Correction Of Kyphotic Deformity Research Articles

Single-Stage Transpedicular Approach for Circumferential Arthrodesis in Traumatic Lumbar Vertebral Body Burst Fractures

Abstract Background Traumatic vertebral burst fractures can be surgically approached via different approaches (anterior/posterior, or combined). Posterior transpedicular approach (PTA) is a posterior approach that has the advantage of achieving circumferential arthrodesis via single posterior-only approach. The purpose of this study was to analyze our experience with PTA in management of traumatic lumbar burst fractures (TLBFs). Methods All consecutive patients with TLBFs managed with PTA over 3 years’ duration were included in this retrospective study. Correction of kyphotic deformity and change in neurologic status were analyzed to assess outcome. Cobb’s angle and American Spinal Injury Association (ASIA) grade were used for this purpose. Results There were 12 males and 8 females. Five patients had complete (ASIA-A) while 12 had incomplete injury. The mean preoperative Cobb’s angle was 14.23 degrees that improved to–3.21 degrees postoperatively (mean kyphosis correction: 17.44 degrees). None of the patients developed iatrogenic nerve root injury. There was no perioperative mortality. The mean Cobb’s angle was 1.45 degrees at 36 months’ follow-up. Four patients developed cage subsidence but none required revision surgery. Postoperatively, 13 (65%) patients showed neurologic improvement and none deteriorated. The average ASIA score improved from 2.82 to 4.23. A fusion rate of 96% was observed at last follow-up. Conclusion The advantages of PTA including sense of familiarity with posterior approach among spine surgeons, lesser approach-related morbidity, and results comparable to anterior/combined approaches, make the PTA an attractive option for managing TLBFs. Although technically difficult, it can be successfully used for circumferential arthrodesis in the lumbar region without sacrificing nerve roots.

Evaluation of correction of kyphotic deformity in dorso-lumbar spinal injuries by posterior stabilization with pedicular screw rod fixation

<p class="abstract"><strong>Background:</strong> Acute injury to dorso-lumbar spine is the second most frequent site after cervical spine in adults. The injury, although not associated with high mortality, causes severe morbidity. The management of the traumatic dorso-lumbar spine injuries has improved considerably in the last few years. The objective of the study was to evaluate correction of kyphotic deformity in dorso-lumbar spinal injuries by posterior stabilization with pedicular screw rod fixation.</p><p class="abstract"><strong>Methods:</strong> The study includes 52 patients with dorso-lumbar spinal injuries with or without neurological deficit treated between 2006 and 2014. Pre and postoperative kyphosis was measured by Cobb’s method on plain radiographs. Pre and postoperative neurological status was evaluated based on Frankel’s classification. All un-stable dorso-lumbar spine injuries where two or more columns are involved on X-ray and CT scan were included in the present study.<strong></strong></p><p class="abstract"><strong>Results:</strong> Majority of the patients were in the age group of 20-30 years (38.5%) followed by 31-40 years (30.8%). Males were more than females. The most common mode of injury was road traffic injury in 71.2% of the cases. The most common level of injury was at L1 in 28.8% of the cases followed by at level D12 in 25% of the cases. In all the groups the mean kyphosis angle is reduced significantly. Overall the improvement rate was 94.2% and failure rate was only 5.8%.</p><p><strong>Conclusions:</strong> In conclusion the posterior reduction and internal fixation is a useful procedure in the treatment of the acute injuries of the dorsolumbar spine. </p>

Surgical treatment of severe congenital kyphosis in an adult patient: rare clinical observation and a brief literature review

The paper presents a clinical case of surgical treatment of an adult patient with severe rigid congenital kyphosis developed due to multiple anomalies in the thoracolumbar spine. Surgical intervention included vertebral column resection (VCR) and the deformity correction using segmental third-generation instrumentation with transpedicular fixation. The VCR made it possible to correct the relationship between vertebrae in the anomaly zone, to improve the shape of the spinal canal and increase its volume, and to achieve apparent mobility of the spine at the apex of the kyphosis. Preservation of the anterosuperior portion of the body of the resected vertebra allowed avoiding anterior mesh cage use to support and reconstruct the anterior supporting column of the resected segment. This enabled performing necessary correction of severe kyphotic deformity, reduced the risk of neurological complications, and favored the formation of solid bone block in the long-term period after surgery.

Le mystère Blutch

Spinal osseous tuberculosis, or Pott's spine, although very common in endemic countries, has a lower incidence in very young children. However, the infection has the propensity to cause greater vertebral destruction in this age group, leading to severe structural kyphotic deformity and associated neurologic deficits. We report the case of a 19-month-old child with severe tubercular kyphotic deformity of the upper thoracic spine managed with posterior vertebral column resection (VCR) and nonfusion posterior pedicle screw instrumentation.This 19-month-old boy presented with 1-month history of spontaneous-onset, progressive, painful rigid kyphotic deformity of the upper back associated with spastic paraparesis with bowel and bladder incontinence. Magnetic resonance imaging showed severe destruction of bodies of D4–D7 vertebrae with cord edema and draping of the spinal cord over the internal gibbus at D4–D7. Surgery was performed with a restricted anterior fusion via single-stage posterior VCR at D4–D7 with nonfusion pedicle screw instrumentation from D1 to D9, with subsequent extension of instrumentation to D10 after 4 months.Multilevel posterior VCR with a restricted fusion and nonfusion pedicle screw instrumentation beyond the resection site can be safely done in young children (age <3 years) requiring rigid tubercular kyphotic deformity correction. However, these patients require regular follow-up and may need multiple surgeries.

Impact of Screw Type on Kyphotic Deformity Correction after Spine Fracture Fixation: Cannulated versus Solid Pedicle Screw.

Study DesignRetrospective review.PurposeTo detect the effect of cannulated (poly-axial head) and solid (mono-axial head) screws on the local kyphotic angle, vertebral body height, and superior and inferior angles between the screw and the rod in the surgical management of thoracolumbar fractures.Overview of LiteratureBiomechanics studies showed that the ultimate load, yield strength, and cycles to failure were significantly lower with cannulated (poly-axial head) pedicle comparing to solid core (mono-axial head).MethodsThe medical charts of patients with thoracolumbar fractures who underwent pedicle screw fixation with cannulated or solid pedicle screws were retrospectively reviewed; the subjects were followed up from January 2011 to December 2015.ResultsTotal 178 patients (average age, 36.1±12.4 years; men, 142 [84.3%]; women, 28 [15.7%]) with thoracolumbar fractures who underwent surgery and were followed up at Hamad Medical Corporation were classified, based on the screw type as those with cannulated screws and those with solid screws. The most commonly affected level was L1, followed by L2 and D12. Surgical correction of the local kyphotic angle was significantly different in the groups; however, there was no significant difference in the loss of correction of the local kyphotic angle of the groups. Surgical correction of the reduction in the vertebral body height showed statistical significance, while the average loss of correction in the reduction of the vertebral body height was not significantly different. The measurement of the angles made by the screws on the rods was not significantly different between the cannulated (poly-axial head) and solid (mono-axial head) screw groups.ConclusionsSolid screws were superior in terms of providing increased correction of the kyphotic angle and height of the fractured vertebra than the cannulated screws; however, no difference was noted between the screws in the maintenance of the superior and inferior angles of the screw with the rod.

The rationale of surgical treatment in pediatric spine tuberculosis

Introduction: Extrapulmonary TB in pediatric patient affects the quality of life and must be considered seriously. Early surgical treatment is needed to eradicate infection, preserve the physis, and simultaneously correct the deformity. The aim of this study is to assess the efficacy of conservative treatment compared to early surgical treatment regarding neurological improvement, kyphotic correction, and pain relieve. Method: This is a retrospective case series. We reviewed 28 pediatric spine tuberculosis in Dr. Soetomo General Hospital Surabaya, Indonesia during year 2010-2012. All patients have received TB drugs and indicated for surgical treatment, yet the 15 patients did not provide parental consent. These were selected as non-surgical group. Thirteen patients obtained surgical treatment including bone graft, w/o instrumentation (surgical group). All clinical data were collected at the time of diagnosis and a year after treatment. The improvement of kyphotic (thoracic segments) was defined as narrowing of post-treatment Cobb’s angle. Conversely, lordotic improvement (cervical or lumbar segments) was defined as widening Cobb’s angle. Improvement of neurological status (Frankel classification) was analyzed using chi-square test. The deformity correction and pain relieved were analyzed using independent-samples t-test. All statistical analyses were conducted by SPSS-23. Result: VAS improvement was not significant. Frankle classification in the surgical group was significantly better. The kyphotic deformity correction was 0% (n=8) in the non-surgical group and, 57.1% (n=4) in the surgical group. There lordotic deformity correction was 74.1% (n=4) in non-surgical group and 83.3% (n=5) in surgical group. There is a significant difference of the kyphotic deformity correction between both groups. but no significant difference in lordotic correction. Conclusion: Surgical management showed better outcomes in the degree of correction (stopped and corrected the kyphosis progression), and also in the neurological improvement.

Management of Pediatric Posttraumatic Thoracolumbar Vertebral Body Burst Fractures by Use of Single-Stage Posterior Transpedicular Approach

The posterior transpedicular approach (PTA) is a posterior approach that has the advantage of achieving circumferential arthrodesis by a single posterior-only approach. The purpose of this study was to analyze our experience with PTA in the management of pediatric traumatic thoracolumbar burst fractures (TTLBFs). Consecutive pediatric patients (age ≤18 years) with TTLBFs treated with PTA for 6 years were included in this retrospective study. Correction of kyphotic deformity and change in neurologic status were analyzed to assess outcome. The Cobb angle and American Spinal Injury Association (ASIA) grade were used for this purpose. There were 6 male and 8 female patients. Five patients had complete injury (ASIA-A), and 9 had incomplete injury. The mean Thoracolumbar Injury Classification and Severity score was 6.71. The mean preoperative Cobb angle was 14.71° and improved to -3.35° postoperatively (mean kyphosis correction -18.05°). Two of the patients experienced iatrogenic nerve root injury. There was 1 postoperative mortality due to complications unrelated to the surgery. The mean Cobb angle was -0.07° at the 32.2-month follow-up visit. Six patients experienced cage subsidence, but none required revision surgery. Postoperatively, 11 (78.5%) patients showed neurologic improvement, and none experienced deterioration. The average ASIA score improved from 2.5 to 3.78. A fusion rate of 100% (n = 12) was observed at the last follow-up visit. The present study demonstrates that PTA is a feasible approach in selected pediatric patients with unstable traumatic thoracolumbar burst fractures, with results comparable with those in the adult population. This study demonstrates in detail the procedure, along with the neurologic and radiologic outcomes of this approach in the pediatric population.

Single Level Proximal Thoracic Pedicle Subtraction Osteotomy for Fixed Hyperkyphotic Deformity: Surgical Technique and Patient Series

Thoracic hyperkyphosis can display pathological deterioration, resulting in either hyperlordotic cervical compensation or sagittal malalignment. Various techniques have been described to treat fixed malalignment. Pedicle subtraction osteotomy (PSO) is commonly used in the lumbar spine and frequently limited to the distal thoracic spine. This series focuses on the surgical specificities of proximal thoracic PSO, with clinical and radiological outcomes. To report the surgical specificities and assess the clinical and radiological outcomes of proximal thoracic osteotomies for correction of rigid kyphotic deformities. This is a retrospective review of 10 consecutive patients who underwent single level proximal thoracic PSO (T2-T5). Preoperative and postoperative full-body EOSTM radiographs, perioperative data, and complications were recorded. The surgical technique and its nuances were described in detail. Patients had mean age of 41.8 yr and 50% were female. The technique provided correction of segmental and global kyphosis, 26.6° and 29.5°, respectively. Patients reported reciprocal reduction in C2-C7 cervical lordosis (37.6°-18.6°, P < .001), significantly correlating with the reduction of thoracic hyperkyphosis (R =0.840, P = .002). Mean operative time was 291 min, blood loss 1650 mL, and mean hospital stay was 13.8 d. Three patients reported complications that were resolved, including 1 patient who was revised because of a painful cross link. There were no neurological complications, pseudarthroses, instrumentation breakage, or wound infections at a minimum of 2-yr follow-up. Proximal thoracic PSO can be a safe and effective technique to treat fixed proximal thoracic hyperkyphosis leading to kyphosis reduction and craniocervical relaxation.

Tuberculous Spondylolisthesis: A Reappraisal of the Clinicoradiologic Spectrum and Surgical Treatment Paradigm.

Spinal tuberculosis (TB) is a common infectious disease prevalent in developing countries and an increasing issue in developed countries. The association of tuberculosis with spondylolisthesis is rarely reported in literature. The aim of our review is to analyze the clinical features and radiologic characteristics of TB spondylolisthesis and to provide a concise update on its surgical management, based on the literature. A systematic review was performed after conducting a thorough search of the PubMed database. Articles were selected systematically and reviewed completely and relevant data were summarized and discussed. Nineteen articles were selected for the review. The most common clinical manifestation was focal back pain, followed by motor deficit. Most patients had grade 2 listhesis and associated tubercular abscess. The anterior as well as the posterior surgical approach have their own advantages and the choice of approach depends on the location of disease, ease of access, achievement of spinal stability, and avoidance of spread of contiguous infection. Although a posterior approach and fixation using pedicular screws and rods along with debridement of pus or granulation tissue is the favored approach in dorsolumbar TB, an anterior approach, corpectomy, and fusion are preferred in cervical TB. Treatment of TB spondylolisthesis encompasses a wide spectrum of surgical options. However, the mainstay of treatment is chemotherapy. The indications for which surgical management may have an upper hand over medical management are spinal cord compression, significant instability, large tubercular abscess, painful vertebral lesions, kyphosis, and infection by multidrug-resistant TB or extreme drug-resistant TB, when medical management alone does not help. Surgery is effective in these situations by achieving radical debridement, permanent stability, prevention of further neurologic deterioration, and early recovery. Even although conservative management may help in certain cases, a posterior approach, decompression, and fusion are preferred for unstable dorsolumbar disease, whereas an anterior approach is preferred for cervical disease. Combined approaches can be considered in pediatric spinal TB for the correction of kyphotic deformity and its consequent maintenance.

Spinal TB: Impact of Research Evidence on Clinical Practice

The evidence generated while treating the patients is the key for growth of science. Finding answers to series of research questions spread over many years may change the clinical practice. This presentation is based on 25 research questions, 44 publications while treating 3300 patients over last 28 years ( 1990-2017) which has substantially changed the objective of treatment in spinal tuberculosis (TB) from healing of lesion with sequelae of spinal deformity and paraplegia to achieving healed status with near normal spine. Three cases of late-onset paraplegia were evaluated (1990) by newly introduced MRI. The syringohydromyelia and severe cord atrophy were attributed as the cause of paraplegia. We conducted a series of prospective studies to define and correlate MRI observations on spinal cord in paraplegia and followed the treatment outcomes. The cord edema, myelomalacia, cord atrophy and syringomyelia were observed in cases with neural complications. The patients with cord edema and liquid compression are predictor for neural recovery, while dry lesions and myelomalacia for poor neural recovery. The mild cord atrophy was consistent with neural recovery while severe cord atrophy with sequalae of neural deficit. Upto 76% canal encroachment was found compatible with intact neural state. Spinal deformity in TB spine is better prevented than treated. The contagious vertebral body disease with intact disc spaces, subperiosteal and paravertebral, septate abscesses, intra-osseous and intraspinal abscesses are considered features of spinal TB and resolution of abscess and fatty replacement is characteristic of healing. The clinicoradiological predictors for diagnosing spinal TB in predestructive disease were defined. Only 35% patients achieved healed status on MRI by DOTS regimen at 8 months, Hence, it is unscientific to stop antitubercular treatment (ATT) at fixed time schedule. The criteria to suspect multi-drug resistant (MDR)-TB and guide to treatment were defined. Residual Kyphotic deformity in spine TB produces severe proximal/distal degeneration of spine and/or late-onset paraplegia. We correlated the final kyphosis with initial vertebral body (VB) loss, where 1.5 VB height loss will produce 600 spinal deformity or more, hence surgical correction of spinal deformity is indicated. The surgical steps of kyphotic deformity correction are: anterior corpectomy, posterior column shortening, instrumented stabilization, anterior gap grafting and posterior fusion in a single stage and sequentially. The surgical incision of costo-transversectomy was modified so that kyphosis correction and posterior Hartshill instrumentation can be performed simultaneously. The retroperitoneal extrapleural approach for dorsolumbar spine was described. Meta-analysis of spinal instrumentation in TB spine established the lack of defined indication of instrumented stabilisation. Panvertebral/ long segment disease, kyphotic deformity correction are listed as indications of instrumented stabilisation in TB spine. The end point of treatment in spinal TB still eludes us to resolve the optimum duration of ATT regimen. The PET scan may be used to define it. We believe if a clinician works slow and steady on a series of research questions and by sustained focused efforts can change the clinical practice. We after this sustained research work could contribute in framing Bone and Joint TB guidelines and publish as monograph.

Clinical outcome and surgical strategies for late post-traumatic kyphosis after failed thoracolumbar fracture operation: Case report and literature review.

Rationale:Thoracic-lumbar vertebral fracture is very common in clinic, and late post-traumatic kyphosis is the main cause closely related to the patients’ life quality, which has evocated extensive concern for the surgical treatment of the disease. This study aimed to analyze the clinical outcomes and surgical strategies for late post-traumatic kyphosis after failed thoracolumbar fracture operation.Patient concerns:All patients presented back pain with kyphotic apex vertebrae between T12 and L3. According to Frankel classification grading system, among them, 3 patients were classified as grade D, with the ability to live independently.Diagnoses:A systematic review of 12 case series of post-traumatic kyphosis after failed thoracolumbar fracture operation was involved.Interventions:Wedge osteotomy was performed as indicated—posterior closing osteotomy correction in 5 patients and anterior open-posterior close correction in 7 patients.Postoperatively, thoracolumbar x-rays were obtained to evaluate the correction of kyphotic deformity, visual analog scales (VAS) and Frankel grading system were used for access the clinical outcomes.Outcomes:All the patients were followed up, with the average period of 38.5 months (range 24–56 months). The Kyphotic Cobb angle was improved from preoperative (28.65 ± 11.41) to postoperative (1.14 ± 2.79), with the correction rate of 96.02%. There was 1 case of intraoperative dural tear, without complications such as death, neurological injury, and wound infection. According to Frankel grading system, no patient suffered deteriorated neurological symptoms after surgery, and 2 patients (2/3) experienced significant relief after surgery. The main VAS score of back pain was improved from preoperative (4.41 ± 1.08) to postoperative (1.5 ± 0.91) at final follow-up, with an improvement rate of 65.89%.Lessons:Surgical treatment of late post-traumatic kyphosis after failed thoracolumbar fracture operation can obtain good radiologic and clinical outcomes by kyphosis correction, decompression, and posterior stability.

To study the outcomes of posterior decompression and fixation of tuberculosis of dorsolumbar spine

Introduction: Spinal TB generally starts in the vertebral bodies and the intervertebral discs and is thus called “spondylodiscitis”. It is not only important due to the high prevalence but also because upto 30% of cases develop serious neurological sequelae from compression of the spinal cord, such as para paresis and paraplegia. Although clinical and radiological findings are clear in tuberculosis of the spine, making an early and definite diagnosis is not yet easy, because disease progression is slow and insidious. If there are no complications and if the lesion is limited to the vertebrae, anti-tubercular chemotherapy can treat tuberculosis​ ​. However, with proper indications, surgical procedures are superior in the prevention of neurological deterioration, maintenance of stability, prevention of deformity, early recovery and early mobilization. Tubercular kyphosis is an unstable lesion that tends to progress at least until there is a sound body fusion anteriorly. The wide lesions, abscess formations, sinuses, vertebral deformities and neurological deficits due to spinal tuberculosis should be treated surgically. To date, there are several surgical treatment methods in the literature. Nowadays, tuberculous spine treatment and management has greatly evolved. Aim: To study the results of only posterior decompression and fixation in dorsolumbar tuberculosis spine in view of neurological status, amount of fusion, amount of correction of kyphotic deformity and life style status over the period of time. Materials and Methods: 60 patients were taken in the study initially but out of them 10 did not come for regular follow up. So study consisted of 50 patients. All patients (n=50) who were included in the study had tuberculosis of spine at dorsal and/or lumbar with or without neurological deficit and with or without deformity.All of 50 patients were managed by only posterior decompression and fixation. We studied the cases for development of deformity at dorsal and lumbar spine treated by posterior decompression and fixation and their neurological status according to GERTZBEIN GRADING​​, rate of fusion according to BRIDWELL SCORE​, pain status by DENNIS PAIN SCALE​ and functional ability according to DENNIS WORK SCALE​ and final outcome was assessed according to ​SEYBOLD AND BAYLEY SCALE. Neurological function on admission was graded according to Frankle et al​. Results and Discussion: In the current series of 50 patient’s posterior instrumentation performed to decrease and stabilize the kyphotic unstable segment. Functional outcome was significantly better in posteriorly fixed group of patients with average score being 14.66 (good) according to Seybold and Bayley score. Better targeting of the disease focus with removal of disease focus, possible posterior reconstruction, rapid healing, added stability and better fusion, which all fulfilled by the posterior fixation and decompression and has the better functional outcome. Conclusion: From the present study, we concluded that functional outcome is better according to Seybold and Bayley Scale in form of pain relief, work performance, fusion and neurological outcome after posterior decompression and fixation.Posterior fixation is safe and helps in early mobilization and rehabilitation.

Effect and Strategy of 1-stage Interrupted 2-level Transpedicular Wedge Osteotomy for Correcting Severe Kyphotic Deformities in Ankylosing Spondylitis

Prospective study. To investigate the safety, outcome, and strategy of the 1-stage interrupted 2-level transpedicular wedge osteotomy for correcting the severe kyphotic deformity in ankylosing spondylitis (AS). There has been a large series in the literature reporting on results of osteotomy for the correction of kyphotic deformity secondary to AS. However, few articles have reported, in detail, the plan, design, strategy, and effect of 1-stage interrupted 2-level transpedicular wedge osteotomy for the correction of severe kyphotic deformity in AS. From May 2003 to February 2010, 24 consecutive patients, 17 males and 7 females, suffering from AS with severe spinal kyphosis, underwent 1-stage interrupted 2-level transpedicular wedge osteotomy in our hospital by the corresponding author. Improvements in relevant parameters were recorded and clinical results were evaluated. The average operating time was 282±43 minutes, and the average blood loss was 2202±737 mL. All the global and regional spinal alignments improved to relatively normal status: the global thoracolumbar kyphosis angle improved from 101.5±10.8 to 24.8±5.8 degrees (P<0.001), the thoracolumbar kyphosis improved from 37.9±5.1 to 0.7±12.8 degrees (P<0.001), and the lumbar lordosis improved from 35.0±9.2 to -25.7±10.9 degrees (P<0.001). Meanwhile, the chin-brow vertical angle improved from 79.5±5.1 to 8.5±2.7 degrees (P<0.001), and the sagittal imbalance distance improved from 49.6±6.5 to 11.5±3.5 cm (P<0.001). All the patients could walk with horizontal vision and lie on their backs postoperatively, and scoliosis research society-22 scores improved from 1.6±0.2 preoperatively to 4.3±0.2 at the 2-year follow-up. The mean time of follow-up was 52±28 months. Fusion of the osteotomy was achieved in each patient and no instances of loss of correction or implant failure were noted. For correcting severe kyphosis in patients with AS, the 1-stage interrupted 2-level transpedicular wedge osteotomy is a safe and effective technique that significantly improves appearance and function.

ANTERIOR AND POSTERIOR FIXATION OF SPINAL FRACTURE IN PATIENTS WITH ANKYLOSING SPONDYLITIS

Objective. To evaluate the outcomes and methods of surgical treatment of patients with fractures of the cervical and thoracolumbar spine in ankylosing spondylitis. Material and Methods . The study included 19 patients with ankylosing spondylitis, spinal fractures were diagnosed in seven of them. The average age of patients with fractures was 39 years (range: 32-58 years). Injuries to the cervical spine were observed in three patients, and to the lumbar - in four. Among patients with lumbar spine injuries, a clinical picture of profound inferior paresis was observed in one patient with previous kyphosis. Paraplegia was diagnosed in two patients with fractures at the C 5 -C 6 level, and radicular pain - in one patient with injury at the C 5 -C 6 level. The remaining patients had no neurological disorders. Patients were operated on in the period from three days to two weeks after the injury. CT study to confirm the diagnosis was performed in all patients. Injuries to the cervical spine were treated by anterior fixation, to the thoracolumbar spine - by transpedicular fixation. Results . The results were evaluated according to X-ray and CT findings, as well as to a degree of neurological regression. Complications, instrumentation removal and increase in spinal deformity were not observed. In one patient with the cervical spine fracture, the pain caused by radicular irritation was eliminated. A regression of neurological complications from Frankel B to Frankel D was observed in one patient with the Th 12 -L 1 fracture. Conclusion . Surgical stabilization of the spine is the method of choice for the treatment of spinal fractures in ankylosing spondylitis. Graduated correction of kyphotic deformity in fractures may be one of the elements of surgical treatment.

Posterior three-column osteotomies for the treatment of rigid thoracic kyphosis – a case series

ObjectiveTo evaluate the results and complications of a series of patients who underwent three-column osteotomy using the posterior approach for correction of complex cases of rigid dorsal kyphotic deformity. MethodsReview of clinical records and images of 15 consecutive cases of pedicle subtraction osteotomies, bone-disk-bone osteotomies, or vertebral column resection, recording the etiology, type and level of osteotomy, extension of fixation, complications, and pre- and post-surgical measurements of the sagittal curves and pelvic parameters. ResultsSix pedicle subtraction osteotomies were performed, one of which in two adjacent vertebrae, as well as two bone-disk-bone osteotomies and seven vertebral column resection, two of which were performed in two adjacent vertebrae. The mean correction was 39.3° for the angular kyphosis and 33.9° for dorsal kyphosis. The corrections were similar regardless of the kind of osteotomy, the operated spinal segment, or the approach in one or two levels, but this may be a sample effect.Eight complications were observed in six patients (40% of cases): two medical complications, five early and one late surgical complication (over 90 days after surgery). There were three reoperations within less than one year from the initial surgery and one case of persistent paraparesis. Clinical complications were resolved without sequelae. There was no significant loss of correction during the segment, except in two cases of major mechanical failure due to a junctional segment fracture. ConclusionDespite being complex and aggressive procedures, prone to various complications, osteotomies with resection of the three columns are highly effective in the correction of rigid kyphotic deformities and safe enough to justify its use in selected cases.

Management and Outcome Analysis of Pediatric Unstable Thoracolumbar Spine Injury: Large Surgical Series with Literature Review.

Pediatric thoracolumbar spine fractures are considered rare injuries with paucity of publication across the globe. Further, spine injuries in children are comparatively rarer, and pediatric spine differs from adults, both biomechanically and anatomically; so, adult spine management strategy cannot be applied to pediatric cases, and exact guidelines for management of pediatric spinal injury is lacking. The current study is undertaken to study epidemiology, surgical management, and outcome of pediatric dorsolumbar unstable spine injury. A total of 25 pediatric patients were analyzed retrospectively with thoracic, thoracolumbar junction and lumbar spine injuries, who were managed surgically at our institute since June 2008, formed the cohort of the present study. There were 19 males and six females with a mean age 14.8 years. Clinically, complete spinal cord injuries were observed in 11 (44%), and rest 14 had incomplete injury. Most common mode of injury was fall (76%) in contrast to the western countries and the thoracolumbar junction was the most common affected site. Among all patients who underwent surgical intervention, 68% cases had posterior decompression and pedicle screw fixation. Mean duration of hospital stay was 18 ± 31 days. The mean follow-up period was 13.83 ± 5.97 months. In incomplete neurological injury group, a total of 13 patients showed neurological improvement, out of which four cases improved by two Frankel grades, eight patients improved by at least 1 grade, and rest one by Grade 3 (Frankel Grade B to E). Neurological outcome was statistically significant in relation to the level of fracture (P - 0.03) and preoperative Frankel grade, however, other factors, for example, gender, mode of injury, type of fracture, various surgical approaches with instrumentation, and correction of kyphotic deformity were found to be statistically nonsignificant. Surgical management of unstable pediatric dorsolumbar spine is a safe and an effective procedure which can provide good neurological outcome. The current study is one of largest series of cases managed surgically in this part of the world.

Surgical treatment of a patient with posttraumatic syringomyelia associated with complex posttraumatic deformity of the spine

A clinical case of surgical treatment of a female patient with posttraumatic syringomyelia which led to tetraparesis and dissociated sensory loss in the trunk and upper and lower limbs is presented. Clinical manifestations of these spinal cord changes occurred 21 years after complicated fracture of the L1 vertebra associated with complex posttraumatic spinal deformity. Multistage surgical intervention made it possible to restore liquorodynamics, perform the necessary correction of severe kyphotic deformity of the spine, and reduce the risk of torso imbalance. As a result, the syrinx practically disappeared at all levels of the study.

VERTEBRAL COMPLICATIONS OF LATE-ONSET NEONATAL SEPSIS

Objective. To analyze characteristic features of spinal lesions as a manifestation of late-onset neonatal sepsis. Material and Methods . Medical histories, clinical, and instrumental data of 9 children operated on for consequences of spinal lesions associated with late-onset neonatal sepsis were studied. Design: retrospective clinical study. Level of evidence - IV. Results . Neonatal sepsis occurred at the age of 5 days to 2.5 months after birth. Main clinical manifestations of the disease were caused by pneumonia observed in 7 of 9 children. Spinal lesion was diagnosed within 3-12 months after the disease onset. Its main manifestation was kyphotic deformity caused by the T 4 -T 11 vertebral body destruction. Average age of children at surgery was 13.4 months (range: 7 to 21 months). All patients underwent two-stage surgical treatment including anterior fusion and posterior instrumentation of the spine. Long-term results were followed for up to 5 years. Conclusion . Spinal lesions as a manifestation of late-onset neonatal sepsis are rare disorders, and are characterized by vast destruction of vertebral bodies and development of paravertebral and epidural abscesses in neurologically intact patients. However, they are diagnosed only after the onset of kyphosis. Verification of spondylitis etiology fails due to the prior massive antibiotic therapy and insufficient examination in the acute phase of sepsis. Surgical treatment of spondylitis caused by late-onset neonatal sepsis is carried out when the infection is under control, and aims at the anterior column reconstruction and the correction of kyphotic deformity.

Osteotomias posteriores de três colunas para tratamento de cifose dorsal rígida – Série de casos

ObjectiveTo evaluate the results and complications of a series of patients who underwent three‐column osteotomy using the posterior approach for correction of complex cases of rigid dorsal kyphotic deformity. MethodsReview of clinical records and images of 15 consecutive cases of pedicle subtraction osteotomies, bone‐disc‐bone osteotomies, or vertebral column resection, recording the etiology, type and level of osteotomy, extension of fixation, complications, and pre‐ and post‐surgical measurements of the sagittal curves and pelvic parameters. ResultsSix pedicle subtraction osteotomies were performed, one of which in two adjacent vertebrae, as well as two bone‐disc‐bone osteotomies and seven vertebral column resection, two of which were performed in two adjacent vertebrae. The mean correction was 39.3° for the angular kyphosis and 33.9° for dorsal kyphosis. The corrections were similar regardless of the kind of osteotomy, the operated spinal segment, or the approach in one or two levels, but this may be a sample effect.Eight complications were observed in six patients (40% of cases):two medical complications, five early and one late surgical complication (over 90 days after surgery). There were three reoperations within less than one year from the initial surgery and one case of persistent paraparesis. Clinical complications were resolved without sequelae. There was no significant loss of correction during the segment, except in two cases of major mechanical failure due to a junctional segment fracture. ConclusionDespite being complex and aggressive procedures, prone to various complications, osteotomies with resection of the three columns are highly effective in the correction of rigid kyphotic deformities and safe enough to justify its use in selected cases.

Optimal chin-brow vertical angle for sagittal visual fields in ankylosing spondylitis kyphosis.

Chin-brow vertical angle (CBVA) is very important in correction of thoracolumbar kyphotic deformity in ankylosing spondylitis (AS), especially for the patients with cervical ankylosis. In previous study, Suk et al. stated that the patients with CBVA between -10° and 10° had better horizontal gaze. Unfortunately, in our clinical practice, we found the patients with CBVA between -10° and 10° after surgery usually complained of difficulty in cooking, cleaning, desk working and the like, although they had excellent horizontal gaze. In other words, for the patients with cervical ankylosis, good horizontal gaze existed together with poor downward gaze. Then, which condition do the patients prefer? Is there a compromise solution that makes a better quality life possible for the patients? In this research, we studied AS patients with cervical ankylosis, aiming to investigate the optimal CBVA for deformity correction. 25 AS thoracolumbar kyphotic patients with cervical ankylosis were studied, whose function and expectation of visual field related to life quality were assessed by questionnaire before and after surgery. Pre- and post-operative CBVA were obtained on lateral photos of the patients with free-standing posture, and 50 cases of CBVA were included, which were divided into six groups according to the angle irrespective of surgery (Group A, CBVA<0°; Group B, 0°≤CBVA<10°; Group C, 10°≤CBVA<20°; Group D, 20°≤CBVA<30°; Group E, 30°≤CBVA<40°; Group F, CBVA≥40°). Kruskal-Wallis test was used to assess all the groups in terms of various items in the questionnaire, while Mann-Whitney test was used to assess every two groups. In overall evaluation, Group C (10°-20°) obtained the optimal expectation (p<0.05); Group B, C and D (0°-30°) obtained better function (p<0.05), and there was no significant difference between the 3 groups. In appearance, Group A, B and C (<20°) were better than the other groups both in function and expectation (p<0.05), without dramatic difference among the three groups. In outdoor activities, Group A, B, C and D (<30°) were better in most of the items (p<0.05). In indoor activities, Group C and D (10-30°) were much better (p<0.05). AS thoracolumbar kyphotic patients with cervical ankylosis had the best satisfaction when 10°≤CBVA<20°.