Pulmonary Function in Idiopathic Scoliosis COMPARATIVE EVALUATION by kse10139

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Pulmonary Function in Idiopathic Scoliosis: COMPARATIVE
EVALUATION BEFORE AND AFTER ORTHOPAEDIC
CORRECTION
KUDDUSI GAZIOGLU, LOUIS A. GOLDSTEIN, DEJI FEMI-PEARSE and PAUL N. YU
J Bone Joint Surg Am. 1968;50:1391-1399.



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                      Pulmonary                                                  Function                                         in            Idiopathic                                            Scoliosis
         CoIPAntATmvE                               EVALUATION                           BEFORE                  AND               AFTER                 ORTHOPAEDIC                        C01I1IECTI0N*t

                                        BY         KUDDUSI               GAZIOGLU,                     M.D4,                 LOUIS              A.      GOLDSTEnN,                     M.D4,

                  I)EJI          FEMI-PEA1ISE,                        M.D.,                AND         PAUL                  N.        YU,          M.D4,              ROCHESTER,                               NEW          YORK

       Front         1/ic Cardiopulmonary                               Unit,            Department                     of        .1edicine              an(l          Division              of      Orthopedic                    Surgery,
                      Department                       of     Surgery,                 University                of      Rochester                    School           of     Medicine                    and         Dentistry,
   and         Orthopedic                     Clinic           and       Pulmonary                     Function                        Laboratory,                  Strong             Memorial                  Hospital,                  Rochester


              Most                patients                     with             scoliosis                have                     no         cardiopulmonary                  symptoms                           during            the
 early             stages                  of developmemit                                 of the         deformity                             event           whemi             there             is a rapid                     progression
of the thoracic        spinal     curvature.        Relatively     few patients       have   significant         symptoms
as young     adults     considering          the extensive     asymmetry        of the thoracic        cage and distor-
tion  of the     vital    organs.      However,         as the patients      grow    older,    severe      scoliosis     oftemi
causes                    cardiopulmonary        decompensation.                                                        Although                         the    pulmonary                                 function in the
scoliotic                    l)atiemits   of preterminal         phase                                                   has beeni                        ivell described
                                                                                                                                                                       2 .5                 22,     relatively        little
attentiomi                       has    been       givemi    to changes                                                 in pulmonary         fumiction     which     might Ii occur
the     early                    phase      of scoliotic         deformity                                              and     followimig     orthopaedic        correction     of                                                                          the
curvature.                         This      paper       reports      such                                         studiesn a group
                                                                                                                         i                 of patiemits      with    idiopathic
 scoliosis                     before               amid         after                orthopaedic                            correctiomi                       of       the         spinal                 curve.

                                                                                                       Methods
              Pulmomiary-fumiction                                            tests          were            carried                    out          imi sixty-two                      patients                      with          idiopathic
scoliosis.                     Fifty-three                           miorunal               subjects                    served                  as      couitrols.                   Both                 patients                   amid          normal
subjects                       were                between                     ten          amid        twenty                          years             old.              Twenty-six                           of        the           fifty-three
normal                     subjects                    were           siblings                 of      the            patients,                       imicluding                    one            pair          of       twimis.
              A      follow-up                           evaluation       was                    made     in thirty-three                                              of       the   sixty-two    patients
after              correction                          of the       scoliotic                      curvature.         The                                     entire            spimie amid pelvis     were                                            visu-
alized               by          makimig                    fourteeui                  by        thirty-six                        imich            flints.         The             degree                 of       the          spimial             curve
was            measured                            front              these              films           usimig                   Cobb’s                 method,                        which                   employs                   the           amigle
formed       by                    the           iuitersectiout                         of perpendiculars,                                  erected                           from             the          superior     surface                               of
the    proximal                              end      vertebra                         amid front     the                          inferior      surface                          of         the           distal    end vertebra.
              A spiuial                    curve              of 0 to                 25       degrees                  was             graded                 as      mild            or          Cla.ss         I deformity.                           We
did    not                 have   amiy                      patient               in        this        category.                             A spimial curve                               of 25 to                    49         degrees                   was
graded                    as moderate                            or           Class           II        deformity,                             amid a curve                               of 50 to                      74         degrees                   was
graded                u.s severe                    or        Class              III         deformity.                            There                were             five          patiemits                  imi Class                   II       and
forty-sevemi                          patients               mi Class         III.                  Patiemits   with    75 to 100 degrees              deformity      were
graded                    as     very   severe                          or Class                    IV deformity. rfemi patients       were    imi this     class. The
couivexity                       of the thoracic                           spimial                  curve as to the right
                                                                                                         w                       in fifty-four      (87 per cent)       of
the           patiemtts.
              Pulmomiary                           fumtctiomi                 tests         comisisted                   of nteasurememits                                      of the               subdivisions                         of lumig
volume,                        minute                    vemitilation,                         oxygemi                   uptake,                       tinted               vital                 capacities                       and             related
          *    Presemited                    iii    part         at      the          Annual             Meeting                       of     the       Scoliosis                 Research                  Society,                Mimineapolis,
Miminesota,                    September                    7, 1967.
          tSupported            in part        by   gramits-imi-aid                                            front           the    National        heart                            Institute,                 U.S.         Public         health
Service       (HE-3966,           011-00209          amid HE-5500),                                                    the       Genesee       Valley       heart                            Association,                     the     llochstet-
ter    Fund        amid the        Comnionwealth         Fund.
           260     Crittenden            Boulevard,           Rochester,                                             New    York                        14620.
         § Work         performed          during       the tenure of                                        a    Commonwealth                                Fellowship                  in Medicine.                       Present
address:          Department           of    Medicimie,           Lagos                                          University                          Medical                 School,                P.M.B.                 12003,              Lagos,
 Nigeria.

VOL.      50-A,            NO.        7.     OCTOBER                   1968                                                                                                                                                    1391
             1392                                K.          GAZIOGLU,                         L.     A.       GOLDSTEIN,                                    0.            FEMn-PEAR5E,             AND              P.      N. YU


                                                                                                                                 TABLE                        I

            PHYSICAL                        CH;iIm.#{149}iciEutmsTucs                    OF          NORMAL                       SUBJECTS                             AN!)          PATIF:NTS      WITH                  IDIOPATHIC                        ScoLuosms


                                                                No.     of                                   Age                                       Height                                    Arm-Span                                           Weight
                                                               Subjects                                   ( Years)                                (Centimeters)                                (Centimeters)                                   (Kilograms)

            Normal
                   Female                                             30                                     15.8                                            161                                           163                                               56
                      SD                                                                                      3.1                                               8                                             7                                              12
                   Male                                               23                                     14. 5                                           166                                          166                                                60
                          SD                                                                                  2.7                                                      9                                        10                                           16
            Scoliosis
                   Female                                             53                                     14                                              158                                          161                                                49
                        SI)                                                                                   2.8                                                     7                                          8                                           11
                   Male                                                9                                     15                                              170                                           176                                               62
                      SI)                                                                                     2.6                                                     9                                     12                                               11




            measurenTremit.s,                                   maximum                               expiratory                                  flow-volume                                  curve,                  diffusimig                            capacity,                     niem-
            bramie               diffusimig                     capacity,                           and           pulmonary                                  capillary                         blood                 volume.
                  A Collins        nimie-liter       spiromet.er         with                                                                          diffusimig     capacity      umtit, Becknian’s                                                                              carbon
            monoxide        infrared         analyzer          (IR-215),                                                                             and      oxygemi     amtalyzer      (C2)  were                                                                      the         inst.ru-
            ment.s                   for       measuring                            lung             volume,                       diffusing                               capacity,                  membramie                                  diffusimig                   capacity,
            amid              pulmonary                            capillary                         blood                  volume.                          Residual                           volume                      was                determinied the
                                                                                                                                                                                                                                                       by
            helium                    dilutiomi                 method                     as previously                                  described                                by        Meneely                      and             Kaltreider Using
                                                                                                                                                                                                                                                20#{149}                       a
            wedge                    spirometer,                            both               flow-volume                                amid               timed                   vital         capacity                            curves                     were         recorded
            simult.auieously                                    from  a forced     expiratiolt        followimig    a deep    imtspiration.                                                                                                                  These   t.racimtgs
            were       projected                                 on an oscilloscope            screen      amid were    photographed                                                                                                                        with   a Polaroid
            camera                           Diffusimig                      capacity,        membrane                                                 diffusing                              capacity,                      amid pulmomiam’y        capil-
            lary              blood             volume                       were      measured by the                                             sintgle     breath                             method                      of Ogilvie,     Forster
            and            associates      9,18,21

                          The      orthopaedic                                  treatmentt                         consisted                                 in correction                              of the curvature by                                 1-Jarring-
            ton           instrumentation                                   alone,      rib                   resection                            and          Harrington                                instrumemitatiomi,                                             and             pre-
            operative                            localizer                    cast,                 ligament                            release                        on          the          contcave                     side                 of             the         curve,             and
            Harrington                                  instrumemttation.                                 Subsequently,                                  spine                      fusiomt               with              the                  use              of     a     large
            amoumit                    of fresh                    autogenous                               iliac               bone               stabilized                           the       spine
                                                                                                                                                                                                  in the                  corrected                              positiomt.
            Itt         all          1)atiemits,                  the             average                     period                     of         recumbency                                   w-a.s three                            and              omie-half                      momit.hs
            and     the                    average                    cast  immobilization                                            was                         approximately                             eight                           in the
                                                                                                                                                                                                                                           mouths                      post-
            operative                         period.                   The   average                                       pre-correction                                curve                         was    62                        degrees,                       whereas                 the
            average                        fimial             curve                after              correction                               and                stabilization was                   21             degrees.                          Pulnionary


                                                                                                                                 TABLE                  II
           MEAN            VALUES           OF      PULMONARY                      Furccrios                 TESTSIN            PATmENTS                wm’rim             IDmoPATIImc            5coLmosm                 AND           IN      NORMAL                SUBJECTs’


                               \-C                     RV                  TLC                 RV/TLC                FEV           % in                 MEFR                       MMF             V max.                    IIIL                  Drm                        Vc
                                (L)                     (L)                 (L)                     (%)              i”           2”      3”         (L/min.)                    (L/sec.)         (L/sec.)             (mu/min/miimn                 hg/MI)              (mn1/I2)

Patients
ClasslI                        2.6                       .9                 3.5                     24                     87       97             98                      204       2.i              3.8                       18                          46                     44
Classlil                       2.7                       .8                   3.5                   24                     84       95             98                      169       1.9              3.7                    lii                            38                     45
CIassIV                        2.6                       .8                   3.4                   23                     85       96             99                      170       2.4              3.6                    15                        39                          4i
All     Patients               2.7                       .8                   3.5                   24                     84       95 98                     172                    2.0              3.7                       itt                    39                          44
      SD                         .4                      .2                  .6                       5                7            3         2                       53                .4                 .8                     3                      8                         ii

Normal                         3.8                    1.0                  4.6                      21               85           97     99                  297                     3.5              6.6                    18                        47                          43
   SD                            .5                     .3                   .7                       4                7            4      3                   74                      .5             1.0                     3                          #{182}1                   13

                                      \-C                =     Vital capacity                                                                     IMF             =        Maximum               mnid-expiratory                 flOW
                                      RV                 =     Residual     volume                                                             Vmax.              =        Peak     flow
                                       TLC                =   Total        lung         capacity                                               Da                 =        Diffusing           capacity
                                       FEV                =    Forced             expiratory            volume                                 DM                 =        Diffusing           capacity            of the               mnemnbrane
                                       I%IEF R            =    Maximum                    expiratory           flow      rate                   Vc                =         Pulmonary               capillary      blood              volume
           C Regression                    equations              derived              from        normals          were
                                                                                                                   used      to               compare                      the      tests       after         adjusting                   age,          armii-span       weight
                                                                                                                                                                                                                                                                            and            in

normals             and        patients.

                                                                                                                                                         THE                 JOURNAL                OF          BONE              AND              JOINT                SURGERY
                                                                  PULMONARY                            FUN(”l’lON                    IN      II)I(i)PA’l’llI(’               s(’OLIOsls



                                                                                                                                                                                                          NORMAL

                                                                                                                                                                                                    SCOLIOSIS                 _______




            --%
            K,

            Lj
            ci




                                                   VITAL                CAPACITY                                           RESIDUALVOLUME                                                              TOTAL LUNG
                                                                                                                                                                                                     CAPACITY
                                                                                                                           Cui.uri’ I
        Percemi               t age          (If     pretlicterl                   val L iPs    of      1aug          vol        irma’s       i mi Pttt          ieti I s wit           Ii i(liopat               liic      scol         iosis          (I tiring           the
l)1’(IIl)ei’tttiV(’                        l)(’m’i(l.            For         coriip:Lm’isl            )mi, mi(Irnial             values                comii(lere(l                    as      100        lx!r      cemit          are           sluavmithe
                                                                                                                                                                                                                                                   (lB
l(!ft      (If       each                 colunimi.


 fiuiiction                     \\5                  nieasure(l                           set-cut            to        ten            days               prior              to          orthopntedic                              iuiterveutt.ioui                            ItIi(l
 (iuriuig                    tIiC             iiiteu’val               between                  omie         an(l       four              s-ears        after             remnoval                   of      the          cast..
                                                                                                                           Results

                  riji                             J shOWs               l)hVsicttl                    characteristics                                  of        the            tornial                  subjects                       ami(I           l)atieltts.

 The                age, height,                                and          ieight              mm1)0th                groups                    iveu’e          quite              sinmilar.                   Jut ‘1ahle                      II       are          imi-
cllu(IC(l 1 ll(’nteaui                                      Vaitles                 Itli(istituidItl(l             of
                                                                                                      (le’l’jatiolls                                             various               J)ttlItIii(’t(’rs                 of Pt1lniOIial
fuuiction                           ill            both            l)itti(1it5                 an(l           uiorntal                     subjects.              rflie          i)redicted                         values            of              these
l)itmtttti(’t(’t’S                                  jut the            l)Ittieutt5                    were             estiuttateti               by         regressiomi                           eluatmolts               Ol)t.ailie(l                      jut
noruital                       5tll)ects.                           Stat ist ically,                           t he           l)(5t          iuidepelldleult                            Variai)Ies                         t
                                                                                                                                                                                                                      fom equations
                                                                                                                                                                                                                   hese
                   age,               height                      ol’aunii s)aui,  an(l                        i’eig1it              in      uiomnial                   sul)jects.             .FlieICf()1e,                 ()fli1)ttI’i5()li

of these                        f.(’sts between                               l)itti(’lits             muid         llOlIflttl              511l)jd’et.s           was           niade               after           statistically                       ad-
justing                      age,             arni            spoil,              amid!        weight               iut 1)0th              OU)5                  (female                     auid         niale            separately).
                 Vii al capacity,         ntaxiiituni                                                        expiuat.orv                          flow          rate,             nitaxiniunt                        mui(l-expiratory                                       flow,
amidi            l)(’Itk flow     nteasimred          front                                                    floiv-volunte                                  ctmrves               were      the                     best      parautteters                                     of
l11llIti0liitt’Y                            function                         for      different.iat.ioui.
                 Chart                     I shows                     th(         perceuttage            of                  predicted                          valimes               of      mesidual
                                                                                                                                                                                                      volulue                       aIR!              total
mug                       (‘ItEteity                       of         the          patients                    jut      the           l)reoperIttive                              period.                    For            couitl)arison,                                 itormual
alues                       N)lisideled                           as         100          pem’ cemit                 are         showmi                out the                left            of      each               coltintti.
                  r1lt(         nieami                    value              of       vital            ca)Itcit.y             va.s          71         ier        ceuit           of         the          utornmril.               Because                           the
residual                            ‘VOllIlfle                    remaniedi       withimi      normal         limits,                                            the        total              lung
                                                                                                                                                                                                 capacity                          was                not re-
 duce(l                t.o the                            sante           exteunt      as the      vital        capacity.
                  i\Ieasurenteuit                                        of the       tinted vital    cal)acities                                            fIniledl        to             reveal         amt’           abuiormality.
 However,                             flow                rates              (maxiununt                           expiratory                          maximuni
                                                                                                                                                   flow,                                     mid-expiratory                                  flow,                  and
 ijeak  ffinv)                       1-iteasuredi      frouit forced       expirat.iomt                                                                  were              reduced                     almuost               to          half            of the               mtor-
 mimI values                          (Chart      II).
                  rfhe          nteami     value     of the     diffusiuig       capacity                                                                        for        the             whole                group              of           Patiemits
                                                                                                                                                                                                                                                     was

VOL.              50-A,        NO.             7,       OCToBER                      1968
1394                    K.      GAZIOGLU,           L.       A.   GOLDSTEIN,              D.        FEIm-PEARSE,               ANI)       P.      N.     YU


                                                                                                                                               NORMt.L        ________
                                                                                                                                         SCOLIOSIS            _________



         -%




          K,



          ci




                               MAXIMUM   EXP.                                  MAXIMUM  MID.EXP                                                PEAK        FLOW             RATE
                               FLOW RATE                                       FLOW RATE
                                                                               CH.tmtr         II
     Percemitage       (if predict         ed    values      of forced      expirat      or)’            flow    rat P:It imi i I s
                                                                                                                      es iem             Wi    I Ii n III p:tt Ii ic   ((     ,lim (iS
(luring        the    preoperat            ive     pem’io(I.    For    coniparison , mi Irnial               val imes Icmii(leI’eI            I a’       1( )( ) pet        cem :i mc
                                                                                                                                                                              it
shown       oh    the    left    of     each       coltimmi.




                                                                                                                                PREOPERATIVE               _________
                                                                                                                               POST      OPERATIVE         __________
                                                                                                       110%




                       VITAL                  CAPACITY                                  RESIDUAL                                         TOTAL   LUNG
                                                                                         VOLUME                                            CA PAC I T Y
                                                                           CHART           III

      Coniparisomi       iii    pem’centage        (If      PreoPerIti   ive      and     postoperat                ive   l)re(licte(l            values( 1 litmig      v(Illmmues
iii   patients       ss’it Ii idiopathic                 scoliosis.

                                                                                                TIlE      JOURNAL         OF      BONE            ANI)     JOINT            st:ituF:mtY
                                                                  l)Uu:\IoNAlfl.                            F’t’N(”l’lJN                         IN            ll)IOI’A’l’ElI(’                     5(’OLlOsIs                                                   1393


                                                                                                                                                                                                             PREOPERATIVE                         I::::.:...:.:.:.:.:.:.:fI
                                                                                                                                                                                                             POSTOPERATIVE


                                                                                                                                                                         83%
                       80



                       60-


                   40



                    20



                          0
                                          MAXIMUM   EXP                                                                       MAXIMUM   MID. EXP                                                                                  PEAK                 FLOW
                                          FLOW RATE                                                                           FLOW RATE
                                                                                                                              (‘ii.iti’               IV

   C I1I1l)1m’iS(    I I imI p(’r(’emi                                   tage      (If      preoper:tt                      ive amid              p        (   )pertt
                                                                                                                                                               st              ive           J)mC(liCt        ed      val1CS
                                                                                                                                                                                                                        I          of      forced           expirat(       I-

rv flav     i’tt  es iii 1)11 icmit                                       vitli          i(li(Il)tt           hic         s(oli(Iis.


not.       Sigllificalitly                                    (liflereuit                   froni                that mi nornial                                   subjects,                       although               in sixteeut      pat.ieuits
the            individual                             figure               of        diffusimig                   capacity      was                               abutornially                               low.          The     miienul)mamie      (hf-
fusing                 elj)1tcity                        :111(1      PIllniouia1’’                              capillary              blood                       voliunte                        iu    estiniated                     imi thirty-four
liI)t’fliItl                  stll)jeCt5                          amid jut        twemity-seven                                   l)atiemits.                       Seveuiteen                               of      twentv-seveui                               patiemits
had               t’e(ltlCP(l                             Iiienil)rauie                               diffusimig           CaJ)aeity.                            l)ecrease                         iui            (lifmusiuig                   capacity                        muid
nteuiilrauie                              (liliusilig                       ca)acity                                      proportiontl                                  to        the           lung               volunte.             Ott           the        other
baud,               PlllutioliitlY                                capillary                    blood                  voluuiie                                     uiorunal                   in all patients.
               Altogether,                                        t.veiitv-nimte                            l)atient.s                    had                  abnorniality                            itt          one            or          more                  the
                                                                                                                                                                                                                                                                    of

             of
l)ntm’mt1it(’t(u5 l)ttlIiiOIlitI’Yfunction.     Iii this group,    fourteeui                                                                                                                                        ha(1 l)redolttiuialit                              ab-
norntalitv     in stml)(livisions of lung voluune     which   was characterized                                                                                                                                                  mnaiuilv                by reduc-
tion           of t.li( vital                                 cipacitv               auid             its       conipouieutts                          ; three                     had imiipairutiemit.                           of the                 expirato-
l.y                      I’flt(5             ; an(1             twelve                   had                l)re(Ionniulanit                                   difficulty                      iui dif’fusiuig                      capacity.                       In          eleven
of the             patiemits,                            ll1Ot’e          t.hiIlIi           one              category                          of fumictiolimil                                inipairnient                               was          presemit..                rFlte
t\V()           )hysiologieal                                   abnoriitalit.ies                               which                 were                  niost                  frequeuitly                         observed                         were              restric-
tive           l)att          (‘lIi             IIli(i        imiti)murntelit                          of        (liffusing                     capacity.
               Chart                      III            shows                  postoperative                                      findings                             of vital                  capacity,                        residual                    volume,                    and
total                   lulig                   capacity                          expressed                                 itt           percenitage                                   of       the               respective                          predicted                         values.
Preoperative                                    l)re(lictedl                       figures       were                              also included                                         for       comparison                                on        the    left side    of
each               colmtuiimi.                      lollowing                           correction                                   amid stabilization                                              of the                     spinal                 curve,      the  vital
capacity                              iml)roved                            from                       73        to         90             per          cemit                 of         predicted                         value                arid           the          total             lung
capacity                        fuont                    77         to      97            per               cenit.            Some                    imicrease
                                                                                                                                                              jn                  residual            volume                            from     95 to                      110
per            cent.          of           j)ue(liCted                          values                       was            also                noted.                         there
                                                                                                                                                                             Also,                 had    been                          improventeuit                               in
expiratorv                                      flow       rItteS            as           (lel)iCt                  Pd! by                maxintum                                 expirIttory                                m
                                                                                                                                                                                                                          flow, axintumit                           mid-
expiratorv                                                 1111(1 peak                        flow                                                     IV).
               Pi’ior                 t   (.)    oi’thopaedic                                   treat
                                                                                                              rates               (Chart
                                                                                                                     unent, abmiornialit.y                                        in         pulntomiar’                         functiomi                     w’a.s b-
                                                                                                                                                                                                                                                                   o
sel’Ve(l                    Hi             sevemiteemi                             thirty-three
                                                                                  of                                               l)atienits                           vlio          underwent                           surgery,                           aui(l twelve
of       these                        l)atielits                showed                     au          iliil)rOventelit                               towar(l                      normal      in                    l)ulmouiIir                            functioui
tests               followimig                                 correction                              of           the           spinal                       curve.
                                                                                                                                                                   In             the           rentaimiimtg                   sixt.eeli               patients,
l)lllntollary                              funct.iomi                       was                 wit.hiui                    miornial                       lintits                     before                 arid          after                   correction                      of       the
VOl..          50-.\,            No.             7,       OCTOBER                        1968
1396                          x.     GAZIOGLU,                       L.       A.      GOLDSTEIN,                  D.     FEMI-PEARSE,                       AND          P.      N.      YU


scoliotic        curve.      A thirteen-year-old                                                 girl,  durimig     surgery,    had     vigorous                                                    bleeding         from
the      exposed        area   arid     required                                                 twelve      umtits    of blood     transfusion.                                                       Postoperatively,
she      had           a stormy                     course                with              bilateral                  pneumomtia,                     bilateral                   pneuntot.horax,                               l)leural
effusiomi,              amid salmomiella         ga.st.roenteritis.            She was                                                       treated         by bilateral                                chest.    catheter
draimtage                amid oxycillimi.      Follow-up            roentgemiographic                                                              studies      showed                               bilateral       pleural
thickening                   with     diminished            right       diaphragmatic                                                               excursioui.       Her                              presurgical           pul-
monary                  function        tests                       showed          restrictive           abnormality-vital     capacity,                                                             2.2 liters
(69 per                cemit of normal).                               A year          after      surgery,        there     was     further                                                            deterioratiomt
                                                                                                                                                                                                                itt

restrictive                 respiratory                           abnormality-vital             capacity,         1.S liters      which                                                            remaimied         the
same            four years                 after         surgery.                     Her          spinal              curve,            however,                  was            reduced                  front         45       to        10
degrees                as      a result                   of     corrective                         surgery                    despite            worsenlimig                     of      pulniollary                       functiomi
due        to      sequelae                   of        the        puteumonia                            amid          pleural            effusion.
        Pulmonary                             functioui                tests      were                        performed                     at regular                      initervals                       fom’ niore    than
several      years                       iui twenty                  of thirty-three                              patiemits                who were                      surgically                       treated       in order
to      assess              amiy           improvememit                              one          year             after          surgery.                  There
                                                                                                                                                             was          mto appreciable                                im-
provememit                     in the               pulmonary                            function      itt    eighteen                of these                twemit.y                patieuits                 flllowing
the        determinations                                 made                 omie year                      after            surgery.               In       two              patients,                   however,                    some
improvement                         ta.s       noted.                One             girl had          a vital             capacity               of 70 per                     cent          of uiormal                  before
surgery,                83         per       cent         omie         year              after          surgery,                 amid      98        per       ccitt            three          years             after           surgery.
Another                 girl had    a vital                            capacity                    of 72 per                    cent       ofnormal                    before       surgery,                         57 per                 cent
one year                  after  surgery,                               amid 102                   per  cent                    three        years                after       surgery.
           There               was           no         statistical                      correlatiolt                      between                omiset            or          degree               of     the          spinal              de-
formity                 with      the  impairmemit         of pulmonary            fumtctiont     or with    the      improvement                                                                                                         of
pulmomiary                   functiomi    following      surgery.       Likewise,      no statistical     correlation         was                                                                                                  foumid
betw-een                 the    degree     of correction          of the    spinal    curvature       amid improventemit                                                                                                          of pul-
monary                  function                    following                       surgery.


                                                                                                  Discussion
           Imi the                 begimining                   of        our            study               we         observed                that           the     predicted       values     of                                        pul-
momiary                fumictiomi                  in     some                patients                   may             vary              deal
                                                                                                                                         a great            dependimig         out the    miormal
values            of         differemit                 sources        1,7,8,14,17               Subsequently,                            pulmonary                           fumictioui               studies              were
performed                    imi twenty-six          normal                                           siblings      of the    patiemits      amid twenty-seveui                                                                    other
normal                 subjects   itt the     same      age                                       group        who    had  similar      emiviromimenital          and                                                          socio-
economic                  levels     as those      of the                                        patients.        We comisider      the resultsthese in fifty-three
normal                 subjects                    as satisfactory            control     criteria                                          for        evaluation.                          Hepper,      Black,      amid
Fowler                 observed                      a close      correlation         between                                             arm          spami amid                       height      imi 258     miormal
subjects                 (arm    spami to height                                              ratio
                                                                                                  =          1.03         in     males     amid 1.01                      iii     fentales).                   Maiiy
authors                suggested      substitutimig                                           arm            span          for      height    for the                           predicted                    values              of         lung
volume                 in      patients                   whose                    height              has         beemt          short.ened
                                                                                                                                           by          spinal                 deforntity.                       We        also
demonstrated                               close          correlation                        between                     arm        span          and           mi our
                                                                                                                                                               height                 miormal              subjects
(arm            span           to          height              ratio      =         1.02          in         males             amid        1.01itt         females).                    Imi        couitrast,        we
found              no          statistical                      correlation                         between                       arm      span                 and    height                          imi patients                          with
scoliosis.                   Therefore,                        arm       spanwas                   used     for                  predictiomi                   of various                           parameters                         of
pulmomiary                          fumictiont                 based                 upon               the            regression                 equatiomis                      obtaimied                     front            miornial
subjects.
           Objective     difference       imi pulmonary                                                                function          between      patiemits       amid miormal     sub-
jects        ha.s beemi established           by statistically                                                                 adjusting         age,   arm     span,      amid weight      in
both         groups.
           Twemity-miine       of sixty-two       patients                                                              had        abnormal                     pulmonary                            fumictioii,               mainly
with        reduced              lung    volumes                                   and      expiratory                          flow rates.                   However,                        in     the    majority       of
patients,                    the    abnormalities                                        imi pulmonary                             function                   were     mild.                       Mankimi,        Graham,
and        Schack                   amid Westgate                              also          reported                    an      impairment                        of pulmomiary                             fumictiomi
                                                                                                                                                                                                               in   ami

early            stage              of      the         disease.
                                                           PULMONARY                           FUNCTION                       IN         II)IOPATHIC                  SCOLIOSIS                                                      1397

             Imi genem’al,                               niauty              authors                  observed                           a positive                     correlatiomi                    betweeui                     impairmemit
of        pulmitouiar                               function                      amid          severity                      of         the          spimial            curvature,5,i6,22#{149}
                                                                                                                                                                                 2                          Iii      our study,
niome              1)ttt.ielitS                         with           Class               IV         deformity              had            physiological                             abmiormnality                       thait  those
ivitlt       Class                 II        deformity.                          For           example,             iii     Class            II 20 per                   ceuit,         imi Cla.ss  III                   43 per cemit,
Itflfil jut Class                         IV            60 per              cent           of the               patients                    were           foumid              to      have            ahmiorma.l                        pulniomiary
function.                  However,                                no statistical     correlation          was                                                    foumid betweemi                                 the degree     or outset
of the                deformity                                amid the physiological             abnormality                                                          imi the entire                                group   of patiemits.
This              observation,                                  compared
                                                                as                               with               that            of other                workers,                    may            be         due         to      iuiaccurate
estintatiomi                            of         omiset             of      the          scoliosis                      imi some               patiemits                   because              it        was          ntaimily                  bmLsed        out
imiforniatiomi                            givemi                by         the          l)tiremits             who                might               fail liote to the              true       outset              of deforniit.y
auid to the                           rather    small                            nuniber                  of patiemits                          in differemit   classes       which                                        may      miot be suf-
ficiemit for                         a reasomiable                               statistical                 evaluation.                            Reid,     by studying
                                                                                                                                                                        luuigs    at                                     uiecropsy,
st.at.e(l           that                  omie of the                       importauit        factors      in assessing                                                   pat.hophysiological                 ahuiorma.hity
is the             age               of     omiset of                       severe     spimial     curvature 22#{149}
             The               pat.terui                   of vemitilatory                             abnormality                               in our               patients
                                                                                                                                                                            wa.s quite                      sintilar                to      that
reported                           by              other                workers          2,5,19,22,25,26#{149}               Reduced                       lumig             volume,                   particularly                                vital
capacity,                      was                the        most        comniomi      abutormality                                                     (Chart                 I).      Because                      residual        volume
changes                   rather                        imisigitificauitly        from     the     normal                                                 values,                    the total                    lung      Ca)acity
                                                                                                                                                                                                                               was
less   i-educed                                   than           the    vital      capacity.       Consequemitly,       the      residual      volume                                                                                               to total
lumig capacity                                     ratio         imi some      patiemits     showed      an abmiormal       high     value    bearing                                                                                              a super-
ficial  resemblance                                            to that       of emphysema            amid chronic     bromichitis.         As poimited                                                                                              out     by
Bergofsky,                                Turimio,                    and           Fishmami,           itt         emphysenta                           the            residual               volunte                   is absolutely
imicreased,                             while                  the          total              lumig            capacity                        may              be          normal.                 Out           the             other             hand,                 iui
patieuits                     with             thoracic                      deformity,                         while               the          residual                 volume                 is slightly                        decreased                    or
normal,                        the           total               lumig           capacity                      is         usually                reduced.
             We               foumid                rio difference                             in helium   mixing                                      index,       mimiute     ventilation,                                          and oxygeum
uptake                        betweeui                  the    patiemits                          amid the  miormal                                       subjects.        Fishman           amid                                   a.ssociates
                                                                                                                                                                                                                                         2,22

imidicated                           that                imi patients                          with             kyphoscoliosis,                   although                     physiological                              dead               space
is       mtorntal,                 alveolar                      vemitilation                         is sacrificed                            because                  of     small            tidal              volunte.
             \e               failed                to         reproduce                       maxintum                            breathimig                    capacity                   faithfully                   imt both                  pat      ieuit.s
autd         miormria.l                     subjects.                       However,                          tests               such           as      vital            capacity,                    simigle            breath                   diffiusiuig
capacity                  ,    flow-volume,                                 amid t ime-volume                                       curves               were            readily              reproducible.                               Abmiornial
flow         rates                 (maximum                          expiratory                    flow,                  maximum                       mid-expiratory                               flow,           amid peak                     flow),
associated                              with              miormal                 t.imned             vital                capacities                    mt patieuits,                       merit                imiterpretat.iomi                         since
these              abmiorniahities                                     are generally                             observed                           in obstructive                           respiratory                             inipairmemit,
although                mione of the                                  patiemits   had                         obstructive                            pulmomiary                       disease.        It has                        been     showmi
i)\’ Dayniaui                            amid byFry     and Hyatt     that                                                     iii miormal    subjects       gas flow chamiges       propol’-
t.iouiately                        ivithi    the   degree    of imtflat.ion                                                       of the   lungs.      Since    iutflatiomi capacity         of                                                                the
lumig         in          some                     patiemits                  with             thoracic                      deformity                      is reduced,                         decrease                      in         flow        rates            is
expected.                            Daymami                         further                   showed                      that           initial           portion                   of      flow           of         forced               expiratory
volume                     is effort-dependent..                                               This       concept                           should      riot                  prevent               interpret.at.iomi                             of l)eitk
floiv ill                differenit      lung    diseases.                                             Maximum                               expiratory                       flow,           imiitial     forced                          expirat.ory
volunte,                       and      maximum                                  mid-expiratory                                       flow      fall also     more     or less imito                                                        this   effort-
depemidemit                       portion      of                           forced     expiratory                                    volumne 10,24 arid
                                                                                                                                           6              are     most    frequently                                                          used
a.s tests                     to         dist.imiguish                        various      physiological                                            respiratory        abnormalities.           In                                                 this       ami(l
iui another                             study ii, we                        found     that     the     peak                                      flow     measurememit          is reproducible                                                            amid
useful             itt        imiterpretimig                               different                  respiratory                              abmiormalities.
             As          showmt                     by         Cadigani                    amid        associates,                             diffusing                 capacity                 varies                 proportionately
ivitli            chamiges                        imt lung                  volume.                   We             also           observed                     this                     in
                                                                                                                                                                               relatiomiship       sixteen                  pat ients
whose                diffusing                           capacity                       arid      lung                    volumes                 were             both              reduced.
             Pulmomiar                                  capillary         blood                       volume     was                                   normal      jut all pat.ieuits,                                         evemi though
some               of           t.hent                   had      reduced                          lumig volume.                                      This    findimig    suggests                                        a     compensatory
\.oI,.       50-A,             NO.           7,     OCTOBER                      1968
1398                            K.         GAZIOGLU,                         L.     A.     GOLDSTEIN,             D.      FEMI-PEARSE,                         ANI)          P.       N.      YU



adaptatiomi,                         possibly   expansjon         of                                  the    pulmonary                              capillary                        bed           imt order                    to        provide
an adequate                           gas exchange        between                                        alveoli    and                      red       blood               3,9,18,cells
            During                       postoperative                                periods,               an          improvement                                  of          pulmonary                           fumtctioni                  was
observed     in twelve                                       of  seventeen                            patients.                   It is possible          that                                  sixteemi             patients       who
had normal      pulmonary                                        function                         tests      before                and after     surgical                                   treatment                   would     have
a better   chance     for                                  their   pulmonary                              function                   to remain      normal                                     in the             future      because
of        correction         of                   the spinal                         curve.
            The      pattern                       of follow-up                          pulmonary                        function                 tests              was            not         changed                      after          initial
improvement                                     following                  surgery,                    indicating       that                              correction                             of        the           spinal                 curve
was    the                 factor                  in the                improvement                          of pulmonary                                  status. two                    Ingirls,            however,
three              years                  after           surgery,                       there         was             further               improvement                                     in        pulmomiary                            status.
It        is possible                     that           correction                       of the           thoracic                   deformity                       enabled                     their          respiratory                           ap-
paratus                   to        function                   better                with          time.
            Cotrel             22        observed                  in         a series              of 353              patients               an         average                       of 30 to 40 per                               cent       im-
provement                           in respiratory                                capacity            after            orthopaedic                       correction                          of scoliot.ic                     deforntity.
The          improvement                           was greatest      in the more          severe      cases,     that                                                                      is, where     spimial curva-
ture         was more                       than 100 degrees    before     spine     fusion.       In our study                                                                            we found      no correla-
tion         between                       changes     in pulmonary           function         after     orthopaedic                                                                           procedure        and   amiy
of the             followimig:                     (a)      degree                   of correction                       of the            curvature,                          (b)         degree                of preoperative
curvature,                      or (c) onset                      of the deformity.         James                                      and         22   recommended                                    orthopaedic
operative                      treatment                        if a scoliotic      curvature                                         was          likely     to progress                                  to become                            more
than            60        degrees.                   Information                              concerning                      pulmomtary                        functiomi                     evaluatiomi                        after           cor-
rection              of         the             scoliosis               is rather                  scanty,                   because               the          studies                    are         apt          to         involve                 dif-
ferent            groups                    of patients,         particularly                                       with              reference         to                    their          ages,        the                   degree               amid
type            of the                   thoracic        deformity,           and                                 different                 orthopaedic                                 procedures’
                                                                                                                                                                                              12,13,22,23



                                                                                                    Summary

            Pulmonary                             function                    studies             were         reported                    in sixty-two                              patieuits                with              idiopathic
scoliosis            with                ages        ranging                       between               ten           and        twenty                  years                   and         were            compared                          with
the         data           obtained                    from                  fifty-three                normal                    subjects     of a similar                                        age         group.                     Twenty-
Six        of the          normal                    subjects                     were           siblings      of                the patients.
            Abnormalities            in                                 pulmonary                          function                    were       noted                           in twemtty-nimie                                patiemits.
There           was       a predominamit                                       restrictive                       type             of      respiratory                              abnormality                                imi fourteemi,
a reduction                          in         pulmonary                           diffusing              capacity                   in     twelve,                   and              a decrease                       in      expiratory
flow          rates     in                three.      The                     most          common       physiological                                  abnormality                                       was    a decrease                            imi
lung           volumes,                      particularly                                in vital  capacity         and                             its components.                                        Decrease        in                       pul-
monary                     diffusing                       capacity                        was        usually                associated                          with      reduced                                  lung                  volumes.
Pulmonary                       capillary                      blood                     volume          was             normal        in                all     patients.
            Omie to four                          years       after     corrective                         surgery,                    follow-up      pulmonary                                         functiomi                      evalua-
tion         was repeated                                 in thirty-three                            patients.                   In      these   patients,      the                                    average                       precorrec-
tion          spinal                 curve               was            62         degrees,            and             the        average                  final              curve                after            correction                         and
stabilization                 was 21 degrees.         In the postoperative                                                                     period,       improvementt                                         of pulmomiary
funtction               toward       normal       was    observed      in twelve                                                                   patients.         Sixteen                                     of thirty-three
patiemits             had     normal      pulmonary         function     before                                                               and      after     surgical                                    treatment,          sug-
gesting              that  they    \%TOUld have                                               a better     chance      for                         their    pulmonary                                        status                  to      remain
normal               in the future     because                                               of correction        of their                           spinal    curves.

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