Thoracolumbar Junction Research Articles

Transcranial Magnetic Stimulation in the Diagnosis of Compressive Myelopathy at the Thoracolumbar Junction.

The disc level in the thoracolumbar junction at which measurement of the central motor conduction time in the lower limbs (CMCT-LL) is useful for a diagnosis remains unclear. Therefore, this study investigated the spinal vertebral level at which compressive myelopathy due to ossification of the ligamentum flavum in the thoracolumbar junction is detectable using CMCT-LL. We preoperatively measured CMCT-LL in 57 patients (42 men, 15 women; aged 35-85 years) with a single ossification of the ligamentum flavum from the T10-11 to T12-L1 disc levels and in 53 healthy controls. Motor evoked potentials after transcranial magnetic stimulation, compound muscle action potentials, and F waves were recorded from the abductor hallucis. Central motor conduction time in the lower limbs was calculated as follows: Motor evoked potential latency - (compound muscle action potential latency + F latency - 1)/2 (ms). Central motor conduction time in the lower limbs was compared between patients and controls. Compressive lesions were located at the T10 to 11 level in 27 patients, the T11 to 12 level in 28, and the T12-L1 level in 2. Central motor conduction time values in the lower limbs at the T10 to 11 level (19.9 ± 4.7 ms) and T11 to 12 level (18.1 ± 3.4 ms) were significantly longer than control values (11.8 ± 1.1 ms; P < 0.01). Central motor conduction time in the lower limbs was not calculated at the T12-L1 level because motor evoked potentials were not recorded in any patient. We confirmed that CMCT-LL was significantly longer in patients with ossification of the ligamentum flavum at the T10 to 11 and T11 to 12 levels because the S2 segment of the spinal cord is caudal at the T12 vertebral body level. Therefore, CMCT-LL is useful for diagnosing thoracolumbar junction disorders proximal to the T12 vertebral body level.

ОПТИМИЗАЦИЯ ХИРУРГИЧЕСКОЙ КОРРЕКЦИИ ЗОНЫ ГРУДОПОЯСНИЧНОГО ПЕРЕХОДА: СРАВНИТЕЛЬНОЕ БИОМЕХАНИЧЕСКОЕ ИССЛЕДОВАНИЕ МЕТОДОВ ТРАНСПЕДИКУЛЯРНОЙ ФИКСАЦИИ ПРИ РОТАЦИОННОМ НАГРУЖЕНИИ

Objective: To analyze various transpedicular (TP) fixation options for the thoracolumbar junction (TLJ) under rotational loads. Methods: A finite element model of the thoracolumbar spine was generated as part of a study. The model includes vertebrae Th9-Th11 and L2-L5 but excludes Th12 and L1. The model also integrates metallic structural elements, such as a vertebral body replacement (VBR) implant (interbody cage) and a TP system. We modeled the result of decompressive-stabilizing surgery for type C vertebral injuries (according to the classification scheme proposed by F. Magerl et al, 1994). The study analyzes four variants of TP fixation with different screw lengths and the influence of the presence or absence of transverse reinforcements. Results: It was found that during rotational loading, the maximum stress in bone structures occurs at the contact surface between the VBRs and the endplates of both adjacent vertebrae to the removed ones. In metallic hardware, the highest stress is observed on the interbody cage and in the TP screws installed in the Th10 and Th11 vertebral bodies. A comparison of different stabilization options reveals that the TP system with short monocortical screws and without transverse reinforcements provides moderate levels of stress. The use of bicortical screws without crosslinks results in a significant increase in stress, especially at the contact surface in the vertebral endplates and the intervertebral support device. On the other hand, the use of transverse reinforcements with short screws reduces stress, providing an optimal stabilization option. However, bicortical screws with crosslinks did not show significant benefits. Conclusion: Upon scrutinizing the biomechanical efficiency of different TP fixation methods, it has been determined that utilizing a TP system equipped with monocortical screws and two crosslinks results in the most even stress distribution caused by the rotational load. Keywords: Thoracolumbar junction, burst fracture, transpedicular fixation, finite element analysis, rotational loading.

The choice of classification to determine the optimal tactics for treatment of the thoracolumbar junction traumatic injuries.

Aim: To evaluate the influence of the degree of detail of the nature of the pathomorphological changes in the osteoligamentous structures on the tactics of treating the patients with the traumatic damage to the thoracolumbar junction. Materials and Methods: A retrospective analysis of the treatment tactics was carried out in 96 patients with a traumatic injury of the thoracolumbar junction, both those who underwent a surgical treatment and those who underwent a conservative therapy. The lesions were classified using F. Magerl and AOSpine classifications; the neurological status was assessed according to the ASIA scale, the nature of the damage was specified using the McCormack criteria. The statistical data processing was performed using the Random Forest machine learning algorithm. Results: The nature of the injury makes it possible to unambiguously determine the optimal method of therapy when using the F. Magerl classification with a probability of 58.33%, while in relation to the AOSpine classification this figure is 55.21%. When building the models that include the nature of the damage, the level of the neurological disorders and the McCormack criteria, it was found that the use of the F. Magerl classification demonstrates an error in unambiguously determining the most effective treatment method at the level of 26.04%, while the use of AOSpine this figure was 21.88%. Conclusions: The application of the AOSpine classification is more promising for the development of a multifactorial algorithm for the treatment of the traumatic injuries of the thoracolumbar junction.

Postictal vertebral fractures: Incidence, risk factors, and clinical outcomes. A systematic review

IntroductionVertebral fractures in postictal patients with no prior acute or chronic trauma history are rare but can lead to severe neurological complications if missed during the initial evaluation. Research questionWhat are the prevalence and risk factors associated with vertebral fractures? What are the characteristics of these fractures in terms of their location, severity, and clinical outcome? Materials and methodsA comprehensive literature search using MeSH terms was conducted. Data from previously published studies and three new cases from the authors' institution were collected. The variables included demographic information, seizure history, medical comorbidities, fracture characteristics, and treatment details. Descriptive statistics summarize the data. Inferential statistics (t-test, Mann-Whitney U test, chi-squared test, Fisher's exact test, and logistic regression) were used to identify the risk factors for vertebral fractures. ResultsThe review included nine studies with a total of 19 patients, and three additional unpublished cases from the authors' institution. The median patient age was 50 years, with male predominance. No significant differences were found between the groups in osteoporosis, seizure history, antiepileptic drug use, or alcohol or drug abuse. The most common sites of fracture were the midthoracic spine for compression fractures and thoracolumbar junction for burst fractures. Risk factors for fractures include greater muscle mass, lower bone mineral density, longer convulsions, and recurrent convulsions. DiscussionThe mechanism of injury involved violent muscle contractions during seizures. ConclusionThis review summarizes the current knowledge and provides evidence for best practices in the management of seizure-induced vertebral fractures.

Comparison of 3D-navigation and fluoroscopic guidance in percutaneous pedicle screw placement for traumatic fractures of the thoracolumbar junction

IntroductionFractures of the thoracolumbar junction are the most common vertebral fractures and can require surgical treatment. Several studies have shown that the accuracy of pedicle screw placement can be improved by the use of 3D-navigation. Still only few studies have focused on the use of navigation in traumatic spine injuries. Research questionThe aim of this study was to compare the screw placement accuracy and radiation exposure for 3D-navigated and fluoroscopy-guided percutaneous pedicle screw placement in traumatic fractures of the thoracolumbar junction. Materials and methodsIn this single-center study 25 patients undergoing 3D-navigated percutaneous pedicle screw placement for traumatic fractures of the thoracolumbar junction (T12-L2) were compared to a control group of 25 patients using fluoroscopy. Screw accuracy was determined in postoperative CT-scans using the Gertzbein-Robbins classification system. Additionally, duration of surgery, dose area product, fluoroscopy time and intraoperative complications were compared between the groups. ResultsThe accuracy of 3D-navigated percutaneous pedicle screw placement was 92.66 % while an accuracy of 88.08 % was achieved using standard fluoroscopy (p = 0.19). The fluoroscopy time was significantly less in the navigation group compared to the control group (p = 0.0002). There were no significant differences in radiation exposure, duration of surgery or intraoperative complications between the groups. Discussion and conclusionThe results suggest that 3D-navigation facilitates higher accuracy in percutaneous pedicle screw placement of traumatic fractures of the thoracolumbar junction, although limitations should be considered. In this study 3D-navigation did not increase fluoroscopy time, while radiation exposure and surgery time were comparable.

Surgical therapy of spinal metastases of the thoracolumbar junction: Morbidity and postoperative revision rate according to surgical complexity

Surgical therapy of spinal metastases of the thoracolumbar junction: Morbidity and postoperative revision rate according to surgical complexity

A cadaver study: The relationship of vital organs of the thoracolumbar junction during a far lateral approach using a T-12 corpectomy model

A cadaver study: The relationship of vital organs of the thoracolumbar junction during a far lateral approach using a T-12 corpectomy model

CLINICO-RADIOLOGICAL OUTCOMES IN SHORT SEGMENT FIXATION INCLUDING FRACTURE LEVEL FOR UNSTABLE THORACOLUMBAR JUNCTION FRACTURES (T10-L2)

Background: Thoracolumbar region being a transition zone is frequently injured during trauma. Treatment aims to achieve stable fixation while preserving mobility, prevent deformity, and improve neurology. Short-segment fixation, with fracture level pedicle screw fixation, is popular for preserving motion. This study assesses the clinico-radiological outcomes for short segment fixation including fracture level for unstable thoracolumbar fractures. Methods: This was an observational study conducted at a tertiary care center from December 2020 to November 2022 after receiving ethical approval among single level burst fractures (AO type A3 &amp; A4) at the thoracolumbar junction. Patients with AO type B and C fractures, osteoporotic burst fractures, lack of surgical consent, and multi-level vertebral fractures were excluded from the study. The study utilized ASIA impairment scale, Visual Analogue Score(VAS), and radiological parameters (Kyphotic angle and Loss of vertebral body height) to assess patients immediately, postoperatively and at 6 weeks, 3 months, and 6 months follow-up. Results: Out of 20 patients,70% of the fractures were AO type A3, while the remaining 30% were type A4. The injury resulted in a 56.25 ± 13.75% loss of vertebral height. The mean kyphotic angle improved significantly from 24.38 ± 3.77 degrees preoperatively to 5.92 ± 1.91 degrees at 6 months post-operatively. The VAS scores showed significant improvement from 7.85 ± 0.67 preoperatively to 0.65 ± 0.81 at 6 months postoperatively. Conclusions: Use of pedicle screw in the fractured vertebra can result in significant improvement in post-operative pain and kyphosis correction utilizing fewer motion segment with satisfactory clinic-radiological outcome.

Thoracolumbar/Lumbar Degenerative Kyphosis-The Importance of Thoracolumbar Junction in Sagittal Alignment and Balance.

To conduct a more comprehensive study of sagittal alignment in patients with thoracolumbar/lumbar (TL/L) degenerative kyphosis. A total of 133 consecutive patients from September 2016 to March 2019 with degenerative spinal kyphosis were enrolled. These patients were divided into different types according to sagittal alignment, including thoracolumbar junctional kyphosis (TLJK). Then, we divided the patients with TLJK into two groups: the Sagittal Balance group (C7-SVA < 50 mm) and the Sagittal Imbalance group (C7-SVA ≥ 50 mm). The sagittal parameters of each type or group were compared and correlation analysis was conducted. Thoracolumbar/lumbar degenerative kyphosis consists of four types: Type I, lumbar kyphosis; Type II, degenerative flat back; Type III, thoracolumbar junctional kyphosis; and Type IV, global kyphosis. According to different sagittal alignments, Type III can further be divided into three subtypes: IIIA, with smooth kyphosis of thoracic and upper lumbar; IIIB, like a clasp knife, with a flat thoracic and lumbar angle; and IIIC, with bigger thoracic kyphosis and lumbar lordosis. The thoracolumbar kyphosis angle (°) of the three subtypes were -23.61 ± 5.37, -25.40 ± 7.71, and -40.01 ± 8.40, respectively. Lumbar lordosis was correlated with thoracic kyphosis (IIIA, r = -0.600, p = 0.005; IIIB, r = -0.312, p = 0.046; IIIC, r = -0.657, p = 0.015), and correlated with sacral slope (IIIA, r = 0.537, p = 0.015; IIIB, r = 0.654, p = 0.000; IIIC, r = 0.578, p = 0.039). All spinopelvic parameters were compared between the Sagittal Balance group and the Sagittal Imbalance group, and only the thoracolumbar kyphosis angle showed statistical difference (t = -2.247, p = 0.028). The common characteristics of thoracolumbar junctional kyphosis were found to be a bigger thoracolumbar junctional angle and vertex of kyphosis located in the thoracolumbar junction (T10-L2). Despite TLJK, a change in the thoracic angle was still important to maintain sagittal balance. The thoracolumbar junction plays an important role in sagittal alignment and balance.

Iatrogenic spinal cord herniation

Introduction: Spinal cord herniation occurs idiopathically or is due to defective or weakened dura mater resulting from iatrogenic or traumatic lesions. Although there have been many reports of idiopathic cases, there are few reports of postoperative iatrogenic spinal cord herniation. The authors describe a rare case of postoperative spinal cord herniation in the cervical spine, with an extensive analysis of reported cases Materials and methods: This article reports a documented case of postoperative spinal cord herniation. The case description is followed by an analysis of the literature. Results: A 67-year-old woman who had cervical laminectomy 3 weeks before for cervical laminectomy, presented with neck pain and torticollis after coughing. The MRI findings showed a cervical medulla herniation with cerebrospinal fluid (CSF) leakage. The patient underwent surgery to reduce the herniation and duroplasty with subsequent complete resolution of symptoms. Over the previous 50 years (1973–2023), 16 post-operative spinal cord herniation cases were reported. The mean patient age was 43.3 years (range 15–67 years). There was a male predominance (80%). The mean onset period after surgery was 292 weeks (range, 1 week to 728 weeks). Clinical symptomatology was polymorphic with non-specific signs. Conclusion: Iatrogenic spinal cord herniation is an extremely rare occurrence after spine surgery. The diagnosis must be evoked in case of any neurological degradation after surgery of the cervical spine, thoracic spine or thoracolumbar junction. The surgical management gives satisfactory clinical results.

Water depth and speed may have an opposite effect on the trunk vertical displacement in horses trotting on a water treadmill.

To measure the trunk vertical displacement (VD) in horses trotting on a water treadmill (WT) at different water depths (WDs) and speeds. 6 sound Standardbred horses (median age 12 years [IQR:10.5-12]). The horses were trotted on a WT at 2 speeds (3.5 m/s and 5 m/s) and during 4 conditions: dry treadmill (DT), WD at mid-cannon (WD-CAN), mid-radius (WD-RAD), and shoulder (WD-SHOUL). The dorsoventral movement was obtained with accelerometers placed over the withers, thoracolumbar junction (T18), tuber sacrale (TS), and sacrum (S5). The VD was defined with the median value of the upward (Up) and downward (Down) amplitudes of the vertical excursion during each stride. The difference of VD at each sensor location was compared between the DT and the 3 WDs, and between the 2 trotting speeds for the same condition. The VD amplitudes were significantly increased at any sensor location when trotting in water at WD-CAN and WD-RAD compared to DT (P < .05 for all), with the highest increase at WD-RAD and T18. When the speed increased from 3.5 to 5 m/s, the VD amplitudes were significantly decreased at T18 at each water level (P = .03), and at WD-RAD only for the withers and TS (P = .03). Both water depth and speed affect the trunk VD in horses at trot on a WT with an opposite effect. The VD increases when increasing the WD up to mid-radius, while the VD decreases when increasing the trotting speed, with the main effects observed at the thoracolumbar junction.

Contusion Spinе Injury in the Thoracolumbar Junction Region

Summary – Contusion spine injuries resulting from direct traumatic mechanisms that lead to spinal cord lesion are relatively rare during peacetime. The specific characteristics of such injuries are not extensively covered in contemporary literature. The need to optimize treatment methods for military personnel engaged in active combat operations on the territory of Ukraine necessitates an examination of this specific type of injury.&#x0D; Objective: To describe the clinical presentation and explore possible therapeutic approaches for closed contusion spinal cord injuries in the thoracolumbar junction.&#x0D; Materials and Methods: We conducted an analysis of patient data from those admitted for inpatient treatment at the Romodanov Neurosurgery Neurosurgery of National Academy of Medical Sciences of Ukraine, as well as patients referred to other healthcare institutions in Kyiv, from February 2022 to May 2023.&#x0D; Results: We analyzed the treatment outcomes of 5 patients, aged 27 to 53 years (mean age: 37.6 years), presenting with initial neurological deficits classified as ASIA A. Surgery was performed in 3 patients. All cases underwent wide laminectomy with facetectomy at the level of injury. Large arachnoid cysts were drained, and in one case, a subdural hematoma was removed. Posterior spinal fusion using an 8-screw transpedicular system was performed in all patients, utilizing a minimally invasive percutaneous approach. At the 2-month follow- up positive dynamics were observed in all patients. Neurological status improved to ASIA B in 2 cases and ASIA C in 1. Recovery of proprioceptive sensitivity was noted, as well as an increase in the intensity of neuropathic pain (up to 5-7 points at 2 months). In 2 patients undergoing conservative therapy, the neurological impairment level remained ASIA A, with pain intensity not exceeding 2 points.&#x0D; Conclusions: The findings emphasize the need for more comprehensive instrumental assessment in patients with suspected contusion spinal cord injuries. Active use of surgical treatment methods in this type of injury contributes to achieving better clinical outcomes.

Safety Considerations When Dry Needling the Multifidi in the Thoracolumbar Region: A Cadaveric Study.

Dry needling the lumbar multifidi is a technique used by physical therapists to effectively treat low back pain. While studies have examined the safety considerations in the upper lumbar spine related to the kidneys and lungs, none have investigated the possibility of entering the spinal canal in this region. The purpose of this cadaveric ultrasound-guided dry needling exploration was to determine if a dry needle can penetrate the ligamentum flavum at the T12/L1 interspace and enter the spinal canal using a paramedian approach in a fresh-frozen, lightly fixed cadaver in the prone position. Cadaveric study. The procedure was performed on a cadaver in the prone position. The needle was advanced under ultrasound guidance to determine if a 0.30 x 50 mm dry needle inserted 1.0 cm lateral to the spinous process of T12 and directed medially at a 22-degree angle could penetrate the ligamentum flavum and enter the spinal canal. As determined via ultrasound, a dry needle can penetrate the ligamentum flavum and enter the spinal canal at the thoracolumbar junction using this technique. This interprofessional collaboration demonstrates that a dry needle can penetrate the ligamentum flavum to enter the spinal canal at T12/L1 using a documented technique for dry needling the multifidus. A thorough understanding of human anatomy along with the incorporation of available technology, such as ultrasound, may decrease the risk of adverse events when dry needling the multifidi at the thoracolumbar junction. Level IV.

Radiological and Functional Outcomes of Conservatively Managed Osteoporotic Vertebral Fractures at the Thoracolumbar Junction: A Cross Sectional Study

OBJECTIVE This study examined how osteoporotic vertebral fracture (OVF) patients treated conservatively at a multi-specialty hospital were progressing clinically and radiologically. METHODS This cross sectional, observational study was conducted at Sir Ganga Ram Hospital, New Delhi, India during the period of July 2021 to October 2021. Cases with at least a 6-month follow-up were evaluated. VAS pain score, Oswestry Disability Index (ODI), and local kyphotic angle (COBB’s angle) at the time of fracture and at the latest follow-up were recorded and analyzed. RESULTS There were 30 patients (female: male = 2.75:1) with a mean age of 67.37 years (45-85). The average VAS score at the time of fracturewas 8 (6 to 10) and at the time of final follow-up was 2 (1 to 6) (p = 0.001). The average ODI score at the time of fracture was 44 (35 to 62) and at the time of final follow up was 5 (4 to 40) (p = 0.001). The average Cobb’s angle at the time of fracture was 14.31o and at the final follow up was 15.66o (p = 0.011). CONCLUSIONS Conservative management of OVF can lead to an increase in the local kyphotic angle. The fact that the patients experienced significant decreases in VAS pain scores and ODI scores by the final follow-up leads to the conclusion that patients can have a good quality of life even with conservative management of osteoporotic vertebral fractures. KEYWORDS conservative management, osteoporotic, thoracolumbar, vertebral fracture

Evaluation of the effectiveness of the short-segment thoracolumbar instrumentation

Aims: This prospective study aimed to compare the long-term follow-up findings of patients with short-segment thoracolumbar instrumentation with the long-term follow-up findings results of patients with long-segment thoracolumbar instrumentation. Merthods: Patients who underwent surgery for a thoracolumbar junction spine fracture were included in this study. The patient's age, gender, and neurological impairment, "AOSpine Classification Scale", "Visual Analog Scale (VAS)", "modified Japanese Orthopedic Association (mJOA)" and "Oswestry Disability Index (ODI)" scores, pedicle and/or pars interarticularis fractures, anterior, middle, and posterior height loss of the fractured vertebral body (mm), the height loss rate of the fractured vertebra, angulation degree, sagittal and axial spinal canal diameters (mm) and presence of bone fragment extending into the spinal canal on CT images were recorded at admission to the hospital, and the end of the sixth month after surgical intervention. Duration of anesthesia and surgery time, the amount of bleeding during the surgery, the radiation level (mGy) released by fluoroscopy, performing laminectomy, length of stay in the intensive care unit, and hospital were recorded. Additionally, the stability and integrity of the instrumentation were examined with dynamic X-ray images. Results: Preoperative fractured vertebra collapse rates (t=4.175, p=0.001) and surgery times (t=4.175, p=0.001) were different between groups In the long-segment group, preoperative VAS scores (Z=-2.687, p=0.007), mJOA scores (Z=-2.585, p=0.010), and ODI scores (t=53.253, p&lt;0.001) were different from postoperative long-term follow-up values. In addition, in the short segment group, preoperative VAS scores (Z=-2.214, p=0.027), mJOA scores (Z=-2.333, p=0.020), and ODI scores (t=48.338, p&lt;0.001) were different from the postoperative long-term follow-up values. ROC-curve analysis and Logistic Regression analysis results revealed that any study parameter could not predict the decision-making for inserting screws into the fractured vertebra, the need for laminectomy, the risk of developing postoperative instability, or the worse prognosis risk of mJOA. Conclusion: This study's results showed that short-segment instrumentation, which is performed by inserting a screw into the fractured vertebra, is as effective as long-segment instrumentation in providing both clinical and radiological improvement in patients. At the same time, it has advantages such as less operating time, less surgical bleeding, and short anesthesia time. However, it was determined that no parameter of the study could predict the placement of screws in the fractured spine, the need for laminectomy, the risk of postoperative instability, or the prognosis risk of mJOA. Therefore, it was concluded that conducting this study on a larger patient population would be appropriate.

The value of the posterior ligamentous complex in traumatic injury of thoracolumbar junction. Part 1. Morphology and biomechanics

According to modern concepts, one of the basic criteria for the stability of the spinal motion segment in case of its traumatic damage is the integrity of the posterior ligamentous complex (PLC). Regarding the thoracolumbar junction (TLJ) as a zone that is most vulnerable to traumatic injuries, the Thoracolumbar Injury Classification and Severity Score and the clinically oriented AO Spine Thoracolumbar Spine Injury Classification System are used in determining therapeutic approaches in which the state of the thoracic spine is one of three key parameters. The term PLC was first proposed in 1963 by F.W. Holdsworth. However, only the widespread introduction of magnetic resonance imaging into clinical practice made it possible to fully reveal the informativeness of the specified parameter. The complex includes the interspinous, supraspinous ligaments, ligamentum flavum and facet joint capsule. The purpose of the review is to organize modern ideas about the morphology, biomechanical features, clinical significance, and diagnostic possibilities of detecting damage to the PLC in traumatic injuries of the TLJ area. In the first part, the morphological and biomechanical features of the PLC of the TLJ zone are considered in detail. When describing the morphology of some ligaments, the main attention is paid to their length, fixation zones, and certain layers, if such are distinguished. In addition, the relative anatomical location of the considered structures was taken into account. Histological features are indicated only in terms of their biomechanical significance. The analysis of literature data made it possible to organize the data characterizing the biomechanical parameters of each ligament of the PLC for each spinal motion segment of the area under consideration. Stiffness indicators, breaking force, fracture energy, strength and deformation limits, maximum deformation and elastic modulus were taken into account. The features of the load-deformation curve of the TLJ ligaments and methods of calculating the nonlinear change in the stiffness of each ligament of the PLC within the limits of physiological loads are considered. The phenomenon of preload and its clinical significance are described. Some aspects of the interaction between the elements of the passive stabilization system under different load patterns are considered. The data presented in the first part of the review can be useful for a general understanding of the principles of biomechanics of the spinal motion segment and may be used in the construction of highly detailed computer models.

Thoracolumbar junction fracture and long instrumented fusion, a trial on a standardized surgical technique with long term clinical outcomes

AimTo investigate the role of fusion construct properties, vertebral column reconstruction (VCR) techniques, steroid therapy, laminectomy versus ligamentotaxis in treatment of thoracolumbar junction fractures (TLJF). MethodsA non-randomized clinical trial was conducted. All the eligible patients with TLJF (T12-L2) were operated with a standardized long fusion protocol and followed. Fusion rate, hardware failure, sagittal imbalance and functional outcome were identified as the primary outcome. P < 0.05 was defined as significant. ResultsNinety-nine long fusions were reviewed in the final analysis. The mean age was 35.7 ± 13.80 years with 79.8 % male predominance. Fifty-eight percent of the patients were neurological intact. Fifty-six percent underwent concurrent laminectomy and VCR using autografts while the remaining 43.4 % received ligamentotaxis. The patients follow up (median = 25 months) showed 93.9 % solid fusion rate, 70.7 % activity independency, 1% hardware failure, 10.1 % sagittal imbalance and 4 % wound complications. Sagittal imbalance was associated with steroid therapy (p = 0.006), laminectomy (p = 0.003) and preoperative neurological deficits (p = 0.0001) and age (p = 0.049). Interestingly, Steroid therapy was associated with improved neurological and functional outcomes in impaired patients (p < 0.05). Laminectomy was associated with favorable functional outcome (OR = 9.7, CI: 2.09–45.67). ConclusionOur standardized long fusion protocol was associated with significant outcomes with low morbidities. Autograft mixture yield to a robust union in and over fusion construct. Methylprednisolone therapy in non-intact patients was associated with improved clinical outcomes but simultaneously, has negative impact on sagittal imbalance. Laminectomy and steroid therapy should be carefully considered in impaired patients due to their negative impact on sagittal balance.

Lumbar lordosis restoration by minimally invasive short-segment fusion with anterior column realignment for adult spinal deformity: minimum 2-year follow-up.

The efficacy of anterior column realignment (ACR) remains relatively unclear, possibly because some safety concerns have limited its adoption and extensive evaluation. The authors aimed to study whether a minimally invasive surgery (MIS) triad consisting of ACR, lateral lumbar interbody fusion, and percutaneous pedicle screw fixation in a select group of adult spinal deformity (ASD) patients helps shorten fusion length without compromising clinical and radiographic outcomes over a minimum 2-year follow-up period. A series of 61 ASD patients (mean age 72.8 years) with pelvic incidence (PI) - lumbar lordosis (LL) (PI-LL) mismatch > 10° underwent the short-segment MIS triad (mean fusion length 3.0 levels) as a single-stage operation with a mean operative time and estimated blood loss of 157 minutes and 127 mL, respectively. Exclusion criteria were 1) thoracic scoliosis as the main deformity, 2) thoracolumbar junction kyphosis > 25°, 3) ankylosed facet joints, and 4) previous spinal fusion surgery. Seven patients, who needed fusion to be extended to S1, underwent mini-open transforaminal lumbar interbody fusion at L5-S1. The segmental disc angle at the ACR level more than quintupled, averaging from 2.9° preoperatively to 18.9° at the latest follow-up (p < 0.0001). LL, in turn, nearly doubled from 17.0° to 32.8° (p < 0.0001) and PI-LL decreased by nearly half from 28.8° to 13.2° (p < 0.0001). At the same time, other spinopelvic deformity parameters as well as Oswestry Disability Index (ODI) scores significantly improved. Patients were divided into two groups at the latest postoperative evaluation: 36 patients whose PI-LL improved to < 10° and 25 patients who maintained a PI-LL mismatch > 10°. Binary logistic regression revealed preoperative PI-LL mismatch as the only factor that significantly influenced this dichotomous separation postoperatively. Receiver operating characteristic curve analysis identified the critical preoperative mismatch of 26.4° with 68% sensitivity and 84% specificity. Despite this different radiographic consequence, the two groups had an equally successful clinical outcome with no significant difference in ODI scores. As long as the ASD characteristics are consistent with the authors' exclusion criteria, the short-segment MIS triad served as an excellent surgical option in the patients with preoperative PI-LL mismatch < 26.4°, but the technique also worked well even in those with a mismatch > 26.4°, although ideal spinopelvic alignment targets were not necessarily achieved in these patients.

Spondylodiscitis instrumented fusion, a prospective case series on a standardized neurosurgical protocol with long term follow up

PurposeTo investigate the fusion construct properties, construct length, intervertebral prosthesis (IVP) selection, bone grafting methods, complications management, and follow-up outcomes of spondylodiscitis fusion. MethodThis case series was conducted in Al-Zahra University referral hospital from March 2016 to November 2021. All the surgery-eligible patients were enrolled. Those who did not participate or failed the neurosurgical intervention were excluded. A unified neurosurgical protocol was defined. After operation and follow-up, all variables were documented. IBM SPSS v.26 was used for data analysis. P-value ≤ 0.05 was considered significant. ResultNinety-two patients were reviewed in the final analysis with 65.2 % males. The mean age was 55.07 ± 14.22 years old. The most frequent level of pathology and surgery was the lumbar spine (48.9 %). Short and long constructs were almost equally used (57.6 and 42.4 %, respectively). Bone graft mixture was the dominant IVP (75 %). The most frequent persistent postoperative symptom was back pain (55.4 %), while the neurological deficits resolution rate was 76.7 %. The fusion rate was 92.3 %. Proximal junctional kyphosis incidence was 16.3 % and had a significant association with on-admission neurological symptoms, thoracic and thoracolumbar junction involvements (p < 0.05). Follow-up Oswestry disability index scores showed 44.6 % of the patients had mild or no functional disabilities. Advanced age, On-admission deficits, comorbidities, titanium cages, and poor fusion status were associated with poor functional outcomes and higher mortality rates (P < 0.05). ConclusionThe introduced neurosurgical protocol could effectively achieve acceptable SD treatment, spine stabilization, and fusion with low long-term surgical complications. Autologous bone graft mixture in comparison to titanium cages showed a higher fusion rate with a lower mortality rate. Patients with older age, neurological symptoms, and comorbidities are expected to experience less favorable clinical outcomes.

Outcome of Decompressive Laminectomy with or without Posterior Screw Fixation for Thoracic Ossification of the Ligamentum Flavum with Disc Degeneration

Objective: Thoracic myelopathy caused by the ossification of the ligamentum flavum (OLF) is commonly treated with surgical decompression. This study aimed to compare the clinical and radiological outcomes of surgical decompression without posterior screw fixation (decompressive laminectomy [DL] group) and with posterior screw fixation (laminectomy with screw fixation [LSF] group) for thoracic myelopathy due to OLF with disc degeneration.Methods: A retrospective review of 35 patients (DL group, n = 19; LSF group, n = 16) was conducted. Clinical variables (Japanese Orthopaedic Association scores) and radiological variables (including sagittal vertical axis, pelvic tilt, thoracic kyphosis, sacral slope, lumbar lordosis (LL), segmental Cobb’s angle, dynamic Cobb’s angle, and dynamic thoracolumbar junction [dTLJ] at the operated level) were measured preoperatively and 1 year postoperatively.Results: Both groups exhibited significant improvements in clinical characteristics postoperatively. LL significantly increased at 1 year postoperatively in both groups. Other sagittal alignment parameters did not change significantly. The dTLJ did not differ significantly between the groups preoperatively; however, the dTLJ of the DL group was larger than that of the LSF group at 1 year postoperatively. There was no significant difference between the groups’ dynamic Cobb’s angles or risk of complications.Conclusion: Decompression surgery for OLF resulted in clinical improvement regardless of whether posterior fixation was performed. Decompression without posterior fixation could allow thoracolumbar motion preservation and might be an effective approach for thoracic OLF with disc degeneration.