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Purpose: To evaluate the surgical results of full horizontal tendon rectus muscle transposition to the superior rectus muscle insertion, augmented by posterior fixation sutures, in patients with double elevator palsy. Methods: In this retrospective comparative study, 17 patients treated by the augmented Knapp procedure (study group) were compared with 28 patients treated by the standard Knapp procedure (control group). Pre-operative and postoperative vertical deviation in primary position, ocular motility, binocular function, and rate of reoperation were evaluated. Results: The mean preoperative near and distance deviations (hypotropia) decreased by 93% and 97% in the study group and 68% and 69% in the control group, respectively. The improvement in near and distance deviation was statistically more significant in the study group than the control group ( P = .001 for each parameter). The mean preoperative elevation deficiency in abduction and adduction improved by 64% and 66% in the study group and 37% and 39% in the control group, respectively. The improvement in elevation deficiency in abduction and adduction was statistically significantly greater in the study group than the control group ( P = .001 and .04, respectively). Reoperation was required in 15 patients (54%) in the control group and 2 (12%) in the study group during the follow-up period of 26 ± 4 months. Conclusions: The postoperative improvement in near and distance deviation and elevation deficiency in abduction and adduction was significantly better in the augmented Knapp procedure than the standard Knapp procedure. This procedure demonstrated a stronger effect in the treatment of double elevator palsy. [ J Pediatr Ophthalmol Strabismus . 2022;59(1):17–23.]

Objective Patients with instability because of congenital craniovertebral anomalies often have complex C1-C2 osseovascular anomalies. C2 nerve root sacrifice has been described to address such difficult anatomy during posterior C1-C2 fixation and has its own downsides. Its preservation as a recent alternative poses greater surgical challenge, and the considerations differ from other causes of craniovertebral junctional instability; the pertaining outcomes have been scarcely studied. The objective of this study was to prospectively determine the feasibility and outcomes related to C2 nerve root preservation in patients with congenital atlantoaxial dislocation (CAAD) after posterior C1-C2 fixation. Methods In this observational study, 63 patients (126 nerve roots) with CAAD after posterior fixation were prospectively assessed. Underlying osseovascular anomalies affecting the feasibility of C2 nerve root preservation, and C2 nerve–related dysfunction at 12 months follow-up were analyzed. Results The overall C2 nerve root preservation rate was 89.7%. Even in the presence of extreme joint obliquity/spondyloptosis and anomalous vertebral artery, it was feasible in about three fourths. After preservation, 28.3% patients developed new-onset C2 nerve root dysfunction: neuralgia in 2, dysesthesia in 6, and hypoesthesia/paresthesia in 9. The symptoms were not disabling in most patients. Conclusions In most patients with CAAD, C2 nerve root preservation is feasible despite an aberrant bony and vascular anatomy. A few patients after nerve root preservation develop related symptoms that are conservatively manageable, with no significant adverse consequences. Given the controversy in the literature on C2 nerve sacrifice–related outcomes, we favor an attempt at C2 nerve root preservation.

AIM: To describe the experience with half-width vertical muscles transposition (VRT) augmented with posterior fixation sutures. METHODS: The clinical charts of all patients, who underwent half-width VRT augmented with posterior fixation sutures for sixth cranial nerve palsy from January 2003 to December 2018, were retrospectively reviewed. For each patient, pre- and post-operatively, the largest measured angle was used for the calculations, usually resulting with the angle for distance, except in young infants, where measurements were made at near fixation using the Krimsky test. RESULTS: Fifteen patients met the inclusion criteria for the study, of them 9 (60.0%) had also medial rectus muscle recession at the time of surgery. Mean follow-up period was 21.4±23.2mo (range 1.5-82mo). Preoperative mean esotropia was 51.3±19.7 prism diopter (PD; range 20-90 PD). Postoperative mean deviation on final follow-up was 7.7±20.2 PD (range -40 to 35 PD; P=0.018). In all patients with preoperative abnormal head position, improvement was noted. Ten (66.7%) patients had improvement in abduction and 10 (66.7%) patients reported improvement in their diplopia, by final follow-up. The addition of medial rectus recession was correlated with a larger change in postoperative horizontal deviation compared to baseline (P=0.026). Two (13.3%) patients developed a vertical deviation in the immediate postoperative period which had resolved in one of them. CONCLUSION: Half-width VRT augmented with posterior fixation suture, with or without medial rectus muscle recession, is an effective and safe procedure for esotropia associated with sixth cranial nerve palsy. A major improvement in the angle of deviation is expected. Most patients will have improvement in their abnormal head position and diplopia.

ResumoAs fraturas vertebrais osteoporóticas são um tipo comum de fratura e afetam um número significativo da população com osteoporose. Apesar do elevado risco de fratura, a ocorrência concomitante de fraturas vertebrais em níveis não contíguos é muito rara. Reportamos o caso de uma paciente com três fraturas explosivas da coluna dorsolombar em níveis não contíguos, tratada com cifoplastia e fixação posterior transpedicular por via percutânea. Seis meses após a cirurgia, a paciente tem marcha autônoma, sem dor, e, radiologicamente, não existem evidências de perda de redução das fraturas.

Objective Posterior fossa decompression is the treatment of choice in type 1 Chiari malformation (CM-1) without bony instability. Although surgical fixation has been recommended by a few authors recently, comparative studies to evaluate these treatment strategies using objective outcome tools are lacking. Methods Seventy-three patients with pure CM-1 (posterior fossa bony decompression [PFBD], n = 21; posterior fossa bony and dural decompression [PFBDD], n = 40; and posterior fixation [PF], n = 12) underwent a postoperative outcome assessment using Chicago Chiari Outcome Score (CCOS). Logistic regression analysis detected predictors of an unfavorable outcome. Results Minimally symptomatic patients generally underwent a PFBD while most of the clinically severe patients underwent a PFBDD (p = 0.049). The mean CCOS score at discharge was highest in the PF (12.0 ± 1.41) and lowest in PFBDD group (10.98 ± 1.73, p = 0.087). Patients with minimal preoperative clinical disease severity (adjusted odds ratio [AOR], 4.58; 95% confidence interval [CI], 1.29–16.31) and PFBDD (AOR, 7.56; 95% CI, 1.70–33.68) represented risks for an unfavorable short-term postoperative outcome. Though long-term outcomes (CCOS) did not differ among the 3 groups (p = 0.615), PFBD group showed the best long-term improvements (mean follow-up CCOS, 13.71 ± 0.95), PFBDD group improved to a comparable degree despite a poorer short-term outcome while PF had the lowest scores. Late deteriorations (n = 3, 4.1%) occurred in the PFBDD group. Conclusion Minimally symptomatic patients and PFBDD predict a poor short-term postoperative outcome. PFBD appears to be a durable procedure while PFBDD group is marred by complications and late deteriorations. PF does not provide any better results than posterior fossa decompression alone in the long run.

Objective Although a retro-odontoid pseudotumor associated with rheumatoid arthritis is a well-known clinical entity, little is known about retro-odontoid pseudotumors not associated with rheumatoid arthritis due to their rarity. Methods Between 2006 and 2019, consecutive patients with nonrheumatoid pseudotumors were included and retrospectively compared with patients with rheumatoid pseudotumors. Results Nineteen patients had nonrheumatoid pseudotumors (mean age, 73 ± 6 years; male, 53%). All had cervical lesions including ossified anterior and posterior longitudinal ligaments with a history of cervical surgery in 5. The mean thickness of the pseudotumors at diagnosis was 8.1 mm (range, 4.2-17.2 mm). Pseudotumor thickness had a significant negative correlation with the atlantodental interval (p = 0.008) and the subaxial range of motion (p = 0.049). In comparison with 7 rheumatoid pseudotumor patients, nonrheumatoid pseudotumor patients were older (p = 0.042), had a higher proportion of males (p = 0.023), had a smaller atlantodental interval (p = 0.007), and had larger pseudotumors at diagnosis (p = 0.030). Of the 19 patients, 18 received posterior fixation with or without C1 laminectomy, while the other received C1 laminectomy alone. The percent pseudotumor thickness at follow-up to those at diagnosis was 91%, 77%, 68%, 46%, 58%, and 49% at 1, 3, 6, 12, 24, and 36 months after surgery, respectively. Conclusion This study revealed markedly clinical and radiological differences between nonrheumatoid and rheumatoid pseudotumors. The main etiology for nonrheumatoid pseudotumors was subaxial cervical degeneration and ossified lesions. There were good outcomes following posterior fixation and time-dependent pseudotumor regression within 12 months.

Bilateral posterior hip dislocations are extremely rare. Symmetric dislocations can be easily missed out. A 74-year-old man presented to the emergency department after sustaining a dashboard injury. The right hip showed a dislocation clinically and radiographically. The left hip joint had a fracture dislocation which was confirmed radiographically. The right hip joint post-reduction was stable but the left hip joint was highly unstable after reduction and was managed with posterior fixation. After fixation, the left hip joint was fully stable and the patient had an excellent prognosis at follow-up of 1 year. The mechanism of injury must be properly studied and a strong suspicion must be kept for concomitant dislocation in the presence of a high-velocity injury as clinical examination in these situations can be misleading. Once adequately diagnosed, the treatment protocols are simple and the outcomes are excellent for the patient.

Management of a “difficult airway” poses one of the most relevant and challenging tasks for anesthesiologists. Unanticipation with difficult airway and endotracheal intubation during the conduction of general anesthesia may result in complications and fatality. We report the case of a 14 yr old boy for planned C5-C6 spine fixation under general anaesthesia. Unanticipated difficult oral intubation after three failed attempts, managed by a stylleted cuffed endotracheal tube, head up tilt of the operation table, shoulder support, cricoid pressure and rotation of the endotracheal tube anticlockwise at the glottic opening.

Purpose: To analyze and determine the postoperative visual acuity and complications after intraocular implantation of an iris-claw lens in aphakic patients. Setting: Sri Devaraj Urs Medical College, Kolar, Karnataka, India. Design: Retrospective study. Materials and Methods: Medical records of cataract and aphakic patients who underwent posterior fixation of iris claw lens over a five-year period were reviewed for collection and analysis of data. Results: The study comprised 138 eyes of 57.25% female and 42.75% male with mean age of 62.84 ± 8.649 years. The follow up period was 6 to 24 months. The mean preoperative CDVA was 0.44 + 0.23 logMAR. After 1 year of follow up period the mean postoperative CDVA was 0.3+ 0.15 logMAR which was statistically significant (p Conclusions: This study showed the merits of retrofixated iris claw lens over AC IOL and SF IOL in terms of simple technique, short learning curve, satisfying overall visual outcome, less risk of complications and good safety profile. Keywords: Aphakia, Enclavation, Iris claw, Retrofixation.

BACKGROUND : Lateral lumbar interbody fusion (LLIF) is used to treat multiple conditions, including spondylolisthesis, degenerative disc disorders (DDD), adjacent segment disease (ASD), and degenerative scoliosis. While many advocate for posterior fixation with LLIF, stand-alone LLIF is increasingly being performed. Yet the fusion rate for stand-alone LLIF is unknown. PURPOSE : Determine the fusion rate for stand-alone LLIF. STUDY DESIGN : Systematic Review. METHODS : We queried MEDLINE, COCHRANE, and EMBASE for literature on stand-alone LLIF fusion rate with a publication cutoff of April 2020. LLIF surgery was considered stand-alone when not paired with supplemental posterior fixation. Cohort fusion rate differences were calculated and tested for significance (p RESULTS : A total of 2,735 publications were assessed. Nineteen studies met inclusion criteria, including 736 patients and 1,103 vertebral levels. Mean age was 61.7 years with BMI 26.5 kg/m2. Mean fusion rate was 85.6% (range, 53.0%-100.0%), which did not different significant by number of levels fused (1-level, 2-level, and ≥3-level). Use of rhBMP-2 was reported in 39.3% of subjects, with no difference in fusion rates between studies using rhBMP-2 (87.7%) and those in which rhBMP-2 was not used (83.9%, OR=1.37, p=0.448). Fusion rate did not differ with the addition of a lateral plate, or by underlying diagnosis. All-complication rate was 42.2% and mean reoperation rate was 11.1%, with 2.3% reoperation due to pseudarthrosis. Of the studies comparing stand-alone to circumferential fusion, pooled fusion rate was found to be 80.4% vs. 91.0% (p=0.637). CONCLUSIONS Stand-alone LLIF yields high fusion rates overall. The wide range of reported fusion rates and lower fusion rates in studies involving subsequent surgical reoperation highlights the importance of being well-trained in this technique and employing a rigorous algorithm when indicating patients for stand-alone LLIF. Future research should focus on examining risk factors and patient-reported outcomes in stand-alone LLIF.

The ankylosed spine is prone to fracture even as a result of minor trauma due to its changed biomechanical properties. Fractures in ankylosing spondylitis (AS) patients are highly unstable and surgical intervention for fixation is warranted. Implant failure rates are high and combined anterior and posterior fixation is required to enhance the fixation outcome. For fusion, anterior interbody fusion or posterior bone graft fusion is often adopted. Here, we introduce a new method which combines vertebroplasty with anterior and posterior approaches to improve pain control, facilitate the long-term fixation outcome and mechanics, and decrease perioperative risks with prompt stabilization, especially in patients with spine curve deformity. Here, we present two AS cases with cervical spine fracture treated with this new method.

Study Design: Retrospective radiological analysis. Objectives: Translaminar screw (TLS) placement is one of the fixation techniques in the subaxial cervical spine. However, it can be difficult to use in small diameter of the lamina. This study proposed a novel bicortical laminar screw (BLS) and analyzed the related parameters using computed tomography (CT). Methods: Cervical CT images taken at our institution from January 2013 to March 2017 were used for measurement. On the axial images, the maximum screw length (MSL) and trajectory angle (TA) of BLS and TLS were measured, together with the distance from the midline (DM) to the BLS entry point and the lamina width (LW). On the parasagittal images, the height of the lamina (LH) was measured. Results: MSL of BLS and TLS were 21.00 and 20.97 mm, 19.02 and 20.91 mm, 18.45 and 21.01 mm, and 20.00 and 21.01 mm in C3, C4, C5, and C6, respectively. TA of the BLS and TLS were 21.24° and 34.90°, 19.05° and 34.22°, 18.65° and 33.61°, and 18.30° and 34.51° at C3, C4, C5, and C6, respectively. DM were 6.44, 5.77, 5.68, and 6.03 at C3, C4, C5, and C6, respectively. LW and LH were 3.52 and 12.44 mm, 2.87 and 12.49 mm, 2.76 and 12.42 mm, and 3.18 and 13.30 mm at C3, C4, C5, and C6, respectively. Conclusion: We suggest that BLS fixation is a feasible alternative option for posterior fixation to the lamina of the subaxial cervical spine. It may be especially useful when pedicle screw, lateral mass screw, and TLS are not appropriate.

Objective To compare the Schanz screw insertion angle and the loss of the regional kyphosis correction in thoracolumbar burst fractures following posterior short instrumentation surgery. Methods Patients with a thoracolumbar burst fracture between levels T11-L2 were divided into two groups (parallel and divergent) according to the angle formed between the Schanz screw and the vertebral plateau. Regional kyphosis was evaluated in preoperative, immediate postoperative and last follow-up radiographs. Results Of the 58 patients evaluated, 31 had a parallel assembly and 27 had a divergent assembly. When we analyzed the angle of kyphosis, no statistical difference was observed between the pre- and postoperative radiographs. However, a statistical difference in the last follow-up radiographs and in the final loss of the kyphosis correction was confirmed. Conclusion The insertion of Schanz screws with a divergent assembly presents better radiographic results with less loss of kyphosis correction angle when compared with the parallel assembly technique. Level of Evidence III; Retrospective cohort study.

To compare transoral and endoscopic transnasal anterior release without odontoidectomy and posterior reduction and fixation to treat irreducible atlantoaxial dislocation (IAAD). From June 2006 to January 2017, 35 consecutive patients with IAAD underwent transoral (Tr-Oral group) or endoscopic transnasal (Tr-Nasal group) release and posterior fixation and fusion in our department. Clinical neurological recovery (Japanese Orthopedic Association (JOA) score) and radiological reduction parameters including atlantodontoid interval (ADI), space available for the cord (SAC) and cervicomedullary angle (CMA) were analyzed and compared. The operation duration, blood loss, length of intensive care unit (ICU)/hospital stay and complications were recorded. All 35 patients (18 and 17 patients in the Tr-Oral and Tr-Nasal groups, respectively) were followed up for a mean of 36.4 months (range, 21–60 months). All patients achieved excellent anatomical reduction and clinical neurological recovery, with no significant differences between the two groups. The JOA score, ADI, SAC and CMA were not significantly different between the two groups at various postoperative points. Although the Tr-Oral group had shorter operation time and less blood loss than the Tr-Nasal group, the Tr-Nasal group tended to have a significantly shorter hospital/ICU stay, earlier extubation and earlier oral intake than the Tr-Oral group. The transoral and endoscopic transnasal approaches can achieve equivalent release and reduction effects when treating IAAD. Compared to the transoral approach, the endoscopic transnasal route is less invasive with earlier extubation and oral intake, shorter hospital/ICU stays and lower medical costs, which is conducive to enhanced recovery after surgery.

Introduction Implant subsidence is a potential complication of spinal interbody fusion and may negatively affect patients subjected to procedures relying on indirect decompression such as minimally invasive transpsoas lateral lumbar interbody fusion (LLIF). The porous architecture of a recently developed titanium intervertebral cage maximizes bone-to-implant contact and minimizes stress shielding in laboratory experiments; however, its subsidence rate in patients has not yet been evaluated. The goal of this current study was to evaluate implant subsidence in patients subjected to LLIF. Methods Our institutional review board-approved single-center experience included 29 patients who underwent 30 minimally invasive LLIF from July 2017 to September 2018 utilizing the novel 3D-printed porous titanium implants. Radiographs, obtained during routine postoperative follow-up visits, were reviewed for signs of implant subsidence, defined as any appreciable compromise of the vertebral endplates. Results Radiographic subsidence occurred in 2 cases (6.7%), involving 2 out of 59 porous titanium interbody cages (3.4%). Both cases of subsidence occurred in four-level stand-alone constructs. The patients remained asymptomatic and did not require surgical revision. Ten surgeries were stand-alone constructs, and 20 surgeries included supplemental posterior fixation. Conclusions In our patient cohort, subsidence of the porous titanium intervertebral cage occurred in 6.7% of all cases and in 3.4% of all lumbar levels. This subsidence rate is lower compared to previously reported subsidence rates in patients subjected to LLIF using polyetheretherketone implants.

Background: Anterior transarticular screw fixation (ATSF) of C1/C2 can be used for the treatment of unstable dens fractures. Here, we evaluated the feasibility of an anterior C1/C2 fixation in elderly patients with unstable dens fractures. Furthermore, we tried to analyze safe entry zones for ATSF surgery. Methods: A consecutive cohort of 13 patients with unstable dens fractures were treated with ATSF of C1/C2 between January 2015 and October 2016. If necessary, an additional screw was placed into the odontoid process. The placement was radiographically analyzed using the 3D Arcadis Orbic (Siemens, Erlangen, Germany). Additionally, computed tomography scans of the cervical spine from 50 trauma patients were analyzed to evaluate safe entry zones for anterior odontoid screw fixation and for ATSF. Results: ATSF was performed in 13 cases (7 female, 6 male; mean age 81.80 years). One screw had to be corrected intraoperatively due to initial malplacement. Neurological deficits or an injury of the vertebral artery were not observed. All patients suffered from swallowing difficulties during the postoperative course, without lesions of the esophagus or the trachea. In 4 patients (30.8%), an additional posterior fixation was offered to the patients due to progressive loosening of the screws. The anatomical-radiographic analyzes revealed a significantly shallower angle of trajectory for anterior odontoid screw fixation (24.9° ± 5.85°) than for ATSF (39.1° ± 6.44° (left); 40.5° ± 6.79° (right) P = 0.02). Conclusions: The ATSF of C1/C2 might be a valuable option in the treatment of instable C1/C2 fractures, especially in the elderly or in patients with short necks and/or high body mass index due to the steeper trajectory compared with odontoid screw placement. Yet available screws seem to be of inferior resistance compared with the biomechanical properties of a dorsal fixation. Further studies should focus on screws with better mechanical properties and probably additional cement augmentation. Level of Evidence: 4.

An anterior approach to the lumbar spine is increasingly used in performing fusion. Depending on the level to be treated, several approaches have been developed to deal with the anatomic obstacles encountered: pure anterior, oblique anterior or lateral, and trans- or pre-psoas. Conventional techniques incur risk of muscle lesion and severe bleeding, and have been replaced by minimally invasive approaches, often with video assistance after rapid closure of laparoscopic approaches with gas insufflation. There has, in parallel, been great progress in anterior spinal instrumentation systems. Non-existent when these techniques were first developed, they have become increasingly sophisticated, and now employ a variety of stand-alone or not cages and anterior screwed plate that can be associated together or to posterior fixation. Each approach and type of fixation has its specific technical requirements that need to be fully mastered so as to minimize risk, especially regarding vessels, and to enable the patient to enjoy the benefit of their very low morbidity. We shall therefore detail here each step of the pure anterior approach, which is most often used for L5S1, the oblique and lateral approaches, mainly used for L2L5, and also the preparation of the lumbar spine for anterior interbody fusion, with the respective instrumentations. We shall then consider the pros, cons and risks, and also spinal or general contraindications that may sometimes preclude this option. From this, we shall derive the specific optimal and wrong indications for anterior lumbar surgery, to help decision-making when fusion is indicated.

Basilar invagination are uncommon syndrome that occurs when the superior part of the odontoid (part of the C2 vertebrae) migrates upward through foramen magnum and that causes bulbomedullary compression. Basilar invagination are divided on bases of that causation in trau matic and other one is developmental. Mostly seen basilar invagination are developmental. Here with describe a case of 13yr old female with developmental craniovertebral junction abnormality in form of congenital atlanto axial dislocation with Platiebasia with basilar invagination which is treated with decompression and occipital plate and screw based posterior fixation with its clinical as well as radiological outcome. Keywords: Basilar invagination, AtlantoAxial dislocation, Platybasia, OC Fusion, Craniovertebral junction anomaly, Brainstem compression.

Study Design: This was an interventional randomized trial. Summary of Background Data: Fractures of the thoracolumbar spine represent 90% of all spine fractures, and the thoracolumbar burst fractures (Type A fractures) are the most common in the spine and important cause of posttraumatic kyphotic deformity. The cause of this problem appears to be the structural and mechanical deficiency of the anterior column following indirect fracture reduction by posterior fixation. Objective: The objective of this study was to evaluate the effects of transpedicular intracorporeal grafting associated with short-segment transpedicular fixation on kyphosis progression in patients with thoracolumbar burst fracture Type A3/A4. Materials and Methods: Fifty-nine consecutive patients with thoracolumbar burst fracture were treated with short-segment transpedicular monoaxial screw fixation. Patients were simply randomized divided into transpedicular grafting (TPG) (n = 35; A3 = 20 and A4 = 15) and non-TPG (n = 24; A3 = 19 and A4 = 5). The average follow-up was 21.1 ± 4.2 (range: 16–26) months for the entire study group: 22.1 ± 4.5 months for the TPG group and 20.2 ± 4.8 months for the non-TPG group (P = 0.49). Results: The global mean kyphosis angle before surgery was 21.93° ±3.92°, with 22.06° ±3.55° in the TPG group and 20.75° ±4.68° for non-TPG; P = 0.93. The mean kyphosis angle at the end of follow-up for the entire study was 9.21° ±8.86°, with 8.70° ±2.11° for TPG and 14.08° ±4.73° for non-TPG, (TPG vs. non-TPG, P = 0.010). No obvious clinical complications in both the groups were documented. Conclusions: Our findings demonstrate that transpedicular bone grafting associated with short-segment fixation in thoracolumbar burst fractures has caused a significant effect on the prevention of kyphosis progression after surgery.

Objective Atlantoaxial fixation is technically demanding and challenging, especially in cases with anatomical abnormality. The purpose of this study is to report the effectiveness of the three-dimensional (3D)-customized guiding template for placement of C1 and C2 screws in cases with abnormalities. Method Two patients with anatomical abnormality and one without were included. The preoperative computed tomography (CT) image was analyzed using our software. The entry point, trajectory, and depth of the screws were designed based on these images. Templates with screw guiding cylinders and cervical spine model were created. In operation, guiding templates were applied directly to the laminae. Drilling, tapping, and screwing were performed through the cylinders. To evaluate the accuracy, deviation of the screw axis from the preplanned trajectory was measured on postoperative CT. A classification system was taking to evaluate the pedicle screw insertion. Results In complex cases, one of C2 screws has grade 2 deviation, and two has grade 1. There was no deviation in screws of C1. All patients achieved symptoms free after 6 months follow-up. Conclusion Although 3D-printed template for atlantoaxial fixation still has limitation in complex cases, it has been proved usefulness and makes the most difficult and dangerous spinal posterior fixation easy to achieve.

Simplified loading conditions such as pure moments are frequently used to compare different instrumentation techniques to treat spine disorders. The purpose of this study was to determine if the use of realistic loading conditions such as muscle forces can alter the stresses in the implants with respect to pure moment loading. A musculoskeletal model and a finite element model sharing the same anatomy were built and validated against in vitro data, and coupled in order to drive the finite element model with muscle forces calculated by the musculoskeletal one for a prescribed motion. Intact conditions as well as a L1-L5 posterior fixation with pedicle screws and rods were simulated in flexion-extension and lateral bending. The hardware stresses calculated with the finite element model with instrumentation under simplified and realistic loading conditions were compared. The ROM under simplified loading conditions showed good agreement with in vitro data. As expected, the ROMs between the two types of loading conditions showed relatively small differences. Realistic loading conditions increased the stresses in the pedicle screws and in the posterior rods with respect to simplified loading conditions; an increase of hardware stresses up to 40 MPa in extension for the posterior rods and 57 MPa in flexion for the pedicle screws were observed with respect to simplified loading conditions. This conclusion can be critical for the literature since it means that previous models which used pure moments may have underestimated the stresses in the implants in flexion-extension and in lateral bending.

It has been reported that superior rectus transposition combined with medial rectus recession can provide as good results as transposition of both vertical rectus muscles, with no adverse effects on torsion or postoperative vertical misalignment. Further augmentation of transposition surgery can be achieved through the use of posterior fixation sutures, myopexy and botulinum toxin into the medial rectus. We report a patient with complete bilateral traumatic sixth cranial nerve palsies who underwent sequential superior rectus transposition surgery combined with medial rectus recession. The surgery was augmented with a myopexy (posterior suture joining superior and lateral recti with no scleral fixation) in the first eye and with a posterior fixation suture (with scleral fixation) in the second eye. After the second procedure, despite a significant improvement in horizontal alignment, the patient developed 15 degrees of incyclotorsion which was attributed to the scleral fixation suture. The patient underwent removal of the scleral suture and 3 months postoperatively had a significant reduction in incyclotorsion to 8 degrees; however this continued to be a barrier to fusion. Vertical rectus transposition of superior and inferior recti augmented with posterior scleral fixation sutures is one type of conventional surgery for complete lateral rectus palsy. In more recent times, it has become common to transpose the superior rectus alone along with recession of the contracted medial rectus. This procedure can also be augmented with a posterior fixation suture which may or may not be attached to the sclera. Whilst this surgery has gained popularity it is not without risk as demonstrated by our case in which transposition of the superior rectus was associated with postoperative incyclotorsion. In this case a possible explanation may be the use of a the posterior scleral fixation suture as it did not occur when no scleral fixation was used. Furthermore, removal of the posterior scleral fixation suture did reduce the torsion significantly although it did not eliminate it.

Background Thoracolumbar spine fractures are common injuries that can result in significant disability, deformity and neurological deficit. Controversies exist regarding the appropriate radiological investigations, the indications for surgical management and the timing, approach and type of surgery. Aim of the Work to discuss: Guidelines and controversies of short versus long posterior fixation in management of thoracolumbar spine fractures. Patients and Methods 20 articles were identified through specified electronic databases. After application of the inclusion and exclusion criteria, 9 comparative studies were finally included in this systematic review. Various other approaches were used in combination with posterior pedicle screw fixation according to the underlying pathology (e.g. Discectomy, Laminectomy, Vertebroplasty, Kyphoplasty, etc.). A total of 194 patients underwent short segment pedicle screw fixation compared to 158 patients who underwent Long segment pedicle screw fixation for various indications. The majority of the included trials were small studies with between 12 and 69 participants. The patients’ characteristics were comparable within each study group. Individual patient data were available from these articles. Results A total of 194 patients underwent short segment pedicle screw fixation compared to 158 patients who underwent Long segment pedicle screw fixation for various indications. The majority of the included trials were small studies with between 12 and 69 participants. The patients’ characteristics were comparable within each study group. Individual patients data were available from these articles; longest follow up post operative record was about 71 months; 162 male and 93 female in these studies; the mean age about 38 years; the level of thoracolumbar fracture was: 60 patients at T12,104 patients at L1 and 41 patients at L2. Conclusion This review suggest work on the guidelines with evaluating of each case according to age, angels, height, weight (BMI), comorbidities, ability to anaesthesia and types of instability in the patient before as osteoporosis and kyphosis. Degree of angels of cobb and kyphotic angel which are major factors determine if posterior long or short.

Objective This retrospective study investigated the clinical and radiographic outcomes following temporary transpedicular posterior instrumentation between two cohorts of patients with thoracolumbar fractures (TLF) who underwent selective or bi-segments intervertebral articular process fusion. Methods Patients with TLF who underwent the temporary posterior fixation with selective fusion (Group SF), or bi-segments fusion (Group BF) were studied. Superior intervertebral articular process and interlaminar fusion were performed in Group SF, whereas in Group BF, the patients underwent bi-segments fusion in both superior and inferior articular processes, as well as interlaminar fusion. We measured the distal and proximal intervertebral mobility, regional kyphotic angle, and vertebral height before and after surgery in both groups. Greenough Low-Back Outcome Score was used to assess the clinical outcomes. Results Sixty-five patients with TLF from T12 to L2 fractures were enrolled in the study period: 33 patients in the Group SF and 32 patients in the Group BF. All the patients experienced fracture healing (mean follow-up time: 19.7 months). The mean postoperative functional outcomes were 65.0 ± 2.0 points for the Low-Back Outcome Score in the Group SF and 65.2 ± 1.8 for the Group BF. A progressive regional kyphotic angle was observed with time regardless of fusion but was not significantly different between the two groups. There was a statistical difference between unfused inferior proximal adjacent and inferior distal adjacent segment regardless of fracture segments. Conclusions The strategy of selective fusion is reported to be useful for the treatment of patients with TLF. The motion in the un-fused and adjacent segment could be better regained after instrumentation removal in the selective fusion group. Level of evidence Level 3.

Introduction:Spinal fractures related to diffuse idiopathic skeletal hyperostosis (DISH) are almost always caused by a long lever arm, so treatment of the fractures requires stabilization of long segments of the spine. Treatment of unstable sacral fractures in DISH patients with ankylosis of the sacroiliac joints requires a treatment strategy that includes a consideration of the condition of the spine. This article is the first report of an unstable sacral fracture in a patient with DISH. Case Report:A 95-year-old male fell and presented with severe low back pain. An X-ray and computed tomography showed unstable pelvic fracture (AO type C2) and ankylosis of the lumbar spine due to DISH. We performed minimally invasive spinopelvic posterior fixation and internal anterior fixation (INFIX) for stabilization of the pelvic fracture. Initially, due to the long lever arm created from the lumbar spine to the pelvis, we performed L2-iliac posterior stabilization while the patient was in a prone position. After that, we performed INFIX to stabilize the anterior pelvis while the patient was positioned supine. The postoperative clinical course of the patient was uneventful and bony fusion was achieved as seen on X-ray obtained 1 year postoperatively. Conclusion:This patient was ankylosed from spine to pelvis due to DISH and sacroiliac joint ankylosis and sustained bilateral sacral fractures which dissociated the sacrum from the rest of the pelvis. Therefore, this fracture required spinopelvic fixation from the ankylosing spine to the pelvis. Because this patient was so elderly and in poor general health, we performed minimally invasive spinopelvic posterior fixation using percutaneous pedicle screws. We considered that many screw insertions that would equivalently stabilize the spine several segments above and below the fracture would be needed to stabilize the sacral fractures in this patient with DISH. In this case, we stabilized the unstable right pelvis, in a patient with

Cervical pyogenic spondylodiscitis is rare but can lead to severe clinical problems that often require aggressive surgical treatment for neurological deterioration and life-threatening conditions. Although combined surgical procedures are often utilized to treat multilevel cervical regions, there is a clinical debate regarding the appropriate order and timing of surgeries using the anterior and posterior approaches. Here, we report a case of severe multilevel cervical pyogenic spondylodiscitis treated using a three-staged surgical strategy consisting of cervical laminectomy, posterior fixation, and anterior corpectomy and fusion with an autologous long bone graft; the outcome was quite favorable. Our report demonstrates the safety and usefulness of three-staged surgery in the multilevel cervical region, especially under urgent situations.

Background: The number of vertebral levels involved in fixing a spine fracture is reduced with short same-segment posterior fixation (SSPF). Short same-segment posterior fixation with pedicle fixation at the fracture level provides biomechanical advantages for kyphosis correction maintenance, lowering failure rates, and increasing spinal motion and early rehabilitation [1-4]. Materials and Methods: Between 2014 and 2016, all patients with thoracolumbar junction fractures in our study were analysed using biomechanical criteria and clinical outcomes. The immediate postoperative radiographs were compared to follow-up radiographs to assess any loss of correction by measuring the kyphotic angle using Cobb's technique. Clinical result was also assessed using the Oswestry disability score at each follow-up. The reliability of the intraobserver and interobserver was investigated. Results: In our study, 35 patients with unstable thoracolumbar fractures were operated on with a posterior spinal fixation system and pedicle screw insertion at the level of the fractured vertebrae during 2014 to 2016. The average time between visits was 18 months. In all of the cases, the average preoperative kyphotic angle was 17.2°, which improved to 5.9° immediately postoperatively, resulting in a mean of 65 percent correction. The average postoperative Cobb's angle was 7.7° at final follow-up, retaining a 55 percent correction. Disability improved from 78% mean preoperatively to 47.27% mean postoperatively at final follow-up. Conclusion: When compared to traditional SSPF, short same-segment posterior fixation has a lower implantation failure rate and improved biomechanical stability; nevertheless, long-term kyphosis correction was not maintained to the same level, which was statistically insignificant. Despite the lack of kyphosis correction, long-term clinical pain and disability improved. This study indicated that SSPF decreases implantation failure rate and reoperation rate and offers greater biomechanical advantages.

Fused motion segments have been documented to alter the biomechanics of the cervical spine and compromise its stability. Current literature describes a growing association between the presence of prior noninstrumented fused cervical segments and the predisposition to acute, traumatic instability at adjacent levels. We present the case of a stable cervical spine fracture pattern in a patient with a history of multilevel noninstrumented anterior cervical spine fusion-initially presenting as a small, nondisplaced unilateral facet fracture that ultimately progressed to overt displacement with kyphosis resulting in acute cervical pain and instability. The patient underwent urgent open reduction and instrumented posterior fixation. We discuss the challenges associated with a timely diagnosis and offer insight into the surgical management of this rare yet potentially catastrophic complication.

Background Occipitocervical instability may result from transcondylar resection of the occipital condyle. Initially, patients may be able to maintain a neutral alignment but severe occipitoatlantal subluxation may subsequently occur, with cranial settling, spinal cord kinking, and neurological injury. Objective To evaluate the ability of posterior fixation constructs to prevent progression to severe deformity after radical unilateral condylectomy. Methods Eight human cadaveric specimens (Oc-C2) underwent biomechanical testing to compare stiffness under physiological loads (1.5 N m). A complete unilateral condylectomy was performed to destabilize one Oc-C1 joint, and the contralateral joint was left intact. Unilateral Oc-C1 or Oc-C2 constructs on the resected side and bilateral Oc-C1 or Oc-C2 constructs were tested. Results The bilateral Oc-C2 construct provided the greatest stiffness, but the difference was only statistically significant in certain planes of motion. The unilateral constructs had similar stiffness in lateral bending, but the unilateral Oc-C1 construct was less stiff in axial rotation and flexion-extension than the unilateral Oc-C2 construct. The bilateral Oc-C2 construct was stiffer than the unilateral Oc-C2 construct in axial rotation and lateral bending, but there was no difference between these constructs in flexion-extension. Conclusion Patients who undergo a complete unilateral condylectomy require close surveillance for occipitocervical instability. A bilateral Oc-C2 construct provides suitable biomechanical strength, which is superior to other constructs. A unilateral construct decreases abnormal motion but lacks the stiffness of a bilateral construct. However, given that most patients undergo a partial condylectomy and only a small proportion of patients develop instability, there may be scenarios in which a unilateral construct may be appropriate, such as for temporary internal stabilization.

Odontoid fractures represent one of the most common and controversial injury types affecting the cervical spine, being associated with a high incidence of nonunion, morbidity, and mortality. These complications are especially common and important in elderly patients, for which ideal treatment options are still under debate. Stable fractures in young patients maybe treated conservatively, with immobilization. Although halo-vest has been widely used for their conservative management, studies have shown high rates of complications in the elderly, and therefore current evidence suggests that the conservative management of these fractures should be carried out with a hard cervical collar or cervicothoracic orthosis. Elderly patients with stable fractures have been reported to have better clinical results with surgical treatment. For these and for all patients with unstable fractures, several surgical techniques have been proposed. Anterior odontoid fixation can be used in reducible fractures with ideal fracture patterns, with older patients requiring fixation with 2 screws. In other cases, C1-C2 posterior fixation maybe needed with the best surgical option depending on the reducibility of the fracture and vertebral artery anatomy. In this paper, current evidence on the management of odontoid fractures is discussed, and an algorithm for treatment is proposed.

Short-segment temporary posterior spinal instrumentation has been widely used to treat thoracolumbar burst fractures. However, kyphosis recurrence without hardware failure has become a concern. Therefore, we investigated risk factors for kyphosis recurrence after short-segment temporary fixation for thoracolumbar burst fractures. Our prospective multicenter study involved 76 consecutive patients with thoracolumbar burst fractures who underwent short-segment temporary posterior fixation using ligamentotaxis with Schanz screws and without fusion. Patients were divided into two groups -kyphosis recurrence and no kyphosis recurrence- according to correction loss of the kyphotic angle. Clinical and radiographic data were examined to reveal the risk factors for postoperative kyphosis recurrence. After surgery, all patients experienced fracture union. Kyphotic deformity was reduced significantly, and maintenance of the reduced vertebra was successful. However, mean 9.1° loss of correction in kyphotic angle was observed. Statistical analysis revealed that a high ratio of canal compromise before surgery, as seen on computed tomography scanning, and a large preoperative kyphotic angle influenced kyphosis recurrence. In conclusion,short-segment temporary posterior fixation yields satisfactory results regarding reduction and maintenance of fractured vertebrae. However, correction loss after implant removal is associated with a high compromised canal ratio before surgery and a large preoperative kyphotic angle.

A clinical case of a single-step transoral removal of C2 and C3 vertebral bodies with subsequent stabilization of the C1–C4 spinal segment through the same approach (with additional submandibular approach to insert screws into the C4 vertebra body) without dissection of the mandible and tongue is presented. The first experience of anterior stabilization of the C1–C4 spinal segment using a custom-made instrumentation system demonstrated its effectiveness. It was shown that, taking into account the length of the cervical spine resection, the anterior stabilization with a custom-made plate should be combined with standard methods of posterior fixation. Innovative surgical technologies allow optimizing the surgical technique of cervical spine stabilization and provide earlier rehabilitation of a patient.

BACKGROUND: Information on the performance of posterior fixation with cortical screw (CS) versus pedicle screw (PS) trajectories for stabilizing thoracolumbar burst fractures is limited. Therefore, we sought to analyze stability with CS versus PS in short- and long-segment fixations using a 3-column spinal injury model. METHODS: Nondestructive flexibility tests: (1) intact, (2) intact + short fixation, (3) intact + long fixation, (4) after burst fracture, (5) short fixation + burst fracture, and (6) long fixation + burst fracture using thoracic spine segments (7 CS, 7 PS). RESULTS: With CS, the range of motion (ROM) was significantly greater with short-segment than with long-segment fixation in all directions, with and without burst fracture (P ≤ .008). With PS and burst fracture, ROM was significantly greater with short fixation during lateral bending and axial rotation (P

Principles in medializing and lateralizing vocal folds have not changed a lot within the last decades (Isshiki et al, 1974; Bruenings, 1911). We present a feasibility study for a completely new approach to perform medialization and lateralization of immobile vocal folds. The method was tested on 20 human larynges by inserting a 21G needle into the vocal fold, medializing (or, in other cases, lateralizing) the vocal cord and fixing the needle at the cricoid cartilage posteriorly. The anterior and posterior fixation points of the needle allow for a stable positioning of the needle, which we consider necessary in both cases of medialization or lateralization. The needle position was examined visually as well as three-dimensionally via cone beam computed tomography.

Study design This was a prospective study of 50 patients of thoracolumbar fracture dislocation treated at a single institution with short-segment fixation with the inclusion of fracture level. Purpose To assess the outcomes of including the fracture level in short-segment fixation for thoracolumbar fracture dislocation. Overview of literature Traditionally, thoracolumbar fracture dislocation is treated with long-segment posterior fixation. However, to save motion segments, short-segment fixation has been used instead in many cases of thoracolumbar trauma. Methods In this study, 50 patients with thoracolumbar fracture dislocation were treated with short-segment fixation with inclusion of the fracture level; patients with pathological fractures or with a McCormack load-sharing score >6 were excluded. The 50 patients were prospectively followed for at least 1 year. The duration of surgery, blood loss, and complications were noted. The Visual Analog Scale (VAS) score was used to measure pain, and the American Spinal Injury Association (ASIA) scale was used to determine the neurological status at follow-up. Preoperative, immediate postoperative, and final follow-up X-rays were used to measure the kyphotic angle using Cobb's method. Results The mean age of our patients was 33.4 years, and the male:female ratio was 1.9:1. The mean follow-up period was 18.4 months (range, 12-23 months). Injuries were mainly at the thoracolumbar junction area (T11-L2, 41 cases, 82%). The average duration of surgery was 94.6 minutes, and the average blood loss was 394.8 mL. Postoperative infection occurred in two cases and implant failure in one case. The kyphosis angle values were as follows: average preoperative, 26.80°±14.50°; immediate postoperative, 4.30°±8.70°; and final follow-up, 5.50°±110°. The ASIA scale and VAS score at final follow-up showed improvement. Conclusions Inclusion of the fracture level in short-segment fixation for thoracolumbar fracture dislocation (McCormack load-sharing score ≤6) gives good kyphosis correction and correction maintenance. It can also obviate the need for traditional long-segment fixation.

Study design Retrospective review. Objective Evaluate radiographic and clinical outcomes for infants and children, who underwent rigid occipito-cervical fixation for traumatic craniocervical dissociation (tCCD). Summary of background data Traumatic craniocervical dissociation is devastating. Children are at high risk but make up a large number of survivors. Non-rigid fixation has traditionally been favored over screw and rod constructs due to inherent challenges involved with instrumenting the pediatric craniocervical junction. Therefore, outcomes for rigid occipito-cervical instrumentation in infants and young children with tCCD remain uncertain. Methods Retrospective review of children who survived tCCD between 2006 and 2016 and underwent rigid occipito-cervical fixation. Results Fifteen children, from 8 months to 8 years old (mean, 3.8 yr), were either a passenger (n = 11) or a pedestrian (n = 4) in a motor vehicle accident. Seven patients had weakness: five with quadriplegia, one with hemiparesis, and one with bilateral upper extremity paresis. Ten patients had concurrent C1-2 instability. At last follow-up, four patients had improved motor function: one with bilateral upper extremity paresis and one with hemiparesis regained full strength, one with quadriplegia regained function on one side while another regained function in bilateral upper extremities. All underwent rigid posterior occipito-cervical fixation, with two patients requiring additional anterior and posterior fixation at non-contiguous levels. Fourteen patients were stable on flexion-extension x-rays at a mean follow-up of 31 months (9-1 yr or longer, 7-2 yr or longer). There were no cases of deformity, growth disturbance, or subaxial instability. Conclusion Children who survive tCCD may regain function after stabilization. Rigid internal rod and screw fixation in infants and young children safely provided long-term stability. We advocate using C2 translaminar screws to exploit the favorable anatomy of pediatric lamina to minimize the risks of occipitocervical (OC) instrumentation. Level of evidence 4.

Background: There are various posterior fixations utilized with transforaminal lumbar interbody fusion (TLIF). Previous studies have focused on the comparison of two fixation techniques. Materials and Methods: Sixty five patients with single-level lumbar disease were included in this retrospective study. Group A was treated by TLIF with bilateral pedicle screw (BPS), Group B treated by TLIF with unilateral pedicle screw (UPS), and Group C treated by TLIF with UPS plus contralateral translaminar facet screw (UPSFS). The operative time, blood loss, Oswestry disability index (ODI), Japanese Orthopaedic Association Scores (JOA), and visual analog scores (VAS) were recorded. Radiographic examination was used to assess fusion rates and incidence of screw failure. Results: The blood loss and operative times were 188.69 ± 37.69 ml and 132.96.5 ± 8.69 min in BPS group, 117.27 ± 27.11 ml and 99.32 ± 12.94 min in UPS group, and 121.50 ± 22.54 ml and 112.55 ± 9.42 min in UPSFS group; UPS and UPSFS were better than BPS (P < 0.05). The mean followup time was 38.2 months. Fusion rates were – BPS group: 95.6%, UPS group: 90%, UPSFS: 95% (P > 0.05). Screw and/or rod failures were found in three groups (BPS group: 1, UPS group: 2 and UPSFS: 1, P > 0.05). The average postoperative VAS, ODI, and JOA scores of BPS, UPS, and UPSFS were improved significantly in each group compared to preoperative scores (P < 0.05); there were no significant differences between any two groups at each followup time point (P > 0.05). Conclusion: UPSFS with TLIF is a viable treatment option that provides satisfactory clinical results; the clinical outcome and the complication rate were comparable to BPS. In addition, the invasive of UPSFS cases was comparable to UPS and better than BPS cases. For UPS, it could be used in suitable patients.

A 70 years old lady presented to us with history of a fall 3 months prior. She had suffered a type 2 odontoid fracture with atlantoaxial dislocation, that was not reducible by traction. She had symptoms of neck pain with inability to hold the neck upright. The patient was subsequently planned for anterior release and reduction of odontoid fracture dislocation with posterior stabilization in the same sitting. The patient was treated with cervical skeletal traction and immobilized. However, she developed occipital sore during the period and was mobilized with brace after which she developed myelopathic symptoms and gait disturbance due to the collapse of fracture segment. The patient was planned for anterior release and fixation with contoured reconstruction plate fixing C1 lateral mass to the lateral mass on the right side and C1 lateral mass to C2 body on the left side primarily with distraction of the C1–C2 joint by autologous tricortical iliac bone graft. The posterior stabilization was planned after healing of the sore, and the patient was counseled for the same. However, the patient was lost on follow-up and returned at 3-month postoperative period with collapse of the graft, resubluxation of C1–C2 segment, and failure of anterior fixation. The standard modality of treatment for such cases includes an anterior release of contracted soft tissues and ligaments and posterior stabilization with fusion in a single setting. However, it is the posterior fixation that stabilizes the fracture and prevents it from redislocation. Anterior fixation as a stand-alone treatment in osteoporotic bone has high risks of failure due to severe posterior tensile stresses. This article describes the importance of posterior fixation in osteoporotic bone based on our experience.

Case We present here a case of chronic pelvic separation 22 years after twin natural delivery in a 49-year-old woman surgically treated with anterior and posterior stabilization. The functional and radiological recovery after a 4-year follow-up was extremely good. Conclusion Postpartum pubic symphysis diastasis is a rare but dreaded complication of natural delivery. Nonoperative treatment is still considered the gold standard. However, when pain persists despite nonoperative treatment and when a pelvic radiograph reveals a pubic diastasis greater than 2 cm, surgery is recommended. In the case of low back pain because of sacroiliac joint lesions, posterior fixation is indicated.

Introduction: Correction of cervical deformity can be achieved using anterior cervical fixation and fusion techniques. However, supplemental posterior fixation is a critical component for ensuring biomechanical longevity and favorable patient outcomes. We present a novel percutaneous technique for posterior cervical fixation in patients where cervical pedicle (CP) screws may not be feasible and midline muscle dissection is not needed. Methods: Three patients presented to our hospital with cervical pathology amendable to circumferential cervical fusion. After adequate deformity correction was performed through an anterior cervical decompression and fusion, staged posterior supplemental fixation was achieved using percutaneous CP inlet (CPI) screws using a percutaneous muscle-sparing approach. Results: All three patients underwent CPI screw placement without postoperative neurovascular complications. Postoperative radiographic follow-up showed the desired, proper screw placement, with continued maintained cervical alignment. Conclusions: CPI screw placement may be alternative hybrid screw that achieves a advantageous safety profile while also avoiding an open midline exposure.

Background: This study aimed to compare the clinical outcomes and complications between two minimally invasive surgical techniques: percutaneous transiliac plate fixation and iliosacral (IS) screw fixation for the treatment of Tile C-type pelvic bone fractures.Materials and Methods: We retrospectively reviewed the data of 77 consecutive patients with Tile C pelvic ring injuries who underwent either percutaneous transiliac plate fixation or IS screw fixation in a single academic center between November 2007 and January 2018. Posterior plating was indicated for those with sacral dysmorphism or bilateral sacral fractures, including spinopelvic dissociation. We recorded patients’ demographics, surgery-related data, and postoperative surgical outcomes and compared the incidence of complications and revision surgery rates between the two groups.Results: Overall, 14 patients were included in the plate group, while 63 were included in the IS screw fixation group. No significant differences were observed in the patients’ demographics between the two groups except for a longer interval from injury to surgery (13.5 days vs. 5.4 days, P = 0.001). Both groups acquired fracture union in all cases. There was one case of infection requiring surgical debridement in the plating group. Notably, nerve injury (n = 3) and implant loosening (n = 5) occurred in the IS screw group, but the difference was not significant.Conclusions: Both percutaneous posterior transiliac plating and IS screw fixation in patients with Tile C-type pelvic bone fractures showed good results. We recommend IS screw fixation as the primary treatment and propose posterior plating as treatment for sacral dysmorphism and bilateral sacral alar fractures in patients with spinopelvic dissociation.

Background Posterior pedicle screw fixation had been applied to maintain spinal stability and avoid further nerve damage in thoracolumbar fracture. This study aimed to evaluate the efficacy of short-segment posterior fixation with monoaxial pedicle screws versus polyaxial pedicle screws in treating thoracolumbar fracture. Methods A total of 75 patients with thoracolumbar fracture who underwent short-segment posterior fixation with monoaxial pedicle screw (group A) or polyaxial pedicle screw (group B) were retrospectively enrolled. The patient demographic and radiological data were analyzed between the two groups. Results A total of 63 patients with an average age of 44.7±11.5 years were finally recruited in this study. There were no significant differences in age, gender, fracture level, thoracolumbar injury classification and severity scale (TLISS) score, American Spinal Injury Association (ASIA) score, Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classification, and hospital stay between the two groups (P>0.05). At the last follow-up, the prevertebral height ratio and normal-to-injured vertebral height ratio were significantly decreased in group A compared to group B (P=0.027 and P=0.007, respectively). Conclusions Short-segment posterior fixation with monoaxial or polyaxial pedicle screw for fractured thoracolumbar vertebra can restore injured vertebral height. Compared with polyaxial pedicle screw, monoaxial pedicle screw endows stronger leverage which is more beneficial for restoring injured vertebral height and recovery of the damaged endplate in thoracolumbar short-segment posterior fixation.

The aim was to study surgical outcomes in hangman’s fractures in paediatric and adolescent patients and to demonstrate evolution in posterior surgery from C1-C2-C3 fusion to C1 sparing techniques. Patients (aged ≤ 18 years) operated at a tertiary level centre between September 2011 to February 2018 with more than 1 year of follow-up were included. Neurological status, type of fracture, operating time, blood loss, follow-up, and complications were assessed. Nine patients were included, with mean age mean of 16.45 years, with a mean follow-up of 42.78 months. Six patients having neurological deficit showed improvement. Two patients, one having undergone C1-C3 lateral mass screw rod fixation (LMSF) and other had C2 pedicle screw with C3 LMSF, developed kyphosis for which fixation was further extended caudally. One patient with an old hangman’s fracture with reabsorbed axis pedicle underwent C2 body screw along with C3-C4 pedicle screw rod fixation and C2 pedicle reconstruction. All patients showed evidence of postoperative fusion. Hangman’s fractures in young patients can be successfully managed via posterior fixation. In our centre, we have evolved in the direction of motion preservation at C1 C2 joint, along with 3 column stable fixation of the C2 pedicle. C2 pedicle reformation has allowed motion preserving surgery in complex fracture types. Extension of construct till C4 in selected cases is important to prevent postoperative kyphosis.

Ankylosing spondylitis cervical spine fractures (ASCFs) are particularly unstable and need special consideration when selecting appropriate internal fixation technology. However, there is a lack of related biomechanical studies. This study aimed to investigate the biomechanical influence of the pattern, length, and density of instrumentation for the treatment of ASCF. Posterior, anterior, and various combined fixation approaches were constructed using the finite element model (FEM) to mimic the surgical treatment of ASCFs at C5/6. The rate of motion change (RMC) at the fractured level and the internal stress distribution (ISD) were observed. The results showed that longer segments of fixation and combined fixation approaches provided better stability and lowered the maximal stress. The RMC decreased more significantly when the length increased from 1 to 3 levels (302% decrease under flexion, 134% decrease under extension) than from 3 to 5 levels (22% decrease under flexion, 23% decrease under extension). Longer fixation seems to be more stable with the anterior/posterior approach alone, but 3-level posterior fixation may be the most cost-effective option. It is recommended to perform surgery with combined approaches, which provide the best stability. Long skipped-screwing posterior fixation is an alternative technique for use in ASCF patients.

Study Design: Prospective observational study. Objective: In ACDF, graft failure and subsidence are common complications of surgery. Depending on the cervical fixation, different biomechanical characteristics are applied on the grafts. This aims to describe the incidence of cervical spacer failure in patients with cervical degenerative condition according to the cervical fixation method and sagittal balance. Method: From November 2011 to December 2015, 262 patients who underwent cervical spine surgery were enrolled prospectively. Patients were divided into 3 groups based on fixation method: anterior plate/screw (APS), posterior lateral mass screw (LMS), pedicle screw (PPS) groups. Serial X-rays and CT scans were utilized to evaluate radiologic outcomes. Results: Mean patient ages were 56.1 years in the APS group, 61.5 years in the LMS group, and 57.6 years in the PPS group ( P = 0.002). Allospacer failure was most common in the APS group, compared to the LMS and PPS groups (chi-square, P = 0.038). Longer fusion level was associated with greater allospacer failure (Baseline 2 level surgery; Odds ratio (OR) 3.4 in 3 level, 15.2 in 4 level, P = 0.036,0.013). Higher T1 slope was correlated with less allospacer failure (OR 0.875, P = 0.001). ORs of allospacer failure in the LMS and PPS groups were 0.04 and 0.02, respectively, ( P = 0.01, 0.01), compared with the APS group. Conclusion: This study was able to show that allospacer failure in multi-level ACDF surgery is more common with a longer fusion length, less postoperative T1 slope, and an anterior plate-screws technique. Pedicle screws provided the best biomechanical stability among the 3 constructs.

Background This study compared the biomechanics of artificial pedicle fixation in spine reconstruction with a 3-dimensional (3D)-printed prosthesis after total en bloc spondylectomy (TES) by finite element analysis. Methods A thoracolumbar (T10–L2) finite element model was developed and validated. Two models of T12 TES were established in combination with different fixation methods: Model A consisted of long-segment posterior fixation (T10/11, L1/2) + 3D-printed prosthesis; and Model B consisted of Model A + two artificial pedicle fixation screws. The models were evaluated with an applied of 7.5 N·m and axial force of 200 N. We recorded and analyzed the following: (1) stiffness of the two fixation systems, (2) hardware stress in the two fixation systems, and (3) stress on the endplate adjacent to the 3D-printed prosthesis. Results The fixation strength of Model B was enhanced by the screws in the artificial pedicle, which was mainly manifested as an improvement in rotational stability. The stress transmission of the artificial pedicle fixation screws reduced the stress on the posterior rods and endplate adjacent to the 3D-printed prosthesis in all directions of motion, especially in rotation. Conclusions After TES, the posterior long-segment fixation combined with the anterior 3D printed prosthesis could maintain postoperative spinal stability, but adding artificial pedicle fixation increased the stability of the fixation system and reduced the risk of prosthesis subsidence and instrumentation failure.

Background We aimed to evaluate radiologic and clinical outcomes of ankle fractures involving posterior fragments that were fixed with a posterior plate by the posterolateral approach. Methods Sixty-five patients who were followed for at least 12 months and were older than 18 years were included. The posterior malleolus fractures were classified according to the Haraguchi classification system with computed tomography (CT). The posterior malleolus fragments were fixed with a plate through a posterolateral approach. Intra-articular step-off, reduction of the posterior malleolar fragment, and fibular position in the incisura were evaluated by early postoperative CT. American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analog scale pain score were used for clinical assessment. Results The posterior malleolus fractures were classified as Haraguchi type 1 in 45 patients (69.2%), Haraguchi type 2 in 12 patients (18.5%), and Haraguchi type 3 in eight patients (12.3%). No patients showed signs of instability or loss of reduction on direct radiographs during follow-up. Postoperative CT showed no loss of reduction in the posterior malleolus and tibiofibular alignment. On evaluation, there was no intra-articular step-off ( Conclusions We conclude that direct posterior fixation with the posterolateral approach can be a good option for ankle fractures involving posterior malleolar fragments.