Vertebral Body Resection Research Articles

En bloc vertebra resections and lung cancer

Non-small cell lung cancer (NSCLC) invading the chest wall and vertebral bodies account for less than 5% of newly diagnosed patients, and their surgical management still represents, despite recent advances in material research, multimodality therapy and surgical techniques, a clinical unmet issue. They usually occur as direct unilateral invasion involving mostly the antero-lateral paths of the vertebral bodies, and costovertebral groove. Computed tomography and magnetic resonance imaging studies are pivotal to assess operability and guide the type of surgical management which must always aim the en bloc resection of the tumor with clean surgical margins and spine reconstruction. While there is no need of vertebral body resection for NSCLC invading the ipsilateral ribs and vertebral transverse processes, hemi-vertebrectomy or total vertebrectomy is required when tumors invade the ipsilateral side or more than 50 percent of the vertebral body, respectively. Different approaches (anterior, posterior or their combination, etc.) and different types of vertebral resection and stabilization have been described. Preoperatively, one may consider embolization of the endovascular intercostal-somatic arteries feeding the tumor one day before the operation to mitigate intraoperative blood losses. Despite high morbidity and tumor recurrence rates, 5-year survival rates of 60% have been recently reported for NSCLC invading the vertebral body. As a consequence, surgery shall be considered in well-selected NSCLC patients and in large-volume thoracic and spine surgical.

Hybrid Therapy for Metastatic Epidural Spinal Cord Compression: Technique for Separation Surgery and Spine Radiosurgery.

Despite major advances in radiation and systemic treatments, surgery remains a critical step in the multidisciplinary treatment of metastatic spinal cord tumors. To describe the indications, rationale, and technique of "hybrid therapy" (separation surgery and concomitant spine stereotactic radiosurgery [SRS]) along with practical nuances. Separation surgery describes a posterolateral approach for circumferential epidural decompression and stabilization. The goal is to decompress the spinal cord, stabilize the spine, and create adequate separation between the neural elements and the tumor for SRS to achieve durable tumor control. A transpedicular route to achieve ventrolateral access and limited resection of the tumorous vertebral body is carried out. In the setting of high-grade cord compression, caution must be taken when performing the tumor decompression. "Separation" of the ventral epidural tumor component anteriorly creates space for concomitant SRS while a simple laminectomy would not adequately achieve this goal. Dissection of the posterior longitudinal ligament allows maximal ventral decompression. Gross total tumor resection is not crucial for durable tumor control using the "hybrid therapy" model. Thus, attempts at ventral tumor resection may unnecessarily increase operative morbidity. Cement augmentation of the construct or vertebral body may improve construct stability. CT myelogram is the preferred exam for postoperative SRS planning. Radiosurgical planning constitutes a multidisciplinary effort and guidelines for contouring in the postoperative setting have recently become available. Separation surgery is an effective, well-tolerated, and reproducible surgery. It provides safe margins for concomitant SRS. Combined, this "Hybrid Therapy" allows durable local control, maintenance of spinal stability, and palliation of symptoms, while minimizing operative morbidity.

“Shelter Technique” in the Treatment of Ossification of the Posterior Longitudinal Ligament Involving the C2 Segment

Anterior or posterior decompression has been widely used to treat patients with ossification of the posterior longitudinal ligament (OPLL). However, when OPLL extends to the C2 level, the complex anatomic structures around the C2 vertebral body and postoperative destabilization or kyphosis would make it difficult to perform anterior or posterior surgery. This study proposed a novel technique named "shelter technique" to deal with C2 OPLL. Sixteen patients with cervical OPLL involving the C2 segment were included. The OPLL below C2 was dealt with anterior controllable antedisplacement and fusion, including diskectomy of involved levels, resection of the anterior vertebral bodies, installation of the intervertebral cages and anterior cervical plate, isolation of the vertebrae-OPLL complex (VOC), and the final hoisting of the VOC. When dealing with C2 OPLL, the posterior portion of the C2 vertebral body was resected to create the shelter based on the thickness of the C2 OPLL, which could provide space for further antedisplacement of the ossified mass behind the C2 vertebra. Finally, OPLL behind C2 was moved forward together with the antedisplacement of VOC below C2. Postoperative magnetic resonance imaging and computed tomography scan showed sufficient decompression of the spinal cord, including the C2 segment, and the shelter provided enough space for the antedisplacement of the ossified mass behind the C2 segment. At the final follow-up of 1 year, neurologic function of all patients recovered significantly. The shelter technique can be relatively effective and safe for patients with OPLL involving the C2 segment. However, further studies with more cases and longer follow-up will be required to reveal the surgical value of the technique.

Surgical treatment of thoracic disc herniation: an overview.

Surgical treatment of thoracic disc herniation (TDH) is technically demanding due to its proximity to the spinal cord. Literature review. Symptomatic TDH is a rare condition predominantly localized between T8 and L1. Surgical indications include intractable back or radicular pain, neurological deficits, and myelopathy signs. Giant calcified TDH (> 40% spinal canal occupation) are frequently associated with myelopathy, intradural extension, and post-operative complications. Careful pre-operative planning helps reduce the risk of complications. Pre-operative CT and MRI identify the hernia's location and size, calcifications, and intradural extension. The approach must provide adequate dural sac visualization with minimal manipulation of the cord. Non-anterior approaches are favoured if they provide at least equal exposure than anterior approach owing to higher risk of pulmonary morbidity associated with anterior approach. A transthoracic approach is recommended for central calcified herniated discs. A posterolateral approach is often suitable for non-calcified lateralized TDH. Thoracoscopic approaches are less invasive but have a substantial learning curve. Retropleural mini-thoracotomy is an acceptable alternative. Pre-operative identification of the pathological level is confirmed by intra-operative level check. Intra-operative cord monitoring is preferable but warrant further studies. Magnification and adequate lightening of the surgical field are paramount (microscope, thoracoscopy). Intra-operative CT scan with navigation is becoming increasingly popular since it provides real-time control on the decompression. Indications of fusion consist of pre-operative back pain, Scheuermann's disease, multilevel resection, wide vertebral body resection (> 50%), and herniation at thoracolumbar junction. Neurological deterioration, dural tear, and subarachnoid-pleural fistula are the most severe complications. Further improvements are still warranted in thoracic spine surgery despite the advent of minimally invasive techniques. Intra-operative CT scan will probably enhance the safety of the TDH surgery.

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

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

Musculo-cutaneous flap for reconstruction surgery for deep surgical site infection after total en bloc spondylectomy: A technical note

Abstract Background Total en bloc spondylectomy (TES) is potential radical resection surgery for spinal tumors. Surgical procedure of TES includes extremely wide detachment of surrounding soft tissue from pathological vertebra, resulting in impairment of blood supply. Moreover, massive dead space inevitably is made after vertebral body resection. Therefore deep surgical site infection (SSI) after TES could be intractable. To date, suitable treatment for deep SSI after TES has not been established. Case description A 72 years old man underwent TES of 12th thoracic level via single posterior approach for primary leiomyosarcoma. Postoperative additional irradiation was performed. One year after surgery, late infection around the cage occurred. We removed the cage followed by autologous iliac bone grafting, we treat the wound by open therapy and daily irrigation, followed by negative pressure wound therapy. Four-month later, we performed musculo-cutaneous flap using latissimus dorsi muscle with plastic surgeons. At the follow-up visit one year after flap surgery, no evidence of recurrence of infection was observed. Conclusion Musculo-cutaneous flap is one of treatment options to fill the dead space and to control deep SSI after TES.

Simultaneous anterior vertebral column resection-distraction and posterior rod contouring for restoration of sagittal balance: report of a technique

With an increasingly aging population, adult spinal deformity is becoming more common. This can be associated with increased morbidity. Results from multicentre studies of deformity surgery correction confirm complication rates as high as 40 percent. Most often a bad result is associated with inadequate restoration of the sagittal balance. Posterior vertebral body resection has been described as a method to correct significant deformity, but this is a complicated procedure. It is possible to do this in the thoracic spine where nerve roots can be sacrificed, but it is difficult in the lumbar spine due to the significant role of the lumbar nerve roots. We describe a safer technique for correction of deformity using a three stage process. This appears to be a good technique for revision surgery.

Modification in Surgical Technique for Posterior Vertebral Column Resection

Introduction Surgical treatment of severe and rigid spinal deformities is usually difficult and challenging to perform. The goal of surgical treatment is to obtain a satisfactory balance both in sagittal and coronal planes. In rigid deformities, the osteotomies are usually insufficient; vertebral column resection is the only option of treatment. To reduce the operation time and complications, a single stage, posterior vertebral column resection (PVCR) is defined by Suk et al. It enables rotational and translational correction of spinal column and provides an opportunity for manipulation of anterior and posterior column simultaneously. In the original PVCR, posterior elements of resection side were removed first and then the anterior part removed and correction was performed. The authors decided to make a modification in PVCR as performing the posterior total laminectomy, facetectomy, and pediclectomy after vertebral body resection. This method has two major advantages; minimization of the blood loss from epidural veins after laminectomy and protection of the neural elements from direct injury during vertebral body resection. Patients and Methods A total of 11 patients between the age of 3 and 63 years, diagnosed with severe spinal deformity with limited flexibility, who underwent modified PVCR were reviewed. The average follow-up was 2 years (range, 5 months–3 years). There were six female and five male patients with a mean age of 18 years. Severe congenital scoliosis was found in seven patients, congenital kyphosis in two patients, neurofibromatosis in one patient, and posttraumatic kyphosis in one patient. The surgery consisted of temporary fixation of vertebral column, resection of vertebral body first then resection of posterior elements, followed by deformity correction and fusion. Results The mean estimated blood loss was 1,072 mL (range, 350–2,000 mL). Overall, 39.45% (range, 33–50%) of total blood loss occurred after vertebral body resection, 60.91% (range, 50–67%) occurred after posterior elements removal. The ratio of estimated blood loss to estimated body blood volume was 26% (range, 19–52%). The deformity correction was 60% in the coronal plane. No neurological complications were encountered. Conclusion The PVCR is a complicated, technically demanding procedure with possible risks for major complications. All correction attempts must be performed under direct inspection, palpation of tension in the spinal cord by a highly experienced surgeon. Spinal cord neuromonitoring is a must to prevent neurological injuries. The authors modified the original technique defined by Suk and performed by various surgeons. The authors believe that making vertebral body resection before laminectomy would decrease the blood loss and protect the spinal cord. The validity of this new modified technique should be demonstrated in a prospective, randomized, controlled study with a larger patient population allowing comparison of age-matched subgroups.

1118 Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) including partial or complete resection of vertebral bodies in patients with non-seminomatous germ cell tumors (NSGCT)

1118 Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) including partial or complete resection of vertebral bodies in patients with non-seminomatous germ cell tumors (NSGCT)

Separation Surgery for Spinal Metastases: Effect of Spinal Radiosurgery on Surgical Treatment Goals

The treatment of epidural spinal cord compression due to metastatic cancer represents an important clinical challenge. The NOMS (neurologic, oncologic, mechanical, and systemic) framework facilitates the determination of the optimal combination of systemic, radiation, and surgical therapies for individual patients. Spinal stereotactic radiosurgery (SRS) is an effective and safe modality for achieving durable control of local disease. Integrating SRS into the postoperative treatment plan allows surgical goals to be modified, thus decreasing the extent of tumor resection required. Separation surgery is indicated for patients with spinal cord compression secondary to solid tumor metastases. During separation surgery, the spinal column is stabilized and the epidural tumor is resected without requiring significant vertebral body resection. Tumor separation from the spinal cord allows patients to undergo postoperative SRS. The combination of separation surgery and high-dose hypofractionated or single-fraction SRS results in high local tumor control at 1 year and is an effective palliative paradigm for this patient population.

Clinical significance of radiological stability in reconstructed thoracic and lumbar spine following vertebral body resection.

ObjectiveVertebral body replacement following corpectomy in thoracic or lumbar spine is performed with titanium mesh cage (TMC) containing any grafts. Radiological changes often occur on follow-up. This study investigated the relationship between the radiological stability and clinical symptoms.MethodsThe subjects of this study were 28 patients who underwent corpectomy on the thoracic or lumbar spine. Their medical records and radiological data were retrospectively analyzed. There were 23 cases of tumor, 2 cases of trauma, and 3 cases of infection. During operation, spinal reconstruction was done with TMC and additional screw fixation. We measured TMC settlement in sagittal plane and spinal angular change in coronal and sagittal plane at postoperative one month and last follow-up. Pain score was also checked. We investigated the correlation between radiologic change and pain status. Whether factors, such as the kind of graft material, surgical approach, and fusion can affect the radiological stability or not was analyzed as well.ResultsMean follow-up was 23.6 months. During follow-up, 2.08±1.65° and 6.96±2.08° of angular change was observed in coronal and sagittal plane, respectively. A mean of cage settlement was 4.02±2.83 mm. Pain aggravation was observed in 4 cases. However, no significant relationship was found between spinal angular change and pain status (p=0.518, 0.458). Cage settlement was seen not to be related with pain status, either (p=0.644). No factors were found to affect the radiological stability.ConclusionTMC settlement and spinal angular change were often observed in reconstructed spine. However, these changes did not always cause postoperative axial pain.

Cervical cord decompression using extended anterior cervical foraminotomy technique.

ObjectiveAt present, gold-standard technique of cervical cord decompression is surgical decompression and fusion. But, many complications related cervical fusion have been reported. We adopted an extended anterior cervical foraminotomy (EACF) technique to decompress the anterolateral portion of cervical cord and report clinical results and effectiveness of this procedure.MethodsFifty-three patients were operated consecutively using EACF from 2008 to 2013. All of them were operated by a single surgeon via the unilateral approach. Twenty-two patients who exhibited radicular and/or myelopathic symptoms were enrolled in this study. All of them showed cervical cord compression in their preoperative magnetic resonance scan images.ResultsIn surgical outcomes, 14 patients (64%) were classified as excellent and six (27%), as good. The mean difference of cervical cord anterior-posterior diameter after surgery was 0.92 mm (p<0.01) and transverse area was 9.77 mm2 (p<0.01). The dynamic radiological study showed that the average post-operative translation (retrolisthesis) was 0.36 mm and the disc height loss at the operated level was 0.81 mm. The change in the Cobb angle decreased to 3.46, and showed slight kyphosis. The average vertebral body resection rate was 11.47%. No procedure-related complications occurred. Only one patient who had two-level decompression needed anterior fusion at one level as a secondary surgery due to postoperative instability.ConclusionsCervical cord decompression was successfully performed using EACF technique. This procedure will be an alternative surgical option for treating cord compressing lesions. Long-term follow-up and a further study in larger series will be needed.

Transpedicular N-butyl cyanoacrylate–mediated percutaneous embolization of symptomatic vertebral hemangiomas

The resection of spinal hemangiomas is often challenging because of characteristic high-volume and potentially prohibitive intraoperative blood loss. Although transarterial embolization can mitigate this risk, it can be suboptimal when tumor arterial supply is diffuse or poorly defined. The authors present their experience in the use of preoperative percutaneous direct injection of spinal hemangiomas with N-butyl cyanoacrylate (NBCA) as an effective preoperative adjunct that may reduce operative blood loss and facilitate resection of these vascular tumors. Four patients with symptomatic spinal hemangiomas were treated using percutaneous transpedicular direct NBCA-Lipiodol injection; 2 patients had undergone prior spinal angiography, with suboptimal transarterial embolization in 1. Each patient underwent percutaneous bilateral transpedicular NBCA-assisted tumor embolization prior to resection. Retrospective analysis of operative times, blood loss, and clinical data is presented. There were no complications associated with the percutaneous NBCA embolization technique. The procedure was effective at facilitating tumor removal and minimizing intraoperative blood loss, especially at the vertebral body resection stage. Improved tumor filling was achieved as the filling characteristics of dilute NBCA-Lipiodol mixture within large-channel, high-flow hemangiomas were appreciated with experience. Transpedicular NBCA direct-puncture embolization of spinal hemangiomas is an effective preoperative adjunct that facilitates resection of these highly vascular tumors. It is particularly useful when transarterial embolization is unsafe or suboptimal due to constraints imposed by the local angioarchitecture.

Pelvic fixation for adult scoliosis

Obtaining a fusion, especially to the sacrum for adult deformity correction remains a challenge. Prior to modern fixation techniques, the reported fusion rates for adult scoliotic deformities were low. However sacropelvic fixation techniques for adult deformity continue to evolve. As a result, modern day pelvic fixation techniques have improved fusion rates at the base of long constructs. The purpose of this article is to discuss the history, indications, and modern fixation techniques for pelvic fixation in the surgical management of adult scoliosis patients. We searched PUBMED using the search terms pelvic fixation, deformity, lumbopelvic, sacropelvic, and iliac fixation. Linkage or association studies published in English and available full-text were analyzed specifically regarding techniques and innovations in pelvic fixation. Sacropelvic fixation should be considered in any patient with a long construct ending in the sacrum, those patients with associated risk factors for loss of distal fixation or high risk for pseudarthrosis at L5-S1, and those undergoing three column osteotomies or vertebral body resections in the low lumbar spine. Current pelvic fixation techniques with iliac screws, multiple screw/rod constructs, and S2-alar-iliac screws are all viable techniques for achieving pelvic fixation. There is growing evidence that pelvic fixation may become the standard for obtaining long fusions in adult scoliosis. Although technically challenging, in selected cases the use of four pelvic screws and/or four rods across the lumbosacral pelvis can help address pseudarthroses, implant breakage, and screw pullout secondary to osteoporosis. Ultimately, indications and techniques should be individualized to the patient and based on surgeon preference and experience.

Minimally invasive lateral extracavitary corpectomy: cadaveric evaluation model and report of 3 clinical cases

In this paper, the authors' goal was to demonstrate the clinical and technical nuances of a minimally invasive lateral extracavitary approach (MI-LECA) for thoracic corpectomy and anterior column reconstruction. A cadaveric feasibility study and the subsequent application of this approach in 3 clinical cases are reported. Six procedures were completed in 3 human cadavers. Minimally invasive, extrapleural thoracic corpectomies were performed with the aid of a 24-mm tubular retraction system, using a posterolateral incision and an oblique approach angle. Fluoroscopy and postprocedural CT scanning, using 3D volumetric averaging software, was used to evaluate the degree of bone removal and decompression. Three clinical cases, including a T-11 burst fracture, a T-7 plasmacytoma, and a T4-5 vertebral body (VB) tuberculosis lesion, were treated using the approach. At 6 cadaveric levels, the mean circumferential volumetric decompression was 48% ± 16%, and the mean resection of the VB was 72% ± 13%. The mean change in anterior and posterior vertebral height with expansion of the corpectomy cage was 47 and 61 mm, respectively. There were no violations of the pleura or dura. Pedicle screw reliability was 95.8% (23 of 24 screws) with a single lateral breach. All 3 patients in the clinical cohort had excellent clinical outcomes. There was a single pleural tear requiring chest tube drainage. Operative images and a video clip are provided to illustrate the approach. A minimally invasive lateral extracavitary thoracic corpectomy has the ability to provided excellent spinal cord decompression and VB resection. The procedure can be completed safely and successfully with minimal blood loss and little associated morbidity. This approach has the potential to improve upon established traditional open corridors for posterolateral thoracic corpectomy.

A Novel Technique for Temporary Fixation During Posterolateral Thoracic Corpectomy

Description of novel technique. The objective of this study is to describe a novel technique of temporary fixation for posterolateral thoracic corpectomy. Posterolateral approaches have been used to successfully perform thoracic corpectomies for a variety of pathologies. As currently described, these approaches require the use of temporary fixation, usually in the form of unilateral pedicle screws and rod. One limitation of this technique is that the vertebral body may only be approached from one side at a time, as the temporary fixation rod obstructs the view of the surgeon or the assistant. The authors introduce a novel technique for temporary fixation during posterolateral thoracic corpectomy. A series of 8 patients is presented in whom a temporary fixation cross-rod was placed diagonally between cephalad and caudad contralateral pedicle screws. This allowed simultaneous access to the vertebral bodies by 2 surgeons, thereby improving exposure and decreasing operative time and estimated blood loss. There were no complications related to temporary fixation during the procedures, and no translational movement was observed. Diagonal temporary rod fixation is a useful modification of standard posterolateral thoracic corpectomy techniques that allows simultaneous bilateral access for vertebral body resection.

Long-Term Outcomes of En Bloc Resection of Non-Small Cell Lung Cancer Invading the Thoracic Inlet and Spine

The purpose of this study was to determine whether en bloc resection of non-small cell lung cancer (NSCLC) invading the thoracic inlet (TI) and spine can provide good long-term outcomes. We studied 54 consecutive patients treated with en bloc resection of NSCLC invading the TI and spine between 1992 and 2009 at our center. There were 36 men and 18 women with a mean age of 51 years (range, 37 to 71 years). Tumor resection involved at least 2 vertebral levels. We divided the patients into 3 groups based on whether vertebral invasion involved the transverse process only, the intervertebral foramina, requiring hemivertebrectomies with spinal fixation, or the vertebral body, requiring total vertebral body resection with spinal fixation. Induction chemotherapy was given to 27 (50%) patients including 3 who also received induction radiotherapy. Nine (17%) patients were in the transverse process group, 42 (78%) in the intervertebral foramina group, and 3 (6%) in the vertebral body group. Resection involved the subclavian artery in 19 (35%) patients. Complete resection was achieved in 49 (91%) patients. There were no perioperative deaths or residual neurologic impairments. Recurrence occurred in 31 (57%) patients and was local (n=6), systemic (n=24), or both (n=1). Local recurrence was more common in patients with N2-3 disease (p=0.0008) and subclavian artery involvement (p=0.031). There was a nonsignificant increase in local recurrence in patients with positive resection margins (40% vs 10%, p=0.058). The 1-, 5-, and 10-year survival rates were 82%, 31%, and 31%, respectively. The 1-, 5- and 10-year disease-free survival rates were 63%, 28%, and 28%, respectively. Five patients are alive and free of disease 10 years after surgery. By multivariate analysis, factors that independently affected survival were incomplete (R1) resection (p=0.006; odds ratio 67; 95% confidence interval 1.5 to 11.3) and subclavian artery involvement (p=0.037; odds ratio 0.46; 95% confidence interval 0.2 to 0.9). Good long-term survival can be achieved in highly selected patients with NSCLC invading the TI and spine, provided complete en bloc resection is performed.

Initial experience with the use of an expandable titanium cage as a vertebral body replacement in patients with tumors of the spinal column: a report of 95 patients

Vertebral body resection to treat spine tumors necessitates reconstruction to maintain spinal stability. The durability of reconstruction may be a challenge in cancer patients as treatment with chemotherapy and/or radiation coupled with poor nutritional status may compromise bone quality. We present a series of patients who underwent implantation of an expandable titanium cage (ETC) for reconstruction after vertebral body resection for primary or metastatic spine tumors. We report the functional outcome, assess the durability of reconstruction, and describe complications associated with this procedure. A retrospective review of patients undergoing placement of ETC after vertebrectomy for spinal tumor at our institution was performed. From September 2001 to August 2006, 95 patients underwent implantation of an ETC for reconstruction of the anterior spinal column following vertebrectomy for tumor (75 one-level, 19 two-level, 1 three-level). All patients underwent spinal stabilization as well. The median survival after surgery was 13.7months; 23 patients had primary spinal tumors and 72 had metastatic tumors. Numerical pain scores were significantly improved postoperatively indicating a palliative benefit. No new neurological deficits were noted postoperatively, except when intentional neurological sacrifice was performed for oncologic reasons. Median height correction of 14% (range 0-118%) and median improvement in sagittal alignment of 6° (range 0-28°) were demonstrated on immediate postoperative imaging. Three patients experienced hardware related complications, one of which had posterior migration of the ETC. On postoperative imaging, 12 patients demonstrated subsidence of greater than 1mm, but none required operative revision. Use of an ETC for spinal reconstruction in patients with spinal tumors is safe, decreases pain associated with pathologic fracture, protects neurologic function, and is durable. We found a very low incidence of cage-related construct failures and no significant problems with subsidence.

Growth of Spinal Motion Segmentin Children after Vertebral Body Resection in the Thoracolumbar and Lumbar Spine

Objective. To assess the growth and development of the fused spinal motion segment in children operated on with application of transpedicular fixation for congenital spinal deformity associated with disorders in vertebral formation. Material and Methods. The outcomes of surgery in 31 patients aged of 1 year and 9 months to 6 years and 11 months with a single congenital malformation of the spine were assessed. The surgery involved the hemivertebra resection, deformity correction with posterior instrumentation, spondylodesis, and posterior local fusion of fixed spinal motion segments with autobone. The rate of bone block formation and the size of fused spinal motion segment in the region of hemivertebra resection were assessed on the basis of postoperative X-rays. New functional unit of the spine was compared with the adjacent intact vertebral bodies in dynamics. Results. The mean follow-up period was 60 months. Solid bone fusion was achieved in all patients. The growth and development of the fused spinal motion segment in the region of hemivertebra resection kept pace with the growth of adjacent intact vertebrae. Conclusion. The fused spinal motion segment develops after hemivertebra resection without delay in increase in height and anterior-posterior size of fused vertebrae. After hemivertebra resection the fused spinal motion segment is developing without delay in growth of height and anterior-posterior size of vertebral bodies involved in the block. New functional unit of the spine consistently develops and enables normal growth and development of the whole spine.

The Safety and Efficacy of Cadaveric Allografts and Titanium Cage as a Fusion Substitutes in Pyogenic Osteomyelitis

The safety and efficacy of various fusion substitutes in pyogenic osteomyelitis has not been investigated. We evaluated and compared the cadaveric allograft and titanium cages used to reconstruct, maintain alignment and achieve fusion in the management of pyogenic spinal infection. There were 33 patients with pyogenic osteomyelitis underwent fusion in this study. Fifteen of the 33 patients were operated on by fusion with allografts (cadaveric patella bones) and 18 of those were operated with titanium mesh cages filled with autologous cancellous iliac bone. After the affected disc and vertebral body resection with pus drainage, cadaveric allograft or titanium cages were inserted into the resected space. Posterior transpedicular screw fixation and rod compression in resected space, where cadaveric allograft or titanium cages were inserted, was performed to prevent the malposition in all patients except in 1 case. Recurrent infection was identified by serial erythrocyte sedimentation rate and cross reactive protein follow-up. Osseous union and recurred infection available at a minimum of 2 years following operation was identified. The amount of kyphosis correction and the subsidence were measured radiographically. Spinal fusion was achieved in 29 of 33 patients. In the cadaveric allograft group, 93.3% of patient (14 of 15) showed the osseous union while 83.3% of patient (15 of 18) in the titanium cage group showed union. Subsidence was noted in 12 of the patients. Twelve patients (36.3%) showed unsettling amounts of subsidence postoperatively whereas 46.6% of patients in the cadaveric allograft group and 37.7% of patients in the titanium cage group showed similar subsidence, respectively. There were statistical difference in the fusion rate (p=0.397) and subsidence rate (p=0.276) between the two groups. There was significant statistical difference in the postoperative improvement of segmental kyphosis between the two groups (p=0.022), that is the improvement in sagittal alignment was greater in the titanium cage group than in the cadaveric allograft group. There was no case of recurred infection. The cadaveric allograft and titanium cages are effective and safe in restoring and maintaining sagittal plane alignment without increased incidence in infection recurrence in pyogenic osteomyelitis. The postoperative improvement of segmental kyphosis was better in the cage group.