Transpedicular vertebral body augmentation reinforced with pedicle screw fixation in fresh traumatic A2 and A3 lumbar fractures: comparison between two devices and two bone cements.

This retrospective study compares efficacy and safety of balloon kyphoplasty (BK) with calcium phosphate (Group A) versus KIVA implant with PMMA (Group B) reinforced with three vertebrae pedicle screw constructs for A2 and A3 single fresh non-osteoporotic lumbar (L1-L4) fractures in 38 consecutive age- and diagnosis-matched patient populations. Extracanal leakage of both low-viscosity PMMA and calcium phosphate (CP) as well as the following roentgenographic parameters: segmental kyphosis (SKA), anterior (AVBHr) and posterior (PVBHr) vertebral body height ratio, spinal canal encroachment (SCE) clearance, and functional outcome measures: VAS and SF-36, were recorded and compared between the two groups. All patients in both groups were followed for a minimum 26 (Group A) and 25 (Group B) months. Extracanal CP and PMMA leakage was observed in four (18 %) and three (15 %) vertebrae/patients of group A and B, respectively. Hybrid fixation improved AVBHr, SKA, SCE, but PVBHr only in group B. VAS and SF-36 improved postoperatively in the patients of both groups. Short-segment construct with the novel KIVA implant restored better than BK-fractured lumbar vertebral body, but this had no impact in functional outcome. Since there was no leakage difference between PMMA and calcium phosphate and no short-term adverse related to PMMA use were observed, we advice the use of PMMA in fresh traumatic lumbar fractures.

Less invasive reduction and fusion of fresh A2 and A 3 traumatic L 1-L 4 fractures with a novel vertebral body augmentation implant and short pedicle screw fixation and fusion.

The aim of this clinical study was to report on the efficacy in reduction and safety in PMMA leakage of a novel vertebral augmentation technique with PEEK and PMMA, together with pedicle screws in the treatment of fresh vertebral fractures in young adults. Twenty consecutive young adults aged 45 ± 11 years with fresh burst A3/AO or severely compressed A2/AO fractures underwent via a less invasive posterior approach one-staged reduction with a novel augmentation implant and PMMA plus 3-vertebrae pedicle screw fixation and fusion. Radiologic parameters as segmental kyphosis (SKA), anterior (AVBHr) and posterior vertebral body height ratio (PVBHr), spinal canal encroachment (SCE), cement leakage and functional parameters as VAS, SF-36 were measured pre- and post-operatively. Hybrid construct restored AVBHr (P < 0.000), PVBHr (P = 0.02), SKA (P = 0.015), SCE (P = 0.002) without loss of correction at an average follow-up of 17 months. PMMA leakage occurred in 3 patients (3 vertebrae) either anteriorly to the fractured vertebral body or to the adjacent disc, but in no case to the spinal canal. Two pedicle screws were malpositioned (one medially, one laterally to the pedicle at the fracture level) without neurologic sequelae. Solid posterolateral spinal fusion occurred 8-10 months post-operatively. Pre-operative VAS and SF-36 scores improved post-operatively significantly. This study showed that this novel vertebral augmentation technique using PEEK implant and PMMA reduces and stabilizes via less invasive technique A2 and A3 vertebral fractures without loss of correction and leakage to the spinal canal.

Cervical spondylodiscitis associated with oesophageal perforation: a rare complication after anterior cervical fusion.

Anterior cervical instrumented fusion is a commonly performed spinal surgery with relatively low complication rate. Especially, spinal infections are very rare and often associated with oesophageal perforation secondary to hardware migration. We present a rare complication of cervical spondylodiscitis in a 24-year-old man after an anterior cervical fusion. He had sustained a C5/C6 fracture dislocation associated with incomplete tetraplegia and he was treated by a combined staged posterior (lateral mass screws) and anterior (plate, PEEK) cervical fusion with an uneventful postoperative course with exception of light dysphagia for liquids. Three months after surgery, the patient developed fever and severe dysphagia. A barium-swallow study was indicative for oesophageal perforation, while MRI of the neck demonstrated spondylodiscitis C5/C6 accompanied by a prevertebral and epidural abscess. The treatment consisted of surgical debridement and evacuation of the abscesses, removal of the anterior spinal implants and insertion of a mesh cage with iliac bone graft. The weakened oesophagus posterior wall was enhanced with resorbable interrupted sutures and a 6-week course of antibiotics was administered. Dysphagia improved significantly while interbody fusion occurred 5 months following revision surgery. Five years postoperatively motor and sensor function had returned to normal limits. Dysphagia or deterioration of preexisted dysphagia in the late postoperative setting should be considered carefully and evaluated for oesophageal perforation and complicated spinal infection. In the case of not completed fusion, removal of the implants followed by meticulous debridement and insertion of titanium mesh cage, filled with autogenous bone graft lead to successful fusion and infection eradication.

Proximal Tibiofibular Joint Ganglion Cyst: A Rare Cause of Calf Pain.

Intramuscular cysts are rare at the proximal calf. However, their etiology is varied, making accurate diagnosis and treatment really difficult. Ganglion cyst (GC) of the proximal tibiofibular (PTF) joint is a very rare entity with an estimated prevalence of 0.76%. Intramuscular extension of the GC arising from the PTF joint is an even rarer lesion, and only a few cases have been published in the literature. Hereby, we report an infrequent case of a GC arising from the PTF joint with a sizable pedicle and intramuscular (lateral head of gastrocnemius) extension to the posterolateral aspect of the right calf.

An infected Andersson lesion presented with incomplete paraplegia in a patient with ankylosing spondylitis. A unique case report with literature review.

INTRODUCTION: A relatively rare and unknown entity in patients with ankylosing spondylitis is the Andersson lesion (AL). It was first described by Andersson in 1937 as destructive vertebral or disco-vertebral lesion of the spine without history of trauma. AL may result from inflammation or stress fracture of the rigid spine, while there is no evidence for an infectious origin. To our knowledge, only one case with an infected AL has been published many years ago; we hereby present the second case, but the first one with severe neurologic deterioration. CASE PRESENTATION: A 79-year-old male patient was presented to our emergency department and his neurological examination on admission revealed incomplete paraplegia below the Th10 level. Plain radiograms at the level of 10th thoracic vertebra revealed a lesion mimicking a severe vertebral fracture. The computed tomography confirmed the diagnosis of the AL and due to the significant local instability and the neurologic deficit, the patient underwent posterior decompression and stabilization. During decompression, we noticed purulence and extensive debridement was performed. The cultures of the Th10 pus revealed Enterococus sp, while the same pathogen was developed to urine cultures. The patient received intravenous antibiotics for 4 weeks, followed by per os antibiotic therapy. At the 18-month follow-up our patient had significant improvement of this functional status. DISCUSSION: Most studies support that inflammatory or traumatic/mechanical (pseudarthrosis) etiology are the most possible causes of Anderson lesions. Possible neurological deterioration should be investigated and demonstrates significant spinal instability. The integrity of the posterior column should be investigated, and exclusion of other concomitant lesions should be done. In cases with instability due to the fractured posterior elements, surgical intervention is mandatory. Spine surgeons should be competent to differentiate fracture from the Andersson lesion. In this rare case we highlight also that spine surgeons should obtain intraoperative cultures in cases with Andersson lesions, to exclude the minor possibility of the infectious origin of the entity and/or the possible secondary contamination of the affected area.

An Intrathoracic Meningocele in a Neurofibromatosis Type I Patient Mimicking Severe COVID-19 Disease.

Intrathoracic meningoceles (IM) are quite rare; they are commonly associated with neurofibromatosis type 1 (NF-1). We report a case of a 55-year-old lady who was admitted to our emergency department with a sore throat, mild fever, cough, and right-sided chest pain, and tested positive for coronavirus disease 2019 (COVID-19). Ιmaging revealed a meningocele in the right upper pulmonary area, attributed to her NF-1. Clinicians should be aware that patients with NF-1 can develop IM, and they should be included in the differential diagnosis of patients with an intrathoracic mass.

Late-Onset Hematoma Due to Bleeding of a Small Branch of the Lateral Circumflex Femoral Artery Following Proximal Femur Intramedullary Nailing.

Intramedullary nailing of proximal femur fracture is not deprived of complications, although vascular complications are very rare and a high index of suspicion is required for timely diagnosis. This case report describes how a late-onset hematoma formation and bleeding of a small branch of the lateral circumflex femoral artery can complicate intramedullary nailing after a pertrochanteric fracture. To the best of our knowledge, this complication has never been reported and should be considered among the possible vascular complications of intramedullary nailing. Orthopedic surgeons should be aware of the vascular complications that can occur even with late-onset presentation and even from small vessels, while administration of anticoagulants is an aggravating factor. Elderly patients with proximal femur fractures are more susceptible to vascular injury due to the structure of their vessels and the vicinity of the fracture to the arterial supply of the hip.

Tibia Tuberosity Fracture and Patellar Tendon Rupture Combination in a Pediatric Patient: Case Report and Narrative Review.

A combination of tibial tuberosity (TT) fracture (TTF) along with patellar tendon (PT) rupture (PTR) is rare. We report a 15-year-old male who presented to our ED with acute knee pain and an inability to actively extend the knee after jumping during a basketball game. Diagnosis of simultaneous PTR is crucial as it changes clinical management. It is, therefore, important to maintain a high index of suspicion for the combination of TTF and PT injury.

Initial clinical experience with a novel vertebral augmentation system for treatment of symptomatic vertebral compression fractures: a case series of 26 consecutive patients.

BACKGROUND: Minimally invasive vertebral augmentation procedures are widely used to treat vertebral compression fractures although procedural polymethylmethacrylate cement leakage remains common. We report herein our initial experience with a novel vertebral augmentation technique designed to treat symptomatic vertebral osteoporotic fractures and osteolytic metastases with minimal cement extravasation. METHODS: Forty-two vertebral fractures were identified in 26 consecutive patients (mean age 74 ± 9 years). All patients were treated with a novel percutaneous vertebral augmentation device (Kiva VCF Treatment System, Benvenue Medical, Santa Clara, CA, USA). Indications for surgery included recent (≤ 3 months) symptomatic osteoporotic vertebral fracture (n = 34) and pathologic vertebral fractures (e.g. metabolic bone disease, myeloma, metastasis) (n = 8) located between T10 and S1. Patient outcomes were evaluated pre-treatment and at 2- and 6-month follow-up visits. Postoperative cement extravasation was assessed with computed tomography. Patient-reported back pain was quantified using an 11-point numeric scale. Back-specific functional disability was self-reported with the Oswestry Disability Index on a 0 to 100% scale. RESULTS: No cases of intraoperative hypotension, respiratory disturbance, neurological deterioration, infection, or death were observed. There were 2 (4.8%) levels where anterior cement leakage was visible radiographically in patients with osteolyses. No intracanal leakage was observed. Back pain scores improved 71% (p < 0.001) from pre-treatment to the 6-month follow-up. Back function improved 56% from baseline to 6 months (p < 0.001). CONCLUSIONS: The initial clinical experience with the Kiva System demonstrated significant improvements in back pain and function with minimal and clinically insignificant procedural cement leakage.

High medium-term survivorship and durability of Zweymüller-Plus total hip arthroplasty.

BACKGROUND AND PURPOSE: The Zweymüller-Plus system (SL-Plus stem, Bicon-Plus threaded cup) for primary total hip arthroplasty (THA) was introduced in 1993, as a successor of the Alloclassic THA with a few modifications in the conical stem shape and a new biconical threaded cup with a spherical shape. The medium-term performance of this system is not well established. To better understand the potential impact these design changes have had on (1) survivorship, (2) implant stability and (3) periprosthetic osteolysis, we studied patients who underwent THA using the SL-Plus stem and Bicon-Plus. METHODS: We retrospectively reviewed the cases of 148 patients (153 hips) who underwent Zweymüller-Plus primary THA after an average of 11 years. RESULTS: With revision for aseptic failure of biological fixation as the endpoint, survivorship was 98% for the stem and 100% for the cup. Focal osteolysis was observed in 6.6% of cups and 29% of stems. Four hips (2.6%) were revised because of aseptic failure of the biologic fixation and three hips (1.95%) for deep infection. As much as 146 stems and 149 cups were evaluated to be stable. CONCLUSION: Zweymüller-Plus THA resulted in high survivorship and durability at 11 years, although the rate of osteolysis around the stem indicated polyethylene wear.

A unique cause of Gamma 3 cut-out: A case report and literature review.

Gamma 3 nail is a wide spread intramedullary device for fixation of per trochanteric fractures. Cut out of the lag screw is the most common complication of this implant. We present a 62-year-old female patient, who underwent a total hip arthroplasty following cut out of a Gamma 3 nail in the femoral neck. The cause of the cut out in our case is actually unique. Our intraoperative findings accompanied with the radiographic evaluation argue that the malposition of the set screw was the cause of failure, due to the rotational instability of femoral head-lag screw unit. We present this case with detailed description, highlighting the proper use of this specific nail and appose a brief literature review.

Pubic Bone Aplasia as an Incidental Finding in the Adult Population: Case Report and Review of the Literature.

Pubic bone aplasia is a rare finding that is either diagnosed as incidental finding or associated with various clinical syndromes. It is usually discovered in early childhood, however, there are few reported cases of late discovery during adulthood. We present a case of a 64-year-old male with unilateral superior pubic rami aplasia, discovered incidentally during workup for sustained trauma. Our patient reported treatment for unilateral hip dislocation in his early childhood and had a history of operated undescended testes ipsilaterally. This exact constellation of pubic rami aplasia, undescended testes and hip dysplasia is unique in the available literature. Even though our patient had a normal life and the pubic aplasia was discovered incidentally, it is important to always assess these patients for systemic involvement, either from the musculoskeletal system or other organs, in order to provide better treatment for them.

Late Onset Atraumatic Ceramic Head Fracture of a Hybrid Ceramic Bearings Total Hip Arthroplasty.

Ceramic head fracture is a major complication of ceramic-on-ceramic (CoC) total hip arthroplasty (THA) and though new generation ceramics have lowered the rates, although it is still a great concern. We report a case of late onset (more than 10 years after surgery) ceramic head fracture of a hybrid ceramic bearings to emphasize on its unusual clinical manifestation. Furthermore, we highlight the late onset presentation and also the rarity of this complication with this particular hybrid ceramic bearings. A relevant review of the literature revealed that hybrid ceramic bearings need to be more thoroughly studied to understand modes of their failure and to reach a consensus on how to reduce and prevent these disastrous complications.

Traumatic Spondylolisthesis of the Fourth Lumbar Vertebra Without Neurologic Deficit or Fracture of the Posterior Elements.

Acute traumatic spondylolisthesis in the lumbosacral spine is an uncommon injury. Traumatic dislocation of the fourth lumbar vertebra over the fifth lumbar vertebra (L4/L5) is extremely rare since few studies have been reported in the current literature. We report on a 53-year-old man, who had a motor vehicle accident and sustained an injury of the lumbar spine without neurological impairment. The radiographic evaluation disclosed an L4/L5 traumatic spondylolisthesis, classified as Meyerding grade III without any fracture of the posterior vertebral elements. To the best of our knowledge, this is the sixth case of L4 traumatic spondylolisthesis without concomitant fracture of the posterior vertebral elements and the third case without any neurological deficit among them. The patient underwent open reduction and posterior instrumentation. Intraoperatively, the posterior ligamentous complex, the capsules of the facet joints and also the disc were found torn, although facets, neural arch, and pedicles were intact. Following decompression and reduction of the spondylolisthesis without any neurologic complications, we performed pedicle screws and rods fixation from the third to the fifth lumbar vertebra (L3-L5). The patient had an uneventful recovery and returned to his previous activity three months after surgery. The four-year follow-up evaluation showed normal spinal alignment, successful pain-free fusion without neurologic complications. Flexion/distraction injury without simultaneous rotation at the L4/L5 segment during traffic accidents or the fall of a heavy object on the bent back accompanied with posterior ligament weakness is thought to be the probable mechanism for this type of injury. Concomitant neurologic impairment is associated with the majority of L4/L5 spondylolisthesis cases. Posterior decompression, reduction, and posterior instrumentation enhances bony fusion, improves the patient's neurologic status and restores the sagittal alignment.

Os Vesalianum Pedis in a Young Adult: A Case Report and Literature Review.

Os vesalianum pedis is a rare accessory foot ossicle. It is usually asymptomatic, however, it can be an infrequent cause of lateral foot pain. We present the case of a 19-year-old healthy male with lateral foot pain after an inversion-type injury. Initial X-rays were mistaken for fracture of the fifth metatarsal, however, a high index of suspicion for the presence of the os vesalianum led us to perform imaging of the contralateral foot; a mirror image with contralateral os vesalianum was revealed. The patient was treated conservatively and had an excellent outcome. In the context of trauma, os vesalianum must be differentiated from other causes of lateral foot pain, such as Iselin's disease, avulsion fracture of the fifth metatarsal, Jones fracture, and others. Os vesalianum pedis is characterized as a rounded ossicle, with smooth edges, surrounded by cortical bone. Prompt diagnosis is essential as it changes the management.

A Smart Technique to Remove Ruptured Inflatable Bone Tamp From the Vertebral Body in Balloon Kyphoplasty.

Accidental rupture of the inflatable bone tamp is a rare but possible complication during balloon kyphoplasty. We describe an easy and minimal invasive technique to remove this foreign body from fractured vertebra. A 62-year-old female patient with severe osteoporosis had a low energy trauma and sustained burst fracture of the 12th thoracic (Th12) vertebra. The inflated bone tamp was not possible to be fully deflated and during the maneuvers to withdraw the balloon, it was disassembled and trapped under the distal end of working cannula, remaining within the bone cavity formed by balloon. Since no standard recommendation for this complication exists in current literature, we faced the dilemma of either leaving ruptured bone tamp in situ or removing it with a more extensive approach. We decided to use an alternative minimal invasive technique and managed to remove it through the right pedicle using a small size straight pituitary rongeur forceps under biplane continuous image intensifier and neuromonitoring. Subsequently, balloon kyphoplasty (BK) was performed through the left cannula accompanied with pedicle screw fixation of the adjacent vertebrae. The patient was followed up to our outpatient department for one year without complications. This extremely rare complication during BK consists of a challenge for spine surgeons and interventional radiologists. The described technique is relatively easy, safe, minimal invasive, time-saving and avoids further complications related with trapping of foreign bodies within the vertebral body.

Horizontal (Transverse) Intraarticular Metacarpal Head Fracture in a Young Adult.

Metacarpal head fractures are rare injuries that usually occur during trauma. These fractures are classified into 10 groups, with horizontal (transverse) being the rarest type of fractures. To our knowledge, very few cases have been reported in the literature to date. Here, we present the case of a 21-year-old male who sustained multiple ipsilateral hand injuries accompanied by a horizontal (transverse) fracture of the fourth metacarpal. He underwent open reduction and fixation with Kirschner wires followed by intensive rehabilitation. He finally regained complete active range of motion and grip strength three months after the operation. However, at nine months postoperatively, he developed avascular necrosis, which was asymptomatic and did not need any intervention. Therefore, it is important to maintain a high index of suspicion for possible complications and follow patients regularly, probably even for as long as 12 months after the initial injury.

Immunologic adverse reaction associated with low-carbide metal-on-metal bearings in total hip arthroplasty.

BACKGROUND: An increased incidence of periprosthetic osteolysis, resulting in loss of biologic fixation, has been reported in contemporary THAs with low-carbide metal-on-metal compared with metal-on-polyethylene couple bearings. Although a hypersensitivity reaction attributable to Co and Cr debris is reportedly a potential cause for failure of THAs with high-carbide bearings, there are no evidence-based data for this reaction in low-carbide metal-on-metal bearings, although such hypersensitivity might be related to osteolysis. QUESTIONS/PURPOSES: We investigated whether there were differences in immunologic hypersensitivity reactions in retrievals from revised THAs with ceramic-on-polyethylene versus metal-on-metal bearing couples. PATIENTS AND METHODS: We compared newly formed capsule and periprosthetic interface membranes from revision surgery for aseptic failure from 20 patients with low-carbide bearings and 13 patients with ceramic-on-polyethylene bearings. For control tissue, we obtained samples from the hip capsule during the primary THA implantation in 13 patients with low-carbide bearings and seven with ceramic-on-polyethylene bearings. We examined the tissues with conventional histologic and immunohistochemical methods. RESULTS: Compared with tissue from the control subjects and patients with ceramic-on-polyethylene bearings, the tissues from patients with low-carbide metal-on-metal bearings were associated with (1) extensive necrosis and fibrin exudation in the newly formed hip capsule and (2) diffuse and perivascular lymphocytic infiltration of a higher degree than in the hips with ceramic-on-polyethylene bearings in conventional histologic examination, and (3) more T than B cells. CONCLUSIONS: The conventional histologic and immunohistochemical findings in tissues retrieved from failed THAs with low-carbide metal-on-metal bearings are consistent with a link between hypersensitivity and osteolysis with low-carbide bearing couples.

Factors affecting low back pain in adolescents.

STUDY DESIGN: Prospective multifactorial study on low back pain (LBP) in adolescents. BACKGROUND DATA: Most studies on LBP have focused on adults although many investigations have shown that the roots of LBP lie in adolescence. Several mechanical, physical, and behavioral factors have been associated with nonspecific LBP in adolescents. OBJECTIVE: To investigate the effect of all previously reported parameters together with psychological and psychosocial factors using advanced statistics, on LBP in adolescents aged 15 to 19 years. MATERIAL AND METHODS: Six hundred and eighty-eight students aged 16±1 years from 5 randomly selected high schools participated in this study and completed a questionnaire containing questions on daily activity, backpack carrying, psychological and psychosocial behavior. Anthropometric data as well as biplane spinal curvatures together with questionnaire results were included in the analysis using advanced statistics. RESULTS: LBP reported 41% of the participants. Generally, statistically significant correlations were found between LBP (0.002), physical activity (P<0.001), physician consultation (P=0.024), and depression (P<0.001). Sex-related differences were shown regarding LBP intensity (P=0.005) and frequency (P=0.013), stress (P<0.03), depression (P=0.005), and nervous mood (P=0.036) in favor of male students. Male adolescents had continuous energy (P=0.0258) and were calm (P=0.029) in contrast with female counterparts. DISCUSSION: LBP was sex-related and was less common in adolescents with frequent activity. Adolescent girls with stress, depressive mood, and low energy have more LBP than boys, which makes physician consultation for LBP more common in female adolescents. CONCLUSIONS: Systematic physical activity and control of psychological profile should decrease LBP frequency and intensity.

Does Wallis implant reduce adjacent segment degeneration above lumbosacral instrumented fusion?

Delayed complications following lumbar spine fusion may occur amongst which is adjacent segment degeneration (ASD). Although interspinous implants have been successfully used in spinal stenosis to authors' knowledge such implants have not been previously used to reduce ASD in instrumented lumbar fusion. This prospective controlled study was designed to investigate if the implantation of an interspinous implant cephalad to short lumbar and lumbosacral instrumented fusion could eliminate the incidence of ASD and subsequently the related re-operation rate. Groups W and C enrolled initially each 25 consecutive selected patients. Group W included patients, who received the Wallis interspinous implant in the unfused vertebral segment cephalad to instrumentation and the group C selected age-, diagnosis-, level-, and instrumentation-matched to W group patients without interspinous implant (controls). The inclusion criterion for Wallis implantation was UCLA arthritic grade UCLA grade II in the adjacent two segments cephalad to instrumentation. All patients suffered from symptomatic spinal stenosis and underwent decompression and 2-4 levels stabilization with rigid pedicle screw fixation and posterolateral fusion by a single surgeon. Lumbar lordosis, disc height (DH), segmental range of motion (ROM), and percent olisthesis in the adjacent two cephalad to instrumentation segments were measured preoperatively, and postoperatively until the final evaluation. VAS, SF-36, and Oswestry Disability Index (ODI) were used. One patient of group W developed pseudarthrosis: two patients of group C deep infection and one patient of group C ASD in the segment below instrumentation and were excluded from the final evaluation. Thus, 24 patients of group W and 21 in group C aged 65+ 13 and 64+ 11 years, respectively were included in the final analysis. The follow-up averaged 60 +/- 6 months. The instrumented levels averaged 2.5 + 1 vertebra for both groups. All 45 spines showed radiological fusion 8-12 months postoperatively. Lumbar lordosis did not change postoperatively. Postoperatively at the first cephalad adjacent segment: DH increased in the group W (P = 0.042); ROM significantly increased only in group C (ANOVA, P < 0.02); olisthesis decreased both in flexion (P = 0.0024) and extension (P = 0.012) in group W. The degeneration or deterioration of already existed ASD in the two cephalad segments was shown in 1 (4.1%) and 6 (28.6%) spines in W and C groups, respectively. Physical function (SF-36) and ODI improved postoperatively (P < 0.001), but in favour of the patients of group W (P < 0.05) at the final evaluation. Symptomatic ASD required surgical intervention was in 3 (14%) patients of group C and none in group W. ASD remains a significant problem and accounts for a big portion of revision surgery following instrumented lumbar fusion. In this series, the Wallis interspinous implant changed the natural history of ASD and saved the two cephalad adjacent unfused vertebra from fusion, while it lowered the radiographic ASD incidence until to 5 years postoperatively. Longer prospective randomized studies are necessary to prove the beneficial effect of the interspinous implant cephalad and caudal to instrumented fusion. We recommend Wallis device for UCLA degeneration I and II.