Outcome of hemivertebra resection in congenital thoracolumbar kyphosis and scoliosis by posterior approach.

OBJECTIVE: To find out the long term outcome of deformity correction by hemivertebra resection in congenital thoracolumbar spinal deformities by a single posterior approach. METHODS: This is a retrospective study carried out at the Department of Spine Surgery, Combined Military Hospital, Rawalpindi, Pakistan from April 2006 to April 2013. All operated patients having single level hemivertebrae of thoracolumbar spine with at least two years follow up were included. Data was analyzed using SPSS ver. 17. RESULTS: There were 24 patients with mean age of 17 years (SD=8.41). Male to female ratio was 9(37.5%): 15(62.5%). Mean operation time was 4.23 hours (SD=1.2). Mean blood loss was 787 ml (SD=479). Mean follow up was for 5 years and 7 months (SD=30 months). Mean pre-op scoliosis was 51 degrees (SD=22), which improved to 20 degrees (SD=15) on last follow up (61% improvement). Mean pre-op kyphosis was 42 degrees (SD=35), which improved to 13 degrees (SD=15) on last follow up (69% improvement). Mean pre-op sagittal shift was 22mm (SD=24.9), which improved to 6mm (SD=9.37) on last follow up (73% improvement). Mean pre-op coronal shift was 34mm (SD=27.1), which improved to 8mm (SD=8.58) on last follow up (76% improvement). Five patients had complications. One proximal junctional kyphosis, one implant failure, one transient deficit and two wound infections. CONCLUSIONS: Posterior resection of hemivertebrae for congenital thoracolumbar deformities gives excellent correction of deformity in experienced hands and has acceptable complication rate.

Multi level lumbosacral spinal fusion including lumbo-Sacral (L5-S1) junction fixation in adult deformity surgery; is postero- lateral fusion at (L5-S1) alone adequate?

BACKGROUND/AIMS: To assess the revision rate at L5-S1 when only posterior fixation with pedicle screws is done with multi-level spinal fixation. PATIENTS AND METHODS: The Retrospective quasi experimental study was conducted at the Combined Military Hospital, Rawalpinidi and comprised data from 2009 to 2014 of patients in whom multi-level posterior decompression including lumbosacral junction (L5-S1) with laminectomy and posterior fixation with pedicle screws was done till L3 and higher. Those with known cause of implant failure like osteoporosis, osteomalacia and infection were excluded. Patients were followed up and need for revision at L5-S1 level was assessed. RESULTS: Of the 22 cases, 5(23%) were males and 17(77%) were females with an overall mean age of 64±10.38 years (range 48-84 years). Mean number of levels fixed was 5.22±1.15 the highest level of fixation being T11. Mean follow-up was 08±3.22 months and focused only at the failure of fixation at L5-S1. Two (9%) cases showed implant loosening and required revision at L5-S1 because of screw cut out. CONCLUSIONS: Properly placed pedicle screws were adequate with fusion for multilevel spinal fixations.

Outcome of surgical treatment of cervical spondylotic myelopathy: Experience in 120 patients.

OBJECTIVES: To document the outcome of spinal surgery in patients of cervical spondylotic myelopathy. METHODS: The quasi-experimental study was conducted at the Department of Spine Surgery at Combined Military in a tertiary care hospital in Rawalpindi from 2006 to 2013. A pre-designed proforma was used for each patient and records were kept a custom-built computer database. Neurik grading was used to assess neurological status preoperatively, at 6 months, 1 year and 2 years. RESULTS: There were 120 patients with a mean age of 60.08 years (range 26-82, standard deviation 13.13). Of them 108 (90%) were males and 12 (10%) females. The preoperative neurologic status was Nurick\'s grade 0 in 6 (5%) patients There were 120, I in 9 (7.5%), II in 23 (19.16%), III in 28 (23.33%) and IV in 19 (15.83%) and V in 35 (28.16%). The spine was approached anteriorly in 48 (40%) patients and posteriorly in 72 (60%). Single level was involved in 23 (19.16), two in 30 (25%), three in 22 (18.33%) and four in 45 (37.5%) cases. Anterior cervical disc excision and fusion was done in 26 (21.67%), anterior corpectomy and fusion with bone graft or a cage in 21(17.5%) cases, laminoplasty in 9 (7.5%), laminectomy with lateral mass screw fixation with reconstruction titanium plate in 37 (30.83%) or with rod 24 (20%). In 3 (2.5%) cases only decompressive laminectomy was done. At 6 months Nurick 0 was in 26 %21.67%), I in 14 (11.67), II in 17 (14.16), III in 21 (17.5), IV in 29 (24.16%) and V in 13 (10.83). At one year Nurick grade was 0 in 38 (32.67%, I in 16 (13.33%), II in 14 (11.67), III in 15 (12.5%), IV in 23 (19.16) and V in 14 (11.67%). At the end of 2 years Neurik grade was 0 in 40 (33.33%), I in 15 (12.5%), II in 13 (10.83%), III in 16 (13.33%), IV in 22 (18.33% and V in 14 (11.67%). CONCLUSIONS: Single, double and triple levels with predominantly anterior cervical spondylotic myelopathy pathology can be operated anteriorly while multi-level disease with lordotic spine should be approached posteriorly.

Surgical management of contiguous multilevel thoracolumbar tuberculous spondylitis.

INTRODUCTION: Tuberculous spondylitis (TBS) is the most common form of extra-pulmonary tuberculosis. The mainstay of TBS management is anti-tuberculous chemotherapy. Most of the patients with TBS are treated conservatively; however in some patients surgery is indicated. Most common indications for surgery include neurological deficit, deformity, instability, large abscesses and necrotic tissue mass or inadequate response to anti-tuberculous chemotherapy. The most common form of TBS involves a single motion segment of spine (two adjoining vertebrae and their intervening disc). Sometimes TBS involves more than two adjoining vertebrae, when it is called multilevel TBS. Indications for correct surgical management of multilevel TBS is not clear from literature. MATERIALS AND METHODS: We have retrospectively reviewed 87 patients operated in 10 years for multilevel TBS involving the thoracolumbar spine at our spine unit. Two types of surgeries were performed on these patients. In 57 patients, modified Hong Kong operation was performed with radical debridement, strut grafting and anterior instrumentation. In 30 patients this operation was combined with pedicle screw fixation with or without correction of kyphosis by osteotomy. Patients were followed up for correction of kyphosis, improvement in neurological deficit, pain and function. Complications were noted. On long-term follow-up (average 64 months), there was 9.34 % improvement in kyphosis angle in the modified Hong Kong group and 47.58 % improvement in the group with pedicle screw fixation and osteotomy in addition to anterior surgery (p < 0.001). Seven patients had implant failures and revision surgeries in the modified Hong Kong group. Neurological improvement, pain relief and functional outcome were the same in both groups. CONCLUSION: We conclude that pedicle screw fixation with or without a correcting osteotomy should be added in all patients with multilevel thoracolumbar tuberculous spondylitis undergoing radical debridement and anterior column reconstruction.

Tuberculosis of the craniovertebral junction.

PURPOSE: Tuberculosis (TB) of craniovertebral junction (CVJ) occurs in 1-5 % of cases of TB spondylitis. This can be a life-threatening condition due to mass effect of infective process or resultant instability. Surgical indications for TB of CVJ are not clear from literature. METHODS: We have reviewed all the patients with TB of CVJ admitted at our center between 2005 and 2010. RESULTS: There were 15 patients including 10 males and 5 females. Average age was 38 years and average duration of symptoms was 8 months. All patients were started on multidrug antituberculous chemotherapy and skull traction. Those patients who failed to respond in 4-6 weeks and had persistent instability or neurological deficit were offered surgery. Rest was treated conservatively by immobilisation or traction. All five patients who were surgically treated had occipitocervical fusion (OCF) with titanium screws and plate/rod construct combined with posterior decompression if needed. Only one patient needed anterior surgery in addition to OCF at a later stage. All patients improved neurologically whether they were treated surgically or conservatively. Only difference was that surgically treated patients had earlier pain relief, mobilisation, neurological improvement and lesser complications. CONCLUSION: We recommend that all patients with TB of CVJ with instability and neurological compromise, who fail to respond to 4-6 weeks of antituberculous chemotherapy and skull traction should be offered occipitocervical fusion with or without posterior decompression. Anterior surgery will be needed only in those few cases who do not improve neurologically after OCF.