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Case: Two patients (ages 5 and 14 years) with Larsen syndrome and severe cervical kyphosis (patient 1) and spondyloptosis (patient 2), as well as complete anterior-posterior dissociation of the cervical spine, presented with severe, progressive myelopathy. Both patients underwent preoperative halo-gravity traction to slowly reduce the deformity followed by staged anterior-posterior decompression and fusion. Both patients demonstrated complete return of neurologic function., Conclusion: Patients with Larsen syndrome should be screened for cervical deformity at the time of diagnosis. Proper screening will facilitate early detection and treatment of significant deformities to prevent neurologic deterioration, which can be catastrophic in these patients., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B588)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Cervical laminoplasty was initially described for the management of cervical myelopathy resulting from multilevel stenosis secondary to ossification of the posterior longitudinal ligament. The general concepts are preservation of the dorsal elements, preservation of segmental motion, and expansion of the spinal canal via laminar manipulation. No clear evidence suggests that laminoplasty is superior to either posterior laminectomy or anterior cervical diskectomy and fusion. However, laminoplasty has its own advantages, indications, and complications. Surgeons have refined the technique to decrease complication rates and improve efficacy. Recent efforts have highlighted less invasive approaches that are muscle sparing and associated with less postoperative morbidity. Although the long-term outcomes suggest that cervical laminoplasty is safe and effective, continued research on the development of novel modifications that decrease common complications, such as C5 nerve palsy, axial neck pain, and loss of lordosis, is required.

Study Design: This is a retrospective cohort study., Objective: To determine whether age, sex, and race have independent effects on sagittal pelvic parameters., Summary of Background Data: Pelvic parameters and sagittal balance correlate with health-related quality of life and are important for patient assessment and surgical planning. Age, sex, and race are 3 unalterable patient factors that may influence pelvic morphology., Methods: We conducted a retrospective review of consecutive adult patients who presented to our radiology practice between 2010 and 2015 and had a standing, lateral lumbosacral radiograph. Any patients without both femoral heads and L1-S1 visible on the radiograph, and any patients presenting with traumatic injury, coronal deformity, prior instrumentation, spondylolisthesis, or neoplasm of the spine were excluded. Univariate analysis determined differences in measurements among African American, white, and Hispanic races, as well as between male and female sexes. Correlation analysis between age and different measurements was also conducted. Multivariable regression was then used to determine the independent effect of age, sex, and race on pelvic parameters., Results: We investigated 1801 adults (older than 18 y) and 1246 had a recorded race. There were 1165 women, 636 men, 525 whites, 404 African Americans, and 317 Hispanics. Multivariable regression demonstrated a statistically significant increase in pelvic tilt (PT), pelvic incidence (PI), and pelvic incidence-lumbar lordosis (PI-LL) with aging, and statistically significant decrease in sacral slope (SS) and LL with aging. Women had a statistically greater LL than men. African Americans had a statistically smaller PT and greater SS and PI-LL relative to whites, while Hispanics had a statistically smaller PT and PI-LL, and a statistically greater SS and LL relative to whites., Conclusions: Pelvic parameters were different between sexes, among races, and changed with age. These findings are important for patient assessment and preoperative planning to obtain optimal sagittal balance., Level of Evidence: Level 3.

Study Design: Cadaver study., Objective: To investigate the safety of the extraforaminal lumbar interbody fusion approach., Summary of Background Data: Over the last decade the number of techniques available for lumbar interbody fusion has increased. Recent interest has developed in an extraforaminal approach to the intervertebral disc to reduce the morbidity associated with facetectomy. The safety of this extraforaminal corridor with regards to the exiting nerve root and lumbar plexus has yet to be assessed., Methods: With the cadaver prone, the C-arm was positioned over the disc of interest and aligned perpendicular to the superior endplate of the inferior vertebral body, with the superior articular process bisecting the available disc space. Three needles were passed into the disc and labeled medial, middle, and lateral. After needle placement, each nerve root and the lumbar plexus were dissected. The distance of each needle to these structures was measured and discectomy was performed to assess potential graft length from a transforaminal and extraforaminal approach., Results: We performed the method on levels L1-L5 bilaterally on 2 cadavers, totaling 16 attempts for each needle position. The average distance to nerve of the medial approach (3.2±1.1 mm) was statistically greater than both the middle (1.1±1.4 mm) and lateral (-0.2±2.9 mm) approaches (P<0.0001 for both). The distance to plexus of the medial approach (14.3±6.2 mm) was greater than the middle (9.2±6.1 mm) approach and statistically greater than the lateral (5.2±5.6 mm) approach (P=0.001). There was a greater graft length available by the extraforaminal lumbar interbody fusion approach (36.1±2.7 mm) than the transforaminal lumbar interbody fusion approach (29.3±3.5 mm, P<0.0001)., Conclusions: The safest trajectory was the medial, passing adjacent to the superior articular process. The close proximity, however, means that neuromonitoring and tubular dilators would be necessary to use this technique in a clinical setting., Level: Level V.

Background: Tandem spinal stenosis refers to spinal canal diameter narrowing in at least 2 distinct regions of the spine, most commonly the lumbar and cervical regions. This entity can be an asymptomatic radiographic finding, or it can present with severe myelopathy and lower-extremity symptoms. Tandem spinal stenosis may impact surgeon decision-making when planning either cervical or lumbar spine surgery, and there is currently no consensus in the literature regarding the treatment algorithm for operative intervention., Methods: A MEDLINE literature search was performed using PubMed, the Cochrane Database of Systematic Reviews, and Embase from January 1980 to February 2015 using Medical Subject Heading queries for the terms "tandem spinal stenosis," "cervical stenosis AND lumbar stenosis," and "concomitant spinal stenosis." We included studies involving adult patients, tandem spinal stenosis of the cervical and lumbar regions, and a minimum of 5 patients. Articles that did not discuss spinal disorders or only explored disorders at a single spinal region were excluded., Results: The initial database review resulted in 234 articles. After abstracts were reviewed, only 17 articles that met inclusion criteria were identified: 2 cadaveric studies, 5 clinical studies of patients with radiographic tandem spinal stenosis, and 10 clinical studies of patients with symptomatic tandem spinal stenosis., Conclusions: Tandem spinal stenosis is a common condition present in up to 60% of patients with spinal stenosis. This disorder, however, is often overlooked, which can lead to serious complications. Identification of tandem spinal stenosis is paramount as a first step in management and, although there is still no preferred intervention, both staged and simultaneous procedures have been shown to be effective. Surgeons may utilize a single, staged, or combined approach to decompression, always addressing cervical myelopathy as a priority.