Anterior Posterior Stabilization Research Articles

Impact of implant removal on quality of life and loss of correction in the treatment of traumatic fractures of the thoracolumbar spine

BackgroundBenefit of implant removal in spine surgery remains unclear. While there is mostly consensus about necessity of implant removal in posterior-only stabilized patients, the effect of this measure in cases with combined anterior-posterior stabilization is undetermined. With this work we present a retrospective analysis of 87 patients with traumatic thoracolumbar vertebral fractures concerning quality of life (QOL), loss of correction (LOC) and range of motion (ROM). The effect of implant removal on the outcome 18–74 months after surgery was analyzed to determine how implant removal affects radiologic, functional and quality-of life-related parameters. Patients and methods87 patients suffering from a traumatic vertebral body fracture (T11 – L2) were included. Quality of life was determined using four different scoring systems (SF 36, VAS, Oswestry, LBOS). Clinical examination included range of motion. Radiologic findings were correlated with QOL. ResultsPatients with removal of the internal fixator had a trend towards better range of motion than patients with posterior instrumentation left in place. Radiologic findings showed no correlation to QOL. Implant removal led to better values in Oswestry and SF-36. 69% of patients after removal reported a reduction of their symptoms.All patients with persistence of severe pain after implant removal belonged to subgroup II.2 (anterior monosegmental fusion with bone graft) ConclusionRemoval of the internal fixator can lead to a reduction of symptoms. Patient selection is crucial for successful indication. Radiologic findings do not correlate with QOL.

En bloc vertebrectomy of a thoracic Ewing sarcoma including posterior arch: 3 years later

Ewing’s sarcoma of the mobile spine is a very rare pathology, especially after 30 years of age. The clinical manifestations and radiological aspects can be confusing, which delays the diagnosis. Approximately 25% of patients present with metastatic disease at diagnosis which worsen the prognosis. In localized forms the therapeutic goal is a surgical en bloc wide resection of the tumor, a restoration of spinal column stability and avoidance of recurrence through multimodal therapy including chemotherapy and radiotherapy. We report a case of primary Ewing´s sarcoma of 12th thoracic vertebra in 30 years old man treated with chemotherapy and a double approach en bloc vertebrectomy. The reconstruction was performed with anterior bone grafting and posterior stabilization. No tumor recurrence was observed at the 3 year follow-up assessment. Imaging and clinical aspects were analyzed as well as the management modalities and outcome. Keywords: Ewing sarcoma; thoracic spine; surgery; En bloc vertebrectomy.

Hounsfield units as predictor for cage subsidence and loss of reduction: following posterior-anterior stabilization in thoracolumbar spine fractures.

A retrospective, longitudinal cohort study. The purpose of this study was to examine whether Hounsfield units (HUs), as an alternative bone mineral density measurement to dual-energy X-ray absorptiometry and quantitative computed tomography, which lead to additional radiation exposure for patients, has an effect on the maintenance of reduction in bisegmental Cobb angle (CA) and cage subsidence in patients who receive bisegmental spine stabilization after traumatic thoracolumbar spine fractures. A total of 81 patients with a mean follow-up of 12months were analyzed. CAs and cage subsidence were measured intraoperatively and at follow-up. HU was measured, and patients were subsequently assigned based on HU to three HU subgroups (group 1: HU < 110 [poor bone quality (BQ)]; group 2: HU 180-110 [diminished BQ]; group 3: HU > 180 [good BQ]). Following anterior stabilization, loss of reduction and cage subsidence differed between patients with poor and diminished BQ but not significantly, and both groups showed significantly more loss of reduction and cage subsidence than patients with good BQ. BQ, estimated with HU, had significant effects on cage subsidence and loss of reduction. We recommend measuring HU before surgery and applying additional treatment strategies, such as polymethylmethacrylate augmentation of endplates or anterior plates, for patients with HU < 180. These slides can be retrieved under Electronic Supplementary Material.

Functional and Radiological Outcomes of Anterior Decompression and Posterior Stabilization via Posterior Transpedicular Approach in Thoracic and Thoracolumbar Pott's Disease: A Retrospective Study.

Study DesignThis is a retrospective study.PurposeTo determine the efficacy and safety of a posterior transpedicular approach with regard to functional and radiological outcomes in people with thoracic and thoracolumbar spinal tuberculosis.Overview of LiteratureSpinal tuberculosis can cause serious morbidity, including permanent neurological deficits and severe deformities. Medical treatment or a combination of medical and surgical strategies can control the disease in most patients, thereby decreasing morbidity incidence. A debate always existed regarding whether to achieve both decompression and stabilization via a combined anterior and posterior approach or a single posterior approach exists.MethodsThe study was conducted at the Indian Spinal injuries Centre and included all patients with thoracic and thoracolumbar Pott's disease who were operated via a Posterior transpedicular approach. Data regarding 60 patients were analyzed with respect to the average operation time, preoperative and postoperative, 6 months and final follow-up American Spinal Injury Association (ASIA) grading, bony fusion, implant loosening, implant failure, preoperative, postoperative, 6 months and final follow-up kyphotic angles, a loss of kyphotic correction, Oswestry disability index (ODI) score, and visual analog scale (VAS) score. Data were analyzed using either a paired t -test or a Wilcoxon Signed Rank test.ResultsThe mean operation time was 260±30 minutes. Fifty-five patients presented with evidence of successful bony fusion within a mean period of 6±1.5 months. Preoperative dorsal and lumbar angles were significantly larger than postoperative angles, which were smaller than final follow-up angles. The mean kyphotic correction achieved was 12.11±14.8, with a mean decrease of 5.97 and 19.1 in VAS and ODI scores, respectively.ConclusionsAnterior decompression and posterior stabilization via a posterior transpedicular approach are safe and effective procedures, with less intraoperative surgical duration and significant improvements in clinical and functional status.

Surgical treatment of C2 hangman’s fracture

Purpose. To evaluate the treatment efficacy in patients with C2 hangman’s fracture. Materials and methods. During the period from 2012 to2015 in the Regional Neurosurgical Department 5 patients with hangman’s fracture of C2 vertebra underwent surgery (3 males and 2 females). Fracture type II was diagnosed in 2 patients, IIа type — in 2 persons, type III — in 1 patient. All patients had such clinical symptoms as cervicalgia, deteriorating on the movement. Four patients underwent transpedicular stabilization of C1—C2–C3 with skeletezation of lateral mass, one patient had a combination of posterior instrumentation with anterior plating C2–C3 by Medtronic Atlantis. Posterior stabilization was achieved by Medronic Vertex system. Results. During the operation, all patients achieved fusion of an injured segement. The patients were activated the same or next day after surgery. The volume of rotational motion in craniovertebral junction was limited to 180є—200є, but this did not worse the quality of life of the (VAS 8.9 and 2.3, NDI 80.6—19.6 % before and within the investigation, respectively). CT control was performed in 6 months. Fracture healing and the complete stability of the damaged segment were achieved in 6 months. Conclusions. Surgical treatment of C2 hangman’s fractures by posterior transpedicular/transarticular or anterior-posterior stabilization is a high-effective method for rapid restoration of ordinary physically active social life.

Post-traumatic Spondylodiscitis. Update, Series of 17 Patients and Review of the Literature

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.

Surgical options for lumbosacral fusion: biomechanical stability, advantage, disadvantage and affecting factors in selecting options

Numerous surgical procedures and instrumentation techniques for lumbosacral fusion (LSF) have been developed. This is probably because of its high mechanical demand and unique anatomy. Surgical options include anterior column support (ACS) and posterior stabilization procedures. Biomechanical studies have been performed to verify the stability of those options. The options have their own advantage but also disadvantage aspects. This review article reports the surgical options for lumbosacral fusion, their biomechanical stability, advantages/disadvantages, and affecting factors in option selection. Review of literature. LSF has lots of options both for ACS and posterior stabilization procedures. Combination of posterior stabilization procedures is an option. Furthermore, combinations of ACS and posterior stabilization procedures are other options. It is difficult to make a recommendation or treatment algorithm of LSF from the current literature. However, it is important to know all aspects of the options and decision-making of surgical options for LSF needs to be tailored for each patient, considering factors such as biomechanical stress and osteoporosis.

Posterior Transpedicular Dynamic Stabilization versus Total Disc Replacement in the Treatment of Lumbar Painful Degenerative Disc Disease: A Comparison of Clinical Results

Study Design. Prospective clinical study. Objective. This study compares the clinical results of anterior lumbar total disc replacement and posterior transpedicular dynamic stabilization in the treatment of degenerative disc disease. Summary and Background Data. Over the last two decades, both techniques have emerged as alternative treatment options to fusion surgery. Methods. This study was conducted between 2004 and 2010 with a total of 50 patients (25 in each group). The mean age of the patients in total disc prosthesis group was 37,32 years. The mean age of the patients in posterior dynamic transpedicular stabilization was 43,08. Clinical (VAS and Oswestry) and radiological evaluations (lumbar lordosis and segmental lordosis angles) of the patients were carried out prior to the operation and 3, 12, and 24 months after the operation. We compared the average duration of surgery, blood loss during the surgery and the length of hospital stay of both groups. Results. Both techniques offered significant improvements in clinical parameters. There was no significant change in radiologic evaluations after the surgery for both techniques. Conclusion. Both dynamic systems provided spine stability. However, the posterior dynamic system had a slight advantage over anterior disc prosthesis because of its convenient application and fewer possible complications.

Surgical Planning for the Treatment of Thoracolumbar Fractures: Anterior, Posterior, or Combined Approach?

Burst fractures commonly occur at the thoracolumbar junction. After the decision has been made for surgical stabilization, the surgeon must select a surgical approach based on the patients' pathology, comorbidities, and surgical familiarity. The posterior approach is the most commonly used approach, as it is extensile, allows stabilization of multiple segments, allows deformity reduction maneuvers, and is most familiar to spinal surgeons. Anterior stabilization is appropriate for direct decompression of anterior compressive pathology, although it is less familiar to most spinal surgeons and often requires an approach surgeon. Combined anterior–posterior stabilization is the most rigid construct and may be most appropriate for incomplete neurological deficit at the cauda equina or conus medullaris level due to retropulsed anterior bone. This article will review the advantages and disadvantages of each approach to facilitate surgeon selection.

The relationship of anterior and rotatory laxity between surgical navigation and clinical outcome after ACL reconstruction

Recently, a computer-assisted navigation system has been used for the quantitative evaluation not only of anterior-posterior (AP) laxity but also rotational laxity of the tibia intraoperatively. The purpose of this study was to investigate how intraoperative AP or rotational laxities measured by the navigation system could correlate with postoperative AP and rotational laxities of the patients. 125 patients who underwent primary isolated anatomical single- or double-bundle ACL reconstruction or augmentation using multistranded autologous hamstring tendons were included in the study after a minimum of 2-year follow-up. Clinically, absolute value and side-to-side difference (SSD) of AP translation of the tibia were measured by KT-2000 preoperatively and postoperatively. Intraoperative measurement of AP translation of the tibia and total range of tibial rotation of the ACL-injured knee were carried out using the computer-assisted navigation system. We have investigated the relationship between intraoperative measurements using the navigation system and AP laxity measurements using the KT-2000 knee arthrometer as well as rotational laxity measurements using the manual pivot shift test. There was a positive correlation between the SSD of preoperative AP translation of the tibia measured by KT-2000 arthrometer and the reduction in AP laxity following ACL reconstruction measured by the navigation system. However, we found no significant correlation between the reduction in AP laxity measured by the navigation system and the SSD of AP translation of the tibia measured by the KT-2000 arthrometer at final follow-up. Postoperatively, eight patients had a positive pivot shift test. Using the navigation system pre- and post-ACL reconstruction, these patients could not be identified by high absolute values for AP laxity nor rotational laxity. Although AP and rotational laxities vary largely among the patients, and AP and rotational stabilization are successfully achieved immediately after ACL reconstruction, intraoperative AP and rotational laxity measured by the navigation system did not influence the postoperative AP and rotational laxities after ACL reconstruction. III.

Decompression, Correction, and Interbody Fusion for Lumbar Burst Fractures Using a Single Posterior Approach

Burst fractures of the lumbar spine with instability or severe kyphosis are best served by surgical treatment. The question as to how these fractures should be approached and stabilized (anteriorly, posteriorly, or combined anteroposteriorly) is controversial. We performed decompression, correction, and interbody fusion using a single posterior approach for Denis type B or C lumbar burst fractures with severe kyphosis. The operative technique is as follows: after partial laminectomy, the bone fragment, which had migrated into the spinal canal, is impacted into the posterior wall of the vertebral body. After curetting the injured disk, bone chips and adapted lamina are inserted into the disk space for anterior support. Five Denis type B or C burst fractures demanding >20 degrees kyphosis correction were treated by this procedure. Mean follow-up was 41 months. We evaluated neurologic assessment and localized kyphotic angle. The neurologic function of all 5 patients improved by at least 1 grade, as measured by the Frankel grading scale. Mean values of localized kyphosis improved from a mean 23.0. before surgery to -3.0 degrees after surgery. At follow-up examination, average regional kyphosis was -2.4 degrees . No implant failure was observed at follow-up. Bony fusion was achieved in all patients. The advantages of this operative procedure are it is safe for the neural structures and complete spinal canal decompression and kyphosis correction are achieved, while providing anterior support and posterior stabilization.

Spontaneus resolution of a traumatic vertebral artery pseudoaneurysm

Injuries of the vertebral artery are rare and are usually seen after penetrating or blunt cervical trauma. Vertebral artery injuries (VAI) have been reported in 0.5% of blunt trauma cases. These injuries can lead to hemorrhage, thrombosis, arteriovenous fistula or traumatic pseudoaneurysm in the early or late period. They must be treated carefully due to their increased risk of morbidity and mortality. In this case report, we present a case of asymptomatic traumatic vertebral artery pseudoaneurysm(TVAP) seen after cervical spinal trauma with C5-C6 listhesis developing afterwards, treated with anterior-posterior stabilization and fusion. Spontaneous resolution of the pseudoaneurysm is demonstrated by vertebral arter angiogrphy.

Volumetric Changes of Iliac Crest Autografts Used to Reconstruct the Anterior Column in Thoracolumbar Fractures

Patients with a thoracolumbar injury had a reconstruction of the anterior column using an tricortical iliac crest autograft. The volume and the length of the autograft were measured after 9 and 21 months using computed tomography. To assess the volumetric change of an iliac crest autograft used to perform a reconstruction of the anterior column. Iliac crest autografts are commonly used to reconstruct the anterior column following spinal fractures. However, very few reports have actually looked into the changes within the autograft following surgery. To our knowledge, no study has actually measured the loss of volume and length taking place within the graft using a CT scan. From January 1995 through May 2000, 27 patients of the 155 operated patients treated with a posterior-anterior stabilization of a fracture within the thoracic and lumbar spine were included in this study. Selection criteria were a postoperative CT and the reconstruction of the anterior column using an iliac crest autograft. A CT scan was performed before instrumentation removal and 1 year after instrumentation removal. These scans were used to evaluate the volume and length of the graft. There is a significant loss of graft volume (about 40%), half of which was not seen until after instrumentation removal. There is a correlation between the volumetric loss and the initial volume of the graft. The loss in length (24%) results in a correctional loss of the superior-inferior endplate angle totalling 12 degrees. All grafts showed good contact to the adjoining vertebrae with no case of a pseudarthrosis. The results show that more than a third of the initial graft volume is absorbed during the consolidation process. The loss was greater, the larger the volume of the initial graft was. The efficiency, however, was not dependent on the initial graft size.

Unilateral Cervical Facet Fractures With Subluxation: Injury Patterns and Treatment

This is a retrospective study of patients with unilateral cervical facet fractures from a Level I academic trauma center. We sought to examine fracture patterns involving only the facets, to examine the incidence of associated neurologic and vascular injuries, and to determine optimum management strategies for these injuries. Most of the literature regarding unilateral cervical facet injuries has resulted from studies evaluating dislocated locked facets, "fracture-dislocations," or fractures of the lateral mass and pedicle. We retrospectively reviewed our experience with unilateral fractures of the facets, identifying 25 cases over a 5-year period. Presenting history, neurologic examination, imaging findings, method of reduction, interval to surgery, type of surgery, and evaluation for vascular injuries were recorded. Fusion was assessed by plain radiographs and computed tomography scans at follow-up. All 25 patients were treated operatively. Ten of the fractures involved the superior articular process, 13 involved the inferior articular process, and 2 cases involved both. The most commonly affected level was at C6/7. Twenty-one of the 25 patients underwent anterior stabilization, 3 underwent posterior stabilization, and 1 underwent anterior-posterior stabilization. Eleven patients underwent diagnostic 4-vessel angiography, revealing 2 patients with vertebral artery injuries. Average follow-up was 11.5 months. There were no identifiable nonunions. We conclude the following: (a) anterior discectomy and fusion with a static (constrained) plating system is appropriate treatment for this type of injury, (b) in the absence of significant neurologic deficit with residual canal or foraminal stenosis, preoperative closed reduction is not necessary, (c) a small percentage of these patients will have vertebral artery injury, thus warranting screening with 16-slice computed tomographic angiography.

Circumferential fusion for sub-axial cervical spine fracture — subluxations

Fracture subluxation or traumatic spondylolisthesis of sub-axial cervical spine is a common but serious spinal injury encountered by neurosurgeons. It is frequently associated with spinal cord injury. Although decompression of spinal cord either anteriorly or posteriorly depending upon the site of compression is straight forward, there is no consensus regarding the approach for stabilization of spine either anterior or posterior or both, after decompression of spinal cord. Circumferential fusion involves combined anterior and posterior stabilization of sub-axial cervical spine. Some of the cases of circumferential fusion performed by the author are presented here. Anterior stabilization was performed with titanium cage or iliac graft insertion at corpectomy or discectomy site along with Anterior cervical plating and posterior stabilization was performed with Apofix clamps or interspinous wiring (cable) or lateral mass plating. Also one patient in whom only anterior stabilization was performed but who had recurrence of dislocation is also cited as an example of inadequacy of only one approach of stabilization to a 3 column cervical spine injury.

Injuries of the cervical spine in patients with ankylosing spondylitis: experience at two trauma centers

The cervical spine in a patient with ankylosing spondylitis (AS) (Bechterew disease) is exposed to maximal risk due to physical load. Even minor trauma can cause fractures because of the spine's poor elasticity (so-called bamboo spine). The authors conducted a study to determine the characteristics of cervical fractures in patients with AS to describe the standard procedures in the treatment of this condition at two trauma centers and to discuss complications of and outcomes after treatment. Between 1990 and 2006, 37 patients were surgically treated at two institutions. All patients were examined preoperatively and when being discharged from the hospital for rehabilitation. Single-session (11 cases) and two-session anterior-posterior (13 cases), anterior (11 cases), posterior (two cases), and laminectomy (one case) procedures were performed. The injury pattern, segments involved, the pre- and postoperative neurological status, and complications were analyzed. Preoperative neurological deficits were present in 36 patients. All patients experienced improvement postoperatively, and there was no case of surgery-related neurological deterioration. In patients in whom treatment was delayed because of late diagnosis, preoperative neurological deficits were more severe and improvement worse than those treated earlier. The causes of three deaths were respiratory distress syndrome due to a rigid thorax and cerebral ischemia due to rupture of the vertebral arteries. There were 12 perioperative complications (32%), three infections, one deep venous thrombosis, five early implant failures, and the three aforementioned fatalities. There were no cases of epidural hematoma. In all five cases in which early implant failure required revision surgery, the initial stabilization procedure had been anterior only. A comparison of complications and the outcomes at the two centers revealed no significant differences. The standard intervention for these injuries is open reduction, anterior decompression and fusion, and anterior-posterior stabilization; these procedures may be conducted in one or two stages. Based on the early implant failures that occurred exclusively after single-session anterior stabilizations (five of 10--a failure rate of 50%), the authors have performed only posterior and anterior procedures since 1997 at both centers. Diagnostic investigations include computed tomography scanning or magnetic resonance imaging of the whole spine, because additional injuries are common. The causative trauma may be very slight, and diagnosis may be delayed because plain radiographs can be initially misinterpreted. In cases in which diagnosis is delayed, patients present with more severe neurological deficits, and postoperative improvement is less pronounced than that in patients in whom a prompt diagnosis is established. Because of postoperative pulmonary and ischemic complications, the mortality rate is high. In the present series the mortality rate was lower than the mean rate reported in the literature.

Combined Stabilization of Thoracolumbar Spine Fractures

Introduction: Isolated dorsal instrumentation in thoraco-lumbar spine fractures may lead to loss of reduction after implant removal and subsequent re-kyphosing. Thus, reconstruction of the anterior body defect using expandable cages or allografts in addition to dorsal stabilization may enhance stability. Patients and Methods: In the following study we report on 89 patients (30 female, 59 male) with a mean age of 46.5 ± 20.6 years (MW ± SEM) who sustained unstable fractures or tumor destruction of the thoraco-lumbar spine. Fracture care included primary dorsal stabilization by internal fixator. All patients received in a second step ventral corporectomy and vertebral body replacement by expandable titanium cages (n = 75; Ulrich, Germany) or iliac crest bone grafts (n = 14). From T3 to L1 a thoracoscopic anterior approach was performed; L3 to L5 region was assessed by lumbotomy. In addition, the anterior column was stabilized by a fixed-angle plate (MACS, Aesculap, Germany) since 2002. Results: The operating time for the anterior approach averaged 160 ± 42 min. Patients tolerated the thoracoscopic approach well. We experienced no cage dislocation in the group of patients with fixed-angle plate fixation (before 2002 n = 4). There were n = 11 (9.8%) complications (aortic injury n = 1, iliac vein injury n = 1, cerebrospinal fluid leak n = 4, wound infection n = 5). Conclusion: Combined posterior–anterior stabilization of the thoraco-lumbar spine allows for a meticulous reconstruction and stabilization of graduated height of the anterior column. Primary dorsal instrumentation leads to tension stability and simplifies reduction. An additional anterior fixed-angle plate system may help to prevent cage dislocation.

Posterior spinal epidural abscess: an unusual complication of vertebroplasty

ObjectiveComplications after vertebroplasty are rare. There are few reported infectious complications requiring surgical management such as corpectomy with anterior reconstruction and posterior stabilization, although we have not seen any reports about epidural abscess in the literature. We present a patient in whom posterior epidural abscess developed after vertebroplasty in which drainage and antibiotherapy were required for treatment. MethodsA 70-year-old female with a painful T12 osteoporotic compression fracture underwent percutaneous vertebroplasty using polymethylmethacrylate without complication. One week after vertebroplasty, however, she had fever and increased back pain. On clinical examination, soft tissue abscess formation was determined at the vertebroplasty site. This was drained surgically and antibiotic treatment was started. At follow-up, she had progressive neurological deterioration (paraparetic) on the 18th day after abscess drainage. MRI of the thoracolombar spine revealed posterior spinal epidural abscess at the T11/12 level. Partial laminectomy and drainage were performed. She had complete neurological recovery in the follow-up period. ConclusionAn epidural abscess, which is an unusual complication of vertebroplasty, represents a medical and surgical emergency. Treatment is generally urgent surgical drainage combined with antibiotics. The patient should be evaluated in detail for systemic infectious disease and comorbid conditions before the vertebroplasty procedure.

The management of complex soft-tissue defects after spinal instrumentation

Wound dehiscence after spinal instrumentation presents a challenging problem to the surgeon.[1][1]–[8][2] Soft-tissue complications after operation are most commonly seen in patients with poor nutritional status, in the presence of injury to the spinal cord, following multiple operations and in

Scoliosis in Association With Infantile Hypophosphatasia

A case study of scoliosis in two siblings with infantile hypophosphatasia and review of literature are presented. To report the rare occurrence of scoliosis in two siblings with infantile hypophosphatasia and detail problems in the surgical management of scoliosis in this rare disease. To the authors' knowledge there is only one reported case of scoliosis in infantile hypophosphatasia. However, there is no report describing the nature of the curve, its progression, or the surgical management of scoliosis in infantile hypophosphatasia. The first sibling was diagnosed shortly after birth to have scoliosis that progressed rapidly despite brace treatment. At 4 years, he underwent anterior convex arthrodesis and posterior T6-L1 Luque trolley stabilization. Because of further curve progression, he had to undergo corrective anterior and posterior osteotomies, stabilization, and fusion at 11 years of age. The second sibling was diagnosed to have scoliosis at the age of 3 years and underwent anterior thoracoscopic release and posterior Luque trolley stabilization. The first sibling with a mild form of infantile hypophosphatasia had to undergo multiple procedures to attain fusion and arrest of curve progression. The second sibling with a severe variety of infantile hypophosphatasia surprisingly attained a spontaneous fusion of the curve following the initial correction and stabilization with no further progression at 9-year follow-up. Curve progression and fusion rates following scoliosis correction are not related to the disease severity or biochemical findings. These rapidly progressive curves are amenable to surgical correction despite the unfavorable metabolic nature of the disease. Hypercalcemia and seizures responding to pyridoxine are complications in the postoperative period of which the surgeon should be aware.