Spinal Dural Ectasia Spectrum: Management of Two Cases and Systematic Review of the Therapeutic Options.

OBJECTIVE: To describe 2 cases with pathologic expansion of lumbosacral dura mater exerting compression on lumbosacral nerves treated with placement of lumboperitoneal shunt (LPS). Although dural ectasia (DE) is asymptomatic in most cases, a systematic review of the literature was performed focusing on the management when it causes symptoms. METHODS: Pubmed/Medline and Embase databases were searched for the surgical management of DE. Both pediatric and adult patients were included. The presence of a cerebrospinal fluid leak was considered an exclusion criterion. An additional search was performed to provide a more complete picture of the DE spectrum considering meningoceles as a severe form of dural expansion. RESULTS: Differentiating DE from meningocele, only 20 patients were treated for symptomatic DE. Surgical management varied according to presentation and etiopathogenesis: blood patch or fibrin glue were attempted in case of intracranial hypotension, followed eventually by LPS or marsupialization or dura reduction in cases of failure, whereas LPS or spinal decompression were proposed in cases of radiculopathy or cauda equina syndrome. CONCLUSION: DE is a rare condition mostly associated with connective tissue disorders. The different etiopathogenesis may explain how it causes symptoms in specific conditions. Treatments should be chosen according to this and may be proposed at the appearance of symptoms since dural expansion is a self-sustained mechanism.

Superior mesenteric artery syndrome following spine surgery in idiopathic adolescent scoliosis: a systematic review.

Superior mesenteric artery syndrome (SMAS) is a rare and unpredictable complication after correction spine surgery for adolescent idiopathic scoliosis (AIS). The management of this condition is poorly investigated, with controversial outcomes. This investigation systematically reviewed current evidence on pathogenesis, risk factors, management, and outcomes of SMAS following correction spine surgery for AIS. The present systematic review was conducted according to the 2020 PRISMA statement. All the included investigations reported SMAS presentation following scoliosis correction surgery in AIS. 29 articles with 61 eligible patients were included in this review. The mean age of the patients was 15.8 ± 7.2 years. The mean weight was 45.3 ± 8.0 kg, the mean height 159.6 ± 13.6 cm, and the mean BMI 16.5 ± 2.9 kg/m2. The mean duration of the treatment for SMAS was 21.6 ± 10.3 days. The mean interval between spine surgery and symptoms of SAMS was 69 days, with high between-studies variability (3 days to 4 years). Prompt identification of risk factors and an early diagnosis are necessary to manage SMAS and reduce the risk of complications. Additional investigations are required to establish risk factors and diagnostic criteria.Level of evidence Level IV, systematic review.

Ponte osteotomies for treatment of spinal deformities: they are not all made equal.

PURPOSE: To compare surgical outcomes of Ponte's osteotomies for treatment of adolescent idiopathic scoliosis (AIS), Scheuermann's kyphosis (SK), and adult scoliosis (AdS). METHODS: We conducted a retrospective review of patients with AIS, SK, and AdIS who underwent posterior spinal instrumented fusion (PSIF) at our Institution from January 2019 to December 2022. Demographics, imaging, and intraoperative data (including number of osteotomies performed, blood losses, surgical timing, and complications) were extracted from patient charts. RESULTS: A total of 80 patients (62 AIS, 7 SK, and 11 AdS) were enrolled in the study. All patients were treated with a PSIF and a total of 506 Ponte osteotomies were performed (5.8 ± 4.1, 9.3 ± 2.4, and 7.5 ± 2.5 average osteotomies per patient in the AIS, SK, and AdS group, respectively; p = 0.045). Average time per osteotomy was 6.3 ± 1.5 min in the AIS group, and 5.8 ± 2.1 and 8.7 ± 4.0 in the SK and AdS group, respectively (p = 0.002). Blood loss was significantly smaller in the SK group (8.6 ± 9.6 ml per osteotomy) compared to AIS group (34.9 ± 23.7 ml) and AdS group (34.9 ± 32.7 ml) (p = 0.001). A total of 4 complications were observed in the AIS group (1.1%) and 2 complications in the AdS group (2.4%), but this was not statistically significant. CONCLUSIONS: Our study shows that Ponte's osteotomies are safe and effective in surgical treatment of AIS, SK, and AdS. Blood loss and execution time per osteotomy are significantly smaller in the SK group compared to AIS and AdS. No significant differences were noted in terms of complications between the three groups.

Scoliosis and rare diseases: our experience with the Prader-Willi syndrome.

INTRODUCTION: Prader-Willi syndrome (PWS) represents a difficult challenge for spine surgeons, due to the association of a structural scoliosis, with a prevalence between 15 and 86%. Conservative therapy is a viable option, but surgery is increasingly becoming the treatment of choice. METHODS: The authors reviewed a series of 15 patients affected by PWS treated at their institution between 2008 and 2023. The mean age at index treatment was 9 years and 3 months (range 1-15 years) with a prevalence of female subjects. Primary scoliotic curve ranged from 14 to 102°, and mean thoracic kyphosis was 56° (range 20-75°). Eleven patients underwent conservative treatment, while four were treated surgically. RESULTS: Mean follow-up was 5 years and 3 months (range 2-12 years). Among the 11 patients treated conservatively, only two showed improvements of the coronal curve, while the remaining nine displayed a worsening of the deformity during follow-up. Complication rate after surgery was 75%. One patient developed paraplegia after pedicle screw positioning. One patient displayed rod breakage and PJK that required revision surgery proximally. Hardware deep infection was seen in one case where it was necessary to proceed with instrumentation removal after 10 years. DISCUSSION AND CONCLUSIONS: Spine surgery represents a convincing option in patients affected by PWS, but the risks of complications are high. Correct patient selection must be the main objective, and multilevel pedicle screw fixation should be the procedure of choice. Traditional growing rod should be prudently evaluated in every single case.

Surgical limits, pitfalls, and potential solutions in kyphectomy in myelomeningocele: three cases and systematic review of the literature.

OBJECTIVES: To describe surgical treatment of 3 cases of severe and progressive thoracolumbar kyphosis in myelomeningocele and provide a systematic review of the available literature on the topic. METHODS: Medical records and pre- and post-operative imaging of 3 patients with thoracolumbar kyphosis and myelomeningocele were reviewed. A database search was performed for all manuscripts published on kyphectomy and/or surgical treatment of kyphosis in myelomeningocele. Patients' information, preoperative kyphosis angle, type of surgery, levels of surgery degrees of correction after surgery and at follow-up, and complications were reviewed for the included studies. RESULTS: Three cases underwent posterior vertebral column resection (pVCR) of 2-4 segments at the apex of the kyphosis (kyphectomy). Long instrumentation was performed with all pedicle screws constructed from the thoracic spine to the pelvis using iliac screws. According to literature review, a total of 586 children were treated for vertebral kyphosis related to myelomeningocele. At least one vertebra was excised to gain some degree of correction of the deformity. Different types of instrumentation were used over time and none of them demonstrated to be superior over the other. CONCLUSION: Surgical treatment of progressive kyphosis in myelomeningocele has evolved over the years incorporating all major advances in spinal instrumentation techniques. Certainly, the best results in terms of preservation of correction after surgery and less revision rates were obtained with long construct and screws. However, complication rate remains high with skin problems being the most common complication. The use of low-profile instrumentation remains critical for treatment of these patients.

Navigated, percutaneous, three-step technique for lumbar and sacral screw placement: a novel, minimally invasive, and maximally safe strategy.

BACKGROUND: Minimally invasive spine surgery is a field of active and intense research. Image-guided percutaneous pedicle screw (PPS) placement is a valid alternative to the standard free-hand technique, thanks to technological advancements that provide potential improvement in accuracy and safety. Herein, we describe the clinical results of a surgical technique exploiting integration of neuronavigation and intraoperative neurophysiological monitoring (IONM) for minimally invasive PPS. MATERIALS AND METHODS: An intraoperative-computed tomography (CT)-based neuronavigation system was combined with IONM in a three-step technique for PPS. Clinical and radiological data were collected to evaluate the safety and efficacy of the procedure. The accuracy of PPS placement was classified according to the Gertzbein-Robbins scale. RESULTS: A total of 230 screws were placed in 49 patients. Only two screws were misplaced (0.8%); nevertheless, no clinical sign of radiculopathy was experienced by these patients. The majority of the screws (221, 96.1%) were classified as grade A according to Gertzbein-Robbins scale, seven screws were classified as grade B, one screw was classified as grade D, and one last screw was classified as grade E. CONCLUSIONS: The proposed three-step, navigated, percutaneous procedure offers a safe and accurate alternative to traditional techniques for lumbar and sacral pedicle screw placement. Level of Evidence Level 3. Trial registration Not applicable.

Double spinal cord tethering and congenital kyphosis in a 4-year-old boy.

PURPOSE: Congenital kyphosis (CK) is an uncommon condition that develops due to a defect of formation or segmentation of one or more vertebrae during the first weeks of embryonic life and can be frequently associated with abnormalities of the spinal cord. Meningocele manqué (MM) is a rare congenital malformation consisting of intradural fibrous bands tethering the spinal cord, oftentimes in combination with a split cord malformation. The aim of this manuscript is to describe combined surgical management of a rare case of CK associated with double spinal cord tethering. STUDY DESIGN: Case report. METHODS: We report the case of a 4-year-old boy presenting with a combination of congenital kyphosis due to L2 fully segmented posterior hemivertebra and double spinal cord tethering, at the level of the filum terminale and at L1-L2 due to an intradural ventral fibrous band. RESULTS: Spinal cord detethering and L2 hemivertebra resection with kyphosis correction were achieved with a single stage procedure. Segmental kyphosis was corrected from 45° to 11° post-operatively. Apart from a transitory sensory impairment, no immediate or delayed complications were noted and, at 2 years follow-up, correction and spinal alignment were stable. CONCLUSION: To the best of our knowledge, this is the first case to report the simultaneous occurrence of congenital kyphosis and double spinal cord tethering due to MM and tethering of the filum terminale. Our case report shows that surgical correction of the deformity and spinal cord detethering can be safely and effectively achieved during the same surgical procedure.

ACUTE DESTRUCTIVE HIP SEPTIC ARTHRITIS IN A YOUNG ADULT PATIENT: CASE REPORT (v2).

The Authors describe a case of rapid right hip destructive septic arthritis in a 50-year-old male patient with no previous noteworthy medical history. Patient arrived to our attention following a one week history of right hip pain. Laboratory markers and imaging at presentation were negative. However, on a follow-up examination significant joint effusion was noted and joint tap was performed. Despite wide spectrum antibiotic therapy institution, significant joint damage was observed. This required surgical femoral head excision with antibiotic loaded spacer, followed by hip arthroplasty surgery 12 weeks afterwards. Complete healing of the infection and recovery of pain-free joint motion was noted at 1 year follow-up.

WHICH PROBLEMATICS IN THA AFTER ACETABULAR FRACTURES: EXPERIENCE OF 38 CASES.

Background: Within a timeframe of 8 years (2008-2016), 38 patients have undergone total hip replacement surgery for coxarthrosis or aseptic necrosis secondary to acetabulum fractures. Materials and Methods: The study included 27 males and 11 females between 42 and 70 years of age, all of whom came from other institutions. The follow-up period ranged between a minimum of 4.6 and a maximum of 9.7 years. Results: At the final follow-up, all patients were evaluated using the Merle D'Aubigne and Pastel model. Optimal results were found in all the cases. Three patients benefited from surgical revisitation with implant exchange following infection and one/two state reimplatation at seven, fourtheen et twenty-seven months respectively. Two patients benefited from cotyle revision due to chronic instability of the implant. Conclusions: The scope of the study was to present all the possible surgical difficulties that can come up with prosthetic implants. More particularly, hip implants after acetabulum fractures qualifies as a "difficult primary implant".

Intraoperative CT-guided navigation versus fluoroscopy for percutaneous pedicle screw placement in 192 patients: a comparative analysis.

BACKGROUND: Percutaneous pedicle screw (PPS) placement is a key step in several minimally invasive spinal surgery (MISS) procedures. Traditional technique for PPS makes use of C-arm fluoroscopy assistance (FA). More recently, newer intraoperative imaging techniques have been developed for PPS, including CT-guided navigation (CTNav). The aim of this study was to compare FA and CTNav techniques for PPS with regard to accuracy, complications, and radiation dosage. MATERIALS AND METHODS: A total of 192 patients with degenerative lumbar spondylolisthesis and canal stenosis who underwent MISS posterior fusion ± interbody fusion through transforaminal approach (TLIF) were retrospectively reviewed. Pedicle screws were placed percutaneously using either standard C-arm fluoroscopy guidance (FA group) or CT navigation (CTNav group). Intraoperative effective dose (ED, mSv) was measured. Screw placement accuracy was assessed postoperatively on a CT scan using Gertzbein and Robbins classification (grades A-E). Oswestry disability index (ODI) and visual analog scale (VAS) scores were compared in both groups before and after surgery. RESULTS: A total of 101 and 91 procedures were performed with FA (FA group) and CTNav approach (CTNav group), respectively. Median age was 61 years in both groups, and the most commonly treated level was L4-L5. Median ED received from patients was 1.504 mSv (0.494-4.406) in FA technique and 21.130 mSv (10.840-30.390) in CTNav approach (p < 0.001). Percentage of grade A and B screws was significantly higher for the CTNav group (96.4% versus 92%, p < 0.001), whereas there were 16 grade E screws in the FA group and 0 grade E screws in the CTNav group (p < 0.001). A total of seven and five complications were reported in the FA and CTNav group, respectively (p = 0.771). CONCLUSIONS: CTNav technique increases accuracy of pedicle screw placement compared with FA technique without affecting operative time. Nevertheless, no significant difference was noted in terms of reoperation rate due to screw malpositioning between CTNav and FA techniques. Radiation exposure of patients was significantly higher with CTNav technique. LEVEL OF EVIDENCE: Level 3.

Revision Surgery Using Retrograde Nail versus Replating in Nonunion Distal Femur Fracture Treated with Plate.

Articular distal femur fractures represent 4% to 6% of femur fractures. Locking compression plates (LCPs) are the main treatment option. Nevertheless, a reoperation rate of 12.9% has been reported; nonunion is reported at 4.8%, delayed union at 1.6%, and malunion at 0.6%. Treatment of nonunions can be challenging as no unanimous consensus regarding the best surgical technique has been reached. The aim of this study was to evaluate and compare two types of revision surgery as treatment of LCP-treated articular distal femoral fracture nonunion: retrograde nail or replating. A retrospective cohort study of patients admitted from January 2015 to February 2017 for nonunion of AO/OTA 33C2 fractures previously treated with a lateral LCP was conducted. Patients were treated either with intramedullary nailing (Group A) or with replating (Group B). One independent observer performed clinically and radiographically followed up at 1, 3, 6, 9, 12, 24, and 36 months after surgery. The nonunion scoring system (NUSS) was used. Nine patients were included in our study. The mean follow-up was 2 years. Five patients were treated with intramedullary nailing and four with replating. The NUSS score was 24.2 ± 6.8 in the nailing group and 37.3 ± 3 in the replating group (P=0.03). In the nailing group, radiographic consolidation was obtained in all cases. In the replating group, nonunion was found in 3 patients and failure of osteosynthesis in one patient. Therefore, four patients (Group B) underwent implant removal and retrograde femoral nailing, obtaining radiological healing. The union time was 7.6 months in the nailing group. Retrograde intramedullary nailing can be used as an effective treatment of aseptic AO-33C distal femoral nonunion following primary locking plating.

Stepwise approach for vertebral hemangioma in children: case-reports and treatment algorithm proposal.

PURPOSE: To discuss a treatment algorithm for vertebral hemangioma in children. METHODS: Vertebral hemangioma (VH) is a rare cause of low back pain in children. In most cases, VHs present as incidental findings and do not require invasive diagnostic procedure. In case of symptomatic presentation, different approaches can be used. Over the years, we have developed a treatment algorithm for VH in children based on our clinical experience. In this manuscript, we propose a stepwise approach to treatment of VHs based on tumor extension and the degree of spinal cord/nerves compression with or without neurological deficit. RESULTS: According to the proposed protocol, we discuss two cases of aggressive VH treated at our institution by a multidisciplinary team. The first case is about a young girl treated with percutaneous one-level posterior instrumentation followed by medical adjuvant therapy for an L4 "Stage 3" VH. The second case is about an 8-year-old boy with rapidly progressive myelopathy due to T11 "Stage 4" VH treated with a combined anterior and posterior surgery (i.e., posterior decompression and fusion followed by vertebrectomy and expandable cage placement) after preoperative arterial embolization. CONCLUSION: Given the lack of international guidelines and consensus with regard to treatment of VHs in children, we believe our proposal for a stepwise approach combining clinical and radiological characteristics of the lesion may help guide treatment of this condition in children.

Distal femur complex fractures in elderly patients treated with megaprosthesis: Results in a case series of 11 patients.

BACKGROUND: Surgical treatment of complex fractures of the distal femur in the elderly is controversial. Osteoporosis and pre-existent osteoarthritis are common comorbidities in the elderly which add to the need for early walking and rapid restoration of function and also pose significant obstacles to achievement of satisfactory results with standard fixation techniques. Recently, several authors have suggested that primary arthroplasty could be a viable alternative option to standard fixation techniques in selected patients with complex distal femur fractures. AIM: To present our experience with 11 cases of distal femur fractures treated with knee arthroplasty and large femoral resection in a population of patients over the age of 85. METHODS: Data from 11 consecutive patients (10 females, 1 male) presenting with acute intra-articular supracondylar or intercondylar distal femur fractures and with pre-existent primary osteoarthritis who were treated with primary knee arthroplasty were recorded. We collected standard demographic data, comorbidities and patient reported outcomes including Visual Analogical Scale (VAS), Oxford Knee Score (OKS) and Barthel's Index. Post-operative joint range of motion (ROM) and standard radiographic data were also collected. RESULTS: At a mean follow-up of 23.2 mo, all of the implants were well-positioned and osteointegrated. Furthermore, all the patients were alive and walking either independently or with walking aids. There was a marked improvement in pain (VAS 4.5 postop vs 1.9 at the last follow-up), OKS score (29.5 postop vs 36.81 at the last follow-up), ROM (96.2° postop vs 102° at the last follow-up) and restoration of pre-injury ambulatory status (average Barthel Index 77.3). The radiographic evaluations showed good restoration of the articular geometry. No deaths and no complications were recorded. CONCLUSION: In conclusion, we believe that knee megaprosthesis in the case of complex fractures of the distal femur is a valid surgical choice. This is particularly true in elderly patients with severe osteoporosis and pre-existing osteoarthritis. It is important to note that this surgery should be performed by surgeons with proven experience in prosthetic hip and knee surgery and that a scrupulous selection of the cases is completed.

A Modified Self-Growing Rod Technique for Treatment of Early-Onset Scoliosis.

Surgical treatment of early-onset scoliosis (EOS) remains challenging as no definitive surgical technique has emerged as the single best option in this varied patient population1-3. Although the available surgical techniques may differ substantially, they all share the same goals of achieving and maintaining deformity correction, allowing physiological spinal growth, and reducing the number of operations and complications. Herein, we present a modified self-growing rod technique that represents a valid alternative to the existing surgical procedures for EOS. Description: The patient is positioned prone on a radiolucent table, and the spine is prepared and draped in a standard fashion. A posterior midline skin incision is made from the upper to the lower instrumented level. Subperiosteal exposure of the spine is carried out, ensuring that capsules of the facet joints are spared. Pedicle screws are inserted bilaterally at the cranial and caudal ends of the instrumentation. Fixation with pedicle screws of at least 3 levels at the top and bottom end is usually advised; in nonambulatory patients with pelvic obliquity, caudal fixation can be extended to the pelvis with bilateral iliac screws. Sublaminar wires are positioned bilaterally at every level between the cranial and caudal ends of the instrumentation and are passed as medially as possible to avoid damage to the facet joints. Four 5-mm cobalt-chromium rods are cut, contoured, and inserted at each end of the construct. Ipsilateral rods are secured with use of sublaminar wires, making sure that they overlap over a sufficient length to allow for the remaining spinal growth. Correction of the deformity is achieved with use of a combination of cantilever maneuvers and apical translation by progressive and sequential tightening of the sublaminar wires. The wound is closed in layers over a subfascial drain. The patient is allowed free mobilization after surgery. No postoperative brace is required. Alternatives: Nonoperative alternative treatment for EOS includes serial cast immobilization and bracing4. Alternative surgical treatments include traditional growing rods5, magnetically controlled growing rods6, the vertical expandable prosthetic titanium rib-expansion technique7, and the Shilla technique8. The use of compression-based systems (i.e., staples or tether)9 or early limited fusion has also been reported by other authors. Rationale: The main advantage of our technique is that it relies on physiological spinal growth and does not require surgery or external devices for rod lengthening, which is particularly beneficial in frail patients with a neuromuscular disease in whom repeated surgery is not advised. Segmental fixation by sublaminar wires allows good control of the deformity apex during growth. Concerns regarding early fusion of the spine have not been confirmed in our mid-term follow-up study10. Expected Outcomes: This technique allows correction of the deformity and continuous spinal growth in the years following surgery. At 6.0 years postoperatively, the average main curve correction was reported to be 61% and the average pelvic obliquity correction was 69%. The spine was reported to lengthen an average of 40.9 mm (range, 14.0 to 84.0 mm) immediately postoperatively, and the T1-S1 segment was reported to continue growing at 10.5 mm/year (range, 3.6 to 16.5 mm/year) thereafter10. The most common complication is rod breakage at the thoracolumbar junction, which seems to be more common in patients with idiopathic or cerebral palsy EOS and during the pubertal growth spurt10. Important Tips: Subperiosteal exposure of the spine should be carried out, making sure to preserve facet joints in the unfused area of the spine.Achieve segmental fixation with use of sublaminar wires at every level and pedicle screws at the top and bottom ends of the instrumentation.If pelvic imbalance is present and the patient is nonambulatory, pelvic fixation with iliac screws is advised.First round correction of the deformity is achieved with a cantilever technique; correction fine-tuning can be performed by tightening sublaminar wires.Consider utilizing thicker rods in cases of idiopathic or cerebral palsy EOS. Acronyms and Abbreviations: EOS = early-onset scoliosisAP = anteroposteriorEV = end vertebraSSEP = somatosensory evoked potentialsMEP = motor evoked potentialsPJK = proximal junctional kyphosisSMA = spinal muscular atrophyCP = cerebral palsyPACU = post-anesthesia care unit.

Is vertebral stenting kyphoplasty a good choice in the treatment of osteoporotic vertebral fracture? A series of 47 patients (v2).

Background: The incidence of vertebral fragility fracture is increasing over last three decades with an essential impact on quality of life. Some devices were proposed to improve conventional kyphoplasty in the last five years, known as vertebral stenting kyphoplasty (VSK). Materials and Methods: All osteoporotic vertebral fractures (OVF) treated with VSK, single-level fracture without neurological impairment, and with more than 24 months of follow-up were included in the study. We recorded fracture types according to DGOU classification, fracture level, regional kyphosis angle (RKA), Oswestry disability index (ODI), and complications. Results: Forty-seven consecutive patients were included. RKA significantly improved from pre to postoperative values (p<0.000001) and to follow-up values (p<0.00001). A significant difference was found between preoperative RKA of (OF2+OF3) and OF4 (p<0.00001), confirmed immediately after surgery (p= 0.005425) and at last follow up (p= 0.000947). A significant difference was found in correction of RKA between (OF2+OF3) and OF4 at injury time and after treatment (p<0.00001), and it was confirmed at the last follow-up (p=0.000026). ODI showed a significant difference between (OF2+OF3) and OF4 type of fractures (p=0.038216). We recorded five complications: 2 cases of leakage without neurological impairment, two progressions of kyphosis, and one implant migration. Conclusions: VSK is an excellent and reliable option in the treatment of OVF, with good clinical results and preservation of obtained RKA at the time of treatment. However, in case of vertebral collapse with the involvement of both vertebral plates, surgeons must be aware of possible implant failure or migration. Level of Evidence: 4.

10-Year Clinical, Functional, and X-ray Follow-Up Evaluation of a Novel Posterior Percutaneous Screw-Rod Instrumentation Technique for Single-Level Pyogenic Spondylodiscitis.

Medical treatment with antibiotic therapy remains the mainstay of treatment for pyogenic spondylodiscitis (PS). Nevertheless, orthopaedic treatment is also very important in relieving pain, preventing neurological damage, and avoiding development of spinal deformities (e.g., scoliosis, kyphosis) due to spinal instability. Rigid thoracolumbosacral orthosis (TLSO) bracing is often needed in patients with PS, and average duration of treatment of 3 to 4 months. However, TLSO bracing can be poorly tolerated and limit ability of the patient to go back to a normal life. In 2004 our group developed an alternative surgical treatment to TLSO bracing by percutaneous posterior screw-rod bridge instrumentation of the infected level. This treatment allows early and free mobilization of the patients and is associated with faster recovery, lower pain scores and improved quality of life as previously reported. Herein, we report the clinical outcome of the first 3 patients who have completed the 10 years follow-up mark after the procedure. A case report is also described and details of the procedure are provided.

Stromal-like Wilms tumor cells induce human Natural Killer cell degranulation and display immunomodulatory properties towards NK cells.

The similarity of stromal-like Wilms tumor (str-WT) cells with mesenchymal stem cells (MSC), suggests their relevant role in the interplay with immune cells in the tumor microenvironment. We investigated the interaction between str-WT cells and NK cells. We observed that str-WT cells expressed some major ligands for activating and inhibitory NK cell receptors. Moreover, they expressed inhibitory checkpoint molecules involved in the negative regulation of anti-tumor immune response. The analysis of the interaction between str-WT cells and NK lymphocytes revealed that activated NK cells could efficiently degranulate upon interaction with str-WT cells. On the other hand, str-WT cells could exert potent inhibitory effects on cytokine-induced activation of NK cell proliferation and phenotype, which were mediated by the production of IDO and PGE2 inhibitory factors. Our data provide insight into the molecular interactions between str-WT cells and NK lymphocytes that may result in different outcomes possibly occurring in the WT microenvironment.

Mid-term results of a modified self-growing rod technique for the treatment of early-onset scoliosis.

AIMS: To report the mid-term results of a modified self-growing rod (SGR) technique for the treatment of idiopathic and neuromuscular early-onset scoliosis (EOS). METHODS: We carried out a retrospective analysis of 16 consecutive patients with EOS treated with an SGR construct at a single hospital between September 2008 and December 2014. General demographics and deformity variables (i.e. major Cobb angle, T1 to T12 length, T1 to S1 length, pelvic obliquity, shoulder obliquity, and C7 plumb line) were recorded preoperatively, and postoperatively at yearly follow-up. Complications and revision procedures were also recorded. Only patients with a minimum follow-up of five years after surgery were included. RESULTS: A total of 16 patients were included. Six patients had an idiopathic EOS while ten patients had a neuromuscular or syndromic EOS (seven spinal muscular atrophy (SMA) and three with cerebral palsy or a syndrome). Their mean ages at surgery were 7.1 years (SD 2.2) and 13.3 years (SD 2.6) respectively at final follow-up. The mean preoperative Cobb angle of the major curve was 66.1° (SD 8.5°) and had improved to 25.5° (SD 9.9°) at final follow-up. The T1 to S1 length increased from 289.7 mm (SD 24.9) before surgery to 330.6 mm (SD 30.4) immediately after surgery. The mean T1 to S1 and T1 to T12 growth after surgery were 64.1 mm (SD 19.9) and 47.4 mm (SD 18.8), respectively, thus accounting for a mean T1 to S1 and T1 to T12 spinal growth after surgery of 10.5 mm/year (SD 3.7) and 7.8 mm/year (SD 3.3), respectively. A total of six patients (five idiopathic EOS, one cerebral palsy EOS) had broken rods during their growth spurt but were uneventfully revised with a fusion procedure. No other complications were noted. CONCLUSION: Our data show that SGR is a safe and effective technique for the treatment of EOS in nonambulatory hypotonic patients with a neuromuscular condition. Significant spinal growth can be expected after surgery and is comparable to other published techniques for EOS. While satisfactory correction of the deformity can be achieved and maintained with this technique, a high rate of rod breakage was seen in patients with an idiopathic or cerebral palsy EOS. Cite this article: Bone Joint J 2020;102-B(11):1560-1566.

Uncorrect diagnosis of tubercolar spondylodiscitis in aggressive and bone destructive metastasis of melanoma: A case report and literature review.

Differential diagnosis of destructive osteolytic spinal lesions can be a diagnostic challenge. In this study, we described a rare case of spinal metastases from primary desmoplastic melanoma which had incorrectly been diagnosed and treated as tuberculous spondylodiscitis. An 82-year-old male patient with ongoing low back pain and a history of lumbar localized Pott's performed a lumbar spine MRI that showed osteolytic lesion with first hypothesis of spondylodiscitis L2-L3. The patient was hospitalized and cause of worsening of the lumbar pain underwent a following series of non-diagnostic CT-guided and open lumbar biopsy at L2-L3 with unsuccessful antibiotic-antitubercular therapy. A new MRI revealed a worsening of previous lesions, extension of the osteolytic lesion at the level of L1-L2 and L3-L4 with neurological impairment. The diagnosis of metastatic melanoma was obtained with surgical decompression and open posterior biopsy procedure. The case described is pathognomonic of the difficulty in detecting the correct diagnosis in front of similar clinical and radiological manifestations. The presence of a previous Pott's disease in the same involved vertebral site was of crucial importance in deflecting the correct diagnostic classification of the pathology, which was possible to ascertain only following an extensive biopsy sampling in the last surgery performed.

A rare case of tertiary syphilis spondylodiscitis of the upper cervical spine: Diagnostic and therapeutic complexity, review of literature.

Syphilis is a sexually transmitted disease caused by the spirochetes Treponema pallidum. Syphilitic spinal lesions present as erosive bone lesions often simulating spondylodiscitis or cancer. In this article we describe a rare case of cervical osteolytic lesion from tertiary syphilis. A 45-year-old male with axial neck pain, without fever presented with an isolated osteolytic lesion at C3. Tuberculous spondylitis was initially suspected. A new CT and contrast enhanced MRI of the cervical spine and of the neck showed an extention of the bone lesion at C3 with bilateral lymphadenomegaly. To confirm the diagnosis of tertiary syphilis, US-guided biopsy of the lymph nodes was performed. The patient was treated with i.m. benzylpenicillin 2.4 MIU and the follow-up showed clinical and radiological resolution of the condition. The aim of this case report is to raise awareness of tertiary syphilis in the differential diagnosis of lytic lesions of the spine among the spinal community.