Multilevel thoracic and lumbar ligamentum flavum ossification in an achondroplasic-a rare presentation.

INTRODUCTION: Achondroplasia is a rare autosomal dominant condition characterized by stenosis in spinal canal. Multilevel Ossification of the ligamentum flavum in the spine is a rare occurrence which too can contribute to stenosed canal. CASE PRESENTATION: We report a case of an Indian achondroplasic dwarf with multilevel ossification of ligamentum flavum (OLF) at thoracic and lumbar segment. She presented in the outpatient department with bilateral weakness in legs with complete foot drop on the left side and was non-ambulatory. She was managed surgically by instrumentation with multiple interbody fusions with wide decompression and excision of OLF. The patient responded well to the surgery and became a walker after 2-year follow-up. DISCUSSION: Achondroplasic patients may present rarely with multiregional and multilevel OLF. It is important to identify them preoperatively so as to have good surgical outcome. Wide laminectomy, removal of the ossified ligament, and fusion with instrumentation resulted in the improvement of the patient's neurological symptoms and functions.

Proximal Junctional Kyphosis after Pediatric Angular Kyphotic Deformity Correction: Are we Missing Something?

PURPOSE: Corrective maneuvers in an angular kyphotic deformity have its own problems including early complications such as neurological deficit and late complications such as proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). This article discusses the probable mechanisms, leading to PJK in pediatric severe angular kyphotic deformities and preventive strategies for the same. We will also assess natural course of untreated PJK and its devastating consequences. MATERIALS AND METHODS: Three patients, two 13-year males presented with progressive, painless thoracolumbar kyphoscoliotic deformity, with segmental kyphosis 100° and 140° and scoliosis of 33° and 78°, respectively, and one 14-year-old female presented with angular kyphotic deformity of 60° with apex at D11-12 level. RESULTS: Posterior vertebral column resection with segmental deformity correction with good coronal and sagittal balance was done. In the follow-up, PJF was seen. Second surgery was done with the extension of instrumentation to D4 along with deformity correction in both the male patients. The female patient did not opt for a revision surgery, and we are following the natural history of this case. CONCLUSION: In severe thoracolumbar angular kyphotic deformities with normal or negative sagittal balance, it might be a safer option to select the sagittal stable vertebra as upper instrumented vertebra based on the C2 plumb line on the preoperative standing lateral radiographs. However, a study with a larger sample size is needed to validate our hypothesis.

Sacropelvic fixation techniques - Current update.

Sacropelvic is a complex junctional area owing to the complex regional anatomy and higher biomechanical stress. However extension of construct is indicated in cases with complex deformities, high grade spondylolisthesis, and complex fractures. The challenges remain which includes pseudoarthrosis and fixation failures. The fixation techniques have constantly evolved over time with better results with iliac screws and S2-alar-iliac screws. This article gives background on evolution, biomechanics, and recent update of use of robotics for sacropelvic fixation.

Management and prognosis of acute traumatic cervical central cord syndrome: systematic review and Spinal Cord Society-Spine Trauma Study Group position statement.

PURPOSE: Spinal Cord Society (SCS) and Spine Trauma Study Group (STSG) established a panel tasked with reviewing management and prognosis of acute traumatic cervical central cord syndrome (ATCCS) and recommend a consensus statement for its management. METHODS: A systematic review was performed according to the PRISMA 2009 guidelines. Delphi method was used to identify key research questions and achieve consensus. PubMed, Scopus and Google Scholar were searched for corresponding keywords. The initial search retrieved 770 articles of which 37 articles dealing with management, timing of surgery, complications or prognosis of ATCCS were identified. The literature review and draft position statements were compiled and circulated to panel members. The draft was modified incorporating relevant suggestions to reach consensus. RESULTS: Out of 37 studies, 15 were regarding management strategy, ten regarding timing of surgery and 12 regarding prognosis of ATCCS. CONCLUSION: There is reasonable evidence that patients with ATCCS secondary to vertebral fracture, dislocation, traumatic disc herniation or instability have better outcomes with early surgery (< 24 h). In patients of ATCCS secondary to extension injury in stenotic cervical canal without fracture/fracture dislocation/traumatic disc herniation/instability, there is requirement of high-quality prospective randomized controlled trials to resolve controversy regarding early surgery versus conservative management and delayed surgery if recovery plateaus or if there is a neurological deterioration. Until such time decision on surgery and its timing should be left to the judgment of physician, deliberating on pros and cons relevant to the particular patient and involving the well-informed patient and relatives in decision making. These slides can be retrieved under Electronic Supplementary Material.

Reliability of Allen Ferguson classification versus subaxial injury classification and severity scale for subaxial cervical spine injuries: a psychometrics study.

STUDY DESIGN: A psychometrics study. OBJECTIVES: To determine intra and inter-observer reliability of Allen Ferguson system (AF) and sub-axial injury classification and severity scale (SLIC), two sub axial cervical spine injury (SACI) classification systems. SETTING: Online multi-national study METHODS: Clinico-radiological data of 34 random patients with traumatic SACI were distributed as power point presentations to 13 spine surgeons of the Spine Trauma Study Group of ISCoS from seven different institutions. They were advised to classify patients using AF and SLIC systems. A reference guide of the two systems had been mailed to them earlier. After 6 weeks, the same cases were re-presented to them in a different order for classification using both systems. Intra and inter-observer reliability scores were calculated and analysed with Fleiss Kappa coefficient (k value) for both the systems and Intraclass correlation coefficient(ICC) for the SLIC. RESULTS: Allen Ferguson system displayed a uniformly moderate inter and intra-observer reliability. SLIC showed slight to fair inter-observer reliability and fair to substantial intra-observer reliability. AF mechanistic types showed better inter-observer reliability than the SLIC morphological types. Within SLIC, the total SLIC had the least inter-observer agreement and the SLIC neurology had the highest intra-observer agreement. CONCLUSION: This first external reliability study shows a better reliability for AF as compared to SLIC system. Among the SLIC variables, the DLC status and the total SLIC had least agreement. Low-reliability highlights the need for improving the existing classification systems or coming out with newer ones that consider limitations of the existing ones.

Feasibility of Sub-Axial Cervical Laminar Screws, Including C7, in the Indian Population: A Study on 50 Patients Using Computed Tomography-Based Morphometry Measurements.

STUDY DESIGN: Observational study of computed tomography (CT) data. PURPOSE: We performed a CT-based radiographic analysis of sub-axial cervical lamina in the Indian population to assess the feasibility of laminar screws. OVERVIEW OF LITERATURE: Morphometric studies have been performed for populations of various ethnic groups, but none exist for Indian populations. METHODS: Cervical spine CT scans of 50 adults with a minimum slice thickness of <2 mm (0.5-2 mm) were obtained from the database of a single center in northern India. Measurements (e.g., length, thickness, and height) were taken in millimeters along the axial, coronal, and sagittal planes. Three measurements were made to assess laminar anatomy, namely, the translaminar/screw length, laminar thickness, and sagittal laminar height. RESULTS: The final sample comprised 500 laminae in 50 patients, resulting in 1,500 measurements. The mean translaminar lengths of the C3, C4, C5, C6, and C7 laminae were 19.48 mm, 19.60 mm, 19.61 mm, 20.49 mm, and 22.85 mm, respectively. The mean thick- , 19.60 , 19.60 mm, 19.61 mm, 20.49 mm, and 22.85 mm, respectively. The mean thick- mm, 19.61 mm, 20.49 mm, and 22.85 mm, respectively. The mean thick- , 19.61 , 19.61 mm, 20.49 mm, and 22.85 mm, respectively. The mean thick- mm, 20.49 mm, and 22.85 mm, respectively. The mean thick- , 20.49 , 20.49 mm, and 22.85 mm, respectively. The mean thick- mm, and 22.85 mm, respectively. The mean thick- , and 22.85 mm, respectively. The mean thick , and 22.85 mm, respectively. The mean thicknesses of these cervical laminae were 3.12 mm, 2.62 mm, 2.56 mm, 3.47 mm, and 5.20 mm, respectively. The mean sagittal heights of these laminae were 9.38 mm, 9.80 mm, 10.12 mm, 11.31 mm, and 13.84 mm, respectively. Except for the C7 vertebrae, all other levels had a success rate of <10% in the Indian population using the criteria of a laminar height of at least 9 mm and thickness of 4.5 mm. Limited success was achieved at the C5, C6, and C3 levels. CONCLUSIONS: To the best of our knowledge, the present study is the only series on the feasibility of laminar screws in the sub-axial cervical spine in the Indian population. We found that Indian patients have smaller anatomical dimensions and thus, are not suitable for laminar screws in the sub-axial cervical spine, barring C7, which is contrary to findings for populations in western and south Asian countries.

Computed Tomography-Based Occipital Condyle Morphometry in an Indian Population to Assess the Feasibility of Condylar Screws for Occipitocervical Fusion.

STUDY DESIGN: A retrospective computed tomography (CT)-based morphometric study of 82 occipital condyles in the Indian population, focusing on critical morphometric dimensions with relation to placing condylar screws. PURPOSE: This study focused on determining the feasibility of placing occipital condylar screws in an Indian population using CT anatomical morphometric data. OVERVIEW OF LITERATURE: The occipital condylar screw is a novel technique being explored as one of the options in occipitocervical stabilization. Sex and ethnic variations in anatomical structures may restrict the feasibility of this technique in some populations. To the best of our knowledge, there are no CT-based data on an Indian population that assess the feasibility of occipital condylar screws. METHODS: We measured the dimensions of 82 occipital condyles in 41 adults on coronal, sagittal, and axial reconstructed CT images. The differences were noted between the right and left sides and also between males and females. Statistical analysis was performed using the t-test, with a p-value of <0.05 considered significant. RESULTS: Mean sagittal length and height were 17.2±1.7 mm and 9.1±1.5 mm, respectively. Mean condylar angle/screw angle was 38.0°±5.5° from midline, with mean condylar length and width of 19.6±2.6 mm and 9.5±1.0 mm, respectively. Average coronal height on the anterior and posterior hypoglossal canal was 10.8±1.4 mm and 9.0±1.4 mm, respectively. The values in females were significantly lower than those in males, except for screw angle and condylar width. Based on Lin et al.'s proposed criteria, eight of 82 condyles were not suitable for condylar screws. CONCLUSIONS: Preliminary CT morphometry data of the occipital condyle shows that condylar screws are anatomically feasible in a large portion of the Indian population. However, because a small number of population may not be suitable for this technique, meticulous study of preoperative anatomy using detailed CT data is advised.

Morphometric Study of C1 Pedicle and Feasibility Evaluation of C1 Pedicle Screw Placement with a Novel Clinically Relevant Radiological Classification in an Indian Population.

STUDY DESIGN: A retrospective computed tomography (CT)-based morphometric study of 84 C1pedicles in an Indian population focusing on critical morphometric dimensions vis-a-vis C1 pedicle screw placement. PURPOSE: To determine the feasibility of C1 pedicle screw placement in an Indian population and propose a novel classification system for the same. OVERVIEW OF LITERATURE: At present, C1 pedicle screws are rarely used, and very few studies have focused on the feasibility of pedicle screw placement in terms of racial, gender, and ethnic variations in anatomical structures. There are no CT-based data on C1 pedicles that assess the feasibility of pedicle screw placement in the Indian population. METHODS: We measured C1 pedicle diameter on CT coronal scan images of 42 adult patients. Extramedullary height (EMH) and intramedullary height (IMH) were measured. We examined the differences between the right and left atlas pedicles and compared measures between males and females. These data were analyzed using significance tests. Based on the results, we propose a novel classification system, which we believe will help in determining the feasibility of C1 pedicle screw placement. RESULTS: Forty-two adult patients (84 pedicles) were examined. Average EMH and IMH were 4.48±0.91 and 0.86±0.77, respectively. Approximately, 32% of the C1 pedicles had bone thicknesses of <4 mm, 49% had IMH of <1 mm, and 38% had no pedicles. The average thickness in women was 4.21±0.93 mm, which was significantly thinner than that in men (4.73±0.81 mm, p=0.004). Right and left pedicles were not significantly different. CONCLUSIONS: Our data indicate that approximately one-third of the Indian population may not be suitable candidates for C1 pedicle screw placement. Caution should be exercised while placing type 1B and type 2 pedicles based on our proposed classification system.

Dysplastic L5-S1 Spondyloptosis in a 3-Year-Old Child: A Case Report and Review of the Literature.

A three-year-old girl presented with primary complaint of severe low back pain with radiation to both lower limbs below the knees since 2 months following history of fall and marked restriction of her daily routine activities. After clinicoradiological evaluation she was diagnosed of having dysplastic L5-S1 spondyloptosis. A staged procedure was planned after thorough discussion with her parents. During initial stage she underwent posterior decompression along L5-S1 segment including exposure of bilateral L5 and S1 nerve roots followed by instrumented reduction (L3-S2 5.5 mm pedicle screws) utilizing a rotational-translational technique. No interbody fusion was done at L5-S1 level and inner nuts of bilateral L3, L4, and S2 screws were intentionally kept loose. Subsequently after about symptom-free three-year follow up, she presented with recurrence of symptoms and underwent revision surgery as per initial plan discussed with her parents. Removals of posterior implants were done followed by stabilization with larger diameter pedicle screws (6.5 mm) at L5 and S1 level. During the same stage through anterior transperitoneal approach L5-S1 interbody fusion was done. At one-year follow-up after second-stage definitive surgery, patient remains symptom-free and fully active without any radiological evidence of reduction loss or implant failure.

Reliability assessment of AOSpine thoracolumbar spine injury classification system and Thoracolumbar Injury Classification and Severity Score (TLICS) for thoracolumbar spine injuries: results of a multicentre study.

PURPOSE: The aim of this multicentre study was to determine whether the recently introduced AOSpine Classification and Injury Severity System has better interrater and intrarater reliability than the already existing Thoracolumbar Injury Classification and Severity Score (TLICS) for thoracolumbar spine injuries. METHODS: Clinical and radiological data of 50 consecutive patients admitted at a single centre with a diagnosis of an acute traumatic thoracolumbar spine injury were distributed to eleven attending spine surgeons from six different institutions in the form of PowerPoint presentation, who classified them according to both classifications. After time span of 6 weeks, cases were randomly rearranged and sent again to same surgeons for re-classification. Interobserver and intraobserver reliability for each component of TLICS and new AOSpine classification were evaluated using Fleiss Kappa coefficient (k value) and Spearman rank order correlation. RESULTS: Moderate interrater and intrarater reliability was seen for grading fracture type and integrity of posterior ligamentous complex (Fracture type: k = 0.43 ± 0.01 and 0.59 ± 0.16, respectively, PLC: k = 0.47 ± 0.01 and 0.55 ± 0.15, respectively), and fair to moderate reliability (k = 0.29 ± 0.01 interobserver and 0.44+/0.10 intraobserver, respectively) for total score according to TLICS. Moderate interrater (k = 0.59 ± 0.01) and substantial intrarater reliability (k = 0.68 ± 0.13) was seen for grading fracture type regardless of subtype according to AOSpine classification. Near perfect interrater and intrarater agreement was seen concerning neurological status for both the classification systems. CONCLUSIONS: Recently proposed AOSpine classification has better reliability for identifying fracture morphology than the existing TLICS. Additional studies are clearly necessary concerning the application of these classification systems across multiple physicians at different level of training and trauma centers to evaluate not only their reliability and reproducibility, but also the other attributes, especially the clinical significance of a good classification system.

Microdiscectomy or tubular discectomy: Is any of them a better option for management of lumbar disc prolapse.

OBJECTIVES: Various types of minimally invasive techniques have been developed for the treatment of lumbar disc herniation. The original laminectomy was refined into microdiscectomy (MD). MD is the gold standard in management of lumbar disc herniation and is used as a yardstick for comparison with newer procedures such as tubular discectomy. So far, no studies have been reported in Indian population comparing tubular discectomy and microdiscectomy. The aim of this study was to compare immediate postoperative and 1-year outcome of patients undergoing tubular discectomy with those undergoing MD and to evaluate the learning curve as well as complication rates of tubular discectomy. MATERIALS AND METHODS: Forty-six patients of MD and 102 (48 early and 54 late) patients of tubular discectomy (TD) were operated at Indian Spinal Injuries Centre, which is a tertiary level center between July 2009 and January 2012. They were studied for the following data: Baseline characteristics, visual analog scale (VAS) for leg pain and back pain, Oswestry Disability Index (ODI) scores, length of hospital stay, time taken to return to work, duration of surgery, intra- and post-operative complications, and reoperation rates. RESULTS: The VAS score for leg pain, back pain, and ODI scores showed improvement in both groups during the 1(st) year after surgery. Time taken to return to work and mean hospital stay was shorter in case of TD as compared to MD group. The mean duration of surgery was 34 min shorter for conventional MD. The incidence of dural tear was 6.5% in MD group and 10.4% in early TD and decreased to 7.4% in late TD group. CONCLUSION: This study revealed that rate of recovery is significantly faster for TD as compared to conventional MD. In contrast, we encountered fewer complications in MD approach as compared to TD which although were not statistically significant and which also decreased as we gained experience.

A case of severe and rigid congenital thoracolumbar lordoscoliosis with diastematomyelia presenting with type 2 respiratory failure: managed by staged correction with controlled axial traction.

INTRODUCTION: Congenital lordoscoliosis is an uncommon pathology and its management poses formidable challenge especially in the presence of type 2 respiratory failure and intraspinal anomalies. In such patients standard management protocols are not applicable and may require multistage procedure to minimize risk and optimize results. CASE DESCRIPTION: A 15-year-old girl presented in our hospital emergency services with severe breathing difficulty. She had a severe and rapidly progressing deformity in her back, noted since 6 years of age, associated with severe respiratory distress requiring oxygen and BiPAP support. She was diagnosed to have a severe and rigid congenital right thoracolumbar lordoscoliosis (coronal Cobb's angle: 105° and thoracic lordosis -10°) with type 1 split cord malformation with bony septum extending from T11 to L3. This leads to presentation of restrictive lung disease with type 2 respiratory failure. As her lung condition did not allow for any major procedure, we did a staged procedure rather than executing in a single stage. Controlled axial traction by halogravity was applied initially followed by halo-femoral traction. Four weeks later, this was replaced by halo-pelvic distraction device after a posterior release procedure with asymmetric pedicle substraction osteotomies at T7 and T10. Halo-pelvic distraction continued for 4 more weeks to optimize and correct the deformity. Subsequently definitive posterior stabilization and fusion was done. The detrimental effect of diastematomyelia resection in such cases is clearly evident from literature, so it was left unresected. A good scoliotic correction with improved respiratory function was achieved. Three years follow-up showed no loss of deformity correction, no evidence of pseudarthrosis and a good clinical outcome with reasonably balanced spine. CONCLUSION: The management of severe and rigid congenital lordoscoliotic deformities with intraspinal anomalies is challenging. Progressive reduction in respiratory volume in untreated cases can lead to acute respiratory failure. Such patients have a high rate of intraoperative and postoperative morbidity and mortality. Hence a staged procedure is recommended. Initially a less invasive procedure like halo traction helps to improve their respiratory function with simultaneous correction of the deformity, while allowing for monitoring of neurological deficit. Subsequently spinal osteotomies and combined halo traction helps further improve the correction, following which definitive instrumented fusion can be done.

Antepartum surgical management of Pott's paraplegia along with maintenance of pregnancy during second trimester.

INTRODUCTION: The existing literature is limited and inconclusive regarding management of spinal tuberculosis with neurological deficit during advanced pregnancy. None of the previously published case series concerning this problem during the second trimester of pregnancy have explored the option of simultaneous surgical intervention for it along with maintenance of pregnancy. CASE REPORT: A 22-year-old woman with 26 weeks of pregnancy (2nd trimester) presented with upper back pain for the past 2 months, inability to move both lower limbs for the last 1 week, bladder and bowel dysfunction for the past 5 days (Frankel Grade B). Patient subsequently underwent MRI scan dorsal spine and the image findings were suggestive of spinal tuberculosis T2 level. After obstetric evaluation and opinion of the expectant mother, in view of extensive neurological deficit which progressed rapidly, decision was taken for surgical intervention along with maintenance of pregnancy. Patient was positioned in right lateral position after giving general anesthesia using double lumen endotracheal tube with lung isolation technique. Exposure was done using transthoracic third rib excision approach. Decompression was achieved by radical debridement at T2 vertebrae level followed by multiple rib strut grafts and stabilization with screw and rod construct between T1 and T3 vertebrae. Intra-operative measures including type of anesthesia, prevention of maternal hypotension, hypoxemia and hypothermia, and fetal monitoring by attending obstetrician were undertaken to maintain feto-maternal safety. Postoperative ultrasonography evaluation of the fetus revealed a normal study. Post-surgery histopathological evaluation of the surgical specimen confirmed tuberculosis infection and the patient continued anti-tubercular drug therapy for 9 months. She delivered a healthy girl child at 36 weeks of gestation by cesarean section. After about 14 months of postoperative follow-up, patient has completely recovered motor power with mild persistent sensory symptoms. She is self-voiding with mild constipation requiring occasional intermittent laxative use. Radiological improvements in comparison to the previous reports were also seen at the last follow-up. CONCLUSION: Although this is only a single case but being the first to our knowledge, the good results highlight the point that both surgical management and maintenance of pregnancy during second trimester complicated by Pott's paraplegia are possible, involving a multi-disciplinary team approach for optimal maternal and fetal outcome.

A rare case of chronic subdural haematoma presenting with paraparesis: A case report and review of literature.

OBJECTIVES: To report a rare case of spontaneous chronic subdural haematoma presenting with paraparesis and to highlight that subdural haematoma as one of the differential diagnoses for unexplained paraparesis. SUMMARY OF BACKGROUND DATA: Chronic subdural haematoma is common in elderly people usually presenting with altered mental status, monoplegia, headache and seizure. But spontaneous chronic subdural haematoma resulting in paraparesis is not reported in the literature. METHODS: A 58-year-old male patient presented with weakness of bilateral lower limbs and retention of urine and constipation. Patient was thoroughly evaluated and analysed. CONCLUSION: Spontaneous chronic subdural haematoma should be considered as one of the deferential diagnosis for paraparesis in elderly.

A novel technique for reduction of unreducible lumbar fractures in ankylosing spondylitis.

STUDY DESIGN: Retrospective case series study. PURPOSE OF STUDY: Fractures in ankylosed lumbar spine are difficult to reduce and it is like attempting to reduce the ends of a long bone fracture of an extremity. Simple compression from the posterior results in the anterior column opening in lumbar spine because of the inherent lordosis present there, which usually requires combined approach, if the gap is extensive. Purpose of our study is to describe a new technique for reduction of lumbar fracture not reducing through conventional technique in ankylosing spondylitis. There are no techniques described for reduction of these complex fractures in the literature to the best of our knowledge. METHODS: Four patients were operated by a new modified staged posterior approach. Two patients had AIS D neurology, one patient had AIS A neurology and one patient had normal neurology (AIS E). Patients were operated in a staged procedure in a single sitting, as single posterior procedure did not allow for complete reduction of lumbar fracture. The patients were first positioned prone and instrumentation was done. To close the anterior gap, patients were then positioned lateral and reduction and stabilization of fracture was done. RESULTS: Mean age of the patients was 50 years. Average time of surgery was 3 h 40 min. All four patients operated with this modified posterior approach had fusion 6 months after surgery. There were no significant complications. CONCLUSION: We recommend this technique to be used in fractures in lumbar ankylosed spine as they have tendency to open anteriorly after trauma. It helps in closure of anterior column in a single surgery and obviates the need for anterior surgery in these patients.

Pelvic obliquity in neuromuscular scoliosis: radiologic comparative results of single-stage posterior versus two-stage anterior and posterior approach.

STUDY DESIGN: retrospective comparative study (Level III). OBJECTIVE: to compare the operative results of posterior fusion and a 2-stage anterior L5-S1 fusion followed by posterior fusion in neuromuscular scoliosis patients with significant pelvic obliquity (PO). SUMMARY OF BACKGROUND DATA: PO in neuromuscular scoliosis is common and a challenging problem that affects proper sitting balance, necessarily addressing the deformity and proper maintenance of the correction. METHODS: a total of 54 patients with neuromuscular scoliosis and significant PO (>10°) were divided into 2 groups. Group 1 (n = 24) was operated on for posterior fusion and pelvic fixation. Group 2 (n = 30) included patients who were subjected to a first-stage procedure consisting of a lumbosacral junction release and fusion through a midline retroperitoneal approach and then a second-stage procedure of posterior fusion and pelvic fixation. Parameters measured included length of the follow-up, number of fusion levels, age at operation, forced vital capacity, operative time, estimated blood loss, and postoperative complications. Radiologic parameters measured before surgery, after surgery at the time of discharge, and at a final follow-up included Cobb angle, T1 translation, sitting pelvic obliquity (PO) in the frontal plane, C7 plumb line, thoracic kyphosis, lumbar lordosis, and sacral inclination angle in the sagittal plane. RESULTS: the correction of scoliosis was similar in both groups. The preoperative PO averaged 19.5° in Group I and 22.9° in Group II (P = 0.22), which corrected after surgery to 9.7° versus 7.4° (P = 0.23), respectively. Group II correction progressively improved significantly compared to Group I (7.0° vs. 11.6° at P = 0.046) at the latest follow-up. A 40.6% correction (mean correction = 7.9) in sitting PO in Group I compared to 70.7% correction (mean correction = 5.9°) in Group II was observed (P = 0.004). The average loss of correction of PO at the final follow-up was lesser in group II, but not statistically significant (P = 0.07). CONCLUSION: anterior fusion of the lumbosacral junction followed by posterior fusion provides superior correction and maintenance of PO in patients with neuromuscular scoliosis.

Video-Assisted Thoracoscopic Surgery Plus Lumbar Mini-Open Surgery for Adolescent Idiopathic Scoliosis

PURPOSE: The objectives of this study are to describe the outcome of adolescent idiopathic scoliosis (AIS) patients treated with Video Assisted Thoracoscopic Surgery (VATS) plus supplementary minimal incision in the lumbar region for thoracic and lumbar deformity correction and fusion. MATERIALS AND METHODS: This is a case series of 13 patients treated with VATS plus lumbar mini-open surgery for AIS. A total of 13 patients requiring fusions of both the thoracic and lumbar regions were included in this study: 5 of these patients were classified as Lenke type 1A and 8 as Lenke type 5C. Fusion was performed using VATS up to T12 or L1 vertebral level. Lower levels were accessed via a small mini-incision in the lumbar area to gain access to the lumbar spine via the retroperitoneal space. All patients had a minimum follow-up of 1 year. RESULTS: The average number of fused vertebrae was 7.1 levels. A significant correction in the Cobb angle was obtained at the final follow-up (p = 0.001). The instrumented segmental angle in the sagittal plane was relatively well-maintained following surgery, albeit with a slight increase. Scoliosis Research Society-22 (SRS-22) scores were noted have significantly improved at the final follow-up (p < 0.05). CONCLUSION: Indications for the use of VATS may be extended from patients with localized thoracic scoliosis to those with thoracolumbar scoliosis. By utilizing a supplementary minimal incision in the lumbar region, a satisfactory deformity correction may be accomplished with minimal post-operative scarring.

Video-assisted thoracoscopic surgery for correction of adolescent idiopatic scoliosis: comparison of 4.5 mm versus 5.5 mm rod constructs.

PURPOSE: The purpose of this study is to report the comparative results of thoracoscopic correction achieved via cantilever technique using a 4.5 mm thin rod and the poly-axial reduction screw technique using a 5.5 mm thick rod in Lenke type 1 adolescent idiopathic scoliosis (AIS). MATERIALS AND METHODS: Radiographic data, Scoliosis Research Society (SRS) patient-based outcome questionnaires, and operative records were reviewed for forty-nine patients undergoing surgical treatment of scoliosis. The study group was divided into a 4.5 mm thin rod group (n = 24) and a 5.5 mm thick rod group (n = 25). The radiographic parameters that were analyzed included coronal curve correction, the most caudal instrumented vertebra tilt angle correction, coronal balance, and thoracic kyphosis. RESULTS: The major curve was corrected from 49.8 degrees and 47.2 degrees pre-operatively to 24.5 degrees and 18.8 degrees at the final follow-up for the thin and thick rod groups, respectively (50.8% vs. 60.2% correction). There were no significant differences between the two groups in terms of kyphosis, coronal balance, or tilt angle at the time of the final follow-up. The mean number of levels fused was 6.2 in the thin rod group, compared with 5.9 levels in the thick rod group. There were no major intraoperative complications in either group. CONCLUSION: Significant correction loss was observed in the thin rod system at the final follow-up though both groups had comparable correction immediately post-operative. Therefore, the thick rod with poly axial screw system helps to maintain post-operative correction.

Vascular injury in thoracolumbar spinal surgeries and role of angiography in early diagnosis and management.

STUDY DESIGN: A retrospective outcomes study. OBJECTIVE: To stress on the importance of early diagnosis with the help of angiography and proper treatment of vascular injuries occurring during thoracolumbar surgeries and to report our results. SUMMARY OF BACKGROUND DATA: Vascular injury is a rare but dangerous complication that can develop during thoracolumbar surgeries and if not treated properly then it can lead to severe complications including the death of the patient. METHODS: The patients included in this study were the ones who were suspected to have a possible vascular injury after a thoracolumbar surgery. Contrast enhanced computed tomography was performed for patients having clinical signs suggesting vascular injury. Among these patients, who were suspected to have active bleeding and major vessel injury on computed tomography were further subjected to angiography. RESULTS: Of the 10 cases included in the study, vascular injury was identified to be arterial in origin in 8 cases and venous in 3 cases. Among the 8 cases of identified arterial injury, angiography was performed in 4 cases, of which 3 were found to have active bleeding and were subjected to immediate intervention. Of the 4 cases in which angiography was not performed, 3 of them expired at variable postoperative periods. Complications developed in total 5 cases including 3 cases of mortality, 1 case of infection, and 1 case of cauda equina syndrome. CONCLUSIONS: The vascular injuries during thoracolumbar spinal surgeries need immediate and aggressive treatment. In arterial injuries, we can prevent serious consequences by subjecting the patient to an angiography as early as possible followed by a therapeutic embolization. In contrast, for venous injuries if hemostasis has been confirmed, then an immediate intervention may not be always required.