Does computed tomography-guided percutaneous catheter drainage is effective for spinal tuberculous abscess: a midterm results.

STUDY DESIGN: Retrospective cohort study. PURPOSE: To evaluate an effectiveness and report a midterm clinical outcome in pain and neurological status in spinal tuberculous abscess after treated by CT-guided percutaneous catheter drainage. OVERVIEW OF LITERATURE: Spinal tuberculosis is one of the destructive forms of tuberculosis infection, which can cause undesirable consequences. The gold standard of surgical treatment of spinal tuberculosis with tuberculous abscess is radical debridement, abscess drainage, and bone grafting of the defect via anterior approach. However, this treatment may lead to several serious complications. CT-guided percutaneous catheter drainage is an alternative procedure for this condition and may reduce the serious complications from standard surgical treatment. MATERIALS AND METHODS: The medical record of the patients with spinal tuberculosis with tuberculous abscess who underwent CT-guided percutaneous catheter drainage (CT-guided PCD) from 2015 to 2021. The visual analog pain scale (VAS), Frankel grading scale, duration of drainage, amount of spinal tuberculous abscess, and complications were evaluated. RESULTS: Twenty-nine patients (mean age 44 years old) were included in the study. All patients were followed up for 24 to 72 months with an average of 36 months. Level involvements were mostly found in L1-L2 followed by L2-L3 and T12-L1 levels. A 14-Fr catheter was the mostly use followed by 16-Fr catheter. Amount of abscess drainage ranged from 110 to 2,490 ml (mean 599 ml). The drainage duration ranged from 6 to 42 days (mean 17 days). Additional surgery was performed in three patients due to subsequent mechanical instability developed despite successful drainage of abscess. At the last follow-up, VAS, Frankel grading scale were improved significantly in all patients without complications. CONCLUSIONS: CT-guided percutaneous catheter drainage is a safe and effective alternative procedure in the treatment of spinal tuberculous abscess patients with high success rate, less complications, and satisfied midterm outcomes.

Comparison of post-operative wound pain between interlaminar and transforaminal endoscopic spine surgery: which is superior?

STUDY DESIGN: Prospective cohort study PURPOSE: The objective is to compare post-operative wound pain in patients treated by endoscopic surgery between interlaminar and transforaminal approach at lumbar region. OVERVIEW OF LITERATURE: There are two common approaches for endoscopic lumbar spine surgery, interlaminar and transforaminal approach. The wound size of these two approaches is about the same. However, post-operative wound pain may differ according to the entrance area. METHODS: We conducted a prospectively cohort study including all patients underwent full endoscopic lumbar spine surgery by single surgeon between January 2016 to October 2019. Wound pain using visual analog scale (VAS) at post-operative day 1 and day 14 were collected. VAS back pain, VAS leg pain, Oswestry Disability Index (ODI), modified McNab criteria and complications were also collected. RESULTS: There were 313 patients included in the study. There was no significant difference in VAS wound pain between interlaminar and transforaminal group. Interestingly, subgroup analysis in interlaminar group found statistically significant higher VAS for wound pain at post-operative day 1 when significant bone resection was done by power burr. VAS back-leg pain and ODI have improved significantly between pre-operative and last follow up in both approaches. CONCLUSIONS: Wound pain from endoscopic spine surgery is minimal. This study found no difference in wound pain between endoscopic interlaminar and transforaminal approach. Both approaches show favorable clinical outcomes with few serious complications rate. Further study with long term follow up is needed.

Comparison between 1 g and 2 g of Intrawound Vancomycin Powder Application for Prophylaxis in Posterior Instrumented Thoracic or Lumbosacral Spine Surgery: A Preliminary Report.

BACKGROUND: Surgical site infection (SSI) after instrumented spinal surgery is one of the most serious complications in spite of the routine use of prophylactic intravenous (IV) antibiotics. Many studies have suggested that intrawound vancomycin powder, applied during the intraoperative period, may decrease the incidence of SSI after surgery. However, the appropriate dose of vancomycin has not yet been reported. PURPOSE: The purpose of the study is to compare between the use of 1 g and 2 g intrawound vancomycin powder and to find out which of these two groups can reduce the rate of deep wound infection in posterior instrumented thoracic or lumbosacral spine surgery. MATERIALS AND METHODS: The preliminary study was conducted from July 2013 to July 2015 at Lerdsin Hospital. A total of 400 patients were enrolled in the study, and their individual demographics were recorded. All patients underwent posterior instrumented thoracic or lumbosacral spine surgery. Of these, 131 patients received IV cefazolin and 2 g of vancomycin powder intrawound application, 134 patients received 1 g of intrawound vancomycin powder in addition to IV cefazolin, and 135 patients were given only IV cefazolin and were assigned as the control group. RESULTS: One hundred and thirty-one patients were treated with posterior instrumented thoracic or lumbosacral fusions using IV cefazolin and adjuvant 2 g of intrawound vancomycin powder. Five patients in this group developed deep infections (3.8%). One hundred and thirty-four patients were treated with posterior instrumented thoracic or lumbosacral fusions using IV cefazolin and adjuvant 1 g of intrawound vancomycin powder. Of these, four patients developed deep infections (2.98%). One hundred and thirty-five patients in the control group were treated with posterior instrumented thoracic or lumbosacral using only IV cefazolin as prophylaxis. Of these, four patients developed deep infections (2.96%). Coagulase-negative staphylococcus was the most common isolated organism. There were no adverse clinical outcomes or wound complications due to local application of vancomycin powder. CONCLUSION: The preliminary result could not state the relation of intrawound vancomycin powder to the deep infection; further study with adequate sample size is required.

Comparison of Segmental Mobility in Lumbar Extension Radiographs between a New Technique ("Fulcrum Bending Position") and Conventional Standing Position in Spondylolisthesis Patients.

STUDY DESIGN: Cross-sectional study. PURPOSE: This was carried out to evaluate the benefit of a 'fulcrum bending position' compared with the standing position for evaluation of sagittal translation and sagittal rotation in symptomatic patients with spondylolisthesis. OVERVIEW OF LITERATURE: In lumbar X-ray, the standing position is the most common position used in determining abnormalities in lumbar movement. Lack of standardized method is one of the pitfalls in this technique. We hypothesized that the new technique, that is, fulcrum bending position, may reveal a higher translation and rotation in spondylolisthesis patients. METHODS: The extension lumbar radiographs of 36 patients with low-grade spondylolisthesis were included in the analysis and measurement. Sagittal translation and sagittal rotation were measured in both the routine standing position and in our new technique, the fulcrum bending position, which involves taking lateral cross-table images in the supine position wherein the patient lies on a cylindrical pipe to achieve maximum passive back extension by the fulcrum principle. RESULTS: Results of the measurement of sagittal translation in both positions revealed that compared with the extension standing position, the fulcrum bending position achieved a statistically significant increase of 1.57 mm in translation of the vertebra position (95% confidence interval [CI], 0.52-2.61; p=0.004). The measurement of sagittal rotation in both positions revealed that when compared with the extension standing position, the fulcrum bending position achieved a statistically significant increase of 3.47° in the rotation of the vertebra (95% CI, 1.64-5.30; p<0.001). CONCLUSIONS: For evaluation of both sagittal translation and sagittal rotation in symptomatic patients with spondylolisthesis, compared with the extension standing position, the fulcrum bending position can achieve an increased change in magnitude. Our technique, that is, the fulcrum bending position, may offer an alternative method in the detection or exclusion of pathological mobility in patients with spondylolisthesis.

Extended Posterior Decompression and Instrumented Fusion for Spinal Tuberculosis.

STUDY DESIGN: Retrospective cohort. PURPOSE: To evaluate clinical outcomes, including pain and neurologic status, and to evaluate radiographic outcomes of patients treated with extended posterior decompression, posterior fixation, and fusion in different vertebral segments. OVERVIEW OF LITERATURE: The standard surgical treatment of spinal tuberculosis is radical debridement via anterior approach. However, this approach may lead to several serious complications. Meanwhile, extended posterior approach, the posterior surgical approach, involving the removal of posterior elements, ribs, and pedicles, is an alternative option that can achieve the aims of treatment in this disease and may reduce the serious complications from anterior approach. METHODS: The medical records and imaging of 50 patients admitted with spinal tuberculosis from January 2010 to June 2016 were reviewed. The Visual Analog Scale (VAS), Frankel grading scale, and kyphotic Cobb angle between the pre- and postoperative periods were used to evaluate the patients. RESULTS: The patients had significant improvement of VAS score in all the groups. The T/T-L, L, and L-S group scores improved from 7.2±1.5 to 1.7±1.2 (p<0.01), from 8.1±1.8 to 1.7±1.4 (p<0.01), and from 7.9±2.2 to 1.7±0.8 (p<0.01), respectively, and overall, the patient scores (n=50) improved from 7.8±1.4 to 1.7±1.3 (p<0.01). Ten patients (20%) had Frankel grade E preoperatively, which was improved to 38 patients (76%) postoperatively. A significant improvement of the kyphotic Cobb angle was observed when compared at the preoperative, early postoperative, and final follow-up period in the T/T-L, L, and L-S groups. The loss of correction angle in the LS group was 7.7°±4.3° at the final follow-up compared with the early postoperative correction angle at 9.1°±5.8°, with no statistically significant difference. CONCLUSIONS: Extended posterior decompression, posterior instrumentation, and fusion are effective methods of surgery for treatment of spinal tuberculosis involved in the thoracic, thoracolumbar, lumbar, and lumbosacral regions.

Congenital Spinal Canal Stenosis with Ossification of the Ligamentum Flavum in an Achondroplastic Patient: A Case Report and Literature Review.

Achondroplasia has an effect on intracartilaginous ossification during the development of the spine resulting in a narrow spinal canal. This abnormal anatomy could make an achondroplastic patient tend to have spinal canal stenosis. We reported a case of congenital spinal canal stenosis with achondroplasia combined with ossified ligamentum flavum (OLF) at the thoracolumbar and lumbar spine, which was treated by decompressive surgery. We reported a 52-year-old Thai male with achondroplasia presented with progressive myelopathy and neurogenic claudication due to spinal canal stenosis. Spinal canal stenosis was observed at T10/11 and L1-L5 and OLF at T10/11 through L5 varying in size. Laminectomy and removal of the OLF were performed at T11 and L1-L5. The patient's neurological symptom improved after the surgery. He could walk with a walker at the time of 6-month follow-up postoperatively. In this report, we describe a rare case of achondroplasia with OLF presenting with progressive myelopathy and claudication symptoms from multiple levels of spinal canal stenosis. Laminectomy, removal of the ossified ligament, and fusion with instrumentation resulted in the improvement of the patient's neurological symptoms and function.

Chronic posterior atlantoaxial subluxation associated with os odontoideum: a rare condition. A case report and literature review.

Introduction: Os odontoideum is a rare cervical lesion. This unusual condition is sometimes associated with atlantoaxial subluxation, which is mostly anterior subluxation. Posterior atlantoaxial subluxation due to os odontoideum is extremely rare. Case presentation: We report an unusual case of a 60-year-old Thai female, who was diagnosed as having chronic posterior atlantoaxial subluxation associated with os odontoideum with progressive myelopathy. The patient underwent posterior arch of C1 laminectomy and an occipito-C3 fusion using an occipital plate, C2 pedicle screws, C3 lateral mass screws and autologous iliac crest strut bone graft arthrodesis. During three years of follow-up, she was clinically significantly improved and postoperative radiographs showed a solid osseous fusion without loss of correction or implant failure. Discussion: Chronic posterior atlantoaxial subluxation associated with os odontoideum is rare. This condition can cause occipital-cervical pain, myelopathy, intracranial symptoms, or death. Surgical decompression and stabilization is the treatment of choice. Principles of treatment are to prevent sudden death from neurological compromise, improve neurological status, stabilize the cervical spine, and improve quality of life. Surgical options include atlantoaxial fusion, occipito-C2 fusion, and occipito-C3 fusion. Decision making depends on the location of spinal cord compression, area for arthrodesis, and bone quality.

Metastatic Basal Cell Adenocarcinoma of Submandibular Gland to the Spine: An Extremely Rare Condition.

BACKGROUND: Basal cell adenocarcinomas are rare malignant neoplasms of salivary glands, accounting for <1% of salivary gland tumors. Few cases of distant metastases have been reported. CASE DESCRIPTION: A 50-year-old Thai man was diagnosed with basal cell adenocarcinoma of the submandibular gland with pulmonary and cervical spine metastases with progressive myelopathy. He was treated with wide surgical resection of the soft tissue tumor and modified radical neck dissection, anterior cervical total corpectomy with fusion combined with posterior decompression and fusion of the cervical spine, and surgical wound coverage by anterolateral thigh free tissue transfer, followed by adjuvant radiotherapy. At 18-month follow-up, the patient remained in good condition, and no signs of local recurrence or contiguous spreading were detected. Postoperative radiographs showed solid osseous fusion without loss of correction or implant failure. CONCLUSIONS: This case highlighted an extremely rare condition of metastatic basal cell adenocarcinoma of the submandibular gland to the lung and spine, which, to our knowledge, has not been previously reported in the literature.

What Are the Functional Outcomes After Total Sacrectomy Without Spinopelvic Reconstruction?

BACKGROUND: After total sacrectomy, many types of spinopelvic reconstruction have been described with good functional results. However, complications associated with reconstruction are not uncommon and usually result in further surgical interventions. Moreover, less is known about patient function after total sacrectomy without spinopelvic reconstruction, which may be indicated when malignant or aggressive benign bone and soft tissue tumors involved the entire sacrum. QUESTIONS/PURPOSES: (1) What is the functional outcome and ambulatory status of patients after total sacrectomy without spinopelvic reconstruction? (2) What is the walking ability and ambulatory status of patients when categorized by the location of the iliosacral resection relative to the sacroiliac joint? (3) What complications and reoperations occur after this procedure? METHODS: Between 2008 and 2014, we performed 16 total sacrectomies without spinopelvic reconstructions for nonmetastatic oncologic indications. All surviving patients had followup of at least 12 months, although two were lost to followup after that point (mean, 43 months; range, 12-66 months, among surviving patients). During this time period, we performed total sacrectomy without reconstruction for all patients with primary bone and soft tissue tumors (benign and malignant) involving the entire sacrum with no initial metastasis. The level of resection was the L5-S1 disc in 14 patients and L4-L5 disc in two patients. We classified the resection into two types based on the location of the iliosacral resection. Type I resections went medial to or through or lateral but close to the sacroiliac joint. Type II resections were far lateral (more than 3 cm from the posterior iliac spine) to the sacroiliac joint. Musculoskeletal Tumor Society (MSTS) scores, physical function assessments, and complications were gleaned from chart review performed by the treating surgeons (PK, BS). Video documentation of patients walking was obtained at followup in eight patients. RESULTS: The mean overall MSTS scores was 17 (range, 5-27). Thirteen patients were able to walk, five without walking aids, two with a cane and sometimes without a walking aid, three with a cane, and three with a walker. Thirteen of 14 patients who had bilateral Type I resections or a Type I resection on one side and Type II on the contralateral side were able to walk, five without a walking aid, and had a mean MSTS score of 19 (range, 13-27). Two patients with bilateral Type II resection were only able to sit. Complications included wound dehiscences in 13 patients (which were treated with reoperation for drainage), sciatic nerve injury in seven patients, a torn ureter in one patient, and a rectal tear in one patient. CONCLUSIONS: Without spinopelvic reconstruction, most patients in this series who underwent total sacrectomy were able to walk. Good MSTS scores could be expected in patients with bilateral Type I resections and patients with a Type I on one side and a Type II on the contralateral side. Total sacrectomy without spinopelvic reconstruction should be considered as a useful alternative to reconstructive surgery in patients who undergo Type I iliosacral resection on one or both sides. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Primary leiomyosarcoma of the spine treated with total en bloc spondylectomy: the first case in Thailand-a case report and literature review.

Leiomyosarcoma is a rare type of malignant soft tissue tumor and also one of the most aggressive soft tissue sarcomas. It commonly occurs in uterus, abdominal viscera, retroperitoneal space and soft tissue of the extremities. Primary osseous leiomyosarcoma is a rare condition. Furthermore, primary leiomyosarcoma of the spine is extremely rare. Only few cases have been reported. However, the treatment and outcomes remains controversial. Therefore, the objective of this case report is to illustrate the management of this extremely rare disease by using total en bloc spondylectomy (TES) procedure, which is one of a suitable option for surgical resection of the spinal tumors. In this study, we presented an unusual case of a 61-year-old female, who was diagnosed as primary leiomyosarcoma of the twelfth thoracic spine with liver metastasis, treated with total en bloc spondylectomy of the twelfth thoracic vertebra followed by chemotherapy. On last follow-up, 6 months after the surgery, the clinical outcome remained in good condition and no signs of local recurrence. In conclusion, primary leiomyosarcoma of the spine is an extremely rare and difficult to diagnosis. Immunohistochemistry studies are very important for confirmation of the diagnosis. Standard treatment remains controversial. However, surgical resection is still treatment of choice. One of the most effective surgical options is TES, which give the better outcome and minimize local recurrence, if indicate.

Cervical Radiculopathy: Incidence and Treatment of 1,420 Consecutive Cases.

STUDY DESIGN: Retrospective case series. PURPOSE: To determine the incidence of cervical radiculopathy requiring operative intervention by level and to report on the methods of treatment. OVERVIEW OF LITERATURE: Cervical radiculopathy is a common cause of pain and can result in progressive neurological deficits. Although the pathology is well understood, the actual incidence of cervical radiculopathy at particular spinal levels ultimately requiring operative intervention is unknown. METHODS: A large consecutive series of patients operated on by a single surgeon were retrospectively analyzed. The incidence of cervical radiculopathy at each level was defined for every patient. Procedures used for operative treatment were noted. Health related quality of life (HRQL) scores were collected both pre-operatively and postoperatively. RESULTS: There were 1305 primary and 115 revision operations performed. The most common primary procedures performed were anterior cervical discectomy and fusion (ACDF, 50%) and anterior cervical corpectomy and fusion (ACCF, 28%). The most commonly affected levels were C6 (66%) and C7 (62%). Reasons for revision were pseudarthrosis (27%), clinical adjacent segment pathology (CASP, 63%), persistent radiculopathy (11%), and hardware-related (2.6%). The most common procedures performed in the revision group were posterior cervical decompression and fusion (PCDF, 42%) and ACDF (40%). The most commonly affected levels were C7 (43%) and C5 (30%). Among patients that had their index surgery at our institution, the revision rate was 6.4%. In both primary and revision cases there was a significant improvement in Neck Disability Index and visual analogue scale scores postoperatively. Postoperative HRQL scores in the revision cases were significantly worse than those in the primary cases (p <0.01). CONCLUSIONS: This study provides the largest description of the incidence of cervical radiculopathy by level and operative outcomes in patients undergoing cervical decompression. The incidence of CASP was 4.2% in 3.3 years in this single institution series.

Neck Pain following Laminoplasty.

Study Design Retrospective evaluation of prospectively collected data. Objective To compare preoperative and postoperative neck pain following laminoplasty using the Neck Disability Index (NDI). Methods Seventy-two patients undergoing laminoplasty from 2006 to 2009 at a single institution were identified. Thirty-four patients with a minimum 1-year follow-up who completed preoperative, 6-week, and 1-year postoperative NDI questionnaires were enrolled. Demographic data and surgical data including estimated blood loss (EBL), length of surgery, number of laminoplasty levels, complications, and length of hospitalization were collected. Results Mean age was 62 years (range: 34 to 88), mean follow-up was 17 months (range: 12 to 31), and there were 21 men and 13 women. Diagnoses were cervical spondylotic myelopathy (n = 26), ossification of the posterior longitudinal ligament (n = 6), and central cord syndrome (n = 2). Mean EBL was 120 mL (range: 50 to 200), and mean surgical time was 152 minutes (range: 70 to 240). Average number of laminoplasty levels was 3 (range: 1 to 5). The open door technique was used, and 24/34 (71%) did not have laminoplasty at C3 and C7. No intraoperative complications were noted, and average hospital stay was 1.6 days (range: 1 to 7). Significant improvement in NDI total score was noted at 1 year (p < 0.002) and in NDI pain score at 6 weeks (p < 0.028) and 1 year (p < 0.007) postoperatively. Conclusions Patients having laminoplasty experienced significant improvement in NDI pain subscore and NDI total scores at a minimum of 1 year postoperatively.

Comparison of Smith-Petersen osteotomy versus pedicle subtraction osteotomy versus anterior-posterior osteotomy types for the correction of cervical spine deformities.

STUDY DESIGN: Retrospective case controlled study. OBJECTIVE: To describe the amount of correction obtained with different types of osteotomies in the cervical spine when treating cervical deformity. SUMMARY OF BACKGROUND DATA: Although the corrective power of various osteotomies in the thoracic and lumbar spine are well described, there are no reports in the literature on the corrective capabilities of osteotomies in the cervical spine to guide preoperative planning for cervical and cervicothoracic deformities. METHODS: Patients who underwent cervical osteotomies for cervical deformity were identified in a 10-year period from 2000 to 2010. Demographics, surgery type, osteotomy type (Smith-Petersen Osteotomy [SPO], pedicle subtraction osteotomy [PSO], anterior-osteotomy [ATO]), operative details, and radiographs were collected for preoperative and ultimate postoperative time points. Cervical lordosis and basion plumb line were collected to assess angular and translational corrections. RESULTS: A total of 61 patients had surgery for cervical deformity in the study period. The mean angular correction generated through 1 SPO was 10.1° per level (range, 1.0°-24.9°/level) and the mean translational correction was 1.8 cm (range, 0.5-4.0 cm/SPO). A PSO generated a mean angular correction of 34.5° (range, 28.2°- 80.0°/level, maximum 1/case) per PSO and translational correction of 2.5 cm per PSO (range, 0.2-5.6 cm). An ATO generated a mean angular correction of 17.1° per osteotomy (range, 3.5°-32.1°/level) and translational correction of 1.0 cm per osteotomy (range, 0.1-3.0 cm/level; total, 0.5-3 cm). Combined ATO and SPO with posterior cervical fusion generated a mean angular correction of 27.8° per osteotomy (range, 3.7°-66.7°/level) and translational correction of 2.6 cm per osteotomy (range, 0.2-7.0 cm/level). CONCLUSION: Posteriorly based osteotomies provided better translational correction than ATOs. The angular correction achieved by 1 PSO was similar to ATO+SPOs. ATO+SPOs provided equal or better corrections than isolated PSOs, with equal length of stay and less estimated blood loss. LEVEL OF EVIDENCE: 4.

Correlation of cord signal change with physical examination findings in patients with cervical myelopathy.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To determine whether cord signal change (CSC) visualized on magnetic resonance imaging (MRI) correlates with level-specific physical examination findings as well as other signs of cervical myelopathy. SUMMARY OF BACKGROUND DATA: Although CSC is often used as a marker for severe cervical spine pathology, it is not known whether CSC detected on MRI actually translates clinically into level-specific findings detected on physical examination. METHODS: A consecutive series of patients with CSC evident on MRI operated on by a single surgeon from 2010 to 2012 were retrospectively analyzed. Patients' preoperative reflex examination (biceps, brachioradialis, and triceps) including abnormal reflexes (Hoffman sign, inverted radial reflex, clonus, and Babinski) were recorded. Patients were deemed to have an examination consistent with the level of CSC if they had normal reflexes cranial to the level of CSC, were hypo-reflexic at the affected level, and hyper-reflexic caudal to the level of CSC. RESULTS: Forty-three patients with CSC were identified during the study period (Table 1). Isolated T2 CSC was present in 35 patients, and concomitant T1 and T2 CSC was present in 8 patients. Interestingly, the reflex examination correlated poorly with the cranio-caudad level of CSC, with only 11 of 43 patients (26%) having a concordant examination. In patients with CSC, 16% had clonus, 67% had Hoffman sign, 44% had Romberg sign, and 60% had a gait abnormality. CONCLUSION: CSC visualized on MRI correlates poorly with the upper extremity reflex examination in patients with cervical myelopathy. Of the pathological reflexes, Hoffman sign has the strongest association with CSC, but still was only positive in 67% of cases. More sensitive clinical measures need to be developed to more accurately associate CSC detected on MRI to the clinical severity of cervical spondylotic myelopathy.

Anterior cervical osteotomy for fixed cervical deformities.

STUDY DESIGN: Description of surgical technique with case series. OBJECTIVE: To describe the surgical management of fixed cervical deformities using an anterior osteotomy of the cervical spine. SUMMARY OF BACKGROUND DATA: Although posteriorly based osteotomies of the cervical spine have been described in the past, there are no reports of the surgical technique for performing an anterior osteotomy of the cervical spine for fixed cervical deformities. METHODS: Description of a single surgeon's technique for performing an anterior cervical osteotomy and his experience in performing this technique from 2000 to 2010 in a consecutive series of patients. Demographics, operative details, and clinical/radiographical outcomes were collected. The cohort was separated into 2 groups. Group 1 had anterior osteotomy only with or without posterior instrumentation whereas group 2 had anterior osteotomy and Smith-Petersen osteotomies with posterior instrumentation. RESULTS: A total of 38 patients (group 1 = 17, group 2 = 21) underwent an anterior osteotomy in the study period with an average follow-up of 3.4 years (range, 1.0-6.3 yr). All but 7 cases were revision cases. Group 1 had shorter length of surgery and less estimated blood loss than group 2 (length of surgery 220 vs. 313 min, P < 0.01; estimated blood loss 189 vs. 294 mL, P = 0.02).The mean angular correction achieved in group 1 was less than that of group 2, although not statistically significant (23° vs. 33°, P = 0.15). There was less mean translational correction achieved in group 1 compared with group 2 (1.3 vs. 3.7 cm, P = 0.03). Both groups had improvements in the neck disability index with surgery and were similar between groups (20 vs. 19.7, P = 0.78). There were no neurological complications or intraoperative neuromonitoring changes in either group. CONCLUSION: The use of an anterior osteotomy in the cervical spine is safe and effective for the correction of fixed deformities of the cervical spine. When necessary, Smith-Petersen osteotomies can add to the angular and translational correction to achieve a satisfying outcome for patients. LEVEL OF EVIDENCE: 4.

Dynamic radiographic criteria for detecting pseudarthrosis following anterior cervical arthrodesis.

BACKGROUND: While interspinous motion analysis is commonly used to determine the status of an anterior cervical fusion, the accuracy of this technique is unclear. We believed that three questions needed to be answered. What degree of image magnification is ideal? How much motion should be considered "adequate" for making dynamic radiographs? What is the optimal amount of interspinous motion for detecting pseudarthrosis? METHODS: We performed a retrospective study of 125 patients (109 fused segments and 153 pseudarthrotic segments) who had undergone reexploration with confirmation of fusion status. Interspinous motion at each operatively treated level and one superjacent level was measured by two independent investigators twice. Reliabilities of interspinous motion analysis at different magnification rates (25%, 100%, 150%, and 200%) were evaluated for fifty randomly selected segments to determine the optimal magnification, which we used for the remainder of the measurements. Fusion status was also determined on computed tomography (CT) by two other raters. We compared the intraoperative findings with those based on dynamic radiographs (with use of cutoff values of 1 and 2 mm of interspinous motion as the indication of pseudarthrosis) and CT. RESULTS: On radiographs, both 150% and 200% magnification yielded higher interobserver and intraobserver reliabilities compared with 25% and 100% magnification, and the reliabilities at 150% and 200% were similar to each other, so subsequent measurements were made at 150%. The cutoff value of interspinous motion for detecting pseudarthrosis was 0.9 mm as determined with receiver operating characteristic curve analysis. Compared with CT, interspinous motion of ≥ 1 mm showed relatively low sensitivity (79.5%) and negative predictive value (77.1%) and similar specificity (97.0%) and positive predictive value (97.4%). Using interspinous motion of ≥ 2 mm as the cutoff decreased the sensitivity and negative predictive value to 46.6% and 56.8%, respectively. Our evaluation of what constituted adequate dynamic motion for making the radiographs showed that, with use of interspinous motion of ≥ 1 mm as the cutoff for detecting pseudarthrosis, superjacent interspinous motion of ≥ 4 mm increased the sensitivity and negative predictive value (86.3% and 83.4%) compared with those associated with alternative cutoffs of superjacent interspinous motion (≥ 3.5, ≥ 5, and ≥ 6 mm), and the specificity (96.1%) and positive predictive value (96.9%) were reasonable. CONCLUSIONS: Use of interspinous motion of ≥ 1 mm as the cutoff for detection of anterior cervical pseudarthrosis on radiographs magnified 150% and made with superjacent interspinous motion of ≥ 4 mm yielded accuracies comparable with those of CT.

Patients with proximal junctional kyphosis requiring revision surgery have higher postoperative lumbar lordosis and larger sagittal balance corrections.

STUDY DESIGN: Case control study. OBJECTIVE: To evaluate risk factors in patients in 3 groups: those without proximal junctional kyphosis (PJK) (N), with PJK but not requiring revision (P), and then those with PJK requiring revision surgery (S). SUMMARY OF BACKGROUND DATA: It is becoming clear that some patients maintain stable PJK angles, whereas others progress and develop severe PJK necessitating revision surgery. METHODS: A total of 206 patients at a single institution from 2002 to 2007 with adult scoliosis with 2-year minimum follow-up (average 3.5 yr) were analyzed. Inclusion criteria were age more than 18 years and primary fusions greater than 5 levels from any thoracic upper instrumented vertebra to any lower instrumented vertebrae. Revisions were excluded. Radiographical assessment included Cobb measurements in the coronal/sagittal plane and measurements of the PJK angle at postoperative time points: 1 to 2 months, 2 years, and final follow-up. PJK was defined as an angle greater than 10°. RESULTS: The prevalence of PJK was 34%. The average age in N was 49.9 vs. 51.3 years in P and 60.1 years in S. Sex, body mass index, and smoking status were not significantly different between groups. Fusions extending to the pelvis were 74%, 85%, and 91% of the cases in groups N, P, and S. Instrumentation type was significantly different between groups N and S, with a higher number of upper instrumented vertebra hooks in group N. Radiographical parameters demonstrated a higher postoperative lumbar lordosis and a larger sagittal balance change, with surgery in those with PJK requiring revision surgery. Scoliosis Research Society postoperative pain scores were inferior in group N vs. P and S, and Oswestry Disability Index scores were similar between all groups. CONCLUSION: Patients with PJK requiring revision were older, had higher postoperative lumbar lordosis, and larger sagittal balance corrections than patients without PJK. Based on these data, it seems as though older patients with large corrections in their lumbar lordosis and sagittal balance were at risk for developing PJK, requiring revision surgery. LEVEL OF EVIDENCE: 3.

Total sacrectomy for low-grade malignant peripheral nerve sheath tumour: a case report.

We report on a 58-year-old woman who underwent total sacrectomy and spinopelvic reconstruction for a low-grade malignant peripheral nerve sheath tumour involving the sacrum. One week later, she developed deep wound infection, and the entire spinopelvic reconstruction was removed. At the 36-month followup, the patient had no pain and was able to walk with a walking frame. There was no sign of recurrence or metastasis.

A comparative study of radiographic results using HEALOS collagen-hydroxyapatite sponge with bone marrow aspiration versus local bone graft in the same patients undergoing posterolateral lumbar fusion.

BACKGROUND: Autologous bone harvested from the iliac crest is the gold standard for lumbar spinal fusion. However postoperative donor site pain and morbidity have been reported. Local bone graft is insufficient and contains some soft-tissue attachment. Therefore, Healos (DePuy Spine, Raynham, MA, USA) is currently bone graft substitute that was introduced for spinal fusion with good results but radiographic fusion rate has not been clearly defined yet. OBJECTIVE: To assess the radiographic fusion rate of HEALOS with bone marrow aspiration versus autologous bone graft in the same patients undergoing posterolateral lumbar fusion. MATERIAL AND METHOD: A retrospective radiographic outcome study of radiographic fusion rate from plain radiographs in 55patients indicatedforposterolateral lumbar fusion in Lerdsin General Hospital between April 2005 and December 2006 was done. The patients were implanted with HEALOS collagen-hydroxyapatite sponge with bone marrow aspiration and local bone graft on each side of Posterolateral Lumbar Fusion. Twenty-seven patients were included in the present study according to the authors'inclusion criteria. Plain radiographs were collected and radiographic fusion rate was assessed for at least two years follow-up. RESULTS: The two years post operative radiographic fusion rate was 29.63% (8/27) in Healos/BMA group and 62.96% (17/27) in LBG group. At three-years follow-up, radiographic fusion rate of 36.84% (7/19) was achieved in the Healos/ BMA group and 78.93% (15/19) in the LBG group. CONCLUSION: In the present study, Healos collagen-hydroxyapatite sponge with bone marrow aspiration had lower radiographic fusion rate when compared to local bone graft in posterolateral lumbar fusion at two years post operative. The results of the Healos/BMA group was increased fusion rate with time but remained lower than LBG group at three and four years follow-up.

Proximal junctional kyphosis results in inferior SRS pain subscores in adult deformity patients.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: We aimed to examine the difference in clinical outcomes in proximal junctional kyphosis (PJK). SUMMARY OF BACKGROUND DATA: To date, PJK has been primarily a radiographical finding. Inferior outcomes associated with PJK have not been reported. We performed an analysis of PJK in adult deformity patients to identify risk factors and to evaluate clinical outcomes. METHODS: A total of 364 patients at a single institution from 2002 to 2007 with adult scoliosis, with an average 3.5 years' follow-up were analyzed. Inclusion criteria were age more than 18 years and fusion greater than 5 levels from any thoracic upper instrumented vertebrae to any lower instrumented vertebrae. Cobb measurements in the coronal and sagittal plane in addition to measurements of the PJK angle at postoperative time points were performed. Clinical assessment was performed using Scoliosis Research Society (SRS) scores and the Oswestry Disability Index. RESULTS: The prevalence of PJK was 39.5% (144/364). The average age in the non-PJK group (n-PJK) was 48.9 versus 53.3 in the PJK group (PJK), and, specifically, age more than 60 years posed a higher prevalence. The prevalence of osteoporosis was 9.8% versus 20.4% in the n-PJK versus PJK groups, respectively. Sex, body mass index, revision surgery, and smoking status were not different between groups. Pain was prevalent in 0.9% versus 29.4% in n-PJK versus PJK, which resulted in lower composite SRS Pain scores (mean change +1.2 vs. +0.8), despite no differences seen in other SRS domains, total SRS score, or Oswestry Disability Index. On multivariate analysis, the presence of pain of the upper back was highly predictive of PJK (odds ratio, 12.5, 95% confidence interval, 2.5-63.2). Radiographically, no differences were seen between groups. However, increasing distance of the upper instrumented vertebrae to C7 plumb line had a higher prevalence of PJK. Instrumentation type, surgical approach, and crosslink use were not different between groups. CONCLUSION: PJK results in worse clinical outcomes measured by the SRS Pain subscore. Our regression model suggests that pain in the upper back has a strong predictive value for PJK. LEVEL OF EVIDENCE: 3.