A morphological characterization of the lumbar neural arch in females and males with degenerative spondylolisthesis.

BACKGROUND: Although Degenerative Spondylolisthesis (DS) is a common osseous dysfunction, very few studies have examined the bony morphology of lumbar the neural arch in the population afflicted with DS. Therefore, this study aimed to characterize the neural arch (NA) morphology along the entire lumbar spine in individuals with degenerative spondylolisthesis (DS) and compare them to healthy controls. METHODS: One hundred CTs from a database of 500 lumbar CTs of spondylolisthesis were selected. We excluded vertebral fractures, non-L4-L5 slips, previous surgeries, vertebral spondyloarthropathies, and scoliosis. Scans were divided into a study group of 50 individuals with single-level DS (grades 1-2) at L4-5 (25 males and 25 females), and an age-sex matched control group of 50 individuals. Linear and angular measurements from all lumbar segments included: vertebral canals, intervertebral foramens, pedicles, and articular facets. RESULTS: Compared with the controls, all individuals with DS had greater pedicle dimensions in the lower lumbar segments (∆ = 1 mm-2.14 mm) and shorter intervertebral foramens in all the lumbar segments (∆range:1.85 mm-3.94 mm). In DS females, the lower lumbar facets were mostly wider (∆ = 1.73-2.86 mm) and more sagittally-oriented (∆10°) than the controls. Greater prevalence of grade-3 facet arthrosis was found only in the DS population (DS = 40-90%,controls = 16.7-66.7%). In DS males, degenerated facets were observed along the entire lumbar spine (L1-S1), whereas, in DS females, the facets were observed mainly in the lower lumbar segments (L4-S1). Individuals with DS have shorter intervertebral foramens and greater pedicle dimensions compared with controls. CONCLUSIONS: Females with DS have wider articular facets, more sagittally-oriented facets, and excessively degenerated facets than the controls. This unique NA shape may further clarify DS's pathophysiology and explain its greater prevalence in females compared to males.

A morphometric analysis of all lumbar intervertebral discs and vertebral bodies in degenerative spondylolisthesis.

PURPOSE: Most morphometric studies on lumbar degenerative spondylolisthesis (DS) have focused solely on the L4-L5 slipped level, neglecting the shape of the entire lumbar segments. The purpose of this study was to present a morphometric analysis of the entire lumbar IVDs and VBs in DS. METHODS: Out of 500 lumbar CTs, the first 100 CTs, 50 with DS at L4 and 50 age- and sex-matched control CTs, were randomly selected. All lumbar IVD and VB heights, widths, lengths and sagittal wedging as well as lumbar lordosis (LL) and sacral inclination (SI) were measured and relevant ratios calculated. The prevalence of lumbar vertebral osteophyte was also measured. RESULTS: A total of 6700 measurements were taken. Age, height, weight and BMI had no effect on all parameters. Compared with controls, in females with DS, the majority of IVDs were flatter, with increased kyphotic wedging at L1-L2 (Δ1.3°) and L2-L3 (Δ1.8°), turning to lordotic wedging at L3-L4 (Δ5.9°), and decreased lordotic wedging at L4-L5 (Δ2.7°) and L5-S1 (Δ5.3°). The posterior IVD/VB ratio of all lumbar levels, middle IVD/VB ratio of L3-S1 and anterior IVD/VB ratio of L4-S1 were smaller. In males with DS, the L2-L3 IVD manifested more kyphotic wedging (Δ3.8°), the L4 VB wedging was more lordotic (Δ2.4°) and all L4-L5 IVD/VB ratios and L3-L4 middle and posterior IVD/VB ratios were smaller. CONCLUSIONS: Individuals with DS have a more generalized degenerative disc disease on all lumbar vertebral levels, characterized by decreased disc space heights and kyphotic posture of the upper lumbar segments, occurring more predominantly in females than in males with DS.

Seven years follow-up for total lumbar facet joint replacement (TOPS) in the management of lumbar spinal stenosis and degenerative spondylolisthesis.

PURPOSE: To evaluate the feasibility and clinical improvement of a total posterior arthroplasty system in the surgical management of lumbar degenerative spondylolisthesis and or spinal stenosis. METHODS: During a 1-year period (June 2006 to July 2007), ten patients were enrolled in a non-randomized prospective clinical study. The primary indication was neurogenic claudication due to spinal stenosis with single-level degenerative spondylolisthesis. Patients were evaluated with X-rays and MRI scans, visual analog scale (VAS) for back and leg pain, the Oswestry disability questionnaire, and the SF-36 health survey preoperatively, at 6 weeks, 3 months and 6 months and at 1, 2, 3 and 7 years postoperatively. RESULTS: The VAS score for back pain dropped from 56.2 preoperatively to 12.5 at 6 weeks and 19 at 7 years follow-up. The VAS score for worse leg pain dropped from 83.5 before surgery to 13 at 6 weeks and 8.8 at 7 years follow-up. The ODI dropped from 49.1 preoperatively to 13.5 at 6 weeks and 7.8 at 7 years follow-up. MRI examination at 7 years after surgery did not demonstrate stenosis adjacent to the stabilized segment. Spondylolisthesis did not progress in any of the cases. One patient had a symptomatic L3-L4 far lateral disc herniation 5 years after surgery whose symptoms resolved with non-operative treatment. In one patient, conversion to posterolateral fusion was performed due to an early device malfunction. CONCLUSION: In patients with spinal stenosis and degenerative spondylolisthesis, decompression and posterior arthroplasty with the TOPS System can maintain clinical improvement and radiologic stability over time.

Vertebral growth modulation by posterior dynamic deformity correction device in skeletally immature patients with moderate adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective, comparative, multicenter. INTRODUCTION: Growth modulating spinal implants are used in the management of scoliosis such as anterior vertebral body tethering. A motion-sparing posterior device (PDDC) was recently approved for the treatment of moderate AIS. The purpose of this study was to determine if the PDDC can modulate growth in skeletally immature patients with AIS. METHODS: From a database of patients treated with the PDDC over 4 years, we identified those who had a minimum of 2 years follow-up. Pre-operative and post-operative Cobb angles and coronal plane wedging of the apical vertebra were evaluated on standing full length radiographs. Independent sample t test and one-way ANOVA with post-hoc Tukey HSD analysis was used to compare three groups in varying skeletal maturity: Risser 0-1, Risser 2-3, and Risser 4-5. RESULTS: 45 patients (14.2-years old, 11-17) were evaluated with a mean pre-op curve of 46° (35°-66°). The average preoperative major curve magnitude, of either Lenke 1 or 5 curve type, was similar among the three groups 47.6°, 46° and 41.5°. Deformity correction was similar in the three groups, with reduction to 26.4°, 20.4° and 26.2°, respectively, at final follow-up [p < 0.05]. Pre-op wedging 7.4° (3.8°-15°) was reduced after surgery to 5.7° (1°-15°) (p < 0.05). Of those patients, Risser 0-1 (n = 16) had preoperative wedging of 9.5° (6°-14.5°) that was reduced to 5.4° (1°-8°) postoperatively (p < 0.05); Risser 2-3 (n = 15) had pre-op 7.7° (4°-15°) vs. post-op 7.0° (3°-15°); Risser 4-5 (n = 14) had pre-op 4.8° (3.8°-6.5°) vs. post-op 4.7° (3.7°-6.5°). Delta Wedging in Risser 0-1 stage was significantly different than for Risser 2-3 and for Risser 4-5. CONCLUSION: The posterior dynamic deformity correction device was able to modulate vertebral body wedging in skeletally immature patients with AIS. This was most evident in patients who were Risser 0-1. In contrast, curve correction was similar among the three groups. This finding lends support to the device's ability to modulate growth.

Diabetes mellitus as a risk factor for the development of lumbar spinal stenosis.

BACKGROUND: Diabetes mellitus is a multi-organ disorder affecting many types of connective tissues, including bone and cartilage. Certain skeletal changes are more prevalent in diabetic patients than in non-diabetic individuals. A possible association of diabetes mellitus and lumbar spinal stenosis has been raised. OBJECTIVES: To compare the prevalence of diabetes mellitus in patients with spinal stenosis, degenerative disk disease or osteoporotic vertebral fractures. METHODS: A cross-sectional analysis was performed of 395 consecutive patients diagnosed with spinal stenosis, degenerative disk disease or osteoporotic vertebral fractures. All the patients were examined by one senior author in the outpatient orthopedic clinic of a large general hospital between June 2004 and January 2006 and diagnosed as having lumbar spinal stenosis (n=225), degenerative disk disease (n=124), or osteoporotic vertebral fractures (n=46). RESULTS: The prevalence of diabetes mellitus in the three groups (spinal stenosis, osteoporotic fracture, degenerative disk disease) was 28%, 6.5% and 12.1%, respectively, revealing a significantly higher prevalence in the spinal stenosis group compared with the others (P=0.001). The higher prevalence of diabetes in the stenotic patients was unrelated to the presence of degenerative spondylolisthesis. CONCLUSIONS: There is an association between diabetes and lumbar spinal stenosis. Diabetes mellitus may be a predisposing factor for the development of lumbar spinal stenosis.

Surgical management of moderate adolescent idiopathic scoliosis with a fusionless posterior dynamic deformity correction device: interim results with bridging 5-6 disc levels at 2 or more years of follow-up.

OBJECTIVE: A posterior dynamic deformity correction (PDDC) system was used to correct adolescent idiopathic scoliosis (AIS) without fusion. The preliminary outcomes of bridging only 3-4 discs in patients with variable curve severity have previously been reported. This paper examines a subgroup of patients with the authors' proposed current indications for this device who were also treated with a longer construct. METHODS: Inclusion criteria included a single AIS structural curve between 40° and 60°, curve flexibility ≤ 30°, PDDC spanning 5-6 levels, and minimum 2-year follow-up. A retrospective review was conducted and demographic and radiographic data were recorded. A successful outcome was defined as a curve magnitude of ≤ 30° at final follow-up. Any serious adverse events and reoperations were recorded. RESULTS: Twenty-two patients who met the inclusion criteria were operated on with the PDDC in 5 medical centers. There were 19 girls and 3 boys, aged 13-17 years, with Risser grades ≥ 2. Thirteen had Lenke type 1 curves and 9 had type 5 curves. The mean preoperative curve was 47° (range 40°-55°). At a minimum of 2 years' follow-up, the mean major curve measured 25° (46% correction, p < 0.05). In 18 (82%) of 22 patients, the mean final Cobb angle measured ≤ 30° (range 15°-30°). Trunk shift was corrected by 1.5 cm (range 0.4-4.3 cm). The mean minor curve was reduced from 27° to 17° at final follow-up (35% correction, p < 0.05). For Lenke type 1 patterns, the mean 2D thoracic kyphosis was 24° preoperatively versus 27° at final follow-up (p < 0.05), and for Lenke type 5 curves, mean lumbar lordosis was 47° preoperatively versus 42° at final follow-up (p < 0.05). The mean preoperative Scoliosis Research Society-22 questionnaire score improved from 2.74 ± 0.3 at baseline to 4.31 ± 0.4 at 2 years after surgery (p < 0.0001). The mean preoperative self-image score and satisfaction scores improved from preoperative values, while other domain scores did not change significantly. Four patients (18%) underwent revision surgery because of nut loosening (n = 2), pedicle screw backup (n = 1), and ratchet malfunction (n = 1). CONCLUSIONS: In AIS patients with a single flexible major curve up to 60°, the fusionless PDDC device achieved a satisfactory result as 82% had residual curves ≤ 30°. These findings suggest that the PDDC device may serve as an alternative to spinal fusion in select patients.

Static and Dynamic Balance in Adults Undergoing Lumbar Spine Surgery: Screening and Prediction of Postsurgical Outcomes.

INTRODUCTION: Balance and fall risk before and after lumbar surgery was assessed to determine whether balance at baseline predicts long-term postsurgical outcomes. METHODS: Forty-three patients in the United States and Israel performed the single-leg stance (SLS) test, four square step test (FSST), and 8-foot up-and-go (8FUG) test before and 2 to 4 months after lumbar spine surgery. They completed the Oswestry Disability Index (ODI) and pain rating before and 12 months after lumbar surgery. RESULTS: From baseline to follow-up, the SLS time was 3.74 seconds longer (P = 0.01), the FSST time was 1.94 seconds faster (P < 0.001), and the 8FUG time was 1.55 seconds faster (P = 0.02). Before surgery, 26% of the patients were considered high fall risk according to the FSST and 51% according to the 8FUG. Postsurgery, all patients could complete the physical tests, but 26% remained at high fall risk according to the 8FUG and 7.5% according to the FSST. The three physical measures together explained 30% of the variance in postsurgical ODI scores (P = 0.02). Age was not correlated with performance. DISCUSSION: Risk of falling is higher than surgeons suspect. Balance tests (ie, SLS, FSST, and 8FUG) are quick and easy to administer. The findings support the importance of screening for balance and fall risk in adults undergoing lumbar spine surgery.

Long-term results for total lumbar facet joint replacement in the management of lumbar degenerative spondylolisthesis.

OBJECTIVE: The authors evaluated the long-term clinical outcome of a total posterior arthroplasty system in the surgical treatment of lumbar spinal stenosis with degenerative spondylolisthesis. METHODS: Between June 2006 and July 2007, 10 patients with neurogenic claudication due to spinal stenosis and single-level degenerative spondylolisthesis were enrolled in a nonrandomized prospective clinical study. The patients were evaluated with radiographs and MRI scans, the visual analog scale (VAS) for back and leg pain, the Oswestry Disability Index (ODI), and the SF-36 health survey preoperatively and at 6 weeks, 3 months, 6 months, 1 year, 2 years, 3 years, 7 years, and 11 years postoperatively. RESULTS: The mean VAS score for leg pain dropped from 83.5 before surgery to 13 at 6 weeks and 17 at 11 years after surgery. The mean VAS score for back pain dropped from 56.2 preoperatively to 12.5 at 6 weeks and 14 at 11 years after surgery. The mean ODI score decreased from 49.1 preoperatively to 13.5 at 6 weeks and 16 at 11 years after surgery. MRI at 11 years demonstrated stenosis adjacent to the stabilized segment in one patient. This patient was not symptomatic. The authors did not find evidence of progression of the spondylolisthesis in any of the cases. In one patient, conversion to posterolateral fusion was performed due to an early device malfunction. CONCLUSIONS: The results of this 11-year follow-up study demonstrate that, in patients with spinal stenosis and degenerative spondylolisthesis, decompression and posterior arthroplasty maintain clinical improvement and radiological stability.

Brace treatment in adolescent idiopathic scoliosis: risk factors for failure-a literature review.

Brace treatment is the most common nonoperative treatment for the prevention of curve progression in adolescent idiopathic scoliosis. The success reported in level 1 and 2 clinical trials is approximately 75%. The aim of this review was to identify the main risk factors that significantly reduce success rate of brace treatment. A literature search using the MEDLINE and Embase databases was conducted. Studies were included if they identified specific risk factor(s) for curve progression. Studies that looked at nighttime braces, superiority of one type of brace over another, the effect of physical therapy on brace performance, cadaver or nonhuman studies were excluded. A total of 1,022 articles were identified of which 25 met all of the inclusion criteria. Seven risk factors were identified: Poor brace compliance (eight studies), lack of skeletal maturity (six studies), Cobb angle over a certain threshold (six studies), poor in-brace correction (three studies), vertebral rotation (four studies), osteopenia (two studies), and thoracic curve type (two studies). Three risk factors were highly repeated in the literature which identified specific subgroups of patients who have a much higher risk to fail brace treatment and to progress to fusion. This data demonstrates that 60% to 70% of the patients referred to bracing are Risser 0 and 30% to 70% of this group will not wear the brace enough to ensure treatment efficacy. Furthermore, Risser 0 patients who reach the accelerated growth phase with a curve ≥40° are at 70% to 100% risk of curve progression to the fusion surgical threshold despite proper brace wear. Skeletally immature patients with relatively large magnitude scoliosis who are noncompliant are at a higher risk of failing brace treatment.

Instrumented slip reduction and fusion for painful unstable isthmic spondylolisthesis in adults.

BACKGROUND CONTEXT: Although in situ posterolateral fusion is considered the gold standard for surgical treatment of low-grade adult spondylolisthesis, correction of the sagittal translation by instrumented slip reduction is more controversial in adults; nevertheless it may delay adjacent level disc degeneration. PURPOSE: The present study was undertaken to evaluate the safety and clinical outcome of operative instrumented slip reduction in 12 adults with isthmic spondylolisthesis accompanied by advanced disc degeneration at that level. STUDY DESIGN: This study was a retrospective review of 12 consecutive lumbar or lumbosacral isthmic slip, which underwent operative slip reduction in our institute. PATIENT SAMPLE: All adult patients having operative instrumented slip reduction of isthmic spondylolisthesis from January 2000 to December 2005 were assessed. OUTCOME MEASURES: Outcome measures included the Oswestry Disability Index (ODI) for low back pain and the visual analog scale (VAS) of back and leg pain. Patient outcome was assessed by work status, participation in sports activities and intake of pain medications. METHODS: Between January 2000 and December 2005, we performed slip reduction on 12 adults aged 28 to 62 years (average 47) with symptomatic lumbar or lumbosacral isthmic spondylolisthesis. The indications for surgery were long-standing low back and leg pain that had not responded to nonoperative management. RESULTS: The vertebral slip ranged between 15% and 90% (average 34%). Radiologic evidence of adult slip progression was available in 5 patients, one had a de novo slip formation and the others had increased sagittal translation on flexion-extension lateral x-rays. All 12 patients underwent posterior decompression, pedicle screw fixation, slip reduction, and posterior lumbar interbody fusion. The slip was anatomically reduced by 100% in 5 patients and between 90% and 95% in 7 (average 95% for the group). X-rays revealed no evidence of instrumentation failure at a mean follow-up of 38 months (range: 18 to 72). Minimal loss of correction (5%) was observed in 2 cases. No neurologic complications were encountered. The mean preoperative ODI of 49 dropped to 12 postoperatively (range: 0 to 20). The mean preoperative VAS for back pain of 7.3 dropped to 1.6 after surgery (range: 0 to 3). The mean preoperative VAS for leg pain of 8 dropped to 1 after surgery (range: 0 to 4). Five patients were followed for more than 3 years: none had evidence of adjacent level disc disease. CONCLUSIONS: Our results may support performing slip reduction in selected adults with isthmic spondylolisthesis.

Efficacy of Head Repositioning in Restoration of Electrophysiological Signals During Cervical Spine Procedures.

PURPOSE: To evaluate the frequency of loss of neurophysiological potentials during head positioning, the usefulness of head repositioning to restore the potentials, and the effect on neurological outcome. METHODS: We retrospectively reviewed consecutive cervical spine surgeries performed at the Israel Spine Center, Assuta Medical Center, during 2006 to 2013. Surgeries performed with neuromonitoring (transcranial-electric motor evoked potentials, somatosensory evoked potentials, electromyographic recordings) were included. Demographic data, medical history, findings at neurological examination and imaging, electrophysiological data recorded during surgery, and neurological outcomes were collected and analyzed. RESULTS: Three hundred eighty-one patients met inclusion criteria. Loss of potentials detected in nine patients during patient positioning and repositioning was undertaken with the aim of restoring electrophysiological signals. In 5/9 patients, repositioning resulted in immediate reappearance of potentials; in 1/5, potentials were affected again during decompression. In 4/9, repositioning did not immediately restore electrophysiological signals; in », potentials reappeared later during the decompression and in ¾, potentials had not recovered till the conclusion of surgery. There were new neurological deficits in 2/9, including one patient with loss of potential that was not restored with repositioning and the one in whom potential was restored but lost again during decompression. CONCLUSIONS: Intraoperative neuro monitoring is an efficient tool to alert the surgical team to potential neurological damage. Head reposition often restores the electrophysiological signals with possible prevention of impending sequelae.

Mid- to long-term outcome of disc excision in adolescent disc herniation.

BACKGROUND CONTEXT: Adolescent disc herniation and its surgical treatment have been the subjects of many published clinical series. The majority of these series were heterogeneous; the number of adolescent patients (12-17 years) as opposed to young adults (18-20 years) was generally small and the length of follow-up varied greatly. Although the short-term outcome of disc excision in adolescents was mostly favorable, their long-term outcome is unknown. OBJECTIVES: To evaluate the mid- and long-term results of discectomy in patients younger than 17 years of age. STUDY DESIGN: Retrospective examination of a series of adolescent patients under the age of 17 years who underwent surgery for lumbar intervertebral disc herniation. PATIENT SAMPLE: The medical records of 26 patients (15 males, 11 females, 12-17 years old [average 14.6]) who were operated for lumbar intervertebral disc herniation in three spine centers between 1984 and 2002 were reviewed. These subjects represented the total number of patients meeting the criteria of adolescents undergoing discectomy for lumbar disc herniation in these institutions during the study period. All patients were located and contacted by an independent observer not involved in the care of these patients. Low back pain associated with leg pain was the main clinical symptom in 20 patients (77%), leg pain in 4 (15%), and back pain in 2 (8%). They all underwent posterior disc excision: 23 (88%) patients had one level discectomy, and 3 (12%) had simultaneous discectomy at two levels. The L4-L5 interspace was involved 19 times, and the L5-S1 interspace 10 times. Slipped vertebral apophysis was diagnosed in 4 patients (15%). Twelve of the 26 patients (46%) had a first-degree relative with a history of lumbar disc herniation. OUTCOME MEASURES: Telephone interviews provided follow-up data for 26 patients. Results were classified as excellent, good, moderate, or poor according to current symptom status, the need for additional surgery, the Oswestry Disability Index, and back and leg pain scores. RESULTS: The average time from surgery to follow-up was 8.9 years (range 3-21 years). At follow-up, the clinical results were excellent in 13 patients (50%), good in 4 (15%), moderate in 8 (31%), and poor in 1 (4%). Four subjects (15%) underwent a subsequent disc excision in the lumbar region, and one of them later underwent fusion. CONCLUSIONS: Discectomy provides satisfactory clinical results in young patients with disc herniation. The rate of reintervention (15%) is comparable to that in adults, indicating that discectomy for young patients should be approached similarly to that in adults.

Anterior decompression combined with corpectomies and discectomies in the management of multilevel cervical myelopathy: a hybrid decompression and fixation technique.

OBJECT: The authors retrospectively evaluated the safety and efficacy of a decompression and fixation technique in the treatment of patients with multilevel cervical spondylotic myelopathy (CSM). METHODS: The authors describe the "hybrid decompression fixation" technique, a procedure involving a combination of corpectomies and discectomies to preserve a vertebra intact within the area of the decompression, thus augmenting mechanical stability. The authors retrospectively reviewed outcomes in 25 patients with multilevel CSM in whom the hybrid technique was performed between 1999 and 2003. Twelve patients underwent a single-level corpectomy and three-level discectomies. In 13 patients a two-level corpectomy and adjacent four-level discectomies were conducted, leaving a vertebral bridge the middle. All patients underwent fusion involving placement of disc and vertebral body cages filled with autogenous local bone and supplemental anterior dynamic plate fixation. The mean preoperative Nurick grade was 3 and improvement in status was reflected by a postoperative decrease to 2.6 (p < 0.05). In one patient neurological deterioration was demonstrated. At the end of the follow-up period (mean 29 months) radiography revealed evidence of osseous fusion in 24 patients; fusion status could not be determined in one patient. No evidence of late-onset instrumentation-related failure was observed in any of the 25 patients. CONCLUSIONS: The authors found the hybrid technique to be safe and efficient for anterior decompression in patients with multilevel CSM. The use of this technique obviates the need for staged circumferential procedures.

Remote Cerebellar Hemorrhage Complicating Unintended Durotomy in Lumbar Spine Surgery.

STUDY DESIGN: Case reports and retrospective review of accidental durotomies in lumbar surgeries during 5 years. OBJECTIVES: To draw attention to a potentially serious complication of incidental durotomy-remote cerebellar hemorrhage. SUMMARY AND BACKGROUND DATA: Accidental durotomy is a frequent complication of spinal surgery. In most cases the outcome of incidental durotomy is favorable. A delayed potentially serious complication of CSF loss during and after lumbar surgery is remote cerebellar hemorrhage (RCH). METHODS: During 2008-2012, 1169 lumbar spine procedures were performed at our spine center. In 210 surgeries incidental or intentional durotomies occurred. All patients with durotomies were managed with suturing of the dural wound followed by deep wound drainage left for 5 days and tight wound closure. RESULTS: Of the 210 patients with CSF loss three patients were identified to suffer from RCH-an incidence of 0.26%. The three patients ages 56, 67 and 75 years developed RCH between 36-192 hours after surgery. All three were managed with supportive treatment and close clinical supervision. A gradual clinical and radiological improvement was noted in all three patients. CONCLUSIONS: Severe headache after spinal surgery and or declining mental status should not be attributed only to low CSF pressure secondary to dural tearing. It can also be the result of remote cerebral or cerebellar hemorrhage. Once the diagnosis of RCH is made, close clinical supervision is mandatory. In most cases non-operative supportive treatment may lead to eventual full clinical recovery.

Surgical management of moderate adolescent idiopathic scoliosis with ApiFix®: a short peri- apical fixation followed by post-operative curve reduction with exercises.

Surgery in adolescent idiopathic scoliosis (AIS) is a major operative intervention where 10-12 vertebrae are instrumented and fused. A smaller motion preserving surgery would be more desirable for these otherwise healthy adolescents. The ApiFix® system is a novel less invasive short segment pedicle screw based instrumentation inserted around the apex of the main curve. The system has a ratchet mechanism that enables gradual postoperative device elongation and curve correction. The ratchet is activated by performing specific spinal exercises. The unique features of the device allow curve correction without fusion. The system which has a CE approval was employed in adolescents with main thoracic curves. More than a dozen of ApiFix surgeries have been performed so far. The preoperative Cobb angle was 45° ± 8, and 25° ± 8 at final follow up. The following is a report on three adolescent females aged 13-16 years with curves between 43°-53° and Risser sign of 1-4 who underwent surgery with ApiFix®. Two pedicle screws were inserted around the curve apex and the ratchet based device with polyaxial ring connectors was attached to the screws. No fusion attempt was made. Operative time was around one hour. Two weeks after surgery the patients were instructed to perform Schroth like daily exercises with the aim of rod elongation and gradual curve correction. Patients were followed between 6 months to 2 years. Curves were reduced and maintained between 22- 33°. Patients were pain free and were able to perform their spinal exercises. Postoperative gradual elongation of the device was observed. No screw loosening or rod breakage were observed. No adding on or curve progression was seen. Three factors may contribute to the ApiFix® success: polyaxial connections that prevent mechanical failure, gradual curve correction by spinal motion and spinal growth modulation. The ApiFix® system allows managing moderate AIS with a simple and minor surgical intervention. Recovery is rapid with negligible motion loss. It allows gradual and safe curve correction with high patient satisfaction. It may also serve as an internal brace for AIS.

Light aircraft crash--a case analysis of injuries.

BACKGROUND: As air travel increases and the number of commercial and non-commercial flights rises, so does the number of aircraft accidents. The improved safety standards of the aviation industry result in a growing number of survivors of aircraft crashes, but there are no management guidelines for the treatment of these survivors. OBJECTIVES: To present our experience in treating five survivors of a light aircraft crash that occurred in August 1995 near Jerusalem. RESULTS: All five survivors sustained vertebral column injuries, which was the only injury in most of the survivors. We discuss the mechanism of injury. CONCLUSIONS: Investigation of injuries' pattern in survivors of aircraft crash is important for establishing management protocols in trauma centers.

An unusual combination of a lumbar seat belt injury and hemorrhagic contusion of the lower thoracic cord in a 2-year-old child: a case report.

We describe a previously unreported combination of lumbar flexion-distraction ligamentous disruption and incomplete thoracic spinal cord injury in a 2-year-old boy. Magnetic resonance imaging of the thoracolumbar spine showed hemorrhagic cord contusion at the T11-T12 level. Plain radiographs showed mild kyphosis of the L3-L4 segment. Fluoroscopy showed pathological motion at L3-L4 in flexion indicating a ligamentous injury. The lumbar spine was surgically stabilized and at 1-year follow-up, a remarkable neurological recovery was noted. We believe that physicians managing children with multiple trauma injuries should be aware of this rare type of injury that might be underdiagnosed.

Discitis and isthmic spondylolisthesis: a case report.

Spondylolysis and spondylolisthesis are common causes of low back pain in children and adolescents. Disc space infection is less common, but is another cause of severe back pain in this population. The combination of both processes in the same segment is rare. This case report is of a 13-year-old patient with isthmic lumbosacral spondylolisthesis and disc space infection at the same level. A patient who presented with severe low back pain and a radiological picture of isthmic slip with end plate irregularities and anterior bridging osteophyte was diagnosed with disc space infection at the slip level. He was managed with intravenous antibiotics for 6 weeks, followed by oral medication for an additional 2 weeks. At follow-up 28 weeks later, a spontaneous radiological fusion at the slip level was noted with complete relief of his symptoms. The patient was able to resume sports activities. In conclusion, isthmic spondylolisthesis and disc space height infection might coexist. Nonoperative treatment will usually result in spontaneous fusion and the complete relief of symptoms.

Inferior vena cava thrombosis presenting as lumbar radiculopathy.

Lumbar epidural varices either primary or secondary to outflow obstruction have been implicated in causing lumbar radiculopathy. We report a case of an adolescent male who presented with lumbar radiculopathy attributable to thrombosed lumbar epidural varix as a result of inferior vena cava thrombosis emanating from factor V Leiden mutation. This rare cause of radiculopathy was diagnosed on contrast-enhanced computerized tomography. All symptoms resolved shortly after initiation of intravenous heparin therapy. The relevant literature is reviewed.