Lumbar Disc Herniation­the Significance of Symptom Duration for the Indication for Surgery.

BACKGROUND: Lumbar disc surgery is among the more common spinal procedures. In this paper, we report the current treatment recommendations for patients with symptomatic disc herniation. METHODS: This review is based on pertinent publications retrieved by a selective literature search in PubMed using the terms [timing] AND [lumbar disc herniation], supplemented by other relevant articles and guidelines. RESULTS: Symptoms resolve in 60% to 80% of patients with herniated discs in 6-12 weeks, and in 80% to 90% over the long term (≥ 1 year). According to the guidelines, 6-12 weeks of conservative treatment are recommended in the absence of significant neurologic deficits. Early surgery is indicated in case of worsening pain or new onset of neurologic deficits. Lumbar disc herniation associated bladder or bowel dysfunction (cauda equina syndrome) is considered an absolute surgical emergency that requires immediate decompression (within 24 to 48 hours). Patients with severe motor deficits (MRC ≤ 3/5) benefit from early intervention and should be offered surgery within three days, if possible, for the best chance of recovery. The degree of weakness and the duration of symptoms have been identified as risk factors for incomplete recovery. Early surgery can be considered in patients with mild paresis (MRC 4/5) in case of functional impairment (e.g., quadriceps paresis). CONCLUSION: Longer symptom duration and lower motor scores are associated with worse outcome and a lower chance of neurologic recovery. The recovery rate for motor deficits ranges from 33% to 75%, depending on the timing and modality of treatment as well as the motor score.

[Posterior instrumented correction and fusion of adolescent idiopathic scoliosis]. / Dorsale Korrekturspondylodese der idiopathischen Adoleszentenskoliose.

OBJECTIVE: Balanced frontal curve correction with horizontal shoulder levels, restoration of sagittal plane and vertebral derotation with a fusion length as short as possible. INDICATIONS: Curves larger than 40-50° Cobb angle; furthermore age, location, degree of rotation, and sagittal plane deviation have to be considered. SURGICAL TECHNIQUE: Posteriorly, segmental pedicle screw instrumentation with a high screw density (80%) and both titanium alloy and cobalt chrome rods. Freehand screw placement under consideration of both natural and deformity-induced pedicle morphology. Correction via reduction screws or instruments. Combined correction technique with rod rotation, segmental screw approximation to the generally concave rod and segmental correction of vertebral translation. Moderate concave distraction and convex compression. If needed, final in situ bending of the rods. Schwab type I osteotomies; in rigid curves type II osteotomies. Fusion with local bone, allogenic bone and/or bone substitutes (i.e., tricalcium phosphate). Intraoperative placement of a thoracic epidural catheter for postoperative pain control. Neurological monitoring throughout the procedure. POSTOPERATIVE MANAGEMENT: Mobilization on postoperative day 1 with focus on pain management and nutrition. Return to school after 4 weeks. Physiotherapy after 3 months, cycling after 3-6 months, and full sport activities after 1 year. RESULTS: Frontal curve correction of 60-80%, sufficient sagittal plane correction. Correction of rib hump 40%. Patient satisfaction is high at 95% and long-term revision rates of < 10%.

Analysis of the Spinopelvic Parameters in Patients with Fragility Fractures of the Pelvis.

BACKGROUND: We investigated the spinopelvic parameters of lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS) in patients with fragility fractures of the pelvis (FFPs). We hypothesized that these parameters differ from asymptomatic patients. METHODS: All patients treated for FFPs in a center of maximal care of the German Spine Society (DWG) between 2017 and 2021 were included. The inclusion criteria were age ≥ 60 years and the availability of a standing lateral radiograph of the spine and pelvis in which the spine from T12 to S1 and both femoral heads were visible. The baseline characteristics and study parameters were calculated and compared with databases of asymptomatic patients. The two-sample t-Test was performed with p < 0.05. RESULTS: The study population (n = 57) consisted of 49 female patients. The mean age was 81.0 years. The mean LL was 47.9°, the mean PT was 29.4°, the mean SS was 34.2° and the mean PI was 64.4°. The mean value of LLI was 0.7. LL, LLI and SS were significantly reduced, and PI and PT were significantly increased compared to asymptomatic patients. CONCLUSIONS: The spinopelvic parameters in patients with FFPs differ significantly from asymptomatic patients. In patients with FFPs, LL, LLI and SS are significantly reduced, and PI and PT are significantly increased. The sagittal spinopelvic balance is abnormal in patients with FFPs.

Efficacy of a 4-Antigen Staphylococcus aureus Vaccine in Spinal Surgery: The STaphylococcus aureus suRgical Inpatient Vaccine Efficacy (STRIVE) Randomized Clinical Trial.

BACKGROUND: Staphylococcus aureus is a global pathogen that is frequently responsible for healthcare-associated infections, including surgical site infections (SSIs). Current infection prevention and control approaches may be limited, with S. aureus antibiotic resistance remaining problematic. Thus, a vaccine to prevent or reduce S. aureus infection is critically needed. We evaluated the efficacy and safety of an investigational 4-antigen S. aureus vaccine (SA4Ag) in adults undergoing elective open posterior spinal fusion procedures with multilevel instrumentation. METHODS: In this multicenter, site-level, randomized, double-blind trial, patients aged 18-85 years received a single dose of SA4Ag or placebo 10-60 days before surgery. SA4Ag efficacy in preventing postoperative S. aureus bloodstream infection and/or deep incisional or organ/space SSIs was the primary end point. Safety evaluations included local reactions, systemic events, and adverse events (AEs). Immunogenicity and colonization were assessed. RESULTS: Study enrollment was halted when a prespecified interim efficacy analysis met predefined futility criteria. SA4Ag showed no efficacy (0.0%) in preventing postoperative S. aureus infection (14 cases in each group through postoperative day 90), despite inducing robust functional immune responses to each antigen compared with placebo. Colonization rates across groups were similar through postoperative day 180. Local reactions and systemic events were mostly mild or moderate in severity, with AEs reported at similar frequencies across groups. CONCLUSIONS: In patients undergoing elective spinal fusion surgical procedures, SA4Ag was safe and well tolerated but, despite eliciting substantial antibody responses that blocked key S. aureus virulence mechanisms, was not efficacious in preventing S. aureus infection. Clinical Trials Registration. NCT02388165.

SPINE20 recommendations 2021: spine care for people's health and prosperity.

PURPOSE: The focus of SPINE20 is to develop evidence-based policy recommendations for the G20 countries to work with governments to reduce the burden of spine disease, and disability. METHODS: On September 17-18, 2021, SPINE20 held its annual meeting in Rome, Italy. Prior to the meeting, the SPINE20 created six proposed recommendations. These recommendations were uploaded to the SPINE20 website 10 days before the meeting and opened to the public for comments. The recommendations were discussed at the meeting allowing the participants to object and provide comments. RESULTS: In total, 27 societies endorsed the following recommendations. SPINE20 calls upon the G20 countries: (1) to expand telehealth for the access to spine care, especially in light of the current situation with COVID-19. (2) To adopt value-based interprofessional spine care as an approach to improve patient outcomes and reduce disability. (3) To facilitate access and invest in the development of a competent rehabilitation workforce to reduce the burden of disability related to spine disorders. (4) To adopt a strategy to promote daily physical activity and exercises among the elderly population to maintain an active and independent life with a healthy spine, particularly after COVID-19 pandemic. (5) To engage in capacity building with emerging countries and underserved communities for the benefit of spine patients. (6) To promote strategies to transfer evidence-based advances into patient benefit through effective implementation processes. CONCLUSIONS: SPINE20's initiatives will make governments and decision makers aware of efforts to reduce needless suffering from disabling spine pain through education that can be instituted across the globe.

Complications in TLIF spondylodesis-do they influence the outcome for patients? A prospective two-center study.

PURPOSE: Transforaminal lumbar interbody fusion (TLIF) is a widely accepted surgical procedure for degenerative disk disease. While numerous studies have analyzed complication rates and risk factors this study investigates the extent to which complications after TLIF spondylodesis alter the clinical outcome regarding pain and physical function. METHODS: A prospective clinical two-center study was conducted, including 157 patients undergoing TLIF spondylodesis with 12-month follow-up (FU). Our study classified complications into three subgroups: none (I), minor (IIa), and major complications (IIb). Complications were considered "major" if revision surgery was required or new permanent physical impairment ensued. Clinical outcome was assessed using visual analog scales for back (VAS-B) and leg pain (VAS-L), and Oswestry Disability Index (ODI). RESULTS: Thirty-nine of 157 patients (24.8%) had at least one complication during follow-up. At FU, significant improvement was seen for group I (n = 118) in VAS-B (-50%), VAS-L (-54%), and ODI (-48%) and for group IIa (n = 27) in VAS-B (-40%), VAS-L (-64%), and ODI (-47%). In group IIb (n = 12), VAS-B (-22%, P = 0.089) and ODI (-33%, P = 0.056) improved not significantly, while VAS-L dropped significantly less (-32%, P = 0.013) compared to both other groups. CONCLUSION: Our results suggest that major complications with need of revision surgery after TLIF spondylodesis lead to a significantly worse clinical outcome (VAS-B, VAS-L, and ODI) compared to no or minor complications. It is therefore vitally important to raise the surgeon´s awareness of consequences of major complications, and the topic should be given high priority in clinical work.

Georg Schmorl Prize of the German Spine Society (DWG) 2017: correction of spino-pelvic alignment with relordosing mono- and bisegmental TLIF spondylodesis.

INTRODUCTION: A balanced ratio of the main parameters of lumbar lordosis (LL) and pelvic incidence (PI) has high clinical relevance. A postoperative mismatch of LL and PI has been described in the literature to be associated with an inferior clinical outcome and higher postoperative revision rates. The aim of this retrospective, radiological study is to evaluate the magnitude of relordosing in mono-/bisegmental TLIF spondylodesis affecting the spino-pelvic alignment and the main contributing factors. MATERIALS AND METHODS: 164 patients (pat.) underwent monosegmental (n = 115, G1) and bisegmental (n = 49, G2) TLIF spondylodesis, respectively, for different indications in 2016 in our hospital. Pelvic incidence, lumbar lordosis (preop., postop., 3 months postop.), implanted cage sizes, and the use of additional Smith-Petersen osteotomies were analysed retrospectively. Patients were divided into three groups depending on match of LL/PI (PI-LL < 10° green, PI-LL = 10-20° yellow, PI-LL > 20° red). Furthermore, a differentiation was made between surgeons with more than or less than 10 years of spinal surgery experience, respectively. RESULTS: 29.6% of pat. in G1 and 16.3% in G2 showed a highly pronounced preoperative spino-pelvic mismatch (red). A high grade of mismatch (yellow) between LL/PI was seen in 29.6% in G1 and in 38.8% in G2. The remaining patients already had a balanced ratio of LL/PI (green). Through relordosing TLIF the LL could be corrected significantly (p < 0.05). Therefore, the number of patients with a balanced sagittal alignment (green) increased from 40.9% preop. to 70.4% postoperative in G1 and from 44.9 to 85.7% in G2 (p < 0.05). The number of pat. with highly pronounced preoperative mismatch (red) could be lowered in G1 from 29.6 to 13.9% and in G2 from 16.3 to 2% postoperative (p < 0.05). In G1, the preoperative LL could be corrected from 46.3° to 53.8° (yellow) and 35.7° to 45.8° (red), while in G2, a correction was possible from 43.4° to 51.5° (yellow) and 36.6° to 50.1° (red) (p < 0.05). No significant difference of segmental/complete LL was found between radiologic measurement immediately postoperative and at the 3-month follow-up. In monosegmental fusion higher cages sizes lead to a better match of LL/PI (p < 0.05). The specific cage lordosis (5° vs. 10°) had no influence on the extent of relordosing. Experienced surgeons had significant higher postoperative matches of LL/PI (p < 0.05) and accomplished more osteotomies (p < 0.05). DISCUSSION: This retrospective study demonstrates that significant relordosing and, therefore, correction of the spino-pelvic alignment are possible with mono-/bisegmental TLIF spondylodesis. Positive influence of higher cage sizes and surgeon's experience was shown. We conclude that the ratio of LL/PI should be taken into account preoperatively in lumbar fusion surgery when planning mono-/bisegmental TLIF spondylodesis to optimize spino-pelvic alignment. These slides can be retrieved under Electronic Supplementary Material.

Intra- versus postoperative initiation of pain control via a thoracic epidural catheter for lumbar spinal fusion surgery.

BACKGROUND: Thoracic epidural anesthesia (TEA) is one of the pillars of perioperative pain care. Particularly for spine surgery which causes significant postoperative pain TEA seems like an appealing option. However, beneficial effects of a TEA are questionable when the catheter is not used intraoperatively, a decision that is usually based on the surgeon's wish to perform immediate neurological examination postoperatively. METHODS: Forty patients undergoing transforaminal lumbar interbody fusion surgery (TLIF) were randomized into two groups. Patients received preoperative insertion of a TEA. For patients in the intraoperative group an epidural infusion was started preoperatively and maintained throughout. For patients in the postoperative group the epidural infusion was started once neurological examination had been performed. The primary outcome measure in this study was postoperative requirements of piritramide during the first two postoperative hours. Secondary outcomes involved postoperative pain numeric rating scale (NRS) scores, intraoperative opioid requirements, side effects and ability to perform direct postoperative neurological examination. RESULTS: Postoperative group patients required significantly more opioids both intra- and postoperatively (P=0.036 and P=0.039) and NRS scores were significantly higher on admission to recovery, at 30 and 60 min as compared to patients in the intraoperative group (P=0.013; P=0.004 and P=0.012). Early postoperative neurological examination was feasible in all patients in both groups. CONCLUSIONS: Epidural catheters used intraoperatively during TLIF are feasible, significantly reduce pain, intra- and postoperative use of opioids and do not influence the quality of neurological tests directly after the surgical procedure.

Predictors of shoulder level after spinal fusion in adolescent idiopathic scoliosis.

BACKGROUND: For patients with adolescent idiopathic scoliosis, shoulder balance influences their treatment satisfaction and psychological well-being. Several parameters are known to affect postoperative shoulder balance, but few prognostic models are as yet available. PURPOSE: This study aimed to identify independent predictive factors that can be used to assess preoperatively which patients are at risk of postoperative shoulder elevation, and to build a linear prediction model. METHODS: N = 102 patients with all Lenke types were reviewed radiographically before surgery and 1 year afterward. The outcome measures were coracoid height difference (CHD), clavicular angle (CA), and clavicle-first rib intersection difference (CiRID). Predictive factors commonly used in the literature were investigated using correlation analysis and statistical testing. Significant contributing factors were included in three multiple linear regression models (for CHD, CA, and CiRID). RESULTS: The mean shoulder level (CHD) significantly changed from a lower left shoulder value of -8.5 mm before surgery to 3.3 mm at the follow-up examination. A high preoperative left shoulder level by CiRID, a large amount of Cobb angle correction of the distal thoracic curve, a low preoperative Cobb angle in the lumbar curve, and a structural proximal thoracic curve proved to be determinants and thus risk factors for left-sided shoulder elevation after surgery. The three models predicting CHD, CA, and CiRID at the follow-up examination included these four risk factors and were significant. CONCLUSIONS: Preoperative variables have the strongest influence on shoulder level after spinal instrumentation. Additionally, extensive correction of the distal thoracic curve can cause elevation of the left shoulder.

Surgical correction of scoliosis in patients with severe cerebral palsy.

INTRODUCTION: There is a lack of data in the literature on surgical correction of severe neuromuscular scoliosis in patients with serious extent of cerebral palsy. The purpose of this retrospective cohort study was to analyze the radiological and clinical results after posterior-only instrumentation (group P) and combined anterior-posterior instrumentation (group AP) in severe scoliosis in patients with Gross Motor Function Classification System grades IV and V. MATERIALS AND METHODS: All eligible patients who underwent surgery in one institution between 1997 and 2012 were analyzed, and charts, surgical reports, and radiographs were evaluated with a minimum follow-up period of 2 years. RESULTS: Fifty-seven patients were included (35 in group P, 22 in group AP), with a median follow-up period of 4.1 years. The preoperative mean Cobb angles were 84° (34 % flexibility) in group P and 109° (27 % flexibility) in group AP. In group P, the Cobb angle was 39° (54 % correction) at discharge and 43° at the final follow-up, while in group AP the figures were 54° (50 % correction) at discharge and 56° at the final follow-up. Major complications occurred in 23 vs. 46 % of the patients, respectively. Preoperative curve flexibility was an important predictor for relative curve correction, independently of the type of surgery. CONCLUSION: Posterior-only surgery appears to lead to comparable radiological results, with shorter operating times and shorter intensive-care unit and hospital stays than combined surgery. The duration of surgery was a relevant predictor for complications.

Expert's comment concerning Grand Rounds case entitled "vertebral column resection for complex congenital kyphoscoliosis and type I split cord malformation" (Hua Hui, Zhen-Xing Zhang, Tuan-Min Yang, Bao-Rong He, Ding-Jun Hao).

INTRODUCTION: Comment on a case report on a challenging case of a severe spinal congenital deformity with a type I split spinal cord malformation (SSCM) in a 23-year-old with initial neurological symptoms. MATERIAL AND METHODS: The patient was treated with a halo gravity traction over one month. A posterior vertebral column resection cephalad to the bony spur at T12 was done and moderate frontal and sagittal plane curve correction was achieved without resection of the bony spur. CONCLUSIONS: In conclusion, despite a quite clear recommendation in the current literature to first surgically address the type 1 SSCM prior to correction of any spinal deformity, the authors of the present case chose to leave the bony spur. Still it remains to be seen if in this very case the spur will become clinically apparent in the future or not. As long as larger studies on curve correction without spur resection in SSCM are not available, spur resection prior to any type of curve correction remains the golden standard.

Silicate-substituted calcium phosphate as a bone graft substitute in surgery for adolescent idiopathic scoliosis.

STUDY DESIGN AND OBJECTIVE: The purpose of this prospective clinical study is to evaluate the clinical and radiographic outcomes using a silicate-substituted calcium phosphate (Si-CaP) as a bone graft substitute in surgery for adolescent idiopathic scoliosis (AIS). In posterior corrective surgery for AIS, harvesting autologous bone from the iliac crest still represents the gold standard to augment the local bone graft though it is comparatively invasive and associated with donor site morbidity. Si-CaP enriched with bone marrow aspirate (BMA) might be an appropriate bone graft extender to overcome these difficulties. METHODS: Eighteen female and three male patients with AIS who underwent corrective posterior instrumentation were observed clinically and radiographically for a minimum of 24 months. In all cases, 20-40 ml Si-CaP granules (ACTIFUSE) mixed with BMA from vertebral bodies was used to extend the local bone graft. Fusion was assessed by standardized conventional radiographs regarding loss of correction and implant failure. Clinical outcome was evaluated with use of the Scoliosis Research Society-22 patient Questionnaire (SRS-22) and a Visual Analog Scale (VAS) for back pain. RESULTS: Cobb angle of major curves averaged 63° preoperatively, 22° after surgery, and 24° at final follow-up, with a maximum loss of correction of 7° recorded after 4 months. No adverse effects related to the study material had been observed. In all patients, there was no evidence of implant failure, and formation of an increasingly densifying 'fusion mass' was visible, as assessed by conventional radiography. VAS score for back pain averaged 1.7 before surgery, 2.3 at discharge, and 1.5 at final follow-up. Outcome assessment using the SRS-22 revealed a significantly enhanced overall health-related quality of life (84 vs. 74 % before surgery; P = 0.0005) due to a significant improvement of the domains 'self image' (77 vs. 59 %; P = 0.0002) and 'pain' (88 vs. 80 %; P = 0.02). Patients' management satisfaction averaged 93 %. CONCLUSIONS: Si-CaP augmented with BMA from vertebral bodies seems to prove an effective, safe, and easy to handle bone graft extender in scoliosis surgery and thus a suitable alternative to bone harvesting procedures.

Pulmonary function after anterior double thoracotomy approach versus posterior surgery with costectomies in idiopathic thoracic scoliosis.

INTRODUCTION: The surgical approach in the treatment of idiopathic thoracic scoliosis depends on the type of curve involved. In anterior correction, the rib hump is corrected by derotating the thoracic spine. In posterior scoliosis surgery, additional rib hump resection is sometimes necessary to achieve an optimal cosmetic result. The aim of this study was to compare pulmonary function in these two patient groups. MATERIALS AND METHODS: Forty patients in the anterior group (A) were treated with standard double thoracotomy, with an anterior derotation spondylodesis and a primary stable dual-rod system. The posterior group (P) included 29 patients who were treated with a pedicle screw-based posterior instrumentation spondylodesis, with additional rib hump resection. Pulmonary function was evaluated preoperatively, on the 12th postoperative day, and at 3, 6, 12 and 24 months during the follow-up. RESULTS: The patients' mean age was 15 years in group A and 19 in group P with a standard deviation 8.7 years and a significant difference. With regard to body height or weight there were no significant differences between the two groups. In group A, the deterioration in pulmonary function immediately after the operation (from [Formula: see text] 75.3 %/71.3 % preoperatively to 38.5 %/36.1 % postoperatively) was clearer than in group P ([Formula: see text] 71.6 %/65.7 % preoperatively to 47.7 %/48.4 % postoperatively). During a follow-up period of 3 months, the values improved in both groups in comparison with the values immediately after the operation. Up to the 2 year follow-up, pulmonary function in the posterior and anterior groups corresponded to the preoperative values, with no significant differences. There was a trend toward moderately increased values in the posterior group and moderately decreased values in the anterior group at the 2-year follow-up examination, in comparison with the preoperative baseline, but without a statistically significant difference. Two major complications occurred in the anterior group, with reintubation and several bronchoscopy examinations due to atelectasis. CONCLUSION: The severe deterioration in group A is caused by the substantial trauma with double thoracotomy in contrast to rib hump resection. For patients with severe restrictive pulmonary distress, posterior instrumentation in combination with rib hump resection would be preferable to an anterior procedure involving double thoracotomy. Respiratory physiotherapy exercise should be administered in order to minimise postoperative pulmonary distress. In conclusion opening of the chest wall leads to deterioration of pulmonary function with improvement to the preoperative values after 6 months in the posterior and after 24 months in the anterior group.

Spontaneous lumbar curve correction in selective anterior instrumentation and fusion of idiopathic thoracic scoliosis of Lenke type C.

BACKGROUND: Posterior pedicle screw instrumented correction and fusion have become the gold standard in the surgical treatment of thoracic scoliosis. However, in thoracic Lenke type C curves selective posterior fusion of the thoracic curve may lead to spinal imbalance. The aim of the study was to analyse the radiological results of selective anterior thoracic fusion using a standard open dual rod technique with special respect to spontaneous lumbar curve correction (SLCC). METHODS: Twenty-eight patients (26 patients with Lenke 1C and 2 patients with Lenke 2C curves) with an average age of 15 years were surgically treated with an anterior dual rod system through a standard open double thoracotomy approach. Average clinical and radiological follow-up was 4 years (24-84 months). RESULTS: Fusion was carried out mostly from end-to-end vertebra. The primary curve was corrected from 61.6° (average correction on reverse bending films 42.9 %) to 27.1° (56.0 % correction) with an average loss of correction of 2.2°. The secondary lumbar curve measured 47.7° preoperatively (40-56°, average correction on reverse bending films 66.2 %) and corrected spontaneously to 30.1° (36 % SLCC) and remained stable without any cases of deterioration or decompensation during follow-up. Lumbar apical vertebral translation increased minimally by an average of 4 mm directly, postoperatively, and returned to an average of preoperative values during follow-up. All but two curves remained as type C lumbar modifier at follow-up. Preoperatively, three patients showed a marked coronal imbalance of more than 3 cm (all left, average 4.0 cm); at follow-up, two patients were still out of balance by more than 3 cm (all to the left, average 3.4 cm). Preoperatively, a marked shoulder imbalance of more than 1.0 cm was found in 11 patients; this was corrected in all patients to <1.0 cm at follow-up. The apical vertebral rotation measured according to Perdriolle was corrected from 23.5° to 15.0° in the thoracic spine (36.2 % correction) with an average clinical reduction of the rib hump of 63.2 %. In the lumbar spine, there was no relevant radiological derotation; however, clinically, the lumbar hump corrected spontaneously by 44.3 %. Thoracic kyphosis measured 28.5° preoperatively and 32.3° at follow-up. All six patients with a preoperative hypokyphosis (<20°) of an average of 9.5° were successfully corrected to an average thoracic kyphosis of 23.8° at follow-up. There were no cases of junctional thoracolumbar kyphosis. There were neither reoperations nor implant failures with pseudarthrosis. CONCLUSION: Selective anterior correction and fusion in primary thoracic curves with lumbar modifier type Lenke C resulted in a reliable and satisfactory SLCC. Advantages of anterior versus posterior techniques are the true segmental derotation with excellent rib hump correction and a superior restoration of thoracic kyphosis.

Sagittal balance of thoracic lordoscoliosis: anterior dual rod instrumentation versus posterior pedicle screw fixation.

Posterior pedicle screw fixation is now the standard treatment for surgical correction of idiopathic scoliosis and has largely replaced anterior techniques, but there have been reports describing a lordogenic effect of segmental pedicle screw instrumentation in the thoracic spine. This clinical study compared anterior dual rod instrumentation with posterior pedicle screw fixation for idiopathic thoracic lordoscoliosis, including 42 patients (7 male, 35 female; average age 16 years, range 12-34) who underwent posterior pedicle screw fixation (n = 20) or anterior dual rod instrumentation (n = 22) at two centers. The average follow-up period was 33 months (24-108 months). Inclusion criteria were a diagnosis of adolescent idiopathic scoliosis with a structural thoracic curve (Lenke 1-3) and thoracic hypokyphosis (T4-T12 < 20°). The main thoracic curve magnitude and sagittal profile on standing radiographs were evaluated. Thoracic kyphosis was significantly restored from preoperatively 10.2° to 23.4° postoperatively in the anterior group and from 7.6° to 12.9° in the posterior group (P < 0.005). Kyphosis improved significantly better in the anterior group than in the posterior group (P < 0.005). The preoperative and postoperative main thoracic curve values were 63° (48-80°) and 25.2° in the anterior group and 60.6° (50-88°) and 23.6° in the posterior group, with no significant differences between the groups. No neurological or other severe complications were observed. Anterior dual rod instrumentation in patients with thoracic lordoscoliosis allows significantly better restoration of thoracic kyphosis than posterior pedicle screw instrumentation.

Long-term follow-up after en bloc resection and reconstruction of a solitary paraganglioma metastasis in the first lumbar vertebral body: a case report.

INTRODUCTION: Paragangliomas are rare tumors that originate from the autonomic nervous system-associated paraganglia. They metastasize infrequently. Malignancy can only be demonstrated by the presence of chromaffin tissue at sites where it usually is not present, such as bone, lung or liver, or local recurrence after total resection of a primary mass. Paragangliomas within the central nervous system are usually intradural near the conus medullaris. The metastatic spread of a retroperitoneal paraganglioma to a vertebral body is extremely rare, and there are only a few cases reported in the literature. CASE PRESENTATION: We report the case of a 16-year-old Caucasian girl who had undergone resection of a retroperitoneal paraganglioma that measured 15 × 11.5 × 9.5 cm. After further staging, a solitary metastatic paraganglioma was detected in the first lumbar vertebral body. After initial chemotherapy, marginal en bloc resection and reconstruction were performed followed by radiotherapy. Histologic examination of the specimen revealed that the tumor cells did not show any response to preoperative chemotherapy, which is in line with a few other reports in the literature. Ten years after operative treatment, the patient is free of complaints, very satisfied with the result and without signs of local recurrence or distant metastases. CONCLUSION: We recommend en bloc spondylectomy and local radiotherapy in the treatment of solitary spinal metastatic paragangliomas.

Left convex thoracic scoliosis: retrospective analysis of 25 patients after surgical treatment / Escoliose torácica sinistro-convexa: análise retrospectiva de 25 pacientes após o tratamento cirúrgico / Escoliosis torácica convexa izquierda: análisis retrospectivo de 25 pacientes después de tratamiento quirúrgico

OBJECTIVE: A retrospective analysis of clinical and radiological data was conducted, with an emphasis on perioperative complications and risk factors and a minimum follow-up period of two years. The postoperative quality of life was assessed using the SRS-22 questionnaire. METHODS: Between 1999 and 2009, 25 patients (nine male, 16 female) with LCTS, with a mean age of 13.7 years (2.3-29.8 years), were treated with correction and instrumented fusion at a single institution. Seven patients had congenital scoliosis and 18 patients had noncongenital scoliosis (idiopathic, n = 5; neuropathic, n = 4; neoplasm-associated/iatrogenic, n = 3; secondary to other conditions, n = 6). The average preoperative Cobb angle was 74° (49-102°). RESULTS: A mean correction of 51 percent was achieved postoperatively. The mean Cobb angle at the final follow-up examination was 45° (19-85°), with a significant loss of correction of 8.8° on average. Major complications affected five patients (20 percent): respiratory insufficiency requiring prolonged intubation, intraoperative cardiac arrest with resuscitation being necessary twice in one patient, persistent clonus, low-grade infection, implant-based complications requiring revision surgery, and adding-on. Minor complications were observed in 22 patients (88 percent), mainly gastrointestinal and pulmonary. No cases of paraplegia or death occurred. A noncongenital etiology had been diagnosed before the age of 10 years in all of the patients who had major complications. The best score on the SRS-22 questionnaire was achieved in the domain of pain (87 percent), while the poorest was in the domain of self-image (68 percent). CONCLUSIONS: The results of this study emphasize an increased complication rate in patients with LCTS scheduled for scoliosis surgery. Additional preoperative examinations (MRI, paediatric consultation, cardiologic consultation, pulmonary function test) are mandatory in patients with LCTS. Preoperatively, patients should be informed about the increased cardiopulmonary and neurological risk which may be associated with scoliosis surgery.

OBJETIVO: Foi realizado estudo retrospectivo baseado em parâmetros clínicos e radiológicos, com ênfase nas complicações, fatores de risco e seguimento mínimo de dois anos. A qualidade de vida pós-operatória foi avaliada por meio do questionário SRS-22. MÉTODOS: No período de 1999 a 2009, 25 pacientes (nove do sexo masculino e 16 do sexo feminino) com idade variando de 2,3 a 29,8 anos (média de idade de 13,7 anos) foram submetidos a tratamento cirúrgico por meio de instrumentação e artrodese. Sete pacientes apresentavam escoliose congenital, cinco apresentavam escoliose idiopática, quatro neuropática, três associada à neoplasia ou iatrogenia, e seis associada a outras doenças. A média dos valores pré-operatórios do ângulo de Cobb foi 74° (49-102°). RESULTADOS: A média de correção no pós-operatório foi de 51 por cento. Na avaliação de seguimento final, o valor médio do ângulo de Cobb foi 45° com variação de 19 a 85°, tendo ocorrido significante perda da correção com o valor médio de 8.8°. Complicações maiores ocorreram em cinco pacientes (20 por cento): insuficiência respiratória requerendo entubação prolongada, parada cardíaca intraoperatória com ressuscitação, clônus persistente, infecção de baixo grau, complicações com implantes requerendo revisão cirúrgica, e descompensação do tronco. Complicações menores foram observadas em 22 pacientes (88 por cento), sendo principalmente gastrointestinais e pulmonares. Nenhum caso de paraplegia ou morte ocorreu na série de pacientes estudados. As curvas de etiologia não congênita foram diagnosticadas antes dos 10 anos de idade em todos os pacientes que apresentaram complicações maiores. O melhor escore do questionário SRS-22 foi observado no domínio da dor (87 por cento), e o pior no domínio da autoimagem (68 por cento). CONCLUSÕES: O resultado do estudo enfatiza as altas taxas de complicação nos pacientes portadores de escoliose torácica sinistro-convexa que são submetidos ao tratamento cirúrgico. Avaliações pré-operatórias adicionais (RNM, avaliação pediátrica, avaliação cardiológica, teste de função pulmonar) devem ser realizadas nesse grupo de pacientes. Antes do procedimento, os pacientes devem ser informados acerca do alto risco de complicações cardiopulmonares e neurológicas associadas ao tratamento cirúrgico da deformidade.

OBJETIVO: Fue realizado un análisis retrospectivo de datos clínicos y radiológicos, con énfasis en complicaciones perioperatorias y factores de riesgos, y un período mínimo de seguimiento de 2 años. La calidad de vida posoperatoria fue evaluada usándose el cuestionario SRS-22. MÉTODOS: entre 1999 y 2009, 25 pacientes (nueve del sexo masculino, 16 del sexo femenino) con ETCI, con edad promedio de 13,7 años (2,3 - 29,8 años) fueron tratados con corrección y fusión instrumentada, en una única institución. Siete pacientes tenían escoliosis congénita y 18 pacientes tenían escoliosis no congénita (idiopática, n = 5; neuropática, n = 4; asociada a neoplasma/iatrogénica, n = 3; secundaria de otras condiciones, n = 6). El ángulo de Cobb preoperativo promedio fue 74º (49-102º). RESULTADOS: una corrección promedio de 51 por ciento fue alcanzada después de la operación. El ángulo de Cobb promedio, en el examen final de seguimiento, fue 45º (19-85º), con una pérdida significativa de corrección de 8,8º en promedio. Complicaciones graves afectaron a cinco pacientes (20 por ciento): insuficiencia respiratoria que requirió intubación prolongada, paro cardíaco intraoperativo con resucitación siendo necesaria dos veces para un paciente, clonus persistente, infección leve, complicaciones con implantes que precisaron de otra cirugía, y accesorios. Complicaciones de menor importancia fueron observadas en 22 pacientes (88 por ciento), principalmente gastrointestinales y pulmonares. No ocurrieron casos de paraplejía ni de muerte. Una etiología no congénita fue diagnosticada, antes de la edad de 10 años, en todos los pacientes que tuvieron complicaciones graves. La mejor puntuación en el cuestionario SRS-22 fue obtenida en el dominio de dolor (87 por ciento), mientras que la peor se registró en el dominio de la autoimagen (68 por ciento). CONCLUSIONES: Los resultados de este estudio enfatizan una tasa de complicación aumentada en pacientes portadores de ETCI con programación de cirugía de escoliosis. Exámenes preoperatorios adicionales (IRM, consulta pediátrica, consulta cardiológica, prueba de función pulmonar) son obligatorios en pacientes con ETCI. Antes de la operación, los pacientes deben ser informados sobre los mayores riesgos cardiopulmonar y neurológico que pueden estar vinculados a la cirugía de escoliosis.

Feasibility and efficacy of preoperative epidural catheter placement for anterior scoliosis surgery.

BACKGROUND: Postoperative pain control via thoracic epidural catheters (TECs) is an important aspect of postoperative care, and ample evidence highlights its positive physiologic effects and superiority to intravenous analgesia. If epidural catheters for postoperative pain relief are used in scoliosis surgery, current practice is the intraoperative placement of the TEC by the surgeon because preoperative placement is considered challenging and dangerous. On the basis of magnetic resonance imaging of scoliotic spines, the authors developed a technique for preoperative placement of TEC and investigated its safety and feasibility. METHODS: Patients undergoing anterior scoliosis surgery were included, who received preoperative placement of TEC. Postoperative pain, problems associated with the TEC placement, possible side effects, radiographic data, and insertion levels of the TEC were noted. RESULTS: The apex vertebra was identified as a possible site for TEC placement due to dural sac shift leaving a wider epidural space on the convex side. Scoliosis-induced rotation of the vertebrae required realignment of the needle toward the convex side. Sixty patients were included. The success rate for TEC placement was 96.6%: one failed attempt, one catheter placed intrapleurally, and one patient with Horner syndrome. Seven percent of patients required additional rescue analgesia. All other patients had pain scores within acceptable limits (Visual Analogue Scale <5). CONCLUSIONS: The authors have demonstrated that it is possible to insert a TEC in patients with scoliotic spines with a high degree of success using a redesigned approach and thus provide adequate postoperative analgesia with a single epidural catheter. However, precautions have to be taken.