|Year : 2002 | Volume
| Issue : 5 | Page : 207-215
Leeds procedure - a treatment modality for scoliosis
SS Sangwan, RC Siwach, R Sing, P Singh
Department of Orthopaedic Surgery, Pt. B.D.S. Post Graduate Institute of Medical Sciences, Rohtak, 124 001, India
S S Sangwan
9J/14, Medical Enclave, Rohtak 124 001
|How to cite this article:|
Sangwan S S, Siwach R C, Sing R, Singh P. Leeds procedure - a treatment modality for scoliosis. Indian J Med Sci 2002;56:207-15
Scoliosis is derived from the Greek word meaning curvature. It is perhaps the earliest evident disease with which mankind was faced, it being an obvious physical problem as well as for its cosmetic blemish. Galen coined the word Scoliosis and his treatment of spinal deformities were basically crude methods following principles of forcible traction and distraction in suspension. Although management of scoliotic patients has changed many a time since the beginning of this century, we are still no closer to knowing the exact etiology of what we call "Idiopathic scoliosis".  This progressive deformity ineffectively treated may produce not only a cosmetic problem of varying degree but also severe psychological and physical disability restricting in some the span of life and in many other by enjoyment of it. 
The management of Scoliosis has long remained in the narrow margins of conservative treatment with plaster casts, and braces worn for years. But these methods have not been able to bring all curvatures into the realms of acceptability. But now it is widely appreciated that the results of surgical correction are better and desirable. 
Management of Scoliosis has evolved tremendously over the past years. Hibbs was among the first to treat spinal deformities with a posterior fusion. 
Anterior spinal surgery has in the past 30 years come to play an invaluable role in the management of spinal deformities. It may be expected to lead to a greater degree of correction with higher incidence of solid fusion than from posterior surgery alone. Certainly with instrumentation such as Dwyer apparatus when used, leads to greater degree of correction of curvature than that from posterior fusion with Harrington instrumentation by about 15-20%. Further more if one uses a Zielke device a significant improvement is possible. 
In 1986, Archer A, Dickson A and Deacon  advocated a new management philosophy: Idiopathic Scoliosis in LEEDS. They said that Harrington instrumentation alone does little to alter the rotational deformity with which scoliotic patient presents. They advocated a two stage procedure, in the first stage loosening of the curve was done by discectomy after approaching the spine from anterior. Second stage included posterior Harrington fixation and derotation by Luque wiring; posterior spinal fusion; and followed by costoplasty (Leeds procedure). This procedure gave better results. Keeping in view this philosophy a study was conducted on the patients with scoliotic deformities of the spine who have been operated by `Leeds' procedure, to evaluate the anterior spinal surgery as an approach and to present an overview of results and complications that may occur with this procedure.
| ¤ Material and Methods|| |
The prospective study included forty patients of thoracic and lumbar scoliosis who were operated and managed in the Department of Orthopaedic Surgery, Pt. B.D. Sharma PGIMS, Rohtak during last five years.
A detailed history of disease and general physical examination of the patients were done. Patients were investigated for preanaesthetic fitness. Preoperative height of the patient was recorded. Preoperative clinical photographs of the patient were obtained for postoperative comparison. Pulmonary function tests of the patient were done by spirometer with maximal possible effort and were recorded. Roentgenographic investigation of the patient were done including x-rays of spine [Figure 1] and x-ray of left wrist of patient. Relevant special investigation of the patient (CT/MRI) were also done according to the requirements of the case. Patients were put on Head Halter and pelvic belt traction for the week while they were awaiting surgery. The weights for traction were gradually increased as per tolerance of the patients. Patients were duly informed preoperatively regarding the procedure to be done and about the postoperative breathing exercises and physiotherapy etc. An informed consent was obtained about the possible risk of neurological deficit.
| ¤ Surgical Technique|| |
A. First stage (Anterior discectomy): Right or left lateral position is used according to the side of disease and a sand bag was placed to exaggerate the deformity. The surgeon stands on the spinal side of the patient for better view of the vertebrae with the patient lying in lateral position with the convexity of the Scoliosis upwards. Anterior approach to spine depends on the site of primary curve. Transthoracic approach was used for thoracic Scoliosis, approach to thoracolumbar spin was through the bed of 10m rib and anterior extraperitoneal approach to lumbar spine was used.
Procedure for discectomy: After the verterbral column has been visualised after retraction of the lung, the disc excision was carried out. Disc was removed by sharp dissection, removing two thirds of the annulus fibrosus followed by removal of nucleus pulposus and the remnants of the annulus on the convex side of the curve. The cartilage was removed with a sharp angled curret. Following complete disc removal each interspace was packed with gelfoam or surgicele while the remaining discs were being excised. In patients where there was wedging of vertebrae, it was also excised. Bone grafts from the excised rib were cut of the required length and placed between vertebral bodies. At the end of operation intercostal drain was inserted before the chest was closed in layers and diaphragm was sutured with vicryl if opened. The drain ' was connected to under water seal and removed after 72 hours, when a chest film showed complete expansion of the lung and no collection of fluid. After chest tube removal patients were put on head halter, pelvic traction and lateral traction.
B. Second stage (posterior spine surgery): After about two weeks postoperative, second stage operation was done. Patient was positioned prone on well padded wooden frame, so that the abdomen hanged free, the skin was incised sharply in line slightly favouring the scoliosis so that at the apex the skin incision was some one-third of the way from the vertical to apical spinous process. Vertebrae were exposed from upper to lower neutral vertebral. After subperiosteal exposure of the lamina, site was prepared for placement of upper Harrington hook under the inferior facet of the neutral vertebrae of the scoliotic curve. Site was prepared over the lamina of lower neutral vertebra for insertion of lower hook. A special square hook (Moe modification) is used as the lower Harrington hook to prevent the rotation of the rod. Both the hooks were thus inserted and their stability checked. The lamina and the transverse processes over both the concave and convex side of the curve were denuded and bone slivers thus created were than turned below and upwards to create grafts. The articular surface of the facet joints are especially denuded to enhance the joint arthrodesis as in Hibb's method. Grafts from the ribs removed during costoplasty were also put for effective arthrodesis. Spinous process were removed. Sublaminar wires were doubled over and the doubled end bent into a half circle. The double end was then inserted by hand from below upwards through one lamniotomy to emerge through the one above. Four to six sublaminar wires were thus put in. Harrington rod was moulded to create the thoracic kyphosis and it was first inserted in the upper hook and later introduced into the lower hook. In Leed's procedure, the Harrington rod was not distracted much with an outtrigger. Only enough tension is applied to keep the hooks in place. Then the wires were tightened on Harrington rod one by one. First the wires near the hooks are tightened while the assistant keeps the deformity corrected by pushing the side of chest.
Costoplasty: The skin over the convex side was elevated from over the hump. The ribs were identified by palpation and the overlying muscles were divided by cutting diathermy in line of the rib for about 5 cm from the tip of the transverse process. The periosteum was then elevated from the rib and pleura was elevated with help of rib shears. The ribs were then divided at the level of the transverse processes to the angle of the rib. This was performed at all levels where ribs were prominent maximum 5-6 ribs were removed. The grafts prepared from the ribs were placed over denuded bone for fusion.
Stagnara's wake up test : The test was considered a gold standard and was done in every case of posterior instrumentation due to non-availability of the spinal monitoring system. The patients were duly informed before induction of the anaesthesia regarding the wake up test. They were asked to wriggle their toes.
Anaesthetist was informed 15 minutes before procedure regarding the conduction of the wake up test. The patient was then made light of the anaesthesia and asked to wriggle his/ her toes. After successful conduction of the test patient was reanesthetised and wound closure was done.
Postoperatively patients were given chest physiotherapy, adequate analgesia and antibiotics. X-rays were done to assess the improvement [Figure 2] & [Figure 3]. Clinical photograph were taken at final follow up to see end correct results.
Patients were given either brace or a body cast for postoperative external immobilisation for about 6 months till the fusion of grafts occurs.
Evaluation was done in each case for 1.Correction gained by anterior surgery, 2. Complication associated with the surgery, 3. Acceptability of cosmetic appearance to patients and the parents i. Good - General acceptability, ii. Fair - improvement with general satisfaction, iii. Poor- General dissatisfaction
| ¤ Results|| |
A total of forty patients (16 male and 24 females with thoracic or lumbar scoliosis underwent surgical correction by Leed's procedure. Age varied from 10-25 years, the most common age group was 15-16 years. Location of curve was thoracic in 24, thoracolumbar in 12 and lumbar in 4 patients. Curve was right sided in 72% of the patients and 28% left sided. The extent of curves varied from a minimum of four vertebrae to maximum of eleven vertebrae and 35% of patients had seven vertebrae involved. Apical vertebrae was found to be ninth thoracic in 20% cases followed by eighth in 15% cases. In the first stage of anterior discectomy 4-5 discs were removed in 72 percent cases. All patients were put on traction preoperatively and for an average of 2 weeks after anterior loosening. Average time taken during anterior surgery was 2 hr. and for posterior surgery 3 hrs. Average number of vertebrae fused were eight in 65% of the patients with range of five to eleven vertebrae. On average 4-5 ribs were removed during costoplasty. Post operative immobilisation was given in the form of POP body cast in 66% cases and with milwaukae brace in rest of the patients. Average correction obtained after anterior surgery was 25% and after combined procedure was 45%. Follow up ranged from 1 year to 5 years. Average loss of correction during this period was 0-4 degree in 45% cases. The pulmonary function tests on average decreased immediately postoperatively. Forty five percent of cases had 10-25% loss of pulmonary functions. Appreciable increase in height was observed in 6 cases (15%) with two cases showing decrease in height due to pseudoarthosis. Ten patients had correction of one grade (as per Nash and Moe method) in the rotation of apical vertebrae.
Major complications during the study were paraparesis 4%, respiratory complications either pneumonitis, dyspnea, lung collapse, haemothorax in 16% cases, superficial and deep infection in 12% cases and pseudoarthosis occurring in 6 (15%) cases. 80% of the patients had good to fair level of satisfaction after surgery in the form of cosmetic correction and 20% of the patients were not satisfied with the results.
| ¤ Discussion|| |
Scoliosis is a deformity which has presented the most interesting, intriguing and difficult problems in orthopaedics. There has remained a consistent tendency to advice braces, plaster casts and mechanical devices to such patients. In India, late presentation of patients, lack of awareness and delay in treatment due to shortage of treatment facilities adds to the woes of the patient. Harrington  evolved his spinal instrumentation based on the principle of distraction of spine for deformity correction and addition of stabilizing fusion to counter the high incidence of metal failure. As the scoliotic deformity unresolved itself with further study, the three dimensional nature of the deformity of idiopathic scoliosis was understood Somerveille  suggested alternative title of "Rotational Lordosis".
Dwyer  and Zielke  appreciated that anterior approach to thoracic and lumbar spine provided better correction of scoliotic deformities within the limits of risks of neurological complications. In present study 40 cases of scoliosis were operated by anterior discectomy during first stage and posterior procedure and bone grafting and costoplasty during second stage.
Average age of patients was 15 years in our study as compared to 12.5 years reported by Dickson  in his study with Leeds procedure. It is likely that assessment can be made relatively at an early age with an active screening programmes for idiopathic scoliosis in a specific target population. In the Indian set up patients presented at a later age due to lack of health education and facilities of treatment. The deformity so becomes severe at the time of presentation. Right sided curves are common (72%), in 1941, the report of the research committee of American Orthopaedic association presented that right side curves were present in 80%  Majority of our cases had either single thoracic or thoracolumbar curve with extent varying from 4 to 11 vertebrae. Cobbs angle varied from 52°-98°. Curve goes into realms of cosmetic unacceptability after it goes above 40o and thus becomes an indication for surgical intervention. These same findings were realised by Dickson & Lawton  when they described that as the curve magnitude increases upto 45 degree, the proportion of successful results with bracing diminishes readily and surgical intervention becomes increasingly imminent.
We had gone for 2 stage procedure because with increase in curve size the mobility of correction of the curve diminishes and a more aggressive approach become necessary.  Above 60°an anterior space making procedure is necessary.  For a curve of upto 90 0 , this can be performed at disc level. Above that level, wedge resection of vertebrae is required. We had kept a figure of 50 for anterior surgery. It was appreciated that each curve and deformity has own personality and consistently attempting only one type of procedure on each and every case would be unjustified. Each case should be studied individually and type of management should be decided on the basis of four essential factors: a) progression potential b) curve at presentation, c) presence of paralysis and d) underlying pathologic conditions. On an average of 7-8 vertebrae were fused in 65% of the cases, aim was to achieve anterior as well as posterior fusion to provide a more stable spine with least possibility of further progression of deformity by removing all the centres of growth. The minimum fusion area was said to include every vertebra in the primary curve. Duboussett  noted growth related progression of curves after solid posterior fusion in young patients with paralytic scoliosis. He termed this the "Crank-shaft phenomenon" because the entire spine and trunk gradually rotated and deformed as scoliosis progressed.
On an average, 45% of operative correction was achieved by surgery by both procedures out of which 25% correction was obtained by anterior surgery alone. Schultz and Hirsch  and Aaro and Dahlborih  found that for thoracic curves the average correction obtained by Harrington instrumentation was on the average 50% in the coronal plane with little or nothing in the transverse plane, the rib hump remained unchanged. In 1986, Archer et al  in a study on Leeds procedure found the results that overall a 65.5% correction of Cobb's angle and 50% correction in rotation was also achieved. In the present study, 10 cases (25%) made a grade I of correction in apical rotation. Moe and Winter  outlined that when internal instrumentation such as Dwyer apparatus is used, the percentage of correction of curvature was greater than that with posterior fusion with Harrington instrumentation by about 15 to 20 percent. Furthermore, if one uses a device as described by Zielke, a significant improvement in derotation is possible. 
The anterior approach to the thoraco lumbar spine is an extensive procedure and is associated with numerous complication. Extensive knowledge of anatomy, meticulous dissection of tissue, accurate technique are absolutely necessary to minimise morbidity and mortality. Respiratory complications observed in 4 cases can be minimised by careful pre and post operative pulmonary physiotherapy, half hourly inflation of lung by the anaesthetist to avoid postoperative atelectasis, complete inflation of lung before closure and careful maintenance of chest tube drain. Pseudoarthrosis observed in two cases was due to early ambulation and breakage of Harrington rod or cutting through of hooks were responsible for this. One patient developed monoparesis in left lower limb after anterior discectomy (grade 2/5) although deficit recovered by conservative treatment. It was realised that observation of the status of spinal cord function was necessary per operatively by somatosensory evoked potential (SSEP) machines. Due to nonavailability of the instrument in our institute, a more cautious approach was followed. McAfee  studying complications of anterior approaches to thoracolumbar spine observed complication in 20% of cases. They observed pseudoarthrosis and pulmonary problem most common, advised regarding meticuous technique and respiratory physiotherapy in most cases.
| ¤ Summary|| |
The present study comprises of forty patients of scoliosis in growing age group (10-25 years) with Cobbs angles ranging from 52"-98". They were treated with Leeds procedure which is by anterior loosening followed by Posterior Harrington fixation + Luque derotation + Fusion and Costoplasty. Majority of the curves were thoracic (60%), and right sided (72%). Average correction of the deformity after surgery was 45%. Satisfaction level of patients and parents was good in 60% of the cases. The modality of treatment was decided on the basis of personality of each case, its demand and requirement, time of presentation and the potential for increasing severity. Anterior spinal surgery for scoliosis is an effective procedure in hands of experienced surgeons and it reduces stiffness of the curve, shorten the anterior column, decreases thoracic lordosis which leads to some improvement of pulmonary function. But there is greater risk of damage to vital structures with higher risks of cardiorespiratory failure. The potential risks have to be balanced with the expected rewards. The optimum method of correction has to be decided by careful preoperative evaluation. Combined procedure of anterior and posterior surgery causes lesser decrease in pulmonary functions than costoplasty alone, and achieving better cosmetic correction. This study reaffirms the role of anterior spinal surgery in India as the patients due to lower levels of health awareness present late and with severe deformities.
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[Figure 1], [Figure 2], [Figure 3]