Postoperative Spinal Deformity Research Articles

Pediatric spinal arachnoid cysts with compressive myelopathy: single-center experience and update on surgical management.

This study describes the surgical outcome of pediatric primary spinal arachnoid cysts (SACs) presenting with compressive myelopathy and gives an update on the classification and management of these rare lesions. We performed a single-center retrospective analysis of pediatric patients operated for primary spinal arachnoid cysts. The clinical and radiologic profiles and surgical outcomes of these children were analyzed. Subgroup analysis was done in the laminoplasty vs laminectomy groups to see for the development of spinal deformity. There were 10 males and seven females with a mean age of 10.4years (range:6-14years). The cysts extended to an average of 5.2 levels (range:2-8). They were extradural in seven (41%) and intradural in 10 (59%). Six intradural and four extradural cysts underwent laminectomy (n = 10) while four intradural and three extradural cysts underwent laminoplasty (n = 7). Although three out of 10 cases in the laminectomy group and none in the laminoplasty group had post-operative spinal deformity, this result was not statistically significant (p = 0.110). There was a moderate negative correlation between post-operative cord occupancy ratio (COR) and post-operative McCormick grade (Pearson correlation coefficient = -0.453, p = 0.068), suggesting that higher CORs are associated with lower McCormick grades. Symptomatic pediatric primary spinal arachnoid cysts are safely and effectively managed by marsupialization or microsurgical excision. Considering the growing age group, laminoplasty rather than laminectomy should be the standard surgical procedure to prevent late postoperative spinal deformity. Clinically significant recurrences are rare in the setting of adequate cord expansion and restored subarachnoid CSF flow following surgery.

Successful detection of multiple communicating holes in multiple spinal extradural arachnoid cysts by using time-spatial labeling inversion pulse magnetic resonance imaging: illustrative case.

Spinal extradural arachnoid cysts (SEACs) communicate with the subarachnoid space through small communicating dural holes. The precise preoperative detection of all communicating holes, followed by minimally invasive dural closure, is the ideal treatment to prevent postoperative spinal deformities, especially in cases of multiple SEACs. However, standard imaging methods often fail to detect communicating hole locations. Although a few cases of successful single-hole detection via cinematic magnetic resonance imaging (MRI) have been reported, this modality's ability to detect multiple holes has not been demonstrated. The authors describe the case of a 14-year-old male with myelopathy due to multiple SEACs at T5-8 and T8-12. Myelography revealed a complete block at the T8 level; no cephalic cyst or communicating holes were identified. Time-spatial labeling inversion pulse (T-SLIP) MRI revealed cerebrospinal fluid flow into the cyst at T10 and T7. A limited laminectomy or hemilaminectomy was performed at T7 and T10, and two dural holes were closed without a total cystectomy. The patient's gait disturbance and rectal disorder disappeared. The cysts were confirmed to have completely disappeared on conventional MRI at 1 year postoperatively. T-SLIP MRI, a cinematic MRI, is useful for detecting multiple communicating holes in SEACs.

The application of lightweight AI algorithms in postoperative rehabilitation of breast cancer

The prevalence of breast cancer as a major global cancer has underscored the importance of postoperative recovery for breast cancer patients. Among the issues, postoperative patients are prone to spinal deformities, including scoliosis, which has drawn significant attention from healthcare professionals. The primary aim of this study is to design a postoperative recovery platform for breast cancer patients that can effectively detect posture changes, provide feedback and support to medical staff, assist doctors in formulating recovery plans, and prevent spinal deformities. The feasibility of the recovery platform is also validated through experiments. The development and validation of the experimental recovery platform. The recovery platform includes instrument design, patient data collection, model training and fine-tuning, and postoperative body posture evaluation by comparing preoperative and postoperative conditions. The evaluation results are provided to doctors to facilitate the formulation of personalized postoperative recovery plans. This paper comprehensively designs and implements the recovery platform and verifies its feasibility through simulation experiments. Statistical methods were employed for the validation of the rehabilitation platform in simulated experiments, with a significance level of p < 0.05. In comparison to static assessments like CT scans, this paper introduces a dynamic detection method that provides a more insightful analysis of body posture. The experiments also demonstrate the preventive capability of this method against post-operative spinal deformities, ultimately enhancing patients’ self-image, restoring their confidence, and enabling them to lead more fulfilling lives.

Preoperative examination and intraoperative cerebrospinal fluid leakage test for minimally invasive surgery of spinal extradural arachnoid cysts: illustrative case.

Spinal extradural arachnoid cysts (SEACs) are rare and can cause spinal dysfunction. Total cyst removal and duraplasty via multiple laminectomies are commonly performed. However, to avoid postoperative spinal deformity and axial pain, a minimally invasive surgery via selective laminectomy may be optimal. Therefore, preoperative detection of the dural fistula site is required. A 25-year-old male presented with a 2-month history of progressive gait disturbance and back pain. Conventional magnetic resonance imaging (MRI) revealed SEACs at the T9 to L2 level but did not reveal the dural fistula. Further examinations were performed using sagittal time-spatial labeling inversion pulse MRI and cone-beam computed tomography myelography with a spinal intrathecal catheter, which indicated a dural fistula on the left side at the T12 level. On the basis of these results, dural repair was performed via selective laminectomy. Furthermore, an intraoperative cerebrospinal fluid leakage test by intrathecally injecting saline via a spinal catheter confirmed complete closure of the dural fistula, with no other fistulas. These comprehensive pre and intraoperative examinations may be useful for minimally invasive and selective surgeries in patients with SEACs.

Predictors for spinal deformity following resection of intramedullary tumor via posterior approach: a systematic review and meta-analysis

PurposeThe present study aimed to identify the clinical predictive factors for worsened spinal deformity (SD) following surgical resection via posterior approach for primary intramedullary tumors.MethodsA systematic search was performed using PubMed, Web of Science, and Scopus databases to extract potential references. Observational studies reporting predictive factors for worsened SD following surgical resection via posterior approach for primary intramedullary tumors were included. The odds ratio (OR) was calculated for dichotomous parameters.ResultsFour retrospective cohort studies were included in the meta-analysis. They were comprised of two groups of patients; those who developed SD (n = 87) and those who did not (n = 227). For patients with IMSCTs, age under 25 years as well as age under 13 years were the demographic variables associated with postoperative SD (odds ratio [OR] 3.92; p = 0.0002 and OR 4.22; p = 0.003). In both the fusion and the non-fusion subgroups, preoperative spinal deformity strongly predicted postoperative SD (OR 11.94; p < 0.001), with the risk highly elevated among the non-fusion patients (OR 24.64; p < 0.0002). Thoracolumbar junction involvement was also found to be a predictor of postoperative SD for patients with IMSCT (OR 2.89; p = 0.02).ConclusionThis study highlights the importance of considering age, preoperative spinal deformity, and thoracolumbar junction involvement as predictors of postoperative spinal deformity following surgical resection for IMSCT. These findings may provide guidance for the management of these patients, including the development of preoperative planning strategies and the selection of the most appropriate surgical approach for high-risk patients.

Non-dysraphic intramedullary spinal cord lipoma of the child: Report of 3 cases

Background and purposeNon-dysraphic intramedullary spinal cord lipomas (NDSCL) represent 1% of spinal cord tumors. They are less frequent than dysraphic spinal cord lipomas and clinical presentation is unspecific. There are no guidelines on surgical management. Material and methodsWe report three observations of NDSCL in children, focusing on the clinical presentation, surgical management and postoperative outcome. ResultsThe patients, one female and two males, aged from 5 months to 10 years presented with neurological deterioration, pain, spinal rigidity and in two cases, a subcutaneous mass. Spinal MRI found intradural lipomas without spina bifida, located in the cervico-thoracic area in all cases. The lipoma extended to the medulla oblongata in two cases and was in the lumbar region in the third. These lipomas were massive, requiring decompression surgery. Surgery confirmed the lipoma to be subpial. We performed debulking of the lipoma without attempting total resection, and with or without dural plasty and laminoplasty, followed by minerva cast in two cases, and avoidance of standing in the youngest. Satisfactory recovery occurred in all three cases. After a follow-up between 4 months and 9 years, the outcome was favorable in all cases, and no patient presented with secondary spinal deformation or lipoma progression. ConclusionNDSCL is a rare entity, which often manifests with progressive pain and neurological deficits. In our experience, partial resection with or without dural plasty and laminoplasty has been associated with satisfactory postoperative outcomes and no recurrence of symptoms. We should be attentive to the risk of postoperative spinal deformity in these young patients.

Role of Posterior Longitudinal Ligament Complex in Spinal Deformity Secondary to Surgical Resection of the Intradural Tumor.

In most cases, complete resection of the intradural tumor is accompanied by long-term neurological complications. Postoperative spinal deformity is the most common complication after surgical resection of intradural tumors, and posterior longitudinal ligament complex (PLC) plays an important role in postoperative spinal deformity. In this study, we investigated the role of PLC in spinal deformity after the surgical treatment of intradural tumors. We analyzed the data of 218 consecutive patients who underwent intradural tumor resection from 2000 to 2018 in this retrospective study. Before 2010, patients underwent laminoplasty without maintaining the integrity of PLC (laminoplasty group, n=155). After 2010, patients performed single-port laminoplasty to maintain the integrity of PLC (laminoplasty retain posterior ligament complex group, n=63). The score of quality of life, painful cortex, spinal cord movement, progressive kyphosis or scoliosis, perioperative morbidity, and neurological results were analyzed in the laminoplasty group and laminoplasty retain posterior ligament complex group. The distributed variable was shown as mean ± standard deviation and an independent t-test or one-way analysis of variance was calculated. There are 155 patients (71.1%) included in the laminoplasty group, and 63 patients (28.9%) in the laminoplasty retain posterior ligament complex group. The average age of patients was 42 ± 2.3 years, and the average modified McCormick score was 2. There were 158 (72.4%) patients with intramedullary tumors and 115 (52.7%) patients with extramedullary tumors. The length of hospital stays (8 days vs. 6 days; p=0.023) and discharge to inpatient rehabilitation (48.4% vs. 26.9%; p=0.012) were significantly lower in the laminoplasty retain posterior ligament complex group than the laminoplasty group. There was no significant difference in the risk of progressive deformity between the two groups at 18months after surgery (relative risk 0.12; 95% confidence interval [CI] 0.43-1.25; p=0.258) and at 20months after surgery (relative risk 0.24; 95% CI 0.21-2.1). Laminoplasty retains posterior ligament complex showed no impact on the spinal deformities compared with laminoplasty, but significantly improved the postoperative spinal activity, alleviated pain symptoms, and reduced hospital recovery time.

Laminoplasty versus Laminectomy in the Treatment of Primary Spinal Cord Tumors in Adult Patients: A Systematic Review and Meta-analysis of Observational Studies.

The present systematic review and meta-analysis was conducted to compare the safety and efficacy of the two approaches for primary spinal cord tumors (PSCTs) in adult patients (laminoplasty [LP] vs. laminectomy [LE]). LE is one of the most common procedures for PSCTs. Despite advantages of LP, it is not yet widely used in the neurosurgical community worldwide. The efficacy of LP vs. LE remains controversial. Adult patients over 18 years of age with PSCT at the level of the cervical, thoracic, and lumbar spine were included in the study. A literature search was performed in MEDLINE via PubMed, EMBASE, The Cochrane Library, and Google Scholar up to December 2021. Operation time, hospital stay, complications, and incidence of postoperative spinal deformity (kyphosis or scoliosis were extracted. A total of seven retrospective observational studies with 540 patients were included. There were no significant differences between LP and LE group in operation time (p =0.25) and complications (p =0.48). The LE group showed larger postoperative spinal deformity rate than the LP group (odds ratio, 0.47; 95% confidence interval [CI], 0.27-0.84; p =0.01). The LP group had a shorter hospital stay (standardized mean differences, -0.68; 95% CI, -1.03 to -0.34; p =0.0001) than the LE group. Both LP and LE have comparable operative times and total complications in the treatment of PSCT. LP was superior to LE in hospital stay and postoperative spinal deformity rate. However, these findings are limited by the very low quality of the available evidence. Randomized controlled trials are needed for further comparison.

Long-term Follow-up Results of Reconstructive Laminoplasty With L-shaped Leibinger Mini-plate for Posterior Approach in the Treatment of Intraspinal Tumor Surgery

Laminoplasty using mini-plates is one of the most common surgical techniques in surgery for intraspinal pathologies. However, limited are present in the literature. The aim of this study was to determine its long-term clinical and radiologic outcome, specifically using an L-shaped mini-plate. Patients who underwent surgery for spinal intradural pathology from January 2008 to December 2019 were retrospectively reviewed. Those who received laminoplasty using the Leibinger mini-plate and were followed for more than 2 years were included. Patient demographics and clinical and radiographic data were reviewed and analyzed. A total of 117 patients (male:female= 47:70; mean age 50.9 years, range 16-92 years) were included, and mean follow-up period was 50.3 months (range 24-151 months). The most common pathology was schwannoma (n= 66, 56.4%) followed by meningioma (n= 30, 25.6%). Gross total resection was achieved in 82.9% (n= 97). Clinical outcomes at last follow-up were mostly good and excellent (n= 95, 81.2%). Computed tomography at the postoperative 1-year follow-up were available in 32 patients (27.4%) and the overall fusion rate was 89.3% (50 of 56 laminae). The fusion rate was significantly lower in the cervical spine compared to other locations (50% vs. thoracic [100%], lumbar [85.7%], P < 0.002). No displacement of laminae or postoperative spinal deformity were observed throughout the follow-up. Laminoplasty using L-shape Leibinger mini-plates had an 89.3% fusion rate, and no displacement of the re-attached laminae was observed. We think it is a safe and feasible option in surgeries for intraspinal pathologies.

Vertebral plate and ligament composite laminoplasty in spinal cord tumor surgery: Analysis of 94 patients.

ObjectivesThe aim of this study was to evaluate the value and long-term effect of laminectomy or laminoplasty in spinal cord tumor surgery.Patients and methodsPatients with spinal cord tumor treated in Department of Neurosurgery from January 2016 to October 2019 were included in this study. Posterior median approach tumor resection was preceded in 94 cases. Vertebral plate and ligament composite replant (laminoplasty group) was proceeded in 34 cases, and vertebral plate resection (laminectomy group) was proceeded in 60 cases. All patients were followed up and neurological function imagings were conducted 1 week, 3 months, and 6 months postsurgery to evaluate the surgical efficiency and spinal stability.ResultsTotal resection was achieved in 84 patients (89.0%); subtotal resection was achieved in 10 patients (11%). There was no significant difference between thelaminectomy group and laminoplasty group in terms of operative time, surgical site, infection rate, cerebrospinal fluid (CSF) infection, CSF leak, and length of hospitalization (P > 0.05). The incidence of postoperative spinal deformity was 15.0% in the laminectomy group and 11.7% in the laminoplasty group (P > 0.05). Laminoplasty vs laminectomy was associated with a similar risk of progressive deformity. However, for the cervical patients, there is significant difference (P < 0.05) in the spinal deformity. For the patients with incision vertebral segments >3, there is no significant difference in the spinal deformity (P > 0.05). Bone fusion was achieved in 7 (20%) patients in the laminoplasty group. Laminoplasty vs laminectomy was associated with a similar risk of progressive deformity.ConclusionVertebral plate and ligament composite replant is a simple and practical method in spinal cord tumor surgery. Neither every case got bone fusion nor positive results turned out in survival analysis, but it is still valuable in reducing spinal deformity, especially in cervical vertebra spinal cord tumor surgery.

Instrumentation following intradural tumor resection: A case analyses and literature review.

Background: Resection of intradural spinal tumors typically utilizes a posterior approach and often contributes to significant biomechanical instability and sagittal deformity.Methods: We searched PubMed for studies regarding pre- and postoperative spine biomechanics/alignment in patients with intradural tumors undergoing posterior decompressions.Results: Three patients underwent posterior decompressions with instrumented fusions to preserve good sagittal alignment postoperatively. Variables analyzed in this study included the extent of preoperative and postoperative deformity, the number of surgical levels decompressed and fused, the different frequencies of instability following the resection of cervical versus thoracic versus lumbar lesions, and whether pediatric patients were most likely to develop instability.Conclusion: Simultaneously performing instrumented fusions following posterior spinal decompressions for tumor removal proved optimal in preventing postoperative spinal deformity. Further, “open” surgical procedures offered more optimal/definitive tumor removal versus minimally invasive approaches, and the greater operative exposure and resultant increased risk for instability were remediated by performing simultaneous fusion.

Risk factor analysis of progressive spinal deformity after resection of intramedullary spinal cord tumors in patients who underwent laminoplasty: a report of 105 consecutive cases.

Laminoplasty has been used in recent years as an alternative approach to laminectomy for preventing spinal deformity after resection of intramedullary spinal cord tumors (IMSCTs). However, controversies exist with regard to its real role in maintaining postoperative spinal alignment. The purpose of this study was to examine the incidence of progressive spinal deformity in patients who underwent laminoplasty for resection of IMSCT and identify risk factors for progressive spinal deformity. Data from IMSCT patients who had undergone laminoplasty at Beijing Tsinghua Changgung Hospital between January 2014 and December 2016 were retrospectively reviewed. Univariate tests and multivariate logistic regression analysis were used to assess the statistical relationship between postoperative spinal deformity and radiographic, clinical, and surgical variables. One hundred five patients (mean age 37.0 ± 14.5 years) met the criteria for inclusion in the study. Gross-total resection (> 95%) was obtained in 79 cases (75.2%). Twenty-seven (25.7%) of the 105 patients were found to have spinal deformity preoperatively, and 10 (9.5%) new cases of postoperative progressive deformity were detected. The mean duration of follow-up was 27.6 months (SD 14.5 months, median 26.3 months, range 6.2-40.7 months). At last follow-up, the median functional scores of the patients who did develop progressive spinal deformity were worse than those of the patients who did not (modified McCormick Scale: 3 vs 2, and p = 0.04). In the univariate analysis, age (p = 0.01), preoperative spinal deformity (p < 0.01), extent of tumor involvement (p < 0.01), extent of abnormal tumor signal (p = 0.02), and extent of laminoplasty (p < 0.01) were identified as factors associated with postoperative progressive spinal deformity. However, in subsequent multivariate logistic regression analysis, only age ≤ 25 years and preoperative spinal deformity emerged as independent risk factors (p < 0.05), increasing the odds of postoperative progressive deformity by 4.1- and 12.4-fold, respectively (p < 0.05). Progressive spinal deformity was identified in 25.7% patients who had undergone laminoplasty for IMSCT resection and was related to decreased functional status. Younger age (≤ 25 years) and preoperative spinal deformity increased the risk of postoperative progressive spinal deformity. The risk of postoperative deformity warrants serious reconsideration of providing concurrent fusion during IMSCT resection or close follow-up after laminoplasty.

Modified Laminoplasty for Degenerative Cervical Spondylosis: The Technique of Floating Laminoplasty.

Background:Laminoplasty is an established alternative to laminectomy for posterior cervical decompression in spondylotic myelopathy. However, standard laminoplasty requires internal fixation, which is often not obtainable in developing countries. We present our experience with a technique of noninstrumented (floating) laminoplasty developed to avoid the need to anchor the laminoplasty to the anterior elements.Methods:We have used floating laminoplasty (FL) for posterior cervical decompression in patients with cervical spondylosis since 2004 and report the technique and our experience with it between 2009 and 2014 when C-arm and magnetic resonance imaging became available in our unit. Patients who had classical laminectomy and hemilaminectomies were excluded. The operation involved bilateral approach to the laminae through a midline incision with generous sparing of the supraspinous, interspinal and interlaminar ligaments. During closure the laminoplasty was hitched to the ligamentum nuchae. Nurick grading was used for clinical evaluation. Patients were followed for at least 1 year.Results:There were 36 patients with age range between 32 and 72 years (mean: 56.5 years). Male to female ratio was 3:1. Most patients presented with advanced disease, with 25%, 36%, and 30% at Nurick Grade 3, 4, and 5, respectively. Postoperatively, all (100%) patients with Nurick Grade 2 and 3 improved to Grade 1 or 0, while 9 (69%) of the 13 at Grade 4 improved to Grade 2 or better. Only 1 (9.1%) of 11 operated at Grade 5 did not improve while 3 (27%) improved to Grade 2 or better. No postoperative instability was identified on follow-up.Conclusion:FL is a safe and simple procedure that preserves spine stability and minimizes postoperative spinal deformity.

Safety and Efficacy of the Use of Intrathecal Morphine for Spinal Three Column Osteotomy.

IntroductionThe use of intrathecal morphine has the potential to help alleviate the pain that patients experience undergoing spinal surgeries. Complications can cause immobilization, which can lead to vascular thrombosis and ileus. Studies have shown epidural analgesia significantly lowered postoperative pain scores in scoliosis surgeries. Intrathecal anesthesia has been shown to have good pain control over the initial 24-hour postoperative period.PurposeDetermine if intrathecal morphine would reduce postoperative pain with minimal side effects.MethodsThe surgical case logs from three spinal deformity surgeons from a single academic medical center were reviewed retrospectively. This included cases where more than five levels of fusion occurred and surgery involved an osteotomy. The records of 17 patients were queried, and patient and surgical data were collected. The patients were divided into two groups: eight patients were administered intrathecal morphine and nine patients received no morphine. Postoperative pain scores were obtained hourly over the initial 24 hours postoperatively by nurses trained to obtain pain scores from the Numeric Pain Rating Scale. In addition, the rates of any noted side effects were recorded. Analysis of variance (ANOVA) and Fisher’s exact tests were used to calculate any statistical significance with p < 0.05 considered to be significant.ResultsThe maximum and total 24-hour postoperative pain scores had a mean of 5.6 (standard deviation = 4.2; p = 0.4266) and 69.3 (standard deviation = 57.8; p = 0.9189), respectively, for patients administered intrathecal morphine. The patients who did not receive intrathecal morphine had total pain scores of 3.9 (standard deviation = 4.5) and 65.7 (standard deviation = 79.7), respectively. Though the results were not statistically significant, there was a potential trend toward decreased in pain mean scores in the first 10 hours for the intrathecal morphine group. There was no statistical difference in the rate of side effects between patients.ConclusionsThe use of intrathecal morphine did not significantly appear to reduce postoperative pain in patients when compared to intravenous or oral narcotics. There was a potential trend in a reduction in postoperative pain during the first 10 hours postoperatively, but this did not reach a statistically significant value and did not hold up after the first 10 hours postoperatively. However, it was noted that intrathecal morphine was safe to use in postoperative spinal deformity surgery as no statistical significance in side effects was noted.

Spinal cord tumors in children: A review of 21 cases treated at the same institution

IntroductionSpinal cord tumors in children (SCTC) are rare with a frequent diagnostic delay. Its management is multidisciplinary and challenging due to functional implications. The position of surgery is now better established but the role and timing of chemotherapy (CT) and radiotherapy (RT) still remains under debate. Adverse effects of treatments are important to be taken into account, in the follow-up of these children. The aim of this paper was to present a series of 21 cases of SCTC treated at the same institution, to briefly present clinical features, treatments and outcome, with a special focus on spinal deformities in children with this condition. Material and MethodsTwenty-one consecutive SCTC were referred to our institution from 1990 to 2014. Data regarding age, sex, diagnostic delay, clinical examination, MRI, surgery, pathology, other treatment (CT and RT), orthopedic issues and follow-up of these children were retrospectively recorded. ResultsMean age was 8years (standard deviation: 5.2years) (range: 4 months–17years). Mean diagnosis delay was 5.5 months (standard deviation: 6.5 months) (range: 0 days–18 months). All children (10 girls, 11 boys) were operated on (10 partial removals, 7 subtotal and 4 gross total removals) as first-line treatment. Pathological results showed 12 juvenile pilocytic astrocytomas, 1 grade III astrocytoma, 1 grade IV astrocytoma, 3 oligodendrogliomas, 2 ependymomas, 1 glioblastoma and 1 rhabdoid tumor. Fourteen children (66.7%) received additional treatment: 12 CT and 7 RT. Ten children had postoperative spinal deformities. Mean follow-up (FU) was 71 months (5 months–180 months), with a median FU at 60 months, where 8 tumor progressions and 4 deaths were observed. Overall, survival (at 5years) was 81% and progression free survival (at 5years) was 67%. ConclusionSurgery is the goal standard for SCTC and the only appropriate treatment in cases of a low-grade lesion with stable disease on MR follow-up. Additional treatment must be reserved for high-grade lesions or tumor progression not attainable by a second look surgery. Spinal deformities are a frequent complication. Overall, survival and event free survival primarily depends on the pathology. Studies involving more centers are obligatory with the aim of collecting more cases and drawing more definitive conclusions regarding the management of these tumors.

Assessment of stability during gait in patients with spinal deformity—A preliminary analysis using the dynamic stability margin

Daily living activities are dynamic, requiring spinal motion through space. Current assessment of spinal deformities is based on static measurements from full-spine standing radiographs. Tools to assess dynamic stability during gait might be useful to enhance the standard evaluation. The aim of this study was to evaluate gait dynamic imbalance in patients with spinal deformity using the dynamic stability margin (DSM). Twelve normal subjects and 17 patients with spinal deformity were prospectively recruited. A kinematic 3D gait analysis was performed for the control group (CG) and the spinal deformity group (SDG). The DSM (distance between the extrapolated center of mass and the base of support) and time-distance parameters were calculated for the right and left side during gait. The relationship between DSM and step length was assessed using three variables: gait stability, symmetry, and consistency. Variables’ accuracy was validated by a discriminant analysis. Patients with spinal deformity exhibited gait instability according to the DSM (0.25 m versus 0.31 m) with decreased velocity (1.1 m s−1 versus 1.3 m s−1) and decreased step length (0.32 m versus 0.38 m). According to the discriminant analysis, gait stability was the more accurate variable (area under the curve AUC = 0.98) followed by gait symmetry and consistency. However, gait consistency showed 100% of specificity, sensitivity, and accuracy of precision. The DSM showed that patients with spinal malalignment exhibit decreased gait stability, symmetry, and consistency besides gait time-distance parameter changes. Additional work is required to determine how to apply the DSM for preoperative and postoperative spinal deformity management.

Spinal Realignment for Adult Deformity: Three-column Osteotomies Alter Total Hip Acetabular Component Positioning.

A goal of adult spinal deformity surgery is correction of sagittal imbalance by increasing lumbar lordosis (LL), allowing a previously retroverted pelvis to normalize as evidenced by decreases in pelvic tilt (PT). Realignment of pelvic orientation may alter the position of preexisting total hip arthroplasties (THAs). Twenty-seven patients with unilateral THA who underwent thoracolumbar fusions for adult spinal deformity from the pelvis to L1 or above were retrospectively reviewed (levels fused, 10.3 [range, 6 to 17]; age, 70 ± 9 years). Comparisons of preoperative and postoperative spinal deformity parameters, acetabular tilt (AT), and acetabular cup abduction angle (CAA) were performed, with subgroup analysis for those who had undergone three-column osteotomy and those who had not. Preoperative deformity was severe, with findings of a sagittal vertical axis >9 cm, PT >25°, and pelvic incidence-LL >20°. Postoperatively, AT decreased significantly (-7° ± 10°; P < 0.001), signifying relative acetabular retroversion. Comparing patients with three-column osteotomy versus those without, AT changes were greater in those with three-column osteotomy (11° ± 7° and -2 ± 10°, respectively; P = 0.024). AT was significantly correlated with changes of PT (r = 0.704; P < 0.001) and LL (r = -0.481; P = 0.011). AT decreased (ie, retroverted) 1° for every 3.23° of LL or 1.13° of PT correction. The coronal plane CAA did not change substantially. Spinal deformity correction, with techniques such as three-column osteotomy, result in significant THA acetabular component repositioning in the sagittal plane. Resultant decreased AT (ie, retroversion) theoretically may affect tribology, wear, and joint stability and warrants further investigation.

Spinal tumors in children: long-term retrospective evaluation of a series of 134 cases treated in a single unit of pediatric neurosurgery

Background contextSpinal tumors in childhood are rare and heterogeneous, and their treatment is very demanding. It is necessary to both manage the disease and preserve the spinal stability so that the spine can grow normally. As a consequence, results in terms of both mortality and morbidity are often suboptimal. PurposeThe results of a single pediatric neurosurgery institution are reported to highlight the peculiarities and pitfalls of the management of this disease. Tumors are analyzed from the point of view of their localization, histology, and outcome in terms of mortality and morbidity, with a special focus on postoperative spinal deformity. Study designThe study design was retrospective. Patient sampleBetween 1995 and 2011, 134 children (75 males and 59 females) were admitted for spinal tumors, accounting for 7.7% of all the patients admitted for central nervous system malignancies. The mean age was 8.5 years (14 days–26 years), and the mean follow-up was 28 months (3 months–13 years). Outcome measuresClinical and radiological outcomes were evaluated to assess mortality, morbidity, and surgical outcomes. A special interest was directed toward morbidity related to spinal deformity and neurologic deficits. MethodsPatients were divided into four groups: intramedullary (46 patients), intradural extramedullary (25 patients), extradural (53 patients), and paravertebral tumors (10 patients). Data were obtained retrospectively from medical records and radiological archives. ResultsLow-grade glioma was the most common histology (14.1%). One hundred seventeen patients were surgically treated, with a total of 138 surgical procedures. A posterior approach was chosen in 111 cases, with osteoplastic laminotomy in 80. Radiotherapy was administered to 22 patients and chemotherapy to 26. At the last follow-up, 16 patients (11.9%) had died. A good control of the tumor with clinical improvement was reported in 100 patients (74.6%). Five patients developed a spinal instability (3.7%). ConclusionsThe goals of surgery should be histology, spine and nerve root decompression, and preservation of spinal stability. In our experience, osteoplastic laminotomy was a good surgical approach to perform the resection of the tumor with a low risk of secondary spinal instability.

Clinical classification and selection of surgical approaches for cervical spinal dumbbell tumors

To explore the clinical classification and selection of surgical approaches for cervical spinal dumbbell tumors. The clinical data of 87 patients with cervical spinal dumbbell tumors undergoing surgical operations from January 2005 to December 2012 at our hospital were analyzed retrospectively. According to the size of inner and outer parts of tumors and the presence or absence of spinal bone damage, the cervical spinal dumbbell tumors were divided into 4 types of intraspinal predominant (I, n = 48), extraspinal predominant (II, n = 1), intrapinal and extraspinal without damage of spinal bone (III, n = 15) and intrapinal and extraspinal type with damage of spinal bone (IV, n = 7). Different surgical approaches were selected on the basis of tumor classification: posterior median-hemilamina approaches for type I tumors, lateral-muscle gap approaches for type II tumors, ateral-muscle gap-hemilamina or lateral-muscle gap-posterior median-hemilamina approaches for type III tumors, posterior far lateral-muscle gap-hemilamina or posterior median-muscle gap-hemilamina approaches plus posterior occipital cervical or cervical spinal bone graft fusion and internal fixation for type IV tumors. Among them, 83 cases underwent total resection and another 4 subtotal resection in one-stage operation. The postoperative follow-up period had a range of 9 months to 6 years (mean, 3.2 years). There was no recurrence of tumors for total resection and 1 case of tumor recurrence for subtotal resection. During the follow-up period, the clinical manifestations of 85 patients improved while another 2 deteriorated. And there was no occurrence of spinal deformity. Clinical classification of cervical spinal dumbbell tumor plays an important guiding role in the selection of surgical approaches. Adopting appropriate surgical approaches based on tumor type can not only improve the rate of total resection of tumor but also reduce the incidence of postoperative spinal deformity.

Long-term disease and neurological outcomes in patients with pediatric intramedullary spinal cord tumors.

Radical resection is recommended as the first-line treatment for pediatric intramedullary spinal cord tumors (IMSCTs), but it is associated with morbidity, including risk of neurological decline and development of postoperative spinal deformity. The authors report long-term data on clinical and treatment determinants affecting disease survival and neurological outcomes. Case records for pediatric patients (< 21 years of age at presentation) who underwent surgery for IMSCTs at the authors' institution between January 1975 and January 2010 were analyzed. The patients' demographic and clinical characteristics (including baseline neurological condition), the treatment they received, and their disease course were reviewed. Long-term disease survival and functional outcome measures were analyzed. A total of 55 patients (30 male and 25 female) were identified. The mean duration of follow-up (± SEM) was 11.4 ± 1.3 years (median 9.3 years, range 0.2-37.2 years). Astrocytomas were the most common tumor subtype (29 tumors [53%]). Gross-total resection (GTR) was achieved in 21 (38%) of the 55 patients. At the most recent follow-up, 30 patients (55%) showed neurological improvement, 17 (31%) showed neurological decline, and 8 (15%) remained neurologically stable. Patients presenting with McCormick Grade I were more likely to show functional improvement by final follow-up (p = 0.01) than patients who presented with Grades II-V. Kaplan-Meier actuarial tumor progression-free survival rates at 5, 10, and 20 years were 61%, 54%, and 44%, respectively; the overall survival rates were 85% at 5 years, 74% at 10 years, and 64% at 20 years. On multivariate analysis, GTR (p = 0.04) and tumor histological grade (p = 0.02) were predictive of long-term survival; GTR was also associated with improved 5-year progression-free survival (p = 0.01). The prognosis for pediatric IMSCTs is favorable with sustained functional improvement expected in a significant proportion of patients on long-term follow-up. Long-term survival at 10 years (75%) and 20 years (64%) is associated with aggressive resection. Gross-total resection was also associated with improved 5-year progression-free survival (86%). Hence, the treatment benefits of GTR are sustained on extended follow-up.