Severe adolescent idiopathic scoliosis: posterior staged correction using a temporary magnetically-controlled growing rod.

PURPOSE: A two-staged posterior correction, using a temporary magnetically controlled growing rod (MCGR), was employed to gradually and safely correct severe adolescent idiopathic scoliosis (AIS). The aim of the study is illustrating the results of this procedure. METHODS: A retrospective review of a consecutive series of 17 severe AIS. The first surgery was a posterior release (multiple Ponte osteotomies) with implant of pedicle screws and MCGR on the concave side of the curve. In post-operative days, a distraction was applied with MCGR, which allowed to obtain a total mean lengthening of 2 cm in about 2 weeks, with no complications arising. In the second posterior surgery, MCGR was removed and the definitive rods were applied for final fusion. The mean pedicle screws density was 93.3% (85-100). The extension of the final posterior fusion-instrumentation was of 13.8 levels (12-15). RESULTS: At an average follow-up (FU) of 2.9 years, the main scoliosis curves from average pre-operative Cobb angle of 98.2° (91°-138°) bent down to 38.3° (35°-76°) after definitive fusion (p < 0.05); at last FU, the overall correction was 58.7% (50.4-71.2), with an average correction loss of 2.1° (1.5°-3.1°). At last FU, no complications were reported. CONCLUSIONS: Gradual traction with MCGR in severe AIS proved to be a safe method to achieve progressive curve correction before posterior final fusion, with no neurologic complications associated to more aggressive one-stage surgeries. In a staged approach, MCGR appears as an alternative to halo traction, avoiding frequent traction-related complications.

High grade isthmic spondylolisthesis; can reduction always re-align the unbalanced pelvis?

BACKGROUND: Recently, various studies have reported the importance of distinguishing between balanced and unbalanced SL, sustaining the importance of SL reduction in unbalanced cases. In this study we present our experience in the treatment of isthmic spondylolisthesis in young patients, observing the correlation between SL reduction and sagittal correlation between spine and pelvis. METHODS: This is a retrospective study of a series of patients treated surgically for isthmic spondylolisthesis. Inclusion criteria were L5-S1 isthmic spondylolisthesis of III° or IV°, pediatric age, clinical and radiographic follow up of at least 1 year. Radiographic evaluation included the following elements: grade and percentage of listhesis (%L), lumbar lordosis (LL), lumbar-sacral angle (LSA), pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT) distinguishing between "balanced" and "unbalanced" patients. Radiographic values were confronted by using Student's t- test, obtaining a statistically significant difference for values inferior to 0,05. RESULTS: Based on inclusion criteria, 28 patients were selected for our retrospective analysis, 19 female and 9 male. Mean age at surgery was 15,6 years. Mean follow up was 3 years and 3 months (min. 1 year - max 6 years and 7 months). Spondylolisthesis reduction was statistically significant both in balanced and in unbalanced patients, but pelvic incidence values did not improve significantly. We observed fewer mechanical complications in patients treated with interbody support. CONCLUSION: In our study, differences between pre-op and post-op spinopelvic alignment values were not statistically significant, even though spondylolisthesis reduction was statistically significant in all cases. Our study could be considered an initial attempt to correlate spinopelvic changes to spondylolisthesis reduction in a progressive manner, and possibly in the future, generate threshold values of reduction for ideal spinopelvic alignment in every different patient.

Osteoporotic thoracolumbar compression fractures: long-term retrospective comparison between vertebroplasty and conservative treatment.

PURPOSE: To compare long term clinical and radiographic outcomes in osteoporotic vertebral compression fractures of the thoracolumbar spine treated with conservative treatment and percutaneous vertebroplasty. METHODS: The retrospective study with inclusion criteria focused on osteoporotic fractures of the thoracolumbar junction (T10-L2). Clinical outcomes were evaluated by using the VAS, Oswestry and SF36 questionnaires. Radiographic outcomes were evaluated by comparing the following sagittal parameters: body angle, sagittal index of fractured vertebral body and adjacent vertebral segments kyphosis. Complications in terms of adjacent vertebral fractures and cement leakage are reported. RESULTS: Percutaneous vertebroplasty provided better vertebral body height restoration, but was associated with a higher incidence of adjacent fractures (20%) than conservative treatment (3.5%). This fact may explain why patients treated with percutaneous vertebroplasty had worse overall kyphotic alignment at final follow-up. Cement leakage was frequent, but always asymptomatic and generally no serious complications occurred. CONCLUSIONS: Percutaneous vertebroplasty represents a safe treatment for osteoporotic vertebral compression fractures, although it may be associated with a higher incidence of adjacent fractures and therefore worse thoracolumbar kyphosis and long-term follow-up than conservative treatment. These slides can be retrieved under Electronic Supplementary Material.

Segmental vs non-segmental thoracic pedicle screws constructs in adolescent idiopathic scoliosis: is there any implant alloy effect?

PURPOSE: The aim of this study is to understand how many anchor sites are necessary to obtain maximum posterior correction of idiopathic scoliotic curve and if the alloy of instrumentation, stainless steel or titanium, may have a role in the percent of scoliosis correction. METHODS: We reviewed 143 consecutive patients, affected by AIS (Lenke 1-2), who underwent a posterior spinal fusion with pedicle screw-only instrumentation between 2002 and 2005. According to the implant density and alloy used we divided the cohort in four groups. RESULTS: All 143 patients were reviewed at an average follow-up of 7, 2 years, the overall final main thoracic curve correction averaged 61.4%, whereas the implant density within the major curve averaged 71%. A significant correlation was observed between final% MT correction and preoperative MT flexibility and implant density. CONCLUSIONS: When stainless steel instrumentation is used non-segmental pedicle screw constructs seem to be equally effective as segmental instrumentations in obtaining satisfactory results in patients with main thoracic AIS. When the implant alloy used is titanium one, an implant density of ≥60% should be guaranteed to achieve similar results.

Implant Complications After Magnetically Controlled Growing Rods for Early Onset Scoliosis: A Multicenter Retrospective Review.

BACKGROUND: Traditional growing rods have a reported wound and implant complication rate as high as 58%. It is unclear whether the use of magnetically controlled growing rods (MCGR) will affect this rate. This study was performed to characterize surgical complications following MCGR in early onset scoliosis. METHODS: A multicenter retrospective review of MCGR cases was performed. Inclusion criteria were: (1) diagnosis of early onset scoliosis of any etiology; (2) 10 years and younger at time of index surgery; (3) preoperative major curve size >30 degrees; (4) preoperative thoracic spine height <22 cm. Complications were categorized as wound related and instrumentation related. Complications were also classified as early (<6 mo from index surgery) versus late (>6 mo). Distraction technique and interval of distraction was surgeon preference without standardization across sites. RESULTS: Fifty-four MCGR patients met inclusion criteria. There were 30 primary and 24 conversion procedures. Mean age at initial surgery was 7.3 years (range, 2.4 to 11 y), and mean duration of follow-up 19.4 months. Twenty-one (38.8%) of 54 patients had at least 1 complication. Fifteen (27.8%) had at least 1 revision surgery. Six (11.1%) had broken rods (2 to 4.5 and 4 to 5.5 mm rods); two 5.5 mm rods failed early (4 mo) and 4 late (mean=14.5 mo). Six (11.1%) patients experienced 1 episode of lack or loss of lengthening, of which 4 patients subsequently lengthened. Seven patients (13.0%) had either proximal or distal fixation-related complication at average of 8.4 months. Two patients (3.7%) had infections requiring incision and drainage; 1 early (2 wk) with wound drainage and 1 late (8 mo). The late case required removal of one of the dual rods. CONCLUSIONS: This study shows that compared with traditional growing rods, MCGR has a lower infection rate (3.7% vs. 11.1%). MCGR does not appear to prevent common implant-related complications such as rod or foundation failure. The long-term implication remains to be determined. LEVEL OF EVIDENCE: Level IV.

Does hybrid fixation prevent junctional disease after posterior fusion for degenerative lumbar disorders? A minimum 5-year follow-up study.

PURPOSE: Medium- to long-term retrospective evaluation of clinical and radiographic outcome in the treatment of degenerative lumbar diseases with hybrid posterior fixation. METHODS: Thirty patients were included with the mean age of 47.8 years (range 35 to 60 years). All patients underwent posterior lumbar instrumentation using hybrid fixation for lumbar stenosis with instability (13 cases), degenerative spondylolisthesis Meyerding grade I (6 cases), degenerative disc disease of one or more adjacent levels in six cases and mild lumbar degenerative scoliosis in five patients. Clinical outcomes were evaluated using Oswestry disability index (ODI), Roland and Morris disability questionnaire (RMDQ), and the visual analog scale (VAS) pain scores. All patients were assessed by preoperative, postoperative and follow-up standing plain radiographs and lateral X-rays with flexion and extension. Adjacent disc degeneration was also evaluated by magnetic resonance imaging (MRI) at follow-up. RESULTS: At a mean follow-up of 6.1 years, we observed on X-rays and/or MRI 3 cases of adjacent segment disease (10.0 %): two of them (6.6 %) presented symptoms and recurred a new surgery. The last patient (3.3 %) developed asymptomatic retrolisthesis of L3 not requiring revision surgery. The mean preoperative ODI score was 67.6, RMDQ score was 15.1, VAS back pain score was 9.5, and VAS leg pain score was 8.6. Postoperatively, these values improved to 28.1, 5.4, 3.1, and 2.9, respectively, and remained substantially unchanged at the final follow-up: (27.7, 5.2, 2.9, and 2.7, respectively). CONCLUSIONS: After 5-year follow-up, hybrid posterior lumbar fixation presented satisfying clinical outcomes in the treatment of degenerative disease.

Does surgery for Scheuermann kyphosis influence sagittal spinopelvic parameters?

PURPOSE: To analyze changes in sagittal spinopelvic parameters (SSPs) after surgical treatment of Scheuermann's Kyphosis (SK). METHODS: We analyzed 20 patients affected by SK and subjected to posterior correction of the kyphosis by facetectomy, Ponte osteotomy, fusion and multilevel instrumentation with pedicle screw system. Four spinal and three pelvic parameters were measured: sagittal vertical axis (SVA), thoracic kyphosis (TK), thoracolumbar kyphosis, lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS) and pelvic tilt (PT). Analysis of changes in postprocedural SSPs compared to preoperative values was performed. RESULTS: TK passed from 78.6° preoperatively to 45.8° (p = 0.003). LL passed from 74.5° preoperatively to 53.5° (p = 0.01). No significant changes occurred in SVA, SS, PT and PI compared to preoperative values. CONCLUSION: We confirm the positive effect of surgery by Ponte osteotomy and posterior spinal fusion on TK and LL in patients with SK. In our experience, pelvic parameters did not change after surgery.

Long-term systemic metal distribution in patients with stainless steel spinal instrumentation: a case-control study.

STUDY DESIGN: Case-control study. OBJECTIVE: To verify whether metal ions in the serum of patients bearing spinal stainless steel instrumentation were elevated over the long-term period after implantation of stainless steel prostheses and to determine whether these levels could predict potential unfavorable outcomes. SUMMARY OF BACKGROUND DATA: Instrumented spinal arthrodesis, the standard procedure to correct scoliosis, routinely remains in situ for the lifetime of the patient. Elevated metal ion levels have been reported at short-term follow-up, but the long-term status, possibly related to systemic toxic effects, is unknown. METHODS: Twenty-two patients treated for scoliosis with posterior spinal arthrodesis using stainless steel instrumentation were included. Minimum follow-up was 10 years. Oswestry Disability Index and visual analog scale were recorded. Chromium (Cr) and nickel (Ni) levels were measured (ng/mL) and compared with levels in a control group including 30 healthy subjects. A receiver-operating characteristic curve was calculated on the basis of the clinical assessment (pain and disability) and the x-ray picture; the cutoff values for the parameters were settled, and the ion-testing potential was considered as a surrogate marker for failure. RESULTS: The level of Cr was significantly increased in patients, compared with controls (P=0.018). A remarkable Cr release without any clinical-radiologic sign was recorded in some female patients. A high specificity (93%), positive likelihood ratio (7.00), and overall accuracy (77%) were calculated for Cr; these indicate a high risk of failure when the levels exceeded the cutoff value, which was 0.6 ng/mL. No significant difference between the groups was found for Ni (P=0.7). CONCLUSIONS: Cr testing is suggested as a reliable marker for the malfunctioning assessment and as a support for standard procedures, especially with doubtful diagnosis. Furthermore, high levels of Cr ions were observed in female patients. This finding deserves attention especially when counseling young fertile women.

Transforaminal Lumbar Interbody Fusion in Degenerative Disk Disease and Spondylolisthesis Grade I: Minimally Invasive Versus Open Surgery.

BACKGROUND: Interbody fusion represents an efficient surgical treatment in degenerative lumbar disease, achieving satisfying outcome in >90% of cases. Various studies have affirmed the advantages of percutaneous and minimally invasive techniques with regard to minimized damage on soft tissues during surgical procedure, but their efficacy in comparison with the classic open surgical procedures has not yet been demonstrated. MATERIALS AND METHODS: This is a retrospective study. We compared 30 consecutive patients affected by disk degenerative disease or grade I degenerative spondylolisthesis that were treated with minimally invasive transforaminal lumbar interbody fusion (mini-TLIF) to a group of 34 consecutive patients presenting similar pathologic findings and demographic characteristics that underwent interbody fusion by traditional open approach (open-TLIF). All patients were treated between 2006 and 2010. Patients' mean age was 46 years (min 28-max 56) and 51 years (min 32-max 58), respectively. Mean follow-up was 23 months (min 12-max 38) and 25 months (min 12-max 40), respectively. Clinical evaluation was performed by using Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) questionnaires. Radiographic evaluation was performed on standing and dynamic x-rays before operation and at final follow-up. RESULTS: There was a statistically significant improvement in clinical scores (VAS and ODI) in both groups. Early postoperative VAS score was significantly lower in the mini-TLIF group. Mean hospital stay and mean blood loss were significantly higher in the open-TLIF group than in the mini-TLIF group (7.4 vs. 4.1 d and 620 vs. 230 mL, respectively). Surgical time length of the procedure was higher in the mini-TLIF group. There were no major neurological complications in any of the patients. At final follow-up, radiographic evaluation showed good implant stability in both groups. CONCLUSIONS: Mini-TLIF is a safe and efficient procedure and, when correctly and carefully performed, can reach good results, similar to those obtained with traditional open surgical techniques, even though it may require a longer surgical time at least during the first stages of the learning curve. Reduced surgical invasiveness, short hospital stay, and limited blood loss represent the major advantages of minimally invasive technique.

Changes in spino-pelvic alignment after surgical treatment of high-grade isthmic spondylolisthesis by a posterior approach: a report of 41 cases.

PURPOSE: To analyze changes in spino-pelvic parameters (SPPs) after surgery of high-grade lumbar isthmic spondylolisthesis (HDIS). METHODS: We analyzed 41 patients affected by HDIS operated upon by attempt of reduction and posterior spinal fusion with pedicle screw systems with or without interbody fusion. Pelvic tilt (PT), lumbar lordosis (LL), pelvic incidence (PI), and sacral slope (SS) were measured, and patients were further divided into balanced and unbalanced pelvis subgroups. RESULTS: SS passed from 46.8° ± 9.8° preoperatively to 50.1° ± 10.1° (p = 0.02). PT passed from 26.7° ± 6.7° preoperatively to 22.9° ± 7.5° (p = 0.003). Unbalanced patients showed significantly higher PT and lower SS compared to the balanced patients preoperatively, and these corrected after surgery. Patients with instrumentation failure (n = 5) had significant increase in PT values postoperatively (p = 0.018). CONCLUSIONS: We confirmed the positive effect of surgery on the SPPs in patients affected by HDIS, which showed different patterns of corrections with surgery for balanced and unbalanced pelvis patients.

Approaches to treating NF1 tibial pseudarthrosis: consensus from the Children's Tumor Foundation NF1 Bone Abnormalities Consortium.

BACKGROUND: Neurofibromatosis 1 (NF1) is an autosomal dominant disorder with various skeletal abnormalities occurring as part of a complex phenotype. Tibial dysplasia, which typically presents as anterolateral bowing of the leg with subsequent fracture and nonunion (pseudarthrosis), is a serious but infrequent osseous manifestation of NF1. Over the past several years, results from clinical and experimental studies have advanced our knowledge of the role of NF1 in bone. On the basis of current knowledge, we propose a number of concepts to consider as a theoretical approach to the optimal management of tibial pseudarthrosis. METHODS: A literature review for both clinical treatment and preclinical models for tibial dysplasia in NF1 was performed. Concepts were discussed and developed by experts who participated in the Children's Tumor Foundation sponsored International Bone Abnormalities Consortium meeting in 2011. RESULTS: Concepts for a theoretical approach to treating tibial pseudarthrosis include: bone fixation appropriate to achieve stability in any given case; debridement of the "fibrous pseudarthrosis tissue" between the bone segments associated with the pseudarthrosis; creating a healthy vascular bed for bone repair; promoting osteogenesis; controlling overactive bone resorption (catabolism); prevention of recurrence of the "fibrous pseudarthrosis tissue"; and achievement of long-term bone health to prevent recurrence. CONCLUSIONS: Clinical trials are needed to assess effectiveness of the wide variation of surgical and pharmacologic approaches currently in practice for the treatment of tibial pseudarthrosis in NF1. LEVEL OF EVIDENCE: Level V, expert opinion.

5.5-mm Cobalt-Chrome vs 6-mm Titanium Alloy Rods in Surgical Treatment of Lenke 1 Adolescent Idiopathic Scoliosis With High-Density Pedicle Screws and Direct Vertebral Rotation on Differently Shaped Rods: A Retrospective Comparative Cohort Study.

BACKGROUND: The gold standard of surgical treatment of adolescent idiopathic scoliosis (AIS) consists of a posterior approach requiring complex 3-dimensional correction with multisegmental pedicle screws and 2 contoured rods. The substantial corrective forces and the ability of the rod to withstand these forces rely on its biomechanical properties. The aim of this study is to compare outcomes of 5.5-mm cobalt-chrome (CoCr) and 6-mm titanium alloy (TiAl) rods in surgical correction in Lenke 1 AIS patients. TiAl has greater elasticity, which may facilitate the correction maneuver, whereas the stiffness of CoCr may result in stronger correction forces. The literature provides no clear indications about which rod may allow better correction and safety. METHODS: A total of 64 consecutive patients (30 CoCr vs 34 TiAl) with Lenke 1 AIS <100°, with 2 years minimum follow-up, requiring correction and posterior fusion at our institution were included. The primary outcome measure was coronal and sagittal correction and loss of correction at 2-year follow-up. Secondary outcome measures compared peri- and postoperative complications. RESULTS: The mean coronal correction was higher in the CoCr group: -73.6% ± 7.4 vs -65.5% ± 11 (P = 0.001). Mean T5-T12 kyphosis did not change significantly after surgery. In patients with hypokyphosis (<10°), an improvement in thoracic kyphosis was observed in both groups, but the improvement was significantly higher in the TiAl group (P = 0.038). In patients with hyperkyphosis (>40°), a similar reduction in thoracic kyphosis was observed in both groups. At follow-up, no coronal correction loss occurred. The sagittal correction loss was slight (0.5° ± 1.5 for the CoCr group, 1.5° ± 3 for the TiAl group) but statistically higher in the TiAl group (P = 0.032). There were no mechanical complications. One revision was required for infection in the CoCr group. CONCLUSION: In this series of Lenke 1 AIS, with the limitations of the study, 5.5-mm CoCr rods have provided better correction in the coronal plane than 6-mm TiAl rods. However, TiAl rods have been found to be associated with higher increase of thoracic kyphosis in hypokyphotic curves, although the clinical relevance of this finding could be questionable. CLINICAL RELEVANCE: This article provides surgeons with more information regarding rod material options when correcting Lenke 1 AIS.

Osteoblasts from a mandibuloacral dysplasia patient induce human blood precursors to differentiate into active osteoclasts.

Mandibuloacral dysplasia type A (MADA) is a rare disease caused by mutations in the LMNA gene encoding A type lamins. Patients affected by mandibuloacral dysplasia type A suffer from partial lipodystrophy, skin abnormalities and accelerated aging. Typical of mandibuloacral dysplasia type A is also bone resorption at defined districts including terminal phalanges, mandible and clavicles. Little is known about the biological mechanism underlying osteolysis in mandibuloacral dysplasia type A. In the reported study, we analyzed an osteoblast primary culture derived from the cervical vertebrae of a mandibuloacral dysplasia type A patient bearing the homozygous R527H LMNA mutation. Mandibuloacral dysplasia type A osteoblasts showed nuclear abnormalities typical of laminopathic cells, but they proliferated in culture and underwent differentiation upon stimulation with dexamethasone and beta-glycerophosphate. Differentiated osteoblasts showed proper production of bone mineral matrix until passage 8 in culture, suggesting a good differentiation activity. In order to evaluate whether mandibuloacral dysplasia type A osteoblast-derived factors affected osteoclast differentiation or activity, we used a conditioned medium from mandibuloacral dysplasia type A or control cultures to treat normal human peripheral blood monocytes and investigated whether they were induced to differentiate into osteoclasts. A higher osteoclast differentiation and matrix digestion rate was obtained in the presence of mandibuloacral dysplasia type A osteoblast medium with respect to normal osteoblast medium. Further, TGFbeta 2 and osteoprotegerin expression were enhanced in mandibuloacral dysplasia type A osteoblasts while the RANKL/osteoprotegerin ratio was diminished. Importantly, inhibition of TGFbeta 2 by a neutralizing antibody abolished the effect of mandibuloacral dysplasia type A conditioned medium on osteoclast differentiation. These data argue in favor of an altered bone turnover in mandibuloacral dysplasia type A, caused by upregulation of bone-derived stimulatory cytokines, which activate non-canonical differentiation stimuli. In this context, TGFbeta 2 appears as a major player in the osteolytic process that affects mandibuloacral dysplasia type A patients.

Ex vivo observation of human intervertebral disc tissue and cells isolated from degenerated intervertebral discs.

PURPOSE: Disc degeneration, and associated low back pain, are a primary cause of disability. Disc degeneration is characterized by dysfunctional cells and loss of proteoglycans: since intervertebral tissue has a limited capacity to regenerate, this process is at present considered irreversible. Recently, cell therapy has been suggested to provide more successful treatment of IVD degeneration. To understand the potential of cells to restore IVD structure/function, tissue samples from degenerated IVD versus healthy discs have been compared. METHODS: Discal tissue from 27 patients (40.17 ± 11 years) undergoing surgery for degenerative disc disease (DDD), DDD + herniation and congenital scoliosis, as controls, was investigated. Cells and matrix in the nucleus pulposus (NP) and annulus fibrosus (AF) were characterized by histology. AF- and NP-derived cells were isolated, expanded and characterized for senescence and gene expression. Three-dimensional NP pellets were cultured and stained for glycosaminoglycan formation. RESULTS: Phenotypical markers of degeneration, such as cell clusters, chondrons, and collagen disorganization were seen in the degenerate samples. In severe degeneration, granulation tissue and peripheral vascularization were observed. No correlation was found between the Pfirrmann clinical score and the extent of degeneration. CONCLUSION: The tissue disorganization in degenerate discs and the paucity of cells out of cluster/chondron association, make the IVD-derived cells an unreliable option for disc regeneration.

Surgical treatment of early onset scoliosis in neurofibromatosis.

Case series report of twenty-three patients, aged between 4 and 11 years, were surgically treated at the Authors' Spine Surgery Division in the past 15 years. Mean follow-up is 5 years (range, 18 months to 15 years). Mean age at the time of surgical procedure was 9.1 years (range, 4 years to 11 years). Average scoliosis was 48° (range, 38° to 82°) and skeletal maturity according to Risser sign was 0 in all of the patients. Patients were divided into 2 Groups according to the surgical procedure adopted. Posterior only instrumentation was performed in 16 patients that presented with a thoracic kyphosis lower than 50° (Group A), in the remaining 7 patients showing thoracic kyphosis exceeding 50°, combined anterior and posterior instrumented arthrodesis was performed (Group B). One patient, belonging to Group A, was instrumented with growing rod without fusion. Average correction of scoliosis was 60%, overall complication rate 24% and major 7%. Crankshaft phenomenon was observed in 21% (Group A): in these cases, anterior arthrodesis was performed after a mean 15-month from first surgical procedure. Fusion failure was observed in 1 (Group B) patient who underwent revision of posterior instrumentation. Clinical and radiographic evaluation at F-up showed good outcome in terms of deformity progression and quality of life. Early and aggressive surgery is the most effective management for dystrophic curves in neurofibromatosis has been proven to be. Our experience confirms the need for spinal stabilization even in pediatric age in rapidly progressive spinal deformities.

Spine Infections: The Role of Fluorodeoxyglucose Positron Emission Tomography (FDG PET) in the Context of the Actual Diagnosis Guideline.

Spondylodiscitis is an infectious process that requires numerous health care professionals to be clearly diagnosed and eventually successfully treated. It implies a variety of microbiological agents and conditions; during the diagnostic workup, it is difficult to correctly identify them, and the clinician has to rapidly choose the correct treatment to avoid permanent injuries to the patient. In this context, we conducted a review to better understand the most suitable use of Positron Emission Tomography with 18-Fluoro-deossi-glucose (FDG PET) in a patient suspected of spondylodiscitis, based on current guidelines and literature.. We wanted to review the role of FDG PET in the spondylodiscitis diagnosis and follow up in the context of the current guidelines.

Vertebroplasty: benefits are more than risks in selected and evidence-based informed patients. A retrospective study of 59 cases.

Vertebral compression fractures represent a frequent pathology among elderly population, with potentially devastating consequences. More than 20 years have passed since percutaneous vertebroplasty was initially used in the treatment of angiomas, representing nowadays a widely used treatment for osteoporotic vertebral fractures. The authors present a retrospective review of 59 consecutive patients (in total 94 fractured levels) that underwent polymethylmethacrylate percutaneous vertebroplasty for vertebral compression fractures due to senile or secondary osteoporosis. All fractures were free from neurologic involvement and were classified as A1 type according to Magerl classification. All of patients were initially treated conservatively, by application of orthosis that allows immediate deambulation. At control, patients who complained of pain and limitation of daily activities underwent MRI. If presence of marrow signal changes, especially hypertense signal in T2-weighted images was confirmed, percutaneous vertebroplasty procedure was performed (we could call it "sub-acute" procedure). A limited group of patients that did not tolerate brace and had an insufficient pain control underwent vertebroplasty "in acute", few days after fracture. Immediate post-operative pain reduction and follow-up clinical outcome (estimating quality of life and residual back pain) were evaluated by means of Visual Analogue Scale, SF-36 and Oswestry Disability Index. In the immediate post-operative course a significant pain relief was found in 39 patients (66.1%), moderate pain relief in 17 (28.8%), while 3 (5.1%) did not achieve relevant pain improvement. Pain intensity and life quality was maintained within satisfactory limits after a mean follow-up of 16 months. In conclusion, percutaneous vertebroplasty is an effective and safe procedure for treating vertebral compression fractures in the elderly. It provides immediate pain relief and allows early mobilization, thus avoiding potentially severe complications related to persistent back pain and prolonged bed rest. When performed by experienced surgeon complication rate is low, representing a safe procedure, able to provide a satisfactory outcome.

Thoracic pedicle subtraction osteotomy in the treatment of severe pediatric deformities.

The traditional surgical treatment of severe spinal deformities, both in adult and pediatric patients, consisted of a 360° approach. Posterior-based spinal osteotomy has recently been reported as a useful and safe technique in maximizing kyphosis and/or kyphoscoliosis correction. It obviates the deleterious effects of an anterior approach and can increase the magnitude of correction both in the coronal and sagittal plane. There are few reports in the literature focusing on the surgical treatment of severe spinal deformities in large pediatric-only series (age <16 years old) by means of a posterior-based spinal osteotomy, with no consistent results on the use of a single posterior-based thoracic pedicle subtraction osteotomy in the treatment of such challenging group of patients. The purpose of the present study was to review our operative experience with pediatric patients undergoing a single level PSO for the correction of thoracic kyphosis/kyphoscoliosis in the region of the spinal cord (T12 and cephalad), and determine the safety and efficacy of posterior thoracic pedicle subtraction osteotomy (PSO) in the treatment of severe pediatric deformities. A retrospective review was performed on 12 consecutive pediatric patients (6 F, 6 M) treated by means of a posterior thoracic PSO between 2002 and 2006 in a single Institution. Average age at surgery was 12.6 years (range, 9-16), whereas the deformity was due to a severe juvenile idiopathic scoliosis in seven cases (average preoperative main thoracic 113°; 90-135); an infantile idiopathic scoliosis in two cases (preoperative main thoracic of 95° and 105°, respectively); a post-laminectomy kypho-scoliosis of 95° (for a intra-medullar ependimoma); an angular kypho-scoliosis due to a spondylo-epiphisary dysplasia (already operated on four times); and a sharp congenital kypho-scoliosis (already operated on by means of a anterior-posterior in situ fusion). In all patients a pedicle screws instrumentation was used, under continuous intra-operative neuromonitoring (SSEP, NMEP, EMG). At an average follow-up of 2.4 years (range, 2-6) the main thoracic curve showed a mean correction of 61°, or a 62.3% (range, 55-70%), with an average thoracic kyphosis of 38.5° (range, 30°-45°), for an overall correction of 65% (range, 60-72%). Mean estimated intra-operative blood loss accounted 19.3 cc/kg (range, 7.7-27.27). In a single case (a post-laminectomy kypho-scoliosis) a complete loss of NMEP occurred, promptly assessed by loosening of the initial correction, with a final negative wake-up test. No permanent neurologic damage, or instrumentation related complications, were observed. According to our experience, posterior-based thoracic pedicle subtraction osteotomies represent a valuable tool in the surgical treatment of severe pediatric spinal deformities, even in revision cases. A dramatic correction of both the coronal and sagittal profile may be achieved. Mandatory the use of a pedicle screws-only instrumentation and a continuous intra-operative neuromonitoring to obviate catastrophic neurologic complications.

Does use of pre-operative low-dose CT-scan in adolescent idiopathic scoliosis improve accuracy in screw placement? Results of a retrospective study.

PURPOSE: To evaluate the efficacy of pre-operative low-dose radiation computed tomography (CT) in optimizing screw placement in patients with adolescent idiopathic scoliosis (AIS). METHODS: 49 patients with AIS who required correction and posterior fusion between January 2018 and December 2019 were included in this retrospective study. All patients underwent surgery performed by the same team of experienced surgeons. Patients were divided in two groups. The study group received a pre-operative low-dose CT scan (CT group, n = 25), differently from the control group (CG, n = 24). Patients of both groups received a post-operative low-dose CT scan. The primary outcome measure was the accuracy of screw placement on the Gertzbein-Robbins scale (grades A and B were considered acceptable). Secondary outcome measures included a comparison of perioperative complications. RESULTS: A total of 1045 screws were placed. In CT group (n = 25, screws = 528) and CG (n = 24, screws = 517), trajectories were grade A or B in 94.5% and 93.6% of screws, respectively. Two screws (one for each group) were removed because of intra-operative-evoked potentials alteration and one screw required revision after post-operative imaging. No correlation was found between the malpositioning rate and the proximity to the apex of the curve, conversely a significative peak of misplacements was observed at T3 (p < 0.01). No neurological and vascular complications related to screw placement were recorded. There was not intergroup difference neither in screw accuracy (Chi-Square, 2-tailed Fisher's exact, p = 0.63), nor in complications rate. CONCLUSION: Pre-operative low-dose CT scan as surgical plan does not contribute in reducing pedicle screw misplacement rate. STUDY DESIGN: Retrospective comparative cohort study. LEVEL OF EVIDENCE: III.