Esophageal Perforation After Anterior Cervical Surgery: A Case Report and Literature Review.

SUMMARY AND BACKGROUND: Esophageal perforation (EP) after anterior cervical surgery is a rare but potentially life-threatening condition. EP caused by malpositioned implants in cervical spine injury with multiple comorbidities is challenging to treat simultaneously. STUDY: This was a case report study. PURPOSE OF STUDY: The aim of this study was to present successful treatment of EP in a subluxated C5-C6 level with implant failure, infection, septicemia, and comorbidities. The aim was to emphasize the need for a multispecialty approach while treating serious complications. CASE: A 72-year-old woman presented to the ER with a history of operated cervical spine a week ago and having breathlessness, fever, wound infection, and tracheostomy in situ. After primary investigations, the patient was initially treated in the intensive care unit, where bleeding from the tracheostomy site was noticed. Upon endoscopy, EP was diagnosed due to implant failure. She was operated for revision cervical spine surgery (drainage of pus with anterior and posterior cervical fixation) and percutaneous endoscopic gastrostomy tube insertion (esophageal diversion). On exploration of EP, a decision was made to perform conservative treatment as initial tag sutures did not hold due to infection. Postoperatively, the patient developed rectal bleed 3 times, which was ultimately treated with cecal bleed embolization. The infected cervical wound was managed with an open dressing. The patient was managed with intermittent assisted ventilation through tracheostomy postoperatively. Barium swallow at 10 weeks confirmed healing of EP and oral feed was started. Tracheostomy closure was performed once the wound had healed, and the patient was discharged with improved neurology at 12 weeks. CONCLUSIONS: Perioperative problems after cervical surgery such as breathing difficulty, wound discharge, and worsening of neurology may lead to suspicion of underlying EP due to implant failure. Upper gastrointestinal endoscopy needs to be considered for a prompt diagnosis. Revision spine surgery with treatment of perforation simultaneously and maintenance of enteral nutrition through a percutaneous endoscopic gastrostomy tube with a multispecialty approach is recommended for this potentially life-threatening condition.

Brachial Plexus Injury due to Central-line Insertion during Kypho-scoliosis Deformity Correction.

INTRODUCTION: Internal Jugular Venous (IJV) cannulation or central-line insertion is frequently performed during kyphoscoliosis deformity correction surgery or spine surgery with high risk. This helps monitor central venous pressure and administer medicines when required. Although many complications of IJV cannulation have been reported in the literature, its effect on brachial plexus is not known. The objective of this paper was to report a rare complication of IJV during scoliosis surgery. CASE PRESENTATION: We reported a case of 27-year-old male who was operated for severe kyphoscoliosis correction where preoperatively IJV cannulation was done. Repeated attempts were done during IJV cannula insertion due to altered anatomy. Eventually, cannula insertion was done using ultrasound modality and surgery for correction was done. Postoperatively patient developed right upper extremity weakness and sensory loss although the clinical result of kyphoscoliosis correction was acceptable. EMG-NCV study proved it brachial plexus injury. The patient was treated with intravenous steroid and physiotherapy. The patient recovered completely within 6 months of surgery. CONCLUSION: We reported a case of kyphoscoliosis deformity corrective surgery where IJV cannulation led to brachial plexus injury and was eventually recovered with medications and physiotherapy.

Comparison of Clinical Outcome and Radiologic Parameters in Open TLIF Versus MIS-TLIF in Single- or Double-Level Lumbar Surgeries.

PURPOSE: The objective of this study was to compare clinical and radiologic parameters between minimally invasive surgery-transforaminal lumbar interbody fusion (MIS-TLIF) and open TLIF. METHODS: Data of 145 patients who underwent single- or double-level TLIF procedures with an open (n = 76) or a MIS (n = 69) technique were analyzed. Average operation time, estimated blood loss, and hospital stay were compared between open TLIF and MIS-TLIF. Improvement in clinical scores was analyzed using visual analog scale (VAS) and Oswestry Disability Index (ODI) scores in both groups and statistically compared using t tests. Radiologic parameters, such as lumbar lordosis, focal lordosis at the index level, and pelvic incidence (PI), were calculated at preoperative, postoperative, and final follow-up for comparison. The differences in improvement between open and MIS groups were analyzed using unpaired t tests. RESULTS: Average follow-up was 35.8 ± 15.4 months in open TLIF and 37.9 ± 14.4 months in MIS-TLIF. The average blood loss and operation times were higher and hospital stay was less in MIS-TLIF compared to open TLIF. VAS scores were improved from preoperative (8.5 ± 0.6) to postoperative (2.1 ± 0.8) and preoperative (8.4 ± 0.8) to postoperative (2.0 ± 0.7) in open TLIF and MIS-TLIF, respectively (P < .0001), and ODI scores were improved from preoperative (55.2 ± 5.2) to postoperative (22.5 ± 4.3) and preoperative (56.7 ± 4.9) to postoperative (22.0 ± 5.0) in open TLIF and MIS-TLIF, respectively (P < .0001). Similarly, there were significant improvements in lumbar lordosis and focal lordosis at the index level with a difference of 3.9° and 2.5°, respectively, in open TLIF and 4.0° and 2.9°, respectively, in MIS-TLIF. However, there were no differences in PI in both groups. There were 9 (11.8%) and 9 (13%) complications encountered in open TLIF and MIS-TLIF, respectively. Two patients from open TLIF and 5 from MIS-TLIF had to undergo revision surgeries without any statistical difference. CONCLUSIONS: Open TLIF and MIS-TLIF are equally efficient surgical techniques with similar clinical and radiologic outcomes. MIS-TLIF is associated with less intraoperative blood loss and hospital stay; however, it increases operation time significantly.

Clinical Correlation of Intraoperative Neuromonitoring in 319 Individuals Undergoing Posterior Decompression and Fixation of Spine.

STUDY DESIGN: This was a prospective study. OBJECTIVES: To correlate improvement in motor evoked potential (MEP) during spine surgery with postoperative clinical improvement. MATERIALS AND METHODS: Three hundred fifty-three patients operated for posterior spinal decompression and fixation surgeries were prospectively selected and followed up. Patients who underwent lumbar, dorsal, and cervical surgeries were grouped into-group A, B, and C, respectively. Intraoperative neuromonitoring was done using MEP with free-running electromyography. Improvements in MEP scores were calculated in percentage. Similarly, postoperative improvement in Oswestry disability index (ODI) and visual analog scale (VAS) scores at 3 months were calculated in percentage. Improvements in MEP scores were correlated with clinical improvement using the Spearman ρ test and the r value was calculated to find out the association. RESULTS: Of 353 patients, 319 (250-group A, 38-group B, and 31-group C) were included for the study. VAS and ODI improved significantly from preoperative 8.5±0.8 and 62.9±14.5, to postoperative 2.3±1.1 and 15.9±11.5, respectively, in the entire group. Average preoperative MEP were 127.8±191.0 mV on the right side and 132.3±206.6 mV on the left side, which significantly improved to 163.7±231.2 mV (P=0.0001) and 155.2±219.6 mV (P=0.0001), respectively, showing 157.0% and 178.5% improvement. Correlating MEP improvement with postoperative improvement in ODI showed poor correlation (r=0.088 right and 0.030 left sides). Similarly, correlating MEP improvement with improvement in VAS showed r=0.110 on the right and -0.023 on the left side suggesting poor correlation. Postoperative neurological complications (0.56%) were found in 2 patients in the form of screw malpositioning. CONCLUSIONS: Intraoperative neuromonitoring showed significant improvement during posterior decompression and fixation surgery, and reduction in postoperative neurological complication. The study also exhibited significant postoperative clinical improvement. However, improvement in MEP did not correlate with postoperative clinical improvement suggesting that it has no predictive role.

Hypokalemic Paraparesis Progressing to Quadriparesis in a Case of Intradural Spinal Tumor.

INTRODUCTION: This study aims to present a case of spinal intradural tumor with paraparesis referred for surgery, which later progressed to quadriparesis and subsequently found to have hypokalemia due to primary hyperaldosteronism causing a clinical dilemma. CASE REPORT: A 46-year-old male was referred for surgery from peripheral center with a diagnosis of an intradural tumor at L1. The patient presented to us with paraparesis, which progressed to quadriparesis. On evaluation, the patient was found to have low serum potassium levels of 1.6 mmol/L with hypertension. The plasma aldosterone-renin was elevated which was suggestive of primary hyperaldosteronism. Further, investigations in the form of CT abdomen suggested the presence of a right adrenal adenoma. The patient was diagnosed with hypokalemia-induced quadriparesis and treated conservatively with potassium supplementation and later spironolactone. The patient recovered completely in 72 h and was able to walk independently before discharge. CONCLUSION: Spinal tumor may not always be the cause for patient's paraparesis; non-spinal factors such as hypokalemia should be kept in mind. The presence of intradural spinal tumor with hypokalemia may cause decision dilemma regarding treatment and interdisciplinary approach is recommended to facilitate the treatment.

Reoperations Following Lumbar Spinal Canal Stenosis.

In the current clinical scenario, restenosis following the primary surgical procedure for lumbar canal stenosis is being frequently noticed. A number of studies have evaluated the reoperation rates following different surgical procedures for lumbar canal stenosis. However, a dilemma still exists about the surgical procedures, associated comorbidities and reoperation rates. In this study, we have reviewed the existing literature for lumbar canal stenosis surgery and their reoperation rates. A PubMed search for all papers stating "reoperation after spinal stenosis," "revision surgery after spinal stenosis," and "reoperations and lumbar canal stenosis" were explored. A total of 440 publications were found, of which 23 publications were shortlisted. The existing literature on reoperation rates after surgery for lumbar canal stenosis was reviewed and analyzed. From the literature search, 29680 patients who underwent surgeries for spinal stenosis have been included in the review. 11.65% ± 4.25% of them underwent reoperations following the primary procedure with a followup period of 6.80 ± 3.90 years. Fenestration surgeries showed an average reoperation rate of 7.58% ± 5.29% in 8.28 ± 6.26 years followup as compared to laminectomy alone (12.70% ± 7.49%, 6.50 ± 2.12 years followup). Laminectomy with or without fusion showed a reoperation rate of 11.22% ± 4.25% in 6.00 ± 2.60 years followup period. The comparative results of these studies were however not significant. The causes of reoperation were multifactorial ranging from the type of procedure performed, associated comorbidities or smoking. Statistical data do not indicate the superiority of any particular type of surgery, which reduces the rate of reoperation. The causes for reoperation are inadequate decompression or instability. The literature does not give statistics for these complications in the papers. Smoking is an independent risk factor for revision surgery. Diabetes reduces the time interval between the initial surgery and the revision surgery. This review highlights the causes of reoperations in various lumbar stenosis surgeries, associated comorbidities and expected outcome.

A Rare Case of Pheohyphomycotic Lumbar Spondylodiscitis Mistreated as Koch's Spine.

Pheohyphomycosis is an uncommon infection and its association in spondylodiscitis has not yet been reported. The purpose of this case report is to describe a rare case of Pheohyphomycotic spondylodiscitis and methods to diagnose and manage the patient with less invasive techniques. A 29-year-old male patient presented to the outpatient department with complaints of gradually increasing low back pain with bilateral lower limbs radicular pain since one and a half years. He had associated fever, weight loss, voice changes, and dry, scaly, erythematous skin with elevated ESR. The patient had been taking anti-Koch's therapy since 1 year with little relief in pain and no radiological improvement. Percutaneous pedicle biopsy of L4 vertebra was taken under local anaesthesia and confirmed Pheohyphomycosis which was treated with antifungal medications. The patient showed sequential improvement with long term antifungal treatment. He was eventually able to walk independently without support.

Analysis of diaphragmatic movement before and after pulmonary rehabilitation using fluoroscopy imaging in patients with COPD.

BACKGROUND: The diaphragm is the principal inspiratory muscle. The purpose of this study was to assess improvements in diaphragmatic movement before and after pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD), using a fluoroscopy-guided chest X-ray. PATIENTS AND METHODS: Among 117 patients with COPD receiving pulmonary rehabilitation who underwent the initial fluoroscopy-guided chest X-ray and pulmonary function test, 37 of those patients who underwent both initial and follow-up fluoroscopy and pulmonary function tests were enrolled in this study. After hospital education, participants received pulmonary rehabilitation through regular home-based training for at least 3 months by the same physiatrist. We assessed the changes in diaphragm area with fluoroscopy-guided posteroanterior chest X-rays between pre- and postpulmonary rehabilitation. To minimize radiation hazards for subjects, the exposure time for fluoroscopy to take chest X-rays was limited to less than 5 seconds. RESULTS: There were significant improvements (2,022.8±1,548.3 mm(2) to 3,010.7±1,495.6 mm(2) and 2,382.4±1,475.9 mm(2) to 3,315.9±1,883.5 mm(2); right side P=0.001 and left side P=0.019, respectively) in diaphragmatic motion area during full inspiration and expiration in both lungs after pulmonary rehabilitation. Pulmonary function tests showed no statistically significant difference between pre- and postpulmonary rehabilitation. CONCLUSION: The study suggests that the strategy to assess diaphragm movement using fluoroscopy is a relatively effective tool for the evaluation of pulmonary rehabilitation in COPD patients in terms of cost and time savings compared with computed tomography or magnetic resonance imaging.

Effect of posterior multilevel vertebral osteotomies on coronal and sagittal balance in fused scoliosis deformity caused by previous surgery: preliminary results.

STUDY DESIGN: Prospective case series study. OBJECTIVE: To study the effect of posterior multilevel vertebral osteotomy (posterior crack osteotomy) on coronal and sagittal balance in patients with the fusion mass over the spine caused by previous surgery. SUMMARY OF BACKGROUND DATA: Few studies have investigated revisional scoliosis surgery with the fusion mass using osteotomy. METHODS: Among patients who had a history of prior surgery for scoliosis correction and posterior fusion, those showing progression of the curve postoperatively due to nonunion, implant failure, or adding-on phenomenon were enrolled. All patients were treated using posterior crack osteotomy. For clinical evaluation, the pre- and postoperative Gross Motor Function Classification System score for walking status and the Berg balanced scale were used. For radiological evaluation, pre- and postoperative Cobb angle, and coronal and sagittal balance factors were used. RESULTS: Ten patients (5 males and 5 females) were enrolled. The preoperative diagnosis was neuromuscular scoliosis (3 cases), syndromic scoliosis (1 case), congenital scoliosis (5 cases), and neurofibromatosis (1 case). Osteotomies were performed at 3.3±1.3 levels on average. Pre- and postoperative Cobb angles were 70.8°±30.0° and 28.1°±20.0° (P=0.002 (0.97)), respectively. In pre- and postoperative evaluation of coronal balance, the coronal balance, clavicle angle, and T1-tilt angle were 36.8±27.1 mm and 10.4±8.5 mm, 6.7°±8.0° and 3.3°±1.5°, and 7.8°±19.0° and 4.7°±2.1°, respectively (P=0.002, 0.002, 0.002). In pre- and postoperative evaluation of sagittal balance, the spinal vertical axis, thoracic kyphosis, and lumbar alignments were 25.1±37.8 mm and 14.1±21.8 mm, 33.5°±51.1° and 29.7°±27.4°, and 45.7°±34.8° and 48.9°±23.1° (P=0.002, 0.169, 0.169). The walking and functional statuses did not change (P=0.317, 0.932). Although pulmonary and gastrointestinal complications were noted, the patients were discharged without complications. CONCLUSION: Posterior crack osteotomy can be used effectively in revisional scoliosis surgery and the clinical and radiological results seem to be acceptable. LEVEL OF EVIDENCE: 4.

Does delaying surgery in immature adolescent idiopathic scoliosis patients with progressive curve, lead to addition of fusion levels?

PURPOSE: To analyze the changes in the curve extent, pattern and the fusion level in adolescent idiopathic scoliosis (AIS) patients who undergo delayed surgery instead of early surgery. METHODS: Thirty-five immature AIS patients whose radiographs demonstrated an initial primary curve of more than 40° with a subsequent increase of 10° before attaining skeletal maturity with brace were enrolled. The initial and the final radiographs taken before surgery were compared to assess the changes in curve extent, pattern and the fusion levels as recommended by King's, Lenke's and Suk's guidelines. RESULTS: The average age of 35 AIS patients was 12.7 ± 1.6 years. The time interval between initial and final radiography was 39.3 ± 20.2 months and the degree of progress of the primary curve was 13 ± 9.7°. Fusion levels changed in 33 (94.2%), 33 (94.2%) and 32 (91.4%) patients according to King's, Lenke's and Suk's guidelines, respectively. Curve pattern was changed in 2 (5.7%), 12 (34.3%) and 10 (28.6) patients by King's, Lenke's and Suk's guidelines. The mean number of levels requiring fusion increased from 9.4 ± 2.1 at initial visit to 11.1 ± 1.8 at the final follow-up using King's guidelines, 9.7 ± 2.2-11.6 ± 2.0 as per Lenke's guidelines and 9.1 ± 2.0-11.5 ± 2.3 when fusion was planned using Suk's guidelines (p < 0.001 in all guidelines). CONCLUSIONS: Delay of surgery in immature AIS patients whose Cobb's angle exceed 40° initially and showing subsequent progression of the curve, of more than 10° can lead to alterations in the curve pattern and the need for increase in fusion levels.

Short apical rib resections thoracoplasty compared to conventional thoracoplasty in adolescent idiopathic scoliosis surgery.

PURPOSE: To introduce a modified technique of thoracoplasty (short apical rib resection thoracoplasty (SARRT)) and compare its clinical, functional radiological outcomes and postoperative lung functions with conventional thoracoplasty (CT) in scoliosis surgery. METHODS: Retrospectively review of adolescent idiopathic scoliosis patients who underwent corrective surgery with thoracoplasty from 2006 to 2010 was performed. Thoracoplasty was performed in 58 patients (CT in 31 and SARRT in 27 patients). 21 patients who underwent deformity correction only, without thoracoplasty were taken as control group (non-thoracoplasty, NT). To evaluate the outcome of SARRT, radiological parameters, pulmonary functions and clinical outcomes were compared among all the three groups. RESULTS: Age, sex and scoliosis types were evenly distributed between 3 groups (p = 0.66, 0.92, 0.31). Number of levels fused, change in Cobb angle, lordosis, kyphosis, coronal balance, sagittal balance, coronal translation and sagittal translation were not significantly different among the three groups (p > 0.05 for all). There was 38.6% improvement in rib hump in NT, 44.04% in CT and 60.9% correction in SARRT group. Pulmonary complications were significantly higher in the CT group, especially in view of pleural rupture, pulmonary effusion and intercostal neuralgia (p = 0.041, 0.029, 0.049). There was no difference among three groups in postoperative pulmonary function but the score of satisfaction as sub-category in SRS-22 questionnaire was decreased in CT groups (p = 0.046). CONCLUSIONS: SAART is effective in correcting the rib deformity without altering the pulmonary functions and SAART has less number of pulmonary complications as compared to CT.

Changes in the spinopelvic parameters of elite weight lifters.

OBJECTIVE: To describe the changes in the spinopelvic parameters in weight lifters and evaluate the factors leading to spinal anatomical changes (eg, spondylolysis and listhesis). DESIGN: Case-control study. SETTING: Tertiary, institutional. PARTICIPANTS: The study group participants were practicing weight lifters in the athletes' village of the 2012 London Olympics. A total of 21 elite weight lifters were enrolled. Their data were compared with those of 45 healthy volunteers in the control group. INTERVENTIONS: Comparative radiological evaluations were performed among the 21 elite weight lifters. Spinopelvic parameters (radiographic analysis), including total (TLL), upper (ULL), and lower (LLL) lumbar lordoses, sacral slope, pelvic tilt (PT) and incidence, lumbar index, and disc angles, were assessed. MAIN OUTCOME MEASURES: The proportional ratio of ULL and LLL to TLL (ULL/TLL and LLL/TLL) was measured to describe the proportion effect. These values were compared with those of the control group. Weight lifters with and those without anatomical changes were subdivided into a deformed and nondeformed group, respectively, and further analyzed for differences. The correlation between these spinal parameters and the amount and duration of weight lifting training was also analyzed. RESULTS: Anatomical changes in the lumbar spine were seen in 6 weight lifters (28.6%, P = 0.01). The mean TLL, ULL, and LLL values (59.8, 22.6, and 37.2 degrees, respectively) were increased, whereas PT (10.3 degrees) was decreased in the athletes compared with the volunteers (P = 0.001, 0.005, 0.07, and 0.018, respectively). The ULL/TLL was higher in the deformed group than in the nondeformed group (P = 0.036). The duration and amount of weight lifting training were not correlated with the spinopelvic parameters measured in this study. CONCLUSIONS: The elite weight lifters had increased lumbar lordosis and decreased PT compared with the healthy volunteers. The ULL/TLL ratio may be used as a predictive marker for lumbar deformation.

Multiaxial high-modularity spinopelvis (HMSP) fixation device in neuromuscular scoliosis: a comparative study.

PURPOSE: To compare radiological and clinical results in patients operated for neuromuscular scoliosis with pelvic fixation using high-modularity spinopelvic screw (HMSP) designed by authors. METHODS: Of 54 patients with neuromuscular scoliosis, group 1 comprised of 27 patients with conventional pelvic fixation; and group 2 comprised of 27 patients using HMSP. Results were evaluated radiologically and functionally. We compared preoperative and postoperative complications, especially the loosening or breakage of spinopelvis fixation device, failure of fixation, and the change of shadow around the spinopelvis fixation device. RESULTS: There was no difference of correctional power, preoperative average Cobb's angle of each group was 79.8 and 75 to postoperative 30.2 and 28.3 (P < 0.05). Pelvic obliquity improved from average 18.3°-8.9° in group I and average 24.3°-12.5° in group II (P < 0.05). However, there was no difference between two groups (P > 0.05). Average blood loss was 2,698 ml in group 1 and 2,414.8 ml in group 2 (P > 0.05). Average operative time was 360 min in group 1 and 332 min in group 2 (P = 0.30). There was no difference found between two groups regarding gait and functional evaluation. On the all cases of group 1 and 2, the change of shadow around the spinopelvis fixation device was observed. There was one case of the fracture of spinopelvis fixation device in group I. CONCLUSION: There was no difference of Cobb's angle and correctional power between the groups using HMSP when compared with the group using standard spinopelvis fixation device. Therefore, HMSP can be used more effectively in case of neuromuscular scoliosis.

Effects of vertebral column distraction on transcranial electrical stimulation-motor evoked potential and histology of the spinal cord in a porcine model.

BACKGROUND: Spinal cord injury can occur following surgical procedures for correction of scoliosis and kyphosis, as these procedures produce lengthening of the vertebral column. The objective of this study was to cause spinal cord injury by vertebral column distraction and evaluate the histological changes in the spinal cord in relationship to the pattern of recovery from the spinal cord injury. METHODS: Global osteotomy of all three spinal columns was performed on the ninth thoracic vertebra of sixteen pigs. The osteotomized vertebra was distracted until transcranial electrical stimulation-motor evoked potential (TES-MEP) signals disappeared or decreased by >80% compared with the baseline amplitude; this was defined as spinal cord injury. The distraction distance at which spinal cord injury occurred was measured, the distraction was released, and the TES-MEP recovery pattern was observed. A wake-up test was performed, two days of observations were made, and histological changes were evaluated in relationship to the recovery pattern. RESULTS: Spinal cord injury developed at a distraction distance of 20.2 ± 4.7 mm, equivalent to 3.6% of the thoracolumbar spinal length, and the distraction distance was correlated with the thoracolumbar spinal length (r = 0.632, p = 0.009). No animals exhibited complete recovery according to TES-MEP testing, eleven exhibited incomplete recovery, and five exhibited no recovery. During the two days of observation, all eleven animals with incomplete recovery showed positive responses to sensory and motor tests, whereas none of the five animals with no recovery had positive responses. On histological evaluation, three animals that exhibited no recovery all showed complete severance of nerve fibers (axotomy), whereas six animals that exhibited incomplete recovery all showed partial white-matter injury. CONCLUSIONS: Parallel distraction of approximately 3.6% of the thoracolumbar length after global osteotomy resulted in spinal cord injury and histological evidence of spinal cord damage. The pattern of recovery from the spinal cord injury after release of the distraction was consistent with the degree of axonal damage. Axotomy was observed in animals that exhibited no recovery on TES-MEP, and only hemorrhagic changes in the white matter were observed in animals that exhibited incomplete recovery.

Clinical results of XMR-assisted percutaneous transforaminal endoscopic lumbar discectomy.

BACKGROUND: Although percutaneous endoscopic lumbar discectomy (PELD) has shown favorable outcomes in the majority of lumbar discectomy cases, there were also some failures. The most common cause of failure is the incomplete removal of disc fragments. The skin entry point for the guide-needle trajectory and the optimal placement of the working sleeve are largely blind, which might lead to the inadequate removal of disc fragments. The objective of this study was to present our early experiences with image-guided PELD using a specially designed fluoroscope with magnetic resonance imaging-equipped operative suite (XMR) for the treatment of lumbar disc herniation. METHODS: This prospective study included 89 patients who had undergone PELD via the transforaminal approach using an XMR protocol. Pre- and postoperative examinations (at 12 weeks) included a detailed clinical history, visual analogue scale (VAS), Oswestry disability index (ODI), and radiological workups. The results were categorized as excellent, good, fair, and poor according to MacNab's criteria. At the final follow-up, the minimum follow-up time for the subjects was 2 years. The need for revision surgeries and postoperative complications were noted on follow-up. RESULTS: Postoperative mean ODI decreased from 67.4% to 5.61%. Mean VAS score for back and leg pain improved significantly from 4 to 2.3 and from 7.99 to 1.04, respectively. Four (4.49%) patients underwent a second-stage PELD after intraoperative XMR had shown remnant fragments after the first stage. As per MacNab's criteria, 76 patients (85.4%) showed excellent, 8 (8.89%) good, 3 (3.37%) fair, and 2 (2.25) poor results. Four (4.49%) patients had remnant disc fragments on XMR, which were removed during the same procedure. All of these patients had either highly migrated or sequestrated disc fragments preoperatively. Four (4.49%) other patients needed a second, open surgery due to symptomatic postoperative hematoma (n = 2) and recurrent disc herniation (n = 2). CONCLUSIONS: This prospective analysis indicates that XMR-assisted PELD provides a precise skin entry point. It also confirms that decompression occurs intraoperatively, which negates the need for a separate surgery and thus increases the success rate of PELD, particularly in highly migrated or sequestrated discs. However, further extensive experience is required to confirm the advantages and feasibility of PELD in terms of cost effectiveness.

Analysis of factors that affect shoulder balance after correction surgery in scoliosis: a global analysis of all the curvature types.

PURPOSE: To identify factors that can affect postoperative shoulder balance in AIS. METHOD: 89 adolescent idiopathic scoliosis patients with six types of curvatures who underwent surgery were included in this study. Whole spine antero-posterior and lateral radiographs were obtained pre- and postoperatively. In radiograms, shape and changes in curvatures were analyzed. In addition, four shoulder parameters and coronal balance were analyzed in an effort to identify factors significantly related to postoperative shoulder balance. RESULT: In general, all the four shoulder parameters (CHD, CA, CRID, RSH) were slightly increased at final follow up (t test, P < 0.05), although there was a decrease in Lenke type II and IV curvatures. However, pre- and postoperative shoulder parameters were not significantly different between each curvature types (ANOVA, P > 0.05). Moreover, no significant differences of pre- and postoperative shoulder level between different level of proximal fusion groups (ANOVA, P > 0.05) existed. In the analysis of coronal curvature changes, no difference was observed in every individual coronal curvatures between improved shoulder balance and aggravated groups (P > 0.05). However, the middle to distal curve change ratio was significantly lower in patients with aggravated shoulder balance (P < 0.05). In addition, patients with smaller preoperative shoulder imbalance showed the higher chance of aggravation after surgery with similar postoperative changes (P < 0.05). CONCLUSIONS: Significant relations were found between correction rate of middle, and distal curvature, and postoperative shoulder balance. In addition, preoperative shoulder level difference can be a determinant of postoperative shoulder balance.

Intraoperative airway obstruction in a Duchenne muscular dystrophy patient.

PURPOSE: To report a complication of airway obstruction during spinal deformity correction surgery in Duchenne muscular dystrophy (DMD) patient, due to lordoscoliosis, airway malacia, and prone surgical positioning, which was rectified by changing the position of the patient and surgery was successfully completed. CASE DESCRIPTION: A 15-year-old boy was diagnosed with DMD and admitted for surgical treatment of thoracolumbar scoliosis. The patient's preoperative Cobb's angle was 79° and the kyphotic angle was -19°. During the initial period of surgery, while in the prone position, peak inspiratory pressure (PIP) suddenly increased from 20-21 to 38-41 cmH2O, wheezing sounds were heard on auscultation of both lungs, and his blood pressure began to fall. Under suspicion of airway problem, intraoperative fiberoptic bronchoscopy was performed which confirmed airway obstruction. Attributing patient's prone position as the cause of airway obstruction, the surgical position of the patient was changed from prone to semi-lateral. After this change, the PIP stabilized to within normal limits (20-23 cmH2O). The surgical correction was successfully completed with a posterior-only pedicle screw by the free-hand technique, with the patient in the semi-lateral position for the rest of surgery. CONCLUSIONS: Lordoscoliosis and airway malacia in a patient with DMD can lead to occlusion of the tracheobronchial lumen when the patient is in the prone position. Changing the patient's position from prone to semi-lateral can be of help to reverse this airway obstruction and complete the surgery. Pedicular screw insertion can be safely and effectively carried out in this position using free-hand technique.

Centroid method: an alternative method of determining coronal curvature in scoliosis. A comparative study versus Cobb method in the degenerative spine.

BACKGROUND CONTEXT: Although the Cobb method is considered the gold standard, the centroid method may offer a reasonable alternative in adult scoliosis because it has better inter- and intraobserver reliabilities in adolescent scoliosis. PURPOSE: To compare the reliabilities of the Cobb and the centroid methods for measuring coronal curvature in degenerative scoliosis in older patients. STUDY DESIGN: Observational study involving three examiners. PATIENT SAMPLE: Sixty whole spine posteroanterior (PA) radiographs were collected. OUTCOME MEASURES: Data were analyzed to determine inter- and intraobserver reliabilities. METHODS: Sixty whole spine PA radiographs of patients older than 60 years were collected to compare the reliabilities of the centroid and the Cobb methods for measuring coronal curvature in degenerative scoliosis. Three examiners using both methods independently measured radiographs twice. Data were analyzed to determine inter- and intraobserver reliabilities. RESULTS: Intraobserver comparisons of all the 60 radiographs revealed that inter- and intraclass correlation coefficients (ICCs) of the Cobb and the centroid methods were both excellent (greater than 0.979 vs. greater than 0.918), and mean absolute differences (MADs) were similar (less than 1.58 vs. less than 2.02). In interobserver comparisons, ICCs of the Cobb method were higher than that of the centroid method (greater than 0.922 vs. greater than 0.799), and the MADs of the Cobb method were lower than that of the centroid method (less than 2.91 vs. less than 4.84). Comparisons of radiographs subdivided by severity showed that the ICCs of the Cobb and the centroid methods were both excellent (greater than 0.819 vs. greater than 0.801), and their MADs were similar (less than 2.29 vs. less than 2.53) for intraobserver comparisons. Interobserver comparisons showed that ICCs and MADs were dependent on the severity of coronal curvature, and the ICCs of the Cobb method (greater than 0.698) were greater than that of the centroid method (greater than 0.507). Furthermore, MAD values for the Cobb method were lower than that for the centroid method (less than 3.59 vs. less than 6.07). Moreover, these results are contradictory to the previous study, which showed the higher reliability of the centroid method in measures of adolescent scoliosis. CONCLUSIONS: In the present study, the reliability of the centroid method was found to be more susceptible to the severity of disease in older patients, despite its demonstrated greater reliability in adolescent scoliosis. Our findings show that the selective use of these two methods in old and young patients can increase the reliabilities of measurements made.

Isolated percutaneous thoracoplasty procedure for skeletally mature adolescent idiopathic scoliosis patients, with rib deformity as their only concern: short-term outcomes.

STUDY DESIGN: Prospective case series study. OBJECTIVE: To study the effect of percutaneous thoracoplasty-only procedure on curve pattern in mature adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The rib hump prominence on the convex side is the major cosmetic concern among patients with AIS. Thoracoplasty combined with spinal fusion is a commonly used procedure in scoliosis. However, there are no studies regarding the effect of isolated thoracoplasty procedure on curve pattern in skeletally matured patients with AIS. METHODS: The study involved 7 skeletally matured female patients with AIS. The convex rib hump deformity was measured preoperatively using hump height and hump angle. We performed thoracoplasty without spinal fusion in patients with the Cobb angle less than 40° but with prominent hump deformity. Thoracoplasty was performed percutaneously using 1 or 2 transverse incisions along the rib hump, and apex portions of the deformed ribs were resected. The Cobb angle was measured before surgery, immediately after surgery, and at final follow-up visit. In all cases, clinical satisfaction was assessed using the Scoliosis Research Society Instrument (SRS-22 questionnaires) and trunk appearance perception scale before surgery and at final follow-up visit. RESULTS: The mean patient age was 20.24 years and an average of 4 ribs were resected. The mean preoperative hump height and hump angle of 38.14 mm and 14.14° improved to 11.70 mm and 11.42° respectively, after surgery (P = 0.018 and 0.042). Preoperative and the final follow-up mean Cobb angles were 35.43° and 45.00°, respectively (P = 0.028). On average, the mean thoracic curve progressed by 9.57°. Preoperative Scoliosis Research Society Instrument SRS-22 questionnaires and trunk appearance perception scale scores of 4.09 and 2.57 respectively improved to and 4.26 and 3.66 after surgery (P = 0.126 and 0.014). CONCLUSION: Percutaneous thoracoplasty-only procedure gives significant rib humps correction and satisfactory clinical outcome. However, progression of the curve was observed after surgery. This suggests that the convex ribs function as a buttress for curve progression.

Paraganglioma in the cauda equina. A case report.

Paraganglioma of the cauda equina is rare, and diagnosis is difficult. A 47-year-old woman presented with backache, with a 2-year history of pain radiating in her right lower extremity. Initial neurologic examination revealed mild hypaesthesia in the L4 dermatome on both sides. Spine MRI showed a well-delinated intradural extramedullary mass compressing the spinal cord. It extended from L2 to L4, with anterior compression of the spinal cord which was displaced posteriorly. Clinical and radiological findings suggested an ependymoma. Surgical decompression was performed from L2 to L4 through lumbar laminectomy under microscope. Intraoperatively, the patient experienced unexplained paroxysmal hypertension while manipulating the tumour, which was not relieved by hypotensive medication but resolved immediately after resection of the mass. Postoperatively, the neurologic status improved and the radiating pain was relieved. Histopathologic examination showed cellular perivascular arrangement which looked like 'pseudorosettes'. Taken together, these histologic and radiologic findings suggested a benign myxopapillary ependymoma. However, immunohistochemical examination showed reactivity with synaptophysin and chromogranin. Finally, histological examination of the specimen revealed a 'Zellballen' pattern of paraganglioma, and the final diagnosis of paraganglioma with secreting function was confirmed. Paraganglioma is a rare tumour that can exhibit a secreting function causing paroxysmal hypertension which may be life threatening. Therefore, the differential diagnosis is important. The diagnosis is based on close examination of the clinical, radiologic and pathologic findings.