bluuebunny/crossref_metadata_2025 huggingface dataset:
Use of an Interspinous Device above the Level of Interbody Fusion: Does it Reduce the Worsening of Adjacent Segment Degeneration?
Authors: Sudarshan Pramod , Panda Aditya Prasad , Paramasivam Aghilavendan , Varma Vamsi Krishna , Hegde Sajan
Published: April 2016

Introduction

Lumbar fusion in degenerative conditions has universally provided good results. However, adjacent segment degeneration, either afresh or worsening of a low grade degeneration in the segment above has been indicated for the pain and low functional outcome on long term follow-ups. Interspinous implants have been used to off load the facets and prevent spinal canal narrowing in stenosis with good results. This paper analyses the novel idea of using an interspinous device above the level of fusion to decelerate the physiologic process and reduce the incidence of adjacent segment degeneration (ASD).

Material and Methods

12 patients were analyzed in the study. The inclusion criteria for the study was degeneration of the disc above the level of intended fusion with no or less than 50% disc height reduction and no nerve root compression. Patients with more than 50% height reduction or severe arthritic facet joints underwent fusion at two levels and were excluded from the study. Patients with failed back syndrome and significant osteoporosis were also excluded from the study. Coflex (Paradigm) interspinous device was used in the level above the fusion in all cases. Clinical and radiographic criteria for ASD was assessed at the latest followup. VAS and ODI functional outcome was analyzed.

Results

12 patients with mean age of 63 years who underwent surgery between September 2012 and March 2014 were analyzed in the study. Mean followup was 27 months (Range 18–36 months). Single level fusion was performed in 9 cases and Two level fusion in 3 cases. Coflex device was implanted at L3–4 in 8 cases and L4–5 in 4 cases. All 12 patients had a good fusion in the 6 months radiograph. Disc height improvement was seen in the level above, with no evidence of stenosis or listhesis at the latest followup. Worsening of already existant ASD in one patient was noticed but did not require surgical intervention. VAS and ODI showed significant ( p < 0.05) improvement postoperatively. No infection or reoperation was needed in any of the 12 patients.

Conclusion

ASD remains a significant reason causing failed back syndrome requiring reoperations in lumbar fusion. Use of interspinous device not only preserves a motion segment from fusion, but also shows promise in reducing the incidence of degeneration above the level of fusion. Further studies with larger sample size and long term followup is necessary to support the conclusion.
The Stand-Alone Cervical Cages with Integrated Screw Fixation: Results in 315 Consecutive Operated Levels
Authors: El-Maghraby Hussien , Joshi Shabin
Published: April 2016

Introduction

Background: Cervical disc disease at C2/3, C3/4 and C7/T1 is less common. Fusion with cages & plating is the standard treatment at these levels and in multi-level disc disease. This is not without significant risks related to the need of larger exposure and anterior muscular dissection. Stand-alone cages with integrated screw fixation obviate the need for plating and larger exposure.

Material and Methods

To assess the exposure / cage related morbidities and fusion rates in Stand-Alone cervical cages with Integrated Screw Fixation. Design: Retrospective chart review. Subjects: 315 levels were operated in 253 patients from February 2009 to February 2015. Single and Multilevel cages were performed in 201 and 52 patients respectively. 201 of the 253 patients underwent single level discectomy with Stand-Alone cervical cages with Integrated Screw Fixation at C3/4 and C7/T1 levels. 52 patients underwent 114 multi-level discectomies with Stand-Alone cervical cages with Integrated Screw Fixation

Results

Operative time was shorter. There was no reported permanent exposure/ cage related morbidities in all operated levels. 3 patients with traumatic disc disruption required further surgery for lateral mass fixation. 12 patients had mild dysphagia that resolved during follow up with no patient having complains of dysphagia at 3- months follow up. Fusion rates were 95% at single level and 90% at multi-level discectomies at the last follow up. No patient required cage related surgical revision.

Conclusion

The current results support the use of Stand-Alone cervical cages with Integrated Screw Fixation especially at difficult levels at C3/4 and C7/T1 and in multi-level discectomies as it obviate the need for plating and larger exposure with less reported dysphagia and implant related complications.
Prevalence and Significance of Vitamin D deficiency in Patients with Idiopathic Scoliosis Requiring Corrective Surgery
Authors: Michael Antony Louis Rex , Hampton Matthew James , Evans Owain , Breakwell Lee , Cole Ashley , Naylor Beverley
Published: April 2016

Introduction

Vitamin D deficiency may affect children in terms of growth disturbance, deformity and metabolic disease. The senior authors have felt significant difference in bone quality intra operatively and wondered if vitamin D status was relevant in this. The aim was to assess the prevalence of vitamin D deficiency in a cohort of patients undergoing scoliosis correction surgery for adolescent idiopathic scoliosis (AIS) and to assess if Vitamin D deficiency had any significance/correlation to the pre-operative cobb angle or pain scores.

Material and Methods

Any patient undergoing corrective surgery for AIS who had pre-operative Vitamin D sample taken. From January to December 2014 a total of 69 records were assessed yielding a cohort of 41 patients undergoing surgery for Adolescent Idiopathic Scoliosis (AIS) with a recorded pre-operative total 25-OH vitamin D level. Three tiers of Vitamin D level were assessed including normal > 50nmol/L, insufficiency < 50 but  > 25nmol/L and deficiency < 25nmol/L as per local guidelines for Vitamin D deficiency in children. Patients' age, sex, pre-operative vitamin D levels, Cobb angles at time of surgery, pre-operative back pain scores were recorded.

Results

41 Children with a recorded Vitamin D level pre-operatively were analyzed. There were 4 male and 37 females. The average age at surgery was 15 years,(range 12 – 17). Of the 41 patients 9 (22%) were Vitamin D Deficient (range 10–25), 14 (34%) were insufficient (range 29.3–49.8) and 18 (44%) were above the treatment level (range 54.8 – 139.1). The average pre-operative Cobb angle for the deficient patients was 68 (range 50–89) compared with 64 (range 48 – 85) for the insufficient patients and 62 (range 44–76) for the patients with normal Vitamin D levels. The pain scores for each of the 3 groups revealed that the patients in each group complained of a similar (moderate) amount of back and rest pain pre-operatively.

Conclusion

Vitamin D deficiency in children leads to reduced calcium absorption from the bowel and may lead to skeletal deformity and rickets. The effect on bone healing of Vitamin D deficiency may have an affect on the quality of spinal fusion required as part of the surgical treatment for AIS and it is not known whether those patients undergoing surgery have adequate levels. This study reveals that 56% of patients had Vitamin D levels requiring supplementation. Further work is being undertaken to evaluate pain values, fusion time and deformity correction in those children with insufficient or deficient levels of vitamin D.post-op complications and hospitalisation
The Effect of Post-Operative Complications in Complex Adult Spinal Deformity Surgery on Surgical Outcomes: an International, Large-scale, Prospective Multi-center Study
Authors: Cheung Kenneth M. C. , Bow Cora , Samartzis Dino , Kwan Kenny , Dekutoski Mark , Schwab Frank , Boachie-adjei Oheneba , Kebaish Khaled , Christopher Ames , Yong Qiu , Matsuyama Yukihiro , Dahl Benny , Hossein Mehdian , Pellise Ferran , Carreon Leah Y. , Shaffrey Christopher , Fehlings Michael , Lenke Lawrence
Published: April 2016

Introduction

This large-scale study aimed to determine the effect of non-neurological complications in complex adult spine deformity surgery upon post-operative functional/disability profiles.

Methods

This is an international prospective multi-center study involving 15 sites from North America, Europe, and Asia. Adult patients with severe spinal deformity were assessed at 6 weeks and 6 months post-operatively. Non-neurological complications were recorded and grouped into intraoperative events, minor and major complications. Post-operative functional/disability outcomes were evaluated by Oswestry Disability Index (ODI) and SRS-22 pre-operatively and at each follow-up ( Fig. 1 ).

Results

269 subjects were included (68% women and 32% men; mean age: 57.8 years). There were no significant differences in pre-operative ODI and SRS-22 scores between patients with and without major complication. At 6 weeks and 6 months after surgery, patients with major complications had significantly worse ODI and SRS-22 scores compared with patients without major complications ( p < 0.005). Both groups with and without major complications showed statistically significant functional improvement 6 months after surgery ( p < 0.0001). Improvement in functional scores were similar in patients with and without intra-operative events and/or minor complications (p > 0.05).

Conclusion

Based on the largest, multi-center study addressing complex adult spine deformity patients, worse post-operative functional/disability profiles were noted up until 6 months follow-up in patients who experienced major complications than those that did not. Similar functional/disability profiles were noted in patients who experienced intra-operative or minor complications. This study further broadens the understanding of postoperative surgical outcomes, risk profiles, and clinical/patient expectations following such deformity surgeries. [Figure: see text]
The Convex Manipulation: An Alternative Technique in Surgical Treatment of Adolescent Idiopathic Scoliosis
Authors: Oggiano Leonardo , La Rosa Guido
Published: April 2016

Introduction

Concave derotation is the traditional correction maneuver in adolescent idiopathic scoliosis surgery. However, the positioning of thoracic pedicle screws at concave side of the curve can be quite challenging, because of the small pedicle size and the wide variation in its morphological characteristics, due to the vertebral dystrophy observed in scoliotic patients. Then, to reduce risks of neural damages, and ensure the same strenght of derotation maneuver, a convex manipulation through an all-level pedicle screws convex instrumentation can be performed. We report perioperative and 2-year results in a consecutive series of patients treated by convex manipulation through an all-level pedicle screws convex instrumentation.

Material and Methods

From January 2013 to January 2015 we surgical treated 36 consecutive patients (28 F, 8 M, mean age 13 years) affected by thoracic adolescent idiopathic scoliosis (Lenke type 1, 27 patients, and Lenke type 2, 9 patients). Mean pre-operative Cobb angle was 56°±6° in Lenke type 1 group and 51°±4° plus 32°±3° in Lenke type 2 group. We performed a posterior access only in all patients using polyaxial pedicle screws at each level on the convex side of the curve. Derotation and manipulation maneuvers were performed on the convex prebent rod. In all cases motor-evoked potentials monitoring was used. Mean follow-up time was 27 months.

Results

The average percentage of coronal correction was 76 ± 5% (mean post-operative Cobb angle 15°±4°), with no neurological complications. Concerning the post-operative kyphosis, we observed a slight decrease of mean values compared with pre-operative measurements (mean reduction of thoracic kyphosis 5°±2°). At 2-year follow-up no changes in coronal nor in sagittal plane were observed. The mean operative time was 210 ± 30 minutes, with a mean blood loss of 500 ± 100 ml. Using the free-hand technique, the mean time of pedicle screws positioning in the thoracic area on the convex side was 2 ± 1 minutes from T6 to T12, and 4 ± 1 minutes from T3 to T5. Whenever included in the area of arthrodesis, T2 was usually instrumented with the Universal Clamps, to reduce the stiffness of the construct. Instead, T1 has never been included in the arthrodesis area.

Conclusion

This case-series study shows the effectiveness and the safety of convex manipulation in Lenke type 1 and type 2 scoliosis. The coronal correction obtained with this technique is comparable to that obtained with the traditional concave derotation. Other advantages are the short operative time, the low intra-operative blood loss and, mostly, a lower risk of neurological complications.
Can EOS 3D Morphological Analysis Better Correlate with Pain Patterns than the Lenke Classification
Authors: Simoes Leonardo , Ouellet Jean , Jiang Fan , Aldebeyan Sultan , Aoude Ahmed , Sun Jenny , Ferland Catherine , Saran Neil , Bote Sheila
Published: April 2016

Introduction

Adolescent Idiopathic Scoliosis (AIS) has been thought to be a relatively painless three dimensional (3D) deformity of the spine, but some studies has shown that the incidence of mild to moderate pain in AIS ranges from 25 to 50%. With the arrival of the new low dose radiation EOS technology, it is now possible to quantify intersegmental changes of the scoliotic spine in an upright position that could be related to pain.

Hypothesis

EOS 3D morphological analysis of AIS patients will better correlate with presence of pain than the Lenke classification.

Methods

Fifty-nine patients (7 male/52 female, mean age of 14.3 years old) who were scheduled for elective posterior spinal fusion with diagnosis of AIS. Preoperative clinical pain data recorded consisted of: 1) numerical visual analogue (VAS) pain scores quantifying patients average and worst pain over the preceding month; 2) SRS22 scores. Preoperative PA and lateral imaging were utilized to reconstruct and generate 3D models using the EOS software. Global and segmental intervertebral orientation in all three planes including the Da Vinci diagram identifying maximal deformity orientation were generated and correlated with patients' clinical presentation. In addition, standard curve magnitude, curve classification (Lenke) and pelvic parameters were also analyzed to observe their association to pain. Statistical analysis was performed with GraphPad Prism 6.

Results

Lenke classification and its subtypes did not correlate with pain, nor did any of the classic curve parameters, with the exception of the presence of hyper lumbar lordosis (>60 degrees) (r = 0.32, p = 0.06). Hyperlordotic patients reported greater pain intensity than normal lordotic patients (U = 81.50, p = 0.04). Additional new 3D parameters from both global and intersegmental vertebral orientations in space were investigated. With the exception of high intervertebral frontal, lateral tilt of L4 over L5, no 3D correlations with pain patterns were observed.

Conclusion

Despite the additional 3D morphological analysis generated by the EOS imaging, we were not able to identify anatomical characteristics associated to the pain experience reported by patients, with the exception of hyperlumbar lordosis.
Single Stage Hemivertebra Excision and Correction of Congenital Scoliosis
Authors: Elbanna Yasser
Published: April 2016

Introduction

Congenital scoliosis isa progressive three-dimensional deformity caused by congenital anomalies of vertebrae that result in an imbalance of the longitudinal growth of the spine. Failure of the vertebral formation if complete will produce hemivertebra with unilateral pedicle

Material and Methods

The study included 30 patients with thoracic (16)and lumbar (14) hemivertebra. Posterior only hemivertebra resection with correction by short segment fixation was done for all cases. Intr-operative monitoring was used in (11) cases.

Results

Full correction was achieved in all cases. Temporary neurological deficit occurred in only two cases.

Conclusion

Because of the development in anesthesia and post-operative care, today posterior hemivertebra resection has become the standard treatment method for the single hemivertebra of the thoracolumbar and lumbar region.
Should the Spinous Process be Harvested as Bone Graft in Idiopathic Scoliosis Surgery?
Authors: Lai Po-Liang , Yeh Yu-Cheng , Niu Chi-Chien , Chen Lih-Huei , Chen Wen-Jer
Published: April 2016

Introduction

The spinous process is commonly resected during posterior fusion of adolescent idiopathic scoliosis (AIS) to allow for a wider fusion bed and more local autologous bone graft. However, the spinous process is an important structure in the posterior ligament complex and anchors paraspinal muscles. With the development of pedicle screw instrumentation and the potential fusion ability in adolescents, the need for resecting the spinous process in this procedure should be further investigated. The purpose of this study is to compare the fusion rate, duration of surgery, blood loss, surgical outcomes and complications between harvesting and preserving the spinous process in posterior spinal fusion of AIS.

Material and Methods

From January 2003 to December 2008, 104 consecutive AIS patients who underwent primary posterior fusion with local autologous bone grafts and who were followed for a minimum of 24 months were reviewed. The patients were divided into a harvesting group ( n = 61) who had the spinous process harvested, and a preserving group ( n = 43) who had the spinous process preserved. Radiographic assessments of structural curves were reviewed pre-operatively, 3 days, and 3 and 6 months post-operatively, and then annually. Blood loss, duration of surgery, pseudoarthrosis, post-operative back pain and other complications were also recorded at these time points and compared between the two groups.

Results

There were no significant differences in the duration of surgery between the harvesting and preserving groups (216 ± 47 versus 224 ± 50 minutes, p = 0.40), however blood loss was significantly higher in the harvesting group was statistically higher (983 ± 446 ml) than in the preserving group (824 ± 361 ml; p = 0.048). The pre- and post-operative Cobb angles, correction rates, and loss of correction of the structure curves were similar in both groups. Based on radiographic evaluation, the incidence of pseudoarthrosis was similar in both groups (3/58 versus 2/41; p = 0.95). Post-operative back pain or soreness was significantly higher in the harvesting group (16/58 versus 4/43; p = 0.03).

Conclusion

The surgical outcomes and fusion rates between harvesting and preserving the spinous process were comparable, despite significantly lower blood loss and less back pain or soreness in the preserving group. Thus, resecting the spinous process as local autologous bone graft may not be necessary in posterior fusion for AIS patients.
Apical Vertebral Rotation Assessment in AIS: What is the Best Method Scoliometer, X-ray or MRI?
Authors: Cho Woojin
Published: April 2016

Introduction

There are many factors correlated to the vertebral rotation in AIS patients such as the distance between the apex of rib and vertebra (rib-vertebral distance: RVD) on lateral X-rays, MRI or the Scoliometer measurement. However, no study has shown the relationship between those factors and the apical vertebral rotation.

Methods

Out of 380 consecutive AIS patients who underwent corrective surgery, 22 patients who had preoperative MRI and complete radiographic images stored in PACS were identified. Various angles and distances including Main Thoracic curve (MT), T5–12 sagittal profile, Apical Vertebral Translation (AVT), Apical Vertebral Rotation (AVR), RVD, trunk depth, and axial rotation of apical vertebra on MRI (AVRMR) were measured. Scoliometer angles (SA) for these patients were found in the charts as well. Rib Trunk ratio (RTR) was calculated by RVD/trunk depth. Each paired value was compared with find any significant correlation.

Results

The radiographic measurement and correlation values are shown in the table. There was no significant correlation between thoracic and lumbar parameters while the larger curves had the greater rotation. RTR was correlated with MT, T5–12 and T-AVT, but not T-AVR. MRI and Scoliometer could not predict the T-AVR as well.

Conclusion

This study shows that we can predict the amount of coronal and saggital deformities from lateral X-rays, but not the axial rotational deformities. Supine MRIs cannot predict AVR and standing MRIs may be helpful. Scoliometer angles predict L-AVR, but not T-AVR probably due to the combination of rib cage deformity and vertebral rotation. During the corrective surgeries in AIS, deformity surgeons may still need to consider the deformity of rib cage itself, even with the direct derotation of vertebral column.
Augmented Reality Mobile Applications to Interactively Show Complex Spine Pathologies: First Version
Authors: Galvez Marcelo , Rojas Gonzalo , Fuentes Jorge , Asahi Takeshi , Montoya Carlos , Vidal Aarón , Currie Willam , Chahin Andrés
Published: April 2016

Introduction

Visualization of complex human body structures such as the spine and his malformations such as, foraminal stenosis, spine stenosis, and herniated disk is a challenge. Augmented Reality is the combination of a real scene supplemented, or augmented, by computer generated information, such as image, video or graphical animations. Android and iOS based mobile devices such as smartphones and tablets are being increasingly massive adoption and with higher performance characteristics.

Material and Methods

Sagittal 2D T2w TSE sequence MRI (TR 4420 milliseconds, TE 130 milliseconds, FoV 320x320, Matrix 448x448, Voxel Size 0.7x0.7x3 mm) and sagittal CT (kVp 140, 1 mm slice thickness, 0,30x0,30 mm pixel spacing, B31s kernel) images were scanned in a 57 years old male patient. Both images were co-registered using “Linear registration” algorithm of 3D Slicer v 3.6 software. CT image was segmented using threshold option (113–1303 Hounsfield units) of 3D Slicer and then L4-L5 vertebral bodies was extracted manually using ImageJ v1.49n version. The L4-L5 intervertebral disk was segmented using “simple region growing” algorithm of 3D Slicer, and then was cleaned manually using ImageJ software. Mesh of L4-L5 and intervertebral disk was generated using 3D Slicer “Model Maker” algorithm with default options, and HC Laplacian smoothing (MeshLab software). The iOS-Android application were created using C# language and software tools: Unity 4.5x (graphic engine; www.unity3d.com ), 3Ds Max ( www.autodesk.com ), Visual Studio 2013 ( www.microsoft.com ), and Qualcomm Vuforia for Unity Android & iOS (Augmented Reality, developer.vuforia.com).

Results

By focusing the printed target image using iOS-Android app,L4-L5 vertebral bodies and the intervertebral disk of the patient was shown in 3D. The user can rotate the spine with the two-finger twist gesture, by rotating the view angle over the target image, or rotating the target image itself. The size of the spine can be changed by modifying the distance between the mobile device and the target image, or by the pinch gesture. Augmented reality demonstrated new views from inside spine (using total immersion feature of augmented reality) and relationship of normal structures and different pathologies.

Conclusion

The application described here demonstrates the use of augmented reality technique with medical images of patients with spine pathologies. The application shows how to use ubiquitous mobile devices to display advanced medical information in a 3D interactive application. The application is useful to show, explain and describe in a 3D, interactive and immersive way the spine pathology that the patient has. More work must be done to create an automatic CT-MRI registration, segmentation, creation of mesh, smoothing and decimation of vertebral bodies and an intervertebral disk.
The Shilla Growth Guidance Technique for Paediatric Scoliosis at 3-year Follow-up: a Preliminary Report
Authors: Sekouris Nick , Pilihou Anastasia , Vlahos Eugenios , Soultanis Konstantinos , Sapkas Giorgos , Flouda Lito
Published: April 2016

Introduction

To present the technique and the outcomes of the use of the Shilla system in children scoliosis.

Materials and Method

The Shilla system has been used in 4 children of 5 ½ -8 years old to treat scoliosis of 60°-70°. To place the system, a subperiosteal approach of the apex and a percutaneous approach of the curve extremities had been performed. In that way, a spontaneous spinal fusion is avoided. The edging screws can slip on the rod and permit spine to grow-up. Cobb angle, screw slipping, T1-S1 lengthening, and complications had been recorded.

Results

The Cobb angle average improved to 22° from (65°) and the T1-L1 lengthening average was 6,8 cm. No spontaneous spinal fusion has been noted. In 2 children, a revision surgery to replace the upper thoracic screw and the rod had been performed. A left leg neurapraxia happened, which resolved after 1 week. A preserved sagittal balance of the spine was observed during the 3 years of follow-up.

Conclusion

The percutaneous placement of the thoracic screws is used to avoid spontaneous fusion, but this is challenging and increases the risk of complications. Despite the complications, in all the children, a good surgical correction of the scoliosis was done, a normal grow-up has been noted, and the sagittal balance was preserved instead of other expandable systems, which are fixed only at the curve extremities.
Damage Control Surgery for Thoracolumbar Spine Fractures by Percutaneous Pedicle Fixation in Polytrauma Patients: Initial Experience
Authors: Valencia Manuel , Leiva Andres , Novoa Felipe , Riera Jose , Contesse Ivan , Illanes Juan Cristobal
Published: April 2016

Introduction

Spine fractures in polytrauma patients are relatively common. About one third require surgical treatment. Open surgical stabilization in these patients may increase morbidity and mortality associated with prolonged surgical time, bleeding and hypothermia. Internal fixation with minimally invasive techniques is an alternative for the treatment of vertebral fractures in polytrauma patients, diminishing local and systemic risks associated with open techniques.

Material and Methods

Polytrauma patients with unstable thoracolumbar spine fractures, treated by percutaneous pedicle fixation techniques, between June 2013 and March 2015.

Results

5 patients. Injury mechanisms involved: height fall, height fall associated with extensive skin burn of dorsal region and motor vehicle accidents. Fracture level where between T6 to L5. According to AOSpine trauma classification: 3 B2, 1 B3 and 1 A4. Surgery was performed on an average of 5 days since trauma. 2 levels were fixated in 2 patients, 3 in other 2 patients and one patient had a lumbopelvic fixation. The average of intraoperative bleeding was 70 ml and of operative time was 100 minutes. No patient had postoperative local infection or complications from surgery. No patients required revision surgery or deferred anterior column stabilization surgery. All patients had at least 6 months follow-up.

Conclusion

Percutaneous pedicle fixation is an alternative for treatment of unstable vertebral fractures in polytrauma patients with poor general or local conditions. The results in this series are encouraging in the sense of accomplishing stabilization without increasing the morbidity and mortality associated to basal conditions.
Spinal Canal Decompression and Neurological Outcome in Thoracolumbar Burst Fractures; A Review of Evidence- Based Data
Authors: Elwardany Omar
Published: April 2016

Background

The association between neurologic recovery and initial compromise of spinal canal has not been frequently documented and the controversy persists regarding the management of bone fragments within the spinal canal after thoracolumbar burst fractures. Although, the surgical clearance of the spinal canal, either by direct removal of bone fragments or by ligamentotaxis, is generally accepted as the treatment of choice for burst fractures, debate persists as to whether surgical decompression is necessary to treat burst fractures.

Objective

To better understand whether the degree of neurologic recovery from thoracolumbar burst fractures is affected and predicted by initial compromise of spinal canal and to which extent the decompression is helpful, via reviewing the evidence-based data of the literature.

Methods

Up-to-date, the experimental and clinical literature concerning the role of, and the biological rationale for, surgical decompression after acute Spinal Cord Injury (SCI) were reviewed. Evidence from clinical trials was categorized as Class I (well-conducted randomized prospective trials), Class II (well-designed comparative clinical studies), or Class III (retrospective studies).

Conclusion

Although, there is a biological evidence from experimental studies in animals that decompressive surgery may improve neurological recovery after SCI, the role of surgical decompression in patients with SCI is only supported by Class III and limited Class II evidence. Accordingly, decompressive surgery for thoracolumbar burst fractures can only be considered a practice option.
Low Back Pain- How Significant are the Spinopelvic Parameters?
Authors: Sai Krishna M. L. V. , Sharma Deep , Menon Jagdish , Barathi Deepak
Published: April 2016

Introduction

Since the discovery of pelvic incidence by Legaye et al. in 1998, many other sagittal spinopelvic radiographic parameters have been described as determinants of good sagittal balance. Alteration in these parameters has been linked to various spinal ailments producing degeneration to deformity. This have been proved by Roussouly et al. in his landmark paper, which showed a positive correlation between PI and Low Back Pain (LBP). However in the subsequent studies the same correlation could not be derived. Thus, we aim to study the role of high PI as a causative variable for Low back pain in our population. Materials and Methods: The study was approved by our institute review board and the ethical committee. We included all the patients visiting our OPD with complaints of LBP for more than three months and giving consent for the study. All patients underwent a thorough clinical and radiological examination, to rule out any apparent cause of LBP. We excluded patients with spinal deformity, fracture, infection, malignancy and with a history of previous spine surgery. A total of 67 patients were thus included in the study. Another age and sex matched group of asymptomatic volunteers ( n = 75) were also recruited as a control group. All the patients and volunteers underwent a standardized lateral sagittal digital radiograph of the whole spine including the base of the skull till the proximal ⅓ thigh (subject naturally standing up, looking horizontally, hands resting on a vertical support, upper limbs relaxed and elbows half bent). All the subjects were at a specific distance from the radiographic source and a single shot of x- rays have been used centering around D12. The sagittal spinopelvic parameters were measured using the Surgimap spine software version 2.1.2 by a single observer. The parameters measured were pelvic incidence PI, pelvic tilt PT, sacral slope SS, thoracic kyphosis TK, lumbar lordosis LL, lordotic and kyphotic vertebra. The comparisons were drawn between the patients and controls using appropriate statistical methods.

Results

The mean values obtained in patients with low back pain were PI-48.04, PT-12.61, SS-35.5, LL-50.57 and TK-26.79. Corresponding values in healthy volunteers were PI-47.85, PT-13.03, SS-34.8, LL-54.68 and TK-24.03. We have found no statistically significant difference in the values of any sagittal spinopelvic parameters measured between the two groups.

Conclusion

Based on the results derived from our study we conclude that there is no statistically significant correlation between any of the measured sagittal spinopelvic radiographic parameters and the occurrence of LBP.
Psychological Distress can be Determined before Lumbar Surgeries with a Clinically Applicable, Easy-to-use Tool: the Short form of the DRAM
Authors: Lazary Aron , Sziat Julia , Szövérfi Zsolt , Kiss Laszlo , Varga Péter Pál
Published: April 2016

Introduction

The Distress and Risk Assessment Method (DRAM) is a tool for measuring the psychological risk factors in low back pain patients. In our previous study, the DRAM scale, its categories as well as its components (Zung Depression Scale (ZDS) and Modified Somatic Perception Questionnaire (MSPQ)) proved to be significant predictors for global treatment outcome in routine lumbar degenerative surgeries. On the other hand, the original DRAM has to be calculated from 45 items making that a long and clinically impractical tool. The aim of the study was to develop and validate a short form of the DRAM (sDRAM) and to determine the prognostic power of the new version in terms of the global treatment outcome.

Material and Methods

Classic Test Theory were applied for item reduction after the exploratory factor analysis of ZDS and MSPQ on the dataset of a large ( N = 1837) cohort of surgically treated low back pain patients. Internal consistency and the correlation of the shortened DRAM (sDRAM) with the original scale were analyzed. After that, a two-step cluster analysis of sDRAM was applied to determine the cut-off scores. The prognostic value of the scale and its categories was tested on a prospective cohort of routine lumbar degenerative surgeries ( N = 445) where global treatment outcome was assessed two years after the surgery by a Likert scale.

Results

The sDRAM consisted of five ZDS items (1, 6, 7, 12, 18) and three MSPQ items (3, 9, 11) preserving the original item-distribution ratio. sDRAM scale (range: 0–24) was highly correlated with the DRAM scale (range: 0–99) (r=0.88). Cluster analysis of the patients showed a four-cluster structure in the cohort similarly to the original questionnaire. Cut-off scores (sZDS > 6, sMSPQ > 2) were used to formulate the sDRAM categories (Normal, At risk, Distressed). The sDRAM scale showed a significant association with the global treatment outcome in a logistic regression model ( p < 0.001, B=0.258, OR=1.3) and in ROC analysis (AUC=0.744, p < 0.001) and it was similar to the original DRAM ( p < 0.001, B=0.066, OR=1.07 as well as AUC=0.72, p < 0.001). Risk for poor outcome was significantly associated with the suggested categories of sDRAM (6%, 20%, 39% of poor outcome in “Normal,” “At Risk” and “Distressed” subgroups, Chi-square=38.9, df=2, p < 0.001).

Conclusion

A shorter, clinically applicable method for the assessment of DRAM has been developed. The sDRAM consists of 8 items and correlates with the original questionnaire. sDRAM and its categories proved to be significantly associated with global treatment outcome. The tool can be used for preoperative risk assessment and reduction strategies, however, further validation is needed to show its utility in different, wider patient-groups.
Predictive Factors for the Outcome of Surgical Treatment of Lumbar Spondylolysis in Young Sporting Individuals
Authors: Debnath Ujjwal K. , Goel Vivek
Published: April 2016

Introduction

Only few sporting individuals with symptomatic lumbar pars injuries require surgical repair and it is often difficult to predict the outcome following surgery. The results on predictive factors of outcome after direct repair of pars defect have not been studied.

Material and Methods

52 consecutive young sporting individuals with a mean age of 19 years (range 8–35years) were treated surgically for lumbar pars defect confirmed on imaging studies (i.e., SPECT, CT and MRIscans). 50 patients completed the VAS (visual analogue scores), ODI (Oswestry Disability Index) and SF-36 (Short Form) questionnaires as a part of their assessment. Preoperative background variables were used in a multiple regression model to find the strongest predictor of post-operative outcome as measured by ODI.

Results

Buck's screw repair of the pars defect was performed in 44 patients (33M: 11 F). Unilateral in 8 patients (7M: 1F) and bilateral in 36 patients (26M: 10F). Although age at surgery showed linear co-linearity (ρ=0.32, p < 0.05), it was not significant in the model. The most consistent association with the preoperative VAS score were the pre and post operative ODI scores i.e., ρ =0.51 ( p < 0.01) and ρ =0.33 ( p < 0.05) respectively. In the bilateral group, with Buck's repair at a single level i.e., 33/36 (93%) patients had returned to sports at a mean time of 7.5 months (range 6–12months). Overall, 44/52 (84%) individuals had returned to their sports with post-treatment ODI score of < 10. The stepwise regression modeling suggested six independent factors (pre-operative ODI, pre-operative SF36pcs, Buck's repair, multiple operations, professionalism and pars defect at L3), as the determinants of the outcome (i.e., post-operative ODI.) in 80.9% patients (R2=0.809).

Conclusion

The outcome after direct repair of pars defect below 25 years of age runs a predictable course. Professionalism in sports has a high impact on the outcome. Preoperative ODI and SF-36 pcs scores are significant predictors of good functional outcome. The regression equation can predict the outcome in 80.9% sporting individuals undergoing Buck's repair.
Transpedicular Screw Placement for Subaxial Cervical Trauma with Neuronavigation. Experience in a Third World Country. Hospital Santo Tomas. Panama
Authors: De Leon Alvino , Villarreal Orlando , Hermida Jose , Altafulla Juan
Published: April 2016

Introduction

Hospital Santo Tomas is a tretary trauma center in Panama. Subaxial cervical trauma represents a major issue in the care of patients admitted to the neurosurgery department. Lateral mass screw placement is commonly used for posterior fixation. The aim of this abstract is to present our experience not only with transpedicular screws but also doing this with a neuronavigation system and to evaluate the associated risks.

Materials and Methods

19 patients in need of posterior fixation with subaxial cervical trauma were stabilized by transpedicular screws from 2010 to 2012 were included. The patients were all male between 20 and 34 years of age. After hemodynamics parameter were assessed and other major trauma was ruled out the neurologic assessment was made. We used the Frankel grading scale and 10 patients were graded A, 4 graded C, 3 graded D an 2 graded E. By this moment a whole body CT was already done. 12 patients have C4-C5 subluxation and the remain had subluxation elsewhere in the subaxial cervical spine. 13 patients needed closed reduction which was assessed by plain films. All patiens had thin cut CT and navigation was planned. All patients were induced by a nueroanesthesiolgy. A three pin head holder was applied and the patients were put in a down face position. Calibration of the navigation system was performed and a standard posterior cervical spine with laminectomy was done. Our hospital does not count until that moment with the aid of intraoperative neurophysiological monitoring. The average surgical time was 3 hours and the blood loss was 750 cc in average. In total 52 screws were placed. All the patients went to a immediately postoperative CT scan. And the screws placement was assessed. No screw mal placement was and no complications during the placement were recorded. The patients were managed in the neurosurgical ward and were discharge 48 hours after the operation with a cervical collar. They were assessed one week after the intervention to review the surgical wound and to preformed a neurological exam. All patients were follow in the outpatient clinic and all were given physical therapy that initiated in the immediately postoperative period.

Results

Of the Frankel a group three of went on to have grade C, two were graded B and the remain did not improve. One patient in the Frankel C and one in the Frankel D group did better during follow up. No surgical wound infections were recorded. Only one of the patients died from and unrelated cause of pneumonia. All patients were assessed with dynamic films and show no movement. The follow up was up to a year. No patients were lost during that time in the follow up.

Conclusion

Tanspedicular screw placement is a safe option for posterior fixation. Neuronavigation is and excellent tool for avoiding complications.
Does the Position of the Spacer in Tlif have an Influence on Anatomical Parameters Such as Segmental Lordosis, Foraminal Height? A Prospective Randomized Study
Authors: Ronai Marton , Varga Péter Pál
Published: April 2016

Introduction

In a prospective randomized trial we aimed to validate PMMA spacer in TLIF. Compared with standard, preformed PEEK spacer we didn't find significant difference regarding the clinical outcome, completed bony fusion, subsidence or loosening. When performing TLIF there are different arguments to position the intervertebral spacer in different position (anterior or posterior) In this prospective, randomized study we would like to compare the segmental anatomical changes following the position of a custom made PMMA spacer in monosegmental TLIF.

Material and Methods

In our study we planned to collect 60 consecutive patients to whom we perform one level TLIF in the lumbar spine. The patients are randomized in two groups by the GraphPad QuickCalcs software. Group A is standard TLIF with PMMA spacer placed in the anterior part of the intervertebral space. Group B is standard TLIF with PMMA spacer positioned in the posterior part of the intervertebral space. Patients between 18–65 years/o were inclouded. Patients with a high grade spondylolisthesis, metabolic bone desease, spinal infection, cancer, severe scoliosis (Cobb over 30°) were excluded. We evaluate changes in segmental, and overall lordosis and in the height of the neuroforamen according to the position of the spacer.

Results

58 patients, 31 in group A and 27 in group B, has a minimum of one year follow up. In both groups the segmental lordosis increased. The mean change was 6° in group A and 4° in group B, the difference was not significant. The foraminal height also increased in both groups, the mean change was 18% in group A and 27% in group B but this difference was not significant eather.

Conclusion

Anterior position of the intervertebral spacer seems to provide more possibility to correct lumbar lordosis, but the advantage on posterior position hasn't been shown significant in this study. Better foraminal height restoration was found in the posterior position of the spacer, but there was no correlation of this parameter to the clinical outcome. We can conclude that both positions provide good radiological and clinical result.
Verification of Nerve Decompression Using Mechanomyography
Authors: Wessell Nolan , Ghacham Wael , Khalil Jad , Zavatsky Joseph , Bartol Stephen
Published: April 2016

Introduction

Assessment of nerve root decompression in surgery is largely based on visualization and tactile feedback. Often times, visualization can be limited, such as in minimally invasive surgery, and tactile feedback is a subjective assessment that makes the evaluation of successful nerve decompression difficult. Electromyography (EMG) has been proposed as an assessment tool but EMG responses are often difficult to quantify. Alternatively, mechanomyography (MMG) provides a quantifiable response with minimal signal to noise ratio compared with EMG. MMG provides a sensitive tool to accurately quantify mechanical responses to motor action potentials generated by electrical stimulus, allowing more reliable assessment of nerve decompression. The objective of this study was to assess the ability of mechanomyography to quantitatively demonstrate successful nerve root decompression. Materials and Methods Seventy-two (72) nerves roots in 46 patients undergoing lumbar decompression procedures were examined using MMG. Nerves were stimulated upstream from the compression site and the lowest threshold current needed to generate a muscle response was determined. Signal response sizes were recorded before and after decompression. Visual-analog scale (VAS) scores were collected pre and post-operatively.

Results

Ninety percent (90%) of patients (65/72) had elevated stimulation thresholds (>1mA) prior to decompression. After decompression, 98% of patients (64/65) with elevated current thresholds exhibited a drop in threshold of ≥ 1mA ( p < 0.001). A post-decompression increase in response amplitude was recorded in all patients. VAS scores improved post-decompression (6.8 versus 1.1, p < 0.001) with a positive correlation between decreased stimulation thresholds and improved VAS scores ( p < 0.001).

Conclusion

MMG is an effective tool that can be used to differentiate normal and compressed nerves by quantifying the mechanomyographic response to a stimulating current. MMG allows one to measure the effect of decompression, judge its effectiveness in real time, and eliminate the subjectivity seen in tactile feedback methods. When the adequacy of decompression is uncertain, MMG can guide the surgeon toward additional or alternative procedures to ensure complete nerve root decompression.
Movement along the Spine Induced by Transcranial Electrical Stimulation (TES) Related to the Montage of Electrodes
Authors: Hoebink Eric
Published: April 2016

Introduction

Transcranial Electrical Stimulates Motor Evoked Potentials (TES-MEP) is a safe technique for neuromonitoring during spinal surgery. However induced movement can cause injuries and delay surgical procedures. When TES movements are evoked by other than monitored muscles, one may expect that adjustments in stimulation paradigms and electrode montages may minimize movement while preserving quality of monitoring. In this study, TES evoked seismic evoked responses (SER) are studied at different electrodes montage during spinal deformity surgery.

Materials and Methods

In 12 patients undergoing corrective spine surgery, intra-operative TES-MEP was performed. Accelero transducers recorded SER in two directions at 4 different locations of the spine for TES-electrode montages groups Cz-Fz and C3-C4. A resulting acceleration value, SERr, was computed. A paired t-test was used to compare the means of SER and the relationship between movement and TES electrode montages.

Results

SER's are the strongest in the upper body. All mean SER's values of the Cz-Fz group are up to 5 times larger when compared with the C3–4 group. However, there are no differences between the C3-C4 and Cz-Fz groups in the lower body locations. Both electrode montage groups show gradual decreasing steps of all mean SER values along the spine from cranial to caudal. For the upper body locations there were no significant correlations of SERr between both montages, whereas in contrast, a significant correlation of SERr exists at the lumbar region.

Conclusions

At supramaximum levels, movements resulting from multipulse TES is likely caused by relative strong contractions from muscles in the neck resulting from extracranial direct stimulation. When interchanging electrode montages in individual cases, the movement in the neck may become reduced. At lumbar levels transcranial evoked muscle contractions dominate movement in the surgical exposed areas likely dominated by local muscles.