Surgical treatment of scoliosis

The first detailed clinical description of scoliosis belongs to Ambroise Paré, who also outlined the basic principles of treating scoliosis with an iron apparatus. At the same time, as some authors point out, this disease was also known to Hippocrates, who used wooden splints to correct spinal deformities.

Analyzing the results of examination and surgical treatment of 377 patients, S.A. Mikhailov (2000) found that the presence of concomitant osteoporosis and osteopenia is one of the factors of loss of postoperative correction and in 14.2% of patients with scoliosis is the cause of fracture of the supporting bone structures of the spine. This study shows the need to determine the density of the vertebral bodies in the preoperative period and the feasibility of drug treatment and the choice of optimal treatment tactics.

In surgical treatment of severe forms of scoliosis, the percentage of complications is quite significant (18.7%). A.I. Kislov et al. (2000), according to various authors, indicates the proportion of complications in this category of patients from 11.8 to 57%. The imperfection of methods and devices for treating patients with severe progressive forms of scoliosis and kyphoscoliosis requires further in-depth study of the problem and the search for optimal solutions. To prevent severe complications, such as massive blood transfusion syndrome during deformity correction operations in scoliosis patients, E.E. Biryukova et al. (2001) recommend normovolemic hemodilution with the collection of 500 ml of blood before surgery and its return at the height of blood loss.

The main distinguishing feature of congenital spinal deformities is their rigidity. Immobility is especially pronounced in cases of segmentation disorders, and conservative treatment and preoperative mobilization are contraindicated in such cases.

Surgeons have been performing surgical correction of scoliosis for over 150 years. Of all surgical interventions, posterior osteoplastic fixation of the spine has gained the greatest recognition. However, the results of this operation have been disappointing, since it provides partial preservation of correction in an average of 11+3.6% of operated patients. As early as 1839, Guerrin reported the successful use of myotomy of the paravertebral muscles. However, in subsequent years, other authors managed to achieve only minor correction of the deformation using this method.

L.I. Shulutko (1968) considered it necessary to perform tenoligamentocapsulotomy on the concave side of the curvature, and then supplement it with one or another type of operation on the spine. At present, due to low efficiency, mobilizing operations are used only as an element of surgical intervention. Large deformations of the spine are eliminated through operations on the bodies and intervertebral discs of the vertebrae.

Correction of congenital spinal deformities involves surgical treatment of deformities based on hemivertebrae and wedge-shaped vertebrae. Experience in surgical treatment of this pathology has been accumulated since the beginning of the 20th century. The most effective surgical correction of kyphosis in children is achieved using hook contractors with sublaminar fixation according to Luque; rigid polysegmental CD systems are used for adolescents and adults. A number of authors, evaluating the clinical experience of using transosseous osteosynthesis and transpedicular fixation of spinal injuries and diseases, believe that this method allows intraoperative elimination of multiplanar deformity, additional correction in the postoperative period if necessary, and early activation of patients without the use of external immobilization. A method of correction using two rods and rigid segmental fixation with sublaminar wires was proposed by Edward Luke. Paul Harrington (1988) created his endocorrector, consisting of two metal rods operating on the principle of distraction and contraction. When using the Harrington-Luc method, the surgical correction was 65+4.4°, and with the Armstrong method - 44.5+4.8°. However, the use of the Armstrong method for pronounced rigid curvatures (deformation angle greater than 60°) is not justified due to the technical impossibility of installing the structure on the convex side of the curvature.

Yu. I. Pozdnikin and A. N. Mikiashvili (2001), using a three-component version of surgical treatment of kyphoscoliosis, including surgical mobilization, skeletal, craniotibial traction and subsequent correction and stabilization of the deformation with a Harrington-type distractor, achieved correction within 50 to 85.5% of the initial curvature. Based on the methods of Harrington and Luke, J. Cotrel and J. Dubousset developed an original method of spine correction using rods, hooks and their segmental fixation to the vertebral arches. A. Dwyer (1973) and K. Zielke (1983) proposed rather complex techniques using anterior approaches for surgical correction of scoliosis. At the same time, the authors themselves note up to 43% of complications. According to some authors, operations on the vertebral bodies allow achieving better correction of spinal curvatures. For correction and stabilization of spinal deformities, Ya.L. Tsivyan (1993), J.E. Lonstein (1999) suggest performing operations on the vertebral bodies and correction with a metal endocorrector.

A.I. Kazmin (1968) was the first to develop and apply a two-stage surgical treatment method for scoliosis: the first stage is the use of a metal distractor to correct and fix the lumbar curvature, the second stage is a discotomy or wedge resection of the thoracic spine. The development and introduction of spinal endocorrectors into clinical practice made it possible to create a corrective force at one time and maintain it throughout the entire treatment period.

Since 1988, A.I. Kislov et al. (2000) has been using a controlled spinal distractor of his own model, which facilitates additional correction of scoliosis by 5-20°.

I.A. Norkin (1994) developed and successfully used a dynamic device that allows correction of kyphoscoliosis in the sagittal and frontal planes during the entire period of a child's growth. The Novosibirsk Research Institute of Traumatology and Orthopedics uses the Dynesys system (Sulzer, Switzerland), consisting of titanium transpedicular screws and elastic-elastic elements connecting them. According to the authors, in the early postoperative period, restabilization of the vertebral segment occurs, while maintaining functional mobility in it, and the method of dynamic fixation has undoubted prospects. According to literary data, the Cotrell-Dubousset endocorrector is the most common and effective system.

S. T. Vetrile and A. A. Kuleshov (2000, 2001) studied the results of treatment of 52 patients suffering from scoliosis. CD Horizon instruments were used for surgical correction. This method was used according to the classical technique and in combination with discectomy, spondylectomy, interlaminectomy. The differentiated approach made it possible to correct scoliosis up to 60° and significantly regress neurological disorders in patients with neurological symptoms. In order to stabilize the achieved correction of spinal deformities of various genesis, many authors used and recommended various methods of spondylodesis.

A promising direction in the treatment of spinal deformities of various genesis is the development and implementation of external correction and fixation devices. The use of these devices makes it possible to perform one-stage correction, and in the case of gross and rigid curvatures of the spine, to continue correcting deformations in various planes.

Doctor of Medical Sciences, Professor of the Department of Traumatology and Orthopedics Ibragimov Yakub Khamzinovich. Surgical treatment of scoliosis // Practical Medicine. 8 (64) December 2012 / Volume 1

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