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Assaf Berger, Laurence Mangel, Sharif Basal, Zvi Lidar, Gilad J Regev, Morsi Khashan, Dror Ofir, and Khalil Salame


Surgery for foot drop secondary to lumbar degenerative disease is not always associated with postoperative functional improvement. It is still unclear whether early decompression results in better functional recovery and how soon surgery should be performed. This study aimed to evaluate predicting factors that affect short- and long-term recovery outcomes and to explore the relationship between timing of lumbar decompression and recovery from foot drop in an attempt to identify a cutoff time from symptom onset until decompression for optimal functional improvement.


The authors collected demographic, clinical, and radiographic data on patients who underwent surgery for foot drop due to lumbar degenerative disease. Clinical data included tibialis anterior muscle (TAM) strength before and after surgery, duration of preoperative motor weakness, and duration of radicular pain until surgery. TAM strength was recorded at the immediate postoperative period and 1 month after surgery while long-term follow-up on functional outcomes were obtained at ≥ 2 years postsurgery by telephone interview. Data including degree and duration of preoperative motor weakness as well as the occurrence of pain and its duration were collected to analyze their impact on short- and long-term outcomes.


The majority of patients (70%) showed functional improvement within 1 month postsurgery and 40% recovered to normal or near-normal strength. Univariate analysis revealed a trend toward lower improvement rates in patients with preoperative weakness of more than 3 weeks (33%) compared with patients who were operated on earlier (76.5%, p = 0.034). In a multivariate analysis, the only significant predictor for maximal strength recovery was TAM strength before surgery (OR 6.80, 95% CI 1.38–33.42, p = 0.018). Maximal recovery by 1 month after surgery was significantly associated with sustained long-term functional improvement (p = 0.006).


Early surgery may improve the recovery rate in patients with foot drop caused by lumbar degenerative disease, yet the strongest predictor for the extent of recovery is the severity of preoperative TAM weakness. Maximal recovery in the short-term postoperative period is associated with sustained long-term functional improvement and independence.

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Morsi Khashan, Micheal Raad, Mostafa H. El Dafrawy, Varun Puvanesarajah, and Khaled M. Kebaish


The authors evaluated the neurological outcomes of adult spinal deformity patients after 3-column osteotomy (3CO), including severity and long-term improvement of neurological complications, as well as risk factors for neurological deficit at 1 year postoperatively. Although 3CO is effective for correcting rigid spinal deformity, it is associated with a high complication rate. Neurological deficits, in particular, cause disability and dissatisfaction.


The authors retrospectively queried a prospective database of adult spinal deformity patients who underwent vertebral column resection or pedicle subtraction osteotomy between 2004 and 2014 by one surgeon at a tertiary care center. The authors included 199 adults with at least 1-year follow-up. The primary outcome measure was change in lower-extremity motor scores (LEMSs), which were obtained preoperatively, within 2 weeks postoperatively, and at 6 and 12 months postoperatively. To identify risk factors for persistent neurological deficit, the authors compared patient and surgical characteristics with a declined LEMS at 12-month follow-up (n = 10) versus those with an improved/maintained LEMS at 12-month follow-up (n = 189).


At the first postoperative assessment, the LEMS had improved in 15% and declined in 10% of patients compared with preoperative scores. At the 6-month follow-up, 6% of patients continued to have a decline in LEMS, and 16% had improvement. At 12 months, LEMS had improved in 17% and declined in 5% of patients compared with preoperative scores. The only factor significantly associated with a decline in 12-month LEMS was high-grade spondylolisthesis as an indication for surgery (OR 13, 95% CI 3.2–56).


Although the LEMS declined in 10% of patients immediately after 3CO, at 12 months postoperatively, only 5% of patients had neurological motor deficits. A surgical indication of high-grade spondylolisthesis was the only factor associated with neurological deficit at 12 months postoperatively.

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Rajiv Saigal, Darryl Lau, Rishi Wadhwa, Hai Le, Morsi Khashan, Sigurd Berven, Dean Chou, and Praveen V. Mummaneni


Long-segment spinal instrumentation ending at the sacrum places substantial biomechanical stress on sacral screws. Iliac (pelvic) screws relieve some of this stress by supplementing the caudal fixation. It remains an open question whether there is any clinically significant difference in sacropelvic fixation with bilateral versus unilateral iliac screws. The primary purpose of this study was to compare clinical and radiographic complications in the use of bilateral versus unilateral iliac screw fixation.


The authors retrospectively reviewed 102 consecutive spinal fixation cases that extended to the pelvis at a single institution (University of California, San Francisco) in the period from 2005 to 2012 performed by the senior authors. Charts were reviewed for the following complications: reoperation, L5–S1 pseudarthrosis, sacral insufficiency fracture, hardware prominence, iliac screw loosening, and infection. The t-test, Pearson chi-square test, and Fisher exact test were used to determine statistical significance.


The mean follow-up was 31 months. Thirty cases were excluded: 12 for inadequate follow-up, 15 for lack of L5–S1 interbody fusion, and 3 for preoperative osteomyelitis. The mean age among the 72 remaining cases was 62 years (range 39–79 years). Forty-six patients underwent unilateral and 26 bilateral iliac screw fixation. Forty-one percent (n = 19) of the unilateral cases and 50% (n = 13) of the bilateral cases were treated with reoperation (p = 0.48). In addition, 13% (n = 6) of the unilateral and 19% (n = 5) of the bilateral cases developed L5–S1 pseudarthrosis (p = 0.51). There were no sacral insufficiency fractures. Thirteen percent (n = 6) of the unilateral and 7.7% (n = 2) of the bilateral cases developed postoperative infection (p = 0.70).


In a retrospective single-institution study, single versus dual pelvic screws led to comparable rates of reoperation, iliac screw removal, postoperative infection, pseudarthrosis, and sacral insufficiency fractures. For spinopelvic fixation, placing bilateral (vs unilateral) pelvic screws produced no added clinical benefit in most cases.