Anterior Strut Grafting Research Articles

Comparison of Short-Segment Pedicle Instrumentation with Supplemental Hook Fixation under Axial Compression in Relation to Graft Positioning and Posterior Ligamentous Integrity: A Biomechanical Study on the Calf Spine.

Study DesignBiomechanical study.PurposeThis study investigates the benefits of supplemental hook fixation (SHF) on short-segment pedicle instrumentation (SSPI) in relation to anterior strut graft positioning. In addition, it seeks to determine whether the integrity of the posterior ligamentous complex (PLC) affects the stability of the spinal construct.Overview of LiteratureImplant and/or bone failure with progressive kyphotic deformity after SSPI is common. To prevent this, several approaches are available, including SHF, anterior strut grafting, use of longer spinal constructs, and extension of the fusion to additional adjacent segments.MethodsA total of eight calf spines were instrumented with SSPI (n=4) and SHF (n=4) with strain gauges on the implants. Strain measurements were performed under axial compression in the following order: intact spine, corpectomy, ventral positioned strut grafting, posterior positioned strut grafting, ventral positioned grafting with resected PLC, and corpectomy with resected PLC.ResultsThe SHF group showed slightly lower strain values than SSPI in instrumented corpectomy-only specimens, but there were no statistically significant differences between them (p >0.05). The SHF group was significantly more stable than SSPI when strut grafting is employed, regardless of the location of the grafts (p =0.000). In the SSPI group, ventral positioning of the graft contributed significantly to the stability (p =0.000). There was no statistically significant difference between the ventral or posterior positioning of the graft in the SHF group (p =0.187). In addition, the integrity of the PLC did not affect stability in either group (p >0.005).ConclusionsAlthough not statistically significant, our investigation demonstrated that the most stable method was the SHF along with ventral positioned strut graft. However, if the SSPI is the treatment of choice, ventral positioned strut graft support will be useful in minimizing the risk of implant failure and progressive kyphotic deformity.

Three-dimensional translations following posterior three-column spinal osteotomies for the correction of severe and stiff kyphoscoliosis

Background ContextPosterior three-column spinal osteotomies were shown to be effective to treat severe and stiff kyphoscoliosis. Translations at the site of osteotomy after deformity correction were commonly seen intraoperatively, which might cause potential neurologic deficits. However, this phenomenon was not thoroughly discussed in the current literature. PurposeThis study aimed to evaluate the three-dimensional (3D) translations at the three-column osteotomy site and their effects on neurologic outcome in the surgical correction of severe and stiff kyphoscoliosis. Study Design/SettingA retrospective study was carried out. Patient SampleSixty-nine patients treated by posterior three-column spinal osteotomy for severe kyphoscoliosis of idiopathic, congenital, neuromuscular, neurofibromatosis, and tuberculosis origin were included. Outcome MeasuresGeneral, coronal, and sagittal translations were graded three-dimensionally according to the theory of Meyerding. MethodsThe charts of 69 clinical patients with severe and stiff kyphoscoliosis treated by posterior three-column osteotomy from January 2013 to June 2015 were reviewed. There were 35 male patients with an average age of 21.5 years and 34 female patients with an average age of 22.5 years. The etiologies of these spinal deformities were idiopathic, congenital, neuromuscular, neurofibromatosis, and tuberculosis. According to our classification system of spinal cord neurologic function, there were 41 type A, 13 type B, and 15 type C cases. The 3D spine models were reconstructed from thin-sliced computed tomography (CT) scan, and the 3D translations at the three-column osteotomy site were graded and analyzed. ResultsThe incidences of general translation (GT), frontal translation (FT), and sagittal translation (ST) were 62.3%, 52.2%, and 26.1%. The incidence of evoked potential (EP) change in cases with GT/FT being or more than grade II (GT, 42.9%; FT, 50.0%) was significantly higher than that with GT/FT being less than grade II (GT, 16.7%; FT, 18.2%), whereas the incidence of EP change in cases with ST being or more than grade I (33.3%) was significantly higher than that with ST being less than grade I (9.8%). No linear correlations were found between spine shortening distance, deformity correction rate, and the degree of translation. ConclusionsThe 3D translations are common in posterior three-column spinal osteotomies regardless of anterior strut graft placement. The increase of translation will increase neurologic risks, with GT or FT less than grade II and ST less than grade I being relatively safe.

Spinal Osteotomy for Sagittal Deformities using “Posterior Only Approach”: A Novel Classification System

Introduction Numerous types of posterior approach based osteotomies have been described but often there is a loss of clarity on the best osteotomy for each patient. We have proposed a morphological classification of sagittal deformities based on the status of the anterior and posterior column, the extent of column deficiency and the flexibility of the deformity. This classification will be useful as guideline for osteotomy selection and for comparing the practice preferences and outcomes between different institutions. Methods We analyzed retrospectively collected data for 187 posterior based osteotomies for sagittal deformity. A morphological classification of sagittal deformity was created on basis of collected data. The deformities with intact anterior and posterior column was Type I, where 1A had mobile disc spaces and 1B ankylosed segments. Type II had deficiency of any one column with IIA having a deficiency of posterior column only and Type IIB of anterior column only. Type III had an insufficiency of both columns with Type IIIA being less than 60°, IIIB > 60° and IIIC having buckling collapse. We then prospectively analyzed this morphological classifcation in seventy-five patients with sagittal deformity who underwent various osteotomy procedures for different pathologies. We matched all the cases for six types of anatomical spinal osteotomies and one salvage procedure (anterior strut fusion). The osteotomy procedures considered were partial facetectomy, Ponte's osteotomy, pedicle substraction osteotomy, disc bone osteotomy, single vertebrectomy, multilevel vertebrectomy and salvage procedure in the form of anterior strut grafting. Results The mean age was 20.1years and mean sagittal deformity was 67.70°(28–129°). An average correction of 41% (11 to 78%) was achieved and an association of more complex osteotomies for higher class of deformities was noted. The inter-observer agreement for four spine surgeons classifying the 75 deformities was noted to be high (agreement rate K-0.83) using the above morphological classification. A chi-square analysis performed to test the association between the classification and the type of osteotomy, which showed an observable trend with a highly significant association ( p < 0.001) showing that the type of osteotomy to be performed could be predicted by the classification. Conclusion The proposed classification of the sagittal deformity had a high inter-observer agreement and was useful in predicting the type of osteotomy. The classification would be valuable in training and teaching purposes. This classification could also be used for comparing the osteotomy selection and outcomes between different institutions.

Dystrophic thoracic spine dislocation associated with type-1 neurofibromatosis: Case report and rationale for treatment

The authors report a rare case of spontaneous dystrophic thoracic spine dislocation in a 14-year-old boy with neurofibromatosis type 1 (NF-1). Anteroposterior and lateral standing radiographs showed a dysplastic kyphoscoliotic deformity, with the thoracic kyphosis and scoliosis measuring 75° and 69°, respectively. Three-dimensional reconstruction after computed tomography demonstrated spondyloptosis at T5-T6 with overlapping of T5 over T6 and T7. The patient underwent circumferential fusion with anterior fibular strut grafting mechanically secured between the inferior and superior endplates of T5 and T7 followed by an instrumented posterior fusion from T2 to L1 and thoracoplasty. There was satisfactory resolution of the deformity with stabilization at the last follow-up evaluation.

Severe Thoracic Kyphosis with Neuropathy in a Three-Year-Old Child: A Case Report.

Childhood spondylodiscitis occurs in 0.4 to 2.4 per 100,000 children each year1. Early diagnosis is important to prevent the development of major complications such as sepsis, spinal cord injury, and severe angular thoracic kyphosis. We report a rare case of a child who first presented as a two-month-old premature infant with an initial diagnosis of congenital cystic adenomatoid malformation (CCAM) of the lung and spondylodiscitis of the seventh and eighth vertebrae of the thoracic spine. The aim of the report is to highlight some challenges in identifying spondylodiscitis in very young children, including difficulty with the detailed neurological evaluation, the need for serial neuromonitoring assessments, progression of spinal deformity following attempted posterior spinal fusion, and technical difficulties involved in corrective surgery. The patient’s family was informed that data concerning the case would be submitted for publication, and they provided consent. This patient, who had been diagnosed in utero with CCAM of the lung, was born two months prematurely and was admitted to the neonatal intensive care unit for respiratory support. Routine computerized tomography (CT) of the chest revealed thoracic angular deformity with destruction of the seventh and eighth thoracic vertebral bodies and a lingular CCAM lesion of the left lung (Figs. 1A through 1-D). Differential diagnosis included congenital abnormality of the spine and vertebral osteomyelitis. Subsequently, she underwent lobectomy of the left upper lobe for the CCAM and debridement of the T7 and T8 vertebral bodies. Anterior strut-grafting was not performed because spondylodiscitis had not yet been diagnosed. During debridement, bone and disc tissue were sent for histopathological examination and cultures. Fig. 1 Fig. 1-A Posteroanterior radiograph of the spine shows the overlap of disc spaces between T5 and T10 caused by kyphosis. Fig. 1-B Lateral radiograph depicts the anomalous nature of the spinal vertebral bodies of T7 and T8 …

Clinical Outcomes of Combined Anterior and Posterior Spinal Fusion for Dystrophic Thoracolumbar Spinal Deformities of Neurofibromatosis-1

Retrospective study. To analyze the clinical outcomes of anterior and posterior spinal fusion (APSF) using a fibular strut autograft (FSAG) and to investigate the morphological changes in the reconstructed spinal column of dystrophic deformities in neurofibromatosis (NF)-1. APSF is desirable for dystrophic deformities in NF-1 with more than 50° of dystrophic kyphosis. There are few reports regarding the clinical outcomes of APSF in which the morphological changes over time of the anterior strut graft have been investigated. The clinical and radiographic outcomes of APSF with FSAG were investigated in 10 consecutive patients with dystrophic deformity in NF-1. For qualitative and quantitative analyses, the chronological changes in the FSAG configuration, length, and diameter were evaluated. The mean follow-up period was 9 years, 9 months (range, 1-30 years). Graft bone erosion and postoperative curve progression were not observed in any patient. In quantitative analyses of the anterior strut, the mean ratio of the latest and immediately postoperative FSAG lengths was 0.98 (0.93-1.09). The mean central/peripheral ratios of the FSAG diameter (central portion/[upper end + lower end]/2) were 1.02 (0.92-1.10) immediately after surgery, and 1.01 (0.92-1.07) at the latest follow-up, with no significant change between these 2 time points (P = 0.937). The mean preoperative cross-sectional area of the apical vertebral body and its mean virtual cross-sectional area at the final follow-up were 3.80 (1.83-5.43) and 4.87 (2.46-7.00) cm(2), respectively, with a significant difference between these 2 parameters (P = 0.0078). The mean final/preoperative ratio was 1.31 (1.10-1.43). APSF with FSAG for dystrophic deformity in NF-1 successfully reconstructed a reliable spinal column with a rich bone stock. The FSAG and surrounding vertebral bodies were free from postoperative erosion due to dystrophic changes and maintained their stability for a long time.

Severe Neurofibromatosis Kyphoscoliosis, Posterior Wedge Osteotomy, Halo-traction, and Anterior Autograft Strut Fusion, With 28-Year Follow-up

Case report with very long-term follow-up. To demonstrate the lasting value of correction and stabilization with multiple anterior autogenous strut grafting. Although anterior strut grafting has been shown to be ideal for neurofibromatosis kyphosis, there have been no reports as to whether the benefit is maintained or lost over many years. This is a single case report with very long-term follow-up. This adult patient, operated in February 1982, has been followed for 28 years, and is doing very well in life, although her pulmonary capacity is compromised. Although patients with severe spine deformity because of neurofibromatosis tend to deteriorate with time, this patient demonstrates that with aggressive correction and fusion management, a long-term good quality of life can be achieved.

Late Stress Fracture of a Well-Consolidated Strut Graft After Total Spondylectomy in the Thoracolumbar Spine

A retrospective study of three patients of delayed stress fracture of anterior strut graft after total spondylectomy. The aim of this paper is to report a possible risk of removal of instrumentation after total spondylectomy. Solid fusion of anterior column usually means stable spine and reports of delayed stress fracture of an anterior strut graft are rare. The authors reviewed the medical history and imaging data of three patients who suffered late stress fracture after total spondylectomy. All three patients had total spondylectomy as a treatment of malignant tumor of thoracic spine. After removal of posterior instrumentation, they sustained stress fracture of the anterior strut, which is already incorporated well. Removal of instrumentation may cause stress fracture of anterior strut grafts after total spondylectomy. Solid fusion of anterior column usually indicates stable spinal column and reported delayed stress fracture of anterior strut graft is rare. The authors reviewed the medical history and images of three cases with late stress fracture after total spondylectomy. All three cases had total spondylectomy as a treatment of malignant tumor of thoracic spine. After removal of posterior instrumentation, they had stress fracture of anterior strut, which is already incorporated well. Removal of posterior instrumentation may cause stress fracture of anterior strut grafts after total spondylectomy.

Posterior/anterior combined surgery for thoracolumbar burst fractures—posterior instrumentation with pedicle screws and laminar hooks, anterior decompression and strut grafting

A prospective clinical study. The purpose of this study was to evaluate prospectively a large group of patients with thoracolumbar burst fractures who were treated with a posterior/anterior combined procedure and to report on the surgical outcomes, complications and radiographic results. A total of 100 consecutive patients were surgically managed with posterior instrumentation, anterior decompression and anterior strut grafting. There were 71 males and 29 females; the mean age was 36 years. Patients with osteoporotic delayed vertebral body collapse were excluded. The mean follow-up period was 30 months. Surgical outcomes such as operative time, blood loss and sagittal alignment were investigated. A neurological assessment was performed by a rating system based on the American Spine Injury Association impairment scale. An interbody fusion was judged using plain X-ray and computed tomographic scans. The mean operative time was 256 min and the mean operative bleeding was 985 ml. Most of the patients were ambulatory within 3 days after surgery. Of the 76 patients with neurological injury, 54 (71.1%) recovered function following surgery. The mean local kyphosis angle was 12.2° kyphotic preoperatively and 0.8° lordotic at the final observation. The mean correction angle was 15.7° and correction loss was 2.6°. No instrumentation failure was observed and the postoperative fusion rate was 99%. Posterior/anterior combined surgery with posterior pedicle screws and hooks fixation, and reconstruction by simultaneous strut grafting and anterior decompression, achieved short segment fixation and can be a useful option for surgically treating thoracolumbar burst fractures.

Combination of the AO-Magerl and Load-Sharing Classifications for the Management of Thoracolumbar Burst Fractures

The AO-Magerl classification is widely accepted for the appropriate management of patients with thoracolumbar burst fractures; however, it fails to assess the ability of the injured spine to withstand compressive loading and cannot predict instrumentation failure after short-segment posterior fixation. The load-sharing classification depends on the degree of comminution and apposition of bony fragments.We retrospectively classified according to both classifications 100 consecutive patients with 1-level thoracolumbar burst fractures treated nonoperatively or operatively within a 7-year period. Sixty neurologically intact patients (60%) were treated nonoperatively, 15 (15%) had short posterior instrumentation, 15 (15%) had short anterior instrumentation, and 10 (10%) had combined short posterior instrumentation and anterior strut grafting. Twenty-five of the 40 (60%) surgically treated patients had neurological impairment on admission. Clinical outcome was assessed using a pain and working ability scale. Mean follow-up was 52 months (range, 24-70 months). Function was satisfactory in 55 (92%) nonoperatively treated patients and in 33 (83%) surgically treated patients. Neurological improvement by American Spinal Injury Association (ASIA) grade was observed in patients with incomplete paraplegia (70% of neurologically impaired patients) who were treated operatively.The combination of AO-Magerl and load-sharing classifications provides for accurate selection of treatment, surgical approach, and length of instrumentation, and can guide the decision for additional anterior surgery.

Outcome of Osteoplastic Laminotomy for Excision of Spinal Cord Tumours

To evaluate the outcome of osteoplastic laminotomy after excision of primary tumours of the thoracolumbar and lumbar spine. Records of 10 male and 11 female consecutive patients aged 15 to 57 (mean, 37) years who underwent osteoplastic laminotomy for excision of spinal cord tumours in the thoracolumbar (n=13) and lumbar (n=8) spine were reviewed. After tumour resection, the removed posterior elements were reattached to the superior and inferior processes using anchoring sutures. Pre- and post-operative functional status was retrospectively graded according to the modified McCormick scale. Spinal deformities were classified as sagittal and coronal malalignment, segmental instability, and spondylolisthesis. The mean follow-up duration was 43 (range, 12-108) months. The mean number of laminae excised was 1.3 (range, 1-4). At the final follow-up, the modified McCormick scale score improved in 16 patients, remained unchanged in 4, and deteriorated in one. No patient developed any severe complication, recurrence, spondylolisthesis, or aseptic necrosis of grafted laminae. In 2 patients their spinal deformities became worse: one had segmental instability of 17 degrees at L3-4 secondary to non-union of the L3 lamina; the other (with type-I neurofibromatosis and dystrophic deformity) underwent fusion for severe low back pain and lumbar kyphosis and progressive rotational dislocation, despite union of the grafted L2 lamina. Osteoplastic laminotomy preserves the structures that could be important for spinal stability and may reduce the risk of deformities. Anterior strut grafting and posterior fusion may be necessary in neurofibromatosis patients with dystrophic deformities.

Steroids and Risk Factors for Airway Compromise in Multilevel Cervical Corpectomy Patients

Prospective, randomized, double-blind study. To evaluate intravenous corticosteroids in preventing delayed extubation after multilevel corpectomy and strut graft reconstructive procedures and to identify risk factors for delayed extubation in these patients. We performed a prospective, randomized double-blind study in patients undergoing multilevel cervical corpectomy procedures. Our hypothesis was that high-dose perioperative steroids would decrease edema and thus decrease the incidence of delayed extubation. We studied patients undergoing 2- or 3-level anterior cervical corpectomy procedures with anterior strut graft reconstruction. Sixty-six patients were randomized to receive 3 doses of either intravenous dexamethasone (n = 35) or saline (n = 31). The first dose was given before the incision, with subsequent doses given 8 and 16 hours later. Patients remained intubated until postoperative day 1, at which time a cuff leak test was performed by the anesthesiology attending. If a leak was present, the patient was extubated. If not, the test was repeated each postoperative day until a leak was present, indicating a patent airway. Five of 35 (14%) in the steroid group and 6 of 31 (19%) in the saline group required delayed extubation (P = 0.22). There were no statistical differences in preoperative parameters of age, gender, diagnosis, smoking history, BMI, number of operative levels, or preoperative American Society of Anesthesiologists rating between the 2 groups. Similarly there were no differences between the groups for duration of anesthesia, intraoperative colloids or crystalloids, intraoperative blood loss, or intraoperative urine output. The data for both groups were pooled to evaluate risk factors for delayed extubation. The only statistically significant risk factor for delayed extubation in this study was female gender (P = 0.0001). Based on our data, we cannot recommend intravenous dexamethasone for prevention of delayed extubation after multilevel anterior cervical corpectomy and strut grafting procedures.

Use of a Noninvasive Halo in Children

Retrospective review of clinical experience in children using a new noninvasive halo. To report on the efficacy, complications and indications for use of a noninvasive halo in the pediatric population. A halo vest with pins in the skull is the gold standard for providing maximum immobilization and control of the cervical spine. Inherent complications include scarring, infection, cerebral spinal fluid leakage, loosening of pins, and penetration of the cranial vault. Less invasive orthoses historically provide significantly less immobilization and control of the cervical spine. A Minerva cast has problems with patient tolerance and skin care. The noninvasive halo was used on 30 children (ages 6 months to 16 years) for the following indications: muscular torticollis release, 18 children; cervical fusion immobilization 7 children; closed reduction of C1-C2 rotatory subluxation, 5 children. The noninvasive halo was successful with no complications in 29 of 30 patients. One complication consisted of dislodgment of a C2-C4 anterior strut graft, though fusion ensued without further surgery and the clinical result was successful. Longstanding C1-C2 rotatory subluxations were safely reduced in 5 children with the noninvasive halo. In 18 children following sternocleidomastoid release, the cervical spine was successfully immobilized in an overcorrected position after surgery. A noninvasive halo was used successfully for postoperative immobilization of children with stable cervical spines. This device was particularly useful for the gentle and safe reduction of C1-C2 subluxations, and for postoperative immobilization in an overcorrected position following stenocleidomastoid release for congenital muscular torticollis.

In Vitro Analysis of Anterior and Posterior Fixation in an Experimental Unstable Burst Fracture Model

A biomechanical comparison of fixation constructs in an experimental fracture model. To determine the relative postoperative stability of anterior graft and plating with that of posterior or combined fixation constructs in an unstable thoracolumbar burst fracture model. Several treatment modalities have been proposed for unstable thoracolumbar burst fractures, but the optimal technique is unclear. Previous cadaveric biomechanical studies in unstable burst fracture models have not considered the commonly used posterior (interpedicular) and anterior (plate) constructs. Nine human spine segments (T11-L3) were potted in epoxy and scanned using dual energy x-ray absorptiometry and computed tomography. Intact specimens had baseline flexibility testing. Unstable L1 burst fractures as verified by computed tomography were created using an impulse load and posterior surgical osteoligamentous destabilization (ie, transection of the lamina, interspinous ligaments, facet capsules, and ligamentum flavum). Specimens were instrumented posteriorly with pedicle screws and rods and tested to 6 Nm in flexion-extension, lateral bending, and torsion. Corpectomy and strut grafting were then performed, and testing was repeated in varying order with posterior fixation, anterior plating and circumferential fixation. Range of motion (ROM) and neutral zone was calculated for each test and fixation groups were compared using analysis of variance. All specimens had AO B1.2 (unstable burst) fractures. Mean ROM for posterior-only constructs was significantly less than that of the intact in lateral bending, flexion, and extension (P<0.001). Anterior-only constructs after corpectomy and strut grafting generally resulted in a smaller ROM versus intact in flexion (NS: P=0.1) and lateral bending (P<0.001). In contrast, all anterior-only and posterior constructs had greater ROM than intact in torsion (all at P<0.05). Circumferential fixation resulted in statistically smaller ROM compared with all other constructs (P< or =0.04), and reached that of the intact specimen in torsion. Increased ROM was correlated with greater fracture comminution for posterior-only fixation (P<0.05), and was weakly correlated with lower dual energy x-ray absorptiometry score (R=0.3) for anterior-only fixation. Circumferential instrumentation provided the most rigid fixation, followed by posterior fixation with anterior strut grafting, posterior fixation alone, and by anterior fixation with strut grafting. These results were dependent on bone quality and the comminution severity of the fracture. These results should aid surgical decision making in addition to other factors in the overall clinical situation.

The Fate of Anterior Autogenous Bone Graft After Anterior Radical Surgery With or Without Posterior Instrumentation in the Treatment of Pyogenic Lumbar Spondylodiscitis

A retrospective clinical study. To assess the results of anterior strut grafting and the loss of the reduction in anterior interbody fusion and anterior interbody fusion combined with posterior instrumental fusion in pyogenic spondylodiscitis. Resorption of the anterior graft is an ominous sign following most anterior surgery. Thus, additional posterior instrumentation has been used to prevent collapse of the anterior graft. However, its effect is controversial, and few studies have examined the fate of the anterior strut graft. Twenty-four consecutive patients underwent surgical treatment for pyogenic spondylodiscitis. The patients were divided into Group I (anterior interbody fusion) and Group II (anterior interbody fusion + posterior instrumented fusion). The sagittal angle, intervertebral height, and complications relating to the anterior graft were compared. Solid bone fusion was achieved in 23 (95.8%) patients. The sagittal angle and the intervertebral height were similar in Groups I and II (P = 0.61, P = 0.89, respectively). In Groups I and II, the postoperative sagittal angle was maintained until 1 month after surgery (P > 0.05), but it decreased significantly by 3 months after surgery (P < 0.05). In Groups I and II, intervertebral height correction was maintained until 1 month after surgery (P > 0.05), but by 3 months after surgery, it had collapsed significantly (P < 0.05). Subsidence of the graft occurred through the damaged endplate. Group I included 1 case of graft dislodgement necessitating revision; there were no such cases in Group II. There were no recurrences of infection in either group. Reduction of intervertebral height and loss of sagittal profile occurred in both groups. Complications relating to the bone graft were more common in Group I than in Group II. Despite loss of correction, both groups had a high fusion rate without recurrence of infection. The reduction of intervertebral graft height appears to be the result of destruction of the endplate either due to surgical debridement or the infective process.

Minimum 5-Year Follow-up Surgical Results of Post-traumatic Thoracic and Lumbar Kyphosis Treated With Anterior Instrumentation

A retrospective follow-up study of post-traumatic thoracic and lumbar kyphosis after anterior instrumentation with anterior plate and dual rod systems. To investigate the outcome of anterior vertebrectomy, anterior strut grafting, and anterior instrumentation in patients with > 30 degrees sagittal contour deformity. Post-traumatic kyphosis may lead to mechanical pain due to the impairment of physiologic sagittal contours as well as cosmetic complaints. Forty patients with post-traumatic kyphosis were followed for a minimum of 5 years. Mean age was 44.7 +/- 12.4 years (range, 18-65 years); 18 were female and 22 were male. All patients underwent anterior vertebrectomy and decompression; anterior fusion was carried out with costal or iliac ala grafts. Patients were randomly assigned into 2 treatment groups: correction and internal fixation was performed by using either plate-screw (n = 20) or double rod-screw (n = 20). Patients were also evaluated clinically by using Pain and Functional Assessment Scale (PFA) and SRS-22 questionnaire. Before surgery, the mean value for local sagittal contours was 51.4 degrees +/- 13.8 degrees; after surgery, it was reduced to 7.0 degrees +/- 7.6 degrees, resulting in an 88.7% +/- 11.3% correction (P = 0.00). At the last follow-up visit, a mean correction loss of 1.4 degrees +/- 1.8 degrees was found. A statistically significant improvement in local kyphosis angles and PFA scores was found after surgery and at the last visit. In 92.5% of the patients (n = 36), pain completely resolved; and in the remaining 3 patients, it is markedly reduced. Neurologic improvement was achieved in all of the 24 patients with neural claudication and other neurologic findings. Solid fusion mass was obtained in all patients. The type of instrumentation system did not differ significantly in terms of kyphotic deformity correction rates, correction losses, PFA scores, and SRS-22 scores. Final PFA scores showed a statistically significant correlation with SRS-22 scores (r = -0.918, P < 0.01). Final pain, function, mental status, self image and satisfaction domain scores and total SRS-22 score were > or = 4. The time from trauma to operation and the severity of kyphotic deformity were inversely correlated with postoperative correction rates. On the other hand, these 2 parameters were positively correlated with both final PFA and final SRS-22 scores (P < 0.01). In light of the present study's findings, we suggest that the technique of anterior decompression, strut grafting, and anterior instrumentation is an effective method for the treatment of post-traumatic kyphotic deformity and that the success of the technique depends on the time from trauma to operation and the severity of baseline deformity, regardless of the type of instrumentation.

Evaluation of Spinal Fusion Using Autologous Anterior Strut Grafts and Posterior Instrumentation for Thoracic/Thoracolumbar Kyphosis

A retrospective cohort study. To evaluate anterior strut grafts in spinal fusion for thoracic/thoracolumbar kyphosis. Autologous strut grafts harvested from the fibula, iliac crest, and rib are frequently used for treating severe kyphosis and kyphoscoliosis. However, a majority of the studies have presented mixed patient populations kyphosis and/or scoliosis, treated either with anterior or anteroposterior fusion. Very few reports have presented an evaluation of autologous strut grafts for anterior fusion with posterior instrumentation for the treatment of kyphotic deformities. A total of 23 patients comprised the study. Diagnosis was granulomatous infection (9 patients), congenital (6), posttraumatic (4), neurofibromatosis (1), ankylosing spondylitis (1), Scheuermann disease (1), and plasmacytoma of the vertebral body with pathologic fracture (1). Average age at surgery was 41 years (range 6-77). Indication for surgery was pain with or without progression in 15 patients and additional progressive neurologic deficit in the other 8. Anterior strut grafts consisted of the autologous fibula (9 patients), iliac (10), fibula and ribs (2), fibula and iliac (1), and fibula, iliac, and ribs (1). The fusion areas were thoracic (11 patients), thoracolumbar (11), and cervicothoracic (1). Anterior decompression was performed in 8 patients because of the presence of neurologic symptoms caused by cord compression. Dorsal fusion was performed in all patients with third-generation systems. Average 4.2 vertebrae were fused anteriorly. Mean follow-up bracing time was 9.7 months. Average kyphosis measured 50.9 degrees before surgery and 32.5 at a mean follow-up of 4.5 years (P < 0.0001). No graft breakages were noted at final follow-up. Solid fusion was achieved in all patients. No donor site complications were observed. Of the 8 patients presenting with neurologic deficits, 4 had full recovery, 3 had partial recoveries, and 1 had no improvement. Loss of postoperative correction > 5 degrees was observed in 3 patients. At final follow-up, 3 patients complained of occasional pain, and 1 complained of pain when lying on the back, particularly on hard surfaces. Adequate correction was maintained throughout an average follow-up of 4.5 years, and solid fusion was obtained in all patients. Anterior strut grafts, supplemented with posterior fusion with instrumentation provide a good treatment alternative for the treatment of kyphosis deformity of the spine as a result of various etiologies.

Neurofibromatosis type I with severe dystrophic kyphoscoliosis and its operative management via a simultaneous anterior-posterior approach: a case report and review of the literature

Background context Neurofibromatosis is an autosomal-dominant hereditary disorder with two subtypes: NF-1 (type I) and NF-2 (type II). NF-1 is a complex disorder with a constellation of manifestations that can also entail skeletal abnormalities, including spinal deformity of a noncongenital nature with early age onset. The short, sharp, angular curve usually present in the thoracic region, as exhibited in NF-1, presents a quandary in its surgical management. Various studies have reported on the efficacy of anterior correction as opposed to posterior alone, whereas others have advocated a sequential, combined approach to diminish the degree of deformity and achieve solid arthrodesis. However, despite solid arthrodesis, curve progression may still ensue. Nonetheless, a simultaneous anterior-posterior approach to treat such a condition of NF-1 with severe dystrophic kyphoscoliosis is a rare occurrence. Purpose To describe the presentation and operative management of a patient with NF-1 and severe dystrophic kyphoscoliosis. Study design A case report and review of the literature. Methods A clinical and radiographic review of a 51-year-old male patient who presented with NF-1, a 165-degree thoracic kyphotic deformity, associated scoliosis, varied degree of vertebral destruction of T9–T11, and paraparesis below T10. Results Operative intervention of the deformity consisted of a simultaneous anterior-posterior approach and entailed posterior cord exposure, anterior vertebrectomy of T9–T11, cord decompression, posterior osteotomy (posterior elements were auto-fused), anterior distraction and kyphosis correction, anterior strut grafting, anterior rod instrumentation, and posterior compression instrumentation and fusion from T6–L2. The deformity was reduced, sold fusion was noted, and the patient was asymptomatic. Conclusions A simultaneous anterior-posterior approach for the surgical treatment of severe dystrophic kyphoscoliosis in neurofibromatosis type I is an avenue to properly visualize the spinal cord, achieve solid arthrodesis, and to minimize as well as prevent the progression of deformity.

Gertzbein and Load Sharing Classifications for Unstable Thoracolumbar Fractures

From 1996 to 1998, 30 consecutive patients with Level 1 thoracolumbar spinal injury were classified and treated according to the Gertzbein classification and the load sharing classification. A posterior short segment pedicle screw implant was used in 21 patients; anterior decompression with strut grafting and application of the Kaneda device was used in three patients; and six patients were treated with short posterior instrumentation and an anterior strut graft. The average followup was 32 months (range, 24-50 months). The clinical outcome was satisfactory in 22 of 30 patients. Five of nine patients had neurologic improvement. Radiographic imaging findings showed a slight loss of reduction, but the clinical outcome of the patients was not affected. No pseudarthrosis and no implant failures were recorded. The Gertzbein classification correlates the type of fracture with the degree of mechanical instability and neurologic lesion. The load sharing classification correlates fracture comminution and displacement with mechanical stability and implant failure. Patient selection is a fundamental component for a successful outcome. The best candidates for surgery are cooperative patients who require spinal mobility, patients who are able to tolerate a two-stage reconstruction, and patients in good general health.

Use of a Noninvasive Halo in Pediatric Spine Surgery

A halo vest with pins in the skull is the gold standard for providing maximum immobilization and control of the cervical spine. Inherent complications include infection, scarring, penetration of the cranial vault, and pin loosening. Other less invasive orthoses provide significantly less immobilization and control of the cervical spine. A pinless halo (Figures 1–4) has been developed with the goal of providing cervical spine immobilization and control approaching the standard halo in a less invasive fashion. This noninvasive halo holds the head with pads on the forehead and occiput connected through a universal joint to an adjustable vest. This study evaluates the use of this device in the management of a variety of pediatric cervical spine disorders.Figure 1: Anterior view rotated and laterally flexed.Figure 2: Posterior view.Figure 3: Oblique view.Figure 4: Anterior rotated view.MATERIALS AND METHODS Twelve patients with a variety of pediatric cervical spine disorders have been treated at our institution with the Lerman Noninvasive Halo since 1997. A retrospective chart review was performed to determine the effectiveness of the halo and its complications. The age of the patients, underlying conditions, surgical procedures, duration in the halo, and complications directly related to the halo were recorded. The use of the halo was considered a success if the patient tolerated its use for the duration of the planned therapy with the desired effect. RESULTS Twelve patients ages 2 to 16 years were treated with the noninvasive halo (Table 1). One patient initially failed treatment with a standard halo after pin site loosening and skin necrosis and was successfully transitioned to the noninvasive halo. There were compliance issues with this patient because the family removed the noninvasive halo vest without consequence. Complications directly related to the brace were seen in 3 of the 12 patients. Two patients experienced facial swelling and skin breakdown early in their course of treatment and were converted to a standard halo. Both of these patients were under 4 years of age. Another patient was immobilized postoperatively after anterior-posterior cervical fusion with anterior strut graft. The graft migrated anteriorly, which was thought to be the result of motion in the sagittal plane. The remaining 9 patients experienced no complications related to the halo. Treatment was considered a success in eight of these patients.Table 1: Patients placed in noninvasive haloDISCUSSION The noninvasive halo successfully controlled rotation and lateral bending of the cervical spine. It was quite successful in positioning the head and neck of patients with congenital muscular torticollis after sternocleidomastoid release, and in the gentle and safe reduction of C1–C2 rotatory subluxation. Use of the noninvasive halo for small children under 4 years of age led to facial soft tissue problems in 2 of 4 children. We do not recommend the noninvasive halo after structurally unstable cervical fusion, because an anterior strut graft migrated in one child. We suspect that the migration was secondary to flexion/extension motion greater than that permitted in a standard halo. The noninvasive halo has also been well tolerated after cervical spine fusion with stable constructs for a variety of conditions. INDICATIONS Positioning of structurally stable fusion. Salvage after complications of standard halo immobilization. Postoperative positioning following sternocleidomastoid release for congenital muscular torticollis. Reduction of C1–C2 rotatory subluxation. CONTRAINDICATIONS Immobilization of structurally unstable cervical spine.