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Study Design: Retrospective cohort study., Objective: The aim of this study was to compare the incidence of proximal junctional kyphosis (PJK), proximal junctional failure (PJF), and clinical outcomes of patients who did and did not receive posterior ligament complex (PLC) augmentation using a semitendinosus allograft when undergoing long-segment posterior spinal fusion for adult spinal deformity., Summary of Background Data: Clinical research on the augmentation of the PLC to prevent PJK and PJF has been limited to small case series without a comparable control group., Methods: From 2014 to 2019, a consecutive series of patients with adult spinal deformity who underwent posterior long-segment spinal fusion with semitendinosus allograft to augment the PLC (allograft) or without PLC augmentation (control) were identified. Preoperative and postoperative spinopelvic parameters were measured. PJK, PJF, and Oswestry Disability Index (ODI) scores were recorded and compared between the two groups. Univariate and multivariate analysis was performed. P ≤ 0.05 was considered significant., Results: Forty-nine patients in the allograft group and 34 patients in the control group were identified. There were no significant differences in demographic variables or operative characteristics between the allograft and control group. Preoperative and postoperative spinopelvic parameters were also similar between the two groups. PJK was present in 33% of patients in the allograft group and 32% of patients in the control group (P = 0.31). PJF did not occur in the allograft group, whereas six patients (18%) in the control group developed PJF (P = 0.01). Postoperative absolute ODI was significantly better in the allograft group (P = 0.007)., Conclusion: The utilization of semitendinosus allograft tendon to augment the PLC at the upper instrumented vertebrae in patients undergoing long-segment posterior spinal fusion for adult deformity resulted in a significant decrease in PJF incidence and improved functional outcomes when compared to a cohort with similar risk of developing PJK and PJFLevel of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: This was a retrospective analysis of a prospectively collected consecutive case series of patients with adult spinal deformity (ASD)., Objective: This study aimed to investigate the impact of the geometrical sagittal shape of the corrected spine on the development of proximal junctional kyphosis (PJK). Several studies have documented risk factors for PJK in ASD surgery. Geometrical assessment is vital for evaluating sagittal spinal deformity. It is essential to assess the postoperative geometrical shape of the spine and the location of the correction in the spine to decrease postoperative junctional stress and PJK., Methods: Consecutive patients with ASD who underwent corrective fusion with long constructs to the pelvis were included. Patients with neuromuscular disease, congenital and adolescent scoliosis, infection, and spinal tumor were excluded. We investigated the spinopelvic and geometrical parameters of the whole spine. The locations of the thoracic and lumbar apical vertebrae and the inflection vertebrae (IV), where the curvature of the associated adjacent vertebral bodies changes from kyphosis to lordosis, were investigated. The subjects were divided into PJK included patients who underwent revision surgery for junctional failure or with a change in proximal junctional angle ≥ 20°, and non-PJK groups., Results: A total of 139 patients (mean age, 69.6 years; range 18-82 years) were included. There were 47 and 92 patients in the PJK and non-PJK groups, respectively. The IV were located significantly cranial and posterior, the lumbar apex were located significantly posterior in the PJK group at the immediate postoperative time points. The significant risk factors for PJK on binary logistic regression were cranial IV and posterior lumbar apical vertebrae. The incidence of PJK in patients with IV at T12 or cranial tends PJK significantly higher (69%) than at L1 or caudal (26%)., Conclusions: Geometrical spinal shape should be taken into account to reduce the rate of postoperative mechanical complications., Level of Evidence: Level of evidence III.

Background: The importance of sagittal alignment in healthy individuals and in reconstructive spinal surgery has been studied over the last 15 years. The aim of the present study was to assess the long-term effects of abnormal sagittal alignment on hardware after posterior thoracolumbar spinal fusion., Methods: Patients who had undergone revision surgery (revision cohort, n = 34) due to breakage of their implants were compared retrospectively with patients who had intact implants at the final follow-up investigation after a long posterior thoracolumbar and/or lumbar spinal fusion (control cohort, n = 22). Clinical data and radiological parameters including the sagittal vertical axis (SVA), pelvic incidence (PI), lordosis gap (LG), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), thoracic kyphosis (TK), and the femoral obliquity angle (FOA) were assessed on full-spine lateral radiographs obtained in regular standing position. Data were analysed using descriptive statistics, parametric and non-parametric inferential statistics., Results: Patients in the breakage group (female n = 21, male n = 9, mean age 60.9 ± 15.6 years) had a higher anterior shift of the C7 plumb line (SVA) (p = 0.02), retroversion of the pelvis (PT) (p < 0.001), PI-LL mismatch (LG) (p = 0.001), and PI (p = 0.002) than the intact group (female n = 10, male n = 12, mean age 65.7 ± 12.4 years). No significant difference was registered between groups in regard of SS, LL, TK, FOA, and the mean number of comorbidities., Conclusion: Failure of restoration of the SVA and the LG to the acceptable ranges, especially in patients with a high PI, may be regarded as a risk factor for the long-term failure of implants after posterior thoracolumbar spinal fusion.

Background: Selective fusion of double curves in patients with scoliosis is considered to spare fusion levels. In 2011, we studied the lumbosacral takeoff angle, defined as the angle between the center-sacral vertical line and a line through the centra of S1, L5, and L4. The lumbosacral takeoff angle was shown to moderately correlate with the lumbar Cobb angle, and a predictive equation was developed to predict the lumbar Cobb angle after selective fusions. The purposes of the present study were to validate that equation in a separate cohort and to assess differences in outcomes following selective and nonselective fusion., Methods: Patients with Lenke 1B, 1C, 3B, or 3C curve patterns undergoing fusion (both selective and nonselective) with pedicle screw constructs and a minimum of 2 years of follow-up were included. Selective fusion was defined as a lowest level of fixation cephalad to or at the apex of the lumbar curve. To validate the previously derived equation, we used this data set and analysis of variance to check for differences between the actual and calculated postoperative lumbar Cobb angles. Pearson correlation, multiple linear regression, and t tests were used to explore relationships and differences between the selective and nonselective fusion groups., Results: The mean calculated postoperative lumbar Cobb angle (and standard deviation) (22.35° ± 3.82°) was not significantly different from the actual postoperative lumbar Cobb angle (21.08° ± 7.75°), with an average model error of -1.268° (95% confidence interval, -2.649° to 0.112°). The preoperative lumbar Cobb angle was larger in patients with deformities that were chosen for nonselective fusion (50.2° versus 38.9°; p < 0.001). Performing selective fusion resulted in a 3.5° correction of the lumbosacral takeoff angle (p < 0.001), whereas nonselective fusion resulted in a 9.3° correction (p < 0.001)., Conclusions: The lumbosacral takeoff angle can be used to predict the residual lumbar Cobb angle and may be used by surgeons to aid in the decision between selective and nonselective fusion. The change in the lumbosacral takeoff angle following selective fusion is small. Improvement in the lumbosacral takeoff angle and coronal balance is greater in association with nonselective fusion., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective: This study was carried out to analyze the surgical effect of cervical spine sagittal alignment for patients with Hirayama disease (HD)., Methods: Forty-four subjects were retrospectively analyzed for the parameters of cervical spine sagittal alignment. The case group consisted of 23 patients with HD, whereas the control group consisted of 21 healthy adolescent subjects. Pre- and postoperative cervical spine sagittal parameters of the patients with HD were collected; the cervical sagittal parameters of the healthy adolescent subjects were also collected. Sagittal alignment parameters were compared between the patients with HD and the healthy adolescent subjects, and between the pre- and postoperative parameters for the patients with HD., Results: Forty-four subjects completed the follow-up, with the average follow-up period being 18.0 months. No significant differences were detected between the HD and control groups for clinical parameters (P > 0.05). The preoperative HD group had smaller values compared with the control group in the sagittal parameters of C2-7 cervical lordosis (CL) angle, T1 slope, thoracic inlet angle (TIA), and cervical tilt angle (P < 0.05). For the patients with HD, the preoperative values were smaller compared with the postoperative HD values for the parameters of C2-7 CL angle, T1 slope, and cervical tilt angle (P < 0.05). We found no significant differences between the postoperative patients with HD and the healthy subjects, including C2-7 CL angle, C2-7 sagittal vertical axis, T1 slope, TIA, neck tilt angle, cervical tilt angle, and cranial tilt angle (P > 0.05)., Conclusions: Patients with HD have sagittal imbalance of the cervical spine compared with age-matched healthy adolescent subjects, and surgical treatment could correct the sagittal imbalance., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Study Design: Retrospective review of a multicenter, prospective database., Objective: Our aim was to compare complication rates and maintenance of radiographic correction at 2 years after posterior spinal fusion (PSF) with or without cross-links in patients with cerebral palsy (CP)-related scoliosis., Summary of Background Data: Cross-links are frequently used in PSF to correct scoliosis in patients with CP because they are thought to increase the stiffness and torsional rigidity of the construct., Methods: We reviewed the records of patients with CP who underwent primary PSF with or without cross-links between August 2008 and April 2015. Inclusion criteria were minimum follow-up of 2 years, availability of complications data (implant failure, surgical site infection, revision), and pre- and postoperative measurements of the major curve (measured using the Cobb method). The 256 patients included in this analysis had a mean age of 14.1 ± 2.7 years. Ninety-four patients had cross-links (57% using one cross-link; 43% using two cross-links) and 162 patients did not have cross-links. P < 0.05 was considered statistically significant., Results: The two groups did not differ significantly with regard to sex, age at surgery, preoperative menarche status, Gross Motor Function Classification System level, major curve magnitude, pelvic obliquity, kyphosis, and lordosis angles. There were no significant differences between groups in the correction achieved or the maintenance of correction at 2 years for the major curve, pelvic obliquity, kyphosis, or lordosis (all P > 0.05). Complication rates were similar between the cross-link group (16%, N = 15) and the non-cross-link group (14%, N = 22)., Conclusion: At 2 years after PSF to treat CP-related scoliosis, patients had no significant differences in the degree of correction achieved, the maintenance of correction, or the rate of complications between those whose fusion constructs used cross-links and those whose constructs did not., Level of Evidence: 3.

Purpose: Postoperative standing radiographs are usually performed before hospital discharge after AIS fusion. However, patients are often still painful and have not recovered yet their physiological balance. The aim of this study was therefore to evaluate the relevance of such early radiographs and more specifically investigate whether postoperative alignment could be analyzed., Methods: All consecutive AIS patients operated between January 2015 and December 2015 were included. All patients underwent biplanar stereoradiographs before hospital discharge, at 4 months postoperative and at last follow-up. Fifteen parameters (eight coronal and seven sagittal), reflecting correction and spinal alignment were measured and compared. The incidence of implant misplacement, requiring or not surgical revision, was recorded., Results: In total, 100 patients were included. A significant difference was found for 12 out of the 15 (80%) parameters between the first erect radiograph and the 4-month follow-up visit, including the CVA and the SVA, which are commonly used to assess postoperative alignment. Clavicle, UIV and LIV tilts also decreased significantly at 4 months postoperative. In opposition, no significant change occurred for the same parameters between the 4-month visit and latest follow-up. In nine patients, a pedicle screw was considered misplaced on the first radiograph, but all patients remained asymptomatic and no revision was performed., Conclusion: There is no need for additional immediate postoperative radiographs in AIS, if an intraoperative radiograph has already been taken. This finding could help reducing radiation exposure in immature patients and should be further studied in other etiologies. These slides can be retrieved under Electronic Supplementary Material.

Background: Spinous processes and posterior ligaments, such as inter- and supraspinous ligaments are often sacrificed either deliberately to harvest osseous material for final spondylodesis e.g. in deformity corrective surgery or accidentally after posterior spinal instrumentation. This biomechanical study evaluates the potential destabilizing effect of a progressive dissection of the posterior ligaments (PL) after instrumented spinal fusion as a potential risk factor for proximal junctional kyphosis (PJK)., Methods: Twelve calf lumbar spines were instrumented from L3 to L6 (L3 = upper instrumented vertebra, UIV) and randomly assigned to one of the two study groups (dissection vs. control group). The specimens in the dissection group underwent progressive PL dissection, followed by cyclic flexion motion (250 cycles, moment: + 2.5 to + 20.0 Nm) to simulate physical activity and range of motion (ROM) testing of each segment with pure moments of ±15.0 Nm after each dissection step. The segmental ROM in flexion and extension was measured. The control group underwent the same loading and ROM testing protocol, but without PL dissection., Results: In the treatment group, the normalized mean ROM at L2-L3 (direct adjacent segment of interest, UIV/UIV + 1, PJK-level) increased to 104.7%, 107.3%, and 119.4% after dissection of the PL L4-L6, L3-L6, and L2-L6, respectively. In the control group the mean ROM increased only to 103.2%, 106.7%, and 108.7%. The ROM difference at L2-L3 with regard to the last dissection of the PL was statistically significant (P = 0.017) and a PL dissection in the instrumented segments showed a positive trend towards an increased ROM at UIV/UIV + 1., Conclusions: A dissection of the PL at UIV/UIV + 1 leads to a significant increase in ROM at this level which can be considered to be a risk factor for PJK and should be definitely avoided during surgery. However, a dissection of the posterior ligaments within the instrumented segments while preserving the ligaments at UIV/UIV + 1 leads to a slight but not significant increase in ROM in the adjacent cranial segment UIV/UIV + 1 in the used experimental setup. Using this experimental setup we could not confirm our initial hypothesis that the posterior ligaments within a long posterior instrumentation should be preserved.

Purpose: Thoraco-lumbar kyphosis (TLK) is poorly described in the literature and its surgical treatment remains equivocal for patients with low pelvic incidence. The aim of the study was to identify which surgical correction would yield the best functional results as measured by the Oswestry score., Materials and Methods: This is a retrospective study including patients described as a type 1 of Roussouly's classification with a thoraco-lumbar kyphosis. Fifty-six patients with degenerative spinal disease were included, 42 (75%) with scoliosis and 14 (25%) without. Patients had a median age of 56 years (49-63), and there were 6 (11%) men. The primary outcome was the functional Oswestry disability index (ODI)., Results: At last follow-up, the median ODI was 15 (Q1-Q3: 6-23). In the degenerative spinal disease group, the median ODI was 7 (3.5-20) at last follow-up. Ten (84%) patients were classified as Roussouly's type 1 after surgery. In the degenerative scoliosis group, the ODI was 17 (8-23) in patients classified as Roussouly's type 1 and 20 (7.5-25) in patients classified as Roussouly's type 2 with no significant difference between these groups (p = 1). There were two patients classified as Roussouly's type 3a and their ODI at last follow-up were of 60 and 50., Conclusion: It seems that keeping the physiological morphology is the treatment of choice. For patients with degenerative scoliosis, reducing the kyphosis could work. We do not recommend to increase the lordosis and obtain a type 3 morphology with an anteverted pelvis because of the risk of PJK and poor functional results.

Study Design: Technical note., Objective: We describe a novel technique of bilateral longitudinal sacral osteotomy allowing direct reduction of high pelvic incidence (PI) and correction of sagittal imbalance., Methods: A 25-year-old female patient presented with a disabling lumbo-sacral kyphosis fused in situ through previous operations with residual low-grade wound infection and grade IV L5/S1 spondylolisthesis with severity index (SI) of 65%. A two-stage correction was performed. First anterior in situ fixation of the L4-L5-S1 segments was performed using a hollow modular anchorages (HMA) screw and L3/L4 anterior interbody cage. The second stage consisted of instrumentation of the lower lumbar spine and pelvis; placement of an S1 transverse K-wire as pivot point and bilateral longitudinal sacral osteotomy which allowed for gradual retroversion of the central sacrum relative to the pelvis., Results: Sacrum was derotated by 30° which allowed to restore spinal sagittal balance and decrease SI by 15%. Postoperative recovery was complicated by a flare up of the pre-existing deep wound infection., Conclusions: Bilateral longitudinal sacral osteotomy appears to be a safe and efficient way of correcting the sagittal imbalance caused by an extremely high PI. Although technically demanding, it achieves good radiological and functional outcomes and avoids entering the spinal canal.

Purpose: Patients with Fontan circulation have increased cardio-respiratory risk during major spinal surgery. We report a case of severe scoliosis with a Cobb angle of 123.3° in a 16-year-old boy with Fontan circulation treated with single stage posterior segmental pedicle screw instrumentation and fusion., Methods: Case report., Results: The use pre-operative halo-ring traction for a duration of 6 weeks in this case lead to improvement in cobb angle from 123.3°, kyphotic angle 87.1° to cobb angle of 78.0°, kyphotic angle 57.2° (on bending and stress films). The operation was completed in 150 min, blood loss 1050 ml (25 ml/kg), and cell salvage of 490 ml. He was immediately extubated post correction, but monitored in ICU for a day. Total length of stay was 8 days without any perioperative morbidity or allogeneic blood transfusion. Final post-operative radiograph showed a cobb angle of 44.2°, kyphotic angle 22.8°. Follow up at 27 months showed solid union with no significant loss of correction., Conclusion: From this case experience, pre-operative halo traction is a useful surgical strategy in patients with Fontan circulation with severe kyposcoliosis to achieve adequate correction without additional osteotomies to minimize the risk of surgical correction.

Background: Although anterior cervical decompression and fusion with a stand-alone cage (ACDF-SAC) is accepted as a suitable procedure, the outcomes of the multi-level procedure remain controversial. The aim of this study is to compare the clinical and radiologic outcomes achieved with single versus two-level ACDF-SAC along with identification of the factors that contribute to loss in mean disc height (MDH) and change in cervical lordotic angle (CLA)., Methods: A total of 109 consecutive patients who underwent ACDF-SAC for degenerative spondylosis were reviewed. Patients were divided into two groups according to surgical level (group A, single; group B, two) and were followed for at least 1 year. Clinical outcomes were evaluated using the visual analog scale (VAS) and Robinson's criteria. The fusion and subsidence rates, MDH, CLA, anterior, and posterior vertebral body height of the fused segments (AVBH, PVBH) were measured retrospectively from plain radiographs., Results: Clinical outcomes were similar in both groups, in terms of decreasing VAS score and a grade higher than "good" by Robinson's criteria. The fusion and subsidence rates for each group were found to be 92.2, 91.1, 14.1, and 20.0 %, respectively. The MDH (mm) increased by 1.44 ± 0.96 in group A, 1.57 ± 0.79 and 1.66 ± 0.69 for each surgical level in group B over the 12 postoperative months. The CLA (°) decreased by 1.70 ± 4.04 and 0.75 ± 6.12 over the 12 postoperative months from its presurgery value, the rate of kyphosis >5° was 26.6 and 22.2 % for each group. All compared values were not significantly different between the two groups. Correlation analysis revealed that the AVBH/PVBH ratio exhibited a positive correlation with CLA change in both groups (r = 0.368, 0.397; p = 0.018, 0.040)., Conclusions: The overall outcomes achieved with two-level ACDF-SAC were similar to those achieved with single-level ones. In addition, the AVBH/PVBH ratio might be a predictable marker for a postoperative kyphosis.

Study Design: Retrospective case-control study., Objectives: To analyze the results of two surgical treatments for lower lumbar tuberculous spondylitis with neurological deficits in the aged., Methods: We studied 33 cases of lower lumbar spinal tuberculous spondylitis treated in our center from January 2006 to October 2010. The cases were divided into two groups: 16 cases (group A) underwent single- or two-stage anterior debridement, bone grafting and posterior instrumentation, and 17 cases (group B) underwent single-stage posterior debridement, decompression, interbody fusion and instrumentation. Clinical and radiographic results were analyzed and compared between the groups., Results: Patients were followed for a mean of 41.3 months (range 36-48 months). The average operative durations were 276.9±23.8 and 193.8±22.5 min in groups A and B, respectively. The average hospital stay was 18.2±3.2 days for group A and 13.4±1.6 days for group B. Average intraoperative blood loss for groups A and B was 1187.5±163.0 and 804.7±134.1 ml, respectively. Operative complications affected four patients in group A and one in group B. Solid fusion occurred at 12 months in the other 32 cases. Neurological status was significantly improved in all cases. Kyphosis was significantly corrected after surgical management, but loss of correction occurred in both groups., Conclusion: Single-stage posterior debridement, decompression, interbody fusion and instrumentation might be a better surgical treatment than combined posterior and anterior approaches for lower lumbar tuberculous spondylitis with neurological deficits in the aged, offering fewer complications and a better quality of life.

Study Design: A retrospective review., Objective: To study time to development, clinical and radiographic characteristics, and management of proximal junctional kyphosis (PJK) following thoracolumbar instrumented fusion for adult spinal deformity (ASD)., Summary of Background Data: PJK continues to be a common mode of failure following ASD surgery. Although literature exists on possible risk factors, data on management remain limited., Methods: A retrospective review of medical records of 289 consecutive ASD patients who underwent posterior segmental instrumentation incorporating at least 5 segments was conducted. PJK was defined as proximal kyphotic angle >10 degrees., Results: PJK occurred in 32 patients (11%) at a mean follow-up of 34 months (range, 1.3-61.9±19 mo). Sixteen (50%) patients were revised (mean, 1.7 revisions; range, 1-3) at a mean follow-up of 9.6 months (range, 0.7-40 mo); primary indications for revision were pain (n=16), myelopathy (n=6), instability (n=4), and instrumentation protrusion (n=2). Comparison of preindex and postindex surgery radiographic parameters demonstrated significant improvement in mean lumbar lordosis (24 vs. 42 degrees, P<0.001), pelvic incidence-lumbar lordosis mismatch (30 vs. 11 degrees, P<0.001), and pelvic tilt (29 vs. 23 degrees, P<0.011). The mean T5-T12 kyphosis worsened (30 vs. 53 degrees, P<0.001) and the mean global sagittal spinal alignment failed to improve (9.6 vs. 8.0 cm, P=0.76). There was no apparent relationship between the absolute PJK angle and revision surgery (P>0.05)., Conclusions: The patients in this series who developed PJK had substantial preoperative positive sagittal malalignment that remained inadequately corrected following surgery, likely resulting from a combination of inadequate surgical correction and a significant compensatory increase in thoracic kyphosis. In the absence of direct relationship between a greater PJK angle and worse clinical outcome, clinical symptoms and neurological status rather than absolute reliance on radiographic parameters should drive the decision to pursue revision surgery.

Study Design: A retrospective clinical study was conducted and related literatures were reviewed., Object: This study aimed to evaluate outcome of multilevel anterior cervical discectomy and fusion with plate fixation for juvenile unilateral muscular atrophy of the distal upper extremity accompanied by cervical kyphosis., Summary of Background Data: Juvenile unilateral muscular atrophy of the distal upper extremity is a rare disease. Traditional treatment uses a neck collar to immobilize neck motion. However, if the disease is accompanied by cervical kyphosis, conservative treatment is difficult to correct cervical kyphosis and the prognosis is worsened. Therefore, it is important to initially apply surgical treatment for juvenile unilateral muscular atrophy accompanied with cervical kyphosis., Methods: From March 2008 to May 2010, 4 patients were transferred to our spine medical center because of a history of slowly progressive distal weakness and atrophy of their hands and forearms. Four patients were diagnosed with Hirayama disease accompanied with cervical kyphosis based on their clinical representations and radiologic findings. After conservative treatment failed, these patients underwent multilevel anterior cervical discectomy and fusion with plate fixation. The clinical outcomes were retrospectively evaluated with follow-up ranging from 1.5 to 3 years., Results: The clinical and radiologic follow-up indicated satisfactory clinical relief from symptoms, cervical sagittal alignment and cervical spinal canal volume, for all the patients. Within 6 months after surgery, the JOA score improved from a preoperative average of 14 to a postoperative average of 16.3; JOA recovery rates of all patients were more than good level. The muscle strengths of intrinsic muscles, wrist flexors and extensors, and biceps and triceps muscle improved on average by 1 grade. No complications occurred., Conclusions: Hirayama disease is a rare disease, a proper diagnosis of which can be made based on significant clinical symptoms and neurological imaging (dynamic MRI). The primary results from this study showed the tendency that multilevel anterior cervical discectomy and fusion with plate fixation is a preferred treatment for patients showing anterior effacement and apparent cervical kyphosis.

Purpose: Adolescent idiopathic scoliosis (AIS) is a tridimensional deformity characterized by coronal and sagittal profiles changes. We present a series of 62 patients affected by AIS and treated by thoracic Universal Clamps and transpedicular lumbar screws hybrid system., Methods: Mean age was 13 years. Average pre-operative Cobb angle was 63° ± 12°. Patients were divided into two groups depending on the kyphosis angle: lower than 45° (51 patients, 82.3 %, mean 21° ± 3°) and higher than 45° (11 patients, 17.7 %, mean 62° ± 6°)., Results: The average percentage of coronal correction was 70 ± 3 % (mean post-operative Cobb angle 19° ± 4°, P < 0.001). In patients with pre-operative physiological thoracic kyphosis-hypokyphosis, we observed an increase in the average value (32° ± 4°, P < 0.001), while in patients with pre-operative hyperkyphosis, mean decrease of thoracic kyphosis was 19° ± 3° (43° ± 4°, P < 0.001)., Conclusions: This case-series study showed the efficacy and safety of Universal Clamp hybrid system in correcting coronal deformity and restoring physiological thoracic kyphosis in patients affected by AIS.

Objective: To explore the radiographic risk factors of senior thoracolumbar proximal junctional kyphosis (PJK) after lumbar long segment fusion., Methods: From January 2009 to December 2011, the PJK group enrolled 9 patients who satisfied the following criteria: being older than 60 years, having lumbar fusion operation no less than 4 levels, upper instrumented vertebrae being L1 or L2, emerging PJK in 2-year follow-up, and the control group enrolled 10 matched patients without PJK. Their sagittal parameters including sagittal vertical axis, thoracic kyphosis, lumbar lordosis, upper instrumented vertebral angle, pelvic incidence, sacral slope, pelvic tilt, lumbo-pelvic lordosis on full length spine lateral film were measured, the oswestry disability index (ODI ) scores of the two groups in the last follow up recorded, and the parameters and ODI scores of two groups compared., Results: The phenomena of PJK emerged average 7.9 months post-operation. The patients' lumbar lordosis reduced and compensatory pelvic appeared backward obviously after PJK emerged. Compared with the control group, lumbar lordosis, pelvic radius-T12 (PR-T12), upper instrumented vertebral angle were small in the PJK group, suggesting more severe lumbar pelvic imbalance. The ODI scores of the PJK group and contral group were 40.6 ± 15.9 and 21.5 ± 15.0 respectively, and the difference was significant., Conclusion: PJK after lumbar long segment fixation of elderly patients can aggravate the sagittal imbalance and reduce functional scores. The operator should pay great attention to restoring the lumbo-pelvic lordosis.

Background: Patient and surgical factors are known to influence operative blood loss in spinal fusion for adolescent idiopathic scoliosis (AIS), but have only been loosely identified. To date, there are no established recommendations to guide decisions to predonate autologous blood, and the current practice is based primarily on surgeon preference. This study is designed to determine which patient and surgical factors are correlated with, and predictive of, blood loss during spinal fusion for AIS., Methods: Retrospective analysis of 340 (81 males, 259 females; mean age, 15.2 y) consecutive AIS patients treated by a single surgeon from 2000 to 2008. Demographic (sex, age, height, weight, and associated comorbidities), laboratory (hematocrit, platelet, PT/PTT/INR), standard radiographic, and perioperative data including complications were analyzed with a linear stepwise regression to develop a predictive model of blood loss., Results: Estimated blood loss was 907±775 mL for posterior spinal fusion (PSF, n=188), 323±171 mL for anterior spinal fusion (ASF, n=124), and 1277±821 mL for combined procedures (n=28). For patients undergoing PSF, stepwise analysis identified sex, preoperative kyphosis, and operative time to be the most important predictors of increased blood loss (P<0.05). For ASF, the mean arterial pressure at incision and the operative time were predictive (P<0.05). The following formula was developed to estimate blood loss in PSF: blood loss (mL)=C+Op-time (min)×(6.4)-pre-op T2-T12 kyphosis (degrees)×(8.7), C=233 if male and -270 if female., Conclusion: We find sex, operative time, and preoperative kyphosis to be the most important predictors of increased blood loss in PSF for AIS. Mean arterial pressure and operative time were predictive of estimated blood loss in ASF. For posterior fusions, we also present a model that estimates blood loss preoperatively and can be used to guide decisions regarding predonation of blood and the use of antifibrinolytic agents., Level of Evidence: Retrospective study: Level II.

Background: Melnick-Needles syndrome (MNS) is a rare X-linked dominant disorder affecting the skeletal system and connective tissue. To date, < 70 cases with MNS have been documented. Although few reports in the literature have shown that these patients might develop kyphoscoliosis, there is no report regarding long-term follow-up of patients with MNS undergo spine surgery. The aim of this study is to describe 2 unique cases of MNS with long-term follow-up after instrumented posterior spinal fusion, multiple-level Ponte osteotomies, and pedicle subtraction osteotomies., Methods: A 17-year-old female patient (patient 1) was evaluated for the first time at our institution. She was diagnosed with MNS, severe kyphoscoliosis, and restrictive lung disease. After pulmonary function improvement, she underwent posterior spinal fusion. Halo-femoral traction with gradual weight increase was used a week before spinal surgery. Surgical correction of her spinal deformity was achieved through a hooks-and-wires construct. The second patient was an 18-year-old female (patient 2) who carried the diagnosis of MNS when she was first seen at our institution. She had a significant thoracolumbar junction kyphosis and gibbous. She also suffered from significant pulmonary disease with a stent in her right main stem bronchus. A posterior procedure consisting of multiple-level Ponte osteotomies and pedicle subtraction osteotomy at L2 was carried out., Results: Eight- and 5-year follow-up of patients 1 and 2, respectively, demonstrated solid fusion, a well-maintained correction, and no evidence of implant breakage., Conclusions: The reported cases add to the literature of excellent long-term results of spinal deformity correction with instrumented posterior spinal fusion in patients with MNS. Patients with this condition should be closely monitored from early childhood for the development of spine deformity so that early referral to a spine surgeon can be made followed by appropriate treatment, if necessary.

Background: Conradi-Hunermann syndrome (CHS) is a rare metabolic syndrome with several orthopaedic problems. Early-onset scoliosis is of great importance because of often rapidly progressive nature and high risk of postoperative complications., Objectives: To report the 34-year follow-up and outcome of a patient with CHS treated with combined anterior and posterior fusion without instrumentation., Methods: All available clinical and radiographs of a female patient with CHS retrospectively reviewed. Overall health status, sagittal and coronal deformity, pulmonary function test, and outcome questionnaires were evaluated., Results: Initial films at the age of 4 months showed a curve of 37 degrees from T6-T11 and a curve of 17 degrees from T11-L2. Thoracic kyphosis was measured at 43 degrees. Standing films at the age of 2 years and 2 months showed progression of both the curves to 50 and 66 degrees, respectively, and a significant spinal imbalance. The kyphosis also progressed to 57 degrees. She underwent a staged anterior inlay graft spinal fusion with autograft and allograft ribs from T8-L1 and posterior in situ fusion from T6-L1 with corticocancellous allograft. Solid radiographic fusion was observed 18 months after surgery. She was 36 years old at her latest follow-up, 34 years after surgery, with neutral clinical coronal and sagittal balance. No significant pain and respiratory complaint at moderate sports and normal daily life activity. "Vital capacity" and "total lung capacity" were 65% and 75%, respectively, of the normal. Thoracic curve of 35 degrees (T6-T11) and right thoracolumbar curve of 53 degrees from T11-L2 with a solid fusion fromT6-L1 with kyphosis measured over the fused area of 40 degrees were observed. Her overall mean Scoliosis Research Society-22 score was 3.68. She is an MBA graduate from a competitive school and currently works full-time., Conclusions: Although the treatment of early-onset scoliosis has significantly evolved over the past 3 decades, the traditional method of anterior release and fusion and staged in-situ posterior fusion posterior fusion with postoperative immobilization showed acceptable deformity correction and maintenance of the pulmonary function over the 34 years.

Study Design: Systematic review., Objective: To assess whether the presence or magnitude of postsurgical malalignment in the coronal (scoliosis) or sagittal plane (kyphosis/spondylolisthesis) affects the risk of cervical adjacent segment pathology (ASP)., Summary of Background Data: ASP occurs in selected patients who have undergone surgical treatment for cervical spondylosis. The reasons are multifactorial; however, postsurgical alignment may play a key role. To elucidate this issue, a systematic review of the literature was undertaken., Methods: A systematic search in PubMed was conducted for literature published in English language through February 15, 2012. Studies in adults, designed to evaluate postsurgical sagittal or coronal malalignment as risk factors for radiographical or clinical ASP, were sought. Studies of pediatric or oncological patients were excluded. Case reports, case series, and patient populations of less than 10 patients were also excluded. Unadjusted risk ratios (RRs) and 95% confidence intervals were calculated to evaluate the association between alignment and the risk for developing ASP., Results: The search yielded 338 citations. Of that, 311 were excluded at the title and abstract level. Of the 27 selected for full-text review, 5 poor-quality retrospective studies met the inclusion criteria and described sagittal imbalance measures as risk factors for radiological ASP after anterior surgery. No studies examined ASP after posterior cervical surgery. Three studies provided data from which unadjusted RRs and 95% confidence intervals could be calculated. These studies showed an increased risk of ASP associated with malalignment (RR, 2.24 [95% confidence interval, 1.40-3.56]; RR, 2.40 [1.33, 4.33]; RR, 1.32 [0.96, 1.81]). No study evaluating coronal imbalance as a risk factor for cervical ASP was found and none reported on clinical ASP., Conclusion: There is low-grade evidence from 3 published studies that postsurgical sagittal imbalance may increase the risk for cervical radiological ASP., Consensus Statement: An attempt should be made to maintain or restore cervical lordosis in surgical intervention for cervical disorders. Strength of Statement: Weak.

Study Design: Systematic review., Objective: To review the literature on proximal junctional kyphosis (PJK) as a specific form for proximal adjacent segment pathology and report on the incidence, timing, risk factors, and effect on health-related quality of life (HRQOL) outcomes reported for PJK., Summary of Background Data: PJK is a complication of spinal deformity surgery that can compromise outcomes and necessitate revision surgery. Multiple risk factors have been associated with PJK, making the etiology multifactorial. Knowledge of the risk factors is important for minimizing the occurrence of PJK and to allow surgeons to take measures for its prevention when possible., Methods: A systematic search of PubMed, CINAHL, EMBASE, the Cochrane Library, and Google Scholar through February 15, 2012, was performed. The focus was on studies designed to evaluate PJK in patients who had surgery for scoliosis and/or kyphosis. Adjusted effect sizes and significance based on adjusting for confounders were reported if available, otherwise, crude risk ratios and 95% confidence intervals were calculated., Results: The search yielded 85 citations and 8 met the criteria for inclusion. The incidence of PJK ranged from 17% to 39% and the majority seemed to occur within 2 years of surgery. The most common patient demographic associated with a higher PJK risk was increased age. Surgery-related risk factors were fusions to the sacrum, combined anterior/posterior surgery, thoracoplasty, and upper instrumented vertebra at T1-T3. Postoperative hypokyphosis or hyperkyphosis was associated with an increased risk of PJK. Despite the presence of PJK, health-related quality of life outcomes were not affected., Conclusion: Patients at higher risk for PJK are those who are of older age, who had fusions to the sacrum, combined anterior/posterior surgery, thoracoplasty, and an upper instrumented vertebra at T1-T3. Despite the presence of PJK, no differences were noted in health-related quality of life outcomes., Consensus Statement: 1. The risk of developing PJK above a spinal deformity fusion is 17% to 39%, with most noted by 2 years postoperative., Level of Evidence: Moderate. Strength of Statement: Strong. 2. The risk factors of PJK development include increased age, fusion to sacrum, combined ASF/PSF, thoracoplasty, UIV at T1–T3, and nonanatomic restoration of thoracic kyphosis., Level of Evidence: Low. Strength of Statement: Weak. 3. The development of PJK does not seem to have a detrimental effect on HRQOL outcomes, at least in milder/nonrevision forms., Level of Evidence: Moderate. Strength of Statement: Weak.

Study Design: Retrospective review of a multicenter series., Objective: This study was conducted to specifically identify the complication rate of growing rod surgery in patients with normal (10°-40°) versus abnormal thoracic kyphosis., Summary of Background Data: Surgical treatment options for progressive early onset scoliosis include spinal fusion versus growth-sparing techniques. The current most commonly employed growing rod technique involves short fusions at the foundation sites using either hooks or screws as anchors and placement of dual growing rods spanning the deformity. Although the coronal deformity in these patients has been studied extensively, the sagittal profile has received less attention as a possible factor in complication rates and patient outcomes., Methods: Out of 387 patients who underwent surgical placement of growing rods, 90 patients had complete clinical and radiographical data, with 2-year follow-up after initial surgery. Patients were categorized into 3 groups on the basis of preoperative thoracic kyphosis magnitude: less than 10° (K- group), 10°-40° (N group), and more than 40° (K+ group). Patient diagnosis, demographics, surgical information, radiographical measurements, and complication types were tabulated and analyzed. A P value of <0.05 was considered significant for all statistical tests., Results: The K- group experienced 27 total complications including 15 general medical complications, the N group had 20 total and 4 general complications, and the K+ group had 55 total and 22 general complications. Patients in the K+ group were 3.1 times more likely to experience a complication than those in the N group, which was statistically significant (P < 0.05). When considering all types of complications, length of follow-up, T2-T5 proximal kyphosis, postoperative Cobb angle, and rod diameter were identified as confounding variables. When the confounding variables were taken into consideration in the analysis, the odds ratios were no longer significant between the N and K+ groups. Patients in the K+ group and K- group were 2.95 and 2.89 times more likely to experience a general medical complication than those in the N group, respectively (P > 0.05). The rate of implant-related complications between the groups did not reach statistical significance, although the K+ group had the most implant complications (n = 34), including 25 rod breakages in 16 patients. Syndromic patients had 2.9 times the risk of having an overall complication when compared with the entire patient series (P < 0.05). The number of patients who experienced multiple complications was higher in the K- and K+ groups than in the N group., Conclusion: Patients with thoracic hyperkyphosis present even more of a challenge with respect to complications, specifically implant-related complications. Our study shows that growing rod surgery in patients with kyphosis more than 40° has significantly more general and implant complications than that in patients with normal thoracic kyphosis. Implant complications were more common in hyperkyphotic (>40°) patients and increased linearly with increasing kyphosis. The most common implant complication was rod breakage. Patients with hyperkyphotic thoracic spines, particularly syndromic patients, must be monitored closely and parents should be counseled regarding the likelihood of future adverse events.

Study Design: Forty-six patients with degenerative lumbar scoliosis, and treated with selective segmental transforaminal lumbar interbody fusion (TLIF), were studied retrospectively., Objectives: To investigate the surgery outcomes of the posterior-only approach with selective segmental TLIF for the treatment of degenerative lumbar scoliosis., Summary of Background Data: Degenerative lumbar scoliosis usually occurs late in the life of patients with no history of scoliosis. TLIF has been successfully used in the surgical treatment of other degenerative diseases of the lumbar spine., Methods: Forty-six patients with degenerative lumbar scoliosis and treated with selective segmental TLIF were studied retrospectively. There were 14 male and 32 female patients, with a mean age of 66.4 years. The indications for TLIF of the motion segment included segmental kyphosis in the lumbar spine, significant vertebral translation in any orientation, segmental instability, and significant upper endplate obliquities of L3 or L4. All the patients were followed for a mean duration of 42 months postoperatively. Radiographic evaluation included Cobb angle of scoliosis, lumbar lordosis angle, and segmental lordosis angle. The clinical outcomes were assessed by means of Japanese Orthopedic Association score and patient satisfaction index., Results: The mean preoperative Cobb angle of 31.7 ± 14.4 degrees was corrected to 10.2 ± 6.5 degrees at the final follow-up (t = 15.262, P < 0.001), and the correction rate was 67.8%. The mean preoperative lumbar lordosis angle of -27.5 ± 12.6 degrees was corrected to -39.3 ± 9.7 degrees (t = 12.165, P < 0.001), and the correction rate was 44.4%. The mean preoperative segmental lordosis angle of -6.5 ± 5.1 degrees in the TLIF segment was increased to -11.6 ± 5.9 degrees, and the correction rate was 80%. Besides, the segmental deformity and vertebral translation were also corrected. The mean preoperative Japanese Orthopedic Association score of 14.1 ± 4.2 was increased to 22.2 ± 4.8 (t = 11.453, P < 0.001), and 81% of patients would undergo this surgery again with the same results., Conclusions: Selective segmental TLIF is helpful in correcting lumbar lordosis, segmental deformity, and translation, and thus obtaining satisfactory outcome in the treatment of degenerative lumbar scoliosis.

The goal of this study was to determine the efficacy and feasibility of surgical management of advanced thoracolumbar spine tuberculosis with kyphosis in children in poor general condition with 1-stage posterior decompression, interbody grafts, and posterior instrumentation and fusion. Between 2006 and 2008, 7 children with advanced thoracolumbar spinal tuberculosis accompanied by kyphosis and in poor general condition were treated with 1-stage posterior decompression, interbody grafts, and posterior instrumentation and fusion followed by chemotherapy. Mean follow-up was 34 months (range, 27-42 months). Patients were evaluated pre- and postoperatively for erythrocyte sedimentation rate (ESR), neurological status, pain, spinal canal compromise, and kyphotic angle. Spinal tuberculosis was completely cured and the grafted bones fused in all 7 patients. There was no recurrence of the disease in any patient at final follow-up. In all patients, ESR was normal within 3 months, Frankel neurological classification improved, and pain relief was obtained. Average canal compromise was 52.57% (range, 35%-75%) preoperatively and 9.86% (range, 0%-19%) postoperatively. Average preoperative kyphosis was 37.9°, which decreased to 5.4° postoperatively. There was no significant loss of correction at last follow-up. Our results show that 1-stage posterior decompression, interbody grafts, and posterior instrumentation and fusion followed by chemotherapy is an alternative treatment for children with advanced thoracolumbar spinal tuberculosis and in poor general condition., (Copyright 2010, SLACK Incorporated.)

Study Design: Prospective, observational study., Objective: To evaluate biomechanical changes associated with cervical arthrodesis using a cylindrical titanium cage., Summary of Background Data: Anterior cervical discectomy and fusion (ACDF) is the "gold standard" for treating cervical disc disease. In an effort to avoid the morbidity associated with autogenous bone graft harvesting, cervical cages are used to achieve fusion. The cages should allow for restoration and maintenance of natural disc height, angulations, and displacements at the operated levels., Methods: Fifty-four patients underwent standard ACDF using a "stand alone" cylindrical cage implant. Lateral radiographic views of the cervical spine were obtained before surgery, on the first day postoperatively, and at 12 months postoperatively. Disc height, vertebral alignment, angle of lordosis, and range of motion at operated levels were quantified prospectively by distortion compensated Roentgen analysis., Results: At 12 months postoperatively, solid fusion was achieved but the cylindrical cage failed to preserve disc height, prevent kyphosis, and preserve natural intervertebral alignment. We observed significant cage subsidence and malalignment., Conclusion: We noticed several unfavorable outcomes when performing an analysis of radiographic parameters after ACDF using a cylindrical titanium cage. Thus, the use of a "stand alone" cylindrical cage in ACDF should be considered with caution.

The number of reports describing osteoporotic vertebral fracture has increased as the number of elderly people has grown. Anterior decompression and fusion alone for the treatment of vertebral collapse is not easy for patients with comorbid medical problems and severe bone fragility. The purpose of the present study was to evaluate the efficacy of one-stage posterior instrumentation surgery for the treatment of osteoporotic vertebral collapse with neurological deficits. A consecutive series of 21 patients who sustained osteoporotic vertebral collapse with neurological deficits were managed with posterior decompression and short-segmental pedicle screw instrumentation augmented with ultra-high molecular weight polyethylene (UHMWP) cables with or without vertebroplasty using calcium phosphate cement. The mean follow-up was 42 months. All patients showed neurologic recovery. Segmental kyphotic angle at the instrumented level was significantly improved from an average preoperative kyphosis of 22.8-14.7 at a final follow-up. Spinal canal occupation was significantly reduced from an average before surgery of 40.4-19.1% at the final follow-up. Two patients experienced loosening of pedicle screws and three patients developed subsequent vertebral compression fractures within adjacent segments. However, these patients were effectively treated in a conservative fashion without any additional surgery. Our results indicated that one-stage posterior instrumentation surgery augmented with UHMWP cables could provide significant neurological improvement in the treatment of osteoporotic vertebral collapse.

Surgical site infection (SSI) following spinal surgery is a frequent complication and results in higher morbidity, mortality and healthcare costs. Patients undergoing surgery for spinal deformity (scoliosis/kyphosis) have longer surgeries, involving more spinal levels and larger blood losses than typical spinal procedures. Previous research has identified risk factors for SSI in spinal surgery, but few studies have looked at adult deformity surgeries. We retrospectively performed a large case cohort analysis of all adult patients who underwent surgery for kyphosis or scoliosis, between June 1996 and December 2005, by our adult spine division in an academic institution to asses the incidence and identify risk factors for SSI. We reviewed the electronic patient records of 830 adult patients. SSI was classified as deep or superficial to the fascia. 46 (5.5%) patients were found to have a SSI with 29 patients (3.5%) having deep infections. Obesity was found to be an independent risk factor for all SSI and superficial SSI (P = 0.014 and P = 0.013). As well, a history of prior SSI was also found to be a risk factor for SSI (P = 0.041). Patient obesity and history of prior SSI lead to increased risk of infection. Since obesity was related to an increased risk of both superficial and deep SSI, counseling and treatment for obesity should be considered before elective deformity surgery.

Study Design: A prospective study on the clinical outcomes in patients with tuberculous spondylitis treated by a 2-stage operation (posterior and anterior) using posterior spinal instrumentation., Objective: To evaluate the clinical outcomes of the 2-stage surgical treatment (first stage: placement of posterior instrumentation and second stage: anterior debridement and bone grafting) for tuberculous spondylitis., Summary of Background Data: There have been few reports describing the effects of 2-stage surgical treatment for tuberculous spondylitis., Methods: Ten patients (5 men and 5 women) with tuberculous spondylitis were treated by 2-stage operations. Age at the initial operation was 64.6+/-14.8 years (average+/-SD) (range: 47 to 83 y). The clinical outcomes were evaluated before and after the surgery in terms of hematologic examination, pain level, and neurologic status. Bone fusion and changes in sagittal alignment were examined radiographically., Results: All patients showed suppression of infection, bony fusion, relief of pain, and recovery of neurologic function. No significant changes were observed in kyphosis angle at the final follow-up. There were no incidences of severe complications or recurrence., Conclusions: Our results showed that posterior and anterior 2-stage surgical treatment for tuberculous spondylitis is a viable surgical option for cases in which conservative treatment has failed. However, the changes in sagittal alignment showed that this strategy provides limited kyphosis correction.

Study Design: Case report., Objective: To report a case of false-negative intraoperative motor-evoked potentials (MEP) that developed paraplegia after surgery., Summary of Background Data: Although several false-negative results have been reported with somatosensory-evoked potentials, there is no report noted with MEP. Therefore, several authors have preferred using MEPs as a gold standard in neuromonitoring., Methods: We report a case of false-negative MEP during the scoliosis surgery which is the first report showing false-negative MEPs during operation., Results: A 15-year-old girl with severe kyphoscoliosis (Cobb angle, 140 degrees) in neurofibromatosis was operated for correction and posterior spinal fusion surgery, using pedicle screw instrumentation. Intraoperative neuromonitoring did not show any change in MEPs throughout the procedure, however, she woke-up with paraplegia. Immediate implant release could not recover her neurology functionally at last follow-up. Positive event during the operation was massive blood loss which could not show drop in MEPs as an ischemic cord injury (probable cause). Postoperative CT scan in both patients did not show any injury with pedicle screw as implants were well placed within the pedicles. Reviewing the literature, we could not find out any prospective study in animals identifying false-negative results with MEPs., Conclusion: From our experience of false-negative MEPs, we conclude that unwanted events with use of MEP in scoliosis or other spinal surgeries. We propose further prospective research on animals to solve this issue.

Study Design: This paper is a retrospective chart review., Objective: This study assesses single-stage thoracic vertebrectomy with circumferential reconstruction and stabilization. Preoperative and postoperative thoracic kyphotic angles and other outcomes are analyzed., Summary of Background Data: Pathologic and traumatic thoracic vertebral body fracture deformity can be corrected by an anterior vertebral body corpectomy and reconstruction. If the pathology is primarily posterior, then laminectomy and posterolateral instrumentation may be preferred. In some patients, simultaneous anterior and posterior correction of instability and fracture is necessary and is now possible with a single-stage Stanford University Medical Center (SUMC) technique with similar results to the traditional 2-stage approach., Methods: Thirty patients who underwent 31 single-stage thoracic vertebrectomies with circumferential reconstructions for thoracic spine fractures between 2004 and 2006 at SUMC were retrospectively reviewed. All surgeries were performed prone; operative technical details are reported. The preoperative and postoperative thoracic kyphotic angles were measured by Cobb angle evaluation using lateral chest plain films and magnetic resonance imaging. Other outcome measures evaluated included operative time, blood loss, neurologic and functional outcomes, postoperative pain, and treatment complications., Results: The mean follow-up was 17.21 months (range: 9 to 30 mo) and preoperative kyphosis was 20.4 degrees (range: 6.0 to 57.9 degrees). The average postoperative kyphosis was 8.3 degrees (range: 1.8 to 2.67 degrees) and correction of kyphosis was 16.2 degrees (range: 6 to 30 degrees). The median estimated blood loss was 1411.67 mL (range: 300 to 4000 mL) and mean operating time was 4.8 hours (range: 2.8 to 8.6 h). Complications included 2 hardware failures requiring revision, 2 infections, and 1 dural laceration. Pain, Frankel Grade, and functional status were improved in all, except 1 preoperatively bedridden patient., Conclusions: Thoracic kyphotic correction is possible through a prone single-stage simultaneous anterior vertebrectomy and posterior reconstruction. Sufficient anterior and posterior correction of instability and fracture using the SUMC technique is possible with similar results to the traditional 2-stage approach.

Study Design: Experimental study., Objective: To investigate whether anterior spine fusion in the immature porcine spine has an adverse effect on the development of spinal canal., Summary of Background Data: Neurocentral cartilage (NCC) is located in the posterior vertebral body and responsible for the development of posterior aspect of the spinal canal. Injury to the NCC interferes with the development of the spinal canal., Methods: Twelve 8-week-old domestic pigs were used to develop an anterior fusion model. A standard procedure as L3-L4, L4-L5 discectomy, and L3-L5 anterior instrumented spine fusion was performed. To evaluate the development of the spinal canal, all subjects had computed tomography scans before the procedure and at the final follow-up. The spinal canal area was measured at the control level (CL) (L2), arthrodesis level (AL) (L4), superior (L3), and inferior (L5) instrumented level (SIL and IIL). Percent change in spinal canal area from before surgery to final follow-up was also calculated. RESULTS.: Eleven subjects were available for the study. All subjects developed local kyphosis over the fused segments. The average area of L2 (CL) was 0.56 +/- 0.06 cm before surgery. The average areas of the L3 (SIL), L4 (AL), and L5 (IIL) were 0.62, 0.70, and 0.77 cm, respectively. At the final follow-up the average area of L2 was 1.20 cm. The average areas of the SIL, AL, and IIL were 1.16, 1.19, and 1.33 cm, respectively. The percent increase in spinal canal area at the CL was 116.6% whereas it was 85.8%, 71.0%, and 71.2% at SIL, AL, and IIL, respectively., Conclusion: Anterior spinal arthrodesis in the immature porcine spine results in iatrogenic retardation on spinal canal growth. This effect is most likely related to the tethering effect of the interbody fusion over the NCC. Although, it is difficult to directly extrapolate these findings to clinical practice, the spine surgeons operating on pediatric patients should be aware of this possibility.

To investigation of the outcomes of indirect posterior decompression with corrective fusion for myelopathy associated with thoracic ossification of the longitudinal ligament, and prognostic factors. Conservative treatment for myelopathy associated with thoracic ossification of the longitudinal ligament (OPLL) is mostly ineffective, and treatment is necessary. However, many authors have reported poor surgical outcomes, and no standard surgical procedure has been established. We have been performing indirect spinal cord decompression by posterior laminectomy and simultaneous corrective fusion of the thoracic kyphosis. Twenty patients underwent indirect posterior decompression with corrective fusion, and were included in this study. The follow-up period was minimum 2 years and averaged 2 years and 9 months (2-5 years 6 months). Operative results were examined using JOA scoring system (full marks: 11 points) and Hirabayashi's recovery rate, as excellent (100-75%), good (74-50%), fair (49-25%), unchanged (24-0%) and deteriorated (i.e., decrease in score less than 0%). Cases in which the spinal cord is floating from OPLL on intraoperative ultrasonography were defined as the floating (+) group, and those without floating as the floating (-) group. In addition, we used compound muscle action potentials (CMAP) as intraoperative spinal cord monitoring and the cases were divided into three groups: Group A, no change in potential; Group B, potential decreased, and Group C, potential improved. The mean pre- and postoperative JOA scores were 6.2 and 8.9 points, respectively, and the recovery rate was 56%. The outcome was rated excellent in three, good in eight, fair in six, unchanged in two, and deteriorated in one. The mean preoperative thoracic kyphosis measured 58 degrees , and was corrected to 51 degrees after surgery. On intraoperative ultrasonography, 12 cases were included in the floating (+) and 8 in the floating (-) groups; the recovery rates were 58 and 52%, respectively, showing no significant difference between the recovery rates of the two groups. Regarding intraoperative CMAP, the outcome was excellent in one, good in seven, fair in four, and unchanged in one in Group A; fair in one, unchanged in one, and deteriorated in one in Group B, and excellent in two and good in one in Group C. The recovery rates were 50, 48 and 68.3% in Groups A, B and C, respectively, showing that the postoperative outcome was significantly poorer in Group B. Although indirect posterior decompression with corrective fusion using instruments obtained satisfactory outcomes, not all cases achieved good outcomes using this procedure. We consider that additional application of anterior decompressive fusion is preferable when improvement of symptoms occurs not satisfactory after indirect posterior decompression with corrective fusion using instruments. Intraoperative spinal cord monitoring of CMAP demonstrated that the spinal cord was already impaired during the laminectomy via the posterior approach. Concomitant intraoperative monitoring of CMAP to avoid impairment of the vulnerable spinal cord and corrective posterior spinal fusion with indirect spinal cord decompression is recommendable as a method capable of preventing postoperative neurological aggravation.

The authors report on a prospectively followed series of 35 patients with injuries of the thoracolumbar spine from T7 to L3. The radiological course after combined posterior-anterior surgery with anterior column reconstruction with a distractible vertebral body replacing implant demonstrated a stable reconstruction technique with almost no re-kyphosing. In 18/18 patients with CT follow-up intervertebral fusion was observed as bony bridging lateral to the VBR implant. The functional/clinical outcome of the patients was analysed with a set of eight validated outcome scales. After an average follow-up period of 2(1/2) years encouraging results were noticed. The neurological improvement rate (> or =1 Frankel/ASIA grade) was 8/12 patients (67%) with a complete recovery in 6 cases. 17/29 patients returned to former occupation; 20/29 patients returned to former leisure activities; 24/28 patients rated their general outcome as "unlimited and pain free" or "occasionally and/or mild complaints" with a VAS score of >80 (scale 0-100). The psychometric questionnaires revealed good results with strong correlation comparing the different scoring systems statistically: mean McGill Pain Questionnaire 12.5 (0-40); mean Oswestry Disability Index 20% (0-51). 13/29 patients scored <4 in the Roland and Morris Disability Questionnaire. The German back pain questionnaire (Funktionsfragebogen Hannover Rücken) showed a mean "functional capacity" of 75%, corresponding with moderate restriction. We concluded the presented method as highly effective to completely reduce and maintain an anatomic spinal alignment. The outcome tended to be better in comparison with non-operatively treated patients as well as with norm populations with low back pain.

Anterior procedures in the cervical spine are feasible in cases having anterior aetiologies such as anterior neural compression and/or severe kyphosis. Halo vests or anterior plates are used concurrently for cases with long segmental fixation. Halo vests are bothersome and anterior plate fixation is not adequately durable. We developed a new anterior pedicle screw (APS) and plate fixation procedure that can be used with fluoroscope-assisted pedicle axis view imaging. Six patients (3 men and 3 women; mean age, 54 years) with anterior multisegmental aetiology were included in this study. Their original diagnoses comprised cervical myelopathy and/or radiculopathy (n = 4), posterior longitudinal ligament ossification (n = 1) and post-traumatic kyphosis (n = 1). All patients underwent anterior decompression and strut grafting with APS and plate fixation. Mean operative time was 192 min and average blood loss was 73 ml. Patients were permitted to ambulate the next day with a cervical collar. Local sagittal alignment was characterised by 3.5 degrees of kyphosis preoperatively, which improved to 6.8 degrees of lordosis postoperatively and 5.2 degrees of lordosis at final follow-up. Postoperative improvement and early bony union were observed in all cases. There was no serious complication except for two cases of dysphagia. Postoperative imaging demonstrated screw exposure in one screw, but no pedicle perforation. APS and plate fixation is useful in selected cases of multisegmental anterior reconstruction of cervical spine. However, the adequate familiarity and experience with both cervical pedicle screw fixation and the imaging technique used for visualising the pedicle during surgery are crucial for this procedure.

Study Design: Retrospective study., Objective: To report the use of a reliable and safe technique for the surgical management of severe and rigid angular kyphotic deformities with neurologic deficits., Summary of Background Data: Severe and rigid angular kyphotic deformity can result in difficult to treat neurologic deficits. Previously described techniques are an ordeal for both the patient and the surgeon and run the risk of damaging the compromised spinal cord because of stretch, compression, deformation, and direct intraoperative cord manipulation during the procedure., Methods: Seventeen consecutive patients with neurologic deficits due to severe and rigid angular kyphotic deformity were treated with circumferential neurologic decompression and correction by one-shot in situ cantilever bending at the apex of the deformity with a fixed hinge in the compromised spinal cord. The procedure involved minimal manipulation, stretching, compression, and deformation of the vulnerable cord. Minimum follow-up after surgery was 2 years (range: 2.5-6.4 years). Mean Cobb angle of kyphotic deformity was 105.3 degrees (range: 85 degrees -121 degrees ). All patients exhibited neurologic deficits. There were 6, 7, and 4 patients classified as Frankel B, C, and D, respectively. Etiologic diagnoses were congenital kyphosis in 6 and postinfectious kyphosis in 11 patients., Results: Mean operation time was 194 minutes and average blood loss was 1621 mL. All patients showed neurologic improvement. Two of the Frankel B patients improved to Frankel E and 2 each to Frankel D and C. Two of the Frankel C patients improved to Frankel D, whereas 5 improved to Frankel E. All Frankel D patients improved to Frankel E. Kyphotic deformity correction was 30% in the sagittal plane. Complications were minor., Conclusion: Circumferential neurologic decompression and one-shot cantilever bending correction with a fixed hinge in the compromised cord is a safe and effective alternative for surgical treatment of severe and rigid angular kyphotic deformities with neurologic deficits.

Study Design: A retrospective review., Objective: To assess the utility of preoperative halo immobilization in the avoidance of swallowing complications-associated occipitocervical fixation., Summary of Background Data: The craniocervical region is commonly affected by a number of pathologic processes. Fixation of the upper cervical spine to the occiput provides an excellent means of treating these conditions. Occipitocervical fixation, however, is associated with a number of potential complications. One under-reported postoperative complication is the swallowing difficulty that some patients experience. Another is the overall patient dissatisfaction with postoperative head position. One means that the authors have used to avoid these complications is the use of preoperative halo vest fixation., Methods: In this article, we report our experience with preoperative halo vest immobilization for occipitocervical fusion in 12 consecutive patients over a 5-month period and its effect on postoperative complications. We also report our experience with the index case of this series in which the patient required operative revision because of severe postoperative dysphagia and stridor after an occipitocervical fusion., Results: All patients achieved satisfactory postoperative head position using the preoperative halo immobilization technique. One patient experienced transient dysphagia, which did not require intervention. No patients experienced any complications related to the placement of the halo vest itself., Conclusions: Preoperative halo immobilization allows patients, who are going to have their head permanently fixed in a particular position, to determine if they are able to tolerate the new head position. This allows the surgeon to adjust the head position before permanently locking the patient in the position, if necessary. We, therefore, advocate the use of preoperative halo immobilization as a means of assuring physiologic craniocervical neutrality and the avoidance of the resultant complications.

Study Design: Case report., Objective: To describe a technique of thoracic fixation in pediatric cases with anatomy not amenable to hooks and pedicle screws., Summary of Background Data: Intralaminar screws have been described in cervical and lumbar spines. There is only 1 report of the use of thoracic intralaminar screws being used for kyphotic deformity in adult patients., Methods: We performed fixation of the thoracic spine using laminar screws in 2 patients with severe spinal deformities in whom pedicle screws and hooks failed to maintain the desired correction. Clinical and radiologic features of both cases are reported. The surgical technique is described., Results: Intralaminar screws of the thoracic spine were successfully placed in 2 children with severe spinal deformities to achieve proximal fixation. Neither dorsal nor ventral cortical bone violations of the laminae were identified. In 1 case, pedicles were too small and sclerotic to accommodate pedicle screws. The second case was characterized by pedicle screw pull-out after corrective procedure, and the following revision with hooks caused fracture of the lamina. The intralaminar screws were subsequently used as proximal fixation to correct the deformity. No screw failure was encountered. Neither patient developed neurologic complications as a result of the screws., Conclusions: This procedure was used as a salvage technique in this series. However, our experience outlines the applicability of this technique at different thoracic levels and appears to be a useful tool in the armamentarium of the spinal surgeon dealing with patients with complex spinal deformities and difficult anatomy.

Study Design: A retrospective study., Objectives: To determine postsurgical correlations between thoracic and lumbar sagittal curves in lumbar degenerative kyphosis (LDK) and to determine predictability of spontaneous correction of thoracic curve and sacral angle after surgical restoration of lumbar lordosis and fusion., Summary of Background Data: To our knowledge, there are only a limited number of articles about the relationship between thoracic and lumbar curve in sagittal thoracic compensated LDK., Methods: Retrospective review of 53 consecutive patients treated with combined anterior and posterior spinal arthrodesis. We included patients with sagittal thoracic compensated LDK caused by sagittal imbalance in this study. Total lumbar lordosis, thoracic kyphosis, sacral slope, and C7 plumb line were measured on the pre- and postoperative whole spine lateral views. Postoperative changes in thoracic kyphosis, sacral slope, and C7 plumb line according to the surgical lumbar lordosis restoration were measured and evaluated., Results: The mean preoperative sagittal imbalance by plumb line was 78.3 mm (+/-76.5); this improved to 13.6 mm (+/-25) after surgery (P < 0.0001). Mean lumbar lordosis was 9.4 degrees (+/-19.2) before surgery and increased to 38.4 degrees (+/-13.1) at follow-up (P < 0.0001). Mean thoracic kyphosis was 1.1 degrees (+/-12.7) before surgery and increased to 17.6 degrees (+/-12.2) at follow-up (P < 0.0001). Significant preoperative correlations existed between kyphosis and lordosis (r = 0.772, P < 0.0001) and between lordosis and sacral slope (r = 0.785, P < 0.0001). Postoperative lumbar lordosis is correlated to thoracic kyphosis increase (r = 0.620, P < 0.0001). Postoperative lumbar lordosis is correlated to sacral slope increase (r = 0.722, P < 0.0001)., Conclusion: Reciprocal relationship exists between lumbar lordosis and thoracic kyphosis in sagittal thoracic compensated LDK. Surgical restoration of lumbar lordosis for LDK brings about high level of statistical correlation to thoracic kyphosis improvement. At the same time, the reciprocal relationship is maintained.

Objectives: We evaluated our treatment algorithm used in adult patients with tuberculous spondylitis together with long-term treatment results., Methods: The study included 55 adult patients (26 males, 29 females; mean age 50 years; range 23 to 71 years) with tuberculous spondylitis. The patients underwent four different treatment methods including non-operative treatment (NO, 6 patients), posterior debridement, fusion and instrumentation (PDFI, 21 patients), anterior debridement, instrumentation and fusion (ADIF, 21 patients), and finally, urgent radical debridement (RD, 11 patients) due to financial limitations of the patients. All the patients received antituberculous therapy for 12 months. On presentation, 17 patients (30.9%) had neurologic deficits (ADIF, 6 patients; RD, 11 patients). Neurologic assessment was made according to the Frankel grading system. The results were evaluated with respect to kyphosis, sagittal balance, neurologic recovery, and patient satisfaction. The mean follow-up period was 95.3 months (range 66 to 114 months)., Results: Radiographically, successful bone fusion was achieved in all the patients. Following treatment, all surgically treated groups exhibited decreases in the kyphotic angle. The mean correction was significantly greater in ADIF (17.5 degrees ) and PDFI (12.1 degrees ) groups compared to the RD group (4.9 degrees ) (p<0.05). Final increases in the kyphotic angle were 0.7 degrees , 1.2 degrees , 1.4 degrees , and 1.6 degrees in NO, PDFI, ADIF, and RD groups, respectively. The mean sagittal deviations in the first postoperative month were +2 mm, +11 mm, +12 mm, and +14 mm in NO, PDFI, ADIF, and RD groups, respectively, which remained unchanged till the end of follow-up. Complete neurologic recovery was obtained in all but one patient. All the patients expressed satisfaction with the treatment. No recurrences or reactivation of disease were observed., Conclusion: This study showed that, with appropriate patient selection, the results of NO, PDFI, and ADIF were satisfactory and comparable.

The early clinical results with the Bryan Cervical Disc prosthesis are encouraging but 2 recent small published series have noted postoperative radiologic kyphosis of the functional spinal unit (FSU) of 4 and 6 degrees. The current study was undertaken to accurately assess the extent of any sagittal deformity after the use of this prosthesis in a substantial, multisurgeon case series. The neutral, erect x-rays of 67 consecutive patients (88 disc levels) operated by one of 3 surgeons, were examined using manual and digital image analysis techniques for FSU sagittal angulation (lordosis), prosthesis shell angulation, segmental olisthesis, and overall cervical alignment. Measurement accuracy was confirmed using interobserver and intraobserver studies. There was a median loss of 2 degrees in FSU lordosis when compared with preoperative imaging (P<0.0001, range: 8-degree loss to 5-degree gain). A median 2 degrees of prosthesis shell kyphosis also occurred (range: 15-degree kyphosis to 12-degree lordosis) but shell angulation correlated weakly with the change in FSU lordosis (rs=0.37, P=0.001). There was a significant difference in the median loss of FSU lordosis between surgeon 1 and surgeons 2 and 3 (3.5 degrees vs. 2 degrees, P=0.005). Median olisthesis of the prosthesis shells was -0.1 mm (range: +1.5 to -2.5 mm). Median postoperative overall cervical lordosis reduced by 4 degrees (P<0.004). A small loss in median FSU lordosis was observed after insertion of the Bryan disc. The observed changes were generally small but varied among both the patients and the surgeons, suggesting that variables may exist which contribute to postoperative sagittal alignment. These are the subject of an accompanying study.

Despite the increasing number of reports on surgical treatments for thoracolumbar osteoporotic vertebral collapse with neurological deficits, the choice of surgery remains controversial. In this retrospective study, we compared the outcomes of posterior and anterior surgeries for single-level osteoporotic vertebral collapse with neurological deficit in the thoracolumbar spine. Both posterior and anterior surgical approaches were performed with a consistent procedure for a single surgical indication at one institution. Twenty-four patients treated with posterior surgery and 28 patients treated with anterior surgery were followed-up over an average of 5 years after surgery. Radiographic results (kyphotic angle, bony fusion, and instrumentation failure), neurological improvement, and surgical complications were compared between the two groups. The average correction angle after surgery was larger in the posterior group than in the anterior group (P = 0.013), but not at final follow-up (P = 0.755). The average loss of correction was also higher in the posterior group than in the anterior group (P = 0.037). There was no significant difference in neurological outcomes between anterior and posterior approaches (P = 0.080). Two-way analysis of variance (ANOVA) showed that the neurological outcome was better in wedge type than in flat type vertebral collapse, regardless of the type of surgical approach (P = 0.0093). In wedge type vertebral collapse, neurological improvement tended to be greater after anterior than after posterior surgery. In four of six cases with instrumentation failure in the anterior group, a titanium cage subsided more than 5 mm but bony fusion was eventually achieved without causing neurological problems. In the posterior group, six cases experienced instrumentation failure during the postoperative course (two cases with screws loosened from pedicles and bodies, and one case with breakage of a screw neck). None of the patients developed instrumentation-related neurological problems. Two cases in each group developed pseudoarthrosis. In single-level osteoporotic vertebral collapse with neurological deficit, anterior surgery tended to improve neurological deficit in wedge type, but not in flat type collapse, compared with posterior surgery.

Study Design: A case report., Objective: To report the first myotonic dystrophy case in which cervical kyphosis had been surgically corrected., Summary of Background Data: Myotonic dystrophy is an autosomal dominant disease that shows myotonia, progressive muscle atrophy, and other various symptoms. Instability of the neck is expected to cause disorders of the cervical spine; however, there are no detailed reports on deformity of cervical spine associated with this disease., Methods: A 43-year-old man with cervical kyphosis due to myotonic dystrophy had undergone an occiput-T2 fusion with autogenous iliac bone using spinal instrumentation., Results: The activity of daily life of the patient had improved markedly, and the good results continued to be preserved for 5 years. There were not any major perioperative complications., Conclusions: Surgical correction of cervical spine is not necessarily a contraindication for myotonic dystrophy.

Study Design: We retrospectively studied 24 consecutive pediatric patients with lumbar kyphosis due to myelodysplasia who had received corrective surgical treatment with the Warner and Fackler technique from 1994 to 2004., Objectives: The purpose of the study was to evaluate the technical problems and outcome and to identify complications of this treatment modality, especially regarding the biomechanics., Summary of Background Data: The management of lumbar kyphosis (8%-20%) in conjunction with myelodysplasia is difficult. In 1993, Warner and Fackler presented an elegant surgical technique, which was used here., Methods: Corrective surgery was performed in 24 patients with an average preoperative lumbar kyphosis of 124 degrees . The correction was achieved by kyphectomy combined with stabilization using rods and wires as described by Warner and Fackler. Outcome was rated and complications were identified using data from the clinical records. For biomechanical analysis of the surgical construct, a force model was developed., Results: The mean extent of lumbar kyphosis could be corrected from 124 degrees before surgery to 43 degrees after surgery. Biomechanical analysis showed that inadequate correction results in implant failure., Conclusion: Surgery should always be performed with the intention to reestablish the sagittal profile inasfar as possible so as to reduce the risk of implant failure.

Study Design: Case report., Objectives: To report on a patient with Pott disease, progressive neurologic deficit, and severe kyphotic deformity, who had medical treatment fail and required posterior/anterior decompression with instrumented fusion. Treatment options will be discussed., Summary of Background Data: Tuberculous spondylitis is an increasingly common disease worldwide, with an estimated prevalence of 800,000 cases., Methods: Surgical treatment consisting of extensive posterior decompression/instrumented fusion and 3-level posterior vertebral column resection, followed by anterior debridement/fusion with cage reconstruction., Results: Neurologic improvement at 6-month follow-up (Frankel B to Frankel D), with evidence of radiographic fusion., Conclusions: A 70-year-old patient with progressive Pott paraplegia and severe kyphotic deformity, for whom medical treatment failed is presented. A posterior vertebral column resection, multiple level posterior decompression, and instrumented fusion, followed by an anterior interbody fusion with cage was used to decompress the spinal cord, restore sagittal alignment, and debride the infection. At 6-month follow-up, the patient obtained excellent pain relief, correction of deformity, elimination of the tuberculous foci, and significant recovery of neurologic function.

Study Design: A retrospective study was conducted to investigate the incidence and prognosis of postoperative lumbar nerve root palsy after surgical treatment for adult spinal deformity., Objective: To decipher the incidence of postoperative lumbar nerve root palsy and recovery in 361 adult spinal deformity patients who underwent 407 spinal fusion surgeries., Summary of Background Data: Although lumbar nerve root palsy is a known complication of spinal surgery, there are no large studies that have examined its incidence or prognosis., Methods: Three hundred and sixty-one consecutive patients who underwent 407 procedures for adult deformity spinal surgery were reviewed. Patients in this study did not have spinal cord injury or nerve root compression on the postoperative imaging study (obtained for change in neurologic examination). The incidence of nerve root palsy was based on postoperative muscle strength, which was followed for a minimum of 3 and an average of 7 years., Results: The overall incidence of lumbar nerve root palsy was 2.9% with a 1.4% incidence in primary and 3.8% incidence in revision surgery. The incidence was 0.9, 1.5, and 7.4% for fusion of <5 levels, 5 to 10 levels, and >10 levels, respectively. The incidence of nerve root palsy for posterior only, same day anterior-posterior, and staged posterior was 1.3, 3, and 7.2%, respectively. While L5 was the most commonly injured nerve root, all other lumbar nerve roots were also involved. There were no S1 injuries. Although there was some recovery in most injuries, Grade IV injuries had the best recovery at 1-year follow-up., Conclusion: Patients with increasingly complex spinal deformities are at a higher risk for postoperative lumbar nerve root palsy. These injuries can be treated nonoperatively when there is no identifiable cause on postoperative imaging studies.

Background: Transthoracic discectomy is an established surgical procedure for the treatment of thoracic disk disease. Most authors advocate interbody fusion after transthoracic discectomy. The purpose of this study was to determine if there were any adverse consequences in foregoing interbody fusion after transthoracic discectomy., Methods: Eighteen consecutive patients underwent transthoracic discectomy without fusion between 1996 and 2002 at Mayo Clinic (Rochester, MN). There were 11 women and 7 men with the mean age of 54 years (range, 28-84 years). Surgical indications were radiculopathy in 1 patient and myelopathy in 17. Follow-up data were obtained from the clinic visits and telephone surveys. We used the available pre- and postoperative radiographs for 16 patients at the last follow-up to establish the incidence of postoperative kyphosis and/or scoliosis at the operated level. Mean duration of the radiographic follow-up was 22 +/- 24 (SD) months., Results: None of the patients reported the onset of a new axial spine pain postoperatively. No patient developed segmental kyphosis or scoliosis at the operated level during the follow-up period. Fifteen of 18 (83%) patients had significant improvement in their neurological symptoms and signs. Two patients remained unchanged. An 83-year-old patient had a slight worsening of her gait after surgery. Specifically, the only 3 nonambulatory patients regained ambulation after discectomy. There were 4 complications: 1 wound infection, 1 pleural effusion requiring pleurodesis, 1 cerebrospinal fluid leak, and 1 case of disabling intercostal neuralgia., Conclusions: These results indicate that interbody fusion may not be necessary for selected patients undergoing transthoracic discectomy. Further long-term follow-up is needed to evaluate the development of late spinal instability and resultant deformity after this procedure.