A descriptive study on the adjacent segment degeneration related signs following a lumbar fusion procedure.

BACKGROUND: Adjacent segment degeneration (ASD) is a frequent complication following vertebral fusion procedures and is defined as the condition where patients recover after the initial procedure but develop compatible symptoms with radiological injuries in the segments adjacent to the fused ones at a later stage. The objective of the study was to describe the frequency and analysis of ASD related signs following a lumbar fusion procedure. METHODS: Observational descriptive retrospective study on patients with degenerative or instability conditions, operated on by posterolateral or circumferential lumbar fusion procedure. Pedicle screws, interbody peek cages (polyether-ether-ketone) and autologous bone graft were used. Clinical (pain and disability) and radiological (instability, rotation, disc height loss, radiological degeneration evaluated by X-ray and MR) variables were analysed. RESULTS: Postoperative disc height loss was observed in 159 free discs among 112 patients (42.6%) (95% CI: 36.4-48.8%). Anterior or posterior slippage (anterolisthesis or retrolisthesis) at the end of the follow-up period was observed in 33 patients (12.5%). Upper segment rotation increased in the postoperative period in 36 patients (13.6%). Radiological disc degeneration was observed in 107 discs among 72 patients, being more frequent in the immediate upper disc with grade 2 and 3 changes at the end of follow-up in 48 discs from 35 patients (13.6%) (95% CI: 13.4-23.1%). Radiological ASD signs were observed in 151 patients (57.4%; 95% CI: 51.2-63.6%) and 53 of them (20.2%; 95% CI: 15.1-25.2%) who also showed clinical ASD symptoms (clinical and radiological ASD). Degeneration changes with degrees IV and V shown by a preoperative and magnetic resonance (MR) study at end of the follow-up period performed in 73 patients (27.7%), were observed in 46 discs among 32 patients (43.8%) (95% CI: 31.8-55.9%). CONCLUSIONS: Radiological ASD signs evaluated in every free disc following a lumbar fusion procedure are observed with a variable frequency. All free discs after fusion were assessed as they could indicate mechanisms of compensation of lordosis loss and should be taken into consideration in a prospective revision surgery.

Long-Term Reliability of the Two-Segment Fusion Technique in the Treatment of Thoracolumbar Fractures Using Screws in the Fractured Vertebra.

BACKGROUND: There is some controversy about which is the best approach, decompression technique and number of fixed levels in the surgical treatment for burst thoracolumbar fractures. Without a neurological injury, correcting thoracolumbar kyphosis and preventing mechanical failure should be the main concerns. The two-segment short fusion with screws at fractured vertebra by posterior approach was performed in 64 patients. Although a significant increase of postoperative kyphosis was observed, there were not clinical consequences, nor was there reintervention for mechanical failure. METHODS: Patients with unstable T11-L2 burst fractures and a two-level fusion including screws at the injured vertebra between 2000 and 2015 were included in the study. Demographic, clinical, and radiological variables were analyzed. Thoracolumbar, segmental, and vertebral kyphosis and anterior and posterior vertebral height were measured preoperatively, postoperatively, at one-year, and at the end of follow-up in the radiological study. The statistical analysis consisted of a descriptive analysis, and we used the t test to compare the preoperative, postoperative, one-year, and end-of-follow-up radiographs to observe a thoracolumbar T10-L2 kyphosis increase. Significance level was established at P < .05. RESULTS: Fifty-four patients were included. A statistically significant increase of vertebral, segmental, and thoracolumbar kyphosis (P < .05) was observed during follow-up, without clinical consequences. CONCLUSIONS: Two-segment fusion is an effective technique and allows initial deformity kyphotic correction after thoracolumbar burst fracture. The thoracolumbar kyphosis increased during the follow-up, without pain, disability, or mechanical failure. LEVEL OF EVIDENCE: 2a.

Sagittal Deformity Correction in a Patient Suffering From Diffuse Idiopathic Skeletal Hyperostosis Who Previously Underwent a Total Hip and Bilateral Knee Replacement.

INTRODUCTION: Physiological aging frequently leads to degenerative changes and spinal deformity. In patients with hypolordotic fusions or ankylosing illnesses such as diffuse idiopathic skeletal hyperostosis or ankylosing spondylitis, compensation mechanisms can be altered causing severe pain and disability. In addition, if a total hip replacement and/or knee replacement is performed, both pelvic and lower limbs compensation mechanisms could be damaged and prosthetic dislocation or impingement syndrome could be present. Pedicle subtraction osteotomy has proven to be the optimal correction technique for spinal deformation in patients suffering from a rigid spine. CASE PRESENTATION: A 70-year-old male patient with diffuse idiopathic skeletal hyperostosis criteria and a rigid lumbar kyphosis, who previously underwent a total hip and knee replacement, had severe disability. We then performed corrective surgery by doing a pedicle subtraction osteotomy. The procedure and outcomes are presented here. CONCLUSION: In symptomatic patients with sagittal imbalance and a rigid spine, pedicle subtraction osteotomy can indeed correct spinal deformity and re-establish sagittal balance.

Secondary thoracolumbar deformity and sagittal imbalance due to osteoporosis in a young man with Cushing's disease: A case report.

INTRODUCTION: To describe an unusual case of Cushing's disease with spontaneous axial pain due to multiple consecutive vertebral fractures which led to secondary deformity that required surgical treatment. PRESENTATION OF CASE: A 43-year-old man was referred to our service with back pain without previous trauma. He was diagnosed of refractory arterial hypertension and we observed centripetal obesity during exploration. With clinical findings and laboratory studies, ACTH-dependent Cushing's syndrome due to a pituitary microadenoma was diagnosed and the patient underwent an endoscopic-assisted endonasal transsphenoidal resection. Dual energy X-ray absorptiometry (DXA) revealed spine and hip osteoporosis. Moreover, X-ray, MR and CT showed multiple vertebral osteoporotic compression fractures in thoracic and thoracolumbar area. Secondary kyphosis thoracolumbar deformity and sagittal imbalance was treated by two-level Smith-Petersen osteotomies (SPO) and instrumented posterolateral arthrodesis T10-L3 using fenestrated pedicles screws with polymethyl methacrylate (PMMA). At six years of follow-up dual energy X-ray absorptiometry (DXA) recovered normal values (T-score lumbar spine L2-L4 1.4 and T-score hip -1.9) and X-ray study showed an adequate sagittal vertebral axis. DISCUSSION: Osteoporosis is a common feature of CD and fractures occur in 30-50% of cases. Treating the underlying cause reduces the risk of new fractures. Medical therapy is usually enough but consecutive multiple vertebral fractures related to glucocorticoid excess may lead to secondary painful deformity. CONCLUSION: Vertebral compression fractures result from secondary corticoid-induced osteoporosis in Cushing's disease. Early detection and treatment of primary disease decreases the risk of new fractures. However, unusual secondary spinal deformity or disability may require surgery.

An Unusual Case of Radicular Pain Caused by Bilateral Lumbar Synovial Cyst: A Case Report and Review of the Literature.

INTRODUCTION: Spinal synovial cysts (SSCs) constitute an uncommon degenerative lesion of the spine. They are usually asymptomatic but they may also cause symptoms of variable severity. SSCs are benign growths adjoining the facet joints that may induce low back pain, lumbar radiculopathy, and neurological deficit. There are different treatment options that range from conservative management to interventions like image-guided epidural steroid injection or direct cyst puncture and finally to open or endoscopic spinal canal decompression and spinal bone fusion with/without instrumentation. A discussion of current management options for this unusual disease is presented. Material and Methods. A 52-year-old female patient presented with low back pain and left leg pain. Plain radiography demonstrated instability at the L4-L5 level. Magnetic resonance images (MRIs) revealed a bilateral cystic lesion at the L4-L5 level with associated instability and degenerative disc disease at the level L5-S1. Initially, conservative treatment was performed by aspiration of the left cyst and infiltration with corticosteroids with improvement of the pain for 1 year. After this period, the radicular and the low back pain reoccurred. RESULTS: Following leg pain recurrence, a hybrid L4-S1 fusion was performed. After surgery, there was clinical improvement and six months later, the patient returned to daily activities. The radiological study after five-year follow-up shows adequate implant position, without signs of loosening, compatible with solid fusion. CONCLUSION: After reviewing the literature, the optimal management for patients with symptomatic lumbar synovial cyst must be very individualized, which is essential to achieve a favorable outcome.

Emergency stabilisation by single-stage posterior transpedicular approach for treatment of unstable lumbar spine fracture with neurological injury.

Management of unstable thoracolumbar fractures remains controversial. Furthermore, when these are accompanied by related neurological injury, the choice of approach, decompression technique and timing of the intervention could have a neuroprotective effect. In terms of site, the lumbar spine represents only 1.2% of cases, yet fractures with severe instability and neurological injury call for attainment of the same goals, i.e., neurological stability and decompression. After suffering high-energy trauma as a result of an accidental fall, a young male patient presenting with unstable injury of the lumbar spine and neurological impairment compatible with incomplete cauda equina syndrome was treated with emergency stabilisation and decompression through single-stage posterior transpedicular approach. At one year of the intervention, the patient is making good progress, with absence of lumbar pain, isolated deficit in left ankle dorsiflexion with no need of orthosis or cane, adequate sphincter control and return to his previous activity. Patients who present with unstable injury of the lumbar spine and incomplete neurological involvement can benefit from emergency stabilisation and decompression treatment by posterior transpedicular approach, with improvement in neurological status and functional recovery.

Thoracic pedicle subtraction osteotomy for correction of proximal junctional kyphosis after surgery for adolescent idiopathic scoliosis: A case report.

INTRODUCTION: Complications in the upper thoracic spine are not uncommon after corrective surgery for deformities in adults and adolescents. Proximal junctional failure has been linked to structural osseous or ligamentous failure and proximal junctional kyphosis has been described as an increase in preoperative proximal kyphosis. CASE DESCRIPTION: A 20-year-old male patient intervened after atypical development of idiopathic scoliosis, with rapid progression nearing skeletal maturity. While an increase in the magnitude of the main thoracic curve in the coronal plane was observed, the progression of structural sagittal plane deformity of the proximal thoracic curve was not identified due to poor visualization. This resulted in improper identification of curve type and choice of fusion levels, with progressive residual kyphosis across follow-up. At the age of 27, the patient was re-intervened by means of pedicle subtraction osteotomy in the apical area of the proximal thoracic deformity. Although an adequate correction was achieved, the remaining deformity of 50° and the proximal failure required extending the instrumentation and fusion to the cervical spine. This has shown itself to be an effective technique for correction of proximal residual or progressive symptomatic fixed kyphosis, thereby avoiding the morbidity of the anterior or combined approaches. CONCLUSIONS: In adolescent deformity, an adequate preoperative planning including clinical and radiological study must be carried out, paying special attention to the sagittal plane to identify major and minor structural curves. The pedicle subtraction osteotomy, despite being a demanding technique and not entirely risk-free, has shown itself to be an effective corrective technique.

Radiographic and Functional Results following Subtalar Arthroereisis in Pediatric Flexible Flatfoot.

INTRODUCTION: Flexible flatfoot (FFF) is one of the most common skeletal disorders in children. In symptomatic patients who do not respond to conservative measures, surgery may be an option. Subtalar arthroereisis consists of limiting excessive eversion of the subtalar joint through different types of implants. MATERIALS AND METHODS: We carried out a retrospective study of 16 patients (32 feet) intervened for FFF with a subtalar device (arthroereisis), across the period of 2008-2015 with a minimum follow-up period of one year. Pre- and postoperative measures of the Moreau-Costa-Bartani angle, dorsoplantar (DP) and lateral (L) talocalcaneal angle, talonavicular coverage angle, and naviculocuboid overlap were used to evaluate correction of the deformity. Two expert surgeons from the Pediatric Orthopedics Unit took separate measurements of these angles for subsequent analysis purposes and to obtain the interobserver correlation coefficient for quantitative variables. Pre- and postoperative differences in the measurement of angles were ascertained using Student's t-test for paired samples; and a functional evaluation of the patients intervened was carried out pre- and postoperatively by administering the parent version of the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C) during a clinical interview. All statistical analyses were performed using the SPSS v. 19.0 program (SPSS, Chicago, IL), with values being deemed statistically significant at p<0.05. RESULTS: A breakdown of the study population showed 81.25% (13 patients) males and 18.75% (3 patients) females, with mean age of 9 years (7-11). The interobserver coefficient for quantitative variables displayed a very high degree of concordance (0.7-0.9), indicating that the validity of the measures was adequate. Pre- and postoperative analysis of differences in the measurement of angles was statistically significant (p<0.005). In terms of functional evaluation, the postoperative results were positive, with statistical significance for the "school and play", "emotional", and "footwear" domains of the OxAFQ-C scale and no differences in the "physical" domain. CONCLUSION: Subtalar arthroereisis is a valid option for the treatment of symptomatic pediatric flatfoot, with good postoperative functional and radiographic results.

Risk factors related to adjacent segment degeneration: retrospective observational cohort study and survivorship analysis of adjacent unfused segments.

OBJECT: Adjacent segment disease (ASD) has been described as a frequent complication after a lumbar spinal fusion procedure, though its incidence and the factors related to its appearance are not well established. The radiographic signs that identify ASD in unfused segments may be a consequence of biomechanical changes induced by the fusion procedure. This study sought to analyse the incidence of radiographic changes (radiographic ASD) in all adjacent unfused segments, the clinical changes that require a second procedure (clinical ASD), and the risk factors of their appearance evaluated at different follow-up times. METHODS: We conducted a retrospective cohort study of patients fused for degenerative spine disease and instability to analyse ASD risk factors using actuarial estimation, comparison of the Kaplan-Meier survival curves of each variable, and Cox proportional-hazards regression analysis. RESULTS: Among the 263 patients included in the study, radiographic changes were observed in 57.4% and related clinical changes in 20.2%. The univariate analysis showed a higher risk of ASD in patients with smaller post- vs. pre-operative lumbar lordosis (p = .018), diagnosis of lumbar canal stenosis (p = .019), fusion of three or more vs. fewer levels (p = .009) and those fixed with top-loading screws vs. side-connecting screws (p = .001). Cox proportional-hazards regression analysis showed that the use of top-loading pedicle screws and three or more levels of fusion led to a 3- and 2-fold higher risk of degeneration in adjacent unfused segments respectively. CONCLUSIONS: Risk of a second surgical procedure due to clinical changes is 3-fold higher in patients with three or more levels of fusion, and 2.5-fold higher in patients intervened with top-loading pedicle screws.

The impact of urgent intervention on the neurologic recovery in patients with thoracolumbar fractures.

BACKGROUND: We carried out an observational longitudinal retrospective study between 2000 and 2009 in 28 patients who underwent surgery for unstable vertebral fractures with neurologic deficits. METHODS: For the statistical analysis, we used the Chi2-test to compare proportions in independent groups and the exact Fisher test and the Wilcoxon test for repeated measures, and we compared the mean values using the Mann-Whitney U test at a significance level of P<0.05. Timing to surgical intervention (urgent ≤8 vs. >8 h), and neurologic status using the American Spinal Injury Association (ASIA) Impairment Scale at baseline and at the end of follow-up were assessed. We tested the ASIA score improvement at the end of follow-up using multiple regression analysis, adjusted by variables such as ISS, timing of intervention, location, approach and type of fracture. RESULTS: Twenty-eight patients were included in the analysis. Of the total, 11 (39.2%) underwent surgery urgently (≤8 h) and 17 (60.8%) in >8 h. The mean difference in the neurologic improvement in all patients was 0.97 (95% CI, 0.51-1.42) and was statistically significant (P=0.001). The mean difference in the neurologic improvement in patients with incomplete lesions was 1.59 (95% CI, 1.01-2.17, P=0.001). In these patients, the mean improvement for those intervened in less than 8 h was 1.73 compared to those operated on after more than 8 h (mean improve 0.47) with a difference statistically significant (P=0.007). CONCLUSIONS: Urgent surgery was associated with neurologic improvement in patients with spinal cord injury (SCI). This improvement was mainly observed in patients with an incomplete lesion.

Free disease long-term survival in primary thoracic spine leiomyosarcoma after total en bloc spondylectomy: A case report.

INTRODUCTION: To describe an unusual primary vertebral leiomyosarcoma in thoracic spine. PRESENTATION OF CASE: An isolated lesion of the T11 vertebra in a 62-year-old woman with no neurologic deficit is reported. Imaging findings indicated a nonspecific high-grade malignant lesion. TC-guided biopsy failed thus open incisional biopsy was needed. A diagnosis of low-intermediate mesenchymal sarcoma was made. A total en bloc spondylectomy of T11 was performed with three-column reconstruction. The histology and immunostaining showed the appearance of leiomyosarcoma. After diagnosis, post-operative radiation therapy was performed. Metastatic lesion was ruled out by CT scans of the chest, abdomen and pelvis, in addition to total body radionuclide scanning and 18-F-FDG-PET. After five years of follow-up, no signs of local recurrence, metastasis or distant lesions suggesting a primary lesion were observed. DISCUSSION: Vertebral primary leiomyosarcoma is exceedingly rare. Primary vertebral leiomyosarcoma diagnosis must be performed when the metastatic origin is excluded. For the treatment of primary tumors, total en bloc spondylectomy (TES) is the technique of choice to achieve marginal or wide tumor resection, decrease the risk of local recurrence and remote lesions and increase survival. CONCLUSIONS: A well-planned pre-operative study and a wide surgical excision can result in local tumor control and long-term survival. This case presents the longest disease-free survival period of a primary leiomyosarcoma in spinal location after total en bloc spondylectomy.

Spinal Epidural Hematoma Related to Vertebral Fracture in an Atypical Rigid Diffuse Idiopathic Skeletal Hyperostosis: A Case Report.

INTRODUCTION: Spinal epidural hematoma (SEH) is a rare disease that causes cord compression and neurologic deficit. Spontaneous SEH is related to minor trauma, bleeding disorders, and anticoagulant medications. Posttraumatic SEH has been associated with low-energy spine hyperextension injuries in patients with ankylosing spinal disorders such as ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis (DISH). A variant named atypical DISH-like with SEH is reported. OBJECTIVE: To describe the management, diagnosis, and treatment of an unusual SEH case in a patient causing delayed neurologic deficit with rigid atypical DISH-like spine. CASE DESCRIPTION: An elderly woman with prior antiplatelet therapy presented with delayed neurological deficit suffering trauma after falling. Computed tomography (CT) imaging studies reveal hyperextension fracture pattern and signs mimic DISH missed on standard X-ray images. Magnetic resonance (MR) study demonstrates posterior epidural mass compatible with SEH in thoracic spine with cord compression. Using a midline posterior approach, an urgent intervention and a left multiple partial unilateral decompressive laminectomy at T4-T7 and a long instrumented fusion at T3-T9 were performed for achieving spinal stability and neurological improvement, both of which were observed. CONCLUSION: Patients with rigid spine who sustain low-energy injuries may be prone to have a fracture and epidural hematoma, especially if they take anticoagulant medications. Imaging studies including MR and CT scans should be reviewed carefully to rule out any occult fracture. Urgent or early surgical hematoma drainage and instrumented fusion must be performed to achieve stability and functional recovery.

Unusual Spinal Epidural Lipomatosis and Lumbosacral Instability.

Introduction. Epidural lipomatosis is most frequently observed in patients on chronic steroid treatment. Only a few idiopathic epidural lipomatosis cases have been described. Material and Methods. 64-year-old male patient presented with low back pain and left leg pain. Later, the patient experienced neurogenic claudication and radicular pain in the left leg without urinary dysfunction. Plain radiography and magnetic resonance imaging demonstrated an abnormal fat tissue overgrowth in the epidural space with compression of the dural sac, degenerative disc disease at L4-L5 level, and instability at L5-S1. Endocrinopathic diseases and chronic steroid therapy were excluded. If conservative treatment failed, surgical treatment can be indicated. Results. After surgery, there was a gradual improvement in symptoms and signs, and six months later the patient returned to daily activities and was neurologically normal. Conclusion. In the absence of common causes of neurogenic claudication, epidural lipomatosis should be considered. The standard test for the diagnosis of epidural lipomatosis is magnetic resonance (MR). At first, conservative treatment must be considered; weight loss and the suspension of prior corticosteroid therapy are indicated. In the presence of neurological impairment, the operative treatment of wide surgical decompression must be performed soon after diagnosis.