Combined Anteroposterior Approach Research Articles

Predictors of failure after primary anterior cervical discectomy and fusion for subaxial traumatic spine injuries

IntroductionTraumatic subaxial fractures account for more than half of all cervical spine injuries. The optimal surgical approach is a matter of debate and may include anterior, posterior or a combined anteroposterior (360º) approach. Analyzing a cohort of patients initially treated with anterior cervical discectomy and fusion (ACDF) for traumatic subaxial injuries, the study aimed to identify predictors for treatment failure and the subsequent need for supplementary posterior fusion (PF).MethodsA retrospective, single center, consecutive cohort study of all adult patients undergoing primary ACDF for traumatic subaxial cervical spine fractures between 2006 and 2018 was undertaken and 341 patients were included. Baseline clinical and radiological data for all included patients were analyzed and 11 cases of supplementary posterior fixation were identified.ResultsPatients were operated at a median of 2.0 days from the trauma, undergoing 1-level (78%), 2-levels (16%) and ≥ 3-levels (6.2%) ACDF. A delayed supplementary PF was performed in 11 cases, due to ACDF failure. On univariable regression analysis, older age (p = 0.017), shorter stature (p = 0.031), posterior longitudinal ligament (PLL) injury (p = 0.004), injury to ligamentum flavum (p = 0.005), bilateral facet joint dislocation (p < 0.001) and traumatic cervical spondylolisthesis (p = 0.003) predicted ACDF failure. On the multivariable regression model, older age (p = 0.015), PLL injury (p = 0.048), and bilateral facet joint dislocation (p = 0.010) remained as independent predictors of ACDF failure.ConclusionsACDF is safe and effective for the treatment of subaxial cervical spine fractures. High age, bilateral facet joint dislocation and traumatic PLL disruption are independent predictors of failure. We suggest increased vigilance regarding these cases.

Evolution of patient-reported outcome measures, 1, 2, and 5 years after surgery for subaxial cervical spine fractures, a nation-wide registry study

BACKGROUND CONTEXTA longer duration of patient follow up arguably provides more reliable data on the long-term effects of a treatment. However, the collection of long-term follow up data is resource demanding and often complicated by missing data and patients being lost to follow up. In surgical fixation for cervical spine fractures, data are lacking on the evolution of patient reported outcome measures (PROMs) beyond 1-year of follow up. We hypothesized that the PROMs would remain stable beyond the 1-year postoperative follow up mark, regardless of the surgical approach. PURPOSETo assess the trends in the evolution of patient-reported outcome measures (PROMs) at 1, 2-, and 5-years following surgery in patients with traumatic cervical spine injuries. STUDY DESIGNNation-wide observational study on prospectively collected data. PATIENT SAMPLEIndividuals treated for subaxial cervical spine fractures with anterior, posterior, or combined anteroposterior approaches, between 2006 and 2016 were identified in the Swedish Spine Registry (Swespine). OUTCOME MEASURESPROMs consisting of EQ-5D-3Lindex and the Neck Disability Index (NDI) were considered. METHODSPROMs data were available for 292 patients at 1 and 2 years postoperatively. Five-years PROMs data were available for 142 of these patients. A simultaneous within-group (longitudinal) and between group (approach-dependent) analysis was performed using mixed ANOVA. The predictive ability of 1-year PROMs was subsequently assessed using linear regression. RESULTSMixed ANOVA revealed that PROMs remained stable from 1- to 2-years as well as from 2- to 5-years postoperatively and were not significantly affected by the surgical approach (p<0.05). A strong correlation was found between 1-year and both 2- and 5-years PROMs (R>0.7; p<0.001). Linear regression confirmed the accuracy of 1-year PROMs in predicting both 2- and 5-years PROMs (p<0.001). CONCLUSIONPROMs remained stable beyond 1-year of follow up in patients treated with anterior, posterior, or combined anteroposterior surgeries for subaxial cervical spine fractures. The 1-year PROMs were strong predictors of PROMs measured at 2, and 5 years. The 1-year PROMs were sufficient to assess the outcomes of subaxial cervical fixation irrespective of the surgical approach.

Surgical Approach to Cervical Fractures in Ankylosing Spondylitis Patients: Rationale and Surgical Strategy

Current literature lacks objective criteria to determine surgical management in patients with ankylosing spondylitis who sustain cervical fractures. The purpose of our study was to analyze the determinants for stratifying surgical approach, evaluate the outcome in patients, and postulate a management strategy. This was a retrospective study of patients with ankylosing spondylitis who underwent surgery for cervical spine injury with a minimum follow-up of 2 years. Neurological recovery, fracture pattern including translation and angulation, surgical duration, blood loss, and postoperative complications were recorded, and a comparative analysis of these factors with anterior, posterior, and combined surgical approaches was performed. The study included 43 men with a mean age of 57 years; 49% underwent anterior-only stabilization, 16% underwent posterior-only stabilization, and 35% underwent combined anteroposterior stabilization. Mean operative time was significantly lower in anterior-only (81.4 minutes; P < 0.05) and posterior-only (124 minutes; P < 0.05) approaches compared with combined approach (266.6 minutes). Mean blood loss was significantly lower in anterior-only (87.5 mL, P < 0.05) approach compared with posterior-only (714.7 mL) and combined (912.7 mL) approaches. Mean translation was 1.8 mm, 1.7 mm, and 3.7 mm in anterior, posterior, and combined approaches (P < 0.05), respectively. Our study provides insights into management of cervical spine fractures in ankylosing spondylitis patients. A fracture displacement ≤2 mm may be successfully managed by an anterior approach, while the posterior approach may be beneficial in similar fractures warranting instrumentation extending to the thoracic spine. All other fractures warrant a combined surgical approach.

Anterior To Psoas lumbar and lumbosacral combined with posterior reconstruction in Adult Spinal Deformity: A bicentric European study

IntroductionLateral lumbar fusion via the trans-psoas approach is popular in adult deformity reconstruction. To overcome its limitations (neurological damage to the plexus and lack of applicability to the lumbosacral junction), a modified anterior-to-psoas (ATP) approach has been described and used. Research questionTo investigate the results of ATP lumbar and lumbosacral fusion, in a cohort of adult patients treated with combined anteroposterior approaches for adult spinal deformity (ASD). Materials and methodsASD patients surgically treated at two tertiary spinal centres were followed up. Forty patients were treated with combined ATP and posterior surgery: 11 with open lumbar lateral interbody-fusions (lumbotomy LLIF) and 29 with lesser invasive oblique lateral interbody-fusions (OLIF). Preoperative demographics, aetiology, clinical characteristics, and spinopelvic parameters were comparable between the two cohorts. ResultsAt a minimum 2-year follow-up, both cohorts showed significant improvements in patient reported outcome measures (PROMs), i.e. Visual Analogue Scale and Core Outcome Measures Index, as well as radiological parameters, with no significant differences based on the type of surgical approach. No significant differences were found in major (P ​= ​0.457) and minor (P ​= ​0.071) complications between the two cohorts. Discusson and conclusionAnterolateral lumbar interbody fusions, whether performed via a direct or oblique approach, proved to be safe and effective adjuvants to posterior surgery in patients with ASD. No significant complication differences were noted between techniques. In addition, the anterior-to-psoas approaches limited the risks of post-operative pseudoarthrosis by providing solid anterior support to lumbar and lumbosacral segments, demonstrating a positive impact on PROMS.

Combined anteroposterior approaches in lateral position treatment of lumbosacral tuberculous in single-stage

BackgroundThe local anatomy of the lumbosacral region of spine is complicated, with special biomechanical characteristics. For surgical management of tuberculous spondylitis reported in the literature, the methods would be two-stage anterior and posterior approaches or one-stage anterior and posterior approach with patient’s intraoperative position being changed. These types of surgery approaches would result in long operative duration and more intraoperative blood loss, and most important there is no coordination between anterior and posterior procedures.MethodsThe purpose of this study was to introduce a new procedure called in the lateral position single -stage combined anteriorposterior approaches for treatment of lumbosacral tuberculous spondylitis and to evaluate its preliminary surgical outcomes. Fifteen patients with lumbosacral tuberculous spondylitis who underwent single-stage anterior and posterior radical focal debridement and reconstruction in lateral position in our hospital from April 2005 to June 2012 were included in the study. There were 6 males and 9 females with the average age of 46.8 years. The tuberculous lesions involved the following regions: L3-4 in 5cases, L4-5 in 5 cases, L5-S1 in 2 cases, L4 in one case, and L5 in 2 cases. The assessment of surgical outcomes was conducted with clinical symptoms and radiological findings,including operative time, blood loss. deformity angle, Frankel grade and Kirkaldy-Willis evaluation.ResultsOperation posture: The right lateral position was used for 11 patients and the left lateral position was used for the remaining 4 patients. The average duration of operation for the 15 patients was 270 min. The average intraoperative blood loss was 1720 ml. The mean follow-up period was 4.2 years. There was no recurrence. The postoperative radiological findings showed that the interbody bone grafts were fixed without any dislodgment. There was significant difference between preoperative and postoperative lumbosacral lordotic angles. Kirkaldy-Willis classification rating for the 13 cases with satisfactory results.ConclusionSingle-stage combined anterior and posterior surgical management of lumbosacral tuberculous spondylitis with patient in lateral position can achieve radical focal debridement, anterior and posterior procedure coordination and spinal reconstruction.

Surgical Management of Paediatric Thoracolumbar Tuberculosis by a Combination of Anterior and Posterior Versus Posterior Only Approach: A Systematic Review and Meta-Analysis.

Systematic Review and Meta-analysis. This systematic review and meta-analysis is aimed to assess effectiveness, safety, clinical, functional and radiological outcome of either combined anteroposterior or posterior-only approach in the surgical management of active tubercular disease of paediatric thoracolumbar spine. A systematic literature search through PubMed, Scopus, Web of Science and Cochrane Library database was performed. Data extraction was undertaken following methodological quality assessment. 9 out of the 182 publications identified, were included for analysis. A total of 247 patients were analysed. Two amongst the 9 studies were retrospective comparative studies evaluating posterior approach with combined anteroposterior approach and were considered for comparative meta-analysis. Blood loss and duration of surgery was significantly higher in the anteroposterior group, as compared to the posterior-only group. There was no significant difference between the 2 groups in terms of post-operative kyphosis angles, final kyphosis angles, number of complications, functional outcome and spinal fusion time. However, all the included studies were non-randomised and retrospective. Only 2 of them had a control group with a high heterogeneity amongst these 2 studies. The inference from the studies included in this review suggests that equivalent results can be achieved with posterior-only approach for thoracolumbar tuberculosis in children as compared to anteroposterior approach, with much lower complexity, reduced blood loss and shorter surgical time. However, due to the high risk of bias and considerable heterogeneity among the studies included, we cannot conclude whether one approach is better than the other.

Safety and efficacy of posterior vertebral column resection in complex pediatric deformities

BackgroundVertebral column resection (VCR) is a well-known technique used for correction of complex spinal deformities. VCR could be done through a posterior only approach (Pvcr), or a combined anteroposterior approach, with almost comparable results. Early studies of Pvcr have reported high rates of complications, while subsequent studies have reported a reasonable complication rate. In this study, the authors represent and evaluate the initial results of using the Pvcr technique to correct complex pediatric deformities.ObjectiveTo evaluate the safety and efficacy of performing Pvcr to correct complex pediatric deformities.MethodsRetrospective cohort study of data was collected from the database of pediatric deformity patients who were operated for correction of their deformities using posterior instrumentation and Pvcr at a single institution from 2015 to 2019.ResultsTwenty-one pediatric patients with a mean age 15.2 ± 3.5 years were enrolled in this study. The mean follow-up period was 26.3 ± 3.1 months. The mean Cobb angle has been decreased significantly from 82.9 ± 23.9 degrees to 28.8 ± 14.2 immediately after correction (correction rate 66.9 ± 10.8%, p < 0.001) with slight increase to 30.2 ± 14.9 after 24 months of follow-up (correction loss 4.3 ± 3.1%). The mean kyphotic angle has decreased significantly from 74.1 ± 15.9 to 25.4 ± 4.5 immediately after correction (correction rate 65.4 ± 2.9%, p < 0.001) with slight increase to 26.7 ± 5.2 after 24 months of follow-up (correction loss 4.8 ± 3.5%). The mean estimated blood loss was 2816.7 ± 1441.5 ml. The mean operative time was 339 ± 84.3 min. Self-image domain (part of SRS-22 questionnaire) has significantly improved from a mean preoperative of 2.3 ± 0.5 to a mean postoperative of 3.9 ± 0.4 after 24 months of correction (p < 0.001). As regards complications, chest tubes were inserted in 17 cases (81%), one case (4.8%) had suffered from deep wound infection and temporary respiratory failure, while 3 cases (14.3%) had neurological deficits.ConclusionPosterior vertebral column resection is considered a highly effective release procedure that aids in the correction of almost any type of complex pediatric deformities with a correction rate reaching 66.9 ± 10.8%. However, Pvcr is a challenging procedure with high estimated blood loss and risk of neurological deficits, so it must be done only by experienced spine surgeons in the presence of good anesthesia and neuromonitoring teams.

Outcomes Of The Combined Anteroposterior Approach For Forequarter Amputation In Shoulder Girdle Tumours.

Forequarter amputation (FQA) is the surgical treatment of choice for tumours in the upper extremity and shoulder girdle that infiltrate the neurovascular bundle, shoulder joint and muscles of the shoulder girdle in non-salvageable cases. In both curative and palliative settings, FQA can serve as an effective oncological treatment for local control of tumour. All patients who underwent FQA in our unit from January 2016 till August 2019 for oncological indications were included in our study and their clinical outcomes were calculated. Thirteen patients were included in the study including 8 male patients. Mean age of patients at surgery was 20 years (Range 10-53 years) with a minimum follow up of 6 months or till patient was deceased earlier. Six patients had primary osteosarcoma, 4 had Ewing's sarcoma, 2 had Spindle cell sarcoma while 1 had Giant cell tumour. Six patients underwent surgery with curative intent. No major per operative complication was encountered in any of the cases with a mean blood loss of 350 ml and mean duration of surgery being 75 minutes. At last, follow up only 6 patients were alive, with 2 patients alive with disease (Metastasis) and undergoing palliative treatment. None of our patients had local recurrence. Mean survivorship for the whole cohort was 9.2 months (Range 3-18 months) with a mean survivorship for the deceased group was 7.1 months (Range 3-16 months) and mean survivorship for alive patients was 11.6 months (range 9-18 months). All the alive patients had phantom limb sensations and only one had a prosthesis in place only for cosmetic reasons, at last follow up. Although FQA is a significantly body disfiguring procedure, but in large tumours of shoulder girdle, this is a viable option for local control of the disease. Based on our study, although relatively small sample size, we propose the combined anteroposterior approach to be safe and reliable for advanced shoulder girdle tumours.

Total sacrectomy with a combined antero-posterior surgical approach for malignant sacral tumours

PurposeTo investigate the indications, approaches, resection methods, and complications of total sacrectomy with a combined antero-posterior approach for malignant sacral tumours.MethodsFourteen cases of primary malignant sacral tumours treated with total sacrectomy between January 2012 and 2018 were retrospectively analysed. All patients presented with pre-operative lumbosacral pain or constipation. A combined antero-posterior approach was used for tumour resection, and the spinal pedicle screw rod system was used to achieve ilio-lumbar stability. The visual analogue scale (VAS) and Musculoskeletal Tumor Society (MSTS) scores were used to assess pain and lower limb function, respectively. The mean operative time and intra-operative blood loss were 6.54 hours and 2935 mL, respectively. The mean follow-up period was 62 months.ResultsNone of the patients died peri-operatively. At the last follow-up, ten patients were continuously disease-free, three were alive with disease, and one died of disease from lung metastasis. Tumour recurrence occurred in three patients. The MSTS scores ranged from 6 to 28 (20.00–93.33%, 6/30–28/30) with an average of 20 (66.67%, 20/30). Seven patients could walk independently in public, five could only walk at home using a walking aid, and two could only lie down and stand for a short time. Thirteen patients developed post-operative complications such as skin necrosis, screw loosening, connecting rod fracture, neuropathic pain, sciatic nerve injury, dysuria, and urinary incontinence.ConclusionTotal sacrectomy can effectively treat malignant sacral tumours with good resection boundaries and prognosis. However, the high incidence of post-operative complications may impact post-operative neurological function.

Haematogenous Spondylodiscitis in Patients With Liver Cirrhosis: Case Series of 36 Patients.

A retrospective study of 36 liver cirrhosis patients presenting with spondylodiscitis. The aim of this study was to analyze the characteristics of spondylodiscitis in the presence of liver cirrhosis and furthermore, to evaluate the outcome of surgery in this specific group of patients. The incidence of haematogenous spondylodiscitis is increasing. The coexistence of liver cirrhosis makes the course of the disease more aggressive. A total of 36 liver cirrhosis patients presented with haematogenous spondylodiscitis. The onset of infection, clinical course and outcomes of management were reviewed retrospectively. The associated comorbidities were cardiac in 17 patients, diabetes in 19, renal insufficiency in 16, and another focus for infection in nine cases. Neurological deficits were found in 24 patients (67%) and fever in 15 cases. Nine patients had septic manifestations. The lumbar spine was affected in 25 patients (69%). Noncontiguous spinal infection was found in nine patients (25%) and epidural abscess in 24 individuals. The preoperative C-reactive protein was elevated in all cases. The causative organism was most commonly Staphylococcus aureus (17 patients). A combined anteroposterior approach was necessary in 28 patients and a minimallly invasive surgery was performed in 30 cases. In-hospital mortality was 14% (5 patients). The neurological improvement rate was 82%. The postoperative antibiotic therapy was taken for more than 8 weeks in 22 patients. In 15 patients, a combination of antibiotics was necessary. Spinal infection in the presence of liver cirrhosis is challenging. The rate epidural abscess formation is relatively high. Early diagnosis remains the main cornerstone in the management and the indication for surgery should be carefully considered. Minimally invasive techniques should be used when possible to minimize complication rate, and higher amounts of intraoperative blood loss should be expected. 4.

Surgical treatment of traumatic thoracolumbar fractures: a retrospective review of 101 cases.

To evaluate the outcomes of vertebral stabilisation after acute traumatic thoracolumbar fractures, correlating the outcome with patient clinical data, type and location of fracture, presence of neurological damage, timing of surgical intervention and number of instrumented levels. The results have been evaluated also through the AO classification and AOSIS score. Retrospective analysis of 101 patients with traumatic thoracolumbar injuries from T3 to L5 operated 2011-2016 by posterior or antero-posterior fixation. The demographic data, trauma dynamics, number and type of fractures, associated lesions, timing of surgery, hospital stay, AOSIS score, RKA, SF-36 and ODI scores, pre- and post-operative neurological condition (ASIA grade), possible complications and re-interventions were evaluated for each patient. Fractures mainly involved the region between T11 and L2. The probability of medullary involvement increases with the increase in severity of the main fracture type with no relation with the vertebral region. Type B and C fractures were common in the thoracic region and rare in the thoracolumbar junction. ODI and SF-36 scores were significantly better in patients with a lower AOSIS score, specifically in lesions classified as type A, amyelic and with no comorbidity. No difference was found in the clinical scores between thoracic, thoracolumbar and lumbar fractures, nor between male and female patients. None of the 10 patients with ASIA A lesion at presentation achieved any degree of recovery: 50% of them had a thoracic lesion. Re-intervention rate was 15%. Hospital stay was significantly higher in patients with type C fractures, and complication rate was on average 14% (7% in type A fractures, 16% in B and 25% in C). This study confirmed the validity of the posterior approach in the surgical treatment of thoracolumbar fractures. Outcomes and complication risks are related to fracture severity. Surgical treatment can be recommended even with an AOSIS score of two or three. The combined antero-posterior approach could be useful in cases with LSC > 8, especially in the thoracolumbar region. The degree of neurological recovery depends on fracture type, location, ASIA score and presence of comorbidities. Early intervention in myelic patients allows for a better prognosis. Level of evidence III retrospective case series.

Revisiting the surgical corridors for cervical Type IIb-c dumbbell neurofibroma: A series of two unconventional approaches and review of literature.

Background:Cervical sub-axial dumbbell neurofibromas (NFs) account for nearly 20% of all NFs, with prognosis depending on the extent of excision. When majority of tumor is extra-foraminal (Tomaya's Type IIb and c), certain unconventional anterolateral or posterolateral neck approaches are used for maximum safe excision. In our article, we provide a brief review of the literature regarding various surgical approaches, emphasizing the utility of posterolateral or combined anterior and posterior neck approaches for such giant NF.Methods:We performed a retrospective analysis of prospectively maintained surgical databases, from our hospital discharge codes, for all cervical Type IIb-c dumbbell NF patients, who underwent surgery at our institution between 2015 and 2019. Clinical variables included age at admission, clinical presentation, and surgical difficulties, and the outcome was analyzed.Results:Four patients of age ranging from 22 to 45 years (M:F 3:1) were operated by posterolateral (n = 3) and combined anteroposterior (n = 1) approach. Three patients underwent near-total excision and one patient had total excision. One patient with tumor capsule attached to roots of upper brachial plexus had motor deficit, who was re-admitted for neurotization. There was no intraoperative complication.Conclusion:Posterolateral approach for cervical dumbbell giant NFs is safe, effective, and promises maximum safe excision. The major blood vessels including carotid artery or jugular veins in neck and vertebral artery at foraminal portion are directly under vision and control of surgeon. Despite near-total excision, wherein small part of adhered capsule is left, recurrence rate is low.

Friday, September 28, 2018 9:00 AM–10:00 AM best papers Friday: 152. Anterior reconstruction provides better outcomes when correcting mild flexible cervical deformity

BACKGROUND CONTEXT The correction of mild flexible cervical deformity (CD) can be addressed through different surgical approaches. Each approach results in a unique complication profile, but the capacity for realignment of the cervical spine in mild flexible CD has not previously been evaluated. We aimed to determine whether an anterior, posterior, or combined anteroposterior approach in this setting resulted in different clinical or radiographic outcomes. PURPOSE To determine whether an anterior approach utilized for correction of mild flexible CD results in better clinical and radiographic outcomes, when compared to posterior or combined anteroposterior approaches. STUDY DESIGN/SETTING Retrospective review of prospective, multicenter CD database. PATIENT SAMPLE A total of 121 operative CD patients. OUTCOME MEASURES Radiographic parameters, HRQOLs (NDI, NRS, dysphagia), complications, reoperations, OR time, length of stay, estimated blood loss. METHODS A prospective database of operative cervical deformity patients was analyzed. Inclusion criteria were cervical kyphosis>10˚, cervical scoliosis>10˚, cSVA>4cm or CBVA>25˚. Mild cervical deformity was defined by cSVA of 3-5cm and/or kyphosis of 5° on preop flexion or extension radiographs. Groups were categorized by anterior (A), posterior (P), and anteroposterior (AP) approach, and 1-way ANCOVA was utilized to compare radiographic, operative, and clinical outcomes, while controlling for cSVA and TS-CL Statistical significance set at p RESULTS A total of 121 patients met inclusion and with similar avg age and female predominance in each group. Preop cSVA (45.3; 39.3mm vs. 26.1mm; p CONCLUSIONS The anterior approach for mild flexible cervical deformity resulted in greater C2-7 lordosis and better C2S, while leading to a lower NDI in comparison to the posterior approach alone. EBL and OR time were also lower with the anterior approach, while all approaches had similar rates of complications and reoperations.

Treatments and prognoses for spinal giant cell tumors recurrence after total spondylectomy

Objective To investigate the treatment and prognosis of spinal giant cell tumors recurrence after total spondylectomy. Methods Between February 2001 and February 2016, five female patients suffered from spinal giant cell tumors recurrence after total spondylectomy were retrospectively analyzed. They underwent total spondylectomy with an age ranging from 17 to 63 years old (average 32.6 years). Four cases were primary cases and 1 was recurrent case at the first time of visit. Tumors were located in the thoracic vertebrae in 3 cases, including 1 case in T10 and 2 cases in T11. Tumors were involved in lumbar vertebrae in 2 cases, which were L2 and L5, respectively. According to Tomita spinal tumor classification, all cases were type 5. The Frankel classification for spinal cord injury was grade A in 1 case, grade C in 1 case, grade D in 1 case and grade E in 2 cases. Reoperation was introduced to treat the recurrent tumors after total spondylectomy with adjuvant radiotherapy and drug. The effect of tumor therapy, postoperative complications, nerve function and so on were observed in follow-up. Results One patient was treated with total en bloc spondylectomy (TES) and 4 patients was treated with piecemeal total spondylectomy. The operative approach was one-stage posterior approach in 4 patients and combined antero-posterior approach in 1 patient. One patient received radiotherapy and 1 patient was treated with bisphosphonate post operation. The spinal cord function recovered to grade D in 1 patient and grade E in 4 patients. The average interval of recurrence after total spondylectomy was 12-57 months (average 29.6 months). At the second visit, the Frankel classification was grade C in 1 patient. Grade D and grade E were in 2 patients, respectively. Three patients were treated with reoperation to resect the tumors. One patient received radiotherapy and another one was untreated. All 5 patients were followed up with 47-196 months (average 108 months). Four patients survived without tumor and 1 patient without treatment for recurrence survived with tumor. Two patients occurred internal fixation fractures were treated with revision surgery. One of the patients had postoperative spinal canal infection and was cured after internal fixation removal, irrigating and drainage, and antibiotic treatment. The loosening screw in 1 patient was fixed again. Two patients suffered from obvious titanium mesh subsidence (>5 mm). In the last follow-up, there were 1 patients with Frankel grade A, 1 with grade D and 3 with grade E. Conclusion Active reoperation combined with radiotherapy and drugs therapy can significantly improve the prognosis of patients with recurrent spinal giant cell tumors after total spondylecmy. Key words: Spine; Giant cell tumor of bone; Recurrence; Reoperation

Arthroscopic anatomical reconstruction of anterior talofibular ligament and calcaneofibular ligament for chronic ankle instability

Objective To compare the clinical efficacy of anteroposterior approach (APA) versus anterior approach (AA) for decompression, fusion and fixation for single-level unstable thoracolumbar vertebrae fractures concomitant with incomplete neurologic symptoms and injury to posterior ligament complex (PLC). Methods From February 2006 to June 2012, 55 patients were treated for single-level unstable thoracolumbar vertebrae fractures.Of them, 27 were treated by only anterior decompression and lateral screw-rod instrumentation and 28 by anterior decompression and fusion combined with open posterior pedicle fixation of one to two segments above and below the fracture position. The 2 groups were compared at post-operative 3 and 12 months in terms of visual analogue scale (VAS), overall score of short-form health survey (SF-36), Japanese Orthopaedics Association (JOA) score of lower back, Oswestry disability index (ODI), loss ratio of anterior margin of vertebral height, endplate angle of kyphotic deformity of superior-inferior adjacent vertebrae, wedge angle of fractured vertebra via radiographic measurement and canal compromise rate. The neurologic functional recovery was analyzed using the American Spine Injury Association (ASIA) evaluation system at postoperative 12 months. Results There were no significant differences in operative time, amount of blood loss or postoperative drainage between the 2 groups (P>0.05). At postoperative 3 months, the VAS and JOA scores in the APA group were significantly better than those in the AA group (P 0.05). All the comparative indexes were significantly improved than the preoperative values in all the patients in the 2 groups at both 3 and 12 months (P<0.05). Conclusions Compared with the merely anterior approach, the combined antero-posterior approach may have advantages of better immediate and persistent reduction, steadily rebuilding fractured alignment, continuously maintaining injured biomechanical stability, and obviously improving neurological function.As the antero-posterior approach allows for combination of posterior auxiliary reduction and fixation with anterior definitive support and decompression, it may lead to a safe and effective treatment of unstable single-level thoracolumbar fracture concomitant with incomplete neurologic and PLC impairments. Key words: Thoracic vertebrae; Lumbar vertebrae; Fracture, bone; Fracture fixation, internal; Surgical approach

Surgical Treatment of Sacral Neurogenic Tumor: A 10-year Experience with 64 Cases.

To explore the outcomes of surgical treatment of sacral neurogenic tumors Between 1 January 2003 and 31 December 2012, data on 64 patients with sacral neurogenic tumors treated with surgery were retrospectively analyzed. The mean age of the 64 cases (35 males and 29 females) was 37.2 years (range, 21-69 years); 38 had neurilemmomas and 26 neurofibromas. Thirty-four of the tumors involved S 1 and S 2 , 11 S 3 or lower, and 19 were single presacral soft tissue masses. Tumors were removed via anterior, posterior or combined anteroposterior approaches. Patients with unstable sacroiliac joints underwent iliolumbar fixation. Depending on the extent of tumor involvement, one of three surgical approaches was used: a single anterior approach (19 patients), single posterior approach (25 patients), or a combined anteroposterior approach (20 patients). The mean operation time was 3 h (range, 2-6 h) and the mean blood loss 878 mL (range, 400-3120 mL). The mean duration of follow-up was 58.2 months (range, 24-93 months). These surgeries had the following complications. Three patients had massive intraoperative hemorrhage and posterior back pain and discomfort postoperatively. One patient had intraoperative ureteral injuries requiring intraoperative ureteral catheterization. In two patients, the tumor involved the S 1 nerve roots bilaterally, necessitating their removal, which resulted in obvious lower limb motion and sphincteric dysfunction. In 13 patients with unilateral tumor involvement of the nerve roots of S 1 and lower spinal levels, only the contralateral nerve roots of the S1 and lower levels were preserved; eight of these patients had impaired bladder and bowel function. Posterior incisions failed to heal in 10 patients, secondary wound healing occurred in nine of them and one required a gluteus maximus myocutaneous flap. Three patients developed postoperative cerebrospinal fluid leaks that were and alleviated by waist belt compression bandaging and placing them in the Trendelenburg position. Eight patients developed tumor recurrences postoperatively; pathological examination of the tissue excised in the second surgeries revealed malignant changes in the three patients with neurilemmomas. There were no intraoperative deaths. Rod fractures occurred in three of the 18 patients requiring iliolumbar reconstruction. The clinical characteristics of sacral neurogenic tumors make them easy to diagnose. The approach to resection should be determined by the location and size of the tumor. Patients with huge tumors may lose considerable blood intraoperatively and a have higher risk rate of postoperative complications.

En Bloc Resection of Primary Malignant Bone Tumor in the Cervical Spine Based on 3-Dimensional Printing Technology.

To investigate the feasibility and safety of en bloc resection of cervical primary malignant bone tumors by a combined anterior and posterior approach based on a three-dimensional (3-D) printing model. Five patients with primary malignant bone tumors of the cervical spine underwent en bloc resection via a one-stage combined anteroposterior approach in our hospital from March 2013 to June 2014. They comprised three men and two women of mean age 47.2 years (range, 26-67 years). Three of the tumors were chondrosarcomas and two chordomas. Preoperative 3-D printing models were created by 3-D printing technology. Sagittal en bloc resections were planned based on these models and successfully performed. A 360° reconstruction was performed by spinal instrumentation in all cases. Surgical margins, perioperative complications, local control rate and survival rate were assessed. All patients underwent en bloc excision via a combined posterior and anterior approach in one stage. Mean operative time and estimated blood loss were 465 minutes and 1290 mL, respectively. Mean follow-up was 21 months. Wide surgical margins were achieved in two patients and marginal resection in three; these three patients underwent postoperative adjuvant radiation therapy. One vertebral artery was ligated and sacrificed in each of three patients. Nerve root involved by tumor was sacrificed in three patients with preoperative upper extremity weakness. One patient (Case 3) had significant transient radiculopathy with paresis postoperatively. Another (Case 4) with C 4 and C 5 chordoma had respiratory difficulties and pneumonia after surgery postoperatively. He recovered completely after 2 weeks' management with a tracheotomy tube and antibiotics in the intensive care unit. No cerebrovascular complications and wound infection were observed. No local recurrence or instrumentation failure were detected during follow-up. Though technically challenging, it is feasible and safe to perform en bloc resection of cervical primary bone tumors. This is the most effective means of managing cervical spine tumors. Preoperative 3-D printing modelling enables better anatomical understanding of the relationship between the tumor and cervical spine and can assist in planning the surgical procedure.

Large desmoid-type fibromatosis of the shoulder girdle: operative approach selection and clinic outcome

Surgical resection of large desmoid-type fibromatosis (DTF) of the shoulder girdle is challenging. This article discusses the operative approach and evaluates the clinic outcome. Twenty-one cases between June 2003 and June 2012 were retrospectively reviewed. Eleven patients newly diagnosed and ten had previous operations. Mean tumour size was 10.5cm (range, 7.0-19.0cm). We divided the shoulder girdle into four regions; the adopted surgical resection was en bloc in 18 cases and piecemeal resection in three. In nine cases we took an anterior approach, ten a posterior approach and two a combined anteroposterior (AP) approach. Brachytherapy with permanent I(125) implantation was applied in all cases. All 21 patients were followed up for a mean of 49.8 (range, 18-136) months. Recurrence was seen in two patients, with the overall recurrence rate of 9.5%. The Musculoskeletal Tumour Score (MSTS) was between 56.7 and 96.7%, with the average at 78.9% and excellent-good rate 95.2%. Complications were found in three of the 21 patients (14.3%). Surgical resection with the precondition of preserving vital structure for large DTF of the shoulder girdle is necessary. According to our new partition, it was suitable to take an anterior approach when regions I or I + II were involved, posterior approach for regions II, III or II + III; combined AP approach when involving region I + II + III; and anterior or posterior approach for region IV, depending upon tumour location.

A single-stage single-surgical approach for the treatment of pyogenic spinal infection

Background Pyogenic spinal infection (PSI) is the most common cause of spinal infection, affecting mainly the vertebral body. Nonoperative treatment is associated with high failure and mortality rates, especially in patients with impaired immune system. There is debate as regards the most appropriate approach and whether to use an implant at the infected site immediately or to wait for a second stage after a period of antibiotic coverage and whether to use one or combined anteroposterior approaches. Objective The aim of this work was to study the results of single-stage debridement, bone graft and immediate internal fixation for PSI cases through one approach. Study design This study was a retrospective review of 23 cases of PSI. Patients and methods The medical records, haematological results, radiological imaging, bacteriology and biopsy results of 23 patients of PSI were reviewed. The posterior approach was used in cases of thoracolumbar infection and the anterior approach was used in cervical spinal cases. Patients were treated with single-stage debridement, bone autograft and immediate internal fixation through the same approach, followed by parenteral antibiotics for 4-6 weeks and oral antibiotics until normalization of the inflammatory markers with good clinical and radiological response. Functional results were assessed using the Oswestry disability index questionnaire and the physical function domain score of SF-36 questionnaire. Results All patients showed complete resolution of infection and achieved solid bony fusion in a sound position without chronicity, relapse or persistence of infection. All patients showed neurological recovery and returned to their preoperative activity with good functional outcome as evidenced by significant improvement in the preoperative Oswestry disability index mean score and the physical function domain score of SF-36 questionnaire. Conclusion Single-stage single-approach surgical debridement, interbody fusion using bone graft and immediate internal fixation, is a safe and effective treatment for PSI.

Long‐term outcome following surgical treatment of sacral chordoma

Sixteen sacral chordoma surgeries performed at a single institution during the 1983-2008 period were retrospectively studied. Our aim is to assess surgical treatment and long-term outcomes. Fifteen patients underwent primary wide excision, and one intralesional excision using ethanol for local control and radiation therapy (RT). A combined anteroposterior approach for large tumors above S2, and wide excision was performed with the modified threadwire-saw (MT-saw) after 1997. Fourteen of the 15 patients had wide margins, one a wide margin with contamination. The MT-saw was facilitated sacral excision with wide margins. Eleven patients are alive for 5-28 years. Five patients died before 10 years, two patients experienced sepsis, and one of another disease. Two patients died of local recurrence (LR) and another of multiple metastases after intralesional excision and wide excision with contamination, respectively. LR and complications occurred 4 each of 11 patients with tumors ≥ 10 cm, neither with tumors < 10 cm. The overall 5- and 10-year survival rate with wide surgical margins was 13/16 (81.3%) and 8/13 (61.5%). A combined anteroposterior approach for large tumors, and the MT-saw facilitates sacral excision with wide margins. Wide excision is recommended for younger patients.