Different pedicle osteosynthesis for thoracolumbar vertebral fractures in elderly patients.

INTRODUCTION: Pedicle screws' stability, especially in osteoporotic fractures, is a really problem for spinal surgeons. Nowadays, little is known about the influence of different screw types and amount of cement applied. This single-center retrospective observational study has the aim of evaluating the middle- to long-term mechanical performances of different types of screws in elderly patients with thoracolumbar fractures. MATERIALS AND METHODS: A total of 91 patients (37 males and 54 females), treated between 2011 and 2016, affected by somatic osteoporotic fractures aged over 65 years were treated. We divided patients into three different populations: solid screws, cannulated screws and cannulated screws augmented with poly methyl methacrylate cement (PMMA). Patients were radiologically evaluated with X-rays in pre- and post-surgery and at the follow-up (FU). Clinical evaluations were made with VAS and Oswestry Disability Index. RESULTS: A total of 636 screws were implanted (222 pedicle screws, 190 cannulated and 224 cannulated screws with PMMA augmentation). At FU, we found significative differences between populations in terms of mechanical performances. We founded five cases of loosening; these were reported in solid screws group and in cannulated screws one. No mechanical failures were reported in cannulated screws with augmentation of PMMA. No rods breakage cases were reported. CONCLUSION: All stabilization methods showed good clinical results, but cannulated screws augmented with PMMA seem to provide better implant stability with the lowest rate of loosening. These slides can be retrieved under Electronic Supplementary Material.

Surgical treatment of scoliosis in neurofibromatosis type I: A retrospective study on posterior-only correction with third-generation instrumentation.

BACKGROUND: Scoliosis is the most common orthopedic complication of neurofibromatosis type I. Scoliosis can be occurred with two patterns: dystrophic or idiopathic-like. In adolescence, in consideration of bone dystrophy, osteopenia, and often associated hyperkyphosis, most of the authors recommend an anterior-posterior approach. According to other authors, modern instrumentations could be sufficient to sustain a solid posterior arthrodesis. MATERIALS AND METHODS: Ten patients were diagnosed with scoliosis in neurofibromatosis type I aged between 8 and 25 years, Cobb angle of the thoracic curve >45°, and minimum follow-up (FU) of 1 year and treated with posterior-only approach with third-generation high-density instrumentations. Radiographic measurements were performed on the coronal and sagittal planes. Nonparametric tests (Friedman test and Wilcoxon test) were applied to evaluate the reducibility of the preoperative curve (T0), the postoperative surgical correction (T1), and its maintenance on FU. RESULTS: Statistics showed results compared to those evaluated in the literature with a combined approach regarding surgical correction and its maintenance on FU. On T1, a median correction of 53.5% of the scoliotic curve and of 33.7% of the thoracic hyperkyphosis was observed. On FU, the correction was maintained. A global improvement in balance was appreciated. The curves, despite rigid, showed a relative reducibility to bending tests and traction. No significant complications occurred. CONCLUSIONS: The posterior-only approach produces a satisfactory correction of the dystrophic neurofibromatosis scoliosis if associated with the use of high-density third-generation instrumentations. We are confident in recommending posterior-only approach in dystrophic neurofibromatosis scoliosis with coronal curves till 110° and coexisting thoracic kyphosis till 80°.

Is cast an option in the treatment of thoracolumbar vertebral fractures?

BACKGROUND: Thoracolumbar vertebral fractures are common in high-energy trauma and often are associated to other concomitant injuries. Currently, brace and Closed Reduction and Casting (CRC) are the two conservative treatments proposed by literature. Despite CRC was widely used in the past, today brace is preferred. The aim of our study is to evaluate clinical and radiographic outcomes of thoracolumbar type A fractures, not associated with other injuries, treated with CRC. MATERIALS AND METHODS: We retrospectively evaluated all patients treated from 2008 to 2015, with a mean age of 26.69 years (range 15-45). All patients were affected by AO type A fracture: 26 type A1, 17 type A2, and 21 type A3. All patients were evaluated by X-ray, computed tomography, and magnetic resonance imaging. Radiological evaluations included vertebral kyphosis (VK), segmental kyphosis (SK), regional kyphosis (RK) angle, and vertebral ratio (VR) measures. Patients were clinically assessed through visual analog scale, Oswestry Disability Index, Roland-Morris Disability Questionnaire, and Short Form 36 Health Survey. RESULTS: Seventy-four patients (41 males and 33 females) were included in the study. At follow-up (mean 28.48 months ± 5.16), we found significant improvements in VK (P = 0.000013), SK (P = 0.000455), and RK (P = 0.000016). No significant differences were observed in VR (P = 0.26). Good clinical results were reported in patients in all scores and 90.7% of patients returned to work. CONCLUSIONS: Closed reduction and casting is still a reliable treatment option in selected thoracolumbar fractures without spinal cord involvement. A correct fracture evaluation, patient compliance, and motivation are essentials. LEVEL OF EVIDENCE: IV.

Over 70° thoracic idiopathic scoliosis: Results with screws or hybrid constructs.

BACKGROUND: Adolescent idiopathic scoliosis is the most common type of scoliosis. High degrees curve can be treated with the anterior, posterior, or combined anterior-posterior approach. Contrarily to the anterior approach, the posterior one is widely used nowadays for its good correction outcomes and relatively low-complication rate. MATERIALS AND METHODS: We evaluated retrospectively 27 patients, treated with posterior approach. Patients were divided into two groups, namely pedicle screws group (PSG) and hybrid group (pedicle screws + sublaminar bands). Radiographic measurements, including thoracic and lumbar Cobb° measurements of primary and secondary curves, coronal balance and sagittal balance, kyphosis and lordosis, curve flexibility, first and last vertebra included in the arthrodesis, and implant density were evaluated. Clinical patients' satisfaction was also evaluated with Scoliosis Research Society (SRS) 24 questionnaire. RESULTS: Considering both groups, on preoperative X-rays, the average primary scoliotic curve angle was 83.56° ± 10.96° (range 70°-112°), whereas the global flexibility was 64° ± 7.63 (range 46°-72°). The curves were classified following the Lenke classification: 17 Type 1, 2 Type 2, and 8 Type 3. The primary curve resulted to be well corrected in both groups. In T0, the groups were homogeneous, but in T1 and follow-up, PSG stated a better mean value. No other significative differences can be found between groups for all other items (P > 0.05). Clinical results of SRS 24 were excellent in both groups. CONCLUSIONS: The posterior approach proved to be an excellent technique for obtaining good clinical and radiographic results if the surgeon adopts the third-generation high-density implants. LEVEL OF EVIDENCE: III.

Thoracic-lumbar-sacral spine sagittal alignment and cranio-mandibular morphology in adolescents.

PURPOSE: The relationship between thoracic-lumbar-sacral spine sagittal alignment and craniofacial morphology is still controversial. Evidence-based results are difficult to obtain and scientific studies are inhomogeneous. The aim of this study was to investigate the difference of thoracic-lumbar-sacral spine posture and cephalometric values comparing two groups of subjects with different cranial structure in the sagittal plane. METHODS: Eighty-one subjects were consecutively selected and divided into two groups, according to the orientation of the condyle-orbital plane (CoOr) with respect to the superior maxilla (SpP): Group1: 49 subjects 11.6 (2.1) years showing posterior-rotation of CoOr: SpP^CoOr ≤ -2°, -4.1°(2.1°); Group2: 32 subjects 12.9 (2.3)years showing anterior-rotation of CoOr: SpP^CoOr ≥ 2°, 3.7°(1.9°). Each patient underwent in blinding, Spinal Mouse recording and cephalometry of the skull. RESULTS: Group1 showed a significant forward tilting of the spine 4.4°(1.8°) with respect to Group2 2.4°(1.3°) (p < 0.0001) and higher values related to the vertical dimension of the skull: higher maxillary divergency (p < 0.0001), steep occlusal plane (p < 0.0007), higher gonial angle (p < 0.001). DISCUSSION: The results of this study showed a difference in the thoracic-lumbar-sacral spine inclination between groups with different craniofacial morphology. The achievement of this outcome is important to improve our multidisciplinary evaluation and treatment planning.

Spinal fusion with Cotrel-Dubousset instrumentation for neuropathic scoliosis in patients with cerebral palsy.

STUDY DESIGN: Retrospective. OBJECTIVE: To report on the treatment of patients with cerebral palsy and neuropathic scoliosis with third-generation instrumented spinal fusion by Cotrel-Dubousset instrumentation. SUMMARY OF BACKGROUND DATA: Second-generation instrumented spinal fusion is considered the standard for progressive neuropathic scoliosis in cerebral palsy, despite high complication rates. Evidence is needed to evaluate the increasing use of third-generation instrumented spinal fusion in similar patients. METHODS: Patients with cerebral palsy and spinal deformity treated consecutively by 1 surgeon with Cotrel-Dubousset instrumentation and minimum 2-year follow-up were reviewed. An outcome questionnaire was administered at final follow-up. RESULTS: A total of 60 patients were included. Mean age was 15 years at surgery. Mean follow-up was 79 months. There were 26 anteroposterior and 34 posterior-only procedures. Correction of coronal deformity and pelvic obliquity averaged 60% and 40%, respectively. Major complications affected 13.5% of patients, and included implant loosening, deep infection, and pseudarthrosis. Minor complications affected 10% of patients. Outcome questionnaires showed marked improvements in the areas of satisfaction, function, and quality of life after surgery. CONCLUSIONS: Segmental, third-generation instrumented spinal fusion provides lasting correction of spinal deformity and improved quality of life in patients with cerebral palsy and neuropathic scoliosis, with a lower pseudarthrosis rate compared to reports on second-generation instrumented spinal fusion.