bluuebunny/crossref_metadata_2025 huggingface dataset:
Is Preoperative Duration of Symptoms a Significant Predictor of Functional Status and Quality of Life Outcomes in Patients Undergoing Surgery for the Treatment of Degenerative Cervical Myelopathy?
Authors: Tetreault Lindsay , Kopjar Branko , Wilson Jefferson , Arnold Paul , Fehlings Michael
Published: April 2016

Introduction

Longstanding compression of the spinal cord in patients with degenerative cervical myelopathy (DCM) may result in irreversible neural tissue damage. This study aims to analyze whether a longer duration of symptoms is associated with poor surgical outcomes and to determine the optimal timing for decompressive surgery.

Material and Methods

Three hundred and fifty patients with symptomatic DCM were prospectively enrolled in either the CSM-North America or International study at 12 sites in North America. For each patient, extensive demographic information was collected, including age, co-morbidities, and a self-reported estimate of preoperative duration of symptoms. Postoperative functional status and quality of life were evaluated at 6-, 12- and 24-months using the modified Japanese Orthopaedic Association (mJOA), Nurick grade, Neck Disability Index (NDI) and Short-Form-36 (SF-36) Physical (PCS) and Mental (MCS) Component Scores. Change scores between baseline and 12-month follow-up were computed for each outcome measure. Duration of symptoms was dichotomized into a “short” and “long” group at several cut-offs. An iterative mixed model analytic approach procedure was used to evaluate differences in change scores on the mJOA, Nurick, SF-36 MCS and PCS and NDI between duration groups in 1-month increments. Two models were constructed: 1) an unadjusted model between duration of symptoms and surgical outcome and 2) a model adjusting for significant independent covariates identified through stepwise regression analysis.

Results

Our cohort consisted of 201 (57.43%) men and 149 (42.57%) women, with a mean age of 57.49 ± 11.77 years (range: 29–87 years). The mean duration of symptoms was 25.71 ± 36.68 months (range: 1–240 months). In unadjusted analysis, patients with a duration of symptoms shorter than 4 months had significantly better functional outcomes based on the mJOA ( p = 0.04) than patients with a longer duration of symptoms (>4 months). On average, patients with a shorter duration of symptom improved by 3.71 on the mJOA, whereas those with a duration 4 months or longer only exhibited a 2.96 mean gain. Twelve months was identified as the next important cut-off beyond which patients had a significantly worse outcomes on the mJOA; however, this difference was smaller. Following adjusted analysis, cut-offs of 4 and 12 months remained significant. Duration of symptoms was not associated with Nurick or SF-36 PCS or MCS in either the unadjusted or adjusted models.

Conclusion

Patients who are operated on within 4 months of symptom presentation have better mJOA outcomes. It is recommended that patients with DCM are diagnosed in a timely fashion and referred early for surgical consultation. Our study does not support the traditional conservative “watchful waiting” approach to symptomatic patients with DCM.
Lumbar Spondylolisthesis: Radiographic Criteria of Instability
Authors: Hajj Rabih , Assaf Yara , Lahoud Jean-claude , Hoyek Fadi
Published: April 2016

Introduction

The goal of this study was to compare the radiographic criterias of “static” and “dynamic” lumbar degenerative spondylolisthesis. The sensitivity of standing lateral flexion/extension (SLFE) radiographs and magnetic resonance imaging (MRI) was used to categorize the spondylolisthesis to provide the patient with the ideal treatment.

Material and Methods

Prospective study where patients were screened using standing lumbar spine SLFE radiographs and MRI. They had their plain films assessed for the degree of spondylolisthesis and were designated “dynamic” or “static” based on the current literature criteria. Axial and sagittal T2 MRIs were evaluated for associated facet fluid (FF) and interspinous fluid (ISF). We compared then the radiographic results with our per-op findings and studied the sensitivity of SLFE radiographs and MRIs.

Results

22 patients were included and evaluated for the presence of spondylolisthesis. Patients with greater than 3mm of instability on SLFE films were more likely to have FF ( p = 0.026) and ISF ( p = 0.027). If ISF was present on MRI, there was a positive predictive value (PPV) of 83.3% that there would be greater than 3mm instability on plain films. Absence of FF on MRI has a PPV of 75% for instability less than 3 mm on plain films. If ISF is present on MRI, the likelihood ratio of finding greater than 3mm instability on plain films was 3.45. The presence of FF on MRI had a likelihood ratio of 2.53 for instability. The presence of both parameters FF and ISF increased the likelihood ration to 5.08.

Conclusion

The presence of FF and/or ISF on MRI is associated with instability greater than 3mm on SLFE films. The presence of 1 or more of the following criteria: slip distance greater than 3mm, FF greater than 3mm and positive ISF permit us to consider the spondylolisthesis as dynamic and allow us to perform a posterior spinal fusion.
Long Term Experience with Reduction Technique in High Grade Spondylolisthesis in the Young
Authors: Sudarshan Pramod , Panda Aditya , Paramasivam Aghilavendan , Varma Vamsi Krishna , Hegde Sajan
Published: April 2016

Introduction

Surgical management of high grade spondylolisthesis in the young is not only challenging but also controversial, from in-situ fusion to complete reduction. It is fraught with dangers such as neurological injury, pseudoarthrosis and progressive deformity with subsequent global sagittal imbalance. We describe our experience of progressive reduction technique and restoration of lumbosacral alignment.

Material and Methods

A retrospective review of patients who underwent surgery between 1998 and 2012. The surgical technique involved positioning the hips in extension with traction, pedicle screw fixation, correction of lumbosacral kyphosis with a specific distraction maneuver, wide decompression, and gradual reduction of the deformity and maintenance of reduction with interbody fusion. All patients were serially assessed at 1, 3, 6 months and yearly thereafter with clinical, radiological and outcome measures (ODI and VAS).

Results

27 patients with high grade spondylolisthesis at L5-S1 (3 cases Grade 3, 7 Grade 4, 17 Grade 5) with an average age of 13.9 years were reviewed. Mean follow-up was 120 months (range 24–192). All patients presented a solid fusion at the 6 month visit; mean slip percentage was reduced from 89% to 23%, with all cases reduced to grade 2 or less. The slip angle improved from 45° to 3° postoperatively, with improvement in sacral slope from 13° to 35°. 4 spondyloptosis patients had concomitant scoliosis which corrected spontaneously after the surgery and did not need further intervention. All but one patient (96.2%) had good functional outcomes and returned to their full normal activities. One patient developed a deep infection necessitating implant removal, with eventual deformity progression leading to a poor outcome. Three patients (11.1%) suffered partial drop foot that resolved in full by 12 weeks.

Conclusion

Our technique demonstrated a significant reduction of high grade spondylolisthesis, with restoration of global sagittal balance via correction of the lumbosacral kyphosis. Though surgically demanding, it is safe, reproducible and gives satisfying outcomes.
The Correlation of Anchor Density and the Curve Correction of Adolescent Idiopathic Scoliosis Surgery
Authors: Yeh Yu-Cheng , Lai Po-Liang , Chen Wen-Jer , Niu Chi-Chien , Chen Lih-Huei
Published: April 2016

Introduction

Pedicle screw instrumentation has been shown to provide better curve correction with solid three-column fixation in adolescent idiopathic scoliosis (AIS) surgery. The levels of spinal segments to be fused are based on Lenke classification. However, the optimal anchor density of fixation points in AIS surgery to achieve cost effective curve correction remains unclear. The purpose of the study is to analyze the correlation between curve correction and anchor density in pedicle screw based posterior fusion of AIS.

Material and Methods

From Jan. 2003 to Dec. 2008, 121 consecutive AIS patients underwent primary posterior fusion with pedicle screw based fixation and followed up for a minimum of 24 months were reviewed. Anchor density was defined as the number of screws per fused spinal segment. Radiographs were assessed at preoperative, postoperative 0, 3, 6, 12 and every 12 months until last follow up. The relation between anchor density and correction rate in Lenke subgroups were analyzed.

Results

There were 14 male and 107 female patients enrolled and aged 14.1 years old at the time of surgery. The number of Lenke type 1, 2, 3, 4, 5 and 6 curve patients were 67, 22, 9, 2, 14 and 7 respectively. For all patients, the mean correction rate was 63.1 ± 15.8% in all structural curves and 67.0 ± 12.0% in major curves only. The mean anchor density was 1.30 ± 0.18. There was no correlation between anchor density and major curve correction rate (r=0.24, p = 0.01). Patients of anchor density >1.30 (=mean anchor density of all patients) had similar correction rate with patients of anchor density <=1.30 in the major curves (67.9 ± 13.2% vs 66.0 ± 10.4%, p = 0.38). For Lenke type 1, 2 and 3 curves, there was no correlation between major curve correction rate and anchor density (Lenke 1: r=0.02, p = 0.88; Lenke 2: r=0.30, p = 0.18; Lenke 3: r = −0.20, p = 0.60) with mean anchor density of 1.29 ± 0.15, 1.23 ± 0.17 and 1.23 ± 0.10 respectively. For Lenke type 5 curves, the major curve correction rate was positively correlated with anchor density (r=0.61, p = 0.02) with mean anchor density of 1.51 ± 0.23.

Conclusion

There was no significant correlation between curves correction rate and anchor density in pedicle screw based instrumentation of adolescent idiopathic scoliosis surgery. Although for major thoracolumbar/lumbar curves, anchor density may play a role in curve correction, further investigation is still needed.
VEPTR: Single Centre Experience of 9 Years
Authors: Wimmer Cornelius , Siam Ahmed Ezzat , Pfandlsteiner Thomas
Published: April 2016

Introduction

The operative treatment of scoliosis with vertical expandable prosthetic titanium rib (VEPTR) implants has been established in Europe since 2002. Between 2005 and 2014, we have treated 72 scoliosis patients with VEPTR implants.

Methods

This is a prospective uncontrolled study in a single scoliosis center. Of 72 cases; 51 were females and 21 males, with a mean age of 7.5 years (3–13 years). The underlying pathology was congenital scoliosis in 39 cases, neuromuscular scoliosis in 21 and early-onset scoliosis in 12. The grade of the deformity has been measured according to Cobb method of anteroposterior radiographs; pre- and postoperatively, and after every distraction of the rods. This took place every 6–9 months until post-pubertal end-fusion operation. The evaluation included patient (or parents') satisfaction score, complication rate and growth of the patient. Of 72 children, 10 have been already operated before.

Results

The primary deformity ranged from 45° to 130° with a mean of 65°. After the first correction, the mean Cobb angle was 32° (25°- 75°). No complications occurred during the instrumentation surgery. The mean operative time was: 95 minute. (65–175 minute.), with a mean blood loss of 125 ml. In all cases, intraoperative neuromonitoring with SEP and MEP has been performed. In 29 cases, a “rib-to-lumbar spine-hybrid” has been used, and combined with a “rib-to-rib” in 32 cases. In the other 11 cases, a “rib-to-pelvis” construct has been used. Delayed wound healing occurred in 4 patients, another patient had pneumonia, that was successfully treated. Proximal hook dislocation occurred in 14 cases after distraction. Skin perforation complicated 10 cases and needed partial removal of implant. No neurological complications or deep spinal infection occurred. The mean hospital stay was 18 days after first implantation (14–31). One to 12 distraction operations have been done in 52 patients. A deformity correction with a mean of 15,7° grades have been achieved (19.8%). In 20 cases, the secondary scoliosis have been later instrumented. In 12 cases, the implant has been removed and replaced by pedicular-screw growing rod system. The end-fusion operation has been already performed in 12 cases.

Conclusion

The early results have been considerable. Yet after 9 years of experience with the VEPTR systems, some major problems occurred with the proximal junctional kyphosis and with implant-related complications. Like other growth-sparing systems, the VEPTR implant showed a complication-rate of 29%
Treatment of Early Onset Scoliosis - An Early Experience of Growing Rod Insertion and Lengthening
Authors: Khan Ed Simor Khan Mor Japar , Ayu Paul Ngalap , Goh Jin Hee , Singh Manmohan , Rashid Mohd Zakhiri Mohd , Amir Dzulkarnain , Mohamad Fazir
Published: April 2016

Introduction

Early onset scoliosis normally found in children from the age of birth till 10 years old with female preponderance. Any lateral spinal curvature of 10 degrees or more by reference to Cobb's angle measurement is diagnosed as scoliosis. The deformities is three dimensional thus affecting spinal growth in multiple planes. Scoliosis has been classified based on it's underlying causes such as congenital, idiopathic and also secondary causes as neuromuscular scoliosis or syndromic scoliosis.

Material and Methods

A retrospective study of patients seen in Orthopedic and Traumatology department of Hospital Kuala Lumpur. The age of patients ranges from 8 to 13 years old and are diagnosed with scoliosis regardless of the etiology. Twenty two patient (nine males, thirteen females) whom underwent surgical intervention are the subjects of this study. Spine correction details includes Cobb'sangle, T1-S1 length, Coracoid Height Difference (CHD), Clavicle Ribcage intersection point Difference(CRID), Clavicular Tilt Angle Difference(CTAD), Vertebral height, Apex distance from CSVL and rate of lengthening were collected. Data were then statistically analyzed.

Results

The results obtained after data analysis were as followes: Mean age of surgery is 11.1(between 13 and 7.7). Improvement of Cobb's angle immediately post op is 33.71%(between 54.55 and 15.56). Final improvement is 48.66 (between 69.09% and 27.59%). T1S1 length improved immediately post operatively by 12.28% and at final lengthening was 26.41%. An improvement of shoulder CHD immediately post op by 38.33% and at final by 51.96% was observed. Balance CRID improve post operatively 35.21% and final 31.86%. Balance CTAD showed improvement post operatively by 24.38% and final by 23.64%. Overall shoulder balance improved post operatively by 32.64% and final was 35.72%. Reduction of coronal distance immediate postoperatively by 36.30% and final at 54.89%.

Conclusion

Growing rod is not only one of the best option to prevent the progression of curvature, it is also a good method in correcting the co-existing curvature. With a good correction of curvature, it will facilitate in achieving the maximal correction for definitive fusion later. The outcome of our center is comparable with the results published by other international studies. Treatment of Early Onset Scoliosis with growing rod technique is safe and effective.
A Clinical Prediction Rule for Functional Outcomes in Patients Undergoing Surgery for Severe Degenerative Cervical Myelopathy: Analysis of an International AOSpine Prospective Multicentre Dataset of 254 Subjects
Authors: Tetreault Lindsay , Kopjar Branko , Cote Pierre , Arnold Paul , Fehlings Michael
Published: April 2016

Introduction

Patients with cervical spondylotic myelopathy (CSM) may be severely impaired, have reduced quality of life and present with deleterious signs and symptoms. Patients with severe myelopathy (mJOA < 12) often improve following surgery; however, some may not achieve a minimum clinically important difference (MCID), whereas others may have exceptional outcomes. Due to varying prognoses among this group, it is important to predict outcome in these patients and use this knowledge to manage expectations. This study aims to determine the most important clinical predictors of surgical outcome in patients with severe CSM.

Material and Methods

Of the 757 patients enrolled in the CSM-North America or International studies, 254 (33.55%) presented with severe myelopathy as classified by a mJOA < 12 points. A prediction model was developed to distinguish between patients who improve to mild or moderate myelopathy postoperatively (mJOA≥12) and those who remain significantly impaired (mJOA < 12). Univariate analyses evaluated the relationship between this outcome and various clinical predictors. Multivariate Poisson regression was used to formulate the final prediction model and to compute the relative risks. A secondary model was constructed to predict which patients would achieve a MCID on the mJOA, defined as a change score of three or more points in patients with severe disease.

Results

Our cohort consisted of 153 men and 101 women with ages ranging from 28 to 86 (mean: 60.09 ± 12.06 years). The mean preoperative mJOA was 9.42 ± 1.67. One hundred and fifty-four (60.63%) patients improved to a score ≥12 at 1-year postoperative, whereas 145 (57.09%) achieved a MCID on the mJOA. Baseline severity score (RR: 1.07, 95%C.I.: 1.02–1.13), hyperreflexia (RR: 0.83, 95%C.I.: 0.72–0.96), lower limb spasticity (RR: 0.75, 95%C.I.: 0.65–0.86), and age (RR: 0.97, 95%C.I.: 0.95–0.99) were significant predictors of a mJOA≥12 following univariate analysis. The final model consisted of three statistically significant variables and one clinically relevant predictor: baseline severity score (RR: 1.09, 95%C.I.: 1.03–1.15), duration of symptoms (RR: 0.94, 95%C.I.: 0.89–0.99), co-morbidity score (RR: 0.96, 95%C.I.: 0.91–1.00) and the sign lower limb spasticity (RR: 0.76, 95%C.I.: 0.66–0.87). The AUC for this model was 0.75 (95%C.I.: 0.67, 0.83). Improvement by the MCID could not be effectively predicted by a combination of clinical variables.

Conclusion

Severe patients were more likely to achieve a score ≥12 on the mJOA if they had a higher preoperative mJOA score and a shorter duration of symptoms; a lower co-morbidity score (fewer and less severe concomitant disease); and did not have lower limb spasticity.
C5 Palsy after ACDF: Topographic Correlation with Chassaigne's Tubercle (C6)? A Fresh Cadaveric Study
Authors: Rajabian Ali , Quraishi Nasir A.
Published: April 2016

Introduction

Our aim was to explore the possible topographic correlation of C5 nerve root with regards to its course and regional relation to C6 tubercle. We hypothesized that etiologic mechanisms proposed thus far in the current literature although may have some plausible explanation, however they still cannot explain why C5 and not any other adjacent level suffer a post-operative palsy.

Materials and Methods

Fresh cadaver had extensive layer by layer dissection performed by 2 surgeons (one of whom has extensive experience as an anatomy demonstrator and dissector). Roots of Brachial plexus were exposed in relationship cervical transverse processes. Photographs were taken at each stage of the exposure.

Results

We observed a close relation of path of C5 root with the C6 tubercle bilaterally, moreover we noted a sharper decent of C5 in comparison with the other adjacent roots.

Conclusion

Sharper angle of C5 nerve root, variations in intra-operative neck position and shoulder pull may play a role in predisposing the nerve root to neuropraxia against this most prominent lateral cervical boney element. We speculate that C5 nerve palsy may be related to the close association of the C5 nerve with Chassaigne's tubercle (C6). We would suggest a closer analysis of the C5 nerve in this region using finite element analysis with emphasis on the close proximity of the nerve and changes due to cervical motion. [Figure: see text][Figure: see text][Figure: see text][Figure: see text]
Anterior Coloumn Reconstruction with Stand Alone Titanium Cage, without Anterior Plating in Tuberculosis Cervical Spine. An Experience of 47 Patients
Authors: Qazi Qazi Muhammad Amin , Imran Muhammad , Akram Rizwan , Javed Shahzad , Ahmad Naeem , Aziz Amer
Published: April 2016

Introduction

Tuberculosis is a common problem specially in under developed countries. Tuberculosis of the vertebral column constitutes nearly 50% of all lesions of osteoarticular tuberculosis. The commonest site for the disease is in the peridiscal region. Treatment option usually is anti tuberculous chemotherapy but in some patients usually with severe pain and involving neurology, instability, large abcess, surgery is recommended. To our knowledge there is not a single publication in literature in which standalone titanium cage and bone graft without anterior plating is used in the treatment of TBS. The aim of this study is to evaluate the efficacy of standalone titanium mesh cages in TB cervical spine.

Material and Methods

A retrospective study of 47 patients with cervical tuberculous spondylitis (TBS) was performed at Ghurki trust teaching hospital. This study approved by the Institutional Review board and the ethics committee, included 47 patients with TBS of cervical spine who gave their informed consent to be included in the research. All patients had radical debridement, decompression, anterior coloumn reconstruction and instrumentation with standalone titanium cage without anterior plating filled with autologous iliac bone graft. The diagnosis of TBS was based on clinical correlation including night fever, loss of weight, fatigue and neck pain, laboratory investigations including ESR, CRP and tuberculin test were done in all patients. Visual analogue score (VAS) and frankel scoring system was used to score pain severity and grade neurological status. ATT was started preoperatively. The radiographic assessment included preoperative standard anteroposterior and lateral views. Cobbs methos was used to measure the sagittal profile.

Results

61.6% patients fell in age group 3–35 years and 28.4% fell in group 36–70 years of age. 26 were men and 21 were women. Out of all patients 26 had pre op frankel grade E and 4pts had grade D and 10 pts had grade C and 2 pts had grade B and five pts had grade A preoperatively. Post operatively one patient of grade A remained same while other four improved to grade C in follow up and rest of all pts. improved to grade E in two year follow up. Pre-op cob's angle was 39.06 ± 10.92 (Mean±SD) which improved to -5.51 ± 4.77 (Mean±SD). P value is < 0.05. In comparison of visual analogue score there is also statistically significant difference in pain improvement. All patients had single stage radical debridement, decompression and instrumentation. Anterior coloumn reconstruction was done in all patients using standalone titanium cage.

Conclusion

The use of titanium cages effectively restores the sagittal deformity in TB spine with no donor site morbidity.
Single Stage Anterior Corpectomy and Posterior Instrumentation in Tuberculous Spondylitis with Varying Degrees of Neurological Deficit
Authors: Debnath Ujjwal K. , McConnell Jeffrey R.
Published: April 2016

Introduction

The study is an outcome of patients with tuberculous spondylitis, progressive neurologic deficit, and kyphotic deformity, who underwent single stage anterior corpectomy and posterior decompression with instrumented fusion

Material and Methods

20 (6M:14F) patients with spinal TB and varying degrees of motor deficits underwent surgery during the past 7 years. The range of age was from 2 to 65 years old (mean age of 34.8 years). The average duration of symptom was seven months (ranging from 3 months to 1 year). Anti-tuberculosis chemotherapy was initiated in all patients and continued for more than four weeks until ESR < 40mm/H before surgery. All had a minimum of 12 months of follow up (mean follow-up period 16 months). One patient had upper cervical disease, 10 patients had thoracic disease and 8 patients had lumbar or lumbo sacral involvement. The disease in 7 patients was characterized by Frankel Grade A/B (Medical Research Council Grade 0/5), in 8 patients by Frankel Grade C (unable to walk even with support) and 4 patients had Frankel Grade D (walk with support but weak legs) on admission. The kyphotic angle ranged from 5° to 40° before operation, with an average of 18° ± 12°. Three children below 10years of age underwent anterior corpectomy and debridement with rib or fibular grafts and posterior instrumented fusion. All the 17 patients underwent anterior corpectomy, debridement with cage insertion and posterior instrumented fusion. Physiotherapy was instituted in all patients.

Results

Local symptoms of pain were relieved significantly by three weeks postoperatively (mean VAS scores reduced from 6.8 to 2.7). 17/19 patients (89.4%) neurological deficit had excellent or good clinical results (P > 0.05). 6/7 patients improved from Frankel A/B to Frankel E (normal activity), ⅞ patients improved from Frankel C to Frankel E and all 4 patients with Frankel D became normal to Frankel 5. The average ESR was normal (10 ± 5mm/h) within 6 months in all patients. The average kyphotic angle decreased to 7 ° ± 5° postoperatively. Solid fusion was achieved in all cases. No significant loss of deformity correction was noted in these patients. Only one patient with lumbo-sacral disease showed recurrence after 18months of disease free interval.

Conclusion

Single stage anterior corpectomy with autogenous rib grafts or cage insertion and posterior instrumentation are safe and effective methods in the surgical management of spinal tuberculosis with neurological deficit. Combined single stage surgery helps to correct and maintain the deformity, foci clearance, spinal-cord decompression and pain relief in the treatment of tuberculous spondylitis.
A Five-year Prospective Clinical and Radiological Review of a Semi-constrained Ceramic-Ceramic Cervical Disc Replacement
Authors: Swamy Girish , Mitsiou Konstantinos , Burget Filip , Nanjayan Shashi , Bommireddy Rajendranath , Klezl Zdenek
Published: April 2016

Introduction

Artificial cervical disc replacement [CDR] has emerged as a viable treatment alternative to fusion for the management of symptomatic compressive radiculopathy and / or myelopathy. This paper evaluates the clinical and radiological outcomes of patients treated with a second generation semi-constrained CDR with a ceramic-ceramic articulation.

Material and Methods

We conducted a prospective cohort study of all patients undergoing a cervical disc replacement for cervical disc pathology, during the period from April 2007 to April 2010 using the Discocerv ceramic disc replacement. 42 patients were available for final clinical and radiological follow-up. Both, clinical and radiological evaluation was performed at each clinical visit at 6 weeks, 6 months, 12 months and 2 years and 5 years.

Results

Three patients were lost for follow-up. C5-C6 was the commonest level. There were 34 single level cases and 8 two level cases. The NDI improved significantly ( p < 0.05) from a mean preoperative score of 56% to a score of 20% at final follow-up. The mean preoperative mobility at the index level unit was 12.2 ± 4.5°, this decreased to 7.9 ± 3.2° at six weeks, but slightly increased to 12.9 ± 2.9° at 1 year (gain not significant). Heterotrophic ossification [HO] was noted in 10 [23%] patients.

Conclusion

Based on our study of cervical disc replacement with a ceramic-ceramic bearing surface, this appears to be a viable option in the treatment of variety of cervical pathologies. This ceramic-ceramic interface eliminates potential problems like metallosis but further longer-term results should be reported.
The Physical and Mental Health in the Conservative Treatment of the Idiopathic Scoliosis
Authors: Diaremes Panagiotis , Christodoulou Evangelos , Kafchitsas Konstantinos , Christodoulou Anastasios , Symeonidis Panagiotis
Published: April 2016

Introduction

Idiopathic scoliosis may lead to physical and psychosocial impairment as it mostly appears before and/or during puberty. Both ability of young patients to confront the stress of a chronic disease and self esteem, affect their psychosomatic development and their future quality of life. Purpose of this study was to describe and evaluate health associated quality of life in patients with idiopathic scoliosis.

Material and Methods

In this study the physical and mental health of 69 young patients with idiopathic scoliosis was compared with a control group of the same age. The patients were treated with a Cheneau brace because of Idiopathic scoliosis with Cobb angles between 15°and 40°. We used a modified short form 36 questionnaire. We evaluated the eight sections of the SF-36 questionnaire in both groups (vitality, physical functioning, bodily pain, general health perceptions, physical role functioning, emotional role functioning, social role functioning, mental health). The statistical analysis was performed with the Sigma Plot software.

Results

In comparison to the coeval control group (mean age 17,9 years) the group with idiopathic scoliosis (mean age 18,1 years) showed significant higher bodily pain levels. We did not observe any significant differences between the two groups in the sections of vitality, physical functioning, general health perceptions, physical role functioning, emotional role functioning, social role functioning and mental health.

Conclusion

According to our results, bodily pain is more intense by conservative treated patients with idiopathic scoliosis as in the control group. Nevertheless, psychological and psychosocial adjustment of these patients is the same as their contemporaries without significant differences.
Coronal and Sagittal Plane Correction in Adolescent Idiopathic Scoliosis (AIS) using All Pedicle Screw versus Hybrid Instrumentation. A Systematic Review
Authors: Mostafa Wael , El-Sharkawi Mohammad , Koptan Wael , Darwish Manal , Quraishi Nasir A.
Published: April 2016

Introduction

Using all pedicle screw (APS) technique for the treatment of AIS is said to be more effective than hybrid instrumentation (HI). However this has not been proven yet. This systematic review on studies comparing all pedicle screw and hybrid instrumentation in the treatment of AIS tries to answer this question.

Material and Methods

Pubmed and Medline Databases have been searched for articles from 1990 to June 2015 using the keywords “adolescent idiopathic scoliosis,” “hybrid” and “screw.” Only papers with full text in English were reviewed. Eleven articles met the inclusion criteria (only adolescent idiopathic scoliosis, main thoracic and thoracolumbar curves, posterior instrumentation and fusion only i.e., no anterior release, at least 2 of the parameters evaluated is mentioned preoperative and at final follow up “one coronal plane parameter and one sagittal plane parameter”). Ten of the articles were retrospective cohort studies and one was a prospective cohort study. Level of evidence for all of them was 3. The following parameters were evaluated preoperative and at final follow up: thoracic kyphosis, main thoracic Cobb's angle, coronal correction ratio, global sagittal balance and global coronal balance. The follow up duration ranged from 2 – 5 years. Meta-analysis could not been performed because of the heterogeneity of the data.

Results

The total number of patients was 614 (306 APS, 308 HI). The only significant difference found was the coronal correction ratio (67.71% in APS vs 58.34% in HI, p = 0.001). Thoracic kyphosis changed from 24.5° to 21.3° in the APS group and from 25.4° to 23.6° in the HI group ( p = 0.419). Global coronal balance changed from 15mm to 8.8mm in the APS group and from 14.6mm to 8.9mm in the HI Group ( p = 0.811). Global Sagittal Balance changed from (−7)mm to (−4.6)mm in the APS and from (−1)mm to (−3.6)mm in the HI group ( p = 0.344).

Conclusion

Using all pedicle screw technique for the treatment of AIS may achieve better coronal plane correction. Contrary to the common belief, the use of Hybrid instrumentation does not lead to a better sagittal correction than all pedicle screw technique.
Vertical Expandable Prosthetic Titanium Rib (VEPTR) Complications
Authors: Abouyoussef Islam , Ventura Norberto
Published: April 2016

Introduction

This retrospective study evaluates the complications and radiographic results of 30 patients treated with VEPTR for correction of complex spine deformities in children.

Material and Methods

30 cases of spine deformities followed up for a minimum of 2 year and maximum of 7 years, were retrospectively reviewed. 8 congenital malformation of spine, 3 infantile scoliosis and the others were spinal deformities associated with; spinal cord tumors, osteogenesis imperfecta, Jarcho Levin syndrome, spinal muscular atrophy, arthrogriphosis, myelomeningocele and congenital myopathy. The age at surgery varied between 2 and 12 years (6.65). We studied the postoperative change in cobb's angels (in antero-posterior and lateral views), space available for lung (SAL) and complication patterns in relation to number of lengthening operations.

Results

Complications: the complications rate was (36.6%). Complications varied from mortality “one case (3.3%)” to skin sloughing, surgical site infection, junctional kyphosis, metal failure, and pelvic hook migration. The average Cobb's angles preoperatively in the antero-posterior view were 86.8°, while the postoperative average was 55° (average correction 31.8°). The average (SAL %) was 82.3% preoperatively, and has been improved to become 93.5% postoperatively.

Conclusion

VEPTR represents a good alternative to “spine to spine growing rod techniques” and vertebral column resections “VCR” in spite of its complications rate with regard to the nature of deformity and number of “lengthening reoperations,” however it should be used in well selected cases.
Why Does C5 Palsy Occur after Prophylactic Bilateral C4-5 Foraminotomy in Open-Door Cervical Laminoplasty? A Risk Factor Analysis
Authors: Liu Gabriel , Reyes Ma. Ramona , Riew K. Daniel
Published: April 2016

Introduction

Prophylactic bilateral foraminotomy has been shown to reduce the risk of C5 palsy after open-door laminoplasty surgery. However, it does not totally eliminate it. Other factors such as inherent cord pathology may play a role in its development.

Material and Methods

A retrospective review to evaluate the efficacy of bilateral C4–5 foraminotomy in preventing occurrence of postoperative C5 palsy and to identify possible risk factors for its development was performed. A total of 70 consecutive patients who underwent open-door laminoplasty with bilateral C4–5 foraminotomy were included. Clinical, radiographic, and operative data were reviewed. Development of postoperative C5 palsy was analyzed.

Results

Fifty-four males and 16 females were reviewed. Mean age was 56 years (range, 30–86 years). The primary pathology was spondylosis in 76% of cases and ossified posterior longitudinal ligament in 21%. Radiographic evidence of C4–5 foraminal stenosis was seen in 81% of the patients. The mean duration of preoperative symptoms was 7 ± 19 months. Four (5.7%) out of 70 patients developed C5 palsy after open-door laminoplasty with bilateral C4–5 foraminotomy. Multivariate analysis showed that a long duration of preoperative symptoms (> 12 months) and the presence of preoperative C4–5 T2-MRI cord signal change were statistically significant risk factors for the development of C5 palsy even after bilateral C4–5 foraminotomy in open-door laminoplasty ( p < 0.0001 and P 0.036 respectively).

Conclusion

While bilateral C4–5 foraminotomy may reduce post-laminoplasty C5 palsy when compared with the historical cohort, foraminotomies do not eliminate C5 palsy occurrence. Prolonged duration of symptoms and presence of preoperative T2-MRI cord signal change increased the risk for developing postoperative C5 palsy in laminoplasty patients who underwent bilateral C4–5 foraminotomy.
Efficacy of a Postoperative Infection Prevention Protocol in Spine Surgery
Authors: Pantoja Samuel , Luna Felipe , Hervé Beatrice , Gutierrez Cecilia , Postigo Roberto
Published: April 2016

Introduction

post operatory wound infection is an unwanted complication of spine surgery. Infection rate ranges from 2.1 to 5.5%, and the consequences in some cases can be devastating for the patient and for the medical team. Material and Method: we compare post-operative wound infection incidence before and after the implementation of a wound infection prevention protocol specific for major spine surgery established in our Center in collaboration with the HealthCare Associated Infection Committee (HCAIC). Post operatory wound infection incidence was reviewed for 4 years after implementation. The protocol consisted on a 28 point check list, that included: skin preparation with chlorhexidine one day before surgery at home, and at entrance the morning of the surgery; strict control of blood glucose under 200mg/dL before surgery; programming instrumented surgeries preferably as the first surgery of the Operating Room (OR); OR with laminar air flow; OR temperature between 18°-22°C during surgery (64.4°-71.6°F); skin preparation with alcohol-based chlorhexidine and covering with adherent antimicrobial incise drapes at surgery; Cefazolin prophylaxis (or Clindamycin in case of β-lactam antibiotics allergy) no more than 60 minutes before skin incision and a new dose every 3 hours during surgery; strict control of patient temperature at 36°C(96.8F) with the aid of warming blankets (Bair Hugger®); maintaining a target Hemoglobin of 7–9 g/dL with restriction of blood transfusion indication; hematocrit and glycemia control after surgery and the morning after.

Results

After the introduction of the protocol we found a progressive reduction in the post operatory wound infection rate in spinal surgery from 2.89% in 2009 (before the protocol), to 2,5% in 2010, 1,71% in 2011 and 1.56% in 2012. During the surveillance made by the HCAIC, we observed a rise in the infection rate during 2013 (2.02%) which was associated with breaches in protocol adhesion. The relevance of the check list control by the OR nurse was reinforced and the strict control of patient temperature at 36°C(96.8F) with warming blankets used before, during surgery and in recovery room was added. With this new update and more strict control of protocol adhesion, we reduced the infections rate to 0.95% in 2014.

Conclusion

We consider that a wound infection prevention protocol specific for spine surgery, with proper surveillance and strict follow-up, is an effective way for reducing the infection rate in spine surgery. Although, the microbiological environment for every center is different, we think that this protocol can be used as a guide for centers were this complication becomes an issue.
Factors Leading to a Poor Functional Outcome in Spinal Meningioma Surgery: Clinical and Surgical Remarks on 173 Cases
Authors: Raco Antonino , Pesce Alessandro , Toccaceli Giada , Dominicucci Maurizio , Delfini Roberto
Published: April 2016

Introduction

Spinal meningiomas are common spinal tumors in most cases benign and with a good surgical prognosis. However, specific location, infiltration of spinal cord, vascular encasement or spinal root involvement can bring to a less favorable prognosis. Aim of this work is to systematically the influence of this factors in the neurological outcomes of our patients.

Matherial and Methods

224 consecutive patients with spinal meningiomas treated from 1976 to 2013 in our institution were analyzed; among these 51 were excluded for incomplete clinical data or follow up. The remaining 173 cases were classified regarding to: sex, age, symptoms, axial location, Simpson Grade resection, Functional pre/postoperative status.

Results

Most recurring onset symptoms were pain (32,9%) and motor deficit (31,8%); Thoracic spine was the most severely affected (69,8%). The functional improvement on the follow up was observed in 86,7% of cases, 6,4% of patients resulted stable and 6,9% worsened; a low functional grade before surgery was connected to a lesser improvement after. Anterolateral meningiomas were the most represented (42,2%); a gross total resection (Simpson Grade I and II) was conducted in 98,8% and a macroscopically complete removal without dural resection or coagulation (Simpson III) was performed in 1,2%. 98,3% of meningiomas were classified as Grade I WHO. Recurrence rate was of 2,3% and 7 cases presented complications (4 of 7 required surgical procedure).

Conclusions

We can adfirm that negative prognostic factors in our study were: anterior or antero-lateral axial topography, long-lasting symptoms before diagnosis, WHO Grade > I, Simpson Grade resection II and III, sphincter involvement and worse functional grade at onset.
Right versus Left Sided Exposures of the Recurrent Laryngeal Nerve (RLN) and its' Branches- A Fresh Cadaveric Study Relevant to the Cervical Spine
Authors: Rajabian Ali , Quraishi Nasir A.
Published: April 2016

Introduction

The higher vulnerability of RLN in anterior approach to the cervical spine on the right versus left sides is the subject of ongoing debate. While most cadaveric studies have focused on in situ variations in course and local structural relations of the RLN as a suitable guide, they have mostly been done in preserved (fixed) cadavers or without relevance to the needs of spinal exposure. Our aim was to perform surgically relevant exposures of the anterior cervical spine with particular attention to observing the potential vulnerabilities of the RLN on right and left side in fresh cadaveric specimens. In addition, we aimed to explore its branches.

Materials and Methods

12 cadavers had extensive layer by layer dissections by 2 surgeons (one with extensive experience as anatomy dissector). The RLNs and its branches were exposed in their entire length and explored for vulnerability. (Each stage was photographed)

Results

In all specimens, we demonstrated that right sided approach clearly causes undue stretch of the nerve and its branches particularly below C5 (photographed). The left side provided a good exposure without undue traction on the nerve. However, the terminal oesophageal branches of the nerve were especially vulnerable to this stretch or direct pressure on the left side.

Conclusion

Traction neuropraxia of the upper oesophageal branches of the RLN nerve may provide an alternative explanation for the transient post-op dysphagia (upto 60%). The laryngeal supply of the RLN benefits from Galen's anastomotic nerve supply of SLN (Ansa of Galen) and hence the neuropraxia of the nerve is less frequently symptomatic. Below C5, the left sided anterior cervical approach permits a wider access to the entire anterior cervical spine with less risk to the RLN. Neuropraxia induced on the oesophageal branches (directly by retractors or indirectly by traction) could provide a possible explanation for transient post-op dysphagia. We believe that this will help spinal surgeons to refine their surgical technique and thus reduce the incidence of iatrogenic injury. [Figure: see text][Figure: see text][Figure: see text][Figure: see text]
Long-term Clinical and Radiological Outcome Evaluation of 3- and 4 Level ACDF with a Zero-profile Implant. Impact of Cervical Sagittal Alignment on Clinical Outcome
Authors: Barbagallo Giuseppe , Certo Francesco , Palmucci Stefano , Albanese Vincenzo
Published: April 2016

Introduction

Concerns remains on the role of ACDF in multilevel cervical disease as opposite to posterior approaches, and on the importance of cervical sagittal alignment in influencing long-term clinical outcome. We aim to analyze the efficacy of 3- and 4-level ACDF with a zero-profile implant in restoring cervical sagittal alignemnt as well as the impact of alignment on clinical outcome, both at early and long-term follow-up. And also to evaluate type and rate of complications.

Material and Methods

24 patients (14 male), ranging in age from 41 to 77 years (mean 58.4) and suffering from multilevel spondylosis, were enrolled. Neurological improvement was graded according to the Nurick scale. NDI, VAS and SF-36 were used for pre- and postoperative functional evaluation. Imaging included X-rays, CT and MRI before surgery; X-rays were obtained at every follow-up visit and CT scan at last follow-up. Sagittal alignment was assessed before and after surgery using the Cobb method. Fusion rate was studied on both X-rays and CT scan. Complications were analyzed and dysphagia evaluated using the Bazaz scale.

Results

Mean follow-up ranges from 24 to 72 months (mean 39). No intra- or postoperative complications, either related to surgical technique or to devices implanted, were encountered. Mean neck pain VAS score decreased from a 6.7 ± 2.9 to 1.6 ± 2.3 ( p < 0.01). Mean arm pain VAS score decreased from 5.9 ± 2.9 to 0.9 ± 1.4 ( p < 0.01). There were significant improvements ( p < 0.01) in SF36 and NDI following surgery. Five patients complained of mild dysphagia (20.8%). Three of them (12.5%) showed complete resolution within two months (short-term dysphagia); the other two (8.3%) within six months (medium-term dysphagia). No case of long-term dysphagia (more than 6 months) was observed. According to Pitzen criteria, radiographic fusion was achieved in 90% of patients. Cobb angle had a significant improvement both after surgery and at long-term follow-up.

Conclusion

3- and 4-level ACDF with a zero-profile device is safe and effective. It allows satisfactory neurological and functional outcome as well as interbody fusion. Multilevel anterior approach provides satisfactory sagittal alignment restoration, and this is associated with persistent clinical improvement at long-term follow-up.