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Olumide A. Danisa, Christopher I. Shaffrey, John A. Jane, Richard Whitehill, Gwo-Jaw Wang, Thomas A. Szabo, Carolyn A. Hansen, Mark E. Shaffrey and Donald P. K. Chan

spinal fractures. Spine 18: 466–473, 1993 38. Michele AA , Krueger FJ : Surgical approach to the vertebral body. J Bone Joint Surg (Am) 31 : 873 – 878 , 1949 Michele AA, Krueger FJ: Surgical approach to the vertebral body. J Bone Joint Surg (Am) 31: 873–878, 1949 39. Roy-Camille R , Saillant G , Mazel C : Plating of thoracic, thoracolumbar and lumbar injuries with pedicle screw plates. Orthop Clin North Am 17 : 147 – 159 , 1986 Roy-Camille R, Saillant G, Mazel C: Plating of

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Michael J. Rauzzino, Christopher I. Shaffrey, James Wagner, Russ Nockels and Mark Abel

The indications for surgical intervention in patients with idiopathic scoliosis have been well defined. The goals of surgery are to achieve fusion and arrest progressive curvature while restoring normal coronal and sagittal balance. As first introduced by Harrington, posterior fusion, the gold standard of treatment, has a proven record of success. More recently, anterior techniques for performing fusion procedures via either a thoracotomy or a retroperitoneal approach have been popularized in attempts to achieve better correction of curvature, preserve motion segments, and avoid some of the complications of posterior fusion such as the development of the flat-back syndrome. Anterior instrumentation alone, although effective, can be kyphogenic and has been shown to be associated with complications such as pseudarthrosis and instrumentation failure. Performing a combined approach in patients with scoliosis and other deformities has become an increasingly popular procedure to achieve superior correction of deformity and to minimize later complications. Indications for a combined approach (usually consisting of anterior release, arthrodesis with or without use of instrumentation, and posterior segmental fusion) include: prevention of crankshaft phenomenon in juvenile or skeletally immature adolescents; correction of large curves (75°) or excessively rigid curves in skeletally mature or immature patients; correction of curves with large sagittal-plane deformities such as thoracic kyphosis (> 90°) or thoracic lordosis (> 20°); and correction of thoracolumbar curves that need to be fused to the sacrum. Surgery may be performed either in a staged proceedure or, more commonly, in a single sitting. The authors discuss techniques for combined surgery and complication avoidance.

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Sean M. Jones-Quaidoo, Travis Hunt, Christopher I. Shaffrey and Vincent Arlet

spondylolisthesis. A comparison of three surgical approaches . Spine 24 : 1701 – 1711 , 1999 11 Newman PH : A clinical syndrome associated with severe lumbosacral subluxation . J Bone Joint Surg Br 47 : 472 – 481 , 1965 12 Ogilvie JW : Complications in spondylolisthesis surgery . Spine 30 : 6 Suppl S97 – S101 , 2005 13 Schoenecker PL , Cole HO , Herring JA , Capelli AM , Bradford DS : Cauda equina syndrome after in situ arthrodesis for severe spondylolisthesis at the lumbosacral junction . J Bone Joint Surg Am 72 : 369 – 377 , 1990 14

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Anna Kristina E. Hart, John H. Greinwald JR., Christopher I. Shaffrey and Gregory N. Postma

the thoracic duct susceptible to injury during anterior surgical approaches to the spine, yet our review of the literature revealed only nine cases of thoracic duct injury occurring as a result of this type of surgery. All of them involved surgery of the thoracic and/or lumbar spine, 4, 8, 16, 19, 24 and in all nine cases this complication manifested as an intraoperative chyle leak, postoperative chylothorax, chyloretroperitoneum, or a combination of these. Chylothorax ensued in three of the four cases in which injury to the thoracic duct was noted intraoperatively

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Adam S. Kanter, Christopher I. Shaffrey, Praveen Mummaneni, Michael Y. Wang and Juan S. Uribe

circumferential minimally invasive spinal correction techniques and clinical outcomes, as well as the cost effectiveness of these procedures in comparison to traditional open procedures. Complications following three-column reconstruction are evaluated, including variables such as patient characteristics, pathology, and surgical approach. Unilateral versus bilateral iliac screws are appraised. Algorithms are proposed for cervical deformity and treatment strategies to aid in decision making for minimally invasive surgery regarding lumbar deformities. And finally, an evolutionary

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Christopher I. Shaffrey, Gregory C. Wiggins, Cynthia B. Piccirilli, Jacob N. Young and LaVerne R. Lovell

C ervical spondylotic myelopathy results from the degenerative process of vertebral columns and related soft-tissue structures. This results in stenosis and cervical cord compression with myeloradiculopathy. Nonsurgical (conservative) treatment results in a 64% nonimprovement rate, with 26% of those patients displaying neurological deterioration. 5 Anterior and posterior surgical approaches have been reported for treatment of cervical spondylotic myelopathy. With multisegment cervical disease, wide laminectomy has been a standard therapy. Complications

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Jay Jagannathan, Jonathan H. Sherman, Tom Szabo, Christopher I. Shaffrey and John A. Jane Sr.

T he management of cervical radiculopathy is a controversial area in spine surgery. Although most patients are thought to achieve resolution of symptoms without surgical intervention, 6 , 7 recent data, including randomized controlled studies have provided evidence that surgical intervention may improve short-term disability related to pain when compared with conservative management. 8 , 22 When surgical intervention is chosen, the surgical approach can vary significantly. Although posterior approaches have traditionally been favored in the management

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Gregory C. Wiggins, Sohail Mirza, Carlo Bellabarba, G. Alex West, Jens R. Chapman and Christopher I. Shaffrey

Object

Anterior decompression and stabilization for thoracic spinal tumors often involves a thoracotomy and can be associated with surgical approach–related complications. An alternative to thoracotomy is surgery via a costotransversectomy exposure.

To delineate the risks of surgery, the authors reviewed their prospective database for patients who had undergone surgery via either of these approaches for thoracic or thoracolumbar tumors. The complications were recorded and graded based on severity and risk of impact on patient outcome.

Methods

Between September 1995 and April 2001, the authors performed 29 costotransversectomies (Group 1) and 18 thoracolumbar or combined (Group 2) approaches as initial operations for thoracic neoplasms. The age, sex, pre-operative motor score, and preoperative Frankel grade did not significantly differ between the groups. In the costotransversectomy group there were greater numbers of metastases, upper thoracic procedures, and affected vertebral levels; additionally, the comorbidity rate based on Charlson score, was higher. The mean Frankel grades at discharge were not significantly different whereas the discharge motor and last follow-up motor scores were better in Group 2. There were 11 Group 1 and seven Group 2 patients who suffered at least one complication. The number or patients with complications, the mean number of complications, and severity of complications did not differ between the groups.

Conclusions

Compared with anterior or combined approaches, the incidence and severity of perioperative complications in the surgical treatment of thoracic and thoracolumbar spinal tumors is similar in patients who undergo costotransversectomy. Costotransversectomy may be the preferred operation in patients with significant medical comorbidity or tumors involving more than one thoracic vertebra.

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Editorial

Surgical complications in adult spondylolisthesis

Michael G. Fehlings and Doron Rabin

,242 patients undergoing surgical treatment for either isthmic spondylolisthesis (IS) or DS. The Scoliosis Research Society morbidity and mortality database was queried for cases of DS and IS that were entered between 2004 and 2007. Ten deaths (0.1% of cases) and 945 complications (9.2% of cases) were reported. Dural tears, neurological complications, and implant failure were the most common types of surgery-related morbidity. There were no significant differences in complication rates among surgical approaches. Somewhat surprisingly, revision surgery was not associated with

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Michael G. Fehlings and Randolph J. Gray

. Ninety-five percent of patients with cervical radiculopathy experienced improvement of their symptoms. Loss of cervical lordosis (defined as segmental Cobb angle < 10°) was seen in 30 (18.5%) of patients. The overall cohort did not show any statistically significant progression of the focal or segmental kyphosis with time. Age over 60 years at the time of surgery and preoperative lordosis of less than 10° have been identified as risk factors of worsening sagittal alignment. Since the original description in the late 1940s, the surgical approaches to cervical