Dysplasias in the Child's Spine.

Many of the skeletal dysplasias impact the spinal column causing scoliosis, kyphosis, stenosis, and/or instability at various segments of the spine. Understanding how a particular dysplasia is likely to manifest is important to ensure proper screening and treatment decisions. Equally important is understanding the natural history of specific spine abnormalities, such as awareness of the resolution of the cervical kyphosis common to infants with diastrophic dysplasia. Many patients with rarer dysplasias are best cared for by teams of providers including neurosurgeons, orthopedic surgeons, geneticists, pulmonologist, and anesthesiologists who are familiar with the various issues surrounding each particular dysplasia.

The role of multi-modal intra-operative neurophysiological monitoring in corrective surgeries for thoracic tuberculosis with kyphosis.

OBJECTIVE: The aim of this study was to assess the performance and utility of motor evoked potentials (MEP) and somatosensory evoked potentials (SSEP) during corrective surgery for thoracic tuberculosis with kyphosis (TTK). METHODS: 68 patients (mean age 31.7 ± 20.3 years) who underwent corrective surgery for TTK from 2012 to 2019 were included in this retrospective study. Patients were neurologicaly evaluated before and after surgery with systematic neurologic examinations. Intraoperative neurophysiological monitoring (IONM) with SSEP and MEP was carried out. A receiver operating characteristic (ROC) curve and area under ROC curve (AUC) were used to identify the diagnostic accuracy of potential recovery. RESULTS: IONM alerting occurred in 12 surgeries (12/68, 17.6%), of which 6 were SSEP alerting, 2 MEP alerting, and 4 combinations of both SSEP and MEP. Among the 12 cases where there was IONM alerting, 3 (25%) had postoperative neurological deficits(PND), whereas one patient had PND without IONM alerting. IONM sensitivity and specificity were 0.75 (95% CI 0.22-0.99) and 0.86 (95% CI 0.74-0.93) respectively. Positive predictive value (PPV) and negative predictive value (NPV) were 0.25 and 0.98 respectively. The AUC of evoked potential recovery in diagnosing PND was 0.884. CONCLUSION: Our study showed that multi-modal IONM with SSEP and MEP can effectively indicate a potential neural injury and predict PND during TTK corrective surgery. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

The relationship between thoracic kyphosis and age, and normative values across age groups: a systematic review of healthy adults.

BACKGROUND: Thoracic kyphosis is reported to increase with ageing. However, this relationship has not been systematically investigated. Peoples' kyphosis often exceeds 40°, but 40° is the widely accepted cut-off and threshold for normality. Consequently, patients may be misclassified. Accurate restoration of kyphosis is important to avoid complications following spinal surgery. Therefore, specific reference values are needed. The objective of the review is to explore the relationship between thoracic kyphosis and age, provide normative values of kyphosis for different age groups and investigate the influence of gender and ethnicity. METHODS: Two reviewers independently conducted a literature search, including seven databases and the Spine Journal, from inception to April 2020. Quantitative observational studies on healthy adults (18 years of age or older) with no known pathologies, and measuring kyphosis with Cobb's method, a flexicurve, or a kyphometer, were included. Study selection, data extraction, and study quality assessment (AQUA tool) were performed independently by two reviewers. The authors were contacted if clarifications were necessary. Correlation analysis and inferential statistics were performed (Microsoft Excel). The results are presented narratively. A modified GRADE was used for evidence quality assessment. RESULTS: Thirty-four studies (24 moderate-quality, 10 high-quality) were included (n = 7633). A positive moderate correlation between kyphosis and age was found (Spearman 0.52, p < 0.05, T5-T12). Peoples' kyphosis resulted greater than 40° in 65% of the cases, and it was significantly smaller in individuals younger than 40 years old (x < 40) than in those older than 60 years old (x > 60) 75% of the time (p < 0.05). No differences between genders were found, although a greater kyphosis angle was observed in North Americans and Europeans. CONCLUSION: Kyphosis increases with ageing, varying significantly between x < 40 and x > 60. Furthermore, kyphosis appears to be influenced by ethnicity, but not gender. Peoples' thoracic sagittal curvature frequently exceeds 40°. TRIAL REGISTRATION: The review protocol was devised following the PRISMA-P Guidelines, and it was registered on PROSPERO ( CRD42020175058 ) before study commencement.

Cifosis patológica en la columna pediátrica / Pathologic kyphosis in the pediatric spine

En este manuscrito se revisan las diferentes causas que producen aumento de la cifosis torácica (dorso curvo), específicamente en niños y adolescentes. Las causas del dorso curvo que se analizan en este artículo son: Dorso curvo postural, idiopático, neuromuscular, congénito y enfermedad de Scheuermann. Se centra en los factores que producen su aparición, características de su evolución y tratamiento.

This manuscript reviews the different causes that lead to increased thoracic kyphosis, specifically in children and adolescents. The causes of increased thoracic kyphosis that will be discussed in this article are: postural, idiopathic, neuromuscular, congenital, and Scheuermann's disease. This paper focuses on the factors that produce its appearance, characteristics of its evolution, and treatment.

Risk factors of the poor long-term prognosis of osteoporotic vertebral fractures: A multicenter cohort study.

INTRODUCTION: The presence of existing osteoporotic vertebral fracture (OVF) increases the mortality risk. However, the influence of the characteristics of OVF is unclear. This study aimed to investigate the influence of new OVF on patients' long-term prognosis using our past cohort study. METHOD: This is an extension study of our cohort study carried out between 2005 and 2007. In the present extension study, of 420 patients, 197 whose contact information was available at the 6-month follow-up were included in the telephone survey in 2018. Five patients refused to participate in the survey, and 82 could not be contacted. Eventually, 110 patients were enrolled. Of the Demographic data, radiological findings, medical history, and clinical outcome were investigated at injury onset and at the 6-month follow-up. A proportional hazard model was used to investigate the risk factors for mortality. RESULTS: Among 110 patients, 33 died. Male sex and low body mass index (BMI <18.5 kg/m2) were significant risk factors for mortality [hazard ratio (HR) = 6.40, 1.01-40.50; 5.24, 1.44-19.04, respectively]. The history of stroke and liver disease increased the risk of mortality (HR = 13.37, 1.93-92.7; 6.62, 1.15-38.14, respectively). As regards radiological findings, local kyphosis progression per 1° or ≥7° were significant risk factors of mortality (HR = 1.20, 1.06-1.36; 5.38, 1.81-16.03, respectively). CONCLUSIONS: A telephone survey at 12 years after the occurrence of OVF analyzed risk factors for mortality and showed that a progression of local kyphosis in fractures between injury onset and 6 months after injury was a risk factor of poor prognosis.

Spinal postural alignment measurements using markerless digital photography.

BACKGROUND: A device that can measure posture alignment repeatedly is important for the prevention of hyperkyphosis. OBJECTIVE: We devised a markerless measurement method for hyperkyphosis using digital photography and investigated the correlation with other noninvasive measurements and the validity and accuracy of this method. METHODS: The study included 27 participants. The craniovertebral angle in supine (CVAS) and craniohorizontal angle in supine (CHAS) were calculated from digital photographs of the head and neck areas of the studied subjects with ImageJ. The correlations of CVAS and CHAS with the kyphosis index (KI) and block method (BM) were investigated. Intrarater correlation coefficient and Bland-Altman analyses were used to verify the reliability and accuracy of the measured results. RESULTS: CHAS exhibited an excellent correlation with the KI and the BM. The intra- and interrater reliabilities of CHAS were almost perfect. Bland-Altman analysis revealed that CHAS was associated with minor addition errors. CONCLUSION: CHAS founded an excellent correlation and reliability with the conventional spinal postural alignment measurements. The addition error suggested that the manual was needed to confirm the landmark. The CHAS is a method used to measure the spinal postural alignment in a supine position without markers and without exposing the skin surface.

Severe thoracolumbar congenital kyphosis treated with single posterior approach and gradual "in situ" correction.

BACKGROUND: Congenital kyphosis results from the failed formation of the vertebrae during the embryonic period and may be associated with cardiac, urogenital, or spinal cord anomalies. Surgical treatment is the best choice through anterior, posterior, or both approaches. OBJECTIVES: This study aims to evaluate the effect of posterior gradual correction using the "in situ" bender to correct severe thoracolumbar congenital kyphosis with or without osteotomy or excision of the vertebra. METHODS: Twenty-five patients with an age range of 2-23 (mean ± SD = 12.58 ± 6.03) years with severe thoracolumbar kyphosis were treated surgically at our institution between 2004 and 2013. Pedicle screwing, osteotomy, and gradual "in situ" bending through the single posterior approach were the choices of treatment. Cobb's angle, patient's height, and SRS-22r were used to evaluate the patients preoperatively and postoperatively. Follow-up periods were 35-136 months. RESULT: Cobb's angle pre-surgery range was 35-180 (81.48 ± 39.1) degrees improved post-surgery to 0-45 (21.72 ± 13.47) degrees (p-value <0.0001). The range of patients' standing height pre-surgery was 79-170 (142.42 ± 24.85) centimeters increased after surgery to 81-175 (147.76 ± 26.33) centimeters (p-value <0.0001). SRS-22r pre-surgery range was between 2.12 and 3.904 (3.2 ± 0.77) and improved post-surgery to 4.16 and 4.96 (4.59 ± 0.29) (p-value = 0.046). CONCLUSION: Gradual correction with the "in situ" bender with or without osteotomy through the single posterior approach can give satisfying clinical (patients' standing height and SRS-22r scores) and radiological (Cobb's angle) results to treat severe congenital thoracolumbar kyphosis.

The clinical efficacy and experience of bipedicular percutaneous vertebroplasty combined with postural reduction in the treatment of Kümmell's disease.

BACKGROUND: Kümmell's disease is a special type of osteoporotic vertebral fracture that causes chronic low back pain and deformity, which seriously affects the living quality of patients. PVP is commonly used to treat osteoporotic vertebral fractures and can quickly relieve low back pain. So, the objective of this study was to analyze the clinical efficacy and experience of bipedicular percutaneous vertebroplasty combined with postural reduction for the treatment of Kümmell's disease. METHODS: A retrospective analysis of patients with Kümmell's disease who underwent bipedicular percutaneous vertebroplasty was conducted from February 2016 to May 2018. Operative time, VAS, bone cement injection volume, cement leakage rate, compression improvement of vertebral front edge and vertebral center, and correction degree of kyphosis were collected and analyzed meticulously. RESULTS: The operative time was 45.33 ± 7.64 min. The volume of bone cement injected was 5.38 ± 1.33 ml. The compression improvement of vertebral front edge was 7.31 ± 1.21%. The compression improvement of vertebral center was 10.34 ± 1.15% and the correction degree of kyphosis was - 2.73 ± 0.31゜. Bone cement leakage occurred in 6 of 39 patients (15.38%), but no clinical symptoms were observed. The VAS scores were significantly lower at 1 day after the surgery, 6 months and at the last follow-up than before the surgery (P = 0.000, respectively). The VAS score was lower at the last follow-up than at 1 day after the surgery (P = 0.001). CONCLUSION: Bipedicular percutaneous vertebroplasty combined with postural reduction could achieve satisfactory analgesic effect in the treatment of Kümmell's disease, and restore the height of the vertebral body and improve kyphosis to some extent.

Percutaneous versus open posterior stabilization in AOSpine type A3 thoracolumbar fractures.

BACKGROUND: The purpose of this retrospective cohort study was to compare treatment strategies of two level-one trauma centers regarding clinical and radiological outcomes focusing on non-osteoporotic AOSpine type A3 fractures of the thoracolumbar spine at levels T11 to L2. METHODS: Eighty-seven patients between 18 and 65 years of age that were treated operatively in either of two trauma centers were included. One treatment strategy includes open posterior stabilization whereas the other uses percutaneous posterior stabilization. Both included additional anterior fusion if necessary. Demographic data, McCormack classification, duration of surgery, hospital stay and further parameters were assessed. Owestry Disability Index (ODI), Visual Analog Scale (VAS) and SF-36 were measured for functional outcome. Bisegmental kyphosis angle, reduction loss and sagittal alignment parameters were assessed for radiological outcome. Follow up was at least 24 months. RESULTS: There was no significant difference regarding our primary functional outcome parameter (ODI) between both groups. Regarding radiological outcome kyphosis angle at time of follow up did not show a significant difference. Reduction loss at time of follow up was moderate in both groups with a significantly lower rate in the percutaneously stabilized group. Surgery time was significantly shorter for posterior stabilization and anterior fusion in the percutaneous group. Time of hospital stay was equal for posterior stabilization but shorter for anterior fusion in the open stabilized group. CONCLUSION: Both treatment strategies are safe and effective showing only minor loss of reduction. Clinical relevant differences in functional and radiographic outcome between the two surgical groups could not be demonstrated. TRIAL REGISTRATION: It was conducted according to ICMJE guidelines and has been retrospectively registered with the German Clinical Trials Registry (identification number: DRKS00015693, 07.11.2018).

Is It Growth or Natural History? Increasing Spinal Deformity After Sanders Stage 7 in Females With AIS.

BACKGROUND: Accurate prognosis and treatment decisions in adolescent idiopathic scoliosis (AIS) demand a reliable radiographic marker of growth cessation. Specifically, Sanders Stage 7 (SS7) is a useful marker of spine growth cessation in females and is proposed as a bracing endpoint. The purpose of this study was to determine the amount of curve progression noted in female individuals with AIS after achieving SS7. We hypothesize that a subset of patients continues to progress at a greater rate than the natural history at SS7. METHODS: This retrospective review included female patients with AIS treated at a single institution from May 2008 to 2018. Patients required a hand radiograph demonstrating SS7 and concurrent spine radiograph measuring <50 degrees, plus 2-year follow-up spine radiograph. Curve types were categorized by the modified Lenke Classification. Risser grade, menarche, height, weight, and bracing data were collected. Progression was defined as an increase of the main curve ≥5 degrees. Comparison between groups was analyzed using independent t tests and χ or Fisher exact tests as appropriate. Binary logistic regressions were used to construct a model predictive of progressing beyond 50 degrees or undergoing surgery. RESULTS: A total of 89 patients met inclusion criteria, average main curve magnitude 33 degrees (SD 9) at SS7 and 38 degrees (SD 11) at 2-year follow-up. Forty-five (51%) patients progressed ≥5 degrees and 17 (19%) progressed at least 10 degrees. Seventy patients had curves <40 degrees at SS7 and 22 (31%) progressed to >40 degrees at 2 years. Eleven (12%) patients progressed to >50 degrees or had surgery at 2-year follow-up. Receiver operating characteristic curve analysis identified a threshold of 39.5 degrees curvature at SS7 associated with progression to >50 degrees or surgery (area under the curve=0.94, P<0.001, sensitivity=100%, specificity=87%). Patients with initial curves >40 degrees did have additional height gained (2.1 cm; SD 1.5), but this was not different than those <40 degrees, P>0.05. In addition, no other variables had statistically significant association with those that progressed (P>0.05). CONCLUSIONS: A curve >40 degrees at SS7 is at high risk for progressing to a curve measuring >50 degrees or requiring surgery. Those with curves below this threshold still have potential to make clinically significant progression after skeletal maturity. Follow-up of patients beyond SS7 is essential for curves measuring >40 degrees. Reaching SS7 with a curve <50 degrees may not be the endpoint for curve progression, even if predictive of the end of spinal growth. LEVEL OF EVIDENCE: Level III-retrospective research study.

Is Anterior Release Obsolete or Does It Play a Role in Contemporary Adolescent Idiopathic Scoliosis Surgery? A Matched Pair Analysis.

STUDY DESIGN: A retrospective analysis of a prospectively collected database was performed. OBJECTIVE: The purpose of this study is to compare 3-dimensional correction associated with the anterior release (AR) and contemporary posterior instrumentation versus posterior-only surgery. SUMMARY OF BACKGROUND DATA: The role of AR as a tool in the treatment of adolescent idiopathic scoliosis (AIS) has seen a decline with the popularization of thoracic pedicle screw instrumentation. METHODS: Five surgeons were queried for all surgical thoracic AIS cases from 2003 to 2010 treated with thoracoscopic AR/fusion and contemporary posterior instrumentation and fusion and thoracic pedicle screw instrumentation (>80% screws) with 2-year follow-up. These cases were then matched with posterior spinal fusion only cases from a multicenter prospective database. The 2 groups were matched on the basis of major curve magnitude within 5 degrees, T5-T12 kyphosis within 9 degrees, and angle of trunk rotation within 9 degrees. Radiographic and clinical parameters were compared for the 2 groups. Continuous variables were analyzed with analysis of variance and categorical dependent variables with the χ test. RESULTS: A total of 47 cases of AR were matched to 47 (1:1 match) posterior spinal fusion cases. Preoperative parameters were similar between groups (P>0.05). Postoperatively, AR cases had a lower major curve (20 vs. 25 degrees, P=0.034; 72% vs. 66% correction, P=0.037). T5-T12 kyphosis was greater in the AR cases (26 vs. 20 degrees; P=0.005). The angle of trunk rotation was similar for the groups. Anchor density was lower in the AR group (1.6 vs. 1.9; P<0.0001). There were 3 complications associated with the AR: 1 pneumothorax and 2 conversions to minithoracotomies for failure to maintain single lung ventilation. CONCLUSIONS: AR improves coronal and sagittal plane correction in contemporary AIS surgery with a satisfactory complication profile with less pedicle screw density required for clinically similar corrections. A further prospective study on the benefits of AR may help define specific indications.

Global sagittal spinal alignment in patients with degenerative low-grade lumbar spondylolisthesis.

PURPOSE: Global sagittal spinal alignment undergoes changes on the basis of sagittal malalignment (trunk inclined forward) in natural degenerative progression. We hypothesized that this change would associate with the disease state of the degenerative lumbar spondylolisthesis (DS). This study aimed to evaluate the global sagittal spinal alignment of low-grade DS by classifying in accordance with sagittal vertical axis (SVA). METHODS: The DS group was classified into three types according to the adult spinal deformity classification: type 1, SVA < 40 mm; type 2, 40 mm ≤ SVA < 95 mm; and type 3, 95 mm ≤ SVA. Age and sagittal spinal parameters (thoracic kyphosis, lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI)) were compared among three types. RESULTS: There were statistically significant differences in age, LL, PI, and PT among the three types. In comparison between two types, there was a statistically significant difference between type 1 and type 2 and between type 1 and type 3, but not between type 2 and type 3 in these parameters. PI tended to increase as the type increases. Furthermore, there was significant difference between types 1 and 3. CONCLUSION: We evaluated the features of the DS types classified by sagittal alignment. Large PI is one of the risk factors for SVA deterioration of DS. PI may be involved in the onset and progression of DS.

Surgical Treatment of Ankylosing Spondylitis with Andersson Lesion.

Ankylosing spondylitis (AS) with an Andersson lesion may cause kyphosis. As the disease progresses, kyphosis gradually worsens. When conservative treatment does not improve the symptoms, surgery is often needed to correct the deformity. The optimal surgical approach for ankylosing spondylitis with kyphosis remains controversial. Here, we introduce our surgical procedure of pseudoarticular debridgement and osteotomy of the apical vertebrae of the Cobb angle. We found that both the kyphosis and associated symptoms improved significantly after 13 months of follow-up.

Safe trajectory for an occipital condyle screw: A computer simulation study.

OBJECTIVE: The purpose of this study was to evaluate the feasibility of posterior occipital condyle screw (OCS) placement analysis of the safe trajectory area for screw insertion. METHODS: Computed tomographic angiography scans of patients (46 males and 27 females) with normal occipitocervical structures were obtained consecutively. Vertebral artery (VA)-occiput distance <4.0 mm was defined as "unfeasible" for OCS fixation, and occipital-atlas angulation was measured to assess the feasibility of screw placement. Next, the placement of 3.5 mm diameter OCS was simulated, the probability of breach of structures surrounding occipital condyles was calculated, and placement parameters were analyzed. RESULTS: OCS placement was feasible in 91.1% (133/146) of occipital condyles, and the feasible probability also presented a significant sex-related difference: The probability was higher for males than for females (95.7% vs. 83.3%, p < 0.05). The incidence of anatomical structures injured under screw placement limitation was 18.8% (VA), 81.2% (hypoglossal canal), 59.4% (occipital-atlas joint), and 40.6% (occiput bone surface). There were no significant differences between the left and right condyles in relation to the measured parameters (p > 0.05). The screw range of motion was significantly smaller in females than in males (p < 0.05). The feasibility of OCS placement and OCS range of motion were significantly greater in the kyphosis group (>5°) than in the other two groups (p < 0.05). CONCLUSION: OCS placement is a feasible technique for occipital-cervical fusion. The male group and occipitocervical region kyphosis group had a wider available space for OCS placement. Tangent angulation may be useful for the accurate and safe placement of an OCS.

Effect of cervical flexion and extension on thoracic sagittal alignment.

INTRODUCTION: The cervical spine has the largest sagittal motion in the whole spine, and cervical alignment affects the thoracic sagittal alignment. However, the effects of cervical flexion and extension on thoracic sagittal alignment have not been investigated in detail. The purpose of this study was to analyze the change of thoracic sagittal alignment following cervical flexion and extension. SUBJECTS AND METHODS: A total of 55 consecutive patients (42 men and 13 women; average age 49.1 years) who presented to our department with spinal degenerative disease between January 2016 and September 2017 were enrolled in our study. Subjects with a history of trauma, infection, tumor, inflammatory disease, ossification, or cervical deformities, and those who had undergone spinal surgery were excluded. The following parameters were analyzed: occipito-axial angle (O-C2), C2 slope (C2S), C2-C7 angle, T1 slope (T1S), thoracic kyphosis, T1-T4 angle, T5-T8 angle, T9-T12 angle, lumbar lordosis, sacral slope, pelvic tilt in cervical flexion, neutral, and extension. RESULTS: Cervical flexion significantly decreased O-C2, C2-C7 angles and T1S, and increased C2S. Cervical extension conversely changed these parameters. At cervical flexion, the correlation of C2-C7 angle with thoracic parameters was maintained, except for the T1-T4 angle. At cervical extension, the correlation was observed with T1S and T1-T4 angle. CONCLUSION: Cervical flexion affects the T1S and T5-T8 angle, but there is no significant change in T1-T4 and T9 and lower spino-pelvic columns. This study suggests that T2-T4 can be considered as a stable distal end when cervical long fixation for corrective surgery is performed.

Effect of thoracic and pelvic anteroposterior diameters on spinal sagittal alignment.

PURPOSE: This study aimed to analyze the effect of the thoracic anteroposterior diameter (TAPD) and pelvic anteroposterior diameter (PAPD) on global sagittal alignment in asymptomatic patients with normal sagittal alignment. PATIENT SAMPLE: The study investigated 2042 adult patients who initially presented at our hospital with a hip and knee problem without history of symptoms related to the entire spine. Only 57 patients with normal global sagittal alignment (C2-7 sagittal vertical axis (SVA) and C7-S1 SVA of <10 mm) were considered. METHODS: The whole-spine standing lateral radiographs were obtained to analyze the following parameters: pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), thoracic inlet angle (TIA), T1 slope, cervical spinal parameters (angle of C0-2, C2-7, and C0-7), TAPD, and PAPD. Statistical analysis was performed using Pearson correlation coefficients and multiple regression analyses. RESULTS: All the parameters showed a normal distribution. TAPD had a significant relationship with thoracic kyphosis (TK; r = 0.458), TIA (r = 0.677), and C0-2 angle (r = 0.294) but no significant relationship with T1 slope and other cervical parameters. PAPD had a significant relationship with PI (r = 0.309) and PT (r = 0.463) but no significant relationship with LL, SS, and TK. The multiple regression analysis showed that TIA = 21.974 + 0.405 (TK) + 0.188 (TAPD) (p < 0.0001). CONCLUSIONS: TAPD and PAPD are associated with TIA, TK, C0-2 angle, PI, and PT, all of which act as key factors in spinal sagittal alignment. Although they did not directly correlate with other cervical parameters, T1 slope, and LL, TAPD and PAPD might have indirect effects on cervical and lumbar spinal sagittal alignment through their relationships with TIA, TK, and PI.

What constitutes the fat signal detected by MRI in the spine of patients with ankylosing spondylitis? A prospective study based on biopsies obtained during planned spinal osteotomy to correct hyperkyphosis or spinal stenosis.

OBJECTIVE: Study the MRI signal of fatty lesions (FL) by immunohistological analysis of vertebral body biopsies of patients with ankylosing spondylitis (AS) compared with degenerative disc disease (DDD). METHODS: Biopsies obtained during planned surgery from vertebral edges where MRI signals of FL was detected were stained with H&E. Immunofluorescence (IF) staining was performed to quantify osteoblasts and osteoclasts. Bone marrow (BM) composition, grade of cellularity and quantification of cells were analysed on six randomly chosen high-power fields (HPF; 0.125 mm2) at 200-fold magnification per patient by two experienced researchers in a blinded manner. RESULTS: Biopsies of 21 patients with AS and 18 with DDD were analysed. Adipocytes were found in the BM of 19 patients with AS (90.5%) versus 5 with DDD (27.8%) (p<0.001), while inflammatory infiltrates were found in in the BM of 8 patients with AS (38.1%) versus 14 with DDD (77.8%) (p=0.035) and fibrosis in 6 patients with AS (28.6%) versus 4 with DDD (22.2%) (p=n .s.). The most frequently detected cells were adipocytes in AS (43.3%) versus DDD (16.1%, p=0.002) and inflammatory mononuclear cells in DDD (55%) versus AS (11.0%, p=0.001). Using IF staining, there was more osteoblastic than osteoclastic activity (6.9 vs 0.17 cells/HPF) in FL as compared with inflammatory BM (1.3 vs 7.4 cells/HPF), respectively. CONCLUSION: MRI FL correspond to presence of adipocytes, resulting to change of cellular homeostasis towards diminution of osteoclasts in the BM of patients with AS. The cross-talk between the different cell types and osteitis, fat and new bone formation needs further study.

Kyphosis - A risk factor for positioning brachial plexopathy during spinal surgeries.

OBJECTIVE: The aim of this study was to evaluate the differences in transcranial electric motor-evoked potentials - TceMEP on upper limbs and the incidences of postoperative brachial plexopathy between patients with kyphotic and scoliotic trunk shapes. METHODS: In the period of January 2011-January 2017, 61 consecutive patients (mean age: 18.4 years ± 4.4 years (range: 10-32)) with pediatric spinal deformity underwent surgery in our Department. Eight of them had a kyphotic trunk deformity (Scheuermann kyphosis, neurofibromatosis, posterior thoracic hemivertebra), and the rest of the 53 patients had a scoliotic trunk deformity (mostly adolescent idiopathic scoliosis - AIS, lateral hemivertebra). The TceMEP recordings in all four limbs were analyzed every 30 min, or upon the surgeon's command. Upper limb TceMEP recordings were used as a control of systemic and anesthetic related changes, and as the indicator of positioning brachial plexopathy. RESULTS: Four out of 8 patients (50.0%) from the kyphotic group experienced noteworthy decreases in TceMEP amplitude (≥65%) in one or both arms, and only 2 out of 53 patients (3.8%) from the scoliotic group, confirming significant statistical difference (Chi-square 16.75, p < 0.05). Two out of 8 patients with decreases in TceMEP amplitude suffered from transitory postoperative brachial plexopathy, and both of them were from the kyphotic group. CONCLUSION: It seems that kyphotic trunks have a higher risk for positioning-related brachial plexopathy, probably due to distribution of trunk's weight onto only four points (two iliac bones and two shoulders), compared to the scoliotic trunks that have wider weight-bearing areas. We emphasize the importance of proper patient positioning and close intraoperative neuro-monitoring of all four limbs in more than one channel per limb. LEVEL OF EVIDENCE: Level IV Therapeutic Study.

Phenotypic heterogeneity of kyphoscoliosis with vertebral and rib defects: a case series.

Disorders associated with multiple vertebral segmentation defects may have additional rib anomalies in form of absence or hypoplastic ribs, fanning of ribs, etc. Spondylocostal dysostosis is genetic disorder with abnormal vertebral segmentation and rib anomalies. Diagnosis is often delayed because of non-familiarity with the characteristic features. There are six genes identified for spondylocostal dysostosis, of which SCDO5 is responsible for autosomal dominant form of the disorder. Retrospective study was conducted in Genetic and Metabolic unit of a tertiary hospital in north India over a period of 9 years. Twenty patients with a clinical diagnosis of congenital scoliosis were identified, and reviewed. Three patients were discussed in an earlier report and 11 subsequent patients, are described in this case series here. The median age at presentation was 34 months. The patients showed hemivertebrae, vertebral fusion, fusion of ribs, fanning of ribs. Hydrocephalus/ventriculomegaly was found in three cases and diastematomyelia was identified in one case. Other associated anomalies included corpus callosal agenesis, club foot and capillary malformation. One parent showed rib/spinal defects in two cases. Further studies are needed to characterise the phenotype and genetic basis of scoliosis in Indian patients.

Distal Junctional Failure Following Pediatric Spinal Fusion.

BACKGROUND: Adjacent segment pathology is a known complication after spinal fusion, but little has been reported on junctional failure. A series of adolescent patients presented with acute distal junctional failure (DJF). We sought to determine any common features of these patients to develop a prevention strategy. METHODS: A retrospective review was conducted of pediatric patients who developed DJF after instrumented spinal fusion performed at 2 institutions from 1999 to 2013. Patients with proximal junctional failure or junctional kyphosis without failure were excluded. RESULTS: Fifteen subjects were identified with mean follow-up of 38 months. Distal failure occurred a mean of 60 days after index surgery, with history of minor trauma in 4 patients. Failures included 3-column Chance fracture (11) or instrumentation failure (4). Thirteen patients presented with back pain and/or acute kyphosis, whereas 2 asymptomatic patients presented with healed fractures. Two patients also developed new onset of severe lower extremity neurological deficit after fracture, which improved but never resolved after revision. A total of 13/15 subjects required revision surgery, typically within 1 week. Complications associated with revision surgery were encountered in 8 patients (62%). Major complications that required return to the operating room included 2 deep infections, 2 instrumentation failures, and dense lower extremity paralysis that improved after medial screw revision and decompression. At final follow-up, 10 patients are asymptomatic, 2 have persistent neurological deficit, 2 have chronic pain, and 1 has altered gait with gait aid requirement. CONCLUSIONS: This study analyzes a heterogenous cohort of spinal fusion patients who developed DJF from 3-column Chance fracture or instrumentation failure. Revision surgery is typically required, but has a high complication rate and can result in severe neurological deficit, highlighting the morbidity of this complication. It is unclear whether level of the lowest instrumented vertebra contributes to DJF. Increased awareness of junctional failure in children may prompt additional studies to further characterize risk factors and preventative strategies. LEVEL OF EVIDENCE: Level IV-study-type case series.