Posterior Distraction Research Articles

The Effect of Intraoperative Overdistraction on Subsidence Following Anterior Cervical Discectomy and Fusion.

Retrospective cohort. The purpose of this study was to evaluate the effect of overdistraction on interbody cage subsidence. Vertebral overdistraction due to the use of large intervertebral cage sizes may increase the risk of postoperative subsidence. Patients who underwent anterior cervical discectomy and fusion between 2016 and 2021 were included. All measurements were performed using lateral cervical radiographs at 3 time points - preoperative, immediate postoperative, and final follow-up >6 months postoperatively. Anterior and posterior distraction were calculated by subtracting the preoperative disc height from the immediate postoperative disc height. Cage subsidence was calculated by subtracting the final follow-up postoperative disc height from the immediate postoperative disc height. Associations between anterior and posterior subsidence and distraction were determined using multivariable linear regression models. The analyses controlled for cage type, cervical level, sex, age, smoking status, and osteopenia. Sixty-eight patients and 125 fused levels were included in the study. Of the 68 fusions, 22 were single-level fusions, 35 were 2-level, and 11 were 3-level. The median final follow-up interval was 368 days (range: 181-1257d). Anterior disc space subsidence was positively associated with anterior distraction (beta = 0.23; 95% CI: 0.08, 0.38; P = 0.004), and posterior disc space subsidence was positively associated with posterior distraction (beta = 0.29; 95% CI: 0.13, 0.45; P < 0.001). No significant associations between anterior distraction and posterior subsidence (beta = 0.07; 95% CI: -0.06, 0.20; P = 0.270) or posterior distraction and anterior subsidence (beta = 0.06; 95% CI: -0.14, 0.27; P = 0.541) were observed. We found that overdistraction of the disc space was associated with increased postoperative subsidence after anterior cervical discectomy and fusion. Surgeons should consider choosing a smaller cage size to avoid overdistraction and minimize postoperative subsidence.

Patient Tailored Surgery in Saethre-Chotzen Syndrome: Analysis of Reoperation for Intracranial Hypertension.

Saethre-Chotzen syndrome (SCS) is a syndromic craniosynostosis with pathogenic variants in the TWIST1 gene showing a broad phenotypic spectrum. Controversies exist in the literature regarding surgical management with single one-stage versus patient-tailored surgery and the related reoperation rate for intracranial hypertension of up to 42%. At our center, SCS patients are offered patient-tailored surgery with single-stage fronto-orbital advancement and remodeling or fronto-orbital advancement and remodeling and posterior distraction in an individually determined order. The authors' database identified 35 confirmed SCS patients between 1999 and 2022. Involved sutures in craniosynostosis were left unicoronal (22.9%), bicoronal (22.9%), sagittal (8.6%), bicoronal and sagittal (5.7%), right unicoronal (2.9%), bicoronal and metopic (2.9%), bicoronal, sagittal and metopic (2.9%), and bilateral lambdoid (2.9%). There was pansynostosis in 8.6% and no craniosynostosis in 14.3% of the patients. Twenty-six patients, 10 females, and 16 males were operated on. Mean age at the first surgery was 1.70 years, and 3.86 years at the second surgery. Eleven of 26 patients had invasive intracranial pressure monitoring. Three patients presented with papilledema before the first surgery and 4 afterward. Four of the 26 operated patients were operated initially elsewhere. The other 22 patients were initially referred to our unit and underwent patient-tailored surgery. Nine of these patients (41%) had a second surgery, and 3 (14%) of them were because of raised intracranial pressure. Seven (27%) of all operated patients had a complication. Median follow-up was 13.98 years (range, 1.85-18.08). Patient-tailored surgery in a specialized center and long-term follow-up allow for a low reoperation rate for intracranial hypertension.

Low radius of curvature growth-friendly rib-based implants increase the risk of developing clinically significant proximal junctional kyphosis.

Clinically significant proximal junctional kyphosis (PJK) occurs in 20% of children with scoliosis treated with posterior distraction-based growth-friendly surgery. In an effort to identify modifiable risk factors, it has been theorized biomechanically that low radius of curvature (ROC) implants (i.e., more curved rods) may increase post-operative thoracic kyphosis, and thus may pose a higher risk of developing PJK. We sought to test the hypothesis that early onset scoliosis (EOS) patients treated with low ROC distraction-based implants will have a greater risk of developing clinically significant PJK as compared to those treated with high ROC (straighter) implants. We conducted a retrospective review of prospectively collected data obtained from a multi-centre EOS database on children treated with rib-based distraction with a minimum 2-year follow-up. Variables of interest included: implant ROC at index (220mm or 500mm), participant age, pre-operative scoliosis, pre-operative kyphosis, and scoliosis etiology. PJK was defined as clinically significant if revision surgery with a superior extension of the upper instrumented vertebrae was performed. In 148 participants with scoliosis, there was a higher risk of clinically significant PJK with low ROC (more curved) rods (OR: 2.6 (95% CI 1.09-5.99), χ2 (1, n = 148) = 4.8, p = 0.03). Participants had a mean pre-operative age of 5.3years (4.6y 220mm vs 6.2y 500mm, p = 0.002). A logistic regression model was created with age as a confounding variable, but it was determined to be not significant (p = 0.6). Scoliosis etiologies included 52 neuromuscular, 52 congenital, 27 idiopathic, 17 syndromic with no significant differences in PJK risk between etiologies (p = 0.07). Overall, participants had pre-op scoliosis of 69° (67° 220mm vs 72° 500mm, p = 0.2), and kyphosis of 48° (45° 220mm vs 51° 500mm, p = 0.1). The change in thoracic kyphosis pre-operatively to final follow-up (mean 4.0 ± 0.2years) was higher in participants treated with 220mm implants compared to 500mm implants (220mm: 7.5 ± 2.6° vs 500mm: - 4.0 ± 3.0°, p = 0.004). Use of low ROC (more curved) posterior distraction implants is associated with a significantly greater increase in thoracic kyphosis which likely led to a higher risk of developing clinically significant PJK in participants with EOS. Level III - retrospective comparative study.

Early cranial vault distraction for a more balanced and enhanced expansion: a 3D craniometric analysis of anterior versus posterior distraction osteogenesis in patients with craniosynostosis.

Posterior distraction osteogenesis (DO) is widely accepted for the treatment of craniosynostosis. The aim of this study was to quantitatively compare the effect of DO on the cranial vault according to the age of the patient and direction of distraction. This was a retrospective study of patients with craniosynostosis who underwent DO in the anteroposterior direction. Postdistraction changes in intracranial volume (ICV), anteroposterior distance, biparietal distance, cranial height, and frontal bossing angle were measured using Mimics software on CT scans. Craniometric data were analyzed using a multivariate regression model. Thirty-two patients (16 anterior and 16 posterior DOs) were included in the study. The mean ICV increase in the anterior and posterior DO group was 211 cm3 (range 142-281 cm3) and 214 cm3 (range 150-279 cm3), respectively. Patients who were aged 1 year or younger showed a greater percentage increase in ICV than patients older than 1 year. In the anterior DO group, a more balanced increase in both anterior and posterior anteroposterior distance was observed in patients aged 1 year or younger when compared to patients older than 1 year. In the posterior DO group, a bigger expansion and smoother contour in the posterior cranial fossa was observed in patients aged 1 year or younger. Both anterior and posterior DO are effective surgical options for expanding the cranial vault in patients with craniosynostosis. Early distraction appeared to show greater morphological changes in the growing cranial vault than those predicted with the vector of distraction.

Craniofacial reconstructions in children with craniosynostosis

Craniosynostosis is a rare congenital disease of the skull. They arise when one or more cranial sutures ossify prematurely. This causes an obstruction to normal brain growth and leads to specific deformations of the skull, which may result in intracranial hypertension and cognitive delay. We have retrospectively analysed all children treated at the Unit of paediatric neurosurgery of the University Medical Centre Ljubljana between June 2015 and September 2020. The following items have been recorded: affected suture, underlying syndromic condition, hydrocephalus, Chiari malformation, raised intracranial pressure, age at surgery, surgical technique, need for multiple operations and surgical complications. During the study period, 71 children have been treated for craniosynostosis. The median postoperative follow-up was 31 months. There were: 54.9% sagittal, 25.3% metopic, 14.0% unicoronal, 1.4% bicoronal and 1.4% unilateral lambdoid craniosynostosis. Multiple sutures were affected in 2.8% cases. 7.0% of the cases were syndromic. Overall, 74 surgical procedures have been performed: frontoorbital advancement represented 40.5% of them; biparietal remodelling 32.4%: total cranial vault remodelling 22.9%; posterior distraction 2.7%; posterior expansion 1.3%. Median age at surgery was 12.8 months. The treatment of craniosynostosis is surgical and requires a multidisciplinary approach, with expertise in plastic and reconstructive surgery, maxillofacial surgery and neurosurgery. The aim of surgical treatment is to release the constrictive and deformative effect that the synostosis has on skull growth. This requires a remodelling of the neurocranium and, if necessary, of the viscerocranium. Beyond aesthetic purposes, the primary aim of surgical treatment is to permit a normal development of the brain.

Is there a chance for regeneration of intervertebral discs? A preliminary study

Introduction: Segmental instability of the spine caused by the decreased height of intervertebral discs is one of the major causes of chronic low back pain affecting 70-80% of the adult population. The decrease in height is due to degenerative lesions induced by vertical compression overload of the disc. Objective: A preliminary study was performed to determine if disc degeneration due to overload could be stopped. We hypothesized that disc distraction during fission surgery from posterior approach could reduce the pressure on the discs, degeneration could be stopped, and perhaps the function could be restored. Methods: To characterize the condition of the discus, we used the determination glycosaminoglycan content, which is responsible for the disc-bound water content and thus for ensuring its elasticity. The use of gadolinium contrast agent in MRI (dGEMRIC) is an accepted method for determining the glycosaminoglycan content of the intervertebral disc, as the concentration of absorbed contrast agent is inversely proportional to the number of glycosaminoglycans in the intervertebral discs. In addition to pre- and postoperative dGEMRIC data, we examined disc height, lumbar lordosis, visual analog pain scale, and the Oswestry Disability Index. Results: All patients underwent monosegmental fusion Mowing posterior distraction of the affected segment due to segmental instability. During the surgeries, lumbar lordosis did not decrease despite posterior distraction. The heights of the discus increased by an average of 3 mm, the pain decreased, and the Oswestry Disability Index improved. In the dGEMRIC studies, an average of 309.18 units/cm(2) of gadolinium accumulated in the discs before surgery, which decreased postoperatively to 174.43 units/cm(2). All changes were significant at the p = 0.05 significance level. Conclusion: The trend of our preliminary results suggests that increasing the height of the discs can reduce the hydrostatic pressure in the discs, resulting in an increase in the amount of glycosaminoglycans, which can stop the degeneration of the discs and also initiate regeneration processes.

Posterior vault distraction osteogenesis in Apert syndrome

Apert syndrome is an uncommon autosomal dominant condition with a varied clinical spectrum which includes premature cranial and facial suture fusion and complex upper and lower limb syndactilies. In this manuscript, we share our posterior vault distraction osteogenesis (PVDO) experience regarding Apert syndrome patients so that a larger patient population may benefit. In addition, we aimed to determine an onset of elevated intracranial pressure in the long term follow up.&#x0D; A retrospective study was performed on consecutive patients with syndromic craniosynostosis who were diagnosed with Apert syndrome, underwent PVDO between 2012 and 2019, and received at least 2 years of follow-up care. Demographic data, diagnosis, surgery related data, and outcome data (perioperative and mid-term complications and need for additional surgery), were verified by means of medical records, clinical photographs, radiographic images, and interviews with all included patients and/or their parents.&#x0D; The present study included 14 patients who were diagnosed respectively with Apert syndrome (n = 14). The average posterior advancement distance achieved was 19.37 ± 3.0 mm. Two patients included in this study presented major complications, but neither experienced permanent sequelae or a lethal course. Two Apert patients presented cerebral spinal fluid (CSF) leakage (Clavien–Dindo type II). One patient presented a onset of elevated intracranial pressure at 4 years of follow up.&#x0D; PVDO is an effective procedure at alleviating intracranial pressure and present a low complication rate.&#x0D; &#x0D; &#x0D;

The effect of posterior compression of the facet joints for initial stability and sagittal profile in the treatment of thoracolumbar fractures: a biomechanical study

PurposeSurgical treatment of thoracolumbar A3-fractures usually comprises posterior fixation—in neutral position or distraction—potentially followed by subsequent anterior support. We hypothesized that additional posterior compression in circumferential stabilization may increase stability by locking the facets, and better restore the sagittal profile.MethodsBurst fractures Type A3 were created in six fresh frozen cadaver spine segments (T12–L2). Testing was performed in a custom-made spinal loading simulator. Loads were applied as pure bending moments of ± 3.75 Nm in all six movement axes. We checked range of motion, neutral zone and Cobb’s angle over the injured/treated segment within the following conditions: Intact, fractured, instrumented in neutral alignment, instrumented in distraction, with cage left in posterior distraction, with cage with posterior compression.ResultsWe found that both types of instrumentation with cage stabilized the segment compared to the fractured state in all motion planes. For flexion/extension and lateral bending, flexibility was decreased even compared to the intact state, however, not in axial rotation, being the most critical movement axis. Additional posterior compression in the presence of a cage significantly decreased flexibility in axial rotation, thus achieving stability comparable to the intact state even in this movement axis. In addition, posterior compression with cage significantly increased lordosis compared to the distracted state.ConclusionAmong different surgical modifications tested, circumferential fixation with final posterior compression as the last step resulted in superior stability and improved sagittal alignment. Thus, posterior compression as the last step is recommended in these pathologies.

Novel Approach to Improving Knee Range of Motion in Arthrogryposis with a New Working Classification.

Arthrogryposis multiplex congenita (AMC) is a rare condition defined as contrac-tures in multiple joints. Surgical interventions for severe knee flexion contractures have included posterior release, distraction and extension with external fixation and distal femoral extension osteotomies. These operations have been able to achieve knee extension, but not increase the range of motion. The purpose of this study was to review our experience with peroneal nerve decompression, posterior knee release and proximal femoral shortening. We retrospectively reviewed the medical charts and radiographs of all patients with a diagnosis of arthrogryposis who underwent aforementioned procedure. There were 39 patients with 73 knees included in the analysis with a mean follow-up of 21 months. The mean preoperative arc of motion was 45° and last followup arc of motion was 79° (p < 0.0001). The mean last followup flexion contracture was 8° (p < 0.0001). Additional subanalyses were performed on those with followup greater than 24 months and those with flexion contractures >60°; there were no differences found in these groups. This study demonstrates that it is possible to achieve a functional range of motion of the knees in patients with AMC while improving ambulatory function.

Posterior vault distraction technique: how I do it

Posterior cranial vault distraction is an effective technique when a significant increase in the intracranial volume is required in patients with craniosynostoses. This technique has been proven to be safe and time saving and usually is associated with low perioperative morbidity as well as low intraoperative bleeding. Herein a technique is presented starting from the preoperative planning, describing the surgical steps of the operation and the postoperative distraction protocol used by the authors. The authors present important tips and tricks aiming to minimise complications and undesired events.

A novel posterior multiple screws distraction reducer system versus anterior release, posterior internal distraction, and subsequent spinal fusion for severe scoliosis

PurposeWe previously reported anterior release, posterior internal distraction, and subsequent spinal fusion (ARPIDF) for the correction of severe scoliosis with a satisfactory correction rate. However, surgical procedures were completed in 2–3 stages. Here we compare Cobb angle of ≥90° in scoliosis correction between a novel posterior multiple screws distraction reducer (MSDR) system and ARPIDF.MethodsThirty-six patients with severe scoliosis treated by MSDR or ARPIDF (n = 18 in both groups). We retrospectively analyzed and compared outcome measures between the two groups over a minimum follow-up duration of 2 years. The following variables were compared between the two groups: age at surgery, sex, etiology, flexibility of the main thoracic curve, number of fused segments and screws, operation time, estimated blood loss, hospitalization time, follow-up duration, various radiological parameters, complication rate, and Scoliosis Research Society-30 score.ResultsThere were no significant between-group differences with respect to age, sex, etiology, flexibility of the main thoracic curve, number of fused segments and screws, and follow-up duration. Further, there was no significant difference in terms of preoperative, postoperative, and final follow-up findings of the radiographic data. However, the ARPIDF group had longer operation and hospitalization times and greater blood loss. In the ARPIDF group, 4 patient developed complications (infection, intraoperative neuromonitoring changes, transient dyspnea); none of these events occurred in the MSDR group.ConclusionThe use of MSDR helped achieve greater scoliosis correction with a shorter operation time, lower blood loss, and lower complication rate than the use of ARPIDF. MSDR facilitates safer and easier correction of severe scoliosis without increasing surgical risk.

Clinical Features of Bilambdoid and Sagittal Synostosis (BLSS): A Retrospective Multicenter Study in Japan.

Bilambdoid and sagittal synostosis (BLSS), a rare form of multisutural craniosynostosis, is sometimes known as the Mercedes-Benz syndrome due to the appearance of the fused sagittal and bilateral lambdoid sutures. Although previous studies have described some of its clinical features, the pathology of this disease is not yet fully understood. Moreover, it has been pointed out that BLSS is more common among individuals of Hispanic ethnicity, but its incidence in Asia remains unclear. In the present study, BLSS cases in Japan were analyzed to determine the characteristics of the condition in Japan. Three hospitals in Tokyo participated in the present study. Patients with BLSS who underwent cranial remodeling were included. Data on patient demographics, clinical symptoms, status of the cranial sutures, morphological subclassification, surgical procedures, developmental status, and genetic mutations were analyzed. In total, 22 patients met the enrollment criteria and were included, indicating a higher incidence of BLSS in Japan than in other nations reported in previous studies. In terms of morphological subclassification, there were 15 brachycephalic, 4 dolichocephalic, and 3 normocephalic. For the initial cranial procedure, 7 patients underwent a single-stage cranioplasty, 13 underwent a posterior distraction, and 2 underwent lateral expansion. Patients with a normocephalic cranial morphology tended to undergo surgery at an older age than patients with the other two types. Appropriate timing for surgery is important for healthy development; hence, surgeons should remember that BLSS can lead to "balanced dysmorphism" that may have led to a delay in diagnosis due to its normal-looking morphology.

Surgical Management of FGFR2 Mutation-Related Syndromic Craniosynostosis: Retrospective Review of a 45-Year Experience By a Single Surgeon

PURPOSE: Mutations in the fibroblast growth receptor 2 (FGFR2) gene have been identified in syndromic craniosynostosis syndromes such as Apert, Crouzon, and Pfeiffer syndrome. Patients have severe malformations of the skull and face requiring multiple complex reconstructive procedures. As described by Paul Tessier, surgical correction of such patients is performed for 3 main reasons: functional, morphologic, and psychological. The surgical treatment algorithm has evolved over time. Despite numerous articles describing treatment of syndromic craniosynostosis, there are few reports of long-term results. Long-term follow up of patients after midface surgeries is important for evaluating which techniques result in consistent favorable outcomes, and which should be improved. We present a retrospective review reporting surgical procedures performed by a single surgeon in patients with Apert, Crouzon, and Pfeiffer Syndrome over a period of 45 years, with the intent to delineate procedures that have been effective over time. We also present our surgical treatment algorithm for pediatric patients with FGFR2 mutation–related syndromic craniosynostosis based on the senior author’s experience. METHODS: A retrospective review was performed of all patients with FGFR2 mutation–related syndromic craniosynostosis that underwent reconstruction for craniofacial defects, as performed by the senior author between 1975 and 2020. Patients without syndromic craniosynostosis were excluded. Inclusion criteria was limited to Apert, Crouzon, and Pfeiffer syndromes. Surgical procedures and complications were recorded for patients at all stages of the reconstructive process. RESULTS: A total of 68 patients were identified who had complete records for evaluation, including 30 patients with Apert syndrome, 27 patients with Crouzon syndrome and 11 patients with Pfeiffer syndrome. The average patient age was 30±15.8 years, with a range of 3–77 years of age. Mean long-term follow-up after initial surgery was 10.5 ± 10.1 years. Primary procedures performed for correction of craniofacial deformities included posterior distraction or expansion (10.3%), frontal expansion (14.7%), fronto-orbital advancement (39.7%), facial bipartition (11.8%), Le Fort III (19.1%), and Le Fort I (23.5%). Mean ages at which procedures were performed were 1.5 ± 1.6 years for posterior distraction or expansion, 1.1 ± 1.2 years for fronto-orbital advancement, 6.2 ± 3.8 years for monobloc frontoacial advancement, 4.6 ± 1.8 years for monobloc frontofacial advancement with facial bipartition, 13.2 ± 8.2 years for Le Fort III, and 17.0 ± 3.8 years for Le Fort I. Additional procedures commonly used included nasal bone grafts (25.0%) and lateral canthopexies (19.1%). CONCLUSIONS: This study, with an extensive long-term follow-up period, presents a pediatric surgical treatment algorithm for patients with FGFR2 mutation–related syndromic craniosynostosis. Our treatment algorithm entails a posterior distraction or expansion and fronto-orbital advancement at 6 months, monobloc frontofacial advancement ± facial bipartition at age 6 or 7, or a Le Fort III if morphologically indicated, and in most cases, a Le Fort I at age 17 or 18. Although multiple reconstructive procedures are necessary, complications are rare. This treatment algorithm results in good results in adolescence, allowing patients to integrate into mainstream life. However, patients tend to prematurely age, a problem that is not addressed by the current pediatric surgical treatment algorithm. Future directions include defining aesthetic surgical management of adults.

Secondary Synostosis After Posterior Vault Distraction in Craniosynostosis: Possible Role of Compression From Distraction

Secondary Synostosis After Posterior Vault Distraction in Craniosynostosis: Possible Role of Compression From Distraction

Reconsideration of the transoral odontoidectomy in complex craniovertebral junction patients with irreducible anterior compression

BackgroundAlthough the single-stage posterior realignment craniovertebral junction (CVJ) surgery could treat most of the basilar invagination (BI) and atlantoaxial dislocation (AAD), there are still some cases with incomplete decompression of the spinal cord, which remains a technique challenging situation.MethodsEleven patients were included with remained myelopathic symptoms after posterior correction due to incomplete decompression of the spinal cord. Transoral odontoidectomy assisted by image-guided navigation and intraoperative CT was performed. Clinical assessment and image measurements were performed preoperatively and at the most recent follow-up.ResultsEleven patients were followed up for an average of 47 months. Symptoms were alleviated in 10 of 11 patients (90.9%). One patient died of an unknown reason 1 week after the transoral approach. The clinical and radiological parameters pre- and postoperatively were reported.ConclusionTransoral odontoidectomy as a salvage surgery is safe and effective for properly selected BI and AAD patients after inadequate indirect decompression from posterior distraction and fixation. Image-guided navigation and intraoperative CT can provide precise information and accurate localization during operation, thus enabling complete resection of the odontoid process and decompression of the spinal cord.

Posterior Distraction Using Springs in Syndromic and Multisuture Craniosynostosis: Improving the Technique.

Posterior distraction is the preferred surgical treatment for particularly Apert and Crouzon syndrome in most craniofacial centers, using either external distractors or springs. The authors prefer the use of springs and have adapted their technique to further improve outcomes. All patients who were treated with the adapted technique for occipital expansion using springs were included. The most significant adaption that the authors introduced in 2017 is using a bony hinge at the top of the vault instead of at the caudal edge of the occiput. A total of 8 posterior expansions with springs were performed. No complications occurred and the springs were also successfully applied in cases with extremely thin bone. If indicated, a simultaneous foramen magnum decompression was performed and this was easier to combine with a hinge at the top of the vault. Posterior distraction with springs is a safe and effective procedure and allows a simultaneous foramen magnum decompression. Planning the hinge at the vault allows intracranial volume gain at the site of the posterior skull base.

The relation between pelvic trauma (fractured pelvis) with posterior urethral distraction injury associated with erectile dysfunction

Background: The aim was to study the relation between posterior urethral distraction injury due to pelvic trauma (fractured pelvis) with erectile dysfunction and to do the clinical assessment of Erectile dysfunction by penile Doppler study for assessment of peak flow velocity. Material and Methods: Total number of cases included in the study was 13, out of which 5 patients belonged to young (<30 years) age group, 5 patients belonged to middle (30-50 years) age group and 3 patients belonged to old age group. Out of the total 13 patients, 8 patients had pelvic fracture associated with urethral injury and 5 patients had traumatic urethral stricture without pelvic fracture. Results: Out of 8 patients of pelvic fracture with urethral injury, all 8 developed erectile dysfunction after trauma. While among 5 patients of traumatic urethral stricture without pelvic fracture, 3 patients developed erectile dysfunction after trauma. While in traumatic urethral injury without pelvic fracture, amongst 3 patients who had erectile dysfunction, 2 patients had reduced flow on penile Doppler ultrasound and were classified as vascular erectile dysfunction while 1 patient was having a normal flow on penile Doppler ultrasound and was classified as neurogenic/psychological erectile dysfunction. Conclusion: Pelvic fracture associated urethral injury has a high incidence of erectile dysfunction. Vascular erectile dysfunction in such patients is more common than neurogenic/psychological erectile dysfunction. And postoperatively (urethroplasty), there is no significant decrease in penile colour doppler vascularity in such patients.

Is prophylactic formal fusion with implant revision necessary in non-ambulatory children with spinal muscular atrophy and growing rods who are no longer lengthened?

Single center, retrospective chart review. To determine if routine posterior spinal fusion (PSF) is unnecessary in non-ambulatory growing rod graduates with SMA. Most non-ambulatory children with SMA develop early-onset scoliosis (EOS). Posterior growing rods (GR) have been shown safe and effective in managing spinal deformities in these children. The best management of these children, once graduated from their GR, is currently unknown. In this study, we report the clinical results of managing these children without routine definitive fusion following a course of GR treatment. A single-center, retrospective chart and radiographic review was performed on children with SMA treated with posterior distraction GR, with a two-year minimum follow-up since final lengthening. Electronic medical records and radiographs were reviewed for demographic variables, Cobb measurements, implant revisions, occult radiographic implant failure, symptomatic failure, and/or conversion to PSF. 12 patients (2 type 1, 9 type 2, 1 type 1/2) met inclusion criteria. Mean age at growing rod insertion was 6.2years of age (range 4.1-8.2) and age at final lengthening 10.3years of age (range 9.3-11.9). The mean time between last lengthening and latest clinical or radiographic review was 5.5 (range 2.1-9.0) years. Average mean pre, post, final Cobb angles were 71°, 27° (p < 0.001), 25°. Following final lengthening, only one patient required hardware revision and conversion to definitive fusion in attempts to alleviate chronic hip pain, which was unsuccessful. One additional patient was found to have an occult rod failure that has not required treatment. While limited by sample size, this single-center cohort of non-ambulatory SMA patients with EOS treated with similar constructs suggests that routine, definitive fusion in SMA GR graduates may be unnecessary. Level IV.

Sacroiliac Joint Ligaments and Sacroiliac Pain: A Case–Control Study on Micro- and Ultrastructural Findings on Morphologic Alterations

Background: The sacroiliac joint (SIJ) is a common source of low back pain. SIJ pain has shown to have negative impact on patients’ quality of life. Although clinically there is an increasing interest to treat SIJ-related pain both conservatively and surgically, the underlying mechanisms related to pathology in that region are poorly understood. One hypothesis is that the SIJ ligaments are structurally altered in SIJ pain. Objectives: The given study investigated patient cases with different pain durations undergoing posterior distraction arthrodesis of the SIJ, with subsequent micro- and ultrastructural assessment of the interosseous and posterior SIJ ligaments compared with autopsy controls without known history of low back pain. Study Design: Case–control study. Morphologic-pathological analysis of tissue samples obtained during surgery with controls from legal medicine. Setting: Rural hospital setting in Halberstadt, Germany. Methods: SIJ ligaments were removed from 6 patients undergoing SIJ arthrodesis for histological and ultrastructural assessment in scanning and transmission electron microscopy, and compared with 6 controls without known history of SIJ pathology. Results: A number of alterations were observed in the ligaments of patients with SIJ, namely ligament disruption, collagen loosening and coiling, vascularization, and hemorrhage. In some areas, these changes were observed in proximity to healthy (structurally unaltered and intact tissues), indicative of a potential disease progression. Comparison to controls yielded a significant correlation between SIJ pathology and the level of collagen degeneration (φ ≥ 0.82; P &lt; 0.001). Limitations: Small sample size, method of tissue removal from patients may have influenced tissue integrity. Conclusions: The combined clinical, histological, and ultrastructural analysis provided, to our knowledge, first-time evidence of morphologic SIJ ligament alteration of a nontraumatic and noninflammatory cause. Further research is necessary to elucidate these structural changes and to substantiate pain duration and patient-history-dependent changes at the ligaments of the posterior pelvis

Treatment of single-segment lumbar tuberculosis with minimally invasive posterior internal fixation combined with anterior small incision debridement

To review the clinical efficacy of minimally invasive pedicle fixation combined with anterior small incision focus debridement for single-segment lumbar spine tuberculosis, a total of 31 patients with single-segment marginal lumbar tuberculosis were enrolled in the study. All the patients received quadruple anti-tuberculosis chemotherapy for 2 weeks before surgery and treatment with minimally invasive posterior internal fixation, anterior small incision focus debridement, and bone graft fusion. Those patients with preoperative kyphosis deformity were initially treated with appropriate posterior distraction correction. Except for 1 patient who healed 2 weeks after medical dressing change, the remaining 30 patients healed as expected. All the patients had no screwrelated surgical complications, neurological dysfunction, vascular injury, and other complications. The average visual analog scale scores at 3 months postoperatively were significantly decreased to 1.4 ± 1.5 ( P &lt; 0.05). In conclusion, under the premise of treatment using appropriate, effective anti-tuberculosis agents, this surgical procedure for managing patients with lumbar vertebral tuberculosis achieved satisfactory results, effectively reducing the exposure range and fusion segments in simple anterior focus debridement and internal fixation. Using minimally invasive posterior pedicle screw fixation can effectively increase spine stability, reduce fusion segment, and decrease anterior surgical trauma and complications.