Surgical Approach Algorithm in the Treatment of Lumbar and Thoracolumbar Pyogenic Spondylodiscitis.

AIM: To reveal the efficiency of our surgical approach algorithm in patients with thoracolumbar pyogenic spondylodiscitis based on the involvement of anatomical structure. MATERIAL AND METHODS: Data of patients who underwent debridement or stabilization surgery for thoracolumbar pyogenic spondylodiscitis from January 2012 to December 2018 were reviewed. Lumbar and thoracolumbar spondylodiscitis was classified into four stages based on anatomical involvement. Infection was limited in the disc space, which had not spread to the endplate in stage 1 and progressed as two-level corpus involvement of > 1/2 of vertebral corpus bony destruction or as failed treatment in stage 4. Neurological function was evaluated using Frankel's grading postoperatively. Functional outcomes were categorized according to the Kirkaldy-Willis criteria. RESULTS: The study included 39 patients, with a mean age of 58.2 years. Of these patients, 10, 12, 13, and 4 had stages 1, 2, 3, and 4 spondylodiscitis, respectively. The mean follow-up period was 60.2 (12-184) months. All patients with stages 1 and 2 spondylodiscitis had grade E injury; 2 and 10 patients with stage 3 had grades D and E injuries, respectively; two patients with stage 4 had grade D injury and two had grade E injury at the last follow-up. Moreover, 100%, 84.6%, and 50% of the patients with stages 1 and 2, 3, and 4 spondylodiscitis achieved good or excellent results, respectively. CONCLUSION: The choice of the surgical technique depends on the destruction severity at the adjacent vertebral corpus. Surgical staging system for spondylodiscitis is useful and reliable in choosing appropriate surgical techniques.

Spinal fusion in facioscapulohumeral dystrophy for hyperlordosis: A case report.

RATIONALE: Facioscapulohumeral muscular dystrophy (FSHD) is the third most common muscular dystrophy, which is associated with facial, shoulder girdle, and paraspinal muscle atrophy. Most of the patients develop hypokyphosis and hyperlordosis in the course of the disease, to preserve standing posture. Corrective fusion is contraindicated in these patients as the surgery results with loss of compensatory hyperlordosis and leads to loss of trunk balance while standing. Although spinal fusion in neuromuscular scoliosis is a known treatment option, there are no studies in the literature on the spinal fusion of this specific patient group. PATIENT CONCERNS: In this case report we have presented a 66-year-old woman, who was admitted with back and abdominal pain, inability to sit straight, abdominal discomfort, and numbness in the lower extremities after prolonged sitting. DIAGNOSES: The patient developed severe hyperlordosis causing intra-abdominal disorders, radicular symptoms, and sitting discomfort due to FSHD. INTERVENTIONS: The patient underwent T2-S1 fusion and successful fusion was achieved. OUTCOMES: Individualized Neuromuscular Quality of Life Questionnaire (INQoL) was used to assess preoperative and 3 years postoperative functional outcomes. All domains and total score improved at the end of the follow-up period and successful fusion was verified radiologically. LESSONS: This case suggests that spinal fusion may provide functional improvement in carefully selected patient groups. Patient stratification considering spinal disability is required for further studies in this specific indication.

Posterior Approach Alone Versus Combined Anterior and Posterior Approach in the Management of Vertebral Tuberculosis.

AIM: To compare posterior surgery alone versus combined anterior and posterior surgery for the management of spinal tuberculosis. MATERIAL AND METHODS: Data from 31 consecutive patients who underwent surgery for spinal tuberculosis were analyzed retrospectively. Patients were divided into two groups as group A (posterior surgery alone) or group B (combined anterior and posterior surgery), and groups were compared in terms of invasiveness of the procedure, spinal deformity, fusion, neurological status, and postoperative complications. RESULTS: Group A included 16 patients (mean age: 56 years, range: 29-75) with a mean follow-up period of 29 months (range 12-60) while group B included 15 patients (mean age: 60 years, range: 35-73) with a mean follow-up period of 28 months (range 12-60). Procedurally, average operation time and mean length of hospitalization were shorter, and mean blood loss was lower in group A (p < 0.05) compared to group B. Postoperative bone fusion took significantly (p < 0.05) longer time in group A (10.5 ± 2.1 months)than in group B (9.3 ± 3.1 months), and all patients with a neurological deficit recovered completely during the postoperative period. No significant differences were observed between two groups with respect to postoperative complications (p > 0.05). CONCLUSION: Combined anterior-posterior surgery may not be required for treating vertebral tuberculosis as posterior surgery alone appears to be sufficient.

Palliative Posterior Instrumentation versus Corpectomy with Cage Reconstruction Treatment for Thoracolumbar Pathological Fracture.

STUDY DESIGN: Single-center, retrospective cohort study. PURPOSE: We aimed to evaluate and compare the clinical outcomes in patients who underwent palliative posterior instrumentation (PPI) versus those who underwent corpectomy with cage reconstruction (CCR) for thoracolumbar pathological fracture. OVERVIEW OF LITERATURE: The requirement for anterior support after corpectomy has been emphasized in the treatment of pathological fractures of the vertebrae. However, for patients with a relatively short life expectancy, anterior reconstruction may not be required and posterior instrumentation alone may provide adequate stabilization. METHODS: A total of 43 patients with metastases of the thoracolumbar spine underwent surgery in the department of orthopaedic and traumatology of Istanbul University Faculty of Medicine from 2003 to 2016. Surgical outcomes were assessed on the basis of survival status, pre- and postoperative pain, complication rate, and operation time. RESULTS: PPI was performed for 22 patients and CCR was performed for 21 patients. In the PPI group, the follow-up period of the five surviving patients was 32 months. The remaining 17 patients died with a mean survival duration of 12.3 months postoperatively. In the CCR group, the five surviving patients were followed up for an average of 14.1 months. The remaining 16 patients died with a mean survival duration of 18.7 months postoperatively. No statistically significant difference (p=0.812) was noted in the survival duration. The Visual Analog Scale scores of the patients were significantly reduced after both procedures, with no significant difference noted on the basis of the type of surgical intervention (p>0.05). The complication rate in the CCR group (33.3%) was higher compared with that in the PPI group (22.7%); however, this difference was not noted to be statistically significant (p=0.379). The average operation time in the PPI group (149 minutes) was significantly shorter (p=0.04) than that in the CCR group (192 minutes). CONCLUSIONS: The PPI technique can decompress the tumor for functional improvement and can stabilize the spinal structure to provide pain relief.

A multidisciplinary clinical approach to facioscapulohumeral muscular dystrophy.

BACKGROUND AND PURPOSE: Impaired shoulder function is the most disabling problem for daily life of Fascioscapulohumeral muscular dystrophy (FSHD) patients. Scapulothoracic arthrodesis can give a high impact to the functionality of patients. Here we report our experience with scapulothoracic arthrodesis and spinal stenosis surgery in FSHD patients. METHODS: 32 FSHD patients were collected between 2015-2016. Demographical and clinical features were documented. All the patients were neurologically examined. The Medical Research Council (MRC) and the FSHD evaluation scale was used to assess muscle involvement1. Scapulothoracic arthrodesis and spinal stenosis surgeries were performed in eligible patients. RESULTS: There were 16 male and 16 female (mean age 34.4 years; range 12-73) patients. 6 shoulders of 4 patients aged between 2132 years underwent scapulothoracic arthrodesis (two bilateral, one left and one right sided). Only one 63 years old female patient with severe hyperlordosis had spinal fusion surgery. All of the patients undergoing these corrective surgeries have better functionality in daily life, as well as superior shoulder elevation. CONCLUSION: Until the emergence and clinical use of novel therapeutics, surgical interventions are indicated in carefully selected patients with FSHD to improve arm movements, the posture and the quality of life of patients in general. Scapulothorosic arthrodesis is a management with good clinical results and patient satisfaction. In selected cases other corrective orthopedic surgeries like spinal fusion may also be considered.

Selection of distal fusion level in terms of distal junctional kyphosis in Scheuermann kyphosis. A comparison of 3 methods.

OBJECTIVE: The aim of this study was to investigate the effect of distal fusion level selection on the distal junctional kyphosis (DJK) in Scheuermann kyphosis (SK) patients who underwent posterior fusion. METHODS: Thirty-nine SK patients who underwent posterior fusion with a minimum follow-up of 3 years were retrospectively evaluated. According to the distal fusion level, patients were divided into 3 groups. Group S; lowest instrumented vertebra (LIV) was the sagittal stable vertebra (SSV), Group F; LIV was the first lordotic vertebra (FLV) and, Group L; LIV was the lower end vertebra (LEV). DJK was evaluated according to distal level selection. RESULTS: Thoracic kyphosis (TK) decreased from 73.3° (SD ± 7.9°) to 39° (SD ± 8.7°) postoperatively, with a mean correction rate of 46% (SD ± 13) (p < 0.0001). In 11 patients, FLV and SSV was the same vertebra. In remaining 28 patients, 10 patients were in Group S, 15 patients were in Group F and 3 patients were in Group L. In Group S, none of them developed DJK, however, DJK was observed 9 of 15 patients in Group F. DJK was developed in all cases in Group L. There is a statistically higher risk for developing DJK when FLV or LEV was selected as LIV (p < 0.05). CONCLUSION: Selecting SSV for the distal fusion level has been found to be effective for preventing DJK. Selecting distal fusion level proximal to SSV will increase the risk of DJK which may become symptomatic and require revision surgery. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Effect of growing rod on sagittal and spinopelvic parameters in early-onset scoliosis patients.

Growing rod is a commonly used surgery for early-onset scoliosis (EOS). However, the effect of growing-rod lengthening on the spinopelvic alignment is unclear. In this study, 21 EOS patients treated by growing rod were evaluated retrospectively and thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI) , sacral slope (SS), pelvic tilt (PT), and sagittal vertical axis (SVA) were measured. Preoperatively, the mean TK, LL, PI, PT, SS, and SVA were 27.4°, 35.2°, 43.8°, 7.5°, 33.8°, and 47.7 mm respectively. After the last lengthening, TK, LL, PI, PT, SS, and SVA were 28.3°, 28.06°, 41.4°, 7°, 5.2°, and 42.6 mm, respectively. The sagittal plane parameters in our EOS patients were not significantly altered during the lengthening period.

The efficacy of cell saver method in the surgical treatment of adolescent idiopathic scoliosis.

OBJECTIVE: The aim of the study was to evaluate the efficacy of the intraoperative blood salvage cell saver method for allogeneic blood transfusion in the surgical treatment of adolescent idiopathic scoliosis with pedicle screw and rod combination. METHODS: The study included 33 patients (5 males and 28 females) who underwent surgery due to adolescent idiopathic scoliosis. Patients were divided into 2 groups; 16 patients (mean age: 17.1±3.9 years) in Group A were operated using the cell saver (Medtronic Autolog; autologous cell saver machine) method and the 17 patients (mean age 18.7±6.8 years) in Group B (control group) were treated without cell saver. The Cobb angle, levels of pedicle fixation, operation time, postoperative bleeding, hemoglobin change, allogeneic blood replacement and the amount of autologous erythrocytes were recorded. RESULTS: Mean level of pedicle fixation was 12.9±1.54 vertebra using a mean of 21.1±3.21 screws in Group A and 12.8±1.47 vertebra using 18.7±3.59 screws in Group B (p>005). The mean operation time was 224 (Group A: 228±58; Group B: 221±60) minutes. There were no statistically significant differences in the demographic characteristics of both groups (p>0.05). The preoperative mean hemoglobin levels were 12.2±1.47 mg/dl in Group A and 13.1±1.56 mg/dl in Group B. Postoperative mean hemoglobin level was 11.3±1.62 mg/dl in Group A and 9.86±0.93 mg/dl in Group B (p=0.004). The mean amount of autologous erythrocyte replacement was 284±139 ml. The mean postoperative bleeding was 834±253 ml in Group A and 759±380 ml in Group B (p>0.05). The mean allogeneic blood replacement was 1.88±0.88 units in Group A and 1.94±1.34 in Group B (p>0.05). CONCLUSION: Autologous erythrocyte replacement was possible using the cell saver method. However, there was no decrement in allogeneic blood replacement using cell saver in the surgical treatment of adolescent idiopathic scoliosis.

Growing rod instrumentation in the treatment of early onset scoliosis.

The goal of the treatment of early onset scoliosis (EOS) is correction of the deformity while still allowing for spinal growth. The aim of this study was to determine the safety and effectiveness of the single and dual growing rod techniques and which technique was the most effective in the management of EOS respectively. From 2003 to 2009, 23 patients underwent single (15) or dual (8) growing rod procedures using a pedicle screw construct and tandem connectors. The etiology of the patients' spinal deformities were as follows; infantile, juvenile idiopathic, congenital and neuromuscular. Clinical evaluation included age, sex, diagnosis, follow-up, number and frequency of lengthenings, and complications. Radiographic evaluation included measured changes in Cobb angle, kyphosis, lordosis, frontal and sagittal balance. Overall 46 lengthening procedures were performed, the average number of lengthening procedures being 2.1 +/- 1.14 per patient. The average time between two lengthening procedures was 13 (2-28) months. Average follow-up time was 40.8 +/- 20.6 months.The mean coronal Cobb angle was improved from 64.8° +/- 16.6° to 39.7°+/- 16.4°.Statistically, at the final follow-up, early postoperative measurements in the coronal plane were better in the dual growing rod group than in the single rod group. Nine patients underwent fusion surgery. Their mean age was 11 (10-14) years, with a follow-up of 34.6 (14-54) months. The mean Cobb angle before fusion was 58.7° (40°-75°). There were 0.9 complications per patient in all groups, 0.38 in the dual rod and 1.2 in the single rod group, respectively. Dual growing rods result in better deformity correction and stability of correction with an acceptable complication rate.

Surgical treatment of primary tumors of the sacrum.

Twenty-two patients with primary tumors of the sacrum were surgically treated between 1983 and 1997. Seventeen male and 5 female patients were followed up for a mean of 53.6 months (range 12-203 months). The histopathologic diagnoses were giant cell tumor (GCT) in 7 patients, chordoma in 4 patients, aneurysmal bone tumor in 3 patients, chondrosarcoma in 2 patients, osteoblastoma in 2 patients, synovial sarcoma in 2 patients, Ewing's sarcoma in 1 patient, and simple bone cyst in 1 patient. Currettage and thermo- or chemocauterization was applied to 8 patients, a subtotal sacrectomy was done in 11 patients, and total sacrectomy and lumbopelvic stabilization was done in 3 patients. The surgical margins were wide in all patients with GCT. The surgical margins were wide in 3 patients and wide contaminated in 1 patient with chordoma. The 2 patients with chondrosarcoma had high sacral lesions and were managed with total sacrectomy and lumbopelvic fixation. The surgical margin was wide in 1 patient and wide contaminated in the other, who relapsed locally and systemically in the 30th postoperative month. Three patients with aggressive aneurysmal bone cyst and 1 patient with simple bone cyst were managed by curettage and thorough debridement. One patient with low sacral Ewing sarcoma was managed by subtotal sacrectomy with wide margins. The two osteoblastomas were localized to the posterior elements of the sacrum. None of the patients relapsed. Most of the tumors of the sacrum are benign aggressive lesions or low grade malignancies. Intralesional resections in the form of curettage, with the addition of chemo- or thermocauterization, provide a complete cure for benign lesions. In contrast, wide resections are necessary for complete disease control in radio- and chemoresistant malignancies. Nerve root dissection should be performed in order to achieve wide margins.

Thoracolumbar flexion-distraction injuries combined with vertebral body fractures.

Surgery was performed on 25 patients with combination injuries (flexion-distraction injury plus vertebral body fracture): 8 patients with anterior-column failure (compression) and 17 patients with anterior-column plus middle-column failure (burst). Patients with compression received posterior instrumentation and underwent fusion; patients with burst received posterior instrumentation and later underwent anterior decompression and fusion. Eleven patients in the burst group had a neurologic deficit. Single dural tears were discovered in 7 patients during the posterior-instrumentation procedure. By the end of the follow-up period (mean, 34.4 months; range, 18-76 months), neither implant failure nor loss of correction had occurred. Combined mechanisms may go unrecognized and thereby result in increased morbidity and inappropriate treatment. Proper evaluation of the posterior elements is of utmost importance for the diagnosis of flexion-distraction injuries with vertebral body fractures. After diagnosis, treatment should be started with a posterior procedure.

Three-stage surgery in the management of severe rigid angular kyphosis.

There are conflicting data regarding the management of rigid kyphosis. None of the currently known techniques can completely correct severe kyphosis without resulting in residual deformity. Seven patients with local kyphosis exceeding 60 degrees were operated on to achieve complete correction of the deformity. The surgery consisted of total spondylectomy of the deformed vertebra and simultaneous application of compression-distraction forces to this area. The operation included three stages: The initial stage includes resection of posterior spinal elements and temporary fixation. In the second stage, an anterior corpectomy is performed to conclude the resection, and simultaneous antero-posterior correction is obtained. The final stage includes another posterior procedure to achieve a precise correction and to correct any compensatory curves. All patients were operated on using this technique in a single session. The mean preoperative and postoperative kyphosis angles were 76.1 degrees (range, 65 degrees -92 degrees) and 6 degrees (range, 0 degrees -13 degrees), respectively. Complete bony fusion was achieved after a mean follow-up period of 38 months (range, 26-52 months) without any neurological sequelae or significant loss of correction.

Metastatic spinal neurofibrosarcoma.

Neurofibrosarcomas are rare tumors usually arising in somatic soft tissues or peripheral nerves. Four cases of metastatic neurofibrosarcoma to the spine have been reported before. The current case is unusual because of the presence of two distinct, metachronous spinal metastasis and lung metastasis. A 30-year-old woman with neurofibromatosis and a history of previous neurofibrosarcoma resection presented with back pain. Radiologic evaluation revealed a lytic lesion of the eleventh thoracic vertebra. A transthoracal corpectomy, reconstruction by Harms' cage and posterior instrumentation, and fusion were carried out. After the completion of adjuvant chemotherapy, a solitary pulmonary nodule was detected. Shortly after resection of the metastatic pulmonary nodule, the patient complained of acute onset low-back pain. Radiologic assessment revealed another lytic lesion in the L5 vertebra after 6 months. Again, a corpectomy, anterior and posterior instrumentation, and fusion were carried out. Eight months after the second spinal resection, another solitary pulmonary metastasis was diagnosed and resected. The patient's health status suddenly deteriorated 26 months after the initial spinal metastatectomy, and she died. Though local control can be achieved in more than 80% of the patients with neurofibrosarcoma by wide surgical resection followed by adjuvant chemo- and radiotherapy, most patients die of systemic metastasis. The current patient survived 50 months after the initial resection of a forearm neurofibrosarcoma. Despite achieving local control, she died due to systemic recurrence. Prolonged survival with the help of chemo- and radiotherapy justifies our aggressive surgical strategy for the treatment of spinal metastasis in order to achieve neurologic cure and spinal stability.