Preoperative Kyphosis Research Articles

Anterior vertebral body tethering shows mixed results at 2-year follow-up.

Retrospective chart review. To report 2-4-year outcomes of anterior vertebral body tethering (AVBT) for adolescent idiopathic scoliosis (AIS). AVBT is a relatively new procedure to correct AIS spine curvature and few outcomes studies have been published. Patients from 2015 to 2017 with 2-year follow-up were included. Successful outcomes were defined as curves 35° or less without revision surgery. We also compared outcomes between thoracic and lumbar ABVT. There were 19 AVBTs in 17 patients, 13 thoracic and 6 lumbar. Nine curves (47%) in nine patients (53%) were successful. Preoperative kyphosis averaged 26° in the successful group and 14° in the unsuccessful group (P = 0.0337). Immediate correction for lumbar ABVTs (76%) was greater than thoracic ABVTs (43%) (P = 0.0140). Correction per level per month was greater in lumbar ABVTs (2.9° vs. 0.1°) (0.0440). Preoperative Sanders Maturity Scale (SMS) was 3.7 for successful cases and 2.5 for unsuccessful cases (P = 0.0232). Final SMS was 7.7 for successful cases and 5.7 for unsuccessful cases (P = 0.0518). All successful cases and 50% of unsuccessful cases were mature at final follow-up (P = 0.0294). There were four (24%) revision procedures, and three involving lumbar AVBTs. There were nine (47%) broken tethers. Despite several final curves > 35°, four revisions, and nine broken tethers, the majority of patients (53%) were considered successful. Lumbar ABVTs correct more intraoperatively and faster postoperatively. Patients who are tethered during or slightly after the curve acceleration phase of growth may have more successful outcomes than patients tethered prior to the curve acceleration phase. AVBT requires further study with longer outcomes to define best practices for indications, level selections, and surgical techniques. IV.

Posterior Stabilization Without Neural Decompression in Osteoporotic Thoracolumbar Fractures With Dynamic Cord Compression Causing Incomplete Neurological Deficits.

Study Design:Prospective cohort study.Objectives:Management of osteoporotic vertebral compression fracture (OVCF) remains an unsolved problem for a spine surgeon. We hypothesize that instability at the fracture site rather than neural compression is the main factor leading to a neurological deficit in patients with OVCF.Methods:In this study, the prospective data of patients with osteoporotic fractures with incomplete neurological deficits from January 2015 to December 2017 was analyzed in those who underwent posterior instrumented fusion without neural decompression.Results:A total of 61 patients received posterior indirect decompression via ligamentotaxis and stabilization only. Of these 17 patients had polymethylmethacrylate (PMMA) augmented screws and in 44 patients no PMMA augmentation was done. The mean preoperative kyphosis was 27.12° ± 9.63°, there was an improvement of 13.5° ± 6.87° in the immediate postoperative period and at the final follow-up, kyphosis was 13.7° ± 7.29° with a loss of correction by 2.85° ± 3.7°. The height restoration at the final follow-up was 45.4% ± 18.29%. In all patients, back pain was relieved, and neurological improvement was obtained by at least 1 American Spinal Injury Association Impairment Scale in all except 3 patients.Conclusion:We propose that neural decompression of the spinal cord is not always necessary for the treatment of neurological impairment in patients with osteoporotic vertebral collapse with dynamic mobility. Dynamic magnetic resonance imaging is a valuable tool to make an accurate diagnosis and determine precise surgical plan and improving the surgical strategy of OVCF.

Modified mini-open SRS-Schwab grade 4 osteotomy combined with percutaneous pedicle screws fixation in post-traumatic thoracolumbar kyphosis

BackgroundWe aimed to analyze the clinical results of Schwab grade 4 osteotomy combined with percutaneous pedicle screws (PPS) fixation for treatment of post-traumatic thoracolumbar kyphosis (PTK).MethodsThirty four patients with PTK (group A) were included in our study. The average age was 54.9 ± 3.3 years. All patients had severe back pain with 8.6 ± 1.3 VAS scores. The affected level was T12 in 16 patients and L1 in 18 patients. The average preoperative regional kyphosis angle (RKA) was 30.7 ± 6.00. Three patients had neurological dysfunction with ASIA grade D. All patients underwent Schwab grade 4 osteotomy combined with PPS fixation. The control group (Group B) were 26 PTK patients treated with Schwab grade 4 osteotomy and open pedicle screws fixation in our institution.ResultsOperation time in groups A and B was 280 ± 50 min and 210 ± 30 min, respectively (P < 0.05). Estimated blood loss in groups A and B was 310 ± 70 ml and 630 ± 40 ml, respectively (P < 0.05). No cerebral spinal fluid leakage, segmental nerve function damage, and other complications observed during and after the operations in both groups. RKA, SVA, and LL improved significantly after surgery in both groups (P < 0.05). The average correction rate in groups A and B was 64.5 and 66.3% (P > 0.05). CT showed that the misplacement rate in groups A and B was 5.5 and 6.6% (P > 0.05). The average follow-up in groups A and B was 25.2 ± 7.6 months and 30.6 ± 2.7 months. No fracture and other complications were observed in both groups. Solid bone fusion was showed in all cases at 6 months follow-up. In groups A and B, all patients with preoperative neurological dysfunction recovered to ASIA grade E at the last follow-up. The VAS score of back pain improved significantly from 8.6 ± 1.3 to 1.6 ± 1.0 at the last follow-up in group A (P < 0.05), while it improved significantly from 8.3 ± 1.2 to 3.0 ± 1.1 at the last follow-up in group B (P < 0.05). VAS of back pain was better in group A than that in group B.ConclusionSchwab grade 4 osteotomy combined with percutaneous pedicle screws fixation is a minimally invasive, safe and effective method for PTK treatment.

294. Ambulatory neuromuscular scoliosis patients have similar rates of infection, perioperative complications and revision to adolescent idiopathic scoliosis patients

BACKGROUND CONTEXT It is well known that patients with NMS are victims of severe pathological progression. When examined as a collective group, NMS has a worse prognosis and surgical outcomes than its AIS counterpart. However, not all operative patients with diagnoses of cerebral palsy, Duchenne muscular dystrophy or other NMS pathology necessarily suffer the same poor outcomes associated with the class. PURPOSE Our aim with this study is to examine more mildly affected NMS patients to determine whether their surgical outcomes are comparable to AIS with regards to patient safety. STUDY DESIGN/SETTING Retrospective review from prospectively collected database. PATIENT SAMPLE A total of 48 NMS and 158 AIS patients OUTCOME MEASURES Perioperative complications (infection, pulmonary, DVT, neurologic, cardiovascular, revision) METHODS Radiograph and retrospective chart review of NMS and AIS patients undergoing PSF with pedicle screws from 2005-2018 were analyzed. Group 1 included NMS patients who could ambulate without assistance (GMFCS I-III). Group 2 was AIS patients. Demographics, intra-op parameters, and radiographic measurements were collected at pre- and post-op. Wilcoxon rank sums tests and chi-square tests were performed. RESULTS Group 1 (n = 48) and Group 2 (n = 158) were similar in age, sex, preoperative kyphosis, pre- and postoperative Cobb angle, and Cobb correction. Additionally, EBL (600mL vs 500mL; p=0.143), postoperative transfusions (4 vs 9; p=0.5), and perioperative complications within 30 days (4 vs 10; p=0.5) were similar between groups. Specifically, infections (0 vs 5; p = 0.592), DVT (0 vs 1;p = 0.232), revisions (1 vs 4; p = 1.0), and mortality (p = 1.0) were statistically similar. However, group 2 NMS patients did have increased fusion levels (p CONCLUSIONS NMS inherently confers high risk of blood loss, longer surgeries and fusions, complications, ICU and hospitals stays. Our data confirm longer fusion levels, surgical time, and hospital stay, with lower extubation rates. Infection rate, revisions and overall complications were similar to the AIS population as were the radiographic outcomes. This suggests that NMS patients who are ambulating can expect surgical outcomes quite comparable to AIS patients with further room for improvement in surgical duration and anesthesia protocols. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

P82. A proper spinal column shortening in PVCR make a better result

BACKGROUND CONTEXT PVCR has been plagued with high neurologic deficits risk. Spinal column shortening can decrease the tension of the spinal cord and increase the compliance of the spinal cord to correction in PVCR. However, there was few studies focus on the spinal column shortening in severe spine deformity treated with PVCR. PURPOSE The purpose of this study was to provides the data of spinal column shortening in posterior vertebral column resection (PVCR) based on a single center. STUDY DESIGN/SETTING A retrospective study. PATIENT SAMPLE A total of 57 severe spine deformity patients (24 female and 33 male) received PVCR were included in this study, the mean age was 24.2±14.8 years old. OUTCOME MEASURES The spinal column shortening distance (SD) and the resection space distance (RD) were measured on CT scan. Then, the shortening percentage (SP: SD/RD*100%) was calculated. Patient's demographics, radiographic parameters, IONM and neurologic function were reviewed. METHODS Severe spine deformity patients with no neurologic deficits, from 2013 to 2017, were reviewed. All patients received PVCR at a single institution, and the deformity correction was based on spinal column shortening over the resected gap during PVCR. The spinal column shortening distance (SD) and the resection space distance (RD) were measured on CT scan. Then, the shortening percentage (SP: SD/RD*100%) was calculated. Patient's demographics, radiographic parameters, IONM and neurologic function were reviewed. RESULTS There were 46 scoliokyphosis patients, the mean preoperative scoliosis of 109.15±17.57° was corrected to 46.72±17.10°, and the mean preoperative kyphosis of 88.68±28.44° was corrected to 32.15±16.90°. The mean SD was 1.27±0.53 cm and the mean SP was 45.78±19.35% on the coronal plane. The mean SD was 1.32±0.55 cm and the mean SP was 45.65±13.41% on the sagittal plane. There were 11 angular kyphosis patients, the mean preoperative kyphosis of 98.38±16.56° was corrected to 37.38±10.66°. The mean SD was 1.71±0.82 cm and the mean SP was 47.22±15.11% on the sagittal plane. The SD and SP at different spinal segment (T1-5, T6-10, T11-L1 and L2-L5) have some differences at coronal and sagittal plane. Four patients (7%) had a spinal cord monitoring change, including one patient suffered from failed wake-up test. The spinal cord monitoring of all above patients returned to normal after adjust the correction, and all those patients showed no neurological impairment after surgery. There was no permanent paraplegia in this study. CONCLUSIONS During PVCR procedure, a proper spinal column shortening can increase the tolerance of the spinal cord to the PVCR correction, and it is beneficial to reduce the neurological complications. The proper distance of spinal column shortening was approximately 50% of the resection space, but excessive shortening should be avoided. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Outcome Analysis of Anterior Reconstruction with Rib Grafts in Tuberculosis of the Thoracic Spine.

Introduction:Tricortical iliac bone is the gold standard as an autograft for the reconstruction of the anterior column in tuberculosis (TB) of the thoracic spine. However, the quantity of graft needed is significant. It creates a considerable defect in the pelvic bone, causing graft site complications, including pain, pelvic instability, fractured ilium, herniated muscle, or abdominal contents. To prevent these donor site morbidities, ribs that were removed during the versatile approach were used for anterior reconstruction. The aim of this study was to assess the clinical and radiological results of the reconstruction of the anterior column of the spine with the help of an excised rib during the versatile approach.Subjects and Methods:This retrospective study was undertaken at a tertiary care center with a study duration of 14 years. Between January 2004 and December 2016, 52 patients with thoracic Koch's spine had anterior column reconstructed with multiple rib grafts. A single surgeon performed all operations. Indications for the surgery in these patients were the presence of neurologic deficit (49 patients) and vertebral column instability (3 patients). The preoperative kyphosis angle and visual analog scale (VAS) score were compared with postoperative values using a paired t-test.Results:All patients underwent a minimum follow-up of 18 months and were evaluated clinicoradiologically. Good bony fusion with neurological recovery was achieved in all cases. The VAS score for back pain improved significantly postsurgery. There was one case of graft buckling treated conservatively.Discussion:Appropriate anterior reconstruction forms the cornerstone of successful surgical management of spinal TB. The “Versatile approach” used offers anterior and posterior access in the lateral position. In these patients, we obviated the need for iliac crest graft using multiple segments of the rib for anterior column reconstruction. This meticulous rib grafting technique gives good functional outcome in terms of solid bony fusion.Conclusion:Meticulous rib grafting technique gives 360° bony fusion and good functional outcome in surgery for thoracic spinal TB. It has the advantage of avoiding the complications associated with a tricortical iliac crest graft.

Posterior vertebral column resection for correction of thoracolumbar kyphosis after failed anterior instrumented fusion

To explore the effectiveness of posterior vertebral column resection for failed thoracolumbar anterior instrumented fusion.Ten patients with anterior fusion with refractory pain, progressive neurological deficits, and kyphosis were recruited. Anterior removal of the implant and posterior vertebral column resection were performed. The mean operating time, intraoperative blood loss, kyphosis angle, visual analog scale pain score, Oswestry disability index, bone fusion time, and complications were assessed in a minimum 18-month follow-up.The mean operating time was 323.5 ± 63.6 minutes, with a mean blood loss of 1189 ± 253.4 mL. The mean preoperative kyphosis angle of 54.6° ± 8.0° immediately decreased to 4.8° ± 1.5° after revision surgery and eventually to 6.8° ± 1.3° at the final follow-up. The mean bone fusion time was 6.8 ± 1.2 months. All patients had satisfactory sagittal and coronal balance with no implant failure at the last follow-up. The average visual analog scale score was 6.2 ± 1.0 preoperatively, and it decreased to 2.6 ± 0.5 at the last follow-up. No patient suffered from neurological deterioration. The Oswestry disability index decreased from 39.8% ± 4.6% preoperatively to 24.5% ± 4.7% at the final follow-up. Complications occurred in 4 patients: 3 experienced tearing of the lung, and 1 had a superficial wound infection.Anterior removal of the implant and posterior vertebral column resection constituted a safe and effective revision surgery for patients with prior anterior fusion with rigid postsurgical deformities.

Kyphosis Correction in Patients Undergoing a Four-Level Anterior Cervical Discectomy and Fusion

IntroductionCervical kyphotic deformity can be quite debilitating. Most patients present with neck pain, but they can also present with radiculopathy, myelopathy, altered vertical gaze, swallowing problems, and even cosmetic issues from the severe kyphotic deformity. After failing conservative management, surgery remains the only option for halting symptom progression. Surgical options for cervical kyphosis have included anterior-only approaches, posterior-only approaches, or 360- and 540-degree reconstructions. This paper addresses the correction of cervical kyphotic deformity via an anterior-only approach consisting of a four-level anterior cervical discectomy and fusion (ACDF).MethodsWe interrogated our procedure log system and the keyword “anterior cervical discectomy and fusion (ACDF)” was typed into the search bar. All patients with an ACDF for the past five years were reviewed and patients with a four-level ACDF were selected. Chart review was performed and patients presenting with multi-level cervical stenosis with kyphosis were included in the study. Pre- and post-surgery images were reviewed, and the degrees of pre-operative kyphosis and post-operative lordosis were measured.Results Our search produced 20 patients. All the patients had a diagnosis of multi-level cervical stenosis with or without myelopathy and were all symptomatic. Pre-operative kyphosis ranged from 2.3 to 35 (mean 11.5) degrees, and post-operative lordosis ranged from 2 to 38 (mean 16) degrees. All the patients had varying degrees of kyphosis correction post-surgery which ranged from 6 to 44 (mean 27) degrees. Significant improvement or complete resolution of symptoms post-operatively occurred in all patients.Conclusion Four-level ACDF in carefully selected patients can be used to correct cervical alignment in patients presenting with symptomatic multi-level cervical stenosis with kyphosis.

Comparison of perioperative complications following posterior column osteotomy versus posterior-based 3-column osteotomy for correction of rigid cervicothoracic deformity: a single-surgeon series of 95 consecutive cases.

The correction of severe cervicothoracic sagittal deformities can be very challenging and can be associated with significant morbidity. Often, soft-tissue releases and osteotomies are warranted to achieve the desired correction. There is a paucity of studies that examine the difference in morbidity and complication profiles for Smith-Petersen osteotomy (SPO) versus 3-column osteotomy (3CO) for cervical deformity correction. A retrospective comparison of complication profiles between posterior-based SPO (Ames grade 2 SPO) and 3CO (Ames grade 5 opening wedge osteotomy and Ames grade 6 closing wedge osteotomy) was performed by examining a single-surgeon experience from 2011 to 2018. Patients of interest were individuals who had a cervical sagittal vertical axis (cSVA) > 4 cm and/or cervical kyphosis > 20° and who underwent corrective surgery for cervical deformity. Multivariate analysis was utilized. A total of 95 patients were included: 49 who underwent 3CO and 46 who underwent SPO. Twelve of the SPO patients underwent an anterior release procedure. The patients' mean age was 63.2 years, and 60.0% of the patients were female. All preoperative radiographic parameters showed significant correction postoperatively: cSVA (6.2 cm vs 4.5 cm [preoperative vs postoperative values], p < 0.001), cervical lordosis (6.8° [kyphosis] vs -7.5°, p < 0.001), and T1 slope (40.9° and 35.2°, p = 0.026). The overall complication rate was 37.9%, and postoperative neurological deficits were seen in 16.8% of patients. The surgical and medical complication rates were 17.9% and 23.2%, respectively. Overall, complication rates were higher in patients who underwent 3CO compared to those who underwent SPO, but this was not statistically significant (total complication rate 42.9% vs 32.6%, p = 0.304; surgical complication rate 18.4% vs 10.9%, p = 0.303; and new neurological deficit rate 20.4% vs 13.0%, p = 0.338). Medical complication rates were similar between the two groups (22.4% [3CO] vs 23.9% [SPO], p = 0.866). Independent risk factors for surgical complications included male sex (OR 10.88, p = 0.014), cSVA > 8 cm (OR 10.36, p = 0.037), and kyphosis > 20° (OR 9.48, p = 0.005). Combined anterior-posterior surgery was independently associated with higher odds of medical complications (OR 10.30, p = 0.011), and preoperative kyphosis > 20° was an independent risk factor for neurological deficits (OR 2.08, p = 0.011). There was no significant difference in complication rates between 3CO and SPO for cervicothoracic deformity correction, but absolute surgical and neurological complication rates for 3CO were higher. A preoperative cSVA > 8 cm was a risk factor for surgical complications, and kyphosis > 20° was a risk factor for both surgical and neurological complications. Additional studies are warranted on this topic.

Essential lordosis revisited.

Significant correction of an adolescent idiopathic scoliosis in the coronal plane through a posterior approach is associated with hypokyphosis. Factors such as the magnitude of the preoperative coronal curve, the use of hooks, number of levels fused, preoperative kyphosis, screw density, and rod type have all been implicated. Maintaining the normal thoracic kyphosis is important as hypokyphosis is associated with proximal junctional failure (PJF) and early onset degeneration of the spine. The aim of this study was to determine if coronal correction per se was the most relevant factor in generating hypokyphosis. A total of 95 patients (87% female) with a median age of 14 years were included in our study. Pre- and postoperative radiographs were measured and the operative data including upper instrumented vertebra (UIV), lower instrumented vertebra (LIV), metal density, and thoracic flexibility noted. Further analysis of the post-surgical coronal outcome (group 1 < 60% correction and group 2 ≥ 60%) were studied for their association with the postoperative kyphosis in the sagittal plane using univariate and multivariate logistic regression. Of the 95 patients, 71.6% (68) had a thoracic correction of > 60%. Most (97.8%) had metal density < 80%, while thoracic flexibility > 50% was found in 30.5% (29). Preoperative hypokyphosis (< 20°) was present in 25.3%. A postoperative thoracic hypokyphosis was four times more likely to occur in patients with thoracic correction ≥ 60% (odds ratio (OR) 4.08; p = 0.005), after adjusting for confounding variables. This association was not affected by metal density, thoracic flexibility, LIV, UIV, age, or sex. Our study supports the 'essential lordosis' hypothesis of Roaf and Dickson, i.e. with a greater ability to translate the apical vertebra towards the midline, there is a commensurate lengthening of the anterior column due to the vertebral wedging. Cite this article: Bone Joint J 2020;102-B(4):513-518.

Five or more proximal anchors and including upper end vertebra protects against reoperation in distraction-based growing rods.

Retrospective multi-center enrollment. To examine the impact of patient and surgical factors on proximal complication and revision rates of early onset scoliosis patients using a multicenter database. Proximal anchor pullout and junctional kyphosis are common causes necessitating revision surgery during growth friendly treatment of early onset scoliosis (EOS). Many options exist for proximal fixation and may impact the rate of these complications. Retrospective review of multicenter database of patients with growth friendly constructs for EOS. Inclusion criteria were patients with index instrumentation < 10years of age and minimum of 2year follow-up. 353 patients met the inclusion criteria and had the following constructs: growing rods with spine anchors = 303; growing rods with rib anchors = 15 and VEPTR = 35. Mean age at index instrumentation was 6.0years. Mean preoperative Cobb angle was 76° and mean kyphosis was 54°. Mean follow-up was 6.0years. 21.8% of patients (77/353) experienced anchor pullout. Lower anchor pullout rates were associated with a higher numbers of proximal anchors (p = 0.003, r = - 0.157), and 5 or more anchors were associated with lower rates of anchor pullout (p = 0.014). Anchor type (rib hooks vs spine anchors vs rib cradle) did not impact rate of anchor pullout (p = 0.853). Kyphosis data was available for 198 patients. 23.2% (46/198) of these patients required proximal extension of their construct after index surgery. Initial instrumentation below the upper end vertebrae (UEV) of kyphosis was associated with higher rates of subsequent proximal revision; 28.9% (20/69) compared to 20.1% (26/129) for those instrumented at or above the UEV (p = 0.035). Preoperative kyphosis and change in thoracic kyphosis were not associated with anchor pullout (p = 0.436, p = 0.115) or proximal revision rates (p = 0.486, p = 0.401). Five or more anchors are associated with lower rates of anchor pullout. Proximal anchor placement at or above the UEV resulted in a significant decrease in rates of proximal extension of the construct.

A study on clinicoradiological outcome of posterior and posterolateral decompression and stablisation with pedicle screws and fusion for tuberculosis of dorsal and lumber spine

INTRODUCTION: Tuberculosis is ubiquitous in distribution. Globally, nearly 30 million people suffer from tuberculosis. 3 million deaths occur due to tuberculosis per year. India has burden of 6 million cases. Recent increase in the incidence is due to concomitant tuberculosis with HIV infection and drug resistance. Of these 1-3% constitutes skeletal system involvement. Spinal tuberculosis(50%) is the most common form of skeletal tuberculosis. The evolution of treatment of tuberculosis of spine have passed through different phases of development from Pre-antitubercular era through Postantitubercular era and from Radical surgery through Middle path regimn. Traditionally, the anterior approach is the gold standard approach because vertebral bodies and disc spaces are most commonly affected, and the anterior approach allows direct access to the diseased vertebral bodies for debridement and abscess drainage, allows wide decompression and reconstruction of the defect. A combined anterior debridement and posterior instrumentation helps to overcome stability related drawbacks of anterior approach alone. However, it entails two surgeries (single event or staged) with additional morbidity and is indicated for patients with significant deformity. In posterior or posterolateral approaches anterior and lateral column can be reached through extra pleural approach. Posterior approach provides excellent exposure for circumferential spinal cord decompression, allows multiple level posterior instrumentation above and below the level of pathology, more stable construct ,less morbid surgery, allows earlier rehabilitation and is a familiar approach. AIM OF THE STUDY: The aim of this prospective study is to analyse the clinicoradiological outcome of posterior and posterolateral decompression, stabilisation with pedicle screws and fusion for tuberculosis of dorsal and lumbar spine done in our institution from July 2010 to June 2012. OBJECTIVES : (a) To study the effectiveness of posterior and posterolateral decompression, stabilisation with pedicle screws and fusion for tuberculosis of dorsal and lumbar spine. (b) To study the improvement in the angle of kyphosis. (c) To show that posterior surgery allows early mobilisation. (d) To evaluate that posterior surgery associated with reduced morbidity and mortality. MATERIALS AND METHODS: This study was conducted in our Hospital on 15 patients with Tuberculosis of Dorsal and Lumbar spine from July 2010 to June 2012. All patients were treated with posterior or posterolateral approach and stabilised with Pedicle screw system. Selection criteria: The Inclusion criteria is age group of 12 to 70 years of age, mild to moderate amount of cold abscess. no improvement with conservative treatment and worsening of neurological deficit. Patients less than 12 years of age,huge cold abscess, severe kyphotic deformity with internal gibbus and patients not fit for anaesthesia are excluded from the study. During study age of patient, mode of presentation, Level of the lesion and associated co morbid condition are considered. Anti tuberculous therapy started. RESULTS: This study was conducted in our Hospital on 15 patients with Tuberculosis of Dorsal and Lumbar spine from July 2010 to June 2012. All patients were treated with posterior or posterolateral approach and stabilised with Pedicle screw system. The mean follow up period was 12 months (range 6-26 months). The following are the results of the study: The mean duration between surgery and onset of symptoms was 10.2 months (range 5-14 months). The mean surgical time was 3 hours 20 minutes (range 2h 20 min-4hr 10 min). The average blood loss was 800 ml (400 ml – 1500 ml). The mean preoperative Visual analog score was 8.7 (range7-10)which improved to 1.7(1-4) at final follow up implying better pain score postoperatively. The mean preoperative ESR value was 111.8 which improved to 31.7 at final follow up which indicates improvement in disease activity. Before surgery, 7 patients were classified as Frankel grade C,2 patients each with grade B,D and E& one patient with grade A.After surgery,all patients with grade C improved to one grade. Out of 2 patients with grade B,one improved to grade C and other improved to grade D.Of the patients with grade D, one improved to grade E and the other remained with grade D.One patient with grade A havenot recovered. The mean preoperative kyphosis in the thoracic and thoracolumbar spine was 27.9 degrees which was corrected to a mean of 9.5 degrees in the final follow up radiographs implying better correction and maintenance of kyphosis. CONCLUSION: The posterior/posterolateral approach (extracavitory approach) gives a reasonable access to the lateral and anterior aspects of the cord for an equally good decompression of the cord. It is a less morbid approach and avoids problems associated with thoracotomy and laprotomy. It facilitates early mobilization and avoids problems of prolonged recumbency. It provides better functional outcome and significantly better sagittal plane and kyphosis correction. Posterior approach preferred because of its familiarity, its simplicity, and its low complication rate.

Radiological outcomes following hyperlordotic cage insertion in anterior cervical discectomy and fusion.

Cervical alignment is associated with myelopathy and quality of life. Anterior cervical discectomy and fusion (ACDF) aims to decompress neural structures and optimise cervical alignment. This study examines the quantitative impact of the hyperlordotic 15° ACDF cage on cervical alignment, and compares it to that of the standard lordosis cage. A retrospective analysis of radiographical parameters of cervical alignment was conducted in 80 consecutive ACDF patients from two institutions between 2013 and 2017. Forty received 15° cages, 40 received standard cages. Pre- and post-operative Cobb angles and sagittal vertical axes (SVA) were generated from radiographical imaging utilising the SurgimapTM program. Changes in lordosis and SVA were compared within and between groups, and the significance of the change evaluated using the Student t-test. In both groups, post-operative device level, segmental, and global Cobb angles were superior to preoperative values (P<0.05), especially among patients with preoperative kyphosis (P<0.05). Trends suggested greater changes in lordosis in the 15° group, but they did not reach statistical significance (P=0.06-0.23). However, subgroup analyses indicated greater device level Cobb angle change in patients less than 65 yo (P=0.049), and those with preoperative lordosis (P=0.003). Neither standard nor hyperlordotic cages significantly improved SVA in this study. Hyperlordotic and standard cages both improve cervical lordosis segmentally and globally. Hyperlordotic cages were not shown to be statistically superior to standard cages in this study. Prospective studies featuring consistent imaging modalities are necessary to further delineate their utility.

Patient-Reported SRS-24 Outcomes Scores After Surgery for Adolescent Idiopathic Scoliosis Have Improved Since the New Millennium

Study DesignObservational. ObjectiveTo examine changes in patient-reported two-year postoperative outcomes via the Scoliosis Research Society (SRS)-24 Outcomes Instrument from 2001 through 2015. Summary of Background DataTechniques for correction of adolescent idiopathic scoliosis (AIS) have evolved over the years, but it is unclear how these changes have impacted patient-reported outcomes. MethodsAIS patients with two-year postoperative follow-up from a prospective multicenter registry were divided into three-year groups based on trends in surgical approach and construct type (2010–2014: 52% anterior, 43% posterior hybrids; 2005–2011: 3% anterior, 5% posterior hybrids; 2012–2015: 0% anterior, 0.2% posterior hybrids). Because of the ordinal scale (1-5) and bipolar nature of the response sets for the SRS-24, domain/total scores were categorized as ≤3 (predominantly negative) or 4-5 (predominantly positive). Variables were compared across the three groups. ResultsA total of 1,695 patients were analyzed; 172 (2010–2014), 926 (2005–2011), and 597 (2012–2015). Average age was 14.7 ± 2 years, the average primary curve was 55° ± 13°, and the group was primarily female (82%). There was a decline in the rate of positive scores for preoperative pain and self-image across the three groups (p < .05). There was an increase in the rate of positive scores for two-year postoperative self-image after surgery, function after surgery, and satisfaction (p < .05). Decreases in length of hospital stay, blood loss, surgical time, preoperative kyphosis, and postoperative trunk shift were observed (p < .05). Increases were observed in levels fused, preoperative major coronal curve, preoperative rib prominence, preoperative trunk shift, percentage correction of major curve, kyphosis restoration, and the rate of double/triple curves (p < .05). ConclusionThe percentage of patients with positive postoperative SRS scores has increased in the modern era, providing evidence that newer surgical techniques are resulting in improved outcomes based on the patients' perspectives. Interestingly, recent patients were more afflicted with negative pain and self-image before surgery.

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.

P99. Medical issues complicate 90-day return to the ED after spinal deformity surgery: a review of 346 patients

BACKGROUND CONTEXT Return to the ED continues to be a quality measure in health care. The purpose of this study was to describe one institution's experience with visits to the ED following spinal deformity surgery. There were 11.8% of patients returned to ED within 90 days mostly with medical complaints – more than half by 30 days. There were no risk factors identified, however, a majority of complaints appear to be preventable. PURPOSE Return to the hospital after surgery is frequently being used as a quality metric. The purpose of this study is to evaluate the reasons and risk factors for ED visits less than 90 days. STUDY DESIGN/SETTING Ambispective chart review. PATIENT SAMPLE A total of 346 patients were included: 274 idiopathic scoliosis, 48 neuromuscular, 10 Scheurmann's kyphosis, 3 spondylolisthesis (grade 4), and 11 other. OUTCOME MEASURES Return to ED with medical-related complaints, return to ED with surgical-related complaints, age, BMI, preoperative kyphosis, levels fused. METHODS A review of spinal deformity surgeries between 2011-2018 was performed. Radiographic, operative and hospital stay data was collected. Median and interquartile range (IQR) was with Wilcoxon-Signed Rank and Kruskal-Wallis tests. Patients who returned to the ED for any reason within 90 days were analyzed. ED visits were categorized as medical and surgical. Medical visits included but not limited to fever, pain, and seizures. Surgical visits included but not limited to wound infection, and surgical site infection. RESULTS A total of 346 patients were included: 274 idiopathic scoliosis, 48 neuromuscular, 10 Scheurmann's kyphosis, 3 spondylolisthesis (grade 4) and 11 other. Forty-one patients (11.8%) returned to the ED within 90 days; 32 (78%) returned with medical-related complaints: pain (n=14), fever (n=6), constipation (n=4), spasm/seizures(n=2), syncope (n=3), fall (n=1) and dysnea (n=2). Nine patients (22%) returned with surgical-related complaints: drainage from incision (n=6), wound infection (n=2), and baclofen pump failure (n=1); 65.8% (n=27) returned to the ED within 30 days. There was no significant difference in age (13.19 vs 12.42 years, p=0.27), BMI (18.27 vs 17.13, p=0.33) preoperative Cobb (47.30 vs 46.0, p=0.731), preoperative kyphosis (16 vs 17, p=0.971), and levels fused (10 vs 11,=0.359) between those did not return to the ED and those who did. Blood loss (300 vs 350ml,p=0.973), surgical time (230 vs 228,p=0.180), and length of stay (4 vs 4, p=0.94) were also similar between the two cohorts. Neuromuscular distribution was also similar (12.8% vs 21.9%). CONCLUSIONS A total of 11.8% of patients returned to ED within 90 days, mostly with medical complaints – more than half by 30 days. Although no risk factors were found in this study, the findings present an opportunity to better improve discharge planning and care coordination. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

191. Operative treatment for thoracic adult Scheuermann kyphosis: preoperative disability and surgical outcomes

BACKGROUND CONTEXT While there is a substantial amount of information regarding treatment for adolescent Scheuermann kyphosis, little data exists on surgical outcomes for thoracic adult Scheuermann kyphosis (TASK). Comparison of surgical outcomes for TASK to outcomes for adult scoliosis patients may assist patient counseling and formulation of treatment strategies. PURPOSE Evaluate preoperative disability and surgical outcomes for TASK compared to adult scoliosis. STUDY DESIGN/SETTING Retrospective analysis of a prospective multicenter adult spine deformity (ASD) database. PATIENT SAMPLE TASK and adult scoliosis patients with no history of prior spine surgery, enrolled into a multicenter database and subsequently surgically treated. OUTCOME MEASURES Scoliosis Research Society-22r questionnaire (SRS-22r), Short Form Health Survey-36 (SF-36), numeric rating scale (NRS) back and leg pain, Oswestry Disability Index (ODI), neck disability index (NDI). METHODS ASD patients age >18 years enrolled into a prospective multicenter ASD database were evaluated for (1) TASK (as defined by Sorensen's criteria) and (2) no history of spine surgery prior to database enrollment. Following database enrollment, TASK patients were treated surgically, pre- and postoperative demographic, radiographic, patientreported outcome measures, and surgical complications were evaluated and compared to surgically treated adult scoliosis (AS) patients (as defined by Scoliosis Research Society ASD classification) matched according to age, upper instrumented vertebra (UIV), lower instrumented vertebra (LIV) and total levels fused, with minimum 2-year follow-up. RESULTS Twenty of 27 TASK patients eligible for study were evaluated [mean follow-up 2.9 year (2-5 years), age 43.2 years (18.5-78.9), preoperative thoracic kyphosis 74.3° (61.2-107.5°), lumbar lordosis 71.7° (28.2-88.9°). Mean TASK postoperative thoracic kyphosis was 50.6° (41.2-61.4), postoperative lumbar lordosis 62.6 (44.1-89), levels fused 13.8 (11-18)], median UIV= T2, LIV= L3. TASK complication rate was 50% including PJK 5% (n=1), DJK 5% (n=1), and implant failure 10% (n=2). Comparing TASK to matched AS patients, TASK had similar preoperative back pain (6.9 vs 6.4), ODI (37.6 vs 32.7), SRS-22r total (2.8 vs 3.0), SRS-22r self image (2.2 vs 2.6), SF36-PCS (34.6 vs 38.1), and NDI (21.3 vs 24.5), respectively (p>0.05). Postoperative patient reported outcomes were similar for TASK and AS including back pain (4.4 vs 4.2), ODI (24.1 vs 23.8), SRS-22r total (3.6 vs 3.8), SRS-22r self image (3.8 vs 3.8), SF36-PCS (48.7 vs 50.9), and NDI (23.2 vs 23.0), respectively (p>0.05). Postoperative complications were similar for TASK and matched AS including, PJK, DJK, infection, implant failure and revision spine surgery (p CONCLUSIONS Evaluation of surgically treated TASK patients matched to adult scoliosis according to age, UIV and LIV demonstrates TASK has a negative impact on pain, disability, and self image analogous to adult scoliosis. Surgical treatment for TASK demonstrates excellent improvements in pain and self-image, with similar associated postoperative complication rates at minimum two-year follow-up as adult scoliosis. Treating physicians should be cognizant of the negative impact TASK can have on quality of life and responsiveness to surgical treatment. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

P144. Scheuermann's kyphosis patients are at a higher risk for PJK: irrespective of instrumentation type

BACKGROUND CONTEXT PJK has been well documented with pedicle screws in AIS patients. In Scheurmann's kyphosis (SK), PJK has been reported with hybrid fixation in the presence of shorter fusion. The literature is deficient about PJK in SK with all pedicle screw constructs. PURPOSE To find the incidence of PJK in SK with different instrumentation types. STUDY DESIGN/SETTING Ambispective Review. PATIENT SAMPLE A total of 84 SK patients that were corrected with either pedicle screws (PS), hybrid fixation (HF) or anterior/posterior fusions with hybrid fixation (AP). OUTCOME MEASURES Number of fusion levels, percent correction, UIV, LIV, pre- and postoperative PJK, sagittal balance and demographic data. PJK was definded as more than 10 degrees. METHODS X-ray and chart review of all SK patients operated with all pedicle screws (PS), hybrid fixation (HF) and anterior/posterior fusions with hybrid fixation (AP) were reviewed. Number of fusions levels, percent correction, UIV, LIV, pre- and postoperative PJK, sagittal balance and demographic data was collected. PJK was defined as more than 10 degrees. Fisher's exact testm Kruskal-Wallis, Wilcoxon ranked sum test were used. RESULTS Eighty-four total patients: PS (n=29), HF (n =24), and AP (n=31). Median preoperative kyphosis was higher in the AP compared to PS and HF (89 vs 77 vs 81.5, p 0.05). Overall, at postoperative 47.6% of patients had PJK, and at final 70.2%. Immediate postoperative -PJK was significantly higher in PS (13.4 vs HF:15 vs AP 14, p =0.07). T2 was the most common UIV for AP (71%) and HF (71%) compared to T3 for PS (59%) (p CONCLUSIONS Incidence of PJK appears to be higher in SK compared to that reported in AIS. Patients with pedicle screw fixation appear to be at the highest risk. UIV at T3 or proximally has significantly lower PJK. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Posterior vertebral column resection for congenital rigid spinal deformities

Background: The goal in surgical management of complex spinal deformities is to safely realign the spine as much as possible in both sagittal and coronal planes. Standard posterior and or middle column osteotomies are associated with limitations to correct the severe rigid curves. The purpose of this study was to assess the clinical and radiographic results of posterior vertebral column resection (PVCR) for surgical management of complex congenital rigid spinal deformities. Methods: Thirty-five patients with congenital rigid spinal deformities were enrolled in this prospective study. Preoperative measurement of curve magnitude and stiffness was done. Postoperative degrees of correction also were measured. The mean percentage of correction was calculated. Intraoperative and postoperative complications were reported. The minimum follow-up period was 2 yr. Results: Nineteen patients had rigid kyphosis and 16 had kyphoscoliosis. Their etiologies were due to congenital vertebral anomalies. An average of 1.5 vertebrae were resected intraoperatively. Radiographically the mean preoperative kyphosis was 68.9 degrees and in those patients with kyphoscoliosis, the mean preoperative value was 38 degrees. They improved on immediate follow-up to 24.5 and 11 degrees, respectively. At final follow-up the mean loss of correction in the sagittal plane was 3.6 degrees, which was statistically insignificant. All patients showed solid fusion at final follow-up. Complications were noted in seven patients, including dural tear, pleural tear, and postoperative wound infection that were managed accordingly. Conclusions: Single-stage PVCR is a highly effective option in the management of rigid spinal deformities with satisfactory clinical and radiographic outcomes.

Prevalence and risk factors of axial neck pain in patients undergoing multilevel anterior cervical decompression with fusion surgery

ObjectivesThe aim of this study was to explore the prevalence and risk factors for axial neck pain in patients undergoing multilevel anterior cervical decompression with fusion surgery.MethodsIn this study, 88 patients, who underwent multilevel anterior cervical decompression with fusion surgery from January 2012 to January 2017, were retrospectively reviewed. Based on the postoperative axial neck pain, the patients were classified into two groups: axial pain group and no axial pain group. The patients were followed up 3 weeks, 3 months, and 1 year after cervical anterior surgery for the early- and long-term clinical evaluation. The possible effect factors included demographic variables (age, sex, BMI, smoking, drinking, heart disease, hypertension, diabetes, preoperative kyphosis, preoperative axial neck pain, preoperative JOA scores, and ODI) and surgery-related variables (surgical option, vertebral lesions, spinal canal stenosis rate, superior fusion segment, presence of intramedullary high signal intensity).ResultsThe prevalence of axial neck pain was 27.3% (24 cases of 88). Our results showed that preoperative axial neck pain (62% vs 23%, P < 0.001) and preoperative kyphosis (42% vs 21.9%, P < 0.001) were risk factors for axial pain after multilevel anterior cervical surgery. Additionally, for patients with preoperative cervical kyphosis, compared to no axial pain group, the axial neck group was significantly more likely to exist a higher preoperative angle of C2–7 (13.31 ± 2.33 vs 7.33 ± 2.56, P < 0.001) and a higher correction range for kyphosis (20.24 ± 4.12 vs 12.34 ± 3.12, P < 0.001). However, for all the patients with postoperative axial symptoms, the improvement rate of axial pain was significantly higher for patients without cervical kyphosis at the early-term follow-up (3 weeks) (P = 0.032), no significant differences were found at the medium-term (P = 0.554) and long-term follow-up (P = 0.902), and improvements of clinical symptom have no obvious difference at the last follow-up.ConclusionsOverall, preoperative axial neck pain and kyphosis could predict axial neck pain for patients undergoing multilevel anterior cervical decompression with fusion surgery, and recovery of cervical kyphosis may contribute to the long-term recovery of neural function, but may also suffer from risk of short-term axial pain, which could be reduced through moderate cervical curvature recovery.