Local Kyphotic Angle Research Articles

Posterior short-segment fixation with transforaminal lumbar interbody fusion for the treatment of unstable lower lumbar fracture

Background: The objective of this study was to evaluate the clinical and radiographic results of posterior short-segment pedicle screw fixation and transforaminal lumbar interbody fusion (TLIF) in selected types of lower lumbar fractures. Methods: Twenty-seven patients with lower lumbar fractures were enrolled in this study. Demographic data, neurologic grade, anterior vertebral body heights, vertebral body translation, segmental Cobb angle, and management-related complications were assessed. The minimum follow-up period was 2 yr. Results: Twenty male patients and seven female patients underwent the procedure, with a mean operative time of 182 min. Mean blood loss was 588 mL. The mean preoperative local kyphotic angle was 9.5 degrees that improved to 2.5 degrees postoperatively. The loss of correction was insignificant at the final follow-up. The preoperative percentage of height lost improved from a mean of 52.5% to a mean of 89.05% postoperatively, and at last follow-up no loss of correction in height was noted compared to the postoperative results. No pseudarthrosis or metal failure was detected. All patients who were Frankle E on admission remained neurologically intact. Conclusions: Posterior short-segment fixation with pedicle screw fixation augmented with TLIF might be a possible choice for selected patients with unstable lower lumbar fractures, particularly in split fractures, burst fractures with a reversed cortex sign, and traumatic spondylolisthesis.

The Outcome of Radiofrequency Kyphoplasty in the Treatment of Vertebral Compression Fractures in Osteoporotic Patients.

Study DesignRetrospective study.PurposeThe study aims to assess the effectiveness and safety of radiofrequency (RF) kyphoplasty in the treatment of vertebral compression fractures (VCFs) in osteoporotic patients.Overview of LiteratureVertebroplasty and balloon kyphoplasty are established procedures for the treatment of osteoporotic VCFs. However, RF kyphoplasty is a new method which controls cement viscosity.MethodsWe reviewed the results of 41 consecutive patients with 23 thoracic and 38 lumbar VCFs who underwent RF kyphoplasty. The study population included 14 males (34%) and 27 females (66%). The mean patients age was 78 years (range, 51–89 years), and the follow-up period was 1 year. Clinical and radiographic analyses were performed during follow-up at 6 weeks, 6 months, and 1 year. All patients were assessed clinically pre- and postoperative using the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). Radiological assessment with X-ray in two views preoperatively, postoperatively, and during follow-up visits.ResultsThe mean preoperative VAS was 8.7 (range, 5–10; standard deviation [SD], 1.2). Postoperatively, VAS decreased by 3.3 (range, 2–5; SD, 0.9). At the end of the follow-up, VAS decreased by 1.22 (range, 0–7; SD, 1.6). The mean preoperative ODI score was 85.9, decreasing to 9.6 postoperatively and improving to 18.4 during the 1-year follow-up. The mean local kyphotic angle was 9.04° before the procedure and decreased by a mean of 6.16° after the operation and at the end of the follow-up. The mean increase in vertebral body height was 3.3 mm postoperatively and after 1-year follow-up. The rate of cement leakage was 8% (five out of 61 levels of fracture).ConclusionsRF kyphoplasty is a safe and effective augmentation technique with an advantage of controlling the cement viscosity to minimize the risk of cement leakage. It also shortens operation time.

Characteristic Reconstitution of the Spinal Langerhans Cell Histiocytosis in Young Children.

Pediatric Langerhans cell histiocytosis (LCH) often results in vertebral compression fracture. However, few reports have reported vertebral remodeling during the course of LCH. We aimed to investigate the longitudinal reconstitution and transformation of the affected vertebrae and the adjacent structures in young children with spinal LCH. We recruited 13 patients, including 16 affected vertebrae, diagnosed with LCH via biopsy. The average age at first visit was 3.6 years. The average follow-up period was 10.2 years. Vertebral lesions involved L2 in 3 cases; T12, L1, or L5 in 2 cases; and C4, C5, C7, T5, T8, T9, or L3 in 1 case. We measured the ratios of the height of the affected vertebra and 1 vertebra above the affected one to that of the second vertebra above the affected one, local kyphotic angles, and the ratio of the height of the center of the adjacent disk to that of one disk above it. The collapse of the affected vertebra was most severe after 1 year of disease onset. The rate of reconstitution accelerated at 2 years or later of disease onset. The recovery speed of the anterior wall was faster than that of the center height. While the height of the affected vertebrae was restored, the thickness of the adjacent disk also increased. Further, the height of the adjacent vertebrae increased in a similar manner. The average local kyphosis angle shifted to lordosis within the first 3 years. The heights of not only the disk but also the adjacent vertebra increased during the vertebral collapse phase in pediatric spinal LCH patients. These transformations may affect the realignment of the sagittal spinal balance at the earlier stage of the disease. During the collapse phase, the heights of the adjacent vertebrae and disks increase but after the affected vertebrae reconstituted, the augmentation of adjacent vertebrae and disks diminished. Level IV.

LONG SEGMENT VERSUS SHORT SEGMENT FIXATION WITH INDEX LEVEL IN THORACOLUMBAR BURST FRACTURE

Background The goal of this study is to compare the results of long segment fixation versus short segment fixation with index level. Methods Fifty patients were enrolled in two groups twenty five patients each. First group was treated by long segment fixation. Second group was treated by short segment fixation with index level screw. Results This was found to be statistically significant comparing between long segment fixation group with short segment with index level group regarding mean intraoperative blood loss, mean operative time and mean incision length. At the final follow it was found that the mean LKA preoperatively, after 3months and 6 months postoperatively was statistically insignificant. Conclusion The results of short segment fixation with index level are encouraging and comparable to those of long segment fixation regard correction of local kyphotic angle with less motion segments fixation in short segment group.

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.

Which one is more effective for the treatment of very severe osteoporotic vertebral compression fractures: PVP or PKP?

PurposeThe purpose of this study was to compare the clinical efficacy and safety of percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) in the treatment of the elderly with very severe osteoporotic vertebral compression fractures (vsOVCFs).MethodsFrom September 2012 to September 2015, 57 patients with vsOVCFs who had undergone PVP and PKP surgeries at our medical center were reviewed retrospectively, at least 2 years follow-up. All patients were divided into PVP group (n=31) and PKP group (n=26). Clinical data including clinical and radiological evaluation results were performed pre- and postoperatively.ResultsThe operation time of PVP group (29.6±3.3 minutes) was less than that of PKP group (37.4±4.2 minutes), with significant differences (P<0.05). Compared with preoperative data, the VAS scores, Oswestry disability index (ODI) scores, and local kyphotic angle were improved with significant differences at 1 day after surgery and the last follow-up in two groups (P<0.05). However, there were no differences in VAS and ODI scores between the two groups (P>0.05). The local kyphotic angle of PVP group was more than that of PKP group after surgery, with significant differences (P<0.05). At 1 day after surgery and the last follow-up, the anterior height of vertebrae fractured was significantly improved compared with preoperative in PKP group (P<0.05), and there was no statistical difference compared with preoperative in PVP group (P>0.05). However, there were no significant differences between the two groups in the leakage rate of bone cement (P>0.05) and incidence of adjacent-level vertebra fracture (P>0.05).ConclusionBoth PVP and PKP can significantly relieve the pain of the patients with vsOVCFs. Restoring the vertebral height and local kyphotic angle corrections of PKP are comparatively better than those of PVP. However, the operation time of PKP is significantly longer than that of PVP and PKP is not superior in the leakage rate of bone cement and incidence of adjacent-level vertebra fracture compared to PVP.

Evaluation of Posterior Stabilization Reinforced with Intravertebral Titanium Mesh Cages in Treating Acute Thoracolumbar Burst Fractures

Background Data: Burst fractures are commonly provoked by axial compression which disrupts the anterior column. In this setting, posterior stabilization using pedicle screws alone may lead to delayed kyphosis and instrumentation failure due to inadequate support of the anterior column.Purpose: To evaluate the efficacy of pedicle screw instrumentation combined with transpedicular titanium mesh cage augmentation for treatment of burst fractures.Study Design: Prospective descriptive cohort clinical case study.Patients and Methods: Fourteen neurologically intact patients with acute incomplete thoracolumbar burst fracture (AO type A 3.1), and operated upon through period from January 2016 to June 2017 were included. Patients were treated using a three vertebrae pedicle screw fixation construct combined with bilateral transpedicular titanium mesh cage augmentation of the fracture. Patients were followed for at least one year. Data about pain (VAS), function (ODI) and vertebral body deformity (Beck index and local kyphotic angle) were recorded prospectively.Results: Patients were operated within 5 days after trauma. The mean VAS score improved after surgeryfrom 8.2±1.3 to 3.7±1.1 postoperatively and to 1.8±0.7 at final follow up (P<0.05). The mean ODI score improved from 69.4±5.2 preoperatively to 17.2±2.4 at final follow up. The mean Beck index improved from 0.63 preoperatively to 0.81 postoperatively and to 0.79 at final follow up. The mean local kyphotic angle improved from 20.4o preoperatively to 11.5o postoperatively and declined to 13.7o at final visit. No patient had neurological deterioration or hardware failure during the follow up.The mean follow up was 13.4±1.8 months.Conclusion: Posterior stabilization using pedicle screw fixation in combination with titanium mesh cage augmentation can maintain vertebral restoration, prevent hardware failure and lead to better clinical outcome. (2018ESJ162)

Kyphotic Angle of the Motion Segment Most Accurately Predicts Injury to the Ligamentous Complex on Computed Tomography Scan of Thoracolumbar Fractures

To define radiologic parameters and the diagnostic accuracy of computed tomography (CT) scan on posterior ligamentous complex (PLC) injury, identified by magnetic resonance imaging (MRI) in patients with thoracolumbar (TL) fracture. We retrospectively analyzed 88 patients with TL fractures divided into 2 groups by PLC status evident on MRI: intact and ruptured. The parameters assessed included the anterior fractured vertebral body height (AVH) and posterior fractured vertebral body height, upper and lower AVH, anterior/posterior vertebral height ratio, AVH ratio, local kyphotic angle (LKA), region angle (RA), sagittal index (SI), Gardner angle (GA), Gardner index (GI), Cobb angle, interspinous distance (ISD), upper and lower ISD, ISD ratio, interspinous distance minus (ISDM), interspinous angle (ISA), and upper and lower ISA. The t test, Pearson χ2 test, and multivariate logistic regression were used. PLC rupture (vs. intact) was associated with RA, GA, GI, ISD, ISD ratio, and ISDM. The positive risk factors for PLC rupture were GA, LKA, SI, and RA. The negative risk factors for PLC rupture were SI greater than 20° and GI. PLC rupture was associated with the SI, upper interspinous distance, ISD ratio, ISDM, and ISA in those with type A1/A2 fractures and the GA, GI, ISD, ISD ratio, and ISDM in those with type A3/A4 fractures. An RA greater than 16°, SI greater than 20°, and GI greater than 24° were associated with PLC injury in patients with type A TL fractures, and an RA greater than 16° and SI greater than 20° predicted PLC injury in type A1 and A2 fractures. An SI greater than 20°, GI greater than 24°, LKA greater than 26°, and ISD ratio greater than 56% predicted PLC injury in type A3 and A4 fractures.

Thoracoscopically Assisted Vertebral Reconstruction Simultaneously with Percutaneous Pedicle Screws Fixation for Management of Thoracic and Thoracolumbar Spinal Fractures.

Background Data: Thoracic and thoracolumbar fractures are commonly provoked by axial compression which disrupts the anterior column. In this setting, posterior stabilization using pedicle screws alone may lead to delayed kyphosis and hardware failure due to inadequate anterior column support. Application of thoracoscopic anterior column reconstruction while patient in prone position for posterior percutaneous instrumentation is a minimally invasive combined technique.Purpose: To evaluate the outcome of percutaneous pedicle screw instrumentation in combination with thoracoscopically assisted vertebral reconstruction using expandable titanium cage.Study Design: Prospective clinical case study.Patients and Methods: Eighteen patients with acute thoracolumbar fractures with different preoperative neurological status were recruited for this study. Patients were treated using a short segment percutaneous screw fixation construct combined with thoracoscopic corpectomy and insertion of expandable cage. Patients were followed for at least 6 months. Visual analogue scale (VAS), Oswestry disability index (ODI) and local kyphotic angle were recorded prospectively and compared to preoperative parameters. Intraoperative data including operative time, blood loss and perioperative complication was documented.Results: Patients were operated within 7 days after trauma using combined anterior and posterior stabilization technique. Mean operative time was 213±42 min (Range, 170-300). The mean blood loss was 225±79 ml (Range, 100-350). The mean VAS score improved significantly after surgery. The mean of ODI preoperatively was 74±6.9 preoperatively and improved after 6 months to become 17.5±14.6. The mean regional kyphotic angle was 22.6±6.82ᴼ preoperatively, improved to 6.9±4.1ᴼ postoperatively and at final follow-up it became 8.67±4.8ᴼ. No patient had neurological deterioration or hardware failure during ≥6 months of follow up.Conclusion: our data suggest that thoracoscopic anterior reconstruction and decompression augmented with posterior percutaneous in prone position yield good clinical and radiological results with minimal complications in thoracolumbar trauma. (2018ESJ158)

Vertebral augmentation with the SpineJack® in chronic vertebral compression fractures with major kyphosis

Osteoporotic vertebral compression fractures (OVCFs) are an important health issue for which minimally invasive techniques are a feasible treatment. The SpineJack® (Vexim) is an intravertebral expandable system designed to improve the correction of the structural modifications caused by OVCFs. Its ability to stabilise and reduce OVCFs at the acute phase being already well established, we sought to evaluate the feasibility of vertebral augmentation with the SpineJack® in chronic kyphotic OVCFs. All consecutive patients treated with the SpineJack® were prospectively included if they met the following criteria: (1) OVCF considered unstable (grade A3 according to Magerl's classification). (2) Local kyphotic angle ≥ 20°. (3) OVCF older than 6 weeks. (4) Back pain with visual analogue scale (VAS) ≥ 4. Nineteen consecutive patients (16 women [84.2%] and 3 men [15.8%]; mean age 73.2 ± 8.2 years) were included. Treatment was performed after a mean delay of 5.8 months ± 2.9 (range 1.5-12). Median visual analogue scale significantly improved from 7 preoperatively (IQR 6-9) to 2 (IQR 1-5) at 6 months (p < 0.01). Significant kyphosis reduction (i.e. ≥ 30%) was obtained in 94.7% of cases. Secondary adjacent level fractures (SALFs) were noted in 21.1% of cases and were correlated with the importance of the kyphosis reduction. Vertebral augmentation with the SpineJack® is feasible and seems able to correct major structural deformities in chronic OVCFs. SALFs were noted in a substantial amount of cases. Preventive adjacent vertebroplasty might be useful in patients with several risk factors for SALFs. • Vertebral augmentation with SpineJack® is effective to correct major structural deformities e.g. height loss and kyphosis. • Successful reduction is reachable with SpineJack® in chronic (older than 6 weeks) OVCFs. • Aggressive reduction of major kyphosis might promote SALFs and complementary adjacent vertebroplasties prevent their occurrence.

Effect of an intensive conservative therapy with daily teriparatide administration and rehabilitation for osteoporotic delayed vertebral collapse and paralysis.

Although patients with osteoporotic delayed vertebral collapse (ODVC) have frequently been treated surgically, the efficacy and limitation of conservative treatment for it have not yet been reported. The purpose of this study was to investigate the effectiveness and limitation of further intensive conservative treatment for patients with ODVC.Patients treated for ODVC from 2011 to 2014 with a follow-up period of more than 1 year were eligible. The fundamental treatment strategy consisted of surgical treatment following intensive conservative treatment with daily teriparatide and rehabilitation for 3 months. We conducted a surgical treatment for patients who could not keep standing position by themselves because of prolonged leg paralysis or intolerable back pain. We performed a logistic regression model in which surgical treatment was set as an objective variable, and other related factors including sex, age, the level of affected vertebrae, the quality of paralysis, changing rate (δ) of spinal canal encroachment, local kyphotic angle, mobility of collapsed vertebrae, EuroQol questionnaires (EQ5D), numerical rating scale (NRS), and Frankel grade as explanatory variables. We also plotted receiver operating curves (ROCs) to investigate the cutoff values of parameters at the baseline.Thirty patients (6 males and 24 females, mean age 76.7 years) were enrolled. Eventually 12 out of 30 patients avoided surgical treatment because their symptoms were improved. Logistic regression showed that δ of local kyphotic angle (odds ratio: 1.072), P = .01), mobility of collapsed vertebrae (1.063, 0.01), EQ5D (0.98, 0.04), and NRS (1.113, 0.01) were significantly correlated with the need for surgical treatments. Among the factors at baseline, only the mobility of collapsed vertebrae showed a significant value of area under a curve (AUC = 0.727, P = .008).The results that 40% of patients with ODVC did not need further surgical treatment after the intensive conservative treatment was of great significance. Patients with greater mobility of collapsed vertebrae might be treated surgically as quickly as possible.

Percutaneous kyphoplasty for the treatment of distal lumbosacral pain caused by osteoporotic thoracolumbar vertebral fracture.

Background Kyphoplasty has been demonstrated to be minimally invasive and effective in treating osteoporotic vertebral fracture patients with back pain over the level of the fractured vertebrae. Rare studies have reported on thoracolumbar vertebral fracture patients presenting with distal lumbosacral pain (DLP). Whether kyphoplasty had a favorable therapeutic benefit for these patients remains unclear. Purpose To evaluate the therapeutic efficacy of kyphoplasty in treating osteoporotic thoracolumbar vertebral fracture (OTVF) patients with DLP and assess the clinical significance of focal tenderness to palpation in these patients. Material and Methods Thirty-two OTVF patients who only complained of DLP were treated by kyphoplasty. The vertebral heights, local kyphotic angle, Visual Analogue Scale (VAS), and Oswestry Disability Index (ODI) scores were assessed preoperatively, one day after surgery, and at last follow-up. All patients were evaluated regarding their degree of satisfaction with kyphoplasty. In addition, we compared the therapeutic efficacy of kyphoplasty in patients with and without focal tenderness to palpation. Results All patients successfully underwent kyphoplasty without complications. The vertebral heights, local kyphotic angles, VAS, and ODI scores were all significantly improved after kyphoplasty and maintained at last follow-up in our patients ( P < 0.001). At last follow-up, all patients expressed satisfaction with kyphoplasty. No significant differences in these parameters were detected between patients with and without focal tenderness. Conclusion The possibility of thoracolumbar vertebral fractures in elderly patients complaining of DLP should not be neglected. Kyphoplasty presents a superior benefit in treating OTVF patients with DLP. The absence of focal tenderness does not influence the clinical efficacy in these patients.

Percutaneous kyphoplasty for the treatment of very severe osteoporotic vertebral compression fractures with spinal canal compromise

BackgroundVery severe osteoporotic vertebral compression fractures (vsOVCFs) are osteoporotic vertebral compression fractures with vertebral body collapse to less than one third of their original height. Few data are available about the use of percutaneous kyphoplasty (PKP) in treating vsOVCFs with spinal canal compromise. The aim of this study was to evaluate the safety and efficacy of percutaneous kyphoplasty (PKP) for the treatment of vsOVCFs with spinal canal compromise.MethodsThirty-five patients who suffered vsOVCFs with spinal canal compromise but without neurological deficits were treated by PKP between January 2009 and October 2014. The vertebral height, local kyphotic angle (LKA), visual analogue scale (VAS) and Oswestry Disability Index (ODI) values were assessed before the operation, 1 day after the operation and at the final follow-up.ResultsSignificant improvements on the VAS and ODI were noted 1 day post-operatively (p < 0.01), and these results were preserved at the final follow-up. The vertebral height was restored and the LKA was improved after surgery (p < 0.01). No neurological deterioration was found. Five of 35 vertebrae (14.3%) of cement leakages were all asymptomatic. Four new OVCFs in three patients were identified.ConclusionPKP is a safe and effective procedure for the treatment of vsOVCFs with spinal canal compromise, achieving significant vertebral height restoration and kyphotic angle reduction and leading to a significant pain relief and improvement in function.

Compensatory mechanism of the spine after corrective surgery without lumbar-sacral fixation for traumatic thoracolumbar kyphotic spine deformity.

It remains unclear whether long fusion including lumbar-sacral fixation is needed in corrective surgery to obtain good global sagittal balance (GSB) for the treatment of traumatic thoracolumbar kyphotic spine deformity. The purposes of this study were to evaluate compensatory mechanism of the spine after corrective surgery without lumbar-sacral fixation and to evaluate the parameters affecting the achievement of good GSB post-operatively. Twenty (20) subjects requiring corrective surgery (distal end of fixation was L3) were included in this study. The radiographic parameters were measured pre-operatively and at one month after surgery. Sagittal Vertical Axis (SVA), Lumber Lordosis angle altered by fracture (fLL), Thoracic Kyphosis angle altered by fracture (fTK), Pelvic Tilt (PT), Sacral Slope (SS), Pelvic Incidence (PI), Segmental Lumbar Lordosis (sLL: L3-S/L4-S), and local kyphotic angle were measured. The correlation between correction of local kyphotic angle (CLA) and the change in radiographic parameters was evaluated. Post-operatively, subjects with SVA<50mm and PI-fLL<10°were regarded as the "goodGSB group (G group). The radiographic parameters affecting the achievement of G group were statistically evaluated. fLL, sLL:L3-S and sLL:L4-S were decreased indirectly because the local kyphosis was corrected directly (CLA: 26.5±8.6°) (P<0.001). CLA and the change in fLL showed significant correlation (r=0.821), the regression equation being: Y=-0.63X+3.31 (Y: The change in fLL, X: CLA). The radiographic parameters significantly affecting the achievement of G group were: SVA, PT, PI-fLL, sLL: L3-S, and sLL: L4-S (P<0.01). The main compensatory mechanism was the decrease of lordosis in the lumbar spine. fLL was decreased to approximately 60% of CLA after surgery. SVA was not corrected by the compensatory mechanism.

Results of Posterior Vertebral Column Resection: Surgical Modification of Suk Technique.

Study Design:Consecutive, retrospective review.Objectives:To evaluate and report a modified posterior vertebral column technique.Methods:We present a retrospective analysis of 20 patients. Patients having severe 3-dimensional deformity with flexibility less than 20% and managed by posterior vertebral body resection (PVCR) between 2011 and 2014 were included in this study. There were 12 female and 8 male patients, with a mean age of 18 year (range = 3-63 years).Results:The average follow-up was 3.5 years (2-5 years). The preoperative coronal plane deformity was 84° (70° to 120°) and corrected to 42° (28° to 68°), showing 60% scoliosis correction. Average preoperative local kyphotic angle was 92° (82° to 110°). Correction rate for kyphosis was 62%. All patients after surgery showed their baseline neurological status, and no complications were encountered. The mean estimated blood loss was 1072 mL (350-2000 mL). Thirty-nine percent (33% to 50%) of total blood loss occurred after vertebral body resection, and 61% (50% to 67%) blood loss occurred after the removal of posterior elements. The ratio of estimated blood loss to estimated body blood volume was 26% (range = 19% to 52%).Conclusion:We found that 60% of total bleeding occurs during and after posterior bone resection. Spinal cord is open to possible iatrogenic direct spinal cord injury with surgical instruments for a much shorter period of time compared with the original technique.

Comparison of curative effect of unilateral and bilateral vertebral pedicle screw instrumentation for treatment of thoracolumbar burst fractures

Objective To compare the efficacy of unilateral and bilateral pedicle screw instrumentation for treatment of thoracolumbar burst fractures. Methods A retrospective case-control analysis was made on 50 patients with thoracolumbar burst fractures free from neurological deficit admitted between January 2008 and October 2013. There were 37 males and 13 females, aged from 24 to 51 years (mean, 36 years). Injuries were caused by high falls in 23 patients, traffic accidents in 18 and crashing accidents in 9. Distribution of the injured segment was T11 in 6 patients, T12 in 16, L1 in 20 and L2 in 8. Based on the surgical procedures, the patients were assigned to unilateral pedicle screw fixation group (n=35) and bilateral pedicle screw fixation group (n=15). Operation time, intraoperative blood loss and hospital length of stay were recorded. Visual analogue scale (VAS), Oswestry disability index (ODI), kyphotic angle and anterior vertebral height were evaluated before surgery, after surgery and at 1-year follow-up. Results No screw lessening, screw breakage or infection occurred at 1-year follow-up. Unilateral and lateral pedicle screw instrumentation groups revealed no significant differences in operation time [(81.4± 10.0)min vs. (83.3±13.6)min], intraoperative blood loss [(194.0±65.4)ml vs. (212.0±61.9)ml] and hospital length of stay [(10.3±1.3)d vs. (9.9±1.5)d] (P>0.05). After operation, VAS and ODI in unilateral pedicle screw instrumentation group (3 points, 73.9) showed no significance from these in lateral pedicle screw instrumentation group (2 points, 72.1) (P>0.05). VAS was within 1 point and ODI was within 20 at 1-year follow-up, showing no significant differences between the two groups (P>0.05). After operation, correction of kyphotic Cobb angle and restoration of anterior vertebral body height in unilateral pedicle screw instrumentation group (8°, 26.7%) showed no significance from these in lateral pedicle screw instrumentation group (11°, 32.1%) (P>0.05). Loss of local kyphotic Cobb angle and anterior vertebral body height in unilateral pedicle screw instrumentation group (2°, 3%) showed no significance from these in lateral pedicle screw instrumentation group (1°, 2%) at 1-year follow-up (P>0.05). Conclusion Both methods have comparable efficacy in restoring vertebral height and improving spinal kyphosis for treatment of thoracolumbar burst fractures. Key words: Spinal fractures; Fracture fixation, internal; Pedicle screws

Relationship between clinical symptoms of osteoporotic vertebral fracture with intravertebral cleft and radiographic findings.

With aging of the population, the numbers of osteoporotic vertebral fractures with intravertebral cleft have been increasing. However, the details of clinical symptoms of osteoporotic vertebral fractures with intravertebral cleft are poorly understood. The purpose of this study was to evaluate the relationship between clinical symptoms of osteoporotic vertebral fractures with intravertebral cleft and radiographic findings. Two hundred seventeen patients with single-level osteoporotic vertebral fractures with intravertebral cleft were examined. Clinical symptoms were evaluated using Numerical Rating Scale for back pain and the Oswestry Disability Index for physical disability. The presence of delayed neurologic deficit was also detected. Radiography and computed tomography were used to measure local kyphotic angle and vertebral instability and to detect the presence of posterior wall fracture of the vertebral body. Correlations between clinical symptoms of osteoporotic vertebral fractures with intravertebral cleft and radiographic findings were investigated. Mean Numerical Rating Scale and Oswestry Disability Index were 7.4 and 58.0%, respectively. Delayed neurologic deficit occurred in 41 patients (19%). The mean local kyphotic angle, vertebral instability, and rate of posterior wall fracture of the vertebral body were 19.4°, 7.3°, and 91%, respectively. Numerical Rating Scale and Oswestry Disability Index were statistically correlated with vertebral instability but not with local kyphotic angle and presence of posterior wall fracture. In the patients with delayed neurologic deficit, vertebral instability was significantly higher and posterior wall fractures were significantly more frequent than in the patients without delayed neurologic deficit. Local kyphotic angle was not correlated with delayed neurologic deficit. Vertebral instability is a factor causing symptoms of osteoporotic vertebral fractures with intravertebral cleft. In addition, vertebral instability may be the predominant cause of delayed neurologic deficit. To manage osteoporotic vertebral fractures with intravertebral cleft and delayed neurologic deficit efficiently, it may be important to control vertebral instability of osteoporotic vertebral fractures.

Posterior Only Vertebral Column Resection (PVCR) for Fixed Angular Kyphosis (FAK)

Introduction VCR is the most suitable osteotomy for rigid angular kyphosis especially if the correction needed is high. The prospective cohort study assessed the efficacy of Posterior Vertebral Column Resection (PVCR) in management of Fixed Angular Kyphosis (FAK). Patients and Methods Thirteen cases of FAK managed by PVCR in Assiut University Hospital and followed up for a mean of 20.31 (12–48) months. Seven cases (53.8%) were females and six cases were males, the mean age was 13.77 years. Eleven cases were congenital (84.6%) and two cases were post tuberculous. Five cases (38.5%) affected the thoracic region, six cases (46.2%) affected thoracolumbar region and two cases (15.4%) affected lumbar region. VAS, ODI, SRS-22, and neurology together with local kyphotic angle were compared pre, post and at last follow up visit. One case suffered progressive paraplegia. Results Five osteotomies were at L1; four at D11, and one osteotomy at D10, D12, L2 and L3. The VAS improved from 6.57 ± 2.14 to 1.29 ± 0.75 ( p = 0.001). The mean ODI improved from 56.22 ± 20.59 to 22.81 ± 11.33 ( p = 0.001). Total SRS-22 score improved from 2.11 ± 0.60 to 3.35 ± 0.65 ( p = 0.002). The mean local kyphotic angle improved from 65.38°±29.95 to 14.69°±19.78 ( p = 0.001), the mean operative time was 465.38 ± 76.44 (320–600) minutes and the mean blood loss was 3323 ± 934.6 (1600–4500) cc. The preoperatively neurologically impaired case recovered completely. Four cases suffered complications (30%), one case suffered postoperative weakness of quadriceps which improved with physiotherapy, two cases suffered asymptomatic proximal junctional kyphosis and one case experienced pull out screws which was revised. Conclusion PVCR seems to be highly effective tool for correction of fixed angular kyphosis avoiding the morbidity of anterior or combined approaches.

Indication for Partial Vertebral Osteotomy and Realignment in Posterior Spinal Fixation for Osteoporotic Thoracolumbar Vertebral Collapse with Neurological Deficits.

Instrumented spinal fixation is ordinarily required in patients who present with myelopathy or cauda equina syndrome secondary to vertebral collapse following osteoporotic thoracolumbar fracture. Posterior spinal fixation is a major surgical option, and partial vertebral osteotomy (PVO) through a posterior approach is occasionally reasonable for achievement of complete neural decompression and improvement of excessive local kyphosis. However, the indications and need for PVO remain unclear. The objectives of this retrospective study were to determine the efficacy and safety of posterior spinal fixation with or without PVO for osteoporotic thoracolumbar vertebral collapse and identify patients who require neural decompression and alignment correction by PVO. We retrospectively reviewed the clinical records of 20 patients (13 females, 7 males; mean age, 67.1 years) who underwent instrumented posterior fixation for osteoporotic thoracolumbar vertebral fracture. Clinical outcomes were assessed by the Japanese Orthopedic Association score and visual analog scale scores in the lumbar and leg areas. PVO was added with posterior spinal fixation in eight patients because neural decompression was incomplete after laminectomy as indicated by intraoperative echo imaging. Neurological and functional recovery significantly improved during follow-up. Clinical outcomes in patients who underwent PVO were similar to those in patients who did not undergo PVO. However, correction of the local kyphotic angle and improvement of spinal canal compromise after surgery was significant in patients who underwent PVO. The patients who required PVO had a less local kyphotic angle in the supine position and higher occupation rate of the fractured fragment in the spinal canal in the preoperative examination.

Cervical cage without plating in management of type II / II A Hangman’s fracture combined with intervertebral disc injury

BackgroundSurgical intervention is increasingly performed as the primary treatment of unstable Hangman’s fracture. Some authors have advocated using anterior C2/3 discectomy with interbody fusion and plating to treat unstable Hangman’s fracture combined with intervertebral disc injury; however, there are few reports on unstable Hangman’s fracture treated by anterior interbody fusion with the cervical cage (PEEK material) solely.MethodsThis study was to assess the efficacy of the cervical cage in management of unstable Hangman’s fracture combined with intervertebral disc injury. A cohort of 15 patients with unstable Hangman’s fractures fulfilling the inclusion criteria were prospectively submitted to surgical treatment of anterior C2/3 discectomy and interbody fusion using the cervical cage without plating. According to the Levine and Edwards classification, there were 5 type II, and 10 type IIA cases. The clinical outcome (the visual analog scale and the clinical post-traumatic neck score), radiological findings (angulation, translation, and disc height), and bone healing were assessed at 3, 6, 12, and 24 months.ResultsAll the patients were followed up successfully. There were no intra- or postoperative complications observed. Solid fusion was achieved in all cases by 6 months after surgery. The local kyphotic angle was corrected significantly with the mean preoperative 12.31 ± 2.96 degrees, initial postoperative −1.98 ± 1.62 degrees and the latest follow-up −1.72 ± 1.60 degrees respectively (P < 0.05).The translation was also corrected significantly with the mean preoperative 3.20 ± 1.16 mm, initial postoperative 0.97 ± 0.36 mm, and the latest follow-up 1.05 ± 0.34 mm respectively (P < 0.05). The mean visual analog scale and the clinical post-traumatic neck score improved significantly following surgery (P < 0.05).ConclusionsThis case series demonstrates that anterior C2/3 discectomy and interbody fusion with the cervical cage solely is effective and reliable in management of type II / IIA Hangman’s fracture with C2/3 disc injury when properly indicated.