonstein, J. E.; Denis, F.; Kubic, P. T.; Wheeler, W. B.; and Ozolins, A. L.: Reconstructive spine surgery in pediatric patients with major loss in vital capacity. J. Pediat. Orthop., 16: 284-292, 1996.

Renshaw et al. [sic]: Severe scoliosis in cerebral palsy - a comparison of operative and nonoperative treatment. In Meeting Highlights of the First Annual Scientific Meeting, Australian Paediatric Orthopaedic Society. Sydney, Australia, August 1-2, 1992. J. Pediat. Orthop., 13: 412, 1993.

Richards, B. S.: Delayed infections following posterior spinal instrumentation for the treatment of idiopathic scoliosis. J Bone Joint Surg, 77-A: 524-529, April 1995.

Rodgers, W. B.; Williams, M. S.; Schwend, R. M.; and Emans, J. B.: Spinal deformity in myelodysplasia. Correction with posterior pedicle screw instrumentation. Spine, 22: 2435-2443, 1997.

Rossier, A. B., and Cochran, T. P.: The treatment of spinal fractures with Harrington compression rods and segmental sublaminar wiring. A dangerous combination. Spine, 9: 796-799, 1984.

Saer, E. H., III; Winter, R. B.; and Lonstein, J. E.: Long scoliosis fusion to the sacrum in adults with nonparalytic scoliosis. An improved method. Spine, 15: 650-653, 1990.

Sanders, J. O.; Evert, M.; Stanley, E. A.; and Sanders, A. E.: Mechanisms of curve progression following sublaminar (Luque) spinal instrumentation. Spine, 17: 781-789, 1992.

Sponseller, P. D.; Whiffen, J. R.; and Drummond, D. S.: Interspinous process segmental spinal instrumentation for scoliosis in cerebral palsy. J. Pediat. Orthop., 6: 559-563, 1986.

Sullivan, J. A., and Conner, S. B.: Comparison of Harrington instrumentation and segmental spinal instrumentation in the management of neuromuscular spinal deformity. Spine, 7: 299-304, 1982.

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Swank, S. K.; Cohen, D. S.; and Brown, J. C.: Spine fusion in cerebral palsy with L-rod segmental spinal instrumentation. A comparison of single and two-stage combined approach with Zielke instrumentation. Spine, 14: 750-759, 1989.

Taddonio, R. F.: Segmental spinal instrumentation in the management of neuromuscular spinal deformity. Spine, 7: 305-311, 1982.

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Wimmer, C., and Gluch, H.: Aseptic loosening after CD instrumentation in the treatment of scoliosis: a report about eight cases. J. Spinal Disord., 11: 440-443, 1998.

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Fig. 2-B::

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Fig. 3-B:: Anteroposterior translation.

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Fig. 3-C:: Coronal plane angulation.

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Fig. 3-D:: Sagittal plane angulation.

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Fig. 3-E:: Transverse plane angulation.

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Fig. 4-B: Anteroposterior radiograph, made at four years and three months postoperatively with the patient sitting, showing maintenance of the correction.

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Fig. 5-B::

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Fig. 5-D::

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: TABLE IData on the Patients

Case	Gender, Age(yrs. + mos.)	Weight(kg)	Diagnosis	Ambulatory Status* (grade)		Scoliosis† (degrees)			Pelvic Obliquity (degrees)			Abnormal Kyphosis (degrees)			Abnormal Lordosis (degrees)
Preop.	Postop.	Preop.	Postop.	Latest Follow-up	Preop.‡	Postop.	Latest Follow-up	Preop.§	Postop.	Latest Follow-up	Preop.	Postop.	Latest Follow-up
1	F, 12 + 6	31	Cerebral palsy-like dis.	4	3	80	20	45	17	6	14	-	-	-	10	56	55
2	F, 9 + 0	19	Cerebral palsy-like dis.	4	3	70	15	21	29	0	0	70	60	40	-	-	-
3	F, 12 + 2	18	Cerebral palsy-like dis.	4	3	79	21	29	32	10	-4#	5	20	25	-	-	-
4	F, 9 + 7	23	Cerebral palsy-like dis.	4	3	95	38	45	41	15	10	39**	58	71	-	54	70
5	M, 17 + 0	28	Cerebral palsy-like dis.	4	3	107	68	87	30	22	10	-	-	-	-	-	-
						114	68	75
6	F, 12 + 4	23	Cerebral palsy	4	3	46	6	13	24	12	5	70	61	58	-	-	-
7	M, 22 + 2	28	Cerebral palsy-like dis.	4	3	105	26	26	46	9	3	0	37	35	11	54	52
8	M, 13 + 6	39	Cerebral palsy-like dis.	4	3	60	26	20	23	12	8	120*	56	73	-	-	-
9	M, 5 + 4	17	Cerebral palsy	4	3	79	18	16	14	7	25	34**	23	12	-	42	20
10	M, 16 + 6	34	Cerebral palsy-like dis.	4	3	37	9	14	11	5	0	106**	51	60	-	36	39
11	M, 8 + 11	24	Cerebral palsy-like dis.	4	3	84	26	36	20	0	8	-	-	-	-	-	-
12	M, 20 + 2	40	Cerebral palsy	4	3	38	13	23	40	9	8	-	-	-	-	-	-
						98	33	34
13	F, 14 + 6	36	Cerebral palsy-like dis.	4	3	-	-	-	-	-	-	88	46	51	-	-	-
14	F, 10 + 0	17	Cerebral palsy-like dis.	4	3	35	7	11	-	-	-	61	51	34	-	-	-
15	F, 15 + 4	25	Cerebral palsy	4	3	33	17	19	19	7	5	79	51	67	-	-	-
16	F, 22 + 2	38	Cerebral palsy-like dis.	4	3	40	20	14	20	10	2	90	63	68	80	65	58
17	F, 14 + 5	34	Cerebral palsy-like dis.	4	3	35	0	0	32	0	0	22	22	25	127	42	48
18	M, 10 + 6	19	Cerebral palsy-like dis.	4	3	75	12	22	15	0	2	-	-	-	-	-	-
19	M, 14 + 4	35	Cerebral palsy-like dis.	4	3	40	21	27	-	-	-	55**	40	36	-	37	34
20	F, 21 + 2	29	Cerebral palsy-like dis.	4	3	63	19	26	29	0	5	-	-	-	-	-	-
21	F, 15 + 1	30	Cerebral palsy-like dis.	4	3	92	17	18	48	9	7	-	-	-	-	-	-
22	M, 13 + 9	45	Cerebral palsy-like dis.	2	2	38	4	0	30	1	5	84	33	20	-	-	-
						70	18	18
23	M, 20 + 8	30	Cerebral palsy-like dis.	4	3	115	67	94	37	24	15	-	-	-	-	-	-
						139	81	91
24	M, 10 + 0	36	Cerebral palsy-like dis.	4	3	33	15	14	24	0	0	71	26	38	-	-	-
						92	12	15
25	M, 14 + 11	31	Cerebral palsy-like dis.	4	3	37	6	3	21	2	0	-	-	-	-	-	-
						86	20	14
26	F, 14 + 2	31	Cerebral palsy	2	2	59	10	20	20	0	0	-	-	-	126	64	64
27	F, 17 + 3	34	Cerebral palsy	4	3	33	21	14	31	6	0	-	-	-	-	-	-
						68	20	9
28	F, 13 + 11	20	Cerebral palsy-like dis.	2	2	92	34	39	38	7	2	-	-	-	-	-	-
29	F, 16 + 8	20	Cerebral palsy-like dis.	4	3	52	21	17	45	0	4	85**	22	29	-	-	-
						96	39	48
30	M, 9 + 3	28	Cerebral palsy-like dis.	4	3	88	20	23	29	3	0	2	24	26	-	-	-
31	M, 14 + 8	41	Cerebral palsy	4	3	47	24	26	-	-	-	97**	27	34	-	50	51
						64	26	28
Avg. for cerebral palsy or cerebral palsy-like disease††	14 + 3	29
Major curves (n = 30)						74	23 (69)	27 (64)	28	7 (75)	5 (82)
Compensatory curves (n = 9)						56	27 (52)	31 (45)
32	F, 17 + 4	45	Myelomeningocele	3	3	55	32	33	29	15	26	15	26	56	-	-	-
						59	35	45
33	M, 16 + 4	30	Myelomeningocele	4	3	86	40	35	37	5	4	20	38	40	8	40	34
34	F, 11 + 0	22	Myelomeningocele	4	3	50	14	24	30	2	0	63	50	75	-	-	-
						61	6	9
35	M, 15 + 1	24	Myelomeningocele	2	1	45	19	10	25	5	0	116**	50	70	-	50	38
						56	15	7
36	F, 10 + 0	18	Myelomeningocele	2	2	30	12	11	17	0	0	24	37	23	115	40	42
37	F, 12 + 2	40	Myelomeningocele	4	3	30	0	0	19	3	7	-	-	-	-	-	-
						62	21	18
38	F, 11 + 0	67	Myelomeningocele	4	3	60	13	13	12	4	10	-	-	-	-	-	-
39	F, 10 + 2	34	Myelomeningocele	4	3	-	-	-	-	-	-	78	20	15	-	-	-
40	M, 19 + 8	39	Myelomeningocele	4	3	60	5	9	27	9	0	67	39	26	-	-	-
Avg. for myelo- meningocele	13 + 8	35
Major curves (n = 8)						59	18 (69)	18 (69)	25	5 (80)	6 (76)
Compensatory curves (n = 4)						45	16 (64)	17 (62)
41	M, 15 + 7	68	Duchenne musc. dystrophy	4	3	30	20	15	26	0	0	16	18	17	23	52	57
						90	23	18
42	M, 12 + 10	45	Duchenne musc. dystrophy	4	3	39	11	10	19	2	0	15	12	18	-	-	-
						54	13	10
43	M, 14 + 5	50	Duchenne musc. dystrophy	4	3	75	16	16	24	0	4	6	10	7	-	-	-
44	M, 12 + 9	50	Duchenne musc. dystrophy	4	3	30	19	15	17	0	3	15	22	35	20	38	41
						37	11	11
Avg. for Duchenne musc. dystrophy‡‡	13 + 11	53
Major curves (n = 4)						64	16 (75)	14 (78)
Compensatory curves (n = 3)						33	17 (48)	13 (61)	22	1 (95)	2 (91)
45	F, 9 + 0n	29	Spinal musc. atrophy	4	3	46	10	18	35	10	10	19	30	38	-	-	-
						79	11	15
46	F, 23 + 9	60	Myopathy	1	1	55	20	15	-	-	-	-	-	-	94	49	39
47	M, 18 + 0	39	Nonfamilial dysautonomia	1	1	72	15	30	13	3	10	-	-	-	-	-	-

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: TABLE IData on the Patients

Case	Gender, Age(yrs. + mos.)	Weight(kg)	Diagnosis	Ambulatory Status* (grade)		Scoliosis† (degrees)			Pelvic Obliquity (degrees)			Abnormal Kyphosis (degrees)			Abnormal Lordosis (degrees)
Preop.	Postop.	Preop.	Postop.	Latest Follow-up	Preop.‡	Postop.	Latest Follow-up	Preop.§	Postop.	Latest Follow-up	Preop.	Postop.	Latest Follow-up
1	F, 12 + 6	31	Cerebral palsy-like dis.	4	3	80	20	45	17	6	14	-	-	-	10	56	55
2	F, 9 + 0	19	Cerebral palsy-like dis.	4	3	70	15	21	29	0	0	70	60	40	-	-	-
3	F, 12 + 2	18	Cerebral palsy-like dis.	4	3	79	21	29	32	10	-4#	5	20	25	-	-	-
4	F, 9 + 7	23	Cerebral palsy-like dis.	4	3	95	38	45	41	15	10	39**	58	71	-	54	70
5	M, 17 + 0	28	Cerebral palsy-like dis.	4	3	107	68	87	30	22	10	-	-	-	-	-	-
						114	68	75
6	F, 12 + 4	23	Cerebral palsy	4	3	46	6	13	24	12	5	70	61	58	-	-	-
7	M, 22 + 2	28	Cerebral palsy-like dis.	4	3	105	26	26	46	9	3	0	37	35	11	54	52
8	M, 13 + 6	39	Cerebral palsy-like dis.	4	3	60	26	20	23	12	8	120*	56	73	-	-	-
9	M, 5 + 4	17	Cerebral palsy	4	3	79	18	16	14	7	25	34**	23	12	-	42	20
10	M, 16 + 6	34	Cerebral palsy-like dis.	4	3	37	9	14	11	5	0	106**	51	60	-	36	39
11	M, 8 + 11	24	Cerebral palsy-like dis.	4	3	84	26	36	20	0	8	-	-	-	-	-	-
12	M, 20 + 2	40	Cerebral palsy	4	3	38	13	23	40	9	8	-	-	-	-	-	-
						98	33	34
13	F, 14 + 6	36	Cerebral palsy-like dis.	4	3	-	-	-	-	-	-	88	46	51	-	-	-
14	F, 10 + 0	17	Cerebral palsy-like dis.	4	3	35	7	11	-	-	-	61	51	34	-	-	-
15	F, 15 + 4	25	Cerebral palsy	4	3	33	17	19	19	7	5	79	51	67	-	-	-
16	F, 22 + 2	38	Cerebral palsy-like dis.	4	3	40	20	14	20	10	2	90	63	68	80	65	58
17	F, 14 + 5	34	Cerebral palsy-like dis.	4	3	35	0	0	32	0	0	22	22	25	127	42	48
18	M, 10 + 6	19	Cerebral palsy-like dis.	4	3	75	12	22	15	0	2	-	-	-	-	-	-
19	M, 14 + 4	35	Cerebral palsy-like dis.	4	3	40	21	27	-	-	-	55**	40	36	-	37	34
20	F, 21 + 2	29	Cerebral palsy-like dis.	4	3	63	19	26	29	0	5	-	-	-	-	-	-
21	F, 15 + 1	30	Cerebral palsy-like dis.	4	3	92	17	18	48	9	7	-	-	-	-	-	-
22	M, 13 + 9	45	Cerebral palsy-like dis.	2	2	38	4	0	30	1	5	84	33	20	-	-	-
						70	18	18
23	M, 20 + 8	30	Cerebral palsy-like dis.	4	3	115	67	94	37	24	15	-	-	-	-	-	-
						139	81	91
24	M, 10 + 0	36	Cerebral palsy-like dis.	4	3	33	15	14	24	0	0	71	26	38	-	-	-
						92	12	15
25	M, 14 + 11	31	Cerebral palsy-like dis.	4	3	37	6	3	21	2	0	-	-	-	-	-	-
						86	20	14
26	F, 14 + 2	31	Cerebral palsy	2	2	59	10	20	20	0	0	-	-	-	126	64	64
27	F, 17 + 3	34	Cerebral palsy	4	3	33	21	14	31	6	0	-	-	-	-	-	-
						68	20	9
28	F, 13 + 11	20	Cerebral palsy-like dis.	2	2	92	34	39	38	7	2	-	-	-	-	-	-
29	F, 16 + 8	20	Cerebral palsy-like dis.	4	3	52	21	17	45	0	4	85**	22	29	-	-	-
						96	39	48
30	M, 9 + 3	28	Cerebral palsy-like dis.	4	3	88	20	23	29	3	0	2	24	26	-	-	-
31	M, 14 + 8	41	Cerebral palsy	4	3	47	24	26	-	-	-	97**	27	34	-	50	51
						64	26	28
Avg. for cerebral palsy or cerebral palsy-like disease††	14 + 3	29
Major curves (n = 30)						74	23 (69)	27 (64)	28	7 (75)	5 (82)
Compensatory curves (n = 9)						56	27 (52)	31 (45)
32	F, 17 + 4	45	Myelomeningocele	3	3	55	32	33	29	15	26	15	26	56	-	-	-
						59	35	45
33	M, 16 + 4	30	Myelomeningocele	4	3	86	40	35	37	5	4	20	38	40	8	40	34
34	F, 11 + 0	22	Myelomeningocele	4	3	50	14	24	30	2	0	63	50	75	-	-	-
						61	6	9
35	M, 15 + 1	24	Myelomeningocele	2	1	45	19	10	25	5	0	116**	50	70	-	50	38
						56	15	7
36	F, 10 + 0	18	Myelomeningocele	2	2	30	12	11	17	0	0	24	37	23	115	40	42
37	F, 12 + 2	40	Myelomeningocele	4	3	30	0	0	19	3	7	-	-	-	-	-	-
						62	21	18
38	F, 11 + 0	67	Myelomeningocele	4	3	60	13	13	12	4	10	-	-	-	-	-	-
39	F, 10 + 2	34	Myelomeningocele	4	3	-	-	-	-	-	-	78	20	15	-	-	-
40	M, 19 + 8	39	Myelomeningocele	4	3	60	5	9	27	9	0	67	39	26	-	-	-
Avg. for myelo- meningocele	13 + 8	35
Major curves (n = 8)						59	18 (69)	18 (69)	25	5 (80)	6 (76)
Compensatory curves (n = 4)						45	16 (64)	17 (62)
41	M, 15 + 7	68	Duchenne musc. dystrophy	4	3	30	20	15	26	0	0	16	18	17	23	52	57
						90	23	18
42	M, 12 + 10	45	Duchenne musc. dystrophy	4	3	39	11	10	19	2	0	15	12	18	-	-	-
						54	13	10
43	M, 14 + 5	50	Duchenne musc. dystrophy	4	3	75	16	16	24	0	4	6	10	7	-	-	-
44	M, 12 + 9	50	Duchenne musc. dystrophy	4	3	30	19	15	17	0	3	15	22	35	20	38	41
						37	11	11
Avg. for Duchenne musc. dystrophy‡‡	13 + 11	53
Major curves (n = 4)						64	16 (75)	14 (78)
Compensatory curves (n = 3)						33	17 (48)	13 (61)	22	1 (95)	2 (91)
45	F, 9 + 0n	29	Spinal musc. atrophy	4	3	46	10	18	35	10	10	19	30	38	-	-	-
						79	11	15
46	F, 23 + 9	60	Myopathy	1	1	55	20	15	-	-	-	-	-	-	94	49	39
47	M, 18 + 0	39	Nonfamilial dysautonomia	1	1	72	15	30	13	3	10	-	-	-	-	-	-

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: TABLE IIOperative and Outcome Data

Case	Additional Procedures	Est. Blood Loss (ml)		Durat. of Op. (mins.)		Durat. of Follow-up(mos.)	Satisfaction	Pseudarthrosis		Implant-Related Problems
Post. Proc.	Ant. Proc.	Post. Proc.	Ant. Proc.	Possible	Definite
1	No	500		410		68	Satis.	Yes		Rod and wire breakage
2	No	1250		392		72	Satis.
3	No	700		385		94	Satis.
4	No	800		465		43	Very satis.
5	No	750		475		47	Satis.
6	No	600		555		51	Very satis.
7	Ant. arthrod.	1200		510	365	40	Very satis.
8	No	1500		540		48	Very satis.
9	No	1000		400		98	Very satis.
10	No	350		420		38	Very satis.
11	No	800		375		35	Satis.
12	No	1800		470		51	Very satis.
13	No	850		510		50	Satis.
14	No	500		390		55	Very satis.
15	No	900		570		31	Satis.
16	No	1500		510		49	Satis.
17	Ant. arthrod.	1400	600	490	360	44	Neither satis. nor unsatis.
18	No	900		415		82	Neither satis. nor unsatis.
19	Eggshell osteot.	1000		660		38	Very satis.
20	No	1000		470		36	Very satis.
21	No	2500		435		30	Satis.
22	No	1500		450		24	Very satis.
23	No	4000		625		60	Very satis.	Yes		Rod breakage bilat.
24	No	900		410		36	Very satis.
25	No	1000		415		36	Satis.
26	No	2200		405		26	Satis.
27	No	1300		480		32	Satis.
28	No	600		480		32	Satis.
29	Eggshell osteot.	1400		555		27	Very satis.
30	No	1200		480		27	Very satis.
31	Eggshell osteot.	2500		540		26	Very satis.			Trans. connect. breakage
Avg. for cerebral palsy or cerebral palsy-like disease		1239	600	474	363	46
32	Post. interbody arthrod.; lipoma excision	1950		675		56	Satis.	Yes		Rod breakage bilat.; trans. connect. and wire breakage
33	Ant. arthrod. and detethering	1600		400	285	33	Very satis.			Trans. connect. and wire breakage
34	Ant. arthrod. and detethering	1800		370	340	60	Very satis.		Yes
35	Ant. arthrod. and detethering	300	850	555	420	49	Died from renal failure			Wire breakage
36	Ant. arthrod.	250	750	280	445	54	Very satis.
37	No	1100		540		24	Very satis.
38	No	250		375		32	Very satis.
39	Post. osteot.	1200		300		29	Satis.
40	Post. interbody arthrod. and osteot.	1700		680		60	Very satis.
Avg. for myelomeningocele		1128	800	464	373	44
41	No	1500		530		64	Very satis.
42	No	2150		370		48	Very satis.
43	No	2500		390		25	Satis.
44	No	3000		525		36	Satis.
Avg. for Duchenne musc. dystrophy		2288		454		43
45	No	500		375		100	Satis.
46	Ant. arthrod.	2500	900	500	310	28	Very satis.
47	Ant. arthrod. and post. osteot.	5000	250	780	395	69	Satis.

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: TABLE IIOperative and Outcome Data

Case	Additional Procedures	Est. Blood Loss (ml)		Durat. of Op. (mins.)		Durat. of Follow-up(mos.)	Satisfaction	Pseudarthrosis		Implant-Related Problems
Post. Proc.	Ant. Proc.	Post. Proc.	Ant. Proc.	Possible	Definite
1	No	500		410		68	Satis.	Yes		Rod and wire breakage
2	No	1250		392		72	Satis.
3	No	700		385		94	Satis.
4	No	800		465		43	Very satis.
5	No	750		475		47	Satis.
6	No	600		555		51	Very satis.
7	Ant. arthrod.	1200		510	365	40	Very satis.
8	No	1500		540		48	Very satis.
9	No	1000		400		98	Very satis.
10	No	350		420		38	Very satis.
11	No	800		375		35	Satis.
12	No	1800		470		51	Very satis.
13	No	850		510		50	Satis.
14	No	500		390		55	Very satis.
15	No	900		570		31	Satis.
16	No	1500		510		49	Satis.
17	Ant. arthrod.	1400	600	490	360	44	Neither satis. nor unsatis.
18	No	900		415		82	Neither satis. nor unsatis.
19	Eggshell osteot.	1000		660		38	Very satis.
20	No	1000		470		36	Very satis.
21	No	2500		435		30	Satis.
22	No	1500		450		24	Very satis.
23	No	4000		625		60	Very satis.	Yes		Rod breakage bilat.
24	No	900		410		36	Very satis.
25	No	1000		415		36	Satis.
26	No	2200		405		26	Satis.
27	No	1300		480		32	Satis.
28	No	600		480		32	Satis.
29	Eggshell osteot.	1400		555		27	Very satis.
30	No	1200		480		27	Very satis.
31	Eggshell osteot.	2500		540		26	Very satis.			Trans. connect. breakage
Avg. for cerebral palsy or cerebral palsy-like disease		1239	600	474	363	46
32	Post. interbody arthrod.; lipoma excision	1950		675		56	Satis.	Yes		Rod breakage bilat.; trans. connect. and wire breakage
33	Ant. arthrod. and detethering	1600		400	285	33	Very satis.			Trans. connect. and wire breakage
34	Ant. arthrod. and detethering	1800		370	340	60	Very satis.		Yes
35	Ant. arthrod. and detethering	300	850	555	420	49	Died from renal failure			Wire breakage
36	Ant. arthrod.	250	750	280	445	54	Very satis.
37	No	1100		540		24	Very satis.
38	No	250		375		32	Very satis.
39	Post. osteot.	1200		300		29	Satis.
40	Post. interbody arthrod. and osteot.	1700		680		60	Very satis.
Avg. for myelomeningocele		1128	800	464	373	44
41	No	1500		530		64	Very satis.
42	No	2150		370		48	Very satis.
43	No	2500		390		25	Satis.
44	No	3000		525		36	Satis.
Avg. for Duchenne musc. dystrophy		2288		454		43
45	No	500		375		100	Satis.
46	Ant. arthrod.	2500	900	500	310	28	Very satis.
47	Ant. arthrod. and post. osteot.	5000	250	780	395	69	Satis.

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	Study*
Maloney et al.⁵¹(1990)	Gau et al.³⁵(1991)	Neustadt et al.⁵⁴(1992)	Present Study
Type of instrumentation	Unit rod	Luque-Galveston	Cotrel-Dubousset	Isola-Galveston
No. of patients (M/F)	10 (7/3)	68 (40/28)	18 (7/11)	47 (23/24)
No. (percent) of patients who had neuropathic disorder	8	58 (85)	16	42 (89)
Avg. age (range) (yrs.+ mos.)	15 (8 to 19)	14 + 8 (9 to 38)	19 + 2 (NA)	14 + 3 (5 + 4 to 23 + 9)
No. (percent) of anterior procedures	9	20 (29)	8	8 (17)
Avg. duration of posterior procedures (mins.)	361	295	252	473
Avg. estimated blood loss during posterior procedures (ml)	2400	NA	1945	1324
Avg. hospital stay (days)	27	NA	14	16
No. (percent) of patients managed with bracing	NA	45 (66)	7	11 (23)
Avg. duration of follow-up (range) (mos.)	48 (19 to 60)	48	27 (24 to 40)	47 (24 to 100)
No. (percent) of patients who had deep wound infection	0	2 (3)	0	0
No. (percent) of patients who had delayed wound infection	0	NA	NA	1 (2)
No. (percent) of patients who had pseudarthrosis	0	7 (10)	0	4 (9)
No. (percent) of patients who had reoperation	1	5 (7)	1	5 (11)
Scoliosis
Avg. magnitude (preop./postop./latest follow-up) (degrees)	86/21/NA	73/NA/33	70/38/41	70/21/24
Avg. correction (percent)	76	55	41Â§	70/66
Pelvic obliquity
Avg. magnitude (preop./postop./latest follow-up) (degrees)	41/7/NA	17/NA/8	19#/12#/NA	27/6/5
Avg. correction (percent)	84	53	37	78/81
Avg. hyperlordosis (preop./postop./latest follow-up) (degrees)	NA	-102/NA/-59	**	-108/-52/-50

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	Study*
Maloney et al.⁵¹(1990)	Gau et al.³⁵(1991)	Neustadt et al.⁵⁴(1992)	Present Study
Type of instrumentation	Unit rod	Luque-Galveston	Cotrel-Dubousset	Isola-Galveston
No. of patients (M/F)	10 (7/3)	68 (40/28)	18 (7/11)	47 (23/24)
No. (percent) of patients who had neuropathic disorder	8	58 (85)	16	42 (89)
Avg. age (range) (yrs.+ mos.)	15 (8 to 19)	14 + 8 (9 to 38)	19 + 2 (NA)	14 + 3 (5 + 4 to 23 + 9)
No. (percent) of anterior procedures	9	20 (29)	8	8 (17)
Avg. duration of posterior procedures (mins.)	361	295	252	473
Avg. estimated blood loss during posterior procedures (ml)	2400	NA	1945	1324
Avg. hospital stay (days)	27	NA	14	16
No. (percent) of patients managed with bracing	NA	45 (66)	7	11 (23)
Avg. duration of follow-up (range) (mos.)	48 (19 to 60)	48	27 (24 to 40)	47 (24 to 100)
No. (percent) of patients who had deep wound infection	0	2 (3)	0	0
No. (percent) of patients who had delayed wound infection	0	NA	NA	1 (2)
No. (percent) of patients who had pseudarthrosis	0	7 (10)	0	4 (9)
No. (percent) of patients who had reoperation	1	5 (7)	1	5 (11)
Scoliosis
Avg. magnitude (preop./postop./latest follow-up) (degrees)	86/21/NA	73/NA/33	70/38/41	70/21/24
Avg. correction (percent)	76	55	41Â§	70/66
Pelvic obliquity
Avg. magnitude (preop./postop./latest follow-up) (degrees)	41/7/NA	17/NA/8	19#/12#/NA	27/6/5
Avg. correction (percent)	84	53	37	78/81
Avg. hyperlordosis (preop./postop./latest follow-up) (degrees)	NA	-102/NA/-59	**	-108/-52/-50