bluuebunny/crossref_metadata_2025 huggingface dataset:
Characterization of Distribution of Segmental Changes in Cervical Alignment after Lumbar Pedicle Subtraction Osteotomy
Authors: Ailon Tamir , Scheer Justin , Shaffrey Christopher , Lafage Virginie , Protopsaltis Themistocles , Ames Christopher ,   International Spine Study Group
Published: April 2016

Introduction

Adult spinal deformity (ASD) patients with positive sagittal malalignment develop compensatory cervical hyperlordosis to maintain horizontal gaze, which spontaneous improves following lumbar PSO. We sought to characterize the segmental distribution and characteristics of these reciprocal changes in a similar patient group.

Material and Methods

Change in cervical radiographic measures from baseline to 6 weeks postop in 27 patients who underwent lumbar pedicle subtraction osteotomy (PSO) for correction of sagittal malalignment was assessed. Parameters included: C2–7 sagittal vertical axis (C2–7 SVA), C2-S1 SVA, C7-S1 SVA, pelvic incidence-lumbar lordosis mismatch (PI-LL) pelvic tilt (PT) and T1 and T9 spino-pelvic inclination (SPI). The cobb method was used for: occiput (C0)-C2, C2-T1, C2-C7. Harrison method for: Segmental angles between C2-T1. Vertebral body slopes were measured at the occiput (C0S), axis (C2S), T1 (T1S) and S1 (SS).

Results

All thoracolumbar parameters significantly improved to below established alignment thresholds: C2-S1 SVA (146/47mm), C7-S1 SVA (119/17mm), PI-LL (34.9/1.3 deg), PT (30.2/19.7 deg) ( p < 0.001). C2–7 SVA did not significantly change. Mean cervical lordosis (C2–7) decreased (19.9–14.1, p = 0.05, range 27.4, -40.9). Majority of the reciprocal decrease in C2–7 occurred at C3–4 (59.1%) and C4–5 (27.2%, Figure) with little at C5/6 (13.6%) and none at C6/7. Mean lordosis increased 1 deg at C2/3. There was an additional 1.3 deg decrease at C7-T1, accounting for 16.5% of the total decrease in C2-T1 angle (−6.9 deg). The C0-C2 angle increased 1.6 degrees. C2S and SS increased 5.8 and 10.3 deg, respectively ( p < 0.005) whereas C0S and T1S did not change significantly.

Conclusion

Following successful correction of positive sagittal malalignment, reciprocal changes in cervical alignment ensue. The majority of relaxation in hyper-lordosis occurs at C3–4 and C4–5. The angle between the occiput and C2 increased slightly to maintain head balance in response to decreased subaxial lordosis.
Effect of Topical versus Parentral Tranexamic Acid on Blood Loss in Spinal Deformity Surgery. A Prospective Randomized Controlled Trial
Authors: El-Sharkawi Mohammad , Sayed Sherif , Gad Wael , El-Meshtawy Mohamed
Published: April 2016

Introduction

Massive hemorrhage and massive blood transfusion are not uncommon in spinal deformity surgery. There are many factors which may affect the perioperative blood loss. Multiple studies showed the beneficial effects of parentral tranexamic acid (TXA) in decreasing intraoperative blood loss but there is a lack of knowledge about the effect of topical use of tranexamic acid. The aim of this study is to evaluate the effect of using tranexamic acid topically versus parentrally on the amount of intra operative blood loss.

Material and Methods

Between 2011 and 2014, eighty three patients (49 females/34 males, mean age 17 ± 4 ys, body weight 49 ± 6 kg) underwent correction (in the form of multiple Ponte osteotomies, PSO, PVCR) and posterior spinal fusion for spinal deformity (57 AIS, 14 congenital scoliosis, 12 syndromic). These patients were randomized into one of three groups. In group 1 ( n = 31 patients), TXA was used topically. TXA was sprayed directly in the wound and sponges soaked with it were used. In group 2 ( n = 29 patients), intravenous TXA was used intra-operatively. In group 3 ( n = 23 patients), TXA acid was used neither topically nor systemically. Intraoperative blood loss and the number of blood units transfused were recorded for all patients. The three groups were comparable in the mean age, body weight, operative time, type of deformity, type of osteotomy, number of fused segments, number of screws used.

Results

The mean operative time was (240 minute ± 50). The mean blood loss in group 1 was 1353 ± 273 cc, 1271 ±279 cc in group 2, and 1430 ± 311 cc in group 3. The mean number of blood units transfused in group 1 was 2.65 ± 0.587, 2.3 ± 0.571 in group 2, and 3.4 ± 0.5 in group 3. There were no significant differences in intraoperative blood loss and number of units of transfused blood between the first and second groups while there was a significant difference between them and the control group. One patient developed DVT in the intravenous TXA group.

Conclusion

Topical TXA is as effective as intravenous TXA and may be used safely to decrease the need for blood transfusion and intraoperative blood loss.
Surgical Site Infection in Spinal Operations a Tertiary Centre Review of 4557 Consecutive Procedures over 5 Years
Authors: Fawi Hassan , Ahmed Mohamed , Sousa Jose , Lewis Megan , Ahuja Sashin
Published: April 2016

Background

Surgical Site Infection (SSI) is a potential inherent risk of any surgical intervention. SSI can pose significant consequences especially in spinal surgery. Previous research showed that there are seasonal variations in the incidence of SSI with numbers peaking in summer months.

Objective

To evaluate (1) incidence of Surgical Site Infection (SSI) for consecutive operations in a tertiary center, (2) the commonest pathogen, (3) The management in our unit and its long-term outcome, and (4) Effect of seasonal change on SSI.

Methods

Consecutive spinal operations ( N = 4557) between Jan 2007 – Jan 2012 were studied looking for SSI using the Centres for Disease Control National Health Safety Network criteria. All patients with SSI positive criteria were included in the study. Further evaluation was based on the study objectives.

Results

4557 procedures were assessed, of which 30.5% were Decompressions, Variable Thoraco-Lumbar Fusions (inc. ALIf, TLIF, XLIF, Deg. Scoliois correction) 25.8%, Cervical operations 18.8%, Scoliosis operations 10.5%, Decompressions and Interspinious spacers 6.9%, and miscellaneous procedures were 7.5%. In total 8.5% of cases were revision surgeries. The incidence of SSI was 4.9% with 62.1% Male and 37.9% Females. Commonest organisms were Coagulase Negative Staph 31.7%, Staph Aureus 26.8%, Pseudomonas 7%, MRSA 4%, and polymicrobial 30.5%. The average time to detection of infection was 23 days (3–200). Of the positive SSI cases, 9.75% needed surgical debridement. 2.4% needed removal of metal work/Replacement. They all made uneventful long-term recovery. 54.9% of SSI had their operations in the summer months, while 45.1% were operated in the Autumn/Winter months.

Conclusion

Bearing in mind the low infection rate of deep surgical site infections we encountered: Most of the SSI cases were effectively treated in our unit by using antibiotics only; The close liaison with our microbiology unit was and remains of paramount importance; There is no clear difference found in our study between Summer/Spring and Autumn/Winter months in the rate of developing SSI.
Surgical Results of 135 Thoraco-Lumbar Fractures Treated with Open Posterior Multi-Level Segmental Fixation: A Single Center Experience
Authors: Wasserberg Jonathan , Veres Robert , Urbansky Milan
Published: April 2016

Introduction

Surgical treatment strategies for thoraco-lumbar spine fractures differ widely around the world. Choice of operative approach varies depending on many factors including fracture classification, presence of spinal cord injury and whether subluxation or dislocation is present. Combinations of anterior and posterior approaches vary depending on surgeon choice, available resources and fracture morphology. We reviewed our experience of thoraco-lumbar vertebral fractures treated at our institution from Jan 14 – May 2015 to determine if our policy of posterior multi- level segmental fixation produced acceptable restoration of spinal alignment and reduction of kyphosis.

Materials and Methods

A retrospective cohort review was performed using the hospital electronic medical records system (Cerner, USA). All surgical cases were identified from the operating theater records. Only fractures from T1 to L5 were included. Imaging was reviewed using the hospital PACS system and classified according to the AO thoraco -lumbar classification system. Spinal cord injury was classified according to the ASIA scale. Post-operative images were reviewed and levels of fixation recorded. Accuracy of screw placement was assessed. Neurological status at discharge was recorded.

Results

135 cases of TL fracture underwent surgery via an open posterior approach. Screw placement was performed using C-arm fluoroscopy.Data on the extent of kyphosis reduction is presented. Post-operative results in cases of vertebral subluxation and dislocation are presented. Early surgical outcome in cases with spinal cord injury are presented. Due to the high level of loss to follow up in our region we were unable to carry out longitudinal outcome studies.

Conclusion

The majority of thoraco -lumbar fractures can be managed by posterior approaches alone with good surgical outcomes. Type C fractures and fractures with dural tears and nerve damage can be adequately dealt with via this approach. The majority of cases had pedicle screw fixation two levels above and one level below the affected level. This strategy allowed good reduction of deformity, especially for fractures at L1, where fixation only to T12 can be associated with late onset of adjacent segment degeneration.The inability to carry out longitudinal outcome measures is an acknowledged weakness of our study, but the short-term surgical results are comparable to those in the literature using other surgical strategies. This retrospective cohort review supports our continuing use of the posterior multi-level segmental approach for T-L fractures irrespective of fracture type.
Psychosocial Representations of the Illness before Lumbar Spine Surgery and Their Effects on Recovery
Authors: Pócza-Véger Petra , Csabai Márta , Barzó Pál
Published: April 2016

Introduction

Psychosocial representation of the illness means those personal and mental meanings and thoughts which the patient connects with his/her own condition. The examination of representation of the illness is very important to understand the behavior of the patients because these representations contain of the patients' beliefs about their illness or injury. These beliefs influence the cure, the duration of recovery and these beliefs affect the strategies, which the patients use to cope with the illness. In clinical environment, the nonverbal methods help the exploration of representations of the illness, since the physical status can hamper the verbal expression of burdens (for example: pain, suffering). In such cases, we can use the PRISM task (Pictorial Representation of Illness Self-Measure) to measure the burden of suffering. Methods and Materials: In our research, there have been 110 inpatients (52 men). We have examined the patients before lumbar surgery, using the following tests: Psychological Vulnerability Questionnaire, Hospital Anxiety and Depression Scale, Somatosensory Amplification Scale and PRISM-D (drawing version of PRISM task) and we followed how many days the patients stayed at the clinic after the operation. Using the PRISM-D, we are observing the patients drawing the in some spatial formations, which are the following: 1. Self-shield (the patient draws the important things around herself/himself), 2. Illness-shield (the patient draws the important things around the illness), 3. Protective line (the patient draws the important things in horizontal or/and vertical line), 4. Network (the important things and the illness are diffused in space of the current life), 5. Fusion (the important things and the illness intersect with the self or every circle intersect with each other), 6. Self-part (the illness is drawn in the self and the other important things are located far away from the self).

Results

We have found that those patients who have drawn their illness in their own Self ( Self-part), went home later than the other patients (Self-shield: p = 0,004, Fusion: p = 0,026, Illness-shield: p = 0,008, Protective line: p = 0,036, Network: p = 0,004). But those patients, who represented their illness in Self-shield spatial formation, went home earliest (mean: 4,14 days). Although, these patients were the most vulnerable in the whole population.

Conclusion

Our results suggest the illness modifies the self-identity because the information related to the pain becomes the most essential in the organization of the self. It could be problematic, if majority of the self-scheme consists of illness-scheme. We can see this in Self-part spatial formation, thus it is affirmable if the illness-scheme increase within the Self, the recovery will slow down. This is often the case with the patients having low back pain.
Posterior Vertebral Column Resection: A Salvage for Thoracolumbar Kyphosis after Failed Anterior Instrumented Fusion
Authors: Chen Fei , Dai Zhehao
Published: April 2016

Introduction

Anterior thoracolumbar spine surgery is typically indicated for restoration of structural stability and /or decompression of neural element secondary to trauma, tumor or infection. But postoperative complications especially kyphosis poses distinct challenges to the spinal surgeon. The aim of this study was to explore the effects of posterior vertebral column resection of thoracolumbar kyphosis after failed anterior instrumented fusion.

Material and Methods

A retrospective study was conducted of 10 patients of kyphotic deformity with previous failed anterior surgery in our department from October 2005 to December 2009. The indications for revision surgery included pain refractory to conservative treatment, progressive neurological deficit and kyphosis. Anterior removal of the implant and posterior vertebral column resection (PVCR) was performed. Mean operating time, average intraoperative blood loss, kyphosis angle, the visual analog scale (VAS), Oswestry disability index (ODI), bone fusion time and complications were used for clinical assessment in a minimum 18-month follow-up (18 – 60 months).

Results

The mean age was 38.7 years old (ranging from 24 to 56 years old) and the average kyphosis angle was 54.60 (ranging from 45 0 to 74 0). Mean operating time was 323.5 (range 245 minute to 420 minute) with average intraoperative blood loss of 1189 ml (range 850 ml to 1550 ml). After revision surgery, Kyphosis angle was 4.800 (range3- 70) immediately and 6.80 (range 5 to 90) at the 18 months follow-up and there was good bony fusion in every case. The average time of bony fusion was 6.8 months (range 5–9 months). All patients had satisfied spinal sagittal and coronal balance at the last follow-up. None of our patients experienced implant failure. The average preoperative VAS was 6.2, falling to 2.6 at the 18 months follow-up with significant improvement. None of the patients suffered any surgery-related neurological deterioration and one patient whose neurological status was Frankel Grade C improved to Grade D. The ODI changed form a mean value of 39.8 (rang 31–48) preoperatively to 24.5 (rang 15–29) at the final follow-up. The difference was statistically significant. Complications occurred in four patients (40%); these included three with tearing of the lung and one with a superficial wound infection.

Conclusion

Despite the technically demanding procedure, anterior removal of the implant and posterior vertebral column resection was a safe and effective revision surgery for patients with prior anterior fusion with rigid post-surgical deformities.
Patient-reported Outcomes following Elective Surgery for Lumbar Degenerative Disease: Effect of Peri-operative Complications on Outcomes
Authors: Chotai Silky , Parker Scott , Sivaganesan Ahilan , McGirt Matthew , Cheng Joseph , Devin Clinton
Published: April 2016

Introduction

There is a paradigm shift toward rewarding providers for quality rather than volume. Complications appear to occur at a fairly consistent frequency when looking at large aggregate datasets. Understanding how complications affect long-term patient reported outcomes (PROs), following degenerative lumbar surgery, is vital. Our hypothesis was that 90-day complications would adversely affect long term PROs compared with a cohort that did not experience a complication. Methods 906 consecutive patients undergoing elective surgery for degenerative lumbar disease over a period of four-years were enrolled into a prospective longitudinal registry. PROs: ODI, NRS-Back and leg pain (BP, LP), Quality of life (EQ-5D), and NASS satisfaction questionnaire were recorded at baseline and 12-month follow-up. Complications were divided into major (surgical site infection, hardware failure, new neurological deficit, pulmonary embolism, hematoma and MI) and minor (urinary tract infection, pneumonia and deep venous thrombosis).

Results

Thirteen percent (118) of patients developed complications: (major-12% (108) and 8% (68)-minor) within 90-days after surgery. The patients with complications had significantly higher ODI scores at 12-months (29.43 ± 17.7 versus 25.2 ± 18.33, p = 0.02) after surgery. In a multivariable linear regression analysis, after controlling for array of preoperative variables, the occurrence of a major complication was not associated with worsening ODI scores 12-month after surgery. There was no difference in the percent of patients achieving minimal clinically important difference MCID for disability (66% vs 64%), back (55% vs 56%) and leg pain (62% vs 59%), quality of life (19% vs14%) and patient satisfaction rates (82% vs 80%) between those without and with major complications.

Conclusion

The occurrence of major complications did not significantly affect the PROs 12-month after surgery. These patients achieve clinically meaningful outcomes and patient satisfaction, as much as those without complication. This information allows a physician to council patients on the fact that a complication creates frustration, cost, and inconvenience, however it does not appear to adversely affect clinically meaningful long-term outcomes and satisfaction.
Transforaminal Lumber Interbody Fusion (TLIF) Clinical and Radiological Outcome
Authors: Alassiri Khaled
Published: April 2016

Objective

To evaluate the clinical and radiological outcome of TLIF in the treatment of Spondylolisthesis, degenerative disc disease and recurrent herniation of lumber disc. Methodology: A retrospective study, between Jan 2009 and December 2011.The patients with chronic back pain (more than 6 months of disability and refractory to conservative management) with or without leg pain / neurological deficit due to degenerative spondylolisthesis, degenerative disc disease and recurrent lumber disc herniation treated with Transforaminal Lumber Interbody Fusion (TLIF) were included. It was a retrospective review of the patient files to assess the pre and postoperative symptomatology, findings on clinical examination, radiological characteristics. The same procedure was performed in all cases by a single spine surgeon. The clinical outcome was assessed using Oswestry Disability Index (ODI) scoring system. Bony fusion was assessed based on a pre-set criteria on plain radiographs at 18 months postoperatively.

Results

Of 25 there were 16 male (64%) and 9 female (36%) patients with a mean age of 40 years (range: 20–60), who underwent TLIF (Transforaminal Lumber Interbody Fusion). 9 patients diagnosed as degenerative disc disease, 12 with spondylolisthesis and 4 having recurrent disc herniation. Of the 25 patients who underwent TLIF, in 14 (56%) cases fusion was performed at L5-S1, in 9 (36%) at segment L4-L5 and in 2 (8%) at L3-L4. We found subjective improvement in symptoms of back pain in 19 (76.0%) of 25 patients, leg pain in 15 (83.3%) of 18, and 04 (66.67%) & 02(40.0%) improvement in sensory and motor deficit respectively postoperatively. Based on the Oswestry Disability Index (ODI) and Visual Analog Pain Scale (VAS), showed significant improvement from preoperative 7.1 & 42.3 to 2.5 & 17.5 ODI and VAS scores at 18 months postoperatively respectively, with an overall improvement of 4.6 VAS and 24.8 ODI scores. A radiological fusion was observed at 18 months postoperatively on anterio-posterior (AP) and lateral X-rays following the pre set criteria in 23 of 25 patients (92.00%).

Conclusion

TLIF is a safe and effective method to treat chronic low back pain in patients with spondylolisthesis, degenerative disc disease and recurrent disc herniation. Our results confirm that TLIF is an option that is associated with good clinical and radiological outcome.
Preoperative Norepinephrine Levels in Cerebrospinal Fluid and Plasma of Pediatric Patients Predict Postoperative Pain Intensity after Spinal Fusion Surgery
Authors: Ferland Catherine , Parent Alexandre , Saran Neil , Ingelmo Pablo , Marchand Serge , Sarret Philippe , Ouellet Jean
Published: April 2016

Introduction

The purpose of the present study was to investigate if preoperative concentrations of monoamine neurotransmitters that are known to be involved in descending pain modulation are associated with perioperative pain intensity in a pediatric cohort of patients with idiopathic scoliosis scheduled for elective spinal fusion surgery.

Material and Methods

Patients scheduled to undergo spinal surgery for Adolescent Idiopathic Scoliosis (AIS) between the ages of 12 and 18 years were recruited from the outpatient clinic of the Shriners Hospital for Children ( n = 50). Plasmatic and cerebrospinal fluid concentrations of epinephrine (EPI), norepinephrine (NE), and their respective metabolite metanephrine (ME) and normetanephrine (NME), were assessed. Five mL of blood were collected for study analysis in an EDTA-coated collection tube after the anesthesia induction. Prior to the intratechal epimorphine injection, 2 mL of cerebrospinal fluid was collected in a low binding protein tube. Monoamine neurotransmitters were derivatized by reductive diethylation analyzed by liquid chromatography coupled with tandem mass spectrometry on TripleTOF 5600 mass spectrometer. At all time points throughout the study (preoperative, first postoperative 24 hours = postoperative day 1 (POD1), second 24 hours = postoperative day 2 (POD2) and postoperative 6 weeks follow-up visit), pain intensity was rated with the use of the Faces Pain Scale-Revised (FPS-R). Linear regressions were performed to assess the predictive role of catecholamine levels for postoperative pain. The Mann-Whitney-U test was used to assess differences in baseline characteristics between patients reporting presence of pain and pain-free patients as well as for all other comparisons other than correlations.

Results

Our results demonstrate that patients reporting persistent postsurgical pain 6 weeks after surgery have greater preoperative peripheral and/or central norepinephrine (NE) and normetanephrine levels when compared with patients reporting no pain at follow-up. Likewise, in the acute postoperative period, patients reporting moderate-to-severe pain intensity had higher preoperative central NE levels.

Conclusion

These results support the evidence for a potential role of catecholamine levels in predicting postoperative pain intensity and sympathetically maintained pain, which could place pediatric patients at risk for the development of chronic postsurgical pain. Incidence and severity of persistent postoperative pain may be reduced by specific NE preoperative interventions.
Treatment Options for Odontoid Fractures. A Comparasion between Anterior and Posterior Approaches
Authors: Neto Jamil Farhat , Veiga José Carlos Esteves , Daniel Jefferson Walter
Published: April 2016

Introduction

Odontoid fractures account for 9% to 15% of adult, cervical spine fractures, and are the most common fractures in the geriatric cervical spine. The mechanism of injury generally results from hyperflexion or hyperextension of the cervical spine during low-energy impacts in the elderly or high-energy impacts in the young and middle aged. No consensus exists on the optimal treatment (surgical or conservative) and the most relevant outcome parameter (osseous union, fracture stability or clinical outcome). Neurologic injuries associated with these fractures are rare. Material and Methods This study was a retrospective chart review of 13 patients who were treated for odontoid process fractures between November 2010 and May 2015. Inclusion criteria: Patients with odontoid fractures submitted to surgical treatment. Data were obtained from medical charts and spinal column imaging reports. Medical charts, imaging studies and the patient's outcomes were submitted to descriptive analysis in the pre-operative and post-operative period. The data submitted to descriptive analysis were: Fracture gaps; the direction and degree of odontoid process displacement; the odontoid fracture line anatomy; the degrees of the atlantoaxial instability; and the contact between the fractured odontoid and the axis vertebrae. We used conventional radiographs, three-dimensional computed tomographic (3D-CT) scans, and magnetic resonance images. We used the Grauer Algorithm for defining the surgical treatment modality. We identified the solid bone union through the presence of bony bridges and the definite continuity of cortical bone.

Results

A total of 13 patients who underwent surgical treatment for odontoid fracture were identified. The patients were 76.9% men, the mean age = 32.92 years. Traffic accidents (69,2%) were the most common cause of trauma. The main symptom was pain (84.6%) in the posterior cervical region. The elapsed median time from accident to surgery was 30 days. Mean follow-up was 20 months. Odontoid screw technics (38,4%) and Harms posterior technic (38,4%) were the most common surgical treatment adopted as primary surgical treatment. The most common Grauer's line fracture type was type B on 8 cases. 2 patients referred chronic cervical pain after surgery, 1(20%) were submitted to anterior technic and 1 (12,5%) posterior technic. We had 2 cases with complications, all submitted to posterior technic, 1 with CSF leak and 1 with vertebral artery lesion. No mortality was observed.

Conclusion

There was no difference between anterior or posterior approach when analyzing the cervical chronic pain and mortality. However, there were more complications in cases covered by the posterior approach. A well-designed prospective study with a larger number of cases is needed to better elucidate optimal treatment algorithms from both an outcomes and cost-effectiveness perspective.
Outcome Prediction in Elective Spine Surgery: A Prospective Cohort Study
Authors: Shiban Ehab , Meyer Bernhard , Shiban Youssef , Mühlberger Andreas
Published: April 2016

Objectives

To identify associations between demographic characteristics, anxiety, depression, social support, psychological and physical health in relation to self reported disability following elective spine surgery.

Methods

Study design: Prospective cohort study. Patients were asked preoperatively to complete a series of questionnaires, including the Oswestry Disability Index (ODI), the anxiety sensitivity index (ASI-3), the SF-36, the visual analogue scale for pain (VAS), the Berliner Social Support Scale, the PTSS-10 for PTSD symptoms and indicate demographic variables concerning education or partnership for example. The evaluation was based on the ODI filled out 3 months postoperatively. The univariate and multivariate analysis between risk factors and outcome parameter (ODI) was assessed with correlation coefficients and multivariate logistic regression.

Results

144 patients met all inclusion criteria, 54% were male, 46% were female. Regardless of the operation dimension 75% had a lower ODI score at 3 months postoperatively compared with preoperatively and hence had a higher functionality after the operation. Preoperatively high values in age (r=0,153; p = 0,087), pain (VAS) (r=0,287; p = 0,01), trait anxiety(r=0,197; p = 0,027), PTSS (r=0,163; p = 0,069), ODI (r=0,459; p < 0,001) and low levels of social support (BSSS) (r = −0,148; p = 0,099) and education (r = −0,156; p = 0,098) correlated with high levels of ODI postoperatively which identifies all the mentioned variables as potential risk factors. A stepwise logistic regression model showed significant association with age, pain (VAS), state anxiety (STAI-S), and depression symptoms (ADS-K) ( p < 0,000).

Conclusion

Preoperative psychological status is associated with worse clinical outcome following elective spine surgery. A screening instrument allowing the identification of such patients is feasible.
Less False Negative in Neuromonitoring Lumbar Screws
Authors: Garcia Pedro Cortes , Lorensu Pedro Perez , Rodriguez Bernabe Deniz
Published: April 2016

Introduction

IOM is a standard care in cases of scoliosis.. there is more controversial their use in mubar pathology.. there are 5% lessions of nerve roots. There is a debate about the stimilation thresholds, to evaluate possibilities of medial positioning pedicular screws. The objetive of this paper is Evaluation of the effect of chronic compression of the lumbar roots in relation to thresholds direct stimulation. Material and Methods:Study Design:• prospective case series with measurement and threshold register direct stimulation of lumbar roots.• 80 patients (43 women and 199 nerve roots) consecutive undergoing spinal surgery in a period of six months (January to October 2014), 7 surgeons and one neurophysiologist.• Average age: 52.87 (SD = 14.9)• 199 were stimulated nerve roots formDirect recording their stimulation threshold.

Results

Stimulating a nerve roots 199 average 2.82 per patient (SD = 1• 52 (26.1%) were considered preoperatively chronically compressed. No differences were found in thresholds stimulation of different lumbar levels (e.g., L2, L3, L4, L5 and S1) or chronically compressed roots or non-compressed (ANOVA, p > 0.05; p = 0.190). Average maximum stimulation intensity 6.34 mA (SD = 7.2). Nerve roots uncompressed presented a average intensity threshold stimulation 4.33 mA (SD = 3.6) chronically compressed nerve roots. They had an average intensity thresholdstimulation of 11.93 mA (SD = 10.9). This difference was statistically significant (TStudent, p < 0.0001). No association was found between age and theaverage intensity of stimulus or between roots chronically compressed or non-compressed.

Conclusion

If you are using direct stimulation path of the pedicle and / or to confirm the screw indemnity pedicle, we bear in mind theexistence of symptoms of nerve root compression previously. As shown in this study, these variables determine a threshold stimulation intensity greater root to confirm the proper positioning screw. We could generate false negative results, and thus to detect a possible improper positioning intrapedicular screw.
Prospective Multicenter Assessment of Early Complication Rates Associated with Adult Cervical Deformity (ACD) Surgery in 78 Patients
Authors: Smith Justin , Lafage Virginie , Shaffrey Christopher , Protopsaltis Themistocles , Passias Peter , Schwab Frank , O'Brien Michael , Gupta Munish Chandra , Mundis Gregory , Hart Robert , Kim Han Jo , Klineberg Eric , Riew K. Daniel , Ames Christopher ,   International Spine Study Group
Published: April 2016

Introduction

Although adult cervical deformity (ACD) can have profound impact, few reports have focused on the treatment of these patients. We present early complication rates associated with surgical treatment for ACD based on a prospective multicenter cohort.

Material and Methods

Prospective multicenter database of consecutive operative ACD patients was reviewed for early (<30 days from surgery) complications. Enrollment required at least one of the following: cervical kyphosis > 10°, cervical scoliosis > 10°, C2–7 SVA > 4cm or chin-brown vertical angle > 25°.

Results

78 patients (59% women) underwent surgical treatment for ACD and had a mean age of 60.7 years and previous surgery in 52%. Surgical approaches included anterior-only (A, 14%), posterior-only (P, 49%), anterior-posterior (AP, 35%) and posterior-anterior-posterior (PAP, 3%). Mean numbers of fused anterior and posterior vertebral levels were 4.7 and 9.4, respectively. A total of 52 early complications (Figure) were reported, including 26 minor and 26 major (Table) for an overall complication rate of 66.7%. 22 (28.2%) patients had at least one minor complication, and 19 (24.4%) had at least one major complication. Overall, 45 (57.7%) patients had at least one complication. The most common complications included dysphagia (11.5%), deep wound infection (6.4%), new C5 motor deficit (6.4%) and respiratory failure (5.1%). One mortality (1.3%) was reported. Overall early complication rates were significantly different based on approach: A (27.3%), P (68.4%) and AP/PAP (79.3%) ( p = 0.007).

Conclusion

Among 78 patients treated for ACD and prospectively followed, a total of 52 early complications were reported (26 minor, 26 major). Overall, 45 (57.7%) patients had at least one complication and 24.4% of patients had at least one major complication. Significantly higher rates of complications were associated with combined and posterior-only approaches compared with anterior-only approaches. These findings may prove useful in treatment planning and patient counseling.
Development and Implantation of an Individualized 3D Printed Titanium Cage for Cervical Fusion
Authors: Spetzger Uwe
Published: April 2016

Introduction

At present, all available cervical fusion cages have standardized sizes and mimic the anatomy of the intervertebral disc space more or less. Usually, the patient's anatomy is adapted during the surgery to the cage. Our idea was to respect the individual patient's anatomical situation and manufacture an individual cage with a perfect fitting accuracy. The production of individualized cages might be the next step for further improvement of spinal implants due to their perfect fit and improved load bearing surface.

Material and Methods

The computer-assisted planning, manufacturing, and implantation of the individualized cervical cage was performed in close co-operation with 3D-Systems Corporation, Rock Hill, SC 29730, USA and EIT Emerging Implant Technologies GmbH, Tuttlingen, Germany. A 3D model of the patient's cervical spine obtained from CT data was rendered. This model is the basis for the exact simulation of the operation. The newly developed 3D planning algorithms and special reconstruction software implemented in a high-end image-processing computer allow a virtual surgical procedure. The correction of degenerative deformities by repositioning of vertebrae and also the virtual resection of osteophytes is possible. The cage implantation can be simulated to check the accuracy of fit. These data are the basis for the production of the cage. This custom-made cage is manufactured of trabecular titanium by selective laser melting (3D printing procedure).

Results

The pilot project of the first implantation of an individualized cervical cage ever resulted in a high accuracy of fit of the implant. During surgery the cage ‘found’ its correct position after suspending disctraction due to its unique endplate design. Furthermore, it was impossible to move the cage in any direction. Thus, it can be assumed that the individualized cervical implant provides excellent primary fitting accuracy and stability.

Conclusion

Preconditions for the manufacturing of individualized cervical fusion cages using specific patient data are given. The implantation is uncomplicated. The improved load-bearing surface will lower the rate of implant dislocation and subsidence. The next essential steps will be to improve the workflow of the surgical simulation and shorten the time of the overall production process. The manufacturing of individualized cages at a reasonable price has to be figured out by spine surgeons and the industry.
Image of Slack Spinal Cord
Authors: Fujita Masaru
Published: April 2016

Introduction

In general, the spinal cord was constricted at the level of spinal canal stenosis. Rarely, spinal cord curved above the level of stenosis like the slack rope. There was no report about this image we called slack spinal cord.

Material and Methods

Slack spinal cord was shown in 7 patients. The average age was 70 years old. Multiple spinal canal stenosis were shown at the junction of thoracolumbar spine. The level of the most cranial stenosis was L1/2; 4 patients and Th12/L1; 3 patient. 5 patients of them presented a symptom of lumbar spinal canal stenosis. 2 patients presented myelopathy.

Results

Laminectomy was performed for them. Slack spinal cord was improved after operation. The reasons of slack spinal cord were considered as moving the spinal cord to the cranial side or compressed by redundant spinal nerve roots. The denticulate ligaments are fibrous spinal structures that are generally believed to stabilize the spinal cord within the vertebral canal. In anatomical study, the structures of these ligaments were different in the spinal level. At the lower thoracic level, the denticulate ligament is thin and long band. Furthermore, the strength of this ligament is decreased at the lower spinal levels. Considering these anatomical characteristics and slack spinal cord is shown commonly at the caudal site of spinal cord, we guess the conus medullaris move to cranial side like redundant nerve root.

Conclusion

Slack spinal cord is rarely observed as the secondary change with spinal canal stenosis.
Spinal Osteotomy for Sagittal Deformities using “Posterior Only Approach”: A Novel Classification System
Authors: Rajasekaran S. , Reddy Sreekanth , Shetty Ajoy Prasad , Kanna Rishi
Published: April 2016

Introduction

Numerous types of posterior approach based osteotomies have been described but often there is a loss of clarity on the best osteotomy for each patient. We have proposed a morphological classification of sagittal deformities based on the status of the anterior and posterior column, the extent of column deficiency and the flexibility of the deformity. This classification will be useful as guideline for osteotomy selection and for comparing the practice preferences and outcomes between different institutions.

Methods

We analyzed retrospectively collected data for 187 posterior based osteotomies for sagittal deformity. A morphological classification of sagittal deformity was created on basis of collected data. The deformities with intact anterior and posterior column was Type I, where 1A had mobile disc spaces and 1B ankylosed segments. Type II had deficiency of any one column with IIA having a deficiency of posterior column only and Type IIB of anterior column only. Type III had an insufficiency of both columns with Type IIIA being less than 60°, IIIB > 60° and IIIC having buckling collapse. We then prospectively analyzed this morphological classifcation in seventy-five patients with sagittal deformity who underwent various osteotomy procedures for different pathologies. We matched all the cases for six types of anatomical spinal osteotomies and one salvage procedure (anterior strut fusion). The osteotomy procedures considered were partial facetectomy, Ponte's osteotomy, pedicle substraction osteotomy, disc bone osteotomy, single vertebrectomy, multilevel vertebrectomy and salvage procedure in the form of anterior strut grafting.

Results

The mean age was 20.1years and mean sagittal deformity was 67.70°(28–129°). An average correction of 41% (11 to 78%) was achieved and an association of more complex osteotomies for higher class of deformities was noted. The inter-observer agreement for four spine surgeons classifying the 75 deformities was noted to be high (agreement rate K-0.83) using the above morphological classification. A chi-square analysis performed to test the association between the classification and the type of osteotomy, which showed an observable trend with a highly significant association ( p < 0.001) showing that the type of osteotomy to be performed could be predicted by the classification.

Conclusion

The proposed classification of the sagittal deformity had a high inter-observer agreement and was useful in predicting the type of osteotomy. The classification would be valuable in training and teaching purposes. This classification could also be used for comparing the osteotomy selection and outcomes between different institutions.
Tranexamic Acid Administration in Adolescent Idiopathic Scoliosis Surgery Reduces % Total Blood Volume Loss
Authors: Butler Elissa , Garber Tara , Ledonio Charles , Polly David W. , Cohn Claudia
Published: April 2016

Introduction

Multilevel spinal fusion surgery for adolescent idiopathic scoliosis (AIS) is typically associated with significant blood loss. Antifibrinolytics such as tranexamic acid (TXA) have been proposed to reduce both blood loss and the need for transfusions. This study compares the blood loss and % total blood volume loss of AIS surgery patients with or without tranexamic acid.

Materials and Methods

A retrospective comparative case-control study design was used to evaluate multilevel spinal fusion operations for AIS by a single surgeon from October 2011 to August 2014. Efficacy of TXA was evaluated by comparing mean estimated blood loss (EBL) and %TBV loss (calculated by Nadler's formula: males = 0.3669 * Ht m3 + 0.03219 * Wt kg + 0.6041; females = 0.3561 * Ht m3 + 0.03308 * Wt kg + 0.1833). Clinical factors including number of levels fused and length of operation were tested for correlation with % TBV loss.

Results

From 2011 to 2014, 36 adolescents underwent AIS surgery (18 with and 18 without TXA). Mean age was 16 (±3) years and 86% (31/36) were female (controls 15/18 and TXA 16/18). There were no statistically significant mean differences between the ()TXA and (+)TXA groups in terms of the following: BMI (20.2 vs 22.2); estimated blood volume (3380 mL vs 3797 mL); levels fused (9.6 levels vs 10.5 levels); EBL (583 mL vs 474 mL) ( p = 0.18); and EBL per level fused (61 mL/level vs 43 mL/level). Percent total blood volume loss and % TBV per level fused was significantly less in the TXA group (12% and 1%) compared with control group (17% and 2%) ( p < 0.05). There was a moderate but significant direct correlation between number of levels fused ( p = 0.024) and length of operation ( p = 0.007) with % total blood volume loss.

Conclusions

Administration of TXA during pediatric scoliosis surgery reduced % total blood volume loss by 30% compared with no TXA.
Do Racial Differences Affect Surgical Outcomes in Patients with Degenerative Cervical Myelopathy?: Results from the Prospective Multicenter AOSpine International Study on 479 Patients
Authors: Nagoshi Narihito , Tetreault Lindsay , Nakashima Hiroaki , Nouri Aria , Fehlings Michael
Published: April 2016

Introduction

Degenerative cervical myelopathy (DCM) is the most common disease of the cervical spine in the elderly worldwide, and surgical decompression is a widely accepted procedure to prevent neurological deterioration. Although racial background affects clinical outcomes in various medical conditions and diseases, few studies have evaluated the impact of racial differences on surgical outcome after DCM. The purpose of this study is to comprehensively evaluate whether racial background is an independent predictor of surgical outcomes for DCM.

Material and Methods

A total of 479 patients with symptomatic DCM were prospectively enrolled in the AOSpine CSM-International study at 16 global sites. Patients' functional status were evaluated using the modified Japanese Orthopedic Assessment scale, the Nurick score, the Neck Disability Index, and the Short- Form 36 (SF-36) Health Survey. Improvements in functional status and QOL were assessed between baseline and 24-months follow-up. A mixed model analytic approach was used to evaluate differences in surgical outcome between races, while controlling for relevant baseline characteristics and surgical factors.

Results

Of the 479 DCM patients, 324 (67.64%) and 106 (22.13%) were Caucasians and East Asians, respectively. Other races were excluded as there were too few patients to conduct separate analyses. There was no difference in the incidence of ossification of the posterior longitudinal ligament (OPLL) between the two races; however a greater percentage of Caucasians in India (46.15%) and Turkey (41.38%) exhibited OPLL than Caucasians at sites in other regions. The frequency of spondylosis was significantly higher in Caucasians ( p < 0.0001). Caucasians had a significantly longer duration of symptoms ( p = 0.0002), a greater number of co-morbidities ( p = 0.0288), and a lower preoperative score on the SF-36 Physical Component Score ( p = 0.0002) than East Asians. At 24-months postoperative, there were no significant differences in functional status or QOL between East Asian and Caucasian patients, after adjusting for variations in baseline characteristics, surgical preferences and disease causation. In addition, rates of perioperative complications were not significantly difference between the races ( p = 0.261).

Conclusion

Although the frequency of subcategories of DCM differs between racial backgrounds, this does not affect surgical outcomes for DCM. Decompressive surgery for DCM is equally safe, and provides comparable functional gains both in Caucasians and East Asians. Although the prevalence of OPLL in East Asians has generally been thought to be higher than amongst Caucasians, our findings indicate that individuals from India and Turkey may also be at a high risk of OPLL development.
Post-traumatic Spondylodiscitis. Update, Series of 17 Patients and Review of the Literature
Authors: Abdelrahman Hamdan , Shousha Mootaz , Boehm Heinrich
Published: April 2016

Introduction

With increased risk and predisposing factors, the incidence of pyogenic spondylitis is rising. The term locus minoris resistentiae is defined as a place of less resistance, any part or organ which is more susceptible than others to the attack of a morbific agent. Hence the posttraumatic spondylodiscitis becomes not uncommon with acute or chronic presentation. In the literature only 17 publications (1939–2012) are reporting on a total of 20 cases.

Material and Methods

A retrospective uncontrolled clinical case-series in a single institution. Between January 2000 and May 2015, 17 patients were operated due to vertebral osteomyelitis after spinal fracture. We have analyzed the preoperative condition, risk factors, diagnostic findings, time between fracture and presentation, causative organism, treatment and outcome

Results

Total of 17 patients; 9 males and 8 females with mean age 68 years (44–81). High energy Trauma was reported by 5 patients. The mean interval between the fracture and spinal infection was 111.6 days (5 - 601). Twelve patients presented within less than 3 months of the fracture, whereas 5 presented later. Affected region was lumbar in 12, thoracic in 4 and cervical in one patient. Comorbidities were found in 94% of the patients: DM in 9 cases, renal insufficiency in 6 and cardiac diseases in 8 cases. Associated infections had been detected in 12 (71%). Mean CRP at time of presentation was 115 mg/l, WBCs 11x103/mm3 and ESR 81 mm/hr. The most common isolated organism was Staph. aureus in 9 cases (53%). Mean VAS after injury was 6.8/10 and at the time of presentation with spinal infection was 7.8/10. The most common presenting symptoms were increased local pain in all patients, fever in 11 and neurological manifestations in 6 patients. All patients except 2 patients, who died preoperatively, had been treated surgically (anterior Debridement and posterior stabilization).

Conclusion

Spinal osteomyelitis is commonly caused by hematogenous seeding. Predisposing factors that compromise the immune system render the host more susceptible to spinal infection. The fracture hematoma represents a suitable site for inoculation and development of infection and this can explain the acute presentation. The altered local vascularity at the fracture site can lead to blood stagnation and facilitate the bacterial seeding. Inflammatory parameters can be mildly elevated after trauma and should be differentiated from increase due to infection.