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Ki Young Lee, Jung-Hee Lee, Kyung-Chung Kang, Won-Ju Shin, Sang Kyu Im and Seong Jin Cho

A dult spinal deformity (ASD) is a disease that induces pain and disability because of spinal malalignment, which negatively affect patients’ quality of life. Due to the recent increase in the average life expectancy, the prevalence of ASD has increased, and surgical treatment for senior patients with active lifestyles has drawn attention. Although restoration of sagittal alignment can produce excellent radiological and clinical outcomes, sagittal decompensation due to pseudarthrosis (rod fracture), proximal junctional kyphosis (PJK), caudal junctional kyphosis

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Ki Young Lee, Jung-Hee Lee, Kyung-Chung Kang, Won-Ju Shin, Sang Kyu Im and Seong Jin Cho

A dult spinal deformity (ASD) is a disease that induces pain and disability because of spinal malalignment, which negatively affect patients’ quality of life. Due to the recent increase in the average life expectancy, the prevalence of ASD has increased, and surgical treatment for senior patients with active lifestyles has drawn attention. Although restoration of sagittal alignment can produce excellent radiological and clinical outcomes, sagittal decompensation due to pseudarthrosis (rod fracture), proximal junctional kyphosis (PJK), caudal junctional kyphosis

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Justin S. Smith, Ellen Shaffrey, Eric Klineberg, Christopher I. Shaffrey, Virginie Lafage, Frank J. Schwab, Themistocles Protopsaltis, Justin K. Scheer, Gregory M. Mundis Jr., Kai-Ming G. Fu, Munish C. Gupta, Richard Hostin, Vedat Deviren, Khaled Kebaish, Robert Hart, Douglas C. Burton, Breton Line, Shay Bess, Christopher P. Ames and The International Spine Study Group

fracture, the retrospective study suggested that residual postoperative sagittal malalignment and greater BMI may be associated with greater risk of rod fracture. The present prospective study confirms the added risk of rod fracture with greater BMI and confirms that sagittal spinopelvic alignment may also be a risk factor, but instead of postoperative residual sagittal malalignment, the present study suggests that it is the magnitude of sagittal alignment correction that may be a more important factor. The findings of the present study demonstrate a markedly higher

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Sandi Lam and Larry T. Khoo

Object

Vertebroplasty and kyphoplasty are minimally invasive procedures used to treat persistently symptomatic vertebral compression fractures (VCFs). Both interventions usually involve injection of polymethyl methacrylate (PMMA). The purpose of this technical note was to review the theory and surgical technique for a novel percutaneous system for fracture reduction and stabilization of VCFs by using bone graft.

Methods

This technical note highlights the Optimesh system as an alternative method of minimally invasive VCF reduction and stabilization with the delivery of a bone graft containment device. Instead of using PMMA as in vertebroplasty or kyphoplasty, this system allows the delivery of allograft and/or autograft bone, with its osteoinductive, osteoconductive, and osteogenic properties.

Conclusions

This system allows for restoration of sagittal alignment of the spine with direct control of bone graft delivery by using a mesh graft containment device that allows for ingrowth of new bone and vascular tissue.

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H. Gordon Deen, Jaime Aranda-Michel, Ronald Reimer and John D. Putzke

Object

Organ transplant recipients are at risk for vertebral compression fractures (VCFs). The goal of this study was to determine whether kyphoplasty is an effective treatment for VCFs that develop in this patient population.

Methods

Six consecutive patients who had undergone an organ transplant (five liver and one kidney transplant) had a total of 13 symptomatic VCFs that were treated with balloon kyphoplasty. Postprocedure follow-up duration ranged from 6 to 12 months. The mean visual analog scale pain score was 9.3 before treatment and declined to 1.8 after treatment. This improvement was highly significant (p < 0.001). Intake of narcotic drugs decreased or was eliminated in all patients, and there were no complications related to the procedure. There was one instance of clinically insignificant extraosseous cement extravasation. Sagittal alignment was improved by 5° in one patient and was unchanged in the remaining five. During the follow-up period, a new fracture developed adjacent to a treated level in one patient. This was successfully treated with an additional kyphoplasty procedure.

Conclusions

Kyphoplasty can be performed safely in organ transplant recipients with VCF, in whom results are just as favorable as those seen in patients with no history of organ transplantation.

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Gregory C. Wiggins, Michael J. Rauzzino, Christopher I. Shaffrey, Russ P. Nockels, Richard Whitehill, Mark E. Shaffrey, James Wagner and Tord D. Alden

This study was conducted to determine the safety, efficacy, and complication rate associated with the anterior approach in the use of a new titanium mesh interbody fusion cage for the treatment of unstable thoracolumbar burst fractures. The experience with this technique is compared with the senior authors' (C.S., R.W., and M.S.) previously published results in the management of patients with unstable thoracolumbar burst fractures.

Between 1996 and 1999, 21 patients with unstable thoracolumbar (T12-L3) burst fractures underwent an anterolateral decompressive procedure in which a titanium cage and Kaneda device were used. Eleven of the 21 patients had sustained a neurological deficit, and all patients improved at least one Frankel grade (average 1.2 grades). There was improvement in outcome in terms of blood loss, correction of kyphosis, and pain, as measured on the Denis Pain and Work Scale, in our current group of patients treated via an anterior approach when compared with the results in those who underwent a posterior approach.

In our current study the anterior approach was demonstrated to be a safe and effective technique for the management of unstable thoracolumbar burst fractures. It offers superior results compared with the posterior approach. The addition of the new titanium mesh interbody cage to our previous anterior technique allows the patient's own bone to be harvested from the corpectomy site and used as a substrate for fusion, thereby obviating the need for iliac crest harvest. The use of the cage in association with the Kaneda device allows for improved correction of kyphosis and restoration of normal sagittal alignment in addition to improved functional outcomes.

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Michael P. Kelly, Lawrence G. Lenke, Jakub Godzik, Ferran Pellise, Christopher I. Shaffrey, Justin S. Smith, Stephen J. Lewis, Christopher P. Ames, Leah Y. Carreon, Michael G. Fehlings, Frank Schwab and Adam L. Shimer

OBJECTIVE

The authors conducted a study to compare neurological deficit rates associated with complex adult spinal deformity (ASD) surgery when recorded in retrospective and prospective studies. Retrospective studies may underreport neurological deficits due to selection, detection, and recall biases. Prospective studies are expensive and more difficult to perform, but they likely provide more accurate estimates of new neurological deficit rates.

METHODS

New neurological deficits were recorded in a prospective study of complex ASD surgeries (pSR1) with a defined outcomes measure (decrement in American Spinal Injury Association lower-extremity motor score) for neurological deficits. Using identical inclusion criteria and a subset of participating surgeons, a retrospective study was created (rSR1) and neurological deficit rates were collected. Continuous variables were compared with the Student t-test, with correction for multiple comparisons. Neurological deficit rates were compared using the Mantel-Haenszel method for standardized risks. Statistical significance for the primary outcome measure was p < 0.05.

RESULTS

Overall, 272 patients were enrolled in pSR1 and 207 patients were enrolled in rSR1. Inclusion criteria, defining complex spinal deformities, and exclusion criteria were identical. Sagittal Cobb measurements were higher in pSR1, although sagittal alignment was similar. Preoperative neurological deficit rates were similar in the groups. Three-column osteotomies were more common in pSR1, particularly vertebral column resection. New neurological deficits were more common in pSR1 (pSR1 17.3% [95% CI 12.6–22.2] and rSR1 9.0% [95% CI 5.0–13.0]; p = 0.01). The majority of deficits in both studies were at the nerve root level, and the distribution of level of injury was similar.

CONCLUSIONS

New neurological deficit rates were nearly twice as high in the prospective study than the retrospective study with identical inclusion criteria. These findings validate concerns regarding retrospective cohort studies and confirm the need for and value of carefully designed prospective, observational cohort studies in ASD.

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Gwynedd E. Pickett, Demytra K. Mitsis, Lali H. Sekhon, William R. Sears and Neil Duggal

Object

Cervical arthroplasty offers the promise of maintaining motion of the functional spinal unit (FSU) after anterior cervical discectomy. The impact of cervical arthroplasty on sagittal alignment of the FSU needs to be addressed, together with its effect on overall sagittal balance of the cervical spine.

Methods

The authors prospectively reviewed radiographic and clinical outcomes in 14 patients who received the Bryan Cervical Disc prosthesis (Medtronic Sofamor Danek, Memphis, TN), for whom early (< 6 months) and late (6–24 months) follow-up data were available. Static and dynamic radiographs were measured by hand and computer to determine the angles formed by the endplates of the natural disc preoperatively, those formed by the shells of the implanted prosthesis, the angle of the FSU, and the C2–7 Cobb angle. The range of motion (ROM) was also determined radiographically, whereas clinical outcomes were assessed using the Neck Disability Index (NDI), and Short Form–36 (SF-36) questionnaires.

The ROM was preserved following surgery, with a mean preoperative sagittal rotation angle of 8.96°, which was not significantly different from the late postoperative value of 8.25°. When compared with the preoperative disc space angle, the shell endplate angle in the neutral position became kyphotic in the early and late postoperative periods (mean change −3.8° in the late follow-up period; p = 0.0035). The FSU angles also became significantly more kyphotic post-operatively, with a mean change of −6° (p = 0.0006). The Cobb angles varied widely preoperatively and did not change significantly after surgery. There was no statistical correlation between the NDI and SF-36 outcomes and cervical kyphosis.

Conclusions

Cervical arthroplasty preserves motion of the FSU. Both the endplate angle of the treated disc space and the angle of the FSU became kyphotic after insertion of the Bryan prosthesis. The overall sagittal balance of the cervical spine, however, was preserved.

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Toshimi Aizawa, Tetsuro Sato, Hirotoshi Sasaki, Fujio Matsumoto, Naoki Morozumi, Takashi Kusakabe, Eiji Itoi and Shoichi Kokubun

Object

Thoracic myelopathy is uncommon compared with cervical myelopathy. In this study, data obtained in patients with thoracic myelopathy caused by degenerative processes of the spine were retrospectively analyzed to clarify the surgical outcomes and to examine the various factors affecting the postoperative improvement.

Methods

Between 1988 and 2002, 132 patients with thoracic myelopathy underwent surgery and a minimum 2-year observation period. Clinical data were collected from medical and operative records, and sagittal alignment of the spine was measured on radiographs. The patients were evaluated pre- and postoperatively using the modified Japanese Orthopaedic Association (JOA) scale (maximum score 11). The relationships among various factors affecting the preoperative severity of myelopathy and postoperative improvement were also examined.

Results

The population consisted of 97 men (mean age at surgery was 58 years) and 35 women (mean age at surgery 62 years). Myelopathy was caused by ossification of the ligamentum flavum (OLF) in 73 patients, ossification of the posterior longitudinal ligament (OPLL) in 21, combined OLF–OPLL in 10, intervertebral disc herniation (IDH) in 15, posterior bone spur in 11, and OLF with IDH or posterior bone spur in one patient each. The surgical outcome was relatively good: a mean preoperative JOA score of 5.3 improved to a mean score of 7.8 at the last follow-up, 50 months on average after surgery. Thoracic myelopathy caused by OPLL, however, was associated with lower postoperative scores and recovery rates. In more than half of the patients the authors documented an increase of kyphosis of less than 2°.

Conclusions

Patients with a shorter preoperative duration of symptoms and milder myelopathy experienced significantly better postoperative neurological conditions, which indicated that those who present earlier with fewer disabilities should be recommended to undergo surgery in time, although the surgical treatment for OPLL still involves many problems.

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K. Anthony Kim, Matthew McDonald, Justin H. T. Pik, Paul Khoueir and Michael Y. Wang

Object

To assess the safety and efficacy of the DIAM implant, the authors compared the mean 12-month outcomes in patients who underwent lumbar surgery with DIAM placement and in those who underwent lumbar surgery only.

Methods

Of 62 patients who underwent simple lumbar surgery (laminectomy and/or microdiscectomy) in a 24-month period, 31 underwent concomitant surgical placement of a DIAM interspinous process spacer (33 devices total). Radiographic imaging, pain scores, and clinical assessments were obtained postoperatively to a mean of 12 months (range 8–25 months). Patients who did not undergo implantation of an interspinous process spacer (Group C) were compared with and stratified against patients who underwent placement of a DIAM implant (Group D).

In Group D, no statistically significant differences were noted in anterior or posterior disc height when comparing patients pre- and postoperatively. Compared with Group C, a relative kyphosis of less than 2° was noted on postoperative images obtained in Group D. No statistically significant differences in visual analog scale (VAS) pain scores or MacNab outcomes were noted between Groups C and D at a mean of 12 months of follow up. Complications in Group D included three intraoperative spinous process fractures and one infection.

Conclusions

After simple lumbar surgery, the placement of a DIAM interspinous process spacer did not alter disc height or sagittal alignment at the mean 12-month follow-up interval. No adverse local or systemic reaction to the DIAM was noted. No difference in VAS or MacNab outcome scores was noted between the groups treated with or without the DIAM implants, particularly when the DIAM was used to alleviate low-back pain.