Is open anterior advantageous to posterior decompression and reconstruction in fresh A3 to C3/AO type thoracolumbar junction fractures? A systematic review.

INTRODUCTION: Surgical outcomes of open anterior and open posterior approaches, for thoracolumbar A3 to C3/AO type fractures, are compared. METHODS: A PubMed search was conducted from 1990 to 2024 related to anterior, posterior, and combined approaches. Inclusion criteria: Fresh traumatic T10 to L2 fractures, age ≥13 years, ≥10 cases, minimum follow-up 6 months. Exclusion criteria: Cadaveric studies, pathological fractures, reviews, thoracoscopy-assisted, mini-open lateral (MOLA) and minimal invasive anterior or posterior approaches. Coleman Methodology Scores (CMS) (modified for spinal trauma) indicated potential selection bias in the selected studies. PRISMA guidelines were adapted. RESULTS: Nineteen studies with 847 participants were selected. The average CMS quality score was fair. The anterior approach, although it better decompresses the compromised spinal canal, it is also associated with increased surgical complications compared to the posterior approach. The neurological outcome, the loss of correction and the reoperation rate, were similar to both approaches. This systematic review favors posterior approach. CONCLUSIONS: The anterior approach is demanding and is associated with a higher rate of surgical complications compared to the posterior approach. The limitations of the selected studies included inconsistence in the: 1) approaches selection, 2) classifications of the fracture types and the neurological status and 3) variety of instrumentations used. PROSPERO ID: CRD42023484222.

Quality of Life in Adult Patients Receiving Cervical Fusion for Fresh Subaxial Cervical Injury: The Role of Associated Spinal Cord Injury.

PURPOSE: To study postoperative Health-Related Quality of Life (HRQOL) after instrumented fusion for fresh subaxial cervical trauma and the effect of spinal cord injury (SCI). METHODS: From a total of 65 patients, 17 (26%) patients suffered on admission from SCI. Twenty-five patients underwent anterior, 25 posterior, and 15 circumferential cervical surgery for a single cervical injury. Sagittal roentgenographic parameters were measured in 65 age-matched asymptomatic controls and in patients on admission, eight months postoperatively and at final follow-up (lower C2-C7 curvature, cervical sagittal vertical axis (cSVA), spinocranial angle (SCA), T1-slope, neck tilt (NT), thorax inlet angle (TIA), cervical tilt (CT), cranial tilt (CrT), and occiput-C2 angle (C0-C2)). In the last evaluation, SCI patients were compared with their counterparts without SCI using national validated HRQOL instruments (SF-36 and neck disability index (NDI)). RESULTS: Fusion included an average of 3 vertebrae (range 2-4 vertebrae). All 65 patients were followed for an average of 5.5 years, (range 3-7 years) postoperatively. In the last evaluation, 10 (15.4%) patients with incomplete SCI improved postoperatively at 1-2 grades. At the last observation, patients with SCI showed poorer HRQOL scores than their counterparts without SCI. In particular, each SF-36 domain score was correlated with SCA, T1-slope, cSVA, and CT. At baseline, patients showed higher NT, CrT, and C0-C2 angle than controls. Eight months postoperatively, cSVA, NT, TIA, and cranial tilt (CrT) were increased in patients. In the last observation, there was difference in the sagittal roentgenographic parameters between patients with SCI compared to those without SCI. Patients aged ≥55 years had postoperatively increased cSVA, NT, and CrT compared to their younger counterparts. CONCLUSION: At the final observation, HRQOL scores were lower in patients with SCI than in their non-SCI counterparts, obviously because of the associated neurologic impairment. SF-36 scores correlated with several sagittal roentgenographic parameters. These correlations should be taken in consideration by spine surgeons when performing cervical spine surgery for fresh cervical spine injuries.

Posterior Occipitocervical Fusion for Unstable Upper Cervical Trauma in Old and Elderly Population, Although Decreases Upper Cervical Rotation, Does Not Significantly Increase Neck Disability Index.

BACKGROUND: Despite the research progress in the thoraco-lumbo-pelvic balance, cervical spine balance has only recently gained increasing interest. To our knowledge, there is a lack of research regarding sagittal occipitocervical spine balance restoration following posterior occipitocervical fusion (POCF). PURPOSE: The primary outcome measure is the evaluation of sagittal cervical alignment roentgenographic parameters and the secondary is the functional outcome (NDI), following POCF for upper (C1 & C2) cervical trauma (UCT) in coexistence with upper cervical spine degeneration. Patients and Methods. Twenty old and elderly patients aged 62 ± 12 years with evident upper cervical degeneration, who received POCF for upper C1 & C2 unstable cervical spine injuries, were included. C2-C7 lordosis, C2-C7 SVA, spinocranial angle (SCA), T1-slope, neck tilt (NT), thorax inlet angle (TIA), cervical tilt (CT), cranial tilt (CrT), and C0-C1 angle were measured. The subfusion angle was used to study the behavior of the unfused cervical segments below fusion. The Neck Disability Index (NDI) was used for the functional outcome evaluation. 29 age-matched individuals were used as controls for radiographic analysis and self-reported functional status comparison. RESULTS: The roentgenographic data were measured 3 and 39 ± 12 months postoperatively. Twelve patients showed no disability, and eight showed mild disability. Postoperatively, the patients stood with less C2-C7 lordosis, SCA, and CT (P < 0.02) but with higher NT (P < 0.02) in comparison to the controls. The patient's neck disability (NDI) was increasing as TIA increases (P=0.023). Subfusion angle seems to adapt to C2-C7 lordosis (P < 0.0033) and C0-C2 angle (P < 0.003) without any changes till the last evaluation. CONCLUSIONS: POCF sufficiently restored occipitocervical sagittal balance along with functional outcome similar to controls in adult and elderly individuals with evident upper cervical degeneration. We do not recommend POCF for young active individuals without occipitocervical pathology, but in contrary, we recommend the removal of the spinocranial connection hardware after cervical fusion is completed.

Three-level lumbar Ponte osteotomies with less invasive pelvic fixation improve spinal balance, quality of life and decrease disability in adult and elderly women with moderate adult spinal deformity.

PURPOSE: To report on quality of life and radiological changes of Ponte osteotomies (POs) with long fixation for primary and revision surgery, in elderly women with adult spinal deformity (ASD). METHODS: Sixty-seven (67) women, aged 69 ± 7 years, received 3 POs, spinopelvic fixation plus TLIFs. Forty-nine (73%) patients received primary and 18 (27%) revision surgery. Survivorship analysis was made for unplanned revision surgery for broken rods (BR); proximal junction failure (PJF); and deep wound infection (DWI). ODI and SF-36 were used for disability (ODI) and quality of life (SF-36) evaluation. RESULTS: In total, 201 lumbar POs were made and 9.55 ± 3 levels fused. All patients were available 49 ± 11 months postoperatively. Postoperatively, SVA, CSVL, PI-LL, scoliosis, PT and T9-spinopelvic inclination were reduced, while LL and SS were increased significantly. At the final visit, PI-LL ≤ 10° was achieved in 26 (39.4%) patients; ≤ 15° in 51 (76%) patients, while all 67 patients showed a PI-LL ≤ 20°. Unplanned reoperation was performed in 11 (16.4%) patients: for BR in 5 (7.5%); for PJF in 3 (4.5%) and for DWI in 3 (4.5%) patients, respectively. With end point the reoperation for any reason the survival ± SE was 67.8% ± 0.1; for PJF 89.6 ± 0.065; and for BR 76% ± 0.1 in the final evaluation. There was no difference in survival between the primary and revision surgery groups (P = 0.568). ODI and SF-36 scores were improved postoperatively. CONCLUSIONS: Three-segment lumbar POs offered and maintained sufficient improvement of lumbar lordosis along with restoration of the sagittal and coronal spinal alignment, improvement of quality of life and disability of female adult and elderly population after primary and revision surgery for ASD.

Contemporary less invasive spinal instrumentation for AO C-type posterior pelvic ring injuries.

OBJECTIVE: This study evaluates efficacy and safety of contemporary spinal instrumentation for AO/type C posterior pelvic ring (PPR) injuries. METHODS: Twenty-two consecutive patients, aged 36 ± 17 years, were managed with spinal instrumentation with spinopelvic fixation (SPF) or non-spinopelvic fixation (NSPF) and less invasive surgery. There were 16 vertically unstable sacral fractures and six iliosacral dislocations. Matta score was used for fragment diastasis and Majeed's score for functional outcome evaluation. RESULTS: All patients were followed for 61 ± 8 months postoperatively. The operative time was less in NSPF (P < 0.001). SPF was applied in six cases and NSPF in 16 cases. Postoperatively, fragment diastasis was reduced from 16 ± 13 to 2.6 ± 3.8 mm (P < 0.000). There was no statistically significant difference in fracture reduction between SPF and NSPF (P = 0.16). Majeed score was 83 ± 16 postoperatively. There was a significant correlation between Matta score and Majeed score (P = 0.013). There were two cases with spinal instrumentation failure. Low-grade infection occurred in one patient, without hardware failure, that was eradicated after hardware removal. From ten patients with incomplete neurologic impairment on admission, eight showed postoperatively full and two partial recovery without direct sacral decompression. Patients with preoperative neurologic impairment showed lower postoperative Majeed score than those without neurologic impairment (P = 0.027). There was no correlation between neurologic impairment and recovery and type of PPR injury. CONCLUSIONS: SPF and NSPF with contemporary spinal instrumentation for C AO-type PPR injury with less invasive methods are safe and effective techniques that reduce and maintain PPR disruption allowing early mobilization, neurologic recovery and improved Majeed score. These slides can be retrieved under electronic supplementary material.

A unilateral less invasive posterolateral approach for disc debridement and titanium cage insertion supplemented by contralateral transfascial screw fixation for high-morbidity patients suffering from septic thoracolumbosacral spondylodiscitis.

PURPOSE: This case series reports on the efficacy and safety of a less invasive posterolateral approach for septic thoracolumbosacral spondylodiscitis in high-morbidity patients. METHODS: Twenty consecutive severe sick (ASA > III) patients (14 men and 6 women), with an average age of 64 ± 14 years, suffering from septic subacute and chronic thoracolumbosacral spondylodiscitis were selected to undergo a one-stage less invasive unilateral posterolateral disc space debridement, supplemented by an ipsilateral titanium cage implantation and pedicle screw fixation plus a contralateral transfascial pedicle screw fixation. RESULTS: Two high-risk patients with severe comorbidities (ASA stage IV and V, respectively) died on days 1 and 8 postoperatively because of non-surgical complications such as massive lung embolism and acute myocardial infract, respectively. Three patients with incomplete paraplegia (ASIA C) preoperatively were improved after the surgery to ASIA D (two patients) and E (one patient), respectively, while there was no neurological deterioration in any patient postoperatively. From the 18 patients that survived, ten patients were available for the final follow-up 8.8 ± 2.7 years postoperatively. In two patients with spondylodiscitis caused by gram(-) bacteria, the posterior instrumentation was finally removed because of asymptomatic fistula emerging from posterior instrumentation solely, 15 and 19 months after surgery. The survivals at 2.5 and 10 years with revision as end point was 87.4% (95% CI 58.1-96.7); while in the "worst case scenario" the survivals at 2.5 and 10 years were: 66.7% (95% CI 40.4-83.4%); 47.7% (95% CI 23.2-68.8%) and 47.7% (95% CI 23.2-68.8%), respectively. CONCLUSIONS: The less invasive posterolateral approach for disc debridement and titanium cage insertion seems to be an alternative surgery for severe sick adult immunosuppressed patients with septic thoracolumbosacral spondylodiscitis that cannot tolerate traditional open transthoracic, thoracolumbar, retroperitoneal or combined approaches. The study has been registered in the Public Registry ClinicalTrials.gov PRS with the ID: NCT03472131.

Short Lumbosacral Decompression Plus Fixation Does Not Change the Spinopelvic Balance on Patients With Moderate Degenerative Spondylolisthesis and Associated Spinal Stenosis.

STUDY DESIGN: A retrospective cohort study. OBJECTIVES: To investigate whether decompression plus short segment lumbosacral fixation changes the sagittal baseline spinopelvic parameters in patients with moderate degenerative spondylolisthesis (DS) and associated degenerative lumbar spinal stenosis (DLSS). SUMMARY OF BACKGROUND DATA: Spinal decompression and fusion are commonly performed in DS with associated DLSS. Spinopelvic alignment after surgery for DS is an important research topic. The effect of short lumbosacral instrumented fusion on the global sagittal spinal balance has not been sufficiently studied. METHODS: Thirty-four consecutive adult patients (21 women, 13 men) aged 62 ± 11 years with balanced spines [sagittal vertical axis (SVA) ≤ 40 mm] received decompression and two to three vertebrae fixation plus fusion for DS grades I and II, associated with symptomatic DLSS. Age, gender, number of segments fused, posterolateral fusion (PLF) versus PLF plus posterior lumbar interbody fusion (PLIF) and segmental lordosis (SL) in the free segment above instrumentation were studied for a minimum follow-up of 60 months. The roentgenographic variables measured are T12-S1 lumbar lordosis (LL), SVA, sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), SL, and anterior (ADH) and posterior disc height (PDH) in the suprajacent free lumbar segment. Clinical outcomes were assessed with visual analog scale and Oswestry Disability Index. RESULTS: SVA significantly (p = .05) decreased postoperatively but returned to the baseline value at the final observation. Younger individuals (≤59 years) stood with greater SS (p = .036) 6 months postoperatively and with less SVA in all 3 periods of observation (p = .013, .046, and .024) than their older (>59 years) counterparts. Patients with monosegmental stenosis showed on baseline less SVA (p = .028), PT (p = .031), and PI (p = .004) than their two-segmental stenosis counterparts. PI preoperatively to the last evaluation was significantly smaller in the patients who received 360° fusion (p<.016). CONCLUSIONS: Short lumbosacral fixation does not significantly change the preoperative sagittal spinopelvic balance in adult patients with preoperatively balanced spines who have DS and DLSS. LEVEL OF EVIDENCE: Level III.

Unique Migration of a Septic Loosened Metal-on-metalCementless Total Hip Arthroplasty: A Case Report and Literature Review.

INTRODUCTION: Total hip arthroplasty (THA) is one of the most successful and cost- effective surgical procedures developed during the last century. Although, chronic infection accompanied with granulomatous allergic reaction from Cobalt (Co),Chromium (Cr) debris after metal-on-metal (MoM) THA implantation can cause severe osteolysis, with subsequent loosening and migration of the implants. There are many cases with intrapelvic migration of these implants, however to best of our knowledge, there is no report of a complete horizontal migration (on frontal plane) of the whole THA prosthesis without disassembly accompanied with severe bone destruction. CASE REPORT: A 52-year-old female patient was admitted to the authors' department with inability to weight bear. Because of bilateral developmental hip dysplasia (Type II, Hartofilakidis classification) she underwent THA bilaterally at another institution about 20 years ago. On admission, the initial plain roentgenogram of the hip was impressive, disclosing sclerotic, osteolytic lesions, associated with perforation of the lateral and medial cortices of the proximal femur, and migration to 90-degree horizontal position on the frontal plane of the whole prosthesis. Based on the preoperative planning, the implants were removed through a small medial longitudinal approach accompanied with lateral debridement. The patient denied revision surgery and the final result was a resection arthroplasty. CONCLUSION: THA is one of the most clinically successful surgical procedures, although inappropriate patient or implant selection for primary hip arthroplasty can lead to the necessity of complex revision surgery after late-diagnosed postoperative complications such as infection, loosening, and migration of the prosthesis. A well-designed preoperative plan is mandatory when handling such cases. Clinicians when faced with THA migration, rare or common, should definitely rule out the infection. Adverse reactions to metal debris (ARMD) can also lead to significant displacement of a hip prosthesis, although coexistence of metallosis and infection cannot be excluded in advance.

PEEK versus Silicon Interspinous Spacer for Reduction of Supradjacent Segment Degeneration following Decompression and Short-Segment Instrumentation for Degenerative Lumbar Spinal Stenosis.

PURPOSE: A retrospective study that aims to report Adjacent Segment Degeneration (ASD) incidence and spinopelvic balance in short lumbosacral instrumentation for degenerative lumbar spinal stenosis. Although ASD is a common complication following lumbar fusion, the effect of an interspinous spacer (IS) in the supradjacent segment in short lumbosacral instrumented fusion and its interaction with spinopelvic balance has not been studied adequately. METHODS: From 55 consecutive age-, diagnosis-, and gender-matched patients aged 60±11 years, 17 (Group R) received PEEK IS; 18 (Group S) received Silicon IS compared with 20 controls (Group C) without receiving any IS. The functional outcome was evaluated with VAS and ODI. Spinopelvic balance was evaluated using SVA, T12-S1 LL, SS, PT, PI, and supradjacent segment disc heights. All spines were preoperatively balanced (SVA<40 mm). RESULTS: The follow-up averaged out to 56±11 months. VAS and ODI scores improved postoperatively in all 3 groups. SS and anterior disc height in the supradjacent free segment increased postoperatively compensatory to spinal alterations. Although 6, 4, and 5 patients from Groups R, S, and C, respectively, showed radiological progression of the preoperative degeneration grade in the supradjacent disc, only 2, 1, and 2 patients in Groups R, S, and C, respectively, developed symptomatic ASD in the 1st supradjacent segment solely. No additional surgery was required in any patient. CONCLUSION: ASD incidence in the supradjacent segment following short lumbar fusion did not statistically significantly differ between PEEK and Silicon IS. There was a trend towards lower ASD incidence in Silicon IS. IS reduced ASD in both 1st and 2nd supradjacent segments. The authors speculate that soft stabilization provided by IS may be more advantageous for preventing ASD. This trial is registered with ClinicalTrials.govNCT03477955.

Effect of the Chêneau Brace in the Natural History of Moderate Adolescent Idiopathic Scoliosis in Girls: Cohort Analysis of a Selected Homogenous Population of 100 Consecutive Skeletally Immature Patients.

STUDY DESIGN: Α series study. OBJECTIVES: To evaluate the relationships between the effectiveness of brace in reduction of scoliosis angle, axial trunk rotation (ATR), and patients' compliance, in skeletally immature females with moderate adolescent idiopathic scoliosis (AIS), treated with Chêneau brace for a minimum of three years. SUMMARY OF BACKGROUND DATA: According to some authors, braces are ineffective, whereas others find that braces stop scoliosis progression and that the outcome has been related to patient's compliance. METHODS: From the 100 patients who were initially recruited, 88 patients were included in the final analysis. The average ± SD primary scoliosis angle before brace application was 36.8° ± 9.9°, 32.7° ± 6.3°, and 33.5° ± 11.5° for major thoracic, thoracolumbar, and lumbar curvatures, respectively. All patients were aged ≥10 years at treatment initiation, and their Risser index varied from 0 to II. Eighty-eight patients were followed for at least three years with brace treatment, whereas 43 patients were reevaluated 31 ± 7 months after brace weaning. In baseline and while in brace, the scoliosis Cobb angle, Risser index, menarche age, ATR, and patient's compliance were recorded. RESULTS: In the 88 patients, the brace reduced the major thoracic, thoracolumbar, and lumbar scoliosis one month after brace onset while "in brace" to 26° ± 11° (29% ± 18%, p = .0006), 23° ± 8° (31% ± 20%, p = .00001), and 24° ± 11° (34% ± 21%, p = .00043), respectively; thereafter, no significant decrease of the curves was recorded. Total bracing time averaged at 45 ± 19 months (range 36-96) and brace weaning averaged at 17 ± 2 years (range 15-19). Six of the 88 (6.8%) individuals underwent surgery for scoliosis progression. In the 43 patients who were reevaluated 31 ± 7 months after brace weaning, scoliosis angle and ATR increased insignificantly, compared to the three years' values. CONCLUSIONS: Chêneau orthosis reduced while "in brace" AIS in girls with sufficient compliance, with a low rate (6.8%) of patients who underwent surgery. LEVEL OF EVIDENCE: Level 3.

Percutaneous Injection of Strontium Containing Hydroxyapatite versus Polymethacrylate Plus Short-Segment Pedicle Screw Fixation for Traumatic A2- and A3/AO-Type Fractures in Adults.

INTRODUCTION: Polymethacrylate (PMMA) is commonly used in vertebroplasty and balloon kyphoplasty, but its use has been associated with complications. This study tests three hypotheses: (1) whether strontium hydroxyapatite (Sr-HA) is equivalent to PMMA for restoring thoracolumbar vertebral body fractures, (2) whether the incidence of PMMA leakage is similar to that of Sr-HA leakage, and (3) whether Sr-HAis is resorbed and substituted by new vertebral bone. MATERIALS AND METHODS: Two age- and sex-matched groups received short percutaneous pedicle screw fixation plus PEEK implant (Kiva, VCF Treatment System, Benvenue Medical, Santa Clara, CA, USA) filled with either Sr-HA (Group A) or PMMA (Group B) after A2- and A3/AO-type thoracolumbar vertebral body fractures. The Visual Analog Scale (VAS) score and imaging parameters, which included segmental kyphosis angle (SKA), vertebral body height ratios (VBHr), spinal canal encroachment (SCE), bone cement leakage, and Sr-HA resorption, were compared between the two groups. RESULTS: The average follow-up was 28 months. No differences in VAS scores between Groups A and B were observed at baseline. Baseline back pain in both groups improved significantly three months postoperatively. Anterior, middle, and posterior VBHr did not differ between the two groups at any time point. SKA was improved insignificantly in both groups. SCE decreased insignificantly in both groups on 12-month follow-up using computed tomography (CT). PMMA leakage was observed in one patient, while no Sr-HA paste leakages occurred. Sr-HA resorption and replacement with vertebral bone were observed, and no new fractures were observed. CONCLUSIONS: As all hypotheses were confirmed, the authors recommend the use of Sr-HA instead of PMMA in traumatic spine fractures, although more patients and longer follow-up will be needed to strengthen these results. This trial is registered with NCT03431519.

Exploiting expert systems in cardiology: a comparative study.

An improved Adaptive Neuro-Fuzzy Inference System (ANFIS) in the field of critical cardiovascular diseases is presented. The system stems from an earlier application based only on a Sugeno-type Fuzzy Expert System (FES) with the addition of an Artificial Neural Network (ANN) computational structure. Thus, inherent characteristics of ANNs, along with the human-like knowledge representation of fuzzy systems are integrated. The ANFIS has been utilized into building five different sub-systems, distinctly covering Coronary Disease, Hypertension, Atrial Fibrillation, Heart Failure, and Diabetes, hence aiding doctors of medicine (MDs), guide trainees, and encourage medical experts in their diagnoses centering a wide range of Cardiology. The Fuzzy Rules have been trimmed down and the ANNs have been optimized in order to focus into each particular disease and produce results ready-to-be applied to real-world patients.

Lumbar vertebral hemangioma mimicking lateral spinal canal stenosis: case report and review of literature.

Context Hemangiomas are the commonest benign tumors of the spine. Most occur in the thoracolumbar spine and the majority are asymptomatic. Rarely, hemangiomas cause symptoms through epidural expansion of the involved vertebra, resulting in spinal canal stenosis, spontaneous epidural hemorrhage, and pathological burst fracture. Findings We report a rare case of a 73-year-old woman, who had been treated for two months for degenerative neurogenic claudication. On admission, magnetic resonance imaging and computed tomographic scans revealed a hemangioma of the third lumbar vertebra protruding to the epidural space producing lateral spinal stenosis and ipsilateral nerve root compression. The patient underwent successful right hemilaminectomy for decompression of the nerve root, balloon kyphoplasty with poly-methyl methacrylate (PMMA) and pedicle screw segmental stabilization. Postoperative course was uneventful. Conclusion In the elderly, this rare presentation of spinal stenosis due to hemangiomas may be encountered. Decompression and vertebral augmentation by means balloon kyphoplasty with PMMA plus segmental pedicle screw fixation is recommended.