Abra-ka-diskus: Vanishing Calcified Herniated Thoracic Disk.

Herniated thoracic disk has an incidence of 1/1 million. Treatment options for a calcified herniated disk include conservative management or diskectomy with or without fusion. We describe a patient who presented a year ago with a 5-month history of back pain, thoracic radiculopathy, and normal physical examination. Imaging revealed a giant calcified herniated thoracic disk at T10-T11. She underwent epidural steroid injections and chiropractic manipulation. Imaging obtained at 1-year follow-up showed near-complete resorption of the calcified thoracic disk.

[Robot-assisted PVP for the treatment of osteoporotic fractures of the upper thoracic vertebra].

OBJECTIVE: To investigate the clinical effect of "Tianji" orthopedic robot-assisted percutaneous vertebro plasty(PVP) surgery in the treatment of upper thoracic osteoporotic fracture. METHODS: A retrospective analysis was performed on 32 patients with upper thoracic osteoporotic fracture who underwent PVP surgery in Shenzhen Hospital of Traditional Chinese Medicine from August 2016 to June 2022. There were 8 males and 24 females, ranging in age from 58 to 90 years old, with a mean of (67.75±12.27) years old. Fifteen patients were treated with robot-assisted PVP surgery (robot group), including 3 males and 12 females, with an average age of (68.5±10.3) years. Fracture location:1 case of T2 fracture, 1 case of T3 fracture, 3 cases of T4 fracture, 3 cases of T5 fracture, and 7 cases of T6 fracture. The follow-up period ranged from 1.0 to 3.0 months, with a mean of (1.6±0.7) months. Seventeen patients underwent routine PVP surgery (conventional group), including 5 males and 12 females, with an average age of (66.8±11.6) years old. Fracture location:1 case of T1 fracture, 5 cases of T4 fracture, 2 cases of T5 fracture and 9 cases of T6 fracture. The follow-up period ranged from 0.5 to 4.0 months, with a mean of (1.5±0.6) months. Preoperative and postoperative visual analogue scale(VAS) and Oswestry disability index(ODI) scores were compared between the two groups, and the number of punctures, perspective times, operation time, intraoperative blood loss, bone cement distribution, bone cement leakage, and intraoperative radiation dose were compared between the two groups. RESULTS: Number of punctures times, perspective times, operation time, intraoperative blood loss, bone cement distribution, bone cement leakage and intraoperative radiation dose in the robot group were all significantly better than those in the conventional group(P<0.05). VAS of 2.03±0.05 and ODI of (22.16±4.03) % in the robot group were significantly better than those of the robot group before surgery, which were (8.67±0.25) score and (79.40±7.72)%(t=100.869, P<0.001;t=25.456, P<0.001). VAS of 2.17±0.13 and ODI of (23.88±6.15)% in the conventional group were significantly better than those before surgery, which were (8.73±0.18) score and (80.01±7.59)%(t=121.816, P<0.001;t=23.691, P<0.001). There was no significant difference in VAS and ODI between the two groups after operation (t=-3.917, P=0.476;t=-0.922, P=0.364). CONCLUSION: Robot-assisted PVP in the treatment of upper thoracic osteoporotic fractures can further improve surgical safety, reduce bone cement leakage, and achieve satisfactory clinical efficacy.

Mini-open Pedicle Subtraction Osteotomy versus Standard Posterior Approach for Ankylosing Spondylitis-related Spinal Kyphosis: A Comparative Study.

OBJECTIVE: Surgical strategy for spinal kyphosis in patients with ankylosing spondylitis (AS) has been challenging. Pedicle subtraction osteotomy (PSO) through a minimally invasive (MI) approach has been developed with promising clinical outcomes. We aimed to compare the effectiveness and safety of PSO via an MI approach and a standard posterior approach (SPA) for treating AS-related spinal kyphosis. METHODS: A total of 41 patients with AS-related spinal kyphosis who underwent PSO through an MI approach (MI surgery [MIS] group: n = 25) or SPA (SPA group: n = 16) between January 2015 and July 2020 were retrospectively included. Spinopelvic parameters were evaluated before the surgery, immediately after the surgery, and at the 2-year follow-up. Clinical data including operative time, estimated blood loss, blood transfusion, level of fusion, incision length, bed rest period, length of hospitalization, and surgical complications were compared between the two groups. The Scoliosis Research Society outcomes instrument-22 (SRS-22) was administered to assess patients' quality of life at the latest follow-up. Comparisons between the two groups were performed using independent sample t-test or Chi-square test. RESULTS: Characteristics and baseline kyphosis of the two groups were matched. At the 2-year follow-up, in the MIS group, the average correction values of the sagittal vertical axis and global kyphosis (GK) were 9.5 cm and 44.3°, respectively. Compared with the SPA group, the MIS group had similar correction values and correction losses after surgery. No obvious differences were observed in any radiographic parameters, except for GK, immediately after surgery and at the 2-year follow-up between the two groups (p > 0.05). The MIS group had a significantly shorter operative time, lesser blood loss, lesser transfusion volume, shorter fusion level, and lesser time to mobilization than did the SPA group. Higher average functional activity scores of SRS-22 were obtained in the MIS group than in the SPA group. CONCLUSION: Mini-open PSO may be an effective alternative to the SPA for treating AS-related spinal kyphosis, with comparable correction effect, lesser surgical trauma and faster recovery. This comparative study may provide valuable guidance for surgical decision-making and patient counseling.

Can anterior vertebral body tethering provide superior range of motion outcomes compared to posterior spinal fusion in adolescent idiopathic scoliosis? A systematic review.

PURPOSE: Anterior vertebral body tethering (AVBT) was introduced as a fusionless alternative to treating adolescent idiopathic scoliosis (AIS) while preserving range of motion (ROM). This is the first systematic review to compare the ROM outcomes between AVBT and PSF in treating AIS. METHODS: We conducted a comprehensive search on PubMed, EMBASE, MEDLINE, and Cochrane Library. Inclusion criteria were patients with AIS treated with AVBT or PSF or both, and clearly defined ROM outcomes; exclusion criteria were scoliosis other than AIS, biomechanical or cadaveric studies, non-English publications, case reports, conference summaries, unpublished literature, commentaries, and reviews. Primary outcome was ROM. Secondary outcomes included Cobb angle correction, quality of life (QOL), complications, and muscle strength and endurance. RESULTS: Twelve studies were included in this review. We found moderate evidence to support that AVBT results in superior ROM outcomes than PSF while achieving comparable Cobb angle correction with low evidence. The comparison of QOL outcomes between AVBT and PSF remained inconclusive. In addition to the complications noted conventionally in PSF, AVBT could result in over-correction and distal adding-on. We also found very low evidence to support that AIS patients treated with AVBT have superior muscle strength and endurance when compared to those treated with PSF. CONCLUSIONS: AVBT provides better preservation of ROM and muscle strength postoperatively when compared with PSF, while achieving comparable curve correction. Future studies should explore the spinal growth trajectory to determine the window of opportunity for AVBT in AIS.

Do hypokyphotic adolescent idiopathic scoliosis patients treated with Ponte osteotomy obtain a better clinical efficacy? A preliminary retrospective study.

STUDY DESIGN: A retrospective case-control study. OBJECTIVE: To evaluate whether Ponte osteotomy improves thoracic kyphosis and to determine its clinical efficacy in hypokyphotic adolescent idiopathic scoliosis (AIS). METHODS: Eighty consecutive Lenke type 1 AIS patients with hypokyphotic curves who underwent posterior spinal fusion by one spine surgeon at a single institution were recruited. According to whether Ponte osteotomy was performed, the patients were divided into two groups. The preoperative, immediate, one-year postoperative, and two-year postoperative radiographs were analyzed. The demographic characteristics, surgical information, radiographic parameters, Scoliosis Research Societye-22 (SRS-22) questionnaire, and complications were compared. RESULTS: The sagittal alignment and coronal alignment were both improved in the Ponte group and the control group postoperatively. There was no significant difference in the preoperative parameters between the two groups, except the TL/L, CB, and LL. Significant differences were found in the MT (15.18° ± 2.84° vs. 20.33° ± 3.75°, P < 0.001) and TK (24.23° ± 2.71° vs. 19.93° ± 2.38°, P < 0.001) at the two-year follow-up. The Ponte group had a longer operation time and more intraoperative blood loss. No significant difference was observed between the groups in the SRS-22 scores at the final follow-up. CONCLUSIONS: Ponte osteotomy could obtain better coronal correction and sagittal contour restoration in AIS patients with hypokyphosis. However, Ponte osteotomies might lead to more intraoperative blood loss and longer operation time. Moreover, no discrepancy was found in the postoperative health-related quality of life of the included patients. Therefore, we considered that the Ponte osteotomy may be an alternative method to restore the desired thoracic kyphosis, which needs further study.

Safety of early postoperative hydrotherapy in dogs undergoing thoracolumbar hemilaminectomy.

OBJECTIVES: Hydrotherapy is a common part of the postoperative care after surgical treatment of thoracolumbar intervertebral disc extrusion in dogs. There are currently no guidelines on when to commence hydrotherapy after surgery. Early hydrotherapy may be associated with an increased risk of postoperative complications including surgical site infection and neurological deterioration. The goal of this study was to report the prevalence and types of postoperative complications in dogs receiving early hydrotherapy. MATERIALS AND METHODS: Eighty-three dogs commencing hydrotherapy within 5 days after surgical treatment for thoracolumbar intervertebral disc extrusion were included in a retrospective descriptive study. All postoperative complications were recorded. RESULTS: Ten minor and 16 major complications were recorded in a total of 26 dogs. The majority of recorded complications were unlikely, but not excluded to be, caused by the initiation time of hydrotherapy. One dog developed a surgical site infection and one dog had a confirmed further extrusion of the originally operated intervertebral disc, which may have been influenced by early initiation of hydrotherapy. CLINICAL SIGNIFICANCE: Early hydrotherapy is possibly associated with occurrence of postoperative complications. Associations between the reported complications and early hydrotherapy, and possible benefits of early hydrotherapy, need to be further investigated before early initiation of hydrotherapy can be recommended.

Fully Endoscopic 360° Decompression Surgery for Thoracic Spinal Stenosis: Technical Note and Report of 8 Cases.

BACKGROUND: Surgical options for treating thoracic spinal cord compression that results from circumferential stenosis typically involve instrumented fusion procedures. The authors present here an outpatient, awake, endoscopic surgical option for treating thoracic stenosis that avoids fusion. OBJECTIVES: To evaluate the outcome and safety of combining fully endoscopic transforaminal and posterior approaches for ventral and dorsal decompression of thoracic spinal stenosis. STUDY DESIGN: Retrospective case review. SETTING: Single-center acute-care hospital. METHODS: Eight patients with single-level, significant stenosis of the thoracic spinal canal were treated with fully endoscopic transforaminal and posterior approaches to achieve 360° ventral and dorsal decompression. Patients were followed up to 30 months postoperatively. Axial back pain was measured by the Visual Analog Scale (VAS) score, and paired Student t-test was used for statistical analysis. RESULTS: Successful decompression was achieved in all 8 patients. All surgeries were performed as outpatient procedures under local anesthesia with intravenous (IV) sedation. There were no intraoperative dura tears, spinal cord or nerve root injury, postoperative infections, or cases of iatrogenic-induced segmental instability. All patients had significant improvement with VAS scores significantly lower postoperatively. LIMITATIONS: Small case series evaluated retrospectively with 15-month average follow-up. CONCLUSIONS: Combining fully endoscopic transforaminal and posterior approaches for both ventral and dorsal decompression under local anesthesia with IV sedation is an effective and safe minimally invasive surgical treatment for thoracic spinal stenosis.

Use of acupuncture as adjuvant analgesic technique in dogs undergoing thoracolumbar hemilaminectomy.

The aim of this study was to investigate the analgesic efficacy of a preoperative acupuncture treatment in 24 client-owned dogs undergoing thoracolumbar hemilaminectomy. Dogs were randomly assigned to either group A (Acupuncture) or group C (Control). Before skin incision, group A was treated with acupuncture, performed under general anaesthesia for 30 min. Rescue intraoperative fentanyl was administered following a 20% increase in cardiovascular parameters compared to baseline values, measured before incision. An observer masked to the treatment assessed pain, pre- and postoperatively, with the Glasgow (GCPS), the Colorado (CPS) pain scales and a Visual Analogue Scale (VAS); additionally, the mechanical thresholds (MT) were measured with the Electronic von Frey Anaesthesiometer (EVF) at four points located near the herniated disc. The groups were compared with respect to intraoperative cardiovascular and respiratory variables, rescue fentanyl administered in total and at different surgical events (first incision [FI], drilling [DR], disc removal [RE] and skin suturing [ST]), and pre- and postoperative pain scores and MT. Group A received less fentanyl than group C (P = 0.014); this difference was significant at FI P = 0.035) and RE (P = 0.004). The improvement in postoperative CPS score (P = 0.013), VAS score (P = 0.003) and MT (P = 0.001) compared to preoperative values was greater for group A than for group C, whereas the treatment assignment had no effect on postoperative changes in GCPS compared to baseline. Pre-operative acupuncture may help improving perioperative analgesia in dogs with intervertebral disc herniation undergoing thoracolumbar hemilaminectomy.

Percutaneous Endoscopic Thoracic Decompression for Thoracic Spinal Stenosis Under Local Anesthesia.

BACKGROUND: Thoracic spinal stenosis (TSS), a common vertebral degenerative disease, is generally treated via surgical decompression. Percutaneous endoscopic thoracic decompression (PETD) under local anesthesia is considered a relatively safe, minimally invasive procedure. Few reports detail the success of endoscopic decompression for treatment of TSS caused by ossification of ligamentum flavum, the most common cause of TSS. This study investigated application of PETD for treatment of TSS caused by ossification of ligamentum flavum, ossification of posterior longitudinal ligament, or thoracic disc herniation. METHODS: From January 2017 to January 2019, 12 consecutive patients (6 men and 6 women) underwent PETD. TSS was caused by ossification of ligamentum flavum in 5 patients, thoracic disc herniation in 5 patients, and ossification of posterior longitudinal ligament in 2 patients. All cases were followed up for 1 year postoperatively. Preoperative and postoperative neurologic status was evaluated using the modified Japanese Orthopaedic Association score, and complications were documented. RESULTS: Average modified Japanese Orthopaedic Association score improved significantly from 6.25 ± 1.60 preoperatively to 9.75 ± 1.21 at final follow-up. Dural tear was observed in 1 case during the intervention, and 1 case had transient worsening of preoperative paralysis. Recovery at final follow-up was classified as excellent in 5 cases, good in 6 cases, and poor in 1 case. CONCLUSIONS: This retrospective analysis showed that PETD under local anesthesia may be a feasible alternative to treat TSS in elderly patients with other underlying complications for whom general anesthesia or major surgical trauma would be harmful.

Three Cases of Brucellar Spondylitis with Noncontiguous Multifocal Involvement.

BACKGROUND: Brucellosis is an endemic disease. Brucellar spondylitis is mainly manifested as a unifocal lesion, but noncontiguous multifocal brucellar spondylitis is more rare. CASE DESCRIPTION: Herein, we report 3 patients with noncontiguous multifocal involvement of brucellar spondylitis who are over 51 years of age. The diagnosis was established by using magnetic resonance imaging (MRI) and positive brucellar agglutination test. All patients were cured with antibrucellosis chemotherapy and surgery. For patients with a high degree of suspicion of noncontiguous multifocal brucellar spondylitis, especially elderly patients, screening with the use of serologic test for brucellosis and whole spine MRI is crucial to reduce the rate of misdiagnosis and missed diagnosis. CONCLUSIONS: Clinicians should raise awareness of noncontiguous multifocal brucellar spondylitis. The Wright agglutination test and whole spine MRI are the key methods to reduce misdiagnosis and missed diagnosis of noncontiguous multifocal brucellar spondylitis. Drug therapy for brucellar spondylitis is the basis, and surgical treatment is complementary therapy. The use of alternative chemotherapy and surgery for noncontiguous multifocal brucellar spondylitis is also safe and effective.

Minimally Invasive Separation Surgery for Metastases in the Vertebral Column: A Technical Report.

BACKGROUND: Epidural spinal cord compression (ESCC) is a common and severe cause of morbidity in cancer patients. Minimally invasive surgical techniques may be utilized to preserve neurological function and permit the use of radiation to maximize local control. Minimally invasive techniques are associated with lower morbidity. OBJECTIVE: To describe a novel, minimally invasive operative technique for the management of metastatic ESCC. METHODS: A minimally invasive approach was used to cannulate the pedicles of the thoracic vertebrae, which were then held in place by Kirschner wires (K-wires). Following open decompression of the spinal cord, cannulated screws were placed percutaneously with stereotactic guidance through the pedicles followed by cement induction. Stereotactic radiosurgery is performed in the postoperative period for residual metastatic disease in the vertebral body. RESULTS: The minimally invasive technique used in this case reduced tissue damage and optimized subsequent recovery without compromising the quality of decompression or the extent of metastatic tumor resection. Development of more minimally invasive techniques for the management of metastatic ESCC has the potential to facilitate healing and preserve quality of life in patients with systemic malignancy. CONCLUSION: ESCC from vertebral metastases poses a challenge to treat in the context of minimizing potential risks to preserve quality of life. Percutaneous pedicle screw fixation with cement augmentation provides a minimally invasive alternative for definitive treatment of these patients.

Meta-analysis of epidural analgesia in patients undergoing pancreatoduodenectomy.

Background: The optimal analgesic technique after pancreatoduodenectomy remains under debate. This study aimed to see whether epidural analgesia (EA) has superior clinical outcomes compared with non-epidural alternatives (N-EA) in patients undergoing pancreatoduodenectomy. Methods: A systematic review with meta-analysis was performed according to PRISMA guidelines. On 28 August 2018, relevant literature databases were searched. Primary outcomes were pain scores. Secondary outcomes were treatment failure of initial analgesia, complications, duration of hospital stay and mortality. Results: Three RCTs and eight cohort studies (25 089 patients) were included. N-EA treatments studied were: intravenous morphine, continuous wound infiltration, bilateral paravertebral thoracic catheters and intrathecal morphine. Patients receiving EA had a marginally lower pain score on days 0-3 after surgery than those receiving intravenous morphine (mean difference (MD) -0·50, 95 per cent c.i. -0·80 to -0·21; P < 0·001) and similar pain scores to patients who had continuous wound infiltration. Treatment failure occurred in 28·5 per cent of patients receiving EA, mainly for haemodynamic instability or inadequate pain control. EA was associated with fewer complications (odds ratio (OR) 0·69, 95 per cent c.i. 0·06 to 0·79; P < 0·001), shorter duration of hospital stay (MD -2·69 (95 per cent c.i. -2·76 to -2·62) days; P < 0·001) and lower mortality (OR 0·69, 0·51 to 0 93; P = 0·02) compared with intravenous morphine. Conclusion: EA provides marginally lower pain scores in the first postoperative days than intravenous morphine, and appears to be associated with fewer complications, shorter duration of hospital stay and less mortality.

Antecedentes: La técnica analgésica óptima tras una duodenopancreatectomía permanece en debate. El objetivo de este estudio fue analizar si la analgesia epidural (epidural analgesia, EA) presenta resultados clínicos superiores en comparación con las alternativas no epidurales (non­epidural alternatives, N­EA) en pacientes que se someten a una duodenopancreatectomía. Métodos: Se realizó una revisión sistemática con metaanálisis de acuerdo con las recomendaciones PRISMA. El 28 de agosto de 2018, se realizó una búsqueda en las bases de datos relevantes de la literatura. El objetivo primario fueron las puntuaciones de dolor. Los objetivos secundarios fueron el fracaso del tratamiento de la analgesia inicial, las complicaciones, la duración de la estancia hospitalaria y la mortalidad. Resultados: Se incluyeron tres ensayos aleatorizados y controlados y ocho estudios de cohortes (25.089 pacientes). Las N­EA estudiadas fueron: morfina intravenosa (iv), infiltración continua de la herida, catéteres torácicos paravertebrales bilaterales y morfina intratecal. Los pacientes con EA tuvieron una puntuación de dolor marginalmente más baja en los días postoperatorios 0 a 3 en comparación con la morfina iv (diferencia de medias (MD) = ­ 0,50, i.c. del 95% ­0,80 a ­0,21; P < 0,001) y puntuaciones de dolor similares en comparación con la infiltración continua de la herida. El fallo del tratamiento ocurrió en el 28,5% de los pacientes con EA, principalmente por inestabilidad hemodinámica o control inadecuado del dolor. La EA se asoció con menos complicaciones (razón de oportunidades, odds ratio, OR = 0,69, i.c. del 95% 0,061 a 0,79; P < 0,001), menor duración de la estancia hospitalaria (MD = ­2,69 días, i.c. del 95% ­2,76 a ­2,62; P < 0,001) y menor mortalidad en comparación con la morfina iv (OR = 0,69, i.c. del 95% 0,51 a 0,93; P = 0,01). Conclusión: La EA proporciona puntuaciones de dolor ligeramente más bajas en los primeros días postoperatorios en comparación con la morfina iv y parece asociarse con menos complicaciones, menor duración de la estancia hospitalaria y menor mortalidad.

Thermal-ablation of vertebral metastases prevents adverse events in patients with differentiated thyroid carcinoma.

PURPOSE: To evaluate a strategy that used thermal-ablation of vertebral metastases (VM) to prevent vertebral related events (VRE) in patients with differentiated thyroid cancer (DTC). METHODS: This single center study retrospectively reviewed records and post-operative imaging of all DTC patients treated with thermal-ablation for asymptomatic VMs. Rate of local tumor control at first post-operative imaging, 12 and 24 months after thermal-ablation and rate of VREs at 12 and 24 months among the treated VMs were reported. New VMs that occurred during the follow-up and were not considered for additional thermal-ablation were moniroted and VREs were reported. RESULTS: Thermal-ablation was used to achieve local control of 41 VMs in 28 patients. Median post-treatment follow-up was 22 months [range: 12-80] and the mean delay for first post-operative imaging was 2 months [range: 0.6-7.5]. Local control at first post-operative imaging, 12 and 24 months was achieved in 87.8%, 82.9% and 75.6%, respectively. Among the treated VMs the rates of VRE was 7.3% at 2 years, significantly lower if local control was achieved at first post-operative imaging than if it was not (0% vs 30%, p = 0.011, OR = 0.184 [95%CI = 0.094-0.360]). After thermal-ablation procedures, 19 news VMs occurred in 11 patients (39.2%) with a median interval of 8 months [range 1-26] and remained untreated. Among these untreated VMs, the rate of VREs at 2 years was significantly higher compared to the treated VMs: (36.8% vs. 7.3%, p = 0.008, OR = 0.135, [95%CI = 0.030-0.607]). CONCLUSION: local tumor control of VMs using thermal-ablation decreases the risk of VREs in DTC patients.

Can posterior implant removal prevent device-related vertebral osteopenia after posterior fusion in adolescent idiopathic scoliosis? A mean 29-year follow-up study.

PURPOSE: To determine whether posterior implant removal prevents stress-shielding-induced vertebral osteopenia within the posterior fusion area in surgically treated patients with adolescent idiopathic scoliosis (AIS). METHODS: Eighteen patients with major thoracic AIS (mean age, 43.3 years; range, 32-56 years; mean follow-up, 28.8 years, range, 20-39 years) who underwent posterior spinal fusion (PSF) alone between 1973 and 1994 were included. Participants were divided into implant removal (group R, n = 10, mean interval until implant removal, 50 months) and implant non-removal groups (group NR, n = 8). Bone mineral density was evaluated using the Hounsfield units (HU) of the computed tomography image of the full spine. The HU values of the UIV-1 (one level below the uppermost instrumented vertebra), apex, LIV+1 (one level above the lowermost instrumented vertebra), and LIV-1 (one level below the lowermost instrumented vertebra; as a standard value) were obtained. Stress-shielding-induced osteopenia was assessed as the UIV-1/LIV-1, apex/LIV-1, and LIV+1/LIV-1 HU ratios (× 100). RESULTS: Overall (median, 25th-75th percentile), the apex (144.7, 108.6-176.0) and LIV+1 (159.4, 129.7-172.3) demonstrated lower HU values than LIV-1 (180.3, 149.2-200.2) (both comparisons, p < .05). Comparison of groups R and NR showed no significant differences in the scoliosis correction rate, bone mineral density of the proximal femur, the HU absolute values of all investigated vertebrae, or in the HU ratios of the investigated vertebrae to LIV-1. CONCLUSION: Instrumented PSF causes stress-shielding-induced osteopenia of the vertebral body within the fusion area in adulthood, which cannot be prevented by posterior implant removal, probably due to firm fusion mass formation. These slides can be retrieved under Electronic Supplementary Material.

Three-step Reduction Therapy of Integrated Chinese and Western Medicine for Thoracolumbar Burst Fracture.

Objective: To investigate and compare the efficacy of three-step reduction (TSR) therapy of integrated Chinese and Western Medicine and posterior open (PO) surgery for thoracolumbar burst fracture. Methods: We selected 60 patients diagnosed with thoracolumbar burst fracture and received treatment in our hospital from December 2014 to March 2017. According to randomized digital table, they were randomly divided into TSR and PO groups. VAS pain grade, Oswestry disability index, height of centrum front, Cobb's angle of spine, bleeding, and complication of internal fixation of the two groups were compared. Results: Postoperative reduction of injured centrum, regained volume of canalis vertebralis, volume of bleeding, and early functional rehabilitation of TSR group were better than that of PO groups (P < 0.05). Conclusion: Through three-step reduction combined pedicle screw fixation surgery, we can achieve satisfied reduction of thoracolumbar burst fracture, rebuild the height of centrum, recover the biomechanics function of spine, and reduce bleeding. Three-step reduction therapy is an effective therapy for thoracolumbar burst fracture.

Biomechanical assessment of proximal junctional semi-rigid fixation in long-segment thoracolumbar constructs.

OBJECTIVEProximal junctional kyphosis (PJK) and failure (PJF) are potentially catastrophic complications that result from abrupt changes in stress across rigid instrumented and mobile non-fused segments of the spine (transition zone) after adult spinal deformity surgery. Recently, data have indicated that extension (widening) of the transitional zone via use of proximal junctional (PJ) semi-rigid fixation can mitigate this complication. To assess the biomechanical effectiveness of 3 semi-rigid fixation constructs (compared to pedicle screw fixation alone), the authors performed cadaveric studies that measured the extent of PJ motion and intradiscal pressure changes (ΔIDP).METHODSTo measure flexibility and ΔIDP at the PJ segments, moments in flexion, extension, lateral bending (LB), and torsion were conducted in 13 fresh-frozen human cadaveric specimens. Five testing cycles were conducted, including intact (INT), T10-L2 pedicle screw-rod fixation alone (PSF), supplemental hybrid T9 Mersilene tape insertion (MT), hybrid T9 sublaminar band insertion (SLB1), and hybrid T8/T9 sublaminar band insertion (SLB2).RESULTSCompared to PSF, SLB1 significantly reduced flexibility at the level rostral to the upper-instrumented vertebral level (UIV+1) under moments in 3 directions (flexion, LB, and torsion, p ≤ 0.01). SLB2 significantly reduced motion in all directions at UIV+1 (flexion, extension, LB, torsion, p < 0.05) and at UIV+2 (LB, torsion, p ≤ 0.03). MT only reduced flexibility in extension at UIV+1 (p = 0.02). All 3 constructs revealed significant reductions in ΔIDP at UIV+1 in flexion (MT, SLB1, SLB2, p ≤ 0.02) and torsion (MT, SLB1, SLB2, p ≤ 0.05), while SLB1 and SLB2 significantly reduced ΔIDP in extension (SLB1, SLB2, p ≤ 0.02) and SLB2 reduced ΔIDP in LB (p = 0.05). At UIV+2, SLB2 similarly significantly reduced ΔIDP in extension, LB, and torsion (p ≤ 0.05).CONCLUSIONSCompared to MT, the SLB1 and SLB2 constructs significantly reduced flexibility and ΔIDP in various directions through the application of robust anteroposterior force vectors at UIV+1 and UIV+2. These findings indicate that semi-rigid sublaminar banding can most effectively expand the transition zone and mitigate stresses at the PJ levels of long-segment thoracolumbar constructs.

Hounsfield units as predictor for cage subsidence and loss of reduction: following posterior-anterior stabilization in thoracolumbar spine fractures.

STUDY DESIGN: A retrospective, longitudinal cohort study. OBJECTIVE: The purpose of this study was to examine whether Hounsfield units (HUs), as an alternative bone mineral density measurement to dual-energy X-ray absorptiometry and quantitative computed tomography, which lead to additional radiation exposure for patients, has an effect on the maintenance of reduction in bisegmental Cobb angle (CA) and cage subsidence in patients who receive bisegmental spine stabilization after traumatic thoracolumbar spine fractures. METHODS: A total of 81 patients with a mean follow-up of 12 months were analyzed. CAs and cage subsidence were measured intraoperatively and at follow-up. HU was measured, and patients were subsequently assigned based on HU to three HU subgroups (group 1: HU < 110 [poor bone quality (BQ)]; group 2: HU 180-110 [diminished BQ]; group 3: HU > 180 [good BQ]). RESULTS: Following anterior stabilization, loss of reduction and cage subsidence differed between patients with poor and diminished BQ but not significantly, and both groups showed significantly more loss of reduction and cage subsidence than patients with good BQ. CONCLUSION: BQ, estimated with HU, had significant effects on cage subsidence and loss of reduction. We recommend measuring HU before surgery and applying additional treatment strategies, such as polymethylmethacrylate augmentation of endplates or anterior plates, for patients with HU < 180. These slides can be retrieved under Electronic Supplementary Material.

Solitary juvenile xanthogranuloma in the spine pretreated with neoadjuvant denosumab therapy followed by surgical resection in a 5-year-old child: case report and literature review.

PURPOSE: We present a case report that describes neoadjuvant denosumab therapy initiated in a child with a solitary giant cell-rich juvenile xanthogranuloma tumor involving the spine, and review the current literature. METHODS: A giant cell-rich histiocytic lesion involving the 11th thoracic vertebral body was identified in a healthy 5-year-old girl with persistent back and pelvic pain for several months. Imaging examinations and an open biopsy were performed to obtain a definite pathologic diagnosis. As the tumor appeared to be aggressive in nature, we administered adjuvant therapy with denosumab preoperatively and then performed a total spondylectomy. RESULTS: Histopathology confirmed that the tumor was juvenile xanthogranuloma. No tumor metastases or recurrence were detected at the 3-year follow-up, and the patient was asymptomatic. CONCLUSIONS: In giant cell-rich tumors, denosumab is occasionally used as neoadjuvant or adjuvant therapy, especially for tumors in difficult locations or with substantial soft tissue extensions. Rare adverse events in children include skin infections and disruption of calcium homeostasis. Surgical treatment is aimed at removing the tumor and relieving the symptomatic spinal cord compression. Use of denosumab as neoadjuvant therapy for juvenile xanthogranuloma involving the spine has not been reported previously.

Awake Intradural Spinal Tumor Resection; Case Report and Literature Review.

BACKGROUND: Meningioma is a common slow-growing spinal tumor with a predilection for intradural occurrence. Patients usually present with pain followed by ataxia and sensory and sphincter problems. The gold standard treatment in these cases is gross total microsurgical resection under general anesthesia. However, there exist high-anesthetic-risk patients unsuitable for general anesthesia. Performing spinal surgeries under local anesthesia and sedation has been reported, albeit rarely for mostly minimally invasive procedures but not for open intradural pathologies. CASE DESCRIPTION: We report a 63-year-old woman with critical aortic stenosis, coronary artery disease, and severe chronic obstructive airways disease who presented with 10 months' history of worsening back pain and bilateral leg pain, ataxia, hyperreflexia in lower limbs, as well as altered lower limb sensation. Magnetic resonance imaging revealed a contrast-enhancing intradural lesion at T6/7 with severe spinal cord compression. However, the patient was American Society of Anesthesiologists class IV and her cardiac disease was not amenable to intervention. She underwent thoracic laminectomy and excision of the tumor under local anesthesia and sedation with no significant complications and clinical improvement. CONCLUSION: Our illustrative case and literature review suggest that using local anesthesia and sedation to perform spinal surgeries including intradural tumors is possible even in high-risk patients with good outcome. Our American Society of Anesthesiologists class IV patient tolerated the surgery well with gross total tumor resection and subsequent resolution of the symptoms.

Intraoperative Traction May Be a Viable Alternative to Anterior Surgery in Cerebral Palsy Scoliosis ≥100 Degrees.

BACKGROUND: For large scoliosis, 2 strategies to maximize correction include intraoperative traction and/or anterior release. It is unclear which patients will benefit the most form either approach. The purpose of our study is to compare the radiographic, perioperative clinical outcomes, and health-related quality of life (HRQoL) outcomes of 2 approaches when used in severe neuromuscular scoliosis in the setting of cerebral palsy (CP). METHODS: In total, 23 patients with minimum 2-year follow-up, major curves ≥100 degrees, and in whom treatment included posterior spinal fusion were evaluated. Eighteen were treated with posterior spinal fusion with intraoperative traction and 5 with anterior/posterior spinal fusion (APSF). The baseline characteristics, perioperative outcomes, and preoperative and 2-year follow-up data for HRQoL and radiographic measures were compared. RESULTS: The groups had similar age, sex, nutritional and seizure status, GMFCS level, and change in CPCHILD scores. The groups had similar curve magnitude (120 vs. 105 degrees, P=0.330) and flexibility (28% vs. 40%, P=0.090), but the APSF group had less pelvic obliquity (POB) (24 vs. 42 degrees, P=0.009). There were similar postoperative major curves (37 vs. 40 degrees, P=0.350), but greater correction in POB (33.5 vs. 14 degrees of correction, P=0.007) in the traction group. The APSF group had longer anesthesia times (669 vs. 415 min, P=0.005), but similar hospital stays, intensive care unit and days intubated, estimated blood loss, cell saver, and red blood cells used. Although the APSF group had twice the rate of complications (22% vs. 40%) during the first 90 days postoperatively, this did not reach statistical significance. CONCLUSIONS: Both intraoperative traction and anterior surgery were used to aid correction in severe CP scoliosis. Anterior surgery did not offer superior correction or better HRQoL, and was associated with increased operative times, whereas intraoperative traction was associated with greater correction of POB. Intraoperative traction may be a viable alternative to an anterior release in severe CP scoliosis. LEVEL OF EVIDENCE: Level II.