Normal pressure hydrocephalus due to an iatrogenic giant lumbar pseudomeningocele after posterior lumbar interbody fusion: illustrative case.

BACKGROUND: Iatrogenic pseudomeningocele incidence after lumbar surgery is 0.068%-2%, and most lumbar pseudomeningoceles are smaller than 5 cm; however, in rare cases, "giant" pseudomeningoceles greater than 8 cm in size may develop. Normal pressure hydrocephalus (NPH) is another rare condition in which the ventricles expand despite the presence of normal intracranial pressure. To date, pseudomeningocele associated with NPH has not been reported. OBSERVATIONS: An 80-year-old woman underwent L3-5 laminectomy and posterior lumbar interbody fusion, and her symptoms improved after surgery. However, dementia appeared 1 month after surgery. Repeated brain computed tomography showed ventricular enlargement, and lumbar magnetic resonance imaging showed a long pseudomeningocele in the subcutaneous tissues at the L4 level. Here, the authors report a rare case of an iatrogenic giant pseudomeningocele accompanied by NPH after lumbar surgery. The symptoms of NPH in the present case occurred after spinal surgery and recovered after dural repair surgery, indicating that the changes in cerebrospinal fluid circulation and/or pressure due to pseudomeningoceles may cause NPH. LESSONS: The prevention of dural tears through precise surgical technique and primary repair of dural tears are the best approaches to prevent pseudomeningocele incidence and subsequent events.

Clinical outcomes of late decompression surgery following cervical spinal cord injury with pre-existing cord compression.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The purpose of the current study was to examine the effectiveness of late decompression surgery for traumatic cervical spinal cord injury (CSCI) with pre-existing cord compression. SETTING: Murayama Medical Center, National Hospital Organization, Tokyo, Japan. METHODS: In total 78 patients with traumatic CSCI without bone injury hospitalized in 2012-2015 in our institute for rehabilitation after initial emergency care were divided into four groups according to the compression rate (CR) of the injured level and whether or not decompression surgery was performed. Neurological status was evaluated by American Spinal Injury Association impairment scale (AIS), Barthel index, and Spinal Cord Independence Measure (SCIM). RESULTS: In the severe compression group (CR ≥ 40%), >2 grade improvement in the AIS was observed in 30% of patients with surgical treatment, although it was not observed in any patient without surgery. The SCIM improvement rate at discharge was 60% in the surgical treatment group and 20% in the non-surgical treatment group. In the minor compression group (CR < 40%), >2 grade improvement in the AIS was observed in 18% of patients with surgical treatment and in 11% without surgery. The SCIM improvement rate at discharge was 52% in the surgical treatment group and 43% in the non-surgical treatment group. CONCLUSIONS: These results indicate that surgical treatment has an advantage for patients following traumatic CSCI with severe cord compression. In contrast, surgical efficacy is not proved for CSCI patients without severe cord compression.

Walking balance and compensatory gait mechanisms in surgically treated patients with adult spinal deformity.

BACKGROUND CONTEXT: Gait patterns and their relationship to demographic and radiographic data in patients with adult spinal deformity (ASD) have not been fully documented. PURPOSE: This study aimed to assess gait pattern in patients with ASD and the effect of corrective spinal surgery on gait. DESIGN/SETTING: This is a prospective case series. PATIENT SAMPLE: The gait patterns of 33 consecutive women with ASD (age 67.1 years; body mass index [BMI] 22.5±2.5 kg/m2, Cobb angle 46.8±18.2°, coronal vertical axis [CVA] 1.5±3.7 cm, C7 sagittal vertical axis [SVA] 9.1±6.4 cm, pelvic incidence minus lumbar lordosis [PI-LL] 38.2±22.1°, and lean volume of the lower leg, 5.5±0.6 kg) before and after corrective surgery were compared with those of 33 age- and gender-matched healthy volunteers. OUTCOME MEASURES: Scoliosis Research Society Patient Questionnaire (SRS22r), Oswestry Disability Index (ODI), and forceplate analysis. METHODS: All subjects underwent gait analysis on a custom-built forceplate using optical markers placed on all joints and spinal processes. Dual X-ray absorptiometry scores were used to calculate the lean composition of the lower legs. Subjects with ASD were followed for at least 2 years post operation. RESULTS: Preop mean values showed that patients with ASD had a significantly worse gait velocity (54±10 m/min vs. 70.7±12.9 m/min, p<.01) and stride (97.8±13.4 cm vs. 115.3±15.1 cm, p<.01), but no difference was observed in the stance-to-swing ratio. The right and left ground reaction force vectors were also discordant in the ASD group (vertical direction; r=0.84 vs. r=.97, p=.01). The hip range of motion (ROM) was also significantly decreased in ASD. Correlation coefficient showed moderate correlations between the preoperative gait velocity and the gravity line (GL), PI, ROM of the lower extremity joints, and lean volume, and between the stride and the lean volume, GL, and PI-LL. Gait pattern, stride, and velocity all improved significantly in the patients with ASD after surgery, but were still not as good as in healthy volunteers. The SRS22r satisfaction domain correlated moderately with postoperative gait velocity (r=0.34). CONCLUSIONS: The patients with ASD had an asymmetric gait pattern and impaired gait ability compared with healthy volunteers. Gait ability correlated significantly with the GL, spinopelvic alignment, lower extremity joint ROM, and lean volume. The surgical correction of spinopelvic alignment and exercises to build muscle strength may improve the gait pattern and ability in patients with ASD.

Upper Cervical Fusion in Children With Spondyloepiphyseal Dysplasia Congenita.

BACKGROUND: Paraplegia or death secondary to upper cervical spine instability and spinal cord compression are known consequences of spondyloepiphyseal dysplasia congenita (SEDC). Stabilization and occasionally decompression of the upper cervical spine are indicated to treat upper cervical instability and stenosis. The purpose of this study was to report the results of upper cervical spine fusion in children with SEDC who had upper cervical instability. METHODS: Twenty children (17 females and 3 males) with SEDC who underwent upper cervical spine fusion at a mean age of 72 months were retrospectively analyzed. Three of these children were under the age of 2. Fifteen children had posterior instrumentation and fusion whereas 5 children had posterior in situ fusion without use of any implant. Thirteen of 20 children had iliac crest autograft. Radiographic and clinical results were reported. RESULTS: The average follow-up period was 8 years and 8 months. All children with instrumentation achieved fusion. Three of 5 children who had no instrumentation had nonunion (1 child had a stable nonunion and did not need revision; 1 had a single noninstrumented revision and ended up with a stable nonunion without further intervention; and the third one had a noninstrumented revision and had to have a second, instrumented, revision to achieve fusion). Six children had thoracolumbar scoliosis or kyphoscoliosis which required surgical management.No postoperative neurological deficits were observed. Two of the 3 children with a preoperative neurological deficit showed full recovery and the third one remained unchanged. Pseudarthrosis is the main complication for the noninstrumented group. Distal junctional instability after successful fusion is seen at long-term follow-up (average=6 y) for 13% of patients in instrumented group. CONCLUSIONS: Instrumentation and iliac bone grafting results in 100% upper cervical fusion for SEDC children who demonstrated instability before surgery. LEVEL OF EVIDENCE: Level IV-therapeutic.

Atlantoaxial Subluxation after Pyogenic Spondylitis around the Odontoid Process.

Study Design. A case report and review of the literature. Objective. The aim of this study was to describe the conservative management of pyogenic spondylitis around the odontoid process. Summary of Background Data. Atlantoaxial subluxation after pyogenic spondylitis is rare. The therapeutic approach to infection of the upper cervical spine is controversial. Methods. Medical chart and radiological images of a 76-year-old male patient were retrospectively reviewed. Radiography revealed atlantoaxial subluxation, and an abscess was seen around the odontoid process on magnetic resonance images. Intravenous antibiotics and a halo vest were used to treat the patient. We then observed the patient's conservative treatment course. Results. C-reactive protein levels returned to normal 4 weeks after administration of the intravenous antibiotics. The patient's muscle weakness also completely recovered 8 weeks after administration of the intravenous antibiotics. Because the patient was able to walk without any support, surgical treatment was not necessary. Conclusions. Pyogenic spondylitis of the upper cervical spine is a rare manifestation. Surgical or conservative treatment must be selected carefully based on the patient's symptoms. If early diagnosis and treatment can be provided to the patients, conservative treatment can be achieved.

Reoperation rate and risk factors of elective spinal surgery for degenerative spondylolisthesis: minimum 5-year follow-up.

BACKGROUND CONTEXT: The favorable outcome of surgical treatment for degenerative lumbar spondylolisthesis (DS) is widely recognized, but some patients require reoperation because of complications, such as pseudoarthrosis, persistent pain, infection, and progressive degenerative changes. Among these changes, adjacent segmental disease (ASD) and same segmental disease (SSD) are common reasons for reoperation. However, the relative risks of the various factors and their interactions are unclear. PURPOSE: The purpose of this study was to determine the longitudinal reoperation rate after surgery for DS and to assess the incidence and independent risk factors for ASD and SSD. STUDY DESIGN: This study is a retrospective consecutive case series of patients with DS who were surgically treated. PATIENT SAMPLE: We assessed 163 consecutive patients who were surgically treated for DS between 2003 and 2008. Individual patients were followed for at least 5 years after the initial surgery. OUTCOME MEASURES: The primary end point was any type of second lumbar surgery. Radiographic measurements and demographic data were reviewed. We compared patients who underwent reoperation with those who did not. Logistic regression analysis was used to determine the relative risk of ASD and SSD in patients surgically treated for DS. METHODS: Radiographic measurements and demographic data were reviewed. We identified the incidence and risk factors for reoperation, and we performed univariate and multivariate analyses to determine the independent risk factors for revision surgery for SSD and for ASD as the two distinct reasons for the reoperation. Age, gender, etiology, body mass index (BMI), and other radiographic data were analyzed to determine the risk factors for developing SSD and ASD. RESULTS: The average patient age was 65.8 (50-81 years; 73 women and 90 men; mean follow-up, 5.9±1.6 years). Eighty-nine patients had posterior lumbar interbody fusion and 74 had laminotomies. Twenty-two patients had L3-L4 involvement and 141 had L4-L5 involvement. The cumulative reoperation rate was 6.1% at 1 year, 8.5% at 2 years, 15.2% at 3 years, 17.7% at 5 years, and 23.3% (38/163 patients) at the final follow-up. A significantly higher reoperation rate was observed for patients undergoing laminotomy than for patients undergoing posterior lumbar interbody fusion (33.8% vs. 14.4%, p=.01). Eighteen patients (11.0%) had SSD, and 13 patients (8.9%) developed ASD. Higher BMI (obesity) and greater disc height (greater than 10 mm) predicted the occurrence of SSD in the multivariate model (BMI=odds ratio 4.11 [95% confidence interval 1.29-13.11], p=.016; disc height=3.18 [1.03-9.82], p=.044), and gender (male) and facet degeneration (Fujiwara grade greater than 3) predicted the development of ASD in the multivariate model (gender=4.74 [1.09-20.45], p=.037; facet degeneration=6.31 [1.09-36.52], p=.039). CONCLUSIONS: The incidence of reoperation in patients surgically treated for DS was 23.2% at a mean time of 5.9 years. A significantly higher incidence of reoperation was observed in patients treated with decompression alone compared with those treated with decompression and fusion. Body mass index and disc height were identified as independent risk factors for SSD, whereas male gender and facet degeneration were identified as independent risk factors for ASD. The results of this comprehensive review will guide spine surgeons in their preoperative planning and in the surgical management of patients with DS, thereby reducing the reoperation rate.

Incidence and the risk factors of spinal deformity in adult patient after spinal cord injury: a single center cohort study.

STUDY DESIGN: A retrospective consecutive case series of adult spinal cord injuries (SCIs) patients. OBJECTIVE: To assess the incidence and risk factors of spinal deformity in a large sample of patients with SCIs. Post-traumatic spinal deformities are well-recognized sequelae of SCIs. Despite the devastating complications for SCI patients with trunk imbalance, the incidence, clinical outcomes, and independent risk factors of scoliosis after SCI remain controversial. MATERIALS AND METHODS: We assessed 214 consecutive adult compressive SCI patients who were hospitalized in our hospital. We compared patients who developed spinal deformities with those who did not. Univariate and multivariate analyses to determine the independent risk factors were performed. Age, gender, etiology, ASIA grade (American Spinal Injury Association) surgery, and other demographic data were analyzed to determine the risk factors for developing a spinal deformity. RESULTS: The average patient age was 58.3 years (20-86 years). The etiology was trauma (n = 158), ossification of ligament (n = 22), infectious (n = 17), and others. One hundred fifty-two patients had cervical spine involved, 62 had thoracic spine involved. 26 patients classified as ASIA A, 54 were ASIA B, 96 were ASIA C, and 42 were ASIA D 4. One hundred thirty-five patients had either decompression or decompression and fusion surgery. The incidence of spinal deformities was 21 % (44/214). The mean Cobb angle was 28.9 degrees (13-38°). ASIA grade and surgery predicted the occurrence of spinal deformity in both the univariate model (ASIA grade, OR: 1.59 [95 % CI: 1.04-2.44; P = 0.032]; Surgery, OR: 4.47 [95 % CI: 1.89-10.06; P = 0.0007]) and the multivariate model (ASIA grade, OR: 1.63 [95 % CI: 1.04-2.57; P = 0.033]; Surgery, OR: 4.59 [95 % CI: 1.91-11.04; P = 0.0006]), whereas surgery was the most important risk factor in the Cox model (HR: 3.50 [95 % CI: 1.56-7.88; P = 0.0025]). CONCLUSIONS: The SCI patients with high ASIA grades and those who had undergone surgery had a higher likelihood of developing a spinal deformity. Of these risk factors, surgery was the stronger risk factor.

Lumbosacral fixation using sacroiliac buttress screws: a modification to the Jackson technique with intrasacral rods.

BACKGROUND: The use of intrasacral rods has been previously reported for posterior lumbosacral fixation. However, problems associated with this technique include poor stability of the rod in the sacrum, difficulty in contouring the rod to fit the lateral sacral mass, and the complicated assembly procedure for the rod and pedicle screws in the thoracolumbar segments after insertion of the rod into the sacrum. METHODS: We used a screw with a polyaxial head instead of an intrasacral rod, which was inserted into the lateral sacral mass and assembled to the rod connected cephalad to pedicle screws. The dorsal side of the screw was stabilized by the sacral subchondral bone at the sacroiliac joint with iliac buttress coverage, and the tip of the screw was anchored by the sacral cortex. RESULTS: Three different cases were used to illustrate lumbosacral fixation using intrasacral screws as an anchor for the spinal instrumentation. Effective resistance of flexural bending moment and fusion were achieved in these patients at the lumbosacral level. CONCLUSIONS: An intrasacral screw can be stabilized by subchondral bone with iliac buttress coverage at the dorsal and ventral sacral cortex. Posterior spinal fusion with this screw technique enables easier assembly of the instrumentation and presents better stabilization than that provided by the previously reported intrasacral rod technique for correction and fusion of thoracolumbar kyphoscoliosis.

Sagittal Cervical Alignment in Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective case series of surgically treated adolescent scoliosis patients. OBJECTIVES: To assess the radiographic changes of cervical kyphosis and identify the possible factors affecting postoperative sagittal cervical kyphosis in surgically treated patients with adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Cervical kyphosis is a well-recognized phenomenon in patients with adolescent idiopathic scoliosis. Despite recent reports, the prevalence, radiographic changes, and possible factors affecting postoperative sagittal cervical kyphosis are controversial. MATERIALS AND METHODS: A retrospective review of a single-center database was performed on 133 consecutive patients with adolescent idiopathic scoliosis treated with long instrumented (more than 5 levels) spine fusion (minimum, 2 years; mean, 3.3 years; range, 2 to 5.5 years). A total of 89 patients met all of the inclusion criteria. Preoperative and postoperative radiographic measurements and patient demographics were investigated. RESULTS: Postoperative cervical kyphosis was observed in 46 patients. Cobb angle decreased from 48.1° ± 13.1° to 15.4° ± 11.1° at the final follow-up. Cervical kyphosis significantly decreased from 5.5° ± 8.9° preoperatively to -1.5° ± 8.9° at the final follow-up. No difference was observed for T2-T5, T5-T12, lumbar lordosis, sacral slope, pelvic incidence, pelvic tilt, and sagittal vertical axis during the follow-up. Notably, T2 sagittal tilt was significantly increased from preoperatively to the final follow-up. Pearson correlation coefficient test showed a strong correlation between postoperative cervical lordosis and T2 sagittal tilt (r = 0.73; p < .001). CONCLUSIONS: Despite the significant increase of cervical lordosis, 85% of patients still have a kyphotic or less lordotic cervical spine. The strong positive association between cervical lordosis and T2 sagittal tilt suggests that the sagittal cervical alignment of adolescent idiopathic scoliosis patients is closely related to the global sagittal spine balance rather than thoracic kyphosis.

Effect of sports modification on clinical outcome in children and adolescent athletes with symptomatic lumbar spondylolysis.

OBJECTIVE: This cohort study aimed to report the compliance of young athletes with nonoperative treatment and to clarify the role of sports modification on clinical outcome of symptomatic spondylolysis. DESIGN: This study included patients with a chief complaint of low back pain participating in regular sports activity, having spondylolysis, and being treated and followed up between 1990 and 2002 in the authors' hospital. RESULTS: One hundred thirty-two athletes were included in this study: 78 males and 54 females. The mean age of the patients was 13 yrs (range, 7-18 yrs). Only 56 patients (42.4%) were compliant to nonoperative treatment. Eighty-six patients (65%) stopped all sports activities for at least 3 mos, and 46 patients (35%) stopped exercising for a variable period of less than 3 mos. The grading of clinical outcome after nonoperative treatment was as follows: excellent in 48 patients (36.4%), good in 74 patients (56.1), fair in 6 patients (4.5%), and poor in 4 patients (3%). The patients who stopped sports for at least 3 mos were 16.39 times more likely to have an excellent result than those who did not stop sports. Bony healing on radiographs did not correlate with clinical outcome. CONCLUSIONS: Timely cessation of sports activity for 3 mos is considered an effective method of nonoperative treatment for young athletes with symptomatic lumbar spondylolysis.

Chest cage angle difference and rotation of main thoracic curve are independent risk factors of postoperative shoulder imbalance in surgically treated patients with adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective case series of surgically treated adolescent patients with scoliosis. OBJECTIVE: To assess the prevalence and independent risk factors for postoperative shoulder imbalance in surgically treated adolescent patients with idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Despite recent reports that have identified risk factors for postoperative shoulder imbalance, the relative risks remain unclear. METHODS: A retrospective review of 85 consecutive patients treated with thoracic fusion with a minimum 2-year follow-up (mean, 3.1 yr) was conducted to investigate the patient radiographical measurements and demographics. Shoulder height difference (SHD) was measured as the graded height difference of the soft tissue shadows. A SHD more than 2 cm indicated an unbalanced shoulder. Patient demographics and radiographical data were studied to determine risk factors for postoperative SHD. The potential risk factors included age, sex, Risser sign, Cobb angle, flexibility, and apical vertebral rotation (AVR) of the main curve, upper-instrumented vertebra level, SHD, and clavicle chest cage angle difference (CCAD). Univariate and multivariate logistic regression analyses were performed to determine the independent risk factors for postoperative shoulder imbalance. RESULTS: Of the 85 patients, 21 patients presented postoperative shoulder imbalance. The univariate analysis indicated age, Risser sign, Cobb angle of the main curve, AVR of the main curve, and CCAD as risk factors, but the multivariate logistic regression analysis showed that only AVR of the main curve and CCAD were independent risk factors for postoperative shoulder imbalance (AVR, P = 0.04, odds ratio (OR): 3.54; CCAD, P = 0.01, OR: 5.10). CONCLUSION: Postoperative shoulder imbalance was observed in 25% of the surgically treated adolescent patients. The CCAD and AVR of the main thoracic curve were independent risk factors for postoperative shoulder imbalance in surgically treated patients with adolescent idiopathic scoliosis. The significant correlation between CCAD and postoperative shoulder imbalance seen in this study strongly suggests that the relationship of the shoulder girdle and chest cage has a role in maintaining shoulder balance.

Clavicle chest cage angle difference (CCAD): a novel predictor of postoperative shoulder imbalance in patients with adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective case series of surgically treated patients with adolescent scoliosis. OBJECTIVE: To establish a new radiographical measurement method to determine the best preoperative predictor of postoperative shoulder balance. SUMMARY OF BACKGROUND DATA: Shoulder balance is an important aspect of the overall cosmetic balance in patients with adolescent idiopathic scoliosis. Despite recent reports, it is still difficult to estimate the postoperative shoulder balance accurately. METHODS: A retrospective review of 89 consecutive patients who had thoracic fusion with a minimum 2-year follow-up (mean, 3.1 yr) was conducted to investigate the radiographical measurements and patient demographics. The shoulder height difference (SHD) was measured as the graded height difference of the soft tissue shadows. SHD more than 2 cm indicated an unbalanced shoulder. The clavicle chest cage angle difference (CCAD) was established and evaluated. The CCAD was graded as grade A: no imbalance (<0°), grade B: mild imbalance (0°-10°), and grade C: significant imbalance (>10°). RESULTS: Of the 89 patients, 22 patients had a moderate or significant SHD at 2 years postoperatively and were categorized as the unbalanced shoulder group (unbalanced SD). A significant difference was observed in preoperative CCAD between the balanced and unbalanced SD groups (P = 0.01). The intraclass correlation coefficient for CCAD was 0.94 among the observers. CCAD was consistent from the preoperative to the final postoperative follow-ups in both groups. The classification of the CCAD preoperatively indicated that 12 of 22 (54.4%) patients who were classified into the postoperative unbalanced SD group showed grade 3 CCAD preoperatively, whereas only 9 of 67 (13.4%) patients who were classified in the postoperative balanced SD group had grade 3 CCAD preoperatively. CONCLUSION: The developed method to predict postoperative shoulder balance was demonstrated to be easy to perform, reliable, and practical. Additionally, we classified the estimation of postoperative shoulder imbalance by preoperation CCAD. The results of this comprehensive review will guide spinal surgeons in their preoperative planning and in the surgical management of adolescent idiopathic scoliosis to reduce postoperative shoulder imbalance. LEVEL OF EVIDENCE: 4.

Does the intraoperative tranexamic acid decrease operative blood loss during posterior spinal fusion for treatment of adolescent idiopathic scoliosis?

STUDY DESIGN: Retrospective, observational study. OBJECTIVE: To assess the efficacy and safety of tranexamic acid (TXA) in decreasing operative blood loss and the need for transfusion during posterior spinal fusion for the treatment of idiopathic scoliosis in adolescents. SUMMARY OF BACKGROUND DATA: Blood loss associated with spinal surgery is a common potential cause of morbidity and often requires a blood transfusion, which subjects patients to the known risks of blood transfusion including transmission of diseases. Since the 1990s, intraoperative administration of antifibrinolytics has gained popularity. This study assesses the efficacy and safety of TXA in controlling blood loss during posterior spinal fusion for the treatment of idiopathic scoliosis in adolescents at 1 institution. METHODS: A retrospective comparative analysis of 106 consecutive adolescents undergoing posterior spinal fusion procedures at 1 institution was performed. Patients were analyzed according to treatment group: controls (63) and TXA (43). There were no significant differences in demographic (age, sex, and comorbidities) or surgical traits (surgical time, number of fused vertebrae, preoperative hematocrit and hemoglobin) between the 2 groups. RESULTS: TXA group had significantly less intraoperative blood loss (613 ± 195 mL) than the control group (1079 ± 421 mL; P < 0.001) as well as postoperative blood loss (155 ± 86 mL and 263 ± 105 mL, respectively; P < 0.001). TXA group received significantly less blood during the surgical procedure than the control group (258 ± 246 mL and 377 ± 200 mL, respectively; P < 0.001). There were no major intraoperative complications for any of the treatment groups. CONCLUSION: TXA treatment group lost significantly less blood and received significantly fewer blood transfusions than the control group without significant differences in intra- and postoperative complications. A multicenter randomized prospective analysis would provide additional information of the efficacy and safety of TXA.

C5 nerve root palsy after cervical laminoplasty and posterior fusion with instrumentation.

STUDY DESIGN: Consecutive case series. OBJECTIVE: To compare the incidence and clinical characteristics of postoperative fifth cervical nerve root palsy (C5 palsy) in patients with cervical myelopathy treated by laminoplasty alone and laminoplasty with posterior instrumentation. SUMMARY OF BACKGROUND DATA: In patients who have multilevel cervical myelopathy with reducible kyphosis or instability, the authors have performed laminoplasty together with instrumented fusion to restore lordosis and stability. There seems to be a high incidence of postoperative C5 palsy in these patients. METHODS: Seventy-three patients with a mean age of 60.5 years and multilevel cervical myelopathy treated by laminoplasty from 1995 to 2005 were reviewed. Incidence, side, and severity of muscle weakness from patients with C5 palsy after posterior instrumented fusion (instrumented group) was compared with those without instrumentation (noninstrumented group). Radiologic parameters were assessed to identify predisposing factors. RESULTS: Overall 10 of 73 (14%) patients developed the C5 palsy, of which 5 (50%) of 10 patients were in instrumented group, and 5 of 63 (8%) patients were in noninstrumented. Three of 5 (60%) had the palsy on the same side of the opened lamina in the instrumented group, in the same proportion as the noninstrumented. Three (60%) patients in instrumented group developed deltoid weakness grade 1, but none in the noninstrumented had weaker than grade 3. All of the palsied in the instrumented group recovered within 2 years after surgery without removal of implant. Of the 5 patients with the palsy in the instrumented group, 3 had anterolisthesis before surgery and posterior translation of C4 on C5 by the surgery, and no patient without the palsy had the anterolisthesis. CONCLUSIONS: Posterior cervical fusion using instrumentation for restoration of lordotic alignment combined with laminoplasty is highly associated with severe postoperative C5 palsy in patients with multilevel cervical myelopathy and C4 anterolisthesis.

Low back pain in pediatric athletes with unilateral tracer uptake at the pars interarticularis on single photon emission computed tomography.

STUDY DESIGN: Retrospective clinical study with radiographic and medical chart review. OBJECTIVE: To study the clinical characteristics and outcome of pediatric athletes with low back pain and unilateral tracer uptake on single photon emission computed tomography (SPECT) at the pars interarticularis but no defect on radiographs. SUMMARY OF BACKGROUND DATA: Some pediatric athletes with low back pain have no findings on plain radiographs but a unilateral SPECT uptake at the pars interarticularis. However, little is known about these patients. METHODS: Twenty-two pediatric athletes who had low back pain with increased tracer uptake on SPECT unilaterally at the pars interarticularis but no defect on plain radiograph were evaluated. The following criteria were used for evaluation: age, male-to-female ratio, duration of symptoms, vertebral level, and presence of spina bifida occulta or scoliosis. RESULTS: The average age was 12.3 +/- 2.5 years. The male-to-female ratio was 1.2:1. The average duration of symptoms was 21 +/- 23 weeks. Nineteen (86%) had increased uptake at L5. Six (27%) had spina bifida occulta and 8 (36%) had scoliosis. Eighteen (82%) patients showed an excellent outcome. The patients who presented with a longer history of symptoms or a concomitant spina bifida occulta had an increased risk of having occasional aching with vigorous activity when compared with the patients who did not (P < 0.05). CONCLUSIONS: Athletes who have low back pain and increased tracer uptake unilaterally at the pars interarticularis on SPECT are younger than those previously reported patients with spondylolysis proven by a defect on radiographs. Some of these lesions do progress to "frank" spondylolysis seen on radiographs, but favorable clinical outcomes from nonoperative treatment can be expected. Patients with a longer pain history or concomitant spina bifida occulta may need careful follow-up because they are at increased risk of having occasional low back pain.

A prospective study of de novo scoliosis in a community based cohort.

STUDY DESIGN: A 12-year prospective study of de novo scoliosis in a community based cohort. OBJECTIVE.: To investigate factors associated with development of de novo scoliosis. SUMMARY OF BACKGROUND DATA: De novo scoliosis is becoming one of the most prevalent findings in the aging spine, and this condition is associated not only with severe back or leg symptoms but also with complicated surgical outcomes. Cross-sectional studies were limited in distinguishing de novo scoliosis from preexisting deformities, and there had been controversies over the etiology of degenerative scoliosis. METHODS: Community based volunteers were recruited, then examined by orthopedic physicians. Radiologic measurements using entire spine radiographs included the angle of scoliosis and sagittal spinal curvatures, sagittal spinal balance, grade of bone atrophy, number of degenerated discs, and vertebral fractures. We defined radiologic parameters, the disc index, and lateral osteophyte difference to evaluate the asymmetrical spinal degeneration. RESULTS: A total of 60 subjects aged 50-84 years and without scoliosis at baseline were selected and followed for a mean of 12.0 years. De novo scoliosis >or=10 degrees developed in 22 subjects, and logistic regression analysis revealed that the baseline disc index and lateral osteophyte difference values were independent predictors (P < 0.05). CONCLUSIONS: Incidence of de novo scoliosis was predictable by assessing asymmetric disc degeneration in frontal radiograph. More than 20% decrease in unilateral disc height or more than 5 mm longer osteophyte on one side led to increased incidence of de novo scoliosis, which might also influence long-term results of spinal surgery.

Lumbar spondylolysis in pediatric and adolescent soccer players.

BACKGROUND: Lumbar spondylolysis in young soccer players has not been studied extensively. PURPOSE: The purpose of this study was to review lumbar spondylolysis in young soccer players, describe the causes, and report the results of nonoperative treatment emphasizing the cessation of activity for 3 months. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The authors reviewed 57 child and adolescent soccer players (35 boys and 22 girls) with lumbar spondylolysis who came to their outpatient clinic for back pain evaluation. These patients received different modalities of nonoperative treatment, including cessation of sports and wearing a thoracolumbosacral orthosis. Soccer skills, field position, side of dominant leg, age, initiating event of low back pain, duration of symptoms, and nonoperative treatment were reviewed. Clinical outcome of treatment was assessed by the Steiner-Micheli criteria at the most recent follow-up (minimum 2 years). The Fisher exact test was used to compare all the data. RESULTS: Of the patients, 43% noticed that pain started after a high-velocity kick. Thirty-three (58%) of 57 patients had excellent results with no pain during sports, 20 (35%) good, 3 (5%) fair, and 1 (2%) poor. Subjects who ceased playing soccer for 3 months had better results than those who did not comply with this restriction. CONCLUSION: The authors recommend stopping sports for at least 3 months in cases of lumbar spondylolysis in young soccer players who hope to return to their previous level of play without back pain.

The association between brace compliance and outcome for patients with idiopathic scoliosis.

This was a prospective study on the association of brace compliance and curve progression in idiopathic scoliosis. Compliance was measured electronically by embedding a temperature sensor and logger in the Wilmington scoliosis brace. To date there have been no studies that relate objective measures of compliance in a scoliosis brace to treatment outcomes. Thirty-four subjects with idiopathic scoliosis were monitored over the duration of their brace wear. Compliance data were downloaded and analyzed. The compliance rate for the patients whose curve progressed (>5 degrees) was 62%; the compliance rate for the patients who did not progress was 85% (P = 0.004). In the group that had high compliance (>90%), one of the nine subjects' curves progressed (11%). In the group with low compliance (<90%), 14 of the 25 subjects' curves progressed (56%, P = 0.0075). Results indicate that the more patients comply with brace treatment, the better their chances of a favorable outcome.

Compliance monitoring of brace treatment for patients with idiopathic scoliosis.

STUDY DESIGN: Prospective, blinded study to evaluate compliance with treatment. OBJECTIVE: To evaluate objectively idiopathic scoliosis patients' compliance with Wilmington brace treatment. SUMMARY OF BACKGROUND DATA: Patients' compliance with brace treatment for idiopathic scoliosis traditionally has been determined from patient or parent interviews or both; however, the hours reported by patients are subjective and consequently are not accurate. METHODS: Study participants were 61 consecutive patients with idiopathic scoliosis: 54 girls and 7 boys. Inclusion criteria were curvature of more than 20 degrees and less than 45 degrees of Cobb angle before brace treatment. Actual hours worn per day were measured using a compliance monitor, and compliance was determined by the percentage of actual hours worn in accordance with the prescribed regimen. Accuracy of compliance from hours reported by patients was compared with actual hours measured by the monitor. Correlations between compliance and prescribed regimen and age were analyzed. RESULTS: The overall compliance measured by the monitor was 75 +/- 27% (mean +/- S.D.), and the frequency distribution was similar to a Gaussian distribution. The compliance determined from hours reported by patients was 85 +/- 24%, which was higher than that from actual hours measured by the monitor (P = 0.01). There was a negative correlation between age and compliance (rho = -0.30, P = 0.025); 10-, 12-, and 14-year-old patients had 84, 77, and 60% average compliance, respectively. Compliance among patients with different prescribed regimens (8, 12, 16, or 23 hours of wear) showed no statistical difference (P = 0.361). CONCLUSIONS: Patients with idiopathic scoliosis complied with 75% of prescribed regimen on average and overreported their hours of brace wear to their physician. Age affected compliance. There was no statistical difference in compliance among patients with different prescribed regimens. The present study confirms the need for a compliance monitor to accurately evaluate use and outcome of brace treatment.