Decompression surgery for lumbar spinal canal stenosis in octogenarians; a single center experience of 121 consecutive patients.

INTRODUCTION: With increasing age, ubiquitous degeneration processes lead to a narrowing of the spinal canal. Degenerative lumbar spinal stenosis (DLSS) causes functional disability and is associated with back and lower extremity pain in older individuals. The goal of this study was to determine if decompression surgery can be performed safely and provide a stable benefit in our octogenarian patient population. METHODS: In this retrospective study, 121 patients over the age of 80 (mean age: 82.7 years SD: 2.4 years) with the diagnosis of central spinal canal stenosis who underwent posterior decompression surgery without fusion for DLSS between January 2006 and August 2013 were followed up from November to December 2013. Peri- and post-operative complications were recorded. Walking distances and visual analogue scale (VAS) scores were determined before surgery and at follow up time (mean follow up time 36 months). Patient's satisfaction with treatment was documented with the overall satisfaction degree scale in Zurich Claudicatio Questionnaire (ZCQ). RESULTS: The peri-operative complication rate was 6.6% with five dural tears, two wound infections and one epidural haematoma. Four patients required revision surgery (three re-decompression and one secondary spondylodesis). Walking distance improved from 147 meters (SD ±110 m) to 340 m (SD ±170 m) p < .001. Pain improved with change of the VAS scores from 7.2 (SD ±1.2) to 4.5 (SD ±1.0), p < .001. The overall satisfaction scale in ZCQ was 2.2 at follow up. CONCLUSION: A minimal surgical intervention, namely decompression, improves walking ability, decreases pain and has marginal potential for complications in patients with DLSS who are over 80 years old.

Pelvic incidence-lumbar lordosis mismatch predisposes to adjacent segment disease after lumbar spinal fusion.

PURPOSE: Several risk factors and causes of adjacent segment disease have been debated; however, no quantitative relationship to spino-pelvic parameters has been established so far. A retrospective case-control study was carried out to investigate spino-pelvic alignment in patients with adjacent segment disease compared to a control group. METHODS: 45 patients (ASDis) were identified that underwent revision surgery for adjacent segment disease after on average 49 months (7-125), 39 patients were selected as control group (CTRL) similar in the distribution of the matching variables, such as age, gender, preoperative degenerative changes, and numbers of segments fused with a mean follow-up of 84 months (61-142) (total n = 84). Several radiographic parameters were measured on pre- and postoperative radiographs, including lumbar lordosis measured (LL), sacral slope, pelvic incidence (PI), and tilt. RESULTS: Significant differences between ASDis and CTRL groups on preoperative radiographs were seen for PI (60.9 ± 10.0° vs. 51.7 ± 10.4°, p = 0.001) and LL (48.1 ± 12.5° vs. 53.8 ± 10.8°, p = 0.012). Pelvic incidence was put into relation to lumbar lordosis by calculating the difference between pelvic incidence and lumbar lordosis (∆PILL = PI-LL, ASDis 12.5 ± 16.7° vs. CTRL 3.4 ± 12.1°, p = 0.001). A cutoff value of 9.8° was determined by logistic regression and ROC analysis and patients classified into a type A (∆PILL <10°) and a type B (∆PILL ≥10°) alignment according to pelvic incidence-lumbar lordosis mismatch. In type A spino-pelvic alignment, 25.5 % of patients underwent revision surgery for adjacent segment disease, whereas 78.3 % of patients classified as type B alignment had revision surgery. Classification of patients into type A and B alignments yields a sensitivity for predicting adjacent segment disease of 71 %, a specificity of 81 % and an odds ratio of 10.6. CONCLUSION: In degenerative disease of the lumbar spine a high pelvic incidence with diminished lumbar lordosis seems to predispose to adjacent segment disease. Patients with such pelvic incidence-lumbar lordosis mismatch exhibit a 10-times higher risk for undergoing revision surgery than controls if sagittal malalignment is maintained after lumbar fusion surgery.

IkappaB kinase epsilon and TANK-binding kinase 1 activate AKT by direct phosphorylation.

AKT activation requires phosphorylation of the activation loop (T308) by 3-phosphoinositide-dependent protein kinase 1 (PDK1) and the hydrophobic motif (S473) by the mammalian target of rapamycin complex 2 (mTORC2). We recently observed that phosphorylation of the AKT hydrophobic motif was dramatically elevated, rather than decreased, in mTOR knockout heart tissues, indicating the existence of other kinase(s) contributing to AKT phosphorylation. Here we show that the atypical IκB kinase ε and TANK-binding kinase 1 (IKKε/TBK1) phosphorylate AKT on both the hydrophobic motif and the activation loop in a manner dependent on PI3K signaling. This dual phosphorylation results in a robust AKT activation in vitro. Consistently, we found that growth factors can induce AKT (S473) phosphorylation in Rictor(-/-) cells, and this effect is insensitive to mTOR inhibitor Torin1. In IKKε/TBK1 double-knockout cells, AKT activation by growth factors is compromised. We also observed that TBK1 expression is elevated in the mTOR knockout heart tissues, and that TBK1 is required for Ras-induced mouse embryonic fibroblast transformation. Our observations suggest a physiological function of IKKε/TBK1 in AKT regulation and a possible mechanism of IKKε/TBK1 in oncogenesis by activating AKT.

Asymmetry of the multifidus muscle in lumbar radicular nerve compression.

OBJECTIVE: The multifidus muscle is the only paraspinal lumbar muscle that is innervated by a single nerve root. This study aimes to evaluate if the asymmetry of the multifidus muscle is related to the severity of compression of the nerve root or the duration of radiculopathy. METHODS: MRI scans of 79 patients with symptomatic single level, unilateral, lumbar radiculopathy were reviewed for this retrospective case series with a nested case-control study. The cross-sectional area (CSA) of the multifidus muscle and the perpendicular distance of the multifidus to the lamina (MLD) were measured bilaterally by two radiologists and set into relation to the severity of nerve compression, duration of radiculopathy and probability of an indication for surgical decompression. RESULTS: In 67 recessal and 12 foraminal symptomatic nerve root compressions, neither the MLD ratio (severe 1.19 ± 0.55 vs less severe nerve compression: 1.12 ± 0.30, p = 0.664) nor the CSA ratio (severe 1 ± 0.16 vs less severe 0.98 ± 0.13, p = 0.577) nor the duration of symptoms significantly correlated with the degree of nerve compression. MR measurements of multifidus were not different in patients with (n = 20) and those without (n = 59) clinical muscle weakness in the extremity caused by nerve root compression. A MLD >1.5 was, however, associated with the probability of an indication for surgical decompression (OR 3, specificity 92%, PPV 73%). CONCLUSIONS: Asymmetry of the multifidus muscle correlates with neither the severity nor the duration of nerve root compression in the lumbar spine. Severe asymmetry with substantial multifidus atrophy seems associated with the probability of an indication of surgical decompression.

Perforation and bacterial contamination of microscope covers in lumbar spinal decompressive surgery.

OBJECTIVE: To determine the integrity of microscope covers and bacterial contamination at the end of lumbar spinal decompressive surgery. MATERIALS AND METHODS: A prospective study of 25 consecutive lumbar spinal decompressions with the use of a surgical microscope was performed. For detection of perforations, the microscope covers were filled with water at the end of surgery and the presence of water leakage in 3 zones (objective, ocular and control panel) was examined. For detection of bacterial contamination, swabs were taken from the covers at the same locations before and after surgery. RESULTS: Among the 25 covers, 1 (4%) perforation was observed and no association between perforation and bacterial contamination was seen; 3 (4%) of 75 smears from the 25 covers showed post-operative bacterial contamination, i.e. 2 in the ocular zone and 1 in the optical zone, without a cover perforation. CONCLUSIONS: The incidence of microscope cover perforation was very low and was not shown to be associated with bacterial contamination. External sources of bacterial contamination seem to outweigh the problem of contamination due to failure of cover integrity.

Posterior correction of thoracic adolescent idiopathic scoliosis with pedicle screw instrumentation: results of 48 patients with minimal 10-year follow-up.

PURPOSE: Since early 1990s pedicle screws in thoracic spine have been used in posterior correction of adolescent idiopathic scoliosis (AIS). Long-term results are scarce. We report clinical, radiological and pulmonary function results of 48 consecutive patients with 10-year minimal follow-up. METHODS: Forty-eight consecutive patients (42 females, 6 males) with 41 Lenke 1 (lumbar modifier A = 19, B = 8, C = 14), 7 Lenke 2 (lumbar modifier A = 2, B = 4, C = 1) were operated for AIS from posterior with pedicle screw alone instrumentation. Risser stage at the time of operation was 0-3 in 24, more than 3 in 24 patients. Mean age was 15.3 years. The data were prospectively collected preoperatively, at 6 weeks, 2 years and 10 years postoperatively. Cobb angle, sagittal and coronal balance, distal adjacent disc angle and lowest fused vertebral tilt were documented at all time-points. Choice of fusion levels is described. Not every vertebra was instrumented with pedicle screws. The implant density was average one pedicle screw per vertebra or 50 %. Derotation and translation of apical vertebrae on the concave side were performed for correction. The overall outcome and the outcome of different curve types were analyzed statistically. RESULTS: Lowest instrumented vertebra (LIV) was distal end vertebra in two-thirds of the patients and was one below distal end vertebra in one-third of the patients. The main thoracic curve correction was 63 %, from 58° ± 12° preoperative to 21° ± 9° at 6 weeks. The Cobb angle was 23° ± 10° at 2 years and 26° ± 10° at 10 years. The apical vertebral rotation improved 35 %, the non-instrumented lumbar curves improved 47 %, the distal adjacent disc angle decreased from 6° ± 3° preoperatively to -2° ± 4° postoperatively and the last instrumented vertebral tilt decreased from 23° ± 8° preoperatively to 5° ± 5° postoperatively. All these parameters remained stable up to 10-year follow-up. The scoliosis correction was not associated with any change in the preoperative thoracic kyphosis and lumbar lordosis. The % FVC remained unchanged with 74 ± 21 % preoperatively to 74 ± 11 % at 2 years and 75 ± 10 % at 10 years. The SRS-24 score was 93 ± 18 points at 2 years and 95 ± 22 points at 10 years. There were no neurological complications, no pedicle screw-related complications. CONCLUSION: Posterior correction of thoracic AIS with pedicle screw instrumentation is safe and produces a long-term stable correction and high patient satisfaction. An implant density of 50 % is sufficient to achieve these results. LIV can be the distal end vertebra or one below the distal end vertebra depending on the position of the distal end vertebra to the centre sacral line. The preoperative pulmonary function does not change on long term.

Extent of decompression and incidence of postoperative epidural hematoma among different techniques of spinal decompression in degenerative lumbar spinal stenosis.

STUDY DESIGN: Prospective radiographic cohort study. OBJECTIVE: To study the extent of bony decompression and dural sac expansion after laminectomy (including subtotal laminectomy and laminotomy with midline resection), bilateral fenestration, and unilateral fenestration with contralateral undercutting in lumbar spinal canal stenosis. Further, to investigate differences of incidence and extent of early postoperative epidural hematoma in these approaches. SUMMARY OF BACKGROUND DATA: There are different techniques of decompression in lumbar spinal stenosis. An overall good clinical outcome has been reported with different biomechanical consequences, but no morphometric comparative reports exist on these approaches. METHODS: Using the data of a previous prospective study of 30 patients, who underwent lumbar decompression for degenerative stenosis, 49 levels treated with 3 different kinds of surgical approaches were analyzed: (1) laminectomy (including subtotal laminectomy, laminotomy with midline resection); (2) bilateral fenestration; and (3) unilateral fenestration with contralateral undercutting. In all 3 groups, the cross-sectional area of the maximum bony stenosis and dural sac compression (bony margins and dural sac expansion) were measured in each operated level before and after the operation. Occurrence of epidural hematoma and its size were noted in the 3 groups. RESULTS: Median postoperative bony stenosis was not significantly different in the groups, being 330 mm(2), 333.5 mm(2), and 261.5 mm(2), respectively, in groups 1, 2, and 3. There was no statistically significant difference between the median postoperative extension of dural sac areas in the 3 groups, measuring 125 mm(2), 123 mm(2), and 137 mm(2). The incidence of epidural hematoma was similar in the 3 groups. Levels where postoperative epidural hematoma was detected had larger bony decompression independent of the surgical approach compared with the whole group. CONCLUSIONS: Unilateral and bilateral approaches achieve a similar amount of dural sac extension by a lesser extent of bony resection in comparison with the laminectomy approach. There is a tendency of increased postoperative hematoma in approaches with greater bony decompression area.

Sacral dome resection and single-stage posterior reduction in the treatment of high-grade high dysplastic spondylolisthesis in adolescents and young adults.

OBJECTIVE: The description of the operation technique and retrospective review of 15 consecutive patients who were treated by posterior sacral dome resection and single-stage reduction with pedicle screw fixation for high-grade, high-dysplastic spondylolisthesis. MATERIALS AND METHODS: All the patients had high-grade, high-dysplastic spondylolisthesis L5 and were treated by posterior sacral dome resection and posterior single-stage reduction from L4-S1. The average age at the time of surgery was 17.3 (11-28) years. The average follow-up time is 5.5 (2-11.6) years. Clinical and radiological data were retrospectively reviewed. RESULTS: Spondylolisthesis was reduced from average 99% preoperative to 29% at the last follow-up. L5 incidence improved from 74° to 56°, the lumbosacral angle improved from 15° kyphosis to 6° lordosis, lumbar lordosis decreased from 69° to 53° from preoperative to the last follow-up. While pelvic incidence of 77° remained unchanged, sacral slope decreased from 51° to 46° and pelvic tilt increased from 25° to 30°. Clinical outcome was subjectively rated to be much better than before surgery by 14 out of 15 patients. Four out of 15 patients had temporary sensory impairment of the L5 nerve root which resolved completely within 12 weeks. There were no permanent neurological complications or no pseudarthrosis. CONCLUSION: The sacral dome resection is a shortening osteotomy of the lumbosacral spine which allows a single-stage reduction of L5 without lengthening of lumbosacral region in high-grade spondylolisthesis, which helps to avoid neurological complications. This is a safe surgical technique resulting in a good multidimensional deformity correction and restoration of spino-pelvic alignment towards normal values with a satisfactory clinical outcome.

Analysis of internal construct validity of the SRS-24 questionnaire.

PURPOSE: The SRS-24 questionnaire was originally validated using methods of classical test theory, but internal construct validity has never been shown. Internal construct validity, i.e. unidimensionality and linearity, is a fundamental arithmetic requirement and needs to be shown for a scale for summating any set of Likert-type items. Here, internal construct validity of the SRS-24 questionnaire in adolescent idiopathic scoliosis (AIS) patients is analyzed. METHODS: 232 SRS-24 questionnaires distributed to 116 patients with AIS pre-operatively and at postoperative follow-up were analyzed. 103 patients were females; the average age was 16.5 ± 7.1 years. The questionnaires were subjected to Rasch analysis using the RUMM2020 software package. RESULTS: All seven domains of the SRS-24 showed misfit to the Rasch model, and three of seven were unidimensional. Unidimensionality and linearity could only be achieved for an aggregate score by separating pre- and postoperative items and omitting items which caused model misfit. Reducing the questionnaire to six pre-operative items (p = 0.098; 2.25% t tests) and five postoperative items (p = 0.267; 3.70% t tests) yields model fit and unidimensionality for both summated scores. The person-separation indices (PSI) were 0.67 and 0.69, respectively, for the pre- and postoperative patients. CONCLUSIONS: The SRS-24 score is a non-linear and multidimensional construct. Adding the items into a single value is therefore not supported and invalid in principle. Making profound changes to the questionnaire yields a score which fulfills the properties of internal construct validity and supports its use a change score for outcome measurement.

Anterior short correction in thoracic adolescent idiopathic scoliosis with mini-open thoracotomy approach: prospective clinical, radiological and pulmonary function results.

INTRODUCTION: This is a prospective study of adolescent patients in whom idiopathic thoracic scoliosis was corrected by short anterior fusion through a mini-open thoracotomy approach. Clinical, radiological and pulmonary function results of minimal 2-year (2-6) follow-up are presented. MATERIALS AND METHODS: Consecutive 62 patients with Lenke 1 and 2 curves, having main thoracic scoliosis of up to 75°, were prospectively included. The shoulder imbalance in Lenke 2 patients was less than 20 mm. Thoracic scoliosis was corrected by short anterior fusion. The thoracic spine was exposed by an 8-cm mini-open thoracotomy incision. The operation technique and choosing of fusion levels are thoroughly described. Complete 360° discectomies and convex side vertebral endplates osteotomies are essential for deformity corrections with short fusions. Single-rod 5.5-mm titanium implants were used. The age at the time of operation was mean 15.2 years; 56 patients had a single thoracic curve and 6 patients had a double thoracic curve. There were almost equal numbers of patients with lumbar modifier A, B or C. The average length of fusion was 5.5 (4-7) vertebrae. The average length of fusion was 3.5 (2-6) vertebrae shorter than the average curve length. RESULTS: The instrumented thoracic curves improved by 58.3% at 6 weeks and 56.3% at the last follow-up. Apex thoracic vertebral rotation improved by 73.78% at 6 weeks and 76.24% at the last follow-up. The non-instrumented upper thoracic curve improved by 25% in double thoracic scoliosis, where the mid-thoracic curve was selectively fused, and the non-instrumented lumbar curves improved by 33.9% at the last follow-up. The radiological changes from 6 weeks to the last follow-up were statistically not significant. The clinical rib hump improved by 54% at the last follow-up. There were no significant changes in the pulmonary function. FVC% was 81.04% preoperatively, 76.41% at 6 months and 80.38% at the 2-year follow-up. The results of SRS 24 questionnaire improved from a total of 61.40 points preoperatively to 100.50 points at 6 months and 98.62 points at the 2-year follow-up. There were no neurological or thoracotomy related complications, no pseudarthrosis, no implant pullout or breakage. CONCLUSION: A good deformity correction without loss of correction or adding on, a good cosmetic result and good patient's satisfaction were achieved through shorter than end-to-end thoracic fusions. The radiological residual deformity is acceptable. Anterior correction of thoracic scoliosis with a short spinal fusion is recommended to keep the large part of the spine mobile. A very short fusion, small thoracotomy incision, low-profile implants and complete closure of parietal pleura are keys to prevent reduction in postoperative lung function.

Changes in health-related quality of life after spinal fusion and scoliosis correction in patients with cerebral palsy.

BACKGROUND: The literature is scarce on the impact of spinal fusion for scoliosis in patients with cerebral palsy (CP) regarding the health-related quality of life (HRQL). The purpose of this study was to evaluate the outcome of surgical scoliosis correction measured by the subjective change in the HRQL and the objective radiologic changes. Factors that could influence the subjective outcome were examined to investigate their correlation to the results of HRQL. METHODS: A retrospective review of 50 consecutive patients with CP, who had spinal fusion for scoliosis with minimal 2-year follow-up was carried out. Radiographic data were obtained from preoperative, postoperative, and last follow-up examinations. The assessment of the HRQL was done through a modified version of the "Caregiver Priorities and Child Health Index of Life with Disabilities" questionnaire, assessed by the caregivers of the patients. RESULTS: There was a significant improvement (P = 0.001) of HRQL after the operation. The satisfaction rate of the patients with the outcome of the operation was 91.7%. There was an average of 64.3% scoliosis correction, 57.7% pelvic tilt correction, 53% improvement of apical vertebral rotation, and 67.2% improvement of apical vertebral translation. At the last follow-up, the average scoliosis angle was 32.0 degrees and pelvic tilt was 8.8 degrees. Weak but not significant correlation between the amount of scoliosis correction and the subjective change in the HRQL could be established (R = 0.321, P = 0.078). No correlation between the occurrence of complications and changes in the HRQL (P = 0.122) or the satisfaction rate with the outcome of the operation (P = 0.764) was found. Extension of spinal fusion to sacropelvis had no influence on the occurrence of complications (P = 0.42) or on the changes in HRQL (P = 0.71). CONCLUSIONS: Life quality improved after surgical scoliosis correction in patients with CP. There is a high satisfaction rate of patients and their caregivers. Subjective changes in HRQL after the operation do not correlate with objective radiographic changes brought about by the operation, which indicates that the present operation indications and achieved correction are adequate to achieve an improvement of the subjective HRQL in this patient group. LEVEL OF EVIDENCE: Therapeutic level IV, retrospective study.

LumbSten: the lumbar spinal stenosis outcome study.

BACKGROUND: Lumbar spinal stenosis is the most frequent reason for spinal surgery in elderly people. For patients with moderate or severe symptoms different conservative and surgical treatment modalities are recommended, but knowledge about the effectiveness, in particular of the conservative treatments, is scarce. There is some evidence that surgery improves outcome in about two thirds of the patients. The aims of this study are to derive and validate a prognostic prediction aid to estimate the probability of clinically relevant improvement after surgery and to gain more knowledge about the future course of patients treated by conservative treatment modalities. METHODS/DESIGN: This is a prospective, multi-centre cohort study within four hospitals of Zurich, Switzerland. We will enroll patients with neurogenic claudication and lumbar spinal stenosis verified by Computer Tomography or Magnetic Resonance Imaging. Participating in the study will have no influence on treatment modality. Clinical data, including relevant prognostic data, will be collected at baseline and the Swiss Spinal Stenosis Questionnaire will be used to quantify severity of symptoms, physical function characteristics, and patient's satisfaction after treatment (primary outcome). Data on outcome will be collected 6 weeks, and 6, 12, 24 and 36 months after inclusion in the study. Applying multivariable statistical methods, a prediction rule to estimate the course after surgery will be derived. DISCUSSION: The ultimate goal of the study is to facilitate optimal, knowledge based and individualized treatment recommendations for patients with symptomatic lumbar spinal stenosis.

The Damaged Spinal Cord Is a Suitable Target for Stem Cell Transplantation.

Background. Given individuals with spinal cord injury (SCI) approaching 2 million, viable options for regenerative repair are desperately needed. Human central nervous system stem cells (HuCNS-SC) are self-renewing, multipotent adult stem cells that engraft, migrate, and differentiate in appropriate regions in multiple animal models of injured brain and spinal cord. Preclinical improved SCI locomotor function provided rationale for the first-in-human SCI clinical trial of HuCNS-SC cells. Evidence of feasibility and long-term safety of cell transplantation into damaged human cord is needed to foster translational progression of cellular therapies. Methods. A first-ever, multisite phase I/IIa trial involving surgical transplantation of 20 million HuCNS-SC cells into the thoracic cord in 12 AIS A or B subjects (traumatic, T2-T11 motor-complete, sensory-incomplete), aged 19 to 53 years, demonstrated safety and preliminary efficacy. Six-year follow-up data were collected (sensory thresholds and neuroimaging augmenting clinical assessments). Findings. The study revealed short- and long-term surgical and medical safety (well-tolerated immunosuppression in population susceptible to infections). Preliminary efficacy measures identified 5/12 with reliable sensory improvements. Unfortunately, without thoracic muscles available for manual muscle examination, thoracic motor changes could not be measured. Lower limb motor scores did not change during the study. Cervical cord imaging revealed, no tumor formation or malformation of the lesion area, and secondary supralesional structural changes similar to SCI control subjects. Interpretation. Short- and long-term safety and feasibility support the consideration of cell transplantation for patients with complete and incomplete SCI. This report is an important step to prepare, foster, and maintain the therapeutic development of cell transplantation for human SCI.

Expression and hydroxylamine cleavage of thymosin alpha 1 concatemer.

Human thymosin alpha 1 (Talpha1) is an important peptide in the development and senescence of immunological competence in human, and many studies have reported the expression of this peptide. In this study, we designed and synthesized the Talpha1 gene according to the E. coli codon usage preference and constructed a 6xTalpha1 concatemer. The latter was inserted into an E. coli expression vector pET-22b (+), and transformed into E. coli BL21 (DE3). After induction with IPTG, the concatemer protein was successfully expressed in E. coli then cleaved by hydroxylamine to release the Talpha1 monomer. Gly-SDS-PAGE and mass spectrometry confirmed that the recombinant protein was cleaved as intended. The bioactivity of the Talpha1 monomer was analyzed by lymphocyte proliferation and by mitochondrial activity in two different tumor cell lines. This study provides a description of the preparation of a bioactive Talpha1, which may prove useful in future biomedical research.

Scoliosis correction with pedicle screws in Duchenne muscular dystrophy.

This report describes the spinal fixation with pedicle-screw-alone constructs for the posterior correction of scoliosis in patients suffering from Duchenne muscular dystrophy (DMD). Twenty consecutive patients were prospectively followed up for an average of 5.2 years (min 2 years). All patients were instrumented from T3/T4 to the pelvis. Pelvic fixation was done with iliac screws similar to Galveston technique. The combination of L5 pedicle screws and iliac screws provided a stable caudal foundation. An average of 16 pedicle screws was used per patient. The mean total blood loss was 3.7 l, stay at the intensive care unit was 77 h and hospital stay was 19 days. Rigid stabilisation allowed immediate mobilisation of the patient in the wheel chair. Cobb angle improved 77% from 44 degrees to 10 degrees, pelvic tilt improved 65% from 14 degrees to 3 degrees. Lumbar lordosis improved significantly from 20 degrees to 49 degrees, thoracic kyphosis remained unchanged. No problems related to iliac fixation, no pseudarthrosis or implant failures were observed. The average percentage of predicted forced vital capacity (%FVC) of the patients was 55% (22-94%) preoperatively and decreased to 44% at the last follow-up. There were no pulmonary complications. One patient with a known cardiomyopathy died intraoperatively due to a sudden cardiac arrest. The rigid primary stability with pedicle screws allowed early mobilisation of the patients, which helped to avoid pulmonary complications.

Dual Sequential Short Anterior Correction in Double Major Adolescent Idiopathic Scoliosis.

STUDY DESIGN: retrospective comparative study. INTRODUCTION: The standard surgical technique for double major adolescent idiopathic scoliosis (AIS) has been the fusion of both thoracic and thoracolumbar/lumbar curves from the posterior approach. Although short anterior correction is established in AIS with single thoracic or thoracolumbar/lumbar curves, anterior correction in double major curves has not yet been described. The purpose of this study is to compare this novel technique with standard posterior pedicle screw instrumentation in double major AIS. METHODS: 19 consecutive patients with a double major AIS were treated surgically either with pedicle screw instrumentation and posterior fusion (n = 11) or dual anterior short instrumentation and fusion (n = 8) of both curves. The mean follow-up was 5.6 ± 3 years (2-10 years). Clinical and radiologic results, results of pulmonary function, and Scoliosis Research Society (SRS) questionnaire are analyzed and compared. RESULTS: The length of fusion was 7.6 ± 0.7 vertebrae with the anterior technique and 12 ± 1 vertebrae with the posterior technique (p < .001). Cobb angle correction was 78% and 53% in thoracic curves, and 80% and 59% in lumbar curves with posterior and anterior technique respectively (p < .05). The preoperative pulmonary function remained unchanged to the last follow-up in both groups. The scores of SRS-24 questionnaire were similar preoperatively and at the last follow-up in both groups. CONCLUSION: This novel technique of dual sequential short anterior correction is an alternative to the standard posterior long fusions in the double major AIS. A significantly less amount of mobile segments needs to be fused leaving the thoracolumbar junction mobile and saving at least one lumbar mobile segment distally. LEVEL OF EVIDENCE: Level III.

Postoperative intravenous morphine consumption, pain scores, and side effects with perioperative oral controlled-release oxycodone after lumbar discectomy.

BACKGROUND: Oral opioid formulations contribute to postoperative analgesia. In this study, we evaluated the perioperative application of oral controlled-release oxycodone to reduce postoperative IV morphine consumption and opioid side effects after lumbar discectomy. METHODS: Forty patients scheduled for elective lumbar discectomy over 1 or 2 levels were included in this prospective, randomized, double-blind, placebo-controlled study. Every 12 h patients received either 20 mg oral controlled-release oxycodone or placebo, from the evening before surgery until the second postoperative morning. All patients received IV morphine via a morphine patient-controlled analgesia device for postoperative analgesia. Acetaminophen 1 g was administered to all patients every 6 h. Postoperative IV morphine consumption was assessed separately for T(0)-T(24) and T(24)-T(48). Postoperative assessments were conducted every 6 h for the first 48 h after surgery. Postoperative analgesia assessments included pain at rest, during coughing, and with motion, using a visual analog scale. Nausea, vomiting, pruritus, sedation, and bowel function were also assessed every 6 h. Patients rated their satisfaction with postoperative analgesia 72 h postoperatively. RESULTS: Postoperative IV morphine consumption was significantly reduced during T(0)-T(24) (26 +/- 10 mg vs 52 +/- 29 mg) and T(24)-T(48) (13 +/- 8 mg vs 33 +/- 18 mg) in the controlled-release oxycodone group compared with that in the placebo group. Pain scores at rest, during coughing, and with motion were significantly lower during the first 48 postoperative hours in the controlled-release oxycodone group. Postoperative nausea and vomiting were significantly reduced during the first 24 h in the controlled-release oxycodone group. Lastly, the controlled-release oxycodone group also experienced significantly earlier recovery of bowel function and had higher patient satisfaction with pain therapy. CONCLUSIONS: Perioperative oral controlled-release oxycodone reduces postoperative IV morphine consumption after lumbar discectomy while providing good analgesia with fewer side effects compared with placebo.

"Bone-οn-Bone" surgical reconstruction of moderate severity, flexible single curve adolescent idiopathic scoliosis: continuing improvements of the technique and results in three scoliosis centers after almost twenty years of use.

The "bone-on-bone" reconstruction for adolescent idiopathic scoliosis is reviewed in this article. Extensive use over the past 18 years has identified it's functional benefits outstanding clinical results, and very limited complications. This is an extensive update of it's application, since it's introduction, 18 years ago.

Clinical outcome in lumbar decompression surgery for spinal canal stenosis in the aged population: a prospective Swiss multicenter cohort study.

STUDY DESIGN: This is a prospective, multicenter cohort study including 8 medical centers in the metropolitan area of the Canton Zurich, Switzerland. OBJECTIVES: To examine whether outcome and quality of life might improve after decompression surgery for degenerative lumbar spinal stenosis (DLSS) even in patients older than 80 years and to compare data with a younger patient population from our own patient collective. SUMMARY AND BACKGROUND DATA: Lumbar decompression surgery without fusion has been shown to improve quality of life in lumbar spinal canal stenosis. In the population older than 80 years, treatment recommendations for DLSS show conflicting results. METHODS: Eight centers in the metropolitan area of Zurich, Switzerland agreed on the classification of DLSS, surgical principles, and follow-up protocols. Patients were followed from baseline, at 6 months, and 12 months. Baseline characteristics were analyzed with 5 different questionnaires "Spinal Stenosis Measure, Feeling Thermometer, Numeric Rating Scale, 5D-3L, and Roland and Morris Disability Questionnaire." In addition, our study population was compared with a younger control group. Furthermore, we calculated the minimal clinically important differences. RESULTS: Thirty-seven patients with an average age of 82.5 ± 2.5 years reached the 12-month follow-up. Spinal Stenosis Measure scores, the Feeling Thermometer, the Numeric Rating Scale, and the Roland and Morris Disability Questionnaire showed significant improvements at the 6-month and 12-month follow-ups (P < 0.001). One EQ-5D-3Lsubgroup "anxiety/depression" showed no significant improvement (P = 0.109) at 12-month follow-up. The minimal clinically important difference for the "Symptom Severity scale" in the Spinal Stenosis Measure was achieved with improvement of 70% in the older patient population. CONCLUSION: Patients 80 years or older can expect a clinically meaningful improvement after lumbar decompression for symptomatic DLSS. Our patient population showed significant positive development in quality of life in the short- and long-term follow-ups. LEVEL OF EVIDENCE: 3.

The Effect of Epidural Steroid Injection on Postoperative Outcome in Patients From the Lumbar Spinal Stenosis Outcome Study.

STUDY DESIGN: Retrospective analysis of data from patients participating in the Lumbar Spinal Stenosis Outcome Study (LSOS). OBJECTIVE: The aim of LSOS was to assess clinical outcomes after surgical or nonoperative treatment in patients with and without prior epidural steroid injections. SUMMARY OF BACKGROUND DATA: Epidural steroid injections (ESI), a common treatment modality, reduce symptoms in the short-term, but according to a subgroup analysis from the Spine Patient Outcomes Research Trial (SPORT) they reduce the amount of improvement after subsequent surgical or nonoperative treatment. METHODS: The data of 281 patients with lumbar spinal stenosis who had completed baseline and 6-month follow-up assessments were analyzed. Patients completed the Spinal Stenosis Measure (SSM). Changes in the SSM scores from baseline to follow-up were compared between patients with and without prior ESI, for the surgical and nonsurgical treatment groups. RESULTS: The mean (SD) age of the patients was 75 (8.7) years. 229 patients underwent surgery and 111 of these had received an ESI in the 12 months before surgery. Of the 52 patients treated nonoperatively, 29 had received a prior ESI. The unadjusted changes (improvement) in the SSM-symptom scores between baseline and 6 months' follow up were: surgery and prior ESI 0.95, surgery and no prior ESI 0.78 (P = 0.15); no surgery and prior ESI 0.28, no surgery and no prior ESI 0.29 (P = 0.85). When adjusted for confounding factors, the reduction in SSM-symptom score was greater for surgery than for nonoperative treatment by 0.41 points (P < 0.001); the effect of having had an ESI prior to study entry was -0.08 (P = 0.40). CONCLUSION: The analysis of outcomes in the LSOS cohort provided no evidence that ESIs have a negative effect on the short-term outcome of surgery or nonoperative treatment in patients with lumbar spinal stenosis. LEVEL OF EVIDENCE: 3.