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Supplemental Material for Do the Choice of Fusion Construct With and Without Autograft Influence the Fusion and Complication Rates in Patients Undergoing 1 or 2-Level Anterior Cervical Discectomy and Fusion Surgery? A PRISMA-Compliant Network Meta-Analysis by Sathish Muthu, Vibhu Krishnan Vishwanathan, Ricardo Rodrigues-Pinto, Juan P. Cabrera, Stipe Ćorluka, Christopher T. Martin, Michael J. Collins, Neha Agarwal, Yabin Wu, Jeffrey C. Wang, Hans-Jorg Meisel, Zorica Buser, and AO Spine Knowledge Forum Degenerative in Global Spine Journal

Supplemental Material for The Effect of COVID-19 on Spine Surgery by Emily S. Mills MD, Ethan Faye BS, Kevin Mertz BS, Andy Ton BS, Jeffrey C. Wang MD, Raymond J. Hah MD, and Ram K. Alluri MD in Global Spine Journal

Supplemental material, sj-pdf-1-hpi-10.1177_11207000221126968 for Increased dislocation rates following total hip arthroplasty in patients with ankylosing spondylitis by Brian C Chung, Michael Stefl, Hyunwoo Paco Kang, Raymond J Hah, Jeffrey C Wang, Lawrence D Dorr and Nathanael D Heckmann in HIP International

Supplemental material, sj-pdf-4-hpi-10.1177_11207000221126968 for Increased dislocation rates following total hip arthroplasty in patients with ankylosing spondylitis by Brian C Chung, Michael Stefl, Hyunwoo Paco Kang, Raymond J Hah, Jeffrey C Wang, Lawrence D Dorr and Nathanael D Heckmann in HIP International

Supplemental material, sj-pdf-2-hpi-10.1177_11207000221126968 for Increased dislocation rates following total hip arthroplasty in patients with ankylosing spondylitis by Brian C Chung, Michael Stefl, Hyunwoo Paco Kang, Raymond J Hah, Jeffrey C Wang, Lawrence D Dorr and Nathanael D Heckmann in HIP International

Supplemental material, sj-pdf-1-hpi-10.1177_11207000221126968 for Increased dislocation rates following total hip arthroplasty in patients with ankylosing spondylitis by Brian C Chung, Michael Stefl, Hyunwoo Paco Kang, Raymond J Hah, Jeffrey C Wang, Lawrence D Dorr and Nathanael D Heckmann in HIP International

Supplemental material, sj-pdf-4-hpi-10.1177_11207000221126968 for Increased dislocation rates following total hip arthroplasty in patients with ankylosing spondylitis by Brian C Chung, Michael Stefl, Hyunwoo Paco Kang, Raymond J Hah, Jeffrey C Wang, Lawrence D Dorr and Nathanael D Heckmann in HIP International

Supplemental material, sj-pdf-2-hpi-10.1177_11207000221126968 for Increased dislocation rates following total hip arthroplasty in patients with ankylosing spondylitis by Brian C Chung, Michael Stefl, Hyunwoo Paco Kang, Raymond J Hah, Jeffrey C Wang, Lawrence D Dorr and Nathanael D Heckmann in HIP International

Supplemental material, sj-pdf-3-hpi-10.1177_11207000221126968 for Increased dislocation rates following total hip arthroplasty in patients with ankylosing spondylitis by Brian C Chung, Michael Stefl, Hyunwoo Paco Kang, Raymond J Hah, Jeffrey C Wang, Lawrence D Dorr and Nathanael D Heckmann in HIP International

Supplemental material, sj-pdf-3-hpi-10.1177_11207000221126968 for Increased dislocation rates following total hip arthroplasty in patients with ankylosing spondylitis by Brian C Chung, Michael Stefl, Hyunwoo Paco Kang, Raymond J Hah, Jeffrey C Wang, Lawrence D Dorr and Nathanael D Heckmann in HIP International

BackgroundPreoperative anxiety is a common phenomenon in plastic surgery that has been associated with numerous negative patient outcomes. Little is known about the preferences of plastic surgeons regarding management of patient preoperative anxiety OBJECTIVE: To determine the preferences of plastic surgeons regarding the assessment and reduction of adult preoperative patient anxiety in their primary practice setting.MethodsThe membership of the American Council of Academic Plastic Surgeons (ACAPS) was surveyed using an anonymous, online questionnaire from April to June of 2020.ResultsA total of 100 participants from a membership of 532 responded (19%). The majority of respondents (63%) did not formally assess patient anxiety but supported the use of standardized scales to measure anxiety (57%). Most plastic surgeons preferred patient education (81%), family member presence (69%), and visit from the anesthesiologist (54%) to reduce patient anxiety. Plastic surgeons also allocated the most responsibility to anesthesiologists (63%) and plastic surgeons (62%) to reduce preoperative anxiety.DiscussionMost plastic surgeon members of ACAPS did not assess their patients' anxieties preoperatively but appeared willing to use anxiety scales. Plastic surgeons also supported several measures to reduce anxiety, especially patient education, family member preferences, and anesthesiologist visits. Although plastic surgeons appeared to hold multiple parties responsible to manage preoperative anxiety, they held themselves and anesthesiologists most responsible. Future studies are needed to determine whether these views cohere with those of other healthcare providers and whether these preferences change for pediatric patients.Level of evidence vThis journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Supplementary_material_1 for Anterior Versus Posterior Decompression for Degenerative Thoracic Spine Diseases: A Comparison of Complications by Aidin Abedi, Blake Formanek, Raymond Hah, Zorica Buser and Jeffrey C. Wang in Global Spine Journal

Introduction: To report a case of monoparesis caused by a vertebral artery (VA) anomaly and foraminal stenosis treated with microvascular decompression by the posterior approach. Material and Methods: A 51-year-old man was referred because of a 4-year history of progressive left shoulder pain refractory to other forms of treatment and a 7-month history of arm weakness. Clinical and radiologic evaluation showed an abnormally tortuous loop of left C5-6 cervical foramina with foraminal stenosis causing direct C6 nerve root compression. Results: Left posterior cervical C5-6 facetectomy and fusion was done to decompress the nerve root. The C6 nerve root was identified and well decompressed. The patient’s symptoms resolved after surgery, supporting the posterior decompression of a cervical nerve root compressed by a vertebral artery loop and stenosis for the relief of pain and weakness. Conclusion: Cervical root compression by an anomalous extracranial VA accompanied with foraminal stenosis is a rare cause of radiculopathy and weakness. The best management of such lesions combined with arterial compression and stenosis, is the posterior approach with bony and nerve root decompression., Introduction: Cervical arthroplasty is increasingly being considered as an alternative option to cervical arthrodesis in younger, active patients. Two of the most commonly commercially available cervical disc prostheses are ProDisc-C (DePuy Synthes) and Prestige-LP (Medtronic). Studies comparing the clinical outcomes of the two systems are lacking. Material and Methods: Six consecutive patients with cervical spondylosis with radiculopathy underwent cervical arthroplasty with ProDisc-C. Five subsequent patients with cervical spondylosis with radiculopathy underwent cervical arthroplasty with Prestige-LP. Demographic information, presentation, radiographic findings, hospital stay, heterotopic ossification, clinical outcome, and return to work were compared between two groups. Results: 67% of the patients who received ProDisc-C were female, compared to 60% in the Prestige-LP group. Average ages at surgery were 42.7 (ProDisc-C) and 42 (Prestige-LP). The most commonly affected level was C6/7 (63% of all participants), followed by C5/6 (27%) and C4/5 (9%). All patients had neck pain and radiculopathy. Weakness was seen in 67% of the ProDisc-C group and 80% of the Prestige-LP group. All patients failed conservative management. All patients had a MRI study of the cervical spine demonstrating disc herniation and disc-osteophyte complex causing cervical canal and foraminal stenoses correlating with clinical symptomatology. There were no complications related to cervical arthroplasty. Length of stay was 1 day for Prestige-LP, and 0.67 day for ProDisc-C. Significant improvement or resolution of preoperative symptoms was seen in all patients at 4 weeks. Heterotopic ossification was seen in 33% of the patients who received ProDisc-C, compared to 0% with Prestige-LP. Artificial disc motion was seen in flexion/extension radiographs in 67% of patients with ProDisc-C and 100% of patients with Prestige-LP. Return to work time was 4.3 weeks for ProDisc-C and 6.7 weeks for Prestige-LP. Average follow-up period was 31 months. Conclusion: Patients who undergo cervical arthroplasty with ProDisc-C or Prestige-LP generally have a short hospital stay (overnight or less) and good clinical outcome. Heterotopic ossification was seen more frequently with ProDisc-C. Disc prosthesis motion with flexion and extension was preserved more frequently with Prestige-LP., Objective: Bony overgrowth and spontaneous fusion were complications of cervical arthroplasty. In contrast, we observed the bone loss phenomenon or bone remodeling of vertebral bodies at operation segment after cervical arthroplasty. The purpose of our study is to investigate a potential complication, bone loss of anterior portion of vertebral bodies at operation segment after cervical total disc replacement (TDR) and to discuss the clinical significance. Materials and Methods: All enrolled patients were followed up more than 24 months after cervical arthroplasty using Baguera-C. Clinical evaluations included recording demographic data and measuring the visual analog scale and neck disability index. Radiographic evaluations included measurements of the functional spinal unit range of motion and changes such as bone loss and bone remodeling. We classified the grading of bone loss of operation segment (grade 1: disappearance of anterior osteophyte or small minor bone loss, grade 2: bone loss of anterior portion of vertebral bodies at operation segment without exposure of artificial disc, grade 3: significant bone loss with exposure of anterior portion of artificial disc). Results: Forty-eight patients were enrolled in our study. Among them, bone loss phenomenon was developed in 29 patients (Grade 1: 15, Grade 2:6, Grade 3:8). Grade 3 bone loss was significantly associated with post-operative neck pain (P < .05). Bone loss was related to motion preservation of operation segment effect after cervical arthroplasty in contrast to heterotopic ossification. Conclusions: Bone loss may be a potential complication of cervical TDR and affect to early post-operative neck pain. However, it did not affect mid- to long-term clinical outcomes or prosthetic failure at the last follow-up. Also, this phenomenon may have the motion preservation effect of operation segment after cervical TDR., Introduction: Multi-level cervical ADR (Artificial Disc Replacement) would be regarded as both clinically & radiologically more demanding compared to single level switch with concomitant requirement of biomechanically delicate ‘even’ stress distribution among the ADR devices inserted to corresponding levels as well as possibility of greater load shift both on intermediate or adjacent levels. However, scarce references could be cited regarding the clinical efficacy and its relation to the ‘preserved’ cervical motion after switch to multilevel cervical ADR. The purpose of this study is to compare cervical ROM(Range of Motion) in simple X-ray between preoperation and postoperation in patients who underwent multilevel ADR and to assess which radiological measurements was statistically related to successful clinical outcomes. Material and Methods: A series of 24 patients who were diagnosed as multi-level cervical disc herniation or stenosis and eventually underwent multi-level cervical ADR operation between Feb 2012 to Dec 2015 were included in this study. These were 17 male: 7 female patients with the mean age of 52.3 ± 8.1 years. As for the investigated parameters, the clinical outcome before operation and on the final follow-up was assessed using NRS (Numeric Rating Scale). The subjects were divided as successful pain relief group vs unsuccessful pain relief group with the definition of successful pain relief group as more than 50% reduction of NRS after surgery. As for the radiological parameters, coronal tilt angle of ADR devices, C2-7 SVA (sagittal vertical axis), C2-7 and ADR inserted level sagittal alignment and ROM using Cobb’s angle measurement method were assessed both before op and on the final follow-up. The Mean follow-up period was 429.0 ± 389.0 days. Results: The mean preoperative NRS of 8±0.9 was reduced to 3.1±0.6 for success and 5.4 ± 0.5 for unsuccessful group with significant difference between the group on the scale of clinical improvement. Radiologically, for the all 24 multilevel ADR cases, the C2-7 SVA (from 22.3 ± 9 to 26 ± 8.8 mm) as well as lordosis at ADR level (from 0.3 ± 7.4 to 4.0 ± 4.3o) improved significantly while flexion at ADR levels (from 15.4 ± 6.8 to 10 ± 6.5o), ROM at ADR levels (from 22.6 ± 9.2 to 18.0 ± 8.2o), and consequently C2-7 flexion (from 16.2 ± 11.4 to 9.7 ± 6.8o) reduced significantly. The overall C2-7 ROM was well maintained for successful group (from 49.9 ± 13.8 to 51.1 ± 7.4o) while significantly reduced for unsuccessful group (from 49.7 ± 13.1 to 39.8 ± 12.8o) with significant inter-group difference in angular change (1.2 ± 15.3o vs -9.9 ± 11.2o, P = .037). This was attributable to the significant reduction of ROM at ADR switched levels for unsuccessful group (from 23.8 ± 11.2 to 15.4 ± 8.3o) compared to successful group (from 22 ± 8.4 to 19.3 ± 8.2o), with consequent significant inter-group difference in angular change (-2.8 ± 8.5o vs -8.4 ± 7.8o, P = .027). Conclusion: The overall sagittal alignment as well as lordosis at ADR switched levels improved after multilevel cervical ADR. However, ROM at the ADR levels, especially flexion movements were reduced significantly, consequently leading to the decrease in overall cervical flexional movement. As for the inter-group radiological differences, a significant reduction of ROM at ADR switched levels leading to a significant reduction of overall C2-7 ROM was noted for unsuccessful group compared to successful group., Introduction: The evolution of lumbar disc disease treatment for two levels has been treated habitually by posterior arthrodesis. The development of lumbar prosthesis has allowed preserve the sagittal balance and preserve the biomechanics of the lumbar spine. Specific cases of lumbar degenerative disc disease can be treated by hybrid constructs with total disc arthroplasty (TDA) and anterior lumbar intersomatic fusión (ALIF); showing lower risk of complications such as facet syndrome, dysfunction of the implant or adjacent segment disease. Material and Methods: A retrospective longitudinal study of 17 patients with chronic low back pain with or without radiculopathy association, evidence on magnetic resonance associated with Pfirmann changes III-V, two lumbar segments was performed. All patients underwent surgical treatment by hybrid construct segments L4-L5 (ATD) and L5-S1 (ALIF), are followed for through clinical evaluation of Oswestry (ODI) and visual analogue pain scale (VAS) presurgical and postsurgical at 3, 6, 12 and 24 months. Results: All 17 patients were follow-up. With degenerative disc disease L4-L5 and L5-S1 segment treated by ATD in the L4-L5 and ALIF segment in L5-S1, 10 men (58%) and 7 women (42%) with a mean age 41 years (58-24 years) are reported L5-S1 segment. The ODI decreased from 41% to 20% and VAS decreased from 7 to 3 points, both at 24 months follow-up. Conclusion: We were able to reproduce through this series of cases favorable clinical response using the hybrid construct multilevel lumbar disc disease. In our case series decided choose to make ALIF the L5-S1 segment as the anatomical shape of this segment is usually variable with greater anterior opening and lower to posterior, as well as its dependence on position according to the slope sacred, necesary for sagittal balance. Current implants for TDA despite being constrained, where the instantaneous axis of rotation is to be similar to the disc, still has no physiological contours that preserve the distribution of axial loads necesary for absorbing shocks, so we prefer to use TDA in a more regular Surface (L4-L5). Thus preserve through the combination of the sagittal balance implants, the best resistance and load distribution, the permeability of the foramen and the initial height of physiological disc., Introduction: Investigation the expression of PDGF-β and GFAP in rats with spinal cord injury as a marker of neurologic recovery between groups treated with erythropoietin (EPO) and methylprednisolone (MP). Methods: 30 adult female rats were randomly divided to three even groups. A laminectomy was applied to thoracic 9th vertebra and contusion injury was induced by extradural application of an aneurysm clips. On group 1 rats received one time intratechal administration of normal saline. Group 2 rats received metilprednisolone and, group 3 rats received erythropoietin. Motor neurological function were evaluated by the Basso, Beattie and Bresnahan locomotor rating scale (BBB scale). 30 days after the surgery, T8-10 segments of the spinal cords were extracted and the immunohistochemical assay revealed that the number of PDGF-β and GFAP positive cells. Results: In the last control showed that BBB score in the EPO group showed an increase from 1 to 12 (P < .05). The immunohistochemical assay revealed that the number of PDGF-β and GFAP positive cells was significantly higher in EPO group (P = .000) when compared to MP and control groups. The effect of PDGF-β expression on the locomotor function, we determined that PDGF-β expression and locomotor function after a spinal injury has a strong relationship (P < .05). Conclusion: EPO seems to better increase the expression of PDGF-β thus, produce better results in locomotor functions when compared to MP., Introduction: When image guidance is not available or to confirm such technology, superficial anatomical landmarks still play a role in providing surgeons with estimations of the position of deeper anatomical structures. To our knowledge, surface landmarks for the position of the odontoid process have not been investigated or described. Therefore, the current anatomical study was performed. Materials and Methods: One-centimeter metallic rods were placed in the philtrum of ten adult cadaveric head specimens. To assess the position relative to the odontoid process, lateral and anteroposterior radiographs were taken in the neutral position using fluoroscopy. The relationship of the philtrum as marked with the metal rod was then documented. Results: The philtrum of the upper lip, as marked with a metallic rod was a good approximation of the odontoid process. The majority of specimens demonstrated an exact approximation of the philtrum as a superficial anatomical landmark for the odontoid process on anteroposterior views. The philtrum was always overlying the odontoid process in the sagittal plane. In the majority of the specimens, the philtrum overlaid most of the odontoid process in a craniocaudal direction. Descriptive findings from radiographic findings indicate a reasonable approximation between the philtrum and the midportion of the odontoid process. Conclusions: The philtrum of the upper lip can serve as a first line of estimation of the position of the odontoid process. We consider this a new superficial landmark for the odontoid process. This could be useful for the positioning and planning of approach for patients undergoing spine surgery., Introduction: Traditional surgery for spinal sagittal deformity is morbid and costly. The pelvis is proposed as an alternative osteotomy site. A more distal site may produce larger deformity correction. This study evaluated the effect of osteotomy opening angle (OA) progression to resting length of surrounding muscles using a mathematical model. Methods: Four muscles crossing the osteotomy site were chosen: Gluteus Medius (GMED), Gluteus Maximus (GMAX), Piriformis (P) and Tensor Fascia Lata (TFL). Basic geometric laws were used to derive predictive equations to calculate the length and stretch ratio (SR, new muscle length / initial length) of these muscles as the OA increases. These equations depend on the spatial location of the muscle insertion points. Average insertion points were obtained from an OpenSim software model. GMAX and GMED were subdivided into 3 (anterior, middle and posterior), as they are relatively wide. Calculated SRs were compared to the threshold SR for rabbit Extensor Digitorum Longus muscle (25.4%); there are no reported human SR threshold values for the investigated muscles. Results: OA correlates with SR positively for TFL and anterior GMED, and negatively for the rest of muscles. A 20° OA was selected based on another study. For this OA, the SR approximately decreases 6%, 5%, 6%, 8% and 5% for posterior GMED, anterior GMAX, middle GMAX, posterior GMAX and P, respectively. It increases 8% and 4% for anterior GMED and TFL, respectively. It does not change for middle GMED. Conclusion: BPO changes the length of some of the surrounding muscles. For the practical OA range, these changes are not considerable. The reported critical value (25.4%) is higher than the maximum SR for investigated muscles (8% for anterior GMED). Note that we only considered the non-stimulated passive response of the muscles. Moreover, physiological motions may compound the OA effect on SR, the effects of which were not investigated in this study., Introduction: Rheumatoid arthritis (RA) often involves synovial joints of the cervical spine, including the atlanto-occipital joint, atlantoaxial joint, and facet joints. In the lumbar spine, erosion of discovertebral joints and facet joints has been reported in RA patients. However, there is no synovium in the discovertebral joints, so the pathology of lumbar spondylitis in RA patients remains unclear. In addition, histological evaluation of RA lesions in both the discovertebral joints and facet joints at the same spinal level has not yet been performed. The purpose of this study is to histologically evaluate lumbar involvement in RA by investigating rats with collagen-induced arthritis (CIA) and to assess the potential effects of RA on the discovertebral joints and facet joints. Material and Methods: Seven-month-old female Sprague-Dawley rats were divided into groups with CIA and without CIA (control). All rats were sacrificed at 8 weeks after initial sensitization and the lumbar spine (L5/6) was harvested. Then the lumbar spine block specimens were stained with Villaneuva bone stain and sectioned in the midsagittal plane. The left facet joints were also sectioned in the midaxial plane. Specimens were studied under a microscope and infiltration of inflammatory cells was investigated. Results: In the CIA group, lumbar lesions were confirmed in 13/18 rats (76%). Lymphocytes only infiltrated into the anterior rim of the vertebral bodies in 2 rats, while lymphocytes only infiltrated the facet joints in 4 rats. Both sites were involved in 7 rats. In addition, osteoclasts invaded the anterior rim of the vertebral bodies and formed cavities that also contained lymphocytes. Formation of pannus was seen in the facet joints. Conclusion: Infiltration of inflammatory cells into the anterior rim of the vertebral bodies alone or into the facet joints alone was demonstrated in some rats with CIA, while both sites were involved in other rats. Therefore, lesions at the anterior rim of the vertebral body did not arise secondary to facet joint involvement, but were caused by CIA along with synovial lesions of the facet joints., Introduction: Intervertebral disc (IVD) degeneration is one of the main causes for chronic back pain. Injection of autologous stem cells is still an experimental treatment for disc degeneration showing limited success so far. This is attributed to a low survival rate of the injected cells due to the harsh environment within the disc, which is hypoxic, acidic, low in nutrients, and possibly inflamed in a degenerative state. Studies performed in animal models have reported that juvenile chondrocytes display a better cell survival and production of extracellular matrix than stem cells, possibly due to chondrocytes being more accustomed to an avascular environment. Recently, it has been shown that adult human nasal septum chondrocytes (ie, easily available cells in an autologous setting, under minimally invasive conditions) have an increased rate of proliferation and synthesis of proteoglycan (GAG) and collagen in contrast to articular chondrocytes (ACs). This study was aimed at assessing whether human nasal chondrocytes (NCs) could be an opportune cell source for autologous cell transplantation therapy in the treatment of IVD degeneration. Material and Methods: Human bone marrow stromal cells (MSCs), ACs, and NCs were isolated from biopsies and expanded in cell culture for 2 passages. Thereafter, cells were cultured in either normoxic or hypoxic (2% O2) conditions for 4 weeks in 3D pellet culture The chondrogenic media with either regular (4.5 g/l) or low (1 g/l) glucose levels were complemented either with or without the growth factor TGFβ1. The cell survival and the capability to form IVD-like tissue were evaluated by means of histological and biochemical analysis. Results: Quantification of DNA shows that the cell number of MSC decreased by more than 25% in the absence of TGFβ1 and was barely retained in the presence of the growth factor independent of environmental condition. ACs behaved similar to MSCs with the exception that the cell number increased in hypoxic conditions with the addition of TGFβ1, but independent of the glucose concentration. Surprisingly, the number of NC slightly increased (>12%) in all conditions without TGFβ1. Furthermore, the supplement of TGFβ1 increased the cell number by at least 48% in any of environmental conditions. Histological Safranin O staining and biochemical analysis showed for all three cell sources that TGFβ1 was necessary for an adequate production of GAG. The reduction of glucose decreased the level of GAG in pellets formed by MSCs in both hypoxia and normoxia. In contrast, GAG production of ACs was unaffected by changes in glucose concentration, however hypoxic conditions influenced ACs to synthesize more GAG. Interestingly, NCs do not favor hypoxic conditions for GAG production, nonetheless in combination with decreased glucose levels they show a trend to produce the most GAG (35 pgr) compared to ACs and MSCs. Conclusion: Our findings indicate that compared to MSCs and ACs, NCs are more prone to survive and synthesize cartilaginous extracellular matrix in vitro in conditions resembling those of the IVD (ie, low oxygen and low glucose concentration) and are therefore an excellent candidate for a cell based therapy of degenerative disc disease., Introduction: Adolescent idiopathic scoliosis (AIS) is a lateral deviation of the spine associated with vertebral rotation whose etiology is not defined. Several theories have been proposed, but none is absolutely conclusive. One such theory suggests the primary involvement of muscles due to myopathy, affecting mainly the erector and paravertebral rotator muscles. However, previous studies indicate that muscle involvement could result from neuromuscular conditions, and, more recent work correlates AIS to genetic polymorphisms. Some polymorphisms have been associated to physical performance and muscle power through their effects on muscle tissue. The gene coding for the angiotensin converting enzyme (ACE), has polymorphisms corresponding to an insertion (allele I) or deletion (allele D) of 287 base pairs. The expression of different alleles may affect the plasma levels of angiotensin II, and muscles with aerobic characteristics (type I fibers) such as the erector and rotators of the spine. Material and Methods: To evaluate a possible relationship of ACE gene polymorphisms with the development of the AIS we evaluated their relative expression in samples of the rotator muscles of the spine, collected during corrective surgery of 21 patients with AIS, and a predominance of fibrosis and fatty proliferation in the concavity side of the deformity. Results: We could find no difference in the expression of the ACE gene or its polymorphisms (insertion/deletion) in the multifidus muscles removed from the concavity and convexity of the apex of the thoracic deformity. Conclusion: Thus, we could not find evidence of ACE polymorphism involvement in the development of AIS., Introduction: The adolescent idiopathic scoliosis is a multifactorial disease, and its etiology related to genetic factors and environment. Patients present 3-dimensional deformity, and its main characteristic trunk rotation. This deformity can be related to the primary disease or secondary due to multifidius muscles. The objective of this study is to analyze and compare the fatty degeneration of these muscles by means of magnetic resonance imaging and histopathology. Material and Methods: Ten patients that undergone corrective surgery for adolescent idiopathic scoliosis had multifidius muscle samples taken from the top of the thoracic deformity. Samples were analyzed for fatty degeneration and fibrosis and compared their histopathological findings with axial MRI (T1-weight) of the same region using the ImageJ software. Results: Higher fatty degeneration of the multifidus muscle was found in the concavity of the thoracic curve of patients with adolescent idiopathic scoliosis in the histopathological and image analysis, whereas the fatty degeneration in the MRI demonstrated that higher the deformity greater was the degeneration observed (rho = 0.85, P < .0). No significant correlation between the MRI image and the fatty involution was noted in the histopathological analysis neither in the concavity (rho = 0.09; P = .797) nor in the convexity (rho = 0.02, P = .955). Conclusion: Both MRI and histopathological analysis of multifidius muscles from the apex of the deformity of patients with adolescent idiopathic scoliosis demonstrated higher fatty degeneration in the concavity of the curve. The difference between concavity and convexity assessed by MRI is higher as much severe is the scoliotic curve., Introduction: Spinal cord injury leads to cellular necrosis as secondary damage caused by ischemia. Free radical formation and lipid peroxidation play a novel role in the pathophysiology of tissue lesions. Antioxidant therapy has been proposed to minimize the reactive oxygen species and reduce the secondary lesions. The objective of the paper is to analyze the frequency and efficacy of the experimental antioxidant therapy studies. Materials and Methods: Research was performed in pubmed.gov using the keywords “antioxidants” and “spinal cord injury”, from January 2000 to December 2015, resulting in 686 papers. Nontraumatic injury, no antioxidant therapy, lack of neurological and functional assessment and non experiment studies were excluded. After the exclusion criteria, 43 were included. Results: The most used therapies were melatonin (16.2%), quercitin (9.3%), epigallocatecin and edaverone (6.9%). The most frequent administration mode was intraperitoneal (72,09%). The posology and administration mode varied greatly, and mostly one dose was used (39.53%). The elapsed time from trauma to treatment was 0-15 minutes (41.8%), 15-60 minutes (30%) and more than 1 hour (10.6%). Histology was done in 32 papers (74.41%). BBB scale system was the main functional measurement (55.8%), followed by the inclined plane test (16.2%) and the Tarlov Scale (13.9%). Positive outcomes were observed in 37 papers (86,04%). Conclusion: The heterogeneity of antioxidant treatment with different types, doses, and measurements observed limit the comparison of efficacy. Standardized protocols are necessary to make clinical translation possible., Introduction: Animal models of spinal cord injury (SCI) are used both to study the biological responses and the potential therapies under controlled conditions. An appropriate model should be selected considering the hypothesis and outcomes assessments. In a systematic review, we categorized the SCI animal models, based on the study aims, species, injury techniques, levels of injury, and outcome measurements. Material and Methods: An extended search was carried out in the electronic databases of Medline. Results: Among a total of 2870 publications, 2209 fulfilled our inclusion criteria. The most common aims of included studies were the evaluation of different factors or pathophysiologic changes. The most common level of injury was thoracic. Contusion was the most common pattern of injury followed by transection. In the half of studies, both biological and behavioral tests were used to assess outcomes. Conclusions: Prior to choose an animal model, the study aims should be exactly defined. While contusion models better mimic the neuropathology of human injuries, transection models are helpful to study anatomic regeneration. Rats are the most common and best suited species for SCI models. Newer SCI animal models need to be improved and validated., Introduction: Despite abundant studies regarding the pathophysiology of traumatic spinal cord injuries (TSCI), there is a controversy about the fate of neurons following mechanical insult. For development of new therapies to either preserve the spared neurons or promote axonal regeneration and remyelination, selection of the injury model and time of intervention is crucial for the efficacy of therapy. Here we evaluated the fate of neurons after TSCI by conducting a systematic review. Material and Methods: We searched PubMed and EMBASE with no temporal or linguistic restrictions. In addition, hand-search was performed in the bibliographies of relevant studies. Non-interventional animal studies evaluating time-dependent pathological changes of neurons following acute mechanical trauma to the spinal cord were included. The outcome measures were neuronal death as well as changes occurring in the axon and myelin integrity and their function postinjury. Results: Following injury neuronal loss occurs through both necrotic and apoptotic cell death. The first sign of apoptosis was detected at 1 h postinjury which reaches to a maximum at 7-8 mm from the epicenter by 3 days postinjury. TSCI causes apoptosis also in the brain. Although the survival of supraspinal neurons depends on the severity of the injury and anatomical location of their axons, some supraspinal neurons can survive the injury up to at least 1 year PI. Axonal regeneration after transection initiates earlier compared with compression or contusion models. This early regenerative process is also associated with axonal die back. Growing fibers are detectable within the lesion cavity during the intermediate phase. Demyelination begins 12-24 h PI and peaks at 8 weeks postinjury. Remyelination was detected as early as 1 week postinjury. The number of demyelinated/remyelinated axons at the injury epicenter was not significantly different between transection and contusion models of injury. However, the demyelination/remyelination process is more limited to the injury site in transactions. Conclusion: As secondary injury is a progressive event, detailed understanding of time-dependent neuronal response to TSCI in rats will improve the process of examining the safety and efficacy of the intervention by reliable methods not interfered by the injury-related changes and subsequently may accelerate translation of treatments to the clinical application. Acknowledgement: This project has been support by the Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences (fund number: 93-02-38-25620)., Introduction: Diffusion being the most important source of disc nutrition, factors affecting it needs to be studied accordingly. Ole of endplate and annulus fibrosus has been extensively studied. But the relation of disc height to the diffusion characteristics has not been studied till date. The present study evaluates the 24 hr diffusion characteristics and its peak signal intensity change connecting with the axial disc width and length. Material and Methods: Twenty-five lumbar discs of 5 healthy volunteers were included in the study. IV gadodiamide (0.3mmol/kg) was given as a contrast material and serial MRI images were taken at 10 min, 2 hrs, 4 hrs, 6 hrs, 12 hrs and 24 hrs. Axial images at cranial, middle and caudal zones of the discs were obtained. Using region of interest (ROI) boxes, signal intensity changes in the intervertebral disc along with disc height were measured in the sagittal sections. The enhancement percentage of each time period (EP) and peak enhancement rise time (T rise) were calculated. Results: The peak signal intensity was seen at 6 hrs in all the discs. Axial width and length of the disc was found to be inversely proportional to the diffusion at central nucleus pulposus. Also as the sagittal height of the disc increased in each individual, peak signal intensity at 6 hrs decreased. Conclusion: The present noninvasive in-vivo study documents the relation between disc height, axial length and width to that of the diffusion at central nucleus pulposus., Introduction: Skeletal fluorosis is endemic in at least 22 states in India. Andhra Pradesh is one of the worst effected states. Ossification and thickening of ligaments result in cervical stenosis and progressive spinal cord compression leading to cervical myelopathy and quadriperesis. Diagnosis of cervical myelopathy is often difficult due to subtle symptoms and lack of suspicion. The success of the treatment depends on early surgical intervention. Many a times, patients from endemic area present late with severe myelopathy. MRI is considered too be the gold standard test for diagnosing cervical myelopathy. Utilising MRI as the screening test is neither cost effective nor feasible. By developing self screening tests and symptoms, awareness can be created in the endemic population to seek the medical help early. Currently there are no screening tools available in the world literature. As the disease is endemic to us, it becomes our responsibility to develop these tools. With a combination of simple questionnaire and easily elicitable clinical tests, we aim to develop self screening tools for fluorotic myelopathy. Material and Methods: The study was conducted in two phases. In phase I, screening tools were developed with 30 cervical myelopathic patients with cord compression on MRI, underwent surgery and improved as cases; 30 patients with neck/radicular complaints but no myelopathic symptoms and no cord compression on imaging as controls. 20 items from the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) and five easily demonstrable clinical signs namely Hoffman test, rapid grip and release test, finger escape sign, Romberg’s test and tandem walking were evaluated. Data was analyzed by univariate analysis and multiple logistic regression analysis. According to the resulting odds ratio, b-coefficients, and p value, items were chosen and assigned a score. In Phase 2, the validity of the developed questionnaire and tests were evaluated in 480 subjects by five health workers in endemic population in India with the help of National Program for Prevention and Control of Fluorosis (NPPF). Those who satisfy the criteria were subjected to the MRI examination and results were analyzed. The urine samples of the patients was analysed for fluoride content. Results: Five questions were chosen by statistical analysis and each assigned a score of two. A score greater than or equal to six as cut-off and two of the five positive clinical tests was found to predict the cervical myelopathy with the area under the ROC curve of 0.78, sensitivity of 91.6% and a specificity of 63.2%.Of the clinical tests, Romberg test was found to demonstrate highest sensitivity (83%). Of the 480 subjects screened with these developed tools, 37 (7.7%) were found to satisfy the criteria of them 11 were found to have radiological cord compression with a positive predictive value of 0.84. Urine fluoride was above the threshold (1.5 ppm) in 95 of 120 samples measured with average of 3 ppm and maximum recorded up to 8 ppm. Conclusion: Simple self screening tools with a combination of five questions and five clinical tests were found to successfully screen the fluorotic myelopathy. Presence of three of five positives in the questionnaire or two of five positive tests was found to be highly sensitive for screening. Of all the clinical tests, Romberg test was found to be highly sensitive in predicting cervical myelopathy. These tools can be utilized to rapidly screen the cervical myelopathy in the outpatient clinic as well as for epidemiological purpose by educating the local heath workers., Introduction: With the rise of life expectancy worldwide, automatically will impact on the increment of degenerative disease, including the degenerative spondylolisthesis. This phenomenon is followed with rapid development of orthopedic instrumentation. This facts gave rise to the question: Is it necessary to reduce the degenerative spondylolisthesis? Besides, it is difficult technically and lot of complication could happen. Materials and Method: This is an experimental study to evaluate the soft tissue role on stability on degenerative spondylolisthesis model on the animal model (Porcus domesticus). Samples are grouped into in situ instrumentation group and instrumentation after reduction group. The initial step is destabilization procedure including bilateral facet joints resection, total discectomy, and preservation of anterior and posterior ligaments. The caudal vertebra are fixated, while the cranial vertebra are free. Then, anterior shear force is applied to the cranial vertebra using testing machine. Afterwards, pedicle screw-rods system is implanted on both groups. Anterior shear force is applied on the instrumented samples once again. The test is terminated once the displacement reach 5 mm. Result: Mean value of maximal shearing force needed to achieve 5 mm listhesis on in situ instrumentation group is 506,6667 ± 59,62103; in instrumentation after reduction group is 325,0000 ± 63,98125. Mann-Whitney analysis test result comparing both groups is P = .08, which is significantly different. Conclusion: There is significant difference in maximum anterior shear force needed to achieve 5 mm listhesis between both groups. This could happen due to the role of soft tissue to add the spine stability on in situ instrumentation group., In humans, vertical posture acquisition caused several changes in bones and muscles which can be assumed as verticalization. Pelvis, femur, and vertebral column gain an extension position which decreases muscular work by paravertebral muscles in the latter. It’s widely known that 6 different morphological categories exist; each category differs from the others by pelvic parameters and vertebral column curvatures. Both values depend on the Pelvic Incidence, calculated as the angle between the axes passing through the rotation centre of the two femur heads and the vertical axis passing through the superior plate of the sacrum. The aim of this study is to evaluate the distribution of stress and the resulting strain along the axial skeleton using finite element analysis. The use of this computational method allows performing different analyses investigating how different bony geometries and skeletal structures can behavior under specific loading conditions. A computerized tomography (CT) of artificial bones, carried on at 1.5 mm of distance along sagittal, coronal and axial planes with the knee at 0° flexion (accuracy 0.5 mm), was used to obtain geometrical data of the model developed. Lines were imported into a commercial code (Hypermesh by Altair®) in order to interpolate main surfaces and create the solid version of the model. In particular six different models were created according Roussoli’s classification, by arranging geometrical position of the skeletal components. Loading conditions were obtained by applying muscular forces components to T1 till to L5, according to a reference model (Daniel M. 2011), and a fixed constrain was imposed on the lower part of the femurs. Materials were assumed as elastic with an Elastic modulus of 15 GPa, a Shear Modulus of 7 GPa for bony parts, and an Elastic modulus of 6 MPa, a Shear Modulus of 3 MPa for cartilaginous parts. Six different simulations have been carried out in order to evaluate the mechanical behavior of the human vertebral column arranged according to the Russoli’s classification; results confirm higher solicitations obtained varying configurations from case I to case VI. In particular way, first three cases seem to supply the different loading configurations spreading stresses in almost all the bony parts of the column, while the remaining others three cases produce an higher concentration of stress around the lower part of spine (L3, L4, L5). Results confirm a good agreement with those present in literature (Winkle at al. 1999), an equivalent Von Mises average stress was of 0,55 MPa was found on the intervertebral disks with the higher values reached on the lower part of the column. A comparison of results obtained for Case I with literature (Galbusera et al., and El Rich et al. 2004), shows a good agreement in terms of normal compressive force, while more evident differences with Galbusera’s results can be found for shear force and sagittal moment. The results underline a relationship between PI increase, and accordingly of PT and LL, and the distribution of load forces. Load forcesi is exerted mainly on distal vertebrae, especially on L4 and L5., Introduction: Clinical case series in the literature suggest that kyphoplasty may be an option to stabilize a traumatic instable thoracic-lumbar spinal segment after incomplete burst fracture. This suggestion is in a certain contrast to the classical biomechanical idea of segmental instability after injury of the middle column according to Denis. Purpose of this study is to evaluate the effect of kyphoplasty to stabilize the posttraumatic segmental instability and its influence to adjacent levels using a robotic based spine tester. Material and Methods: 14 osteoporotic human multisegmental spine samples (TH11 – L3) have been tested. Intact kinematic values of each FSU were recorded, using a robot based spine tester combined with an active 3D motion tracking without and with follower preload. These values have been used as baseline. After standardized induction of an incomplete burst fracture to L1, the kinematic testing was repeated to record the posttraumatic (instable) values. The fractured vertebra (L1) was then reconstructed by kyphoplasty. Kinematic values of each FSU was investigated after kyphoplasty. Results: The experimental induced incomplete burst fracture resulted in a significant increased range of motion (ROM) of the Level TH12 – L1 for extension-flexion, lateral bending and axial rotation. No significant increase in adjacent levels was noticed. Increase in ROM for axial rotation was 201% (p = 0.001), for extension flexion 132% (P = .0002) and lateral bending 277% (P = .0002) of intact kinematic values. After kyphoplasty a significant reduction of the posttraumatic instable values of the Level TH12 - L1 have been observed for all three movement directions. ROM was reduced for axial rotation to 80% (P = .002), for extension-flexion to 90% (P = .0002) and lateral bending to 71% (P = .0002) of the fractured kinematic values. However, for all three movement directions initial intact values could not have been restored and a significant increase in ROM resulted compared to the values before injury. In comparison to intact values ROM remained increased by 161% (P = .002) for axial rotation, by 120% (P = .001) for extension-flexion and by 197% (P = .0002) for lateral bending. No significant changes in adjacent levels were seen. Conclusion: Kyphoplasty seems to have the potential to reduce segmental instability after trauma. However, in the presented model intravertebral reconstruction failed to restore intact values and a significant instability remained. This observation may increase our understanding to the stabilizing effect of kyphoplasty but unfortunately does not answer, how much gain in stabilization is necessary to achieve good clinical outcomes. The biomechanically observed remaining instability after kyphoplasty suggests that this treatment has limited potential to stabilize a true traumatic instability., Introduction: Anterior cervical discectomy and fusion has been associated with the development of adjacent segment degeneration (ASD). Cervical total disc arthroplasty (TDA) is an alternative to fusion to prevent ASD, as studies have demonstrated that TDA can replicate physiologic motion. An innovative disc prostheses with a mobile axis of rotation and made of polycrystalline diamond, one of the hardest and most durable substances known, can replicate physiologic motion while minimizing wear debris. The purpose of this study was to assess the motion response of this TDA implanted in human cervical spines. Biomechanical assessment was performed in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) after 1- and 2-level TDA. Material and Methods: Nine cadaveric C3-T1 spine specimens were tested (38.3 ± 5.8 years). The testing apparatus allowed continuous cycling in FE, LB, and AR to ±1.5 Nm. Compressive preloads (0 N, 150 N) were used in FE. Vertebral motion was measured using optoelectronic measurement. TDA implantation was performed consistent with company guidelines (Triadyme-C, Dymicron, Orem, UT, USA). Three dimensional (3D) CT based analysis was used to calculate center of rotation (COR).The PLL was resected and a medial uncinatectomy was performed to accommodate the prosthesis. Experimental protocol: Intact, C5-C6 TDA (n = 9), C6-C7 TDA (n = 7). ANOVA was used for statistical analyses, significance: p < 0.05. Results: C5-C6 ROM (deg) Intact to 1-level TDA: FE (0 N): 12.6±2.6 to 11.7±1.8 (p = 0.32) FE (150 N): 12.8±2.5 to 10.5±2.1 (p = 0.03). LB: 8.5±2.8 to 3.7±1.0 (p < 0.01). AR: 10.4±1.1 to 6.2±1.9 (p < 0.01). Neutral zone (deg): FE (0 N): 0.8±0.5 to 1.4±0.5 (p = 0.00). FE (150 N): 1.8±0.7 to 1.8±0.8 (p = 0.97). Change in COR: FE (150 N): 1.0±1.1 mm posteriorly (n = 8, p < 0.05) and 0.6±1.4 mm caudally (n = 8, p = 0.3). C6-C7 ROM (deg) Intact to 2nd-level TDA: FE (0 N): 11.5±3.4 to 12.4±3.3 (p = 0.07). FE (150 N): 10.0±3.4 to 11.4±3.0 (p = 0.15). LB: 7.5±2.8 to 5.1±2.3 (p = 0.07). AR: 7.7±1.7 to 5.3±0.9 (p = 0.02). Neutral zone (deg): FE (0 N): 0.8±0.4 to 1.1±0.2 (p = 0.01). FE (150 N): 1.5±1.0 to 2.1±0.9 (p = 0.30). Change in COR: FE (150 N): 1.4±0.8 mm posteriorly (n = 7, p < 0.01) and 0.3±2.0 mm cranially (n = 7, p = 0.7). Conclusion: This innovative disc prosthesis design restored FE ROM to intact levels. In LB the TDA maintained 68% of ROM at C6-C7 and 43% at C5-C6. In AR 60% of the ROM was maintained at C5-C6 and 69% at C6-C7. Other biomechanically tested designs of TDA have shown similar reduction in LB and AR. The decrease in LB and AR after TDA may be a multifactorial phenomenon. Device kinematics, placement and tensioning of the remaining soft tissues during prosthesis insertion may play a role in maintained motion. This novel polycrystalline diamond tri-lobed TDA design, effectively replicated COR at both operated levels. Data suggests that this TDA provides similar cervical spine kinematics as compared to the preoperative condition., Introduction: Sacropelvic fixation is commonly used during long fusions of adult deformity surgeries to overcome the complications associated with the fusions ending at S1. Among multiple techniques for sacropelvic fixation, the S2 alar-iliac (S2AI) screws and iliac screws with lateral connectors are frequently used. However, the sacropelvic fixation is still associated with a very high rate of mechanical failure. In particular, the polyaxial screw head coupling the shaft has been shown as the first part failing against load, and this was suggested as a protective feature of the screw preventing screw or rod failure. Hence, we aimed to compare the biomechanical strength of the S2AI screws to the iliac screws with lateral connectors using finite element analysis (FEA). Moreover, we evaluated the least length of the screw to maintain the stability of the sacropelvic fixation, and the safe range of angle in the coupling of the polyaxial head to the pedicle screw. Material and Methods: A 3-dimensional finite element (FE) model of the normal spinopelvis (L4-Pelvis) was generated using Mimics, a CT image processing software, and ANSYS FE Modeler, a FE model generation software. The pedicle screws were placed on the L4-S1 with five different lengths of S2AI screws and iliac screws, namely, 60 mm, 70 mm, 80 mm, 90 mm and 100 mm. The total numbers of element for spinopelvis and implant are approximately 50 000 and 3000, respectively. Various loads are applied to the spinopelvic FE model through the displacement- and angle-controlled method. Through the series FEA using ANSYS, the principal maximum stress as well as the von Mises equivalent stress on both fixation appliances and bone structures was specifically calculated. In addition, the various failure characteristics of both bone and implant such as screw breakage and disintegration between screw head and shaft were quantitatively predicted using the failure criteria of each material. Results: Through the parametric study of FEA results, the optimized screw type and the screw insertion depth for all of screw types can be identified. The optimized angle of screw head for S2AI can be determined as well. In both fixations, it was confirmed that as the screw insertion depth increases, the amount of equivalent stress as well as principal maximum stress decreases. Conclusion: FEA results demonstrated that the S2AI screws provided better stability with less stress fields in comparison with the iliac screws with lateral connectors in most of loading conditions. The least length of the screw to maintain the stability of the sacropelvic fixation was longer for iliac screw fixation. S2AI screws that were used with angled position were prone to failure more easily with the increase of head-shaft angulation., Introduction: Pseudarthrosis remains a problem affecting the success of anterior cervical discectomy and fusion. Increased stiffness from internal fixation has a positive effect on arthrodesis and various supplemental fixation techniques have been developed with this in mind. Machined intrafacet allograft spacers have been studied for their effect on foraminal height and anecdotal experience supports a positive effect on construct stiffness; however, biomechanical studies are limited. Our objective was to evaluate the biomechanical advantage gained from the placement of intrafacet allograft spacers (IAS) in an unstable single level and 2-level anterior cervical discectomy fusion (ACDF) pseudarthrosis construct. Material and Methods: Seventeen C3-7 fresh-frozen human cadaveric spines (10 male and 7 female; mean age 51 years) were tested. Nine were used for the single level ACDF group and eight for the two-level group. Range of motion in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) at 1.5 Nm were collected in four testing configurations for one and two-level groups: 1) Intact spine; 2) ACDF with interbody graft and plate/screw; 3) ACDF with interbody graft and plate/loosened screws; and 4) ACDF with interbody graft and plate/loosened screws supplemented with intrafacet allograft spacer. Results: All fixation configurations resulted in statistically significant decreases in range of motion in all bending planes compared to the intact spine (p < 0.05). One Level: Performing ACDF with interbody graft and plate on the intact spine reduced FE, LB, and AR 60.0%, 64.9%, and 72.9% from intact respectively. Loosening the ACDF screws decreased these reductions to 40.9%, 44.6, and 52.1%. The addition of intrafacet allograft spacers to the loose condition (rescue) increased these reductions to 74.0%, 84.1%, and 82.1%. These differences were not statistically significant. Two Level: Performing ACDF with interbody graft and plate on the intact spine reduced FE, LB, and AR 72.0%, 71.1%, and 71.2% respectively. Loosening the ACDF screws decreased these reductions to 55.4%, 55.3%, and 51.3%. The addition of intrafacet allograft spacers to the loose condition significantly increased these reductions to 82.6%, 91.2%, and 89.3% (P < .05). Conclusion: Our data demonstrated that supplementation of a loose ACDF construct with intrafacet allograft spacers significantly increases stability and has potential applications in treating cervical pseudoarthrosis and decreasing non-union risk in multilevel ACDF., Introduction: Numerous bone graft substitutes (BGS) are available as alternatives to iliac crest autograft. Fusion success is normally defined by the presence of bridging bone between vertebrae at the operative site. The number of fused segments is often quoted as a measure of clinical performance for BGSs; however, it does not provide any quantifiable measure of the quality of the fusion. BGSs should resorb over time to leave normal healthy bone that responds to mechanical load and remodels to the principle axis of strain. This study analysed and compared the porosity and direction of trabeculae of bone formed in the BGS region to that of normal bone as a measure of the fusion quality. Materials and Methods: Anterior cervical discectomy and fusion for single and multi-level symptomatic cervical radiculopathy was completed in 13 patients (20 spinal levels) using a PEEK interbody cage. The cage was filled with The cage was filled with i-FACTOR (Cerapedics Inc.), a Peptide Enhanced BGS. Post-operative radiographic follow-up was conducted at 3 and 6 months using Cone-Beam CT. The BGS region in the interbody cages, which had been deemed fused by the operating surgeon, was isolated using a semi-automated algorithm to segment the bone in the region of interest whilst compensating for both beam hardening and x-ray scattering. This was performed using Mimics (Materialise) software. The porosity of the regions was determined by wrapping the segmented models and individual trabeculae were identified by ray-casting. The segmented 3D bone models were subjected to ray-casting to identify the internal trabecular direction and volume of bone in each direction. Directions were related to the orientations of the cage (using the radiographic cage markers) and were represented via a 3D histogram rose plot using 10° increments. Results: The porosity of the bone formed from the graft approaches the porosity seen in corresponding healthy bone (in a nonadjacent vertebral body) over time. Analysis of trabecular direction in the control bone sites showed not only the major directions of the trabecular which relate to the major axis of strain in the bone, but also an array of supportive directions. The trabeculae of the fused bones at 3 months show similar major directions but not the supportive directions. The trabeculae of the fused bones at 6 months show a smaller proportion of major directions but in the same direction as the health bone compared to the 3-month data but has more supportive directions as in the normal bone. Conclusions: The change in porosity and trabecular orientation over time and a trend towards normal bone characteristics suggest that, despite being enclosed within a stiff interbody cage, the BGS region is being stimulated to remodel along a principle orientation that is similar to that observed within normal bone. The trabecular orientation observed at 3 and 6 months is not the same, indicating a remodelling predicted by Frost’s Mechanostat, with remodelling occurring along the main axis of strain, thus remodelling to a similar structure to the healthy bone., Introduction: Sit-to-stand and stand-to-sit (STS) are determinant tasks linked to independence in daily life with an average of 60 repetitions per day (Janssen et al, 2002). It has been shown that STS exacerbates pain in NSLBP patients (Dall & Kerr, 2010) and is greater energy demanding in individuals with non-specific low back pain (NSLBP) compared to healthy participants (Shum et al, 2009). Trunk muscles electromyography (EMG) highlighted differences between NSLBP and healthy participants in functional tasks such as lift (Lu et al, 2001) or walking (Lamoth et al, 2006). To the best of our knowledge, few studies have investigated muscles activity during STS in NSLBP patients. Investigating trunk muscles EMG of NSLBP patients during STS would provide a better understanding mechanisms of pain and enable to adapt therapeutic management. This study aimed to compare trunk muscles cocontraction between chronic NSLBP and healthy participants. Material and Methods: EMG of erector spinae (ES) (at L1 level) and rectus abdominus (RA) were measured bilaterally in 12 patients with chronic NSLBP and 9 healthy participants. Endurance tests of back (Sorensen test) and abdomen (flexor Ito-Shirado test) muscles were respectively used to normalize ES and RA EMG amplitude. Then, each participant realized 3 trials of STS movement from an adjusted stool (knee at 90°). For each STS movement a percentage of cocontraction time (PCT) and a cocontraction index (CCI) (Lewek et al., 2004) were calculated to respectively evaluate activation pattern and degree of cocontraction for each following pairs: ES right/ES left, ES right/RA left, ES right/RA right, ES left/RA right, ES left/RA right and RA left/RA right. The average of CCI for all ES/RA pairs was considered to compute a global flexor/extensor CCI value. Statistical analysis was performed using Mann-Whitney U test. Results: Analysis of PCT showed no significant (P > .05) difference between the two groups for sit-to-stand and stand-to-sit movements. Conversely, analysis of CCI showed significant (P < .05) higher global flexor/extensor CCI values in NSLBP group for both the sit-to-stand and stand-to-sit movements. Conclusion: These present findings suggested that during STS movement NSLBP patients had a similar activation pattern between trunk muscles but with a higher degree of cocontraction. These observations are consistent with results observed on lifting (Lu et al., 2001) and walking (Gamkhar et al, 2015). The higher degree of cocontraction could explain a part of the persistence of pain in NSLBP population. These results should be confirmed on a larger number of participants., Introduction: Foraminal stenosis is a clinical challenge in both diagnosis and treatment. Current surgical strategies involve placement of interbody devices, which may indirectly decompress foramina via height restoration. Alterations of foraminal volume have been shown to improve patients’ pain and Oswestry scores. However, optimally measuring foraminal volume has been elusive and limited thus far. A multidisciplinary spine research team has developed a novel Finite Element Analysis 3D computational method of measuring foraminal volume using open-source animation software (Blender©). Purpose: To develop a tool that can measure foraminal volume and look at the effect of anterior interbody fusion device shape and placement on foraminal volume restoration. Material and Methods: 3D finite element models of L5-S1 segments were reconstructed from CT scans of patients with foraminal stenosis. The models simulated disc distraction by inserting interbody devices (IBDs) with posterior disc heights of 6, 8, and 10 mm and lordosis of 20° or 30° (i.e.,6x20, 6x30). After creating an icospheric mesh to fit at the neural foramen, Shrinkwrap and Boolean modifiers were applied and molded the mesh to the foramen’s narrowest areas. Volume of the mesh was then calculated by the software. Results: Foraminal volume increased from its baseline value by 67% and 97% for the 6x20 and 6x30 IBDs and by 99% and 136% for the 8x20 and 8x30 IBDs, respectively. 10x20 and 10x30 IBDs resulted in the largest foraminal volume increases from baseline (145% and 201%). Conclusion: Computational foraminal volumetric modeling measurement technique has the potential for objective, reproducible assessment of neural foraminal stenosis. Measuring foraminal volume with 3D computational modeling provides a repeatable quantitative measure of the narrowest portion of the neural foramen., Introduction: Early onset scoliosis (EOS) adversely impairs pulmonary function by reducing thoracic volume (TV). Surgical treatment with growing rods (GR) controls curve progression and simultaneously allows for continued spinal growth via sequential lengthening until definitive fusion. However, the impact of growing rod lengthening on thoracic volume is unknown. A multidisciplinary spine research team has developed novel methodology to obtain patient-specific thoracic volumes from conventional orthogonal radiographs using open-source 3D graphics and animation software which has been validated to be accurate within 4% of CT scans. However this method proved to be lengthy (4-8 hours/model) so our team developed registration software to semi-automatically compute thoracic volumes cutting down processing time by half. Purpose: Computational thoracic volume modeling using investigator-developed registration software that interfaces with open source 3D graphics software (Blender©), to determine if TV increases with sequential lengthening in growing rod treatment for Early Onset Scoliosis patients. Material and Methods: A graphical interface software was developed to perform 3D reconstruction of the thorax from biplanar xrays and automatically calculate thoracic volume in Blender©. Software converted registered points on the biplanar xrays to a 3D model. Thoracic volume was calculated from 2 sequential PA and lateral thoracic xrays preop and post-GR lengthening. TV was correlated with T1-T12 height and Cobb angle respectively. Results: 4 EOS patients (2 boys, 2 girls) were aged 6, 6, 1 and 10 years before surgery. There was a substantial increase in TV from baseline by 9.6, 26.7, 5.4 and 5.6% then by 26.8, 53.6, 20.8 and 26.9% respectively in two selected Lengthening Procedures. There was a significant correlation between TV and T1-T12 height (r = 0.94; P < .01) but no significant correlation with Cobb angle (12-78 degrees). Conclusion: GR treatment for EOS substantially contributes to TV increase from 10% to 27% as the child grows based on a semi-automated computational model. Other contributing factors in a growing child most likely play a role in thoracic development; thus clinical correlation studies with larger samples are recommended., Introduction: The surgical correction of severe sagittal spine imbalance is often the only way to release patients’ back pain and to improve their quality of life. Pedicle subtraction osteotomy (PSO) has become the procedure of election for a variety of diseases, demonstrating high potential for sagittal correction (up to 40°) and long-term fusion upon instrumentation with posterior fixation and anterior interbody cages. However, PSO is related to frequent post-operative complications, in particular rod breakage (rate 16%-39%) and nonunion (12%-31%).1-3 The prevention of these phenomena traditionally passes through a trial-and-error approach based on surgeons’ experience rather than on a clear understanding of the biomechanical implications of the adopted hardware configuration.1-5 The aim of the study is, therefore, to study the biomechanics of alternative scenarios related to the instrumentation of a destabilized spine segment after PSO at lumbar level. Alternative 2-rods, 3-rods and 4-rods configurations are compared, discussing the usage of accessory (connected to primary rod) or satellite (independently anchored) rods and of interbody cages adjacent to the osteotomy. Material and Methods: A lumbar finite element model of a patient with flat-back was developed and validated.7 PSO leading to an overall lordosis correction of 30° was reproduced at L3. Different hardware configurations useful to treat the destabilization following PSO and inspired to the current clinical literature were compared: a simple 2-primary-rod configuration, 2-rods + 1 accessory rod, 2-rods + 1 satellite rods, 2-rods + 2 accessory rods, 2-rods + 2 satellite rods.2 The usage of interbody cages adjacent to PSO level was also studied. Standing condition (compressive force of 500 N along the spinal curvature) and superposed bending moments of ±7.5 Nm in flexion-extension, lateral bending and axial rotation were simulated. The range of motion (ROM), the stress/loads acting on the spinal rod and the force transmitted anteriorly on the osteotomy rims and posteriorly on the instrumentation were calculated and compared across different scenarios. Results: A significant ROM reduction, but comparable across different scenarios, was found for all the models with respect to the intact state. Using additional rods (2-rods vs. 3-rods vs. 4-rods) gradually increases the loads on the posterior instrumentation, while reducing the local stress on the spinal rods at the osteotomy level and the load transmitted through the anterior spine. As concerns the secondary rods technique, using 2 satellite rods decreases the stress on the primary rods more than using accessory rods. 4-rods configurations supplemented with interbody cages above and below the osteotomy level leads to the lowest stress and loads on the posterior instrumentation, while increasing the loads on the anterior spine. Conclusion: Hardware configuration greatly influences the biomechanics of a PSO-destabilized segment. The usage of secondary rods and interbody cages can effectively reduce the loads on the instrumentation, being beneficial to reduce rod breakage and avoid nonunion in clinical practice. Our findings provide a clear and detailed biomechanical insight of the clinical experience related on the instrumentation of PSO.2,6 References 1. Luca A, Lovi A, Galbusera F, Brayda-Bruno M. Revision surgery after PSO failure with rod breakage: a comparison of different techniques. Eur Spine J. (2014) 23 (Suppl 6): S610–S615. 2. Smith JS, Shaffrey E, Klineberg E, Shaffrey CI, Lafage V, Schwab FJ, Protopsaltis T, Scheer JK, Mundis GM Jr, Fu KM, Gupta MC, Hostin R, Deviren V, Kebaish K, Hart R, Burton DC, Line B, Bess S, Ames CP; International Spine Study Group. Prospective multicenter assessment of risk factors for rod fracture following surgery for adult spinal deformity. J Neurosurg Spine. 2014 Dec;21(6):994-1003 3. Smith JS, Shaffrey CI, Ames CP, Demakakos J, Fu KM, Keshavarzi S, Li CM, Deviren V, Schwab FJ, Lafage V, Bess S; International Spine Study Group. Assessment of symptomatic rod fracture after posterior instrumented fusion for adult spinal deformity. Neurosurgery. 2012 Oct;71(4):862-7. 4. Berjano P, Bassani R, Casero G, Sinigaglia A, Cecchinato R, Lamartina C. Failures and revisions in surgery for sagittal imbalance: analysis of factors influencing failure. Eur Spine J (2013) 22 (Suppl 6): S853–S858. 5. Scheer JK1, Tang JA, Deviren V, Buckley JM, Pekmezci M, McClellan RT, Ames CP. Biomechanical analysis of revision strategies for rod fracture in pedicle subtraction osteotomy. Neurosurgery. 2011 Jul;69(1):164-72. 6. International Spine Study Group et al. Reducing rod breakage and nonunion in pedicle subtraction osteotomy: the importance of rod number and configuration in 264 patients with 2-year follow-up. Proceedings of the NASS 30th Annual Meeting / The Spine Journal 15 (2015) 87S–267 S. 7. Ottardi C, Galbusera F, Luca A, Prosdocimo L, Sasso M, Brayda-Bruno M, Villa T. Finite element analysis of the lumbar destabilization following pedicle subtraction osteotomy. Med Eng Phys. 2016 May;38(5):506-9., Introduction: Adult spinal deformity (ASD) consists of coronal and sagittal spinal misalignment. These severe deformities change the entire trunk shape. As a consequence, the shape of the abdomen is modified. Xipho-pubic angle (XPA) was used, in a previous study, as a measurement of anterior abdominal wall fascial lengthening after spinal sagittal correction. The aim of our study is to demonstrate the relationship of sagittal spinal deformity to the shape of the abdomen and to evaluate the association between parameters of abdominal deformity and sagittal alignment measures and the related clinical outcomes. Material and Methods: Cohort retrospective multi-center study (International Spine Study Group database). The population, stratified in three groups (“A”, “B” and “C”) according to XPA cut-off values (103° and 113°), was compared in terms of Xypho-pubic distance (XPd), sagittal spinal parameters and health-related quality of life score (HRQoL). Patients demographics included age, gender, body mass index (BMI), patients’ reported outcomes (PRO) (Oswestry Disability Index -ODI-, the Scoliosis Research Society-22 Patient Questionnaire -SRS-22r-, Short Form-36 -SF-36- Mental -MCS- and Physical -PCS- Component Scores. Results: A total of 278 patients with a mean age 57.67± 13.39, BMI of 26.58 ± 5.15 and 85.9% of females were included in the study. Of the 278 patients, 83 (29.9%) had XPA ≥ 113° (group “A”), 63 (22.7%) had XPA between 103,01° – 113° (group “B”) and 132 (47.5%) with a value of XPA < 103° (group “C”). Differences statistically significant were found comparing the three groups in term of XPd (all, P < .01), sagittal spinal parameters (PI-LL, PT and SVA: all, p < 0.01), and HRQoL (ODI, SF-36 PSC and SRS Activity: all, P < .05). In particular patients with lower degree of XPA were associated with greater sagittal deformities, poorer health status and shorter XPd. Conclusion: Spinal deformity clearly affects the abdominal cavity configuration in term of xipho-pubic distance. Furthermore, XPA is parameter strongly related with XPd, sagittal spino-pelvic parameters and HRQoL scores. The regression analysis shows that XPA of 113º is correlated with ODI of 20 and defining this cut-off value as indicator of minimal disability., Introduction: The occurrence of Golden ratio or Phi number has been observed in several aspects of the nature. In the human body, several examples of Golden proportion have been documented such as face and dental geometry, extremity and hand fingers bone length proportion, cardiac cycle sequences and DNA gene-coding region sequences, as to mention just a few of them. The pathogenesis of idiopathic scoliosis has so far remained elusive and purely understood despite decades of dedicated research into its origin. Over the years, practically every structure of the body has been incriminated from the collagen-type of the back muscles to the deep centers of the central nervous system, from the melatonin levels to genetically induced disorder. Despite all these efforts, however, no single cause of this intriguing disorder has been defined and, frequently, it has been difficult to distinguish causative factors from those that may result from the condition. Material and Methods: A consecutive search of vertebral column images from two different hospital radiology databases was done ranging from January 2012 to December 2015. Female and male subjects were included into the search with the upper cut-off age of 55 years. The measurements included the height of the anterior and posterior aspects of the vertebral bodies and the diagonal line connecting the posterior-superior corner with the anterior-inferior corner of the vertebral body. The images were viewed and measured on the hospital database using on-site DICOM image viewer. The measurement of the proportion was calculated by dividing the anterior-inferior corner to posterior-superior corner distance with the mean value of the sum of anterior and posterior vertebral height. The study included images from 464 individuals for a total of 1112 vertebras measured (232 thoracic and 878 lumbar) that were divided in three different groups by age and scoliosis pathology: Young non-scoliosis subjects, Adult non-scoliosis subjects and Scoliosis subjects (young and adult) for 30, 334 and 100 subjects in each group, respectively. Inter- and intra-observer reliability checking was done for the measurements of reliability validation. Results: The initial theoretical hypothesis of this study was the idea that a φ or golden proportion number (1618) could exist in the morphometric proportions of the vertebra as seen on the lateral X-ray images. This study confirmed this hypothesis showing that the mean of the sum of the thoracic and lumbar vertebral bodies, 1.599, did fall into a tolerance range of acceptance of 1.17% from the golden proportion validity range. However, while performing the study, an interesting, collateral observation was found. A significant and steady difference was observed in the proportional values of the vertebras of individuals affected with idiopathic scoliosis as compared to individuals not suffering this pathological condition. The mean proportional value for the vertebras measured in individuals affected with idiopathic scoliosis was found to be 1.494 that was 6.7% less than the values of the non-scoliotic patients and 7.7% less than the φ value. And that was true for both adult and young patients, indifferently. Conclusion: The authors do recognize, being vertebrae a tri dimensional object, that there are many lines one can play with and, finally, will be able to find a golden proportion correspondence. Consequently, we do not state that the vertebra has a shape or measures such as to be surely classified in the golden proportion objects category, however, it is our opinion that the proximity to the φ number can be regarded as extremely high. We do, however, state that we have found a steady proportion, that can be easily calculated on lateral X-ray images, that shows a significant change between the vertebrae of the individuals not affected and those affected by idiopathic scoliosis. What might be the anatomical or pathological significance of these different values is probably still to be defined. The personal opinion of the authors of this study can be condensed in two main thoughts: the first one is that this proportional difference could be an easily accessible clinical tool to differentiate those individuals at risk of developing idiopathic scoliosis and the second, more futuristic idea, is that the different proportional shape of single rectangular elements forming an erect chain might have a different stability pattern, potentially explaining why the spine tends to curve developing scoliosis, a disease whose origin is still lacking a definitive understanding., Introduction: The number of spine surgeries is on increasing trend over the recent past, few of the reasons being rise in technologies and number of surgeons performing spinal surgeries. But how far the surgeon’s health is affected in the process is not clearly understood. Forward head posture (FHP) is a clinical entity leading to neck pain which is regularly affecting the younger generation due to the usage of smart phones. FHP can also affect the spine surgeons over the period. Material and Methods: Prospective study conducted at our institute on 3 spine surgeons with different experience levels. Running video of the surgery was recorded at an angle perpendicular to the operative field. Palpable C7 spinous process was marked on the surgeon’s neck pre-operatively. Post operatively all the videos involving three surgeons were analysed. Duration of the whole surgery was divided into different phases (exposure, fixation, decompression, fusion, closure). Time taken for different phases in the surgery was also noted. Snapshots of the video were taken whenever the surgeon changes his position and using surgimap version 2.2.9.9.4 all images were calibrated. Head flexion angle(HFA), neck flexion angle (NFA), cranio-vertebral angle (CVA) along with average load on spine during the surgery of all the three surgeons were calculated. Results: The height of the surgeons was 184 cm, 178 cm, 170 cm. On an average, HFA of the surgeon remained around 140 degrees for all the phases. NFA ranges from 70-90 degrees with highest being for the tallest surgeon. CVA remained less than 15 degrees in all phases for the entire surgery part. The distance between center of ear to center of the shoulder blades was ranging between 80.47 mm to 204.65 mm. Duration for exposure is 40 ± 5.3 min, fixation (each screw) is 6 ± 3.5 min, decompression (each level) is 10 ± 3 min and for closure is 15 ± 6.4 min. Average load on spine has been more than 60 pounds at all times during the surgery. Conclusion: When the neck stays in such a position on a daily basis, there is a huge pressure on the surgeon’s neck making it highly vulnerable. Based on the above study we propose an entity called surgeons neck syndrome affecting the spine surgeons who are at risk of aggravating the degenerative pathology over the years., Introduction: Full comprehension of spinal pathologies and treatment strategies cannot be achieved without an understanding of the underlying spinal vertebral biomechanics. This is achieved by understanding the biomechanics in a normal subject and then assessing how the particular pathology has caused a deviation from normal.1,2 The intervertebral foramen (IVF) have fixed boundaries though its dimensions vary depending on the height of the individual disc spaces.3 Changes to the disc morphology can therefore cause reduced IVF diameters.4 The aim of this study is to identify the variations in area of the intervertebral disc (IVD) and the intervertebral foramen (IVF) during low trunk rotation in healthy volunteers. This will provide normal variant data and further our understanding on the effect of lumbar spine rotation on neural compression and the patho-biomechanics of low back pain. Material and Methods: Study Design: In vivo Kinematic MRI study of the changes in the dimensions of the Lumbar Intervertebral Discs and Neural Foramens during trunk rotation. Ten healthy male volunteers aged 20-30 years old with no history of spinal pathology were recruited. Each volunteer underwent an MRI scan of the lumbar spine in three positions; neutral, right lateral rotation and left lateral rotation. All volunteers provided written consent and ethical approval was obtained. The Sagittal T2 weighted images were used to assess the intervertebral foramen and intervertebral discs of the volunteers at the L3/L4, L4/L5 and L5/S1 intervertebral level. Image J software magnified the images x600 in order to manually outline the boundaries of the IVF, parasagittal disc (PSD) and midsagittal disc (MSD). These images were then used to calculate the area, width and height of these structures in the neutral, right lateral and left lateral position. Results: This study has shown that the area, height and width of the intervertebral foramen and intervertebral discs at L3/L4, L4/L5, and L5/S1 alter significantly in response to left and right lateral rotation of the lumbar spine as compared to the neutral position. During rotation the area and width of the IVF of L3/L4 and L4/L5 decrease on the rotated side (P < .005). The IVF height of L3/L4 also decreases whereas the height of L4/L5 increases (P < .005). The IVF area, width and height of L5/S1 increase on the rotated side. Reciprocal changes were seen at the IVF on the opposite side. Rotation significantly reduced the parasagittal intervertebral disc area at all levels and on both sides (P < .005). On the rotation side there was an associated increase in the intervertebral disc height at L3/L4 and an increase in width at both L3/L4 and L4/L5 (P < .005). Conclusion: Rotation of the lower trunk caused morphologic changes in the intervertebral discs and intervertebral foramens at the L3/L4, L4/L5, and L5/S1 levels. This provides us with normal variant data and furthers our understanding on the treatment benefits of manipulation therapy in spinal conditions. References 1. Fujimori T, Iwasaki M, Nagamoto Y, Ishii T, Masafumi K, Murase T, Sugiura T, Matsuo Y, Sugamoto K, Yoshikawa H. Kinematics of the thoracic spine in trunk rotation. Spine. 2012:37(21): E1318-E1325. 2. Fujii R, Sakaura H, Mukai Y, Hosono N, Ishii T, Iwasaki M, Yoshikawa H, Sugamoto K. Kinematics of the lumbar spine in trunk rotation: in vivo three-dimensional analysis using magnetic resonance imaging. Eur Spine J. 2007:16(11):1867-1874. 3. Crock HV. Normal and pathological anatomy of the lumbar spinal nerve root canals. J Bone Joint Surg Br. 1981;63B(4):487-490. 4. Fujiwara A, An HS, Lim T, Haughton VM. Morphologic changes in the lumbar intervertebral foramen due to flexion-extension, lateral bending, and axial rotation: an in Vitro Anatomic and Biomechanical Study. Spine. 2001;26(8):876-882., Introduction: No study to date has considered the curve pattern in terms of the Lenke classification during evaluation of cervical sagittal balance. In the present study, we sought to correlate curve patterns with cervical sagittal parameters in adolescent patients with idiopathic scoliosis. Materials and Methods: This was a cross-sectional, retrospective descriptive study. We collected information from medical records and evaluated lateral panoramic X-rays of 49 scoliosis patients. Data were quantitatively evaluated using the Cobb of C2-C7, the distance from the head center of gravity to C7, the T1 slope and the thoracic inlet angle, neck tilt, C7-S1 SVA, principal curve angle, the proximal Cobb thoracic curve, the Cobb thoracolumbar/lumbar curve, and kyphosis at T1-T12. All results were tabulated and statistically analyzed to objectively evaluate the relationship between thoracic spinal alignment in the sagittal plane and cervical sagittal balance. The significance level was set to 5%. Results: The T1 slope differed significantly among the various kyphosis sagittal modifiers (P < .05); this parameter clearly varied by the type of modifier. Inverse correlations were evident between the T1-T12 kyphotic index and the Cobb C2-C7; and between the T1 slope and the Cobb C2-C7. Both relationships had r values > 0 and P values < .05. Conclusions: The cervical lordosis values were lower than the normal values described in the literature, suggesting loss of cervical sagittal lordosis in our patients. The T1 slope was significantly associated with changes in sagittal alignment, and varied by the curve type and the sagittal modifiers in play., Introduction: Although three-column osteotomy (3CO; pedicle subtraction osteotomy [PSO] or vertebral column resection [VCR]) can provide powerful alignment correction and disability improvement in adult cervical deformity (ACD), these procedures are complex and associated with high complication rates. Previous reports on complications associated with 3CO for ACD have been primarily based on retrospective complication collection, which may substantially underestimate the true rates. Our objective was to provide a prospective assessment of cervical alignment improvement and complications in ACD patients treated with 3CO. Materials and Methods: Although three-column osteotomy (3CO; pedicle subtraction osteotomy [PSO] or vertebral column resection [VCR]) can provide powerful alignment correction and disability improvement in adult cervical deformity (ACD), these procedures are complex and associated with high complication rates. Previous reports on complications associated with 3CO for ACD have been primarily based on retrospective complication collection, which may substantially underestimate the true rates. Our objective was to provide a prospective assessment of cervical alignment improvement and complications in ACD patients treated with 3CO. Results: All 24 ACD patients treated with 3CO (15 PSO/9 VCR) achieved minimum 90-day follow-up (71% women, mean age 62 years, previous surgery in 54%). Diagnoses included: cervical sagittal imbalance (92%), cervical kyphosis (38%), proximal junctional kyphosis (17%), coronal deformity (8%) and distal junctional kyphosis (4%). The mean number of posterior fusion levels was 13, and 4% also had an anterior fusion. The most common 3CO levels were T1 (38%), T2 (29%) and T3 (21%). A total of 25 (19 major/6 minor) complications were reported, with 14 (58%) and 6 (25%) patients affected, respectively. Overall, 17 (71%) patients had at least one complication. The most common complications were excessive blood loss (>1.7 L, 25%), neurologic deficit (17%), distal junctional kyphosis (DJK, 8%), wound infection (13%), and cardiorespiratory failure (8%). Four (17%) patients required re-operation within 90-days (2 for nerve root motor deficit, 1 deep wound infection, 1 implant pain/prominence). Cervical sagittal alignment improved significantly following 3CO: cervical lordosis (CL, 3° to 13°, P = .031), C2-7 sagittal vertical axis (66 mm to 44 mm, P < .001), and T1 slope minus CL (46° to 27°, P < .001). Conclusions: Among 24 ACD patients treated with 3CO, cervical sagittal alignment improved significantly following surgery. Overall, 17 (71%) patients had at least one complication (19 major/6 minor). The most common complications were excessive blood loss (>1.7 L), neurologic deficit, DJK, wound infection, and cardiorespiratory failure. Future research focused on reducing these complications may present the greatest opportunities for safety and cost improvements for these procedures., Introduction: Despite the potential for profound impact of adult cervical deformity (ACD) on function and health-related quality of life, there remains a paucity of high-quality studies that assess outcomes of surgical treatment for these patients. Our objective was to assess outcomes following surgical treatment for ACD based on a prospective multicenter consecutive case series. Materials and Methods: Surgically treated ACD patients eligible for 1-year follow-up were identified from a prospectively collected multicenter database. Baseline deformity characteristics, surgical parameters, and 1-year outcomes were assessed. Standardized outcome measures included: Neck Disability Index (NDI, range 0-100), neck pain numeric rating scale (NRS) score (range 0-10), and EQ-5D index (range 0 -1) and subscores (range 1-3). Paired sample t-tests were used to compare 1-year and baseline measures. Results: Of 77 ACD patients, 55 (71%) had 1-year follow-up (64% women, mean age 61 years, mean Charlson Comorbidity Index [CCI] of 0.6, previous cervical surgery in 44%). Diagnoses included: cervical sagittal imbalance (62%), cervical kyphosis (60%), proximal junctional kyphosis (8%), and coronal deformity (10%). Posterior fusion was performed in 85% (mean number of vertebral levels=10), and anterior fusion was performed in 29% (mean number of vertebral levels = 5). Three-column osteotomy was performed in 24% of patients. Mean operative time was 6.5 hours and mean estimated blood loss was 0.9 L. At 1-year following surgery, ACD patients had significant improvement in NDI (50.5 to 38.0, P < .001), neck pain NRS (6.9 to 4.3, P < .001), EQ-5D index (0.51 to 0.66, P < .001), and EQ-5D subscores: mobility (1.9 to 1.7, P = .019), usual activities (2.2 to 1.9, P = .007), pain/discomfort (2.4 to 2.1, P < .001), anxiety/depression (1.8 to 1.5, P = .014). A nonsignificant trend favoring improvement was observed for EQ-5D self-care (1.5 to 1.3, P = .070). Compared with patients that achieved 1-year follow-up, those lost to follow-up did not differ significantly with regard to age, gender, CCI, number of fused anterior or posterior vertebral levels, or baseline NDI, neck pain NRS, or EQ-5D scores. Conclusions: Based on a prospective multicenter series of adults with cervical deformity, surgical treatment provided significant improvement in multiple measures of pain and function, including the NDI, neck pain NRS score, and EQ-5D. Further follow-up will be necessary to assess the durability of these surgical procedures and the resulting improved outcomes., Introduction: The understanding of normative values of the radiographic parameters is important for the understanding of spinal deformity and for the establishment of radiographic thresholds in the setting of sagittal realignment surgeries. In the setting of adult spinal deformity, recent literature has demonstrated the role of the cervical alignment on the context of global spinal deformity. However, the vast majority of data about cervical alignment were based solely on a homogeneous North-American cohort, not taking into account the diversity in age, ethnicity, and geographic locales. The aim of this study is to investigate the normative values and chain of correlations across cervical sagittal parameters in a Brazilian population sample. Material and Methods: This is a prospective observational study including adult asymptomatic subjects who underwent full spine radiographs. The subjects were stratified by age into 3 groups (18-39 y/o, 40-59 y/o, and ≥ 60 y/o) and radiographic parameters were compared across age groups, using ANOVA, and gender, using student t-tests. The relationships across various radiographic parameters were calculated by the Pearson product-member correlation coefficients. A significance level of p < 0.05 was adopted. Results: 130 asymptomatic volunteers (mean 48y) met the inclusion criteria and were evaluated. The mean and range of cervical sagittal parameters in normative Brazilian population were identified. Subjects ≥ 60 y/o had significantly higher values for C7-SVA (P = .024) than the two younger age groups. Cervical Lordosis (CL) presented negative correlation with CSVA (r = -0.182; P = .038) and positive correlation with T1-Slope (r = 0.425; P < .001). A significant positive correlation occurred between C7-SVA and T1-Slope (r = 0.335; P < .001), between CSVA and T1-Slope (r = 0.445; P < .001) and between CSVA and T1-Slope minus CL (r = 0.480; P < .001). Multilinear regression analysis applied to predict the CSVA identified the CL and T1-Slope playing a significant influence in the CSVA (P < .001) and leading to the predictive formula: CSVA= -0,434xCL + 0,968xT1-Slope. Conclusion: This study is the first to describe normative values of cervical sagittal parameters in Brazilian population. The chain of correlation between these parameters was confirmed. The CSVA can be predicted by two different postural parameters, Cervical Lordosis and the T1-Slope., Introduction: Spondylolysis in the cervical spine is a rare condition. Only few cases were reported in the literature. Its association with osteopetrosis has been described by some authors but remains exceptional; it is most often indicative of the disease. We presented the case of a cervical spondylosis in a patient with osteopetrosis. Methods: We reported the case of a 20 year-old woman, followed for a left femur stress fracture on osteopetrosis treated conservatively, which consults for bilateral cervicobrachial Neuralgia following accidental hyperextension of the cervical spine. The clinical examination found a paravertebral muscular contracture, associated with painful upper cervical spines spinous processes on palpation. Neurological examination was normal. Radiological assessment by AP and lateral X-rays and a CT scan showed a C2 spondylolysis. In the absence of signs of instability on dynamic X-rays, the patient was treated conservatively. Results: At a 2 years follow-up, there was no signs of cervical instability with the persistence of an intermittent neck pain. Conclusions: Spondylolysis with or without spondylolisthesis is rare in the cervical spine. It was reported for the first time by perlman in 1951 which was described as a defect of the pars interarticularis, in the junction between the upper and lower articular processes. The presence of these lesions in patients suffering from osteopetrosis was recognized by suziki and szapanos since the eighty’s. The cause of this spondylolysis remains controversial with congenital theory based on the association of embryonic developmental abnormalities in these newborns, however autopsies of patients did not reveal spondylolysis. Only a dozen cases have been reported in the literature. In a series of seven patients published in 1998 by martin only two had a cervical spondylolysis and a case reported a multiple locations spondylolysis. Clinically, the lesion is usually asymptomatic. It’s found incidentally on cervical X-rays after a benign trauma. Treatment can be sufficient with a cervical collar but this treatment can be considered only if there is no signs of instability on dynamic X-rays of the cervical spine, as in our case. A case of posterior C1-C4 fusion has been reported in the series of Martin but with an evolution towards nonunion after a two years follow-up. Osteopetrosis should be recognized as a cause of pathological spondylosis that may affect the cervical or lumbar spine, especially in children. Orthopedic treatment represent a successful option when there is no signs of instability associated., Introduction: The goal of our study was to determine the incidence of adjacent segment level pathology preoperatively in patients with Klippel-Feil syndrome (KFS) and compare it to the incidence in patients who have undergone anterior cervical discectomy and fusion. Secondarily, we hypothesized that patients with KFS and anterolisthesis would be more likely to develop symptomatic and radiological adjacent segment level disease. Methods: Twenty patients with Klippel-Feil syndrome from a single institution were followed for X years. Serial imaging and follow-up (serial visits) were used to determine adjacent segment level disease. Patients were separated in two categories: those with anterolisthesis adjacent to their congenitally fused segments and those without. Results: Twenty patients with an average age of 9.5 yrs were identified. The average follow-up period was 33 months; range 4-108 months. Nineteen patients received a diagnosis of KFS during incidental imaging. One patient was diagnosed as part of a workup for myelopathy caused by a disc herniation adjacent to two fused segments. Eight patients had no listhesis in cervical levels adjacent to fused vertebral segments while 12 had listhesis. The two most common levels of listhesis were at C3-C4 and C4-C5 (five patients each). Five patients in the listhesis group had an increase in listhesis through the follow-up period. There were no differences in the development of symptoms between patients who had and did not have listhesis. All non-operative patients were asymptomatic at last follow-up. Conclusion: Our follow-up was limited, but this study does not support the assumption that a congenitally fused segment predisposes a patient to a rate of adjacent segment level disease similar to patient who has undergone an anterior cervical discectomy and fusion. We found no increased risk of symptomatic adjacent segment level disease in KFS patients who had anterolisthesis adjacent to a congenitally fused segment., Introduction: Wry neck or loxia which is a systolic condition can be known as a fixed or dynamic tilt, rotation or flexion of head and neck which was defined by Tubby in 1912. It can be classified due to the position of head and neck in to; laterocollis, rotational torticollis, retrocollis. As a whole it can be typed to congenital, acquired and spasmotic. Muscular fibrosis, congenital spine abnormalities or toxic and traumatic brain injury are some conditions which can lead to this problem. Basically, the cause of congenital torticollis is unknown. The most problematic part is sternocleidomastoid which is shorter than usual or excessive contracted can lead to both limited rotation and lateral bending. The incidence of congenital torticollis is 0.3-2%. Both males and females are equally affected and no racial preference is seen, and no worldwide geographical restriction is noted. First line of treatment at a very young age is physical therapy by stretching and strengthening to improve the muscle, but most of the cases require surgical intervention to release the muscle with better result in ages 1-4. Around 80-90% of CMTs are also associated with skull distortion causing craniofacial asymmetry, and between 10-20% of the cases with hip joint malformations. Although assymetry is one of the most common condition in these patienst, little is known about craniofacial assymetry prevalenc and its changes due to aging. After occurance of permanent deformity like plagiocephaly and hemihypoplasia, and even without potential of growth and remodeling, opperative treatment may of little value. We report a 24 year old girl with neglected torticollis with her postoperative results. Case Report: A 24-year-old girl suffered from congenital torticollis was examined. She had asymmetry in her face and maxillofacial complex. She had crossbite and posterior openbite which makes some problems in masticatory muscles unilaterally. Results: Clinical manifestations in an adult patient suffered from congenital torticollis. Conclusion: Postoperation better results can be achieved maxillofacial deformities were considered. Physiotherapy for this part and treatments for tempromandibular joint could be useful to have more stable results., Introduction: The Fallen Head Syndrome (Dropped Head Syndrome [DHS]) is a little condition described in the literature, relatively rare. It has epidemiological data linked to specific diseases, but not in general. It can affect patients of any age but predominantly in the elderly, in a ratio of 3:2 between men and women. It has several etiologies including myopathies, neuropathies, joint diseases neuromuscular, metabolic and neurological. Its pathophysiology is also not well understood, it is believed to be caused by weakness of the extensor muscles of the neck contracture of the flexor muscles or a combination of these changes. When no underlying pathology can be diagnosed, receive the name Isolated myopathy Neck Stretcher (isolated neck extensor myopathy [INEM]). The case in question it is young patient underwent surgical treatment scoliosis, who left outpatient treatment after consultation return, evolving, after about a year and a half, with DHS. Material and Methods: It is clinically examined the patient, applied to new radiographs, comparing with earlier; held review of medical records and literature, and register through photographs after signing the consent form. Results: With diagnosis of neuromuscular scoliosis, was submitted on 11 October 2014, surgical treatment for posterior approach of the thoracic and lumbar curves. Attends return visit on 27 October 2014, keeping postoperative evolution habitual. However interrupts outpatients, returning only on 23 June 2016. Nesta consultation showed deformity spinal flexion cervical (“chin on chest”). Surgical treatment in two stages: 1) Installation cervical traction halo; 2) cervical arthrodesis. The literature describes the DHS as a relatively rare condition that occurs predominately in patients elderly. In some cases you can identify a neurological underlying disease, inflationary or metabolic, with other associated systemic symptoms, such as example weakness of other muscle groups in addition to the neck extensors. Conclusion: The DHS is a condition associated with several etiologies, with significant impact on quality of life of patients. It takes effort to the scientific community elucidation of remaining knowledge gaps., Introduction: Concave apical pedicles in scoliosis are known to be narrow and dysplastic. Neural structures too, are known to migrate towards concavity. This leaves little room for error while inserting pedicle screws. Present study aimed to assess relative advantages of inserting concave apex screws vis-à-vis other constructs. Materials and Methods: This was a retrospective analysis of prospectively collected single-surgeon, single centre data. Patients (n = 61) undergoing scoliosis surgery from September 2004 to September 2013 were included. Exclusion criteria were pseudarthrosis, implant failure, kyphoscoliosis and postoperative infection. Curves were classified into two groups; group A-without screws anchoring concave apex and group B-with screws anchoring concave apex. Group A had varied constructs including some with sublaminar wires on concave apex and some with screws only on convex apex. Results: Based on inclusion-exclusion criteria, 86 individual curves in 59 patients were selected; group A (n = 54) and group B (n = 32). Both groups were comparable in terms of follow-up period, age, sex and etiology (idiopathic and nonidiopathic). However, group A had larger (79.8+25.20) and more rigid curves (28.6% flexibility) than group B (51.8+16.30 with 51.1% flexibility). Hence, immediate postoperative correction was less significant in group A (53.8%) vis-à-vis group B (65.8%) (2-tailed P = .0075). However, no statistically significant difference was noted between the two groups in terms of gains of instrumented correction over and above preoperative flexibility (group A-23.4%, group B-13.5%) (2-tailed P = .21). At a median follow-up of 12 months, loss of correction between the two groups (A:1.4%, B:7%) was not significantly different (2-tailed P = .06). No patient in either group had any neurological deterioration. Conclusions: Over a relatively short follow-up period, the present study could not demonstrate any gains in using apical concave pedicle screws. A larger, prospective, multicenter study with a longer follow-up may shed more light on the risk-benefit ratio., Introduction: Growth guiding instrumentation is the current and perspective option for early onset scoliosis (EOS) correction. The purpose of this study is to review 15 years results of growth guiding instrumentation in EOS patients. Methods: We retrospectively evaluated 55 EOS cases treated in a single clinical center with growth guiding implant developed by us, from the index surgery to the final fusion. Diagnosis were: infantile idiopathic scoliosis, juvenile idiopathic scoliosis, Congenital scoliosis, Spondyloepiphyseal dysplasia. Radiographs were reviewed for major and minor Cobb angles, thoracic kyphosis and lumbar lordosis. Mean growth of the instrumented spine and complication were recorded. Results: Complete clinical chart of 55 cases were available during the follow-up period. 43 patients underwent anterior convex epiphysiodesis and posterior growth guiding instrumentation. In remaining 12 patients transpedicular growing instrumentation utilized. Derotational maneuver used for the curve correction in all cases. Mean age at the index surgery was 9,8 years and at the final fusion it was 14,3 years. Major Cobb angle improved from 69,6 to 23,7, minor Cobb angle improved from 46,4 to 16,1. Preoperative thoracic kyphosis was 25,1 and changed to 29,1 after final fusion. Lumbar lordosis was 37,8 and 34,9 at the end of follow-up. Mean growth of the instrumented spine was 7,2 mm/year. The most common complications were proximal junction kyphosis (4 cases), upper anchor displacement (4 cases) with rod migration out of the upper anchors due to rapid spinal column growth (5 cases), loss of correction (3 cases) and rod breakage (1 case). Conclusion: Combination of anterior convex epiphysiodesis and posterior growth guiding instrumentation is reliable concept for the EOS correction and spinal column growth preservation. In selected cases, transpedicular growing instrumentation without anterior epiphysiodesis may be used. Postoperative complications were minor and manageable., Introduction: Use of all- pedicle screw instrumentation in adolescent idiopathic scoliosis surgical treatment allows to obtain significant improvement in clinical and radiographic results. Significant variability is reported in medical literature about the ideal screw density in order to obtain the optimal correction and its maintenance over time. Aim of the study was to evaluate the percentage of curve correction and its maintenance over time comparing low versus high pedicle screw density. Material and methods: From January 2012 to November 2015, a continuous series of 65 patients underwent to posterior correction and instrumented fusion. Inclusion criteria were: adolescent idiopathic scoliosis, age, Introduction: Despite recent studies that have investigated risk factors for postoperative shoulder balance, very few work has paid attention to how do surgery and postoperative compensation impact on shoulder balance, especially in severe and rigid scoliosis, and the related risk factors remain unclear. To study the effect of surgery and postoperative compensation on shoulder balance in severe and rigid scoliosis, a retrospective study was conducted. Material and Methods: The parameters of preoperative, postoperative, and minimum 2-year follow-up radiographs of 48 consecutive patients with severe and rigid scoliosis who underwent posterior spinal fusion surgery were evaluated. We regarded radiographic shoulder height (RSH) as shoulder balance parameter and divided the patients into improved and aggravated groups of shoulder balance after surgery and at follow-up. And also, patients were divided into 9 groups based on different kinds of changes of shoulder balance after surgery and at follow-up. These parameters were compared to analyze factors for shoulder balance among groups. Results: The average Cobb angle and flexibility of the main thoracic curve (MTC) were 107.4° ± 15.9° and 16.4% ± 10.2% before surgery. The RSH were -17.37 mm ± 21.94 mm before surgery, 1.74 mm ± 22.11 mm after surgery, and 4.61 mm ± 18.27 mm at follow-up. After surgery, the preoperative flexibility of proximal thoracic curve (PTC) and Cobb angle of lumbar curve (LC) were significantly greater in the group of patients with aggravated shoulder balance. The improved shoulder balance group had significantly larger correction rate of the MTC and smaller correction rate ratio of the PTC to the MTC than the aggravated group after surgery. At follow-up, the flexibility of the PTC, and the correction rate ratio of the PTC to the MTC and the PTC to the LC, were significantly greater in the improved group. The aggravated group had larger correction rate of the LC and more distal adding-on than the improved group at follow-up. Conclusion: In severe and rigid scoliosis, the appropriate collocation of correction rates of the PTC, the MTC and the LC is very important for surgeons to make good correction of the shoulder imbalance at surgery and to maintain the shoulder balance at follow-up., Introduction: Spinal deformity correction surgery has been one of the most challenging procedure in spine surgery with high incidence of intro-operative complications. In order to decrease the rate of complication or prevent the complication, a retrospective study was conducted to analyze the risk factors of major complications after spinal deformity surgery. Methods: Between January 2011 and December 2014, 254 consecutive patients undergone spinal deformity surgery in our department were divided into two groups based on if they had major complications after surgery. Univariate and multivariate analysis (logistic regression) were used to identify the risk factors. Results: 29 patients had major complications after surgery. Univariate risk factors showed that Medical history, previous Scoliosis operation history, Preoperative neurological injury, the vertebral number of major Curve, Cobb of major curve, Kyphosis (>90 degree), Time of operation, Operative bleeding and osteotomy of group I were higher or longer than those of group II. VC MAX% and Orthopedic rate of group I were worse than those of group II. Logistic regression identified that Preoperative nerve injury(OR = 5.976); Medical history >10 years(OR = 4.095); Maximal voluntary ventilation observed/predicted5 h (OR = 3.510); osteotomy(OR = 3.472)were final risk factors for major complications. Conclusions: Major complications after surgery to treat spinal deformity can be predicted through preoperative nerve injury, medical history, maximal voluntary ventilation observed/predicted. Time of operation and osteotomy during the surgery. The patients with these risk factors need more preoperative care and postoperative care to reduce the occurrence of major complications., Introduction: Multiple techniques are utilized for distal fixation in patients with neuromuscular scoliosis. Although there is evidence of benefits with the S2-Iliac fixation technique, this remains controversial. The objective of this study is to evaluate the radiological outcomes and complications associated with this surgical technique in a pediatric population. Material and Methods: An observational retrospective case series study was designed. All pediatric patients between January 2011 and February 2014 diagnosed with neuromuscular scoliosis associated with pelvic obliquity, which required surgery with fixation unto S2-Iliac, were included. Clinical and radiological findings and complications were presented with measures of central tendency. Comparison of deformity correction was carried out using a non-parametric analysis for related samples (Wilcoxon signed-rank test). Significance set at P < .05. Results: A total of 31 patients diagnosed with neuromuscular scoliosis that met inclusion criteria were analyzed. The leading cause of neuromuscular scoliosis in 23 (74.2%) patients was spastic cerebral palsy. The correction of pelvic obliquity in the immediate postoperative period was of 76%, which is statistically significant. The extent of correction that patients maintained at the end of the follow-up was analyzed, and it was found that there were no significant differences in this magnitude, compared with the immediate postoperative pelvic obliquity; the Mean follow-up time was 9 ± 7 months. Regarding postoperative adverse events, occurred in 71% of patients, the most common outcome was pneumonia (21.2%). The overall rate of complications related to instrumentation was low (2.6%), that corresponds to one patient with an intra-articular screw in the left hip that required repositioning. Conclusion: S2-Iliac fixation for the treatment of neuromuscular scoliosis is a safe alternative, in which the onset of adverse events is related to the comorbidities of patients instead of the surgical procedure itself. An approximate correction of 76% of pelvic obliquity is maintained during the follow-up., Introduction: Selective fusion of thoracic and thoracolumbar/lumbar curves in adolescent idiopathic scoliosis is a concept critically debated in the literature. Our purpose of this study to evaluate efficacy of selective fusion criteria in Lenke 1C and 5C curves. Material and Methods: We analysed the prospective collected data of 22 adolescent idiopathic scoliosis operated at our institute from 2011 to 2015 with mean follow up of 2.4 years. Decision regarding selective fusion was taken based on preoperative radiological parameters. Apical vertebral translation, apical vertebral rotation, cobb angle ratio and kyphosis at different sagittal regions of spine measured and analysed. Patients were selected for selective fusion on the basis of criteria in literature for selective fusion and patient’s guardian informed consent. Radiological parameters like correction of cob angle, coronal decompensation, adding on, and junctional kyphosis were recorded during follow up. Functional outcome were measured with SRS-22 score. Results: 22 adolescent idiopathic scoliosis with mean age of 15.4 years and 20 patients were females. 14 patients were of Lenke 1C and 8 patients of Lenke 5C curves. Mean major Cobb’s angle was 67.4 degree and compensatory curve was 40.1 degree and final correction to 18.5 degree for major curve (72.5% correction)and 22.6 degree for compensatory curve(43.6% correction). Cobb correction was maintained during the follow up. One patient with coronal decompensation of 2.4 cm and junction kyphosis of 4 degree noted another one patient. None of them required revision surgery (no adding on). SRS-22 postoperative outcomes showed mean final score of 4.26. Conclusion: Selective fusion can be possible with careful study of preoperative x-rays. Larger prospective multicentre cohort is required for better understanding of selective fusion in scoliosis. Comprehensive selection criteria and patient acceptability are the major concerns of the selective fusion in scoliosis., Introduction: Neuromuscular scoliosis surgery, compared to idiopathic scoliosis, associates with a higher rate of complications such as infection and intraoperative bleeding. The objectives of this study are to evaluate short and mid-term outcomes of the surgical treatment of neuromuscular scoliosis. Material and Methods: A retrospective review of patients with neuromuscular scoliosis that underwent surgical treatment was conducted. We evaluated surgical technique, curve correction, early and late complications, reoperation rate and mortality. Results: A total of 33 patients (mean age 15 years, range 8-23 years) with neuromuscular scoliosis were treated surgically between 2013 and 2015. Most common diagnoses were cerebral palsy (30%) followed by Duchenne muscular dystrophy (12%). 72% of patients used brace previous to surgery. All surgeries consisted in a single posterior approach for posterolateral instrumented fusion. Pre and postoperative mean curve was 61 ± 23º and 18 ± 7º respectively. Mean surgical bleeding was 1216 ± 574 ml while surgical time was 271 ± 85 minutes. 54% of patients required intra and postoperative red blood cells transfusion. Average levels fused were 12 ± 2 and pedicular screw density was 78±12%. No intraoperative complications were reported. Eleven (33%) postoperative complications were reported and 81% were infectious type (36% surgical wound infections). With a mean follow-up of 305 ± 300 days, five patients required reoperation from whom four underwent surgical debridement because of wound infection. No deaths were seen. Conclusion: Surgical treatment of neuromuscular scoliosis is effective in deformity correction and balance restoration, however it is important to consider the high rate of complications associated., Introduction: Characteristic pelvic waddle gait has been described in high-grade spondylolisthesis in the past. To date, no study has been done to characterise gait pattern in high grade spondylolisthesis using modern 3D gait analysis. No study has been done to analyse change in gait, postoperatively in high grade spondylolisthesis using modern 3D gait analysis. Aim of this study was to carry out 3D gait analysis in high grade spondylolisthesis pre- and postoperatively to characterise gait pattern. Materials and Methods: This was a prospective interventional case series. Consecutive patients with high-grade (Meyerding grade 4) spondylolisthesis underwent pre and postoperative 3D gait analysis studies. Intervention carried out was posterior decompression + posterolateral instrumented fusion with partial reduction. Gait deviation index (GDI) score, Gait profile score (GPS) were used to analyse the gait. Common gait features in coronal, sagittal and transverse plane were noted pre operatively and compared to postoperative changes. Results: All 4 patients had Meyerding grade 4 spondylolisthesis pre operatively. Mean age at surgery was 14.5 years and all were female. Mean length of follow up was 25.75 months (range 19-33). Pre and postoperatively mean GDI score were 76.35 and 91.72. Mean pre- and postoperative right/left GPS were 10.33/9.16 and 7.75/6.85 respectively. All of them underwent posterior decompression + posterolateral instrumented fusion with partial reduction. Surgery achieved reduction to Meyerding grade 1 in all patients. Common preoperative features in coronal plane included pelvic obliquity and increased hip abduction. In sagittal plane, posterior pelvic tilt, reduced flexion of hip at initial contact, increased flexion of knee at initial contact, decreased extension of knee in stance, decreased second rocker in foot was noted. In transverse plane, increased external rotation of hips and foot progression angle. Postoperatively all sagittal parameters normalised. Hip abduction, hip external rotation, and external foot progression angle improved but did not return to normal. Conclusion: In high-grade spondylolisthesis common preoperative gait abnormalities in coronal, sagittal and transverse plane were identified giving rise to characteristic gait pattern. Gait abnormalities concern patients. Posterior decompression, posterolateral instrumented fusion and partial reduction normalised all sagittal gait parameters. Increase in walking velocity, step and stride length were noted post operatively., Introduction: Prune-belly syndrome (PBS) is a rare congenital syndrome characterized by three main features: a deficiency of abdominal wall musculature, urinary tract malformations and cryptorchidism. PBS predominantly affects boys with a recent reported incidence of 3.6-3.8 per 100,000 live male births. There is wide variation in disease severity; besides the genitourinary manifestations patients may also have gastrointestinal, orthopedic, and cardiopulmonary abnormalities. 50% to 65% of patients may develop an orthopedic abnormality, being the most common scoliosis (25%) followed by clubfoot (22%). Hypotheses have been made about the absence of abdominal wall musculature and the development of scoliosis. It is believed that intra-abdominal pressure plays an important role in the stabilization of the spine and absence of the anterior tension band to the axial skeleton may subsequently lead to imbalance of the muscles. In the current literature many studies have described the frequency of scoliosis associated with this syndrome rather than the treatment options. There is only one study in which two patients with scoliosis and with a tendency to lordosis underwent surgical correction with the technique of Galveston-Luque with a combined anterior and posterior approach. Material and Methods: Male, 12 years old with an ultrasound diagnosis of Prune Belly Syndrome, witha history of multiple surgical interventions that includes: bilateral orchidopexy, urinary tract reconstruction and abdominoplasty. Image studies display a scoliosis of 10º of Cobb angle and kyphosis between T10 to L2 of 39º. Operative treatment was indicated because of the magnitude, etiology and expected progression of the deformity with further growth. The patient underwent surgical correction with a posterior approach pedicle screw fixation technique from T5 to L3, an osteotomy was performed at the apex and allograft was used. No complications presented during the intervention or the hospitalization. The patient was discharge onday eight after surgery. On the first follow-up control he presented fine, with no complains. The radiographs showed a kyphosis T10 to L2 of 1º. Results: Five years after surgery the patient presents asymptomatic, with no neurological deficit, pain or any type of complications. Images show no migration or implant failure and correction is maintained with a kyphosis between T10 to L2 of 2º. Conclusion: Although in the literature Scoliosis or lordo-scoliosis are the most frequent orthopedic manifestation in PBS, in this patient the main deformity is a kyphosis showing the importance of the abdominal wall musculature not only for the prevention of coronal deformities of the spine but also for the prevention of the sagittal. The reported technique with pedicle screw fixation is effective so far, with great clinical and radiological outcomes., Introduction: The surgical treatment of adolescent idiopathic scoliosis (AIS), due to extensive surgery can have high complication rates. Our objective was to determine the rate of major complications (that need surgical re-intervention) after surgical treatment of AIS in a single institution cohort. Furthermore, we wanted to identify those factors that can predict the development of major complications. Material and Methods: We retrospectively analyzed demographic, pre- and perioperative clinical data of AIS patients operated in the National Center for Spinal Disorders between 2006 and 2016. The prognostic value of twelve pre- and perioperative factors (age, gender, previous spine deformity surgery, heart disease, lung disease, Cobb degree of major curve, ventral release surgery, HALO traction, level of instrumentation, OR time, blood loss, experience of the anesthesiologist in deformity surgeries) were investigated in a binomial logistic regression analysis. The predictive value of the model was tested in a ROC analysis. Results: 205 surgically treated AIS patients were included in the study. The mean age of the patients was 15 years (range: 11-18). The female: male ratio was 4:1. The median major curve was 68 Cobb degrees (range: 38-137). The median OR time was 435 minutes (range: 180-800), the median blood loss was 1185 ml (range: 500 ml - 7 700 ml). The major complication rate was 8.2% (17 complications in 13 patients), and included deep wound infection (3.4%), neurological complication (1.9%), loss of correction (0.9%), hardware failure (0.9%) and CSF leakage (0.9%). In binomial logistic regression analysis OR time and concurrent heart and lung disease were significantly associated with the occurrence of major complications (whole model: P < .001, Chi2 = 36.4 df = 6, R_N⁁2 = 0.43). The ROC analysis showed that the model has an excellent predictive value (c-index = 0.909, P < .001). Conclusions: The present study identifies three predictive variables on major complications after AIS surgery. High OR time, previous heart and lung disease predicted significantly a postoperative major complication. Predicting major complications gives the chance for the surgical team to avoid them., Introduction: The real risk of progression of idiopathic scoliosis is considered to vary during different growing phases, but detailed knowledge is not available. The rates described in several historical papers have long been considered the most relevant description of the progression risk of scoliosis during growth, but more recent data suggest the natural history to be even more aggressive. The aim of this study is to provide a systematic review, if possible a meta-analysis, of current literature about the natural history of scoliosis during growth in order to provide details about the risk of progression. Materials and Methods: We searched the MEDLINE, EMBASE and SCOPUS databases up to November 2015. Eligible studies were prospective or retrospective studies that enrolled patients with infantile (IIS), juvenile (JIS) or adolescent idiopathic scoliosis (AIS) that were followed up without any treatment from the time of detection. Of the 1663 citations screened, we assessed 61 full-text articles and included 16 of these (4083 participants). Results: Considering studies regarding infantile, juvenile and adolescent IS separately, we found that they were heterogeneous with regard to the most of the study characteristics and outcomes, so it was not possible to perform a meta-analysis. Forty-eight per cent of patients affected by infantile IS showed progression (range 5-80%) while 52% had spontaneous resolution. A curve progression of > 5° change in the Cobb angle was noticed in 33% of a mixed group of patients affected by JIS or AIS (range 14,7-68%). Twenty-eight per cent of patients affected by AIS had a progression of > 5° (range 10,3-100%). Fifty-two per cent of patients from one study had a progression and concluded growth with a Cobb angle greater than 50°. Some authors reported the rate of scoliosis progression, which ranged from 2.2° to 9.6° Cobb per year. Conclusion: Most of the studies were shown to have confounding factors related to some kind of conservative treatment administered at some point during the follow up period, so many patients were not followed unconditionally until skeletal maturity. What is clear from almost all of the studies is the risk of progression of the Cobb angle during growth, even if the rate of scoliosis progression is extremely variable among studies., Objective: The purpose of this study is to report our early experience of the use of the growing rods for the management of the early onset scoliosis and review the bibliography. Materials and Methods: A self-growing rod system have been used in 5 children of 5.5-11 years old to treat scoliosis of 60°-70°. The etiology of the scoliosis was in 2 children syndromic, in 1 neuromuscular and in 2 neurofibromatosis. Cobb angle, screw slipping, T1-S1 lengthening, and complications had been recorded during a follow-up of 4 years. A review of the bibliography has been done focusing on the rod lengthening, on the time of lengthening, on the spine growth, on the Cobb angle, and on the risk of complications. Results: The T1-L1 lengthening average was 6,8 cm. The Cobb angle average improved to 22° from (65°) and no spontaneous spinal fusion has been noted. In 2 children, a revision surgery to replace the upper thoracic screw and the rod had been performed. A left leg neurapraxia happened, which resolved after 1 week. The data on literature reveals that the traditional growing rods have better lengthening (8,8 cm average) when the time of lengthening is every 6 months, better Cobb angle improvement, more operations and no significate difference of the rate of the complications. Conclusions: The growing rods are a safe option to manage early onset scoliosis., Introduction: According to SRS guidelines, surgical treatment of idiopathic scoliosis should be considered when the deformity reaches 45-50 Cobb’s degree threshold. Objective: To estimate the frequency of surgical treatment of scoliosis in a population of patients with idiopathic scoliosis who receive brace treatment for deformities exceeding 45 Cobb degree. Material and Methods: A prospective nonrandomized cohort study. Inclusion criteria: pediatric patients with diagnosed idiopathic scoliosis; main curve more than 45° (Cobb) at first consult, orthotic treatement (Chêneau brace). We collected prospectively medical data of patients aged 2 to 18 years, receiving orthotic treatement (Chêneau brace) in a single institution from 05.2015 to 08.2016. All patients have standing frontal and lateral X-ray of the spine, X-ray films were estimated according to the Cobb’s method. Patients were counseled independently by general orthopedist and spinal surgeon, the limitation of conservative treatment and the possibilities of surgical treatment were discussed; the expectations and concerns of patients and their parents regarding the surgical treatment were recorded. Results: The cohort included 70 children, 14 - male, 56 - female. There were 12 patients with early-onset scoliosis (2-10 years) and 58 patients aged from 10 to 18 years. The magnitude of main curve in children with EOS was 45-50° in 4 cases, 51 - 80° - 8 children; in children older than 10 years 45-50° deformity was observed in 21 cases, 51 - 90° curve - in 37 cases. The patients were informed about the possibilities of surgical deformity correction. 22 patients gave primary consent to be surgically treated, but in fact operative treatment during the study period in this cohort was performed only in 6 patients (including 1 patient with EOS). It should be mentioned that the surgery costs and post-op rehabilitation is fully covered by state budget and insurance companies. The most common objection to the surgical treatment of the patients’s parents were grouped into several blocks: Fear of neurologic disorder (paraplegia) - 80%; expected inability to bend the body - 87.1%; expected inability to quickly return to normal life after the operation - 81%; subjective positive dynamics – curve reduction on X-ray wearing the brace (regardless of the absolute magnitude of the curve) - 40%; fear of necessity of reoperation - 25.7%; fear of death - 2.8%. Conclusion: Surgery for idiopathic scoliosis in a cohort of patients having orthotic treatement (Chêneau brace) when the main curve reaches the “surgical threshold” was conducted in 8.6% of cases in 15 months. Patients’ who receive bracing and their parents, do not adequately respond to the information about the true complication rate after surgical correction of idiopathic scoliosis and are themselves a “conservative population”. This fact may represent the national features of Russian medicine where modern health technologies goes hand in hand with XIX-XX century myths., Introduction: There are many types of spinal deformity in patients with spina bifida, and as the paralysis level higher, so does the incidence of scoliosis. But there are few reports that focus on the deformity type related to the neurological level. This study investigated the relationship between spinal deformity type and neurological level in patients with spina bifida. Material and Methods: A total of 27 patients with spina bifida over 10 years of age were reviewed at the final check-up in outpatient. We evaluated the type of spinal deformity, Cobb angle, associated deformity and the Sharrard classification. Results: The Sharrard classification was class I in 4 patients, class III in 6 patients, class IV in 8 patients, class V in 6 patients and class VI in 3 patients. Two patients in class I had severe kyphoscoliosis, and 2 had severe lordoscoliosis, with over 60 degrees of scoliosis. Four patients in class III had tethered cord, and 2 of 4 patients had mild scoliosis. Five patients in class IV had tethered cord, and 2 of 5 patients had mild scoliosis, of 1 patient had hemivertebtra. Four patients in class V had tethered cord, and 1 of 4 patients had mild scoliosis. Another one patient in this class was congenital scoliosis with butterfly vertebra. Three patients in class VI had tethered cord without scoliosis. There was no sagittal deformity in the lower than class III. Conclusion: This study indicated that most scoliosis were related to the tethered cord without sagittal deformity in the lower than class III. And there tended to be higher Cobb angle as the paralysis level higher., Introduction: Global balance relies on a series of visual and vestibular inputs as well as cerebellar integration that responds to the pathologic rotation of the spinal column in AIS. Corrective maneuvers create postural alteration of anatomic alignment of segments that require adaptive modification of the unfused anatomic parameters in order to maintain balance postoperatively. This study aims to analyze the radiographic markers which may help predict proprioceptive temporal alterations in postoperative coronal alignment. Material and Methods: 48 consecutive pts surgically treated for AIS with pedicle screw only constructs through a posterior only approach and 2 year follow-up were reviewed. Pts with complete radiographic images stored on the same electronic imaging system were measured by a single deformity surgeon. Pt demographics were compiled. Standard radiographs from the preop, early postop (, Introduction: Lumbar spondylolysis is a common disease (6-7% in the population) that can cause disabling low back pain in pediatric and adolescent age. It’s characterized by a unilateral or bilateral defect in the pars interarticularis of the vertebra, typically L5, due to acute or repetitive microtrauma or can be congenital. When conservative treatment doesn’t resolve this problem, surgical treatment is the ideal solution. Pedicle screw fixation and fusion has been shown to result in loss of motion and eventually adjacent segment disease, particularly harmful at this age. So repair of the defect with internal fixation and cancellous bone grafting is a treatment option that avoids fusion. The authors describe the result of direct pars repair with a minimum follow-up of 5 years, using pedicle screws, rods, and laminar hook construct. Material and Methods: From 2005 and 2012, 19 patients (12 males and 7 females) have been treated using the pedicle screws, rods and hook laminar construct. The median age was 15.2 yrs. (range 11.3-19.5). The level affect was L5 in 16 patients and L4 in 3 patients. We have completed a retrospective review of the data with demographic, clinical and radiographic trends. This study has been approved by the institutional review board. Regarding the surgical technique, we have done meticulous preparation of the pars defect, burring it and using cancellous bone grafting for the repair. In addition no injuries to the facet joint capsule have been done. Then the pedicle screw, rod and laminar hook has been placed in compression, to facilitate the bony union. Results: According to the MacNab criteria for pain evaluation, patients have reported the following results: 12 excellent, 6 good, 1 fair results. Bony fusion was assessed with plain radiographs. Complete bone healing has been observed in all the cases. No failures or dislodging of the implants have been observed in the follow-up. All the patients have come back to full sport activity after 6 months from the operation. Conclusions: Direct pars defect repair in spondylolysis with this technique has been shown to be very effective, sparing the need for fusion and avoiding the possible adjacent segment disease. Of course, many patients respond well to conservative treatment, so the surgical procedure is reserved to a small percentage. The results are very good, and similar to previous studies published., Introduction: No standardized surgical technique for severe rigid scoliosis management with few reports on the use of perioperative halo-gravity traction in treating severe rigid scoliosis. A retrospective study. To evaluate safety and efficacy of staged posterior surgery of severe rigid scoliosis correction. First stage is posterior facetal osteotomies and pedicular screw fixation. Second stage is halo-gravity traction for 3 weeks. Third stage is final correction maneuver techniques with rods application. Material and Methods: Ten patients with a minimum 1 year follow-up who underwent three stage correction techniques for severe rigid scoliosis (cobb angle above 100 degree) were analyzed. (First stage: posterior facetal osteotomies and pedicular screws application. Second stage: halo gravity traction for three weeks. Third stage: is definite correction techniques doing multiple chevron osteotomies, apical sublaminar wires if needed and rods application with derotation, compression distraction techniques). Patients demography age at date of examination (range, 11-28 y; mean, 15.6 y), sex (6 female, 4 male), major coronal curve magnitude (range, 106-148 degrees; average, 123 degrees), major sagittal curve magnitude (range, 70-110 degrees; average, 90 degrees). Complications related the procedures were reviewed. Results: Radiographic outcomes showed Cobb angle improvement of 29% after halo traction and it measured 55 degrees (range, 43-85 degrees) at the last follow-up, for a 58% correction. Kyphosis improved to 59 degrees (range, 42-74degrees) at last follow-up. T1-S1 increased by about 88 mm. There were no permanent neurological deficits in this series. Conclusion: Treatment of severe rigid scoliosis is very challenging. With modern instrumentation methods, posterior only staged surgeries with halo-gravity traction is a safe, tolerated method of applying gradual, traction to maximize final correction. There were no permanent neurologic deficits in this series., Introduction: Lumbosacral spondyloptosis produces global sagittal and often coronal imbalance and is associated with major patient morbidity including increased neurological risk. Surgical treatment includes in situ 360-degree fusion, spondylolisthesis reduction techniques and L5 vertebrectomy followed by L4 to sacrum circumferential fusion. In situ fusion is safer but does not correct lumbosacral kyphosis and global spinal alignment. Reduction techniques and L5 vertebrectomy can correct spino-pelvic balance at the expense of a high rate of neurological complications. We present a patient with a dysplastic lumbosacral spondyloptosis and severe coronal and sagittal imbalance with the discussion of treatment and surgical outcomes at 2-year postoperative follow-up. Material and Methods: Case report of a patient with spondyloloptosis (grade 5 spondylolisthesis). Clinical and radiological outcome data at two years are presented. Results: A 15-year-old girl presented with a three-year history of persistent low back pain refractory to physiotherapy and analgesia. Postural changes and radicular symptoms affecting the right leg were added in the last 6 months. Delay in diagnosis resulted in a highly progressive deformity producing severe global coronal and sagittal imbalance, as well as abnormal spino-pelvic parameters. On clinical presentation, the patient was mostly confined on a wheelchair due to back and leg pain. On examination, she had developed significant listing of the trunk towards the left side with a thoracic and lumbar curve and costo-pelvic impingement related to muscle spasm, as well as marked positive sagittal imbalance with lumbosacral kyphosis, compensatory lumbar lordosis and thoracic hypokyphosis. Decreased sensation was associated with tingling and pins/needles down her right foot. Muscle power was reduced at L5/S1 distribution to grade 3 on the right side with preserved bladder/bowel function. She underwent a posterior spinal fusion from L4-S1 with the transfixation screw technique, which corrected the lumbosacral kyphosis and restored local and global balance of the spine and pelvis. In the immediate postoperative period, she developed a stress fracture of the inferior end plate of S1 with anterior angulation and bladder symptomatology. An extension of the fusion to the pelvis combined with L5-S2 posterior decompression was performed and led to an uneventful recovery. At latest follow-up, our patient had normal neurological function and examination. She had a well-balanced spine in both planes with spontaneous resolution of the coronal curves. A solid fusion was associated with excellent functional outcomes and return to normal activities including sports. Conclusion: Lumbosacral spondyloptosis is associated with a high risk of neurological injury and can lead to global spinal deformity in both the coronal and sagittal planes. Surgical treatment is very challenging, associated with high rates of permanent injury to the L5 and sacral nerve roots and non-union. The transfixation technique is a relatively easy and safer treatment option that can restore local lumbosacral and global sagittal balance with a lesser neurological risk. Extension of the instrumentation to the pelvis can reduce the risk of sacral insufficiency fractures. Spontaneous correction of the coronal deformity may occur in the presence of a stable lumbosacral fusion. In our patient, this technique has produced very satisfactory clinical outcomes and high patient satisfaction., Introduction: Growing rod (GR) technique in the management of early onset scoliosis is found to be safe and effective in correcting and maintaining the deformity. However, the available GR systems are too expensive and not available for wider usage. Present study evaluates the safety, efficacy and radiological outcome of indigenously developed growing rod (GR) technique in the management of early onset scoliosis and discusses the technical considerations. Material and Methods: 10 patients (8 girls and 2 boys) with early onset scoliosis treated with GR technique (8 single GR and 2 dual GR) with a minimum of two distractions and a mean follow-up of 2.3 yrs (range 5 years-18 months) were included. Eight were girls and 2 were boys. Mean age at the time of GR instrumentation was 4.5 years (3-6 yrs). 5.5 mm pedicle screws were inserted at distal stable and proximal stable vertebrae with two small incisions and two 5.5 mm rods were inserted sub-muscularly and joined by rod-rod connector. Rods were contoured to the sagittal profile while taking care to allow sliding. Radiographic evaluation included measured changes in scoliosis Cobb angle, kyphosis, lordosis, frontal and sagittal balance, length of T1–S1 and instrumentation over the treatment period, and space available for lung ratio. Results: The mean scoliosis improved from 75.6° to 53.6° (27.8%). Mean increase in T1-S1 length was 16.6%. Coronal Plumb line showed relative improvement of 52.7% where as the trunk shift showed improvement of 95.2%. Space available for lung (SAL) improved by 3.4% on convex side and 2.5% on concave side. There was 9.2% improvement in the hemi-thoracic area on convex side compared to 4.4% improvement on concave side. None had rod breakage but one patient proximal thoracic kyphosis (dual GR) had proximal screw pull-out on convex side. There were no significant differences in any of the radiological parameters between single Vs dual GR. Conclusion: Indigenous GR technique is safe and effective in the treatment of early onset scoliosis. They are highly effective in correcting the trunk shift to improve the coronal balance and cosmetic appearance in children. Incidence of implant failure can be minimized by using thicker rod. Kyphosis poses problems of proximal screw pull-out and can be avoided by contouring the rod., Introduction: Significant postoperative trunk shift (TS) was occasionally noted in our practice causing patient dissatisfaction. Poor surgical planning and decision as well as the surgeon’s inclination to save the patients more lumbar motion segments are frequent causes. This retrospective cohort study aimed at analyzing our own case series in a trial to discover possible warning signs or guidelines to avoid this problem. Material and Methods: Eighty-eight consecutive patients with spinal deformity (44 AIS, 32 congenital, 5 syndromic, 4 associated with Scheuermann kyphosis, 3 Neurofibromatosis), treated by single stage posterior spinal fusion with all pedicle screws were retrospectively reviewed. Sixty patients (68%) were females and 28 (32%) were males. The following parameters were reviewed: age, preop. TS, time, Curve type (etiologies other than idiopathic scoliosis were described according to Lenke classification according to their pattern), lowest instrumented vertebra (LIV), post-operative TS (distance between Vertical Trunk Reference Line (VTRL) and Central Sacral Vertical Line (CSVL). Results: Seven cases (8%) developed TS. The mean TS was 37 mm (ranging from 20- 63 mm). In six patients, the fusion stopped at the lumbar apical vertebra (LAV) and in 1 case, fusion extended down to the sacrum. Three cases of TS (3.4%) were Lenke type 5C and 4 (4.5%) were Lenke type 6C. In the cases of Lenke 5C the LIV was L3 which was LAV. In Lenke 6c curves the LIV was L5 in 3 cases and S2 in 1 case. In the case where fusion was extended to S2 the original curve was too rigid Eighty-one cases did not develop trunk shift. In 64 cases (72.7%), fusion stopped at LAV or above and in 17 cases (19.3%) fusion extended down to the sacrum or the pelvis. The estimated risk of TS in the shorter fusion group was 0.086 and the estimated risk in the longer fusion group was 0.056 with estimated relative risk (RR) 1.55.with 95% Confidence Interval 0.180-14.148. In 6 cases of TS revision surgery was performed extending the fusion to the pelvis using S2-iliac screws and correction was achieved in 5 case. The case who have not undergone revision was satisfied and refused reoperation. Conclusion: Stopping fusion at the Lumbar Apical vertebra may be a risk factor for the development of trunk shift and extending the fusion more distally (LAV+1) is recommended., Introduction: Adolescent idiopathic scoliosis (AIS, OMIM #181800) is a three-dimensional deformity of the spine that causes a coronal imbalance up to 10 degrees. 70-80% of scoliosis diagnosed in adolescent is idiopathic. A recent epidemiology report on adolescent idiopathic scoliosis (AIS) has demonstrated a significant AIS burden in the European countries, affecting the 2-3% of the population under age 18, with more than 1 million AIS cases in EU. The role of genetic factors involved in AIS is widely accepted. However, it has been recently proposed the implication of epigenetics in the etiology of AIS. Epigenetics is defined as changes in gene activity and expression that occur without alteration in DNA. The environment, the nutrition, and the lifestyle are some of the factors that can modulate the epigenome, so contributing to AIS progression. Epigenetics has produced a high impact in biomedical research and is providing new biomarkers for the diagnosis and prognosis of diseases. In this context, miRNAs are very promising biomolecules to be used as biomarkers because miRNAs act as signaling molecules and participate in many biological process, due to their extreme stability and easy obtainment. Material and Methods: This is a prospective study based on an experimental analysis of the epigenetic profile of AIS. This investigation program has been approved for the ethics committee of University Hospital la Fe, Valencia, Spain. The inclusion criteria for the patients group were diagnosed for AIS with a Cobb angle > 10º and marked scoliosis, minimum follow up for two years, no previous surgical treatment, radiographies available, age between 12-18 years old. Exclusion criteria were: smoker, active infectious or inflammatory process during extraction, antioxidants intake, neurologic pathology, congenital syndrome pathology, and patients with scoliosis due to secondary causes. Physical examination consisted on measurement of the following parameters: age, sex, and body mass index (BMI) (Kg/cm2). A complete neurological exploration including motor and sensory balance, abdominal reflexes, as well as, patellar and Achilles reflexes were performed. Coronal and sagittal balance evaluation with the plumb test. Vertebral rotation assessment on Adam Test using the Scoliosis Research Society (SRS) scoliometer, and finally, deformity clinical evaluation using the trunk aesthetic clinical evaluation which consist on shoulder, scapular, thoracic and pelvic asymmetry assessment (TRACE). Physic evaluation for the control group was the same excluding the TRACE form. A radiological study was made for all patients included, based on two standing X-rays, anteroposterior and lateral views. It was mandatory to include from skull to pelvis. Risser method was used for skeletal maturity while the Cobb method was used to measure the coronal deformity. Finally coronal (C7-CSVL lines) and sagittal (C7-S1 lines) balance have been taken into account. According to the SRS criteria, for the present study, it has been considered the diagnosis of scoliosis when the coronal value of the deformity was up to 10 Cobb degrees Classification of the deformity for each patient using The Lenke Classification System for Scoliosis were also collected. Finally, all individuals included have completed scoliosis and general health questionnaires, specifically SRS-22, CAVIDRA and SF-36 for patients group and SF-36 for control group. Circulating miRNAs were purified from plasma samples from patients and control population through Next Generation Sequencing (NGS) and validated posteriorly with the use of RT-qPCR. Results: In the present study they were included 30 patients and 13 healthy subjects. The average of age in the patient group was 15 years. The male to female ratio was 1: 5, respectively. 43.33% had AIS familiar history. After miRNAs sequencing using NGS a study was conducted searching potential biomarkers for AIS. The random forest model was able to establish a first signature composed by 6 miRNAs that could distinguish patients from healthy subjects. The most important predictors of the disease were miR-122-5p, miR-671-5p, miR-223-5p, miR-1226-5p, miR-27a-5p and miR-1306-3p. Three biomarkers (miR-122-5p, miR-27a-5p and miR-223-5p) were over-expressed in AIS patients while miR-671-5p showed a lower expression when compared with the control group. Furthermore, for miR1306-3p no significant expression differences were found between groups. With all this information, a signature consisting of 4 miRNAs (miR-122-5p, miR-27a-5p, miR-223-5p and miR-1306-3p) was finally defined. This signature was validated by RT-qPCR achieving a high sensitivity (92, 9%) and specificity (72.7%), with an area under the curve of 0.95. Then we conducted a functional analysis of genetic pathways using the DIANA-miRPath program and the Genes and Genomes Kyoto Encyclopedia, in order to explain the relationship between the selected miRNAs with target genes, finding their influence on routes involved in osteoblast differentiation / osteoclasts and bone metabolism. Conclusion: This is the first work which propose the use of circulating miRNAs as biomarkers in the Idiopathic Adolescent Scoliosis. It has been found evidence of alterations in bone metabolism and activity of osteoclasts / osteoblasts in patients AIS mediated by miRNAs. It has been proposed a signature composed of 4 miRNAs that could discriminate with high sensitivity and specificity AIS patients and healthy subjects, and therefore could be used in the future for the bio molecular diagnosis of disease., Introduction: The reported incidence of postoperative pseudarthrosis in adult sagittal deformity is 0 to 29%. Risk factors associated with pseudarthrosis include age (>55), greater BMI, thoracolumbar kyphosis (>20), long level fusion (>11), laminectomy, rod factors (materials and diameter), and pedicle subtraction osteotomy. However, there exist limitations and controversies in data. Therefore, a retrospective study has been performed to evaluate the risk factors for postoperative pseudarthrosis in adult sagittal deformity. Material and Methods: Sixty patients with adult sagittal deformity were enrolled who underwent PSO (pedicle subtraction osteotomy). Patients were divided into groups with or without pseudarthrosis (pseud group vs non-pseud group). With a minimum 2-year follow-up, risk factors included spinopelvic parameters, fused segments, age, bone mineral density (BMD), body mass index (BMI), and joint pathologies at the hip and knee (postoperative hip fracture and untreated gonoarthrosis). Results: The mean SVA in each preoperative, postoperative, and last follow up period was 164 mm, -8 mm and 28 mm. Optimal SVA were achieved 98.3% as a whole (59/60), 100% in overcorrection group (47/47), 92.3% in under-correction group (12/13) postoperatively, and 47 patients (78% as a whole, 95.7% (45/47) in overcorrection group, 15.3% (2/13) in under-correction group) at the last follow up. Twenty seven patients (45%) were diagnosed with pseudarthrosis by the average period of 21months (8∼47months). The mean LL in each preoperative, postoperative, and last follow up period was 3°, -66° and -62°. Significant differences between the two groups with regard to risk factors included, correction of LL, and joint pathologies (P = .0167, P < .0001, respectively). Conclusion: Despite the effectiveness of overcorrection of LL with PSO in adult sagittal deformity, higher incidence of pseudarthrosis was seen compared to previous reports. Preventive options to consider may include, applications of multiple-rod construct or efforts to decrease events leading to hip fracture, in patients with an operative plan of overcorrecting lumbar lordosis with PSO, and especially perioperative treatments such as joint reconstruction should be considered in cases with untreated gonarthroses., Introduction: The present classification systems for adult spinal deformity (ASD) are based on the etiology and/or radiological parameters of the disease. Previous research however, suggests that other parameters (age, gender, BMI, HRQoL) may also affect the level of disability as well as the treatment decision. The aim of this study was to identify the potential groups of parameters that may be useful in classifying ASD using Cluster Analysis (CA). Material and Methods: Retrospective analysis of prospectively collected data utilizing the database of multi-center ASD study group was performed at the baseline (413 pts; 352 females; 131 degenerative –D-, 282 idiopathic –I-; mean age: 49.9 ± 20.0) as well as the 1st year follow-up (186 pts,; 157 females; 46 D, 136 I; mean age: 49.2 ± 19.1). CA was done in two steps; 1) Pre-clustering: The log-likelihood criteria were used followed by the selection of the optimal number of clusters by the algorithm; and 2) Hierarchical clustering of pre-clusters; for the entire data set as well as stratified by diagnosis (D or I) and age (> or < 50). Results: Are demonstrated on Figure 1a (entire set), b (D and I) and c (> and < 50) at the baseline and f/up. As can be seen, the CA consistently (for the entire group and the subgroups) isolated the clusters in three distinct groups of (not necessarily in hierarchical order): 1) HRQoL parameters; and 2) Sagittal plane; 3) Coronal plane radiological parameters. Conclusions: The results of this CA demonstrate that three groups of parameters (HRQoL and two plane radiological) are necessary and adequate to describe and/or classify ASD in general as well when stratified for age and diagnosis. This finding is significant in the sense that the present classification(s) do not contain all these groups and may need to be critically re-evaluated. 1st Cluster 2nd Cluster 3 rd Cluster a) Entire data set Baseline Major Curve Cobb Angle (0.931)MT curve (0.892)Coronal balance (0.669)TL-L curve (0.613)PT curve (0.473) Global tilt (0.791)L gap (0.720)PI-LL (0.704)Pelvic Tilt (0.645)SVA (0.591)Lordosis (0.476)Sagittal Balance (0.406) ODI (0.740)SRS22 (0.673)SF36 PCS (0.558)Back pain (0.483)Age (0.423)Leg pain (0.422) 1st year Major Curve Cobb Angle (0.841)MT curve (0.786)TL-L curve (0.719) ODI (0.760)Back pain (0.660)SRS22 (0.660)Leg pain (0.630)COMI score (0.570)SF36 PCS (0.490) Lordosis (0.860)Sacral Slope (0.820)Pelvic Incidence (0.680) b) Stratified by diagnosis (Grey shading for D, no shading for I) Baseline SRS22 (0.790)ODI (0.749)COMI score (0.707)Back pain (0.430)SF36 PCS (0.406) Major Curve Cobb Angle (0.910)TL-L curve (0.850)Coronal balance (0.780)MT curve (0.580) Global tilt (0.832)L gap (0.785)PI-LL (0.702)Sagittal Balance (0.659)SVA (0.629)Pelvic Tilt (0.601)Lordosis (0.550) 1st year SRS22 (0.882)SF36PCS (0.821)ODI (0.773)COMI score (0.760)Back pain (0.468) Major Curve Cobb Angle (0.780)TL-L curve (0.730)Mt curve (0.480)Sacral Slope (0.430)Lordosis (0.410) Alcohol drug abuse (0.940)Blood clots (0.940) Baseline COMI score (0.860)SRS22 (0.860)ODI (0.810)SF36 PCS (0.670)Back pain (0.660)Leg pain (0.510) Major Curve Cobb Angle (0.900)Coronal balance (0.770)MT curve (0.730)TL-L curve (0.670) Global tilt (0.800)Pelvic Tilt (0.670)PI-LL (0.640)L gap (0.560)SVA (0.560)Age (0.520) 1st year SRS22 (0.870)COMI score (0.840)ODI (0.810)Back pain (0.660)SF36 PCS (0.650) Major Curve Cobb Angle (0.880)MT curve (0.800)TL-L curve (0.690) Sacral Slope (0.571)Lordosis (0.561) c) Stratified by Age (Grey shading for ≤ 50 years, N shading for > 50 years) Baseline COMI score (0.820)ODI (0.800)SRS22 (0.800)Back pain (0.660)SF36 PCS (0.660)Leg pain (0.460) Major Curve Cobb Angle (0.910)Coronal balance (0.800)Mt curve (0.780)TLL curve (0.640) Global tilt (0.757)PI-LL (0.706)Pelvic Tilt (0.634)L gap (0.487) 1st year SRS22 (0.798)COMI score (0.745)ODI (0.725)Back pain (0.665)SF36 PCS (0.475)Leg pain (0.460) Major Curve Cobb Angle (0.935)MT curve (0.888)TL-L curve (0.764) Lordosis (0.800)Sacral Slope (0.760)Pelvic Incidence (0.540) Baseline SRS22 (0.813)COMI score (0.756)ODI (0.739)Back pain (0.494)SF36 PCS (0.455) Major Curve Cobb Angle (0.897)MT curve (0.802)Coronal balance (0.763)TL-L curve (0.739) Global tilt (0.824)PI-LL (0.734)L gap (0.730)Pelvic Tilt (0.638)Sagittal Balance (0.612)SVA (0.602)Lordosis (0.557) 1st year SRS22 (0.850)ODI (0.778)COMI score (0.772)SF36 PCS (0.706)Back pain (0.492) Major Curve Cobb Angle (0.953)TL-L curve (0.864)MT curve (0.826) Kidney disease (0.479)Depression (0.476), Introduction: Factors affecting the natural history and treatment outcomes are being investigated in order to identify the best and proper clinical approach in ASD. Our recent research suggests the critical age for the surgery to become more complex to be at early 30s. However, the evidence is still insufficient on whether age by itself, as well as gender has any effect on treatment outcomes.The aim of this study is to determine the clinical impact of age and gender on treatment results in surgically treated ASD patients. Material and Methods: Prospectively collected data from a multicentric ASD database was analyzed and all surgical patients with a minimum f-up of 1 year were included and analyzed for demographic, clinical, radiological and health related quality of life (HRQOL) parameters. Patients were separated into two groups based on improvement in HRQOL parameters by minimum clinically important difference (MCID). Student’s t-test and chi-square test were used to analyze the effect of age and gender on outcome measurements followed by a multivariate binary logistic regression model for these results with statistical significance. Results: A total of 186 patients (157 female, 29 male) with a mean age of 49.2 ± 19.1 years were analyzed. Age was found to affect only SF-36 PCS score significantly (P < .05) (Table 1A), with an odds ratio of 1.017 (unit by unit) of improving SF-36 PCS score on multivariate analysis (P < .05) (Table 1B). The breaking point in age for this effect was calculated to be 37.5 years (AUC = 58.0, P = .05). On the other hand, gender was found not to have a significant effect on any of the HRQOL scores. Conclusion: This study demonstrates that patient age may have a positive effect on treatment outcome parameters in surgically treated patients with ASD and the breaking point of this effect may be earlier than generally anticipated. Gender on the other hand, does not seem to affect results. This information may be important in patient counseling for the anticipated outcomes of surgery. Table 1. Student’s t-test (a) and multivariate binary logistic regression model (b) results on the relations between age and HRQOL. Please note that only SF36 PCS was included into the regression model as it is the only parameter with statistical significance on Student’s t-test. a. Mean Std. dev p ODI Un-improved 44.81 19.26 0.197 Improved 52.91 20.15 COMI Un-improved 46.25 25.52 0.346 Improved 55.62 19.21 SF36 MCS Un-improved 50.80 20.56 0.139 Improved 55.40 19.35 SF36 PCS Un-improved 49.67 21.33 0.034 Improved 56.24 18.34 SRS22 Un-improved 51.50 21.16 0.678 Improved 52.79 19.53 95% C.I for OR b. B S.E. Wald Df p OR Lower Upper Age .017 .008 4.425 1 .035 1.017 1.001 1.033 Constant -.800 .449 3.176 1 .075 .450, Introduction: The prevalence of Adult Spine Deformity (ASD) is increasing and the need for surgical deformity correction has subsequently increased. Although surgery has been proven to be effective, results have not been consistently good. Pre-operative depression has been associated with decreased rates of improvement in lumbar spine surgery;but the impact of pre-operative psychosocial factors in ASD results is not fully understood. The aim of this study is to determine the clinical impact of pre-operative psychological factors on outcome scores and treatment results using SF36-MCS tool. Material and Methods: Prospectively collected data from a multicentric adult deformity database for surgically treated patients with a minimum of 1-year follow-up was analyzed. Patients were dichotomized into groups of improved or unimproved based on the MCIDs of individual HRQoL scores. Student’s t-test analysis was used to analyze the effect of baseline SF36MCS on treatment results followed by a univariate binary logistic regression model to measure the effect of the SF36-MCSand a clinically useful SF-36 MCS was determined by ROC Curve analysis. Results: A total of 186 patients, (157 female, 29 male) were analyzed. The two cohorts of patients (improved & unimproved) show no significant difference in baseline SF36MCS using ODI, COMI or SRS22. For SF36PCS however, the un-improved cohort had significantly lower mean baseline SF36MCS (P < .001). SF36-MCS was found to have an Odds Ratio of 0,914in improving SF36PCS score (unit by unit) (P < .001). SF-36 MCS cut-off point 43.97 was found to be predictive of SF36PCS (AUC = 0.631: P < .001). Conclusion: This study demonstrates that baseline psychological factors as assessed by Sf36 MCS cannot predict treatment outcomesby ODI, COMI or SRS22, in keeping with previous publications.However, a lower baseline SF36MCS is predictive of poorer surgical outcomemeasured by the SF36PCS tool. Figure 1. Student t-test analysis for all HRQOL outcomes measures (grey area) & univariate logistic regression analysis for SF36 PCS . (SF 36PCS is the only signifinicant outcome measure on t-test) Mean (std dev) Baseline SF36 MCS P-Value ODI Un-improved 38.89 (8.25) 0.487 Improved 41.45 (11.95) COMI Un-improved 42.09 (8.34) 0.881 Improved 41.22 (11.46) SF36-PCS Un-improved 39.35 (11.14) 0.025 Improved 43.44 (12.07) SRS22 Un-improved 42.17 (11.12) 0.415 Improved 40.65 (12.13) Univariate Logistic Regresision analysis P-Value Odds Ratio 95% C.I for OF Lower Upper SF36_MCS_ baseline ,000 ,914 ,884,945 Constant ,000 40,577, Introduction: We determine the change in spinal sagittal parameters which may occur throughout the day by comparing spinal sagittal measurements taken early in the morning to measurements taken in the evening in healthy hospital workers. Methods: Thirty-five employees were enrolled in the study. For each subject, two standing left lateral orthoroentgenograms were obtained at 8 o’clock a.m and at 6 o’clock p.m. Six spinopelvic parameters were measured on the X-rays. Thereafter, the subjects were divided into two cohorts according to their BMI as low BMI and high BMI. Results: Thirty-five subjects; 16 males, 19 females with a mean age of 25.97 ± 8.21 were evaluated. There is no significant change between morning and evening for each parameter. Direct relationship was shown between TK and LL, LL and SS, PT and PI minus LL, SVA and PI minus LL in addition to an inverse relationship between SS and PT, SS and PI minus LL, TK and PI minus LL, SS and PT, SVA and LL. (P < .05). SVA were found to be higher in the high BMI group, and daily change was lower in the high BMI group, but the differences were not statistically significant. Only the change in PT value was found to be statistically significant in low BMI group. Conclusion: There is no significant change in the spinopelvic parameters throughout the day. Compensatory mechanisms will work to prevent collapse of spinal sagittal balance in a day., Introduction: Lumbopelvic fixation has been an important advancement in spine surgery, specifically for obtaining spino-pelvic stability for adult deformity correction, and offsetting stresses placed on sacral screws. However, Iliac screws are not without complications including infection, screw prominence, and instrumentation failure (IF). Kasten et al reviewed 78 patients treated with adult deformity found a 11.5% infection rate. OʼShaughnessy et al. found a 6.1% rate of elective iliac screw removal in a review of 395 similar patients. Literature review demonstrates pseudoarthrosis failure rates between 5 and 15%. Kuklo et al reported a 4.9% pseudoarthrosis rate with hardware failure, while Kasten et al. found broken implants resulted in a 15.3% rate of pseudarthrosis.Our institution utilizes modified iliac screw starting points highlighted by more medial starting points, placing iliac screw heads in line with S1 pedicle screws. We hypothesize this technique is associated with decreased rates of elective screw removal secondary to prominence, infection and IF. Material and Methods: Retrospective database review at UMMS between 2006-2015 of 57 patients undergoing lumbopelvic fixation with a modified iliac screw starting site, for treatment of adult deformity secondary to degenerative scoliosis, posttraumatic kyphoscoliosis, and flat back syndrome. Primary outcome measure: Rates of: 1) elective removal of Iliac screws, 2) infection, 3) IF (breakage of rods/pelvic screws/pedicle screws), 4) revision surgery for Pseudoarthrosis/IF. Secondary outcome measures: 1) estimated blood loss and 2) length of stay. Patients were contacted via telephone in order to ensure no loss to follow-up with respect to elective removal of hardware or revision surgery at outside institutions. Results: The patient population consisted of 17.5% males (N = 10) and 82.5% females (N = 47). The average age was 58.2 years old (SD 11.7 years). Average follow-up was 22 months. Early infection rate (less than 1 month after primary procedure requiring surgical intervention) was 3.5% and late infection rate (more than 1 month after primary procedure requiring surgical intervention) was 12.2%. Overall infection rate was 15.7%. Elective removal of Iliac screws rate was 3.5% (N = 2) and IF via radiographic review was 35% (N = 20), but revision surgery rate for pseudoarthrosis/IF was 5.2% (N = 3). Revision surgery rate for proximal junctional failure/kyphosis was 3.5% (N = 2). IF occurred below (N = 15), above (N = 2), and both above and below (N = 3) the L5 pedicle screw. Average time of diagnosis of broken instrumentation was 16 months. Average Estimated Blood Loss was 1727 cc, with length of stay averaging 8.6 days. Conclusion: Our modified LPF technique demonstrated relatively low rates of elective screw removal (3.5%), likely from decreased screw prominence. Our infection rate is similar to previously reported rates in the literature. The discrepancy between our relatively high rate of radiographic IF and much lower revision surgery rate demonstrates the low clinical significance of radiographic findings in isolation. The time to IF supports following patients with adult deformity reconstruction well past the 1-year benchmark., Introduction: Many methods had been reported for the coronal and sagittal correction of adult degenerative scoliosis. Controversy exists as to the role of SPO, PSO, ALIF and XLIF in deformity correction of adult degenerative scoliosis. Material and Methods: Thirty-eight ADS cases were treated with one stage of posterior multilevel Ponte osteotomy and full discectomy releases combined with key segment anterior structural column support and instrumentation. The thoroughly interbody release and fusion with local bone were done both side in all involved segments, a little bigger inserter were inserted into cave side to neutralize the tilted vertebrae. The operating time and the blood loss were recorded. Mean follow-up was at least two years. All the subjects were analyzed by visual analog scale (VAS), Oswestry Disability Index (ODI), and SF-36 scores, SRS 22 before and after surgery and at final follow-up. The scoliotic curve, thoracic kyphosis, lumbar lordosis, pelvic incidence (PI), pelvic tilt (PT), sacral slope, and C7 plumb line were measured. For the statistical analysis, multivariate multiple regression models were formulated, considering as significant (P < .05). Results: The average operating time were 350 min and the mean blood loss were 720 ml. A statistically significant clinical and radiological amelioration was noted after surgery and at final follow-up. The ODI, and SF-36 scores, SRS 22 improved. The Cobb angle of lumbar lordosis and spino-pelvic parameters (PI, PT, sacral slope) returned to the normal range after surgery. Conclusion: Posterior Ponte osteotomy releases produced more motion than facetectomy alone in axial rotation and sagittal correction maneuvers. Full discectomy release destabilized spinal column significantly in all force applications. Key segment anterior structural column support could neutralize the tilted vertebrae maximally. So, it is easy for the coronal and sagittal correction if three factors working together., Introduction: Surgery is widely performed for lumbar degenerative kyphosis (LDK), but its effectiveness as compared with nonsurgical treatment has not been demonstrated. Methods: In this prospective study, surgical candidates with LDK were enrolled at three spine centres. 2 treatment options were performed either surgery using a pedicle subtraction osteotomy or nonsurgical care. Outcomes were measured using a Visual Analog Scale (VAS) of back pain, the Oswestry disability index (ODI), and the 32-item short-form health survey (SF-36), which consists of physical component summary (PCS) and mental component summary (MCS) scores, and using radiologic outcomes and treatment-related complications. Of the 126 LDK patients treated during the reference period, 97 patients were enrolled (47 in the surgical group and 50 in the nonsurgical group). Results: This study showed a significant effect favouring surgery in terms of VAS, ODI, PCS, and MCS scores, and radiologic outcomes. However, the complication rate was high in the surgical group. Analysis showed a significant advantage for surgery at 6 months postoperatively in terms of ODI and SF-36 scores, and these benefit remained significant at 2 years. Conclusions: LDK patients that underwent surgery showed significantly greater improvement in all outcome variables than patients treated non-surgically., Introduction: Adult spinal deformity (ASD) has multiple etiologies and it develops over the years. Typical radiological findings are loss of lumbar lordosis (LL) 1 in relation to pelvic incidence (PI), PI-related amount of compensatory pelvic retroversion, pelvic tilt (PT) and reduction of thoracic kyphosis and hyperlordosis of cervical spine. 2 Most previous studies on spinal deformity and impact on health related quality of life (HRQoL) measures have been made of selected ASD patients or normative non-symptomatic population. 3-6 Our aim was to evaluate the occurrence of sagittal disorders in an unselected consecutive cohort of adult patients with a prolonged degenerative symptomatic spine disorder. For comparison of the disability and HRQoL outcomes, the patients were categorized into no, moderate or marked sagittal disorder. Materials and Methods: Consecutive adult patients (N = 874) with prolonged degenerative spinal disorders referred to Central Hospital of Jyväskylä spine clinic during one year and were recruited to the study. Exclusion criteria were age, Introduction: Little is known with respect to changes in the segmental thoracic and thoracolumbar kyphosis, which are major parameters influencing sagittal balance of the spine. The authors investigated the detailed segmental changes of those parameters by ageing. Material and Methods: A total of 326 normal asymptomatic males were divided into 2 groups; group 1 (mean age, 21.2 ± 1.7; n = 175) and group 2 (mean age, 64.1 ± 6.4; n = 151). After taking a standing sagittal radiograph, the sagittal spinal and pelvic parameters were measured. Thoracic and thoracolumbar kyphosis were classified according to segments A, C7 UEP (upper end vertebra)–T5 UEP; B, T5 UEP–T10 UEP; C, T10 UEP–T12 LEP (lower end vertebra); and D, (T12 LEP–L2 LEP), and analyzed between 2 groups, respectively. Results: Thoracic kyphosis (21.1° ± 7.7° vs 30.0° ± 8.8°, P, Introduction: Recent research in sagittal plane proposed age-adjusted alignment thresholds. However, impact of these thresholds on postoperative HRQL is yet to be investigated. This study aims to compare 2 yr clinical outcomes of patients (pts) who underwent surgical reconstructions based on their achievement to age-adjusted alignment ideals. Material and Methods: Retrospective review of prospectively collected database. Patients were included if > 18 years, underwent surgical correction of adult spinal deformity with a complete 2 yr FU. Pts were stratified into 3 groups based on achievement of age-adjusted thresholds in pelvic tilt (PT), pelvic incidence minus lumbar lordosis (PI-LL), sagittal vertical axis (SVA). First group included pts who reached the exact age-adjusted threshold ±10 yrs (MATCHED), other two groups included pts who were over corrected (OVER), and under corrected (UNDER). Clinical outcomes including actual value and offset from age-adjusted ODI, SF36-PCS and SRS-22 (PROM) were compared between groups at 2 yr FU. Results: 343 patients (57.0 years and 83% F) were included. Sagittal profile of the population was: PT = 23.6°, SVA = 65.8 mm, PI-LL = 15.6°. At 2-year follow-up there was a significant improvement in all sagittal modifiers with 25.7%, 24.3% and 33.1% of the patients matching their age alignment targets in terms of PT, PI-LL and SVA respectively. For PT and PI-LL the 3 groups (MATCHED, OVER, UNDER) had comparable values and offsets from age-adjusted PROM. However, for SVA groups, patients in UNDER had significantly worse HRQOL than the two other groups. Patients in PT, PI-LL, and SVA UNDER groups were significantly younger than the other groups, P < .05. Conclusion: At 2 yr following ASD surgical treatment only 24.3% to 33.1% of the pts reached age-adjusted alignment thresholds. Those under corrected in SVA demonstrated worse clinical outcomes. No significant improvements were found between matched and overcorrected pts, with overcorrection being an established risk for PJK. These results further emphasize the need for patient specific operative planning., Introduction: Halo traction has traditionally been used in the treatment of severe spinal deformities and growing rod systems have been known since the Luque trolley. There is an argument that slow correction as opposed to instant correction might yield a better adaptation of the spine, because of the viscoelastic properties of the intervertebral discs. Recently, percutaneously expandable magnetic rods have become available for the treatment of young children. There is very little experience regarding the use of such systems in the adult spine. We describe the successful use of these rods to treat a severe spastic hyperlordosis in an adult. Case Report: A 28-year-old university student with cerebral palsy presented with abdominal wall pain and increasing difficulty sitting in her brace-fitted wheel chair. Clinically there was residual motor function of the legs, severe hyperlordosis, flexion-adduction deformities of the hips and a visual aortic pulse below the umbilicus. The spine was palpable directly under the skin. Bracing and botox injections had been exhausted and radiographs showed a lordosis angle of 150 degrees. MRI and duplex ultrasound showed that the aortic bifurcation as well as the confluence of the iliac veins were stretched out in front of the spine and pressing against the abdominal wall. While a primary anterior approach was tempting because of the tall, distracted discs, we did not pursue this further because of the preceived high risk of vascular complications. In a first surgery, a radical posterior release was performed and a pelvic as well as a thoracic anchor were constructed. Between these anchors, a hinged construct with 2 MAGEC rods was inserted with the motors positioned subcutaneously. Over a period of 3 months, the rods were expanded with the deformity slowly correcting further. She then required a release and a rectus-psoas transfer to straighten her hip joints. After assessing her sagittal plane balance when standing with help, we finalized the correction with a slightly positive SVA at a lordosis angle of 75 degrees by completing a posterior instrumented fusion from T9 to the pelvis. Until 2 years postop, there have been no complications, no construct failure and she has returned to limited, aided standing and walking. Discussion: This is the first such case published. Slow percutaneous distraction was successful and aided by a progessive reduction in disc height under physiological loading. We feel that the concept of slow, controlled distraction deserves renewed thought also in severe adult spinal deformity., Introduction: The length of stay (LOS) following adult spinal deformity (ASD) surgery is a critical time period allowing for recovery to levels safe enough for to return home or to rehabilitation. Thus, the goal is to minimize it for conserving hospital resources and third party payer pressure. Factors related to LOS have not been studied nor has a predictive model been created. The purpose was to create a preoperative predictive model to predict the LOS following ASD surgery. Material and Methods: Retrospective review of a multicenter, prospective ASD database. Inclusion criteria: operative pts, age >18 yrs, ASD. Pts with staged surgery at a separate hospitalization or LOS >30 days were excluded. 66 variables were initially evaluated with 40 being used for model building following univariable predictor importance ≥0.90, redundancy, and collinearity testing. Variables included: demographic data, comorbidities, preop HRQOL, preop coronal and sagittal radiographic parameters, and modifiable surgical factors. A generalized linear model was constructed using a training dataset developed from a boostrapped sample with replacement using a random number generator. Pts randomly omitted from the boostrapped sample were included in the testing dataset. Accuracy was calculated by comparison of predicted LOS to the actual LOS. Results: A total of 689 patients were eligible with 653 meeting inclusion criteria. The mean LOS was 7.9 ± 4.1 days (median = 7, range: 1-28). Following bootstrapping, a total of 893 pts were modeled, Training: 653, Testing: 240(36.6%). The linear correlations for the training and testing datasets were 0.632 and 0.507, respectively. Testing dataset accuracy within 2 days of actual LOS was 75.4% (181/240 pts). The top 10 predictors were the following in decreasing order: staged surgery (yes/no), C7 SVA, number of posterior levels fused, Charlson Comorbidity Index, Total number of comorbidities, preop ODI score, iliac fixation (yes/no), preop SRS Activity score, preop SRS Appearance scores, and number of interbody fusion levels. Conclusion: A successful model was created to predict LOS following ASD surgery to an accuracy of 75% within 2 days. There are some factors related to LOS that are not likely captured in large databases, which may partially explain the 75% accuracy, such as rehab bed availability and social support resources., Introduction: After previously performed, unbalanced lumbar spinal fusions, revision surgery typically consists in extension of the fusion into the previously un-instrumented lumbar or thoracic spine. Pedicle subtraction osteotomy (PSO) with extension of the existing fusion is a powerful correction tool. It typically involves sacrificing at least two additional proximal motion segments in order to achieve meaningful correction and fixation. Blood loss, neuro-trauma due to extensive intra-spinal canal work, and soft tissue trauma to the posterior muscular structures is usually extensive. Adjacent TLIF fusion and Smith-Peterson osteotomy have only a limited ability to restore spinal balance. Material and Methods: We surgically treated 20 consecutive patients presenting with failed posterior lumbar fusion surgery (PLF). Pain and Oswestry score were documented prior to surgery, at 3 month, 6 month and annual follow up. Aim of surgical treatment was to primarily address the flat back deformity by osteotomies within the existing fusion. Surgery consisted of a triple approach from posterior, anterior and posterior again (BFB): 1) Back: After an initial posterior approach with limited exposure of the spinal canal and the foramina of the fused level(s) existing instrumentation was removed, a limited osteotomy through the PLF mass was performed until some mobility in the relevant motion segment(s) was achieved. Pedicle screws were placed or exchanged at the relevant levels. The wound was temporarily closed and the patient was turned over into supine position. 2) Front: Through a standard retroperitoneal approach the relevant disc(s) space(s) were exposed, followed by anuloplasty, complete nucleotomy and endplates preparation. In cases of previous TLIF fusions the implant was removed. A wedged ALIF cage, filled with autologous bone, was inserted and locked with screws and the anterior approach was closed. 3) Back: The patient was turned back into prone position, the original posterior approach was re-opened, the pedicle screws were connected under compression onto rods and the posterior wound definitively closed. Results: Four patients were male. Mean age was 52.1 (34-76) years. Of the 20 patients six had a prior L5-S1, seven had a prior L4-S1, three a L3-S1, one a L2-S1, one a L5-Ilium fusion and one L3-L5 floating fusion. There was no death or other serious outcomes as paralysis or major bleeding. As intraoperative cell saver was used only 4 patients required additional transfusion. One patient had a complex scoliosis fusion revised. Half of the patients had an extension of the fusion. At 2 year follow up one patient considered the outcome as poor, 3 as fair, 9 as good and 7 as excellent. The Oswestry score improved from 52.5 pre op to 24.3 at last follow up, the pain score from 8.75 to 3.46 respectively. Conclusion: We consider BFB osteotomy and fusion as a viable treatment option for active, younger patients in sagittal unbalanced, failed prior lumbar fusion surgery. One can preserve the remaining lumbar motion segments. However larger sample seize and longer term follow-up is necessary., Introduction: In recent years, the rate of utilization of 3-column osteotomy (include pedicle subtraction osteotomy (PSO) and vertebral column resection) has significantly increased, with a reported 3.2-fold increase in the use of PSO between 2008 and 2011 alone. With increased surgical volumes, the post-operative risk and care have become an important factors in the pre-operative risk assesment when proposing these techniques to treat complex spinal deformity, The purpose of this study is to determine the incidence and factors associated with intensive care unit (ICU)-level complications after adult spinal deformity (ASD) surgery. Material and Methods: A review of the American College of Surgeons National Quality Improvement Program database was performed for the years 2007–2013 to identify adult patients who underwent instrumented fusion for ASD. Intensive care unit-level complications were examined, and included: intraoperative cardiac arrest, prolonged ventilation, reintubation, pulmonary embolism, renal failure, cardiac arrest, myocardial infarction, and septic shock. Results: Among 1250 patients who underwent surgery for ASD, the rate of ICU-level complications was 5.4%; 0% for intraoperative cardiac arrest, 2.7% for prolonged ventilation, 1.8% for reintubation, 1.2% for pulmonary embolism, 0.1% for renal failure, 0.2% for cardiac arrest, 0.8% for myocardial infarction, and 0.7% for septic shock. Factors associated with ICU-level complications included male sex (OR 1.68; 95% CI, 1.01 – 2.80; P = .043), prolonged operative time (OR 1.26; 95% CI, 1.16 – 1.38; P < .001), and dependent functional status (OR 2.22; 95% CI, 1.02 – 4.84; P = .044). Conclusion: The findings of this study suggest that the rate of ICU-level complications after scoliosis surgery is approximately 5.4%. Certain preoperative and operative factors may increase the risk of these events including male gender, prolonged surgical time and dependent functional status. These factors should be considered when planning for surgery and for risk assessment., Introduction: Parkinson disease often leads to abnormal posture or sagittal alignment inducing significant disability. The underlying pathophysiology of these deformities is largely unknown, and their management remains difficult.1 Association between poor bone quality and severe muscular dysfunction lead to complicated spine surgery.2 Because the functional results of long fusion for Parkinson patients remained unclear3-5, we proposed to retrospectively review a cohort of long fusions for spinal deformities in patients suffering of Parkinson disease. The aim of the study was to assess the functional benefit and patient satisfaction after long spinal fusion surgery despite complications, and tried to highlight the predictive factors of satisfactory functional results. Material and Methods: We retrospectively reviewed 18 patients suffering of Parkinson disease operated of spinal deformities in our spinal surgery centre between 2002 and 2014. Severity of their Parkinson disease was assessed at last follow up using the MDS-UPDRS and MMSE scores. Primary endpoint was the Owestry Disability Index (ODI)6 at last follow-up compared to the ODI before surgery. Patient satisfaction was assessed at last follow up. Complications needed revisions were recorded. Sagittal parameters were assessed before and at last follow up on full lateral spine X-Rays using the Keops software (Smaio, Lyon). We searched for variables associated with the postop ODI score adjusted on preop ODI. Comparison between pre and post-operative scores and sagittal parameters was done using the parametric student-t test. A linear regression was built to assess the effect of relevant predictors of ODI. All analyses were performed using R (version 3.1.3., R Core team). Results: Median age at surgery was 69.3 years (64-72.7). Median fusion length was of 10 levels fused (9-16). Median follow up was 44.4 months (36- 62.4). Preoperative ODI was 64 (59-77) and last follow up was 49 (40 – 57). Difference was statistically significant (P = .0014). There was no difference between pre-operative and last follow up physical and mental SF-12 rates (P = .48 and P = 1 respectively). Fifteen patients (83%) were very satisfied (n = 5) or satisfied (n = 10) of the surgery and would have choose the same procedure again. Six patients (33%) underwent one surgical revision, complication occurred at 1.28 years (0.7 -1.6). On these 6 patients, 2 underwent two surgical revisions. Improvement of sagittal balance was statistically non-significant (P = .35). Mismatching between pelvic incidence and lumbar lordosis was lower at last follow up than before with a median of 9° (-4.4; 18.3) and 15.9° (1.61-70.4) respectively (P = .24). The median MDS-UPDRS score at last follow up 14.5 (11.5-20.5)/ 16 (16-16.7)/ 40.5 (38.5-45.5)/ 5(3.5-5.7). The MMSE score at last follow up was 26 (22.7-27.7). Predictors of last follow up ODI score: In multivariate analysis, only age was significantly associated with last follow up ODI (estimate: -9.8, P = .5). Conclusion: Even if patients suffering of Parkinson disease with spinal deformations have a high risk of surgical spine complications, the enhancement of their autonomy and their satisfaction after long spinal fusion have to be borne in mind before rejecting surgery, especially with motivated patients. Perfect postoperative sagittal alignment doesn’t seem to be mandatory. References 1. MRCP KMD, van de Warrenburg MD BP, MD MCP, et al (2011) Postural deformities in Parkinson’s disease. The Lancet Neurology 10:538–549. doi: 10.1016/S1474-4422(11)70067-9 2. Sarkiss CA, Fogg GA, Skovrlj B, et al (2015) To operate or not?: A literature review of surgical outcomes in 95 patients with Parkinson’s disease undergoing spine surgery. Clinical Neurology and Neurosurgery 134:122–125. doi: 10.1016/j.clineuro.2015.04.022 3. Bourghli A, Guérin P, Vital J-M, et al (2012) Posterior spinal fusion from T2 to the sacrum for the management of major deformities in patients with Parkinson disease: a retrospective review with analysis of complications. Journal of Spinal Disorders and Techniques 25: E53–60. doi: 10.1097/BSD.0b013e3182496670 4. Wadia PM, Tan G, Munhoz RP, et al (2011) Surgical correction of kyphosis in patients with camptocormia due to Parkinson’s disease: a retrospective evaluation. J Neurol Neurosurg Psychiatry 82:364–368. doi: 10.1136/jnnp.2009.176198 5. Peek AC, Quinn N, Casey ATH, Etherington G (2009) Thoracolumbar spinal fixation for camptocormia in Parkinson’s disease. J Neurol Neurosurg Psychiatry 80:1275–1278. doi: 10.1136/jnnp.2008.152736 6. Fairbank JCT, Pynsent PB (2000) The Oswestry Disability Index. Spine 25:2940–2953. doi: 10.1097/00007632-200011150-00017, Introduction: The understanding of normative values of radiographic parameters allows surgeons to customize the surgical objective in the setting of the adult spinal deformity treatment. However, significant differences in spinopelvic alignment have been reported across different ethnicities. The aim of this study is to investigate the normative values and chain of correlations across spinopelvic parameters in a Brazilian population sample. Material and Methods: This is a prospective observational study including adult asymptomatic subjects who underwent full spine radiographs. The subjects were stratified by age into 3 groups (18-39 y/o, 40-59 y/o, and > 60 y/o) and radiographic parameters were compared across age groups, using ANOVA, and gender, using student t-tests. The relationships across various radiographic parameters were calculated by the Pearson product-member correlation coefficients. Results: 130 asymptomatic volunteers (mean 48y) met the inclusion criteria and were evaluated. The mean and range of sagittal parameters in normative Brazilian population were identified. Subjects ≥ 60 y/o had significantly higher values for SVA (P = .024) and TPA (P = .009) than the two younger age groups. TPA significantly correlated with the following spino-pelvic parameters: LL (r = -0.172, P = .005), PT (r = 0.776, P < .001), PI (r = 0.508, P < .001), PI-LL (r = 0.717, P < .001), SVA (r = 0.409, P < .001) and T1 Slope (r = 0.172, P = .050). There was a significantly higher mean of the SVA and TPA in the subjects ≥ 60 y/o, compared with the two other age groups (P = .024 and P = .009). It was also observed a significant correlation of the TPA with the following parameters: LL (r = -0.172, P = .005), PT (r = 0.776, P < .001), PI (r = 0.508, P < .001), PI-LL (r = 0.717, P < .001), SVA (r = 0.409, P < .001) and T1 Slope (r = 0.172, P = .050). Conclusion: The normative values of sagittal parameters in a sample of a Brazilian population were presented in this study. Moreover, to date, this is the first analysis of the normative value of TPA in asymptomatic subjects. This study demonstrated a significant physiologic trunk inclination (higher SVA and TPA) with increasing age. The chain of correlations between spinal segments was confirmed by the significant correlation of the TPA with all the other parameters, with the exception of sacral slope., Introduction: Adult degenerative scoliosis (ADS) is a common problem in the World, usually those over the age of 60. A retrospective study of 34 patients (age 60-83 years) with ADS with SPL. According to ODI, ASIA, SVA, VAS data, patients with ADS and SPL who were undergo spinal fusion have different clinical and X-ray outcomes in different operative technics.There are not enough reports in the literature, describing the outcomes of pts with ADS and SPL operatively treated. Our study set out to compare clinical and radiographic outcomes in operative treated ADS pts with SPL with or without vertebra reduction. Methods: A retrospective study of 34 patients (age 60-83 years) with ADS with SPL. Mean follow-up period was 4 years (2-5 years). Inclusion criteria: age >60 yrs, no prior surgery, and ADS (scoliosis ≥20 degrees, sagittal vertical axis (SVA) ≥6 cm, pelvic tilt (PT) ≥25 degrees, or thoracic kyphosis (TK)>60 degrees). Demographic, radiographic and HRQOL data evaluated including: Oswestry Disability Index (ODI), ASIA and VAS pain scale. Patients divided into 2 groups in depending on the applied surgical techniques: in the first group in 18 cases with transpedicular screw fixation, multilevel SPO+PSO, second group with transpedicular screw fixation, multilevel SPO+TLIF with vertebra reduction. There was no significantly difference between pre-op age, VAS, ASIA and ODI in both groups. Results: In the first group a full restoration of the sagittal & coronal balance was achieved. In the second group, we did not achieve a full postoperative restoration of the sagittal & coronal balance. Post-op ODI, VAS and ASIA improvement in all groups but no significantly different between them. I group had significantly better SVA (≤4 cm) then II SVA (≥5 cm) (P = .03). At 3 years control showed, the I groups had significantly better ODI (36%) and VAS (3,1) then II (54%/4,9) (P = .04). Conclusions: PSO with multilevel SPO and transpedicular screw fixation allow to achieve good clinical outcomes. Deformities corrections without SPL reduction does not influence on sagittal balance restoration and fusion post-op. To confirm these the obtained results require more observations., Introduction: This study is designed for retrospective case-control, questionnaire study. Objective of this study is to describe the changes in self-perceived mobility in patients after long level lumbar fusion with or without iliac screw. Iliac screw fixation is used in spinopelvic instrumentation for variable diseases. The loss of motion resulting from spinal fusion lead to morbidity and a negative impact on quality of life. Recently measuring disability, HRQOL and health utility has become widely used. But standardized HRQOL doesn’t reflect Asian sedentary life style. To our knowledge, there is no study compares the self-perceived outcomes of iliac screw fixation, especially related to Asian sedentary life style. Materials and Methods: This study includes 47 patients who underwent thoracolumbar and lumbar fusion (more than 4 levels) with a minimum follow-up period of 1 year. The patients were divided into two groups on using iliac screw or not. Group 1 consisted of 19 patients and group 2 consisted of 28 patients. We made 1 questionnaire including 7 questions and each question is representative of typical Asian sedentary life style. The outcome of both group were statically compared. Results: Patients with iliac screw fixation group did significantly worse in all questions compared to preoperative states. But there were no significant differences between pre- and post- operative states in lumbosacral fusion without iliac screw fixation group. Also as compared to the non-iliac screw group, the iliac screw group reported significantly worse self-perceived mobility for all questions in our questionnaire. Conclusion: The current study demonstrate that patients underwent lumbosacral fusion with iliac screw fixation have morbidity and poor self-perceived mobility in Asian sedentary life style. The results suggest that surgeons should discuss with patients about morbidity and life style change after surgery before long level lumbosacral fusion including pelvic fixation, Introduction: Lumbar and/or thoracolumbar kyphosis with sagittal imbalance is one of the main causes of negative impacts on the quality of life. Spinal osteotomies should be needed to achieve ideal sagittal curve correction in these patients. Pedicle subtraction osteotomy (PSO) is well-known for powerful corrective osteotomy technique. To review the radiographic and clinical outcomes of lumbar or thoracolumbar kyphotic deformity patients treated with osteotomies including PSO. And to investigate global and regional sagittal balance after corrective surgery, global sagittal parameters such as SVA, PT, T1 pelvic angle (T1PA), PI-LL mismatch and achieved PSO angle, regional kyphotic angle, TL junction Cobb angle analyzed among preoperatively, postoperative 1 month and final follow-up at the standing whole spine radiographs. Outcome variables included radiographic evaluations (SVA, PT, T1 PA, and PI-LL mismatch) at postoperative 1 month and final and clinical outcomes (ODI, VAS of back and leg pain, and SRS-22r). Methods: Thirty-eight patients (31 women and 7 men) who underwent pedicle subtraction corrective osteotomy were enrolled from 2009 to 2015. 30 lumbar flatback deformity (3 degenerative flatback and the other 27 postfusion flatback) and 8 delayed posttraumatic kyphosis patients were included. Preoperative, postoperative 1 month, and final whole spine standing sagittal radiographs were obtained and analyzed by achieved PSO angle, regional curves (thoracic, thoracolumbar, lumbar Cobb angle), local kyphotic angle and apical vertebra distance(AVD) in patients with posttraumatic kyphosis, pelvic parameters (pelvic incidence(PI) and pelvic tilt [PT]) and global balance (sagittal vertical axis [SVA], T1 pelvic angle(T1PA)). Early perioperative and delayed fusion or instrumentation related complications were also reviewed. Results: Mean age was 63 years old (range 46-74), and follow-up was 25 months. Mean age of flatback deformity was 65 years old and 56 years for posttraumatic kyphosis. Previous surgery in post-fusion flatback deformity was mean 2.4 spine operations PSO levels of lumbar flatback deformity were L1(2), L2(4), L3(13), and L4(11). PSO levels of post-traumatic kyphosis were T12(4), L1(4). In patients with flatback deformity, Mean angle of PSO of flatback was 29.5° (range 17°∼40°). Preoperative 1.8° lumbar kyphosis, 31° PT, 176 mm SVA, 52° PI-LL mismatch, and 41° T1PA were significantly improved in 57° lumbar lordosis, 14° PT, 17 mm SVA, -6° PI-LL, and 11° T1PA at postoperative 1 month and well maintained these parameters finally. In patients with posttraumatic kyphosis, mean corrected kyphotic angle was 35° (range 20°∼40°). Preoperative 42° TL Cobb angle, 79 mm SVA, 92 mm AVD were significantly improved in 6.5° TL kyphosis, 19 mm SVA, and 6 mm AVD and well maintained finally. The mean score of ODI, VAS of the back pain/leg pain, and SRS-22r patient questionnaire of lumbar flatback deformity patients was significantly improved at the final follow-up (P < 0.05). preoperative mean ODI(67), VAS of the back pain(8), VAS of the leg pain(7), and mean SRS22r(2.0) were significantly improved into 25 ODI, 2.8 VAS of the back pain, 2.3 VAS of the leg pain, 3.7 SRS-22r score at the final. Preoperative mean ODI(56), VAS of the back pain(7.5), VAS of the leg pain(6), and mean SRS22r(2.2) of delayed posttraumatic kyphosis patients were significantly improved into 19 ODI, 2.1 VAS of the back pain, 1.6 VAS of the leg pain, 4.0 SRS-22r score at the final. Reoperation was 12 cases(40%): early reoperation were 6 cases (20%): 4 acute proximal junctional failures due to 2 UIV fractures, one UIV+1 fracture and one proximal screw loosening; one neurological deficit and one hematoma revision. Delayed revision surgery were 6 cases (20%): 3 fusion extension due to delayed proximal junctional kyphosis; 1 nonunion at L5S1; one symptomatic rod fracture revision, one delayed compression fracture with neurological deficit. Conclusions: Lumbar or thoracolumbar kyphotic deformity patients can be treated with osteotomies including PSO. Pedicle subtraction Osteotomy (PSO) is very effective for the correction of post-fusion lumbar flatback deformity and/or delayed post-traumatic kyphosis with global and regional sagittal imbalance. Patient satisfaction with surgery and overall radiographic and clinical outcomes are excellent even though higher rates of perioperative and delayed complications., Introduction: Lumbar hyperlordosis is seen as a compensatory mechanism in sagittal malalignment. Hyperlordosis may also be seen after overcorrection with spinal osteotomies, but rarely causes clinically significant negative sagittal imbalance because of the thoracic compensation. Hypercorrection in the lumbar spine leading to negative sagittal balance with pelvic anteversion can reduce quality of life. This uncommon condition needs surgery aimed to reduce lumbar lordosis, which has received little attention in the literature. Material and Methods: We describe a case of a 45 year old woman with a history of juvenile scoliosis treated conservatively. From the age of 42 she underwent 3 surgeries: T3-L4 posterior fusion, L4-L5 XLIF with posterior extension of fusion and finally L3-L4 XLIF with posterior revision 3 years after the first procedure. Despite the aggressive surgical treatment the patient complained of persistent lumbar pain and lower limb pain (ODI: 68 VAS back: 10 VAS legs:7). Upon examination she presented with sagittal and coronal imbalance. The negative sagittal imbalance, caused by the extension of her fusion to the pelvis with excessive lordosis, resulted in an negative SVA (-64 mm) and a negative pelvic tilt (-3°). Other preoperative spinopelvic parameters were: LL 62°, PI 37°, TK 45°. A posterior column osteotomy was performed at L2-L3, where the disc was not fused. Distraction through the osteotomy site and structural grafting were applied. Coronal correction was obtained by asymmetrical distraction. Results: Postoperative lumbar lordosis was reduced by 18° to a final LL of 44°, SVA was -1,5 mm, PT +4°, TK 49°. No complications were observed. Conclusion: Kyphosing posterior column osteotomy is a surgical technique that can be used to restore sagittal balance in patients with fixed lumbar hyperlordosis and negative sagittal balance. Appreciation of a patient’s balanced sagittal alignment and available compensatory mechanisms can help ensure appropriate osteotomies are planned and executed., Introduction: Adult spinal deformity (ASD) describes a complex spectrum of spinal conditions presenting in adulthood that result in abnormal spinal alignment in axial, coronal and sagittal planes. Conservative management is offered as the first line of treatment but its efficacy is not supported by literature. Different surgically approaches with various grade of invasiveness are described in literature: open surgery (OP), minimally invasive surgery (MIS) and hybrid technique (OP+MIS). The aim of this systematic review is to investigate risks and complications in ASD surgery. Materials and Methods: A systematic review of the available English literature about ASD perioperative (≤3 months) and long-term (> 3 months) surgical complications on Pubmed, Embase, Medline, Google Scholar and Cochrane Central Register of Controlled Trials (CENTRAL) databases was conducted. Retrospective (minimum 24 months follow-up for OP and 18-months for hybrid and MIS) or prospective studies (minimum 18 months follow-up) including randomized controlled trials, nonrandomized trials, cohort studies, case-control studies, and case series published in 2005 or later were included. Postoperative complications were all stratified by surgical approach. Open surgery included anterior, posterior or combined approaches with three-column osteotomies and non-three-column osteotomies. MIS techniques were percutaneous screws fixation, lateral lumbar interbody fusion (LLIF), anterior column realignment (ACR), Axial lumbar interbody fusion (AxiaLIF), and MIS transforaminal lumbar interbody fusion (MIS-TLIF). Results: One hundred-seven articles were ultimately eligible for analysis. 90 analyzed OP, 6 concerning MIS, 7 about hybrid, 2 MIS-hybrid, 1 MIS-OP-hybrid and 1 OP-hybrid. For open approach the data of 13164 patients (mean age 52.1 and mean follow-up 3.5 years) were extracted, there were 4451 complications and a complication rate of 0.34. Specifically, major perioperative complications occurred at a mean rate of 0.09, minor perioperative complications occurred at a mean rate of 0.10, and long-term complications occurred at a mean rate of 0.11. For hybrid and MIS 647 and 480 patients were analyzed respectively (mean age 64.8 and 63.8; mean follow-up 2.3 and 2.6 years). Major perioperative complications occurred at a mean rate of 0.15 for hybrid approach and 0.06 for MIS, minor perioperative complications occurred at a mean rate of 0.21 and 0.09, long-term complications occurred at a mean rate of 0.19 and 0.11 respectively. Conclusion: Aging of population, increased active life expectations and improvements in instruments and surgical techniques have involved an increased of spinal surgery for ASD. An appropriate and correct information providing realistic expectations to the patients and their family about risks and complications is mandatory before surgery., Introduction: Pelvic incidence (PI) was first described by Legaye and could be considered as a constant for each individual because it is an anatomical parameter once the growth is completed. This parameter has a cardinal importance in the regulation of the sagittal curves of the spine because there is a correlation between pelvic incidence and other spino-pelvic parameter. Adult deformities are often characterized by a mismatch between pelvic incidence and lumbar lordosis as well as coronal malalignment. Recently some classification of adult spinal deformities have been proposed and they rely on the fact that pelvic incidence is a fixed parameter, thus representing the base on which the new shape of the spine can be built. The purpose of this study is to analyze the modification of spino-pelvic parameters in patients who underwent long spinal fusion to the sacrum or to the ilium for correction of adult deformities. Material and Methods: The pre and immediate post-operative X-rays of 65 patients that underwent surgical correction for coronal, sagittal, or combined adult deformity between 2012 and 2015 were retrospectively analyzed. We included patients who had thoraco-lumbar fusion and we excluded revision surgeries, patients affected by tumors, autoimmune disease or infection. We divided the population in two groups: group A (n = 22) had fusion from the thoracic spine to S1, group B (n = 43) from the thoracic spine to the ilium. The spino-pelvic parameters were measured on the full standing spine pre-operative and post-operative x-rays by different surgeons checking the inter-observer variability. Results: Group A was composed by 18 women and 4 men with an average age at the time of surgery of 64.2 years. The mean pre and post-operative PI in this group were respectively 57° and 61° with a mean difference of 4° that was statistically significant (P < .05). In group B there were 4 men and 39 women and the average age was 65.6. The mean pre-operative PI was 53° and decreased to a mean value of 50° at post-operative control (mean difference 3°; P < .05). Conclusion: We observed that pelvic incidence changed in both groups. This result may be due to the position of the patient during surgery. The PI may decrease when fixation reaches the ilium due to the forced hyperextension of the hips and the aggressive correction maneuvers which create stress across the sacro-iliac joints (SIJ) and change the position of the sacrum within the pelvis. Conversely, the PI may increase in patients with fixation to the sacrum because of the long lever arm on the SIJ that forcing the sacrum into a more horizontal position. Pelvic incidence is still regarded as a key parameter in the planning of an adult deformity correction, although some papers have been recently published about its modification in the elderly and after surgery. Our work suggests that we still lack knowledge in the deformity correction methods and perhaps new parameters might be taken in consideration in the future., Introduction: Spondylolisthesis is characterized by slipping the upper vertebra lower on the previous direction or in more severe cases, anterior, and caudal. It can be classified according to rating Spinal Deformity Study Group - SDSG in six grades according to the degree of slip of the vertebrae, pelvic incidence and squamous pelvic equilibrium. It is common low back pain with or without radiation to the lower limbs, sensory and motor function in the lower limbs, postural changes and sometimes neurogenic claudication, defined as pain in the lower extremities, numbness or weakness associated with wandering or remain seated. To assess pain and functional capacity of a patient with spondylolisthesis, high-grade neglected. Materials and Methods: Patient, female, 27 years old, pregnant women diagnosed with spondylolisthesis type 6, with the presence of postural changes without motor deficit, paresthesia in dermatomes L5 and S1 (Scale ASIA) and Visual Analogue Scale (EVA) 9 in the lower back. The degree of slippage was determined using a lateral view of the lumbar spine in the standing position. It was performed conventional functional kinesiological evaluation before and after physical therapy twice a week lasting 50 minutes each session for 15 weeks. During the sessions lumbar segmental stabilization exercises were associated with breathing exercises, diaphragmatic and application of bipolar interferential current for analgesia in the lower back. At the end of the sessions we used the Oswestry Disability Index 2.0, a functional questionnaire that allows us to evaluate the function and capacity of the patient. Results: After 30 sessions of physiotherapy in five months, patients showed a significant decrease in back pain (VAS = 2), paresthesia (only S1) with improved performance of activities of daily living. The results found in Oswestry index was 26%, indicating that the patient has a moderate disability. Conclusion: Although the radiographic images contain important anatomical changes, the proposed conservative treatment provided a significant improvement in functional kinesiological frame with functional capacity guarantee., Introduction: The objectives of this study were to access the effectiveness of surgery and nonoperative treatment regimens for patients with adult spinal deformity (ASD) in terms of responsiveness of pain, disability, and quality of life; and to evaluate the complication and revision rate of large modern surgical series. Materials and Methods: A systematic review of articles in English using PubMed between 2005 and 2015. Only articles that reported baseline and follow-up ODI data were included for further analysis. Data extraction of articles using predefined data fields and risk of bias assessment were done independently by 2 authors. Results: 26 articles were analyzed, most of them were retrospective (n = 22; 84.6%). The average postoperative improvement in ODI was -19.1 (±9.0), NRS back pain -4.14 (±1.38), NRS leg pain -3.36 (±1.33), SF36-PC 11.2 (±5.07), SF36-MC 9.93 (±4.96). Surgery presented very large effect size in reducing disability (1.28), back (1.94) and leg (1.4) pain, and medium effect size in increasing physical (0.49) and mental (0.5) components of quality of life. No effects on back pain (-0.13), disability (-0.06) and quality of life (PCSF36 = 0.01; MCSF36 = 0.01) were observed in nonoperative series. The complication rate ranged from 9.52% to 81.52% in surgical cohorts (weighted mean: 39.62% ±16.62). No complications were recorded from the nonsurgical series. The need for revision surgery ranged from 1.72% to 40.0% (weighted mean: 15.71% ±8.99). Conclusions: These data may assist clinicians in determining how much to expect these outcomes to change after surgical treatment that may assist in counseling patients, informing providers and policy makers., Introduction: Tranexamic acid (TXA) and cell saver (CS) are successfully used to reduce bleeding in major surgery. The increase in the number and complexity of spinal deformity corrective surgeries, blood loss, often requiring massive intraoperative transfusions, becomes a major limiting factor during surgery. This scenario is particularly during posterior vertebral column resection (PVCR), where extensive intraoperative blood loss may pose a major risk to the patient, preventing smooth execution of the procedure. The purpose of this work is to study the efficacy of the intraoperative administration of TXA and CS in spine surgery with regard to the reduction of perioperative bleeding, blood needs and possible postoperative complications deriving from its use. Material and Methods: Observational, longitudinal, retrospective study of patients who underwent transpedicular arthrodesis surgery in adult deformity at the Leon hospital from 1 January 2007 until 31 December 2015. We collected sociodemographic variables, diagnosis, type of surgery, arthrodesis levels, surgical time, perioperative complications, bleeding, transfusion, hospital stay and complications. Classified in three groups: Group A (n = 26), patients who were administered TXA. Group B (n = 21), intraoperative CS. Group C (n = 30), patients not administered TXA or CS. We did a statistical analysis using SPSS software v22.0. Results: 77 patients, 68% women, 65 years, Levels fused 7. There is no difference in the demographic, surgery duration, number of levels fused, days of hospital stay and surgery complications between the three groups. Patients who were administered TXA received 20% fewer allogenic blood transfusions (P = .041). Patients in the CS group had 21% less reduction of postoperative haemoglobin (P = .029). TXA reduced the intraoperative bleeding 27% in comparison with control group. There aren’t more infections, seromas or complications with CS or TXA. Conclusion: TXA and CS reduced the demand for allogenic transfusion and had less reduction of postoperative haemoglobin, but not increases the development of post-surgical complications., Introduction: Corrective surgery in kyphoscoliosis is high demanding surgery for both surgeon and patient due to necessity of performing osteotomies, nowadays OLIF is widely performed to achieve minimally invasive lumbar lateral interbody fusion. In our study we used OLIF minimally invasive as first step to aim lumbar interbody fusion and to start correcting the lumbar sagittal balance. Material and Methods: From February 2016 to June 2016 we have collected 8 patients with lumbar kyphoscoliosis. There were 3 males and 5 females (average age 65,6 ys), in 6 cases we performed 3 levels OLIF at L2-L3, L3-L4 and L4-L5; in 1 case OLIF L4-L5, in 2 cases L3-L4 and L4-L5. In all cases we used right lateral decubitus. We observed verticalization time, clinical function, healing time and complications. Results: In all 8 cases after 2 days the patients were verticalized, blood loss was less than 50 cc; the OLIF procedure required almost 45 minutes per level. The correction gained on sagittal balance after stand alone OLIF was 5.3° level. In all cases according to PROLO and VAS score we had excellent results. As complication in 3 patients we had transient psoas weakness and thigh numbness on left side; in 2 cases with posterior long construct (T10-L5) we had sacro iliac inflammatory disease resolved with corticosteroid injections. Conclusion: OLIF is a safe and reproducible technique and it’s useful during the first of the correction of lumbar kyphoscoliosis., Introduction: The osteoarthritis of knee with flexion contracture may result in the changes in spinopelvic parameters in normal asymptomatic spine. The aim of this study is to evaluate the influence of knee joint flexion contracture to sagittal spinopelvic alignment by comparing groups of gonarthrosis with knee joint flexion contracture over 10 degree and those without contracture. Material and Methods: A total of 59 patients with gonarthrosis having knee joint pain over 1 year, and normal asymptomatic spine were included (mean age 66.7 ± 9.8, M/F=30/19). Volunteers with history of spine operation, spinal disease, chronic pain in their back, scoliosis, spondylolisthesis, 1-3 segmental disc space narrowing, and/or compression fractures in radiographs were excluded. They were divided into 2 groups according to the degree of flexion contractures in the knee joint (Group 1, without knee joint flexion contracture, n = 29, Group 2 > 10°, n = 30). After taking a standing sagittal radiograph, the following parameters were included: distances from C7 plumb to the postero-superior endplate of S1(C7PL), thoracic kyphosis (TK) between T5 upper endplate (UEP) and T12 lower endplate (LEP), thoracolumbar kyphosis (TLK, T10 UEP - L2 LEP), lumbar lordosis (LL, T12 LEP - S1 UEP), pelvic tilt (PT), pelvic incidence (PI), and femoral tilt angle (FTA). They were analyzed between 2 groups, respectively. Results: There were no significant differences between two groups in C7PL (0.0 ± 3.1 cm in Group 1 vs. -0.8 ± 2.9 cm in Group 2, P = .45), TK (26.1 ± 10.8° vs. 22.4 ± 10.1°, P = .30), TLK (6.5 ± 8.4° vs. 9.9 ± 5.9°, P = .17), LL (-53.0 ± 8.1° vs. -53.1 ± 10.2°, P = .10), PI (49.6 ± 8.7° vs. 53.5 ± 14.1°, P = .30), PT (12.6 ± 8.3° vs. 16.9 ± 10.5°, P = .18), FPA(7.2 ± 0.08° vs. 1.1 ± 7.2°, P = .08), and FTA(5.4 ± 3.2° vs. 15.8 ± 3.4°, P = .00). Conclusion: In the patients with gonarthrosis, the flexion contracture of knee joint over 10° did not show the difference of the spinopelvic angular parameters by the quantitative measurements of the pelvic and spinal parameters., Introduction: Cervical spondylosis is a degenerative disease of the vertebral column and associated soft tissue structures that can gradually progress as a normal aging process. These spondylotic changes can cause irritation or impingement to the nerve roots or spinal cord known as radiculopathy or myelopathy, respectively. Cervical spondylotic myelopathy (CSM) is a severely debilitating disease that can progress to several severe consequences such as spasticity and weakness of the limbs, clumsiness of the hands, and in extreme cases, paralysis. Several surgical treatment modalities for CSM and can be approached anteriorly, posteriorly, or circumferentially. The current controversy with the anterior approach is whether anterior cervical decompression and fusion (ACDF) or anterior cervical corpectomy and fusion (ACCF) is more efficacious in treating multilevel CSM. The most current Cochrane review to examine surgical options for cervical radiculopathy or myelopathy was published in 2010. Since then numerous studies have compared ACDF to ACCF for this indication, but have led to variable data without explicit answers to this controversial topic. Materials & Methods: We reviewed and analyzed peer-reviewed articles published since the 2010 Cochrane review that examined the use of ACCF for patients with a diagnosis of CSM. Only studies with a minimum follow-up period of two years and at least one clinical or radiographic outcome were included. Data collected included grafts and constructs used, mean blood loss (MBL), operative times, clinical and radiographic outcomes including fusion rates, and complications reported. Results: 13 studies were included in this review article. The most common constructs reported were fibular struts with and without halo vests, mesh filled titanium cages, PEEK cages, and expandable titanium cages (Figure 1) with the use of autogenic or allogenic graft. Mean follow-up in these studies ranged between 24 months and 8.5 years. MBL reported by these studies ranged between 108 and 1011 cubic centimeters (cc). The mean operative time ranged between 119 and 268 minutes. Nine studies reported fusion rates (79-100%). Five of the studies showed a 100% fusion rate by final follow-up and two others reported rates over 93%. Each of the studies demonstrated significant improvements in one or more of the following: JOA and mJOA scores, Nurick grades, VAS scores, and NDI scores. Eleven of the studies reported either segmental lordosis changes and/or C2-C7 Cobb angle changes on radiographic measures and each showed significant post-operative improvement in their reported metric. Complications reported included CSF leak, dysphagia, hoarseness, epidural hematoma, dural tear, C5 radiculopathy, and cage dislodgement and subsidence. Conclusion: This review article shows that ACCF is a relatively safe and effective surgical option for CSM, despite carrying certain risks expected of any anterior cervical approach. If the pathology lies behind the vertebral body, then ACCF should be greatly considered. When used for suitable indications, ACCF can improve signs and symptoms of CSM and improve functional outcomes with minimal complication rates., Background: Anterior cervical discectomy and fusion (ACDF) has gained well popularity and been accepted as an effective treatment on a various cervical spinal pathologies especially cervical disc pathologies (Disc Prolapse & DDD) meanwhile it is associated with many complications both intra and post operation. Aim of the Study: To evaluate the early complications of ACDF intraoperatively & postoperatively. Patients and Methods: This multicenter prospective study of 50 patients 38 male (76%) and 12 females (24%) their ages distributed form 35- 60 years (mean of age 42.5 years), the study was started from January 2013 to October 2014, we followed up them for 6 weeks and evaluate the clinical and radiographic signs of complications. Results: There were 18 patients (36%) had transient dysphagia, 15 (30%) had donor site pain, 1 patient (2%) each had slippage of cage, postoperative hematoma, dural tear & wrong level surgery. None of these patients had recurrent laryngeal nerve injury, esophageal injury, or acute postoperative infection. Conclusion: Not all complications required surgical intervention and can be treated nonoperatively with careful follow up. Our results are comparable with what was reviewed in other literatures. Yet the incidence of complications is increased with more than one level fusion and in multiple co-morbid disorders (including diabetes, smoker.), Introduction: This study compared patients undergoing one level anterior cervical discectomy without fusion versus anterior cervical discectomy with fusion. Methods: The study included forty patients operated at either C5-C6 level or at the C6-C7 level: a group of anterior cervical microdiscectomy without fusion performed at one level on 20 consecutive patients was matched to a second group of 20 patients with single-level of anterior cervical discectomy with fusion, based on level, age and sex. The kinematic analysis included the range of motion, intervertebral angulations, anteroposterior translation and disc height assessed for the cervical functional spinal units at the operated level and adjacent levels. Results: At the operated level the range of motion and the translation were minimal in the anterior cervical discectomy without fusion group, both for the C5-C6 and C6-C7 levels, and absent in the cervical discectomy with fusion group. The superior adjacent levels range of motion and the translation were greater in the ACDF group compared with the ACD group. Conclusions: The clinical results of anterior cervical microdiscectomy without fusion and anterior cervical discectomy with fusion were comparable. In cervical microdiscectomy without fusion the elastic fibrous intradiscal scar at the operated level allows a small degree of mobility and the adjacent cervical levels are not overstressed. No need for anterior cervical discectomy with fusion to trait a single level cervical disc herniation than in selected cases., Introduction: Surgical experience has been postulated to play a role in perisurgical morbidity in spine surgery. However no current data exists to verify this statement and if there is surgical threshold at which the morbidity decreases. This study investigates the impact of surgeon volume on inpatient morbidity after 1–2 level anterior cervical discectomy and fusion (ACDF). Material and Methods: Data from the Nationwide Inpatient Sample from the year 2009 were extracted. All adult patients who underwent an elective 1–2 level ACDF for degenerative cervical spine disease were identified. Surgeon volume was analyzed as a continuous and categorical variable (very-low, low, medium, high, and very-high volume). A multivariate logistical regression analysis was performed to calculate the adjusted odds ratios of in-hospital complication occurrence in relation to surgeon volume. Results: A total of 11,388 admissions were analyzed. The overall complication rate was 2.7%, and the surgical complication rate was 1.2%. Following regression analysis, increasing surgeon volume (evaluated continuously) was independently associated with lower odds of perioperative complication development (OR 0.99; 95% CI, 0.98 – 0.99). Complications in non-teaching hospitals occurred in 2.5% of cases, compared to 2.8% in teaching hospitals (P = .313). Very-low volume surgeons (performing less than 12 procedures per year; less than 1 per month) showed a significant increase in overall complications (OR 1.65; 95% CI, 1.05 – 2.58), when compared to very-high volume surgeons. Both very-low volume surgeons (OR 2.20; 95% CI, 1.11 – 4.37) and low-volume surgeons (performing less than 24 procedures per year; OR 2.13; 95% CI, 1.10 – 4.13) had a significant increase in surgical complications. Conclusion: In this retrospective analysis of a nationwide database, increasing surgeon volume was independently associated with significantly lower odds of perioperative complications following 1–2 level ACDF. Complication rates at teaching and non-teaching hospitals were similar. Additionally, a potential threshold of 1 procedure per month was found to significantly decrease overall complication rates; performing 2 or more procedures per month significantly decreased surgical complication rates., Introduction: Anterior cervical discectomy and fusion surgery has evolved over the period of time. Traditional techniques have complications such as graft subsidence, graft site morbidity, implant loosening, dysphasia and prolonged hospital stay. Cervical interbody spacer with integrated screws (coalition) offer a minimally invasive, less disruptive and earlier recovery option so we can discharge the patient on same day. Materials and Methods: We analysed prospectively collected data of total 37 patients with cervical myelopathy and/or radiculopathy which were operated with one level anterior cervical discectomy and fusion. Coalition is an integrated screws and spacer system designed to provide the biomechanical strength of a traditional anterior cervical discectomy and fusion. The procedure is streamlined by low profile instrumentation which facilitates a less invasive approach through a smaller incision. All patients were discharged within 24 hours after surgery, most on the same evening. All patients were followed up for a minimum period of one year. Patients were evaluated by neck disability index, visual analogue score for arm & neck, mJOA score, Bazaz-Yoo dysphasia index, fusion and implant failure. Results: 33 patients were evaluated as 4 patients were lost in follow up. Mean age of 46 years, 19 male & 14 females. Compared to preoperative scores, visual analogue scale pain score and Neck Pain Disability Index reduced significantly (P < .01). Statistically significant improvement in mJOA score was observed (P < .05). X-rays and CT demonstrated good fusion. Two patients complained of moderate and one of mild transient dysphasia. No device-related complications occurred and no fractures. Conclusions: Low profile cervical implants are safe in anterior cervical discectomy and fusion with low complication rates. It allows effective decompression and fusion, early recovery and lesser hospital stay., Introduction: Cervical pedicle screw fixation and Magerl screw fixation provide good correction of cervical alignment, rigid fixation and a high fusion rate. However, malpositioning of the screws is not a rare occurrence and the insertion of screws has a potential risk of neurovascular injury. Thus, it is necessary to determine a safe insertion procedure for these screws. To avoid complications during cervical pedicle screw and Magerl screw insertion, the authors developed a new technique which is a mold shaped to fit the lamina. Material and Methods: Preoperative CT scan images of 1 mm slice thickness were obtained of the whole surgical area. The CT data were imported into a computer navigation system. We developed a 3D full-scale model of the patient’s spine using a rapid prototyping technique from the CT data. Molds of the left and right sides at each vertebra were also constructed. One hole (2.0 mm in diameter and 2.0 cm in length) was made in each mold for the insertion of a screw guide. We performed a simulated surgery using the bone model and the mold before operation in all patients. The mold was firmly attached to the surface of the lamina and the guide wire (K wire of 1.42 mm in diameter) was inserted using the intraoperative image of lateral vertebra. The proper insertion point, direction and length of the guide were also confirmed both with the model bone and the image intensifier in the operative field. Then, drilling using a cannulated drill and tapping using a cannulated tapping device were carried out. Twenty consecutive patients who underwent posterior spinal fusion surgery using this technique since 2009 are included. The screw positions in the sagittal and axial planes were evaluated by postoperative CT to check for malpositioning. Results: The screw insertion was done in the same manner as the simulated surgery. With the aid of this guide the cervical pedicle screws and Magerl screws could be easily inserted even at the level where the pedicle seemed to be very thin and sclerotic on the CT image. Postoperative CT showed that more than 95% of the screws were in the ideal position and there were no critical breaches of the screws. Conclusion: The present method employing the device using a 3D image guide appears to be easy and safe to use. The technique may improve the safety of cervical pedicle screw and Magerl screw insertion even in difficult cases with narrow sclerotic pedicles. Based on this study, we concluded that this procedure can provide a safe insertion of cervical pedicle screws and Magerl screws for critical cases., Introduction: Repetitive extension strain of cervical spine is a risk factor for degenerative cervical spine disorders. The relationship between the repetitive flexion or extension posture on the cervical spine on labor and the degenerative change of the cervical spine, and the factors effecting on the degenerative change of the cervical spine are to be identified. Material and Methods: To identify the factors effecting on the degenerative change of the cervical spine, age, sex, height, weight, body mass index, smoking, DM, time engaging in labor, and cervical spine posture (flexion or extension) required repetitively on labor were investigated on the subjects. In addition, to evaluate the level of degenerative change of the cervical spine on 83 people in the flexion group (flexion strain) and 83 people in the extension group (extension strain), cervical degenerative index (CDI) in the simple cervical spine lateral radiograph was used to score (0-60 points) the degenerative severity. Results: 166 samples (flexion group: 83 people, extension group: 83 people) participated in this study, and for the CDI, the cervical spine flexion group scored 7.8 ± 6.2 points, and the cervical spine extension group scored 12.2 ± 6.0 points to show that the cervical spine extension group had significant degenerative change in the cervical spine. On the multiple linear regression test conducted to verify the risk factors effecting on the degenerative change of the cervical spine, age (P = .004), contraction of DM (P = .029), and extension posture of cervical spine (P < .001) showed to have influence on the degenerative change of the cervical spine. Conclusion: Repetitive extension posture on the cervical spine on labor and contraction of diabetes affect on degenerative change of the cervical spine, therefore, training on the medical care and posture on labor are required to prevent the progression of degenerative change in the cervical spine., Background: In patients with cervical stenosis, functional impairment of the motor pathways is traditionally measured by determination of motor and sensory evoked potentials. The current study aims at establishing a reliable and objective way to measure corticospinal excitability and plastic changes of the motor area in patients with cervical myelopathy using navigated TMS. Methods: 18 patients with a cervical myelopathy due to cervical spinal canal stenosis were examined preoperatively with nTMS. On the basis of the initial JOA score two patient groups were established (JOA12). We determined the resting motor threshold, recruitment curve and cortical silent period for the FDI muscle. Using the MEP responses at 105% RMT a weighted map of cortical motor function was created for both hemispheres. Accordingly, eight healthy subjects were examined. Results: nTMS revealed a reduced cortical excitability in the patient group. Although the resting motor threshold was comparable in both groups (P = .366) the corticospinal excitability estimated by the recruitment curve was reduced in the patient group (31.5 ± 38 / 48.7 ± 35.8 compared to healthy 149.5 ± 82.6 / 57.9 ± 35.8, P = .007). Interestingly, patients were partly able to compensate for spinal impairment by mechanisms of cortical plasticity. In patients with only mild symptoms (JOA>12) a compensatory higher activation of non-primary motor areas was detected (P < .05). In contrast, patients with severe impairment (JOA, Introduction: The cervicothoracic junction is a unique region in the spine. Disc herniations at the cervicothoracic junction (C7/T1 level) are unusual and there have only been a few studies on patients with herniated C7/T1 discs. In addition, previous studies did not focus on the mechanism and causes of solitary cervicothoracic junction disc herniation. The authors investigated the characteristics, symptom duration, clinical course, and biomechanics of cervicothoracic junction disc herniation by comparing patients with C7/T1 disc herniation (C7/T1 group) with control groups (patients with C5/6 disc herniation and healthy patients). Material and Methods: 28 patients who underwent C7/T1 single-level disc surgery between 2006 and 2015 were included. We excluded patients who underwent multi-level surgery at the same time. Patients with adjacent vertebral level surgery in the past were also excluded in order to evaluate the characteristics of solitary C7/T1 disc herniation. For radiographic comparison, patients in the herniated C5/6 disc group (C5/6 group) and the healthy control group were cohort matched. For evaluation of the height of the shoulder and sternal notch, we used cervical spine plain X-rays and magnetic resolution imaging (MRI). The data were collected by four neurosurgeons to reduce bias. We investigated the characteristics, symptom duration, clinical course, pre- and post-operative symptoms, and trauma history. We also evaluated the height of the shoulder and manubrium (sternal notch), as well as the body mass index (BMI) for each group. Results: In the C7/T1 group, C7/T1 disc herniation usually occurred in the foraminal space and most patients presented with C8 nerve root deficits. The C7/T1 group was significantly associated with a history of trauma (P < .001). In addition, compared to the C5/6 group (6.67 ± 0.49) and normal group (6.88 ± 0.41), the cervical vertebral body was much more readily observed in the plain cervical lateral X-ray image in the C7/T1 group (7.36 ± 0.71). The height of the sternal notch did not show any significant differences. Conclusion: There are some characteristic aspects of C7/T1 disc herniation. The disc herniates laterally because of the absence of Luschka joints at this level. Hand motor weakness is common and is due to compression of the C8 root, which is mainly composed of a motor component. A history of trauma was closely related with C7/T1 disc herniation. A lower location of the shoulder may increase the mobility of the cervicothoracic junction, increasing the rate of disc herniation at the junction., Introduction: Anterior cervical discectomy and fusion (ACDF) using titanium cages is considered to be a standard procedure for the treatment of cervical degenerative disc disease. Bone substitutes are widely used to pack the cage to avoid the complications related to bone harvesting from the donor site. Recently a porous hydroxyapatite/collagen (Hap/Col) composite has been developed as a next-generation bone substitute. The aim of this study is to investigate the effectiveness of a porous Hap/Col composite as a packing material in the titanium cages for ACDF. Material and Methods: A total of 20 patients (16 one-level and 4 two-level surgery) underwent ACDF for cervical degenerative diseases. In all cases, titanium cages were filled with hybrid grafts using bone marrow aspirate (BMA) combined with a porous Hap/Col composite. Stand-alone cages were used in one-level surgery and anterior plates were added in two-level surgery. Lateral radiographs and computed tomography were used to assess cage subsidence and fusion status at final follow up (Ave.14.6months, 6∼24 months). Results: Cage subsidence was present at 5 segments in one-level surgery and at no segments in two-level surgery. 91.7% of the treated segments were evaluated as solid fusion (15/16 in one-level and 7/8 in two-level surgery). No revision surgery for nonunion were requested. Conclusion: High fusion rates were obtained after ACDF using a porous Hap/Col composite-packed titanium cages. A porous Hap/Col composite can be expected to promote bony fusion in the early stage after surgery., Introduction: Cervical spondylotic myelopathy (CSM) is a condition in which compression of the spinal cord results from degenerative change and an unstable spine. Two main causes of this condition are cervical spondylosis (CS) and ossification of the posterior longitudinal ligament (OPLL). Many authors have reported satisfactory surgical outcomes of laminoplasty for CSM. However, there is still some controversy concerning the prognostic factors. The purpose of this study is to analyze various prognostic factors that could impact the surgical outcomes of expansive laminoplasty. Material and Methods: We retrospectively reviewed the outcome of consecutive 45 patients who underwent ‘modified unilateral open-door laminoplasty using hydroxyapatite spacers and malleable titanium miniplates’ between June 2008 and May 2014. Clinical outcome was assessed using Frankel grade and Japanese Orthopaedic Association (JOA) scale. We defined a good clinical outcome as a JOA recovery rate greater than 75% in this study, and patients were divided into two groups (good vs poor outcome groups). Results: Mean preoperative JOA scale in each group was significantly different (14.95 ± 3.21 in the good outcome group and 10.78 ± 6.07 in the poor outcome group [P < .001]). The preoperative cervical ROM was significantly greater in the poor clinical outcome group than in the good clinical outcome group (29.89° ± 10.11 in the good outcome group and 44.35° ± 8.88 in the poor outcome group [P < .001]). Between the presumptive factors, increased preoperative JOA scale (OR 1.271, 95% CI 1.005 – 1.607), decreased preoperative cervical ROM (OR 0.858, 95% CI 0.786 – 0.936) were statistically correlated with good outcomes of patients with laminoplasty in CSM on univariate analysis. And these factors demonstrated an independent association with clinical outcomes (preoperative JOA scale OR 1.344, 95% CI 1.019 – 1.774, P = .036, preoperative cervical ROM OR 0.860, 95% CI 0.788 – 0.940, P =.001). Conclusion: There have been various prognostic factors of laminoplasty in patients with CSM. In this study, the higher preoperative JOA scale had a relationship with good clinical outcomes after laminoplasty. And greater preoperative cervical spine ROM was associated with poor clinical outcomes after laminoplasty. These results may suggest that cervical mobility and preoperative patient neurologic status may have an influence on the clinical outcome of laminoplasty., Introduction: The internet allows the average person to access a vast quantity of information and educational resources. Health related searches are quite common, comprising 4.5% of individual queries entered into a search engine and 53.5% of patients report having utilised the internet to obtain information about medical conditions. The majority of patients believe that the health information found on the internet is of a standard that is either the same or better than that of their doctor In patients attending elective spinal outpatient clinics, use of the internet to research their condition has been found to be common. YouTube is the most popular video website in the world, with 1 billion unique visitors a month. Health related videos that are uploaded to YouTube are not subjected to peer review or regulated in any other way. The aim of this study is to assess the quality of anterior cervical discectomy and fusion (ACDF) videos found on YouTube and identify video factors associated with quality. Methods: YouTube was searched using the phrase “anterior cervical discectomy and fusion.” The first 50 videos were reviewed and rated according to the DISCERN, JAMA, and HON ranking systems. Information about each video was collected, including number of views, length of time since video was posted, percentage positivity (defined as number of likes the video had, divided by the total number of likes or dislikes of that video), number of comments and who was the author of the video. Any associations between these factors and video quality were tested. Results: Each video had been viewed on average 96239 times. 36% of the videos were produced by surgeons, 46% were patient testimony. The average quality of the videos was poor, with average scores of 1.78/5 using the DISCERN criteria, 1.63/4 using the JAMA criteria and 1.96/8 using the HON criteria. When assessed using the JAMA or HON criteria, videos produced by surgeon authors scored significantly higher than patient testimony videos. No other factor was found to be significantly associated with quality. Conclusions: The quality of ACDF videos found on YouTube is low, with a preponderance of videos consisting solely of patient testimony. These results align with the previously reported poor quality of YouTube videos on other healthcare subjects. YouTube videos should not be recommended as a means of educating patients about ACDF., Introduction: Interspinous bursitis (Baastrup’s disease) is a well-known disease that is characterized radiologically by the close approximation of opposing spinous processes, resulting in spinal degeneration such as sclerosis of the adjacent spinous processes and adventitious bursa formation in the intervening interspinous soft tissues. Most of them is the lumbar lesion. Cervical interspinous bursitis has rarely reported. In addition, propagation of the bursa into the dorsal epidural space can result in intraspinal cyst that may cause symptomatic spinal stenosis. No case with the cervical epidural cyst from interspinous burusitis has been reported. Material and Methods: This study reports a rare case with cervical interspinous bursitis causing subacute myelopathy and reviews literatures. A 71-year-old woman presented with progressive myelopathy and motor weakness for one month. Lateral radiograph demonstrated apposition of the spinous processes of C3 and C4. Magnetic resonance imaging demonstrated bursal fluid between the C3 and C4 spinous processes, as well as a posterior epidural cyst compressing the spinal cord. CT scan showed sclerosis with cysts at between the C3 and C4 vertebral bodies. Results: The patient underwent the C3-C6 laminoplasty with the laminotomy of C2 and C7. Intraoperatively, a cystic membrane was encountered under the flavum of C3/4 and removed. Pathological diagnosis was bursitis. The specimens revealed that edematous collagen fivers with vascular proliferation were covered with epithelial cells. Fibroblasts and inframatory cells were proliferating. Postoperatively the patient had almost full-recovery of myelopathy and motor weakness. Interspinous bursitis is commonly seen in the lumbar spine and rarely reported in the cervical spine. Moreover, epidural cyst associated with the interspinous burusits has been reported in a few cases of the lumbar lesions. To the best of our knowledge, this is the first report of cervical Baastrup’s disease with an epidural cyst causing myelopathy. Conclusion: Intraspinal posterior epidural cyst associated with the interspinous burusitis could occur in the cervical spine, although it was rare. It might cause progressive myelopathy., Introduction: T1 nerve root comprises brachial plexus together with C5 through C8 roots. Only T1 root is protected by the thoracic cage at its origin probably because it bears an important hand function. Therefore, T1 radiculopathy seems to be thought quite rare lesion and its features in symptomatology have not been clarified yet. We report 4 cases of T1 radiculopathy and findings useful for the diagnosis. Material and Methods: All of the cases (3 males and 1 female; 56 through 75 years old) underwent posterior foraminotomy unilaterally at T1-T2 disc levels. We are assured of their diagnosis by improvement in subjective symptoms or objective signs after surgeries. Evaluations were done on the following 6 items: 1) chief complaints, 2) initial symptoms, 3) arm or finger numbness at first visit, 4) muscle strength on manual muscle testing (examined muscles are triceps, ext digitorum communis, first dorsal inteross, abd digiti minimi, ext poll longus, add poll, and abd poll brevis, 5) grip power, 6) compressing spinal factors. Results: Chief complaints of all cases were hand dysfunctions. Paresthesia was complained in little finger in 2 cases, in ulnar upperarm in 1, and in none in 1. Weakness were detected on manual muscle testing in finger extensors in 3 cases, in first dorsal interosseous in 3, in abductor digiti minimi in 3, in extensor pollicis longus in 3, in adductor pollicis in 4 and in abductor pollicis brevis (ABPB) in 4. ABPB was the weakest on MMT in all cases. Their grades on MMT were 1 in 1 case, 2 in 2 and 3 in 1. Atrophy of ABPB was observed in all cases. Grip power on the affected side was 19 through 88 (average: 58) % compared to the normal side. Compressing spinal factors causing T1 radiculopathy were laterally herniated disc in 1 case and foraminal stenosis due to hypertrophy of facet joints in 3 cases. Conclusion: Patient with T1 radiculopathy complains hand dysfunction. Atrophy or severe weakness of abductor pollicis brevis, mimicking carpal tunnel syndrome, is the feature of T1 radiculopathy., Introduction: It is well known how the usage of disk prosthesis, in case of spondilodiscoarthopaties or single disk herniation, might be a good option instead of classical anterior approach. The anterior cervical discectomy and fusion, especially when is single level, doesn’t change the overall cervical movement, while maintaining the correct lordosis of this segment. On the other hand, the ACDF carries itself some negative sequels as an alterations of kinetics on the treated level or the chance to develop a disc disease or some instability on the adjacent levels. From early nineties the arthroplasty or the positioning of interbody prosthesis, represents a valid alternative, more physiologic, to a cervical fixation. This technique leads both to recovering or maintaining the correct disc height and the right lordosis, and to preserving and keeping the mobility of the treated level. Material and Methods: From 2006 to 2015, 42 patient underwent arthroplastic procedure for cervical single level disease. Patient averaged 41.5 (27-56) at the index procedure. The implanted prosthesis are so divided: 17 PRODISC-C®, 17 DISCOVER®, 5 BRIAN® and 3 PRESTIGE II®. The average follow-up is 5-year long. We evaluated both the clinical, submitting the NDI and VAS scale, and the radiological outcome in order to evaluate the unlikely spontaneous fusion or the system’s pull-out. Results: Among the 42 patient, 37 responded to the follow-up. The average per-operation VAS was 8.5 while the post-op was 1.6. We’ve been able to evaluate only the post-op NDI which was 20%. Under the radiological point-of view, we encountered 3 case of subsidence, 2 case of dislocation, 1 “very-early” re-surgery for the persistence of clinical symptoms and 18 cases of heterotopic ossification. Conclusion: The arthoplastic procedure, in our experience, ensures a significant reduction on the cervical and brachial pain, permits both the maintaining of the movement on the treated level and the warranting of some stability. In the same time, this technique decreases the risk to develop disc disease to the adjacent level. According to our study, we can conclude that the arthoplastic procedure, if performed in very selected cases, is an acceptable alternative to the ACDF., Introduction: Evaluation of clinical and radiological outcome of stand alone anchored spacer (Zero P) in anterior cervical discectomy and fusion. Material and Methods: Retrospective study done between May 2009 and 2010 in 21 patients with cervical disc prolapse selected for anterior cervical discectomy and fusion with cervical radical syndrome or neurological deficit, failure of conservative treatment for atleast 6 weeks and responding findings on MRI. Results: Patients had significant reduction in VAS radicular arm pain, VAS neck pain and NPAD within 3 months. No significant difference between male and femle patients. No screw pull out or implant failure during the follow up and radiological evidence of fusion in 9 months post operative period. Conclusion: Ideal cervical fusion substitute and gives maximal comfort. Maintains spinal alignment, foraminal height and provides immediate stability in compression and avoids axial displacement .Prevents dysphagia and soft tissue morbidity. Fusion in all patients and obviates the need of cervical orthosis., Introduction: Demineralized bone matrix (DBM) is been utilized for cervical arthrodesis in order to reduce non-Fusion rates. Aim of this stud was to evaluate the influence of DBM on the radiological and clinical outcome after anterior cervical discectomy and fusion (ACDF) with stand-alone PEEK cages. Methods: Retrospective age-, gender- and number of levels-matched pair analysis was performed on 200 patients following ACDF with stand-alone PEEK cage between 2007 and 2013 with a minimum follow up of 12 months. In the study group, DBM was used as an osteogenic filling substance. Radiographic follow-up included static and dynamic radiographs. Changes in the operated segments were measured and compared to radiographs directly after surgery. Clinical outcome was evaluated the EuroQOL questionnaire (EQ-5D). Results: 45% of patients were female. Mean age was 55 years. There were no significant differences in radiological outcome between both groups: Fusion (76.8 vs. 79.7%; P = .56), subsidence (17.7 vs 18.3, P = 1.0), changes in cervical alignment (P = .6). Moreover, there were also no significant differences in clinical outcome between both groups: neck pain P = .89, arm pain P = .53, myelopathy changes P = .185, EuroQOL Index P = .127). Conclusions: Application of DBM in ACDF with stand-alone PEEK Cages have no influence on radiological or clinical outcome, Introduction: Cervical 2 (C2) pedicle screw fixation is often used during posterior cervical fusion. C2 pedicle diameter and feasibility of screw placement are always considered during cervical instrumentation. We believe that C2 pedicle diameter and its relationship with the vertebral artery is often miscalculated and underestimated based on the preoperative CT scan images, as the axial CT cuts are performed in the plane parallel to the disc space and tangential to the pedicle. The goal of this study was to determine C2 pedicle diameter on axial images and images parallel to the C2 pedicle using intraoperative O-arm reconstruction. Materials and Methods: In this study, there were 33 patients, including 20 males and 13 females. Age ranged from 44 to 89 yr with mean age of 63.7 yr. All patients underwent C2 pedicle screw placement between September 2013 and August 2016, 14 patients with cervical myelopathy, 9 with cervical fracture, 6 with cervical kyphotic deformity, 2 with failure of cervical construct, 1 with C2-3 subluxation and lesion, respectively. Images of C2 pedicles were obtained using O-arm with try-planar reconstruction. The axial images were not manipulated but were assessed as provided and C2 pedicle diameters were measured. After that the axial plane was positoned parallel to the C2 using plane rotation function of the O-arm and new measurements were performed. The axial and oblique widths of C2 pedicle on the screen were measured on the axial and oblique images using a regular ruler, and therefore called “screen width of C2 pedicle”. O-arm software at this point does not provide the measurement tool. Results: The axial width of C2 pedicles ranged from 6 to 15 mm with mean of 10.44 ± 2.15 mm on the right side, and from 7 to 14 mm with mean of 10.29 ± 1.72 mm on the left side. The oblique width of C2 pedicles ranged from 10 to 19 mm with mean of 14.73 ± 1.85 mm on the right side, and from 12 to 19 mm with mean of 15.33 ± 1.67 mm on the left side. These measurements indicate oblique screen widths of C2 pedicles are 1.4 and 1.5 times higher that axial screen width on the right and left side, respectively. Conclusions: The axial and oblique images of O-arm provide valuable assessment of C2 pedicle width. The oblique screen width of C2 pedicles is better to be used for predicting the feasibility of C2 pedicle screw placement than its axial screen width. Since this assessment may help in surgical decision-making at no added cost or radiation exposure, we suggest obtaining screen width of C2 pedicle whenever considering C2 pedicle screw inserting., Introduction: The objective of this study is to develop guidelines that outline how to best manage (1) patients with mild, moderate and severe myelopathy and (2) nonmyelopathic patients with evidence of cord compression with or without clinical symptoms of radiculopathy. These guidelines will be used to enhance quality of care by establishing clinical protocols for the treatment of DCM and will assist clinicians with decision making by providing evidence-based recommendations for important areas of management. Material and Methods: Five systematic reviews of the literature were conducted to synthesize evidence on disease natural history; risk factors of disease progression; the efficacy, effectiveness and safety of nonoperative and surgical management; the impact of preoperative duration of symptoms and myelopathy severity on treatment outcomes; and the frequency, timing and predictors of symptom development. A multidisciplinary guideline development group used this information, in combination with their clinical expertise, to develop recommendations for the management of DCM. The benefits and harms, financial impact, acceptability, feasibility and patient preferences of each recommendation were carefully considered. Results: Our recommendations were: (1) “We recommend surgical intervention for patients with moderate and severe DCM;” (2) “We suggest offering surgical intervention or a supervised trial of structured rehabilitation for patients with mild DCM. If initial non-operative management is pursued, we recommend operative intervention if there is neurological deterioration and suggest operative intervention if the patient fails to improve;” (3) “We suggest not offering prophylactic surgery for non-myelopathic patients with evidence of cervical cord compression without signs or symptoms of radiculopathy. We suggest that these patients be counseled as to potential risks of progression, educated about relevant signs and symptoms of myelopathy, and be followed clinically;” and (4) “Non-myelopathic patients with cord compression and clinical evidence of radiculopathy with or without electrophysiological confirmation are at a higher risk of developing myelopathy and should be counselled about this risk. We suggest offering either surgical intervention or non-operative treatment consisting of close serial follow-up or a supervised trial of structured rehabilitation. In the event of myelopathic development, the patient should be managed according to the recommendations above.” Conclusion: These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in patients with DCM by promoting standardization of care, decreasing the heterogeneity of management strategies and encouraging clinicians to make evidence-informed decisions., Introduction: Degenerative cervical myelopathy (DCM) is a progressive, degenerative spine disease that is often treated surgically. Reported rates of surgical complications vary substantially across the literature and depend on definitions, surgeon experience, study design, and methods of data collection. There is a pressing need to develop high-quality standardized definitions of surgical complications in order to accurately evaluate the safety of surgical procedures. This review aims to (1) outline how biomechanical and hardware-related complications are defined in the literature and (2) evaluate the quality of definitions using a novel 4-point rating system. Material and Methods: An electronic database search was conducted in MEDLINE, MEDLINE in Process, EMBASE and Cochrane Central Register of Controlled Trials for studies that reported on complications related to DCM surgery and included at least 10 surgically treated patients. Data extracted included study design, surgical details, and definitions and rates of surgical complications. A four-point rating scale was developed to assess the quality of definitions for each complication. Results: Our search yielded 3582 citations, 76 of which met eligibility criteria and were summarized in this review. Defined complications included non-union (n = 55), adjacent segment pathology (n = 16), sagittal instability (n = 13), graft subsidence (n = 10), pseudoarthrosis (n = 7), vertebral slip (n = 5), graft dislodgement (n = 4), post-operative kyphosis (n = 2), heterotopic ossification (n = 2), graft collapse (n = 2), hinge fracture (n = 2), and spring-back closure (n = 1). Identification of complications was based on qualitative and quantitative criteria, often observed on radiographs or computed tomography scans. Reported rates of non-union or pseudoarthrosis (0.0-51.6%) and adjacent segment pathology (0.0-60.0%) varied substantially between studies. The incidence of subsidence differed depending on whether it was evaluated qualitatively (3.2-3.3%) or quantitatively (10.8% to 36.2%). Rates of graft dislodgement varied minimally across studies (0.2 -1.7%). Conclusion: Reported incidences of various biomechanical and hardware-related complications vary widely in DCM surgery, especially for non-union/pseudoarthrosis, adjacent segment pathology and instability. This summary serves as a first step for standardizing definitions and developing guidelines for accurately reporting surgical complications., Introduction: Anterior cervical decompression for degenerative cervical myelopathy (DCM) is associated with unique perioperative complications, including difficulty or discomfort swallowing (dysphagia) and changes in sound production (dysphonia). Reported rates of dysphagia and dysphonia vary substantially in the literature and are often dependent on method of data collection, diagnostic strategies, study design and definitions. Due to this inconsistency, it is difficult to accurately convey surgical risk to patients and appropriately manage their expectations. This review serves as a first step to developing guidelines for accurate reporting of surgical complications and aims to (1) outline how dysphagia and dysphonia are defined in the literature and (2) assess the quality of definitions using a novel 4-point rating system. Material and Methods: An electronic database search was conducted in MEDLINE, MEDLINE in Process, EMBASE and Cochrane Central Register of Controlled Trials for studies that reported on dysphagia, dysphonia or other related complications of DCM surgery and included at least 10 patients. Data extracted included study design, surgical details, and definitions and rates of surgical complications. A four-point rating scale was developed to assess the quality of definitions for each complication. Results: Our search yielded 3582 citations, 15 of which met eligibility criteria and were summarized in this review. Defined complications included dysphagia (n = 13), dysphonia (n = 2), swelling complications (n = 2) and voice fatigue (n = 1). Rates of dysphagia varied substantially (0.0% to 43.1%) depending on whether this complication was patient reported (0.0% to 10.9%), detected using a modified Swallowing Quality of Life questionnaire (43.1%) or Bazaz criteria (8.8%-50.0%), or diagnosed using an extensive protocol consisting of clinical assessment, a bedside swallowing test, evaluation by a speech and language pathologist and a modified barium swallowing test/fiberoptic endoscopy (42.9%). The reported incidences of dysphonia ranged from 0.63% to 36.5% depending on definitions (patient-reported versus patient-reported and confirmed by laryngoscope) and timing of postoperative evaluation. Conclusion: There is substantial variability in reported rates of dysphagia and dysphonia. As a result, there is a pressing need to standardize definitions; unification of terminology will enable improved evaluation of the overall safety of surgery, important risk factors, and the impact of these complications on recovery rate, patient satisfaction and costs. Furthermore, an accurate assessment of complications will benefit both the patient and surgeon by empowering patient-informed choice, facilitating shared decision-making and enabling a better evaluation of risks and benefits of each procedure., Introduction: Bone mineral density (BMD) is important in predicting mechanical strength of cage subsidence in increasing aging population. However, BMD based on cervical vertebrae is not routinely measured for cervical degenerative diseases. This study determined the association of the subsidence in anterior cervical discectomy and fusion (ACDF) and BMD data based on lumbar vertebrae. Methods: Radiological data of patients who underwent ACDF for one-level disc disease at our hospital were retrospectively collected from January 2012 to December 2014. Radiography and computed tomography scans were performed for radiological evaluation. Global cervical lordosis (GCL), fused segment angle (FSA), fused segment height (FSH), and disc space height (DSH) were measured and analyzed. Results: Successful bone fusion was achieved at the final follow-up examination in all patients who underwent ACDF. However, loss of disc height over 3 mm at the surgical level was observed in two patients in the osteoporosis group. Although all outcomes of the osteoporosis group were slightly lower than those of the normal group, there was no significant difference between the groups (P > .05). Conclusion: BMD based on lumbar vertebrae was not a significant factor to subsidence after ACDF. To better understand the cervical bone, it may be necessary to obtain BMD of surgical levels., Introduction: Axis fractures, basillary invaginations (BI) and reumatological diseases (RD) frequently need surgical treatment. The patients treated surgically with posterior C1-C2 stabilization in our clinic because of axis pathologies were presented in this study. Material and Methods: A retrospective analysis of 39 patients, still on follow-up, who underwent surgical treatment for axis pathologies in our clinic between May 2008 and April 2016 was presented. Osseous pathology, cerebral peduncle, spinal cord, ligaments and pannus formations were investigated by using x-ray radiography, thin-section computed tomography and magnetic resonance imaging. Results: Gender ratio was equal. Mean age was 45.8 (18-88). Twenty-five cases (68.9%) were fractures, 6 cases (13.7%) were BI and 8 cases (17.2%) were RD. Myelopathy and weakness were the main findings in patients with BI and RD where pain was dominant in patients with fracture. For the patients with BI and RD, one patient from each were underwent occipitocervical stabilization/fusion while C1-C2 occipitocervical stabilization/fusion with Goel technique was performed for the rest. For the patients with pure Type II and Type IIA odontoid fractures, C1-C2 posterior stabilization/fusion was applied while, for the patients with odontoid fractures combined with subaxial cervical fractures, long-segment posterior stabilization/fusion was preferred. Grafting was not performed to 11 of the fracture patients, who applied within 21 days after trauma and to whom reduction could be accomplished. A Bone graft was placed inside C1-C2 lateral mass articulation bilaterally for the patients applied later than 21 days and the patients with BI and RD. Bone fusion was achieved for all of the early-applied fracture patients without any grafting performed and 16 of the later-applied fracture, BI and RD patients. Conclusion: Posterior stabilization maintains enough and essential rigidity for achieving bone fusion in C2 pathologies. For early-stage odontoid fractures with transverse ligament injury, posterior stabilization is enough for achieving fusion without the need for grafting., Introduction: Cervical myelopathy is more frequent elderly people and is the leading cause of spinal cord dysfunction in this population. Neural decompression procedures for both laminectomy with fusion and laminoplasty have improved the neurological symptoms caused by myelopathy in these patients. It is known that both procedures could lead to fully described complications; However, there has not been determined if there are any functional advantage in patients managed operatively with laminectomy and fusion versus laminoplasty. Material and methods: We studied 46 patients diagnosed with cervical spondylotic myelopathy who underwent to operative management with neural decompression with laminectomy and fusion or laminoplasty (open door). A retrospective matched cohort analysis was made studying 46 patients with operative management, 23 patients with laminectomy and 23 with laminoplasty 23 (door open) for the treatment of neural multi-level involvement of cervical spondylotic myelopathy. Clinical outcome after 2 year of surgical treatment was analyzed considering the modified scale of Japanese Orthopedics Association (mJOA), the Nurick and NDI (neck disability index), the t-student and homogeneity tests was performed, considering a P < .05 as significant. Results: The gender distribution was 19 women and 27 men, with an average age of 72.2 years, there were no difference in clinical results by gender, age and affected levels between the two groups (laminectomy vs laminoplasty, P > .05). Regarding the functional outcomes resulted with mJOA, Nurick, and NDI; no statistical difference was found between laminectomy with fusion and laminoplasty. (P > .05). Conclusions: Patients in both groups, laminectomy with fusion and laminoplasty, reported similar functional outcomes after treatment of cervical spondylotic myelopathy at 2 year follow up. Prospective randomized controlled trials are needed to determine whether a procedure is truly superior., Introduction: The aim of this study is to explore the ability of medication and non-surgical treatments to predict the pain recovery of sequestrated lumbar disc herniations and the time of surgical treatment. Material and Methods: This study included 136 patients who presented with unilateral leg and low back pain and received definitive diagnoses of sequestrated lumbar disc herniation. We compared the degree of decreased pain with respect to treatments, as well as in patients who could not undergo surgery. From 2011 to 2014, we retrospectively investigated patients’ clinical statuses using a visual analogue scale (VAS). We followed patients for at least 1 year and correlated pain changes over time. Patients with increases in VAS despite treatment (eg, medication, physical therapy, and non-surgical treatment) underwent surgical treatment. Results: VAS decreased gradually until 6 weeks from pain onset, patients with sequestrated lumbar disc herniations (P < .001). All patients who underwent non-surgical treatment such as selective nerve root block or epidural steroid injection experienced more rapid VAS improvement during the immediate post-operative period compared with other patients. However, this difference was not statistically significant (P > .05). Nineteen (13.9%) of the 136 patients underwent lumbar discectomy. In these patients, the postoperative VAS decrease was statistically significant until 1 month postoperatively (P < .001). Conclusion: We observed the potential for spontaneous resorption with sequestrated lumbar disc herniation. Patients with sequestrated lumbar disc herniations may be conservatively managed for up to 6 weeks. Non-surgical treatments help with symptom relief. However, such treatments do not hasten the natural history of a sequestrated lumbar disc herniation. We recommend surgery for patients with an increased VAS despite receiving conservative treatment., Introduction: The pathophysiology of lumbar radiculopathy includes both mechanical compression and biochemical irritation of apposed neural elements. Inflammatory and immune cytokines have been implicated, induced by systemic exposure of immune-privileged intervertebral disc tissue. Surgical intervention provides for improved symptoms and quality of life, but persistent postoperative neuropathic pain (PPNP) afflicts a significant fraction of patients. This study compared the inflammatory and immune phenotypes among patients undergoing structural surgery for lumbar radiculopathy and spinal cord stimulation for neuropathic pain. Materials and Methods: Consecutive patients undergoing surgical intervention for lumbar radiculopathy or neuropathic pain were studied. Demographic data included age, gender, and VAS and neuropathic pain scores. Serum was evaluated for cytokine levels (IL-6, Il-17, TNF-α) and cellular content (WBC/differential, lymphocyte subtypes). The primary analysis differentiated molecular and cellular profiles between radiculopathy and neuropathic pain patients. Subgroup analysis within the surgical radiculopathy population compared those patients achieving relief of symptoms and those with PPNP. Results: Heightened IL-6, Il-17, and TNF-α levels were observed for the lumbar radiculopathy group compared with the neuropathic pain group. This was complemented by higher WBC count and a greater fraction of Th17 lymphocytes among radiculopathy patients. In the lumbar discectomy subgroup, pain relief was seen among patients with preoperatively elevated IL-17 levels. Those patients with PPNP refractory to surgical discectomy exhibited normal cytokine levels. Conclusions: Differences in Th17 immune activation are seen among radiculopathy and neuropathic pain patients. These cellular and molecular profiles may be translated into biomarkers to improve patient selection for structural spine surgery., Introduction: Lumbar disc herniation is a common spinal column degenerative disease, which has an increased population incidence as age increases. Patient’s symptoms are related to spinal nerve compression, radiculopathy and lumbar pain. In some cases, acute neurological deficits can also be present. Surgical or conservative treatment is individualized as well as the proper moment to intervene. However, rehabilitation is required through neurofunctional physiotherapy. Prognosis after surgical interventions depends on several factors such as the pre-operative neurological status, clinical complaints and clinical risk factors. Patient’s social and professional issues are also relevant. Pain, functional, and economic Index Scales such as the three described in this paper, help to predict prognosis. This study aims to evaluate patients post-operative prognosis in those submitted to microdiscectomy with the use of pain, functional, life quality and work activities return Index Scales, and also validate their use for patients with lumbar disc herniation. Material and Methods: An observational, longitudinal retrospective study was performed including all adulthood patients that were submitted to microdiscectomy as treatment for single-level degenerative lumbar disc herniation during a period of 3 years and with a 1-year follow-up. Patients that harbored other spinal column degenerative conditions, such as spondylosis and spondylolisthesis, were excluded. Data such as identification, professional issues and images were collected before and after the surgical operative procedures. In addition, three questionnaires were applied: Visual Analogic Scale (VAS), Roland Morris, and Prolo Index Scales. Literature review using scientific databases was also performed. Fisher’s Exact, Spearman’s Rank Correlation and Tukey’s Range Tests assessed the statistical variables among the 3 selected Index Scales. The Institutions Ethics Committee on Human Research approved the research project in January 2012. Results: After inclusion and exclusion criteria were applied, sixteen patients were selected but only 10 had a 1-year follow up in outpatient clinic. Post-operative pain improvement was identified after 6 months when compared to the pre-operative Visual Analogic Scale, Roland Morris and Prolo Index Scales. After 1 year, this pain improvement difference had reduced. No difference was identified among patients considering work activity return after 6 and 12 months. Those that were not working after 6 months were still not working after 12 months. Post-operative pain limited back-to-daily activities but was not a significant statistical factor. It was also noticed that VAS, Rolland Morris and Prolo pre-operative Index Scales, had significant correlation after 6 and 12 months. Causal relations among the studied variables indicated internal validity. Conclusion: The 3 identified Index Scales were effective in post-operative prognostication to evaluate patients with lumbar disc herniation. They also showed that they have significant correlation among each other. This study indicates that prognosis is favorable in patients submitted to microdiscectomy for single-level degenerative lumbar disc herniation. The 1-year post-operative lumbar and sciatic pain is reduced and back-to-work activities are limited but not due to pain. Perhaps other unidentified factors, such as social and professional issues, contribute to these findings., Introduction: Patients with pain after structural spine surgery may have a persistent postoperative neuropathic pain (PPNP) phenotype or structural pathology that warrants further treatment. Differentiating these has practical implications about patient selection for the next appropriate intervention and currently there are no validated tools to assist the clinician. Material and Methods: Sequential patients referred to a spinal cord stimulation (SCS) clinic with postoperative pain after spine surgery were included. Pain severity was measured by Visual Analog Scale (VAS) score and quality was assessed by the Douleur Neuropathique 4 (DN4) score. Disability was quantified by the Oswestry Disability Index (ODI). Psychological distress was tested by the Beck Anxiety Index (BAI) and Beck Disability Index (BDI). All patients were evaluated for residual or recurrent stenosis, post-laminectomy instability, pseudoarthrosis, and adjacent segment disease. Results: Among 150 patients, 68% were suitable patients for SCS whereas the remainder were candidates for decompression with or without fusion. There were similar VAS pain severity scores, overall DN4 scores, and ODI disability scores between the two groups (α = 0.05). Similar BAI and BDI scores were seen between surgical groups, but both forms of psychological distress increased with higher VAS and DN4 scores (P < .001 for all comparisons). Whereas the DN4 score did not differentiate surgical cohorts, specific components were significantly higher among SCS patients (burning pain, allodynia) or among structural patients (electric shocks). Conclusion: Patients referred for SCS therapy after spinal surgery should be rigorously evaluated for structural disease that warrants intervention. Managing psychological distress is important for either group and some features of the DN4 score can be applied to differentiate the surgical cohorts., Introduction: The aim of this study was to assess the outcome of symptomatic lumbar degenerative disease treated with topping-off technique (Coflex combined with fusion) and compare two-segment fusion at mid-long term follow-up; and find out whether the topping-off technique can reduce the rate of adjacent segment degeneration (ASD) after fusion. Material and Methods: One hundred and fifty-four consecutive patients who received topping-off surgery (76 patients) and two-segment fusion surgery (88 patients) from March 2009 to March 2012 were studied. All patients included in the analysis had a minimum of three years of follow-up. Radiographic and clinical outcomes between the two groups were compared. A logistic regression analysis was used to analyze risk factors for developing radiographic ASD. Results: Significant differences in clinical outcomes were observed between these two groups at three post-operative years (all, P < .05). Compared with the fusion group, the topping- off group showed preserved mobility at the Coflex level (P = .000), which is associated with less blood loss (P = .000), shorter duration of surgery (P = .000) and lower incidence of ASD (Chi-square test, rate topping-off vs fusion = 13.2 vs 26.1%, P = .039). There were no differences in complications between the two groups. Conclusion: Mid-long term follow-up efficacy and safety be- tween topping-off and fusion were similar, while topping-off reduced the rate of ASD. Under strict indications, topping-off surgery is an acceptable alternative to fusion surgery for the treatment of two-segment lumbar disease., Introduction: To evaluate the rate of revision surgery after posterior Coflex interspinous dynamic stabilization for degenerative disorders of the lumbar spine, and to discuss its causes and management, a retrospective study was conducted. Methods: From Sept 2007 to July 2015, 295 consecutive patients with degenerative disorders of the lumbar spine were treated with decompression and Coflex interspinous dynamic stabilization in our hospital. In order to evaluate the rate of revision surgery among these patients, and to discuss its causes and management, a retrospective study was conducted and all revision patients were treated and followed up to evaluate the clinical outcome through patient’s satisfaction. Results: Among 295 patients in this study, there were 16 patients underwent revision surgery and the total rate of reoperation was 5.4%. The duration between revision procedure and primary procedure was 15.1 ± 23.4 months (range, 0.1-60 months) in these patients. Among the 16 patients, 6 patients (37.5%) were underwent reoperation due to non-implant related complications such as infection of the wound or local hematoma. These 6 patients all healed with debridement or hematoma evacuation. Another 10 patients (62.5%) who underwent reoperation due to implant related complications. There were two patients who had topping-off procedure initially developed pedicle screw loosening or nerve root adhesion and were treated with re-implantation of the fixation or neurolysis. Another 8 patients who had single level Coflex dynamic stabilization developed symptoms related to the deterioration of the degeneration at previous segment or adjacent segment. Those patients were managed with decompression and fusion with pedicle screw fixation. None of the 16 patients who underwent revision surgery was directly related to the Coflex implant such as migration, loosening or dislocation of the Coflex implant and fracture of the spinous process. These revision patients were followed up for 28.6 ± 12.6 months (range, 6-48 months) and 93.8% of the patients were satisfied with the revision surgery at the final follow-up. Conclusion: Coflex interspinous dynamic stabilization for the treatment of degenerative disorders of the lumbar spine was safe and the reoperation rate was low. The main cause of the revision surgery including wound infection, local hematoma, or degeneration at previous segment or adjacent segment was not directly related to Coflex implant itself., Introduction: Surgical treatment of lumbar spondylolisthesis provides reliable clinical and radiographic results though complication rates vary significantly and few studies have investigated the association between slip reduction and complications. The purpose of this study was to determine complication rates in adult patients undergoing 1- or 2-level lumbar fusion for spondylolisthesis and to examine the association between slip reduction and complication rates. Material and Methods: Adult patients undergoing fusion for spondylolisthesis between June 2006 and June 2012 at a single tertiary academic spine center were identified. Inclusion criteria were: age 18 or older, lumbar spondylolisthesis (isthmic or degenerative), 1- or 2-level fusion and a minimum of 1-year follow-up. Electronic medical records were reviewed to collect demographic and complication-related data. Pre- and post-operative slip severity was quantified using the Meyerding grade. Descriptive statistics were summarized and complication rates were compared between groups with and without slip reduction. Results: 104 patients with a mean age of 52.3 years were included. 21.1% (n = 22) presented with an isthmic spondylolisthesis and 44.2% (n = 46) had a degenerative spondylolisthesis. Preoperatively 58 patients (55.8%) had a grade 1 slip and 41 (39.4%) had a grade 2 slip. In total 53.8% (n = 56) patients demonstrated surgical reduction of their spondylolisthesis by one Meyerding grade. At an average follow-up of 2.6 years 33.7% (n = 35) of the patients experienced a complication. The most common complications were adjacent segment degeneration in nine (8.7%) patients and incidental durotomy in seven (6.7%) patients. There was no difference in complication rates between those with and without a reduction of their spondylolisthesis. Conclusion: Our study demonstrates that 54% of patients with a low-grade spondylolisthesis had a one grade reduction of their slip following surgical treatment. The overall complication rate in our cohort was 33.7%. Surgical reduction of the spondylolisthesis was not associated with a higher rate of complications. Thus, reduction of low-grade adult isthmic and degenerative spondylolisthesis can likely be considered safe surgical practice., Introduction: The use of biologic technologies for the treatment of degenerative spinal diseases is undergoing rapid clinical and scientific development. Patients with an instability in the spinal motion segment profit from stabilization by dorsal fixation in combination with interbody fusion. BMP- 2 has gained broad acceptance as an adjuvant to spinal fusion when used with interbody fusion device to improve the ossification process. Materials and Methods: The clinical and surgical experience of patients treated for degenerative lumbar spine disease has been analyzed retrospectively. We included 17 patients with neurological deficits causing by spinal stenosis and instability after degenerative disc disease. All patients underwent a posterior lumbar interbody fusion in combination with BMP- 2 filled cages. Over the time from more than 8 years 13 patients were monitored prospectively with clinical examination, radiographs and CT-scans. Results: All patients improved from the operative procedure by reduced pain relief over the follow up time. No further neurological deficits were monitored in the period. No significant adjacent level degeneration was seen in the CT scans over 8 years follow up. Additional operative procedures in lumbar spine was not necessary. Side effects of BMP 2 were not detected. But there was clear evidence of vertebral endplate osteoclastic activity in the radiographs at 3 months in all patients. None of the patients were clinically symptomatic; events were radiographic findings. All patients showed radiographic evidence of fusion at the 6 months follow up CT scans. There was no ongoing ossification after the 6 month period. Some ossification was found in the surgical approach and around the pedicle screws. Ectopic ossification was not found over the follow up period of 8 years in CT-scans. Conclusion: The good results over a long time follow up of our small group of patients received BMP 2 for spinal interbody fusion gives a suggestion that faster fusion might provide an adjacent level degeneration in lumbar spine degeneration. The effects of BMPs seen after 3 month in the CT scans on osteoclast activity didn’t cause in clinical deficits to the patient. To evaluate these phenomena, dose dependency, osteogenic activity and associated osteoclastic activity attendant with the use of BMP-2 is studied in a large animal model., Introduction: The Synfix-LR(Synthes, Switzerland) has been used for anterior standard alone device to negate the need of posterior screw fixation for treatment of discogenic back pain. However we have used Synfix-LR and posterior screw fixation simultaneously to overcome various problems. In this study, we are going to introduce the usefulness of Synfix-LR in difficult cases. Material and Methods: From January 2011 to May 2014, about 1200 patients underwent Anterior Lumbar Interbody Fusion in our hospital. In these cases, 28 cases used Synfix-LR and pedicle screw fixation to overcome various difficulties. Mean age is 66.7. Male patients were 13 and female patients were 15. Follow up underwent by regular X-ray at post operative 1 month, 3 months, 6 months and 1 year. Functional outcomes and radiological measurements were recorded and reported. Results: 10 patients had severe modic change and endplate sclerosis and vacuum disc. We thought that the contact between cage and endplate not be stable so that enforce cage stability with anterior screwing.7 patients had end plate irregularity due to previous vertebral compression fracture. Some patients had large dimple at vertebral body. That case, we filled dimple with allograft and used anterior screwing for holding cage. 5 patients had high sacral slope and listhesis so that S1 body shape became ball surface. At this case we could predict cage instability and non-union. So we use anterior screwing for adding stability. 2 patients had pedicle anomaly unable to posterior pedicle screws. 3 patients had interspinous device and developed back pain, so remain interspinous device and underwent ALIF with anterior screws. 1 patient had fused vertebra at L4, L5, S1. So that pedicle screw fixation had some difficulty then use d additional anterior screws. VAS and ODI were improved. Radiological factors such as anterior height, posterior height, percentage of listhesis, segmental angle were all improved. There is one case of cage subsidence. All cases showed good union state. Conclusion: We investigated the practically extended indication of Synfix-LR cage instead of conventional cage in ALIF. It provided additional stability so that helps to reduce motion of cage. It leaded to solid fusion state. Screw integral PEEK cage system is very useful to overcome tough lumbar fusion cases., Introduction: X-ray (XR) measurements taken in a supine position are often underestimated. There is no literature to recommend a conversion ratio (CR) from supine data to an erect data in adult spinal deformities (ASD) patients. The aim is to find a conversion ratio for XR measurements from supine to erect position in adult lumbar scoliosis and sagittal alignments. Material and Methods: Consecutive XR images of ASD patients were retrospectively measured by 2 spine surgeons. Supine lumbar XR measurements were compared against erect XR measurements. SPSS analysis made. Results: 100 patients were included, 85 females and 15 male. Average age was 67.9 (42-93) yrs. Average scoliosis Cobb angle in supine and erect positions are 21.1 (±9.6)° & 26.7 (±11.7)° respectively and this was statistically significant. Cobb angle CR is 1.3. Average sagittal Cobb angle of T10-L2, T12-S1, Sacral Slope (SS), Pelvic Tilt (PT) & Pelvic Incidence (PI) in supine and erect positions are 6.9/8.6; -35.7/-37.4; 33.4/30.6; 23.3/26.2 and 60.0/60.0 respectively. Average CR from supine to erect XR measurements for scoliosis, T10-L2, T12-S1, SS, PT, PI are 1.3, 1.2, 1.2, 1.0, 1.3, 1.0 times respectively. With increasing Erect Cobb angle from, Introduction: The aim of this study is to describe the results obtained in relation to the frequency of arthrodesis performed in lumbosacral spine surgeries because of disc pathology in more than 3,000 patients over a period of 10 years. They were operated between January 2005 and December 2015 in our department of Orthopedics and Traumatology in Corporación Medica of General San Martin in Buenos Aires, Argentina. All patients were operated by the same surgical team including surgeon, assistants and surgical scrub nurse. In all of them we used the same surgical technique for arthrodesis, which consists only in the utilization of local chipping bone and blood crest. The results were surprising because of in more than 3000 operated patients only 157 were arthrodesis, from which with this surgical technique that we used we had less than 2% of pseudoarthrosis always without the utilization of bone substitute or iliac bone. In absolutely all cases where we did not do arthrodesis, the osteosynthesis material used was removed after 6 to 8 months postoperative to reinstate the complete spine mobility; this as an established protocol of our department. Materials and Methods: More than 3000 patients were evaluated, of which 157 were arthrodesis. All patients were studied by Rx and MRI except 64 patients who were studied with TAC for being unable to be exposed to a magnetic field. All treated by the same surgeon, assistants and scrub nurse. Patients which were operated for another pathology that was not discal were excluded from this study; as narrow channels, infections, fractures and / or tumors. Surgical technique: After the finalization of the respective surgery we proceed to the arthrodesis of it doing a decortication of the lamins, imbrication of the spinous and using blood pulled out from the posterior iliac crest through an abbocath and local bone chipping by the assistant or the scrub nurse. Results: Only in 157 patients we did arthrodesis over 3000 operated. The proportion of arthrodesis compared to the total lumbosacral spine surgeries in our service is very low. The percentage of pseudoarthrosis we have using this method of arthrodesis is less than 2%, which is not significant to us. Although we had a few pseudoarthrosis none of the patients had postoperative complications. All surgical wounds healed normally, without any secretions or phlogosis. No patients required re operation, all returned to their daily lives in a few months. The following up on them was from 8 months at least to 3 years in some cases. Conclusions: After an exhaustive study of each of our patients we conclude that only in a very few surgeries is necessary an arthrodesis as surgical technique in lumbosacral disc surgery. Concerning to the arthrodesis carried out it gives us excellent results the use of local chipping bone and blood crest instead of bone substitute and bone crest. This technique is usually used in our department and gives us great results., Introduction: Degenerative disc disease is a major malady afflicting young and working class population. The treatment modalities may vary from simple non-operative methods like physiotherapy to an intensively invasive procedure like spinal fusion. Minimal invasive procedures like nucleoplasty and annulo-nucleopalsty are still finding its place in the management step ladder. We here by decided to study the intermediate term clinical outcomes in patients undergoing Disc Fx in the surgical treatment of contained lumbar disc herniations (CLDH) and degenerative disc disease (DDD). Methods: We retrospectively collected data for all patients who underwent Disc Fx as a treatment modality for lumbar DDD and CLDH between September 2010 and December 2014. All included patients had failed a trial of at least 6 months of non-operative treatment which included physiotherapy, acupuncture or chiropractic treatment. DDD was defined as reduction in disc height but no less than 4 mm absolute height and no disc bulge. CLDH was defined as a disc protrusion but no prolapse or sequestration. All patients had back and or leg pain. The patients were assessed on various factors affecting the clinical outcome which included BMI, smoking status, approach to disc, and discography. Provocative Discography was performed for all the levels for all the patients undergoing nucleoplasty. Visual analogue scale (VAS), Oswestry Disability Index (ODI) and MacNab criteria scores were recorded for every patient pre–operatively, immediate post–operatively, at half, one and two years after the procedure. Results: A total of 51 patients underwent annulo-nucleoplasty with 66 procedures. The mean age was 41 years (range: 20-63 years) with a gender distribution of 13 females (25%) and 38 males (75%) and 67% smokers. There were 43 (84%) in the DDD subgroup and 8 (16%) in the CLDH subgroup based on the preoperative MRI scan. The pathologic level in decreasing order were L5S1 (45%), L4L5 (41%), L3L4(12%) and L2L3(2%) respectively. Concordant discography was recorded in 47 levels (71%) and discordant pain was recorded in 19 levels (29%). There were significant improvement in VAS and ODI scores (P < .01) at immediate post-op, 6 months, 12 months and 2 years follow-up with none of the patients requiring surgical reintervation. The percentage of patients with excellent/good MacNab outcomes was 39% in immediate postop, 49% in 6 month, 57% at 1-year and 78% at 2-year follow-up. The proportions of patients with excellent/good MacNab outcomes at any time points after the procedure were significantly greater than those before the procedure. Univariate analysis revealed that discography positivity was significantly associated with improvement in ODI scores at 6 and 12-month follow-up. VAS and MacNab scores were not statistically affected by majority of demographics except BMI and smoking. BMI and smoking status has significant influence on VAS scores at 6 and 12-month follow-up. Conclusion: We can conclude that Disc Fx can be considered as a safe and minimally invasive procedure which can be offered to patients to provide significant pain relief for a period of at least 2 years. This would help them to either delay or avoid a spinal fusion., Introduction: Extreme lateral interbody fusion (XLIF) allows for deformity correction by inserting a wide and large wedge-shaped interbody cage of 10-degree angle. The procedure is characterized by indirect decompression which results in an increase in the spinal canal area and the intervertebral foramen area via ligamentotaxis. In this study, we compared a combined posterior and anterior fusion approach using the XLIF and percutaneous pedicle screws (PPS) with conventional approaches (TLIF/PLIF) with respect to sagittal alignment correction in patients with lumbar degenerative spondylolisthesis. Material and Methods: Twenty-six patients underwent XLIF with percutaneous pedicle screw instrumentation for lumbar degenerative spondylolisthesis since September 2013 (9 males, 17 females, mean age 67.7 years) (hereafter, X group). Disc height (mm), slip (mm), and disc angle (°) were measured for these patients on pre- and postoperative lateral plain radiographs and compared with 26 patients who recently underwent TLIF/PLIF (14 males, 12 females, mean age 63.7 years) (hereafter, T group). Both in the X and T groups, patients consecutively underwent surgery performed by a single surgeon. A 10° lordotic cage was used as the XLIF implant. Results: The mean preoperative disc height, slip, and disc angle in the X group were 6.98 mm, 6.73 mm, and 5.68°, respectively, while those in the T group were 7.48 mm, 6.73 mm, and 2.88°. The mean postoperative disc height, slip, and disc angle in the X group were 11.7 mm, 2.47 mm, and 10.8°, respectively, while those in the T group were 10.2 mm, 4.33 mm, and 5.85°. For the correction of sagittal alignment, the mean disc height, slip, and disc angle, were +4.74 mm, -4.27 mm, and +5.16°, respectively, in the X group compared to +2.69 mm, -2.69 mm, and +2.96° in the T group, indicating that the correction effect was significantly greater in the X group than the T group. Conclusion: This study suggested that XLIF allows a wider range of patients to be a candidate for surgery including elderly patients and patients with more severe deformity, and that XLIF is less invasive as compared to conventional procedures. In addition, the XLIF has a high ability to correct sagittal alignment because a large cage is placed on a hard surface area of the vertebral body margin. Therefore, it is considered to be an extremely useful surgical approach for the treatment of lumbar degenerative spondylolisthesis. The number of patients with severe spondylolisthesis was, however, limited in this series, thus further investigation on the limitation of its indication is required., Introduction: Unilateral pedicle screw fixation has similar post-operative outcomes as bilateral fixation in degenerative lumbar spine disease. Unilateral fixation is faster, less invasive and cheaper. Furthermore a wide endplate coverage by the intersomatic cage improves load sharing, thereby increasing fusion rate and lowering the risk of subsidence. Material and Methods: 39 patients (25 men and 14 women, median age 53 years) underwent unilateral TLIF with a modular PEEK cage (Interfuse S TM, VTI). The cage is intraoperatively assembled within the disc space with a variable number of modules. It can be implanted unilaterally through a small access channel. Indications for surgery included spinal stenosis with primary or post-laminectomy instability, recurrent disc herniation, first-grade non-lytic listhesis. All patients underwent immediate post-operative CT scan and follow-up evaluation including a clinical and radiographic assessment 2 months post-operatively and clinical/CT evaluations at 6 and 12 months. Results: Median follow-up was 10,2 months (range 1-28). Cage positioning was straightforward, no surgical complication occurred. Postoperative CT always showed appropriate cage positioning and a wide endplate coverage: 55% (range 47-64%) along the transverse diameter and 68% (range 61-74%) along the antero-posterior diameter. Two months after surgery the Oswestry Disability Index was improved in all patients and X-ray did not show any dislocation of the implants, except in one case associated with loosening of a screw. 6-months assessment was available for 33 patients and 12 months assessment for 26 patients: all were still clinically improved and CT did not show signs of pseudarthrosis. Conclusion: According to our experience, unilateral TLIF can be safely and effectively performed with the use of the InterFuse modular cage, taking advantage of the small size of its modules and allowing a customized coverage of large or irregular endplates. This appears particularly useful in revision surgery and osteoporosis., Introduction: In the interspinous surgery, there has been a change in the paradigm for which the use of rigid or flexible devices inserted with open and percutaneous technique, which served only as a spacer, was supplemented by the use of devices for the fixation and fusion interspinous. The device for fixation with interspinous fusion has primary stability and mobility control in all axes (greater flexion-extension) blocking the two functional units. Each device has its own characteristics, but the objective is to place it as close as possible to the lamina (interlaminar).The interspinous fixation system is comparable with the screws. The presence of the fusion, which was considered a complication in the spacers (motion surgery), is the final result of the interspinous surgery. Material and Methods: Our experience covers 120 cases operated from 2003 to 2014 with degenerative disease of the spine including 80 treated with rigid or flexible spacers (54 monolevel, 16 double, 5 triple and 5 associated with other stabilization systems) and 40 cases with fixation device interspinous (30 single and 10 double-layer). Each patient was studied preoperatively with dynamic RX, CT and MRI and follow up with RX dynamic to 6, 12 and 24 months and, in some cases, CT reconstructions. They have been used for the clinical evaluation of the VAS and ODI scales preoperatively and at 12 months. Results: The clinical outcome at 12 months was comparable between the two groups with significant improvement in VAS and ODI values. In cases treated with spacers 60%, at 2 years, did not present mobility (not visible to simple X-ray the probably fusion) while in the device group for fixation and fusion at 2 years have seen the fusion in 90% of cases. In 6 cases (7.5%) treated with spacers, it was necessary a revision surgery: removal of the presence of a bilateral isthmic lysis unrecognized preoperatively, in 2 cases a reoperation for recurrence, one contralateral without removal of the device, a spinous process fracture with inability to place the device, removing a dislocation, an event that had been treated with 3 levels reappearance of intense pain that necessitated the removal and direct decompression and stabilization with pedicle screws.In the device group for fixation complications were one case of intraoperative fracture with positioning impossibility, a fracture of the spinous process asymptomatic, asymptomatic hyperostosis and a mobilization, but none required reoperation. Conclusion: The interspinous surgery requires proper selection of patients and has probably resulted in fusion even in the spacers. In the literature published studies are short term and therefore probably the result in fusion is more common than reported. In our experience the use of interspinous device is a possible and viable strategy in the treatment of degenerative lumbar diseases., Introduction: Lumbar microdiscectomy is the most commonly performed spine surgery procedure. Over time lumbar discectomy has evolved to a minimally invasive procedure performed in an outpatient setting in many international institutions. Patients traditionally have been advised to restrict activity following lumbar spine surgery.1 However, post-operative instructions are heterogeneous. The purpose of this report is to assess, by survey, the post-operative care practices and recommendations of Australasian neurosurgeons in the era of the modern lumbar microdiscectomy. Material and Methods: A survey of Australasian Neurosurgeons was conducted by email invitation sent to all full members of the Australasian Neurosurgical Society. The survey consisted of 11 multi-choice questions answered by an anonymized online survey distributed electronically by the Australasian Neurosurgical Society. The survey consisted of questions relating to operative indications, technique, and post-operative instructions for lumbar microdiscectomy. Results: The survey was sent to all Australasian Neurosurgeons. 71 responses were received of which 68 were complete (28.9%). The geographic distribution of respondents was well spread. Only complete responses are included. Operative Indications: most surgeons reported they would consider a period of either 4-8 weeks (42.7%)(29) or 8-12 weeks (32.4%)(22) as the minimum duration of radicular pain adequate to offer surgery. Operative Technique: unilateral muscle dissection with unilateral discectomy was practiced by 76.5%(52) of surgeons. A tubular retractor system was used by 20.6%(14). Operative microscope was the most commonly employed method of magnification (76.5%)(52), no magnification was used by only (2.94%)(2). Post-operative Care. The majority of surgeons (55.9%)(38) always refer patients to undergo inpatient physiotherapy. No sitting restrictions were advised by 22.1%(15) of surgeons with 39.7% (27) advising patients to sit as comfort allows post-operatively. When advised sitting restrictions were most commonly recommended for a period of up to four weeks (57.4%)(39). Lifting restrictions were advised by 83.8% of surgeons. Such restrictions were most commonly advised for periods up to 4-8 weeks (52.17%). Conclusion: This study reports the results of a survey of Australasian neurosurgeons regarding lumbar discectomy practices. The vast majority of neurosurgeons perform unilateral muscle dissection and discectomy under magnification. A majority of Australian neurosurgeons advised sitting restrictions. Lifting restrictions are advised by approximately 80% of Australasian neurosurgeons. The persistent recommendation of activity restrictions following lumbar discectomy is consistent with a recent survey of British spine surgeons.2 The results of these two surveys suggest a possible role for further investigation of the role of post-operative activity restrictions following lumbar discectomy in the era of minimally invasive spine surgery. References 1. Carragee EJ, Han MY, Yang B, Kim DH, Kraemer H, Billys J. Activity restrictions after posterior lumbar discectomy. A prospective study of outcomes in 152 cases with no postoperative restrictions. Spine. 1999;24(22):2346–51. 2. McGregor AH, Ben Dicken, Jamrozik K. National audit of post-operative management in spinal surgery. BMC Musculoskelet Disord. 2006;7(1):1., Introduction: Lumbar canal stenosis is conventionally treated with surgical decompression with or without fusion. Transforaminal lumbar interbody fusion (TLIF) is usually performed with bilateral pedicle screws fixation. TLIF done by unilateral approach which reduces the exposure and cost of surgery has been described in literature with variable results. We have evaluated the clinical outcomes and fusion rates in selected group of the patients who were operated by TLIF using unilateral pedicle screws (low implant load construct). Materials and Methods: Retrospective analysis of 54 patients (29 females, 25 males and mean age of 43) operated in our institute by single surgeon with minimum one year follow-up. Inclusion criteria were predominant single leg radiculopathy due to single level lumbar disc disease with modic endplate changes and >50% maintained disc height. Exclusion criteria were patients with multilevel stenosis, severe osteoporosis, severe facetal arthropathy, > grade 1 spondylolisthesis, > 50% disc height lost and morbid obesity. Exposure was done only on the side of radiculopathy followed by unilateral pedicle screw fixation and interbody fusion. Visual analogue scale (VAS) and Oswestry disability index (ODI) were analyzed for clinical assessment. Fusion and implant failure were determined on follow-up radiological assessment. Operative time and hospitalization periods were also evaluated. Results: The mean follow-up duration was 20.4 months. The mean preoperative VAS score was 6.7 and 4.3 for leg and back pain, respectively. Postoperatively pain in the symptomatic side lower extremity and the back improved significantly to 1.6 and 1.7 respectively (P < .05). The ODI was improved significantly from 41.5 to 14.6% (P < .05). All patients were showed good fusion without any screw back out or cage displacement. Average duration of surgery was 64.3 minutes with average duration of hospital stay was 2.4 days. Conclusions: Satisfactory results were acquired with TLIF conducted through the unilateral approach using low implant load construct in selected group of patients with lumbar canal stenosis and unilateral radiculopathy. This procedure with less exposure provides earlier recovery with good fusion. Further studies are required for indentifying comprehensive selection criteria and assessing fusion., Introduction: Oblique lateral interbody fusion (OLIF) is a minimally invasive surgical methods that can access L4-5 level of lumbar spine, via a narrow corridor formed by anterior border of psoas and lateral border of the aorta (or iliac artery). However, depending on the incidence angle of the cage insertion, the contralateral nerve root is at risk of injury. The purpose of this study is to examine the maximum safe incidence angle of cage insertion when performing OLIF without violating the contralateral nerve root at disc level, using a series of computed tomography (CT) scans of the lumbar spine of patients that underwent OLIF at (or including) L4-5 level. Material and Methods: Between July 2013 and January 2015, 36 consecutive patients underwent OLIF at L4-5 (or including L4-5 in cases of multilevel fusion) at our institution. All patients had CT scans of lumbar spine taken in right decubitus positions to simulate patient’s actual position during surgery. On axial view of CT scan, maximum safe incidence angle (MSIA) for cage insertion was defined as the angle formed by a horizontal line connecting anterior borders of the facet joints and a line connecting the anteromost border of the psoas in contact with vertebral body and contralateral L4 exiting root. If the incidence angle of the cage insertion exceeds the MSIA, there wound be a potential for violation of neural elements. Cage tilt angle (CTA) was defined as the angle between a line connecting anterior borders of the facet joints and a horizontal line parallel to the longitudinal length of the cage. Postoperative VAS and ODI scores were measured, and transient and persistent postoperative complications were noted. Results: A total of 36 L4-5 levels were operated by OLIF. The mean MSIA was 28.7 degrees (range 13.4-38.1). The mean CTA was 13.9 degrees (range 3.7-27.7). There were no cases in which CTA exceeded MSIA at the operated level. The VAS(back/leg) and ODI decreased significantly postoperatively, from 6.3/6.5 and 27.0% to 2.6/2.1 and 19% respectively. There was 1 case of ventral dural tear during cage insertion (MSIA 31.2), 1 case of transient ipsilateral psoas paresis, and 4 cases of transient ipsilateral anterior thigh numbness that resolved within 1 month. Conclusion: From the measurements from our small number of cases, we advise the incidence angle of cage insertion to be kept below 28.7 degrees to avoid damaging the neural structures. Larger number of cases will be needed to further validate our findings., Introduction: Oblique lateral interbody fusion (OLIF) is a minimally invasive surgical method that can access L2-5 levels of lumbar spine via retroperitoneal anteropsoas approach. While OLIF has advantage of using interbody cages with larger footprints compared to posterior approach fusion methods, some have reported similar levels of subsidence compared to posterior approaches. This study aims to evaluate the rates of radiological subsidence by operated levels, classify the types of subsidence by location and pattern, and compare the clinical outcomes between subsidence and no subsidence groups. Materials and Methods: The radiological data and medical records of 68 patients who underwent OLIF between June 2013 and December 2015 were reviewed. All patients were followed up for minimum of 12 months. Computed tomography (CT) scans were taken postoperatively, and at 6 and 12 months’ follow up visits. Fusion status and subsidence was assessed using CT data. Subsidence was defined as cage settling of ¡Ã2 mm into the adjacent endplates. Intraoperative endplate violation was defined as subsidence that was identified on postoperative CT. The pattern of subsidence was classified as: caudal contralateral (type I), bilateral caudal (type II), and bilateral cranial and caudal (type III). For clinical assessment, VAS and ODI scores were measured preoperatively and at each follow up visits. Any perioperative/postoperative complications were also noted. Results: Mean age was 64.6 ± 8.6 (40-79) and mean bone density was -1.6 ± 0.7 (-4.0 -1.0). Total number of operated levels was 97 (single level: 46, two levels: 15, three levels: 7). Overall subsidence rate was 32.4% (22 of 68 patients) and incidence rate was 24.7% (24 of 97 levels). Intraoperative endplate violation accounted for 12.5% (3 of 24) of total subsidence. Mean subsidence depth was 2.7 ± 1.0 (2-5)mm. The types of subsidence by location were: caudal contralateral (type I) in 41.7% (10 of 24), bilateral caudal (type II) in 33.3% (8 of 24) and bilateral cranial and caudal (type III) in 25.0% (6 of 24). Overall fusion rates at 12 months were 93.9% and 92.3% in the subsidence and no subsidence group respectively (P = .78). The level with highest incidence of subsidence was L4-5 (16.5%) followed by L3-4 (8.2%). VAS and ODI significantly improved in both groups postoperatively with no significant difference between subsidence and no subsidence groups. Conclusion: The authors classified subsidence by pattern and location. Contralateral caudal subsidence was most common pattern of subsidence, and lower levels were more vulnerable, especially L4-5. Fusion rates and clinical outcomes were not significantly affected by radiological subsidence. In order to minimize subsidence the authors recommend more meticulous endplate preparation and cage insertion, as well as extra attention to angle of cage insertion especially during operation of L4-5 level., Introduction: Exercise and physiotherapy is the mainstay of treatment for back pain. Within this, back groups are widely accepted as an efficient method of rehabilitating and utilising exercise for this group as well as post-surgical patients. Exercise is well documented as an integral aspect for managing back pain but is less well documented as to the efficacy of back group programmes and content1. A less researched area is the response of certain subgroups of back pain patients to physiotherapy rehabilitation. If certain sub-groups of patients are shown to demonstrate more improvement than others, this may help in decision making for referral to rehabilitation groups. Materials and Methods: All patients referred for a variety of back pain conditions including post spine surgery to the Physiotherapy led back rehabilitation group were reviewed over a 2 year period. At first attendance they completed Oswestry Disability Questionnaires (ODI), identified physical functional goals relevant to their lifestyle they wished to achieve and physical functional tests based on the Harding measures. The patients attended 1 session per week in a time period of between 8 and 16 weeks depending on measures and goal attainment. The patients were categorized according to condition into 4 subgroups; Post micro-discectomy, fusion, mechanical low back pain (LBP) and scoliosis. Results: 59 pts in total with a mean age 46 age range from 17-71, duration of symptoms 3 months to 30 years were reviewed. The initial ODI scores on average reduced from 40.67%, to 24.68% with an average change of 15.69%. Subgroup analysis demonstrated fusion as the greatest self-reported improvement with duration of symptoms from 3 months to 4yrs, ODI was 50% initially reducing to 26% with an average change of 23.7%. Micro-discectomy patients, had duration of symptoms from 3 months to 5 years with ODI average ranging from 42% to 27.4% with an average change of 14.7%. Mechanical LBP ranged from 8months to 30yrs with ODI of 41% to 21% and average change 15.5%. Scoliosis demonstrated least improvement with duration of symptoms 1year to 30 years with ODI 24.8% to 17% average change of 7.4%. This is based on the minimal clinical important difference (MCID) validated as 10% change for patient significance for the ODI. All patients demonstrated improvement in the physical measures testing. Conclusion: All the sub-groups of back pain patients referred benefitted from individual exercise programmes within a group rehabilitation setting as measures demonstrated improvement in all areas. Post fusion surgery patients demonstrated greatest improvement which may direct referral for rehabilitation. Of interest the data suggests even the patients with long duration of symptoms post-surgically benefitted from back group referral. The groups were not homogenous in nature with wide ranges of symptoms and outcome measures but this reflects the real variation and complexity of these patients. 1. Poquet N, Lin C, Heymans MW, van Tulder MW, Esmail R, Koes BW, Maher C (2016) Back schools for acute and sub-acute non-specific low-back pain; Cochrane database of systematic reviews, Introduction: Coccydynia is pain arising from the coccygeal region. The origin can be multifactorial with several associated factors such as obesity, female gender and low mood. Several non-operative methods such as physiotherapy, shock wave therapy and ultrasound have been described. Operative interventions viz., local steroid injections, manipulation under anaesthesia (MUA) and coccygectomy are well established treatment modalities. However, the long term results of surgical interventions are debatable with studies quoting a success rate ranging from 63-90%. Materials and Methods: Our aim is to identify if age, trauma and BMI are independent prognostic factors in patients treated for coccydynia. We reviewed all patients who presented to our teaching institute with a primary diagnosis of coccydynia from Jan 2011 to Jan 2015. Data was obtained by retrospective review of the hospital database clinical coding system. All patients who had injections, MUA or coccygectomy were included. Patient notes were reviewed to obtain demographics, co-morbidities, aetiology, type of intervention and outcomes. We used patient reported satisfaction score as the primary outcome measure. We hypothesised that patients who had trauma and with high BMI (>25) would be less satisfied with treatment of coccydynia. We divided patients into four groups based on their BMI as per WHO guidelines as follows. Group A (BMI 18.5-24.9), Group B (25-29.9), Group C (30-39.9) and Group D (>40). We used Student T test to compare means of our data to assess if any significant difference could be found between the groups. A P value, Introduction: Anywhere between 60 to 90% of people in India are affected with low back pain at some point of time in their lives and Spondylolisthesis is found to be two to five times more frequent.Spondylolisthesis that are resistant to conservative measures or presenting with neurological deficits requires surgery.The severity of the disease is always complicated by Sacral inclination, Loss of lordosis and the Grade of the Spondylolisthesis.Though there are many surgical methods to combat this, our the Transdiscal Transpedicular fixation with Intertransverse fusion with bone graft scores much better than the pedicle screw fixation and other techniques to retain the spine biomechanics and improve symptomatically. Aim: To establish combined Posterior Decompression, Posterior Guided Transpedicular Trans discal Interbody fusion with Posterior inter transverse fusion with bone graft as the treatment for Meyerding 3/4 lumbar spondylolisthesis. To provide satisfactory results by relief of pain, relief and prevention of neurological deficits. Methods and Materials: Study between 2010 to 2013 a series of 31 cases (9 males and 22 females) with High grade spondylolisthesis of 3 and 4 Meyerding classification who had neurological deficit or those who found no use with conservative measures in SSSIHMS Puttaparthy, india. A thorough history, clinical, radiological evaluation with X ray, MRI and CT of LS spine with calculation of pre op Visual Analog Score, Oswestry Disability Index, Zurich Claudication Questionnare was done. From the X ray pelvic tilt, sacral slope and pelvic incidence were analysed. MRI was done to assess the disc status by Pfirrmann criteria and neurological structures. Posterior Decompression, Posterior Guided Transpedicular Trans discal Interbody fusion with Posterior inter transverse fusion with bone grafts taken from Posterior superior iliac spine was done under X ray guidance. Intra op parameters were monitored.Post operatively the patients were assessed radiologically to assess construct stability, implant position, implant migration or loosening, formation of solid fusion or indication of pseudarthrosis and clinically by all the above scores on 0th, 1st,1 week,6 weeks,3 months, 6 months, 1 year, 2 years and 3 years post op.Adequate Back care and strengthening exercises were taught and encouraged.All the cases were followed up for a minimum of 3 years. Statistically assessed by SPSS software version 17.0. Results: The average blood loss was 210 ml, Surgical time was 85 minutes. The average time for fusion was 14 weeks. Return to daily activities was average 3–6 months. ODI scores decreased from average of 74% to 11%, Zurich claudication score improved, VAS on average decreased from 9 to 1 or 0 finally at the end of 3 years.The Paired T test improved at the end of 3 years. There were 4 complications (1 case implant failure, 2 cases neurological deficits, 1 case of dural tear which all needed re exploration). Conclusions: Posterior Decompression, Posterior Guided Transpedicular Trans discal Interbody fusion combined with intertransverse fusion led to magical results and the advantages of this technique are lower incidence of neurologic complications, speed of execution and faster return to normal life., Introduction: Several spinal complications can occur in a patient with ankylosing spondylitis. Extensive disco-vertebral destructive lesions are known but rare and may be associated with sagittal imbalance and pain symptoms resistant to medical treatment. We reported through this work a new case of spontaneous spinal nonunion in a patient with ankylosing spondylitis. Methods: This was a 38 year-old patient followed for ankylosing spondylitis for 20 years who consulted for pain in the thoracolumbar junction lasting for 2 years and resistant to medical treatment. A dynamic CT scan showed a totally fused thoracolumbar spine except for the D11-D12 level where there was a posterior vertebral arch and superior endplate disruptions with sings of instability on CT cuts in kyphosis. An additional MRI showed inflammatory spondylitis and an angioma of D11. The patient initially was treated with a thoracolumbar corset without sensible improvement. Surgical treatment was indicated given the persistence of pain. He had a posterior approach with D10-L2 fixation and postero-lateral graft followed by a second procedure through a retro-peritoneal extra-pleural anterior approach, given access to the endplate nonunion and the interposition of an autologous tri-cortical bony graft. Results: At a last follow-up of 3 years, patient was completely indolent with a circumferential fusion on last CT scan, but a predicted loss of motion. Conclusions: These lesions have been described for the first time in 1937 by Anderson, since then, several theories have been advanced to explain these disco-vertebral damages. It was Wu PC, Ho E et al. who studied first the pathophysiology of this complication and demonstrate the role of articular processes fractures in the genesis of these lesions. Several mechanisms may explain the occurrence of this nonunion: the persistence of a certain disc mobility leads to an escaping phenomenon to the global spinal fusion; a secondary fracture of the articular processes, following a benign spinal trauma; a stress fracture of the posterior articular processes, on an ankylosed and kyphotic spine. Several cases were reported in the literature, the orthopedic treatment hasn’t given good results and authors agree on the need for a circumferential vertebral fusion of the articular processes fractures posteriorly and vertebral endplates, anteriorly. Spinal nonunions in patients with ankylosing spondylitis are rare but their ignorance can lead to serious functional complications. Conservative treatment isn’t sufficient in the treatment of the spinal nonunions. Only a circumferential graft through a double surgical approach is recommended for this type of injury, for better chances of consolidation., Introduction: Degenerative disc diseases which are common in elder population and are very varied. The patients are also variable for their symptoms as pain, motor and sensory deficits. There are many approaches to lumbar disc hernia such as open surgery and minimally invasive techniques. Fusion surgery is indicated in patients with intervertebral height decreases. Interbody cage is a choice in some patients with intervertebral fusion. Material and Methods: We studied 25 patients with transpediculer stabilization. TLIF and XLIF is used in intervertebral fusion with cage. They are chosen in patients with foraminal stenosis, degenerative scoliosis and decreased intervertebral height. Intervertebral fusion and intervertebral fusion with cage are compared. Results: We observed foraminal stenosis are progressed less likely in the patients with interbody cage. And postoperative MRI has shown more fusion in interbody cage patients.The patients a re followed up for 6 months. Conclusion: In the literature, interbody fusion with interbody cage resulted better outcome in terms of pain and mobility. Our results showed that interbody cage has a benefit of reducing postoperative foraminal stenosis and preservation of intervertebral height, and also helps the intervertebral fusion., Introduction: Surgery of the degenerative lumbosacral spine is experiencing a growing interest in interbody fusion with cages. The sagittal balance has an important place in the spinal pathology, enabling a comprehensive analysis of the static disorders. The aim of our study was to study the influence of posterior lumbar interbody fusion posteriorly (PLIF) on lumbar-pelvic parameters and sagittal balance. Methods: This was a retrospective study including 31 patients who had PLIF, over a period of 10 years with a mean follow-up of 5.6 years. All patients were investigated by telemetric radiographs of the spine from the front and side, in knee extension, with centered radiographs of the lumbar spine. For the assessment of functional impairment, we used the score of Beaujon-Lassalle (B-L) and the Oswestry index of disability (ODI). Results: The average age was 46 years, with a sex ratio of 0.4. The etiology was dominated by spondylolisthesis in 25 cases (20 spondylolysis and 5 degenerative) and 6 cases of degenerative discopathy. The study of spinal statics helped find 80% of types 3 and 4 backs. The lumbar-pelvic parameters averaged 53° for the pelvic incidence (PI), 35° for the sacral slope (SS) and 17° for the pelvic Version (PV). The average value of the T9 sagittal offset was 11° and 54 mm for the C7 plumb line. Functionally, we found a B-L score of 8.4 points on average and an average ODI of 57.9%. Postoperatively, we found 58% of types 3 and 4 backs. We did not find statistically significant differences in the pelvic parameters at last follow-up except for the T9 sagittal offset (P = .003) and C7 plumb line (P = .001). 71% of patients had a well-balanced back. No parameters studied had significant superiority on functional recovery. Conclusions: Many works have allowed a better understanding of the fusion by incorporating it into the scheme of static and dynamic spine. Preservation or optimization of sagittal balance are at present part of the specifications of lumbosacral arthrodesis. Only the restoration of balanced spinal statics (normal values of the C7 plumb line and T9 sagittal offset) guarantees us excellent functional and radiographic results and a solid fusion of interbody arthrodesis without repercussions on adjacent discs. It’s necessary to analyze the sagittal balance parameters in the management of degenerative lumbar spine. This will determine the type and modalities of future surgery., Introduction: We aimed to identify potential risk factor for unfavourable outcome following lumbar spine surgery for degenerative disc disease. Methods: Study design: Prospective cohort study. Patients were asked preoperatively to complete a series of questionnaires (N = 14), including the Oswestry Disability Index (ODI), the anxiety sensitivity index (ASI-3), the SF-36, the visual analogue scale for pain (VAS), the Berliner Social Support Scale, the PTSS-10 for PTSD symptoms and indicate demographic variables concerning education or partnership for example. The evaluation was based on the ODI filled out 1 year postoperatively. The univariate and multivariate association between risk factors and outcome parameter (ODI) was assessed with correlation coefficients and multivariate logistic regression. Results: 99 patients met all inclusion criteria. 50 patients were male (50.5%); mean age was 60 years. Most patients were married or in a steady relationship (74.8%). Preoperatively age (r = 0.230; P = .025), pain (VAS) (r = 0.380; P < .001), trait anxiety (r = 0.244; P = .019), PTSS (r = 0.222; P = .034), ODI (r = 0.404; P < .001), depression score ADS-K (r = 0.258; P = .013) and low education (r = -0.281; P = .009) and lower SF-36 Physical Composite Score (r = -0,487; P < .001) correlated with worse ODI scores at 1 year. Conclusion: Clinical outcome one year after surgery is influenced by age and physical status before surgery. Mental comorbidities and social status are also influential on clinical outcome. A preoperative screening tool seems feasible., Introduction: Demographic trends make it incumbent on spine surgeons to recognize the special challenges involved in caring for older patients. Aim of this study was to identify variables that may predict early mortality in geriatric patients over the age of 90. Methods: Retrospective analyses of all patients over the age of 90 years, which were treated between 2006 and 2014 at our department for degenerative spine disease, were performed. Patient characteristics, type of treatment and comorbidities were analyzed with regards to the 30-day mortality rate. Results: 25 patients were identified. Mean age was 92.8 years (range 91-101), 21 (84%) patients were female. 16 (64%) patients were on anticoagulation therapy. 17 (68%) patients were treated operatively. Mean Hospital stay was 14 days (range 2-40). Mean charlson comorbidity index was 5.5 (range 0-12) and mean diagnosis count was 12 (range 2-24). The 30-days mortality rate was 17% in the surgically treated group compared to 0% in the conservatively treated group (P = .2). Gender (P = .42), diagnosis count (P = .65), charlson index (P = .65) and anticoagulation therapy (P = .9) did not correlate with the 30-day mortality rate. Cause of death was pulmonary embolism in two cases and was unknown in one case. Conclusion: 30-day mortality rate in patients over 90-years-old following elective spine surgery is very high. Standard geriatric prognostic scores seem less reliable for these patients. Prospective validations studies are needed in order to establish treatment recommendations for such patients., Introduction: To compare the mid-term efficacy between Coflex and Transforaminal Lumbar Interbody Fusion (TLIF) in treating lumbar spinal stenosis(LSS) with positive nerve root sedimentation sign (Sed-sign) and observe the relationship between surgical results and the change of Sed-sign. Material and Methods: We retrospectively reviewed 206 patients who presented with LSS and received spinal surgery in our institution from January 2009 to December 2013. All patients underwent MRI of the lumbar spine. A positive Sed-sign was determined as the absence of nerve root sedimentation at the level above or below the level of maximum stenosis on MRI. Clinical outcomes were investigated using the patient-assessed quantitative measurement of visual analog scale (VAS) and the Oswestry Disability Index (ODI). Thirty-three patients (male: female = 13:20) with positive Sed-sign were included and classified according to the surgery they received (Coflex group vs TLIF group). Comparison of radiological data (Sed-sign) and clinical outcome (VAS and ODI) were conducted. Results: There was no significant difference between Coflex group and TLIF group in baseline parameters (gender, age and BMI). Overall, 94% patients got excellent recovery. In the final follow-up, both Coflex group and TLIF group had a significant clinical improvement compared to preoperative data (P < .05), as shown by VAS and ODI. Additionally, no significant difference was found between the two groups during the follow-up (P > .05). Radiological evaluation revealed that the Sed-sign of 75.7% patients turned negative and maintained well to final follow-up. Those who had negative Sed-sign postoperatively showed greater clinical improvement than those who had positive Sed-sign in the final follow-up (P < .05). Conclusion: The Coflex is an efficacious option for the treatment of lumbar spinal stenosis, which is comparable to the lumbar fusion surgery. The lumbar decompression surgery can significantly help the Sed-sign turn negative, which shows better clinical improvement in the mid-term follow-up., Introduction: Lumbar spinal stenosis (LSS) is a disorder caused by a narrowing of the spinal canal as result of the degeneration of both the facet joints and the intervertebral discs. With the advancements in clinical and diagnostic knowledge, the treatment has changed from various non-operative modalities to decompression, and subsequently, decompression and fusion. In more recent years, a growing tendency toward less invasive decompressive procedures has emerged, and nowadays many neurosurgeons prefer microdecompression for LSS. However, specific attention should be paid not to injure the pars interarticularis and if excessive facetectomy is performed fusion is required. Recently the technological progress focused on facet joint fixation and in this scenario the Facet-Wedge® system is gaining interest. Facet Wedge system offers a novel posterior approach in achieving primary stability in lumbar spinal fixation with a comparable primary stability to pedicle screws. Methods: This study included patients (n = 25) with LSS (group 1) in whom microdecompression and Facet Wedge implant has been performed. Data have been compared with a homogenous group of patients with LSS where no facet wedge has been implanted following microdecompression. Clinical findings have been observed preoperatively and 3, 6, 12 months post-operatively using dedicated questionnaires (Zurich Claudication Questionnaire, Visual Analog Scale and Oswestry Disability Index). Secondary outcome measures were length of hospital stays, perioperative and postoperative complications. Results: One year following surgical treatment, 92% of the patients of group 1 presented good improvement of symptoms and 95% of the patients referred satisfaction for surgery. Overall, patients of group 1 presented significantly less back pain as compared with group 2 (P < .05) and better clinical outcome when compared with group 2 (P < .01). There was no difference in length of hospital stays between the two groups (P =.175). Conclusion: According to our features, the Facet Wedge system showed significant and clinically meaningful improvements in pain and disability for up to 1 year when associated with standard microdecompression for LSS. These data, however, need further studies and a longer period of follow-up., Introduction: The activL artificial lumbar disc is a motion preserving total disc replacement device for the treatment of low back pain due to degenerative disc disease. Following FDA approval in June 2015, a 10 year post-market surveillance study on the safety, efficacy and satisfaction of the activL device was initiated. Results from the first year are presented. Methods: Surgeons who implanted the activL artificial disc post-market approval were asked to complete a written survey addressing their knowledge of safety issues involving activL, as well as their experiences on the clinical performance of the activL device. Demographics for patients receiving the post-market activL device were collected on separate device utilization requisition (DUR) cards which were completed at the time of surgery. Results: The surgeons surveyed reported no revisions surgeries, device removals, re-operations at the index level and were not aware of any adverse events or medical device reports submitted by their patients. Surgeons were satisfied with the overall device effectiveness, specifically range of motion and stability, and were satisfied with the pain relief and neurological status in their patients following activL implantation. From the DUR cards returned, the average patient age was 40 yrs. (range 25-64) and the majority of patients were male (48% male, 39% female, 13% unidentified), which is comparable to patient demographics in the clinical trial1. The number of procedures performed at L5-S1 (42%) was incrementally greater than L4-L5 (38%). This difference was greater in the clinical trial patients (69% vs. 26% for L5-S1 and L4-L5, respectively)1. Surgeons surveyed did not report differences in safety or efficacy with activL at L4-L5 compared to L5-S1. Conclusions: Surgeons surveyed were satisfied with the overall performance of the activL device and did not report any safety concerns. Demographics of the patients receiving the post-market activL device is similar to study patients from the clinical trial, suggesting that future safety and efficacy outcomes from the post-market use of activL can be inferred from long term data from the clinical trial. 1. Garcia R Jr et al., (2015) Lumbar Total Disc Replacement for Discogenic Low Back Pain: Two-year Outcomes of the activL Multicenter Randomized Controlled IDE Clinical Trial. Spine. 40(24):1873-81., Introduction: Usually, the static analisis of the spinal sagittal shape is based on a vertebral semantic, focusing on the curves (lordosis, kyphosis) and the spinopelvic parameters (pelvic incidence, sacral slope, pelvis tilt, sagittal balance). This analisis failed in defining a normal shaped spine, and in relating strictly the incidence to the lordosis. The author proposes a very different analisis of the sagittal spinal shape, named “the Pendulum Rule.” It enable to define an ideal biomechanical shaped spine and classify the sagittal shape precisely using a discogenic, vertical and dynamic analisis of the spine. The thorax restabilizaton in patients treated with stand alone ALIF (and/or discal cementoplasty) in spinal disorders abide by this rule. Material and Methods: 300 hundreds sagittal shapes have been studied. A vertical analisis (according to gravity) is carried out, reintegrating the spine into an analisis of the muscular body’s scheme and relating it to the respiration. The biomechanical spine is assimilated to three intricated Mongol bows. Different apex (contact between the vertebral body and the plumb line) are defined. They are related to muscular tension lines or attaches. The lungs apex are paramount to explain the spine. The trunk is always swaying but lungs pressure (when breathing in) stabilize it either in an anteroposterior plan or in the sagittal plane. The repartition of the apex has been assessed in all the spine drawing specific lines. Results: More than 95% of the studied spine abide by the “Pendulum law” which states that: “whatever the spine is (including the common variation or abnormalities), the standing position consist in placing the Superior Lung apex according to the following rules. In the anteroposterior view: the plumb line equidistant from the lung apex is maintain above the sacral apex. In the sagittal view: the plumb line from the superior lung apex is equidistant of the thoracic apex and the lumbar apex. The two Pelvico-thoracic lines (the line linking the sacrum apex to the antero-inferior lung apex and the line linking the center of the femoral head to the postero-inferior lung apex) cross each other in the point “E”, exactly above the plumb line droping from the superior lung apex and in front of the lumbar apex. Therefore, the Pendulum Law relates the sagittal shape to the gravity, the muscular body’s scheme and the breathing. An ideal biomechanical sagittal shape lines up the thoracic apex and the sacral apex vertically. The alignement of the symphysis, the lumbar apex and the thoracic apex cross the vertebral bodies obliquely and harmoniously. The lumbar apex (in front of the upper plate of L4) is placed above the center of the femoral head. Conclusion: The Pendulum Law relates the sagittal shape, the muscular body’s scheme and the act of breathing to gravity. Most of the commons Abnormalities are intregrated according to this rule. The Pendulum is the “vertical tension” of the body’s scheme that enable us to move harmoniously. (As the length of the femur is strictly related to the ideal flexion/extension of the Knee). Lordosis is related to pneumatic stabilization of the trunk and definitively not to the pelvic incidence. We should not use rods and screws in common degenerative spinal disorders. Stand alone procedures restore the disc space height and enable the patient to restabilize in a more physiological way., Introduction: The vascular narrowing or obstruction reduces blood flow to the lower limb during exercise or at rest. Symptoms may range from intermittent claudication to pain at rest. Narrowing of these arteries may produce pain in the buttocks or the thighs as well as the legs. Sometimes, these symptoms may be similar to lumbar radicular pain. Moreover, spine surgeons may overlook obstructive vascular lesions of lower limb in patients with lumbar degenerative disease such as spinal stenosis and spondylolisthesis. We investigated clinical and radiological findings of concomitant vascular pathologic lesions in patients with degenerative lumbar disease. Methods: If patients presented with weak or no pulsation of dorsalis pedis artery, edema of both legs, and past histories related with vascular lesion of lower limb, we evaluated doppler sonography of veins and arteries of lower extremities. And, if vascular abnormal findings were detected in sonography, computed tomography angiography (CTA) of lower extremities was performed. Radiologic and clinical characteristics of concomitant vascular lesions of lower limb were analyzed. Results: Since 2013, vascular doppler sonography was performed in 335 patients who were suspicious of vascular lesions. Among them, CTA of lower extremities was evaluated in 58 patients. Mean ages was 69.4 years old (male/female 35/23). Sever narrowing or total occlusion of major arteries was revealed in 23 patients. Deep vein thrombosis was detected in 2 patients. Surgical treatment plans were cancelled or changed in 21 patients. There was higher incidence of histories of smoking, diabetics, and coronary artery stenting. Conclusions: As increasing of elderly patients, the incidence of concomitant obstructive vascular lesions of lower extremities may be increased in patients with lumbar degenerative disease. If patients present with weak or no pulsation of dorsalis pedis artery or lower limb edema, the clinician should consider sonography or CTA of vascular lesions of lower limb. Differential diagnosis of obstructive vascular lesions of lower limb with lumbar degenerative diseases is important for preventing unnecessary invasive procedures and surgical treatments., Introduction: The purpose of this study was to compare the radiological and clinical outcomes obtained in patients with lumbar spondylolisthesis in L4-5 who have undergone either instrumented anterior lumbar interbody fusion (ALIF), instrumented lateral lumbar interbody fusion (LLIF) or instrumented posterior lumbar interbody fusion (PLIF), especially with regard to the development of adjacent-segment degeneration (ASD). Material and Methods: The medical records of patients who underwent ALIF, PLIF or LLIF for single level spondylolisthesis on L4-5 at single center from January 2011 to December 2012 were retrospectively reviewed. Patient inclusion criteria for the study were: 1) diagnosed as L4-5 single level spondylolisthesis; 2) minimal ASD preoperatively 3) a minimum follow-up duration of 12 months. Patient exclusion criteria were: 1) requiring more than two-level fusions; 2) prior surgery in L4-5 level; 3) preexistent ASD. Radiographic measurements including preoperative and postoperative foraminal and disc height, segmental and lumbar lordosis, percentage of vertebral slippage, reduction rate were reviewed. Incidence of ASD and clinical outcomes were evaluated and compared between 3 groups. Clinical outcome by VAS, ODI and modified MacNab criteria were measured preoperatively, postoperatively and compared. Results: 82 patients who underwent instrumented L4–5 fusion for their L4-5 spondylolisthesis were included in this study and divided according to the surgical approach (ALIF: 27, LLIF: 24, PLIF: 31). Average follow-up period was 35.42 ± 9.35 months. Adjacent-segment degeneration was found in 40.7% (11), 37.5% (9) and 64.5% (20) of the patients in the ALIF, LLIF and PLIF group. ALIF and LLIF group showed favorable results compared to PLIF group in less incidence of ASD. These superiority was evident between ALIF and PLIF (P = .037) but not statistically significant between LLIF and PLIF (P = .091). The ALIF and LLIF groups had significantly increased disc and foraminal height compared to the PLIF group. The ALIF group had significantly improved lordosis compared to both other PLIF, LLIF groups. Our study showed that all three approaches significantly reduce spondylolisthesis and revealed ALIF have better ability to reduce the spondylolisthesis with a significant difference between the three interbody fusion approaches Clinical success rates (excellent, good by modified MacNab criteria) were 92.5, 91.6 and 87.0% in the ALIF, LLIF and PLIF groups. There were no statistically significant intergroup differences in clinical outcome by VAS, ODI. Conclusion: 3 different fusion techniques can produce good outcomes in treating lumbar spondylolisthesis in L4-5, but ALIF and LLIF are more advantageous in preventing the development of ASD, which may resulted from different ability to restore the postoperative sagittal balance and less intra-operative injury to posterior structures., Introduction: To see if visualisation of a medial epidural spill on the image intensifier at the time of the transforaminal epidural steroid injection (TFESI) was associated with more pain relief. Material and Methods: Over 300 patients were treated with a TFESI between September 2012 and December 2015. 215 patients met inclusion criteria; 111 males and 104 females with a mean age of 53.3. The outcome measures included whether or not the patient had pain relief, their change in PROMs scores and whether or not they had a subsequent operation. Results: The study group included 101 patients who had disc herniations, 94 patients who had lateral recess stenosis (LRS), 53 patients who had foraminal stenosis (FS) and 41 patients who had spondylolisthesis of which there were combinations. 28% of TFESIs worked without recurrence, 43% of TFESIs worked but then recurred and 29% of cases did not work at all. In the pain recurrence group, the average time it took for pain to recur was 2.8 months. Visualisation of a rootogram and medial epidural spill were not predictive of patient outcomes and there was no statistically significant differences in outcome and whether the TFESI was successful between the 4 groups (Disc/LRS/FS/SPL). Conclusion: There were strong correlations between duration of symptoms (DoS) and pain intensity/disability scores and patient outcome. There was a significant difference between pre-injection and post-injection PROMs scores with regards to all different measures (P < .05). There was no correlation between presence of epidural spill and change in PROMs scores., Introduction: Osteoporosis and tumors can induce sacral insufficiency fractures (SIFs). SIFs cause severe low back pain and immobilization. The purpose of our study is to describe our experience and assess the safety and effectiveness of minimally invasive percutaneous sacroplasty in patients with osteoporotic SIFs. Methods: We reviewed cases of percutaneous sacroplasty performed since 2009. We used data only from patients with osteoporotic SIFs who were followed for more than 12 months after sacroplasty. Tumor-related SIFs were excluded from our analysis. The following clinical parameters were investigated: initial diagnosis, symptoms, visual analog scale (VAS) of pain, functional mobility scale (FDC) score, past history of illness, amount of bone cement infused, and complications related to sacroplasty. Also, the following radiological parameters were analyzed: the pattern of SIFs, T-score cement leakage, and concomitant fractures in other sites. Results: 68 patients were enrolled in our study (4 males and 64 females). The mean age of the subjects was 76.8 ± 6.2 years. All patients had severe osteoporosis (mean T score: -3.9 ± 0.5). Percutaneous sacroplasty was performed under fluoroscopic guidance. No major complications or procedure-related morbidity occurred. FDS and VAS scores significantly improved after sacroplasty, and the improvements lasted through the final follow-up period (P < .05). Conclusions: Percutaneous sacroplasty is an effective minimally invasive treatment for osteoporotic SIFs refractory to conservative management. The study subjects experienced significant relief of pain, and increased mobility., Introduction: The most disastrous complications of alkaptonuria are ochronotic spondyloarthropathy which causes painful and disabling joints along with spine. In late stages of the disease nucleus pulposes may be ossified with heavy pigmentation of ligamentum flavum and ultimately leading to spinal canal stenosis. Ochronotic myelopathy is an extremely rare condition where only few cases have been reported in cervical and thoracic region. Here we report a rare case of tandem stenosis of spinal canal involving thoracic and lumbar region. Material/Case Report: A 53 year old female presented with back pain radiating to bilateral lower limbs since 3 years. Neurological evaluations showed features of thoracic myelopathy. Plain radiographs showed degenerative spine with inter vertebral disc calcifications, ankylosis, and osteoporosis with bilateral sacroilitis. MRI scan of thoraco-lumbar spine showed diffused annular bulge, flaval hypertrophy from T9-T10 to L5-S1 level with severe cord compression at thoracic level. Urine analysis showed large amounts of homogentisic acid confirmed by thin layer chromatography. Results: She underwent thoracic laminectomy and lumbar fenestration laminotomy with nerve root decompression. Hypertrophied and blackish coloured ligamentum flavum was characteristic intraoperative finding. HPE showed chondrocytic cytoplasm containing melanin like pigmentatation. Discussion: Accumulation of HGA and its oxidation products like benzoquinone results in bluish-black pigmentation of connective tissues which is termed as Alkaptonuric Ochronosis. The musculoskeletal manifestations are commonly reported to occur in spine where abnormal calcifications of intervertebral disc are a characteristic finding. Retrospective diagnosis of alkaptonuria by identifying “Black disc” intra-operatively has been reported by many authors where low back ache radiating to lower limbs was the commonest symptom. There have been only few reports in literature stating that decompressive procedures improved the neurological status of the patients with alkaptonuria. Our patient showed significant weakness in bilateral lower limbs which were improved over a period of time and were successfully walking with the help of crutches by 6 months. Conclusion: One of the rare outcomes of alkaptonuria is ochronotic arthopathy especially involving lumbar spine with or without degeneration of other major joints. The present case signifies the importance of whole spinal screening as the region involved is more than one. Our case of tandem canal stenosis in thoracic and lumbar segments is one of the rarest reported cases till date., Introduction: Lumber steroid injection can be endorsed as a treatment component for lumberosecral radicular pain syndrome resulting from disc herniation. The facet joint steroid injection seems to be beneficial for patient with chronic backache due to the facet joint arthritis and in the lumber Spondylosis. Materials and Methods: We did a retrospective review of 31 patients whom we treated between 2011 to 2014 with follow-up (6 months to 24 months) There were 19 females and 12 males, age 29- 81 years 5 patients had previous surgery for simple discectomy to posterior spinal fusion. 4 patients had multipal disc prolapse 3-4 level, 2 patients had severe lumbar Spondylosis and spinal stenosis. The reaming 20 patients had single level disc prolapse. All these patients were given caudal and facet joint block. Results: The pre and post steroid injection oswestay score was done. After steroid injection the oswestay improved by 30%. Majority of the patients had pain relieve for 2-18 months. The pain relieve relief was much better in the non operative group with single level disc prolapse and those patients with lumber Spondylosis. Conclusion: In patient with chronic back pain there is inflamatory basis for pain generation. Lumber steroid injection seems to be beneficial in patients with disc prolapse and lumber Spondylosis. In the literature various randomized trials has been done and their results are controversial. Our study showed definitive improvement in terms of pain and function of our patient., Introduction: Generally, the area of radicular leg pain due to lumbar disc herniation (LDH) is considered to be related to dermatome. On the other hand, it has been reported that radicular leg pain in patients with LDH is closely associated with myotome rather than dermatome. To analyze the anatomical components of radicular leg pain, we investigated the area of muscle tenderness in lower extremities in LDH patients. Material and Methods: Thirty patients (20 men and 10 women, mean age: 41 years) with clinically diagnosed as single-level unilateral radiculopathy (L5 or S1) due to LDH were included in this study. Eleven (6 men and 5 women, mean age: 41 years) were diagnosed as L5 radiculopathy (L5 group), and 19 (14 men and 5 women, mean age: 41 years) were diagnosed as S1 radiculopathy (S1 group). Postoperative leg pain relief proved that the diagnosis of single-level radiculopathy was correct in all patients. Before surgery, muscle tenderness in lower extremities was examined by the sole examiner (Y.K.) at the following muscles: gluteus maximus, gluteus medius, biceps femoris, adductor magnus, vastus lateralis, rectus femoris, vastus medialis, tibialis anterior, fibularis, gastrocnemius medial head, and gastrocnemius lateral head. The same pressure forces (approximately 4kg/cm2) were simultaneously applied to bilateral leg muscle via the thumb of the examiner at so called “motor point” of each muscle. When muscle tenderness in the affected side was significantly severer than that in the unaffected side, the muscle in the affected side was determined to have a positive muscle tenderness sign. Results: Both L5 group and S1 group had positive muscle tenderness signs at multiple muscles. The incidence of positive muscle tenderness sign (L5 group/S1 group; muscle) was 9.1%/78.9%; gluteus maximus, 90.1%/84.2%; gluteus medius, 54.5%/89.5%; biceps femoris, 0%/0%; adductor magnus, 27.3%/21.1%; vastus lateralis, 9.1%/0%; rectus femoris, 0%/10.5%; vastus medialis, 63.6%/57.9%; tibialis anterior, 72.7%/52.6%; fibularis, 45.5%/36.9%; gastrocnemius medial head, and 36.4%/47.4%; gastrocnemius lateral head, respectively. In gluteus maximus, S1 group showed a significantly higher positive incidence than L5 group (P < .01 Fisher’s exact test). In the other muscles, there was no significant difference between L5 group and S1 group. Conclusion: The present study revealed that the patients with LDH have positive muscle tenderness signs at many site of their leg muscles. The presence of positive muscle tenderness sign at gluteus maximus suggests S1 radiculopathy, and this finding is useful for differential diagnosis between L5 and S1 radiculopathy., Introduction: Causal treatment of a chronic disease like Low Back Pain (LBP) reduces the burden of disease, but it requires precise and unambiguous diagnosis, especially when the etiology is far from obvious. In such cases, the appropriate selection of diagnostic tools ensures success. The purpose of this case presentation is to highlight the importance of anatomical and functional data that SPECT CT scan has provided in the diagnosis and treatment of LBP in a middle-aged woman with concurrent pelvic venous congestion & Bertolotti syndromes. Material and Methods: We present a case of a 47-year old woman who presented with chronic LBP that transitioned from intermittent to persisting pain and “heaviness” in the pelvis on a daily basis for the last year. Symptoms were aggravated with standing and walking while radiation into the pelvis and buttocks was also common. These symptoms, although consistent with Bertolotti syndrome, were accompanied by a ten-year recurrent deep pelvic pain, “heaviness,” and discomfort. Information obtained from both the history and the clinical examination pointed to atypical LBP. SPECT CT scan revealed mild L3-L4 facet radiotracer uptake, severe disc and facet radiotracer uptake at L4-L5, a retroaortic left renal vein, and a dilated left gonadal vein. Up to that moment the patient had undergone several clinical and imaging tests including lumbar MRI and a negative pelvic ultrasound. Neither medications nor physical therapy or chiropractic treatment had offered significant relief. Results: Based on the above findings, the patient received steroid injection therapy in the L4-L5 facet joints, which provided a short term (up to 3 weeks) relief of symptoms by 50% to 60%. As a result, the remaining amount of pain directed our interest into pelvic venous congestion syndrome regardless of a negative pelvic ultrasound. Therefore, even despite the fact that the left retroaortic renal vein and symtomatology were pointing to nutcracker phenomenon rather than to nutcracker syndrome, we elected to order a dedicated pelvic MRI for further exploration. Pelvic MRI findings were consistent with pelvic congestion syndrome. We referred the patient to the interventional radiology where she underwent bilateral ovarian vein embolization, which provided 90% relief of symptoms. At a two and six-month follow up, the patient reported mild intermittent LBP, which was attributed to Bertolotti syndrome. Conclusion: This case-report study underlines the significance of the proper evaluation of medical information retrieved from physical assessment as well as from imaging data. It also delivers the following message: even though the rationale of diagnostic procedures requires consistency, deviating from the “norm” when warranted is a cornerstone in the rapid and successful management of unusual situations requiring clinical astuteness., Introduction: Low back pain is a very common condition with an important subjective component where often appear simulation behavior, either to obtain a secondary gain (malingering) or a primary gain (factitious disorder). Objectives: To evaluate the usefulness of Structured Inventory of Malingering Symptoms (SIMS) in a group of patients referred to the Pain Unit with medically unexplained low back pain (MUL). Material and Methods: Prospective study. All back pain referred to the Pain Unit of the Hospital de León for a year. After multidisciplinary evaluation the SIMS was administered to all patients who were diagnosed of MUL. After unstructured psychiatric interview (gold standard) was performed and statistical analysis was performed to determine the predictive values of the scale. Results: 274 patients with low back pain were referred. 95 (34.67%) were diagnosed of MUL after multidisciplinary assessment. 40 were positive for simulation symptoms in SIMS. 30 of these positives were confirmed after the psychiatric interview. 55 were negative in SIMS but in three cases were diagnosed of simulation in the interview. The positive predictive value of the interview was 75% and negative predictive value of 94.54%. Among the ten patients with false-positive result for simulation in nine cases another mental disorder was diagnosed as clinical origin. Conclusion: The negativity of the SIMS allows with high security to discard simulation in patients with low back pain. Positivity has good predictive value or makes suspect the presence of another mental disorder as clinical origin., Introduction: Neurological recovery and outcomes following surgery in cervical spondylotic myelopathy are variable and cannot be accurately predicted preoperatively. Preoperative investigation modalities, including MRI have demonstrated poor efficacy in predicting neurological outcome. Diffusion Tensor Imaging (DTI) indices have shown promise as a tool to reliably assess spinal cord function and have been used in the assessment of cervical spondylotic myelopathy. However, efficacy of DTI indices in predicting post-operative recovery has not been studied before. We aimed to analyse post operative neurological outcomes in cervical spondylotic myelopathy using DTI indices to identify predictive factors for neurological recovery and to document postoperative changes seen in DTI indices. Materials and Methods: We prospectively performed a cohort study on thirty-five patients of cervical spondylotic myelopathy that underwent surgical decompression. DTI evaluation was performed preoperatively and at 1 year following surgery. Analysis was performed on the DTI indices and correlated with clinical outcomes. Clinical disability was assessed using Nurick grade. The patients were sub grouped based on clinical disability into group1- independent ambulators (Nurick1 and 2) and group2- assisted ambulators (Nurick grade 3,4 and 5). DTI indices- Fractional anisotropy (FA), Apparent diffusion coefficient (ADC), Relative anisotropy (RA), Volume ratio (VR) and eigen vectors(E1, E2 and E3) were obtained and clinical evaluations were made pre-operatively and 12 months post-operatively. Results: Twenty-six patients were available for final follow up at 12 months. Twenty patients showed improvement by at least 1 Nurick grade, 5 maintained the pre-operative Nurick grade status and 1 patient was noted to have deterioration by 1 grade. The MRI showed adequate decompression in all patients irrespective of the clinical outcome however, DTI indices showed variable results. There were significant improvements in postoperative DTI indices for ADC (P = .002), E1 (P < .001) and E2 (P = .012) values in patients who showed neurological recovery at 12 months. Post-operative DTI indices for coefficients ADC, E1 and E2 in neurologically static/worsened individuals remained unchanged or insignificant (P > .05). The mean pre-operative DTI indices remained similar in the neurological improved and unimproved patients. Sub group analysis based on ambulatory status also produced no significant relationships with the DTI indices post-operatively. Conclusion: Post operative DTI indices were sensitive to identify post operative clinical outcome following surgery, showing comparable change with recovery, and no significant change was seen in patients that showed no recovery or worsened after surgery. The DTI indices however, did not have value preoperatively, in predicting neurological recovery following surgery in cervical spondylotic myelopathy., Introduction: Low back pain is a major symptom related reason for visiting a physician worldwide both for its clinical significance as strong economic burden in healthcare systems. This study aimed to review and analyze the diagnosis and management of patients older than 18 years who attended due to low back pain to the emergency department of a third level hospital in Bogota, Colombia. Based on this results and literature review we propose a management algorithm for emergency rooms. Methods: An observational cross-sectional study was conducted by reviewing 750 medical records of patients with diagnosis of low back pain treated at the emergency department of third level hospital in Bogotá, Colombia between January 2010 and December 2013. Variables analized included demographic data, red flags presentation, imaging studies requested and pain management strategies used. Results: From 750 medical records, 550 were included in the analysis. Mean age of patients was 51.6 years and 61.6% were female. At least one red flag was identified in 48.1% (242) of patients. Only 8% did not present red flags. Pain related to trauma was the most common red flag (72.5%) followed by age > 55 years (50.5%). Plain radiography was the most frequent requested study (53.9%). Within the group of patients without red flags, 45% had a diagnostic image. The most widely used pharmacological management was the combination of opioids and nonsteroidal antiinflammatory drugs (NSAIDs) in 29.1%, followed by monotherapy with opioids (22%). After initial mangement at the emergency department 23.4% of patients required hospitalization. Conclusions: Low back pain is a frequent chief complaint at the emergency department with most patients presenting at least one red flag, most of the times related with trauma. Plain radiography is an excellent diagnostic tool and remains the most frequent ordered imaging study. The most frequent pharmacological management was NSAIDs combined with opioids. Nevertheless, institutional attention protocols to improve low back pain management should be considered. Based on the results found in this study and a literature review, we found that pain mechanisms are consistent with literature reports. According to our findings a management algorithm for low back pain in the emergency room is proposed. The algorithm begins with an excellent anamnesis and physical examination that seeks to identify red flags and individual risk factors for serious conditions. If red flags are detected, imaging studies should be carried out with concomitant pharmacologic treatment with postural hygiene recommendations., Introduction: At a large university Orthopedic department, the need for emergency spinal imaging (ESI) arises on a regular basis. In most instances, magnetic resonance imaging (MRI) is the imaging modality that is primarily requested. Depending on a number of factors, MRI is not always immediately available to us and in these instances we often resort to computed tomography (CT) as a first line of imaging. In some cases though, additional MRI is necessary after CT in order to ascertain a diagnosis, which in turn creates delays in the diagnostic work-up. Once a diagnosis has been made and an indication for emergency surgery has been established, other factors, such as the immediate availability of an operating theatre and an anesthesia team may again cause delay in performing emergency spinal surgery. At present, we have no precise knowledge of the possible consequences or even the absence of such. We therefore decided to prospectively collect and analyze all such events and the associated decisions, delays and pathways, starting 2012. This abstract is based on initial data from January through September 2012. At presentation, the complete data for 2012 will be available. We defined ESI as the need for cross-sectional imaging in any situation where the affected patient’s history and clinical symptoms render likely or possible a diagnosis, which would justify urgent spinal surgery. Material and Methods: Starting with January 1st, 2012 and after obtaining ethics board approval, we began to collect data on all cases in which ESI was requested from the radiology department. Amongst the parameters collected are: Suspected diagnosis, imaging modality requested, imaging modality available, delay to primary imaging, day of the week and time of the day, whether the primary imaging modality was sufficient to decide on the patient’s treatment, whether secondary imaging was required, delay to secondary imaging and what the final treatment strategy was. In cases, where a decision for surgery was made, the time from decision to incision was recorded as well as the reason for any delays. Status at discharge was recorded. Within 24 hours of each event, the data was entered into a customized Microsoft Excel spreadsheet residing on the department server and available from all workstations. In this initial presentation, data is presented by means of descriptive statistics only. Results: Including September 2015, 131 events of ESI were recorded. The affected patients were 19 females and 10 males, aged on average 57 years with ages ranging from 25 to 89 years. There were 7 situations after previous in-house spinal surgery and 22 situations in which patients presented without previous surgery. The suspected diagnoses were disc herniations, postoperative epidural hematoma, disc reherniations, spinal infection, spinal ischemia and implant misplacement in descending order. MRI was the primary imaging modality requested in 27 cases, CT in 2 cases. MRI was the primary imaging modality obtained in 16 cases, CT in 13 cases. The most frequent reasons given for MRI unavailability were work overload (MRI requires significantly more time than CT) and unavailability of a trained MRI technician. There were 4 situations, where the on-call radiologist felt that a CT would be sufficient to examine the suspected pathology, only 1 of which required an additional MRI after the CT. In 3 cases of primary CT, MRI was additionally required whereas in only 1 case of primary MRI, an additional CT was necessary. When primary imaging was sufficient, the delay from imaging request to a secured diagnosis was 3.4 hours on average, ranging from 0 to 27 hours. In the 4 patients requiring secondary ESI, the total delay was on average 17 hours, ranging from 4 to 29 hours. Secondary imaging was necessary in 3 cases, where primary MRI had been requested and CT had been performed, but also in 1 case, where primary MRI had been requested and performed. In the latter case, an additional pelvic CT was obtained after a spinal MRI did not explain an incomplete polyradicular paralysis of the right leg in a patient with chronic lymphatic leukemia. Secondary pelvic CT in this case substantiated plexus compression by enlarged pelvic lymph nodes. In 14 cases, surgery was recommended to patients as a result of the clinical picture and the imaging results. 3 of these patients elected conservative care over surgery and 11 emergency interventions were booked with the operating department. These were mostly primary disc surgeries and 1 case of a re-herniation. 3 cases required laminectomy or other decompression for additional spinal stenosis. The delay from decision to incision was 9.4 hours on average, ranging from 1,3 to 22 hours. The reasons for delay were unavailability of an operating theatre or an anesthesia team because of other emergency surgeries being performed at the time of our booking, but also patient indecision in 1 case and patients unwilling to remain “nil by mouth” in 2 cases. Conclusion: Diagnostic and surgical decision making in emergency situations is a complex process, influenced by multiple factors, all of which potentially have relevant consequences. In this preliminary series, we found that primary MRI (16 instances) was sufficient to ascertain a diagnosis with the exception of 1 case, whereas primary CT (13 instances) required 3 additional MRI to generate a reliable diagnosis. These initial data suggest that except in cases where implant position is the key issue, MRI should be the primary ESI of choice. Additional imaging requires additional time and in this series, the mean delay from imaging request to decision was 3.4 as opposed to 17 hours, when a single imaging study was sufficient as opposed to when secondary ESI was necessary. An additional 9,4 hours delay from decision to incision has to be added to these numbers. Our database is too small at current, to allow for any conclusions as to whether these delays translate into any clinically relevant differences in outcome., Introduction: Recently, posttraumatic stress disorder symptoms (PTSD) were attributed to spine surgery. Furthermore, PTSD symptoms were associated with reduced clinical benefit. However, PTSD is seen in up to 10% of the normal population and there was no preoperative evaluation for PTSD symptoms. We previously demonstrated that PTSD symptoms are very common before surgery and negatively influence clinical outcome at 3 months follow up. Aim of this study was to assess the incidence and influence of PTSD Symptoms on clinical outcome one year after surgery. Methods: A prospective study of patients undergoing elective spine surgery for degenerative disc disease was performed. The patients were evaluated for PTSD using the PTSS score before, 3 and 12 months after surgery. In addition SF36 physical composite score (PCS), Oswestry Disability Index (ODI), EuroQOL 5D questioner and pain visual analog scale (VAS) were completed preoperatively, 3 and 12 months after surgery. Incidence and influence of PTSD symptoms on clinical outcome were examined. Results: 184 patients met the inclusion criteria. 52.7% were male, mean age was 59.4 years. Abnormal PTSS scores were observed in 43.7%, 20% and 22% of cases before, 3 and 12 months following surgery, respectively. However, only 8% developed PTSD symptoms only after surgery. At one year follow up patients with abnormal PTSS scores had a worse clinical outcome compared to their counterparts (SF36 PCS: 33.1 vs 40.0 P = .002; EuroQOL Index: 0.64 vs 0.78, P = .11, VAS Pain 5.6 vs 3.7 P = .001). Conclusion: PTSD symptoms are associated with worse outcome following elective spine surgery. However, the vast majority of patients that exhibit PTSD symptoms had already exhibited symptoms before surgery. Thereby the PTSS score seems nonspecific in the preoperative setting., Introduction: There are different definitions of arthrodesis, alignment and subsidence in the cervical spine. We aimed to compare the accuracy of different objective radiographic techniques in after anterior cervical discectomy and fusion and correlated those with clinical outcome. Methods: A retrospective analysis of 200 radiographs of patients following ACDF with stand alone-PEEK cages with a minimum follow up of 12 months was performed. For assessment of fusion one measurement was obtained from plain radiographs: the presence or absence of bridging bone in the operated segment. Three measurements were obtained from flexion-extension radiographs: Cobb angle and the distance between the tips as well as the distance between the bases of the spinous processes of the operated segment. Measurement of more than 2 mm between the bases of the spinous processes was defined as pseudarthrosis as recommended by the joint guidelines committee of the AANS/CNS. Cervical alignment was assed using the Katsuura, Lang and Cobb methods. Subsidence was measured with the mochida method, ventral segmental height reduction and dorsal segmental height reduction. Correlation between the different radiological methods and clinical outcome was performed. Results: Fusion rates varied greatly depending on the method used (from 43.9% to 89.4%). The Pearson correlations between pseudarthrosis and the use of the distance between the tips of spinous process method, the Cobb angle method and the presence or absence of bridging bone was 0.595 (P < .001), 0.187 (P = .007) and 0.224 (P < .001). The area under the receiver operating characteristic curve for the spinous process method was found to be 0.732, as compared with 0.557 for the Cobb angle method and 0.581 for the bridging bone method, for the measurement of pseudarthrosis. None of the methods used had any correlation with clinical outcome. The rate of improvement or stability of the cervical alignment was seen in 83.2%, 36.6% and 43.3% using the Laing, Katsuura and Cobb methods, respectively. Neck pain correlated with the cervical alignment using the Cobb (P = .27) and the Katsuura (P = .034) assessment methods but failed to correlate with Laing assessment method (P = .102). Subsidence rates were 62%, 48% and 27% using the mochida, ventral and dorsal segmental height reduction assessment methods, respectively. Pearson correlations between the mochida and ventral and dorsal height reduction assessment methods was poor (ventral: r = 0.39, P = .66 and dorsal 0.007, P = .921). Pearson correlations between the ventral and dorsal segmental height assessment was fair (r = 0.391, P < .0001). Subsidence using the mochida method correlated with neck pain at last follow up (P = .047), but did not correlate with clinical outcome with the other measurement methods. Conclusions: Fusion rates varied greatly depending on the method used. Regardless of the measurement method, pseudarthrosis did not correlate with worse clinical outcome. The assessment of cervical alignment is highly depended of the method used. Cervical alignment using the Katsuura and Cobb methods correlated with clinical outcome and last follow up. Subsidence rates varied strongly depending on the measurement method used. Clinical outcome correlated with subsidence when the mochida assessment method is used., Introduction: Despite widespread use of lumbar spinal fusion as a treatment for back pain, outcomes remain variable. Optimizing patient selection can help to reduce adverse outcomes. This research seeks to conduct a literature review to better understand the factors associated with optimal post-operative results following lumbar spinal fusion for chronic back pain, and the current tools used for patient subjective evaluation. Materials and Methods: The PubMed database was searched for clinical trials related to psychosocial determinants of outcome following lumbar spinal fusion surgery, evaluation of commonly used patient subjective outcome measures, and perioperative cognitive, behavioral, and educational therapies. The reference lists of included studies were also searched by hand for additional studies meeting inclusion criteria. English language and translated foreign language studies were included, as were any studies published between 1985 and the present. A total of 49 studies were included in support of the research questions addressed in this review. Results: Patients’ perception of good health prior to surgery and low cardiovascular comorbidity predict improved postoperative physical functional capacity and greater patient satisfaction. Depression, tobacco use, and involvement in litigation predict poorer outcomes following lumbar fusion. Incorporation of cognitive-behavioral therapy perioperatively can address these psychosocial risk factors and improve outcomes. The SF-36, EQ-5D, visual analog pain scale, brief pain inventory, and ODI can each provide specific feedback which can track patient progress and are important to understand when evaluating the current literature. Conclusions: The interplay of the various social and psychological factors surrounding lumbar spinal fusion are not fully understood when considering outcomes, and require further study. This review provides a summary of the current available information and explains commonly used assessment tools to guide clinicians in decision making when caring for patients with chronic lower back pain., Introduction: Symptomatic lumbar disc herniation is a rare occurrence during gestation despite the fact that low back pain complicates around 56% of pregnant patients. In line with this, cauda equina during pregnancy have only been documented in literature twice and considered as extremely rare. Advancements in surgical technique coupled with the proven safety of magnetic resonance imaging has made lumbar discectomy a viable and justifiable procedure at any stage of pregnancy. This paper was created to present a rare case of a pregnant patient with cauda equina syndrome treated surgically with lumbar microdiscectomy employing progressive local anesthesia as a novel alternative to neuraxial anesthesia. Material and Methods: A 30-year old multigravid primiparous woman with seven-month history of intermittent low back pain sought consult at 14 weeks’ gestation because of severe right leg pain which confined her to bed rest at home. There was noted associated saddle anesthesia of the perineum, urinary incontinence and constipation without any recalled precipitating factors. Physical examination revealed weakness of the right foot evertors and plantar flexors, loss of sensation in the L5-S1 nerve root distributions, and positive straight leg raise bilaterally. MRI confirmed an extruded disc at L5-S1. Patient was diagnosed with cauda equina syndrome and was advised to undergo surgery. Intraopertaively, the patient was positioned via modified knee chest on an Andrew frame, and underwent right-sided L5S1 foraminotomy, laminotomy and discectomy L5S1 under microscopic guidance under progressive local anesthesia. Post-operatively, the patient experienced immediately reported relief of her leg pain. Later on, she delivered prematurely at 33 weeks’ gestation by to a live baby boy via normal spontaneous delivery. At one year follow-up, patient denied any low back pain, residual paresthesia or motor weakness of both lower extremities, saddle anesthesia, nor urinary or bowel disturbances. Results: The surgical and anesthetic technique used in the study resulted in the desired outcome of decompression of the spinal cord and involved nerve roots, relief of patient pain post-operatively, disappearance of symptoms of cauda equina syndrome, and, ultimately, the uncomplicated delivery of a healthy infant. Conclusion: This case represents the only documented use of progressive local anesthesia positioned in modified knee chest position in lumbar surgery in a pregnant patient suffering from cauda equina syndrome. A rare condition in its own right, cauda equina syndrome is just as debilitating in the pregnant patient as it is in the normal population and still constitutes an orthopedic emergency that should be managed promptly without hesitation. As highlighted in this report, progressive local anesthesia may be a quick, effective, and non-expensive anesthetic option for these cases and in cases where neuraxial anesthesia is contraindicated., Introduction: The aim of this study is to evaluate the relationship between pelvic swing, a new pelvic parameter, and disk degeneration. The L5-S1 and L4-L5 disks are the transition points where body weight is transferred from the sacrum to the pelvis. The pelvis makes a swinging movement to both sides when a person is in motion. The L4-L5 and L5-S1 disks are the segments located in this transition region, which has the greatest participation in pelvic swing and where disk degeneration is the most frequently observed. Moerover, lumbar disk degeneration is more common in women than in men. Materials and Methods: 40 male and 40 female patients were included in the study. The mean age of the subjects was 30–50 years. Those with spondylolisthesis, deformity, congenital anomaly, history of operation, and a body mass index of >30 kg/m2 were excluded from the study. Magnetic resonance imaging (MRI) and lumbosacral spine XRay were prescribed to the patients with a complaint of back pain. Patients with degeneration at L4-L5 on MRI were assigned to the patient group, and those without degeneration were assigned to the control group. Four groups were established: group 1, female patients; group 2, female controls; group 3, male patients; group 4, male controls. Pelvic swing was measured over the anterior-posterior lumbosacral spine XRay. A line was drawn from the center of the top endplate of the sacrum to the center of the femoral head. This line was joined with an imaginary line perpendicular to the ground. The angle between the lines was taken into consideration and called the pelvic swing (PS). Measurements were performed separately by four researchers. The study is still in progress, and the number of groups should be increased (Figure 1). Results: The mean PS was found to be higher in the female patients than in the female controls, higher in the male patients than in the male controls, higher in the female patients than in the male patients, and higher in the female controls than in the male controls. Data analysis was performed by using SPSS 17.0 software for Windows. The Kolmogorov-Smirnov test was used to investigate if continuous variables had a normal distribution. The Levene test was used to investigate the homogeneity of the variances. Descriptive statistics were presented as median (interquartile range). The Bonferroni-corrected Mann-Whitney U test was used to investigate the significance of the intergroup difference in PS angle. Bonferroni correction was implemented in this study to control the type I error in all possible multiple comparisons. Based on the Bonferroni correction, results were considered as significant if their p values were, Introduction: Cauda equina syndrome is a pathological process with clinical signs and symptoms associated with lumbar disc herniation (incidence of approximately 2%). This pathology presents low back pain with or without radicular pain in lower extremities with impaired bladder and/or bowel control and loss of sexual sensation. The objective is to describe the clinical presentation of this syndrome and the outcome in five patients and literature review. Materials and Methods: Observational, longitudinal, retrospective study of patients diagnosed of cauda equina at the Torrejon hospital from 1st of January 2013 until 1st of June 2015. We collected sociodemographic variables, etiology, treatments and sequelae. Results: 7 patients (5 males and 2 female) with cauda equina syndrome by lumbar pathology. The average age was 45 years (range 40-50 years). Etiology: 6 patients had compression by disc extrusions and one ischemic / toxic after epidural injection. All patients had early surgery with canal decompression and circumferential spinal fusion after radiological study (CTscan, MRI, Angio-MRI). The time of clinic evolution: < 24 hours (5 patients), < 72 hours (1 patient) and < 1 week (1 patient). There were two complications: One second surgery by hematoma and one seroma resolved without surgery. Outcomes, in patients with compressively etiology: 100% have no motor symptoms but 50% had visceral or sensory clinical. The patient who debuted after epidural infiltration presented a late (after 14 months) and incomplete motor recovery, neuropathic pain and visceral clinic persist. Conclusion: This syndrome is a surgical emergency, by this is very important the early diagnosis. We present an infrequent case by ischemic / toxic damage (6 cases described in the literature). The early surgical decompression (, Introduction: According to many reseurchers, degenerative disk diseases is pandemic of the XXI century. Herniated disc at the lumbosacral spine is found in 61% of patients with degenerative diseases of the spine. Parallel advancements in image guidance technology and minimal access techniques continue to push the frontiers of minimally invasive spine surgery. While traditional intraoperative imaging remains widely used, newer platforms, such as 3D-fluoroscopy, cone-beam CT, and intraoperative CT/MRI, have enabled safer, more accurate instrumentation placement with less radiation exposure to the surgeon. This work reviews a private experience of uses of image guided system in lumbar spine endoscopic procedure. Materials and Methods: The authors used the O-ARM and S7 navigation system for percutaneous endoscopic lumbar disk herniation removal (PELD). This retrospective study included 52 patients who underwent transforaminal procedure for migrated disk herniation. Image- guided navigation utillizated in 9 cases. Pre- and postoperated examination included visual analogue scale (VAS) Oswestry Disability Index (ODI), radiological workup and time of operation. Results: Postoperative mean ODI decreased from 77.27 ± 7.1% to 16 ± 1.6%. All of patient noted improve theire pain status. Mean VAS score for back pain improve from 9.27 ± 0.27 to 1.87 ± 0.93 and leg pain from 8.0 ± 0.67 до 1.62 ± 0.98. Analysis of radiological work up confirms advantages of navigated PELD versus non navigated. There is common radiation dose was 1.5 ± 0.5 mSv in the group of patients undergone procedure navigation versus 5.3 ± 0.7 mSv in non navigated group. The mean of operation time was not deferent in both groups. Conclusions: Utilization of intraoperative cone-beam CT combined with navigation system in PELD decreases of common radiation dose versus traditional fluoroscopy. Improvement of visualisation and online control of instruments support increasing of quantity “best result” of surgery via improving of quality of nerve structures decompression., Introduction: Collagen is a major structural component of the intervertebral disk (IVD) array, and isresponsible for form and tensile strength. The purpose of this study was to evaluate the specific collagens I, II and III by immunohistochemistry and correlate them with radiological data of patients with lumbar degenerative discopathy (LDD). Materials and Methods: The IVD were obtained from twenty-three patients with LDD refractory to conservative treatment who required surgical treatment. Anti-collagen antibodies I, II and III were used for the determination of the protein collagen expression by immunohistochemistry. All data were correlated (Spearman’s-Rho) with radiographic findings of the patients and the Pffirman and Weishaupt classification. This study was approved by the Ethics Committee Circle/FSG 0153 and CAAE 40422114.3.0000.5341. Results: The data showed higher protein expression of collagen III (31.42%) compared to collagen I and II expression in chondrocyte clusters. Positive correlation was also determined (P < .01) between the degree of IVD degeneration and the percentage of protein expression of collagen II matrix in IVD. Further, a positive correlation (P < .05) was determined between the degree of facet degeneration and the percentage of expression of collagen I in the IVD chondrocyte clusters. Conclusion: The degenerated IVD presents a clear tendency to repair through the high protein expression of collagen III, indicating the possibility of IVD recovery and the possibility of viable stem cells in tissue that can regenerate the injury of patients with LDD., Introduction: Genotoxicity may be caused by intrinsic and extrinsic factors and determine the level of DNA damage that may be associated with several pathologies. Studies on the assessment of genotoxicity in the intervertebral disc (IVD) are scarce. The purpose of this study was to evaluate the genotoxicity in IVD and correlate it with the radiological data of patients with lumbar degenerative discopathy (LDD). Materials and Methods: The IVD were obtained from eight patients with LDD refractory to conservative treatment who required surgical treatment. For the determination of genotoxicity the IVD were digested enzymatically and subjected to Comet Assay to determine the degree of DNA damage. The genotoxic Damage Index (DI) and the Damage Frequency (DF) were determined. All data were correlated (Spearman’s-Rho) with radiographic findings of the patients and the Pffirman classification. This study was approved by the Ethics Committee under number CAAE 40422114.3.0000.5341. Results: The evaluation of the Comet Assay allowed an unprecedented definition of mean genotoxic values of DI and DF for each degree of IVD degeneration. The data generated showed a positive correlation (P < .01) between the increase of the average genotoxic DI and increasing the degree of IVD degeneration. These unique data characterize the need for investment in further studies to determine the factors associated with correlation of genotoxic damage with the severity of LDD. Conclusion: The comet assay showed a correlation between increased DNA damage and the severity of the LDD, which can justify the difficulty of repairing the damage and tissue regeneration., Introduction: The definition of cell differentiation capacity of adult mesenchymal stem cells (mSC) imposes a serious constraint on the applicability of this system in regenerative therapy. The purpose of this study was to evaluate the differentiation capacity of mSC isolated from the intervertebral disc (IVD) for future use in regenerative medicine in patients with lumbar degenerative discopathy (LDD). Materials and Methods: The IVD this study were obtained from patients with LDD refractory to conservative treatment which required surgical treatment. The mSC were isolated according to the methodology deposited in the INPI and characterized by flow cytometry. The differentiation capacity of isolated cells was determined by cultivation in specific media for 30 days with inductors for adipogenic and osteogenic differentiation. The cells were stained with Alizarin Red S (Osteocytes) and Oil Red O (adipocytes) to determine differentiation. This study was approved by the Ethics Committee under number CAAE 40422114.3.0000.5341. Results: The mSC isolated showed all the characteristics required by the International Cell Therapy Society (Plastic adherence, characterization by flow cytometry and differentiation). Furthermore, mSC were able to differentiate after one month of cultivation in specific media for adipogenic and osteogenic tissue when observed using specific staining. In addition to osteocytes and adipocytes it was also possible to visualize mSC residues, demonstrating the induction of these cells to differentiate. Conclusion: The mSC were able to differentiate into adipocytes and osteocytes under cultivation conditions and thus define their capacity for future application in regenerative medicine for patients with LDD., Introduction: Lumbar degenerative discopathy (LDD) affects millions of people worldwide and is among the most common causes of disability and chronic suffering. Thus it is necessary to invest in basic research to further understand its pathophysiology. The purpose of this study was to evaluate the histopathology of the intervertebral disc (IVD) for the elucidation of the degenerative disease factors. Materials and Methods: The IVD were obtained from twenty-three patients with LDD refractory to conservative treatment who required surgical treatment. Van Gieson and Verhoeef stainings were used for histopathological evaluation. The data were correlated (Spearman-Rho) with the information obtained in the histological evaluations of Alcian/PAS, MassonTrichrome and Safranin O/FCF. All data were correlated with radiographic findings of the patients and the Pffirman classification. This study was approved by the Ethics Committee Circle/FSG 0153 and CAAE 40422114.3.0000.5341. Results: The results of the histopathological evaluation allowed defining a positive correlation between the evaluated stainings. Thus, the greater the misalignment of collagen (Van Gieson and Masson trichrome), the greater the amount of chondrocyte clusters (Safranin O/FCF) and the higher the acid mucopolysaccharide deposit (Alcian/PAS) around these clusters in IVD. Verhoeff staining also allowed the further identification of the elastic fibers in the IVD evaluated, including a determination that they have a smaller amount of these fibers as compared to the negative control of the disease. Conclusion: The associated use of histological stains allows defining a set of important degenerative features that are important in understanding LDD., Introduction: Lumbar osteochondrosis corresponds to the inflammation of vertebral endplates as part of spinal degeneration that can cause mechanic low back pain (LBP). Conservative treatment with pain management and physical therapy to lumbar arthrodesis are described. The aim of this study is to evaluate the results of intradiscal steroid injection (ISI) for the treatment of LBP secondary to osteochondrosis. Material and Methods: A retrospective review of patients with LBP secondary to osteochondrosis diagnosed by magnetic resonance imaging (MRI) and treated with ISI was conducted. MRI characteristics, pre and postprocedure symptoms, complications, recurrence rate and the need of fusion were evaluated. Results: A total of 45 patients with a mean age of 50 (26-76) years were treated with ISI for LBP secondary to osteochondrosis between 2014 and 2016. 92% of patients presented one level osteochondrosis. Most affected levels were L5S1 (48%) and L4L5 (35%). Seven cases were postsurgical. All patients underwent other spinal infiltration beside ISI (facet joint infiltration in 96% and peridural transforaminal infiltration in 54% of patients). A 75% follow-up was achieved with a mean time of 5 (2-25) months. Postprocedure LBP disappeared in 42% of patients and in 21% it decreased an average of 70%. 27% of patients presented recurrent LBP with a mean asymptomatic period of 5 months and just one required lumbar fusion. One postprocedure L5 radiculitis was the only complication seen. Conclusion: ISI represents a safe and effective alternative for the treatment of LBP secondary to osteochondrosis. However, prospective and ISI alone studies are required to better evaluate the effectiveness of this procedure., Introduction: Lumbar disc herniation is one of the main surgical pathologies of the spine. There are many different surgical techniques for its treatment, but current trends are towards minimally invasive surgery. This study evaluates the initial results of a series of patients with lumbar disc herniation treated with percutaneous endoscopic lumbar discectomy (PELD). Material and Methods: A retrospective review of patients with lumbar disc herniation that underwent PELD was conducted, including worker’s compensation patients (WCP). Variables evaluated were disc herniation characteristics, bleeding, operating time, pre and postoperative symptoms, complications and recurrence rate. Results: We included 14 patients (mean age 40.7 years, range 24-76 years) operated for a first episode (n = 8) or recurrent lumbar disc herniation (n = 6). 43% were WCP, mostly heavy workers (n = 3). Most frequent location was posterolateral (n = 8), followed by foraminal (n = 5) and extraforaminal (n = 1). Five disc herniation were at L4-L5, four at L5-S1), three at L3-L4 and two at L5-LSTV. All went transforaminal approach, 57% at prone and 43% at lateral position. Mean surgical time was 117.9 ± 34 minutes, having the lateral position a statistically significant longer duration than the prone one (144 ± 18 vs 117 ± 30 minutes, P = .006). Four patients presented recurrent pain, of which two underwent conventional discectomy and fusion, one a selective radicular block and one opted for conservative treatment. Of the thirteen patients followed for one year, 69.2% remained asymptomatic with no significant difference between patients with and without worker’s compensation (P = .22). No surgical complications were reported. Conclusion: PELD is a good alternative for the treatment of lumbar disc herniation including WCP, however it is important to consider the difficulties of the surgical technique and the steep learning curve., Introduction: In 2014, the estimated incidence of new primary cancers in Brazil was 576,000 (2.84%) among a total population of 202,768,662. No official government statistics exist regarding the prevalence of spinal metastases among cancer patients. Knowledge of the descriptive prevalence of surgical operative procedures in patients who harbour spinal epidural neoplastic metastases remains lacking in the Brazilian medical literature, and this information could supplement the lack of epidemiological cancer data. The objective of this study is to generate descriptive numerical comparisons among patients undergoing operations for spinal epidural neoplastic metastases with respect to neurosurgical operative procedures and other surgically treated spinal column and spinal nervous tissue diseases. Material and Methods: The study design was descriptive. This research involved a retrospective review of collected data from the electronic archives of patients who underwent neurosurgeries in the Division of Neurosurgery of a single quaternary hospital between February 1997 and January 2015. The prevalence of spinal metastases was compared to the total of neurosurgeries and with those of other surgical spinal column and spinal nervous tissue diseases. Research data were organized into the five descriptive categories for numerical comparisons. Trend analysis was applied to determine the yearly pattern of prevalence. The Institutions Ethics Committee on Human Research approved the research project on January 2016. Statistical analyses were expressed by frequency, confidence interval, and trend analysis. Results: A total of 12,802 neurosurgical procedures were identified. These procedures were classified as follows: skull and brain, 11,192 (87.42%); spinal column and spinal nervous tissue, 1,462 (11.42%); and peripheral nerves, 148 (1.16%). Surgical procedures for the 1,462 (100%) cases of spinal column and spinal nervous tissue diseases were distributed by nosology as follows: degenerative intervertebral disk and spondylosis, 768 (52.54%); neoplastic, 279 (19.08%); traumatic, 221 (15.11%); congenital, 163 (11.14%); infectious and inflammatory, 27 (1.85%); and vascular, 4 (0.28%). With respect to the distribution of the 279 (100%) surgical procedures for spinal column and spinal nervous tissue neoplastic diseases, 124 (44.44%) procedures were for intradural neoplasms, and 155 (55.56%) procedures were for epidural spinal column neoplasms. The 155 (100%) operations for epidural neoplastic diseases were distributed into two groups: primary epidural neoplasms, 42 (27.10%); and secondary epidural neoplasms, 113 (72.90%). Spinal column epidural neoplastic metastases (secondary neoplasms) represented 0.88% of the 12,802 neurosurgical procedures. The yearly surgical trend prevalence was unchanged (no increase nor decrease) for surgical procedures in spinal metastases relative to the total number of performed neurosurgeries (event rate: 0.9%/year). Conclusion: Surgical procedures for spinal metastasis are uncommon with respect to all neurosurgical operative procedures but are common compared to the overall number of spinal column and spinal nervous tissue surgeries. Trend analysis indicates an unchanging trend of prevalence for spinal metastasis surgeries during the 19-year study period., Introduction: The aim of this study was to determine the prevalence and correlation between intraspinal gassequester and intradiscal vacuum phenomenon (IVP) and their clinical relevance. Material and Methods: In a retrospective study, 1200 CT scans were evaluated in both asymptomatic (CT Abdomen) and symptomatic (CT WS). Patients criteria included prevalence of VP and intraspinal gas sequester, their assation with other spine deaseases and clinical manifestations. Results: We found IVP in 42,91% of examinated CT scans. Gas sequesters inside the spinal canal was found in 80 patients (6.66%) which means - in nearly every fifteenth patient. In all of the cases where a gassequester in spinal canal was found, IVP and osteochondrosis were also present. The half of our study group patients with gassequesters in spinal canal had used anticoagulant medication on a long term basis trought their medical history. Conclusion: Gas in the spinal canal is not as rare phenomenon as it is assumed in the literature. Based on the results of the study it is mostly an asymptomatic appearance. We suppose that the condition of blood vessels as well as the diffusion capacity of endplates play an important role in the gas development of gas cysts and sequester., Introduction: Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by flowing ossification of the anterolateral spine with or without peripheral ossification of entheses. The prevalence of DISH is approximately 17% in a population over 50 years and rises with age. Risk factors for the development of DISH include obesity, hypertension and diabetes mellitus. Although the presence of DISH is associated with cardiovascular diseases, prevalence research was only conducted in patients with cardiac disease. In the current study the prevalence of DISH is assessed in a population with vascular disease and thus a high prevalence is expected. Material and Methods: Computed tomography (CT) scans were collected from patients over the age of 50 that had undergone an endovascular aneurysm repair (EVAR) in our hospital between 2009 and 2013 with a CT scan obtained preoperatively or within one week after surgery. The region of interest (T6 to the sacrum) had to be present in the CT image for inclusion and DISH was diagnosed according to the Resnick criteria. In case the bridging ossification was near complete or if only two contiguous bridges were present, the CT scan was allocated to an ‘early phase’ group. Simultaneous presence of DISH and ankylosing spondylitis, leading to rejection of the diagnosis according to the Resnick criteria, was also recorded. Results: In total 161 CT scans from EVAR patients (86.3% male; mean age 72.7 years) were included for the evaluation of the presence of DISH. The prevalence of DISH was 22.3% for males and 22.7% for females. The ‘early phase’ was scored in 9.9% of the CT images and concurrent DISH and ankylosing spondylitis was present in 2 male subjects (1.2%). Conclusion: The overall prevalence of (early) DISH was 33.5% in a population older than 50 years and treated for an aneurysm of the aorta. Vascular disease and DISH might be directly associated to each other or risk factors such as hypertension and obesity cause this relatively high prevalence as these are associated to both DISH and aortic aneurysms. The high prevalence of DISH in female patients was unexpected because previous investigations on prevalence showed a higher prevalence in males., Introduction: Several factors, such as osteoporosis, obesity, and lack of exercise, contribute to low back pain. This longitudinal study aimed to investigate the risk factors for low back pain in local residents of Yonago, Japan. Material and Methods: Our study conducted in 2014 comprised 96 participants (34 males and 62 females; mean age of 73.9 years at beginning of the study) of general medical examination, living in Yonago, Japan, who provided informed consent. We assessed low back pain using the visual analog scale (VAS) and divided local residents into two groups. Group A included residents with worsening low back pain experienced from 2014 to 2016. Group B included residents who experienced no change in low back pain during the study period. We compared body mass index (BMI), bone mineral density (%YAM), skeletal muscle mass, standing posture, and exercise frequency, which was defined as physical activity at least twice a week. We then used logistic regression analysis to identify the risk factors for low back pain. Results: 40.8% of Group A residents exercised regularly and 81.2% of Group B residents exrcised regularly. There was significantly difference between Group A and B (P < .001). There were no significant differences in BMI, skeletal muscle mass, standing posture, and bone density between the two groups. Logistic regression analysis revealed lack of exercise, as assessed using VAS, as a significant risk factor for worsening low back pain (odds ratio, 0.19; P = .002; 95% confidence interval, 0.07–0.53). In addition, as per VAS assessment, average bone mineral density of residents who worsened low back pain in spite of getting regular exercise was 75.4% (%YAM) and that of residents did not worsen low back pain without getting exercise was 83.4%.There was significantly difference (P < .04).The residents with who had low bone density did not get benefit from its preventive effects. Conclusion: Our results indicate that regular exercise is useful in preventing low back pain. However, people with low bone density did not get enough exercise to benefit from its positive, preventive effects. As the residents in this region tend to be elderly, we speculate that the low back pain is associated with osteoporosis. Although exercise is typically suggested to prevent low back pain in patients, it may not be effective in preventing low back pain associated with osteoporosis., Introduction: Currently there is very less data available about the epidemiological pattern and mechanism of cervical spine injuries in Indian subcontinent. The aim of the current study was to document the demographic pattern, mode of injury, level of cervical spine injury in patients so that it can be extrapolated for formulating guidelines in developing nations for proper management of this life threatening injury. Material and Methods: This study comprised of 275 patients of cervical spine injury admitted in a tertiary care centre from January 2006 to October 2015.The data analysed included the patient’s age, sex, and occupation, the place of injury (rural/ urban), associated injuries, level of injury, and neurological status according to American Spinal Injury Association Scale was noted. Results: The mean age was (3 to 95) and male to female ratio was 11.5: 1. Majority (30%) of cases were of third and fourth decade. 60% of patient fall from height as mechanism of injury. The urban to rural ratio of patients was 3:1 and 184 patients (67%) belonged to the rural areas. The most common mode of injury in the present study was fall from height, 166 cases (60%) of which most of them occurred while working and fall from tree. Dislocation at C 5-6 vertebral level was commonest and a C 5 vertebra was most commonly fractured. Incomplete cord injury of ASIA grade C scale was the commonest pattern seen in 156 cases. Head injury was commonest associated injury with cervical spine injury. Conclusion: Identification of demographic data and mechanism of injury pattern helps to identify the preventable risk factors for controlling them. Proper education and training of paramedical staff in rural areas of initial aid and transportation of patients having spinal cord injuries can reduce the frequency and morbidity of spine injuries, Introduction: Routine in-hospital postoperative radiographs following surgical treatment of traumatic thoracolumbar injuries is a common practice despite a lack of evidence supporting its utility. Previous studies have concluded that postoperative radiographs following lumbar fusion for degenerative conditions have limited clinical value, especially in the absence of changes in symptoms or examination. The same has been suggested for cervical fusion, whether performed for trauma or degeneration. In order to obtain these radiographs, patients are subject to radiation and inconvenience at a cost to the healthcare system. These images may not only provide little value, but may also be detrimental due to prolonged immobilization or unnecessary intervention, such as advanced imaging (ie, computed tomography, magnetic resonance imaging) or surgery. The purpose of this study is to determine if routine in-hospital postoperative radiographs following surgical treatment of traumatic thoracolumbar injuries is necessary in the absence of changes in symptoms or examination. Material and Methods: We performed a retrospective chart review of the patients at a Level 1 trauma center who underwent surgical treatment of traumatic thoracolumbar injuries between December 2006 and October 2015. Upright AP and lateral radiographs were obtained postoperatively, which were reviewed by one of the surgeons prior to discharge. Patients who subsequently underwent revision spine surgery were identified and further analyzed to elucidate the rationale for intervention, as well as to obtain demographic information, diagnosis, index procedure, and revision procedure. The primary outcome was return to the operating room for findings on routine post-operative spine radiographs. Results: Five-hundred patients (353 males and 147 females) were identified with a mean age of 44.6 years (range, 18-90) between December 2006 and October 2015. Only one patient, an 18-year-old male who sustained a L2 burst fracture in a fall from 65 feet, had revision surgery secondary to abnormal routine postoperative radiographs in the absence of other findings. Six other patients (five males and one female) with a mean age of 35.8 years (range, 18-75) underwent revision surgery due to worsening or persistent neurologic deficits, or findings from advanced imaging. The injury patterns included 4 burst fractures and 3 flexion-distraction injuries. Five patients had percutaneous posterior stabilization and 2 patients had open posterior decompressions and instrumented fusion as the index procedure (Table 1). Conclusion: Routine in-hospital postoperative radiographs following the surgical treatment of thoracolumbar injuries are of little value, especially in the absence of changes in examination or symptoms. The rate of revision surgery during the initial hospitalization was 1.4% (7/500) in our study. Only 0.2% (1/500) returned to the operating room for revision of instrumentation as a result of an abnormality found on routine postoperative radiographs. With the present emphasis on cost-efficiency and evidence-based practice, this study may contribute to a movement to discontinue routine postoperative radiographs following spine surgery., Introduction: Despite the pivotal role of MR imaging, CT scan continues to serve as an important tool for decision-making in diagnosing SLSS. Little is known about the correlation between CT parameters and clinical presentation of patients with SLSS. Material and Methods: 75 patients (mean age 62±6.64 years, 67% female), with SLSS severe enough to indicate surgery, were included in this study. In total of data examination and classical questionnaires (VAS, ZCQ, ODI), patients were divided in three clinical groups: 22 pts with predominant low back pain without any symptoms of neurogenic claudication or radiculopathy (group LBP), 21 pts with monolateral radiculopathy (group MLP), 32 pts with neurogenic claudication or bilateral radiculopathy (group NC). For all patients CT imaging was performed and thirteen radiological parameters were measured. The association between radiological and clinical findings was tested using logistic regression analysis. Results: A t test demonstrated that the differences between all groups in age, gender, BMI were not statistically significant. Minimal parasagittal distance (mPSD) between the ventral surface of the superior articular process and intervertebral disc (odds ratio[OR]: 0.62; 95% confidence interval [CI]: 0.44, 0.86; P = .0047) is the most statistically significant CT parameter for patients in group LBP. Cross-sectional area (CSA) of the spinal canal (OR: 0.98; CI: 0.97, 0.99; P = .0006) and the depth of the lateral recesses (LRD) – minimal distance from the articular process to the posterior edge the vertebral body (OR: 0.42; CI: 0.22, 0.80; P = .0077) are the only independent variables associated with symptoms in group NC. We were unable to identify the specific CT imaging parameters to patients with monolateral radiculopathy. Conclusion: CT scan may help for decision-making in the diagnosis and treatment of some forms of SLSS when prevail the symptoms of back pain or neurogenic claudication or bilateral radiculopathy. Further careful study of the possible correlation of clinical and radiological parameters of spinal stenosis is necessary., Introduction: The infectious spondylitis leads to disability in 80% of cases especially in socially active middle age patients. The neurological disorders caused by irritation or structural changes in spinal cord (SC) can manifest by radicular syndrome, by complete or incomplete paraplegia or bladder and bowel dysfunctions. The pathogenesis is conditioned by mechanical compression or vascular changes in SC. The pre-op diagnosis of SC structure in tuberculosis and non-specific spondylitis is important not only for surgical tactic but for prognosis of total effect of treatment. Methods: 51 consequently operated patients aged from 21 till 78 years old (average 48,7 yrs) were included into prospective cohort study (study period - from December 2015 till May 2016). The inclusion criteria were clinical signs of myelopathy, MRI and bacteriological confirmation of spondylitis’ etiology. The clinical parameters included into study were a) the backpain severity estimated by 10-degrees visual-analog scale (VAS); b) motor and sensitive disorders counting according ASIA (mod. 2011) and Frankel scale (Fr. types, A-E), c) Oswestry disability index (ODI). The radiological criteria included five parametric signs 1) number of affected vertebrae, 2) apical Cobb angle (CA), 3) maximal degree of spinal canal stenosis (square, SCSs), 4) maximal degree of lineal antero-posterior compression (APC) of sac dural, 5) apical SC kyphosis (SCK, measured similar to Ferguson angle) and two non-parametric ones: 1) the level of vertebral lesions and 2) MRI myelopathy signs of SC – gliosis (or myeloischemia), atrophy, syringes. All MRI studies was performed on the Exelart Vantage, Toshiba, 1,5T. Statistical data: «Statistical Package for the Social Sciences» (SPSS), version 22.0 (SPSS Inc., Chicago, IL, USA).The study was limited by pre-op period only because of severe implant-related artifact after spinal surgery. Results: According to Frankel types, the spondylitis patients were divided as A (9.8%), B (11.7%), C (11.7%), D (17.6%) and E (33.3%). According to prospective bacterial tests the spondylitis etiology was identified as tuberculosis (TB) in 43% and non-TB in 56% cases. Gliosis (myeloischemia) was the prevalent SC changes in both group (68%) despite the spondylitis’ etiology. The SCSs and SCK was significantly higher in TB in compare with non-TB spondylitis (p ≤ 0,05). It was not confirmed dependence between the Frankel types and SCSs, but it correctly confirmed with APC degree. We did not find neither VAS nor ODI correlation with etiology of spondylitis. Moreover, it was not find links between the neurologic disorders counting by Frankel sc. and type of structural SC changes and ODI parameters. Conclusions: It was confirm that degree of SC compression and its sagittal deformity depend on etiology and significantly severe in patients with TB in compare with non-TB spondylitis. Despite this, we didn’t find links between severity of neurological disorders, counted by Frankl scale and MRI-visualized SC changes. From other side, such dependence clearly appeared with an apical antero-posterior compression of sac dural (APC)., Introduction: Osteoporotic fracture, especially in proximal femur and spine, is one of the common causes of elderly persons becoming bed ridden in Japan, and it is known that most osteoporotic fractures in spine are morphometric fractures without back pain. The present study was conducted to assess spine fractures with opportunistic screening using CT in postmenopausal Japanese women. Materials and Methods: The subjects were Japanese women over 60 years old who underwent CT scan of truck for several reasons between April 2015 and March 2016 in Kawasaki Medical School Hospital. Result: We evaluated morphometric fracture using sagittal reconstruction from DICOM data of CT. 2,364 women had CT examination, and fractures were detected in 486 women. 187 women (39%) had treatment of osteoporosis. We gave feedback of the fracture information to 299 non treatment women, and 70 women came office visit. Conclusion: This method may improve the treatment rate of osteoporosis in Japan., Introduction: In recent years magnetically controlled growing rods have been included in our treatment arsenal for EOS (early onset scoliosis) with clinical and hospital advantages of performing elongations without the need of multiple surgeries. Material and Methods: We have involved 15 EOS patients from our institution. Mean follow-up of 8 months (14-4 months). All patients have been studied post-operatively with simple X-rays and ultrasound at every elongation. We analyzed the Cobb angle, thoracic kyphosis and compared the T1-S1 distance preoperatively, and at the latest elongation procedure. Results: A total of 15 EOS patients were collected for this study. Cataloged by etiology neuromuscular was the most frequent followed by syndromic. Average age was 8.2 year-old (6-10 yo). All patients were stabilized using a double rod construct. Attending to fixation methods: only in one case were used proximal and distal pedicle screws; for the rest of cases it was performed a hybrid construct with cranial hooks and caudal pedicle screws. Elongations were performed every 3 months at the clinic, noninvasively. Patients and their families returned home just after the procedure. NO complications were detected at this point. Mean preoperative Cobb angle was 76º (98º-63º). Mean Cobb angle after surgery measured 40º (63º-39º) which means an average of 60% of correction. Mean preoperative thoracic kyphosis was 61º (68º-15º) which experimented an improvement to postoperative 43º (60º-35º). Most important of all, it was objectified an improvement of the T1-S1 distance from 264 mm pre-operatively to 286 mm at the end of follow-up. Rod elongation was measured before and after each procedure using simple X-ray and ultrasound. Mean values obtained at the concavity were 13.38 mm and 13,85 mm when using radiography and ultrasound, respectively, while at the convexity were 8.71 mm and 9.3 mm. Values obtained by magnetically controlled device, radiographs and ultrasounds were compared statistically. Conclusions: Magnetically controlled growing rods are an effective alternative for the treatment of EOS patients. Ultrasounds are as accurate as radiographs for measuring rod elongations., Introduction: The sagittal spinal parameters can be measured in the spine lateral radiographs, whatever it’s taken by the latericumbent position or the full-length lateral radiographs in upright position. Nowadays, more and more studies have paid more attention to the spine sagittal balance. The sagittal lumbar-pelvis parameter measurement is wildly used in many studies. Unfortunately, the sagittal alignment is different from various positions. The difference and correlation of lumbar-pelvis parameters between the most popular position, latericumbent position and upright standing position, are still unclear. This study aims to investigate the difference of sagittal parameters in spine lateral radiographs between latericumbent and upright positions, identify the correlation of standing lumbar lordosis (LL) and latericumbent lumbar-pelvis parameters, and establish a linear fitting formula. Material and Methods: The sagittal alignment of 157 continuous patients was assessed using Surgimap software from two kinds of lateral radiographs, to acquire the following parameters: lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), L4-L5 intervertebral angle (IVA4-5), L4-L5 intervertebral height index (IHI4-5), and PI-LL. The statistical analysis was calculated by SPSS 19.0 software. The Kolmogorov-Smirnov Test, Pair t-tests, Pearson correlation analyses, and Multivariate linear regression analysis were used to analyze the data. Results: We found there were significantly statistical difference in LL, SS, PT, IVA4-5, and PI-LL, except for PI and IHI4-5 in the two positions. The result showed a significant relativity between standing LL and latericumbent LL, PI, and SS. Thus, a predictive formula of standing LL was obtained with latericumbent LL, PI, and SS as predictors. Conclusion: Not all of sagittal parameters obtained from two positions are identical. When making surgery plans before lumbar spine surgery, spinal surgeons should give sufficient consideration to differences between the two views. We can predict standing LL with the formula when we couldn’t get whole-spine lateral standing radiographs., Objective: To determine the improvement in terms of mean change in postoperative kyphotic angle after anterior decompression and cage placement with bone graft in tuberculosis of Thoraco-lumbar spine. Methods: The Quasi Experimental study was conducted in the Department of Orthopaedics and Spine of Ghurki Trust Teaching Hospital, Lahore from 1st May 2015 to 31st May 2016.50 patients who qualify the inclusion criteria were included. All patients underwent anterior decompression and placement of Interbody Titanium Mesh Cage with packed bone graft. Pre and Post-operative lateral view x-rays were taken to check and record the post operative change in kyphotic angle. A Boston brace was applied for at least 6 months. Data was analyzed using SPSS 17.0 Results: There were 38(63.3%) males and 22(36.7%) females. The patients aged between 15-30 years were 32(53.3%), those between aged 31-45 years were 15(25%) and between 46-60 years there were 13(21.7%).There were 10 (16.6%) patients with 0-10 degree improvement, 36(60%) patients with 11-20 degree improvement and 14(23.4%) patients with 21-30 degree improvement. Paired t-test result for change in angle is P = .000. Conclusion: Anterior decompression along with Titanium mesh cage and bone graft in patients suffering from caries spine showed immediate post operative improvement in kyphotic angle., Introduction: Postoperative infections increase morbidity and mortality rates in spine surgery and generate additional costs for the healthcare system. It has been proposed that blood transfusions increase the risk of wound infection, urinary tract infection, pneumonia, and sepsis. The aim of this study was to determine the incidence of infection in patients who received blood transfusions in major deformity surgery involving at least eight levels, hypothesizing that transfusions are a risk factor for postoperative infection. Materials and Methods: A retrospective cohort study conducted from 2012 to 2015 identified 56 patients meeting the study criteria who had received spine surgery involving the fusion of eight levels or more. Patient-specific characteristics, starting and ending hematocrits, number of units transfused, use of vancomycin powder, drain usage, and infections including urinary tract infection, wound infection, pneumonia, Clostridium difficile, and sepsis were documented. Differences in infection risk between those who did and did not undergo a transfusion and their 95% confidence intervals were calculated. Results: Groups were similar with respect to baseline and surgical characteristics except for smoking status, operative time, estimated blood loss, and ending hematocrit. The overall infection rate was greater in patients who underwent transfusion than those who did not (36% versus 10%; P = .03). Wound infections (n = 5) were only observed in those who underwent a transfusion. Smokers were more likely to receive a transfusion and were also more likely to experience infection. A stratified analysis demonstrated an increased risk of infection associated with transfusion; however, the risk was greater in smokers, suggesting the effect of transfusion on infection could be modified by smoking. Patients undergoing transfusion experienced a significantly longer hospital stay (P = .01). Conclusion: Allogeneic red blood cell transfusion in major spine surgery could be a risk factor for postoperative infection. This increased risk seems to be magnified in those who smoke. Further studies are warranted, and risks of blood loss and transfusion-related complications in smokers also potentially merit exploration., Introduction: Tuberculous spondylodiscitis affects around 50% of all patients with musculoskeletal tuberculosis. Tuberculous lesions often involve the intervertebral disc, the endplates of the adjacent superior and inferior vertebral bodies. With progression of the disease severe destruction of these elements occur. The indications for surgical intervention are the presence of progressive neurologic deficit, intractable pain, abscess formation, kyphotic deformity, instability and for diagnosis. Material and Methods: To describe the efficacy of the posterior only surgery for achievement of debridement, reconstruction of the anterior column and segmental stabilization in 12 cases with tuberculous spondylitis. 12 cases with tuberculous spondylitis including 9 females and 3 males with spondylodiscitis are presented. The ages ranged between 20 to 62 years. 6 were loacated in thoracolumbar 3 in thoracic and 3 in the lumbar region. two were associated with abscess formation, 2 with previous maltreatment had severe kyphosis. In 4 cases one or 2 level corpectomy was done. and in the remaining ones partial corpectomy with debridement of the affected endplates were done. In 2 cases with abscess, the collections were evacuated. Reconstruction of anterior column was done with titanium expandable cages in 4, autograft in 2 and allograft in 6 cases. Antituberculous medication was started as soon as possible. Result: All patients pain disappeared post operatively, neurological deficit disappeared gradually but completely. Kyphotic deformity was corrected and good stabilization was seen in X-ray. No recurrence of the symptoms was seen. Conclusion: The mainstay of surgical intervention is debridement, reconstruction of the anterior column and segmental fixation. This can be achieved either with combined anterior posterior surgery or anterior only surgery. Although, posterior only procedures might hold great promise in the management of tuberculous spondylitis, many questions about long-term efficacy and safety remains. Although, our case series, has shown very good outcome. it is clear that additional long-term, prospective, comparative data is required before this route may be considered as a replacement for more demanding traditional corridors. Undoubtedly, improved learning curve, using surgical microscope and vigilant neuromonitoring are necessary for better performance and outcome., Introduction: Presence of gas in spine on radiological imaging is a sign of degeneration. Unlike in appendicular skeleton, it very rarely represents infection called emphysematous osteomyelitis. Emphysematous osteomyelitis of spine is a rare infection of bone caused by gas forming microorganisms. We describe one such rare case diagnosed early and treated successfully with timely surgical intervention and appropriate postoperative antibiotics. Methods: We analyse the medical records, clinical history, per operative findings, radiological images, histopathological images, culture and sensitivity reports, laboratory reports and follow up findings of a rare case diagnosed as emphysematous osteomyelitis of spine. We also review literatures reporting similar cases and analyse the clinical and radiological findings in these cases to help differentiate more common gas forming degenerative conditions from infection. Results: Literatures descrided that gas shadows in degenerative conditions are usually small, localised, surrounded by sclerotic rim and are associated with other degenerative changes without vertebral collapse. In vertebral compression fractures and in primary tumors, which are the next commonest conditions showing gas shadows, the shape of the gas shadows are usually linear, band like or triangular and is well demarcated and associated with vertebral collapse. In infective spondylitis the distribution of the gas is usually uneven displaying a bubble like pattern and characteristically extending into the paravertebral soft tissues. In our case, apart from clinical and laboratory features of high grade fever and chills, eleveated ESR and leucocyte count, radiological findings like presence of intravertebral gas in the absence of vertebral collapse, spreading throughout the vertebral body and extending into the prevertebral tissue and psoas muscle helped in differentiating it from other benign conditions causing vertebral vacuum phenomenon. The diagnosis was confirmed by biopsy and culture. Early surgical decompression and stabilization with appropriate antibiotics helped in the recovery of the patient. Conclusions: Emphysematous osteomyelitis of spine is rare and difficult to diagnose. Clinical, laboratory and subtle radiological findings may help in its early diagnosis, and timely surgical intervention with appropriate antibiotic may result in favourable outcome., Introduction: Tuberculosis is still a burden particularly in developing countries accounting for 9.6 million cases and 1.5 million deaths in the year 2014 globally. About 1-2% of all tuberculosis are skeletal tuberculosis, among which more than 50% are spinal tuberculosis. Tuberculosis is commonly seen in thoracic region. Cervicothoracic junctional (CTJ) tuberculosis is uncommon and has rarely been described in the literature. Approach and surgical stabilization at CTJ is technically challenging. We describe a technique of stabilizing CTJ by posterior only approach using cervical and thoracic pedicle screws and the results of CTJ tuberculosis managed by this technique. Materials and Methods: Histologically proven tubercular infections of spine with radiological evidence of destruction between C7 to T3 vertebra managed surgically by posterior only approach using pedicle screws in our institute between 2011-2015 with a minimum of 1 year follow up were selected. Demographic data, clinical history, operative time, blood loss, perioperative complications and duration of stay in hospital were analyzed among by retrospective review of medical records. Preoperative total vertebral loss and postoperative correction of kyphosis were calculated by method described by British Medical Research Council. Loosening of screws, hardware failure or loss of correction were analyzed from radiographic images. Neurological improvement was assessed by ASIA and Shanmugasundaram’s grading of paraplegia. Results: 8 cases (4 males and 4 females) were included in the study with an average age of 39 years. Pain and difficult in walking due to myelopathy or weakness was the most common symptom. The primary site of involvement was C7T1 in 3 cases, T2T3 in 2, T1T2, T3T4 and T4T5 in 1 case each. Most patients presented with Stage 2 myelopathy (4 cases), 2 cases presented with stage 3, while 1 case with intact neurology and another with stage 5 with bladder incontinency. The total vertebral loss ranged from 0.45-2.26 with average of 1.12. The average operative time and blood loss were 157 minutes and 362 ml respectively. 1 patient developed complete motor paraplegia with intact sensations post operatively with recovered completely at 3 months. All patients were treated with 1-year course of antitubercular medications. The average follow-up period was 19 months (range 12–32 months). At final follow up all patient improved significantly neurologically and radiological images showed no evidence of implant failure or screw loosening. The angle of kyphosis was corrected from a preoperative value of 34.9 degrees to 18.7 degrees post operatively which maintained at 20.6 degrees at final follow up. Conclusion: The use of cervical pedicle screws in place of traditionally used lateral mass screws simplifies many technical difficulties at CTJ in tuberculosis. The screws being in alignment with that of thoracic pedicle screws makes the insertion of the connecting rod easier eliminating the need for difficult contouring or use of domino connector and thereby reducing the operative time, blood loss and extent of exposure. Pedicle screws being biomechanically superior to lateral mass screws allow a shorter instrumentation. Anterior column debridement and reconstruction through posterior approach eliminates the need for more morbid anterior procedures., Introduction: Surgical site infection (SSI) following spinal deformity surgery has considerable medical, social, and financial impact on patients and their families. In recent years many studies have identified risk factors for the development of SSI in adult and pediatric population. Despite the knowledge of risk factors for SSI, there is no high quality evidence for prevention strategies and the infection rates remain high. Now days the best evidence is based on Best Practice guidelines and infection prevention protocols. Material and Methods: A multidisciplinary group developed an infection prevention protocol by using the previous institutional information and the current literature. A retrospective descriptive study was designed to assess the rates of SSI, the prevalence of the known risk factors and the causative microorganisms. This data was compared with a prospectively collected information posterior the implementation of the protocol. The inclusion criteria are based on the CDC guidelines and definitions for SSI. Results: The prior rate for SSI was 5.1%, according to the etiology specific rates are as follows: Syndromic (20%), Neuromuscular (13%), congenital (6.1%) and Idiopathic (1.7%).The median age was 17.63, with a median of body mass index (16.4) and albumin (3.31). (75%) of the patients had a previous spine intervention. All had a posterior fusion approach, and (87,5%) required an intraoperative blood transfusion; the median time for the administration of prophylactic antibiotic prior to the incision was 40,19 minutes. 90.9% were due to a gram-negative microorganism, being the most common the Enterobacteriaceaes. Two patients infected with P. aeruginosa required implant removal. After the protocol implementation SSI rate was (1.2%), and for neuromuscular etiology (4.3%). The SSI rates for syndromic, congenital and idiopathic scoliosis were reduced to (0%). Conclusion: SSI remains an important topic for research. Based on the reported risk factors and with the collaboration of all members of the operating room team proper interventions can be made. At our institution the application of a standardized infection prevention protocol reduced the rates of SSI., Introduction: Postoperative surgical site infection (SSI) places a significant cost burden on both patients and healthcare systems. Treatment requires readmission, incision and drainage, and prolonged courses of antibiotics. Numerous studies have identified risk factors for a postoperative SSI after spine surgery, but none have identified specific risk factors for increased treatment costs or length of stay in the management of a postoperative infection. Material and Methods: A retrospective review of all patients undergoing spine surgery at a single institution between January 2010 and December 2012 was performed to identify patients requiring secondary surgical intervention for SSI. Demographic and financial data from both the index admission as well as all subsequent readmissions for postoperative SSI were reviewed. Independent variables abstracted from patient records were analyzed using bivariate regression and multiple linear regression to determine the nature and extent of their associations with total direct hospital costs and length of stay. Results: 146 of 3101 patients (4.7%) required a return to the operating room for postoperative surgical site infection following spine surgery. 90 patients (61%) had been discharged prior to diagnosis of SSI. This cohort resulted in 110 readmissions and cumulatively underwent 138 I&Ds for management of postoperative spine SSI. 13/90 patients (14%) required more than one readmission and 22/90 patients (24%) ultimately required multiple I&Ds during management. The mean number of I&Ds per infection was 1.5. Average length of stay for the index operation and secondary readmission were 6.7 days and 9.6 days, respectively. Mean direct cost of treatment for SSI was $16,258 (median $10,463, range $2,572 – $138,134). In regression analysis, length of stay, number of levels fused, MRSA, decreased serum albumin on readmission, and number of I&Ds required were significantly associated with increased treatment costs. Conclusion: Length of stay was strongly associated with an increase in total direct cost, consistent with findings of previous studies. Likewise, low serum albumin and MRSA-positive cultures were associated with significantly greater length of stay and in turn higher direct costs. Low serum albumin represents a potentially modifiable risk factor in the treatment of SSI. Further study is needed to investigate the relationship between poor nutrition status and increased length of stay and total costs in the treatment of SSI following spine surgery., Introduction: Parallel to increased risk and predisposing factors the incidence of vertebral osteomyelitis is rising. There are many systemic factors which can negatively affect the immune system. The term locus minoris resistentiae is defined as a place of reduced resistance (any part or organ which is more susceptible than others) against the attack of a morbific agent. Spinal instability has rarely been described as a cause of depressed localized immunity. In this study, we present 18 patients with hematogenous infection on top of preexisting lytic olisthesis (LO) in the lumbar spine. Methods: A retrospective clinical case-series. Out of 402 patients who have been treated in our center for haematogenous lumbar spinal infection between Jan.2005 and Dec. 2015 we have identified 23 patients with LO. Of those 18 (78%) attracted the infection at same site of the LO (15 with grade I, 2 with II and one grade III olisthesis). We analyzed the preoperative condition, risk factors, diagnostic findings and presentation, causative organisms, treatment and outcomes. Results: In the totalof18 patients males dominated females by 14 to 4 with a mean age of 67.7 years (49-85).Of them 14 patients were overweight or obese (mean BMI of 27.7), 8 patientshad ASA score of III or more, 6 suffered fromDM, another 6 from cardiac diseases and two from liver cirrhosis. Other sites of infection were found in 7 patients. Neurological deficit (ASIA C&D)at the time of presentation had developed in 6 cases, fever in another 6. Multifocal infection was found in 2 cases, additional epidural abscess in 11 and psoas abscess in 6 individuals. All patients except 1 patient, diagnosed with CT-guided biopsyand treated conservativelyrequired surgery(ventrodorsal techniquein 11 patients and PLIF technique in 6 cases). The mean follow up (FU) reached 2.5 years. Mean CRP at time of presentation was 66 mg/l (8.9 at last FU), WBC of 9.6x103/mm3 (6.7 at last FU) and ESR of 76 mm/h (31 at last FU). A causative organism could be isolated in12 patients (67%); Staph. epidermidis in 4 of them. Neurological deterioration occurredin one patient, one morbidly obese individual had postoperative wound healing problems and one patient had to be reoperated 11 months later due to infection of the adjacent cranial segment. Discussion: Spinal osteomyelitis is commonly caused by hematogenous seeding. Predisposing factors that compromise the immune system render the host more susceptible to spinal infection. The LO represents a suitable site for inoculation of organisms and in this series increased the possibility of development of infection up to 78%. The altered vascularity leads to blood stagnation and facilitates the bacterial seeding. The LO could be an example of locus minoris resistentiae that can attract an organism and develop spinal infection., Introduction: Post-operative complications have been associated with cervical fusion procedures with the infection being a common and debilitating one. The aim of our study was to determine whether having an existing psychiatric disorder is a risk factor for developing post-operative infection following anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF). Materials and Methods: In this retrospective study PearlDiver Technologies was used to analyze Humana database from 2007 to 2015. Patients who underwent primary cervical spine surgery: ACDF or PCF were included in the study. This group was subdivided into: patients who were diagnosed with psychiatric disorders and patients who were never diagnosed with specific psychiatric disorders prior to surgery. Depression, anxiety, bipolar and schizophrenia were included as psychiatric disorders in the study. Patients were followed for 1 and 3 months post-operatively to detect whether they had infection or not. In order to detect if patients with psychiatric disorders are more prone to severe infection, sepsis rates were reviewed separately. Results: Total of 34,007 patients were included in this study. Eighty percent of these patients had ACDF while the remaining had PCF. Overall, post-op infection rates within 1 and 3 months were 3% and 4.2%, respectively. When ACDF and PCF patients were reviewed separately, there was a dramatic difference regarding the infection rates. At one-month follow up infection rate for ACDF patients was 1.8%, while it was 7.7% for PCF patients (P < .001). Within 3 months rates were 2.6% and 10%, respectively (P < .001). Two point four percent of female patients developed post-op infection within 1 month compared to male patients with a ratio of 3.6% (P < .001). Patients with mental disorders had post-op infection rates of 3.2% and 4.4% within 1 and 3-month follow up, respectively, compared to 2.5% and 3.5% in patients who were never diagnosed with a specific psychiatric disorder (P < .05). When procedures were reviewed separately, effect of mental health on post-op infection rates was statistically significant for ACDF patients but not for PCF patients. 2.6% patients with depression only and 2% of patients with anxiety only developed infection within 1 month. Total sepsis rates were 1.4% and 2.1% at 1 month and 3 months post-operatively. 1.3% patients with psychiatric diseases developed sepsis within 1 month and it increased to 1.9% within 3 months after the surgery. Among patients without any specific psychiatric illness sepsis rates at 1 and 3-month follow up periods were 1.2% and 1.8%, respectively. Conclusions: In this retrospective study 3% of the patients developed post-op infection within 1 month after the surgery. Patients with mental disorders had significantly higher rates of post-operative infection compared to patients who were never diagnosed with a specific psychiatric disorder. Infection rates for patients with single mental disorder were close to patients without mental disorder. This suggests that patients with multiple disorders are the main contributing factor for higher infection rates. However, mental health did not increase the risk factor for post-operative sepsis., Introduction: Surgical site infection (SSI) is a significant complication in instrumented spinal surgery as it is associated with prolonged morbidity and poor functional outcome. It is relatively frequent and the reported incidence varies from 0.7 to 11%. There are many studies concerning C-reactive protein (CRP) serum levels and it appears to be a sensitive index in the follow-up of SSI, but less specific in the diagnosis. Materials and Methods: We prospectively evaluated 31 patients (20 men and 11 women) who underwent instrumented lumbar spinal surgery at our Hospital between February and July 2016. All patients received pre ad intraoperative prophylactic antibiotics (cephazolin 2 g), starting 1 hour before skin incision. CRP serum levels were routinely measured and recorded on days 3 and 7 after surgery. Results: According to the literature, we have found that PCR level was particularly elevated (probably reaching a peak level) on day three, and was significantly lower on seventh day in all patients but two. In the first three days elevated CRP levels could be a normal (acute inflammatory) response to surgery, while a sustained elevation of CRP to 7 days appears to be a reliable signal of an early infection. In particular, in 91% of cases, the CRP level at 7 day was more than halved and in 65% of cases the CRP level was even back to normal. In only two cases (6%), CRP remained high and almost unchanged. One of these patients developed a superficial SSI and one a deep SSI as confirmed by the subsequent neuroradiological imaging. We treated these patients with broad-spectrum antibiotics only on CRP levels basis and they could eventually recover from SSI without removing the hardware. The patient developing a superficial SSI underwent a surgical revision for wound cleaning. CRP level certified in a highly sensitive manner and in the early stages the appearance of a SSI and prevented in both cases the hardware removal. Conclusion: In our preliminary study CRP level proved to be a fast, simple, sensitive and cost-effective parameter for the detection of early infectious complications. The SSI represents, to date, a major complication in instrumented lumbar spine surgery: its early detection through a careful monitoring of the PCR may be a useful tool in the diagnosis and may prevent hardware removal. This is only a preliminary study and larger cohort of patients need to be studied in the next future., Introduction: Spondylodiscitis remains a major cause of spinal injury, with subsequent neurological damage. In Mexico, tuberculosis continues to be the main cause of infection, although pyogenic causes seem to have increased along the years. The primary objective of this reviewed is the description of epidemiological factors, which among these include: age, gender, etiologic agent and the spinal segment most commonly involved. Methods: This study consists in a retrospective observational based on electronic case records of 2 years from a tertiary reference hospital in Guadalajara, México. Case records, microbiology reports, imaging studies, histopathology and surgical reports of all spinal infection cases were studied. Etiologic agent, risk factors and co-morbidities were also analyzed. Results: Sixty-eight cases of primary spondylodiscitis were reviewed, 36 male and 32 female, with a mean age of 59.6 years. In this study were identified 22 cases with tuberculosis, 5 cases with Brucella and 20 pyogenic infection, 21 cases reported negative culture results without etiology being identified. The main related comorbidities were diabetes mellitus, chronic kidney disease, obesity, alcoholism, liver disease, and immunosuppression. Over 41% involvement was in the thoracolumbar junction of the spine. Staphylococcus aureus was the main agent isolated from pyogenic infections. Conclusion: Spontaneous infective spondylodiscitis affects men and females equally with and without medical co-morbidities. It often involves the thoracolumbar junction spine and a third of patients are culture negative. Tuberculosis remains the leading cause of spondylodiscitis in our country., Introduction: Use of metal implants in infective pathology has been controversial due to concerns over biofilm formation and persistence of bacteria. Although metallic implants have shown satisfactory outcomes in tuberculous spondylodiscitis, there use in pyogenic spondylodiscitis has been widely debated. We performed a study to assess the safety and outcomes of posterior instrumentation and transforaminal lumbar interbody fusion (TLIF) with titanium cages in the treatment of pyogenic lumbar spondylodiscitis. Materials and Methods: Retrospective analysis was performed on prospectively collected data of 27 consecutive cases of lumbar pyogenic spondylodiscitis treated with posterior instrumentation and TLIF between the periods of January 2009 to December 2012. All cases with biopsy proven spondylodiscitis were included and assessed for clinical presentation, medical co-morbidities, indication for surgery, culture positivity, organism isolated, duration of antibiotic instituted, previous surgical procedures and blood marker profile. All cases with tuberculous spondylodiscitis were excluded. The indications for surgical treatment were failed conservative management in 17, neurodeficit in 6 and significant bony destruction in 4 patients. Cases were analyzed for safety, radiological and clinical outcomes of TLIF using bone graft ± titanium cages. Interbody metallic cages with bone graft were used in 17 cases and 10 cases used only bone graft. All patients empirically received intravenous Ofloxacin and Cefoperazone+Sulbactum combination postoperatively and modified as per antibiotic sensitivity parameters. If no organism could be isolated the empirical antibiotics were continued for period of 4 weeks and then changed to oral antibiotics for a further period of 4 weeks. Results: The mean age was 48 years (22-83 years) with an average follow up of 30 months (22 months to 60 months). Culture isolated an organism in 8 cases including E.coli (N = 3), P. aeruginosa (N = 3) and S. aureus (N = 2). There were no cases reporting, cage migration, loosening and reoccurrence of infection at final follow up. Follow up MRI was performed in 20 cases which documented complete resolution of infection in all. Clinical outcomes were assessed using Kirkaldy-Willis criteria which showed 14 excellent, 9 good, 3 fair and 1 poor result. The mean focal deformity improved with the use of bone graft ± interbody cages and the deformity correction was maintained at final follow up. The mean pre-operative focal lordosis for graft group was 8.5°(2-16.5°) which improved to 10.9°(3.3-16°). The mean pre-operative focal lordosis in the group treated with cages was 6.7°(0-15°) which improved to 7°(0-15°). Definitive evidence of fusion was noted 16 patients with probable fusion in 10 patients with no cases with suspected pseudoarthrosis. Conclusion: TLIF for pyogenic spondylodiscitis provides adequate clearance of the infected tissue and gives satisfactory functional outcome. The radiological outcomes including deformity correction, maintenance of the correction and final fusion are satisfactory with this approach. TLIF with titanium cages may be safely used in the treatment of pyogenic lumbar spondylodiscitis provided thorough and adequate debridement of infected tissue can be achieved, appropriate antibiotic coverage is instituted and close follow up of the clinical progress is maintained., Introduction: The aim of the paper is to analyse extent, pattern and speed of neurological recovery, which plays vital role in reducing disability, in medically as well as medically + surgically treated patients of dorsal spine tuberculosis. In most cases, despite full motor neurological recovery often spasticity hampers mobility, ambulation and ultimately faulters employment leads to burden over family and society. Materials and Methods: 31 patients were diagnosed with TB dorsal spine from June 2011 to March 2013. Of these, 17 pateints had progressive nuerodeficit despite medical treatment and underwent decompression and pedicle screw fixation with posterolateral fusion using suitable approach as per the location of disease. Antitubercular treatment as per the RNTCP guidelines given for next 8 months till radiological signs of healing was present. Functional outcome(symptomatic improvement), qualitative neurological recovery (NR; gait, ambulation, resumption of employment) were measured. Nurick RR and ASIA PDIR were evaluated (preoperatively, 15 days, 1 month, 3 month, 6 month, 8 month i.e. completion of ATT). In nurick grade grade 0 signifies root signs, which does not affect qualitative NR, so not included, 80% considered 100 percentile and calculations made. Results: The functional outcome in the form of symptomatic improvement was faster in M+S group than M group. Of the M group, nurick grade 4 (9), grade 5(6) and ASIA score varying from (10 to 38) preoperatively were included. Only one patient deteriorated from M group needed surgical intervention. Mean recovery rate of nurick grade and ASIA PDIR in M group respectively (15 day-3.33/6.88, 1 month 15.33/36.88, 3 month 40.33/60.38, 6 month 67/89.44, 8 month 71.67/95%), suggests that NR took place between 3-6 months, attaining full recovery in almost all patients except one. Recovery attain plateau phase between 6 to 8 months. Mean recovery rate of nurick grade and ASIA PDIR in M+S group respectively (15 day-30/53.85, 1 month 60.69/82.78, 3 month 64.22/92.17, 6 month 72.45/96.72, 8 month 77.45/100%) suggests that NR took place between 1 to 3 month with plateau phase between 6 to 8 months, attaining full recovery in all subjects. NR in M+S group is speedier than M group alone. Conclusion: Study shows there is no significant neurological difference between two groups, after initial 8 months. Neurological recovery in S+M patients is speedier than M group due to debridement and local clearance of disease. Pattern of NR in M group suggests that almost all patients recovered at the end of 8 month, while M+S group 80% NR occurred within first 3 months. Abbreviations 1. MRR – mean recovery rate of nurick grade 2. PDIR – percentage deficit improvement ratio for ASIA score 3. M Group – medically treated group as per RNTCP 4. M+S Group – medically as well as surgically treated group, Introduction: Postoperative wound infections after spine surgery are a severe complication. In general it is not a matter of a superficial skin infection, in most cases it is a deep infection with contamination of all soft tissue layers. Difficult therapeutic situations are in case of the combination of patients of old age, spine surgery because of degenerative spinal canal stenosis and the need of an instrumentation because of segmental instability. In most cases these patients have an ASA Classification grade 3, they are immobile already for years because of the narrowing of the spinal canal and they are threatened to lose their social independence. A special algorithm in preoperative preparation of the patient, diagnostics including sonication of implants and therapy, based on the results and findings of W. Zimmerli in the treatment of infected knee and hip arthroplasty will be introduced. Material and Methods: The revision includes a prospective randomized follow up with a comparison of two groups of patients with and without the standardized procedure. All patients were treated surgically. One topic was the follow up of the preoperative preparation of the patient. In one group a normal three times surgical washing up, normal surgical covering and a transparent foil. The other group f.e. with a 10 minutes washing and an antiseptic foil and further differences. The other topic, diagnostics and therapy, was f.e. the comparison between the diagnostic tool of sonication and how it was included in a standardized procedure and the evaluation of antibiotic bioavailability. Results: The conversion in the preoperative preparation lead to a significant reduction of postoperative wound infections. The use of f.e. sonication improved the isolation of the right bacteria spectrum in its sensitivity from 60% up to 77% without deterioration of specificity. Other parameters like the way of biopsy extraction also improved the outcome significantly. Conclusion: Standardized procedures in the preoperative preparation process is an important tool to reduce postoperative wound infection especially in an increasing number of geriatric spine patients. In case of an infection the mentioned algorithm in diagnostics and therapy is useful. Demand and recommendation is a pre-ward microbiologically process screening of the patients or a screening while hospitalization., Introduction: The spinal column is involved in less than 1% of all cases of tuberculosis (TB). Spinal TB (Pott’s disease) is a very dangerous type of skeletal TB as it can be associated with neurologic deficit due to compression of adjacent neural structures and significant spinal deformity. Methods: We present the case of a woman, aged 59, who was admitted to the Department of Orthopedics because of an osteolytic lesion of the cervical spine (C3). 2 months earlier, the patient complained of neck pain without numbness of the hands. On physical examination, the woman was apyrexial and complained of pain over the cervical spinal area. Neurological examination revealed no focal motor weakness. The roentgenograms of chest, pelvis and cranium were without pathological changes. Abdominal ultrasonography was normal. CT scan revealed a osteolytic lesion of the body of C3 and of the third and ninth right ribs. An MRI scan revealed compression fracture of the C3 vertebral body with infiltration of paraspinal tissues at the vertebral column. The lesion resembled neoplasm metastasis. Results: A CT scan guided biopsy was done and the neuropathological examination of the biopsy showed typical granulomatous inflammation with characteristic infiltrate of lymphocytes, epithelioid macrophages and Langhans-type multi nucleated giant cells. The diagnosis of tuberculosis was made and the patient was treated medically with an immobilization of the neck for 12 months with an uneventful recovery. Conclusion: The prognosis for spinal tuberculosis is improved by early diagnosis and rapid intervention. A high degree of clinical suspicion is required if patients present with chronic neck pain, even in the absence of neurological symptoms and signs. Medical treatment is generally effective. Surgical intervention is necessary in advanced cases with marked bony involvement, abscess formation, or paraplegia., Introduction: Intramedullary spinal tuberculosis is a rare disease entity, which was first described by Abercrombie in 1828. Material and Methods/ Case: 25 year old male presented with low back pain, progressive weakness in lower limbs since one month & bladder incontinence since two weeks. Neurological examination revealed grade 3 power in both lower limbs and hypoaesthesia below D8 level. Knee, ankle reflexes were exaggerated with clonus. Babinski reflex was positive bilaterally. There were no signs of meningeal irritation. His ESR was 77 mm at the end of one hour. HIV ELISA was negative. MRI of spine there was a intramedullary lesion of 12 x 9 mm at the level of D8 vertebra which was hypointense on T1, isointense lesion in T2 & demonstrated ring enhancement on gadolinium contrast. Patient was started on multidrug treatment (Isoniazid, Rifampicin, Ethambutol, & Pyrazinamid) and a short course of dexamethasone. And at 12 weeks patient did not show any signs of improvement. Surgical resection was performed, D7-8 laminectomy followed by midline durotomy was performed. Spinal cord was swollen and there was no evidence of any extramedullary lesion. Posterior longitudinal myelotomy was done. We found a grayish mass with a good plane of cleavage from the surrounding cord. A grey, irregular, multilobulated soft mass measuring 12×10×6 mm was removed completely (Figure 2b). Surgery was uneventful & post-operative his neurological remained same. Results/ Outcome: Histopathology examination showed diffuse & dense infiltrate compromising of lymphocytes, plasma cells, & neutrophils with large areas of caseous necrosis surrounded by sheets of epitheloid cell & Langerhans type of giant cells. At 3 months after surgery his lower limb power in hip & knee was completely recovered, with recovered bowel & bladder retention. Post-operative after 15 months patient was walking without support & had functional power in both lower limbs. Conclusion: Tuberculoma should be considered in the differential diagnosis of all intramedullary space occupying lesions irrespective of age or presence of extracranial focus of tuberculosis in countries endemic to tuberculosis. Most of these patients respond well to anti tuberculous drug therapy with good functional recovery, however, timely surgical decompression in selected cases, provide excellent long-term outcome., Introduction: Typical imaging findings in Tuberculous (TB) spondylitis are involvement of two or more adjacent vertebral bodies with involvement of the intervening disc. However, with extension of the disease, it might extend to the posterior element adding difficulty in differentiation that lesion from spinal metastases. It is the aim of this study to detect helpful MRI findings that help in differentiating TB spondylitis with three column involvement from spinal metastases. Material and Methods: The study is a retrospective study of 22 patients with TB spondylitis (average age, 53 years) proved by biopsy during open surgery and had three column spinal involvement. The following points were studied: pedicle involvement, degree of spinal deformity, vertebral body and disc damage (collapse) and paravertebral and epidural abscess formation. Results: The thoracic spine was the mostly involved (73%, 16 patients), followed by the lumber (18%, 4 patients) and lastly thoracolumber and lumbosacral junctions (4.5% 1 patient for each), Totally, 48 vertebrae were affected and each of them was studied separately. Pedicle involvement was most common in thoracic spine (83%), followed by lumber spine (15%) and lastly sacral spine (2%). Vertebral body collapse in vertebral bodies with pedicle involvement was present in 34 vertebrae (71%). More than 50% vertebral body collapse was present in 56% of affected vertebrae. Disc space was completely destroyed in 25 (52%) and partially destroyed in 19 (40%) of affected disc levels. Paravertebral and epidural abscesses are present in 95% and 86% respectively. Kyphosis was present in 68% of cases with a mean angle of 29 degrees. Conclusion: Involvement of the posterior spinal elements is not uncommon in spinal TB and usually associated with relatively severe vertebral body and disc destruction, prevertebral and epidural abscess, and kyphosis., Introduction: To review the clinico-radiological outcome of single stage posterior surgery in predicted progressive kyphosis of Dorsal and dorso-lumbar tubercular lesion. Material and Methods: From July 2004 to June 2015, records of 45 patients (male 16 and female 29), age ranged from 20-59 years, were divided into dorsal (GrD) and dorso-lumbar group (GrDL). The initial kyphosis (Kºini), initial predicted deformity (Kºpred/ini), the preoperative kyphosis (Kºpre), pre-operative predicted deformity (Kºpred/pre), the Progression of Deformity (Kºpre - Kºini) and the Predicted Deformity Progression (Kºpred/pre - Kºpred/ini) was measured. After surgery, the postoperative kyphosis (Kºpost) and Correction of Deformity (Kºpost - Kºpre) was recorded. The last follow up records included, final kyphosis (Kºfinal), postoperative Loss of Correction (Kºfinal - Kºpost) and Residual Deformity (Kºfinal - Kºpre). Results: The mean progression after 1 month and the mean predicted progression had been highly significant (unpaired t test, P < .001) in both GrD and GrDL, Surgery resulted significant improvement of neurology, pain and disability scores (chi-squared test, P < .05) as well as deformity correction (paired t test, P < .05). At the end of 5 years the loss of correction and residual deformity was insignificant (unpaired t test, P > .05) in comparison to Kºini. Overall significant satisfactory outcome was achieved in 40(88.9%) cases (chi squared test, P < .05). Conclusion: Single stage posterior instrumentation yields satisfactory results in predicted kyphosis progression of dorsal and dorso-lumbar tuberculosis., Introduction: Globally Echinococcus granulosis (cestode warm) is the commonest parasitic infestation affecting the spine. Spinal schistosomiasis is a rare presentation of parasitic infestation of the spine by mainly Schistosoma mansoni or Schistosoma heamatobium infection. The two species are endemic in South America, middle east and sub-Saharan Africa. We report spinal schistosomiasis in an 8-year-old school boy who presented to Fort portal regional referral hospital in Western Uganda in October 2015. Objective: To present a rare case of spinal schistosomiasis in an 8-year-old school boy who leaves near Lake Albert in Western Uganda. Material and Methods: An 8-year-old school boy presented with one-year history of back pain associated with deformity and 6 months’ history of progressive weakness of lower limbs and in ability to walk. Neurological status was Frankel B. Radiological picture of thoracic spine showed fusiform paravertebral shadow at T9/T10 which closely resembles that of tuberculous spondylitis. Biopsy and histological examination of the paravertebral mass showed degenerate oval shaped ova like structures with spine similar to Schistosoma eggs. So far no single case of spinal schistosomiasis from Uganda has been reported in literature as opposed to pyogenic and tuberculous spondylitis. Results: The patient was empirically started on anti TB treatment based on clinical examination and plain thoracic spine x-rays. Decompressive surgery done through left sided thoracotomy and paravertebral abscess drained and debridement done at T8/T9/T10 and spine stabilized with tricortical graft obtained from iliac crest. On arrival of histology results anti TB treatment was stopped and treatment changed to Praziquantel 60mg/Kg single dose and steroid(prednisolone) 1mg/kg as definitive treatment. Follow Up and Progress: Patient was discharged from hospital after one-month course of Praziquantel and prednisone with Frankel C neurological status. Two months’ letter his neurological status had improved to Frankel E though he still had residual thoracic kyphosis. Conclusion: Spinal schistosomiasis is rare, serious but curable condition and should be considered as differential diagnosis in inflammatory spine disorder’s particularly in those who visit or leave in endemic areas. Treatment should include a combination of anti-Schistosoma medication and corticosteroids as well as the different forms of supportive care., Introduction: As hospital compensation becomes increasingly dependent on pay-for-performance and bundled payment compensation models, hospitals seek to reduce costs and improve outcomes by decreasing length of stay (LOS), PAUs (30 day all-cause readmissions/revisits), and in-hospital PPCs (as defined by CMS). We sought to evaluate hospital-reported outcomes measures for elective lumbar procedures at Tertiary Centers(TC) versus Community Centers(CC) within the same hospital system. Material and Methods: A physician-driven, single medical system, prospective database consisting of one TC and four CC was retrospectively evaluated for the three most common lumbar surgeries: laminectomy, laminectomy with fusion, and microdiscectomy. 431 consecutive adults who underwent one of these procedures were evaluated from January-July 2015. The primary outcome was LOS, and secondary outcomes were PPCs and PAUs. Independent variables included: age, illness severity (SOI), surgical procedure, and surgical specialty (orthopaedic or neurosurgery). Results: Regression models for LOS were developed for each procedure. For microdiscectomy, the TC had a 0.28 day (95% CI, 0.04-0.53 days; P = .026) longer adjusted LOS. Inpatient status and performing a multilevel microdiscectomy also significantly increased the adjusted LOS. For laminectomy, the TC had a 1.46 day (95% CI, 0.61-2.31 days; P = .001) longer adjusted LOS. Surgery by a neurosurgeon, inpatient status, and discharge to a facility also significantly increased the adjusted LOS. For laminectomy with fusion, the surgical facility did not significantly affect LOS (95% CI, -0.41-0.85 days; P = .49), but SOI, multilevel fusions, interbody fusion, and discharge to a facility all significantly increased the LOS. Surgery by a neurosurgeon significantly reduced the LOS, however. Regression models demonstrated no significant difference in PAU and PPC rates between TC and CC for all procedures. The TC had 4.73 higher odds of revisit/readmission than CC for patients undergoing laminectomy, but this trend was not statistically significant (95% CI, 0.81-27.65; P = .084). TC had 2.19 higher odds of revisit/readmission than CC for patients undergoing laminectomy with fusion, but this was not statistically significant (95% CI, 0.47-10.11; P = .32). Patients undergoing laminectomy with fusion had 81% lower odds of sustaining a PPC at the TC, but this trend was not statistically significant (95% CI, 0.02 -1.54; P = .12). The cost of performing microdiscectomy, laminectomy, or laminectomy with fusion is 2.13 (P < .001), 1.87 (P = .006), and 1.18 (P = .009) times greater at the TC versus CC, respectively. Conclusion: TC have significantly longer LOS for patients undergoing microdiscectomy or laminectomy, but not laminectomy with fusion. The TC trended towards higher revisit/readmission rates for laminectomy with and without fusion, and lower PPC rates for laminectomy with fusion. These findings suggest performing microdiscectomy or laminectomy at a TC may have a longer LOS without improving PPCs or PAUs, and at nearly double the cost of care. Performing a laminectomy with fusion at a TC may be more reasonable with a similar LOS, PPCs, and PAUs, but the cost is still greater compared to CC. This surgeon-driven data can help develop more effective protocols to decrease LOS, while minimizing PPCs and PAUs., Introduction: Spinal cord tumors (SCT) are relatively uncommon and usually require surgical treatment. Readmission within 30 days after discharge is an important indicator of health care quality. The aim of this study was to investigate the rates and causes of unplanned readmissions and reoperations after SCT surgery. Materials and Methods: A retrospective analysis of patients’ charts at a single center from May 2007 to September 2015 was completed. Inclusion criteria: history of laminectomy with excision of neoplasm in the spinal cord. Exclusion criteria: (1) surgery outside the timeframe; (2) less than 19 years old; (3) non-neoplastic intramural pathologies; (4) previous resection at the same location; (5) metastatic lesions. Results: We found 131 patients that met criteria. Six patients (4.5%) were readmitted within 30 days and two within 90 days (1.5%). Four underwent reoperation: one for a cerebrospinal fluid leak, two for pseudomenigoceles, and one for repeat laminectomy. Resection of intramedullary tumors resulted in twice the risk of having one or more complications compared to extramedullary tumors (RR 2.0; 95% CI: 1.0 to 4.2; P = .057), and nearly four times the risk of having a neurological complication (RR 3.8; 95% CI 1.5 to 9.5; P = .005). Conclusion: This study analyzes readmission, reoperation and complication rates for the surgical care of SCT highlighting how SCT surgery is still involved with morbidity in experienced and specialized centers. This information is useful both for health care enhancement projects and for evidence-based patient counseling., Introduction: Complications from opioid analgesics for the treatment of pain are greater than those of other classes of medications yet increasing numbers of patients are treated with narcotics. The efficacy of these drugs in chronic conditions is debated. In this study we assessed spine specialists’ attitudes toward opioid analgesics and their beliefs regarding the impact of these drugs on spine surgery outcomes. Methods: AOSpine members in North America and Europe were surveyed via the Internet and asked to describe their practice, the source of patient referrals to them and the treatment these patents had received prior to entering their care. The physicians were also asked when narcotics should be introduced for acute and chronic spine related conditions. Finally, surgeons were asked if patients treated with narcotics have inferior surgical outcomes. Results: Narcotics were prescribed at higher rates in the US than in Europe. US specialists used these drugs more frequently for of acute problems (ie, LDH and CR) versus chronic conditions and kept patients on these medications for longer periods after surgery than did their European colleagues. One- to two-thirds of patients first seen by specialists were already treated with opioid analgesics by the referring physician. More specialists thought that narcotics should never be started for chronic conditions such as spinal stenosis and spondylolisthesis except during acute pain episodes (P < .05) or for post-operative care. While the figures vary by condition, on average 23.6% (range 11.3-28.5%) of the specialists consider prescribing opioid analgesics a bridge to surgery. Concerning the influence of narcotics use on surgical outcome, 37% of those surveyed responded that they hinder outcome, 43% thought they do not, and 20% answered that they do not know. Surgeons who do not prescribe narcotics in chronic conditions feel that they hinder spine surgery outcome. Conclusions: Opioid use is not uncommon as a treatment option, though spine specialists believe that they should be prescribed mainly as a bridge to surgery or only during acute episodes. Even so, only 43% of surgeons believe that these drugs are safe., Pakistan is country with a population of 192 million with an annual growth of 1.49%.making it the 6th most populated country on earth.The average life expectancy is 63 years. Corruption is rife and we have the richest rulers in this one of the poorest nations on earth solely due to bad governance.Less than 2%of the GDP is spent on health.None of the MDGs has been met. Pakistan is ranked 5 in high burden of TB. 3 million TB cases are known and 100000 are added each year so 270/100000 people have TB.TB spine is endemic and late presentation with neurological deficit is the normal. Traffic is chaotic.accidents account for spine injuries.Firearm injuries thanks to the war on terror abound.Poor safety measures at work and recreational places add to the burden of spine pathology significantly. Degenerative diseases of the spine are on the rise. Scoliosis kyphosis are common especially in the poor 60%live below the poverty line. There did not exist a spine center for these poor people of Pakistan! We decided to make a start and started on self help basis and set up the Ghurki Trust Teaching Hospital Spine Center. $8.5million has so far been raised from the people of Pakistan who are the most charity giving people in the world given their per capita income. An MRI CT Flouroscopy Spinal cord monitoring system Image Intensifies 5 modular antibacterial walls ORs CSSD Physio and Rehab EMG NCS equipment Orthotics manufacturing facility 200 beds unit was inaugurated on 9 April 2014. The workload has doubled in these 2 years and 5 more state of the art ORs are being built to be commissioned by early 2017. All poor patients are treated free $125000 are spent each month for totally free treatment.Free food to all patients and one attendant is provided.cheaper quality implants have been arranged from China and local titanium implants being developed at almost 1/3 the price. It is the only AO spine recognised spine training center in Pakistan and people from 9 countries have done spine fellowships todate About 40 local spine trainees have been trained over the years and we run the largest FCPS orth programme in Pakistan with Hand Trauma Paediatric orthopaedics Arthroscopy Arthroplasty Spine Plastics Flaps all under one roof with 9 consultants and 26 trainees at any given time.We are now ranked amongst the top if not the top orthopaedic spine training programme in Pakistan., Introduction: Administrative datasets typically utilize ICD9-CM codes and CPT codes as their primary sources of data. ICD-9 CM and CPT codes have been used to successfully identify information about patients such as specific spine diagnoses, surgical approach, and procedures performed. The invasiveness index developed by Mirza et al quantifies the extent of spine surgical intervention and assigns a numerical score based on the number of vertebral levels decompressed, fused, and instrumented and has been shown to have high reproducibility across observers. Recently, a CPT code based invasiveness index has been developed in which invasiveness values were assigned to different CPT codes. The goal of our study was to analyze the validity and accuracy of such a CPT code based invasiveness index and assess its strengths and weaknesses in assessing a study population. Material and Methods: A retrospective review on 451 patients who underwent spine surgery at a single academic institution was conducted. The medical record was used to collect demographic data on each patient. Reviewer based invasiveness scores were calculated by analyzing the operative report for each patient and CPT codes in the hospital administrative databases were used to calculate a CPT based invasiveness index score. Univariate regression analysis was used to assess the relationship between the reviewer based invasiveness score and CPT code based invasiveness score for each patient. Patients were then divided into 3 CPT code accuracy sub-groups (overestimation, match, underestimation of the CPT code based invasiveness score) and these subgroups were analyzed in terms of demographics, initial ED admission rates, non-elective procedures, reoperation, level of surgery, myelopathy presence, initial approach, procedure type (laminectomy, laminectomy/foraminotomy, discectomy, corpectomy, fusion/arthrodesis, or instrumentation). Results: Based on univariate analysis, CPT based index scoring was positively correlated with the reviewer based score with R2 of 0.690. Bland-Altman plots of the scoring differences plotted against the reviewer based scores demonstrated that the CPT based score overestimated the reviewer score by a mean of 1.25 points (P < .001). Univariate analysis of this plot showed that as reviewer based scores increased, the CPT based score tended to overestimate the reviewer score even further. The CPT code based invasiveness index had increased accuracy for patients in lower ASA classes, and those undergoing laminotomy/foramintomy and discectomy procedures, and those undergoing surgery for herniated disc, radiculopathy, and lumbar stenosis diagnoses. The CPT code based invasiveness score tended to overestimate invasiveness in posterior fusion, or instrumentation, anterior approach procedures, or for surgery done for cervical level diagnoses or lumbar spondylolisthesis or degenerative disease diagnoses. Conclusion: The strong correlation found between the CPT based invasiveness index and the reviewer based invasiveness index underscores the validity of the CPT based invasiveness index. However, we find that the reliability of this scoring system may be less consistent at times and that the CPT based invasiveness index tended to overestimate true invasiveness scores with increasingly invasive procedures. This imprecision of the CPT based index should be taken into account and adjusted for accordingly before applying it broadly when utilizing it for population studies., Introduction: Spinal disorders are a highly prevalent cause of disability and compromise of quality of life in the Brazilian population. There is paucity of published data on the economic and social impact of spinal disorders in Brazilian health system. We aimed to evaluate national trends of spine surgeries in the Brazilian Public Health System (Unified Health System [Sistema Único de Saúde] – SUS) over the past 20 years. Materials and Methods: Data on spinal procedures in Brazil between 1995 and 2014 were collected through the website of the Information Technology Department of the Unified Health System (DATASUS), which is maintained by the Brazilian Ministry of Health. Data on the number of admissions for spine surgery, total hospital charges, mean hospital days, and mortality were collected from this database using all codes related to spinal surgeries. National trends in hospital charges, number of procedures, and their relationship with geographic location were summarized. Costs were corrected by the IGD-DI index for 2014. Results: During the past 20 years, there has been an increase of 226% in the number (from 9,826 in 1995, to 22,304 procedures in 2014) and 540% in the total costs of spine surgeries (from R$ 27,094,634.28 in 1995, to R$ 146,469,077.32 in 2014) in SUS. The mean hospital stay remained the same over the years (mean 9.7 days in 1995, and 9.1 in 2014). Intra-hospital mortality rate after admission for spine surgery was 0.89% in 1995 and 1.65% in 2014. The mean number of spine surgeries covered by SUS per 100,000 people was 6.31 in 1995 and 11 in 2014. This proportion was quite different according to region. In 2014, the number of spine surgeries per 100,000 population according to region was: 5.18 Northeast, 5.54 North, 10.64 Southeast, 16.45 Midwest, and 23.69 South. Total hospital charges were also different among regions. Conclusion: Our analysis depicts the national trends in the economic burden of spine surgery on the Brazilian public health system. The differences in spine surgery data across regions portray the socioeconomic disparities of this large country., Introduction: Open pedicle screw fixation and fusion has been the traditional treatment for operative spine fractures, but several recent studies have challenged the need for fusion in the setting of adequate fixation, demonstrating comparable radiographic and functional results without fusion. Percutaneous treatment of spine fractures has been demonstrated to have decreased blood loss, operative time, and post-operative pain, but fixation of traumatic injuries without fusion raises the concern for failure of the instrumentation secondary to stress fatigue. Treatment of these unstable injuries with minimally invasive facet fusion using a tubular system in addition to percutaneous instrumentation represents an alternative strategy that may reduce morbidity, while promoting long term construct stability. The purpose of this study is to compare the maintenance of correction of unstable, operative spine fractures that underwent percutaneous fixation with and without facet fusion. A secondary outcome was to critically evaluate the hardware constructs for loosening and failure during a short-term follow-up period. Material and Methods: Using CPT codes, we conducted a retrospective review of all operative thoracic and lumbar spine fractures using our institutional billing and coding database from 2006 to 2013. One-hundred and forty-one cases were obtained from the database. Fifty-five cases were excluded for lack of post-operative radiographs and comorbidities. Eighty-seven had radiographs and operative reports available for review. Maintenance of correction was the primary outcome. One-week postoperative radiographs and all available follow-up radiographs were analyzed for the Cobb angle (lateral view) using the vertebral levels at the apices of the construct to evaluate for progressive kyphosis and loss of correction. We also examined each radiograph for instrumentation fracture, loosening (greater than 2 mm of radiolucency around any screw), or screw pullout. Results: The mean follow-up of for all patients was 33 weeks. There average amount of kyphotic progression was 3.2 degrees. There were no cases of instrumentation fracture during this follow-op period. Overall, the rate of screw loosening was 24%. There was no significant difference in the rate of loosening or progression of kyphosis in patients with facet fusion (with or without bone morphogenetic protein [BMP]) and without facet fusion. There was no difference in the percentage of screw pullout between groups. A total of 19 patients (22%) eventually underwent instrumentation removal, of which, only 2 constructs were loose (10.5%). Conclusion: We did not demonstrate a significant difference in the progression of kyphosis postoperatively between patients with and without facet fusion. Additionally, no difference in kyphotic progression was noted when facet fusions were performed with or without BMP. In thoracic and lumbar spinal column injuries, where percutaneous fixation is indicated, the addition of facet fusion may be superfluous. Interestingly, we found a significantly higher rate of screw loosening (24%) than previously reported for percutaneous cases, but loosening was not significantly different between fused and non-fused groups. The clinical significance of this instrumentation loosening remains unclear, as only 2 of 19 instrumentation removals had loosening, and further clinical follow-up is needed., Introduction: Standard techniques for lumbar pedicle screw and rod fixation involve open exposure and extensive muscle dissection. Percutaneous pedicle screw system minimises the morbidity associated with traditional open approaches without compromising the quality of spinal fixation. A preliminary experience with this device has been encouraging. The purpose of this study was to demonstrate operative techniques and experiences with percutaneous lumbar pedicle screw and rod insertion for internal fixation of the lumbar spine without use of Zig. Material and Methods: It was hospital based retrospective interventional study done at the department of Orthopaedics, B.P. Koirala Institute of Health Sciences, Dharan, Nepal over a period of 2 and half years. The study enrolled 30 patients aged 18-55 years who had presented with traumatic fracture of thoracic and lumbar spine. All thirty patients underwent percutaneous pedicle screw and rod fixation and successful percutaneous single/two level fusions. The follow up period ranged from 6 to 24 months. Results: The study comprised of 25 males and 5 females. Average patient’s age was 36.5 years (range 18-55 years). The common mode of injury was fall from height, road traffic accident, physical assault followed by sports related injury. All patients were having unstable spine fracture without neurological deficit. Operation time, loss of blood, post operative pain was less in percutaneous method. Post operative rehabilitation was easier. Spinal fusion was achieved in all patients in 6 months to 1 year time. There was no post-operative neurological deficit, infection, implant failure. Conclusion: Our early experience suggests that minimally invasive approaches for performing lumbar fusion, is able to achieve the same clinical results as conventional open procedures., Introduction: During the mini-open posterior corpectomy, percutaneous instrumentation without fusion is performed above and below the corpectomy level. In this study, we wished to compare perioperative and long-term implant failure rates of patients that underwent non-fused percutaneous instrumentation to traditional open instrumented fusion. Methods: Adult patients who underwent posterior thoracic corpectomies with cage reconstruction from 2009 to 2014 were identified. Patients who underwent mini-open corpectomy had percutaneous instrumentation without fusion and patients who underwent open corpectomy had instrumented fusion above and below the corpectomy site. We compared perioperative outcomes and rates of implant failure requiring reoperation between the open (fused) and mini-open (unfused) group. Results: A total of 75 patients were identified and 53 patients were available for follow-up: 32 open and 21 mini-open. Mean age was 52.8 years and 56.6% were male. There were no significant differences in baseline variables between the two groups. The overall perioperative complication rate was 15.1%, and there was no significant difference between the open and mini-open group (18.8% vs. 9.5%) (P = .259). Mean hospital stay was 10.5 days. The open group required a significantly longer stay than the mini-open group (12.8 vs. 7.1 days) (P = .001). Overall implant failure rates requiring reoperation were 1.9% at 6-months, 9.1% at 1-year, and 14.7% at 2-years. There were no significant differences in reoperation rates between the open and mini-open group at 6-months (3.1% vs. 0.0%, P = .413), 1-year (10.7% vs. 6.3%, P = .620), and 2-years (18.2% vs. 8.3%, P = .438). Overall mean follow-up was 29.2 months. Conclusions: These findings suggest that percutaneous instrumentation without fusion in mini-open transpedicular corpectomies offers similar implant failure and reoperation rates as open instrumented fusion as far out as 2 years follow-up., Introduction: Open lumbar transforaminal interbody fusion it’s an accepted technique used on a wide range of pathologies. We reviewed our first experience and collected clinical and radiological results in patients managed with intersomatic lumbar fusion using a minimally invasive transforaminal approach (MIS TLIF) in degenerative spine disease. Material and Methods: Between January 2013 and June 2015, 53 patients underwent MIS TLIF; 38 met the inclusion criteria. Fourteen were females and 24 were males; mean age was 47.8 years. Three patients underwent 3-level lumbar fusion, 8 patients underwent 2-level lumbar fusion and the rest of the patients underwent 1-level fusion. Conditions leading to surgery were spondylolisthesis (isthmic or degenerative), disc hernia associated with instability of the segment involved and foraminal disc hernia. Mean body mass index (BMI) was 32.2. Mean follow up was 22.5 months (12-36 months). The VAS scores for pre and post surgical lumbar and radicular pain were studied at 3, 6 and 12 months; also, surgical time, intra-operative bleeding, fluoroscopy time, hospital stay, post-surgery complications, and intersomatic fusion as shown on CT scan and by the Bridwell Scale were also studied. Results: VAS score decreased between the pre and post-surgery period both for lumbar pain (VAS 5.23 to 1.57) and radicular pain (VAS 7.52 to 0.52). Mean surgical time was 172 minutes (125-250); intraoperative bleeding was 188 mL (120–250). Total fluoroscopy time was 1.12 minutes (0.21-2.54) and hospital stay was 2.18 days (0 to 4 days, for one ambulatory patient). All the patients were able to walk within one day of surgery. Complications included: one hematoma in the tubular decompression wound requiring drainage and suture, one self-limited hematoma, a K-wire fractured and remained inside the vertebral body, one case of non-union with system disassembly, and an interbody cage was detached from the intersomatic space. No infections or neurological complications were observed. The intersomatic fusion rate was 97.3%. Conclusion: In our series including 38 patients managed with MIS TLIF, good results were observed in terms of post-surgery pain amelioration and short hospital stay; also patients were able to resume their everyday activities. MIS TLIF is a valid option to achieve fusion and decompression in lumbar degenerative disease. The learning curve has a direct impact in surgical time, but not in the results related to post-surgical pain, need for transfusions, gait, recovery and discharge., Introduction: Minimally invasive spine (MIS) surgery was effective and usefull for a variety of degenerative disorders. We reviewed some cases of MIS surgery and describe a series of patients with non-degenerative spine disease managed minimally invasive. Material and Methods: 27 patients managed with MIS in the period 2009-2015 were assessed. Case reports, images and follow up, pre and post surgical VAS score, blood loss, hospital length of stay, mortality, complications, associated surgical procedures, implant removal, pre and post-neurological status were studied. All the patients with a case report, images and complete follow up were included. Twenty two patients met the inclusion criteria: 15 males and 7 females, mean age 45.1 (range 12-84). Post surgery average follow up was 32.7 months (6-78 months). Conditions leading to the procedure were: 14 fractures, 2 tumors and 6 spine infections. Instrumentation was removed after 14.3 months on average in 8 patients with fractures (8-24). The rest of the patients underwent associated fusion (mini-open approach, 5, and minimally invasive corpectomy, 2). Five patients also underwent bipedicular kiphoplasty. Results: VAS score improved 7.1 points on average as compared to the presurgical score. Mean blood loss was: trauma (25 mL), tumors (20 mL), infections (175 mL). No patient exhibited neurological deficit worsening according to the Frankel Scale. Mean hospital stay was 2.9 days for the trauma patients (including an additional anterior approach), 1 day for the tumor patients and 8.2 days for the infection patients. As for the complications, self-limiting retroperitoneal bleeding was observed in one patient, and one case of material fatigue was detected. Conclusion: A good outcome was seen in this series of 22 patients undergoing MIS for non-degenerative conditions in terms of pain control, complications and a short hospital stay. This suggests that MIS is a valid option for the management of a selected group of patients., Introduction: Conventional anterior cervical discectomy and fusion (ACDF) or corpectomy surgeries have been the treatment of choice for cervical myeloradiculopathies caused by ossification of posterior longitudinal ligament(OPLL), herniated cervical disc (HCD) or foraminal stenosis(FS) combined with bony degenrations. But neck motion limitation after multilevel ACDF and/or corpectomy & reconstruction would not be avoidable, and axial neck pain is also considerable. Moreover development of adjacent level degeneration after ACDF still requires further improvements. Then anterior cervical microforaminodiscectomy (ACMFD) which is one of non-fusion surgical technique was introduced in selected levels for multilevel myeloradiculopathies. The purpose of this study is to evaluate feasibility of microforaminodiscectomy in selected levels whether can minimize fusion surgery on cases of multilevel cervical myeloradiculopathies. Materials and Methods: Patients(3 females and 15 males) with bilateral or unilaterally dominant upper extremity myeloradiculopathies, who was defined multilevel pathologies such as OPLL, HCD or FS on image studies, and underwent ACMFD combined with ACDF or corpectomy & reconstruction in other levels between Dec. 2010 and Dec. 2013 were included. Total number of fusions were 31disc levels including ACDF(17 disc levels) and corpectomy& reconstruction (14 disc levels) and total number of ACMFD were 22 disc levels with 1 level was approached by transuncal and transcorporeal trajectories simultaneously. Combination surgeries included 1level ACDF and 1 level ACMFD is 7cases, 1level ACDF and 2level ACMFD is 1cases, 2level ACDF and 1level ACMFD is 1case, 2level ACDF and 2level ACMFD is 1case, 3level ACDF and 1level ACMFD is 1case, 1level corpectomy and 1level ACMFD is 4case, 1level corpectomy and 2level ACMFD is 2case, and 2level ACDF and 1level corpectomy and 1level ACMFD is 1case. Pre- and post-operative arm, shoulder and neck pain were evaluated by Visual Analogue Scale(VAS). Functional outcomes were evaluated using Neck Disability Index(NDI). Cervical lordosis angle(Cobb angle) was measured pre and post operatively. And neck range of motion(ROM) was measured by segmental Cobb angle on flexion and extension. Results: Arm and shoulder pain relief was assessed by Visual analogue scale(VAS) postoperative immediately and 2,4,6 months after procedure. Early post-operatively there was significant improvement in VAS arm and shoulder pain (P < .05). After one year VAS arm and shoulder pain (P < .0001, P = .001, respectively). VAS neck pain was much improved immediately, but slightly increase at last follow-up (P < .05). The functional outcome was measured by Neck disability index(NDI) and relatively good in almost. Cervical lordosis curve angles(Cobb angle) were improved just after surgery (±3.6°, P < .01). Segmental Cobb angles on flexion and extension view were preserved on the level of ACMFD. Major complications such as recurrence of HCD, instrumental failure or fusion failure were not found at this study periods. Conclusions: For minimizing fusion surgeries on the cases of multilevel cervical myeloradiculopathies, combination anterior approaches such as anterior cervical microforaminodiscectomy in selected levels with fusion surgery by ACDF and/or corpectomy and reconstruction in other levels are applicable methods. Segmental Cobb angles of ACMFD levels were preserved pre and post operatively on this study periods. But more cases and long term follow up are required for establishing spinal stability., Purpose: The efficacy and safety of endoscopic posterior cervical foraminotomy (EPCF) has been demonstrated for single level cervical radiculopathy, but no report in the medical literature has described the clinical results of 2-level EPCF. The aim of this study was to assess the clinical and radiological outcomes of 2-level EPCF performed in patients with cervical radiculopathy. Methods: Twenty-two consecutive patients (9 females and 13 males) that underwent 2-level EPCF with cervical radiculopathy from January 2012 to January 2014 were included in this study. Clinical outcomes were assessed before surgery and at 1, 3, 6, 12, and 24 months postoperatively using visual analogue scale for neck (n VAS) and arm (a VAS), neck pain and disability scale (NPDS), and neck disability index (NDI) scores. Radiological outcomes were assessed by measuring segmental lordosis (SL), C2-7 lordosis, and disc height index (DHI) before surgery and at 12, and 24 months postoperatively. Results: Mean VAS, NPDS, and NDI scores were significant improved at 1-month postoperatively versus preoperative values and these improvements were maintained at 2 years after surgery. SL and C2-7 lordosis were significantly increased after surgery, and no instability in dynamic view was observed during the 2-year follow-up period. Percentage DHIs of operated discs were also maintained without significant change at 2 years after surgery. One patient suffered from transient motor palsy due to root retraction. Conclusions: Two-level EPCF can be safely preformed and should be considered an alternative to 2-level anterior cervical discectomy and fusion (ACDF) or open posterior cervical foraminotomy (PCF) in selected patients., Introduction: Complications in back surgery remain the most challenging issue. They influence negative the outcome and may lead to abandon certain procedures in operative therapy. Despite of: 1) improved operating technique (minimally invasive), 2) high quality implants, technologies and 3) human factor (specialized, certified spine centers with skilled surgeons), up to 30% complications in short construct fusions and 50% in long constructs will be reported in the literature. We investigated, if a different suitable technique for similar pathologies may decrease adverse events in spine surgery. Material and Methods: 2 groups of patients underwent from March 2012 to September 2015 decompression and fusion for degenerative and inflammatory changes in lumbar and thoracic spine. The dorsal fixation was either a pedicle screws fixator or an interspineous fusion device. In the first group (with pedicle screws) there were 124 patients, follow up 12 to 40 months (mean 26). In the second group 118 patients (with interspinous fusion device), follow- up 12 to 40 months (mean 24). Fusion was determined by CT and X- rays at least 6 and 12 months post OP. Results: Group 1: Indications: degenerative 81 (65%), discitis 43 (35%). Group 2: 92 patients (78%) received a stand alone interspinous fusion device and 26 (22%) additionally a cage. Indications: degenerative 118 (100%). Mean values for ODI and VAS (back) VAS (leg) in the first and second group respectively: Pre OP: 62 /6,9/ 6,5 58 /6,1/ 7,4 3 months: 42/ 4,1/ 2,2 28/ 3,3/ 1,9 6 months: 36/ 3,8/ 2,4 24/ 3,0/ 2,2 12 months: 32/ 3,6/ 2,0 28/ 3,2/ 2,4 24 months: 28/ 3,4/ 2,0 22/ 3,0/ 2,0 2 years post OP in the first group the improvement of ODI was 55%. VAS back 51% and VAS legs 70%. In the second group: ODI: 60%, VAS back 51%, VAS leg 73%. Complications: Group 1: loosening (8), dural tears (8), epidural hematoma (7), seroma (6), screw malplacement (6), subsidence (5), screw breakage (4), pseudarthrosis (3), CSF leakage (2), infection (1), cauda syndrome (1), vertebra fracture (1). Two patients died during the follow up period on underlying comorbidities. In the second group: seroma (9), subsidence (5), epidural hematoma (4), dural tears (3), infection (2), CSF leakage (2) pseudarthrosis (2). 52 adverse events (42%) occurred in the first group and 27 (23%) in the second one. 28 repeat surgeries (23%) were necessary in the first group and 19 (16%) in the second one. Conclusion: Both groups are comparable concerning indications and pre Op parameters with similar outcomes. The surgery, despite it was minimally invasive, was more aggressive using pedicle screws. Some pathologies cannot be treated with interspineous fusion. It cannot provide comparable stability especially in rotation. In terms of complications the interspinous decompression and fusion (with or without supplemental cage) was better as classical 360° decompression and fusion with pedicle screws. In some degenerative spine disorders if pedicle screws could be replaced by interspineous fusion device, the surgeon should consider it making decision for surgery. It could reduce complications., Introduction: Extreme lateral interbody fusion (ELIF) has gained wide popularity as a minimally invasive treatment allowing for indirect decompression of neural elements. However, evidence regarding the influence of facet degeneration (FD) and facet tropism (FT) towards indirect decompression is lacking. The aim of the study was to evaluate whether FD and FT impair indirect decompression in patients undergoing ELIF. Material and Methods: 37 patients undergoing ELIF were included in a retrospective single-center study. Radiographic parameters including disc height, segmental disc angle, foraminal area, coronal Cobb angle, lumbar lordosis, FD and FT as well as clinical outcome parameters (Oswestry Disability Index and Visual Analogue Scale) were measured pre- and postoperatively. FD and FT were correlated with radiographic and clinical outcome parameters in order to determine predictors restricting indirect decompression. Results: 37 patients with a total of 74 levels were analyzed. Clinical and radiographical outcome measures including central canal area (Δ = +17.2 mm2), mean disc height (Δ = +3 mm), and foraminal area (Δ = +9.9 mm2) revealed significant improvement compared to before surgery (P ≤ .05). Patients with severe FD (“Locked Facets”) were more likely to have FT ≥ 12° (32.3%) compared to patients without/mild (grade 0 and 1; 10%) or moderate FD (grade 2 and 3; 13%), P ≤ .05. FD and FT did not affect the amount of restoration of disc height, foraminal area, canal surface area or clinical outcome measures (P ≥ .05). Conclusions: High degree of facet degeneration and facet tropism (“Locked Facets”), do not impair indirect decompression of neural elements in ELIF. FD and FT are not relative contraindications in patients undergoing ELIF. Neural decompression and significant clinical improvement can be achieved in patients presenting with severe FD and FT undergoing ELIF., Background: Vertebral body fractures in the osteoporotic spine can cause a significant loss in sagittal balance associated with instability and stenosis. Usually, this would entail an anterior-posterior strategy combining anterior column reconstruction with posterior decompression and stabilization. In old and multimorbid patients with poor bone quality, this incurs a number of undesirable consequences. For one, it requires an additional anterior surgery. For two, metallic vertebral body replacements have a high risk of subsidence and loosening when placed onto osteoporotic bone because of their high point-loads at the implant-bone interface. Methods: Five patients received anterior column reconstruction via a posterior-only approach. In one case, the vertebral body replacement was performed to treat an infected and instable kyphoplasty. One other patient received vertebroplasty-style augmentation of 2 instable disc spaces, which were adjacent to healed, wedge-shape compression fractures. The patients were followed for global reduction in back pain, claudication when present, postural control and range of mobility. Radiographs and CT scans – when indicated – were used to examine the constructs for stability and signs of fusion. Results: 1 patient suffered a major complication technically unrelated to the procedure. None of the constructs failed during the follow-up time and the gains in pain reduction and mobility remained stable for all patients. There were radiolucent seams around the cranial screws in 2 patients, but these did not relate to an increase in pain or a reduction in mobility. Beginning cortical bridging in the anterior column was seen in 1 patient. One of the five patients died after 2 years follow-up at age 87 from cardiac disease. Conclusions: The best treatment for old and multimorbid patients with severe spinal problems will remain a controversial topic. It is just as easy to do too much as it is to do too little. However, often these patients clearly state that they do no longer wish to continue with a conservative course of treatment that neither improves their mobility, nor their pain. When deciding on a surgical strategy, it must be our goal to achieve a correct surgical solution with the least possible amount of invasivity. This technique of anterior column reconstruction adds little additional surgery to a post., Introduction: Cervical radiculopathy (CR) as a result of cervical disc herniation (CDH) is the most common symptom of cervical degenerative disc disease. CR is characterized by pain and dysfunction of a cervical spinal nerve, the roots of the nerve or both. When conservative treatment fails, surgical treatment is considered. Although safe, surgery may be associated with serious complications and a prolonged period of recovery. Currently, there is a trend in spinal surgery toward less invasive techniques. Cervical nucleoplasty is a minimally invasive procedure for percutaneous disc decompression. To our knowledge no randomized controlled trials (RCTs) are available and good literature overviews are lacking. The goal of this Cochrane review is to determine whether cervical nucleoplasty improves clinical and functional outcomes as compared to no treatment or placebo treatment, conservative treatment and surgery for patients with cervical radicular pain and/or radiculopathy due to disc herniation. Material and Methods: The search was conducted on the following databases: EMBASE, MEDLINE, OvidSP, CENTRAL, Cochrane CENTRAL Register of Controlled Trials, Web of Science, Scopus (Elsevier), CINAHL, PubMed, ClinicalTrials.gov, Google Scholar, PEDro, World Health Organization and Clinical Trials Registry Platform (ICTRP). We included all full journal publications of quantitative studies for review, ((quasi) RCTs, non-RCTs and CCTs (observational studies, case studies, and case series) since the number of RCTs were limited. All studies involving male or female patients (18 years of age or older) with cervical radicular pain, radiculopathy, or both, due to single level degenerative disc disease of the cervical spine corresponding to the affected level, were reviewed. Nucleoplasty was compared to no treatment or placebo treatment, conservative treatment and surgery. Primary outcomes were pain intensity of the arm and neck and neck-related functional status. Data extraction and management, assessment of risk of bias, and analysis were performed according to our published Cochrane protocol. Results: Based on all abstracts 402 articles were potentially eligible for inclusion. Of these 17 studies were included for analyses of which four studies had comparison groups. No RCTs with open surgery were found. Of the examined studies 1121 patients were treated with nucleoplasty, 146 patients with conservative treatment and 192 with surgery. No clinically relevant or functional differences were found between nucleoplasty compared to surgery or conservative treatment. Conclusion: Cervical nucleoplasty may improve clinical and functional outcomes in patients with CDH but high-quality RCTs with large patient samples and long-term effects are necessary to draw stronger conclusions, Introduction: Symptomatic herniated thoracic disc (TDH) account only for 0.15 -1.8% of all spine surgeries. Several surgical techniques have been described but almost all the literature favors the anterior approach even though high risk of complications exists (7-29%).Posterior approach has been associated to a high complication rate (34-56%). Hott et al concluded that all central calcified disks should be approached through an anterior or anterolateral approach. Barbarena et al concludes also that in order to minimize complications open thoracotomy should be used for these lesions. Objective was to describe our mini-costo-transversectomy in the management of calcified and giant thoracic disc herniation as a safe and easier procedure for disk rare pathology. Material and Methods: A retrospective analysis of all thoracic discs operated under the tubular retractor were analyzed. 5 were considered as giant and calcified. All five patients underwent a tubular discectomy. Nurick grading scale was analyzed for all five patients. Results: All patients were operated by the same technique, by using tubular retractor system, using a poster lateral approach. Mini-costo-transvesectomy was performed in all patients. Mean age was 54.8 years old (32-64). Follow up (4 – 48 months). None of all 5 patients had worsening of the Nurick scale after surgery. Non neurological complications were observed associated to the posterior approach. Conclusion: Because the rarity of these lesions and their chronic presentation, it can be difficult for spinal surgeons to gain experience, making management of the lesions challenging. Although the posterior approach has been associated with poor outcome and complications in calcified thoracic discs we present 5 giant and calcified discs without any neurological deficit associated with the approach. The tubular system can help surgeons to have a quick and safe approach to thoracic discs using a posterior approach which is more familiar to most spine surgeons. The posterior can be as safe as the anterior or anterolateral approach., Introduction: The visualisation of the operating field is limited in minimally invasive spine surgery. Remote devices like endoscopes, robotic systems, navigation, microscopes or x- ray allow controlling the intraoperative procedure. In most cases it occurs using the C- arm. In percutaneous pedicle screw techniques the x- ray exposure to the surgeon is according to literature reports 3,2, times higher as in open surgery. The aim of this study was to prove, if wireless pedicle screw placement allows to reduce the intraoperative fluoroscopy time and if depends on level of education, it means if the surgeon experience is a positive factor. Material and Methods: 190 patients with vertebral fractures underwent a percutaneous pedicle screw stabilization from March 2012 to September 2016 in our institution. There were 76 women and 114 men in age from 15 to 89 years (mean 58). In 93 cases wireless pedicle screw placement technique and in 97 K-wire technique was applied. 1438 screws were inserted in T1 to S1: 676 wireless (47%) and 762 K-wire (53%). 120 surgeries were performed by experienced consultants and 70 by residents. Results: Fluoroscopy time per screw was 4 to 66 seconds (mean 16) in wireless and 10 to 69 seconds (mean 30) in K-wire introduced screws. It means 47% less radiation for the surgeon in wireless technique. The trainees needed in average 31 seconds and skilled surgeons 18 second per screw. It means beginners needed 52% more radiation to insert the screws properly. After 5-6 surgeries radiation time was nearly equal in both groups. There were 2 malplacements (0.1%) which required 1 revsion surgery. The most frequent procedure was a fixator with 8 screws (74 cases), commonly in thoracic spine. In this series a surgeon needed in K- wire based screws 36 seconds and wireless in 17 seconds per screw (53% less fluoroscopy in wireless technique). The whole radiation time per procedure was 2,3 minutes in wireless and 5,7 minutes in k- wire technique (60% less x-ray time per procedure in wireless group). Conclusion: Only patients with vertebral fractures were included into the study to provide a homogenous collective. Both patients groups are comparable, the pathology treated and the technique were similar. Wireless pedicle screw placement technique allows reducing intraoperative fluoroscopy time at 47%, compared to K-wire based technique. Skilled surgeons achieve to have 55% less radiation compared to trainees. Both surgeon groups needed 5 to 6 surgeries to get familiar with the wireless system and were able to decrease the fluoroscopy time at 45%. As most stabilizing systems are quite complicated it remains an issue to create systems, which allow a steep lerning curve., Introduction: Surgical approaches to lumbar foramoinal disc herniations have been varied. Facet removal for exposing foramen brought about fusion surgeries in traditional concept. Facet sparing extraforaminal approach as non-fusion surgery also have been an acceptable concept. Recently facet joint preserving contralateral approach was introduced to the lumbar spinal stenosis with foraminal stenosis. Tubular retractor guided contralateral approach is a kind of minimally invasive techniques for preserving spinal functional units, and can reach to foramen. We introduced this procedure to these conditions and simultaneously removal of contralateral foraminal herniated discs. This is a retrospective study for aiming to compare the clinical results between extraforaminal approachs and contralateral approaches, and to give consideration of adequate conditions for each approach. Materials and Methods: The cases of extraforaminal approach from Sep. 2010 to Dec. 2015 were underwent 15 patients with suffering unilaterally dominant leg pain, who were 10 female and 5 male and mean age was 69 years. And the cases of contralateral approach were selected from the cases of bilateral decompression through unilateral approach which were performed to 48 patients with 86 levels from Feb. 2012 to Feb. 2016. Among these cases contralateral discectomy were underwent to 10 patients with 13 levels, who were 5 Male and 5 female and mean age was 64 years. Truly extraforaminal disc herniations were exclusion criteria on contralateral approach. Outcome measurements were used Visual analogue scale pre- and post-operatively on pathology side buttock and leg pain, and functional outcomes were evaluated by using the MacNab criteria. Results: For the extraforaminal approach patients, there was significant improvement in VAS back pain and VAS leg pain postoperatively (P < .001). At follow-up of 6.8 ± 1.7 months, there was also significant improvement in VAS back pain and VAS leg pain (P < .001). The functional outcome was mostly excellent and good. One patient who were recurred required revision with same procedure (6%). For contralateral approach patients, there were slightly improvement in VAS back pain, but significant improvement VAS leg pain postoperatively (P < .001). At follow-up of 6.5 ± 1.3 months, there was slightly improvement in VAS back pain, but significant improvement in VAS leg pain (P < .001). The functional outcome was excellent and good in 9 patients, but 1 patient was fair. No one had revision surgery at this study periods. Conclusions: Contralateral approach can lead central decompression with widening of opposite side foraminal stenosis simultaneously. In the condition of central and/or lateral recess stenosis combined with foraminal disc herniation, this procedure should be effective to solve these problems by contralateral discectomy at the same time. More cases and long term follow up should be needed for over limitations such as extraforaminal disc hernation, recurrence of disc herniation, foraminal restenosis and preservation of biomechnical stability., Introduction: Clinical outcomes in XLIF are significantly influenced by indirect decompression effect. Inappropriate cage insertion may cause intra-operative endplate fractures (EFs), which may result in failure to obtain the intended effect. We herein report on our evaluation of intra-operative EFs in XLIF. Material and Methods: We included 70 patients (41 men and 29 women; mean age of 67.4 years [22 to 82]; 138 segments [one at Th12/L1; 10 at L1/2; 35 at L2/3; 48 at L3/4; 44 at L4/5]) who underwent XLIF in Sep. 2013 or later for early stage lumber disease and who were followed up for 6 months or longer. We determined EFs by plain X-ray lateral images taken immediately after and on the following day of the operation, and categorized them by severity according to the medical literature by Sharma, et al. (G1, impaction of a unilateral edge of the cage on the endplate; G2, impaction of a bilateral edge of the cage on the endplate; G3, impaction of the one-third or more of the height of the cage on the endplate). In addition, we investigated the height of the cage, the level of EFs, and subsidence of the cage following the fractures, and also evaluated characteristics of patients in whom fractures occurred. Results: EFs occurred in 14 patients (7 men and 7 women; one of one segment at Th12/L1; one of 10 at L1/2; one of 35 at L2/3; nine of 48 at L3/4; seven of 44 at L4/5). The severity of the fracture was G1 for 16 segments, G2 for two, and G3 for one. Progression of severity from G1 to G2 was observed in one segment, G1 to G3 in one, and G2 to G3 in two. These progressions occurred between two weeks and three months after the operation. The height of the cage was 9 mm for eight cages, 10 mm for 10, and 11 mm for one, and all of the cages were 10º wedge-shaped cages. There were no significant differences in age, sex, and preoperative bone density between patients with and without fractures. Conclusion: When XLIF was initially introduced, taller cages were used and EFs commonly occurred with 10-mm and 11-mm cages. Since the trial cages were inserted after sufficient cleaning of the intervertebral disc space, a rongeur, sharp ring curette, or other spine instrument may have caused damage to the endplate. Subsequently, in the case of narrow intervertebral disc space, widening of the intervertebral disc space has been performed by using trial cages before cleaning of the intervertebral disc space to prevent EFs. Recently, cages height has generally been 8 or 9 mm, and EFs tend to occur in cases with a high degree of deformation accompanied by osteophytes, which have to be chiseled before insertion, or cases that require angle technique between upper segments in multilevel spinal fusion. However, the severity of subsidence following the fractures is considered to be mild where the corners of the large XLIF cage are placed on the harder portion of the endplate., Introduction: Conventional surgery for lumbar intervertebral foraminal stenosis has been done as much more invasive methods such as osteoplastic hemilaminectomy or total facetectomy with intervertebral fusion. The purpose of this study was to evaluate the Microendoscopic Intrapedicular Partial Pediculotomy (ME-IP3) as minimally invasive method. Material and Methods: 3 male and 4 female patients (age rang = 39-68 years, mean = 54.3 years) with the JOA scores ranging from 7 to 19 points (mean of 12.7 points) were included in this study. All patients had L5 radiculopathy with the L5-S1 intervertebral foraminal stenosis expect one patient of L4-5 stenosis. The clinical results were assessed according to a clinical scoring system established by the Japanese Orthopaedic Association (JOA score, full points = 29), percent improvement of the JOA score (%IP), operation time, intraoperating blood loss, and period of out of bed. Mean follow-up time was twelvemonths (ten-fourteen months). Results: Mean operating time was 97.6 minutes ranged from 70 to 138 minutes. Intraoperative blood loss was less than 5 ml, and period of out of bed was one day in all patients. The mean postoperative JOA score was 21.7 points ranged from 14 to 27 points, and %IP was 55.2%. Conclusion: The results of this study showed that ME-IP3 is a reliable and safe technique for intraforaminal decompression with good clinical outcomes. This technique provides excellent exposure with minimal invasion for the bony and neural structures. ME-IP3 seems to be a viable alternative to open surgery for lumbar foraminal stenosis., Introduction: Traditional anterior and posterior approaches to thoracolumbar region are related with significant neurological morbidity and long term complications related to sagittal alignment, deformity and bone healing. The advent of minimally invasive approaches has dramatically changed this scenario, allowing wide neural decompressions and proper alignment of the spine. Material and Methods: We present 10 consecutive patients treated with minimally invasive lateral retropleural and retroperitoneal thoracolumbar approach and corpectomy, using expandable cage. The conditions were acute fractures (4), sagittal imbalance (3) osteoporotic fractures (3). Operative results, complications, follow-up, pre and postoperative VAS and Oswestry scale were assessed. Results: In every case the procedures were successfully completed with posterior percutaneous pedicle screws. Levels involved were T12 (1 case), L1 (6 cases), L3 (2 cases) and L4 (1 case) vertebral bodies replacements. Complications: there were pleural tears in 5 of 7 retropleural approaches, a chest tube was placed intraoperatively and removed in the following 48 hours, without any long-term sequelae. In the case of L4 osteoporotic fracture we noticed inferior platform L3 breakage that solved with the expandable system. Minimal blood loss was recorded (, Introduction: Several studies have proven that vacuum cementing in hip replacement produces a more homogenous cement with a superior bone cement interface in comparison to the standard technique. It also has the potential to reduce so called cement embolism. We therefore thought of a simple technique to apply this advantage also in kyphoplasty. Material and Methods: Each patient had the standard Kyphoplasty procedure with a ballon placed in the vertebra via the two pedicles of the fractured vertebra in the routine manner. A 50 ml Luer Lock Syringe (encluded in the Set) was then fixed to the one side and pressure applied by pulling on the syringe whilst the cement was slowly applied or sucked in via the other side. In case there was too much blood aspirated the syringe was constantly changed to maintain constant pressure. This maneuver was repeated until cement visibly seeped out into the vacuum syringe. Then cement was also applied via the vacuum side. The total amount of cement was measured and the post op Xray was assessed by an independent blinded radiologist. He had to record any cement leak and the spreading of the cement. If there was any doubt about leakage a CT scan was performed. Results: 74 consecutive patients with 88 Kyphoplasties were prospectively collected so far. We found less cement leak than in a previous group and in the published results of kyphoplasty when counting any leak. The Cement seemed more homogeneously spread throughout the vertebra. Conclusion: Vacuum assisted cement application is a simple procedure with a minimal prolongation of the operating time and no added cost that so far has the potential to lead to less cement leak than classic kyphoplasty. However, to prove its value this will have to be verified by proper designed randomized controlled studies., Introduction: Percutaneous cement discoplasty (PCD) has been recently introduced to treat vertical instability associated with end stage lumbar disc degeneration. By filling the cavity of the disc characterized by vacuum phenomenon significant improvement in axial pain and disability can be achieved. The minimal invasive technique is safe and effective in elderly patients who are not eligible candidate for extended stabilization surgeries. In this study, the effect of the PCD procedure on the foraminal area as well as the lumbar sagittal and coronal alignment was determined. Methods: A prospective cohort of 25 patients underwent mono- or multisegmental PCD procedure was analysed. Lumbar (LI-SI) lordosis, scoliosis Cobb angle as well as pelvic parameters (PI, PT, SS) were measured on standing radiograph preoperatively, the day after the surgery and at 6-month follow-up. The change in the foramen area was determined on lateral radiograph and adjusted on the adjacent non-treated segment. Visual analogue scale for pain and Oswestry Disability Index was completed by the patients. Statistical analyses were made in SPSS 20.0 software. Results: A significant increase in lumbar lordosis was measured right after the surgery (42.4° vs. 46.4°, P < .05) and the effect was constant with time (45.6°, P > .05). An improvement in the coronal balance was also determined (lumbar Cobb angle: 10.9°preop, 7.1°postop, P < .05 and 7.9° at 6 M follow-up, P > .05). Mean foraminal area significantly increased due to the indirect decompression effect of the procedure (125.5+50.0 vs. 178.6+50.1, P < .001). Both leg and low back pain as well as disability significantly decreased after the procedure and the improvement was constant (P < .05). Walking ability of the patient has also significantly improved (P < .01) after the procedure. Conclusion: PCD technique is and effective minimal invasive option to treat axial pain and consequent disability related to lumbar vacuum discs. Sagittal and coronal alignment can be improved with the properly applied technique since a significant indirect foraminal decompression is realized. These factors can significantly contribute to the pain relief and increase of the patients’ functional capacity, however a larger, multicenter, prospective study is needed to confirm these associations., Introduction: In recent years, the number of publications on lumbar interbody fusions has increased considerably. Since 1930, Capener, who was the first person who described an anterior approach to management of spondylolisthesis, to what we know today as minimally invasive surgeries. All this has led to surgery for lumbar interbody fusion has become common to treat different pathologies such as spondylolisthesis, degenerative disc disease, recurrent disk herniations, spinal deformity and nonunion sagittal and coronal plane technique. This descriptive work aims to evaluate the clinical evolution, of degenerative scoliosis in patients undergoing minimally invasive technique XLIF (eXtreme Lateral Interbody Fusion) and OLIF (Oblique Lumbar Interbody Fusion) without posterior instrumentation in the service of Neurosurgery at the Hospital Universitario Mayor (HUM) in Colombia. Material and Methods: A description cohort of patients undergoing XLIF and OLIF at the HUM during the years 2014 and 2015. Patients who were treated for degenerative scoliosis are included. They are excluded from this study patient with tumor, traumatic or infectious disease. For this was performed OLIF and XLIF classically described, and pre-operative and post-operative epidemiological, clinical and radiological features were measured. Results: 7 patients were operated, 4 (57%) were female and 3 (42%) male. Mean age was 51,8y (21-75). 6 patients were operated more than a lumbar level. The XLIF technique was developed for L1-L2 level; and for other levels developed the OLIF technique. The intervened levels were in order: L3-L4: 7 (41%), L4-L5:4 (23%), L1-L2 and L2-L3: 3 (17%). In the visual analog scale (VAS) was a improvement pre-operative vs post-operative (8,8 vs 2,5), as well Oswestry Index (68% vs 10,8%) in one year follow-up. There were no complications related to the surgical procedure, the mean procedure time was 2,9 hours, the mean intraoperative blood loss was 75 cc and the mean postoperative hospital stay was 1.5 days. Regarding the radiological findings, the lumbopelvic balance was preserved as the lumbar lordosis pre-operative vs post-operative; but we could see a return of the disc height, obtaining an increase of diameter of the spinal canal secondary correction disc height and ligamentous structures stretch. Conclusion: The minimally invasive technique XLIF and OLIF; are safe procedures, which was reproducible in our institution; and they are an alternative of anterior interbody fusion. This has several advantages over different types of approaches, including minor surgical trauma, less risk of blood transfusion requirement, less pain in the immediate post-operative and less time in hospital. In our experience we got an improvement in their symptoms, pain (VAS) and disability (Oswestry Index). Radiologically we could see a return of the disc height, which leads to a direct and indirect decompression of nerve structures, obtaining an increase of diameter of the spinal canal secondary correction disc height and ligamentous structures stretch. In turn we found very similar results compared to those described in the literature., Introdution: To evaluate the advantages, disadvantages, results and the early complication of the percutaneous pedicle screw fixation using Sextant system for the treatment of vertebral column fractures in the cross-sectional study. Materials & Methods: 48 injured lumbar spinal column fracture patients have been treated with percutaneous pedicle screw fixation using Sextant system from January 2011 to June 2015. As a method of evaluation, the incision size, the intraoperative and postoperative volume of blood loss, operation time, postoperative hospital stay, the sagittal Cobb’s angle, intraoperative and postoperative complication were recorded. Results: There was a significant difference between the preoperative and postoperative kyphotic deformity angle (P < .05). The progressive kyposis after 6 month of postoperation were realized in 4 cases (8%), but they were in mild levels (, Introduction: Percutaneous trans-sacral approach procedures such as neuroplasty using a Racz catheter or epiduroscope are frequently performed as treatment option for lumbar disc herniation (LDH) but they are limited in that they cannot completely remove the causing pathology. Recently, with the development of laser technology, trans-sacral epiduroscopic laser decompression (SELD) has been receiving attention as an alternative tool and few reports have demonstrated its effectiveness, but there are insufficient reports of results. The purpose of this study is to report preliminary clinical and radiololgic results of SELD for the treatment of LDH in a single center experience. Material and Methods: 21 patients (M: F = 3:4) who underwent SELD for the treatment of single-level LDH were retrospectively evaluated for minimal 12 month follow-up. Their medical records including demographic data, diagnosis, complication, epiduroscopic findings and degree of symptom relief were investigated. The mean age of patients were 53.7 years and mean BMI was 23.3. All patients received same routine protocol procedures under local anesthesia by single surgeon using Ho: Yag laser. Clinical outcome were evaluated using visual analogue scale (VAS) scores for back and leg pain and functional status was measured with Oswestry disability index (ODI). Radiologic outcome were evaluated by comparing the changes of disc size on magnetic resonance image (MRI) scans, preoperatively, postoperatively and at final follow-up. Results: Fifteen patients (71.4%) showed symptom relief immediate postoperatively after the procedure and 18 patients (85.7%) showed relief at final follow-up. The average VAS scores for back pain decreased from 8.2 to 3.5 at immediate postoperative and to 1.5 at final follow-up. The average VAS scores for leg pain decreased from 6.9 to 2.75 at immediate postoperative ant to 2.35 at final follow-up, respectively. Mean ODI improved from 48 to 23 postoperatively and further decreased to 14 at final follow-up. Immediate postoperative MRI showed subtle changes in most of the patients (18/21, 85.7%), however, final follow-up images revealed significant reduction of disc pathology in 80.9% (17/21 patients). There was no procedure related complication in all patients except mild headache after the operation in two patients. One patient received microdiscectomy under general anesthesia due to recurrence of disc herniation after 3 month. Conclusion: The results of this preliminary study show significant improvements of VAS score and ODI after SELD for LDH with back and leg pain at minimal 12 months follow-up. Postoperative MRI scans revealed significant decrement of the disc size and reduction of neural compression. The SELD is suggested to be an effective therapeutic modality for patients with symptomatic LDH., Question: For the surgical treatment of unstable odontoid fractures in old age several several surgical procedures are possible: direct anterior screw fixation of the dens, with one or two screws at the age. This often leads to pseudarthrosis of odontoid with an unstable fracture situation. This leads to the loosening of screws in osteoporotic bone metabolism. Revision surgery as the dorsal open technique with C1/C2-screw fixation and iliac crest bone graft and cerclage is very stressful for the elderly. The dorsal percutaneous screw fixation C1/C2 can lead to healing of the odontoid fracture. After completion of the fracture healing the screw fixation can be removed. Methodology: In a prospective study was carried out 10 patients over 60 years with unstable pseudarthrosis of odontoid undergone a revision surgery with percutaneous posterior stabilization with C1/C2-screw fixation. All patients received an initial anterior screw fixation with one or two screws. In the absence of fracture healing, or screw loosening with pseudarthrosis of the odontoid a revision surgery was performed with percutaneous posterior stabilization with C1/C2- screw fixation. The surgery was performed with 3D image converter for documentation of the reposition preoperatively and postoperatively to control the screw position. Intraoperative the percutaneous approach was documented with the exact image converter in two planes, ap and strictly laterally. Postoperative clinical controls were performed and CT inspection to document the stability and healing of the pseudarthrosis of the odontoid within a year. Results: In the period from January 2007 to December 2012 in 10 patients with unstable pseudarthrosis of the odontoid after previous anterior screw fixation, were stabilized with the posterior stabilization with percutaneous screw fixation C1/C2. 4 women and 6 men with a mean age of 69.8 years / - 7.7 (median 70, min 57, max 82) were stabilized. The mean OR-time was 59.9 min / - 38.8 (median 45, min 36, max 165).In the mean follow-up of 382 days / - 324 (median 273), all patients had a stable course. In 8/10 patients healing of the pseudarthrosis of the odontoid could be demonstrated by CT. In 3/10 the dorsal screws were removed. Conclusions: The C1/C2 dorsal percutaneous screw fixation for unstable pseudarthrosis of the odontoid is a safe and promising, the patient little burdensome procedure. With the help of 3D imager the operating profit can be improved. Especially the older patients benefit from this supply strategy with high healing of the pseudarthrosis of the odontoid. The metal removal can be effected by healing of the pseudarthrosis of the odontoid, and thus the C1/C2-Joint can be given free again., Question: For the surgical treatment of unstable odontoid fractures in old age several surgical procedures are possible: direct anterior screw fixation of the odontoid; dorsally by C1/C2-screw-osteosynthesis, open with iliac crest bone graft and cerclage (n.Gallie) or; dorsally by C1/C2-screw-osteosynthesis percutaneously with two C1/C2-screws. The ventral direct screw in osteoporotic bone metabolism is not successful, the dorsal C1/C2-screwing in open technique with iliac crest bone graft and cerclage is very stressful for the elderly. The percutaneus C1/C2-screw-osteosynthesis can lead to healing of the odontoid fracture; after completion of the fracture healing the screw fixation can be removed. Methodology: In a prospective study 32 patients with unstable odontoid fracture and an age over 60 years were stabilized with percutaneous posterior dorsal screw fixation C1/C2. The surgery was performed with 3D image converter for documentation of the reposition preoperatively and postoperatively to control the screw position. Intraoperative the percutaneous approach was documented with the exact image converter in two planes, ap and strictly laterally. Postoperative clinical controls were performed and CT inspection to document the stability and the healing of the fracture of the odontoid within a year. Results: In the period from January 2007 to December 2012 was carried out in 32 patients with unstable odontoid fractures with percutaneous screw fixation C1/C2 posterior stabilization. 17 women, 15 men with a mean age of 81.8 years / - 7.5 (median 84, min 57, max 91) were stabilized. The mean OR-time was 50.0 min / - 24.3 (median 44.5, Min 16, Max 123). In the mean follow-up of 117 days / - 244 (median 29.5), all patients had a stable course. In 12/32 patients the healing of the fracture could be demonstrated by CT, in 3/32 the metal was removed. Conclusions: The C1/C2 dorsal percutaneous screw fixation of unstable odontoid fractures is a safe and promising, the patient little burdensome procedure. With the help of 3D-imaging operating profit can be improved. Especially the older patients benefit from this supply strategy with high healing rate of the fractures. The metal removal can be effected by fracture healing of the odontoid, and thus the C1/C2-joint can be given free again., Introduction: Vertebral compression fractures are considered as common conditions that cause function disability, chronic pain, progressive kyphosis and comorbidities. This study was conducted to evaluate the efficacy of using of mesh with bone graft in short and long term treatment of fractured vertebrae clinically. Material and Methods: Forty patients (43.58 ± 13.8 years) with vertebral compression fractures were treated using transpedicular placement of intervertebral titanium mesh cages with bone graft from August 2013 to August 2015 at Soliman Faqeeh Hospital in Jeddah, Saudi Arabia. We evaluated pain relief and improvement of daily activity function using visual analogue scale (VAS) score and Oswestry disability index (ODI) system pre-, post and one year after the operation. We assessed kyphotic angles (KA) and Cobb angle (CA) using plain x-rays and computed tomography (CT) pre-operatively, immediately post-operatively, and after one year of follow-up. Results: We found a statistically significant decrease in visual analogue scale (VAS) score when compared pre-operatively (8.80 ± 1.13) to immediately and one year post-operatively respectively (4.2 ± 1.27, 1.18 ± 1.36, P = .018). There was also a statistically significant decrease Oswestry disability index (ODI) system scores when pre-operative scores (91.35% ± 2.24%) were compared to immediate and one year post-operative scores (40.3% ± 16.43%, 29.40% ± 16.63%, P = .012). These results show a significant improvement of daily activity functions and pain relief. Both Kyphotic (KA) and Cobb (CA) angle showed significant improvements postoperatively (KA 20.33° ± 6.16° to 10.55° ± 4.11°, P = .002/ CA 10.5° ± 4.273° to 7.12° ± 2.99°, P =.001). There was no statistically significant difference in terms of Kyphotic (KA) and Cobb (CA) angles during the follow-up period (P > .05). Conclusion: The use of titanium mesh cages with bone graft technology is effective in treatment of Patients with vertebral compression fractures providing better quality of life by immediate and sustained relief of pain. It also improves both KA and CA immediately after the operation with maintenance of stable radiological progression through the period of follow-up., Introduction: MIS-DLIF (direct lateral lumbar interbody fusion) using tubular retractor has been used for the treatment of lumbar degenerative diseases. Although addition of intraoperative monitoring (IOM) of neural structures potentially decreased the perioperative neurological complications, blunt retroperitoneal and trans-psoas dissection poses a risk of injury to the lumbar plexus, especially at lower lumbar level. As an alternative, MIS-OLIF (oblique lateral lumbar interbody fusion) uses a window between the prevertebral venous structures and psoas muscle, and gets an access to the target disc obliquely. Theoretically, MIS-OLIF preserves psoas muscle and lumbosacral plexus with reducing the complication of direct lateral approach, and the need for IOM related to trans-psoas approach is questionable. The purpose of this study was to evaluate the safety of MIS-OLIF without IOM by comparing the incidence of perioperative complication in patients who underwent multi-level OLIF with or without IOM for the treatment of lumbar degenerative disease. Material and Methods: From October 2013 to March 2016, 129 consecutive patients underwent multi-level OLIF for the treatment of L1-S1 level degenerative disease were identified and retrospectively reviewed. The study group comprised 57 patients in IOM group (M: F=1:1.37, mean age=65.8 (range 35∼83)) and 72 patients in non-IOM group (M: F=1:2.1, mean age=67.1 (range 40∼85)). For clinical outcomes, self-reported measures including visual analogue scale (VAS) and Oswestry disability index (ODI) were used. A perioperative complication classification based on the relation to surgical procedure and effect duration was used. Perioperative complications until 3 month postoperatively were reviewed for the patients. Results: There was significant improvement of clinical outcomes in both groups without statistically significant difference. Overall, there were 13 (22.8%) procedure-related complications in IOM group and 17 (23.6%) in non-IOM group. In IOM group, there were 7 (12.2%) cases of transient leg symptoms that resolved spontaneously within 3 month postoperatively, including: 1 case of hip flexor weakness; 2 leg numbness; 1 leg pain, 2 asymptomatic temperature differences between each lower extremity and 1 asymptomatic leg swelling. In non-IOM group, there were 11 (15.2%) cases of transient leg symptoms; 2 case of hip flexor weakness; 3 leg numbness; 1 leg pain, 3 cold sensation and 2 leg swelling. Of all procedure-related complications in IOM group, 4 (7.0%) were classified as persistent, and 3 (4.1%) in non-IOM group. There were 3 procedure-related persistent leg symptoms in both groups respectively but without statistical difference (5.2% vs 4.1%) The most common procedure-related complication in both group were transient leg hypesthesia & cold sensation (3.5% vs 4.1%, N/S). The overall incidence of approach-unrelated complication accounted for 7.0% in IOM group and 8.3% in non-IOM group respectively. There were 4 re-operation cases in IOM group (7%; 1 local hematoma, 1 postoperative infection, 1 screw malposition, 1 persistent leg pain) and 3 in non-IOM group (4.1%; 1 local hematoma, 1 postoperative infection, 1 ureter injury). Conclusion: In our report of multi-level lumbar diseases, the OLIF technique may be performed safely without the aid of IOM in terms of procedure-related perioperative neural complications by eliminating the risk of unwanted muscle and nerve manipulations., Introduction: Unstable vertebral body fractures of the thoracolumbar junction of the type AO A3.1 are generally treated by ventral monosegmental spinal fusion. The support is provided by iliac crest bone graft. This results in part of the cases in cracks or necrosis of the graft or in lack of connection to the end plate. The contact area and chip cross-sections are very different, associated with the donor site morbidity. Cages, as the trabecular metal cage, with large contact surface (2 * 3 cm) and cancellous structure can replace the iliac crest grafts. Materials and Methods: In a prospective study 95 patients with unstable vertebral body fractures and ventral defect situtation, most of them were initially instrumented posterior bisegmental, were treated by thoracoscopic anterior implantation of a trabecular metal cage for monosegmental fusion with plate fixation. The patients underwent radiological examinations during the course (gain of correction, loss of correction), as well as evaluation of satisfaction by Odom score. Results: In the period from Januar 2010 to Dezember 2013 95 patients with fresh unstable vertebral fractures were treated by ventral monosegmental spondylodesis with a trabecular metal cage instead of iliac bone crest. 37 women and 58 men showed fractures type A1.2, but most type A3.1 of the thoracolumbar junction. The mean age was 47.1 years / - 11.5 (min 24, max 74). The average operational time was 105 min / - 27 (Min 56, Max 177). The follow-ups after 3,6 months and most 1 year demonstrated good results. The loss of correction was small. All cages integrated firmly, the patients were largely asymptomatic. The removal of the internal fixator was between 4 - 8 months. Conclusion: The implantation of a trabecular metal cage with cancellous bone structure can replace the iliac crest bone graft in the monosegmental ventral management of unstable spinal fractures. In contrast to ventral spondylodesis by iliac crest bone grafts fusion and consolidation results after 3 months, a loss of correction hardly occurs. In addition there is no donor site morbidity and operational time is reduced. Abb. 1, Introduction: Vertebral fractures are considered as one of the most common injuries in Saudi Arabia during the last years due to the high rate of road traffic accidents and accidents affecting construction and industry workers. Minimally invasive spine surgery has improved significantly through the last decade. This type of surgery should have the same results as conventional treatment but with less morbidity and improved body healing so can help patient to back to normal life. This study was conducted to evaluate the efficacy of augmentation of the minimal invasive fixation by titanium mesh implant with bone grafting in the fracture site in improving patient’s quality of life. Material and Methods: Twenty four patients (38.58 ± 14.2 years) with vertebral fractures were treated using minimal invasive fixation by titanium mesh implant with injectable bone graft through percutaneous approach from August 2013 to August 2015 at Soliman Faqeeh Hospital in Jeddah, Saudi Arabia. We used visual analogue scale (VAS) score and Oswestry disability index (ODI) system pre-, post and one year after the operation to evaluate pain relief and improvement of daily activity function. Plain x-rays and computed tomography were used pre-operatively, immediately post-operatively, and after one year of follow-up to assess kyphotic angle (KA) and Cobb angle (CA) so we can evaluate the condition and the progress of healing. Results: A statistically significant decrease in visual analogue scale (VAS) score was found when compared pre-operatively (8.79 ± 0.23) to immediately and one year post-operatively respectively (4.21 ± 0.26, 1.21±0.3, P < .001). We also found a statistically significant decrease Oswestry disability index (ODI) system scores when pre-operative scores (91.25% ± 0.48%) were compared to immediate and one year post-operative scores (38.92% ± 2.89%, 27.5% ± 2.88%, P = .041). These results indicate significant and sustained improvement of daily activity functions and pain relief. Both Kyphotic (KA) and Cobb (CA) angle showed significant improvements postoperatively (KA 20.36° ± 1.88° to 7.96° ± 0.73°, P < .001/ CA 10.5° ± 0.63° to 6.29° ± 0.52°, P < .001). We did not find any statistical significant difference in terms of Kyphotic (KA) and Cobb (CA) angles during the follow-up period (P > .05). Conclusion: Augmentation of the minimal invasive fixation by titanium mesh implant with injectable bone graft can give immediate and sustained relief of pain and better quality of life. It also improves both KA and CA immediately after the operation with maintenance of stable radiological progression through the period of follow-up., Introduction: Surgical treatment for a symptomatic lumbar disc herniation (LDH) is required in those patients with “red flags” and/or after failed conservative management. Microendoscopic discectomy (MED) is an alternative to open discectomy (OD), with associated benefits, but it has not yet been positioned as its replacement. Our objective is to analyze the available literature to compare the effectiveness of the MED and OD for the treatment of symptomatic LDH. Material and Methods: The literature search was conducted in PUBMED and EMBASE in September 2016 using the key words endoscopy and lumbar herniation. After reviewing the titles and limiting the search to clinical trials, a total of 37 studies were identified. The abstracts of these studies were analyzed. Those that compared the MED with the OD for the treatment of the LDH were selected and extensively reviewed. Finally, four of these studies were selected, after fulfilling inclusion and exclusion criteria. Three of the authors extracted the data and analyzed the quality of the selected studies. A meta-analysis was performed with the obtained data (pain [general, lumbar, radicular], satisfaction, and re-intervention) using the RevMan 5.3 software. Results: A total of 298 patients were included in this analysis. Those patients treated with MED reported significantly less general pain (mean difference 13.08, CI 95% [-13.42 a -12.73], P < .00001), less low back pain (odds ratio (OR) 0.19, IC 95% [0.08-0.49], P = .005) and were more satisfied with the procedure (OR 0.34, IC 95% [0.14-0.82], P = .02). No statistically significant differences were identified for radicular pain and the need of reinterventions. Conclusion: Although MED could present a benefit in low back pain and patients’ satisfaction, the existing literature cannot demonstrate the superiority of MED over OD for the treatment of LDH, given the scarce amount of clinical trials and the inadequate presentation of the results of available studies., Introduction: Thoracic disc disease is a rare entity in clinical medicine and is treated via a number of different surgical approaches circumferentially orientated around the spine, from a traditional thoracotomy to less invasive posterior and posterior-lateral approaches. Furthermore, there is a paucity of outcome results and data comparing the different approaches. We describe our experience at a single institution using a minimally invasive (MIS) approach via a tubular retractor system to the thoracic spine and its feasibility for transpedicular thoracic discectomies and compared our clinical results to our more traditional open transpedicular approach. Material and Methods: We performed a retrospective review of all cases performed between 2011 and 2016 comparing the results of a total of 8 patients with thoracic disc disease resulting in myelopathy with or without radicular symptoms treated surgically with an open approach (3 patients, 4 levels) or an MIS approach (6 patients, 7 levels). We then compared length of surgery, blood loss, time to ambulate, and looked at major and minor complications. Results: For all MIS cases, the postoperative imaging demonstrated excellent decompression that meets the requirements and standard of what is accomplished with an open approach. There were no post-operative complications in either group. Patients who underwent an MIS approach had decreased blood loss and had an earlier time to ambulate (within 24-48 vs. >48 for all open cases). The average surgery time was longer for the MIS approach with a steep learning course to acquire the technical fine-tuning for MIS. There were no major or minor complications in either group. Conclusion: MIS thoracic disc disease is a rare and challenging disease, much different than the lumbar or cervical spine due to the anatomy and its adjacent structures. However, similar to the MIS approach to the lumbar spine, this approach has similar benefits including decreased blood loss, shorter operative times, and decreased length of stay. Also, this approach allows patients to ambulate at an earlier stage. Overall, MIS transpedicular thoracic discectomies is a safe and feasible approach to the thoracic spine for thoracic disc herniation in selected patients., Introduction: The use of pedicle screws is widespread in spinal surgery for degenerative, traumatic, and oncological diseases. Until today, a standard fluoroscopy or portable radiographs have been routinely used during pedicle screw placement to help a correct surgical placement of pedicle screw instrumentation. With these conventional methods, the median pedicle screw accuracy ranges from 86.7% to 93.8%, even if perforation rates ranging from 21.1% to 39.8% are referred in literature. The intraoperative navigational with 3-D computed tomography (CT) based computer-guidance systems, have sensibly minimized the risk of pedicle screw misplacement, with overall perforation rates ranging from between 4.8% and 2.2%. Material and Methods: Since July 2008 to June 2016, we had experience of 700 cases of Mini-TLIF and percutaneous TPS fixation with Viper system from using iC-arm fluoroscopy, pre-CT image fusion 3D navigation to robotic 3D Zeego iCT with Brainlab Navigation. Screw positions were subsequently checked with a final postoperative cb-CT scan. 426 patients underwent single-level fusion, two leves 206, three levels 42, 4 levels 28, five levels 5 and six levels 2. Results: There were 6.9% pedicle perforations greater than 2 mm by using iC-arm fluoroscopy, 3.2% by pre-CT image fusion 3D navigation, and 0.5% by robotic 3D Zeego iCT with Brainlab Navigation. Conclusion: We demonstrate that use of intraoperative robotic 3D Zeego iCT with Navigation has been reported to increase accuracy than using iC-arm fluoroscopy ., Introduction: As Percutaneous Transforaminal Endoscopic Discectomy (PTED) for lumbar disk herniation (LDH) is performed under local anesthetics, patients are able to give feedback to the surgeon during the procedure. Because the discectomy can be a painful procedure, optimal analgesia and sedation is necessary. The objective of this study is to assess the safety and efficacy of Dexmedetomidine as a sedative for patients undergoing PTED. Material and Methods: Patients undergoing PTED for an LDH were prospectively included in this observational study. Patients received both Remifentanil and Dexmedetomidine as maintenance and Dormicum as induction. A bolus of Ketamine was administered only when the patients perceived more pain. Outcomes assessed were pre- and postoperative VAS scores for leg pain, back pain and anxiety for surgery or anesthetics, hemodynamic and respiratory parameters and satisfaction of the patient, surgeon and sedation specialist with the level of sedation. Furthermore, postoperative side effects of the anesthetics and sedatives (e.g. nausea, vomiting) were recorded. Results: A total of 32 consecutive patients were included of which 53.1% male. According to the neurosurgeons, of all cases 87.6% were either “good” or “very good” when it comes to the sedation itself and 96.9% reported “good” or “very good” when it comes to cooperation of the patients during sedation. This was respectively 78.2% and 87.5% for the sedation specialist. VAS scores for back pain and leg pain before surgery were respectively 4.8 ± 3.0 and 7.3 ± 1.9. VAS scores post-surgery were 2.8 ± 2.2 for back pain and 1.8 ± 1.7 for leg pain. The mean of the mean arterial pressure (MAP) before surgery was 100.2 ± 16.7 and post-surgery 78.3 ± 12.8. In one case there was almost a respiratory depression but saturation levels (>98%) remained stable throughout the surgery. Five hours post-surgery, 81.3% said not to feel nauseated. 6.3% (n = 2) patients reported having constant headache. Conclusion: In this patient population, sedation with dexmedetomidine during PTED yields a high satisfaction rate surgeons, sedation specialist and patients. Serious complications were not observed, but hemodynamics during PTED needs to be monitored continuously., Introduction: Anterior approaches to the lumbar spine are increasing for the treatment of degenerative disc disease (DDD). Exposure of anterior lumbar spine can be obtained both with a transperitoneal and with an extraperitoneal approach, with different types of skin incisions. In this study we describe a new anterior skin and subcutaneous dissection for retroperitoneal approach to the lumbar spine using a 3 cm semilunar perinavel incision that allows exposure and access to multiple lumbar intervertebral discs (from L3 to S1). Materials and Methods: This technique is performed with a 270° perinavel incision for a single level (i.e. L5-S1 or L4-L5 or L3-L4) or for multiple levels (from L3 to S1). The anterior sheath of the left rectus muscle is dissected and the muscle is retracted upward and laterally, to preserve the inferior epigastric vessels. The peritoneum and the left ureter are then gently pushed from the left to the right side until the psoas muscle is seen. The arcuate ligament is cut. Left common iliac artery and vein are then visualized and mobilized to expose the lower lumbar spine, with a “sliding window” technique. Deep retractors are fixed to the bony surface and a “ring retractor” is connected to the blades in order to achieve stability and maintain the best visualization of the surgical field. After indentification of the disc spaces, under endoscopic assistance discectomy is performed, end plates well prepared to implant the cage for finl fusion. The anterior longitudinal ligament is finally closed. The whole procedure is performed through the “perinavel” incision. Results: In this preliminary study we didn’t observe intraoperative complications, abdominal structure lesions or skin necrosis. All the incisions healed completely at a 3-months follow up, demonstrating that this type of access doesn’t interrupt the arterial supply to the abdominal skin. Conclusion: Anterior approach is becoming a more common approach to address degenerative disc disorders. Levels from L3-L4 to L5-S1 can be easily reached with an anterior perinavel skin incision. The anterior retroperitoneal approach to the lumbar spine is mainly used to treat L4-L5 and L5-S1 levels. In literature several different technique have been described with the dual aim to reduce exposure related complications and to perform a multilevel approach in a single step. A single peri-navel skin incision is frequently used in laparoscopic surgery and it is gaining in popularity because of its minimally invasivity and good cosmetic and postoperative pain outcomes. To authors’ knowledge, an anterior retroperitoneal access using a unique peri-navel skin incision to perform multiple discectomies and ALIFs hasn’t been previously described. Multiple level discectomy and fusion though a minimally invasive anterior approach with a unique small incision reduces surgical aggression, decreases postoperative pain, abdominal morbidity and blood loss. Postoperative recovery, bed rest length of hospitalization and cosmetic result can show better results. A “sliding window” mobilization of the abdominal access allows the surgeon to reach intervertebral levels from L3 to S1 in a single step., Introduction: MIS TLIF is a technique which preserves much of the Paraspinal muscles and is known to produce excellent results post operatively compared to the open TLIF method. Material and Methods: This is a prospective study is to evaluate the clinical outcome of MIS TLIF over a period of 24 months follow up. Sixty two (62) patients underwent MIS TLIF, between January 2012 to December 2013. Forty one (41) patients were able to complete the 24 months. Clinical outcomes were assessed using VAS, ODI, and SF-36 and serial radiographs were obtained at 6 weeks, 3 months, 6 months, 12 months and 24 months at UKM spine clinic. Results: There were 16 males, 25 females with 2 year follow up, and mean age 58.41 yrs. 26 patients underwent single level fusion and 15 patients’ more than one level fusion. 44% had spondylolisthesis 56% had degenerative disc disease. Mean operative time was 123.24 mins. Mean blood loss was 200 ml Mean hospital stay was 5.7 days. Improvement of ODI from 51.9% to 9.78%. VAS improved as well from 7.79 to 1.41. No patient had to be converted to Open TLIF. There were three cases of dural tear and one screw cut. Conclusion: MIS TLIF is a safe and effective technique with an outstanding result that meets the expectation of the patients in the early post-operative period., Introduction: Indications of Percutaneous endoscopic lumbar discectomy are ever expanding with progressive understanding of lumbar disc herniation and endoscopic anatomy with advent of new surgical instruments and techniques. Proper classification for management of different types of lumbar disc herniation by percutaneous endoscopic discectomy is lacking. Based on characteristics of lumbar disc herniations as in Table 1 we are proposing a new classification “Endoscopic surgical difficulty grade/score classification” and based on remnant disc material and degree of symptom resolution after endoscopic discectomy as in Table 2 we are also proposing a new outcome measure “Endoscopic surgical success grade/score classification”. The proposed classifications are comprehensive and applicable as it has taken consideration of anatomy, special issues associated with disc. This classification will help to differentiate different types of lumbar disc herniations and guide for choosing cases according to expertise. Material and Method: EMR records of 104 consecutive patients treated between December 2015 to May 2016 by percutaneous endoscopic discectomy for different lumbar disc herniations either by PETLD (transforaminal, outside in) or PEILD (interlaminar, annular sealing) approach by expert endoscopic spine surgeon who have done more than 1500 endoscopic discectomy were reviewed retrospectively. We have given grade/score to each lumbar disc herniation and surgical success grade (Grade I: Mildly Difficulty, Grade II: Moderately Difficulty, Grade III: Severely Difficult, Grade IV: Extremely Difficult) / score (Unsuccesssful / Partially Unsuccessful / Successful / Completely Successful). We have analyzed outcome of surgical management of our patients according to Endoscopic surgical success grade/score, McNab’s criteria and VAS taking Endoscopic surgical difficulty grade/score as prime variable. Results: Surgical success based on Endoscopic surgical success grade/score is 98.1%. Good to excellent result according to Mc Nab criteria is 96.1% .There is significant resolution of pain. Preoperative VAS 7.13 ± 0.72 changed to 1.78 ± 0.89 postoperatively (P < .005). Sex, herniation level, surgical difficulty grade were not associated with difference in surgical success grade and Mc Nab grade (P > .005). Special issues of disc herniation and diagnosis were associated with difference in Endoscopic surgical success grade/score and Mc Nab grade (P < .005) we had 2 complications of transient motor weakness. Conclusion: Any types of lumbar disc herniations can be treated by percutaneous full endoscopic techniques with more than 96% of success by expert endoscopic spine surgeon (evolution of indications). The proposed classifications are comprehensive and applicable., Introduction: Vertebral augmentation procedures with polymethylmethacrylate (PMMA) are used increasingly for pain relief in patients with symptomatic osteoporotic or neoplastic vertebral compression fractures. There is concern, however, about the intraoperative, perioperative, and postoperative complications associated with PMMA especially in case of severe osteoporosis (i.e osteogenesis imperfecta). Elastoplasty is a new vertebral augmentation procedure in which a silicone cement is used instead of PMMA. The silicone cement is more elastic than PMMA and it could be helpful to prevent further fractures especially in presence of a severe osteoporosis. Materials and Methods: We report a case of a 47-year-old patient with type IV Osteogenesis Imperfecta (OI) and a severe low back pain. The anamnesis of the patient was positive for various fractures of the arms and of the legs that was occurred during the childhood. The patient didn’t refer any trauma at the spine. The radiographic examination of the lumbar spine showed a mild (< 25% height loss) vertebral compression fracture of L4, a severe (> 40% height loss) vertebral compression fracture of L2 and a moderate (25%-40% height loss) vertebral compression fracture of L1. The MRI confirmed that all these fractures were recent (edema in the STIR sequences) and that the posterior vertebral wall was not involved by the fractures. The densitometric evaluation showed a severe osteoporosis (vertebral T-Score – 4,8). The Patient was initially conservatively treated with the use of three point spinal orthosis but after three weeks for the persistence of the pain the patient was candidate to a vertebral cement augmentation procedure. Taking in account the patient’s severe osteoporosis and the risk of the subsequent vertebral fractures related to the OI we decided to perform a ballon elastoplasty using a silicone cement (VK100, BONWRX, Phoenix, AZ). The procedure has been performed under local anesthesia in the operating room of the Interventional Radiology Unit using an Interventional Image Guided System to control the cement diffusion and to early recognize any cement leakage. After the procedure a 3D rotational acquisition was performed to check the final cement position. The Patient was clinically and radiographically reviewed at 1, 3, 6 and 12 months of follow-up. Results: During the procedure there were not any complications any cement leakage was observed. The absence of cement leakage was confirmed by the 3D rotational acquisition. Immediately after the procedure the Patient referred a complete remission of the pain and it was stable at the 12 months follow-up. After 14 months from the procedure the Patient sustained a new low energy trauma resulting in a fracture of T11 while the vertebrae near the treated levels did not sustained any lesions. Conclusion: From our experience the use of an elastic cement seems to be protective against adiacent levels fractures. ballon elastoplasty seems to protective. We don’t recorded any cement leakage and any complication using the silicone cement. We think that to avoid complications it is crucial to follow strictly the cement’s preparation and utilization rules (preparation time and low pressure injection)., Introduction: Microendoscopic spine surgery is minimally invasive surgery, but there is a risk of dural puncture due to the narrow surgical space. Consequently, the surgeons need extensive training. Many researchers have demonstrated surgical complications during microendoscopic discectomy (MED) or laminotomy (MEL), but none have focused on dural puncture. In this study, we examine which instruments surgeons used that caused dural puncture and how the dural punctures were repaired. Materials and Methods: Nine hundred nineteen patients underwent MED for lumbar herniation or MEL for lumbar spinal stenosis in Iwai hospital from January through December 2014. We evaluated the incidence and location of dural punctures, the instruments that caused dural puncture, the repair methods, and postoperative paralysis. Results: The incidence of dural punctures was 4.8% (44 of 919 patients). The tools that caused dural puncture were: 16 curettes, 13 chisels, 7 Kerrison Rongeurs, 4 hernia forceps, 2 penfields, and 2 suction tubes. The locations of dural tears were: 27 in the same direction (61.4%), 13 in the opposite direction (29.5%), and 4 in the center (9.1%). All repair methods were performed microendoscopically and included: 11 dural sutures with fibrin glue, 3 dural sutures with fibrin glue and PGA sheets, 21 fibrin glue and PGA (Polyglycolic acid) sheets, and 9 fibrin glue only. Postoperative paralysis including temporary paralysis occurred in 7 patients (15.9%). Conclusion: Dural tears were mostly caused by sharp instruments, such as curettes, rongeurs, and chisels. However, any surgical instrument that touches the dural membrane must be used carefully because even tools without sharp edges can cause dural puncture. Most patients with dural tears were treated without incident; however, 7 patients did develop paralysis including temporary paralysis., Introduction: The use of conventional uniportal spinal endoscopic decompression surgery for lumbar spinal stenosis can be limited by technical difficulties and a restricted field of vision. The purpose of our study is to describe the technique for percutaneous biportal endoscopic decompression (PBED) for lumbar spinal stenosis and analysis of clinical postoperative results. Materials and Methods: We performed a unilateral laminotomy with bilateral foraminal decompression using a unilateral biportal endoscopic system in patients with single-level lumbar stenosis. We enrolled only patients were followed up for >12 months after PEBD. Fifty-eight patients were enrolled in our study. This approach was based on two portals: one portal was used for continuous irrigation and endoscopic viewing and the other portal was used to manipulate the instruments used in the decompression procedures. Clinical parameters such as the Oswestry disability index (ODI), Macnab criteria, and postoperative complications were analyzed. Results: Neural decompression was effectively performed in all enrolled patients. Mean ODI was significantly lower after PBED. Out of 58 patients, 47 (81.0%) had a good or excellent result according to the Macnab criteria. Postoperative ODI and visual analog scale values were significantly improved compared with preoperative values. Conclusions: From a surgical point of view, percutaneous biportal endoscopy is very similar to microscopic spinal surgery, permitting good visualization of the contralateral sublaminar and medial foraminal areas. We suggest that the PBED, which is a minimally invasive procedure, is an alternative treatment option for degenerative lumbar stenosis., Background: Minimally invasive stabilization techniques (MISS) are gaining in importance in the treatment of spinal fractures. The purpose of this investigation was to evaluate the complication rate of this new procedure. Especially the complications of the hardware (screws and rods) will be illustrated. Methods: In the years 2010-14 a total of 670 patients have been stabilized with MISS techniques in spinal fractures. In 118 patients of this collective we used cement augmentation of the screws in instable osteoporotic fractures. The complications have been divided in intraoperative, postoperative and implant related complications. Data collection has been prospective. Especially complications and hardware problems of the new technique has been described. The results have been compared with the complications results in the open procedure technique of the MCS 2 study from the German Society of Trauma surgery (DGU). Results: We found 7 patients with infection and operative revision. In all patients it was not necessary to remove the implant. In 5 patients we saw loosening of the set screws. In 2 cases there was a loss of reduction and gaining kyphosis. It was necessary to indicate an early revision. In one case it was an incidental finding. In total the complication rate of intra - and postoperative complications is 2.1% Compared to the study group, the rate in the open procedure is 9.4%. Intraoperative bleeding and conversion to open procedure was not observed. There was no revision necessary because of mal positioning of a pedicle screw. Conclusion: The percutaneous stabilization technique of spinal fractures is a safe procedure. In general the complication rate is less than in the open techniques. We found implant-related complications such as loosening of the set screws. This should be recogniced and improved from the companies., Introduction: Minimally invasive spine surgery is a other way to solve common spine pathologies. these techniques have shown less aggression to the tissues and therefore less postoperative pain, shorter hospital stay, less blood loss, lower rate of infection and also faster reincorporation to the activities of daily living.Describe our experience on a case series treated with minimal invasive spine surgery, trough short term follow up and identifying the complications. Material and Methods: A prospective analysis was made on 116 patients who underwent surgery by the same surgical team, from September 2015 to June 2016. Evaluating short term follow up we registered time of surgery, blood loss, complications, hospital stay, pre- and postoperatively neurologic evaluation, as well as scales of disability index and quality of life. The surgical and demographics surgical data were analyzed with the program SPSS version 20. Results: A total of 116 patients at a mean age of 49.7 + 15.7 (21 to 85 years), were intervened of which 76 (65%) were lumbar pathology and 37 (32%) cervical. The most common procedures were lumbar tubular discectomy (31), bilateral tubular decompression (17), TLIF (7); and anterior cervical discectomy and fusion (35). Mean blood loss was 50.6 cc, 1.7 days of hospital stay, pre- and postoperative pain VAS were 7.4% and 2.3% respectively pre- and postoperative Owestry (ODI) were 64.6% and 13.1%, pre- and postoperative SF-36 of 37.8% and 90.3%. There were no major complications, one surgical wound infection on a diabetic patient and incidental durotomy on 3 patients one of them with a contained CSF fistula managed conservatively. Conclusions: The actual tendency towards minimal invasive surgery has been justified on multiple studies for neoplastic and degenerative pathology, with the preservation of the structures that support the spine biomechanics. The benefits should not replace the primary objectives of surgery and its use depends on the surgeon abilities, the pathology and the adequate selection of the techniques. We found that the tubular access allows techniques such as discectomy, fusion and corpectomy with no limits of exposure, avoiding manipulation of adjacent structures, with fewer complications and that it is possible at a public hospital., Introduction: Adjacent segment pathology (ASP) after posterior lumbar interbody fusion (PLIF) surgery using conventional pedicle screw (PS) often requires surgical treatment, but traditional surgical technique for ASP had inherent drawback that essentially involved the unproblematic level, index fused segments, in surgical procedure, which should be burdened for both surgeons and patients due to larger skin incision and muscle dissection, greater blood loss, and so on. The authors believe that an ideal method for ASP is to perform the surgery only at the ASP level, for which we suggest a use of cortical bone trajectory-based pedicle screw (cortical screw, CS). The study aimed to present a new minimally invasive surgical technique using cortical bone trajectory (CBT)-pedicle screw (cortical screw, CS) for ASP after PLIF surgery. Materials and Methods: Twelve consecutive patients who complained back pain and claudication due to ASP after PLIF surgery and not reponded to conservative treatment were included in the study. Our surgical technique is described briefly, as followings. After midline skin incision of approximately 6 cm, posterior decompression was performed. Interbody preparation and two polyetheretherketone cages were kept. Bilateral CS at the cranial vertebra was inserted under fluoroscopic guidance. 35 or 40mm-length rod was assembled with the screw head of CS. Then, using Domino system, the two rods (one from the CS and one from the existing PS) were connected and tightened firmly. For evaluation of the surgical technique, the primary outcome was fusion rate at six months and one year after surgery based on dynamic radiographs and computed tomography images. Secondary outcomes included (1) patient satisfaction, (2) clinical outcomes based on pain intensity, oswestry disability index, and a 12-item short form health survey, (3) radiologic outcomes, and (4) surgical outcomes and complications. Results: All patients had solid fusion in 1-year follow-up: Fusion at six-months post-surgery was achieved in 7 of 12 patients (58%), and at one-year post-surgery, fusion was achieved in 12 of 12 patients (100%). In patient satisfaction, 9 of 12 enrolled patients (75%) responded “completely pain-free and improved,” remained 3 patients (25%) responded “significantly improved but still some pain and/or discomfort,”. Based on these responses, all five enrolled patients were satisfied with our technique. Clinical outcomes were also improved significantly in all clinical parameters. In surgical outcomes, the mean operative time was 100 minutes (range: 90–130 minutes), and the mean length of skin incision was 6.3 cm (range: 6–8 cm). In radiologic evaluation at six months and one year after surgery, none had screw-related complications such as peripheral hollow-rim and cortical violation of pedicle and screw pull-out, and no cage-related complication such as cage migration was observed. There were no complications during surgery or the follow-up period. Conclusion: This new method using CS for ASP has great merits over traditional surgical method that can lead to similar fusion rate and better clinical outcomes under significantly less skin incision and muscle dissection, as one of a minimally invasive method. Further studies will be necessary to better determine its efficacy and safety., Introduction: Lumbar Interbody Fusion with Cortical Bone Trajectory screws has proven to be effective posterior fixation for lumbar degenerative conditions. Applying posterior compression force with pedicle screw heads is sometime difficult, because of small operative exposure. Also Cortical Bone Trajectory screws fixation with interbody cage has shown to be less stable in axial rotation and lateral bending compared with conventional pedicle screw fixation. Objective: To describe the operative method and assess the preliminary clinical outcome of Combined Pedicle Screw Trajectories with One Rod (CTOR) for lumbar interbody fusion. Operative Method: Following lumbar decompression with inferior facetectomy and interbody fusion with kidney bean shape cage, we place Cortical Bone Trajectory screws for cephalad level pedicles and Roy-Camille like pedicle screw trajectory (perpendicular to the posterior plane of the vertebra and straight forward) for the caudal vertebrae with entry point at the exposed superior facet. With the advantage of pedicle screw heads proximity, we connect all four screw’s heads with one curved rod. By placing the rod caudally, tightening the caudal level screws first and cephalad screws approximated to the rod with set screw tightening, we can apply posterior compression force. Methods: Between July 2014 and March 2016, twenty-one patients who underwent CTOR, one patient was lost to follow up because of his medical comorbidity unrelated to the operation. Therefore 20 patients (male/ female: 7/13 the average age was 63 at the time of surgery) were followed for an average 9 .2 months (3-18 months) and analyzed retrospectively. The items reviewed were; operation time, blood loss, perioperative complications, and Visual analogue scale for back pain and leg pain. Results: The average operation time was 131 minutes (104-195minutes) and estimated blood loss was 71.2 g (20-160 g). An 81 year-old man exhibited postoperative cerebrospinal leakage without apparent intraoperative dural tear which required dural augmentation with PGA non–woven fabric sheets with fibrin glue. Good pain relief was achieved in all patients. Conclusion: Combined Pedicle Screw Trajectories with One Traversing Rod fixation for lumbar interbody fusion led to good compatible clinical results with conventional PLIF procedures. And this novel procedure might contribute to more stable construct, because of it’s combined trajectory of the screws and a traversing rod served as cross connector. Biomechanical properties of this fixation are yet to be determined to support these results., Introduction: Percutaneous kyphoplasty had been widely used in treating osteoporosis vertebral compression fracture, but whether bone cement would bring extra stress to adjacent vertebra was still under debate. At the same time, sandwich type fracture is a special type of fracture, the fate of the middle one was controversial. We believed the fate of sandwiched vertebra is the best indicator of secondary fracture due to cement. Material and Methods: We retrospectively collected consecutive patients between 2013.1 and 2015.6. One group included patients with sandwich type fracture, another group was composed of patients with multilevel fracture, but more than one vertebra in between. Demographical parameter, peri-operation data and radiological evidence were collected. Secondary fractures were recorded and compared between groups. Results: Total 120 patients with 323 vertebrae were enrolled in our study. The mean follow-up time was 26.33 months(12-48) with minimum follow-up of 1 year, and average cement usage is 4.77 ml. The mean VAS pre and post operation were 8.32 (6-10) vs 1.43 (0-8), 6(5.4%) patients still had unrelieved pain. As for the new fracture, there were 11(17.7%) and 12(24.5%) patients in sandwich and non-sandwich group had second fracture. Only mortality and corticoid usage are related to secondary fracture (P < .05). Conclusion: Sandwich type fracture have a similar secondary fracture rate compared with non-sandwich type, which suggests that cement augmentation vertebra will not increase adjacent vertebra fracture risk., Introduction: With the increasing number of lumbar fusions being performed, many innovations have emerged for which the goal is to minimize invasiveness and improve outcome. Many procedures require specialized retractors, implants or insertion instruments. Authors describe their experience with paramedian MIS-TLIF utilizing standard implants and instruments and compare the results with classical TLIF. Materials and Methods: A prospective randomized study with 20 individuals undergoing single-level TLIF for spondylolisthesis randomized into “Classical” (n = 10) or “MIS” (n = 10) groups was conducted. Blood loss, postoperative pain (VAS-back & VAS-leg), analgesic requirements and daily life activities during hospital stay and at the 3-month follow-up were evaluated. Pre & post-operative MR images were studied to evaluate invasiveness of procedures. Results: Paramedian approach was successfully performed in all patients with no conversions to classical TLIF. There was no significant difference in either VAS-back or VAS-leg pain. Mean length of incision was 3.5 cm (2.8-4 cm) and 6.3 cm (5.3-7.6 cm); Surgery-time (min) was140 ± 33&179 ± 35; C-arm-time(s) 15 ± 3 & 30 ± 5; estimated-blood-loss (ml) was 757 ± 255 & 150 ± 30; drainages (cc) 480 ± 326 & 175 ± 50 and Hospital-stay (day) was 8 ± 1.5 & 5 ± 1.5 respectively for classical and MIS group. Axial T1 and T2 weighted images revealed less altered signal in the paraspinal musculature in MIS group. Conclusions: The study documents the feasibility of MIS-TLIF through paramedian approach with the clinical results comparable to classical TLIF with added advantages of lower blood loss, reduced hospital stay, lower analgesic requirements and faster recovery of daily life activities. Importantly, paramedian MIS-TLIF requires only standard implants, instruments, and retractors with no added cost and can be adopted easily., Introduction: Despite that most cases of craniocervical junction fractures can be treated nonoperatively with reduction and subsequent immobilization in a rigid cervical collar or halo, in some instances, operative management is necessary and can be accomplished by using either anterior or posterior fusion techniques. Open posterior procedures can result in significant blood loss, pain, and limited cervical range of motion. Also variability of C2 anatomy can make instrumentation challenging and prone to potentially severe complications. We want to show a minimally invasive, navigation-guided technique for surgical treatment of Levine-Edwards (L-E) Type I, Type II hangman’s fractures and C1 Type II (Jefferson’s) fractures. Material and Methods: For 6 patients: 2 with L-E Type I, 2 with L-E Type II hangman’s fracture and 2 with Jefferson fracture percutaneous screw fixation was performed: 4 directly through the fracture site and 2 C1- C2 transarticular fixation. This technique was facilitated by the use of intraoperative CT O-arm scan and StealthStation S7 Surgical Navigation System. Results: Of the 6 patients, 2 were women, 4 were men, age range was 33–69 years. No intraoperative or postoperative complications occurred. All patients were obtained flexion-extension radiographs the day after surgery nd at 6 weeks. For all patients, dynamic imaging demonstrated a stable construct. Conclusion: Craniocervical junction fractures can be safely repaired with the use of percutaneous minimally invasive surgical technique. This technique may be appropriate, depending on circumstances, for L-E Type I, L-E Type II hangman’s and Jefferson fractures; however, the degree of associated ligament injury and disc disruption must be checked., Introduction. The most common and reliable methods of C1-C2 fusion are the fixation by Harms and by Magerl techniques. The main advantages of Magerl technique are the great opportunities for minimally invasive performing. The two main methods of posterior transarticular stabilization are known: neuronavigated percutaneous technique and open surgery. It is possible to decrease the surgical trauma using lateral transmuscular approach with tubular retractor and endoscopic assistance in the case of CT navigation absence. Materials and methods. Eighty-nine patients with upper cervical fractures were treated from 2011 till 2016. The posterior transarticular fixation with canulated screws was applied at 31 cases. The open surgical treatment by posterior midline access to C1-C2 was performed in 15 patients who required posterior decompression or additional translaminar fusion. The posterolateral transmuscular approach was used in 16 patients who suffered from reducible atlantoaxial dislocations. Two patients with upper cervical fractures were successfully treated using minimally invasive Magerl technique with endoscopic assistance. Surgical technique. The closed reduction and immobilization in Halo were used during the surgical treatment as the first step. The second step included four small skin incisions (15 mm) provided minimally invasive technique: two of them were used for endoscopic-assist approaches to facet joints of C2-C3 through the tubular retractors and two – for K-wires and canulated instruments’ ports. Than the entry points at the C2 facets for the K-wires and screws were exposed. Afterwards the K-wire was put through the posterior C2 elements to lateral mass of atlas from each side under the video and X-ray control. Finally we drilled the canals for screws in C1-C2 with following putting the screws over the K-wires. Results: The placement of screws was correct according to CT data. There were no postoperative complications in patients with posterolateral transmuscular approach usage. The good orthopedic and clinical outcomes were observed in all these patients. Conclusions. The posterior C1-C2 transarticular fixation with endoscopic assistance could be the alternative to open surgery or percutaneous procedures. The usage of this minimal invasive technique is possible for treatment of reducible dislocations in case of normal vertebral artery course. The small skin incisions and surgical corridor as well as the minimal damage of cervical muscles allows decreasing the postoperative complications., Introduction: The O arm is a mobile intraoperative imaging platform. It provides 2D fluoroscopy and 3D reconstruction and allows for lateral patient access similar to a C arm. This study reports on the initial results of using the O arm in pedicle screw placement. Materials and Methods: Twenty patients (13 males and 7 females) underwent lumbar pedicle screw placement using the O arm between August 2012 and July 2014. Age range was 36 to 65 years. All patients suffered from severe degenerative lumbar spine disease and exhausted all methods of conservative treatment. All patients underwent on table O arm imaging during and at the end of surgery including 3D reconstructions. Results: Two cases needed one screw readjustment each after doing the final O arm check. This was attributed to inadvertent movement of the reference frame. All cases had 100% proper final placement of all screws confirmed on table before wound closure. Conclusions: The use of the O arm is extremely helpful in complex spine surgery. It allows on table confirmation of accuracy of pedicle screw placement. No patient needed postoperative CT scan to check accuracy of placement., Introduction: Quality of life in patients with primary and metastatic tumors of the spine mainly depends on the surgery quality. The use of intraoperative computed tomography (iCT) and neuronavigation system in the surgical treatment of spinal tumors allows us to identify prevalence of neoplasia directly in the operating room, to oversee the resection zone and to provide spine stabilization under altered anatomy. Methods: 187 patients underwent surgical treatment for primary and metastatic tumors of the spine from January 2002 to January 2016. We used iCT with neuronavigation system since August 2013. During this period, 26 patients underwent transcutaneous biopsy as a diagnostic procedure and 45 patients underwent surgery. The aim of our study was to assess the effectiveness of iCT and navigation system in the diagnosis and surgical treatment of patients with spinal tumors of different origin and prevalence. Results: The main advantages of iCT and navigation system use have been analyzed in the diagnosis and surgical treatment of primary and metastatic tumors of the spine. There are no any implant-related complications. In all cases extend of decompression was sufficiently. After en-bloc resection of tumor according to the control studies contrast uptake were not observed. Conclusions: The use of iCT and neuronavigation system in the diagnosis and surgical management of primary and metastatic tumors of the spine improves the efficacy and safety of treatment under altered anatomy and the absence of external reference points and minimizes the radiation exposure., Introduction: The use of navigation system in spine surgery has gained recent popularity to improve the accuracy of pedicle screw placement. In this study, we investigated the perforation rates of pedicle screw (PPS) placement with O-arm navigation system in lumbar surgery. Material and Methods: Total of 346 pedicle screws were implanted in 58 patients using O-arm navigation system. In all cases, pedicle screws on the left side were inserted by a skilled spine surgeon and pedicle screws on the right side were inserted by an unskilled surgeon (getting training within 4 years). The accuracy of PPS was evaluated after surgery using computed tomography (CT) and classified into 4 grades (0.1.2.3 grade) with grade 2 and 3 representing perforation. The difference of the perforation rates between the skilled and the unskilled surgeon were examined. Results: Grade 0 was 86.7% (300/346), grade 1 was 10.7% (37/346), grade 2 was 0.9% (3/346), grade 3 was 1.7% (6/346). The perforation rate of all screws was 2.6% (9/346). The perforation rates of the skilled and the unskilled surgeon side were 1.2% (2/173) and 4.1% (7/173) respectively. Conclusion: This study indicated that the use of O-arm navigation system in PPS placement have very beneficial implication, however the surgeon’s techniques may affect the accuracy of PPS placement in lumbar surgery., Introduction: Pedicle screw insertion in complex spinal deformity such as scoliosis is challenging, and is complicated by morphometric limitations of pedicle dimensions, altered anatomical landmarks for insertions and abnormal orientation in space. AIRO intraoperative CT navigation systems have reported excellent screw placement however accuracy in the clinical scenario of complex spinal deformity has not been reported previously. The purpose of this study is to validate the accuracy of pedicular screw placement with the use of AIRO navigation system in cases with complex spinal deformity. Materials and Methods: A prospective study was performed on 31 patients undergoing complex spinal deformity correction surgery using posterior pedicle screw instrumentation. The cases included 24 scoliotic and 7 kyphotic deformities of the thoracic and lumbosacral spine. We used the mobile AIRO CT based navigation system for pedicular screw placement. The average cobb angle was 68.3° (range 60°-104°). The average number of segment instrumented was 12 (range 5-15) and mean number of screws per patient was 15 (range 7-24). Following the instrumentation, all screws were evaluated by an intraoperative CT scan. Analysis was performed to estimate the accuracy of screw placement, time for screw insertion and radiation exposure. Breach greater than >2 mm were considered for analysis. Critical breach was considered to be > 4 mm, non critical breach was between 2- 4 mm. Results: Total of 455 pedicle screws were inserted from T1 to iliac region. There were 116 pedicle screws in the upper thoracic spine, 171 in the lower thoracic and 168 in lumbosacral spine. There were total of 27 screws with pedicle breach noted, including 10 medial, 16 lateral and 1 anterior wall breach. No case was clinically symptomatic for malpositioned pedicle screw. Among Medial breach (n = 10) only 1 screw had a critical breach needing revision and 9 screws had non critical breach. Four of 9 cases with medical breach were planned breach on the convex side of the curve as a lateral trajectory did not offer adequate purchase in the pedicle due to contorted pedicel anatomy. Among lateral breach (n = 16), 10 screws were planned for in-out pedicle screw insertion, 4 screws showed non critical breach and 2 screws with critical breach. After accounting for planned breach, the effective breach rate was 2.8% resulting in 97.2% accuracy for pedicle screw placement using AIRO in complex spine deformity. We also encountered 44 pedicles which had to be abandoned as pedicle screw insertion was not possible. In all cases, we were able to scan whole of the planned instrumented levels in one single scan. Average screw insertion time was 1.76 ± 0.89 minutes (range 0.42- 5.35 minutes). Average radiation exposure to the patient was 9.7 ± 2.36 msv (range 4.49- 18.83msv). Conclusion: Considering the clinical scenario of complex pedicle anatomy in spinal deformity AIRO navigation showed an excellent accuracy rate of 97.2%. It is quite safe, highly versatile and can be easily integrated into existing operation theatre setup. It also eliminates the radiation exposure to operating room personnel during the procedure., Introduction: There is a growing consensus of the effectiveness, efficiency, outcomes and economics of MIS spinal fusions. While the body of evidence in the scientific literature demonstrates these values, MIS often comes at a risk to the surgeon through occupational hazard of the increased reliance on fluoroscopy in the operating room and the impact of long days wearing heavy protective lead aprons. The former has been proven to lead to an increased risk of malignancy and cataracts while the latter has led an increased incidence of spinal injuries and other orthopedic ailments in spine surgeons. Computer assisted surgery systems that can guide surgeons during fusion procedures have been reported to reduce the need for fluoroscopy. Materials and Methods: Data were collected retrospectively from 4 hospitals for patients operated with robotic-guidance in a MIS approach (RGM), and compared with patients operated with fluoroscopic-guidance MIS (FGM). All cases were instrumented fusions using a minimally invasive technique with pedicle screws inserted in a percutaneous para-median approach. Results: Altogether, data from 627 patients were collected, 403 RGM patients and 224 FGM. There were no significant differences in age, sex or BMI between arms or surgeons, except for 1 of the 4 groups in RGM that was significantly older by about 6 years. There were 7.2 screws per case in RGM, vs. 5.5 in FGM. Skin-to-skin time per screw was almost equal, with 32.8 minutes for RGM and 33.9 for FGM. Total case fluoro time per screw was 11.3 seconds per screw, vs. 27.4 seconds for FGM. Conclusions: This retrospective analysis demonstrates that use of robotic guidance MIS can significantly reduce the surgeon’s exposure to intraoperative fluoroscopy compared to fluoro-guided MIS in the hands of experienced MIS surgeons. In a standard 2-level case using 6 pedicle screws surgeons could reduce their exposure by about 1.5 minutes of radiation. Extrapolating these data for surgeons performing 100 or more lumbar fusions annually leads to significant reductions to hazardous radiation., Introduction: Surgical management of traumatic C2 fractures is technically challenging due to anatomical relationships between osseous and neurovascular structures. 3D imaging-based intraoperative navigation systems are increasingly used to improve accuracy of the procedure and patient’s safety. Purpose of this retrospective study is to evaluate surgical workflow and applicability of navigated spinal instrumentation with the mobile AIRO intraoperative computed tomography (iCT) scanner in a series of patients submitted to cervical posterior arthrodesis. Material and Methods: We performed a retrospective analysis of patients affected by Anderson type II fractures of the odontoid process, who underwent C1-C2 posterior cervical arthrodesis using Harms technique, from October 2014 to August 2016. Screws were positioned with the only aid of intraoperative Airo-based CT navigation, without fluoroscopic control. Results: Patient population, aged from 60 to 93 years, includes seven patients. Six patients underwent C1-C2 posterior stabilization, while in one case extension of stabilization to C3 was required due to a pathologic fracture. A total of 30 screws were placed, with 1 case requiring repositioning of 1 screw after accuracy control with intraoperative CT scan had shown incorrect placement. No patient showed intraoperative vascular injury, new neurologic postoperative deficits or postoperative implant failure during the follow-up period. Conclusion: Implementation of intraoperative Airo-based CT navigation for posterior stabilization of C1-2 fractures facilitates correct screw placement and increases the safety of the procedure., Introduction: Percutaneous fluoroscopy assisted pedicle screw fixation for thoracolumbar spine fractures is associated with preservation of posterior musculature, less blood loss, shorter operative time, lower infection risk, less postoperative pain, shorter rehabilitation time as well as shorter hospital stay when compared to open surgery, but with increased radiation exposure for the surgical team and patients. Robotic assisted spine surgery is an emerging field of surgery that has been shown to reduce radiation exposure with high level of safety. The purpose of this study is to evaluate the outcome of robotic assisted percutaneous pedicle screw fixation with for thoracolumbar spine fractures. Material and Methods: A ambispective review of all patients with thoracolumbar fractures who were managed with robotic assisted percutaneous transpedicular screw fixation (Renaissance, Mazor roboticsl) at our medical center between November 2009 and July 2016. Demographic data, accuracy rates, post operative alignment, radiation exposure were evaluated. Results: Twenty two patients (14 males and 8 females) underwent robotic assisted percutaneous transpedicular screw fixation between November 2009 and July 2016 for type A and B (AO) thoracolumbar fractures. The average age was 41.1 years (range 17-82). Twelve cases were due to falls from height, 3 for MVA, 3 extension type injuries, and four from other mechanisims. Three of the patients were poly trauma patients, four had rib fractures and three others had calcaneous fractures as well. 154 screws were placed in total. Levels operated ranged from 3-7 levels, with 5 to 13 screws were used per case. In three cases cemented fenestrated screws were used. Mean total case radiation time per screw was 4.1 seconds (ranged 1.8-4.7 including registration, screw and rod placement). Only one screw was removed and inserted again manually (0.65%) because of malplacement. There were no treatment-related complications. There were no revision surgeries. Conclusion: Robotic assisted percutaneous pedicle screw fixation for thoracolumbar spine fractures is a safe method for screw placement for thoracolumbar trauma cases. It allows restoration of the sagittal alignment with satisfactory clinical results even for geriatric patients and poly trauma patients with reduced radiation to the patient and surgeon when compared to free hand techniques. The non fusion screw fixation allows removal of the screws if needed after healing has set. A comperative study with other navigation techniques is needed., Introduction: Spinal navigation is an important tool during surgery with pedicular screws. Since 2 years (September 2014), we have implemented the use of an intraoperative mobile CT (iCT, AIRO system). This CT is routinely coupled with spinal navigation during screw positioning, either with percutaneous or open technique. CT is also used to check position of screws before patient leaving operatory room. Compared to traditional fluoroscopy, potential advantages of navigation techniques are better accuracy in screw positioning, less risk of neurological injury, less radiation exposure for surgical team. Potential disadvantages are prolongation of surgical time and, in case a CT is coupled with a navigation system, an augmentation of radiation exposure for patients. In this retrospective analysis, we report our experience on a series of 175 patients operated at thoracic and lumbar levels with pedicular screws. Material and Methods: Retrospective evaluation of a series of 175 patients submitted to surgery with pedicular screws at thoracic and/or lumbar levels (cervical spine excluded). Main goal of this analysis was to check the reliability of a navigation system coupled with CT. To obtain this, we explored 2 parameters: the rate of intraoperative repositioned screws (screws that were repositioned by surgeon after intraoperative control CT) and operative time (measured from skin incision to skin closure). Secondary objectives were to assess rate of malpositioned screws (grade 3-4-5 using Heary classification), and to compare it with our previous experience with another type of mobile 3-D imaging system (O-arm). Results: Our series includes 175 patients (89 women and 86 men), with a mean age of 64 years. Two-thirds of patients were operated for a degenerative disease of the spine (lumbar spinal stenosis with instability, spondylolisthesis, adjacent segment disease), while in the other cases indications were traumatic diseases or instability due to infection. Mean number of instrumented levels was 2.5. Mean number of intraoperative scans was 2.0 (DS 0.29). Mean radiation exposure was 12.43 mSv (measured on 92 patients). More than 700 pedicular screws were analyzed. Mean operative time was 266 minutes in non-previously operated cases, 358 minutes in revision surgeries (P < .0001). Overall, nine screws were intraoperatively repositioned in 9 patients: on intraoperative control CT, 5 were judged too medial, 1 was too low, and 2 were laterally placed. One screw was repositioned because of a modification of EMG during positioning, before intraoperative CT. One patient in this series (0.005%) needed revision surgery for a malpositioned screw on L5, that was not checked with intraoperative CT after repositioning. Duration of surgery and rate of repositioning significantly diminished in last 70 operated patients, compared to first 75. Conclusion: Reliability of navigation system coupled with iCT is very high, as shown by the very low number of intraoperatively repositioned screws. In our experience, this rate is significantly lower than with other imaging systems we used (fluoroscopy, O-arm). We consider this parameter more accurate in judging navigation reliability than screw position measured on intraoperative or postoperative CT by a radiologist. In many cases indeed, final position of screws in the pedicle may be judged as acceptable by surgeon, even if it will not be judged as radiologically correct with most of the classification system that are used for this purpose. Operative time is significantly higher with this system than with free-hand technique or with intraoperative fluoroscopic control, but in our experience is not higher than with other 3-D imaging systems as the O-arm. Longer operative times do not depend on number of intraoperative scans (that were almost always 2 in our series). Finally, we identified a clear learning-curve effect, as shown by the lower rate of intraoperatively repositioned screws, lower operative time and lower number of misplaced screws in the last 70 patients., Introduction: Vertebral hemangioma is a benign tumor that accounts for approximately 2% of the benign tumors in the body, and 0.8% of the lesions of the skeletal system. Its incidence peaks between the ages of 30 – 50 years. Hemangiomas in the pediatric population are rare with less than 10 cases reported. Material and Methods: In this report we describe the case of a 14 year old female who came to our clinic with one year history of back pain that progressed to severe. She was diagnosed with lumbar Tuberculosis. MRI shows a progression of the lesion so she was sent to our hospital where Vertebral Hemangioma was diagnosed. Propranolol treatment of 20 mg was given to her for 6 months. Results: She responded dramatically with MRI control at 6 months with a reduction of 90% of the hemangioma. Posterior instrumentation treatment was added. Patient after one year treatment is actually without pain and no neurologic sequels. Conclusion: Vertebral hemangiomas in pediatric age are not common. This is the reason why when clinical and radiographical is suspected it is important to perform an adequate diagnosis and treatment. Once we have done the diagnosis management with propanolol as an optional treatment, in some cases at first line it has demonstrated to be a reliable method with low recurrence and in patients with neurologic and instability the use of propranolol improves column surgery having as a mechanism of vasoconstriction, suppressing angiogenesis with induction of endothelial cellular apopthosis resulting in the decrease of the hemangioma. Although it has only been one year of treatment we have seen satisfactory results with neurologic deficit improvement and resulting in minimal pain scale., Introduction: There’s a known connection between the back-pain and psychical problems. However, we suppose the direct causality between stress and lumboischialgia. Material and Methods: A prospective cohort study, from april 2014 untill august 2014. We’ve examined 39 Patients (19 W / 20 M), age-median 42 years. Patients with an acute back pain episode, without a relevant previous history, were given an modified HADS-D and FW7 charts, as well as the pain-score was evaluated. Results: Abnormal Scores for HADS-D were present in 51% of patients, for FW7 in 42%. About 50% of patients reported having an deep existential oder emotional problem. Combined together we found a relevant score deviation in 75% of patients, with an acute deep emotional or existential problem in 79% of the patients. Theese factors did not correlate with the pain-score. Conclusion: There’s a possible causality between stress and an acute back-pain. This should be considered in primary therapy concepts and indication criteria., Introduction: Spinal cord injury (SCI) leads to a profound reduction in bone mineral density (BMD) and disturbances of the skeletal trabecular microarchitecture. The pathogenesis of osteoporosis after SCI is complex and differs from other forms of this problem. The aim of this study is to review the most recent literature on prevention and evidence-based treatments of osteoporosis in SCI patients. Material and Methods: MEDLINE, EMBASE, PubMed and the Cochrane Library were used to identify papers from 1946 to June 17, 2015. The search strategy involved the following keywords: spinal cord injury, osteoporosis, and bone loss. Results: A total of 51 studies met inclusion criteria. Most of these studies were small and of poor or fair quality and only 15 randomized controlled trials (involving 356 patients) were found. There are low levels of evidences that Bisphosphonates (Clodronate, Etidronate, Alendronate, Zoledronic acid) in the first year after injury, Vitamin-D analogs and Alendronate plus calcium for one year and beyond are effective in the prevention or treatment of bone loss. Electrical stimulation was also useful after acute SCI. For other rehabilitation modalities after SCI data are insufficient. Conclusion: No recommendations can be made from our review, due to the variable interventions and timing and usually low levels of evidence from these studies. Therefore, more research is needed to increase the knowledge base regarding the various interventions to prevent or treat bone loss after SCI., Introduction: Chronic low back pain has many differential diagnosis.Osteitis Condensans Ilii usually asymptomatic but uncommonly may cause lower back pain. Although it may present as seronegative spondyloarthopathy, Osteitis condensans ilii is a bone sclerosis characterized by nonspecific inflammation, highly dense bone hardening phenomenon, particularly in the ilium by 2/3 of the bone and do not change the joint space. middle-aged woman, especially late in the pregnancy, childbirth, and other infections of pelvic cavity. it is hypothesized that ligamentous laxity at the sacroiliac joints leads to instability and subsequent sclerosis. Aim: To prove not all Sacroiliac pain are Sacroilitis but some can be Osteitis Condensans Ilii. Methods and Materials: It is a Case series of 21 patients who had axial back pain with sacroiliac pain (13 males and 8 females) between a duration of 1 year from June 2015 to July 2016 of the age group 22 to 40 years. Multi centeric study done at various hospitals in Chennai. All patients with chronic low back pain were evaluated by taking history, clinical examination. Initially all the patients underwent X ray of the LS spine. Suspected cases of different pathologies underwent further radiological evalaution and eventually all the patients were taken MRI and CT screening. European Spondyloarthropathy Study Group Criteria for the classification of spondyloarthropathies and 2010 ACR/EULAR RA Classification Criteria was used to rule out Spondyloarthropathy and Rheumatoid arthritis respectively. Blood investigations were done. All patients were graded by Oswestry disability index score, Zurich claudication score and VAS. Results: Out of the 21 cases, 4 cases were diagnosed to have degenerative disc disease, 13 cases had intervertebral disc prolapse with grade 2 to 3 sacroilitis. 2 were diagnosed to have Aneursymal bone cyst. 2 cases were diagnosed to have osteitis condensans ilii. All the patients of Osteitis condenses Ilii were post partum and treated with physiotherapy, analgesics and one patient underwent steroid injections. All the patients improved symptomatically. Oswestry disability index score decreased from 96% to 9%. VAS decreased from 9 to 1 and Zurich claudication score significantly improved. Discussion: Not all cases with Sacroiliac pain are termed as Sacroilitis. Eyes should be wide open when a post partum patient comes with axial back pain and has significant SI joint tenderness. The disease presents at an early stage and it is often bilateral. Primary responsibility is to rule out other significant causes of low back pain. Physiotherapy and conservative management remains to be the safe and effective way of managing the patients. CT screening and MRI is the investigation of choice., Introduction: Osteoporotic vertebral compression fractures (VCF) are very frequent and cause significant morbidity in elderly patients. When pain and disability are high, cement augmentation represents a valid therapeutic option, that may prevent collapse and kyphosis and reduce vertebral pain. We present a case of VCF where vertebroplasty, even if correctly performed, was not sufficient to prevent kyphosis. Bad quality of bone led to significant vertebral deformity and to cement mobilization. The patient was treated with teriparatide, with fracture healing and clinical amelioration. Material and Methods: An 85 year-old woman presented after a minor fall at home with intense lumbar pain. Radiological examination revealed an L1 vertebral fracture (Genant grade 1) that was initially treated conservatively. Medical history was positive for severe osteoporosis (t score of -3.5), previously treated with bisphosphonates. After 1 month, lumbar pain was worse, and new CT scan revealed progression of vertebral collapse at L1. Decision was made to treat with vertebroplasty. She was then better for 1 month, but then pain reappeared, and physiotherapy was recommended. After 6 months, she was unable to walk because of pain, and new CT revealed collapse progression at the level of the fracture, with anterior mobilization of cement. Results: The case was discussed and multiple option were taken into consideration. Because of age and significant osteoporosis, direct surgical approach with reconstruction and posterior stabilization was considered too invasive and risky. Patient was then treated with teriparatide daily for 22 months. Pain improved significantly, and patient gained ability to walk after 1 month of treatment. CT scans at 6 months and 22 months revealed complete healing with bony fusion anterior to L1, surrounding previously positioned cement. No other invasive treatment was needed. Conclusion: Teriparatide could represent a viable option in old patients with VCF that progress after cement augmentation., Introduction: The assessment of patient-reported outcomes (PRO) in spine care provides useful information for quality improvement, effectiveness, and comparative effectiveness. The objective of this study was to evaluate the perceptions about PROs among Latin America (LA) spine surgeons and to evaluate the barriers to implement its routine. Materials and Methods: Internet-based survey to evaluate knowledge and perceptions on the use of PROs among members of AOSLA. The results of this survey supported the development of AOSLA Quality Assessment Registry. Results: A total of 731 participants from 22 countries answered the electronic questionnaire, a response rate of 52.02%. In general, more than 70% of participants agree that: PROs are useful to evaluate treatment outcomes, they help to monitor outcomes and burden of disease, they can benefit the patients, they facilitate physician-patient communication, and they are useful to compare the results of different centers. However, 36.8% of participants reported not using any PROs in their current activities. The main barriers to implementing PROs collection in routine practice were reported to be lack of time and structure (electronic database, assistants, etc) to perform this activity. However, when asked if they would use an electronic database to store and manage patient data, 87% of participants answered that they would use it routinely to monitor clinical outcomes of patients. Differences among countries were identified. The rationale of AOSLA Quality Assessment Registry is described in detail. Conclusions: This survey identified the barriers to the use of PROs and clinical registries in spine care in LA. Strategies for overcoming these barriers should be addressed in order to fully implement a large clinical registry of spine care in LA., Introduction: The nature of the Aneurysmal Bone Cyst (ABC) of the spine is still controversial among benign tumor, often identifiable in the “aggressive” form (Enneking stage 3) or pseudotumoral lesion. It is well known instead the very high risk of intraoperative bleeding, indicating a strongly unfavorable relationship between the surgical morbidity and the nature of the disease. Excellent results have been obtained in the treatment of ABC by repeated arterial embolizations (SAE), without any surgery, while some alternative treatments have been recently proposed and investigated for cases in which SAE is unsuitable or ineffective. This study presents the results of our initial experience in the treatment of vertebral ABC through the use of concentrated autologous mesenchymal stem cells (MSCs). Patients and Methods: Two teenagers aged 15 years, male, and 14 years, female, came to our attention both with diagnosis of ABC in C2 vertebra which was histologically confirmed. They were both neurologically intact, the girl complained of neck pain. The arteriography showed in both cases close relationships between the pathological ABC vascularization and the vertebral and cervical ascending arteries, making treatment by selective arterial embolization unsuitable. After discussion with the parents of patients, we jointly decided for an alternative treatment by direct injection of MSCs: 1) harvesting from the iliac crest of 60 cc of bone marrow (by needle aspiration); 2) separation of MSCs using the concentration system Res-Q™ 60 BMC; 3) injection of MSCs into the ABC area. In the second case the treatment was repeated three times at distance of 4 and 8 months. We recently treated other 3 patients, who have a follow up period of 5 months and 1 month. Results: Clinical and radiological follow-up of 27 months from the first treatment in both cases. In the first case the presence of newly formed bone within the ABC appeared as a clear sign of recovery just a month after the first treatment and increased gradually, until the cyst appeared completely ossified one year after the treatment, with associated disappearance of the pain. In the second case an initial sclerotic peripheral margin appeared after the second treatment and later ossification progressed after the third treatment, concurrently with the disappearance of the pain. Conclusion: Treatment with repeated SAE is considered effective in the treatment of ABC even if not without risks, mainly related to the frequent and repeated exposure to ionizing radiation. Furthermore, in a certain percentage of cases the procedure is not technically executable, especially for the presence of arteries afferent to the medullar vascularization. Inconsistent results were obtained with other procedures: the injection of calcitonin, steroid, alcoholic solutions, or the use of sclerosing substances. Radiation therapy it is not considered the first choice. Recently, promising results have been achieved by the injection of mononuclear cells derived from bone marrow in the treatment of Aneurysmal Bone Cyst. Based on the early results obtained in the two cases described, the injection of MSCs can be considered a valid alternative in the treatment of vertebral ABCs untreatable by embolization., Introduction: The incidence of degenerative spinal diseases that need a lumbar interbody fusion surgery has increased with an increase in the elderly population. However, after the lumbar interbody fusion surgery, patients commonly have severe pain, requiring adequate bed rest for a long time. Moreover, associated complications can occur, and the chances of early rehabilitation can be inevitably delayed. We performed a 1-day minimally invasive spine (MIS) lumbar interbody fusion that required no hemovac insertion and no skin suture and led to early ambulation. Here, we report the surgical procedure and results. Materials and Methods: This study was designed as a retrospective review of clinical and surgical parameters. From January 2013 to August 2014, 49 patients who received the MIS trnasforaminal lumbar interbody fusion (TLIF) for 1-day MIS lumbar interbody fusion surgery were included in this study. All patients received MIS TLIF with the MIS retractor system (Tubular/Caspar/Taylor) by using the MISS decompression technique (unilateral decompression/bilateral decompression/unilateral approach bilateral decompression). Two cases were of foraminal stenosis, 1 of recurred HNP, 13 of spinal stenosis, and 33 of spondylolisthesis. The surgical procedures performed were as follows: 1) epidural catheter insertion for anesthesia and postoperative pain control; 2) midline subdermal dissection procedure; 3) MIS TLIF (unilateral/bilateral); 4) bleeding control procedure: a. meticulous bleeding control, b. fibrinogen/thrombin-based collagen fleece bleeding control, c. fluid-type anti-adhesive agent (osmotic pressure compression effect for bleeding control), d. Gelform covering: barrier for hematoma from outside to inside of the spinal canal; 5) percutaneous transpedicular screwing under the subdermal dissection plane; 6) tight subdermal plan suture (conjoined suture of split fascia and subdermal skin); 7) skin sealing procedures: secure skin closure system and zip surgical skin closure system. Postoperatively, wound dressing was not needed. The wounds were only checked every 3-4 days. Epidural catheter was removed on the second day after the operation. Intravenous antibiotics were injected for 3 days after the operation.We checked the surgery-related results using the intraoperative, postoperative conditions and postoperative complications and clinical results by using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) in the immediate postoperatively (1∼2 day), 1 month, 3 month, 6 month and in the 12th month. Results: The mean age was 65.27 ± 9.57 years, and the sex ratio was (male/female) 20/29. The average follow-up period was 26.04 ± 7.25 months. Regarding the operation segment, 33 patients underwent 1 segment operation; 13, 2 segment; and 3, 3 segment (average: 1.39 ± 0.61 segment). Average intraoperative bleeding was 178.47 ± 73.70 cc (per level: 128.60 cc). The average operation time was 109.49 ± 32.71 min (per level: 78.90 min). An average midline skin incision was 3.90 ± 1.18 cm (per level: 2.80 cm). The possible ambulation time was 0.94 ± 0.88 day. The discharge time after antibiotic injection for 3 days was 4.88 ± 1.51 days. In the corresponding order of preoperative and immediate postoperative, 3-month, 6-month, and final follow-up, the VAS (back) were as follows: 6.33 ± 0.94, 3.14 ± 1.12, 2.47 ± 0.58, 2.29 ± 0.65, and 2.31 ± 0.77; VAS (leg): 7.37 ± 0.70, 2.69 ± 0.85, 2.29 ± 0.46, 2.14 ± 0.58, and 2.24 ± 0.80; and ODI: 39.37 ± 3.05, 29.29 ± 5.78, 22.59 ± 2.99, 20.27 ± 2.59, and 18.63 ± 3.13. Postoperative VAS (back), VAS (leg) and ODI improved significantly immediate postoperatively ((P < .0001). Postoperative complications were two cases of transient motor weakness (all cases recovered sufficiently after the follow-up period), four of wound suture due to avulsion of operation field (all cases healed completely after the follow-up period), no cases of revision due to hematoma, one of dural tear, and two of cage subsidence or implant failure. Conclusion: The results indicated excellent clinical results of the 1-day minimally invasive lumbar interbody fusion surgery, without any serious complications. With the development of an infection control system for the lumbar interbody fusion surgery, a real comfortable 1-day lumbar interbody fusion surgery will be possible., Introduction: Pedicle screws fixation to stabilize lumbar spinal fusion has become the gold standard for posterior stabilization. However their positioning remain difficult due to variation in anatomical shape, dimensions and orientation, which can determine the inefficacy of treatment or severe damages to close neurologic structures. Image guided navigation allows to drastically decrease errors in screw placement but it is used only by few surgeons due to its cost and troubles related to its using, like the need of a localizer in the surgical scenario and the need of a registration procedure. An alternative image guided approach, less expensive and less complex, is the using of patient specific templates similar to the ones used for dental implants or knee prosthesis. Materials and Methods: Like proposed by other authors we decided to design the templates using CT scans. Template developing is done, for each vertebra, using a modified version of ITK-SNAP 1.5 segmentation software. At first we segment the spine bone and then the surgeon chose screw axes using the same software. We design each template with two hollow cylinders aligned with the axes, to guide the insertion in the pedicle, adding contact points that fit on the vertebra, to obtain a template right positioning. The templates were manufactured in ABS using a 3D printer. After same in-vitro tests, using a synthetic spine, we studied a solution to guarantee template stability with simple positioning and minimizing intervention invasiveness. Preliminary ex-vivo animal testing on porcine specimens has been conducted to evaluate template performance in presence of soft-tissue in place, simulating dissection and vertebra exposure. For verification, the surgeon examined post-operative CT-scans to evaluate K-wires positioning. After the ex-vivo test we started with a small clinical human trial which it is still in progress at the time of writing this abstract. Results: During the ex-vivo animal test sessions, template alignment resulted easy thanks to the spinous process contact point. Their insertion required no additional tissue removal respect to the traditional approach. The positioning of contact points on vertebra’s lamina and articular processes required just to shift the soft tissue under the cylinders bases. The surgeon in some cases evaluated false stable template positions since not each of the 4 contact points were actually in contact with the bone surface and tried the right position. CT evaluation demonstrate a positive results in 96.5% of the K-wires implanted. Conclusions: Our approach allows to obtain patient specific templates that does not require the complete removal of soft tissue around vertebra. Guide positioning is facilitated thanks to the using of the spinous processes contact point, while false stable positions can be avoided using four redundant contact points. The templates can be used to guide the drill, the insertion of Kirschner in case oth use of cannulated screws or to guide directly the screw. After these prelimiary ex-vivo animal tests we obtained the authorization of the Italian Health Ministry to start the human study. The preliminary results of this study will be presented during the conference., Introduction: Surgical management of the cervical kyphosis is rarely described in the literature. Herein we will describe our surgical strategy in correction of the cervical kyphotic deformity in 22 cases which were caused by a various etiologies. Other aims are to report the possibility of complications and to demonstrate our technique of multilevel cervical osteotomy which is necessary for optimal lordotic neck. Osteotomy also might be helpful in prevention of segmental roots complications. Material and Methods: 22 patients including 12male and 10 females are presented. with consideration of surgical management, combined 360 degree anterior posterior or 540 degree surgery were done in 20. In 6 cases posterior cervical osteotomy was done. Results: 22 patients including 12male and 10 females are presented. with consideration of surgical management, combined 360 degree anterior posterior or 540 degree surgery were done in 20. In 6 cases posterior cervical osteotomy was done. Conclusion: Management of the cervical spine kyphosis in particular severe ones pose a challenge to the surgeon. This means that precise preoperative decision making is necessary for correction of this deformity. Segmental root injuries which are due to severe foraminal stenosis and traction of the subaxial cervical roots remain the most frequent postoperative complication of excessive correction of the cervical kyphosis. However, multilevel cervical osteotomy described above might prevent this kind of complication. Furthermore, although, one stage surgery was done in majority of the cases and severe neurological deficit which was observed in only one case, result in that we believe two stage surgery might permit the spinal cord and the corresponding roots to accommodate with new curvature with time., Introduction: ALIF procedures through an anterior, retroperitoneal approach are a common and safe way in degenerative spine surgery for reconstructing the anterior column. Nevertheless, the approach itself, the cage design and the instruments for implantation make the procedure sometime risky with extended radiation exposure and longer surgery time with the risk of higher blood loss. We conducted a study to evaluate a novel titanium cage for anterior lumbar surgery with improved instruments for implantation. Material and Methods: The study included 182 patients in the last 19 months (Jan 2015 to July 2016) who underwent 360 degree spinal single- and two-level fusion because of lumbar spinal stenosis or spondylolisthesis. We evaluated surgery duration of the posterior and anterior approaches. Blood loss and X-Ray exposure time was assessed. Patient data was compared between single- and two-level procedures and between one-time and two-time surgeries. Results: Due to the improved design of the cage and its instruments, Surgery duration could be optimized to a mean of 42 minutes in single-level ALIF procedures. Blood loss was diminished down to 46 ml and radiation time was decreased to a minimum amount of time. Conclusion: The cage design and its corresponding instruments can optimize the surgical procedure in degenerative lumbal spinal fusion when performing ALIF procedures. The cage design and the instruments used have great impact on surgical time, blood loss and even on radiation exposure., Introduction: The purpose of this study was to assess prospectively the operative results and complications of treatment of cervical spinal canal stenosis (CCS) by anterior cervical discectomy and fusion (ACDF) using a newly-introduced Modular Cage-Plate Construct (AMCPC). Material and Methods: Fifteen patients (eight males and seven females) with symptomatic CCS were treated by ACDF, with a mean age of 51.2 years. Four patients had cervical myelopathy and eleven had radiculopathy. The fixation technique was AMCPC with fusion by local autogenous bone graft. Total number of operated levels was 25 levels, with a mean 1.67 levels/patient. Postoperative assessment depended upon clinical and radiological results. Results: Mean operative time was 69.6 minutes/level and 116 minutes/patient. Average blood loss was 78 mL/level and 130 mL/patient. Mean hospital stay was 2.8 days. Postoperative dysphagia/dysphonia persisted in one patient for one year. All wounds healed per premium. One patient developed C5-radiculopathy with grade-2 deltoid weakness that recovered after three months. According to Odom’s criteria, overall results were excellent in thirteen patients (86.67%), good in one (6.67%) and fair in one patient. In thirteen patients (23 cage-plates, 92%) the implant was shown to be completely contained until the end of follow-up (24 months). One patient had a broken screw and one had screw backing-out, both did not necessitate revision. The achieved sagittal profile was maintained without sinking-in of any cage. Conclusion: AMCPC can be used safely for a variety of disorders requiring instrumentation and fusion. It is advantageous to stand-alone cage and to rigid cage- plates when intra-operative flexibility is needed. It overcomes the disadvantages of stand-alone cage; sinking-in, cage-dislodgement and postoperative rekyphosis. In addition, it obviates the need for wearing postoperative neck collar., Introduction: Lumbar fusion in degenerative conditions has universally provided good results. However, adjacent segment degeneration, either a fresh or worsening of low grade degeneration in the segment above has been indicated for the pain and low functional outcome on long term follow-ups. Pedicle screw based dynamic stabilization devices optimize load sharing and ensure transitional stabilization. We analyze the use of Transition (Globus medical) to decelerate the physiologic process and reduce the incidence of Adjacent Segment Degeneration (ASD). Materials and Methods: 12 patients (5 female, 7 male; mean age: 53 years, range: 34 – 67 years) who underwent posterior lumbar instrumentation with the transition as semi-rigid, hybrid dynamic stabilization and fusion system were analyzed in the study. The inclusion criteria for the study was degeneration of the disc above the level of intended fusion with no or less than 50% disc height reduction and no nerve root compression. Patients with more than 50% height reduction or severe arthritic facet joints underwent fusion at two levels and were excluded from the study. Patients with failed back syndrome and significant osteoporosis were also excluded from the study. Clinical and radiographic criteria for ASD were assessed at the latest follow-up. Visual analogue score (VAS) and Oswestry Disability Index (ODI) functional outcomes were analyzed. Results: 12 patients, mean age 53 years, mean follow-up of 36 months (12-72months). Transition was used above single level TLIF in 10 cases and two levels TLIF in 2 cases. Transition device was implanted at L3-4 in 8 cases and L4-5 in 4 cases. All 12 patients had a good fusion on follow-up x-rays. Disc height improvement was seen in the level above, with no evidence of stenosis or listhesis at the latest follow-up. Worsening of already existent ASD in one patient was noticed but did not require surgical intervention. VAS and ODI showed significant (P < .05) improvement postoperatively. No infection or reoperation was needed in any of the patients. Conclusions: ASD remains a significant reason causing failed back syndrome requiring reoperations in lumbar fusion. Transition allows a more robust fixation with better restoration of lordosis. Implantation of a motion preserving dynamic stabilization device immediately adjacent to a fused level instead of extending a rigid construct may reduce the subsequent development of adjacent-segment disease. Further studies with larger sample size and long term follow-up are necessary to support the conclusion., Introduction: Total body replacement systems are widespread and mainly made from titanium. Initially established as fixed titanium mesh-cages nowadays often designed as expandable anterior body replacements. Recently cages fully made from PEEK or carbon became more and more popular especially for anterior column reconstruction in tumor surgery. They are mostly crafted as monobody cages without expandable options. This study was set up to evaluate the applicability, efficacy and safety of a new expandable PEEK cage as vertebral body replacement. Material and Methods: 52 consecutively implanted PEEK-XRL-Vertebral-Body-Replacement Devices (Depuy/Synthes) for anterior column reconstruction in thoracolumbar trauma and tumor cases were retrospectively analyzed. The modular implant consists of a central body which can be filled with bone graft on which two endplates are attached. All parts can be customized (sizes and angulation of body and endplates) to the individual intraoperative situation. Clinical and radiological follow up were performed 2, 6 and 12 months post operatively. After 12 months a CT scan was performed in most cases to evaluate osseous consolidation. Standing- x-rays were performed at every follow-up. Bi-segmental kyphosis angle and cage height were measured. Descriptive analyses have been executed. Results: Since 2013 52 XRL-Cages have been implanted (31 male/21 females, mean age 45.9 years); 42 cases due to trauma (15 paraplegic), ten cages due to spinal metastatic diseases. 16 procedures have been performed as single, 36 in a two stages procedure; one mono-segmental, 38 bi-segmental and three three-segmental ventral fusions. All cages in trauma cases were filled with autologous bone. There were no intraoperative and 4 perioperative complications: two hematomas and one wound breakdown needed revision surgery, in one patient transient hyposensitivity at the thigh occurred. One patient died ten days post-operatively due to his underlying tumor disease. 39 patients could be followed up for a mean of 0.7 (min 0.1; max 2.5) years. The radiologic analysis showed two cases of implant malpositioning and four cases of early subsidence which were all secondary stable. In one patient a posterior implant failure with breakage of a pedicle screw, secondary cranial and caudal subsidence of the cage and incomplete osseous consolidation was found two years post-operatively. No revision surgery was required in all cases. No collapse or malfunction of the modular expansion system was documented. A mean loss of two degrees bi-segmental lordotic correction angle was documented from early (mean 0.05 years) to latest post-operative imaging (mean 0.7 years). 23 patients received a CT-scan at mean 0.9 years post-operatively. 18 showed continuous, 5 showed incomplete osseous consolidation with stable implants. Conclusion: The modular, expandable XRL-PEEK-Cage showed promising preliminary clinical and radiological results in 39 cases with a mean follow up of 0.7 years. No implant related complication or collapse of the cage itself could be seen. Therefore, the implant seems to be save for anterior vertebral body reconstruction in trauma and tumor patients. Further extensive long term data need to be evaluated., Introduction: Lumbosacral fusions (LSF) are frequent operations. Due to highly mobile segments L4-S1, meeting a rigide sacro-pelvic complex, LSF’s underly special biomechanical challenges. Revision rates up to 20% are reported. Increased risk of construct loosening and pseudarthrosis has lead to increased numbers of extended lumbosacral (S1-pedicle screw / S2-ala-screw) and lumbopelvic instrumentations. Lumbopelvic instrumentations have potential for complications and are in instabile situations not always mandatory. Significant enhancement using a S1 pedicle ala screw (S1-PAS) was demonstrated in biomechanical studies. In the present work we demonstrate the first clinical experiences using the new S1-PAS. Material and Methods: 35 patients with indication to augment lumbosacral instrumentation (spondylolisthesis, osteoporosis, lumbosacral revisions and pseudarthrosis, lumbosacral scoliosis) were treated during a period of 12 months, using a polyaxial screw-rod system and the S1-PAS. The S1-PAS is a dual, fixed-angle lockable pedicle-screw-system. The ala screw may be divergently placed next to the S1-screw or with a starting position medial to the S1-screw also divergently (crossing position). The min. follow-up was 6 weeks, for fusion assesment 6 months were necessary. The technical data and intraoperative handling criteria were recorded prospectively. Clinical, surgical and demographic data were retrospektiv analyzed, as well as significant complications or adverse events. Results: 35 patients were treated in a 1 year span. No intraoperative complications or implant associated „adverse events”. Mea nage 54 years, (19 m, 16f). S1 - screw - calibre 7.0 mm, S1-ala-screw 6.0 mm. Bicortical purchase was planned. IN average 2,9 segments were treated.(range 1-9segments). 1 pat. With unilat.fixation of S2-AI screw. Pedicle screw length in S1 45 mm in average.(min. 35 mm, max. 50 mm), Ala-screw 41 mm in average(min. 30, max. 50). Revisions were needed in 3 patients. 2 times in psuedarthrosis of the prox. Endsegment., once L5/S1 in a case of multisegmental fusion ≥5. 5 pat. Were lost to follow-up>3months. Fusion rate was 90%. 17 pat. with use of crossing position. No clinical or radiological irritation oft he SI joint by the ala-screw postoperatively. Conclusion: The use of the S1-PAS allows for a biomech., augmented lumbosacral fusion avoiding sacro-iliac fixation. The S1-PAS allows for less soft tissue mobilisation compared to instrumentation with S1-PS and S2-Ala-screw, better anchorage as well as faster screw placement. S1-PAS could be placed safely in every patient independent of local anatomy or deformity. The clinical results complement earlier biomechanical data and demonstrate that the S1-PAS is a reasonable extension for instrumentation options in LSF with special biomech. demands. Multisegmental fusions, especially in pat. with sagittal imbalance, are the mechanical limits for a reasonable use oft he S1-PAS. Ideal indications for LSF are patients with spondylolisthesis, lumbosacral pseudarthrosis with short instrumentation., Introduction: Biomaterials are widely used in prosthetic and drug delivery devices. Nanomembranes produced by electrospinning technique mimic the nanoscale properties of the native extracellular matrix and provide highly porous and interconnecting fibers with a high surface area-to-volume ratio. Polyamide-6 (PA6) is a synthetic and biocompatible polymeric material that has good mechanical and physical features. The maleinized soybean oil (SOMA) is a source of essential fatty acids and tocopherols, related to antioxidant and anti-inflammatory properties. The incorporation of SOMA to PA6 chains imparts toughness to the polymer, which is important to support handling and cellular morphogenesis. This study focused on preparation and characterization of polyamide-6 melt that reacted with SOMA to create a biofunctional and bioactive scaffold for disc pathology therapy. Methods: The nanomembranes were produced from solutions of commercial PA6 and PA6/SOMA 95/5 in 85% v/v formic acid. The systems were electrospun at a feeding rate of 0.1 ml/h, using a syringe-collector distance of 15 cm and an applied voltage of about 25 kV. The morphological and microstructural properties of the obtained nanomembranes were investigated by field-emission scanning electron microscope (FEG-SEM) and wide-angle X-ray diffraction (WAXD), respectively. The electrospun nanofibers were also tested for their ability to incorporate growth factors. Results: FEG- SEM micrographs revealed that defect-free nanofibers with uniform morphology could be obtained from 32% wt polymer solutions. Commercial PA6 and PA6/SOMA 95/5 nanofibers exhibited average diameters of 0.78 ± 0.22 μm and 141 ± 6 nm, respectively. The high surface area combined with microporous structure of nanofibers favors metabolic exchange and other biofunctional properties. The crystalline structures (α and γ forms) of PA6/SOMA 95/5 and their transitions in electrospun nanofibers are being thoroughly investigated. The samples were resistant to the sterilization process (120 mmHg/45 min) and free from organic solvent residue. The nanomembranes successfully loaded and preserved the chosen bioactive growth factor, thus being able to act additionally as a drug delivery device for clinical applications. Conclusion: Many significant recent advances in biomaterials occurred at the interface of clinical medicine and materials science and engineering. The nanofibrillar materials developed in this work may represent a promising tool in regenerative medicine, including disc pathology. Since PA6 is an FDA-approved polymer, these nanomaterials emerge as suitable bioactive scaffolds for medical applications. Further investigation is required to evaluate the efficacy of the repair using these electrospun filaments and to determine the real benefit to patient., Introduction: The aim of this study was to predict the prognosis of osteoporotic vertebral body fractures by using the finite element method. Some osteoporotic vertebral body fractures are crushed after a few weeks, others keep these forms. In this study, by using the finite element method, we evaluated the breaking forth (N) of the fractured osteoporotic vertebras at the initial CT scans and determined the critical point of the breaking forth (N) which would predict crushed vertebras. Material and Methods: We conducted a retrospective study of the fresh osteoporotic vertebral fractures at our institution. We evaluated the clinical features, radiological changes, and biomechanical effects in patients who had fresh osteoporotic vertebral body fractures. A three-dimensional finite element method was used to biomechanically analyze the strength of the osteoporotic vertebral fractures. Results: Between Apr. 2015 and Sep.2016, 196 (male 55, female 141) fresh osteoporotic vertebral fractured patients took a check-up at our outpatient department. The average age was 78.9±0.6 years old (54-99 years old). The average bone mineral density was 53.3 ± 0.5 (YAM). 24% of all the patients showed crushed vertebras after a few weeks. 130 patients were underwent CT scan during an early stage. However, only 37 patients were able to be evaluated the breaking forth (N) by finite element method. 21 of these 37 patients’ vertebras resulted in crush vertebra after a few weeks. The finite element method revealed he critical point of .the breaking forth (N) which predict crushed vertebras. Conclusion: These results demonstrate that the usefulness of finite element method to the prognosis of osteoporotic vertebral body fractures. The finite element method analysis may detect the surgical indication of osteoporotic vertebral fractures by predicting crushed vertebras., Introduction: Simulators have become a standard in medicine when it comes to training and assessment of medical skills. Especially in surgery, simulators are increasingly available for a wide spectrum of procedures to increase patient safety and to offer enhanced training opportunities (Michael, Abboudi, Ker, Khan, Dasgupta and Ahmed, 2014). Increasingly, surgical simulation systems feature virtual-, mixed- or augmented-reality (VR/MR/AR) as their core technology. Such simulators offer realistic setups and a real time metric-based performance feedback for surgical trainees.Although spine care procedures have undergone major technological and procedural advancements, the current evidence base concerning the application and effectiveness of VR/MR/AR-based simulators is inconsistent. Moreover, only 11% of neurosurgery residency program directors reported to use spine simulators as an educational tool in a recent survey (Kshettry, Mullin, Schlenk, Recinos and Benzel, 2014). We therefore set out a systematic review to identify the current state of VR/MR/AR simulator applications for training and assessment in spine care procedures. Moreover, we sought to review the evidence base on VR/MR/AR based simulator use with particular comparison to traditional training approaches in spine care. Materials and Methods: We conducted a systematic review searching five literature databases (“PubMed”, “PsycINFO”,” “EMBASE”, “CENTRAL” and “MetaRegister of Current Controlled Trials”) for peer-reviewed literature between 2005 and 2016 about VR/MR/AR Simulators used for spine care. Two researchers reviewed titles, abstracts and full texts according to our inclusion and exclusion criteria. Reliability was checked in terms of inter-rater agreement. Discordances were discussed and solved with a third reviewer. Additionally a quality appraisal of the included articles was conducted using the Medical Education Research Study Quality Instrument Tool (MERSQI). Results: Initially, after title and abstract screening, 63 articles underwent full-text review. Finally, 19 relevant articles matched eligibility criteria and all contents and data were systematically synthesized. The majority of reports on VR based simulators in spine care aimed to establish a training curriculum and to evaluate the simulator. The most simulated medical procedure (7 times) was Pedicle Screw Placement/Insertion followed by (Percutaneous) Vertebroplasty (4 times).The most used outcomes were performance related with particular interest to technical skills, eg, precision metrics. Results of the identified articles were very heterogeneous: 8 articles showed that the simulator trained group(s) outperformed the non-simulator trained group and 8 articles showed the effectiveness of training on a simulator by using before and after training comparisons. 6 articles focused on validity of the simulator. MERSQI ratings (highest possible score = 18) ranged from 7.0 to 13.5 with a mean of 11.47 (Standard deviation = 1.81). Conclusion: This Systematic Review was the first to summarize the current literature base on the use of VR/MR/AR-based simulators in spine care. Because the results of the studies were too heterogeneous a meta-analysis was not possible. Limitations are being discussed. As simulation is becoming increasingly important in spine care, our review finally suggests future areas of research and development for VR based simulators in spine care., Introduction: Spine surgery for spine tumors and complex reconstruction can predispose to extensive intraoperative bleeding. Extensive bleeding requires intraoperative transfusion of not just packed-red-blood-cells (PRBCs) for hemoglobin replacement, but also platelets and coagulation factors imperative for clot formation. Decisions about how much platelet transfusion or coagulation factor replacement needs to occur can be delayed by standard laboratory tests. Thromboelastography (TEG) provides information about platelet function, clot strength, and fibrinolysis which PT/INR/aPTT do not provide. In addition, testing can be performed as rapid point-of- care assays intraoperatively for fast decision-making and correction of coagulopathy with further transfusions if necessary. Materials and Methods: Two patients underwent complex long segment spinal procedures, with greater than 2000 cc estimated blood loss (EBL). A 73 year-old with a previously metastatic myoepithelial carcinoma to T8 underwent radiation and decompression and T6-T10 instrumented fusion. He subsequently presented with local tumor recurrence, and was found to have extension of the tumor into the adjacent levels, tumor in the surround soft tissues, with hardware failure and kyphotic deformity. He was intact on exam, and underwent surgery with tumor resection and replacement and extension of hardware given. A vascular tumor was encountered and the patient experienced greater than 2500 cc of EBL. The second patient was a 64 year-old man with a previous discitis/osteomyelitis who presented with complex deformity and kyphosis and underwent a two level thoracolumbar corpectomy and a nine level instrumented fusion, with greater than 2500 cc of EBL. They both underwent intraoperative transfusion with packed red blood cells (PRBCs), platelets, and fresh frozen plasma (FFP). Subsequently, a rapid TEG test was performed intraoperatively to determine need for further transfusion. Results: The patient sunderwent intraoperative transfusion with PRBCs, platelets, and FFP. To determine if continued coagulopathy was present and to decide if further transfusion was necessary, a rapid intraoperative TEG test was performed, which showed good clot integrity and formation, directing expectant need for further platelet/FFP transfusion. Conclusions: Rapid thromboelastography testing provides information that can assist in determining whether a continued coagulopathy is present. Results can guide operative actions, such as administration of further blood products for coagulopathy., Introduction: The internet is the tool usually employed for regular health research) research by patients. However, online available texts remain unregulated and lack proper evaluation of information. The poor quality of the texts on spinal disorders available in Portuguese impairs the medical-patient relationship. The objective is to verify the quality and the validity of internet information in spinal pathologies, in Portuguese. As a proposal, hybrid software for automatic text analysis, based on Artificial Intelligence techniques, is under development. Materials and Methods: Research was performed on most frequently used search engines – Google, Yahoo and Bing – using the terms “cirurgia de coluna” (spinal surgery), “tumor de coluna” (spine tumor), and “hérnia de disco” (disc herniation), and the first 30 results of each research mechanism were evaluated. Duplicated or nonfunctional pages, videos, home-pages without a main text, photos, Google Maps pages, social media, news, shopping sites and game sites were excluded. The DISCERN Instrument was used to evaluate the quality of information provided by one reviewer. The questions are divided into 3 sections and scored on a 5-point Likert scale. Thus the maximum score was 80 and the minimum score was 15 (if question 2 did not apply after a negative answer to question 1). The results were displayed as median (for the DISCERN score), relative and absolute frequencies. Jama Benchmark Criteria was used to evaluate the validity of the text, also by one reviewer. Results: Sixty-eight websites were analyzed. The overall rating score given for question 16 of the DISCERN instrument was not always faithfully represented by the summative score for all items. However, by using the DISCERN Instrument, no text achieved a score of more than 61 out of 80 (76.25%). Besides the median score was 39.5 out of 80, representing the poor quality of most Portuguese web sites. Through Jama Benchmark Criteria it was observed that none of the articles had the 4 points and that most of them lacked the references and conflict of interest disclosure. Conclusion: The websites regarding spinal diseases in Portuguese have poor quality data, resulting in erroneous information to the patients and compromising the treatment or the patient choice. Also, important features to consider the text reliable are lacking, such as exposing conflicts of interest and references. Regarding future perspectives, it is expected to meet this through the development of a software that employs quantitative and qualitative techniques to assess patients who use the Internet as a source of information., Introduction: Graft technique in anterior cervical discectomy and fusion surgery has evolved over the period of time. Donor site morbidity of autologous bone graft harvested from the iliac crest and poor or lack of osteogenic and osteoinductive property with high cost of allograft and other synthetic bone substitute techniques are well documented. Traditional techniques have complications such as graft subsidence, implant loosening, dysphasia and prolonged hospital stay. Cervical low profile integrated screws-spacer device with bone marrow aspirate and local bone debris as a graft offer a minimally invasive, less disruptive, cost effective and earlier recovery option. Materials & Methods: We analysed prospectively collected data of 48 patients with cervical myelopathy and/or radiculopathy. Coalition is a low profile integrated screws-spacer device designed to provide the biomechanical strength of a traditional anterior cervical discectomy and fusion. The procedure is streamlined by low profile instrumentation which facilitates a less invasive approach through a smaller incision. Bone marrow aspirate from sternum mixed with gelfoam and local bone debris taken out while doing decompression were used as graft. 33 patients were operated with one level, 12 with two level & 3 with three level anterior cervical discectomy and fusion. All patients were followed up for a minimum period of one year. X-ray and CT scan were done in all the patients after 1 year to see the fusion. Patients were evaluated for fusion, implant failure, neck disability index, visual analogue score for arm & neck, mJOA score, and dysphasia index. Results: 44 patients were evaluated as 4 patients were lost in follow up. Mean age of 46 years, 28 male & 16 females. X-rays and CT demonstrated good fusion 91 and 94% respectively. Compared to preoperative scores, visual analogue scale pain score and Neck Pain Disability Index reduced significantly (P < .01). Statistically significant improvement in mJOA score was observed (P < .05). Two patients complained of moderate and one of mild transient dysphasia. No device-related complications occurred and no fractures. Conclusions: Bone marrow aspirate with local bone debris as a graft provide a less morbid alternative to conventional techniques and achieve good fusion. Usage along with low profile cervical implants allows effective decompression, fusion and early recovery., Introduction: Anterior cervical discectomy and fusion (ACDF) was first introduced in the 1950s, and has become one of the most common surgical procedures for cervical radiculopathy and myelopathy recalcitrant to conservative management. The procedure involves structural graft placement in the interbody space. A number of structural graft options have become available. Two of the most common graft options used are allograft and synthetic cages. This study aims to compare the complication rates between these two structural graft options. Material and Methods: Orthopaedic subset within the PearlDiver database was queried for patients undergoing ACDF using structural allograft or synthetic cage between 2007 and 2014 using ICD-9 and CPT codes. The initial cohort was stratified by type of grafting material, number of fused levels, and presence of corpectomy. Data outputs included number of ACDF procedures per year, patient age at the time of surgery, patient gender, geographical regions within the United States, surgical setting and total procedural costs. Complications were detected via ICD-9 coding. For statistical analysis, the chi-squared test was used to calculate statistical significance of the difference in complication rates. Results: A total of 11,308 ACDF procedures in the dataset used a synthetic cage, and 7,835 procedures used structural allograft. Overall complication rates were 8.71% for synthetic cage versus 7.76% for structural allograft, P < .01. Dysphagia was more commonly noted in the structural allograft cohort, 0.64% versus 0.33% (P < .01). Respiratory complications occurred more frequently with cages, 0.57% versus 0.31% (P = .03). Both cohorts had a similar revision rate within 2 years (0.56% versus 0.50%, P = .23). Conclusion: A total of 11,308 ACDF procedures in the dataset used a synthetic cage, and 7,835 procedures used structural allograft. Overall complication rates were 8.71% for synthetic cage versus 7.76% for structural allograft, P < .01. Dysphagia was more commonly noted in the structural allograft cohort, 0.64% versus 0.33% (P < .01). Respiratory complications occurred more frequently with cages, 0.57% versus 0.31% (P = .03). Both cohorts had a similar revision rate within 2 years (0.56% versus 0.50%, P = .23)., Introduction: Current treatment of VCF type A1.1 and sometimes A1.2 in young patients can apply two approaches: conservative and invasive treatment with brace or arthrodesis with PSF, both with high social costs and decreasing of patients quality of life. At the same time surgical options can be considered irreversible. Kyphoplasty and vertebroplasty allow percutaneous approach to treat this type of fractures in elderly patients, but there are really poor indications of using PMMA in young people. Materials and Methods: Velox(a phase-pure, micro-crystalline, calcium-deficient and micro-porous hydroxyapatite) is the latest generation of biomaterial that improves and solves two primary issues: burning of bone tissue regeneration and immediate mechanical strength properties. Approaching this way, mechanical properties of Velox allow the primary goal of a good and definitive final result and patient’s immediate recovery. Treatment provides posterior mono or bilateral approach with needles and, or without balloons, as known. It is also possible to verify Velox injection step by step because of his radiopacity. Results: Five patients have been treated with Velox, three with A1.1 and two with A1.2 vertebral compression fracture. Mean age was fortytwo years. Recovery was performed in one day(twentyfour hours) and a three months follow-up CT scan showed an almost complete rehabitation of the biomaterial. Conclusions: This biomaterial(Velox), despite to a few preliminary procedures and a short term follow-up, could be a real effective solution in the treatment of VCF A1.1 and A1.2 type, filling critical size bone defects and solving problems like long period immobilization with brace and avoiding open surgery., Introduction: Spine surgeons are embracing advanced biologic technologies in an attempt to help millions of people achieve a better outcome in spine surgery and cell-based therapies seem to offer a promising approach. Due to their properties and characteristics human mesenchymal stem cells (MSCs) appear to have great therapeutic potential. Many different populations of MSCs have been described and to understand whether they have equivalent biological properties is a critical issue for their therapeutic application. Material and Methods: Human vertebral bone marrow was harvested from vertebral pedicles during spinal surgical procedures involving posterolateral arthrodesis. Vertebral bone marrow in toto and expanded human vertebral bone marrow cells, cultured under normoxic and hypoxic conditions, were analyzed to evaluate multidifferentiation potential, cellular proliferation and gene expression for markers of osteoblast differentiation and homeobox genes of HOX and TALE subfamilies. Results: Under hypoxic condition in toto human vertebral bone marrow can be maintained in culture for a greater number of steps with respect to concentrated vMSCs and it also generates mature cells of all mesenchymal lineages with greater efficiency, when induced into osteogenic, adipogenic and chondrogenic differentiation. In addition, analyses of homeobox genes of HOX and TALE subfamilies showed that in toto human vertebral bone marrow cultured under hypoxic condition displayed distinct and specific levels of expression for HOX and TALE signatures. Conclusion: The in vitro ability and capability of in toto human vertebral bone marrow cultured under hypoxic condition is very interesting at the light of a clinical application for bone fusion in spine surgery., Introduction: Reliable information about nutritional status before spine surgery is needed to optimize postoperative outcomes, especially regarding vitamin D and albumin serum levels. The aim of this study was to investigate the relationship between vitamin D and albumin serum levels in patients undergoing spine surgery and their quality of life after the procedure. Material and Methods: For this, patients undergoing spinal surgery in the thoracic and lumbar levels were evaluated. All surgeries were performed at a same referral hospital. One day before the surgery, the subjects had serum albumin and vitamin D concentrations evaluated. One year after surgery, we evaluated their quality of life through the Oswestry and SR-22 questionnaires (validated versions for the Brazilian language). The occurrence of infection and time of wound healing were also collected. Preoperative nutritional values and quality of life of patients were analyzed using the chi-square test. The relationship between nutritional status and the occurrence of infection and the healing time were evaluated by Pearson correlation coefficient. Results: 46 patients were included, 17 men (37%) and 29 women (63%). The most frequent disease was degenerative (58.7%), followed by deformity (19.6%), infection (8.7%), fracture (8.7%) and tumour (4.4%). The average nutritional values were 19,1ng/mL (standard deviation 6.6) for vitamin D and 3.9g/dL (standard deviation 0.6) for albumin. There was no association between vitamin D and quality of life of patients measured by Owestry (P = .77) and the SR-22 (P = .55) questionnaires. It was also not observed association between quality of life and albumin when measured by Owestry questionnaire (P = .35), but there was association when measured by SR-22 (P = .03). The average healing time was 18 days (standard deviation 14) and there was infection in 19% of surgeries performed. No correlation was found between these variables and nutritional values. Conclusion: In conclusion, there was no association between vitamin D and albumin and the quality of life of patients when measured by the Owestry questionnaire, as well as the healing time and the occurrence of infection. Moreover, preoperative albumin was associated with quality of life measured by the SR-22 questionnaire., Introduction: Low back pain is an increasing global health problem, which is associated with intervertebral disc (IVD) degeneration. The current treatment strategy is surgical intervention, like discectomy followed by spinal fusion. After discectomy the empty space is filled with bone substitute or an autograft and the symptomatic segment undergoes an intersomatic or posterior fusion with pedicle screw or plate based stabilisation. However, clinical observations showed that partial IVD tissue removal after discectomy leads to an insufficient subsequent spinal ossification. Recently it was shown, that human IVD cells co-cultured with human mesenchymal stem cells (MSC) prevented bone formation (1). Antagonists of the bone morphogenic proteins (BMP) such as gremlin (GREM1), noggin (NOG) and chordin (CHRD) were identified as possible factors inhibiting osteogenesis of osteoprogenitor cells (2,3). The endogenous expression of these antagonists within the IVD remains, however, unknown. Hence the aim of this study was the investigation of the secretion of BMP antagonists in IVD cells, as the nucleus pulposus cells (NPC) and the annulus fibrosus cells (AFC). Material and Methods: IVD cells (NPC and AFC) were isolated from patients undergoing spinal surgery with ethically approved protocol. NPC and AFC (P1) (N = 5) were encapsulated in 1.2% alginate beads (4 millions/ml) and cultured in proliferation medium (LG-DMEM + 10% FCS, six beads per 2 mL). After four days the conditioned medium was collected and analysed for secretion of BMP antagonists by ELISA, using human GREM1, NOG and CHRD detection kits (Clone Cloud-Clone corp., cat. # SEC128Hu, SEC130Mi and SEC126Hu). Further, CHRD, NOG and GREM1 were visualised in NPC and AFC by immunocytochemistry. Results: The secretion of BMP antagonists in the conditioned medium were detected with levels between 0.30 ± 0.17 ng/0.5 M IVD cells and 2.10 ± 0.52 ng/0.5 M IVD cells (expression presented as mean ± SD). Whereas GREM1 showed a significant difference between expression in NPC (2.11 ± 0.53) to AFC (0.86 ± 0.35) (P = .0022). Expression of NOG, GREM1 and CHRD in NPC and in AFC could also be confirmed on protein level by immunocytochemistry. CHRD was nuclear localised in the cells. Conclusion: Within the study we could confirm expression of the BMP antagonists within the IVD cells. This might be a main reason of incomplete spinal fusion and cage failure in patients after incomplete IVD removal. BMP antagonists like GREM1, NOG and CHRD could be detected in NPC and AFC on the transcript and protein levels. However, secretome analysis to confirm BMP antagonist secretion needs to be performed. Furthermore, it is still unknown, if the third IVD cell type, cartilaginous endplate cells (CEPC), also plays a role in spinal non-union. References 19. Chan SCW, Tekari A, Benneker LM, Heini PF and Gantenbein B (2015). Arthritis Res Ther 18, no. 1 20. Canalis E, Economides AN and Gazzerro E (2003). Endocr Rev 24, no. 2 21. Stafford DA, Brunet LJ, Khokha MK, Economides AN and Harland RM (2011). Development 138, no. 5 Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Lindenhof Foundation “Forschung und Lehre” (#15-05) and by direct funds from Hansjörg Wyss and Hansjörg Wyss Medical, US. We thank Eva Roth for laboratory assistance., Introduction: Osteoporosis is a systemic disease affecting postmenopausal women mostly resulting in an increased fracture risk. In women aged, Introduction: Tuberculosis is the leading cause of death in third world countries, from a single infectious disease. It paralyses the society when it affects the spine because of its resultant neurological deficit in the form of quadriplegia, paraplegia, loss of bladder and bowel control, bed sores, and continuous financial burden on family and whole society. Early spinal decompression and stabilization with standalone cage have dramatic results in terms of improvement in neurology, relief of pain, and correction of deformity. The objective of the study is to determine outcome of anterior decompression and stabilization with locally made standalone cage and bone graft in caries spine in terms of improvement of neurology, relief of pain, and improvement of kyphotic angle. Material and Methods: It is a prospective case series study including 1049 cases who were treated at GTTH from 2003 to 2016. After taking history, examination and investigations as well as proper consent, all patients were treated with anterior decompression and then stabilization was achieved with bone graft and standalone locally made cage. After surgery, patients were followed at 6 weeks, 3 months, 6 months, and upt0 august 2016 to assess neurology, relief of pain, and kyphotic angle.The data was initially entered on pre formed questionnaire and then analyzed on SPSS 17.0. Results: The majority of the patients belong from poor or middle class family and the male were dominant.Back pain was the chief complaint in almost half of the patients.The major cause of the delayed presentation was management of such patients in periphery .There was no association between the previous history of tuberculosis and caries spine.Neurology improved in 92% of patients, pain relieved in 95% of cases, and there was mean correction of 18 degrees in kyphotic angle at the end of 1-year follow-up and the patients who were followed for 3 years, there is no significant change in kyphotic angle after it. Conclusion: Early diagnosis and early intervention give excellent results. After anterior decompression, stabilization with cage and bone graft results in significant improvement of neurology, relief of pain, and correction of kyphotic deformity. There is no need for added instrumentation., Introduction: Demonstrate and identify bone fusion method which conforms to “traditional posterolateral” approach and shows superior fusion outcome. Material and Methods: Single surgeon Prospective application and use of Bone Marrow Aspiration (BMA) combined with use of allograft demineralized bone fibers with/without local harvest autograft in posterior/posterolateral spinal fusion with instrumentation in lumbar/lumbosacral, thoracic/thoracolumbar and cervical spinal fusion. Dates of Inclusion: March 2014-June 2016 Technique: Variable – posterior/posterolateral +/- combined with anterior or PLIF/TLIF, Total Cases/Analyzed: 119/78 (Exclusion for this analysis was use of BMP or TLIF/PLIF or DLIF without posterolateral fusion adjunct. Results: ∼2% Incomplete/Non fusion, no requirement/need of revision of fusion at this time, Long segment fusion show “halo effect” around instrumentation at “ends” of fusion – improves with time. Conclusion: ∼2% fusion failure with no revision, Halo effect around instrumentation not related to success of fusion, Fiber volume used is related to density of fusion mass, Autograft volume related to early greater density of fusion mass, “Woven Configuration” of fiber graft appears to be related to success of fusion, Fiber Graft: BMA::1.5:1 optimal ratio, no carrier, 100% viable cells, no less than 20 cc but preferable 30 cc allograft fiber per level of fusion, institutional saving of ∼15-20% compared to fusion with additional growth proteins, Noncontroversial., Introduction: The rates of pulmonary embolism (PE) and deep vein thrombosis (DVT) in paediatric scoliosis patients have been estimated at 0.04% and 0.01% respectively. Following 2 cases of life-threatening perioperative venous thrombosis in children with spastic quadriplegia undergoing major spinal deformity surgery we reviewed our unit’s policy of venous thromboembolism (VTE) risk management.To assess whether our current policies differ from those of colleagues around the country we carried out a survey of U.K. spinal surgeons currently performing paediatric scoliosis correction. Material and Methods: Twenty-eight consultant respondents were questioned regarding their experience of PE and related deaths following idiopathic and neuromuscular/syndromic scoliosis surgery. Attitudes towards VTE risk management and thromboprophylaxis were explored. Results: Only 2 consultants have experienced a PE in their patients. One followed surgery for a neuromuscular scoliosis and one for an idiopathic scoliosis. One respondent had experienced a death related to VTE. The routine screening of ambulant and non-ambulant scoliosis patients takes place in 11% of units. Thirty-seven percent of respondents consider VTE to be a problem in scoliosis surgery. Eighteen percent of respondents routinely prescribe chemical thromboprophylaxis for adolescent idiopathic scoliosis patients and 25% for neuromuscular/syndromic patients. The remainder rely upon mechanical thromboprophylactic methods. Conclusion: Thromboembolic events are rare in children undergoing scoliosis surgery. Our recent experiences raise questions about how we can improve pre-operative, intra-operative and post-operative care for these patients to reduce the risk of further life-threatening VTE. The majority of those questioned do not view VTE as a problem in paediatric scoliosis surgery and do not routinely screen for VTE or prescribe chemical thromboprophylaxis. Discussions with radiology and haematology experts regarding preoperative detection of DVT or PE have unfortunately brought us no nearer to suitably sensitive and specific tests. We must therefore focus efforts on ensuring adequate intravascular filling and using mechanical VTE prophylaxis intra and post-operatively. We propose that all future VTE complications in this population be recorded on the British Spine Registry so that future research can be conducted to identify those patients at the highest risk of VTE and develop nationally agreed screening guidelines and indications for VTE prophylaxis., Introduction: Sagittal malalignment of the spine is associated with reduced life quality. Additionally, it has a predominant effect on the clinical outcome of the surgical management of spinal disorders. The goal of this study was to determine the role of the sagittal imbalance of the spine in the failure of the posterior fixation of the spine. Materials and Methods: In this retrospective study, a study group (female n = 23, male n = 15, age range: 15-83 years) who underwent a revision surgery due to breakage of the implants was compared with a control group (female n = 14, male n = 13, age range: 58-82 years). Whole spine lateral radiographies, obtained in standardized standing position, were investigated for lordosis gap (LG), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), sagittal vertical axis (SVA), lumbar lordosis (LL), and thoracic kyphosis (TK). Data were analyzed using descriptive statistics, parametric and non-parametric inferential statistics, Pearson and Spearman correlation analyses. Results: In the study and control groups, the sagittal spinopelvic parameters yielded the following results: LG (medians: 27.8 vs 13.5, P < .05), PI (means: 66.7 vs 55.5, P < .05), PT (medians: 31.7 vs 25.7), SS (medians: 34 vs 30.6), SVA (medians: 72 vs 65.6), LL (medians: 38.4 vs 46.1), and TK (means: 31.7 vs 32.6), respectively. Additionally, correlation analyses revealed significant relationships between LG (P = .02), PI (P = .003), PT (P = .03), and SS (P = .05) and breakage of the implants. Conclusion: Considerable deviation from the normal values of sagittal spinopelvic parameters (in particular, LG, PI, PT, and SS) was associated with higher rates of breakage of the rods and screws in the posterior fixation of thoracolumbar spine., Introduction: To demonstrate that the combination of levobupivacaine, ketorolac and adrenaline is effective in improving postoperative pain control in patients undergoing spinal fusion surgery, and reduces the use of PCA (patient controlled analgesia), length of stay in hospital, days of physiotherapy and pain score. Material and Methods: A total of 37 patients who underwent spinal fusion surgery received wound infiltration with the combination of levobupivacaine (200mg/100 ml in 0.9% N-Saline), ketorolac (30 mg) and adrenaline (0.5 mg). PCA use, morphine consumption, length of stay in the hospital, days of physiotherapy and pain score (from 0 to 3) were prospectively recorded, side effects, and morbidity and mortality were prospectively recorded. Results: 16 patients were males (mean age:43), 21 were females (mean age:57). No side effects were recorded. 2 patients had surgical complications related to the procedure. 19 patients in total (51.35%) used the PCA for one day postoperatively; only 3 of these patients (15.79%) used the PCA for two days. The arithmetic mean of the daily use of oral morphine was 18.65 mg overall, 18.50 mg for the first day post-op, 23.50 mg for the second day. The arithmetic mean of the pain score was 1.26 overall, 1.65 in the first day post-op, 1.62 for the second day. The average duration of physiotherapy was 4.3 days overall, and 4.09 excluding the two patients with surgical complications. The average length of stay in the hospital was 6.76 days overall, and 5.26 days excluding the two patients with surgical complications. Patients happy overall after their stay were 32 (86.49%). Of the 5 patients (13.51%) not happy overall, 2 had surgical complications and 3 had significant post-op pain. Conclusion: Our data suggest that the studied wound infiltration is a safe and feasible option to provide good postoperative analgesia control. It also allows low usage of opioids and hospital costs. A case-control study will be organised in order to obtain higher level of evidence., Introduction: Issues were raised at the Royal National Orthopaedic Hospital (RNOH) following lack of documentation of pre and post-operative clinical findings for spinal patients undergoing major surgery. Discussions and meetings among spinal Consultants and Neurologists based at RNOH were held and a team (including junior doctors supervised by Dr Cowan) was created in order to look into the issues, aiming for improving the quality of junior doctor clerking/documentation (pre and post-operatively). We hypothesised that a standardised clerking pro-forma for surgical spinal patients admitted to RNOH (reporting pre and post-op neurological findings) would improve the clinical practise and allow an appropriate management of both clinical and legal issues in case of intra-op complications. Material and Methods: An Audit looking into the quality of the pre and post-op clinical documentation for surgical spinal patients was carried out at the RNOH in March 2016. A retrospective data collection was performed. Inclusion criteria: surgical spinal patients operated from 1/7/15 to 21/7/15 for first round, and in June-July 2016 for second round. Multidisciplinary notes and clinic letters of 30 of the selected patients were scrutinised, using paper notes and NoteOn (February 2016). Available published literature was reviewed. Data collected, analysed and discussed (March 2016). The Spinal clerking pro-forma was produced (March 2016). Results and pro-forma were sent to all Spinal Consultants and all junior doctors based at the RNOH, seeking for feedback. Pro-forma was implemented, put on trial and recommended to all doctors (April 2016). Further data collection (second round) and analysis took place in June-July 2016, using the same criteria set up for the initial collection. Compliance by the doctors to the use of the suggested pro-forma and potential advantages of his use were discussed at Audit meeting, and formal implementation will take place. Results: First round pre-op: 53.3% normal neurology documented just in clinic letters; 23.3% normal neurology briefly mentioned in clerking; 10% normal neurology with full assessment documented; 6.7% impaired neurology briefly mentioned; 6.7% impaired neurology fully documented. First round post-op: 63.3% normal neurology briefly documented; 13.3% normal neurology from clinic letters; 13.3% transient impaired neurology (brief documentation); 10% impaired neurology (2 with brief documentation and 1 from clinic letter). Full documentation in the notes (including both patients with intact and impaired neurology: 0. Second round: 30% pro-forma used; 77.8% normal neurology fully documented; 22.2% impaired neurology fully documented. 70% pro-forma not used: 90.5% normal neurology (73.7% brief documentation, 22.3% no documentation); 9.5% impaired neurology briefly documented. Conclusion: We recommend the use of our pro-forma at the RNOH as it allows the surgeons and clinicians to fully assess surgical spinal patients and record detailed pre and post-op neurological findings, in keeping with GMC/NICE Guidelines. It is also a safe medical and legal approach to surgical complications, allowing the best possible management planning. We would like to formalise the introduction of the studied pro-forma within our Trust and re-audit (third cycle) the findings at 3-6 months from his formal introduction., Introduction: Tranexamic acid (TXA) has been reported to be effective on reduction of postoperative blood loss in prosthetic replacement arthroplasty and spondylodesis. We have examined the efficacy of intravenous administration of TXA in lumbar posterior decompression (lumbar spinous-process splitting laminoplasty). Material and Methods: We retrospectively studied 68 patients undergoing lumbar posterior decompression by classifying them into the TXA group (36 patients; mean age of 64 years; 2013.4-2014.7) and the non-TXA group (32 patients; mean age of 60 years; 2014.8-2015.9). The TXA intravenous administration was just before and after 3 hours past operation. And each time we administrated 1000 mg of the TXA intravenously. Results: Postoperative blood loss was significantly less in the TXA group (non-TXA group: mean 121 ml, TXA group: mean 76 ml). Both intraoperative (non-TXA group: mean 79 ml, TXA group: mean 59 ml) and postoperative (non-TXA group: mean 86 ml, TXA group: mean 42 ml) blood losses per intervertebral space showed significant differences between the two groups, showing that TXA was effective in controlling blood loss. Neither group had postoperative complications such as symptomatic thrombosis. Conclusion: In this study, intravenous administration of TXA significantly reduced postoperative blood loss, indicating its effectiveness in controlling postoperative bleeding (non-TXA group: mean 121 ml, TXA group: mean 76 ml). However, further study with an increased sample size is needed to study timing of TXA administration and onsets of postoperative complications., Introduction: Sarcopenia measured by normalized total psoas area (NTPA) has been shown to predict mortality and adverse events (AE) in numerous surgical populations. It’s possible relation with postoperative outcomes after surgery for degenerative spine disease (DSD) has not been investigated. This study aimed to 1) Describe the distribution and predictors of NTPA; 2) Determine relationship between sarcopenia, frailty and postoperative outcomes; 3) Determine relationship between sarcopenia, frailty and length of stay, discharge disposition and in-hospital mortality. Material and Methods: This is an ambispective study from a quaternary academic centre. Total psoas area (TPA) at mid-L3 level on pre-operative CT scan adjusted for height (NTPA) defined sarcopenia. Modified Frailty Index (mFi)[11 clinical variables] defined frailty. Correlation with in-hospital adverse events (using validated SAVES), mortality, length of stay and discharge disposition was examined. NTPA was measured and distribution and predictors of sarcopenia were determined. Association of sarcopenia and frailty with post-operative outcomes was determined after adjusting for known and suspected confounders using multivariate logistic regression. Results: 102 patients >65 years old undergoing elective lumbar surgery for DSD (L4-S1) between 2009 and 2013 were included. Median Spine Surgical Invasiveness Index was 8 (IQR 2-10). Mean NTPA was 674mm2/m2 (293.21- 1636.25). Inter- and intra-observer reliability were near perfect with Kappa 0.95-0.97 and 0.94- 1.00 respectively. NTPA was predicted by gender and BMI. NTPA did not predict AE for either adjusted (OR 1.06 per 100 mm2/ m2, 95% CI 0.91 to 1.23, P = .45) or unadjusted analysis (OR 1.04 per 100 mm2/ m2, 95% CI 0.90 to 1.19, P = .62). Age, BMI, mFI, and ASA were not associated with the adverse events. Discharge disposition was not predicted by NTPA (rho -0.04, P = .67) or mFI (P = .14). NTPA was not predictive of in hospital mortality, but increasing mFI was associated with increased risk of mortality on unadjusted analysis OR 3.12 (95% CI 1.21 to 8.03) per 0.1 increase in frailty score (P = .006). Conclusions: In contrast to other surgical groups, sarcopenia (NTPA) or frailty (mFI) did not predict acute care complications in elderly undergoing simple lumbar spine surgery for DSD. While Normalized Total Psoas Area can be reliably measured in this population, it may not be an appropriate surrogate for sarcopenia given the anatomical relationship to spinal function., Introduction: The aim of this paper is to describe the results obtained in 120 patients, in which we did a vertebroplasty because of a vertebral fracture with collapse of the superior endplate less than 30% and without rupture of the back wall. They were operated between January 2015 and August 2016 in our department of Orthopedics and Traumatology in Corporación Medica of General San Martin in Buenos Aires, Argentina. All the patients were operated by the same surgeon. In all cases we used the same technique, which consists in the transpedicular unilateral filling of the vertebrae through a working cannula with methyl methacrylate. In many cases there was leaking vertebral intradiscal and intracanal. In all patients in whom there was intradiscal leaking there was a marked decrease of pain in the immediate postoperative without any extra complication.The results were very good because in none of these cases the patients experienced any complications or annexes symptoms with this type of surgical technique used. Materials and Methods: 120 patients, 44 men and 76 women who underwent a unipedicular vertebroplasty according to established protocols were evaluated. Patients with more than one fracture, fractures with a compromised of the back wall, fractures with a collapse of more than 30% of the upper endplate and those which we had to use a bipedicular filling technique were excluded from this study. All patients were studied with Rx and MRI; only in 15 cases we used CT with 3D reconstruction. All treated by the same surgeon. In 32 cases the superior disc filling technique was done because of pain and injury of the annulus. Surgical technique: Location of the fractured vertebrae under Rx, posterior approach. Unipedicular placement of the working cannula, cementation of it and in 32 cases rupture of the upper endplate with the respective disk filling. Results: In all cases patients had a partial or total remission of their symptoms. Only 7 patients had postoperative complications because of an intracanal leaking, which were decrease in strength and sensitivity in both lower limbs that remitted entirely at most 20 days after surgery. In the cases where we did superior disc filling patients evolved with a marked improvement in their pain in the early postoperative days compared to the usual vertebroplasties without any complications. All surgical wounds healed normally, without any secretions or phlogosis. All patients returned to their usual duties after a few weeks. Conclusions: After an exhaustive study of each of our patients we conclude that in most cases where intradiscal or intracanal leaking occur patients have no significant complications and always their symptoms remit. We find a direct relationship between the pressurization system and leaking. This method is commonly used in our service with excellent results., Introduction: Body mass index (BMI), bone mineral density (BMD), cage materials and degree of disc distraction are risk factors for cage subsidence after PLIF. The purpose of the study is to evaluate risk factors for subsidence after posterior lumbar interbody fusion (PLIF). Material and Methods: From January 2010 to January 2015, a total of 69 patients (93 segments) who were diagnosed with degenerative lumbar disease at the current authors’ institution and followed up at least for 1 year were included in this retrospective study. Data on all factors related to cage subsidence were taken into consideration. The degree of association for each of the factors was determined through the calculation of odds ratio (OR), with a 95% confidence interval. Logistic regression analyses were performed. P-value was set below 0.05. Results: There are no significant associations between fused segment level and cage subsidence (P = .588), and also there are no significant associations between cage materials and cage subsidence (P = .371). In univariate analysis, only the degree of disc distraction had a significant association with cage subsidence (P = .047, OR, 1.239). Various factors significant with p less than 0.20 level in univariate analyses were included in the multivariate analyses. In multivariate analyses, DM (P = .027, OR, 3.873), osteoporosis (P = .047, OR, 3.606) and degree of disc distraction (P = .017, OR, 1.343) had a significant associations with cage subsidence. In addition, there are significant associations between cage subsidence and instrument failure (P = .008, OR, 8.235). Conclusion: DM and osteoporosis which may affect bony structures are significant associations with cage subsidence after PLIF. Also, cage insertion with excessive disc distraction during operation may affect cage subsidence after PLIF., Introduction: Lumbar spinal stenosis surgery is a frequent intervention in spine centers worldwide. Blood products requirements for this surgeries tend to be overestimated in general population. Blood transfusions are preventable adverse events given that there are risk factors that can be mitigated prior to surgery. The aim of this study was to identify and describe postsurgical bleeding and transfusion requirements in a cohort of patients who underwent surgery for lumbar spinal stenosis and analyze possible determinant sociodemographic and surgical factors associated with blood transfusion. Materials and Methods: A cross-sectional observational study was conducted. Clinical records of 367 patients treated in a third level hospital located in Bogota Colombia undergoing surgery for lumbar spinal stenosis between 2003 and 2013 were reviewed. Personal background, sociodemographic and surgical variables, and their influence in post-surgical blood loss and transfusion requirements were analyzed. Patients with oncologic conditions, previous spine surgery and bleeding disorders were excluded. Univariate analysis, bivariate analysis and logistic regression of variables affecting postoperative blood transfusion were conducted. Results: 367 clinical records were reviewed. The median age was 57 years and 55.6% were female. Among the medical history, most frequent comorbidities were hypertension (37.3%), diabetes mellitus (10.6%) and cardiopathy (7.6%). Lumbar decompression was the most frequent procedure (55.6%) and the majority of patients required two level instrumentation surgery (79.8%). Intraoperative Bleeding was classified in 3 different categories: Mild (less than 50 ml), moderate (50-500 ml) and severe bleeding (>500 ml). Mild blood loss was observed in 35.1% of patients; 42.5% and 22.5% of patients presented moderate and severe bleeding respectively. Although, most patients had moderate and severe intraoperative bleeding only 26 patients (7.1%) required blood transfusion. After statistical analysis, the binary logistic regression revealed that history of heart disease (OR 4.68, CI 1.12 -19.44), intraoperative bleeding > 500 ml (OR 6.74, CI 2,09 - 21.74) and level of surgery (>2 operated levels) (OR 3.97, CI 1.20 to 13.09) were statistically associated with the need for blood transfusion. Conclusion: History of cardiopathy, multilevel surgery (more than 2 instrumented levels) and severe intraoperative bleeding (greater than 500 ml) were positively associated with blood transfusion requirement after spinal stenosis surgery. Mitigation of these risk factors and strategies to reduce intraoperative blood loss may decrease the amount of blood transfusion requirements., Introduction: Thoracic myelopathy due to ossified ligamentum flavum(OLF) is a very rare condition. We analysed our patients and have made attempts to find the factors which affect the surgical outcome. We also studied the associated spinal degenerative conditions which we saw in our patients with thoracic OLF. Material and Methods: We retrospectively analysed 20 patients with thoracic OLF. All except one patient underwent laminectomy with excision of the OLF. Whenever there was a other associated spinal compressive lesion (n = 9) i.e lumbar or cervical, it was treated in the same sitting, except in one patient who could not withstand anesthesia due to unstable cardiac condition. We reviewed the patients’ age, preoperative duration of symptoms and preoperative and postoperative neurological condition on basis of Japanese Orthopedic Association (JOA) scoring system. Results: All of our patients underwent operative intervention, 19 patients underwent laminectomy and excision of OLF. One patient had disc prolapse alongwith OLF, as the compression due to the disc was more severe, we decided to operate only for the disc and the OLF was followed clinically and radiologically. We have follow-up of 16 patients from 3 months to 8 years. 4 patients were lost to follow-up. 8 patients had excellent result, 6 had a good result and 1 patients remained the same and 1 deteriorated. Acute presentation had a bad outcome, other factors determining outcome were age of patient and duration of symptoms and preoperative neurological condition. None of our patients had complications of CSF leak, operative hematoma or wound infection/dehiscence. Treatment of associated spinal degenerative conditions like lumbar canal stenosis and cervical stenosis was required in 8 of our patients. There was no increased complication rate in these patients. Conclusion: Early diagnosis and meticulous wide surgical excision of the OLF, can give good results. The associated symptomatic compressive lesions (cervical or lumbar) should be treated in the same sitting. Age, long duration of symptoms and severity of symptoms (poor grade) were poor prognostic factors. The single case with acute presentation in our series had a bad outcome., Introduction: The presence of a dural tear or leakage of cerebrospinal fluid can cause serious problems such as pseudomenigocele, which is a rare complication of spine surgery. Pseudomeningocele is an accumulation of cerebrospinal fluid after an injury meningeal dura. We performed a clinical study in order to evaluate the treatment of pseudomeningocele with its aspiration and injection with Plateley Rich Plasma (PRP). Material and Methods: During the years 2014 and 2015 five patients were diagnosed with pseudomeningocele at Clinico San Carlos Hospital. These patients suffered dural tear from various etiologies such as trauma and spinal surgery. As to its location, four were lumbar and one cervical. Initially the lesions were treated with reparation and coverage but despite this a remission of the tumor was not obtained. The MRI performed confirmed the presence of a subcutaneous fluid collection that communicated with the spinal canal through a fistula. To treat the pseudomeningocele a ultrasound-guided drainage and infiltration with PRP were performed. Results: A control MRI was performed two months after the infiltration in all cases observing no collections. At last follow-up the patients were asymptomatic and the wounds evolved satisfactorily. The patients lived an active life without any functional limitation, in comparison with the preoperative clinical limitations. Conclusion: The treatment of the pseudomeningocele is controversial. On one hand, there is medical management with rest and antibiotic therapy, repeated aspirations, closed suction drainage or subarachnoid CSF with hemolytic epidural patch. On the other hand, the definitive treatment is surgical repair of the dural defect. In our cases, due to a poor evolution after surgical treatment, we decided to aspirate the pseudomeningocele and inject PRP. The evolution of all cases was favorable and we therefore recommend this treatment as an alternative when other treatment options have been ruled out., Introduction: Spinal dural tear is a common complication of spinal surgery and its incidence is affected by several factors, including diagnosis, patient characteristics and the type of surgical procedures performed. If the tear is not treated appropriately during surgery, it may cause severe consequences such as, persistent leakage of cerebrospinal fluid (CSF) and the formation of a pseudomeningocoele, producing headache, nausea and back pain. Dural tear is often underreported by hospitals and thus may be more common than previously thought. We set out to evaluate the incidence of dural tear during spinal operations and to assess patient outcomes. Material and Methods: Data was collected prospectively from both a spinal complications folder, which was filled out at the time of any intra-operative complication, and electronic patient records. All patients had questionnaires at 6-month follow-up including the Oswestry Disability Index (ODI), Visual Analogue Scores for leg pain (VAL) and back pain (VAB), and EuroQol-5 dimensions (EQ5D-5 L). Results: There were a total of 609 spinal operations performed during the eight month period.108 were cervical, 20 were thoracic and 481 were in the lumbar spine. 22 patients had intra-operative dural tears; 20 of these were in the lumbar spine, the other 2 occurred during Anterior Cervical Discectomy and Fusion (ACDF) procedures. These corresponded to a rate of dural tears in the lumbar spine of 4.1% and 1.8% in the cervical spine. Only 2 of the patients who sustained intra-operative dural tears required re-exploration. Of those 22 patients, three were lost to follow-up and one did not have any pre-operative data. We therefore analysed data from the remaining 18 patients. Follow-up questionnaires confirmed that 61% of these patients with intra-operative dural tears found an improvement in symptoms, while 11% reported no change. Conclusion: The presence of dural tears during the procedure is presented as a predictor of postoperative surgical site infection, longer inpatient stay and an increase in re-operation rate, and thus leading to poor outcome. Compared to previous studies conducted in other spinal units, dural tear rates in the Ipswich Spinal unit are low. However, outcome results were not as good as previous reported studies. However, by conducting this project, we can inform patients during the consenting process of a risk of dural tear of 4.1%., Introduction: Majority of spine cases especially lumbar surgeries are done through posterior approach where the patient has to be in prone position for longer durations. The positional complications are higher if the patient is under General Anaesthesia. Ocular and aural complications are very commonly reported in the recent past due to improper positioning of the patient during anaesthesia. Here we report a rare case of Tietze’s syndrome developed few months post operatively after lumbar fixation with pedicle screw system due to malpositioning during the surgery. Material and Methods: A 40 year old male patient presented to our outpatient clinic with back pain and severe radiculopathy 10 months ago. He underwent lumbar decompression surgery 7 years back. At present after thorough clinical and radiological examination he was diagnosed with L4-L5 instability with L3-S1 Lumbar Canal Stenosis for which he underwent Posterior stabilization, fusion and decompression. After 15 days he started complaining of para sternal pain on right side of the chest. On examination there was swelling, redness tenderness and local rise of temperature at the site. Bone scintigraphy, CT scan and MRI Dorsal Spine were done. Results: All three investigations came with the positive co-relation of the diagnosis made and was confirmed with Tietze’s syndrome of 6th and 7th ribs. After exhaustion of conservative management we now performed Rib Cartilage Excision of the involved ribs. After excision, the cartilage was found to be inflamed and sent them for HPE. Post cartilage excision, patient showed signs of improvement and the persisting pain were no more. Discussion: Positional complications in spine surgeries are not uncommon. The most common one is posterior ischaemic optic neuropathy that may either result due to improper padding of the eye causing a direct pressure effect when the patient is under general anaesthesia or due to blood loss, hypotension and anaemia which all three may conspire to produce the condition. But here we report a rare complication of prone mispositioning leading to Tietze’s syndrome which itself is a rare entity. It is mostly seen in the upper ribs but very rarely reported in lower ribs. The incidence of Tietze’s syndrome is not well studied and hence only few clinicians have a handful of experience with it. In chronic cases, local cortisone injection has been found to be useful. When all the conservative methods are exhausted, surgical option of rib cartilage excision can be done. Conclusion: Tietze’s syndrome which is a self-limiting chronic pain condition is itself a rare entity. Its occurrence following mispositioning when placed in prone is a rarest complication reported till date. Also rib cartilage excision is a good option in Tietze’s syndrome if all the conservative measures fail and has to be done with guarded prognosis as well., Introduction: Pacemakers are currently identified as a contraindication for the use of magnetic growth rods (MGRs). This arises from concern that magnetic fields generated by the MGR external remote controller (ERC) during lengthening procedures may induce pacemaker dysfunction. We investigated (1) whether MGR lengthening affects pacemaker function, and (2) if the magnetic field of a pacemaker affects MGR lengthening. Materials and Methods: MGRs were tested in conjunction with an magnetic resonance imaging-compatible pacemaker, which was connected to a virtual patient under continuous cardiac monitoring. To determine whether pacemaker function was affected during MGR lengthening, the electrocardiogram trace was monitored for arrhythmias, whereas an ERC was applied to lengthen the MGRs at varying distances from the pacemaker. To investigate if MGR lengthening was affected by the presence of a pacemaker, at the start and end of the experiment, the ability of the rods to fully elongate and shorten was tested to check for conservation of function. Results: When the pacemaker was in normal mode, < 16 cm away from the activated ERC during MGR lengthening, pacemaker function was affected by the ERC’s magnetic forces. At this distance, prophylactically switching the pacemaker to tonic mode before lengthening prevented occurrence of inappropriate pacing discharges. No deleterious effect of the pacemaker’s magnetic field on the MGR lengthening mechanism was identified. Conclusions: Magnetic resonance imaging-compatible pacemakers appear safe for concomitant use with MGRs, provided a pacemaker technician prophylactically switches the pacemaker to tonic function before outpatient lengthening procedures., Congenital kyphosis is a rare deformity, but frequently involves a high risk of intra operative motor neurophysiological events that could result in irreversible Sequelae. Study Design: Retrospective cohort. Objective: Determining factors that may increase the risk of producing a neurophysiological intra operative event as could be localization of the hemivertebra, magnitude of the deformity, type of kyphosis and previous neurological examination. Material and Methods: X-rays and medical records of 9 patients with congenial kyphosis were reviewed. An average age of 10 years with a range of 5 to 17 year-old. Kyphosis classification according to McMaster have been: type 1 (4 cases), Type 2 (2 cases) and Type 3 (4 cases). Attending to the location: thoracic in 6 cases, 3 cases thoracolumbar and 2 cases lumbar. All patients have undergone surgical treatment: posterior osteotomy in 5 cases and 5 cases through a double approach. Mean global kyphosis was 53 degrees with a range of 85 to 30. Mean kyphosis correction after surgery was 17 degrees with a range of 29 to 10. We performed a logistic regression analysis with the following independent variables: kyphosis angle, location and type of defect looking for the relationship with the presence or absence of intra operative motor neurophysiological event. Results: Table 1.TypeDeformityLocalitationDARAgeIKyphosisPosterior hemivertebra L450º5IIIKypho scoliosisFusion T10, T11 T12 and posterior hemivertebra70º17IIIKypho scoliosisPosterior Hemivertebra L150º12IIIKypho scoliosisHemivertebra T6, T7, T860º16IIKyphosisAnterior fusión T11-L285º13IKypho scoliosisposterolateral hemivertebraT1140º6IIKypho scoliosisFusion and hemivertebra l T4-T642º14IKypho scoliosisPosterolateral hemivertebraT1049º13IIIKypho scoliosisPosterolateral hemivertebraT10+ partial fusionT9-T1254º14iKyphosisHemivertebra T1130º11 In four cases motor neurophysiological events occurred during the surgery. No statistically significant relationship has been found with the deformity magnitude, the location or the type of deformity. Conclusion: Congenital kyphosis is not a common condition but it is characterized by a high neurological operative risk. There is a tendency to produce intra operative motor neurophysiological events elated with more severe cases and when the hemivertebra is located in the thoracic spine., Introduction: Cervical spine injuries are immanently accompanied by trauma to cerebral neck arteries. Material and Methods: A prospective cohort study, from Oct. 2013 to Oct. 2015. Overall 76 Patients (39W/37 M) of mediane age 77 years, with either fractures, or discoligamentary injuries have been examined with duplex-sonography and / or CT-angiograpy. About 80 Patients with a cervical-spine-distorsion have been evaluated with the same modalities as well. We used the statistic-programme Bias 11.01. Results: The overall incidence of a traumatic a.carotis-interna-dissection was 2.5%, in 50% of cases (1.2%) with a neurological symptomatology. For the vertebral artery seems the incidence of 10.5%, with 25% of symptomatic patients (2.6%) comparatively high. We’ve identified the osteophytes and dislocation as the major risk factors. The canalis vertebralis and skull-base are the regions mostly prone to vascular injury. In case of distorsions we have found no vascular trauma. Conclusion: One should look for vascular injuries in case of cervical spine trauma. The curent therapy option is the anticoagulation in a case of neurologically asymptomatic lesions. The symptomatic patients could benefit from endovascular techniques., Introduction: Traumatic spondylolisthesis of the axis (C2) with the fracture extending into the vertebral body has been incompletely characterized. Small case series have demonstrated high rates of neurological injury and cite difficulty treating closed due to greater instability secondary to extensive ligamentous injury. We hypothesize that this fracture pattern has minimal risk of ligamentous injury and can be adequately treated with closed methods. Material and Methods: Retrospectively, all patients admitted to a level 1 trauma center from 2004-2015 with acute C2 fractures were identified and classified based on CT imaging. Patients with anterior translation and C2-3 angulation less than 5 mm and 15 degrees respectively met the inclusion criteria for the study. Patients who underwent surgery or were not followed until conclusion of treatment were excluded. Results: 107 hangman’s variant fractures (14.5%) were identified from a database of 735 acute C2 fractures. 106 of the 107 patients displayed no neurologic injury related to the cervical spine at the time of presentation. 63 patients met the inclusion criteria and were followed as outpatient’s until collar or halo vest removal. All fractures progressed to union without progressive displacement or late neurological injury. No difference was observed in radiographic outcome between patients treated in a hard collar or halo orthosis. Conclusion: While widely considered a difficult fracture to treat with closed means, hangman variants are relatively neurologically benign injuries with low incidence of ligamentous injury. Fractures with less than 5 mm of horizontal translation and 15 degrees of angulation can be treated with external immobilization without the necessity of MRI. Our results suggest no advantage of halo immobilization versus hard collar orthosis., Introduction: Treatment of fractures of the odontoid peg depends on the type of fracture according to the classification of Anderson d’Alonso, the degree of dislocation and the patient compliance. Material and Methods: We report the case of a 57 year old male, suffering a Typ III fracture of the dens axis. Initially, he was treated with an external halo fixateur. Eight weeks later, increased dislocation of the dens axis was evident and no fracture consolidation could be noted. Results: The fracture was then stabilized anteriorly with two double-threaded screws using the technique of Knöringer after osteotomy of the fracture area for reduction of the dislocation. Three weeks further, caudal dislocation of the Knöringer screws with destruction of the third cervical vertebrae was noted. An anterior removal of the screws was necessary. Posterior instrumentation and fusion C0 - C4 was performed. Conclusion: We discuss possible pitfalls of indication and treatment including anterior fusion techniques., Introduction: A case of post-traumatic posteriorly impacted irreducible odontoid fracture reported. Objective was to discuss the difficulty observed in reduction of such fractures and to propose the alternative surgical method for reduction of such posteriorly impacted fractures. This was a case of posteriorly impacted irreducible Type 2 odontoid fracture. Obliquity of the fracture line and posterior impaction of odontoid fragment over the base of odontoid process precluded anterior trans-oral approach & manipulation. Impaction could not get overcome even by heavy traction. Material and Methods: A 16 years old man with vehicular accident sustained cervical spine injury with neck pain and no neurological deterioration. Type 2 odontoid fracture with posterior displacement was noted on further imaging. Acceptable reduction was achieved by posterior reduction & instrumentation. Results: As the heavy traction failed to dis-impact the fracture, patient was repositioned prone and instrumented posteriorly. Intra-articular distraction between C1-C2 joint was attempted to reduce the fracture and unlock the facet joints, if ever present, which failed. Instrumentation & distraction along rods with posterior pull to axis vertebra through a sub-laminar wire achieved reasonable reduction. Patient remained neurologically intact. Conclusion: Due to peculiar fracture geometry and posterior impaction, this fracture was less amenable to axial cervical traction or anterior trans-oral approach. Posterior instrumentation using lateral mass screws in atlas and pedicle screws in axis with connecting rods used to distract the joint which reduced the fracture reasonably well. Intra-articular distraction with posterior traction to axis helped in reducing the fracture by leverage of transverse ligament. Such a reduction maneuver can be applied safely to get an acceptable reduction in difficult to reduce odontoid fractures., Introduction: We describe a technique of reduction and stabilization of unifacetal or bifacetal dislocation of subaxial cervical spine by posterior only approach using pedicle screws and analyze the clinical and radiological results of the patients treated with this technique. Methods: Medical records of patients with unifacetal or bifacetal dislocations of subaxial cervical spine treated with cervical pedicle screws between January 2011 to June 2015 were analyzed retrospectively. Neurological assessment was done pre-operatively and at final follow up by ASIA grading, motor and sensory scores. Radiological outcome was analyzed by comparing the degree of translation and segmental lordosis between the pre-operative and immediate post-operative radiographic images using surgimap software and position of pedicle screws by CT scan. Results: 13 patients (11 males and 2 females) with an average age of 47 years (17-80 years) were included in the study. The commonest mechanism of injury was road traffic accident and the average time of presentation was 3.9 days. Post operative X-ray showed reduction of anterior translation from an average of 38% pre-op (16%-100%) to 1% post-op (0%-4%) and restoration of sagittal alignment from 12° of kyphosis pre-op (7° to -36°) to 2°degree of lordosis post-op (-4° to 13°). The position of pedicle screws showed intact in 42 pedicles, medial breaches in 10 and lateral breaches in 6. The average follow up was 33 months 12 days (6 -53 months). Two patients expired due to chest infection and one patient with ASIA ‘A’ quadriplegia was lost to follow up. At final follow-up 5 patients with ASIA ‘D’ and one patient with ASIA ‘C’ paraplegia improved to normal (ASIA ‘E’). While in remaining patients neurology remained normal pre and post operatively. Conclusion: We describe a technique of reduction and stabilization of fracture dislocation of subaxial cervical spine by a single posterior approach using pedicle screws. The advantages of this technique being lesser operative time, blood loss, less morbidity, superior biomechanical strength, short segment instrumentation, lesser chances of traction injury to the cord, its feasibility in delayed presentations and allowing discectomy and interbody grafting through posterior approach., Introduction: Several studies have indicated that early decompression may be beneficial for traumatic spinal cord injury in the cervical spine. This study is designed to investigate the impact of hospital teaching status on the timing of intervention and inpatient morbidity and mortality after surgery for acute spinal cord injury (SCI). Material and Methods: Data from the Nationwide Inpatient Sample (2002 – 2011) were reviewed. Patients were included if they had a diagnosis of closed vertebral column fracture with SCI, underwent spine surgery, and were admitted urgently or emergently. Early intervention (the day of or the day after admission), inpatient morbidity, and impatient mortality rates were compared between groups – teaching versus nonteaching hospitals. Multivariable regression analyses were performed to control for patient characteristics, injury mechanisms, and others. Results: A total of 9,236 patients were identified (mean age 43 years, 82.6% male gender), with 78.7% admitted to a teaching hospital (n = 7272) and 21.3% to a nonteaching hospital (n = 1964). The most common injury mechanism was motor vehicle collision in 43.9% of cases, the most common fracture location was between C5 and C7 (35.3%), and 22% of cases were complete SCIs. Following multivariable analysis, teaching status was significantly associated with early intervention (OR 1.12; 95% CI, 1.01 – 1.25), but not with complication development (OR 1.09; 95% CI, 0.98 – 1.23) or mortality (OR 1.19; 95% CI, 0.91 – 1.56). Conclusion: In this nationwide study, patients with vertebral column fractures with SCI who were admitted to teaching hospitals were more likely to receive early intervention compared to patients admitted to nonteaching hospitals. On the other hand, inpatient morbidity and mortality did not differ depending on hospital teaching status. Future studies into the long-term implications of admission to teaching versus nonteaching hospitals for patients with SCI are encouraged., Introduction: Pedicle screw fixation of lower cervical spine is a new technique that provides a alternative to posterior lateral mass plating. Although biomechanical studies suggest the use of pedicle screws to reconstruct the cervical spine, placing screw in small cervical pedicle poses a technical challenge. Penetreation of screw in pedicle is a primary complication associated with screw insertion in the lower cervical spine. Material and Methods: This is retrospective interventional study done at the department of Orthopaedics, B.P.Koirala Institute of Health Sciences, Dharan, Nepal over a period of 2 years from March 2012 to April 20014. A total of 55 patients with cervical spine injuries were treated by pedicle screw. The patient’s age ranged from 20 to 60 years and the mean follow-up was 12 weeks. Results: The study comprised of 55 patients with cervical spine injuries were treated by pedicle screw The age incidence in this series ranged from 20 years to 60 years. 40 patients were males and 20 was female. All had fractures or fracture dislocation at different levels of lower cervical spine.The mechanism of injury included falls from height (80%), motor vehicle accidents (18%) and sports related injury (2%). Conclusion: It is indicated in patients with osteoporotic bone or when rigid internal fixation can not be achieved by conventional techniques., Introduction: Fractures of the axis are common, but multiple ones of the axis are much rarer, and their management creat still controversises. The aim of treatment should be achieving primary stability, early mobilization, preserved cervical range of motion, and favorable outcome. Material and Methods: A 62-year-old man was admitted to our neurosurgicaldepartment one day after a traffic accident. He had only persistent neck pain without radicular pain. Neurological examinationwas completely normal. The CT scan showed a complex fracture of the axis consisting of a fracture of the dens and a hangman fracture. Results: The surgical procedure was performed using an anterior cervical approach under fluoroscopic guidance. First, a C2–C3 fusion was performed using an iliac crest graft. Then an anterior odontoid screw was placed under fluoroscopic guidance and through the left superior hole of a cervicale plate. Finally, the anterior plating of C2–C3 was achieved. Postoperative course was uneventful and patient was discharged at day 3. Conclusion: This single time procedure was able to achieve the different aims of treatment of the fractures of the axis., Introduction: Type II odontoid fractures (Alexander- Alonzo)are usually offered surgery. Anterior screw is the common surgical treatment. For fractures unsuitable for ant screw or with associated instability posterior atlanto axial fixation is offered .Twenty five patients of type II odontoid fractures (unsuitable for anterior odontoid screw) underwent an anterior retropharyngeal approach with anterior screw pate fixation and eight among them, who had associated atlantoaxial instability underwent additional bilateral anterior transarticular screws. All patients treated by this technique had 100% fracture site bone union without any implant failure. Longest follow up has been 3 years. Material and Methods: Time period Feb 2011 – Sept 2016. 25 patients, age 15yrs – 78yrs, Males 15, females 10, of (Anderson and D’ Alonzo) Type II (16) and II A (9) fractures of odontoid were treated by this technique. 20 patients, age 15yrs – 78yrs, Males 12, females 8, of (Anderson and D’ Alonzo) Type II (13) and II A (7) fractures of odontoid were treated by this technique. Following an anterior extra pharyangeal approach the fracture site was exposed and fixed in compression mode with specialized VSP (variable screw placement) plate and screws. For patients with associated instability, bilateral anterior trans articular screws were used to fix the atlantoaxial joints. Results: No transfusion was required in any case and no case required additional procedure. All patients showed bone union across fracture site at 3 months. Complications and Sequale: Three elderly patients (>70 yrs) complained of dysphagia for 2-3 days after surgery, 3 patients (including the ones with dysphagia) had mild hypoglossal weakness which recovered in a week. Neck pain persisted in 9 patients for 4 weeks which responded to analgesics. Long-term follow-up imaging has been at 3 years in 7 patients, without implant failure and 100% bone fusion. Conclusion: All 25 patients who underwent this procedure had bone union across the fracture at 3 months with no case of implant failure. There was no similar description of anterior compression plate screws with bilateral anterior trans articular screws for odontoid fractures in literature. However better implant design with locking screws need to be devised and more centers have to perform this surgery to realize the long term results and complications., Introduction: Many studies have focused on the axons regeneration after Spinal cord injury (SCI). And fibrinogen was found to be an inhibitory factor for axons regeneration. However, most of these studies were based on animal experiments and in vitro trials. Few studies reported the serum concentrations of fibrinogen in patients with SCI. The purpose of this study is to investigate the circulating serum concentrations of fibrinogen in patients with SCI, and to determine the correlation between fibrinogen concentrations and patients’ JOA score and ASIA impairment scale. Materials and Methods: A total of 306 patients who were diagnosed with acute SCI from January 2008 to March 2016 were included in the study. Additionally, 427 patients with traumatic fractures of the extremities at the same period (220 patients with single fracture and 207 patients with multiple fractures) were enrolled as control groups. The fibrinogen serum concentrations in different groups were recorded and compared with each other. And the relationship between fibrinogen serum concentrations and JOA score, ASIA impairment scale in patients with SCI were analyzed. Results: The mean serum concentrations of fibrinogen within two days after injury were 2.63 ± 0.76 g/l in SCI group, 3.02 ± 3.03 g/l in single fracture group and 2.86±0.91 g/l in multiple fractures group, respectively. It’s significantly lower in SCI group comparing with the fracture groups (P = .003). The positive rate of fibrinogen concentrations were 12.42% (38) in SCI group, 25.45% (56) in single fracture group and 25.13% (52) in multiple fractures group, which were significantly lower in SCI group (P < .01). However, no significant difference was detected between the single and the multiple fractures group (P > .05). In patients with SCI, spearman correlation analysis revealed a negative correlation between fibrinogen serum concentrations and patients’ JOA score or ASIA Impairment scale ((r1 = 0.203, r2 = 0.17, P < .01). Conclusions: The serum concentrations of fibrinogen and positive rate were significantly lower in patients with SCI than those with fractures. And the fibrinogen concentrations were negatively correlated with the neurological function in patients with SCI according to ASIA and JOA scores., Introduction: Traumatic SCI is a catastrophic event that has a major impact on the individual, as well as the healthcare system. The optimal timing for surgical decompression after traumatic SCI is controversial. To determine whether clinical outcomes after traumatic spinal cord injury (SCI) are better when surgical decompression is performed early (, Introduction: Evaluation of the results obtained in our hospital with surgical treatment of fractures of the odontoid process (types II and II according to D’Alonzo classification) in the elderly population. Material and Methods: Retrospective study of patients 65 and older with odontoid fractures types II and III surgically treated in our hospital during the period 2005-2015. Type of surgical technique, presence of consolidation during the follow-up and subsequent clinical course were evaluated. We identified a subgroup of “very old” patient (according to medical literature with age > 80 years), comparing the results with the patients with 65-79 years. Results: 25 patients were included, 19 with type II fractures and 6 type III fractures. The mean age was 79.5 years, with 11 patients over 80. Two of the patients had been treated previously with cervical immobilization in other centers. The surgical technique used was based on displacement and complexity of the fracture, according to findings of the cervical MRI; 8 screwed performed anterior approach, in 16 patients a posterior fixation was performed, and an anterior screw placement was realized in 9 patients One patient died in the short tem postoperative period. The average hospital stay was 22 days in the subgroup with age 65-79 years and and 55 days in the group with >80 years. During follow-up, signs of healing were observed in 75% of cases with no significant differences according with the type of treatment or age The consolidation rate was higher in type III fractures although statistical significance was not reached. The complication rate was similar among age subgroups. Conclusion: Surgical treatment of odontoid fractures is an effective treatment that provides good results even in the older population, without significantly increasing the rate of complications. Surgical option has replaced the conservative treatment in these type of fractures., Introduction: Surgical treatment patients with upper cervical spine trauma actual problem. Material and Methods: 88 patients with of upper cervical spine injury, treated 2011-2015. In all cases, surgical treatment was performed using different stabilizing systems. CT performed to all patients with suspected cervical spine injury before and after the operative treatment. Selective angiography of brachiocephalic vessels was carried out according to indications to assess the collateral blood flow. Before surgery, spine was fixed in a “Philadelphia” collar. After surgery on the second day was performed in a soft collar. Reposition was made on the operating table.In 38(43%) cases, was used. only J. Harms technic, performed with 4 and 6, screw structures in C1-C2, C2-C3, C1-C3, C1-C2-C3 segments. In 14(16%) posterior fixation was performed with 2 screws on one level at C1-C1 and C2-C2. Occipitospondylodesis was applied in 30(34%) cases. Frontal fixation was performed 6(7%) times - cannulated screw in odontoid of C2. Control CT was performed in 3, 6, 9 and 12 months after surgery. Results of treatment were estimated by using VAS, ODI, RDQ scales and questionnaires Evaluation of pain was carried out using VAS before the operative treatment, at 1, 5, 10 days, 1, 3, 6, 9 months. It was found that pain rapidly regresses during the first week after surgery: occipitospondylodesis 5-6 points, single- and multi-level fixation 4-5, cannulated screw 3-4 to the end of the first week after surgery. Most satisfied with the quality of life in the early and late postoperative period are patients operated with connulated screw and single-level fixation. In the remaining groups quality of life improved more quickly than a less extended structure was established. It is worth noting that in these 2 groups (occipitospondylodesis and multilevel fixation) at 1 month after surgery difference in the quality of life was not significant. Catamnesis ranged from 1 to 36 months. Results: Orthopaedic good or excellent results obtained in 100% of cases. Consolidation occurred within the period from 3 till 12 months. Clinically significant complication was in 1 case. In 3 cases were asymptomatic malposition of screws. No mortality and infectious complications. The results of the functional state estimation in the early and late postoperative period on scales ODI and RDQ as follows: patients with occipitospondylodesis gradient of the absolute values in the range of 76% -30% and 5.12 points, respectively; patients with multi-level fixation of 72% -25% and 12-4 points; patients with single-level fixation of 72% -20% and 12-2; patents with cannulated screw 68%-20% and 12-2. Conclusion: For fractures of the C2 vertebra such as Hangman type, and unstable fractures of C1 monosegmental transpedicular C2-C2 and C1-C1, lateral mass fixation, preserves the physiological properties of the craniocervical transition with sufficient stability in the zone of fracture, for consolidation. An anterior odontoid fixation with cannulated screw is most preferred for fractures of the odontoid process of C2 type 2, because preservation of C1-C2 joint function. In the best long-time quality of life patients with single-level posterior fixation and fixation with cannulated screw., Introduction: In Chile, amateur diving is a frequent summer activity. Spinal injuries after diving in recreational context can lead to catastrophic consequences, mostly in young and economically active population. Material and Methods: We reviewed 45 patients hospitalized in our center, admitted to the neurosurgery unit between 2006 and 2016, with spinal injuries due to diving accidents. Data was collected from their initial admission and from follow-up records. Statistic analysis was performed using Microsoft Excel 2010 and STATA v10. Results: Of the total number of patients evaluated, all sustained injuries. Mean age was 32 (SD: 15 - 55) years. 96% were mens (43/45). All reported injuries occurred during summer. Alcohol consumption was present in 44% of cases. The most affected segment was cervical (91%), and the most common injuries were C5-C6 dislocation and fracture (20%) and C4-C5 dislocation and fracture (18%). 29% of patients presented severe neurological compromise (ASIA A, B, C) at time of admission. Surgical treatment was required in 49% of cases, the majority using an anterior cervical approach. The other 51% underwent orthopedic management. NASCIS 2 methylprednisolone protocol was used in 13% of cases. Overall, 22% of patients received steroid therapy. Thirty day mortality for the cohort was 6.7%, all ASIA A. Mean hospital stay was 18 (SD: 1 - 354) days. Conclusion: Diving accidents in Los Angeles Chile, while uncommon can result in spinal injuries with drastic consequences, including permanent physical disability, mortality and a profound socioeconomic impact. In our experience, an optimal initial trauma assessment follow by early surgical and orthopedic management resulted in best clinical results. The consumption of alcohol worsen the outcomes. Prevention strategies should be implemented to reduce the incidence and impact of this problem., Introduction: We have reviewed the case records of 7 patients with odontoid fractures treated by anterior odontoid screw fixation Material and Methods: The mean age at the time of injury was 67.3 years old(range 28–87 years old) Of these patients, 5 were men and two were women. The mechanism of injury in all was high-energy trauma; 1 patient was injured in motor vehicle accident, 5 patients fell from a height, and 1 patient injured head by falling object. There were 5 patients with Anderson and D’Alonzo type II fractures and 2 with type III. Results: The mean interval to the operation was 10.7 days (range 1–25 days), The mean operation time was 75 minutes(55–115 minutes). Two patient were died from pneumonia and cancer within 3 months after operation. The remaining 5 patients were followed. The mean follow-up period was 12 months (range 6–24 months). Clinical results were evaluated using X-ray, CT scan and MRI. Of 5 patients, 4(80%)achieved bony union by anterior screw fixation. One patient, in a case of non-union, did not require a secondary operation. No patient developed infection or neurological injury after surgery. A full of range of motion was obtained in all cases. Conclusion: We conclude that anterior screw fixation, although technically demanding, is an effective and relatively safe procedure in the treatment of odontoid fractures., Introduction: Cervical spine fractures may be associated to potential catastrophic sequelae for patients, together with elevated direct and indirect costs related to their management. Their incidence in rugby players has increased in the recent years, mainly due to higher energy mechanisms as a result of progressively faster and bigger players. Our objective is to present a case series of rugby players with cervical spine fractures, focusing on their injury mechanism and treatment. Material and Methods: We reviewed the medical records and imaging of patients treated in our center for a cervical spine fracture due to a rugby-related accident since 2009 (seven-year period). We recorded demographics, characteristics of the injury mechanism, type of fracture and treatment modality. We performed a literature review, focusing on injury mechanism, prevention and return to sport timing after these injuries. Results: Case series of six male patients (mean age 21.6 years [18-26]), only one of them (16.7%) presented neurological impairment (ASIA Impairment Scale, (AIS) D), which evolved to complete recovery (AIS E) after surgical treatment. Five patients (83.3%) were injured during a tackle (three tacklers and two tackled players) and only one patient (16.7%) was injured in a scrum. In two patients (33.4%) the injury was missed during the initial assessment with X-rays and it was detected with a computed tomography scan performed at a mean of 7 days [6-9] after the accident due to persistent neck pain. The C6-C7 segment was the most frequently affected (50%, 3/6 patients) and 83.3% (5/6 patients) required surgical treatment due spinal instability. The available literature describes an increase in injuries as a result tackling, but with a higher incidence of neurological impairment in scrum-related accidents. Modifications to regulations have been introduced in order to reduce the risk of injury, but with no real results yet. There is still no consensus regarding return to rugby (and its timing) after a cervical spine fracture. Conclusion: Cervical spine fractures must be ruled out in rugby players presenting with neck pain after game-related trauma. The incidence of these injuries is progressively increasing, their management usually requires surgery and there is still no consensus regarding return to play., Introduction: Neglected cervical dislocations have been variably defined as luxation’s presenting more than 2 weeks, 3 weeks or 8 weeks. Various authors have described combinations of soft tissue and/or bony resections for intra operative achievement of optimum alignment and/ or reduction. With this background, we present our experience of an alternative approach of single stage anterior corpectomy in 8 cases of irreducible neglected subaxial cervical spine fracture dislocations presenting with a mean delay of 3 months. Material and Methods: Records of 12 patients with neglected cervical subaxial dislocations presenting to a tertiary referral centre form a period extending from January 2012 to December 2014 were reviewed. Among them 8 patients were irreducible and included for analysis while reducible dislocation was excluded. Those who failed closed reduction underwent anterior corpectomy with autologous tricortical iliac crest bone grafting and plating with foraminal clearance. The dislocated vertebrae encroaching the spinal canal was planned for corpectomy, aiming for spinal canal clearance, decompression, fusion and maintaining align ment. All patient was attempted to fusion and stabilize with tricortical iliac crest graft and low profile anterior cervical plate. Garden well tong inserted under GA- 20 KG for 10 minutes to assesss reducibility. No reduction or distraction at dislocated facet was noticed on fluoroscopy. The cervical spine was exposed by standard Smith and Robinson approach from left side. A complete microscopic anterior corpectomy, was performed, with complete anterior decompression of the cord assessed with penfield. Graft size was measured and tricortical iliac crest graft of measured size harvested and inserted in the corpectomy site. Plate of appropriate size inserted. Mobilisation of the patient was started second day. Follow-up radiographs included anteroposterior, lateral with CT scanning at 12 months. The neck movements were also painless at 12 months follow-up. The clinical and radiological signs were suggestive of good interbody fusion. Results: The mean delay in presentation was 10 to 16 (mean, 12) weeks, mean age was 37.5 yrs (25 – 55yrs). The mean follow-up was 26 (range, 14–36) months. 4 patients improved form ASIA C to ASIA D, 2 improved form ASIA C to ASIA E, 1 patient improved form ASIA D to ASIA E and one of the patient remained static at ASIA C. All patients showed evidence of adequate fusion on CT scan. The mean duration of surgery was 148 minutes with average blood loss of 350 ml. The average cost of surgery was 200 USD. Conclusion: Persistent dislocations are not easily amenable to closed reduction owing to the fact that they have been found to be associated with fibrosis and ossification around the vertebral bodies, unco-vertebral and facet joints. Our method is single approach, single level corpectomy of the lower vertebra causing compression of the spinal cord. This technique is to achieve decompression, stabilization & fusion of unstable sub axial cervical dislocation injury in a single stage is associated with excellent fusion in all cases, neurological recovery., Introduction: Fractures of the odontoid bone are the most common injuries of the upper cervical spine, following a trauma associating a combination of antero-posterior shearing forces and compression. The evolution towards nonunion is frequently explained by vascular phenomena and mechanical loads. We reported the case of a nonunion of the odontoid bone diagnosed after an 8 months posttraumatic delay. Methods: He was a 23 year old man, who presented with a posttraumatic torticollis lasting for eight months for which he has consulted several times but no diagnosis was retained. Clinical examination found an irreducible torticollis without neurological signs. Plain radiography showed a mobile odontoid nonunion on the dynamic views. CT scan and MRI confirmed the diagnosis and the absence of spinal cord injuries. He had an occipitocervical fusion through a posterior approach after a reduction period of 21 days through a continuous traction by a cranial halo. Results: At last follow-up of 2 years, the patient was indolent with disappearance of torticollis and no neurological signs but with a certain limitation of rotation. Conclusions: Nonunion is a common complication of fractures of the odontoid bone, explained by, in one hand, a fragile vascularisation which is epiphyseal type and, in other hand, by the occipito-altoido-axis complex which causes a physiological stress on the odontoid. Immediate neurological lesions are rare but extremely serious. The natural evolution of nonunion of the odontoid bone remains unpredictable with possible onset of myelopathy. The treatment is mostly surgical by an occipitocervical fusion or direct bone grafting of nonunion fixed by screws associated or not to an anterior plate. This technique preserves good mobility in rotation but is difficult to implement, other techniques may be cited as the C1-C2 wire lacing with bone graft. Nonunion of the odontoid bone is an injury that often goes unnoticed whose natural evolution is unpredictable. The occipitocervical fusion is a neurologically low-risk method which gives satisfactory results with moderate functional impairment., Introduction: Unifacet dislocation of the cervical spine is a very common injury. Most of the authors recommend urgent close reduction in an awake, alert and cooperative patient. If the reduction could not be achieved by closed means, then open reduction and internal fixation is recommended. The belief is that conservative treatment can lead to chronic neck pain and facet joints osteoarthritis. The aim of this paper is to evaluate the short term outcome of conservative treatment of these injuries. Material and methods: In the period 2002 to 2015 we identified 36 patients with unifacet dislocations of lower cervical spine. None of them had neurology. All of these patients were treated in skeletal traction with cone caliper and weight depending on the level of injury. All of them were kept in traction for 6 weeks and then in SOMI brace for further 6 weeks. At the end of 12th week the brace was removed and flexion and extension X- ray views were performed. These patients were followed up for an average of 2 years (from 6 months to 5 years). These patient were given physiotherapy and analgesia if they have pain occasionally. Results: We noted that 5 out of 36 patients continued having chronic neck pain, but the remaining eleven patients had satisfactory results. This showed that conservative treatment of the unifacet dislocation will work in selected patients with out neurology. Conclusion: Conservative treatment of unifacet dislocations of the lower cervical spine can achieve satisfactory results. In our series only 13.9% developed chronic neck pain. This is very little as compare to surgical treatment patients and complication of the surgery. Our study showed that conservative treatment also has a role in the treatment of unifacet dislocation of cervical spine not all patient require surgery. These patients have good range of movement of the neck., Introduction: Spontaneous spinal epidural hematoma (SSEH) manifests from blood accumulating in the epidural space, compressing the spinal cord and leading to the acute onset of neurological deficits. Despite the pathology’s obscurity, supported by the paucity of reported cases, the high morbidity of untreated SSEH warrants its inclusion in the differential diagnosis of any presentation suggesting spinal cord involvement. The condition’s contested etiology, low incidence, and extensively varying symptoms, which range from local vertebral pain to paresis, create a spectrum too wide for generalized treatment. Decompressive laminectomy and drainage is standard, though spontaneous recoveries have been reported. In fact, nonsurgical management is a viable course of action often overlooked in current literature, though it remains unclear which type of SSEH patient will benefit from surgery. This uncertainty translates into sub-optimal management principles, with a mortality rate of over 5% and a morbidity rate ten times as high. This study aims to investigate parameters that affect SSEH’s progression, outlining a best-practice therapeutic approach. Material and Methods: Review of literature containing a case series of patients, managed either surgically or nonsurgically, with neural examination before and after treatment, yielded 65 cases from 12 studies. Furthermore, 6 cases were presented from our institution. All data were analyzed under the American Spinal Injury Association (ASIA) guidelines. Results: Over 50% of SSEH patients do not fully recover. 30% of patients that presented with an ASIA score of A did not improve with surgery, though every SSEH patient who presented at C or D improved. Spontaneous recovery is rare - only 23% of patients were treated nonsurgically. Patients managed nonsurgically were 3 times as likely to have an initial score of D - the least severe score before full recovery - than their surgically managed counterparts. This indicates that nonsurgical management tends towards low-risk patient presentations. However, not all patients treated nonsurgically present with minimal neural deficit. 33% of patients managed nonsurgically had an initial score of A or B, all improving to a score of D or E without surgery. Furthermore, 73% of the nonsurgically managed patients made a full recovery, as opposed to the 48% of patients managed surgically that fully recovered. Conclusion: We recommend close neurological monitoring and early imaging be completed for any patient with suspected SSEH. Once confirmed, rapid determination of those requiring surgical intervention should be based on the evolution of their neurological status from time of onset to the latest neurological examination. The degree of preoperative neural deficit is a major prognostic factor. If spontaneous recovery is manifested, the nonsurgical approach is a feasible, overlooked, and 25% more effective. In addition, our case study documents one such SSEH patient making a full recovery through nonsurgical management. This spontaneous recovery is an ideal model to atraumatically study the reversibility of acute spinal cord compression symptoms without intervention, and to identify the critical timeframe until irreversible damage occurs. However, laminectomy and drainage should be readily available should the patient’s impaired neurological status stagnate or worsen, supported by the inverse correlation between operative interval and the resulting extent of recovery., Introduction: Due to increasing ossification and to the changing stiffness of the spine, patients with ankylosing spondylitis suffer spinal fractures more often. Trivial falls are not rarely the cause of the fracture and the injury. The changed biomechanics count for the increased number of injury patterns and neurological deficits. Material and Methods: Radiological evaluation is difficult and spinal fractures are overlooked in a considerable amount of patients. The patients need specific surgical treatment and strategies considering the biomechanical properties. Fractures of the thoracic and lumbar spine need multi-level instrumentations, fractures of the cervical spine need to be addressed with dorsoventral fusion techniques. Results: We describe our patient collective of 2009-2013 with 35 consecutive patients with spinal fractures and ankylosing spondylitis. The cause of trauma and localisation of fracture, as well as the neurological deficits are depicted. Surgical strategies used are described and the therapy-free intervall is analyzed. Conclusion: Patients with spinal fractures and ankylosing spondylitis need specivic diagnostics and very specific surgical treatment. The knowledge of the disease with its unique pitfalls is important to manage these patients adequately., Introduction: Achieving adequate surgery for early onset scoliosis (EOS) is difficult because of these challenges: the need to correct the deformity, the need to allow adequate spine growth, the need to allow adequate lung development, the need to minimize complications. GSP system was found to solve these troubles with minimal complications in comparison with other techniques. Material and Methods: Combined prospective and retrospective study on 15 patient with early onset scoliosis treated surgically with the GSP system in Assuit University Hospital Egypt and postoperative follow up and analysis of the results and complication was done after the index surgery and after each 6months programmed lengthening all of the following parameters was assessed: 1) Cobb’s angle correction, 2) T1-S1 height, 3) apical vertebral translation (AVT), 4) space available for the lung (SAL) ratio, 5) shoulder and pelvic balance. Also, surgical details are mentioned including: 1) single or dual rod technique used, 2) operative time, 3) blood loss, 4) mean arterial blood pressure during surgery, 5) neuromonitoring during surgery, 6) intraoperative complications. Results: GSP system is a very successful method in management of early onset scoliosis as regarding correction of the deformity, allowing spine growth, allowing proper lung development. However, it has some complication that can be avoided by proper patient selection and proper surgical technique. Conclusion: GSP is a good system for management of EOS with good patient selection and good surgical experience., Introduction: Fracture spine is a common traumatic event. The morbidity of such event is high and many studies to decrease the magnitude of this morbidity were done. Management of fracture spine varies between operative and non-operative options. Operative techniques varies between open posterior, percutaneous posterior and anterior techniques. Vertebroplasty or kyphoplasty may be suitable in certain types. Open posterior approach is the most commonly used approach, however chronic postoperative back pain is a very common complain. Muscle ischemia and subsequent necrosis was said to be the cause of this postoperative pain in cases with no detectable other causes eg, osteoarthritis. Material and Methods: Comparative prospective study on 20 patient with fracture affecting the lumbar vertebrae that are managed surgically with (TPSF) 10 through traditional midline approach and 10 with wiltse approach. Surgical technique and details of the fracture vertebra and type of the fracture are recorded as well as surgical time, blood loss and intraoperative complications. Follow up is done at 6 weeks 3 and 6 months and VAS was recorded at each visits. MRI at 6 months is done and degree of muscle necrosis was calculated by an expert radiologist. Results: Patient with wiltse approach has less blood loss, less operative time, less postoperative pain, less pain at the short and long term follow up. Conclusion: Wiltse approach appear to have lesser degree of postoperative pain, less muscle necrosis and less degree of blood loss., Purpose: The increasing number of fragility fractures of the sacrum is a clinical challenge, they present distinct fracture patterns and surgical treatment is limited by bone loss in face of osteoporosis. Methods: Using statistical computational methods, the mean bone mass distribution in Hounsfield units (HU) was calculated with Computed Tomography (CT) scans from 13 pelves with an non-displaced fracture of the sacrum (11 females and 2 males, mean age 79.6 years, SD +/-9.2). They were compared with intact pelves of 60 adults (32 females and 28 males, mean age 8.3 years, SD+/- 5.3). Virtual bone probes were measured along trans-sacral corridor S1 and S2. Results: A distinct bone mass distribution was found: Along trans-sacral corridors, a peak of high HU was located at the outer extremes corresponding to cortical bone of the auricular surface. This was followed by a region of minimal HU located paraforaminally lateral, a zone commonly called “alar void”. In the fractured sacra, very low HU were observed in the vertebral bodies. The fractured side had higher HU in the sacral ala comparing to the non-fractured side. Conclusions: The distinct fracture patterns occurring in fragility fractures of the sacrum could be explained by the lowest bone mass located paraforaminally lateral. The very low bone mass in the sacral bodies may explain screw loosening seen in treating these fractures. The comparably higher bone mass on the fractured side may be a valuable diagnostic tool., Introduction: The objective is to report the epidemiology, clinical aspects and outcome on the management of spinal cord injury (SCI) in children and adolescents. Materials and Methods: A retrospective study of children and adolescents diagnosed with spinal cord injury (SCI) was performed. The medical records and radiological images were reviewed. Variables were tabulated regarding the mechanism of trauma, level of injury, fracture classification, neurological examination, associated injuries, surgical techniques, outcome and complications. Patients without radiological evaluation in the preoperative and/or postoperative period and patients with SCI due to gunshot wound were excluded from the paper. All patients were evaluated preoperatively and at the last follow-up with a clinical and radiological examination. Results: Ninety-three children and adolescents with SCI were identified. The mean age of the sample was 16.0 (±2.87) years, varying from 1 to 18 years. Most of the patients were male (66.7%, 62/93). Falling was the main cause in 72% of the fractures, followed by car accidents (25.8%), and falling of heavy objects on the back (2.2%). The median time from injury to medical management was 8 (6 to 24) hours. Associated injuries in other sites than the spine were present in 38 cases (40.9%). The lumbar spine was the most common fractured segment. Multiple vertebra fracture was observed in 35 (37.6%) cases. Surgical treatment was performed in 89 cases (95.7%). The median time from injury to surgery was 4 (3 to 7) days. The pedicle screw was the most common device used for fixation in 82 cases (92.1%). The posterior approach was utilized in 81 patients (91.0%). Patients that underwent internal fixation without placement of autologous bone had the instrumentation removed 1.24 years (±0.48) after the surgical procedure. Perioperative complications were observed in 13 of the 93 patients (14%). Pneumonia was the most common complication being observed in 5 patients (38.5%). The variables related to unfavorable outcome (Frankel < 5) in the last evaluation were fracture on the upper thoracic level (P < .001) and AO classification type C (P < .001). Conclusions: SCI in children and adolescent are usually caused by a fall. Multiple fractures of the spine were observed in one-third of the patients. Visceral lesions were observed in 40.9% of the cases. Nineteen (19) percent of the patients did not achieve a normal neurological examination (Frankel E). The risk factors associated were fracture on the upper thoracic level (P < .001) and AO classification type C (P < .001)., Introduction: Transverse sacral fractures constitute less than 1% of all spinal fractures and only 3% to 5% of all sacral fractures. Because of their location, they have a high incidence of neurological deficits. Despite their gravity, no well-designed treatment protocol for these fractures exists until now. Purpose: Describe the clinical features of the transverse sacral fractures; the protocol and result of their treatment. Materials and Methods: It is a descriptive retrospective study of 6 years from 2011 to 2016. We included high transverse sacral fractures. Exclusion criteria are less transversal sacral fractures and conservative treatment. Results: We compiled 5 cases of high transverse sacral fractures over a period of 6 years. All the patients were men. The mean age was 30 years (range: 27–33). Injury mechanism was a fall usually landing on buttcocks. Clinically, all patients reported sacroccigeal pain. 4 of them presented the bladder blower disturbance (BBD) characterized by incontinence, retention or flaccid sphincters. All patients did not have associated thoracolumbar injuries. In every case, a plain X-ray and a computed tomography scan were obtained at admission. Magnetic resonance imaging was performed only in the case of neurological deficit. All the fractures were classified as type III according to Denis ET all. The fracture level was S2. All patients were operated at a mean period of 15 days (range: 13–18 days) following their injuries. A posterior reduction and stabilization using segmental lumbopelvic instrumentation in the case neurologically intact or screw plate in four cases was attempted, followed by extensive laminectomies of the lumbosacral area and posterolateral fusion in case of BBD. The relevant nerve roots were explored bilaterally and were found to be intact in 75% of cases. At mean 9.8 months clinical outcome was satisfactory with no local pain, neurological recovery (control of the urethral and anal sphincters; Perianal sensation) and no local infection; while the radiological results showed bone healing. Conclusion: Sacral fractures are frequently misdiagnosed. Because of the degree of displacement and the high chances of nonunion, the transverse sacral fracture should be considered unstable and be treated with stabilization. Decompression is required in cases of neural compression and should be performed even with fifteen days delay., Introduction: Sacral fractures in elderly patients are possible with low energy trauma but they can present the same patterns of fracture. Our goal was to evaluate the clinical outcome of ilio-pelvic fixation in patients over 65 years old. Material and Methods: From November 2014 to September 2016 we have analyzed 5 patients with Denis type 2 fracture and age > 65 years old. There were 3 males and 2 females (average age 72.4 years), in 4 cases there were anterior pelvis fractures or acetabular fractures; none of our cases had neurological symptoms. We observed verticalization time, clinical function, healing time and complications. The follow up was at least 1 year. Results: In all 5 cases after 3 days the patients were verticalized; according to Majeed scoring to evaluate the clinical function: postoperative pain, standing, sitting, work ability respectively were 18.2, 24.0, 8.6, 16.2 so were good results in all 5 cases. We had 1 case of superficial wound infection. Conclusion: Iliolumbar fixation has the advantage of a stable fixation that can allow patient to weight bearing early and quick verticalization., Introduction: Prompt surgical management after traumatic spinal cord injury (SCI) is nowadays recommended. After the initial impact, a plethora of secondary events is initiated. Among these, raised intraparenchymal pressure with consecutive increased intrathecal pressure has probably been underestimated. Recent studies provide some evidence that measuring the intraspinal pressure and durotomy might be beneficial for the patient. However, before performing these procedures an in-depth knowledge about the spinal meninges and their peculiarities is essential for spine surgeons. Material and Methods: A literature review of relevant articles is provided according with self designed neuroanatomical illustrations and appropriate institutional MRI scans of meningeal structures and spaces in the physiologic and posttraumatic situation. Results: Several differences between cranial and spinal meninges need to be highlighted. The arrangement of these structures creates some compartmentalization, which might be altered after spinal trauma. Recent data shows that the spinal cord is compressed against the dura mater in a significant amount of SCI patients causing a “compartment-like” syndrome. This implies that in some patients durotomy with consecutive expansion duroplasty in order to reduce intraspinal and improve spinal cord perfusion pressure seems to be justified. Among others, the role of the pia mater should not be underestimated. A review about the current neuroanatomical understanding of spinal meninges with according neuroradiologic examinations and their potential contribution to the acute and chronic surgical management is provided. Conclusion: A profound knowledge— even on an ultrastructural level - about the spinal meningeal structures is essential for surgeons dealing with SCI patients in the acute and chronic setting., Introduction: Spinal cord decompression with pedicle screws stabilization in case of traumatic injuries might be associated with a significant blood loss and morbidity with a considerable contribution of injured muscles in postoperative pain syndrome. The objective of this study is to compare the results of conventional interventions with less invasive ones using paraspinal approach and endoscopic assistance. Materials and Methods: This is a prospective non-randomized longitudinal case-control study of 74 consecutive patients. All patients presented with fresh fractures of either lumbar spine or thoracolumbar junction. Type of vertebra body injuries were complete and incomplete burst fractures (A3 and A4 types). 39 patients were treated using paraspinal approach for pedicle screws placement and less invasive transpedicular decompression (LISS group). Endoscopic assistance during decompresson was applied in 20 cases. Nineteen out of those patients were treated using combined approach applying less invasive anterior spondylodesis with endoscopic assistance. In 35 cases a conventional approach was used with broad exposure of spinal column structures, pedicle screws fixation and decompressive laminectomy (control group). 14 patients out of this group were treated using combined approach with conventional anterior spondylodesis. The length of approach, time of surgical intervention, blood loss and ODI 6 months after surgery were compared in two groups. Electromyography and ultrasound examination were used to assess postoperative paraspinal muscles injury. Student’s t-test was used to assess statistical significance of differences between two groups of patients. Results: A size of incision for dorsal decompression and stabilization approach was smaller in LISS group, mean values for LISS and control groups were 44.67 ± 0.74 mm and 110.71 ± 0.23 mm respectively (P < .0001). Intraoperatively blood loss almost halved in LISS group, mean values for LISS and control groups in case of short fixation (2 segments) were 242.56 ± 9.08 versus 480.00 ± 22.66 respectively (P < .0001), in case of extended fixation (3-4 segments) mean values were 250.00 ± 17.50 ml and 518.75 ± 26.57 ml respectively (P < .0001). Additional reduction in blood loss was achieved applying endoscopic assistance (227.0 ± 8.32 ml versus 269.00 ± 18.36 ml, P = .0032). Average duration of surgical intervention was 125.00 ± 5.00 min in LISS group and 166.77 ± 6.84 min in control group (P < .0001). A mean size of ventral approach in LISS group was 89.26 ± 5.00 mm versus 140.43 ± 0.63 mm in control group (P < .0001). Blood loss was considerably smaller in LISS group, mean values for LISS and control group were 478.95 ± 62.28 ml and 750.00 ± 73.75 ml respectively (P = .0042). Also a significant decrease in duration of surgical intervention was evident in LISS group (152.63 ± 6.18 min versus 228.57± 17.47 min in control group, P < .0001). Mean ODI scores were 13.50 ± 1.58% in LISS group versus 22.38 ± 1.84% in control group 6 months after surgery (P = .0004) and 8.00 ± 0.91% versus 14.00 ± 1.39% respectively 12 months after intervention (P = .0126). Electroneuromyography and ultrasound examination confirmed intact status of paraspinal muscles in LISS group. Conclusion: Less invasive techniques are effective measures to achieve a considerable decrease in blood loss, duration of interventions and intraoperative tissue damage. Preservation of tissues including paraspinal muscles using MISS techniques results in a significant long term decrease in ODI scores after spinal instrumentations., Introduction: Thoracolumbar (T-L) fracture management aims to prevent deformity and to promote healing. This requires identification and characterisation of the injury. The introduction of trauma protocols means that where there has been a dangerous mechanism of injury or the patient exhibits abnormal physiology, a CT scan is the default radiological investigation. This leaves a subgroup of patients who may have suffered T-L spinal trauma in whom plain X-rays (XRs) are performed. Our clinical experience suggests that AP (antero-posterior) views in these people are not particularly useful in management. The purpose of the study was to determine the contribution made by AP XRs in the management of people with these relatively low velocity injuries. Material and Methods: All people with a history of T-L trauma and suspected abnormal XR referred to the spinal service over 20 weeks were reviewed. Those with a CT scan performed prior to XRs were excluded. Four Consultant Spine Surgeons and four Consultant Neuroradiolgists were shown the lateral XR along with the history and examination findings recorded on the referral data base (ie, the information given to the consultant on the day of the referral). If patients had both erect and supine XRs on the same day, only the erect XRs were included in the study. We assumed that the latter were probably the films on which the referrals were based. If they were performed on different days, both the erect and supine XRs were included. They were asked to provide a management and/or follow-up imaging plan based on the XR. Then they were shown the AP XR and asked if they would like to change their advice. Any changes in advice were recorded. Results: 52 patients were included in the study. 34 sets of supine XRs and 40 sets of erect XRs were included (all with lateral and AP except 4 cases with only lateral erect XRs performed). This yielded 1152 film-consultants. Average age was 58.5 years (SD 18.9 years) with 30 males and 22 females. 45/52 (87%) were AO type A (compression-type) fractures and 7/52 (13%) had no clear fractures identified (possibly due to poor quality of the film or due to other underlying spinal deformities obscuring the picture). 24/52 (46%) of fractures appeared to be osteoporotic. 54% have fractures were between T11 and L2 inclusive. There was universal agreement between all assessors that in all cases the AP XR did not change the management plan. It was noted that they can be helpful to confirm levels at the TL junction if the lumbosacral junction is not demonstrated on the lateral film. Conclusion: Our results suggest that AP XRs do not contribute to the management of low velocity thoraco-lumbar fractures. Larger studies are required to support these findings but there appears to be potential to reduce both cost and radiation exposure., Introduction: To evaluate results regarding pain relief, spinal stabilization, and complication after treatment with percutaneous vertebroplasty and kyphoplasty. Material and Methods: A consecutive group of patients, undergoing vertebroplasty (103 patients) and kyphoplasty (82 patients) at our institution, between January 2010 and December 2014, were retrospectively reviewed. 103 patients underwent 127 vertebroplasty procedures under local anesthesia, and 82 patients underwent 88 kyphoplasty procedures, 13 under general and 75 under local anesthesia. A radiological assessment was achieved by the percentage of height restored, using both the preoperative and postoperative radiographs. The Visual analog scale scores, obtained pre and postoperatively were used for the clinical assessment. The activity levels were assessed preoperatively, after discharge and at the last follow up period, by the ambulatory status. Results: The vertebroplasty restored 28.61% anterior column and 31.42% middle column of the lost height. The kyphoplasty restored 34.61% anterior column and 52.34% middle column of the lost height (P = .432, P = .027). The postoperative pain was improved in all patients after both procedures. The postoperative Visual analog scale was 3.268 after the VP and 2.356 after the kyphoplasty (P = .634). The activity levels were improved in all patients after both procedures. Conclusion: The kyphoplasty was more efficient in restoring the middle vertebral body height than the VP in the treatment of Osteoporotic Compression Fractures. However, both procedures showed similar clinical improvements in the pain and restoration of the anterior vertebral body height in the treatment of Osteoporotic Compression Fractures., Introduction: Ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are spine disorders causing ossification of the spinal ligaments and loss of segmental motion. Both AS and DISH are associated with a significantly increased risk of spine fractures, even from relatively mild trauma, due to the long lever arms caused by the ossified ligaments, in combination with reduced bone quality. Conservative and operative treatment of spine fractures in these disorders is associated with high rates of complications and neurological deficit; hence there remains some controversy about the optimal approach. Since 2008, we have been treating these fractures with percutaneous instrumentation combined with poly methyl methacrylate (PMMA) augmentation of the pedicle screws. The current study assesses the outcomes associated with this surgical technique. Material and Methods: All imaging records for patients with who underwent surgery for thoraco-lumbar spine fractures between 2008-2015 at the Galilee Medical Center were reviewed, and cases with AS or DISH) were identified (n = 24). For these cases, a retrospective imaging and chart review was carried out, assessing surgical parameters and outcomes. Results: Twenty-six (24) patients with a thoraco-lumbar spine fracture and AS or DISH underwent surgery at the Galilee Medical Center since 2008. Eleven of the patients had a diagnosis of AS (45.8%), and thirteen had a diagnosis of DISH (54.16%). patients were predominantly (16/24) male, with a mean age at surgery of 76 years (range 54-88). Extent of vertebral involvement in ankylotic disease, as determined by review of the imaging averaged 14 vertebrae. Ankylosing disease was found in the thoracic vertebrae alone (19.2%), in thoracic and lumbar vertebrae (76.9%), or in cervical thoracic, and lumbar vertebrae (3.8%). Most (80.8%) of the patients underwent surgery within 7 days of admission, with 79.2% undergoing surgery within 48 hours. Percutaneous instrumentation spanned 2-6 levels. Surgical times ranged from 0:55-5:03 hours (mean 2:11 hours). Mean pre-post operative Hemoglobin concentration reduction was 1.21 gr%, with only 4 patients requiring blood product supplementation. 4 patients (16.6%) were admitted to ICU following surgery, for a duration of 2-7 days. 11 patients (45.8%) had medical post-operative complications, 1/24 had a superficial incisional infection. One patient died during the followup period due to an unrelated reason. The mean length of hospital stay was 14.55 days (3-33). Conclusions: This retrospective case-series of 24 consecutive patients demonstrates that percutaneous instrumentation allows rapid post-operative mobilization with relatively few surgical and post-surgical complications. Comparison with other published retrospective reviews shows favorable outcomes., Introduction: For lumbar burst fractures in young population, sometimes surgical treatment is chosen if destractionor neurological deficit is sever. Most of the time, two-disc levels fixation (above 1, below 1) is chosen, however, not small number of cases has burst fractre with intact caudal endplates. We propose here, combined posterior single disc level fixation and anterior interbody reconstruction for burst fractures with intact caudal endplate at lumbar lesion. Although 2 approaches are required, this method allows good clinical and radiological outcomes, minimizing the level fused. Material and Methods: Ten cases with lumbar burst fractures with intact caudal endplate (L1: 5, L2: 4, L3: 1) were treated by this 2-staged procedure. Average age was 30 (24-39). There were 4 males and 6 females. Indication was strictly limited to cases with injured posterior element and intact caudal endplate. Four cases had neurological disturbance (Frankel type 4). In the initial operation, a single disc-level fusion between affected vertebrae and cranial adjacent intact vertebral was performed using pedicle screw system. In this operation, the kyphotic alignment was reduced using the screw system. Then, anterior interbody fusion with cage and autogenous graft was performed. To assess clinical outcomes, vertebral kyphotic angle, two-levels kyphotic angle (affected vertebra-cranial adjacent intact vertebrae), and lordosis of the lumbar spine were measured in the preoperative period, immediately after the operations, and in the final follow-up period. Perioperative complication and final activity in the daily living were recorded. Results: In all cases, bony fusion was obtained. In 4 cases with Frankel grade 4, neurological status was improved in the final period. Average vertebral kyphotic angle of the affected vertebra was decreased from 17 deg. To 9 deg. Two-levels kyphotic angle was decreased from 17 to 8 (P < .05). Lordosis of the lumbar spine was also improved. As perioperative complication, one case suffered from superficial infection. In all cases, social activities were regained finally. No case claimed of loss of range of motion in their lumbar spine. Conclusion: Lumbar burst fractures with intact caudal endplate were successfully treated using single disc level fixation via 2-staged posterior and anterior approach. Since we can minimize the number of vertebrae fused in this method, while preservation of sagittal alignment is possible, this method is recommended as one of the minimum invasive technique., Introduction: To evaluate the clinical and Radiological outcome of spine fixation for unstable fractures at dorsolumbar junction including fractured vertebrae in Pedicular screw fixation. Material and Methods: Department of Orthopaedics and Spine surgery Ghurki Trust Teaching hospital Lahore Pakistan, Department of orthopedics and Traumatology, Khyber Teaching Hospital Peshawar, Pakistan from January 2010 to December 2014. One hundred and forty three patients were included in this study with single level fracture from D11 to L2. All patients had unstable fractures which needed fixation. Fixation was done from posterior with transpedicular screws and rods. We included fracture vertebrae in the fixation by putting transpedicular screws in fractured vertebrae. Patients were evaluated both radiologically and clinically. Radiological parameters were anterior and posterior vertebral heights, Cobb angle and sagittal index and clinical parameters were back pain using Visual Analogue Score (VAS) and disability using Oswestry disability index (ODI). All these parameters were measured before surgery immediately after surgery and at 6 months post-operatively. The data was analyzed using SPSS software version 17. Results: We included 143 patients in our study. Out of them 93 were males and 50 were females. In majority of our cases cause for spine trauma was fall from height, followed by road traffic accidents. Levels of spine fractures were 23, 47, 51, 22 at D11, D12, L1 and L2 respectively. The mean Cobb angle was 7.35 ± 4.57 preoperatively which improved to 2.18 ± 1.71 at final follow up. The mean anterior vertebral height was 17.45 ± 3.8 mm, which increased to 27.02 ± 3.83 mm at 6 month visit. The posterior vertebral body height was 26.81 ± 5.291 mm before surgery which increased to 39.63 ± 3.59 mm at 6 months postoperative visit. The pre-operative average sagittal index was 17.42°, which was reduced to an average 6.83° post operatively. According to Oswestry disability index for pain and mobility, the mean pre-operative score was 67.14 ± 17.68% which changed to 39.81 ± 20.56% at 6 months postoperative follow-up. Visual analogue score was 7.3 ± 1.3 preoperatively and it improved to 2.4 ± 0.9 at six months. No major complications occurred in our study like neurological deterioration, screw pull out, breakage of implant and Deep Vein Thrombosis, etc. Conclusion: Our study showed that transpedicular screw fixation is a good option for better outcome. When we include the fractured vertebrae in transpedicular screw fixation it improves the biomechanical stability i.e it gives extra pedicle for fixation which shorten the fixation segment and also help in reduction and deformity correction., Introduction: Vertebral fractures are one of the most important consequences of osteoporosis and trauma injuries, due to the particular anatomy and biomechanics of the entire spinal segment. This kind of disease is very important in medical care for their both economic and social impact. In medical literature, the incidence of vertebral fractures is variable, amounting to about 700:100,000 (90% due to osteoporosis, 10% trauma injuries) and approximately 10% of patients present a Multiple Fractures Vertebrae, defined as the involvement of >2 or more vertebrae. Material and Methods: From 2008 to 2016 about 902 patients underwent surgery for vertebral fracture; 97 of them presented a MFV (average age 63.7, 17-76); 83% of them presented a fracture due to osteoporosis and 17% by trauma injuries. In 32% were performed kiphoplasty and 68% spinal arthrodesis with posterior approach. Results: In one case of those who underwent kyphoplasty we had a cement leakage which however has not led to any complications for the patient. Regarding patients undergoing spinal arthrodesis in one case we had a malposition of the screws, for this reason he underwent again to surgery and one case of pull-out of the screws at a distance of about 7 months that lead as well to a re-operation. Conclusion: Treatment of these fractures appears to be a topic of discussion, it can be both surgical and conservative; the presence of neurological deficit, acute or chronic pain, vertebral instability and deformity correction leads to surgical indications, about 200:100,000 people: the most common approach to these fracture is the posterior way although there is still not a common consensus on the use of mono or pluri segmental instrumentation for these type of fractures. In our experience patients undergoing kyphoplasty procedure presented all an excellent post-operative recovery and return to normal daily activities quickly whereas patients who underwent spinal arthrodesis needed a longer recovery not referring always an optimal recovery status referred to the pre-op. Regarding the spinal arthrodesis we believe that short fixations (maximum 2 level above or below the fracture) should be preferred, when the case permits, for faster recovery time. By performing this study we were able to note that over the years has changed the type of treatment chosen, preferring more an arthrodesis rather than kyphoplasty, certainly because we improved our knowledge of this kind of diseases and how to treat them better., Introduction: Patients with unstable thoracolumbar spine fractures require surgical treatment to relieve pain, address paralysis, and stabilize the spine to prevent further segmental deformity. Optimal surgical treatment, however, still remains controversial. The purpose of this study is to examine the efficacy and safety of vertebrectomy and reconstruction of vertebral body using an expandable cage via a single-stage posterior approach for trauma-related unstable thoracolumbar spine fractures. Material and Methods: Thirty patients underwent single-stage posterior-only vertebral column resection and vertebral body reconstruction using an expandable cage. The spinal levels affected were T12 in 6 patients, L1 in 9, L2 in 4, L3 in 7, L4 in 3, and L5 in 1. Neurologic status was classified using the American Spinal Injury Association (ASIA) Impairment Scale, while functional outcome was analyzed using a visual analog scale (VAS) for back pain. Segmental Cobb angles were measured above and below the fractured vertebral body preoperatively, immediate postoperatively, and at the last follow-up. Results: The preoperative neurologic status was ASIA grade E in 6 patients, grade D in 13 patients, grade C in 5 patients, and grade B in 6 patients. Postoperatively, neurologic stability was demonstrated in 8 patients (26.7%), and 22 (73.3%) showed improvement in the ASIA grade. The mean preoperative VAS score was 8.6, which decreased to 4.3 postoperatively, and to 1.7 at the final follow-up. The mean preoperative segmental lordotic angle was 8.9°, which increased to 17.4° postoperatively, and decreased to 16.1° at the last follow-up. The mean operating time was 202.3 min, and the mean blood loss was 784.6 mL. Regarding surgical complications, an intraoperative dural tear occurred in two patients in earlier cases and cage subsidence in two severe osteoporotic patients. Conclusion: The results of our series suggest the feasibility, efficacy, and safety of this surgical option for unstable thoracolumbar spine fractures. This technique from a single posterior approach offers several advantages over traditional anterior or anterior-posterior combined approaches using strut graft or nonexpandable implants., Introduction: Spine fractures resulting from many causes particularly falls from height and road traffic accidents. It’s a major cause of disability if not treated properly. Many advocates are in the favor that pedicle fixation method is comparatively a safer procedure when compared to the risk factor at a non-pedicle counterpart. Open spine surgery is known with several limitations which include blood loss, elongated post-operative pain and disability risk. Minimal incision techniques were, therefore, a ‘looked-for’ advancement. Pedicle screw can be Polyaxial cannulated screw or Monoaxial solid screw. Our aim is to explore and find out if the screw design differences will affect the correction of the deformity after fixation of unstable spine fractures. Also, we compare the percentage of loss of Kyphotic correction after fixation between Polyaxial cannulated screw and Monoaxial solid screw systems. An attempt is made to compare short segment and long segment fixation with respect to the above said two groups. Methods and Materials: Retrospective case series of all pedicle screw fixation for traumatic thoracolumbar fracture (Open vs. MIS) in Hamad General Hospital, Doha, Qatar. The use of cannulated screws (CS) and solid core screws (SCS) during the two surgical modes named “traditional open” (OPEN) and “minimally invasive” (MISS) are considered for the study. The data comprised of patient details for the five years from 2011 to 2015 including pre-operative, intra-operative and post-operative data along with those about three follow-ups. General demographic of the patient (Age, sex), the data such as mechanism of injury, injury level, type of surgery (Open vs MISS), type of screwed used (cannulated screws and solid core screws) along with radiological parameters (vertebral height and kyphotic angle of the fractured vertebra) was collected. Results: 172 cases with traumatic thoracolumbar fracture underwent to pedicle screw fixation (Open vs MIS) either with CS or SCS. 142 male and 28 female, average age 36.1 ± 12.4 years, 100 open and 72 MIS, 76 solid and 96 cannulated screws. The average pre-operative, intra-operative and postoperative kyphotic angle of the fractured vertebra is respectively 18.9 ± 9.9 (range from 1 to 90), 7.4 ± 6.7 (range from 0 to 40) and 8.1 ± 6.5 (range from 0 to 40) degrees and an average 13.08 degree angle reduction is quantified with solid screws and 8.96 degrees with cannulated screws. Average height reduction in the pre-operative and post-operative stages shows a wide difference which indicates a successful height gain after surgery, and it is supported statistically while performing ANOVA (P < .05) in solid group comparing to cannulated one. Conclusion: Solid screws are found to be more superior in the increased correction of kyphotic angle and the height of the fractured vertebra., Introduction: Traumatic thoracolumbar spine fractures mostly occur in relatively young patients as a consequence of high energy trauma. Dependent of fracture morphology and neurology, surgical stabilization with a posterior implant might be necessary. Debate remains whether posterior implants after thoracolumbar spine fracture stabilization should be removed routinely or only in symptomatic cases. Possible concerns of implants are decreased motion, disc degeneration, facet arthrosis, metal fretting, infections and osteopenia caused by stress shielding. On the contrary, removal of the implant is a secondary surgical procedure with accompanying risks such as surgical site infection, neurovascular injury and refracture. The aim of this study was to evaluate safety, patient satisfaction and quality of life after implant removal. Material and Methods: A retrospective cohort study was performed concerning 102 patients that underwent posterior implant removal after posterior stabilization of one or more traumatic thoracolumbar fractures between 2003 – 2015 in our university medical center. All available radiographic material from time of injury was reassessed for latest AO fracture classification and degree of kyphosis before and after implantation removal. Outpatient hospital charts were reviewed to gather information about the amount of subjective complaints before and after implant removal. All patients were invited to fill out three validated questionnaires concerning quality of life (SF-36, EQ-5D) and back specific function (RMDQ) after implant removal. Additionally, questions concerning satisfaction regarding the procedure were presented. Results: The mean time between fracture surgery and implant removal was 12 months (IQR 10-14), the mean age was 38 years (18-78). Mean time from implant removal to time of questionnaire was seven years (SD 43). Complications were present in 8% of cases, most of which were superficial wound infections. Sixty-two patients (61%) responded to our invitation to fill in the questionnaires. Scores were stratified for polytrauma patients (ISS ≥ 16) which was an effect modifier. The average quality of life was slightly lower compared to a normative population but still considerably high. Patients had less back pain related disability compared to chronic low back pain patients. The majority of all groups experienced benefit, satisfaction and would hypothetically undergo a re-removal. After removal there was a kyphosis increase which did not correspond with clinical outcome. Removal decreased most complaints and routine(asymptomatic) patients also experienced benefit. A subjective increase of complaints after removal was reported in 11% of patients. Conclusion: Overall, this study shows that implant removal after posterior fixation of thoracolumbar spine fractures is a safe procedure and provides high patient satisfaction. Overall patients have a fairly good quality of life. Most symptomatic and asymptomatic patients report benefit from removal. However low risks of complications and increase of symptoms have to be weighted for individual patients., Background: Gold-standard surgical treatment for vertebral compression fractures (VCF) includes vertebroplasty and kyphoplasty, which relies on cement to provide vertebral body (VB) stability, VB height increase and lordotic alignment. However, cement-kyphoplasty fails primary VB restoration in 34% of cases and secondary loss of height in 18-63%. Cement has adverse effect of bony consolidation and fracture healing favoring the migration of the bloc of cement. It also affects biomechanical properties of bone, increases stiffness and rigidity, which may promote adjacent fractures. Additionally, cement leakage may cause spinal cord compression, and pulmonary embolism, which may be potentially serious. Recently, a novel OsseoFix Spinal Fracture Reduction System has become available. It features a percutaneously implantable titanium scaffold that expands within the vertebral body. The aim of this study is to evaluate VCF fixation using OsseoFix without cement. We hypothesized that the titanium mesh scaffold without cement can adequately restore VB height and sagittal alignment lost in VCFs, translating to good radiological outcomes. Material and Methods: 13 patients (5 males and 8 females, mean age 63.5) diagnosed with VCFs were included in this study. Osteoporosis, trauma and tumor were concomitant with VCFs in 7, 3 and 3 patients, respectively. A total of 28 vertebrae were treated, with one implant in 6 vertebrae and two implants in 22 vertebrae. Anterior, middle and posterior VB heights (AH, MH, PH) and index level Kyphotic angle (KA) were evaluated pre- operatively, at immediate post-operatively, and at last follow-ups. Results: All 50 implants were optimally positioned and deployed without any complication. Stabilization of the collapsed vertebral body was achieved in all 28 vertebras. Mean follow-up was 26 months (18-34months). The postoperative kyphotic angle (KA) revealed significant improvements (KA 12.2° to 7.2°, P < .01) with partial loss of reduction at final follow-up (KA 8.6°). AH, an indicator of vertebral body reduction, improved significantly from 20.6 ± 1.9 mm preoperatively to 25.1 ± 2.0 mm (P < .05) postoperatively, but decreased to 21.5 ± 1.1 (P < .01 [postoperative vs. follow-up]) at final follow-up. Correspondingly, MH improved from 18.39 ± 1.7 mm to 24.6 ± 2.0 and finally declined to 22.5 ± 1.9 mm. PH changed from 28,31.8±1.7 mm to 32.3 ± 1.9 mm postoperatively to 30.7 ±1 .9 mm at final follow-up. Conclusions: Percutaneous implantation of OsseoFix to treat VCFs provides good radiological outcomes at a low complication rate. As it provides an adequate maintenance of reduction, OsseoFix implantation offers an effective alternative to vertebroplasty or kyphoplasty, eliminating any cement-related complications. This study prompts additional studies with longer follow-ups for this novel cement-free vertebral stent as a potential next-generation treatment of VCFs., Introduction: The vertebral fracture is a wound that grows from a vertebral body to the vertebral function unit. In Mexico the most affected vertebras are the ones between T11 and L1 in the 52% of the cases, in which the 45% happen after a bursting wound, most of them are caused by fallings (50.5%). The toracolumbar vertebral column bursting fractures can be treated in a conservative or surgical ways. Having a lack of information regarding this cases in Mexico. The objective is identify the category of the evidence and the recommendation of conservative treatment for these kind of fractures. Material and Methods: A check up was performed in the period started in April 2014 and finished in June 20015, selecting articles according to their design, related to the toracolumbar vertebral column bursting fractures and their possible treatment, published in electronic bibliographies during January 2009 and January 20015. Results: It was found a total of 9,504 articles in which 7 fulfill the criteria of selection and were included for their analysis. A total of 435 patients were analyzed, in which 72 patients received a surgical treatment and 363 received a conservative treatment. Showing an evidence of “1b” with a recommendation force type “A”. Conclusion: According to the evidence, the conservative treatment is a choice for the patients with stable bursting fracture, without neurological wound and in one level of the toracolumbar vertebral column., Purpose: The purpose of our study is to evaluate the therapeutic efficacy of short-segment percutaneous pedicle screw fixation with polymethylmethacrylate (PMMA) augmentation for the treatment of osteoporotic thoracolumbar compression fracture with osteonecrosis. Methods: Osteoporotic thoracolumbar compression fractures with avascular necrosis were treated by short-segment PPF with PMMA augmentation. Eighteen were followed up for more than 2 years. The kyphotic angle, compression ratio, visual analog scale (VAS) score for back pain, and the Oswestry Disability Index (ODI) were analyzed. In addition, radiologic and clinical parameters of PPF group were compared with percutaneous vertebroplasty (PVP) group. Results: Vertebral height and kyphotic angle of the compressed vertebral bodies were significantly corrected after the operation (P < .05). Further, restored vertebral height was maintained during the 2 or more years of postoperative follow-up. Compared to the PVP group the postoperative compression ratio and kyphotic angle were significantly lower in the PPF group (P < .05). The postoperative ODI and VAS of the PVP group were significantly higher than the PPF (P < .05). Conclusions: According to our results, short-segment PPF with PMMA augmentation may be an effective minimally invasive treatment for osteoporosis in cases of osteoporotic vertebral compression fractures with Kummell’s osteonecrosis., Introduction: Preclinical evidence suggests that persistent compression of the spinal cord after a primary injury represents a reversible form of secondary injury which, if ameliorated in an expeditious fashion, may lead to reduced neural tissue injury and improved outcomes. The objective of this guideline is to discuss the timing of surgical decompression in patients with traumatic spinal cord injury (SCI) and central cord syndrome. Material and Methods: A systematic review of the literature was conducted to address the following key questions: (1) what is the efficacy and effectiveness of early decompression (≤ 24 hours) compared with late decompression (>24 hours) or conservative therapy based on clinically important change in neurological status?; (2) does timing of decompression influence functional or administrative outcomes?; (3) what is the safety profile of early decompression compared with late decompression or conservative therapy?; (4) what is the evidence that early decompression has differential efficacy or safety in subpopulations?; and (5) what is the comparative cost-effectiveness of early versus late decompression? A multidisciplinary guideline development group used this information, in combination with clinical expertise, to develop recommendations for the timing of surgical decompression in patients with SCI and central cord syndrome. The benefits and harms, financial impact, acceptability, feasibility and patient preferences of each recommendation were carefully considered. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weak recommendation is indicated by “we suggest”. Results: The main conclusions from the systematic review included: (1) isolated studies reported statistically significant and clinically important improvements following early decompression (versus late) at 6 months (cervical injury, low strength of evidence) and following discharge from inpatient rehabilitation (all levels, very low level evidence) but not at other time points; (2) in one study on acute central cord syndrome without instability, a marginally significant improvement in total motor scores was reported at six and 12 months in patients managed early versus late; however, there were no significant differences between groups with respect to improvement in AISA Impairment Scale (very low strength of evidence); and (3) there were no significant differences in length of acute care/rehabilitation stay or in rates of complications between treatment groups (low to very low level evidence). Our recommendations were: “We suggest that early surgery be considered as a treatment option in adult patients with traumatic central cord syndrome” and “We suggest that early surgery be offered as an option for adult acute SCI patients regardless of level.” Quality of evidence for both recommendations was considered low. Conclusion: These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in patients with acute SCI and central cord syndrome by promoting standardization of care, decreasing the heterogeneity of management strategies and encouraging clinicians to make evidence-informed decisions. These guidelines are intended to be used by first responders, emergency room physicians, critical care specialists, neurologists and spine surgeons., Introduction: Given its potent anti-inflammatory actions, methylprednisolone sodium succinate (MPSS) may have potential neuroprotective effects in patients with spinal cord injury (SCI) when administered at high doses. The objective of this guideline is to outline the appropriate use of MPSS in patients with traumatic SCI. Material and Methods: A systematic review of the literature was conducted to address the following key questions: (1) what is the efficacy, effectiveness and safety of MPSS compared with no pharmacologic treatment?; and (2) what is the evidence that MPSS has differential efficacy or safety in subpopulations? A multidisciplinary guideline development group used this information, in combination with their clinical expertise, to develop recommendations for the use of MPSS. The benefits and harms, financial impact, acceptability, feasibility and patient preferences of each recommendation were carefully considered. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weaker recommendation is indicated by “we suggest.” Results: The main conclusions from the systematic review included: (1) there were no differences in motor change at any time point in patients treated with MPSS compared to those not receiving steroids (moderate level evidence); (2) when MPSS was administered within 8-hours of injury, pooled results at 6- and 12-months indicate modest improvements in mean motor scores in the MPSS group compared with the control group (moderate level evidence); (3) there was no statistical difference between treatment groups in the risk of death, wound infection, gastrointestinal hemorrhage, sepsis, urinary tract infection, pneumonia or decubitus ulcers (moderate level evidence). Our recommendations were: (1) “We suggest not offering a 24 hour infusion of high dose MPSS to adult patients who present after 8 hours of acute SCI” (moderate evidence); (2) “When started within 8 hours of injury, we suggest that a 24 hour infusion of high dose MPSS be offered to adult patients with acute SCI as a treatment option” (moderate evidence); and (3) “We suggest not offering a 48 hour infusion of high dose MPSS for adult patients with acute SCI” (no included studies, expert opinion). Conclusion: These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care, decreasing the heterogeneity of management strategies and encouraging clinicians to make evidence-informed decisions. These guidelines are intended for use by first responders, emergency room physicians, critical care specialists, neurologists and spine surgeons., Introduction: Patients with spinal cord injury (SCI) are at an increased risk of venous thromboembolism (VTE) due to hypercoagulability, stasis and intimal injury. The prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE) is critical in this high-risk population. The objective of this study is to develop guidelines that outline optimal anticoagulation strategies in patients with SCI. Material and Methods: A systematic review of the literature was conducted to address the following key questions: (1) what is the comparative effectiveness and safety of pharmacological, mechanical and/or invasive anticoagulation strategies for preventing DVT and PE; and (2) what is the optimal timing to initiate and/or discontinue anticoagulation prophylaxis following injury. A multidisciplinary guideline development group used this evidence, in combination with their clinical expertise, to develop recommendations for the optimal prophylaxis strategies. The benefits and harms, financial impact, acceptability, feasibility and patient preferences of each recommendation were carefully considered. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weaker recommendation is indicated by “we suggest”. Results: The main conclusions from the systematic review included: (1) patients treated with enoxaparin had a lower rate of DVT than those who received no pharmacological prophylaxis; (2) there were no significant differences in the rate of DVT between patients treated with enoxaparin versus dalteparin or low molecular weight heparin (LMWH) versus unfractionated heparin (UFH); (3) the risks of DVT and PE were greater in a fixed-dose UFH group, but the risk of bleeding was significantly higher in an adjusted-dose UFH group; (4) ptients treated with combined pharmacological and mechanical prophylaxis had lower rates of DVT than those who received only pharmacological therapies; however, this difference did not translate into a reduced risk of PE; and (5) the risk of DVT was significantly lower in patients treated within 72 hours of injury compared to those treated after 72 hours of injury. Our recommendations included: (1) “We suggest that prophylactic antithrombotic pharmacological therapy be offered to minimize the risk of thromboembolic events in the acute period after SCI”; (2) “We suggest that prophylactic antithrombotic pharmacological therapy, consisting of either subcutaneous LMWH or fixed-dose UFH be offered to minimize the risk of thromboembolic events in the acute period after SCI. Given the potential for increased bleeding events with the use of adjusted-dose UFH, we suggest against this treatment option”; and (3) “We suggest commencing prophylactic antithrombotic pharmacological therapy within the first 72 hours after injury in order to minimize the risk of venous thromboembolic complications during the period of acute hospitalization”. Conclusion: These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care, decreasing the heterogeneity of management strategies and encouraging clinicians to make evidence-informed decisions. These guidelines are intended to be used by emergency room physicians, critical care specialists, anesthesiologists, vascular medicine physicians, neurologists and spine surgeons., Introduction: Magnetic resonance imaging (MRI) is the gold standard for imaging the spinal cord and related soft tissues; however, there remains debate about the appropriate use of MRI in patients with acute spinal cord injury (SCI) as it requires considerable resources and may be risky in trauma patients with respiratory difficulties or hemodynamic instability. The objective of this guideline is to outline the role of MRI in clinical decision making and outcome prediction in patients with traumatic SCI. Material and Methods: A systematic review of the literature was conducted to address the following key questions and inform guideline development: (1) how does the acquisition of a baseline MRI influence management strategy(ies) and, consequently, neurologic, functional, patient-reported and safety outcomes?; (2) do spinal cord lesion characteristics, pattern and length identified on baseline MRI predict neurologic, functional, patient-reported, and safety outcomes?; (3) do spinal cord characteristics identified on diffusion tensor imaging (DTI) predict neurologic, functional, patient-reported and safety outcomes?; (4) is there evidence to suggest that baseline MRI is cost-effective in patients with acute SCI? This review focused on longitundial studies which controlled for baseline neurologic status. A multidisciplinary guideline development group (GDG) used this information, in combination with clinical expertise and patient input, to develop recommendations on the use of MRI in the evaluation and treatment of patients with SCI. The benefits and harms, financial impact, acceptability, feasibility and patient preferences of each recommendation were carefully considered. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weaker recommendation is indicated by “we suggest”. Results: The main conclusions from the systematic review included: (1) no studies were identified that directly evaluated the impact of baseline MRI on treatment strategies; however, in one study, patients in a MRI-protocol group improved by an additional 7/10 of a Frankel grade compared to those who did not receive MRI (very low level evidence); (2) longer intramedullary hemorrhage (two studies, moderate evidence) and smaller spinal canal diameter at the level of maximal spinal cord compression (one study, low level of evidence) were predictive of decreased neurological recovery; (3) several features were inconsistently associated with worse neurologic recovery, including presence of intramedullary hemorrhage or intra-axial hematoma (three of five studies showed association, low quality evidence), maximum canal compromise (one of two studies showed association, low quality evidence) and longer edema length (no association in two of three studies following multivariate analysis, very low quality evidence) and (4) there was no association between degree of maximal spinal cord compression, lesion length, or cord edema and neurological recovery (low to moderate level evidence). Based on the limited available evidence and the clinical expertise of the GDG, our recommendations were: (1) “We suggest that MRI be performed in adult patients with acute spinal cord injury prior to surgical intervention, when feasible, to facilitate improved clinical decision-making” (quality of evidence, very low) and (2) “We suggest that MRI should be performed in adult patients in the acute period following SCI, before or after surgical intervention, to improve prediction of neurologic outcome” (quality of evidence, low). Conclusion: These guidelines should be implemented into clinical practice to improve outcomes and prognostication for patients with SCI by promoting standardization of care and encouraging clinicians to make evidence-informed decisions. These guidelines are intended to be used by emergency room physicians, critical care specialists, radiologists, neurologists and spine surgeons., Introduction: Rehabilitation plays a central role in maximizing function and facilitating community reintegration following a spinal cord injury (SCI). Despite this, many fundamental questions remain regarding the timing and efficacy of various rehabilitation strategies. The objective of this study is to develop guidelines that outline the appropriate type and timing of rehabilitation in patients with acute SCI. Material and Methods: A systematic review of the literature was conducted to address the following questions: (1) Does the time interval between injury and commencing rehabilitation affect outcome? (2) What is the comparative effectiveness of different rehabilitation strategies? (3) Are there patient or injury characteristics that impact the efficacy of rehabilitation? (4) What is the cost-effectiveness of various rehabilitation strategies? A multidisciplinary guideline development group used this information, in combination with their clinical expertise, to develop recommendations for the type and timing of rehabilitation. The benefits and harms, financial impact, acceptability, feasibility and patient preferences of each recommendation were carefully considered. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weaker recommendation is indicated by “we suggest”. Results: The main conclusions from the systematic review included: (1) there was no difference between body weight supported treadmill training (BWSTT) and conventional rehabilitation with respect to improvements in Functional Independence Measure-Locomotor (FIM-L) and Lower Extremity Motor Scores (LEMS) (low level evidence); (2) functional electric stimulation (FES) resulted in slightly better FIM Motor, FIM Self-Care and Spinal Cord Independence Measure (SCIM) Self-Care subscores compared with conventional occupational therapy (low level evidence); and (3) there were no differences between training unsupported sitting and control/standard in-patient therapy with respect to maximal lean test, maximal sideward reach test, T-shirt test, and Canadian Occupational Performance Measure performance and satisfaction scores (low level evidence). Our recommendations were: (1) We suggest rehabilitation be offered to patients with acute spinal cord injury when they are medically stable and can tolerate required rehabilitation intensity (no included studies; expert opinion; (2) We suggest BWSTT as an option for ambulation training in addition to conventional overground walking, dependent on resource availability, context, and local expertise (low evidence); (3) We suggest that individuals with acute and subacute cervical SCI be offered FES as an option to improve hand and upper extremity function (low evidence); and (4) Based on the absence of any clear benefit, we suggest not offering additional training in unsupported sitting beyond what is currently incorporated in standard rehabilitation (low evidence). Conclusion: These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care, decreasing the heterogeneity of management strategies and encouraging clinicians to make evidence-informed decisions. These guidelines are intended for use by neurologists, spine surgeons, physiatrists, sport medicine physicians and rehabilitation specialists (including physiotherapists and occupational therapists)., Introduction: Traumatic vertebral burst fractures can be surgically approached via different approaches including anterior, posterior, or combined approaches. The posterior transpedicular approach (PTA) is a posterior approach that has the advantage of achieving circumferential arthrodesis via single posterior only approach. However, the presence of indispensable lumbar nerve roots makes it surgically challenging approach in lumbar region. Material & Methods: We conducted a retrospective study at our tertiary care trauma centre to analyse our experience with PTA in the management of traumatic lumbar burst fractures (TLBFs). All consecutive patients with TLBFs managed with PTA over 5 years duration were analysed and 35 patients with available followup were included. Neurological outcome, correction of kyphosis, complications and operative parameters were analysed. Inpatient/outpatient records and operation notes were scrutinised to collate data. Radiological data was retrieved from institutional picture archiving and communication system.Correction of kyphotic deformity and change in neurological status were analysed to assess outcome. Cobb’s angle and ASIA grade were used for this purpose. Results: There were 21 males and 14 females. L1& L2 were the most common vertebrae involved. Eight patients had complete (ASIA-A) while 22 had incomplete injury. The mean preoperative cobb’s angle was 13.97° that improved to -3.57° postoperatively, thus achieving a mean kyphosis correction of 17.54°. None of the patients developed iatrogenic nerve root injury. There was no peri-operative mortality. Two patients developed wound dehiscence that required debridement. At a mean followup of 29.1 months, mean cobb’s angle was 1.23°. Eight patients developed cage subsidence but none required revision surgery. Postoperatively, 27 (77.1%) patients showed neurological improvement and none deteriorated. The average ASIA score improved from 2.97 to 4.17. A fusion rate of 59.3% was observed at last followup. Conclusions: The advantages of PTA including sense of familiarity with posterior approach amongst spine surgeons, lesser approach related morbidity and results comparable to anterior or combined approaches, make PTA an attractive option for managing TLBFs. Although technically difficult in lumbar region, it can be used for circumferential arthrodesis without sacrificing the nerve roots., Introduction: The thoracic and lumbar fractures in the immature skeleton are rare injuries. Material and Methods: In order to know the characteristics of these lesions in our environment and compare with those the adults, a transversal and descriptive study of adolescents between 12 and 18 years who were hospitalized for thoracic and lumbar fracture in two centers of high level trauma in our country for 8 year was performed. The variables studied were applied statistical analysis descriptive and correlation. Results: They were studied 135 spinal fractures in 96 patients, 125 were traumatic fractures and 10 fractures projectile gun. An increase in the frequency of thoracic and lumbar fractures in adolescents with increasing age was found. They were found significant date by associating the causes of damage with associated lesions (P = .006) and the initial neurological damage associated with the final neurological damage (P = .001). Conclusion: The thoracic and lumbar fractures in adolescents caused by road accidents are associated with lesions in the chest and abdomen. And when are caused by falls are associated with lower extremity fractures. In addition, 13.5% of cases showed significant changes toward improvement in the initial neurological damage., Introduction: Traumatic burst fractures make up between 30 to 64% of all thoracolumbar spine fractures. Fractures of this type are very painful for patients and offer a unique challenge for the spine surgeon not only in terms of pain control but also in terms of biomechanical strength and maintenance of deformity correction. A number of different approaches, techniques, and instrumentation have been used for the operative treatment of thoracolumbar injury, each with their own inherent limitations. To our knowledge, there has never been documented use of mesh-contained bone graft for vertebral body augmentation with non-fusion short-segment pedicle screw and rod fixation for the operative management of burst fractures. Material and Methods: Our patient is a 55-year old right hand dominant male who presented following a fall from 5 feet while on a ladder working on his shed. He had landed on his buttocks. He complained of excruciating low back pain without radiation and exhibited significant percussion tenderness. He denied any bowel or bladder incontinence and there was no paresis or saddle anesthesia. His past medical and surgical history are negative and he denies use of tobacco products. The initial lumbar plain film x-ray demonstrated anterior wedging of the L1 vertebral body. A computed tomography scan was then conducted which demonstrated a burst fracture with resultant 25% height loss. Magnetic resonance imaging did not demonstrate posterior ligamentous injury. Due to his intractable back pain he was taken to the operative suite where we placed percutaneous screws at T12 and L2 before performing the percutaneous vertebral body augmentation utilizing mesh contained bone graft. About 12 cc of bone graft was tamped into the mesh bag and placed into the vertebral body of L1 through a unilateral extrapedicular method. Titanium pedicle screws were used bilaterally at the level of T12 and L2 along with rods. The patient was given a TLSO brace for ambulation and was weight bearing the night of the surgery and his pain was significantly reduced. The patient was discharged home the following day. He was followed up at 2 weeks post op and only complained of minimal back spasms. Results: At his 2-month post op visit the patient endorsed improvement in back pain and was actually back to work pouring concrete. He was given a 60-pound weight restriction but later requested to increase the weight restriction to 75 pounds. Post-operative imaging was obtained on post-operative day 1, 1 month post-operatively and 4 months post-operatively. Conclusion: Stabilizing a burst fracture associated with thoracolumbar trauma is feasible using completely minimally invasive techniques. Here, we describe a treatment modality that allows for vertebral body height restoration, kyphotic deformity correction, spinal canal diameter widening through ligamentotaxis, and vertebral body fracture healing. Even in the setting of fractured pedicles our described procedure is possible and demonstrated a decrease in pain, a short hospital stay, and quick return to work., Introduction: To evaluate the efficacy of short segment stabilization compared with that of long-segment stabilization in terms of clinical and the radiological outcomes in unstable thoracolumbar junction burst fractures. Material and Methods: 88 patients (age range 19-50, mean 32 years) with thoracolumbar burst fracture (T10–L2) in Magerl Type A fractures underwent posterior pedicle screw fixation from January 2004 to December 2014, studied retrospectively. They were divided into two groups: the short-segment group (SS) included pedicle screw fixation in the fractured vertebral body (six screws), and the long-segment group (LS) included pedicle screw fixation, 2 level above and 2 level below the fractured vertebral body (8 screws). Clinical parameters: back pain using VAS and disability ODI, neurological deficit (using ASIA grade) and radiologic parameters (Cobb angle, the kyphotic deformation and vertebral height) were measured before surgery and immediately after surgery and at 3, 6 and 12 months postoperatively. Overall outcomes were evaluated using the modified Mcnab criteria at the last follow-up. Chi-squared test and paired-t test were used for statistical analysis using SPSS. Results: 36 and 52 patients in the short-segment and long-segment group, respectively. Male-female ratio was 1:0.44 and 1:0.57, the mean age of the patients was 30.6 ± 8.4 and 33.4 ±8.4 years and the mean follow-up period was 24.5 and 16.8 months in SS-segment and LS-segment respectively. In the SS-group, the fractured vertebral body level was L1, T12, L2, T11, and T10 in 15 (41.6%), 10 (27.7%), 6 (15.6%), 3 (08.3%), and 2 (05.56.3%) cases and in the LS-group, the fractured vertebral body level was L1, T12, L2, T11, and T10 in 22 (42.31%),17 (32.69%), 5 (9.61%), 5 (9.61%) and 3 (5.76%) cases, respectively. Both groups achieved satisfactory clinical outcomes modified (Mcnab criteria). In the SS-group, 8 (22.22%), 21 (58.33%), and 7 (1944%) cases were considered to have excellent, good, and fair outcome and in the LS-group, 18 (34.61%), 25 (48.08%), 6 (11.54%), and 3 (5.77%) cases were considered to have excellent, good, fair, and poor outcome, respectively. The mean kyphotic angle at preoperative, postoperative and final follow up was 13.5±6.3, 13.4±4.3, 8.5±6 and 4.4±3.1, 5.4±2.8, 6.0±4.0 in the SS and LS-group respectively. The average loss of kyphosis correction was 7.5° ± 4.4° in the SS-group and 10.5° ± 4.8° in the LS- group at the final follow-up, with no significant differences between the two groups (P > .05). The mean pre and post operative kyphotic deformation of vertebral body was 5.1±3.2, 4.8±2.3 and 1.9±1.3, 2.2±2.1 and at final follow up was 4.5 ±4.0 and 4.0±1.5 in the SS and LS- group respectively (p > 0.05). The mean anterior and posterior vertebral height also showed significant improvements postoperatively, which were maintained at the final follow-up. The mean ODI and VAS scores at the end of 1 year were 17.5%, 16.5% and, 3.6 ± 1.8 2.9 ± 1.4 in SS and LS- group respectively. There was no case of major complication after surgery and during the follow-up period. Conclusion: Short-segment pedicle screw fixation including the fractured vertebral body might be as effective as long-segment pedicle screw fixation for the treatment of unstable thoracolumbar spinal burst fracture., Introduction: This paper presents a prospective comparative case study with the objective to test the hypotheses, wherever: a) PEEK with either Sr-HA or PMMA equally restores thoracolumbar A2 and A3/AO type vertebral body fractures; b) both Sr-HA and PMMA have similar leakage; c) Sr-HA is fully resorbed and replaced by bone. Materials & Methods: Two matched groups of 10 patients, each received percutaneous pedicle screws plus PEEK filled with Sr-HA or PMMA. Segmental kyphosis (SKA), anterior (AVBHr), middle (MVBHr) and posterior (PVBHr) vertebral body height ratio, spinal canal encroachment (SCE), cement leakage, Sr-HA resorption were recorded and compared. The follow-up was 28 months, range 24-33 months. Results: AVBHr, MVBHr, SKA and SCE improved postoperatively in both groups. PMMA leakage observed in one case and there was no Sr-HA leakage. In contrast to PMMA complete Sr-HA resorption and replacement with bone was recorded 8 months postoperatively. Conclusions: The three hypotheses of this prospective comparative case study were all justified from the achieved radiological results, Introduction: The natural healing of spinal tuberculosis occurs by spontaneous fusion of vertebral bodies with or without kyphotic deformity. We report a rare case of Late onset paraplegia secondary to traumatic fracture of fusion mass in healed tuberculosis which has not been reported till date. Material/Case Report: A 56 year old male patient sustained road traffic accident was diagnosed with fracture of fusion mass in already healed tuberculosis. He presented with weakness in both lower limbs with ASIA-C grading of spinal cord injury. Results: He was treated with posterior instrumented stabilization and decompression. Patient recovered well post operatively and has regained his complete power of both lower limbs. Discussion: Late onset paraplegia in old healed spinal tuberculosis is a well known entity that maybe caused due to compression of cord by a internal gibbus or when the formed granulation/ fibrous tissue constricts the cord. Fusion mass fractures are not very uncommon in conditions such as ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis. Traumatic fractures tend to occur at the adjacent vertebral bodies to the fused ones as the biomechanical stress at the junctional site is far higher than at the center of the fused mass. In healed spinal tuberculosis, resultant deformity would be kyphosis. The angle of kyphosis is directly propotional to the resulting neurological deficit. Fractures of fused mass in healed tuberculosis are similar to the fractures in other ossifying bone lesions. Conclusion: Purpose of this article is to document the rare possibility of late onset paraplegia in un-instrumented old healed spinal tuberculosis with kyphotic deformity, due to fracture of fusion mass as seen in ankylosing spondylitis., Introduction: Vertebroplasty and kyphoplasty(VP/KP) are a successful treatment method for vertebral compression fractures(VCF) and improving pain. Although incidence of symptomatic complication for them is 1.6-3.8%, it has been reported to lead a range of 5-80% radiological complications. Material and Methods: Between June 2010 and December 2015, we performed VP/KP procedure for 52 cases who suffered from VCF and these cases retrospectively analyzed. Results: The group included 32 female (61.5%) and 20 male (38.5%), all of the patients were admitted with the complaint of severe pain and neurological examinations were intact in 48 (92.3%). The criterion for performing VP/KP was accepted as hyperintensity in T2 and/or STIR sequences in MRI. VP/KP was introduced to 71 VCF. Forty-two cases had a history of trauma, but initial diagnosis was tumor in 10 cases, inside whose 4 had weakness and/or numbness. Average of preoperative VAS were 8,09 points. All operations were performed under local anesthesia. KP was applied to 29(55.,8%) and VP 23(44.2%) patients, via bilateral transpedincular approach in 39 and unilateral in 13 cases. Average VAS was 2.3 (P ≤ .05). Postoperative CT scans showed no cement leakage in 27 (51,9%). Leakage was observed in 25(48.1%). Distribution of leakage according to region as follows; towards the intervertebral disk space in 12 (23.07%), epidural venous plexus in 11 (21.1%), paravertebral space in 6 (11.5%) and into spinal canal in 4 (7.6%) patients, while there was a reported pulmonary embolism in 1 (1.9%) case. The mean follow-up was 23.7 months. There was a reduction in segmental kyphotic angles from an average degree of 19.9 to 17.2 (P ≥ .05) which wasn’t statistically significant. Conclusion: VP/KP treatments have low symptomatic complication rates, on the other hand cement leakage is higher than expected. Using local anesthesia in VP/KP procedures is helpful to make the surgeon more alert for these complications during both guide installment and cement placement; even if a cement leakage occurs., Introduction: Objective: To investigate if evidence-based principles of oncologic resection for primary spinal tumors are correlated with 1) an acceptable morbidity and mortality profile and 2) satisfactory health-related quality of life (HRQOL) measures. Summary of Background Data: Respecting oncologic principles for primary spinal tumor surgery is correlated with lower recurrence rates. However, these interventions are often highly morbid. Material and Methods: A systematic literature review was performed to address the objectives by searching MEDLINE and EBMR databases. Articles that met our inclusion criteria were reviewed. GRADE guidelines were used for recommendation formulation. Results: A total of 25 articles addressing the morbidity and mortality profile of primary spinal tumor surgery were identified. For sacral tumors, complication rates of up to 100% have been reported and complication-related death ranged from 0 to 27%. Mobile spine tumor complication rates varied from 13 to 73.7% and complication-related death ranged from 0 to 7.7%. Seven articles examining HRQOL for this patient population were identified. The limited literature showed comparable patient HRQOL profiles to those with benign conditions such as degenerative disc disease. Conclusion: 1) Respecting oncologic principles for primary spinal tumors, is correlated with high AE rates. We recommend that primary spinal tumor surgeries be performed in experienced centers with multidisciplinary support teams and that prospective AE collection be promoted (strong recommendation/very low certainty of the evidence). 2) Oncologic resection of primary tumors of the spine is associated with HRQOL that more closely approximates normative values with increasing duration of follow-up, but decreases with disease recurrence. We recommend primary spinal tumor surgery be performed with a curative intent whenever possible, even at the expense of greater initial morbidity to optimize long term HRQOL (strong recommendation/very low certainty of the evidence)., Introduction: Spinal simple bone cysts, also known as solitary cysts, are extremely unusual benign primary bone tumors in children, with few cases reported in the literature. Material and Methods: case presentation of an incidental MRI finding of a C2 Simple bone cyst in a 13-year-old female patient is reported. The MRI findings were consistent with a cystic lesion in the vertebral body of C2, facing the right vertebral artery. Complementary angiography suggested a benign condition of the lesion. Patient underwent cervical curettage followed by tumor excision. A lateral submandibular approach to the upper cervical spine was used and careful bone resection was possible with a radiofrequency assisted burr and no instrumentation or fixation was required. The procedure was challenging, due to the proximity of the right vertebral artery with the cyst. The stability of the defect was ensured by filling it with bone allograft and by prescribing a postsurgical plastic cervical collar to maintain neck immobilization. Results: Histological examination showed fibrotic areas with fat necrosis, chronic inflammation, and reactive changes in the tissues examined. At the 6-month follow up visit, the grafts were incorporated into the vertebral body of C2. Conclusions: Solitary bone cysts are infrequent entities in the cervical vertebrae and preservation of spine stability without instrumentation to avoid neurological complications is often challenging. In this case, the proximity of the cyst to the right vertebral artery and the risk of injury was high, however the surgical approach used was successful and no recurrence or instability were evidenced on postoperative MRI., Introduction: The purposes of this study are to investigate affecting factors and overall survival between initial Radiation therapy prior to surgical treatment (Group 1) and radiation therapy following initial surgical treatment (Group 2) at the diagnosis of cervical metastasis. Material and Methods: A retrospective analysis of medical records was performed on 36 cervical metastatic patients from February 2007 to December 2015. Overall survival (OS), OS after cervical metastasis, OS after surgery, neurological and pain outcomes were analyzed between Group 1 and Group 2. Affecting factors of overall survival included; primary tumor type, initial treatment modality, Tomita score, Eastern Cooperative Oncology Group, Karnofsky performance scale (KPS), Nurick grade, Frankel classification, preoperative symptom and Spinal stability neoplastic score. Results: Both groups showed improvement of postoperative VAS. The difference of pre- and post-operative JOA score was 1.3 ± 1.9 in Group 2 (P = .03). OS after cervical metastasis was 7.0 months in Group 1 and 15.8 months in Group 2. OS after surgery was 4.5 months and 15.3 months in each Group. There was statistical significance of OS after cervical metastasis in each Group (P < .05). Factors related to overall survival after cervical metastasis were primary tumor type, initial treatment modality and preoperative symptoms (P < .05). Conclusion: Surgery had a good effect on pain control. The improvement of post-operative JOAS was better in Group 2. Surgery could provide longer OS after cervical metastasis. Early surgery in patients expected good prognosis before neurologic deficit may be a good decision in confined to cervical metastasis., Introduction: Cervical localization of spinal primitive tumors is relatively rare. The choice of the best surgical strategy for the treatment of these lesions, in order to obtain an accetable radicality, is very difficult in these site. Cervical pain is the most common symptom. The early diagnosis of these tumor is not easy because frequently patients present non-specific symptoms and because radiological examinations are usually negative. Only after performing more detailed examinations, such as CT-scan and MRI it is possible underwent a diagnostic biopsy, which is mandatory in these patients. Material and Methods: The authors report the experience of a small group of patients (15) affected by cervical primitive malignant tumors: 4 osteosarcomas, 1 aggressive osteoblastoma, 5 chordomas, 3 chondrosarcomas, 2 sinovial cell sarcomas. The mean age was 42 years (ranged from 11 to 61 years), the mean follow-up was 21 months (ranged from 8 to 42 months). The levels of resection were: 1 level of vertebrectomy in 4 patients, 2 level of vertebrectomy in 4 patients, 3 level of vertebrectomy in 5 patients, 4 levels of vertebrectom in 2 patients. In every patient we performed a double approach, in two patients the second approach was performed 48 hours after the first one to minimize the surgical stress. In two cases we performed a trans-mandibular approach because of the rostral localization of the tumor. In all patients we performed a long fixation (occipito-cervico-thoracic fixation) associated with cages filled with anterior autogenous cortico-spongiosus bone chips. Results: Three patients had a local recurrence, respectively at 20, 25 and 34 months after surgery and they died due to pulmunary involvement after about 12-15 months from the local recurrence (only one patient underwent local surgery). One patient died 23 months after surgery for general progression without signs of local recurrence. One patient died within one week from surgery for vascular complications. The other patients are alive, with no signs of local disease (locally free-desease) and no signs of sistemic disease (NED: no evidence desease). Conclusion: En bloc resection for primary cervical tumor of the spine is a challenge for the surgeons due to the complexity of the anatomy of this region: the presence of the vertebral artery (both resected in two cases without neurological damage), the contiguity of the aero-digestive tract and of the main encephalic vessels, the presence of medulla oblongata and spinal cord. Three patients had under- lesional damage after surgery, in partial remission after some months. All other patients hadn’t neurological damages. Our high percentage of local recurrences and of major complications (5 deaths) is probably due to anatomical complexity of the region, where sometimes is very difficult, or even impossible, to obtain acceptable resection margins., İntroduction: The aim of the study is to show the results of hemivertebrectomy with only unilateral approach in treatment of lung cancer with vertebra invasion. Material and Method: Ten patients with an average age of 59 (49-65) years with lung cancer with thoracal vertebra invasion were operated between 2008 and 2015. Biopsy was performed in all patients for diagnosis. The diagnosis of the patients was, non-small cell carcinoma in seven patients, squamous cell carcinoma in two patients and adenocarcinoma in one patient. Chemothreapy and 60 GyRT radiotherapy were given before surgery. Unilateral thoracal spine exposure was used for vertebra resection after limited laminectomy and root sacrification. Results: In patients who undergone vertebral resection, the resected segments were between T2 and T5. Mean resected vertebrae count was 3 (2-4) and mean corpus resection extent was 40.5% (30-69). Mean follow-up duration of the patient was 24 months (8-84). 1 year survival rates of the patients included were 70%, while 5-year survival rates were 10%. Conclusion: In treatment of lung cancer with spine invasion, it is possible to achive clear surgical margins.Due to lack of the enough strength to prevent deformity from unharmed anatomic structure, strong instrumentations are necessary., Introduction: “Frailty” is a state of decreased homeostatic reserve that may be estimated based on the presence of preoperative comorbidities. In this study, the objective was to develop a preoperative metastatic spinal tumor frailty index (MSTFI) that could estimate length of stay, morbidity, and mortality. Materials and Methods: A large inpatient hospitalization database was searched from 2002-2011 to identify 4,583 patients with spinal metastasis who underwent surgery. The primary location of the metastatic tumor types included breast (21.1%), lung (34.1%), thyroid (3.8%), renal (19.9%) and prostate (21.1%) cancer. Multiple logistic regression model identified anemia, congestive heart failure, chronic lung disease, coagulopathy, electrolyte abnormalities, pulmonary circulation disorders, renal failure, malnutrition, and pathologic fractures as independent parameters that were used to construct the MSTFI. Each patient received one point for each of the above co-morbidities in a given patient and the total score was used to strtatify patients into groups based on their estimated frailty. Patients with 0 comorbidities were categorized as “not frail,” 1 as “mildly frail,” 2 as “moderately frail,” and ≥3 as “severely frail.” Results: The overall perioperative complication rate was 19.3% and in-patient mortality was 3.0%. Compared to patients without frailty, patients with mild (odds ratio [OR] 2.12; 95% CI, 1.74 – 2.59), moderate (OR 3.81; 95% CI, 3.05 – 4.76), and severe frailty (OR 8.11; 95% CI, 6.34 – 10.38) had significantly increased odds of complication development. Likewise, patients with mild (OR 2.73; 95% CI, 1.64 – 4.52), moderate (OR 4.10; 95% Ci, 2.39 – 7.04), and severe frailty (OR 6.34; 95% CI, 3.61 – 11.1) were more likely to die during their hospital stay. Length of stay also increased significantly by MSTFI (P < .001). Conclusion: In surgically treated patients with spinal metastasis, several patient comorbidities were significantly associated with the development of major complications after surgery for metastatic spinal tumors. The metastatic spine tumor frailty index was found to be associated with LOS, major complications, and in-hospital mortality, and LOS, however future studies are required to externally validate the proposed model before establishing definite conclusions., Introduction: The association of teratoma and spinal malformations such as meningomyelocele (MMC) is a rare condition, and only few reports concerning the coexistance of a neoplasm within an MMC have been published. Reported cases however, are mainly presacral or sacrococcygeal, while our case is with lumbar location. We report an unusual case of lumbar mature teratoma which presented inside a ruptured lumbar meningomyelocele. This case is reported to highlight the clinical presentation and management of lumbar teratoma associated with myelomeningocele in a neonate. Despite the severe associated lesions in the lumbar area the child has no neurological deficit. Material and Methods: A full-term, male infant presented with a 5/7 cm lumbar tumor formation uncovered with normal skin. Intra-operatively a soft tissue mass with oval form, irregular hard and reddish color in the upper region and soft component in its lower part was found.Total removal of the tumor was achieved. Proximal to the tumor mass we found an open meningomyelocele, which was sealed. Results: The neonate was discharged without any neurological deficit or sign of hydrocephalus. The final pathological diagnosis was mature teratoma. Follow-up at first year didn’t reveal any recurrence or neurological deficit and a normal sphincter tone was evaluated. Conclusion: Accompanying a spinal dysraphic state, the mature teratoma in our case may support the theory for a tumor actually arising from a dysraphism and growing outwards to produce the mass. The treatment of lumbar mature teratoma associated with MMC is essentially surgical., Introduction: In cases of recurrent or residual lesions the choice of treatment strategy may be debated. Therefore, we assessed short- and long-term ependymoma of the cauda equina outcomes. Materials and Methods: In Burdenko Neurosurgical Institute between February 2009 and October 2013, 50 patients (23 males, 27 females) underwent removal ependymomas of the cauda equina. The mean age of this patient was 38.7 years (18-76 years). The mean follow-up was 52.2 months (6-300 months). Patients were divided into 2 groups: Group 1 consisted of 36 patients with primary tumors; Group 2 consisted of 14 patients who had operated yet. We used Frankel, Karnofsky, VAS, Kawabata scales and MRI for evaluation outcomes. Results: In our according data we have one patient with recurrence after five years from first group, and two patients had recurrence after subtotal resection from second group. Pain were relieved in 26 patients (72%) in first group, and 10 (72%) in second. One patient worsened from first group. In second group four patients were unsatisfactory with the outcome (28%). Neurologically, in first group 18 patients (50%) had a clinical improvement and 16 patients (44.5%) were neurologically unchanged. Two patients (5.5%) worsened. In second group, 3 patients (21.4%) had a clinical improvement; 9 patients (64.2%) were unchanged. One patient worsened. Conclusion: Microsurgical removal is maintaining method of treatment of extramedullary ependymomas of the cauda equine. In cases of recurrence, radiotherapy (in some cases, radiosurgery) is considered as additional option of treatment., Introduction: Vascular tumors of spinal cord is a rare pathology which by histological nature is most often presented by hemangioblastomas and cavernomas of different localization. Cavernomas and hemangioblastomas arise sporadically, however hemangioblastomas may be associated with the von Hippel-Lindau disease. The spectrum of clinical manifestations of these pathologies is quiet wide – from asymptomatic carriage to severe neurological deficit that lead to permanent disability or death of the patient. Materials and Methods: From 2013 to 2015 Burdenko Neurosurgery Institute operated 350 patients with intramedullary tumors of different histological nature. Among them there were 31 of intramedullary hemangioblastomas. Of these, three patients had diagnoses of von Hippel-Lindau disease. In addition to that, Burdenko Neurosurgery Institute performed 26 surgeries for removal of cavernous malformations (CM) on various parts of the spinal cord. Those included 19 intramedullary cases (5.4%), 3 extramedullary ones, 2 intradural ones and 2 extradural cases. Retrospectively, there were examined 19 patients with cavernous malformations of intramedullary location. The diagnosis is based on MRI data and neurological examination. The patients were assessed on a McCormick classification part of preoperative and postoperative treatment. Results: For patients with hemangioblastomas mean follow up was 45 months (36-144 months). The average time of pathogenic pathway was 36 months (12-300 months). MRI examinations of 21 patients showed syringomyelia. Postoperatively only two patients had deterioration of neurological condition, with the rest of the patients showing preoperative state. For cavernous malformations, the average age of the patients was 44 (20-76 years old). The average duration of symptoms was 8-9 months, with the follow-up period of 4-6 months. The average size of tumors ranged from 0.4 to 1.2 cm. The average removal time was 1.0 to 3.5 hours and the average intraoperative blood loss was 130-300 ml. On the first day after the surgery one patient developed intradural hemorrhage after removal of the intramedullary hemorrhage. Conclusion: Surgery of vascular tumors of the spinal cord is a sophisticated and multicomponent task that requires a search for the correct approach to treat the patient, a decision made on the need for embolization of vascular tumor, as well as microsurgical treatment when needed., Introduction: Most of patients with malignant tumor have metastasis to the spine. Fortunatly 10% of them only have symptoms due to epidural tumor. There were match papers about quality of life patients who underwent spine metastasis removal or any other palliative surgery. But we didn’t found one in Russian publications. Our study has to demonstrate advantages of targeting method, which we used for increasing quality of treatment patients with metastatic disease. Methods: 70 patients from 16 to 81 ages have undergone surgery on the spine due to metastatic disease in period from 2009 to 2016 years. A lot of tumors were presented clear cell renal cancer – 30,3%, 23,1% were plasmocitomas (multiple myeloma), 10,5% cases of metastasis without primary tumor, other tumors (melanoma, thymoma, metastatic tumors of the gastrointestinal tract, uterus, ovary, lung, prostate, pancreas, thyroid) took around 3,5% only. Before surgery Tukuhashy, Tomita, Bauer and van Der Leaden prognosis scales were used for survival prognosis and accepted for every patient. We used QLQ C-30 for evaluating quality of life during 1 year after surgery, sighed checkpoints on time before surgery, 1, 3, 6, 12 month after surgery. Quality of decompression we confirmed by comparing of preop and postop MRI and CT scans. Result: Maximal follow-up was 12 month for 5 patients only. The highest growth of quality of life was watched in first 3 month after surgery for more than half percent of patients. We found the main factors effected to quality of life of patients with spine metastasis. Conclusions: Surgical decompression of nerve structures and reconstruction of the spine is the main method to increase quality of life patients with spread cancer to the spine, due to relief of pain and improve of extremity weakness. It is clear that spine metastasis excision does not affect to the common survival of patients in last stage of metastatic disease. This fact makes necessary to consultation each cases by team which consists oncologists, radiologists and surgeons of different profiles for making decision about ability of surgery., Introduction: Malignant peripheral nerve sheath tumor (MPNST) is the sixth most common type of soft tissue sarcoma. Most MPNSTs arise in association with a peripheral nerve or preexisting neurofibroma. Among all primary spinal neoplasms, approximately two-thirds are intradural extramedullary lesions; nerve sheath tumors, mainly neurofibromas and schwannomas, comprise approximately half of them. Current surgical management of MPNST is similar to that of other high-grade soft tissue sarcomas. Materials and Methods: A 27-year-old female with known neurofibromatosis (NF) since her childhood presented with a 6-month history of severe lower back pain and pain radiating to the both leg. Sensory loss was detected below S1 bilaterally and she referred obstipation, urinary incontinency for 4 months. She suffered from a internal iliac deep vein thrombosis at the right side for a month. Behind the symptoms, a giant sacral tumor was diagnosed by CT, and MRI studies. Biopsy proved a MPNST with high cellular atypia. Staging CT scans excluded other localizations of MPNST. Results: En bloc tumor resection from a single posterior approach and a lumbopelvic stabilization using closed loop technique was performed. Soft tissue reconstruction was made using rotatory gluteal muscle flaps. 1 year after the surgery she did not need any constant pain medication and she had neither motor nor sensory deficit at the lower extremities She used self urinary cathetering and had an automatic bowel control. During the regular 1 year follow-up local recurrence was not observed in the sacrum, but the check-up PET CT verified a new giant MPNST at a thoracic localization (Th11-12). En bloc resection was performed from a combined postero-anterior approach. After the second surgery we did not observe any deterioration in motor or sensory functions. Conclusions: En bloc resection with wide/marginal surgical margins is the oncologically proper treatment for MPNST. Approximately 25% of patients developed a postoperative complication, most commonly new sensory deficits. This rate probably represents an inevitable complication of nerve sheath tumor surgery. The surgical treatment is the exclusive option in the therapy of nerve sheath tumors even in case of multiple localisation of the malignant form., Introduction: A quarter of all people dying in Germany succumb to cancer. In 40% spinal metastases are present. Cement augmentation combined with tumor ablation may be an option in painful metastases or metastases with fractures. Cementing alone leads to dislocation of metastases and scattering of tumor mass in the patient. (Archimedes). Local reduction of tumor mass should be performed whenever possible. The use of ablation systems next to nervous and vascular structures is potentially dangerous. This observational study is to assess security and efficacy of a new spinal intravertebral radiofrequency-ablation (t-RFA) probe. Material and Methods: From 11/2013 - 6/2016 we treated 29 patients (18f, 12 m) with 79 vertebral bodies with t-RFA followed by radiofrequency-kyphoplasty.(RFK) Mean follow-up 12 months. Mean age 67 years (Range 51-83 years). All vertebrae treated unipedicular. Cancers types were: breast (14), multiple myeloma (7), lung (2), chondrosarcoma (1), prostate (1), urothel (1), cancer of unknown primary (1), gastric (1) and non-hodgkin lymphoma (1). Combination of osteosynthesis in 3 pat., 1 patient total hip arthroplasty. Preop. scores were: SINS, MESCC, modified Bauer, Tomita, revised Tokuhashi, Karnofsky Performance Index, ODI. Pain on visual analog scale(VAS) pre- and postoperatively. The ablation system contains a navigable, bipolar electrode with two thermocouples, which allow real-time temperature monitoring at the proximal end of the ablation zone. The ablation zones were planned preoperatively via CT and MRI. Perioperative examination for neurological or other deficits. Results: Procedures were securely performed via real-time temperature monitoring and controlled by fluoroscopy. The maneuverability of the ablation device allowed via unipedicular access the exact positioning of the device in the planned ablation zone. No neurological deficits or vascular lesions due to t-RFA. One cement extravasation intraoperative with affection of a peripheral nerve with intercostal neuralgia (, Introduction: Spinal schwannomas usually present as extramedullary, intradural tumors. Is a benign tumor that arises mainly in sensory nerve sheaths. Intraosseous lesions are rare, accouting for less than 0,2% of primary bone tumors, and majority are located in the mandible and sacrum. We report a extremely rare spinal intraosseous schwannoma and provide an updated review. Material and Methods: A 38-year-old female presented with paresthesia of both lower extremities and thoracic back pain. Preoperative MRI showed a large mass extending into the parevertebral muscles and spinal canal that appeared to originate from the posterior elements of T3. Computed tomography showed a large lytic lesion of T3. The most likely preoperative diagnosis according to radiologists in our hospital was a osteoblastoma or a aneurysmatic bone cyst. Preoperative selective arterial embolization of the lesion was performed. Using a posterior extracavitary approach the tumor was completely separated and surgically resected from the spinal nerve root with a clear border. No adhesions were identified between the dura and tumor. No involvement of nerves with the tumor was identified. Results: Histological results confirmed a diagnosis of intraosseous schwannoma with no remnants of an originating nerve. Tumor recurrence was not observed at 2 year follow-up. Conclusion: Our case emphasizes the heterogeneous presentation of the nerve sheath cell tumors in the differential diagnosis of the primary vertebral tumors. Proper diagnosis requires radiological tests, gross intraoperative findings, and postoperative histological results., Introduction: Intramedullary astrocytomas are the second highest frequency of occurrence of all intramedillary spinal cord tumors, and it accounts for 6-8% of all spinal tumors. There are many factors can influence on survival and fictional outcomes after surgical treatment astrocytomas, a top is histological characteristics of the tumor. In our study we evaluated patients with low- and high-grade gliomas from several options: duration of life, functional status, age, gender and other clinical factors. Materials and Methods: In Burdenko Neurosurgical Institute more than 385 patient were underwented removal intramedullary spinal cord tumor from 2002 to 2015. There are 55 patients with intramedullary low-grade (37 patients, 67%) and high-grade (18 patients, 33%) astrocytomas. Tumors were located in the cervical spine in 27 cases(49%), cervicothoracic spine – 7 (12%), in thoracic – 17 (30%), cauda equina – 4 (9%). There were 24 male (43%) and 31 female (57%) patients. All patients were undewented decompressive laminectomy and resection or biopsy of intramedul6ary tumors. During operation, we usually use fluoroscopy, MEPP and ultrasound destruction. The median follow-up was 6 years. Results: Histological characteristics were: 19 patients (35%) had Grade I astrocytomas, 19 patients (35%) had Grade II astrocytomas, 14 patients (25%) - Grade III astrocytomas, 3 patients (5%)- Grade IV. Sensitive disorder were in 48 cases (87%). Motor disorders: without paresis were 6 patients (11%), monoparesis – 7 patients (13%), hemiparesis – 4 patients (7%), paraparesis – 12 patients (22%) and tetraparesis – 19 patients (47%). Bladder dysfunctions had 25 patients (45%). 3 patients (5%) were died for the first year after operation (in one case – progression of tumor, in two cases – progression of general disease). 16 patient (30%) had been better after removal of tumor (transition from one McCormick grades up), 23 patients (45%) had been worst (transition from one or two McCormick grades down) and 13 patients (20%) hadn’t changes McCormick grade (this is patients with first or second McCormick grade). Conclusions: Spinal cord astrocyromas are rare disease, which are requires multimodal view on treatment and recovery. Histological characteristics and total removal of tumors have a huge influence on the length of survival. Radiotherapy and chemotherapy allows preventing recurrence of disease., Introduction: Extramedullary hematopoiesis (EMH) is a known complication of beta-thalassemia due to ineffective erythropoiesis and remote sites of hematopoiesis can occur in various anatomic locations. Treatment often involves a combination of transfusions and radiotherapy. In rare cases, severe epidural EMH can develop within the spinal canal causing progressive spinal cord compression and possibly permanent deficits. Materials and Methods: We present the case of a 54-year old male, with known beta-thalassemia and hemochromatosis, who presented with progressive thoracic myelopathy. Emergent MRI revealed an epidural mass at T5-T9 with severe spinal cord compression. Due to the rapidity of onset and the rapid progression, gross total resection was performed through a unilateral T5-T9 hemilaminectomy, with parallel treatment using tranexamic acid, blood and platelet transfusions. A literature review was performed in search of a consensus regarding the optimal management for these cases. Results: Complete neurological recovery was noted. Adjuvant radiotherapy was performed, with stability of paravertebral EMH sites at last follow-up (3 months full spine MRI). No epidural recurrence or residual mass was seen. Our literature review describes prior cases of epidural EMH with spinal cord compression. Currently there is no consensus regarding the management of these rare cases. Conclusion: In cases of progressive neurologic impairment, surgery can safely be performed in an emergency setting, without excessive hemorrhagic risk. Prior hematologic adjuvant treatment remains mandatory. Albeit considered highly radiosensitive, the optimal management for extramedullary hematopoiesis with neurological impairment remains unproven and is currently based on case-by-case situations., Introduction: Many patients use the internet for accessing health information due to the ease of access. However, there are few guarantees as to the reliability and accuracy of the information available on these websites. This study examined the quality and content of the Internet webpages found on the top 5 search engines. Our aim was to evaluate the quality and accessibility of the information for patients on metastatic spinal cord compression (MSCC) on the internet. Method: To identify potential websites for assessment, the 5 most commonly used search engines were identified and a search for “metastatic spinal cord compression” was performed on each search engine, utilising the first 2 pages of websites listed within each engine. Each website was categorised according to its authorship, and then was assessed using the recognised scoring systems from the (Journal of American Medical Association [JAMA] and DISCERN criteria, metastatic spinal cord compression content quality). We also noted the websites for the presence of the quality-based Health on the net (HON) code. Results: An initial search yielded 56 websites through the top 5 search engines. Exclusion criteria were: websites requiring login or sign-up, duplicate websites, social media sites and discussion boards were excluded. 23 unique websites were identified and analysed. 5 websites were academic, 9 were produced by physicians, 6 were commercial and 3 were non-commercial. There were significant differences noted between the categories on the DISCERN score (Range 16-74), JAMA benchmark criteria and only 5 websites had the presence of the HON code. Academic and physician-related websites contained better quality information than commercial and non-physician sites and the Internet sites with the HON code demonstrated more transparency of content. There was one exception with a commercial site scoring the highest individual DISCERN score. Conclusion: The overall quality of information regarding metastatic spinal cord compression is limited. Internet websites that were reviewed displayed an abundance of variation in the quality of information that was supplied. There was a large discrepancy in the DISCERN scores with inconsistency surrounding recommended treatment options as well as the majority of them lacking information on how treatment effects overall quality of life, and describing what happens with no treatment both scoring the lowest, indicating the added importance of the doctor patient relationship., Introduction: Balloon kyphoplasty is a widely accepted surgical technique to treat spinal compression fractures in osteoporotic vertebrae and is currently used to treat neoplastic pathologic compression fractures as well. Despite its popularity, this technique’s efficacy in treating vertebral compression fractures in patients with spinal metastasis is yet to be accepted. The purpose of this study ist o to assess the efficacy of kyphoplasty in controlling pain and improving quality of life in oncologic patients with metastatic disease and pathologic compression fractures. Material and Methods: A literature search through medical database was conducted (Pubmed, EMBASE, Cochrane, LILACS) for randomized controlled trials comparing balloon kyphoplasty versus traditional treatment for compression fractures from metastatic disease of the spine. Two investigators independently assessed all titles and abstracts to select potential articles to be included. Only randomized controlled trials (RCT) were included. Inclusion criteria consisted of trials involving patients with pathologic compression fractures due to spinal metastasis or multiple myeloma treated with balloon kyphoplasty procedure as one of the study interventions, while the control group was any other treatment modality. The risk of bias in individual studies was assessed. The authors declare no conflicts of interest. Results: Two studies, with a combined total of 181 patients met inclusion criteria. Due to heterogeneity, meta-analysis of data was not possible and individual analysis of studies was performed. There is moderate evidence that patients treated with balloon kyphoplasty displayed better scores for pain (NRS), disability (RDQ), quality of life (SF-36), and functional status (KPS) compared to the conventional treatment group. Patients treated with kyphoplasty also have better recovery of vertebral height. Conclusion: This study concluded that balloon kyphoplasty could be considered as an early treatment option for patients with symptomatic neoplastic spinal disease although further randomized clinical trials should be performed for improvement of quality of evidence., Introduction: Chordomas are rare malignant neoplasms that affect the axial skeleton, commonly affecting people over 40 years. The sacrococcygeal region is the most frequently affected location. Cervical location is not usual and literature evidence is scarce. It’s approach in cervical spine is controversial. Material and Methods: A case report of a cervical chordoma in a 55 years-old male who attended to the emergency department with severe cervical pain and swallowing limitation for six months is presented. MRI showed a loculated osteolytic mass compromising the right neural root path of C2 extending to C1 and C3. 60% narrowing of the medullary canal was documented with involvement of the ipsilateral vertebral artery. A multidisciplinary team was guaranted to ensure a complete resection of the tumor. A combined anterior approach and a posterior approach were used. Tumoral resection, corpectomy and replacement of the vertebra involved and posterior stabilization of the cervical spine were performed. Results: During surgery a friable and violaceous tumor compromising C2 and C3 was observed. The histopathology confirmed the diagnosis of chordoma. No complications after surgery were documented and significant improvement of the cervical pain and swallowing capacity were reported by the patient after surgery. Patient received adjuvant postoperative radiotherapy. At 12 months follow up, patient did not present recurrence of the disease. Conclusions: In patients that debut with severe cervical pain resistant to conventional treatment, other etiologies must be considered i.e tumoral etiologies. Cervical chordomas remain rare entities and its management continues to be challenging due to their insidious and extensive nature. A multidisciplinary approach may guarantee better results., Introduction: Osteochondroma or osteogenic exostosis is the most common benign bone tumors. It can be solitary or multiple within the scope of the Hereditary multiple exostoses disease. Spinal location is estimated between 1 and 4%. We reported the case of an osteochondroma of the third cervical vertebra. Methods: It was a 29 years-old woman with a one year history of swelling of the neck. Clinical examination found a hard painless mass of 15 cm in diameter without skin reaction. Extension of the cervical spine was limited but neurological examination was normal. Cervical spine x-rays revealed an ossified mass developed at the posterior cervical area. Computed tomography has found a well limited polylobed mass of bony density developed from the spinous process of the third cervical vertebra. A magnetic resonance imaging helped identifying the cartilaginous cuff thick. Upon extension investigations we found an associated exostosis of the left distal femur and another one of the right proximal tibia. The patient had an excisional biopsy of the spinous process through a posterior approach. Histology confirmed the diagnosis of osteochondroma and eliminated signs of malignancy. Results: At 3 years follow-up, the neck motion was painless and no signs of recurrence were found. Conclusion: The treatment of choice for spinal exotoses remains excisional surgery, even for asymptomatic tumors. This will avoid considerable growth of these tumors, preventing neurological signs due to medullary compression and especially to avoid malignant degeneration that can occur in 1% of solitary exostosis, and in 10 20% in case of Hereditary multiple exostoses. Histological examination is essential after each surgical excision, firstly to confirm the diagnosis and secondly to eliminate malignant transformation. The prognosis at long term follow-ups is good. However, recurrences may occur after incomplete resection. The osteochondroma is a benign bone lesion, cervical localization is rare. Early diagnosis and treatment can prevent the installation of an irreversible neurologic deficit. MRI is the modality of choice for the identification of the bone tumor, its extent and its impact on the nervous structures., Introduction: Osteoblastoma is a rare benign tumor. It represents less than 1% of all benign bone tumors. His predilection for the spine is known (40% of cases). We reported three cases of osteoblastoma (one in the cervical spine and two in the lumbar spine) and discussed the diagnostic and therapeutic issues. Methods: Observation 1: He was a 17 year old patient who presented with cervicobrachial right neuralgia lasting for 2 years treated medically. The clinical examination confirmed a neurogenic upper limb pain without neurological deficiency. Plain X-rays were normal and CT scan showed a geodic lesion blowing the postero-inferior cortex of the vertebral pedicle of C6. The patient underwent an excisional biopsy through a posterior approach with bony graft followed by a 3 months immobilization by a neck minerva. At a 3 years follow-up there was no signs of recurrence of the tumor. Observation 2: He was a 36 year old man who presented with low back associated with cruralgia. Imaging showed a geodic lesion of 3 cm in diameter taking half of the vertebral body of L1. The lesion was hyperintense on bony scintigraphy. The treatment consisted of an excisional biopsy through a double posterior and anterior approach in same operation with bone grafting and plate fixation. Histology confirmed the diagnosis of an osteoblastoma and there was no signs of recurrence at a two years follow-up. Observation 3: He was a 12 year old boy who consulted for low back pain lasting for one year. Clinical examination found a spinal stiffness without associated scoliosis. Plain radiographs showed an osteolysis of the posterior arch of L5. CT scan showed a lytic process of the right pedicle, the two lamina and the spinous process of L5. The patient underwent an excisional biopsy of the tumor through a direct posterior approach with a postero-lateral bone graft and an L4-S1 fixation. Histology confirmed the diagnosis of osteoblastoma. At last follow-up of 5 years, patient reported only intermittent mild low back pain and no signs of tumor recurrence on last investigations. Conclusions: Osteoblastoma generally manifests by an intermittent pain with night predominance. For spinal localizations, it comes with scoliosis in 50% of cases, mainly for thoracolumbar locations. Neurological signs may be observed (25-50%). On radiology, it is most often a geodic lesion usually exceeding 2 cm in size. CT scan shows the tumor bony extent. MRI shows the tumor mass and the signal abnormality in the adjacent soft tissue. Definitive diagnosis is made by histological examination, since this tumor almost always requires surgical treatment. Spinal osteoblastoma is a rare lesion. It should be considered given a back pain associated with scoliosis. Radiology suspects the diagnosis which is confirmed by pathological examination. Surgical resection must have tumor-free margins to prevent recurrence., Introduction: Osteoblastoma is a rare, benign, osteoid-producing and slow growing primary bone tumor, arising usually in long bones or in the spine, with a slight male predominance. Optimal tumor control can be achieved with radical resection. Depending on its localization and loss of weight-bearing structures, extensive intraoperative reconstruction may be needed. Materials and Methods: We describe the surgical treatment of a C1 (atlantal) osteoblastoma diagnosed in a young male with neurofibromatosis type 1, presenting with progressive neck pain. We detail the surgical procedure for complete excision and stabilization using a bilateral occipitoaxial spinal interarticular stabilization (bOASIS) technique. Load-bearing capacity after bilateral C1 lateral mass resection was achieved using titanium cages with integrated bone graft. A standard posterior occipito-cervical construct completed the instrumentation for the cranio-vertebral junction. Both vertebral arteries were preserved. Results: The post-operative course was uneventful. The patient remained pain free and neurologically intact at 1 year follow-up. Postoperative X-rays, CT and MRI showed optimal fusion and confirmed gross total resection, without tumor recurrence at 1 year follow-up. Biomechanical challenges of C1 lateral mass reconstruction are detailed. Conclusion: To the best of our knowledge this is the first case of bilateral C1 lateral mass reconstruction by this technique reported in the literature. Biomechanical studies focused on C1 lateral mass reconstruction are needed to better understand this intricate segment of the cranio-vertebral junction., Introduction: Despite advances in surgical techniques for spinal metastases, these procedures are often accompanied by substantial blood loss resulting in patients requiring blood transfusion either during intra or postoperative period. Allogeneic blood transfusion has been no doubt the main replenishment method for lost blood, and saving numerous lives. However, the effects of blood transfusion have been shown to be debatable in various oncological surgeries. We aimed to evaluate the influence of perioperative blood transfusion on the outcomes of patients undergoing spinal tumour surgery. Methods: This retrospective study included 247 patients who underwent surgery for spinal metastases in our university hospital between 2005 & 2014. Outcome variables for this analysis were survival and postoperative complication rate among transfused and non-transfused patients. Survival was calculated in months from date of surgery till death. Cox regression analysis was performed for survival. Kaplan-Meier survival estimates were performed and log rank test was used to compare the estimates between the subgroups. Logistic regression analysis was exploited to determine the factors influencing postoperative complications. Results: The overall median blood transfusion was 1 unit (0-10). Overall, 46 patients (19%) experienced at least one postoperative complication, of which 7 patients had more than one complication. The proportion of patients who developed any complication was significantly less for non-transfused patients than transfused patients (21% vs 42%, P = .01). In univariate analysis, significant variables for developing any complication were blood transfusion units, preoperative ECOG score, preoperative Hb level and number of vertebral metastases. Multivariate analysis revealed that increased amount of blood transfusion units (OR = 2.56, 95% CI: 2.01-2.88, P = .01) was independent predictor of any postoperative complication. Overall median survival was 15 months; 95% CI:11-21 months. Patients who received blood transfusion had decreased median survival compared to those who were not transfused (11 vs 21 months). Log rank test revealed that the difference in the survival rates between transfused and non-transfused patients, however, was not significant (P = .24). Generally, there was a trend towards lower survival rates among transfused compared to non-transfused patients at 6-month, 12-month and 18-month post-operation though the differences were not significant. Univariate Cox regression analyses showed that preoperative ECOG, gender, primary tumour and amount of blood transfusion units have significant influence on survival. In multivariate model, only the primary tumour and preoperative ECOG were significant predictors of survival. Conclusions: Increased number of blood transfusion units was associated with postoperative complications. Blood transfusion was associated with decreased survival in univariate analysis but not in multivariate analysis. Revisiting blood transfusion trigger in patients with spinal metastases is recommended. Patient blood management strategies including autologous transfusion in these high-risk groups of patients should be explored further for minimizing ABT use and its related potential risks., Introduction: Surgical management of spinal tumours offers tremendous benefits of addressing cord compression, segmental instability or both, thereby improving patients’ quality of life. Surgery necessitates hospitalisation, which if increase adds to treatment costs, straining on the healthcare system. Reduction of length of stay (LOS) would keep costs under control. We hypothesized that length of hospitalization can be influenced by various factors in patients undergoing spinal tumour surgery. This study aims to identify potentially modifiable factors that might influence the length of hospitalisation in patients undergoing spinal tumour surgery and thereby providing information for improving postoperative care and reducing the LOS. Methods: We retrospectively evaluated 259 patients who underwent surgery for primary or metastatic spine tumours in our institution between 2005 and 2014. Patients’ demographics, operative data and hospital characteristics were retrieved from electronic medical records. LOS was determined from the date of surgery to the date of discharge. Multivariate linear regression was attempted to investigate the factors influencing LOS. Results: Average LOS was 16 ± 15 days. General condition in terms of ECOG score was the most significant factors influencing LOS (P < .001). Other variables significantly associated with LOS in multivariate model were preoperative haemoglobin (P = .01), number of decompression levels (P = .05) and number of allogeneic blood transfusion units (P = .05). Increase age was also moderately associated with prolonged length of stay (P = .07). Conclusion: Our study demonstrated various factors influencing LOS. These data should prove useful for treating team to address the correctable factors like preoperative haemoglobin, blood transfusion and decompression levels to reduce LOS. Reduction of LOS will provide patients who have a shorter predicted survival to return home earlier to spend quality time outside the hospital., Introduction: With the advancement multidisciplinary cancer care and surgical technique, surgery has evolved as an important treatment modality. We propose that posterior vertebral column reconstruction can be performed safely on patients requiring surgery for symptomatic spinal metastasis to improve their quality of life. Material And Methods: A prospective study was conducted in UKM Spine centre involving 23 patients with single level spinal metastasis operated between the year 2012-2015. All patient presented either with pain, instability or with neurological deficit. 5 patients were lost to follow up due to logistics reason.The patients were assessed using VAS score, ASIA score for the neurological deficit and ECOG score for overall quality of life. Results: Pre and post operative VAS score improved from mean of 6.06 to 2.39. The ECOG score improved from 2.56 to 1.61. With the exception of one case with ASIA A, the other patients improved to a grade C, D or E post operatively. Survival rates ranges from 4 months to 52 months. 12 patients was still alive in May 2015 when the results were analysed. Conclusion: PVCR showed favourable outcome with improved VAS, ECOG and patient neurological status and ambulatory capacity in patients with single level spinal metastasis., Introduction: Vertebroplasty is minimally invasive procedures are recommended in osteoporotic and malignant metastasis in patients with a poor medical condition and with a poor prognosis. Transoral vertebroplasty (TOV) can be successfully used to reduce pain and provide stability in the palliative treatment of metastases of the vertebral axis. This procedure has the advantage of providing rapid pain relief and has been described in some case reports. Material and Methods: A case of 38-year-old female who was suffering from liver and lung metastasis of hemangiopericytoma and a painful lytic metastasis to the axis causing cervical torticollis and limitation in head rotation TOV under general anesthesia was performed with guidance of tow digital fluoroscopy. Visual Analog Scale(VAS) was used before and after the procedure. An AP and LAT cervical x-ray were done to evaluate the cement placement. Results: The procedure was effective in achieving pain relief also the neck tilt and limitation in rotation were returned to normal the VAS significantly drop from 9 to 0. Follow up for 9 months she remains pain free. Conclusion: TOV is an effective procedure of cervical pain resulting from malignant involvement of C2., Introduction: Lumbar disc herniations(LDH) can be initially diagnosed like a tumor. Sequestrated/migrated disc herniations may also appear like tumors in MRI investigations. In this study, we reported 4 cases with LDH that was operated on prediagnosis of extradural tumore. Material and Methods: Case 1: A 62 years old female with complaint of left leg pain for 2 weeks. She has numbness and her MRI scans were revealed that there was a lesion with ring-like enhancement after contrast injection at L2 level however it has no connection with intervertebral disc space. She was improved at the 5 months follow-up. Case 2: A 62 years old male with complaint of right leg pain for 1 month. He has numbness and slightly weakness. His MRI scans were revealed a lesion was located at L3 vertebra and it was showed dense contrast enhancement. He was improved at the 2 months follow-up. Case 3: A 34 years old female with a complaint of right leg pain for 3 weeks. She has numbness and slightly weakness. MRI scans showed that a lesion with circumferential contrast enhancement at level of L4 corpus. She was improved at 12 months follow-up. Case 4: A 38 years old female with complaints of severe low back and right leg pain for 2 weeks. She has numbness and weakness. MRI showed a lesion with dense enhancement after contrast injection through L5 and S1 levels. She was improved at 22 months follow-up. Results: LDHs were commonly appeared a hypointense lesion without contrast enhancement in adults because of degeneration. On the other hand, infectious process and tumors obtain a distinct contrast enhancement to diagnostic accuracy. Conclusion: Infrequently, sequestrated disc fragments also enhanced with contrast. Particularly, the fragments can appear as diffuse and/or circumferential enhancement according to resorbtion period. LDH should be kept in mind for acute onset of leg pain.

Study Design Systematic review. Objective To compare the effectiveness and safety between iliac crest bone graft (ICBG), non-ICBG autologous bone, and allograft in cervical spine fusion. To avoid problems at the donor site, various allograft materials have been used as a substitute for autograft. However, there are still questions as to the comparative effectiveness and safety of cadaver allograft compared with autologous ICBG. Methods A systematic search of multiple major medical reference databases was conducted to identify studies evaluating spinal fusion in patients with cervical degenerative disk disease using ICBG compared with non-ICBG autograft or allograft or non-ICBG autograft compared with allograft in the cervical spine. Radiographic fusion, patient-reported outcomes, and functional outcomes were the primary outcomes of interest. Adverse events were evaluated for safety. Results The search identified 13 comparative studies that met our inclusion criteria: 2 prospective cohort studies and 11 retrospective cohort studies. Twelve cohort studies compared allograft with ICBG autograft during anterior cervical fusion and demonstrated with a low evidence level of support that there are no differences in fusion percentages, pain scores, or functional results. There was insufficient evidence comparing patients receiving allograft with non-ICBG autograft for fusion, pain, revision, and functional and safety outcomes. No publications directly comparing non-ICBG autograft with ICBG were found. Conclusion Although the available literature suggests ICBG and allograft may have similar effectiveness in terms of fusion rates, pain scores, and functional outcomes following anterior cervical fusion, there are too many limitations in the available literature to draw any significant conclusions. No individual study provided greater than class III evidence, and when evaluating the overall body of literature, no conclusion had better than low evidence support. A prospective randomized trial with adequate sample size to compare fusion rates, efficacy measures, costs, and safety is warranted.

GSJ883256_Appendix1 for Structural Allograft Versus PEEK Implants in Anterior Cervical Discectomy and Fusion: A Systematic Review by Amit Jain, Majd Marrache, Andrew Harris, Varun Puvanesarajah, Brian J. Neuman, Zorica Buser, Jeffrey C. Wang, S. Tim Yoon, Hans Jörg Meisel and AOSpine Knowledge Forum Degenerative in Global Spine Journal

Supplemental Material, GSJ_Supplemental_Material for Cell Therapy for Treatment of Intervertebral Disc Degeneration: A Systematic Review by Dino Samartzis, Niccole M. Germscheid, Michael G. Fehlings, Charles G. Fisher, Marinus de Kleuver, F. Cumhur Öner, S. Tim Yoon, Luiz R. Vialle, Hans-Joerg Meisel, Neha Agarwal, Patrick C. Hsieh, Andrea Skelly, Jong-Beom Park, Darrel Brodke, Jeffrey C. Wang, S. Tim Yoon and Zorica Buser in Global Spine Journal

Supplemental Material, GSJ739610_suppl_mat for Spine Surgeon Treatment Variability: The Impact on Costs by Matthew D. Alvin, Daniel Lubelski, Ridwan Alam, Seth K. Williams, Nancy A. Obuchowski, Michael P. Steinmetz, Jeffrey C. Wang, Alfred J. Melillo, Amit Pahwa, Edward C. Benzel, Michael T. Modic, Robert Quencer, and Thomas E. Mroz in Global Spine Journal

Background: Platelet-rich plasma (PRP) has emerged as a popular biologic treatment for musculoskeletal injuries and conditions. Despite numerous investigations on the efficacy of PRP therapy, current utilization of this treatment within the United States is not widely known. Purpose: To investigate the national utilization of PRP, including the incidence and conditions for which it is used in the clinical setting, and to determine the current charges associated with this treatment. Study Design: Descriptive epidemiology study. Methods: Using a national database (PearlDiver) of private insurance billing records, we conducted a comprehensive search using Current Procedural Terminology (CPT) codes to identify patients who received PRP injections over a 2-year period (2010-2011). Associated International Classification of Diseases, 9th Revision (ICD-9) codes were identified to determine the specific conditions the injection was used to treat. The aggregate patient data were analyzed by yearly quarter, practice setting, geographic region, and demographics. PRP therapy charges were calculated and reported as per-patient average charges (PPACs). Results: A total of 2571 patients who received PRP injections were identified; 51% were male and 75% were older than 35 years. The overall incidence ranged from 5.9 to 7.9 per 1000 patients over the study period. PRP was most commonly administered in hospitals (39%) and ambulatory surgical centers (37%) compared with in private offices (26%). The most common conditions treated were knee meniscus/plica disorders, followed by unspecified shoulder conditions, rotator cuff injuries, epicondylitis, and plantar fasciitis. Further evaluation revealed that 25% of all patients received injections for cartilage-related conditions, 25% meniscus, 25% unspecified, 12% tendon, 8% glenoid labrum, and 5% ligament. The PPAC for PRP treatment was US$1755 per injection. Conclusion: Despite a lack of consensus regarding PRP indications and efficacy, we observed widespread application of this treatment for a myriad of musculoskeletal injuries. Most treated patients were older than 35 years, and the most commonly treated conditions included cartilage and meniscus disorders. Given the current controversy surrounding this treatment, further studies are necessary to guide clinicians on the value of this therapy for each clinical diagnosis.

Background: Treatment of patellofemoral instability has evolved as our understanding of the relevant pathoanatomy has improved. In light of these developments, current practice patterns and management trends have likely changed to reflect these advancements; however, this has not been evaluated in a formal study. Purpose: To determine nationwide patient demographics, surgical trends, and postoperative complications associated with the operative management of patellar instability surgery. Study Design: Descriptive epidemiological study. Methods: A large private-payer database (PearlDiver) comprising patients covered by Humana and United Healthcare insurance policies was retrospectively reviewed using Current Procedural Terminology (CPT) codes to identify patients who underwent surgery for patellar instability. The study cohort was established by querying for patients billed under CPT codes 27420, 27422, or 27427 while satisfying the diagnostic requirement of patellar instability (International Classification of Diseases–9th Revision codes 718.36, 718.86, or 836.3). Patient demographics, surgical trends, concomitant procedures, and postoperative complications were determined. Results: A total of 6190 patients underwent surgical management for patellar instability. Adolescents (age range, 10-19 years) represented 51.5% of cases, and 59.6% were female. The number of patellar instability procedures increased annually over the study period in both the Humana (P = .004, R 2 = 0.76) and United Healthcare (P = .097, R 2 = 0.54) cohorts. The most common concomitant procedures were lateral retinacular release (43.7%), chondroplasty (31.1%), tibial tubercle osteotomy (13.1%), removal of loose bodies (10.5%), osteochondral grafting (9.5%), and microfracture surgery (9.5%). Manipulation under anesthesia was required in 4.6% of patients within 1 year. Patellar fracture within 1 year and infection within 30 days occurred in 2.1% and 1.2% of patients, respectively. Conclusion: Patellar instability surgery has increased over the past decade. This finding may be attributed to growing clinical evidence to support these procedures as well as increased surgeon familiarity and comfort with these specific techniques. We observed an unexpectedly high rate of concomitant lateral retinacular release. Overall, the rates of commonly recognized complications (stiffness, patellar fracture, and postoperative infection) were similar to those observed in smaller case series.

Bone morphogenetic proteins are a group of structurally related proteins within the TGF-β superfamily of proteins with a diverse repertoire of functions in embryonic and adult organisms. As is apparent from the name, the members first characterized participate in bone growth, development, and remodeling. The “morphogenic” activity per se is defined as the induction of a recapitulation of endochondral bone formation by appropriate stem cells. The regenerative capacity of bone has been recognized since ancient times. The mechanism, applications, and conceptual basis of bone transplantation, bone implantation, ectopic bone formation, and exogenously induced bone formation have been studied by many investigators for more than a century. This review examines the efforts to characterize this activity in the European and American literature over approximately the last century. Because of the inherently complex nature of the process induced by these molecules (inflammation, stem cell proliferation, cartilage differentiation, replacement of cartilage with bone) it is important to evaluate previous investigations through a histological perspective. The cellular basis of the contemporary bioassay for BMP activity is illustrated and discussed from the histological point of view.

Secreted phosphoprotein 24 kD (Spp24) is a bone matrix protein that appears to be derived primarily from the liver and delivered to other tissues in a protective complex. A significant role in bone growth and turnover is suggested by genetic studies that associate the gene locus (SPP2) with bone mineral density and bone quality. The function of this protein in the normal bone environment is unknown but clues are given by the fact that Spp24, or proteolytic products of Spp24, bind cytokines of the TGF-β superfamily and also activate intracellular signaling pathways. Several potential biotherapeutics have been engineered from this protein including materials that enhance BMP-induced bone healing and, on the other hand, materials that inhibit BMPs in clinical situations where this is called for such as reducing BMP-induced inflammation and inhibiting tumors dependent on BMP autocrine systems. As understanding of the structure and function of this protein increases, more opportunities for rationally developed therapeutics will become apparent.