Management of aortic injury during minimally invasive lateral lumbar interbody fusion.

PURPOSE: Minimally invasive lateral approaches to the lumbar spine allow for interbody fusion with good visualization of the disk space, minimal blood loss, and decreased length of stay. Major neurologic, vascular, and visceral complications are rare with this approach; however, the steps in management for severe vascular injuries are not well defined. We present a case report of aortic injury during lateral interbody fusion and discuss the use of endovascular repair. METHODS: This study is a case report of an intraoperative aortic injury. RESULTS: A 59-year-old male with ankylosing spondylitis suffered an acute L1 Chance fracture after mechanical fall. He was taken to the operating room for a T10-L4 posterior instrumented fusion followed by a minimally invasive L1-L2 lateral interbody fusion for anterior column support. During the discectomy, brisk arterial bleeding was encountered due to an aortic injury. The vascular surgery team expanded the incision in an attempt to control the bleeding but with limited success. The patient underwent intraoperative angiogram with placement of stent grafts at the level of the injury followed by completion of the interbody fusion. Despite the potentially catastrophic nature of this injury, the patient made a good recovery and was discharged home in stable condition with no new neurologic deficits. CONCLUSIONS: This case highlights the importance of immediate recognition and imaging of any potential vascular injury during minimally invasive lateral interbody fusion. Given the poor outcomes associated with attempted open repair, endovascular techniques provide a valuable tool for the treatment of these complex injuries with significantly less morbidity.

Circumferential fusion for degenerative lumbar spondylolisthesis complicated by distal junctional grade 4 spondylolisthesis in the sub-acute post-operative setting.

INTRODUCTION: Surgical management for lumbar stenosis is generally safe and provides significant improvements in pain, disability, and function. Successful lumbar decompression hinges on removing an appropriate amount of lamina and other compressive pathology in the lateral recess. Too little bony decompression can result in persistent pain and disability, while over resection of the pars and/or facets may jeopardize spinal stability. CASE REPORT: In this unique report, we present for the first time an acute iatrogenic grade 4 L5-S1 spondylolisthesis distal to a L3-5 laminectomy and circumferential instrumented fusion due to bilateral iatrogenic L5 pars fractures and its management and clinical outcomes after revision operation. The patient presented with worsening pain, neurologic compromise, and severe sagittal imbalance. The iatrogenic, high-grade spondylolisthesis was urgently addressed with a L5-S1 anterior lumbar interbody fusion and extension of posterior instrumentation to the pelvis, which resulted in considerable pain relief, resolution of neurologic deficits, and reconstitution of acceptable sagittal imbalance. CONCLUSION: All attempts during a lumbar decompression should be made to prevent iatrogenic pars fractures, as they may result in severe sagittal imbalance, neurologic compromise, and persistent disability. Iatrogenic, high-grade L5-S1 spondylolisthesis can be successfully treated with reduction using circumferential fusion of the lumbosacral junction.

Surgical treatment of thoracic disc disease via minimally invasive lateral transthoracic trans/retropleural approach: analysis of 33 patients.

Thoracic disc herniations are associated with serious neurological consequences if not treated appropriately. Although a number of techniques have been described, there is no consensus about the best surgical approach. In this study, the authors report their experience in the operative management of patients with thoracic disc herniations using minimally invasive lateral transthoracic trans/retropleural approach. A series of 33 consecutive patients with thoracic disc herniations who underwent anterior spinal cord decompression followed by instrumented fusion through lateral approach is being reported. Demographic and radiographic data, perioperative complications, and clinical outcomes were reviewed. Forty disc levels in 33 patients (18F/15M; mean age, 52.9) were treated. Twenty-three patients presented with myelopathy (69 %), 31 had radiculopathy (94 %), and 31 had axial pain (94 %). Among patients with myelopathy, 14 (42.4 %) had bladder and/or bowel dysfunction. In the last eight cases (24 %), the approach was retropleural instead of transpleural. Patients were followed up for 18.2 months on average. The mean length of hospital stay was 5 days. None of the patients developed neurological deterioration postoperatively. Among 23 patients who had myelopathy signs, 21 (91 %) had improved postoperatively. The mean preoperative visual analog scale pain score, Oswestry Disability Index score, SF-36 PCS, and mental component summary scores were 7.5, 42.4, 29.6, and 37.5 which improved to 3.5, 33.2, 35.5, and 52.6, respectively. Perioperative complications occurred in six patients (18.1 %), all of which resolved uneventfully. Minimally invasive lateral transthoracic trans/retropleural approach is a safe and efficacious technique for achieving adequate decompression in thoracic disc herniations in a less invasive manner than conventional approaches.

Minimal invasive anterolateral transthoracic transpleural approach: a novel technique for thoracic disc herniation. A review of the literature, description of a new surgical technique and experience with first 12 consecutive patients.

STUDY DESIGN: A retrospective review of a case series. OBJECTIVE: To describe a novel surgical technique for a minimally disruptive lateral transthoracic transpleural approach to treat thoracic disc herniations. SUMMARY OF BACKGROUND DATA: Thoracic disc herniation is a relatively uncommon spinal condition, and surgical treatment is indicated for patients with myelopathy or radiculopathy that failed to respond to conservative therapy. Presently there is no consensus about the best approach to address thoracic disc herniations. Using the novel retractor system (MaXcess), the authors describe a novel minimally disruptive approach that allows the surgeons to perform a standard anterior discectomy and fusion with instrumentation while minimizing approach-related morbidity. METHODS: A series of 12 patients with single-level thoracic disc herniations who underwent anterior spinal cord decompression followed by instrumented fusion through a novel retractor system is being reported. Demographic and radiographic data, perioperative complications, and clinical outcomes were reviewed. RESULTS: Twelve patients were enrolled with an average age of 51 years (range, 23 to 67 y). The average follow-up was 28 months (range, 12 to 33 mo). The average length of hospital stay was 5 days (range, 2 to 12 d). The average preoperative visual analog scale pain score was 9 (range, 7 to 10), which later decreased to 3 (range, 0 to 5) at final follow-up. All patients with myelopathy and/or sphincter dysfunction had significant improvement of their symptoms. One patient had pleural effusion and 1 patient had intercostal neuralgia. CONCLUSIONS: Anterior decompression using a transthoracic transpleural approach provides excellent exposure and allows consistent decompression of thoracic disc herniations. This study demonstrated that a new minimally invasive, transthoracic transpleural decompression technique can be safely performed for single-level thoracic disc herniations. The early results showed that this technique allows less dissection, along with the advantages of conventional thoracotomy.

Osseous remodeling after femoral head-neck junction osteochondroplasty.

UNLABELLED: Femoral head-neck junction osteochondroplasty is commonly used to treat femoroacetabular impingement, yet remodeling of the osteochondroplasty site is not well described. We therefore describe bony remodeling at the osteochondroplasty site and analyze clinical outcomes and complications associated with femoral osteochondroplasty. We retrospectively reviewed 135 patients (150 hips) who underwent femoral head-neck osteochondroplasty combined with hip arthroscopy, surgical hip dislocation, periacetabular osteotomy, or proximal femoral osteotomy. The minimum clinical followup was 10 months (mean, 22.3 months; range, 10-65 months). We assessed the femoral-head neck offset, head-neck offset ratio, alpha angle, and cortical remodeling. We used the Harris hip score to determine hip function. We observed an increase in the head-neck offset, offset ratio, and decrease in the alpha angle postoperatively and at latest followup. Ninety-eight of 113 (87%) hips had partial or complete recorticalization at the osteochondroplasty site. The mean Harris hip score improved from 64 to 85. We excised heterotopic bone in one hip. There were no femoral neck fractures. The deformity correction achieved with femoral head-neck osteochondroplasty is maintained and recorticalization occurs in the majority of cases during the first two years. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Technique for total hip arthroplasty in a patient with through-knee amputation.

Degenerative joint disease is not uncommon in patients with lower extremity amputations. These patients are candidates for joint arthroplasty procedures; however, certain modifications may be necessary during the procedure to overcome the challenges presented by the amputation. The authors describe a total hip arthroplasty in a 51-year-old patient 45 years after an ipsilateral through-knee amputation. The patient was informed that the data concerning his case would be submitted for publication, and he consented.

Thoracolumbar Vertebral Column Resection With Rectangular Endplate Cages Through a Posterior Approach: Surgical Techniques and Early Postoperative Outcomes.

BACKGROUND: Thoracolumbar pathology can result in compression of neural elements, instability, and deformity. Circumferential decompression with anterior column reconstruction is often required to restore biomechanical stability and minimize the risk of implant failure. OBJECTIVE: To assess the safety and viability of wide-footprint rectangular cages for vertebral column resection (VCR). METHODS: We performed VCR with wide-footprint rectangular endplate cages, which were designed for transthoracic or retroperitoneal approaches. We present our technique using a single-stage posterior approach. RESULTS: A total of 45 patients underwent VCR with rectangular endplate cages. Mean age was 58 yr. Diagnoses included 23 tumors (51%), 14 infections (31%), and 8 deformities (18%). VCRs were performed in 10 upper thoracic, 17 middle thoracic, 14 lower thoracic, and 4 lumbar levels. Twenty-four cases involved a single level VCR (53%) with 18 two-level (40%) and 3 three-level (7%) VCRs. Average procedure duration was 264 min with mean estimated blood loss of 1900 ml. Neurological outcomes were stable in 27 cases (60%), improved in 16 (36%), and worse in 2 (4%). There were 7 medical and 7 surgical complications in 11 patients. There were significant decreases in postoperative thoracic kyphosis (47° vs 35°, P = .022) and regional kyphosis (34° vs 10°, P < .001). There were 2 cases of cage subsidence due to intraoperative endplate violation, neither of which progressed on CT scan at 14 and 35 mo. CONCLUSION: Posterior VCR with rectangular footprint cages is safe and feasible. This provides improved biomechanical stability without the morbidity of a lateral transthoracic or retroperitoneal approach.

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain.

BACKGROUND CONTEXT: The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016. PURPOSE: The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. STUDY DESIGN: This is a guideline summary review. METHODS: This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors. RESULTS: Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature. CONCLUSIONS: The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.

Cone Beam Intraoperative Computed Tomography-based Image Guidance for Minimally Invasive Transforaminal Interbody Fusion.

Transforaminal lumbar interbody fusion (TLIF) is commonly used for the treatment of spinal stenosis, degenerative disc disease, and spondylolisthesis. Minimally invasive surgery (MIS) approaches have been applied to this technique with an associated decrease in estimated blood loss (EBL), length of hospital stay, and infection rates, while preserving outcomes with traditional open surgery. Previous MIS TLIF techniques involve significant fluoroscopy that subjects the patient, surgeon, and operating room staff to non-trivial levels of radiation exposure, particularly for complex multi-level procedures. We present a technique that utilizes an intraoperative computed tomography (CT) scan to aid in placement of pedicle screws, followed by traditional fluoroscopy for confirmation of cage placement. Patients are positioned in the standard fashion and a reference arc is placed in the posterior superior iliac spine (PSIS) followed by intraoperative CT scan. This allows for image-guidance-based placement of pedicle screws through a one-inch skin incision on each side. Unlike traditional MIS-TLIF that requires significant fluoroscopic imaging during this stage, the operation can now be performed without any additional radiation exposure to the patient or operating room staff. After completion of the facetectomy and discectomy, final TLIF cage placement is confirmed with fluoroscopy. This technique has the potential to decrease operative time and minimize total radiation exposure.

Evaluation of shoulder balance in the normal adolescent population and its correlation with radiological parameters.

A descriptive clinical study in healthy adolescents was done to evaluate the clinical shoulder balance and analyze the correlation between clinical and radiological parameters which are currently used to evaluate shoulder balance. In addition to trunk shift and rib hump, shoulder balance is one of the criteria that are used to evaluate the outcomes in spinal deformity surgery. Several methods have been proposed to evaluate the shoulder balance in scoliotic patients; however, there is no uniformity to these methods in the current literature. Patients who applied to pediatric clinic without musculoskeletal pathology formed the patient population. Volunteers were asked to fill out a questionnaire assessing shoulder balance perception and had their clinical photograph taken simultaneously with a P-A chest X-ray. The clinical shoulder balance was evaluated through analysis of the clinical photograph. The X-rays were used to evaluate the radiological shoulder balance. The evaluated parameters included coracoid height difference (CHD), clavicular angle (CA), the clavicle-rib cage intersection difference (CRID), clavicular tilt angle difference (CTAD), and T1-tilt. The study group was composed of 48 male and 43 female patients with an average age of 13.6 +/- 2.1 (10-18) years. In the questionnaire, all patients stated that their shoulders were level. The digital photographs revealed that only 17(18.7%) adolescents had absolutely level shoulders. The average height difference between shoulders was 7.5 +/- 5.8 mm. The average CHD was 6.9 +/- 5.8 mm, average CA was 2.2 +/- 1.7 degrees , average CRID was 4.8 +/- 3.6 mm, average CTAD was 4 +/- 3.2 degrees , and average T1-tilt was 1.3 +/- 1.4 degrees . CHD, CA, and CRID demonstrated high correlation with clinical pictures, whereas CTAD demonstrated moderate and T1-tilt demonstrated only mild correlation. The radiological parameters used to evaluate the shoulder balance correlate with the clinical appearance. Contrary to popular belief, shoulder balance in healthy adolescents often does not exist.

Radiation exposure with hybrid image-guidance-based minimally invasive transforaminal lumbar interbody fusion.

The transforaminal lumbar interbody fusion (TLIF) is used for the treatment of back and leg pain secondary to spinal stenosis, degenerative disc disease, and spondylolisthesis. Minimally invasive surgery (MIS) is associated with less estimated blood loss (EBL), decreased length of stay, lower infection rates, and similar outcomes compared to the traditional TLIF. Fluoroscopy time has been reported with MIS-TLIF, but there are limited data on specific radiation dosages. We performed a retrospective analysis of a prospectively acquired cohort of patients undergoing MIS-TLIF. A total of 50 patients were included. Mean age was 53 years with 60% women and mean BMI of 30 (range 21-41). Diagnoses were as follows: 45 stenosis (90%), 29 spondylolisthesis (58%), 5 facet cysts (10%), 3 scoliosis (6%), and 1 cauda equina syndrome (2%). A single level was fused in 33 cases (66%), two levels in 15 (30%), three levels in 2 (4%). Average cage height was 10 mm with mean EBL of 80 ml and operative time of 240 min. The average radiation doses from intraoperative CT scan and fluoroscopy were 35.3 and 26.5 mGy, respectively. Average CT scan and fluoroscopy times were 5.2 and 37.1 s, respectively, for a total of 42.2 s. Average length of stay was 3 days (range 1-7 days). Although these data represent a preliminary experience, by streamlining the timing of intraoperative CT scan and minimizing the amount of intraoperative fluoroscopy, this protocol has the potential for decreasing operative time and radiation exposure.

Discoid meniscus: an ultrastructural study with transmission electron microscopy.

BACKGROUND: The ultrastructure of the normal menisci has been thoroughly investigated and found to correlate with meniscal tears. Although discoid menisci are accepted to have the same composition as their normal counterparts, to our knowledge, no study in the literature has investigated this issue. PURPOSE: To investigate the ultrastructure of the discoid menisci and compare it with nondiscoid menisci. STUDY DESIGN: Descriptive laboratory study. METHODS: Meniscal biopsies were taken from 12 patients who were operated for meniscus tear and diagnosed with discoid meniscus and from 6 patients who were operated for meniscal tear and did not have a diagnosis of discoid meniscus. The samples were examined with transmission electron microscopy. RESULTS: The study group demonstrated a decrease in the number of collagen fibers compared with the control group. Also, the homogeneous course of the collagen fibers observed in the control group was replaced by a heterogeneous course in the study group. CONCLUSION: The ultrastructure of the discoid meniscus is different from the normal menisci. CLINICAL RELEVANCE: This difference may contribute to the vulnerability of the discoid meniscus to tears.

Radiographic measurement of the sagittal plane deformity in patients with osteoporotic spinal fractures evaluation of intrinsic error.

Cobb method has been shown to be the most reliable technique with a reasonable measurement error to determine the kyphosis in fresh fractures of young patients. However, measurement errors may be higher for elderly patients as it may be difficult to determine the landmarks due to osteopenia and the degenerative changes. The aim of this study is to investigate the intrinsic error for different techniques used in evaluation of local sagittal plane deformity caused by OVCF. Lateral X-rays of OVCF patients were randomly selected. Patient group was composed of 28 females and 7 males and the mean age was 62.7 (55-75) years. The kyphosis angle and the vertebral body height were analyzed to reveal the severity of sagittal plane deformity. Kyphotic deformity was measured by using four different techniques; and the vertebral body heights (VBH) were measured at three different points. The mean intra-observer agreement interval for kyphosis angle measurement techniques ranged from +/-7.1 to +/-9.3 degrees while it ranged from +/-4.5 to +/-6.5 mm for VBH measurement techniques. The mean interobserver agreement interval for kyphosis angle ranged from +/-8.2 to +/-11.1 degrees , while it was between +/-4.5 to +/-6.5 mm for vertebral body height measurement techniques. This study revealed that although the intra and interobserver agreement were similar for all techniques, they are still higher than expected. These high intervals for measurement errors should be taken into account when interpreting the results of correction in local sagittal plane deformities of OVCF patients after surgical procedures such as vertebral augmentation techniques.

[Salter osteotomy: an overview]. / Salter osteotomisi.

Pelvic osteotomies are an integral part of treatment in developmental dysplasia of the hip after 18 months. This article focuses on the innominate osteotomy which was introduced by Richard Salter in 1961. Salter innominate osteotomy is a complete pelvic osteotomy that hinges on the symphysis pubis and results in anterolateral displacement of the acetabulum. The derotated acetabulum is held in place with a bone graft and fixed with Kirschner wires. Salter osteotomy has been performed over four decades and excellent short- and long-term results have been reported from different centers all over the world. Its success is closely related to appropriate patient selection and meticulous surgical technique with strict adherence to prerequisites.

Fatigue Failure in Extra-Articular Proximal Tibia Fractures: Locking Intramedullary Nail Versus Double Locking Plates-A Biomechanical Study.

OBJECTIVES: The goal of this study is to compare the fatigue strength of a locking intramedullary nail (LN) construct with a double locking plate (DLP) construct in comminuted proximal extra-articular tibia fractures. METHODS: Eight pairs of fresh frozen cadaveric tibias with low bone mineral density [age: 80 ± 7 (SD) years, T-score: -2.3 ± 1.2] were used. One tibia from each pair was fixed with LN, whereas the contralateral side was fixed with DLP for complex extra-articular multifragmentary metaphyseal fractures (simulating OTA 41-A3.3). Specimens were cyclically loaded under compression simulating single-leg stance by staircase method out to 260,000 cycles. Every 2500 cycles, localized gap displacements were measured with a 3D motion tracking system, and x-ray images of the proximal tibia were acquired. To allow for mechanical settling, initial metrics were calculated at 2500 cycles. The 2 groups were compared regarding initial construct stiffness, initial medial and lateral gap displacements, stiffness at 30,000 cycles, medial and lateral gap displacements at 30,000 cycles, failure load, number of cycles to failure, and failure mode. Failure metrics were reported for initial and catastrophic failures. RESULTS: DLP constructs exhibited higher initial stiffness and stiffness at 30,000 cycles compared with LN constructs (P < 0.03). There were no significant differences between groups for loads at failure or cycles to failure. CONCLUSIONS: For the fixation of extra-articular proximal tibia fractures, a LN provides a similar fatigue performance to double locked plates. The locked nail could be safely used for fixation of proximal tibia fractures with the advantage of limited extramedullary soft tissue damage.

Spinal implants and radiation therapy: the effect of various configurations of titanium implant systems in a single-level vertebral metastasis model.

BACKGROUND: The combination of surgery and radiation therapy is a common clinical practice in the treatment of spinal tumors. Although it is known that metallic implants disturb radiation therapy beams, it is not known what kind of dose distributions appear with spinal irradiation in the presence of a spinal implant. The aim of the present study was to investigate the effect of various spinal implant constructs on the dose of radiation delivered to the spinal canal in a single-level metastasis model. METHODS: We performed four spinal implant reconstructions on standard sawbones spine models: posterior instrumentation without anterior column reconstruction, posterior instrumentation with anterior column reconstruction with use of a titanium cage, anterior instrumentation with anterior column reconstruction with use of a titanium cage, and anterior instrumentation with anterior column reconstruction with use of chest tubes filled with bone cement. Irradiation with two different radiation therapy units (a cobalt-60 teletherapy unit and a linear accelerator) was performed twice for each model in a posterior-to-anterior direction, and thermoluminescent dosimeters were used to measure the dose changes in the anterior, middle, and posterior portions of the spinal canal. RESULTS: Compared with the sawbones-only model, the posterior instrumentation reconstructions resulted in a 5% to 7% decrease in the radiation dose delivered to the spinal canal with both radiation therapy units, whereas the anterior instrumentation reconstructions resulted in a 1% decrease in the dose delivered with the linear accelerator unit and a < or = 2% increase in the dose delivered with the cobalt-60 teletherapy unit. When thermoluminescent dosimeters in the middle of the spinal canal were evaluated individually, anterior instrumentation with anterior column reconstruction with use of bone cement-filled chest tubes resulted in a 5.5% increase in the radiation dose delivered with the cobalt-60 teletherapy unit, whereas all of the other instrumentation models resulted in a <1% disturbance in the radiation dose delivered with both radiation therapy units. CONCLUSIONS: The posterior instrumentation systems did not result in the delivery of an increased dose of radiation to the spinal cord, suggesting that current radiation therapy regimens may be performed without additional harm. The anterior instrumentation systems also appeared to be relatively safe when irradiation was performed with the linear accelerator unit. However, when irradiation was performed with use of the cobalt-60 teletherapy unit, there was an increase in the dose of radiation delivered to the spinal canal in the presence of the anterior instrumentation systems, particularly the anterior column reconstruction with use of bone cement-filled chest tubes. These dose-perturbation characteristics might be important to consider during the calculation of radiation therapy protocols for patients who are going to receive high doses or recurrent treatments that would reach the tolerance limits of the spinal cord.

Comparison of extraarticular leakage values of radiopharmaceuticals used for radionuclide synovectomy.

OBJECTIVES: Radionuclide synovectomy is a reliable therapy in patients with chronic synovitis. However, radiation doses delivered to non-target organ systems due to leakage of radioactive material from the articular cavity are an important disadvantage of this procedure. In this study we compared extraarticular leakage values of the 3 commonly used radiopharmaceuticals; 90Y-citrate, 90Y-silicate and 186Re-sulfide colloid. MATERIALS AND METHODS: Thirty-five patients with persistent synovitis were enrolled in the study. Twenty-two hemophilic, 8 rheumatoid arthritis and 5 patients with pigmented villonodular synovitis were studied. 90Y labeled silicate and citrate were used for knee joints and 186Re-sulfide for intermediate sized joints. Radiocolloid leakage values were evaluated using a gamma camera with 20% window centered over the bremsstrahlung photopeak of 90Y and a respective window over the 137 keV photopeak of 186Re. Regions of interest were drawn over the injection site, the regional lymph nodes and the background areas. Leakage of radiocolloid was calculated by dividing the counts/pixel in the regional lymph node area to the counts/pixel in the injection site. RESULTS: No visible leakage was observed. The median leakage values calculated for 90Y-citrate, 90Y-silicate and 186Re-sulfide were found as 1.9%, 2.4% and 2.7%, respectively. The difference between the variability of leakage values was not statistically significant (p > 0.05). CONCLUSION: There was no significant difference in terms of extraarticular leakage between 9Y-citrate, 9Y-silicate and 186Re-sulfide radiocolloids.

Adult Spinal Deformity Correction with Multi-level Anterior Column Releases: Description of a New Surgical Technique and Literature Review.

STUDY DESIGN: Case series. OBJECTIVE: To evaluate radiographic and clinical outcomes of adults with spinal deformity treated with multilevel anterior column releases (ACR). SUMMARY OF BACKGROUND DATA: Pedicle subtraction osteotomy can be used effectively to correct spinal deformity; however, it is not without complications. ACR is an attractive alternative minimally invasive technique for spinal deformity correction, although few clinical reports on its clinical effectiveness exist. METHODS: Adults with spinal deformity who underwent multilevel ACRs (≥2) followed by open posterior instrumentation with a minimum 1-year follow-up were retrospectively reviewed. Deformity radiographic data and clinical outcomes, including the Oswestry Disability Index (ODI) and the EuroQol-5D were analyzed. RESULTS: Eight patients [7 female, 1 male; mean age 65 y (49-79 y)] met inclusion criteria. The mean follow-up was 18.4 months (12-28 mo). The average number of levels treated with an ACR per patient was 2.4 (2-3). There were no anterior approach-related complications. The average number of levels instrumented posteriorly was 8.1 (3-15). Six patients underwent Schwab type 1 posterior osteotomies (partial facetectomies). After the first anterior stage, there was a significant increase in the lumbar lordosis and significant decreases in the sagittal vertical axis, pelvic tilt, and lumbopelvic mismatch (P<0.05). After the second stage there was no significant change in the sagittal vertical axis, lumbar lordosis, pelvic tilt, or lumbopelvic mismatch relative to the values obtained after ACR. There was significantly less disability postoperatively [ODI: 15 (0-30)] compared with preoperatively [ODI: 46 (16-80)] (P<0.01). There was significant improvement in general health after operation, as assessed by the EuroQol-5D utility scores [preop: 0.44 (0.21-0.82) vs. postop: 0.71 (0.60-0.80)] (P=0.01). Back and leg visual analog scale pain scores improved significantly postoperatively. CONCLUSIONS: A staged approach using multilevel ACRs with open posterior instrumentation has an acceptable complication profile and provides excellent restoration of sagittal and coronal balance and pelvic parameters in adults with spinal deformity.

Multilevel Corpectomy With Anterior Column Reconstruction and Plating for Subaxial Cervical Osteomyelitis.

STUDY DESIGN: A retrospective case series. OBJECTIVE: The aim of this study was to evaluate patients with cervical spine osteomyelitis who underwent multilevel (≥2) subaxial corpectomies and anterior column reconstruction and plating. SUMMARY OF BACKGROUND DATA: Neglected multilevel subaxial cervical osteomyelitis is a potentially dangerous disease. As it is rare, early radiographic and clinical outcomes after multilevel anterior corpectomy and reconstruction for subaxial cervical osteomyelitis are incompletely defined. METHODS: Adults who underwent multilevel corpectomy and anterior plating/reconstruction for subaxial cervical osteomyelitis at two institutions were reviewed. Analysis of patient demographics, operative details, and radiographic cervical alignment parameters [segmental kyphosis, cervical lordosis, C2-7 sagittal vertical axis (SVA)] was performed. RESULTS: Nineteen patients [15 males, four females; average age 48 years (20-81 yrs)] met inclusion criteria. The majority had pre-operative neurologic deficits or was immunosuppressed. All were treated with ≥6 weeks of intravenous antibiotics following operation. All had anterior plating/reconstruction with titanium cages (expandable-6; mesh-6) or structural bone graft (fibular allogaft-6; tricortical iliac crest-1). The average number of corpectomies was 2.4 (2-4). The average numbers of levels fused anteriorly was 4.4 (4-6) and posteriorly was 6.3 (4-9). The majority of patients (74%) was treated with an anterior/posterior approach. Average follow-up was 16 ±â€Š9 months. There was significant improvement in all cervical alignment parameters (segmental kyphosis, C2-7 SVA, cervical lordosis). No intraoperative complications occurred and no patient deteriorated neurologically postoperatively. Postoperative complications included anterior cage/graft dislodgement (n = 2), recurrent neck hematomas requiring revision (n = 1), epidural hematoma (n = 1), and wound infection (n = 1). Sixty percent of patients had persistent neurologic dysfunction at final follow-up. None required reoperation for recurrent infection or pseudarthrosis. CONCLUSION: Although overall prognosis and neurologic recovery are guarded in medically fragile patients with multilevel subaxial cervical osteomyelitis, reconstruction with multilevel (≥2) corpectomy and anterior reconstruction/plating results in excellent restoration of cervical alignment and low rates of recurrent infection and pseudarthrosis. LEVEL OF EVIDENCE: 4.

Anterior corpectomy via the mini-open, extreme lateral, transpsoas approach combined with short-segment posterior fixation for single-level traumatic lumbar burst fractures: analysis of health-related quality of life outcomes and patient satisfaction.

OBJECTIVE: The authors present clinical outcome data and satisfaction of patients who underwent minimally invasive vertebral body corpectomy and cage placement via a mini-open, extreme lateral, transpsoas approach and posterior short-segment instrumentation for lumbar burst fractures. METHODS: Patients with unstable lumbar burst fractures who underwent corpectomy and anterior column reconstruction via a mini-open, extreme lateral, transpsoas approach with short-segment posterior fixation were reviewed retrospectively. Demographic information, operative parameters, perioperative radiographic measurements, and complications were analyzed. Patient-reported outcome instruments (Oswestry Disability Index [ODI], 12-Item Short Form Health Survey [SF-12]) and an anterior scar-specific patient satisfaction questionnaire were recorded at the latest follow-up. RESULTS: Twelve patients (7 men, 5 women, average age 42 years, range 22-68 years) met the inclusion criteria. Lumbar corpectomies with anterior column support were performed (L-1, n = 8; L-2, n = 2; L-3, n = 2) and supplemented with short-segment posterior instrumentation (4 open, 8 percutaneous). Four patients had preoperative neurological deficits, all of which improved after surgery. No new neurological complications were noted. The anterior incision on average was 6.4 cm (range 5-8 cm) in length, caused mild pain and disability, and was aesthetically acceptable to the large majority of patients. Three patients required chest tube placement for pleural violation, and 1 patient required reoperation for cage subsidence/hardware failure. Average clinical follow-up was 38 months (range 16-68 months), and average radiographic follow-up was 37 months (range 6-68 months). Preoperative lumbar lordosis and focal lordosis were significantly improved/maintained after surgery. Patients were satisfied with their outcomes, had minimal/moderate disability (average ODI score 20, range 0-52), and had good physical (SF-12 physical component score 41.7% ± 10.4%) and mental health outcomes (SF-12 mental component score 50.2% ± 11.6%) after surgery. CONCLUSIONS: Anterior corpectomy and cage placement via a mini-open, extreme lateral, transpsoas approach supplemented by short-segment posterior instrumentation is a safe, effective alternative to conventional approaches in the treatment of single-level unstable burst fractures and is associated with excellent functional outcomes and patient satisfaction.