Preoperative Halo-Gravity Traction for Patients with Severe Focal Kyphosis in the Upper Thoracic Spine: A Safe and Effective Alternative for Three-Column Osteotomy.

STUDY DESIGN: Retrospective review. OBJECTIVE: To evaluate the effect of preoperative Halo-gravity traction (HGT) in the treatment of severe focal kyphosis in the upper thoracic spine (UTS), and to propose the indications that HGT could serve as an alternative for three-column osteotomy (3CO) among these patients. SUMMARY OF BACKGROUND DATA: The HGT has been proven to be effective for severe kyphoscoliosis secondary to multiple etiologies. However, the safety and efficacy of HGT in severe focal kyphosis in UTS was still unclear. METHODS: Patients with focal kyphosis in UTS undergoing HGT and without 3CO operation were reviewed. The sagittal focal kyphosis was measured at pre-, posttraction, and postoperation. The neurologic function at pretraction, posttraction, and postoperation were assessed according to the American Spinal Injury Association (ASIA) grading. The complications during HGT, operation, and follow-up were recorded. The comparison between pretraction and posttraction was performed using paired samples t test. RESULTS: A total of 19 patients were included in this study, with a mean age of 13.2 ±â€Š5.8 years. The average duration of HGT was 62.6 ±â€Š8.4 days, during which the average kyphosis decreased from 95.3 ±â€Š16.4° to 64.1 ±â€Š19.2° (P < 0.001). After HGT, the ASIA grade improved from C to D in three patients and from C to E in three patients, from D to E in seven patients, from B to D in one patient. No deterioration in neurologic function was observed during HGT. The neurological status in one patient improved from ASIA C at pretraction to ASIA E at postoperation, but deteriorated to C at 4 years follow-up. CONCLUSION: Preoperative HGT could help to correct deformity and improve neurological deficit. 3CO procedure might be unnecessary in patients with severe focal kyphosis in UTS with the utilization of HGT.Level of Evidence: 4.

Role of conservative treatment of cervical spine injuries.

Conservative treatment still has an important role to play, despite the increasing possibilities of surgical treatment. Treatment starts at the site of trauma. Transportation and immobilisation in braces are discussed. Skeletal skull traction can be used for realignment and reduction, and eventually used in halo-vest treatment. The advantages and disadvantages of these different treatment options are discussed.

Trends in epidemiology and management of type II odontoid fractures: 20-year experience at a model system spine injury tertiary referral center.

STUDY DESIGN: A retrospective cohort study of consecutive type II Odontoid fractures presenting to a Level 1 Regional Model Systems Spinal Cord Injury Center between June 1985 and July 2006. OBJECTIVE: To assess trends in management of type II Odontoid fractures presenting to a Level 1 Model Systems Regional Spinal Cord Injury Center over a 20-year period. SUMMARY OF BACKGROUND DATA: Type II Odontoid fracture management is controversial, and a majority of studies have had relatively small cohorts. There is no consensus regarding definitive treatment, particularly in older patients. METHODS: Medical records of 263 consecutive type II Odontoid fractures from June 1985 to July 2006 were retrospectively reviewed. Patients were excluded if they had neurologic deficits, nonacute fracture, or ambiguous fracture classification. A cohort of 192 neurologically intact, acute type II odontoid fractures were identified. Admission records were reviewed for age, date of injury, date of admission, date of discharge, mechanism of injury, associated injuries, medical comorbidities, and radiologic findings. RESULTS: There was a statistically significant increase in the rate of presentation of type II odontoid fractures with time. The average age and medical comorbidities of the patient did not change over time. The probability of operative management markedly increased over time, corresponding to a statistically significant increase in length of hospital stay for patients undergoing surgery. The discharge disposition correlated significantly to both age of the patient and associated injuries. CONCLUSIONS: The number and frequency of type II odontoid fractures compared with other spine injuries seems to be increasing over the last 2 decades, which may be correlated with the increasing number of elderly persons in the population, given that referral patterns have been unchanged at our institution. Prospective outcomes data are needed to better elucidate optimal treatment algorithms from both, an outcomes and cost-efficacy perspective.

Clinical and Radiological Outcomes of Less Invasive Temporary Internal Distraction Followed by Staged Pedicle Screw Instrumentation in Adolescents with Severe Idiopathic Scoliosis at 2-Year Minimum Follow-Up.

OBJECTIVES: Temporary placement of an internal distraction rod is one of the surgical options in the treatment of severe scoliosis to avoid preoperative halo traction or vertebral column resection. This technique can be applied in a single session or staged. The aim of our study was to report the outcomes of less-invasive temporary internal distraction (LI-TID) in the surgical treatment of adolescents with severe idiopathic scoliosis (IS). METHODS: We performed a single-center, retrospective study of 22 adolescents (19 girls; mean age, 14.8 ± 2.0 years) with severe IS (major curve, ≥90°) who had undergone LI-TID, followed by staged pedicle screw instrumentation, with a minimum of 2 years of follow-up available. The demographic data, radiographic outcomes, pulmonary function test results, perioperative data, revised 22-item Scoliosis Research Society Outcomes questionnaire results, complications, and neuromonitoring data were collected. RESULTS: The average major curve was 120° (range, 90°-160°) preoperatively and 59° (range, 29°-69°) at the final follow-up examination. Thoracic kyphosis (T5-T12) had improved from an average of 80° preoperatively to 33° postoperatively (range, 22°-69°), and the spinal height (T1-S1) had increased from 332 mm (range, 198-432 mm) preoperatively to 405 mm (range, 258-495 mm) at the final follow-up visit. Of the 22 patients, 5 (22.7%) had experienced an intraoperative neuromonitoring change without postoperative neurologic deficits, and 2 had developed superior mesenteric artery syndrome, with resolution after conservative treatment. The mean percentage of the predicted forced vital capacity had improved from 44.5% ± 11.3% to 66.5 ± 10.8 at final follow-up (P < 0.05). The total questionnaire score had improved significantly from 2.9 ± 0.61 to 4.1 ± 0.44 (P < 0.05). CONCLUSION: The results from the present study have shown that staged LI-TID, followed by pedicle screw instrumentation, is safe and effective in adolescents with severe IS, with improvements in spinal deformity, pulmonary function, and health-related quality of life.

Preoperative and Intraoperative Skull Traction Combined with Anterior-Only Cervical Operation in the Treatment of Severe Cervical Kyphosis (>50 Degrees).

OBJECTIVE: To evaluate the clinical and radiographic outcomes of an anterior-only approach for the correction of severe cervical kyphotic deformities. METHODS: We performed a retrospective study of 33 consecutive patients with severe cervical kyphosis treated with an anterior cervical operation and preoperative and intraoperative skull traction. Cobb angle, kyphosis index (KI), kyphosis level, C2-7 sagittal vertical axis (SVA), and T1 slope were measured. The preoperative and postoperative Japanese Orthopedic Association (JOA) scores, visual analog scale (VAS) score for neck pain, Neck Disability Index (NDI) scores, and cervical alignment were compared. RESULTS: The mean angle of the kyphosis was 83.2 ± 20.4°. The mean Cobb angle of the operative region was 71.7 ± 18.5° preoperation, which was reduced to 10.6 ± 5.7° postoperation (mean correction, 85.2%). The mean KI was 75.1 ± 18.2 preoperation, which was reduced to 14.4 ± 9.1 postoperation (mean correction, 80.8%). The preoperative and postoperative mean C2-7 Cobb angle was 53.8 ± 16.5° and 14.7 ± 7.6°, respectively. The preoperative and postoperative mean C2-7 SVA was 3.9 ± 14.5 mm and 12.8 ± 7.3 mm, respectively. The preoperative and postoperative mean T1 slope was -9.4 ± 15.7° and 7.3 ± 13.1°, respectively. The average postoperative C2-7 Cobb angle, Cobb angle of the operative region, KI, C2-7 SVA, and T1 slope changed significantly compared with preoperative values (P < 0.05). The average postoperative JOA, VAS, and NDI scores improved significantly compared with preoperative scores (P < 0.05). CONCLUSIONS: Preoperative and intraoperative skull traction combined with anterior-only cervical operation may be a safe and effective technique for treating severe cervical kyphosis. If the postoperative correction is >80%, sufficient decompression could be achieved.

Traumatic Posterolateral C1-C2 Dislocation Complicated with Locked Lateral Mass and Type II Odontoid Fracture-5-Year Follow-up.

OBJECTIVE: We sought to document our experience in managing a rare complex of traumatic posterolateral atlantoaxial dislocation combined with locked lateral mass and type II odontoid fracture. METHOD: A 30-year-old male patient was referred to the author's department. He complained of a decrease in neck range of motion following a traffic accident. Neurologic examination was normal. Computed tomography and open-mouth radiographs showed a type II odontoid fracture and a posterolateral dislocation with a laterally locked left lateral mass at the C1-C2 level. Considering the difficulty and risk in reduction, due to this rare instability and dislocation, a 2-staged treatment was performed. With up to 11 kg skull traction for 7 days before surgery, the locked lateral mass and the lateral dislocation was finally reduced without any neurologic deficit. And once closed reduction was confirmed by open-mouth and lateral X-ray views in the cervical spine, a second staged C1-C2 surgical fixation and fusion with iliac bone graft was performed to achieve a normal anatomic alignment with a better stability. RESULT: The patient showed significant amelioration of neck symptoms postoperatively, and a successful reduction and fixation of the C1-C2 articulation was achieved. At the 5-year follow-up, solid bone fusion was evident on the computed tomography scan. CONCLUSION: For traumatic posterolateral atlantoaxial dislocation complicated with type II odontoid fracture, a closed reduction of the lateral dislocation before operation is both useful and safe because surgeons do not need to reduce the extremely rare lateral dislocation during the operation. Posterior atlantoaxial stabilization and fusion, rather than the occipitocervical fusion as reported previously, is biomechanically stable enough to achieve solid fusion in this rare trauma while not sacrificing the occipitoatlantal joint.

A prospective randomized controlled study of VAX-D and TENS for the treatment of chronic low back pain.

Low back pain is one of the most significant medical and socioeconomic problems in modern society. International guidelines call for evidence-based management for the pain and disability associated with musculoskeletal disorders. The purpose of this randomized controlled trial is to address the question of efficacy and appropriateness of vertebral axial decompression (VAX-D) therapy, a new technology that has been shown in clinical research to create negative intradiscal pressures, and has been shown to be effective in treating patients presenting with chronic low back pain (> 3 months duration) with associated leg pain. Successful outcome was defined as a 50% reduction in pain utilizing a 10 cm Visual Analog Pain Scale and an improvement in the level of functioning as measured by patient-nominated disability ratings. Patients were randomly assigned to VAX-D or to TENS which was used as a control treatment or placebo. The TENS treatment demonstrated a success rate of 0%, while VAX-D demonstrated a success rate of 68.4% (p < 0.001). A statistically significant reduction in pain and improvement in functional outcome was obtained in patients with chronic low back pain treated with VAX-D.