Adjacent Spinal Levels Research Articles

Phase II Clinical Trial of Second Course of Stereotactic Body Radiotherapy for Spinal Metastases

Purpose: The optimal method for the second course of stereotactic body radiotherapy (SBRT) for spinal metastases remains poorly established. This single-center, single-arm, phase II trial was conducted to propose a safe and effective salvage spine SBRT. Methods: The patients initially treated with SBRT for spine-targeted protocol treatment, or for areas adjacent to the spine, were enrolled. The second SBRT dose was 30 Gy delivered in five fractions; the spinal cord dose constraint was 15.5 Gy at the maximum point dose. The brachial or lumbosacral plexuses were dose-constrained to <30 Gy if the boundary between the nerves and tumors was detected. The primary endpoint was dose-limiting toxicity (DLT) (grade ≥ 3 severe radiation-related toxicity) within a year after the second SBRT. Results: The second SBRT was administered to the same spinal level in 12 patients and to an adjacent spinal level in 8 patients. SBRT2 was performed for 14 painful lesions, 10 MESCC, and 6 oligometastases, with some lesions having multiple indications. The median interval between SBRT sessions was 21 months (range: 6–51 months). The median follow-up duration was 14 months. No radiation myelopathy or local failure was reported during the follow-up period. DLT was confirmed in two patients (10%) within a year, both of whom developed grade 3 lumbosacral plexopathy. These two patients received SBRT twice to the S1–2 and S1–5 vertebrae, respectively, and both experienced paralysis of the tibialis anterior muscle (L5 level). Grade 3 late adverse effects (including lumbosacral plexopathy and vertebral compression fracture) were observed in 25% of the patients throughout the entire follow-up period. Conclusions: The second spine SBRT achieved good local control without causing myelopathy. However, one-quarter of the patients experienced grade 3 late adverse effects, suggesting that the treatment protocol carries a risk of toxicity.

Impact of osteoporosis and Cement-Augmented fusion on adjacent spinal levels Post-Fusion Surgery: Patient-Specific finite element analysis

Cement-augmentation is a technique commonly used during posterior lumbar instrumented fusion (PLIF) to reinforce compromised osteoporotic vertebral bone, minimize the risk of loosening screws, enhance stability, and improve overall surgical outcomes. In this study, we introduce a novel segmented vertebral body regional modeling approach to investigate the effects of osteoporosis and cement-augmented lumbar fusion on disc biomechanics at spinal levels adjacent to the fused vertebrae. Using our previously validated personalized-poroelastic-osteoligamentous FE model of the spine, fusion was simulated at L4-L5, and the biomechanics of adjacent levels were studied for 30 patients (non-osteoporotic patients (N = 15), osteoporotic patients (N = 15)). PLIF models, with and without cement-augmentation, were developed and compared after an 8 h-rest period (200 N), following a 16 h-cyclic compressive loading of 500–1000 N (40 and 20 min, respectively). Movement in different directions (flexion/ extension/ lateral bending/ axial rotation) was simulated using 10Nm moment before and after cyclic loading. The material mapping algorithm was validated by comparing the results of voxel-based and parametric models. The FE cement-augmented models, subject to daily activity loading, demonstrated significant differences in disc height loss and fluid loss as compared to non-cemented models. The calculated axial stress and fiber strain values were also significantly higher for these models. This work demonstrates that although osteoporosis does not significantly alter the time-dependent characteristics of adjacent IVDs post-surgery, cement-augmentation increases the risk of adjacent segment disease (ASD) incidence. A holistic understanding of the trade-offs and long-term complex interplay between structural reinforcement modalities, including cement augmentation, and altered biomechanics warrants further investigation.

Correlation Between the Severity of Multifidus Fatty Degeneration and the Size of Ossification of Posterior Longitudinal Ligament at Each Spinal Level.

This study aimed to investigate the correlation between ossification of the posterior longitudinal ligament (OPLL) size and multifidus fatty degeneration (MFD), hypothesizing that larger OPLL sizes are associated with worse MFD. One hundred four patients with cervical OPLL who underwent surgery were screened. OPLL occupying diameter and area ratios, the severity of MFD using the Goutallier classification, and range of motion (ROM) of cervical flexion-extension (ΔCobb) were measured. Correlation analyses between OPLL size, MFD severity, and ΔCobb were conducted. MFD severity was compared for each OPLL type using one-way analysis of variance. The final clinical data from 100 patients were analyzed. The average Goutallier grade of C2-7 significantly correlated with the average OPLL diameter and area occupying ratios, and OPLL involved vertebral level (r = 0.58, p < 0.01; r = 0.40, p < 0.01; r = 0.47, p < 0.01, respectively). The OPLL size at each cervical level significantly correlated with MFD of the same or 1-3 adjacent levels. ΔCobb angle was negatively correlated with the average Goutallier grade (r = -0.31, p < 0.01) and average OPLL occupying diameter and area ratios (r = -0.31, p < 0.01; r = -0.35, p < 0.01, respectively). Patients with continuous OPLL exhibited worse MFD than those with segmental OPLL (p < 0.01). OPLL size is clinically correlated with MFD and cervical ROM. OPLL at one spinal level affects MFD at the same and 1-3 adjacent spinal levels. The worsening severity of MFD is associated with the longitudinal continuity of OPLL.

Clinical and Radiographic Outcomes for Patients with Cervical Adjacent Segment Disease Treated with Anterior Cervical Discectomy and Fusion with Integrated Interbody Spacers

Anterior cervical discectomy and fusion (ACDF) is among the most common spine procedures. Adjacent segment disease (ASD), characterized by degenerative disease at an adjacent spinal level to a prior fusion, is a well-recognized and significant sequela following ACDF. Adjacent segment ACDF may be considered after the failure of non-surgical options for patients with symptomatic ASD. This study aimed to assess the incidence of dysphagia and other complications as well as radiographic outcomes in adult patients who have undergone ACDF with an integrated interbody spacer device for symptomatic ASD. This was a retrospective review of patients who underwent ACDF for symptomatic ASD with commercially available integrated interbody spacers by three spine surgeons at an academic institution from March 2018 to April 2022. Demographic, radiographic, and postoperative data were collected, including dysphagia, device-related complications, and the need for revision surgery. There were 48 patients (26 male, 22 female) who met inclusion criteria (mean age 59.7 years, mean body mass index 19.5 kg/m2) who underwent ACDF for symptomatic ASD (1one-level, n= 44; 2-level, n= 4). Overall, 12 patients (25%) experienced dysphagia postoperatively before the first follow-up appointment. Nine of 44 (20.4%) of 1-level ACDF patients experienced dysphagia, and 3 of 4 (75%) of 2-level ACDF patients experienced dysphagia. Three patients had severe dysphagia which prompted an otolaryngology referral. Two of those patients remained symptomatic at 6 weeks postoperatively. Of 43 patients with prior plate cage systems, none required hardware removal at the time of surgery. Preoperative global and segmental lordosis were 9.07° ± 8.36° (P= 0.22) and 3.58° ± 4.57° (P= 0.14), respectively. At 6 weeks postoperatively, global and segmental lordosis were 11.44° ± 9.06° (P= 0.54) and 5.11° ± 4.44° (P= 0.44), respectively. This constitutes a change of+2.37° and+1.53° in global and segmental lordosis, respectively. The mean anterior disc height change between preoperative and immediate postoperative time points was 6.3 ± 3.1 mm. Between the immediate postoperative and 6-week postoperative time points, the mean anterior disc height change was -1.5 ± 2.7 mm. Between the immediate postoperative and 3-month postoperative time points, the mean anterior disc height change was -3.7 ± 5.0 mm. The posterior disc height changes at the same time points were 2.5 ± 1.7 mm, -0.4 ± 1.8. and -0.5 ± 1.4 mm, respectively. This fusion rate was 50% and 70% at 6 months and 1 year post-surgery, respectively. ACDF with integrated spacer is a viable alternative to traditional plate-cage systems for symptomatic ASD. An advantage over traditional plate-cage systems is that the removal of prior instrumentation is not needed in order to place implants. Based on a review of the literature, these standalone systems allowed for a shorter operative time and had less incidence of dysphagia than plate-cage systems for ASD after ACDF. The different standalone and plate-cage systems used in treating ASD after ACDF surgeries should be compared in prospective studies.

The influence of over-distraction on biomechanical response of cervical spine post anterior interbody fusion: a comprehensive finite element study.

Introduction: Anterior cervical discectomy and fusion (ACDF) has been considered as the gold standard surgical treatment for cervical degenerative pathologies. Some surgeons tend to use larger-sized interbody cages during ACDF to restore the index intervertebral disc height, hence, this study evaluated the effect of larger-sized interbody cages on the cervical spine with ACDF under both static and cyclic loading. Method: Twenty pre-operative personalized poro-hyperelastic finite element (FE) models were developed. ACDF post-operative models were then constructed and four clinical scenarios (i.e., 1) No-distraction; 2) 1mm distraction; 3) 2mm distraction; and 4) 3mm distraction) were predicted for each patient. The biomechanical responses at adjacent spinal levels were studied subject to static and cyclic loading. Non-parametric Friedman statistical comparative tests were performed and the p values less than 0.05 were reflected as significant. Results: The calculated intersegmental range of motion (ROM) and intradiscal pressure (IDP) from 20 pre-operative FE models were within the overall ranges compared to the available data from literature. Under static loading, greater ROM, IDP, facet joint force (FJF) values were detected post ACDF, as compared with pre-op. Over-distraction induced significantly higher IDP and FJF in both upper and lower adjacent levels in extension. Higher annulus fibrosus stress and strain values, and increased disc height and fluid loss at the adjacent levels were observed in ACDF group which significantly increased for over-distraction groups. Discussion: it was concluded that using larger-sized interbody cages (the height of ≥2mm of the index disc height) can result in remarkable variations in biomechanical responses of adjacent levels, which may indicate as risk factor for adjacent segment disease. The results of this comprehensive FE investigation using personalized modeling technique highlight the importance of selecting the appropriate height of interbody cage in ACDF surgery.

Spinal displacement during thoracic manipulative therapy in mechanical neck pain patients: an observational study

ABSTRACT Introduction Thoracic manipulative therapy (TMT) is recommended for treating patients with mechanical neck pain (MNP). However, there are multiple proposed recommendations for the mechanism for neck pain reduction. Objective To investigate displacement of the cervicothoracic spine during the application of TMT in patients with MNP. Methods Thirty-five male patients with MNP were recruited. Displacements of C3, C5, C7, T2, T4 and T6 were measured using a motion capture system while a therapist applied a grade III central posteroanterior TMT (cpa-TMT) to T6. Results Mean (SD) displacement ranged from 2.2 (0.62) to 5.5 (1.1) mm. A significant decrease in neck pain intensity at rest was found after the application of the cpa-TMT (mean difference 17 mm, p < 0.001). A downward trend in spinal displacement was noted, with the largest and smallest displacement occurring at T6 and C3, respectively. Correlations between the displacement of T6 and adjacent spinal levels were moderate to high (Pearson’s r range 0.70–0.90, p < 0.001). It was showed that cpa-TMT applied to T6 produced the PA displacement toward the upper cervical spine. Conclusion TMT produces spinal segmental displacements toward the upper cervical spine in MNP patients. These segmental displacements would activate the alleviation effect at both the spinal and supraspinal levels resulting in neck pain reduction. These findings would provide supporting evidence for the use of TMT in neck pain reduction.

Finite Element Analysis-Based Evaluation of the Patient-Specific Spinal Rods for a Reduced Risk of Adjacent Segment Disease

Adjacent Segment Disease (ASD) is a postoperative drawback of spinal fusion surgery which yields an increase in the range of motion in the adjacent spinal level. Therefore, the main aim of this study is to investigate the optimum mechanical properties of the spinal rod allowing a reduced rigidity in the spinal fixation level for decreasing the displacement of the adjacent segment. In this study, the spinal fixation system was modelled and attached to L3-L4 level. The elasticity modulus of the rods and the follower load were parametrically defined in order to investigate their optimum values under physiological loading conditions of extension. The maximum displacement value determined for the upper adjacent intervertebral disc was defined as the output parameter. Thereafter, the biomechanical response of the spinal bone-implant complex was simulated using Finite Element Analysis (FEA). Using the parametric FEA results, a polynomial mathematical model was constructed and Response Surface Method (RSM) was used to plot the relationship between input and output parameters. According to the results of the study, the optimum elasticity modulus of the rods and the suggested follower load have been determined as 80.8 GPa and 303.84 N, respectively. The maximum principal strain values obtained in the pedicle screws were 746 µℇ, 1563 µℇ, 3037 µℇ and 2937 µℇ, respectively. However, since the results are strongly associated with anatomical and biomechanical differences, the proposed patient-specific approach may enhance the accuracy for a more successful spinal fusion surgery operation in terms of minimizing the risk of ASD.

Comparative biomechanical analyses of lower cervical spine post anterior fusion versus intervertebral disc arthroplasty: A geometrically patient-specific poroelastic finite element investigation.

Background/ObjectiveThe optimal surgical technique for the treatment of cervical degenerative disc disease (CDDD) towards decreasing the risk of adjacent segment disease (ASD) remains elusive. This study aimed to comparatively investigate the biomechanics of the lower cervical spine following fusion (ACDF) and artificial disc arthroplasty (Bryan® and Prestige LP®) using a validated geometrically patient-specific poroelastic finite element modeling (FEM) approach.MethodsTen subject-specific pre-operative models were developed and validated based on a FEM approach. Poroelastic models were then constructed using post-operation images for three different treatment scenarios: ACDF; Prestige LP® and Bryan® artificial discs at the C5–C6 level. The biomechanical responses at both surgical and adjacent spinal levels were studied subject to static and cyclic loading.ResultsPostoperatively, greater range of motion (ROM), higher annulus fibrosus stress and strain values, and increased disc height and fluid loss at the adjacent levels were detected post ACDF, as compared with pre-op as well as artificial disc arthroplasty. The facet joint forces were larger for the Prestige LP® disc, particularly during extension. The lowest values in disc height and fluid exchange were observed in the Bryan® artificial disc arthroplasty models.ConclusionBiomechanical analyses revealed that ACDF poses the highest potential risk for adjacent disc degeneration. The artificial discs investigated here (Prestige LP® and Bryan®) not only preserved motion at the instrumented level, but also sustained the pre-op ROM and decreased the intradiscal pressure (IDP) and facet joint forces (FJFs) at adjacent levels, particularly during flexion/extension. The Bryan® artificial disc demonstrated the most efficacy in maintaining the natural poroelastic characteristics of adjacent discs.The translational potential of this articleThis study provided a technique for clinicians to use quantitative data towards subject-specific evaluation to comparatively evaluate the impact of ACDF and disc arthroplasty using two types of artificial discs on the biomechanics of the cervical spine. It confirms differences in the poroelastic characteristics of adjacent discs for different fixation techniques, and reveals the advantage of artificial discs with a flexible core for decreasing the risk of ASD.

Flexible thecoscopy for extensive spinal arachnoiditis.

Chronic adhesive spinal arachnoiditis (SA) is a complex disease process that results in spinal cord tethering, CSF flow blockage, intradural adhesions, spinal cord edema, and sometimes syringomyelia. When it is focal or restricted to fewer than 3 spinal segments, the disease responds well to open surgical approaches. More extensive arachnoiditis extending beyond 4 spinal segments has a much worse prognosis because of less adequate removal of adhesions and a higher propensity for postoperative scarring and retethering. Flexible neuroendoscopy can extend the longitudinal range of the surgical field with a minimalist approach. The authors present a cohort of patients with severe cervical and thoracic arachnoiditis and myelopathy who underwent flexible endoscopy to address arachnoiditis at spinal segments not exposed by open surgical intervention. These observations will inform subsequent efforts to improve the treatment of extensive arachnoiditis. Over a period of 3 years (2017-2020), 10 patients with progressive myelopathy were evaluated and treated for extensive SA. Seven patients had syringomyelia, 1 had spinal cord edema, and 2 had spinal cord distortion. Surgical intervention included 2- to 5-level thoracic laminectomy, microscopic lysis of adhesions, and then lysis of adhesions at adjacent spinal levels performed using a rigid or flexible endoscope. The mean follow-up was 5 months (range 2-15 months). Neurological function was examined using standard measures. MRI was used to assess syrinx resolution. The mean length of syringes was 19.2 ± 10 cm, with a mean maximum diameter of 7.0 ± 2.9 mm. Patients underwent laminectomies averaging 3.7 ± 0.9 (range 2-5) levels in length followed by endoscopy, which expanded exposure by an average of another 2.4 extra segments (6.1 ± 4.0 levels total). Endoscopic dissection of extensive arachnoiditis in the dorsal subarachnoid space proceeded through a complex network of opaque arachnoidal bands and membranes bridging from the dorsal dura mater to the spinal cord. In less severely problematic areas, the arachnoid membrane was transparent and attached to the spinal cord through multifocal arachnoid adhesions bridging the subarachnoid space. The endoscope did not compress or injure the spinal cord. Intrathecal endoscopy allowed visual assessment and safe removal of intradural adhesions beyond the laminectomy margins. Further development of this technique should improve its effectiveness in opening the subarachnoid space and untethering the spinal cord in cases of extensive chronic adhesive SA.

P5. Fixation stability of four different cervical disc prostheses endplate configurations

<h3>BACKGROUND CONTEXT</h3> Motion preservation devices have become increasingly popular in the treatment of spinal pathologies that require biomechanical support following removal of the degenerated tissue. As these devices continue to be developed to treat multiple adjacent diseased spinal levels, like the use of multiple disc prostheses or placement of a disc prosthesis adjacent to a fused level, in-depth biomechanical data that supports these established surgical methods are needed. <h3>PURPOSE</h3> To assess immediate stability of four cervical disc prostheses under low endurance multidirectional cyclic loading conditions in a cadaveric cervical spine model. <h3>STUDY DESIGN/SETTING</h3> Each prosthesis was implanted in a cervical functional spinal unit (FSU) and cyclically loaded 2000 times under physiological ranges of combined flexion/extension coupled with axial rotation at a rate of 2.5deg/s. <h3>PATIENT SAMPLE</h3> There were 16 (C4-C5) and 16 (C6-C7) FSUs dissected from eight male and eight female cadaveric cervical spines with an average age of 55.9 +/- 9.7 years. Three FSUs were not usable due to poor tissue quality which reduced the sample size to 29 FSUs. <h3>OUTCOME MEASURES</h3> A one-way repeated measures ANOVA with a Student Newman-Keuls test was used to compare differences in the combined motion data. Anteroposterior endplate migration of both the upper and lower implant components was measured after 20, 250, 500, 1,000, 1,500 and 2,000 cycles. Tests were stopped if implant component migration exceeded 3mm or endplate fracture was observed, and migrations less than 0.3mm were defined as clinically stable. <h3>METHODS</h3> Four cervical disc prostheses that had a similar ball and socket type articulation mechanism but varying endplate fixation features were tested: 1. A clinically used and FDA-approved single central keel (SCK). 2. A clinically used (outside the U.S.) low profile teeth (LPT) with domed endplate shape to allow a better fit in case of concave vertebral endplate. 3. A clinically used (outside the U.S.) tripod keel (TK) and 4. Small single keel (SSK). A minimum sample size of six implants per prosthesis type were used. Three additional TK disc prostheses and two additional LPT disc prostheses were implanted. Specimens were cyclically tested 2,000 times at a rate of 2.5deg/s to an end limit of 1.5Nm in flexion or extension coupled with 1.5Nm of right and left axial rotation resulting in a total applied moment of 2.25Nm. A one-way repeated measures ANOVA with a Student Newman-Keuls test was used to compare differences in the combined motion data. Anteroposterior endplate migration of both the upper and lower implant components was measured after 20, 250, 500, 1,000, 1,500, and 2,000 cycles. Tests were stopped if implant component migration exceeded 3mm or endplate fracture was observed, and migrations less than 0.3mm were defined as clinically stable. <h3>RESULTS</h3> No statistical difference was found between the combined (flexion plus extension) sagittal plane range of motion or the combined (left plus right) axial motion. All but one of the specimen migration values were below 0.3mm. Upper prosthesis component migration ranged between 0.02mm and 0.08mm and between 0.01mm and 0.04mm for the lower components. No significant differences occurred between the upper components or the lower prosthesis components of any implant type. <h3>CONCLUSIONS</h3> Three different low profile endplate fixation designs for a cervical disc were found to provide comparable immediate holding strength to an existing FDA-approved central-based keel design. <h3>FDA DEVICE/DRUG STATUS</h3> Prodisc C (Approved for this indication), Prodisc C Vivo (Investigational/Not approved), Prodisc C Nova (Investigational/Not approved), Prodisc C SK (Investigational/Not approved).

Minimally invasive tubular laminectomies in multilevel spine surgery-an illustrative case-based review of techniques and combined approaches.

Minimally invasive techniques have become part of the spine surgeons' armamentarium and are currently utilized to treat many conditions involving the cervical, thoracic, lumbar and sacral spine. Surgical treatment of severe degenerative conditions such as multilevel spinal stenosis, tandem stenosis, combination of stenosis or disk herniation and spondylolisthesis at adjacent spinal levels, as well as extensive infections or hematomas, may require a multilevel tailored approach with all the challenges that such surgical planning entails. Although the use of minimally invasive tubular decompressive procedures has gained widespread popularity in the recent years, the adoption of such techniques during multilevel spine surgery can be at times challenging. A careful tailored selection of the surgical approach that better fits needs and expectations of the patient is therefore consequential to achieve good clinical and radiological outcome without compromising efficiency and results. Many surgical techniques have been described in literature but very few reports on the use of combined tubular approached are currently present. We therefore present an illustrative review of techniques for tubular laminectomies and combined approaches that can be utilized in the surgical treatment of multilevel spinal conditions. Illustrative cases documenting common and less common indications for the use of minimally invasive laminectomies are also presented.

The role of periradicular infiltration in dorsal root ganglion stimulation for chronic neuropathic pain

BackgroundTargeting the correct spinal level is essential in dorsal root ganglion (DRG) stimulation. Anatomical selection of the DRG alone is not ideal since the pain area is not necessarily confined to the borders of the dermatomes. This study aims to establish the role of periradicular infiltration therapy (PRT) in the preoperative assessment of the correct level for DRG stimulation performed under general anesthesia.MethodWe report a prospective study of 20 patients selected for DRG stimulation and submitted to a PRT for identification of the spinal level. Lead implantation for the stimulation trial occurred under general anesthesia: 19 patients experienced positive results and underwent implantation of the pulse generator. All patients suffered from chronic neuropathic pain unresponsive to best medical treatment. PRT levels were compared with the levels targeted with DRG leads. Patients were followed for up to 12 months; pain intensity and coverage of the painful area were assessed.ResultsIn 12 patients, the trial leads were placed on the same level as previously tested positive by PRT. In 6 patients, leads were placed in the PRT target and additionally in adjacent spinal levels. In one case, the selected target for the trial diverged from the PRT target because of intense fibrosis in the chosen level. Coverage of the target area of at least 50% was achieved by two-thirds of the patients. For the six subjects with additional implanted leads as a consequence of the PRT results, 80% achieved a coverage of at least 50%. A total of 47.4% of the patients achieved sustained significant pain relief in the last follow-up. None of the patients needed a repeated surgery for implantation of additional leads.ConclusionsPRT is a helpful tool to confirm the stimulation targets. A PRT preceding the stimulation trial is an additional opportunity to optimize the coverage of the target area with stimulation-induced paresthesia for patients operated under general anesthesia.

Long-Term Results after Multilevel Fusion of the Cervical Spine and the Cervicothoracic Junction: To Bridge or Not To Bridge?

For patients with multilevel degenerative cervical myelopathy, laminectomy and fusion are widely accepted techniques for ameliorating the disorder. However, the idea of whether one should bridge the cervicothoracic junction to prevent instrument failure or adjacent segment disease has been a subject of controversial discussion. In the present study, we compared the incidence of these complications and the revision rates in multilevel fusions extending to C7 or T1-T3. In the present single-center, retrospective cohort study, patients with multilevel degenerative cervical myelopathy treated with laminectomy and fusion to C7 or T1-T3 from 2004 to 2016 were included for evaluation. The primary outcome measure was radiologically proven complications at the most caudal level or the adjacent spinal fusion level. Laminectomy and multilevel fusion were performed in 84 patients. After applying the exclusion criteria, 20 patients with fusion to C7 (treated from 2004 to 2012; follow-up, 124.6 ± 10.6 months) and 38 patients with fusion to T1-T3 (treated from 2008 to 2016; follow-up, 58.2 ± 15.7 months) were evaluated. The incidence of complications at the most caudal or adjacent level of fusion was twice as high (P= 0.087; NS) in the C7 group (11 of 20; 55.0%) compared with the T1-T3 group (11 of 38; 28.9%). In the C7 group, 9 of the 20 patients (45.0%) had required revision surgery compared with 2 of 38 patients (5.3%) in the T1-T3 group (P= 0.001). We found that fewer revisions were necessary if the fusion had extended to the thoracic spine. Thus, we recommend bridging the cervicothoracic junction when fusion starts at C0-C3.

Acute Cervical Facet Joint Inflammation After a Prolonged Dental Procedure: A Case Report

Background: Facet joints of the spine are the only true synovial joints between adjacent spinal levels. Degenerative disease changes of the joint, or facet arthropathy, can be asymptomatic. However, pain can occur when the joint becomes acutely inflamed. Specifically, cervical facet arthropathy and associated neck pain can be difficult to treat. Case Report: We present a case of a 64-year-old man with known lumbar spondylosis who developed acute neck pain after a dental procedure. Magnetic resonance imaging (MRI) revealed inflammation of the left C2-C3 facet joint. This patient achieved successful relief of pain with an intraarticular corticosteroid injection followed by physical therapy. Careful consideration was given to a detailed therapy protocol in order to regain pain-free active range of motion of the neck. Conclusion: To our knowledge, this is the first reported case of acute facet inflammation after a dental procedure. Additionally, this report highlights the value of intraarticular corticosteroids for an acutely inflamed facet joint. In order to prevent injury, dentists and oral surgeons should be attentive to neutral spine positioning, especially during prolonged procedures. Key words: Arthritis, cervical spine, corticosteroids, dentistry, facet joint, neck pain, physical therapy, posture

Long-Term Follow-Up of Anterior Spinal Fusion for Thoracolumbar/Lumbar Curves in Adolescent Idiopathic Scoliosis.

Retrospective patient series analysis with update of long-term data. To define the long-term prognosis of the thoracolumbar/lumbar correction after selective anterior spinal fusion (ASF) in adolescent idiopathic scoliosis (AIS). The ASF is a well-described procedure for the treatment of AIS. The correction reliability over time, the consequences in adjacent spinal levels and patient's quality of life are fundamental for the characterization of AIS treatment. One hundred seven patients were submitted to single-rod ASF for thoracolumbar/lumbar (ThL/L) AIS between 1993 and 2016 in a single-surgeon experience. Seventy five were available for final follow-up evaluation 9 years ±4 (2-23) after surgery. A clinical and sequential radiographic evaluations were performed. The mean age at surgery was 16 years ± 2.33 (14-20) and 94 (87%) were females. The mean final follow-up of the 75 patients available was 9 years ± 4 (2-23). Sixty-five patients had a Lenke type 5C curve and 10 had a type 6C curve. The mean values of the Scoliosis Research Society 22 (SRS-22) questionnaire in Lenke 5C was 92 ± 9 (71-109) and in Lenke 6C 90.3 ± 9 (75-107). In Lenke 5C group, the mean preoperative ThL Cobb angle was 38.4° ± 9.3 (21-60) and the postoperative was 5.9° ± 4.5 (0-18; P < 0.001) being similar at the final follow-up (P > 0.05). In Lenke 6C group, the mean preoperative ThL Cobb angle was 58.6° ± 13.9 (40-90) and the postoperative ThL Cobb was 22.6° ± 14.5 (5-48, P < 0.001) being similar at the final follow-up (P > 0.05). The mean preoperative Thoracic (Th) Cobb angle was 39° ± 7.6 (30-50), the postoperative was 30.6° ± 10.1 (14-49, P < 0.008) and in the final follow-up was 29.3° ± 10.7 (11-48, P < 0.011). ASF is a safe procedure in the treatment of ThL/L with good long-term results and high rates of satisfaction among patients with AIS Lenke type 5C. The partial correction was frequent in Lenke type 6C despite the absence of progression in the non-instrumented curves. 4.

Bilateral cervical facet dislocations at two adjacent levels: A case report

Background:Cervical facet dislocations are rare in patients sustaining traumatic subaxial injuries. They occur due to hyperflexion-distraction and can occur unilaterally or bilaterally resulting in significant spinal instability. Bilateral facet dislocations at one level are less common than unilateral dislocations, while bilateral facet dislocations at adjacent spinal levels have only been reported twice in literature.Case Description:A 31-year-old male presented with bilateral facet dislocations at two adjacent cervical levels (C6/C7 and C7/T1) following a fall from 40 to 50 feet. The patient had undergone a C6/C7 disk arthroplasty a few weeks before the traumatic event.Conclusion:Here, we present the unique case of cervical bilateral jumped facets occurring at two adjacent levels (i.e., C6–C7 and C7–T1). Notably, the antecedent cervical C6–C7 arthroplasty likely contributed to the altered load distribution, leading to this unusual instance of bilateral adjacent level facet dislocations. In such cases, surgical reduction and fixation may prove technically challenging warranting, therefore, careful preoperative planning.

Gastric ulceration causing thoracic spondylodiscitis: a first case of a rare complication post oesophagectomy.

We report the case of an 84-year-old male, who presented with septicaemia, abdominal and back pain. The patient had a background of oesophageal carcinoma and had undergone previous oesophagectomy and gastric pull-up operation 10 years ago. A computerised topography scan demonstrated a probable gastro-vertebral communication with a destructive process at the T8/T9 vertebral level. Further evaluation with MRI clearly showed the tract between the two structures and confirmed the diagnosis of spondylodiscitis at the adjacent spinal level. The patient was resuscitated, treated with intravenous antibiotics and kept nil by mouth. A subsequent gastroscopy demonstrated an eroding gastric ulcer at the enteric opening of the tract between the tubal stomach and the spinal column. The diagnosis was discussed with the patient, his family and the surgical multidisciplinary team. Given the extent of disease and his multiple medical co-morbidities, the decision was made for conservative management and symptom control. This is the first case of a gastro-vertebral communication causing spondylodiscitis to be described in the literature.

Radiologic Evaluation of Chronic Vertebral Compression Fractures and Role of Vertebral Augmentation.

The literature has classified chronic vertebral compression fractures (VCF) as those still "symptomatic" four or more months after onset. Pain is regarded as the predominant chronic symptom; however, radiologic changes are important in evaluating fracture progression. This review examines a series of patients with chronic fractures and both persistence of spinal pain combined with radiologic changes, such as worsening collapse, spinal angulation, the development of vertebral edema and clefts, as well as the development of new fractures at adjacent spinal levels. In patients with clear progressive radiologic changes in addition to pain, vertebral augmentation on an average of 9.3 months after injury was effective in reducing the pain and stabilizing these more chronic osteoporotic fractures. A comparison of the pre- and post-procedure visual analog scale score (VAS) indicated an average of 66% reduction in pain. There are several reasons for the development of chronic symptomatic fractures. Most commonly, interventional treatment is delayed in a patient already diagnosed with VCF after a long period of conservative treatment, yet pain persists, or the initial clinical and radiologic evaluation misses the fracture, leading to a delay in diagnosis and treatment. In this report, management in these patients and the role of late vertebral augmentation for chronic symptomatic fractures is clarified based on the findings of various radiologic changes seen on both initial and follow-up radiologic studies.

A very rare case of cervicothoracic vertebral synostosis spanning eight adjacent segments: congenital vs acquired

Cervical roentgenogram revealed a long-segment cervicothoracicvertebral fusion spanning 8 adjacent spinal levels. The patient wasevaluated with computed tomography (CT) and magnetic resonance(MR) imagings of the spine, electromyography (EMG) and growthdifferentiation factor 6 (GDF6) gene mutation analysis. Imagingfindings were atypical for congenital block vertebrae and therewas no GDF6 mutation. A revision of very old medical records andpatient’s recollections revealed long-term stay in sanatorium forrehabilitation of chronic partially-treated brucella spondylodiscitisduring adolescence. Block vertebrae spanning several levels havepreviously been reported; but, this is the first report of an acquiredcervicothoracic fusion spanning 8 adjacent vertebral bodies.

Survival analysis of the Wallis interspinous spacer used as an augment to lumbar decompression

Object: The Wallis fixed interspinous spacer may augment traditional decompression in the treatment of lumbar spinal stenosis. The aim of this study was to determine factors influencing survival of the Wallis interspinous spacer and to identify specific modes and predictors of failure.Methods: We performed a retrospective cohort study of 244 Wallis interspinous spacers implanted in 195 consecutive patients with a mean age of 56 years (range 21–87) to augment single or multi-level decompression. We examined patient demographics, indications for surgery, surgical techniques and pathology on magnetic resonance imaging (MRI). A Kaplan-Meier survival analysis was performed.Results: Median follow-up was 4.5 years (range 2–8). Sixteen patients were lost to follow-up. Repeat MRI was performed in 98 patients (50%). A recurrent stenosis was found in 21% of patients (41/195) and occurred at a similar incidence at the level of the spacer and at adjacent spinal levels. Revision decompression was performed in 19 patients (10%) at 2.8 ± 1.8 years (range 6 months-6 years) with implant removal in 15 and conversion to fusion in 4 patients. No specific patient factors or pre-operative MRI findings predicted failure. Five-year survival was 91% (95% CI: 79–96%).Conclusions: The Wallis implant is generally implanted without complication when used as an adjunct to decompression with a good medium term survival. Though disc heights were maintained, the Wallis spacer did not however appear to reduce the incidence of recurrent spinal or foraminal stenosis from that expected from decompression alone.