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STUDY DESIGN This study constitutes a systematic review of the literature. OBJECTIVE The aim of this study was to identify and present all available studies that report on the costs of osteobiologics used in anterior cervical discectomy and fusion (ACDF). METHODS The literature was systematically reviewed to identify studies with specific inclusion criteria: (1) randomized controlled trials and observational studies, (2) in adult patients, (3) with herniated disc(s) or degenerative cervical spine disease, (4) reporting on either direct or indirect costs of using specific osteobiologics in an ACDF operation. (5) Only studies in English were included. The quality of the included studies was assessed using the MINORS and RoB 2.0 tools. RESULTS Overall, 14 articles were included; one randomized controlled trial and 13 observational studies. The most commonly used osteobiologics other than autograft/iliac crest bone graft (ICBG) were allograft and bone morphogenetic protein (BMP). None of the studies was reported to be industry-supported. There was considerable heterogeneity on the reported costs. Overall, most studies reported on surgery-related costs, such as anesthesia, operating room, surgical materials and surgeon's fee. Only two studies, both using allograft, reported the exact cost of the osteobiologic used (450 GBP, $700). Some of the studies reported on the cost of care during hospitalization for the surgical operation, such as radiology studies, emergency room costs, cardiologic evaluation, laboratory studies, pharmacy costs, and room costs. Only a few studies reported on the cost of follow-up, reoperation, and physical therapy and rehabilitation. CONCLUSION Based on the data of this current systematic review, no recommendations can be made regarding the cost-effectiveness of using osteobiologics in ACDF. Given the high costs of osteobiologics, this remains a topic of importance. The design of future studies on the subject should include cost effectiveness.

Supplemental Material for What Is the Evidence Surrounding the Cost-Effectiveness of Osteobiologic Use in ACDF Surgery? A Systematic Review of the Literature by Andreas K. Demetriades, Georgios Mavrovounis, Moritz Deml, Kyaw Min Soe, Zorica Buser, Hans-Jörg Meisel, and AO Spine Knowledge Forum Degenerative in Global Spine Journal

Introduction: To report a case of monoparesis caused by a vertebral artery (VA) anomaly and foraminal stenosis treated with microvascular decompression by the posterior approach. Material and Methods: A 51-year-old man was referred because of a 4-year history of progressive left shoulder pain refractory to other forms of treatment and a 7-month history of arm weakness. Clinical and radiologic evaluation showed an abnormally tortuous loop of left C5-6 cervical foramina with foraminal stenosis causing direct C6 nerve root compression. Results: Left posterior cervical C5-6 facetectomy and fusion was done to decompress the nerve root. The C6 nerve root was identified and well decompressed. The patient’s symptoms resolved after surgery, supporting the posterior decompression of a cervical nerve root compressed by a vertebral artery loop and stenosis for the relief of pain and weakness. Conclusion: Cervical root compression by an anomalous extracranial VA accompanied with foraminal stenosis is a rare cause of radiculopathy and weakness. The best management of such lesions combined with arterial compression and stenosis, is the posterior approach with bony and nerve root decompression., Introduction: Cervical arthroplasty is increasingly being considered as an alternative option to cervical arthrodesis in younger, active patients. Two of the most commonly commercially available cervical disc prostheses are ProDisc-C (DePuy Synthes) and Prestige-LP (Medtronic). Studies comparing the clinical outcomes of the two systems are lacking. Material and Methods: Six consecutive patients with cervical spondylosis with radiculopathy underwent cervical arthroplasty with ProDisc-C. Five subsequent patients with cervical spondylosis with radiculopathy underwent cervical arthroplasty with Prestige-LP. Demographic information, presentation, radiographic findings, hospital stay, heterotopic ossification, clinical outcome, and return to work were compared between two groups. Results: 67% of the patients who received ProDisc-C were female, compared to 60% in the Prestige-LP group. Average ages at surgery were 42.7 (ProDisc-C) and 42 (Prestige-LP). The most commonly affected level was C6/7 (63% of all participants), followed by C5/6 (27%) and C4/5 (9%). All patients had neck pain and radiculopathy. Weakness was seen in 67% of the ProDisc-C group and 80% of the Prestige-LP group. All patients failed conservative management. All patients had a MRI study of the cervical spine demonstrating disc herniation and disc-osteophyte complex causing cervical canal and foraminal stenoses correlating with clinical symptomatology. There were no complications related to cervical arthroplasty. Length of stay was 1 day for Prestige-LP, and 0.67 day for ProDisc-C. Significant improvement or resolution of preoperative symptoms was seen in all patients at 4 weeks. Heterotopic ossification was seen in 33% of the patients who received ProDisc-C, compared to 0% with Prestige-LP. Artificial disc motion was seen in flexion/extension radiographs in 67% of patients with ProDisc-C and 100% of patients with Prestige-LP. Return to work time was 4.3 weeks for ProDisc-C and 6.7 weeks for Prestige-LP. Average follow-up period was 31 months. Conclusion: Patients who undergo cervical arthroplasty with ProDisc-C or Prestige-LP generally have a short hospital stay (overnight or less) and good clinical outcome. Heterotopic ossification was seen more frequently with ProDisc-C. Disc prosthesis motion with flexion and extension was preserved more frequently with Prestige-LP., Objective: Bony overgrowth and spontaneous fusion were complications of cervical arthroplasty. In contrast, we observed the bone loss phenomenon or bone remodeling of vertebral bodies at operation segment after cervical arthroplasty. The purpose of our study is to investigate a potential complication, bone loss of anterior portion of vertebral bodies at operation segment after cervical total disc replacement (TDR) and to discuss the clinical significance. Materials and Methods: All enrolled patients were followed up more than 24 months after cervical arthroplasty using Baguera-C. Clinical evaluations included recording demographic data and measuring the visual analog scale and neck disability index. Radiographic evaluations included measurements of the functional spinal unit range of motion and changes such as bone loss and bone remodeling. We classified the grading of bone loss of operation segment (grade 1: disappearance of anterior osteophyte or small minor bone loss, grade 2: bone loss of anterior portion of vertebral bodies at operation segment without exposure of artificial disc, grade 3: significant bone loss with exposure of anterior portion of artificial disc). Results: Forty-eight patients were enrolled in our study. Among them, bone loss phenomenon was developed in 29 patients (Grade 1: 15, Grade 2:6, Grade 3:8). Grade 3 bone loss was significantly associated with post-operative neck pain (P < .05). Bone loss was related to motion preservation of operation segment effect after cervical arthroplasty in contrast to heterotopic ossification. Conclusions: Bone loss may be a potential complication of cervical TDR and affect to early post-operative neck pain. However, it did not affect mid- to long-term clinical outcomes or prosthetic failure at the last follow-up. Also, this phenomenon may have the motion preservation effect of operation segment after cervical TDR., Introduction: Multi-level cervical ADR (Artificial Disc Replacement) would be regarded as both clinically & radiologically more demanding compared to single level switch with concomitant requirement of biomechanically delicate ‘even’ stress distribution among the ADR devices inserted to corresponding levels as well as possibility of greater load shift both on intermediate or adjacent levels. However, scarce references could be cited regarding the clinical efficacy and its relation to the ‘preserved’ cervical motion after switch to multilevel cervical ADR. The purpose of this study is to compare cervical ROM(Range of Motion) in simple X-ray between preoperation and postoperation in patients who underwent multilevel ADR and to assess which radiological measurements was statistically related to successful clinical outcomes. Material and Methods: A series of 24 patients who were diagnosed as multi-level cervical disc herniation or stenosis and eventually underwent multi-level cervical ADR operation between Feb 2012 to Dec 2015 were included in this study. These were 17 male: 7 female patients with the mean age of 52.3 ± 8.1 years. As for the investigated parameters, the clinical outcome before operation and on the final follow-up was assessed using NRS (Numeric Rating Scale). The subjects were divided as successful pain relief group vs unsuccessful pain relief group with the definition of successful pain relief group as more than 50% reduction of NRS after surgery. As for the radiological parameters, coronal tilt angle of ADR devices, C2-7 SVA (sagittal vertical axis), C2-7 and ADR inserted level sagittal alignment and ROM using Cobb’s angle measurement method were assessed both before op and on the final follow-up. The Mean follow-up period was 429.0 ± 389.0 days. Results: The mean preoperative NRS of 8±0.9 was reduced to 3.1±0.6 for success and 5.4 ± 0.5 for unsuccessful group with significant difference between the group on the scale of clinical improvement. Radiologically, for the all 24 multilevel ADR cases, the C2-7 SVA (from 22.3 ± 9 to 26 ± 8.8 mm) as well as lordosis at ADR level (from 0.3 ± 7.4 to 4.0 ± 4.3o) improved significantly while flexion at ADR levels (from 15.4 ± 6.8 to 10 ± 6.5o), ROM at ADR levels (from 22.6 ± 9.2 to 18.0 ± 8.2o), and consequently C2-7 flexion (from 16.2 ± 11.4 to 9.7 ± 6.8o) reduced significantly. The overall C2-7 ROM was well maintained for successful group (from 49.9 ± 13.8 to 51.1 ± 7.4o) while significantly reduced for unsuccessful group (from 49.7 ± 13.1 to 39.8 ± 12.8o) with significant inter-group difference in angular change (1.2 ± 15.3o vs -9.9 ± 11.2o, P = .037). This was attributable to the significant reduction of ROM at ADR switched levels for unsuccessful group (from 23.8 ± 11.2 to 15.4 ± 8.3o) compared to successful group (from 22 ± 8.4 to 19.3 ± 8.2o), with consequent significant inter-group difference in angular change (-2.8 ± 8.5o vs -8.4 ± 7.8o, P = .027). Conclusion: The overall sagittal alignment as well as lordosis at ADR switched levels improved after multilevel cervical ADR. However, ROM at the ADR levels, especially flexion movements were reduced significantly, consequently leading to the decrease in overall cervical flexional movement. As for the inter-group radiological differences, a significant reduction of ROM at ADR switched levels leading to a significant reduction of overall C2-7 ROM was noted for unsuccessful group compared to successful group., Introduction: The evolution of lumbar disc disease treatment for two levels has been treated habitually by posterior arthrodesis. The development of lumbar prosthesis has allowed preserve the sagittal balance and preserve the biomechanics of the lumbar spine. Specific cases of lumbar degenerative disc disease can be treated by hybrid constructs with total disc arthroplasty (TDA) and anterior lumbar intersomatic fusión (ALIF); showing lower risk of complications such as facet syndrome, dysfunction of the implant or adjacent segment disease. Material and Methods: A retrospective longitudinal study of 17 patients with chronic low back pain with or without radiculopathy association, evidence on magnetic resonance associated with Pfirmann changes III-V, two lumbar segments was performed. All patients underwent surgical treatment by hybrid construct segments L4-L5 (ATD) and L5-S1 (ALIF), are followed for through clinical evaluation of Oswestry (ODI) and visual analogue pain scale (VAS) presurgical and postsurgical at 3, 6, 12 and 24 months. Results: All 17 patients were follow-up. With degenerative disc disease L4-L5 and L5-S1 segment treated by ATD in the L4-L5 and ALIF segment in L5-S1, 10 men (58%) and 7 women (42%) with a mean age 41 years (58-24 years) are reported L5-S1 segment. The ODI decreased from 41% to 20% and VAS decreased from 7 to 3 points, both at 24 months follow-up. Conclusion: We were able to reproduce through this series of cases favorable clinical response using the hybrid construct multilevel lumbar disc disease. In our case series decided choose to make ALIF the L5-S1 segment as the anatomical shape of this segment is usually variable with greater anterior opening and lower to posterior, as well as its dependence on position according to the slope sacred, necesary for sagittal balance. Current implants for TDA despite being constrained, where the instantaneous axis of rotation is to be similar to the disc, still has no physiological contours that preserve the distribution of axial loads necesary for absorbing shocks, so we prefer to use TDA in a more regular Surface (L4-L5). Thus preserve through the combination of the sagittal balance implants, the best resistance and load distribution, the permeability of the foramen and the initial height of physiological disc., Introduction: Investigation the expression of PDGF-β and GFAP in rats with spinal cord injury as a marker of neurologic recovery between groups treated with erythropoietin (EPO) and methylprednisolone (MP). Methods: 30 adult female rats were randomly divided to three even groups. A laminectomy was applied to thoracic 9th vertebra and contusion injury was induced by extradural application of an aneurysm clips. On group 1 rats received one time intratechal administration of normal saline. Group 2 rats received metilprednisolone and, group 3 rats received erythropoietin. Motor neurological function were evaluated by the Basso, Beattie and Bresnahan locomotor rating scale (BBB scale). 30 days after the surgery, T8-10 segments of the spinal cords were extracted and the immunohistochemical assay revealed that the number of PDGF-β and GFAP positive cells. Results: In the last control showed that BBB score in the EPO group showed an increase from 1 to 12 (P < .05). The immunohistochemical assay revealed that the number of PDGF-β and GFAP positive cells was significantly higher in EPO group (P = .000) when compared to MP and control groups. The effect of PDGF-β expression on the locomotor function, we determined that PDGF-β expression and locomotor function after a spinal injury has a strong relationship (P < .05). Conclusion: EPO seems to better increase the expression of PDGF-β thus, produce better results in locomotor functions when compared to MP., Introduction: When image guidance is not available or to confirm such technology, superficial anatomical landmarks still play a role in providing surgeons with estimations of the position of deeper anatomical structures. To our knowledge, surface landmarks for the position of the odontoid process have not been investigated or described. Therefore, the current anatomical study was performed. Materials and Methods: One-centimeter metallic rods were placed in the philtrum of ten adult cadaveric head specimens. To assess the position relative to the odontoid process, lateral and anteroposterior radiographs were taken in the neutral position using fluoroscopy. The relationship of the philtrum as marked with the metal rod was then documented. Results: The philtrum of the upper lip, as marked with a metallic rod was a good approximation of the odontoid process. The majority of specimens demonstrated an exact approximation of the philtrum as a superficial anatomical landmark for the odontoid process on anteroposterior views. The philtrum was always overlying the odontoid process in the sagittal plane. In the majority of the specimens, the philtrum overlaid most of the odontoid process in a craniocaudal direction. Descriptive findings from radiographic findings indicate a reasonable approximation between the philtrum and the midportion of the odontoid process. Conclusions: The philtrum of the upper lip can serve as a first line of estimation of the position of the odontoid process. We consider this a new superficial landmark for the odontoid process. This could be useful for the positioning and planning of approach for patients undergoing spine surgery., Introduction: Traditional surgery for spinal sagittal deformity is morbid and costly. The pelvis is proposed as an alternative osteotomy site. A more distal site may produce larger deformity correction. This study evaluated the effect of osteotomy opening angle (OA) progression to resting length of surrounding muscles using a mathematical model. Methods: Four muscles crossing the osteotomy site were chosen: Gluteus Medius (GMED), Gluteus Maximus (GMAX), Piriformis (P) and Tensor Fascia Lata (TFL). Basic geometric laws were used to derive predictive equations to calculate the length and stretch ratio (SR, new muscle length / initial length) of these muscles as the OA increases. These equations depend on the spatial location of the muscle insertion points. Average insertion points were obtained from an OpenSim software model. GMAX and GMED were subdivided into 3 (anterior, middle and posterior), as they are relatively wide. Calculated SRs were compared to the threshold SR for rabbit Extensor Digitorum Longus muscle (25.4%); there are no reported human SR threshold values for the investigated muscles. Results: OA correlates with SR positively for TFL and anterior GMED, and negatively for the rest of muscles. A 20° OA was selected based on another study. For this OA, the SR approximately decreases 6%, 5%, 6%, 8% and 5% for posterior GMED, anterior GMAX, middle GMAX, posterior GMAX and P, respectively. It increases 8% and 4% for anterior GMED and TFL, respectively. It does not change for middle GMED. Conclusion: BPO changes the length of some of the surrounding muscles. For the practical OA range, these changes are not considerable. The reported critical value (25.4%) is higher than the maximum SR for investigated muscles (8% for anterior GMED). Note that we only considered the non-stimulated passive response of the muscles. Moreover, physiological motions may compound the OA effect on SR, the effects of which were not investigated in this study., Introduction: Rheumatoid arthritis (RA) often involves synovial joints of the cervical spine, including the atlanto-occipital joint, atlantoaxial joint, and facet joints. In the lumbar spine, erosion of discovertebral joints and facet joints has been reported in RA patients. However, there is no synovium in the discovertebral joints, so the pathology of lumbar spondylitis in RA patients remains unclear. In addition, histological evaluation of RA lesions in both the discovertebral joints and facet joints at the same spinal level has not yet been performed. The purpose of this study is to histologically evaluate lumbar involvement in RA by investigating rats with collagen-induced arthritis (CIA) and to assess the potential effects of RA on the discovertebral joints and facet joints. Material and Methods: Seven-month-old female Sprague-Dawley rats were divided into groups with CIA and without CIA (control). All rats were sacrificed at 8 weeks after initial sensitization and the lumbar spine (L5/6) was harvested. Then the lumbar spine block specimens were stained with Villaneuva bone stain and sectioned in the midsagittal plane. The left facet joints were also sectioned in the midaxial plane. Specimens were studied under a microscope and infiltration of inflammatory cells was investigated. Results: In the CIA group, lumbar lesions were confirmed in 13/18 rats (76%). Lymphocytes only infiltrated into the anterior rim of the vertebral bodies in 2 rats, while lymphocytes only infiltrated the facet joints in 4 rats. Both sites were involved in 7 rats. In addition, osteoclasts invaded the anterior rim of the vertebral bodies and formed cavities that also contained lymphocytes. Formation of pannus was seen in the facet joints. Conclusion: Infiltration of inflammatory cells into the anterior rim of the vertebral bodies alone or into the facet joints alone was demonstrated in some rats with CIA, while both sites were involved in other rats. Therefore, lesions at the anterior rim of the vertebral body did not arise secondary to facet joint involvement, but were caused by CIA along with synovial lesions of the facet joints., Introduction: Intervertebral disc (IVD) degeneration is one of the main causes for chronic back pain. Injection of autologous stem cells is still an experimental treatment for disc degeneration showing limited success so far. This is attributed to a low survival rate of the injected cells due to the harsh environment within the disc, which is hypoxic, acidic, low in nutrients, and possibly inflamed in a degenerative state. Studies performed in animal models have reported that juvenile chondrocytes display a better cell survival and production of extracellular matrix than stem cells, possibly due to chondrocytes being more accustomed to an avascular environment. Recently, it has been shown that adult human nasal septum chondrocytes (ie, easily available cells in an autologous setting, under minimally invasive conditions) have an increased rate of proliferation and synthesis of proteoglycan (GAG) and collagen in contrast to articular chondrocytes (ACs). This study was aimed at assessing whether human nasal chondrocytes (NCs) could be an opportune cell source for autologous cell transplantation therapy in the treatment of IVD degeneration. Material and Methods: Human bone marrow stromal cells (MSCs), ACs, and NCs were isolated from biopsies and expanded in cell culture for 2 passages. Thereafter, cells were cultured in either normoxic or hypoxic (2% O2) conditions for 4 weeks in 3D pellet culture The chondrogenic media with either regular (4.5 g/l) or low (1 g/l) glucose levels were complemented either with or without the growth factor TGFβ1. The cell survival and the capability to form IVD-like tissue were evaluated by means of histological and biochemical analysis. Results: Quantification of DNA shows that the cell number of MSC decreased by more than 25% in the absence of TGFβ1 and was barely retained in the presence of the growth factor independent of environmental condition. ACs behaved similar to MSCs with the exception that the cell number increased in hypoxic conditions with the addition of TGFβ1, but independent of the glucose concentration. Surprisingly, the number of NC slightly increased (>12%) in all conditions without TGFβ1. Furthermore, the supplement of TGFβ1 increased the cell number by at least 48% in any of environmental conditions. Histological Safranin O staining and biochemical analysis showed for all three cell sources that TGFβ1 was necessary for an adequate production of GAG. The reduction of glucose decreased the level of GAG in pellets formed by MSCs in both hypoxia and normoxia. In contrast, GAG production of ACs was unaffected by changes in glucose concentration, however hypoxic conditions influenced ACs to synthesize more GAG. Interestingly, NCs do not favor hypoxic conditions for GAG production, nonetheless in combination with decreased glucose levels they show a trend to produce the most GAG (35 pgr) compared to ACs and MSCs. Conclusion: Our findings indicate that compared to MSCs and ACs, NCs are more prone to survive and synthesize cartilaginous extracellular matrix in vitro in conditions resembling those of the IVD (ie, low oxygen and low glucose concentration) and are therefore an excellent candidate for a cell based therapy of degenerative disc disease., Introduction: Adolescent idiopathic scoliosis (AIS) is a lateral deviation of the spine associated with vertebral rotation whose etiology is not defined. Several theories have been proposed, but none is absolutely conclusive. One such theory suggests the primary involvement of muscles due to myopathy, affecting mainly the erector and paravertebral rotator muscles. However, previous studies indicate that muscle involvement could result from neuromuscular conditions, and, more recent work correlates AIS to genetic polymorphisms. Some polymorphisms have been associated to physical performance and muscle power through their effects on muscle tissue. The gene coding for the angiotensin converting enzyme (ACE), has polymorphisms corresponding to an insertion (allele I) or deletion (allele D) of 287 base pairs. The expression of different alleles may affect the plasma levels of angiotensin II, and muscles with aerobic characteristics (type I fibers) such as the erector and rotators of the spine. Material and Methods: To evaluate a possible relationship of ACE gene polymorphisms with the development of the AIS we evaluated their relative expression in samples of the rotator muscles of the spine, collected during corrective surgery of 21 patients with AIS, and a predominance of fibrosis and fatty proliferation in the concavity side of the deformity. Results: We could find no difference in the expression of the ACE gene or its polymorphisms (insertion/deletion) in the multifidus muscles removed from the concavity and convexity of the apex of the thoracic deformity. Conclusion: Thus, we could not find evidence of ACE polymorphism involvement in the development of AIS., Introduction: The adolescent idiopathic scoliosis is a multifactorial disease, and its etiology related to genetic factors and environment. Patients present 3-dimensional deformity, and its main characteristic trunk rotation. This deformity can be related to the primary disease or secondary due to multifidius muscles. The objective of this study is to analyze and compare the fatty degeneration of these muscles by means of magnetic resonance imaging and histopathology. Material and Methods: Ten patients that undergone corrective surgery for adolescent idiopathic scoliosis had multifidius muscle samples taken from the top of the thoracic deformity. Samples were analyzed for fatty degeneration and fibrosis and compared their histopathological findings with axial MRI (T1-weight) of the same region using the ImageJ software. Results: Higher fatty degeneration of the multifidus muscle was found in the concavity of the thoracic curve of patients with adolescent idiopathic scoliosis in the histopathological and image analysis, whereas the fatty degeneration in the MRI demonstrated that higher the deformity greater was the degeneration observed (rho = 0.85, P < .0). No significant correlation between the MRI image and the fatty involution was noted in the histopathological analysis neither in the concavity (rho = 0.09; P = .797) nor in the convexity (rho = 0.02, P = .955). Conclusion: Both MRI and histopathological analysis of multifidius muscles from the apex of the deformity of patients with adolescent idiopathic scoliosis demonstrated higher fatty degeneration in the concavity of the curve. The difference between concavity and convexity assessed by MRI is higher as much severe is the scoliotic curve., Introduction: Spinal cord injury leads to cellular necrosis as secondary damage caused by ischemia. Free radical formation and lipid peroxidation play a novel role in the pathophysiology of tissue lesions. Antioxidant therapy has been proposed to minimize the reactive oxygen species and reduce the secondary lesions. The objective of the paper is to analyze the frequency and efficacy of the experimental antioxidant therapy studies. Materials and Methods: Research was performed in pubmed.gov using the keywords “antioxidants” and “spinal cord injury”, from January 2000 to December 2015, resulting in 686 papers. Nontraumatic injury, no antioxidant therapy, lack of neurological and functional assessment and non experiment studies were excluded. After the exclusion criteria, 43 were included. Results: The most used therapies were melatonin (16.2%), quercitin (9.3%), epigallocatecin and edaverone (6.9%). The most frequent administration mode was intraperitoneal (72,09%). The posology and administration mode varied greatly, and mostly one dose was used (39.53%). The elapsed time from trauma to treatment was 0-15 minutes (41.8%), 15-60 minutes (30%) and more than 1 hour (10.6%). Histology was done in 32 papers (74.41%). BBB scale system was the main functional measurement (55.8%), followed by the inclined plane test (16.2%) and the Tarlov Scale (13.9%). Positive outcomes were observed in 37 papers (86,04%). Conclusion: The heterogeneity of antioxidant treatment with different types, doses, and measurements observed limit the comparison of efficacy. Standardized protocols are necessary to make clinical translation possible., Introduction: Animal models of spinal cord injury (SCI) are used both to study the biological responses and the potential therapies under controlled conditions. An appropriate model should be selected considering the hypothesis and outcomes assessments. In a systematic review, we categorized the SCI animal models, based on the study aims, species, injury techniques, levels of injury, and outcome measurements. Material and Methods: An extended search was carried out in the electronic databases of Medline. Results: Among a total of 2870 publications, 2209 fulfilled our inclusion criteria. The most common aims of included studies were the evaluation of different factors or pathophysiologic changes. The most common level of injury was thoracic. Contusion was the most common pattern of injury followed by transection. In the half of studies, both biological and behavioral tests were used to assess outcomes. Conclusions: Prior to choose an animal model, the study aims should be exactly defined. While contusion models better mimic the neuropathology of human injuries, transection models are helpful to study anatomic regeneration. Rats are the most common and best suited species for SCI models. Newer SCI animal models need to be improved and validated., Introduction: Despite abundant studies regarding the pathophysiology of traumatic spinal cord injuries (TSCI), there is a controversy about the fate of neurons following mechanical insult. For development of new therapies to either preserve the spared neurons or promote axonal regeneration and remyelination, selection of the injury model and time of intervention is crucial for the efficacy of therapy. Here we evaluated the fate of neurons after TSCI by conducting a systematic review. Material and Methods: We searched PubMed and EMBASE with no temporal or linguistic restrictions. In addition, hand-search was performed in the bibliographies of relevant studies. Non-interventional animal studies evaluating time-dependent pathological changes of neurons following acute mechanical trauma to the spinal cord were included. The outcome measures were neuronal death as well as changes occurring in the axon and myelin integrity and their function postinjury. Results: Following injury neuronal loss occurs through both necrotic and apoptotic cell death. The first sign of apoptosis was detected at 1 h postinjury which reaches to a maximum at 7-8 mm from the epicenter by 3 days postinjury. TSCI causes apoptosis also in the brain. Although the survival of supraspinal neurons depends on the severity of the injury and anatomical location of their axons, some supraspinal neurons can survive the injury up to at least 1 year PI. Axonal regeneration after transection initiates earlier compared with compression or contusion models. This early regenerative process is also associated with axonal die back. Growing fibers are detectable within the lesion cavity during the intermediate phase. Demyelination begins 12-24 h PI and peaks at 8 weeks postinjury. Remyelination was detected as early as 1 week postinjury. The number of demyelinated/remyelinated axons at the injury epicenter was not significantly different between transection and contusion models of injury. However, the demyelination/remyelination process is more limited to the injury site in transactions. Conclusion: As secondary injury is a progressive event, detailed understanding of time-dependent neuronal response to TSCI in rats will improve the process of examining the safety and efficacy of the intervention by reliable methods not interfered by the injury-related changes and subsequently may accelerate translation of treatments to the clinical application. Acknowledgement: This project has been support by the Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences (fund number: 93-02-38-25620)., Introduction: Diffusion being the most important source of disc nutrition, factors affecting it needs to be studied accordingly. Ole of endplate and annulus fibrosus has been extensively studied. But the relation of disc height to the diffusion characteristics has not been studied till date. The present study evaluates the 24 hr diffusion characteristics and its peak signal intensity change connecting with the axial disc width and length. Material and Methods: Twenty-five lumbar discs of 5 healthy volunteers were included in the study. IV gadodiamide (0.3mmol/kg) was given as a contrast material and serial MRI images were taken at 10 min, 2 hrs, 4 hrs, 6 hrs, 12 hrs and 24 hrs. Axial images at cranial, middle and caudal zones of the discs were obtained. Using region of interest (ROI) boxes, signal intensity changes in the intervertebral disc along with disc height were measured in the sagittal sections. The enhancement percentage of each time period (EP) and peak enhancement rise time (T rise) were calculated. Results: The peak signal intensity was seen at 6 hrs in all the discs. Axial width and length of the disc was found to be inversely proportional to the diffusion at central nucleus pulposus. Also as the sagittal height of the disc increased in each individual, peak signal intensity at 6 hrs decreased. Conclusion: The present noninvasive in-vivo study documents the relation between disc height, axial length and width to that of the diffusion at central nucleus pulposus., Introduction: Skeletal fluorosis is endemic in at least 22 states in India. Andhra Pradesh is one of the worst effected states. Ossification and thickening of ligaments result in cervical stenosis and progressive spinal cord compression leading to cervical myelopathy and quadriperesis. Diagnosis of cervical myelopathy is often difficult due to subtle symptoms and lack of suspicion. The success of the treatment depends on early surgical intervention. Many a times, patients from endemic area present late with severe myelopathy. MRI is considered too be the gold standard test for diagnosing cervical myelopathy. Utilising MRI as the screening test is neither cost effective nor feasible. By developing self screening tests and symptoms, awareness can be created in the endemic population to seek the medical help early. Currently there are no screening tools available in the world literature. As the disease is endemic to us, it becomes our responsibility to develop these tools. With a combination of simple questionnaire and easily elicitable clinical tests, we aim to develop self screening tools for fluorotic myelopathy. Material and Methods: The study was conducted in two phases. In phase I, screening tools were developed with 30 cervical myelopathic patients with cord compression on MRI, underwent surgery and improved as cases; 30 patients with neck/radicular complaints but no myelopathic symptoms and no cord compression on imaging as controls. 20 items from the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) and five easily demonstrable clinical signs namely Hoffman test, rapid grip and release test, finger escape sign, Romberg’s test and tandem walking were evaluated. Data was analyzed by univariate analysis and multiple logistic regression analysis. According to the resulting odds ratio, b-coefficients, and p value, items were chosen and assigned a score. In Phase 2, the validity of the developed questionnaire and tests were evaluated in 480 subjects by five health workers in endemic population in India with the help of National Program for Prevention and Control of Fluorosis (NPPF). Those who satisfy the criteria were subjected to the MRI examination and results were analyzed. The urine samples of the patients was analysed for fluoride content. Results: Five questions were chosen by statistical analysis and each assigned a score of two. A score greater than or equal to six as cut-off and two of the five positive clinical tests was found to predict the cervical myelopathy with the area under the ROC curve of 0.78, sensitivity of 91.6% and a specificity of 63.2%.Of the clinical tests, Romberg test was found to demonstrate highest sensitivity (83%). Of the 480 subjects screened with these developed tools, 37 (7.7%) were found to satisfy the criteria of them 11 were found to have radiological cord compression with a positive predictive value of 0.84. Urine fluoride was above the threshold (1.5 ppm) in 95 of 120 samples measured with average of 3 ppm and maximum recorded up to 8 ppm. Conclusion: Simple self screening tools with a combination of five questions and five clinical tests were found to successfully screen the fluorotic myelopathy. Presence of three of five positives in the questionnaire or two of five positive tests was found to be highly sensitive for screening. Of all the clinical tests, Romberg test was found to be highly sensitive in predicting cervical myelopathy. These tools can be utilized to rapidly screen the cervical myelopathy in the outpatient clinic as well as for epidemiological purpose by educating the local heath workers., Introduction: With the rise of life expectancy worldwide, automatically will impact on the increment of degenerative disease, including the degenerative spondylolisthesis. This phenomenon is followed with rapid development of orthopedic instrumentation. This facts gave rise to the question: Is it necessary to reduce the degenerative spondylolisthesis? Besides, it is difficult technically and lot of complication could happen. Materials and Method: This is an experimental study to evaluate the soft tissue role on stability on degenerative spondylolisthesis model on the animal model (Porcus domesticus). Samples are grouped into in situ instrumentation group and instrumentation after reduction group. The initial step is destabilization procedure including bilateral facet joints resection, total discectomy, and preservation of anterior and posterior ligaments. The caudal vertebra are fixated, while the cranial vertebra are free. Then, anterior shear force is applied to the cranial vertebra using testing machine. Afterwards, pedicle screw-rods system is implanted on both groups. Anterior shear force is applied on the instrumented samples once again. The test is terminated once the displacement reach 5 mm. Result: Mean value of maximal shearing force needed to achieve 5 mm listhesis on in situ instrumentation group is 506,6667 ± 59,62103; in instrumentation after reduction group is 325,0000 ± 63,98125. Mann-Whitney analysis test result comparing both groups is P = .08, which is significantly different. Conclusion: There is significant difference in maximum anterior shear force needed to achieve 5 mm listhesis between both groups. This could happen due to the role of soft tissue to add the spine stability on in situ instrumentation group., In humans, vertical posture acquisition caused several changes in bones and muscles which can be assumed as verticalization. Pelvis, femur, and vertebral column gain an extension position which decreases muscular work by paravertebral muscles in the latter. It’s widely known that 6 different morphological categories exist; each category differs from the others by pelvic parameters and vertebral column curvatures. Both values depend on the Pelvic Incidence, calculated as the angle between the axes passing through the rotation centre of the two femur heads and the vertical axis passing through the superior plate of the sacrum. The aim of this study is to evaluate the distribution of stress and the resulting strain along the axial skeleton using finite element analysis. The use of this computational method allows performing different analyses investigating how different bony geometries and skeletal structures can behavior under specific loading conditions. A computerized tomography (CT) of artificial bones, carried on at 1.5 mm of distance along sagittal, coronal and axial planes with the knee at 0° flexion (accuracy 0.5 mm), was used to obtain geometrical data of the model developed. Lines were imported into a commercial code (Hypermesh by Altair®) in order to interpolate main surfaces and create the solid version of the model. In particular six different models were created according Roussoli’s classification, by arranging geometrical position of the skeletal components. Loading conditions were obtained by applying muscular forces components to T1 till to L5, according to a reference model (Daniel M. 2011), and a fixed constrain was imposed on the lower part of the femurs. Materials were assumed as elastic with an Elastic modulus of 15 GPa, a Shear Modulus of 7 GPa for bony parts, and an Elastic modulus of 6 MPa, a Shear Modulus of 3 MPa for cartilaginous parts. Six different simulations have been carried out in order to evaluate the mechanical behavior of the human vertebral column arranged according to the Russoli’s classification; results confirm higher solicitations obtained varying configurations from case I to case VI. In particular way, first three cases seem to supply the different loading configurations spreading stresses in almost all the bony parts of the column, while the remaining others three cases produce an higher concentration of stress around the lower part of spine (L3, L4, L5). Results confirm a good agreement with those present in literature (Winkle at al. 1999), an equivalent Von Mises average stress was of 0,55 MPa was found on the intervertebral disks with the higher values reached on the lower part of the column. A comparison of results obtained for Case I with literature (Galbusera et al., and El Rich et al. 2004), shows a good agreement in terms of normal compressive force, while more evident differences with Galbusera’s results can be found for shear force and sagittal moment. The results underline a relationship between PI increase, and accordingly of PT and LL, and the distribution of load forces. Load forcesi is exerted mainly on distal vertebrae, especially on L4 and L5., Introduction: Clinical case series in the literature suggest that kyphoplasty may be an option to stabilize a traumatic instable thoracic-lumbar spinal segment after incomplete burst fracture. This suggestion is in a certain contrast to the classical biomechanical idea of segmental instability after injury of the middle column according to Denis. Purpose of this study is to evaluate the effect of kyphoplasty to stabilize the posttraumatic segmental instability and its influence to adjacent levels using a robotic based spine tester. Material and Methods: 14 osteoporotic human multisegmental spine samples (TH11 – L3) have been tested. Intact kinematic values of each FSU were recorded, using a robot based spine tester combined with an active 3D motion tracking without and with follower preload. These values have been used as baseline. After standardized induction of an incomplete burst fracture to L1, the kinematic testing was repeated to record the posttraumatic (instable) values. The fractured vertebra (L1) was then reconstructed by kyphoplasty. Kinematic values of each FSU was investigated after kyphoplasty. Results: The experimental induced incomplete burst fracture resulted in a significant increased range of motion (ROM) of the Level TH12 – L1 for extension-flexion, lateral bending and axial rotation. No significant increase in adjacent levels was noticed. Increase in ROM for axial rotation was 201% (p = 0.001), for extension flexion 132% (P = .0002) and lateral bending 277% (P = .0002) of intact kinematic values. After kyphoplasty a significant reduction of the posttraumatic instable values of the Level TH12 - L1 have been observed for all three movement directions. ROM was reduced for axial rotation to 80% (P = .002), for extension-flexion to 90% (P = .0002) and lateral bending to 71% (P = .0002) of the fractured kinematic values. However, for all three movement directions initial intact values could not have been restored and a significant increase in ROM resulted compared to the values before injury. In comparison to intact values ROM remained increased by 161% (P = .002) for axial rotation, by 120% (P = .001) for extension-flexion and by 197% (P = .0002) for lateral bending. No significant changes in adjacent levels were seen. Conclusion: Kyphoplasty seems to have the potential to reduce segmental instability after trauma. However, in the presented model intravertebral reconstruction failed to restore intact values and a significant instability remained. This observation may increase our understanding to the stabilizing effect of kyphoplasty but unfortunately does not answer, how much gain in stabilization is necessary to achieve good clinical outcomes. The biomechanically observed remaining instability after kyphoplasty suggests that this treatment has limited potential to stabilize a true traumatic instability., Introduction: Anterior cervical discectomy and fusion has been associated with the development of adjacent segment degeneration (ASD). Cervical total disc arthroplasty (TDA) is an alternative to fusion to prevent ASD, as studies have demonstrated that TDA can replicate physiologic motion. An innovative disc prostheses with a mobile axis of rotation and made of polycrystalline diamond, one of the hardest and most durable substances known, can replicate physiologic motion while minimizing wear debris. The purpose of this study was to assess the motion response of this TDA implanted in human cervical spines. Biomechanical assessment was performed in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) after 1- and 2-level TDA. Material and Methods: Nine cadaveric C3-T1 spine specimens were tested (38.3 ± 5.8 years). The testing apparatus allowed continuous cycling in FE, LB, and AR to ±1.5 Nm. Compressive preloads (0 N, 150 N) were used in FE. Vertebral motion was measured using optoelectronic measurement. TDA implantation was performed consistent with company guidelines (Triadyme-C, Dymicron, Orem, UT, USA). Three dimensional (3D) CT based analysis was used to calculate center of rotation (COR).The PLL was resected and a medial uncinatectomy was performed to accommodate the prosthesis. Experimental protocol: Intact, C5-C6 TDA (n = 9), C6-C7 TDA (n = 7). ANOVA was used for statistical analyses, significance: p < 0.05. Results: C5-C6 ROM (deg) Intact to 1-level TDA: FE (0 N): 12.6±2.6 to 11.7±1.8 (p = 0.32) FE (150 N): 12.8±2.5 to 10.5±2.1 (p = 0.03). LB: 8.5±2.8 to 3.7±1.0 (p < 0.01). AR: 10.4±1.1 to 6.2±1.9 (p < 0.01). Neutral zone (deg): FE (0 N): 0.8±0.5 to 1.4±0.5 (p = 0.00). FE (150 N): 1.8±0.7 to 1.8±0.8 (p = 0.97). Change in COR: FE (150 N): 1.0±1.1 mm posteriorly (n = 8, p < 0.05) and 0.6±1.4 mm caudally (n = 8, p = 0.3). C6-C7 ROM (deg) Intact to 2nd-level TDA: FE (0 N): 11.5±3.4 to 12.4±3.3 (p = 0.07). FE (150 N): 10.0±3.4 to 11.4±3.0 (p = 0.15). LB: 7.5±2.8 to 5.1±2.3 (p = 0.07). AR: 7.7±1.7 to 5.3±0.9 (p = 0.02). Neutral zone (deg): FE (0 N): 0.8±0.4 to 1.1±0.2 (p = 0.01). FE (150 N): 1.5±1.0 to 2.1±0.9 (p = 0.30). Change in COR: FE (150 N): 1.4±0.8 mm posteriorly (n = 7, p < 0.01) and 0.3±2.0 mm cranially (n = 7, p = 0.7). Conclusion: This innovative disc prosthesis design restored FE ROM to intact levels. In LB the TDA maintained 68% of ROM at C6-C7 and 43% at C5-C6. In AR 60% of the ROM was maintained at C5-C6 and 69% at C6-C7. Other biomechanically tested designs of TDA have shown similar reduction in LB and AR. The decrease in LB and AR after TDA may be a multifactorial phenomenon. Device kinematics, placement and tensioning of the remaining soft tissues during prosthesis insertion may play a role in maintained motion. This novel polycrystalline diamond tri-lobed TDA design, effectively replicated COR at both operated levels. Data suggests that this TDA provides similar cervical spine kinematics as compared to the preoperative condition., Introduction: Sacropelvic fixation is commonly used during long fusions of adult deformity surgeries to overcome the complications associated with the fusions ending at S1. Among multiple techniques for sacropelvic fixation, the S2 alar-iliac (S2AI) screws and iliac screws with lateral connectors are frequently used. However, the sacropelvic fixation is still associated with a very high rate of mechanical failure. In particular, the polyaxial screw head coupling the shaft has been shown as the first part failing against load, and this was suggested as a protective feature of the screw preventing screw or rod failure. Hence, we aimed to compare the biomechanical strength of the S2AI screws to the iliac screws with lateral connectors using finite element analysis (FEA). Moreover, we evaluated the least length of the screw to maintain the stability of the sacropelvic fixation, and the safe range of angle in the coupling of the polyaxial head to the pedicle screw. Material and Methods: A 3-dimensional finite element (FE) model of the normal spinopelvis (L4-Pelvis) was generated using Mimics, a CT image processing software, and ANSYS FE Modeler, a FE model generation software. The pedicle screws were placed on the L4-S1 with five different lengths of S2AI screws and iliac screws, namely, 60 mm, 70 mm, 80 mm, 90 mm and 100 mm. The total numbers of element for spinopelvis and implant are approximately 50 000 and 3000, respectively. Various loads are applied to the spinopelvic FE model through the displacement- and angle-controlled method. Through the series FEA using ANSYS, the principal maximum stress as well as the von Mises equivalent stress on both fixation appliances and bone structures was specifically calculated. In addition, the various failure characteristics of both bone and implant such as screw breakage and disintegration between screw head and shaft were quantitatively predicted using the failure criteria of each material. Results: Through the parametric study of FEA results, the optimized screw type and the screw insertion depth for all of screw types can be identified. The optimized angle of screw head for S2AI can be determined as well. In both fixations, it was confirmed that as the screw insertion depth increases, the amount of equivalent stress as well as principal maximum stress decreases. Conclusion: FEA results demonstrated that the S2AI screws provided better stability with less stress fields in comparison with the iliac screws with lateral connectors in most of loading conditions. The least length of the screw to maintain the stability of the sacropelvic fixation was longer for iliac screw fixation. S2AI screws that were used with angled position were prone to failure more easily with the increase of head-shaft angulation., Introduction: Pseudarthrosis remains a problem affecting the success of anterior cervical discectomy and fusion. Increased stiffness from internal fixation has a positive effect on arthrodesis and various supplemental fixation techniques have been developed with this in mind. Machined intrafacet allograft spacers have been studied for their effect on foraminal height and anecdotal experience supports a positive effect on construct stiffness; however, biomechanical studies are limited. Our objective was to evaluate the biomechanical advantage gained from the placement of intrafacet allograft spacers (IAS) in an unstable single level and 2-level anterior cervical discectomy fusion (ACDF) pseudarthrosis construct. Material and Methods: Seventeen C3-7 fresh-frozen human cadaveric spines (10 male and 7 female; mean age 51 years) were tested. Nine were used for the single level ACDF group and eight for the two-level group. Range of motion in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) at 1.5 Nm were collected in four testing configurations for one and two-level groups: 1) Intact spine; 2) ACDF with interbody graft and plate/screw; 3) ACDF with interbody graft and plate/loosened screws; and 4) ACDF with interbody graft and plate/loosened screws supplemented with intrafacet allograft spacer. Results: All fixation configurations resulted in statistically significant decreases in range of motion in all bending planes compared to the intact spine (p < 0.05). One Level: Performing ACDF with interbody graft and plate on the intact spine reduced FE, LB, and AR 60.0%, 64.9%, and 72.9% from intact respectively. Loosening the ACDF screws decreased these reductions to 40.9%, 44.6, and 52.1%. The addition of intrafacet allograft spacers to the loose condition (rescue) increased these reductions to 74.0%, 84.1%, and 82.1%. These differences were not statistically significant. Two Level: Performing ACDF with interbody graft and plate on the intact spine reduced FE, LB, and AR 72.0%, 71.1%, and 71.2% respectively. Loosening the ACDF screws decreased these reductions to 55.4%, 55.3%, and 51.3%. The addition of intrafacet allograft spacers to the loose condition significantly increased these reductions to 82.6%, 91.2%, and 89.3% (P < .05). Conclusion: Our data demonstrated that supplementation of a loose ACDF construct with intrafacet allograft spacers significantly increases stability and has potential applications in treating cervical pseudoarthrosis and decreasing non-union risk in multilevel ACDF., Introduction: Numerous bone graft substitutes (BGS) are available as alternatives to iliac crest autograft. Fusion success is normally defined by the presence of bridging bone between vertebrae at the operative site. The number of fused segments is often quoted as a measure of clinical performance for BGSs; however, it does not provide any quantifiable measure of the quality of the fusion. BGSs should resorb over time to leave normal healthy bone that responds to mechanical load and remodels to the principle axis of strain. This study analysed and compared the porosity and direction of trabeculae of bone formed in the BGS region to that of normal bone as a measure of the fusion quality. Materials and Methods: Anterior cervical discectomy and fusion for single and multi-level symptomatic cervical radiculopathy was completed in 13 patients (20 spinal levels) using a PEEK interbody cage. The cage was filled with The cage was filled with i-FACTOR (Cerapedics Inc.), a Peptide Enhanced BGS. Post-operative radiographic follow-up was conducted at 3 and 6 months using Cone-Beam CT. The BGS region in the interbody cages, which had been deemed fused by the operating surgeon, was isolated using a semi-automated algorithm to segment the bone in the region of interest whilst compensating for both beam hardening and x-ray scattering. This was performed using Mimics (Materialise) software. The porosity of the regions was determined by wrapping the segmented models and individual trabeculae were identified by ray-casting. The segmented 3D bone models were subjected to ray-casting to identify the internal trabecular direction and volume of bone in each direction. Directions were related to the orientations of the cage (using the radiographic cage markers) and were represented via a 3D histogram rose plot using 10° increments. Results: The porosity of the bone formed from the graft approaches the porosity seen in corresponding healthy bone (in a nonadjacent vertebral body) over time. Analysis of trabecular direction in the control bone sites showed not only the major directions of the trabecular which relate to the major axis of strain in the bone, but also an array of supportive directions. The trabeculae of the fused bones at 3 months show similar major directions but not the supportive directions. The trabeculae of the fused bones at 6 months show a smaller proportion of major directions but in the same direction as the health bone compared to the 3-month data but has more supportive directions as in the normal bone. Conclusions: The change in porosity and trabecular orientation over time and a trend towards normal bone characteristics suggest that, despite being enclosed within a stiff interbody cage, the BGS region is being stimulated to remodel along a principle orientation that is similar to that observed within normal bone. The trabecular orientation observed at 3 and 6 months is not the same, indicating a remodelling predicted by Frost’s Mechanostat, with remodelling occurring along the main axis of strain, thus remodelling to a similar structure to the healthy bone., Introduction: Sit-to-stand and stand-to-sit (STS) are determinant tasks linked to independence in daily life with an average of 60 repetitions per day (Janssen et al, 2002). It has been shown that STS exacerbates pain in NSLBP patients (Dall & Kerr, 2010) and is greater energy demanding in individuals with non-specific low back pain (NSLBP) compared to healthy participants (Shum et al, 2009). Trunk muscles electromyography (EMG) highlighted differences between NSLBP and healthy participants in functional tasks such as lift (Lu et al, 2001) or walking (Lamoth et al, 2006). To the best of our knowledge, few studies have investigated muscles activity during STS in NSLBP patients. Investigating trunk muscles EMG of NSLBP patients during STS would provide a better understanding mechanisms of pain and enable to adapt therapeutic management. This study aimed to compare trunk muscles cocontraction between chronic NSLBP and healthy participants. Material and Methods: EMG of erector spinae (ES) (at L1 level) and rectus abdominus (RA) were measured bilaterally in 12 patients with chronic NSLBP and 9 healthy participants. Endurance tests of back (Sorensen test) and abdomen (flexor Ito-Shirado test) muscles were respectively used to normalize ES and RA EMG amplitude. Then, each participant realized 3 trials of STS movement from an adjusted stool (knee at 90°). For each STS movement a percentage of cocontraction time (PCT) and a cocontraction index (CCI) (Lewek et al., 2004) were calculated to respectively evaluate activation pattern and degree of cocontraction for each following pairs: ES right/ES left, ES right/RA left, ES right/RA right, ES left/RA right, ES left/RA right and RA left/RA right. The average of CCI for all ES/RA pairs was considered to compute a global flexor/extensor CCI value. Statistical analysis was performed using Mann-Whitney U test. Results: Analysis of PCT showed no significant (P > .05) difference between the two groups for sit-to-stand and stand-to-sit movements. Conversely, analysis of CCI showed significant (P < .05) higher global flexor/extensor CCI values in NSLBP group for both the sit-to-stand and stand-to-sit movements. Conclusion: These present findings suggested that during STS movement NSLBP patients had a similar activation pattern between trunk muscles but with a higher degree of cocontraction. These observations are consistent with results observed on lifting (Lu et al., 2001) and walking (Gamkhar et al, 2015). The higher degree of cocontraction could explain a part of the persistence of pain in NSLBP population. These results should be confirmed on a larger number of participants., Introduction: Foraminal stenosis is a clinical challenge in both diagnosis and treatment. Current surgical strategies involve placement of interbody devices, which may indirectly decompress foramina via height restoration. Alterations of foraminal volume have been shown to improve patients’ pain and Oswestry scores. However, optimally measuring foraminal volume has been elusive and limited thus far. A multidisciplinary spine research team has developed a novel Finite Element Analysis 3D computational method of measuring foraminal volume using open-source animation software (Blender©). Purpose: To develop a tool that can measure foraminal volume and look at the effect of anterior interbody fusion device shape and placement on foraminal volume restoration. Material and Methods: 3D finite element models of L5-S1 segments were reconstructed from CT scans of patients with foraminal stenosis. The models simulated disc distraction by inserting interbody devices (IBDs) with posterior disc heights of 6, 8, and 10 mm and lordosis of 20° or 30° (i.e.,6x20, 6x30). After creating an icospheric mesh to fit at the neural foramen, Shrinkwrap and Boolean modifiers were applied and molded the mesh to the foramen’s narrowest areas. Volume of the mesh was then calculated by the software. Results: Foraminal volume increased from its baseline value by 67% and 97% for the 6x20 and 6x30 IBDs and by 99% and 136% for the 8x20 and 8x30 IBDs, respectively. 10x20 and 10x30 IBDs resulted in the largest foraminal volume increases from baseline (145% and 201%). Conclusion: Computational foraminal volumetric modeling measurement technique has the potential for objective, reproducible assessment of neural foraminal stenosis. Measuring foraminal volume with 3D computational modeling provides a repeatable quantitative measure of the narrowest portion of the neural foramen., Introduction: Early onset scoliosis (EOS) adversely impairs pulmonary function by reducing thoracic volume (TV). Surgical treatment with growing rods (GR) controls curve progression and simultaneously allows for continued spinal growth via sequential lengthening until definitive fusion. However, the impact of growing rod lengthening on thoracic volume is unknown. A multidisciplinary spine research team has developed novel methodology to obtain patient-specific thoracic volumes from conventional orthogonal radiographs using open-source 3D graphics and animation software which has been validated to be accurate within 4% of CT scans. However this method proved to be lengthy (4-8 hours/model) so our team developed registration software to semi-automatically compute thoracic volumes cutting down processing time by half. Purpose: Computational thoracic volume modeling using investigator-developed registration software that interfaces with open source 3D graphics software (Blender©), to determine if TV increases with sequential lengthening in growing rod treatment for Early Onset Scoliosis patients. Material and Methods: A graphical interface software was developed to perform 3D reconstruction of the thorax from biplanar xrays and automatically calculate thoracic volume in Blender©. Software converted registered points on the biplanar xrays to a 3D model. Thoracic volume was calculated from 2 sequential PA and lateral thoracic xrays preop and post-GR lengthening. TV was correlated with T1-T12 height and Cobb angle respectively. Results: 4 EOS patients (2 boys, 2 girls) were aged 6, 6, 1 and 10 years before surgery. There was a substantial increase in TV from baseline by 9.6, 26.7, 5.4 and 5.6% then by 26.8, 53.6, 20.8 and 26.9% respectively in two selected Lengthening Procedures. There was a significant correlation between TV and T1-T12 height (r = 0.94; P < .01) but no significant correlation with Cobb angle (12-78 degrees). Conclusion: GR treatment for EOS substantially contributes to TV increase from 10% to 27% as the child grows based on a semi-automated computational model. Other contributing factors in a growing child most likely play a role in thoracic development; thus clinical correlation studies with larger samples are recommended., Introduction: The surgical correction of severe sagittal spine imbalance is often the only way to release patients’ back pain and to improve their quality of life. Pedicle subtraction osteotomy (PSO) has become the procedure of election for a variety of diseases, demonstrating high potential for sagittal correction (up to 40°) and long-term fusion upon instrumentation with posterior fixation and anterior interbody cages. However, PSO is related to frequent post-operative complications, in particular rod breakage (rate 16%-39%) and nonunion (12%-31%).1-3 The prevention of these phenomena traditionally passes through a trial-and-error approach based on surgeons’ experience rather than on a clear understanding of the biomechanical implications of the adopted hardware configuration.1-5 The aim of the study is, therefore, to study the biomechanics of alternative scenarios related to the instrumentation of a destabilized spine segment after PSO at lumbar level. Alternative 2-rods, 3-rods and 4-rods configurations are compared, discussing the usage of accessory (connected to primary rod) or satellite (independently anchored) rods and of interbody cages adjacent to the osteotomy. Material and Methods: A lumbar finite element model of a patient with flat-back was developed and validated.7 PSO leading to an overall lordosis correction of 30° was reproduced at L3. Different hardware configurations useful to treat the destabilization following PSO and inspired to the current clinical literature were compared: a simple 2-primary-rod configuration, 2-rods + 1 accessory rod, 2-rods + 1 satellite rods, 2-rods + 2 accessory rods, 2-rods + 2 satellite rods.2 The usage of interbody cages adjacent to PSO level was also studied. Standing condition (compressive force of 500 N along the spinal curvature) and superposed bending moments of ±7.5 Nm in flexion-extension, lateral bending and axial rotation were simulated. The range of motion (ROM), the stress/loads acting on the spinal rod and the force transmitted anteriorly on the osteotomy rims and posteriorly on the instrumentation were calculated and compared across different scenarios. Results: A significant ROM reduction, but comparable across different scenarios, was found for all the models with respect to the intact state. Using additional rods (2-rods vs. 3-rods vs. 4-rods) gradually increases the loads on the posterior instrumentation, while reducing the local stress on the spinal rods at the osteotomy level and the load transmitted through the anterior spine. As concerns the secondary rods technique, using 2 satellite rods decreases the stress on the primary rods more than using accessory rods. 4-rods configurations supplemented with interbody cages above and below the osteotomy level leads to the lowest stress and loads on the posterior instrumentation, while increasing the loads on the anterior spine. Conclusion: Hardware configuration greatly influences the biomechanics of a PSO-destabilized segment. The usage of secondary rods and interbody cages can effectively reduce the loads on the instrumentation, being beneficial to reduce rod breakage and avoid nonunion in clinical practice. Our findings provide a clear and detailed biomechanical insight of the clinical experience related on the instrumentation of PSO.2,6 References 1. Luca A, Lovi A, Galbusera F, Brayda-Bruno M. Revision surgery after PSO failure with rod breakage: a comparison of different techniques. Eur Spine J. (2014) 23 (Suppl 6): S610–S615. 2. Smith JS, Shaffrey E, Klineberg E, Shaffrey CI, Lafage V, Schwab FJ, Protopsaltis T, Scheer JK, Mundis GM Jr, Fu KM, Gupta MC, Hostin R, Deviren V, Kebaish K, Hart R, Burton DC, Line B, Bess S, Ames CP; International Spine Study Group. Prospective multicenter assessment of risk factors for rod fracture following surgery for adult spinal deformity. J Neurosurg Spine. 2014 Dec;21(6):994-1003 3. Smith JS, Shaffrey CI, Ames CP, Demakakos J, Fu KM, Keshavarzi S, Li CM, Deviren V, Schwab FJ, Lafage V, Bess S; International Spine Study Group. Assessment of symptomatic rod fracture after posterior instrumented fusion for adult spinal deformity. Neurosurgery. 2012 Oct;71(4):862-7. 4. Berjano P, Bassani R, Casero G, Sinigaglia A, Cecchinato R, Lamartina C. Failures and revisions in surgery for sagittal imbalance: analysis of factors influencing failure. Eur Spine J (2013) 22 (Suppl 6): S853–S858. 5. Scheer JK1, Tang JA, Deviren V, Buckley JM, Pekmezci M, McClellan RT, Ames CP. Biomechanical analysis of revision strategies for rod fracture in pedicle subtraction osteotomy. Neurosurgery. 2011 Jul;69(1):164-72. 6. International Spine Study Group et al. Reducing rod breakage and nonunion in pedicle subtraction osteotomy: the importance of rod number and configuration in 264 patients with 2-year follow-up. Proceedings of the NASS 30th Annual Meeting / The Spine Journal 15 (2015) 87S–267 S. 7. Ottardi C, Galbusera F, Luca A, Prosdocimo L, Sasso M, Brayda-Bruno M, Villa T. Finite element analysis of the lumbar destabilization following pedicle subtraction osteotomy. Med Eng Phys. 2016 May;38(5):506-9., Introduction: Adult spinal deformity (ASD) consists of coronal and sagittal spinal misalignment. These severe deformities change the entire trunk shape. As a consequence, the shape of the abdomen is modified. Xipho-pubic angle (XPA) was used, in a previous study, as a measurement of anterior abdominal wall fascial lengthening after spinal sagittal correction. The aim of our study is to demonstrate the relationship of sagittal spinal deformity to the shape of the abdomen and to evaluate the association between parameters of abdominal deformity and sagittal alignment measures and the related clinical outcomes. Material and Methods: Cohort retrospective multi-center study (International Spine Study Group database). The population, stratified in three groups (“A”, “B” and “C”) according to XPA cut-off values (103° and 113°), was compared in terms of Xypho-pubic distance (XPd), sagittal spinal parameters and health-related quality of life score (HRQoL). Patients demographics included age, gender, body mass index (BMI), patients’ reported outcomes (PRO) (Oswestry Disability Index -ODI-, the Scoliosis Research Society-22 Patient Questionnaire -SRS-22r-, Short Form-36 -SF-36- Mental -MCS- and Physical -PCS- Component Scores. Results: A total of 278 patients with a mean age 57.67± 13.39, BMI of 26.58 ± 5.15 and 85.9% of females were included in the study. Of the 278 patients, 83 (29.9%) had XPA ≥ 113° (group “A”), 63 (22.7%) had XPA between 103,01° – 113° (group “B”) and 132 (47.5%) with a value of XPA < 103° (group “C”). Differences statistically significant were found comparing the three groups in term of XPd (all, P < .01), sagittal spinal parameters (PI-LL, PT and SVA: all, p < 0.01), and HRQoL (ODI, SF-36 PSC and SRS Activity: all, P < .05). In particular patients with lower degree of XPA were associated with greater sagittal deformities, poorer health status and shorter XPd. Conclusion: Spinal deformity clearly affects the abdominal cavity configuration in term of xipho-pubic distance. Furthermore, XPA is parameter strongly related with XPd, sagittal spino-pelvic parameters and HRQoL scores. The regression analysis shows that XPA of 113º is correlated with ODI of 20 and defining this cut-off value as indicator of minimal disability., Introduction: The occurrence of Golden ratio or Phi number has been observed in several aspects of the nature. In the human body, several examples of Golden proportion have been documented such as face and dental geometry, extremity and hand fingers bone length proportion, cardiac cycle sequences and DNA gene-coding region sequences, as to mention just a few of them. The pathogenesis of idiopathic scoliosis has so far remained elusive and purely understood despite decades of dedicated research into its origin. Over the years, practically every structure of the body has been incriminated from the collagen-type of the back muscles to the deep centers of the central nervous system, from the melatonin levels to genetically induced disorder. Despite all these efforts, however, no single cause of this intriguing disorder has been defined and, frequently, it has been difficult to distinguish causative factors from those that may result from the condition. Material and Methods: A consecutive search of vertebral column images from two different hospital radiology databases was done ranging from January 2012 to December 2015. Female and male subjects were included into the search with the upper cut-off age of 55 years. The measurements included the height of the anterior and posterior aspects of the vertebral bodies and the diagonal line connecting the posterior-superior corner with the anterior-inferior corner of the vertebral body. The images were viewed and measured on the hospital database using on-site DICOM image viewer. The measurement of the proportion was calculated by dividing the anterior-inferior corner to posterior-superior corner distance with the mean value of the sum of anterior and posterior vertebral height. The study included images from 464 individuals for a total of 1112 vertebras measured (232 thoracic and 878 lumbar) that were divided in three different groups by age and scoliosis pathology: Young non-scoliosis subjects, Adult non-scoliosis subjects and Scoliosis subjects (young and adult) for 30, 334 and 100 subjects in each group, respectively. Inter- and intra-observer reliability checking was done for the measurements of reliability validation. Results: The initial theoretical hypothesis of this study was the idea that a φ or golden proportion number (1618) could exist in the morphometric proportions of the vertebra as seen on the lateral X-ray images. This study confirmed this hypothesis showing that the mean of the sum of the thoracic and lumbar vertebral bodies, 1.599, did fall into a tolerance range of acceptance of 1.17% from the golden proportion validity range. However, while performing the study, an interesting, collateral observation was found. A significant and steady difference was observed in the proportional values of the vertebras of individuals affected with idiopathic scoliosis as compared to individuals not suffering this pathological condition. The mean proportional value for the vertebras measured in individuals affected with idiopathic scoliosis was found to be 1.494 that was 6.7% less than the values of the non-scoliotic patients and 7.7% less than the φ value. And that was true for both adult and young patients, indifferently. Conclusion: The authors do recognize, being vertebrae a tri dimensional object, that there are many lines one can play with and, finally, will be able to find a golden proportion correspondence. Consequently, we do not state that the vertebra has a shape or measures such as to be surely classified in the golden proportion objects category, however, it is our opinion that the proximity to the φ number can be regarded as extremely high. We do, however, state that we have found a steady proportion, that can be easily calculated on lateral X-ray images, that shows a significant change between the vertebrae of the individuals not affected and those affected by idiopathic scoliosis. What might be the anatomical or pathological significance of these different values is probably still to be defined. The personal opinion of the authors of this study can be condensed in two main thoughts: the first one is that this proportional difference could be an easily accessible clinical tool to differentiate those individuals at risk of developing idiopathic scoliosis and the second, more futuristic idea, is that the different proportional shape of single rectangular elements forming an erect chain might have a different stability pattern, potentially explaining why the spine tends to curve developing scoliosis, a disease whose origin is still lacking a definitive understanding., Introduction: The number of spine surgeries is on increasing trend over the recent past, few of the reasons being rise in technologies and number of surgeons performing spinal surgeries. But how far the surgeon’s health is affected in the process is not clearly understood. Forward head posture (FHP) is a clinical entity leading to neck pain which is regularly affecting the younger generation due to the usage of smart phones. FHP can also affect the spine surgeons over the period. Material and Methods: Prospective study conducted at our institute on 3 spine surgeons with different experience levels. Running video of the surgery was recorded at an angle perpendicular to the operative field. Palpable C7 spinous process was marked on the surgeon’s neck pre-operatively. Post operatively all the videos involving three surgeons were analysed. Duration of the whole surgery was divided into different phases (exposure, fixation, decompression, fusion, closure). Time taken for different phases in the surgery was also noted. Snapshots of the video were taken whenever the surgeon changes his position and using surgimap version 2.2.9.9.4 all images were calibrated. Head flexion angle(HFA), neck flexion angle (NFA), cranio-vertebral angle (CVA) along with average load on spine during the surgery of all the three surgeons were calculated. Results: The height of the surgeons was 184 cm, 178 cm, 170 cm. On an average, HFA of the surgeon remained around 140 degrees for all the phases. NFA ranges from 70-90 degrees with highest being for the tallest surgeon. CVA remained less than 15 degrees in all phases for the entire surgery part. The distance between center of ear to center of the shoulder blades was ranging between 80.47 mm to 204.65 mm. Duration for exposure is 40 ± 5.3 min, fixation (each screw) is 6 ± 3.5 min, decompression (each level) is 10 ± 3 min and for closure is 15 ± 6.4 min. Average load on spine has been more than 60 pounds at all times during the surgery. Conclusion: When the neck stays in such a position on a daily basis, there is a huge pressure on the surgeon’s neck making it highly vulnerable. Based on the above study we propose an entity called surgeons neck syndrome affecting the spine surgeons who are at risk of aggravating the degenerative pathology over the years., Introduction: Full comprehension of spinal pathologies and treatment strategies cannot be achieved without an understanding of the underlying spinal vertebral biomechanics. This is achieved by understanding the biomechanics in a normal subject and then assessing how the particular pathology has caused a deviation from normal.1,2 The intervertebral foramen (IVF) have fixed boundaries though its dimensions vary depending on the height of the individual disc spaces.3 Changes to the disc morphology can therefore cause reduced IVF diameters.4 The aim of this study is to identify the variations in area of the intervertebral disc (IVD) and the intervertebral foramen (IVF) during low trunk rotation in healthy volunteers. This will provide normal variant data and further our understanding on the effect of lumbar spine rotation on neural compression and the patho-biomechanics of low back pain. Material and Methods: Study Design: In vivo Kinematic MRI study of the changes in the dimensions of the Lumbar Intervertebral Discs and Neural Foramens during trunk rotation. Ten healthy male volunteers aged 20-30 years old with no history of spinal pathology were recruited. Each volunteer underwent an MRI scan of the lumbar spine in three positions; neutral, right lateral rotation and left lateral rotation. All volunteers provided written consent and ethical approval was obtained. The Sagittal T2 weighted images were used to assess the intervertebral foramen and intervertebral discs of the volunteers at the L3/L4, L4/L5 and L5/S1 intervertebral level. Image J software magnified the images x600 in order to manually outline the boundaries of the IVF, parasagittal disc (PSD) and midsagittal disc (MSD). These images were then used to calculate the area, width and height of these structures in the neutral, right lateral and left lateral position. Results: This study has shown that the area, height and width of the intervertebral foramen and intervertebral discs at L3/L4, L4/L5, and L5/S1 alter significantly in response to left and right lateral rotation of the lumbar spine as compared to the neutral position. During rotation the area and width of the IVF of L3/L4 and L4/L5 decrease on the rotated side (P < .005). The IVF height of L3/L4 also decreases whereas the height of L4/L5 increases (P < .005). The IVF area, width and height of L5/S1 increase on the rotated side. Reciprocal changes were seen at the IVF on the opposite side. Rotation significantly reduced the parasagittal intervertebral disc area at all levels and on both sides (P < .005). On the rotation side there was an associated increase in the intervertebral disc height at L3/L4 and an increase in width at both L3/L4 and L4/L5 (P < .005). Conclusion: Rotation of the lower trunk caused morphologic changes in the intervertebral discs and intervertebral foramens at the L3/L4, L4/L5, and L5/S1 levels. This provides us with normal variant data and furthers our understanding on the treatment benefits of manipulation therapy in spinal conditions. References 1. Fujimori T, Iwasaki M, Nagamoto Y, Ishii T, Masafumi K, Murase T, Sugiura T, Matsuo Y, Sugamoto K, Yoshikawa H. Kinematics of the thoracic spine in trunk rotation. Spine. 2012:37(21): E1318-E1325. 2. Fujii R, Sakaura H, Mukai Y, Hosono N, Ishii T, Iwasaki M, Yoshikawa H, Sugamoto K. Kinematics of the lumbar spine in trunk rotation: in vivo three-dimensional analysis using magnetic resonance imaging. Eur Spine J. 2007:16(11):1867-1874. 3. Crock HV. Normal and pathological anatomy of the lumbar spinal nerve root canals. J Bone Joint Surg Br. 1981;63B(4):487-490. 4. Fujiwara A, An HS, Lim T, Haughton VM. Morphologic changes in the lumbar intervertebral foramen due to flexion-extension, lateral bending, and axial rotation: an in Vitro Anatomic and Biomechanical Study. Spine. 2001;26(8):876-882., Introduction: No study to date has considered the curve pattern in terms of the Lenke classification during evaluation of cervical sagittal balance. In the present study, we sought to correlate curve patterns with cervical sagittal parameters in adolescent patients with idiopathic scoliosis. Materials and Methods: This was a cross-sectional, retrospective descriptive study. We collected information from medical records and evaluated lateral panoramic X-rays of 49 scoliosis patients. Data were quantitatively evaluated using the Cobb of C2-C7, the distance from the head center of gravity to C7, the T1 slope and the thoracic inlet angle, neck tilt, C7-S1 SVA, principal curve angle, the proximal Cobb thoracic curve, the Cobb thoracolumbar/lumbar curve, and kyphosis at T1-T12. All results were tabulated and statistically analyzed to objectively evaluate the relationship between thoracic spinal alignment in the sagittal plane and cervical sagittal balance. The significance level was set to 5%. Results: The T1 slope differed significantly among the various kyphosis sagittal modifiers (P < .05); this parameter clearly varied by the type of modifier. Inverse correlations were evident between the T1-T12 kyphotic index and the Cobb C2-C7; and between the T1 slope and the Cobb C2-C7. Both relationships had r values > 0 and P values < .05. Conclusions: The cervical lordosis values were lower than the normal values described in the literature, suggesting loss of cervical sagittal lordosis in our patients. The T1 slope was significantly associated with changes in sagittal alignment, and varied by the curve type and the sagittal modifiers in play., Introduction: Although three-column osteotomy (3CO; pedicle subtraction osteotomy [PSO] or vertebral column resection [VCR]) can provide powerful alignment correction and disability improvement in adult cervical deformity (ACD), these procedures are complex and associated with high complication rates. Previous reports on complications associated with 3CO for ACD have been primarily based on retrospective complication collection, which may substantially underestimate the true rates. Our objective was to provide a prospective assessment of cervical alignment improvement and complications in ACD patients treated with 3CO. Materials and Methods: Although three-column osteotomy (3CO; pedicle subtraction osteotomy [PSO] or vertebral column resection [VCR]) can provide powerful alignment correction and disability improvement in adult cervical deformity (ACD), these procedures are complex and associated with high complication rates. Previous reports on complications associated with 3CO for ACD have been primarily based on retrospective complication collection, which may substantially underestimate the true rates. Our objective was to provide a prospective assessment of cervical alignment improvement and complications in ACD patients treated with 3CO. Results: All 24 ACD patients treated with 3CO (15 PSO/9 VCR) achieved minimum 90-day follow-up (71% women, mean age 62 years, previous surgery in 54%). Diagnoses included: cervical sagittal imbalance (92%), cervical kyphosis (38%), proximal junctional kyphosis (17%), coronal deformity (8%) and distal junctional kyphosis (4%). The mean number of posterior fusion levels was 13, and 4% also had an anterior fusion. The most common 3CO levels were T1 (38%), T2 (29%) and T3 (21%). A total of 25 (19 major/6 minor) complications were reported, with 14 (58%) and 6 (25%) patients affected, respectively. Overall, 17 (71%) patients had at least one complication. The most common complications were excessive blood loss (>1.7 L, 25%), neurologic deficit (17%), distal junctional kyphosis (DJK, 8%), wound infection (13%), and cardiorespiratory failure (8%). Four (17%) patients required re-operation within 90-days (2 for nerve root motor deficit, 1 deep wound infection, 1 implant pain/prominence). Cervical sagittal alignment improved significantly following 3CO: cervical lordosis (CL, 3° to 13°, P = .031), C2-7 sagittal vertical axis (66 mm to 44 mm, P < .001), and T1 slope minus CL (46° to 27°, P < .001). Conclusions: Among 24 ACD patients treated with 3CO, cervical sagittal alignment improved significantly following surgery. Overall, 17 (71%) patients had at least one complication (19 major/6 minor). The most common complications were excessive blood loss (>1.7 L), neurologic deficit, DJK, wound infection, and cardiorespiratory failure. Future research focused on reducing these complications may present the greatest opportunities for safety and cost improvements for these procedures., Introduction: Despite the potential for profound impact of adult cervical deformity (ACD) on function and health-related quality of life, there remains a paucity of high-quality studies that assess outcomes of surgical treatment for these patients. Our objective was to assess outcomes following surgical treatment for ACD based on a prospective multicenter consecutive case series. Materials and Methods: Surgically treated ACD patients eligible for 1-year follow-up were identified from a prospectively collected multicenter database. Baseline deformity characteristics, surgical parameters, and 1-year outcomes were assessed. Standardized outcome measures included: Neck Disability Index (NDI, range 0-100), neck pain numeric rating scale (NRS) score (range 0-10), and EQ-5D index (range 0 -1) and subscores (range 1-3). Paired sample t-tests were used to compare 1-year and baseline measures. Results: Of 77 ACD patients, 55 (71%) had 1-year follow-up (64% women, mean age 61 years, mean Charlson Comorbidity Index [CCI] of 0.6, previous cervical surgery in 44%). Diagnoses included: cervical sagittal imbalance (62%), cervical kyphosis (60%), proximal junctional kyphosis (8%), and coronal deformity (10%). Posterior fusion was performed in 85% (mean number of vertebral levels=10), and anterior fusion was performed in 29% (mean number of vertebral levels = 5). Three-column osteotomy was performed in 24% of patients. Mean operative time was 6.5 hours and mean estimated blood loss was 0.9 L. At 1-year following surgery, ACD patients had significant improvement in NDI (50.5 to 38.0, P < .001), neck pain NRS (6.9 to 4.3, P < .001), EQ-5D index (0.51 to 0.66, P < .001), and EQ-5D subscores: mobility (1.9 to 1.7, P = .019), usual activities (2.2 to 1.9, P = .007), pain/discomfort (2.4 to 2.1, P < .001), anxiety/depression (1.8 to 1.5, P = .014). A nonsignificant trend favoring improvement was observed for EQ-5D self-care (1.5 to 1.3, P = .070). Compared with patients that achieved 1-year follow-up, those lost to follow-up did not differ significantly with regard to age, gender, CCI, number of fused anterior or posterior vertebral levels, or baseline NDI, neck pain NRS, or EQ-5D scores. Conclusions: Based on a prospective multicenter series of adults with cervical deformity, surgical treatment provided significant improvement in multiple measures of pain and function, including the NDI, neck pain NRS score, and EQ-5D. Further follow-up will be necessary to assess the durability of these surgical procedures and the resulting improved outcomes., Introduction: The understanding of normative values of the radiographic parameters is important for the understanding of spinal deformity and for the establishment of radiographic thresholds in the setting of sagittal realignment surgeries. In the setting of adult spinal deformity, recent literature has demonstrated the role of the cervical alignment on the context of global spinal deformity. However, the vast majority of data about cervical alignment were based solely on a homogeneous North-American cohort, not taking into account the diversity in age, ethnicity, and geographic locales. The aim of this study is to investigate the normative values and chain of correlations across cervical sagittal parameters in a Brazilian population sample. Material and Methods: This is a prospective observational study including adult asymptomatic subjects who underwent full spine radiographs. The subjects were stratified by age into 3 groups (18-39 y/o, 40-59 y/o, and ≥ 60 y/o) and radiographic parameters were compared across age groups, using ANOVA, and gender, using student t-tests. The relationships across various radiographic parameters were calculated by the Pearson product-member correlation coefficients. A significance level of p < 0.05 was adopted. Results: 130 asymptomatic volunteers (mean 48y) met the inclusion criteria and were evaluated. The mean and range of cervical sagittal parameters in normative Brazilian population were identified. Subjects ≥ 60 y/o had significantly higher values for C7-SVA (P = .024) than the two younger age groups. Cervical Lordosis (CL) presented negative correlation with CSVA (r = -0.182; P = .038) and positive correlation with T1-Slope (r = 0.425; P < .001). A significant positive correlation occurred between C7-SVA and T1-Slope (r = 0.335; P < .001), between CSVA and T1-Slope (r = 0.445; P < .001) and between CSVA and T1-Slope minus CL (r = 0.480; P < .001). Multilinear regression analysis applied to predict the CSVA identified the CL and T1-Slope playing a significant influence in the CSVA (P < .001) and leading to the predictive formula: CSVA= -0,434xCL + 0,968xT1-Slope. Conclusion: This study is the first to describe normative values of cervical sagittal parameters in Brazilian population. The chain of correlation between these parameters was confirmed. The CSVA can be predicted by two different postural parameters, Cervical Lordosis and the T1-Slope., Introduction: Spondylolysis in the cervical spine is a rare condition. Only few cases were reported in the literature. Its association with osteopetrosis has been described by some authors but remains exceptional; it is most often indicative of the disease. We presented the case of a cervical spondylosis in a patient with osteopetrosis. Methods: We reported the case of a 20 year-old woman, followed for a left femur stress fracture on osteopetrosis treated conservatively, which consults for bilateral cervicobrachial Neuralgia following accidental hyperextension of the cervical spine. The clinical examination found a paravertebral muscular contracture, associated with painful upper cervical spines spinous processes on palpation. Neurological examination was normal. Radiological assessment by AP and lateral X-rays and a CT scan showed a C2 spondylolysis. In the absence of signs of instability on dynamic X-rays, the patient was treated conservatively. Results: At a 2 years follow-up, there was no signs of cervical instability with the persistence of an intermittent neck pain. Conclusions: Spondylolysis with or without spondylolisthesis is rare in the cervical spine. It was reported for the first time by perlman in 1951 which was described as a defect of the pars interarticularis, in the junction between the upper and lower articular processes. The presence of these lesions in patients suffering from osteopetrosis was recognized by suziki and szapanos since the eighty’s. The cause of this spondylolysis remains controversial with congenital theory based on the association of embryonic developmental abnormalities in these newborns, however autopsies of patients did not reveal spondylolysis. Only a dozen cases have been reported in the literature. In a series of seven patients published in 1998 by martin only two had a cervical spondylolysis and a case reported a multiple locations spondylolysis. Clinically, the lesion is usually asymptomatic. It’s found incidentally on cervical X-rays after a benign trauma. Treatment can be sufficient with a cervical collar but this treatment can be considered only if there is no signs of instability on dynamic X-rays of the cervical spine, as in our case. A case of posterior C1-C4 fusion has been reported in the series of Martin but with an evolution towards nonunion after a two years follow-up. Osteopetrosis should be recognized as a cause of pathological spondylosis that may affect the cervical or lumbar spine, especially in children. Orthopedic treatment represent a successful option when there is no signs of instability associated., Introduction: The goal of our study was to determine the incidence of adjacent segment level pathology preoperatively in patients with Klippel-Feil syndrome (KFS) and compare it to the incidence in patients who have undergone anterior cervical discectomy and fusion. Secondarily, we hypothesized that patients with KFS and anterolisthesis would be more likely to develop symptomatic and radiological adjacent segment level disease. Methods: Twenty patients with Klippel-Feil syndrome from a single institution were followed for X years. Serial imaging and follow-up (serial visits) were used to determine adjacent segment level disease. Patients were separated in two categories: those with anterolisthesis adjacent to their congenitally fused segments and those without. Results: Twenty patients with an average age of 9.5 yrs were identified. The average follow-up period was 33 months; range 4-108 months. Nineteen patients received a diagnosis of KFS during incidental imaging. One patient was diagnosed as part of a workup for myelopathy caused by a disc herniation adjacent to two fused segments. Eight patients had no listhesis in cervical levels adjacent to fused vertebral segments while 12 had listhesis. The two most common levels of listhesis were at C3-C4 and C4-C5 (five patients each). Five patients in the listhesis group had an increase in listhesis through the follow-up period. There were no differences in the development of symptoms between patients who had and did not have listhesis. All non-operative patients were asymptomatic at last follow-up. Conclusion: Our follow-up was limited, but this study does not support the assumption that a congenitally fused segment predisposes a patient to a rate of adjacent segment level disease similar to patient who has undergone an anterior cervical discectomy and fusion. We found no increased risk of symptomatic adjacent segment level disease in KFS patients who had anterolisthesis adjacent to a congenitally fused segment., Introduction: Wry neck or loxia which is a systolic condition can be known as a fixed or dynamic tilt, rotation or flexion of head and neck which was defined by Tubby in 1912. It can be classified due to the position of head and neck in to; laterocollis, rotational torticollis, retrocollis. As a whole it can be typed to congenital, acquired and spasmotic. Muscular fibrosis, congenital spine abnormalities or toxic and traumatic brain injury are some conditions which can lead to this problem. Basically, the cause of congenital torticollis is unknown. The most problematic part is sternocleidomastoid which is shorter than usual or excessive contracted can lead to both limited rotation and lateral bending. The incidence of congenital torticollis is 0.3-2%. Both males and females are equally affected and no racial preference is seen, and no worldwide geographical restriction is noted. First line of treatment at a very young age is physical therapy by stretching and strengthening to improve the muscle, but most of the cases require surgical intervention to release the muscle with better result in ages 1-4. Around 80-90% of CMTs are also associated with skull distortion causing craniofacial asymmetry, and between 10-20% of the cases with hip joint malformations. Although assymetry is one of the most common condition in these patienst, little is known about craniofacial assymetry prevalenc and its changes due to aging. After occurance of permanent deformity like plagiocephaly and hemihypoplasia, and even without potential of growth and remodeling, opperative treatment may of little value. We report a 24 year old girl with neglected torticollis with her postoperative results. Case Report: A 24-year-old girl suffered from congenital torticollis was examined. She had asymmetry in her face and maxillofacial complex. She had crossbite and posterior openbite which makes some problems in masticatory muscles unilaterally. Results: Clinical manifestations in an adult patient suffered from congenital torticollis. Conclusion: Postoperation better results can be achieved maxillofacial deformities were considered. Physiotherapy for this part and treatments for tempromandibular joint could be useful to have more stable results., Introduction: The Fallen Head Syndrome (Dropped Head Syndrome [DHS]) is a little condition described in the literature, relatively rare. It has epidemiological data linked to specific diseases, but not in general. It can affect patients of any age but predominantly in the elderly, in a ratio of 3:2 between men and women. It has several etiologies including myopathies, neuropathies, joint diseases neuromuscular, metabolic and neurological. Its pathophysiology is also not well understood, it is believed to be caused by weakness of the extensor muscles of the neck contracture of the flexor muscles or a combination of these changes. When no underlying pathology can be diagnosed, receive the name Isolated myopathy Neck Stretcher (isolated neck extensor myopathy [INEM]). The case in question it is young patient underwent surgical treatment scoliosis, who left outpatient treatment after consultation return, evolving, after about a year and a half, with DHS. Material and Methods: It is clinically examined the patient, applied to new radiographs, comparing with earlier; held review of medical records and literature, and register through photographs after signing the consent form. Results: With diagnosis of neuromuscular scoliosis, was submitted on 11 October 2014, surgical treatment for posterior approach of the thoracic and lumbar curves. Attends return visit on 27 October 2014, keeping postoperative evolution habitual. However interrupts outpatients, returning only on 23 June 2016. Nesta consultation showed deformity spinal flexion cervical (“chin on chest”). Surgical treatment in two stages: 1) Installation cervical traction halo; 2) cervical arthrodesis. The literature describes the DHS as a relatively rare condition that occurs predominately in patients elderly. In some cases you can identify a neurological underlying disease, inflationary or metabolic, with other associated systemic symptoms, such as example weakness of other muscle groups in addition to the neck extensors. Conclusion: The DHS is a condition associated with several etiologies, with significant impact on quality of life of patients. It takes effort to the scientific community elucidation of remaining knowledge gaps., Introduction: Concave apical pedicles in scoliosis are known to be narrow and dysplastic. Neural structures too, are known to migrate towards concavity. This leaves little room for error while inserting pedicle screws. Present study aimed to assess relative advantages of inserting concave apex screws vis-à-vis other constructs. Materials and Methods: This was a retrospective analysis of prospectively collected single-surgeon, single centre data. Patients (n = 61) undergoing scoliosis surgery from September 2004 to September 2013 were included. Exclusion criteria were pseudarthrosis, implant failure, kyphoscoliosis and postoperative infection. Curves were classified into two groups; group A-without screws anchoring concave apex and group B-with screws anchoring concave apex. Group A had varied constructs including some with sublaminar wires on concave apex and some with screws only on convex apex. Results: Based on inclusion-exclusion criteria, 86 individual curves in 59 patients were selected; group A (n = 54) and group B (n = 32). Both groups were comparable in terms of follow-up period, age, sex and etiology (idiopathic and nonidiopathic). However, group A had larger (79.8+25.20) and more rigid curves (28.6% flexibility) than group B (51.8+16.30 with 51.1% flexibility). Hence, immediate postoperative correction was less significant in group A (53.8%) vis-à-vis group B (65.8%) (2-tailed P = .0075). However, no statistically significant difference was noted between the two groups in terms of gains of instrumented correction over and above preoperative flexibility (group A-23.4%, group B-13.5%) (2-tailed P = .21). At a median follow-up of 12 months, loss of correction between the two groups (A:1.4%, B:7%) was not significantly different (2-tailed P = .06). No patient in either group had any neurological deterioration. Conclusions: Over a relatively short follow-up period, the present study could not demonstrate any gains in using apical concave pedicle screws. A larger, prospective, multicenter study with a longer follow-up may shed more light on the risk-benefit ratio., Introduction: Growth guiding instrumentation is the current and perspective option for early onset scoliosis (EOS) correction. The purpose of this study is to review 15 years results of growth guiding instrumentation in EOS patients. Methods: We retrospectively evaluated 55 EOS cases treated in a single clinical center with growth guiding implant developed by us, from the index surgery to the final fusion. Diagnosis were: infantile idiopathic scoliosis, juvenile idiopathic scoliosis, Congenital scoliosis, Spondyloepiphyseal dysplasia. Radiographs were reviewed for major and minor Cobb angles, thoracic kyphosis and lumbar lordosis. Mean growth of the instrumented spine and complication were recorded. Results: Complete clinical chart of 55 cases were available during the follow-up period. 43 patients underwent anterior convex epiphysiodesis and posterior growth guiding instrumentation. In remaining 12 patients transpedicular growing instrumentation utilized. Derotational maneuver used for the curve correction in all cases. Mean age at the index surgery was 9,8 years and at the final fusion it was 14,3 years. Major Cobb angle improved from 69,6 to 23,7, minor Cobb angle improved from 46,4 to 16,1. Preoperative thoracic kyphosis was 25,1 and changed to 29,1 after final fusion. Lumbar lordosis was 37,8 and 34,9 at the end of follow-up. Mean growth of the instrumented spine was 7,2 mm/year. The most common complications were proximal junction kyphosis (4 cases), upper anchor displacement (4 cases) with rod migration out of the upper anchors due to rapid spinal column growth (5 cases), loss of correction (3 cases) and rod breakage (1 case). Conclusion: Combination of anterior convex epiphysiodesis and posterior growth guiding instrumentation is reliable concept for the EOS correction and spinal column growth preservation. In selected cases, transpedicular growing instrumentation without anterior epiphysiodesis may be used. Postoperative complications were minor and manageable., Introduction: Use of all- pedicle screw instrumentation in adolescent idiopathic scoliosis surgical treatment allows to obtain significant improvement in clinical and radiographic results. Significant variability is reported in medical literature about the ideal screw density in order to obtain the optimal correction and its maintenance over time. Aim of the study was to evaluate the percentage of curve correction and its maintenance over time comparing low versus high pedicle screw density. Material and methods: From January 2012 to November 2015, a continuous series of 65 patients underwent to posterior correction and instrumented fusion. Inclusion criteria were: adolescent idiopathic scoliosis, age, Introduction: Despite recent studies that have investigated risk factors for postoperative shoulder balance, very few work has paid attention to how do surgery and postoperative compensation impact on shoulder balance, especially in severe and rigid scoliosis, and the related risk factors remain unclear. To study the effect of surgery and postoperative compensation on shoulder balance in severe and rigid scoliosis, a retrospective study was conducted. Material and Methods: The parameters of preoperative, postoperative, and minimum 2-year follow-up radiographs of 48 consecutive patients with severe and rigid scoliosis who underwent posterior spinal fusion surgery were evaluated. We regarded radiographic shoulder height (RSH) as shoulder balance parameter and divided the patients into improved and aggravated groups of shoulder balance after surgery and at follow-up. And also, patients were divided into 9 groups based on different kinds of changes of shoulder balance after surgery and at follow-up. These parameters were compared to analyze factors for shoulder balance among groups. Results: The average Cobb angle and flexibility of the main thoracic curve (MTC) were 107.4° ± 15.9° and 16.4% ± 10.2% before surgery. The RSH were -17.37 mm ± 21.94 mm before surgery, 1.74 mm ± 22.11 mm after surgery, and 4.61 mm ± 18.27 mm at follow-up. After surgery, the preoperative flexibility of proximal thoracic curve (PTC) and Cobb angle of lumbar curve (LC) were significantly greater in the group of patients with aggravated shoulder balance. The improved shoulder balance group had significantly larger correction rate of the MTC and smaller correction rate ratio of the PTC to the MTC than the aggravated group after surgery. At follow-up, the flexibility of the PTC, and the correction rate ratio of the PTC to the MTC and the PTC to the LC, were significantly greater in the improved group. The aggravated group had larger correction rate of the LC and more distal adding-on than the improved group at follow-up. Conclusion: In severe and rigid scoliosis, the appropriate collocation of correction rates of the PTC, the MTC and the LC is very important for surgeons to make good correction of the shoulder imbalance at surgery and to maintain the shoulder balance at follow-up., Introduction: Spinal deformity correction surgery has been one of the most challenging procedure in spine surgery with high incidence of intro-operative complications. In order to decrease the rate of complication or prevent the complication, a retrospective study was conducted to analyze the risk factors of major complications after spinal deformity surgery. Methods: Between January 2011 and December 2014, 254 consecutive patients undergone spinal deformity surgery in our department were divided into two groups based on if they had major complications after surgery. Univariate and multivariate analysis (logistic regression) were used to identify the risk factors. Results: 29 patients had major complications after surgery. Univariate risk factors showed that Medical history, previous Scoliosis operation history, Preoperative neurological injury, the vertebral number of major Curve, Cobb of major curve, Kyphosis (>90 degree), Time of operation, Operative bleeding and osteotomy of group I were higher or longer than those of group II. VC MAX% and Orthopedic rate of group I were worse than those of group II. Logistic regression identified that Preoperative nerve injury(OR = 5.976); Medical history >10 years(OR = 4.095); Maximal voluntary ventilation observed/predicted5 h (OR = 3.510); osteotomy(OR = 3.472)were final risk factors for major complications. Conclusions: Major complications after surgery to treat spinal deformity can be predicted through preoperative nerve injury, medical history, maximal voluntary ventilation observed/predicted. Time of operation and osteotomy during the surgery. The patients with these risk factors need more preoperative care and postoperative care to reduce the occurrence of major complications., Introduction: Multiple techniques are utilized for distal fixation in patients with neuromuscular scoliosis. Although there is evidence of benefits with the S2-Iliac fixation technique, this remains controversial. The objective of this study is to evaluate the radiological outcomes and complications associated with this surgical technique in a pediatric population. Material and Methods: An observational retrospective case series study was designed. All pediatric patients between January 2011 and February 2014 diagnosed with neuromuscular scoliosis associated with pelvic obliquity, which required surgery with fixation unto S2-Iliac, were included. Clinical and radiological findings and complications were presented with measures of central tendency. Comparison of deformity correction was carried out using a non-parametric analysis for related samples (Wilcoxon signed-rank test). Significance set at P < .05. Results: A total of 31 patients diagnosed with neuromuscular scoliosis that met inclusion criteria were analyzed. The leading cause of neuromuscular scoliosis in 23 (74.2%) patients was spastic cerebral palsy. The correction of pelvic obliquity in the immediate postoperative period was of 76%, which is statistically significant. The extent of correction that patients maintained at the end of the follow-up was analyzed, and it was found that there were no significant differences in this magnitude, compared with the immediate postoperative pelvic obliquity; the Mean follow-up time was 9 ± 7 months. Regarding postoperative adverse events, occurred in 71% of patients, the most common outcome was pneumonia (21.2%). The overall rate of complications related to instrumentation was low (2.6%), that corresponds to one patient with an intra-articular screw in the left hip that required repositioning. Conclusion: S2-Iliac fixation for the treatment of neuromuscular scoliosis is a safe alternative, in which the onset of adverse events is related to the comorbidities of patients instead of the surgical procedure itself. An approximate correction of 76% of pelvic obliquity is maintained during the follow-up., Introduction: Selective fusion of thoracic and thoracolumbar/lumbar curves in adolescent idiopathic scoliosis is a concept critically debated in the literature. Our purpose of this study to evaluate efficacy of selective fusion criteria in Lenke 1C and 5C curves. Material and Methods: We analysed the prospective collected data of 22 adolescent idiopathic scoliosis operated at our institute from 2011 to 2015 with mean follow up of 2.4 years. Decision regarding selective fusion was taken based on preoperative radiological parameters. Apical vertebral translation, apical vertebral rotation, cobb angle ratio and kyphosis at different sagittal regions of spine measured and analysed. Patients were selected for selective fusion on the basis of criteria in literature for selective fusion and patient’s guardian informed consent. Radiological parameters like correction of cob angle, coronal decompensation, adding on, and junctional kyphosis were recorded during follow up. Functional outcome were measured with SRS-22 score. Results: 22 adolescent idiopathic scoliosis with mean age of 15.4 years and 20 patients were females. 14 patients were of Lenke 1C and 8 patients of Lenke 5C curves. Mean major Cobb’s angle was 67.4 degree and compensatory curve was 40.1 degree and final correction to 18.5 degree for major curve (72.5% correction)and 22.6 degree for compensatory curve(43.6% correction). Cobb correction was maintained during the follow up. One patient with coronal decompensation of 2.4 cm and junction kyphosis of 4 degree noted another one patient. None of them required revision surgery (no adding on). SRS-22 postoperative outcomes showed mean final score of 4.26. Conclusion: Selective fusion can be possible with careful study of preoperative x-rays. Larger prospective multicentre cohort is required for better understanding of selective fusion in scoliosis. Comprehensive selection criteria and patient acceptability are the major concerns of the selective fusion in scoliosis., Introduction: Neuromuscular scoliosis surgery, compared to idiopathic scoliosis, associates with a higher rate of complications such as infection and intraoperative bleeding. The objectives of this study are to evaluate short and mid-term outcomes of the surgical treatment of neuromuscular scoliosis. Material and Methods: A retrospective review of patients with neuromuscular scoliosis that underwent surgical treatment was conducted. We evaluated surgical technique, curve correction, early and late complications, reoperation rate and mortality. Results: A total of 33 patients (mean age 15 years, range 8-23 years) with neuromuscular scoliosis were treated surgically between 2013 and 2015. Most common diagnoses were cerebral palsy (30%) followed by Duchenne muscular dystrophy (12%). 72% of patients used brace previous to surgery. All surgeries consisted in a single posterior approach for posterolateral instrumented fusion. Pre and postoperative mean curve was 61 ± 23º and 18 ± 7º respectively. Mean surgical bleeding was 1216 ± 574 ml while surgical time was 271 ± 85 minutes. 54% of patients required intra and postoperative red blood cells transfusion. Average levels fused were 12 ± 2 and pedicular screw density was 78±12%. No intraoperative complications were reported. Eleven (33%) postoperative complications were reported and 81% were infectious type (36% surgical wound infections). With a mean follow-up of 305 ± 300 days, five patients required reoperation from whom four underwent surgical debridement because of wound infection. No deaths were seen. Conclusion: Surgical treatment of neuromuscular scoliosis is effective in deformity correction and balance restoration, however it is important to consider the high rate of complications associated., Introduction: Characteristic pelvic waddle gait has been described in high-grade spondylolisthesis in the past. To date, no study has been done to characterise gait pattern in high grade spondylolisthesis using modern 3D gait analysis. No study has been done to analyse change in gait, postoperatively in high grade spondylolisthesis using modern 3D gait analysis. Aim of this study was to carry out 3D gait analysis in high grade spondylolisthesis pre- and postoperatively to characterise gait pattern. Materials and Methods: This was a prospective interventional case series. Consecutive patients with high-grade (Meyerding grade 4) spondylolisthesis underwent pre and postoperative 3D gait analysis studies. Intervention carried out was posterior decompression + posterolateral instrumented fusion with partial reduction. Gait deviation index (GDI) score, Gait profile score (GPS) were used to analyse the gait. Common gait features in coronal, sagittal and transverse plane were noted pre operatively and compared to postoperative changes. Results: All 4 patients had Meyerding grade 4 spondylolisthesis pre operatively. Mean age at surgery was 14.5 years and all were female. Mean length of follow up was 25.75 months (range 19-33). Pre and postoperatively mean GDI score were 76.35 and 91.72. Mean pre- and postoperative right/left GPS were 10.33/9.16 and 7.75/6.85 respectively. All of them underwent posterior decompression + posterolateral instrumented fusion with partial reduction. Surgery achieved reduction to Meyerding grade 1 in all patients. Common preoperative features in coronal plane included pelvic obliquity and increased hip abduction. In sagittal plane, posterior pelvic tilt, reduced flexion of hip at initial contact, increased flexion of knee at initial contact, decreased extension of knee in stance, decreased second rocker in foot was noted. In transverse plane, increased external rotation of hips and foot progression angle. Postoperatively all sagittal parameters normalised. Hip abduction, hip external rotation, and external foot progression angle improved but did not return to normal. Conclusion: In high-grade spondylolisthesis common preoperative gait abnormalities in coronal, sagittal and transverse plane were identified giving rise to characteristic gait pattern. Gait abnormalities concern patients. Posterior decompression, posterolateral instrumented fusion and partial reduction normalised all sagittal gait parameters. Increase in walking velocity, step and stride length were noted post operatively., Introduction: Prune-belly syndrome (PBS) is a rare congenital syndrome characterized by three main features: a deficiency of abdominal wall musculature, urinary tract malformations and cryptorchidism. PBS predominantly affects boys with a recent reported incidence of 3.6-3.8 per 100,000 live male births. There is wide variation in disease severity; besides the genitourinary manifestations patients may also have gastrointestinal, orthopedic, and cardiopulmonary abnormalities. 50% to 65% of patients may develop an orthopedic abnormality, being the most common scoliosis (25%) followed by clubfoot (22%). Hypotheses have been made about the absence of abdominal wall musculature and the development of scoliosis. It is believed that intra-abdominal pressure plays an important role in the stabilization of the spine and absence of the anterior tension band to the axial skeleton may subsequently lead to imbalance of the muscles. In the current literature many studies have described the frequency of scoliosis associated with this syndrome rather than the treatment options. There is only one study in which two patients with scoliosis and with a tendency to lordosis underwent surgical correction with the technique of Galveston-Luque with a combined anterior and posterior approach. Material and Methods: Male, 12 years old with an ultrasound diagnosis of Prune Belly Syndrome, witha history of multiple surgical interventions that includes: bilateral orchidopexy, urinary tract reconstruction and abdominoplasty. Image studies display a scoliosis of 10º of Cobb angle and kyphosis between T10 to L2 of 39º. Operative treatment was indicated because of the magnitude, etiology and expected progression of the deformity with further growth. The patient underwent surgical correction with a posterior approach pedicle screw fixation technique from T5 to L3, an osteotomy was performed at the apex and allograft was used. No complications presented during the intervention or the hospitalization. The patient was discharge onday eight after surgery. On the first follow-up control he presented fine, with no complains. The radiographs showed a kyphosis T10 to L2 of 1º. Results: Five years after surgery the patient presents asymptomatic, with no neurological deficit, pain or any type of complications. Images show no migration or implant failure and correction is maintained with a kyphosis between T10 to L2 of 2º. Conclusion: Although in the literature Scoliosis or lordo-scoliosis are the most frequent orthopedic manifestation in PBS, in this patient the main deformity is a kyphosis showing the importance of the abdominal wall musculature not only for the prevention of coronal deformities of the spine but also for the prevention of the sagittal. The reported technique with pedicle screw fixation is effective so far, with great clinical and radiological outcomes., Introduction: The surgical treatment of adolescent idiopathic scoliosis (AIS), due to extensive surgery can have high complication rates. Our objective was to determine the rate of major complications (that need surgical re-intervention) after surgical treatment of AIS in a single institution cohort. Furthermore, we wanted to identify those factors that can predict the development of major complications. Material and Methods: We retrospectively analyzed demographic, pre- and perioperative clinical data of AIS patients operated in the National Center for Spinal Disorders between 2006 and 2016. The prognostic value of twelve pre- and perioperative factors (age, gender, previous spine deformity surgery, heart disease, lung disease, Cobb degree of major curve, ventral release surgery, HALO traction, level of instrumentation, OR time, blood loss, experience of the anesthesiologist in deformity surgeries) were investigated in a binomial logistic regression analysis. The predictive value of the model was tested in a ROC analysis. Results: 205 surgically treated AIS patients were included in the study. The mean age of the patients was 15 years (range: 11-18). The female: male ratio was 4:1. The median major curve was 68 Cobb degrees (range: 38-137). The median OR time was 435 minutes (range: 180-800), the median blood loss was 1185 ml (range: 500 ml - 7 700 ml). The major complication rate was 8.2% (17 complications in 13 patients), and included deep wound infection (3.4%), neurological complication (1.9%), loss of correction (0.9%), hardware failure (0.9%) and CSF leakage (0.9%). In binomial logistic regression analysis OR time and concurrent heart and lung disease were significantly associated with the occurrence of major complications (whole model: P < .001, Chi2 = 36.4 df = 6, R_N⁁2 = 0.43). The ROC analysis showed that the model has an excellent predictive value (c-index = 0.909, P < .001). Conclusions: The present study identifies three predictive variables on major complications after AIS surgery. High OR time, previous heart and lung disease predicted significantly a postoperative major complication. Predicting major complications gives the chance for the surgical team to avoid them., Introduction: The real risk of progression of idiopathic scoliosis is considered to vary during different growing phases, but detailed knowledge is not available. The rates described in several historical papers have long been considered the most relevant description of the progression risk of scoliosis during growth, but more recent data suggest the natural history to be even more aggressive. The aim of this study is to provide a systematic review, if possible a meta-analysis, of current literature about the natural history of scoliosis during growth in order to provide details about the risk of progression. Materials and Methods: We searched the MEDLINE, EMBASE and SCOPUS databases up to November 2015. Eligible studies were prospective or retrospective studies that enrolled patients with infantile (IIS), juvenile (JIS) or adolescent idiopathic scoliosis (AIS) that were followed up without any treatment from the time of detection. Of the 1663 citations screened, we assessed 61 full-text articles and included 16 of these (4083 participants). Results: Considering studies regarding infantile, juvenile and adolescent IS separately, we found that they were heterogeneous with regard to the most of the study characteristics and outcomes, so it was not possible to perform a meta-analysis. Forty-eight per cent of patients affected by infantile IS showed progression (range 5-80%) while 52% had spontaneous resolution. A curve progression of > 5° change in the Cobb angle was noticed in 33% of a mixed group of patients affected by JIS or AIS (range 14,7-68%). Twenty-eight per cent of patients affected by AIS had a progression of > 5° (range 10,3-100%). Fifty-two per cent of patients from one study had a progression and concluded growth with a Cobb angle greater than 50°. Some authors reported the rate of scoliosis progression, which ranged from 2.2° to 9.6° Cobb per year. Conclusion: Most of the studies were shown to have confounding factors related to some kind of conservative treatment administered at some point during the follow up period, so many patients were not followed unconditionally until skeletal maturity. What is clear from almost all of the studies is the risk of progression of the Cobb angle during growth, even if the rate of scoliosis progression is extremely variable among studies., Objective: The purpose of this study is to report our early experience of the use of the growing rods for the management of the early onset scoliosis and review the bibliography. Materials and Methods: A self-growing rod system have been used in 5 children of 5.5-11 years old to treat scoliosis of 60°-70°. The etiology of the scoliosis was in 2 children syndromic, in 1 neuromuscular and in 2 neurofibromatosis. Cobb angle, screw slipping, T1-S1 lengthening, and complications had been recorded during a follow-up of 4 years. A review of the bibliography has been done focusing on the rod lengthening, on the time of lengthening, on the spine growth, on the Cobb angle, and on the risk of complications. Results: The T1-L1 lengthening average was 6,8 cm. The Cobb angle average improved to 22° from (65°) and no spontaneous spinal fusion has been noted. In 2 children, a revision surgery to replace the upper thoracic screw and the rod had been performed. A left leg neurapraxia happened, which resolved after 1 week. The data on literature reveals that the traditional growing rods have better lengthening (8,8 cm average) when the time of lengthening is every 6 months, better Cobb angle improvement, more operations and no significate difference of the rate of the complications. Conclusions: The growing rods are a safe option to manage early onset scoliosis., Introduction: According to SRS guidelines, surgical treatment of idiopathic scoliosis should be considered when the deformity reaches 45-50 Cobb’s degree threshold. Objective: To estimate the frequency of surgical treatment of scoliosis in a population of patients with idiopathic scoliosis who receive brace treatment for deformities exceeding 45 Cobb degree. Material and Methods: A prospective nonrandomized cohort study. Inclusion criteria: pediatric patients with diagnosed idiopathic scoliosis; main curve more than 45° (Cobb) at first consult, orthotic treatement (Chêneau brace). We collected prospectively medical data of patients aged 2 to 18 years, receiving orthotic treatement (Chêneau brace) in a single institution from 05.2015 to 08.2016. All patients have standing frontal and lateral X-ray of the spine, X-ray films were estimated according to the Cobb’s method. Patients were counseled independently by general orthopedist and spinal surgeon, the limitation of conservative treatment and the possibilities of surgical treatment were discussed; the expectations and concerns of patients and their parents regarding the surgical treatment were recorded. Results: The cohort included 70 children, 14 - male, 56 - female. There were 12 patients with early-onset scoliosis (2-10 years) and 58 patients aged from 10 to 18 years. The magnitude of main curve in children with EOS was 45-50° in 4 cases, 51 - 80° - 8 children; in children older than 10 years 45-50° deformity was observed in 21 cases, 51 - 90° curve - in 37 cases. The patients were informed about the possibilities of surgical deformity correction. 22 patients gave primary consent to be surgically treated, but in fact operative treatment during the study period in this cohort was performed only in 6 patients (including 1 patient with EOS). It should be mentioned that the surgery costs and post-op rehabilitation is fully covered by state budget and insurance companies. The most common objection to the surgical treatment of the patients’s parents were grouped into several blocks: Fear of neurologic disorder (paraplegia) - 80%; expected inability to bend the body - 87.1%; expected inability to quickly return to normal life after the operation - 81%; subjective positive dynamics – curve reduction on X-ray wearing the brace (regardless of the absolute magnitude of the curve) - 40%; fear of necessity of reoperation - 25.7%; fear of death - 2.8%. Conclusion: Surgery for idiopathic scoliosis in a cohort of patients having orthotic treatement (Chêneau brace) when the main curve reaches the “surgical threshold” was conducted in 8.6% of cases in 15 months. Patients’ who receive bracing and their parents, do not adequately respond to the information about the true complication rate after surgical correction of idiopathic scoliosis and are themselves a “conservative population”. This fact may represent the national features of Russian medicine where modern health technologies goes hand in hand with XIX-XX century myths., Introduction: There are many types of spinal deformity in patients with spina bifida, and as the paralysis level higher, so does the incidence of scoliosis. But there are few reports that focus on the deformity type related to the neurological level. This study investigated the relationship between spinal deformity type and neurological level in patients with spina bifida. Material and Methods: A total of 27 patients with spina bifida over 10 years of age were reviewed at the final check-up in outpatient. We evaluated the type of spinal deformity, Cobb angle, associated deformity and the Sharrard classification. Results: The Sharrard classification was class I in 4 patients, class III in 6 patients, class IV in 8 patients, class V in 6 patients and class VI in 3 patients. Two patients in class I had severe kyphoscoliosis, and 2 had severe lordoscoliosis, with over 60 degrees of scoliosis. Four patients in class III had tethered cord, and 2 of 4 patients had mild scoliosis. Five patients in class IV had tethered cord, and 2 of 5 patients had mild scoliosis, of 1 patient had hemivertebtra. Four patients in class V had tethered cord, and 1 of 4 patients had mild scoliosis. Another one patient in this class was congenital scoliosis with butterfly vertebra. Three patients in class VI had tethered cord without scoliosis. There was no sagittal deformity in the lower than class III. Conclusion: This study indicated that most scoliosis were related to the tethered cord without sagittal deformity in the lower than class III. And there tended to be higher Cobb angle as the paralysis level higher., Introduction: Global balance relies on a series of visual and vestibular inputs as well as cerebellar integration that responds to the pathologic rotation of the spinal column in AIS. Corrective maneuvers create postural alteration of anatomic alignment of segments that require adaptive modification of the unfused anatomic parameters in order to maintain balance postoperatively. This study aims to analyze the radiographic markers which may help predict proprioceptive temporal alterations in postoperative coronal alignment. Material and Methods: 48 consecutive pts surgically treated for AIS with pedicle screw only constructs through a posterior only approach and 2 year follow-up were reviewed. Pts with complete radiographic images stored on the same electronic imaging system were measured by a single deformity surgeon. Pt demographics were compiled. Standard radiographs from the preop, early postop (, Introduction: Lumbar spondylolysis is a common disease (6-7% in the population) that can cause disabling low back pain in pediatric and adolescent age. It’s characterized by a unilateral or bilateral defect in the pars interarticularis of the vertebra, typically L5, due to acute or repetitive microtrauma or can be congenital. When conservative treatment doesn’t resolve this problem, surgical treatment is the ideal solution. Pedicle screw fixation and fusion has been shown to result in loss of motion and eventually adjacent segment disease, particularly harmful at this age. So repair of the defect with internal fixation and cancellous bone grafting is a treatment option that avoids fusion. The authors describe the result of direct pars repair with a minimum follow-up of 5 years, using pedicle screws, rods, and laminar hook construct. Material and Methods: From 2005 and 2012, 19 patients (12 males and 7 females) have been treated using the pedicle screws, rods and hook laminar construct. The median age was 15.2 yrs. (range 11.3-19.5). The level affect was L5 in 16 patients and L4 in 3 patients. We have completed a retrospective review of the data with demographic, clinical and radiographic trends. This study has been approved by the institutional review board. Regarding the surgical technique, we have done meticulous preparation of the pars defect, burring it and using cancellous bone grafting for the repair. In addition no injuries to the facet joint capsule have been done. Then the pedicle screw, rod and laminar hook has been placed in compression, to facilitate the bony union. Results: According to the MacNab criteria for pain evaluation, patients have reported the following results: 12 excellent, 6 good, 1 fair results. Bony fusion was assessed with plain radiographs. Complete bone healing has been observed in all the cases. No failures or dislodging of the implants have been observed in the follow-up. All the patients have come back to full sport activity after 6 months from the operation. Conclusions: Direct pars defect repair in spondylolysis with this technique has been shown to be very effective, sparing the need for fusion and avoiding the possible adjacent segment disease. Of course, many patients respond well to conservative treatment, so the surgical procedure is reserved to a small percentage. The results are very good, and similar to previous studies published., Introduction: No standardized surgical technique for severe rigid scoliosis management with few reports on the use of perioperative halo-gravity traction in treating severe rigid scoliosis. A retrospective study. To evaluate safety and efficacy of staged posterior surgery of severe rigid scoliosis correction. First stage is posterior facetal osteotomies and pedicular screw fixation. Second stage is halo-gravity traction for 3 weeks. Third stage is final correction maneuver techniques with rods application. Material and Methods: Ten patients with a minimum 1 year follow-up who underwent three stage correction techniques for severe rigid scoliosis (cobb angle above 100 degree) were analyzed. (First stage: posterior facetal osteotomies and pedicular screws application. Second stage: halo gravity traction for three weeks. Third stage: is definite correction techniques doing multiple chevron osteotomies, apical sublaminar wires if needed and rods application with derotation, compression distraction techniques). Patients demography age at date of examination (range, 11-28 y; mean, 15.6 y), sex (6 female, 4 male), major coronal curve magnitude (range, 106-148 degrees; average, 123 degrees), major sagittal curve magnitude (range, 70-110 degrees; average, 90 degrees). Complications related the procedures were reviewed. Results: Radiographic outcomes showed Cobb angle improvement of 29% after halo traction and it measured 55 degrees (range, 43-85 degrees) at the last follow-up, for a 58% correction. Kyphosis improved to 59 degrees (range, 42-74degrees) at last follow-up. T1-S1 increased by about 88 mm. There were no permanent neurological deficits in this series. Conclusion: Treatment of severe rigid scoliosis is very challenging. With modern instrumentation methods, posterior only staged surgeries with halo-gravity traction is a safe, tolerated method of applying gradual, traction to maximize final correction. There were no permanent neurologic deficits in this series., Introduction: Lumbosacral spondyloptosis produces global sagittal and often coronal imbalance and is associated with major patient morbidity including increased neurological risk. Surgical treatment includes in situ 360-degree fusion, spondylolisthesis reduction techniques and L5 vertebrectomy followed by L4 to sacrum circumferential fusion. In situ fusion is safer but does not correct lumbosacral kyphosis and global spinal alignment. Reduction techniques and L5 vertebrectomy can correct spino-pelvic balance at the expense of a high rate of neurological complications. We present a patient with a dysplastic lumbosacral spondyloptosis and severe coronal and sagittal imbalance with the discussion of treatment and surgical outcomes at 2-year postoperative follow-up. Material and Methods: Case report of a patient with spondyloloptosis (grade 5 spondylolisthesis). Clinical and radiological outcome data at two years are presented. Results: A 15-year-old girl presented with a three-year history of persistent low back pain refractory to physiotherapy and analgesia. Postural changes and radicular symptoms affecting the right leg were added in the last 6 months. Delay in diagnosis resulted in a highly progressive deformity producing severe global coronal and sagittal imbalance, as well as abnormal spino-pelvic parameters. On clinical presentation, the patient was mostly confined on a wheelchair due to back and leg pain. On examination, she had developed significant listing of the trunk towards the left side with a thoracic and lumbar curve and costo-pelvic impingement related to muscle spasm, as well as marked positive sagittal imbalance with lumbosacral kyphosis, compensatory lumbar lordosis and thoracic hypokyphosis. Decreased sensation was associated with tingling and pins/needles down her right foot. Muscle power was reduced at L5/S1 distribution to grade 3 on the right side with preserved bladder/bowel function. She underwent a posterior spinal fusion from L4-S1 with the transfixation screw technique, which corrected the lumbosacral kyphosis and restored local and global balance of the spine and pelvis. In the immediate postoperative period, she developed a stress fracture of the inferior end plate of S1 with anterior angulation and bladder symptomatology. An extension of the fusion to the pelvis combined with L5-S2 posterior decompression was performed and led to an uneventful recovery. At latest follow-up, our patient had normal neurological function and examination. She had a well-balanced spine in both planes with spontaneous resolution of the coronal curves. A solid fusion was associated with excellent functional outcomes and return to normal activities including sports. Conclusion: Lumbosacral spondyloptosis is associated with a high risk of neurological injury and can lead to global spinal deformity in both the coronal and sagittal planes. Surgical treatment is very challenging, associated with high rates of permanent injury to the L5 and sacral nerve roots and non-union. The transfixation technique is a relatively easy and safer treatment option that can restore local lumbosacral and global sagittal balance with a lesser neurological risk. Extension of the instrumentation to the pelvis can reduce the risk of sacral insufficiency fractures. Spontaneous correction of the coronal deformity may occur in the presence of a stable lumbosacral fusion. In our patient, this technique has produced very satisfactory clinical outcomes and high patient satisfaction., Introduction: Growing rod (GR) technique in the management of early onset scoliosis is found to be safe and effective in correcting and maintaining the deformity. However, the available GR systems are too expensive and not available for wider usage. Present study evaluates the safety, efficacy and radiological outcome of indigenously developed growing rod (GR) technique in the management of early onset scoliosis and discusses the technical considerations. Material and Methods: 10 patients (8 girls and 2 boys) with early onset scoliosis treated with GR technique (8 single GR and 2 dual GR) with a minimum of two distractions and a mean follow-up of 2.3 yrs (range 5 years-18 months) were included. Eight were girls and 2 were boys. Mean age at the time of GR instrumentation was 4.5 years (3-6 yrs). 5.5 mm pedicle screws were inserted at distal stable and proximal stable vertebrae with two small incisions and two 5.5 mm rods were inserted sub-muscularly and joined by rod-rod connector. Rods were contoured to the sagittal profile while taking care to allow sliding. Radiographic evaluation included measured changes in scoliosis Cobb angle, kyphosis, lordosis, frontal and sagittal balance, length of T1–S1 and instrumentation over the treatment period, and space available for lung ratio. Results: The mean scoliosis improved from 75.6° to 53.6° (27.8%). Mean increase in T1-S1 length was 16.6%. Coronal Plumb line showed relative improvement of 52.7% where as the trunk shift showed improvement of 95.2%. Space available for lung (SAL) improved by 3.4% on convex side and 2.5% on concave side. There was 9.2% improvement in the hemi-thoracic area on convex side compared to 4.4% improvement on concave side. None had rod breakage but one patient proximal thoracic kyphosis (dual GR) had proximal screw pull-out on convex side. There were no significant differences in any of the radiological parameters between single Vs dual GR. Conclusion: Indigenous GR technique is safe and effective in the treatment of early onset scoliosis. They are highly effective in correcting the trunk shift to improve the coronal balance and cosmetic appearance in children. Incidence of implant failure can be minimized by using thicker rod. Kyphosis poses problems of proximal screw pull-out and can be avoided by contouring the rod., Introduction: Significant postoperative trunk shift (TS) was occasionally noted in our practice causing patient dissatisfaction. Poor surgical planning and decision as well as the surgeon’s inclination to save the patients more lumbar motion segments are frequent causes. This retrospective cohort study aimed at analyzing our own case series in a trial to discover possible warning signs or guidelines to avoid this problem. Material and Methods: Eighty-eight consecutive patients with spinal deformity (44 AIS, 32 congenital, 5 syndromic, 4 associated with Scheuermann kyphosis, 3 Neurofibromatosis), treated by single stage posterior spinal fusion with all pedicle screws were retrospectively reviewed. Sixty patients (68%) were females and 28 (32%) were males. The following parameters were reviewed: age, preop. TS, time, Curve type (etiologies other than idiopathic scoliosis were described according to Lenke classification according to their pattern), lowest instrumented vertebra (LIV), post-operative TS (distance between Vertical Trunk Reference Line (VTRL) and Central Sacral Vertical Line (CSVL). Results: Seven cases (8%) developed TS. The mean TS was 37 mm (ranging from 20- 63 mm). In six patients, the fusion stopped at the lumbar apical vertebra (LAV) and in 1 case, fusion extended down to the sacrum. Three cases of TS (3.4%) were Lenke type 5C and 4 (4.5%) were Lenke type 6C. In the cases of Lenke 5C the LIV was L3 which was LAV. In Lenke 6c curves the LIV was L5 in 3 cases and S2 in 1 case. In the case where fusion was extended to S2 the original curve was too rigid Eighty-one cases did not develop trunk shift. In 64 cases (72.7%), fusion stopped at LAV or above and in 17 cases (19.3%) fusion extended down to the sacrum or the pelvis. The estimated risk of TS in the shorter fusion group was 0.086 and the estimated risk in the longer fusion group was 0.056 with estimated relative risk (RR) 1.55.with 95% Confidence Interval 0.180-14.148. In 6 cases of TS revision surgery was performed extending the fusion to the pelvis using S2-iliac screws and correction was achieved in 5 case. The case who have not undergone revision was satisfied and refused reoperation. Conclusion: Stopping fusion at the Lumbar Apical vertebra may be a risk factor for the development of trunk shift and extending the fusion more distally (LAV+1) is recommended., Introduction: Adolescent idiopathic scoliosis (AIS, OMIM #181800) is a three-dimensional deformity of the spine that causes a coronal imbalance up to 10 degrees. 70-80% of scoliosis diagnosed in adolescent is idiopathic. A recent epidemiology report on adolescent idiopathic scoliosis (AIS) has demonstrated a significant AIS burden in the European countries, affecting the 2-3% of the population under age 18, with more than 1 million AIS cases in EU. The role of genetic factors involved in AIS is widely accepted. However, it has been recently proposed the implication of epigenetics in the etiology of AIS. Epigenetics is defined as changes in gene activity and expression that occur without alteration in DNA. The environment, the nutrition, and the lifestyle are some of the factors that can modulate the epigenome, so contributing to AIS progression. Epigenetics has produced a high impact in biomedical research and is providing new biomarkers for the diagnosis and prognosis of diseases. In this context, miRNAs are very promising biomolecules to be used as biomarkers because miRNAs act as signaling molecules and participate in many biological process, due to their extreme stability and easy obtainment. Material and Methods: This is a prospective study based on an experimental analysis of the epigenetic profile of AIS. This investigation program has been approved for the ethics committee of University Hospital la Fe, Valencia, Spain. The inclusion criteria for the patients group were diagnosed for AIS with a Cobb angle > 10º and marked scoliosis, minimum follow up for two years, no previous surgical treatment, radiographies available, age between 12-18 years old. Exclusion criteria were: smoker, active infectious or inflammatory process during extraction, antioxidants intake, neurologic pathology, congenital syndrome pathology, and patients with scoliosis due to secondary causes. Physical examination consisted on measurement of the following parameters: age, sex, and body mass index (BMI) (Kg/cm2). A complete neurological exploration including motor and sensory balance, abdominal reflexes, as well as, patellar and Achilles reflexes were performed. Coronal and sagittal balance evaluation with the plumb test. Vertebral rotation assessment on Adam Test using the Scoliosis Research Society (SRS) scoliometer, and finally, deformity clinical evaluation using the trunk aesthetic clinical evaluation which consist on shoulder, scapular, thoracic and pelvic asymmetry assessment (TRACE). Physic evaluation for the control group was the same excluding the TRACE form. A radiological study was made for all patients included, based on two standing X-rays, anteroposterior and lateral views. It was mandatory to include from skull to pelvis. Risser method was used for skeletal maturity while the Cobb method was used to measure the coronal deformity. Finally coronal (C7-CSVL lines) and sagittal (C7-S1 lines) balance have been taken into account. According to the SRS criteria, for the present study, it has been considered the diagnosis of scoliosis when the coronal value of the deformity was up to 10 Cobb degrees Classification of the deformity for each patient using The Lenke Classification System for Scoliosis were also collected. Finally, all individuals included have completed scoliosis and general health questionnaires, specifically SRS-22, CAVIDRA and SF-36 for patients group and SF-36 for control group. Circulating miRNAs were purified from plasma samples from patients and control population through Next Generation Sequencing (NGS) and validated posteriorly with the use of RT-qPCR. Results: In the present study they were included 30 patients and 13 healthy subjects. The average of age in the patient group was 15 years. The male to female ratio was 1: 5, respectively. 43.33% had AIS familiar history. After miRNAs sequencing using NGS a study was conducted searching potential biomarkers for AIS. The random forest model was able to establish a first signature composed by 6 miRNAs that could distinguish patients from healthy subjects. The most important predictors of the disease were miR-122-5p, miR-671-5p, miR-223-5p, miR-1226-5p, miR-27a-5p and miR-1306-3p. Three biomarkers (miR-122-5p, miR-27a-5p and miR-223-5p) were over-expressed in AIS patients while miR-671-5p showed a lower expression when compared with the control group. Furthermore, for miR1306-3p no significant expression differences were found between groups. With all this information, a signature consisting of 4 miRNAs (miR-122-5p, miR-27a-5p, miR-223-5p and miR-1306-3p) was finally defined. This signature was validated by RT-qPCR achieving a high sensitivity (92, 9%) and specificity (72.7%), with an area under the curve of 0.95. Then we conducted a functional analysis of genetic pathways using the DIANA-miRPath program and the Genes and Genomes Kyoto Encyclopedia, in order to explain the relationship between the selected miRNAs with target genes, finding their influence on routes involved in osteoblast differentiation / osteoclasts and bone metabolism. Conclusion: This is the first work which propose the use of circulating miRNAs as biomarkers in the Idiopathic Adolescent Scoliosis. It has been found evidence of alterations in bone metabolism and activity of osteoclasts / osteoblasts in patients AIS mediated by miRNAs. It has been proposed a signature composed of 4 miRNAs that could discriminate with high sensitivity and specificity AIS patients and healthy subjects, and therefore could be used in the future for the bio molecular diagnosis of disease., Introduction: The reported incidence of postoperative pseudarthrosis in adult sagittal deformity is 0 to 29%. Risk factors associated with pseudarthrosis include age (>55), greater BMI, thoracolumbar kyphosis (>20), long level fusion (>11), laminectomy, rod factors (materials and diameter), and pedicle subtraction osteotomy. However, there exist limitations and controversies in data. Therefore, a retrospective study has been performed to evaluate the risk factors for postoperative pseudarthrosis in adult sagittal deformity. Material and Methods: Sixty patients with adult sagittal deformity were enrolled who underwent PSO (pedicle subtraction osteotomy). Patients were divided into groups with or without pseudarthrosis (pseud group vs non-pseud group). With a minimum 2-year follow-up, risk factors included spinopelvic parameters, fused segments, age, bone mineral density (BMD), body mass index (BMI), and joint pathologies at the hip and knee (postoperative hip fracture and untreated gonoarthrosis). Results: The mean SVA in each preoperative, postoperative, and last follow up period was 164 mm, -8 mm and 28 mm. Optimal SVA were achieved 98.3% as a whole (59/60), 100% in overcorrection group (47/47), 92.3% in under-correction group (12/13) postoperatively, and 47 patients (78% as a whole, 95.7% (45/47) in overcorrection group, 15.3% (2/13) in under-correction group) at the last follow up. Twenty seven patients (45%) were diagnosed with pseudarthrosis by the average period of 21months (8∼47months). The mean LL in each preoperative, postoperative, and last follow up period was 3°, -66° and -62°. Significant differences between the two groups with regard to risk factors included, correction of LL, and joint pathologies (P = .0167, P < .0001, respectively). Conclusion: Despite the effectiveness of overcorrection of LL with PSO in adult sagittal deformity, higher incidence of pseudarthrosis was seen compared to previous reports. Preventive options to consider may include, applications of multiple-rod construct or efforts to decrease events leading to hip fracture, in patients with an operative plan of overcorrecting lumbar lordosis with PSO, and especially perioperative treatments such as joint reconstruction should be considered in cases with untreated gonarthroses., Introduction: The present classification systems for adult spinal deformity (ASD) are based on the etiology and/or radiological parameters of the disease. Previous research however, suggests that other parameters (age, gender, BMI, HRQoL) may also affect the level of disability as well as the treatment decision. The aim of this study was to identify the potential groups of parameters that may be useful in classifying ASD using Cluster Analysis (CA). Material and Methods: Retrospective analysis of prospectively collected data utilizing the database of multi-center ASD study group was performed at the baseline (413 pts; 352 females; 131 degenerative –D-, 282 idiopathic –I-; mean age: 49.9 ± 20.0) as well as the 1st year follow-up (186 pts,; 157 females; 46 D, 136 I; mean age: 49.2 ± 19.1). CA was done in two steps; 1) Pre-clustering: The log-likelihood criteria were used followed by the selection of the optimal number of clusters by the algorithm; and 2) Hierarchical clustering of pre-clusters; for the entire data set as well as stratified by diagnosis (D or I) and age (> or < 50). Results: Are demonstrated on Figure 1a (entire set), b (D and I) and c (> and < 50) at the baseline and f/up. As can be seen, the CA consistently (for the entire group and the subgroups) isolated the clusters in three distinct groups of (not necessarily in hierarchical order): 1) HRQoL parameters; and 2) Sagittal plane; 3) Coronal plane radiological parameters. Conclusions: The results of this CA demonstrate that three groups of parameters (HRQoL and two plane radiological) are necessary and adequate to describe and/or classify ASD in general as well when stratified for age and diagnosis. This finding is significant in the sense that the present classification(s) do not contain all these groups and may need to be critically re-evaluated. 1st Cluster 2nd Cluster 3 rd Cluster a) Entire data set Baseline Major Curve Cobb Angle (0.931)MT curve (0.892)Coronal balance (0.669)TL-L curve (0.613)PT curve (0.473) Global tilt (0.791)L gap (0.720)PI-LL (0.704)Pelvic Tilt (0.645)SVA (0.591)Lordosis (0.476)Sagittal Balance (0.406) ODI (0.740)SRS22 (0.673)SF36 PCS (0.558)Back pain (0.483)Age (0.423)Leg pain (0.422) 1st year Major Curve Cobb Angle (0.841)MT curve (0.786)TL-L curve (0.719) ODI (0.760)Back pain (0.660)SRS22 (0.660)Leg pain (0.630)COMI score (0.570)SF36 PCS (0.490) Lordosis (0.860)Sacral Slope (0.820)Pelvic Incidence (0.680) b) Stratified by diagnosis (Grey shading for D, no shading for I) Baseline SRS22 (0.790)ODI (0.749)COMI score (0.707)Back pain (0.430)SF36 PCS (0.406) Major Curve Cobb Angle (0.910)TL-L curve (0.850)Coronal balance (0.780)MT curve (0.580) Global tilt (0.832)L gap (0.785)PI-LL (0.702)Sagittal Balance (0.659)SVA (0.629)Pelvic Tilt (0.601)Lordosis (0.550) 1st year SRS22 (0.882)SF36PCS (0.821)ODI (0.773)COMI score (0.760)Back pain (0.468) Major Curve Cobb Angle (0.780)TL-L curve (0.730)Mt curve (0.480)Sacral Slope (0.430)Lordosis (0.410) Alcohol drug abuse (0.940)Blood clots (0.940) Baseline COMI score (0.860)SRS22 (0.860)ODI (0.810)SF36 PCS (0.670)Back pain (0.660)Leg pain (0.510) Major Curve Cobb Angle (0.900)Coronal balance (0.770)MT curve (0.730)TL-L curve (0.670) Global tilt (0.800)Pelvic Tilt (0.670)PI-LL (0.640)L gap (0.560)SVA (0.560)Age (0.520) 1st year SRS22 (0.870)COMI score (0.840)ODI (0.810)Back pain (0.660)SF36 PCS (0.650) Major Curve Cobb Angle (0.880)MT curve (0.800)TL-L curve (0.690) Sacral Slope (0.571)Lordosis (0.561) c) Stratified by Age (Grey shading for ≤ 50 years, N shading for > 50 years) Baseline COMI score (0.820)ODI (0.800)SRS22 (0.800)Back pain (0.660)SF36 PCS (0.660)Leg pain (0.460) Major Curve Cobb Angle (0.910)Coronal balance (0.800)Mt curve (0.780)TLL curve (0.640) Global tilt (0.757)PI-LL (0.706)Pelvic Tilt (0.634)L gap (0.487) 1st year SRS22 (0.798)COMI score (0.745)ODI (0.725)Back pain (0.665)SF36 PCS (0.475)Leg pain (0.460) Major Curve Cobb Angle (0.935)MT curve (0.888)TL-L curve (0.764) Lordosis (0.800)Sacral Slope (0.760)Pelvic Incidence (0.540) Baseline SRS22 (0.813)COMI score (0.756)ODI (0.739)Back pain (0.494)SF36 PCS (0.455) Major Curve Cobb Angle (0.897)MT curve (0.802)Coronal balance (0.763)TL-L curve (0.739) Global tilt (0.824)PI-LL (0.734)L gap (0.730)Pelvic Tilt (0.638)Sagittal Balance (0.612)SVA (0.602)Lordosis (0.557) 1st year SRS22 (0.850)ODI (0.778)COMI score (0.772)SF36 PCS (0.706)Back pain (0.492) Major Curve Cobb Angle (0.953)TL-L curve (0.864)MT curve (0.826) Kidney disease (0.479)Depression (0.476), Introduction: Factors affecting the natural history and treatment outcomes are being investigated in order to identify the best and proper clinical approach in ASD. Our recent research suggests the critical age for the surgery to become more complex to be at early 30s. However, the evidence is still insufficient on whether age by itself, as well as gender has any effect on treatment outcomes.The aim of this study is to determine the clinical impact of age and gender on treatment results in surgically treated ASD patients. Material and Methods: Prospectively collected data from a multicentric ASD database was analyzed and all surgical patients with a minimum f-up of 1 year were included and analyzed for demographic, clinical, radiological and health related quality of life (HRQOL) parameters. Patients were separated into two groups based on improvement in HRQOL parameters by minimum clinically important difference (MCID). Student’s t-test and chi-square test were used to analyze the effect of age and gender on outcome measurements followed by a multivariate binary logistic regression model for these results with statistical significance. Results: A total of 186 patients (157 female, 29 male) with a mean age of 49.2 ± 19.1 years were analyzed. Age was found to affect only SF-36 PCS score significantly (P < .05) (Table 1A), with an odds ratio of 1.017 (unit by unit) of improving SF-36 PCS score on multivariate analysis (P < .05) (Table 1B). The breaking point in age for this effect was calculated to be 37.5 years (AUC = 58.0, P = .05). On the other hand, gender was found not to have a significant effect on any of the HRQOL scores. Conclusion: This study demonstrates that patient age may have a positive effect on treatment outcome parameters in surgically treated patients with ASD and the breaking point of this effect may be earlier than generally anticipated. Gender on the other hand, does not seem to affect results. This information may be important in patient counseling for the anticipated outcomes of surgery. Table 1. Student’s t-test (a) and multivariate binary logistic regression model (b) results on the relations between age and HRQOL. Please note that only SF36 PCS was included into the regression model as it is the only parameter with statistical significance on Student’s t-test. a. Mean Std. dev p ODI Un-improved 44.81 19.26 0.197 Improved 52.91 20.15 COMI Un-improved 46.25 25.52 0.346 Improved 55.62 19.21 SF36 MCS Un-improved 50.80 20.56 0.139 Improved 55.40 19.35 SF36 PCS Un-improved 49.67 21.33 0.034 Improved 56.24 18.34 SRS22 Un-improved 51.50 21.16 0.678 Improved 52.79 19.53 95% C.I for OR b. B S.E. Wald Df p OR Lower Upper Age .017 .008 4.425 1 .035 1.017 1.001 1.033 Constant -.800 .449 3.176 1 .075 .450, Introduction: The prevalence of Adult Spine Deformity (ASD) is increasing and the need for surgical deformity correction has subsequently increased. Although surgery has been proven to be effective, results have not been consistently good. Pre-operative depression has been associated with decreased rates of improvement in lumbar spine surgery;but the impact of pre-operative psychosocial factors in ASD results is not fully understood. The aim of this study is to determine the clinical impact of pre-operative psychological factors on outcome scores and treatment results using SF36-MCS tool. Material and Methods: Prospectively collected data from a multicentric adult deformity database for surgically treated patients with a minimum of 1-year follow-up was analyzed. Patients were dichotomized into groups of improved or unimproved based on the MCIDs of individual HRQoL scores. Student’s t-test analysis was used to analyze the effect of baseline SF36MCS on treatment results followed by a univariate binary logistic regression model to measure the effect of the SF36-MCSand a clinically useful SF-36 MCS was determined by ROC Curve analysis. Results: A total of 186 patients, (157 female, 29 male) were analyzed. The two cohorts of patients (improved & unimproved) show no significant difference in baseline SF36MCS using ODI, COMI or SRS22. For SF36PCS however, the un-improved cohort had significantly lower mean baseline SF36MCS (P < .001). SF36-MCS was found to have an Odds Ratio of 0,914in improving SF36PCS score (unit by unit) (P < .001). SF-36 MCS cut-off point 43.97 was found to be predictive of SF36PCS (AUC = 0.631: P < .001). Conclusion: This study demonstrates that baseline psychological factors as assessed by Sf36 MCS cannot predict treatment outcomesby ODI, COMI or SRS22, in keeping with previous publications.However, a lower baseline SF36MCS is predictive of poorer surgical outcomemeasured by the SF36PCS tool. Figure 1. Student t-test analysis for all HRQOL outcomes measures (grey area) & univariate logistic regression analysis for SF36 PCS . (SF 36PCS is the only signifinicant outcome measure on t-test) Mean (std dev) Baseline SF36 MCS P-Value ODI Un-improved 38.89 (8.25) 0.487 Improved 41.45 (11.95) COMI Un-improved 42.09 (8.34) 0.881 Improved 41.22 (11.46) SF36-PCS Un-improved 39.35 (11.14) 0.025 Improved 43.44 (12.07) SRS22 Un-improved 42.17 (11.12) 0.415 Improved 40.65 (12.13) Univariate Logistic Regresision analysis P-Value Odds Ratio 95% C.I for OF Lower Upper SF36_MCS_ baseline ,000 ,914 ,884,945 Constant ,000 40,577, Introduction: We determine the change in spinal sagittal parameters which may occur throughout the day by comparing spinal sagittal measurements taken early in the morning to measurements taken in the evening in healthy hospital workers. Methods: Thirty-five employees were enrolled in the study. For each subject, two standing left lateral orthoroentgenograms were obtained at 8 o’clock a.m and at 6 o’clock p.m. Six spinopelvic parameters were measured on the X-rays. Thereafter, the subjects were divided into two cohorts according to their BMI as low BMI and high BMI. Results: Thirty-five subjects; 16 males, 19 females with a mean age of 25.97 ± 8.21 were evaluated. There is no significant change between morning and evening for each parameter. Direct relationship was shown between TK and LL, LL and SS, PT and PI minus LL, SVA and PI minus LL in addition to an inverse relationship between SS and PT, SS and PI minus LL, TK and PI minus LL, SS and PT, SVA and LL. (P < .05). SVA were found to be higher in the high BMI group, and daily change was lower in the high BMI group, but the differences were not statistically significant. Only the change in PT value was found to be statistically significant in low BMI group. Conclusion: There is no significant change in the spinopelvic parameters throughout the day. Compensatory mechanisms will work to prevent collapse of spinal sagittal balance in a day., Introduction: Lumbopelvic fixation has been an important advancement in spine surgery, specifically for obtaining spino-pelvic stability for adult deformity correction, and offsetting stresses placed on sacral screws. However, Iliac screws are not without complications including infection, screw prominence, and instrumentation failure (IF). Kasten et al reviewed 78 patients treated with adult deformity found a 11.5% infection rate. OʼShaughnessy et al. found a 6.1% rate of elective iliac screw removal in a review of 395 similar patients. Literature review demonstrates pseudoarthrosis failure rates between 5 and 15%. Kuklo et al reported a 4.9% pseudoarthrosis rate with hardware failure, while Kasten et al. found broken implants resulted in a 15.3% rate of pseudarthrosis.Our institution utilizes modified iliac screw starting points highlighted by more medial starting points, placing iliac screw heads in line with S1 pedicle screws. We hypothesize this technique is associated with decreased rates of elective screw removal secondary to prominence, infection and IF. Material and Methods: Retrospective database review at UMMS between 2006-2015 of 57 patients undergoing lumbopelvic fixation with a modified iliac screw starting site, for treatment of adult deformity secondary to degenerative scoliosis, posttraumatic kyphoscoliosis, and flat back syndrome. Primary outcome measure: Rates of: 1) elective removal of Iliac screws, 2) infection, 3) IF (breakage of rods/pelvic screws/pedicle screws), 4) revision surgery for Pseudoarthrosis/IF. Secondary outcome measures: 1) estimated blood loss and 2) length of stay. Patients were contacted via telephone in order to ensure no loss to follow-up with respect to elective removal of hardware or revision surgery at outside institutions. Results: The patient population consisted of 17.5% males (N = 10) and 82.5% females (N = 47). The average age was 58.2 years old (SD 11.7 years). Average follow-up was 22 months. Early infection rate (less than 1 month after primary procedure requiring surgical intervention) was 3.5% and late infection rate (more than 1 month after primary procedure requiring surgical intervention) was 12.2%. Overall infection rate was 15.7%. Elective removal of Iliac screws rate was 3.5% (N = 2) and IF via radiographic review was 35% (N = 20), but revision surgery rate for pseudoarthrosis/IF was 5.2% (N = 3). Revision surgery rate for proximal junctional failure/kyphosis was 3.5% (N = 2). IF occurred below (N = 15), above (N = 2), and both above and below (N = 3) the L5 pedicle screw. Average time of diagnosis of broken instrumentation was 16 months. Average Estimated Blood Loss was 1727 cc, with length of stay averaging 8.6 days. Conclusion: Our modified LPF technique demonstrated relatively low rates of elective screw removal (3.5%), likely from decreased screw prominence. Our infection rate is similar to previously reported rates in the literature. The discrepancy between our relatively high rate of radiographic IF and much lower revision surgery rate demonstrates the low clinical significance of radiographic findings in isolation. The time to IF supports following patients with adult deformity reconstruction well past the 1-year benchmark., Introduction: Many methods had been reported for the coronal and sagittal correction of adult degenerative scoliosis. Controversy exists as to the role of SPO, PSO, ALIF and XLIF in deformity correction of adult degenerative scoliosis. Material and Methods: Thirty-eight ADS cases were treated with one stage of posterior multilevel Ponte osteotomy and full discectomy releases combined with key segment anterior structural column support and instrumentation. The thoroughly interbody release and fusion with local bone were done both side in all involved segments, a little bigger inserter were inserted into cave side to neutralize the tilted vertebrae. The operating time and the blood loss were recorded. Mean follow-up was at least two years. All the subjects were analyzed by visual analog scale (VAS), Oswestry Disability Index (ODI), and SF-36 scores, SRS 22 before and after surgery and at final follow-up. The scoliotic curve, thoracic kyphosis, lumbar lordosis, pelvic incidence (PI), pelvic tilt (PT), sacral slope, and C7 plumb line were measured. For the statistical analysis, multivariate multiple regression models were formulated, considering as significant (P < .05). Results: The average operating time were 350 min and the mean blood loss were 720 ml. A statistically significant clinical and radiological amelioration was noted after surgery and at final follow-up. The ODI, and SF-36 scores, SRS 22 improved. The Cobb angle of lumbar lordosis and spino-pelvic parameters (PI, PT, sacral slope) returned to the normal range after surgery. Conclusion: Posterior Ponte osteotomy releases produced more motion than facetectomy alone in axial rotation and sagittal correction maneuvers. Full discectomy release destabilized spinal column significantly in all force applications. Key segment anterior structural column support could neutralize the tilted vertebrae maximally. So, it is easy for the coronal and sagittal correction if three factors working together., Introduction: Surgery is widely performed for lumbar degenerative kyphosis (LDK), but its effectiveness as compared with nonsurgical treatment has not been demonstrated. Methods: In this prospective study, surgical candidates with LDK were enrolled at three spine centres. 2 treatment options were performed either surgery using a pedicle subtraction osteotomy or nonsurgical care. Outcomes were measured using a Visual Analog Scale (VAS) of back pain, the Oswestry disability index (ODI), and the 32-item short-form health survey (SF-36), which consists of physical component summary (PCS) and mental component summary (MCS) scores, and using radiologic outcomes and treatment-related complications. Of the 126 LDK patients treated during the reference period, 97 patients were enrolled (47 in the surgical group and 50 in the nonsurgical group). Results: This study showed a significant effect favouring surgery in terms of VAS, ODI, PCS, and MCS scores, and radiologic outcomes. However, the complication rate was high in the surgical group. Analysis showed a significant advantage for surgery at 6 months postoperatively in terms of ODI and SF-36 scores, and these benefit remained significant at 2 years. Conclusions: LDK patients that underwent surgery showed significantly greater improvement in all outcome variables than patients treated non-surgically., Introduction: Adult spinal deformity (ASD) has multiple etiologies and it develops over the years. Typical radiological findings are loss of lumbar lordosis (LL) 1 in relation to pelvic incidence (PI), PI-related amount of compensatory pelvic retroversion, pelvic tilt (PT) and reduction of thoracic kyphosis and hyperlordosis of cervical spine. 2 Most previous studies on spinal deformity and impact on health related quality of life (HRQoL) measures have been made of selected ASD patients or normative non-symptomatic population. 3-6 Our aim was to evaluate the occurrence of sagittal disorders in an unselected consecutive cohort of adult patients with a prolonged degenerative symptomatic spine disorder. For comparison of the disability and HRQoL outcomes, the patients were categorized into no, moderate or marked sagittal disorder. Materials and Methods: Consecutive adult patients (N = 874) with prolonged degenerative spinal disorders referred to Central Hospital of Jyväskylä spine clinic during one year and were recruited to the study. Exclusion criteria were age, Introduction: Little is known with respect to changes in the segmental thoracic and thoracolumbar kyphosis, which are major parameters influencing sagittal balance of the spine. The authors investigated the detailed segmental changes of those parameters by ageing. Material and Methods: A total of 326 normal asymptomatic males were divided into 2 groups; group 1 (mean age, 21.2 ± 1.7; n = 175) and group 2 (mean age, 64.1 ± 6.4; n = 151). After taking a standing sagittal radiograph, the sagittal spinal and pelvic parameters were measured. Thoracic and thoracolumbar kyphosis were classified according to segments A, C7 UEP (upper end vertebra)–T5 UEP; B, T5 UEP–T10 UEP; C, T10 UEP–T12 LEP (lower end vertebra); and D, (T12 LEP–L2 LEP), and analyzed between 2 groups, respectively. Results: Thoracic kyphosis (21.1° ± 7.7° vs 30.0° ± 8.8°, P, Introduction: Recent research in sagittal plane proposed age-adjusted alignment thresholds. However, impact of these thresholds on postoperative HRQL is yet to be investigated. This study aims to compare 2 yr clinical outcomes of patients (pts) who underwent surgical reconstructions based on their achievement to age-adjusted alignment ideals. Material and Methods: Retrospective review of prospectively collected database. Patients were included if > 18 years, underwent surgical correction of adult spinal deformity with a complete 2 yr FU. Pts were stratified into 3 groups based on achievement of age-adjusted thresholds in pelvic tilt (PT), pelvic incidence minus lumbar lordosis (PI-LL), sagittal vertical axis (SVA). First group included pts who reached the exact age-adjusted threshold ±10 yrs (MATCHED), other two groups included pts who were over corrected (OVER), and under corrected (UNDER). Clinical outcomes including actual value and offset from age-adjusted ODI, SF36-PCS and SRS-22 (PROM) were compared between groups at 2 yr FU. Results: 343 patients (57.0 years and 83% F) were included. Sagittal profile of the population was: PT = 23.6°, SVA = 65.8 mm, PI-LL = 15.6°. At 2-year follow-up there was a significant improvement in all sagittal modifiers with 25.7%, 24.3% and 33.1% of the patients matching their age alignment targets in terms of PT, PI-LL and SVA respectively. For PT and PI-LL the 3 groups (MATCHED, OVER, UNDER) had comparable values and offsets from age-adjusted PROM. However, for SVA groups, patients in UNDER had significantly worse HRQOL than the two other groups. Patients in PT, PI-LL, and SVA UNDER groups were significantly younger than the other groups, P < .05. Conclusion: At 2 yr following ASD surgical treatment only 24.3% to 33.1% of the pts reached age-adjusted alignment thresholds. Those under corrected in SVA demonstrated worse clinical outcomes. No significant improvements were found between matched and overcorrected pts, with overcorrection being an established risk for PJK. These results further emphasize the need for patient specific operative planning., Introduction: Halo traction has traditionally been used in the treatment of severe spinal deformities and growing rod systems have been known since the Luque trolley. There is an argument that slow correction as opposed to instant correction might yield a better adaptation of the spine, because of the viscoelastic properties of the intervertebral discs. Recently, percutaneously expandable magnetic rods have become available for the treatment of young children. There is very little experience regarding the use of such systems in the adult spine. We describe the successful use of these rods to treat a severe spastic hyperlordosis in an adult. Case Report: A 28-year-old university student with cerebral palsy presented with abdominal wall pain and increasing difficulty sitting in her brace-fitted wheel chair. Clinically there was residual motor function of the legs, severe hyperlordosis, flexion-adduction deformities of the hips and a visual aortic pulse below the umbilicus. The spine was palpable directly under the skin. Bracing and botox injections had been exhausted and radiographs showed a lordosis angle of 150 degrees. MRI and duplex ultrasound showed that the aortic bifurcation as well as the confluence of the iliac veins were stretched out in front of the spine and pressing against the abdominal wall. While a primary anterior approach was tempting because of the tall, distracted discs, we did not pursue this further because of the preceived high risk of vascular complications. In a first surgery, a radical posterior release was performed and a pelvic as well as a thoracic anchor were constructed. Between these anchors, a hinged construct with 2 MAGEC rods was inserted with the motors positioned subcutaneously. Over a period of 3 months, the rods were expanded with the deformity slowly correcting further. She then required a release and a rectus-psoas transfer to straighten her hip joints. After assessing her sagittal plane balance when standing with help, we finalized the correction with a slightly positive SVA at a lordosis angle of 75 degrees by completing a posterior instrumented fusion from T9 to the pelvis. Until 2 years postop, there have been no complications, no construct failure and she has returned to limited, aided standing and walking. Discussion: This is the first such case published. Slow percutaneous distraction was successful and aided by a progessive reduction in disc height under physiological loading. We feel that the concept of slow, controlled distraction deserves renewed thought also in severe adult spinal deformity., Introduction: The length of stay (LOS) following adult spinal deformity (ASD) surgery is a critical time period allowing for recovery to levels safe enough for to return home or to rehabilitation. Thus, the goal is to minimize it for conserving hospital resources and third party payer pressure. Factors related to LOS have not been studied nor has a predictive model been created. The purpose was to create a preoperative predictive model to predict the LOS following ASD surgery. Material and Methods: Retrospective review of a multicenter, prospective ASD database. Inclusion criteria: operative pts, age >18 yrs, ASD. Pts with staged surgery at a separate hospitalization or LOS >30 days were excluded. 66 variables were initially evaluated with 40 being used for model building following univariable predictor importance ≥0.90, redundancy, and collinearity testing. Variables included: demographic data, comorbidities, preop HRQOL, preop coronal and sagittal radiographic parameters, and modifiable surgical factors. A generalized linear model was constructed using a training dataset developed from a boostrapped sample with replacement using a random number generator. Pts randomly omitted from the boostrapped sample were included in the testing dataset. Accuracy was calculated by comparison of predicted LOS to the actual LOS. Results: A total of 689 patients were eligible with 653 meeting inclusion criteria. The mean LOS was 7.9 ± 4.1 days (median = 7, range: 1-28). Following bootstrapping, a total of 893 pts were modeled, Training: 653, Testing: 240(36.6%). The linear correlations for the training and testing datasets were 0.632 and 0.507, respectively. Testing dataset accuracy within 2 days of actual LOS was 75.4% (181/240 pts). The top 10 predictors were the following in decreasing order: staged surgery (yes/no), C7 SVA, number of posterior levels fused, Charlson Comorbidity Index, Total number of comorbidities, preop ODI score, iliac fixation (yes/no), preop SRS Activity score, preop SRS Appearance scores, and number of interbody fusion levels. Conclusion: A successful model was created to predict LOS following ASD surgery to an accuracy of 75% within 2 days. There are some factors related to LOS that are not likely captured in large databases, which may partially explain the 75% accuracy, such as rehab bed availability and social support resources., Introduction: After previously performed, unbalanced lumbar spinal fusions, revision surgery typically consists in extension of the fusion into the previously un-instrumented lumbar or thoracic spine. Pedicle subtraction osteotomy (PSO) with extension of the existing fusion is a powerful correction tool. It typically involves sacrificing at least two additional proximal motion segments in order to achieve meaningful correction and fixation. Blood loss, neuro-trauma due to extensive intra-spinal canal work, and soft tissue trauma to the posterior muscular structures is usually extensive. Adjacent TLIF fusion and Smith-Peterson osteotomy have only a limited ability to restore spinal balance. Material and Methods: We surgically treated 20 consecutive patients presenting with failed posterior lumbar fusion surgery (PLF). Pain and Oswestry score were documented prior to surgery, at 3 month, 6 month and annual follow up. Aim of surgical treatment was to primarily address the flat back deformity by osteotomies within the existing fusion. Surgery consisted of a triple approach from posterior, anterior and posterior again (BFB): 1) Back: After an initial posterior approach with limited exposure of the spinal canal and the foramina of the fused level(s) existing instrumentation was removed, a limited osteotomy through the PLF mass was performed until some mobility in the relevant motion segment(s) was achieved. Pedicle screws were placed or exchanged at the relevant levels. The wound was temporarily closed and the patient was turned over into supine position. 2) Front: Through a standard retroperitoneal approach the relevant disc(s) space(s) were exposed, followed by anuloplasty, complete nucleotomy and endplates preparation. In cases of previous TLIF fusions the implant was removed. A wedged ALIF cage, filled with autologous bone, was inserted and locked with screws and the anterior approach was closed. 3) Back: The patient was turned back into prone position, the original posterior approach was re-opened, the pedicle screws were connected under compression onto rods and the posterior wound definitively closed. Results: Four patients were male. Mean age was 52.1 (34-76) years. Of the 20 patients six had a prior L5-S1, seven had a prior L4-S1, three a L3-S1, one a L2-S1, one a L5-Ilium fusion and one L3-L5 floating fusion. There was no death or other serious outcomes as paralysis or major bleeding. As intraoperative cell saver was used only 4 patients required additional transfusion. One patient had a complex scoliosis fusion revised. Half of the patients had an extension of the fusion. At 2 year follow up one patient considered the outcome as poor, 3 as fair, 9 as good and 7 as excellent. The Oswestry score improved from 52.5 pre op to 24.3 at last follow up, the pain score from 8.75 to 3.46 respectively. Conclusion: We consider BFB osteotomy and fusion as a viable treatment option for active, younger patients in sagittal unbalanced, failed prior lumbar fusion surgery. One can preserve the remaining lumbar motion segments. However larger sample seize and longer term follow-up is necessary., Introduction: In recent years, the rate of utilization of 3-column osteotomy (include pedicle subtraction osteotomy (PSO) and vertebral column resection) has significantly increased, with a reported 3.2-fold increase in the use of PSO between 2008 and 2011 alone. With increased surgical volumes, the post-operative risk and care have become an important factors in the pre-operative risk assesment when proposing these techniques to treat complex spinal deformity, The purpose of this study is to determine the incidence and factors associated with intensive care unit (ICU)-level complications after adult spinal deformity (ASD) surgery. Material and Methods: A review of the American College of Surgeons National Quality Improvement Program database was performed for the years 2007–2013 to identify adult patients who underwent instrumented fusion for ASD. Intensive care unit-level complications were examined, and included: intraoperative cardiac arrest, prolonged ventilation, reintubation, pulmonary embolism, renal failure, cardiac arrest, myocardial infarction, and septic shock. Results: Among 1250 patients who underwent surgery for ASD, the rate of ICU-level complications was 5.4%; 0% for intraoperative cardiac arrest, 2.7% for prolonged ventilation, 1.8% for reintubation, 1.2% for pulmonary embolism, 0.1% for renal failure, 0.2% for cardiac arrest, 0.8% for myocardial infarction, and 0.7% for septic shock. Factors associated with ICU-level complications included male sex (OR 1.68; 95% CI, 1.01 – 2.80; P = .043), prolonged operative time (OR 1.26; 95% CI, 1.16 – 1.38; P < .001), and dependent functional status (OR 2.22; 95% CI, 1.02 – 4.84; P = .044). Conclusion: The findings of this study suggest that the rate of ICU-level complications after scoliosis surgery is approximately 5.4%. Certain preoperative and operative factors may increase the risk of these events including male gender, prolonged surgical time and dependent functional status. These factors should be considered when planning for surgery and for risk assessment., Introduction: Parkinson disease often leads to abnormal posture or sagittal alignment inducing significant disability. The underlying pathophysiology of these deformities is largely unknown, and their management remains difficult.1 Association between poor bone quality and severe muscular dysfunction lead to complicated spine surgery.2 Because the functional results of long fusion for Parkinson patients remained unclear3-5, we proposed to retrospectively review a cohort of long fusions for spinal deformities in patients suffering of Parkinson disease. The aim of the study was to assess the functional benefit and patient satisfaction after long spinal fusion surgery despite complications, and tried to highlight the predictive factors of satisfactory functional results. Material and Methods: We retrospectively reviewed 18 patients suffering of Parkinson disease operated of spinal deformities in our spinal surgery centre between 2002 and 2014. Severity of their Parkinson disease was assessed at last follow up using the MDS-UPDRS and MMSE scores. Primary endpoint was the Owestry Disability Index (ODI)6 at last follow-up compared to the ODI before surgery. Patient satisfaction was assessed at last follow up. Complications needed revisions were recorded. Sagittal parameters were assessed before and at last follow up on full lateral spine X-Rays using the Keops software (Smaio, Lyon). We searched for variables associated with the postop ODI score adjusted on preop ODI. Comparison between pre and post-operative scores and sagittal parameters was done using the parametric student-t test. A linear regression was built to assess the effect of relevant predictors of ODI. All analyses were performed using R (version 3.1.3., R Core team). Results: Median age at surgery was 69.3 years (64-72.7). Median fusion length was of 10 levels fused (9-16). Median follow up was 44.4 months (36- 62.4). Preoperative ODI was 64 (59-77) and last follow up was 49 (40 – 57). Difference was statistically significant (P = .0014). There was no difference between pre-operative and last follow up physical and mental SF-12 rates (P = .48 and P = 1 respectively). Fifteen patients (83%) were very satisfied (n = 5) or satisfied (n = 10) of the surgery and would have choose the same procedure again. Six patients (33%) underwent one surgical revision, complication occurred at 1.28 years (0.7 -1.6). On these 6 patients, 2 underwent two surgical revisions. Improvement of sagittal balance was statistically non-significant (P = .35). Mismatching between pelvic incidence and lumbar lordosis was lower at last follow up than before with a median of 9° (-4.4; 18.3) and 15.9° (1.61-70.4) respectively (P = .24). The median MDS-UPDRS score at last follow up 14.5 (11.5-20.5)/ 16 (16-16.7)/ 40.5 (38.5-45.5)/ 5(3.5-5.7). The MMSE score at last follow up was 26 (22.7-27.7). Predictors of last follow up ODI score: In multivariate analysis, only age was significantly associated with last follow up ODI (estimate: -9.8, P = .5). Conclusion: Even if patients suffering of Parkinson disease with spinal deformations have a high risk of surgical spine complications, the enhancement of their autonomy and their satisfaction after long spinal fusion have to be borne in mind before rejecting surgery, especially with motivated patients. Perfect postoperative sagittal alignment doesn’t seem to be mandatory. References 1. MRCP KMD, van de Warrenburg MD BP, MD MCP, et al (2011) Postural deformities in Parkinson’s disease. The Lancet Neurology 10:538–549. doi: 10.1016/S1474-4422(11)70067-9 2. Sarkiss CA, Fogg GA, Skovrlj B, et al (2015) To operate or not?: A literature review of surgical outcomes in 95 patients with Parkinson’s disease undergoing spine surgery. Clinical Neurology and Neurosurgery 134:122–125. doi: 10.1016/j.clineuro.2015.04.022 3. Bourghli A, Guérin P, Vital J-M, et al (2012) Posterior spinal fusion from T2 to the sacrum for the management of major deformities in patients with Parkinson disease: a retrospective review with analysis of complications. Journal of Spinal Disorders and Techniques 25: E53–60. doi: 10.1097/BSD.0b013e3182496670 4. Wadia PM, Tan G, Munhoz RP, et al (2011) Surgical correction of kyphosis in patients with camptocormia due to Parkinson’s disease: a retrospective evaluation. J Neurol Neurosurg Psychiatry 82:364–368. doi: 10.1136/jnnp.2009.176198 5. Peek AC, Quinn N, Casey ATH, Etherington G (2009) Thoracolumbar spinal fixation for camptocormia in Parkinson’s disease. J Neurol Neurosurg Psychiatry 80:1275–1278. doi: 10.1136/jnnp.2008.152736 6. Fairbank JCT, Pynsent PB (2000) The Oswestry Disability Index. Spine 25:2940–2953. doi: 10.1097/00007632-200011150-00017, Introduction: The understanding of normative values of radiographic parameters allows surgeons to customize the surgical objective in the setting of the adult spinal deformity treatment. However, significant differences in spinopelvic alignment have been reported across different ethnicities. The aim of this study is to investigate the normative values and chain of correlations across spinopelvic parameters in a Brazilian population sample. Material and Methods: This is a prospective observational study including adult asymptomatic subjects who underwent full spine radiographs. The subjects were stratified by age into 3 groups (18-39 y/o, 40-59 y/o, and > 60 y/o) and radiographic parameters were compared across age groups, using ANOVA, and gender, using student t-tests. The relationships across various radiographic parameters were calculated by the Pearson product-member correlation coefficients. Results: 130 asymptomatic volunteers (mean 48y) met the inclusion criteria and were evaluated. The mean and range of sagittal parameters in normative Brazilian population were identified. Subjects ≥ 60 y/o had significantly higher values for SVA (P = .024) and TPA (P = .009) than the two younger age groups. TPA significantly correlated with the following spino-pelvic parameters: LL (r = -0.172, P = .005), PT (r = 0.776, P < .001), PI (r = 0.508, P < .001), PI-LL (r = 0.717, P < .001), SVA (r = 0.409, P < .001) and T1 Slope (r = 0.172, P = .050). There was a significantly higher mean of the SVA and TPA in the subjects ≥ 60 y/o, compared with the two other age groups (P = .024 and P = .009). It was also observed a significant correlation of the TPA with the following parameters: LL (r = -0.172, P = .005), PT (r = 0.776, P < .001), PI (r = 0.508, P < .001), PI-LL (r = 0.717, P < .001), SVA (r = 0.409, P < .001) and T1 Slope (r = 0.172, P = .050). Conclusion: The normative values of sagittal parameters in a sample of a Brazilian population were presented in this study. Moreover, to date, this is the first analysis of the normative value of TPA in asymptomatic subjects. This study demonstrated a significant physiologic trunk inclination (higher SVA and TPA) with increasing age. The chain of correlations between spinal segments was confirmed by the significant correlation of the TPA with all the other parameters, with the exception of sacral slope., Introduction: Adult degenerative scoliosis (ADS) is a common problem in the World, usually those over the age of 60. A retrospective study of 34 patients (age 60-83 years) with ADS with SPL. According to ODI, ASIA, SVA, VAS data, patients with ADS and SPL who were undergo spinal fusion have different clinical and X-ray outcomes in different operative technics.There are not enough reports in the literature, describing the outcomes of pts with ADS and SPL operatively treated. Our study set out to compare clinical and radiographic outcomes in operative treated ADS pts with SPL with or without vertebra reduction. Methods: A retrospective study of 34 patients (age 60-83 years) with ADS with SPL. Mean follow-up period was 4 years (2-5 years). Inclusion criteria: age >60 yrs, no prior surgery, and ADS (scoliosis ≥20 degrees, sagittal vertical axis (SVA) ≥6 cm, pelvic tilt (PT) ≥25 degrees, or thoracic kyphosis (TK)>60 degrees). Demographic, radiographic and HRQOL data evaluated including: Oswestry Disability Index (ODI), ASIA and VAS pain scale. Patients divided into 2 groups in depending on the applied surgical techniques: in the first group in 18 cases with transpedicular screw fixation, multilevel SPO+PSO, second group with transpedicular screw fixation, multilevel SPO+TLIF with vertebra reduction. There was no significantly difference between pre-op age, VAS, ASIA and ODI in both groups. Results: In the first group a full restoration of the sagittal & coronal balance was achieved. In the second group, we did not achieve a full postoperative restoration of the sagittal & coronal balance. Post-op ODI, VAS and ASIA improvement in all groups but no significantly different between them. I group had significantly better SVA (≤4 cm) then II SVA (≥5 cm) (P = .03). At 3 years control showed, the I groups had significantly better ODI (36%) and VAS (3,1) then II (54%/4,9) (P = .04). Conclusions: PSO with multilevel SPO and transpedicular screw fixation allow to achieve good clinical outcomes. Deformities corrections without SPL reduction does not influence on sagittal balance restoration and fusion post-op. To confirm these the obtained results require more observations., Introduction: This study is designed for retrospective case-control, questionnaire study. Objective of this study is to describe the changes in self-perceived mobility in patients after long level lumbar fusion with or without iliac screw. Iliac screw fixation is used in spinopelvic instrumentation for variable diseases. The loss of motion resulting from spinal fusion lead to morbidity and a negative impact on quality of life. Recently measuring disability, HRQOL and health utility has become widely used. But standardized HRQOL doesn’t reflect Asian sedentary life style. To our knowledge, there is no study compares the self-perceived outcomes of iliac screw fixation, especially related to Asian sedentary life style. Materials and Methods: This study includes 47 patients who underwent thoracolumbar and lumbar fusion (more than 4 levels) with a minimum follow-up period of 1 year. The patients were divided into two groups on using iliac screw or not. Group 1 consisted of 19 patients and group 2 consisted of 28 patients. We made 1 questionnaire including 7 questions and each question is representative of typical Asian sedentary life style. The outcome of both group were statically compared. Results: Patients with iliac screw fixation group did significantly worse in all questions compared to preoperative states. But there were no significant differences between pre- and post- operative states in lumbosacral fusion without iliac screw fixation group. Also as compared to the non-iliac screw group, the iliac screw group reported significantly worse self-perceived mobility for all questions in our questionnaire. Conclusion: The current study demonstrate that patients underwent lumbosacral fusion with iliac screw fixation have morbidity and poor self-perceived mobility in Asian sedentary life style. The results suggest that surgeons should discuss with patients about morbidity and life style change after surgery before long level lumbosacral fusion including pelvic fixation, Introduction: Lumbar and/or thoracolumbar kyphosis with sagittal imbalance is one of the main causes of negative impacts on the quality of life. Spinal osteotomies should be needed to achieve ideal sagittal curve correction in these patients. Pedicle subtraction osteotomy (PSO) is well-known for powerful corrective osteotomy technique. To review the radiographic and clinical outcomes of lumbar or thoracolumbar kyphotic deformity patients treated with osteotomies including PSO. And to investigate global and regional sagittal balance after corrective surgery, global sagittal parameters such as SVA, PT, T1 pelvic angle (T1PA), PI-LL mismatch and achieved PSO angle, regional kyphotic angle, TL junction Cobb angle analyzed among preoperatively, postoperative 1 month and final follow-up at the standing whole spine radiographs. Outcome variables included radiographic evaluations (SVA, PT, T1 PA, and PI-LL mismatch) at postoperative 1 month and final and clinical outcomes (ODI, VAS of back and leg pain, and SRS-22r). Methods: Thirty-eight patients (31 women and 7 men) who underwent pedicle subtraction corrective osteotomy were enrolled from 2009 to 2015. 30 lumbar flatback deformity (3 degenerative flatback and the other 27 postfusion flatback) and 8 delayed posttraumatic kyphosis patients were included. Preoperative, postoperative 1 month, and final whole spine standing sagittal radiographs were obtained and analyzed by achieved PSO angle, regional curves (thoracic, thoracolumbar, lumbar Cobb angle), local kyphotic angle and apical vertebra distance(AVD) in patients with posttraumatic kyphosis, pelvic parameters (pelvic incidence(PI) and pelvic tilt [PT]) and global balance (sagittal vertical axis [SVA], T1 pelvic angle(T1PA)). Early perioperative and delayed fusion or instrumentation related complications were also reviewed. Results: Mean age was 63 years old (range 46-74), and follow-up was 25 months. Mean age of flatback deformity was 65 years old and 56 years for posttraumatic kyphosis. Previous surgery in post-fusion flatback deformity was mean 2.4 spine operations PSO levels of lumbar flatback deformity were L1(2), L2(4), L3(13), and L4(11). PSO levels of post-traumatic kyphosis were T12(4), L1(4). In patients with flatback deformity, Mean angle of PSO of flatback was 29.5° (range 17°∼40°). Preoperative 1.8° lumbar kyphosis, 31° PT, 176 mm SVA, 52° PI-LL mismatch, and 41° T1PA were significantly improved in 57° lumbar lordosis, 14° PT, 17 mm SVA, -6° PI-LL, and 11° T1PA at postoperative 1 month and well maintained these parameters finally. In patients with posttraumatic kyphosis, mean corrected kyphotic angle was 35° (range 20°∼40°). Preoperative 42° TL Cobb angle, 79 mm SVA, 92 mm AVD were significantly improved in 6.5° TL kyphosis, 19 mm SVA, and 6 mm AVD and well maintained finally. The mean score of ODI, VAS of the back pain/leg pain, and SRS-22r patient questionnaire of lumbar flatback deformity patients was significantly improved at the final follow-up (P < 0.05). preoperative mean ODI(67), VAS of the back pain(8), VAS of the leg pain(7), and mean SRS22r(2.0) were significantly improved into 25 ODI, 2.8 VAS of the back pain, 2.3 VAS of the leg pain, 3.7 SRS-22r score at the final. Preoperative mean ODI(56), VAS of the back pain(7.5), VAS of the leg pain(6), and mean SRS22r(2.2) of delayed posttraumatic kyphosis patients were significantly improved into 19 ODI, 2.1 VAS of the back pain, 1.6 VAS of the leg pain, 4.0 SRS-22r score at the final. Reoperation was 12 cases(40%): early reoperation were 6 cases (20%): 4 acute proximal junctional failures due to 2 UIV fractures, one UIV+1 fracture and one proximal screw loosening; one neurological deficit and one hematoma revision. Delayed revision surgery were 6 cases (20%): 3 fusion extension due to delayed proximal junctional kyphosis; 1 nonunion at L5S1; one symptomatic rod fracture revision, one delayed compression fracture with neurological deficit. Conclusions: Lumbar or thoracolumbar kyphotic deformity patients can be treated with osteotomies including PSO. Pedicle subtraction Osteotomy (PSO) is very effective for the correction of post-fusion lumbar flatback deformity and/or delayed post-traumatic kyphosis with global and regional sagittal imbalance. Patient satisfaction with surgery and overall radiographic and clinical outcomes are excellent even though higher rates of perioperative and delayed complications., Introduction: Lumbar hyperlordosis is seen as a compensatory mechanism in sagittal malalignment. Hyperlordosis may also be seen after overcorrection with spinal osteotomies, but rarely causes clinically significant negative sagittal imbalance because of the thoracic compensation. Hypercorrection in the lumbar spine leading to negative sagittal balance with pelvic anteversion can reduce quality of life. This uncommon condition needs surgery aimed to reduce lumbar lordosis, which has received little attention in the literature. Material and Methods: We describe a case of a 45 year old woman with a history of juvenile scoliosis treated conservatively. From the age of 42 she underwent 3 surgeries: T3-L4 posterior fusion, L4-L5 XLIF with posterior extension of fusion and finally L3-L4 XLIF with posterior revision 3 years after the first procedure. Despite the aggressive surgical treatment the patient complained of persistent lumbar pain and lower limb pain (ODI: 68 VAS back: 10 VAS legs:7). Upon examination she presented with sagittal and coronal imbalance. The negative sagittal imbalance, caused by the extension of her fusion to the pelvis with excessive lordosis, resulted in an negative SVA (-64 mm) and a negative pelvic tilt (-3°). Other preoperative spinopelvic parameters were: LL 62°, PI 37°, TK 45°. A posterior column osteotomy was performed at L2-L3, where the disc was not fused. Distraction through the osteotomy site and structural grafting were applied. Coronal correction was obtained by asymmetrical distraction. Results: Postoperative lumbar lordosis was reduced by 18° to a final LL of 44°, SVA was -1,5 mm, PT +4°, TK 49°. No complications were observed. Conclusion: Kyphosing posterior column osteotomy is a surgical technique that can be used to restore sagittal balance in patients with fixed lumbar hyperlordosis and negative sagittal balance. Appreciation of a patient’s balanced sagittal alignment and available compensatory mechanisms can help ensure appropriate osteotomies are planned and executed., Introduction: Adult spinal deformity (ASD) describes a complex spectrum of spinal conditions presenting in adulthood that result in abnormal spinal alignment in axial, coronal and sagittal planes. Conservative management is offered as the first line of treatment but its efficacy is not supported by literature. Different surgically approaches with various grade of invasiveness are described in literature: open surgery (OP), minimally invasive surgery (MIS) and hybrid technique (OP+MIS). The aim of this systematic review is to investigate risks and complications in ASD surgery. Materials and Methods: A systematic review of the available English literature about ASD perioperative (≤3 months) and long-term (> 3 months) surgical complications on Pubmed, Embase, Medline, Google Scholar and Cochrane Central Register of Controlled Trials (CENTRAL) databases was conducted. Retrospective (minimum 24 months follow-up for OP and 18-months for hybrid and MIS) or prospective studies (minimum 18 months follow-up) including randomized controlled trials, nonrandomized trials, cohort studies, case-control studies, and case series published in 2005 or later were included. Postoperative complications were all stratified by surgical approach. Open surgery included anterior, posterior or combined approaches with three-column osteotomies and non-three-column osteotomies. MIS techniques were percutaneous screws fixation, lateral lumbar interbody fusion (LLIF), anterior column realignment (ACR), Axial lumbar interbody fusion (AxiaLIF), and MIS transforaminal lumbar interbody fusion (MIS-TLIF). Results: One hundred-seven articles were ultimately eligible for analysis. 90 analyzed OP, 6 concerning MIS, 7 about hybrid, 2 MIS-hybrid, 1 MIS-OP-hybrid and 1 OP-hybrid. For open approach the data of 13164 patients (mean age 52.1 and mean follow-up 3.5 years) were extracted, there were 4451 complications and a complication rate of 0.34. Specifically, major perioperative complications occurred at a mean rate of 0.09, minor perioperative complications occurred at a mean rate of 0.10, and long-term complications occurred at a mean rate of 0.11. For hybrid and MIS 647 and 480 patients were analyzed respectively (mean age 64.8 and 63.8; mean follow-up 2.3 and 2.6 years). Major perioperative complications occurred at a mean rate of 0.15 for hybrid approach and 0.06 for MIS, minor perioperative complications occurred at a mean rate of 0.21 and 0.09, long-term complications occurred at a mean rate of 0.19 and 0.11 respectively. Conclusion: Aging of population, increased active life expectations and improvements in instruments and surgical techniques have involved an increased of spinal surgery for ASD. An appropriate and correct information providing realistic expectations to the patients and their family about risks and complications is mandatory before surgery., Introduction: Pelvic incidence (PI) was first described by Legaye and could be considered as a constant for each individual because it is an anatomical parameter once the growth is completed. This parameter has a cardinal importance in the regulation of the sagittal curves of the spine because there is a correlation between pelvic incidence and other spino-pelvic parameter. Adult deformities are often characterized by a mismatch between pelvic incidence and lumbar lordosis as well as coronal malalignment. Recently some classification of adult spinal deformities have been proposed and they rely on the fact that pelvic incidence is a fixed parameter, thus representing the base on which the new shape of the spine can be built. The purpose of this study is to analyze the modification of spino-pelvic parameters in patients who underwent long spinal fusion to the sacrum or to the ilium for correction of adult deformities. Material and Methods: The pre and immediate post-operative X-rays of 65 patients that underwent surgical correction for coronal, sagittal, or combined adult deformity between 2012 and 2015 were retrospectively analyzed. We included patients who had thoraco-lumbar fusion and we excluded revision surgeries, patients affected by tumors, autoimmune disease or infection. We divided the population in two groups: group A (n = 22) had fusion from the thoracic spine to S1, group B (n = 43) from the thoracic spine to the ilium. The spino-pelvic parameters were measured on the full standing spine pre-operative and post-operative x-rays by different surgeons checking the inter-observer variability. Results: Group A was composed by 18 women and 4 men with an average age at the time of surgery of 64.2 years. The mean pre and post-operative PI in this group were respectively 57° and 61° with a mean difference of 4° that was statistically significant (P < .05). In group B there were 4 men and 39 women and the average age was 65.6. The mean pre-operative PI was 53° and decreased to a mean value of 50° at post-operative control (mean difference 3°; P < .05). Conclusion: We observed that pelvic incidence changed in both groups. This result may be due to the position of the patient during surgery. The PI may decrease when fixation reaches the ilium due to the forced hyperextension of the hips and the aggressive correction maneuvers which create stress across the sacro-iliac joints (SIJ) and change the position of the sacrum within the pelvis. Conversely, the PI may increase in patients with fixation to the sacrum because of the long lever arm on the SIJ that forcing the sacrum into a more horizontal position. Pelvic incidence is still regarded as a key parameter in the planning of an adult deformity correction, although some papers have been recently published about its modification in the elderly and after surgery. Our work suggests that we still lack knowledge in the deformity correction methods and perhaps new parameters might be taken in consideration in the future., Introduction: Spondylolisthesis is characterized by slipping the upper vertebra lower on the previous direction or in more severe cases, anterior, and caudal. It can be classified according to rating Spinal Deformity Study Group - SDSG in six grades according to the degree of slip of the vertebrae, pelvic incidence and squamous pelvic equilibrium. It is common low back pain with or without radiation to the lower limbs, sensory and motor function in the lower limbs, postural changes and sometimes neurogenic claudication, defined as pain in the lower extremities, numbness or weakness associated with wandering or remain seated. To assess pain and functional capacity of a patient with spondylolisthesis, high-grade neglected. Materials and Methods: Patient, female, 27 years old, pregnant women diagnosed with spondylolisthesis type 6, with the presence of postural changes without motor deficit, paresthesia in dermatomes L5 and S1 (Scale ASIA) and Visual Analogue Scale (EVA) 9 in the lower back. The degree of slippage was determined using a lateral view of the lumbar spine in the standing position. It was performed conventional functional kinesiological evaluation before and after physical therapy twice a week lasting 50 minutes each session for 15 weeks. During the sessions lumbar segmental stabilization exercises were associated with breathing exercises, diaphragmatic and application of bipolar interferential current for analgesia in the lower back. At the end of the sessions we used the Oswestry Disability Index 2.0, a functional questionnaire that allows us to evaluate the function and capacity of the patient. Results: After 30 sessions of physiotherapy in five months, patients showed a significant decrease in back pain (VAS = 2), paresthesia (only S1) with improved performance of activities of daily living. The results found in Oswestry index was 26%, indicating that the patient has a moderate disability. Conclusion: Although the radiographic images contain important anatomical changes, the proposed conservative treatment provided a significant improvement in functional kinesiological frame with functional capacity guarantee., Introduction: The objectives of this study were to access the effectiveness of surgery and nonoperative treatment regimens for patients with adult spinal deformity (ASD) in terms of responsiveness of pain, disability, and quality of life; and to evaluate the complication and revision rate of large modern surgical series. Materials and Methods: A systematic review of articles in English using PubMed between 2005 and 2015. Only articles that reported baseline and follow-up ODI data were included for further analysis. Data extraction of articles using predefined data fields and risk of bias assessment were done independently by 2 authors. Results: 26 articles were analyzed, most of them were retrospective (n = 22; 84.6%). The average postoperative improvement in ODI was -19.1 (±9.0), NRS back pain -4.14 (±1.38), NRS leg pain -3.36 (±1.33), SF36-PC 11.2 (±5.07), SF36-MC 9.93 (±4.96). Surgery presented very large effect size in reducing disability (1.28), back (1.94) and leg (1.4) pain, and medium effect size in increasing physical (0.49) and mental (0.5) components of quality of life. No effects on back pain (-0.13), disability (-0.06) and quality of life (PCSF36 = 0.01; MCSF36 = 0.01) were observed in nonoperative series. The complication rate ranged from 9.52% to 81.52% in surgical cohorts (weighted mean: 39.62% ±16.62). No complications were recorded from the nonsurgical series. The need for revision surgery ranged from 1.72% to 40.0% (weighted mean: 15.71% ±8.99). Conclusions: These data may assist clinicians in determining how much to expect these outcomes to change after surgical treatment that may assist in counseling patients, informing providers and policy makers., Introduction: Tranexamic acid (TXA) and cell saver (CS) are successfully used to reduce bleeding in major surgery. The increase in the number and complexity of spinal deformity corrective surgeries, blood loss, often requiring massive intraoperative transfusions, becomes a major limiting factor during surgery. This scenario is particularly during posterior vertebral column resection (PVCR), where extensive intraoperative blood loss may pose a major risk to the patient, preventing smooth execution of the procedure. The purpose of this work is to study the efficacy of the intraoperative administration of TXA and CS in spine surgery with regard to the reduction of perioperative bleeding, blood needs and possible postoperative complications deriving from its use. Material and Methods: Observational, longitudinal, retrospective study of patients who underwent transpedicular arthrodesis surgery in adult deformity at the Leon hospital from 1 January 2007 until 31 December 2015. We collected sociodemographic variables, diagnosis, type of surgery, arthrodesis levels, surgical time, perioperative complications, bleeding, transfusion, hospital stay and complications. Classified in three groups: Group A (n = 26), patients who were administered TXA. Group B (n = 21), intraoperative CS. Group C (n = 30), patients not administered TXA or CS. We did a statistical analysis using SPSS software v22.0. Results: 77 patients, 68% women, 65 years, Levels fused 7. There is no difference in the demographic, surgery duration, number of levels fused, days of hospital stay and surgery complications between the three groups. Patients who were administered TXA received 20% fewer allogenic blood transfusions (P = .041). Patients in the CS group had 21% less reduction of postoperative haemoglobin (P = .029). TXA reduced the intraoperative bleeding 27% in comparison with control group. There aren’t more infections, seromas or complications with CS or TXA. Conclusion: TXA and CS reduced the demand for allogenic transfusion and had less reduction of postoperative haemoglobin, but not increases the development of post-surgical complications., Introduction: Corrective surgery in kyphoscoliosis is high demanding surgery for both surgeon and patient due to necessity of performing osteotomies, nowadays OLIF is widely performed to achieve minimally invasive lumbar lateral interbody fusion. In our study we used OLIF minimally invasive as first step to aim lumbar interbody fusion and to start correcting the lumbar sagittal balance. Material and Methods: From February 2016 to June 2016 we have collected 8 patients with lumbar kyphoscoliosis. There were 3 males and 5 females (average age 65,6 ys), in 6 cases we performed 3 levels OLIF at L2-L3, L3-L4 and L4-L5; in 1 case OLIF L4-L5, in 2 cases L3-L4 and L4-L5. In all cases we used right lateral decubitus. We observed verticalization time, clinical function, healing time and complications. Results: In all 8 cases after 2 days the patients were verticalized, blood loss was less than 50 cc; the OLIF procedure required almost 45 minutes per level. The correction gained on sagittal balance after stand alone OLIF was 5.3° level. In all cases according to PROLO and VAS score we had excellent results. As complication in 3 patients we had transient psoas weakness and thigh numbness on left side; in 2 cases with posterior long construct (T10-L5) we had sacro iliac inflammatory disease resolved with corticosteroid injections. Conclusion: OLIF is a safe and reproducible technique and it’s useful during the first of the correction of lumbar kyphoscoliosis., Introduction: The osteoarthritis of knee with flexion contracture may result in the changes in spinopelvic parameters in normal asymptomatic spine. The aim of this study is to evaluate the influence of knee joint flexion contracture to sagittal spinopelvic alignment by comparing groups of gonarthrosis with knee joint flexion contracture over 10 degree and those without contracture. Material and Methods: A total of 59 patients with gonarthrosis having knee joint pain over 1 year, and normal asymptomatic spine were included (mean age 66.7 ± 9.8, M/F=30/19). Volunteers with history of spine operation, spinal disease, chronic pain in their back, scoliosis, spondylolisthesis, 1-3 segmental disc space narrowing, and/or compression fractures in radiographs were excluded. They were divided into 2 groups according to the degree of flexion contractures in the knee joint (Group 1, without knee joint flexion contracture, n = 29, Group 2 > 10°, n = 30). After taking a standing sagittal radiograph, the following parameters were included: distances from C7 plumb to the postero-superior endplate of S1(C7PL), thoracic kyphosis (TK) between T5 upper endplate (UEP) and T12 lower endplate (LEP), thoracolumbar kyphosis (TLK, T10 UEP - L2 LEP), lumbar lordosis (LL, T12 LEP - S1 UEP), pelvic tilt (PT), pelvic incidence (PI), and femoral tilt angle (FTA). They were analyzed between 2 groups, respectively. Results: There were no significant differences between two groups in C7PL (0.0 ± 3.1 cm in Group 1 vs. -0.8 ± 2.9 cm in Group 2, P = .45), TK (26.1 ± 10.8° vs. 22.4 ± 10.1°, P = .30), TLK (6.5 ± 8.4° vs. 9.9 ± 5.9°, P = .17), LL (-53.0 ± 8.1° vs. -53.1 ± 10.2°, P = .10), PI (49.6 ± 8.7° vs. 53.5 ± 14.1°, P = .30), PT (12.6 ± 8.3° vs. 16.9 ± 10.5°, P = .18), FPA(7.2 ± 0.08° vs. 1.1 ± 7.2°, P = .08), and FTA(5.4 ± 3.2° vs. 15.8 ± 3.4°, P = .00). Conclusion: In the patients with gonarthrosis, the flexion contracture of knee joint over 10° did not show the difference of the spinopelvic angular parameters by the quantitative measurements of the pelvic and spinal parameters., Introduction: Cervical spondylosis is a degenerative disease of the vertebral column and associated soft tissue structures that can gradually progress as a normal aging process. These spondylotic changes can cause irritation or impingement to the nerve roots or spinal cord known as radiculopathy or myelopathy, respectively. Cervical spondylotic myelopathy (CSM) is a severely debilitating disease that can progress to several severe consequences such as spasticity and weakness of the limbs, clumsiness of the hands, and in extreme cases, paralysis. Several surgical treatment modalities for CSM and can be approached anteriorly, posteriorly, or circumferentially. The current controversy with the anterior approach is whether anterior cervical decompression and fusion (ACDF) or anterior cervical corpectomy and fusion (ACCF) is more efficacious in treating multilevel CSM. The most current Cochrane review to examine surgical options for cervical radiculopathy or myelopathy was published in 2010. Since then numerous studies have compared ACDF to ACCF for this indication, but have led to variable data without explicit answers to this controversial topic. Materials & Methods: We reviewed and analyzed peer-reviewed articles published since the 2010 Cochrane review that examined the use of ACCF for patients with a diagnosis of CSM. Only studies with a minimum follow-up period of two years and at least one clinical or radiographic outcome were included. Data collected included grafts and constructs used, mean blood loss (MBL), operative times, clinical and radiographic outcomes including fusion rates, and complications reported. Results: 13 studies were included in this review article. The most common constructs reported were fibular struts with and without halo vests, mesh filled titanium cages, PEEK cages, and expandable titanium cages (Figure 1) with the use of autogenic or allogenic graft. Mean follow-up in these studies ranged between 24 months and 8.5 years. MBL reported by these studies ranged between 108 and 1011 cubic centimeters (cc). The mean operative time ranged between 119 and 268 minutes. Nine studies reported fusion rates (79-100%). Five of the studies showed a 100% fusion rate by final follow-up and two others reported rates over 93%. Each of the studies demonstrated significant improvements in one or more of the following: JOA and mJOA scores, Nurick grades, VAS scores, and NDI scores. Eleven of the studies reported either segmental lordosis changes and/or C2-C7 Cobb angle changes on radiographic measures and each showed significant post-operative improvement in their reported metric. Complications reported included CSF leak, dysphagia, hoarseness, epidural hematoma, dural tear, C5 radiculopathy, and cage dislodgement and subsidence. Conclusion: This review article shows that ACCF is a relatively safe and effective surgical option for CSM, despite carrying certain risks expected of any anterior cervical approach. If the pathology lies behind the vertebral body, then ACCF should be greatly considered. When used for suitable indications, ACCF can improve signs and symptoms of CSM and improve functional outcomes with minimal complication rates., Background: Anterior cervical discectomy and fusion (ACDF) has gained well popularity and been accepted as an effective treatment on a various cervical spinal pathologies especially cervical disc pathologies (Disc Prolapse & DDD) meanwhile it is associated with many complications both intra and post operation. Aim of the Study: To evaluate the early complications of ACDF intraoperatively & postoperatively. Patients and Methods: This multicenter prospective study of 50 patients 38 male (76%) and 12 females (24%) their ages distributed form 35- 60 years (mean of age 42.5 years), the study was started from January 2013 to October 2014, we followed up them for 6 weeks and evaluate the clinical and radiographic signs of complications. Results: There were 18 patients (36%) had transient dysphagia, 15 (30%) had donor site pain, 1 patient (2%) each had slippage of cage, postoperative hematoma, dural tear & wrong level surgery. None of these patients had recurrent laryngeal nerve injury, esophageal injury, or acute postoperative infection. Conclusion: Not all complications required surgical intervention and can be treated nonoperatively with careful follow up. Our results are comparable with what was reviewed in other literatures. Yet the incidence of complications is increased with more than one level fusion and in multiple co-morbid disorders (including diabetes, smoker.), Introduction: This study compared patients undergoing one level anterior cervical discectomy without fusion versus anterior cervical discectomy with fusion. Methods: The study included forty patients operated at either C5-C6 level or at the C6-C7 level: a group of anterior cervical microdiscectomy without fusion performed at one level on 20 consecutive patients was matched to a second group of 20 patients with single-level of anterior cervical discectomy with fusion, based on level, age and sex. The kinematic analysis included the range of motion, intervertebral angulations, anteroposterior translation and disc height assessed for the cervical functional spinal units at the operated level and adjacent levels. Results: At the operated level the range of motion and the translation were minimal in the anterior cervical discectomy without fusion group, both for the C5-C6 and C6-C7 levels, and absent in the cervical discectomy with fusion group. The superior adjacent levels range of motion and the translation were greater in the ACDF group compared with the ACD group. Conclusions: The clinical results of anterior cervical microdiscectomy without fusion and anterior cervical discectomy with fusion were comparable. In cervical microdiscectomy without fusion the elastic fibrous intradiscal scar at the operated level allows a small degree of mobility and the adjacent cervical levels are not overstressed. No need for anterior cervical discectomy with fusion to trait a single level cervical disc herniation than in selected cases., Introduction: Surgical experience has been postulated to play a role in perisurgical morbidity in spine surgery. However no current data exists to verify this statement and if there is surgical threshold at which the morbidity decreases. This study investigates the impact of surgeon volume on inpatient morbidity after 1–2 level anterior cervical discectomy and fusion (ACDF). Material and Methods: Data from the Nationwide Inpatient Sample from the year 2009 were extracted. All adult patients who underwent an elective 1–2 level ACDF for degenerative cervical spine disease were identified. Surgeon volume was analyzed as a continuous and categorical variable (very-low, low, medium, high, and very-high volume). A multivariate logistical regression analysis was performed to calculate the adjusted odds ratios of in-hospital complication occurrence in relation to surgeon volume. Results: A total of 11,388 admissions were analyzed. The overall complication rate was 2.7%, and the surgical complication rate was 1.2%. Following regression analysis, increasing surgeon volume (evaluated continuously) was independently associated with lower odds of perioperative complication development (OR 0.99; 95% CI, 0.98 – 0.99). Complications in non-teaching hospitals occurred in 2.5% of cases, compared to 2.8% in teaching hospitals (P = .313). Very-low volume surgeons (performing less than 12 procedures per year; less than 1 per month) showed a significant increase in overall complications (OR 1.65; 95% CI, 1.05 – 2.58), when compared to very-high volume surgeons. Both very-low volume surgeons (OR 2.20; 95% CI, 1.11 – 4.37) and low-volume surgeons (performing less than 24 procedures per year; OR 2.13; 95% CI, 1.10 – 4.13) had a significant increase in surgical complications. Conclusion: In this retrospective analysis of a nationwide database, increasing surgeon volume was independently associated with significantly lower odds of perioperative complications following 1–2 level ACDF. Complication rates at teaching and non-teaching hospitals were similar. Additionally, a potential threshold of 1 procedure per month was found to significantly decrease overall complication rates; performing 2 or more procedures per month significantly decreased surgical complication rates., Introduction: Anterior cervical discectomy and fusion surgery has evolved over the period of time. Traditional techniques have complications such as graft subsidence, graft site morbidity, implant loosening, dysphasia and prolonged hospital stay. Cervical interbody spacer with integrated screws (coalition) offer a minimally invasive, less disruptive and earlier recovery option so we can discharge the patient on same day. Materials and Methods: We analysed prospectively collected data of total 37 patients with cervical myelopathy and/or radiculopathy which were operated with one level anterior cervical discectomy and fusion. Coalition is an integrated screws and spacer system designed to provide the biomechanical strength of a traditional anterior cervical discectomy and fusion. The procedure is streamlined by low profile instrumentation which facilitates a less invasive approach through a smaller incision. All patients were discharged within 24 hours after surgery, most on the same evening. All patients were followed up for a minimum period of one year. Patients were evaluated by neck disability index, visual analogue score for arm & neck, mJOA score, Bazaz-Yoo dysphasia index, fusion and implant failure. Results: 33 patients were evaluated as 4 patients were lost in follow up. Mean age of 46 years, 19 male & 14 females. Compared to preoperative scores, visual analogue scale pain score and Neck Pain Disability Index reduced significantly (P < .01). Statistically significant improvement in mJOA score was observed (P < .05). X-rays and CT demonstrated good fusion. Two patients complained of moderate and one of mild transient dysphasia. No device-related complications occurred and no fractures. Conclusions: Low profile cervical implants are safe in anterior cervical discectomy and fusion with low complication rates. It allows effective decompression and fusion, early recovery and lesser hospital stay., Introduction: Cervical pedicle screw fixation and Magerl screw fixation provide good correction of cervical alignment, rigid fixation and a high fusion rate. However, malpositioning of the screws is not a rare occurrence and the insertion of screws has a potential risk of neurovascular injury. Thus, it is necessary to determine a safe insertion procedure for these screws. To avoid complications during cervical pedicle screw and Magerl screw insertion, the authors developed a new technique which is a mold shaped to fit the lamina. Material and Methods: Preoperative CT scan images of 1 mm slice thickness were obtained of the whole surgical area. The CT data were imported into a computer navigation system. We developed a 3D full-scale model of the patient’s spine using a rapid prototyping technique from the CT data. Molds of the left and right sides at each vertebra were also constructed. One hole (2.0 mm in diameter and 2.0 cm in length) was made in each mold for the insertion of a screw guide. We performed a simulated surgery using the bone model and the mold before operation in all patients. The mold was firmly attached to the surface of the lamina and the guide wire (K wire of 1.42 mm in diameter) was inserted using the intraoperative image of lateral vertebra. The proper insertion point, direction and length of the guide were also confirmed both with the model bone and the image intensifier in the operative field. Then, drilling using a cannulated drill and tapping using a cannulated tapping device were carried out. Twenty consecutive patients who underwent posterior spinal fusion surgery using this technique since 2009 are included. The screw positions in the sagittal and axial planes were evaluated by postoperative CT to check for malpositioning. Results: The screw insertion was done in the same manner as the simulated surgery. With the aid of this guide the cervical pedicle screws and Magerl screws could be easily inserted even at the level where the pedicle seemed to be very thin and sclerotic on the CT image. Postoperative CT showed that more than 95% of the screws were in the ideal position and there were no critical breaches of the screws. Conclusion: The present method employing the device using a 3D image guide appears to be easy and safe to use. The technique may improve the safety of cervical pedicle screw and Magerl screw insertion even in difficult cases with narrow sclerotic pedicles. Based on this study, we concluded that this procedure can provide a safe insertion of cervical pedicle screws and Magerl screws for critical cases., Introduction: Repetitive extension strain of cervical spine is a risk factor for degenerative cervical spine disorders. The relationship between the repetitive flexion or extension posture on the cervical spine on labor and the degenerative change of the cervical spine, and the factors effecting on the degenerative change of the cervical spine are to be identified. Material and Methods: To identify the factors effecting on the degenerative change of the cervical spine, age, sex, height, weight, body mass index, smoking, DM, time engaging in labor, and cervical spine posture (flexion or extension) required repetitively on labor were investigated on the subjects. In addition, to evaluate the level of degenerative change of the cervical spine on 83 people in the flexion group (flexion strain) and 83 people in the extension group (extension strain), cervical degenerative index (CDI) in the simple cervical spine lateral radiograph was used to score (0-60 points) the degenerative severity. Results: 166 samples (flexion group: 83 people, extension group: 83 people) participated in this study, and for the CDI, the cervical spine flexion group scored 7.8 ± 6.2 points, and the cervical spine extension group scored 12.2 ± 6.0 points to show that the cervical spine extension group had significant degenerative change in the cervical spine. On the multiple linear regression test conducted to verify the risk factors effecting on the degenerative change of the cervical spine, age (P = .004), contraction of DM (P = .029), and extension posture of cervical spine (P < .001) showed to have influence on the degenerative change of the cervical spine. Conclusion: Repetitive extension posture on the cervical spine on labor and contraction of diabetes affect on degenerative change of the cervical spine, therefore, training on the medical care and posture on labor are required to prevent the progression of degenerative change in the cervical spine., Background: In patients with cervical stenosis, functional impairment of the motor pathways is traditionally measured by determination of motor and sensory evoked potentials. The current study aims at establishing a reliable and objective way to measure corticospinal excitability and plastic changes of the motor area in patients with cervical myelopathy using navigated TMS. Methods: 18 patients with a cervical myelopathy due to cervical spinal canal stenosis were examined preoperatively with nTMS. On the basis of the initial JOA score two patient groups were established (JOA12). We determined the resting motor threshold, recruitment curve and cortical silent period for the FDI muscle. Using the MEP responses at 105% RMT a weighted map of cortical motor function was created for both hemispheres. Accordingly, eight healthy subjects were examined. Results: nTMS revealed a reduced cortical excitability in the patient group. Although the resting motor threshold was comparable in both groups (P = .366) the corticospinal excitability estimated by the recruitment curve was reduced in the patient group (31.5 ± 38 / 48.7 ± 35.8 compared to healthy 149.5 ± 82.6 / 57.9 ± 35.8, P = .007). Interestingly, patients were partly able to compensate for spinal impairment by mechanisms of cortical plasticity. In patients with only mild symptoms (JOA>12) a compensatory higher activation of non-primary motor areas was detected (P < .05). In contrast, patients with severe impairment (JOA, Introduction: The cervicothoracic junction is a unique region in the spine. Disc herniations at the cervicothoracic junction (C7/T1 level) are unusual and there have only been a few studies on patients with herniated C7/T1 discs. In addition, previous studies did not focus on the mechanism and causes of solitary cervicothoracic junction disc herniation. The authors investigated the characteristics, symptom duration, clinical course, and biomechanics of cervicothoracic junction disc herniation by comparing patients with C7/T1 disc herniation (C7/T1 group) with control groups (patients with C5/6 disc herniation and healthy patients). Material and Methods: 28 patients who underwent C7/T1 single-level disc surgery between 2006 and 2015 were included. We excluded patients who underwent multi-level surgery at the same time. Patients with adjacent vertebral level surgery in the past were also excluded in order to evaluate the characteristics of solitary C7/T1 disc herniation. For radiographic comparison, patients in the herniated C5/6 disc group (C5/6 group) and the healthy control group were cohort matched. For evaluation of the height of the shoulder and sternal notch, we used cervical spine plain X-rays and magnetic resolution imaging (MRI). The data were collected by four neurosurgeons to reduce bias. We investigated the characteristics, symptom duration, clinical course, pre- and post-operative symptoms, and trauma history. We also evaluated the height of the shoulder and manubrium (sternal notch), as well as the body mass index (BMI) for each group. Results: In the C7/T1 group, C7/T1 disc herniation usually occurred in the foraminal space and most patients presented with C8 nerve root deficits. The C7/T1 group was significantly associated with a history of trauma (P < .001). In addition, compared to the C5/6 group (6.67 ± 0.49) and normal group (6.88 ± 0.41), the cervical vertebral body was much more readily observed in the plain cervical lateral X-ray image in the C7/T1 group (7.36 ± 0.71). The height of the sternal notch did not show any significant differences. Conclusion: There are some characteristic aspects of C7/T1 disc herniation. The disc herniates laterally because of the absence of Luschka joints at this level. Hand motor weakness is common and is due to compression of the C8 root, which is mainly composed of a motor component. A history of trauma was closely related with C7/T1 disc herniation. A lower location of the shoulder may increase the mobility of the cervicothoracic junction, increasing the rate of disc herniation at the junction., Introduction: Anterior cervical discectomy and fusion (ACDF) using titanium cages is considered to be a standard procedure for the treatment of cervical degenerative disc disease. Bone substitutes are widely used to pack the cage to avoid the complications related to bone harvesting from the donor site. Recently a porous hydroxyapatite/collagen (Hap/Col) composite has been developed as a next-generation bone substitute. The aim of this study is to investigate the effectiveness of a porous Hap/Col composite as a packing material in the titanium cages for ACDF. Material and Methods: A total of 20 patients (16 one-level and 4 two-level surgery) underwent ACDF for cervical degenerative diseases. In all cases, titanium cages were filled with hybrid grafts using bone marrow aspirate (BMA) combined with a porous Hap/Col composite. Stand-alone cages were used in one-level surgery and anterior plates were added in two-level surgery. Lateral radiographs and computed tomography were used to assess cage subsidence and fusion status at final follow up (Ave.14.6months, 6∼24 months). Results: Cage subsidence was present at 5 segments in one-level surgery and at no segments in two-level surgery. 91.7% of the treated segments were evaluated as solid fusion (15/16 in one-level and 7/8 in two-level surgery). No revision surgery for nonunion were requested. Conclusion: High fusion rates were obtained after ACDF using a porous Hap/Col composite-packed titanium cages. A porous Hap/Col composite can be expected to promote bony fusion in the early stage after surgery., Introduction: Cervical spondylotic myelopathy (CSM) is a condition in which compression of the spinal cord results from degenerative change and an unstable spine. Two main causes of this condition are cervical spondylosis (CS) and ossification of the posterior longitudinal ligament (OPLL). Many authors have reported satisfactory surgical outcomes of laminoplasty for CSM. However, there is still some controversy concerning the prognostic factors. The purpose of this study is to analyze various prognostic factors that could impact the surgical outcomes of expansive laminoplasty. Material and Methods: We retrospectively reviewed the outcome of consecutive 45 patients who underwent ‘modified unilateral open-door laminoplasty using hydroxyapatite spacers and malleable titanium miniplates’ between June 2008 and May 2014. Clinical outcome was assessed using Frankel grade and Japanese Orthopaedic Association (JOA) scale. We defined a good clinical outcome as a JOA recovery rate greater than 75% in this study, and patients were divided into two groups (good vs poor outcome groups). Results: Mean preoperative JOA scale in each group was significantly different (14.95 ± 3.21 in the good outcome group and 10.78 ± 6.07 in the poor outcome group [P < .001]). The preoperative cervical ROM was significantly greater in the poor clinical outcome group than in the good clinical outcome group (29.89° ± 10.11 in the good outcome group and 44.35° ± 8.88 in the poor outcome group [P < .001]). Between the presumptive factors, increased preoperative JOA scale (OR 1.271, 95% CI 1.005 – 1.607), decreased preoperative cervical ROM (OR 0.858, 95% CI 0.786 – 0.936) were statistically correlated with good outcomes of patients with laminoplasty in CSM on univariate analysis. And these factors demonstrated an independent association with clinical outcomes (preoperative JOA scale OR 1.344, 95% CI 1.019 – 1.774, P = .036, preoperative cervical ROM OR 0.860, 95% CI 0.788 – 0.940, P =.001). Conclusion: There have been various prognostic factors of laminoplasty in patients with CSM. In this study, the higher preoperative JOA scale had a relationship with good clinical outcomes after laminoplasty. And greater preoperative cervical spine ROM was associated with poor clinical outcomes after laminoplasty. These results may suggest that cervical mobility and preoperative patient neurologic status may have an influence on the clinical outcome of laminoplasty., Introduction: The internet allows the average person to access a vast quantity of information and educational resources. Health related searches are quite common, comprising 4.5% of individual queries entered into a search engine and 53.5% of patients report having utilised the internet to obtain information about medical conditions. The majority of patients believe that the health information found on the internet is of a standard that is either the same or better than that of their doctor In patients attending elective spinal outpatient clinics, use of the internet to research their condition has been found to be common. YouTube is the most popular video website in the world, with 1 billion unique visitors a month. Health related videos that are uploaded to YouTube are not subjected to peer review or regulated in any other way. The aim of this study is to assess the quality of anterior cervical discectomy and fusion (ACDF) videos found on YouTube and identify video factors associated with quality. Methods: YouTube was searched using the phrase “anterior cervical discectomy and fusion.” The first 50 videos were reviewed and rated according to the DISCERN, JAMA, and HON ranking systems. Information about each video was collected, including number of views, length of time since video was posted, percentage positivity (defined as number of likes the video had, divided by the total number of likes or dislikes of that video), number of comments and who was the author of the video. Any associations between these factors and video quality were tested. Results: Each video had been viewed on average 96239 times. 36% of the videos were produced by surgeons, 46% were patient testimony. The average quality of the videos was poor, with average scores of 1.78/5 using the DISCERN criteria, 1.63/4 using the JAMA criteria and 1.96/8 using the HON criteria. When assessed using the JAMA or HON criteria, videos produced by surgeon authors scored significantly higher than patient testimony videos. No other factor was found to be significantly associated with quality. Conclusions: The quality of ACDF videos found on YouTube is low, with a preponderance of videos consisting solely of patient testimony. These results align with the previously reported poor quality of YouTube videos on other healthcare subjects. YouTube videos should not be recommended as a means of educating patients about ACDF., Introduction: Interspinous bursitis (Baastrup’s disease) is a well-known disease that is characterized radiologically by the close approximation of opposing spinous processes, resulting in spinal degeneration such as sclerosis of the adjacent spinous processes and adventitious bursa formation in the intervening interspinous soft tissues. Most of them is the lumbar lesion. Cervical interspinous bursitis has rarely reported. In addition, propagation of the bursa into the dorsal epidural space can result in intraspinal cyst that may cause symptomatic spinal stenosis. No case with the cervical epidural cyst from interspinous burusitis has been reported. Material and Methods: This study reports a rare case with cervical interspinous bursitis causing subacute myelopathy and reviews literatures. A 71-year-old woman presented with progressive myelopathy and motor weakness for one month. Lateral radiograph demonstrated apposition of the spinous processes of C3 and C4. Magnetic resonance imaging demonstrated bursal fluid between the C3 and C4 spinous processes, as well as a posterior epidural cyst compressing the spinal cord. CT scan showed sclerosis with cysts at between the C3 and C4 vertebral bodies. Results: The patient underwent the C3-C6 laminoplasty with the laminotomy of C2 and C7. Intraoperatively, a cystic membrane was encountered under the flavum of C3/4 and removed. Pathological diagnosis was bursitis. The specimens revealed that edematous collagen fivers with vascular proliferation were covered with epithelial cells. Fibroblasts and inframatory cells were proliferating. Postoperatively the patient had almost full-recovery of myelopathy and motor weakness. Interspinous bursitis is commonly seen in the lumbar spine and rarely reported in the cervical spine. Moreover, epidural cyst associated with the interspinous burusits has been reported in a few cases of the lumbar lesions. To the best of our knowledge, this is the first report of cervical Baastrup’s disease with an epidural cyst causing myelopathy. Conclusion: Intraspinal posterior epidural cyst associated with the interspinous burusitis could occur in the cervical spine, although it was rare. It might cause progressive myelopathy., Introduction: T1 nerve root comprises brachial plexus together with C5 through C8 roots. Only T1 root is protected by the thoracic cage at its origin probably because it bears an important hand function. Therefore, T1 radiculopathy seems to be thought quite rare lesion and its features in symptomatology have not been clarified yet. We report 4 cases of T1 radiculopathy and findings useful for the diagnosis. Material and Methods: All of the cases (3 males and 1 female; 56 through 75 years old) underwent posterior foraminotomy unilaterally at T1-T2 disc levels. We are assured of their diagnosis by improvement in subjective symptoms or objective signs after surgeries. Evaluations were done on the following 6 items: 1) chief complaints, 2) initial symptoms, 3) arm or finger numbness at first visit, 4) muscle strength on manual muscle testing (examined muscles are triceps, ext digitorum communis, first dorsal inteross, abd digiti minimi, ext poll longus, add poll, and abd poll brevis, 5) grip power, 6) compressing spinal factors. Results: Chief complaints of all cases were hand dysfunctions. Paresthesia was complained in little finger in 2 cases, in ulnar upperarm in 1, and in none in 1. Weakness were detected on manual muscle testing in finger extensors in 3 cases, in first dorsal interosseous in 3, in abductor digiti minimi in 3, in extensor pollicis longus in 3, in adductor pollicis in 4 and in abductor pollicis brevis (ABPB) in 4. ABPB was the weakest on MMT in all cases. Their grades on MMT were 1 in 1 case, 2 in 2 and 3 in 1. Atrophy of ABPB was observed in all cases. Grip power on the affected side was 19 through 88 (average: 58) % compared to the normal side. Compressing spinal factors causing T1 radiculopathy were laterally herniated disc in 1 case and foraminal stenosis due to hypertrophy of facet joints in 3 cases. Conclusion: Patient with T1 radiculopathy complains hand dysfunction. Atrophy or severe weakness of abductor pollicis brevis, mimicking carpal tunnel syndrome, is the feature of T1 radiculopathy., Introduction: It is well known how the usage of disk prosthesis, in case of spondilodiscoarthopaties or single disk herniation, might be a good option instead of classical anterior approach. The anterior cervical discectomy and fusion, especially when is single level, doesn’t change the overall cervical movement, while maintaining the correct lordosis of this segment. On the other hand, the ACDF carries itself some negative sequels as an alterations of kinetics on the treated level or the chance to develop a disc disease or some instability on the adjacent levels. From early nineties the arthroplasty or the positioning of interbody prosthesis, represents a valid alternative, more physiologic, to a cervical fixation. This technique leads both to recovering or maintaining the correct disc height and the right lordosis, and to preserving and keeping the mobility of the treated level. Material and Methods: From 2006 to 2015, 42 patient underwent arthroplastic procedure for cervical single level disease. Patient averaged 41.5 (27-56) at the index procedure. The implanted prosthesis are so divided: 17 PRODISC-C®, 17 DISCOVER®, 5 BRIAN® and 3 PRESTIGE II®. The average follow-up is 5-year long. We evaluated both the clinical, submitting the NDI and VAS scale, and the radiological outcome in order to evaluate the unlikely spontaneous fusion or the system’s pull-out. Results: Among the 42 patient, 37 responded to the follow-up. The average per-operation VAS was 8.5 while the post-op was 1.6. We’ve been able to evaluate only the post-op NDI which was 20%. Under the radiological point-of view, we encountered 3 case of subsidence, 2 case of dislocation, 1 “very-early” re-surgery for the persistence of clinical symptoms and 18 cases of heterotopic ossification. Conclusion: The arthoplastic procedure, in our experience, ensures a significant reduction on the cervical and brachial pain, permits both the maintaining of the movement on the treated level and the warranting of some stability. In the same time, this technique decreases the risk to develop disc disease to the adjacent level. According to our study, we can conclude that the arthoplastic procedure, if performed in very selected cases, is an acceptable alternative to the ACDF., Introduction: Evaluation of clinical and radiological outcome of stand alone anchored spacer (Zero P) in anterior cervical discectomy and fusion. Material and Methods: Retrospective study done between May 2009 and 2010 in 21 patients with cervical disc prolapse selected for anterior cervical discectomy and fusion with cervical radical syndrome or neurological deficit, failure of conservative treatment for atleast 6 weeks and responding findings on MRI. Results: Patients had significant reduction in VAS radicular arm pain, VAS neck pain and NPAD within 3 months. No significant difference between male and femle patients. No screw pull out or implant failure during the follow up and radiological evidence of fusion in 9 months post operative period. Conclusion: Ideal cervical fusion substitute and gives maximal comfort. Maintains spinal alignment, foraminal height and provides immediate stability in compression and avoids axial displacement .Prevents dysphagia and soft tissue morbidity. Fusion in all patients and obviates the need of cervical orthosis., Introduction: Demineralized bone matrix (DBM) is been utilized for cervical arthrodesis in order to reduce non-Fusion rates. Aim of this stud was to evaluate the influence of DBM on the radiological and clinical outcome after anterior cervical discectomy and fusion (ACDF) with stand-alone PEEK cages. Methods: Retrospective age-, gender- and number of levels-matched pair analysis was performed on 200 patients following ACDF with stand-alone PEEK cage between 2007 and 2013 with a minimum follow up of 12 months. In the study group, DBM was used as an osteogenic filling substance. Radiographic follow-up included static and dynamic radiographs. Changes in the operated segments were measured and compared to radiographs directly after surgery. Clinical outcome was evaluated the EuroQOL questionnaire (EQ-5D). Results: 45% of patients were female. Mean age was 55 years. There were no significant differences in radiological outcome between both groups: Fusion (76.8 vs. 79.7%; P = .56), subsidence (17.7 vs 18.3, P = 1.0), changes in cervical alignment (P = .6). Moreover, there were also no significant differences in clinical outcome between both groups: neck pain P = .89, arm pain P = .53, myelopathy changes P = .185, EuroQOL Index P = .127). Conclusions: Application of DBM in ACDF with stand-alone PEEK Cages have no influence on radiological or clinical outcome, Introduction: Cervical 2 (C2) pedicle screw fixation is often used during posterior cervical fusion. C2 pedicle diameter and feasibility of screw placement are always considered during cervical instrumentation. We believe that C2 pedicle diameter and its relationship with the vertebral artery is often miscalculated and underestimated based on the preoperative CT scan images, as the axial CT cuts are performed in the plane parallel to the disc space and tangential to the pedicle. The goal of this study was to determine C2 pedicle diameter on axial images and images parallel to the C2 pedicle using intraoperative O-arm reconstruction. Materials and Methods: In this study, there were 33 patients, including 20 males and 13 females. Age ranged from 44 to 89 yr with mean age of 63.7 yr. All patients underwent C2 pedicle screw placement between September 2013 and August 2016, 14 patients with cervical myelopathy, 9 with cervical fracture, 6 with cervical kyphotic deformity, 2 with failure of cervical construct, 1 with C2-3 subluxation and lesion, respectively. Images of C2 pedicles were obtained using O-arm with try-planar reconstruction. The axial images were not manipulated but were assessed as provided and C2 pedicle diameters were measured. After that the axial plane was positoned parallel to the C2 using plane rotation function of the O-arm and new measurements were performed. The axial and oblique widths of C2 pedicle on the screen were measured on the axial and oblique images using a regular ruler, and therefore called “screen width of C2 pedicle”. O-arm software at this point does not provide the measurement tool. Results: The axial width of C2 pedicles ranged from 6 to 15 mm with mean of 10.44 ± 2.15 mm on the right side, and from 7 to 14 mm with mean of 10.29 ± 1.72 mm on the left side. The oblique width of C2 pedicles ranged from 10 to 19 mm with mean of 14.73 ± 1.85 mm on the right side, and from 12 to 19 mm with mean of 15.33 ± 1.67 mm on the left side. These measurements indicate oblique screen widths of C2 pedicles are 1.4 and 1.5 times higher that axial screen width on the right and left side, respectively. Conclusions: The axial and oblique images of O-arm provide valuable assessment of C2 pedicle width. The oblique screen width of C2 pedicles is better to be used for predicting the feasibility of C2 pedicle screw placement than its axial screen width. Since this assessment may help in surgical decision-making at no added cost or radiation exposure, we suggest obtaining screen width of C2 pedicle whenever considering C2 pedicle screw inserting., Introduction: The objective of this study is to develop guidelines that outline how to best manage (1) patients with mild, moderate and severe myelopathy and (2) nonmyelopathic patients with evidence of cord compression with or without clinical symptoms of radiculopathy. These guidelines will be used to enhance quality of care by establishing clinical protocols for the treatment of DCM and will assist clinicians with decision making by providing evidence-based recommendations for important areas of management. Material and Methods: Five systematic reviews of the literature were conducted to synthesize evidence on disease natural history; risk factors of disease progression; the efficacy, effectiveness and safety of nonoperative and surgical management; the impact of preoperative duration of symptoms and myelopathy severity on treatment outcomes; and the frequency, timing and predictors of symptom development. A multidisciplinary guideline development group used this information, in combination with their clinical expertise, to develop recommendations for the management of DCM. The benefits and harms, financial impact, acceptability, feasibility and patient preferences of each recommendation were carefully considered. Results: Our recommendations were: (1) “We recommend surgical intervention for patients with moderate and severe DCM;” (2) “We suggest offering surgical intervention or a supervised trial of structured rehabilitation for patients with mild DCM. If initial non-operative management is pursued, we recommend operative intervention if there is neurological deterioration and suggest operative intervention if the patient fails to improve;” (3) “We suggest not offering prophylactic surgery for non-myelopathic patients with evidence of cervical cord compression without signs or symptoms of radiculopathy. We suggest that these patients be counseled as to potential risks of progression, educated about relevant signs and symptoms of myelopathy, and be followed clinically;” and (4) “Non-myelopathic patients with cord compression and clinical evidence of radiculopathy with or without electrophysiological confirmation are at a higher risk of developing myelopathy and should be counselled about this risk. We suggest offering either surgical intervention or non-operative treatment consisting of close serial follow-up or a supervised trial of structured rehabilitation. In the event of myelopathic development, the patient should be managed according to the recommendations above.” Conclusion: These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in patients with DCM by promoting standardization of care, decreasing the heterogeneity of management strategies and encouraging clinicians to make evidence-informed decisions., Introduction: Degenerative cervical myelopathy (DCM) is a progressive, degenerative spine disease that is often treated surgically. Reported rates of surgical complications vary substantially across the literature and depend on definitions, surgeon experience, study design, and methods of data collection. There is a pressing need to develop high-quality standardized definitions of surgical complications in order to accurately evaluate the safety of surgical procedures. This review aims to (1) outline how biomechanical and hardware-related complications are defined in the literature and (2) evaluate the quality of definitions using a novel 4-point rating system. Material and Methods: An electronic database search was conducted in MEDLINE, MEDLINE in Process, EMBASE and Cochrane Central Register of Controlled Trials for studies that reported on complications related to DCM surgery and included at least 10 surgically treated patients. Data extracted included study design, surgical details, and definitions and rates of surgical complications. A four-point rating scale was developed to assess the quality of definitions for each complication. Results: Our search yielded 3582 citations, 76 of which met eligibility criteria and were summarized in this review. Defined complications included non-union (n = 55), adjacent segment pathology (n = 16), sagittal instability (n = 13), graft subsidence (n = 10), pseudoarthrosis (n = 7), vertebral slip (n = 5), graft dislodgement (n = 4), post-operative kyphosis (n = 2), heterotopic ossification (n = 2), graft collapse (n = 2), hinge fracture (n = 2), and spring-back closure (n = 1). Identification of complications was based on qualitative and quantitative criteria, often observed on radiographs or computed tomography scans. Reported rates of non-union or pseudoarthrosis (0.0-51.6%) and adjacent segment pathology (0.0-60.0%) varied substantially between studies. The incidence of subsidence differed depending on whether it was evaluated qualitatively (3.2-3.3%) or quantitatively (10.8% to 36.2%). Rates of graft dislodgement varied minimally across studies (0.2 -1.7%). Conclusion: Reported incidences of various biomechanical and hardware-related complications vary widely in DCM surgery, especially for non-union/pseudoarthrosis, adjacent segment pathology and instability. This summary serves as a first step for standardizing definitions and developing guidelines for accurately reporting surgical complications., Introduction: Anterior cervical decompression for degenerative cervical myelopathy (DCM) is associated with unique perioperative complications, including difficulty or discomfort swallowing (dysphagia) and changes in sound production (dysphonia). Reported rates of dysphagia and dysphonia vary substantially in the literature and are often dependent on method of data collection, diagnostic strategies, study design and definitions. Due to this inconsistency, it is difficult to accurately convey surgical risk to patients and appropriately manage their expectations. This review serves as a first step to developing guidelines for accurate reporting of surgical complications and aims to (1) outline how dysphagia and dysphonia are defined in the literature and (2) assess the quality of definitions using a novel 4-point rating system. Material and Methods: An electronic database search was conducted in MEDLINE, MEDLINE in Process, EMBASE and Cochrane Central Register of Controlled Trials for studies that reported on dysphagia, dysphonia or other related complications of DCM surgery and included at least 10 patients. Data extracted included study design, surgical details, and definitions and rates of surgical complications. A four-point rating scale was developed to assess the quality of definitions for each complication. Results: Our search yielded 3582 citations, 15 of which met eligibility criteria and were summarized in this review. Defined complications included dysphagia (n = 13), dysphonia (n = 2), swelling complications (n = 2) and voice fatigue (n = 1). Rates of dysphagia varied substantially (0.0% to 43.1%) depending on whether this complication was patient reported (0.0% to 10.9%), detected using a modified Swallowing Quality of Life questionnaire (43.1%) or Bazaz criteria (8.8%-50.0%), or diagnosed using an extensive protocol consisting of clinical assessment, a bedside swallowing test, evaluation by a speech and language pathologist and a modified barium swallowing test/fiberoptic endoscopy (42.9%). The reported incidences of dysphonia ranged from 0.63% to 36.5% depending on definitions (patient-reported versus patient-reported and confirmed by laryngoscope) and timing of postoperative evaluation. Conclusion: There is substantial variability in reported rates of dysphagia and dysphonia. As a result, there is a pressing need to standardize definitions; unification of terminology will enable improved evaluation of the overall safety of surgery, important risk factors, and the impact of these complications on recovery rate, patient satisfaction and costs. Furthermore, an accurate assessment of complications will benefit both the patient and surgeon by empowering patient-informed choice, facilitating shared decision-making and enabling a better evaluation of risks and benefits of each procedure., Introduction: Bone mineral density (BMD) is important in predicting mechanical strength of cage subsidence in increasing aging population. However, BMD based on cervical vertebrae is not routinely measured for cervical degenerative diseases. This study determined the association of the subsidence in anterior cervical discectomy and fusion (ACDF) and BMD data based on lumbar vertebrae. Methods: Radiological data of patients who underwent ACDF for one-level disc disease at our hospital were retrospectively collected from January 2012 to December 2014. Radiography and computed tomography scans were performed for radiological evaluation. Global cervical lordosis (GCL), fused segment angle (FSA), fused segment height (FSH), and disc space height (DSH) were measured and analyzed. Results: Successful bone fusion was achieved at the final follow-up examination in all patients who underwent ACDF. However, loss of disc height over 3 mm at the surgical level was observed in two patients in the osteoporosis group. Although all outcomes of the osteoporosis group were slightly lower than those of the normal group, there was no significant difference between the groups (P > .05). Conclusion: BMD based on lumbar vertebrae was not a significant factor to subsidence after ACDF. To better understand the cervical bone, it may be necessary to obtain BMD of surgical levels., Introduction: Axis fractures, basillary invaginations (BI) and reumatological diseases (RD) frequently need surgical treatment. The patients treated surgically with posterior C1-C2 stabilization in our clinic because of axis pathologies were presented in this study. Material and Methods: A retrospective analysis of 39 patients, still on follow-up, who underwent surgical treatment for axis pathologies in our clinic between May 2008 and April 2016 was presented. Osseous pathology, cerebral peduncle, spinal cord, ligaments and pannus formations were investigated by using x-ray radiography, thin-section computed tomography and magnetic resonance imaging. Results: Gender ratio was equal. Mean age was 45.8 (18-88). Twenty-five cases (68.9%) were fractures, 6 cases (13.7%) were BI and 8 cases (17.2%) were RD. Myelopathy and weakness were the main findings in patients with BI and RD where pain was dominant in patients with fracture. For the patients with BI and RD, one patient from each were underwent occipitocervical stabilization/fusion while C1-C2 occipitocervical stabilization/fusion with Goel technique was performed for the rest. For the patients with pure Type II and Type IIA odontoid fractures, C1-C2 posterior stabilization/fusion was applied while, for the patients with odontoid fractures combined with subaxial cervical fractures, long-segment posterior stabilization/fusion was preferred. Grafting was not performed to 11 of the fracture patients, who applied within 21 days after trauma and to whom reduction could be accomplished. A Bone graft was placed inside C1-C2 lateral mass articulation bilaterally for the patients applied later than 21 days and the patients with BI and RD. Bone fusion was achieved for all of the early-applied fracture patients without any grafting performed and 16 of the later-applied fracture, BI and RD patients. Conclusion: Posterior stabilization maintains enough and essential rigidity for achieving bone fusion in C2 pathologies. For early-stage odontoid fractures with transverse ligament injury, posterior stabilization is enough for achieving fusion without the need for grafting., Introduction: Cervical myelopathy is more frequent elderly people and is the leading cause of spinal cord dysfunction in this population. Neural decompression procedures for both laminectomy with fusion and laminoplasty have improved the neurological symptoms caused by myelopathy in these patients. It is known that both procedures could lead to fully described complications; However, there has not been determined if there are any functional advantage in patients managed operatively with laminectomy and fusion versus laminoplasty. Material and methods: We studied 46 patients diagnosed with cervical spondylotic myelopathy who underwent to operative management with neural decompression with laminectomy and fusion or laminoplasty (open door). A retrospective matched cohort analysis was made studying 46 patients with operative management, 23 patients with laminectomy and 23 with laminoplasty 23 (door open) for the treatment of neural multi-level involvement of cervical spondylotic myelopathy. Clinical outcome after 2 year of surgical treatment was analyzed considering the modified scale of Japanese Orthopedics Association (mJOA), the Nurick and NDI (neck disability index), the t-student and homogeneity tests was performed, considering a P < .05 as significant. Results: The gender distribution was 19 women and 27 men, with an average age of 72.2 years, there were no difference in clinical results by gender, age and affected levels between the two groups (laminectomy vs laminoplasty, P > .05). Regarding the functional outcomes resulted with mJOA, Nurick, and NDI; no statistical difference was found between laminectomy with fusion and laminoplasty. (P > .05). Conclusions: Patients in both groups, laminectomy with fusion and laminoplasty, reported similar functional outcomes after treatment of cervical spondylotic myelopathy at 2 year follow up. Prospective randomized controlled trials are needed to determine whether a procedure is truly superior., Introduction: The aim of this study is to explore the ability of medication and non-surgical treatments to predict the pain recovery of sequestrated lumbar disc herniations and the time of surgical treatment. Material and Methods: This study included 136 patients who presented with unilateral leg and low back pain and received definitive diagnoses of sequestrated lumbar disc herniation. We compared the degree of decreased pain with respect to treatments, as well as in patients who could not undergo surgery. From 2011 to 2014, we retrospectively investigated patients’ clinical statuses using a visual analogue scale (VAS). We followed patients for at least 1 year and correlated pain changes over time. Patients with increases in VAS despite treatment (eg, medication, physical therapy, and non-surgical treatment) underwent surgical treatment. Results: VAS decreased gradually until 6 weeks from pain onset, patients with sequestrated lumbar disc herniations (P < .001). All patients who underwent non-surgical treatment such as selective nerve root block or epidural steroid injection experienced more rapid VAS improvement during the immediate post-operative period compared with other patients. However, this difference was not statistically significant (P > .05). Nineteen (13.9%) of the 136 patients underwent lumbar discectomy. In these patients, the postoperative VAS decrease was statistically significant until 1 month postoperatively (P < .001). Conclusion: We observed the potential for spontaneous resorption with sequestrated lumbar disc herniation. Patients with sequestrated lumbar disc herniations may be conservatively managed for up to 6 weeks. Non-surgical treatments help with symptom relief. However, such treatments do not hasten the natural history of a sequestrated lumbar disc herniation. We recommend surgery for patients with an increased VAS despite receiving conservative treatment., Introduction: The pathophysiology of lumbar radiculopathy includes both mechanical compression and biochemical irritation of apposed neural elements. Inflammatory and immune cytokines have been implicated, induced by systemic exposure of immune-privileged intervertebral disc tissue. Surgical intervention provides for improved symptoms and quality of life, but persistent postoperative neuropathic pain (PPNP) afflicts a significant fraction of patients. This study compared the inflammatory and immune phenotypes among patients undergoing structural surgery for lumbar radiculopathy and spinal cord stimulation for neuropathic pain. Materials and Methods: Consecutive patients undergoing surgical intervention for lumbar radiculopathy or neuropathic pain were studied. Demographic data included age, gender, and VAS and neuropathic pain scores. Serum was evaluated for cytokine levels (IL-6, Il-17, TNF-α) and cellular content (WBC/differential, lymphocyte subtypes). The primary analysis differentiated molecular and cellular profiles between radiculopathy and neuropathic pain patients. Subgroup analysis within the surgical radiculopathy population compared those patients achieving relief of symptoms and those with PPNP. Results: Heightened IL-6, Il-17, and TNF-α levels were observed for the lumbar radiculopathy group compared with the neuropathic pain group. This was complemented by higher WBC count and a greater fraction of Th17 lymphocytes among radiculopathy patients. In the lumbar discectomy subgroup, pain relief was seen among patients with preoperatively elevated IL-17 levels. Those patients with PPNP refractory to surgical discectomy exhibited normal cytokine levels. Conclusions: Differences in Th17 immune activation are seen among radiculopathy and neuropathic pain patients. These cellular and molecular profiles may be translated into biomarkers to improve patient selection for structural spine surgery., Introduction: Lumbar disc herniation is a common spinal column degenerative disease, which has an increased population incidence as age increases. Patient’s symptoms are related to spinal nerve compression, radiculopathy and lumbar pain. In some cases, acute neurological deficits can also be present. Surgical or conservative treatment is individualized as well as the proper moment to intervene. However, rehabilitation is required through neurofunctional physiotherapy. Prognosis after surgical interventions depends on several factors such as the pre-operative neurological status, clinical complaints and clinical risk factors. Patient’s social and professional issues are also relevant. Pain, functional, and economic Index Scales such as the three described in this paper, help to predict prognosis. This study aims to evaluate patients post-operative prognosis in those submitted to microdiscectomy with the use of pain, functional, life quality and work activities return Index Scales, and also validate their use for patients with lumbar disc herniation. Material and Methods: An observational, longitudinal retrospective study was performed including all adulthood patients that were submitted to microdiscectomy as treatment for single-level degenerative lumbar disc herniation during a period of 3 years and with a 1-year follow-up. Patients that harbored other spinal column degenerative conditions, such as spondylosis and spondylolisthesis, were excluded. Data such as identification, professional issues and images were collected before and after the surgical operative procedures. In addition, three questionnaires were applied: Visual Analogic Scale (VAS), Roland Morris, and Prolo Index Scales. Literature review using scientific databases was also performed. Fisher’s Exact, Spearman’s Rank Correlation and Tukey’s Range Tests assessed the statistical variables among the 3 selected Index Scales. The Institutions Ethics Committee on Human Research approved the research project in January 2012. Results: After inclusion and exclusion criteria were applied, sixteen patients were selected but only 10 had a 1-year follow up in outpatient clinic. Post-operative pain improvement was identified after 6 months when compared to the pre-operative Visual Analogic Scale, Roland Morris and Prolo Index Scales. After 1 year, this pain improvement difference had reduced. No difference was identified among patients considering work activity return after 6 and 12 months. Those that were not working after 6 months were still not working after 12 months. Post-operative pain limited back-to-daily activities but was not a significant statistical factor. It was also noticed that VAS, Rolland Morris and Prolo pre-operative Index Scales, had significant correlation after 6 and 12 months. Causal relations among the studied variables indicated internal validity. Conclusion: The 3 identified Index Scales were effective in post-operative prognostication to evaluate patients with lumbar disc herniation. They also showed that they have significant correlation among each other. This study indicates that prognosis is favorable in patients submitted to microdiscectomy for single-level degenerative lumbar disc herniation. The 1-year post-operative lumbar and sciatic pain is reduced and back-to-work activities are limited but not due to pain. Perhaps other unidentified factors, such as social and professional issues, contribute to these findings., Introduction: Patients with pain after structural spine surgery may have a persistent postoperative neuropathic pain (PPNP) phenotype or structural pathology that warrants further treatment. Differentiating these has practical implications about patient selection for the next appropriate intervention and currently there are no validated tools to assist the clinician. Material and Methods: Sequential patients referred to a spinal cord stimulation (SCS) clinic with postoperative pain after spine surgery were included. Pain severity was measured by Visual Analog Scale (VAS) score and quality was assessed by the Douleur Neuropathique 4 (DN4) score. Disability was quantified by the Oswestry Disability Index (ODI). Psychological distress was tested by the Beck Anxiety Index (BAI) and Beck Disability Index (BDI). All patients were evaluated for residual or recurrent stenosis, post-laminectomy instability, pseudoarthrosis, and adjacent segment disease. Results: Among 150 patients, 68% were suitable patients for SCS whereas the remainder were candidates for decompression with or without fusion. There were similar VAS pain severity scores, overall DN4 scores, and ODI disability scores between the two groups (α = 0.05). Similar BAI and BDI scores were seen between surgical groups, but both forms of psychological distress increased with higher VAS and DN4 scores (P < .001 for all comparisons). Whereas the DN4 score did not differentiate surgical cohorts, specific components were significantly higher among SCS patients (burning pain, allodynia) or among structural patients (electric shocks). Conclusion: Patients referred for SCS therapy after spinal surgery should be rigorously evaluated for structural disease that warrants intervention. Managing psychological distress is important for either group and some features of the DN4 score can be applied to differentiate the surgical cohorts., Introduction: The aim of this study was to assess the outcome of symptomatic lumbar degenerative disease treated with topping-off technique (Coflex combined with fusion) and compare two-segment fusion at mid-long term follow-up; and find out whether the topping-off technique can reduce the rate of adjacent segment degeneration (ASD) after fusion. Material and Methods: One hundred and fifty-four consecutive patients who received topping-off surgery (76 patients) and two-segment fusion surgery (88 patients) from March 2009 to March 2012 were studied. All patients included in the analysis had a minimum of three years of follow-up. Radiographic and clinical outcomes between the two groups were compared. A logistic regression analysis was used to analyze risk factors for developing radiographic ASD. Results: Significant differences in clinical outcomes were observed between these two groups at three post-operative years (all, P < .05). Compared with the fusion group, the topping- off group showed preserved mobility at the Coflex level (P = .000), which is associated with less blood loss (P = .000), shorter duration of surgery (P = .000) and lower incidence of ASD (Chi-square test, rate topping-off vs fusion = 13.2 vs 26.1%, P = .039). There were no differences in complications between the two groups. Conclusion: Mid-long term follow-up efficacy and safety be- tween topping-off and fusion were similar, while topping-off reduced the rate of ASD. Under strict indications, topping-off surgery is an acceptable alternative to fusion surgery for the treatment of two-segment lumbar disease., Introduction: To evaluate the rate of revision surgery after posterior Coflex interspinous dynamic stabilization for degenerative disorders of the lumbar spine, and to discuss its causes and management, a retrospective study was conducted. Methods: From Sept 2007 to July 2015, 295 consecutive patients with degenerative disorders of the lumbar spine were treated with decompression and Coflex interspinous dynamic stabilization in our hospital. In order to evaluate the rate of revision surgery among these patients, and to discuss its causes and management, a retrospective study was conducted and all revision patients were treated and followed up to evaluate the clinical outcome through patient’s satisfaction. Results: Among 295 patients in this study, there were 16 patients underwent revision surgery and the total rate of reoperation was 5.4%. The duration between revision procedure and primary procedure was 15.1 ± 23.4 months (range, 0.1-60 months) in these patients. Among the 16 patients, 6 patients (37.5%) were underwent reoperation due to non-implant related complications such as infection of the wound or local hematoma. These 6 patients all healed with debridement or hematoma evacuation. Another 10 patients (62.5%) who underwent reoperation due to implant related complications. There were two patients who had topping-off procedure initially developed pedicle screw loosening or nerve root adhesion and were treated with re-implantation of the fixation or neurolysis. Another 8 patients who had single level Coflex dynamic stabilization developed symptoms related to the deterioration of the degeneration at previous segment or adjacent segment. Those patients were managed with decompression and fusion with pedicle screw fixation. None of the 16 patients who underwent revision surgery was directly related to the Coflex implant such as migration, loosening or dislocation of the Coflex implant and fracture of the spinous process. These revision patients were followed up for 28.6 ± 12.6 months (range, 6-48 months) and 93.8% of the patients were satisfied with the revision surgery at the final follow-up. Conclusion: Coflex interspinous dynamic stabilization for the treatment of degenerative disorders of the lumbar spine was safe and the reoperation rate was low. The main cause of the revision surgery including wound infection, local hematoma, or degeneration at previous segment or adjacent segment was not directly related to Coflex implant itself., Introduction: Surgical treatment of lumbar spondylolisthesis provides reliable clinical and radiographic results though complication rates vary significantly and few studies have investigated the association between slip reduction and complications. The purpose of this study was to determine complication rates in adult patients undergoing 1- or 2-level lumbar fusion for spondylolisthesis and to examine the association between slip reduction and complication rates. Material and Methods: Adult patients undergoing fusion for spondylolisthesis between June 2006 and June 2012 at a single tertiary academic spine center were identified. Inclusion criteria were: age 18 or older, lumbar spondylolisthesis (isthmic or degenerative), 1- or 2-level fusion and a minimum of 1-year follow-up. Electronic medical records were reviewed to collect demographic and complication-related data. Pre- and post-operative slip severity was quantified using the Meyerding grade. Descriptive statistics were summarized and complication rates were compared between groups with and without slip reduction. Results: 104 patients with a mean age of 52.3 years were included. 21.1% (n = 22) presented with an isthmic spondylolisthesis and 44.2% (n = 46) had a degenerative spondylolisthesis. Preoperatively 58 patients (55.8%) had a grade 1 slip and 41 (39.4%) had a grade 2 slip. In total 53.8% (n = 56) patients demonstrated surgical reduction of their spondylolisthesis by one Meyerding grade. At an average follow-up of 2.6 years 33.7% (n = 35) of the patients experienced a complication. The most common complications were adjacent segment degeneration in nine (8.7%) patients and incidental durotomy in seven (6.7%) patients. There was no difference in complication rates between those with and without a reduction of their spondylolisthesis. Conclusion: Our study demonstrates that 54% of patients with a low-grade spondylolisthesis had a one grade reduction of their slip following surgical treatment. The overall complication rate in our cohort was 33.7%. Surgical reduction of the spondylolisthesis was not associated with a higher rate of complications. Thus, reduction of low-grade adult isthmic and degenerative spondylolisthesis can likely be considered safe surgical practice., Introduction: The use of biologic technologies for the treatment of degenerative spinal diseases is undergoing rapid clinical and scientific development. Patients with an instability in the spinal motion segment profit from stabilization by dorsal fixation in combination with interbody fusion. BMP- 2 has gained broad acceptance as an adjuvant to spinal fusion when used with interbody fusion device to improve the ossification process. Materials and Methods: The clinical and surgical experience of patients treated for degenerative lumbar spine disease has been analyzed retrospectively. We included 17 patients with neurological deficits causing by spinal stenosis and instability after degenerative disc disease. All patients underwent a posterior lumbar interbody fusion in combination with BMP- 2 filled cages. Over the time from more than 8 years 13 patients were monitored prospectively with clinical examination, radiographs and CT-scans. Results: All patients improved from the operative procedure by reduced pain relief over the follow up time. No further neurological deficits were monitored in the period. No significant adjacent level degeneration was seen in the CT scans over 8 years follow up. Additional operative procedures in lumbar spine was not necessary. Side effects of BMP 2 were not detected. But there was clear evidence of vertebral endplate osteoclastic activity in the radiographs at 3 months in all patients. None of the patients were clinically symptomatic; events were radiographic findings. All patients showed radiographic evidence of fusion at the 6 months follow up CT scans. There was no ongoing ossification after the 6 month period. Some ossification was found in the surgical approach and around the pedicle screws. Ectopic ossification was not found over the follow up period of 8 years in CT-scans. Conclusion: The good results over a long time follow up of our small group of patients received BMP 2 for spinal interbody fusion gives a suggestion that faster fusion might provide an adjacent level degeneration in lumbar spine degeneration. The effects of BMPs seen after 3 month in the CT scans on osteoclast activity didn’t cause in clinical deficits to the patient. To evaluate these phenomena, dose dependency, osteogenic activity and associated osteoclastic activity attendant with the use of BMP-2 is studied in a large animal model., Introduction: The Synfix-LR(Synthes, Switzerland) has been used for anterior standard alone device to negate the need of posterior screw fixation for treatment of discogenic back pain. However we have used Synfix-LR and posterior screw fixation simultaneously to overcome various problems. In this study, we are going to introduce the usefulness of Synfix-LR in difficult cases. Material and Methods: From January 2011 to May 2014, about 1200 patients underwent Anterior Lumbar Interbody Fusion in our hospital. In these cases, 28 cases used Synfix-LR and pedicle screw fixation to overcome various difficulties. Mean age is 66.7. Male patients were 13 and female patients were 15. Follow up underwent by regular X-ray at post operative 1 month, 3 months, 6 months and 1 year. Functional outcomes and radiological measurements were recorded and reported. Results: 10 patients had severe modic change and endplate sclerosis and vacuum disc. We thought that the contact between cage and endplate not be stable so that enforce cage stability with anterior screwing.7 patients had end plate irregularity due to previous vertebral compression fracture. Some patients had large dimple at vertebral body. That case, we filled dimple with allograft and used anterior screwing for holding cage. 5 patients had high sacral slope and listhesis so that S1 body shape became ball surface. At this case we could predict cage instability and non-union. So we use anterior screwing for adding stability. 2 patients had pedicle anomaly unable to posterior pedicle screws. 3 patients had interspinous device and developed back pain, so remain interspinous device and underwent ALIF with anterior screws. 1 patient had fused vertebra at L4, L5, S1. So that pedicle screw fixation had some difficulty then use d additional anterior screws. VAS and ODI were improved. Radiological factors such as anterior height, posterior height, percentage of listhesis, segmental angle were all improved. There is one case of cage subsidence. All cases showed good union state. Conclusion: We investigated the practically extended indication of Synfix-LR cage instead of conventional cage in ALIF. It provided additional stability so that helps to reduce motion of cage. It leaded to solid fusion state. Screw integral PEEK cage system is very useful to overcome tough lumbar fusion cases., Introduction: X-ray (XR) measurements taken in a supine position are often underestimated. There is no literature to recommend a conversion ratio (CR) from supine data to an erect data in adult spinal deformities (ASD) patients. The aim is to find a conversion ratio for XR measurements from supine to erect position in adult lumbar scoliosis and sagittal alignments. Material and Methods: Consecutive XR images of ASD patients were retrospectively measured by 2 spine surgeons. Supine lumbar XR measurements were compared against erect XR measurements. SPSS analysis made. Results: 100 patients were included, 85 females and 15 male. Average age was 67.9 (42-93) yrs. Average scoliosis Cobb angle in supine and erect positions are 21.1 (±9.6)° & 26.7 (±11.7)° respectively and this was statistically significant. Cobb angle CR is 1.3. Average sagittal Cobb angle of T10-L2, T12-S1, Sacral Slope (SS), Pelvic Tilt (PT) & Pelvic Incidence (PI) in supine and erect positions are 6.9/8.6; -35.7/-37.4; 33.4/30.6; 23.3/26.2 and 60.0/60.0 respectively. Average CR from supine to erect XR measurements for scoliosis, T10-L2, T12-S1, SS, PT, PI are 1.3, 1.2, 1.2, 1.0, 1.3, 1.0 times respectively. With increasing Erect Cobb angle from, Introduction: The aim of this study is to describe the results obtained in relation to the frequency of arthrodesis performed in lumbosacral spine surgeries because of disc pathology in more than 3,000 patients over a period of 10 years. They were operated between January 2005 and December 2015 in our department of Orthopedics and Traumatology in Corporación Medica of General San Martin in Buenos Aires, Argentina. All patients were operated by the same surgical team including surgeon, assistants and surgical scrub nurse. In all of them we used the same surgical technique for arthrodesis, which consists only in the utilization of local chipping bone and blood crest. The results were surprising because of in more than 3000 operated patients only 157 were arthrodesis, from which with this surgical technique that we used we had less than 2% of pseudoarthrosis always without the utilization of bone substitute or iliac bone. In absolutely all cases where we did not do arthrodesis, the osteosynthesis material used was removed after 6 to 8 months postoperative to reinstate the complete spine mobility; this as an established protocol of our department. Materials and Methods: More than 3000 patients were evaluated, of which 157 were arthrodesis. All patients were studied by Rx and MRI except 64 patients who were studied with TAC for being unable to be exposed to a magnetic field. All treated by the same surgeon, assistants and scrub nurse. Patients which were operated for another pathology that was not discal were excluded from this study; as narrow channels, infections, fractures and / or tumors. Surgical technique: After the finalization of the respective surgery we proceed to the arthrodesis of it doing a decortication of the lamins, imbrication of the spinous and using blood pulled out from the posterior iliac crest through an abbocath and local bone chipping by the assistant or the scrub nurse. Results: Only in 157 patients we did arthrodesis over 3000 operated. The proportion of arthrodesis compared to the total lumbosacral spine surgeries in our service is very low. The percentage of pseudoarthrosis we have using this method of arthrodesis is less than 2%, which is not significant to us. Although we had a few pseudoarthrosis none of the patients had postoperative complications. All surgical wounds healed normally, without any secretions or phlogosis. No patients required re operation, all returned to their daily lives in a few months. The following up on them was from 8 months at least to 3 years in some cases. Conclusions: After an exhaustive study of each of our patients we conclude that only in a very few surgeries is necessary an arthrodesis as surgical technique in lumbosacral disc surgery. Concerning to the arthrodesis carried out it gives us excellent results the use of local chipping bone and blood crest instead of bone substitute and bone crest. This technique is usually used in our department and gives us great results., Introduction: Degenerative disc disease is a major malady afflicting young and working class population. The treatment modalities may vary from simple non-operative methods like physiotherapy to an intensively invasive procedure like spinal fusion. Minimal invasive procedures like nucleoplasty and annulo-nucleopalsty are still finding its place in the management step ladder. We here by decided to study the intermediate term clinical outcomes in patients undergoing Disc Fx in the surgical treatment of contained lumbar disc herniations (CLDH) and degenerative disc disease (DDD). Methods: We retrospectively collected data for all patients who underwent Disc Fx as a treatment modality for lumbar DDD and CLDH between September 2010 and December 2014. All included patients had failed a trial of at least 6 months of non-operative treatment which included physiotherapy, acupuncture or chiropractic treatment. DDD was defined as reduction in disc height but no less than 4 mm absolute height and no disc bulge. CLDH was defined as a disc protrusion but no prolapse or sequestration. All patients had back and or leg pain. The patients were assessed on various factors affecting the clinical outcome which included BMI, smoking status, approach to disc, and discography. Provocative Discography was performed for all the levels for all the patients undergoing nucleoplasty. Visual analogue scale (VAS), Oswestry Disability Index (ODI) and MacNab criteria scores were recorded for every patient pre–operatively, immediate post–operatively, at half, one and two years after the procedure. Results: A total of 51 patients underwent annulo-nucleoplasty with 66 procedures. The mean age was 41 years (range: 20-63 years) with a gender distribution of 13 females (25%) and 38 males (75%) and 67% smokers. There were 43 (84%) in the DDD subgroup and 8 (16%) in the CLDH subgroup based on the preoperative MRI scan. The pathologic level in decreasing order were L5S1 (45%), L4L5 (41%), L3L4(12%) and L2L3(2%) respectively. Concordant discography was recorded in 47 levels (71%) and discordant pain was recorded in 19 levels (29%). There were significant improvement in VAS and ODI scores (P < .01) at immediate post-op, 6 months, 12 months and 2 years follow-up with none of the patients requiring surgical reintervation. The percentage of patients with excellent/good MacNab outcomes was 39% in immediate postop, 49% in 6 month, 57% at 1-year and 78% at 2-year follow-up. The proportions of patients with excellent/good MacNab outcomes at any time points after the procedure were significantly greater than those before the procedure. Univariate analysis revealed that discography positivity was significantly associated with improvement in ODI scores at 6 and 12-month follow-up. VAS and MacNab scores were not statistically affected by majority of demographics except BMI and smoking. BMI and smoking status has significant influence on VAS scores at 6 and 12-month follow-up. Conclusion: We can conclude that Disc Fx can be considered as a safe and minimally invasive procedure which can be offered to patients to provide significant pain relief for a period of at least 2 years. This would help them to either delay or avoid a spinal fusion., Introduction: Extreme lateral interbody fusion (XLIF) allows for deformity correction by inserting a wide and large wedge-shaped interbody cage of 10-degree angle. The procedure is characterized by indirect decompression which results in an increase in the spinal canal area and the intervertebral foramen area via ligamentotaxis. In this study, we compared a combined posterior and anterior fusion approach using the XLIF and percutaneous pedicle screws (PPS) with conventional approaches (TLIF/PLIF) with respect to sagittal alignment correction in patients with lumbar degenerative spondylolisthesis. Material and Methods: Twenty-six patients underwent XLIF with percutaneous pedicle screw instrumentation for lumbar degenerative spondylolisthesis since September 2013 (9 males, 17 females, mean age 67.7 years) (hereafter, X group). Disc height (mm), slip (mm), and disc angle (°) were measured for these patients on pre- and postoperative lateral plain radiographs and compared with 26 patients who recently underwent TLIF/PLIF (14 males, 12 females, mean age 63.7 years) (hereafter, T group). Both in the X and T groups, patients consecutively underwent surgery performed by a single surgeon. A 10° lordotic cage was used as the XLIF implant. Results: The mean preoperative disc height, slip, and disc angle in the X group were 6.98 mm, 6.73 mm, and 5.68°, respectively, while those in the T group were 7.48 mm, 6.73 mm, and 2.88°. The mean postoperative disc height, slip, and disc angle in the X group were 11.7 mm, 2.47 mm, and 10.8°, respectively, while those in the T group were 10.2 mm, 4.33 mm, and 5.85°. For the correction of sagittal alignment, the mean disc height, slip, and disc angle, were +4.74 mm, -4.27 mm, and +5.16°, respectively, in the X group compared to +2.69 mm, -2.69 mm, and +2.96° in the T group, indicating that the correction effect was significantly greater in the X group than the T group. Conclusion: This study suggested that XLIF allows a wider range of patients to be a candidate for surgery including elderly patients and patients with more severe deformity, and that XLIF is less invasive as compared to conventional procedures. In addition, the XLIF has a high ability to correct sagittal alignment because a large cage is placed on a hard surface area of the vertebral body margin. Therefore, it is considered to be an extremely useful surgical approach for the treatment of lumbar degenerative spondylolisthesis. The number of patients with severe spondylolisthesis was, however, limited in this series, thus further investigation on the limitation of its indication is required., Introduction: Unilateral pedicle screw fixation has similar post-operative outcomes as bilateral fixation in degenerative lumbar spine disease. Unilateral fixation is faster, less invasive and cheaper. Furthermore a wide endplate coverage by the intersomatic cage improves load sharing, thereby increasing fusion rate and lowering the risk of subsidence. Material and Methods: 39 patients (25 men and 14 women, median age 53 years) underwent unilateral TLIF with a modular PEEK cage (Interfuse S TM, VTI). The cage is intraoperatively assembled within the disc space with a variable number of modules. It can be implanted unilaterally through a small access channel. Indications for surgery included spinal stenosis with primary or post-laminectomy instability, recurrent disc herniation, first-grade non-lytic listhesis. All patients underwent immediate post-operative CT scan and follow-up evaluation including a clinical and radiographic assessment 2 months post-operatively and clinical/CT evaluations at 6 and 12 months. Results: Median follow-up was 10,2 months (range 1-28). Cage positioning was straightforward, no surgical complication occurred. Postoperative CT always showed appropriate cage positioning and a wide endplate coverage: 55% (range 47-64%) along the transverse diameter and 68% (range 61-74%) along the antero-posterior diameter. Two months after surgery the Oswestry Disability Index was improved in all patients and X-ray did not show any dislocation of the implants, except in one case associated with loosening of a screw. 6-months assessment was available for 33 patients and 12 months assessment for 26 patients: all were still clinically improved and CT did not show signs of pseudarthrosis. Conclusion: According to our experience, unilateral TLIF can be safely and effectively performed with the use of the InterFuse modular cage, taking advantage of the small size of its modules and allowing a customized coverage of large or irregular endplates. This appears particularly useful in revision surgery and osteoporosis., Introduction: In the interspinous surgery, there has been a change in the paradigm for which the use of rigid or flexible devices inserted with open and percutaneous technique, which served only as a spacer, was supplemented by the use of devices for the fixation and fusion interspinous. The device for fixation with interspinous fusion has primary stability and mobility control in all axes (greater flexion-extension) blocking the two functional units. Each device has its own characteristics, but the objective is to place it as close as possible to the lamina (interlaminar).The interspinous fixation system is comparable with the screws. The presence of the fusion, which was considered a complication in the spacers (motion surgery), is the final result of the interspinous surgery. Material and Methods: Our experience covers 120 cases operated from 2003 to 2014 with degenerative disease of the spine including 80 treated with rigid or flexible spacers (54 monolevel, 16 double, 5 triple and 5 associated with other stabilization systems) and 40 cases with fixation device interspinous (30 single and 10 double-layer). Each patient was studied preoperatively with dynamic RX, CT and MRI and follow up with RX dynamic to 6, 12 and 24 months and, in some cases, CT reconstructions. They have been used for the clinical evaluation of the VAS and ODI scales preoperatively and at 12 months. Results: The clinical outcome at 12 months was comparable between the two groups with significant improvement in VAS and ODI values. In cases treated with spacers 60%, at 2 years, did not present mobility (not visible to simple X-ray the probably fusion) while in the device group for fixation and fusion at 2 years have seen the fusion in 90% of cases. In 6 cases (7.5%) treated with spacers, it was necessary a revision surgery: removal of the presence of a bilateral isthmic lysis unrecognized preoperatively, in 2 cases a reoperation for recurrence, one contralateral without removal of the device, a spinous process fracture with inability to place the device, removing a dislocation, an event that had been treated with 3 levels reappearance of intense pain that necessitated the removal and direct decompression and stabilization with pedicle screws.In the device group for fixation complications were one case of intraoperative fracture with positioning impossibility, a fracture of the spinous process asymptomatic, asymptomatic hyperostosis and a mobilization, but none required reoperation. Conclusion: The interspinous surgery requires proper selection of patients and has probably resulted in fusion even in the spacers. In the literature published studies are short term and therefore probably the result in fusion is more common than reported. In our experience the use of interspinous device is a possible and viable strategy in the treatment of degenerative lumbar diseases., Introduction: Lumbar microdiscectomy is the most commonly performed spine surgery procedure. Over time lumbar discectomy has evolved to a minimally invasive procedure performed in an outpatient setting in many international institutions. Patients traditionally have been advised to restrict activity following lumbar spine surgery.1 However, post-operative instructions are heterogeneous. The purpose of this report is to assess, by survey, the post-operative care practices and recommendations of Australasian neurosurgeons in the era of the modern lumbar microdiscectomy. Material and Methods: A survey of Australasian Neurosurgeons was conducted by email invitation sent to all full members of the Australasian Neurosurgical Society. The survey consisted of 11 multi-choice questions answered by an anonymized online survey distributed electronically by the Australasian Neurosurgical Society. The survey consisted of questions relating to operative indications, technique, and post-operative instructions for lumbar microdiscectomy. Results: The survey was sent to all Australasian Neurosurgeons. 71 responses were received of which 68 were complete (28.9%). The geographic distribution of respondents was well spread. Only complete responses are included. Operative Indications: most surgeons reported they would consider a period of either 4-8 weeks (42.7%)(29) or 8-12 weeks (32.4%)(22) as the minimum duration of radicular pain adequate to offer surgery. Operative Technique: unilateral muscle dissection with unilateral discectomy was practiced by 76.5%(52) of surgeons. A tubular retractor system was used by 20.6%(14). Operative microscope was the most commonly employed method of magnification (76.5%)(52), no magnification was used by only (2.94%)(2). Post-operative Care. The majority of surgeons (55.9%)(38) always refer patients to undergo inpatient physiotherapy. No sitting restrictions were advised by 22.1%(15) of surgeons with 39.7% (27) advising patients to sit as comfort allows post-operatively. When advised sitting restrictions were most commonly recommended for a period of up to four weeks (57.4%)(39). Lifting restrictions were advised by 83.8% of surgeons. Such restrictions were most commonly advised for periods up to 4-8 weeks (52.17%). Conclusion: This study reports the results of a survey of Australasian neurosurgeons regarding lumbar discectomy practices. The vast majority of neurosurgeons perform unilateral muscle dissection and discectomy under magnification. A majority of Australian neurosurgeons advised sitting restrictions. Lifting restrictions are advised by approximately 80% of Australasian neurosurgeons. The persistent recommendation of activity restrictions following lumbar discectomy is consistent with a recent survey of British spine surgeons.2 The results of these two surveys suggest a possible role for further investigation of the role of post-operative activity restrictions following lumbar discectomy in the era of minimally invasive spine surgery. References 1. Carragee EJ, Han MY, Yang B, Kim DH, Kraemer H, Billys J. Activity restrictions after posterior lumbar discectomy. A prospective study of outcomes in 152 cases with no postoperative restrictions. Spine. 1999;24(22):2346–51. 2. McGregor AH, Ben Dicken, Jamrozik K. National audit of post-operative management in spinal surgery. BMC Musculoskelet Disord. 2006;7(1):1., Introduction: Lumbar canal stenosis is conventionally treated with surgical decompression with or without fusion. Transforaminal lumbar interbody fusion (TLIF) is usually performed with bilateral pedicle screws fixation. TLIF done by unilateral approach which reduces the exposure and cost of surgery has been described in literature with variable results. We have evaluated the clinical outcomes and fusion rates in selected group of the patients who were operated by TLIF using unilateral pedicle screws (low implant load construct). Materials and Methods: Retrospective analysis of 54 patients (29 females, 25 males and mean age of 43) operated in our institute by single surgeon with minimum one year follow-up. Inclusion criteria were predominant single leg radiculopathy due to single level lumbar disc disease with modic endplate changes and >50% maintained disc height. Exclusion criteria were patients with multilevel stenosis, severe osteoporosis, severe facetal arthropathy, > grade 1 spondylolisthesis, > 50% disc height lost and morbid obesity. Exposure was done only on the side of radiculopathy followed by unilateral pedicle screw fixation and interbody fusion. Visual analogue scale (VAS) and Oswestry disability index (ODI) were analyzed for clinical assessment. Fusion and implant failure were determined on follow-up radiological assessment. Operative time and hospitalization periods were also evaluated. Results: The mean follow-up duration was 20.4 months. The mean preoperative VAS score was 6.7 and 4.3 for leg and back pain, respectively. Postoperatively pain in the symptomatic side lower extremity and the back improved significantly to 1.6 and 1.7 respectively (P < .05). The ODI was improved significantly from 41.5 to 14.6% (P < .05). All patients were showed good fusion without any screw back out or cage displacement. Average duration of surgery was 64.3 minutes with average duration of hospital stay was 2.4 days. Conclusions: Satisfactory results were acquired with TLIF conducted through the unilateral approach using low implant load construct in selected group of patients with lumbar canal stenosis and unilateral radiculopathy. This procedure with less exposure provides earlier recovery with good fusion. Further studies are required for indentifying comprehensive selection criteria and assessing fusion., Introduction: Oblique lateral interbody fusion (OLIF) is a minimally invasive surgical methods that can access L4-5 level of lumbar spine, via a narrow corridor formed by anterior border of psoas and lateral border of the aorta (or iliac artery). However, depending on the incidence angle of the cage insertion, the contralateral nerve root is at risk of injury. The purpose of this study is to examine the maximum safe incidence angle of cage insertion when performing OLIF without violating the contralateral nerve root at disc level, using a series of computed tomography (CT) scans of the lumbar spine of patients that underwent OLIF at (or including) L4-5 level. Material and Methods: Between July 2013 and January 2015, 36 consecutive patients underwent OLIF at L4-5 (or including L4-5 in cases of multilevel fusion) at our institution. All patients had CT scans of lumbar spine taken in right decubitus positions to simulate patient’s actual position during surgery. On axial view of CT scan, maximum safe incidence angle (MSIA) for cage insertion was defined as the angle formed by a horizontal line connecting anterior borders of the facet joints and a line connecting the anteromost border of the psoas in contact with vertebral body and contralateral L4 exiting root. If the incidence angle of the cage insertion exceeds the MSIA, there wound be a potential for violation of neural elements. Cage tilt angle (CTA) was defined as the angle between a line connecting anterior borders of the facet joints and a horizontal line parallel to the longitudinal length of the cage. Postoperative VAS and ODI scores were measured, and transient and persistent postoperative complications were noted. Results: A total of 36 L4-5 levels were operated by OLIF. The mean MSIA was 28.7 degrees (range 13.4-38.1). The mean CTA was 13.9 degrees (range 3.7-27.7). There were no cases in which CTA exceeded MSIA at the operated level. The VAS(back/leg) and ODI decreased significantly postoperatively, from 6.3/6.5 and 27.0% to 2.6/2.1 and 19% respectively. There was 1 case of ventral dural tear during cage insertion (MSIA 31.2), 1 case of transient ipsilateral psoas paresis, and 4 cases of transient ipsilateral anterior thigh numbness that resolved within 1 month. Conclusion: From the measurements from our small number of cases, we advise the incidence angle of cage insertion to be kept below 28.7 degrees to avoid damaging the neural structures. Larger number of cases will be needed to further validate our findings., Introduction: Oblique lateral interbody fusion (OLIF) is a minimally invasive surgical method that can access L2-5 levels of lumbar spine via retroperitoneal anteropsoas approach. While OLIF has advantage of using interbody cages with larger footprints compared to posterior approach fusion methods, some have reported similar levels of subsidence compared to posterior approaches. This study aims to evaluate the rates of radiological subsidence by operated levels, classify the types of subsidence by location and pattern, and compare the clinical outcomes between subsidence and no subsidence groups. Materials and Methods: The radiological data and medical records of 68 patients who underwent OLIF between June 2013 and December 2015 were reviewed. All patients were followed up for minimum of 12 months. Computed tomography (CT) scans were taken postoperatively, and at 6 and 12 months’ follow up visits. Fusion status and subsidence was assessed using CT data. Subsidence was defined as cage settling of ¡Ã2 mm into the adjacent endplates. Intraoperative endplate violation was defined as subsidence that was identified on postoperative CT. The pattern of subsidence was classified as: caudal contralateral (type I), bilateral caudal (type II), and bilateral cranial and caudal (type III). For clinical assessment, VAS and ODI scores were measured preoperatively and at each follow up visits. Any perioperative/postoperative complications were also noted. Results: Mean age was 64.6 ± 8.6 (40-79) and mean bone density was -1.6 ± 0.7 (-4.0 -1.0). Total number of operated levels was 97 (single level: 46, two levels: 15, three levels: 7). Overall subsidence rate was 32.4% (22 of 68 patients) and incidence rate was 24.7% (24 of 97 levels). Intraoperative endplate violation accounted for 12.5% (3 of 24) of total subsidence. Mean subsidence depth was 2.7 ± 1.0 (2-5)mm. The types of subsidence by location were: caudal contralateral (type I) in 41.7% (10 of 24), bilateral caudal (type II) in 33.3% (8 of 24) and bilateral cranial and caudal (type III) in 25.0% (6 of 24). Overall fusion rates at 12 months were 93.9% and 92.3% in the subsidence and no subsidence group respectively (P = .78). The level with highest incidence of subsidence was L4-5 (16.5%) followed by L3-4 (8.2%). VAS and ODI significantly improved in both groups postoperatively with no significant difference between subsidence and no subsidence groups. Conclusion: The authors classified subsidence by pattern and location. Contralateral caudal subsidence was most common pattern of subsidence, and lower levels were more vulnerable, especially L4-5. Fusion rates and clinical outcomes were not significantly affected by radiological subsidence. In order to minimize subsidence the authors recommend more meticulous endplate preparation and cage insertion, as well as extra attention to angle of cage insertion especially during operation of L4-5 level., Introduction: Exercise and physiotherapy is the mainstay of treatment for back pain. Within this, back groups are widely accepted as an efficient method of rehabilitating and utilising exercise for this group as well as post-surgical patients. Exercise is well documented as an integral aspect for managing back pain but is less well documented as to the efficacy of back group programmes and content1. A less researched area is the response of certain subgroups of back pain patients to physiotherapy rehabilitation. If certain sub-groups of patients are shown to demonstrate more improvement than others, this may help in decision making for referral to rehabilitation groups. Materials and Methods: All patients referred for a variety of back pain conditions including post spine surgery to the Physiotherapy led back rehabilitation group were reviewed over a 2 year period. At first attendance they completed Oswestry Disability Questionnaires (ODI), identified physical functional goals relevant to their lifestyle they wished to achieve and physical functional tests based on the Harding measures. The patients attended 1 session per week in a time period of between 8 and 16 weeks depending on measures and goal attainment. The patients were categorized according to condition into 4 subgroups; Post micro-discectomy, fusion, mechanical low back pain (LBP) and scoliosis. Results: 59 pts in total with a mean age 46 age range from 17-71, duration of symptoms 3 months to 30 years were reviewed. The initial ODI scores on average reduced from 40.67%, to 24.68% with an average change of 15.69%. Subgroup analysis demonstrated fusion as the greatest self-reported improvement with duration of symptoms from 3 months to 4yrs, ODI was 50% initially reducing to 26% with an average change of 23.7%. Micro-discectomy patients, had duration of symptoms from 3 months to 5 years with ODI average ranging from 42% to 27.4% with an average change of 14.7%. Mechanical LBP ranged from 8months to 30yrs with ODI of 41% to 21% and average change 15.5%. Scoliosis demonstrated least improvement with duration of symptoms 1year to 30 years with ODI 24.8% to 17% average change of 7.4%. This is based on the minimal clinical important difference (MCID) validated as 10% change for patient significance for the ODI. All patients demonstrated improvement in the physical measures testing. Conclusion: All the sub-groups of back pain patients referred benefitted from individual exercise programmes within a group rehabilitation setting as measures demonstrated improvement in all areas. Post fusion surgery patients demonstrated greatest improvement which may direct referral for rehabilitation. Of interest the data suggests even the patients with long duration of symptoms post-surgically benefitted from back group referral. The groups were not homogenous in nature with wide ranges of symptoms and outcome measures but this reflects the real variation and complexity of these patients. 1. Poquet N, Lin C, Heymans MW, van Tulder MW, Esmail R, Koes BW, Maher C (2016) Back schools for acute and sub-acute non-specific low-back pain; Cochrane database of systematic reviews, Introduction: Coccydynia is pain arising from the coccygeal region. The origin can be multifactorial with several associated factors such as obesity, female gender and low mood. Several non-operative methods such as physiotherapy, shock wave therapy and ultrasound have been described. Operative interventions viz., local steroid injections, manipulation under anaesthesia (MUA) and coccygectomy are well established treatment modalities. However, the long term results of surgical interventions are debatable with studies quoting a success rate ranging from 63-90%. Materials and Methods: Our aim is to identify if age, trauma and BMI are independent prognostic factors in patients treated for coccydynia. We reviewed all patients who presented to our teaching institute with a primary diagnosis of coccydynia from Jan 2011 to Jan 2015. Data was obtained by retrospective review of the hospital database clinical coding system. All patients who had injections, MUA or coccygectomy were included. Patient notes were reviewed to obtain demographics, co-morbidities, aetiology, type of intervention and outcomes. We used patient reported satisfaction score as the primary outcome measure. We hypothesised that patients who had trauma and with high BMI (>25) would be less satisfied with treatment of coccydynia. We divided patients into four groups based on their BMI as per WHO guidelines as follows. Group A (BMI 18.5-24.9), Group B (25-29.9), Group C (30-39.9) and Group D (>40). We used Student T test to compare means of our data to assess if any significant difference could be found between the groups. A P value, Introduction: Anywhere between 60 to 90% of people in India are affected with low back pain at some point of time in their lives and Spondylolisthesis is found to be two to five times more frequent.Spondylolisthesis that are resistant to conservative measures or presenting with neurological deficits requires surgery.The severity of the disease is always complicated by Sacral inclination, Loss of lordosis and the Grade of the Spondylolisthesis.Though there are many surgical methods to combat this, our the Transdiscal Transpedicular fixation with Intertransverse fusion with bone graft scores much better than the pedicle screw fixation and other techniques to retain the spine biomechanics and improve symptomatically. Aim: To establish combined Posterior Decompression, Posterior Guided Transpedicular Trans discal Interbody fusion with Posterior inter transverse fusion with bone graft as the treatment for Meyerding 3/4 lumbar spondylolisthesis. To provide satisfactory results by relief of pain, relief and prevention of neurological deficits. Methods and Materials: Study between 2010 to 2013 a series of 31 cases (9 males and 22 females) with High grade spondylolisthesis of 3 and 4 Meyerding classification who had neurological deficit or those who found no use with conservative measures in SSSIHMS Puttaparthy, india. A thorough history, clinical, radiological evaluation with X ray, MRI and CT of LS spine with calculation of pre op Visual Analog Score, Oswestry Disability Index, Zurich Claudication Questionnare was done. From the X ray pelvic tilt, sacral slope and pelvic incidence were analysed. MRI was done to assess the disc status by Pfirrmann criteria and neurological structures. Posterior Decompression, Posterior Guided Transpedicular Trans discal Interbody fusion with Posterior inter transverse fusion with bone grafts taken from Posterior superior iliac spine was done under X ray guidance. Intra op parameters were monitored.Post operatively the patients were assessed radiologically to assess construct stability, implant position, implant migration or loosening, formation of solid fusion or indication of pseudarthrosis and clinically by all the above scores on 0th, 1st,1 week,6 weeks,3 months, 6 months, 1 year, 2 years and 3 years post op.Adequate Back care and strengthening exercises were taught and encouraged.All the cases were followed up for a minimum of 3 years. Statistically assessed by SPSS software version 17.0. Results: The average blood loss was 210 ml, Surgical time was 85 minutes. The average time for fusion was 14 weeks. Return to daily activities was average 3–6 months. ODI scores decreased from average of 74% to 11%, Zurich claudication score improved, VAS on average decreased from 9 to 1 or 0 finally at the end of 3 years.The Paired T test improved at the end of 3 years. There were 4 complications (1 case implant failure, 2 cases neurological deficits, 1 case of dural tear which all needed re exploration). Conclusions: Posterior Decompression, Posterior Guided Transpedicular Trans discal Interbody fusion combined with intertransverse fusion led to magical results and the advantages of this technique are lower incidence of neurologic complications, speed of execution and faster return to normal life., Introduction: Several spinal complications can occur in a patient with ankylosing spondylitis. Extensive disco-vertebral destructive lesions are known but rare and may be associated with sagittal imbalance and pain symptoms resistant to medical treatment. We reported through this work a new case of spontaneous spinal nonunion in a patient with ankylosing spondylitis. Methods: This was a 38 year-old patient followed for ankylosing spondylitis for 20 years who consulted for pain in the thoracolumbar junction lasting for 2 years and resistant to medical treatment. A dynamic CT scan showed a totally fused thoracolumbar spine except for the D11-D12 level where there was a posterior vertebral arch and superior endplate disruptions with sings of instability on CT cuts in kyphosis. An additional MRI showed inflammatory spondylitis and an angioma of D11. The patient initially was treated with a thoracolumbar corset without sensible improvement. Surgical treatment was indicated given the persistence of pain. He had a posterior approach with D10-L2 fixation and postero-lateral graft followed by a second procedure through a retro-peritoneal extra-pleural anterior approach, given access to the endplate nonunion and the interposition of an autologous tri-cortical bony graft. Results: At a last follow-up of 3 years, patient was completely indolent with a circumferential fusion on last CT scan, but a predicted loss of motion. Conclusions: These lesions have been described for the first time in 1937 by Anderson, since then, several theories have been advanced to explain these disco-vertebral damages. It was Wu PC, Ho E et al. who studied first the pathophysiology of this complication and demonstrate the role of articular processes fractures in the genesis of these lesions. Several mechanisms may explain the occurrence of this nonunion: the persistence of a certain disc mobility leads to an escaping phenomenon to the global spinal fusion; a secondary fracture of the articular processes, following a benign spinal trauma; a stress fracture of the posterior articular processes, on an ankylosed and kyphotic spine. Several cases were reported in the literature, the orthopedic treatment hasn’t given good results and authors agree on the need for a circumferential vertebral fusion of the articular processes fractures posteriorly and vertebral endplates, anteriorly. Spinal nonunions in patients with ankylosing spondylitis are rare but their ignorance can lead to serious functional complications. Conservative treatment isn’t sufficient in the treatment of the spinal nonunions. Only a circumferential graft through a double surgical approach is recommended for this type of injury, for better chances of consolidation., Introduction: Degenerative disc diseases which are common in elder population and are very varied. The patients are also variable for their symptoms as pain, motor and sensory deficits. There are many approaches to lumbar disc hernia such as open surgery and minimally invasive techniques. Fusion surgery is indicated in patients with intervertebral height decreases. Interbody cage is a choice in some patients with intervertebral fusion. Material and Methods: We studied 25 patients with transpediculer stabilization. TLIF and XLIF is used in intervertebral fusion with cage. They are chosen in patients with foraminal stenosis, degenerative scoliosis and decreased intervertebral height. Intervertebral fusion and intervertebral fusion with cage are compared. Results: We observed foraminal stenosis are progressed less likely in the patients with interbody cage. And postoperative MRI has shown more fusion in interbody cage patients.The patients a re followed up for 6 months. Conclusion: In the literature, interbody fusion with interbody cage resulted better outcome in terms of pain and mobility. Our results showed that interbody cage has a benefit of reducing postoperative foraminal stenosis and preservation of intervertebral height, and also helps the intervertebral fusion., Introduction: Surgery of the degenerative lumbosacral spine is experiencing a growing interest in interbody fusion with cages. The sagittal balance has an important place in the spinal pathology, enabling a comprehensive analysis of the static disorders. The aim of our study was to study the influence of posterior lumbar interbody fusion posteriorly (PLIF) on lumbar-pelvic parameters and sagittal balance. Methods: This was a retrospective study including 31 patients who had PLIF, over a period of 10 years with a mean follow-up of 5.6 years. All patients were investigated by telemetric radiographs of the spine from the front and side, in knee extension, with centered radiographs of the lumbar spine. For the assessment of functional impairment, we used the score of Beaujon-Lassalle (B-L) and the Oswestry index of disability (ODI). Results: The average age was 46 years, with a sex ratio of 0.4. The etiology was dominated by spondylolisthesis in 25 cases (20 spondylolysis and 5 degenerative) and 6 cases of degenerative discopathy. The study of spinal statics helped find 80% of types 3 and 4 backs. The lumbar-pelvic parameters averaged 53° for the pelvic incidence (PI), 35° for the sacral slope (SS) and 17° for the pelvic Version (PV). The average value of the T9 sagittal offset was 11° and 54 mm for the C7 plumb line. Functionally, we found a B-L score of 8.4 points on average and an average ODI of 57.9%. Postoperatively, we found 58% of types 3 and 4 backs. We did not find statistically significant differences in the pelvic parameters at last follow-up except for the T9 sagittal offset (P = .003) and C7 plumb line (P = .001). 71% of patients had a well-balanced back. No parameters studied had significant superiority on functional recovery. Conclusions: Many works have allowed a better understanding of the fusion by incorporating it into the scheme of static and dynamic spine. Preservation or optimization of sagittal balance are at present part of the specifications of lumbosacral arthrodesis. Only the restoration of balanced spinal statics (normal values of the C7 plumb line and T9 sagittal offset) guarantees us excellent functional and radiographic results and a solid fusion of interbody arthrodesis without repercussions on adjacent discs. It’s necessary to analyze the sagittal balance parameters in the management of degenerative lumbar spine. This will determine the type and modalities of future surgery., Introduction: We aimed to identify potential risk factor for unfavourable outcome following lumbar spine surgery for degenerative disc disease. Methods: Study design: Prospective cohort study. Patients were asked preoperatively to complete a series of questionnaires (N = 14), including the Oswestry Disability Index (ODI), the anxiety sensitivity index (ASI-3), the SF-36, the visual analogue scale for pain (VAS), the Berliner Social Support Scale, the PTSS-10 for PTSD symptoms and indicate demographic variables concerning education or partnership for example. The evaluation was based on the ODI filled out 1 year postoperatively. The univariate and multivariate association between risk factors and outcome parameter (ODI) was assessed with correlation coefficients and multivariate logistic regression. Results: 99 patients met all inclusion criteria. 50 patients were male (50.5%); mean age was 60 years. Most patients were married or in a steady relationship (74.8%). Preoperatively age (r = 0.230; P = .025), pain (VAS) (r = 0.380; P < .001), trait anxiety (r = 0.244; P = .019), PTSS (r = 0.222; P = .034), ODI (r = 0.404; P < .001), depression score ADS-K (r = 0.258; P = .013) and low education (r = -0.281; P = .009) and lower SF-36 Physical Composite Score (r = -0,487; P < .001) correlated with worse ODI scores at 1 year. Conclusion: Clinical outcome one year after surgery is influenced by age and physical status before surgery. Mental comorbidities and social status are also influential on clinical outcome. A preoperative screening tool seems feasible., Introduction: Demographic trends make it incumbent on spine surgeons to recognize the special challenges involved in caring for older patients. Aim of this study was to identify variables that may predict early mortality in geriatric patients over the age of 90. Methods: Retrospective analyses of all patients over the age of 90 years, which were treated between 2006 and 2014 at our department for degenerative spine disease, were performed. Patient characteristics, type of treatment and comorbidities were analyzed with regards to the 30-day mortality rate. Results: 25 patients were identified. Mean age was 92.8 years (range 91-101), 21 (84%) patients were female. 16 (64%) patients were on anticoagulation therapy. 17 (68%) patients were treated operatively. Mean Hospital stay was 14 days (range 2-40). Mean charlson comorbidity index was 5.5 (range 0-12) and mean diagnosis count was 12 (range 2-24). The 30-days mortality rate was 17% in the surgically treated group compared to 0% in the conservatively treated group (P = .2). Gender (P = .42), diagnosis count (P = .65), charlson index (P = .65) and anticoagulation therapy (P = .9) did not correlate with the 30-day mortality rate. Cause of death was pulmonary embolism in two cases and was unknown in one case. Conclusion: 30-day mortality rate in patients over 90-years-old following elective spine surgery is very high. Standard geriatric prognostic scores seem less reliable for these patients. Prospective validations studies are needed in order to establish treatment recommendations for such patients., Introduction: To compare the mid-term efficacy between Coflex and Transforaminal Lumbar Interbody Fusion (TLIF) in treating lumbar spinal stenosis(LSS) with positive nerve root sedimentation sign (Sed-sign) and observe the relationship between surgical results and the change of Sed-sign. Material and Methods: We retrospectively reviewed 206 patients who presented with LSS and received spinal surgery in our institution from January 2009 to December 2013. All patients underwent MRI of the lumbar spine. A positive Sed-sign was determined as the absence of nerve root sedimentation at the level above or below the level of maximum stenosis on MRI. Clinical outcomes were investigated using the patient-assessed quantitative measurement of visual analog scale (VAS) and the Oswestry Disability Index (ODI). Thirty-three patients (male: female = 13:20) with positive Sed-sign were included and classified according to the surgery they received (Coflex group vs TLIF group). Comparison of radiological data (Sed-sign) and clinical outcome (VAS and ODI) were conducted. Results: There was no significant difference between Coflex group and TLIF group in baseline parameters (gender, age and BMI). Overall, 94% patients got excellent recovery. In the final follow-up, both Coflex group and TLIF group had a significant clinical improvement compared to preoperative data (P < .05), as shown by VAS and ODI. Additionally, no significant difference was found between the two groups during the follow-up (P > .05). Radiological evaluation revealed that the Sed-sign of 75.7% patients turned negative and maintained well to final follow-up. Those who had negative Sed-sign postoperatively showed greater clinical improvement than those who had positive Sed-sign in the final follow-up (P < .05). Conclusion: The Coflex is an efficacious option for the treatment of lumbar spinal stenosis, which is comparable to the lumbar fusion surgery. The lumbar decompression surgery can significantly help the Sed-sign turn negative, which shows better clinical improvement in the mid-term follow-up., Introduction: Lumbar spinal stenosis (LSS) is a disorder caused by a narrowing of the spinal canal as result of the degeneration of both the facet joints and the intervertebral discs. With the advancements in clinical and diagnostic knowledge, the treatment has changed from various non-operative modalities to decompression, and subsequently, decompression and fusion. In more recent years, a growing tendency toward less invasive decompressive procedures has emerged, and nowadays many neurosurgeons prefer microdecompression for LSS. However, specific attention should be paid not to injure the pars interarticularis and if excessive facetectomy is performed fusion is required. Recently the technological progress focused on facet joint fixation and in this scenario the Facet-Wedge® system is gaining interest. Facet Wedge system offers a novel posterior approach in achieving primary stability in lumbar spinal fixation with a comparable primary stability to pedicle screws. Methods: This study included patients (n = 25) with LSS (group 1) in whom microdecompression and Facet Wedge implant has been performed. Data have been compared with a homogenous group of patients with LSS where no facet wedge has been implanted following microdecompression. Clinical findings have been observed preoperatively and 3, 6, 12 months post-operatively using dedicated questionnaires (Zurich Claudication Questionnaire, Visual Analog Scale and Oswestry Disability Index). Secondary outcome measures were length of hospital stays, perioperative and postoperative complications. Results: One year following surgical treatment, 92% of the patients of group 1 presented good improvement of symptoms and 95% of the patients referred satisfaction for surgery. Overall, patients of group 1 presented significantly less back pain as compared with group 2 (P < .05) and better clinical outcome when compared with group 2 (P < .01). There was no difference in length of hospital stays between the two groups (P =.175). Conclusion: According to our features, the Facet Wedge system showed significant and clinically meaningful improvements in pain and disability for up to 1 year when associated with standard microdecompression for LSS. These data, however, need further studies and a longer period of follow-up., Introduction: The activL artificial lumbar disc is a motion preserving total disc replacement device for the treatment of low back pain due to degenerative disc disease. Following FDA approval in June 2015, a 10 year post-market surveillance study on the safety, efficacy and satisfaction of the activL device was initiated. Results from the first year are presented. Methods: Surgeons who implanted the activL artificial disc post-market approval were asked to complete a written survey addressing their knowledge of safety issues involving activL, as well as their experiences on the clinical performance of the activL device. Demographics for patients receiving the post-market activL device were collected on separate device utilization requisition (DUR) cards which were completed at the time of surgery. Results: The surgeons surveyed reported no revisions surgeries, device removals, re-operations at the index level and were not aware of any adverse events or medical device reports submitted by their patients. Surgeons were satisfied with the overall device effectiveness, specifically range of motion and stability, and were satisfied with the pain relief and neurological status in their patients following activL implantation. From the DUR cards returned, the average patient age was 40 yrs. (range 25-64) and the majority of patients were male (48% male, 39% female, 13% unidentified), which is comparable to patient demographics in the clinical trial1. The number of procedures performed at L5-S1 (42%) was incrementally greater than L4-L5 (38%). This difference was greater in the clinical trial patients (69% vs. 26% for L5-S1 and L4-L5, respectively)1. Surgeons surveyed did not report differences in safety or efficacy with activL at L4-L5 compared to L5-S1. Conclusions: Surgeons surveyed were satisfied with the overall performance of the activL device and did not report any safety concerns. Demographics of the patients receiving the post-market activL device is similar to study patients from the clinical trial, suggesting that future safety and efficacy outcomes from the post-market use of activL can be inferred from long term data from the clinical trial. 1. Garcia R Jr et al., (2015) Lumbar Total Disc Replacement for Discogenic Low Back Pain: Two-year Outcomes of the activL Multicenter Randomized Controlled IDE Clinical Trial. Spine. 40(24):1873-81., Introduction: Usually, the static analisis of the spinal sagittal shape is based on a vertebral semantic, focusing on the curves (lordosis, kyphosis) and the spinopelvic parameters (pelvic incidence, sacral slope, pelvis tilt, sagittal balance). This analisis failed in defining a normal shaped spine, and in relating strictly the incidence to the lordosis. The author proposes a very different analisis of the sagittal spinal shape, named “the Pendulum Rule.” It enable to define an ideal biomechanical shaped spine and classify the sagittal shape precisely using a discogenic, vertical and dynamic analisis of the spine. The thorax restabilizaton in patients treated with stand alone ALIF (and/or discal cementoplasty) in spinal disorders abide by this rule. Material and Methods: 300 hundreds sagittal shapes have been studied. A vertical analisis (according to gravity) is carried out, reintegrating the spine into an analisis of the muscular body’s scheme and relating it to the respiration. The biomechanical spine is assimilated to three intricated Mongol bows. Different apex (contact between the vertebral body and the plumb line) are defined. They are related to muscular tension lines or attaches. The lungs apex are paramount to explain the spine. The trunk is always swaying but lungs pressure (when breathing in) stabilize it either in an anteroposterior plan or in the sagittal plane. The repartition of the apex has been assessed in all the spine drawing specific lines. Results: More than 95% of the studied spine abide by the “Pendulum law” which states that: “whatever the spine is (including the common variation or abnormalities), the standing position consist in placing the Superior Lung apex according to the following rules. In the anteroposterior view: the plumb line equidistant from the lung apex is maintain above the sacral apex. In the sagittal view: the plumb line from the superior lung apex is equidistant of the thoracic apex and the lumbar apex. The two Pelvico-thoracic lines (the line linking the sacrum apex to the antero-inferior lung apex and the line linking the center of the femoral head to the postero-inferior lung apex) cross each other in the point “E”, exactly above the plumb line droping from the superior lung apex and in front of the lumbar apex. Therefore, the Pendulum Law relates the sagittal shape to the gravity, the muscular body’s scheme and the breathing. An ideal biomechanical sagittal shape lines up the thoracic apex and the sacral apex vertically. The alignement of the symphysis, the lumbar apex and the thoracic apex cross the vertebral bodies obliquely and harmoniously. The lumbar apex (in front of the upper plate of L4) is placed above the center of the femoral head. Conclusion: The Pendulum Law relates the sagittal shape, the muscular body’s scheme and the act of breathing to gravity. Most of the commons Abnormalities are intregrated according to this rule. The Pendulum is the “vertical tension” of the body’s scheme that enable us to move harmoniously. (As the length of the femur is strictly related to the ideal flexion/extension of the Knee). Lordosis is related to pneumatic stabilization of the trunk and definitively not to the pelvic incidence. We should not use rods and screws in common degenerative spinal disorders. Stand alone procedures restore the disc space height and enable the patient to restabilize in a more physiological way., Introduction: The vascular narrowing or obstruction reduces blood flow to the lower limb during exercise or at rest. Symptoms may range from intermittent claudication to pain at rest. Narrowing of these arteries may produce pain in the buttocks or the thighs as well as the legs. Sometimes, these symptoms may be similar to lumbar radicular pain. Moreover, spine surgeons may overlook obstructive vascular lesions of lower limb in patients with lumbar degenerative disease such as spinal stenosis and spondylolisthesis. We investigated clinical and radiological findings of concomitant vascular pathologic lesions in patients with degenerative lumbar disease. Methods: If patients presented with weak or no pulsation of dorsalis pedis artery, edema of both legs, and past histories related with vascular lesion of lower limb, we evaluated doppler sonography of veins and arteries of lower extremities. And, if vascular abnormal findings were detected in sonography, computed tomography angiography (CTA) of lower extremities was performed. Radiologic and clinical characteristics of concomitant vascular lesions of lower limb were analyzed. Results: Since 2013, vascular doppler sonography was performed in 335 patients who were suspicious of vascular lesions. Among them, CTA of lower extremities was evaluated in 58 patients. Mean ages was 69.4 years old (male/female 35/23). Sever narrowing or total occlusion of major arteries was revealed in 23 patients. Deep vein thrombosis was detected in 2 patients. Surgical treatment plans were cancelled or changed in 21 patients. There was higher incidence of histories of smoking, diabetics, and coronary artery stenting. Conclusions: As increasing of elderly patients, the incidence of concomitant obstructive vascular lesions of lower extremities may be increased in patients with lumbar degenerative disease. If patients present with weak or no pulsation of dorsalis pedis artery or lower limb edema, the clinician should consider sonography or CTA of vascular lesions of lower limb. Differential diagnosis of obstructive vascular lesions of lower limb with lumbar degenerative diseases is important for preventing unnecessary invasive procedures and surgical treatments., Introduction: The purpose of this study was to compare the radiological and clinical outcomes obtained in patients with lumbar spondylolisthesis in L4-5 who have undergone either instrumented anterior lumbar interbody fusion (ALIF), instrumented lateral lumbar interbody fusion (LLIF) or instrumented posterior lumbar interbody fusion (PLIF), especially with regard to the development of adjacent-segment degeneration (ASD). Material and Methods: The medical records of patients who underwent ALIF, PLIF or LLIF for single level spondylolisthesis on L4-5 at single center from January 2011 to December 2012 were retrospectively reviewed. Patient inclusion criteria for the study were: 1) diagnosed as L4-5 single level spondylolisthesis; 2) minimal ASD preoperatively 3) a minimum follow-up duration of 12 months. Patient exclusion criteria were: 1) requiring more than two-level fusions; 2) prior surgery in L4-5 level; 3) preexistent ASD. Radiographic measurements including preoperative and postoperative foraminal and disc height, segmental and lumbar lordosis, percentage of vertebral slippage, reduction rate were reviewed. Incidence of ASD and clinical outcomes were evaluated and compared between 3 groups. Clinical outcome by VAS, ODI and modified MacNab criteria were measured preoperatively, postoperatively and compared. Results: 82 patients who underwent instrumented L4–5 fusion for their L4-5 spondylolisthesis were included in this study and divided according to the surgical approach (ALIF: 27, LLIF: 24, PLIF: 31). Average follow-up period was 35.42 ± 9.35 months. Adjacent-segment degeneration was found in 40.7% (11), 37.5% (9) and 64.5% (20) of the patients in the ALIF, LLIF and PLIF group. ALIF and LLIF group showed favorable results compared to PLIF group in less incidence of ASD. These superiority was evident between ALIF and PLIF (P = .037) but not statistically significant between LLIF and PLIF (P = .091). The ALIF and LLIF groups had significantly increased disc and foraminal height compared to the PLIF group. The ALIF group had significantly improved lordosis compared to both other PLIF, LLIF groups. Our study showed that all three approaches significantly reduce spondylolisthesis and revealed ALIF have better ability to reduce the spondylolisthesis with a significant difference between the three interbody fusion approaches Clinical success rates (excellent, good by modified MacNab criteria) were 92.5, 91.6 and 87.0% in the ALIF, LLIF and PLIF groups. There were no statistically significant intergroup differences in clinical outcome by VAS, ODI. Conclusion: 3 different fusion techniques can produce good outcomes in treating lumbar spondylolisthesis in L4-5, but ALIF and LLIF are more advantageous in preventing the development of ASD, which may resulted from different ability to restore the postoperative sagittal balance and less intra-operative injury to posterior structures., Introduction: To see if visualisation of a medial epidural spill on the image intensifier at the time of the transforaminal epidural steroid injection (TFESI) was associated with more pain relief. Material and Methods: Over 300 patients were treated with a TFESI between September 2012 and December 2015. 215 patients met inclusion criteria; 111 males and 104 females with a mean age of 53.3. The outcome measures included whether or not the patient had pain relief, their change in PROMs scores and whether or not they had a subsequent operation. Results: The study group included 101 patients who had disc herniations, 94 patients who had lateral recess stenosis (LRS), 53 patients who had foraminal stenosis (FS) and 41 patients who had spondylolisthesis of which there were combinations. 28% of TFESIs worked without recurrence, 43% of TFESIs worked but then recurred and 29% of cases did not work at all. In the pain recurrence group, the average time it took for pain to recur was 2.8 months. Visualisation of a rootogram and medial epidural spill were not predictive of patient outcomes and there was no statistically significant differences in outcome and whether the TFESI was successful between the 4 groups (Disc/LRS/FS/SPL). Conclusion: There were strong correlations between duration of symptoms (DoS) and pain intensity/disability scores and patient outcome. There was a significant difference between pre-injection and post-injection PROMs scores with regards to all different measures (P < .05). There was no correlation between presence of epidural spill and change in PROMs scores., Introduction: Osteoporosis and tumors can induce sacral insufficiency fractures (SIFs). SIFs cause severe low back pain and immobilization. The purpose of our study is to describe our experience and assess the safety and effectiveness of minimally invasive percutaneous sacroplasty in patients with osteoporotic SIFs. Methods: We reviewed cases of percutaneous sacroplasty performed since 2009. We used data only from patients with osteoporotic SIFs who were followed for more than 12 months after sacroplasty. Tumor-related SIFs were excluded from our analysis. The following clinical parameters were investigated: initial diagnosis, symptoms, visual analog scale (VAS) of pain, functional mobility scale (FDC) score, past history of illness, amount of bone cement infused, and complications related to sacroplasty. Also, the following radiological parameters were analyzed: the pattern of SIFs, T-score cement leakage, and concomitant fractures in other sites. Results: 68 patients were enrolled in our study (4 males and 64 females). The mean age of the subjects was 76.8 ± 6.2 years. All patients had severe osteoporosis (mean T score: -3.9 ± 0.5). Percutaneous sacroplasty was performed under fluoroscopic guidance. No major complications or procedure-related morbidity occurred. FDS and VAS scores significantly improved after sacroplasty, and the improvements lasted through the final follow-up period (P < .05). Conclusions: Percutaneous sacroplasty is an effective minimally invasive treatment for osteoporotic SIFs refractory to conservative management. The study subjects experienced significant relief of pain, and increased mobility., Introduction: The most disastrous complications of alkaptonuria are ochronotic spondyloarthropathy which causes painful and disabling joints along with spine. In late stages of the disease nucleus pulposes may be ossified with heavy pigmentation of ligamentum flavum and ultimately leading to spinal canal stenosis. Ochronotic myelopathy is an extremely rare condition where only few cases have been reported in cervical and thoracic region. Here we report a rare case of tandem stenosis of spinal canal involving thoracic and lumbar region. Material/Case Report: A 53 year old female presented with back pain radiating to bilateral lower limbs since 3 years. Neurological evaluations showed features of thoracic myelopathy. Plain radiographs showed degenerative spine with inter vertebral disc calcifications, ankylosis, and osteoporosis with bilateral sacroilitis. MRI scan of thoraco-lumbar spine showed diffused annular bulge, flaval hypertrophy from T9-T10 to L5-S1 level with severe cord compression at thoracic level. Urine analysis showed large amounts of homogentisic acid confirmed by thin layer chromatography. Results: She underwent thoracic laminectomy and lumbar fenestration laminotomy with nerve root decompression. Hypertrophied and blackish coloured ligamentum flavum was characteristic intraoperative finding. HPE showed chondrocytic cytoplasm containing melanin like pigmentatation. Discussion: Accumulation of HGA and its oxidation products like benzoquinone results in bluish-black pigmentation of connective tissues which is termed as Alkaptonuric Ochronosis. The musculoskeletal manifestations are commonly reported to occur in spine where abnormal calcifications of intervertebral disc are a characteristic finding. Retrospective diagnosis of alkaptonuria by identifying “Black disc” intra-operatively has been reported by many authors where low back ache radiating to lower limbs was the commonest symptom. There have been only few reports in literature stating that decompressive procedures improved the neurological status of the patients with alkaptonuria. Our patient showed significant weakness in bilateral lower limbs which were improved over a period of time and were successfully walking with the help of crutches by 6 months. Conclusion: One of the rare outcomes of alkaptonuria is ochronotic arthopathy especially involving lumbar spine with or without degeneration of other major joints. The present case signifies the importance of whole spinal screening as the region involved is more than one. Our case of tandem canal stenosis in thoracic and lumbar segments is one of the rarest reported cases till date., Introduction: Lumber steroid injection can be endorsed as a treatment component for lumberosecral radicular pain syndrome resulting from disc herniation. The facet joint steroid injection seems to be beneficial for patient with chronic backache due to the facet joint arthritis and in the lumber Spondylosis. Materials and Methods: We did a retrospective review of 31 patients whom we treated between 2011 to 2014 with follow-up (6 months to 24 months) There were 19 females and 12 males, age 29- 81 years 5 patients had previous surgery for simple discectomy to posterior spinal fusion. 4 patients had multipal disc prolapse 3-4 level, 2 patients had severe lumbar Spondylosis and spinal stenosis. The reaming 20 patients had single level disc prolapse. All these patients were given caudal and facet joint block. Results: The pre and post steroid injection oswestay score was done. After steroid injection the oswestay improved by 30%. Majority of the patients had pain relieve for 2-18 months. The pain relieve relief was much better in the non operative group with single level disc prolapse and those patients with lumber Spondylosis. Conclusion: In patient with chronic back pain there is inflamatory basis for pain generation. Lumber steroid injection seems to be beneficial in patients with disc prolapse and lumber Spondylosis. In the literature various randomized trials has been done and their results are controversial. Our study showed definitive improvement in terms of pain and function of our patient., Introduction: Generally, the area of radicular leg pain due to lumbar disc herniation (LDH) is considered to be related to dermatome. On the other hand, it has been reported that radicular leg pain in patients with LDH is closely associated with myotome rather than dermatome. To analyze the anatomical components of radicular leg pain, we investigated the area of muscle tenderness in lower extremities in LDH patients. Material and Methods: Thirty patients (20 men and 10 women, mean age: 41 years) with clinically diagnosed as single-level unilateral radiculopathy (L5 or S1) due to LDH were included in this study. Eleven (6 men and 5 women, mean age: 41 years) were diagnosed as L5 radiculopathy (L5 group), and 19 (14 men and 5 women, mean age: 41 years) were diagnosed as S1 radiculopathy (S1 group). Postoperative leg pain relief proved that the diagnosis of single-level radiculopathy was correct in all patients. Before surgery, muscle tenderness in lower extremities was examined by the sole examiner (Y.K.) at the following muscles: gluteus maximus, gluteus medius, biceps femoris, adductor magnus, vastus lateralis, rectus femoris, vastus medialis, tibialis anterior, fibularis, gastrocnemius medial head, and gastrocnemius lateral head. The same pressure forces (approximately 4kg/cm2) were simultaneously applied to bilateral leg muscle via the thumb of the examiner at so called “motor point” of each muscle. When muscle tenderness in the affected side was significantly severer than that in the unaffected side, the muscle in the affected side was determined to have a positive muscle tenderness sign. Results: Both L5 group and S1 group had positive muscle tenderness signs at multiple muscles. The incidence of positive muscle tenderness sign (L5 group/S1 group; muscle) was 9.1%/78.9%; gluteus maximus, 90.1%/84.2%; gluteus medius, 54.5%/89.5%; biceps femoris, 0%/0%; adductor magnus, 27.3%/21.1%; vastus lateralis, 9.1%/0%; rectus femoris, 0%/10.5%; vastus medialis, 63.6%/57.9%; tibialis anterior, 72.7%/52.6%; fibularis, 45.5%/36.9%; gastrocnemius medial head, and 36.4%/47.4%; gastrocnemius lateral head, respectively. In gluteus maximus, S1 group showed a significantly higher positive incidence than L5 group (P < .01 Fisher’s exact test). In the other muscles, there was no significant difference between L5 group and S1 group. Conclusion: The present study revealed that the patients with LDH have positive muscle tenderness signs at many site of their leg muscles. The presence of positive muscle tenderness sign at gluteus maximus suggests S1 radiculopathy, and this finding is useful for differential diagnosis between L5 and S1 radiculopathy., Introduction: Causal treatment of a chronic disease like Low Back Pain (LBP) reduces the burden of disease, but it requires precise and unambiguous diagnosis, especially when the etiology is far from obvious. In such cases, the appropriate selection of diagnostic tools ensures success. The purpose of this case presentation is to highlight the importance of anatomical and functional data that SPECT CT scan has provided in the diagnosis and treatment of LBP in a middle-aged woman with concurrent pelvic venous congestion & Bertolotti syndromes. Material and Methods: We present a case of a 47-year old woman who presented with chronic LBP that transitioned from intermittent to persisting pain and “heaviness” in the pelvis on a daily basis for the last year. Symptoms were aggravated with standing and walking while radiation into the pelvis and buttocks was also common. These symptoms, although consistent with Bertolotti syndrome, were accompanied by a ten-year recurrent deep pelvic pain, “heaviness,” and discomfort. Information obtained from both the history and the clinical examination pointed to atypical LBP. SPECT CT scan revealed mild L3-L4 facet radiotracer uptake, severe disc and facet radiotracer uptake at L4-L5, a retroaortic left renal vein, and a dilated left gonadal vein. Up to that moment the patient had undergone several clinical and imaging tests including lumbar MRI and a negative pelvic ultrasound. Neither medications nor physical therapy or chiropractic treatment had offered significant relief. Results: Based on the above findings, the patient received steroid injection therapy in the L4-L5 facet joints, which provided a short term (up to 3 weeks) relief of symptoms by 50% to 60%. As a result, the remaining amount of pain directed our interest into pelvic venous congestion syndrome regardless of a negative pelvic ultrasound. Therefore, even despite the fact that the left retroaortic renal vein and symtomatology were pointing to nutcracker phenomenon rather than to nutcracker syndrome, we elected to order a dedicated pelvic MRI for further exploration. Pelvic MRI findings were consistent with pelvic congestion syndrome. We referred the patient to the interventional radiology where she underwent bilateral ovarian vein embolization, which provided 90% relief of symptoms. At a two and six-month follow up, the patient reported mild intermittent LBP, which was attributed to Bertolotti syndrome. Conclusion: This case-report study underlines the significance of the proper evaluation of medical information retrieved from physical assessment as well as from imaging data. It also delivers the following message: even though the rationale of diagnostic procedures requires consistency, deviating from the “norm” when warranted is a cornerstone in the rapid and successful management of unusual situations requiring clinical astuteness., Introduction: Low back pain is a very common condition with an important subjective component where often appear simulation behavior, either to obtain a secondary gain (malingering) or a primary gain (factitious disorder). Objectives: To evaluate the usefulness of Structured Inventory of Malingering Symptoms (SIMS) in a group of patients referred to the Pain Unit with medically unexplained low back pain (MUL). Material and Methods: Prospective study. All back pain referred to the Pain Unit of the Hospital de León for a year. After multidisciplinary evaluation the SIMS was administered to all patients who were diagnosed of MUL. After unstructured psychiatric interview (gold standard) was performed and statistical analysis was performed to determine the predictive values of the scale. Results: 274 patients with low back pain were referred. 95 (34.67%) were diagnosed of MUL after multidisciplinary assessment. 40 were positive for simulation symptoms in SIMS. 30 of these positives were confirmed after the psychiatric interview. 55 were negative in SIMS but in three cases were diagnosed of simulation in the interview. The positive predictive value of the interview was 75% and negative predictive value of 94.54%. Among the ten patients with false-positive result for simulation in nine cases another mental disorder was diagnosed as clinical origin. Conclusion: The negativity of the SIMS allows with high security to discard simulation in patients with low back pain. Positivity has good predictive value or makes suspect the presence of another mental disorder as clinical origin., Introduction: Neurological recovery and outcomes following surgery in cervical spondylotic myelopathy are variable and cannot be accurately predicted preoperatively. Preoperative investigation modalities, including MRI have demonstrated poor efficacy in predicting neurological outcome. Diffusion Tensor Imaging (DTI) indices have shown promise as a tool to reliably assess spinal cord function and have been used in the assessment of cervical spondylotic myelopathy. However, efficacy of DTI indices in predicting post-operative recovery has not been studied before. We aimed to analyse post operative neurological outcomes in cervical spondylotic myelopathy using DTI indices to identify predictive factors for neurological recovery and to document postoperative changes seen in DTI indices. Materials and Methods: We prospectively performed a cohort study on thirty-five patients of cervical spondylotic myelopathy that underwent surgical decompression. DTI evaluation was performed preoperatively and at 1 year following surgery. Analysis was performed on the DTI indices and correlated with clinical outcomes. Clinical disability was assessed using Nurick grade. The patients were sub grouped based on clinical disability into group1- independent ambulators (Nurick1 and 2) and group2- assisted ambulators (Nurick grade 3,4 and 5). DTI indices- Fractional anisotropy (FA), Apparent diffusion coefficient (ADC), Relative anisotropy (RA), Volume ratio (VR) and eigen vectors(E1, E2 and E3) were obtained and clinical evaluations were made pre-operatively and 12 months post-operatively. Results: Twenty-six patients were available for final follow up at 12 months. Twenty patients showed improvement by at least 1 Nurick grade, 5 maintained the pre-operative Nurick grade status and 1 patient was noted to have deterioration by 1 grade. The MRI showed adequate decompression in all patients irrespective of the clinical outcome however, DTI indices showed variable results. There were significant improvements in postoperative DTI indices for ADC (P = .002), E1 (P < .001) and E2 (P = .012) values in patients who showed neurological recovery at 12 months. Post-operative DTI indices for coefficients ADC, E1 and E2 in neurologically static/worsened individuals remained unchanged or insignificant (P > .05). The mean pre-operative DTI indices remained similar in the neurological improved and unimproved patients. Sub group analysis based on ambulatory status also produced no significant relationships with the DTI indices post-operatively. Conclusion: Post operative DTI indices were sensitive to identify post operative clinical outcome following surgery, showing comparable change with recovery, and no significant change was seen in patients that showed no recovery or worsened after surgery. The DTI indices however, did not have value preoperatively, in predicting neurological recovery following surgery in cervical spondylotic myelopathy., Introduction: Low back pain is a major symptom related reason for visiting a physician worldwide both for its clinical significance as strong economic burden in healthcare systems. This study aimed to review and analyze the diagnosis and management of patients older than 18 years who attended due to low back pain to the emergency department of a third level hospital in Bogota, Colombia. Based on this results and literature review we propose a management algorithm for emergency rooms. Methods: An observational cross-sectional study was conducted by reviewing 750 medical records of patients with diagnosis of low back pain treated at the emergency department of third level hospital in Bogotá, Colombia between January 2010 and December 2013. Variables analized included demographic data, red flags presentation, imaging studies requested and pain management strategies used. Results: From 750 medical records, 550 were included in the analysis. Mean age of patients was 51.6 years and 61.6% were female. At least one red flag was identified in 48.1% (242) of patients. Only 8% did not present red flags. Pain related to trauma was the most common red flag (72.5%) followed by age > 55 years (50.5%). Plain radiography was the most frequent requested study (53.9%). Within the group of patients without red flags, 45% had a diagnostic image. The most widely used pharmacological management was the combination of opioids and nonsteroidal antiinflammatory drugs (NSAIDs) in 29.1%, followed by monotherapy with opioids (22%). After initial mangement at the emergency department 23.4% of patients required hospitalization. Conclusions: Low back pain is a frequent chief complaint at the emergency department with most patients presenting at least one red flag, most of the times related with trauma. Plain radiography is an excellent diagnostic tool and remains the most frequent ordered imaging study. The most frequent pharmacological management was NSAIDs combined with opioids. Nevertheless, institutional attention protocols to improve low back pain management should be considered. Based on the results found in this study and a literature review, we found that pain mechanisms are consistent with literature reports. According to our findings a management algorithm for low back pain in the emergency room is proposed. The algorithm begins with an excellent anamnesis and physical examination that seeks to identify red flags and individual risk factors for serious conditions. If red flags are detected, imaging studies should be carried out with concomitant pharmacologic treatment with postural hygiene recommendations., Introduction: At a large university Orthopedic department, the need for emergency spinal imaging (ESI) arises on a regular basis. In most instances, magnetic resonance imaging (MRI) is the imaging modality that is primarily requested. Depending on a number of factors, MRI is not always immediately available to us and in these instances we often resort to computed tomography (CT) as a first line of imaging. In some cases though, additional MRI is necessary after CT in order to ascertain a diagnosis, which in turn creates delays in the diagnostic work-up. Once a diagnosis has been made and an indication for emergency surgery has been established, other factors, such as the immediate availability of an operating theatre and an anesthesia team may again cause delay in performing emergency spinal surgery. At present, we have no precise knowledge of the possible consequences or even the absence of such. We therefore decided to prospectively collect and analyze all such events and the associated decisions, delays and pathways, starting 2012. This abstract is based on initial data from January through September 2012. At presentation, the complete data for 2012 will be available. We defined ESI as the need for cross-sectional imaging in any situation where the affected patient’s history and clinical symptoms render likely or possible a diagnosis, which would justify urgent spinal surgery. Material and Methods: Starting with January 1st, 2012 and after obtaining ethics board approval, we began to collect data on all cases in which ESI was requested from the radiology department. Amongst the parameters collected are: Suspected diagnosis, imaging modality requested, imaging modality available, delay to primary imaging, day of the week and time of the day, whether the primary imaging modality was sufficient to decide on the patient’s treatment, whether secondary imaging was required, delay to secondary imaging and what the final treatment strategy was. In cases, where a decision for surgery was made, the time from decision to incision was recorded as well as the reason for any delays. Status at discharge was recorded. Within 24 hours of each event, the data was entered into a customized Microsoft Excel spreadsheet residing on the department server and available from all workstations. In this initial presentation, data is presented by means of descriptive statistics only. Results: Including September 2015, 131 events of ESI were recorded. The affected patients were 19 females and 10 males, aged on average 57 years with ages ranging from 25 to 89 years. There were 7 situations after previous in-house spinal surgery and 22 situations in which patients presented without previous surgery. The suspected diagnoses were disc herniations, postoperative epidural hematoma, disc reherniations, spinal infection, spinal ischemia and implant misplacement in descending order. MRI was the primary imaging modality requested in 27 cases, CT in 2 cases. MRI was the primary imaging modality obtained in 16 cases, CT in 13 cases. The most frequent reasons given for MRI unavailability were work overload (MRI requires significantly more time than CT) and unavailability of a trained MRI technician. There were 4 situations, where the on-call radiologist felt that a CT would be sufficient to examine the suspected pathology, only 1 of which required an additional MRI after the CT. In 3 cases of primary CT, MRI was additionally required whereas in only 1 case of primary MRI, an additional CT was necessary. When primary imaging was sufficient, the delay from imaging request to a secured diagnosis was 3.4 hours on average, ranging from 0 to 27 hours. In the 4 patients requiring secondary ESI, the total delay was on average 17 hours, ranging from 4 to 29 hours. Secondary imaging was necessary in 3 cases, where primary MRI had been requested and CT had been performed, but also in 1 case, where primary MRI had been requested and performed. In the latter case, an additional pelvic CT was obtained after a spinal MRI did not explain an incomplete polyradicular paralysis of the right leg in a patient with chronic lymphatic leukemia. Secondary pelvic CT in this case substantiated plexus compression by enlarged pelvic lymph nodes. In 14 cases, surgery was recommended to patients as a result of the clinical picture and the imaging results. 3 of these patients elected conservative care over surgery and 11 emergency interventions were booked with the operating department. These were mostly primary disc surgeries and 1 case of a re-herniation. 3 cases required laminectomy or other decompression for additional spinal stenosis. The delay from decision to incision was 9.4 hours on average, ranging from 1,3 to 22 hours. The reasons for delay were unavailability of an operating theatre or an anesthesia team because of other emergency surgeries being performed at the time of our booking, but also patient indecision in 1 case and patients unwilling to remain “nil by mouth” in 2 cases. Conclusion: Diagnostic and surgical decision making in emergency situations is a complex process, influenced by multiple factors, all of which potentially have relevant consequences. In this preliminary series, we found that primary MRI (16 instances) was sufficient to ascertain a diagnosis with the exception of 1 case, whereas primary CT (13 instances) required 3 additional MRI to generate a reliable diagnosis. These initial data suggest that except in cases where implant position is the key issue, MRI should be the primary ESI of choice. Additional imaging requires additional time and in this series, the mean delay from imaging request to decision was 3.4 as opposed to 17 hours, when a single imaging study was sufficient as opposed to when secondary ESI was necessary. An additional 9,4 hours delay from decision to incision has to be added to these numbers. Our database is too small at current, to allow for any conclusions as to whether these delays translate into any clinically relevant differences in outcome., Introduction: Recently, posttraumatic stress disorder symptoms (PTSD) were attributed to spine surgery. Furthermore, PTSD symptoms were associated with reduced clinical benefit. However, PTSD is seen in up to 10% of the normal population and there was no preoperative evaluation for PTSD symptoms. We previously demonstrated that PTSD symptoms are very common before surgery and negatively influence clinical outcome at 3 months follow up. Aim of this study was to assess the incidence and influence of PTSD Symptoms on clinical outcome one year after surgery. Methods: A prospective study of patients undergoing elective spine surgery for degenerative disc disease was performed. The patients were evaluated for PTSD using the PTSS score before, 3 and 12 months after surgery. In addition SF36 physical composite score (PCS), Oswestry Disability Index (ODI), EuroQOL 5D questioner and pain visual analog scale (VAS) were completed preoperatively, 3 and 12 months after surgery. Incidence and influence of PTSD symptoms on clinical outcome were examined. Results: 184 patients met the inclusion criteria. 52.7% were male, mean age was 59.4 years. Abnormal PTSS scores were observed in 43.7%, 20% and 22% of cases before, 3 and 12 months following surgery, respectively. However, only 8% developed PTSD symptoms only after surgery. At one year follow up patients with abnormal PTSS scores had a worse clinical outcome compared to their counterparts (SF36 PCS: 33.1 vs 40.0 P = .002; EuroQOL Index: 0.64 vs 0.78, P = .11, VAS Pain 5.6 vs 3.7 P = .001). Conclusion: PTSD symptoms are associated with worse outcome following elective spine surgery. However, the vast majority of patients that exhibit PTSD symptoms had already exhibited symptoms before surgery. Thereby the PTSS score seems nonspecific in the preoperative setting., Introduction: There are different definitions of arthrodesis, alignment and subsidence in the cervical spine. We aimed to compare the accuracy of different objective radiographic techniques in after anterior cervical discectomy and fusion and correlated those with clinical outcome. Methods: A retrospective analysis of 200 radiographs of patients following ACDF with stand alone-PEEK cages with a minimum follow up of 12 months was performed. For assessment of fusion one measurement was obtained from plain radiographs: the presence or absence of bridging bone in the operated segment. Three measurements were obtained from flexion-extension radiographs: Cobb angle and the distance between the tips as well as the distance between the bases of the spinous processes of the operated segment. Measurement of more than 2 mm between the bases of the spinous processes was defined as pseudarthrosis as recommended by the joint guidelines committee of the AANS/CNS. Cervical alignment was assed using the Katsuura, Lang and Cobb methods. Subsidence was measured with the mochida method, ventral segmental height reduction and dorsal segmental height reduction. Correlation between the different radiological methods and clinical outcome was performed. Results: Fusion rates varied greatly depending on the method used (from 43.9% to 89.4%). The Pearson correlations between pseudarthrosis and the use of the distance between the tips of spinous process method, the Cobb angle method and the presence or absence of bridging bone was 0.595 (P < .001), 0.187 (P = .007) and 0.224 (P < .001). The area under the receiver operating characteristic curve for the spinous process method was found to be 0.732, as compared with 0.557 for the Cobb angle method and 0.581 for the bridging bone method, for the measurement of pseudarthrosis. None of the methods used had any correlation with clinical outcome. The rate of improvement or stability of the cervical alignment was seen in 83.2%, 36.6% and 43.3% using the Laing, Katsuura and Cobb methods, respectively. Neck pain correlated with the cervical alignment using the Cobb (P = .27) and the Katsuura (P = .034) assessment methods but failed to correlate with Laing assessment method (P = .102). Subsidence rates were 62%, 48% and 27% using the mochida, ventral and dorsal segmental height reduction assessment methods, respectively. Pearson correlations between the mochida and ventral and dorsal height reduction assessment methods was poor (ventral: r = 0.39, P = .66 and dorsal 0.007, P = .921). Pearson correlations between the ventral and dorsal segmental height assessment was fair (r = 0.391, P < .0001). Subsidence using the mochida method correlated with neck pain at last follow up (P = .047), but did not correlate with clinical outcome with the other measurement methods. Conclusions: Fusion rates varied greatly depending on the method used. Regardless of the measurement method, pseudarthrosis did not correlate with worse clinical outcome. The assessment of cervical alignment is highly depended of the method used. Cervical alignment using the Katsuura and Cobb methods correlated with clinical outcome and last follow up. Subsidence rates varied strongly depending on the measurement method used. Clinical outcome correlated with subsidence when the mochida assessment method is used., Introduction: Despite widespread use of lumbar spinal fusion as a treatment for back pain, outcomes remain variable. Optimizing patient selection can help to reduce adverse outcomes. This research seeks to conduct a literature review to better understand the factors associated with optimal post-operative results following lumbar spinal fusion for chronic back pain, and the current tools used for patient subjective evaluation. Materials and Methods: The PubMed database was searched for clinical trials related to psychosocial determinants of outcome following lumbar spinal fusion surgery, evaluation of commonly used patient subjective outcome measures, and perioperative cognitive, behavioral, and educational therapies. The reference lists of included studies were also searched by hand for additional studies meeting inclusion criteria. English language and translated foreign language studies were included, as were any studies published between 1985 and the present. A total of 49 studies were included in support of the research questions addressed in this review. Results: Patients’ perception of good health prior to surgery and low cardiovascular comorbidity predict improved postoperative physical functional capacity and greater patient satisfaction. Depression, tobacco use, and involvement in litigation predict poorer outcomes following lumbar fusion. Incorporation of cognitive-behavioral therapy perioperatively can address these psychosocial risk factors and improve outcomes. The SF-36, EQ-5D, visual analog pain scale, brief pain inventory, and ODI can each provide specific feedback which can track patient progress and are important to understand when evaluating the current literature. Conclusions: The interplay of the various social and psychological factors surrounding lumbar spinal fusion are not fully understood when considering outcomes, and require further study. This review provides a summary of the current available information and explains commonly used assessment tools to guide clinicians in decision making when caring for patients with chronic lower back pain., Introduction: Symptomatic lumbar disc herniation is a rare occurrence during gestation despite the fact that low back pain complicates around 56% of pregnant patients. In line with this, cauda equina during pregnancy have only been documented in literature twice and considered as extremely rare. Advancements in surgical technique coupled with the proven safety of magnetic resonance imaging has made lumbar discectomy a viable and justifiable procedure at any stage of pregnancy. This paper was created to present a rare case of a pregnant patient with cauda equina syndrome treated surgically with lumbar microdiscectomy employing progressive local anesthesia as a novel alternative to neuraxial anesthesia. Material and Methods: A 30-year old multigravid primiparous woman with seven-month history of intermittent low back pain sought consult at 14 weeks’ gestation because of severe right leg pain which confined her to bed rest at home. There was noted associated saddle anesthesia of the perineum, urinary incontinence and constipation without any recalled precipitating factors. Physical examination revealed weakness of the right foot evertors and plantar flexors, loss of sensation in the L5-S1 nerve root distributions, and positive straight leg raise bilaterally. MRI confirmed an extruded disc at L5-S1. Patient was diagnosed with cauda equina syndrome and was advised to undergo surgery. Intraopertaively, the patient was positioned via modified knee chest on an Andrew frame, and underwent right-sided L5S1 foraminotomy, laminotomy and discectomy L5S1 under microscopic guidance under progressive local anesthesia. Post-operatively, the patient experienced immediately reported relief of her leg pain. Later on, she delivered prematurely at 33 weeks’ gestation by to a live baby boy via normal spontaneous delivery. At one year follow-up, patient denied any low back pain, residual paresthesia or motor weakness of both lower extremities, saddle anesthesia, nor urinary or bowel disturbances. Results: The surgical and anesthetic technique used in the study resulted in the desired outcome of decompression of the spinal cord and involved nerve roots, relief of patient pain post-operatively, disappearance of symptoms of cauda equina syndrome, and, ultimately, the uncomplicated delivery of a healthy infant. Conclusion: This case represents the only documented use of progressive local anesthesia positioned in modified knee chest position in lumbar surgery in a pregnant patient suffering from cauda equina syndrome. A rare condition in its own right, cauda equina syndrome is just as debilitating in the pregnant patient as it is in the normal population and still constitutes an orthopedic emergency that should be managed promptly without hesitation. As highlighted in this report, progressive local anesthesia may be a quick, effective, and non-expensive anesthetic option for these cases and in cases where neuraxial anesthesia is contraindicated., Introduction: The aim of this study is to evaluate the relationship between pelvic swing, a new pelvic parameter, and disk degeneration. The L5-S1 and L4-L5 disks are the transition points where body weight is transferred from the sacrum to the pelvis. The pelvis makes a swinging movement to both sides when a person is in motion. The L4-L5 and L5-S1 disks are the segments located in this transition region, which has the greatest participation in pelvic swing and where disk degeneration is the most frequently observed. Moerover, lumbar disk degeneration is more common in women than in men. Materials and Methods: 40 male and 40 female patients were included in the study. The mean age of the subjects was 30–50 years. Those with spondylolisthesis, deformity, congenital anomaly, history of operation, and a body mass index of >30 kg/m2 were excluded from the study. Magnetic resonance imaging (MRI) and lumbosacral spine XRay were prescribed to the patients with a complaint of back pain. Patients with degeneration at L4-L5 on MRI were assigned to the patient group, and those without degeneration were assigned to the control group. Four groups were established: group 1, female patients; group 2, female controls; group 3, male patients; group 4, male controls. Pelvic swing was measured over the anterior-posterior lumbosacral spine XRay. A line was drawn from the center of the top endplate of the sacrum to the center of the femoral head. This line was joined with an imaginary line perpendicular to the ground. The angle between the lines was taken into consideration and called the pelvic swing (PS). Measurements were performed separately by four researchers. The study is still in progress, and the number of groups should be increased (Figure 1). Results: The mean PS was found to be higher in the female patients than in the female controls, higher in the male patients than in the male controls, higher in the female patients than in the male patients, and higher in the female controls than in the male controls. Data analysis was performed by using SPSS 17.0 software for Windows. The Kolmogorov-Smirnov test was used to investigate if continuous variables had a normal distribution. The Levene test was used to investigate the homogeneity of the variances. Descriptive statistics were presented as median (interquartile range). The Bonferroni-corrected Mann-Whitney U test was used to investigate the significance of the intergroup difference in PS angle. Bonferroni correction was implemented in this study to control the type I error in all possible multiple comparisons. Based on the Bonferroni correction, results were considered as significant if their p values were, Introduction: Cauda equina syndrome is a pathological process with clinical signs and symptoms associated with lumbar disc herniation (incidence of approximately 2%). This pathology presents low back pain with or without radicular pain in lower extremities with impaired bladder and/or bowel control and loss of sexual sensation. The objective is to describe the clinical presentation of this syndrome and the outcome in five patients and literature review. Materials and Methods: Observational, longitudinal, retrospective study of patients diagnosed of cauda equina at the Torrejon hospital from 1st of January 2013 until 1st of June 2015. We collected sociodemographic variables, etiology, treatments and sequelae. Results: 7 patients (5 males and 2 female) with cauda equina syndrome by lumbar pathology. The average age was 45 years (range 40-50 years). Etiology: 6 patients had compression by disc extrusions and one ischemic / toxic after epidural injection. All patients had early surgery with canal decompression and circumferential spinal fusion after radiological study (CTscan, MRI, Angio-MRI). The time of clinic evolution: < 24 hours (5 patients), < 72 hours (1 patient) and < 1 week (1 patient). There were two complications: One second surgery by hematoma and one seroma resolved without surgery. Outcomes, in patients with compressively etiology: 100% have no motor symptoms but 50% had visceral or sensory clinical. The patient who debuted after epidural infiltration presented a late (after 14 months) and incomplete motor recovery, neuropathic pain and visceral clinic persist. Conclusion: This syndrome is a surgical emergency, by this is very important the early diagnosis. We present an infrequent case by ischemic / toxic damage (6 cases described in the literature). The early surgical decompression (, Introduction: According to many reseurchers, degenerative disk diseases is pandemic of the XXI century. Herniated disc at the lumbosacral spine is found in 61% of patients with degenerative diseases of the spine. Parallel advancements in image guidance technology and minimal access techniques continue to push the frontiers of minimally invasive spine surgery. While traditional intraoperative imaging remains widely used, newer platforms, such as 3D-fluoroscopy, cone-beam CT, and intraoperative CT/MRI, have enabled safer, more accurate instrumentation placement with less radiation exposure to the surgeon. This work reviews a private experience of uses of image guided system in lumbar spine endoscopic procedure. Materials and Methods: The authors used the O-ARM and S7 navigation system for percutaneous endoscopic lumbar disk herniation removal (PELD). This retrospective study included 52 patients who underwent transforaminal procedure for migrated disk herniation. Image- guided navigation utillizated in 9 cases. Pre- and postoperated examination included visual analogue scale (VAS) Oswestry Disability Index (ODI), radiological workup and time of operation. Results: Postoperative mean ODI decreased from 77.27 ± 7.1% to 16 ± 1.6%. All of patient noted improve theire pain status. Mean VAS score for back pain improve from 9.27 ± 0.27 to 1.87 ± 0.93 and leg pain from 8.0 ± 0.67 до 1.62 ± 0.98. Analysis of radiological work up confirms advantages of navigated PELD versus non navigated. There is common radiation dose was 1.5 ± 0.5 mSv in the group of patients undergone procedure navigation versus 5.3 ± 0.7 mSv in non navigated group. The mean of operation time was not deferent in both groups. Conclusions: Utilization of intraoperative cone-beam CT combined with navigation system in PELD decreases of common radiation dose versus traditional fluoroscopy. Improvement of visualisation and online control of instruments support increasing of quantity “best result” of surgery via improving of quality of nerve structures decompression., Introduction: Collagen is a major structural component of the intervertebral disk (IVD) array, and isresponsible for form and tensile strength. The purpose of this study was to evaluate the specific collagens I, II and III by immunohistochemistry and correlate them with radiological data of patients with lumbar degenerative discopathy (LDD). Materials and Methods: The IVD were obtained from twenty-three patients with LDD refractory to conservative treatment who required surgical treatment. Anti-collagen antibodies I, II and III were used for the determination of the protein collagen expression by immunohistochemistry. All data were correlated (Spearman’s-Rho) with radiographic findings of the patients and the Pffirman and Weishaupt classification. This study was approved by the Ethics Committee Circle/FSG 0153 and CAAE 40422114.3.0000.5341. Results: The data showed higher protein expression of collagen III (31.42%) compared to collagen I and II expression in chondrocyte clusters. Positive correlation was also determined (P < .01) between the degree of IVD degeneration and the percentage of protein expression of collagen II matrix in IVD. Further, a positive correlation (P < .05) was determined between the degree of facet degeneration and the percentage of expression of collagen I in the IVD chondrocyte clusters. Conclusion: The degenerated IVD presents a clear tendency to repair through the high protein expression of collagen III, indicating the possibility of IVD recovery and the possibility of viable stem cells in tissue that can regenerate the injury of patients with LDD., Introduction: Genotoxicity may be caused by intrinsic and extrinsic factors and determine the level of DNA damage that may be associated with several pathologies. Studies on the assessment of genotoxicity in the intervertebral disc (IVD) are scarce. The purpose of this study was to evaluate the genotoxicity in IVD and correlate it with the radiological data of patients with lumbar degenerative discopathy (LDD). Materials and Methods: The IVD were obtained from eight patients with LDD refractory to conservative treatment who required surgical treatment. For the determination of genotoxicity the IVD were digested enzymatically and subjected to Comet Assay to determine the degree of DNA damage. The genotoxic Damage Index (DI) and the Damage Frequency (DF) were determined. All data were correlated (Spearman’s-Rho) with radiographic findings of the patients and the Pffirman classification. This study was approved by the Ethics Committee under number CAAE 40422114.3.0000.5341. Results: The evaluation of the Comet Assay allowed an unprecedented definition of mean genotoxic values of DI and DF for each degree of IVD degeneration. The data generated showed a positive correlation (P < .01) between the increase of the average genotoxic DI and increasing the degree of IVD degeneration. These unique data characterize the need for investment in further studies to determine the factors associated with correlation of genotoxic damage with the severity of LDD. Conclusion: The comet assay showed a correlation between increased DNA damage and the severity of the LDD, which can justify the difficulty of repairing the damage and tissue regeneration., Introduction: The definition of cell differentiation capacity of adult mesenchymal stem cells (mSC) imposes a serious constraint on the applicability of this system in regenerative therapy. The purpose of this study was to evaluate the differentiation capacity of mSC isolated from the intervertebral disc (IVD) for future use in regenerative medicine in patients with lumbar degenerative discopathy (LDD). Materials and Methods: The IVD this study were obtained from patients with LDD refractory to conservative treatment which required surgical treatment. The mSC were isolated according to the methodology deposited in the INPI and characterized by flow cytometry. The differentiation capacity of isolated cells was determined by cultivation in specific media for 30 days with inductors for adipogenic and osteogenic differentiation. The cells were stained with Alizarin Red S (Osteocytes) and Oil Red O (adipocytes) to determine differentiation. This study was approved by the Ethics Committee under number CAAE 40422114.3.0000.5341. Results: The mSC isolated showed all the characteristics required by the International Cell Therapy Society (Plastic adherence, characterization by flow cytometry and differentiation). Furthermore, mSC were able to differentiate after one month of cultivation in specific media for adipogenic and osteogenic tissue when observed using specific staining. In addition to osteocytes and adipocytes it was also possible to visualize mSC residues, demonstrating the induction of these cells to differentiate. Conclusion: The mSC were able to differentiate into adipocytes and osteocytes under cultivation conditions and thus define their capacity for future application in regenerative medicine for patients with LDD., Introduction: Lumbar degenerative discopathy (LDD) affects millions of people worldwide and is among the most common causes of disability and chronic suffering. Thus it is necessary to invest in basic research to further understand its pathophysiology. The purpose of this study was to evaluate the histopathology of the intervertebral disc (IVD) for the elucidation of the degenerative disease factors. Materials and Methods: The IVD were obtained from twenty-three patients with LDD refractory to conservative treatment who required surgical treatment. Van Gieson and Verhoeef stainings were used for histopathological evaluation. The data were correlated (Spearman-Rho) with the information obtained in the histological evaluations of Alcian/PAS, MassonTrichrome and Safranin O/FCF. All data were correlated with radiographic findings of the patients and the Pffirman classification. This study was approved by the Ethics Committee Circle/FSG 0153 and CAAE 40422114.3.0000.5341. Results: The results of the histopathological evaluation allowed defining a positive correlation between the evaluated stainings. Thus, the greater the misalignment of collagen (Van Gieson and Masson trichrome), the greater the amount of chondrocyte clusters (Safranin O/FCF) and the higher the acid mucopolysaccharide deposit (Alcian/PAS) around these clusters in IVD. Verhoeff staining also allowed the further identification of the elastic fibers in the IVD evaluated, including a determination that they have a smaller amount of these fibers as compared to the negative control of the disease. Conclusion: The associated use of histological stains allows defining a set of important degenerative features that are important in understanding LDD., Introduction: Lumbar osteochondrosis corresponds to the inflammation of vertebral endplates as part of spinal degeneration that can cause mechanic low back pain (LBP). Conservative treatment with pain management and physical therapy to lumbar arthrodesis are described. The aim of this study is to evaluate the results of intradiscal steroid injection (ISI) for the treatment of LBP secondary to osteochondrosis. Material and Methods: A retrospective review of patients with LBP secondary to osteochondrosis diagnosed by magnetic resonance imaging (MRI) and treated with ISI was conducted. MRI characteristics, pre and postprocedure symptoms, complications, recurrence rate and the need of fusion were evaluated. Results: A total of 45 patients with a mean age of 50 (26-76) years were treated with ISI for LBP secondary to osteochondrosis between 2014 and 2016. 92% of patients presented one level osteochondrosis. Most affected levels were L5S1 (48%) and L4L5 (35%). Seven cases were postsurgical. All patients underwent other spinal infiltration beside ISI (facet joint infiltration in 96% and peridural transforaminal infiltration in 54% of patients). A 75% follow-up was achieved with a mean time of 5 (2-25) months. Postprocedure LBP disappeared in 42% of patients and in 21% it decreased an average of 70%. 27% of patients presented recurrent LBP with a mean asymptomatic period of 5 months and just one required lumbar fusion. One postprocedure L5 radiculitis was the only complication seen. Conclusion: ISI represents a safe and effective alternative for the treatment of LBP secondary to osteochondrosis. However, prospective and ISI alone studies are required to better evaluate the effectiveness of this procedure., Introduction: Lumbar disc herniation is one of the main surgical pathologies of the spine. There are many different surgical techniques for its treatment, but current trends are towards minimally invasive surgery. This study evaluates the initial results of a series of patients with lumbar disc herniation treated with percutaneous endoscopic lumbar discectomy (PELD). Material and Methods: A retrospective review of patients with lumbar disc herniation that underwent PELD was conducted, including worker’s compensation patients (WCP). Variables evaluated were disc herniation characteristics, bleeding, operating time, pre and postoperative symptoms, complications and recurrence rate. Results: We included 14 patients (mean age 40.7 years, range 24-76 years) operated for a first episode (n = 8) or recurrent lumbar disc herniation (n = 6). 43% were WCP, mostly heavy workers (n = 3). Most frequent location was posterolateral (n = 8), followed by foraminal (n = 5) and extraforaminal (n = 1). Five disc herniation were at L4-L5, four at L5-S1), three at L3-L4 and two at L5-LSTV. All went transforaminal approach, 57% at prone and 43% at lateral position. Mean surgical time was 117.9 ± 34 minutes, having the lateral position a statistically significant longer duration than the prone one (144 ± 18 vs 117 ± 30 minutes, P = .006). Four patients presented recurrent pain, of which two underwent conventional discectomy and fusion, one a selective radicular block and one opted for conservative treatment. Of the thirteen patients followed for one year, 69.2% remained asymptomatic with no significant difference between patients with and without worker’s compensation (P = .22). No surgical complications were reported. Conclusion: PELD is a good alternative for the treatment of lumbar disc herniation including WCP, however it is important to consider the difficulties of the surgical technique and the steep learning curve., Introduction: In 2014, the estimated incidence of new primary cancers in Brazil was 576,000 (2.84%) among a total population of 202,768,662. No official government statistics exist regarding the prevalence of spinal metastases among cancer patients. Knowledge of the descriptive prevalence of surgical operative procedures in patients who harbour spinal epidural neoplastic metastases remains lacking in the Brazilian medical literature, and this information could supplement the lack of epidemiological cancer data. The objective of this study is to generate descriptive numerical comparisons among patients undergoing operations for spinal epidural neoplastic metastases with respect to neurosurgical operative procedures and other surgically treated spinal column and spinal nervous tissue diseases. Material and Methods: The study design was descriptive. This research involved a retrospective review of collected data from the electronic archives of patients who underwent neurosurgeries in the Division of Neurosurgery of a single quaternary hospital between February 1997 and January 2015. The prevalence of spinal metastases was compared to the total of neurosurgeries and with those of other surgical spinal column and spinal nervous tissue diseases. Research data were organized into the five descriptive categories for numerical comparisons. Trend analysis was applied to determine the yearly pattern of prevalence. The Institutions Ethics Committee on Human Research approved the research project on January 2016. Statistical analyses were expressed by frequency, confidence interval, and trend analysis. Results: A total of 12,802 neurosurgical procedures were identified. These procedures were classified as follows: skull and brain, 11,192 (87.42%); spinal column and spinal nervous tissue, 1,462 (11.42%); and peripheral nerves, 148 (1.16%). Surgical procedures for the 1,462 (100%) cases of spinal column and spinal nervous tissue diseases were distributed by nosology as follows: degenerative intervertebral disk and spondylosis, 768 (52.54%); neoplastic, 279 (19.08%); traumatic, 221 (15.11%); congenital, 163 (11.14%); infectious and inflammatory, 27 (1.85%); and vascular, 4 (0.28%). With respect to the distribution of the 279 (100%) surgical procedures for spinal column and spinal nervous tissue neoplastic diseases, 124 (44.44%) procedures were for intradural neoplasms, and 155 (55.56%) procedures were for epidural spinal column neoplasms. The 155 (100%) operations for epidural neoplastic diseases were distributed into two groups: primary epidural neoplasms, 42 (27.10%); and secondary epidural neoplasms, 113 (72.90%). Spinal column epidural neoplastic metastases (secondary neoplasms) represented 0.88% of the 12,802 neurosurgical procedures. The yearly surgical trend prevalence was unchanged (no increase nor decrease) for surgical procedures in spinal metastases relative to the total number of performed neurosurgeries (event rate: 0.9%/year). Conclusion: Surgical procedures for spinal metastasis are uncommon with respect to all neurosurgical operative procedures but are common compared to the overall number of spinal column and spinal nervous tissue surgeries. Trend analysis indicates an unchanging trend of prevalence for spinal metastasis surgeries during the 19-year study period., Introduction: The aim of this study was to determine the prevalence and correlation between intraspinal gassequester and intradiscal vacuum phenomenon (IVP) and their clinical relevance. Material and Methods: In a retrospective study, 1200 CT scans were evaluated in both asymptomatic (CT Abdomen) and symptomatic (CT WS). Patients criteria included prevalence of VP and intraspinal gas sequester, their assation with other spine deaseases and clinical manifestations. Results: We found IVP in 42,91% of examinated CT scans. Gas sequesters inside the spinal canal was found in 80 patients (6.66%) which means - in nearly every fifteenth patient. In all of the cases where a gassequester in spinal canal was found, IVP and osteochondrosis were also present. The half of our study group patients with gassequesters in spinal canal had used anticoagulant medication on a long term basis trought their medical history. Conclusion: Gas in the spinal canal is not as rare phenomenon as it is assumed in the literature. Based on the results of the study it is mostly an asymptomatic appearance. We suppose that the condition of blood vessels as well as the diffusion capacity of endplates play an important role in the gas development of gas cysts and sequester., Introduction: Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by flowing ossification of the anterolateral spine with or without peripheral ossification of entheses. The prevalence of DISH is approximately 17% in a population over 50 years and rises with age. Risk factors for the development of DISH include obesity, hypertension and diabetes mellitus. Although the presence of DISH is associated with cardiovascular diseases, prevalence research was only conducted in patients with cardiac disease. In the current study the prevalence of DISH is assessed in a population with vascular disease and thus a high prevalence is expected. Material and Methods: Computed tomography (CT) scans were collected from patients over the age of 50 that had undergone an endovascular aneurysm repair (EVAR) in our hospital between 2009 and 2013 with a CT scan obtained preoperatively or within one week after surgery. The region of interest (T6 to the sacrum) had to be present in the CT image for inclusion and DISH was diagnosed according to the Resnick criteria. In case the bridging ossification was near complete or if only two contiguous bridges were present, the CT scan was allocated to an ‘early phase’ group. Simultaneous presence of DISH and ankylosing spondylitis, leading to rejection of the diagnosis according to the Resnick criteria, was also recorded. Results: In total 161 CT scans from EVAR patients (86.3% male; mean age 72.7 years) were included for the evaluation of the presence of DISH. The prevalence of DISH was 22.3% for males and 22.7% for females. The ‘early phase’ was scored in 9.9% of the CT images and concurrent DISH and ankylosing spondylitis was present in 2 male subjects (1.2%). Conclusion: The overall prevalence of (early) DISH was 33.5% in a population older than 50 years and treated for an aneurysm of the aorta. Vascular disease and DISH might be directly associated to each other or risk factors such as hypertension and obesity cause this relatively high prevalence as these are associated to both DISH and aortic aneurysms. The high prevalence of DISH in female patients was unexpected because previous investigations on prevalence showed a higher prevalence in males., Introduction: Several factors, such as osteoporosis, obesity, and lack of exercise, contribute to low back pain. This longitudinal study aimed to investigate the risk factors for low back pain in local residents of Yonago, Japan. Material and Methods: Our study conducted in 2014 comprised 96 participants (34 males and 62 females; mean age of 73.9 years at beginning of the study) of general medical examination, living in Yonago, Japan, who provided informed consent. We assessed low back pain using the visual analog scale (VAS) and divided local residents into two groups. Group A included residents with worsening low back pain experienced from 2014 to 2016. Group B included residents who experienced no change in low back pain during the study period. We compared body mass index (BMI), bone mineral density (%YAM), skeletal muscle mass, standing posture, and exercise frequency, which was defined as physical activity at least twice a week. We then used logistic regression analysis to identify the risk factors for low back pain. Results: 40.8% of Group A residents exercised regularly and 81.2% of Group B residents exrcised regularly. There was significantly difference between Group A and B (P < .001). There were no significant differences in BMI, skeletal muscle mass, standing posture, and bone density between the two groups. Logistic regression analysis revealed lack of exercise, as assessed using VAS, as a significant risk factor for worsening low back pain (odds ratio, 0.19; P = .002; 95% confidence interval, 0.07–0.53). In addition, as per VAS assessment, average bone mineral density of residents who worsened low back pain in spite of getting regular exercise was 75.4% (%YAM) and that of residents did not worsen low back pain without getting exercise was 83.4%.There was significantly difference (P < .04).The residents with who had low bone density did not get benefit from its preventive effects. Conclusion: Our results indicate that regular exercise is useful in preventing low back pain. However, people with low bone density did not get enough exercise to benefit from its positive, preventive effects. As the residents in this region tend to be elderly, we speculate that the low back pain is associated with osteoporosis. Although exercise is typically suggested to prevent low back pain in patients, it may not be effective in preventing low back pain associated with osteoporosis., Introduction: Currently there is very less data available about the epidemiological pattern and mechanism of cervical spine injuries in Indian subcontinent. The aim of the current study was to document the demographic pattern, mode of injury, level of cervical spine injury in patients so that it can be extrapolated for formulating guidelines in developing nations for proper management of this life threatening injury. Material and Methods: This study comprised of 275 patients of cervical spine injury admitted in a tertiary care centre from January 2006 to October 2015.The data analysed included the patient’s age, sex, and occupation, the place of injury (rural/ urban), associated injuries, level of injury, and neurological status according to American Spinal Injury Association Scale was noted. Results: The mean age was (3 to 95) and male to female ratio was 11.5: 1. Majority (30%) of cases were of third and fourth decade. 60% of patient fall from height as mechanism of injury. The urban to rural ratio of patients was 3:1 and 184 patients (67%) belonged to the rural areas. The most common mode of injury in the present study was fall from height, 166 cases (60%) of which most of them occurred while working and fall from tree. Dislocation at C 5-6 vertebral level was commonest and a C 5 vertebra was most commonly fractured. Incomplete cord injury of ASIA grade C scale was the commonest pattern seen in 156 cases. Head injury was commonest associated injury with cervical spine injury. Conclusion: Identification of demographic data and mechanism of injury pattern helps to identify the preventable risk factors for controlling them. Proper education and training of paramedical staff in rural areas of initial aid and transportation of patients having spinal cord injuries can reduce the frequency and morbidity of spine injuries, Introduction: Routine in-hospital postoperative radiographs following surgical treatment of traumatic thoracolumbar injuries is a common practice despite a lack of evidence supporting its utility. Previous studies have concluded that postoperative radiographs following lumbar fusion for degenerative conditions have limited clinical value, especially in the absence of changes in symptoms or examination. The same has been suggested for cervical fusion, whether performed for trauma or degeneration. In order to obtain these radiographs, patients are subject to radiation and inconvenience at a cost to the healthcare system. These images may not only provide little value, but may also be detrimental due to prolonged immobilization or unnecessary intervention, such as advanced imaging (ie, computed tomography, magnetic resonance imaging) or surgery. The purpose of this study is to determine if routine in-hospital postoperative radiographs following surgical treatment of traumatic thoracolumbar injuries is necessary in the absence of changes in symptoms or examination. Material and Methods: We performed a retrospective chart review of the patients at a Level 1 trauma center who underwent surgical treatment of traumatic thoracolumbar injuries between December 2006 and October 2015. Upright AP and lateral radiographs were obtained postoperatively, which were reviewed by one of the surgeons prior to discharge. Patients who subsequently underwent revision spine surgery were identified and further analyzed to elucidate the rationale for intervention, as well as to obtain demographic information, diagnosis, index procedure, and revision procedure. The primary outcome was return to the operating room for findings on routine post-operative spine radiographs. Results: Five-hundred patients (353 males and 147 females) were identified with a mean age of 44.6 years (range, 18-90) between December 2006 and October 2015. Only one patient, an 18-year-old male who sustained a L2 burst fracture in a fall from 65 feet, had revision surgery secondary to abnormal routine postoperative radiographs in the absence of other findings. Six other patients (five males and one female) with a mean age of 35.8 years (range, 18-75) underwent revision surgery due to worsening or persistent neurologic deficits, or findings from advanced imaging. The injury patterns included 4 burst fractures and 3 flexion-distraction injuries. Five patients had percutaneous posterior stabilization and 2 patients had open posterior decompressions and instrumented fusion as the index procedure (Table 1). Conclusion: Routine in-hospital postoperative radiographs following the surgical treatment of thoracolumbar injuries are of little value, especially in the absence of changes in examination or symptoms. The rate of revision surgery during the initial hospitalization was 1.4% (7/500) in our study. Only 0.2% (1/500) returned to the operating room for revision of instrumentation as a result of an abnormality found on routine postoperative radiographs. With the present emphasis on cost-efficiency and evidence-based practice, this study may contribute to a movement to discontinue routine postoperative radiographs following spine surgery., Introduction: Despite the pivotal role of MR imaging, CT scan continues to serve as an important tool for decision-making in diagnosing SLSS. Little is known about the correlation between CT parameters and clinical presentation of patients with SLSS. Material and Methods: 75 patients (mean age 62±6.64 years, 67% female), with SLSS severe enough to indicate surgery, were included in this study. In total of data examination and classical questionnaires (VAS, ZCQ, ODI), patients were divided in three clinical groups: 22 pts with predominant low back pain without any symptoms of neurogenic claudication or radiculopathy (group LBP), 21 pts with monolateral radiculopathy (group MLP), 32 pts with neurogenic claudication or bilateral radiculopathy (group NC). For all patients CT imaging was performed and thirteen radiological parameters were measured. The association between radiological and clinical findings was tested using logistic regression analysis. Results: A t test demonstrated that the differences between all groups in age, gender, BMI were not statistically significant. Minimal parasagittal distance (mPSD) between the ventral surface of the superior articular process and intervertebral disc (odds ratio[OR]: 0.62; 95% confidence interval [CI]: 0.44, 0.86; P = .0047) is the most statistically significant CT parameter for patients in group LBP. Cross-sectional area (CSA) of the spinal canal (OR: 0.98; CI: 0.97, 0.99; P = .0006) and the depth of the lateral recesses (LRD) – minimal distance from the articular process to the posterior edge the vertebral body (OR: 0.42; CI: 0.22, 0.80; P = .0077) are the only independent variables associated with symptoms in group NC. We were unable to identify the specific CT imaging parameters to patients with monolateral radiculopathy. Conclusion: CT scan may help for decision-making in the diagnosis and treatment of some forms of SLSS when prevail the symptoms of back pain or neurogenic claudication or bilateral radiculopathy. Further careful study of the possible correlation of clinical and radiological parameters of spinal stenosis is necessary., Introduction: The infectious spondylitis leads to disability in 80% of cases especially in socially active middle age patients. The neurological disorders caused by irritation or structural changes in spinal cord (SC) can manifest by radicular syndrome, by complete or incomplete paraplegia or bladder and bowel dysfunctions. The pathogenesis is conditioned by mechanical compression or vascular changes in SC. The pre-op diagnosis of SC structure in tuberculosis and non-specific spondylitis is important not only for surgical tactic but for prognosis of total effect of treatment. Methods: 51 consequently operated patients aged from 21 till 78 years old (average 48,7 yrs) were included into prospective cohort study (study period - from December 2015 till May 2016). The inclusion criteria were clinical signs of myelopathy, MRI and bacteriological confirmation of spondylitis’ etiology. The clinical parameters included into study were a) the backpain severity estimated by 10-degrees visual-analog scale (VAS); b) motor and sensitive disorders counting according ASIA (mod. 2011) and Frankel scale (Fr. types, A-E), c) Oswestry disability index (ODI). The radiological criteria included five parametric signs 1) number of affected vertebrae, 2) apical Cobb angle (CA), 3) maximal degree of spinal canal stenosis (square, SCSs), 4) maximal degree of lineal antero-posterior compression (APC) of sac dural, 5) apical SC kyphosis (SCK, measured similar to Ferguson angle) and two non-parametric ones: 1) the level of vertebral lesions and 2) MRI myelopathy signs of SC – gliosis (or myeloischemia), atrophy, syringes. All MRI studies was performed on the Exelart Vantage, Toshiba, 1,5T. Statistical data: «Statistical Package for the Social Sciences» (SPSS), version 22.0 (SPSS Inc., Chicago, IL, USA).The study was limited by pre-op period only because of severe implant-related artifact after spinal surgery. Results: According to Frankel types, the spondylitis patients were divided as A (9.8%), B (11.7%), C (11.7%), D (17.6%) and E (33.3%). According to prospective bacterial tests the spondylitis etiology was identified as tuberculosis (TB) in 43% and non-TB in 56% cases. Gliosis (myeloischemia) was the prevalent SC changes in both group (68%) despite the spondylitis’ etiology. The SCSs and SCK was significantly higher in TB in compare with non-TB spondylitis (p ≤ 0,05). It was not confirmed dependence between the Frankel types and SCSs, but it correctly confirmed with APC degree. We did not find neither VAS nor ODI correlation with etiology of spondylitis. Moreover, it was not find links between the neurologic disorders counting by Frankel sc. and type of structural SC changes and ODI parameters. Conclusions: It was confirm that degree of SC compression and its sagittal deformity depend on etiology and significantly severe in patients with TB in compare with non-TB spondylitis. Despite this, we didn’t find links between severity of neurological disorders, counted by Frankl scale and MRI-visualized SC changes. From other side, such dependence clearly appeared with an apical antero-posterior compression of sac dural (APC)., Introduction: Osteoporotic fracture, especially in proximal femur and spine, is one of the common causes of elderly persons becoming bed ridden in Japan, and it is known that most osteoporotic fractures in spine are morphometric fractures without back pain. The present study was conducted to assess spine fractures with opportunistic screening using CT in postmenopausal Japanese women. Materials and Methods: The subjects were Japanese women over 60 years old who underwent CT scan of truck for several reasons between April 2015 and March 2016 in Kawasaki Medical School Hospital. Result: We evaluated morphometric fracture using sagittal reconstruction from DICOM data of CT. 2,364 women had CT examination, and fractures were detected in 486 women. 187 women (39%) had treatment of osteoporosis. We gave feedback of the fracture information to 299 non treatment women, and 70 women came office visit. Conclusion: This method may improve the treatment rate of osteoporosis in Japan., Introduction: In recent years magnetically controlled growing rods have been included in our treatment arsenal for EOS (early onset scoliosis) with clinical and hospital advantages of performing elongations without the need of multiple surgeries. Material and Methods: We have involved 15 EOS patients from our institution. Mean follow-up of 8 months (14-4 months). All patients have been studied post-operatively with simple X-rays and ultrasound at every elongation. We analyzed the Cobb angle, thoracic kyphosis and compared the T1-S1 distance preoperatively, and at the latest elongation procedure. Results: A total of 15 EOS patients were collected for this study. Cataloged by etiology neuromuscular was the most frequent followed by syndromic. Average age was 8.2 year-old (6-10 yo). All patients were stabilized using a double rod construct. Attending to fixation methods: only in one case were used proximal and distal pedicle screws; for the rest of cases it was performed a hybrid construct with cranial hooks and caudal pedicle screws. Elongations were performed every 3 months at the clinic, noninvasively. Patients and their families returned home just after the procedure. NO complications were detected at this point. Mean preoperative Cobb angle was 76º (98º-63º). Mean Cobb angle after surgery measured 40º (63º-39º) which means an average of 60% of correction. Mean preoperative thoracic kyphosis was 61º (68º-15º) which experimented an improvement to postoperative 43º (60º-35º). Most important of all, it was objectified an improvement of the T1-S1 distance from 264 mm pre-operatively to 286 mm at the end of follow-up. Rod elongation was measured before and after each procedure using simple X-ray and ultrasound. Mean values obtained at the concavity were 13.38 mm and 13,85 mm when using radiography and ultrasound, respectively, while at the convexity were 8.71 mm and 9.3 mm. Values obtained by magnetically controlled device, radiographs and ultrasounds were compared statistically. Conclusions: Magnetically controlled growing rods are an effective alternative for the treatment of EOS patients. Ultrasounds are as accurate as radiographs for measuring rod elongations., Introduction: The sagittal spinal parameters can be measured in the spine lateral radiographs, whatever it’s taken by the latericumbent position or the full-length lateral radiographs in upright position. Nowadays, more and more studies have paid more attention to the spine sagittal balance. The sagittal lumbar-pelvis parameter measurement is wildly used in many studies. Unfortunately, the sagittal alignment is different from various positions. The difference and correlation of lumbar-pelvis parameters between the most popular position, latericumbent position and upright standing position, are still unclear. This study aims to investigate the difference of sagittal parameters in spine lateral radiographs between latericumbent and upright positions, identify the correlation of standing lumbar lordosis (LL) and latericumbent lumbar-pelvis parameters, and establish a linear fitting formula. Material and Methods: The sagittal alignment of 157 continuous patients was assessed using Surgimap software from two kinds of lateral radiographs, to acquire the following parameters: lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), L4-L5 intervertebral angle (IVA4-5), L4-L5 intervertebral height index (IHI4-5), and PI-LL. The statistical analysis was calculated by SPSS 19.0 software. The Kolmogorov-Smirnov Test, Pair t-tests, Pearson correlation analyses, and Multivariate linear regression analysis were used to analyze the data. Results: We found there were significantly statistical difference in LL, SS, PT, IVA4-5, and PI-LL, except for PI and IHI4-5 in the two positions. The result showed a significant relativity between standing LL and latericumbent LL, PI, and SS. Thus, a predictive formula of standing LL was obtained with latericumbent LL, PI, and SS as predictors. Conclusion: Not all of sagittal parameters obtained from two positions are identical. When making surgery plans before lumbar spine surgery, spinal surgeons should give sufficient consideration to differences between the two views. We can predict standing LL with the formula when we couldn’t get whole-spine lateral standing radiographs., Objective: To determine the improvement in terms of mean change in postoperative kyphotic angle after anterior decompression and cage placement with bone graft in tuberculosis of Thoraco-lumbar spine. Methods: The Quasi Experimental study was conducted in the Department of Orthopaedics and Spine of Ghurki Trust Teaching Hospital, Lahore from 1st May 2015 to 31st May 2016.50 patients who qualify the inclusion criteria were included. All patients underwent anterior decompression and placement of Interbody Titanium Mesh Cage with packed bone graft. Pre and Post-operative lateral view x-rays were taken to check and record the post operative change in kyphotic angle. A Boston brace was applied for at least 6 months. Data was analyzed using SPSS 17.0 Results: There were 38(63.3%) males and 22(36.7%) females. The patients aged between 15-30 years were 32(53.3%), those between aged 31-45 years were 15(25%) and between 46-60 years there were 13(21.7%).There were 10 (16.6%) patients with 0-10 degree improvement, 36(60%) patients with 11-20 degree improvement and 14(23.4%) patients with 21-30 degree improvement. Paired t-test result for change in angle is P = .000. Conclusion: Anterior decompression along with Titanium mesh cage and bone graft in patients suffering from caries spine showed immediate post operative improvement in kyphotic angle., Introduction: Postoperative infections increase morbidity and mortality rates in spine surgery and generate additional costs for the healthcare system. It has been proposed that blood transfusions increase the risk of wound infection, urinary tract infection, pneumonia, and sepsis. The aim of this study was to determine the incidence of infection in patients who received blood transfusions in major deformity surgery involving at least eight levels, hypothesizing that transfusions are a risk factor for postoperative infection. Materials and Methods: A retrospective cohort study conducted from 2012 to 2015 identified 56 patients meeting the study criteria who had received spine surgery involving the fusion of eight levels or more. Patient-specific characteristics, starting and ending hematocrits, number of units transfused, use of vancomycin powder, drain usage, and infections including urinary tract infection, wound infection, pneumonia, Clostridium difficile, and sepsis were documented. Differences in infection risk between those who did and did not undergo a transfusion and their 95% confidence intervals were calculated. Results: Groups were similar with respect to baseline and surgical characteristics except for smoking status, operative time, estimated blood loss, and ending hematocrit. The overall infection rate was greater in patients who underwent transfusion than those who did not (36% versus 10%; P = .03). Wound infections (n = 5) were only observed in those who underwent a transfusion. Smokers were more likely to receive a transfusion and were also more likely to experience infection. A stratified analysis demonstrated an increased risk of infection associated with transfusion; however, the risk was greater in smokers, suggesting the effect of transfusion on infection could be modified by smoking. Patients undergoing transfusion experienced a significantly longer hospital stay (P = .01). Conclusion: Allogeneic red blood cell transfusion in major spine surgery could be a risk factor for postoperative infection. This increased risk seems to be magnified in those who smoke. Further studies are warranted, and risks of blood loss and transfusion-related complications in smokers also potentially merit exploration., Introduction: Tuberculous spondylodiscitis affects around 50% of all patients with musculoskeletal tuberculosis. Tuberculous lesions often involve the intervertebral disc, the endplates of the adjacent superior and inferior vertebral bodies. With progression of the disease severe destruction of these elements occur. The indications for surgical intervention are the presence of progressive neurologic deficit, intractable pain, abscess formation, kyphotic deformity, instability and for diagnosis. Material and Methods: To describe the efficacy of the posterior only surgery for achievement of debridement, reconstruction of the anterior column and segmental stabilization in 12 cases with tuberculous spondylitis. 12 cases with tuberculous spondylitis including 9 females and 3 males with spondylodiscitis are presented. The ages ranged between 20 to 62 years. 6 were loacated in thoracolumbar 3 in thoracic and 3 in the lumbar region. two were associated with abscess formation, 2 with previous maltreatment had severe kyphosis. In 4 cases one or 2 level corpectomy was done. and in the remaining ones partial corpectomy with debridement of the affected endplates were done. In 2 cases with abscess, the collections were evacuated. Reconstruction of anterior column was done with titanium expandable cages in 4, autograft in 2 and allograft in 6 cases. Antituberculous medication was started as soon as possible. Result: All patients pain disappeared post operatively, neurological deficit disappeared gradually but completely. Kyphotic deformity was corrected and good stabilization was seen in X-ray. No recurrence of the symptoms was seen. Conclusion: The mainstay of surgical intervention is debridement, reconstruction of the anterior column and segmental fixation. This can be achieved either with combined anterior posterior surgery or anterior only surgery. Although, posterior only procedures might hold great promise in the management of tuberculous spondylitis, many questions about long-term efficacy and safety remains. Although, our case series, has shown very good outcome. it is clear that additional long-term, prospective, comparative data is required before this route may be considered as a replacement for more demanding traditional corridors. Undoubtedly, improved learning curve, using surgical microscope and vigilant neuromonitoring are necessary for better performance and outcome., Introduction: Presence of gas in spine on radiological imaging is a sign of degeneration. Unlike in appendicular skeleton, it very rarely represents infection called emphysematous osteomyelitis. Emphysematous osteomyelitis of spine is a rare infection of bone caused by gas forming microorganisms. We describe one such rare case diagnosed early and treated successfully with timely surgical intervention and appropriate postoperative antibiotics. Methods: We analyse the medical records, clinical history, per operative findings, radiological images, histopathological images, culture and sensitivity reports, laboratory reports and follow up findings of a rare case diagnosed as emphysematous osteomyelitis of spine. We also review literatures reporting similar cases and analyse the clinical and radiological findings in these cases to help differentiate more common gas forming degenerative conditions from infection. Results: Literatures descrided that gas shadows in degenerative conditions are usually small, localised, surrounded by sclerotic rim and are associated with other degenerative changes without vertebral collapse. In vertebral compression fractures and in primary tumors, which are the next commonest conditions showing gas shadows, the shape of the gas shadows are usually linear, band like or triangular and is well demarcated and associated with vertebral collapse. In infective spondylitis the distribution of the gas is usually uneven displaying a bubble like pattern and characteristically extending into the paravertebral soft tissues. In our case, apart from clinical and laboratory features of high grade fever and chills, eleveated ESR and leucocyte count, radiological findings like presence of intravertebral gas in the absence of vertebral collapse, spreading throughout the vertebral body and extending into the prevertebral tissue and psoas muscle helped in differentiating it from other benign conditions causing vertebral vacuum phenomenon. The diagnosis was confirmed by biopsy and culture. Early surgical decompression and stabilization with appropriate antibiotics helped in the recovery of the patient. Conclusions: Emphysematous osteomyelitis of spine is rare and difficult to diagnose. Clinical, laboratory and subtle radiological findings may help in its early diagnosis, and timely surgical intervention with appropriate antibiotic may result in favourable outcome., Introduction: Tuberculosis is still a burden particularly in developing countries accounting for 9.6 million cases and 1.5 million deaths in the year 2014 globally. About 1-2% of all tuberculosis are skeletal tuberculosis, among which more than 50% are spinal tuberculosis. Tuberculosis is commonly seen in thoracic region. Cervicothoracic junctional (CTJ) tuberculosis is uncommon and has rarely been described in the literature. Approach and surgical stabilization at CTJ is technically challenging. We describe a technique of stabilizing CTJ by posterior only approach using cervical and thoracic pedicle screws and the results of CTJ tuberculosis managed by this technique. Materials and Methods: Histologically proven tubercular infections of spine with radiological evidence of destruction between C7 to T3 vertebra managed surgically by posterior only approach using pedicle screws in our institute between 2011-2015 with a minimum of 1 year follow up were selected. Demographic data, clinical history, operative time, blood loss, perioperative complications and duration of stay in hospital were analyzed among by retrospective review of medical records. Preoperative total vertebral loss and postoperative correction of kyphosis were calculated by method described by British Medical Research Council. Loosening of screws, hardware failure or loss of correction were analyzed from radiographic images. Neurological improvement was assessed by ASIA and Shanmugasundaram’s grading of paraplegia. Results: 8 cases (4 males and 4 females) were included in the study with an average age of 39 years. Pain and difficult in walking due to myelopathy or weakness was the most common symptom. The primary site of involvement was C7T1 in 3 cases, T2T3 in 2, T1T2, T3T4 and T4T5 in 1 case each. Most patients presented with Stage 2 myelopathy (4 cases), 2 cases presented with stage 3, while 1 case with intact neurology and another with stage 5 with bladder incontinency. The total vertebral loss ranged from 0.45-2.26 with average of 1.12. The average operative time and blood loss were 157 minutes and 362 ml respectively. 1 patient developed complete motor paraplegia with intact sensations post operatively with recovered completely at 3 months. All patients were treated with 1-year course of antitubercular medications. The average follow-up period was 19 months (range 12–32 months). At final follow up all patient improved significantly neurologically and radiological images showed no evidence of implant failure or screw loosening. The angle of kyphosis was corrected from a preoperative value of 34.9 degrees to 18.7 degrees post operatively which maintained at 20.6 degrees at final follow up. Conclusion: The use of cervical pedicle screws in place of traditionally used lateral mass screws simplifies many technical difficulties at CTJ in tuberculosis. The screws being in alignment with that of thoracic pedicle screws makes the insertion of the connecting rod easier eliminating the need for difficult contouring or use of domino connector and thereby reducing the operative time, blood loss and extent of exposure. Pedicle screws being biomechanically superior to lateral mass screws allow a shorter instrumentation. Anterior column debridement and reconstruction through posterior approach eliminates the need for more morbid anterior procedures., Introduction: Surgical site infection (SSI) following spinal deformity surgery has considerable medical, social, and financial impact on patients and their families. In recent years many studies have identified risk factors for the development of SSI in adult and pediatric population. Despite the knowledge of risk factors for SSI, there is no high quality evidence for prevention strategies and the infection rates remain high. Now days the best evidence is based on Best Practice guidelines and infection prevention protocols. Material and Methods: A multidisciplinary group developed an infection prevention protocol by using the previous institutional information and the current literature. A retrospective descriptive study was designed to assess the rates of SSI, the prevalence of the known risk factors and the causative microorganisms. This data was compared with a prospectively collected information posterior the implementation of the protocol. The inclusion criteria are based on the CDC guidelines and definitions for SSI. Results: The prior rate for SSI was 5.1%, according to the etiology specific rates are as follows: Syndromic (20%), Neuromuscular (13%), congenital (6.1%) and Idiopathic (1.7%).The median age was 17.63, with a median of body mass index (16.4) and albumin (3.31). (75%) of the patients had a previous spine intervention. All had a posterior fusion approach, and (87,5%) required an intraoperative blood transfusion; the median time for the administration of prophylactic antibiotic prior to the incision was 40,19 minutes. 90.9% were due to a gram-negative microorganism, being the most common the Enterobacteriaceaes. Two patients infected with P. aeruginosa required implant removal. After the protocol implementation SSI rate was (1.2%), and for neuromuscular etiology (4.3%). The SSI rates for syndromic, congenital and idiopathic scoliosis were reduced to (0%). Conclusion: SSI remains an important topic for research. Based on the reported risk factors and with the collaboration of all members of the operating room team proper interventions can be made. At our institution the application of a standardized infection prevention protocol reduced the rates of SSI., Introduction: Postoperative surgical site infection (SSI) places a significant cost burden on both patients and healthcare systems. Treatment requires readmission, incision and drainage, and prolonged courses of antibiotics. Numerous studies have identified risk factors for a postoperative SSI after spine surgery, but none have identified specific risk factors for increased treatment costs or length of stay in the management of a postoperative infection. Material and Methods: A retrospective review of all patients undergoing spine surgery at a single institution between January 2010 and December 2012 was performed to identify patients requiring secondary surgical intervention for SSI. Demographic and financial data from both the index admission as well as all subsequent readmissions for postoperative SSI were reviewed. Independent variables abstracted from patient records were analyzed using bivariate regression and multiple linear regression to determine the nature and extent of their associations with total direct hospital costs and length of stay. Results: 146 of 3101 patients (4.7%) required a return to the operating room for postoperative surgical site infection following spine surgery. 90 patients (61%) had been discharged prior to diagnosis of SSI. This cohort resulted in 110 readmissions and cumulatively underwent 138 I&Ds for management of postoperative spine SSI. 13/90 patients (14%) required more than one readmission and 22/90 patients (24%) ultimately required multiple I&Ds during management. The mean number of I&Ds per infection was 1.5. Average length of stay for the index operation and secondary readmission were 6.7 days and 9.6 days, respectively. Mean direct cost of treatment for SSI was $16,258 (median $10,463, range $2,572 – $138,134). In regression analysis, length of stay, number of levels fused, MRSA, decreased serum albumin on readmission, and number of I&Ds required were significantly associated with increased treatment costs. Conclusion: Length of stay was strongly associated with an increase in total direct cost, consistent with findings of previous studies. Likewise, low serum albumin and MRSA-positive cultures were associated with significantly greater length of stay and in turn higher direct costs. Low serum albumin represents a potentially modifiable risk factor in the treatment of SSI. Further study is needed to investigate the relationship between poor nutrition status and increased length of stay and total costs in the treatment of SSI following spine surgery., Introduction: Parallel to increased risk and predisposing factors the incidence of vertebral osteomyelitis is rising. There are many systemic factors which can negatively affect the immune system. The term locus minoris resistentiae is defined as a place of reduced resistance (any part or organ which is more susceptible than others) against the attack of a morbific agent. Spinal instability has rarely been described as a cause of depressed localized immunity. In this study, we present 18 patients with hematogenous infection on top of preexisting lytic olisthesis (LO) in the lumbar spine. Methods: A retrospective clinical case-series. Out of 402 patients who have been treated in our center for haematogenous lumbar spinal infection between Jan.2005 and Dec. 2015 we have identified 23 patients with LO. Of those 18 (78%) attracted the infection at same site of the LO (15 with grade I, 2 with II and one grade III olisthesis). We analyzed the preoperative condition, risk factors, diagnostic findings and presentation, causative organisms, treatment and outcomes. Results: In the totalof18 patients males dominated females by 14 to 4 with a mean age of 67.7 years (49-85).Of them 14 patients were overweight or obese (mean BMI of 27.7), 8 patientshad ASA score of III or more, 6 suffered fromDM, another 6 from cardiac diseases and two from liver cirrhosis. Other sites of infection were found in 7 patients. Neurological deficit (ASIA C&D)at the time of presentation had developed in 6 cases, fever in another 6. Multifocal infection was found in 2 cases, additional epidural abscess in 11 and psoas abscess in 6 individuals. All patients except 1 patient, diagnosed with CT-guided biopsyand treated conservativelyrequired surgery(ventrodorsal techniquein 11 patients and PLIF technique in 6 cases). The mean follow up (FU) reached 2.5 years. Mean CRP at time of presentation was 66 mg/l (8.9 at last FU), WBC of 9.6x103/mm3 (6.7 at last FU) and ESR of 76 mm/h (31 at last FU). A causative organism could be isolated in12 patients (67%); Staph. epidermidis in 4 of them. Neurological deterioration occurredin one patient, one morbidly obese individual had postoperative wound healing problems and one patient had to be reoperated 11 months later due to infection of the adjacent cranial segment. Discussion: Spinal osteomyelitis is commonly caused by hematogenous seeding. Predisposing factors that compromise the immune system render the host more susceptible to spinal infection. The LO represents a suitable site for inoculation of organisms and in this series increased the possibility of development of infection up to 78%. The altered vascularity leads to blood stagnation and facilitates the bacterial seeding. The LO could be an example of locus minoris resistentiae that can attract an organism and develop spinal infection., Introduction: Post-operative complications have been associated with cervical fusion procedures with the infection being a common and debilitating one. The aim of our study was to determine whether having an existing psychiatric disorder is a risk factor for developing post-operative infection following anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF). Materials and Methods: In this retrospective study PearlDiver Technologies was used to analyze Humana database from 2007 to 2015. Patients who underwent primary cervical spine surgery: ACDF or PCF were included in the study. This group was subdivided into: patients who were diagnosed with psychiatric disorders and patients who were never diagnosed with specific psychiatric disorders prior to surgery. Depression, anxiety, bipolar and schizophrenia were included as psychiatric disorders in the study. Patients were followed for 1 and 3 months post-operatively to detect whether they had infection or not. In order to detect if patients with psychiatric disorders are more prone to severe infection, sepsis rates were reviewed separately. Results: Total of 34,007 patients were included in this study. Eighty percent of these patients had ACDF while the remaining had PCF. Overall, post-op infection rates within 1 and 3 months were 3% and 4.2%, respectively. When ACDF and PCF patients were reviewed separately, there was a dramatic difference regarding the infection rates. At one-month follow up infection rate for ACDF patients was 1.8%, while it was 7.7% for PCF patients (P < .001). Within 3 months rates were 2.6% and 10%, respectively (P < .001). Two point four percent of female patients developed post-op infection within 1 month compared to male patients with a ratio of 3.6% (P < .001). Patients with mental disorders had post-op infection rates of 3.2% and 4.4% within 1 and 3-month follow up, respectively, compared to 2.5% and 3.5% in patients who were never diagnosed with a specific psychiatric disorder (P < .05). When procedures were reviewed separately, effect of mental health on post-op infection rates was statistically significant for ACDF patients but not for PCF patients. 2.6% patients with depression only and 2% of patients with anxiety only developed infection within 1 month. Total sepsis rates were 1.4% and 2.1% at 1 month and 3 months post-operatively. 1.3% patients with psychiatric diseases developed sepsis within 1 month and it increased to 1.9% within 3 months after the surgery. Among patients without any specific psychiatric illness sepsis rates at 1 and 3-month follow up periods were 1.2% and 1.8%, respectively. Conclusions: In this retrospective study 3% of the patients developed post-op infection within 1 month after the surgery. Patients with mental disorders had significantly higher rates of post-operative infection compared to patients who were never diagnosed with a specific psychiatric disorder. Infection rates for patients with single mental disorder were close to patients without mental disorder. This suggests that patients with multiple disorders are the main contributing factor for higher infection rates. However, mental health did not increase the risk factor for post-operative sepsis., Introduction: Surgical site infection (SSI) is a significant complication in instrumented spinal surgery as it is associated with prolonged morbidity and poor functional outcome. It is relatively frequent and the reported incidence varies from 0.7 to 11%. There are many studies concerning C-reactive protein (CRP) serum levels and it appears to be a sensitive index in the follow-up of SSI, but less specific in the diagnosis. Materials and Methods: We prospectively evaluated 31 patients (20 men and 11 women) who underwent instrumented lumbar spinal surgery at our Hospital between February and July 2016. All patients received pre ad intraoperative prophylactic antibiotics (cephazolin 2 g), starting 1 hour before skin incision. CRP serum levels were routinely measured and recorded on days 3 and 7 after surgery. Results: According to the literature, we have found that PCR level was particularly elevated (probably reaching a peak level) on day three, and was significantly lower on seventh day in all patients but two. In the first three days elevated CRP levels could be a normal (acute inflammatory) response to surgery, while a sustained elevation of CRP to 7 days appears to be a reliable signal of an early infection. In particular, in 91% of cases, the CRP level at 7 day was more than halved and in 65% of cases the CRP level was even back to normal. In only two cases (6%), CRP remained high and almost unchanged. One of these patients developed a superficial SSI and one a deep SSI as confirmed by the subsequent neuroradiological imaging. We treated these patients with broad-spectrum antibiotics only on CRP levels basis and they could eventually recover from SSI without removing the hardware. The patient developing a superficial SSI underwent a surgical revision for wound cleaning. CRP level certified in a highly sensitive manner and in the early stages the appearance of a SSI and prevented in both cases the hardware removal. Conclusion: In our preliminary study CRP level proved to be a fast, simple, sensitive and cost-effective parameter for the detection of early infectious complications. The SSI represents, to date, a major complication in instrumented lumbar spine surgery: its early detection through a careful monitoring of the PCR may be a useful tool in the diagnosis and may prevent hardware removal. This is only a preliminary study and larger cohort of patients need to be studied in the next future., Introduction: Spondylodiscitis remains a major cause of spinal injury, with subsequent neurological damage. In Mexico, tuberculosis continues to be the main cause of infection, although pyogenic causes seem to have increased along the years. The primary objective of this reviewed is the description of epidemiological factors, which among these include: age, gender, etiologic agent and the spinal segment most commonly involved. Methods: This study consists in a retrospective observational based on electronic case records of 2 years from a tertiary reference hospital in Guadalajara, México. Case records, microbiology reports, imaging studies, histopathology and surgical reports of all spinal infection cases were studied. Etiologic agent, risk factors and co-morbidities were also analyzed. Results: Sixty-eight cases of primary spondylodiscitis were reviewed, 36 male and 32 female, with a mean age of 59.6 years. In this study were identified 22 cases with tuberculosis, 5 cases with Brucella and 20 pyogenic infection, 21 cases reported negative culture results without etiology being identified. The main related comorbidities were diabetes mellitus, chronic kidney disease, obesity, alcoholism, liver disease, and immunosuppression. Over 41% involvement was in the thoracolumbar junction of the spine. Staphylococcus aureus was the main agent isolated from pyogenic infections. Conclusion: Spontaneous infective spondylodiscitis affects men and females equally with and without medical co-morbidities. It often involves the thoracolumbar junction spine and a third of patients are culture negative. Tuberculosis remains the leading cause of spondylodiscitis in our country., Introduction: Use of metal implants in infective pathology has been controversial due to concerns over biofilm formation and persistence of bacteria. Although metallic implants have shown satisfactory outcomes in tuberculous spondylodiscitis, there use in pyogenic spondylodiscitis has been widely debated. We performed a study to assess the safety and outcomes of posterior instrumentation and transforaminal lumbar interbody fusion (TLIF) with titanium cages in the treatment of pyogenic lumbar spondylodiscitis. Materials and Methods: Retrospective analysis was performed on prospectively collected data of 27 consecutive cases of lumbar pyogenic spondylodiscitis treated with posterior instrumentation and TLIF between the periods of January 2009 to December 2012. All cases with biopsy proven spondylodiscitis were included and assessed for clinical presentation, medical co-morbidities, indication for surgery, culture positivity, organism isolated, duration of antibiotic instituted, previous surgical procedures and blood marker profile. All cases with tuberculous spondylodiscitis were excluded. The indications for surgical treatment were failed conservative management in 17, neurodeficit in 6 and significant bony destruction in 4 patients. Cases were analyzed for safety, radiological and clinical outcomes of TLIF using bone graft ± titanium cages. Interbody metallic cages with bone graft were used in 17 cases and 10 cases used only bone graft. All patients empirically received intravenous Ofloxacin and Cefoperazone+Sulbactum combination postoperatively and modified as per antibiotic sensitivity parameters. If no organism could be isolated the empirical antibiotics were continued for period of 4 weeks and then changed to oral antibiotics for a further period of 4 weeks. Results: The mean age was 48 years (22-83 years) with an average follow up of 30 months (22 months to 60 months). Culture isolated an organism in 8 cases including E.coli (N = 3), P. aeruginosa (N = 3) and S. aureus (N = 2). There were no cases reporting, cage migration, loosening and reoccurrence of infection at final follow up. Follow up MRI was performed in 20 cases which documented complete resolution of infection in all. Clinical outcomes were assessed using Kirkaldy-Willis criteria which showed 14 excellent, 9 good, 3 fair and 1 poor result. The mean focal deformity improved with the use of bone graft ± interbody cages and the deformity correction was maintained at final follow up. The mean pre-operative focal lordosis for graft group was 8.5°(2-16.5°) which improved to 10.9°(3.3-16°). The mean pre-operative focal lordosis in the group treated with cages was 6.7°(0-15°) which improved to 7°(0-15°). Definitive evidence of fusion was noted 16 patients with probable fusion in 10 patients with no cases with suspected pseudoarthrosis. Conclusion: TLIF for pyogenic spondylodiscitis provides adequate clearance of the infected tissue and gives satisfactory functional outcome. The radiological outcomes including deformity correction, maintenance of the correction and final fusion are satisfactory with this approach. TLIF with titanium cages may be safely used in the treatment of pyogenic lumbar spondylodiscitis provided thorough and adequate debridement of infected tissue can be achieved, appropriate antibiotic coverage is instituted and close follow up of the clinical progress is maintained., Introduction: The aim of the paper is to analyse extent, pattern and speed of neurological recovery, which plays vital role in reducing disability, in medically as well as medically + surgically treated patients of dorsal spine tuberculosis. In most cases, despite full motor neurological recovery often spasticity hampers mobility, ambulation and ultimately faulters employment leads to burden over family and society. Materials and Methods: 31 patients were diagnosed with TB dorsal spine from June 2011 to March 2013. Of these, 17 pateints had progressive nuerodeficit despite medical treatment and underwent decompression and pedicle screw fixation with posterolateral fusion using suitable approach as per the location of disease. Antitubercular treatment as per the RNTCP guidelines given for next 8 months till radiological signs of healing was present. Functional outcome(symptomatic improvement), qualitative neurological recovery (NR; gait, ambulation, resumption of employment) were measured. Nurick RR and ASIA PDIR were evaluated (preoperatively, 15 days, 1 month, 3 month, 6 month, 8 month i.e. completion of ATT). In nurick grade grade 0 signifies root signs, which does not affect qualitative NR, so not included, 80% considered 100 percentile and calculations made. Results: The functional outcome in the form of symptomatic improvement was faster in M+S group than M group. Of the M group, nurick grade 4 (9), grade 5(6) and ASIA score varying from (10 to 38) preoperatively were included. Only one patient deteriorated from M group needed surgical intervention. Mean recovery rate of nurick grade and ASIA PDIR in M group respectively (15 day-3.33/6.88, 1 month 15.33/36.88, 3 month 40.33/60.38, 6 month 67/89.44, 8 month 71.67/95%), suggests that NR took place between 3-6 months, attaining full recovery in almost all patients except one. Recovery attain plateau phase between 6 to 8 months. Mean recovery rate of nurick grade and ASIA PDIR in M+S group respectively (15 day-30/53.85, 1 month 60.69/82.78, 3 month 64.22/92.17, 6 month 72.45/96.72, 8 month 77.45/100%) suggests that NR took place between 1 to 3 month with plateau phase between 6 to 8 months, attaining full recovery in all subjects. NR in M+S group is speedier than M group alone. Conclusion: Study shows there is no significant neurological difference between two groups, after initial 8 months. Neurological recovery in S+M patients is speedier than M group due to debridement and local clearance of disease. Pattern of NR in M group suggests that almost all patients recovered at the end of 8 month, while M+S group 80% NR occurred within first 3 months. Abbreviations 1. MRR – mean recovery rate of nurick grade 2. PDIR – percentage deficit improvement ratio for ASIA score 3. M Group – medically treated group as per RNTCP 4. M+S Group – medically as well as surgically treated group, Introduction: Postoperative wound infections after spine surgery are a severe complication. In general it is not a matter of a superficial skin infection, in most cases it is a deep infection with contamination of all soft tissue layers. Difficult therapeutic situations are in case of the combination of patients of old age, spine surgery because of degenerative spinal canal stenosis and the need of an instrumentation because of segmental instability. In most cases these patients have an ASA Classification grade 3, they are immobile already for years because of the narrowing of the spinal canal and they are threatened to lose their social independence. A special algorithm in preoperative preparation of the patient, diagnostics including sonication of implants and therapy, based on the results and findings of W. Zimmerli in the treatment of infected knee and hip arthroplasty will be introduced. Material and Methods: The revision includes a prospective randomized follow up with a comparison of two groups of patients with and without the standardized procedure. All patients were treated surgically. One topic was the follow up of the preoperative preparation of the patient. In one group a normal three times surgical washing up, normal surgical covering and a transparent foil. The other group f.e. with a 10 minutes washing and an antiseptic foil and further differences. The other topic, diagnostics and therapy, was f.e. the comparison between the diagnostic tool of sonication and how it was included in a standardized procedure and the evaluation of antibiotic bioavailability. Results: The conversion in the preoperative preparation lead to a significant reduction of postoperative wound infections. The use of f.e. sonication improved the isolation of the right bacteria spectrum in its sensitivity from 60% up to 77% without deterioration of specificity. Other parameters like the way of biopsy extraction also improved the outcome significantly. Conclusion: Standardized procedures in the preoperative preparation process is an important tool to reduce postoperative wound infection especially in an increasing number of geriatric spine patients. In case of an infection the mentioned algorithm in diagnostics and therapy is useful. Demand and recommendation is a pre-ward microbiologically process screening of the patients or a screening while hospitalization., Introduction: The spinal column is involved in less than 1% of all cases of tuberculosis (TB). Spinal TB (Pott’s disease) is a very dangerous type of skeletal TB as it can be associated with neurologic deficit due to compression of adjacent neural structures and significant spinal deformity. Methods: We present the case of a woman, aged 59, who was admitted to the Department of Orthopedics because of an osteolytic lesion of the cervical spine (C3). 2 months earlier, the patient complained of neck pain without numbness of the hands. On physical examination, the woman was apyrexial and complained of pain over the cervical spinal area. Neurological examination revealed no focal motor weakness. The roentgenograms of chest, pelvis and cranium were without pathological changes. Abdominal ultrasonography was normal. CT scan revealed a osteolytic lesion of the body of C3 and of the third and ninth right ribs. An MRI scan revealed compression fracture of the C3 vertebral body with infiltration of paraspinal tissues at the vertebral column. The lesion resembled neoplasm metastasis. Results: A CT scan guided biopsy was done and the neuropathological examination of the biopsy showed typical granulomatous inflammation with characteristic infiltrate of lymphocytes, epithelioid macrophages and Langhans-type multi nucleated giant cells. The diagnosis of tuberculosis was made and the patient was treated medically with an immobilization of the neck for 12 months with an uneventful recovery. Conclusion: The prognosis for spinal tuberculosis is improved by early diagnosis and rapid intervention. A high degree of clinical suspicion is required if patients present with chronic neck pain, even in the absence of neurological symptoms and signs. Medical treatment is generally effective. Surgical intervention is necessary in advanced cases with marked bony involvement, abscess formation, or paraplegia., Introduction: Intramedullary spinal tuberculosis is a rare disease entity, which was first described by Abercrombie in 1828. Material and Methods/ Case: 25 year old male presented with low back pain, progressive weakness in lower limbs since one month & bladder incontinence since two weeks. Neurological examination revealed grade 3 power in both lower limbs and hypoaesthesia below D8 level. Knee, ankle reflexes were exaggerated with clonus. Babinski reflex was positive bilaterally. There were no signs of meningeal irritation. His ESR was 77 mm at the end of one hour. HIV ELISA was negative. MRI of spine there was a intramedullary lesion of 12 x 9 mm at the level of D8 vertebra which was hypointense on T1, isointense lesion in T2 & demonstrated ring enhancement on gadolinium contrast. Patient was started on multidrug treatment (Isoniazid, Rifampicin, Ethambutol, & Pyrazinamid) and a short course of dexamethasone. And at 12 weeks patient did not show any signs of improvement. Surgical resection was performed, D7-8 laminectomy followed by midline durotomy was performed. Spinal cord was swollen and there was no evidence of any extramedullary lesion. Posterior longitudinal myelotomy was done. We found a grayish mass with a good plane of cleavage from the surrounding cord. A grey, irregular, multilobulated soft mass measuring 12×10×6 mm was removed completely (Figure 2b). Surgery was uneventful & post-operative his neurological remained same. Results/ Outcome: Histopathology examination showed diffuse & dense infiltrate compromising of lymphocytes, plasma cells, & neutrophils with large areas of caseous necrosis surrounded by sheets of epitheloid cell & Langerhans type of giant cells. At 3 months after surgery his lower limb power in hip & knee was completely recovered, with recovered bowel & bladder retention. Post-operative after 15 months patient was walking without support & had functional power in both lower limbs. Conclusion: Tuberculoma should be considered in the differential diagnosis of all intramedullary space occupying lesions irrespective of age or presence of extracranial focus of tuberculosis in countries endemic to tuberculosis. Most of these patients respond well to anti tuberculous drug therapy with good functional recovery, however, timely surgical decompression in selected cases, provide excellent long-term outcome., Introduction: Typical imaging findings in Tuberculous (TB) spondylitis are involvement of two or more adjacent vertebral bodies with involvement of the intervening disc. However, with extension of the disease, it might extend to the posterior element adding difficulty in differentiation that lesion from spinal metastases. It is the aim of this study to detect helpful MRI findings that help in differentiating TB spondylitis with three column involvement from spinal metastases. Material and Methods: The study is a retrospective study of 22 patients with TB spondylitis (average age, 53 years) proved by biopsy during open surgery and had three column spinal involvement. The following points were studied: pedicle involvement, degree of spinal deformity, vertebral body and disc damage (collapse) and paravertebral and epidural abscess formation. Results: The thoracic spine was the mostly involved (73%, 16 patients), followed by the lumber (18%, 4 patients) and lastly thoracolumber and lumbosacral junctions (4.5% 1 patient for each), Totally, 48 vertebrae were affected and each of them was studied separately. Pedicle involvement was most common in thoracic spine (83%), followed by lumber spine (15%) and lastly sacral spine (2%). Vertebral body collapse in vertebral bodies with pedicle involvement was present in 34 vertebrae (71%). More than 50% vertebral body collapse was present in 56% of affected vertebrae. Disc space was completely destroyed in 25 (52%) and partially destroyed in 19 (40%) of affected disc levels. Paravertebral and epidural abscesses are present in 95% and 86% respectively. Kyphosis was present in 68% of cases with a mean angle of 29 degrees. Conclusion: Involvement of the posterior spinal elements is not uncommon in spinal TB and usually associated with relatively severe vertebral body and disc destruction, prevertebral and epidural abscess, and kyphosis., Introduction: To review the clinico-radiological outcome of single stage posterior surgery in predicted progressive kyphosis of Dorsal and dorso-lumbar tubercular lesion. Material and Methods: From July 2004 to June 2015, records of 45 patients (male 16 and female 29), age ranged from 20-59 years, were divided into dorsal (GrD) and dorso-lumbar group (GrDL). The initial kyphosis (Kºini), initial predicted deformity (Kºpred/ini), the preoperative kyphosis (Kºpre), pre-operative predicted deformity (Kºpred/pre), the Progression of Deformity (Kºpre - Kºini) and the Predicted Deformity Progression (Kºpred/pre - Kºpred/ini) was measured. After surgery, the postoperative kyphosis (Kºpost) and Correction of Deformity (Kºpost - Kºpre) was recorded. The last follow up records included, final kyphosis (Kºfinal), postoperative Loss of Correction (Kºfinal - Kºpost) and Residual Deformity (Kºfinal - Kºpre). Results: The mean progression after 1 month and the mean predicted progression had been highly significant (unpaired t test, P < .001) in both GrD and GrDL, Surgery resulted significant improvement of neurology, pain and disability scores (chi-squared test, P < .05) as well as deformity correction (paired t test, P < .05). At the end of 5 years the loss of correction and residual deformity was insignificant (unpaired t test, P > .05) in comparison to Kºini. Overall significant satisfactory outcome was achieved in 40(88.9%) cases (chi squared test, P < .05). Conclusion: Single stage posterior instrumentation yields satisfactory results in predicted kyphosis progression of dorsal and dorso-lumbar tuberculosis., Introduction: Globally Echinococcus granulosis (cestode warm) is the commonest parasitic infestation affecting the spine. Spinal schistosomiasis is a rare presentation of parasitic infestation of the spine by mainly Schistosoma mansoni or Schistosoma heamatobium infection. The two species are endemic in South America, middle east and sub-Saharan Africa. We report spinal schistosomiasis in an 8-year-old school boy who presented to Fort portal regional referral hospital in Western Uganda in October 2015. Objective: To present a rare case of spinal schistosomiasis in an 8-year-old school boy who leaves near Lake Albert in Western Uganda. Material and Methods: An 8-year-old school boy presented with one-year history of back pain associated with deformity and 6 months’ history of progressive weakness of lower limbs and in ability to walk. Neurological status was Frankel B. Radiological picture of thoracic spine showed fusiform paravertebral shadow at T9/T10 which closely resembles that of tuberculous spondylitis. Biopsy and histological examination of the paravertebral mass showed degenerate oval shaped ova like structures with spine similar to Schistosoma eggs. So far no single case of spinal schistosomiasis from Uganda has been reported in literature as opposed to pyogenic and tuberculous spondylitis. Results: The patient was empirically started on anti TB treatment based on clinical examination and plain thoracic spine x-rays. Decompressive surgery done through left sided thoracotomy and paravertebral abscess drained and debridement done at T8/T9/T10 and spine stabilized with tricortical graft obtained from iliac crest. On arrival of histology results anti TB treatment was stopped and treatment changed to Praziquantel 60mg/Kg single dose and steroid(prednisolone) 1mg/kg as definitive treatment. Follow Up and Progress: Patient was discharged from hospital after one-month course of Praziquantel and prednisone with Frankel C neurological status. Two months’ letter his neurological status had improved to Frankel E though he still had residual thoracic kyphosis. Conclusion: Spinal schistosomiasis is rare, serious but curable condition and should be considered as differential diagnosis in inflammatory spine disorder’s particularly in those who visit or leave in endemic areas. Treatment should include a combination of anti-Schistosoma medication and corticosteroids as well as the different forms of supportive care., Introduction: As hospital compensation becomes increasingly dependent on pay-for-performance and bundled payment compensation models, hospitals seek to reduce costs and improve outcomes by decreasing length of stay (LOS), PAUs (30 day all-cause readmissions/revisits), and in-hospital PPCs (as defined by CMS). We sought to evaluate hospital-reported outcomes measures for elective lumbar procedures at Tertiary Centers(TC) versus Community Centers(CC) within the same hospital system. Material and Methods: A physician-driven, single medical system, prospective database consisting of one TC and four CC was retrospectively evaluated for the three most common lumbar surgeries: laminectomy, laminectomy with fusion, and microdiscectomy. 431 consecutive adults who underwent one of these procedures were evaluated from January-July 2015. The primary outcome was LOS, and secondary outcomes were PPCs and PAUs. Independent variables included: age, illness severity (SOI), surgical procedure, and surgical specialty (orthopaedic or neurosurgery). Results: Regression models for LOS were developed for each procedure. For microdiscectomy, the TC had a 0.28 day (95% CI, 0.04-0.53 days; P = .026) longer adjusted LOS. Inpatient status and performing a multilevel microdiscectomy also significantly increased the adjusted LOS. For laminectomy, the TC had a 1.46 day (95% CI, 0.61-2.31 days; P = .001) longer adjusted LOS. Surgery by a neurosurgeon, inpatient status, and discharge to a facility also significantly increased the adjusted LOS. For laminectomy with fusion, the surgical facility did not significantly affect LOS (95% CI, -0.41-0.85 days; P = .49), but SOI, multilevel fusions, interbody fusion, and discharge to a facility all significantly increased the LOS. Surgery by a neurosurgeon significantly reduced the LOS, however. Regression models demonstrated no significant difference in PAU and PPC rates between TC and CC for all procedures. The TC had 4.73 higher odds of revisit/readmission than CC for patients undergoing laminectomy, but this trend was not statistically significant (95% CI, 0.81-27.65; P = .084). TC had 2.19 higher odds of revisit/readmission than CC for patients undergoing laminectomy with fusion, but this was not statistically significant (95% CI, 0.47-10.11; P = .32). Patients undergoing laminectomy with fusion had 81% lower odds of sustaining a PPC at the TC, but this trend was not statistically significant (95% CI, 0.02 -1.54; P = .12). The cost of performing microdiscectomy, laminectomy, or laminectomy with fusion is 2.13 (P < .001), 1.87 (P = .006), and 1.18 (P = .009) times greater at the TC versus CC, respectively. Conclusion: TC have significantly longer LOS for patients undergoing microdiscectomy or laminectomy, but not laminectomy with fusion. The TC trended towards higher revisit/readmission rates for laminectomy with and without fusion, and lower PPC rates for laminectomy with fusion. These findings suggest performing microdiscectomy or laminectomy at a TC may have a longer LOS without improving PPCs or PAUs, and at nearly double the cost of care. Performing a laminectomy with fusion at a TC may be more reasonable with a similar LOS, PPCs, and PAUs, but the cost is still greater compared to CC. This surgeon-driven data can help develop more effective protocols to decrease LOS, while minimizing PPCs and PAUs., Introduction: Spinal cord tumors (SCT) are relatively uncommon and usually require surgical treatment. Readmission within 30 days after discharge is an important indicator of health care quality. The aim of this study was to investigate the rates and causes of unplanned readmissions and reoperations after SCT surgery. Materials and Methods: A retrospective analysis of patients’ charts at a single center from May 2007 to September 2015 was completed. Inclusion criteria: history of laminectomy with excision of neoplasm in the spinal cord. Exclusion criteria: (1) surgery outside the timeframe; (2) less than 19 years old; (3) non-neoplastic intramural pathologies; (4) previous resection at the same location; (5) metastatic lesions. Results: We found 131 patients that met criteria. Six patients (4.5%) were readmitted within 30 days and two within 90 days (1.5%). Four underwent reoperation: one for a cerebrospinal fluid leak, two for pseudomenigoceles, and one for repeat laminectomy. Resection of intramedullary tumors resulted in twice the risk of having one or more complications compared to extramedullary tumors (RR 2.0; 95% CI: 1.0 to 4.2; P = .057), and nearly four times the risk of having a neurological complication (RR 3.8; 95% CI 1.5 to 9.5; P = .005). Conclusion: This study analyzes readmission, reoperation and complication rates for the surgical care of SCT highlighting how SCT surgery is still involved with morbidity in experienced and specialized centers. This information is useful both for health care enhancement projects and for evidence-based patient counseling., Introduction: Complications from opioid analgesics for the treatment of pain are greater than those of other classes of medications yet increasing numbers of patients are treated with narcotics. The efficacy of these drugs in chronic conditions is debated. In this study we assessed spine specialists’ attitudes toward opioid analgesics and their beliefs regarding the impact of these drugs on spine surgery outcomes. Methods: AOSpine members in North America and Europe were surveyed via the Internet and asked to describe their practice, the source of patient referrals to them and the treatment these patents had received prior to entering their care. The physicians were also asked when narcotics should be introduced for acute and chronic spine related conditions. Finally, surgeons were asked if patients treated with narcotics have inferior surgical outcomes. Results: Narcotics were prescribed at higher rates in the US than in Europe. US specialists used these drugs more frequently for of acute problems (ie, LDH and CR) versus chronic conditions and kept patients on these medications for longer periods after surgery than did their European colleagues. One- to two-thirds of patients first seen by specialists were already treated with opioid analgesics by the referring physician. More specialists thought that narcotics should never be started for chronic conditions such as spinal stenosis and spondylolisthesis except during acute pain episodes (P < .05) or for post-operative care. While the figures vary by condition, on average 23.6% (range 11.3-28.5%) of the specialists consider prescribing opioid analgesics a bridge to surgery. Concerning the influence of narcotics use on surgical outcome, 37% of those surveyed responded that they hinder outcome, 43% thought they do not, and 20% answered that they do not know. Surgeons who do not prescribe narcotics in chronic conditions feel that they hinder spine surgery outcome. Conclusions: Opioid use is not uncommon as a treatment option, though spine specialists believe that they should be prescribed mainly as a bridge to surgery or only during acute episodes. Even so, only 43% of surgeons believe that these drugs are safe., Pakistan is country with a population of 192 million with an annual growth of 1.49%.making it the 6th most populated country on earth.The average life expectancy is 63 years. Corruption is rife and we have the richest rulers in this one of the poorest nations on earth solely due to bad governance.Less than 2%of the GDP is spent on health.None of the MDGs has been met. Pakistan is ranked 5 in high burden of TB. 3 million TB cases are known and 100000 are added each year so 270/100000 people have TB.TB spine is endemic and late presentation with neurological deficit is the normal. Traffic is chaotic.accidents account for spine injuries.Firearm injuries thanks to the war on terror abound.Poor safety measures at work and recreational places add to the burden of spine pathology significantly. Degenerative diseases of the spine are on the rise. Scoliosis kyphosis are common especially in the poor 60%live below the poverty line. There did not exist a spine center for these poor people of Pakistan! We decided to make a start and started on self help basis and set up the Ghurki Trust Teaching Hospital Spine Center. $8.5million has so far been raised from the people of Pakistan who are the most charity giving people in the world given their per capita income. An MRI CT Flouroscopy Spinal cord monitoring system Image Intensifies 5 modular antibacterial walls ORs CSSD Physio and Rehab EMG NCS equipment Orthotics manufacturing facility 200 beds unit was inaugurated on 9 April 2014. The workload has doubled in these 2 years and 5 more state of the art ORs are being built to be commissioned by early 2017. All poor patients are treated free $125000 are spent each month for totally free treatment.Free food to all patients and one attendant is provided.cheaper quality implants have been arranged from China and local titanium implants being developed at almost 1/3 the price. It is the only AO spine recognised spine training center in Pakistan and people from 9 countries have done spine fellowships todate About 40 local spine trainees have been trained over the years and we run the largest FCPS orth programme in Pakistan with Hand Trauma Paediatric orthopaedics Arthroscopy Arthroplasty Spine Plastics Flaps all under one roof with 9 consultants and 26 trainees at any given time.We are now ranked amongst the top if not the top orthopaedic spine training programme in Pakistan., Introduction: Administrative datasets typically utilize ICD9-CM codes and CPT codes as their primary sources of data. ICD-9 CM and CPT codes have been used to successfully identify information about patients such as specific spine diagnoses, surgical approach, and procedures performed. The invasiveness index developed by Mirza et al quantifies the extent of spine surgical intervention and assigns a numerical score based on the number of vertebral levels decompressed, fused, and instrumented and has been shown to have high reproducibility across observers. Recently, a CPT code based invasiveness index has been developed in which invasiveness values were assigned to different CPT codes. The goal of our study was to analyze the validity and accuracy of such a CPT code based invasiveness index and assess its strengths and weaknesses in assessing a study population. Material and Methods: A retrospective review on 451 patients who underwent spine surgery at a single academic institution was conducted. The medical record was used to collect demographic data on each patient. Reviewer based invasiveness scores were calculated by analyzing the operative report for each patient and CPT codes in the hospital administrative databases were used to calculate a CPT based invasiveness index score. Univariate regression analysis was used to assess the relationship between the reviewer based invasiveness score and CPT code based invasiveness score for each patient. Patients were then divided into 3 CPT code accuracy sub-groups (overestimation, match, underestimation of the CPT code based invasiveness score) and these subgroups were analyzed in terms of demographics, initial ED admission rates, non-elective procedures, reoperation, level of surgery, myelopathy presence, initial approach, procedure type (laminectomy, laminectomy/foraminotomy, discectomy, corpectomy, fusion/arthrodesis, or instrumentation). Results: Based on univariate analysis, CPT based index scoring was positively correlated with the reviewer based score with R2 of 0.690. Bland-Altman plots of the scoring differences plotted against the reviewer based scores demonstrated that the CPT based score overestimated the reviewer score by a mean of 1.25 points (P < .001). Univariate analysis of this plot showed that as reviewer based scores increased, the CPT based score tended to overestimate the reviewer score even further. The CPT code based invasiveness index had increased accuracy for patients in lower ASA classes, and those undergoing laminotomy/foramintomy and discectomy procedures, and those undergoing surgery for herniated disc, radiculopathy, and lumbar stenosis diagnoses. The CPT code based invasiveness score tended to overestimate invasiveness in posterior fusion, or instrumentation, anterior approach procedures, or for surgery done for cervical level diagnoses or lumbar spondylolisthesis or degenerative disease diagnoses. Conclusion: The strong correlation found between the CPT based invasiveness index and the reviewer based invasiveness index underscores the validity of the CPT based invasiveness index. However, we find that the reliability of this scoring system may be less consistent at times and that the CPT based invasiveness index tended to overestimate true invasiveness scores with increasingly invasive procedures. This imprecision of the CPT based index should be taken into account and adjusted for accordingly before applying it broadly when utilizing it for population studies., Introduction: Spinal disorders are a highly prevalent cause of disability and compromise of quality of life in the Brazilian population. There is paucity of published data on the economic and social impact of spinal disorders in Brazilian health system. We aimed to evaluate national trends of spine surgeries in the Brazilian Public Health System (Unified Health System [Sistema Único de Saúde] – SUS) over the past 20 years. Materials and Methods: Data on spinal procedures in Brazil between 1995 and 2014 were collected through the website of the Information Technology Department of the Unified Health System (DATASUS), which is maintained by the Brazilian Ministry of Health. Data on the number of admissions for spine surgery, total hospital charges, mean hospital days, and mortality were collected from this database using all codes related to spinal surgeries. National trends in hospital charges, number of procedures, and their relationship with geographic location were summarized. Costs were corrected by the IGD-DI index for 2014. Results: During the past 20 years, there has been an increase of 226% in the number (from 9,826 in 1995, to 22,304 procedures in 2014) and 540% in the total costs of spine surgeries (from R$ 27,094,634.28 in 1995, to R$ 146,469,077.32 in 2014) in SUS. The mean hospital stay remained the same over the years (mean 9.7 days in 1995, and 9.1 in 2014). Intra-hospital mortality rate after admission for spine surgery was 0.89% in 1995 and 1.65% in 2014. The mean number of spine surgeries covered by SUS per 100,000 people was 6.31 in 1995 and 11 in 2014. This proportion was quite different according to region. In 2014, the number of spine surgeries per 100,000 population according to region was: 5.18 Northeast, 5.54 North, 10.64 Southeast, 16.45 Midwest, and 23.69 South. Total hospital charges were also different among regions. Conclusion: Our analysis depicts the national trends in the economic burden of spine surgery on the Brazilian public health system. The differences in spine surgery data across regions portray the socioeconomic disparities of this large country., Introduction: Open pedicle screw fixation and fusion has been the traditional treatment for operative spine fractures, but several recent studies have challenged the need for fusion in the setting of adequate fixation, demonstrating comparable radiographic and functional results without fusion. Percutaneous treatment of spine fractures has been demonstrated to have decreased blood loss, operative time, and post-operative pain, but fixation of traumatic injuries without fusion raises the concern for failure of the instrumentation secondary to stress fatigue. Treatment of these unstable injuries with minimally invasive facet fusion using a tubular system in addition to percutaneous instrumentation represents an alternative strategy that may reduce morbidity, while promoting long term construct stability. The purpose of this study is to compare the maintenance of correction of unstable, operative spine fractures that underwent percutaneous fixation with and without facet fusion. A secondary outcome was to critically evaluate the hardware constructs for loosening and failure during a short-term follow-up period. Material and Methods: Using CPT codes, we conducted a retrospective review of all operative thoracic and lumbar spine fractures using our institutional billing and coding database from 2006 to 2013. One-hundred and forty-one cases were obtained from the database. Fifty-five cases were excluded for lack of post-operative radiographs and comorbidities. Eighty-seven had radiographs and operative reports available for review. Maintenance of correction was the primary outcome. One-week postoperative radiographs and all available follow-up radiographs were analyzed for the Cobb angle (lateral view) using the vertebral levels at the apices of the construct to evaluate for progressive kyphosis and loss of correction. We also examined each radiograph for instrumentation fracture, loosening (greater than 2 mm of radiolucency around any screw), or screw pullout. Results: The mean follow-up of for all patients was 33 weeks. There average amount of kyphotic progression was 3.2 degrees. There were no cases of instrumentation fracture during this follow-op period. Overall, the rate of screw loosening was 24%. There was no significant difference in the rate of loosening or progression of kyphosis in patients with facet fusion (with or without bone morphogenetic protein [BMP]) and without facet fusion. There was no difference in the percentage of screw pullout between groups. A total of 19 patients (22%) eventually underwent instrumentation removal, of which, only 2 constructs were loose (10.5%). Conclusion: We did not demonstrate a significant difference in the progression of kyphosis postoperatively between patients with and without facet fusion. Additionally, no difference in kyphotic progression was noted when facet fusions were performed with or without BMP. In thoracic and lumbar spinal column injuries, where percutaneous fixation is indicated, the addition of facet fusion may be superfluous. Interestingly, we found a significantly higher rate of screw loosening (24%) than previously reported for percutaneous cases, but loosening was not significantly different between fused and non-fused groups. The clinical significance of this instrumentation loosening remains unclear, as only 2 of 19 instrumentation removals had loosening, and further clinical follow-up is needed., Introduction: Standard techniques for lumbar pedicle screw and rod fixation involve open exposure and extensive muscle dissection. Percutaneous pedicle screw system minimises the morbidity associated with traditional open approaches without compromising the quality of spinal fixation. A preliminary experience with this device has been encouraging. The purpose of this study was to demonstrate operative techniques and experiences with percutaneous lumbar pedicle screw and rod insertion for internal fixation of the lumbar spine without use of Zig. Material and Methods: It was hospital based retrospective interventional study done at the department of Orthopaedics, B.P. Koirala Institute of Health Sciences, Dharan, Nepal over a period of 2 and half years. The study enrolled 30 patients aged 18-55 years who had presented with traumatic fracture of thoracic and lumbar spine. All thirty patients underwent percutaneous pedicle screw and rod fixation and successful percutaneous single/two level fusions. The follow up period ranged from 6 to 24 months. Results: The study comprised of 25 males and 5 females. Average patient’s age was 36.5 years (range 18-55 years). The common mode of injury was fall from height, road traffic accident, physical assault followed by sports related injury. All patients were having unstable spine fracture without neurological deficit. Operation time, loss of blood, post operative pain was less in percutaneous method. Post operative rehabilitation was easier. Spinal fusion was achieved in all patients in 6 months to 1 year time. There was no post-operative neurological deficit, infection, implant failure. Conclusion: Our early experience suggests that minimally invasive approaches for performing lumbar fusion, is able to achieve the same clinical results as conventional open procedures., Introduction: During the mini-open posterior corpectomy, percutaneous instrumentation without fusion is performed above and below the corpectomy level. In this study, we wished to compare perioperative and long-term implant failure rates of patients that underwent non-fused percutaneous instrumentation to traditional open instrumented fusion. Methods: Adult patients who underwent posterior thoracic corpectomies with cage reconstruction from 2009 to 2014 were identified. Patients who underwent mini-open corpectomy had percutaneous instrumentation without fusion and patients who underwent open corpectomy had instrumented fusion above and below the corpectomy site. We compared perioperative outcomes and rates of implant failure requiring reoperation between the open (fused) and mini-open (unfused) group. Results: A total of 75 patients were identified and 53 patients were available for follow-up: 32 open and 21 mini-open. Mean age was 52.8 years and 56.6% were male. There were no significant differences in baseline variables between the two groups. The overall perioperative complication rate was 15.1%, and there was no significant difference between the open and mini-open group (18.8% vs. 9.5%) (P = .259). Mean hospital stay was 10.5 days. The open group required a significantly longer stay than the mini-open group (12.8 vs. 7.1 days) (P = .001). Overall implant failure rates requiring reoperation were 1.9% at 6-months, 9.1% at 1-year, and 14.7% at 2-years. There were no significant differences in reoperation rates between the open and mini-open group at 6-months (3.1% vs. 0.0%, P = .413), 1-year (10.7% vs. 6.3%, P = .620), and 2-years (18.2% vs. 8.3%, P = .438). Overall mean follow-up was 29.2 months. Conclusions: These findings suggest that percutaneous instrumentation without fusion in mini-open transpedicular corpectomies offers similar implant failure and reoperation rates as open instrumented fusion as far out as 2 years follow-up., Introduction: Open lumbar transforaminal interbody fusion it’s an accepted technique used on a wide range of pathologies. We reviewed our first experience and collected clinical and radiological results in patients managed with intersomatic lumbar fusion using a minimally invasive transforaminal approach (MIS TLIF) in degenerative spine disease. Material and Methods: Between January 2013 and June 2015, 53 patients underwent MIS TLIF; 38 met the inclusion criteria. Fourteen were females and 24 were males; mean age was 47.8 years. Three patients underwent 3-level lumbar fusion, 8 patients underwent 2-level lumbar fusion and the rest of the patients underwent 1-level fusion. Conditions leading to surgery were spondylolisthesis (isthmic or degenerative), disc hernia associated with instability of the segment involved and foraminal disc hernia. Mean body mass index (BMI) was 32.2. Mean follow up was 22.5 months (12-36 months). The VAS scores for pre and post surgical lumbar and radicular pain were studied at 3, 6 and 12 months; also, surgical time, intra-operative bleeding, fluoroscopy time, hospital stay, post-surgery complications, and intersomatic fusion as shown on CT scan and by the Bridwell Scale were also studied. Results: VAS score decreased between the pre and post-surgery period both for lumbar pain (VAS 5.23 to 1.57) and radicular pain (VAS 7.52 to 0.52). Mean surgical time was 172 minutes (125-250); intraoperative bleeding was 188 mL (120–250). Total fluoroscopy time was 1.12 minutes (0.21-2.54) and hospital stay was 2.18 days (0 to 4 days, for one ambulatory patient). All the patients were able to walk within one day of surgery. Complications included: one hematoma in the tubular decompression wound requiring drainage and suture, one self-limited hematoma, a K-wire fractured and remained inside the vertebral body, one case of non-union with system disassembly, and an interbody cage was detached from the intersomatic space. No infections or neurological complications were observed. The intersomatic fusion rate was 97.3%. Conclusion: In our series including 38 patients managed with MIS TLIF, good results were observed in terms of post-surgery pain amelioration and short hospital stay; also patients were able to resume their everyday activities. MIS TLIF is a valid option to achieve fusion and decompression in lumbar degenerative disease. The learning curve has a direct impact in surgical time, but not in the results related to post-surgical pain, need for transfusions, gait, recovery and discharge., Introduction: Minimally invasive spine (MIS) surgery was effective and usefull for a variety of degenerative disorders. We reviewed some cases of MIS surgery and describe a series of patients with non-degenerative spine disease managed minimally invasive. Material and Methods: 27 patients managed with MIS in the period 2009-2015 were assessed. Case reports, images and follow up, pre and post surgical VAS score, blood loss, hospital length of stay, mortality, complications, associated surgical procedures, implant removal, pre and post-neurological status were studied. All the patients with a case report, images and complete follow up were included. Twenty two patients met the inclusion criteria: 15 males and 7 females, mean age 45.1 (range 12-84). Post surgery average follow up was 32.7 months (6-78 months). Conditions leading to the procedure were: 14 fractures, 2 tumors and 6 spine infections. Instrumentation was removed after 14.3 months on average in 8 patients with fractures (8-24). The rest of the patients underwent associated fusion (mini-open approach, 5, and minimally invasive corpectomy, 2). Five patients also underwent bipedicular kiphoplasty. Results: VAS score improved 7.1 points on average as compared to the presurgical score. Mean blood loss was: trauma (25 mL), tumors (20 mL), infections (175 mL). No patient exhibited neurological deficit worsening according to the Frankel Scale. Mean hospital stay was 2.9 days for the trauma patients (including an additional anterior approach), 1 day for the tumor patients and 8.2 days for the infection patients. As for the complications, self-limiting retroperitoneal bleeding was observed in one patient, and one case of material fatigue was detected. Conclusion: A good outcome was seen in this series of 22 patients undergoing MIS for non-degenerative conditions in terms of pain control, complications and a short hospital stay. This suggests that MIS is a valid option for the management of a selected group of patients., Introduction: Conventional anterior cervical discectomy and fusion (ACDF) or corpectomy surgeries have been the treatment of choice for cervical myeloradiculopathies caused by ossification of posterior longitudinal ligament(OPLL), herniated cervical disc (HCD) or foraminal stenosis(FS) combined with bony degenrations. But neck motion limitation after multilevel ACDF and/or corpectomy & reconstruction would not be avoidable, and axial neck pain is also considerable. Moreover development of adjacent level degeneration after ACDF still requires further improvements. Then anterior cervical microforaminodiscectomy (ACMFD) which is one of non-fusion surgical technique was introduced in selected levels for multilevel myeloradiculopathies. The purpose of this study is to evaluate feasibility of microforaminodiscectomy in selected levels whether can minimize fusion surgery on cases of multilevel cervical myeloradiculopathies. Materials and Methods: Patients(3 females and 15 males) with bilateral or unilaterally dominant upper extremity myeloradiculopathies, who was defined multilevel pathologies such as OPLL, HCD or FS on image studies, and underwent ACMFD combined with ACDF or corpectomy & reconstruction in other levels between Dec. 2010 and Dec. 2013 were included. Total number of fusions were 31disc levels including ACDF(17 disc levels) and corpectomy& reconstruction (14 disc levels) and total number of ACMFD were 22 disc levels with 1 level was approached by transuncal and transcorporeal trajectories simultaneously. Combination surgeries included 1level ACDF and 1 level ACMFD is 7cases, 1level ACDF and 2level ACMFD is 1cases, 2level ACDF and 1level ACMFD is 1case, 2level ACDF and 2level ACMFD is 1case, 3level ACDF and 1level ACMFD is 1case, 1level corpectomy and 1level ACMFD is 4case, 1level corpectomy and 2level ACMFD is 2case, and 2level ACDF and 1level corpectomy and 1level ACMFD is 1case. Pre- and post-operative arm, shoulder and neck pain were evaluated by Visual Analogue Scale(VAS). Functional outcomes were evaluated using Neck Disability Index(NDI). Cervical lordosis angle(Cobb angle) was measured pre and post operatively. And neck range of motion(ROM) was measured by segmental Cobb angle on flexion and extension. Results: Arm and shoulder pain relief was assessed by Visual analogue scale(VAS) postoperative immediately and 2,4,6 months after procedure. Early post-operatively there was significant improvement in VAS arm and shoulder pain (P < .05). After one year VAS arm and shoulder pain (P < .0001, P = .001, respectively). VAS neck pain was much improved immediately, but slightly increase at last follow-up (P < .05). The functional outcome was measured by Neck disability index(NDI) and relatively good in almost. Cervical lordosis curve angles(Cobb angle) were improved just after surgery (±3.6°, P < .01). Segmental Cobb angles on flexion and extension view were preserved on the level of ACMFD. Major complications such as recurrence of HCD, instrumental failure or fusion failure were not found at this study periods. Conclusions: For minimizing fusion surgeries on the cases of multilevel cervical myeloradiculopathies, combination anterior approaches such as anterior cervical microforaminodiscectomy in selected levels with fusion surgery by ACDF and/or corpectomy and reconstruction in other levels are applicable methods. Segmental Cobb angles of ACMFD levels were preserved pre and post operatively on this study periods. But more cases and long term follow up are required for establishing spinal stability., Purpose: The efficacy and safety of endoscopic posterior cervical foraminotomy (EPCF) has been demonstrated for single level cervical radiculopathy, but no report in the medical literature has described the clinical results of 2-level EPCF. The aim of this study was to assess the clinical and radiological outcomes of 2-level EPCF performed in patients with cervical radiculopathy. Methods: Twenty-two consecutive patients (9 females and 13 males) that underwent 2-level EPCF with cervical radiculopathy from January 2012 to January 2014 were included in this study. Clinical outcomes were assessed before surgery and at 1, 3, 6, 12, and 24 months postoperatively using visual analogue scale for neck (n VAS) and arm (a VAS), neck pain and disability scale (NPDS), and neck disability index (NDI) scores. Radiological outcomes were assessed by measuring segmental lordosis (SL), C2-7 lordosis, and disc height index (DHI) before surgery and at 12, and 24 months postoperatively. Results: Mean VAS, NPDS, and NDI scores were significant improved at 1-month postoperatively versus preoperative values and these improvements were maintained at 2 years after surgery. SL and C2-7 lordosis were significantly increased after surgery, and no instability in dynamic view was observed during the 2-year follow-up period. Percentage DHIs of operated discs were also maintained without significant change at 2 years after surgery. One patient suffered from transient motor palsy due to root retraction. Conclusions: Two-level EPCF can be safely preformed and should be considered an alternative to 2-level anterior cervical discectomy and fusion (ACDF) or open posterior cervical foraminotomy (PCF) in selected patients., Introduction: Complications in back surgery remain the most challenging issue. They influence negative the outcome and may lead to abandon certain procedures in operative therapy. Despite of: 1) improved operating technique (minimally invasive), 2) high quality implants, technologies and 3) human factor (specialized, certified spine centers with skilled surgeons), up to 30% complications in short construct fusions and 50% in long constructs will be reported in the literature. We investigated, if a different suitable technique for similar pathologies may decrease adverse events in spine surgery. Material and Methods: 2 groups of patients underwent from March 2012 to September 2015 decompression and fusion for degenerative and inflammatory changes in lumbar and thoracic spine. The dorsal fixation was either a pedicle screws fixator or an interspineous fusion device. In the first group (with pedicle screws) there were 124 patients, follow up 12 to 40 months (mean 26). In the second group 118 patients (with interspinous fusion device), follow- up 12 to 40 months (mean 24). Fusion was determined by CT and X- rays at least 6 and 12 months post OP. Results: Group 1: Indications: degenerative 81 (65%), discitis 43 (35%). Group 2: 92 patients (78%) received a stand alone interspinous fusion device and 26 (22%) additionally a cage. Indications: degenerative 118 (100%). Mean values for ODI and VAS (back) VAS (leg) in the first and second group respectively: Pre OP: 62 /6,9/ 6,5 58 /6,1/ 7,4 3 months: 42/ 4,1/ 2,2 28/ 3,3/ 1,9 6 months: 36/ 3,8/ 2,4 24/ 3,0/ 2,2 12 months: 32/ 3,6/ 2,0 28/ 3,2/ 2,4 24 months: 28/ 3,4/ 2,0 22/ 3,0/ 2,0 2 years post OP in the first group the improvement of ODI was 55%. VAS back 51% and VAS legs 70%. In the second group: ODI: 60%, VAS back 51%, VAS leg 73%. Complications: Group 1: loosening (8), dural tears (8), epidural hematoma (7), seroma (6), screw malplacement (6), subsidence (5), screw breakage (4), pseudarthrosis (3), CSF leakage (2), infection (1), cauda syndrome (1), vertebra fracture (1). Two patients died during the follow up period on underlying comorbidities. In the second group: seroma (9), subsidence (5), epidural hematoma (4), dural tears (3), infection (2), CSF leakage (2) pseudarthrosis (2). 52 adverse events (42%) occurred in the first group and 27 (23%) in the second one. 28 repeat surgeries (23%) were necessary in the first group and 19 (16%) in the second one. Conclusion: Both groups are comparable concerning indications and pre Op parameters with similar outcomes. The surgery, despite it was minimally invasive, was more aggressive using pedicle screws. Some pathologies cannot be treated with interspineous fusion. It cannot provide comparable stability especially in rotation. In terms of complications the interspinous decompression and fusion (with or without supplemental cage) was better as classical 360° decompression and fusion with pedicle screws. In some degenerative spine disorders if pedicle screws could be replaced by interspineous fusion device, the surgeon should consider it making decision for surgery. It could reduce complications., Introduction: Extreme lateral interbody fusion (ELIF) has gained wide popularity as a minimally invasive treatment allowing for indirect decompression of neural elements. However, evidence regarding the influence of facet degeneration (FD) and facet tropism (FT) towards indirect decompression is lacking. The aim of the study was to evaluate whether FD and FT impair indirect decompression in patients undergoing ELIF. Material and Methods: 37 patients undergoing ELIF were included in a retrospective single-center study. Radiographic parameters including disc height, segmental disc angle, foraminal area, coronal Cobb angle, lumbar lordosis, FD and FT as well as clinical outcome parameters (Oswestry Disability Index and Visual Analogue Scale) were measured pre- and postoperatively. FD and FT were correlated with radiographic and clinical outcome parameters in order to determine predictors restricting indirect decompression. Results: 37 patients with a total of 74 levels were analyzed. Clinical and radiographical outcome measures including central canal area (Δ = +17.2 mm2), mean disc height (Δ = +3 mm), and foraminal area (Δ = +9.9 mm2) revealed significant improvement compared to before surgery (P ≤ .05). Patients with severe FD (“Locked Facets”) were more likely to have FT ≥ 12° (32.3%) compared to patients without/mild (grade 0 and 1; 10%) or moderate FD (grade 2 and 3; 13%), P ≤ .05. FD and FT did not affect the amount of restoration of disc height, foraminal area, canal surface area or clinical outcome measures (P ≥ .05). Conclusions: High degree of facet degeneration and facet tropism (“Locked Facets”), do not impair indirect decompression of neural elements in ELIF. FD and FT are not relative contraindications in patients undergoing ELIF. Neural decompression and significant clinical improvement can be achieved in patients presenting with severe FD and FT undergoing ELIF., Background: Vertebral body fractures in the osteoporotic spine can cause a significant loss in sagittal balance associated with instability and stenosis. Usually, this would entail an anterior-posterior strategy combining anterior column reconstruction with posterior decompression and stabilization. In old and multimorbid patients with poor bone quality, this incurs a number of undesirable consequences. For one, it requires an additional anterior surgery. For two, metallic vertebral body replacements have a high risk of subsidence and loosening when placed onto osteoporotic bone because of their high point-loads at the implant-bone interface. Methods: Five patients received anterior column reconstruction via a posterior-only approach. In one case, the vertebral body replacement was performed to treat an infected and instable kyphoplasty. One other patient received vertebroplasty-style augmentation of 2 instable disc spaces, which were adjacent to healed, wedge-shape compression fractures. The patients were followed for global reduction in back pain, claudication when present, postural control and range of mobility. Radiographs and CT scans – when indicated – were used to examine the constructs for stability and signs of fusion. Results: 1 patient suffered a major complication technically unrelated to the procedure. None of the constructs failed during the follow-up time and the gains in pain reduction and mobility remained stable for all patients. There were radiolucent seams around the cranial screws in 2 patients, but these did not relate to an increase in pain or a reduction in mobility. Beginning cortical bridging in the anterior column was seen in 1 patient. One of the five patients died after 2 years follow-up at age 87 from cardiac disease. Conclusions: The best treatment for old and multimorbid patients with severe spinal problems will remain a controversial topic. It is just as easy to do too much as it is to do too little. However, often these patients clearly state that they do no longer wish to continue with a conservative course of treatment that neither improves their mobility, nor their pain. When deciding on a surgical strategy, it must be our goal to achieve a correct surgical solution with the least possible amount of invasivity. This technique of anterior column reconstruction adds little additional surgery to a post., Introduction: Cervical radiculopathy (CR) as a result of cervical disc herniation (CDH) is the most common symptom of cervical degenerative disc disease. CR is characterized by pain and dysfunction of a cervical spinal nerve, the roots of the nerve or both. When conservative treatment fails, surgical treatment is considered. Although safe, surgery may be associated with serious complications and a prolonged period of recovery. Currently, there is a trend in spinal surgery toward less invasive techniques. Cervical nucleoplasty is a minimally invasive procedure for percutaneous disc decompression. To our knowledge no randomized controlled trials (RCTs) are available and good literature overviews are lacking. The goal of this Cochrane review is to determine whether cervical nucleoplasty improves clinical and functional outcomes as compared to no treatment or placebo treatment, conservative treatment and surgery for patients with cervical radicular pain and/or radiculopathy due to disc herniation. Material and Methods: The search was conducted on the following databases: EMBASE, MEDLINE, OvidSP, CENTRAL, Cochrane CENTRAL Register of Controlled Trials, Web of Science, Scopus (Elsevier), CINAHL, PubMed, ClinicalTrials.gov, Google Scholar, PEDro, World Health Organization and Clinical Trials Registry Platform (ICTRP). We included all full journal publications of quantitative studies for review, ((quasi) RCTs, non-RCTs and CCTs (observational studies, case studies, and case series) since the number of RCTs were limited. All studies involving male or female patients (18 years of age or older) with cervical radicular pain, radiculopathy, or both, due to single level degenerative disc disease of the cervical spine corresponding to the affected level, were reviewed. Nucleoplasty was compared to no treatment or placebo treatment, conservative treatment and surgery. Primary outcomes were pain intensity of the arm and neck and neck-related functional status. Data extraction and management, assessment of risk of bias, and analysis were performed according to our published Cochrane protocol. Results: Based on all abstracts 402 articles were potentially eligible for inclusion. Of these 17 studies were included for analyses of which four studies had comparison groups. No RCTs with open surgery were found. Of the examined studies 1121 patients were treated with nucleoplasty, 146 patients with conservative treatment and 192 with surgery. No clinically relevant or functional differences were found between nucleoplasty compared to surgery or conservative treatment. Conclusion: Cervical nucleoplasty may improve clinical and functional outcomes in patients with CDH but high-quality RCTs with large patient samples and long-term effects are necessary to draw stronger conclusions, Introduction: Symptomatic herniated thoracic disc (TDH) account only for 0.15 -1.8% of all spine surgeries. Several surgical techniques have been described but almost all the literature favors the anterior approach even though high risk of complications exists (7-29%).Posterior approach has been associated to a high complication rate (34-56%). Hott et al concluded that all central calcified disks should be approached through an anterior or anterolateral approach. Barbarena et al concludes also that in order to minimize complications open thoracotomy should be used for these lesions. Objective was to describe our mini-costo-transversectomy in the management of calcified and giant thoracic disc herniation as a safe and easier procedure for disk rare pathology. Material and Methods: A retrospective analysis of all thoracic discs operated under the tubular retractor were analyzed. 5 were considered as giant and calcified. All five patients underwent a tubular discectomy. Nurick grading scale was analyzed for all five patients. Results: All patients were operated by the same technique, by using tubular retractor system, using a poster lateral approach. Mini-costo-transvesectomy was performed in all patients. Mean age was 54.8 years old (32-64). Follow up (4 – 48 months). None of all 5 patients had worsening of the Nurick scale after surgery. Non neurological complications were observed associated to the posterior approach. Conclusion: Because the rarity of these lesions and their chronic presentation, it can be difficult for spinal surgeons to gain experience, making management of the lesions challenging. Although the posterior approach has been associated with poor outcome and complications in calcified thoracic discs we present 5 giant and calcified discs without any neurological deficit associated with the approach. The tubular system can help surgeons to have a quick and safe approach to thoracic discs using a posterior approach which is more familiar to most spine surgeons. The posterior can be as safe as the anterior or anterolateral approach., Introduction: The visualisation of the operating field is limited in minimally invasive spine surgery. Remote devices like endoscopes, robotic systems, navigation, microscopes or x- ray allow controlling the intraoperative procedure. In most cases it occurs using the C- arm. In percutaneous pedicle screw techniques the x- ray exposure to the surgeon is according to literature reports 3,2, times higher as in open surgery. The aim of this study was to prove, if wireless pedicle screw placement allows to reduce the intraoperative fluoroscopy time and if depends on level of education, it means if the surgeon experience is a positive factor. Material and Methods: 190 patients with vertebral fractures underwent a percutaneous pedicle screw stabilization from March 2012 to September 2016 in our institution. There were 76 women and 114 men in age from 15 to 89 years (mean 58). In 93 cases wireless pedicle screw placement technique and in 97 K-wire technique was applied. 1438 screws were inserted in T1 to S1: 676 wireless (47%) and 762 K-wire (53%). 120 surgeries were performed by experienced consultants and 70 by residents. Results: Fluoroscopy time per screw was 4 to 66 seconds (mean 16) in wireless and 10 to 69 seconds (mean 30) in K-wire introduced screws. It means 47% less radiation for the surgeon in wireless technique. The trainees needed in average 31 seconds and skilled surgeons 18 second per screw. It means beginners needed 52% more radiation to insert the screws properly. After 5-6 surgeries radiation time was nearly equal in both groups. There were 2 malplacements (0.1%) which required 1 revsion surgery. The most frequent procedure was a fixator with 8 screws (74 cases), commonly in thoracic spine. In this series a surgeon needed in K- wire based screws 36 seconds and wireless in 17 seconds per screw (53% less fluoroscopy in wireless technique). The whole radiation time per procedure was 2,3 minutes in wireless and 5,7 minutes in k- wire technique (60% less x-ray time per procedure in wireless group). Conclusion: Only patients with vertebral fractures were included into the study to provide a homogenous collective. Both patients groups are comparable, the pathology treated and the technique were similar. Wireless pedicle screw placement technique allows reducing intraoperative fluoroscopy time at 47%, compared to K-wire based technique. Skilled surgeons achieve to have 55% less radiation compared to trainees. Both surgeon groups needed 5 to 6 surgeries to get familiar with the wireless system and were able to decrease the fluoroscopy time at 45%. As most stabilizing systems are quite complicated it remains an issue to create systems, which allow a steep lerning curve., Introduction: Surgical approaches to lumbar foramoinal disc herniations have been varied. Facet removal for exposing foramen brought about fusion surgeries in traditional concept. Facet sparing extraforaminal approach as non-fusion surgery also have been an acceptable concept. Recently facet joint preserving contralateral approach was introduced to the lumbar spinal stenosis with foraminal stenosis. Tubular retractor guided contralateral approach is a kind of minimally invasive techniques for preserving spinal functional units, and can reach to foramen. We introduced this procedure to these conditions and simultaneously removal of contralateral foraminal herniated discs. This is a retrospective study for aiming to compare the clinical results between extraforaminal approachs and contralateral approaches, and to give consideration of adequate conditions for each approach. Materials and Methods: The cases of extraforaminal approach from Sep. 2010 to Dec. 2015 were underwent 15 patients with suffering unilaterally dominant leg pain, who were 10 female and 5 male and mean age was 69 years. And the cases of contralateral approach were selected from the cases of bilateral decompression through unilateral approach which were performed to 48 patients with 86 levels from Feb. 2012 to Feb. 2016. Among these cases contralateral discectomy were underwent to 10 patients with 13 levels, who were 5 Male and 5 female and mean age was 64 years. Truly extraforaminal disc herniations were exclusion criteria on contralateral approach. Outcome measurements were used Visual analogue scale pre- and post-operatively on pathology side buttock and leg pain, and functional outcomes were evaluated by using the MacNab criteria. Results: For the extraforaminal approach patients, there was significant improvement in VAS back pain and VAS leg pain postoperatively (P < .001). At follow-up of 6.8 ± 1.7 months, there was also significant improvement in VAS back pain and VAS leg pain (P < .001). The functional outcome was mostly excellent and good. One patient who were recurred required revision with same procedure (6%). For contralateral approach patients, there were slightly improvement in VAS back pain, but significant improvement VAS leg pain postoperatively (P < .001). At follow-up of 6.5 ± 1.3 months, there was slightly improvement in VAS back pain, but significant improvement in VAS leg pain (P < .001). The functional outcome was excellent and good in 9 patients, but 1 patient was fair. No one had revision surgery at this study periods. Conclusions: Contralateral approach can lead central decompression with widening of opposite side foraminal stenosis simultaneously. In the condition of central and/or lateral recess stenosis combined with foraminal disc herniation, this procedure should be effective to solve these problems by contralateral discectomy at the same time. More cases and long term follow up should be needed for over limitations such as extraforaminal disc hernation, recurrence of disc herniation, foraminal restenosis and preservation of biomechnical stability., Introduction: Clinical outcomes in XLIF are significantly influenced by indirect decompression effect. Inappropriate cage insertion may cause intra-operative endplate fractures (EFs), which may result in failure to obtain the intended effect. We herein report on our evaluation of intra-operative EFs in XLIF. Material and Methods: We included 70 patients (41 men and 29 women; mean age of 67.4 years [22 to 82]; 138 segments [one at Th12/L1; 10 at L1/2; 35 at L2/3; 48 at L3/4; 44 at L4/5]) who underwent XLIF in Sep. 2013 or later for early stage lumber disease and who were followed up for 6 months or longer. We determined EFs by plain X-ray lateral images taken immediately after and on the following day of the operation, and categorized them by severity according to the medical literature by Sharma, et al. (G1, impaction of a unilateral edge of the cage on the endplate; G2, impaction of a bilateral edge of the cage on the endplate; G3, impaction of the one-third or more of the height of the cage on the endplate). In addition, we investigated the height of the cage, the level of EFs, and subsidence of the cage following the fractures, and also evaluated characteristics of patients in whom fractures occurred. Results: EFs occurred in 14 patients (7 men and 7 women; one of one segment at Th12/L1; one of 10 at L1/2; one of 35 at L2/3; nine of 48 at L3/4; seven of 44 at L4/5). The severity of the fracture was G1 for 16 segments, G2 for two, and G3 for one. Progression of severity from G1 to G2 was observed in one segment, G1 to G3 in one, and G2 to G3 in two. These progressions occurred between two weeks and three months after the operation. The height of the cage was 9 mm for eight cages, 10 mm for 10, and 11 mm for one, and all of the cages were 10º wedge-shaped cages. There were no significant differences in age, sex, and preoperative bone density between patients with and without fractures. Conclusion: When XLIF was initially introduced, taller cages were used and EFs commonly occurred with 10-mm and 11-mm cages. Since the trial cages were inserted after sufficient cleaning of the intervertebral disc space, a rongeur, sharp ring curette, or other spine instrument may have caused damage to the endplate. Subsequently, in the case of narrow intervertebral disc space, widening of the intervertebral disc space has been performed by using trial cages before cleaning of the intervertebral disc space to prevent EFs. Recently, cages height has generally been 8 or 9 mm, and EFs tend to occur in cases with a high degree of deformation accompanied by osteophytes, which have to be chiseled before insertion, or cases that require angle technique between upper segments in multilevel spinal fusion. However, the severity of subsidence following the fractures is considered to be mild where the corners of the large XLIF cage are placed on the harder portion of the endplate., Introduction: Conventional surgery for lumbar intervertebral foraminal stenosis has been done as much more invasive methods such as osteoplastic hemilaminectomy or total facetectomy with intervertebral fusion. The purpose of this study was to evaluate the Microendoscopic Intrapedicular Partial Pediculotomy (ME-IP3) as minimally invasive method. Material and Methods: 3 male and 4 female patients (age rang = 39-68 years, mean = 54.3 years) with the JOA scores ranging from 7 to 19 points (mean of 12.7 points) were included in this study. All patients had L5 radiculopathy with the L5-S1 intervertebral foraminal stenosis expect one patient of L4-5 stenosis. The clinical results were assessed according to a clinical scoring system established by the Japanese Orthopaedic Association (JOA score, full points = 29), percent improvement of the JOA score (%IP), operation time, intraoperating blood loss, and period of out of bed. Mean follow-up time was twelvemonths (ten-fourteen months). Results: Mean operating time was 97.6 minutes ranged from 70 to 138 minutes. Intraoperative blood loss was less than 5 ml, and period of out of bed was one day in all patients. The mean postoperative JOA score was 21.7 points ranged from 14 to 27 points, and %IP was 55.2%. Conclusion: The results of this study showed that ME-IP3 is a reliable and safe technique for intraforaminal decompression with good clinical outcomes. This technique provides excellent exposure with minimal invasion for the bony and neural structures. ME-IP3 seems to be a viable alternative to open surgery for lumbar foraminal stenosis., Introduction: Traditional anterior and posterior approaches to thoracolumbar region are related with significant neurological morbidity and long term complications related to sagittal alignment, deformity and bone healing. The advent of minimally invasive approaches has dramatically changed this scenario, allowing wide neural decompressions and proper alignment of the spine. Material and Methods: We present 10 consecutive patients treated with minimally invasive lateral retropleural and retroperitoneal thoracolumbar approach and corpectomy, using expandable cage. The conditions were acute fractures (4), sagittal imbalance (3) osteoporotic fractures (3). Operative results, complications, follow-up, pre and postoperative VAS and Oswestry scale were assessed. Results: In every case the procedures were successfully completed with posterior percutaneous pedicle screws. Levels involved were T12 (1 case), L1 (6 cases), L3 (2 cases) and L4 (1 case) vertebral bodies replacements. Complications: there were pleural tears in 5 of 7 retropleural approaches, a chest tube was placed intraoperatively and removed in the following 48 hours, without any long-term sequelae. In the case of L4 osteoporotic fracture we noticed inferior platform L3 breakage that solved with the expandable system. Minimal blood loss was recorded (, Introduction: Several studies have proven that vacuum cementing in hip replacement produces a more homogenous cement with a superior bone cement interface in comparison to the standard technique. It also has the potential to reduce so called cement embolism. We therefore thought of a simple technique to apply this advantage also in kyphoplasty. Material and Methods: Each patient had the standard Kyphoplasty procedure with a ballon placed in the vertebra via the two pedicles of the fractured vertebra in the routine manner. A 50 ml Luer Lock Syringe (encluded in the Set) was then fixed to the one side and pressure applied by pulling on the syringe whilst the cement was slowly applied or sucked in via the other side. In case there was too much blood aspirated the syringe was constantly changed to maintain constant pressure. This maneuver was repeated until cement visibly seeped out into the vacuum syringe. Then cement was also applied via the vacuum side. The total amount of cement was measured and the post op Xray was assessed by an independent blinded radiologist. He had to record any cement leak and the spreading of the cement. If there was any doubt about leakage a CT scan was performed. Results: 74 consecutive patients with 88 Kyphoplasties were prospectively collected so far. We found less cement leak than in a previous group and in the published results of kyphoplasty when counting any leak. The Cement seemed more homogeneously spread throughout the vertebra. Conclusion: Vacuum assisted cement application is a simple procedure with a minimal prolongation of the operating time and no added cost that so far has the potential to lead to less cement leak than classic kyphoplasty. However, to prove its value this will have to be verified by proper designed randomized controlled studies., Introduction: Percutaneous cement discoplasty (PCD) has been recently introduced to treat vertical instability associated with end stage lumbar disc degeneration. By filling the cavity of the disc characterized by vacuum phenomenon significant improvement in axial pain and disability can be achieved. The minimal invasive technique is safe and effective in elderly patients who are not eligible candidate for extended stabilization surgeries. In this study, the effect of the PCD procedure on the foraminal area as well as the lumbar sagittal and coronal alignment was determined. Methods: A prospective cohort of 25 patients underwent mono- or multisegmental PCD procedure was analysed. Lumbar (LI-SI) lordosis, scoliosis Cobb angle as well as pelvic parameters (PI, PT, SS) were measured on standing radiograph preoperatively, the day after the surgery and at 6-month follow-up. The change in the foramen area was determined on lateral radiograph and adjusted on the adjacent non-treated segment. Visual analogue scale for pain and Oswestry Disability Index was completed by the patients. Statistical analyses were made in SPSS 20.0 software. Results: A significant increase in lumbar lordosis was measured right after the surgery (42.4° vs. 46.4°, P < .05) and the effect was constant with time (45.6°, P > .05). An improvement in the coronal balance was also determined (lumbar Cobb angle: 10.9°preop, 7.1°postop, P < .05 and 7.9° at 6 M follow-up, P > .05). Mean foraminal area significantly increased due to the indirect decompression effect of the procedure (125.5+50.0 vs. 178.6+50.1, P < .001). Both leg and low back pain as well as disability significantly decreased after the procedure and the improvement was constant (P < .05). Walking ability of the patient has also significantly improved (P < .01) after the procedure. Conclusion: PCD technique is and effective minimal invasive option to treat axial pain and consequent disability related to lumbar vacuum discs. Sagittal and coronal alignment can be improved with the properly applied technique since a significant indirect foraminal decompression is realized. These factors can significantly contribute to the pain relief and increase of the patients’ functional capacity, however a larger, multicenter, prospective study is needed to confirm these associations., Introduction: In recent years, the number of publications on lumbar interbody fusions has increased considerably. Since 1930, Capener, who was the first person who described an anterior approach to management of spondylolisthesis, to what we know today as minimally invasive surgeries. All this has led to surgery for lumbar interbody fusion has become common to treat different pathologies such as spondylolisthesis, degenerative disc disease, recurrent disk herniations, spinal deformity and nonunion sagittal and coronal plane technique. This descriptive work aims to evaluate the clinical evolution, of degenerative scoliosis in patients undergoing minimally invasive technique XLIF (eXtreme Lateral Interbody Fusion) and OLIF (Oblique Lumbar Interbody Fusion) without posterior instrumentation in the service of Neurosurgery at the Hospital Universitario Mayor (HUM) in Colombia. Material and Methods: A description cohort of patients undergoing XLIF and OLIF at the HUM during the years 2014 and 2015. Patients who were treated for degenerative scoliosis are included. They are excluded from this study patient with tumor, traumatic or infectious disease. For this was performed OLIF and XLIF classically described, and pre-operative and post-operative epidemiological, clinical and radiological features were measured. Results: 7 patients were operated, 4 (57%) were female and 3 (42%) male. Mean age was 51,8y (21-75). 6 patients were operated more than a lumbar level. The XLIF technique was developed for L1-L2 level; and for other levels developed the OLIF technique. The intervened levels were in order: L3-L4: 7 (41%), L4-L5:4 (23%), L1-L2 and L2-L3: 3 (17%). In the visual analog scale (VAS) was a improvement pre-operative vs post-operative (8,8 vs 2,5), as well Oswestry Index (68% vs 10,8%) in one year follow-up. There were no complications related to the surgical procedure, the mean procedure time was 2,9 hours, the mean intraoperative blood loss was 75 cc and the mean postoperative hospital stay was 1.5 days. Regarding the radiological findings, the lumbopelvic balance was preserved as the lumbar lordosis pre-operative vs post-operative; but we could see a return of the disc height, obtaining an increase of diameter of the spinal canal secondary correction disc height and ligamentous structures stretch. Conclusion: The minimally invasive technique XLIF and OLIF; are safe procedures, which was reproducible in our institution; and they are an alternative of anterior interbody fusion. This has several advantages over different types of approaches, including minor surgical trauma, less risk of blood transfusion requirement, less pain in the immediate post-operative and less time in hospital. In our experience we got an improvement in their symptoms, pain (VAS) and disability (Oswestry Index). Radiologically we could see a return of the disc height, which leads to a direct and indirect decompression of nerve structures, obtaining an increase of diameter of the spinal canal secondary correction disc height and ligamentous structures stretch. In turn we found very similar results compared to those described in the literature., Introdution: To evaluate the advantages, disadvantages, results and the early complication of the percutaneous pedicle screw fixation using Sextant system for the treatment of vertebral column fractures in the cross-sectional study. Materials & Methods: 48 injured lumbar spinal column fracture patients have been treated with percutaneous pedicle screw fixation using Sextant system from January 2011 to June 2015. As a method of evaluation, the incision size, the intraoperative and postoperative volume of blood loss, operation time, postoperative hospital stay, the sagittal Cobb’s angle, intraoperative and postoperative complication were recorded. Results: There was a significant difference between the preoperative and postoperative kyphotic deformity angle (P < .05). The progressive kyposis after 6 month of postoperation were realized in 4 cases (8%), but they were in mild levels (, Introduction: Percutaneous trans-sacral approach procedures such as neuroplasty using a Racz catheter or epiduroscope are frequently performed as treatment option for lumbar disc herniation (LDH) but they are limited in that they cannot completely remove the causing pathology. Recently, with the development of laser technology, trans-sacral epiduroscopic laser decompression (SELD) has been receiving attention as an alternative tool and few reports have demonstrated its effectiveness, but there are insufficient reports of results. The purpose of this study is to report preliminary clinical and radiololgic results of SELD for the treatment of LDH in a single center experience. Material and Methods: 21 patients (M: F = 3:4) who underwent SELD for the treatment of single-level LDH were retrospectively evaluated for minimal 12 month follow-up. Their medical records including demographic data, diagnosis, complication, epiduroscopic findings and degree of symptom relief were investigated. The mean age of patients were 53.7 years and mean BMI was 23.3. All patients received same routine protocol procedures under local anesthesia by single surgeon using Ho: Yag laser. Clinical outcome were evaluated using visual analogue scale (VAS) scores for back and leg pain and functional status was measured with Oswestry disability index (ODI). Radiologic outcome were evaluated by comparing the changes of disc size on magnetic resonance image (MRI) scans, preoperatively, postoperatively and at final follow-up. Results: Fifteen patients (71.4%) showed symptom relief immediate postoperatively after the procedure and 18 patients (85.7%) showed relief at final follow-up. The average VAS scores for back pain decreased from 8.2 to 3.5 at immediate postoperative and to 1.5 at final follow-up. The average VAS scores for leg pain decreased from 6.9 to 2.75 at immediate postoperative ant to 2.35 at final follow-up, respectively. Mean ODI improved from 48 to 23 postoperatively and further decreased to 14 at final follow-up. Immediate postoperative MRI showed subtle changes in most of the patients (18/21, 85.7%), however, final follow-up images revealed significant reduction of disc pathology in 80.9% (17/21 patients). There was no procedure related complication in all patients except mild headache after the operation in two patients. One patient received microdiscectomy under general anesthesia due to recurrence of disc herniation after 3 month. Conclusion: The results of this preliminary study show significant improvements of VAS score and ODI after SELD for LDH with back and leg pain at minimal 12 months follow-up. Postoperative MRI scans revealed significant decrement of the disc size and reduction of neural compression. The SELD is suggested to be an effective therapeutic modality for patients with symptomatic LDH., Question: For the surgical treatment of unstable odontoid fractures in old age several several surgical procedures are possible: direct anterior screw fixation of the dens, with one or two screws at the age. This often leads to pseudarthrosis of odontoid with an unstable fracture situation. This leads to the loosening of screws in osteoporotic bone metabolism. Revision surgery as the dorsal open technique with C1/C2-screw fixation and iliac crest bone graft and cerclage is very stressful for the elderly. The dorsal percutaneous screw fixation C1/C2 can lead to healing of the odontoid fracture. After completion of the fracture healing the screw fixation can be removed. Methodology: In a prospective study was carried out 10 patients over 60 years with unstable pseudarthrosis of odontoid undergone a revision surgery with percutaneous posterior stabilization with C1/C2-screw fixation. All patients received an initial anterior screw fixation with one or two screws. In the absence of fracture healing, or screw loosening with pseudarthrosis of the odontoid a revision surgery was performed with percutaneous posterior stabilization with C1/C2- screw fixation. The surgery was performed with 3D image converter for documentation of the reposition preoperatively and postoperatively to control the screw position. Intraoperative the percutaneous approach was documented with the exact image converter in two planes, ap and strictly laterally. Postoperative clinical controls were performed and CT inspection to document the stability and healing of the pseudarthrosis of the odontoid within a year. Results: In the period from January 2007 to December 2012 in 10 patients with unstable pseudarthrosis of the odontoid after previous anterior screw fixation, were stabilized with the posterior stabilization with percutaneous screw fixation C1/C2. 4 women and 6 men with a mean age of 69.8 years / - 7.7 (median 70, min 57, max 82) were stabilized. The mean OR-time was 59.9 min / - 38.8 (median 45, min 36, max 165).In the mean follow-up of 382 days / - 324 (median 273), all patients had a stable course. In 8/10 patients healing of the pseudarthrosis of the odontoid could be demonstrated by CT. In 3/10 the dorsal screws were removed. Conclusions: The C1/C2 dorsal percutaneous screw fixation for unstable pseudarthrosis of the odontoid is a safe and promising, the patient little burdensome procedure. With the help of 3D imager the operating profit can be improved. Especially the older patients benefit from this supply strategy with high healing of the pseudarthrosis of the odontoid. The metal removal can be effected by healing of the pseudarthrosis of the odontoid, and thus the C1/C2-Joint can be given free again., Question: For the surgical treatment of unstable odontoid fractures in old age several surgical procedures are possible: direct anterior screw fixation of the odontoid; dorsally by C1/C2-screw-osteosynthesis, open with iliac crest bone graft and cerclage (n.Gallie) or; dorsally by C1/C2-screw-osteosynthesis percutaneously with two C1/C2-screws. The ventral direct screw in osteoporotic bone metabolism is not successful, the dorsal C1/C2-screwing in open technique with iliac crest bone graft and cerclage is very stressful for the elderly. The percutaneus C1/C2-screw-osteosynthesis can lead to healing of the odontoid fracture; after completion of the fracture healing the screw fixation can be removed. Methodology: In a prospective study 32 patients with unstable odontoid fracture and an age over 60 years were stabilized with percutaneous posterior dorsal screw fixation C1/C2. The surgery was performed with 3D image converter for documentation of the reposition preoperatively and postoperatively to control the screw position. Intraoperative the percutaneous approach was documented with the exact image converter in two planes, ap and strictly laterally. Postoperative clinical controls were performed and CT inspection to document the stability and the healing of the fracture of the odontoid within a year. Results: In the period from January 2007 to December 2012 was carried out in 32 patients with unstable odontoid fractures with percutaneous screw fixation C1/C2 posterior stabilization. 17 women, 15 men with a mean age of 81.8 years / - 7.5 (median 84, min 57, max 91) were stabilized. The mean OR-time was 50.0 min / - 24.3 (median 44.5, Min 16, Max 123). In the mean follow-up of 117 days / - 244 (median 29.5), all patients had a stable course. In 12/32 patients the healing of the fracture could be demonstrated by CT, in 3/32 the metal was removed. Conclusions: The C1/C2 dorsal percutaneous screw fixation of unstable odontoid fractures is a safe and promising, the patient little burdensome procedure. With the help of 3D-imaging operating profit can be improved. Especially the older patients benefit from this supply strategy with high healing rate of the fractures. The metal removal can be effected by fracture healing of the odontoid, and thus the C1/C2-joint can be given free again., Introduction: Vertebral compression fractures are considered as common conditions that cause function disability, chronic pain, progressive kyphosis and comorbidities. This study was conducted to evaluate the efficacy of using of mesh with bone graft in short and long term treatment of fractured vertebrae clinically. Material and Methods: Forty patients (43.58 ± 13.8 years) with vertebral compression fractures were treated using transpedicular placement of intervertebral titanium mesh cages with bone graft from August 2013 to August 2015 at Soliman Faqeeh Hospital in Jeddah, Saudi Arabia. We evaluated pain relief and improvement of daily activity function using visual analogue scale (VAS) score and Oswestry disability index (ODI) system pre-, post and one year after the operation. We assessed kyphotic angles (KA) and Cobb angle (CA) using plain x-rays and computed tomography (CT) pre-operatively, immediately post-operatively, and after one year of follow-up. Results: We found a statistically significant decrease in visual analogue scale (VAS) score when compared pre-operatively (8.80 ± 1.13) to immediately and one year post-operatively respectively (4.2 ± 1.27, 1.18 ± 1.36, P = .018). There was also a statistically significant decrease Oswestry disability index (ODI) system scores when pre-operative scores (91.35% ± 2.24%) were compared to immediate and one year post-operative scores (40.3% ± 16.43%, 29.40% ± 16.63%, P = .012). These results show a significant improvement of daily activity functions and pain relief. Both Kyphotic (KA) and Cobb (CA) angle showed significant improvements postoperatively (KA 20.33° ± 6.16° to 10.55° ± 4.11°, P = .002/ CA 10.5° ± 4.273° to 7.12° ± 2.99°, P =.001). There was no statistically significant difference in terms of Kyphotic (KA) and Cobb (CA) angles during the follow-up period (P > .05). Conclusion: The use of titanium mesh cages with bone graft technology is effective in treatment of Patients with vertebral compression fractures providing better quality of life by immediate and sustained relief of pain. It also improves both KA and CA immediately after the operation with maintenance of stable radiological progression through the period of follow-up., Introduction: MIS-DLIF (direct lateral lumbar interbody fusion) using tubular retractor has been used for the treatment of lumbar degenerative diseases. Although addition of intraoperative monitoring (IOM) of neural structures potentially decreased the perioperative neurological complications, blunt retroperitoneal and trans-psoas dissection poses a risk of injury to the lumbar plexus, especially at lower lumbar level. As an alternative, MIS-OLIF (oblique lateral lumbar interbody fusion) uses a window between the prevertebral venous structures and psoas muscle, and gets an access to the target disc obliquely. Theoretically, MIS-OLIF preserves psoas muscle and lumbosacral plexus with reducing the complication of direct lateral approach, and the need for IOM related to trans-psoas approach is questionable. The purpose of this study was to evaluate the safety of MIS-OLIF without IOM by comparing the incidence of perioperative complication in patients who underwent multi-level OLIF with or without IOM for the treatment of lumbar degenerative disease. Material and Methods: From October 2013 to March 2016, 129 consecutive patients underwent multi-level OLIF for the treatment of L1-S1 level degenerative disease were identified and retrospectively reviewed. The study group comprised 57 patients in IOM group (M: F=1:1.37, mean age=65.8 (range 35∼83)) and 72 patients in non-IOM group (M: F=1:2.1, mean age=67.1 (range 40∼85)). For clinical outcomes, self-reported measures including visual analogue scale (VAS) and Oswestry disability index (ODI) were used. A perioperative complication classification based on the relation to surgical procedure and effect duration was used. Perioperative complications until 3 month postoperatively were reviewed for the patients. Results: There was significant improvement of clinical outcomes in both groups without statistically significant difference. Overall, there were 13 (22.8%) procedure-related complications in IOM group and 17 (23.6%) in non-IOM group. In IOM group, there were 7 (12.2%) cases of transient leg symptoms that resolved spontaneously within 3 month postoperatively, including: 1 case of hip flexor weakness; 2 leg numbness; 1 leg pain, 2 asymptomatic temperature differences between each lower extremity and 1 asymptomatic leg swelling. In non-IOM group, there were 11 (15.2%) cases of transient leg symptoms; 2 case of hip flexor weakness; 3 leg numbness; 1 leg pain, 3 cold sensation and 2 leg swelling. Of all procedure-related complications in IOM group, 4 (7.0%) were classified as persistent, and 3 (4.1%) in non-IOM group. There were 3 procedure-related persistent leg symptoms in both groups respectively but without statistical difference (5.2% vs 4.1%) The most common procedure-related complication in both group were transient leg hypesthesia & cold sensation (3.5% vs 4.1%, N/S). The overall incidence of approach-unrelated complication accounted for 7.0% in IOM group and 8.3% in non-IOM group respectively. There were 4 re-operation cases in IOM group (7%; 1 local hematoma, 1 postoperative infection, 1 screw malposition, 1 persistent leg pain) and 3 in non-IOM group (4.1%; 1 local hematoma, 1 postoperative infection, 1 ureter injury). Conclusion: In our report of multi-level lumbar diseases, the OLIF technique may be performed safely without the aid of IOM in terms of procedure-related perioperative neural complications by eliminating the risk of unwanted muscle and nerve manipulations., Introduction: Unstable vertebral body fractures of the thoracolumbar junction of the type AO A3.1 are generally treated by ventral monosegmental spinal fusion. The support is provided by iliac crest bone graft. This results in part of the cases in cracks or necrosis of the graft or in lack of connection to the end plate. The contact area and chip cross-sections are very different, associated with the donor site morbidity. Cages, as the trabecular metal cage, with large contact surface (2 * 3 cm) and cancellous structure can replace the iliac crest grafts. Materials and Methods: In a prospective study 95 patients with unstable vertebral body fractures and ventral defect situtation, most of them were initially instrumented posterior bisegmental, were treated by thoracoscopic anterior implantation of a trabecular metal cage for monosegmental fusion with plate fixation. The patients underwent radiological examinations during the course (gain of correction, loss of correction), as well as evaluation of satisfaction by Odom score. Results: In the period from Januar 2010 to Dezember 2013 95 patients with fresh unstable vertebral fractures were treated by ventral monosegmental spondylodesis with a trabecular metal cage instead of iliac bone crest. 37 women and 58 men showed fractures type A1.2, but most type A3.1 of the thoracolumbar junction. The mean age was 47.1 years / - 11.5 (min 24, max 74). The average operational time was 105 min / - 27 (Min 56, Max 177). The follow-ups after 3,6 months and most 1 year demonstrated good results. The loss of correction was small. All cages integrated firmly, the patients were largely asymptomatic. The removal of the internal fixator was between 4 - 8 months. Conclusion: The implantation of a trabecular metal cage with cancellous bone structure can replace the iliac crest bone graft in the monosegmental ventral management of unstable spinal fractures. In contrast to ventral spondylodesis by iliac crest bone grafts fusion and consolidation results after 3 months, a loss of correction hardly occurs. In addition there is no donor site morbidity and operational time is reduced. Abb. 1, Introduction: Vertebral fractures are considered as one of the most common injuries in Saudi Arabia during the last years due to the high rate of road traffic accidents and accidents affecting construction and industry workers. Minimally invasive spine surgery has improved significantly through the last decade. This type of surgery should have the same results as conventional treatment but with less morbidity and improved body healing so can help patient to back to normal life. This study was conducted to evaluate the efficacy of augmentation of the minimal invasive fixation by titanium mesh implant with bone grafting in the fracture site in improving patient’s quality of life. Material and Methods: Twenty four patients (38.58 ± 14.2 years) with vertebral fractures were treated using minimal invasive fixation by titanium mesh implant with injectable bone graft through percutaneous approach from August 2013 to August 2015 at Soliman Faqeeh Hospital in Jeddah, Saudi Arabia. We used visual analogue scale (VAS) score and Oswestry disability index (ODI) system pre-, post and one year after the operation to evaluate pain relief and improvement of daily activity function. Plain x-rays and computed tomography were used pre-operatively, immediately post-operatively, and after one year of follow-up to assess kyphotic angle (KA) and Cobb angle (CA) so we can evaluate the condition and the progress of healing. Results: A statistically significant decrease in visual analogue scale (VAS) score was found when compared pre-operatively (8.79 ± 0.23) to immediately and one year post-operatively respectively (4.21 ± 0.26, 1.21±0.3, P < .001). We also found a statistically significant decrease Oswestry disability index (ODI) system scores when pre-operative scores (91.25% ± 0.48%) were compared to immediate and one year post-operative scores (38.92% ± 2.89%, 27.5% ± 2.88%, P = .041). These results indicate significant and sustained improvement of daily activity functions and pain relief. Both Kyphotic (KA) and Cobb (CA) angle showed significant improvements postoperatively (KA 20.36° ± 1.88° to 7.96° ± 0.73°, P < .001/ CA 10.5° ± 0.63° to 6.29° ± 0.52°, P < .001). We did not find any statistical significant difference in terms of Kyphotic (KA) and Cobb (CA) angles during the follow-up period (P > .05). Conclusion: Augmentation of the minimal invasive fixation by titanium mesh implant with injectable bone graft can give immediate and sustained relief of pain and better quality of life. It also improves both KA and CA immediately after the operation with maintenance of stable radiological progression through the period of follow-up., Introduction: Surgical treatment for a symptomatic lumbar disc herniation (LDH) is required in those patients with “red flags” and/or after failed conservative management. Microendoscopic discectomy (MED) is an alternative to open discectomy (OD), with associated benefits, but it has not yet been positioned as its replacement. Our objective is to analyze the available literature to compare the effectiveness of the MED and OD for the treatment of symptomatic LDH. Material and Methods: The literature search was conducted in PUBMED and EMBASE in September 2016 using the key words endoscopy and lumbar herniation. After reviewing the titles and limiting the search to clinical trials, a total of 37 studies were identified. The abstracts of these studies were analyzed. Those that compared the MED with the OD for the treatment of the LDH were selected and extensively reviewed. Finally, four of these studies were selected, after fulfilling inclusion and exclusion criteria. Three of the authors extracted the data and analyzed the quality of the selected studies. A meta-analysis was performed with the obtained data (pain [general, lumbar, radicular], satisfaction, and re-intervention) using the RevMan 5.3 software. Results: A total of 298 patients were included in this analysis. Those patients treated with MED reported significantly less general pain (mean difference 13.08, CI 95% [-13.42 a -12.73], P < .00001), less low back pain (odds ratio (OR) 0.19, IC 95% [0.08-0.49], P = .005) and were more satisfied with the procedure (OR 0.34, IC 95% [0.14-0.82], P = .02). No statistically significant differences were identified for radicular pain and the need of reinterventions. Conclusion: Although MED could present a benefit in low back pain and patients’ satisfaction, the existing literature cannot demonstrate the superiority of MED over OD for the treatment of LDH, given the scarce amount of clinical trials and the inadequate presentation of the results of available studies., Introduction: Thoracic disc disease is a rare entity in clinical medicine and is treated via a number of different surgical approaches circumferentially orientated around the spine, from a traditional thoracotomy to less invasive posterior and posterior-lateral approaches. Furthermore, there is a paucity of outcome results and data comparing the different approaches. We describe our experience at a single institution using a minimally invasive (MIS) approach via a tubular retractor system to the thoracic spine and its feasibility for transpedicular thoracic discectomies and compared our clinical results to our more traditional open transpedicular approach. Material and Methods: We performed a retrospective review of all cases performed between 2011 and 2016 comparing the results of a total of 8 patients with thoracic disc disease resulting in myelopathy with or without radicular symptoms treated surgically with an open approach (3 patients, 4 levels) or an MIS approach (6 patients, 7 levels). We then compared length of surgery, blood loss, time to ambulate, and looked at major and minor complications. Results: For all MIS cases, the postoperative imaging demonstrated excellent decompression that meets the requirements and standard of what is accomplished with an open approach. There were no post-operative complications in either group. Patients who underwent an MIS approach had decreased blood loss and had an earlier time to ambulate (within 24-48 vs. >48 for all open cases). The average surgery time was longer for the MIS approach with a steep learning course to acquire the technical fine-tuning for MIS. There were no major or minor complications in either group. Conclusion: MIS thoracic disc disease is a rare and challenging disease, much different than the lumbar or cervical spine due to the anatomy and its adjacent structures. However, similar to the MIS approach to the lumbar spine, this approach has similar benefits including decreased blood loss, shorter operative times, and decreased length of stay. Also, this approach allows patients to ambulate at an earlier stage. Overall, MIS transpedicular thoracic discectomies is a safe and feasible approach to the thoracic spine for thoracic disc herniation in selected patients., Introduction: The use of pedicle screws is widespread in spinal surgery for degenerative, traumatic, and oncological diseases. Until today, a standard fluoroscopy or portable radiographs have been routinely used during pedicle screw placement to help a correct surgical placement of pedicle screw instrumentation. With these conventional methods, the median pedicle screw accuracy ranges from 86.7% to 93.8%, even if perforation rates ranging from 21.1% to 39.8% are referred in literature. The intraoperative navigational with 3-D computed tomography (CT) based computer-guidance systems, have sensibly minimized the risk of pedicle screw misplacement, with overall perforation rates ranging from between 4.8% and 2.2%. Material and Methods: Since July 2008 to June 2016, we had experience of 700 cases of Mini-TLIF and percutaneous TPS fixation with Viper system from using iC-arm fluoroscopy, pre-CT image fusion 3D navigation to robotic 3D Zeego iCT with Brainlab Navigation. Screw positions were subsequently checked with a final postoperative cb-CT scan. 426 patients underwent single-level fusion, two leves 206, three levels 42, 4 levels 28, five levels 5 and six levels 2. Results: There were 6.9% pedicle perforations greater than 2 mm by using iC-arm fluoroscopy, 3.2% by pre-CT image fusion 3D navigation, and 0.5% by robotic 3D Zeego iCT with Brainlab Navigation. Conclusion: We demonstrate that use of intraoperative robotic 3D Zeego iCT with Navigation has been reported to increase accuracy than using iC-arm fluoroscopy ., Introduction: As Percutaneous Transforaminal Endoscopic Discectomy (PTED) for lumbar disk herniation (LDH) is performed under local anesthetics, patients are able to give feedback to the surgeon during the procedure. Because the discectomy can be a painful procedure, optimal analgesia and sedation is necessary. The objective of this study is to assess the safety and efficacy of Dexmedetomidine as a sedative for patients undergoing PTED. Material and Methods: Patients undergoing PTED for an LDH were prospectively included in this observational study. Patients received both Remifentanil and Dexmedetomidine as maintenance and Dormicum as induction. A bolus of Ketamine was administered only when the patients perceived more pain. Outcomes assessed were pre- and postoperative VAS scores for leg pain, back pain and anxiety for surgery or anesthetics, hemodynamic and respiratory parameters and satisfaction of the patient, surgeon and sedation specialist with the level of sedation. Furthermore, postoperative side effects of the anesthetics and sedatives (e.g. nausea, vomiting) were recorded. Results: A total of 32 consecutive patients were included of which 53.1% male. According to the neurosurgeons, of all cases 87.6% were either “good” or “very good” when it comes to the sedation itself and 96.9% reported “good” or “very good” when it comes to cooperation of the patients during sedation. This was respectively 78.2% and 87.5% for the sedation specialist. VAS scores for back pain and leg pain before surgery were respectively 4.8 ± 3.0 and 7.3 ± 1.9. VAS scores post-surgery were 2.8 ± 2.2 for back pain and 1.8 ± 1.7 for leg pain. The mean of the mean arterial pressure (MAP) before surgery was 100.2 ± 16.7 and post-surgery 78.3 ± 12.8. In one case there was almost a respiratory depression but saturation levels (>98%) remained stable throughout the surgery. Five hours post-surgery, 81.3% said not to feel nauseated. 6.3% (n = 2) patients reported having constant headache. Conclusion: In this patient population, sedation with dexmedetomidine during PTED yields a high satisfaction rate surgeons, sedation specialist and patients. Serious complications were not observed, but hemodynamics during PTED needs to be monitored continuously., Introduction: Anterior approaches to the lumbar spine are increasing for the treatment of degenerative disc disease (DDD). Exposure of anterior lumbar spine can be obtained both with a transperitoneal and with an extraperitoneal approach, with different types of skin incisions. In this study we describe a new anterior skin and subcutaneous dissection for retroperitoneal approach to the lumbar spine using a 3 cm semilunar perinavel incision that allows exposure and access to multiple lumbar intervertebral discs (from L3 to S1). Materials and Methods: This technique is performed with a 270° perinavel incision for a single level (i.e. L5-S1 or L4-L5 or L3-L4) or for multiple levels (from L3 to S1). The anterior sheath of the left rectus muscle is dissected and the muscle is retracted upward and laterally, to preserve the inferior epigastric vessels. The peritoneum and the left ureter are then gently pushed from the left to the right side until the psoas muscle is seen. The arcuate ligament is cut. Left common iliac artery and vein are then visualized and mobilized to expose the lower lumbar spine, with a “sliding window” technique. Deep retractors are fixed to the bony surface and a “ring retractor” is connected to the blades in order to achieve stability and maintain the best visualization of the surgical field. After indentification of the disc spaces, under endoscopic assistance discectomy is performed, end plates well prepared to implant the cage for finl fusion. The anterior longitudinal ligament is finally closed. The whole procedure is performed through the “perinavel” incision. Results: In this preliminary study we didn’t observe intraoperative complications, abdominal structure lesions or skin necrosis. All the incisions healed completely at a 3-months follow up, demonstrating that this type of access doesn’t interrupt the arterial supply to the abdominal skin. Conclusion: Anterior approach is becoming a more common approach to address degenerative disc disorders. Levels from L3-L4 to L5-S1 can be easily reached with an anterior perinavel skin incision. The anterior retroperitoneal approach to the lumbar spine is mainly used to treat L4-L5 and L5-S1 levels. In literature several different technique have been described with the dual aim to reduce exposure related complications and to perform a multilevel approach in a single step. A single peri-navel skin incision is frequently used in laparoscopic surgery and it is gaining in popularity because of its minimally invasivity and good cosmetic and postoperative pain outcomes. To authors’ knowledge, an anterior retroperitoneal access using a unique peri-navel skin incision to perform multiple discectomies and ALIFs hasn’t been previously described. Multiple level discectomy and fusion though a minimally invasive anterior approach with a unique small incision reduces surgical aggression, decreases postoperative pain, abdominal morbidity and blood loss. Postoperative recovery, bed rest length of hospitalization and cosmetic result can show better results. A “sliding window” mobilization of the abdominal access allows the surgeon to reach intervertebral levels from L3 to S1 in a single step., Introduction: MIS TLIF is a technique which preserves much of the Paraspinal muscles and is known to produce excellent results post operatively compared to the open TLIF method. Material and Methods: This is a prospective study is to evaluate the clinical outcome of MIS TLIF over a period of 24 months follow up. Sixty two (62) patients underwent MIS TLIF, between January 2012 to December 2013. Forty one (41) patients were able to complete the 24 months. Clinical outcomes were assessed using VAS, ODI, and SF-36 and serial radiographs were obtained at 6 weeks, 3 months, 6 months, 12 months and 24 months at UKM spine clinic. Results: There were 16 males, 25 females with 2 year follow up, and mean age 58.41 yrs. 26 patients underwent single level fusion and 15 patients’ more than one level fusion. 44% had spondylolisthesis 56% had degenerative disc disease. Mean operative time was 123.24 mins. Mean blood loss was 200 ml Mean hospital stay was 5.7 days. Improvement of ODI from 51.9% to 9.78%. VAS improved as well from 7.79 to 1.41. No patient had to be converted to Open TLIF. There were three cases of dural tear and one screw cut. Conclusion: MIS TLIF is a safe and effective technique with an outstanding result that meets the expectation of the patients in the early post-operative period., Introduction: Indications of Percutaneous endoscopic lumbar discectomy are ever expanding with progressive understanding of lumbar disc herniation and endoscopic anatomy with advent of new surgical instruments and techniques. Proper classification for management of different types of lumbar disc herniation by percutaneous endoscopic discectomy is lacking. Based on characteristics of lumbar disc herniations as in Table 1 we are proposing a new classification “Endoscopic surgical difficulty grade/score classification” and based on remnant disc material and degree of symptom resolution after endoscopic discectomy as in Table 2 we are also proposing a new outcome measure “Endoscopic surgical success grade/score classification”. The proposed classifications are comprehensive and applicable as it has taken consideration of anatomy, special issues associated with disc. This classification will help to differentiate different types of lumbar disc herniations and guide for choosing cases according to expertise. Material and Method: EMR records of 104 consecutive patients treated between December 2015 to May 2016 by percutaneous endoscopic discectomy for different lumbar disc herniations either by PETLD (transforaminal, outside in) or PEILD (interlaminar, annular sealing) approach by expert endoscopic spine surgeon who have done more than 1500 endoscopic discectomy were reviewed retrospectively. We have given grade/score to each lumbar disc herniation and surgical success grade (Grade I: Mildly Difficulty, Grade II: Moderately Difficulty, Grade III: Severely Difficult, Grade IV: Extremely Difficult) / score (Unsuccesssful / Partially Unsuccessful / Successful / Completely Successful). We have analyzed outcome of surgical management of our patients according to Endoscopic surgical success grade/score, McNab’s criteria and VAS taking Endoscopic surgical difficulty grade/score as prime variable. Results: Surgical success based on Endoscopic surgical success grade/score is 98.1%. Good to excellent result according to Mc Nab criteria is 96.1% .There is significant resolution of pain. Preoperative VAS 7.13 ± 0.72 changed to 1.78 ± 0.89 postoperatively (P < .005). Sex, herniation level, surgical difficulty grade were not associated with difference in surgical success grade and Mc Nab grade (P > .005). Special issues of disc herniation and diagnosis were associated with difference in Endoscopic surgical success grade/score and Mc Nab grade (P < .005) we had 2 complications of transient motor weakness. Conclusion: Any types of lumbar disc herniations can be treated by percutaneous full endoscopic techniques with more than 96% of success by expert endoscopic spine surgeon (evolution of indications). The proposed classifications are comprehensive and applicable., Introduction: Vertebral augmentation procedures with polymethylmethacrylate (PMMA) are used increasingly for pain relief in patients with symptomatic osteoporotic or neoplastic vertebral compression fractures. There is concern, however, about the intraoperative, perioperative, and postoperative complications associated with PMMA especially in case of severe osteoporosis (i.e osteogenesis imperfecta). Elastoplasty is a new vertebral augmentation procedure in which a silicone cement is used instead of PMMA. The silicone cement is more elastic than PMMA and it could be helpful to prevent further fractures especially in presence of a severe osteoporosis. Materials and Methods: We report a case of a 47-year-old patient with type IV Osteogenesis Imperfecta (OI) and a severe low back pain. The anamnesis of the patient was positive for various fractures of the arms and of the legs that was occurred during the childhood. The patient didn’t refer any trauma at the spine. The radiographic examination of the lumbar spine showed a mild (< 25% height loss) vertebral compression fracture of L4, a severe (> 40% height loss) vertebral compression fracture of L2 and a moderate (25%-40% height loss) vertebral compression fracture of L1. The MRI confirmed that all these fractures were recent (edema in the STIR sequences) and that the posterior vertebral wall was not involved by the fractures. The densitometric evaluation showed a severe osteoporosis (vertebral T-Score – 4,8). The Patient was initially conservatively treated with the use of three point spinal orthosis but after three weeks for the persistence of the pain the patient was candidate to a vertebral cement augmentation procedure. Taking in account the patient’s severe osteoporosis and the risk of the subsequent vertebral fractures related to the OI we decided to perform a ballon elastoplasty using a silicone cement (VK100, BONWRX, Phoenix, AZ). The procedure has been performed under local anesthesia in the operating room of the Interventional Radiology Unit using an Interventional Image Guided System to control the cement diffusion and to early recognize any cement leakage. After the procedure a 3D rotational acquisition was performed to check the final cement position. The Patient was clinically and radiographically reviewed at 1, 3, 6 and 12 months of follow-up. Results: During the procedure there were not any complications any cement leakage was observed. The absence of cement leakage was confirmed by the 3D rotational acquisition. Immediately after the procedure the Patient referred a complete remission of the pain and it was stable at the 12 months follow-up. After 14 months from the procedure the Patient sustained a new low energy trauma resulting in a fracture of T11 while the vertebrae near the treated levels did not sustained any lesions. Conclusion: From our experience the use of an elastic cement seems to be protective against adiacent levels fractures. ballon elastoplasty seems to protective. We don’t recorded any cement leakage and any complication using the silicone cement. We think that to avoid complications it is crucial to follow strictly the cement’s preparation and utilization rules (preparation time and low pressure injection)., Introduction: Microendoscopic spine surgery is minimally invasive surgery, but there is a risk of dural puncture due to the narrow surgical space. Consequently, the surgeons need extensive training. Many researchers have demonstrated surgical complications during microendoscopic discectomy (MED) or laminotomy (MEL), but none have focused on dural puncture. In this study, we examine which instruments surgeons used that caused dural puncture and how the dural punctures were repaired. Materials and Methods: Nine hundred nineteen patients underwent MED for lumbar herniation or MEL for lumbar spinal stenosis in Iwai hospital from January through December 2014. We evaluated the incidence and location of dural punctures, the instruments that caused dural puncture, the repair methods, and postoperative paralysis. Results: The incidence of dural punctures was 4.8% (44 of 919 patients). The tools that caused dural puncture were: 16 curettes, 13 chisels, 7 Kerrison Rongeurs, 4 hernia forceps, 2 penfields, and 2 suction tubes. The locations of dural tears were: 27 in the same direction (61.4%), 13 in the opposite direction (29.5%), and 4 in the center (9.1%). All repair methods were performed microendoscopically and included: 11 dural sutures with fibrin glue, 3 dural sutures with fibrin glue and PGA sheets, 21 fibrin glue and PGA (Polyglycolic acid) sheets, and 9 fibrin glue only. Postoperative paralysis including temporary paralysis occurred in 7 patients (15.9%). Conclusion: Dural tears were mostly caused by sharp instruments, such as curettes, rongeurs, and chisels. However, any surgical instrument that touches the dural membrane must be used carefully because even tools without sharp edges can cause dural puncture. Most patients with dural tears were treated without incident; however, 7 patients did develop paralysis including temporary paralysis., Introduction: The use of conventional uniportal spinal endoscopic decompression surgery for lumbar spinal stenosis can be limited by technical difficulties and a restricted field of vision. The purpose of our study is to describe the technique for percutaneous biportal endoscopic decompression (PBED) for lumbar spinal stenosis and analysis of clinical postoperative results. Materials and Methods: We performed a unilateral laminotomy with bilateral foraminal decompression using a unilateral biportal endoscopic system in patients with single-level lumbar stenosis. We enrolled only patients were followed up for >12 months after PEBD. Fifty-eight patients were enrolled in our study. This approach was based on two portals: one portal was used for continuous irrigation and endoscopic viewing and the other portal was used to manipulate the instruments used in the decompression procedures. Clinical parameters such as the Oswestry disability index (ODI), Macnab criteria, and postoperative complications were analyzed. Results: Neural decompression was effectively performed in all enrolled patients. Mean ODI was significantly lower after PBED. Out of 58 patients, 47 (81.0%) had a good or excellent result according to the Macnab criteria. Postoperative ODI and visual analog scale values were significantly improved compared with preoperative values. Conclusions: From a surgical point of view, percutaneous biportal endoscopy is very similar to microscopic spinal surgery, permitting good visualization of the contralateral sublaminar and medial foraminal areas. We suggest that the PBED, which is a minimally invasive procedure, is an alternative treatment option for degenerative lumbar stenosis., Background: Minimally invasive stabilization techniques (MISS) are gaining in importance in the treatment of spinal fractures. The purpose of this investigation was to evaluate the complication rate of this new procedure. Especially the complications of the hardware (screws and rods) will be illustrated. Methods: In the years 2010-14 a total of 670 patients have been stabilized with MISS techniques in spinal fractures. In 118 patients of this collective we used cement augmentation of the screws in instable osteoporotic fractures. The complications have been divided in intraoperative, postoperative and implant related complications. Data collection has been prospective. Especially complications and hardware problems of the new technique has been described. The results have been compared with the complications results in the open procedure technique of the MCS 2 study from the German Society of Trauma surgery (DGU). Results: We found 7 patients with infection and operative revision. In all patients it was not necessary to remove the implant. In 5 patients we saw loosening of the set screws. In 2 cases there was a loss of reduction and gaining kyphosis. It was necessary to indicate an early revision. In one case it was an incidental finding. In total the complication rate of intra - and postoperative complications is 2.1% Compared to the study group, the rate in the open procedure is 9.4%. Intraoperative bleeding and conversion to open procedure was not observed. There was no revision necessary because of mal positioning of a pedicle screw. Conclusion: The percutaneous stabilization technique of spinal fractures is a safe procedure. In general the complication rate is less than in the open techniques. We found implant-related complications such as loosening of the set screws. This should be recogniced and improved from the companies., Introduction: Minimally invasive spine surgery is a other way to solve common spine pathologies. these techniques have shown less aggression to the tissues and therefore less postoperative pain, shorter hospital stay, less blood loss, lower rate of infection and also faster reincorporation to the activities of daily living.Describe our experience on a case series treated with minimal invasive spine surgery, trough short term follow up and identifying the complications. Material and Methods: A prospective analysis was made on 116 patients who underwent surgery by the same surgical team, from September 2015 to June 2016. Evaluating short term follow up we registered time of surgery, blood loss, complications, hospital stay, pre- and postoperatively neurologic evaluation, as well as scales of disability index and quality of life. The surgical and demographics surgical data were analyzed with the program SPSS version 20. Results: A total of 116 patients at a mean age of 49.7 + 15.7 (21 to 85 years), were intervened of which 76 (65%) were lumbar pathology and 37 (32%) cervical. The most common procedures were lumbar tubular discectomy (31), bilateral tubular decompression (17), TLIF (7); and anterior cervical discectomy and fusion (35). Mean blood loss was 50.6 cc, 1.7 days of hospital stay, pre- and postoperative pain VAS were 7.4% and 2.3% respectively pre- and postoperative Owestry (ODI) were 64.6% and 13.1%, pre- and postoperative SF-36 of 37.8% and 90.3%. There were no major complications, one surgical wound infection on a diabetic patient and incidental durotomy on 3 patients one of them with a contained CSF fistula managed conservatively. Conclusions: The actual tendency towards minimal invasive surgery has been justified on multiple studies for neoplastic and degenerative pathology, with the preservation of the structures that support the spine biomechanics. The benefits should not replace the primary objectives of surgery and its use depends on the surgeon abilities, the pathology and the adequate selection of the techniques. We found that the tubular access allows techniques such as discectomy, fusion and corpectomy with no limits of exposure, avoiding manipulation of adjacent structures, with fewer complications and that it is possible at a public hospital., Introduction: Adjacent segment pathology (ASP) after posterior lumbar interbody fusion (PLIF) surgery using conventional pedicle screw (PS) often requires surgical treatment, but traditional surgical technique for ASP had inherent drawback that essentially involved the unproblematic level, index fused segments, in surgical procedure, which should be burdened for both surgeons and patients due to larger skin incision and muscle dissection, greater blood loss, and so on. The authors believe that an ideal method for ASP is to perform the surgery only at the ASP level, for which we suggest a use of cortical bone trajectory-based pedicle screw (cortical screw, CS). The study aimed to present a new minimally invasive surgical technique using cortical bone trajectory (CBT)-pedicle screw (cortical screw, CS) for ASP after PLIF surgery. Materials and Methods: Twelve consecutive patients who complained back pain and claudication due to ASP after PLIF surgery and not reponded to conservative treatment were included in the study. Our surgical technique is described briefly, as followings. After midline skin incision of approximately 6 cm, posterior decompression was performed. Interbody preparation and two polyetheretherketone cages were kept. Bilateral CS at the cranial vertebra was inserted under fluoroscopic guidance. 35 or 40mm-length rod was assembled with the screw head of CS. Then, using Domino system, the two rods (one from the CS and one from the existing PS) were connected and tightened firmly. For evaluation of the surgical technique, the primary outcome was fusion rate at six months and one year after surgery based on dynamic radiographs and computed tomography images. Secondary outcomes included (1) patient satisfaction, (2) clinical outcomes based on pain intensity, oswestry disability index, and a 12-item short form health survey, (3) radiologic outcomes, and (4) surgical outcomes and complications. Results: All patients had solid fusion in 1-year follow-up: Fusion at six-months post-surgery was achieved in 7 of 12 patients (58%), and at one-year post-surgery, fusion was achieved in 12 of 12 patients (100%). In patient satisfaction, 9 of 12 enrolled patients (75%) responded “completely pain-free and improved,” remained 3 patients (25%) responded “significantly improved but still some pain and/or discomfort,”. Based on these responses, all five enrolled patients were satisfied with our technique. Clinical outcomes were also improved significantly in all clinical parameters. In surgical outcomes, the mean operative time was 100 minutes (range: 90–130 minutes), and the mean length of skin incision was 6.3 cm (range: 6–8 cm). In radiologic evaluation at six months and one year after surgery, none had screw-related complications such as peripheral hollow-rim and cortical violation of pedicle and screw pull-out, and no cage-related complication such as cage migration was observed. There were no complications during surgery or the follow-up period. Conclusion: This new method using CS for ASP has great merits over traditional surgical method that can lead to similar fusion rate and better clinical outcomes under significantly less skin incision and muscle dissection, as one of a minimally invasive method. Further studies will be necessary to better determine its efficacy and safety., Introduction: Lumbar Interbody Fusion with Cortical Bone Trajectory screws has proven to be effective posterior fixation for lumbar degenerative conditions. Applying posterior compression force with pedicle screw heads is sometime difficult, because of small operative exposure. Also Cortical Bone Trajectory screws fixation with interbody cage has shown to be less stable in axial rotation and lateral bending compared with conventional pedicle screw fixation. Objective: To describe the operative method and assess the preliminary clinical outcome of Combined Pedicle Screw Trajectories with One Rod (CTOR) for lumbar interbody fusion. Operative Method: Following lumbar decompression with inferior facetectomy and interbody fusion with kidney bean shape cage, we place Cortical Bone Trajectory screws for cephalad level pedicles and Roy-Camille like pedicle screw trajectory (perpendicular to the posterior plane of the vertebra and straight forward) for the caudal vertebrae with entry point at the exposed superior facet. With the advantage of pedicle screw heads proximity, we connect all four screw’s heads with one curved rod. By placing the rod caudally, tightening the caudal level screws first and cephalad screws approximated to the rod with set screw tightening, we can apply posterior compression force. Methods: Between July 2014 and March 2016, twenty-one patients who underwent CTOR, one patient was lost to follow up because of his medical comorbidity unrelated to the operation. Therefore 20 patients (male/ female: 7/13 the average age was 63 at the time of surgery) were followed for an average 9 .2 months (3-18 months) and analyzed retrospectively. The items reviewed were; operation time, blood loss, perioperative complications, and Visual analogue scale for back pain and leg pain. Results: The average operation time was 131 minutes (104-195minutes) and estimated blood loss was 71.2 g (20-160 g). An 81 year-old man exhibited postoperative cerebrospinal leakage without apparent intraoperative dural tear which required dural augmentation with PGA non–woven fabric sheets with fibrin glue. Good pain relief was achieved in all patients. Conclusion: Combined Pedicle Screw Trajectories with One Traversing Rod fixation for lumbar interbody fusion led to good compatible clinical results with conventional PLIF procedures. And this novel procedure might contribute to more stable construct, because of it’s combined trajectory of the screws and a traversing rod served as cross connector. Biomechanical properties of this fixation are yet to be determined to support these results., Introduction: Percutaneous kyphoplasty had been widely used in treating osteoporosis vertebral compression fracture, but whether bone cement would bring extra stress to adjacent vertebra was still under debate. At the same time, sandwich type fracture is a special type of fracture, the fate of the middle one was controversial. We believed the fate of sandwiched vertebra is the best indicator of secondary fracture due to cement. Material and Methods: We retrospectively collected consecutive patients between 2013.1 and 2015.6. One group included patients with sandwich type fracture, another group was composed of patients with multilevel fracture, but more than one vertebra in between. Demographical parameter, peri-operation data and radiological evidence were collected. Secondary fractures were recorded and compared between groups. Results: Total 120 patients with 323 vertebrae were enrolled in our study. The mean follow-up time was 26.33 months(12-48) with minimum follow-up of 1 year, and average cement usage is 4.77 ml. The mean VAS pre and post operation were 8.32 (6-10) vs 1.43 (0-8), 6(5.4%) patients still had unrelieved pain. As for the new fracture, there were 11(17.7%) and 12(24.5%) patients in sandwich and non-sandwich group had second fracture. Only mortality and corticoid usage are related to secondary fracture (P < .05). Conclusion: Sandwich type fracture have a similar secondary fracture rate compared with non-sandwich type, which suggests that cement augmentation vertebra will not increase adjacent vertebra fracture risk., Introduction: With the increasing number of lumbar fusions being performed, many innovations have emerged for which the goal is to minimize invasiveness and improve outcome. Many procedures require specialized retractors, implants or insertion instruments. Authors describe their experience with paramedian MIS-TLIF utilizing standard implants and instruments and compare the results with classical TLIF. Materials and Methods: A prospective randomized study with 20 individuals undergoing single-level TLIF for spondylolisthesis randomized into “Classical” (n = 10) or “MIS” (n = 10) groups was conducted. Blood loss, postoperative pain (VAS-back & VAS-leg), analgesic requirements and daily life activities during hospital stay and at the 3-month follow-up were evaluated. Pre & post-operative MR images were studied to evaluate invasiveness of procedures. Results: Paramedian approach was successfully performed in all patients with no conversions to classical TLIF. There was no significant difference in either VAS-back or VAS-leg pain. Mean length of incision was 3.5 cm (2.8-4 cm) and 6.3 cm (5.3-7.6 cm); Surgery-time (min) was140 ± 33&179 ± 35; C-arm-time(s) 15 ± 3 & 30 ± 5; estimated-blood-loss (ml) was 757 ± 255 & 150 ± 30; drainages (cc) 480 ± 326 & 175 ± 50 and Hospital-stay (day) was 8 ± 1.5 & 5 ± 1.5 respectively for classical and MIS group. Axial T1 and T2 weighted images revealed less altered signal in the paraspinal musculature in MIS group. Conclusions: The study documents the feasibility of MIS-TLIF through paramedian approach with the clinical results comparable to classical TLIF with added advantages of lower blood loss, reduced hospital stay, lower analgesic requirements and faster recovery of daily life activities. Importantly, paramedian MIS-TLIF requires only standard implants, instruments, and retractors with no added cost and can be adopted easily., Introduction: Despite that most cases of craniocervical junction fractures can be treated nonoperatively with reduction and subsequent immobilization in a rigid cervical collar or halo, in some instances, operative management is necessary and can be accomplished by using either anterior or posterior fusion techniques. Open posterior procedures can result in significant blood loss, pain, and limited cervical range of motion. Also variability of C2 anatomy can make instrumentation challenging and prone to potentially severe complications. We want to show a minimally invasive, navigation-guided technique for surgical treatment of Levine-Edwards (L-E) Type I, Type II hangman’s fractures and C1 Type II (Jefferson’s) fractures. Material and Methods: For 6 patients: 2 with L-E Type I, 2 with L-E Type II hangman’s fracture and 2 with Jefferson fracture percutaneous screw fixation was performed: 4 directly through the fracture site and 2 C1- C2 transarticular fixation. This technique was facilitated by the use of intraoperative CT O-arm scan and StealthStation S7 Surgical Navigation System. Results: Of the 6 patients, 2 were women, 4 were men, age range was 33–69 years. No intraoperative or postoperative complications occurred. All patients were obtained flexion-extension radiographs the day after surgery nd at 6 weeks. For all patients, dynamic imaging demonstrated a stable construct. Conclusion: Craniocervical junction fractures can be safely repaired with the use of percutaneous minimally invasive surgical technique. This technique may be appropriate, depending on circumstances, for L-E Type I, L-E Type II hangman’s and Jefferson fractures; however, the degree of associated ligament injury and disc disruption must be checked., Introduction. The most common and reliable methods of C1-C2 fusion are the fixation by Harms and by Magerl techniques. The main advantages of Magerl technique are the great opportunities for minimally invasive performing. The two main methods of posterior transarticular stabilization are known: neuronavigated percutaneous technique and open surgery. It is possible to decrease the surgical trauma using lateral transmuscular approach with tubular retractor and endoscopic assistance in the case of CT navigation absence. Materials and methods. Eighty-nine patients with upper cervical fractures were treated from 2011 till 2016. The posterior transarticular fixation with canulated screws was applied at 31 cases. The open surgical treatment by posterior midline access to C1-C2 was performed in 15 patients who required posterior decompression or additional translaminar fusion. The posterolateral transmuscular approach was used in 16 patients who suffered from reducible atlantoaxial dislocations. Two patients with upper cervical fractures were successfully treated using minimally invasive Magerl technique with endoscopic assistance. Surgical technique. The closed reduction and immobilization in Halo were used during the surgical treatment as the first step. The second step included four small skin incisions (15 mm) provided minimally invasive technique: two of them were used for endoscopic-assist approaches to facet joints of C2-C3 through the tubular retractors and two – for K-wires and canulated instruments’ ports. Than the entry points at the C2 facets for the K-wires and screws were exposed. Afterwards the K-wire was put through the posterior C2 elements to lateral mass of atlas from each side under the video and X-ray control. Finally we drilled the canals for screws in C1-C2 with following putting the screws over the K-wires. Results: The placement of screws was correct according to CT data. There were no postoperative complications in patients with posterolateral transmuscular approach usage. The good orthopedic and clinical outcomes were observed in all these patients. Conclusions. The posterior C1-C2 transarticular fixation with endoscopic assistance could be the alternative to open surgery or percutaneous procedures. The usage of this minimal invasive technique is possible for treatment of reducible dislocations in case of normal vertebral artery course. The small skin incisions and surgical corridor as well as the minimal damage of cervical muscles allows decreasing the postoperative complications., Introduction: The O arm is a mobile intraoperative imaging platform. It provides 2D fluoroscopy and 3D reconstruction and allows for lateral patient access similar to a C arm. This study reports on the initial results of using the O arm in pedicle screw placement. Materials and Methods: Twenty patients (13 males and 7 females) underwent lumbar pedicle screw placement using the O arm between August 2012 and July 2014. Age range was 36 to 65 years. All patients suffered from severe degenerative lumbar spine disease and exhausted all methods of conservative treatment. All patients underwent on table O arm imaging during and at the end of surgery including 3D reconstructions. Results: Two cases needed one screw readjustment each after doing the final O arm check. This was attributed to inadvertent movement of the reference frame. All cases had 100% proper final placement of all screws confirmed on table before wound closure. Conclusions: The use of the O arm is extremely helpful in complex spine surgery. It allows on table confirmation of accuracy of pedicle screw placement. No patient needed postoperative CT scan to check accuracy of placement., Introduction: Quality of life in patients with primary and metastatic tumors of the spine mainly depends on the surgery quality. The use of intraoperative computed tomography (iCT) and neuronavigation system in the surgical treatment of spinal tumors allows us to identify prevalence of neoplasia directly in the operating room, to oversee the resection zone and to provide spine stabilization under altered anatomy. Methods: 187 patients underwent surgical treatment for primary and metastatic tumors of the spine from January 2002 to January 2016. We used iCT with neuronavigation system since August 2013. During this period, 26 patients underwent transcutaneous biopsy as a diagnostic procedure and 45 patients underwent surgery. The aim of our study was to assess the effectiveness of iCT and navigation system in the diagnosis and surgical treatment of patients with spinal tumors of different origin and prevalence. Results: The main advantages of iCT and navigation system use have been analyzed in the diagnosis and surgical treatment of primary and metastatic tumors of the spine. There are no any implant-related complications. In all cases extend of decompression was sufficiently. After en-bloc resection of tumor according to the control studies contrast uptake were not observed. Conclusions: The use of iCT and neuronavigation system in the diagnosis and surgical management of primary and metastatic tumors of the spine improves the efficacy and safety of treatment under altered anatomy and the absence of external reference points and minimizes the radiation exposure., Introduction: The use of navigation system in spine surgery has gained recent popularity to improve the accuracy of pedicle screw placement. In this study, we investigated the perforation rates of pedicle screw (PPS) placement with O-arm navigation system in lumbar surgery. Material and Methods: Total of 346 pedicle screws were implanted in 58 patients using O-arm navigation system. In all cases, pedicle screws on the left side were inserted by a skilled spine surgeon and pedicle screws on the right side were inserted by an unskilled surgeon (getting training within 4 years). The accuracy of PPS was evaluated after surgery using computed tomography (CT) and classified into 4 grades (0.1.2.3 grade) with grade 2 and 3 representing perforation. The difference of the perforation rates between the skilled and the unskilled surgeon were examined. Results: Grade 0 was 86.7% (300/346), grade 1 was 10.7% (37/346), grade 2 was 0.9% (3/346), grade 3 was 1.7% (6/346). The perforation rate of all screws was 2.6% (9/346). The perforation rates of the skilled and the unskilled surgeon side were 1.2% (2/173) and 4.1% (7/173) respectively. Conclusion: This study indicated that the use of O-arm navigation system in PPS placement have very beneficial implication, however the surgeon’s techniques may affect the accuracy of PPS placement in lumbar surgery., Introduction: Pedicle screw insertion in complex spinal deformity such as scoliosis is challenging, and is complicated by morphometric limitations of pedicle dimensions, altered anatomical landmarks for insertions and abnormal orientation in space. AIRO intraoperative CT navigation systems have reported excellent screw placement however accuracy in the clinical scenario of complex spinal deformity has not been reported previously. The purpose of this study is to validate the accuracy of pedicular screw placement with the use of AIRO navigation system in cases with complex spinal deformity. Materials and Methods: A prospective study was performed on 31 patients undergoing complex spinal deformity correction surgery using posterior pedicle screw instrumentation. The cases included 24 scoliotic and 7 kyphotic deformities of the thoracic and lumbosacral spine. We used the mobile AIRO CT based navigation system for pedicular screw placement. The average cobb angle was 68.3° (range 60°-104°). The average number of segment instrumented was 12 (range 5-15) and mean number of screws per patient was 15 (range 7-24). Following the instrumentation, all screws were evaluated by an intraoperative CT scan. Analysis was performed to estimate the accuracy of screw placement, time for screw insertion and radiation exposure. Breach greater than >2 mm were considered for analysis. Critical breach was considered to be > 4 mm, non critical breach was between 2- 4 mm. Results: Total of 455 pedicle screws were inserted from T1 to iliac region. There were 116 pedicle screws in the upper thoracic spine, 171 in the lower thoracic and 168 in lumbosacral spine. There were total of 27 screws with pedicle breach noted, including 10 medial, 16 lateral and 1 anterior wall breach. No case was clinically symptomatic for malpositioned pedicle screw. Among Medial breach (n = 10) only 1 screw had a critical breach needing revision and 9 screws had non critical breach. Four of 9 cases with medical breach were planned breach on the convex side of the curve as a lateral trajectory did not offer adequate purchase in the pedicle due to contorted pedicel anatomy. Among lateral breach (n = 16), 10 screws were planned for in-out pedicle screw insertion, 4 screws showed non critical breach and 2 screws with critical breach. After accounting for planned breach, the effective breach rate was 2.8% resulting in 97.2% accuracy for pedicle screw placement using AIRO in complex spine deformity. We also encountered 44 pedicles which had to be abandoned as pedicle screw insertion was not possible. In all cases, we were able to scan whole of the planned instrumented levels in one single scan. Average screw insertion time was 1.76 ± 0.89 minutes (range 0.42- 5.35 minutes). Average radiation exposure to the patient was 9.7 ± 2.36 msv (range 4.49- 18.83msv). Conclusion: Considering the clinical scenario of complex pedicle anatomy in spinal deformity AIRO navigation showed an excellent accuracy rate of 97.2%. It is quite safe, highly versatile and can be easily integrated into existing operation theatre setup. It also eliminates the radiation exposure to operating room personnel during the procedure., Introduction: There is a growing consensus of the effectiveness, efficiency, outcomes and economics of MIS spinal fusions. While the body of evidence in the scientific literature demonstrates these values, MIS often comes at a risk to the surgeon through occupational hazard of the increased reliance on fluoroscopy in the operating room and the impact of long days wearing heavy protective lead aprons. The former has been proven to lead to an increased risk of malignancy and cataracts while the latter has led an increased incidence of spinal injuries and other orthopedic ailments in spine surgeons. Computer assisted surgery systems that can guide surgeons during fusion procedures have been reported to reduce the need for fluoroscopy. Materials and Methods: Data were collected retrospectively from 4 hospitals for patients operated with robotic-guidance in a MIS approach (RGM), and compared with patients operated with fluoroscopic-guidance MIS (FGM). All cases were instrumented fusions using a minimally invasive technique with pedicle screws inserted in a percutaneous para-median approach. Results: Altogether, data from 627 patients were collected, 403 RGM patients and 224 FGM. There were no significant differences in age, sex or BMI between arms or surgeons, except for 1 of the 4 groups in RGM that was significantly older by about 6 years. There were 7.2 screws per case in RGM, vs. 5.5 in FGM. Skin-to-skin time per screw was almost equal, with 32.8 minutes for RGM and 33.9 for FGM. Total case fluoro time per screw was 11.3 seconds per screw, vs. 27.4 seconds for FGM. Conclusions: This retrospective analysis demonstrates that use of robotic guidance MIS can significantly reduce the surgeon’s exposure to intraoperative fluoroscopy compared to fluoro-guided MIS in the hands of experienced MIS surgeons. In a standard 2-level case using 6 pedicle screws surgeons could reduce their exposure by about 1.5 minutes of radiation. Extrapolating these data for surgeons performing 100 or more lumbar fusions annually leads to significant reductions to hazardous radiation., Introduction: Surgical management of traumatic C2 fractures is technically challenging due to anatomical relationships between osseous and neurovascular structures. 3D imaging-based intraoperative navigation systems are increasingly used to improve accuracy of the procedure and patient’s safety. Purpose of this retrospective study is to evaluate surgical workflow and applicability of navigated spinal instrumentation with the mobile AIRO intraoperative computed tomography (iCT) scanner in a series of patients submitted to cervical posterior arthrodesis. Material and Methods: We performed a retrospective analysis of patients affected by Anderson type II fractures of the odontoid process, who underwent C1-C2 posterior cervical arthrodesis using Harms technique, from October 2014 to August 2016. Screws were positioned with the only aid of intraoperative Airo-based CT navigation, without fluoroscopic control. Results: Patient population, aged from 60 to 93 years, includes seven patients. Six patients underwent C1-C2 posterior stabilization, while in one case extension of stabilization to C3 was required due to a pathologic fracture. A total of 30 screws were placed, with 1 case requiring repositioning of 1 screw after accuracy control with intraoperative CT scan had shown incorrect placement. No patient showed intraoperative vascular injury, new neurologic postoperative deficits or postoperative implant failure during the follow-up period. Conclusion: Implementation of intraoperative Airo-based CT navigation for posterior stabilization of C1-2 fractures facilitates correct screw placement and increases the safety of the procedure., Introduction: Percutaneous fluoroscopy assisted pedicle screw fixation for thoracolumbar spine fractures is associated with preservation of posterior musculature, less blood loss, shorter operative time, lower infection risk, less postoperative pain, shorter rehabilitation time as well as shorter hospital stay when compared to open surgery, but with increased radiation exposure for the surgical team and patients. Robotic assisted spine surgery is an emerging field of surgery that has been shown to reduce radiation exposure with high level of safety. The purpose of this study is to evaluate the outcome of robotic assisted percutaneous pedicle screw fixation with for thoracolumbar spine fractures. Material and Methods: A ambispective review of all patients with thoracolumbar fractures who were managed with robotic assisted percutaneous transpedicular screw fixation (Renaissance, Mazor roboticsl) at our medical center between November 2009 and July 2016. Demographic data, accuracy rates, post operative alignment, radiation exposure were evaluated. Results: Twenty two patients (14 males and 8 females) underwent robotic assisted percutaneous transpedicular screw fixation between November 2009 and July 2016 for type A and B (AO) thoracolumbar fractures. The average age was 41.1 years (range 17-82). Twelve cases were due to falls from height, 3 for MVA, 3 extension type injuries, and four from other mechanisims. Three of the patients were poly trauma patients, four had rib fractures and three others had calcaneous fractures as well. 154 screws were placed in total. Levels operated ranged from 3-7 levels, with 5 to 13 screws were used per case. In three cases cemented fenestrated screws were used. Mean total case radiation time per screw was 4.1 seconds (ranged 1.8-4.7 including registration, screw and rod placement). Only one screw was removed and inserted again manually (0.65%) because of malplacement. There were no treatment-related complications. There were no revision surgeries. Conclusion: Robotic assisted percutaneous pedicle screw fixation for thoracolumbar spine fractures is a safe method for screw placement for thoracolumbar trauma cases. It allows restoration of the sagittal alignment with satisfactory clinical results even for geriatric patients and poly trauma patients with reduced radiation to the patient and surgeon when compared to free hand techniques. The non fusion screw fixation allows removal of the screws if needed after healing has set. A comperative study with other navigation techniques is needed., Introduction: Spinal navigation is an important tool during surgery with pedicular screws. Since 2 years (September 2014), we have implemented the use of an intraoperative mobile CT (iCT, AIRO system). This CT is routinely coupled with spinal navigation during screw positioning, either with percutaneous or open technique. CT is also used to check position of screws before patient leaving operatory room. Compared to traditional fluoroscopy, potential advantages of navigation techniques are better accuracy in screw positioning, less risk of neurological injury, less radiation exposure for surgical team. Potential disadvantages are prolongation of surgical time and, in case a CT is coupled with a navigation system, an augmentation of radiation exposure for patients. In this retrospective analysis, we report our experience on a series of 175 patients operated at thoracic and lumbar levels with pedicular screws. Material and Methods: Retrospective evaluation of a series of 175 patients submitted to surgery with pedicular screws at thoracic and/or lumbar levels (cervical spine excluded). Main goal of this analysis was to check the reliability of a navigation system coupled with CT. To obtain this, we explored 2 parameters: the rate of intraoperative repositioned screws (screws that were repositioned by surgeon after intraoperative control CT) and operative time (measured from skin incision to skin closure). Secondary objectives were to assess rate of malpositioned screws (grade 3-4-5 using Heary classification), and to compare it with our previous experience with another type of mobile 3-D imaging system (O-arm). Results: Our series includes 175 patients (89 women and 86 men), with a mean age of 64 years. Two-thirds of patients were operated for a degenerative disease of the spine (lumbar spinal stenosis with instability, spondylolisthesis, adjacent segment disease), while in the other cases indications were traumatic diseases or instability due to infection. Mean number of instrumented levels was 2.5. Mean number of intraoperative scans was 2.0 (DS 0.29). Mean radiation exposure was 12.43 mSv (measured on 92 patients). More than 700 pedicular screws were analyzed. Mean operative time was 266 minutes in non-previously operated cases, 358 minutes in revision surgeries (P < .0001). Overall, nine screws were intraoperatively repositioned in 9 patients: on intraoperative control CT, 5 were judged too medial, 1 was too low, and 2 were laterally placed. One screw was repositioned because of a modification of EMG during positioning, before intraoperative CT. One patient in this series (0.005%) needed revision surgery for a malpositioned screw on L5, that was not checked with intraoperative CT after repositioning. Duration of surgery and rate of repositioning significantly diminished in last 70 operated patients, compared to first 75. Conclusion: Reliability of navigation system coupled with iCT is very high, as shown by the very low number of intraoperatively repositioned screws. In our experience, this rate is significantly lower than with other imaging systems we used (fluoroscopy, O-arm). We consider this parameter more accurate in judging navigation reliability than screw position measured on intraoperative or postoperative CT by a radiologist. In many cases indeed, final position of screws in the pedicle may be judged as acceptable by surgeon, even if it will not be judged as radiologically correct with most of the classification system that are used for this purpose. Operative time is significantly higher with this system than with free-hand technique or with intraoperative fluoroscopic control, but in our experience is not higher than with other 3-D imaging systems as the O-arm. Longer operative times do not depend on number of intraoperative scans (that were almost always 2 in our series). Finally, we identified a clear learning-curve effect, as shown by the lower rate of intraoperatively repositioned screws, lower operative time and lower number of misplaced screws in the last 70 patients., Introduction: Vertebral hemangioma is a benign tumor that accounts for approximately 2% of the benign tumors in the body, and 0.8% of the lesions of the skeletal system. Its incidence peaks between the ages of 30 – 50 years. Hemangiomas in the pediatric population are rare with less than 10 cases reported. Material and Methods: In this report we describe the case of a 14 year old female who came to our clinic with one year history of back pain that progressed to severe. She was diagnosed with lumbar Tuberculosis. MRI shows a progression of the lesion so she was sent to our hospital where Vertebral Hemangioma was diagnosed. Propranolol treatment of 20 mg was given to her for 6 months. Results: She responded dramatically with MRI control at 6 months with a reduction of 90% of the hemangioma. Posterior instrumentation treatment was added. Patient after one year treatment is actually without pain and no neurologic sequels. Conclusion: Vertebral hemangiomas in pediatric age are not common. This is the reason why when clinical and radiographical is suspected it is important to perform an adequate diagnosis and treatment. Once we have done the diagnosis management with propanolol as an optional treatment, in some cases at first line it has demonstrated to be a reliable method with low recurrence and in patients with neurologic and instability the use of propranolol improves column surgery having as a mechanism of vasoconstriction, suppressing angiogenesis with induction of endothelial cellular apopthosis resulting in the decrease of the hemangioma. Although it has only been one year of treatment we have seen satisfactory results with neurologic deficit improvement and resulting in minimal pain scale., Introduction: There’s a known connection between the back-pain and psychical problems. However, we suppose the direct causality between stress and lumboischialgia. Material and Methods: A prospective cohort study, from april 2014 untill august 2014. We’ve examined 39 Patients (19 W / 20 M), age-median 42 years. Patients with an acute back pain episode, without a relevant previous history, were given an modified HADS-D and FW7 charts, as well as the pain-score was evaluated. Results: Abnormal Scores for HADS-D were present in 51% of patients, for FW7 in 42%. About 50% of patients reported having an deep existential oder emotional problem. Combined together we found a relevant score deviation in 75% of patients, with an acute deep emotional or existential problem in 79% of the patients. Theese factors did not correlate with the pain-score. Conclusion: There’s a possible causality between stress and an acute back-pain. This should be considered in primary therapy concepts and indication criteria., Introduction: Spinal cord injury (SCI) leads to a profound reduction in bone mineral density (BMD) and disturbances of the skeletal trabecular microarchitecture. The pathogenesis of osteoporosis after SCI is complex and differs from other forms of this problem. The aim of this study is to review the most recent literature on prevention and evidence-based treatments of osteoporosis in SCI patients. Material and Methods: MEDLINE, EMBASE, PubMed and the Cochrane Library were used to identify papers from 1946 to June 17, 2015. The search strategy involved the following keywords: spinal cord injury, osteoporosis, and bone loss. Results: A total of 51 studies met inclusion criteria. Most of these studies were small and of poor or fair quality and only 15 randomized controlled trials (involving 356 patients) were found. There are low levels of evidences that Bisphosphonates (Clodronate, Etidronate, Alendronate, Zoledronic acid) in the first year after injury, Vitamin-D analogs and Alendronate plus calcium for one year and beyond are effective in the prevention or treatment of bone loss. Electrical stimulation was also useful after acute SCI. For other rehabilitation modalities after SCI data are insufficient. Conclusion: No recommendations can be made from our review, due to the variable interventions and timing and usually low levels of evidence from these studies. Therefore, more research is needed to increase the knowledge base regarding the various interventions to prevent or treat bone loss after SCI., Introduction: Chronic low back pain has many differential diagnosis.Osteitis Condensans Ilii usually asymptomatic but uncommonly may cause lower back pain. Although it may present as seronegative spondyloarthopathy, Osteitis condensans ilii is a bone sclerosis characterized by nonspecific inflammation, highly dense bone hardening phenomenon, particularly in the ilium by 2/3 of the bone and do not change the joint space. middle-aged woman, especially late in the pregnancy, childbirth, and other infections of pelvic cavity. it is hypothesized that ligamentous laxity at the sacroiliac joints leads to instability and subsequent sclerosis. Aim: To prove not all Sacroiliac pain are Sacroilitis but some can be Osteitis Condensans Ilii. Methods and Materials: It is a Case series of 21 patients who had axial back pain with sacroiliac pain (13 males and 8 females) between a duration of 1 year from June 2015 to July 2016 of the age group 22 to 40 years. Multi centeric study done at various hospitals in Chennai. All patients with chronic low back pain were evaluated by taking history, clinical examination. Initially all the patients underwent X ray of the LS spine. Suspected cases of different pathologies underwent further radiological evalaution and eventually all the patients were taken MRI and CT screening. European Spondyloarthropathy Study Group Criteria for the classification of spondyloarthropathies and 2010 ACR/EULAR RA Classification Criteria was used to rule out Spondyloarthropathy and Rheumatoid arthritis respectively. Blood investigations were done. All patients were graded by Oswestry disability index score, Zurich claudication score and VAS. Results: Out of the 21 cases, 4 cases were diagnosed to have degenerative disc disease, 13 cases had intervertebral disc prolapse with grade 2 to 3 sacroilitis. 2 were diagnosed to have Aneursymal bone cyst. 2 cases were diagnosed to have osteitis condensans ilii. All the patients of Osteitis condenses Ilii were post partum and treated with physiotherapy, analgesics and one patient underwent steroid injections. All the patients improved symptomatically. Oswestry disability index score decreased from 96% to 9%. VAS decreased from 9 to 1 and Zurich claudication score significantly improved. Discussion: Not all cases with Sacroiliac pain are termed as Sacroilitis. Eyes should be wide open when a post partum patient comes with axial back pain and has significant SI joint tenderness. The disease presents at an early stage and it is often bilateral. Primary responsibility is to rule out other significant causes of low back pain. Physiotherapy and conservative management remains to be the safe and effective way of managing the patients. CT screening and MRI is the investigation of choice., Introduction: Osteoporotic vertebral compression fractures (VCF) are very frequent and cause significant morbidity in elderly patients. When pain and disability are high, cement augmentation represents a valid therapeutic option, that may prevent collapse and kyphosis and reduce vertebral pain. We present a case of VCF where vertebroplasty, even if correctly performed, was not sufficient to prevent kyphosis. Bad quality of bone led to significant vertebral deformity and to cement mobilization. The patient was treated with teriparatide, with fracture healing and clinical amelioration. Material and Methods: An 85 year-old woman presented after a minor fall at home with intense lumbar pain. Radiological examination revealed an L1 vertebral fracture (Genant grade 1) that was initially treated conservatively. Medical history was positive for severe osteoporosis (t score of -3.5), previously treated with bisphosphonates. After 1 month, lumbar pain was worse, and new CT scan revealed progression of vertebral collapse at L1. Decision was made to treat with vertebroplasty. She was then better for 1 month, but then pain reappeared, and physiotherapy was recommended. After 6 months, she was unable to walk because of pain, and new CT revealed collapse progression at the level of the fracture, with anterior mobilization of cement. Results: The case was discussed and multiple option were taken into consideration. Because of age and significant osteoporosis, direct surgical approach with reconstruction and posterior stabilization was considered too invasive and risky. Patient was then treated with teriparatide daily for 22 months. Pain improved significantly, and patient gained ability to walk after 1 month of treatment. CT scans at 6 months and 22 months revealed complete healing with bony fusion anterior to L1, surrounding previously positioned cement. No other invasive treatment was needed. Conclusion: Teriparatide could represent a viable option in old patients with VCF that progress after cement augmentation., Introduction: The assessment of patient-reported outcomes (PRO) in spine care provides useful information for quality improvement, effectiveness, and comparative effectiveness. The objective of this study was to evaluate the perceptions about PROs among Latin America (LA) spine surgeons and to evaluate the barriers to implement its routine. Materials and Methods: Internet-based survey to evaluate knowledge and perceptions on the use of PROs among members of AOSLA. The results of this survey supported the development of AOSLA Quality Assessment Registry. Results: A total of 731 participants from 22 countries answered the electronic questionnaire, a response rate of 52.02%. In general, more than 70% of participants agree that: PROs are useful to evaluate treatment outcomes, they help to monitor outcomes and burden of disease, they can benefit the patients, they facilitate physician-patient communication, and they are useful to compare the results of different centers. However, 36.8% of participants reported not using any PROs in their current activities. The main barriers to implementing PROs collection in routine practice were reported to be lack of time and structure (electronic database, assistants, etc) to perform this activity. However, when asked if they would use an electronic database to store and manage patient data, 87% of participants answered that they would use it routinely to monitor clinical outcomes of patients. Differences among countries were identified. The rationale of AOSLA Quality Assessment Registry is described in detail. Conclusions: This survey identified the barriers to the use of PROs and clinical registries in spine care in LA. Strategies for overcoming these barriers should be addressed in order to fully implement a large clinical registry of spine care in LA., Introduction: The nature of the Aneurysmal Bone Cyst (ABC) of the spine is still controversial among benign tumor, often identifiable in the “aggressive” form (Enneking stage 3) or pseudotumoral lesion. It is well known instead the very high risk of intraoperative bleeding, indicating a strongly unfavorable relationship between the surgical morbidity and the nature of the disease. Excellent results have been obtained in the treatment of ABC by repeated arterial embolizations (SAE), without any surgery, while some alternative treatments have been recently proposed and investigated for cases in which SAE is unsuitable or ineffective. This study presents the results of our initial experience in the treatment of vertebral ABC through the use of concentrated autologous mesenchymal stem cells (MSCs). Patients and Methods: Two teenagers aged 15 years, male, and 14 years, female, came to our attention both with diagnosis of ABC in C2 vertebra which was histologically confirmed. They were both neurologically intact, the girl complained of neck pain. The arteriography showed in both cases close relationships between the pathological ABC vascularization and the vertebral and cervical ascending arteries, making treatment by selective arterial embolization unsuitable. After discussion with the parents of patients, we jointly decided for an alternative treatment by direct injection of MSCs: 1) harvesting from the iliac crest of 60 cc of bone marrow (by needle aspiration); 2) separation of MSCs using the concentration system Res-Q™ 60 BMC; 3) injection of MSCs into the ABC area. In the second case the treatment was repeated three times at distance of 4 and 8 months. We recently treated other 3 patients, who have a follow up period of 5 months and 1 month. Results: Clinical and radiological follow-up of 27 months from the first treatment in both cases. In the first case the presence of newly formed bone within the ABC appeared as a clear sign of recovery just a month after the first treatment and increased gradually, until the cyst appeared completely ossified one year after the treatment, with associated disappearance of the pain. In the second case an initial sclerotic peripheral margin appeared after the second treatment and later ossification progressed after the third treatment, concurrently with the disappearance of the pain. Conclusion: Treatment with repeated SAE is considered effective in the treatment of ABC even if not without risks, mainly related to the frequent and repeated exposure to ionizing radiation. Furthermore, in a certain percentage of cases the procedure is not technically executable, especially for the presence of arteries afferent to the medullar vascularization. Inconsistent results were obtained with other procedures: the injection of calcitonin, steroid, alcoholic solutions, or the use of sclerosing substances. Radiation therapy it is not considered the first choice. Recently, promising results have been achieved by the injection of mononuclear cells derived from bone marrow in the treatment of Aneurysmal Bone Cyst. Based on the early results obtained in the two cases described, the injection of MSCs can be considered a valid alternative in the treatment of vertebral ABCs untreatable by embolization., Introduction: The incidence of degenerative spinal diseases that need a lumbar interbody fusion surgery has increased with an increase in the elderly population. However, after the lumbar interbody fusion surgery, patients commonly have severe pain, requiring adequate bed rest for a long time. Moreover, associated complications can occur, and the chances of early rehabilitation can be inevitably delayed. We performed a 1-day minimally invasive spine (MIS) lumbar interbody fusion that required no hemovac insertion and no skin suture and led to early ambulation. Here, we report the surgical procedure and results. Materials and Methods: This study was designed as a retrospective review of clinical and surgical parameters. From January 2013 to August 2014, 49 patients who received the MIS trnasforaminal lumbar interbody fusion (TLIF) for 1-day MIS lumbar interbody fusion surgery were included in this study. All patients received MIS TLIF with the MIS retractor system (Tubular/Caspar/Taylor) by using the MISS decompression technique (unilateral decompression/bilateral decompression/unilateral approach bilateral decompression). Two cases were of foraminal stenosis, 1 of recurred HNP, 13 of spinal stenosis, and 33 of spondylolisthesis. The surgical procedures performed were as follows: 1) epidural catheter insertion for anesthesia and postoperative pain control; 2) midline subdermal dissection procedure; 3) MIS TLIF (unilateral/bilateral); 4) bleeding control procedure: a. meticulous bleeding control, b. fibrinogen/thrombin-based collagen fleece bleeding control, c. fluid-type anti-adhesive agent (osmotic pressure compression effect for bleeding control), d. Gelform covering: barrier for hematoma from outside to inside of the spinal canal; 5) percutaneous transpedicular screwing under the subdermal dissection plane; 6) tight subdermal plan suture (conjoined suture of split fascia and subdermal skin); 7) skin sealing procedures: secure skin closure system and zip surgical skin closure system. Postoperatively, wound dressing was not needed. The wounds were only checked every 3-4 days. Epidural catheter was removed on the second day after the operation. Intravenous antibiotics were injected for 3 days after the operation.We checked the surgery-related results using the intraoperative, postoperative conditions and postoperative complications and clinical results by using the Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) in the immediate postoperatively (1∼2 day), 1 month, 3 month, 6 month and in the 12th month. Results: The mean age was 65.27 ± 9.57 years, and the sex ratio was (male/female) 20/29. The average follow-up period was 26.04 ± 7.25 months. Regarding the operation segment, 33 patients underwent 1 segment operation; 13, 2 segment; and 3, 3 segment (average: 1.39 ± 0.61 segment). Average intraoperative bleeding was 178.47 ± 73.70 cc (per level: 128.60 cc). The average operation time was 109.49 ± 32.71 min (per level: 78.90 min). An average midline skin incision was 3.90 ± 1.18 cm (per level: 2.80 cm). The possible ambulation time was 0.94 ± 0.88 day. The discharge time after antibiotic injection for 3 days was 4.88 ± 1.51 days. In the corresponding order of preoperative and immediate postoperative, 3-month, 6-month, and final follow-up, the VAS (back) were as follows: 6.33 ± 0.94, 3.14 ± 1.12, 2.47 ± 0.58, 2.29 ± 0.65, and 2.31 ± 0.77; VAS (leg): 7.37 ± 0.70, 2.69 ± 0.85, 2.29 ± 0.46, 2.14 ± 0.58, and 2.24 ± 0.80; and ODI: 39.37 ± 3.05, 29.29 ± 5.78, 22.59 ± 2.99, 20.27 ± 2.59, and 18.63 ± 3.13. Postoperative VAS (back), VAS (leg) and ODI improved significantly immediate postoperatively ((P < .0001). Postoperative complications were two cases of transient motor weakness (all cases recovered sufficiently after the follow-up period), four of wound suture due to avulsion of operation field (all cases healed completely after the follow-up period), no cases of revision due to hematoma, one of dural tear, and two of cage subsidence or implant failure. Conclusion: The results indicated excellent clinical results of the 1-day minimally invasive lumbar interbody fusion surgery, without any serious complications. With the development of an infection control system for the lumbar interbody fusion surgery, a real comfortable 1-day lumbar interbody fusion surgery will be possible., Introduction: Pedicle screws fixation to stabilize lumbar spinal fusion has become the gold standard for posterior stabilization. However their positioning remain difficult due to variation in anatomical shape, dimensions and orientation, which can determine the inefficacy of treatment or severe damages to close neurologic structures. Image guided navigation allows to drastically decrease errors in screw placement but it is used only by few surgeons due to its cost and troubles related to its using, like the need of a localizer in the surgical scenario and the need of a registration procedure. An alternative image guided approach, less expensive and less complex, is the using of patient specific templates similar to the ones used for dental implants or knee prosthesis. Materials and Methods: Like proposed by other authors we decided to design the templates using CT scans. Template developing is done, for each vertebra, using a modified version of ITK-SNAP 1.5 segmentation software. At first we segment the spine bone and then the surgeon chose screw axes using the same software. We design each template with two hollow cylinders aligned with the axes, to guide the insertion in the pedicle, adding contact points that fit on the vertebra, to obtain a template right positioning. The templates were manufactured in ABS using a 3D printer. After same in-vitro tests, using a synthetic spine, we studied a solution to guarantee template stability with simple positioning and minimizing intervention invasiveness. Preliminary ex-vivo animal testing on porcine specimens has been conducted to evaluate template performance in presence of soft-tissue in place, simulating dissection and vertebra exposure. For verification, the surgeon examined post-operative CT-scans to evaluate K-wires positioning. After the ex-vivo test we started with a small clinical human trial which it is still in progress at the time of writing this abstract. Results: During the ex-vivo animal test sessions, template alignment resulted easy thanks to the spinous process contact point. Their insertion required no additional tissue removal respect to the traditional approach. The positioning of contact points on vertebra’s lamina and articular processes required just to shift the soft tissue under the cylinders bases. The surgeon in some cases evaluated false stable template positions since not each of the 4 contact points were actually in contact with the bone surface and tried the right position. CT evaluation demonstrate a positive results in 96.5% of the K-wires implanted. Conclusions: Our approach allows to obtain patient specific templates that does not require the complete removal of soft tissue around vertebra. Guide positioning is facilitated thanks to the using of the spinous processes contact point, while false stable positions can be avoided using four redundant contact points. The templates can be used to guide the drill, the insertion of Kirschner in case oth use of cannulated screws or to guide directly the screw. After these prelimiary ex-vivo animal tests we obtained the authorization of the Italian Health Ministry to start the human study. The preliminary results of this study will be presented during the conference., Introduction: Surgical management of the cervical kyphosis is rarely described in the literature. Herein we will describe our surgical strategy in correction of the cervical kyphotic deformity in 22 cases which were caused by a various etiologies. Other aims are to report the possibility of complications and to demonstrate our technique of multilevel cervical osteotomy which is necessary for optimal lordotic neck. Osteotomy also might be helpful in prevention of segmental roots complications. Material and Methods: 22 patients including 12male and 10 females are presented. with consideration of surgical management, combined 360 degree anterior posterior or 540 degree surgery were done in 20. In 6 cases posterior cervical osteotomy was done. Results: 22 patients including 12male and 10 females are presented. with consideration of surgical management, combined 360 degree anterior posterior or 540 degree surgery were done in 20. In 6 cases posterior cervical osteotomy was done. Conclusion: Management of the cervical spine kyphosis in particular severe ones pose a challenge to the surgeon. This means that precise preoperative decision making is necessary for correction of this deformity. Segmental root injuries which are due to severe foraminal stenosis and traction of the subaxial cervical roots remain the most frequent postoperative complication of excessive correction of the cervical kyphosis. However, multilevel cervical osteotomy described above might prevent this kind of complication. Furthermore, although, one stage surgery was done in majority of the cases and severe neurological deficit which was observed in only one case, result in that we believe two stage surgery might permit the spinal cord and the corresponding roots to accommodate with new curvature with time., Introduction: ALIF procedures through an anterior, retroperitoneal approach are a common and safe way in degenerative spine surgery for reconstructing the anterior column. Nevertheless, the approach itself, the cage design and the instruments for implantation make the procedure sometime risky with extended radiation exposure and longer surgery time with the risk of higher blood loss. We conducted a study to evaluate a novel titanium cage for anterior lumbar surgery with improved instruments for implantation. Material and Methods: The study included 182 patients in the last 19 months (Jan 2015 to July 2016) who underwent 360 degree spinal single- and two-level fusion because of lumbar spinal stenosis or spondylolisthesis. We evaluated surgery duration of the posterior and anterior approaches. Blood loss and X-Ray exposure time was assessed. Patient data was compared between single- and two-level procedures and between one-time and two-time surgeries. Results: Due to the improved design of the cage and its instruments, Surgery duration could be optimized to a mean of 42 minutes in single-level ALIF procedures. Blood loss was diminished down to 46 ml and radiation time was decreased to a minimum amount of time. Conclusion: The cage design and its corresponding instruments can optimize the surgical procedure in degenerative lumbal spinal fusion when performing ALIF procedures. The cage design and the instruments used have great impact on surgical time, blood loss and even on radiation exposure., Introduction: The purpose of this study was to assess prospectively the operative results and complications of treatment of cervical spinal canal stenosis (CCS) by anterior cervical discectomy and fusion (ACDF) using a newly-introduced Modular Cage-Plate Construct (AMCPC). Material and Methods: Fifteen patients (eight males and seven females) with symptomatic CCS were treated by ACDF, with a mean age of 51.2 years. Four patients had cervical myelopathy and eleven had radiculopathy. The fixation technique was AMCPC with fusion by local autogenous bone graft. Total number of operated levels was 25 levels, with a mean 1.67 levels/patient. Postoperative assessment depended upon clinical and radiological results. Results: Mean operative time was 69.6 minutes/level and 116 minutes/patient. Average blood loss was 78 mL/level and 130 mL/patient. Mean hospital stay was 2.8 days. Postoperative dysphagia/dysphonia persisted in one patient for one year. All wounds healed per premium. One patient developed C5-radiculopathy with grade-2 deltoid weakness that recovered after three months. According to Odom’s criteria, overall results were excellent in thirteen patients (86.67%), good in one (6.67%) and fair in one patient. In thirteen patients (23 cage-plates, 92%) the implant was shown to be completely contained until the end of follow-up (24 months). One patient had a broken screw and one had screw backing-out, both did not necessitate revision. The achieved sagittal profile was maintained without sinking-in of any cage. Conclusion: AMCPC can be used safely for a variety of disorders requiring instrumentation and fusion. It is advantageous to stand-alone cage and to rigid cage- plates when intra-operative flexibility is needed. It overcomes the disadvantages of stand-alone cage; sinking-in, cage-dislodgement and postoperative rekyphosis. In addition, it obviates the need for wearing postoperative neck collar., Introduction: Lumbar fusion in degenerative conditions has universally provided good results. However, adjacent segment degeneration, either a fresh or worsening of low grade degeneration in the segment above has been indicated for the pain and low functional outcome on long term follow-ups. Pedicle screw based dynamic stabilization devices optimize load sharing and ensure transitional stabilization. We analyze the use of Transition (Globus medical) to decelerate the physiologic process and reduce the incidence of Adjacent Segment Degeneration (ASD). Materials and Methods: 12 patients (5 female, 7 male; mean age: 53 years, range: 34 – 67 years) who underwent posterior lumbar instrumentation with the transition as semi-rigid, hybrid dynamic stabilization and fusion system were analyzed in the study. The inclusion criteria for the study was degeneration of the disc above the level of intended fusion with no or less than 50% disc height reduction and no nerve root compression. Patients with more than 50% height reduction or severe arthritic facet joints underwent fusion at two levels and were excluded from the study. Patients with failed back syndrome and significant osteoporosis were also excluded from the study. Clinical and radiographic criteria for ASD were assessed at the latest follow-up. Visual analogue score (VAS) and Oswestry Disability Index (ODI) functional outcomes were analyzed. Results: 12 patients, mean age 53 years, mean follow-up of 36 months (12-72months). Transition was used above single level TLIF in 10 cases and two levels TLIF in 2 cases. Transition device was implanted at L3-4 in 8 cases and L4-5 in 4 cases. All 12 patients had a good fusion on follow-up x-rays. Disc height improvement was seen in the level above, with no evidence of stenosis or listhesis at the latest follow-up. Worsening of already existent ASD in one patient was noticed but did not require surgical intervention. VAS and ODI showed significant (P < .05) improvement postoperatively. No infection or reoperation was needed in any of the patients. Conclusions: ASD remains a significant reason causing failed back syndrome requiring reoperations in lumbar fusion. Transition allows a more robust fixation with better restoration of lordosis. Implantation of a motion preserving dynamic stabilization device immediately adjacent to a fused level instead of extending a rigid construct may reduce the subsequent development of adjacent-segment disease. Further studies with larger sample size and long term follow-up are necessary to support the conclusion., Introduction: Total body replacement systems are widespread and mainly made from titanium. Initially established as fixed titanium mesh-cages nowadays often designed as expandable anterior body replacements. Recently cages fully made from PEEK or carbon became more and more popular especially for anterior column reconstruction in tumor surgery. They are mostly crafted as monobody cages without expandable options. This study was set up to evaluate the applicability, efficacy and safety of a new expandable PEEK cage as vertebral body replacement. Material and Methods: 52 consecutively implanted PEEK-XRL-Vertebral-Body-Replacement Devices (Depuy/Synthes) for anterior column reconstruction in thoracolumbar trauma and tumor cases were retrospectively analyzed. The modular implant consists of a central body which can be filled with bone graft on which two endplates are attached. All parts can be customized (sizes and angulation of body and endplates) to the individual intraoperative situation. Clinical and radiological follow up were performed 2, 6 and 12 months post operatively. After 12 months a CT scan was performed in most cases to evaluate osseous consolidation. Standing- x-rays were performed at every follow-up. Bi-segmental kyphosis angle and cage height were measured. Descriptive analyses have been executed. Results: Since 2013 52 XRL-Cages have been implanted (31 male/21 females, mean age 45.9 years); 42 cases due to trauma (15 paraplegic), ten cages due to spinal metastatic diseases. 16 procedures have been performed as single, 36 in a two stages procedure; one mono-segmental, 38 bi-segmental and three three-segmental ventral fusions. All cages in trauma cases were filled with autologous bone. There were no intraoperative and 4 perioperative complications: two hematomas and one wound breakdown needed revision surgery, in one patient transient hyposensitivity at the thigh occurred. One patient died ten days post-operatively due to his underlying tumor disease. 39 patients could be followed up for a mean of 0.7 (min 0.1; max 2.5) years. The radiologic analysis showed two cases of implant malpositioning and four cases of early subsidence which were all secondary stable. In one patient a posterior implant failure with breakage of a pedicle screw, secondary cranial and caudal subsidence of the cage and incomplete osseous consolidation was found two years post-operatively. No revision surgery was required in all cases. No collapse or malfunction of the modular expansion system was documented. A mean loss of two degrees bi-segmental lordotic correction angle was documented from early (mean 0.05 years) to latest post-operative imaging (mean 0.7 years). 23 patients received a CT-scan at mean 0.9 years post-operatively. 18 showed continuous, 5 showed incomplete osseous consolidation with stable implants. Conclusion: The modular, expandable XRL-PEEK-Cage showed promising preliminary clinical and radiological results in 39 cases with a mean follow up of 0.7 years. No implant related complication or collapse of the cage itself could be seen. Therefore, the implant seems to be save for anterior vertebral body reconstruction in trauma and tumor patients. Further extensive long term data need to be evaluated., Introduction: Lumbosacral fusions (LSF) are frequent operations. Due to highly mobile segments L4-S1, meeting a rigide sacro-pelvic complex, LSF’s underly special biomechanical challenges. Revision rates up to 20% are reported. Increased risk of construct loosening and pseudarthrosis has lead to increased numbers of extended lumbosacral (S1-pedicle screw / S2-ala-screw) and lumbopelvic instrumentations. Lumbopelvic instrumentations have potential for complications and are in instabile situations not always mandatory. Significant enhancement using a S1 pedicle ala screw (S1-PAS) was demonstrated in biomechanical studies. In the present work we demonstrate the first clinical experiences using the new S1-PAS. Material and Methods: 35 patients with indication to augment lumbosacral instrumentation (spondylolisthesis, osteoporosis, lumbosacral revisions and pseudarthrosis, lumbosacral scoliosis) were treated during a period of 12 months, using a polyaxial screw-rod system and the S1-PAS. The S1-PAS is a dual, fixed-angle lockable pedicle-screw-system. The ala screw may be divergently placed next to the S1-screw or with a starting position medial to the S1-screw also divergently (crossing position). The min. follow-up was 6 weeks, for fusion assesment 6 months were necessary. The technical data and intraoperative handling criteria were recorded prospectively. Clinical, surgical and demographic data were retrospektiv analyzed, as well as significant complications or adverse events. Results: 35 patients were treated in a 1 year span. No intraoperative complications or implant associated „adverse events”. Mea nage 54 years, (19 m, 16f). S1 - screw - calibre 7.0 mm, S1-ala-screw 6.0 mm. Bicortical purchase was planned. IN average 2,9 segments were treated.(range 1-9segments). 1 pat. With unilat.fixation of S2-AI screw. Pedicle screw length in S1 45 mm in average.(min. 35 mm, max. 50 mm), Ala-screw 41 mm in average(min. 30, max. 50). Revisions were needed in 3 patients. 2 times in psuedarthrosis of the prox. Endsegment., once L5/S1 in a case of multisegmental fusion ≥5. 5 pat. Were lost to follow-up>3months. Fusion rate was 90%. 17 pat. with use of crossing position. No clinical or radiological irritation oft he SI joint by the ala-screw postoperatively. Conclusion: The use of the S1-PAS allows for a biomech., augmented lumbosacral fusion avoiding sacro-iliac fixation. The S1-PAS allows for less soft tissue mobilisation compared to instrumentation with S1-PS and S2-Ala-screw, better anchorage as well as faster screw placement. S1-PAS could be placed safely in every patient independent of local anatomy or deformity. The clinical results complement earlier biomechanical data and demonstrate that the S1-PAS is a reasonable extension for instrumentation options in LSF with special biomech. demands. Multisegmental fusions, especially in pat. with sagittal imbalance, are the mechanical limits for a reasonable use oft he S1-PAS. Ideal indications for LSF are patients with spondylolisthesis, lumbosacral pseudarthrosis with short instrumentation., Introduction: Biomaterials are widely used in prosthetic and drug delivery devices. Nanomembranes produced by electrospinning technique mimic the nanoscale properties of the native extracellular matrix and provide highly porous and interconnecting fibers with a high surface area-to-volume ratio. Polyamide-6 (PA6) is a synthetic and biocompatible polymeric material that has good mechanical and physical features. The maleinized soybean oil (SOMA) is a source of essential fatty acids and tocopherols, related to antioxidant and anti-inflammatory properties. The incorporation of SOMA to PA6 chains imparts toughness to the polymer, which is important to support handling and cellular morphogenesis. This study focused on preparation and characterization of polyamide-6 melt that reacted with SOMA to create a biofunctional and bioactive scaffold for disc pathology therapy. Methods: The nanomembranes were produced from solutions of commercial PA6 and PA6/SOMA 95/5 in 85% v/v formic acid. The systems were electrospun at a feeding rate of 0.1 ml/h, using a syringe-collector distance of 15 cm and an applied voltage of about 25 kV. The morphological and microstructural properties of the obtained nanomembranes were investigated by field-emission scanning electron microscope (FEG-SEM) and wide-angle X-ray diffraction (WAXD), respectively. The electrospun nanofibers were also tested for their ability to incorporate growth factors. Results: FEG- SEM micrographs revealed that defect-free nanofibers with uniform morphology could be obtained from 32% wt polymer solutions. Commercial PA6 and PA6/SOMA 95/5 nanofibers exhibited average diameters of 0.78 ± 0.22 μm and 141 ± 6 nm, respectively. The high surface area combined with microporous structure of nanofibers favors metabolic exchange and other biofunctional properties. The crystalline structures (α and γ forms) of PA6/SOMA 95/5 and their transitions in electrospun nanofibers are being thoroughly investigated. The samples were resistant to the sterilization process (120 mmHg/45 min) and free from organic solvent residue. The nanomembranes successfully loaded and preserved the chosen bioactive growth factor, thus being able to act additionally as a drug delivery device for clinical applications. Conclusion: Many significant recent advances in biomaterials occurred at the interface of clinical medicine and materials science and engineering. The nanofibrillar materials developed in this work may represent a promising tool in regenerative medicine, including disc pathology. Since PA6 is an FDA-approved polymer, these nanomaterials emerge as suitable bioactive scaffolds for medical applications. Further investigation is required to evaluate the efficacy of the repair using these electrospun filaments and to determine the real benefit to patient., Introduction: The aim of this study was to predict the prognosis of osteoporotic vertebral body fractures by using the finite element method. Some osteoporotic vertebral body fractures are crushed after a few weeks, others keep these forms. In this study, by using the finite element method, we evaluated the breaking forth (N) of the fractured osteoporotic vertebras at the initial CT scans and determined the critical point of the breaking forth (N) which would predict crushed vertebras. Material and Methods: We conducted a retrospective study of the fresh osteoporotic vertebral fractures at our institution. We evaluated the clinical features, radiological changes, and biomechanical effects in patients who had fresh osteoporotic vertebral body fractures. A three-dimensional finite element method was used to biomechanically analyze the strength of the osteoporotic vertebral fractures. Results: Between Apr. 2015 and Sep.2016, 196 (male 55, female 141) fresh osteoporotic vertebral fractured patients took a check-up at our outpatient department. The average age was 78.9±0.6 years old (54-99 years old). The average bone mineral density was 53.3 ± 0.5 (YAM). 24% of all the patients showed crushed vertebras after a few weeks. 130 patients were underwent CT scan during an early stage. However, only 37 patients were able to be evaluated the breaking forth (N) by finite element method. 21 of these 37 patients’ vertebras resulted in crush vertebra after a few weeks. The finite element method revealed he critical point of .the breaking forth (N) which predict crushed vertebras. Conclusion: These results demonstrate that the usefulness of finite element method to the prognosis of osteoporotic vertebral body fractures. The finite element method analysis may detect the surgical indication of osteoporotic vertebral fractures by predicting crushed vertebras., Introduction: Simulators have become a standard in medicine when it comes to training and assessment of medical skills. Especially in surgery, simulators are increasingly available for a wide spectrum of procedures to increase patient safety and to offer enhanced training opportunities (Michael, Abboudi, Ker, Khan, Dasgupta and Ahmed, 2014). Increasingly, surgical simulation systems feature virtual-, mixed- or augmented-reality (VR/MR/AR) as their core technology. Such simulators offer realistic setups and a real time metric-based performance feedback for surgical trainees.Although spine care procedures have undergone major technological and procedural advancements, the current evidence base concerning the application and effectiveness of VR/MR/AR-based simulators is inconsistent. Moreover, only 11% of neurosurgery residency program directors reported to use spine simulators as an educational tool in a recent survey (Kshettry, Mullin, Schlenk, Recinos and Benzel, 2014). We therefore set out a systematic review to identify the current state of VR/MR/AR simulator applications for training and assessment in spine care procedures. Moreover, we sought to review the evidence base on VR/MR/AR based simulator use with particular comparison to traditional training approaches in spine care. Materials and Methods: We conducted a systematic review searching five literature databases (“PubMed”, “PsycINFO”,” “EMBASE”, “CENTRAL” and “MetaRegister of Current Controlled Trials”) for peer-reviewed literature between 2005 and 2016 about VR/MR/AR Simulators used for spine care. Two researchers reviewed titles, abstracts and full texts according to our inclusion and exclusion criteria. Reliability was checked in terms of inter-rater agreement. Discordances were discussed and solved with a third reviewer. Additionally a quality appraisal of the included articles was conducted using the Medical Education Research Study Quality Instrument Tool (MERSQI). Results: Initially, after title and abstract screening, 63 articles underwent full-text review. Finally, 19 relevant articles matched eligibility criteria and all contents and data were systematically synthesized. The majority of reports on VR based simulators in spine care aimed to establish a training curriculum and to evaluate the simulator. The most simulated medical procedure (7 times) was Pedicle Screw Placement/Insertion followed by (Percutaneous) Vertebroplasty (4 times).The most used outcomes were performance related with particular interest to technical skills, eg, precision metrics. Results of the identified articles were very heterogeneous: 8 articles showed that the simulator trained group(s) outperformed the non-simulator trained group and 8 articles showed the effectiveness of training on a simulator by using before and after training comparisons. 6 articles focused on validity of the simulator. MERSQI ratings (highest possible score = 18) ranged from 7.0 to 13.5 with a mean of 11.47 (Standard deviation = 1.81). Conclusion: This Systematic Review was the first to summarize the current literature base on the use of VR/MR/AR-based simulators in spine care. Because the results of the studies were too heterogeneous a meta-analysis was not possible. Limitations are being discussed. As simulation is becoming increasingly important in spine care, our review finally suggests future areas of research and development for VR based simulators in spine care., Introduction: Spine surgery for spine tumors and complex reconstruction can predispose to extensive intraoperative bleeding. Extensive bleeding requires intraoperative transfusion of not just packed-red-blood-cells (PRBCs) for hemoglobin replacement, but also platelets and coagulation factors imperative for clot formation. Decisions about how much platelet transfusion or coagulation factor replacement needs to occur can be delayed by standard laboratory tests. Thromboelastography (TEG) provides information about platelet function, clot strength, and fibrinolysis which PT/INR/aPTT do not provide. In addition, testing can be performed as rapid point-of- care assays intraoperatively for fast decision-making and correction of coagulopathy with further transfusions if necessary. Materials and Methods: Two patients underwent complex long segment spinal procedures, with greater than 2000 cc estimated blood loss (EBL). A 73 year-old with a previously metastatic myoepithelial carcinoma to T8 underwent radiation and decompression and T6-T10 instrumented fusion. He subsequently presented with local tumor recurrence, and was found to have extension of the tumor into the adjacent levels, tumor in the surround soft tissues, with hardware failure and kyphotic deformity. He was intact on exam, and underwent surgery with tumor resection and replacement and extension of hardware given. A vascular tumor was encountered and the patient experienced greater than 2500 cc of EBL. The second patient was a 64 year-old man with a previous discitis/osteomyelitis who presented with complex deformity and kyphosis and underwent a two level thoracolumbar corpectomy and a nine level instrumented fusion, with greater than 2500 cc of EBL. They both underwent intraoperative transfusion with packed red blood cells (PRBCs), platelets, and fresh frozen plasma (FFP). Subsequently, a rapid TEG test was performed intraoperatively to determine need for further transfusion. Results: The patient sunderwent intraoperative transfusion with PRBCs, platelets, and FFP. To determine if continued coagulopathy was present and to decide if further transfusion was necessary, a rapid intraoperative TEG test was performed, which showed good clot integrity and formation, directing expectant need for further platelet/FFP transfusion. Conclusions: Rapid thromboelastography testing provides information that can assist in determining whether a continued coagulopathy is present. Results can guide operative actions, such as administration of further blood products for coagulopathy., Introduction: The internet is the tool usually employed for regular health research) research by patients. However, online available texts remain unregulated and lack proper evaluation of information. The poor quality of the texts on spinal disorders available in Portuguese impairs the medical-patient relationship. The objective is to verify the quality and the validity of internet information in spinal pathologies, in Portuguese. As a proposal, hybrid software for automatic text analysis, based on Artificial Intelligence techniques, is under development. Materials and Methods: Research was performed on most frequently used search engines – Google, Yahoo and Bing – using the terms “cirurgia de coluna” (spinal surgery), “tumor de coluna” (spine tumor), and “hérnia de disco” (disc herniation), and the first 30 results of each research mechanism were evaluated. Duplicated or nonfunctional pages, videos, home-pages without a main text, photos, Google Maps pages, social media, news, shopping sites and game sites were excluded. The DISCERN Instrument was used to evaluate the quality of information provided by one reviewer. The questions are divided into 3 sections and scored on a 5-point Likert scale. Thus the maximum score was 80 and the minimum score was 15 (if question 2 did not apply after a negative answer to question 1). The results were displayed as median (for the DISCERN score), relative and absolute frequencies. Jama Benchmark Criteria was used to evaluate the validity of the text, also by one reviewer. Results: Sixty-eight websites were analyzed. The overall rating score given for question 16 of the DISCERN instrument was not always faithfully represented by the summative score for all items. However, by using the DISCERN Instrument, no text achieved a score of more than 61 out of 80 (76.25%). Besides the median score was 39.5 out of 80, representing the poor quality of most Portuguese web sites. Through Jama Benchmark Criteria it was observed that none of the articles had the 4 points and that most of them lacked the references and conflict of interest disclosure. Conclusion: The websites regarding spinal diseases in Portuguese have poor quality data, resulting in erroneous information to the patients and compromising the treatment or the patient choice. Also, important features to consider the text reliable are lacking, such as exposing conflicts of interest and references. Regarding future perspectives, it is expected to meet this through the development of a software that employs quantitative and qualitative techniques to assess patients who use the Internet as a source of information., Introduction: Graft technique in anterior cervical discectomy and fusion surgery has evolved over the period of time. Donor site morbidity of autologous bone graft harvested from the iliac crest and poor or lack of osteogenic and osteoinductive property with high cost of allograft and other synthetic bone substitute techniques are well documented. Traditional techniques have complications such as graft subsidence, implant loosening, dysphasia and prolonged hospital stay. Cervical low profile integrated screws-spacer device with bone marrow aspirate and local bone debris as a graft offer a minimally invasive, less disruptive, cost effective and earlier recovery option. Materials & Methods: We analysed prospectively collected data of 48 patients with cervical myelopathy and/or radiculopathy. Coalition is a low profile integrated screws-spacer device designed to provide the biomechanical strength of a traditional anterior cervical discectomy and fusion. The procedure is streamlined by low profile instrumentation which facilitates a less invasive approach through a smaller incision. Bone marrow aspirate from sternum mixed with gelfoam and local bone debris taken out while doing decompression were used as graft. 33 patients were operated with one level, 12 with two level & 3 with three level anterior cervical discectomy and fusion. All patients were followed up for a minimum period of one year. X-ray and CT scan were done in all the patients after 1 year to see the fusion. Patients were evaluated for fusion, implant failure, neck disability index, visual analogue score for arm & neck, mJOA score, and dysphasia index. Results: 44 patients were evaluated as 4 patients were lost in follow up. Mean age of 46 years, 28 male & 16 females. X-rays and CT demonstrated good fusion 91 and 94% respectively. Compared to preoperative scores, visual analogue scale pain score and Neck Pain Disability Index reduced significantly (P < .01). Statistically significant improvement in mJOA score was observed (P < .05). Two patients complained of moderate and one of mild transient dysphasia. No device-related complications occurred and no fractures. Conclusions: Bone marrow aspirate with local bone debris as a graft provide a less morbid alternative to conventional techniques and achieve good fusion. Usage along with low profile cervical implants allows effective decompression, fusion and early recovery., Introduction: Anterior cervical discectomy and fusion (ACDF) was first introduced in the 1950s, and has become one of the most common surgical procedures for cervical radiculopathy and myelopathy recalcitrant to conservative management. The procedure involves structural graft placement in the interbody space. A number of structural graft options have become available. Two of the most common graft options used are allograft and synthetic cages. This study aims to compare the complication rates between these two structural graft options. Material and Methods: Orthopaedic subset within the PearlDiver database was queried for patients undergoing ACDF using structural allograft or synthetic cage between 2007 and 2014 using ICD-9 and CPT codes. The initial cohort was stratified by type of grafting material, number of fused levels, and presence of corpectomy. Data outputs included number of ACDF procedures per year, patient age at the time of surgery, patient gender, geographical regions within the United States, surgical setting and total procedural costs. Complications were detected via ICD-9 coding. For statistical analysis, the chi-squared test was used to calculate statistical significance of the difference in complication rates. Results: A total of 11,308 ACDF procedures in the dataset used a synthetic cage, and 7,835 procedures used structural allograft. Overall complication rates were 8.71% for synthetic cage versus 7.76% for structural allograft, P < .01. Dysphagia was more commonly noted in the structural allograft cohort, 0.64% versus 0.33% (P < .01). Respiratory complications occurred more frequently with cages, 0.57% versus 0.31% (P = .03). Both cohorts had a similar revision rate within 2 years (0.56% versus 0.50%, P = .23). Conclusion: A total of 11,308 ACDF procedures in the dataset used a synthetic cage, and 7,835 procedures used structural allograft. Overall complication rates were 8.71% for synthetic cage versus 7.76% for structural allograft, P < .01. Dysphagia was more commonly noted in the structural allograft cohort, 0.64% versus 0.33% (P < .01). Respiratory complications occurred more frequently with cages, 0.57% versus 0.31% (P = .03). Both cohorts had a similar revision rate within 2 years (0.56% versus 0.50%, P = .23)., Introduction: Current treatment of VCF type A1.1 and sometimes A1.2 in young patients can apply two approaches: conservative and invasive treatment with brace or arthrodesis with PSF, both with high social costs and decreasing of patients quality of life. At the same time surgical options can be considered irreversible. Kyphoplasty and vertebroplasty allow percutaneous approach to treat this type of fractures in elderly patients, but there are really poor indications of using PMMA in young people. Materials and Methods: Velox(a phase-pure, micro-crystalline, calcium-deficient and micro-porous hydroxyapatite) is the latest generation of biomaterial that improves and solves two primary issues: burning of bone tissue regeneration and immediate mechanical strength properties. Approaching this way, mechanical properties of Velox allow the primary goal of a good and definitive final result and patient’s immediate recovery. Treatment provides posterior mono or bilateral approach with needles and, or without balloons, as known. It is also possible to verify Velox injection step by step because of his radiopacity. Results: Five patients have been treated with Velox, three with A1.1 and two with A1.2 vertebral compression fracture. Mean age was fortytwo years. Recovery was performed in one day(twentyfour hours) and a three months follow-up CT scan showed an almost complete rehabitation of the biomaterial. Conclusions: This biomaterial(Velox), despite to a few preliminary procedures and a short term follow-up, could be a real effective solution in the treatment of VCF A1.1 and A1.2 type, filling critical size bone defects and solving problems like long period immobilization with brace and avoiding open surgery., Introduction: Spine surgeons are embracing advanced biologic technologies in an attempt to help millions of people achieve a better outcome in spine surgery and cell-based therapies seem to offer a promising approach. Due to their properties and characteristics human mesenchymal stem cells (MSCs) appear to have great therapeutic potential. Many different populations of MSCs have been described and to understand whether they have equivalent biological properties is a critical issue for their therapeutic application. Material and Methods: Human vertebral bone marrow was harvested from vertebral pedicles during spinal surgical procedures involving posterolateral arthrodesis. Vertebral bone marrow in toto and expanded human vertebral bone marrow cells, cultured under normoxic and hypoxic conditions, were analyzed to evaluate multidifferentiation potential, cellular proliferation and gene expression for markers of osteoblast differentiation and homeobox genes of HOX and TALE subfamilies. Results: Under hypoxic condition in toto human vertebral bone marrow can be maintained in culture for a greater number of steps with respect to concentrated vMSCs and it also generates mature cells of all mesenchymal lineages with greater efficiency, when induced into osteogenic, adipogenic and chondrogenic differentiation. In addition, analyses of homeobox genes of HOX and TALE subfamilies showed that in toto human vertebral bone marrow cultured under hypoxic condition displayed distinct and specific levels of expression for HOX and TALE signatures. Conclusion: The in vitro ability and capability of in toto human vertebral bone marrow cultured under hypoxic condition is very interesting at the light of a clinical application for bone fusion in spine surgery., Introduction: Reliable information about nutritional status before spine surgery is needed to optimize postoperative outcomes, especially regarding vitamin D and albumin serum levels. The aim of this study was to investigate the relationship between vitamin D and albumin serum levels in patients undergoing spine surgery and their quality of life after the procedure. Material and Methods: For this, patients undergoing spinal surgery in the thoracic and lumbar levels were evaluated. All surgeries were performed at a same referral hospital. One day before the surgery, the subjects had serum albumin and vitamin D concentrations evaluated. One year after surgery, we evaluated their quality of life through the Oswestry and SR-22 questionnaires (validated versions for the Brazilian language). The occurrence of infection and time of wound healing were also collected. Preoperative nutritional values and quality of life of patients were analyzed using the chi-square test. The relationship between nutritional status and the occurrence of infection and the healing time were evaluated by Pearson correlation coefficient. Results: 46 patients were included, 17 men (37%) and 29 women (63%). The most frequent disease was degenerative (58.7%), followed by deformity (19.6%), infection (8.7%), fracture (8.7%) and tumour (4.4%). The average nutritional values were 19,1ng/mL (standard deviation 6.6) for vitamin D and 3.9g/dL (standard deviation 0.6) for albumin. There was no association between vitamin D and quality of life of patients measured by Owestry (P = .77) and the SR-22 (P = .55) questionnaires. It was also not observed association between quality of life and albumin when measured by Owestry questionnaire (P = .35), but there was association when measured by SR-22 (P = .03). The average healing time was 18 days (standard deviation 14) and there was infection in 19% of surgeries performed. No correlation was found between these variables and nutritional values. Conclusion: In conclusion, there was no association between vitamin D and albumin and the quality of life of patients when measured by the Owestry questionnaire, as well as the healing time and the occurrence of infection. Moreover, preoperative albumin was associated with quality of life measured by the SR-22 questionnaire., Introduction: Low back pain is an increasing global health problem, which is associated with intervertebral disc (IVD) degeneration. The current treatment strategy is surgical intervention, like discectomy followed by spinal fusion. After discectomy the empty space is filled with bone substitute or an autograft and the symptomatic segment undergoes an intersomatic or posterior fusion with pedicle screw or plate based stabilisation. However, clinical observations showed that partial IVD tissue removal after discectomy leads to an insufficient subsequent spinal ossification. Recently it was shown, that human IVD cells co-cultured with human mesenchymal stem cells (MSC) prevented bone formation (1). Antagonists of the bone morphogenic proteins (BMP) such as gremlin (GREM1), noggin (NOG) and chordin (CHRD) were identified as possible factors inhibiting osteogenesis of osteoprogenitor cells (2,3). The endogenous expression of these antagonists within the IVD remains, however, unknown. Hence the aim of this study was the investigation of the secretion of BMP antagonists in IVD cells, as the nucleus pulposus cells (NPC) and the annulus fibrosus cells (AFC). Material and Methods: IVD cells (NPC and AFC) were isolated from patients undergoing spinal surgery with ethically approved protocol. NPC and AFC (P1) (N = 5) were encapsulated in 1.2% alginate beads (4 millions/ml) and cultured in proliferation medium (LG-DMEM + 10% FCS, six beads per 2 mL). After four days the conditioned medium was collected and analysed for secretion of BMP antagonists by ELISA, using human GREM1, NOG and CHRD detection kits (Clone Cloud-Clone corp., cat. # SEC128Hu, SEC130Mi and SEC126Hu). Further, CHRD, NOG and GREM1 were visualised in NPC and AFC by immunocytochemistry. Results: The secretion of BMP antagonists in the conditioned medium were detected with levels between 0.30 ± 0.17 ng/0.5 M IVD cells and 2.10 ± 0.52 ng/0.5 M IVD cells (expression presented as mean ± SD). Whereas GREM1 showed a significant difference between expression in NPC (2.11 ± 0.53) to AFC (0.86 ± 0.35) (P = .0022). Expression of NOG, GREM1 and CHRD in NPC and in AFC could also be confirmed on protein level by immunocytochemistry. CHRD was nuclear localised in the cells. Conclusion: Within the study we could confirm expression of the BMP antagonists within the IVD cells. This might be a main reason of incomplete spinal fusion and cage failure in patients after incomplete IVD removal. BMP antagonists like GREM1, NOG and CHRD could be detected in NPC and AFC on the transcript and protein levels. However, secretome analysis to confirm BMP antagonist secretion needs to be performed. Furthermore, it is still unknown, if the third IVD cell type, cartilaginous endplate cells (CEPC), also plays a role in spinal non-union. References 19. Chan SCW, Tekari A, Benneker LM, Heini PF and Gantenbein B (2015). Arthritis Res Ther 18, no. 1 20. Canalis E, Economides AN and Gazzerro E (2003). Endocr Rev 24, no. 2 21. Stafford DA, Brunet LJ, Khokha MK, Economides AN and Harland RM (2011). Development 138, no. 5 Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Lindenhof Foundation “Forschung und Lehre” (#15-05) and by direct funds from Hansjörg Wyss and Hansjörg Wyss Medical, US. We thank Eva Roth for laboratory assistance., Introduction: Osteoporosis is a systemic disease affecting postmenopausal women mostly resulting in an increased fracture risk. In women aged, Introduction: Tuberculosis is the leading cause of death in third world countries, from a single infectious disease. It paralyses the society when it affects the spine because of its resultant neurological deficit in the form of quadriplegia, paraplegia, loss of bladder and bowel control, bed sores, and continuous financial burden on family and whole society. Early spinal decompression and stabilization with standalone cage have dramatic results in terms of improvement in neurology, relief of pain, and correction of deformity. The objective of the study is to determine outcome of anterior decompression and stabilization with locally made standalone cage and bone graft in caries spine in terms of improvement of neurology, relief of pain, and improvement of kyphotic angle. Material and Methods: It is a prospective case series study including 1049 cases who were treated at GTTH from 2003 to 2016. After taking history, examination and investigations as well as proper consent, all patients were treated with anterior decompression and then stabilization was achieved with bone graft and standalone locally made cage. After surgery, patients were followed at 6 weeks, 3 months, 6 months, and upt0 august 2016 to assess neurology, relief of pain, and kyphotic angle.The data was initially entered on pre formed questionnaire and then analyzed on SPSS 17.0. Results: The majority of the patients belong from poor or middle class family and the male were dominant.Back pain was the chief complaint in almost half of the patients.The major cause of the delayed presentation was management of such patients in periphery .There was no association between the previous history of tuberculosis and caries spine.Neurology improved in 92% of patients, pain relieved in 95% of cases, and there was mean correction of 18 degrees in kyphotic angle at the end of 1-year follow-up and the patients who were followed for 3 years, there is no significant change in kyphotic angle after it. Conclusion: Early diagnosis and early intervention give excellent results. After anterior decompression, stabilization with cage and bone graft results in significant improvement of neurology, relief of pain, and correction of kyphotic deformity. There is no need for added instrumentation., Introduction: Demonstrate and identify bone fusion method which conforms to “traditional posterolateral” approach and shows superior fusion outcome. Material and Methods: Single surgeon Prospective application and use of Bone Marrow Aspiration (BMA) combined with use of allograft demineralized bone fibers with/without local harvest autograft in posterior/posterolateral spinal fusion with instrumentation in lumbar/lumbosacral, thoracic/thoracolumbar and cervical spinal fusion. Dates of Inclusion: March 2014-June 2016 Technique: Variable – posterior/posterolateral +/- combined with anterior or PLIF/TLIF, Total Cases/Analyzed: 119/78 (Exclusion for this analysis was use of BMP or TLIF/PLIF or DLIF without posterolateral fusion adjunct. Results: ∼2% Incomplete/Non fusion, no requirement/need of revision of fusion at this time, Long segment fusion show “halo effect” around instrumentation at “ends” of fusion – improves with time. Conclusion: ∼2% fusion failure with no revision, Halo effect around instrumentation not related to success of fusion, Fiber volume used is related to density of fusion mass, Autograft volume related to early greater density of fusion mass, “Woven Configuration” of fiber graft appears to be related to success of fusion, Fiber Graft: BMA::1.5:1 optimal ratio, no carrier, 100% viable cells, no less than 20 cc but preferable 30 cc allograft fiber per level of fusion, institutional saving of ∼15-20% compared to fusion with additional growth proteins, Noncontroversial., Introduction: The rates of pulmonary embolism (PE) and deep vein thrombosis (DVT) in paediatric scoliosis patients have been estimated at 0.04% and 0.01% respectively. Following 2 cases of life-threatening perioperative venous thrombosis in children with spastic quadriplegia undergoing major spinal deformity surgery we reviewed our unit’s policy of venous thromboembolism (VTE) risk management.To assess whether our current policies differ from those of colleagues around the country we carried out a survey of U.K. spinal surgeons currently performing paediatric scoliosis correction. Material and Methods: Twenty-eight consultant respondents were questioned regarding their experience of PE and related deaths following idiopathic and neuromuscular/syndromic scoliosis surgery. Attitudes towards VTE risk management and thromboprophylaxis were explored. Results: Only 2 consultants have experienced a PE in their patients. One followed surgery for a neuromuscular scoliosis and one for an idiopathic scoliosis. One respondent had experienced a death related to VTE. The routine screening of ambulant and non-ambulant scoliosis patients takes place in 11% of units. Thirty-seven percent of respondents consider VTE to be a problem in scoliosis surgery. Eighteen percent of respondents routinely prescribe chemical thromboprophylaxis for adolescent idiopathic scoliosis patients and 25% for neuromuscular/syndromic patients. The remainder rely upon mechanical thromboprophylactic methods. Conclusion: Thromboembolic events are rare in children undergoing scoliosis surgery. Our recent experiences raise questions about how we can improve pre-operative, intra-operative and post-operative care for these patients to reduce the risk of further life-threatening VTE. The majority of those questioned do not view VTE as a problem in paediatric scoliosis surgery and do not routinely screen for VTE or prescribe chemical thromboprophylaxis. Discussions with radiology and haematology experts regarding preoperative detection of DVT or PE have unfortunately brought us no nearer to suitably sensitive and specific tests. We must therefore focus efforts on ensuring adequate intravascular filling and using mechanical VTE prophylaxis intra and post-operatively. We propose that all future VTE complications in this population be recorded on the British Spine Registry so that future research can be conducted to identify those patients at the highest risk of VTE and develop nationally agreed screening guidelines and indications for VTE prophylaxis., Introduction: Sagittal malalignment of the spine is associated with reduced life quality. Additionally, it has a predominant effect on the clinical outcome of the surgical management of spinal disorders. The goal of this study was to determine the role of the sagittal imbalance of the spine in the failure of the posterior fixation of the spine. Materials and Methods: In this retrospective study, a study group (female n = 23, male n = 15, age range: 15-83 years) who underwent a revision surgery due to breakage of the implants was compared with a control group (female n = 14, male n = 13, age range: 58-82 years). Whole spine lateral radiographies, obtained in standardized standing position, were investigated for lordosis gap (LG), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), sagittal vertical axis (SVA), lumbar lordosis (LL), and thoracic kyphosis (TK). Data were analyzed using descriptive statistics, parametric and non-parametric inferential statistics, Pearson and Spearman correlation analyses. Results: In the study and control groups, the sagittal spinopelvic parameters yielded the following results: LG (medians: 27.8 vs 13.5, P < .05), PI (means: 66.7 vs 55.5, P < .05), PT (medians: 31.7 vs 25.7), SS (medians: 34 vs 30.6), SVA (medians: 72 vs 65.6), LL (medians: 38.4 vs 46.1), and TK (means: 31.7 vs 32.6), respectively. Additionally, correlation analyses revealed significant relationships between LG (P = .02), PI (P = .003), PT (P = .03), and SS (P = .05) and breakage of the implants. Conclusion: Considerable deviation from the normal values of sagittal spinopelvic parameters (in particular, LG, PI, PT, and SS) was associated with higher rates of breakage of the rods and screws in the posterior fixation of thoracolumbar spine., Introduction: To demonstrate that the combination of levobupivacaine, ketorolac and adrenaline is effective in improving postoperative pain control in patients undergoing spinal fusion surgery, and reduces the use of PCA (patient controlled analgesia), length of stay in hospital, days of physiotherapy and pain score. Material and Methods: A total of 37 patients who underwent spinal fusion surgery received wound infiltration with the combination of levobupivacaine (200mg/100 ml in 0.9% N-Saline), ketorolac (30 mg) and adrenaline (0.5 mg). PCA use, morphine consumption, length of stay in the hospital, days of physiotherapy and pain score (from 0 to 3) were prospectively recorded, side effects, and morbidity and mortality were prospectively recorded. Results: 16 patients were males (mean age:43), 21 were females (mean age:57). No side effects were recorded. 2 patients had surgical complications related to the procedure. 19 patients in total (51.35%) used the PCA for one day postoperatively; only 3 of these patients (15.79%) used the PCA for two days. The arithmetic mean of the daily use of oral morphine was 18.65 mg overall, 18.50 mg for the first day post-op, 23.50 mg for the second day. The arithmetic mean of the pain score was 1.26 overall, 1.65 in the first day post-op, 1.62 for the second day. The average duration of physiotherapy was 4.3 days overall, and 4.09 excluding the two patients with surgical complications. The average length of stay in the hospital was 6.76 days overall, and 5.26 days excluding the two patients with surgical complications. Patients happy overall after their stay were 32 (86.49%). Of the 5 patients (13.51%) not happy overall, 2 had surgical complications and 3 had significant post-op pain. Conclusion: Our data suggest that the studied wound infiltration is a safe and feasible option to provide good postoperative analgesia control. It also allows low usage of opioids and hospital costs. A case-control study will be organised in order to obtain higher level of evidence., Introduction: Issues were raised at the Royal National Orthopaedic Hospital (RNOH) following lack of documentation of pre and post-operative clinical findings for spinal patients undergoing major surgery. Discussions and meetings among spinal Consultants and Neurologists based at RNOH were held and a team (including junior doctors supervised by Dr Cowan) was created in order to look into the issues, aiming for improving the quality of junior doctor clerking/documentation (pre and post-operatively). We hypothesised that a standardised clerking pro-forma for surgical spinal patients admitted to RNOH (reporting pre and post-op neurological findings) would improve the clinical practise and allow an appropriate management of both clinical and legal issues in case of intra-op complications. Material and Methods: An Audit looking into the quality of the pre and post-op clinical documentation for surgical spinal patients was carried out at the RNOH in March 2016. A retrospective data collection was performed. Inclusion criteria: surgical spinal patients operated from 1/7/15 to 21/7/15 for first round, and in June-July 2016 for second round. Multidisciplinary notes and clinic letters of 30 of the selected patients were scrutinised, using paper notes and NoteOn (February 2016). Available published literature was reviewed. Data collected, analysed and discussed (March 2016). The Spinal clerking pro-forma was produced (March 2016). Results and pro-forma were sent to all Spinal Consultants and all junior doctors based at the RNOH, seeking for feedback. Pro-forma was implemented, put on trial and recommended to all doctors (April 2016). Further data collection (second round) and analysis took place in June-July 2016, using the same criteria set up for the initial collection. Compliance by the doctors to the use of the suggested pro-forma and potential advantages of his use were discussed at Audit meeting, and formal implementation will take place. Results: First round pre-op: 53.3% normal neurology documented just in clinic letters; 23.3% normal neurology briefly mentioned in clerking; 10% normal neurology with full assessment documented; 6.7% impaired neurology briefly mentioned; 6.7% impaired neurology fully documented. First round post-op: 63.3% normal neurology briefly documented; 13.3% normal neurology from clinic letters; 13.3% transient impaired neurology (brief documentation); 10% impaired neurology (2 with brief documentation and 1 from clinic letter). Full documentation in the notes (including both patients with intact and impaired neurology: 0. Second round: 30% pro-forma used; 77.8% normal neurology fully documented; 22.2% impaired neurology fully documented. 70% pro-forma not used: 90.5% normal neurology (73.7% brief documentation, 22.3% no documentation); 9.5% impaired neurology briefly documented. Conclusion: We recommend the use of our pro-forma at the RNOH as it allows the surgeons and clinicians to fully assess surgical spinal patients and record detailed pre and post-op neurological findings, in keeping with GMC/NICE Guidelines. It is also a safe medical and legal approach to surgical complications, allowing the best possible management planning. We would like to formalise the introduction of the studied pro-forma within our Trust and re-audit (third cycle) the findings at 3-6 months from his formal introduction., Introduction: Tranexamic acid (TXA) has been reported to be effective on reduction of postoperative blood loss in prosthetic replacement arthroplasty and spondylodesis. We have examined the efficacy of intravenous administration of TXA in lumbar posterior decompression (lumbar spinous-process splitting laminoplasty). Material and Methods: We retrospectively studied 68 patients undergoing lumbar posterior decompression by classifying them into the TXA group (36 patients; mean age of 64 years; 2013.4-2014.7) and the non-TXA group (32 patients; mean age of 60 years; 2014.8-2015.9). The TXA intravenous administration was just before and after 3 hours past operation. And each time we administrated 1000 mg of the TXA intravenously. Results: Postoperative blood loss was significantly less in the TXA group (non-TXA group: mean 121 ml, TXA group: mean 76 ml). Both intraoperative (non-TXA group: mean 79 ml, TXA group: mean 59 ml) and postoperative (non-TXA group: mean 86 ml, TXA group: mean 42 ml) blood losses per intervertebral space showed significant differences between the two groups, showing that TXA was effective in controlling blood loss. Neither group had postoperative complications such as symptomatic thrombosis. Conclusion: In this study, intravenous administration of TXA significantly reduced postoperative blood loss, indicating its effectiveness in controlling postoperative bleeding (non-TXA group: mean 121 ml, TXA group: mean 76 ml). However, further study with an increased sample size is needed to study timing of TXA administration and onsets of postoperative complications., Introduction: Sarcopenia measured by normalized total psoas area (NTPA) has been shown to predict mortality and adverse events (AE) in numerous surgical populations. It’s possible relation with postoperative outcomes after surgery for degenerative spine disease (DSD) has not been investigated. This study aimed to 1) Describe the distribution and predictors of NTPA; 2) Determine relationship between sarcopenia, frailty and postoperative outcomes; 3) Determine relationship between sarcopenia, frailty and length of stay, discharge disposition and in-hospital mortality. Material and Methods: This is an ambispective study from a quaternary academic centre. Total psoas area (TPA) at mid-L3 level on pre-operative CT scan adjusted for height (NTPA) defined sarcopenia. Modified Frailty Index (mFi)[11 clinical variables] defined frailty. Correlation with in-hospital adverse events (using validated SAVES), mortality, length of stay and discharge disposition was examined. NTPA was measured and distribution and predictors of sarcopenia were determined. Association of sarcopenia and frailty with post-operative outcomes was determined after adjusting for known and suspected confounders using multivariate logistic regression. Results: 102 patients >65 years old undergoing elective lumbar surgery for DSD (L4-S1) between 2009 and 2013 were included. Median Spine Surgical Invasiveness Index was 8 (IQR 2-10). Mean NTPA was 674mm2/m2 (293.21- 1636.25). Inter- and intra-observer reliability were near perfect with Kappa 0.95-0.97 and 0.94- 1.00 respectively. NTPA was predicted by gender and BMI. NTPA did not predict AE for either adjusted (OR 1.06 per 100 mm2/ m2, 95% CI 0.91 to 1.23, P = .45) or unadjusted analysis (OR 1.04 per 100 mm2/ m2, 95% CI 0.90 to 1.19, P = .62). Age, BMI, mFI, and ASA were not associated with the adverse events. Discharge disposition was not predicted by NTPA (rho -0.04, P = .67) or mFI (P = .14). NTPA was not predictive of in hospital mortality, but increasing mFI was associated with increased risk of mortality on unadjusted analysis OR 3.12 (95% CI 1.21 to 8.03) per 0.1 increase in frailty score (P = .006). Conclusions: In contrast to other surgical groups, sarcopenia (NTPA) or frailty (mFI) did not predict acute care complications in elderly undergoing simple lumbar spine surgery for DSD. While Normalized Total Psoas Area can be reliably measured in this population, it may not be an appropriate surrogate for sarcopenia given the anatomical relationship to spinal function., Introduction: The aim of this paper is to describe the results obtained in 120 patients, in which we did a vertebroplasty because of a vertebral fracture with collapse of the superior endplate less than 30% and without rupture of the back wall. They were operated between January 2015 and August 2016 in our department of Orthopedics and Traumatology in Corporación Medica of General San Martin in Buenos Aires, Argentina. All the patients were operated by the same surgeon. In all cases we used the same technique, which consists in the transpedicular unilateral filling of the vertebrae through a working cannula with methyl methacrylate. In many cases there was leaking vertebral intradiscal and intracanal. In all patients in whom there was intradiscal leaking there was a marked decrease of pain in the immediate postoperative without any extra complication.The results were very good because in none of these cases the patients experienced any complications or annexes symptoms with this type of surgical technique used. Materials and Methods: 120 patients, 44 men and 76 women who underwent a unipedicular vertebroplasty according to established protocols were evaluated. Patients with more than one fracture, fractures with a compromised of the back wall, fractures with a collapse of more than 30% of the upper endplate and those which we had to use a bipedicular filling technique were excluded from this study. All patients were studied with Rx and MRI; only in 15 cases we used CT with 3D reconstruction. All treated by the same surgeon. In 32 cases the superior disc filling technique was done because of pain and injury of the annulus. Surgical technique: Location of the fractured vertebrae under Rx, posterior approach. Unipedicular placement of the working cannula, cementation of it and in 32 cases rupture of the upper endplate with the respective disk filling. Results: In all cases patients had a partial or total remission of their symptoms. Only 7 patients had postoperative complications because of an intracanal leaking, which were decrease in strength and sensitivity in both lower limbs that remitted entirely at most 20 days after surgery. In the cases where we did superior disc filling patients evolved with a marked improvement in their pain in the early postoperative days compared to the usual vertebroplasties without any complications. All surgical wounds healed normally, without any secretions or phlogosis. All patients returned to their usual duties after a few weeks. Conclusions: After an exhaustive study of each of our patients we conclude that in most cases where intradiscal or intracanal leaking occur patients have no significant complications and always their symptoms remit. We find a direct relationship between the pressurization system and leaking. This method is commonly used in our service with excellent results., Introduction: Body mass index (BMI), bone mineral density (BMD), cage materials and degree of disc distraction are risk factors for cage subsidence after PLIF. The purpose of the study is to evaluate risk factors for subsidence after posterior lumbar interbody fusion (PLIF). Material and Methods: From January 2010 to January 2015, a total of 69 patients (93 segments) who were diagnosed with degenerative lumbar disease at the current authors’ institution and followed up at least for 1 year were included in this retrospective study. Data on all factors related to cage subsidence were taken into consideration. The degree of association for each of the factors was determined through the calculation of odds ratio (OR), with a 95% confidence interval. Logistic regression analyses were performed. P-value was set below 0.05. Results: There are no significant associations between fused segment level and cage subsidence (P = .588), and also there are no significant associations between cage materials and cage subsidence (P = .371). In univariate analysis, only the degree of disc distraction had a significant association with cage subsidence (P = .047, OR, 1.239). Various factors significant with p less than 0.20 level in univariate analyses were included in the multivariate analyses. In multivariate analyses, DM (P = .027, OR, 3.873), osteoporosis (P = .047, OR, 3.606) and degree of disc distraction (P = .017, OR, 1.343) had a significant associations with cage subsidence. In addition, there are significant associations between cage subsidence and instrument failure (P = .008, OR, 8.235). Conclusion: DM and osteoporosis which may affect bony structures are significant associations with cage subsidence after PLIF. Also, cage insertion with excessive disc distraction during operation may affect cage subsidence after PLIF., Introduction: Lumbar spinal stenosis surgery is a frequent intervention in spine centers worldwide. Blood products requirements for this surgeries tend to be overestimated in general population. Blood transfusions are preventable adverse events given that there are risk factors that can be mitigated prior to surgery. The aim of this study was to identify and describe postsurgical bleeding and transfusion requirements in a cohort of patients who underwent surgery for lumbar spinal stenosis and analyze possible determinant sociodemographic and surgical factors associated with blood transfusion. Materials and Methods: A cross-sectional observational study was conducted. Clinical records of 367 patients treated in a third level hospital located in Bogota Colombia undergoing surgery for lumbar spinal stenosis between 2003 and 2013 were reviewed. Personal background, sociodemographic and surgical variables, and their influence in post-surgical blood loss and transfusion requirements were analyzed. Patients with oncologic conditions, previous spine surgery and bleeding disorders were excluded. Univariate analysis, bivariate analysis and logistic regression of variables affecting postoperative blood transfusion were conducted. Results: 367 clinical records were reviewed. The median age was 57 years and 55.6% were female. Among the medical history, most frequent comorbidities were hypertension (37.3%), diabetes mellitus (10.6%) and cardiopathy (7.6%). Lumbar decompression was the most frequent procedure (55.6%) and the majority of patients required two level instrumentation surgery (79.8%). Intraoperative Bleeding was classified in 3 different categories: Mild (less than 50 ml), moderate (50-500 ml) and severe bleeding (>500 ml). Mild blood loss was observed in 35.1% of patients; 42.5% and 22.5% of patients presented moderate and severe bleeding respectively. Although, most patients had moderate and severe intraoperative bleeding only 26 patients (7.1%) required blood transfusion. After statistical analysis, the binary logistic regression revealed that history of heart disease (OR 4.68, CI 1.12 -19.44), intraoperative bleeding > 500 ml (OR 6.74, CI 2,09 - 21.74) and level of surgery (>2 operated levels) (OR 3.97, CI 1.20 to 13.09) were statistically associated with the need for blood transfusion. Conclusion: History of cardiopathy, multilevel surgery (more than 2 instrumented levels) and severe intraoperative bleeding (greater than 500 ml) were positively associated with blood transfusion requirement after spinal stenosis surgery. Mitigation of these risk factors and strategies to reduce intraoperative blood loss may decrease the amount of blood transfusion requirements., Introduction: Thoracic myelopathy due to ossified ligamentum flavum(OLF) is a very rare condition. We analysed our patients and have made attempts to find the factors which affect the surgical outcome. We also studied the associated spinal degenerative conditions which we saw in our patients with thoracic OLF. Material and Methods: We retrospectively analysed 20 patients with thoracic OLF. All except one patient underwent laminectomy with excision of the OLF. Whenever there was a other associated spinal compressive lesion (n = 9) i.e lumbar or cervical, it was treated in the same sitting, except in one patient who could not withstand anesthesia due to unstable cardiac condition. We reviewed the patients’ age, preoperative duration of symptoms and preoperative and postoperative neurological condition on basis of Japanese Orthopedic Association (JOA) scoring system. Results: All of our patients underwent operative intervention, 19 patients underwent laminectomy and excision of OLF. One patient had disc prolapse alongwith OLF, as the compression due to the disc was more severe, we decided to operate only for the disc and the OLF was followed clinically and radiologically. We have follow-up of 16 patients from 3 months to 8 years. 4 patients were lost to follow-up. 8 patients had excellent result, 6 had a good result and 1 patients remained the same and 1 deteriorated. Acute presentation had a bad outcome, other factors determining outcome were age of patient and duration of symptoms and preoperative neurological condition. None of our patients had complications of CSF leak, operative hematoma or wound infection/dehiscence. Treatment of associated spinal degenerative conditions like lumbar canal stenosis and cervical stenosis was required in 8 of our patients. There was no increased complication rate in these patients. Conclusion: Early diagnosis and meticulous wide surgical excision of the OLF, can give good results. The associated symptomatic compressive lesions (cervical or lumbar) should be treated in the same sitting. Age, long duration of symptoms and severity of symptoms (poor grade) were poor prognostic factors. The single case with acute presentation in our series had a bad outcome., Introduction: The presence of a dural tear or leakage of cerebrospinal fluid can cause serious problems such as pseudomenigocele, which is a rare complication of spine surgery. Pseudomeningocele is an accumulation of cerebrospinal fluid after an injury meningeal dura. We performed a clinical study in order to evaluate the treatment of pseudomeningocele with its aspiration and injection with Plateley Rich Plasma (PRP). Material and Methods: During the years 2014 and 2015 five patients were diagnosed with pseudomeningocele at Clinico San Carlos Hospital. These patients suffered dural tear from various etiologies such as trauma and spinal surgery. As to its location, four were lumbar and one cervical. Initially the lesions were treated with reparation and coverage but despite this a remission of the tumor was not obtained. The MRI performed confirmed the presence of a subcutaneous fluid collection that communicated with the spinal canal through a fistula. To treat the pseudomeningocele a ultrasound-guided drainage and infiltration with PRP were performed. Results: A control MRI was performed two months after the infiltration in all cases observing no collections. At last follow-up the patients were asymptomatic and the wounds evolved satisfactorily. The patients lived an active life without any functional limitation, in comparison with the preoperative clinical limitations. Conclusion: The treatment of the pseudomeningocele is controversial. On one hand, there is medical management with rest and antibiotic therapy, repeated aspirations, closed suction drainage or subarachnoid CSF with hemolytic epidural patch. On the other hand, the definitive treatment is surgical repair of the dural defect. In our cases, due to a poor evolution after surgical treatment, we decided to aspirate the pseudomeningocele and inject PRP. The evolution of all cases was favorable and we therefore recommend this treatment as an alternative when other treatment options have been ruled out., Introduction: Spinal dural tear is a common complication of spinal surgery and its incidence is affected by several factors, including diagnosis, patient characteristics and the type of surgical procedures performed. If the tear is not treated appropriately during surgery, it may cause severe consequences such as, persistent leakage of cerebrospinal fluid (CSF) and the formation of a pseudomeningocoele, producing headache, nausea and back pain. Dural tear is often underreported by hospitals and thus may be more common than previously thought. We set out to evaluate the incidence of dural tear during spinal operations and to assess patient outcomes. Material and Methods: Data was collected prospectively from both a spinal complications folder, which was filled out at the time of any intra-operative complication, and electronic patient records. All patients had questionnaires at 6-month follow-up including the Oswestry Disability Index (ODI), Visual Analogue Scores for leg pain (VAL) and back pain (VAB), and EuroQol-5 dimensions (EQ5D-5 L). Results: There were a total of 609 spinal operations performed during the eight month period.108 were cervical, 20 were thoracic and 481 were in the lumbar spine. 22 patients had intra-operative dural tears; 20 of these were in the lumbar spine, the other 2 occurred during Anterior Cervical Discectomy and Fusion (ACDF) procedures. These corresponded to a rate of dural tears in the lumbar spine of 4.1% and 1.8% in the cervical spine. Only 2 of the patients who sustained intra-operative dural tears required re-exploration. Of those 22 patients, three were lost to follow-up and one did not have any pre-operative data. We therefore analysed data from the remaining 18 patients. Follow-up questionnaires confirmed that 61% of these patients with intra-operative dural tears found an improvement in symptoms, while 11% reported no change. Conclusion: The presence of dural tears during the procedure is presented as a predictor of postoperative surgical site infection, longer inpatient stay and an increase in re-operation rate, and thus leading to poor outcome. Compared to previous studies conducted in other spinal units, dural tear rates in the Ipswich Spinal unit are low. However, outcome results were not as good as previous reported studies. However, by conducting this project, we can inform patients during the consenting process of a risk of dural tear of 4.1%., Introduction: Majority of spine cases especially lumbar surgeries are done through posterior approach where the patient has to be in prone position for longer durations. The positional complications are higher if the patient is under General Anaesthesia. Ocular and aural complications are very commonly reported in the recent past due to improper positioning of the patient during anaesthesia. Here we report a rare case of Tietze’s syndrome developed few months post operatively after lumbar fixation with pedicle screw system due to malpositioning during the surgery. Material and Methods: A 40 year old male patient presented to our outpatient clinic with back pain and severe radiculopathy 10 months ago. He underwent lumbar decompression surgery 7 years back. At present after thorough clinical and radiological examination he was diagnosed with L4-L5 instability with L3-S1 Lumbar Canal Stenosis for which he underwent Posterior stabilization, fusion and decompression. After 15 days he started complaining of para sternal pain on right side of the chest. On examination there was swelling, redness tenderness and local rise of temperature at the site. Bone scintigraphy, CT scan and MRI Dorsal Spine were done. Results: All three investigations came with the positive co-relation of the diagnosis made and was confirmed with Tietze’s syndrome of 6th and 7th ribs. After exhaustion of conservative management we now performed Rib Cartilage Excision of the involved ribs. After excision, the cartilage was found to be inflamed and sent them for HPE. Post cartilage excision, patient showed signs of improvement and the persisting pain were no more. Discussion: Positional complications in spine surgeries are not uncommon. The most common one is posterior ischaemic optic neuropathy that may either result due to improper padding of the eye causing a direct pressure effect when the patient is under general anaesthesia or due to blood loss, hypotension and anaemia which all three may conspire to produce the condition. But here we report a rare complication of prone mispositioning leading to Tietze’s syndrome which itself is a rare entity. It is mostly seen in the upper ribs but very rarely reported in lower ribs. The incidence of Tietze’s syndrome is not well studied and hence only few clinicians have a handful of experience with it. In chronic cases, local cortisone injection has been found to be useful. When all the conservative methods are exhausted, surgical option of rib cartilage excision can be done. Conclusion: Tietze’s syndrome which is a self-limiting chronic pain condition is itself a rare entity. Its occurrence following mispositioning when placed in prone is a rarest complication reported till date. Also rib cartilage excision is a good option in Tietze’s syndrome if all the conservative measures fail and has to be done with guarded prognosis as well., Introduction: Pacemakers are currently identified as a contraindication for the use of magnetic growth rods (MGRs). This arises from concern that magnetic fields generated by the MGR external remote controller (ERC) during lengthening procedures may induce pacemaker dysfunction. We investigated (1) whether MGR lengthening affects pacemaker function, and (2) if the magnetic field of a pacemaker affects MGR lengthening. Materials and Methods: MGRs were tested in conjunction with an magnetic resonance imaging-compatible pacemaker, which was connected to a virtual patient under continuous cardiac monitoring. To determine whether pacemaker function was affected during MGR lengthening, the electrocardiogram trace was monitored for arrhythmias, whereas an ERC was applied to lengthen the MGRs at varying distances from the pacemaker. To investigate if MGR lengthening was affected by the presence of a pacemaker, at the start and end of the experiment, the ability of the rods to fully elongate and shorten was tested to check for conservation of function. Results: When the pacemaker was in normal mode, < 16 cm away from the activated ERC during MGR lengthening, pacemaker function was affected by the ERC’s magnetic forces. At this distance, prophylactically switching the pacemaker to tonic mode before lengthening prevented occurrence of inappropriate pacing discharges. No deleterious effect of the pacemaker’s magnetic field on the MGR lengthening mechanism was identified. Conclusions: Magnetic resonance imaging-compatible pacemakers appear safe for concomitant use with MGRs, provided a pacemaker technician prophylactically switches the pacemaker to tonic function before outpatient lengthening procedures., Congenital kyphosis is a rare deformity, but frequently involves a high risk of intra operative motor neurophysiological events that could result in irreversible Sequelae. Study Design: Retrospective cohort. Objective: Determining factors that may increase the risk of producing a neurophysiological intra operative event as could be localization of the hemivertebra, magnitude of the deformity, type of kyphosis and previous neurological examination. Material and Methods: X-rays and medical records of 9 patients with congenial kyphosis were reviewed. An average age of 10 years with a range of 5 to 17 year-old. Kyphosis classification according to McMaster have been: type 1 (4 cases), Type 2 (2 cases) and Type 3 (4 cases). Attending to the location: thoracic in 6 cases, 3 cases thoracolumbar and 2 cases lumbar. All patients have undergone surgical treatment: posterior osteotomy in 5 cases and 5 cases through a double approach. Mean global kyphosis was 53 degrees with a range of 85 to 30. Mean kyphosis correction after surgery was 17 degrees with a range of 29 to 10. We performed a logistic regression analysis with the following independent variables: kyphosis angle, location and type of defect looking for the relationship with the presence or absence of intra operative motor neurophysiological event. Results: Table 1.TypeDeformityLocalitationDARAgeIKyphosisPosterior hemivertebra L450º5IIIKypho scoliosisFusion T10, T11 T12 and posterior hemivertebra70º17IIIKypho scoliosisPosterior Hemivertebra L150º12IIIKypho scoliosisHemivertebra T6, T7, T860º16IIKyphosisAnterior fusión T11-L285º13IKypho scoliosisposterolateral hemivertebraT1140º6IIKypho scoliosisFusion and hemivertebra l T4-T642º14IKypho scoliosisPosterolateral hemivertebraT1049º13IIIKypho scoliosisPosterolateral hemivertebraT10+ partial fusionT9-T1254º14iKyphosisHemivertebra T1130º11 In four cases motor neurophysiological events occurred during the surgery. No statistically significant relationship has been found with the deformity magnitude, the location or the type of deformity. Conclusion: Congenital kyphosis is not a common condition but it is characterized by a high neurological operative risk. There is a tendency to produce intra operative motor neurophysiological events elated with more severe cases and when the hemivertebra is located in the thoracic spine., Introduction: Cervical spine injuries are immanently accompanied by trauma to cerebral neck arteries. Material and Methods: A prospective cohort study, from Oct. 2013 to Oct. 2015. Overall 76 Patients (39W/37 M) of mediane age 77 years, with either fractures, or discoligamentary injuries have been examined with duplex-sonography and / or CT-angiograpy. About 80 Patients with a cervical-spine-distorsion have been evaluated with the same modalities as well. We used the statistic-programme Bias 11.01. Results: The overall incidence of a traumatic a.carotis-interna-dissection was 2.5%, in 50% of cases (1.2%) with a neurological symptomatology. For the vertebral artery seems the incidence of 10.5%, with 25% of symptomatic patients (2.6%) comparatively high. We’ve identified the osteophytes and dislocation as the major risk factors. The canalis vertebralis and skull-base are the regions mostly prone to vascular injury. In case of distorsions we have found no vascular trauma. Conclusion: One should look for vascular injuries in case of cervical spine trauma. The curent therapy option is the anticoagulation in a case of neurologically asymptomatic lesions. The symptomatic patients could benefit from endovascular techniques., Introduction: Traumatic spondylolisthesis of the axis (C2) with the fracture extending into the vertebral body has been incompletely characterized. Small case series have demonstrated high rates of neurological injury and cite difficulty treating closed due to greater instability secondary to extensive ligamentous injury. We hypothesize that this fracture pattern has minimal risk of ligamentous injury and can be adequately treated with closed methods. Material and Methods: Retrospectively, all patients admitted to a level 1 trauma center from 2004-2015 with acute C2 fractures were identified and classified based on CT imaging. Patients with anterior translation and C2-3 angulation less than 5 mm and 15 degrees respectively met the inclusion criteria for the study. Patients who underwent surgery or were not followed until conclusion of treatment were excluded. Results: 107 hangman’s variant fractures (14.5%) were identified from a database of 735 acute C2 fractures. 106 of the 107 patients displayed no neurologic injury related to the cervical spine at the time of presentation. 63 patients met the inclusion criteria and were followed as outpatient’s until collar or halo vest removal. All fractures progressed to union without progressive displacement or late neurological injury. No difference was observed in radiographic outcome between patients treated in a hard collar or halo orthosis. Conclusion: While widely considered a difficult fracture to treat with closed means, hangman variants are relatively neurologically benign injuries with low incidence of ligamentous injury. Fractures with less than 5 mm of horizontal translation and 15 degrees of angulation can be treated with external immobilization without the necessity of MRI. Our results suggest no advantage of halo immobilization versus hard collar orthosis., Introduction: Treatment of fractures of the odontoid peg depends on the type of fracture according to the classification of Anderson d’Alonso, the degree of dislocation and the patient compliance. Material and Methods: We report the case of a 57 year old male, suffering a Typ III fracture of the dens axis. Initially, he was treated with an external halo fixateur. Eight weeks later, increased dislocation of the dens axis was evident and no fracture consolidation could be noted. Results: The fracture was then stabilized anteriorly with two double-threaded screws using the technique of Knöringer after osteotomy of the fracture area for reduction of the dislocation. Three weeks further, caudal dislocation of the Knöringer screws with destruction of the third cervical vertebrae was noted. An anterior removal of the screws was necessary. Posterior instrumentation and fusion C0 - C4 was performed. Conclusion: We discuss possible pitfalls of indication and treatment including anterior fusion techniques., Introduction: A case of post-traumatic posteriorly impacted irreducible odontoid fracture reported. Objective was to discuss the difficulty observed in reduction of such fractures and to propose the alternative surgical method for reduction of such posteriorly impacted fractures. This was a case of posteriorly impacted irreducible Type 2 odontoid fracture. Obliquity of the fracture line and posterior impaction of odontoid fragment over the base of odontoid process precluded anterior trans-oral approach & manipulation. Impaction could not get overcome even by heavy traction. Material and Methods: A 16 years old man with vehicular accident sustained cervical spine injury with neck pain and no neurological deterioration. Type 2 odontoid fracture with posterior displacement was noted on further imaging. Acceptable reduction was achieved by posterior reduction & instrumentation. Results: As the heavy traction failed to dis-impact the fracture, patient was repositioned prone and instrumented posteriorly. Intra-articular distraction between C1-C2 joint was attempted to reduce the fracture and unlock the facet joints, if ever present, which failed. Instrumentation & distraction along rods with posterior pull to axis vertebra through a sub-laminar wire achieved reasonable reduction. Patient remained neurologically intact. Conclusion: Due to peculiar fracture geometry and posterior impaction, this fracture was less amenable to axial cervical traction or anterior trans-oral approach. Posterior instrumentation using lateral mass screws in atlas and pedicle screws in axis with connecting rods used to distract the joint which reduced the fracture reasonably well. Intra-articular distraction with posterior traction to axis helped in reducing the fracture by leverage of transverse ligament. Such a reduction maneuver can be applied safely to get an acceptable reduction in difficult to reduce odontoid fractures., Introduction: We describe a technique of reduction and stabilization of unifacetal or bifacetal dislocation of subaxial cervical spine by posterior only approach using pedicle screws and analyze the clinical and radiological results of the patients treated with this technique. Methods: Medical records of patients with unifacetal or bifacetal dislocations of subaxial cervical spine treated with cervical pedicle screws between January 2011 to June 2015 were analyzed retrospectively. Neurological assessment was done pre-operatively and at final follow up by ASIA grading, motor and sensory scores. Radiological outcome was analyzed by comparing the degree of translation and segmental lordosis between the pre-operative and immediate post-operative radiographic images using surgimap software and position of pedicle screws by CT scan. Results: 13 patients (11 males and 2 females) with an average age of 47 years (17-80 years) were included in the study. The commonest mechanism of injury was road traffic accident and the average time of presentation was 3.9 days. Post operative X-ray showed reduction of anterior translation from an average of 38% pre-op (16%-100%) to 1% post-op (0%-4%) and restoration of sagittal alignment from 12° of kyphosis pre-op (7° to -36°) to 2°degree of lordosis post-op (-4° to 13°). The position of pedicle screws showed intact in 42 pedicles, medial breaches in 10 and lateral breaches in 6. The average follow up was 33 months 12 days (6 -53 months). Two patients expired due to chest infection and one patient with ASIA ‘A’ quadriplegia was lost to follow up. At final follow-up 5 patients with ASIA ‘D’ and one patient with ASIA ‘C’ paraplegia improved to normal (ASIA ‘E’). While in remaining patients neurology remained normal pre and post operatively. Conclusion: We describe a technique of reduction and stabilization of fracture dislocation of subaxial cervical spine by a single posterior approach using pedicle screws. The advantages of this technique being lesser operative time, blood loss, less morbidity, superior biomechanical strength, short segment instrumentation, lesser chances of traction injury to the cord, its feasibility in delayed presentations and allowing discectomy and interbody grafting through posterior approach., Introduction: Several studies have indicated that early decompression may be beneficial for traumatic spinal cord injury in the cervical spine. This study is designed to investigate the impact of hospital teaching status on the timing of intervention and inpatient morbidity and mortality after surgery for acute spinal cord injury (SCI). Material and Methods: Data from the Nationwide Inpatient Sample (2002 – 2011) were reviewed. Patients were included if they had a diagnosis of closed vertebral column fracture with SCI, underwent spine surgery, and were admitted urgently or emergently. Early intervention (the day of or the day after admission), inpatient morbidity, and impatient mortality rates were compared between groups – teaching versus nonteaching hospitals. Multivariable regression analyses were performed to control for patient characteristics, injury mechanisms, and others. Results: A total of 9,236 patients were identified (mean age 43 years, 82.6% male gender), with 78.7% admitted to a teaching hospital (n = 7272) and 21.3% to a nonteaching hospital (n = 1964). The most common injury mechanism was motor vehicle collision in 43.9% of cases, the most common fracture location was between C5 and C7 (35.3%), and 22% of cases were complete SCIs. Following multivariable analysis, teaching status was significantly associated with early intervention (OR 1.12; 95% CI, 1.01 – 1.25), but not with complication development (OR 1.09; 95% CI, 0.98 – 1.23) or mortality (OR 1.19; 95% CI, 0.91 – 1.56). Conclusion: In this nationwide study, patients with vertebral column fractures with SCI who were admitted to teaching hospitals were more likely to receive early intervention compared to patients admitted to nonteaching hospitals. On the other hand, inpatient morbidity and mortality did not differ depending on hospital teaching status. Future studies into the long-term implications of admission to teaching versus nonteaching hospitals for patients with SCI are encouraged., Introduction: Pedicle screw fixation of lower cervical spine is a new technique that provides a alternative to posterior lateral mass plating. Although biomechanical studies suggest the use of pedicle screws to reconstruct the cervical spine, placing screw in small cervical pedicle poses a technical challenge. Penetreation of screw in pedicle is a primary complication associated with screw insertion in the lower cervical spine. Material and Methods: This is retrospective interventional study done at the department of Orthopaedics, B.P.Koirala Institute of Health Sciences, Dharan, Nepal over a period of 2 years from March 2012 to April 20014. A total of 55 patients with cervical spine injuries were treated by pedicle screw. The patient’s age ranged from 20 to 60 years and the mean follow-up was 12 weeks. Results: The study comprised of 55 patients with cervical spine injuries were treated by pedicle screw The age incidence in this series ranged from 20 years to 60 years. 40 patients were males and 20 was female. All had fractures or fracture dislocation at different levels of lower cervical spine.The mechanism of injury included falls from height (80%), motor vehicle accidents (18%) and sports related injury (2%). Conclusion: It is indicated in patients with osteoporotic bone or when rigid internal fixation can not be achieved by conventional techniques., Introduction: Fractures of the axis are common, but multiple ones of the axis are much rarer, and their management creat still controversises. The aim of treatment should be achieving primary stability, early mobilization, preserved cervical range of motion, and favorable outcome. Material and Methods: A 62-year-old man was admitted to our neurosurgicaldepartment one day after a traffic accident. He had only persistent neck pain without radicular pain. Neurological examinationwas completely normal. The CT scan showed a complex fracture of the axis consisting of a fracture of the dens and a hangman fracture. Results: The surgical procedure was performed using an anterior cervical approach under fluoroscopic guidance. First, a C2–C3 fusion was performed using an iliac crest graft. Then an anterior odontoid screw was placed under fluoroscopic guidance and through the left superior hole of a cervicale plate. Finally, the anterior plating of C2–C3 was achieved. Postoperative course was uneventful and patient was discharged at day 3. Conclusion: This single time procedure was able to achieve the different aims of treatment of the fractures of the axis., Introduction: Type II odontoid fractures (Alexander- Alonzo)are usually offered surgery. Anterior screw is the common surgical treatment. For fractures unsuitable for ant screw or with associated instability posterior atlanto axial fixation is offered .Twenty five patients of type II odontoid fractures (unsuitable for anterior odontoid screw) underwent an anterior retropharyngeal approach with anterior screw pate fixation and eight among them, who had associated atlantoaxial instability underwent additional bilateral anterior transarticular screws. All patients treated by this technique had 100% fracture site bone union without any implant failure. Longest follow up has been 3 years. Material and Methods: Time period Feb 2011 – Sept 2016. 25 patients, age 15yrs – 78yrs, Males 15, females 10, of (Anderson and D’ Alonzo) Type II (16) and II A (9) fractures of odontoid were treated by this technique. 20 patients, age 15yrs – 78yrs, Males 12, females 8, of (Anderson and D’ Alonzo) Type II (13) and II A (7) fractures of odontoid were treated by this technique. Following an anterior extra pharyangeal approach the fracture site was exposed and fixed in compression mode with specialized VSP (variable screw placement) plate and screws. For patients with associated instability, bilateral anterior trans articular screws were used to fix the atlantoaxial joints. Results: No transfusion was required in any case and no case required additional procedure. All patients showed bone union across fracture site at 3 months. Complications and Sequale: Three elderly patients (>70 yrs) complained of dysphagia for 2-3 days after surgery, 3 patients (including the ones with dysphagia) had mild hypoglossal weakness which recovered in a week. Neck pain persisted in 9 patients for 4 weeks which responded to analgesics. Long-term follow-up imaging has been at 3 years in 7 patients, without implant failure and 100% bone fusion. Conclusion: All 25 patients who underwent this procedure had bone union across the fracture at 3 months with no case of implant failure. There was no similar description of anterior compression plate screws with bilateral anterior trans articular screws for odontoid fractures in literature. However better implant design with locking screws need to be devised and more centers have to perform this surgery to realize the long term results and complications., Introduction: Many studies have focused on the axons regeneration after Spinal cord injury (SCI). And fibrinogen was found to be an inhibitory factor for axons regeneration. However, most of these studies were based on animal experiments and in vitro trials. Few studies reported the serum concentrations of fibrinogen in patients with SCI. The purpose of this study is to investigate the circulating serum concentrations of fibrinogen in patients with SCI, and to determine the correlation between fibrinogen concentrations and patients’ JOA score and ASIA impairment scale. Materials and Methods: A total of 306 patients who were diagnosed with acute SCI from January 2008 to March 2016 were included in the study. Additionally, 427 patients with traumatic fractures of the extremities at the same period (220 patients with single fracture and 207 patients with multiple fractures) were enrolled as control groups. The fibrinogen serum concentrations in different groups were recorded and compared with each other. And the relationship between fibrinogen serum concentrations and JOA score, ASIA impairment scale in patients with SCI were analyzed. Results: The mean serum concentrations of fibrinogen within two days after injury were 2.63 ± 0.76 g/l in SCI group, 3.02 ± 3.03 g/l in single fracture group and 2.86±0.91 g/l in multiple fractures group, respectively. It’s significantly lower in SCI group comparing with the fracture groups (P = .003). The positive rate of fibrinogen concentrations were 12.42% (38) in SCI group, 25.45% (56) in single fracture group and 25.13% (52) in multiple fractures group, which were significantly lower in SCI group (P < .01). However, no significant difference was detected between the single and the multiple fractures group (P > .05). In patients with SCI, spearman correlation analysis revealed a negative correlation between fibrinogen serum concentrations and patients’ JOA score or ASIA Impairment scale ((r1 = 0.203, r2 = 0.17, P < .01). Conclusions: The serum concentrations of fibrinogen and positive rate were significantly lower in patients with SCI than those with fractures. And the fibrinogen concentrations were negatively correlated with the neurological function in patients with SCI according to ASIA and JOA scores., Introduction: Traumatic SCI is a catastrophic event that has a major impact on the individual, as well as the healthcare system. The optimal timing for surgical decompression after traumatic SCI is controversial. To determine whether clinical outcomes after traumatic spinal cord injury (SCI) are better when surgical decompression is performed early (, Introduction: Evaluation of the results obtained in our hospital with surgical treatment of fractures of the odontoid process (types II and II according to D’Alonzo classification) in the elderly population. Material and Methods: Retrospective study of patients 65 and older with odontoid fractures types II and III surgically treated in our hospital during the period 2005-2015. Type of surgical technique, presence of consolidation during the follow-up and subsequent clinical course were evaluated. We identified a subgroup of “very old” patient (according to medical literature with age > 80 years), comparing the results with the patients with 65-79 years. Results: 25 patients were included, 19 with type II fractures and 6 type III fractures. The mean age was 79.5 years, with 11 patients over 80. Two of the patients had been treated previously with cervical immobilization in other centers. The surgical technique used was based on displacement and complexity of the fracture, according to findings of the cervical MRI; 8 screwed performed anterior approach, in 16 patients a posterior fixation was performed, and an anterior screw placement was realized in 9 patients One patient died in the short tem postoperative period. The average hospital stay was 22 days in the subgroup with age 65-79 years and and 55 days in the group with >80 years. During follow-up, signs of healing were observed in 75% of cases with no significant differences according with the type of treatment or age The consolidation rate was higher in type III fractures although statistical significance was not reached. The complication rate was similar among age subgroups. Conclusion: Surgical treatment of odontoid fractures is an effective treatment that provides good results even in the older population, without significantly increasing the rate of complications. Surgical option has replaced the conservative treatment in these type of fractures., Introduction: Surgical treatment patients with upper cervical spine trauma actual problem. Material and Methods: 88 patients with of upper cervical spine injury, treated 2011-2015. In all cases, surgical treatment was performed using different stabilizing systems. CT performed to all patients with suspected cervical spine injury before and after the operative treatment. Selective angiography of brachiocephalic vessels was carried out according to indications to assess the collateral blood flow. Before surgery, spine was fixed in a “Philadelphia” collar. After surgery on the second day was performed in a soft collar. Reposition was made on the operating table.In 38(43%) cases, was used. only J. Harms technic, performed with 4 and 6, screw structures in C1-C2, C2-C3, C1-C3, C1-C2-C3 segments. In 14(16%) posterior fixation was performed with 2 screws on one level at C1-C1 and C2-C2. Occipitospondylodesis was applied in 30(34%) cases. Frontal fixation was performed 6(7%) times - cannulated screw in odontoid of C2. Control CT was performed in 3, 6, 9 and 12 months after surgery. Results of treatment were estimated by using VAS, ODI, RDQ scales and questionnaires Evaluation of pain was carried out using VAS before the operative treatment, at 1, 5, 10 days, 1, 3, 6, 9 months. It was found that pain rapidly regresses during the first week after surgery: occipitospondylodesis 5-6 points, single- and multi-level fixation 4-5, cannulated screw 3-4 to the end of the first week after surgery. Most satisfied with the quality of life in the early and late postoperative period are patients operated with connulated screw and single-level fixation. In the remaining groups quality of life improved more quickly than a less extended structure was established. It is worth noting that in these 2 groups (occipitospondylodesis and multilevel fixation) at 1 month after surgery difference in the quality of life was not significant. Catamnesis ranged from 1 to 36 months. Results: Orthopaedic good or excellent results obtained in 100% of cases. Consolidation occurred within the period from 3 till 12 months. Clinically significant complication was in 1 case. In 3 cases were asymptomatic malposition of screws. No mortality and infectious complications. The results of the functional state estimation in the early and late postoperative period on scales ODI and RDQ as follows: patients with occipitospondylodesis gradient of the absolute values in the range of 76% -30% and 5.12 points, respectively; patients with multi-level fixation of 72% -25% and 12-4 points; patients with single-level fixation of 72% -20% and 12-2; patents with cannulated screw 68%-20% and 12-2. Conclusion: For fractures of the C2 vertebra such as Hangman type, and unstable fractures of C1 monosegmental transpedicular C2-C2 and C1-C1, lateral mass fixation, preserves the physiological properties of the craniocervical transition with sufficient stability in the zone of fracture, for consolidation. An anterior odontoid fixation with cannulated screw is most preferred for fractures of the odontoid process of C2 type 2, because preservation of C1-C2 joint function. In the best long-time quality of life patients with single-level posterior fixation and fixation with cannulated screw., Introduction: In Chile, amateur diving is a frequent summer activity. Spinal injuries after diving in recreational context can lead to catastrophic consequences, mostly in young and economically active population. Material and Methods: We reviewed 45 patients hospitalized in our center, admitted to the neurosurgery unit between 2006 and 2016, with spinal injuries due to diving accidents. Data was collected from their initial admission and from follow-up records. Statistic analysis was performed using Microsoft Excel 2010 and STATA v10. Results: Of the total number of patients evaluated, all sustained injuries. Mean age was 32 (SD: 15 - 55) years. 96% were mens (43/45). All reported injuries occurred during summer. Alcohol consumption was present in 44% of cases. The most affected segment was cervical (91%), and the most common injuries were C5-C6 dislocation and fracture (20%) and C4-C5 dislocation and fracture (18%). 29% of patients presented severe neurological compromise (ASIA A, B, C) at time of admission. Surgical treatment was required in 49% of cases, the majority using an anterior cervical approach. The other 51% underwent orthopedic management. NASCIS 2 methylprednisolone protocol was used in 13% of cases. Overall, 22% of patients received steroid therapy. Thirty day mortality for the cohort was 6.7%, all ASIA A. Mean hospital stay was 18 (SD: 1 - 354) days. Conclusion: Diving accidents in Los Angeles Chile, while uncommon can result in spinal injuries with drastic consequences, including permanent physical disability, mortality and a profound socioeconomic impact. In our experience, an optimal initial trauma assessment follow by early surgical and orthopedic management resulted in best clinical results. The consumption of alcohol worsen the outcomes. Prevention strategies should be implemented to reduce the incidence and impact of this problem., Introduction: We have reviewed the case records of 7 patients with odontoid fractures treated by anterior odontoid screw fixation Material and Methods: The mean age at the time of injury was 67.3 years old(range 28–87 years old) Of these patients, 5 were men and two were women. The mechanism of injury in all was high-energy trauma; 1 patient was injured in motor vehicle accident, 5 patients fell from a height, and 1 patient injured head by falling object. There were 5 patients with Anderson and D’Alonzo type II fractures and 2 with type III. Results: The mean interval to the operation was 10.7 days (range 1–25 days), The mean operation time was 75 minutes(55–115 minutes). Two patient were died from pneumonia and cancer within 3 months after operation. The remaining 5 patients were followed. The mean follow-up period was 12 months (range 6–24 months). Clinical results were evaluated using X-ray, CT scan and MRI. Of 5 patients, 4(80%)achieved bony union by anterior screw fixation. One patient, in a case of non-union, did not require a secondary operation. No patient developed infection or neurological injury after surgery. A full of range of motion was obtained in all cases. Conclusion: We conclude that anterior screw fixation, although technically demanding, is an effective and relatively safe procedure in the treatment of odontoid fractures., Introduction: Cervical spine fractures may be associated to potential catastrophic sequelae for patients, together with elevated direct and indirect costs related to their management. Their incidence in rugby players has increased in the recent years, mainly due to higher energy mechanisms as a result of progressively faster and bigger players. Our objective is to present a case series of rugby players with cervical spine fractures, focusing on their injury mechanism and treatment. Material and Methods: We reviewed the medical records and imaging of patients treated in our center for a cervical spine fracture due to a rugby-related accident since 2009 (seven-year period). We recorded demographics, characteristics of the injury mechanism, type of fracture and treatment modality. We performed a literature review, focusing on injury mechanism, prevention and return to sport timing after these injuries. Results: Case series of six male patients (mean age 21.6 years [18-26]), only one of them (16.7%) presented neurological impairment (ASIA Impairment Scale, (AIS) D), which evolved to complete recovery (AIS E) after surgical treatment. Five patients (83.3%) were injured during a tackle (three tacklers and two tackled players) and only one patient (16.7%) was injured in a scrum. In two patients (33.4%) the injury was missed during the initial assessment with X-rays and it was detected with a computed tomography scan performed at a mean of 7 days [6-9] after the accident due to persistent neck pain. The C6-C7 segment was the most frequently affected (50%, 3/6 patients) and 83.3% (5/6 patients) required surgical treatment due spinal instability. The available literature describes an increase in injuries as a result tackling, but with a higher incidence of neurological impairment in scrum-related accidents. Modifications to regulations have been introduced in order to reduce the risk of injury, but with no real results yet. There is still no consensus regarding return to rugby (and its timing) after a cervical spine fracture. Conclusion: Cervical spine fractures must be ruled out in rugby players presenting with neck pain after game-related trauma. The incidence of these injuries is progressively increasing, their management usually requires surgery and there is still no consensus regarding return to play., Introduction: Neglected cervical dislocations have been variably defined as luxation’s presenting more than 2 weeks, 3 weeks or 8 weeks. Various authors have described combinations of soft tissue and/or bony resections for intra operative achievement of optimum alignment and/ or reduction. With this background, we present our experience of an alternative approach of single stage anterior corpectomy in 8 cases of irreducible neglected subaxial cervical spine fracture dislocations presenting with a mean delay of 3 months. Material and Methods: Records of 12 patients with neglected cervical subaxial dislocations presenting to a tertiary referral centre form a period extending from January 2012 to December 2014 were reviewed. Among them 8 patients were irreducible and included for analysis while reducible dislocation was excluded. Those who failed closed reduction underwent anterior corpectomy with autologous tricortical iliac crest bone grafting and plating with foraminal clearance. The dislocated vertebrae encroaching the spinal canal was planned for corpectomy, aiming for spinal canal clearance, decompression, fusion and maintaining align ment. All patient was attempted to fusion and stabilize with tricortical iliac crest graft and low profile anterior cervical plate. Garden well tong inserted under GA- 20 KG for 10 minutes to assesss reducibility. No reduction or distraction at dislocated facet was noticed on fluoroscopy. The cervical spine was exposed by standard Smith and Robinson approach from left side. A complete microscopic anterior corpectomy, was performed, with complete anterior decompression of the cord assessed with penfield. Graft size was measured and tricortical iliac crest graft of measured size harvested and inserted in the corpectomy site. Plate of appropriate size inserted. Mobilisation of the patient was started second day. Follow-up radiographs included anteroposterior, lateral with CT scanning at 12 months. The neck movements were also painless at 12 months follow-up. The clinical and radiological signs were suggestive of good interbody fusion. Results: The mean delay in presentation was 10 to 16 (mean, 12) weeks, mean age was 37.5 yrs (25 – 55yrs). The mean follow-up was 26 (range, 14–36) months. 4 patients improved form ASIA C to ASIA D, 2 improved form ASIA C to ASIA E, 1 patient improved form ASIA D to ASIA E and one of the patient remained static at ASIA C. All patients showed evidence of adequate fusion on CT scan. The mean duration of surgery was 148 minutes with average blood loss of 350 ml. The average cost of surgery was 200 USD. Conclusion: Persistent dislocations are not easily amenable to closed reduction owing to the fact that they have been found to be associated with fibrosis and ossification around the vertebral bodies, unco-vertebral and facet joints. Our method is single approach, single level corpectomy of the lower vertebra causing compression of the spinal cord. This technique is to achieve decompression, stabilization & fusion of unstable sub axial cervical dislocation injury in a single stage is associated with excellent fusion in all cases, neurological recovery., Introduction: Fractures of the odontoid bone are the most common injuries of the upper cervical spine, following a trauma associating a combination of antero-posterior shearing forces and compression. The evolution towards nonunion is frequently explained by vascular phenomena and mechanical loads. We reported the case of a nonunion of the odontoid bone diagnosed after an 8 months posttraumatic delay. Methods: He was a 23 year old man, who presented with a posttraumatic torticollis lasting for eight months for which he has consulted several times but no diagnosis was retained. Clinical examination found an irreducible torticollis without neurological signs. Plain radiography showed a mobile odontoid nonunion on the dynamic views. CT scan and MRI confirmed the diagnosis and the absence of spinal cord injuries. He had an occipitocervical fusion through a posterior approach after a reduction period of 21 days through a continuous traction by a cranial halo. Results: At last follow-up of 2 years, the patient was indolent with disappearance of torticollis and no neurological signs but with a certain limitation of rotation. Conclusions: Nonunion is a common complication of fractures of the odontoid bone, explained by, in one hand, a fragile vascularisation which is epiphyseal type and, in other hand, by the occipito-altoido-axis complex which causes a physiological stress on the odontoid. Immediate neurological lesions are rare but extremely serious. The natural evolution of nonunion of the odontoid bone remains unpredictable with possible onset of myelopathy. The treatment is mostly surgical by an occipitocervical fusion or direct bone grafting of nonunion fixed by screws associated or not to an anterior plate. This technique preserves good mobility in rotation but is difficult to implement, other techniques may be cited as the C1-C2 wire lacing with bone graft. Nonunion of the odontoid bone is an injury that often goes unnoticed whose natural evolution is unpredictable. The occipitocervical fusion is a neurologically low-risk method which gives satisfactory results with moderate functional impairment., Introduction: Unifacet dislocation of the cervical spine is a very common injury. Most of the authors recommend urgent close reduction in an awake, alert and cooperative patient. If the reduction could not be achieved by closed means, then open reduction and internal fixation is recommended. The belief is that conservative treatment can lead to chronic neck pain and facet joints osteoarthritis. The aim of this paper is to evaluate the short term outcome of conservative treatment of these injuries. Material and methods: In the period 2002 to 2015 we identified 36 patients with unifacet dislocations of lower cervical spine. None of them had neurology. All of these patients were treated in skeletal traction with cone caliper and weight depending on the level of injury. All of them were kept in traction for 6 weeks and then in SOMI brace for further 6 weeks. At the end of 12th week the brace was removed and flexion and extension X- ray views were performed. These patients were followed up for an average of 2 years (from 6 months to 5 years). These patient were given physiotherapy and analgesia if they have pain occasionally. Results: We noted that 5 out of 36 patients continued having chronic neck pain, but the remaining eleven patients had satisfactory results. This showed that conservative treatment of the unifacet dislocation will work in selected patients with out neurology. Conclusion: Conservative treatment of unifacet dislocations of the lower cervical spine can achieve satisfactory results. In our series only 13.9% developed chronic neck pain. This is very little as compare to surgical treatment patients and complication of the surgery. Our study showed that conservative treatment also has a role in the treatment of unifacet dislocation of cervical spine not all patient require surgery. These patients have good range of movement of the neck., Introduction: Spontaneous spinal epidural hematoma (SSEH) manifests from blood accumulating in the epidural space, compressing the spinal cord and leading to the acute onset of neurological deficits. Despite the pathology’s obscurity, supported by the paucity of reported cases, the high morbidity of untreated SSEH warrants its inclusion in the differential diagnosis of any presentation suggesting spinal cord involvement. The condition’s contested etiology, low incidence, and extensively varying symptoms, which range from local vertebral pain to paresis, create a spectrum too wide for generalized treatment. Decompressive laminectomy and drainage is standard, though spontaneous recoveries have been reported. In fact, nonsurgical management is a viable course of action often overlooked in current literature, though it remains unclear which type of SSEH patient will benefit from surgery. This uncertainty translates into sub-optimal management principles, with a mortality rate of over 5% and a morbidity rate ten times as high. This study aims to investigate parameters that affect SSEH’s progression, outlining a best-practice therapeutic approach. Material and Methods: Review of literature containing a case series of patients, managed either surgically or nonsurgically, with neural examination before and after treatment, yielded 65 cases from 12 studies. Furthermore, 6 cases were presented from our institution. All data were analyzed under the American Spinal Injury Association (ASIA) guidelines. Results: Over 50% of SSEH patients do not fully recover. 30% of patients that presented with an ASIA score of A did not improve with surgery, though every SSEH patient who presented at C or D improved. Spontaneous recovery is rare - only 23% of patients were treated nonsurgically. Patients managed nonsurgically were 3 times as likely to have an initial score of D - the least severe score before full recovery - than their surgically managed counterparts. This indicates that nonsurgical management tends towards low-risk patient presentations. However, not all patients treated nonsurgically present with minimal neural deficit. 33% of patients managed nonsurgically had an initial score of A or B, all improving to a score of D or E without surgery. Furthermore, 73% of the nonsurgically managed patients made a full recovery, as opposed to the 48% of patients managed surgically that fully recovered. Conclusion: We recommend close neurological monitoring and early imaging be completed for any patient with suspected SSEH. Once confirmed, rapid determination of those requiring surgical intervention should be based on the evolution of their neurological status from time of onset to the latest neurological examination. The degree of preoperative neural deficit is a major prognostic factor. If spontaneous recovery is manifested, the nonsurgical approach is a feasible, overlooked, and 25% more effective. In addition, our case study documents one such SSEH patient making a full recovery through nonsurgical management. This spontaneous recovery is an ideal model to atraumatically study the reversibility of acute spinal cord compression symptoms without intervention, and to identify the critical timeframe until irreversible damage occurs. However, laminectomy and drainage should be readily available should the patient’s impaired neurological status stagnate or worsen, supported by the inverse correlation between operative interval and the resulting extent of recovery., Introduction: Due to increasing ossification and to the changing stiffness of the spine, patients with ankylosing spondylitis suffer spinal fractures more often. Trivial falls are not rarely the cause of the fracture and the injury. The changed biomechanics count for the increased number of injury patterns and neurological deficits. Material and Methods: Radiological evaluation is difficult and spinal fractures are overlooked in a considerable amount of patients. The patients need specific surgical treatment and strategies considering the biomechanical properties. Fractures of the thoracic and lumbar spine need multi-level instrumentations, fractures of the cervical spine need to be addressed with dorsoventral fusion techniques. Results: We describe our patient collective of 2009-2013 with 35 consecutive patients with spinal fractures and ankylosing spondylitis. The cause of trauma and localisation of fracture, as well as the neurological deficits are depicted. Surgical strategies used are described and the therapy-free intervall is analyzed. Conclusion: Patients with spinal fractures and ankylosing spondylitis need specivic diagnostics and very specific surgical treatment. The knowledge of the disease with its unique pitfalls is important to manage these patients adequately., Introduction: Achieving adequate surgery for early onset scoliosis (EOS) is difficult because of these challenges: the need to correct the deformity, the need to allow adequate spine growth, the need to allow adequate lung development, the need to minimize complications. GSP system was found to solve these troubles with minimal complications in comparison with other techniques. Material and Methods: Combined prospective and retrospective study on 15 patient with early onset scoliosis treated surgically with the GSP system in Assuit University Hospital Egypt and postoperative follow up and analysis of the results and complication was done after the index surgery and after each 6months programmed lengthening all of the following parameters was assessed: 1) Cobb’s angle correction, 2) T1-S1 height, 3) apical vertebral translation (AVT), 4) space available for the lung (SAL) ratio, 5) shoulder and pelvic balance. Also, surgical details are mentioned including: 1) single or dual rod technique used, 2) operative time, 3) blood loss, 4) mean arterial blood pressure during surgery, 5) neuromonitoring during surgery, 6) intraoperative complications. Results: GSP system is a very successful method in management of early onset scoliosis as regarding correction of the deformity, allowing spine growth, allowing proper lung development. However, it has some complication that can be avoided by proper patient selection and proper surgical technique. Conclusion: GSP is a good system for management of EOS with good patient selection and good surgical experience., Introduction: Fracture spine is a common traumatic event. The morbidity of such event is high and many studies to decrease the magnitude of this morbidity were done. Management of fracture spine varies between operative and non-operative options. Operative techniques varies between open posterior, percutaneous posterior and anterior techniques. Vertebroplasty or kyphoplasty may be suitable in certain types. Open posterior approach is the most commonly used approach, however chronic postoperative back pain is a very common complain. Muscle ischemia and subsequent necrosis was said to be the cause of this postoperative pain in cases with no detectable other causes eg, osteoarthritis. Material and Methods: Comparative prospective study on 20 patient with fracture affecting the lumbar vertebrae that are managed surgically with (TPSF) 10 through traditional midline approach and 10 with wiltse approach. Surgical technique and details of the fracture vertebra and type of the fracture are recorded as well as surgical time, blood loss and intraoperative complications. Follow up is done at 6 weeks 3 and 6 months and VAS was recorded at each visits. MRI at 6 months is done and degree of muscle necrosis was calculated by an expert radiologist. Results: Patient with wiltse approach has less blood loss, less operative time, less postoperative pain, less pain at the short and long term follow up. Conclusion: Wiltse approach appear to have lesser degree of postoperative pain, less muscle necrosis and less degree of blood loss., Purpose: The increasing number of fragility fractures of the sacrum is a clinical challenge, they present distinct fracture patterns and surgical treatment is limited by bone loss in face of osteoporosis. Methods: Using statistical computational methods, the mean bone mass distribution in Hounsfield units (HU) was calculated with Computed Tomography (CT) scans from 13 pelves with an non-displaced fracture of the sacrum (11 females and 2 males, mean age 79.6 years, SD +/-9.2). They were compared with intact pelves of 60 adults (32 females and 28 males, mean age 8.3 years, SD+/- 5.3). Virtual bone probes were measured along trans-sacral corridor S1 and S2. Results: A distinct bone mass distribution was found: Along trans-sacral corridors, a peak of high HU was located at the outer extremes corresponding to cortical bone of the auricular surface. This was followed by a region of minimal HU located paraforaminally lateral, a zone commonly called “alar void”. In the fractured sacra, very low HU were observed in the vertebral bodies. The fractured side had higher HU in the sacral ala comparing to the non-fractured side. Conclusions: The distinct fracture patterns occurring in fragility fractures of the sacrum could be explained by the lowest bone mass located paraforaminally lateral. The very low bone mass in the sacral bodies may explain screw loosening seen in treating these fractures. The comparably higher bone mass on the fractured side may be a valuable diagnostic tool., Introduction: The objective is to report the epidemiology, clinical aspects and outcome on the management of spinal cord injury (SCI) in children and adolescents. Materials and Methods: A retrospective study of children and adolescents diagnosed with spinal cord injury (SCI) was performed. The medical records and radiological images were reviewed. Variables were tabulated regarding the mechanism of trauma, level of injury, fracture classification, neurological examination, associated injuries, surgical techniques, outcome and complications. Patients without radiological evaluation in the preoperative and/or postoperative period and patients with SCI due to gunshot wound were excluded from the paper. All patients were evaluated preoperatively and at the last follow-up with a clinical and radiological examination. Results: Ninety-three children and adolescents with SCI were identified. The mean age of the sample was 16.0 (±2.87) years, varying from 1 to 18 years. Most of the patients were male (66.7%, 62/93). Falling was the main cause in 72% of the fractures, followed by car accidents (25.8%), and falling of heavy objects on the back (2.2%). The median time from injury to medical management was 8 (6 to 24) hours. Associated injuries in other sites than the spine were present in 38 cases (40.9%). The lumbar spine was the most common fractured segment. Multiple vertebra fracture was observed in 35 (37.6%) cases. Surgical treatment was performed in 89 cases (95.7%). The median time from injury to surgery was 4 (3 to 7) days. The pedicle screw was the most common device used for fixation in 82 cases (92.1%). The posterior approach was utilized in 81 patients (91.0%). Patients that underwent internal fixation without placement of autologous bone had the instrumentation removed 1.24 years (±0.48) after the surgical procedure. Perioperative complications were observed in 13 of the 93 patients (14%). Pneumonia was the most common complication being observed in 5 patients (38.5%). The variables related to unfavorable outcome (Frankel < 5) in the last evaluation were fracture on the upper thoracic level (P < .001) and AO classification type C (P < .001). Conclusions: SCI in children and adolescent are usually caused by a fall. Multiple fractures of the spine were observed in one-third of the patients. Visceral lesions were observed in 40.9% of the cases. Nineteen (19) percent of the patients did not achieve a normal neurological examination (Frankel E). The risk factors associated were fracture on the upper thoracic level (P < .001) and AO classification type C (P < .001)., Introduction: Transverse sacral fractures constitute less than 1% of all spinal fractures and only 3% to 5% of all sacral fractures. Because of their location, they have a high incidence of neurological deficits. Despite their gravity, no well-designed treatment protocol for these fractures exists until now. Purpose: Describe the clinical features of the transverse sacral fractures; the protocol and result of their treatment. Materials and Methods: It is a descriptive retrospective study of 6 years from 2011 to 2016. We included high transverse sacral fractures. Exclusion criteria are less transversal sacral fractures and conservative treatment. Results: We compiled 5 cases of high transverse sacral fractures over a period of 6 years. All the patients were men. The mean age was 30 years (range: 27–33). Injury mechanism was a fall usually landing on buttcocks. Clinically, all patients reported sacroccigeal pain. 4 of them presented the bladder blower disturbance (BBD) characterized by incontinence, retention or flaccid sphincters. All patients did not have associated thoracolumbar injuries. In every case, a plain X-ray and a computed tomography scan were obtained at admission. Magnetic resonance imaging was performed only in the case of neurological deficit. All the fractures were classified as type III according to Denis ET all. The fracture level was S2. All patients were operated at a mean period of 15 days (range: 13–18 days) following their injuries. A posterior reduction and stabilization using segmental lumbopelvic instrumentation in the case neurologically intact or screw plate in four cases was attempted, followed by extensive laminectomies of the lumbosacral area and posterolateral fusion in case of BBD. The relevant nerve roots were explored bilaterally and were found to be intact in 75% of cases. At mean 9.8 months clinical outcome was satisfactory with no local pain, neurological recovery (control of the urethral and anal sphincters; Perianal sensation) and no local infection; while the radiological results showed bone healing. Conclusion: Sacral fractures are frequently misdiagnosed. Because of the degree of displacement and the high chances of nonunion, the transverse sacral fracture should be considered unstable and be treated with stabilization. Decompression is required in cases of neural compression and should be performed even with fifteen days delay., Introduction: Sacral fractures in elderly patients are possible with low energy trauma but they can present the same patterns of fracture. Our goal was to evaluate the clinical outcome of ilio-pelvic fixation in patients over 65 years old. Material and Methods: From November 2014 to September 2016 we have analyzed 5 patients with Denis type 2 fracture and age > 65 years old. There were 3 males and 2 females (average age 72.4 years), in 4 cases there were anterior pelvis fractures or acetabular fractures; none of our cases had neurological symptoms. We observed verticalization time, clinical function, healing time and complications. The follow up was at least 1 year. Results: In all 5 cases after 3 days the patients were verticalized; according to Majeed scoring to evaluate the clinical function: postoperative pain, standing, sitting, work ability respectively were 18.2, 24.0, 8.6, 16.2 so were good results in all 5 cases. We had 1 case of superficial wound infection. Conclusion: Iliolumbar fixation has the advantage of a stable fixation that can allow patient to weight bearing early and quick verticalization., Introduction: Prompt surgical management after traumatic spinal cord injury (SCI) is nowadays recommended. After the initial impact, a plethora of secondary events is initiated. Among these, raised intraparenchymal pressure with consecutive increased intrathecal pressure has probably been underestimated. Recent studies provide some evidence that measuring the intraspinal pressure and durotomy might be beneficial for the patient. However, before performing these procedures an in-depth knowledge about the spinal meninges and their peculiarities is essential for spine surgeons. Material and Methods: A literature review of relevant articles is provided according with self designed neuroanatomical illustrations and appropriate institutional MRI scans of meningeal structures and spaces in the physiologic and posttraumatic situation. Results: Several differences between cranial and spinal meninges need to be highlighted. The arrangement of these structures creates some compartmentalization, which might be altered after spinal trauma. Recent data shows that the spinal cord is compressed against the dura mater in a significant amount of SCI patients causing a “compartment-like” syndrome. This implies that in some patients durotomy with consecutive expansion duroplasty in order to reduce intraspinal and improve spinal cord perfusion pressure seems to be justified. Among others, the role of the pia mater should not be underestimated. A review about the current neuroanatomical understanding of spinal meninges with according neuroradiologic examinations and their potential contribution to the acute and chronic surgical management is provided. Conclusion: A profound knowledge— even on an ultrastructural level - about the spinal meningeal structures is essential for surgeons dealing with SCI patients in the acute and chronic setting., Introduction: Spinal cord decompression with pedicle screws stabilization in case of traumatic injuries might be associated with a significant blood loss and morbidity with a considerable contribution of injured muscles in postoperative pain syndrome. The objective of this study is to compare the results of conventional interventions with less invasive ones using paraspinal approach and endoscopic assistance. Materials and Methods: This is a prospective non-randomized longitudinal case-control study of 74 consecutive patients. All patients presented with fresh fractures of either lumbar spine or thoracolumbar junction. Type of vertebra body injuries were complete and incomplete burst fractures (A3 and A4 types). 39 patients were treated using paraspinal approach for pedicle screws placement and less invasive transpedicular decompression (LISS group). Endoscopic assistance during decompresson was applied in 20 cases. Nineteen out of those patients were treated using combined approach applying less invasive anterior spondylodesis with endoscopic assistance. In 35 cases a conventional approach was used with broad exposure of spinal column structures, pedicle screws fixation and decompressive laminectomy (control group). 14 patients out of this group were treated using combined approach with conventional anterior spondylodesis. The length of approach, time of surgical intervention, blood loss and ODI 6 months after surgery were compared in two groups. Electromyography and ultrasound examination were used to assess postoperative paraspinal muscles injury. Student’s t-test was used to assess statistical significance of differences between two groups of patients. Results: A size of incision for dorsal decompression and stabilization approach was smaller in LISS group, mean values for LISS and control groups were 44.67 ± 0.74 mm and 110.71 ± 0.23 mm respectively (P < .0001). Intraoperatively blood loss almost halved in LISS group, mean values for LISS and control groups in case of short fixation (2 segments) were 242.56 ± 9.08 versus 480.00 ± 22.66 respectively (P < .0001), in case of extended fixation (3-4 segments) mean values were 250.00 ± 17.50 ml and 518.75 ± 26.57 ml respectively (P < .0001). Additional reduction in blood loss was achieved applying endoscopic assistance (227.0 ± 8.32 ml versus 269.00 ± 18.36 ml, P = .0032). Average duration of surgical intervention was 125.00 ± 5.00 min in LISS group and 166.77 ± 6.84 min in control group (P < .0001). A mean size of ventral approach in LISS group was 89.26 ± 5.00 mm versus 140.43 ± 0.63 mm in control group (P < .0001). Blood loss was considerably smaller in LISS group, mean values for LISS and control group were 478.95 ± 62.28 ml and 750.00 ± 73.75 ml respectively (P = .0042). Also a significant decrease in duration of surgical intervention was evident in LISS group (152.63 ± 6.18 min versus 228.57± 17.47 min in control group, P < .0001). Mean ODI scores were 13.50 ± 1.58% in LISS group versus 22.38 ± 1.84% in control group 6 months after surgery (P = .0004) and 8.00 ± 0.91% versus 14.00 ± 1.39% respectively 12 months after intervention (P = .0126). Electroneuromyography and ultrasound examination confirmed intact status of paraspinal muscles in LISS group. Conclusion: Less invasive techniques are effective measures to achieve a considerable decrease in blood loss, duration of interventions and intraoperative tissue damage. Preservation of tissues including paraspinal muscles using MISS techniques results in a significant long term decrease in ODI scores after spinal instrumentations., Introduction: Thoracolumbar (T-L) fracture management aims to prevent deformity and to promote healing. This requires identification and characterisation of the injury. The introduction of trauma protocols means that where there has been a dangerous mechanism of injury or the patient exhibits abnormal physiology, a CT scan is the default radiological investigation. This leaves a subgroup of patients who may have suffered T-L spinal trauma in whom plain X-rays (XRs) are performed. Our clinical experience suggests that AP (antero-posterior) views in these people are not particularly useful in management. The purpose of the study was to determine the contribution made by AP XRs in the management of people with these relatively low velocity injuries. Material and Methods: All people with a history of T-L trauma and suspected abnormal XR referred to the spinal service over 20 weeks were reviewed. Those with a CT scan performed prior to XRs were excluded. Four Consultant Spine Surgeons and four Consultant Neuroradiolgists were shown the lateral XR along with the history and examination findings recorded on the referral data base (ie, the information given to the consultant on the day of the referral). If patients had both erect and supine XRs on the same day, only the erect XRs were included in the study. We assumed that the latter were probably the films on which the referrals were based. If they were performed on different days, both the erect and supine XRs were included. They were asked to provide a management and/or follow-up imaging plan based on the XR. Then they were shown the AP XR and asked if they would like to change their advice. Any changes in advice were recorded. Results: 52 patients were included in the study. 34 sets of supine XRs and 40 sets of erect XRs were included (all with lateral and AP except 4 cases with only lateral erect XRs performed). This yielded 1152 film-consultants. Average age was 58.5 years (SD 18.9 years) with 30 males and 22 females. 45/52 (87%) were AO type A (compression-type) fractures and 7/52 (13%) had no clear fractures identified (possibly due to poor quality of the film or due to other underlying spinal deformities obscuring the picture). 24/52 (46%) of fractures appeared to be osteoporotic. 54% have fractures were between T11 and L2 inclusive. There was universal agreement between all assessors that in all cases the AP XR did not change the management plan. It was noted that they can be helpful to confirm levels at the TL junction if the lumbosacral junction is not demonstrated on the lateral film. Conclusion: Our results suggest that AP XRs do not contribute to the management of low velocity thoraco-lumbar fractures. Larger studies are required to support these findings but there appears to be potential to reduce both cost and radiation exposure., Introduction: To evaluate results regarding pain relief, spinal stabilization, and complication after treatment with percutaneous vertebroplasty and kyphoplasty. Material and Methods: A consecutive group of patients, undergoing vertebroplasty (103 patients) and kyphoplasty (82 patients) at our institution, between January 2010 and December 2014, were retrospectively reviewed. 103 patients underwent 127 vertebroplasty procedures under local anesthesia, and 82 patients underwent 88 kyphoplasty procedures, 13 under general and 75 under local anesthesia. A radiological assessment was achieved by the percentage of height restored, using both the preoperative and postoperative radiographs. The Visual analog scale scores, obtained pre and postoperatively were used for the clinical assessment. The activity levels were assessed preoperatively, after discharge and at the last follow up period, by the ambulatory status. Results: The vertebroplasty restored 28.61% anterior column and 31.42% middle column of the lost height. The kyphoplasty restored 34.61% anterior column and 52.34% middle column of the lost height (P = .432, P = .027). The postoperative pain was improved in all patients after both procedures. The postoperative Visual analog scale was 3.268 after the VP and 2.356 after the kyphoplasty (P = .634). The activity levels were improved in all patients after both procedures. Conclusion: The kyphoplasty was more efficient in restoring the middle vertebral body height than the VP in the treatment of Osteoporotic Compression Fractures. However, both procedures showed similar clinical improvements in the pain and restoration of the anterior vertebral body height in the treatment of Osteoporotic Compression Fractures., Introduction: Ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are spine disorders causing ossification of the spinal ligaments and loss of segmental motion. Both AS and DISH are associated with a significantly increased risk of spine fractures, even from relatively mild trauma, due to the long lever arms caused by the ossified ligaments, in combination with reduced bone quality. Conservative and operative treatment of spine fractures in these disorders is associated with high rates of complications and neurological deficit; hence there remains some controversy about the optimal approach. Since 2008, we have been treating these fractures with percutaneous instrumentation combined with poly methyl methacrylate (PMMA) augmentation of the pedicle screws. The current study assesses the outcomes associated with this surgical technique. Material and Methods: All imaging records for patients with who underwent surgery for thoraco-lumbar spine fractures between 2008-2015 at the Galilee Medical Center were reviewed, and cases with AS or DISH) were identified (n = 24). For these cases, a retrospective imaging and chart review was carried out, assessing surgical parameters and outcomes. Results: Twenty-six (24) patients with a thoraco-lumbar spine fracture and AS or DISH underwent surgery at the Galilee Medical Center since 2008. Eleven of the patients had a diagnosis of AS (45.8%), and thirteen had a diagnosis of DISH (54.16%). patients were predominantly (16/24) male, with a mean age at surgery of 76 years (range 54-88). Extent of vertebral involvement in ankylotic disease, as determined by review of the imaging averaged 14 vertebrae. Ankylosing disease was found in the thoracic vertebrae alone (19.2%), in thoracic and lumbar vertebrae (76.9%), or in cervical thoracic, and lumbar vertebrae (3.8%). Most (80.8%) of the patients underwent surgery within 7 days of admission, with 79.2% undergoing surgery within 48 hours. Percutaneous instrumentation spanned 2-6 levels. Surgical times ranged from 0:55-5:03 hours (mean 2:11 hours). Mean pre-post operative Hemoglobin concentration reduction was 1.21 gr%, with only 4 patients requiring blood product supplementation. 4 patients (16.6%) were admitted to ICU following surgery, for a duration of 2-7 days. 11 patients (45.8%) had medical post-operative complications, 1/24 had a superficial incisional infection. One patient died during the followup period due to an unrelated reason. The mean length of hospital stay was 14.55 days (3-33). Conclusions: This retrospective case-series of 24 consecutive patients demonstrates that percutaneous instrumentation allows rapid post-operative mobilization with relatively few surgical and post-surgical complications. Comparison with other published retrospective reviews shows favorable outcomes., Introduction: For lumbar burst fractures in young population, sometimes surgical treatment is chosen if destractionor neurological deficit is sever. Most of the time, two-disc levels fixation (above 1, below 1) is chosen, however, not small number of cases has burst fractre with intact caudal endplates. We propose here, combined posterior single disc level fixation and anterior interbody reconstruction for burst fractures with intact caudal endplate at lumbar lesion. Although 2 approaches are required, this method allows good clinical and radiological outcomes, minimizing the level fused. Material and Methods: Ten cases with lumbar burst fractures with intact caudal endplate (L1: 5, L2: 4, L3: 1) were treated by this 2-staged procedure. Average age was 30 (24-39). There were 4 males and 6 females. Indication was strictly limited to cases with injured posterior element and intact caudal endplate. Four cases had neurological disturbance (Frankel type 4). In the initial operation, a single disc-level fusion between affected vertebrae and cranial adjacent intact vertebral was performed using pedicle screw system. In this operation, the kyphotic alignment was reduced using the screw system. Then, anterior interbody fusion with cage and autogenous graft was performed. To assess clinical outcomes, vertebral kyphotic angle, two-levels kyphotic angle (affected vertebra-cranial adjacent intact vertebrae), and lordosis of the lumbar spine were measured in the preoperative period, immediately after the operations, and in the final follow-up period. Perioperative complication and final activity in the daily living were recorded. Results: In all cases, bony fusion was obtained. In 4 cases with Frankel grade 4, neurological status was improved in the final period. Average vertebral kyphotic angle of the affected vertebra was decreased from 17 deg. To 9 deg. Two-levels kyphotic angle was decreased from 17 to 8 (P < .05). Lordosis of the lumbar spine was also improved. As perioperative complication, one case suffered from superficial infection. In all cases, social activities were regained finally. No case claimed of loss of range of motion in their lumbar spine. Conclusion: Lumbar burst fractures with intact caudal endplate were successfully treated using single disc level fixation via 2-staged posterior and anterior approach. Since we can minimize the number of vertebrae fused in this method, while preservation of sagittal alignment is possible, this method is recommended as one of the minimum invasive technique., Introduction: To evaluate the clinical and Radiological outcome of spine fixation for unstable fractures at dorsolumbar junction including fractured vertebrae in Pedicular screw fixation. Material and Methods: Department of Orthopaedics and Spine surgery Ghurki Trust Teaching hospital Lahore Pakistan, Department of orthopedics and Traumatology, Khyber Teaching Hospital Peshawar, Pakistan from January 2010 to December 2014. One hundred and forty three patients were included in this study with single level fracture from D11 to L2. All patients had unstable fractures which needed fixation. Fixation was done from posterior with transpedicular screws and rods. We included fracture vertebrae in the fixation by putting transpedicular screws in fractured vertebrae. Patients were evaluated both radiologically and clinically. Radiological parameters were anterior and posterior vertebral heights, Cobb angle and sagittal index and clinical parameters were back pain using Visual Analogue Score (VAS) and disability using Oswestry disability index (ODI). All these parameters were measured before surgery immediately after surgery and at 6 months post-operatively. The data was analyzed using SPSS software version 17. Results: We included 143 patients in our study. Out of them 93 were males and 50 were females. In majority of our cases cause for spine trauma was fall from height, followed by road traffic accidents. Levels of spine fractures were 23, 47, 51, 22 at D11, D12, L1 and L2 respectively. The mean Cobb angle was 7.35 ± 4.57 preoperatively which improved to 2.18 ± 1.71 at final follow up. The mean anterior vertebral height was 17.45 ± 3.8 mm, which increased to 27.02 ± 3.83 mm at 6 month visit. The posterior vertebral body height was 26.81 ± 5.291 mm before surgery which increased to 39.63 ± 3.59 mm at 6 months postoperative visit. The pre-operative average sagittal index was 17.42°, which was reduced to an average 6.83° post operatively. According to Oswestry disability index for pain and mobility, the mean pre-operative score was 67.14 ± 17.68% which changed to 39.81 ± 20.56% at 6 months postoperative follow-up. Visual analogue score was 7.3 ± 1.3 preoperatively and it improved to 2.4 ± 0.9 at six months. No major complications occurred in our study like neurological deterioration, screw pull out, breakage of implant and Deep Vein Thrombosis, etc. Conclusion: Our study showed that transpedicular screw fixation is a good option for better outcome. When we include the fractured vertebrae in transpedicular screw fixation it improves the biomechanical stability i.e it gives extra pedicle for fixation which shorten the fixation segment and also help in reduction and deformity correction., Introduction: Vertebral fractures are one of the most important consequences of osteoporosis and trauma injuries, due to the particular anatomy and biomechanics of the entire spinal segment. This kind of disease is very important in medical care for their both economic and social impact. In medical literature, the incidence of vertebral fractures is variable, amounting to about 700:100,000 (90% due to osteoporosis, 10% trauma injuries) and approximately 10% of patients present a Multiple Fractures Vertebrae, defined as the involvement of >2 or more vertebrae. Material and Methods: From 2008 to 2016 about 902 patients underwent surgery for vertebral fracture; 97 of them presented a MFV (average age 63.7, 17-76); 83% of them presented a fracture due to osteoporosis and 17% by trauma injuries. In 32% were performed kiphoplasty and 68% spinal arthrodesis with posterior approach. Results: In one case of those who underwent kyphoplasty we had a cement leakage which however has not led to any complications for the patient. Regarding patients undergoing spinal arthrodesis in one case we had a malposition of the screws, for this reason he underwent again to surgery and one case of pull-out of the screws at a distance of about 7 months that lead as well to a re-operation. Conclusion: Treatment of these fractures appears to be a topic of discussion, it can be both surgical and conservative; the presence of neurological deficit, acute or chronic pain, vertebral instability and deformity correction leads to surgical indications, about 200:100,000 people: the most common approach to these fracture is the posterior way although there is still not a common consensus on the use of mono or pluri segmental instrumentation for these type of fractures. In our experience patients undergoing kyphoplasty procedure presented all an excellent post-operative recovery and return to normal daily activities quickly whereas patients who underwent spinal arthrodesis needed a longer recovery not referring always an optimal recovery status referred to the pre-op. Regarding the spinal arthrodesis we believe that short fixations (maximum 2 level above or below the fracture) should be preferred, when the case permits, for faster recovery time. By performing this study we were able to note that over the years has changed the type of treatment chosen, preferring more an arthrodesis rather than kyphoplasty, certainly because we improved our knowledge of this kind of diseases and how to treat them better., Introduction: Patients with unstable thoracolumbar spine fractures require surgical treatment to relieve pain, address paralysis, and stabilize the spine to prevent further segmental deformity. Optimal surgical treatment, however, still remains controversial. The purpose of this study is to examine the efficacy and safety of vertebrectomy and reconstruction of vertebral body using an expandable cage via a single-stage posterior approach for trauma-related unstable thoracolumbar spine fractures. Material and Methods: Thirty patients underwent single-stage posterior-only vertebral column resection and vertebral body reconstruction using an expandable cage. The spinal levels affected were T12 in 6 patients, L1 in 9, L2 in 4, L3 in 7, L4 in 3, and L5 in 1. Neurologic status was classified using the American Spinal Injury Association (ASIA) Impairment Scale, while functional outcome was analyzed using a visual analog scale (VAS) for back pain. Segmental Cobb angles were measured above and below the fractured vertebral body preoperatively, immediate postoperatively, and at the last follow-up. Results: The preoperative neurologic status was ASIA grade E in 6 patients, grade D in 13 patients, grade C in 5 patients, and grade B in 6 patients. Postoperatively, neurologic stability was demonstrated in 8 patients (26.7%), and 22 (73.3%) showed improvement in the ASIA grade. The mean preoperative VAS score was 8.6, which decreased to 4.3 postoperatively, and to 1.7 at the final follow-up. The mean preoperative segmental lordotic angle was 8.9°, which increased to 17.4° postoperatively, and decreased to 16.1° at the last follow-up. The mean operating time was 202.3 min, and the mean blood loss was 784.6 mL. Regarding surgical complications, an intraoperative dural tear occurred in two patients in earlier cases and cage subsidence in two severe osteoporotic patients. Conclusion: The results of our series suggest the feasibility, efficacy, and safety of this surgical option for unstable thoracolumbar spine fractures. This technique from a single posterior approach offers several advantages over traditional anterior or anterior-posterior combined approaches using strut graft or nonexpandable implants., Introduction: Spine fractures resulting from many causes particularly falls from height and road traffic accidents. It’s a major cause of disability if not treated properly. Many advocates are in the favor that pedicle fixation method is comparatively a safer procedure when compared to the risk factor at a non-pedicle counterpart. Open spine surgery is known with several limitations which include blood loss, elongated post-operative pain and disability risk. Minimal incision techniques were, therefore, a ‘looked-for’ advancement. Pedicle screw can be Polyaxial cannulated screw or Monoaxial solid screw. Our aim is to explore and find out if the screw design differences will affect the correction of the deformity after fixation of unstable spine fractures. Also, we compare the percentage of loss of Kyphotic correction after fixation between Polyaxial cannulated screw and Monoaxial solid screw systems. An attempt is made to compare short segment and long segment fixation with respect to the above said two groups. Methods and Materials: Retrospective case series of all pedicle screw fixation for traumatic thoracolumbar fracture (Open vs. MIS) in Hamad General Hospital, Doha, Qatar. The use of cannulated screws (CS) and solid core screws (SCS) during the two surgical modes named “traditional open” (OPEN) and “minimally invasive” (MISS) are considered for the study. The data comprised of patient details for the five years from 2011 to 2015 including pre-operative, intra-operative and post-operative data along with those about three follow-ups. General demographic of the patient (Age, sex), the data such as mechanism of injury, injury level, type of surgery (Open vs MISS), type of screwed used (cannulated screws and solid core screws) along with radiological parameters (vertebral height and kyphotic angle of the fractured vertebra) was collected. Results: 172 cases with traumatic thoracolumbar fracture underwent to pedicle screw fixation (Open vs MIS) either with CS or SCS. 142 male and 28 female, average age 36.1 ± 12.4 years, 100 open and 72 MIS, 76 solid and 96 cannulated screws. The average pre-operative, intra-operative and postoperative kyphotic angle of the fractured vertebra is respectively 18.9 ± 9.9 (range from 1 to 90), 7.4 ± 6.7 (range from 0 to 40) and 8.1 ± 6.5 (range from 0 to 40) degrees and an average 13.08 degree angle reduction is quantified with solid screws and 8.96 degrees with cannulated screws. Average height reduction in the pre-operative and post-operative stages shows a wide difference which indicates a successful height gain after surgery, and it is supported statistically while performing ANOVA (P < .05) in solid group comparing to cannulated one. Conclusion: Solid screws are found to be more superior in the increased correction of kyphotic angle and the height of the fractured vertebra., Introduction: Traumatic thoracolumbar spine fractures mostly occur in relatively young patients as a consequence of high energy trauma. Dependent of fracture morphology and neurology, surgical stabilization with a posterior implant might be necessary. Debate remains whether posterior implants after thoracolumbar spine fracture stabilization should be removed routinely or only in symptomatic cases. Possible concerns of implants are decreased motion, disc degeneration, facet arthrosis, metal fretting, infections and osteopenia caused by stress shielding. On the contrary, removal of the implant is a secondary surgical procedure with accompanying risks such as surgical site infection, neurovascular injury and refracture. The aim of this study was to evaluate safety, patient satisfaction and quality of life after implant removal. Material and Methods: A retrospective cohort study was performed concerning 102 patients that underwent posterior implant removal after posterior stabilization of one or more traumatic thoracolumbar fractures between 2003 – 2015 in our university medical center. All available radiographic material from time of injury was reassessed for latest AO fracture classification and degree of kyphosis before and after implantation removal. Outpatient hospital charts were reviewed to gather information about the amount of subjective complaints before and after implant removal. All patients were invited to fill out three validated questionnaires concerning quality of life (SF-36, EQ-5D) and back specific function (RMDQ) after implant removal. Additionally, questions concerning satisfaction regarding the procedure were presented. Results: The mean time between fracture surgery and implant removal was 12 months (IQR 10-14), the mean age was 38 years (18-78). Mean time from implant removal to time of questionnaire was seven years (SD 43). Complications were present in 8% of cases, most of which were superficial wound infections. Sixty-two patients (61%) responded to our invitation to fill in the questionnaires. Scores were stratified for polytrauma patients (ISS ≥ 16) which was an effect modifier. The average quality of life was slightly lower compared to a normative population but still considerably high. Patients had less back pain related disability compared to chronic low back pain patients. The majority of all groups experienced benefit, satisfaction and would hypothetically undergo a re-removal. After removal there was a kyphosis increase which did not correspond with clinical outcome. Removal decreased most complaints and routine(asymptomatic) patients also experienced benefit. A subjective increase of complaints after removal was reported in 11% of patients. Conclusion: Overall, this study shows that implant removal after posterior fixation of thoracolumbar spine fractures is a safe procedure and provides high patient satisfaction. Overall patients have a fairly good quality of life. Most symptomatic and asymptomatic patients report benefit from removal. However low risks of complications and increase of symptoms have to be weighted for individual patients., Background: Gold-standard surgical treatment for vertebral compression fractures (VCF) includes vertebroplasty and kyphoplasty, which relies on cement to provide vertebral body (VB) stability, VB height increase and lordotic alignment. However, cement-kyphoplasty fails primary VB restoration in 34% of cases and secondary loss of height in 18-63%. Cement has adverse effect of bony consolidation and fracture healing favoring the migration of the bloc of cement. It also affects biomechanical properties of bone, increases stiffness and rigidity, which may promote adjacent fractures. Additionally, cement leakage may cause spinal cord compression, and pulmonary embolism, which may be potentially serious. Recently, a novel OsseoFix Spinal Fracture Reduction System has become available. It features a percutaneously implantable titanium scaffold that expands within the vertebral body. The aim of this study is to evaluate VCF fixation using OsseoFix without cement. We hypothesized that the titanium mesh scaffold without cement can adequately restore VB height and sagittal alignment lost in VCFs, translating to good radiological outcomes. Material and Methods: 13 patients (5 males and 8 females, mean age 63.5) diagnosed with VCFs were included in this study. Osteoporosis, trauma and tumor were concomitant with VCFs in 7, 3 and 3 patients, respectively. A total of 28 vertebrae were treated, with one implant in 6 vertebrae and two implants in 22 vertebrae. Anterior, middle and posterior VB heights (AH, MH, PH) and index level Kyphotic angle (KA) were evaluated pre- operatively, at immediate post-operatively, and at last follow-ups. Results: All 50 implants were optimally positioned and deployed without any complication. Stabilization of the collapsed vertebral body was achieved in all 28 vertebras. Mean follow-up was 26 months (18-34months). The postoperative kyphotic angle (KA) revealed significant improvements (KA 12.2° to 7.2°, P < .01) with partial loss of reduction at final follow-up (KA 8.6°). AH, an indicator of vertebral body reduction, improved significantly from 20.6 ± 1.9 mm preoperatively to 25.1 ± 2.0 mm (P < .05) postoperatively, but decreased to 21.5 ± 1.1 (P < .01 [postoperative vs. follow-up]) at final follow-up. Correspondingly, MH improved from 18.39 ± 1.7 mm to 24.6 ± 2.0 and finally declined to 22.5 ± 1.9 mm. PH changed from 28,31.8±1.7 mm to 32.3 ± 1.9 mm postoperatively to 30.7 ±1 .9 mm at final follow-up. Conclusions: Percutaneous implantation of OsseoFix to treat VCFs provides good radiological outcomes at a low complication rate. As it provides an adequate maintenance of reduction, OsseoFix implantation offers an effective alternative to vertebroplasty or kyphoplasty, eliminating any cement-related complications. This study prompts additional studies with longer follow-ups for this novel cement-free vertebral stent as a potential next-generation treatment of VCFs., Introduction: The vertebral fracture is a wound that grows from a vertebral body to the vertebral function unit. In Mexico the most affected vertebras are the ones between T11 and L1 in the 52% of the cases, in which the 45% happen after a bursting wound, most of them are caused by fallings (50.5%). The toracolumbar vertebral column bursting fractures can be treated in a conservative or surgical ways. Having a lack of information regarding this cases in Mexico. The objective is identify the category of the evidence and the recommendation of conservative treatment for these kind of fractures. Material and Methods: A check up was performed in the period started in April 2014 and finished in June 20015, selecting articles according to their design, related to the toracolumbar vertebral column bursting fractures and their possible treatment, published in electronic bibliographies during January 2009 and January 20015. Results: It was found a total of 9,504 articles in which 7 fulfill the criteria of selection and were included for their analysis. A total of 435 patients were analyzed, in which 72 patients received a surgical treatment and 363 received a conservative treatment. Showing an evidence of “1b” with a recommendation force type “A”. Conclusion: According to the evidence, the conservative treatment is a choice for the patients with stable bursting fracture, without neurological wound and in one level of the toracolumbar vertebral column., Purpose: The purpose of our study is to evaluate the therapeutic efficacy of short-segment percutaneous pedicle screw fixation with polymethylmethacrylate (PMMA) augmentation for the treatment of osteoporotic thoracolumbar compression fracture with osteonecrosis. Methods: Osteoporotic thoracolumbar compression fractures with avascular necrosis were treated by short-segment PPF with PMMA augmentation. Eighteen were followed up for more than 2 years. The kyphotic angle, compression ratio, visual analog scale (VAS) score for back pain, and the Oswestry Disability Index (ODI) were analyzed. In addition, radiologic and clinical parameters of PPF group were compared with percutaneous vertebroplasty (PVP) group. Results: Vertebral height and kyphotic angle of the compressed vertebral bodies were significantly corrected after the operation (P < .05). Further, restored vertebral height was maintained during the 2 or more years of postoperative follow-up. Compared to the PVP group the postoperative compression ratio and kyphotic angle were significantly lower in the PPF group (P < .05). The postoperative ODI and VAS of the PVP group were significantly higher than the PPF (P < .05). Conclusions: According to our results, short-segment PPF with PMMA augmentation may be an effective minimally invasive treatment for osteoporosis in cases of osteoporotic vertebral compression fractures with Kummell’s osteonecrosis., Introduction: Preclinical evidence suggests that persistent compression of the spinal cord after a primary injury represents a reversible form of secondary injury which, if ameliorated in an expeditious fashion, may lead to reduced neural tissue injury and improved outcomes. The objective of this guideline is to discuss the timing of surgical decompression in patients with traumatic spinal cord injury (SCI) and central cord syndrome. Material and Methods: A systematic review of the literature was conducted to address the following key questions: (1) what is the efficacy and effectiveness of early decompression (≤ 24 hours) compared with late decompression (>24 hours) or conservative therapy based on clinically important change in neurological status?; (2) does timing of decompression influence functional or administrative outcomes?; (3) what is the safety profile of early decompression compared with late decompression or conservative therapy?; (4) what is the evidence that early decompression has differential efficacy or safety in subpopulations?; and (5) what is the comparative cost-effectiveness of early versus late decompression? A multidisciplinary guideline development group used this information, in combination with clinical expertise, to develop recommendations for the timing of surgical decompression in patients with SCI and central cord syndrome. The benefits and harms, financial impact, acceptability, feasibility and patient preferences of each recommendation were carefully considered. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weak recommendation is indicated by “we suggest”. Results: The main conclusions from the systematic review included: (1) isolated studies reported statistically significant and clinically important improvements following early decompression (versus late) at 6 months (cervical injury, low strength of evidence) and following discharge from inpatient rehabilitation (all levels, very low level evidence) but not at other time points; (2) in one study on acute central cord syndrome without instability, a marginally significant improvement in total motor scores was reported at six and 12 months in patients managed early versus late; however, there were no significant differences between groups with respect to improvement in AISA Impairment Scale (very low strength of evidence); and (3) there were no significant differences in length of acute care/rehabilitation stay or in rates of complications between treatment groups (low to very low level evidence). Our recommendations were: “We suggest that early surgery be considered as a treatment option in adult patients with traumatic central cord syndrome” and “We suggest that early surgery be offered as an option for adult acute SCI patients regardless of level.” Quality of evidence for both recommendations was considered low. Conclusion: These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in patients with acute SCI and central cord syndrome by promoting standardization of care, decreasing the heterogeneity of management strategies and encouraging clinicians to make evidence-informed decisions. These guidelines are intended to be used by first responders, emergency room physicians, critical care specialists, neurologists and spine surgeons., Introduction: Given its potent anti-inflammatory actions, methylprednisolone sodium succinate (MPSS) may have potential neuroprotective effects in patients with spinal cord injury (SCI) when administered at high doses. The objective of this guideline is to outline the appropriate use of MPSS in patients with traumatic SCI. Material and Methods: A systematic review of the literature was conducted to address the following key questions: (1) what is the efficacy, effectiveness and safety of MPSS compared with no pharmacologic treatment?; and (2) what is the evidence that MPSS has differential efficacy or safety in subpopulations? A multidisciplinary guideline development group used this information, in combination with their clinical expertise, to develop recommendations for the use of MPSS. The benefits and harms, financial impact, acceptability, feasibility and patient preferences of each recommendation were carefully considered. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weaker recommendation is indicated by “we suggest.” Results: The main conclusions from the systematic review included: (1) there were no differences in motor change at any time point in patients treated with MPSS compared to those not receiving steroids (moderate level evidence); (2) when MPSS was administered within 8-hours of injury, pooled results at 6- and 12-months indicate modest improvements in mean motor scores in the MPSS group compared with the control group (moderate level evidence); (3) there was no statistical difference between treatment groups in the risk of death, wound infection, gastrointestinal hemorrhage, sepsis, urinary tract infection, pneumonia or decubitus ulcers (moderate level evidence). Our recommendations were: (1) “We suggest not offering a 24 hour infusion of high dose MPSS to adult patients who present after 8 hours of acute SCI” (moderate evidence); (2) “When started within 8 hours of injury, we suggest that a 24 hour infusion of high dose MPSS be offered to adult patients with acute SCI as a treatment option” (moderate evidence); and (3) “We suggest not offering a 48 hour infusion of high dose MPSS for adult patients with acute SCI” (no included studies, expert opinion). Conclusion: These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care, decreasing the heterogeneity of management strategies and encouraging clinicians to make evidence-informed decisions. These guidelines are intended for use by first responders, emergency room physicians, critical care specialists, neurologists and spine surgeons., Introduction: Patients with spinal cord injury (SCI) are at an increased risk of venous thromboembolism (VTE) due to hypercoagulability, stasis and intimal injury. The prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE) is critical in this high-risk population. The objective of this study is to develop guidelines that outline optimal anticoagulation strategies in patients with SCI. Material and Methods: A systematic review of the literature was conducted to address the following key questions: (1) what is the comparative effectiveness and safety of pharmacological, mechanical and/or invasive anticoagulation strategies for preventing DVT and PE; and (2) what is the optimal timing to initiate and/or discontinue anticoagulation prophylaxis following injury. A multidisciplinary guideline development group used this evidence, in combination with their clinical expertise, to develop recommendations for the optimal prophylaxis strategies. The benefits and harms, financial impact, acceptability, feasibility and patient preferences of each recommendation were carefully considered. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weaker recommendation is indicated by “we suggest”. Results: The main conclusions from the systematic review included: (1) patients treated with enoxaparin had a lower rate of DVT than those who received no pharmacological prophylaxis; (2) there were no significant differences in the rate of DVT between patients treated with enoxaparin versus dalteparin or low molecular weight heparin (LMWH) versus unfractionated heparin (UFH); (3) the risks of DVT and PE were greater in a fixed-dose UFH group, but the risk of bleeding was significantly higher in an adjusted-dose UFH group; (4) ptients treated with combined pharmacological and mechanical prophylaxis had lower rates of DVT than those who received only pharmacological therapies; however, this difference did not translate into a reduced risk of PE; and (5) the risk of DVT was significantly lower in patients treated within 72 hours of injury compared to those treated after 72 hours of injury. Our recommendations included: (1) “We suggest that prophylactic antithrombotic pharmacological therapy be offered to minimize the risk of thromboembolic events in the acute period after SCI”; (2) “We suggest that prophylactic antithrombotic pharmacological therapy, consisting of either subcutaneous LMWH or fixed-dose UFH be offered to minimize the risk of thromboembolic events in the acute period after SCI. Given the potential for increased bleeding events with the use of adjusted-dose UFH, we suggest against this treatment option”; and (3) “We suggest commencing prophylactic antithrombotic pharmacological therapy within the first 72 hours after injury in order to minimize the risk of venous thromboembolic complications during the period of acute hospitalization”. Conclusion: These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care, decreasing the heterogeneity of management strategies and encouraging clinicians to make evidence-informed decisions. These guidelines are intended to be used by emergency room physicians, critical care specialists, anesthesiologists, vascular medicine physicians, neurologists and spine surgeons., Introduction: Magnetic resonance imaging (MRI) is the gold standard for imaging the spinal cord and related soft tissues; however, there remains debate about the appropriate use of MRI in patients with acute spinal cord injury (SCI) as it requires considerable resources and may be risky in trauma patients with respiratory difficulties or hemodynamic instability. The objective of this guideline is to outline the role of MRI in clinical decision making and outcome prediction in patients with traumatic SCI. Material and Methods: A systematic review of the literature was conducted to address the following key questions and inform guideline development: (1) how does the acquisition of a baseline MRI influence management strategy(ies) and, consequently, neurologic, functional, patient-reported and safety outcomes?; (2) do spinal cord lesion characteristics, pattern and length identified on baseline MRI predict neurologic, functional, patient-reported, and safety outcomes?; (3) do spinal cord characteristics identified on diffusion tensor imaging (DTI) predict neurologic, functional, patient-reported and safety outcomes?; (4) is there evidence to suggest that baseline MRI is cost-effective in patients with acute SCI? This review focused on longitundial studies which controlled for baseline neurologic status. A multidisciplinary guideline development group (GDG) used this information, in combination with clinical expertise and patient input, to develop recommendations on the use of MRI in the evaluation and treatment of patients with SCI. The benefits and harms, financial impact, acceptability, feasibility and patient preferences of each recommendation were carefully considered. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weaker recommendation is indicated by “we suggest”. Results: The main conclusions from the systematic review included: (1) no studies were identified that directly evaluated the impact of baseline MRI on treatment strategies; however, in one study, patients in a MRI-protocol group improved by an additional 7/10 of a Frankel grade compared to those who did not receive MRI (very low level evidence); (2) longer intramedullary hemorrhage (two studies, moderate evidence) and smaller spinal canal diameter at the level of maximal spinal cord compression (one study, low level of evidence) were predictive of decreased neurological recovery; (3) several features were inconsistently associated with worse neurologic recovery, including presence of intramedullary hemorrhage or intra-axial hematoma (three of five studies showed association, low quality evidence), maximum canal compromise (one of two studies showed association, low quality evidence) and longer edema length (no association in two of three studies following multivariate analysis, very low quality evidence) and (4) there was no association between degree of maximal spinal cord compression, lesion length, or cord edema and neurological recovery (low to moderate level evidence). Based on the limited available evidence and the clinical expertise of the GDG, our recommendations were: (1) “We suggest that MRI be performed in adult patients with acute spinal cord injury prior to surgical intervention, when feasible, to facilitate improved clinical decision-making” (quality of evidence, very low) and (2) “We suggest that MRI should be performed in adult patients in the acute period following SCI, before or after surgical intervention, to improve prediction of neurologic outcome” (quality of evidence, low). Conclusion: These guidelines should be implemented into clinical practice to improve outcomes and prognostication for patients with SCI by promoting standardization of care and encouraging clinicians to make evidence-informed decisions. These guidelines are intended to be used by emergency room physicians, critical care specialists, radiologists, neurologists and spine surgeons., Introduction: Rehabilitation plays a central role in maximizing function and facilitating community reintegration following a spinal cord injury (SCI). Despite this, many fundamental questions remain regarding the timing and efficacy of various rehabilitation strategies. The objective of this study is to develop guidelines that outline the appropriate type and timing of rehabilitation in patients with acute SCI. Material and Methods: A systematic review of the literature was conducted to address the following questions: (1) Does the time interval between injury and commencing rehabilitation affect outcome? (2) What is the comparative effectiveness of different rehabilitation strategies? (3) Are there patient or injury characteristics that impact the efficacy of rehabilitation? (4) What is the cost-effectiveness of various rehabilitation strategies? A multidisciplinary guideline development group used this information, in combination with their clinical expertise, to develop recommendations for the type and timing of rehabilitation. The benefits and harms, financial impact, acceptability, feasibility and patient preferences of each recommendation were carefully considered. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weaker recommendation is indicated by “we suggest”. Results: The main conclusions from the systematic review included: (1) there was no difference between body weight supported treadmill training (BWSTT) and conventional rehabilitation with respect to improvements in Functional Independence Measure-Locomotor (FIM-L) and Lower Extremity Motor Scores (LEMS) (low level evidence); (2) functional electric stimulation (FES) resulted in slightly better FIM Motor, FIM Self-Care and Spinal Cord Independence Measure (SCIM) Self-Care subscores compared with conventional occupational therapy (low level evidence); and (3) there were no differences between training unsupported sitting and control/standard in-patient therapy with respect to maximal lean test, maximal sideward reach test, T-shirt test, and Canadian Occupational Performance Measure performance and satisfaction scores (low level evidence). Our recommendations were: (1) We suggest rehabilitation be offered to patients with acute spinal cord injury when they are medically stable and can tolerate required rehabilitation intensity (no included studies; expert opinion; (2) We suggest BWSTT as an option for ambulation training in addition to conventional overground walking, dependent on resource availability, context, and local expertise (low evidence); (3) We suggest that individuals with acute and subacute cervical SCI be offered FES as an option to improve hand and upper extremity function (low evidence); and (4) Based on the absence of any clear benefit, we suggest not offering additional training in unsupported sitting beyond what is currently incorporated in standard rehabilitation (low evidence). Conclusion: These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care, decreasing the heterogeneity of management strategies and encouraging clinicians to make evidence-informed decisions. These guidelines are intended for use by neurologists, spine surgeons, physiatrists, sport medicine physicians and rehabilitation specialists (including physiotherapists and occupational therapists)., Introduction: Traumatic vertebral burst fractures can be surgically approached via different approaches including anterior, posterior, or combined approaches. The posterior transpedicular approach (PTA) is a posterior approach that has the advantage of achieving circumferential arthrodesis via single posterior only approach. However, the presence of indispensable lumbar nerve roots makes it surgically challenging approach in lumbar region. Material & Methods: We conducted a retrospective study at our tertiary care trauma centre to analyse our experience with PTA in the management of traumatic lumbar burst fractures (TLBFs). All consecutive patients with TLBFs managed with PTA over 5 years duration were analysed and 35 patients with available followup were included. Neurological outcome, correction of kyphosis, complications and operative parameters were analysed. Inpatient/outpatient records and operation notes were scrutinised to collate data. Radiological data was retrieved from institutional picture archiving and communication system.Correction of kyphotic deformity and change in neurological status were analysed to assess outcome. Cobb’s angle and ASIA grade were used for this purpose. Results: There were 21 males and 14 females. L1& L2 were the most common vertebrae involved. Eight patients had complete (ASIA-A) while 22 had incomplete injury. The mean preoperative cobb’s angle was 13.97° that improved to -3.57° postoperatively, thus achieving a mean kyphosis correction of 17.54°. None of the patients developed iatrogenic nerve root injury. There was no peri-operative mortality. Two patients developed wound dehiscence that required debridement. At a mean followup of 29.1 months, mean cobb’s angle was 1.23°. Eight patients developed cage subsidence but none required revision surgery. Postoperatively, 27 (77.1%) patients showed neurological improvement and none deteriorated. The average ASIA score improved from 2.97 to 4.17. A fusion rate of 59.3% was observed at last followup. Conclusions: The advantages of PTA including sense of familiarity with posterior approach amongst spine surgeons, lesser approach related morbidity and results comparable to anterior or combined approaches, make PTA an attractive option for managing TLBFs. Although technically difficult in lumbar region, it can be used for circumferential arthrodesis without sacrificing the nerve roots., Introduction: The thoracic and lumbar fractures in the immature skeleton are rare injuries. Material and Methods: In order to know the characteristics of these lesions in our environment and compare with those the adults, a transversal and descriptive study of adolescents between 12 and 18 years who were hospitalized for thoracic and lumbar fracture in two centers of high level trauma in our country for 8 year was performed. The variables studied were applied statistical analysis descriptive and correlation. Results: They were studied 135 spinal fractures in 96 patients, 125 were traumatic fractures and 10 fractures projectile gun. An increase in the frequency of thoracic and lumbar fractures in adolescents with increasing age was found. They were found significant date by associating the causes of damage with associated lesions (P = .006) and the initial neurological damage associated with the final neurological damage (P = .001). Conclusion: The thoracic and lumbar fractures in adolescents caused by road accidents are associated with lesions in the chest and abdomen. And when are caused by falls are associated with lower extremity fractures. In addition, 13.5% of cases showed significant changes toward improvement in the initial neurological damage., Introduction: Traumatic burst fractures make up between 30 to 64% of all thoracolumbar spine fractures. Fractures of this type are very painful for patients and offer a unique challenge for the spine surgeon not only in terms of pain control but also in terms of biomechanical strength and maintenance of deformity correction. A number of different approaches, techniques, and instrumentation have been used for the operative treatment of thoracolumbar injury, each with their own inherent limitations. To our knowledge, there has never been documented use of mesh-contained bone graft for vertebral body augmentation with non-fusion short-segment pedicle screw and rod fixation for the operative management of burst fractures. Material and Methods: Our patient is a 55-year old right hand dominant male who presented following a fall from 5 feet while on a ladder working on his shed. He had landed on his buttocks. He complained of excruciating low back pain without radiation and exhibited significant percussion tenderness. He denied any bowel or bladder incontinence and there was no paresis or saddle anesthesia. His past medical and surgical history are negative and he denies use of tobacco products. The initial lumbar plain film x-ray demonstrated anterior wedging of the L1 vertebral body. A computed tomography scan was then conducted which demonstrated a burst fracture with resultant 25% height loss. Magnetic resonance imaging did not demonstrate posterior ligamentous injury. Due to his intractable back pain he was taken to the operative suite where we placed percutaneous screws at T12 and L2 before performing the percutaneous vertebral body augmentation utilizing mesh contained bone graft. About 12 cc of bone graft was tamped into the mesh bag and placed into the vertebral body of L1 through a unilateral extrapedicular method. Titanium pedicle screws were used bilaterally at the level of T12 and L2 along with rods. The patient was given a TLSO brace for ambulation and was weight bearing the night of the surgery and his pain was significantly reduced. The patient was discharged home the following day. He was followed up at 2 weeks post op and only complained of minimal back spasms. Results: At his 2-month post op visit the patient endorsed improvement in back pain and was actually back to work pouring concrete. He was given a 60-pound weight restriction but later requested to increase the weight restriction to 75 pounds. Post-operative imaging was obtained on post-operative day 1, 1 month post-operatively and 4 months post-operatively. Conclusion: Stabilizing a burst fracture associated with thoracolumbar trauma is feasible using completely minimally invasive techniques. Here, we describe a treatment modality that allows for vertebral body height restoration, kyphotic deformity correction, spinal canal diameter widening through ligamentotaxis, and vertebral body fracture healing. Even in the setting of fractured pedicles our described procedure is possible and demonstrated a decrease in pain, a short hospital stay, and quick return to work., Introduction: To evaluate the efficacy of short segment stabilization compared with that of long-segment stabilization in terms of clinical and the radiological outcomes in unstable thoracolumbar junction burst fractures. Material and Methods: 88 patients (age range 19-50, mean 32 years) with thoracolumbar burst fracture (T10–L2) in Magerl Type A fractures underwent posterior pedicle screw fixation from January 2004 to December 2014, studied retrospectively. They were divided into two groups: the short-segment group (SS) included pedicle screw fixation in the fractured vertebral body (six screws), and the long-segment group (LS) included pedicle screw fixation, 2 level above and 2 level below the fractured vertebral body (8 screws). Clinical parameters: back pain using VAS and disability ODI, neurological deficit (using ASIA grade) and radiologic parameters (Cobb angle, the kyphotic deformation and vertebral height) were measured before surgery and immediately after surgery and at 3, 6 and 12 months postoperatively. Overall outcomes were evaluated using the modified Mcnab criteria at the last follow-up. Chi-squared test and paired-t test were used for statistical analysis using SPSS. Results: 36 and 52 patients in the short-segment and long-segment group, respectively. Male-female ratio was 1:0.44 and 1:0.57, the mean age of the patients was 30.6 ± 8.4 and 33.4 ±8.4 years and the mean follow-up period was 24.5 and 16.8 months in SS-segment and LS-segment respectively. In the SS-group, the fractured vertebral body level was L1, T12, L2, T11, and T10 in 15 (41.6%), 10 (27.7%), 6 (15.6%), 3 (08.3%), and 2 (05.56.3%) cases and in the LS-group, the fractured vertebral body level was L1, T12, L2, T11, and T10 in 22 (42.31%),17 (32.69%), 5 (9.61%), 5 (9.61%) and 3 (5.76%) cases, respectively. Both groups achieved satisfactory clinical outcomes modified (Mcnab criteria). In the SS-group, 8 (22.22%), 21 (58.33%), and 7 (1944%) cases were considered to have excellent, good, and fair outcome and in the LS-group, 18 (34.61%), 25 (48.08%), 6 (11.54%), and 3 (5.77%) cases were considered to have excellent, good, fair, and poor outcome, respectively. The mean kyphotic angle at preoperative, postoperative and final follow up was 13.5±6.3, 13.4±4.3, 8.5±6 and 4.4±3.1, 5.4±2.8, 6.0±4.0 in the SS and LS-group respectively. The average loss of kyphosis correction was 7.5° ± 4.4° in the SS-group and 10.5° ± 4.8° in the LS- group at the final follow-up, with no significant differences between the two groups (P > .05). The mean pre and post operative kyphotic deformation of vertebral body was 5.1±3.2, 4.8±2.3 and 1.9±1.3, 2.2±2.1 and at final follow up was 4.5 ±4.0 and 4.0±1.5 in the SS and LS- group respectively (p > 0.05). The mean anterior and posterior vertebral height also showed significant improvements postoperatively, which were maintained at the final follow-up. The mean ODI and VAS scores at the end of 1 year were 17.5%, 16.5% and, 3.6 ± 1.8 2.9 ± 1.4 in SS and LS- group respectively. There was no case of major complication after surgery and during the follow-up period. Conclusion: Short-segment pedicle screw fixation including the fractured vertebral body might be as effective as long-segment pedicle screw fixation for the treatment of unstable thoracolumbar spinal burst fracture., Introduction: This paper presents a prospective comparative case study with the objective to test the hypotheses, wherever: a) PEEK with either Sr-HA or PMMA equally restores thoracolumbar A2 and A3/AO type vertebral body fractures; b) both Sr-HA and PMMA have similar leakage; c) Sr-HA is fully resorbed and replaced by bone. Materials & Methods: Two matched groups of 10 patients, each received percutaneous pedicle screws plus PEEK filled with Sr-HA or PMMA. Segmental kyphosis (SKA), anterior (AVBHr), middle (MVBHr) and posterior (PVBHr) vertebral body height ratio, spinal canal encroachment (SCE), cement leakage, Sr-HA resorption were recorded and compared. The follow-up was 28 months, range 24-33 months. Results: AVBHr, MVBHr, SKA and SCE improved postoperatively in both groups. PMMA leakage observed in one case and there was no Sr-HA leakage. In contrast to PMMA complete Sr-HA resorption and replacement with bone was recorded 8 months postoperatively. Conclusions: The three hypotheses of this prospective comparative case study were all justified from the achieved radiological results, Introduction: The natural healing of spinal tuberculosis occurs by spontaneous fusion of vertebral bodies with or without kyphotic deformity. We report a rare case of Late onset paraplegia secondary to traumatic fracture of fusion mass in healed tuberculosis which has not been reported till date. Material/Case Report: A 56 year old male patient sustained road traffic accident was diagnosed with fracture of fusion mass in already healed tuberculosis. He presented with weakness in both lower limbs with ASIA-C grading of spinal cord injury. Results: He was treated with posterior instrumented stabilization and decompression. Patient recovered well post operatively and has regained his complete power of both lower limbs. Discussion: Late onset paraplegia in old healed spinal tuberculosis is a well known entity that maybe caused due to compression of cord by a internal gibbus or when the formed granulation/ fibrous tissue constricts the cord. Fusion mass fractures are not very uncommon in conditions such as ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis. Traumatic fractures tend to occur at the adjacent vertebral bodies to the fused ones as the biomechanical stress at the junctional site is far higher than at the center of the fused mass. In healed spinal tuberculosis, resultant deformity would be kyphosis. The angle of kyphosis is directly propotional to the resulting neurological deficit. Fractures of fused mass in healed tuberculosis are similar to the fractures in other ossifying bone lesions. Conclusion: Purpose of this article is to document the rare possibility of late onset paraplegia in un-instrumented old healed spinal tuberculosis with kyphotic deformity, due to fracture of fusion mass as seen in ankylosing spondylitis., Introduction: Vertebroplasty and kyphoplasty(VP/KP) are a successful treatment method for vertebral compression fractures(VCF) and improving pain. Although incidence of symptomatic complication for them is 1.6-3.8%, it has been reported to lead a range of 5-80% radiological complications. Material and Methods: Between June 2010 and December 2015, we performed VP/KP procedure for 52 cases who suffered from VCF and these cases retrospectively analyzed. Results: The group included 32 female (61.5%) and 20 male (38.5%), all of the patients were admitted with the complaint of severe pain and neurological examinations were intact in 48 (92.3%). The criterion for performing VP/KP was accepted as hyperintensity in T2 and/or STIR sequences in MRI. VP/KP was introduced to 71 VCF. Forty-two cases had a history of trauma, but initial diagnosis was tumor in 10 cases, inside whose 4 had weakness and/or numbness. Average of preoperative VAS were 8,09 points. All operations were performed under local anesthesia. KP was applied to 29(55.,8%) and VP 23(44.2%) patients, via bilateral transpedincular approach in 39 and unilateral in 13 cases. Average VAS was 2.3 (P ≤ .05). Postoperative CT scans showed no cement leakage in 27 (51,9%). Leakage was observed in 25(48.1%). Distribution of leakage according to region as follows; towards the intervertebral disk space in 12 (23.07%), epidural venous plexus in 11 (21.1%), paravertebral space in 6 (11.5%) and into spinal canal in 4 (7.6%) patients, while there was a reported pulmonary embolism in 1 (1.9%) case. The mean follow-up was 23.7 months. There was a reduction in segmental kyphotic angles from an average degree of 19.9 to 17.2 (P ≥ .05) which wasn’t statistically significant. Conclusion: VP/KP treatments have low symptomatic complication rates, on the other hand cement leakage is higher than expected. Using local anesthesia in VP/KP procedures is helpful to make the surgeon more alert for these complications during both guide installment and cement placement; even if a cement leakage occurs., Introduction: Objective: To investigate if evidence-based principles of oncologic resection for primary spinal tumors are correlated with 1) an acceptable morbidity and mortality profile and 2) satisfactory health-related quality of life (HRQOL) measures. Summary of Background Data: Respecting oncologic principles for primary spinal tumor surgery is correlated with lower recurrence rates. However, these interventions are often highly morbid. Material and Methods: A systematic literature review was performed to address the objectives by searching MEDLINE and EBMR databases. Articles that met our inclusion criteria were reviewed. GRADE guidelines were used for recommendation formulation. Results: A total of 25 articles addressing the morbidity and mortality profile of primary spinal tumor surgery were identified. For sacral tumors, complication rates of up to 100% have been reported and complication-related death ranged from 0 to 27%. Mobile spine tumor complication rates varied from 13 to 73.7% and complication-related death ranged from 0 to 7.7%. Seven articles examining HRQOL for this patient population were identified. The limited literature showed comparable patient HRQOL profiles to those with benign conditions such as degenerative disc disease. Conclusion: 1) Respecting oncologic principles for primary spinal tumors, is correlated with high AE rates. We recommend that primary spinal tumor surgeries be performed in experienced centers with multidisciplinary support teams and that prospective AE collection be promoted (strong recommendation/very low certainty of the evidence). 2) Oncologic resection of primary tumors of the spine is associated with HRQOL that more closely approximates normative values with increasing duration of follow-up, but decreases with disease recurrence. We recommend primary spinal tumor surgery be performed with a curative intent whenever possible, even at the expense of greater initial morbidity to optimize long term HRQOL (strong recommendation/very low certainty of the evidence)., Introduction: Spinal simple bone cysts, also known as solitary cysts, are extremely unusual benign primary bone tumors in children, with few cases reported in the literature. Material and Methods: case presentation of an incidental MRI finding of a C2 Simple bone cyst in a 13-year-old female patient is reported. The MRI findings were consistent with a cystic lesion in the vertebral body of C2, facing the right vertebral artery. Complementary angiography suggested a benign condition of the lesion. Patient underwent cervical curettage followed by tumor excision. A lateral submandibular approach to the upper cervical spine was used and careful bone resection was possible with a radiofrequency assisted burr and no instrumentation or fixation was required. The procedure was challenging, due to the proximity of the right vertebral artery with the cyst. The stability of the defect was ensured by filling it with bone allograft and by prescribing a postsurgical plastic cervical collar to maintain neck immobilization. Results: Histological examination showed fibrotic areas with fat necrosis, chronic inflammation, and reactive changes in the tissues examined. At the 6-month follow up visit, the grafts were incorporated into the vertebral body of C2. Conclusions: Solitary bone cysts are infrequent entities in the cervical vertebrae and preservation of spine stability without instrumentation to avoid neurological complications is often challenging. In this case, the proximity of the cyst to the right vertebral artery and the risk of injury was high, however the surgical approach used was successful and no recurrence or instability were evidenced on postoperative MRI., Introduction: The purposes of this study are to investigate affecting factors and overall survival between initial Radiation therapy prior to surgical treatment (Group 1) and radiation therapy following initial surgical treatment (Group 2) at the diagnosis of cervical metastasis. Material and Methods: A retrospective analysis of medical records was performed on 36 cervical metastatic patients from February 2007 to December 2015. Overall survival (OS), OS after cervical metastasis, OS after surgery, neurological and pain outcomes were analyzed between Group 1 and Group 2. Affecting factors of overall survival included; primary tumor type, initial treatment modality, Tomita score, Eastern Cooperative Oncology Group, Karnofsky performance scale (KPS), Nurick grade, Frankel classification, preoperative symptom and Spinal stability neoplastic score. Results: Both groups showed improvement of postoperative VAS. The difference of pre- and post-operative JOA score was 1.3 ± 1.9 in Group 2 (P = .03). OS after cervical metastasis was 7.0 months in Group 1 and 15.8 months in Group 2. OS after surgery was 4.5 months and 15.3 months in each Group. There was statistical significance of OS after cervical metastasis in each Group (P < .05). Factors related to overall survival after cervical metastasis were primary tumor type, initial treatment modality and preoperative symptoms (P < .05). Conclusion: Surgery had a good effect on pain control. The improvement of post-operative JOAS was better in Group 2. Surgery could provide longer OS after cervical metastasis. Early surgery in patients expected good prognosis before neurologic deficit may be a good decision in confined to cervical metastasis., Introduction: Cervical localization of spinal primitive tumors is relatively rare. The choice of the best surgical strategy for the treatment of these lesions, in order to obtain an accetable radicality, is very difficult in these site. Cervical pain is the most common symptom. The early diagnosis of these tumor is not easy because frequently patients present non-specific symptoms and because radiological examinations are usually negative. Only after performing more detailed examinations, such as CT-scan and MRI it is possible underwent a diagnostic biopsy, which is mandatory in these patients. Material and Methods: The authors report the experience of a small group of patients (15) affected by cervical primitive malignant tumors: 4 osteosarcomas, 1 aggressive osteoblastoma, 5 chordomas, 3 chondrosarcomas, 2 sinovial cell sarcomas. The mean age was 42 years (ranged from 11 to 61 years), the mean follow-up was 21 months (ranged from 8 to 42 months). The levels of resection were: 1 level of vertebrectomy in 4 patients, 2 level of vertebrectomy in 4 patients, 3 level of vertebrectomy in 5 patients, 4 levels of vertebrectom in 2 patients. In every patient we performed a double approach, in two patients the second approach was performed 48 hours after the first one to minimize the surgical stress. In two cases we performed a trans-mandibular approach because of the rostral localization of the tumor. In all patients we performed a long fixation (occipito-cervico-thoracic fixation) associated with cages filled with anterior autogenous cortico-spongiosus bone chips. Results: Three patients had a local recurrence, respectively at 20, 25 and 34 months after surgery and they died due to pulmunary involvement after about 12-15 months from the local recurrence (only one patient underwent local surgery). One patient died 23 months after surgery for general progression without signs of local recurrence. One patient died within one week from surgery for vascular complications. The other patients are alive, with no signs of local disease (locally free-desease) and no signs of sistemic disease (NED: no evidence desease). Conclusion: En bloc resection for primary cervical tumor of the spine is a challenge for the surgeons due to the complexity of the anatomy of this region: the presence of the vertebral artery (both resected in two cases without neurological damage), the contiguity of the aero-digestive tract and of the main encephalic vessels, the presence of medulla oblongata and spinal cord. Three patients had under- lesional damage after surgery, in partial remission after some months. All other patients hadn’t neurological damages. Our high percentage of local recurrences and of major complications (5 deaths) is probably due to anatomical complexity of the region, where sometimes is very difficult, or even impossible, to obtain acceptable resection margins., İntroduction: The aim of the study is to show the results of hemivertebrectomy with only unilateral approach in treatment of lung cancer with vertebra invasion. Material and Method: Ten patients with an average age of 59 (49-65) years with lung cancer with thoracal vertebra invasion were operated between 2008 and 2015. Biopsy was performed in all patients for diagnosis. The diagnosis of the patients was, non-small cell carcinoma in seven patients, squamous cell carcinoma in two patients and adenocarcinoma in one patient. Chemothreapy and 60 GyRT radiotherapy were given before surgery. Unilateral thoracal spine exposure was used for vertebra resection after limited laminectomy and root sacrification. Results: In patients who undergone vertebral resection, the resected segments were between T2 and T5. Mean resected vertebrae count was 3 (2-4) and mean corpus resection extent was 40.5% (30-69). Mean follow-up duration of the patient was 24 months (8-84). 1 year survival rates of the patients included were 70%, while 5-year survival rates were 10%. Conclusion: In treatment of lung cancer with spine invasion, it is possible to achive clear surgical margins.Due to lack of the enough strength to prevent deformity from unharmed anatomic structure, strong instrumentations are necessary., Introduction: “Frailty” is a state of decreased homeostatic reserve that may be estimated based on the presence of preoperative comorbidities. In this study, the objective was to develop a preoperative metastatic spinal tumor frailty index (MSTFI) that could estimate length of stay, morbidity, and mortality. Materials and Methods: A large inpatient hospitalization database was searched from 2002-2011 to identify 4,583 patients with spinal metastasis who underwent surgery. The primary location of the metastatic tumor types included breast (21.1%), lung (34.1%), thyroid (3.8%), renal (19.9%) and prostate (21.1%) cancer. Multiple logistic regression model identified anemia, congestive heart failure, chronic lung disease, coagulopathy, electrolyte abnormalities, pulmonary circulation disorders, renal failure, malnutrition, and pathologic fractures as independent parameters that were used to construct the MSTFI. Each patient received one point for each of the above co-morbidities in a given patient and the total score was used to strtatify patients into groups based on their estimated frailty. Patients with 0 comorbidities were categorized as “not frail,” 1 as “mildly frail,” 2 as “moderately frail,” and ≥3 as “severely frail.” Results: The overall perioperative complication rate was 19.3% and in-patient mortality was 3.0%. Compared to patients without frailty, patients with mild (odds ratio [OR] 2.12; 95% CI, 1.74 – 2.59), moderate (OR 3.81; 95% CI, 3.05 – 4.76), and severe frailty (OR 8.11; 95% CI, 6.34 – 10.38) had significantly increased odds of complication development. Likewise, patients with mild (OR 2.73; 95% CI, 1.64 – 4.52), moderate (OR 4.10; 95% Ci, 2.39 – 7.04), and severe frailty (OR 6.34; 95% CI, 3.61 – 11.1) were more likely to die during their hospital stay. Length of stay also increased significantly by MSTFI (P < .001). Conclusion: In surgically treated patients with spinal metastasis, several patient comorbidities were significantly associated with the development of major complications after surgery for metastatic spinal tumors. The metastatic spine tumor frailty index was found to be associated with LOS, major complications, and in-hospital mortality, and LOS, however future studies are required to externally validate the proposed model before establishing definite conclusions., Introduction: The association of teratoma and spinal malformations such as meningomyelocele (MMC) is a rare condition, and only few reports concerning the coexistance of a neoplasm within an MMC have been published. Reported cases however, are mainly presacral or sacrococcygeal, while our case is with lumbar location. We report an unusual case of lumbar mature teratoma which presented inside a ruptured lumbar meningomyelocele. This case is reported to highlight the clinical presentation and management of lumbar teratoma associated with myelomeningocele in a neonate. Despite the severe associated lesions in the lumbar area the child has no neurological deficit. Material and Methods: A full-term, male infant presented with a 5/7 cm lumbar tumor formation uncovered with normal skin. Intra-operatively a soft tissue mass with oval form, irregular hard and reddish color in the upper region and soft component in its lower part was found.Total removal of the tumor was achieved. Proximal to the tumor mass we found an open meningomyelocele, which was sealed. Results: The neonate was discharged without any neurological deficit or sign of hydrocephalus. The final pathological diagnosis was mature teratoma. Follow-up at first year didn’t reveal any recurrence or neurological deficit and a normal sphincter tone was evaluated. Conclusion: Accompanying a spinal dysraphic state, the mature teratoma in our case may support the theory for a tumor actually arising from a dysraphism and growing outwards to produce the mass. The treatment of lumbar mature teratoma associated with MMC is essentially surgical., Introduction: In cases of recurrent or residual lesions the choice of treatment strategy may be debated. Therefore, we assessed short- and long-term ependymoma of the cauda equina outcomes. Materials and Methods: In Burdenko Neurosurgical Institute between February 2009 and October 2013, 50 patients (23 males, 27 females) underwent removal ependymomas of the cauda equina. The mean age of this patient was 38.7 years (18-76 years). The mean follow-up was 52.2 months (6-300 months). Patients were divided into 2 groups: Group 1 consisted of 36 patients with primary tumors; Group 2 consisted of 14 patients who had operated yet. We used Frankel, Karnofsky, VAS, Kawabata scales and MRI for evaluation outcomes. Results: In our according data we have one patient with recurrence after five years from first group, and two patients had recurrence after subtotal resection from second group. Pain were relieved in 26 patients (72%) in first group, and 10 (72%) in second. One patient worsened from first group. In second group four patients were unsatisfactory with the outcome (28%). Neurologically, in first group 18 patients (50%) had a clinical improvement and 16 patients (44.5%) were neurologically unchanged. Two patients (5.5%) worsened. In second group, 3 patients (21.4%) had a clinical improvement; 9 patients (64.2%) were unchanged. One patient worsened. Conclusion: Microsurgical removal is maintaining method of treatment of extramedullary ependymomas of the cauda equine. In cases of recurrence, radiotherapy (in some cases, radiosurgery) is considered as additional option of treatment., Introduction: Vascular tumors of spinal cord is a rare pathology which by histological nature is most often presented by hemangioblastomas and cavernomas of different localization. Cavernomas and hemangioblastomas arise sporadically, however hemangioblastomas may be associated with the von Hippel-Lindau disease. The spectrum of clinical manifestations of these pathologies is quiet wide – from asymptomatic carriage to severe neurological deficit that lead to permanent disability or death of the patient. Materials and Methods: From 2013 to 2015 Burdenko Neurosurgery Institute operated 350 patients with intramedullary tumors of different histological nature. Among them there were 31 of intramedullary hemangioblastomas. Of these, three patients had diagnoses of von Hippel-Lindau disease. In addition to that, Burdenko Neurosurgery Institute performed 26 surgeries for removal of cavernous malformations (CM) on various parts of the spinal cord. Those included 19 intramedullary cases (5.4%), 3 extramedullary ones, 2 intradural ones and 2 extradural cases. Retrospectively, there were examined 19 patients with cavernous malformations of intramedullary location. The diagnosis is based on MRI data and neurological examination. The patients were assessed on a McCormick classification part of preoperative and postoperative treatment. Results: For patients with hemangioblastomas mean follow up was 45 months (36-144 months). The average time of pathogenic pathway was 36 months (12-300 months). MRI examinations of 21 patients showed syringomyelia. Postoperatively only two patients had deterioration of neurological condition, with the rest of the patients showing preoperative state. For cavernous malformations, the average age of the patients was 44 (20-76 years old). The average duration of symptoms was 8-9 months, with the follow-up period of 4-6 months. The average size of tumors ranged from 0.4 to 1.2 cm. The average removal time was 1.0 to 3.5 hours and the average intraoperative blood loss was 130-300 ml. On the first day after the surgery one patient developed intradural hemorrhage after removal of the intramedullary hemorrhage. Conclusion: Surgery of vascular tumors of the spinal cord is a sophisticated and multicomponent task that requires a search for the correct approach to treat the patient, a decision made on the need for embolization of vascular tumor, as well as microsurgical treatment when needed., Introduction: Most of patients with malignant tumor have metastasis to the spine. Fortunatly 10% of them only have symptoms due to epidural tumor. There were match papers about quality of life patients who underwent spine metastasis removal or any other palliative surgery. But we didn’t found one in Russian publications. Our study has to demonstrate advantages of targeting method, which we used for increasing quality of treatment patients with metastatic disease. Methods: 70 patients from 16 to 81 ages have undergone surgery on the spine due to metastatic disease in period from 2009 to 2016 years. A lot of tumors were presented clear cell renal cancer – 30,3%, 23,1% were plasmocitomas (multiple myeloma), 10,5% cases of metastasis without primary tumor, other tumors (melanoma, thymoma, metastatic tumors of the gastrointestinal tract, uterus, ovary, lung, prostate, pancreas, thyroid) took around 3,5% only. Before surgery Tukuhashy, Tomita, Bauer and van Der Leaden prognosis scales were used for survival prognosis and accepted for every patient. We used QLQ C-30 for evaluating quality of life during 1 year after surgery, sighed checkpoints on time before surgery, 1, 3, 6, 12 month after surgery. Quality of decompression we confirmed by comparing of preop and postop MRI and CT scans. Result: Maximal follow-up was 12 month for 5 patients only. The highest growth of quality of life was watched in first 3 month after surgery for more than half percent of patients. We found the main factors effected to quality of life of patients with spine metastasis. Conclusions: Surgical decompression of nerve structures and reconstruction of the spine is the main method to increase quality of life patients with spread cancer to the spine, due to relief of pain and improve of extremity weakness. It is clear that spine metastasis excision does not affect to the common survival of patients in last stage of metastatic disease. This fact makes necessary to consultation each cases by team which consists oncologists, radiologists and surgeons of different profiles for making decision about ability of surgery., Introduction: Malignant peripheral nerve sheath tumor (MPNST) is the sixth most common type of soft tissue sarcoma. Most MPNSTs arise in association with a peripheral nerve or preexisting neurofibroma. Among all primary spinal neoplasms, approximately two-thirds are intradural extramedullary lesions; nerve sheath tumors, mainly neurofibromas and schwannomas, comprise approximately half of them. Current surgical management of MPNST is similar to that of other high-grade soft tissue sarcomas. Materials and Methods: A 27-year-old female with known neurofibromatosis (NF) since her childhood presented with a 6-month history of severe lower back pain and pain radiating to the both leg. Sensory loss was detected below S1 bilaterally and she referred obstipation, urinary incontinency for 4 months. She suffered from a internal iliac deep vein thrombosis at the right side for a month. Behind the symptoms, a giant sacral tumor was diagnosed by CT, and MRI studies. Biopsy proved a MPNST with high cellular atypia. Staging CT scans excluded other localizations of MPNST. Results: En bloc tumor resection from a single posterior approach and a lumbopelvic stabilization using closed loop technique was performed. Soft tissue reconstruction was made using rotatory gluteal muscle flaps. 1 year after the surgery she did not need any constant pain medication and she had neither motor nor sensory deficit at the lower extremities She used self urinary cathetering and had an automatic bowel control. During the regular 1 year follow-up local recurrence was not observed in the sacrum, but the check-up PET CT verified a new giant MPNST at a thoracic localization (Th11-12). En bloc resection was performed from a combined postero-anterior approach. After the second surgery we did not observe any deterioration in motor or sensory functions. Conclusions: En bloc resection with wide/marginal surgical margins is the oncologically proper treatment for MPNST. Approximately 25% of patients developed a postoperative complication, most commonly new sensory deficits. This rate probably represents an inevitable complication of nerve sheath tumor surgery. The surgical treatment is the exclusive option in the therapy of nerve sheath tumors even in case of multiple localisation of the malignant form., Introduction: A quarter of all people dying in Germany succumb to cancer. In 40% spinal metastases are present. Cement augmentation combined with tumor ablation may be an option in painful metastases or metastases with fractures. Cementing alone leads to dislocation of metastases and scattering of tumor mass in the patient. (Archimedes). Local reduction of tumor mass should be performed whenever possible. The use of ablation systems next to nervous and vascular structures is potentially dangerous. This observational study is to assess security and efficacy of a new spinal intravertebral radiofrequency-ablation (t-RFA) probe. Material and Methods: From 11/2013 - 6/2016 we treated 29 patients (18f, 12 m) with 79 vertebral bodies with t-RFA followed by radiofrequency-kyphoplasty.(RFK) Mean follow-up 12 months. Mean age 67 years (Range 51-83 years). All vertebrae treated unipedicular. Cancers types were: breast (14), multiple myeloma (7), lung (2), chondrosarcoma (1), prostate (1), urothel (1), cancer of unknown primary (1), gastric (1) and non-hodgkin lymphoma (1). Combination of osteosynthesis in 3 pat., 1 patient total hip arthroplasty. Preop. scores were: SINS, MESCC, modified Bauer, Tomita, revised Tokuhashi, Karnofsky Performance Index, ODI. Pain on visual analog scale(VAS) pre- and postoperatively. The ablation system contains a navigable, bipolar electrode with two thermocouples, which allow real-time temperature monitoring at the proximal end of the ablation zone. The ablation zones were planned preoperatively via CT and MRI. Perioperative examination for neurological or other deficits. Results: Procedures were securely performed via real-time temperature monitoring and controlled by fluoroscopy. The maneuverability of the ablation device allowed via unipedicular access the exact positioning of the device in the planned ablation zone. No neurological deficits or vascular lesions due to t-RFA. One cement extravasation intraoperative with affection of a peripheral nerve with intercostal neuralgia (, Introduction: Spinal schwannomas usually present as extramedullary, intradural tumors. Is a benign tumor that arises mainly in sensory nerve sheaths. Intraosseous lesions are rare, accouting for less than 0,2% of primary bone tumors, and majority are located in the mandible and sacrum. We report a extremely rare spinal intraosseous schwannoma and provide an updated review. Material and Methods: A 38-year-old female presented with paresthesia of both lower extremities and thoracic back pain. Preoperative MRI showed a large mass extending into the parevertebral muscles and spinal canal that appeared to originate from the posterior elements of T3. Computed tomography showed a large lytic lesion of T3. The most likely preoperative diagnosis according to radiologists in our hospital was a osteoblastoma or a aneurysmatic bone cyst. Preoperative selective arterial embolization of the lesion was performed. Using a posterior extracavitary approach the tumor was completely separated and surgically resected from the spinal nerve root with a clear border. No adhesions were identified between the dura and tumor. No involvement of nerves with the tumor was identified. Results: Histological results confirmed a diagnosis of intraosseous schwannoma with no remnants of an originating nerve. Tumor recurrence was not observed at 2 year follow-up. Conclusion: Our case emphasizes the heterogeneous presentation of the nerve sheath cell tumors in the differential diagnosis of the primary vertebral tumors. Proper diagnosis requires radiological tests, gross intraoperative findings, and postoperative histological results., Introduction: Intramedullary astrocytomas are the second highest frequency of occurrence of all intramedillary spinal cord tumors, and it accounts for 6-8% of all spinal tumors. There are many factors can influence on survival and fictional outcomes after surgical treatment astrocytomas, a top is histological characteristics of the tumor. In our study we evaluated patients with low- and high-grade gliomas from several options: duration of life, functional status, age, gender and other clinical factors. Materials and Methods: In Burdenko Neurosurgical Institute more than 385 patient were underwented removal intramedullary spinal cord tumor from 2002 to 2015. There are 55 patients with intramedullary low-grade (37 patients, 67%) and high-grade (18 patients, 33%) astrocytomas. Tumors were located in the cervical spine in 27 cases(49%), cervicothoracic spine – 7 (12%), in thoracic – 17 (30%), cauda equina – 4 (9%). There were 24 male (43%) and 31 female (57%) patients. All patients were undewented decompressive laminectomy and resection or biopsy of intramedul6ary tumors. During operation, we usually use fluoroscopy, MEPP and ultrasound destruction. The median follow-up was 6 years. Results: Histological characteristics were: 19 patients (35%) had Grade I astrocytomas, 19 patients (35%) had Grade II astrocytomas, 14 patients (25%) - Grade III astrocytomas, 3 patients (5%)- Grade IV. Sensitive disorder were in 48 cases (87%). Motor disorders: without paresis were 6 patients (11%), monoparesis – 7 patients (13%), hemiparesis – 4 patients (7%), paraparesis – 12 patients (22%) and tetraparesis – 19 patients (47%). Bladder dysfunctions had 25 patients (45%). 3 patients (5%) were died for the first year after operation (in one case – progression of tumor, in two cases – progression of general disease). 16 patient (30%) had been better after removal of tumor (transition from one McCormick grades up), 23 patients (45%) had been worst (transition from one or two McCormick grades down) and 13 patients (20%) hadn’t changes McCormick grade (this is patients with first or second McCormick grade). Conclusions: Spinal cord astrocyromas are rare disease, which are requires multimodal view on treatment and recovery. Histological characteristics and total removal of tumors have a huge influence on the length of survival. Radiotherapy and chemotherapy allows preventing recurrence of disease., Introduction: Extramedullary hematopoiesis (EMH) is a known complication of beta-thalassemia due to ineffective erythropoiesis and remote sites of hematopoiesis can occur in various anatomic locations. Treatment often involves a combination of transfusions and radiotherapy. In rare cases, severe epidural EMH can develop within the spinal canal causing progressive spinal cord compression and possibly permanent deficits. Materials and Methods: We present the case of a 54-year old male, with known beta-thalassemia and hemochromatosis, who presented with progressive thoracic myelopathy. Emergent MRI revealed an epidural mass at T5-T9 with severe spinal cord compression. Due to the rapidity of onset and the rapid progression, gross total resection was performed through a unilateral T5-T9 hemilaminectomy, with parallel treatment using tranexamic acid, blood and platelet transfusions. A literature review was performed in search of a consensus regarding the optimal management for these cases. Results: Complete neurological recovery was noted. Adjuvant radiotherapy was performed, with stability of paravertebral EMH sites at last follow-up (3 months full spine MRI). No epidural recurrence or residual mass was seen. Our literature review describes prior cases of epidural EMH with spinal cord compression. Currently there is no consensus regarding the management of these rare cases. Conclusion: In cases of progressive neurologic impairment, surgery can safely be performed in an emergency setting, without excessive hemorrhagic risk. Prior hematologic adjuvant treatment remains mandatory. Albeit considered highly radiosensitive, the optimal management for extramedullary hematopoiesis with neurological impairment remains unproven and is currently based on case-by-case situations., Introduction: Many patients use the internet for accessing health information due to the ease of access. However, there are few guarantees as to the reliability and accuracy of the information available on these websites. This study examined the quality and content of the Internet webpages found on the top 5 search engines. Our aim was to evaluate the quality and accessibility of the information for patients on metastatic spinal cord compression (MSCC) on the internet. Method: To identify potential websites for assessment, the 5 most commonly used search engines were identified and a search for “metastatic spinal cord compression” was performed on each search engine, utilising the first 2 pages of websites listed within each engine. Each website was categorised according to its authorship, and then was assessed using the recognised scoring systems from the (Journal of American Medical Association [JAMA] and DISCERN criteria, metastatic spinal cord compression content quality). We also noted the websites for the presence of the quality-based Health on the net (HON) code. Results: An initial search yielded 56 websites through the top 5 search engines. Exclusion criteria were: websites requiring login or sign-up, duplicate websites, social media sites and discussion boards were excluded. 23 unique websites were identified and analysed. 5 websites were academic, 9 were produced by physicians, 6 were commercial and 3 were non-commercial. There were significant differences noted between the categories on the DISCERN score (Range 16-74), JAMA benchmark criteria and only 5 websites had the presence of the HON code. Academic and physician-related websites contained better quality information than commercial and non-physician sites and the Internet sites with the HON code demonstrated more transparency of content. There was one exception with a commercial site scoring the highest individual DISCERN score. Conclusion: The overall quality of information regarding metastatic spinal cord compression is limited. Internet websites that were reviewed displayed an abundance of variation in the quality of information that was supplied. There was a large discrepancy in the DISCERN scores with inconsistency surrounding recommended treatment options as well as the majority of them lacking information on how treatment effects overall quality of life, and describing what happens with no treatment both scoring the lowest, indicating the added importance of the doctor patient relationship., Introduction: Balloon kyphoplasty is a widely accepted surgical technique to treat spinal compression fractures in osteoporotic vertebrae and is currently used to treat neoplastic pathologic compression fractures as well. Despite its popularity, this technique’s efficacy in treating vertebral compression fractures in patients with spinal metastasis is yet to be accepted. The purpose of this study ist o to assess the efficacy of kyphoplasty in controlling pain and improving quality of life in oncologic patients with metastatic disease and pathologic compression fractures. Material and Methods: A literature search through medical database was conducted (Pubmed, EMBASE, Cochrane, LILACS) for randomized controlled trials comparing balloon kyphoplasty versus traditional treatment for compression fractures from metastatic disease of the spine. Two investigators independently assessed all titles and abstracts to select potential articles to be included. Only randomized controlled trials (RCT) were included. Inclusion criteria consisted of trials involving patients with pathologic compression fractures due to spinal metastasis or multiple myeloma treated with balloon kyphoplasty procedure as one of the study interventions, while the control group was any other treatment modality. The risk of bias in individual studies was assessed. The authors declare no conflicts of interest. Results: Two studies, with a combined total of 181 patients met inclusion criteria. Due to heterogeneity, meta-analysis of data was not possible and individual analysis of studies was performed. There is moderate evidence that patients treated with balloon kyphoplasty displayed better scores for pain (NRS), disability (RDQ), quality of life (SF-36), and functional status (KPS) compared to the conventional treatment group. Patients treated with kyphoplasty also have better recovery of vertebral height. Conclusion: This study concluded that balloon kyphoplasty could be considered as an early treatment option for patients with symptomatic neoplastic spinal disease although further randomized clinical trials should be performed for improvement of quality of evidence., Introduction: Chordomas are rare malignant neoplasms that affect the axial skeleton, commonly affecting people over 40 years. The sacrococcygeal region is the most frequently affected location. Cervical location is not usual and literature evidence is scarce. It’s approach in cervical spine is controversial. Material and Methods: A case report of a cervical chordoma in a 55 years-old male who attended to the emergency department with severe cervical pain and swallowing limitation for six months is presented. MRI showed a loculated osteolytic mass compromising the right neural root path of C2 extending to C1 and C3. 60% narrowing of the medullary canal was documented with involvement of the ipsilateral vertebral artery. A multidisciplinary team was guaranted to ensure a complete resection of the tumor. A combined anterior approach and a posterior approach were used. Tumoral resection, corpectomy and replacement of the vertebra involved and posterior stabilization of the cervical spine were performed. Results: During surgery a friable and violaceous tumor compromising C2 and C3 was observed. The histopathology confirmed the diagnosis of chordoma. No complications after surgery were documented and significant improvement of the cervical pain and swallowing capacity were reported by the patient after surgery. Patient received adjuvant postoperative radiotherapy. At 12 months follow up, patient did not present recurrence of the disease. Conclusions: In patients that debut with severe cervical pain resistant to conventional treatment, other etiologies must be considered i.e tumoral etiologies. Cervical chordomas remain rare entities and its management continues to be challenging due to their insidious and extensive nature. A multidisciplinary approach may guarantee better results., Introduction: Osteochondroma or osteogenic exostosis is the most common benign bone tumors. It can be solitary or multiple within the scope of the Hereditary multiple exostoses disease. Spinal location is estimated between 1 and 4%. We reported the case of an osteochondroma of the third cervical vertebra. Methods: It was a 29 years-old woman with a one year history of swelling of the neck. Clinical examination found a hard painless mass of 15 cm in diameter without skin reaction. Extension of the cervical spine was limited but neurological examination was normal. Cervical spine x-rays revealed an ossified mass developed at the posterior cervical area. Computed tomography has found a well limited polylobed mass of bony density developed from the spinous process of the third cervical vertebra. A magnetic resonance imaging helped identifying the cartilaginous cuff thick. Upon extension investigations we found an associated exostosis of the left distal femur and another one of the right proximal tibia. The patient had an excisional biopsy of the spinous process through a posterior approach. Histology confirmed the diagnosis of osteochondroma and eliminated signs of malignancy. Results: At 3 years follow-up, the neck motion was painless and no signs of recurrence were found. Conclusion: The treatment of choice for spinal exotoses remains excisional surgery, even for asymptomatic tumors. This will avoid considerable growth of these tumors, preventing neurological signs due to medullary compression and especially to avoid malignant degeneration that can occur in 1% of solitary exostosis, and in 10 20% in case of Hereditary multiple exostoses. Histological examination is essential after each surgical excision, firstly to confirm the diagnosis and secondly to eliminate malignant transformation. The prognosis at long term follow-ups is good. However, recurrences may occur after incomplete resection. The osteochondroma is a benign bone lesion, cervical localization is rare. Early diagnosis and treatment can prevent the installation of an irreversible neurologic deficit. MRI is the modality of choice for the identification of the bone tumor, its extent and its impact on the nervous structures., Introduction: Osteoblastoma is a rare benign tumor. It represents less than 1% of all benign bone tumors. His predilection for the spine is known (40% of cases). We reported three cases of osteoblastoma (one in the cervical spine and two in the lumbar spine) and discussed the diagnostic and therapeutic issues. Methods: Observation 1: He was a 17 year old patient who presented with cervicobrachial right neuralgia lasting for 2 years treated medically. The clinical examination confirmed a neurogenic upper limb pain without neurological deficiency. Plain X-rays were normal and CT scan showed a geodic lesion blowing the postero-inferior cortex of the vertebral pedicle of C6. The patient underwent an excisional biopsy through a posterior approach with bony graft followed by a 3 months immobilization by a neck minerva. At a 3 years follow-up there was no signs of recurrence of the tumor. Observation 2: He was a 36 year old man who presented with low back associated with cruralgia. Imaging showed a geodic lesion of 3 cm in diameter taking half of the vertebral body of L1. The lesion was hyperintense on bony scintigraphy. The treatment consisted of an excisional biopsy through a double posterior and anterior approach in same operation with bone grafting and plate fixation. Histology confirmed the diagnosis of an osteoblastoma and there was no signs of recurrence at a two years follow-up. Observation 3: He was a 12 year old boy who consulted for low back pain lasting for one year. Clinical examination found a spinal stiffness without associated scoliosis. Plain radiographs showed an osteolysis of the posterior arch of L5. CT scan showed a lytic process of the right pedicle, the two lamina and the spinous process of L5. The patient underwent an excisional biopsy of the tumor through a direct posterior approach with a postero-lateral bone graft and an L4-S1 fixation. Histology confirmed the diagnosis of osteoblastoma. At last follow-up of 5 years, patient reported only intermittent mild low back pain and no signs of tumor recurrence on last investigations. Conclusions: Osteoblastoma generally manifests by an intermittent pain with night predominance. For spinal localizations, it comes with scoliosis in 50% of cases, mainly for thoracolumbar locations. Neurological signs may be observed (25-50%). On radiology, it is most often a geodic lesion usually exceeding 2 cm in size. CT scan shows the tumor bony extent. MRI shows the tumor mass and the signal abnormality in the adjacent soft tissue. Definitive diagnosis is made by histological examination, since this tumor almost always requires surgical treatment. Spinal osteoblastoma is a rare lesion. It should be considered given a back pain associated with scoliosis. Radiology suspects the diagnosis which is confirmed by pathological examination. Surgical resection must have tumor-free margins to prevent recurrence., Introduction: Osteoblastoma is a rare, benign, osteoid-producing and slow growing primary bone tumor, arising usually in long bones or in the spine, with a slight male predominance. Optimal tumor control can be achieved with radical resection. Depending on its localization and loss of weight-bearing structures, extensive intraoperative reconstruction may be needed. Materials and Methods: We describe the surgical treatment of a C1 (atlantal) osteoblastoma diagnosed in a young male with neurofibromatosis type 1, presenting with progressive neck pain. We detail the surgical procedure for complete excision and stabilization using a bilateral occipitoaxial spinal interarticular stabilization (bOASIS) technique. Load-bearing capacity after bilateral C1 lateral mass resection was achieved using titanium cages with integrated bone graft. A standard posterior occipito-cervical construct completed the instrumentation for the cranio-vertebral junction. Both vertebral arteries were preserved. Results: The post-operative course was uneventful. The patient remained pain free and neurologically intact at 1 year follow-up. Postoperative X-rays, CT and MRI showed optimal fusion and confirmed gross total resection, without tumor recurrence at 1 year follow-up. Biomechanical challenges of C1 lateral mass reconstruction are detailed. Conclusion: To the best of our knowledge this is the first case of bilateral C1 lateral mass reconstruction by this technique reported in the literature. Biomechanical studies focused on C1 lateral mass reconstruction are needed to better understand this intricate segment of the cranio-vertebral junction., Introduction: Despite advances in surgical techniques for spinal metastases, these procedures are often accompanied by substantial blood loss resulting in patients requiring blood transfusion either during intra or postoperative period. Allogeneic blood transfusion has been no doubt the main replenishment method for lost blood, and saving numerous lives. However, the effects of blood transfusion have been shown to be debatable in various oncological surgeries. We aimed to evaluate the influence of perioperative blood transfusion on the outcomes of patients undergoing spinal tumour surgery. Methods: This retrospective study included 247 patients who underwent surgery for spinal metastases in our university hospital between 2005 & 2014. Outcome variables for this analysis were survival and postoperative complication rate among transfused and non-transfused patients. Survival was calculated in months from date of surgery till death. Cox regression analysis was performed for survival. Kaplan-Meier survival estimates were performed and log rank test was used to compare the estimates between the subgroups. Logistic regression analysis was exploited to determine the factors influencing postoperative complications. Results: The overall median blood transfusion was 1 unit (0-10). Overall, 46 patients (19%) experienced at least one postoperative complication, of which 7 patients had more than one complication. The proportion of patients who developed any complication was significantly less for non-transfused patients than transfused patients (21% vs 42%, P = .01). In univariate analysis, significant variables for developing any complication were blood transfusion units, preoperative ECOG score, preoperative Hb level and number of vertebral metastases. Multivariate analysis revealed that increased amount of blood transfusion units (OR = 2.56, 95% CI: 2.01-2.88, P = .01) was independent predictor of any postoperative complication. Overall median survival was 15 months; 95% CI:11-21 months. Patients who received blood transfusion had decreased median survival compared to those who were not transfused (11 vs 21 months). Log rank test revealed that the difference in the survival rates between transfused and non-transfused patients, however, was not significant (P = .24). Generally, there was a trend towards lower survival rates among transfused compared to non-transfused patients at 6-month, 12-month and 18-month post-operation though the differences were not significant. Univariate Cox regression analyses showed that preoperative ECOG, gender, primary tumour and amount of blood transfusion units have significant influence on survival. In multivariate model, only the primary tumour and preoperative ECOG were significant predictors of survival. Conclusions: Increased number of blood transfusion units was associated with postoperative complications. Blood transfusion was associated with decreased survival in univariate analysis but not in multivariate analysis. Revisiting blood transfusion trigger in patients with spinal metastases is recommended. Patient blood management strategies including autologous transfusion in these high-risk groups of patients should be explored further for minimizing ABT use and its related potential risks., Introduction: Surgical management of spinal tumours offers tremendous benefits of addressing cord compression, segmental instability or both, thereby improving patients’ quality of life. Surgery necessitates hospitalisation, which if increase adds to treatment costs, straining on the healthcare system. Reduction of length of stay (LOS) would keep costs under control. We hypothesized that length of hospitalization can be influenced by various factors in patients undergoing spinal tumour surgery. This study aims to identify potentially modifiable factors that might influence the length of hospitalisation in patients undergoing spinal tumour surgery and thereby providing information for improving postoperative care and reducing the LOS. Methods: We retrospectively evaluated 259 patients who underwent surgery for primary or metastatic spine tumours in our institution between 2005 and 2014. Patients’ demographics, operative data and hospital characteristics were retrieved from electronic medical records. LOS was determined from the date of surgery to the date of discharge. Multivariate linear regression was attempted to investigate the factors influencing LOS. Results: Average LOS was 16 ± 15 days. General condition in terms of ECOG score was the most significant factors influencing LOS (P < .001). Other variables significantly associated with LOS in multivariate model were preoperative haemoglobin (P = .01), number of decompression levels (P = .05) and number of allogeneic blood transfusion units (P = .05). Increase age was also moderately associated with prolonged length of stay (P = .07). Conclusion: Our study demonstrated various factors influencing LOS. These data should prove useful for treating team to address the correctable factors like preoperative haemoglobin, blood transfusion and decompression levels to reduce LOS. Reduction of LOS will provide patients who have a shorter predicted survival to return home earlier to spend quality time outside the hospital., Introduction: With the advancement multidisciplinary cancer care and surgical technique, surgery has evolved as an important treatment modality. We propose that posterior vertebral column reconstruction can be performed safely on patients requiring surgery for symptomatic spinal metastasis to improve their quality of life. Material And Methods: A prospective study was conducted in UKM Spine centre involving 23 patients with single level spinal metastasis operated between the year 2012-2015. All patient presented either with pain, instability or with neurological deficit. 5 patients were lost to follow up due to logistics reason.The patients were assessed using VAS score, ASIA score for the neurological deficit and ECOG score for overall quality of life. Results: Pre and post operative VAS score improved from mean of 6.06 to 2.39. The ECOG score improved from 2.56 to 1.61. With the exception of one case with ASIA A, the other patients improved to a grade C, D or E post operatively. Survival rates ranges from 4 months to 52 months. 12 patients was still alive in May 2015 when the results were analysed. Conclusion: PVCR showed favourable outcome with improved VAS, ECOG and patient neurological status and ambulatory capacity in patients with single level spinal metastasis., Introduction: Vertebroplasty is minimally invasive procedures are recommended in osteoporotic and malignant metastasis in patients with a poor medical condition and with a poor prognosis. Transoral vertebroplasty (TOV) can be successfully used to reduce pain and provide stability in the palliative treatment of metastases of the vertebral axis. This procedure has the advantage of providing rapid pain relief and has been described in some case reports. Material and Methods: A case of 38-year-old female who was suffering from liver and lung metastasis of hemangiopericytoma and a painful lytic metastasis to the axis causing cervical torticollis and limitation in head rotation TOV under general anesthesia was performed with guidance of tow digital fluoroscopy. Visual Analog Scale(VAS) was used before and after the procedure. An AP and LAT cervical x-ray were done to evaluate the cement placement. Results: The procedure was effective in achieving pain relief also the neck tilt and limitation in rotation were returned to normal the VAS significantly drop from 9 to 0. Follow up for 9 months she remains pain free. Conclusion: TOV is an effective procedure of cervical pain resulting from malignant involvement of C2., Introduction: Lumbar disc herniations(LDH) can be initially diagnosed like a tumor. Sequestrated/migrated disc herniations may also appear like tumors in MRI investigations. In this study, we reported 4 cases with LDH that was operated on prediagnosis of extradural tumore. Material and Methods: Case 1: A 62 years old female with complaint of left leg pain for 2 weeks. She has numbness and her MRI scans were revealed that there was a lesion with ring-like enhancement after contrast injection at L2 level however it has no connection with intervertebral disc space. She was improved at the 5 months follow-up. Case 2: A 62 years old male with complaint of right leg pain for 1 month. He has numbness and slightly weakness. His MRI scans were revealed a lesion was located at L3 vertebra and it was showed dense contrast enhancement. He was improved at the 2 months follow-up. Case 3: A 34 years old female with a complaint of right leg pain for 3 weeks. She has numbness and slightly weakness. MRI scans showed that a lesion with circumferential contrast enhancement at level of L4 corpus. She was improved at 12 months follow-up. Case 4: A 38 years old female with complaints of severe low back and right leg pain for 2 weeks. She has numbness and weakness. MRI showed a lesion with dense enhancement after contrast injection through L5 and S1 levels. She was improved at 22 months follow-up. Results: LDHs were commonly appeared a hypointense lesion without contrast enhancement in adults because of degeneration. On the other hand, infectious process and tumors obtain a distinct contrast enhancement to diagnostic accuracy. Conclusion: Infrequently, sequestrated disc fragments also enhanced with contrast. Particularly, the fragments can appear as diffuse and/or circumferential enhancement according to resorbtion period. LDH should be kept in mind for acute onset of leg pain.

Introduction: A prior study showed the touched vertebra (TV), defined as the most cephalad thoracolumbar/lumbar vertebra “touched” by the center sacral vertical line (CSVL), as a potential landmark vertebra & recommended lowest instrumented vertebra (LIV) as well. We evaluated a large cohort of Lenke type 1 & 2 cases to determine if selecting the TV as the LIV will produce optimal positioning at a min. 5 yrs postoperative. Our hypothesis was that it would and that fusing short of the TV would lead to a suboptimal result. Material and Methods: 299 pts with Lenke 1 (n = 207) or Lenke 2 (n = 92) AIS curves at a min. 5 yr f/u were evaluated. The TV was selected on the preoperative x-ray by 2 independent examiners & confirmed for agreement. The LIV selected was compared to the preoperative TV as well as the LIV-CSVL distance at min. 5 yr f/u. Comparison was made on the LIV-CSVL distance in pts fused short of the TV, to the TV or distal to the TV using standard statistical software. Results: When comparing the entire cohort, differences in 5 yr LIV-CSVL absolute values between the 3 groups approached, but did not reach, significance (P = .055). In a subanalysis of the lumbar A modifiers (n = 161), main effect ANOVA indicated a significant difference among the 3 groups (P = .002). Post hoc comparison revealed that pts fused short of the TV (TV-1) had significantly greater LIV-CSVL distance values than those fused to the TV (P = .006) & those fused distal to the TV (TV+1, P = .002). There was no significant difference among the 3 groups when looking at lumbar B (n = 76, p = 0.424) & lumbar C (n = 62, P = .326) modifiers. Conclusion: Selecting the touched vertebra (TV) as the LIV for Lenke type 1A & 2A curves produced optimal LIV positioning at a minimum 5 yrs postoperative, while fusing short of the TV showed statistically increased LIV- CSVL translation. Understanding & utilizing the TV rule assists the surgeon in proper LIV selection in Lenke type 1A & 2A curve patterns for AIS., Introduction: Shoulder balance is important for adolescent idiopathic scoliosis, which affects the patient’s appearance and satisfaction after scoliosis surgery. We report perioperative and 3-year results in terms of deformity correction and shoulder balance in a consecutive series of patients treated by convex manipulation through an all-level pedicle screws convex instrumentation. Material and Methods: From January 2013 to January 2016 we surgical treated 42 consecutive patients (37 F, 5 M, mean age 13 years) affected by Lenke type 1 scoliosis. Mean preoperative Cobb angle was 56° ± 6°. Shoulder balance was evaluated by pre-operative measurement of clavicle angle and T1-tilt. We performed a posterior access only in all patients using polyaxial pedicle screws at each level on the convex side of the curve. Among this patients, we distinguished 2 groups: patients in which posterior column osteotomies (PCO) were performed at the apical level of scoliosis only on the convexity of the curve (10 patients), and patients in which PCO were not performed (32 patients). All the correction maneuvers were performed on the convex prebent rod. In all cases motor-evoked potentials monitoring was used. Mean follow-up time was 32 months. Results: The average percentage of coronal correction was 76 ± 5% (mean postoperative Cobb angle 15° ± 4°), with no neurological complications. Concerning the post-operative kyphosis, we observed a slight decrease of mean values compared to preoperative measurements (mean reduction of thoracic kyphosis 5° ± 2°). At 3-year follow-up no changes in coronal nor in sagittal plane were observed. Concerning post-operative shoulder balance, we reported a statistically significant change in clavicle angle and T1-tilt in patients operated with asymmetrical PCO respect to patients in which PCO were not performed. Conclusion: This case-series study shows the effectiveness and the safety of convex manipulation in Lenke type 1 scoliosis. The coronal correction obtained with this technique is comparable to that obtained with the traditional concave derotation. Concerning shoulder balance correction, PCO, providing a shortening and a higher mobilization of the convex side of the curve, allow a better management of the proximal thoracic spine and, consequently, a better restore of shoulder symmetry., Introduction: The aim of this study is to analyse the sagittal alignment of cervical spine in surgically treated adolescent idiopathic scoliosis(AIS) and its association with alignment of thoracic and lumbar column. Material and Method: A retrospective review of clinical and radiological data from databases of two university hospital spine clinics was performed. 47 consecutive AIS patients were included in the study, the remainder were excluded due to poor quality Xrays where the CS was not properly visible, or previous surgery. Sagittal parameters were evaluated on AP an Lateral X-rays using software: C2-C7 lordosis, C2-C7 SVA, T4-T12 kyphosis, upper thoracic cobb angle, lower thoracic cobb angle, L1-S1 lordosis and Lenke type of scoliosis. These measurements were then evaluated for possible associations with patient age and with pre-existing measurements using t test. Results: There were 42 females and 5 males among retrospective databases; mean age at surgery was 15.21 ± 2.34 years. No significant differences in T1SS, C2-7 SVA, C2-7 Cobb angle, thoracic kyphosis were seen during the follow up. On the other hand, preoperative and postoperative measurements of L1-S1, upper thoracic and main thoracic angles showed significant differences. Conclusion: Patients with AIS appear to compensate for abnormal thoracic alignment with changes in cervical sagittal alignment. Significantly less cervical kyphosis was seen in Lenke 5 and 6, and greater cervical kyphosis in Lenke 1, 2, 3 curves. Overall the study group, cervical alignment showed no significant correlation with the Lenke types., Objective: This retrospective study was designed to assess the impact of intrathecal morphine compared with no intrathecal morphine on blood loss during posterior spine instrumented fusion to correct pediatric idiopathic scoliosis. Material-Method: A retrospective study was done of the data and the anesthetic charts of 95 patients underwent scoliosis surgery between January 2008 and June 2016 by the same orthopedic surgeon. Forty patients were operated without intrathecal morphine (NITM) and 55 with intrathecal morphine (ITM). A statistical comparison has been done between the two groups of the blood loss, the number of patients received blood transfusions and the volume of the blood transfused. Results: Blood loss was significantly greater in NITM group with 2016.1 ± 857.3 ml instead of 725 ± 312.2 ml (P < .0001). All the patients (40 patients) of the NITM group received blood transfusions while only 13 patients (from 55 patients) of the ITM group needed blood transfusions. The volume of blood transfused per patient was significantly greater in the NITM group (726.3 ± 487.3 ml) than in the ITM group (295.4 ± 170.9 ml), (P < .0001). Conclusions: Our data are similar with previous published study and demonstrate that intrathecal morphine in pediatric surgical scoliosis correction decreases significantly the inta-operative blood loss and the number of the blood transfusions., Introduction: In children with juvenile idiopathic scoliosis (JIS), the spinal deformity can have serious consequences for lung development and may reduce life expectancy. The treatment goal of JIS is to maximize growth of the spine and thorax by controlling the spinal deformity, while simultaneously preserving normal lung development. Bracing and growth-friendly spine surgery have been used to control the curve. However, growth-friendly implants usually requires multiple surgeries, is associated with complications and can decrease spinal growth. The effect of bracing on spinal growth is unknown. The aim of the study is to evaluate spinal growth in braced JIS patients. Material and Methods: 38 female JIS patients were retrospectively selected from our database. These patients were diagnosed with JIS and were treated with brace during childhood. Three PA spine radiographs were selected: before start of bracing, after brace treatment and at final follow-up. Age, total length and duration of brace treatment were recorded. The following variables were measured on the radiographs using Surgimap: Cobb angle, T1-T12 length and T1-S1 length. Results: The average age of diagnosis was 7.1 years (1.5-9.5). Brace treatment was started at an average age of 11.3 years with a Risser of 0.5 and was stopped at an average age of 14.6 years with a Risser of 4.2. The brace was prescribed for a mean of 40 months. The Cobb angle of the main curve before and after bracing were 33° (20°-60°) and 31° (10°-63°) respectively. At skeletal maturity, 8 patients were treated surgically with a mean angle of 55° (44°-62°) before surgery. Patients not requiring surgical treatment had an mean angle of 28° (13°-53°) at final follow-up. Before treatment, mean T1-T12 length was 241 mm (147-297), T1-S1 length 385 mm (225-463) and total length 1528 mm (940-1790). After treatment, mean T1-T12 length was 279 mm (205-317), T1-S1 length 446 mm (334-518) and total length 1692 mm (1420-1935). And at last follow-up, mean T1-T12 length was 286 mm (240-328), T1-S1 length 458 mm (379-535) and total length 1711 mm (1545-1945). The total length gain from start brace to last follow-up was 43 mm (8-118) for T1-T12 length, 68 mm (6-200) for T1-S1 length and 141 mm (20-431) for total length. Spinal growth during brace treatment was 14.3 mm/year (T1-T12) and 23.3 mm/year (T1-S1). Conclusions: Brace treatment may be useful for managing JIS in 30 of 38 patients by preventing progression of the curve. The study is descriptive and provide an overview of spinal growth in patients with JIS treated with the Boston brace. Based on Dimeglio’s data, normal spinal growth is 1.1 cm/year (T1-T12) and 1.8 cm/year (T1-S1) between 10 years and skeletal maturity. The braced patients grew 1.4 cm/year (T1-T12) and 2.3 cm/year (T1-S1) during the treatment period indicating that bracing had no significant negative effect on longitudinal spinal growth., Introduction: Adolescent idiopathic scoliosis (AIS) is a three-dimensional spine deformation, whose aetiopathogenesis remains unclear. Current literature indicates a possible vestibular origin of AIS. A vestibular deficit may cause an asymmetrical contraction of the axial muscles, which, in turn, leads to a vertebrae malformation in a period of rapid spinal growth, where compensatory (proprioceptive) mechanisms are quite limited. One way to explore vestibular function is the subjective estimation of the gravitational vertical. Deviations or tilts of the perceived visual vertical are the most sensitive sign of a vestibular tone imbalance in roll and occur with lesions on peripheral or central vestibular pathways from the labyrinth to the vestibular cortex. In this study, we aimed to investigate and compare the contribution of different sensory modalities to the subjective estimation of the gravitational vertical between AIS patients and healthy individuals. Material and Methods: All study subjects (AIS Group, n = 10, age 11-16y, Cobb’s angle > 15o) and healthy age matched adolescents (control group, n = 10) performed a series of subjective internal estimation of verticality in two visual conditions (open/closed eyes) and using three different segments (hand, head and trunk). Specifically, they were asked to control the verticality of a visual rod (displayed on a large TV screen in front of them) using a joystick that was either hand-held [Subjective Visual Vertical (SVV) and Subjective Haptic Vertical (SHV) with open and closed eyes respectively] or attached to the trunk or head [Subjective Postural Vertical (SPV) The rod’s initial tilt position was set at 18o of tilt either clockwise or counterclockwise. An electromagnetic tracking sensor attached to the joystick or the trunk/head measured the rod’s actual deviation from the gravitational vertical in degrees (error). Results: A 2 (group) x2 (visual condition) x3 (segment) ANOVA revealed that the error in the subjective estimation of verticality was greater when the estimate was performed with closed eyes [clockwise: (F(1,18) = 45,67, P = .000); counterclockwise: (F(1,18) = 114.67, P = .000]. Moreover, a significant three-way interaction (counterclockwise direction: F(2,36) = 4.64, P = .016, h2 = .205) confirmed that differences among groups in verticality estimation were dependent on the visual condition and the segment used to perform the test. Post-hoc analysis revealed that AIS subjects had a greater error (deviation from the earth vertical) than controls when estimating verticality with the head and closed eyes (t(18) = −3.6, P = .002). Conclusion: Since head acceleration in the roll direction with closed eyes is mostly sensed by the semi-circular canals, these results suggest the presence of a vestibular tone imbalance in AIS participants. These findings may prove useful in the early diagnosis and prognosis definition of AIS., Introduction: Cervical laminoplasty is an effective procedure for decompressing multilevel spinal cord compression. Posterior compressive bone as well as hypertrophied ligamentum flavum is directly removed and dorsal migration of the spinal cord allows for indirect decompression of the anterior spinal cord. Spinal cord back shift has been considered the desired end point of posterior decompression procedures. However, a wide range of posterior spinal cord drift has been reported in the literature and reported data refer to different averages, such as that of each level for a given patient, or that of each single level, or the mean value of all patients. The aim of our study was to correlate the posterior migration of the spinal cord after extensive laminoplasty to the cervical spine curvature. Materials and Methods: Twenty-nine patients (15 men and 14 women) who underwent bilateral open-door laminoplasty between C3 and C7 levels were included in this study. The average age at operation was 64 years (range, 43-87 years). All patients presented with symptoms of neural compression and magnetic resonance imaging (MRI) findings were consistent with CSM. All patients underwent plain radiographs and MRI pre- and post-operatively. The distance from the posterior edge of each vertebral body to the anterior edge of the spinal cord was measured on sagittal MRI, in order not to be influenced by the postoperative cord expansion. Cervical sagittal alignment was assessed from pre-operative lateral cervical radiographs and classified as lordosis, kyphosis, straight or S-shaped. Results: The posterior spinal cord shift ranged from a maximum of 6.2 mm to a minimum of -0.1 mm, with an average of 1.8 mm. The peak shift was 2.8 mm at C5. The mean posterior spinal cord shifts in the different neck alignment groups were 1.8 mm for the lordosis group, 1.5 mm in the straight-neck group, 1.5 mm in the kyphosis group and 2.4 mm in the S-shaped group. The peak shift was located at C5 in the lordosis group (2.8 mm) and in the straight-neck group (3.1 mm), C7 in the kyphosis group (2.8 mm) and C6 in the S-shaped group (3.9 mm). The minimal posterior spinal cord shift was located at C7 in the lordosis group (1.4 mm) and at C3 in the S-shaped group (1.7 mm), in the straight-neck group (0.4 mm) and in the kyphosis group (0.4 mm). In the lordosis and the S-shaped groups we observed the greatest backward movement in the middle of the cervical spine, at the point of maximum concavity, like a bowstring. Conclusions: The preoperative lordotic alignment of the cervical spine influences the degree of posterior movement of the spinal cord after extended laminoplasty. Cervical lordosis allows a maximal spinal cord back shift. Moreover, the final spinal cord position is different according to the preoperative alignment of the spine, with a bowstring effect in lordosis and S-shaped cervical spines. Finally, the risk of C5 palsy should be anticipated in lordotic and straight spines where the peak shift is located at C5., Introduction: Laminoplasty is frequently performed in cervical myelopathy patients, but can lead to unexpected postoperative C5 palsy. Although several studies have examined the pathogenesis and prevention of postoperative C5 palsy, many controversies remain and some radiological findings identified as risk factors were not correlated with our outcomes. Material and Methods: This study reviewed 116 patients who underwent open-door laminoplasty for cervical spondylotic myelopathy between January 2014 and April 2016. All operations were performed by one surgeon. C5 palsy was defined as weakness [change in manual muscle testing (MMT) score of 1 or 2] of the deltoid muscle. The patients were divided into groups that developed or did not develop C5 palsy. We evaluated the incidence of C5 palsy, the preoperative C2–7 Cobb angle, and Pavlov ratio at the C4/C5 level using simple cervical lateral radiographs. Furthermore, by using computed tomography (CT), we evaluated the existence of an ossified posterior longitudinal ligament (OPLL), the transverse diameter of the C4/5 foramen, and increases in the anteroposterior (AP) diameter of the spinal canal at the C4/5 levels after surgery. To assess the correlation between C4/5 foraminal stenosis and C5 palsy, we subdivided the C4/5 foramina into two groups: 8 with C5 palsy and 192 without C5 palsy. Finally, a high signal intensity on T2-weighted images of the cervical spinal cord preoperatively was noted. Results: Of the 116 patients, 16 cases were excluded and 100 cases were analyzed; postoperative C5 palsy occurred in 8 patients (8%). There were no significant differences between the two groups in sex, age, the presence of an OPLL, or preoperative high signal intensity on T2-weighted images of the cervical spinal cord. The preoperative C2–7 Cobb angle, Pavlov ratio at the C4/C5 level, and increase in AP diameter of the spinal canal at the C4/C5 level were not significantly related to postoperative C5 palsy. However, the average diameter of the C4/5 foramen of the affected side was 2.51 mm, while that of the unaffected side was 3.88 mm (P = .004); a diameter of the C4/5 foramen of less than 2 mm was significantly related to C5 palsy in the binary logistic regression test (P = .000). In this study, a smaller diameter of the C4/5 foramen was the only factor significantly correlated with C5 palsy after laminoplasty. Conclusion: C4/5 foraminal stenosis is one of the best predictors of C5 palsy, which might be related to ischemic/reperfusion injury of the C5 root nerve after laminoplasty. This should be examined further in prospective comparative or basic experimental studies., Introduction: Posterior cervical approach has become the treatment of choice for cervical spinal cord compression related pathology in more than three vertebral levels. Previous studies compared clinical outcomes of cervical laminoplasty with laminectomy and have reported inconsistent findings. There has been a recent development of a hybrid laminoplasty approach (C3 dome osteotomy, C4-6 laminoplasty and upper C7 laminectomy) with muscle sparing techniques. To the best of the authors’ knowledge, there are no studies comparing the results of hybrid laminoplasty with laminectomy with fusion. The aim of this study is to compare and evaluate the surgical outcomes of hybrid laminoplasty with laminectomy with fusion in terms of radiological findings. Material and Methods: A retrospective review of 42 consecutive patients, who had undergone cervical laminectomy with fusion (LF) or hybrid laminoplasty (HLP) by a single surgeon, was performed. Surgical outcomes were assessed and Image J software was used to evaluate pre- and post-operative Magnetic Resonance Imaging (MRI) scans for posterior cord migration and dural sac expansion of the two groups (LF and HLP). Radiological data captured was analysed using SPSS software. Results: 36 cases with pre- and post-op MRI were included in the study. Average follow up duration was 1.5 years. 16 patients had laminectomy with fusion (LF) and 20 had hybrid laminoplasty (HLP). There were no statistically significant differences between the LF and HLP group in terms of age, gender, follow-up duration, pre-operative diagnosis and pre-operative JOA score. There were however 2 cases of post-operative C5 palsy in LF compared to none in HLP. A trend is shown with the laminectomy with fusion (LF) group displaying greater dorsal cord migration than the hybrid laminoplasty (HLP) group at all levels from C2-T1. Comparing between cervical spinal levels, the extent of dorsal cord migration is shown to be greatest at the level of C4-5 in LF (1.94 ± 1.60 mm, P = .01) and C5-6 in HLP (1.71 ± 1.17 mm, P = 0.00). In comparing patients with post-operative C5 palsy with those who did not acquire C5 palsy, dorsal migration was found to be significantly greater in the C5 palsy group at the levels of C4-5 (4.38 ± 0.50 mm vs 1.64 ± 1.04 mm, P = .02), C5-6 (4.97 ± 0.99 mm vs 1.57 ± 1.29 mm, P = .02), C6-7 (4.20 ± 0.83 mm vs 0.77 ± 1.09 mm, P = .02) and C7-T1 (1.74 ± 0.96 mm vs 0.01 ± 1.33 mm, P = .045) as compared to the non-C5 palsy group. Conclusion: This is the first MRI study to prove that there is a trend towards greater posterior cord migration in laminectomy with fusion compared to hybrid laminoplasty in patients presenting with cervical myelopathy. A statistically significant greater dorsal cord migration was found at C4-5 spinal level in patients with C5 palsy., Introduction: Laminoplasty first described by Tsuji in 1982 as an alternative to laminectomy as the treatment for cervical spondylotic myelopathy CSM. The technique was developed in an effort to eliminate the development of instability and kyphosis following laminectomy while achieving minimal reduction in cervical range of movement (ROM) compare to fusion. In the late 1990’s, spinal surgeons experimented the use of maxillofacial fixation plates as an alternative to sutures, anchors and local spinous process auto-grafts to provide a more rigid and lasting fixation of laminoplasty. This eventually led to the advent of laminoplasty mini-plates, which are currently used. Objective: Is to compare laminoplasty with plate and without plate techniques in terms of functional outcome results. Material and Methods: A qualitative and quantitative analysis was performed to evaluate the current available literatures in an attempt to justify the use of plate in laminoplasty. Given the relatively high costs associated with the use of these plates and limited available data in the literatures about laminoplasty techniques and outcome. Results: The principal finding of this study was that there was no statistically significant difference in clinical outcome between the two different techniques of Laminoplasty. Conclusion: There is no enough evidence in the Literatures to support one technique over the other and hence there is no evidence to support change in practice (using or not using the plate in laminoplasty). Randomized control trial will give better comparison between the two groups., Introduction: Laminoplasty is a surgical procedure frequently performed for cervical myelopathy. We investigated correlations between changes in the anteroposterior diameter (APD) of the spinal canal, spinal canal area (SCA), and laminar angle (LA) and clinical outcomes of laminoplasty. Material and Methods: Of the 204 cervical myelopathy patients who underwent laminoplasty from July 2010 to May 2015, 49 patients who were evaluated with pre- and postoperative computed tomography of the cervical vertebrae were included. The average age of the patients was 60.4 years (range, 31–82 years), and the average duration of follow-up was 31.6 months (range, 9–68 months). Changes in the APD and SCA were measured at the middle of the vertebral body. Changes in LA were measured where both pedicles were clearly visible. Clinical outcomes were assessed using the Japanese Orthopedic Association (JOA) score and visual analog scale score for pain preoperatively (1 day before surgery) and postoperatively (last outpatient visit) and examining postoperative complications. Results: The APD showed an average of 54.7% increase from 11.5 to 17.8 mm. The SCA showed an average of 57.7% increase from 225.9 to 356.3 mm2. The LA increased from 34.2° preoperatively to 71.9° postoperatively. The JOA score increased from an average of 9.1 preoperatively to 13.4 postoperatively. Three patients were found to have hinge fractures during surgery. Postoperative complications, including two cases of C5 palsy, were recorded. The correlation coefficient between the LA change and JOA score improvement was −0.449 (P < .05). Patients with a, Introduction: To review outcome of 25 patients who underwent open-door cervical Laminoplasty for multilevel cervical spondylotic myelopathy and OPLL using titanium reconstruction miniplate and screws. Material and Methods: Records of 18 men and 7 women aged 35 to 78 (mean, 62.6) years, who underwent open-door cervical Laminoplasty for myelopathy using titanium reconstruction miniplate alone were reviewed. 4 patients had 5 levels of decompression (C3-C7), 21 patients had 4 levels of decompression (C3-C6). Foraminotomies were performed in 3 cases (12%). A total of 104 laminae were opened, all of them were fixed with a titanium miniplate. In 21 patients, a 20-hole titanium miniplate bent to the contour of a lamina was used and fixed into 4 laminae and 4 patients fixed in 5 laminae levels. In most patients, screw fixation was unicortical, and no spacer or bone graft was used. Demographic data and surgical data including estimated blood loss (EBL), length of surgery, number of laminoplasty levels, complications and length of hospitalization were collected. Clinical outcomes were assessed with neck pain score using visual analog scale, neck disability index. Nurick’s grading was used for quantifying the neurological deficits and outcome analysis was done using Odom’s criteria. Results: The mean follow-up duration was 1.8 (range: 1–5) years. Diagnosis was cervical spondylotic myelopathy (n = 20), ossification of the posterior longitudinal ligament (OPLL, n = 5). Mean estimated blood loss (EBL) was 120 ml (range: 50-200), mean surgery time was 153 min (range: 75-240). Following Nurick`s scale, 23 patients (92%) improved, 2 (08%) had the same Nurick grade. No intraoperative complications were noted and average hospital stay was 6.12 days (range: 5 to 9). Significance improvements in overall NDI scores occurred at 1 year follow up (P < .002). Radiographic evaluation showed an increase in the mean sagittal diameter from 12.2 mm at pre-treatment to 18.3 mm post-surgery. 2 patients developed transient C5 palsy, presenting as shoulder abduction weakness. Conclusion: Open-door Laminoplasty technique using titanium reconstruction miniplate and screws is safe, easy and achieves a good canal expansion and neurological recovery and can be used as an alternative treatment for cases of multilevel cervical spondylitic myelopathy and OPLL patients without instability., Introduction: There are many concerns about ASD after lumbar spinal fusion using pedicle screws. There are many studies about the causes that is natural degenerative change or risk factors. It was to analyze risk factors for adjacent segment disease(ASD), by comparing patients occurred ASD with patients followed more than 10 years after lumbar spinal fusion with pedicle screw fixation for degenerative lumbar spinal disease. Materials and Methods: From August 1988 to December 2005, 581 patients underwent lumbar spinal fusion of 3 and less segment to treat degenerative lumbar disease. Among them, 180 patients underwent revision surgery for ASD or followed more than 10 years were included in this study. Average The mean age at the initial operation was 53.6 years old and the mean follow-up period was 160.6 months. Gender, age, residence, preoperative diagnosis, fusion method, number of fused segments, whether laminectomy of adjacent segments, preoperative degree of disc degeneration of adjacent segments in MRI, wether adjacent segments included L4-5 or L5-S1, and radiological measurements were analyzed. In radiological measurement, pre-& post-operative lumbar lordotic angle (LLA), correction of LLA, post-operative fusion segment lordotic angle(FSLA) per level were estimated. Statistical univariate analysis was performed with the Chi-square test and multivariate logistic regression analysis was done by using SPSS 14.0. (P < .05). Results: There were 40 patients with revision surgery due to ASD. Seven patients were operated by decompression or discectomy and 33 patients needed additional fusion. In univatiate analysis, the frequency of ASD was significantly high in cases that age was more than 65 years old (P = .002), laminectomy of adjacent segment was performed (P = .002), preoperative disc degeneration of adjacent segments in MRI was present(p = 0.001) and post-operative FSLA per level was, Introduction: One of the major concerns after lumbar fusion surgery is the risk of developing adjacent segment disease (ASD). Both Posterior lumbar interbody fusion (PLIF) and posterolateral fusion (PLF) have been widely used by surgeons to address degenerative lumbar disease. However, the risk factors for developing of ASD are not clear. Some studies suggested that there is a higher rate of ASD with interbody fusion due to a more solid fusion, having a more profound effect on the caudal adjacent segment. In this study, we looked at our cohort of patients to investigate this further and establish other risk factors. Materials and Methods: We retrospectively reviewed our spinal unit data base to identify all patients who underwent posterior lumbar interbody fusion (PLIF) and Posterolateral lumbar fusion (PLF) over the last 5 years. 50 Patients of each group were randomly and blindly selected. Those with adjacent segment disease were identified. Co-morbidities, demographics, visual analogue scores preoperatively, then yearly, for the duration of five years were analysed. X-rays and CT scans were analysed and reviewed by 2 independent reviewers to assess the pelvic incidence change and sacral slope change. Results: All procedures were done by 3 spinal surgeons who use the same techniques and instrumentation. The difference of incidence of adjacent segment disease between the two groups was statistically insignificant. Both groups had comparative pre-operative co- morbidities; including smoking, diabetes, hypertension, obesity and steroid use. Both groups had similar socio-economic back grounds. X-rays and CT scans reviews showed no significant difference when assessing the pelvic incidence and sacral slope change (P < .001) with good inter-observer reliability (kappa 0.95). Conclusion: We concluded that smoking, diabetes, hypertension, obesity and steroid use are all risk factors for developing ASD. The incidence of ASD seems to be higher in younger patients with high physical activity. The choice of surgery; PLIF or PLF, does not affect the incidence of ASD., Introduction: Adjacent segment degeneration (ASD) is one of the major complications after lumbar fusion. Several studies have evaluated the risk factors of ASD. Although the paraspinal muscles play an important role in spine stability, no study has assessed the relationship between paraspinal muscle atrophy and the incidence of ASD after lumbar fusion. In the present study, we aimed to verify the known risk factors of ASD, such as body mass index (BMI), preoperative adjacent facet joint degeneration, and disc degeneration, and to assess the relationship between paraspinal muscle atrophy and ASD. Material and Methods: This is a retrospective 1:1 pair analysis matched by age, sex, fusion level, and follow-up period. Among the 510 patients who underwent posterior lumbar fusion for degenerative lumbar disease between January 2009 and October 2009, a total of 50 patients with ASD after surgery were selected. Another group of 50 matched patients with degenerative lumbar disease without ASD after spinal fusion were selected as the control group. Each patient in the ASD group was matched with a control patient according to age, sex, fusion level, and follow up period.The risk factors considered were higher BMI, preoperative adjacent segment disc and facet degeneration, and preoperative paraspinal muscle atrophy and fatty degeneration. The radiographic data were compared between the ASD and control groups to determine the predictive factors of ASD after posterior lumbar fusion by using logistic regression analysis. The study was not externally funded. Results: Multivariate logistic regression analysis indicated that higher BMI (odds ratio [OR]: 1.353, P = .008), preoperative facet degeneration on computed tomography examination (OR: 3.075, P = .011), disc degeneration on magnetic resonance imaging (MRI) (OR: 2.783, P = .003), fatty degeneration (OR: 1.080, P = .044), and a smaller relative CSA of the paraspinal muscle preoperatively (OR: 0.083, P = .003) were significant factors for predicting the development of ASD. Conclusion: The occurrence of radiological ASD is most likely multifactorial, and is associated with a higher BMI, preexisting facet and disc degeneration on preoperative examination, and a smaller preoperative relative CSA of the paraspinal muscle on MRI., Introduction: Nowadays, adjacent segment pathology (ASP) is one of the problematic complications after posterior lumbar interbody fusion (PLIF). We need to seek the effective methods to decrease the incidence of symptomatic ASP and as a result to decrease the revision surgery. Minimum invasive PLIF (MI-PLIF) is one of the good candidates. Purpose of this study is to investigate whether MI-PLIF surgery could decrease the incidence of symptomatic ASP. Material and Methods: At our hospital 467 patients had PLIF between 2005 and 2010. Eligible patients were with single PLIF as an initial lumbar operation. Out of 467, 326 patients with revision surgery, systemic disease, additional decompression at the other segment, and isthmic spondylolisthesis were excluded. Thirty one patients did not satisfy 5-year follow up. Finally, 101 patients were (age; median 65, 37 male and 64 female) included in this study. Follow-up rate was 76%. Forty two patients had PLIF with conventional pedicle screw (C-PS), 33 with percutaneous pedicle screw (P-PS), 26 had stand-alone PLIF (SA). The endpoint was history of the symptomatic ASP at 5 years after operation. Symptomatic ASP was defined to be the pathology with the following three conditions. First, symptom before operation had disappeared or almost completely alleviated postoperatively. Secondly, new symptom had emerged at least three months after operation. Thirdly, the newly emerged symptom was considered to be owing to the pathology confirmed on magnetic resonance imaging(MRI). Results: Of 101 patients, 2 patients in SA group had reoperation at index level by 2 years. Two patients (2%) had reoperation at the adjacent segment by 2 years, and 9 patients (9%) by 5 years. The incidence of the symptomatic ASP was 24% in the C-PS group, 24% in the P-PS group, and 21% in the SA group. There was no significant difference with a small sized effect between the C-PS group and P-PS group (P = .9652, r = .01) nor between C-PS group and SA group (P = .7814, r = .07). Conclusion: In our study minimally invasive PLIF did not have advantage over conventional PLIF in the incidence of adjacent segment pathology., Introduction: The lumbar spinal fusion is an established procedure for the treatment of many degenerative diseases of the lumbar spine and spondylolisthesis. However the development of adjacent-level degeneration has been described in many studies as late effect after lumbar spine fusion. The hybrid system topping off was invented to prevent the manifestation of the adjacent-level degeneration. This system includes a rigid spondylodesis and a flexible instrumentation of the adjacent-level. Purpose of this study is the assessment of clinical and radiological outcome. Material and Methods: In this prognostic prospective study have been patients included with a degenerative disease of the lumbar spine or spondylolisthesis with an indication for a lumbar fusion and additionally radiological signs of degeneration in the adjacent segment without instability (Pfirrmann Grad 2-4). Exclusion criteria were previous surgery of the lumbar spine and no disc degeneration in the MRI in the adjacent segment. All patients were treated with a monosegmental lumbar interbody fusion and dynamic Stabilization (topping off) of the cranial adjacent level (CD HORIZON BalanC™ rod System Fa. Medtronic plc, Dublin, Irland). The patients were subjected to clinical examination and radiographs pre-operatively and one year after the operation. The assessment of the clinical data has been obtained on the basis of the German spine register using the COMI score and VAS score for back- and leg-pain. The statistical program SPSS (Version 22.76 Chicago, IL, USA) was used for the evaluation of the data. Results: In the study have been 21 patients (5 male and 16 female) included. The average age of the patients was 58.9 ± 10.8 (min: 41, max: 78) years old. The average COMI score pre-operatively was 9.0 ± 0.9 (min: 6.7, max: 10.0). In the one-year-follow-up the average COMI score was 4.3 ± 2.4 (min: 0.0, max: 7.5). The results prove a significant reduction of the COMI score in the one-year-follow-up (P = .000). The average pre-operatively VAS was for back-pain 7.6 ± 2.4 (min: 0, max: 10) and for leg-pain 6.9 ± 2.9 (min: 0, max: 10). In the one-year-follow-up the VAS for back-pain was 4.3 ± 2.4 (min: 0, max: 8) and for leg-pain 2.3 ± 3.1 (min: 0, max: 8). Both VAS back- and leg-pain showed a significant reduction in the 1-year follow-up (P = .000). No radiological signs for adjacent-level degeneration have been observed in the one-year-follow-up. A fatigue fracture of the dynamic topping off material was verified in 4 cases (3 female and 1 male) during the follow-up. Conclusion: Biomechanical studies report about reduced stress forces to the adjacent-level after lumbar spinal fusions with the topping off system. However it is being implied that the topping off segment is with a high rigidity combined. Moreover the instrumentation of an additional segment is associated to higher operation morbidity. Our results demonstrate a significant improvement of the clinical outcome and reduction of the pain after lumbar spinal fusion with topping off, one year after the procedure. Our results are similar to standard lumbar fusion according to the literature one year after the operation. Due to the high rate of implant failure this implant is not being used anymore in our clinic., Introduction: Spinal segment arthrodesis has become a widely accepted treatment for degenerative disorders of the lumbar spine. For today rigid internal fixation with 360° fusion has been viewed as the gold standard for spine stabilizing surgery. However spinal fusion alters the normal biomechanics of the spine and eliminates mobile segments causing overload of adjacent segments. At the same time many patients with degenerative disorders have abnormalities of spino-pelvic parameters, which remain postop. Thus, spinal fusion, according to some authors can accelerate the degeneration of adjacent segments, especially under unfavorable biomechanics of the spine. Material and Methods: This retrospective study evaluated 76 patients underwent 360° short fusion lumbar surgery (one and two levels) from 2008 to 2013 for the treatment of degenerative conditions of the lumbar spine. The patients were divided into two groups depending on the presence of symptomatic ASD: first group include 36 patients with symptomatic ASD during 3 years postop, second (control) group include 40 patients with no signs of symptomatic adjacent segment disease. There were 66% females. Mean age of 54 years (range 21-76). Mean follow-up of 4 years (3-7 years). Long cassette standing anteroposterior and lateral radiographs were performed on the preoperative, postoperative and follow-up visits. In all cases we studied preop, postop, and f/up sagittal plane alignment according to Schwab sagittal modifiers. Results: In the I group symptomatic ASD was found in 14 cases (38.9%) during 1 year follow-up. There were 6 cases (42.9%) with sagittal imbalance and 11 cases (78.6%) with the difference between pelvic incidence and lumbar lordosis (PI-LL) more than 11°. Summary after 3 years f/up in I group sagittal imbalance was diagnosed in 23 cases (63.9%), in 26 patients (72.2%) PI-LL was above or equal to 11°. Average postop SVA in the I group was + 6.2 cm, average PI-LL mismatch was 13.2°. 86% of the I group patients required revision surgery. In the II group at 3 year f/up sagittal imbalance was identified in 11 patients (27.5%) with average SVA + 2,8 cm. PI-LL above or equal to 11° was found in 10 cases (25%), average value for the II group patients was 8.1°. Conclusion: Patients with spino-pelvic alignment disturbances such as sagittal imbalance and PI-LL mismatch have statistically significant increasing risks of developing ASD because of overloading the adjacent segments under unfavorable biomechanics of the spine., Introduction: Minimally invasive decompression (MID) is an effective and safe procedure for lumbar spinal stenosis (LSS). In short-to-moderate term follow-up studies, (ie, Introduction: Minimally invasive transforaminal interbody fusion is nowadays a very popular technique. Potential advantages include reduced blood loss, shorter length of stay, and less soft-tissue trauma. Potential disadvantages include increased radiation exposure, longer operative times, and higher risk of screw malpositioning related to a inadequate visualization of anatomical landmarks. Spinal navigation could theoretically improve results with this technique, increasing accuracy during percutaneous screw positioning, decreasing operative time and radiation exposure for both surgeons and patients. We report results on a cohort of 40 operated patients, where we performed mini-open transforaminal interbody fusion (TLIF) at lumbar levels using spinal navigation coupled with an intraoperative mobile CT (iCT-AIRO®), without any use of fluoroscopy, except for the final control of cage position at interbody level. Material and Methods: Series includes 40 cases submitted to mini-open TLIF with 22 mm tubular retractors. All patients were affected by a degenerative disease of the spine, at one or two levels, with monolateral radicular pain. In every case decompression and cage positioning were performed without complications through tubular retractor. Screws were positioned percutaneously, before decompression and cage positioning, using iCT-based spinal navigation, without any use of fluoroscopy. Screw position was checked immediately after positioning. Results: There were 26 men and 14 women, with a mean age of 60 years (36-84). Thirty-six patients were operated by the same surgeon (PS). Six patients underwent a 2-level procedure. Mean follow-up was 10.5 months. We did not observe any neurological complications. Position of screws was optimal in every case, without any screw repositioning during surgery. Mean duration of surgery was 229 minutes. Surgical times reduced significantly in recent operated cases. No patient was reoperated during follow-up. At radiological analysis, 98% of screws were correctly placed in the pedicle (Heary grade 1). No screw was graded 4 or 5. Mean effective dose for patient was under 15 mSV, and not significantly higher than our previous experience with another imaging method (O-arm). This dose compared very favourably with reported dose for fluoroscopic assisted mini-TLIF.1 Mean number of intraoperative scans was 2. Conclusion: In a recent paper, Ruatti et al.2 showed a rate of malpositioned screws higher than 20% using spinal navigation for percutaneous screws. This rate was significantly lower with open technique. Use of spinal navigation coupled with an intraoperative CT significantly augmented, in our experience, accuracy in percutaneous screw positioning, compared with spinal navigation associated with a cone-beam CT (O-arm) or with traditional technique with fluoroscopic control. Reasons for this improvement are different, mostly related with a more stable positioning of the reference star on the iliac crest, and with a better quality of intraoperative imaging. In our series, there was significantly less radiation exposure for the surgical team. Surgical times were significantly higher than traditional open technique without navigation. References 1. Bindal, R. et al. Surgeon and patient radiation exposure in minimally invasive transforaminal interbody fusion. JNS Spine 9;570-573, 2008. 2. Ruatti, S. et al. Interest of intra-operative 3D imaging in spine surgery: a prospective randomized study. Eur. Spine J. (2015). doi:10.1007/s00586-015-4141-5., Introduction: One concern about posterolateral interbody fusion (PLIF) implants is the insufficient primary stability that impacts negatively on fusion rate, increases the chance of subsidence with loss of segmental lordosis. To avoid posterior migration, PLIF also needs to be supplemented with pedicle screws increasing the costs and the surgical complications. Recently, a novel modular PLIF assembled intraoperatively by a rail-and-slot design into the disc space, InterFuse STM, has become available. It can be inserted through the small annulus opening of a classical microdiscectomy, without further facet joint resection preventing the potential for post-operative instability. Once implanted, it provides the largest surface area for load-sharing even when compared to anteriorly inserted cages. The aim of this study is to evaluate the feasibility, safety and outcomes using stand-alone Interfuse-S. We hypothesized that the increased surface area can adequately promote fusion, segmental lordosis with good clinical results obviating the need to add transpedicular screws. Material and Methods: Ten consecutive patients, 5 males and 5 females, with extruded lumbar disc herniation underwent PLIF with InterFuse STM. No pedicle screw fixation was performed. Median age was 37.6 years (range 22-46). All patients underwent a single–level procedure (8 patients at L5-S1, 2 patient at L4-5). The indications were extruded lumbar disc herniation. Results: No surgical complications or neurological deficits were noted, as reflected in a mean hospitalization of 2.3 days. At 12 months FU, mean back VAS decreased from 7 to 2 (P < .01) and leg pain resolved in all patients (P < .01). A 100% rate of successful fusion was observed. No cases of implant subsidence or breakage were found. Segmental lordosis was observed in all patients. There was one case of posterior migration that conducted to revision surgery in an obese and heavy lifter patient. Conclusions: Stand-alone PLIF with InterFuse STM is a feasible and safe technique compared to conventional PLIF or TLIF in young patients with lumbar disc herniation, without compromising clinical and radiological outcomes. With a less invasive approach, adequate end-plate coverage was obtained with slight root traction and minimal facet joint resection, due to the small size of the single modules. A large footprint reduces the possibility of implant subsidence and migration even when used as a stand-alone implant without posterior stabilization., Introduction: To explore the clinical and radiological outcomes of MIS-TLIF in the treatment of lumbar isthmic spondylolisthesis. Material and Methods: 32 patients with lumbar isthmic spondylolisthesis underwent MIS-TLIF by the same surgeon in single institution. There were 14 males and 18 females with an average age of 47.5 years old. 21 cases were rated as degree I, 11 as degree II. The surgery, including bilateral decompression, discectomy for neurological relief, interbody fusion, cage insertion and fixation with pedicle screw, was conducted through a small paraspinal incision and assisted with the Quadrant system. VAS and ODI were adopted to evaluate the clinical manifestation pre- and postoperative. The pre- and postoperative spinopelvic parameters including PI sacral slope, PT, LL, and sagittal vertical axis from C7 plumb line were evaluated. Results: The average follow-up period was 29.6 (24-72) months. The scores of VAS and ODI after sugery and at the final follow-up were lower than those bofere sugeryc (P < .05). The height of intervertebral space after surgery and at the final follow-upincreased significantly compared with that before surgery (P < .05). All operated vertebral segments achieved solid bony fusion at the follow-up of 6.5 months postoperatively. The slip degree, slip angle, and HOD improved significantly. Pelvic parameters and sagittal balance improved subsequently. SS was increased by 4.5 degrees, and PT was decreased by 4.5 degrees. LL was increased by 5.0 degrees and sagittal balance was displaced 5.4 mm backward. Conclusion: MIS-TLIF may be an easy and safe way in the treatment of lumbar isthmic spondylolisthesis. With local deformity corrected after surgery, all spinopelvic parameters changed subsequently., Introduction: Inter-body fusion techniques for degenerative disk disease (DDD) are still a controversial indication in the current literature. Although good clinical results have been reported in several randomized clinical trials for a variety of fusion procedures, the lack of clear indications in the treatment of lumbar DDD and the opportunity to fuse may be partially attributed to the invasiveness of open surgical approaches, which often seem to be overly aggressive procedures for a disease that has been shown to benefit even from conservative treatment. Nevertheless, the emerging diffusion of minimally invasive spine techniques, such as LIF or OLIF, is progressively changing the indication for treating patients with lumbar DDD because they can achieve mono- or plurisegmental interbody fusion, allowing much faster recovery with a very low rate of complications. Materials and Methods: Between January 2010 and September 2015, at our institution, 45 patients (67 levels) underwent lumbar interbody fusion for pure lumbar DDD above the level of L5–S1 through both pure lateral trans-psoas approach (LIF) (n = 31) or oblique lateral retroperitoneal approach (OLIF) (n = 14). Preoperative radiological evaluation included lumbar MRI, CT scan, and dynamic X-rays. Inclusion criteria were chronic axial low back pain exacerbated by prolonged standing and trunk mobility and previous conservative treatment for a period of at least 6 months failed. Patients with radiologically demonstrated frank segmental instability and/or frank radicular conflict and/or those with lumbar stenosis due to spondilosis, were excluded from the study. Only patients with at least 6 months of follow-up were included in the analysis. Clinico-neurological evaluations with VAS, ODI, and SF-36 tests were routinely performed before the intervention and repeated at follow-up to evaluate the clinical course and quality of life. Statistical analyses were performed using SPSS version 15 software (Chicago, IL, USA). P < .01 was considered significant. Results: The total levels treated are 67: L2-L3 in 7 cases (10.4%, 6 in the LIF group and 1 in the OLIF), L3–L4 in 31 cases (46.3%, 28 LIF and 3 OLIF), L4–L5 in 21 cases (31.3%, 15 LIF and 6 OLIF) finally L5-S1 in 8 cases (12.0%, all in the OLIF group). Only two intraoperative complications happened without further events: one patient of the OLIF group presented the rupture of the left common iliac vein due to the blades of surgical retractor, and one patient of the LIF group presented a peritoneal laceration; both the complications were successfully treated. In the post-operative period, 21 patients (46.6%, 19 in the LIF group and 1 in the OLIF group) presented motor deficit (3/5 motor) in the ankle flexion associated to a dysesthesia at the territory of L3 and L4. These symptoms had a progressive resolution within 4 to 6 weeks. 5 patients of the LIF group presented a psoas hematomas, which needed 4 days of bedrest. Two patients of the LIF group presented an L4 palsy with a partial resolution in 1 year. In the OLIF group, 7 patients of the oLIF group presented a fluid retroperitoneal collection which did not require ani treatment in any case and one patient presented persistent pain at the surgical side. Regarding the clinical evaluation with the VAS scale, ODI and SF-36 all the patients presented good results at the final follow-up. In the VAS scale appear a difference of 1.27 points between the LIF and the OLIF group in the post-operative period. Similar results are presents in the ODI where the mean difference result of 7.3%, and in the SF-36 tests where regarding the physical scale the difference results of 6.22 points and in the mental scale the difference of 1.55 points in favor of LIF group. Conclusions: LIF and OLIF represent mini-invasive procedures for treatment of lumbar DDD. Although generally considered more complex compared to traditional posterior procedures, they are safe and effective, allowing the resolution of disk pain with short hospitalization and fast daily activity recovery. The selection of patients and a good preoperative planning, seem to be detrimental factors to obtain good clinical results., Introduction: The use of minimally invasive surgical (MIS) procedures for the treatment of degenerative lumbar spondylolisthesis is increasing although the outcomes of standard open posterior lumbar fusion surgery remain efficient. The question remains what exactly are the benefits of MIS procedures. The aim of the study was to determine the difference between minimally invasive TLIF (MI-TLIF) results and open TLIF procedures regarding the clinical outcomes, perioperative parameters, fusion rate and adverse events. Materials and Methods: In the study, 30 patients with the painful, lumbar degenerative spondylolisthesis (Grade I) not responding to conservative treatment were treated with the open TLIF procedure and 30 patients with minimally invasive TLIF procedure. Clinical outcomes were assessed before, 6 months, one year and two years after the procedure using the Oswestry Disability Index (ODI) and Visual analogue score (VAS) for back and leg pain, with 15% improvement in ODI and 20% in VAS defined as a clinically significant. The perioperative parameters including blood loss, operative times, exposure to fluoroscopy and length of hospital stay were evaluated. The CT scans of the patients were taken accordingly in order to determine the fusion rate. Results: There was a significant improvement for back and leg pain according to ODI and VAS score in both groups with no statistically important difference between the two groups. There was less blood loss and faster recovery time in the MI-TLIF group but higher fluoroscopic exposure and slightly higher length of the surgeries. The fusion rate was the same in the open and MI-TLIF group. Conclusions: Both procedures resulted in significant pain reduction and good functional outcome for the patients with better results in the MI-TLIF group regarding the hospital stay and blood loss. According to our results and according to the literature reviews there is still not enough evidence to state that one procedure is superior to other. In time, the MIS procedure might slowly replace the open technique., Introduction: Surgical goals in adult degenerative scoliosis patients are to reduce pain, correct and prevent further deterioration of deformity, restore coronal and sagittal plane balance. Open long segment reconstructions are associated with high complication rates. In view to reduce surgical morbidity, minimally invasive surgeries have been recommended. However, not all adult spinal deformities can be treated with minimally invasive techniques. Several classifications and treatment levels have been recommended. One such algorithm is MiSLAT treatment level. Aim of our study was to assess the external validity of MiSLAT algorithm and to assess the role of XLIF in management of adult degenerative deformity of spine. Material and Methods: This was a prospective interventional case series from of patients with symptomatic adjacent segment disease, localised and generalised degenerative deformity of spine who underwent XLIF procedure. MiSLAT algorithm was used to decide treatment level for patients. Pre and post-operative patient reported outcome measures like ODI, VAS score, EQ VAS, EQ-5D index were recorded. Radiological parameters like Cobb angle, lumbar lordosis, pelvic tilt, sacral slope and pelvic incidence were analysed pre and post operatively. Complications rate was reviewed. Results: 41 patients had XLIF from May 2012 to January 2016. There were 17 males and 24 females. Mean age at surgery was 61.8 years (range 50 – 94) with a mean follow up of 20.46 months (range 7 – 51). Twelve patients were operated for adjacent segment disease, 13 for localised deformity and remaining 16 for generalised deformity. Among 13 localised deformities, there were 3, 9 and 1 patients with MisLAT type II, III and IV classification respectively. Sixteen of generalised deformity group included 10, 1, 5 patients with MisLAT type IV, V and VI respectively. There was statistical significant difference between pre and post-operative ODI, VAS score, EQ VAS, EQ-5D index. Mean pre and post-operative scoliosis and lumbar lordosis in localised deformity was 11, 23.6 degrees and zero, 28.6 degrees respectively. In generalised deformity group, pre and post-operative scoliosis, lumbar lordosis and pelvic tilt were 27, 14.7, 37 degrees and 12, 34, 16.3 degrees respectively. There were 11 complications (26.8%), including two femoral nerve palsies and one death from pulmonary embolism. The reoperation rate was 4.8% (2 patients) for non-union. Conclusions: XLIF can be used as surgical tool in MiSLAT types II, III and IV deformities, whereas for MiSLAT types V and VI, XLIF can be used in conjunction with open techniques to correct deformity. MiSLAT algorithm can be used safely to guide management plan in adult degenerative deformity of spine. In addition, XLIF has lower complication rates compared to other open surgeries mentioned in literature to date., Introduction: Some studies have indicated PS fixation at UIV is thought to be a possible risk factor of PJF. The purpose of this study was to retrospectively compare the incidence of acute PJF between transverse hook fixation at UIV and PS following ASD surgery. Methods: Forty-seven ASD patients who underwent corrective surgery by a single surgeon were retrospectively reviewed with a minimum 1-year follow-up. The mean age was 67.6 years old (42-83) and the follow-up period was 36.9 months (12-95). T9 as UIV was selected in 17 patients and T10 in 30 patients. Transverse hook was used in 26 patients, and PS was used in 21 patients. Radiographic parameters including SVA, PI-LL, PT, and proximal junctional angle (PJA) were measured before surgery (PreO) and latest follow-up period (PO). Fracture risk was also evaluated using FRAX (WHO Fracture Risk Assessment Tool) before surgery. Acute PJF was defined as UIV and UIV+1 fracture, implant failure or PJK > 15° within the first six months. We compared the several data between the hook group and the PS group with statistical software. Results: The hook group had an acute PJF rate of 19.2% compared to 28.5% in the PS group (P = .20). The mechanisms of acute PJF are as follows; there were 4 patients with UIV fracture and 1 patient with implant failures in the hook group, and there were 6patients with UIV fracture in the PS group. Radiographic parameters in the hook group (PreO/PO) were following; SVA; 119.1/39.1 mm, PI-LL; 46.4/4.6°, and PT;35.8/21.9°. Those in the PS group were as follows; SVA; 92.3/37.3 mm, PI-LL; 37.6/4.5°, and PT;31.9/21.8°. FRAX were 13.7% in the hook group and 13.4% in the PS group. There were no differences in baseline data between the two groups. However, the changes of PJA in the PS group were significantly higher than those in the hook group (7.4/2.9°; P = .05). To analyze the PJA data in the patients with Acute PJF, the changes of PJA were significantly higher in the PS group than those in the hook group (17.0/6.3°; P = .04). Conclusion: Our study doesn’t show that transverse hook as UIV instrument can prevent acute PJF. However, using hook at UIV can prevent the vertebral collapse if UIV fracture occurs. The increased risk of collapse of UIV fracture in the PS group in this study may due to higher mechanical load to UIV using PS. Further biomechanical study should be necessary to clarify our results., Introduction: Adult Spinal Deformity (ASD) causes severe functional disability, reducing the overall quality of life. In view of the growing ASD population, routine monitoring of outcomes covering the overall quality of life, functioning, and disability from a patient’s perspective, will play an important role in future reimbursement and healthcare systems.1,2 In this era of value based care, healthcare providers are putting more emphasis into assessing the value (health gain per unit cost) of treatment provided. In particular for ASD surgery, where a tremendous treatment variability exists, outcome monitoring by means of outcome registries would be of value. However, outcome registries are most valuable if they are comparable between countries and include outcomes that are relevant to the patient population of interest.3 Standardising patient-reported outcomes (PROs) is a key first step; however, this can only achieve its maximum benefit when the measures used are uniform, valid, reliable and risk-adjusted. Therefore, the aim of this study is to highlight the current strengths, weaknesses and gaps in PROs used for assessment of ASD, to provide recommendations for future improvements, and to serve as a foundation for the process of seeking global consensus on standardising outcomes measures in future clinical trials and spine registries worldwide. Material and Methods: This study ultimately consists of three phases: 1) a systematic review of patient-reported outcome used to evaluate outcomes after ASD surgery. We used the domains of the WHO International Classification of Disability, Functioning and Health (ICF) as a framework. 2) a modified five-round Delphi study among international experts starting April 2017, and 3) validation with patient focus groups. Results: Phase 1. The systematic review identified 144 papers that met inclusion criteria, and nine frequently used PROs were identified, such as the ODI, SRS-22 and VAS. These measured 29 potential ICF outcome domains, which could be grouped into 3 of the 4 main ICF chapters: body function (n = 7), activity and participation (n = 19), and environmental factors (n = 3). The three most frequently measured outcome domains are: ‘sensation of pain’, ‘recreation and leisure’, and ‘walking’. Conclusion: Outcome domains related to ‘mobility’ and ‘pain’ are represented well by PROs used in the current literature. Outcomes related to ‘neurological function’ and ‘pulmonary function’, both significantly affected by ASD surgery, are currently not reported.4,5 These findings indicate that currently used PROs may be inadequate to measure all relevant outcomes in ASD patients. In order to achieve a standardised approach and improvement of individual patient evaluation, consensus on a core set of outcome domains for ASD is urgently needed. In phase 2, using a modified Delphi method, the results of this preparatory study will provide the foundation for the development of a global set of core domains, measurement instruments (patient-reported and clinician-based) and contributing factors to these outcomes. The development of this core outcome set will facilitate comparisons across studies, registries, and nations in order to improve the quality of daily clinical practice in this increasing group of patients, with an increasing burden on society. References 1. Porter, M. What is Value in Health Care? N. Engl. J. Med. 2477–2481 (2010). doi:10.1056/NEJMp1415160 2. Harwood, J. L., Butler, C. A. & Page, A. E. Patient-Centered Care and Population Health: Establishing Their Role in the Orthopaedic Practice. J. Bone Joint Surg. Am. 98, e40 (2016). 3. Porter, M. E., Larsson, S. & Lee, T. H. Standardizing Patient Outcomes Measurement. N. Engl. J. Med. 374, 504–506 (2016). 4. Lenke, L. G. et al. Neurologic Outcomes of Complex Adult Spinal Deformity Surgery: Results of the Prospective, Multicenter Scoli-RISK-1 Study. Spine (Phila. Pa. 1976). 41, 204–12 (2016). 5. Lehman, R. A., Kang, D. G., Lenke, L. G., Stallbaumer, J. J. & Sides, B. A. Pulmonary Function Following Adult Spinal Deformity Surgery: Minimum Two-Year Follow-up. J. Bone Jt. Surg. 97, 32–39 (2015)., Introduction: Loss to follow up is highly prevalent after orthopedic surgery. Measuring clinical outcomes after surgery is important to guide an evidence-based approach to care. Loss to follow-up in randomized control trials or clinical registries may present a bias to assessing the efficacy of treatments and reduce the statistical power of study results. Current literature fails to demonstrate the effect of loss to follow up in clinical outcomes studies for ASD. The purpose of this paper is to report the reasons that patients lost to follow-up did not follow-up and the outcomes of care in these patients. Material and Methods: A survey was administered remotely to study a consecutive series of patients who were lost to follow up at greater than one year after being treated with primary multilevel spinal fusion with pelvic fixation for ASD. Patients were excluded if they declined participation or were deceased. Demographic, surgical, and health related quality of life data were collected directly from administrative and medical ontologies. All records were chart reviewed and source verified for accuracy. Four patients were excluded from the study as they were deceased and three patients declined participation in the phone survey. Results: The cohort included 38 patients who were not seen in clinic at one year or greater from their index surgery and 45 patients who followed-up routinely. There was no significant difference in patient reported outcomes between those who followed up and those who were lost to follow up (P = .97). The average improvement in EQ-5D utility score for those lost to follow up was 0.15 while those who followed-up regularly experienced a mean change of 0.17. Mean length of follow up for all patients was 911 days. Patients lost to follow up had significantly lower revision surgery rates than those who followed up (P = .03). All elective revision surgeries on patients lost to follow up were performed by the same surgeon within one year of their index operation. One emergency revision surgery was performed at an outside hospital after a patient was admitted directly from their local ED. ASA scores were significantly higher in patients who were lost to follow up (P = .01). BMI was also a significant predictor of loss to follow up (P = .05). Reasons for not following up in clinic included: I was not offered an appointment (n = 8), I feel good (n = 7), I stay in touch remotely (n = 7), I live too far away (n = 7), I plan to come in soon (n = 6), I was disappointed with my results (n = 5), my surgeon left the institution (n = 4), I see a doctor at home (n = 3), and I didn’t want to find out I need another surgery (n = 1). Conclusion: There are many barriers to follow up from both a patient and a provider’s point of view. Patients who are lost to follow up at greater than one year have similar outcomes as those who follow up in clinic at routine intervals. Advances in telehealth should be directed towards facilitating patient monitoring and the collection of patient reported outcomes after surgery., Introduction: The treatment of adult scoliosis is a continuous challenge even for expert spinal surgeons especially in patients over 50 years old. In some adult patients who present with severe, rigid curves, the use of vertebral osteotomies may be necessary to achieve adequate correction of the deformity. Several general and neurologic complications have been reported, in particular associated with PSO. The aim of this study was to report and analyse the perioperative complications and radiographical results in elderly patients undergoing vertebral osteotomies for spinal deformity correction. Materials and Methods: Our population was composed of 72 consecutive cases of kyphoscoliosis with different sagittal imbalance situations. All patients were classified according to Berjano-Lamartina classification; they were divided into two groups according to the corrective osteotomies they underwent: we only practiced SPO and/or PO in patients that composed group A; we practiced also PSO in patients that composed group B. We retrospectively reported and analysed the perioperative complications. An independent observer collected for each patient on X-rays the following data: Cobb angle, pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), thoracic kyphosis (TK), C7 plumb line (C7PL). The average follow-up was 30 months. Results: The mean age of our study group was 60.7 ± 10.2 years and the median age of 62 years (range: 42 – 82 years old). We had 50 cases of degenerative (spinal) segment diseases (DSD) Type III, 13 cases of Type IVa DSD and 9 cases of Type IVb DSD. Our overall complication rate was 22.2% (16/72 patients). Patients we treated with SPO and/or PO had a complication rate of 16.9% (10/59 patients) wile patients we treated also with PSO had a complication rate of 46.2% (6/13 patients). The mean Cobb primary curve angle of the cohort was 41.75° ± 18.06, residual scoliosis after surgery was 15.41° ± 10.7; the difference between the pre-operative and post-operative Cobb angles was statistically significant (P < .001). We found a pre-operative C7PL average value of 4.49 cm (±4.82), while the post-operative one was 2.08 cm (±3.44), with statistically significant difference. Discussion: The surgical treatment of adult deformities is a challenge also because of the high incidence rate of general and mechanical complications reported in the literature. The posterior surgery necessitates a major multilevel arthrodesis procedure be performed also by using different osteotomies techniques. Previous studies have shown increased complication rates with fusion procedures in elderly patients and our experience support this evidence. Our clinical and radiographic study demonstrates an high incidence of intraoperative complications rate in elderly patients underwent a PSO. Conclusions: PSO is a very useful technique to treat rigid high-grade spinal deformity of the adult but patients who undergo a PSO are at high risk of complications. Our experience demonstrates that patients over 60 with degenerative spinal deformity and sagittal imbalance candidate to a pedicular subtraction osteotomy have 46% of complications rate. PSO is a demanding technique to be considered in very selected and motivated patients who must be carefully informed about the risks of the procedure., Introduction: Decision making in adult spinal deformity (ASD) is one of the most difficult issue in estimating the effects of complications on the outcomes of treatment, especially for surgery in elderly population. The aim of this study was to analyze the decisive factors leading to the specific treatment modalities (i.e., operative vs. non-operative) by comparing the baseline characteristics of operative vs. non-operative patients with ASD over 70 years of age. Moreover, to evaluate the safety and efficacy of surgery; and to compare operative and non-operative management of patients with ASD over 70 years of age even with the setting of complications with a follow-up period of 2 years. Materials and Methods: A retrospective review of collected data from a multicenter database on ASD was performed. Patients over 70 years of age with spinal deformities who were scheduled to undergo surgical treatment and who were treated and/or followed without surgical intervention, participated in this study. Demographic, clinical, surgical, radiological features and HRQOL (SF-36 MCS, SF36-PCS, SRS-22 and ODI) parameters of such group of patients were evaluated pre and post-treatment. Peri/postoperative complications, classified as major (life threatening or requiring additional surgery) and minor were also investigated for their effects on HRQOL parameters at 2 years follow-up. Results: The database had 181 patients (F: 151, M: 30) entry for both operative (n = 85) and non-operative (n = 96) group over 70 years of age with ASD. Of these, 90 of them (F: 71, M: 29; operative: 61, non-operative: 29) had 2-years follow-up. The comparison between operative and non-operative group for demographic, clinical, radiological and HRQOL parameters at baseline showed statistical significance for all the HRQOL parameters, some of the radiological features including; major coronal Cobb angle, proximal thoracic, main thoracic, thoracolumbar and lumbosacral curves; and SRS-Schwab Curve type (P < .05). The calculated optimal cut-off values to diverge operative and non-operative groups for COMI, ODI, SF-36 PCS and SRS-22 were 5.7, 37.0, 37.5 and 3.2, respectively (P < .05). All operative patients (n = 61; F: 46, M: 15) were treated with posterior surgery. A total of 39 osteotomies and 24 interbody fusions were performed. Overall, 135 complications (71 major, 64 minor) and 1 death were observed. The reoperation rate was calculated as 62.3% at the end of 2 years. For all HRQOL parameters except SF-36 MCS, surgically treated patients significantly improved by means of HRQOL parameters two years after the surgery even with the setting of complications (P < .05). Conclusion: This study has demonstrated that surgery provides significant improvements in pain, disability and body perception in patients with ASD over 70 years of age with a follow-up of 2 years, even with the setting of complications., Introduction: The OLIF has widely been applied in the treatment of degenerative diseases of the lumbar spine. In this operation, fluoroscopic guidance is most often used; however, navigation has been shown to improve the accuracy of implant placement and reduce radiation exposure. The aim of this study is to compare intraoperative conditions and clinical results of patients undergoing pre-psoas oblique lateral interbody fusion (OLIF) using navigation or conventional fluoroscopy (C-ARM) techniques. Material and Methods: Patients underwent the OLIF procedure at two tertiary care medical centers, and records were reviewed. Forty two patients were identified; 22 patients underwent the OLIF with navigation, and 20 underwent the procedure with fluoroscopy. Operating time, estimated blood loss, length of hospitalization, surgery-related complications, total radiation exposure and total radiation time were recorded and compared between the 2 groups. Clinical outcomes according to the Smiley-Webster Scale were evaluated. Patients were followed up with a range of 6 to 24 months. Results: There were no significant differences between groups with respect to mean age, gender, weight, primary diagnosis and surgical procedures. The navigation group had zero radiation exposure to the surgeon and radiation time compared to the C-ARM group, with total radiation exposure of 44.59 ± 26.65 mGy and radiation time of 88.30 ± 58.28 seconds (P < .05). For the radiation exposure to the patient, it was significantly lower in the O-ARM group (9.38 mGy) compared to the C-ARM group (44.59 ± 26.65 mGy). Operating room time was slightly longer in the navigation group (2.49 ± 1.35 h) compared to the C-ARM group (2.30 ± 1.17 h) (P > .05), although not statistically significant. No differences were found in estimated blood loss, length of hospitalization, surgery-related complications and outcome scores with an average of 8 month follow up. Conclusion: Compared with C-ARM techniques, using navigation can eliminate radiation exposure to surgeon and decrease radiation exposure to the patient, and it had no significant effect on operating time, estimated blood loss, length of hospitalization, or peri-operative complications in the patients with OLIF procedure. This study shows that navigation is a safe alternative to fluoroscopy during the OLIF procedure in the treatment of degenerative lumbar conditions., Introduction: Despite superior biomechanical properties, the use of pedicle screws in cervical spine remains limited due to technical difficulties and high complication rates. The purpose of this study is to evaluate the usefulness and limitations of navigation technologies incorporating intra-operative 3D-imaging with O-arms in accurate placement of cervical pedicle screws. Material and Methods: A total of 38 patients who underwent cervical pedicle screw instrumentation by single surgeon were included in the study. All the pedicle screws were placed using the same 3D-Navigation system. Intra-operative 3D-images were obtained before and after placement of screws and results were evaluated. Results: The study included analysis of 202 cervical pedicle screws inserted in 38 patients. The indications for surgery included trauma, degenerative spine disease, tumor and infection. Out of the 202 screws, 170 (84.16%) were inserted at the level of C3-C6 vertebrae, followed by 20 (9.9%) and 12 (5.94%) screws at C2 and C7 vertebrae, respectively. After analsysis of screw placement as per Gertzbein Classification, the overall breach rate was found to be 8.4% (17 screws) with 58.82% grade I, 41.18% grade II and nil grade III screw breaches. All the breaches were lateral with highest breach rate at C5 (12.5%) followed by C6 (11.9%) vertebral level. Despite breaches, there were no neurovascular complications due to placement of any of the pedicle screw. Conclusion: The use of intra-operative 3D scans for navigation can make cervical pedicle screw placement more accurate. Better accuracy and intra-operative control can increase surgeon’s confidence in using cervical pedicle instrumentation on more regular basis., Introduction: The proportion of population over the age of 80 is growing undergoing spinal surgery is growing. The use of computer assisted surgery in these patients is challenging due to poor bone quality and at times complex anatomy. We here present a consecutive series of octogenarian patients who underwent robot guided spine surgery robotic (planning of entry point and trajectories, drilling and cannulation of the pedicles). Methods: Prospective data in a spine referral center for robot guided spine surgery was retrospectively analyzed. All patients who were 80 years old or older at the time of surgery were identified. These patients were matched to 120 patients under the age of 80 (a 3:1 ratio). Patients’ age, sex and indication for surgery were documented. Procedure time, accuracy, fluoroscopy usage time, and any instrumentation related complication were documented. Results: Between 2007 and 2013, 192 trajectories were executed in the octogenarian patients and 568 levels in the younger patients. The average age was 83.9 years vs 61.2 (P < .05), 12 patients were males in the octogenarian vs 50 in the younger patients. The highest instrumented in both groups vertebra was T5 and the lowest was S1. MIS was performed in 25 octogenarian patients and 73 younger patients. Average robotic usage time was 6 min and 40 seconds compared to 5 min and 5 seconds in patients under the age of 80 (P < .05); Total fluoroscopy exposure time per screw was 16.3 seconds in the octogenarian’s vs 9.3 seconds in the younger patients (P < .05). 182 (94.5%) executed trajectories were accurate vs 545 (95.9%) accuracy in patients under the age of 80 (NS). No intraoperative complications related to robot usage occurred. Discussion: Spine surgery in the octogenarians is challenging. The combination of osteoporotic bone and multiple spine pathologies in robot guided procedures results in longer procedures and in higher fluoroscopy usage compared to younger patients. However, procedure accuracy and safety is identical to younger patients, allowing optimal instrumentation in these frail patients., Introduction: Minimally invasive spinal fusion surgeries (MIS) are becoming more common as hardware and computer guidance systems evolve. Yet MIS is still the exception rather than the norm with several barriers to adoption that focus on the learning curve, increased radiation exposure and contested clinical value to the patient. In recent years, robotic-guidance has become available for spinal surgeries, aiding surgeons in shortening the learning curve of MIS techniques and reducing the intraoperative exposure to harmful radiation. However, few data were presented on its impact on clinical outcomes, especially in the hands of experienced MIS surgeons. Materials and Methods: Data were collected retrospectively from 4 surgeons for patients operated with robotic-guidance in a MIS approach (RGM), and compared with patients operated with fluoroscopic-guidance MIS (FGM) or open (FGO) approaches. All cases were instrumented fusions using either a minimally invasive technique with pedicle screws inserted in a percutaneous para-median approach, or a classic open approach through a median dissection. Logistic regression analysis was used to assess the odds ratio of complications and surgical revisions. Results: Altogether, data from 705 patients were collected, 403 RGM patients, 224 FGM and 78 FGO. There were no significant differences in age, sex or BMI between arms or surgeons, except for 1 of the 4 groups in RGM that was significantly older by about 6 years. The complication rates were 4.0%, 5.4% and 12.8% for RGM, FGM and FGO respectively. The revision rate for RGM was 3.8% while for both FGO and FGM it was 7.7%. A logistic regression was performed and demonstrated that the odds ratio for surgical complications were 3.0 for FGM (P = .014, 95% confidence interval (CI95) = 1.2-7.1) and 3.1 for FGO (P = .009, CI95 = 1.3-7.3). The odds ratio for surgical revisions was 3.8 for FGM (P = .006, CI95 = 1.5-10.0), and 1.9 for FGO but it was not statistically significant (small sample size). Surgeon, age, gender, BMI, or length of surgery, were non-significant parameters in the regression model. Conclusions: This retrospective analysis demonstrates that use of robotic guidance MIS can significantly reduce surgical complications and revision surgeries when compared to fluoro-guided MIS in the hands of experienced MIS surgeons., Introduction: Spinal intra-operative computer-assisted navigation (CAN) may guide pedicle screw placement. CAN techniques are reported to reduce pedicle screw breach rates across all spinal levels. However, definitions of screw breach vary widely across studies, if reported at all. The absolute quantitative error of spinal navigation systems is theoretically a more precise and generalizable metric of navigation accuracy. It has also been computed variably, and reported in fewer than a quarter of clinical studies of CAN-guided pedicle screw accuracy. The aim of this study was to characterize the correlation between clinical pedicle screw accuracy, based on post-operative imaging, and absolute quantitative navigation accuracy. Material and Methods: We reviewed a prospectively-collected series of 209 pedicle screws placed with CAN guidance, in 30 patients undergoing first-time posterior cervical/thoracic/lumbar/sacral instrumented fusion ± decompression. Each screw was graded clinically by multiple independent raters using the Heary and 2 mm classifications. Clinical grades were dichotomized per convention. The absolute accuracy of each screw was quantified by the translational and angular error in each of the axial and sagittal planes. Results: Acceptable screw accuracy was achieved for significantly fewer screws based on 2 mm grade vs. Heary grade (92.6% vs. 95.1%, P = .036), particularly in the lumbar spine. Inter-rater agreement was good for the Heary classification and moderate for the 2 mm grade, significantly greater among radiologists than surgeon raters. Mean absolute translational/angular accuracies were 1.75mm/3.13° and 1.20mm/3.64° in the axial and sagittal planes, respectively. There was no correlation between clinical and absolute navigation accuracy. Conclusion: Radiographic classifications of pedicle screw accuracy vary in sensitivity across spinal levels, as well as in inter-rater reliability. Correlation between clinical screw grade and absolute navigation accuracy is poor, as surgeons appear to compensate for navigation registration error. Future studies of navigation accuracy should report absolute translational and angular errors. Clinical screw grades based on post-operative imaging may be more reliable if performed in multiple by radiologist raters., Introduction: Recent meta-analysis have evidenced the superior accuracy of navigated spinal instrumentation compared to non-navigated techniques. However, the benefit of intraoperative computed tomography (iCT) compared to intraoperative iso-C 3D C-arm (3D C-arm)-based navigation remains unclear. The aim of the present study was to report our experience and accuracy of navigated pedicle screw insertion with intraoperative CT or 3D C-arm-based spinal imaging in 254 consecutive patients. Materials and Methods: After exposure and attachment of the navigation tracking device, a first iCT or 3D C-arm scan was performed with automatic patient/image co-registration and navigated screw insertion. Screw positioning was then intraoperatively assessed by a second iCT or 3D C-arm scan, based upon which the intraoperative accuracy was determined. In cases that required intraoperative screw revision, navigated repositioning was performed based on the second iCT or 3D C-arm scan. Thereafter, a third iCT or 3D C-arm scan was performed to confirm repositioning. In cases with 3D C-arm navigation, a postoperative CT scan was routinely performed, based upon which the final accuracy was determined compared to the final iCT scan. The general intraoperative screw placement assessability through iCT or 3D C-arm and the intraoperative and final accuracies were retrospectively reviewed and analyzed by an independent observer. Results: Between 2013 and 2016, an implantation of 1359 pedicle screws was performed in 254 patients with either iCT (1063 screws) or 3D C-arm (296 screws) based spinal navigation and automatic patient/image co-registration. The indications for surgery were degenerative disease (155/254; 61%), infectious disease (28/254; 11%), tumors (33/254; 13%) and trauma (38/254; 15%). Direct intraoperative screw assessment with iCT was successfully accomplished for each screw in all patients. In contrast, 19.2% (57/296) of the screws assessed by 3D C-arm imaging were intraoperatively not clearly assessable due to hardware artifacts and limited image quality. Also, 3D C-arm-based spinal navigation yielded lower precision rates compared to navigated instrumentation performed with iCT imaging (intraoperative accuracy: iCT 94.8% vs. 3D C-arm 89.7%, *P < .01; final accuracy: iCT 95.6% vs. 3D C-arm 90.9%, *P < .01). Regarding the immediate intraoperative performance, an analysis of the intraoperative accuracy based on the location of the instrumentation confirmed a significantly higher precision rate of iCT-based screw insertion in the cervical (iCT 98.8% vs. 3D C-arm 84.6%, *P < .0001) and thoracic (iCT 96.4% vs. 3D C-arm 83.3%, *P < .0001) spine, whereas no difference was detected in lumbar-sacral instrumentations (iCT 91.8% vs. 3D C-arm 90.0%; P > .05). Conclusions: Both iCT and 3D C-arm-based spinal navigation solutions with automatic patient/image co-registration are able to provide high pedicle screw accuracy rates. However, immediate intraoperative screw placement assessability and screw placement accuracy in the cervical/thoracic spine appear to be limited with intraoperative 3D C-arm imaging alone., Introduction: Neurological recovery after surgery is not uniform and varied recovery rates between 61 and 88% have been reported in literature. Existing literature is not clear on the reasons resulting in such discrepancy and possible clinico-radiological factors that affect neurological recovery. The current study is a prospective, large scale case-control study to analyse the role of clinical and radiological parameters in the determining recovery of motor deficit in patients with LDH. Materials and Methods: A prospective study was conducted among 556 consecutive microdiscectomy surgeries performed for lumbar disc herniation (L1-2 to L5-S1) during the study period of 15 months.70 consecutive patients who underwent lumbar microdiscectomy for neurological deficit following disc herniation, were followed up for a period of 1 year and assessed for neurological recovery. Presence of motor deficit was considered when clinical examination demonstrated a motor power, Introduction: Radicular pain is common (but exactly how common is uncertain) and surgery is known to be effective. However, Surgery is usually preceded by various “conservative” treatments for which there is often unclear rationale and little evidence of efficacy. Hence, the primary objective of this study was to determine the range and frequency of treatments experienced by people eventually having surgery for lumbar and cervical root compression. The secondary objective was to use existing literature to compare the effect size of these treatments on pain compared to that of surgery. Material and Methods: Prospectively collected data on consecutive people undergoing surgery by one spinal neurosurgeon for sciatica or brachalgia between January 2007 and July 2015 in a UK teaching and private hospital. People were asked to record their symptom duration, details of previous treatments received, pain severity (Visual Analogue Scale, VAS) and self-reported functional limitations caused by their symptoms. Results: Participants preoperative questionnaires were obtained from 93% (n = 1110) of people having surgery for sciatica or brachalgia over nearly 9 years from January 2007 to June 2015. The average age was 58yrs (range 17-94). Half were female (n = 544). The mean duration of symptoms was 35.0 months (sd 70.5; range 0.2-620). 88.7% of people were taking analgesic medication with a mean of 3.3 (sd 2.7) per day; 82% had at least 1 physical therapy; 23.4% had at least 1 injection therapy. Pre and post op VAS pain scores were 7.46 (sd 1.87) v 2.89 (sd 2.72). The improvement in pain was highly significant statistically (t = 36.4; P < .001) and clinically (Cohen’s Effect Size = 2.44). Conclusion: People with cervical or lumbar nerve root compression can wait years before receiving surgery that is associated with substantial treatment benefits. During this time, they are in pain, have limited function and receive a range of treatments that are not based on a diagnosis and are predictably ineffective. The literature also shows no convincing evidence to support the non-surgical treatments as effective treatments for cervical and lumbar nerve root compression. Our results indicate that the manifestations of nerve root compression are poorly understood, therefore the threshold for referral and investigation should be lowered, and guidance needs revising., Introduction: Neurological deficit is a rare, but serious complication following lumbar disc herniation. There are currently very few large scale studies in the literature discussing the correlation of different clinico-radiological factors associated with development of this complication. We aimed to correlate clinical and radiological parameters in the development of motor deficit in patients with lumbar disc herniation in a large scale case-control study. Materials and Methods: We conducted a prospective, consecutive analysis, among a total of 556 cases with lumbar disc herniation (L1-2 to L5-S1) treated with microdiscectomy. During the study period of 15 months, 70 consecutive patients who had presented with motor deficit (with or without bladder symptoms) were included under group 1 (cases). The control group (group 2) which included 70 patients without any pre-operative neurological deficit were selected through random allocation Motor deficit was defined as the occurrence of motor power ≤3/5 (MRC grading) in L2, 3, 4, 5, S1 myotomes. Radiological parameters evaluated included- number and location of herniation level, nature of herniation, presence of migration, bony canal dimension, percentage of canal compromise and dimensions of herniated disc fragment. Clinical parameters studied included- demographic data, co-morbidities, symptomatology, number of symptomatic episodes, Oswestry scores, visual analogue scores, occupational profile and precipitating events. Results: Patients with diabetes (p 0.004), acute onset of symptoms (p 0.036), L3-4 discs (p 0.001), sequestrated discs (p 0.004), superiorly migrated discs (p 0.012) and central discs (p 0.004), greater antero-posterior disc dimension (p 0.023), primary canal stenosis (p 0.0001); and greater canal compromise (p 0.002) had a significant correlation with the development of neurological deficit. When four of more of these risk factors are present, the chance of occurrence of motor deficit is high (Sensitivity of 74%, Specificity of 77%). Age of patient (p 0.067), sex (p 0.999), previous precipitating events (p 0.379), severity of pain (p 0.605), smoking (p 0.309); and number of herniation levels (p 0.266) did not affect the occurrence of deficit. The patients with associated bladder symptoms were similar to the other subset (without bladder symptoms) with respect to all clinico-radiological parameters. However, the time delay since the occurrence of deficit was significantly shorter in patients with bladder involvement (p 0.001). Conclusion: This unique prospective, consecutive analysis of clinic-radiological factors impacting neurodeficit stands out as one of the largest cohort analysis for this complication following lumbar disc herniation. Patients with diabetes, acute presentation of symptoms, central, sequestrated and superiorly migrated discs, high lumbar disc prolapse and greater spinal canal compromise are predisposed to the development of motor deficit., Introduction: Sciatica is a common diagnosis in the general population. Sciatica is most frequently caused by lumbar disk herniation (LDH). Multiple surgical techniques and treatment modalities are available to threat LDH, albeit some with small effect sizes or without compelling evidence. The aim of this survey is to evaluate the current practice patterns and attitudes of surgeons regarding both the surgical and nonsurgical management of LDH worldwide. Material and Methods: A survey including questions on the application of physical examination, expectations regarding different surgical and nonsurgical techniques, factors influencing the outcome of surgery and the documentation of PROMs, was distributed among members of AOSpine International and the EANS. Results: 817 surgeons from 89 countries completed the questionnaire These surgeons perform a total of 62.477 discectomies yearly. Pain medication and steroid injections were expected to be the most effective nonsurgical treatments. The severity of pain and/ or disability and failure of conservative therapy were the most important indications for surgery. A period of 1-2 months of radiculopathy was regarded as a minimum for indicating surgery. Unilateral transflaval discectomy was the procedure of choice among the majority and was expected to be the most effective technique with the lowest complication risk. Almost a third of the surgeons did not register any PROMs. Conclusion: Unilateral transflaval discectomy was expected to be the most effective surgical technique. Techniques described as minimally invasive, were expected to give the lowest postoperative low back pain. However, these techniques were also expected to give the highest risk of recurrent disk herniation. Documentation of PROMs in the treatment of LDH is warranted., Study Design: Case series. Objective: The aim was to look for preoperative clinical and radiological features of intradural disc. Methods: We present prospective analysis of 6 cases of intradural disc herniation at L4-L5 level diagnosed on the basis of intraoperative findings with their clinical, intraoperative and retrospective MRI analysis. Results: All our cases on preoperative MRI findings were reported as having diffuse annular bulge with large posterocentral extrusion at L4-L5 compressing the nerve roots. Our study comprised of males in age group of 30 to 60 years. 4 out of 6 presented with cauda equina syndrome. In 3 cases, cauda equina was associated with sudden deterioration in the power of lower limb muscle groups. We suspect that intradural herniation of disc was synchronous with cauda equina syndrome in these cases, which was very well documented in one of the cases. On retrospective analysis, MRI findings of mass effect in the form of displacement of the traversing nerve roots due to large central disc with crumble disc sign was suggestive of early evidence of intradural disc herniation. Y sign in ventral dura due to splitting of ventral dura and arachnoid mater by disc material was a good diagnostic sign to suspect intradural extra-arachnoid disc. Conclusion: Based on our series and literature review we propose three stages of intradural disc herniation on MRI: Stage 1- Stage of Effacement, Stage 2- Stage of focal discontinuity and Stage 3- Stage of Intradural herniation. We also suggest that sudden deterioration in the power of lower limb muscle groups with cauda equina syndrome in patients having large central disc on MRI especially at L4-5 levels should raise suspicion of intradural herniation of disc., Introduction: Numerous methods of magnification are available for spinal surgeons when performing simple discectomy from conventional, loupes and operative microscope. Advantages exist for the use of magnification in clearer operative field and with the operative microscope enhanced illumination of the operative field. There have been reports which have suggested that there is an increase in wound infections with the operative microscope. We ask if there is any evidence to favour magnification compared with conventional methods in the performance of simple discectomy. Methods: A retrospective review of a multi-centred internationally kept database was performed (SpineTango). The database was searched for primary discectomies. The results were then stratified into conventional magnification; loupe magnification or operative microscope. These were then compared for the rate of dural lesions during surgery and complications from the surgery. Results: We included 6662 operative patients. 1810 were treated by decompression using conventional magnification, 384 by loupe magnification and 4468 by operative microscope. The overall rate of dural lesion was 4.56%. The lowest rates of dural lesions were seen in the conventional group (3.09%) and the highest rate was seen in the Loupes group (8.07%). There was a 1.85 times higher rate of incidental durotomy with the use of surgical loupes. The conventional group had worse outcomes for length of stay, wound infections, surgical time and blood loss. Conclusion: Our results fail to show a true standard in the use of magnification for simple discectomy. It would suggest an increase in the use of magnification may reduce blood loos, wound complications and length of stay. The reason for higher dural lesions in the magnification arms may be the use of magnification after a lesion has been created. Further prospective analysis is required to confirm this however., Introduction: The objective of this study was to investigate the effects of different doses rhBMP-2 on bone healing in an ovine lumbar interbody fusion model. Materials and Methods: In this study 22 sheep underwent two level lumbar interbody fusion using a ventrolateral approach with secondary dorsal fixation at L1/2 and L3/4. After randomization in one level a PEEK-cage was implanted filled with one of three doses rhBMP-2 (0,5 mg; 1 mg; 2 mg) delivered on an ACS. The other level received an empty PEEK-cage or ACS filled cage. Animals were sacrificed after 3 and 6 months and decalcified histology was performed. This included histomorphological analysis as well as histomorphometry of the tissues within the cage. Results: At 3 months after surgery the groups treated with rhBMP-2 showed higher amounts of bone tissue within the cage. At 6 months the amounts of bone tissue increased in all groups, but were still lower in the groups without growth factor. At 3 months there was only one active osteolysis in the cage/ACS. 7 of 8 segments of the rhBMP-2 groups had a compromised bone structure around the implant. These areas were filled with fibrous tissue and fibrocartilage. This finding was not detected in the groups without rhBMP-2 at 3 months. At 6 months most of the segments with an empty cage or cage/ACS showed a chronic inflammation. Predominant cells were macrophages and giant cells. The groups treated with rhBMP-2 showed only a few mild chronic inflammatory reactions. Conclusion: The well-known dose dependent effect of rhBMP-2 on bone healing could also be recognized in our study. Attention has to be payed for the proinflammatory properties of the growth factor. Consistent with other studies we found 2 strong inflammatory reactions, each one in the lowest and highest dose group. Also the potential for causing transient bone resorptions, according to the results of others, was demonstrated. At 3 months 7 of 8 segments treated with rhBMP-2 showed compromised peri-implant bone. Osteoblasts, but not osteoclasts, were seen in the periphery of these areas. It can be concluded that there where bone resorptions which already merged into an increased osteoblastic activity. Usually resorptions occur between 2 and 12 weeks and are followed by a period of increased osteoblastic activity. This finding wasn’t recognized at 6 months anymore. Striking is that at 6 months most of the segments without rhBMP-2 showed a compromised bone structure around the implant with a mild to mainly moderate chronic inflammatory reaction. This cannot be attributed to the growth factor. Also the ACS is degraded at 6 months and is unlikely a possible explanation. Therefore, the cage as a reason must be considered and it has to be questioned whether PEEK is the optimal material for interbody cages., Introduction: Adipose-derived stem cells (ADSCs) have been demonstrated to form vascularized bone in various animal and pre-clinical models. While bone marrow-derived stem cells (BMSCs) have been widely used in spinal fusion studies, adipose offers a number of advantages as an alternative clinical cell source, including a larger available tissue volume, higher stem cell concentration, and reduced donor site morbidity. In this study we compare the efficacy of ADSCs vs. BMSCs in achieving successful spinal fusion when combined with a clinical-grade bone graft substitute in a rat model. Materials and Methods: Adipose-derived stem cells (ADSCs) and bone marrow-derived stem cells (BMSCs) were isolated from the inguinal fat pads and long bones, respectively, of female Lewis rats (6-10 wk old) and cultured in vitro until passage 2 (P2) for subsequent transplantation in our spinal fusion model. The frequency of colony forming unit fibroblast (CFU-F) colonies was also assessed in vitro for both ADSCs and BMSCs. Posterolateral spinal fusion surgery at L4-5 was performed on 36 female Lewis rats (6-10 wk old) divided into 3 experimental groups: [1] Vitoss (Stryker) clinical-grade bone graft substitute only (VO) (n = 12); [2] Vitoss + 2.5 x 106 P2 ADSCs /side (n = 12); and [3] Vitoss + 2.5 x 106 P2 BMSCs /side (n = 12). Fusion was assessed at postoperative week 8 via micro-computed tomography (MicroCT) analysis and manual palpation. Manual palpation scoring was conducted by blinded researchers as follows: 0 = non-fused; 1 = some motion across operative joint but not as mobile as adjacent segments; 2 = fused, no motion across the operated joint. Results: The average fusion volume in the ADSC group was significantly larger than the BMSC and VO groups (44.3 mm3 vs. 27.6 and 30.0 mm3, respectively, P < .01). The mean manual palpation score was the highest in the ADSC group compared with the BMSC and VO groups (1.5 versus 0.7 versus 0.8 P = .03). As has been found in previous studies, ADSCs exhibited a faster proliferative rate and a higher frequency of CFU-F colonies in vitro than BMSCs. Conclusions: When combined with a clinical grade bone graft substitute in a rat model, adipose-derived stem cells yielded increased fusion mass volume and more robust fusion than bone marrow-derived stem cells. Ongoing studies will explore whether this trend holds for freshly isolated and P1 ADSCs as well as in larger animal models., Introduction: As a preliminary study, we photo-immobilize the BMP2 on the collagen sheet with an UV-light reactive azidophenly-natural polymers (Gelatin, O-carboxymethly chitosan, Low molecular weight chitosan), and determine the optimal density of azidophenyl-natural polymers and UV treatment time. The purpose of this study is to confirm the usefulness of photo reactive Az-gel on collagen sheet for the BMP-2 as a carrier in the rat calvarial defect animal model. Material and Methods: Fifty-six male Sprague-Dawley rats, 8 weeks of age, were chosen, randomized into following four groups; Group A as a control group comprising a collagen sheet only cast BMP-2; Group B comprising a collagen sheet with photo-immobilized BMP-2 on azidophenyl-gelatin (Az-Gel); Group C comprising a collagen sheet with photo-immobilized BMP-2 on azidophenyl-O-carboxymethyl chitosan (Az-OCM); and Group D comprising a collagen sheet with photo-immobilized BMP-2 on azidophenyl-low molecular weight chitosan (Az-LMC). The animals were anaesthetized for all surgical interventions, 8-mm defect was made using a trephine burr at animal’s calvaria, and 8-mm collagene sheet, treated according to group) was implanted. Seven animals from each group, a total of 28 animals, were sacrificed at 4 weeks; the remaining 28 animals were sacrificed 8 weeks after implantation. MicroCT analysis and histological assessment involving H&E stain and immunohistochemical stain (RUNX2, osteopontin) were done for qualitative and quantitative evaluation of each group. Results: 1) MicroCT: At 4 weeks, the bone volume fraction was highest in Group at B but difference between the groups was not significance. However, the bone volume fraction at 8 weeks was highest with significant difference (P = .017). At 4 weeks, the trabecular pattern factor and structure model index, the bone microarchitecture parameter, were lowest at Group B with significant difference (P < .01), indicate that there was more trabecular connectedness in Group B. At 8 weeks, the trabecular number per unit lenght was highest at Group B with significant (P = .01). In the 3-D reconstruction image, the new bone generated in the control group and Group D appeared to be located along the defect rim, and was contradistinctively centrally located bridging the entire major axis of the defect in the Group B and Group C. 2) Histology: The results from the H&E staining, the new bone generation tended to occur at the center of defect, relatively independent site from the host bone in the Group B and Group C. The graft resorption and well maturated trabeculae were observed in all groups. The RUNX2 staining showed a significantly highest positively expressed cellular ratio in Group B at 4 and 8 week (P < .01). The expression intensity of osteopontin was strongest in Group B, followed by Group C, compared with week to moderate in control group and Group D. Conclusion: Among the azidophenyl natural polymers, photo-immobilized BMP-2 using Az-Gel on a collagen sheet significantly enhanced new bone formation quantitatively and qualitatively compared with non-photo-immobilized BMP-2 on a collagen sheet. In conclusion, photo-immobilization using Az-Gel on a collagen sheet is a promising technique for the creation of BMP-2 carriers., Introduction: Autograft iliac crest bone remains the “gold standard” in lumbar spinal fusion procedures, including within animal models. However, inbred rodent strains allow for the use of syngeneic allografts in place of autograft bone. Given that larger volumes of bone are available in the femur and since femoral head allografts have been successfully used in a number of clinical spinal fusion studies, we compared the use of autogenous iliac crest with syngeneic femoral and iliac crest allograft bone in the rat model of lumbar spinal fusion. Materials and Methods: Single-level bilateral posterolateral intertransverse process lumbar spinal fusion surgery was performed on 45 female Lewis rats, divided into three experimental groups: [1] iliac crest autograft (n = 15); [2] syngeneic iliac crest allograft (n = 15); and [3] syngeneic femoral allograft bone (n = 15), all consisting of corticocancellous bone. Eight weeks postoperatively, fusion was evaluated via microCT analysis, manual palpation and histology. Bone marrow-derived cells were isolated from the illia and femurs of female Lewis rats, enumerated and cultured in vitro for 10 days in order to determine the frequency of colony unit fibroblast (CFU-F) colonies. Results: Pre-implantation femoral syngeneic allografts were the largest at 0.42 ± 0.10 g, followed by iliac crest allografts at 0.35 ± 0.13 g and finally iliac crest autografts at 0.15 ± 0.10 g. However, 8 weeks post-surgery there was no statistically significant difference in fusion mass volume via micoCT analysis. Upon manual palpation, allograft iliac crest bone resulted in the highest fusion rates with 37.5% bilaterally fused, 37.5% unilaterally fused and 25% non-fused, compared to 15% bilaterally fused, 54% unilaterally fused and 31% non-fused in the autograft group and 7%, 40% and 53% in the femoral allograft group. While the total bone marrow-derived cell yield was significantly higher from femurs as opposed to ilia, preliminary limiting dilution CFU-F assays suggest that the frequency of CFU-F colonies is higher in ilia compared to femurs. Conclusions: Although femoral syngeneic allografts yielded the largest pre-implantation grafts, this did not translate into larger fusion mass volumes eight weeks later, compared to iliac crest grafts. Interestingly, femoral allografts showed lower rates of solid fusion, via manual palpation, than both iliac crest autograft and allograft groups. Preliminary in vitro assays suggest that this difference is associated with an increased frequency of CFU-F forming mesenchymal progenitor cells in the iliac bone marrow compared to femoral bone marrow. As in previous studies, CT fusion scores did not necessarily correlate with manual palpation fusion scores., Introduction: Local intraoperative use of antibiotic powders in spinal fusion surgery, particularly vancomycin, has become an increasingly common prophylactic measure in an attempt to reduce rates of post-surgical infection. While some clinical studies have suggested that the use of vancomycin in spinal fusion procedures is safe and may reduce the rate of infection, localized intraoperative use of vancomycin powder remains controversial. More importantly, the effects of localized antibiotic delivery on spinal fusion outcomes remain unclear. We thus aim to examine the effects of local intraoperative delivery of vancomycin powder and tobramycin powder, an antibiotic commonly used in orthopaedic bone grafting surgeries, in a rat model of posterolateral intertransverse process lumbar fusion. Materials and Methods: Single-level (L4-5) bilateral posterolateral intertransverse process lumbar spinal fusion surgery was performed on 60 female Lewis rats (6-8 week old) using syngeneic iliac crest allograft mixed with the clinical bone graft substitute Vitoss (Stryker) and varying concentrations of antibiotics. More specifically, five experimental groups were studied: [G1] low concentration (14.3 mg/kg) vancomycin (n = 12); [G2] high concentration (71.5 mg/kg) vancomycin (n = 12); [G3] low concentration (28.6 mg/kg) tobramycin (n = 12); [G4] high concentration (143 mg/kg) tobramycin; and, [G5] controls with no antibiotics (n = 12). Eight weeks postoperatively, fusion score and fusion volume were evaluated via microCT analysis (CT scoring per side: 2 = robust fusion; 1 = some narrowing of fusion mass; and, 0 = discontinuity of fusion mass; total score = average of sum of both sides), and manual palpation and histology were performed. Results: Preliminary microCT results revealed that the high-dose vancomycin group [G2] exhibited a significantly lower fusion score and fusion mass volume than controls (preliminary fusion scores: [G1]1.8, [G2]1.2, [G3] 1.6, [G4] 3.0, and [G5] 2.3, respectively, P = .045; preliminary fusion mass volumes; [1]20.7, [2]15.5, [3]22.9, [4]34.9, and [5]31.5 mm3, respectively, P = .002). Manual palpation and histological analysis are currently being performed. Conclusions: Preliminary data suggest that the intraoperative local application of vancomycin at supraphysiological doses may have detrimental effects on spinal fusion. The results of this study potentially indicate that caution is required when considering the amount of intraoperative vancomycin powder to employ when conducting spinal fusion surgery in certain patient populations. Future clinical studies examining the effects of vancomycin dosage on fusion rates would thus be of great interest., Introduction: Oxysterols play an important role in inflammation, apoptosis, cell differentiation and other processes. Recent studies demonstrated that several oxysterol analogues including Oxy133 promote osteogenic while inhibiting adipogenic differentiation of progenitor cells, and simulate cranial bone regeneration and solid fusion in animal models. The aim of our study was to determine the effect of Oxy133 and rhBMP2 on fusion rates and new bone formation in a rat posterolateral fusion (PLF) model. Furthermore, we examined whether Oxy133 could inhibit the adipogenesis that is often present in rhBMP2 induced fusion. Materials and Methods: Sixty four male Lewis rats underwent PLF at two levels L3-4 and L4-5 with control vehicle, Oxy133 and/or rhBMP2. All animals were randomly divided into 8 groups based on the test compound that they received: control (vehicle –DMSO), low dose rhBMP2 (0.5 µg), high dose rhBMP2 (5 µg), rhBMP2 (0.5 µg) plus Oxy133 (20 mg), rhBMP2 (5 µg) plus Oxy133 (20 mg), high dose Oxy133 (20 mg), low dose Oxy133 (5 mg), and rhBMP2 (0.5 µg) plus Oxy133 (5 mg). Eight weeks after surgery animals were euthanized and L2-L6 segments were harvested. In each group, fusion rates were assessed with manual palpation and plain radiographs. Bone parameters including tissue volume (TV), bone volume (BV), BV/TV ratio, trabecular thickness and separation were measured using microCt. Histology was used to evaluate adipogenesis. Results: No fusion was observed in the control group. Based on the manual palpation, 100% fusion was observed in all groups except low dose rhBMP2 group (69%). Based on X-rays 100% fusion was observed in groups: high dose rhBMP2 (5 µg), low dose Oxy133 (5 mg), and rhBMP2 (0.5 µg) plus Oxy133 (5 mg). For other groups fusion rates were between 95-97%, except for the low rhBMP2 group (28%). We observed similar values in BV/TV ratio at L3-4 when Oxy133 groups were compared to rhBMP2 groups alone (44.62%, high Oxy133 vs. 41.47%, high rhBMP2; and 47.18%, low Oxy133 vs. 54.98%, low rhBMP2). Trabecular thickness was slightly lower in Oxy133 groups compared to rhBMP2 (118.44 µm for high Oxy133 vs. 122.39 µm for high rhBMP2; and 123.51 µm for low Oxy133 vs. 135.74 µm for low rhBMP2). At the same time trabecular separation was lower in Oxy133 groups compared to rhBMP2 groups. For groups where Oxy133 and rhBMP2 were used together BV/TV ratio was 40.19%-46.33% and trabecular separation 342.5 µm -405.13 µm. Similar trends in bone parameters were observed at L4-5 level. Fusion masses with high dose Oxy133 had significantly less adipocytes than rhBMP2 groups that showed robust adipocyte formation. Conclusions: In our study both low dose and high dose Oxy133 produced solid fusions with bone densities similar or higher than in the BMP2 groups. High dose Oxy133 group had significantly less adipocytes than high or low dose rhBMP2 groups. Furthermore, high dose Oxy133 was able to significantly inhibit high dose BMP2 induced adipogenesis when combined together. Consistent with previous reports, our preliminary findings suggest that Oxy133 has a significant potential as an alternative to rhBMP2 in spine fusion., Introduction: Spinal column is the commonest site for osseous metastasis. Indications for surgery includes neurologic deficit, obvious or impending instability and/or intractable pain; rarely local tumour control. Patients with spinal metastases have a median survival of 10months and effective palliation of symptoms is principle clinical objective. Many studies have focused on decision making, surgical management and postoperative complications, few focusing on the failure of fixation (FOF) and factors leading to it. This study presents the results of patterns of FOF in metastatic spine tumour surgery (MSTS), clinical presentation before surgery, after failure and factors leading to failure. Methods: This is a retrospective study involving 165 patients undergoing MSTS in a tertiary referral institution between 2005-2015. Data were collected from case notes/hospital electronic records and radiological investigations Centricity Web. Radiological data included SINS score, type of lesion (lytic, mixed, sclerotic, none) and levels of fixation. Surgical data included minimally invasive surgery or open fixation & revision after FOF, levels and type of stabilisation. FOF was defined as breakage of the rod or screw, screw back out or cut out, lysis around the screw, increase in angular deformity, reduction in anterior column height, tilting or subsidence of anterior cage. The endpoint of the evaluation was up to last follow-up or death. The level of fixation was considered as anchor in a vertebra (anterior or posterior) by spine implants. Construct length was categorised as short (1-7 level), intermediate (8-12) or long (>12). Vertebra within the construct without anchor was considered as a level. We excluded patients with previous spine surgery, infection of implant leading to failure, survival 9, while no failure was noticed in patients with SIN score 7. Most are asymptomatic and do not require revision though it may be the early sign of the failure of construct., Introduction: While several clinical prediction rules (CPRs) of survival exist for patients with symptomatic spinal metastasis (SSM), these have variable predictive ability and there is no recognized CPR for health related quality of life (HRQoL). We undertook a critical appraisal of the literature to identify key preoperative predictive factors of clinical outcomes in patients with SSM who were treated surgically. The results of this study could be used to modify or develop new CPRs. Material and Methods: Seven electronic databases were searched (1990 – 2015), without language restriction, to identify studies that performed multivariate analysis of preoperative predictors of survival, neurological, functional and HRQoL in surgical patients with SSM. Individual studies were assessed for class of evidence and the strength of the overall body of evidence for each factor was evaluated using GRADE. Results: Among 4,818 unique citations, 17 were included, all were rated Class III and focused on survival, revealing a total of 46 predictive factors. The strength of the overall body of evidence was very low for 39 and low for 7 predictors, with the latter including 3 negative predictors for all types of primary tumors (radioresistant primary tumor, Charlson comorbidity index score ≥2 and non-ambulatory status) and 4 for breast cancer (shorter time from cancer diagnosis to surgery, emergency hospital admission, primary with undifferentiated histologic grade and negative progesterone receptors). Conclusion: The quality of evidence for predictors of survival was at best low. We failed to identify studies that evaluated preoperative predictive factors for neurological, functional, or HRQoL outcomes in surgical patients with SSM. Further high-quality evidence is needed to accurately estimate predictor effect sizes, for patient education, surgical decision-making and development of CPRs., Introduction: Standard treatment of unstable vertebral metastases consists of stabilizing surgery, followed by external beam radiotherapy, a minimum of two weeks later. This two-week interval, required for wound healing, delays the time before radiotherapy-induced pain relief and local tumor control can be achieved. Furthermore, multiple hospital visits are needed for most radiotherapy fractionation schemes and moreover, currently 30-40% of the patients experience incomplete pain relief. From the patient’s perspective, an alternative treatment strategy that would lead to better and faster pain relief while requiring less hospital visits would be highly desirable. Stereotactic body radiotherapy (SBRT) may be used in combination with surgical stabilization to increase the local dose on the spinal metastasis for better response while actively avoiding irradiation of the surgical area to prevent disturbed wound healing. Therefore the aim of this phase I/II study is to assess the safety and feasibility of combining single fraction SBRT followed by pedicle screw fixation within a 48-hour window for the treatment of painful unstable spinal metastases. Materials and Methods: The present study will be conducted according to the IDEAL recommendations, a framework for systematic evaluation of complex interventions consisting of five stages: Innovation, Development, Evaluation, Assessment and Long term evaluation. A total of 13 patients will be included in two stages. In stage 1, three patients will be included in whom the new procedure will be tested first. In stage 2, ten patients will be included, the main focus is technical feasibility and safety. Information on demographic and clinical characteristics, treatment, toxicity (according to the CTCAE4.0 within 60 days), complications and survival will be systematically collected. Patients with painful spinal metastases from a solid tumor needing surgical stabilization will be included. SBRT is simulated first on a planning CT to deliver a dose of 18 Gy on the metastasis and 8 Gy on the rest of the vertebra while actively avoiding exposure to the posterior surgical area. After SBRT is performed, patients will undergo surgical stabilization within 48 hours according to routine practice. Results: The first ten patients, five males and five females, have successfully been treated according to this new treatment protocol. A posterior approach was used for all surgical procedures, with two conventional open and eight percutaneous procedures. The mean operating time was 82 minutes (±SD33) with a median blood loss of 50 millilitres (range 50-300). The median length of hospital stay was 5 days. None of the patients experienced a wound complication or other study related complication. One patient suffered a grade 3 surgery related complication, which resolved after re-operation. Combination of the procedures was feasible and the patients experienced no discomfort during the SBRT procedure before stabilization of the spine. We expect to be able to present the results of all 13 patients at the time of the conference. Conclusion: The preliminary results suggest that the combination of SBRT and surgical stabilization within 48 hours is safe and feasible. Hereby a new and promising one-stop treatment strategy may have been developed for a difficult to manage, vulnerable patient category., Introduction: The hyper-vascular component in spinal tumor significantly increase technical difficulties and post-op complications risks, including perioperative blood loss which could reach a few liters. The selective vascular embolization is effective to decrease blood loss in adult patients, but it effect is not completely clear in pediatric patients. Material and Design: 13 patients aged from 4 till 16 yrs were investigated during 2005 – 2016 period due to suspicion on monovertebral spinal lytic tumors with a hyper-vascular component in its structure. 11 patients were included into study due to the cervical (1), thoracic (6) and lumbar (4) vertebrae bodies lesions; 2 ones were excluded because of isolated neural arch affect. The back pain was the prominent sign of tumors in all patients; motors or bladder and bowel disorders were in 3. Bone scan with Tс99 was in all cases, the vascular component was suspected by MRI. ABC was diagnosed initially in 5 patients, after surgery one of them was identified as high differentiated low grade angiosarcoma; cavernous hemangioma was in 4, one more case diagnosed as hemangiogenic variant of Gorham-Stout disease («angiogenic octeolysis”). Percutaneous pre-op trepan-biopsy was in 8/13 cases, cytology was equal with post-op histology in 4 (50%). Pre-op selective angiography done in 7/13 patient followed by embolization in 6. The embolization was not performed in one case because of the anastomosis between the tumors’ and spinal cord vessels. The embolization-related complication were not in our series. The blood loss volume was estimated as at the end of surgery as 24-hour after it. The blood loss volume estimated according to hematocrit (Ht) rate due to the Moore’s formula. Two groups of patients (with and without embolization) were compare according to statistic Mann-Whitney U-test with P ≤ .05 significance level. Results: Embolization had reached complete disappearance of clinical signs in patient with Gorham-Stout syndrome: the indication for surgery was cancel, the patient continued effective bisphosphonates treatment next 3 years and was cancel from the final analysis. 5 patients with pre-op embolization and without it underwent surgery with complete vertebral body replacement. In was not find significant different in blood loss between compared groups which was counted as 29% and 24% of the volume of circulated blood (P ≥ .05, Mann-Whitney U-tests 12.5. The early post-op wound infections was in 2 cases (one in each group), both in patients with operative blood loss exceeded 1000.0 ml. Conclusions: It has detected that perioperative blood loss in pediatric patients with spinal tumors included hyper-vascular component in its structure significantly less than in adult patient. It wasn’t confirmed the dependence of perioperative blood loss in such patients from the fact of pre-op endovascular embolization. Perhaps, this negative result could connected with as a small number of cases as a more detailed hemostasis in non-embolized patients. From other side, it is detected that the duration of surgery was shorter and visual control was significantly better in patients after embolization., Introduction: Investigate the safety and efficacy of transarterial embolization in patients with hypervascular spinal metastases and primary tumors before surgical resection. Material and Methods: Thirty nine patients with spinal metastases and primary tumors underwent angiography and preoperative transarterial embolization with spherical particles, coils and the liquid cohesive composition before surgical resection. The following parameters were evaluated: types of tumor, sex, time interval between embolization and surgery, the influence of these parameters on intraoperative blood loss, surgical content, safety for the patient. Results: Intraoperative blood loss in patients undergoing embolization was up to 500 mL - 29 (74.4%), to 1000 mL - 2 (5.1%), to 2000 mL - 3 (7.7%), 2000 mL – 5 (12.8%). Average value of blood loss for RCC 546.2 mL., for other metastases – 373.5 mL., for primary tumors – 2488.8 mL. There have been no in-hospital mortality related with the intraoperative blood loss. All patients received standard supportive care, emergency blood transfusion was not performed. Three (7.7%) patients after endovascular interventions had complications in the form of temporary neurological deficit, fifteen (38.5%) had postembolization syndrome. Conclusion: In the embolization group, intraoperative blood loss was correlated with type of tumor and type of surgical resection. Preoperative embolization is safety and effectively to decrease intraoperative blood loss for patients with hypervascular spinal tumors., Introduction: The incidence of intramedullary tumors is much lower compared to brain intraparenchymal tumors. Surgery of spinal intramedullary tumors has own tricks during approach and removing process. The Burdenko Neurosurgical Institute has a well-established practice of surgical treatment of intramedullary tumors. Materials and Methods: Burdenko Neurosurgical Institute has experience of treatment more than 1000 patients with spinal intramedullary tumors of all ages. In this research we report results of spinal department for treatment of 385 adult patients with spinal intramedullary tumors between 2000 and 2016 years. We identified following histological types: ependymomas, astrocytomas, hemangioblastomas and other types. All patients underwent microsurgical tumor resection with application of ultrasound suction device and electrophysiological monitoring. In some cases, we used a metabolic navigation from 5-aminolevulinic acid to precisely identify the borders of astrocytomas (Grade II, III, IV). This allowed us resections tumors more radically with minimal postoperative deficits. Novalis and Cyber Knife were used as a treatment options for patient requiring. McCormick scale was used for evaluation neurological status. Results: Histological distribution were: 57% – ependymomas, 18% – astrocytomas, 35 10% – hemangioblastomas, and 15% had other histological type of tumors (cavernous malformation, glioblastomas, cancer metastasis and other). Follow-up period was one year, and the post-surgery recovery period took 3 to 6 months. Among the 320 patients under analysis, 33% showed some neurological improvement, 51% had no change, and 16% was revealed neurological deficiency. Conclusions: Using technology of metabolic navigation and electrophysiological monitoring simultaneously allows more radical resection spinal intramedullary tumors with less complications. Radiosurgical treatment of intramedullary tumors allows preventing recurrence., Introduction: Type-II odontoid fractures are the most common cervical fractures encountered in the elderly, with an overall incidence that appears to be rising. Substantial uncertainty continues to surround optimal management of these injuries; while non-operative treatment is associated with a high rate of non-union, surgery is more costly and may be associated with high complication rates in this age group. To provide further evidence on this topic, we performed a value based assessment comparing costs and health gains between these treatment strategies. Material and Methods: We constructed a Markov cost-utility model, with a life-long time horizon, comparing quality-adjusted survival and costs of surgical vs. non-operative treatment (external orthosis), from the perspective of the payer, for the base case of a 75 year-old person with a type-II odontoid fracture. Mean utility values, corresponding to the health states of interest, were calculated from primary data (SF-6D scores) prospectively collected during the AOSpine GOF Study. Probability rates for mortality, complications, failure/fusion were estimated based on a systematic review of the literature. Per patient treatment costs, presented in 2016 US dollars, were obtained from the Healthcare Cost and Utilization Project, National Inpatient Sample, averaged over a 7 year period (2003-2010). Incremental Cost Effectiveness Ratios (ICERs) were evaluated relative to a Willingness to Pay (WTP) threshold of 50,000USD/QALY. One- and two-way sensitivity analyses were performed to identify threshold values for age, cost, utility and probability values. Finally, probabilistic sensitivity analysis, using Monte Carlo Simulation with 1,000 sample iterations, was performed to generate ICER scatterplots and cost-effectiveness acceptability (CEA) curves. Results: Over a lifetime, as compared to non-operative treatment, surgery was associated with an average gain of an additional 0.81 QALYs and additional costs of 12,788USD, resulting in an ICER of 15,725USD/QALY for the base case analysis. With increasing age, surgery became less cost-effective, with age 96 representing the threshold beyond which the ICER exceeded the WTP threshold (ICER at age 85:26,069USD/QALY; ICER at age 95:46,049USD/QALY). Results were also found sensitive to variation in year 1 post-op mortality rates, with surgery becoming less cost-effective as surgical mortality increased and as non-operative treatment morality decreased (Figure 1). Model results were less sensitive to variation in costs or fusion and complication rates for each strategy. Probabilistic sensitivity analysis revealed surgery to be the most cost-effective strategy in 79.3% of the 1000 iterations sampled, as depicted in the ICER scatterplot (Figure 2). Generation of CEA curve demonstrated surgery to the preferred strategy above a WTP threshold of 20,000USD. Conclusion: Surgical treatment for type-II odontoid fractures in the elderly appears to provide better value with respect to costs and health gains compared to non-operative management with external orthosis. However, surgery becomes less cost effective with increasing patient age and increasing probability of early postop death. This implies that while surgery is likely to be the preferred approach for the younger healthier patient, conservative management may be more appropriate for the older patient with a higher probability of short-term mortality. Further studies are needed to confirm the findings presented here., Introduction: Many different techniques of C1-C2 arthrodesis have been developed and screw and rod constructs are actually the most commonly used. However, C2 pedicle or isthmic screw placement is technically demanding and carries the risk of neural and vascular injury. The inferior articular process (IAP) of the axis can be a safe alternative for screw placement in patients with bone or vascular variants of C1-C2 anatomy. We report the results of a CT study of C2 IAP anatomy, which can provide useful parameters for screw placement. We also present the preliminary clinical experience of 25 patients operated with this technique. Material and Methods: Morphological study: 50 CT angiographies of the vertebral arteries (VA) were used for this study, and therefore 100 IAP were considered. We measured on the axial and sagittal planes the length of the facet, the distance between the anterior cortex and the VA and the distance between the screw entry point and the VA. We also measured the angle between the sagittal plane passing through the entry point and the external tangent line of the VA. Clinical report: 25 patients (mean age 63) were treated with C2 IAP screws at the Spine Surgery Department of the University Hospital in Lyon, France, from January 2014 to Jun 2016. The screw entry point was located in the middle of the C2 IAP, and bicortical screws were inserted with a perpendicular trajectory on the sagittal plane and a lateral inclination of 15-20° on the axial plane. Results: Morphological study: the mean length of C2 IAP was 12 ± 2 mm, the mean distance between the anterior cortical layer and the VA was 5.2 ± 1,4 mm, and the mean distance between the screw entry point and the VA was 15.7 ± 1.9 mm. The mean angle we found was 0.2 ± 5.3°, with minimum and maximum values of −13.5° and 14.5° respectively. Clinical report: 13 women and 12 men were treated with C2 IAP screws. 15 of the 25 patients presented post-traumatic C1-C2 instability, 7 patients presented degenerative disease, 1 patient was treated for pseudoarthrosis, 1 for OPLL and 1 for rheumatoid arthritis. There was no post-operative neurological aggravation in this group. All the screws were correctly positioned and there was no VA injury. Among the 5 patients with post-operative complications, only the 3 wound infections were directly related to surgery. No mechanical complication (screw migration or pull-out) was noted post-operatively. Conclusion: C2 screw placement carries the risk of VA injury, and some anatomical condition such as narrow pedicles can increase this risk or even impede the procedure. IAP screws represent a safe alternative option for C2 fixation in some cases, and the morphological and clinical data we present in this study demonstrated that it is a feasible procedure., Introduction: Treatment options for pediatric cervical injuries include external immobilization and surgical fusion. Differences in the operative vs. non-operative treatment outcomes of different cervical injury locations (atlantoaxial vs. subaxial) has not been adequately addressed among pediatric patients. In this study, we performed a retrospective analysis using the Nationwide Inpatient Sample (NIS) database to compare complication rates for cervical injuries after external fixation or spinal fusion in the pediatric population. Material and Methods: Patients under the age of 18 with a discharge diagnosis of cervical spine fracture without spinal cord injury or cervical spine subluxation were identified in the NIS database. Patients who were treated with internal fixation or external immobilization between 2002-2011 were included for analysis. Patients who did not undergo treatment and patients with unspecified fracture level were excluded. Discharge weights were applied and used to produce national estimates. Outcome data included length of stay, in-hospital mortality, discharge disposition, total hospital charges, and development of in-hospital complications. Results: A total of 2,878 pediatric patients with cervical spine injury were identified after application of discharge weights; 1,462 patients (50.8%) with atlantoaxial injury and 1,416 (49.2%) with subaxial spine injury. There were 1,037 atlantoaxial injury patients (70.9%) treated with external immobilization and 425 patients (29.1%) who underwent internal fixation. Significant differences between groups included total charges ($73,786 ± $107,108 for immobilization and $98,158 ± $86,548 for surgery, P = .040), and development of at least one complication (1.9% for immobilization and 6.8% for surgery, P = .029). Mortality (P = .363), length of stay (P = .221) and non-routine discharges (P = .106) were not different between groups. Among patients with subaxial injuries, there were 542 patients treated with external immobilization (38.3%) and 874 patients treated with surgery (61.7%). When comparing external immobilization to surgery for suabxial injury patients, there were no significant differences in sex (68.2% male vs. 65.4%, p = 0.622), primary payer (P = .493), injury mechanism (P = .234), length of stay (6.4 ± 6.7 days vs. 5.5 ± 5.2, P = .196), mortality (P = .430), non-routine discharges (P = .117), complication occurrence (P = .334), or total charges ($69,042 ± $83,614 for external immobilization vs. $83,123 ± $66,491 for surgery, P = .142). Patients with subluxation alone were treated more often with surgical fusion than with external immobilization (2.2% vs. 1.2%, P < .001). Conclusion: The management of cervical spinal injuries in pediatric patients must be informed by the location of the injury. In patients with atlantoaxial injuries, the lower overall complication rate and decreased cost may warrant initial consideration of external fixation for treatment. Complication rates for subaxial injuries did not vary by treatment in this study, leaving both external immobilization and surgical fusion as two viable options for treatment. These results will help guide clinicians in their treatment decisions and support more cost-effective methods for managing cervical injuries., Introduction: There is little information on the incidence of odontoid fractures in recent years and on the current treatment patterns amongst spine surgeons for these fractures. The purpose of the present study was to elucidate recent trends in surgical and nonsurgical treatment of odontoid across patient demographics. Material and Methods: Patients diagnosed with an odontoid fracture from 2005 to 2011 were identified in a national database of records from Medicare (PearlDiver Patient Record Database) using International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedure Terminology (CPT) codes. Treatment groups were stratified as operative or nonoperative. The operative group consisted of fusion and fracture fixation. The nonoperative group included all other treatment modalities including cervical collar and halo vest. Results were analyzed by year, age group, gender, and geographic region. Results: There were a total of 56,230 odontoid fractures identified from 2005 to 2011. There was a 26.2% increase in fracture incidence over this period (P < .0001). The incidence of odontoid fractures increased with each successive age group with a 6.8-fold increase in patients over age 85 years compared to those under age 65 years (P < .001). Incidence was higher in females than males (P < .001) and in the Midwest compared to all other geographic regions (P < .001). There was a trend towards increased operative treatment over the study period from 6.7% in 2005 to 8.0% in 2011 (P < .001). Operative treatment was more common in males (12.0%) than in females (7.1%) (P < .001). Rate of surgery was highest in the West (10.9%) followed by the South (9.3%), Midwest (8.9%) and the Northeast (8.1%) (P < .001). Surgical treatment was most common in the 65-69-year and 70-74-year age groups (12.4% and 12.6% respectively) and least common in the >85-year age group (5.4%). Conclusion: Incidence of odontoid fractures steadily increased over the study period. Patients greater than 85 years were at the highest risk with a nearly 7-fold increase in patients younger than 65 years. There was a slight increase in the overall rate of surgical treatment over the study period; however, nonoperative treatment remained the dominant treatment modality across all years and patient groups. Operative treatment was most common in patients between 65- and 74-years-old and significantly less common in patients over 85-years-old. Although females accounted for a greater percentage of odontoid fractures, males were more likely to be treated operatively. The information on current trends in incidence and treatment of odontoid fractures may serve as a reference for future studies in light of recent evidence that operative treatment may be more cost-effective than nonoperative treatment in select patients., Introduction: Cervical spine injury classification systems should be simple, easy to remember, related to injury severity, a guide surgical planning, reliable, and a predictor of outcome in clinical settings. Neither the mechanistic classification of Allen et al nor the conceptually simple classifications of TJ Harris et al have been capable of satisfying those objectives. We investigated whether the AOSpine subaxial cervical spine classification system predicted injury severity and neurological outcome. Material and Methods: We analyzed relevant clinical, imaging (preoperative CT, MRI, and postoperative MRI), management, and 6-month follow-up ASIA motor score of 92 AIS grades A-C patients with subaxial cervical spine fractures and spinal cord injury. Subaxial cervical spine injuries were classified according to the AOSpine Injury Classification System: A4 fractures are vertebral body fractures with both end-plates protruding into the spinal canal; B2 injuries are hyperflexion with intact anterior elements; B3 injuries are distraction injuries with intact posterior elements and no translation; and C type injuries are fracture dislocations with translation in any axis (X, Y, or Z) with disruption of the discoligamentous complex. We correlated morphology class to age, injury severity score (ISS), follow-up ASIA motor score (AMS), intramedullary lesion length (IMLL), and AIS grade conversion at 6 months post injury. Results: Mean age was 39.3, 83 patients were male, and 69 patients were injured during an automobile accident or following a fall. AOSpine Class was A4 in 8, B2 in 5, B2A4 in 16, B3 in 19, and C in 44 patients. Mean ISS was 29.7 and AMS was 17.1 (A4 = 17.6, B2A4 = 13.9, B2 = 9.8, B3 = 21.8, and C = 18 NS). AIS grade was A in 48, B in 25, and C in 19 patients. IMLL on postoperative MRI was 72 mm [(SD = 37.8): A4 = 68.1 (SD = 25.8); B2A4 = 86.5 (SD = 43.1); B2 = 59.3 (SD = 32.2); B3 = 46.8 (SD = 21.7); and C = 79.9 (SD = 39.1)]. At a mean follow-up of 6 months, mean ASIA motor score was 39.6 [SD = 31.9(A4 = 41.3, B2 = 54.3, B2A4 = 36.2, B3 = 53.9, and C = 33.1)]. Compared to Class B3 patients (simple hyperextension with intact posterior arch and no translation), Class C patients (with translation in any plane) were significantly younger (P < .0001), had longer IMLL (P < .002), and were less likely to have AIS grade conversion to a better grade (P < .02). Conclusions: AOSpine subaxial cervical spine injury classification system successfully predicted injury severity (longer IMLL) and chances of neurological recovery (AIS grade conversion) across different class subtypes., Introduction: Type II odontoid fracture is the most common fracture of CVJ which is often treated surgically. Incidence of non-union is high in cases managed conservatively due to complex nature of these fractures especially type IIA. Anterior odontoid screw fixation is useful in preserving the movements at C1-C2 whereas fixed arthrodesis achieved through posterior approaches lead to loss of motion at C1- C2. Anterior odontoid screw fixation is traditionally contraindicated in type IIA odontoid fractures, unstable odontoid fractures (ruptured transverse ligament, associated Hangman’s fracture or AAD), difficulty in screw placement (severe angulation/translation, anterior oblique fracture line, body habitus) and in cases with high risk of non-union (displaced and irreducible fractures, osteoporosis). Material and Methods: We are reporting 22 patients with type II odontoid fractures. All the patients were surgically treated with anterior odontoid screw. In 4 cases, of which 3 cases, due to severe displacement/angulation and irreducibility of the fracture fragment and 1 case due to difficult trajectory in screw placement, anterior odontoid screw fixation was thought to be contraindicated. Pre operatively, patients underwent X-ray, NCCT and MRI of CVJ to classify the fracture, to know the status of ligaments and rule out other injuries of the cervical spine. We attempted anterior odontoid screw fixation to preserve the neck rotation at C1-C2. In 3 cases out of 4 complex cases, skeletal traction was applied in extension. However, the fracture fragments were not reducible. So we performed anterior odontoid screw fixation (which is otherwise contra indicated) with trans-oral continuous controlled pressure over the posterior pharyngeal wall to realign the fracture in 2 cases. In one case, as the realignment was not possible by pressure over the posterior pharyngeal wall, via transoral - trans pharyngeal microscopic approach, fracture fragment was reduced. All trans oral procedures were done under neuromonitoring. Out of 4 complex cases, in one case of ankylosing spondylitis due to difficult trajectory in screw placement, projecting osteophytes over C2 and C3 were drilled and anterior odontoid screw fixation was done. All patients were followed up till 6 months post operatively with x-rays. In all the 4 complex cases, CT scan was done at 3 months post op. Results: 21 patients had successful fusion in the follow up and maintained normal cervical rotation. In one patient among the 4 complex cases, due to failure of alignment and screw back out after anterior odontoid screw fixation, a second procedure was planned and posterior C1-C2 fusion was done. Conclusion: The rotation at C1-C2 is most important movement at CV junction for human daily activities especially in young individuals. Every attempt should be made to reduce the fracture fragment to do anterior odontoid screw fixation before converting it to posterior fusion. Understading the mechanism of injury and fragment mobility helps in changing contraindication of anterior odontoid screw fixation in patients with complex odontoid fractures to an indication. However, experience & close follow up helps in preserving the C1-C2 rotation., Introduction: MRI is the gold standard for visualization of intervertebral disc (IVD) degeneration. The 9.4 T MRI provides superior resolution and anatomical detail, however it has not yet been applied to the study of lumbar degenerative disc disease. The Pfirrmann1 and the Modified Pfirrmann2 grades, developed on 1 T and 1.5 T MRI respectively, do not take into consideration much of the detail now visible with the 9.4 T MRI. An updated and enhanced MRI grading system of IVD degeneration is therefore required. We developed a 9.4 T MRI grading system accounting for the enhanced definition of the annulus fibrosus (AF) lamellar architecture, nucleus pulposus (NP) and the NP/AF differentiation. We further developed a NP/AF distinction score to investigate whether this would correlate with the 3 T Pfirrmann grade. Additionally, we utilised a simple IVD degeneration classification accounting for the Pfirrmann grade and the new 9.4 T MRI grading system. Materials and Methods: 3 T and 9.4 T MRI (Agilent Technologies) lumbar spine studies were obtained at necropsy of 90 IVDs in 18 ewes involved in an IVD cellular therapy study. Disc degeneration was initiated in the ewes six months prior to necropsy via surgical intervertebral disc injury. The newly developed 9.4 T MRI grading system, evaluating for the AF signal intensity, NP signal intensity, AF lamellae structure, NP/AF differentiation and hypointensities in AF and NP, was applied to the 9.4 T T2 MRI images. Pfirrmann grades were calculated for the 3 T and 9.4 T MRI studies for comparison. A NP/AF distinction score was calculated on the 9.4 T MRI and compared with the overall 3 T Pfirrmann grade. Results: The 9.4 T MRI images demonstrated exceptional resolution and anatomical detail of the intervertebral discs. The 3 T and 9.4 T MRI Pfirrmann grades demonstrated a very strong correlation (R2 1). The NP/AF distinction score also demonstrated a significant correlation with the overall 3 T Pfirrmann grade (R2 0.92, P < .0001). The new 9.4 T MRI grading system did not demonstrate a strong correlation with the 3 T or 9.4 T Pfirrmann grades, R2 0.78 (P < .0001) and R2 0.77 (P < .0001) respectively. However, when the discs were stratified into mild degeneration (Pfirrmann grades 1-2; 9.4 T MRI grades 1-4), moderate degeneration (Pfirrmann grade 3; 9.4 T MRI grades 5-7) and severe degeneration (Pfirrmann grade 4-5; 9.4 T MRI grades 8-10), the new MRI grading system correlated very well with the 3 T and 9.4 T Pfirrmann grades (R2 0.92, P < .0001). An assessment of inter-observer and intra-observer reliability demonstrated acceptable levels of agreement. Conclusion: The 9.4 T MRI Pfirrmann grade demonstrated a strong correlation with the 3 T Pfirrmann grade, with good inter-observer reliability. The NP/AF distinction score correlated well with the overall 3 T Pfirrmann grades suggesting this could be a potential predictive measure of IVD degeneration. The poor correlation observed between the new 9.4 T MRI grading system and existing Pfirrmann grades likely reflects the wider range of scores possible with the new grading system. The new 9.4 T MRI grading system is a reliable tool that is better able to appreciate the subtle changes in IVD degeneration., Introduction: Many techniques are described for the surgical reconstruction of isthmic spondylolisis. Technical difficulties with some constructs have been described (wire breakage and cutting-through-bone with metal wire, bone lesions with directs screwing, difficulty to bend the rod and bone erosion with U-shaped rods under the spinous processess), but the healing of the underlying pseudarthrosis is not always achieved. We describe a new technique of fixation that allows for the application of progressive compression force over the pars interarticularis with a non-rigid device. Material and Methods: The surgical technique consists of the following steps: exposure of the pars defect, preparation and bone grafting; positioning of two polyaxial pedicle screws at the lythic vertebra with standard technique; a rod is inserted connecting horizontally the two screws and piercing the interspinous ligament above the lythic vertebra; commercially available sublaminar bands are passed from the right under base of the spinous process of the lythic vertebra, around the left side of the rod, again under the base of the spinous process from left to right and finally connected to the right side of the rod; tensioning of the band results in compression across the reconstruction, providing stability. A 14 year-old male with severe low back pain associated with a L5 isthmic lysis underwent surgical treatment after 10 months of unsuccessful conservative treatment. The case illustrates the technique. Results: The intraoperative fluoroscopy and the post-operative X-ray demonstrate reduction of the defect and effective compression provided by the fixation system. The patient was mobilized the day after surgery without a lumbar corset and discharged the following day. Physical activity was restricted for the first 6 weeks post-operatively. The patient presented to clinic at a month and half follow-up referring no lumbar pain during rest or light sports activity. Conclusion: The purpose of isthmic reconstruction is to stabilize the vertebral segment in the most anatomical manner with a safe and reproducible technique. Achieving isthmic healing will significantly improve the quality of life of the patient in terms of low back pain allowing for prompt recovery and return to sports activity, as well as reduce the rate of early degeneration of intervertebral disc., Introduction: Intraoperative neurophysiological monitoring (IONM) is not used as a routine in spine surgery in many centers, although it is a standard of care in scoliosis procedures. Although there are many papers claiming that IONM is not needed in cervical procedures. Indeed, irreversible changes during IONM are predictive of severe adverse neurological outcomes (level of evidence class A) which is why it is becoming more popular in cervical spine procedures because it seems to be producing better functional result. Material and Methods: 191 consecutive patients (121male / 70 female; mean age of 60.15, SD = 15.1) who were undergoing cervical spine surgery fpr myelopathy from 2013 -2016 were recruited for the study. Anterior approach 109, posterior approach 82. Total intravenous anesthesia (TIVA) was used in all patients. No muscle relaxant after intubation. IONM was performed by SSEP and TcMEP in all patients. Results: IONM warnings were detected in 14 (7.3%) patients. 9/14 in presurgical cervical positioning of the patients (8/14 in posterior approach), all of them recover after repositioning. 3/14 for reversible hypotension. 2/14 during surgical procedure (one of them didnt recover IONM and woke up with severe tetraparesis). TcMEP were more sensitive than SSEP detecting warnings. Conclusion: Positioning during cervical procedures is a potentially damaging manoeuvre that may require an adequate neurophysiological monitoring technique in order to prevent damage to the spinal cord and consequently, the development of new postoperative neurological deficits., Background: Surgical planning to correct sagittal spinal imbalance is recognized as a key component of the surgical strategy, ensuring better patient outcomes. Surgimap™ is a software designed to simplify surgical planning in patients with adult spinal deformity. Purpose: To evaluate the predictive value of surgical planning using Surgimap™ regarding postoperative sagittal alignment. Methods: We conducted a retrospective evaluation of a prospective cohort to compare the predicted sagittal alignment with a Surgimap™ computer simulation of the surgical correction and real post-operative X-rays. The study involved 40 non-consecutive patients who underwent surgery for sagittal misalignment in a single Orthopedic center between June 2009 and April 2013. Postoperative alignment measured by sagittal vertical axis (SVA) and pelvic tilt (PT) was considered the gold standard. Surgimap prediction of final alignment was considered the test. Planning and postoperative films were classified as properly and improperly aligned. Sensitivity, specificity, and positive and negative predictive values of Surgimap planning [using two different methods of preoperative planning: direct simulation (method A) and simulation after correction of pelvic tilt to 20° (method B)] to detect postoperative improper alignment were calculated. Results: Seventeen (42.5%) of 40 patients had proper post-operative alignment. According to method “A” a proper alignment was achieved in 13 patients [S = 76.5%, Sp = 73.9%, RR = 2.93 (95% CI 1.40; 6.12), P < .001]; According to method “B” a proper alignment was achieved in 15 patients [S = 88.2%, Sp = 60.9%, RR = 2.25 (95% CI 1.32; 23.86), P < .001]. Kappa statistics indicate moderate agreement between actual post-operative alignment and computer prediction. In particular, when compared to method “A”, method “B” demonstrates better performance regarding the ability to predict proper postoperative sagittal alignment (Negative Predictive Value -NPV- of method “B” was 88% vs. 81% by method “A”). Conclusions: The ability of Surgimap™ to predict proper postoperative sagittal alignment was excellent (NPV 81% to 88%) in this cohort. Its ability to predict proper alignment was improved by correction of PT to 20° during planning (Method “B”, NPV 88%)., Introduction: Minimally invasive spine surgery relies heavily on fluoroscopic guidance. Rotational alignment of the vertebral body (VB) is typically assessed using two different techniques. The first involves assessment of the pedicles to ensure that they are symmetrical in size and proximity to the lateral wall of the VB. The second method evaluates the position of the spinous process (SP) to ensure it falls in the center of the lateral walls of the VB. The precision of these techniques may be confounded by anatomic variation and deformation of these structures. This paper aims to evaluate the reliability of these techniques by evaluating the symmetry of these structures on CT scan. Materials and Methods: One hundred lumbar spine CT scans from patients complaining of back pain, without evidence of scoliosis or spondylolisthesis, were reviewed; a total of 500 lumbar vertebrae. Measurements included pedicle height and width, distance from the pedicle to the lateral wall of the VB and the angle of the SP measured from the perpendicular of a line running through the widest point of the VB. The length of the SP was also measured and these values allowed us to calculate the offset from midline of the tip of the SP as would be seen in an AP fluoroscopic image. Considering the measurement error of a Cobb angle is quoted at 5 degrees, we labeled SP angles less than this as relatively perpendicular to the VB. Results: There was no statistical difference appreciated comparing bilateral pedicle height and width or pedicle-lateral wall distance for each VB from L1 to L5. The SP angle was found to deviate relatively equally to the right or left and this varied from level to level even within the same patient. Notably, the deviation of the SP was greater than 5 degrees in 14.4% of the vertebrae. In the L1 body, SP angle was greater than 5 degrees in 12% with the average deviation in these of 5.73 degrees, correlating to an offset of 3.1 mm. L2 SP deviation was greater than 5 degrees only 4% of the time, averaging 6.05 degrees meaning an offset of 4 mm. The L3 the SP deviated 16% of the time averaging 6.36 degrees meaning an offset of 3.7 mm. The L4 SP also deviated 16% of the time, averaging 7.3 degrees with an offset of 3.7 mm. The L5 SP deviated 24% of the time averaging 8.48 degrees meaning an offset of 4.9 mm. Conclusion: Our CT guided anatomical study of the lumbar vertebrae shows that pedicle dimensions and pedicle-lateral wall distance are symmetrical and therefore reliable measures of VB rotation. The novel finding is that the SP is not an accurate marker of midline as it may significantly deviate to one side 4-24% of the time by a margin of 3.7 to 4.9 mm. This occurs more frequently as we move caudal in the lumbar spine. Using the SP to determine midline of the VB may lead to misalignment during localization, increasing the risk of medial or lateral breach of the pedicle wall., Introduction: Selective nerve root blocks (SNRB) play an important role in treating cases with lumar radiculopathy. Traditionally since describing its reported outcomes transforaminal SNRB was being considered as a standard route for lumbar radiculopathy. Technically the transforaminal route of SNRB is a difficult procedure with many reported complications. We here in the study propose a novel technique in SNRB’s. Material and Methods: A clinical study of 100 individuals with lumbar nerve root radiculopathy of spinal origin who does not fit into the surgical management category. Nerve root compression was confirmed by MR Images. Pre-block Visual Analogue Scale(VAS) and ODI scores were taken. Extraforaminal SNRB was given by fellows in spine surgery at our institute in the OT setup under the fluoroscopic guidance. A 23-guage spinal needle was inserted at the junction of pars and transverse process. After feeling the bone at the other end, needle was made to advance few mm laterally (sliding from pars). Contrast dye made from salts of diatrizoic acid was injected. Track of nerve root was visualised and confirmed under c-arm followed by administering 3 cc of 2% xylocaine and 40 mg methylprednisolone acetate through the same needle. Post block VAS score and after 3 weeks ODI score were taken. Results: Pre block VAS score of the cases was 7.6 ± 1.4. ODI score was found to significantly change before (68 ± 17) and 3 weeks (37 ± 12) after the procedure. Immediate post-block the visual analogue score decreased to 2 ± 1. There were no reported complications of neural or vascular deficit. Conclusion: Selective nerve root blocks (SNRB) have gained a larger aspect of importance for the pain physicians. Transforaminal route of SNRB has been the mainstay till date. But we propose a novel technique of SNRB in the lumbar region as it is safe without any major complications and can be learned/ practised easily., Introduction: It is widely accepted that psychiatric comorbidities have a negative influence on clinical outcome following spine surgery for degenerative disc disease. However, most published data is restricted to postoperative measurements and data from preoperative settings in lacking. We previously demonstrated that mental comorbidities at 3 months follow up are very common and negatively influence clinical outcome. Aim of this study was to assess the incidence and influence of mental comorbidities on clinical outcome one year after surgery. Methods: A prospective study of patients undergoing elective spine surgery performed. Evaluation for depression (ADS-K score) and anxiety (STAI-S, STAI-T and ASI-3 scores) were done before and one year after surgery. In addition SF36 physical composite score (PCS), Oswestry Disability Index (ODI), EuroQOL 5D and pain visual analog scale (VAS) were completed preoperatively, 3 and 12 months follow up. Incidence and influence of these psychiatric comorbidities on clinical outcome were examined. Results: 184 patients met the inclusion criteria. 52.7% were male, mean age was 59.4 years. Abnormal anxiety scores were observed in 59.2%, 36.8% and 40.1% of cases before, at 3 and 12 months follow up, respectively. 25.0% of the patients showed abnormal ADS-K scores preoperatively compared to 10.5% and 14.5% at 3 and 12 months follow up, respectively. However, only 10.6% and 6% of patients developed anxiety and depression only following surgery, respectively. At one year follow up patients with abnormal anxiety scores showed a reduced clinical outcome compared to their counterparts (SF36 PCS: 34.7 vs 41.0, P = .005; EuroQol Index: 0.66 vs 0.82, P = .001; ODI: 30.3 vs 17.8 P = .008). Moreover abnormal ADS-K scores at one-year follow up were also associated with reduced clinical outcome (SF 36 PCS: 33.5 vs 39.7, P = .01; EuroQol Index: 0.55 vs 0.79, P = .001; ODI: 34.3 vs 19.4 P = .008). Conclusion: The incidence of depression and anxiety disorders in patients undergoing elective spine surgery is very high. This was also associated with unfavourable outcome one year after surgery. The standard scores for mental health seem highly nonspecific in the preoperative period. Spine specific screening tools are needed., Introduction: All planning for the design and development of educational events and resources for the continuing professional development of clinicians should be based on a solid needs assessment process. In the area of spine surgery, many tools have been used to gather information on educational needs and gaps. These include surveys (both online and at events), literature reviews, analysis of hospital data, diaries of questions, and interviews or focus groups, conducted either alone or in combination. Material and Methods: AOSpine designed a 4-phase needs assessment process to collaboratively conduct a hospital-based needs assessment at the University Hospital Basel. 1. Identify the participants and the surgeon leaders, 2. Agree a project plan with the team, 3. Gather needs assessment data through online questionnaires, interviews and focus groups, diaries of questions asked in daily practice, and any available statistics from the hospital, and 4. Analyze the data, identify the key findings, and create a plan to address the largest needs and gaps. Results: All 21 residents and practicing surgeons who are actively involved in treating spinal pathologies in the department completed the online questionnaire. Nine participated in a follow-up interview and 4 kept a diary of questions over a 1-week period. Analysis of the data created many observations and ideas for delivering education to meet the gaps and perceived needs. For the 12 neurosurgery and orthopedic residents, the 3 highest-rated (weighted average of all responses) pathologies where respondents had a “need for education in the next 2 years” were cervical trauma (4.0), thoracolumbar trauma (3.92), and adult deformity (3.83). For the 9 practicing surgeons, the 3 highest-rated needs were infection (3.00), adult deformity (3.00), and secondary tumors (2.89). In addition to many specific needs being identified for individual pathologies, there was also a high level of interest in surgical approaches and MISS techniques. For 5 specific nontechnical skills, the following gap scores between current and desired level of ability were reported (for residents and practicing surgeons respectively): Use effective communication strategies to gather and share information with patients and their families (0.55, 0.56), Collaborate with other healthcare professionals to implement the treatment plan (0.82, 0.56), Manage your roles as an individual healthcare provider, a member of teams in the hospital or practice, and a leader within healthcare systems (1.18, 1.22), Commit to Lifelong learning, teaching, and mentoring others (1.91, 1.11), and Ensure the best possible outcomes for patients and communities through ethical behavior and adhering to high standards of practice (1.45, 0.67). Conclusion: Inviting all surgeons and trainees from the spinal department to participate in this needs assessment resulted in a high level of engagement and a full online response rate. Using mixed methods and analyzing the data in two groups provided an optimal approach to review the information and to identify key findings. Several plans are now being implemented to meet the identified needs., Introduction: Patients undergoing lumbar surgery often have depressive and anxiety symptoms. Long-term effects of surgery on these psychological symptoms have not been rigorously evaluated. This longitudinal study compared pre- and 2-year postoperative psychological symptoms in 276 lumbar surgery patients and assessed whether change in symptoms was associated with success of surgery. Material and Methods: Several days preop patients completed two psychological surveys, the Geriatric Depression Scale (GDS) (possible score 0-30, ≥11 is positive screen for depression) and the Spielberg State Anxiety Inventory (STAI) (possible score 20-80, population norms are used for comparison). Patients also completed the Oswestry Disability Index (ODI) measuring disability from low back pain (possible score 0-100) and a validated Lumbar Surgery Expectations Survey measuring expected improvement for symptoms, function, and mental health (possible score 0-100). Medical comorbidity was obtained according to a standard index. Two years postop patients again completed the GDS, STAI, and ODI from the perspective of their current condition, and pre- to postop changes in score were calculated. Patients also reported new/worse comorbidity since surgery, and amount of improvement obtained for each expectation from which an overall proportion of expectations fulfilled was calculated (range 0 -1, higher = greater fulfillment). Improvement in GDS and STAI was defined as better psychological well-being. Success of surgery was defined as greater proportion of expectations fulfilled and improvement in ODI scores. Results: Mean age was 55 years, 56% were men, 78% had chronic spine conditions, 28% had major comorbidity preop, 19% reported new/worse comorbidity postop. Mean GDS scores were 9.8 (preop), 5.1 (postop), and 4.8 (within-patient change, P < .0001). More improvement in GDS scores was associated with a greater proportion of expectations fulfilled (P < .0001) and greater improvement in ODI scores (p, Introduction: Understanding of the associated factors with low back pain (LBP) and implementing effective prevention strategies are crucial. If the modifiable associated risk factors (for example, smoking) which develop prevalence and disability due to LBP is uncovered in the working generations, primary care, educational program and so forth could be recommended. Furthermore, potential saving costs for workers’ care system and the society is highly anticipated as well. The purpose of the current cross-sectional survey is to identify a prevalence of present LBP and to analyse modifiable risk factors associated with LBP. Material and Methods: A questionnaire could be collected from 1452 out of 1489 workers of a medical factory in November 2015 (collection rate: 97.5%). A self-administration questionnaire was used in the current survey. Age, gender, body height, body weight, and the type of the work demand were also ascertained in the questionnaire, for evaluation of mental condition. The medical component summary score (MCS) from Medical Outcome Study Short-Form 36-Health Survey (SF-36®) was used for evaluation of mental condition. Associations between LBP and age, gender, BMI, smoking, alcohol intake, regular exercise, work demand and mental condition was evaluated by a multiple logistic analysis (P < .05 = significant). Results: The mean age of the participants was 38.8 ± 12.8 (mean ± standard deviation). The prevalence of LBP in the present week (pwLBP) was 27.7% (28.1% in men, 26% in women). The odd ratio (OR) for aging was 1.40 (95%CI 1.03 -1.90) in the participants with the age 50 to 59 years referring to age 20 to 29 years. The habitual cigarette smoking (the mean dose: 11.9 ± 6.4 cigarettes/day) has an association with pwLBP in young adults, whose age was 37 years or less, and the OR was 2.07 (95%CI 1.47 -2.93). The alcohol intake (the mean dose: 23.4 ± 37.4g/day) also has a mild association with pwLBP and the OR was 1.33 (95%CI 1.05 -1.68, P < .019). The OR of pwLBP was 1.34 (95%CI 1.02 -1.78, P < .044) in the participants with the light to moderate work demand. The OR in the participants with MCS score less than 35 was 2.64 (95%CI 1.96-3.56). Conclusion: Habitual cigarette smoking in the young generation whose age was 37 years or less, alcohol intake, non-sedentary work demand and depressive mood are associated with pwLBP of the employed workers. Therefore, reduction of smoking and alcohol intake, less demand of the non-sedentary work and improvement of depressive mood has a possibility to decrease the present LBP., Introduction: It is known that the QOL for aging patients who have spinal kyphosis deformity is frequently impacted by symptoms of gastric esophageal reflux disease (GERD). There is scattered mention in case study literature where refractory GERD has been seen to improve rapidly after correction of sagittal deformity. The purpose of this study was to evaluate the relationship between gastric esophageal reflux disease and spinal sagittal alignment. Material and Methods: 888 consecutive patients seen at our osteoporosis outpatient clinic between 2009.9 and 2015.7 were asked to complete frequency scale for the symptoms of GERD (FSSG) and Questionnaire for the Diagnosis of Reflux Disease (QUEST) questionnaires. After excluding scoliosis patients, 726 patients (111 males, 615 females) remained who had completed both questionnaires and for whom whole spine radiographs were available. Patients who scored positively on both questionnaires (8 or more on the FSSG and 4 or more on the QUEST) were assigned to the GERD group. On the other hand, non-GERD group was determined as a negative of both questionnaires. Spinal sagittal alignment was evaluated using measurements of thoracic kyphosis (TK: T2-T12), low thoracic kyphosis (T5-12), thoracolumbar sagittal angle (T10-L2), lumber lordosis (LL: T12-S), pelvic tilt (PT), sacral slop (SS), pelvic incidence (PI), and sagittal vertical axis (SVA). From DEXA scan data we calculated total bone mass density from L2-5, and used multiple regression analysis to compare each of the sagittal parameters between the GERD and non-GERD groups. Results: 98 of 726 patients (13.5%) (10 males, 88 females) were included in the GERD group. Non GERD group was 446 patients (66 males, 380 females). Averages were 41.7°/41.5°TK, 34.6°/33.8°T5-12, 21.9°/16.2°at T10-L2, 36.4°/34.5°at T12-S, 28.6°/27.0° SS, 28.5°/26.4° PT, 53.6°/48.3° PI and 52.6mm/45.6 mm SVA for the GERD group and Non-GERD groups respectively. Significant correlation to GERD was found only for TK at T10-L2 and PI (P < .001). Mean BMD (g/cm2) was 0.701/0.736 at L2-5. Conclusion: The diagnostic reliability of the FSSG and QUEST questionnaires individually is reported to be about 60% so studies with endoscopic findings are planned. However, with the combined use of both questionnaires as criteria for this study’s GERD group, reliability is thought to be high. We detected the level of sagittal alignment related GERD. Since the vertebra at the thoracolumbar junction are at high risk for fractures, early detection and treatment of osteoporosis is also important in the prevention of GERD., Introduction: Patient based outcome measures have been recommended for evaluation of patients with spinal disorders and outcome of treatments. Several measurement tools are available in different languages, encouraging multinational studies and the use of international spine registry systems. The Core Outcome Measure Index (COMI) is a self-administered multidimensional questionnaire intended to evaluate the affect of LBP on daily life. It has six core questions about pain (back and leg), function, symptom-specific well-being, quality of life, work and social disability. It is the recommended outcome instrument in the Spine Society of Europe Spine Tango Registry. The aim of this study was to produce a cross-culturally adapted and validated Turkish version of the COMI Back questionnaire. Material and Methods: A cross-cultural adaptation of the COMI into Turkish was carried out using established guidelines. Ninety-six Turkish-speaking patients with non-specific LBP were recruited from orthopedic and physical therapy outpatient clinics in a public hospital. They completed a booklet of questionnaires containing Turkish version of COMI, adjectival pain scale, Roland Morris disability questionnaire (RM), European 5 Dimension Questionnaire (EQ-5D) and brief version of World Health Organization Quality of Life Questionnaire (WHOQOL- BREF). Within following 7-14 days, 67 patients, reported no or minimal changes in their back pain status, completed the Turkish COMI again to assess reproducibility. Results: Data quality was good with very few missing answers. COMI summary index score displayed %3 floor effects and no ceiling effects. The correlations between the COMI summary index score and the each of the full instrument whole scores were found to be excellent to very good (Rho = −0.81−0.74). Reliability expressed as intraclass correlation coefficient (ICC) was 0.95 (95% CI 0.91-0.97. Standard error of measurement (SEMagreement) was acceptable 0.41 and the minimum detectable change (MDC95%) was 1.14. Conclusion: Turkish version of the COMI has acceptable psychometric properties. It is a valid and reliable instrument and cross culturally adapted, in accordance with established guidelines, for the use by Turkish speaking patients. It can be recommended for use in evaluation of patients with chronic LBP in daily practice, in international multicenter studies and in spine registry systems., Introduction: Degenerative spondylolisthesis (DS) remains one of the most common indications for spine surgery. Although large multi-institutional trials supported surgical treatment for this pathology, and recent meta-analysis has compared different fusion techniques, the best surgical management option for patients with only grade 1 disease has not been determined. Therefore, the purpose of this study is to compare decompression and fusion with decompression alone for the treatment of grade 1 degenerative spondylolisthesis. Material and Methods: Following PRISMA guidelines, the MEDLINE, Embase, and Ovid electronic databases were systematically reviewed to assess for studies evaluating patients with grade 1 spondylolisthesis published from January 1996 until July 2016. Within these studies, we stratified all patients into two cohorts; the first group had patients who underwent a decompressive-type surgery and the second cohort consisted of patients who also underwent a fusion procedure. We specifically looked at clinical outcomes, complications, reoperations, and additional surgical details such as blood loss. Descriptive statistics were used to describe both cohorts; then, random effect models were used to determine the rates of the specified outcome metrics, with its 95% confidence intervals. Results: A total of 17 studies met our criteria. There were 9 studies (N = 591 patients) who were part of the decompression cohort, with a mean age of 67 years (range, 62-69 years), a mean BMI of 24 kg/m2 (range, 23-26 kg/m2), and 54% were women. The fusion cohort had 14 studies (N = 434 patients) with a mean age mean 60 years (range, 49-70), had a mean BMI of 24 kg/m2 (range 23-26 kg/m2) and 71% were female). In both cohorts, the pain (leg and low back) significantly decreased, the physical component of the Short Form 36 (SF-36), and overall increased the outcome metric scales. In terms of complications, the decompression cohort had a 7.5% complication rate (95% CI of 2 to 16%) and the fusion had a 9.2% complication rate (95% CI of 7 to 12). In contrast, the reoperation rate was higher in the decompression cohort with a 6% rate (95% CI of 1 to 15%) than in the fusion cohort with a 4.4% rate (95% CI of 2 to 7). Conclusion: With the current literature, it does not appear to be any advantage of one procedure over the other. Patients undergoing decompression alone tended to be older and had a higher percentage of leg pain while fusion patients tended to be younger and have more low back pain. The decompression cohort had fewer complications but a higher revision rate. Future studies specifically assessing patients with low grade DS are needed to determine the benefits and cost effectiveness of one procedure versus another., Introduction: The American Association of Neurological Surgeons launched the National Neurosurgery Quality and Outcomes Database (QOD), a prospective longitudinal registry utilizing patient reported outcome instruments and includes data to measure the safety and quality of spinal surgery. In the present study, the authors analyzed 12-month outcomes data for patients undergoing lumbar fusion surgery for grade 1 degenerative spondylolisthesis. Material and Methods: The prospective QOD dataset from top enrolling sites was retrospectively queried and we found 480 patients undergoing elective spine surgery for one, two, or three level degenerative grade 1 lumbar spondylolisthesis. Baseline, 3-month, and 12-month follow-up readmission rates, re-operation rates, and patient reported outcomes [Oswestry Disability Index (ODI) and back and leg pain Numeric Rating Scale (NRS)] were collected. The absolute differences between 12-month post-operative and baseline ODI and back and leg pain NRS scores were evaluated. Results: The 30-day readmission rate was 3.3%. The 90-day readmission rate was 4.6%. The 30-day re-operation rate was 3.1%. The baseline ODI scores differed from the 12-month scores by an absolute difference of 12.1 ± 8.8 (P < .001). The baseline back and leg-pain NRS scores differed from the 12-month scores by an absolute difference of 3.9 ± 3.1 and 4.0 ± 3.6, respectively (P < .001). Conclusion: This prospectively collected data is uniquely generated through the spine surgeon’s office directly from the patients. Lumbar fusion surgery for grade 1 degenerative lumbar spondylolisthesis is associated with low 30-day re-operation rates and 30- and 90-day readmission rates. Fusion surgery was associated with significant improvements in patient-reported outcomes at one-year follow up., Introduction: Study Design: Ambispective review of the Canadian Spine Outcomes and Research Network (CSORN) registry cohort. Objective: To investigate the effect of surgical wait time (SWT) on the baseline and postoperative patient reported outcome (PRO) metrics in surgical patients with degenerative spondylolisthesis (DS), and to identify independent predictors of outcome in surgical patients with DS. Summary of Background Data: DS is the most common form of lumbar spondylolisthesis. Surgery is considered with failure of non-operative management and persisting symptoms. From a patient perspective, rapid access to spine specialist care is preferred. However SWT to initial spine specialist consult and elective surgery can be prolonged, especially in a single-payer health care system. Material and Methods: Surgical DS patients treated between 2013 and 2015 were identified in the CSORN registry. SWT was defined as the period from surgical wait listing to day of surgery, with study population dichotomy to: (1) SWT < 3-months; and (2) SWT ≥ 3-months. Baseline and post-operative (3-month, 1-year) demographic and PRO metrics were analyzed using bivariate and multivariate modeling. Results: At baseline, the SWT < 3-months cohort had 158 patients while the SWT ≥ 3-months cohort had 146 patients. Both SWT groups had similar distributions of age, gender, symptom duration, and smokers. The SWT < 3-months cohort however had more compensated patients (P < .01). Both groups were also similar in terms of baseline PROs and spine specific metrics except for the SWT ≥ 3-months cohort who were more depressed (P < .01). At 3-months, the SWT ≥ 3-months cohort showed greater satisfaction (96.2% vs. 86.2%, P < .01). This effect was not maintained at 1-year. All other PRO metrics were similar at 3-months and 1-year. Multivariate modeling showed that both surgical wait times and symptom duration were not independent predictors of outcome in surgical DS patients. Subgroup analysis of symptom duration showed indifference in outcomes at 3 months but superior results at 1 year for those with shorter duration of symptoms. Conclusion: Prolonged surgical wait time was not detrimental on the post-operative outcome in surgical patients with degenerative spondylolisthesis. Subgroup analysis however showed better results in patients with shorter duration of symptoms., Introduction: To investigate the long-term effect of pedicle screw-lamina hook plus isthmic bone grafting through Wiltse approach for lumbar spondylolysis in children and adolescent. Material and Methods: From July 2005 to May 2009, 43 patients (31 males, 12 females; 9-25 years old, average 17.2) with lumbar spondylolysis combined with or without slippage were enrolled in our study. All of the patients were treated with the pedicle screw-lamina hook plus isthmic bone grafting and followed up at least for 5 years. There were 33 Single level spondylolysis and 10 double level spondylolysis. The symptom status were evaluated by Visual analogue scale (VAS) score and Oswesty dysfunction index (ODI) preoperatively and at 3days, 3 months, 6 months, 1 year after surgery and the final follow-up. The surgical outcome was assessed by Henderson method. AP view, flexion and extension view, oblique X-rays were performed at every time point. 3D-CT scan was taken 1 year after surgery to assess the bone fusion. Modified Pfirrmann grade was used to evaluate the disc degeneration. And the adjacent segmental degeneration was assessed by the UCLA grade on the X-ray of the final follow-up. Results: All patients were follow-up over 5 years (68-122 months, average 83.3). The surgery was successful, the average operation time was 125 min (85-155 min), the average intraoperative blood loss was 120 ml (80-160m1), and the post-operative drainage was 54m1 (35-85m1). No complication was observed. The VAS and ODI score of postoperative was significantly different from that pre- operation (P < .05). The bone fusion was observed in 39 patients after 1-year follow-up, the fusion rate was 90.7%. There was no detachmented the pedicle screw-lamina hook and intervertebral altitude loss. UCLA grade showed no adjacent segmental degeneration occurred. 8 cases had degeneration of lumbar intervertebral disc on the MRI images at the final follow-up. Conclusion: Compared with the multi-segmental fixation and interbody fusion, the pedicle screw-lamina hook plus isthmic bone grafting is a single-fixation, and this operation is technically simple and no sacrifices of lumbar motion ranges, and it is proved to be effective., Introduction: The sacroiliac joint (SIJ) is a common cause of chronic, unremitting Lower Back Pain (LBP). A significant number of patients do not respond to Conservative Management (CM). New Minimal Invasive SIJ fusion procedures were developed. Material and Methods: 103 Adults with chronic SIJ pain at 9 sites in 4 European countries were randomly assigned to either minimally invasive SIJF using triangular titanium implants (N = 52) or CM (N = 51). CM was performed according to the European guidelines for the diagnosis and management of pelvic girdle pain and consisted of optimization of medical therapy, individualized physical therapy (PT) and adequate information and reassurance as part of a multifactorial treatment. Subjects assigned to CM not benefitting from it for at least 6 months, were allowed cross over to any other treatment, including minimally invasive SIJF. Endpoints included low back pain and leg pain scores, quality of life using EQ-5D-3 L, disability using ODI, SIJ function using ASLR, mental state using Zung depression scale and adverse events. Results: Results. At 6 months, the improvements in LBP and ODI were higher in the SIJF group vs. CM group (both P < .0001) and well exceeding the Minimal Clinical Important Difference (MCID). ASLR, EQ-5D-3 L, Zung depression scale, walking distance and satisfaction were statistically superior in the SIJF group. The frequency of adverse events did not differ between groups. One case of postoperative nerve impingement occurred in the surgical group. In the surgical group, the 12-month improvements in pain, disability and quality of life were similar to those seen at 6 months. 37 (76%) of the subjects assigned to CM and still participating at 6 months had a change of ≤20 in LBP VAS, 21 (43%) of them crossed over to SIJ fusion. Amongst crossovers, changes in pain, ODI and QOL at 6 months after crossover were similar to those in the group initially assigned to surgical care. Conclusion: This study demonstrates that in patients with chronic SIJ pain, minimally invasive SIJF using triangular titanium implants was safe and more effective than CM in relieving pain, reducing disability, improving function, and improving quality of life. The response to minimally invasive SIJF was maintained at 12months. The majority of subjects assigned to conservative management did not benefit (change in LBP VAS ≤20) from it for at least 6 months., Introduction: We introduce a minimally invasive extraforaminal lumbar interbody fusion (ELIF) that is the novel lumbar approach, a newly emerging minimally invasive technique for treating degenerative lumbar disorders. Materials and Methods: 23 patients who received minimally invasive ELIF through the Kambin’s triangle included in this study, retrospectively. ELIF performed through the Kambin’s triangle. We checked the radiologic result as following: 1) implant related complications, and 2) fusion status. Clinical result checked as following: 1) Surgery related neurologic complications 2) Visual Analogue Scale (VAS) and 2) Oswestry Disability Index (ODI). Results: The mean age was 58.96 years and the mean follow-up period was 29.96 months. According to the result, implant related complications were 4 cases (17.39%) and fusion failures were 5 cases (21.74%). We experienced 5 cases (21.74%) of surgery related neurologic complications and all patient’s neurologic complications recovered within 1 month after operation. The mean VAS (Back) prior to surgery was changed as following: Preoperative: 6.43, and 2 years after operation: 3.04. The mean VAS (Leg): Preoperative: 7.70 and 2 years after operation: 2.91. The mean ODI score: Preoperative: 76.78 and 2 years after operation: 29.91. Conclusion: According to the result, we obtained excellent clinical results using the minimally invasive ELIF without any serious traversing or exiting nerve injury. But, fusion rate and cage subsidence remained still overcome issue. If we developing this novel surgical technique, we will obtain the excellent clinical result using the minimally invasive percutaneous procedures., Introduction: Spinal fusion surgery is accepted as the gold standard for the treatment of degenerative disc diseases when a conservative approach fails. The most commonly used devices for this procedure are interbody cages made of metals such as titanium, tantalum or polymers as polyether ether ketone. The mismatch in mechanical properties between the implant and surrounding bone has been largely suggested as a cause of implant subsidence and therefore suboptimal outcomes. While it is largely recognized that the geometry of the interbody cage is crucial in restoring the load patterns, the optimal implant design still remains debatable. Standard implants and instrumentations may be unsuitable for some surgical cases. Hence, patient-specific designs can potentially improve clinical outcome in spinal surgery by creating an optimal match for each anatomy. Recent advances in computational models combined with additive manufacturing technology can be now used to optimize existing device and develop novel implant designs with control over the architecture, which may facilitate cell adhesion and bone in-growth.1,2 Moreover, 3D printable biomaterials such polycarbonate have recently shown feasibility to spinal cages that provide appropriate mechanical properties to withstand the physiological loading configuration and support the process of osteointegration2-4. This study aims to use a particular computational technique such as finite element analyses (FEA) to optimise existing device and design more effective solutions for spinal fusion implants. Material and Methods: Standard FEA were set up to simulate different loading conditions such as compression, flexion, extension and bending on a conventional cage design. Furthermore, a novel cage was designed to match the pre-operative vertebrae derived from computed tomography (CT) images of a patient. Two materials were modelled: titanium and polycarbonate. Titanium was used as control materials during the computational analysis, due to its wide applications in spinal implants. Polycarbonate was included as widely available within additive manufacturing techniques. The influence on the performance of four different filling densities (25%,50%,75%,100%) of 3D printed polycarbonate was studied through mechanical testing. Micro computed tomography (CT) was used to assess structural reproducibility and generate 3D models of the additive manufactured polycarbonate porous structures. For each of the cages, all four filling densities were simulated through a patient-specific two-level model of the spine within a physiological load distribution. Results: Computational results in terms of stress results showed different mechanical responses when using different materials for the spinal cage, manufacturing technique, cage architecture and filling density. In particular, stresses increased with reducing material density. In addition, stress peak values were lower than the respective risk of failure in all the simulated cases, confirming the feasibility of polycarbonate implants. The patient-specific design showed an even stress distribution consistently within anatomical constraints. Conclusion: The process suggested the feasibility of a lighter, affordable and patient-specific interbody cage for spinal fusion. Computational analyses may be utilized to balance the complex requirements of load transfer and porosity to avoid stress-shielding effects and support implant osteointegration. References 1. Capelli C, Serra T, Kalaskar D and Leong J. Computational models for characterisation and design of patient-specific spinal implant. The Spine Journal. 2016; 16: S53-S4. 2. Serra T, Capelli C, Kalaskar D and Leong J. Feasibility of manufacturing a patient-specific spinal implant. The Spine Journal. 2016; 16: S64-S5. 3. Figueroa-Cavazos JO, Flores-Villalba E, Diaz-Elizondo J, et al. Design Concepts of Polycarbonate-Based Intervertebral Lumbar Cages: Finite Element Analysis and Compression Testing. Applied Bionics and Biomechanics. 2016; 2016: 9. 4. Serra T, Capelli C, Toumpaniari R, et al. Design and fabrication of 3D-printed anatomically shaped lumbar cage for intervertebral disc (IVD) degeneration treatment. Biofabrication. 2016; 8: 035001., Introduction: The sacroiliac joint (SIJ) is a contributing factor in 15-30% of patients evaluated for chronic low back pain. A variety of non-surgical treatments are commonly provided for SIJ pain, including physical therapy, SIJ steroid injections and radiofrequency neurotomy. So far, no high-quality evidence supports long-term pain relief from any of these treatments. Over recent years, minimally invasive SIJ fusion (SIJF) has been introduced as a potential treatment alternative. Despite a large number of commercially available devices, very little outcome evidence exists for devices other than triangular titanium implants (TTI). There are three currently ongoing prospective trials on TTI and their preliminary results have shown concordant improvements in pain, disability and quality of life after SIJF. Two of these trials are randomized controlled trials comparing SIJF to conservative management (CM). Herein we pool the current data of the three relevant prospective trials to examine treatment outcome after SIJF using TTI. Material and Methods: The trials included in this pooled analysis are the Investigation of Sacroiliac Fusion Treatment (INSITE) trial, the iFuse Implant System Minimally Invasive Arthrodesis (iMIA) trial and the Sacroiliac Joint Fusion With iFuse Implant System (INSITE) trial. Data from these trials were combined on an individual patient basis and analyzed using mixed modeling taking into account expected variation of patient characteristics and outcomes across sites. Pain was quantified using the visual analogue scale (VAS, range 0-100), disability was assessed using the Oswestry disability index (ODI) and the quality of life was described using the EuroQuol score (EQ-5D-3 L). Results: We included 423 subjects from two geographies (US and Europe). Mean age was 50 years and 70.4% of subjects were women. Mean duration of pain prior to enrollment was >5 years. SIJ pain averaged 80 VAS points at baseline. In the SIJF group, pain levels dropped by 48 VAS points (44-52) at 12 months and 52 VAS points (47-56) at 24 months. Mean reductions in ODI in the SIJF group were 26 (22-29) and 26 (22-30) points at 12 and 24 months, respectively. In the CM groups, changes in pain and ODI scores were minimal. Effect sizes (i.e., the differential in improvement in scores observed with surgery as opposed to CM) were 37.8 points (95% CI 32.4-43.2) for VAS, 18.4 points (95% CI 14.3-22.4) for ODI, and 0.24 points (95% CI 0.17-0.30) for EQ-5D-3 L. Wound-related complications (eg, infection) occurred in 2.1% (95% CI 0.3-4.4%). The early surgical revision rate was 1.2% (0.4-2.5%) and the late revision rate was 1.6% (0.1-5.1%). Conclusion: This pooled analysis provides evidence that in patients with pain originating from the SIJ, SIJF using TTI may lead to early and sustained improvements not only in SIJ pain but also in disability and quality of life. Treatment effect sizes were comparable to those known from prospective trials of other commonly performed spine surgeries. The rates of procedure-related wound problems and early revisions were low and consistent with the minimally invasive nature of the procedure., Introduction: Sacroiliac joint (SIJ) fusion is gaining popularity amongst spine surgeons for treatment of SIJ dysfunction. SIJ fusion can be accomplished by open or minimally invasive (MI) surgery. The MI technique has increased in popularity as it is believed to be associated with minimal blood loss, less surgery time, and decreased length of hospital stay. This is a systematic review of the existing literature to determine the safety of MI SIJ fusion through the determination of the rate of procedural and device related intraoperative and postoperative complications. Material and Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed and Scopus were searched using the terms “sacroiliac joint AND fusion”. All original English language retrospective and prospective studies of at least five patients with reported adverse event or complication rates for MI SIJ fusion were included for analysis. Complications were defined as procedural if reported as most likely or definitely due to the MI surgery and device related if secondary to the implant device. Random effects meta-analysis was performed for pre-operative and post-operative Visual Analog Score (VAS) pain ratings and Oswestry Disability Index (ODI) to quantify the efficacy of MI fusion in studies providing both mean scores and standard deviations (SD). Post-operative VAS and ODI scores were from last recorded follow-up. Results: Fourteen studies met our inclusion criteria. Seven studies reported VAS scores while five studies provided ODI values. Twelve of the studies investigated triangular porous titanium plasma spray coated implants while two studies used hollow modular anchorage screws packed with demineralized bone matrix. A total of 720 patients (499F/221 M) with a mean follow-up of 22 months were included in the analysis. 99 patients (13.75%) underwent bilateral SIJ arthrodesis resulting in a total of 819 SI joints fused. There were 90 documented procedural-related complications (10.99%) with the most common adverse events being surgical wound infection/drainage (n = 13), trochanteric bursitis (n = 11), and hematoma formation (n = 9). 25 adverse events were attributed to be directly caused by the implant device (3.05%) with nerve root impingement (n = 13) being the most common. The rate of revision was found to be 2.56%. The association between the type of implant and device related complications was not statistically significant (P = .955). MI SIJ fusion reduced VAS pain scores from 82.42 (95% CI 79.34-85.51) to 29.03 (95% CI 25.05-33.01) and ODI scores from 57.44 (95% CI 54.73-60.14) to 29.42 (95% CI 20.62-38.21). Patient satisfaction with outcomes was high at 93.14%, with 86.01% stating they would have the same surgery again. Conclusion: MI SIJ fusion reduces pain and improves functionality of accurately diagnosed SIJ dysfunction. Possible risks and complications of the procedure, including those requiring revision, are not uncommon; however patient satisfaction is high. Additional studies are needed to further enhance the safety of the procedure., Introduction: The economic burden of spine-related health care in the United States has been estimated at $100 billion dollars annually and a 65% increase in spine-related health care medical expenditures from 1997 to 2005 was reported. This emphasizes the importance of economic evaluation of surgical procedures. With an increasing system-wide focus on value-based health care, the goal of economic evaluation is to identify high quality of care which minimizes costs. Few studies have compared the costs of different approaches for lumbar fusion surgery. The purpose of this study was to compare the costs of single-level lumbar fusion, performed as (1) posterior instrumented fusion alone (PSF), (2) posterior interbody fusion with posterior instrumentation (PLIF), or (3) minimally invasive lateral interbody fusion with posterior instrumentation (MILIF), over a period of 6 years. Materials and Methods: Patient charts were retrospectively reviewed for demographic and surgical details. Patients were followed up with a telephone questionnaire to obtain information on reoperation status and satisfaction. In order to perform cost estimation from the payer’s perspective, the average surgery-related Medicare reimbursement was calculated for the three treatment groups, for index procedures (PSF-$34,432, PLIF-$36,605, MILIF-$52,879) and reoperations (PSF-$35,098, PLIF-$29,292, MILIF-$43,870) as cost estimates. Using rates published previously, the mean cost for epidural injections per patient was estimated ($2,864). Survival analysis (Kaplan-Meier and multivariate Cox regression analysis) was performed to assess the time to elevated resource use (defined as greater than 90% of patients in this study or $68,672). Multivariate analysis was performed to assess overall satisfaction. Results: A total of 337 patients, 45, 222 and 70 in the PSF, PLIF and MILIF groups respectively, were included. Overall follow-up rate was 63% at 6 years. PSF patients were significantly older (PSF-72 ± 12 vs PLIF-59 ± 13 vs MILIF-65 ± 10 years, P < .001). Surgical time was lowest in the PSF group (P < .001), while blood loss was lowest in the MILIF group (P < .001) at index procedure. The length of stay after the index procedure was not significantly different among groups (P = .369). Kaplan-Meier analysis showed that PLIF patients were less likely to reach the cut-off compared to PSF (P = .002) and MILIF (P = .006) at an average follow-up of 6 years. Multivariate Cox regression analysis showed that PSF patients and MILIF patients were 3.3 and 3.4 times more likely to reach the elevated resource use cut-off (PSF-HR 3.280, P = .017, MILIF-HR 3.370, P = .017). Multivariate logistic regression showed that MILIF patients were 3.3 times more likely to be satisfied compared to PLIF patients (OR 3.320, P = .002). Conclusion: Multivariate Cox regression analysis showed that patients undergoing MILIF or PSF were more likely to have higher resource utilization than those undergoing PLIF and thus incur greater costs to payers at an average follow-up of 6 years. The high cost estimate for procedures in the MILIF group and for reoperations for PSF patients led to greater costs compared to the PLIF group. Multivariate logistic regression demonstrated that patients in the MILIF group were more likely to be satisfied with the overall result of their surgery, compared to PLIF patients., Introduction: The purpose of this study was to determine the feasibility and efficacy of contralateral keyhole endoscopic surgery (CKES) for treating lumbar spinal stenosis and lumbar disc herniation. Material and Methods: We performed percutaneous endoscopic sublaminiar decompression via the contralateral interlaminar approach in 95 patients with central canal stenosis or lateral recess stenosis and/or herniated disc. All procedures were performed under epidural anesthesia. Firstly, the epidural space was accessed under fluoroscopic guidance; the only tip portion of the handmade working sheath was located within the epidural space to prevent nerve compression injury by an instrument. And then we were partially removed the base of spinous process, the caudal edge of the upper lamina and the rostral edge of the lower lamina to make a keyhole using a 3.5-mm drill bit and punch, thereby allowing surgeon to more easily handle endoscope. After the drilling, the contralateral ligamentum flavum was removed by using punch. The lateral recess and the traversing nerve root were completely decompressed. Additionally, we performed selective fragmentectomy in patients with herniated discs. The mean age was 59.2 years and there were 47 men and 48 women. The mean follow-up period was 6.8 months. Clinical results were evaluated using Visual Analog Scale (VAS) and modified MacNab criteria. Results: The symptom was relieved immediately after the surgery. The mean operating time was 68.2 minutes. The VAS score improved significantly from 6.8 points preoperatively to 2.3 points after the surgery. 79 (83.1%) had a good or excellent result according to the MacNab criteria. Complications included two cases of epidural hematoma, three cases of transient dysesthesia and three cases of dura tear. Conclusion: CKES is a safe and effective minimally invasive surgical technique that extends the percutaneous endoscopic lumbar discectomy indications for lumbar disc herniation and is a novel and useful procedure in treating lumbar spinal stenosis, Introduction: Surgery involving a microscope or uniportal endoscope is now one of the most common types of minimally invasive spine surgeries performed worldwide. However, the procedure still has drawbacks related to its narrow view, steep learning curve, and technical problems. Recently, many preliminary or technical reports regarding biportal arthroscopic spinal surgery (BASS) have been published and have demonstrated that BASS can resolve these drawbacks. However, it would useful to determine the degree of paravertebral muscle injury after BASS using two portals and saline irrigation during the entire procedure. Therefore, we examined the radiological status of the paravertebral muscles after BASS. Material and Methods: A total of 48 patients were reexamined by magnetic resonance imaging (MRI) due to the recurrence of neurological symptoms during the follow-up period after BASS using a unilateral inter-laminar approach between September 2015 and March 2016. Of these, 30 patients diagnosed with lumbar spinal stenosis or lumbar disc herniation were included in this retrospective study. Patients with more than the two lesions required for surgery, previous lumbar surgery, spinal infections, or who underwent BASS via a trans-foraminal approach were excluded. We assessed the radiologic status of the paravertebral muscles by grading the extension of paravertebral muscle high signal intensity on T2-weighted MR images (0: normal, 1: partial, 2: total). The MR images were checked and graded on three occasions: preoperatively (aMRI_1), at 1 day after surgery (aMRI_2), and at the time the MRI was re-taken due to the recurrence of neurological symptoms (aMRI_3). The third MRI was taken on the 26th day (range, 1–122 days), on average, after BASS, and then this day was sequentially subdivided into three groups (A: less than 2 weeks, B: 2–4 weeks, C: more than 4 weeks). Then we attempted to determine the critical period when the radiological muscle status was normalized. We also examined the operation time to assess its correlation with muscle status. Results: In the aMRI_1, all cases were graded 0. In the aMRI_2, no cases were graded 0, 29 were 1, and 1 was 2. In the aMRI_3, 12 cases were graded 0, 16 were 1, and 2 were 2. No significant differences were identified among the three groups in terms of age, sex, operation level, operation time, aMRI_1, and aMRI_2. However, in aMRI_3, a significant difference was found among the groups (P = .002, Kruskal-Wallis H test), and in the C group, in particular, the grade was significantly low (P = .006, Dunn multiple comparisons test). The average operation time was 111.3 ± 40.0 min (range, 45–210 min) and it was not significantly correlated aMRI_2 or aMRI_3. However, there was a significant negative correlation between the time when the MRI was re-taken and aMRI_3 (P = .0053, rho = −0.495, Spearman correlation test). Conclusion: Paravertebral muscle injury after BASS was localized to a limited area and spontaneously normalized., Introduction: After spinal cord injury (SCI), primary damage starts with the contusion and hemorrhage and continues with an inflammatory process with glia reactivity, apoptosis, blood-spinal cord barrier (BSCB) disruption and consequently vasogenic edema. Spinal cord edema is a major clinical problem since this structure is contained by the dura and the spinal canal. Swelling leads to nervous tissue compression and ultimately to ischemia and cell death in the next few hours after trauma. The use of corticosteroids following acute SCI is a controversial practice, since the administration of high doses of methylprednisolone (MP) is justified by the work conducted by Bracken MB in the past 2 decades with the National Acute Spinal Cord Injury Studies (NASCIS I, II and III trials). However, the methodological quality of the NASCIS work has been extensively criticized. A new Clinical Practice Guideline recently published for the management of spinal cord trauma advises against the use of MP following SCI, highlighting that the indication has not been approved by the Food and Drug Administration and that currently there is no evidence of level I or II regarding its clinical benefit. Contrariwise, secondary effects have been extensively documented. Since this malpractice continues around the world, particularly in low-income countries, it is important to determine whether MP confers any beneficial effect that justifies its use in acute SCI. For this, we used an acute experimental model of SCI in rats administered with MP and determined the effects on spinal cord edema and the expression of acuaporine-4 (AQP4), a water channel involved in edema formation and resolution. Material and Methods: A total of 24 adult Long-Evans rats weighing 250-400 g were anesthetized with pentobarbital intraperitoneally (i.p.) (50mg/Kg). Rats were subjected to a severe spinal cord contusion at T9, which was generated using an impactor system. Rats treated with MP received an i.p. injection of 30 mg/Kg and an equivalent volume of isotonic saline solution was administered to control animals. Twenty-four h after SCI rats were killed and tissues were fixed and collected to analyze AQP4 expression by immunofluorescence and confocal microscopy, in a separate group of rats, an i.v. bolus of Evans blue was administered 30 min before killing the animals and fresh tissues were collected to assess BSCB integrity. Results: Spinal cord contusion parameters and neurological deficits generated after SCI were very consistent across groups. We observed a clear loss of AQP4 expression in astrocyte processes in the groups treated with MP, regardless of SCI. Spinal contusion seemed not to affect AQP4 expression. Consistently, we found more extravasation of Evans blue in the SCI group treated with MP, suggesting that loss of AQP4 resulted in a diminished capacity for edema resolution. Conclusion: Our results are consistent with the deleterious effect evidenced clinically when SCI patients are treated with MP during the first 24 h, since MP seems to worsen spinal cord edema due to AQP4 down-regulation and persistence of BSCD disruption in injured rats., Introduction: Scoliosis is a three-dimensional deformity of the spine and trunk that affects individuals of all ages. Fusion spinal instrumentation is implemented for individuals with mature spines, while non-fusion spinal instrumentation is implemented for individuals with growing spines. Biomechanical testing of fusion instrumentation is commonly performed using ASTM F1717 standardized testing, but the effects of wedding-band connectors for non-fusion instrumentation has not been evaluated. Patients with a growing spine have fewer pedicle screws to share the load with the spine; therefore, there is a desire for non-fusion instrumentation to withstand greater loads across the instrumentation. The purpose of this study was to characterize the mechanical performance of fusion versus non-fusion instrumentation using ASTM F1717 methodology. Material and Methods: A uniaxial load frame was used to biomechanically test fusion and non-fusion spinal instrumentation with ASTM F1717 methodology. Non-fusion instrumentation consisted of 5.5 mm titanium rods joined with wedding-band connectors at the middle of the 76 mm span between two polyethylene blocks. Rods were anchored to pedicle screws that had been placed in the blocks and offset appropriately for wedding-band connectors. Two experimental groups (fusion and non-fusion spinal instrumentation; n = 5/group) were tested in static compression bending (ie, flexion-extension). Stiffness, yield and ultimate strength were calculated from force-displacement data. Data were analyzed statistically using a Students t-test with the level of significance set at P < .05. Results: Stiffness of non-fusion instrumentation was significantly greater than fusion instrumentation at 48.0 ± 1.9 and 43.4 ± 0.3 N/mm, respectively (P < .01). Yield strengths were similar between non-fusion and fusion instrumentation at 475 ± 60 and 457 ± 17 N, respectively (not significant). Ultimate strength of non-fusion instrumentation was greater than fusion instrumentation at 1,080 ± 9 N versus 1,008 ± 6 N, respectively (P < .01). Conclusion: For non-fusion instrumentation there were significant increases in stiffness (11%) and ultimate strength (7%) when compared with fusion instrumentation. This study helped to establish a baseline for biomechanical testing of non-fusion spinal instrumentation, and show that non-fusion instrumentation can carry larger loads with a higher stiffness than fusion instrumentation., Introduction: Damage to oligodendrocytes (OLs) and myelin are one of the major contributors to functional loss following spinal cord injuries (SCI). Understanding temporal and spatial response of OLs and other myelinating cells including progenitor cells and Schwann cells in animal models can help us comprehending complex pathophysiological responses in human. Here we conducted a systematic review to reach an evidence-based knowledge about myelinating cells fate after SCI. Material and Methods: We searched MEDLINE (1946 to January 2016) and EMBASE (1974 to January 2016) databases, without applying time or language limitation. In addition, we performed hand-search through the relevant papers. Results: After injury, a large number of oligodendrocytes (OLs) and progenitor cells die as early as 15 minutes post injury, initially due to necrosis and then through apoptosis. This loss then extends to the areas distal from lesion by two weeks. On the other hand, progenitor cells proliferate and peak around the first week after injury at the lesion borders to compensate the OL population. Followed by increased number of progenitor cells, they instigate to display OL properties. Until, almost the fourth week post injury when the number of OLs approaches the normal controls. For many years it has been thought that progenitors that express NG2 marker can only differentiate into OLs. However, evidences show a temporal and spatial transition in progenitor cells fate. Evidences based on real-time labelled progenitor cell show between 72 hours to 7 days, NG2+ cell give rise to a population of cells with phagocytic properties. Conclusion: Being post-mitotic, OL are not able to proliferate following SCI to preserve their population. However, a portion of progenitor cells in coordination of Schwann cells (in severe injuries) make up the OL population. Recapitulating this response could be an interesting avenue toward more efficient therapeutics., Introduction: The disability of central nervous system (CNS) for regeneration imputed to inhibitory environment of CNS after injury. Hydrogels belong to a class of water-insoluble polymers and may be either homopolymers or copolymers. Hydrogel scaffolds are shown to assist in tissue regeneration by providing physical and chemical cues to direct axonal regeneration and cellular infiltration into the lesion, or implant site in the spinal cord. However, no optimum protocol has been developed for application of hydrogels for repair of TSCI. Here, we evaluated the efficacy of hydrogels for repair of TSCI through conducting a systematic review and meta analysis. Material and Methods: We searched PubMed and EMBASE with no temporal or linguistic restrictions. In addition, hand-search was performed in the bibliographies of relevant studies. Controlled animal studies used hydrogels without incorporation of cells or any other therapeutic agents were included. Results: The most common synthetic hydrogels has been studied for repair of TSCI are poly(2-hydroxyethyl methacrylate), poly[N-(2-hydroxypropyl)-methacrylamide], poly(ethylene glycol), poly(?-hydroxybutyrate), also, natural origin hydrogels including alginate, chitosan, collagen, fibrin, agarose, hyaloronic acid, starch, Matrigel and NeuroGelTM. In addition, alginate, blends of agarose/methylcellulose and hyaloronan/methyl cellulose and self-assembling peptides are injectable hydrogels recently evaluated for regeneration of TSCI. The effectiveness of hydrogels on repair of TSCI after injury has been evaluated based on axonal regeneration, functional recovery and reduction of scar formation. In addition, the effect of hydrogels on angiogenesis as well as inflammation and integration of implanted scaffold with host tissue have been assessed. Improved functional recovery after implantation of hydrogels was found to be higher in transection than contusion/compression injury model. Additionally, functionalized hydrogels were more efficient in repair compared to non-functionalized ones. Conclusion: Hydrogels may be an appropriate platform to encourage regeneration of the injured spinal cord. There is a hope that these gels along with our deepening understanding of the pathophysiology of TSCI will result in advances in the treatment of TSCI in human subjects in the next few years. Acknowledgement This project has been support by the Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences (fund number: 94-02-38-29150)., Introduction: Blood loss is a major concern in spine surgery. Blood transfusion promotes oxygen delivery and tissue perfusion during long, complex surgeries, yet carries with it rare but notable risks. The hemoglobin (Hb) trigger—the Hb value that initiates clinician administration of packed red blood cells (PRBCs)—is frequently used to evaluate physician compliance with existing transfusion guidelines. Randomized clinical trials have demonstrated similar or improved outcomes among patients receiving blood transfusions using a restrictive Hb trigger—defined as an intraoperative Hb level of, Introduction: Obstructive sleep apnea (OSA) is a significant sleep disorder that is often associated with poor health status. The prevalence of OSA is increasing in the United States. Some studies have shown it to be associated with poorer post-operative outcomes following surgical procedures. Little information exists characterizing inpatient outcomes in patients with OSA undergoing elective spine surgery. Material and Methods: Utilizing data from the National Inpatient Sample from 2002 to 2012, an estimated 78,613 patients with OSA undergoing elective spine surgery for degenerative lumbar and cervical disease were selected and compared to 4,295,538 patients undergoing the same procedures. Post-operative outcomes including: complications of surgery, inpatient mortality, and length of stay were assessed for both groups. Complications were classified as major or minor. Major complications included acute myocardial infarction, cardiac arrest, septicemia, septic shock, stroke, and pulmonary embolism. Minor complications included deep vein thrombosis, pneumonia, surgical complications, post-operative anemia, and urinary tract infections. Finally, a comparison of total hospital charges between the two cohorts was made. Results: Patients with OSA were, on average, five years older than those without OSA (P < .001) and had a larger mean comorbidity burden (2.52 comorbidities compared to 1.16; P < .001). Procedures performed included primary and revision spinal fusions and posterior decompressions. OSA was associated with an increased rate of post-operative complications (3.2% compared to 1.4%; P < .001). OSA was an independent risk factor for major complications based on multivariate logistic regression analysis (OR = 1.31; 95% CI 1.25 to 1.38; P < .001). A slight increase in inpatient mortality rates was seen in the OSA group (0.3% compared to 0.2%; P < .001). Average length of stay was slightly longer for patients with OSA (3.7 days compared to 3.2 days; P < .001), and overall hospital charges were significantly increased in the OSA cohort (56,560$ compared to 37,405$; P < .001). Conclusion: Patients with obstructive sleep apnea often have multiple concomitant comorbidities and are at increased risk of experiencing a more difficult post-operative course following elective spine surgery. Both surgeons and patients should be aware of these risks while weighing the risks and benefits of surgery., Introduction: Dysphagia is a well-known complication after cervical spine surgeries but incidence reporting and risks vary. Although usually transient, dysphagia can be potentially life-threatening if it leads to aspiration pneumonia or upper respiratory tract infection. There is a significant need for more specific and reliable data locating the origin of the swallowing dysfunction. Using a large medical record database that more closely and accurately models the American population as a whole, the aim of this study was to analyze the incidence of aspiration pneumonia, specifying in which stage of swallowing—oral, pharyngeal or esophageal—the dysphagia was occurring. Material and Methods: Patients undergoing Anterior Cervical Discectomy and Fusion (ACDF) and Posterior Cervical Fusion (PCF) from 2007-2014Q2 were selected from records of the nationwide private insurance provider Humana within the Pearl Diver patient records database. ICD-9 diagnosis codes (International Classification of Diseases 9th edition) were used to reveal incidence of post-operative dysphagia by type—oral, pharyngeal and esophageal—within one year of surgery. Cases of pre-existing swallowing conditions were excluded from the analysis. The data was also examined for incidence of patients who developed aspiration pneumonia within one month after dysphagia. Results: From 21701 ACDF patients (11360 female; 10341 male) 15% developed postoperative dysphagia. Fourteen percent of women who underwent ACDF acquired some degree of swallowing dysfunction while 16% of men had dysphagia. Patients with postoperative dysphagia of any type were 13.7 times more likely (P < .0001) to develop aspiration pneumonia than ACDF patients who did not have dysphagia. Of the 3,261 patients who developed dysphagia 5% proceeded to aspiration pneumonia. Pharyngeal and unspecified dysphagia were the most contributable to aspiration pneumonia. With a chi-square statistic of 7.2 and P < .5, these dysphagia types were statistically independent, while other types of dysphagia did not occur alone. Among PCF patients (3255; 1419 female and 1835 male) 18% had postoperative dysphagia. Eighteen percent of men and women who underwent PCF had difficulty swallowing after surgery. PCF patients with dysphagia of any type were 9.3 times more likely (P < .0001) to develop aspiration pneumonia than patients who did not have dysphagia. Of the 575 patients who developed dysphagia, 12% went on to develop aspiration pneumonia. Unspecified and pharyngeal were the most common types of dysphagia leading to aspiration pneumonia, though they were not statistically independent. Conclusions: The results of this study illuminate that PCF is more likely than ACDF to cause some type of patient dysphagia. Furthermore, in our study among ACDF patients men were more prone to dysphagia than women, while there was no difference in gender for PCF patients. Pharyngeal and unspecified dysphagia types led to the most instances of aspiration pneumonia. These findings are critical for physicians evaluating the severity of their patients’ dysphagia and should be considered when deciding if treatment is needed., Introduction: The rate of posterior lumbar spinal fusion (PSF) surgery has increased significantly over the past few years. It remains the most common surgical procedure used to stabilize the spine for a variety of spinal pathologies; however, the impact of blood loss requiring blood transfusions remain a significant concern in this population. The purpose of this study was to identify patient related, disease related or procedure related predictors of postoperative blood transfusions. Material and Methods: This is an ambispective analysis of data from the Canadian Spine Outcomes and Research Network (CSORN). Patients who underwent PSF between 2008 and 2015 were identified. Multivariate analysis was used to identify predictors of blood transfusion from routinely collected patient information including both preoperative and intraoperative items. Results: Of the 772 patients identified to have undergone PSF, 18% required blood transfusion. Overall, there were 54.8% females and the mean age was 60 years. Multivariable logistic regression analysis revealed five significant predictors of blood transfusion: American Society of Anesthesiologist class (ASA), operative time, number of level fused, sacrum involvement and open posterior approach. The odds of transfusion for those with ASA class greater than 1 were six times the odds for those with ASA class 1 (OR 6.1, 95% CI 1.4-27.1, P < .018). For each 60 minutes increase in operating room time, the odds of transfusion increased by 4.2% (OR 1.007, 95% CI 1.004 -1.009, P < .001). Moreover, the odds of transfusion when more than one level were fused was 6 times the odds for one level fusion (OR 5.8, 95% CI 2.6-13.2, P < .001). Also, when the fusion was extended to the sacrum the odds for blood transfusion were three times higher (OR3.2, 95% CI 1.8-5.8, P < .001). Finally, the odds of transfusion for patients undergoing open posterior approach were 12 times the odds for those who had minimal invasive surgery (OR 12.5, 95% CI 1.6-97.4, P < .016). In addition, patients receiving transfusions who underwent lumbar fusion were more likely to have extended hospital stay. Conclusion: ASA > 1, prolonged operative time, multilevel fusion surgery, sacrum involvement and open posterior approach were significant predictors of blood transfusion in posterior lumbar spinal fusion., Introduction: ‘After-hours’ emergent spinal surgeries are frequently necessary, and often performed under sub-optimal conditions. The consequences of performing these often complex surgeries under such conditions on post-operative outcomes are unknown. Methods: One thousand four hundred and forty patients underwent emergent spinal surgery at a single institution between 2009-2013. Surgery was defined as ‘In-Hours’ if completed between 7h00 and 16h00. Surgery was defined as ‘After-Hours’ if more than 50% of the operative time was between 16h01 and 6h59, or if it was performed over the weekend. Data on demographics, diagnosis, surgical intervention, Spine Surgical Invasiveness Score (SSII), operative start time and end time, intra-operative blood loss (IOBL) and post-operative outcome measures (adverse events (AE), mortality, length of stay) were prospectively collected. Results: 664(46.1%) procedures were performed “After-Hours”. OR time and IOBL were similar between groups (P > .05). % of the patients operated “After-Hours” experienced at least an AE compared to % for the “In-Hours” group (P = .0). The number of intra-operative AE/patient was significantly higher in the “After-hours” group (versus, P = .0). ‘After-hours’ designation was an independent predictor of AE on multivaria analysis (adjusted OR 1.30, 95% CI, 1.02-1.66, P = .034). In-hospital mortality doubled in patients who had surgery after hours (4.4% versus 2.1%, P = .01). On multivariate analysis, “After hours” surgery showed a borderline association with in-hospital death (adjusted OR 1.99, 95% CI 0.98-4.06, P = .056). Length of stay was longer in the “After-hours” group (median 1IQR 7-2 versus 1, IQR 7-2, P = .014). However, on multivariate analysis, association between LOS and “After-hours” was not significant (adjusted OR 1.63, 95% CI -0.83-4.10, P = .194). Conclusion: Emergent spine surgery performed ‘after-hours’ is associated an increased in peri-operative adverse events. Higher mortality System changes to facilitate ‘In-Hours’ surgery could mitigate against the adverse outcomes associated with’After-Hours’ surgery., Introduction: Venous thromboembolic events (VTEs) including deep vein thrombosis (DVT) and pulmonary embolism (PE) are preventable complications associated with significant morbidity and mortality after spine surgery. Previous literature focused on timing and incidence of post-operative VTEs after lumbar surgery is limited. The aim of this study was to investigate incidence and risk factors associated with venous thromboembolic events after lumbar spine surgery using a large nationwide sample group. Materials and Methods: Patients who underwent first time isolated lumbar surgery between 2007 and 2014 including any of five types of single or multi-level lumbar procedures were identified using the PearlDiver patient database (PearlDiver Technologies, Inc., Fort Wayne, IN, USA) from private insurance provider Humana Inc. ICD-9 diagnosis codes (International Classification of Diseases 9th edition) were used to search patient records and determine incidence of VTEs among surgery types, patient demographics and comorbidities. Complications including DVT and PE were queried each day from the day of surgery to post-operative day 7 and for periods 0 to 1 week, 0 to 1 month, 0 to 2 months and 0 to 3 months post-operatively. Results: 64,892 patients within the Humana insurance database received lumbar surgery between 2007 and 2014. Overall VTE rate of 0.9% (N = 608) was seen at 1 week, 1.8% (N = 1190) at 1 month and 2.6% (N = 1667) at 3 months postoperatively. Among patients that developed a VTE within one week post-operatively, 45.3% (N = 267) had a VTE on the day of surgery. Patients with one or more identified risk factors had a VTE incidence of 2.73%, compared to 0.95% for patients without risk factors (P < 0.001). Risk factors associated with the highest VTE incidence and odds ratios were primary coagulation disorder (10.01%, OR 4.33), extremity paralysis (7.49%, OR 2.96), central venous line (6.70%, OR 2.87) and varicose veins (6.51%, OR 2.58). Conclusions: This study identifies several patient comorbidities that were independent predictors of post-operative VTE occurrence after lumbar surgery. Clinical VTE risk assessment may improve with increased focus towards patient comorbidities rather than surgery type or patient demographics. Patients undergoing lumbar surgery may be at an increased risk of post-operative VTE occurrence on the day of surgery. We believe our findings on incidence and timing of venous thromboembolic events after lumbar surgery will provide useful information to clinicians when assessing patient risk in the pre- and post-operative periods., Introduction: Fractures of the thoracolumbar spine represent 90% of all spine fractures, 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 to short-segment transpedicular fixation, on kyphosis progression in patients with thoracolumbar burst fracture type A3/A4. Methods: Fifty-nine consecutive patients with thoracolumbar burst fracture treated with short-segment transpedicular mono-axial screw fixation. Patients were simply divided into transpedicular grafting (TPG) (n = 35, A3 = 20, A4 = 15) and non-TPG (n = 24, A3 = 19, 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 = .49). Results: The global mean kyphosis angle before surgery was 21.93 ± 3.92°, with 22.06 ± 3.55° in the TGP group and 20.75 ± 4.68° for non-TGP; P = .93. The mean kyphosis angle after surgery for entire study was 9.21 ± 8.86°, with 8.70 ± 2.11° TGP and 14.08 ± 4.73° NON-TGP, (TGP vs non-TGP, P = .010). No obvious clinical complications in both group it was documented. Conclusion: Our findings demonstrate that transpedicular bone grafting associated to short-segment fixation in thoracolumbar burst fractures has cause a significant effect on prevention of kyphosis progression after surgery., Introduction: Magerl A thoracolumbar fracture is caused by axial compression resulting in loss of vertebral body height (VBH). The main objective of treatment is to restore the VBH in order to limit the subsequent loss of correction, which occurs predominantly within the intervertebral disc space. The analysis of the quality of the reduction in the operating room is routinely made on plain radiographs only. Several studies have analyzed many preoperative parameters of interest including the Cobb angle. However, no prior study has prospectively assessed the postoperative correction of VBH. Our purposes were to (1) compare the relevance of measurements on plain radiographs and computed tomography (CT) scans to assess the postoperative correction of VBH, (2) analyze inter and intraobserver reliability of these two methods and (3) evaluate the correlation between radiographic Cobb angle, radiographic intervertebral disc space height and the VHB measurement using CT scan. Materials and Methods: We prospectively analyzed 40 Magerl A thoracolumbar fractures which required surgical treatment with posterior short-segment pedicle-screw fixation without fusion. Postoperative lateral radiographs and CT scans were reviewed independently by two spine surgeons and one musculoskeletal radiologist, and repeated at two separate times for one surgeon. The main measure was the “vertebral body reduction coefficient” (VBRC) defined as the ratio between the height under the maximal bone depression and the height in the middle of the vertebral body. Intraclass correlation coefficients (ICCs) were utilized to determine inter and intraobserver reliability. Spearman’s correlation coefficients were used to assess the association between the Cobb angle, the disc space height and the VBH. Results: The average age at the time of fracture was 37 ± 19 years old. For each observer, the mean value of radiographic VBRC was significantly different from CT scan VBRC. For the spine surgeon 1, mean value of VBRC was respectively 0.82 ± 0.12 and 0.67 ± 0.1 for plain radiographs and CT scans (P < .0001). For the spine surgeon 2, in the first series of measurements, mean value of radiographic VBRC was 0.82 ± 0.07 and 0.69 ± 0.1 for CT scans (P < .0001). In the second series of measurements, it was respectively 0.81 ± 0.06 and 0.69 ± 0.1 for plain radiographs and CT scans (P < .0001). For the musculoskeletal radiologist, mean value of radiographic VBRC was 0.8 ± 0.12 and was 0.66 ± 0.1 for the CT scan VBRC (P < .0001). The interobserver reliability was fair for plain radiographs and substantial for CT scan. The intraobserver reliability was respectively moderate and substantial. Neither radiographic Cobb angle nor radiographic intervertebral disc space height is correlated to the CT scan VBH measurement. Conclusion: Radiographic evaluation of postoperative VBH is incorrect, unreliable and no radiographic parameter is correlated to CT scan measurements. Improvement regarding development of techniques of vertebral body reconstruction and imaging with three-dimensional reconstruction embarked in the operating room will greatly benefit this type of fracture., Introduction: Thoracolumbar burst fractures represent an everyday challenge in the choice of the appropriate surgical strategy. The Load Sharing Classification (LSC) laid foundations for a scoring system able to indicate which fractures, fixed by short-segment posterior-only pedicle screws constructs, would need for longer instrumentations or an anterior column support. We retrospectively analyzed all the thoracolumbar fractures surgically treated, quantifying the vertebral body’s comminution so as to identify an additional parameter which can highlight the need for an anterior support when posterior fixation alone may be inadequate. Methods: One-hundred-twenty-one patients undergone posterior fixation for unstable thoracolumbar burst fractures were clinically and radiologically assessed. Supplementary anterior fixations were performed in cases of posterior instrumentation failure, impending failure determined on radiological and clinical evidences or symptomatic loss of kyphosis correction. The segmental kyphosis angle was calculated according to the Cobb method. The displacement of fracture fragments was obtained from the sum of the adjacent endplates areas divided by two and subtracted to the area enclosed by the maximum contour of vertebral fragmentation. The percentage of displacement (“spread”) derived from the ratio between this subtraction and the sum of the adjacent endplates areas divided by two. Results: In addition to the LSS the spread showed to be a quantitative measurement of vertebral body fragments displacement, which is easily reproducible with the current CT imaging technologies. There were no mechanical failures in those injuries treated only with posterior fixations showing a preoperative spread below 62.7%, while spreads superior to 100% required a supplementary anterior fixation. Most of the patients in the “grey zone” (between 62.7% and 100%) needed for an additional anterior support because a Grade of Kyphosis Correction (GKC) ≥ 10° had to be reached. Analysis of variance (ANOVA) showed that the effect of preoperative kyphosis (P < .001), LSS (P = .002) and spread (P < .001) on the surgical treatment (posterior or circumferential) were significant. Conclusions: Together with the Load Sharing Score (LSS) (P = .001) and the preoperative kyphosis (P < .0001) the spread (P = .005) was found to be an additional tool which could help in addressing the surgical strategy, providing an objective, entirely quantitative, reproducible and distinctly preoperative indicator., Introduction: Thoracolumbar fractures are commonly managed by posterior pedicle screw fixation. Controversy remains about the number of levels involved in the fixation as the stability of the short segment fixation remains questionable. Recently, it has been shown that application of intermediate screw in the fractured vertebra improves the biomechanical stability of the short segment construct. The aim of this study is to compare the outcome of long segment fixation (LSF) versus short segment fixation with intermediate screws (SSFIS) in the management of the thoracolumbar burst fractures. Material and Methods: Fifty patients with thoracolumbar burst fracture (T11-L2) type A3 and A4 AOSpine classification with a Thoracolumbar Injury Classification and Severity (TLICS) Scale of more than 4 were treated between 2009 and 2014 with posterior pedicle screw fixation. The patients were divided into two groups according to the number of instrumented levels. Group 1 included 25 patients treated with LSF (two levels above and two levels below the fractured level) while group 2 included 25 patients treated by SSFIS (one level above and one level below with 2 intermediate screws in the fractured level). The patients were evaluated for local kyphotic angle (LKA) correction and maintenance, anterior vertebral body height (AVH) compression, visual analogue scale (VAS) for back pain and treatment related complications. Construct failure was defined as screw pullout or instrument breakage. Results: The two groups were similar as regard to age, sex, fractured levels, fracture type, TLICS score, pre-operative local kyphotic angle and anterior vertebral body height compression. Post-operative correction of the local vertebral compression assessed with LKA and AVH significantly improved in both groups compared to the pre-operative degree while there was no significant difference in the two groups in early post-operative or follow up regarding the degree of correction and its maintenance. No construct failure or major treatment related complication were encountered in both groups with significant reduction of VAS in both groups between early post-operative and late follow up. Conclusion: Intermediate screw applied in the fractured level in management of thoracolumbar burst fracture improves the correction and maintenance of local kyphosis in short segment fixation similar to long segment construct with saving vertebral motion levels from being fixed. More randomized controlled and multicenter studies are needed to support these findings., Introduction: Suffering a fracture of the thoraco-lumbar junction with need for combined dorsoventral stabilization constitutes an impairment for the patient. Neurological deficits and palsies are possible. Remaining disorders and pain are reported differently and lead to work incapacity for a certain length of time. Material and Methods: We analyzed 111 patients suffering a fracture of the thoraco-lumbar junction with need for combined dorsoventral stabilization. We studied outcome, remaining neurological deficits, pain and length of work incapacity. Subgroup study involved privately insured and patients with employer’s liability insurance coverage (ELIC). Results: Patients with employer´s liability insurance coverage seemed to be more restricted than patients lacking this kind of insurance coverage. Work incapacity after surgery was 10,36 months, being 6,29 months more compared to other patients (P < .0001; T-Test). Additionally, pain was reported as being more intense than in the patients without ELIC. Conclusion: Insurance status seems to be a strong predictor for the duration of work incapacity following injuries to the thoracolumbar spine., Introduction: Spine fractures are common injuries in trauma population and the thoracolumbar junction (T10-L2) is the most frequently affected segment. In general, neurological impairment as a result of a spine fracture implies surgical treatment, in order to achieve decompression of the neural elements, as well as fixation of the affected vertebral levels, due to traumatic or surgery-induced spinal instability. Short-segment posterior fixation allows us to obtain spinal stability and neural decompression preserving healthy mobile segments, with shorter operative times, reduced intraoperative blood loss and associated costs. There is a lack of information in the literature regarding the management and follow-up of paraplegic patients due to thoracolumbar spine fractures treated with short-segment constructs. The purpose of this study is to describe the survival time of the short-segment fixation in patients under a workers’ compensation program, who underwent surgery after a thoracolumbar spine fracture with neurologic impairment. Material and Methods: We reviewed the medical records and imaging of patients with AO Type C thoracolumbar (T10-L2) spine fractures, with severe motor neurological impairment (ASIA Impairment Scale (AIS) A, B and C), treated in our center with a short-segment spinal fixation (mono or bi segmental) between 1988 and 2011, with a minimum follow up of 5 years. We excluded patients operated with hybrid instrumentations (ie, combination of screws, hooks and/or cables), with incomplete clinical records, operated elsewhere and those who died during the initial admission after the accident. Survival time of the short-segment fixation was estimated through a Kaplan Meier analysis, considering as a response of interest, the time elapsed between the date of the surgery and the date of the reoperation due to failure of the construct. Results: A total of 17 patients met the previously described inclusion criteria and hence were included in our study. The mean age was 34.59 years (SD = 10.24) and 88.24% of the group were males. The average follow-up was 17.24 years (SD 6.18). The main mechanism of injury was fall from a height. The most frequently injured levels were T11-T12 and T12-L1 with nine and five cases, respectively, while T12 was the predominant neurologic level of injury (NLI), with nine cases. Fourteen patients presented complete paraplegia (AIS A) on admission, while two presented AIS B impairment and the remaining one had an AIS C injury. At the end of the follow-up period, only two patients with AIS B impairment presented neurological recovery to AIS C and D respectively. Eleven patients were able to return to some type of work activity. We identified no patients with failure of the short-segment construct during the studied period (100% survival in 14 years). Conclusion: The survival time of the short-segment fixation was a 100% in 14 years. We can hypothesize that short-segment constructs are a viable alternative for the treatment of thoracolumbar spine fractures, even in patients with severe neurologic impairment., Introduction: Human spine is composed of physiological curvatures in the sagittal plane. Specific sports practices can modify these curvatures aiming a better adaptation. Non-harmonious changes in the spine sagittal plane increase the risk of spinal pathology. Soccer is the most practiced sport in the world. Low back pain (LBP) is one of the most frequent complaints in professional soccer players, with impact on the quality of training and the final performance. With this work, the authors aim to characterize sagittal balance in professional soccer players, compare them with the general population and establish a relation between the values of sagittal balance and spinal symptoms. Material and Methods: 37 soccer players of the 1st and 2nd Portuguese Soccer League and 20 individuals from the general population between 18 and 35 years old were recruited. In the clinical and physical activity evaluation were applied the Oswestry Disability Index 2.0 (ODI) and the International Physical Activity Questionnaire (IPAQ short-form), respectively. Radiographic evaluation consisted in the interpretation of radiographs of the spine in extra-long film in all participants. Surgimap ® software was used and the following parameters were measured: pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), sagittal vertical axis (SVA), lumbar lordosis (LL) and thoracic kyphosis (TK). Sagittal balance values were grouped into categories (low, normal, high) according to reference values for the general population. Results: Soccer players have lower radiographic values of sagittal balance compared to the control group. However, only the PT has a statistically significant difference and a practical impact (t(55) = −2.64 P = .011 g-Hedge = −0.82). The players subgroup with low PT does not have adaptive values of SS, LL and TK, as verified in the same control subgroup. LBP frequency is higher in soccer players (57% vs. 50%) but a statistical significant difference between the frequency of LBP and changes in the sagittal balance was not confirmed. LBP is more frequent in soccer players when there are changes (increased or decreased values) of PT, LL and TK. The ODI is negligible in both groups (soccer players, ODI = 5%; control group, ODI = 2.3%). Conclusion: Changes in physiological spinal curvatures are associated with an imbalance in the intervertebral stress distribution. In elite athletes, these changes are particularly important as they can have an impact in the final performance but also because athletes can have targeted functional training in order to prevent injuries. This study characterizes the sagittal balance in a group of soccer players. The reduction of PT verified, which results in the pelvis verticalization, can be explained by the large quadriceps femoris muscle core in this population. The frequency of LBP in soccer players is high when compared to the control group and the overall population (57%, 50%, 25%, respectively) and occurs more when the radiographic sagittal balance values are changed. However, it was not observed any association between radiographic values and low back pain., Introduction: Biological disc replacement using tissue-engineered intervertebral discs (TE-IVD) offers an alternative therapy to traditional treatments for degenerative disc disease (DDD). Recently a composite annulus fibrosus (AF) / nucleus pulposus (NP) disc-like construct has been manufactured and validated in rat tail and beagle cervical spine models in vivo. While cell viability and integration into host tissue was encouraging, the intrinsic biomechanical properties were inferior to native IVDs and implant displacement occurred in several cases. The aim of this study was to investigate the biomechanical responses of composite TE-IVDs combined with a bio-resorbable stabilization system (BSS) to static compression in an ex vivo model utilizing canine cervical spines. Material and Methods: Cervical IVDs from skeletally mature beagles were obtained, washed, and separated into AF and NP tissues. Upon further dissection into small fragments, the tissues were digested in collagenase Type II at 37°C for 12 hours prior to being filtered and centrifuged. NP and AF cells were cultured individually to confluence. Alginate (3% weight/volume) was then seeded with the cultured NP cells (2.5 × 106 cells/ml) and injected into a predesigned mold. Each of the molded NPs was placed in a well of 24-well culture plate as a neutralized collagen gel solution (4 mg/ml seeded with 3 × 106 cells/ml) was pipetted around the NP component. All components were gelled at 37°C to create the AF and TE-IVDs were kept in culture for 4 weeks, facilitating collagen fibril alignment and contraction. Whole cervical spinal motion segments from skeletally mature beagles were dissected and the mechanical compatibility was assessed for each motion segment at different time points: (1) intact, (2) after discectomy, (3) after implantation of the TE-IVD and (4) after implantation of the TE-IVD and application of the BSS ventrally. Unconfined stress relaxation tests were performed up to 15% strain and their instantaneous and equilibrium moduli were calculated and reported normalized to the intact motion segment. One-way ANOVA was performed to determine statistical significance. Results: Intact motion segments showed an equilibrium modulus of 174 ± 36 kPa and an instantaneous modulus of 1760 ± 430 kPa. Mechanical properties from motion segments after discectomy, TE-IVD implantation without BSS, and TE-IVD implantation with BSS were all significantly lower than the intact motion segments. Results from all treatment groups were then normalized to their corresponding intact motion segment mechanics (n = 12). Motion segments after discectomy resulted in 14% ± 6% of the intact equilibrium modulus and 13% ± 4% of the intact instantaneous modulus. Application of the BSS in combination with the TE-IVD revealed a 2-fold increase in the equilibrium modulus and a 2-fold increase in the instantaneous modulus (P ≤ .05) over the groups with TE-IVD implantation only. Conclusion: The TE-IVD combined with a BSS prevents displacement of the TE-IVD while still allowing load sharing to the TE-IVD. Increasing the biomechanical properties of the TE-IVD can result in an implant with similar properties to native IVDs., Introduction: The vertebrae and the pelvis act as an interconnecting chain of segments. Change at one segment leads to a compensatory change in the adjacent segments. The spinopelvic radiographic variables are useful in identifying these compensations. Analyzing the chain of correlations amongst these variables can help in improving our understanding of compensatory mechanisms adopted by the patient in some commonly encountered spine pathologies. In our study, we aimed to identify the relative significance of these radiographic spinopelvic parameters and how they correlate to each other in patients with chronic low back pain and spondylolisthesis when compared to normal population. Material and Methods: The study was approved by our institute review board and the ethical committee. We included all the patients visiting our OPD with complaints of LBP for more than three months and giving consent for the study. All patients underwent a thorough clinical and radiological examination, to rule out any apparent cause of LBP. A total of 67 patients with LBP without any deformity were thus included in the study. We also included a second group of 79 patients with LBP with spondylolisthesis deformity. We excluded patients with spinal deformity (other than spondylolisthesis), fracture, infection, malignancy and with a history of previous spine surgery. Another age and sex matched group of asymptomatic volunteers (n = 75) were also recruited as a control group. All the patients and volunteers underwent a standardized lateral sagittal digital radiograph of the whole spine. The sagittal spinopelvic parameters were measured using the Surgimap spine software version 2.1.2 by a single observer. The parameters measured were PI, pelvic tilt PT, sacral slope SS, thoracic kyphosis TK, lumbar lordosis LL. Pearson correlation was used to find the correlation between the parameters. Results: In the asymptomatic group a significant correlation was found between SS-LL (r-0.817), PI-SS(R-0.813), PI-LL(r-0.692), PI-PT(r-0.589), LL-TK (r-0.505). The correlation among different spinopelvic parameters in patients with chronic low back pain is SS-LL(r-0.661), LL-TK(r-0.609), PI-SS(r-0.580), PI-LL(r-0.533), PI-PT(r-0.527). High correlation was found between, SS-LL(r-0.781), PI-SS(r-0.769), PI-LL(r-0.56), LL-TK(r-0.428), PI-PT(r-0.426), PT-LL(r-0.25) in spondylolisthesis group. Conclusion: Based on the results of our study we conclude that -The highest correlation was between sacral slope and lumbar lordosis among all the three groups. The relative extent of correlation between radiographically measured spinopelvic parameters differs in patients with chronic low back pain when compared to normal individuals. The relative extent of correlation between radiographically measured spinopelvic parameters in patients of spondylolisthesis matches that, observed in the normal population., Introduction: Mental and bodily requirements for Orthopaedic Spine Surgeons include occupational skills and concentrativeness, along with a certain level of physical fitness and psychological stress resistance in case of complications during spine surgery. So far, no study has looked at the Spine Surgeons’ cardiovascular response and influence of physical and mental (psychological) stress during spine surgery in either the attending’s or resident’s position. Material and Methods: This study measured and evaluated stress-relevant cardiovascular parameters during 101 spine surgical procedures of a healthy 40-years old fellowship-trained Spine Surgeon with 12 years of work experience (BMI 25). A digital training computer (Polar Model RS300X), personal body weight scale, and room thermometer were used to record heart rate, calculate weight loss, calorie burn, and environmental temperature during surgery with special regard to the type of surgery, duration and subjective stress level (coded as: “easy”, “moderate”, or “difficult”) along with an analysis of intraoperative complications during procedures. Results: The average maximum heart rate as an attending surgeon (124 bpm) was significantly higher when compared the resident’s heart rate (99 bmp) during surgery (P < .05). The mean loss of body fluids (kilogram body weight) at an average room temperature of 20.4°C after surgery was -0.82 kg (0 to -2.3 kg). The mean loss of body weight (%) per hours was calculated with -1.12% at the attending versus -0.59% at the resident (P < .05). Higher metal workload and stress levels resulted in a higher physiological cardiovascular response, e.g. increased average maximum heart rate and duration of surgery “easy” (103 bpm, 1 h:51 min), “moderate” (125 bpm, 2 h:57 min), and “difficult” (131spm, 3 h:56 min)). There were six intraoperative complications (dural tears [n = 3], pedicel fracture [n = 1], excessive bleeding [n = 1], and unknown lumbar spinal nerve anomaly [n = 1]). Conclusion: For the first time this study evaluated the attending surgeon’s cardiovascular response during spine surgery in comparison to the surgical assistant’s (resident’s). Technically more demanding, complex procedures and longer operating hours resulted in a higher cardiovascular response of the attending surgeon than resident. The observed cardiovascular parameters during spine surgery are similar to those of an intense workout such as fast bicycling or intense circuit training. Long lasting surgeries can cause weight loss and mild dehydration (-2 to -5% of body fluids). In these situations and according to the literature, lack of fluid ingestion and mild dehydration is substantially worsening someone’s cognitive-, visual-, and motor skills. Thus adequate rehydration during surgery is helpful and might prevent intraoperative risks and complications related to possible physical exhaustion during prolonged, complex spine surgeries or in mentally stressful situations., Introduction: Implant instability have a relatively high incidence in aged patients with degenerative diseases of lumbar spine. This problem is not resolved yet and it is essential to assess risk factors that may lead to implant instability while planning intervention. The objective of this study is to determine risk factors that may impact implant stability in patients with degenerative diseases of lumbar spine. Materials and Methods: This is a retrospective evaluation of 160 spinal instrumentations performed in case of spinal degenerative diseases of lumbar spine. Preoperatively patients underwent CT examination and bone density was measured in Hounsfield units (HU). CT scans utilized slice thickness 0.5 mm. Tube voltage was 120 kV, current 300 mA, auto mAs range 180-400; 1.0 sec/3.0mm/0.5x32, helical-pitch 21.0. Transpedicular fixation was used to treat patients either as a stand-alone technique or in combination with transforaminal interbody fusion. Also, if indicated, decompression of nerve roots and spinal cord was performed. Patients with suboptimal placement of pedicle screws and interbody implants were excluded from this study. Patients who underwent degenerative deformity correction and additional pelviosacral fixation were not included in this study. The duration of follow up was 18 months; patients underwent CT examinations at the period of 6, 12, 18 months after interventions. Cases with implant instability were registered and divided into partial and total implant instability. Logistic regression analysis was utilized to assess the relationship between implant instability rate and potential risk factors. Results: The following factors were taken into account assessing risk for implant instability formation: bone density measured in HU, number of fixed levels (the extension of fixation), presence of segments without fusion within fixed zone; bilateral facet joints removal and laminectomy to achieve decompression. The rate of implant instability was growing with bone density in HU getting decreased and a positive relation of implant instability frequency with the number of fixed segments was estimated. Additional significant factor for implant instability development was destabilizing decompression with bilateral facet joints removal. The influence of other factors was found to be negligible. The parameters of general logistic regression for implant instability rate were: B0 = 0.1483, P = .8568 (insignificant); B1 for bone density = −0.0226, P = .0001; B2 for bilateral facet removal = 1.0188, P = .0232; B3 for number of fixed levels = 1.5208, P < .0001. Goodness of fit of general model - Chi-square = 62.40129, P < .0001. Classification of cases – 78.75% correctly predicted, specificity and specificity of estimated model achieve 85.5% and 70% respectively. Regression residuals do not have significant difference from normal distribution (Chi-square, Anderson-Darling and Kolmogorov-Smirnov tests were applied). Conclusion: Apparently, surgical intervention should be planned thoroughly avoiding destabilizing overdecompression because this could be a significant contributing factor for the implant instability formation in future. Bone quality is the most significant contributing factor for implant stability that must be taken into account planning spinal instrumentation. If necessary, augmentation with bone cement must be performed in order to prevent implant instability formation. The extensiveness of fixation should be clearly justified as far as this is also significant factor that may influence implant stability., Introduction: The pedicle screw system for posterior instrumentation to the thoracic and lumbar spine is the general method nowadays. But complications due to screw mal-positioning is still reported, and exact screw positioning needs radiologic confirmation which hazard The purpose of this study is to confirm that accurate thoracic pedicle screw position placed by the patient-specific drill template (PSDT) made by rapid prototyping (RP) and analyze of previously reported PSDT designs and its characteristics. Material and Methods: The preoperative spiral three-dimensional (3-D) CT scan (LightSpeed VCT, GE, USA) was performed on the thoracic spine with 0.625 mm slice thickness and 0.35 mm in-plane resolution. The images were stored in DICOM format and transferred to a workstation running MIMICS 17.0 software, 3-Matic 9.0 (Materialise company, Belgium) to generate a 3-D reconstruction template for the desired thoracic vertebra. The accurate trajectory and screw diameter and length were calculated with UG Imageware 12.1 (EDS Co., USA). The guide template was sterilized and used intra-operatively to assist with the placement of thoracic pedicle screws. After all of the pedicle screws was inserted. We performed the CT scan postoperatively to evaluate the position of thoracic pedicle screws. Using Imageware postoperative CT scan was compared with preplanned trajectory safety and accuracy. After all CBT screws were inserted, we performed a CT scan to evaluate the position of the screws. By using the Imageware program, the postoperative CT scan data were compared with the preplanned trajectory for the assessment of safety and accuracy. We stacked pre-CT and post-CT slices of axial and sagittal planes and measured the distance between the preplanned trajectory and the fixed screws. (Figure 3.) We reviewed 12 previous reports and classified by the shape and system of PSDT which met the inclusion criteria of the review. Results: In total, ten screws were placed using patient-specific drill guide template without violation of single laminar cortex. The drill guide template was fit to the lamina of the vertebra. There was no violation of the spinal canal or the cortex of pedicle by postoperative CT scans. The results of 13 PTSD type which included current study suggest that there is no significant difference in accuracy between the PSTDs. Conclusion: Using the unilateral Spinous Process Non-Covering Hook Type Patient-Specific Drill Template made by the RP provide us the accurate trajectory for thoracic vertebra and classification of PSDT in this study would be helpful for further study., Introduction: Intervertebral disc being avascular depends on nutrition either from endplate or annulus fibrosus (AF). Role of endplate on disc diffusion had been extensively studied. However diffusion of human AF remains poorly understood due to lack of reliable techniques to study AF in-vivo & non-invasively. Present study for the first time evaluates the 24-hr diffusion characteristics of AF in radial, axial & circumferential directions. Material and Methods: 25 discs from 5 healthy volunteers (age < 20 yrs) were studied. Diffusion over 24-hours following I.V gadodiamide injection (0.3mmol/kg) was studied at 10 min, 2, 4, 6, 12 and 24 hrs. Axial images at cranial, middle and caudal zones of the disc were obtained. Vertebral body and endplate signal intensities were measured in sagittal sections. 39 ROIs (24 in AF, 15 in Nucleus-pulposus) at each disc were analyzed. Peak enhancement percentage (EP max) and time to attain EP max (T max) were calculated. Radial (outer Vs inner AF), axial (cranial Vs caudal Vs middle zone) and circumferential diffusion were analyzed. Results: AF showed a biphasic pattern of diffusion with a characteristic “double peak”. Early peak was seen at 10mins (coinciding with T max of VB) and delayed peak at 6 hrs (coinciding with T max of nucleus pulposus) and characteristically noted after T max of endplate (2 hrs). Inner AF showed significant regional differences both at the early and delayed peaks but outer AF had no regional differences in the early peak. In axial direction, both outer and inner AF showed maximum EP at middle zone followed by caudal and least at cranial zone. Conclusion: Annulus fibrosus characteristically showed a “double peak” pattern of diffusion. Both the peaks had different characteristics confirming two different sources of nutrition. An initial peak was contributed by peri-annular vascularity and delayed one via endplate from vertebral body. The fact that even AF depends on endplate for nutrition, help us to better understand the complex nutritional pathways of inter-vertebral discs., Introduction: The intervertebral disc (IVD) has a poor ability of healing. Nevertheless, the presence of resident progenitors having stemness features in the three main anatomical sites of the IVD, the nucleus pulposus (NP), the annulus fibrosus (AF) and the cartilaginous endplate (EP) was reported in few studies. These progenitors represent an alternative potential reservoir of specialized cells for tissue repair and homeostasis. In general, the role of mesenchymal stem cells (MSCs) in the maintenance of tissue homeostasis resides in their ability to secrete bioactive molecules in inflammatory condition, but the trophic and immunomodulatory role of NP, AF and EP cells and progenitors, to our knowledge, was not assessed anymore. Aims of this study are to characterize human cells from NP, AF and EP for their stemness features and to investigate their response to an inflammatory environment in term of ability to produce trophic factors and modulate the inflammation in comparison with MSCs harvested from bone marrow (BMSCs) and subcutaneous adipose tissue (ASCs). Material and Methods: NP, AF and EP cells from lumbar IVD were characterized for their CFU-F ability, immunophenotype, adipo-osteo-chondro-differentiative potential and stemness marker (NANOG, POU5F1) expression. After stimulation with IL-1β, the release of pro/anti-inflammatory mediators (IL-10, IL-6, IL-1Ra, TNFα) and the expression of growth factors (VEGFA, TGFB1), MMPs (1-3-13) and TIMPs (1-3) were evaluated, using ASCs and BMSCs as positive controls. Results: The three kinds of disc cells were able to form colonies, were negative for the expression of the surface markers CD14, CD34, CD45, CD71 and positive for CD44, CD73, CD105, CD151, expressed the stemness markers NANOG and POU5F1 and were able to differentiate toward osteogenic lineage as well as the MSCs. Differently from the MSCs, the disc cells showed no appreciable signs of differentiation towards adipogenic lineage. As expected, a better chondro-differentiation was observed in disc cells in comparison with MSCs in micromass culture. MMP1-3-13, VEGFA upregulation and TGFB downregulation were observed in disc cells and MSCs after IL-1β treatment. A slightly higher basal expression of TIMP1 and an higher basal expression of TIMP3 in MSCs in comparison with disc cells was observed. IL-6 was up-regulated by the pro-inflammatory treatment in all the cells. Basal levels of this cytokine were higher in MSCs in comparison with disc cells. There was a higher release of IL-1Ra in disc cells after IL-1β treatment, but the basal levels of this antagonist were significantly higher in ASCs in comparison with disc cells. Disc cells presented a behavior similar to MSCs in term of TNFα release. A low concentration of the anti-inflammatory IL-10 was detected in disc cells culture supernatant, whereas was undetected in MSCs before and after pro-inflammatory stimulus. Conclusion: The progenitors resident in the IVD showed very similar features to MSCs in term of clonogenic ability, immunophenotype, osteo-differentiation, stemness marker expression, trophic potential and response to a pro-inflammatory stimulus. Due to their preferential commitment towards the chondrogenic lineage, the in situ stimulation of these highly specialized progenitors could enhance a more physiological tissue repair and homeostasis maintenance., Introduction: The ovine annular injury model of disc degeneration has been extensively used to evaluate potential therapeutic modalities for disc repair. However, there are limited studies describing the similar use of this species as a model for evaluating disc reconstitution following microdiscectomy. The goal of the present study was to compare the reproducibility and experimental outcomes of two microdiscectomy models induced in the lumbar spines of sheep using a standard drill bit or limited surgical excision of the annulus fibrosis (annulotomy). Material and Methods: Twelve adult ewes were subjected to pre-operative 3 T MRI followed by either lumbar intervertebral disc injury at two levels induced by a drill bit (n = 6) or by annulotomy (n = 6). Both surgical procedures were induced using a lateral retroperitoneal approach. The annulotomy method consisted of surgical removal of a 3 x 5 mm (approximately 200 mg) tissue from the outer annulus fibrosus (AF) to the nucleus pulposus (NP). The drill bit injury consisted of the lateral insertion of a rotating 3.5 mm diameter drill bit to a depth of 12 mm through the outer annulus fibrosus (AF) to the nucleus pulposus (NP) and parallel to the cartilage end plates. Necropsies were performed six months following microdiscectomies. Complete lumbar spines were removed and subjected to 9.4 T and 3 T MRI, radiographic imaging followed by sectioning through their vertebral bodies using a band saw. Individual lumbar discs were then processed for histological, gross morphological and biochemical analysis which included topographical assessment of proteoglycan content as sulphated glycosaminoglycans (SGAGs), collagen and DNA contents using standard procedures. Results: There was no evidence of disc degeneration on pre-operative MRI. Drill bit injured and annulotomy injured discs demonstrated significantly increased Pfirrmann degenerative scores relative to controls and pre-operative scores. There was no significant difference in Pfirrmann scores between the drill bit injured and the annulotomy induced microdiscectomies. Gross morphology injury scoring was significantly increased in annulotomy injured discs relative to drill bit injured discs. Annulotomy injured discs demonstrated significantly greater disc height loss than drill bit injured discs. Biochemical analysis of the site of disc injury from both microdiscectomy procedures revealed significantly reduced proteoglycan (as S-GAGs) content of the NP and AF relative to the corresponding uninjured controls. However, the annulotomy injured NP region had lower proteoglycan content than the corresponding drill bit injured region. Moreover, the collagen and DNA content of the drill-bit induced microdiscectomy AF region were also higher than for the annulotomy procedure. DNA levels represent a surrogate marker of capillary and blood cell infiltrations. Conclusion: These finding have demonstrated that both the 3.5 mm drill bit and annulotomy procedures are suitable ovine microdiscectomy models that could be used to evaluate novel modalities for disc repair. However, the annulotomy procedure results in a more substantial injury which is probably a more relevant model to the human clinical situation but will also demand more effective therapeutic agents to achieve repair than would be required for the drill bit microdiscectomy model., Objective: Virus are known as origin for various diseases. Vaccination against human papilloma virus is established for avoiding cervix carcinoma. Furthermore, Parvovirus B19 seems to play a role in appearance of cardiomyopathy and rheumatoid arthritis. Disc herniation is generally considered as a degenerative disease. But can we explain a disc herniation in youth and young adults to be degenerative? For evaluation the pathogenicity of parvovirus B19 related to the onset of disc herniation the present study was designed. Methods: Out of 47 patients with lumbar or cervical disc herniation that underwent spinal surgery, the disc herniation was tested for Parvovirus by PCR (cervical prolapse n = 16; lumbar prolapse n = 31). After surgical excision of the herniated disc the sample tissue was placed in RNA-later and stored at −20°C until the virological analysis was made. Initially samples of the patients’ blood serum were screened with ELISA for IgG antibodies. After the mechanical comminution of the disc material the nucleic acid was automatically extracted. Subsequently the viral nucleic acid was detected with quantitative polymerase chain reaction. Prion Protein DNA was added to the lysis buffer before the extraction as a combined extraction and inhibitioncontrol. The validity of the PCR tests was assured through positive controls and standards, which need to be in a certain target range. Results: In 21 samples we could detect positive PCR-results for Parvovirus, while the internal control is in the expected normal range. The serological testing of our patient collective showed a 76.6% IgG-positive result (n = 36), corresponding to the available data in literature for the spread of infection in the average population. Consequently 58.3% of serological positive patients and 44.9% of all patients showed an infection with Parvovirus B19 in herniated disc. Conclusion: The results of Parvovirus in herniated disc are surprising. This evidence suggests a possible correlation between the Parvovirus and the appearance of a disc herniation., Introduction: Intervertebral disc degeneration treatments include nucleus augmentation. However failures during clinical trials have stopped widespread uptake. Development of standardized in-vitro testing methodologies to examine the biomechanical performance of nucleus replacement materials have shown high variability in the mechanical performance of specimens [1]. The aim of this study was to understand the causes of this variability with a computational approach. Material and Methods: Bovine tail specimens (N = 6) were used to develop a standardized in-vitro testing methodology. Specimen were sectioned to isolate the disc with 15 mm of bone each side and imaged with microCT; embedded in PMMA cement; and tested under static compression. Specimen-specific in-silico models of bovine tails specimens were produced: image-based models (ScanIP, Simpleware Ltd.) were developed with a standard protocol to create annulus and nucleus regions of the disc based on standard ratio of cross-sectional area. Material properties were assigned using linear elastic bone [2] and cement, fibre-reinforced annulus, and incompressible nucleus [3]. Computational specimens were loaded in compression replicating the experimental setup (Abaqus, Simulia). For both experimental and computational data, stiffness values and transition displacement were extracted using a tri-linear interpolation of load-displacement data. Three cases of fibre parameters in the annulus were compared: parameters derived from bovine-specific literature data [3], parameters calibrated [4] independently for each specimen, and parameters calibrated using a least square fit over the six specimens. Sensitivity studies were performed on the choice of standard values for the anatomy segmentation. Concordance correlations (R.3.1.1, R foundation for statistical computing) were performed to compare stiffness values and transition displacements for each specimen between each group of computational models. Results: Independent calibration of the fibre parameters led to mean relative errors on the predicted force below 15% for each specimen. Transition displacement values from the tri-linear fit exhibited high concordance between the three type of models (CCC > 0.99). Concordance between stiffness values computed using literature data and those independently calibrated was lower than between those calibrated as a group and values independently calibrated (respectively CCC of 0.85 and 0.95). A 50% variation of the cross sectional area ratio between nucleus and annulus led to a variation in the transition displacement or stiffness values of less than 8%. Conclusion: Using material properties derived in the literature from mechanical testing and average geometry measurements does not permit the reproduction of whole disc mechanical behaviour in static loading in other laboratory conditions. This reflects the wide variation in tissue preparation, specifically hydration levels, which translates into variation in tissue stiffness. Developing a specimen-specific image-based computational approach to reverse-engineer the mechanical behaviour of the fibres in the annulus fibrosis leads to material parameters that account for this tissue variation. This is necessary to be able to model pre-clinical testing conditions, a first step into enabling optimisation of this testing. Acknowledgement This project has been support by the Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences (fund number: 93-02-38-25620). References [1] Schmidt et al, 2016, JBiomech 49 (6) 846-56. [2] Mengoni et al, 2015 in [Uncertainty in Biology: A Computational Modeling Approach], Springer. [3] Monaco et al, 2016, JMorphology 277 244-51. [4] Mengoni M., 2015, opti4Abq, http://dxdoi.org/10.5281/zenodo.16659., Introduction: The pressure distribution inside the intervertebral disc as well as the footprints of fusion implants remain in the focus of current research. To our knowledge pressure mapping sensors have not been used to provide information about the pressure distribution inside the intervertebral disc. We like to present some of the major abilities and pitfalls utilizing these tools. Materials and Methods: We present a method using a pressure mapping sensor (Model 5033 I-Scan; Tekscan, Boston, MA, USA) in a robot-based in-vitro testing setup with a follower load of 350 N.We used six human specimens (L2–L5). Five groups were tested: 1st intact; 2nd intact & 350 N; 3 rd pressure sensor & 350 N; 4th conventional fusion implant & 350 N; 5th expandable, prototype fusion implant & 350 N. The first and second group were used to define the “intact” status. For the third group a lateral, horizontal incision of the L3-L4 intervertebral disc close to the endplate of L3 was made and the pressure sensor pulled through the disc from one side to the other. The fourth and the fifth group consisted of an LLIF procedure with a conventional and a prototype implant with the pressure sensor between implant and endplate of L3. Both implants were covered with a 0.5 mm thick rubber pad to protect the pressure sensor from the spikes of the implants. The calibration of the pressure sensor was performed with a two-point calibration (100N/400 N) according to the manufacturer’s recommendation. The range was based on intradiscal pressure values from the literature. Results: If ROM of the second group is set to 100%, the horizontal incision through the disc resulted in a median ROM of 98% for EF, 146% for AR and 139% for LB. Although the intervertebral disc was completely cut, it showed excellent equalization of the pressure conducted by the movement of the spine. Only at the end points of each movement high pressure peaks could be observed. For EF these were at the ventral respectively dorsal edge of the intervertebral disc. AR and LB exhibited pressure peaks at the dorsolateral edge of the intervertebral disc. Unfortunately the pressure applied by the implants of the 4th and 5th group exceeded the upper calibration limit. Therefore only contact areas could be observed reliably but the detection of the different footprints succeeded well. Due to high sheer forces during insertion of the implants only 3 sensors of the 4th and 2 sensors of the 5th group remained reasonably intact. Conclusion: The insertion of the pressure sensor with a transdiscal incision destabilized the motion segment in AR and LB. In EF it remained stable. The pressure peaks in the intact scenario were located at the dorsolateral edge of the intervertebral disc. This location matched the clinical experience of dorsolateral disc protrusion and prolaps. We recommend two different sensor calibrations for intact and implant scenario, as the loads vary highly. The pressure mapping sensor allows excellent detection of footprint and contact area dynamically throughout biomechanical testing., Introduction: Spinal tuberculous infection is the most common and dangerous form of skeletal tuberculosis. It constitutes 1/3 to 1/2 of all bone and joint tuberculosis. It is a result of hematogenous dissemination from primary focus in the lungs, lymph nodes, etc . According to the current estimates of the WHO, tuberculosis now kills 3 million people a year worldwide. Therefore, early diagnosis and management of spinal TB has special importance in preventing serious complications. Materials and Methods: It is a prospective case series study. 419 patients either through OPD or Emergency Department with Frankel Scale “A” from 2003 to 2011 were included. After taking proper history, examination, investigations and proper consent, all the patients underwent anterior decompression and locally made cage with autologous bone graft. Data was initially entered on pre formed Proforma and then using SPSS 17.0. After surgery, patients were given brace for 6 months and were followed at 6 weeks, 6 months, and then yearly upto 5 years to assess improvement in Frankel scale. The objective of the study was to determine improvement in Frankel Scale after anterior decompression and stabilization with locally made stand alone cage and bone graft in caries spine. Result: 419 patients presented with Frankel Scale “A” between 2003 to 2011. 21(5.01%) patients were lost to follow up. Out of remaining 398, 213(53.52%) were male and 185(46.48%) were females. 123(30.90%) were below 15 years, 167(41.96%) were between 16-40 years and 108 (27.14%) were above 40 years. All patients having Frankel Scale “A”. After 1 year only 19 (4.77%) patients showed Frankel Scale “E” While after 3 and 5 years 167(41.96%) and 189(47.49%) patients show Frankel scale “E”.90(22.61%) patients showed Frankel Scale “D”,67(16.83%) showed “C”, 24 (6.03%) showed “B” while 28(7.04%) patients showed no improvement after 5 years follow up. Conclusion: Early diagnosis and early intervention gives excellent results. However the patients with Frankel Scale “A” with delayed presentation after anterior decompression, stabilization with cage and bone graft results in significant improvement of Frankel Scale. Moreover there is no need for added instrumentation., Introduction: Surgical site infections (SSI) represent a major complication in lumbar spine surgery. While a number of studies have been conducted to review the effect of vancomycin on surgical site infections, a minimal amount have examined its impact on local bone cells at the cellular level. Recent in vitro studies have suggested that vancomycin has an inhibitory effect on osteoblast proliferation and differentiation which may effect fusion rates. The primary purpose of this study was to retrospectively examine our institution’s overall revision rate for pseudarthrosis and infection before and after the routine use of vancomycin powder for lumbar fusions and correlate in vitro data of the effects of vancomycin on osteoblasts at a concentration based on surgical drain samples. Material and Methods: Drain samples were collected and vancomycin levels were analyzed from 37 patients following spinal fusion procedures where powdered vancomycin was placed inside the surgical site for postoperative day 0, 1, 2, and 3. A human osteoblast (HOB) cell line was used to model osteoblasts in vitro. Cell medium was changed to include vancomycin at a concentration based on drain level results. After exposure of the human osteoblasts to vancomycin, cellular metabolic (alamar blue) and osteogenic activity (alkaline phosphatase) was subsequently evaluated. A retrospective chart review of 453 patients including all patients undergoing lumbar fusions with at least 2 years of clinical follow up from 1/1/2007 - 12/31/2009 (pre-vancomycin group) and comparing them to all patients between 1/1/2012 - 12/31/2013 (vancomycin group). I&D codes of CPT: 22010, 22015, 10180 were used to determine which patients had SSI. Data reviewed included number of levels fused, use of bone morphogenetic protein (BMP), and use of inter-body grafts. Results: HOBs exposed to vancomycin concentrations of 1250 ng/ul (POD 0) showed significantly lower alkaline phosphatase activity compared to those exposed to 0, 245(POD 3), 285(POD2), and 500(POD1) ng/ul (P = .017, P = .004, P < .001, and P < .001 respectively). Interestingly, there was a significant increase in ALP activity comparing HOBs exposed to vancomycin concentrations of 285 ng/ul compared to 0 ng/ul (P = .035), whereas there was no significant difference in metabolic activity measured between the cells exposed to 0, 245, 285, 500, and 1250 ng/ul of vancomycin (oneway ANOVA, P = .19). Overall revision for psedarthrosis and infection respectively were: 8/221 (3.6%) and 4/221 (1.8%) in the Vancomycin group and 11/232 (4.7%) and 9/232 (3.9%) in the pre-vancomycin group, with a trend towards significance. There was a significant difference in the use of interbody grafts (P = .016) and BMP use in the pre-vancomycin group (P = .001); however, no significant difference was noted in the number of levels fused. Conclusion: The results of the in vitro data suggest a threshold value of vancomycin that favors osteogenesis, corroborating the in vivo data that vancomycin did not significantly alter our fusion rates despite significantly less use of interbody grafts and BMP use. Further in vivo and in vitro studies are necessary to fully elucidate the optimal dose of vancomycin and its role in the maturation of a fusion., Introduction: The incidence of hematogenous spondylodiscitis is increasing. This may due to a combined effect between an increase in susceptible populations and an improved accuracy in diagnosis. Staph. aureus is the organism accounting for up to 80% of spondylodiscitis cases. MRSA- spondylodiscitis is similarly increasing and represents 10-30% of all Staph. aureus isolates. Patients and Methods: Retrospective analysis of the prospectively collected data of all patients with spinal infection between Jan. 2005 and Dec. 2015. The study revealed 600 patients with hematogenous spinal infections after exclusion of the cases with postoperative, wound infections and the cases treated for infection before this period. A causative organism could be identified from the site of infection in 405 patients (67.5%). Staph aureus was isolated in 171 patients of them. In this substudy we collected all cases of MRSA-spondylodiscitis and analysed the demographic, clinical, radiological and laboratory data as well as the outcomes of management in those patients. Results: This study identified 30 MRSA-patients of a total of 171 hematogenous Staph. aureus-infections (17.5%). There were 8 females and 22 males with mean age of 65 ± 10.9 years (37-81) and 28 (93.3%) were older than 50 years. In that age group, 70.3% of the patients had ASA- Score class III and IV and 33 patients (63.3%) were obese or overweight. The most common comorbidities were cardiac (22 patients), DM (18), renal insuffiecncy (17), peripheral vascular insuffiecncy (16). In 26 cases another site of infection outside the spine was diagnosed at admission. At the time of presentation, 19 patients (63.3%) had received antibiotic treatment for 24.36 days on average (±17.75, range 2-60 days). The pre-surgical interval ranged between 5-90 days (mean 33.14 ± 23.61). At admission neurological deficit was present in 22 patients (73.3%), fever in 20 (an organism could be isolated from blood culture in 17 of them) and sepsis in 10 patients. The lumbar spine was affected in 17 patients (56.7%). In most cases (26 = 80%) one segment was affected. Multifocal (non-contiguous) infection was found in 5 individuals. In 27 patients, epidural abscess was found and in 5 psoas abscess was present. The preoperative inflammatory parameters revealed mean CRP of 161.3 ± 105.84, WBC of 12.11 ± 6.15, ESR of 104.8 ± 23.37. In 3 patients (10%), more than one organism could be isolated (mixed infection). Surgical management was proceeded in 29 patients; combined ventro-dorsal approach was necessary in 26 of them. In three patients, recurrence of infection has been detected and treated surgically (10%). Four patients died with septic shock (one preoperatively), 2 patients with cardiac infarction, one with renal failure and one with respiratory failure (in-hospital mortality of 26.7%). The neurological improvement rate of at least one ASIA-grade reached 78%. Postoperative antibiotic therapy for more than 12 weeks was given in 17 patients (mean period of 70.6 ± 36.36 days). The most commonly used antibiotic was Vancomycin in 19 patients and in 11 patients a combination of antibiotics was necessary. Conclusion: In spite ofadvances in diagnosis and management strategies of spinal infections, the haematogenous spondylodiscitis by MRSA is still a devastating condition. It is associated with significant morbidity and mortality. The type and duration of antibiotic therapy should be organism based, but all patients with previoushospital admission who have been diagnosed with spondylodiscitis without a positive culture should receive an antimicrobial regimen that provides cover for MRSA., Introduction: Infection is a risk inherent to lumbar spine surgery, with overall postoperative infection rates of 1.9-2.1% despite advancements in aseptic technique, prophylaxis, and careful patient selection. Patients with postoperative infection are more likely to die, require revision surgeries, experience pseudarthrosis, osteomyelitis, failure of the primary intervention, and worsening pain and disability. Placement of arterial and central venous catheters (CVCs) in the perioperative setting is routine practice, particularly when caring for patients at risk for hemodynamic instability. Although central line associated infections have been studied extensively, no studies have assessed the risk of postoperative infection with perioperative invasive vascular catheter placement in lumbar spine surgery. Materials and Methods: In this retrospective cohort study, data was collected for patients undergoing lumbar spine surgery between January 2007 and December 2015 with records in the nationwide Humana private insurance database. Patients receiving single- and multi-level fusion, laminectomy, and discectomy were followed retrospectively for two months for perioperative infection complications, including wound infection, osteomyelitis, and subsequent incision and drainage. We then determined how a variety of risk factors, including central venous catheterization and arterial-line placement, modified the risk of postoperative infection. Results: Analysis of 65,158 patient records demonstrated an overall infection rate of 4.7% (2,925/65,158) within 2 months. Only 2.4% (1,526) of patients received a new central venous catheter on the day of their spine surgery, while 15.8% (8,896) received an arterial catheter. Patients receiving a new central venous catheter on the day of their spine surgery were more likely to experience infection (RR 3.0, 95% CI: 2.4-3.7), osteomyelitis (RR 6.6, 95% CI: 3.8-11.3), and undergo an incision and drainage (RR 3.0, 95% CI: 2.0-4.5) within 2 weeks post-op. Likewise, patients receiving a new arterial line on the day of their spine surgery were more likely to experience infection (RR 2.3, 95% CI: 2.0-2.6), osteomyelitis (RR 3.2, 95% CI: 2.2-4.8), and undergo an incision and drainage (RR 2.0, 95% CI: 1.6-2.6) within 2 weeks post-op. These trends were consistent through the 2-month follow-up period, with risk of all outcome measures increasing over that time period. Conclusions: In our study both perioperative CVCs and arterial lines significantly increased the risk of post-operative infections. Because the overall infection rate in lumbar spine surgery is relatively high (4.7% in our study), only 13 patients need to be given a new CVC with lumbar spine surgery in order for one to experience infection (NNH = 13). A causal pathophysiologic explanation for the observed risks is that bacteremia induced by placement of invasive vascular catheters leads to hematogenous seeding of surgical sites. Additionally, patients in need of invasive vascular catheterization may be inherently more ill, and therefore less likely to mount a robust systemic immune response to combat infection. Our data suggest that in patients requiring invasive catheterization, surgeons should consider the marginal risks and benefits of lumbar spine surgery more carefully., Introduction: Infection following lumbar total disc arthroplasty (TDA) is a rare, albeit serious event. Treatment of this condition is challenging due to a) possible involvement of major retroperitoneal vessels, b) tendency for an infection with low pathogenic microbes that are difficult to verify, c) accompanying prevertebral abscesses, and d) little experience of surgeons in handling this rare complication. Although mentioned in each review, today only two case reports about this serious complication after lumbar TDA are available in the literature. Hence, to the best of our knowledge this is the largest case series about infected lumbar TDA published so far. Material and Methods: Three patients (2 male, 1 female, average age: 41 years) with 5 infected lumbar disc prostheses (3 x L4/5, 2x L5/S1). All cases were late infections occurring between 9 months and 6 years following index surgery. Presenting symptoms included abdominal and lumbar back pain (VAS back pain: 8.3, VAS leg pain: 4.3) and cutaneous abdominal fistula. Leukocyte counts and CRP were elevated significantly. Psoatic abscesses were seen on CT- and MRI scans in all 3 cases. Two patients had unsuccessful repeated local abdominal revisions (6 and 8 times). Results: Treatment involved a one stage, two-step revision surgery with posterior stabilization and fusion using pedicle screws. Additionally, an anterior (2x) or a lateral transpsoas approach (1x) with TDA removal and fistula excision followed by stabilisation using titanium cages packed with autologous bone graft was performed. Surgical treatment was accompanied by iv. antibiotic therapy for 3 months. Average OR time was 5 hours (296 Min). Although in average 3 lesions of either the vena cava, the left iliac vein or the ascending iliolumbar vein occurred during anterior surgery average blood loss was only 1.6 l. No postoperative complications occurred and all 3 patients made an uneventful recovery. Serum parameters subsequently returned to normal values. After 12 months follow-up all patients were clinically satisfied (VAS back pain: 0.6, VAS leg pain: 0). Fusion was accomplished in all cases as documented by serial X-rays and CT scans. Conclusion: One stage implant removal and instrumented fusion is an effective and safe surgical treatment for patients with infected lumbar TDA. TDA removal is possible using either anterior or lateral transpsoas approaches. Individual case planning is mandatory to achieve satisfactory results. However, vascular lesions are common and have to be anticipated during the planning and preparation to make this complex revision surgery safe., Introduction: Limited data has been published about the long term effect of a surgical complication. One of the major complications after a spine surgery is the wound infection (surgical site infection, SSI), but the effect of this compliaction on the long term treatment outcome of the index surgery is not known. The aim of the study was to explore the effect of SSIs on the objective and subjective long term outcome in a prospective cohort of lumbar degenerative surgeries. Materials and Methods: One thousand thirty (N = 1030) patients were recruited into the study. Patients underwent single- or two-level microdiscectomy, decompression or instrumented fusion from open posterior approach. Revision surgeries were excluded. A questionnare booklet was filled out before and two years after the index surgery by the subjects. SSIs were diagnosed and treated according to the CDC guidelines. Treatment outcome was determined in terms of the change in Oswestry Disability Index (ODI), Core Outcome Measurement Index (COMI) and pain (VAS). Subjective global treatment outcome (GTO) was also reported by the patients. Comparisons were made applying Chi2-test and t-tests, where P < .05 was considered significant. Results: Prevalence of SSI was 3.9%. A significant difference in score-change of pain and disability between patients with “good” and “poor” GTO (p(ODI) < 0.001, p(COMI) < 0.001, p(VAS) < 0.001) was observed. There was no significant difference in the results of the patient reported outcome measures (ODI, COMI, VAS) in case of an SSI (P > .05) two years after the surgery. On the other hand, patients suffered the complication reported a signifcantly worse GTO two years after the surgery compared to the patients who did not have any wound infection (“poor” outcome in the SSI group was 24% compared to 12% in the non-SSI group, P = .017). Conclusions: Guideline-based diagnosis and management of an SSI after a spine surgery can help to achieve an optimal physical status long term. On the other hand, even in case of a careful treatement process, the appearance of a major complication can signficiantly influence the sunjective patient reported treatment outcome which means an increased risk for patient’s dissatisfection and its psychosoical consequences. Based on our findings, the deeper analysis of the psychological consequences of surgical complications as well as the development of possible mitigation startegies are advised., Introduction: Posterior translaminar approaches for resection of ventral and ventrolaterally placed intradural extramedullary lesions is challenging. Reports using these approaches for ventral lesions show a high neurological complication rate, likely due to spinal cord manipulation. Minimally access surgery (MAS) with image guidance minimizes soft tissue morbidity, and may potentially facilitate tumor resection and lower complication rates for tumors ventral to the spinal cord. We present our results of MAS image guided surgery for intradural ventral and ventrolateral lesions resected through a paramedian oblique tubular MAS approach. Methods: Retrospective review of clinical, radiological and surgical records of patients operated for intradural mass lesions with MAS technique from 2004 to 2016. Preoperative status, lesion location, surgical technique (MAS vs IMTAR) and follow-up surgical results and complications were documented according to the type of MAS technique (image merged vs classic image guided). Results: 54 patients operated using tubular techniques for intradural lesions, there were 12 ventrally located lesions. Mean age was 57 years (range 23-92), 6 males and 6 females. There were 7 meningiomas, 4 schwannomas, and 1 arachnoid cyst. 6 patients presented with myelopathy, 4 with radiculopathy, 2 dorsal pain. Surgery was performed with fluoroscopic guided tubular MAS technique in 7 cases while 5 patients were treated using the IMTAR technique (Maduri et al 2016), both using a posterolateral oblique transmuscular trajectory. Bone removal was tailored to resection needs. Mean blood loss was 253 mL. Miniextracavitary costotrasversectomy was necessary in 3 patients, complete facetectomy in 3 patients and complete pediculectomy in 1 patient. Mean hospital stay was 7.8 days (3-26). Postoperatively, there were no neurological complication and no CSF fistula. 1 patient had superficial wound infection treated with antibiotics. 2 patients with Schwannoma underwent deliberate nerve root sacrifice with expected postoperative radicular sensory loss. GRT was achieved in 13 patients. Mean FU was 24.8 months (1-60), only 1 patient presents myelopathy, 3 patients with dysesthesia controlled with medical treatment. Axial pain is present in 1 patient operated for a C2-C3 meningioma with no radiological signs of instability. Conclusions: Translaminar approach for ventral intradural spinal tumors has been reported to have a 41.6% overall complication rate (25% of postoperative neurological deficit) and 1.5% of mortality (Mehta et al, 2013). MAS facilitates surgical access to ventral and ventrolateral tumors with almost a 180° range of access. Furthermore, implementation of intraoperative image guidance allows customization of surgical trajectory, bone resection and tumor removal thus reducing the risk of neurological complication. In the present series the rate of overall complication and neurological aggravation is low despite the ventral location of the lesions. Although our experience with these techniques is small, we believe that for ventral and ventrally located spinal tumor, the use of MAS image guided tubular techniques optimizes tumor access and may facilitate a reduction in neurological morbidity. Further experience is needed to confirm this., Introduction: The aim of this study was to explore the motivations of spine surgeons who have sought to learn new technical skills through a qualitative analysis of the self-identified motivational factors that purportedly shaped their decision to learn a new technique. Embarking on a learning pathway to gain competence in a new procedural skill is a major undertaking for experienced surgeons. Their expertise in the surgical procedures they routinely use has been obtained through years of practice. To step outside their comfort zone and risk harming their patients while they gain expertise in a new procedure requires strong motivation. To my knowledge, a qualitative analysis of this process has not been done with specific reference to spinal surgery. If we are able to identify salient mediating factors related to changing surgical techniques amongst experienced surgeons, then we may be able to enhance the design of future educational interventions in spinal surgical training. Materials and Methods: The research method was in-depth interviews with spine surgeons who have more than ten years of experience and had made a deliberate choice to adopt a new surgical technique in their practice in the last five years. They were recruited by direct invitation to view an information and consent document in a Dropbox file. Seven surgeons agreed to participate in the study. Results: The surgeons interviewed were all male, four orthopaedic surgeons and three neurosurgeons. Their age range was 44 to 63 years and they had been in specialist practice for between 12 and 30 years. All of them were self-employed, some were in private practice alone but most were working in the public and private health system. The interview transcripts were analysed using direct content analysis with codes derived from existing literature on change of practice motivation.All seven of the surgeons interviewed identified the desire to improve patient outcomes and avoid complications as being the two major motivators for adopting a new technique. Other common factors included having more treatment options, staying up to date and trying something new. Some of them mentioned financial gain and competing with colleagues. They were all asked about techniques they had adopted and techniques they had tried but not taken up. Minimally invasive spinal surgery was identified by all as likely to improve patient outcomes but only two continued with the technique and five decided not to adopt. The other common technique was corrective surgery for degenerative deformity. This apparent dichotomy between seeking a new technique to improve patient outcomes or avoiding having to learn a new technique due to concern over possible complications was a recurring theme during the interviews. Conclusions: The experienced spine surgeons in this study were motivated to adopt a new technique after identifying areas in their practice where patient outcomes could clearly be improved or complications avoided. The process of learning the new technique involved embarking on a learning curve with its potential difficulties, which for some was accepted but for others was a deterrent., Introduction: Retroperitoneal lumbar oblique corridor was defined as the left lateral border of the aorta (or iliac artery) and the anterior medial border of the psoas. The L5/S1 corridor of access was defined transversely from the midsagittal line of the inferior end plate of L5 to the medial border of the left common iliac vessel and vertically to the first vascular structure crossing the midline. This provides a slightly oblique trajectory to the intervertebral disc spaces of L1 to L5, with a separate Pfannenstiel approach required for access to the L5/S1 intervertebral disc space. Consequently, separate incision and position change is needed to perform L5/S1 oblique interbody fusion. To perform oblique lateral interbody fusion from L1 to S1 without separate incision and position change, the authors placed the patient in a 45° right oblique decubitus position. This modified oblique retroperitoneal approach allows extending access to the L5/S1 intervertebral disc without separate incision and position change. In this study, we illustrated a single-incision oblique retroperitoneal approach for lumbar interbody fusion from L1 to S1 in adult spinal deformity and evaluate the radiographical findings and clinical outcomes of patients treated using this technique. Material and Methods: This study included 15 patients scheduled to undergo anterior and posterior long level fusion for lumbar degenerative kyphosis or degenerative lumbar scoliosis. Data collected included blood loss, operative time, incision size, perioperative complications. Pre- and postoperative radiographic parameters and clinical outcome measures were assessed. Mean follow-up time was 22.1 months. Results: The mean Blood loss was 107.4 ml,12.4 ml and 87.6 ml with in 5 levels(8 cases), 4 levels(6 cases) and 3 levels(1case), The mean operative time was 116 minutes, 97minutes and 82 minute the patients with in 5 levels(8 cases), 4 levels(6 cases) and 3 levels(1case). The mean incision sizes were 14.63 cm, 13.82 cm and 12.5 cm in the patients with 5 levels, 4 levels and 3 levels. The mean preoperative sagittal vertical axis was +17.12 cm and postoperative sagittal vertical axis was +2.11 cm. The preoperative lumbar lordosis was 3.28°and the postoperative lumbar lordosis was 48.08°. The mean pelvic incidence was 51.64°. The mean correction angle was 59°. There was no injury to the iliac artery or vein, but there were complaints of groin and medial thigh pain in 3 cases, however the pain disappeared at 3 months postoperatively. There was no retroperitoneal hematoma or herniation. In 2 cases, the peritoneum was torn during the surgery and was sutured immediately with no complication. Conclusion: The outcomes from our study demonstrate that this oblique retroperitoneal approach is a very safe, allowing reproducible access from L1 to S1 for lumbar interbody fusion in adult spinal deformity. It is associated with a short operative time, minimal blood loss. Furthermore, this approach may have a number of theoretical advantages to traditional techniques. It may facilitate greater sagittal deformity correction with placement of lordotic anterior interbody cages, and the need for a three-column osteotomy in the setting of significant deformity may be avoided., Introduction: The fractional curve of adult scoliosis can cause significant radiculopathy. We sought to evaluate the outcomes of patients whose fractional curves were treated with either cMIS or open techniques. Material and Methods: A multicenter retrospective review of an adult spinal deformity database of MIS and open surgically treated patients, with the following inclusion criteria: age >18 years with fractional curves >10°, ≥3 levels of instrumentation, and one of the following: coronal Cobb angle (CCA) > 20°, PI-LL > 10°, PT > 20°, SVA > 5 cm. Results: 420 patients met inclusion criteria for the database, of those, 165 had complete 2 year data. 118 patients had their fractional curves treated, 79 open and 39 cMIS. The fractional curves were similar pre-op (17 cMIS, 19.6 open) and post-op (7 cMIS, 8.1 open), but open had more levels treated (12.1 vs 5.7). cMIS had greater reduction in VAS leg (6.4 to 1.8) than open (4.3 to 2.5). When propensity matched for levels treated (6.6 cMIS and 7.3 open), 40 patients had their fractional curves treated with either cMIS (n = 20) or with open (n = 20) surgery. Both groups had similar fractional curve correction (18° in both groups before surgery, 6.9° in cMIS and 8.5° in open after). cMIS patients had a smaller postoperative coronal Cobb angle (12.5° vs 24.3°) and lower EBL (809 cc vs 2299 cc). Open patients had a higher SVA change (−19.6 vs +13.2), more pelvic fixation (55% vs 15%), and more direct posterior decompressions (80% vs 22.2%). Both groups had similar pre-op leg pain (VAS leg 6.1 cMIS and 5.4 open) and similar postop leg (VAS leg 1.6 cMIS and 3.1 open). All cMIS patients had interbody grafts whereas 35% of open did. The cMIS and open patients had similar reduction in leg pain (change VAS Leg −4.4 vs −2.2). There was no significant difference in change of Cobb angle, PI-LL, LL, ODI or VAS Back. Conclusion: In the treatment of the fractional curve of adult scoliosis with magnitude greater than 10 degrees, patients treated with cMIS achieved similar reduction in leg pain compared to those treated in an open fashion, even though significantly fewer cMIS patients underwent direct decompression of the fractional curve nerve roots., Introduction: There is an inherently difficult learning curve associated with minimal invasive surgical approaches to spinal decompression and fusion. Complication rates and learning curve are often associated with little information about their correlation. Materials and Methods: We did a retrospective review of 126 patients operated by the same surgeon during first five years of independently implementing MISS (Minimal Invasive Spine Surgeries). All surgeries were done by MED (Micro Endoscopic Discectomy) technique (later on also added with MISS fixations) between 2011 and 2016. All had disc herniation and/or lumbar stenosis at single or double level with or without instability and were followed up till date for clinical results, VAS (Visual Analogue Score) and complications. The indoor charts were also reviewed to compare intraoperative blood loss, operative time, hospital stay, and any other complications. Results: Average age was 44 ± 11 years and average operation time was 117 ± 54 minutes. The analysis of the operative time showed that the average surgical time decreased to less than 90 minutes after 30 surgeries. The operative time for MED was around one hour after 50 surgeries and MISS fixations were done in less than 3 hours. After 50 surgeries, the timing for single level discectomy and decompression was less than 60 minutes including bilateral decompression with unilateral approach. Hospital stay was around 3.06 ± 1.38 days which were uniformly same in all surgeries. Pre-operative VAS score was 8.6 ± 0.9 v/s 1.8 ± 1.3 (P < .05) in the post-operative period. Intra-operative and post-operative complications such as dural tear or root injury, postoperative hematoma, incomplete excision requiring revision and loosening of screw cap were found in initial 50 surgeries (11 versus 1 between first 50 and later cases respectively). Conclusion: MISS procedures for discectomies and spine fixations have shown early encouraging results. However, a spine surgeon needs to believe and stay persistent while implementing MISS surgeries inspite of excellent clinical hands on fellowships. As per our case series, first 30 surgeries should be restricted to MISS decompression and discectomy without getting stressed by difficulties. Next 20 cases can be combined with some MISS fixations and mastering the technique. After the first 50 cases, bilateral decompression with or without fixation and TLIF (Trans-Foraminal Lumbar Inter-body Fusion) can be considered., Introduction: Metastatic spinal tumor is a frequent complication in cancer patients. Traditional aggressive surgical strategies for metastatic spinal tumors are associated with high morbidity and complication rates, which can limit their indication in patients with a limited life expectancy. Even as minimally invasive spine stabilization (MISt) gains popularity in Japan, effectiveness for the treatment of metastatic spinal tumors has yet to be established. Methods: The subjects comprised 37 cases that underwent surgery using the MISt technique against metastatic spinal tumors. The cases included 21 men and 16 women, with a mean age at surgery of 66 years old. The primary tumor was: breast cancer in10 cases, prostate cancer in 8 cases, lung cancer in 7 case, and another cancer in 12 cases. We checked operation time, blood loss, length of time taken until recovery, complications, and prediction of the prognosis using the Tokuhashi score, Tomita score and Katagiri score. The Frankel classification was used for paralysis. And we have evaluated instability of the spine using Spine Instability Neoplastic Score (SINS). Results: The mean operation time was 173 minutes (50-410 minutes). The mean blood loss was 123 g (10-810 g). The number of fusion areas was 5.8 vertebrae (3-24 vertebrae).The mean time taken until recovery was 3.7 days (1-14 days). The averageTokuhashi score was 8.9points, Tomita score was 5.3 points, Katagiri score was 3.6 points. SINS score was 9.9 points (indeterminate instability). No complications were reported during the procedure. PS was improved after surgery, and the number of Frankel E cases was 63%. Regarding paralysis, no improvement was observed.In addition, even the survival probability for the group with no paralysis was significantly longer. Conclusions: The benefits of the MISt technique against metastatic spinal tumor is 1) Few infections. 2) Less bleeding. 3) Early recovery. 4) No need to open the wound. 5) A more rapid initiation of postoperative adjuvant therapies. The results of this study revealed that the MISt for patients with metastatic spinal tumor, especially of thoracolumbar spine was safer and less invasive surgical management. It should be considered as palliative surgical strategy in patients with limited life expectancy, to limit morbidity and preserve quality of life., Introduction: Regional neurovascular structures must be avoided during invasive spine hardware placement. During C1 lateral mass screw placement, the C2 nerve root is put in harm’s way. Therefore, the current anatomical study was performed to identify techniques that might avoid such neural injury. Materials and Methods: On 10 cadaveric sides, dissection was carried down to the craniocervical junction. The C2 nerve root was identified and its distal branches traced out into the surrounding posterior cervical musculature. Once dissected, the nerve was displaced inferiorly away from the lateral mass of C1. Results: On all sides, the C2 nerve root could be easily detethered from surrounding tissues. On all sides, this allowed lateral mass screw placement without compression of the nerve. Conclusions: Based on our cadaveric study, the C2 nerve root can be detethered enough at the level of the posterior lateral mass of C1 to avoid its injury during screw placement into this area., Introduction: Myelopathy hand is a characteristic feature of cervical myelopathy. Since there are only a few scales to quantify the severity of cervical compressive myelopathy, there is a need to introduce a universal objective platform in outpatient settings. Virtual-Reality offers promise as a means of producing quantitative data regarding the function of the neural system in the hand. The Leap Motion Controller (LMC) is a small, USB Virtual-Reality motion tracking device that could be used for this purpose. The aim of this study was to assess the reliability and validity of the LMC in the 15-second hand grip-and-release (G-R) test, as compared against human inspection of an external digital camera recording. Moreover, to set a baseline measurement of the number of hand flexion-extension cycles and analyse the degree of motion in young healthy individuals, besides examining gender and dominant hand differences. Materials and Methods: Fifty healthy participants were asked to fully grip-and-release their dominant hand as rapidly as possible for three tests, each separated by a 10-minute rest, while wearing a non-metal wrist splint. The first two tests lasted for 15 seconds, and a digital camera was used to film the anterolateral side of the hand on the first test. The third test lasted for a maximum of three minutes or until subjects fatigued. Three assessors counted the frequency of G-R cycles, of the recorded videos, independently and in a blinded fashion. One assessor counted the frequency of grip-and-release cycles as well as the number of motions (magnitude of motion) from the data output of the LMC. The average mean frequency of the three video observers was compared with that measured by LMC using the Bland-Altman method. Test-retest reliability was examined by comparing the two 15-second tests. Results: The mean number of G-R cycles recorded in each 15-second test was: 47.8 ± 6.4 (test 1, video observer); 47.7 ± 6.5 (test 1, LMC); and 50.2 ± 6.5 (test 2, LMC). Bland Altman indicated a bias of 0.15 cycles (95%CI = 0.10-0.20), with upper and lower limits of agreement −1.16 and 1.46 cycles, respectively. The ICC showed high inter-rater agreement (ICC = 0.998, 95%CI = 0.997-0.999, P < .01). The coefficient of repeatability for the number of cycles was ±5.393, with a mean bias of 3.63. Over 3 minutes, the frequency of cycles (per 10-second interval) decreased, as did the magnitude of motion. However, the decline in frequency preceded that of motion’s magnitude. Participants reached fatigue from 59.38 seconds; 43 participants were able to complete the 3-minute test. There were no statistically significant differences according to gender or dominant hand at most time intervals (P > .05). Conclusions: LMC appears to be valid and reliable in the 15-second grip-and-release test. This serves as a first step toward the development of a universal objective platform for the assessment of cervical myelopathy. Further assessment is warranted to gauge benchmark values in a wider range of healthy individuals and in cervical myelopathy patients. Assessing the LMC as a diagnostic tool in the clinical setting is also necessary., Introduction: Degeneration of the intervertebral disc (IVD) is considered to be a major reason for low back pain. Proinflammatory cytokines, such as tumor necrosis factor α (TNF-α), were shown to be highly expressed in human degenerated IVD, causing a breakdown of extracellular matrix components by stimulation of matrix degrading enzymes. Therefore, therapies that inhibit the expression of proinflammatory cytokines may be a promising therapeutic approach to consider, aiming to reduce inflammation and maintain the IVDs extracellular matrix. However, no clinically relevant in vitro systems to test new anti-inflammatory therapeutics are available to date. The aim of the study was to design and evaluate a proinflammatory and degenerative organ culture model to simulate the early onset of degenerative disc disease (DDD). Material and Methods: Bovine IVDs with endplates were harvested and cultured with or without an intradiscal injection of TNF-α (100 ng TNF-α / IVD) for 4 days. IVDs were cultured within a bioreactor system under 2 different loading and medium conditions: (1) physiological loading (0.02-0.2 MPa; 0.2 Hz; 2h/day, 3 days) and high glucose (4.5 g/L) medium (Phy), or (2) degenerative loading (0.32-0.5 MPa; 5 Hz; 2h/day, 3 days) and low glucose (2 g/L) medium (Deg). IVDs were cultured free swelling between dynamic loading cycles. After the first dynamic loading cycle on day 1, TNF-α was injected into the disc nucleus pulposus (NP) tissue. Disc height was recorded daily after load and free swelling (FS) recovery. Conditioned medium was collected for nitric oxide (NO) and Glycosaminoglycan (GAG) analysis. After 4 days, NP and annulus fibrosus (AF) tissue were harvested and gene expression was analyzed using real-time PCR. GAG/DNA and Hydroxy-proline (OHP)/DNA content of the disc tissue were assessed. One-way ANOVA or Kruskal-Wallis tests were used to determine statistical significance. Results: Degenerative dynamic loading caused significantly higher disc height loss (∼20%) compared to physiological dynamic loading (∼10%). Intradiscal injection of TNF-α did not further induce disc height loss after loading. TNF-α combined with Deg condition up-regulated NO release from IVD (P < .01 Phy vs Deg+TNF-α). TNF-α injection also enhanced GAG release in Phy group (P < .05). Gene expression analysis demonstrated a decrease of type I collagen (COL1) in AF tissue, caused by Deg condition or TNF-α injection (P < .05). TNF-α injection combined with Deg condition induced an up-regulation of interleukin-6 (IL6) and matrix metalloproteinase 1 (MMP1) in NP tissue, as well as increased interleukin-1β (IL1B) gene expression in AF tissue (P < .05). Conclusion: This degenerative and inflammatory model is capable to induce catabolism on organ cultured IVDs indicated by a significant upregulation of catabolic and inflammatory gene expression markers in disc tissue, together with enhanced NO release. The early onset of DDD can be simulated and novel anti-inflammatory treatment approaches can be investigated under relevant conditions by utilizing this model. Further research will aim to analyze the biologic and biomechanical response of selective cytokine inhibitors on organ cultured IVDs as alternative therapies for DDD. Acknowledgements Funded by the Foundation for the Promotion of Alternate and Complementary Methods to Reduce Animal Testing (SET). Zhiyu Zhou was funded by China Scholarship Council and Sino-Swiss Science and Technology Cooperation., Purpose: To investigate the occurrence of inflammatory processes in the sites of disc degeneration in the lumbar and cervical spine by a cytokine gene array and subsequent qPCR. Materials and Methods: Disc samples were obtained from 31 patients undergoing discectomy, 11 men and 20 women, with a mean age of 56 years. RNA was extracted by Trizol/Chloroform method and examined for 28 cytokines by a gene array (n = 6) and then followed up by standard qPCR for eight selected cytokines on all samples Samples had the following characteristics: site = 24x cervical and 7x lumbar; pathology = 11x disc herniation and 20x degenerative disease (all ≥ grade 3); level = 13x one level discectomy and 18x multilevel discectomy. For the patients that underwent multilevel discectomy, one sample was gathered. The nucleus pulposus (NP) and annulus fibrosus (AF) of the lumbar samples were seperately examined. Results were statistically analyzed by the two-sample Kolmogorov–Smirnov test with a significance level of P ≤ .05. Results: In both, cervical and lumbar discs, the interleukines IL-6 and IL-8 were found to be the overall highest expressed genes, whereas the expression of IL-1β, TNF-α and IL-15 (a disc cytokine that has been sparsely investigated up to now) was comparatively low. Interestingly, three previously unreported cytokines could be detected in cervical and lumbar disc tissue: the interferones INA1, IFNA8 and IFNB1. No statistically significant difference was found between cervical and lumbar samples, or between AF and NP samples for any of the investigated genes. Also, no correlation was found between gene expression and gender, age or the extent of the operation (single/multilevel). Conclusions: Our results show that no major differences exist in the inflammatory profile of cervical and lumbar degenerated discs, indicating that novel anti-inflammatory treatments currently under investigation may be applicable independent of the degeneration site. The high expression of IL-6 and IL-8 supports their described relevance in nociception and matrix degradation. Although IL-1β and TNF-α are well described to play a role in the pathogenesis of disc disease, their expression was comparatively low. Importantly, this study is the first to describe the expression of type I interferons (interferons alpha and beta) during disc degeneration, which can have both, proinflammatory and anti-inflammatory properties. Although their role in degenerative disc disease is currently unclear, they are often described to have immunomodulatory effects (e.g. in osteoarthritis) and may hence be a reactive attempt to inhibit inflammation in the disc. Further studies will be required to identify their disc-specific function as well as the role of IL-15, which has also been sparsely investigated thus far., Introduction: Dysphagia is an extensively described complication of anterior cervical discectomy and fusion. It has been proposed that mechanical irritation, additional dissection or displacement of the esophagus by plate placement may contribute to a greater incidence of post-operative dysphagia. The aim of this study was to compare dysphagia symptoms and pain severity of standalone cage systems versus interbody devices in combination with an anterior plate. Material and Methods: A retrospective cohort study identified 377 consecutive patients (stand alone, n = 211; plate and cage, n = 166) meeting the study criteria between the years 2014 to 2015. Patient-specific characteristics and surgical characteristics and Numeric Pain Rating Scale (NRS) scores were collected preoperatively. Complication and readmission rates, the Dysphagia Disability Index (DDI), and NRS scores were collected at one year and two years post-operatively. Results: Both groups were similar with respect to age, gender, body mass index, smoking status, several comorbidities including the Charlson score, and pre-operative NRS scores (5.3 ± 2.1 versus 5.4 ± 1.9 in the stand alone and plate and cage groups, respectively). Patients in the stand along group were more likely to have a primary diagnosis of radiculopathy and less likely to have the diagnosis of myelopathy. They were more likely to have had prior cervical surgery (22.8% vs 13.3%; P = .02). Patients in the plate and cage group were more likely to have multiple levels of surgery (57.8% versus 34.6%; P < .01) and experienced a longer length of surgery (143 ± 51 minutes versus 108 ± 43 minutes; P < .01). Both groups experienced similar complication and readmission rates. The stand along group experienced a higher rate of symptomatic non-union with reoperation but this did not achieve statistical significance (9% versus 4%; P = .07). There was a significantly greater improvement in neck pain scores in the plate and cage group after one and two years post-surgery compared to the stand alone group (2.3 and 3.1 versus 1.6 and 1.5, respectively; P < .01). Post operative DDI scores were similar at 2 years post-surgery (9.4 ± 11.9 versus 9.5 ± 11.7). Conclusion: Chronic dysphagia scores are comparable between standalone cage systems and interbody grafts with plating. We observed a greater improvement in neck pain and a lower incidence of nonunion in the group that underwent interbody graft and plate placement at followup. Further research is needed in order to determine factors that may lead to a higher rate of non union for patients undergoing stand alone cage placement., Introduction: The driving reaction time is defined as the amount of time, on the order of milliseconds or seconds, at which a driver can adequately react to a stimulus requiring them to brake emergently. Although, DRTs can vary depending on variables such as mental processing time, movement time, and device response time there are standard or safe ranges quoted in the literature. Thus, a standardized postoperative DRT might represent an objective indicator for when a patient can resume safe driving after spinal surgery. The objective of our study was to assess driving reaction times (DRTs) after spinal surgery, to establish a timeframe of when postoperative patient’s can safely resume driving. Methods: The MEDLINE and Google Scholar databases were analyzed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement for clinical studies investigating changes in DRTs following cervical and lumbar spinal surgery. Changes in DRTs and patients’ clinical presentation, pathology, anatomical level affected, number of spinal levels involved, type of intervention, pain level, and driving skills were assessed. Results: The literature search identified 12 studies addressing DRTs in postoperative patients; of those studies, 6 studies met the inclusion criteria. Amongst these 6 studies, 5 studies assessed changes in DRT after lumbar spine surgery and 2 studies after cervical spinal surgery. The spinal procedures included were: selective nerve root block (SNRB), anterior cervical discectomy and fusion (ACDF), and lumbar fusion and/or decompression. Overall, DRTs exhibited variable responses to spinal surgery dictated by the patients’ clinical presentation, spinal level involved, and the type of procedure performed. Conclusions: The evidence regarding patients’ ability to resume safe drive after spinal surgery is scarce. Normalization of DRT or returning to pre spinal intervention values represents a widely accepted indicator for safe driving with mixed statistically significance due to multiple confounding factors. Considering the type of spinal intervention, the pain level, opioid consumption, and cognitive function is unique to each case and will be more adequate reflection of when to safely resume driving, Introduction: Diagnostic role of DEXA in bone quality assessment that is required to predict a low energy fracture and implant failure after spinal instrumentations is still questioned because of limited specificity. The aim of this study is to study the relationship between CT and DEXA to assess a potential bias in bone quality assessment. Materials and Methods: This is a cross-sectional study; twenty-five patients were selected for study who underwent a CT scan and DEXA of the lumbar spine. Using DEXA scan of a lumbar spine; BMD (g/cm2) was calculated for each vertebra of lumbar spine (L1-L4 inclusive). The CT scans were performed from the T12-L5 levels. The scans utilized a slice thickness was 0.5 mm, covering a scan area of 50 cm. The scan parameters included: tube voltage 120 kV, tube current 300 mA, auto mAs range 180-400; 1.0 sec/3.0mm/0.5x32, helical-pitch 21.0. Integrated software was utilized for calculations of bone density (Vitrea Version 5.2.497.5523) incorporating a window width/window level ratio of 2000/500. Measurements of bone radiodensity were obtained in HU from each vertebral body in the sagittal, axial and coronal planes from level L1 to L4 inclusively. Radiodensity was measured in two ways: a total vertebra body radiodensity including cortical bone and radiodensity of only a cancellous bone were obtained. Finally a mean value in HU was calculated for cancellous bone and a total vertebra body radiodensity. To study the impact of other structures on bone quality assessment using DEXA, a mean square and radiodensity calculated of right and left vertebra pedicles in frontal plane and a mean square and mean radiodensity calculated of right and left facet joints in axial plain were measured for each vertebra. General factorial regression analysis was applied to study relationships between CT and DEXA data. Results: The required measurements were taken from 100 lumbar vertebrae. The logistic regression analysis demonstrated a strong correlation between BMD measured by DEXA (dependent variable) and CT data (predictors). The estimated multiple correlation coefficient of estimated model accounts for 0.8093, r2 = 0.6550, P < .0001. The estimated parameters of regression model were: B0 = 0.4967149686, p,0,0001; B1 for cancellous bone = −0,0005116753, P = .4633, B2 for a product of facet joints radiodensity and mean square = 0,000003379, P < .0001; B3 for pedicle radiodensity on a frontal image = 0.0001253732, P = .2610; B4 for Pedicle mean square on frontal plane image = −0.0006727354, P = .08682; B5 for total vertebral body radiodensity = 0.0016395253, P = .0201. Beta coefficients for a product of facet joints radiodensity and total vertebral body radiodensity accounted for 0.6729 and 0.3037 respectively. Linear correlation analysis showed only a moderate correlation between a vertebra body and facet joints radiodensity r = 0.4854, P < .0001 (Pearson correlation). Conclusion: The results of bone quality assessment of spine column using DEXA can be strongly influenced by facet joints condition especially in case of degenerative changes. The provided by DEXA results of BMD are partly relevant to vertebral body bone quality assessment and irrelevant to the characteristics of bone in pedicles so that prognostic value of those results might be limited in relation to low energy vertebra fracture and implant stability forecasting., Introduction: Compression fractures of the vertebrae at the junction with PSF are a serious problem. Most often these fractures occur in patients with osteoporosis. The experimental studies (Kebaish K.M. et al., 2013, Basankin I.V. et al, 2015) show the effectiveness of the preventive using of vertebroplasty for preventing fracture of the overlying vertebra above the pedicle screw system. The purpose of our work is the evaluation of the effectiveness of preventive vertebroplasty of vertebra over the PSF in patients with osteoporosis. Material and Methods: The work consists of patients who were treated in our hospital over the vertebral osteoporotic fractures in the period 2012-2014. Osteoporosis was confirmed by performing CT densitometry. The study includes patients with a T-criterion from −2.5 to −4. PSF length was between 2 and 4 segments depending on the type of fracture. Between 4 and 8 screws were implanted to each patient. There were 51 people (34 women) aged 48-76 (mean 62 +/− 2) years. Screws with augmentation were implanted to all patients. Patients were divided into two groups: Group 1 - Control: 27 people - PSF with augmentation; Group 2 - Experienced: 24 people - PSF with augmentation plus prophylactic vertebroplasty of overlying vertebra. Preventive vertebroplasty was performed in the standard way. 7-9 ml of bone cement of high viscosity were introduced in the body of the vertebra by 2 Jamshidi needles. Surgical technique was comparable and performed by 3 surgeons of one department. All patients were discharged from clinic in satisfactory condition. There were no complications of surgical and infectious nature. Control examination was carried out after 3, 6, 12 and 24 months or in some problem cases. Results: Group 1 - control. Using the PSF with augmentation for the treatment of osteoporotic fracture ensured the stability of damaged segments soon after surgery. However, at different periods of time (3 to 9 months.) 7 (25.9%) cases of fractures of overlying vertebra were diagnosed and required surgery. Patients in this group had a normal life and were not exposed high-energy trauma. Group 2 - experienced. Using the PSF with augmentation combined with prophylactic vertebroplasty of overlying vertebra had provided the following results. Adequate stabilization of the affected segments was achieved. Overlying vertebra fracture was detected in 1 (4.1%) case. The patient suffering from epilepsy fell from the height of its own growth as a result of the attack, after a fracture of the vertebra was diagnosed and was located above the prophylactic vertebroplasty. Conclusion: Using vertebroplasty of overlying vertebra (in the volume of 7-9 ml.) is an effective way to prevent vertebral fractures over PSF. The method significantly reduces the number of revision surgeries., Introduction: To evaluate the clinical results of a unipedicular balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures. Material and Methods: Between January 2011 and December 2014, 331 vertebrae of 297 patients, who underwent kyphoplasty for osteoporotic vertebral compression fractures, were analyzed. Group 1, with the bipedicular approach, consisted of 141 vertebrae of 143 patients with a mean age of 74.1 years. Group 2, with unipedicular approach, consisted of 190 vertebrae of 154 patients with mean age of 73.0 years. The plain radiographs, MRI and surgical records were reviewed. Results: In group 1, the mean VAS score changed from 7.29 to 2.73, the mean period of hospitalization was 3.10 days and the mean amount of cement infused was 7.32 cc. The degree of vertebral body collapse was 0.81, 0.73, 0.62 and 0.60 on follow-up, and 15 cases had fresh fracture. In group 2, the mean VAS score changed from 6.38 to 2.42, the mean period of hospitalization was 3.32 days and the mean amount of cement infused was 3.97 cc. The degree of collapse was 0.75, 0.67, 0.62 and 0.60 on follow up and 4 case had fresh fracture. The two groups showed no statistical significance for the change of the VAS score and the period of hospitalization, and the amount of cement was significantly less in group 2. The degree of collapse was not significantly different on the 4 times of follow-up. The frequency of fresh fracture was significantly less in group 2. Conclusion: There were no significant differences in clinical satisfaction and radiological results between the unipedicular and bipedicular kyphoplasty. The advantage of a unipedicular approach is the shorter procedure time than the bipedicular approach and less amount of cement. This is particularly useful in multi-level compression fractures., Introduction: The morbidity of osteoporotic vertebral fractures increases with the ageing of populations globally. Treatment options have ranged from simple immobilization to vertebroplasty with acrylate to formal open surgical stabilization with instrumentation. We studied the results of our treatment in which the affected vertebral body is stented from within before augmentation with acrylate. Material and Methods: Fifty patients with symptomatically painful osteoporotic fractures were treated throughout 2012 till 2014. They were followed up for 24 months. All were female, post-menopausal and had suffered osteoporotic fractures in the lower thoracic or lumbar spines or a combination of both. All had bone density deficits as documented by density scans, and suffered light to moderate degrees of Genant-type vertebral fractures. All were single-level injuries. Excluded were fractures due to secondary malignant spread, multiple-level fractures, injuries with neurological deficit, unstable fractures that required open surgical decompression and fractures that fragmented into the spinal canal. All patients were treated by the same surgeon. The procedure was an image-guided, percutaneous bilateral transpedicular insertion of a trocar that delivered a catheter-mounted, collapsed cobalt-chromium mesh (VBSTM, Synthes GmbH, Solothurn, Switzerland) into the corpus of the vertebra. The mesh is hydraulically expanded with an inner balloon to achieve vertebral height restoration before the balloon is deflated and withdrawn to accommodate polymethylmethacrylate injection. The patient is rested overnight and receives a chest radiograph in addition to a spine check radiograph before being discharged the next morning. We studied the efficacy of pain relief and the chronology of physical activity resumption in the short term and the incidence of adjacent fractures in the long term. The results were tabulated and statistical analysis applied to test for significance. Results: All patients experienced pain relief of varying degrees within 48 hours of the procedure. Forty six patients were able to resume physical activity and mobilise within 24 hours after the treatment while 4 required a longer time which did not exceed 72 hours after the procedure. Eight patients suffered cement leaks anteriorly or laterally into the peri-vertebral region, but which were of no clinical consequence. No pulmonary extravasation was encountered. At 24 months of follow-up, there was no worsening of the fracture profile and no adjacent vertebral fracture was encountered. Conclusion: We propose that vertebral body stenting has effectively relieved the symptoms of pain and radiographically restored vertebral body dimensions in our patients. It has been executed reliably without major complications, and has fared well in our patients even at a minimum of 24 months of follow-up. It has consistently prevented otherwise-deterioration of the fracture profile. Disclosure None of the authors received funds or benefits in any kind pertaining to this subject during the conduct of this study., Introduction: To present updated information on the conservative treatment of osteoporotic Vertebral Fractures. Material and Methods: Forty four consecutive patients, diagnosed with osteoporotic vertebral fracture, underwent the predetermined protocol of conservative treatment (bed rest, titrated analgesia, antiosteoporosis pharmacotherapy, bracing, and supervised physical therapy) after assessment of basic demographic data and clinical examination. They were evaluated every three months for nine months, using visual analog scale (VAS) for backpain, Oswestry Disability Index (ODI), and radiological parameters. Results: At nine months after treatment, there was a significant decrease in the VAS score (P < .0001) and the ODI score (P < .0001), with the final VAS score improving by 52.49% and the ODI score improving by 49.78% from the baseline. There was progressive increase in vertebral collapse (P = .032) with no change in kyphotic or scoliotic angles. Conclusion: Conservative treatment is effective in relieving pain and improving the spine function in such cases without obvious complications and can be therefore an alternative treatment to vertebroplasty or balloon kyphoplasty., Introduction: To analyze the influence of fracture patterns and the result of bone mineral density on cement leakage after percutaneous vertebroplasty for osteoporotic vertebral compression fractures. Material and Methods: Between March 2014 and March 2015, 102 patients with single level osteoporotic compression fracture were treated by percutaneous vertebroplasty, and the clinical data were analyzed retrospectively. There were 15 males and 87 females, with a mean age of 79.1 years (range, 57-98 years). The patients were divided into cement leakage group and no cement leakage group by occurrence of cement leakage based on postoperative CT. Results: The incidence of leakage was 59.1%. Binary logistic analysis revealed that larger volume of bone cement (P, Introduction: It remains unclear whether SCRR manoeuvre alone causes Apical Vertebral Derotation (AVD) and rib hump correction. Although the influence of DVR on AVD and rib hump change has been described, it has been evaluated mainly with indirect methods. This is the first study to evaluate separately the derotational effectiveness of these two manoeuvres during the low-dose Intraoperative Computed Tomography (ICT). The aim was to compare the effectiveness of two main corrective manoeuvres: Single Concave Rod Rotation (SCRR) and Direct Vertebral Rotation (DVR) in regard to Apical Vertebral Rotation (AVR) and rib hump correction in Adolescent Idiopathic Scoliosis (AIS) surgery. Material and Methods: A study group consisted of 38 AIS patients treated by Posterior Scoliosis Surgery (PSS) with all pedicle screw constructs. The mean age when operated was 15.8 years (11.7 – 17.9 years). Written informed consent for the surgery and publication of this study and all images was obtained from each patient and the Medical University of Gdansk Ethics Committee approved the study. All examined patients had dow-dose ICT evaluation (before correction, after SCRR and after DVR) for the safe pedicle screws placement and for confirmation of screw position after corrective manoeuvres. During the first ICT, precorrectional AVR measure with Aaro&Dahlborn method was performed. AVD assessment was performed with our own method. In every case pre and post correctional rib hump angle was measured (Pleura –Pleura line and Spine – Sternum line ratio). All patients had pre and postcorrectional Cobb angle measurement on plain PA and lateral spinal radiographs. Lenke classification was used for the curve pattern evaluation. All patients had Intraoperative Spinal Neuromonitoring (ISN) performed. For statistical analysis SPSS 17v software (SPSS Inc.) was used. A paired Student T-test was used for the examination of statistical differences. R-Spearman test of correlation was used to evaluate the relationship between perioperative variables. Results: We found SCRR ineffective – mean postcorrectional AVR increased insignificantly 1.5° (16.1% worsening) P = .170. On the contrary, an average postcorrectional AVR after DVR decreased significantly mean 3.1° (33.3% improvement) P = .049. Precorrectional rib hump angle was 19.3°, after SCRR - 15° and after DVR - 12.3°. It was found that despite the lack of true derotation after SCRR there was a significant 22.3% decrease of the rib hump P = .043. Although the rib hump decreased significantly 36.3% after DVR as well P = .023. There was also significant difference between a rib hump angle after SCRR and DVR (P = .049). Conclusion: SCRR do not lead to AVD. The true spinal derotation is possible only when DVR systems are used. The decrease of rib hump is achieved both after SCRR and DVR, but the improvement is significantly better after DVR., Introduction: Spontaneous correction of uninstrumented overlying thoracic curves above selective fusion for Lenke 5 adolescent idiopathic scoliosis (AIS) is usually between 29% and 46%. It is known to be influenced by Thoracic Cobb Angle (TCA), TCA on bending, ratio thoracolumbar Cabb angle/TCA, thoracic kyphosis, growth stage and correction of main curve. To our knowledge, preoperative rib hump has never been expressly evaluated as a prognostic factor. Aim: To test rib hump and well-known parameters as prognostic factors of TCA at follow-up above selective fusion for Lenke 5 AIS. Material and Methods: Retrospective monocentric series of 48 Lenke 5 AIS, operated on by posterior selective construct with minimum 2 y follow-up. Demographic data, preoperative thoracic rib hump (measured in mm in trunk anteflexion as the distance between the horizontal tangent line to the apex of rib hump and the hollow of the contralateral ribs at the same distance from midline), frontal, sagittal and bending spinal parameters preoperatively and at last follow-up were recorded. Statistics were performed by STATA 9.2: T-Test to compare mean values, Pearson coefficient to assess correlations, Linear multiregression to assess predictability of final thoracic cobb angle. Results: Main thoracolumbar curve averaged preoperatively 47° (36° - 72°), at follow-up 12° (1° - 28°). Overlying TCA averaged preoperatively 26° (2° à 40°), at follow-up 16° (2° à 41°), that is correction = 37%. TCA difference between preoperative and follow-up was significant (P = .001). Final TCA was correlated to bending TCA (0,63), preoperative TCA(0,62) and rib hump (0,55). Multiregressions confirmed significance of bending TCA exceeding 20° (P = .001), preoperative TCA (P = .011) and rib hump (P = .012). Conclusion: Rim hump was proved to influence final TCA. In case of lenke 5 AIS and overlying curve with rib hump and /or TCA bending exceeding 20°, an extensive construct including both thoracolumbar/lumbar and thoracic curve should be discussed., Introduction: Controversy still exists when selecting the lowest instrumented vertebra (LIV) in major TL/L AIS curves. The decision is typically to stop at L3 vs L4 but is more difficult when the preop L3-4 disc is parallel. We reviewed a large series of Lenke Type 5 & 6 TL/L curves assessing results of LIV selection relative to the lower end vertebra (LEV) and touched vertebra (TV) at 5 yr f/u. We hypothesized that fusing to the LEV in major Thoracolumbar/Lumbar Type 5 & 6 AIS curves will produce acceptable long term results except when the disc below the LEV is parallel (ie, L3/4). In those cases, fusing to the TV, (ie, L4) will lead to better balance & decreased disc angles postop. Material and Methods: 106 Lenke Type 5 & 6 AIS curves were retrospectively reviewed from a large AIS database by 2 examiners who selected the TV from the center sacral vertical line (CSVL), and confirmed the LEV of the curve. The LIV distance from the CSVL (cm), LIV disc angle & overall balance at 5 yr f/u were evaluated. Patients were separated into 3 groups based on the L3-4 disc: open on the convex side of the TL/L curve (Open), closed on the convex side (Closed), or Parallel. Results: 17/106 pts. were in the Open, 61 in the Closed & 28 in the Parallel group. There was a statistically inferior result of stopping at L3 vs L4 in the Open grp with increased LIV-CSVL distance (2 vs 0.7 cm, P = .005) & an increased postop Disc Angle (4 vs 0.2°, P = .003). The Parallel grp also had a statistically greater risk of increased LIV-CSVL translation for those fused to L3 vs L4 (P = .007, Figure 1). There was no difference in postop LIV distance or angle parameters for the Closed pts. with a L3 vs L4 LIV. Conclusion: For Type 5 and 6 TL/L AIS curves, one can reliably stop at L3 & expect a well-centered LIV with minimal disc angulation when the preop L3-4 disc is closed on the convexity of the TL/L curve, but should fuse to L4 when that disc is open on the convexity. When the L3-4 disc is parallel, patients with a L3 LIV will have a greater risk of increased LIV-CSVL translation vs a L4 LIV at minimum 5 yrs f/u., Introduction: Quality of life (QoL) is evaluated in spinal deformities by several questionnaires. Rasch analysis is a statistical methodology to develop good QoL questionnaires, and make them interval instead of ordinal measures. ISYQOL (Italian Spine Youth Quality of Life questionnaire) is the first questionnaire developed through Rasch analysis. The aim of the study was to compare the discriminative validity of ISYQOL versus the actual gold standard questionnaire (SRS-22). Materials and Methods: We performed a cross sectional study. We included in the study 1677 participants (1251 females), median age 14 years (1-3 quartile: 11-14) affected by scoliosis or hyperkyphosis. Consecutive patients of a tertiary outpatients clinic specialized in conservative treatment of spinal deformities completeted the SRS-22 (22 items, 5 categories per item) and ISYQOL (20 items, 3 categories per item) questionnaires before consultation. Multiple linear regressions were computed to predict ISYQOL measure or SRS-22 score (independent variables: age, gender, diagnosis, and bracing). A subgroup analysis was performed through linear regression modelling (variables: age, gender, Cobb degrees, brace dosage and type) to check if each questionnaire was able to discriminate QoL changes according to specific influencing factors. Results: SRS-22 and ISYQOL scores correlate (Spearman -0.68, R2 0.43, P < .001) but the best fit is a parabole (R2 0.51). With ISYQOL above 80% SRS-22 does not change (higher ceiling effect). SRS-22 and ISYQoL detect the effect of age, gender, diagnosis (scoliosis vs hyperkyphosis) and bracing (brace vs no brace) on QoL: F = 92.42 (P < .001) for ISYQOL and F = 85.59 (P < .001) for SRS-22. The variables explained 19% and 14% of the variability for ISYQOL and SRS-22 respectively. The QoL measured by ISYQOL is explained by: age (years), gender, Cobb degrees, brace hours per day and brace type (soft vs hard) (F = 10.69; P < .001; R2 = 0.11); SRS-22 by age and Cobb degrees only (F = 13.66; P < .001; R2 = 0.05). Conclusions: ISYQOL is correlated to SRS-22 but showed a reduced ceiling effect. Despite having considerably less items and categories, ISYQOL appears to be a better measure of QoL during growth in spine deformity individuals in a conservative setting., Introduction: The use of intraoperative traction to facilitate pre-instrumentation curve correction and subsequent screw insertion is not widely practice. We analysed the impact of intraoperative traction as a strategy to optimize implant placement and improve the curve correction in adolescent idiopathic scoliosis. Materials and Methods: We reviewed retrospectively collected data of patients were consecutively operated at our centre by a single surgeon. Group A includes patients were operated during 2008-2011 without intraoperative traction and Group B between 2011-2013 with Skull tong and bilateral skin traction (Traction with 15% of body weight at skull tongs and 10-15% on each leg). Radiological parameters like apical rotation, concave apical screws density and correction of cobb angle and functional outcomes with SRS 22 questioners were measured. Results: Group A (no traction) had 72 patients (86% female) with a mean age of 15.5 years. Group B (traction) had 84 patients (88% female) with a mean age of 14.2 yrs. In group A pre-op mean major Cobb’s angle was 62.8 degree and final correction to 19.5 degree (71% correction). Group B - Pre-op mean major Cobb’s angle was 78.3 degree which reduced to 48.5 degree (40% correction) on traction film and final correction to 13.5 degree(83% correction, P < .001). Apical vertebral rotation changed from mean Nash-Moe grade of 2.6 to 2.2 with traction (P = .011). Concave apical implant density (CAID) was calculated by apical concave sided implant ratio in apical and adjacent vertebra, measured as 87% under traction compared to 26% without (P < .0001). SRS-22 postoperative outcomes showed mean final score of 4.3 in group A and 4.38 in group B with no statistical difference between the groups (P = .66). No complication in relation to traction was observed in group B. Conclusions: Intraoperative traction decreased apical vertebral rotation, allowed for easier placement of apical screws improving the implant density and final curve correction. This technique obviates the need for complex osteotomy techniques and excessive correction manoeuvres to correct larger curves., Introduction: Routine patient-related outcome monitoring is gaining importance in medical care. Healthcare providers are putting more emphasis into assessing the value (health gain per unit cost) of treatment provided.1 However, outcome registries are most valuable if they are comparable between countries and include outcomes that are relevant to the patient population of interest.2,3 The COSSCO (Core Outcome Set for SCOliosis) project aims to reach consensus, across the Nordic Spinal Deformities Societies (Sweden, Denmark, Finland, Norway, The Netherlands), about which patient-relevant outcome domains (e.g. appearance) and subsequent measurement instruments (e.g. SRS-22) are to be included in the 5 national spine outcome registries for adolescents and young adults (10-25years) with a spinal deformity undergoing surgery. Material and Methods: A systematic literature review and quality assesment of existing patient-reported outcomes (PROs) used in adolescent spine deformity studies were conducted. To identify reported outcome domains, PROs were linked to the WHO’s International Classification of Functioning, Disability and Health (ICF) framework. Spinal deformity surgeon representatives from each of the NSDS countries were invited to participate in a modified Delphi study. They were asked to vote which of these outcome domains were considered essential to measure in every patient. The first consensus round was held face-to-face. The second and third round consisted of web-based surveys. Results: A total of 26 PROs were identified in 191 papers that met the inclusion criteria. This provided a list of 39 potential core domains. Through three Delphi rounds, consensus was reached on 14 “core outcome domains”. Existing PROs were studied to identify which core outcome domains they measure, how much time is required to complete them, the availability of validated translations in the Nordic languages and quality metrics. Conclusions: Based on this analysis, the study group advises the implementation of a combination of SRS-22, EQ-5D and a yet to be defined respiratory questionnaire in the Nordic registries as the appriopriate instruments to cover all core outcome domains. A further consensus round will be held on the proposed combination of instruments. The results will be validated among patients (and their parents) and translated into an outcome standard that can be implemented in the Nordic spine registries. The development of this core outcome set will facilitate comparison across registries and will ultimately improve the quality of daily clinical practice by routinely measuring outcomes of care, enabling continuous evaluation and improvement. References 1. Porter, M. E. A Strategy for Health Care Reform — Toward a Value-Based System. N. Engl. J. Med. 361, 109–112 (2009). 2. Porter, M. E., Larsson, S. & Lee, T. H. Standardizing Patient Outcomes Measurement. N. Engl. J. Med. 374, 504–506 (2016). 3. Selby, J. V., Beal, A. C. & Frank, L. The Patient-Centered Outcomes Research Institute (PCORI) National Priorities for Research and Initial Research Agenda. JAMA 307, 1583 (2012)., Introduction: Nowadays, hemivertebra(HV) resection followed by limited fusion and instrumentation is the most used procedure in the treatment of congenital scoliosis in children with HV. This procedure has its well-known risks (particularly neurologic). The purpose of this study is to evaluate the long term results of anterior and posterior convex hemiepiphysiodesis used to treat congenital scoliosis with HV and to evaluate its effect on coronal deformity correction. Material and Methods: This is a retrospective descriptive study performed on 30 children with 33 congenital scoliotic curves operated on using a one staged double approach (anterior+posterior) hemiephysiodesis by bone grafting of the convex side of the curve without instrumentation. A post-operative cast is worn for 3 months. We defined a “Limited Fusion” as the one centered on the HV and including the 2 adjacent levels. An “Extensive Fusion” is the one that is carried on more than one adjacent vertebra to the HV, proximally or/and distally. Patient’s mean age at surgery was 3 years (6 months to 12 years), with an equal distribution of genders and a mean frontal Cobb angle of 42.5°. The mean follow up is 15 years (8 to 25 years). There were 23 isolated HV and 10 HV associated to a congenital bar(CB). Limited Fusion was performed on 21 curves with a mean angle of 37° while Extensive Fusion was performed on 12 curves with a mean angle of 50°. Results: Overall results showed a frontal Cobb angle reduction from 42.5° (18° - 80°) to 29.5° (2° - 77°). Detailed analysis showed that 22 curves had a mean correction of 47% (41° to 21.6°), 8 curves were stabilized (mean Cobb = 38°) and 3 curves had a mean aggravation of 16% (53.7°→64.3°). Subgroup analysis took into account age at surgery, type of the malformation, and Cobb angle. It showed: 57% correction in patients aged 3 years; 55% correction in curves with isolated HV compared to 26% correction in curves with HV and CB; 65% correction in curves 35°. The best correction with Limited Fusion (71%) occurred in case of an isolated HV, with a curve less than 35° and a surgery performed before age of 3. Limited Fusion in patients aged >3 years, with a HV associated to a CB, and a Cobb angle >35° showed a deterioration in 50% of cases, while Extensive Fusion showed a stabilization in 50% and even a mild amelioration in 50% of these patients. Conclusion: A limited convex hemiepiphysiodesis still have a place in congenital scoliosis care, sparing the patient the risks of vertebral resection and instrumentation, fusing the same number of levels, when it is performed in case of isolated HV, in curves less than 35° and in children younger than 3 years old., Introduction: Spinal deformities are usually associated with poor quality of life (HRQoL). Several questionnaires have been developed to evaluate HRQoL in idiopathic scoliosis (the SRS-24, SRS-22, the SQLI and the EOSQ for early onset scoliosis). Rasch analysis is able to turn ordinal scale measures into interval, with obvious clinical and research advantages. Only the SRS-22, the most widely used questionnaire, has been evaluated with Rasch analysis, but showed poor clinimetric properties after Rasch analysis application. The aim of this study was to develop a new questionnaire (ISYQOL: Italian Spine Youth Quality of Life questionnaire) able to satisfy the fundamental requirement for Rasch analysis, for HRQoL evaluation in adolescents with spinal deformities. Materials and Methods: A multistage classical methodology has been used: content analysis of the posted messages by adolescents with spinal deformities in an internet forum (developed in 2006, including 5758 posts and 1156 answers from expert clinicians), to guide the items selection; an opinion poll among 23 experts provided a first version of the questionnaire, with 50 possible items; test of the first draft of the questionnaire (50 questions) in 94 patients; Rasch analysis to generate the second version of the questionnaire (23 questions) that was tested again in 39 patients; finally, 402 participants filled out the last version of the ISYQOL in the waiting room, immediately before medical evaluation. To analyze the data Rasch analysis was performed by using Winsteps Rasch Measurement software (2009, version 3.69.1; partial credit model). Results: We found that 20 items fitted the model and constituted the final version of the ISYQOL questionnaire. Differential Item functioning was significant for brace (−0.87 vs −1.62 logit, respectively; P = .0015), thus allowing comparison among patients with and without brace. The principal component analysis on Rasch residual confirmed the unidimensionality of the ISYQOL. The finding of an addition variable hidden in the ISYQOL Rasch residuals (1st factor Eigenvalue = 2.2) explains 5.2% of the total data variance. Participant reliability of ISYQOL is 0.83 and thus ∼3 significantly different strata can be discerned in the sample. Conclusion: The present work presents the ISYQOL, the first questionnaire developed in the Rasch setting which measure HRQOL in adolescents with spinal deformity. Being Rasch consistent, ISYQOL offers an HRQOL measure which is additive, generalizable and unidimensional thus complying with requirement of a genuine continuous measure. ISYQOL can offer an insight on the impact of the brace prescription., Introduction: Early reports of magnetically controlled growing rods (MCGRs) have demonstrated promising results in the management of early onset scoliosis (EOS). However incidence of device failure has been reported in 0-50% of cases. The reasons for this variation, and the risk factors for device failure, are poorly understood. Similarly, consensus regarding optimum distraction technique, frequency and amount is lacking. Materials and Methods: A retrospective case series of all patients treated with MAGEC (MAGnetic Expansion Control, Ellipse Technologies Inc, Aliso Viejo, CA, USA) rods at a tertiary referral centre was performed. Patient notes and radiographic images were reviewed. Coronal Cobb angles, thoracic height (T1-T12), spinal height (T1-S1) and total rod distraction were measured independently by two authors. Rods were implanted as described by Cheung et al. Subsequent distraction took place at 3 monthly intervals. Each occasion the rods were distracted maximally until clunking was heard. Failed rods were explanted and analysed by an independent team of specialists. Rods were disassembled and the actuator casing was cut open to allow examination of the inner components. Results: 11 patients at our institute had MAGEC rods implanted with 8 meeting the minimum follow up (3 male, 5 female). Average age was 10.1 years. Two had syndromic EOS curves, six were idiopathic curves. Dual rod constructs were used in all cases. Patients underwent an average of 9.5 distractions over a period of 33.3 months. Mean pre-operative Cobb angle was 63.0° and improved to 41.4° following surgery (P = .02). This was maintained at 37.7° (P = .56) at most recent follow up. Thoracic T1-T12 and T1-S1 spinal heights were also significantly improved following surgery (P = .003 and 0.001) and subsequent distraction. 5 patients encountered complications: pain during distraction (n = 1), failure to distract on at least one occasion (n = 4), proximal screw pullout (n = 1) and device failure requiring explantation (n = 3). In two cases, separation of the lead screw from the radial bearing, as a result of drive pin fracture within the actuator portion of the device, was seen radiographically. A third patient’s rods were explanted due to curve progression despite normal radiological images. In this case, pistoning of the rods was seen at the time of surgery. All explanted devices displayed evidence of impingement between the lengthening rod and internal actuator casing. Titanium oxide debris was seen between the magnet and the internal aspect of the outer casing. This debris is thought to bring about device failure by preventing the actuator magnet rotating. Fractured drive pins were found in five of six explanted MCGRs. Conclusion: Our results support the notion that MCGRs are an effective method of spinal growth guidance in patients with EOS. We report higher rates of implant failure than other series using dual rod constructs. We postulate that our higher incidence of mechanical failure is due to over stressing the rods during maximal distraction to the point of clunking., Introduction: Surgical decompression is an effective treatment for cervical spondylotic myelopathy (CSM). However, a number of patients continue to experience substantial neurological impairment post surgery. Riluzole has neuroprotective effects in injuries of the central nervous system. To determine the efficacy of riluzole for promoting neurological improvement in CSM following decompression, we performed a pre-clinical proof of concept experiment and then we translated our work and established a Phase III multi-center randomized controlled clinical trial (CSM-Protect). Material and Methods: Surgical decompression was performed in a rat CSM model and riluzole, or control, was administered. Spinal cord blood flow (SCBF) was evaluated in all CSM rats, in vivo, before and after decompression using FAIR MRI. The long-term outcomes of decompression with or without riluzole treatment determined using neurobehavioural and neuroanatomical assessments. Our multi-center double-blind randomized CSM-Protect trial includes a total of 300 CSM patients undergoing decompression surgery and randomized 1:1 to receive riluzole (2x50 mg daily for 14 days before and 28 days post surgery) or placebo treatment. MJOA score will determine the effectiveness of the combinatorial treatment at 6 months following surgery. Statistical analysis will be performed as a sequential adaptive trial with interim analysis. Results: Rats receiving combinatorial treatment displayed long-term significant neurological improvements associated with preservation of motor neurons and corticospinal tracts compared to rats treated with decompression alone. Riluzole also dramatically reduced the extent of ischemia-reperfusion injury post surgical decompression in our animal model. At present, 274 subjects have been enrolled into the CSM-Protect trial. A planned interim analysis using this sample has commenced. Conclusion: The proposed combinatorial therapy promotes neurological recovery in CSM rats. Confirmation of this proof of concept has been translated from bench to the bedside and we are currently running the CSM-Protect trial to determine the efficacy of this combinatorial treatment option for use in CSM patients., Introduction: Congenital Spinal Stenosis (CSS) is a known predisposing factor for Degenerative Cervical Myelopathy (DCM). Previous studies have suggested that an AP canal diameter less than 12-13 mm or a Torg-Pavlov ratio (TPR) of, Introduction: Multilevel cervical disc disease is a common degenerative disease that is characterized by compressions in the cervical region of the spine; firstly, the interbody disk degeneration and secondly, the sub-sequent deterioration of the facet joints, the thickening of the posterior longitudinal ligament and of the legamentum flavum, lead to progressive compression of the nervous system and, thus, produce myelopathy. As we well know, the treatment is surgical but the gold standard of the technique, especially of the approach, remains controversial and is based on the surgeon experience. Materials and Methods: From 2008 to 2015 we have collected data from archive and we performed this retrospective study which included 304 consecutive patients (187 males and 117 females) that undergoing surgery for multilevel spondylotic disease. Then the patients have been divided into two groups according to surgical approach: anterior (n = 284) and posterior (n = 28). Among them, we selected only the patients of whom surgery has been involved ≥3 intervertebral segments. According to these strict criteria we enrolled 20 patients underwent posterior approach and 12 by the anterior one. The average follow-up was 4 year and 6 months long. We evaluated either clinical parameters and radiological issues before and after surgery. Results: Among the anterior group the patients selected, even with signs of myelopathy, had a better pre-op clinical status either under neurological and general point-of view. Apart that, the selection of the approach has been made on the surgeon preference and thus there’s a slight predilection for the posterior one. The rate of clinical complications, such as temporary dysphagia and or dysphonia was obviously much higher on the anterior group than the posterior. On the posterior group, we had two cases of reoperation due to a screws pull-out, both of them over 1-year of follow-up. The neural recovery rate appeared to be the same between the two groups. Conclusion: Our study clearly shows that there are not significant differences, in terms of clinical and radiological outcome, on the follow-up, even on a long-term one between anterior and posterior approach for multiple level spondylotic cervical disease. We noticed that patients underwent anterior approach tend to have a better post-operative neural function than posterior ones; in the meantime, there is no substantial difference in the clinical recovery rate. This apparently paradoxical result could be explained by better neurological pre-op status of the anterior approach group. We might assume that, when the surgeon is sufficiently skilled on the posterior approach, the choice of the approach should be tailored made, case by case., Introduction: Ossification of the posterior longitudinal ligament (OPLL) is defined as ectopic bone formation within the posterior longitudinal ligament. Although various OPLL features (the extent, shape, and thickness of OPLL as well as the presence of dural ossification) have been defined in the literature, there are no systematic reviews that summarize the associations between these features and clinical outcomes following surgery. The objective of this study was to conduct a systematic review of the literature to determine whether OPLL characteristics are predictive of outcome in patients undergoing surgery for cervical myelopathy. Material and Methods: An extensive search was performed using four electronic databases: MEDLINE, MEDLINE in Process, EMBASE and Cochrane Central of Controlled Trials. Our search terms were OPLL and Cervical. We identified studies in English or Japanese that evaluated the association between cervical OPLL features and surgical outcome. The overall body of evidence was assessed using a scoring system developed by the Grading of Recommendation Assessment, Development and Evaluation (GRADE) Working Group with recommendations from the Agency for Healthcare Research and Quality (AHQR). This systematic literature review is formatted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results: The search yielded a total of 2318 citations. A total of 28 prognostic cohort studies were deemed relevant following a rigorous review process. Among them, only seven retrospective studies conducted a multivariate analysis that controlled for potential confounding variables. Sample sizes ranged from 47 to 133 surgical patients. The main outcome was postoperative Japanese Orthopedic Association (JOA) score and/or recovery rate in six studies and Nurick grade in one. Of these, two were rated as Level II and five as level III evidence. Based on our results, low evidence suggested that patients with a hill-shaped ossification have a worse postoperative JOA score following laminoplasty than those with a plateau-shaped lesion. Based on low evidence, the space available for the spinal cord cannot predict postoperative JOA scores. Furthermore, there is no association between occupying ratio and improvement on the Nurick scale (moderate evidence). There is insufficient evidence to determine the association between JOA outcomes and type of OPLL, presence of dural ossification and occupying ratio. Conclusion: Patients with hill-shaped OPLL have a worse postoperative JOA score than those with plateau-shaped ossification after laminoplasty. Occupying ratio, type of OPLL and the presence of dural ossification are not predictive of surgical outcomes following either anterior or posterior decompression. There are limited articles that used a multivariate analysis to evaluate the association between clinical outcomes and OPLL features. Further high quality studies are needed., Introduction: In the present study we sought to 1) investigate the profile of functional outcome assessment by evaluating the modified modified Japanese Orthopaedic Association (mJOA) and quality of life by SF-36, 2) investigate the correlation between quality of life and functional outcome measures at different follow-up time, and then 3) further understand the ability of the various measures to predict favorable quality of life (health transition item) at different follow-up time for patients undergoing operation for CSM. Material and Methods: We used mJOA assessment and the SF-36 to preoperatively evaluate the patients and again in continuous follow-ups conducted at three months, one year and more than two years after surgery. For evaluating the profile of health status measures (HSMs), changes in clinical effects in each group after surgeries were analyzed by the Wilcoxon rank-sum test. For investigating the correlation between the two HSMs, we computed the Spearman rank correlation analysis. To assess each HSMs’ ability to discriminate HTI, we performed receiver operating characteristic (ROC) curve, area under the curve (AUC) and Spearman rank correlation analysis. Results: 280 CSM patients were enrolled and the mean time of last follow-up was 50.5 months. 1. The mJOA score was improved significantly at any follow-up time. At three months after surgery, the recovery of sensory function was better than motor function, while at one year after surgery and at the final follow-up time, the recovery of sensory and motor function had no significant difference. The mJOA score peaked 16.4 months after the surgery. Before surgery, all patients’ QoL showed varying degrees of decreases in all sections compared to normal population. Two sections—role-physical, and role-emotional—showed the most significant declines. After surgery, with the exception of general-health and social-function at three months after surgery, all the other items at every follow-up time all showed significant improvement. The maximum recovery time point of the physical component score (PCS) was 20.1 months and mental component score (MCS) was 24.1 months after surgery. 2. We found a correlation between improvement in the mJOA score and PCS at 3 months after surgery, but not in MCS. While at 1 year after surgery and the final follow-up, the improvement of mJOA was associated with both PCS and MCS. 3. The AUC and correlation coefficient of PCS showed the highest of the four measures. The recovery rate of mJOA appeared to be the most accurate discriminator at one year after surgery. As for the final follow-up, the results were not consistent as the recovery rate of mJOA showed the highest AUC and the highest correlation coefficient was for MCS. Conclusion: CSM patients can benefit from surgical treatment by significant improvement of neurological function and quality of life, with sensory function and PCS recovering more quickly than motor function and MCS. mJOA (16.2 months), PCS (20.1months) and MCS (24.1 months) reached their maximum recovery points in order. The most responsive indicator varies depending on the follow-up time., Introduction: Cervical spondylotic myelopathy (CSM) is a chronic-degenerative disease and one of the most common causes of spinal dysfunction associated with high morbidity in elderly patients as a result of the diagnosis is made at a very advanced stage of the disease and the only surgical treatment option to benefit this age group with moderate or severe myelopathy. The objective of this paper is to present our results of decompressive spinal surgery for anterior and posterior (surgery 360) via a surgical time, in patients with CSM with severe stenosis of the cervical canal, evaluating functional benefit vs risk, retrospective, linear analysis. Material and Methods: Registration of elderly patients aged 65old was obtained, with diagnosis CSM severe by scale clinical evaluation with Nurick, and m JAO 95%, 22 men, 15 women, mean age of 75 years (range 65-81 years) to 12 months was obtained acceptable clinical changes, Nurick 1; 10%, 2; 54%, 3; 29%, 4; 8%. By analysis of mJAO 78% change to moderate myelopathy, our morbidity prevalence was 16% in the first three months of preoperative disability related to increased monitoring. Conclusion: These results show that surgery 360 decompressive in a single surgical time, is an effective procedure that improves functional neurological outcome and quality of life in patients with CSM severe than one year, which detect which is mainly influenced by the preoperative duration of symptoms, with minimal morbidity and acceptable fusion, maintains cervical lordosis as demonstrated in other reports in the literature., Introduction: Cervical laminoplasty for cervical spondylotic myelopathy causes reduced range of motion (ROM), possibly due to the unintended contracture of the facet joint or a bony union. Though it is rarely studied, ROM may also increase following laminoplasty. Thus far, there are no reports describing the correlation between increased segmental ROM and segmental spondylolisthesis after laminoplasty. The aim of this study was to determine the incidence of increased segmental ROM after laminoplasty and to clarify whether increased ROM is associated with spondylolisthesis. Finally, we explored the effect of increased segmental ROM on clinical results. Material and Methods: We evaluated 187 segments from 39 cervical spondylotic myelopathy patients who underwent bilateral open door laminoplasty from C2 to C7. The segmental ROM and spondylolisthesis were measured using dynamic radiographs that were obtained preoperatively and 2 years postoperatively. The Japanese Orthopaedic Association (JOA) score was used for clinical evaluation. To compare the clinical results, we compared the cases with increased ROM in at least one segment to the remaining cases. Results: Increased segmental ROM (ie, ≥5° increase) was observed in 25/187 segments (13.4%) from 14 cases. There was a strong correlation between increased ROM and spondylolisthesis. A high preoperative disc height was associated with increased segmental ROM 2 years post-operation. Regardless of the correlation with spondylolisthesis, there was no statistically significant correlation between increased segmental ROM and JOA score. Conclusion: The decrease in segmental ROM after laminoplasty was not uniform. Approximately 13.4% of all segments showed increased ROM. The preoperative disc height might influence the risk for increased segmental ROM. Furthermore, increased ROM was correlated with spondylolisthesis in the segment, though it was not correlated with clinical results., Introduction: Cervical spondylotic myelopathy represents the most common indication for surgical treatment in cervical spine, with multiple therapeutic options and implants for treatment. Objective: To evaluate the clinical and radiological results when using an expandable vertebral body prosthesis PEEK plate based along a dynamic anterior plate for the ventral reconstruction of the cervical spine after several levels corpectomy. Materials and Methods: From April 2008 to April 2015, 39 adult patients with the diagnosis of cervical spondylotic myelopathy, underwent corpectomy by anterior approach and application ECD implant (expandable cervical device) and osteosynthesis with dynamic anterior plate. Their clinical course was evaluated by the modified scale of Japanese Orthopaedic Association (M-JOA) and Nurick grading system. The fusion and keeping the correct cervical lordosis was measured with cervical spine radiographs obtained pre-operative, immediate post-operative and 12 months after surgical intervention. Results: 97.4% of patients achieved segment fusion at 12 months, the average correction of lordosis was 13.43 ± 0.76 degrees ϖ, the interbody height at 12 months posterior to surgery decreased on average 0.82 ± 0.37 mm ϖ, clinical evaluation presented significant improvement in both used scales. By comparing the number of segments and specific approached segments, we found that the group with better improvement in Nurick and M-JOA scales is that of two-segment corpectomy in the C3 and C4 levels, followed by the one-level corpectomy at C4 group. The one with less segment height loss at 12 month follow-up was the two-level group at C5 and C6. Conclusion: Utilizing ECD after a cervical corpectomy is an effective and valuable technique as an alternative in the treatment of spondylotic myelopathy cervical and other conditions that may require it, concentrating its benefit in correcting lordosis at a long term compared to other techniques and implants available nowadays., Introduction: Tandem spinal stenosis (TSS) is defined as spinal stenosis that combines cervical and lumbar spinal stenosis. The primary manifestations include intermittent neurological claudication, progressive gait disturbance, and mixed symptoms and signs of the upper and lower extremities. The incidence of tandem spinal stenosis among patients requiring surgery for spinal stenosis is low, and there is limited existing literature on this topic. There is a controversy in the management of these patients. Aim: The Aim of our study is to evaluate the results of a single stage simultaneous decompression surgery for patients with TSS. Methods: Between 1994 and 2014, 149 patients were diagnosed with TSS in a series of 3196 patients who underwent surgery for spinal stenosis (4.6%). Medical records of these 149 patients were studied. Results were evaluated using Nurick’s grade, modified Oswestry disability index (ODI), blood loss, operative time and complications. Results: The ODI score improved from a mean of 69.14 preoperatively to 31.12 at 12 months and 22.04 at final follow-up. The average Nurick’s grade improved from 3.7 preoperatively to 1.82 at 12 months and 1.21 at last follow-up. The average blood loss was 750 ml and average operating room time was 170 min. We had one patient with post op paraplegia who did not recover and 2 patients with Upper limb weakness, which completely recovered at subsequent follow-up. Conclusions: TSS is a rare condition that requires surgical treatment. A single stage simultaneous decompression surgery is an effective approach with excellent outcomes., Introduction: Many studies on sagittal balance in spondylolisthesis have been published; most of them investigate isthmic spondylolisthesis, yet only a few address degenerative spondylolisthesis. North American Spine Society (NASS) clinical guidelines in diagnosis and treatment of degenerative lumbar spondylolisthesis advocate that there is insufficient evidence for or against the use of reduction with fusion. The purpose of current study was to find out whether reduction of the slipped vertebra influences postoperative sagittal spino-pelvic parameters and clinical outcome following posterior fusion in patients with low-grade degenerative spondylolisthesis of a single L3/L4 or L4/L5 lumbar segment. Materials and Methods: Seventy-six patients were included in the prospective study. Full-spine lateral radiographic scans in standing position were taken before and after the procedure, where parameters of sagittal balance, reduction of slipped vertebra and the shape of the lordosis were measured. Clinical improvement was monitored by Oswestry disability index (ODI) questionnaire and Visual Analogue Score (VAS) before surgery and one year after surgery. Results: No direct relation between reduction and clinical outcome could be demonstrated. There was a significant positive correlation between reposition and lumbar lordosis (r = +0.29, P = .005) and lordosis of the segments above the slipped vertebra (r = +0.191, P = .049). There was a weak negative correlation between reduction and lordosis of segments below the affected level (r = −0.138, P = .117) and lordosis of the disc L5/S1 (r = −0.149, P = .098). Insignificant negative correlation existed between reposition and sagittal vertical axis (r = −0.116, P = .158); when patients were divided in groups according to progression or reduction of the slip again no statistical significance was found (+21.6±28.9 mm vs. +16.7±38.5 mm, P = .59). Conclusion: Results of the current study imply that although reduction of slippage cannot significantly enhance the clinical improvement, it does have effect on sagittal re-balancing of the spine., Introduction: Post-operative pain management in surgical patients is strongly correlated with patient satisfaction. There are many strategies utilized, however, most of these strategies are based on narcotics. Given the multiple adverse effects related to narcotics, other strategies have been used. Among these different strategies, the use of liposomal bupivacaine (LB) has provided successful pain relief but the safety has never been evaluated in patients undergoing spine surgery. We attempted to report preliminary results on the side effect profile of LB in patients undergoing posterior laminectomy and instrumented spinal fusion procedures. Our secondary outcomes were readmission rates and length of stay (LOS). Material and Methods: Under Institutional Review Board (IRB) approval, a retrospective review of patients from August 2015 to July 2016 who underwent posterior decompression and instrumented spinal fusion procedures in which LB was used for pain management was performed (N = 33) and compared to a placebo cohort of patients who received sterile saline in similar procedures (N = 21) from an ongoing prospective trial. An alpha error of less than 5% was used to set the threshold for significance for statistical analysis. The study cohort had a mean age of 60.8 years, which was equivalent to the mean age of 61.5 years in the control group (P = .825) and the BMI was also equivalent (29.7kg/m2 versus 31.1kg/m2, P = .402). Both cohorts were similar with the number of decompressed (3.30 versus 3.71; P = .151), and number fused vertebrae (2.91 versus 2.38; P = .053). Results: No significant difference in rates of most common complications between study and control groups including surgical site infections requiring antibiotics 6.1% versus 0%(OR = 3.4, 95% CI of 0.2 to 74; P = .4355), hypotension of less than 90 mmHg systolic 21.2% versus 14.3%(OR = 1.6, 95% CI of 0.37 to 7.1; P = .53), or urinary retention requiring a straight catheter or replacement of Foley catheter 12.1% versus 14.3%(OR = 1.3, 95% CI of 0.30 to 6.0; P = .71), respectively. Interestingly, there was a significant difference between the study and control groups in regards to nausea and/or emesis: 36.4% vs 9.52%(OR = 5.4, 95% CI of 1.1 to 27; p = 0.041). Readmission rates were 0 out of 33 for our study group and 1 out of 21 for our control group (OR 4.9, 95% CI of 0.2 to 126; p = 0.3). One patient from the study group expired secondary to causes unrelated to surgery after being discharged from the hospital. LOS between study and control groups were, 89.0 vs 92.2 hours(p = 0.760), respectively. Conclusion: LB did not lead to increased rates of complication, with the exception of nausea and/or emesis. While the increased rate of nausea and/or emesis was significant, further higher powered studies are necessary to make definitive conclusions on this significance given large uncertainty seen in the wide confidence interval. We also aimed this review at determining if a rebound pain phenomenon leads to readmissions after LB use. With no readmissions, we suspect the extended half-life provides gradual enough decrease in effect to prevent a rebound pain phenomenon. These preliminary results support that LB can be utilized safely in this subset of spine surgery., Introduction: The effect of lumbar fusion of single segment 4-5 (SL4-5) with lumbar healthy adjacent segments on the Lumbar-Pelvis Sagittal Alignment parameter, radiographic ASD (rASD) and its clinical efficacy was discussed according to lumbar types (Roussouly Type). Material and Methods: Between March 2008 and March 2012, 317 patients with lumbar fusion of SL4-5 were collected. 51 cases of them met the inclusion and exclusion criteria (25 males and 26 females, with an average age of 43.45). They were categorized to 4 types according to the types of Roussouly. We compared the VAS, ODI, and JOA scores, and the Lumbar-pelvic parameters, such as pelvic incidence (PI), sacral slope(SS), pelvic tilt (PT), lumbar lordosis (LL), UP arc and intervertebral lordosis of lumbar 4-5(IVA4-5), C7 plumb line /Sacro-femoral distance ratio (C7PL/SFD ratio), of the patients in the preoperative and postoperative and final follow-up. MRI was adopted to evaluate ASD before the surgery, and the UCLA Grading Scale and intervertebral stability criteria of lumbar degeneration were introduced to evaluate ASD after the operation. Changes of the parameters in different periods were statistically analyzed. Results: Mean follow-up time was 42.58 months (36 to 67 months). The distribution of patients according to Roussouly types was high proportion: Type II:15 cases (29.42%)and Type III: 20 cases (39.22%).In Type I group: There were significant improvement (P < .01)in LL, UP arc, IVA4-5and SS in Postoperative and final follow-up, compared with that in preoperative, but PT was decreased. In Type II and III: IVA4-5 significantly improvement (P < .05) in the postoperative and final follow-up compared with that in preoperative, the LL in follow-up significantly increased (P < .05) compared with that in preoperative, while the SS, PT, and PI showed no significant differences. In TypeII UP arc was significantly increased in the final follow-up .In Type IV: The IVA4-5 (P < .05) significantly increased with statistically significant differences to the preoperative, but there was no significant difference in LL, UP arc, SS, PT and PI between preoperative and postoperative. The ratio of C7PL/SFD was significantly decreased in the postoperative and final follow-up compared with that in preoperative in all types .Postoperative and follow-up of patients had significant improvement over preoperative in VAS, ODI, JOA scores. The general prevalence of rASD was 17.64% in all patients. Analysis of rASD risk factors found that: Age, follow-up time, PI, IVA4-5 is a major factor. Conclusion: SL4-5 can significantly increase IVAL4-5, but have different effects to spine-pelvis Sagittal Alignment parameters according to types of Roussouly. IVA4-5 is a significant risk factor, the greater the age, the longer follow-up time, higher PI values more prone to rASD. The view of select the appropriate intervertebral fusion angle is possible to change the adjacent segment degeneration process, reduce the incidence of rASD and improve patient prognosis., Introduction: Systematic and continuous patient-related outcome monitoring is important to assess future value (outcomes relative to cost) of care delivered.1,2 Outcome monitoring through a registry is expected to contribute to quality improvement. A recently performed systematic review showed a lack of evidence that registries had an impact on the quality of spine care.3 To improve the quality of evidence recommendations were presented to improve the underlying methodology; eg, a standardized approach in outcomes registration and a systematic feedback of outcomes of interventions to care professionals.3 Surgical interventions in patients with degenerative lumbar spine disorders are controversial. To improve the institutional quality of surgical care, since May 2012 all new patients are web-based registered (pre-treatment response rate: 97%, n = 6705) and when surgically treated patients are systematically followed over time (global one-year follow-up response rate: 77%). Purpose: to evaluate whether an institutional spine outcome registry could improve the quality of care in surgically treated patients with degenerative lumbar spine disorders. Material and Methods: Definition of two surgical cohorts with baseline (T0) and 1-year follow-up (T1) data: decompression surgery (1-level) (T0 n = 71; T1 n = 54) and interbody fusion surgery (1-level) (T0 n = 169); T1 n = 132). Patient-reported outcome measures (PROMs): functional status (ODI), back and leg pain intensity (NRS), health-related quality of life (EQ5D). Relevant patient-related factors (pre-treatment characteristics, surgery-related) and clinician-based outcomes (complications, revision surgeries) are registered. The feedback to professionals is organised in an online and real-time ‘dashboard’ (ie, complications and outcomes, corrected for influencing factors) and related to known norm values (ODI, EQ5D). For each outcome measure the 10 best and 10 worst performing patients are presented. Currently, these patients are studied in a case series design. The results will be discussed trimestral within the surgical team and after consensus actions to improve the care are defined. Results: Decompression—The PROMs improved: ODI 41.6 (SD 9.6) to 24.1 (SD 14.1), NRSback 7.2 (SD 0.8) to 3.4 (SD 2.3), NRSleg 4.9 (SD 2.9) to 3.0 (SD 2.9), and EQ5D 0.42 (SD 0.23) to 0.74 (SD 0.10). 2015: post-operative complication rate 17%, revision surgery in 2%. Interbody fusion—The PROMs improved: ODI 43.7 (SD 8.3) to 23.5 (SD 13.5), NRSback 7.1 (SD 1.2) to 3.8 (SD 2.2), NRSleg 5.9 (SD 2.1) to 3.3 (SD 2.7), and EQ5D 0.41 (SD 0.28) to 0.74 (SD 0.10). 2015: post-operative complication rate 12%, revision surgery in 20%. Conclusion: Patients in both surgical cohorts improved in relevant outcomes. The support among professionals is high, mainly due to the fact that outcomes are visualised both pooled in the real-time dashboard and individually in the electronic patient file. The one-year follow-up response on PROMs is acceptable.3 Continuous active efforts are needed to improve the response. Currently, the best and worst responders on PROMs of each cohort are studied. The results will be presented at the conference. With these results clinical policy could be improved; eg, through identification of patients with a risk of worse outcomes. This feedback contributes to awareness, peer-to-peer learning and ultimately to improvement of surgical outcomes and value-based spine care. References 1. Porter M. What is Value in Health Care? N. Engl. J. Med. 2010; 2477–2481. 2. Porter ME, Larsson S, Lee TH. Standardizing Patient Outcomes Measurement. N. Engl. J. Med. 2016; 374, 504–506. 3. van Hooff ML, Jacobs WC, Willems PC et al. Evidence and practice in spine registries. A systematic review, and recommendations for future design of registries. Acta Orthop. 2015; 86(5):534-44., Introduction: There is an increasing interest in patient self-reported outcome measures (PROs) after spine surgery.1 PROs include patient’s perspective about quality of life and improvement in functional recovery after surgery, and can provide evidence for the efficacy of surgical treatment. The purpose of this study was to assess whether the health-related quality of life reported by patients who underwent lumbar spine fusion surgery for degenerative spinal disorders, at one year, is similar to the normal adjusted Italian population. Materials and Methods: Consecutive patients who underwent lumbar decompression and transpedicular instrumentation using pedicle screws and rods at L-S levels in 2015 at the Orthopaedic Department of the University of Ferrara were eligible for the study. The study inclusion criteria were: age 18-85 y, absence of pre-existing cognitive or neurological disease, degenerative spine condition and no previous spinal intervention. The patients who consented completed the Italian validated version of Oswestry Disability Index (ODI)2 and SF-36 questionnaire3, during routine follow-up assessment at one year. For each SF-36 dimension, we computed the normal values for the Italian population matched to our study patients for gender and age (adjusted)4 Pain after surgery, and patient satisfaction with surgery were measured by Numerical Rating Scale (0-100) at one year. Results: Of the 45 patients who underwent lumbar spine fusion surgery in 2015, we excluded 12 patients because surgery was due to vertebral fractures, 1 for spine malignancy, and 4 who had any previous surgical intervention for the same disease. One patient had Parkinson’s disease, 4 patients were lost at follow-up and 1 refused the interview. In the 22 patients studied (7 M and 15F, mean age 66±12 y, BMI 28±5) radiological evaluation at the routine follow-up assessments of the vertebral levels fused showed a successful arthrodesis without evidence of pseudoarthrosis. One year after operation, the level of physical function of SF-36 of the study patients was similar to that of the adjusted normal population, and the levels of all the other dimensions of SF-36 of the study patients were slightly better than that of the normal population. According to ODI, 15 patients reported no or minimal disability (range 0-20), five had a moderate disability (range 21-34) and two severe disability (47 and 62, respectively). Median pain score at one year was 2 (Q1-Q3: 1-5). The patients who reported high ODI scores complained of persistent postoperative back and leg pain. In six patients with persistent postoperative pain radiating to the buttock, provocative test for sacroiliac joint involvement as a pain generator were positive. Eighteen out of 22 patients reported a satisfaction with the surgical operation ≥70. Conclusion: This is a pilot study on a small number of patients, with a successful arthrodesis at the radiological evaluation. However, the patients showed a quality of life similar to that of the healthy adjusted population. These results differ from those of Pekkanen et al5, who found a patients’ Physical Component Score worse than that of a Finnish general population sample. These findings need to be confirmed in a large population including patients with previous surgical interventions. References 1. Norvell D.C., Dettori J.R., Chapman J.R.: Success in Spine Care: the Proof is in the Measurement, Part II. Global Spine J 2015;05(06):455-456. 2. Monticone M., Baiardi P., Ferrari S., Mugnai R., Pilastrini P., Vanti C., Zanoli G.: Development of the italian version of the Oswestry Disability Index (ODI-I): A cross-cultural adaptation, reliability and validity study. Spine 2009 1; 34: 2090-5. 3. Apolone G, Mosconi P. The Italian SF-36 Health Survey: translation, validation and norming. J Clin Epidemiol 1998; 51:1025-36. 4. Apolone G, Mosconi P, Ware J. Il questionario sullo stato di salute SF-36. Manuale d’uso e Guida all’Interpretazione dei Risultati. 1997 Milan, Italy; Guerini Ed Associati. 5. Pekkanen L, Neva MH, Kautianen H, Dekker J, Pitulainen K, Wahlman M, Hakkinen A. Disability and health-related quality of life in patients undergoing spinal fusion: a comparison with a general population sample. BMC Muscoloskeletal Disorders 2013; 14:1-8., Objectives: To identify the difference between minimally invasive thoraco lumbar interbody fusion (MI-TLIF) and conventional lumbar fusion for the peri-operative and 12 month lifestyle outcome measures. Method: It was a retrospective secondary data analysis. 36 MI-TLIF patients and 60 conventional surgery patients undergoing single-level lumbar interbody fusion between October 2012 and May 2014 were studied. The peri-operative factors such as duration of surgery, length of hospital stay and peri-operative complications were analysed from patient notes. The 12 month lifestyle measures (pain and discomfort, mobility, anxiety and depression, ability to perform daily tasks, and self-care) were analysed from the patient’s feedbacks via the Euro-Spine Spine Tango forms. Results: There was a statistically significant result in favour of MI-TLIF for all the peri-operative measures. The operative time for MI-TLIF patients was 260.44 minutes (±9.95) in comparison to 297.05 minutes (±9.28) for open patients. The mean length of hospital stay for MI-TLIF was 3.25 days (±0.38) in comparison to 6.92 days (±1.13) for open surgery. MI-TLIF patients had fewer complications from surgery in comparison to the conventional surgery group (MI-TLIF 16.7%, Conventional 43.3%, P = .004). The 12 month lifestyle outcome measures also showed similar advantage for MI-TLIF over the conventional surgery in 3 areas; severe pain (open 29%, MI-TLIF 17% P = .039), moderate mobility (open 69%, MI-TLIF 53% P = .011), and severe anxiety (open 14%, MI-TLIF 3% p = 0.034). Conclusion: For the measures compared MI-TLIF appears to have an advantage over the single level conventional open surgery at the peri operative and short term follow up periods., Introduction: Cortical bone trajectory (CBT) technique has been revisited in recent years with regard to its use in instrumenting the osteoporotic spine. This is most relevant in current practice where we are witnessing a rising elderly demographic index. We looked at the theoretical forte of this technique -- its effectiveness in preventing implant loosening. Material and Methods: From December 2012 till June 2014, 64 adult women underwent lumbar spine decompression and instrumentation using the CBT technique by a single surgeon. They were post-menopausal women with ages ranging from 62 till 92 years old. The surgical indications were for lumbar spine stenosis presenting with radiculopathy. The number of levels operated on ranged from one till four. We excluded patients with metastatic spine disease, infective spine lesions and spondylolisthesis greater than Grade 2. All patients received bi-laminar decompression and 60 had at least one level of interbody fusion. These patients were then followed up for a minimum of 24 months. Of the 64 cases, 3 were lost to follow-up. One patient succumbed to a cerebrovascular event during the follow-up period, another was uncontactable while another declined to be studied. We studied the incidence of loosening with quarterly radiographs in the first year and twice annually in the second, and a CT scan at 12 and 24 months. The films were read and interpreted separately by the author and 2 radiologists, with statistical adjustment of inter-observer variation. Results: Five patients suffered screw loosening, 2 of them having it at the sacral level and the remaining, on the cephalad last-instrumented vertebra. Of the 372 screws implanted, 4 sacral and 7 lumbar were loosened. Loosening was detected at time periods ranging from 3 months to 9 month after surgery, and was invariably associated with failure of fusion at that level. Conclusion: The rates of loosening in our study compare favourably against loosening rates found in classical pedicle screw constructs. Cortical bone trajectory holds the possibility of preventing implant loosening by virtue of its good cortical purchase. Such a likelihood calls for the audit of a larger series to further validate its results. Disclosure The author did not receive funds or benefits in any kind pertaining to this subject during the conduct of this study., Introduction: Degenerative lumbar disc disease is a chronic condition with wide impact over patient’s functional status. Several questionnaires were developed to assess the functional status in patients with chronic low back pain, but the more frequently adopted in published studies are the Oswestry Disability Index (ODI) and the Scoliosis Research Society-22 (SRS-22). The aim of this study is to correlate the different scales of quality of life with each other, trying to determine which individual factors are more decisive for worse or better clinical and functional post-operative outcome. Material and Methods: This is a transversal and observational study considering patients who underwent lumbar spine fusion due to degenerative disc disease, who completed a minimum of 12 months postoperative follow-up. The ODI and SRS-22 questionnaires were applied to all patients and the Pearson’s correlation coefficient was calculated between the ODI and the SRS-22 domains. Results: 61 patients met the inclusion criteria and had data regard the ODI and SRS-22 recorded. 19 were males and 42 females. The mean age of patients was 60.4 years old (19-88 y) and the mean of postoperative follow-up was 29 months (12-67 m). The mean of the questionnaires’ scores were ODI: 43.4 (SD: ±21.7) and SRS-22: 2.74 (SD: ±0.59), while the mean of the SRS-22 domains were Function: 2.66 (SD: ±0.91), Pain: 2.83 (SD: ±0.9), Appearance: 2.64 (SD: ±0.92), Mental 3.03 (SD: ±0.9) and Satisfaction: 3.38 (SD: ±1.15). There was no statistically significant difference in none score between patients gender. The ODI presented inverse significant correlation with SRS-22 total and all domains, except Satisfaction. Significant correlation was also observed between the SRS-22 total and their domains, except between Function. Conclusion: Our results reinforce the reliability of the ODI and SRS-22 (Total and their domains) as outcome measurement tools for lumbar spine fusion follow-up. The lack of correlation between ODI and SRS-22 Satisfaction as well as between SRS-22 Function and Satisfaction suggests that the satisfaction with the surgical treatment was independent of the postoperative disability., Introduction: Electric bone growth stimulators have been used to enhance spinal fusion, but there is a lack of published clinical data demonstrating how often they are used and with which specific procedures. The aim of our study was to identify trends in stimulator use, pair those trends to various grafting materials, and determine if stimulators reduced the risk of revision surgery. Materials and Methods: Through insurance billing records, we identified patients with lumbar disc degeneration who underwent a single- or multi-level anterior lumbar interbody fusion (ALIF). We identified the grafting material used with surgery, if electrical stimulators were used, and the amount reimbursed by Humana to facilities and physicians for each patient subgroup. Results: There was a slight increase in stimulator use from 2008 to 2014 (R2 = .08 multi-level, R2 = .05 single-level). Patients who underwent a multi-level procedure were more likely to receive stimulators than patients who underwent a single-level procedure (P < .05). Grafting options associated with most frequent stimulator use were BMA plus autograft or allograft for single-level and allograft alone for multi-level procedures. Patients treated with BMP were the least likely to be treated with electrical stimulators in both cohorts (P < .05). Patients who received stimulators generally had higher reimbursements. Concurrent PLF (ALIF+PLF) increased the likelihood of being given stimulators, as did obesity (P < .05). Patients who received stimulators had similar revision rates as patients without stimulators (P > .05) except in the multi-level ALIF+PLF cohort, where stimulated patients had higher rates of revision surgery. Conclusions: Stimulators appeared to have little impact on rates of revision surgery. Stimulators were used more often with multi-level ALIFs than single-level ALIFs. Concurrent PLF increased the likelihood of patients’ receiving stimulators. Of patients who received electrical stimulators, most had an ALIF with BMA and autograft or allograft, and the least had an ALIF with BMP. On the day of surgery and over a one year time period, patients who received stimulators were associated with greater reimbursements, potentially an indicator for the added severity of their underlying diagnosis., Introduction: Surgical site infections (SSIs) are a feared complication of spinal surgery, with substantial patient morbidity and high associated costs. Lately, several methods have been reported to try to prevent SSI through decontamination of the wound before closure. These involve adding vancomycin powder to the wound or irrigation of the wound, usually with povidone-iodine. This last method has the advantage of not contributing to antimicrobial resistance. As of yet, the efficacy of both methods are still unclear. We investigated whether the use of intra-wound vancomycin powder or intra-wound povidone-iodine irrigation was associated with a lower incidence of SSIs. Material and Methods: We performed a comparative study with a retrospective control cohort and two consecutive prospective experimental cohorts. All adult patients with instrumented, posterior, open spinal surgery in the period from January 2012 up to April 2016 were included. Patients with fewer than 3 months of follow-up or with a spinal infection at time of surgery were excluded. The control group consisted of the patients before March 2014. From March 2014 until June 2015, patients were irrigated with a 1.3g/L povidone-iodine solution for 2 minutes (first prospective cohort). From June 2015 until April 2016, patients received 1-2 grams of intra-wound vancomycin (second prospective cohort). During the study period, standard peri-operative prophylactic measures did not change. Demographic variables and the incidence of superficial and deep SSIs were registered and compared between the three groups. Deep and superficial SSIs were defined according to the criteria published by the Centers for disease control and Prevention.1 Results: We included a total of 766 patients. Demographic variables did not differ significantly between groups. In the control group of 325 patients, 45 (13.8%) developed an SSI, of which 31 (9.5%) were deep. In the povidone-iodine group, 29 of 261 patients (11.1%) developed an SSI, of which 24 (9.2%) were deep. Compared to the control group, there was no significant difference in the incidence of SSIs. In the vancomycin group, 8 of 180 patients (4.4%) developed an SSI, of which 5 (2.8%) were deep. This reduction was statistically significant when compared to the control group, both for the total risk of SSIs (Relative Risk 0.32, 95%CI 0.16-0.67), and for the risk of deep SSIs (Relative Risk 0.29, 95%CI 0.12-0.74). Conclusion: In this study, intra-wound application of 1-2 grams of vancomycin was associated with a significant reduction in SSIs in instrumented spinal surgery, as has also been reported in other cohort studies. A 1.3g/L povidone-iodine solution did not show a significant difference. It is possible that the povidone-iodine concentration used was too low or the irrigation time too short. Since vancomycin has the disadvantage of promoting bacterial resistance, further research into both forms of intra-wound treatment should be continued. References 1. Mangram, A. J., Horan, T. C., Pearson, M. L., Silver, L. C., Jarvis, W. R., & Hospital Infection Control Practices Advisory Committee. (1999). Guideline for prevention of surgical site infection, 1999. American journal of infection control, 27(2), 97-134., Introduction: Spondylodiscitis represents a condition with significant heterogeneity. A significant proportion of patients are managed without surgical intervention, but there remains a group where surgery is mandated. The aim of our study was to create a scoring system to guide clinicians as to which patients may require surgery. Material and Methods: A retrospective analysis of patients between 2005 to 2014 was performed. Data for 35 variables, characterised as potential risk factors for requiring surgical treatment of spondylodiscitis, was collected. Logistic regression analysis was performed to evaluate the predictability of each. A prediction model was constructed and the model was externally validated using a second series of patients from 2014-2015 meeting the same standards as the first population. The predicted odds were calculated for every patient in the data set. Receiver operating characteristics (ROC) curves were created and the area under curve (AUC) was determined. Results: 65 patients were identified with 21 requiring surgery. Six predictors: distant site infection, medical co-morbidities, immunocompromised, MRI findings, anatomical location and neurology were depicted to be the most consistent variables for surgical intervention. An internally validated scoring system with an AUC of 0.83 with an AIC of 115.2 was developed. External validation using a further 20 patients showed an AUC of 0.71 at 95% confidence interval of 0.50-0.88. Conclusion: A new validated scoring system has been developed which can help guide clinicians as to when surgical intervention may be required. Further prospective analyses are required to further validate the model., Introduction Chronic non-bacterial osteomyelitis (CNBO or NBO) is a heterogeneous group of immune-mediated inflammatory diseases primarily affecting children and adolescent, often associating with rheumatic diseases (RD). The spine involvement is most severe, but relatively rare NBO form; some cases are need the surgery. The Aim of Study: to evaluate the clinical and laboratory peculiarities and efficacy of different treatment strategies for NBO with spine involvement. Materials and Methods: 29 from 91 pediatric patients with NBO were selected due to the spine involvement. The bone affects were confirmed by X-ray, CT, MRI and bone scan. The diagnosis based on the clinical and laboratory tests, incl. WBC, platelets, ESR, C-reactive protein (CRP) levels; it was confirmed by “inflammatory” morphology and negative bacterial (isolates and PCR) bone biopsy and blood tests. The peculiarities of “spinal forms of NBO” (SpNBO) were evaluated in compare with non-spinal ones (non-SpNBO). The efficacy of NSAIDs, bisphosphonates (pamidronate) and TNFα-inhibitors treatment were evaluated by next criteria: dynamics of pain, subjective patients’ feelings and objective tests characterized clinical and laboratory activity, reflecting patients (PVAS) and physicians (MDVAS) impressions and counting according to the 100-degree scale. Results: The mean age of onset of SpNBO was 8.2 years (4.7; 12.8); it was more common in girls - 19/29 (65.5%). Concomitant rheumatic diseases were noted in 58.6%. Multifocal bone lesions more typical for SpNBO (82.8%) with the number of foci 5.0 (3.0; 7.0) in compare with non- SpNBO 2.0 (1.0; 4.0, ρ = 0.0006). The spinal affects more common associated with sternum (24.1%, ρ 0.03) and rib (13.8%, ρ 0.08) lesions and rare - with a foot bone ones (17.2%, p 0.003). There were no any significant differences in quantity of leukocyte, platelets, hemoglobin level, ESR, CRP, frequency of fever, severity of pain syndrome between SpNBO and non-SpNBO groups. NSAIDs as monotherapy was not effective for patients with spinal lesions: the dynamics of patient’s (PVAS), pain and physician’s (MDVAS) assessment were 50.5 (38.5-64.0), 52.0 (33.5-71.5), 56.0 (40.0-77.0) before and 60.0 (45.0-85.0, ρ 0.07), 59.0 (46.5-83.5, ρ 0.27), 66.5 (51.0-90.0, ρ 0.14) after treatment respectively. The NSAID with pamidronate was most effective as a first line therapy in SpNBO patients without associated rheumatic diseases: PVAS, pain and MDVAS were calculated as 76.5 (65.0-90.0), 84.0 (67.0-95.0), 91.0 (80.0-95.0) before and 11.0 (5.0-15.0, ρ 0.028), 10.0 (0.0-14.0, ρ 0.028), 91.0 (80.0-95.0, ρ 0.028) after treatment. TNFα-inhibitors were effective in cases, associated with RD: 45.0 (32.0-45.0), 42.0 (10.0-50.0), 39.0 (35.0-49.0) before and 23.0 (3.0-40.0, ρ 0.11), 15.0 (0.0-37.0, ρ 0.11), 10.0 (5.0-41.0, ρ 0.11) after treatment. The ability to achieve the remission for NSAID was 52.6%, for pamidronate – 88.8%, for TNF α-inhibitors – 73.3%. Only 9/29 patients were operated due to severe spinal instability, deformity progression or back pain. Conclusions: Multiple axial and peripheral skeleton lesions are characterized for SpNBO. NSAID + pamidronate therapy is most effective for it treatment; TNFα-inhibitors could be preferred in NBO accompanied by RD. Despite the rare indications for surgery, it should be indicated in severe spinal instability, deformity and back-pain., Introduction: Medical management is the first line treatment for spondilodiscitis but open debridement and stabilization can be required. XLIF is an increasingly popular interbody fusion technique which is performed through a fast and minimally invasive approach, sparing the anterior longitudinal ligament, and allowing sufficient visualization of the intervertebral discs and bodies to debride as well as possible lateral collections. The limitation of this approach is the levels that can be reached, generally L1-L5 even though a rib resection can permit its proximal amplification to T11-T12. We present 4 patients who underwent surgical treatment utilizing extreme lateral interbody fusion (XLIF) with posterior percutaneous instrumentation. Material and Methods: A retrospective study between January 2010 and September 2015 was performed at Hospital Clinico San Carlos, Madrid. 45 pyogenic spondylodiscitis were found at cervical, dorsal or lumbar levels with at least 1 year follow-up. 32 patients were male and 13 female, mean age was 76 years (range 58-93). Of these 37 cases affected T11 to L5 whereof 4 failed to respond to antibiotherapy being therefore submitted to an XLIF with concomitant posterior percutaneous instrumentation. In the cases an ethiology was found 7 belonged to a urinary tract infection, 6 to abdominal events, 4 to cardiac valve disease, 4 had been submitted to prior spinal surgery, 1 had a catheter infection and 1 an infection of a surgical wound of a femoropoliteal bypass. Results: Bacterial cultures were obtained in 24 patients: 9 were negative, 3 positive to Escherichia coli, 3 to Staphylococcus aureus, 3 to Streptococcus viridans, 3 to Mycobacterium tuberculosis and 1 to Streptococcus mitis, 2 to Enterococcus faecium and faecalis and 1 to Propionibacterium acnes. Mortality rate was 10,9%, none of the deceased patients had been treated surgically. Of the intervened patients 50% presented a 2-level-infection being therefore submitted to a vertebrectomy and a cage with graft was inserted while the other 50% had 1-level-infection where a debridement and insertion of a cage was performed. A postoperative antibiotherapy was maintained at between 6 and 8 weeks postoperatively according to the antibiogram. No postoperative complications were found and no reinterventions were needed. All operated patients presented a normalization of the inflammatory markers and a complete clinical remission of the infection. Conclusion: XLIF with concomitant percutaneous posterior instrumentation is a minimally invasive procedure that allows an adequate exposure to the vertebral bodies and discs to aggressively debride necrotic and infected tissue with little surgical trauma and intraoperative blood loss. It could therefore be a safe alternative to a conventional posterior approach is one or two level spondylodiscitis between D11 and L5., Introduction: Lower back pain (LBP) is the world’s leading cause of disability, with over 632 million people affected. A major etiological factor contributing to LBP is the progressive degeneration of intervertebral discs (IVD), which leads to disc herniation. The current surgical treatment for LBP is lumbar fusion - an invasive surgery which carries considerable risk. In a recent study, the inflammation and edema seen in LBP patients post disc hernia has been attributed to bacterial infection by Proprionibacteria acnes (P. acnes). A recent double blind randomized study demonstrated that antibacterial treatments significantly reduced lower back pain, but the relationship between bacterial infection and disc degeneration remains largely unexplored. Materials and Methods: To further investigate the role of P. acnes in LBP, we first developed a model for reliably detecting a bacterial load in IVDs. This was done by taking samples of bovine IVDs, infecting them with various known concentrations of P. acnes, extracting the DNA following a Chondroitinase digest, and ultimately determining the lowest amount of bacterial genetic material detectable by qPCR. We then isolated DNA from 8 separate surgical samples of deteriorated human IVDs. Results: At a genomic load of 3 ng, which is comparable to an infection of 10,000 cfu/ml, we reliably detected P. acnes presence in an IVD. Three of the eight samples tested positive, indicating that 37.5% of the samples have a bacterial infection of at least 10,000 cfu/ml. Conclusion: These preliminary data support the notion that bacterial infection may be a source of back pain in patients with degenerative discs. More experimental work is required to further substantiate the relationship between P. acnes and IVD deterioration. Our novel qPCR methodology for detecting bacteria in IVDs should progress this research at an accelerated pace, as it is more precise, immediate, and reliable than previously described PCR procedures., Introduction: Infectious spondylitis and tumors are the most common causes for vertebral destruction in patients under 4 yrs old. The multilevel lesions which complicated by early vertebral collapse and kyphosis is obligatory for surgery. Radical debridement with spinal reconstruction are main treatment goals for continued vertebral growth. Material and Methods: Study design: clinical cohort. 20 children (mean age - 3 yrs, min - 8 mns, max 3 yrs 11 mns) underwent two-stages one-narcosis surgery incl. radical debridement, anterior fusion by titanium mesh cage with autograft and posterior instrumentation. Group 1 (n = 15) – active tuberculous spondylitis; group 2 (n = 3) – sequela of late onset neonatal sepsis (LONS) with spinal affect; group 3 (n = 2) – malignant tumors. The diagnosis were confirmed by morphology and bacteriology data. All infectious cases were accompanied with severe kyphosis; neurological disorders. Clinical and radiographic results were analyzed. Results: The mean follow-up was 36 (24 ÷ 45) mns. Significant difference (P = .024) between the groups 1 and 2 were identified in post-op kyphosis angles (M1 = 18.4°, M2 = 27.5°) and degree of angle correction (M1 = 22.3°, M2 = 43.2°). During long-term follow-up, the loss of correction was 1-5° in group 1 and 3.7° in group 2. According to Frankel sc. pre-op neurologic deficit was estimated as grade B 1 in case (TB spondylitis) and grade D in 1 case (GNB); complete neurologic recovery reached postoperatevely. There was not implant-related complication during long term follow-up. The mean duration of the combined (anterior and posterior) surgery was 171 minutes (90 – 240), the mean blood loss - 122 ml (60 to 250). Conclusions: One-stage anterior and posterior surgery in an early age patients has the advantages of reduce blood loss, operation time and early mobilization. It was not detected severe retardation of spinal growth during the study period limited by 45 mns. In our opinion, radical debridement and three spinal column reconstruction with titanium mesh cage and posterior instrumentation is safety and effective procedure for management of spinal infectious and tumors in early aged patients., Introduction: Pyogenic spondylodiscitis represents 3-5% of all cases of osteomyelitis with annual European incidence ranging from 0.4 to 2.4/100000. Diagnosis is often delayed due to paucisymptomatic onset and its low prevalence. The estimated mortality ranges from 0 to 11% and, without an appropriate treatment, recrudescence and residual disability may often occur. Materials and Methods: 205 patients (132 males and 73 females) consecutively diagnosed with pyogenic spondylodiscitis from 2009 to 2016 were enrolled. Mean age was 64.98 ± 0.97. Data from each patient were collected using ad hoc built forms including clinical history and onset, radiological findings, microbiological diagnosis, inflammatory markers, antibiotic and orthopedic treatments, pain VAS score. Each patient has been evaluated at 1, 3, 6, 12 and 24 months from diagnosis. Results: Mean diagnostic delay was 49.90 ± 5.53 days from onset. Most common reported symptoms were: back pain (94.25%), fever (63.64%), limbs radiating pain (42.60%), weight loss (33.54%). 46 patients (22.44%) presented neurological deficits. C-reactive protein was abnormal in 196 patients (95.61%) with higher values in hematogenic infections (74.53 vs 45.73; P < .05), while only 78 patients (38.05%) presented leukocytosis. Diagnostic delay was lower for patients presenting fever (P < .05). 51 patients (24.88%) developed spondylodiscitis after surgical procedures. Lumbar spine was the most frequently involved tract (73.65%). Microbiological diagnosis was assessed in 156 patients (76.10%) with 60% sensibility for surgical biopsy, 57.64% for blood culture and 46.27% for CT-guided biopsy. Staphylococcus aureus was the most frequently isolated pathogen (28.08%). 16 patients (7.80%) presented polymicrobial infections. MR presented higher diagnostic sensibility (96.30%) compared with CT (77.97%) and X-ray (15.38%). Mean duration for antibiotic therapy was 171.91 ± 8.35 days. Intravenous antibiotic therapy was significantly longer in hematogenic and multiple levels spondylodiscitis compared with direct inoculation or single levels infections (47.29 and 37.79 vs 33.40 and 22.71; p < 0.05). 181 patients (88.29%) underwent conservative orthopedic treatment: 123 (67.96%) rigid orthoses made from plaster-cast molds and 58 (32.04%) semi-rigid orthoses. Mean duration for immobilization was 218.17 ± 9.89 days. 62 patients (30.24%) underwent surgery: 53 (85.48%) open surgery and 9 (14.52%) percutaneous stabilizations. Statistically significant differences were observed in VAS scores between conservative and percutaneous treatments at 1 month (6.97 vs 4.4; P < .05). Observed healing rate was 91.47%. E. coli and MRSA spondylodiscitis showed the lowest healing rate (75.00% and 83.33%; P < .001). Residual disabilities occurred in 53 patients (25.85%). Mean diagnostic delay was significantly higher in unhealed patients (106.25 vs 48.04; P < .001). Mortality rate was 6.59%. Conclusion: Pyogenic spondylodiscitis incidence is raising in the last years. Our multidisciplinary approach to spondylodiscitis leads to a lower diagnostic delay, higher efficiency in etiological diagnosis and lower mortality rate compared with literature findings. Lower diagnostic delay statistically correlates with higher therapy success rate. The variability of clinical onset and the diagnostic role of MR are confirmed by our findings. Among laboratory markers, only C-reactive protein showed a significant sensibility, its values correlate with systemic diffusion without statistically significant prognostic role. Hematogenic spondylodiscitis require longer therapy and showed worst clinical outcomes. Appropriate orthopedic treatment ensures a very high healing rate even in patients with neurological impairment., Introduction: Infection of the spine is older than written history that an evidence of vertebral osteomyelitis has been found in prehistoric man as far back as 7000 BC. It encompasses a broad range of clinical entities and accounts for approximately 2% to 7% of all cases of osteomyelitis. Primarily, it is a disease of adults affecting predominantly those in their fifth decade of life. The age-adjusted incidence increases with every decade thereafter. The overall incidence of pyogenic spinal infection is on the increase. Methods: Retrospective analysis of prospectively collected data between 2005 and 2015. Over these eleven years the data of 600 consecutive patients had been reviewed. The patients previously operated at the spinal region of infection and postprocedual infections had been excluded from the study. In patients with haematogenous spinal infection, the collected demographic, clinical, radiological and laboratory data had been analysed and the effects of various causative organisms on these parameters has been studied. Results: The study included 250 females (41.7%) and 350 males (58.3%) (F:M = 1:1.4). The mean age was 66.1years (4-88), which has been increased from 65.5 in 2005 to 67.6 in 2015. The mean bulk (73.7%) of patients were older than 60 years. In this study, 67.3% of patients were overweight or obese (p-value 0.000*). Other comorbidities were found in 83% of the patients; DM in 253 patients (42.2%), Cardiac diseases in 289 (48.2%), renal diseases in 207(43 patients were on renal dialysis), liver cirrhosis in 34 patients. According to ASA- Score, 56.7% of the patients were in class III and IV and it had a positive correlation with age (p-value 0.000*). Other site of infectionwas found in 310 patients (51.7%) as a possible source of infection or a coincident infection. 94% of the patients were referred to us from other hospitals and departments, 59.8% had received antibiotics before admission in our center(one dayand reached 250 days in cases of TB). In 307 patients (51.2%), neurological deficit (ASIA A-D) was found at the presentation. The incidence increased with age (p-value 0.001*), amounting to 54.5% in patients older than 60 years (p-value 0.003*) and reaching 57.4% in patients older than 80 years. It had a significant relation to the infected spinal region; being higher in patients with cervical than thoracic or lumbar affection (p-value 0.000*, 0.543 and 0.997 respectively). The most common region infected was lumbar spine in 402 patients (67%), thoracic spine in 195 (32.5%), cervical spine in 45 (7.5%) and in 11 patients sacroiliac joint infection. Non–contiguous spinal infection was detected in the neuroimaging in 69 patients (11.5%).Multifocal (non-contiguous) infection was detected in 68 patients (11.3%). It had a significant correlation with specific comorbidities such as renal insufficiency in 35 patients (p-value 0.003*) and presence of other sites of infection in 47 patients (p-value 0.003*). The incidence of neurological deficits was higher (p-value 0.000*). The culture-positivity was specifically higher in those patients, that a causative organism could be isolated in 56 of them (p-value 0.005*).Laboratory, mean CRP of 88.7 mg/dl (range 0.8-450), 48.4 in cases of TB.It was normal (, Introduction: Several types of osteotomies have been described such as the Smith-Peterson, pedicle subtraction or vertebral column resection. The decision regarding the choice between the different surgical options is usually made based on severity and curve location, rigidity, patient´s age among others. Severe, complex and rigid deformities can be a challenge and often require a combined anterior and posterior approach and the use of a more aggressive osteotomy. We described the surgical technique of an oblique or asymmetric osteotomy for surgical correction of scoliosis by posterior spinal approach. Material and Methods: An oblique osteotomy used for correction of scoliosis by posterior approach is described, and the outcomes of the last two years 2014-2015 are reported. A case series study was designed. Patients operated for correction of scoliosis in which the oblique osteotomy was used were included. Demographic variables of the population and the pre and postoperative radiological measurements were reported, the correction of the deformity, the sagittal and coronal balance and major complications were assessed. Results: Fourteen patients fulfilled the inclusion criteria, with an average age of 13 years (range 2-22 years), 29% male and 71% female. The most frequent diagnosis was neuromuscular scoliosis 43%, followed by congenital scoliosis 36% and idiopathic 21%. The average length of surgery was 6 hours (range, 4 - 9 hours), blood loss average was 1308 cc (range, 300-3000 cc). Preoperative Cobb angle was on average of 97° with a 44°-144° range, after surgery the average Cobb angle was 45° (range, 22° - 85°). The sagittal imbalance was present in 71% of patients preoperatively and was reduced to 36% of patients in the postoperative period. In the coronal plane preoperative imbalance of 79% of patients decreased to 43% of patients postoperatively. As intraoperative complications one dural tear and two pleural lesions were presented. No death or permanent neurological complications related to surgery were reported. Conclusion: In the literature there is little information about oblique or asymmetric osteotomies for the management of scoliosis in the pediatric population, most of the current literature is based on case reports and in most of the cases this osteotomies are done by a combine anterior and posterior approach; hence the description of this procedure with successful outcomes and low complications provides a safe alternative for the management of this population with severe and rigid deformities mainly in the coronal plane., Introduction: According to long-term follow-up studies, the natural history of untreated Scheuermann’s kyphosis is benign. Yet there is no data available on the radiographic development of the deformity. Our purpose was to investigate the rate of radiographic deformity progression and the relation between kyphosis progression and clinical outcome in patients with untreated Scheuermann’s kyphosis. Materials and Methods: Prospective study. Thoracic kyphosis was measured between Th4 and Th12 from standing lateral radiographs in 19 patients after mean 46-year follow-up. Mean baseline age was 19.2 (range 13 – 36) and at follow-up it was 64.7 (range 56 – 76) years. General health and quality of life questionnaires were administered. A representative sample of a national health examination survey, namely Health 2000, served as a control group. Results: The mean thoracic kyphosis increased from 46° (range 25°-78°) at baseline to 60° (34°-82°) (P < .001) at follow-up. Mean of the vertebrae wedge increased from 8.8° to 9.9° (P = .046). There was no correlation between degree of kyphosis at baseline, age at baseline or length of follow-up and rate of kyphosis progression. Nor was any correlation between extent of kyphosis progression and function at follow-up found. After adjustment for age at follow-up and BMI at 20 years, male Scheuermann’s patients had more often disability due to back pain over the past five years (OR 5.4, 95% CI 1.70-16.85, P = .004) and back pain during the past 30 days (OR 3.6, 95% CI 1.12-11.78, P = .031) than general population. Conclusions: Among patients with moderate Scheuermann’s disease the degree of radiographic deformity progressed slightly during long-term follow-up. However, progression did not predict symptoms, although patients have more back symptoms than general population., Introduction: Ossification of the posterior longitudinal ligament (Th-OPLL) of the thoracic spine sometimes causes severe myelopathy. Since Th-OPLL provides frequent perioperative complications, especially when approached from anteriorly, decision making in the surgical treatment for Th-OPLL is difficult. Recently, use of posterior spinal instrumentation, which enables indirect decompression by maintainance of sagittal alignment and dekyphosis procedure, is favored by many spinal surgeons. However, there has been no study comparing anterior procedure vs posterior procedure using spinal instrumentation. In this study, we compared surgical outcomes for TH-OPLL between anterior procedure and procedures using posterior instrumentation. Material and Methods: Between 1998 and 2016, 32 consequtive cases (Male 10 patients, Female 22 patients, average age at operation 57, follow-up period 1-17 years) of symptomatic TH-OPLL were surgically treated in our group. There were 4 strategies in the surgical management (A method; single anterior approach n = 19, P method; single posterior approach using spinal instrumentation n = 8, PA method; P method followed by A method n = 4, AP method; A method followed by P method n = 1). Additionally, all cases were divided into 2 groups by the use of posterior instrumentation (non-inst method, inst method). Surgical outcomes were evaluated by the Japanese Orthopaedic Association Score (JOA score; total point = 11), improvement ratio of the JOA score, and perioperative complications. Results: In the selection of surgical approach, one case treated by P method was additionally treated by anterior approach due to postoperative paralysis and one case which could not be treated by prone position because of worsening of paralyses was initially treated by anterior approach. Average increase of the JOA score was 25% in the A method, 45% in the P method, 39% in the PA method, and 40% in the AP method. Average increase of the JOA score was 25% in the non-inst method and 42% in the inst method, showing significantly (P < .05) better improvement in the inst method. Complications included specific ones in the anterior approach (cerebrospinal fluid leakage and intracranial hemorrhage) and instrumentation related ones (malposition of screw and back-out of implants). Serious complications were more frequent in the anterior approach. Conclusion: Overall, use of posterior instrumentation seems to be a reasonable strategy in the Th-OPLL. Importantly, in the posterior instrumentation surgery, serious complication was less than in the anterior decompression for Th-OPLL. However, while use of posterior instrumentation showed that anterior decompression is unnecessary in some cases, a few cases did require anterior direct decompression. Therefore, surgical team should be capable of performing both of anterior and posterior procedures for the Th-OPLL and is required to be flexible in choosing approach depending on each case., Introduction: Spinal kyphosis is a very common deformity in spina bifida patients. Kyphotic deformity is particularly common in thoracic and upper lumbar level paraplegics. The combine kyphotic deformity includes congenital (aplasia of posterior spine column) and paralytic components. The paralytic kyphosis is much more common and can be divided into three groups: I - collapsing kyphosis; severe rigid, II - sharpangled kyphosis and III - kyphosis complicated of bedsore on the apex of deformity. Untreated, progressive kyphosis leads to loss of truncal height, difficulties with sitting, and quite often is complicated with skin ulceration on the apex of kyphosis. Progression of the kyphosis may lead to breathing, eating and urination difficulties because of the abdominal contents, which press into the diaphragm, reducing the chest cavity volume with development Thoracic Insufficiency Syndrome. Materials and Methods: The aim of the study was to determine the dynamics of the functional status of the patient with kyphosis due to spina bifida and myelodysplasia, in the result of the surgery. A retrospective analysis of 27 children with kyphosis and spina bifida in age from 18 months to 17 years was performed. All of them previously operated for meningomyelocoele. X-ray, spine CT, MRI of the spine and head were performed to all patients. The results of surgeries were followed in the period from 7 months up to 3 years after surgery. Functional status before and after surgeries was estimated according to the FIM scale (Functional Independent Measure). We performed three types of surgery: 1. growing rods system was applied to the patients of I group; 2. more aggressive surgery was performed to the patients of II group – vertebral column resection (VCR) on apex of kyphosis with stable screw fixation at this level. In the cases of kyphosis with scoliotic component, growing rods system above or/and below the level of VCR, was performed; 3. to patients with severe kyphosis, complicated with skin ulceration, was performed halo-pelvic or halo-spine traction, to reduce the tension of soft tissue. After healing ulcer, we used VCR kyphectomy with screw fixation. Results: 9 children initially had sever neurological disorders (Frenkel Type A and B), one had moderate paraparesis (Frenkel Type D). The quality of life before surgery was, in average, 2-3 point FIM scale. The mean kyphosis correction was 71%. Improvement of neurological status was observed not in one of the cases, but at the same time, the improvement in functional class (FIM scale 4-5 points) and respiratory function of patients were present. Conclusion: Bracing to patients with meningomyelocoele and spinal deformity is usually ineffective. We divided kyphotic deformation of such patients into 3 groups: initial, sever kyphosis, and sever kyphosis with skin ulceration. Surgical correction improves body balance and quality of life. Surgical treatment of patients with kyphosis and spina bifida should be already applied, when the initial kyphosis is more than 10°. Kyphectomy is a challenging procedure with high complication rates, but in the case of heavy rigid kyphosis, it doesn’t have alternatives., Introduction: Spinopelvic parameters are of great value when planning sagittal deformity correction. Many studies describe strong correlations between spinopelvic parameters, which could predict clinical outcome. For sagittal realignment, the formula for postoperative lumbopelvic mismatch (LPM; Lumbar Lordosis (LL) minus pelvic incidence (PI) > ±10°) has recently been described to predict failure and functional outcome after lumbar fusion corrections in adult spinal deformity.1 However, for selective thoracic kyphosis correction in patients with Scheuermann’s kyphosis the relation between these lumbopelvic parameters and functional outcome is unknown. Material and Methods: In 28 surgically treated Scheuermann’s patients (mean age 26.5 years) full spine radiographic assessments at preoperative (PO), 3-months postoperative (FU1) and 14-21 years follow-up (FU2) were available as well as the functional outcome measure (Oswestry Disability Index; ODI) at FU2. ODI ≤ 22 was used as a threshold indicating a healthy population.2 Thoracic kyphosis (TK), LL, PI, Pelvic tilt and the sagittal vertical axis (SVA) were measured to analyze sagittal realignment. Correlations between lumbopelvic mismatch and ODI at FU2 were determined. Results: The average TK was corrected by 26% at FU1 and by 18% at FU2. No strong relation and no clear trends were found in the post-operative sagittal realignment. Pearson’s coefficients of the differences in spinopelvic parameters were not stronger than ±0.63. Calculated LPM occurred in at least 24/28 (86%) patients at FU1 and in 19/28 (68%) at FU2. No relation between LPM and dichotomized functional outcome, based on ODI ≤ 22, could be determined (X2 = 0.146, P = .70). Moreover, at FU2 the average ODI was 20 (SD 18) in this cohort. Conclusions: Sagittal realignment and with that LPM was not predictable in this cohort of surgically treated Scheuermann’s patients. Although measurement accuracy was hampered by poor quality hardcopy X-rays, the variability in the relationship between measured parameters was extremely wide and no strong correlations were found over time between any of the lumbopelvic sagittal parameters. No relationship was found for selective thoracic kyphosis between lumbopelvic parameters and functional outcome. Moreover, despite significant mismatch in lumbopelvic parameters in many patients, the average functional outcome in our cohort was good. We hypothesize that in young and flexible lumbar spines, as is generally the case in Scheuermann’s hyperkyphosis correction, other mechanisms such as hamstrings shortening, loss of correction, body habitus and individual neuromuscular control, also play a role in the realignment of the spine in combination with the mathematical sagittal parameter relationships. Therefore, the planning formula (LL-PI < ±10) derived from degenerative adult spine deformity surgery seems not applicable in planning spinal corrections in Scheuermann’s kyphosis. References 1. Schwab et al. – Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity. Spine 2013. 2. van Hooff et al. – Determination of the Oswestry Disability Index score equivalent to a “satisfactory symptom state” in patients undergoing surgery for degenerative disorders of the lumbar spine-a Spine Tango registry-based study. Spine 2016., Introduction: Pedicle screw constructs have emerged as the leading method of posterior spinal instrumentation, providing excellent correction of adolescent spinal deformities with stable and rigid fixation. Pedicle screws, however, bring about a unique set of potential complications. As an alternative to all-pedicle screw fixations, hybrid constructs intermittently substituting sublaminar hooks have been reported. Materials and Methods: We analysed a cohort of 77 patients (mean age was 16.7 ± 1.9 years old) with adolescent idiopathic kyphoscoliosis, we classify them according to Lenke classification. We divided patients into two groups: patients treated with all-pedicle screw fixation composed Group A; patients treated with hybrid fixation composed Group B. We retrospectively analysed preoperative and postoperative radiographical findings: cervical, thoracic, lumbar and spino-pelvic indexes were recorded. Average follow-up was 30 months. Results: In Group A the mean Cobb angle for the main curve was of 55.78° (±7.4); the mean residual scoliosis after surgery was 15.89° (±14.96). In Group B the mean Cobb angle for the main curve was of 51° (±18.57); the residual scoliosis after surgery was 19° (±16.35). The amount of curve correction of the primary scoliosis curve was statistically significant (P < .001). In the evaluation of the whole groups after surgery, we observed a significant modification of spino-pelvic indexes. The C7PL tends to move posteriorly after surgery. T1 slope, global cervical kyphosis and upper cervical kyphosis were reduced after surgical realignment of the trunk. Discussion and Conclusions: The hybrid technique is an excellent adjunct in the correction of spinal deformity in patients with idiopatic scoliosis. Sublaminar bands utilized in a hybrid construct can achieve corrections equivalent to all-pedicle screw constructs. We found an adaptive behavior of the cervical spine in malalignment of the thoracic and lumbar spine. The sagittal alignment of the cervical spine depends on the alignment of the trunk, and improvement in thoracolumbar alignment is followed by reduction of the cervical lordosis., Introduction: The selection of distal fusion level remains controversial in adolescent idiopathic scoliosis. Description of Lenke in his classification is widely used in selecting fusion levels. We have postulated a new parameter, tilt of vertebrae on traction x-ray view to decide lower instrumented vertebrae. Materials and Methods: Prospective cohort of 26 adolescent idiopathic scoliosis patients who were operated in our institute by single surgeon during June 2013 to July 2014 with minimum two years follow up were included in our study. Preoperative traction x-rays were taken in all patients with standard anteroposterior, lateral and bending films. Tilt of vertebra were measured on anteroposterior and traction view. The vertebrae whose tilt came down ≤10 degree on traction x-ray were taken as lower instrumented vertebrae. Post operative x-rays were taken at 1 week, 6 months and 2 years. Post operative x-rays were analysed for coronal imbalance, lower instrumented vertebrae tilt. Results: Among the 26 patients with mean age of 14.1 years 23 patients were females. 16 patients with lenke 1, one with lenke 2, 3 with lenke 3, 6 with lenke 5 curves. The vertebra with an average tilt of 19.3 degree on anteroposterior x-ray which came down to 8.4 on traction image was selected as lower instrumented vertebra. Cobb angle correction was 74 ± 6.7%. All patients had maintained coronal balance up to recent follow up. Lowest instrumented vertebrae tilt of more than 10 degree was found in 2 patients but none of them required revision surgery (no adding on). Conclusion: Tilt of vertebrae on traction x-ray can be used as one of the parameters to decide lower instrumented vertebrae in adolescent idiopathic scoliosis that may restrict the level of fusion to some extent. Large case series with comparative study require proving this hypothesis., Introduction: Relative anterior spinal overgrowth (RASO) has been described as a potential driver for the onset and progression of adolescent idiopathic scoliosis (AIS). Whether this anterior overgrowth is specific for AIS or also present in non-idiopathic scoliosis has not been reported. The objective of this study is to investigate the presence and magnitude of anterior spinal overgrowth in neuromuscular (NM) scoliosis and to compare this to the same measurements in idiopathic scoliosis and healthy spines. Material and Methods: Supine CT scans of thirty AIS patients (thoracic Cobb angle 21-81°), thirty NM scoliotic patients (thoracic Cobb angle 19-101°) and thirty age-matched non-scoliotic controls were investigated. The relative difference in length in the thoracic curves and corresponding levels in controls ((A-P)/P%) between the anterior (A) and posterior (P) side of each vertebral body and intervertebral disc were determined by using our previously validated 3-D software. Positive values of the height ratio indicate greater anterior length (lordosis). Results: The anterior overgrowth of the thoracic curves did not differ significantly between the AIS (+1.2±2.2%) and NM patients (+0.9±4.1%, P = .663). However, both did differ from the same measurements in controls (−3.0±1.6%; P < .001). Overgrowth correlated linearly with the Cobb angle (AIS r = 0.678, NM r = 0.687). Additional anterior length was localized in the intervertebral discs (AIS: disc +17.5±12.7% versus body −2.5±2.6%; P < .001, NM: disc +19.1±18.0% versus body −3.5±5.1%; P < .001). Conclusion: Anterior overgrowth has been postulated as a possible cause for idiopathic scoliosis, but apparently it occurs in scoliosis with a known origin as well. This suggests that it is part of a more generalized 3-D scoliotic mechanism, rather than its cause. The fact that the intervertebral discs contribute more to this increased anterior length than the vertebral bodies suggests an adaptation to altered loading, rather than a primary osseous growth disturbance., Introduction: Previous work has evaluated the challenges in the treatment of patients with severe and rigid scoliosis and the risks of complications. Furthermore, although several studies have investigated postoperative distal adding-on and attendant risk factors in Lenke type 1A scoliosis, very few have focused on distal adding-on in severe and rigid scoliosis. The aim of this study was to identify associated risk factors of distal adding-on in severe and rigid scoliosis. Material and Methods: In this retrospective study, 48 consecutive patients with severe and rigid scoliosis underwent posterior spinal fusion surgery. The parameters of preoperative, immediately postoperative, and minimum 2-year follow-up radiographs were evaluated. The patients were classified as positive or negative for distal adding-on at follow-up, and risk factors were comparatively analyzed in the two groups. Results: The average Cobb angle and flexibility of the main thoracic curve (MTC) were 107.48 15.98 and 16.4% 10.2%, respectively, before surgery. Distal adding-on was observed in 12 patients (25.0%) at follow-up. Univariate analysis identified several factors significantly associated with distal adding-on. Furthermore, significant independent risk factors identified by stepwise logistic regression analysis included the correction rate of the MTC immediately after surgery (odds ratio: 1.107, 95% confidence interval: 1.024 – 1.197, P 1/4 0.011) and the difference between the lower instrumented vertebra (LIV) and last touching vertebra (LTV) levels (odds ratio: 0.121, 95% confidence interval: 0.028–0.518, P1/40.004). Conclusion: In severe and rigid scoliosis, a high correction rate of the MTC immediately after surgery and the LIV level above the LTV were significantly associated with distal adding-on., Introduction: Due to advancements in medicine, increased rates of diabetes, and an aging population, the number of dialysis dependent patients undergoing elective spine surgeries is increasing. Their general poor health predisposes them to complications. Large studies assessing immediate post-operative outcomes in dialysis dependent patients in this population are lacking in the literature. The purpose of our study was to evaluate inpatient outcomes in dialysis dependent patients undergoing elective cervical spine surgery Material and Methods: Utilizing data from the National Inpatient Sample from 2002 to 2012, an estimated 1,205 dialysis dependent patients undergoing elective primary or revision anterior cervical decompression and fusions (ACDF) and posterior cervical fusions for degenerative conditions were identified and compared to 1,322,737 non-dialysis dependent patients undergoing the same procedures. We selected minor complications, major complications, and inpatient mortality as our primary outcome measures. Major complications included acute myocardial infarction, cardiac arrest, septicemia, septic shock, stroke, and pulmonary embolism. Minor complications included deep vein thrombosis, pneumonia, surgical complications, post-operative anemia, and urinary tract infections. Additionally, we evaluated hospital length of stay, and total hospital costs. Results: Dialysis dependence was associated with higher inpatient mortality rates (5.2% compared to 0.1%; P < .001) and major complication rates (9.2% versus 0.5%; P < .001) versus non-dialysis dependent patients. Dialysis dependence was an independent risk factor for major complications (OR = 2.18, 95% CI = 1.73 – 2.76; P < .001) and inpatient mortality (OR = 10.9, 95% CI = 7.64 – 15.6; P < .001). Dialysis-dependent patients had substantially increased mean lengths of stay (6.0 days compared to 1.9 days; P < .001) and total hospital charges ($31,027, SD = $28,181 compared to $16,764, SD = $11,365; P < .001). Conclusion: Dialysis-dependence is associated with drastically increased complication rates, risk of mortality, and represent a significant financial and psychosocial burden to patients undergoing elective cervical spine surgery. Both surgeons and patients should be aware of these risks while planning elective surgeries., Introduction: Although several studies have reported that cervical laminectomy causes cervical instability, few have reported that C1 laminectomy without fusion causes upper cervical instability. We investigated whether C1 laminectomy without fusion causes upper cervical instability. Material and Methods: We retrospectively analyzed the records of 16 patients who had undergone C1 laminectomy without fusion between January 2004 and December 2014. Upper cervical instability was determined by evaluating atlantoaxial instability and atlanto-occipital dislocation using dynamic radiography. Patients who had upper cervical instability preoperatively were excluded. Follow-up images were examined at 1, 3, 6, and 12 months after discharge, and every year thereafter. Results: Four patients experienced atlantoaxial instability: two with chiari malformation type I, one with calcium pyrophosphate dihydrate (CPPD) crystal deposition disease, and one with a cervicomedullary junction tumor. In two patients with chiari malformation, the atlantodental interval (ADI) was 4.5 mm and 3.5 mm, respectively. In those with CPPD, the ADI was 6.4 mm. In the patient with a cervicomedullary junction tumor, the ADI was 6.2 mm. Two patients experienced atlanto-occipital dislocation: one with chiari malformation and one with CPPD. The basion-dens interval was 15 mm in the patient with chiari malformation and 13 mm in the patient with CPPD. Conclusion: C1 laminectomy usually has little impact on upper cervical instability, such that additive fusion is not demanded. However, we identified several cases of patients without preoperative instability who developed upper cervical instability following C1 laminectomy. Therefore, upper cervical instability should be carefully observed with periodic follow-up imaging., Introduction: Anterior cervical discectomy and interbody fusion is a common treatment for cervical myelopathy or radiculopathy. However, due to mechanical stress and motion of the adjacent segment to index segment, 3% of adjacent segment disease is occurred annually. Recently, zero-profile implant is devised for less contact of adjacent structures and limited contact with adjacent segments. This study compared the occurrence of adjacent segment disease using zero-profile implant versus conventional plate. Material and Methods: 60 patients who underwent anterior cervical discectomy and interbody fusion for single level cervical spondylotic myelopathy, radiculopathy, or intervertebral degeneration that showed no improvement after conservative treatment and were able to follow up for at least 1 year were included in this study. 30 cases that used conventional plate from April 2007 to January 2011 (group A) and 30 cases that used zero-profile implant from March 2011 to February 2014 (group B) were retrospectively reviewed. All operations were performed by our senior surgeon (JS Ahn). Cases with history of trauma, infection, tumor, or previous posterior approach surgery and revision surgery were excluded from the study. Group A consisted of 16 males and 14 females and group B consisted of 17 males and 13 females. The index levels of fusion of group A were 1 case of C3-4; 5 cases of C4-5; 15 cases of C5-6; and 4 cases of C6-7 and of group B were 1 case of C3-4; 3 cases of C4-5; 16 cases of C5-6; and 6 cases of C6-7. The radiologic finding of degenerative change of adjacent segment and clinical manifestation were checked. Results: The average follow up periods were 19.23 months for group A and 14.85 months for group B. Adjacent segment degeneration findings such as osteophyte anterior to vertebral body, narrowing of disc space, and ossification of anterior longitudinal ligament were seen in 8 cases (26%) of group A (7 cases of grade II and 1 case of grade III) and 4 cases (13%) of group B (all 4 cases of grade II), which showed no statistical significant difference between two groups. No clinical manifestation of adjacent segment was found during follow up. Conclusion: Though it was hypothesized that conventional plate will show higher rate of adjacent segmental disease compared to zero-profile implant, the actual result were similar between two groups. This result suggests that adjacent segment degeneration is affected by interbody fusion more than the implant insulting the adjacent tissue, Introduction: Occipito-cervical fixation in a neck retraction position could be dangerous due to the risk of post-operative dysphagia. No study previous study has demonstrated an association between the cervical posture change and cervical spine motion/angle during swallowing. So, the purpose of this study is to analyze the influence of neck posture on the cervical spine motion and angle change during swallowing. Methods: Thirty seven asymptomatic volunteers were recruited for participation this study. A videoflurographic swallowing study was performed in the neutral and retracted neck posture. We analyzed the images of the oral and pharyngeal phases of swallowing and compared the angle and the position changes of each cervical segment. Results: In the neutral posture, C1 and C2 were flexed, while C5, C6, and C7 were extended. C3, C4, C5, C6, and C7 moved posteriorly. All cervical levels, except for C5, moved superiorly. In the retraction posture, C0 and C1 were flexed, while C6 was extended during swallowing. All cervical levels moved posteriorly. C1, C2, C3, and C4 moved superiorly. The comparison between two postures shows that angle change is significantly different between C0, C2, and C5. Posterior translation change is significantly different in the upper cervical spine (C0, C1, and C2) and C7. Superior movement is significantly different in C0. Conclusion: C0 segment is most significantly different between neutral and retraction posture in terms of angle and position change. These data suggest that upper cervical spine including C0 segment could be a critical level of compensation which allows swallowing in the retraction neck posture regarding motion and angle change., Introduction: Risk factors for malnutrition include advanced age and chronic disease. Low serum protein markers such as albumin are commonly used to diagnose malnutrition. However, recent studies have demonstrated that these markers lack specificity in assessing nutritional status and can be influenced by a multitude of factors, most significantly, an underlying inflammatory state. The ICD-9 diagnoses of malnutrition are often made using more thorough criteria such as functional status, recent weight loss, caloric intake, and physical exam findings during nutritional assessments conducted by health-care staff. According to these criteria, even patients undergoing elective cervical spine surgery may be malnourished and large studies evaluating inpatient outcomes in this population are limited. Material and Methods: Utilizing International Classification of Diseases, Ninth Edition, Clinical Modification codes and data from the National Inpatient Sample from 2002 to 2012, an estimated 2,313 malnourished patients undergoing elective cervical spine surgeries for degenerative cervical disease were compared to 1,307,651 patients who were not diagnosed with malnutrition undergoing the same surgeries. Length of stay, post-operative complications, mortality, and total hospital charges were the primary outcome measures. Complications were classified as major or minor. Major complications included acute myocardial infarction, cardiac arrest, septicemia, septic shock, stroke, and pulmonary embolism. Minor complications included deep vein thrombosis, pneumonia, surgical complications, post-operative anemia, and urinary tract infections. Results: Mean age upon admission of malnourished patients was 65.8 (SD = 11.8) compared to 52.8 (SD = 11.8) in patients not diagnosed with malnutrition (p = < 0.001). Major complications in malnourished patients were significantly increased when compared to patients with normal nutritional status (18.9% compared to 0.5%; P < .001). The rate of mortality was forty-five times greater in the malnourished population (4.5% compared to 0.1%; P < .001). Malnutrition was an independent risk factor for both major complications (OR = 6.35, 95% CI = 5.6 – 7.2; P < .001) and inpatient mortality (OR = 4.9, 95% CI = 3.9 – 6.2; P < .001). Patients who were malnourished had a more than seven-fold increase in their mean lengths of stay (15.1 compared to 1.9; P < .001) and three-fold increase in total hospital charges ($52,975 versus $16,566; P < .001.). Conclusion: Risk factors for malnutrition include advanced age and chronic disease and the diagnosis of malnutrition is best made with a formal nutritional assessment. Recent literature has shown that serum protein markers are, oftentimes, not an accurate reflection of underlying nutritional status. As malnutrition substantially increases the risk of post-operative complications, mortality, length of hospital stay, and consequent total hospital charges, screening for malnutrition in those that are at higher risk of being malnourished may be prudent even in the setting of elective cervical spine surgery., Introduction: In many patients with cervical radiculopathy, neural foramens narrow by osteophyte or hypertrophy of uncovertebral joints. For this neural foraminal stenosis, uncoforaminotomy (uncinate resection; UR) simultaneously performed with anterior cervical discectomy and fusion (ACDF) is known to be helpful for a better and faster improvement of patient’s arm pain. However, uncovertebral joints may be an important structure to maintain the stability between two vertebral bodies in the subaxial cervical spine. If they are resected during ACDF procedures, it might affect on the fusion process by causing segmental instability. The purpose of this study was to investigate whether unilateral or bilateral uncinate resection combined with ACDF for the decompression of neural foramen would increase the risk of pseudarthrosis at long-term follow-up. Material and Methods: We retrospectively analyzed 167 patients (89 men, 78 women; mean age, 58.4 ± 10.5 years) who consecutively underwent 1- or 2-level ACDF for cervical spondylotic myelopathy or radiculopathy and were followed for more than 2 years. In all the patients, allografts filled with local chip bone were inserted after discectomy and anterior plating was performed. If a patient had stenotic neural foramens on preoperative MRI and clinically concordant arm pain also, then the involved uncinate processes were totally resected. Uncinate resection was not performed in 46 patients who did not have foraminal stenosis (N-UR group). On the other hand, 121 patients underwent uncinate resection for at least one foramen (UR group). Among them, 89 patients underwent UR unilaterally (U-UR group) and 32 patients, bilaterally (B-UR group)(Table1). Solid fusion was diagnosed as interspinous motion, Introduction: Modic changes are signal intensity changes in adjacent vertebral bone marrow on magnetic resonance imaging (MRI). Few studies have investigated these changes with regard to the cervical spine. Therefore, this study aimed to determine cervical spine degenerative diseases associated with Modic changes. Methods: We conducted a retrospective collection of radiological data in patients with neck pain at our hospital from January 2010 to December 2014. A total of 733 patients were included in this study. Disc herniation grade and disc space height for each cervical segment were evaluated. If Modic changes were present, we recorded the Modic change type based on the literature, vertebral level, age, sex, and surgical requirement. Results: MRI scans of the 733 patients were reviewed, 99 patients exhibited Modic changes in the cervical spine (13.5%). Out of these 99 patients, Modic change type II (87 patients, 87.9%) and C5–6 vertebral level (41 patients, 41.4%) were the most predominant categories. Patients with Modic change showed worse outcomes in regard to disc herniation grade and disc space height than patients without (P < .01). Among 733 patients, 38 patients had undergone anterior cervical discectomy with fusion (ACDF). Patients with Modic changes (13/99 patients, 13.1%) had a greater probability of undergoing ACDF than those without (25/634 patients, 3.9%; P < .01). Conclusion: Modic changes may be an important indication of disc degeneration requiring surgery., Introduction: At the level of the cervico-thoracic junction, the flexible cervical spine meets the more rigid thoracic segments. This, multi-segmental cervical instrumentations ending at this junction may be prone to pronounced adjacent segment degeneration or even failure of the instrumentation. The objective of this study was to compare patient groups with a primarily cervical instrumentation ending at C7 versus an instrumentation including the cervico-thoracic junction ending at T1 or T2 in regard to the rate of consecutive pathologies in the segment adjacent to the lowest instrumented vertebra. Methods: All consecutive patients who had undergone a multi-segmental posterior cervical instrumentation ending either at C7 (“Cis”) or at T1 or T2 (“Trans”) between 04/2007 and 07/2014 were identified (n = 98) and a retrospective chart review and radiographic assessment was performed. Radiographic parameters of degeneration at the adjacent segment below the instrumentation were determined postoperatively and at follow-up, and the need for secondary interventions was documented. Results: Seventy-four patients had a follow-up of at least six months (Cis: n = 58, age 63 ± 11, FU 36 ± 26 months; Trans: n = 16, age 65 ± 13, FU 37 ± 21 months). While the whole cohort showed progressing degeneration at the adjacent segment below the instrumentation at follow-up (P < .001), there were no significant differences between the Cis and Trans groups with regard to the change in kyphosis (P = .162), disc height (P = .204) or disc degeneration according to the Mimura grading system (P = .718). Secondary interventions due to symptomatic lower adjacent segment instability were necessary in 18/58 (31.8%) of the Cis-cases and in 1/16 (6.3%) of the Trans-cases (P = .038). Patients who required a secondary intervention for adjacent segment pathology showed a higher degree of kyphotic change (P = .050). Conclusion: In this retrospective cohort, patients with multi-segmental posterior cervical fusions ending at C7 showed a higher rate of clinically symptomatic degeneration and instability at the adjacent level below the instrumentation when compared to patients with instrumentations spanning the cervico-thoracic junction. Thus, it might be advantageous to bridge the cervico-thoracic junction and to end the instrumentation at T1 or T2 in those cases., Introduction: Accurate location of the skin incision is helpful to decrease the technical difficulty and save the operative time in anterior cervical spine surgery (ACSS). Spine surgeons usually use the traditional neck anatomic structures (hyoid bone, thyroid cartilage and cricoid cartilage) as landmarks during the surgery. However, the reliability of these landmarks has not been validated in actual practice. The purpose of this study is to find out which one of the landmarks is the most accurate for identifying the corresponding cervical levels during ACSS. Materials and Methods: The lateral flexion and extension radiographs of cervical spine on standing position from 30 consecutive patients were obtained from January 2015 to February 2015. The cervical vertebral bodies from C2 to C7 were equally divided into two segments. The cervical segments corresponding to the surface landmarks were recorded on the flexion and extension radiographs, respectively. And the displacement of corresponding cervical segments from the flexion to extension radiographs for each landmark was calculated. Results: Based on the measurement, the mainly corresponding cervical levels for mandibular angle were C2 on both of the flexion and extension films, hyoid bone were reference to C3-4 interspace on flexion film and C3 on extension film, thyroid cartilage corresponded to C5 on both of flexion and extension films, and cricoid cartilage corresponded to C6 on flexion film and C5-6 interspace on extension film, respectively. The ratios of landmark displaced within 2 segments from flexion to extension were 83.3% (25/30) in mandibular angle, 56.7% (17/30) in hyoid bone, 66.7% (20/30) in thyroid cartilage and 56.7% (17/30) in cricoid cartilage, respectively. The mean displacement from flexion to extension films were significant less than 2 segments in mandibular angle, but greater than 2 segments in hyoid bone, thyroid cartilage and cricoid cartilage. Significant differences were found between mandibular angle and the other three landmarks for the displaced segments from flexion to extension (P values were 0.024, 0.049 and 0.024, respectively). Conclusions: The angle of mandible was found to be the most accurate landmark for identifying the cervical level, which corresponded to C2 and C2-3 disc space. Furthermore, the hyoid bone, thyroid cartilage and cricoid cartilage were not reliable to predict the cervical levels during ACSS., Introduction: Traumatic spinal cord injury (SCI) is a leading cause of worldwide disability, healthcare expanse and lost productivity. The goal of SCI management is to prevent secondary injuries in the acute period and restore functional autonomy through intensive rehabilitation once the patient’s medical condition has stabilized. Underlying all medical and physical interventions is the assumption that maximizing neurological function and improving functional autonomy will improve the patient’s long-term quality of life (QoL). As such, many interventional studies in SCI management use QoL as a primary outcome. The goal of this study was to provide overall QoL, health-related QoL and health utility values for patients with traumatic SCI stratified by injury level and neurological status. Material and Methods: The Canadian SCI Community Survey was sent to Canadians living in the community following SCI. The survey covered demographics, SCI classification, secondary complications, comorbidities, needs, community participation, activities and employment, QoL, health care utilization, overall health status and overall QoL. QoL was measured using the LiSAT-11, the SF-12 v2 and a direct question. SF-12 v2 answers were used to generate a health utility score using published preference weights. The impact of demographics, complications and SCI classification on QoL was assessed using ANOVA, multiple linear regressions and ordinal logistic regression analyses. Results: There were 1109 respondents with traumatic SCI. 70% were male. Mean age was 48.3 years at a mean of 18.5 years following injury. ASIA Impairment Scale grade was cervical A or B in 20%, cervical C or D in 28%, thoracolumbar A or B in 32%, thoracolumbar C or D in 16% and E (any level) in 1%. Injury level or AIS grade had no impact on either health utility or QoL assessed by a direct question. Factors affecting QoL included (in decreasing order of importance) a depressed mood, fatigue, injuries caused by a loss of sensation, not working, diabetes, concomitant renal disease, neuropathic pain, constipation, sleep problems, hypertension, sexual dysfunction, pressure ulcers and joint contractures. With a mean health utility score of 0.64 ± 0.12, SCI patients living in the community reported having QoL similar to patients with rhinosinusitis, symptomatic hand osteoarthrosis and healed hip fracture. Conclusion: Once in the community, SCI patients report having a very good QoL. In the years after the injury, chronic medical conditions have more impact on QoL that strictly SCI-related complications. Moreover, injury level and AIS grade do not affect long-term QoL. As such, we believe QoL should not be used as outcomes to assess the effectiveness of interventions targeting neurological function and autonomy in traumatic SCI., Introduction: Gunshot wounds of the spine are not very frequently reported and there is a paucity of neurosurgical literature on the subject. We share our experience of managing 27 patients with thise injuries, sustained in militancy and warlike situations and civilian injuries. Methods: Between 1995 and 2015, 27 cases with low velocity missile injuries of the spine and spinal cord were treated in three service hospitals. All were adult males, with a mean age 30.7 years. The wounds were caused by splinters in eighteen (82%) and bullets in four (18%). Twelve patients received more than one splinter. The cervical and thoracic spines were most frequently involved. In seven cases, there were injuries to other organs. There was extensive initial deficit (quadriplegia, paraplegia) in 18 (82%) cases, while four (18%) had partial deficits. The patients were evaluated by spine radiographs; Myelography was done in four, CT myelography in thirteen and MRI in four patients. Two patients had intramedullary haematoma without any skeletal injury, and were treated conservatively. Seventeen patients were treated operatively, and associated injuries of other organs received priority management. Surgery was in the form of debridement, exploration of spinal cord, haemostasis, decompression and dural repair. Steroids and antibiotics were given routinely. Results: Three patients (two with cervical and one with thoracic spine injury) died preoperatively, and one (with dorsolumbar injury) died in the postoperative period due to multi-organ injury. Patients with complete injury remained completely paralysed, while those with incomplete injury showed improvement in their neurological grades. Initial neurological grade is the best prognostic indicator, and these injuries are often accompanied by multi-organ injuries. There was no instance of postoperative meningitis or CSF leak. These injuries should be explored for debridement and dural repair. Conclusions: Gunshot wounds of the spine are infrequent, and in miltiary settings, are routinely explored. Surgery affords debridement, dural reconstruction, prevention of postoperative CSF leaks and infection, and early rehabilitation., Introduction: Recent guidelines do not recommend routine administration of methylprednisoline (MP) in patients with acute traumatic spinal cord injury (SCI). The objective of this study was to identify patterns of practice and reasons for MP prescription in Latin America (LA). Materials and Methods: Portuguese and Spanish modified-versions of a questionnaire published by Hurlbert and Hamilton were used to evaluate the opinion about MP administration in acute SCI in LA. An e-mail request to participate in the survey was sent to members of AOSpine LA (AOSLA) with a cover letter explaining the objective of this study and an attached link to Survey Monkey. Bivariate and multivariate analyses were conducted with SPSS. Results: A total of 970 AOSLA members from 20 countries answered the electronic questionnaire, a response rate of 69%. Of the total sample, 834 surgeons (86%) reported that they routinely treat patients with acute SCI, and 56.1% of them reported routine administration of MP for these patients. Use of MP was associated with country, specialty, length of clinical practice and number of SCI treated yearly. Among the 468 surgeons that reported routine administration of MP, 56.1% believe in the clinical benefit, 29.3% do this because of fear of litigation, 27.1% because this is a protocol in their hospital, 3.5% because they believe that MP has no major adverse effect, and 30.7% administer it only to young patients. The rationales for MP administration in acute SCI were different among countries and specialty. It was observed that 63.9% of neurosurgeons believe that corticosteroids improve clinical outcomes versus 49.6% of orthopedic surgeons (Chi-square 9.24; P = .002). However, 38.5% of orthopedic surgeons reported that they administer MP because of fear of litigation versus 17.8% of neurosurgeons (Chi-square: 23.12; P < .0001). Regarding country, MP administration in Brazil, Argentina and Mexico is more associated with litigation fear and less associated with belief in clinical efficacy compared with the other countries. Fear of litigation) was reported by 50.8% of Brazilians, 53.8% of Argentines, and 29.1% of Mexicans. This reason was less likely to be mentioned in Chile (15.8%), Colombia (15.2%), Venezuela (12.2%), and Peru (3.0%). Logistic regression analyses demonstrate that fear of litigation as a reason for prescribing MP was independently associated with the orthopedic specialty (Adjusted OR: 2.45, CI95%: 1.49 – 4.02, P < .0001), and working in Brazil (Adjusted OR: 20.29, CI95%: 2.55 – 161.12, P = .004) or Argentina (Adjusted OR: 22.48, CI95%: 2.83 – 178.39, P = .003). Conclusion: Despite increasing evidence against routine MP administration in SCI and international guidelines not recommending its use, this potentially dangerous practice remains common in this continent. More than 50% of prescriptions are based on fear of lawsuit or hospital protocol. Educational campaigns are needed in LA to promote adherence to the current guidelines on MP for acute SCI and this would reduce incorrect practices guided by misperception of lawsuit issues., Introduction: Management of mean arterial blood pressure (MAP) is used to theoretically optimize neurologic recovery following spinal cord injury (SCI). When vasopressors are utilized, unique complications have been noted. The maintenance of MAP through vasopressor support may result in an increased risk of unacceptable complications. Material and Methods: Patients that sustained acute SCI from blunt trauma were identified from a trauma database. Demographic data was collected, including patient age, gender, ethnicity, and BMI. Injury data included injury severity score, severity and level of neurologic injury (initial and final ASIA impairment scale), and number and length of vasopressor usage. Patient outcome data included myocardial infarction, cerebrovascular accident, pneumonia, deep vein thrombosis/pulmonary thromboembolism, acute kidney injury/dialysis, albumin/prealbumin levels, length of ICU stay, hospital length of stay, and in-hospital mortality. An unexposed cohort of trauma patients that did not undergo MAP management was identified and matched to the exposed cohort based on similar injury severity scores. Demographics and outcome data were obtained for the unexposed cohort. Of note, none of the SCI patients received steroids in their management. Results: 67 acute SCI patients receiving MAP management were identified and matched to 67 patients from the trauma registry with similar injury severity scores that did not undergo MAP management. Patients in the MAP management cohort had similar average age (45.54 +/− 18.50 vs. 46.06 +/− 18.79), BMI (29.67 +/− 8.07 vs. 28.64 +/− 6.61), and injury severity score (23.40 +/− 8.87 vs. 23.18 +/− 8.65) to patients in the unexposed cohort. Patient in the MAP management cohort received significantly higher median number of vasopressors (1.00 vs. 0.00, P < .05) and longer duration of vasopressor use (3.90 +/− 2.55 days vs. 0.33 +/− 1.43 days, P < .05). Patients in the MAP management cohort had significantly longer ICU length of stay (14.94 +/− 15.06 days vs. 6.50 +/− 8.95 days, P < .05), longer hospital length of stay (23.31 +/− 22.17 days vs. 12.08 +/− 10.14 days, P < .05), and higher incidence of pneumonia (41.79% vs. 16.42%, P < .05). There was a non-significant trend toward higher incidence of deep vein thrombosis for the MAP management cohort (10.45% vs. 2.99%, P = .0956). Other outcome measures between the cohorts were not statistically different. Regarding neurologic recovery of SCI patients, 41% of patients had a complete injury and 59% had an incomplete injury. 57% of patients had a cervical injury, 41% had a thoracic injury, and 3% had a lumbar injury. Patients had an average recovery of −0.0476 +/−1.75 levels and 0.386 +/− 0.689 ASIA grade. Conclusion: Patients that underwent MAP management protocol had higher number and duration of vasopressors, higher incidence of pneumonia, longer ICU stay, and longer hospitalization than matched patients that did not undergo MAP management. The use of vasopressors may be associated with an increased risk of adverse complications and costs when compared to a physiologically similar cohort, with minimal gains in terms of neurologic improvement. Future prospective studies should be conducted to determine the efficacy of this practice., Introduction: Besides a patient reported outcome measure, there is a need for a simple, reliable and quick to administer tool that formalizes the most relevant clinical and radiological assessment parameters to reflect the spine surgeons’ perspective adequately. Therefore, the AOSpine Knowledge Forum Trauma initiated the development of a new concept of a clinician reported outcome measure for spine trauma (AOSpine CROST). This tool can be used by the treating surgeons, enabling them to evaluate and predict the clinical and functional outcomes of spine trauma patients on the short term (≤12 months) and long term (>12 months) post-trauma. Together with independent patient reported outcome, this tool will provide a holistic view of patients’ health in relation to their spine injury. Materials and Methods: Two separate cross-sectional online surveys were conducted among highly experienced spine surgeons from all world regions to identify relevant clinical and radiological parameters when evaluating clinical and functional outcomes of spine trauma patients. The first survey focused on the thoracic and lumbar spine (TL-survey), the second survey on the subaxial cervical spine (C-survey). Based on a systematic review, the recently developed AOSpine TL- and C-classification systems as well as expert interviews, 16 parameters were included in the TL-survey and 21 in the C-survey. Participants were asked to give their opinion on the relevance of each parameter on a 5-point scale. The results of these surveys formed the basis for the development of a draft version of the AOSpine CROST. This draft version was discussed and pilot tested in an expert committee meeting, and resulted in a definitive version to be validated. Results: Out of the 279 invited spine surgeons, 118 (42.3%) participated in the TL-survey and 108 (38.7%) in the C-survey. The most relevant clinical and radiological parameters were identified, and formalized in a draft version of the AOSpine CROST. After discussing and pilot testing this draft version among clinical cases during an expert committee meeting, a definitive version to be validated was developed, consisting of 10 parameters: neurological status, radiographic sagittal alignment, general bone quality, stability of the injured spine level, spinal column mobility, general physical condition, general psychological condition, functional recovery, wound healing, and implants. Conclusion: The perspectives of a highly generalizable cohort of worldwide experts were explored on clinical and radiological parameters most relevant to evaluate and predict outcomes of spine trauma patients. The identified parameters were formalized and pilot tested, which resulted in the development of a final version of the AOSpine CROST, consisting of 10 parameters. After further validation, the AOSpine CROST will be a helpful tool in clinical practice and research., Introduction: There is no outcome instrument specifically designed and validated for traumatic spinal column injury patients, which makes it is difficult to measure the effect size of various treatment options in a variety of traumatic spinal column injuries. The AOSpine Knowledge Forum Trauma aims to develop and validate such instruments that include both the patients’ and clinicians’ perspective. The International Classification of Functioning, Disability and Health (ICF) is used as the basis for the Patient Reported Outcome Spine Trauma (AOSpine PROST). Material and Methods: Based on the results of 4 preparatory studies and a consensus conference, the AOSpine PROST was developed. A pilot test of the first draft of the Dutch version was conducted among a consecutively selected representative sample of 25 traumatic spinal column injury patients from a level-1 trauma center in the Netherlands. Subsequently, this draft version was cross-culturally translated and adapted into English according to established guidelines in order to develop a final English version of AOSpine PROST. Currently, an international study among 4 Dutch and North-American centers is ongoing to assess the validity of both the Dutch and English versions of the AOSpine PROST. A preliminary analysis was performed to assess the test-retest reliability of the Dutch version, using Intraclass Correlation Coefficient (ICC). Results: The preparatory studies and consensus conference resulted in the selection of 25 ICF categories as core categories for patient reported outcome measurement in adult traumatic spinal column injury patients. Agreement was also reached on the response scale for use in the AOSpine PROST: the Numeric Rating Scale 0-100, with 0 indicating no function at all and 100 the pre-injury level of function. The AOSpine PROST was developed by clustering those 25 core categories into 19 items and implementing them in the selected scale: household activities, work/study, recreation and leisure, social life, walking, travel, changing posture, maintaining posture, lifting and carrying, personal care, urinating, bowel movement, sexual function, emotional function, energy level, sleep, stiffness, loss of strength, and pain. The pilot study of the Dutch version showed very good results for the comprehensibility, relevance, acceptability, feasibility, completeness and internal consistency (Cronbach’s alpha = 0.926). A preliminary analysis including 58 patients from the international validation study showed excellent results for the test-retest reliability of the Dutch version (ICC = 0.898). The average interval between the first and second administration was 9.4 ± 4.1 days (range: 6-27). Conclusion: Following the ICF methodology and including 4 different preparatory studies and a consensus conference, led to the development of a disease-specific patient reported outcome instrument for traumatic spinal column injury patients. Very good results were obtained from a pilot study. Currently, an international multicenter study is ongoing to subject the Dutch and English versions of AOSpine PROST to further validation. A preliminary analysis showed excellent results for test-retest reliability. Ultimately, the AOSpine PROST will be a helpful tool to compare various treatments and improve the quality of health care., Background: The prognosis for spinal cord injuries varies depending on the severity of the injury. There is always hope of recovering some function with spinal cord injuries. The completeness and location of the injury will determine the prognosis. The sooner treatments are implemented to strengthen muscles below the level of the spinal cord injury, the better the prognosis. The first year of recovery is the hardest as the patient is just beginning to adjust to his or her condition. The use of physical and occupational therapy during this time is the key to recovery. The extent of the function fully returning is typically seen in the first two years after the initial injury. To determine the neurological outcome of patients who presented early with those whose presented late. Materials and Methods: It is a descriptive case series done in the Department of Orthopaedics And Spine between Jan 2014 to dec 2016. 5.109 patients who presented to ER or OPD with spinal trauma were included.Those patients who were operated else where or having trauma of more than 10 days or those who were managed conservatively were excluded. After admission, history, examination, and investigations, surgical intervention was done on same day. Every patient was followed regularly for 2 years to assess the neurology.The data was analyzed using SPSS 17.00 Version. Results: There were 109 total patients that presented with spine trauma. 74 (67.9%) were male and 35 (32.1%) were females. Male to female ratio was 2.11:1. Of the 109 total patients that presented 78 (71%) were below 40 years of age and 41(28.5) patients were above 40. 17 (15.6%) had trauma to the cervical spine, 34 (31.2%) to the thoracic spine, 3 (2.8%) to the thoracolumbar spine and 55 (50.5%) to the lumbar spine. 79 (72.5%) patients had a fall from height. 26 (23.9%) were involved in road traffic accidents. 1 (.9%) had assault and 3 (2.8%) had sports injuries. At the time of presentation out of 109 patients, 97 (89%) had their neurology involved while 12 (11%) had intact neurology. 18 (16.5%) presented within the first 24 hrs while 91 (83.5%) presented after 24 hrs. All the patients were operated on the same day of admission.Among the 18 patient who presented with in 24 hours, 17 patients having full recovery with in 12.66 ± 1.2 months. While the late presenters only 15 patients got fully recovered after 2 years follow up while 42 patients having partial neurology recovery and 24 having just sensory improvement and 28 having no improvement after two years follow up. Conclusion: Spinal trauma is an emergency and having high morbidity and mortality rate. Early presentation and surgical intervention in spinal trauma patients having good neurological outcome as compared to delayed presentation and surgery., Introduction: Ankylosing Spondylitis (AS) is a chronic inflammatory disease that predominantly involves the axial skeleton. At its final stage AS is responsible for the spontaneous fusion of all spinal segments as well as sagittal imbalance and osteoporosis. Together these pathologic changes lead to higher risk of falls from height and a 3.3 times greater risk of vertebral fractures. The development of strategies for the treatment of vertebral fractures in AS patients seems to be a good asset for investment. The authors present a descriptive literature review regarding the treatment of vertebral fractures in AS patients. Material and Methods: A systematic review of PubMed was performed, using the terms “spinal fracture” and “ankylosing spondylitis”. The descriptive review included systematic reviews, prospective randomized control trials, prospective/retrospective cohort studies, case-control, and expert opinion, published from 2011 to 2016. Results: After assessment 38 publications were included, 60% of them published between 2014 and 2015 and 55% published in surgery related journals. The majority of the publications corresponded to retrospective cohort studies (53%), 11% cross-sectional studies and 10% prospective cohort studies. From 5 to 15% of AS patients suffers a vertebral fracture. The main mechanism is the hyperextension of a rigid and kyphotic spine, resulting in highly unstable fracture patterns. Previous back pain and structural damage are mostly attributed to disease-related inflammation making diagnose extremely difficult and delaying it in 60% of the cases. Neurologic deficit appears in 33-58% of the thoraco-lumbar fractures, being irreversible in most cases. Neurologic damage secondary to delayed diagnosis occurs in 15% of the patients. Computed tomography is considered critical for confirming the diagnosis of spinal fracture in AS, as well as MRI for a better lesion characterization. Non-operative treatment is an option, however the kyphotic deformity makes bracing difficult. Patients with AS often exhibit a number of co-morbidities, being more prone to complications, especially infection (14% after open surgery). Percutaneous instrumentation has gain popularity, mainly due to a lower amount of blood loss and infection rate. Due to osteoporosis, long lever arms and consequently, a high rate of implant loosening (10% to 15%), most authors recommend multi level internal fixation, with cemented pedicle screws in selected cases. Concerning cervical fractures, the posterior approach allows to reduce the lever arm, being recommended due to biomechanical superiority. Many studies report a higher life expectancy after surgical treatment of vertebral fractures in AS patients, when compared with non-operative treatment. Conclusion: Prevention as wells as early diagnosis and treatment of vertebral fractures in AS patients are the key for a successful outcome. This group of patients present a higher rate of morbidity and mortality, but surgical treatment, especially minimally invasive techniques allow a better outcome. Literature is scarce and high evidence level studies are needed., Introduction: Acute Traumatic Spinal Cord Injury (TSCI) is very common and is often associated with significant morbidity and mortality. Optimal management is impaired by lack of pre hospital care, near absence of universal health insurance and inadequate support services despite improved training and availability of spine surgeons in our practice. The purpose of this study is to evaluate the impact of patient and injury characteristic on patient care and outcome as well as to highlight challenges associated with care of these injuries in our facility. Materials and Methods: This is a retrospective review of patients with spine/ spinal cord injury managed in our institution over 24 months (1st September 2014 to 31st August 2016) using a predesigned proforma. Data collected include biodata, prehospital transport and care, time between injury and presentation, spinal cord segment involved, ASIA score at admission and at time of death or discharge from hospital. The data were analyzed using Statistical Package for Social Sciences (SPSS) 20.0 (SPSS Inc. Chicago, Illinois, USA); p-value ≥ 0.05 was set as significant. Results: A total of 105 patients with suspected spine injury were seen during the period. 83 patients with clinical and radiological evidence of spinal cord injury were studied. Most of the patient were male (81%), the mean age of the patient is 37.39 ± 14.62. Motor vehicular crash account for the commonest cause of injury 59.0%, followed by falls 25.6%. Most injury involved the cervical spinal cord (66.7%). most of the patient (69.2%) presented within 24 hours of injury and 51.3% of these patients were transported by relatives in private cars to the hospital, while only 33.3% were brought to the hospital in an ambulance. None of these patients had a standard pre hospital treatment. Injury was complete (ASIA A) in 35.9%. Pressure ulcer occurred in 12.8%. Thirty-two patients were to be operated based on injury pattern, however only 16 patients had surgical intervention. Most of the surgeries were delayed beyond 2 weeks mainly due to financial constraints, other reasons for delays include implants availability and complications. Most surgeries were anterior cervical approach including ACDF. Four patients died while waiting for surgery while 2 patients declined surgery for financial reasons. Conclusion: Despite improved training of spine surgeon and better facility for care, acute traumatic spinal cord injury remained a significant cause of morbidity and mortality in our practice due to challenges related to intervention., Introduction: Effective management of patients after lumbar surgery requires acknowledging the complexities of co-existing physical and psychosocial variables. Preoperatively identifying these variables, particularly those leading to greater resource utilization, would facilitate in-hospital and discharge management. While effects of surgical and medical variables are well known and there are standard methods to measure them, less is known about the role of psychosocial variables and how to measure them preoperatively. The goal of this analysis was to assess whether preoperatively measured psychosocial variables predict longer length of stay and special discharge requirements after lumbar surgery, independent of surgical and medical variables. Material and Methods: This was a prospective cohort study of 532 consecutive patients undergoing lumbar surgery for diverse diagnoses. Several days before surgery patients completed several surveys, including the Geriatric Depression Scale, the Spielberg State Anxiety Inventory, and a question about tangible social support (“during the past four weeks, was someone available to help you if you needed and wanted help” with five response options ranging from “yes, as much as I wanted” to “no, not at all”). Medical comorbidity was scored according to the Charlson Comorbidity Index, and extent of surgery was described according to the Spine Surgical Invasiveness Index, a validated instrument accounting for vertebral levels, fusion, instrumentation, and approach. The primary outcomes were hospital length of stay (LOS), dichotomized according to routine hospital stay of ≤3 days or >3 days; and requiring services at discharge, dichotomized as to home or to an institution/home with services. Two logistic regression models were considered with LOS and required services at discharge as dependent variables. Results: Mean age was 56 years, 55% were men, 79% had a chronic spine diagnosis, 40% had a positive screen for depression, 62% had greater anxiety than population norms, 77% reported as much social support as they wanted, 2% reported no support, 30% had major medical comorbidity, and 35% were obese. Surgical invasiveness was not normally distributed and was divided into quartiles. 53% has LOS >3 days; in multivariable analysis, longer LOS was predicted by a positive screen for depression (OR 1.6, P = .05), less social support (OR 1.3, P = .04), obesity (OR 1.8, P = .01) more invasive surgery (OR 3.0, P < .0001), older age (OR 1.8, P = .01) and being female (OR 2.0, P = .002). 17% required services at discharge; in multivariable analysis, requiring services was associated with a positive screen for depression (OR 1.9, P = .02), more anxiety (OR 2.4, P = .003), less social support (OR 1.3, P = .04), more comorbidity (OR 1.7, P = .04), older age (OR 3.3, P < .0001) and more invasive surgery (OR 1.9, P < .0001). Conclusion: Psychosocial variables predicted LOS and requiring services after discharge independent of medical comorbidity and extent of surgery. Our analysis is unique because it included psychosocial variables, particularly social support, in the analysis of perioperative outcomes. Our study demonstrated that patients undergoing lumbar surgery are complex in terms of the variables that affect outcomes. In addition, our study showed that these variables can be measured relatively simply and thus can be used proactively to plan perioperative resource utilization., Introduction: Epidural steroid injections (ESI) are an important diagnostic and treatment modality in spine pathology, most notably radiculopathy. The success of these injections has been attributed to the anatomic location reached by the injectate. Both the diagnostic and therapeutic applications for ESI assume that the injectate remains local to the injection site to achieve its effects. However, substantial injectate diffusion after lumbar epidurals has been demonstrated using computerized tomography assessments. While the clinical utility of cervical ESI has been established, little is known about the actual injectate diffusion. The purpose of the current study was to evaluate the injectate dispersal pattern after cervical interlaminar ESI using magnetic resonance imaging (MRI). To the authors’ knowledge, there have been no studies evaluating spinal injectate dispersion using MRI. Material and Methods: After Institutional Review Board approval was obtained, patients were recruited from the spine clinics at the authors’ institution. Patients undergoing standard-of-care cervical ESI who met study criteria were consented. A single fellowship trained musculoskeletal radiologist with extensive experience in administering interlaminar epidural steroid injections performed all of the injections under sterile technique. A 10.1 ml mixture containing 2 mL of 10 mg/ml dexamethasone, 8 ml normal saline, and 0.1 mL of gadolinium contrast was injected with a 22-gauge Tuohy needle into the posterior epidural space at the C7-T1 interval using the pressure release method under fluoroscopic guidance. Within 15 minutes of completing the injection procedure, study participants underwent a cervical spine MRI. T1-weighted sagittal and axial images were used to evaluate the post-injection dispersal pattern. A single board certified radiologist measured the dispersal patterns for axial and circumferential extent using calibrated internal measurement software. Results: A total of 20 patients were consented and enrolled in the study. Four patients were not included in the statistical analysis of the study; 2 patients withdrew and 2 patients were post-consent screen failures. A total of 16 patients (8 males and 8 females) completed the cervical ESI with gadolinium and subsequent MRI. The average age of study participants was 51.18 years old (range 39-64) with average BMI of 29.18 (range 23-35). MRI findings revealed all 16 patients had circumferential dispersal of the injectate. Average cranial migration was 8.11 cm (standard deviation 1.78 cm, range 3.3 to 10.7 cm). Average caudal migration was 6.63 cm (standard deviation 3.35 cm, range 0 to 10.7 cm). Average craniocaudal extent was 14.73 cm (standard deviation 3.15 cm, range 9.3 to 18.7 cm). The caudal epidural extent went below the field of view for 5 of the patients. There were no adverse events reported from the injectate or injection procedure. Conclusion: Fluoroscopy-guided cervical interlaminar ESI resulted in nearly uniform circumferential dispersal within the epidural space with multiple level migration in the cranial and caudal directions. A better understanding of spinal injectate dispersion can help to guide treatment, especially in patients with multilevel disc disease. This study supports using MRI as a safe and accurate tool to evaluate spinal injectate dispersal., Introduction: Despite increased focus on patient satisfaction as a measure of healthcare quality, the factors that influence it are incompletely understood. Postoperative pain, pain management, and patient satisfaction with both of these components are important considerations in postoperative patient care. The aims of this study were to determine the relationships between patient reported pain, inpatient pain medication consumption, satisfaction with pain control, and overall satisfaction with inpatient admission following spine surgery. Material and Methods: A retrospective review was performed for all patients with a completed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey during the study period. Daily averages of patient reported pain using the numerical rating scale (NRS), narcotic usage converted to morphine equivalents, alternative pain medication usage, length of stay, and patient reported satisfaction obtained from HCAHPS surveys were recorded. Statistical analyses were performed to evaluate for correlations between these variables. Results: Of the 316 patients meeting inclusion criteria, 49.7% of patients reported that their pain was “always” controlled and 73.8% were “satisfied” with the hospital admission based on HCAHPS survey response data. There was no association observed between type or amount of pain medication use, including opioids, and satisfaction with pain control nor with the hospital in the postoperative inpatient admission setting (P > .05). The average NRS scores for patients that were satisfied versus those that were not satisfied was nearly identical (3.16 vs. 3.19, P = .89). The perception that staff did everything to provide pain control was significantly associated with hospital satisfaction (P < .001). Conclusion: This study demonstrates that increased narcotic consumption did not correlate with greater pain satisfaction while the perception by patients of the efforts provided by the care team to manage pain did significantly correlate with satisfaction. These results emphasize the importance of open communication and dialogue with patients regarding their experiences and treatment plans while questioning the assumption the provisions of greater amount of narcotics will increase satisfaction., Introduction: A novel ELND (Epidurscopic Laser Neural Decompression) provides an alternative less-invasive technique for treating lumbar spine pathology. This study reports on the outcomes and complications of ELND. Material and Methods: Between October 2008 and September 2015, a total of 219 patients underwent ELND. Indication is central canal stenosis, lumbar disc herniation, chronic lower back pain, post lumbar surgery syndrome. They are no improvement in back pain or radiating pain despite several conservative treatments for a minimum period of 3 months, where the conservative treatment included medication, physical therapy, and injection treatment. Clinical outcomes were evaluated using the visual analog scale (VAS) at follow up days. For the post-procedure complication, we reviewed the medical records and called to the patients. Results: The mean age was 67.1 ± 7.8 years and mean follow-up period was 34 ± 3.1 months. Distribution of disease is spinal stenosis, 94 patients (64%), lumbar disc herniation, 31 patients (21%), post lumbar surgery syndrome, 21 (14%), chronic low back pain, 2 patients (1%). In VAS flow for every disease, lumbar disc herniation is more effective pain improvement than other disease. There is no permanent or chronic complication. Conclusion: In back pain or radiating pain for spine pathology, epiduroscopic laser neural decompression is effective non-surgical treatment. It is more effective for lumbar disc herniation., Introduction: Sport specific funding has increased in the UK to £543 m and prevalence of spondylolisthesis in the athletic population is shown to be 13.9% compared with the general population at 6%. There is limited literature of athletes with healed pars fracture (with bone scan evidence) or spondylolysis and spondylolisthesis returning to sport effectively after either exercise or bracing and this is poorly documented as to type of rehabilitation involved.(1) There is no evidence regarding sports specific retraining for this group of patients. This series demonstrates that a highly individualised assessment is paramount in designing a bespoke physiotherapy programme in returning athletes with bilateral non-union radiologically evident fractures to full performance level and potentially could be utilised in prevention of the injury. Materials and Methods: Four patients who were elite athletes with GB rankings presented with low back pain which was experienced during their sporting activity preventing them from competing. They were aged 17-20 years and participated at National GB Level, in the following sports; triple jump, 100 m, 200 m and 400 m sprint, hurdles and pairs ice-skating. All had radiologic evidence of bilateral spondylolysis and or spondylolisthesis grade one. Outcome measures used were Oswestry Disability Score (ODI) and return to specific sport competition. Highly individualised assessment incorporating sport specific positions and requirements revealed techniques and positions which pre disposed the athlete to injury and perpetuated back pain. A specific rehabilitation programme to target these areas of insufficiency was devised and progressed according to their achievement and demands of the sport. This included neuromuscular control and patterning incorporating multi-planar work from static to dynamic, video feedback and analysis. Results: All the athletes returned to sport at their previous level or higher and none underwent surgery. The triple jumper received a sport scholarship to USA and achieved PB 15.19 m after a year out of competition, qualifying nationally but missing Olympic qualification. The sprinter returned to national university championships, the hurdler returned to competition the following season with 100 m hurdles and the ice skater returned to skate in ice dance competitively. ODI ranged from 20% pre-treatment to 2% post -treatment with all scores significantly improved. Average change in improvement was 16%. Conclusion: This series shows how an individualised assessment and highly specific rehabilitation programme can be effective in returning athletes with radiological evidence of spondylolisthesis pain free to their original sporting levels. Although the prevalence of spondylolisthesis is low within the general population, it is double that within the athletic population and the high physical demands can result in “devastating consequences” on their careers. A specific bespoke programme is effective in realistic high level return to sport. It also suggests that a highly individualised assessment of specific sports techniques applied at an earlier stage of an athlete’s development may result in less injury and loss of competition form. References 1. Bouras T, Korovessis P (2015) ‘Management of spondylolysis and low-grade spondylolisthesis in fine athletes. A comprehensive review Eur J Orthop Surg Traumatol 25 (suppl 1): S167-S175., Introduction: Long-term opioid treatment of low back pain (LBP) is one of the main drivers of opioid dependency and abuse. In the US, opioid medication causes more deaths than any other routine medical treatment of nonfatal conditions and opioid abuse has recently evolved into a national epidemic. It is somewhat surprising that evidence on the efficacy of opioids in the treatment of LBP is lacking. The largest meta-analysis of randomized controlled trials (RCT) comparing opioids to placebo in the treatment of LBP found no evidence for long-term superiority of opioids and only moderate quality evidence for short-term superiority (, Introduction: In lumbar spine degenerative disorders, the clinical presentation may course with pain typically affecting the back or have distribution into the leg or both. Regardless the pain component, the severity of the symptoms is associated with some degree of disability. However, it is still not totally clear which component of pain, if axial back pain or leg distribution, has the highest impact over patient quality of life. The purpose of this study was to characterize which pain component, if leg or back pain, have the more negative influence on functional disability of patients in nonsurgical treatment for degenerative lumbar disorders. Material and Methods: This is a retrospective study including patients undergoing nonsurgical treatment for degenerative lumbar disorders between March and December of 2015 at a single institution. Patients with lower limb disability were excluded. A numerical rating scale (NRS) of leg and back pain were collected and the Quality of Life (QOL) evaluated by the Oswestry Disability Index (ODI) and the SRS-22 questionnaires. The patients were divided in two groups: NRS back pain > leg pain and NRS back pain ≥ leg pain and the QOL parameters were compared between the groups. The NRS leg and back pain was correlated with scores on the SRS-22 and ODI profiles as well. Results: The 179 patients studied include 134 women (74.9%) and 45 men (25.1%). Comparison based on the pain component revealed most significant SRS-22 pain in patients with back pain ≥ leg pain (P = .034) as well as a trend to worst SRS-22 total score (P = .078). Significant correlation was identified of both NRS leg and back pain with ODI and SRS-22 (pain, appearance, activity, mental and total) scores, but greater correlation was obtained with back pain. Conclusion: This study provides evidence that, in lumbar degenerative disease, back pain has the most significant impact on the self-reported patient disability, compared with leg pain. Patients with higher NRS back pain have worst SRS-22 pain score than patients with higher NRS leg pain., Introduction: Low back pain imposes a considerable social and economic burden as one of the most serious public health issues in the developed nations and is one of the most common reasons for presentation to primary health care providers, outpatient or A&E departments. Currently point prevalence of acute low back pain adds up to 40%, one year prevalence exeeds 70% and life time prevalence equates 80%. In Germany therapy costs add up to 50.000.000 Euro per year matching 12.2% of Germany’s gross national product. While risk factors impose in male gender, age, unmarried martial status, and low education level. While the clinical guidelines of the national and international scientific associations provide recommendations regarding medication and physical therapy many questions remain unanswered regarding therapy methods and their value. Material and Methods: 100 patients were matched within 2 groups (chronic back pain vs healthy patients). Amongst the parameters collected were: Patients history, clinical exam, questionaires (NASS, Oswestry, VAS, SF 36) and the MFT S 3 check. The difference in proprioceptive performance within the groups were adressed upfront and at the end of a 18-weeks programm (3 level programm 6 weeks each) of active physical therapy or vibration therapy measuring the sensomotoric index, stability index and symmetry index sitting and standing. Results: No significant difference was found concerning postural stability (sensomotoric index, stability index and symmetry index sitting and standing) within the 2 groups (Mann-Whitney-U-Test) upfront. Though the patients with chronic back pain showed a tendency towards depression in the questionaires. At the end oft he 18 weeks programm patients within the physiotherapy group showed significant improvement of the sitting and standing sensomotoric and stability index while the improvement within the vibration therapy group wasn’t significant. None of the therapies showed superiority respect of absolute differences. No significant differences were seen concerning HADS, ODI, NASS, SF-36. While consisting depression influences pain no other co-variables showed influence in outcome and improvement. Conclusion: Wholebody-vibration might be an effective tool to support proprioception and postural stability, improve balance and strength as an alternative to physiotherapy., Introduction: The basivertebral nerve (BVN) is a sensory nerve within the vertebral body, whose role in pain transmission is thought to be a source of chronic low back pain associated with degenerative vertebral bodies and endplates. The safety and efficay of a novel intraosseous bipolar radiofrequency system (INTRACEPT™) for ablation of the BVN was evaluated in this trial. Material and Methods: 225 patients with chronic low back pain refractory to >6 months of conservative care were enrolled at 18 sites in the United States and Germany in this prospective, double blinded, randomized, sham controlled trial (147 active vs 78 sham arm). MRI had to demonstrate Type 1or 2 Modic changes at, Introduction: The ultimate goal in the surgical management of early onset scoliosis (EOS) is to prevent curve progression while maintaining longitudinal spine growth. Although current surgical techniques (dual growing rods, VEPTR) may prevent curve progression, repetitive interventions are required to lengthen the implants. The Modern Luque Trolley technique has been described in which no repetitive surgery is required for spinal growth. The construct consists of the standard proximal and distal fixed anchors found in dual growing rod with additional gliding spinal anchors capturing the apex of the curve. The aim of this study was to further assess the safety and efficacy of this self-growing rod construct in patients with EOS. Material and Methods: In this retrospective study, we reviewed x-rays and clinical chart of fifteen patients (including the original five) who underwent this self-growing rod construct between 2003 and 2014. Spontaneous spinal growth was measured on anteroposterior x-rays (from T1-L5), and was compared to the expected spinal growth predicted by Demiglio methos. (A. Demiglio et al. 2012). Demographics, underlying diagnosis, follow-up length, correction and maintenance of deformity, number of procedures, and complications were all recorded. Results: The mean age at surgery was 8.8 years (95% CI: 7.4-10.2) and the average follow-up length was 4.2 years (95% CI: 3.3-5.1). The average cobb angle measurements were 64.39 degree pre-operatively (95% CI: 54.18 - 75.68) and 24.79 degree post-operatively (95% CI:18.88-30.69). The average spontaneous spine growth was 1.1 cm per year of follow-up (95%CI: 0.5 -1.8), while the average Cobb angle progression (recurrence) after surgery was 0.31 degrees per year (95% CI: 0.21-0.41). The cohort achieve 65.3% of their expected spinal height with a 95% CI of 50-80%. Six out of fifteen cases grew to the expected growth for their age, while two failed to self-grow and were converted to a non-self-growing construct. The cases that had poor growth had large initial deformities, and large post surgery deformities. We found a moderately inverse correlation between the post-operative Cobb angle and amount of spontaneous height gain (Pearson’s R: −0.575, p 0.012). Three cases outgrew their construct requiring revision surgery to lengthen their rods. Conclusion: Self-growing rod construct is an option for managing EOS without the morbidity of repetitive surgery. Patient selection is critical to ensure good outcome. To optimize spontaneous spinal growth, apical vertebra must be brought to midline by achieving maximal Cobb correction. However, questions such as the effect of wear debris and the risk of spontaneous fusions still remain., Introduction: Shilla technique is a surgical procedure described by R. McCarty that allows the control of the scoliotic deformity in young growing children. The main complication in these patients with early onset scoliosis, operated by classic posterior instrumentation, is the continuation of vertebral body growth and curve deterioration that was described as the crankshaft phenomenon. The Shilla technique, by inserting pedicle screws in the apex of the deformity should theoretically prevent this phenomenon. The purpose of this study is to evaluate the capability of Shilla technique in preventing the crankshaft phenomenon in the treatment of the severe scoliosis in young growing children. Material and Methods: 11 scoliotic children (3 M, 8F), Tanner 0, with a mean age of 9 years (4 to 11 years), and a mean preoperative Cobb coronal angle of 57° (thoracic curve 67°, lumbar curve 55°), were operated by Shilla procedure and were reviewed with a mean follow-up of 4 years (3 years to 6 years 4 months). Seven patients had their final fusion. The number of procedures, except for final arthrodesis, was one in 5 patients and two in 6 patients. Results: The growth continued in all children from 67 cm of sitting height on initial examination to 72.5 cm at final follow-up. The coronal angle was corrected form a mean of 57° to 34° at immediate post-op then increased to 50° at final follow-up. In 7 children, the initial post-op correction deteriorated in both, the “bridged curves” which are the non-fused non instrumented apex curves (54° → 40° in immediate post op → 55° on final follow-up) and in fused instrumented apex curves (67° → 35° in immediate post op → 51° on final follow-up). In the 4 remaining children, there was no deterioration of the curve on the last follow up. Conclusion: The loss of correction we observed is due to Crankshaft Phenomenon. Even though this was expected to happen in bridged curves, it also occurred in the apex fused-instrumented curves. The mean age of the children who deteriorated (10 years 9 months), appears to be its main cause, since these patients were in their ongoing growth spurt. The children with controlled curves having a mean age of 7 years 8 months had not reached yet the growth spurt. In conclusion, the Shilla technique, even in apex fused instrumented curves, was not able to control the Crankshaft Phenomenon during this growth period. This should be taken in consideration for the timing of the final fusion., Introduction: The development of chronic pain is well recognized as an expensive and debilitating public health issue. In the clinical context, knowing which aberrant process is at play would help clinicians to better treat the offending process. Identification of endogenous excitatory and inhibitory mechanisms that are involved in chronic pain seems to be a good indicator of the treatments that will be effective for patients, enabling a more targeted and personalized approach to alleviate pain. We hypothesize that even if two patients present apparently similar clinical diagnosis (eg, scoliosis, chronic pain), the implicated neurophysiological mechanisms will differ and therefore patients will not respond to the same treatments. Material and Methods: Seventy adolescents with idiopathic scoliosis aged between 10-18 years old and reporting persistent back pain (>6 months) were enrolled in a preliminary study. Patients were asked to perform a quantitative sensory testing (QST) to measure changes in regulation of the neurophysiology underlying the nociceptive processes based on the patient’s pain interpretation. A conditioned pain modulation (CPM) procedure with hot water as conditioning stimulus and contact heat as test stimulus was performed. Patients were also asked to complete the following questionnaires to assess the various dimensions of pain: Neuropathic Pain Questionnaire (DN4); Functional Disability Index (FDI); Pittsburgh Sleep Quality Index (PSQI); Revised Children Anxiety and Depression Scale (RCADS) and The Adolescent Pediatric Pain Tool (APPT) assessing the location, intensity and quality of pain. Results: Mean pain intensity was of 7 (range 3-10) on a scale 0-10. Frequency of pain was reported to be everyday in 47% of patients. Location of pain was predominantly in the middle back region (93%) and was of duration of more than a year in 73% of patients. CPM results revealed variability in efficacy to inhibit a pain response, with 42% of the cohort demonstrating a sub-optimal endogenous inhibitory response. Presence of a neuropathic component of pain was found in 22% of patients. Sleep quality was reported to be poor in 78% of patients, and moderate to severe functional disability was reported by 25% of patients. Medication for pain relief was taken on a regular basis in 43% of the cohort. Conclusion: These results support the need to improve our understanding of pain processing in AIS patients. Identified sensory, functional and emotional differences in patients’ pain profiles will allow for personalized therapeutic approaches to improve patient-oriented clinical care., Introduction: Spinal cord-level osteotomies are increasingly used for posterior-only kyphosis correction in children. The segmental distribution of correction after pedicle subtraction osteotomies (PSO) in children remains unclear. This is the first study to outline the distribution of kyphosis correction after cord-level PSO in children and evaluates its implications on the neurological safety after osteotomy. Material and Methods: 15 patients with severe thoracic kyphosis with normal pre-operative neurology undergoing PSO above L1 were included. Average age was 12.3 years (range 7 to 14). Relative sagittal angle correction at the osteotomy and at the adjacent segments, sagittal vertical axis (SVA) and angle of osteotomy was measured utilizing pre & post-operative standing AP & lateral radiographs and measurement software. Results: There were no post-operative neurological deficits. Mean pre-op kyphosis was 107.3 degrees (range 93-133) and mean post-op kyphosis was 53.7 degrees. Mean percentage correction of kyphosis was 45.7% (SD = 6.6). The proportion of sagittal plane correction contributed directly by the osteotomy was 49.3 degrees (range 42-55), whereas the adjacent segments cepahlad and caudad contributed a total of 45 degrees of the correction (Apex+1 = 4.5°, Apex+2 = 2.3°, Apex+3 = 1.3°, Apex+4 = 1° and Apex-1 = 5.5°, Apex-2 = 7.8°, Apex-3 = 8.5°, Apex-4 = 7.5°, Apex-5 = 6.8°). Mean relative shift in the SVA was 17.1 mm (pre-op 26.2 to post-op 9.1 mm). Conclusion: The results document the safety of cord level PSO for severe thoracic kyphosis in children when performed with wide laminectomy in neurologically intact patients. Vertebral segments above and below osteotomy contribute an additional and nearly equal amount of sagittal plane correction to that achieved by osteotomy. Pedicle subtraction osteotomies in children are effective in obtaining sagittal plane correction by focal correction at the level of the PSO and also at adjacent segments of the spine Surgeons can take advantage of the flexibility of the pediatric spine in severe kyphotic deformity correction., Introduction: In an AOSpine knowledge forum deformity study concerning adolescent idiopathic scoliosis deformity surgery international consensus was reached to systematically monitor and registration of patient-related outcomes (ie, patient-reported outcome measures [PROMs] and clinician-based outcome measures).1 Fusion surgery in adolescent deformity is commonly performed and aimed to prevent progression of the curvature and to improve clinical symptoms. Studies evaluating surgical outcomes are mainly based on radiographic measurement of the curvature.2 Evaluation of outcome domains as functioning and health-related quality of life from the patients’ perspective after surgery is recommended,3 but often remain relatively underexposed. Standardization of patient-related outcomes and continuous outcome monitoring of outcome measures covering relevant domains from a patient’s perspective, will play an important role in future reimbursement and in healthcare systems (ie, value-based healthcare).4 The purpose of this study is to evaluate the one-year follow-up patient-related outcomes in consecutively enrolled patients undergoing adolescent spine deformity surgery measured with a standardized and continuous outcome measurements. Material and Methods: This is a single institution prospective consecutive enrolment cohort study. Since March 2014 all patients undergoing scoliosis surgery are systematically monitored over time and registered in an online web-system, which is connected to the patients’ electronic file. Routinely, relevant patient characteristics, radiological, and peri-operative parameters are measured and reported. Patient-reported outcomes used: ODI (functional status), SRS22r and EQ5D (health-related quality of life). Preoperative and one-year follow-up data of patients aged ≤20 years, were studied. Improvement over time is evaluated with the Student’s t-test. The clinical relevancy of patient-reported outcomes is determined by means of previously reported minimal clinical important changes (SRS)5 and a satisfactory symptom state comparable to healthy persons (ODI).6 Clinician-based outcome measures were post-operative complications and revision surgery. Results: 83 patients with adolescent deformities were included for analysis (age 15.1years [SD1.80], range 12-19; females [n = 68; 81.9%]): adolescent idiopathic scoliosis (n = 72), congenital scoliosis (n = 8), secondary scoliosis (n = 3). PROMs response rates: preoperatively 97.1% (134/138), at 1-jaar follow-up 60.1% (83/138). Pre-operatively, the non-responders did not differ from those who completed the PROMs. Patients improved significantly on ODI, EQ5D, SRS-pain, SRS-self-image, SRS-satisfaction, and SRS-total (P < .05). At the 1-year follow-up 76 (91.6%) reported to be satisfied with their back, which is comparable to the ‘normal’ healthy population (preoperatively n = 58 [69.9%]) and 65 patients were relevantly improved on SRS-self-image (78.3%). The number of registered complication was 7 (8.2%) and in 2 patients (2.4%) revision surgery was performed. Conclusion: After adolescent spine deformity surgery patients experience a relevant improvement in functioning health-related quality of life, self-image and satisfaction. The number of registered complications and performed revision surgeries are relatively low. The one-year response to the questionnaires is acceptable, a higher response is recommended to use the results for future studies and to use the as reliable and valuable information for quality control. As scoliosis is surgery is regarded as high complex care, insight in results continuous and standardized outcome monitoring is important to improve outcomes and with that the quality of spine care, which is the basis for value-based spine care. References 1. De Kleuver M, Lewis SJ, Germscheid NM et al. Optimal surgical care for adolescent idiopathic scoliosis. An international consensus. Eur. Spine J. 2014; Dec;23(12):2603-18. 2. Weinstein SL, Dolan LA, Cheng DC et al. Adolescent Idiopathic Scoliosis. Lancet 2008;371:1527-37. 3. Bagó J, Climent JM, Pérez-Grueso FJ, Pellisé F. Outcome instruments to assess scoliosis surgery. Eur Spine J. 2013 Mar;22 Suppl 2: S195-202. 4. Porter M. What is Value in Health Care? N. Engl. J. Med. 2010; 2477–2481. 5. Bagó J, Pérez-Grueso FJ, Les E et al. Minimal important differences of the SRS-22 Patient Questionnaire following surgical treatment of idiopathic scoliosis. Eur Spine J. 2009 Dec;18(12):1898-904. 6. van Hooff ML, Mannion AF, Staub LP et al. Determination of the Oswestry Disability Index score equivalent to a “satisfactory symptom state” in patients undergoing surgery for degenerative disorders of the lumbar spine-a Spine Tango registry-based study. Spine J. 2016 Jun 22. pii: S1529-9430(16)30245-5., Introduction: The aim of this study is to address the progressive modulation of the most wedged vertebra by evaluating the role of the non-fusion instrumented procedure with posterior tethering as adjunct to lengthening by distraction in facilitating spinal modulation of the wedged peak vertebra, in patients with congenital thoracolumbar kyphosis/kyphoscoliosis according to the Hueter-Volkmann law. The authors seek to address the progressive modulation of the most wedged vertebra by analyzing the subjects’ pre-operative and latest follow-up sagittal radiograph. Material and Methods: Ongoing data collection of 14 peak wedged vertebra modulation during surgical management of 13 patients with Type I congenital thoracolumbar kyphosis (5 patients) or kyphoscoliosis (8 patients). Analyzing the subjects’ pre-operative and latest follow-up sagittal radiograph was done .Age at initial surgery averaged 58.6 months, with mean follow-up of 55.6 months (24-78). All were done with Hybrid Rib Construct with clawing fashion through a single posterior approach with at least 4 lengthenings. Results: Two vertebral bodies were selected, the peaked deformed vertebrae within the instrumentation compression level (WICL) and the vertebrae nearest but outside the instrumentation compression process (OICL). Anterior vertebral body height (AVBH) and posterior vertebral body height (PVBH)were measured in both vertebral bodies. Regarding measured vertebrae (WICL) average preoperative anterior/posterior vertebral body height ratio significantly increased from 0.54 to 0.77 in the final follow-up. Regarding measured vertebrae (OICL), the average preoperative AVBH/PVBH ratio increased from 0.76 to 0.79 in the final follow up. Modulation can be confirmed in the most deformed vertebrae (WICL) as the difference between the change in AVBH/PVBH ratio between vertebrae (OICL) and (WICL) was statistically significant (P < .001). Conclusion: Through the compression model adjunct to lengthening through distraction implemented in the surgical management of Early Onset Scoliosis, wedging improves through vertebral modulation (WICL) in comparison with the (OICL). This calls for further studies on the impact of surgical correction of EOS on modulation of the vertebrae., Introduction: Correction maneuvers employed in spine deformity surgeries require the application of high forces and torques, and may induce plastic strains in the posterior instrumentation. Aim of the study was to quantify the plastic strains, which arise during the surgical correction of spinal deformity and estimate Co-Cr rod deformation in surgical treatment of patients affected by adolescent idiopathic scoliosis (AIS) and its possible correlation with different risk factors. Material and Methods: From March 2011 to December 2015 150 patients affected by AIS underwent posterior instrumented fusion. Two 5.5 mm Co-Cr rod were implanted in all patients. Cobb angle value, sagittal balance, rod curvature angle (RC) were evaluated. RC changes were registered and correlated to each factor in order to establish a possible statistically significance in a multivariate analysis. A four point bending tests was experimentally conducted on cobalt-chrome rods in order to quantify their fatigue life. A finite elements analysis (FEM) was conducted in order to establish the percentage of Co-Cr rod deformation after prebending and intraoperative correction maneuvers. Results: Radiographic analysis showed a different mean rod deformation for concave and convex side; 7.8° and 3.9° respectively. At 1 year minimum follow-up RC value increases of 1.5° only for the concave side. At 3,5 years mean follow-up RC value increases of 2,7° for the concave side and 1,3° for the convex, p > 0,05 . FEM showed as prebending influences rod biomechanical properties and its resistance to fatigue. In situ compression and distraction manoeuvres seems to affect more than prebending the biomechanical properties of Co-Cr rod. Comparisons with the experimental tests showed that plastic strains are compatible with a reduced fatigue life of the rods, and thus with an increased risk of early mechanical failure. Conclusion: The use of prebent rods and adequate manufacturing techniques may improve the endurance of spinal instrumentation. Not only rod biomechanical properties but also BMI, age, Risser grade, type of instrumentation, surgical release play an important role in deformity correction and its maintenance over time., Introduction: Magnetically Controlled Growth Rods (MCGRs) received their EU approval in 2009 and FDA approval in 2014 to be used in the treatment of severe cases of early onset scoliosis (EOS). Main advantage of the design is the non-invasive lengthening of the rods in Outpatients Clinic using an external remote controller, thus reducing the number of surgeries and decreasing the chances of infection. However, there have been reports documenting failure of distraction and severe patient reactions, alerting the surgical community about the use of this device and the best monitoring of patients. Material and Methods: This is the first retrieval study involving 17 MCGRs, of the same manufacturer, from 10 patients, revised for metal staining of the skin, progression of scoliosis, swelling, failure of distraction and final fusion. We also collected imaging data for each patient, while all patients and their guardians consented for these implants to be used for this study. First we macroscopically and microscopically inspected the implants, documenting the patterns on the telescopic part of the rods using DSLR photography and optical microscopy, respectively. All implants were radiographed to determine the state of the internal mechanism, while two of them were scanned using a micro-CT prior to sectioning. Scanning Electron Microscopy (SEM) and Energy Dispersive X-ray Spectroscopy (EDX) were performed to identify the surface changes and the elemental composition of debris in the internal mechanism and the telescopic part of the rod. Results: Plain radiographs revealed that 6 out of the 17 MCGRs had a fractured pin in the internal mechanism, while all of them showed signs of surface degradation on the telescopic part of the rod. Surface degradation is linked to the relative movement between the actuator and the telescopic part of the MCGR. The rods with intact pin shared the same pattern of surface degradation, described as distinct lines, parallel to the direction of lengthening, the number of which was indicative of the number of the lengthening procedures. The rods with the fractured pin had increased surface degradation in a continuous and more sever pattern. In all cases, we found fretting and pitting on the damaged area of the telescopic part, using optical microscope and SEM. Sectioning of one rod with intact pin and one rod with fractured pin revealed black debris build up on both rods. EDX indicated that the debris were products of corrosion, while further analysis of the parts of the internal mechanism suggested that parts were considerably corroded as well. Conclusion: We identified a mechanism of pin fracture in MCGRs which may be due to corrosion of the internal mechanism. We recommend surgeons to monitor patients with this implant more closely, especially in cases of loss of distraction ability that could indicate debris build inside the mechanism, preventing normal function., Introduction: Determination of distal fusion levels and direction of rod derotation (RD) and direct vertebral rotation (DVR) are very important factors for deformity correction and preservation of motion segments in the treatment of adolescent idiopathic scoliosis (AIS). This study is to validate the importance of distal fusion level in the treatment of thoracic AIS using RD and DVR following selective thoracic fusion (STF) with pedicle screw instrumentation (PSI). Materials and Methods: Sixty-five patients with thoracic AIS treated by segmental selective thoracic fusion from neutral vertebra (NV) to NV or NV-1 with RD and DVR with a minimum 10-year follow-up were retrospectively analyzed. An adding-on or a lowest instrumented vertebra (LIV) tilt of more than 10° or coronal balance of more than 15 mm were considered unsatisfactory results. Results: The mean Cobb angle of the main thoracic curve was 55.8° before surgery, 16.0° after surgery, and 19° at last follow-up. In the compensatory cranial curve, the preoperative Cobb angle of 27.9° was corrected to 15.2° postoperatively and was 14.9° at last follow-up. In the compensatory caudal curve, the preoperative Cobb angle of 34.9° improved to 11.3° postoperatively and 11.1° at last follow-up. There were 13 cases of unsatisfactory results (10 cases of AD and 3 cases of CB progression) which showed relatively short fusion between distal fusion level and NV and insufficient DVR compared to satisfactory results. Conclusions: Selective thoracic fusion with proper distal fusion level using RD and DVR for thoracic AIS could achieve satisfactory deformity correction as well as compensatory lumbar curve that is maintained at a long-term follow-up. Therefore, distal fusion level which should be extended to NV or NV-1 and sufficient DVR which should be opposite to that of the vertebral rotation were inevitable to achieve satisfactory deformity correction and prevent a distal adding-on phenomenon in the treatment of thoracic AIS., Introduction: Diffusion tensor imaging (DTI), magnetization transfer (MT), and spinal cord (SC) cross-sectional area (CSA) are established measures of microstructural changes and tissue injury, including axonal loss, demyelination, and atrophy. T2*-weighted imaging (T2*w) has previously shown white matter (WM) hyperintensity in focal lesions and disseminated disease, and we introduce WM/grey matter (GM) signal intensity ratio (T2*-WM/GM) as a novel measure of tissue injury. This study in patients with degenerative cervical myelopathy (DCM) assesses how well CSA, FA, MTR, and T2*-WM/GM, extracted at the maximally compressed level (MCL) and in regions rostral (C1-C3) and caudal (C6-C7) to SC compression, quantify WM injury. Material and Methods: 56 DCM patients (age 56.7; 61% male; 32 mild, 14 moderate, 10 severe) underwent comprehensive clinical assessments and DTI, MT, and T2*w (3 T, 13 axial slices, C1-C7). Images were semi-automatically analyzed with Spinal Cord Toolbox (SCT). Metrics extracted at MCL were converted to T-statistics to facilitate group analysis across different rostro-caudal levels. Group comparisons with healthy subjects used T tests, and univariate relationships were analyzed with Spearman correlations. Metrics from total WM were analyzed against global disability, measured using modified Japanese Orthopedic Association (mJOA) score, while metrics from lateral corticospinal tract (LCST) and fasciculus cuneatus (FCun) were analyzed against ipsilateral upper extremity (UE) power (10 myotomes) and UE sensation, respectively. Backwards stepwise linear regression (predicting mJOA) and logistic regression (diagnostic tool) were used for multivariate analysis with age, sex, height, weight, and neck length included as covariates. Results: T2*-WM/GM showed robust group differences at all cord levels (rostral: p = 5 x 10−7, MCL: p = 3 x 10−9, caudal: p = 4 x 10−4), outperforming FA (rostral: p = 0.001, MCL: p = 2 x 10−5, caudal: p = 0.01) and MTR (rostral: p = 0.02, MCL: p = 0.006, caudal: p = 0.98). T2*-WM/GM also provided stronger correlation with mJOA (rostral: r = −0.62, MCL: r = −0.63) than FA (rostral: r = 0.39, MCL: r = 0.53) and MTR (rostral: r = 0.28, MCL: r = 0.38). Rostral T2*-WM/GM predicted ipsilateral weakness (r = 0.65) and sensory deficit (r = 0.71) better than FA (r = 0.57, 0.61, respectively) and MTR (r = 0.27, 0.39, respectively). Linear regression generated a final model that accurately correlated with mJOA (R2 = 0.53, p = 9 x 10−13), retaining only 2 variables: CSAMCL (p = 1 x 10−7) and T2*-WM/GMMCL (p = 0.001). A logistic regression diagnostic model was developed that showed excellent discrimination between healthy and DCM subjects (area under curve = 0.965), retaining 5 variables: MCL CSA (p = 0.01), MCL T2* WM/GM (p = 0.01), rostral FA (p = 0.17), caudal T2* WM/GM (p = 0.17), and rostral CSA (p = 0.20). Conclusion: Our multiparametric approach accurately characterize SC tissue injury, correlating well with global functional impairment (mJOA) and focal neurological deficits, while providing a highly accurate diagnostic tool. T2*-WM/GM ratio shows better correlation with global and focal impairment than FA and MTR. The rostral cord provides unbiased assessment, free of anatomical and magnetic distortions, and shows strong correlations with clinical measures similar to MCL. These methods have potential to provide improved diagnostics, monitoring of disease progression, and prediction of outcomes in DCM and other spinal pathologies., Introduction: Degenerative cervical myelopathy (DCM) is a condition in which extrinsic compression of the spinal cord (SC) occurs due to degenerative changes, causing neurological symptoms and signs of spinal cord dysfunction. These degenerative changes have also been observed in 6-25% of the asymptomatic population, with increasing prevalence in older individuals. We previously demonstrated that quantitative MRI measures of microstructure and atrophy accurately quantify SC tissue injury in DCM, but it is unknown if asymptomatic patients with cord compression also experience similar changes. Material and Methods: 2 subjects without neurological symptoms/signs underwent 3 T MRI including T2-weighted (T2w), diffusion tensor imaging (DTI), magnetization transfer (MT), and T2*-weighted (T2*w) imaging covering C1-C7. Subjects were divided into groups with and without cord compression (defined as indentation, flattening, or focal torsion). SC cross-sectional area (CSA), fractional anisotropy (FA), MT ratio (MTR), and T2*w white matter to grey matter signal intensity ratio (T2*w WM/GM) were calculated at the maximally compressed level (MCL) and uncompressed rostral (C1-C3) and caudal (C6-7) levels and normalized for confounding variables (including age). One-tailed T tests assessed if cord compression subjects exhibited the same differences as DCM subjects (N = 56) in 10 metrics, diagnostic accuracy was assessed with area under receiver operating characteristic curves (AUC), and a binomial test assessed if the same directionality pattern was present. Results: The cord compression group (N = 12, 38%) was older than the uncompressed group (53.9 vs. 38.9, p = 0.004) and showed decreased rostral MTR (50.8 vs. 53.5, p = 0.005, AUC = 0.765), decreased MCL MTR (T statistics: −0.255 vs. 0.254, p = 0.05, AUC = 0.604), and increased rostral T2*w WM/GM (0.875 vs. 0.857, p = 0.05, AUC = 0.675). The other 7 metrics did not show significant differences between groups. However, 8/10 measures showed the same directionality of changes in the cord compression group as previously seen in DCM subjects (p = 0.05). Conclusion: Asymptomatic individuals with spinal cord compression show a pattern of macro- and microstructural changes similar to DCM subjects, suggesting that this group experiences subclinical tissue injury. While these results require further validation, they offer the intriguing possibility that detection of SC tissue injury may be possible in the pre-myelopathic state, once quantitative spinal cord MRI techniques mature sufficiently. These findings have far-reaching implications for all spinal pathologies, including the potential to allow for the diagnosis of myelopathy prior to the onset of tangible neurological symptoms and signs., Introduction: Discrepancies between clinical symptoms and signs of spinal cord compression on static MRI are not uncommon when evaluating cervical spine myelopathy (CSM) patients. However, with the application of kinetic MRI (kMRI), dynamic compression of the cord becomes a new concept to be widely accepted. Material and Methods: Symptomatic CSM patients were selected to have static and dynamic MRI of the cervical spine. Space available for cord (SAC) were measured in T2 weighted sagittal plane at each disc level of the lower cervical (from C2-3 to C7-T1), in three different positions: full flexion, neutral and full extension. The difference of the mean SAC in different positions is analyzed by Mann Whitney U test. P < .05 is considered as statistically significant. Results: There were 32 patients (20 male and 12 female). The mean age of the group was 42. The most affected levels were C5-6 (100%), C4-5 (75%) and C6-7 (63%). The mean SAC in full flexion, neutral and full extension position were 10.54, 9.38 and 8.28 mm respectively, and they differ to each other with statistic significance (P < .05). In all cases, the bulge of the disc and ligamenum flavum was most pronounced in extension position, and became attenuated in flexion position. Interestingly, new compression sites revealed in full extension MRI (hidden hypertrophic ligamentum flavum) were noted in 7 cases (21%). Conclusion: Kinetic MRI is useful for evaluating dynamic compression of the spinal cord. Decision making of treatment as well as preventing adjacent segment syndrome should be based on the status of the disc and ligamentum flavum, not only in static images but also in the permanent dynamic process of the cervical spine., Introduction: Cervical spondylotic myelopathy (CSM) is related to static and dynamic narrowing of the cervical canal. The decrease in diameter of the vertebral canal secondary to disc degeneration and osteophytic production compresses the spinal cord at one or several levels, producing direct damage or secondary ischemic changes. Magnetic resonance imaging (MRI) is the best imaging method to evaluate CSM due to cord compromise by the spinal canal. To date, preoperative CSM evaluation is based on MRI performed in the neutral position. However, some patients presented with CSM and their MRI may even showed intramedullary signal intensity changes but without significant evidence of cord impingement or even obliteration of the subarachnoid spaces that surrounded the cord. Materials and Methods: The objectives of this study were to evaluate the impact of preoperative flexion-extension MRI on decision-making for patients with CSM. Forty patients with CSM were prospectively enrolled. Patients with other causes of myelopathy were excluded. MRI scanning was performed at the maximum active neck flexion and extension the patient could easily achieve. These positions were maintained using custom-built positioning sponges alternatively under the head and shoulders. The authors determined cervical cord sagittal diameter, number of stenotic levels, and severity of cord impingement in flexion, extension, and the neutral positions. Results: MRI demonstrated functional cord impingement (grade 3 of Mühle) in 10% patients in flexion, in 37% in the neutral position, and in 72% in extension. Dynamic MRI, extension position in particular, is a very useful tool to evaluate the true number of levels involved and the degree of narrowing of the cervical canal. Folding of the ligamenta flava explained the increasing of number of spinal cord impingements that were observed. Conclusions: The use of flexion-extension MRI is more precise exploration tool of the spinal cord in CSM. New information provided by flexion-extension MRI dramatically changed our surgical strategy for CSM management., Introduction: Cervical spondylotic myelopathy (CSM) is a common cause of spinal cord dysfunction. T2 signal intensity (T2SI) on magnetic resonance imaging (MRI) is used to assess the clinical severity of patients and post-operative outcome. Recently, diffusion tensor imaging (DTI) which detects microstructural abnormalities beyond the resolution of conventional MRI has been used for assessment of patients with CSM. While both DTI and T2SI have been evaluated as possible biomarkers for CSM, there has not been any study to our knowledge to compare DTI to T2SI to assess disease severity biomarker for recovery. Material and Methods: A retrospective analysis of 44 patients with preoperative DTI was done. Presence or absence of T2SI at the level of maximum compression (LMC) was determined. Normalized T2SI regardless of presence or absence of T2SI at (LMC) was determined by calculating T2SI at LMC/T2SI at level of foramen magnum. LMC Normalized T2SI, +/− T2SI, and FA were obtained and correlated to preop mJOA and ΔmJOA at 3, 6, 12, 24 months. Regression analysis and independent t-tests were used for analysis of the data. Results: There was a significant correlation between preop mJOA and LMC FA (P = .048). There was no significant correlation between LMC normalized T2SI and preop mJOA (P = .47). There was no significant difference in the preop mJOA score for patients with +T2SI versus -T2SI (P = .524). There was an inverse relationship of both LMC FA and LMC normalized T2SI with ΔmJOA at 3 months, R2 = 0.053/P = .133 and R2 = 0.28/P = .243 respectively. No significant difference was found between the ΔmJOA at 3 months of +T2SI and −T2SI groups (P = .729). At 6 months, there was an inverse relationship with ΔmJOA and LMC FA (R2 = 0.068, P = .087). There was an inverse correlation as well between LMC normalized T2SI and ΔmJOA at 6 months (R2 = 0.43, P = .159). Comparison of ΔmJOA at 6 months of -T2SI group to +T2SI group did not show any significant difference (P = .678). At 12 months, there was a significant inverse correlation with FA and ΔmJOA at 12 months (R2 = 0.24, P = .003). However, the P value was 0.227 (R2 = 0.05) for LMC normalized T2SI and ΔmJOA at 12 months. No significant difference was noted for of ΔmJOA at 12 months of -T2SI group to +T2SI (P = .527). There was non-significant inverse correlation for both LMC FA and LMC normalized T2SI with ΔmJOA at 24 months, R2 = 0.1/P = .095 and R2 = 0.015/P = .568 respectively. There was no significant difference in the ΔmJOA at 24 months for patients with +T2SI versus −T2SI (P = .557). Conclusion: In this larger retrospective study of CSM patients, FA at LMC shows to be a better biomarker for determining the disease severity, and both short and long term outcomes compared to T2SI at LMC. Further studies are needed with larger cohorts to assess whether use of both FA and T2SI in combination would add to FA alone., Introduction: Degenerative Cervical Myelopathy (DCM) encompasses a spectrum of age-related conditions of the cervical spine, including spondylosis, which result in progressive spinal cord injury through static and dynamic injury mechanisms. Unfortunately, little is known of the prevalence and constellation of anatomical pathology that presents in these patients and if there are differences between genders. Through detailed review of MRIs from prospective AOSpine multicenter studies, it is the purpose of the present research to report on the global prevalence of degenerative cervical pathologies of surgically treated DCM patients. Such information would be potentially helpful in uncovering etiological factors, provide insight into the natural history, and determine risk factors for DCM. Material and Methods: MRIs of 458 patients were reviewed for the type of pathology, source of stenosis, level of maximum cord compression, levels of spinal cord compression (SCC), and signal changes on T2WI and T1WI. Additionally, a spinal cord occupying ratio (SCOR) within the canal at non-compressed sites was calculated and a SCOR ≥70% was used to identify congenital stenosis. The prevalence of these changes was separated into genders and the proportions were assessed using Chi-square analysis. A P value of ≤.05 was considered as statistically significant. Additionally, the proportion of degenerative changes present alongside other diagnoses was computed as well as the prevalence of pathologies per geographical region. Results: Globally, spondylosis was the most frequent cause of SCC (89.7%) and was frequently accompanied by enlargement of the ligamentum flavum (LF) (59.8%), Figure 1. OPLL was accompanied by spondylosis in 91.7%. Single level disc pathology, OPLL and spondylolisthesis had a prevalence of ∼10%. Associated abnormalities such as vertebrae fusion and congenital stenosis were observed in 2.8% and 8.4%, respectively. Single level disc pathology was less common in North America, congenital stenosis less common in Europe, and OPLL more common and spondylolisthesis less common in Asia-Pacific. Females presented more commonly with single level disc pathology (P = .013) and were less likely to have their maximum site of cord compression at C3-4 (P = .007). Males more commonly presented with spondylosis (P = .017) and enlargement of LF (P = .012). Globally, the C5-6 region was the most frequent maximum compressed site (39.7%) and region for T2WI hyperintensity (38.9%). T2WI hyperintensity more commonly presented in males (P < .001). Conclusion: DCM presents as a constellation of pathologies that most commonly includes multilevel disc and bone pathologies, as well as enlargement of the LF. These findings support that pathological features, including OPLL, are highly interrelated with one another and rarely present in isolation. There appears to be a number of differences in the frequency and constellation of pathologies between genders. Overall, females presented with milder degenerative changes and correspondingly a lower frequency of T2WI hyperintensity of the spinal cord on MRI. There are also variances in the spectrum and prevalence of pathologies between geographical regions and these may be due to a multitude of causes that likely span beyond ethnic factors., Introduction: Magnetic Resonance Imaging (MRI) is the imaging technique that provides the greater amount of information about the cervical spine, as it constitutes the most sensitive technique to show soft tissues and, at the same time, delineate bone structures with great accuracy. Kinematic MRI (k-MRI) adds to these advantages the possibility of studying the cervical spine with motion, as spine disorders are dependent on the patient’s posture. This way k-MRI allows imaging in flexion/ extension and with lateral movements, which allows the identification of otherwise occult pathology, mainly instabilities caused by positional changes, as well as the understanding of atypical symptomatology that might misguide a correct diagnosis. Material and Methods: Three clinical cases which have performed kMRI in the Department of Imaging of Centro Hospitalar de Vila Nova de Gaia/Espinho were selected in order to illustrate the benefits of this technique not only in diagnosis, but also in therapeutical decision guidance. kMRI has been added to the ordinary cervical spine MRI protocol and has been adapted to each patient, including T2 TSE sequences or volumetric T2 SPACE in the sagittal plane in neutral, flexion and extension positions and/or with lateral movements. Results: Case 1: Seventy-two-year-old female with complaints of neck pain and paresthesia in the territory of the median nerve. Clinically she showed a positive Hoffman test. Due to the suspicion of a cervical myelopathy, a cervical kMRI was obtained, showing a C3-C4 anterolisthesis which aggravated with flexion, a C4-C5 retrolisthesis and an increased conflict at C3-C4 due to the prominence of the hypertrophic yellow ligaments. The patient has been proposed for a C4-C5 corpectomy and anterior arthrodesis. Case 2: Thirty-three-year-old female with pseudoxanthoma elasticum, diagnosed with eye and skin examinations, previously proposed for bilateral carpal syndrome surgery, with complaints of upper limb paresthesia and night pain, upper limb edema and asthenia. A kMRI was obtained, showing inversion of the lordosis with flexion, centered in C4/C5. Additionally, discal protusions in C4-C5 and C5-C6 have been described, showing no variation with the dynamic study. The patient was then treated with glucocorticoids with clinical success. Case 3: Fifty-one-year-old male submitted to C1-C2 fixation due to cervical myelopathy. Two years after the surgery the patient kept complaints of severe neck pain, upper limb paresthesia and tetraparesis. A kMRI was obtained and confirmed the suspected instability of the complex dens-anterior arch of C1. The patient was then re-operated with significant muscular strength improvement. It must be noted that imaging quality is slightly undermined by addiction of dynamic studies. Nevertheless, this does not compromise the interpretation of the acquired images and adds the possibility of understanding cervical spine changes with movement. Conclusions: In conclusion, K-MRI adds the benefits of MRI to those of a dynamic study, allowing the diagnosis of otherwise unidentifiable situations, gaining a more and more important role in cervical spine pathology characterization. It is actually a valuable tool in the identification of otherwise unrecognized instabilities and, as already described in literature, increases the surgical indication rate in patients with varied pathologies., Introduction: Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by anterior ossification of the spine with or without peripheral ossifying entheses. In the cervical area, the presence of DISH can lead to dysphagia and airway obstruction. The configuration of the hyperostosis in the cervical spine is markedly different compared with the thoracic or lumbar spine. The reason for this dissimilarity could be the difference in vascular anatomy between the neck and chest/abdominal region since vascular structures may act as a natural barrier against DISH. The aim of this study was to evaluate the relation between the location of the main arterial vessels and the location of the hyperostosis in DISH of the cervical spine. Furthermore, the relation between the cervical hyperostosis and dysphagia was examined. Material and Methods: Five patients with complaints of dysphagia (1 female, 4 males; 65-79 years old) were scanned by CT and diagnosed with DISH according to the Resnick criteria. For comparison, ten control CT scans were collected from patients that were scanned at the emergency department to exclude cerebral vascular injuries (4 females, 6 males; 57-90 years old). At nine levels (3 levels per vertebral body, levels C4, C5 and C6) the locations of the vertebral and carotid arteries were assessed and the surface area of the hyperostosis was measured. A mid-sagittal line and two parallel lateral lines, which intersected the lateral borders of the spinal canal, were used for location determination. The distance between the center of the vertebral body and the trachea and esophagus was measured in C5 just above the endplate on the mid-sagittal line to determine if the trachea and/or esophagus were displaced by the hyperostosis. Results: At all levels the vertebral and carotid arteries were located lateral of the two parallel lateral lines. The area between the two parallel lines contained significantly more hyperostosis compared to the area outside these lines. The size of the bone surface area left of the mid-sagittal line was equivalent to the right surface area and the hyperostosis was thus symmetrically arranged. The ossification was not flowing but more solid in the sagittal view due to the lack of segmental vessels. The distance between the center of the vertebral body and the trachea/esophagus was statistically larger in the DISH group compared to the controls. Conclusion: The new bone in DISH at the cervical level was symmetrically formed ventrally of the vertebral body largely within the two parallel lateral lines, most likely defined by the major arteries that were located lateral of the parallel lines. New bone formation in the cervical spine resulted in ventral displacement of the trachea and esophagus which could explain the development of dysphagia and airway obstruction. In conclusion, the outcomes of this study are consistent with the concept of vascular structures being a natural border for the hyperostosis in DISH., Introduction: Diffusion imaging is a promising technique as it can provide microstructural tissue information and thus potentially show viable change in spinal cords. However, it is limited by various image artifacts. In order to determine an accurate assessment method, instead of using traditional single-shot imaging method, we used newly developed multi-shot high resolution diffusion tensor imaging (DTI) to investigate diffusion metric changes and compare with T2 weighted images before and after decompressive surgery for cervical spondylotic myelopathy (CSM) patients. Methods: T2 W imaging, single-shot DTI, and multi-shot DTI were employed to scan 7 CSM patients before decompressive surgery and 3 months after the surgery. High signal intensity (HSI) was scored in the T2 W images. DTI metrics including fractional anisotropy (FA), axial diffusivity (AD), radial diffusivity (RD) and mean diffusivity (MD) were quantified and compared pre- and post-surgery. In addition, the relationship between imaging metrics and neurologic assessments was examined. Results: The mean grade of cervical canal stenosis recovered to normal from grade 3 three months after the surgery. Compared with low resolution DTI, high resolution DTI provided better images with lower artifact levels, especially following the surgery, due to reduced artifacts from metal implants. Both FA and RD values showed significant differences post-surgery (FA: P = .026, RD: P = .048). Their changes correlated strongly with neurologic assessments. In contrast, T2 W images did not show significant changes before and after the surgery. Conclusion: Multi-shot diffusion imaging showed improve image quality than single shot DWI, and presented superior performance in diagnosis and recovery monitoring for CSM patients than T2 W imaging. DTI metrics can reflect the pathologic conditions of spondylotic spinal cord quantitatively, and might serve as a sensitive biomarker for potential CSM management., Introduction: There is convincing evidence from the preclinical realm that the pharmacologic agent riluzole attenuates certain aspects of the secondary injury cascade leading to diminished neurological tissue destruction in animal SCI models. The safety and pharmacokinetic profile of riluzole have been studied in a multicenter pilot study in 36 patients. Efficacy of riluzole in acute human SCI has not been established. Material and Methods: This ongoing multi-center, international double-blinded phase III RCT will enroll 351 patients with acute C4—C8 SCI and ASIA Impairment Grade A, B or C randomized 1:1 to riluzole and placebo. Primary outcome is the change in ASIA Motor Score (AMS) between baseline and 180 days. Other outcomes include ASIA Upper and Lower Extremity MS; ASIA Sensory Score; ASIA grade; SCIM); SF-36v2; EQ-5D and GRASSP. Two-stage sequential adaptive trial statistical design has 90% power to detect 9 points difference in the ASIA Motor Score at one-sided alpha = .025. Results: A matched cohort analysis performed in the Phase I study showed that riluzole treated cervical SCI patients experienced an additional 15.5 points in AMS recovery at 90 days post injury. Although the phase I study was underpowered to investigate efficacy the current phase III study is poised to definitive address this question. Subject enrollment for this trial began on October 1, 2013. To date, 57 subjects have been enrolled. Average age of the enrolled subjects is 49.7 (SD 16.3); 78% males. ASIA at arrival and Pre-Injury status, ASIA Grade A (50%), B (26%), C (24%). GRASSP 67.1 (SD 62.0), SF35v2 PCS 53.1 (SD 9.2) SF36v2 MCS 54.8 (SD 11.2). Conclusion: This is a Phase III study of riluzole in acute SCI., Introduction: Although less frequent than cervical injuries, thoracic spinal cord injury (SCI) remains an important cause of disability amongst the young; further, many studies, particularly those investigating cellular transplantation, have focused investigation on this clinical subgroup. Using a modern prospective multicenter SCI registry, our objective was to quantify mortality, complications and long-term neurological recovery in thoracic SCI. In addition, we aimed to investigate how treatment related variables, including surgical timing and administration of high-dose steroids, impact these outcomes. Methods: All analyses were based on prospective data from the North American Clinical Trials Network for SCI (NACTN), collected over a 10-year period (2005-2016) from 8 North American centers. We included surgically treated adult patients with an International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) exam performed within the first week and a neurological level of injury (NLI) between T1 and T12. Outcomes of interest included change in ASIA Motor Score (AMS) and ASIA Impairment Scale (AIS) grade at 1, 3, 6 and >12 months follow-up, as well as the incidence of acute in-patient pulmonary complications and mortality. The effects of surgical timing (before or after 24-hours post SCI) as well as intravenous Methylprednisolone (NASCIS II 24 hour protocol) on these outcomes were investigated through use of bivariable and multivariable statistics. Results: Of the 93 patients meeting eligibility (mean age 40.4 ±16.2), 58 (62.4%) were AIS A, 12 (12.9%) AIS B, 14 (15.1%) AIS C and 9 (9.7%) AIS D; 48 patients (51.6%) had a NLI between T1-4, 15 (16.1%) between T5-8 and 30 (32.3) between T9-12. Although there were no acute inpatient mortalities, 53 pulmonary complications were recorded during acute hospitalization (incidence 57.0%), with pleural effusion, pneumothorax and pneumonia the three most commonly observed. Table 1 depicts neurological recovery at patients’ last available follow-up (mean 5 months). For AIS grade A patients, while 15% converted at least one AIS grade at follow-up, improvement in motor function was low (mean 2.2 points), consistent with previous reports. The mean time to surgery was 57.2 hours with 48 patients (64.9%) undergoing surgical decompression/fusion within 24 hours post SCI. Multivariable analysis, adjusting for baseline AIS grade associated surgery before 24 hours with an additional 7 points of AMS recovery as compared to late surgery (Estimate = 7.14, P = .03). Further, late surgical decompression was associated with increased risk of inpatient respiratory complications (IRR = 2.50, P = .04). There was no association between Methylprednisolone administration and neurological or complication outcomes. Conclusion: Consistent with historical reports, thoracic AIS grade A patients experienced little motor recovery, with prognosis for incomplete patients substantially better. Although administration of high-dose IV Methylprednisolone had no effect on clinical outcomes, early surgical decompression was independently associated with improved motor recovery and reduced incidence of pulmonary complications. Table 1. AIS Conversion and AMS change at last available follow-up. AIS at presentation AIS-A AIS-B AIS-C AIS-D AIS-E AMS Improvement AIS-A(N=46) 39 3 3 1 0 2.2 (±6.4) AIS-B(N=12) 2 3 3 3 1 19.6 (±18.0) AIS-C(N=9) 0 0 2 3 4 19.7 (±11.9) AIS-D(N=8) 0 0 0 7 1 11.7 (±11.4), Introduction: Fractures of the thoracolumbar spine usually result from high energy trauma and have a higher incidence in the thoracolumbar transition. The surgical treatment aims to stabilize the spine and correct its alignment. The transpedicular fixation can be performed by a minimally invasive approach or by open surgery. The aim of this study is to analyze patients with vertebral body fractures of T12 or L1 and to compare outcomes of transpedicular percutaneous fixation and open fixation. Material and Methods: Retrospective study of patients with vertebral body fractures of T12 or L1 without neurological signs who underwent percutaneous transpedicular fixation or open transpedicular fixation between January 2013 and April 2015. The sample CT scans were analyzed and the fractures grouped according to the AO classification. The segmental kyphosis angle and the degree of vertebral collapse before and after surgery were also saved in the database. Patients with less than 12 months of follow-up were excluded. The data obtained was analyzed with the software “STATA”. Results: A total of 110 patients with vertebral body fractures of T12 or L1 were identified. Of this sample, 63 (57%) patients underwent percutaneous fixation and 47 (43%) open fixation. In the group of patients undergoing percutaneous fixation 35 (56%) were male and 28 (44%) female, with an average age of 55 years (18-82). There were 44 (70%) patients with isolated fractures of L1 and 19 (30%) with isolated fractures of T12; percutaneous fixation allowed the treatment of fractures of AO types A1 (14%), A2 (11%), A3 (16%), A4 (22%), B1 (34%) and B3 (3%); the average operative time was 60.3 minutes (30-105) and mean postoperative hospital stay was 4.2 days (2-9). In the group of patients undergoing open fixation 23 (49%) were male and 24 (51%) female, with an average age of 53 years (18-74). There were 30 (64%) patients with isolated fractures of L1 and 17 (36%) with isolated fractures of T12; open fixation was used to treat fractures of AO types A1 (11%), A2 (2%), A3 (21%), A4 (19%), B1 (9%), B2 (23%) and B3 (15%); the average operative time was 89 minutes (39-190) and mean postoperative hospital stay was 5.8 days (2 -17). The postoperative complications were: infection (1 case in a patient who underwent open fixation) and mechanical failure of the surgical implants (8 cases in patients undergoing percutaneous fixation). The average postoperative follow-up period of the 110 patients was 25 months (12-39). Conclusion: The majority (57%) of the patients with fractures of T12 or L1 was treated by percutaneous fixation; this procedure allowed a shorter operative time and an earlier discharge and was used predominantly in the treatment of AO B1 fractures. However, it resulted in postoperative mechanical complications. On the other hand, open fixation allowed the surgical treatment of more severe fractures, although it resulted in longer operative and hospitalization times. Mechanical failure associated with percutaneous fixation suggests that these patients are candidates for removal of surgical implants as soon as the fracture is consolidated., Introduction: Our aim was to conduct a randomized controlled trial (RCT) evaluating the efficacy of early (less than 24 hours) versus late (24-72 hours) decompressive surgery in patients with T1-L1 traumatic spinal cord injury (TSCI). Material and Methods: An RCT was conducted using blocked-sample-randomization in the neurosurgery department of Shahid Rajaee Hospital, Shiraz University of Medical Sciences from September 2010 to September 2016. Pre- and postoperative American Spinal Injury Association (ASIA) Impairment Scale (AIS) was assessed, as were ASIA motor/sensory scores, length of hospitalization and mortality. Independent t-test analysis was used to compare ASIA sensory and motor progress at 1, 3, 6 and 12-months follow-up between the early and late groups. To compare the complete and incomplete groups, the repeated measures ANOVA with covariate analysis was utilized. P < .05 was assumed for evaluation of significant differences. Results: Sixty-nine patients met the inclusion/exclusion criteria and consisted of early (n = 31) and late (n = 38) surgery groups. There were 1 deaths in the early and 2 deaths in the late group at 1-year follow up. Twenty-two cases (31.8%) had complete TSCI with no upgrading in AIS scale. For cases with incomplete TSCI, 4, 14, 8 and 1 patients had no, one, two and three level upgrading in AIS scale, respectively, and one patient died. At 1-year follow up, the mean ASIA motor score improved from 66 ± 20.8 to 78 ± 23 in the early group (P = .001), and from 58 ± 14.5 to 67 ± 20.6 in the late group (P = .001). The mean ASIA sensory score improvements were 5 ± 11.7 and 7 ± 12.7 for the early and late groups, respectively. Both ASIA sensory (P < .001) and motor scores (P < .001) had significant improvement from baseline time to 1-year follow-up. In the complete group, a significant improvement in ASIA sensory score was observed at the 12-month follow-up visit (95%CI = 1.8-11.4; P = .009) although there was no significant difference in ASIA motor score (95%CI = -0.5-2.7; P = .186). In the incomplete group, both ASIA sensory (95%CI = 1-11.7; P = .020) and motor scores (95%CI = 12.7-23.5; P < .001) had significant improvements at 12_months follow-up. However, there was no statistically significant difference in ASIA motor (P = .93) and sensory (P = .20) score between early and late groups. On the contrary, there was a significant difference between complete and incomplete groups in motor improvement scale after decompression surgery at one-year follow-up (F(1.32) = 8.208, P = .007). Although there was no statistically significant difference in ASIA motor and sensory score between the two groups, one patient experienced a three-grade AIS scale improvement in the early group. There were 3 and 5 patients with two-grade improvement in AIS scale in the early and late groups, respectively. Conclusion: These results demonstrate overall AIS and motor score improvements in both the early and late surgical intervention groups after traumatic spinal cord injury in the thoracolumbar region. No motor improvements were observed in complete TSCI. There were no significant differences between the early and late groups in ASIA sensory and motor scale at 1, 3, 6, and 12-month follow-ups., Introduction: While anterior column support for thoracolumbar fractures involves constantly evolving surgical procedures and materials, not much patient related outcomes have been reported. Expandable titanium cages are now considered a safe and effective treatment option compared to bone strut grafts to support the anterior spine. In combination with minimal invasive thoracoscopy, surgical damage can be minimized and functional outcomes can be maximally improved after surgery. This is the first study to report on long-term quality of life (QOL) and radiologic outcomes after thoracoscopic anterior stabilization of thoracolumbar fractures with an expandable cage. Material and Methods: Between 2004 and 2012 75 patients with unstable traumatic thoracolumbar fractures had a combined antero-posterior stabilization in our university level 1 trauma center. After posterior stabilization, an expandable titanium cage with additional anterolateral plating was implanted thoracoscopically. At follow-up forty-nine patients without neurologic injury completed the SF36 and EQ5D questionnaires. QOL scores were stratified for ISS (< and ≥16), and compared to a cohort of patients that had solely posterior stabilization and to a general population from the Netherlands. In addition, correlation of QOL with kyphosis and fusion was checked. Results: From the patients that filled in the questionnaires, 44 valid scores could be calculated and questionnaires were filled in at median 48 months (IQR 14 – 84) after anterior surgery. Mean age at accident was 42 years (16-65), fractures consisted of AO type A to C and were located from T6 to L2 and 82% of the fractures were located at T11 to L2. Complications were present in 4 (8%) patients of which one (2%) required a re-operation because of an infection, there was one cage dislocation which remained stable at follow up. Compared to a general population, QOL as reported on the EQ5D was significantly lower on all domains, on the SF36 five out of eight domains scored lower. When compared to a cohort of patients that underwent solely posterior fixation, no differences in QOL were found. QOL scores of patients that filled in the EQ5D and SF36 at consecutive times (n = 14, median 13 months, IQR 12-23) did not improve or worsen significantly. After one year, bony fusion was completed on CT in 98%. While kyphosis (Cobb-angle) from injury to post-operative values decreased significantly, some re-kyphosing occurred at follow up. No correlation was found between final cobb-angles and QOL. Posterior implants were removed in 57% of patients. Patients that had a posterior implant removed showed more kyphosing after posterior implant removal to final follow up compared to patients that had no implant removal. Conclusion: Patients with a thoracolumbar fracture that require a thoracoscopically combined antero-posterior stabilization do not have a worsened quality of life compared to patients with a fracture that only require posterior stabilization. Kyphosis is significantly corrected directly after surgery, but there is some correction loss over time. QOL does not correlate with radiographic outcomes. Compared to a general population, overall quality of life is lower., Introduction: The incidence of adjacent segment degeneration or disease is increasing as the spine surgeries increase. There have been many articles on risk factors causing adjacent segment change after lumbar fusion surgery, but few articles have been released on the topic in thoracolumbar spine. Therefore, we intended to evaluate the change of adjacent segment after posterior instrumentation and fusion in thoracolumbar spine. Material and Methods: From 2000 to 2013, fifty patients were reviewed retrospectively. The patients underwent posterior instrumentation and fusion due to thoracolumbar fracture and were able to follow up more than 2 years. To evaluate the change of adjacent segment, postoperative sagittal angle, disc height and disc angle of adjacent segment were compared with those at the last follow up. We divided the patients into two groups according to age (more or less than 50 years), laminectomy, fusion levels (2 levels or more than 3 levels) and compared the radiologic parameters between groups. Results: The male patients were 36 and the female patients were 14. The average age of the patients was 45.6 years and the mean follow up was 4.3 years. There were no cases of adjacent segment disease. The mean kyphotic sagittal angle progression was 6.8° (P < .05), but the angle of adjacent segment disc did not show significant change between preoperative and last followup. The change of disc height of proximal adjacent segment was 0.3 mm and 0.5 mm of disc height in distal adjacent segment (P < .05). Laminectomy did not make significant difference on the change of adjacent segment, but in the group age less than 50 years, the angle of adjacent disc decreased significantly, 0.8° in proximal adjacent disc and 0.5° in distal adjacent disc (P < .05). There were no significant radiologic changes as the fusion levels is increased. Conclusions: Adjacent segment degeneration or disease after lumbar fusion surgery is not applied to the adjacent segment of thoracolumbar spine. These results are attributed to proximal level of fixation. Mobile segment of lumbar spine may make this difference rather than the instrumentation and fusion procedure itself., Fractures in the ankylosed spine, secondary to ankylosing spondylitis or diffuse idiopathic skeletal hypersotosis (DISH), are often unstable and require surgical stabilization. Standard open pedicle screw and rod fixation with long constructs have good results but are associated with high levels of morbidity. Whilst technically demanding, minimally invasive surgery can potentially reduce the risks of open surgery. This study aims to compare the results of minimally invasive surgical (MIS) techniques, to traditional open surgery. Method: A prospective, ethics-approved database (Spine Tango) at a tertiary referral centre was retrospectively reviewed for results of surgery on fractures of the ankylosed thoracolumbar spine. These were then split into two cohorts: MIS stabilization and fixation or standard open surgery. Results: We identified 17 patients who had presented with ankylosed spines with associated fractures since 2010 with 10 undergoing MIS stabilization and 7 open surgeries. Average age in the MIS was 72 years compared to 56 in the traditional cohort (P < .05). An average of 6.7 levels was stabilized in the MIS group which was comparable with the traditional group. There was a significant difference in the operative time and blood loss in favour of MIS (P < .05) although this did not result in a significantly higher transfusion rate. Radiation exposure time and dose was significantly higher in the MIS group. There were no cases of non-union, significant implant malposition or failure in either group. 2 significant complications including 1 death occurred in the MIS group, and 1 significant complication in the open group. Conclusion: The MIS technique for fractures of the ankylosed spine has shown an acceptable complication rate and good results comparable to open surgery for a high-risk patient population., Introduction: The main goals of the treatment of thoracolumbar fractures are stabilization and promotion of vertebral healing or fusion of the affected segment. Recently, as an alternative for the Open Pedicle Screw Fixation (OPSF) of Thoraco -Lumbar Fractures (TLF), Percutaneous Pedicle Screw Fixation (PPSF) has evolved to minimize soft tissue injury and perioperative morbidity. The purpose of this study was to prospectively compare the clinical and radiological outcomes of three different methods of neurologically intact TLF treatment: OPSF, minimally invasive two-plane conventional fluoroscopy – guided (F-PPSF) and navigation-guided (N-PPSF). Material and Methods: A total of 137 patients underwent either OPSF (n = 50) or F-PPSF (n = 39) or N-PPSF (n = 48) for stabilization of TLF between 2014 and 2016 in two Departments (Orthopaedics and Neurosurgery). Radiographs were obtained before surgery, immediately after surgery, and at the final follow-up for assessment of the restoration of the spinal column. For radiologic parameters, Cobb angle, vertebral wedge angle, and vertebral body compression ratio were evaluated on lateral thoracolumbar radiographs. As a method of clinical evaluation, the intraoperative blood loss, operation time, radiation dose, postoperative hospital stay, the postoperative scar size and perioprative complications. For patient’s pain and functional evaluation, the visual analogue scale (VAS) and the Oswestry Disability Index (ODI) were evaluated. Results: There were significant differences between open and both percutaneous methods of treatment in surgical blood loss and postoperative hospital stay in favour of percutaneous and without significant difference between F-PPSF and N-PPSF. The time of the surgery was the shortest in OPSF. The radiation dose was both the highest for the patient and the lowest (none) for the operative team in N-PPSF. The length of the postoperative scar was equal for all groups. There were two infections and one implant loosening in OPSF group without any significant complication in both percutaneous groups. Postoperative VAS decreased significantly in all groups and there was a significant difference between both percutaneous and OPSF groups at the time of discharge and after 6 weeks postoperatively. There were no statistical differences in VAS between all groups at the final follow-up. For both F-PPSF and N-PPSF ODI was significantly better 6 weeks after the surgery than for OPSF without any difference between all groups at the final follow-up. The regional sagittal Cobb angle, vertebral wedge angle and anterior height of the fractured vertebra all significantly improved in each group immediately after the surgery and at the final follow-up. There were no signifficant differences in the postoperative radiographic improvement between F-PPSF and N-PPSF groups but there was a significant difference in favour of OPSF in the immediate postoperative radiographic parameters in comparison to both percutaneous groups. Conclusion: Both percutaneous pedicle screw fixation techniques were comparable except the radiation dose for the operative team, which was the lowest in N-PPSF group. Although all three groups showed favorable outcomes at the final follow-up, F-PPSF and N-PPSF provided earlier pain relief, better functional improvement, less perioperative complications but worse postoperative radiological outcome in comparison with OPSF., Introduction: Spondylopelvic dissociation is a rare pattern characterized by a transverse sacral fracture in conjunction with bilateral dissociation between the sacrum the pelvis. Severe neurological complications due to the damage of lumbosacral plexus may also occur. Spondylopelvic dissociations are usually misdiagnosed or underestimated, thus potentially leading to chronic low back pain and progressive deformity. Material and Methods: From 2013 to 2016 11 patients (7 females, 4 males) underwent surgery for traumatic spondylopelvic dissociation. Patients averaged 41.2 (15-66) at the index procedure. Nine of them followed a precipitation from height, while the remnant 2 followed a crash. Fractures have been classified according to the system described by Denis. Results: There were 8 “U-shaped” and 3 “Lambda-shaped” fractures; the S1-S2 levels were involved in 5 cases, and the S2-S3 in 6 cases. A concomitant open book pelvic fracture occurred in one case. One patient reported a concomitant bilateral proximal femoral fracture and underwent early surgery. One patient was surgically treated for a fibula fracture and a wrist fracture. One patient underwent an early L1-L3 percutaneous screw fixation for an amyelic L2 fracture and, following a complete diagnosis of spondylopelvic dissociation, a L1-iliac stabilization thereafter. Surgeries were meanly performed 8.4 days after the injury. In all but one patient a posterior spondylopelvic screw fixation was performed; one patient underwent also a S1 laminectomy. At the last available examination 12 (1-34) months postoperatively, no complications were recorded. Conclusion: Spondylopelvic dissociation are rare high-energy injury fractures, and the true nature of the injury is easily missed and diagnosis is delayed. Hence, a comprehensive imaging assessment including CT scan reconstructions needs to provide optimal understanding of the fracture pattern. Early and proper diagnosis and classification will lead to an adequate surgical treatment. A comprehensive assessment of possible associated neurological deficits is also mandatory. This challenging disease can be satisfactory treated with a posterior screw fixation, with or without and associated laminectomy, thus minimizing the risk of neurological deficits, residual instability, deformities and chronic low-back pain. In our experience such a surgical is safe and effective., Introduction: Today’s standard treatment strategy for intervertebral disc (IVD) degeneration is surgical intervention, like discectomy followed by spinal fusion. During spinal fusion the damaged disc is removed, the empty space is filled up with bone substitute or an autograft and the two adjacent vertebral bodies are immobilised. However, clinical observation showed that partial IVD tissue removal could lead to a failure of spinal ossification (1). Recently, it could be shown that human mesenchymal stem cells (MSC) co-cultured with human IVD cells show an inhibition in bone formation (2). In this study we hypothesised that mature human primary osteoblasts (OB) co-cultured with IVD cells would also show inhibitory effects in ossification as previously demonstrated for MSC. Material and Methods: OB were seeded at a density of 13’000 cells / cm2. IVD cells (ie, NPC, AFC and EPC) were encapsulated in 1.2% alginate beads (∼30 µm in ∅ at 4 M cells/mL, ∼75’000 cells/bead) and co-cultured via inserts (PET ∅ 0.4 µm pore size) with OB in the lower part as monolayer. The experiment was performed under hypoxic conditions. Dose response of inhibition was investigated by co-culturing six, nine and twelve NPC, AFC or EPC beads. The experimental groups were stimulated with osteogenic medium. Additionally, three controls were cultured: OB monolayer with osteogenic medium (±empty beads) and with control medium (-MEM + 10% FCS). To quantify ossification, matrix mineralization of OB was measured after 21 days by Alizarin red (ALZR) staining and was quantified by absorbance and normalised to cell activity (Resazurin assay). Furthermore, the alkaline phosphatase (ALP) activity of OB was determined after 21 days and normalised by total protein content (Bradford assay). Results: After 21 days, the OB culture in osteogenic medium ± empty beads (positive control) showed a strong ALZR staining. However, no deposition of mineralised matrix in OB monolayer cultured in control medium could be observed. OB cultured with NPC, AFC and EPC showed a decreased calcium deposition compared to the positive control (N = 2). The ALP activity measured after 21 days (N = 2) was reduced in OB co-cultured with IVD cells compared to positive control. The lowest amount was detected in OB cultured with NP cells (ALP activity / protein content ± SEM, 904.0 ± 262.6 mU/mg), compared to positive control (1975.7 ± 1793.714 mU/mg). Conclusion: In this study we could show a trend that mineralization of primary OB could be inhibited by direct exposure to IVD cells. Like observed in clinics, IVD cells seem to directly influence OB, by apparent inhibition of ossification. Particularly NPC in 3D alginate beads indirectly co-cultured with OB demonstrated inhibitory effects, such as low matrix mineralization in OB monolayer. However, these data need to be further confirmed using more donor repeats. References 1. Watkins R, Watkins R, Hanna R (2014). Medicine (Baltimore) 93: e275. 2. Chan SCW, Tekari A, Benneker LM, Heini PF, Gantenbein B (2015). Arthritis Res Ther 18:29. Acknowledgements This study was supported by the Lindenhof Foundation “Forschung und Lehre” (#15-05) and by direct funds from Hansjörg Wyss and Hansjörg Wyss Medical, US. We thank Eva Roth for laboratory assistance., Introduction: Surgical interventions remain a controversial option for the treatment of chronic discogenic low back pain. Intervertebral disc arthroplasty has become more common due to the potential to minimize adjacent level issues and similar outcomes to the previous standard of fusion surgery. Recent advances in understanding biologic/cell therapies have allowed for the development of minimally invasive procedures to treat discogenic pain and probably degeneration. In this study, the results of an FDA, IDE trial for two lumbar total disc replacement systems were compared to the results of a study assessing safety and efficacy of intradiscal bone-marrow concentrate (BMC) injections as an alternative to surgical procedures. Materials and Methods: Patients from each trial who were screened using very similar inclusion/exclusion criteria were selected from each study to be compared. Patients from both groups were treated by the same physician at the same clinic. Criteria included: 6+ months failed conservative therapy for low back pain, visual analog scale (VAS) pain score of greater than 50mm/100 mm, Oswestry Disability Index (ODI) score of > 40%, absence of abnormal neurological exam, and absence of significant stenosis, herniation, or other compressive pathologies. Statistical comparison of outcomes and adverse events were performed for baseline and all follow-up points between studies (3, 6, 12, and 24 months). Methodological characteristics were virtually identical between studies. Results from each patient were individually obtained and statistically compared. Results: Chi squared distribution analysis was used to assess homogeneity between the studies. Significance testing showed no significant differences between Kineflex™ disc systems and BMC at any time point. Improvements were statistically significantly better in the BMC study group at 3 and 24 months compared to Maverick™ disc replacements (P = .024, 0.038 respectively). Adverse events were more common in both disc replacement systems compared to BMC injection (there were no serious adverse events reported in the BMC study). Maverick patients had baseline ODI/VAS scores of 57.77/82.28 and improved to 22.20/37.73 at 24 months. Kineflex patients had baseline ODI/VAS scores of 62.00/84.01 and improved to 23.75/28.05 at 24 months. BMC patients had baseline ODI/VAS scores of 56.80/82.05, and improved to 16.45/20.25 at 24 months. Conclusion: Previous meta-analyses and systematic reviews have demonstrated fusion and total disc replacement to have near equal efficacy regarding pain and disability and some evidence of lower rates of adjacent segment degeneration in disc replacements. Bone marrow concentrate injections, based on the comparisons in this study, show equal efficacy at resolving discogenic back pain and disability compared to disc replacement surgery. This indirect comparison shows preliminarily that BMC injections may be a viable alternative to surgical procedures, and provides justification for further studies involving direct comparison between the two interventions and/or studies of each intervention with standard conservative treatment control groups., Introduction: An angiopoietin-1 receptor (Tie2) positive subpopulation of nucleus pulposus (NP) cells was recently described as NP progenitor cells (NPPC), which possess multipotency.1,2 Hence, NPPC could represent an outstanding source of cells for intervertebral disc (IVD) regeneration. However, culture conditions to maintain NPPC in vitro are yet unknown. As is the cell number required for successful restoration of mildly degenerated discs. Thus, we aimed to test different isolation methods for Tie2 cells and to observe their survival when injected into IVDs and their regenerative potential. Material and Methods: IVDs were isolated from fresh bovine tails as described previously.3 Degeneration of IVD was induced by injection of ∼100 µl of 60U/mL papain solution and incubation for eight days.4 In parallel on day 7, cells were isolated from allogeneic NP tissue using sequential digestion protocol with 0.19% pronase and 64.5 U/mL collagenase type 2. On day 8, Tie2+ cells and Tie2− cells were sorted using antibody against Tie2 by fluorescence-activated cell sorting (FACS, Facsaria, BD) or magnetic-activated cell sorting (MACS, Miltenyi Biotec). Subsequently, 20’000 Tie2+ and 200’000 Tie2– cells (control) were labeled with DiL (red fluorescence dye, Thermo-Scientific). Cells were mixed with fibrin hydrogel (Tisseel, Baxter) or PBS and injected into the cavity of the degenerative group (DG) and non-degenerated control discs. Followed by seven days of culture in free swelling conditions (absence of loading). On day 15, organ cultures were stopped, and after removal of the cartilage endplates the NP was separated from the annulus fibrosus (AF). Outcome measurements were cell viability (CV) of injected and native cells by cLSM and semi-automated cell counting and GAG/DNA ratio.5 All cells were stained with green fluorescence calcein-AM staining and DAPI, which allowed to distinguish living and dead exogenous and native cells. Results: FACS (n = 9) showed a nearly 10-fold higher Tie2+ cell yield than MACS (n = 2). The 3D cLSM stacks taken from the healthy discs injected with Tie2+ showed a cluster and spheroid-like arrangement of the NPPC in the NP region in contrast to the autochthonous IVD cells. NPPC survival was considerably reduced after seven days of culture embedded in fibrin hydrogel. Whereas CV in PBS was very good with NPPC clustered in the native IVD environment. In the NP-region of non-degenerated discs, CV of exogenous Tie2+ cells in PBS (n = 3) was estimated to be 71 ± 29.2% and 64.5 ± 46.12% for the AF (n = 2), respectively. Tie2− cell’s CV was considerably lower in PBS (∼13% for NP, n = 1). In the DG discs with fibrin hydrogel, CV of Tie2+ in NP (n = 3) dropped from ∼90% down to ∼33%. Conclusion: Problems with nutrition diffusion through fibrin hydrogel or the particular IVD degeneration model could be factors for reduced CV. Also, NPPC can be isolated from bovine NP tissue with a higher yield using FACS and show differentiation into osteo- and adipogenesis. Future studies should focus on which factors maintain the NPPC phenotype in vitro and in vivo and to identify a suitable carrier for NPPC for both, in vitro cell expansion and delivery by injection. Acknowledgement This project was supported by funds from the Swiss National Science Foundation project # 310030_153411, the Gebert Rüf Foundation project # GRS-X028/13 and the Lindenhof Project # 16-05F. We thank Eva Roth for her help in IVD isolation and biomechanical assays. Microscopy was performed by the Microscopy Imaging Center (MIC) and the FACS-work was conducted at the FACS Lab core facility of the University of Bern. References 1. D. Sakai et al. (2012), Nat Commun 3, 1264. 2. A. Tekari et al. (2016), Stem Cell Res Ther 7:1, 75. 3. S.C. Chan, B. Gantenbein-Ritter (2012), J Vis Exp. 4. S.C. Chan et al. (2013), Spine J 13:3, 273-83. 5. B. Ganteinbein-Ritter et al. (2008), Tissue Engineering Part C, Methods 14 (4): 353-358., Introduction: Low back pain is mainly caused by trauma or disc degeneration. We aim for an “inside-out” approach repair for herniated intervertebral discs (IVD) or injuries of the outer annulus fibrosus by using hydrogel in combination with modified silk. The silk’s fibroin contains the human growth and differentiation factor 6 (GDF6), directly produced by baculovirus transduced Bombyx mori larvae in culture. GDF6 was shown to drive mesenchymal stem cells (MSC) towards an IVD-like phenotype.1 Within this study, we investigated the feasibility of a genipin cross-linked fibrin hydrogel using an ex vivo organ culture approach.2 Furthermore, cytotoxicity and proliferation potential of human MSC within the silk material were assessed. Material and Methods: Bovine IVDs were harvested under aseptic conditions.3 After inducing an IVD injury (2 mm biopsy punch), the cavity was filled with a human-based fibrin hydrogel enhanced with genipin. A GMP-compliant silk membrane-fleece composite was placed on the hydrogel to close the injury. Subsequently, IVDs were subjected to in vitro organ culture for 14 days using three loading regimes: 1) complex (0.2 MPa compression and 0 ± 2° torsion at 0.2 Hz for 8h/day), 2) static diurnal (0.2 MPa) and 3) no loading. For complex loading a custom built two-degree of freedom bioreactor was used.4 At the end of culture, the discs were controlled for seal failure, height, metabolic activity, cell death (necrosis and apoptosis), DNA, GAG and collagen (hydroxyproline) contents. qPCR of ECM production and inflammation was performed. Histologies for collagen, proteoglycan and cytoplasm/nuclei were performed on plastic and cryo-sections. Proliferation potential of GDF6-silk was investigated by seeding MSC (P2) on silk fleece-membrane composite for 21 days. Metabolic activity, DNA and GAG content as well as qPCR (aggrecan, collagen 2, and others) were measured on day 0, 7, 14 and 21. All experiments were performed with N = 5 repeats. Results: Macroscopic inspection revealed that the silk seal was not displaced throughout the culture period. Metabolic activity, DNA and GAG content and disc height of the repaired discs did not differ significantly from the injured IVDs. Except for a higher DNA content under static loading for the repaired discs compared to the injured IVDs (P value ≤ .004). Examination of histological sections indicated that the injury created a cavity. Whereas in the repaired discs the induced injury was closed and the cavity was filled with tissue. In vitro experiments on the cellular level attributed a good cell compatibility within the silk and GDF6 silk. Also proliferation, DNA and GAG content did not reveal significant differences among the different silks. qPCR of MSC revealed a trend towards a higher aggrecan to collagen 2 ratio. This ratio indicated a differentiation of MSC towards a nucleus pulposus phenotype. Conclusion: Strikingly, discs responded equally to the injury on opposite sides, suggesting exchange of cytokines either throughout the disc or the culture media. The in vitro experiments attributed the silk a good biocompatibility. Further, GDF6 silk thrives MSC towards a NP-like phenotype. The silk and the hydrogel offer a promising approach to repair and regenerate the IVD after nucleotomy upon disc herniation. Acknowledgements We thank Eva Roth for her help in IVD isolation and biomechanical assays. Microscopy was performed on equipment supported by the Microscopy Imaging Center (MIC), University of Bern, Switzerland. This project was supported by the Gebert Rüf Foundation project # GRS-X028/13. References 1. L.E. Clarke et al. (2014), Arthritis Res. Ther. 16(2): R67. 2. M Likhitpanichkul et al. (2014), Eur Cell Mater 28, 25-38. 3. S.C. Chan, B. Gantenbein-Ritter (2012), J Vis Exp 60: 3490. 4. J. Walser et al. (2012), John Wiley & Sons, Ltd., Introduction: NEL-like molecule-1 (NELL-1) is a potent pro-osteogenic cytokine that has been demonstrated to enhance bone formation when applied locally. PEGylation is a biocompatible process in which polyethylene glycol (PEG) is attached to a protein to prolong its half-life. The primary objective of this study is to investigate the effects of systemic administration of PEG-NELL-1 on fracture repair in an open fracture model in the mouse radius; the secondary objective is to investigate effects on bone mineral density in uninjured bones. Methods: A total of twelve CD-1 mice aged 10 weeks were subjected to 0.15 mm transverse open osteotomies of the bilateral radii. They were treated with weekly tail vein injections of PEG-NELL-1 (n = 5) or PEG phosphate buffered saline (PBS) (n = 7). Animals were sacrificed at week 4. Fracture healing was evaluated by micro-CT and microPET. For the microPET, F-18, is substituted for hydroxyl groups and binds to new bone; therefore uptake is higher in newly formed bone. Bone density was evaluated by Dual-energy X-ray absorptiometry (DXA) and performed on humeri and femurs. Statistical analyses were performed using a Student’s t test. A P value of, Introduction: Previous animal models for spinal cord injury required laminectomy and exposure of the spinal cord to create direct trauma. Imaging studies were not always possible during these experiments. Furthermore, previous studies did not permit a correlation of extent of cord compression with cord injury. The purpose of our study is to determine the relationship between extent of cord compression and the increase in cord pressure in an in-vitro burst fracture model of graded cord compression. Methods: 12 Porcine spinal sections, six thoracic, and six lumbar were harvested from 30 kg pigs. Each spine segment consisted of 7 vertebrae. With the cord exposed and tied off at each end. A hole was drilled in the middle of the most central vertebra of the segment that was carefully created from the most anterior portion of the vertebral body through the posterior wall of the vertebral body without damaging the underlying cord. A 12.5 mm diameter DHS hip screw with 3 mm thread pitch was then inserted into this hole and advanced in a graded fashion. Pressure at the cord was monitored by means of the central hole running longitudinally down the DHS screw toward the cord. As the DHS screw was advanced, pressure was measured at the tip of the screw where it contacted the spinal cord. A radiolucent dye was administered in the subdural space to create a myelogram during the procedure. All the segments were observed under fluoroscopy to monitor the advance of the DHS screw. Results: Accurate measurement of the time averaged pressure showed no significant difference (P < .05) in the pressure/compression curves before and after radiopaque dye injection. Cord Pressures increase dramatically at approximately 65% to full compression. Conclusions: Cord Compression can be obtained in a systematic and controlled manner. Cord Pressures increase dramatically when cord compression reaches approximately 65% to full compression. Our samples exhibited Creep Phenomenon- the tendency of a material to slowly move or deform permanently under the influence of stresses, as repeated measurements at same percentage of compression showed substantially decreased pressures., Introduction: Intermittent treatment with parathyroid hormone (1–34) (PTH) has been shown to increase bone mass and reduce fracture risk in osteoporotic patients. Previously, we established that low-dose (10 μg/kg) PTH (1–34) treatment resulted in increased fusion mass volume in a rabbit model. However, it did not improve biomechanical stiffness over the use of autograft alone, and did not improve fusion when combined with BMP-2 treatment (Lina et al, Spine [Phila Pa 1976]. 2014; 39(5):347). Studies in rodent models have shown that the effects of PTH (1–34) on spinal fusion may be dose-dependent (Ming et al, Spine [Phila. Pa. 1976]. 2012; 37(15): 1275; Abe et al, Bone.2007; 41(5): 775). We thus aim to evaluate whether increasing the administered dosage of PTH (1–34) increases both the volume and biomechanical stiffness of the resulting fusion masses and/or exhibits synergistic effects with low-dose BMP-2 treatment. Materials and Methods: Posterolateral intertransverse process lumbar spinal fusion surgery was performed on 60 male, New Zealand White rabbits. Six experimental groups were evaluated: [1] iliac crest autograft alone (n = 10); [2] autograft + 20 μg/kg PTH (1–34) (n = 10); [3] autograft + 40 μg/kg PTH(1–34) (n = 10); [4] BMP-2 alone (n = 10); [5] BMP-2 + 20 μg/kg PTH (1–34); and, [6] BMP-2 +40 μg/kg PTH (1–34). Fusion was assessed using manual palpation and volumetric CT analysis. Four-point bending nondestructive biomechanical testing was utilized to evaluate the fusion mass stiffness. Results: In the autograft groups, rabbits receiving PTH (1-34) displayed an increased rate of fusion via manual palpation. Increasing doses of PTH (1–34) were found to lead to increased fusion mass volume as assessed via CT. However, increased mechanical stiffness was only observed in the 20 μg/kg group via four-point bending tests. All groups treated with BMP-2 were observed to fuse via manual palpation and CT analysis. The highest dose of PTH (1–34) in combination with BMP-2 was found to lead to significantly increased fusion mass volume compared to treatment with BMP-2 alone, however, no significant differences in mechanical stiffness were observed. Conclusions: Treatment with PTH (1-34) alone increases fusion rate and fusion mass volume in a dose dependent manner. However, significant increases in mechanical stiffness were only observed in the autograft group at a dosage of 20 μg/kg, thus suggesting there may be an optimal dose of PTH(1-34) in the rabbit model. When combined with low-dose BMP-2 treatment, the effects of BMP-2 on fusion dominate. A significant increase in fusion mass volume at a dosage of 40 μg/kg over BMP-2, however, suggests some synergistic effects., Introduction: Lumbar microdiscectomy is a commonly performed surgical procedure for the relief of chronic radicular symptoms. However, the procedure targets neural decompression but does not repair the underlying disc pathology. As a consequence, 10 – 20% of patients re-present with debilitating back pain and approximately 15% undergo further surgical intervention.1,2 In-vitro studies have demonstrated that pre-incubation of mesenchymal progenitor cells (MPCs) with the sulphated polysaccharide, pentosan polysulfate (PPS), for 24 hours, increased their viability and enhanced chondrogenic differentiation. The objective of the present study was to determine if primed MPCs (pMPCs), embedded in a gelatin/fibrin scaffold and inserted into the lesion produced by microdiscectomy, could facilitate disc repair in the ovine model. Material and Methods: Eighteen adult ewes underwent pre-operative 3 T MRI at baseline. Microdiscectomy was performed via a lateral surgical approach at two lumbar disc levels. Adjacent non-operated lumbar discs served as normal controls. The microdiscectomy procedure consisted of a standardized 3 x 5 mm annulotomy which removed approximately 200 mg of annulus fibrosus (AF) plus some nucleous pulposus (NP) tissues. Post microdiscectomy sheep were randomized into 3 groups (n = 6). Group 1, received no further treatment (injured control group); Group 2 were implanted with non-primed MPC (500,000 cells) + scaffold; Group 3 received the pMPC (500,000 cells) + scaffold. Necropsies were performed at six months and lumbar spines were scanned using 3 T and 9.4 T MRI and radiographic imaging. Spinal columns were dissected, individual discs sectioned and NP and AF regions scored using gross morphological and histological assessments. Following subdivision of the discs into 6 regional segments, NP and AF tissues were analysed biochemically for their proteoglycans (PGs) (as S-GAGs), collagen and DNA content. Results: The MPC and pMPC groups (Groups 2 & 3) demonstrated significantly less reduction in disc height relative to the injury group (Group 1) (p < 0.05). Pfirrmann 3 T degeneration scores failed to show a significant difference between the three groups. Gross morphological scoring revealed significantly reduced degeneration scores in Group 3 disc segments overall compared to Group 1 for the NP and AF. The PG content of the contralateral NP for the pMPC group (Group 3) was significantly higher than for Group 1 (P < .01) and not statistically different to the normal control disc values. The PG content of Group 3 discs at the site of injury were greater than Group 1 discs (P < .02). The PG content of the contralateral AF of Group 3 was not significantly different to normal controls discs and greater than Groups 2 discs (P < .04). Histological scoring of the respective groups reflected the gross morphology scores with degeneration scores in Group 3 being lower than in Group 1. Conclusion: Local administration of pMPCs (Group 3), embedded in the gelatin/fibrin carrier, post microdiscectomy reduced disc degeneration and improved disc height relative to microdiscectomy alone (Group1). These findings suggest a potential therapeutic role of pMPCs in limiting the extent of spontaneous disc degeneration in patients post lumbar microdiscectomy and, consequently, the recurrence of low back pain and radiculopathy. References 1. Yorimitsu E, Chiba K, Toyama Y, Hirabayashi K. Long-term outcomes of standard discectomy for lumbar disc herniation: a follow-up study of more than 10 years. Spine 2001;26(6):652–7. 2. Lurie JD, Tosteson TD, Tosteson A, et al. Long-term outcomes of lumbar spinal stenosis: eight-year results of the Spine Patient Outcomes Research Trial (SPORT). Spine 2015;40(2):63–76., Introduction: RNA interference (RNAi) enables inhibition of specific genes by sequence-specific gene silencing by double-stranded RNA (dsRNA). It involves post-transcriptional gene silencing via a process by which dsRNA inhibits gene expression through degradation of a specific, targeted mRNA. Small interfering RNA (siRNA), a type of RNAi, is a hybrid consisting of a sense and antisense strand homologous in sequence to the suppressed gene. Therefore, synthetic siRNA can trigger an RNAi response in mammalian cells and induce inhibition of specific gene expression. Fas death receptor is reported to cause apoptosis of intervertebral disc cells, which results on disc degeneration. We performed the current study to investigate the effect of siRNA on Fas gene expression, apoptosis, and proliferation in rat disc cells treated with serum deprivation. Material and Methods: Disc cells were isolated from nucleus pulposus tissues of 4-week old rats, cultured, and placed in either 10% (normal control) or 0% (apoptosis-promoting condition) fetal bovine serum (FBS) for 48 hours. The expression of Fas and viability (apoptosis and proliferation) of the cells were determined. To suppress Fas gene expressions, siRNA against Fas (Fas siRNA) was synthesized and transfected into the cells using oligonucleotides. The suppression of Fas gene expression was investigated by RT-PCR and densitometry. The effect of Fas siRNA on apoptosis and proliferation of the cells was determined. Negative siRNA and MOCK (transfection agent alone) were used as control. Results: Serum deprivation increased apoptosis by 40.3% and decreased proliferation by 45.3% in disc cells (both, P < .001), and upregulated Fas expression. Fas siRNA suppressed Fas expression in 0% FBS. The rate of suppression by Fas siRNA was 68.5% at the mRNA level (P < .001). Suppression of Fas expression by siRNA significantly inhibited apoptosis by 9.3% and increased proliferation by 21% in 0% FBS (both, P < .05). Conclusion: RNAi-mediated suppression of Fas gene results in significant inhibition of apoptosis and increased proliferation of rat disc cells under serum deprivation. This dual positive effect of RNAi might be a powerful therapeutic approach for disc degeneration by suppression of harmful gene expression. RNAi can also be used in gene function studies for the process of disc degeneration control., Introduction: MIS-DLIF using tubular retractor has been used for the treatment of lumbar degenerative diseases. Although addition of electrophysiological monitoring potentially decreased the perioperative neurological complications, blunt retroperitoneal and transpsoas dissection poses a risk of injury to the lumbar plexus, especially at lower lumbar level. As an alternative, MIS-OLIF uses a window between the prevertebral venous structures and psoas muscle, and gets an access to the target disc obliquely. Theoretically, MIS-OLIF preserves psoas muscle and lumbosacral plexus with reducing the complication of direct lateral approach, and by orthogonal maneuver (oblique to vertical way), the position of cage would be easily controlled. The purpose of this study was to compare the incidence of perioperative complication, difference of cage location and sagittal alignment between MIS-OLIF and MIS-DLIF in the cases of single level surgery at L4-5. Material and Methods: A total of 31 consecutive patients who underwent MIS-DLIF or MIS-OLIF for various L4/5 level pathologies between November 2011 and April 2014 by a single surgeon were retrospectively reviewed. A complication classification based on the relation to surgical procedure and effect duration was used. Perioperative complications until 3 month postoperatively were reviewed for the patients. Radiologic results including the cage location and sagittal alignment were also assessed with plain radiography. Results: The study group comprised 16 patients in DLIF group (M: F = 1:1.7, mean age = 67.8 (range 54∼82)) and 15 patients in OLIF group (M: F = 1:2, mean age = 63.5 (range 49∼75)). There were no significant statistical differences in perioperative parameters (operation time, intraoperative blood loss and hospital stay) and early clinical outcome between two groups. Overall, there were 8 (50.0%) approach-related complications in DLIF group (4 leg paresthesia, 2 leg weakness, 1 wound infection and 1 local hematoma) and 2 (13.3%) in OLIF group. (1 leg paresthesia and 1 local hematoma; p < 0.05) Of all approach-related complications in DLIF group, 2 (12.5%) were classified as persistent, and 6 (37.5%) were classified as transient complications. However, there was no persistent complication in OLIF group. The overall incidence of approach-unrelated complication accounted for 12.4% in DLIF group and 13.3% in OLIF group respectively. The most common non-approach related complication in OLIF group was abdominal ileus. (6.2% vs 13.3%, P < .00). In OLIF group, cage is located mostly in the middle 1/3 of vertebral body, significantly increasing posterior disc space height (38.1% vs 21.2%, P < .05) and foraminal height compared to DLIF group (21.1% vs 12.7%, P < .05), where cage is placed more anteriorly. Global and segmental lumbar lordosis was greater in DLIF group (45.6 ± 11.6° vs 36.5 ± 6.9°, 15.8 ± 4.7° vs 9.5 ± 6.1°) due to anterior cage position without statistical significance. Conclusion: In our report of L4/5 level diseases, the OLIF technique may decrease approach-related perioperative morbidities by eliminating the risk of unwanted muscle and nerve manipulations. Using orthogonal maneuver, cage could be safely placed more posteriorly, resulting better disc and foraminal height restoration. Longer-term follow-up is warranted., Introduction: Extreme lateral interbody fusion (XLIF) is a minimally invasive technique that can be used to relieve radicular pain and neurogenic claudication in patients with degenerative spondylolisthesis, scoliosis and foraminal stenosis. It relies upon indirect decompression, in contradistinction to traditional surgical treatment by direct posterior decompression and fusion procedures. Preoperative prediction of the success of indirect decompression is currently based mainly on radiological criteria.1,2 This study evaluates the reliability of a clinical algorithm that is simply based on the ability for a patient to achieve a pain free posture preoperatively (typically sitting or lying). If this was achievable, our hypothesis was that an indirect decompression would be successful. Materials and Methods: A prospective consecutive series of patients who underwent XLIF by a single surgeon was conducted from October 2014 to June 2016. All patients who were able to achieve a pain-free position underwent XLIF alone. Patients with constant radicular pain underwent XLIF and supplemental direct decompression. The patients’ demographic, clinical data, Oswestry Disability Index (ODI) and visual analogue scale (VAS) for leg pain were collected preoperatively and at 1, 3, 6, and 12 months post-operatively. Results: 26 consecutive patients were recruited into the study with a mean age of 67.4 (range 36-84) and were treated with XLIF at 36 levels (range 1- 4). The most common levels treated were L4/L5 level in 18 patients and L3/L4 in 13 patients. Six patients had supplemental posterior decompressions during the index procedure. Fixation was performed in 24 patients (21 pedicle screws, 3 lateral plate). At 1 month postoperative follow up, leg pain for both groups (XLIF alone and XLIF with direct decompression group) showed significant improvement with reduction of mean VAS score by 5.9 (95% CI 4.3 – 7.5, P < .0001) and reduction of mean ODI by 13.9% (95% CI 3.8% - 24.0%, P = .0115). In XLIF alone group, patients also demonstrated significant improvement, with reduction of mean VAS score by 6.2 (95% CI 4.2 – 8.2, P < .0001) and reduction of mean ODI by 13.3% (95% CI 0.9% - 25.8%, P = .038). There was no significant difference in the treatment effect (mean reduction in VAS and ODI) between the XLIF alone group and the group receiving XLIF with supplemental decompression. No patients required reoperation. Complications included urinary retention in one patient, contralateral leg pain in one patient that resolved at 14 days, cerebrospinal fluid leak in one patient who had decompression, resulting in a remote cerebellar haemorrhage that resolved without further intervention. Conclusion: A single clinical criterion of achieving a pain-free position at rest preoperatively can be used as an aid in selecting patients that may benefit from indirect decompression using XLIF alone. Longer follow up and a larger series is required to assess durability of this algorithm. References 1. Oliveira L, Marchi L, Coutinho E, Pimenta L. A radiographic assessment of the ability of the extreme lateral interbody fusion procedure to indirectly decompress the neural elements. Spine 2010;35: S331–7. doi:10.1097/BRS.0b013e3182022db0. 2. Gabel BC, Hoshide R, Taylor W. An Algorithm to Predict Success of Indirect Decompression Using the Extreme Lateral Lumbar Interbody Fusion Procedure. Cureus 2015;7: e317. doi:10.7759/cureus.317., Introduction: The aim of this study was to assess current spinopelvic parameters measured after extreme-lateral interbody fusion (XLIFR) versus minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), in order to compare postoperative results. Material and Methods: Eighty consecutive patients undergoing single to three level lumbar interbody fusion surgery for common spine degenerative disorders at a single center were recruited to two different groups, according to the surgical technique applied: XLIFR (n = 36) x MIS-TLIF (n = 44). Postoperative (PO) standing lateral films including all lumbar segments and femoral heads were obtained from all included patients and analysed using NuvamapR software by a single experienced spine surgeon. XLIF and MIS-TLIF patients were compared in terms of the following parameters: age, gender, operated levels (number and location), pelvic incidence (PI), lumbar lordosis (LL), segmental lordosis (SL), L4S1 lordosis, pelvic tilt (PT), sacral slope (SS), and mismatch (PI-LL). Data were registered in a specific database created for the study. Results: XLIFR and MIS-TLIF groups were similar in terms of age and gender. In XLIFR group (n = 36), the following spinopelvic parameters were obtained in average: PI 56.1; LL 53.2; PT 16.7; SS 39.5; mismatch (PI-LL) -2.2. For MIS-TLIF group (n = 44): PI 52.6; LL 45.9; PT 19; SS 34.3; mismatch -5.9. A mismatch (PI-LL) greater than 20 degrees was observed in only 7 (8.75%) patients (XLIFR- n = 2; MIS-TLIF– n = 5). Considering single level interbody fusion and excluding L5S1 level, spinopelvic parameters obtained for XLIFR (n = 18) group were: PI 58.3; LL 57.1; PT 16.7; SS 41.8; mismatch -0.61; and for MIS-TLIF (n = 19) group were: PI 57.5; LL 46.6; PT 24.1; SS 33.6; mismatch -9.1. LL, PT, SS and mismatch showed statistically significant different values between XLIFR and MIS-TLIF groups. Conclusion: XLIFR and MIS-TLIF are both adequate surgical techniques for treatment of common spine degenerative disorders, with low risk of decompensation in saggital profile. In this study, XLIFR showed superior efficacy to preserve spinopelvic alignment compared to MIS-TLIF., Introduction: Lateral transpsoatic interbody fusion (LTIF) permits discectomy and insertion of a wide cage resting on the apophyseal ring, while preserving the anterior and posterior annular/ligamentous structures. Commercially available systems employ a series of tube shaped dilators to traverse the psoas muscle and expose the target disc. These systems rely upon a hand held depolarizing device to detect and avoid damage to the exiting nerve roots and lumbar plexus. Despite this methodology, injury to the neural elements has been reported, as has injury to the viscera and vascular structures. We hypothesized that a mini-open technique, permitting direct visualization of retroperitoneal and neural structures, would result in a lower incidence of such injuries. Materials and Methods: From 2007 through 2016, a patient registry accrued >2,000 patients undergoing LTIF. At an average of 2.5 levels/patient, >5,000 levels were done using a mini-open muscle splitting approach, permitting visualization of the retroperitoneal space and digital palpation of the target disc. A transpsoatic dissection plane ventral to the exiting nerve roots and lumbar plexus was established via direct visualization and palpation. Retraction was maintained by table mounted Altus®, DePuy® or Nuvasive® self-retaining systems, or by hand held renal vein retractors. Coronal deformities were approached through the concavity of the curve. In cases involving the L4-5 disc space, coronal angulation of the L4-5 disc was the principal factor determining choice of operative side. Results: There were no instances of peritoneal violation or permanent motor deficit. Incidence of minor sensory deficit at one year was, Introduction: General anesthesia and airway management is the cornerstone of safe care and passage through spine surgery. Emergent reintubation after extubation is a important and potentially dangerous event. Reintubation as a Medicare or Joint Commission metric is likely to come under increasing scrutiny in the changing and cost conscious healthcare environment. These healthcare metrics will be increasingly important to outcomes conscious reimbursement and quality assessment models. The purpose of the present study is to identify those factors that contributed to the need for emergent reintubation amongst a cohort of spine patients, accounting for indication for surgery (trauma, degenerative, deformity, tumor) as well as temporal indications (elective vs emergent surgery), type of surgery (cervical, thoracic, lumbar) and surgical site (anterior, posterior, combined). Materials and Methods: All patients undergoing spine surgery at the University of Washington and Harborview Medical Center were identified from a prospectively collected data base from July 1, 2008 to December 31, 2012. Results: During the collection period, 4995 patients underwent spine surgery requiring intubation. Sixty-six (1.3%) required an un-planned re-intubation. Baseline demographics are as follows: sex: male 49, 17 female; diagnosis: (63.6%) trauma, (21.2%) degenerative, (6.1%) deformity, (6.1%) infections, (3.0%) tumors; surgical site: (62.1%) cervical, (30.3%) thoracic, (7.6%) lumbar; surgical procedure: (16.7%) anterior cervical, (9.1%) a/p cervical, (37.9%) posterior cervical, (28.8%) posterior thoracic, (7.6%) posterior lumbar; position: (16.7%) anterior, 6 (9.1%) anterior/posterior, (74.2%) posterior; index extubation location: (42.4%) in OR/PACU, (57.6%) delayed in ICU; time to re-intubation from extubation: 30 < 24 hours, 8 < 48 hours, 9 < 72 hours, 14 > 72 hours; location of re-intubation: 13 acute care floor, 4 in OR, 49 in ICU; reason for re-intubation: 59 respiratory failure, 3 cardiac, 1 hematoma, 1 sepsis, 1 reduced mentation, 1 hypotension. Of the 66 patients re-intubated, 52 (78.8%) occurred within the first 72 hours and the other 14 occurred more than 3 days post-extubation. The most common cause for re-intubation was respiratory failure in 59 patients with 7 re-intubations related to other causes. Only one re-intubation was felt to be due to a post-operative hematoma in an anterior cervical case. Interestingly, 42 (63.6%) of the 66 patients requiring re-intubation had a spinal traumatic lesion as the surgical indication. Conclusion: The greatest percentage of reintubation events occurred within the first 72 hours and trauma is a risk facture especially in those requiring cervical surgery, either anterior or posterior. Length of surgery or operative variable did not seem to be predictive. Overall the rate of emergent reintubations is very low and therefore one should not guide treatment decisions to aggressively to avoid an otherwise rare event. And finally, patients destined for acute care (ICU etc) have a higher risk and this likely reflects their overall status and injuries However, despite a large patient sample, prospective database and important clinical question we do not feel that large retrospective databases such as these, even collected prospectively are sufficiently strong to use in the construction of healthcare quality metrics for review, CQI and especially reimbursement outcomes models., Introduction: Airway management can be very challenging in patients undergoing posterior occipitocervical fusion (OCF). Limited data exist pertaining to the incidence, risk factors for, severity of and types of airway adverse events following OCF. The purpose of this retrospective cohort study was to quantify the rate of postoperative airway adverse events (AE), describe the types of AE and examine potential risk factors for AE in patients undergoing posterior OCF. Material and Methods: After obtaining IRB approval at our institution a retrospective review of adult patients undergoing OCF at a single tertiary academic spine center was performed. Subjects with a history of spine surgery or with an endotracheal tube or tracheostomy at the time of the OCF were excluded. Chart review was performed to collect data pertaining to patient demographics, airway management strategy, anesthesia, surgical intervention and adverse events. Airway adverse events were classified into three types: Type 1) immediate airway complications (ie, need for reintubation within the first hour following extubation of the patient in the operating room), Type 2) failed extubation in the intensive care unit (ICU) or Type 3) delay of extubation at emergence from anesthesia with transfer of the patient intubated to the ICU. Preoperative and postoperative radiologic studies were used to measure the occipitocervical angle (OC2A) and the change in each patient’s OC2A (dOC2A) was calculated. Descriptive statistics were summarized and differences between patients without an airway AE (Group 1) and with an airway AE (group 2) were examined. Results: Between 2005 and 2013 a total of 59 patients undergoing posterior OCF and meeting study inclusion criteria were identified. No airway AE occurred in 47 (73%) of our patients (Group 1). Of the 16 patients (27%) who experienced an airway AE, four (25%) were Type 1 requiring reintubation, 12 (75%) were transferred to the ICU intubated (Type 3) and 2 of those patients eventually failed extubation in the ICU (Type 2; 16.7% rate of failed ICU extubation). Those patients who experienced airway AE (Group 2) were more likely to have had a surgery lasting greater than 5 hours (P = .009), had surgery of 6 or more lev (P = .012) and were more likely to have been identified as being a difficult intubation (P = .002). Mean dOC2A was not significantly different between Groups 1 and 2 (−1.1 degrees versus −4.4 respectively, P = .127). Conclusion: The incidence of airway AE in our population was 27% indicating that airway management in patients undergoing posterior OCF is challenging and high risk. Decisions regarding timing of extubation must be individualized and factors such as difficult intubation, number of vertebral levels fused and surgical duration must be considered. While surgical attendance to fusion position is important dOC2A was not related to postoperative airway AEs in our cohort. Risk factors for postoperative airway AEs following posterior OCF are multifactorial and require prospective evaluation., Introduction: There is conflicting information about the relationship between tobacco smoking and risk of postoperative complications among anterior cervical discectomy and fusion (ACDF) procedures. With the availability of databases such as the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, it is now possible to identify perioperative outcomes associated with ACDF surgery within a large, nationally representative sample. To our knowledge, no studies have been performed among ACDF patients that evaluate the association of preoperative smoking status with the development of perioperative complications using a national database. We sought to compare the postoperative complications following ACDF surgery among non-smokers to complications among current or ever-smokers. Material and Methods: Patients over the age of 18 undergoing ACDF between 2005-2014, excluding emergency cases, were identified. The following baseline admission data were collected: age, gender, race, height, weight, American Society of Anesthesiologists status, revision status, osteotomy status, presence of at least one comorbidity, and number or anterior instrumented levels. ACS-NSQIP defines “smokers” as patients who have smoked cigarettes in the year before admission for surgery. The number of pack-years of smoking (defined as the product of the number of packs of cigarettes smoked daily and the years the patient has smoked) is also reflected for both previous and current smokers. Outcomes analyzed included development of at least one complication, development of a major complication, in-hospital mortality, and length of stay. Results: A total of 25,869 patients undergoing ACDF were identified; 7,847 (30.3%) current smokers, 18,022 (69.7%) not currently smoking, and 8542 (33.0%) ever-smokers. Logistic regression analysis revealed that current smoking status was not significantly associated with the occurrence of any one complication (OR, 1.054; 95% CI, 0.874 -1.271; P = .584) or any major complication (OR, 1.233; 95% CI, 0.935 -1.627; P = .138). An ever-smoker status was not significantly associated with greater odds of developing any one complication (OR, 1.035; 95% CI, 0.858 -1.249); P = .718) compared to non-smokers. However, ever-smoker status was significantly associated with a higher risk of any major complication (OR, 1.333; 95% CI 1.007 -1.764; P = .044) than for non-smokers. Using the number of pack-years as the primary independent variable, multivariate logistic regression analysis revealed that pack-years was not significantly associated with greater odds of developing any one complication (OR, 0.992; 95% CI, 0.978 -1.006; P = .276) or any major complication (OR, 0.991; 95% CI, 0.972 -1.010; P = .334). Conclusion: Although a positive ever-smoker status was associated with increased odds of developing morbidities compared to never-smokers, there was no relationship between the number of pack-years and the odds of developing any one complication or any major complication. Given the potential deleterious effects of a positive ever-smoker status, as well as the continued debate in the spine literature over the effect of smoking on long-term fusion success, smoking cessation should still be endorsed for ACDF surgery candidates., Introduction: Chronic kidney disease (CKD) remains a worldwide public health problem, with a rising incidence and prevalence of kidney failure. Existing research on CKD and lumbar surgery using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database has been limited to single years of data, non-specific lumbar procedures, and sole use of glomerular filtration rate (GFR) as an indicator of renal dysfunction. The objective of this study was to compare post-lumbar decompression and fusion complication rates and mortality for 1) patients with and without preoperative hemodialysis (HD) use and 2) non-preoperative HD patients with and without renal dysfunction as estimated by GFR and creatinine levels. Material and Methods: Patients over the age of 18 undergoing lumbar fusion between 2005 to 2014, excluding emergency cases, were identified. The following baseline admission data were collected: age, gender, race, American Society of Anesthesiologists status, osteotomy status, height, weight, revision status, and whether the procedure involved multiple levels. The preoperative use of HD was noted for all patients. To estimate preoperative kidney function in patients without HD, the most recent lab values for creatinine collected within 90 days prior the operation were evaluated. GFR was then estimated using the CKD-Epi formula that accounts for race, gender, and age. Outcomes considered included the development of at least one complication, development of a major complication, in-hospital mortality, and length of stay. Results: A total of 29,136 patients undergoing lumbar fusion were identified; 55 (0.19%) with preoperative HD, and 29,081 (99.81%) with no preoperative HD. Logistic regression analysis revealed that preoperative utilization of HD was not significantly associated with the occurrence of any one complication (OR, 1.900; 95% CI, 0.880-4.103; P = 0.102) or any major complication (OR, 2.019; 95% CI, 0.710-5.737; P = .187). Non-HD patients with severe preoperative kidney function impairment demonstrated increased likelihood of any complication (GFR = 15-30 ml/min/1.73m2; OR, 3.82; 95% CI, 2.061-7.082; P =, Introduction: Total single-level or multilevel laminectomy/laminotomy has been widely used in neurosurgery for the removal of spinal intradural-extramedullary (ID-EM) tumors at last decades. In recent years, minimally invasive surgery (MIS) approaches have become increasingly popular for treatment of spinal pathology. There have been prior reports of MIS for ID-EM tumors; however, these have been limited to case reports or small series. Sufficient surgical indications have not yet been thoroughly evaluated. Some controversy has existed concerning the use of unilateral approach for the spinal tumors with foraminal extension or multi-level. Material and Methods: A retrospective analysis of medical records and radiologic data was performed on patients who undergone unilateral laminectomy approaches for the removal of spinal meningiomas and schwannomas by one surgeon in a single center from January 2010 to June 2016. Extradural spinal mass and other ID-EM tumors and patients who followed up loss are excluded. 71 patients were enrolled finally in this study. Schwannomas were 55 cases. Meningiomas were 16 cases. Foraminal extension was found at 20 cases. We investigated the neurologic outcomes, complication rate, gross total removal rate, estimated blood loss (EBL), operation time, hospitalization, recurrence or progression with or without foraminal extension and multi-level. Japanese orthopedic association (JOAS) score, Visual analogue scale (VAS) and McCormick grade were used for the evaluation of postoperative neurologic outcomes. Results: The difference of preoperative and postoperative VAS, JOA score and McCormick grade was 4.3 ± 2.9, 1.8 ± 1.3 and 0.4 ± 0.7. These were statistical significance (P = .000). Complication rate was 12 patients; orthostatic headache was detected in 6 patients, wound dehiscence was observed 1 patient, wound infection was found 2 patients and myelopathy was detected 3 patients. Gross total resection was 66.2%, near total resection was 11.3%, subtotal resection was 16.9% and partial decompression was 5.6%. EBL was 235 ± 157.2 cc. Operation time was 210.4 ± 63 mins. Hospitalization was 13.8 ± 7.5 days. Recurrence or progression rate was 4.2%. In subgroup analysis, EBL with foraminal extension (P = .03), operation time with more 2 levels (P = .04) and the difference of preoperative and postoperative VAS with schwannoma (P = .05) was increased significantly. The present study showed significant improvement of VAS in lumbar level and McCormick grade in cervical level more than other levels. There was no severe kyphotic degeneration after laminectomy. Conclusion: Clinical outcomes of unilateral laminectomy approach for the spinal ID- EM tumors were excellent even in foraminal extension and multi-level cases. The minimal approach does not preclude a low recurrence rate. Unilateral laminectomy approach for patients with relatively short life expectancy would be the good option of surgical approach. That might be also selective option for good general condition and young age patients., Introduction: Metastatic spine disease accounts for 10% to 30% of new cancer diagnoses annually. Surgical intervention is indicated in patients with spinal instability, spinal compression, progressive neurologic deterioration. For the management of spinal metastases two different approaches can be chosen. There are radical resection and palliative resection of the tumor. Surgical decompression and stabilization, along with targeted therapy and bisphosphosphonates, may provide the most promising treatment. In this research the frequency of local recurrences, quality of life and survival were studied depending on the surgical approach. Material and Methods: Between 2009 and 2015, 99 patients with histologically verified renal cell cancer metastasis were retrospectively reviewed. There were 66% males. Mean age of 55 years (range 35-71). Mean follow-up of 12 months. All patients were treated with targeted therapy and bisphosphosphonates. The patients were divided into two groups depending on the surgical approach. In the first group 46 patients underwent radical tumor resection. In the second group 53 - palliative tumor resection. Local recurrences of the tumor were evaluated. Overall survival was calculated using the Kaplan-Meier method. Quality of life was evaluated using a questionnaire SF-36 3, 6 months postoperative follow-up. Results: In the I group a local recurrence occurred in 24.0% (11/46) of patients, in the II group - in 24 cases (45%) during 1 year follow-up. Local recurrences were significantly (P < .001) less frequent in patients with radical tumor resection. The difference in survival between groups wasn’t statistically significant (P < .001). In the first group approach has been shown to be associated with greater blood loss and operative time; in the second group surgery was less invasive. And in the first group were taken more complications such as dural tears, neurological deficit. Consequently, quality of life 3 months after more aggressive surgical approach as radical tumor resection has low rates results. But then 6 months follow up quality of life parameters in both groups were improved. Conclusions: Analysis finds comparable results of survival rates and quality of life 6 months follow-up with both approaches. More aggressive surgical approach as radical tumor resection has fewer frequency of local recurrence, but longer time postoperative recovery. Palliative resection of the tumor is an acceptable approach especially for the patients with comorbidities, because of less invasive and has fewer complications., Introduction: Metastatic spinal cord compression is defined radiographically as an epidural metastatic lesion causing true displacement of the spinal cord from its normal position in the spinal canal. Spinal metastasis is common in patients with malignancy. The spine is the third commonest site for metastasis after lung and liver. Approximately 70% of cancer patients have metastatic disease at death. The spine is involved in up to 40% of those patients. Spinal cord compression may develop in 5% - 10% of cancer patients and up to 40% of patients with pre-existing non-spinal bone metastasis. The management of patients with metastatic spinal cord compression is individualised and can include surgery, radiotherapy or chemotherapy. The role of surgical decompression is expanding with the increase in survival times. Material and Methods: Prospective data collection of consecutive 192 patients referred with suspected metastatic spinal cord compression of whom 151 constituted the most common tumour types were included. Record of surgical intervention and survival times were collected over a 2 year period. Results: A total of 151 patients were identified in the study, 64% were males (96/151) and 36% were females (55/151). Tumours included were breast, prostate, lung, myeloma, renal cell carcinoma and malignancy of unknown origin. The mean age was 67.4 (Median 69 and Range 32-94 years). Breast, prostate and lung primaries represented 15, 34 and 23% respectively. Eighty-seven percent of patients (131/151) were treated non-operatively with an overall mortality rate of 84.7%. The mortality rate at 6 months was 73% (n = 95), range 0-5.7 and median of 1.5 months (P = .0001). The mortality rates at 6 months for breast, prostate and lung primary patients were 50% (mean 2.9, median 3 months), 67% (mean 1.7, median 1.7 months) and 93% (mean 1.7, median 1.5months) respectively (P < .0001). Surgical intervention was performed in 13% of patients (20/151). The overall mortality was 45%. The mortality at 6 months was 30% (n = 6), range 0-4.6 and median 1.6 months (P = .0056). The mortality rates at 6 months for breast, prostate and lung primary patients were 12.5% (mean 4.6 months), 33% (mean 1.3 months) and 100% (mean 1.6 months) respectively (P < .0001). Conclusion: Operative intervention certainly has a role in the management of patients with metastatic spinal cord compression, however, the natural history of the primary tumour should be taken into account when deciding whether or not to intervene surgically. The cost effectiveness of surgical intervention versus palliative care should considered carefully, especially in the current economic climate with ongoing financial pressures on the National Health Service., Introduction: Chordoma is characterized with a high rate of recurrence and questionable response to radiotherapy. Adjuvant chemotherapeutic possibilities are limited because the molecular genetic pathogenesis of the tumor is still not known. The goal of the authors was to find new chromosomal aberrations and gene expression variations of the tumor by using next generation total RNA sequencing, with the possibility of identifying novel molecular targets in chordoma. Material and Methods: Next generation sequencing of total RNA was performed on 8 fresh frozen sacral chordoma samples and 8 nucleus pulposus cell culture samples. Data was analyzed with standard bioinformatic tools available on the Galaxy server (Galaxy Main), to identify fusion transcripts and evaluate differential gene expression. The results were validated by using polymerase chain reaction from the reverse transcripted RNA samples (RT-PCR). Results: A new in-frame gene fusion was observed between the SAMM50 and TBC1D22A genes in the sample of a patient with multiple sacrum chordoma recurrences. Both genes are localized on chromosome 22, and the fusion transcript appears to be the result of a large interstitial deletion in the 22q13 region (over 2.7 Mbp), which is known to be a fragile genomic region. Many of the genes localized within the deleted region (GTSE1, PPARA, WNT7B, CELSR1, FBLN1) have a role in oncogenesis, and PPARA expression was suppressed in all chordoma samples compared to normal cells. Conclusion: This work demonstrates the first successful next generation total RNA sequencing from chordoma. A chromosomal deletion was detected by identifying a fusion transcript of the SAMM50-TBC1D22A genes in a case characterized by several recurrences. The deleted chromosomal region can be associated with oncogenesis, as well as with the susceptibility of recurrence of chordoma. These molecular genetic findings can help to develop general and individualized adjuvant therapeutic options for chordoma patients., Introduction: Minimally invasive (MI) lumbar decompression is a common procedure for spinal stenosis disease. These dorsal decompression procedures can benefit so many patient by reducing pain and recovering the function. Resections of posterior bony structure of lamina and partial or total disc in decompression procedure are often performed, but they are also associated with potential postoperative spinal instability on posterior neural arch. Recently, a number of interspinous spacers (ISS) have been combined with MI decompression for surgery of degenerative lumbar disc disease as a concept of dynamic stabilization. The ISS is designed to restrict segmental motion and theoretically did some potential beneficial effect and avoid the development of adjacent level complications. A current study has been done to evaluate the biomechanical influence of MI decompression plus the DIAM on the pars interarticularis area. Material and Methods: The MI decompression procedures are simulated to including the laminotomy over mainly part of L3 and less part of L4 and discectomy over L3/L4 levels. Finite element models were developed for the intact spine (INT), the DIAM was implanted at L3/4 (DIAM), the unilateral MI decompression procedures with DIAM (DIAM+uni), and the bilateral MI decompression procedures with DIAM (DIAM+bil). The models were subjected to axial loads and pure moments and evaluated by a hybrid method on range of motion (ROM)s, disc stresses, pars interarticularis stresses, and facet joint contact forces. Results: The investigation revealed that it is similar to the disc stresses including adjacent levels after DIAM insertion with uni- or bilateral MI decompression procedures but a considerable increase in stresses over pars interarticularis at L3 in both flexion and extension and decrease in stresses at L4 in extension. In contrast to L4, the amplitude of increasing stresses distribution across L3 pars interarticularis in extension were likely to be observes significantly larger. Conclusion: The MI decompressions are broadly being performed for lumbar spinal stenosis. Surgeon always concerns the risk of stress fracture for remaining posterior neural arch. The ISS did alter the biomechanical behavior in various indications. The effects of ISS combined with MI decompression is still unclear and no previous studies was known or done to study the changes of posterior neural arch with MI decompression procedures plus ISS. The results demonstrate the DIAM apply a distraction force and unload the facet force in posterior element after MI procedure, but this implantation may led to much greater stress concentrated in pars area, especially in upper level of implanted segment. The increased stresses at the pars interarticularis could still be a risk factor for a stress fracture. The surgeon should consider the possibilities for pars fracture in active patient group after these procedures with ISS., Introduction: PJK is not uncommon and can result in significant complication after spinal deformity surgery. Prophylactic vertebroplasty has been shown to reduce the rate of PJK, but optimal cement dosage and configuration has yet to be analyzed. Using a finite element (FE) model we analyzed various dosages and configurations of vertebral cement to see how it influences junctional endplate stress. Material and Methods: A validated FE T6-pelvis osteoporotic spinal model was modified with screws/rods from T10-S1 and various dosages (0 – 5ccs) and configurations (anterior, anterior/central, and central placement) of vertebral cement was simulated in T10 (UIV), T9 (UIV+1), and T8 (UIV+2). With the pelvis fixed, load was applied 10 mm anterior to the center of T6 to simulate a flexion moment. Endplate stresses were recorded from T7 to T9. Results: FEA identified the optimal cement dosage of 2.5 cc in T10, 2 cc in T9, and 1 cc in T8 resulted in the smallest change in stress observed at the inferior endplate of the unadulterated T7 vertebra, relative to the superior endplate of cemented T8 at −7.6%. Larger volumes of cement (5 cc) resulted in larger changes in endplate stresses, including maximum changes of 37.3% and 61.1% with centrally and anteriorly placed cement, respectively. Using this dosage (2.5 cc, 2 cc, 1 cc), optimal cement configuration included anteriorly placed cement in the UIV (T10), anterior/central placement in the UIV+1 (T9), and centrally placed cement in the UIV+2 (T8). This resulted in the lowest endplate stresses in the both cemented (T10, T9, and T8) and more importantly in the unadulterated non-cemented (T7) vertebra. Conclusion: Prophylactic vertebroplasty has been advocated to reduce the rates of PJK and revision surgery, but the number of levels, cement dosage, and configuration has not been evaluated. In this osteoporotic T10-S1 instrumented spine FE model, placing 2.5 cc anteriorly in the UIV (T10), 2 cc anterior/central in the UIV+1 (T9), and 1 cc centrally in the UIV+2 (T8), reduced the endplate stresses in both the cemented (T10, T9, and T8) and more importantly in the supra-adjacent non-cemented T7 vertebra. Decreased endplate stresses may translate to vertebral bodies that are, Introduction: Early onset scoliosis (EOS) is defined as the development of an abnormal spinal curve occurs in growing children before the age of 10. Invasive corrective surgeries are often required for the children ineffectively responding to conservative treatment and curves have rapidly progressed. Surgical implantation such as growing rod system is used to correct spine deformity. The forced growing rod system has been found to demonstrate effective spinal deformation correction; however, it has its shortcomings, such as requiring periodical revision surgeries. The purpose of this study has two aims: one is to design a novel self-adjusted growing rod that would control the spinal deformity and allow the growth of spinal column without repetitive invasive surgeries and secondly, to compare the biomechanical properties of the self-adjusted growing rods to the current clinical-used rods construct in different motions. Material and Methods: The design of the self-adjusted growing rod was center on the mechanism housed within a connector that allowed a unidirectional elongation of the pair of rods. Porcine thoracic spines with 8 vertebrae (n = 6) were used. Each specimen was tested following the grouping: 1) non-instrumented, 2) self-adjusted rods, and 3) rigid rods. Nondestructive bending moments of 5 Nm in the direction of flexion, extension, lateral bending were applied. Rods elongations were recorded and the vertebral motions were measured using a motion tracking system. The biomechanical analysis included the range of motion (ROM) of the instrumented as well as the adjacent levels. Furthermore, the force required for the elongation of the unit length for the self-adjusted rod was also determined. Results: The average pull force of 10.4 N was required for the self-adjusted rod to be lengthened by a single scaled unit. Irrespective of test conditions, all specimens with instrumentations demonstrated a significant decrease of ROM in instrumented levels compared to the specimens without the instrumentations (60.6% and 75.8% decrease in lateral bending and flexion-extension motion for self-adjusted rods; 86.3% and 89% decrease in lateral bending and flexion-extension motion for rigid rods, respectively) (P < .05). However, ROM of specimens of the self-adjusted rods were significantly higher than the rigid rods (P < .05). In terms of the adjacent levels, no significant difference was found among the three groups. Moreover, elongation of self-adjusted rods was observed in lateral bending and flexion motion. Conclusion: In the current study, a prototype of the novel self-adjusted rods construct was successfully designed and utilized in the biomechanical test. The results proved that the self-adjusted rods construct provided more stable instrumented segments than non-instrumented group; and furthermore, preserved more range of motion than rigid rods. It is anticipated that the design will be suitable for treating early onset scoliosis. Most of all, the length of the self-adjusted rods can be modulated by the patients themselves, and hence prevents the patients from repeated invasive lengthening procedures., Introduction: En-bloc resection of a primary malignant sacral tumor with wide oncological margins impacts the biomechanics of the spinopelvic complex deteriorating postoperative morbidity and mortality. The closed loop technique (CLT) for spinopelvic fixation (SPF) uses one single U-shaped rod to connect all pedicle and iliac screws. The method applies the philosophy of non-rigid fixation to avoid the stress-shielding phenomenon and to promote the bony fusion between the lumbar vertebral body and the pelvis. Solid bony connections will be formed within the first 24 months after the surgery. Here, based on the 6 years follow up clinical data, we establish a method to measure the deformation in the hardware system, and to numerically determine the fusion process. Materials and Methods: Retrospectively post-operative CT scans were collected from a male patient who underwent total sacretomy at the age of 42 due to chordoma. CLT technique was used to reconstruct the spinopelvic junction. From our database we collected 12 CT scans during the 6-year long follow up. We defined the 3D geometry of the implant construct and by using image registration algorithms. A common coordinate system for the CLT was used in order to measure and visualize the deformation of the hardware during the 6-year long follow up. We selected a region of interest (ROI) at the proximal level of the construct and the modulus of the displacement during the follow up period was determined. In order to investigate the fusion process we defined a single axial slice based voxel finite element (FE) mesh. The ROI determination was based on the second post-operative CT scan where we had solid bony fusion between the pelvis and the L.V. vertebral body. We determined the Gray scale values, and using linear empirical equation bone mineral density (BMD) values for every mesh element was assigned. For the BMD assignment we determine 10 categories with linearly increasing values and different color codes. Results: The developed method has allowed us to visualize the 3D deformation of the implant construct during the investigated period. The mean displacement value of the ROI during the 6 years was found to be 6.04 mm. We determined and visualized the element distribution over time in the different BMD categories and found in the highest BMD value category on the first post-operative CT was 9 FE mesh elements, at the 2 years FU was 64 FE elements and after 6 years it was 144 FE elements. Conclusion: The observed deformation occurred due to the shock/load absorber characteristics of the CLT providing strong lumbopelvic bony fusion within 2 years. The study results and the measurement method can be used for validation of complex patient specific FE models which can be useful for the individualized pre-operative surgical planning., Introduction: Surgical management of spinal deformity is characterized by significant variability in the rates, costs and approaches to care. Such variability is clear evidence of the absence of an evidence-based approach to care. Areas of both high cost and high variability present potential targets for innovation, cost-saving and the promotion of consensus in clinical practice. The purpose of this study is to: (1) identify and document the range of direct costs for multi-level spinal fusions and reconstructions for ASD; (2) correlate surgical outcomes with administrative data to identify predictors of surgical and patient reported outcomes; (3) determine if there exists a correlation between dollars spent and outcomes achieved in ASD surgery. Material and Methods: Retrospective study of a consecutive series of patients treated with primary multilevel spine surgery for ASD. ASD patients who underwent multilevel spinal fusions from the upper thoracic spine (T3/T4) and lower thoracic spine (T10/T11) to pelvis met inclusion criteria. Patients with incomplete billing or Health Related Quality-of-Life (HRQoL) data were excluded from the study. Demographic, surgical, direct cost data and HRQoL data were collected directly from administrative and medical ontologies. All records were chart reviewed and source verified for accuracy. Results: The cohort included 83 patients. Mean lenght of follow up was 911 days. Direct costs ranged from $26,936-$140,777 (mean = $78,751 +/− $21,592). Cost variability was the highest in blood product utilization (80.64 fold variation for non-zero charges) and lowest for time related operating room costs (3.55 fold variation). Implant costs were the largest contributor to the direct cost of care (46.3%) Median implant direct cost was $33,557. Median implant cost was significantly heigher in patients who experienced positive changes in health status (P = .005). Mean change in EQ-5D Utility score was 0.16 with 66% of patients experiencing an improvement in health status from their spine surgery. There was no statistical difference in health status change for upper vs. lower thoracic fusions (P = .22) or posterior vs. circumferential fusions (P = .82). Lower ASA scores were correlated with greater improvements in health status (P = .009). 34% of patients required revision surgery. Mean time until revision surgery was 382 days. Those who had revision surgery had an average of 1.47 additional surgeries in addition to their index surgery. 46% of obese patients (BMI > 30) had revision surgery, while the revision rate for patients in a healthy range (18.5 < BMI < 25) was 22%. Lower thoracic fusions (31%) were less likely to require revision surgery than fusions to the upper thoracic (48%) but did not reach statistical independence (P = .14). Conclusion: The costs and outcomes of spinal surgery are highly variable. Implants, operating room time, and length of stay were the most important drivers of cost for a hospital admission. Areas of high cost and high variability offer potential targets for cost savings and quality improvements. High BMI and ASA scores were predictors for revision surgery. Surgical approach and length of fusion did not significantly effect changes in health status., Introduction: The high complication rates currently associated with ASD surgery necessitates the development of accurate preoperative complication risk measurements. Frailty has been associated with complication incidence in trauma surgery. Material and Methods: 40 variables in an ASD database were selected to calculate a frailty score for each patient in the database and used to stratify them into 3 frailty cohorts: not frail (NF) 0.5. We then performed a multivariate logistic regression to determine the relationship between frailty cohort and incidence of major complications. Results: Of 417 participants eligible for minimum 2-year follow-up the average ASD-FI score was 0.34 (range 0.0 – 0.8). Compared to NF patients (n = 171), F (n = 162) had a 2.6 day [0.95-4.3] (P < .01) longer and SF (n = 84) had a 6.4 day [4.2-8.7] (P < .001) longer LOS. The adjusted odds of incurring a major intraoperative or postoperative complication was 9.4 times greater for F and 14.5 times greater for SF than NF. Compared with NF, the odds of having a medical complication were 3.9 for F and 14.6 for SF and the odds of having a surgical complication were 1.8 for F and 2.1 for SF. The adjusted odds ratio of developing proximal junctional kyphosis was 4.4 and that of developing a wound infection was 5.1 for SF compared to NF patients. Conclusion: Increasing patient frailty, as measured by the ASD-FI, is associated with increased risk of major complications. The ASD-FI is a potential tool that spine surgeons may use to improve the accuracy of preoperative risk stratification and aid patient counseling., Introduction: The ASD-FI is a risk stratification tool which predicts major complications and prolonged hospital length of stay. The impact of frailty on postoperative improvement in HRQOL is unknown. Material and Methods: ASD patients who underwent ≥4 level instrumented fusion and had minimum 2-year follow-up were stratified by ASD-FI score into categories: not frail 0-3 (NF); frail 3-5 (F); and severely frail >5 (SF). We compared baseline demographic, HRQOL, and radiographic parameters. The primary outcome measure was reaching substantial clinical benefit SCB (SCB) in ODI, SF-36 PCS, back and leg pain. Secondary outcomes included: absolute and change in ODI, PCS, MCS, back and leg pain. SCB thresholds for outcome following lumbar fusion were utilized. Results: 332 patients were identified with 2-year follow-up: 135 NF, 175 F, and 22 SF. F and SF patients were significantly older, had more comorbidities, worse baseline HRQOL and pain scores (e.g. ODI 69.5, 52.5, 27.6 for SF, F, and NF; P < .0001), and worse radiographic deformity (e.g. SVA 130.5, 85.9, and 28.4 mm for SF, F, and NF; P < .0001). At 2-years, ODI, PCS, MCS, back and leg pain were all worse in F/SF than NF patients. More NF than F patients reached SCB for back pain (63.4 vs. 57.5%; P = .045) whereas more F than NF reached SCB for ODI (43.7 vs. 29.3%; P = .025), PCS (56.9 vs. 51.2%; P = .03), and leg pain (45.8 vs. 23.0%; P = .003). SF patients were least likely to achieve SCB for ODI (28.6%), PCS (18.2%), and back pain (28.6%). Conclusion: Despite higher preoperative risk stratification scores, worse baseline HRQOL scores, and greater complication rates, frail patients experience greater improvement in HRQOL and likelihood of reaching substantial clinical benefit compared to non-frail patients., Introduction: Adult spinal deformity (ASD) is a complex group of conditions with a broad range of clinical and radiological characteristics. We had concernsthat the most widely used classification system may lack the ability to evaluate all these characteristics and provide guidance on treatment alternatives. Specifically, although having shown to be associated with outcomes, a multitude of (only) radiological parameters may demonstrate a substantial co-linearity and may not necessarily be useful for classification and guidance purposes.The Aim of this study is to evaluate the impact of Schwab-SRS classification parameters on the treatment outcomes for ASD. Material and Methods: Prospectively collected data from a multicentric adult deformity database of surgically treated ASD patients with a minimum of 1-year follow-up. Using MCID, patients were dichotomized into two groups of improved or unimproved. Chi-Square test analyzed the difference in baseline Schwab-SRS modifiers (Curve types, PI-LL, PT and SVA) of the two cohortsfor ODI, SF-36MCS, SF36-PCS and SRS22. A multivariate logistic regression model was then built when a relationship was found between these parameters and any of the outcome measures. Results: A total of 186 patients, (157 female, 29 male) were included (Figure 1). There were no significant differences inbaseline Schwab-SRS parametersbetween improved and un-improved cohortsforODI, SRS22 and SF36-MCS (P < .05). For SF36-PCS howevera significant difference in baselinePI-LL (0, +, ++) between the cohorts was seen. Multivariate regression analysis shows Odds Ratio of 4.584 to improvement for 3FS6-PCS if PI-LL is 20°(++) (P = .001). Conclusion: Baseline Schwab-SRS parameters PT, Curve type and SVA were not significant prognostic indicators of improvementat 1 year post surgery for all outcome measures. Baseline PI-LL is predictive of reaching MICD at one-year post surgery.These findings suggest that the present classification system may not be a very accurate tool for prognostication in surgically treated patients. In addition, not all radiological parameters included in this system may be neededeither; the usefulness of this classification system may be reduced down to lesser essential parameters. Figure 1. Chi-square test analysis grey area for SF36PCS& multivariate logistic regression analysis. (PI_LL shows significance only with SF36PCS) P20° (++) SF36 PCS_MCID Un-improved 48 16 13 77 Improved 29 18 36 83 Total 77 34 49 160 Multivariate Logistic Regression Analysis SF36PCS P-Value Odds Ratio 95% C.I for OR Lower Upper PI_LL (0) 0,001 PI_LL (+) 0,135 1,862 0,823 4,211 PI_LL (++) 0,000 4,584 2,093 10,039 Constant 0,032 0,604, Introduction: The scope and incidence of adult spinal deformity surgery has been pushed considerably over the last 10 years with more complex and longer reconstructions and corrections. This is to no small part due to the development of different approaches to the spine that allow for a more extensive realignment and reconstruction. However, with more extensive surgical procedures, the risk to the patient including the need for more extensive post-operative care increases. IN this study, we aimed to investigate the incidence and risk factors for prolonged ventilation and reintubation in adult spinal deformity (ASD) surgery. Material and Methods: The American College of Surgeons National Surgical Quality Improvement Program database (2007 – 2013) was reviewed. Inclusion criteria were adult patients over 21 years of age who underwent spinal fusion for ASD. The association between patient/operative characteristics and prolonged ventilation/reintubation was investigated via multivariate analysis. Results are presented as odds ratios (OR) with 95% confidence intervals (CI). Results: There were 1,250 patients who underwent ASD surgery and met our inclusion criteria. Among these, there were 34 patients who required prolonged ventilation (2.7%) and 22 patients who underwent reintubation (1.8%). Factors associated with prolonged ventilation after multivariate analysis were history of bleeding disorder (OR 5.67; 95% CI, 1.01 – 31.83) and operative time over 6 hours (OR 3.72; 95% CI, 1.17 – 11.80). For reintubation, these included older age (OR 1.06; 95% CI, 1.01 – 1.12), history of bleeding disorder (OR 12.21; 95% CI, 2.03 – 73.42), and fusion of 13 or more spinal levels (OR 9.14; 95% CI, 1.53 – 54.63). Conclusion: Prolonged ventilation and reintubation in ASD surgery are uncommon events. Older patients, patients with bleeding disorders, and those undergoing long operations and fusion of 13 more spinal segments may be at an increased risk for these occurrences., Introduction: Substantial clinical benefit (SCB) represents a threshold above which a patient recognizes substantial benefit and may therefore be a desirable target outcome. We investigated the impact of prior spinal fusion on the likelihood of reaching SCB thresholds for 2-year health-related quality of life (HRQOL) after adult spinal deformity (ASD) surgery. Methods: We included ASD patients who achieved minimum 2-year follow-up. We compared baseline demographic, HRQOL, and radiographic features for patients undergoing primary versus revision procedures. The primary outcome measure was reaching SCB threshold in Oswestry Disability Index (ODI), SF-36 physical component summary (PCS), back and leg pain (numeric rating scale; NRS). Secondary outcomes included absolute and change scores in ODI, PCS, back and leg pain. We used SCB thresholds previously reported for outcome following lumbar fusion. Results: 332 patients achieved 2-year follow-up, including 228 primary and 104 revision cases. Those undergoing revision surgery had similar demographic features (age 58.3/55.9, female 80.8/82.9%, Charlson Comorbidity Index (1.9/1.6) to primary surgery patients. Revision surgery patients had worse baseline HRQOL (ODI 48.5/41.2, PCS 29.5/33.4, back 7.5/7.0, and leg pain 4.9/4.3; P < .001) and radiographic deformity (sagittal vertical axis 111.4/45.1, pelvic incidence to lumbar lordosis mismatch 26.7/11.0, pelvic tilt 29.5/21.0; P < .0001). Nevertheless, the number of patients who reached SCB for ODI (38.3/36.3%), PCS (48.5/53.4%), back (53.1/60.5%) and leg pain NRS (28.6/36.9%) did not significantly differ between revision and primary operations. Despite similar magnitudes of improvement of outcomes measures, revision patients had worse 2-year HRQOL for all measures compared with primary surgery patients. Conclusions: Patients undergoing revision ASD surgery have worse baseline HRQOL and radiographic deformity. Although they do not achieve the same absolute level of 2-year HRQOL outcome scores as patients undergoing primary surgeries, they have a similar likelihood of reaching SCB threshold for improvement in 2-year HRQOL., Introduction: Although dysphagia is a common complication after anterior cervical decompression and fusion (ACDF), important risk factors have not been rigorously evaluated. Furthermore, the impact of dysphagia on neurological and quality of life (QOL) outcomes is not fully understood. This study aim is to determine the incidence and risk factors of postoperative dysphagia and evaluate short- and long-term clinical outcomes in patients with this complication. Material and Methods: Four hundred and seventy patients undergoing an ACDF or a 2-stage surgery were enrolled in the prospective AOSpine CSM-North America and International studies at 26 global sites. Logistic regression analyses were conducted to determine important clinical and surgical predictors of dysphagia. Preoperatively and at each follow-up, patients were evaluated using the modified Japanese Orthopedic Association scale (mJOA), Nurick score, Neck Disability Index (NDI), and the Short- Form 36 (SF-36) Health Survey. A two-way repeated analysis of co-variance was used to evaluate differences in outcomes at 6- and 24-months between patients with and without dysphagia, while controlling for relevant baseline characteristics and surgical factors. Results: The overall incidence of dysphagia was 6.2%. Univariately, the major risk factors for perioperative dysphagia were a higher co-morbidity score, the presence of cardiovascular and endocrine disorders, a 2-stage surgery and a greater number of decompressed levels. Based on multivariable analysis, patients were at an increased risk of perioperative dysphagia if they had diabetes, a greater number of decompressed segments, and a 2-stage surgery. Functional, disability and quality of life (QOL) improvements were comparable between patients with and without dysphagia at both short- and long-term follow-up. Conclusion: The most important predictors of dysphagia are endocrine disorders, a greater number of decompressed levels and a 2-stage surgery. Patients with postoperative dysphagia exhibit similar improvements in functional impairment, disability and QOL as patients without dysphagia in both the short- and long-term., Introduction: Dysphagia is a common complication following anterior cervical spine surgery (ACSS). The majority of them occurred in the early postoperative period. The incidences of dysphagia were variable and controversial. The purpose of this study was to determine the incidence of early dysphagia after ACSS with a new scoring system, and to identify the risk factors for it. Materials and Methods: A prospective study was performed and patients who underwent ACSS from March 2014 to August 2014 in our hospital were included in this study. A dysphagia questionnaire was delivered to all of the patients from the first day to the fifth day after ACSS. Patients’ age, gender, body mass index (BMI), operation time, blood loss, hardware use, preoperative JOA score were recorded, and the dC2-C7 angles (postoperative C2-C7 angle minus preoperative C2-C7 angle) were calculated on the plain film. The incidences of dysphagia were analyzed and the risk factors were evaluated. Results: A total of 104 patients who underwent ACSS were included in this study. The incidences of dysphagia from the first to the fifth day after ACSS was 87.5%, 79.81%, 62.14%, 50% and 44.23%, respectively. And there was a good correlation between the new dysphagia scoring system and Bazaz scoring system (P < 0.05). Patients who got early dysphagia after surgery had similar age, gender, blood loss, hardware use and preoperative JOA score comparing with those with no dysphagia. Operative time and BMI were the risk factors for dysphagia during the first to the second day postoperatively. However, the dC2-C7angle was the main risk factor for dysphagia from the third to the fifth day after surgery. Conclusions: There were comparatively high incidences of early dysphagia after ACSS, which were ascribed to operating time, BMI and the dC2-C7 angle. Spine surgeon should consider the degree of dC2-C7 angle when performing the surgery., Introduction: Various factors, including type of bone graft, number of fusion levels, and duration of follow-up, have been reported to influence occurrence of pseudarthrosis after anterior cervical discectomy and fusion (ACDF). However, to our knowledge, there has been no report on the relationships between preoperative radiographic parameters and postoperative pseudarthrosis. The purpose of this study was to determine whether postoperative pseudarthrosis could be predicted according to specific parameters on preoperative plain radiographs, including segmental and global cervical motion and T1 sagittal slope. Material and Methods: We retrospectively analyzed 84 consecutive patients (male: female = 45:39; mean age, 58.9 ± 11.2 years) who underwent ACDF and were followed for more than 2 years. In all patients, allografts filled with local chip bone were inserted after discectomy and anterior plating was performed. On preoperative plain radiographs, various parameters were measured and analyzed; C2-C7 sagittal vertical axis (SVA), T1 sagittal slope, segmental motion, global cervical (C2-C7) motion, segmental interspinous motion, and location of fusion segments. Pseudarthrosis was diagnosed as interspinous motion >1 mm with superjacent interspinous motion ≥4 mm on the magnified plain dynamic lateral radiographs at final follow-up. Multiple logistic regression was performed to analyze the risk factors of pseudarthrosis, and the receiver operating characteristic (ROC) curve was used to define a cutoff value. Results: Eighty-four patients (1 level in 49, 2 levels in 29, and 3 levels in 6) and 125 segments (4 at C3–4, 31 at C4–5, 55 at C5–6, and 35 at C6–7) were included. The pseudarthrosis rate was 29% based on number of patients (24/84) and 20% based on number of segments (25/125). Multilevel surgery and the lowest cervical fusion level showed a higher pseudarthrosis rate (p = 0.01). In multiple logistic regression analysis, C6–7 segment, greater T1 sagittal slope, and greater segmental motion were associated with a higher risk of pseudarthrosis (P < 0.05, respectively). A cutoff value of segmental motion of 12° demonstrated.pseudarthrosis with a sensitivity of 87%, specificity of 84%, and area under the curve of 0.899, indicating moderate accuracy. Conclusion: Greater preoperative segmental motion, greater T1 sagittal slope, and the lowest fusion level (especially C6-7 segment) could be risk factors of pseudarthrosis following ACDF. According to the ROC curve, a preoperative segmental motion >12° is likely to be a clue to predict the development of pseudarthrosis. Surgeons need to be aware of these risk factors which could be detected on preoperative plain radiographs and should consider various supportive procedures to enhance the fusion rate in those cases., Introduction: The objective is to determine the degree of dysphagia and predict factors associated with it. Materials and Methods: Prospective and multicenter observational cohorts of patients with spinal degenerative pathologies undergoing anterior cervical surgery were the target of this investigation, while patients undergoing posterior lumbar surgery were enrolled as a control group to determine the effect of the intubation itself on postoperative dysphagia. The exclusion criteria were trauma, tumors, and infectious diseases, previous history of head and neck surgery, gastroesophageal reflux disease, prolonged use of endotracheal tube or neurological disorders associated with dysphagia. The evaluation was made in the preoperative period and on postoperative days: 1, 7, 21, and 180. The factors analyzed were related to pathology (type (disc herniation, cervical stenosis, level of the disease, and anterior osteophytes)), patient (ASA score, age, BMI, sex, history of hypertension, diabetes mellitus, pulmonary disease, coronary artery disease, cancer, anxiety, depression, and smoking) and surgery (intubation attempts, right or left-sided approach, deep retractors used, release of endotracheal tube cuff pressure, number of fused levels, length of the surgery, and bleeding. The dysphagia was assessed by swallowing satisfaction index and swallowing questionnaires. Patients who refer to having dysphagia after 6 months will undergo an OTL examination. Results: the preliminary results comprise 85 consecutive patients who underwent anterior cervical approach and 105 consecutive cases in which a posterior lumbar approach was performed. The baseline characteristics of the cervical and lumbar cases had no significant difference except regarding length of surgery that was longer in cervical cases and volume of bleeding that was higher in lumbar cases. The satisfaction index and the severity of dysphagia (mild, moderate, and severe) were similar between the cervical and lumbar cases at the preoperative evaluation. The patients who underwent cervical approach had a lower satisfaction index on days 1, 7, and 21 after surgery when compared with the lumbar patients. Patients who underwent anterior approach had a major incidence of dysphagia on day 1 (49.4%, 42/85). Complaints about swallowing are progressively lower on day 7 (25.9%, 22/85) and day 21 (11.8%, 10/85). At 6 months, no swallowing complains was reported. The only variable that showed significance for dysphagia in cervical patients on the day 1 assessment was 2 or more orotracheal intubation attempts (P = .05). Conclusions: the prospective observational multicenter study in Latin America showed that the incidence of dysphagia after anterior cervical approach was 49.4%, 25.9%, 11.8% and 0.0% on 1, 7, 21, and 180 days after surgery. The severity of dysphagia was usually mild or after eating solid food. The only variable that showed significance for dysphagia in cervical patients on the day 1 assessment was 2 or more orotracheal intubation attempts (P = .05)., Introduction: The effects of uncinate process resection (UPR) on cervical spine instability have a controversy according to study type; in vivo, in vitro. To estimate in vivo effects of UPR in the case of anterior cervical discectomy and fusion (ACDF), we evaluated clinical and radiological outcome after ACDF with bilateral UPR. Methods: We collected a clinical and radiological data from January 2011 to June 2015, retrospectively. A total of 29 patients 41 segments were included in this study. All procedure includes bilateral UPR and anterior plate fixation by single surgeon. Coronal reformatted-CT images were used to evaluate the resection rate of uncinate processes. To reduce level induced bias, we converted the area of UPR to proportion of UPR to pre-operative vertebral body (UPR/VB) or pre-operative uncinate process (pUPR). Results: The sum of bilateral pUPR (P = .006) is closely correlated to subsidence. By simple regression analysis, the subsidence could be estimated by following formula; subsidence = 0.896 + 3.980 * sum of pUPR. The subsidence rate was 34%. Comparative analysis revealed no significant difference on clinical outcomes, and fusion rate between subsidence group and non-subsidence group. Conclusion: We performed quantitative analysis of UPR, and correlation analysis with subsidence. Our finding suggests that if the sum of pUPR were more than 52.9%, the possibility of subsidence would increase significantly. (R2 = 0.178, P = .006), Introduction: The influence of psychological and social factors has only recently been acknowledged to impact clinical outcome following spine surgery. Some studies demonstrated that preoperative affective disorders predicts poor outcome after spinal surgery. We aimed to identify potential risk factor for unfavourable outcome following cervical spine surgery for degenerative disc disease. Methods: In a prospective observational study the authors determined quantitative measurements of pain (visual analog scale [VAS]), health related quality of life (HRQL: SF-36 and EuroQOL-5D), disease-specific disability (ODI), metal status (anxiety [STAI-T, STAI-S and ASI-3] and Depression [ASD-K]) and social status (Berliner Social Support Scale [BSSS] and education level). Uni- and multivariate analyses were performed to assess associations between the various preoperative factors and the health related quality of life (HRQL) at 12 months follow up. Results: 51 patients met all inclusion criteria. 34 patients were male (66.7%); mean age was 58.6 years. Most patients were married or in a steady relationship (78.4%). Preoperatively high values in education (r = 0.293; P = .07), SF-36 PCS (r = 0.405; P = .022) and low scores of depression (ASD-K: r = −0.363; P = .011) and anxiety (ASI-3: r = −0.354; P = .013) and ODI (r = −0.343; P = .038) correlated with better HRQL at 1 year postoperatively. Conclusion: Clinical outcome one year after surgery is influenced by pre-operative physical, mental and social status. A screening instrument allowing the identification of such patients is feasible., Introduction: Combining Cobalt Chrome (CoCr) rods with Titanium (Ti) fixtures in cases of adult scoliosis is common because CoCr rods better support the increased correctional forces in these cases compared to Ti rods. However, research in other orthopaedic implants has raised concerns about galvanically accelerated corrosion on the interfaces between the two different materials, leading to early failure of the implants and patient reactions, including metallosis. Here we present the first spine retrieval study of comparing CoCr/Ti constructs with Ti/Ti constructs. Material and Methods: We have received spine instrumentation from 8 patients; 3 patients with CoCr/Ti constructs and 5 patients with Ti/Ti constructs. All patients gave consent for research on their implants. Implants were revised for infection, persistent pain, fractured components, to correct kyphosis and to prevent adjacent segment degeneration. In the case of the persistent pain, metallosis was discovered intraoperatively. All components were macroscopically inspected and documented using DSLR photography, following by microscopic inspection using an optical microscope to identify the contact areas between components and patterns of corrosion and wear. Scanning Electron Microscopy (SEM) and Energy Dispersive X-ray Spectroscopy (EDX) were performed to identify the surface changes and the elemental composition of foreign debris. We then classified the different types and patterns on the rod junctions to develop a visual grading score for corrosion and wear. All junctions were scored by two researchers, expert in corrosion of orthopaedic implants, and then statistical analysis was performed to test the reliability of the proposed score. Results: Macroscopic and microscopic analysis revealed fretting and pitting on most of the junctions, while in 43% of the rod junctions black debris were found. EDX revealed that in the case of CoCr rods, that was Ti transfer from the fixtures to the rods, while in the case of Ti the origin was biological. Using the corrosion score, only 5% of the junctions in CoCr rods showed no signs of damage, while all junctions in Ti rods showed at least some degree of wear. Most of the junctions on CoCr rods and all junctions on Ti rods were moderately damaged, while 7% of the CoCr junctions were severely damaged. K-analysis of the scores from the individual scoring of the junctions showed that the corrosion score is reliable (kappa > 0.7). Using this score, the components which were found with metallosis in the surrounding tissue had one of the lowest overall score. There was no correlation between time of implantation and corrosion score (P = .2968). However, we found that the scores between CoCr and Ti rods are significantly different (P = .0107), with CoCr being more severely damaged. Conclusion: There is evidence in corrosion in all implants with increased scores in the cases of CoCr rods. Corrosion is linked with reasons for revision including fracture of components, however from this study there was no clear link between increased scores and reaction to metal debris, suggesting that patient susceptibility might play a large role to implants failure., Introduction: S2 alar-iliac screw (S2AIS) for lumbosacral fixation is becoming common procedure for deformity surgeries because of inline rod placement, low profile, less complication, and easy to harvest bone graft from iliac bone. Although it is useful surgical technique, there are few reports of comparison regarding optimal entry point of S2AIS so far. The purpose of this study was to determine optimal entry point for S2AIS from the normal Japanese population data. Material and Methods: We used 30 CT scans of pelvis in this study. All the pelvis scanned were free from bony diseases or deformity. These were from 15 males and 15 females CT scans of pelvis. We took 4 mm margin (accounting for half the diameter of a 8.0 mm pedicle screw) for S2AIS from inner ilium cortex, outer ilium cortex, and posterior cortex of the sacrum. We selected two entry points from previous papers. One was 1 mm inferior and 1 mm lateral to the S1 dorsal foramen (A group) and the other was midpoint between S1 and S2 dorsal foramen (B group). We compared between A group and B group regarding all of parameters. We measured (1) screw length, (2) angle in the axial plane, (3) angle in the sagittal plane, (4) angle range in the axial plane, (5) distance from entry point to sacroiliac joint, (6) distance from S2AIS to acetabular roof, (7) distance from S2AIS to sciatic notch, (8) insertion difficulty of S2AIS. Finally we compared each parameter between two groups. Results: In group A, (3) angle in the sagittal plane was significantly smaller and (7) distance from S2AIS to sciatic notch was significantly longer than B. In B group, there were statistically significantly longer regarding (1) screw length, (5) distance from entry point to sacroiliac joint, and (6) distance from S2AIS to acetabular roof than A. The rate of (8) insertion difficulty of S2AIS was much higher in A group. There were no significant differences between two groups regarding other parameters, (2) and (4). Conclusion: Regarding insertion from midpoint between S1 and S2 dorsal foramen, we can use longer screw than A group because of inner entry point. Regarding insertion from 1 mm inferior and 1 mm lateral to the S1 dorsal foramen, we found the number of insertion difficulty cases was much higher than the other entry point. It was because A group was very likely to perforate posterior cortex of the sacrum because of outer entry point. Based on our data, we recommend the insertion from midpoint between S1 and S2 dorsal foramen for S2AIS., Introduction: Morphological restoration of degenerated intervertebral discs through the use of Autologous disc chondrocyte transplantation (ADCT) represents a strategy that offers a potential to accentuate disc metabolism that will achieve mechanic function. This could be demonstrate in a preclinical animal study and was translated into the clinical prospective, controlled, randomized study. Materials and Methods: 78 patients with single level intervertebral disc herniation with acute neurological symptoms or after conservative treatment failure were enrolled from January 2002 to November 2006 in a single institution. Operative procedure was done as a minimal invasive open sequestrectomy done by an experienced neurosurgeon. Cells are transplanted approximately 12 weeks following sequestrectomy to assure that the annulus has healed and will contain the cells. Therefore a single puncture was used. Oswestry low back pain disability questionnaire (OPDQ), Prolo and VAS scores were used for the evaluation. Disc height and water content were assessed by MRI. Demographic data, neurological status and BMI were collected from the patients 6, 12 and 24 months postoperatively. Results: 36 patients were randomized into the Autologous disc chondrocyte transplantation group and 43 patients into the control group. The mean age of the patients was 31.4 years; the mean BMI 23.9. 23 patients from the ADCT group were transplanted in level L5/S1 and 12 patients at level L4/5. There were 7 drop out patients by private reasons. After 24 Months the patients of the treatment group scored an average of 16.4 in the Oswestry questionnaire and 20.4 on the VAS, while the controls got 21.1 in the Oswestry and 22.6 on the VAS. Regarding the Prolo scale, transplanted patients were able to reach a 4.7 and 4.5 in working situation and functional status in comparison to 4.6 and 4.4 in the non-treatment group. The differences between the two groups were much higher by comparison the changes in all scores after the operative treatment and in the 24 month follow up. Reherniation rate was reduced by 52%. No neurological or inflammatory complications were reported. Conclusions: For once, we were able to prove that no harm was done with the transplantation, that is at least as good as the standard procedure and that there is no common adverse effect. Furthermore, even though that there was no statistical difference between the two groups big enough to prove the benefit of the Autologous disc chondrocyte transplantation, we were still able to show that there is a tendency towards that 24 month after transplantation. Indeed, having such small differences may only shows how good our standard procedures already are. Knowing the degeneration process in younger patients is going on over more than 2 years we might just need to oversee the results over a longer period of time., Introduction: factors influencing paraspinal muscle degeneration are still not well understood. Fatty infiltration (FI) is known to be one main feature of the degeneration cascade. The aim of this study was to illustrate the cluster of paraspinal lumbar muscle degeneration on MRI. Material and Methods: Mono-, Pluri- and Multi-segmental lumbar muscles groups were segmented on T2-weighted MR sequences using a novel semiautomatic technique for quantitative muscle/fat discrimination. The degree of fatty infiltration of t3 predefined muscle groups was compared on a 3-dimensional basis, with regard to segment involvement, age and disc degeneration. General linear models were utilized for statistical comparison. Results: N = 78 segments (age: 52.7; range 16 - 87years) could be included. The average fatty infiltration of the mono-segmental muscles (21.1 ± 14.5%) was significantly higher compared to the multi- (16.0 ± 8.8%) and pluri-segmental (8.5 ± 8.0%) muscles. Muscles on the levels L4/5 (P = .09) and L5/S1 (P = .016) showed a significant higher amount of fat compared to the levels L2/3 and L3/4 if degeneration was present. Higher age (P = .039) and disc degeneration (0.025) were co-variables associated with increased fatty infiltration. Conclusion: The complexity of the problematic issue of lower back pain is likely to be beyond the horizon of a simple bony disease. Muscle affection which was shown to correlate will to the degree of degeneration, may truly play a more important role than yet perceived by the general spinal community and would necessitate increased attention in the future., Introduction: Failed back surgery is a nonspecific term that implies that the final outcome of surgery did not meet the expectation of both the patient and the surgeon as it was established before surgery. Expected outcome varies according to the type of structural problems, the number and types of prior surgeries and the psychological health of the patient. These patients have some of the psychosocial problems and multiple operation on them lead to more severe pain and further detonation of their neurology. Materials and Methods: We present 12 cases of failed back surgery. All of them underwent multiple operations on the lumber spine, ie multiple discectomy, laminectomy and/or fusion. The etiology in 6 patients was recurrent disc herniation above the level of fusion. Two patients had nonunion of fusion mass; two had neuropathic pain and iatrogenic instability. In addition 2 patients had facet and sacroiliac joint pain. The number of previous spinal operations varied from 3 to 21. The time lapse of symptoms ranged from 3 months to 5 years. All of these patients had negative x-rays that could not explain the cause of their symptoms, and either CT scan / CT myelogram or MRI scans was done to identify the problem. Result: In all of these patients, the first line of treatment was conservative, namely with analgesia, antidepressants, physiotherapy, caudal and facet joint block. Four patients underwent revision surgery for removal of implant and discectomy just above the fusion level. In Three patients, pain could not be controlled, and these patients had implantation of spinal cord stimulator. This ultimately gave them relief. Conclusion: Failed back surgery syndrome is unfortunately common problem with enormous cost to patient, insurer and society. With a careful history, examination, imaging studies, psychological evaluation and diagnostic injection, a diagnosis can be made in over 90% of the cases. These patients should be treated conservatively with good team work, which include surgeon, psychiatrist, physiotherapist and the pain specialist. Our conclusion come to the fact that more the surgery these patient has more miserable these patients become., Introduction: The principles of lumbar lordosis restoration and sagittal balance are of primary importance in spinal deformity surgery. Biomechanical, clinical and radiological studies suggest that an amount of 75% of the total lumbar lordosis should be in the lower lumbar spine (between L4-S1) to improve outcome of surgical procedures. The most common techniques used to get this target are osteotomies. Smith Petersen Osteotomy (SPO) and Pedicle Subtraction Osteotomy (PSO) are the two most employed techniques. We describe our experience using multiple hyperlordotic cages (HLCs) in degenerative deformity surgery for lumbar lordosis restoration and sagittal imbalance management. Materials and Methods: we report a series of patients underwent multilevel anterior lumbar interbody fusions (ALIF) with HLCs to restore lower lumbar lordosis and sagittal balance realignment. The ALIF procedures were associated to posterior pedicle screw fixation and fusion to increase segmental lordosis and put in compression all the cages. All patients were examined with a standard X-Ray of the whole spine pre- and post- operatively (EOS), with measurement of spinopelvic parameters. We did use titanium HLCs filled with hydroxyapatite or bone graft, with 24°, 20° or 16° degrees of lordosis, on at least 2 levels (L4-L5 and L5-S1). Results: We show that the mean increase in lumbar lordosis was comparable or superior to huge posterior Osteotomy (SPO or PSO). Conclusion: Multiple ALIF with HLC provides a satisfactory increase in lower lumbar lordosis (L4-S1 lordosis). The use of those devices could decrease the need of posterior osteotomies (PSO and SPO) to restore lumbar lordosis and sagittal balance. Posterior major osteotomies have an high rate (up to 40%) of general (especially neurologic and mechanical) complications. However, a good knowledge of the anterior approaches to the lumbar spine and, mostly, pitfalls avoidance and management, is needed to perform this kind of surgery with good results and a low rate of associated complications., Introduction: Although facet dislocations are relatively rare among patients with cervical spine trauma, accounting for about 5% of all cervical trauma, the consequences are often devastating. Approximately a third of patients with unilateral jumped facets are diagnosed with SCI at presentation but there is large variability in the literature with respect to SCI in patients with bilateral jumped facets. The goal of our study was to assess a consecutive series of patients with jumped facet injuries to assess rates of SCI and the impact of sagittal diameter and translation on SCI. Material and Methods: Between 2004 and 2014, a retrospective review at a level I trauma center identified patients with unilateral or bilateral dislocated facets. Demographic data, initial neurological exams, and radiographic findings were reviewed with a detailed assessment of the injury computed tomography (CT) films. We assessed sagittal diameter at the level of the injury as well as the level above and below the injury. We also assessed the amount of translation at the level of injury. Results: Ninety-seven patients were identified as having unilateral or bilateral jumped - 39 were unilateral and 58 bilateral. Of the 97 patients, 61% had a SCI with 38 ASIA A, 4 ASIA B, 4 ASIA C, 13 ASIA D, and 38 ASIA E on admission. When assessing canal diameter at the level of injury, those with ASIA A SCI had an average diameter of 8.00 mm (95% CI 7.50 - 8.50) versus those with ASIA E with an average of 12.63 mm (95% CI 11.83 – 13.44) (P < .001). When assessing translation at the level of injury, those with ASIA A SCI measured 8.03 mm (95% CI 7.19 – 8.86) and those with ASIA E measured 4.22 mm (95% CI 3.48 – 4.95) (P < .001). Due to the small sample size of those with ASIA B (4), C (4) and D (13), we combined those with ASIA A-C and compared them to ASIA D-E with the assumption of significant difference in a general ability to function independently with this separation. Canal diameter at the level of injury for those with ASIA A-C SCI averaged 8.40 mm (SD 1.94 mm) and those with ASIA D-E averaged 12.32 mm (SD 2.46 mm) which was significantly different (P < .001). Translation in patients with ASIA A-C measured 7.72 mm (SD 2.55 mm) compared to those with ASIA D-E which measured 4.39 mm (SD 2.18 mm) which also was significantly different (P < .001). When plotted on a Receiver Operating Characteristic (ROC) curve, translation was a good predictor of ASIA A-C SCI and canal diameter was an almost perfect predictor of ASIA D-E SCI. Conclusion: Patients with greater translation and/or smaller diameter have a higher rate of SCI. We found an average canal diameter of 8.40 mm and translation of 7.72 mm in those with ASIA A-C injuries compared to a diameter of 12.32 mm and translation of 4.39 mm in those with ASIA D-E injuries. Translation was a better predictor of ASIA A-C and diameter was a better predictor of ASIA D-E., Introduction: Whiplash Associated Disorder (WAD) remains a controversial clinical diagnosis. Few models exist to comprehensively assess the clinical effects of rotational and linear acceleration on the cervical spine. As professional rodeo riders are subjected to repeated flexion/extension events during their rides, they represent an ideal population to assess the clinical and radiographic effects of massive acceleration and deceleration on the cervical spine. The purpose of this study was to evaluate the clinical and radiographic effect of a measurable acceleration / deceleration event on the cervical spine in professional rodeo riders using objective clinical data and validated health related quality of life (HRQoL) scores. Material and Methods: The following outcome measures were evaluated: Pre- and post-ride physical examination; Visual Analogue Score (VAS) for Neck, Arm, and Back; Neck Disability Index (NDI); Short Form-36 (SF-36); EuroQuol (EQ-5D); pre- and post-ride MRI of the cervical spine. After informed consent, subjects underwent focused physical examination by a licensed physician and completed the aforementioned validated questionnaires before each ride. Six riders also underwent pre- and post-event MRIs of the cervical-spine. VAS neck and arm pain scores were assessed post-ride. Peak linear accelerometer data were recorded by a mouth-guard accelerometer. Descriptive statistics were performed and pre- and post-ride data were compared using Student’s T-tests with α set at P ≤ .05. Results: Twenty-one male professional roughstock riders (bareback-8, saddle bronc-7, bull riders-6; average age 24.3 ± 5.6 years) were enrolled. They reported to have competed in an average of 55 ± 25 rodeos per year. The minority reported a prior neck injury (5/21) and missing rodeos due to neck injuries (4/21). No riders reported prior neck surgery. Baseline NDI (4.9 ± 6.5), EQ-5D (0.89 ± 0.15), and SF-36 (PCS 51.9 ± 6.2, MCS 55.1 ± 4) were recorded. Seventeen riders’ mouth-guards recorded events >10 g. Mean linear acceleration was 23.8 ± 13.9 g. Peak linear acceleration was 62.8 g. Post-ride VAS for neck pain trended towards higher scores although the difference was not significant (pre: 0.48 v. post: 1.0; P = .10). Post-ride VAS scores for arm pain were not significantly different from pre-ride scores (P > .25). There were no differences in post-ride VAS scores between the bareback, saddle bronc, and bull riding groups (P > .20). Mild disk bulging adjacent to pre-existing disease was noted in 2/6 post-ride MRI scans but no clinically significant changes were identified. Conclusion: Repeated high G-forces did not significantly impact the clinical incidence of neck or back pain in professional rodeo riders, nor did they produce any significant MRI changes. In this population, the extreme G-forces experienced by the cervical spine did not produce any acute cervical symptoms or new neurological deficits. As the G-forces experienced by these riders are significantly greater than most activities of daily living and low-speed rear-end automobile collisions, these data provide a clinically useful context for evaluating patients with whiplash injuries., Introduction: Evidence from forensic necropsy studies indicates that more than 77% of patients in a motor vehicle accident who died at the scene had radiographic proof of upper cervical spine injuries (C1-C3). Almost one half of patients with traumatic upper cervical spine fracture dislocations and spinal cord injury (SCI) do not survive following admission to a trauma center. Sporadic case reports have shown that in these patients admission MRI indicated SCI at the epicenter of fracture dislocation and extension of spinal cord edema into the lower medulla oblongata. In patients with complete SCI there is abrupt interruption of supra-segmental impulses supplying diaphragmatic motor neurons, loss of sympathetic outflow into the intermediolateral cell columns of spinal cord (T1-L2 segments), and unopposed vagal parasympathetic impulses into the sino-atrial node. The resultant catastrophic tetraplegia, loss of diaphragmatic function, neurogenic shock, and cardiac bradyarrhythmias result in instantaneous death at the scene of accident. With today’s rapid response offered by the emergency medical systems, there is a chance for immediate resuscitation and transfer of these victims into Level 1 trauma centers. The mean transfer time from injury to the resuscitation unit at this Level 1 trauma center is 59 minutes. High mortality rate is one of the reasons we find almost no clinical case series of patients with upper cervical spine traumatic SCI and detailed studies such as MRI. We sought to analyze factors that predicted mortality in upper cervical fracture dislocations and SCI. Material and Methods: We investigated relevant independent variables including presence of cardiorespiratory arrest, computed tomography, and MRI characteristics from 73 patients with traumatic upper cervical SCI in order to determine predictors of mortality. Analysis was by multiple logistic regressions. Results: Mean age was 60.2 years (SD = 19.1) and Glasgow Coma Scale (GCS) score was 9.7 (SD = 5.0). Morphology was Anderson D’ Alonzo II/III fractures in 46 (63%), C2 vertebral body fractures (Benzel 1-3) in 14 (19%), and vertical or extension distraction in 6 (8%). Seven patients had no visible fracture dislocation. Injury epicenter was at the C2 vertebral body level in 46 of these patients, odontoid process in 16, C2/3 junction in 3, foramen magnum in 1, and C3 vertebral body in 1 patient. Forty of the total 73 (54.8%) patients died in this series; 29 of the 40 (72.5%) died within 1 month after trauma. Cardiorespiratory arrest was encountered in 42 patients, 30 of whom went on to die (P < .001). The overall intramedullary lesion length (IMLL) on admission MRI was 34.6 millimeters ([mm], SD = 24): in survivors, 24.7 mm (SD = 16.3); in those who died, 41.7 mm (SD = 27.7); and in the 5 patients who had diaphragmatic pacing, 70 mm (SD = 54). Logistic regression analysis indicated that lower admission GCS score (P < .001), older age (P < .01) and longer IMLL (P < .01) were independent predictors of mortality. Conclusion: In traumatic upper cervical SCI, lower GCS score at admission older age, and IMLL were independent predictors of mortality., Introduction: The purpose of this study is to present a series of adolescent patients with cervical facet dislocations to identify the mechanism of injury, severity of neurological injury and rate of neurological recovery. Material and Methods: Between 2004 and 2014, a retrospective review at a level I trauma center identified patients with unilateral or bilateral dislocated facet(s). Demographic data, initial neurological exams, surgical data, radiographic findings, and follow-up records were reviewed. Results: Of the 21 adolescent facet dislocations, 7 were unilateral and 14 bilateral. Mean age was 14.9 years; (range, 12 to 17). Male female ratio was 15:6. All patients presented as a result of a high-energy injury. C6-7 was the most common level of dislocation. 1 of 18 (5.5%) patients with an MRI had a cervical disc herniation. Nine (43%) patients had an associated facet fracture (8 unilateral, 1 bilateral). None of the 12 patients who presented as a complete spinal cord injury (SCI) (AISA A) had any neurological recovery. Only one of the three patients who presented as an incomplete SCI (ASIA B, C, D) had an ASIA grade improvement at final follow-up. Only six patients who presented were neurologically intact (ASIA E). Conclusion: Over half of children with this injury in our study had a complete SCI with no recovery. We believe that the adolescent spine is more resilient to injury, thus requiring a high-energy injury to cause a dislocation but resulting in a high rate of SCI with a low rate of neurological recovery, and a low rate cervical disc herniation., Introduction: Fractures of the odontoid process are among the most common cervical injuries in preschool children, occurring at an average age of 4 years. However, these injuries are infrequently reported in the literature. The reports are mostly confined to one or two cases. These are actually physeal injuries of the basilar synchondrosis between the odontoid process and the body of the axis. However, the odontoid process is angulated anteriorly in majority. Reduction by hyperextension or by cranial traction followed by rigid immobilization results in a high rate of union, in a minority, either suffering irreducible atlantoaxial dislocation, in those with severely angulated odontoid malunion, and in missed cases surgery is warranted. Herein we want to report 6 new cases of synchondrosis odontoid fracture with displacement where four were diagnosed early and two with delay. The fracture could be reduced with hyperextension with traction in four and open reduction in the other two. Material and Methods: 3 boys and three girls at the age of 3 to 6 years with odontoid synchondrosis fracture are presented. Four were admitted shortly after injury and the other two, around 4 months after injury. Three of the acute cases were managed with immobilization in halo after reduction. The other acute one, a non-compliant child, underwent primary C1-C2 fixation. Both neglected ones were associated with irreducible atlantoaxial dislocation. One of these two, with odontoid non-union was reduced with facet releasing followed by a new reduction maneuver with polyester bands. The last one with malunited odontoid fracture could be reduced only after partial odontoidectomy via posterior only approach followed by C1-C2 fixation. Results: All 6 patients recovered and fusion could be achieved. Conclusion: Where majority of acute synchondrosis odontoid fractures heal with external immobilization. Primary surgery has been advocated by some to obviate the need for long-term immobilization. The real challenge is in neglected one with account a small proportion of the fractures with fracture angulation more than 30 degree or significant odontoid displacement which require posterior C1-C2 fixation after alignment .In addition, neglected ones with chronic IAAD require more challenging surgery. From facet release, odontoidectomy and atlantoaxial stabilization. We will describe a new formulation protocol for management of irreducible atlantoaxial dislocation which will facilitate decision making. Furthermore, we will show demonstrative odontoidectomy via posterior only approach which is not done before., Introduction: Trauma patients presenting with a cervical spine injury are often evaluated for associated cerebrovascular injuries. The presence of a vascular injury may lead to the initiation of heparin anticoagulation treatment prior to necessary surgical stabilization. Literature regarding the safety and efficacy of these procedures while a patient is on active anticoagulation is limited requiring further investigation. Materials and Methods: Between May 2013 and November 2015 the authors identified 14 cervical spine trauma patients who underwent spinal stabilization surgery while on heparin anticoagulation treatment. A retrospective examination was completed in an attempt to report outcomes and associated complications in these cases. This patient cohort was compared to 49 cervical spine trauma patients who received cervical stabilization from the same surgeon over the same period without the necessity of anticoagulation therapy. Results: Out of the 14 patients, 11 had successful operations that healed without incident. Although two postoperative complications (a case of pneumonia and a fixation failure requiring reoperation) and one incident of elevated PTT were reported, there were no anticoagulation related complications. Described complications matched those found in our non-anticoagulated cohort. Conclusions: While it would be preferable to avoid undertaking spine procedures on patients actively being anticoagulated, this retrospective review reveals that when necessary, patients on heparin anticoagulation can undergo successful spine stabilization procedures, but close monitoring is required., Introduction: The SRS-Schwab thoracolumbar classification (gSVA) was developed to group patients into three deformity cohorts from mild to severe. The ISSG-Ames cervical deformity classification has a C2-C7 SVA grade (cSVA) on a comparable three cohort scale. The lack of ability to maintain a level gaze has devastating impacts on functional quality of life scores, which could increase frailty scores. Patients with global sagittal imbalance, on the other hand, must exert more energy to maintain truncal alignment, which could also impact frailty status. Material and Methods: Patients’ cSVA and gSVA scores were classified using the classifications proposed by Ames and Schwab, respectively. Frailty was assessed using the ASD-FI and ACD-FI and split into three cohorts: not frail (NF), frail (F), and severely frail (SF). Association of the cSVA and gSVA classifications with frailty were assessed. Results: Of 736 patients in a multi-center global deformity database, the mean frailty score was 0.35. 371 had a gSVA of 0, 140 +, and 276 ++. The Goodman Gamma correlation coefficient for gSVA was 0.51 (ASE 0.04). When adjusted for important operative and preoperative covariates, the odds ratios of increased gSVA were 2.2 [1.5-3.3] (P < .001) times higher for F and 6.1 [3.5-10.5] (P < .001) for SF than NF. In a designated cervical deformity multi-center database with 123 patients, the mean frailty score was 0.26. 30 had a cSVA of 0, 49 +, and 9 ++. The Goodman Gamma correlation coefficient for cSVA and ASD-FI was 0.28 (ASE 0.17). After adjusting, the odds ratios were 4.1 [1.0-16.7] (P < .05) and 14.0 [1.1-171.7] (P < .05) for F and SF compared to NF, respectively. Age is also significantly associated with gSVA (gamma 0.49 ASE 0.05), but not with cSVA. Conclusion: While the odds of a patient being frail trended up with increasing gSVA and cSVA, there was a greater correlation between gSVA and frailty. However, the lower overall frailty in the cervical database may be attributed to multiple factors like surgeon selection bias or the theory that cervical deformity patients might to present earlier due to increased functional burden. More study is needed to distinguish these results., Introduction: Although adult cervical deformity (ACD) has been empirically associated with significant pain and disability, the magnitude of this negative impact has not been objectively quantified. Our objective was to assess whether symptomatic ACD patients have substantial negative health impact based on the EQ-5D compared with United States (U.S.) normative and chronic disease state values. Materials and Methods: ACD patients presenting for surgical evaluation and treatment were identified from a prospectively collected multicenter database. Baseline demographics, deformity characteristics, and EQ-5D scores were collected. EQ-5D scores were compared with age- and gender-matched U.S. normative and chronic disease state values. Results: Of 121 ACD patients, 115 (95%) completed the EQ-5D (61% women, mean age 61 years, previous cervical surgery in 46%). Diagnoses included: cervical sagittal malalignment (63%), cervical kyphosis (60%), proximal junctional kyphosis (9%) and coronal deformity (8%). The mean EQ-5D index was 0.511, which is 35% below the bottom 25th percentile score (0.790) for a similar age- and gender-weighted normative population and worse than the bottom 25th percentile for several other chronic disease states (diabetes [0.708], ischemic heart disease [0.708], and myocardial infarction [0.575]). The EQ-5D index of 0.511 seen in this ACD cohort is comparable to the bottom 25th percentile for blindness (0.543), emphysema (0.508) and heart failure (0.437). Based on EQ-5D subscores, patients reported impact on mobility (87%), daily self-care (47%), daily activities (91%), pain/discomfort (98%), and anxiety/depression (67%). Conclusions: The health impact of symptomatic ACD is substantial, with an EQ-5D index that is 35% below the bottom 25th percentile for an age- and gender-matched normative U.S. population. The markedly negative health impact of ACD was demonstrated across all domains of the EQ-5D. The overall mean EQ-5D index for ACD patients was worse than the bottom 25th percentile for several other chronic disease states, including chronic ischemic heart disease, malignant breast cancer, and malignant prostate cancer, and was comparable to the bottom 25th percentile values for blindness/low vision, emphysema, renal failure, and stroke., Introduction: Cervical kyphosis in general is undesirable and places the cervical musculature at a significant biomechanical disadvantage with resultant morbidity and cord compression. Several surgical techniques are described in the treatment of cervical kyphosis but few reports exist analysing the outcomes of treatment. The aim of our study was to evaluate the clinical and radiological outcomes of a consecutive group of patients with kyphotic deformity of the cervical spine treated at our department with a further emphasis on the surgical approach used (anterior, posterior or combined). Materials and Methods: We conducted a prospective cohort study of 121 consecutive patients undergoing surgical correction for kyphotic deformity of the cervical spine. 107 patients were available for analysis with a minimum 24 months follow-up. Mean age was 54 years degenerative disease was the commonest cause of kyphosis. Patients with acute injuries, tumors, infections and congenital anomalies were excluded. A stand-alone anterior surgery was performed in 73 patients, a stand-alone posterior surgery in 14 patients and combined two or three step procedures in 20 patients. Results: The Neck Disability Index (NDI) improved from a mean of 26.2 preoperatively to 14.4 at two years post- surgery. In 92.5% of cases the value improved or remained un-changed. The mean value in the Nurick system 107 was 0.7 preoperatively and 0.5 at two years after surgery. The VAS mean value for neck and radicular pain changed from 5.9 preoperatively to 2.5 post-operative. If asked whether the patients would undergo the surgery again, 88.2% answered yes, indicating a good patient satisfaction. Of the total number of 107 patients 104 (97.2%) fused at 24 months after surgery. Conclusions: Surgical correction of the kyphotic deformity resulted in marked improvement of the patients’ quality of life, improvement of the neurological condition and of the spine alignment, as documented by radiological examination of the cervical spine. The best correction was achieved by anterior or combined surgery, although the type of surgery had no impact on clinical outcomes of the patients., Introduction: While patient age has been shown to be a risk factor for complications, patients age at different rates, leading to a discrepancy between biological age, or frailty, and chronological age. As patients become increasingly frail, they have been shown to be more vulnerable to adverse outcomes. Material and Methods: The CD-FI was constructed using variables recorded in a multicenter adult cervical deformity database using a validated method. The CD-FI was calculated and used to stratify patients into 3 frailty severities: 0.41 = severely frail (SF). We then performed a multivariate logistic regression to determine the relationship between CD-FI severity, incidence of major complications and hospital length of stay (LOS). Results: Of 61 patients with ≥ one year follow-up, the average CD-FI was 0.26 (range 0.25-0.59). 17 patients were NF, 34 F, and 10 SF. The incidence of major complications increased with increasing frailty with a gamma correlation coefficient of 0.25 (ASE 0.22). The unadjusted odds ratio of having a major complication was 1.13 [Confidence Interval 0.34-3.8] and 2.75 [0.55-13.7] times higher for F and SF compared to NF patients (P > .05). After adjusting for several covariates, the odds ratio of having a major complication was 4.67 [0.51-42.39] (P = .171) for F and 56.00 [2.37-1324.33] (P < .02) for SF compared to NF patients. The incidence of medical complications correlated with frailty and had a gamma correlation coefficient of 0.30 (ASE 0.26). Conclusion: Increasing frailty was associated with increased risk of major complications for CD patients undergoing surgery. This indicates the value of the CD-FI to improve the accuracy of preoperative risk stratification and allow for adequate patient counseling., Introduction: Reciprocal changes in spinal alignment are observed to occur in mobile segments of the spine following fusion. This has been described most frequently in the thoracolumbar spine, and is thought to be a compensatory mechanism. The majority of cervical flexion and extension occur at the craniovertebral junction with observed combined range of range of approximately 45°. With surgical fusion of one or both of these joints, compensatory flexion and extension and maintainance of horizontal gaze can lead to reciprocal changes in the adjacent subaxial spine. We examine our experience of 102 cases of craniovertebral junction fusion over 10 years to look at the incidence of this reciprocal change and its clinical Sequelae. Material and Methods: Retrospective chart review of all patients who underwent a craniovertebral junction fusion procedure from 2004 to 2014 at the university hospital of Lausanne (CHUV). A total of 102 records were found. A total of 15 patients developed radiological subaxial kyphosis during the follow- up period. Of these, 12 underwent C1-C2 fixation and 3 underwent C0-C2 fixation. Trauma was the most common pathology (12 patients), followed by degenerative (2 patients) and tumor (1 patient). Only 1 patient has standing cervical X rays prior to surgery confirming the absence of cervical kyphosis in the preoperative period. The remaining 14 all had preoperative imaging in the supine position. None of these patients displayed any pre-existing kyphosis, and were assumed to have no kyphosis in the upright position. The mean follow up period was 27 months. Upright lateral cervical spine X rays at the most recent follow up were used to measure C0-C1 and C1-C2 angles, and the degree of subaxial kyphosis. Results: All patients had documented subaxial kyphosis on upright cervical spine X rays, measured from the endplate of C2 to the end plate of C7 or the lowest visible endplate. The range of kyphosis was from 1° to 49° (mean 15.6°). All patients were hyperlordotic at the C0-C1 (range 11°-40°, mean 22.14°) and the C1-C2 (range 22°-44°, mean 31.9°) segments. Two patients were symptomatic with mechanical neck pain without neurological deficit attributable to the kyphosis. Both had marked kyphosis (29° & 49°). The first being an elderly male with an odontoid fracture, the second a middleaged female following a severe brain injury and traumatic atlanto-axial rotatory subluxation. Conclusion: Subaxial kyphotic deformity following C1-C2 fixation has been described in both rheumatoid and in non-rheumatoid patients. However, the precise mechanism is not clear. This is seen in 14.7% of our patients following C1-C2 fixation. All patients were fixed with the C1-C2 segment in a lordotic position. The C0-C1 segment is spontaneously in a hyperlordotic position and it appears that the main compensatory mechanism is in the subaxial spine and not at C0-C1. Attention should be paid to the C1-C2 angle when performing a C1-C2 fusion. Upright Xrays are needed to accurately assess these reciprocal changes related to horizontal gaze., Introduction: One stage circumferential osteotomy was applied to treat the congenital cervical scoliosis (also called as osteogenic torticollis). The feasibility, safety and early clinical outcomes were evaluated. Material and Method: Retrospective investigation of 13 cases who received surgical correction procedure due to congenital cervical scoliosis with hemivertebra deformity of cervical spine. The clinical outcomes were evaluated. The severe complication such as the injury of nerve root, spinal cord, vertebral artery and dural sac were collected and recorded. The Cobb angle of structural curve and compensation curve were recorded and compared on CT scan coronal plane reconstruction images. Results: 13 patients with average age of 9.2 ± 3.4 years old (5-15) were treated. There were 8 male and 5 female. Two cases had anterior-posterior osteotomy with Halo-vest immobilization for three months. 11 cases had anterior-posterior-anterior osteotomy with soft collar for 6 weeks. The average operating time was 324 ± 91.9 min with average blood loss 585 ± 319 ml. Five cases had convex side nerve root symptoms post-operatively. Four cases fully recovered 6 months after the operation. One case remained triceps power reduction (grade 3) 24 months after the operation. No other complications. The average follow-up period was 30.0 ± 12.4 months (24-60). The Cobb angle of structural curve was 28.3 ± 11.0°(9∼ 45°) pre-operatively and 6.9 ± 7.8°(0 ∼ 25°) post-operatively. The correction ratio was 78 ± 24%. The Cobb angle of compensation curve was 21.8 ± 5.8° (0 ∼ 25°) pre-operatively and 5.5 ± 4.3°(3 ∼ 23°) post-operatively. The correction ratio was 37 ± 33%. The patient’s appearance improved significantly after the surgery. Conclusion: The one stage circumferential osteotomy for the treatment of the congenital cervical scoliosis is feasible and safe procedure. The clinical and radiological outcomes were satisfactory, Introduction: Cervical myelopathy is the most commonly acquired cause of spinal cord dysfunction and surgery is usually the treatment of choice for those patients. At present, there have been lots of studies concerning the application of multimodal intraoperative monitoring to cervical spine surgery, including the value of predicting postoperative neurological deficits. However, the relation of the craniovertebral junction (CVJ) myelopathy and multimodal intraoperative monitoring (MIOM) change remains unclear. The objective of the study was to seek a relationship between multimodal intraoperative monitoring and corresponding cervical cord myelopathy in high cervical spinal surgery. Materials and Methods: We reviewed multi-modal intraoperative monitoring (MIOM) records of 107 (39 males and 68 females, average age was 54.49 ¡¾ 16.78) consecutive patients with high cervical spinal pathology, who underwent posterior fusion with instrumentation surgery from December 2009 to March 2016. We classified patients into a cervical myelopathy group (26 patients) or a non-myelopathy group (81 patients), based on the cord compression with myelopathy in MRI and analyzed MIOM change in both group respectively. Risk factor analysis of MIOM change was performed in both groups. Results: Our results showed that the 11 patients showed MIOM changes in cervical myelopathy group, 7 patients showed MIOM change in non-myelopathy group. Cervical myelopathy group showed significantly higher incidence of MIOM change than non-myelopathy group (p < 0.01). MIOM change group showed significantly narrower in spinal cord diameter (P 0.01). There is no difference between two groups in sex (P 0.35) and age (P 0.83). There is a relationship between cervical myelopathy and MIOM change. However, there were two cases of false negative MIOM response in cervical myelopathy group. Conclusion: MIOM change might be more common in cervical myelopathy and be correlated with spinal cord diameter. MIOM monitoring could be more useful in the case with myelopathy and canal stenosis., Introduction: A detailed understanding of the cervical spine biomechanics and sagittal alignment parameters is essential during the planning of surgery. Approximately 70-80% of the load in the cervical spine is supported by the posterior column. Cobb angle C2-C7 sagittal vertical axis (SVA) and T1 Slope (SL) are the main parameters to take into account in case of cervical degenerative pathology. The literature shows that cervical kyphosis contributes to the development of myelopathy by different mechanisms. The aims of the study were to evaluate the relationship between the cervical sagittal alignment parameters and surgical clinical outcomes after anterior cervical fusion; determine the role of T1 Slope, C7 Slope, cervical lordosis (CL), C2-C7 plumb line, the ratio CL/C7SL and CL/T1SL in surgical outcome; describe an innovative method to calculate the correct cervical lordosis necessary for every single patient. Materials and Methods: Retrospective study of 70 patients treated with an anterior approach in our center between 2013 and 2014. Great deformities were excluded. The following parameters were calculated by upright x-ray: C7 slope, T1 slope, cervical lordosis, C2-C7 SVA; we calculated the ratio CL/C7SL and CL/T1SL. We analyzed the obtained data with Pearson correlation coefficient and Student t-test. The clinical post-operative outcome was evaluated at 1 year by Neck disability index and VAS score. Results: We founded a significant correlation between C2-C7 SVA, C7 slope, T1 slope and CL / C7 SL with NDI and VAS. There is no correlation between cervical lordosis and clinical outcome. Statistically significant differences were found between group 1 (NDI 0 and VAS 0) and group 3 (NDI > 17 and VAS > 5): C2-C7 SVA (p 0.0026), C7 SL (p 0.0014) T1 SL (0.0095), CL / C7SL (p 0.0012). No significant differences about cervical lordosis (p 0:32) and CL / SL T1 (p 0.29) were found. A value of C2-C7 SVA 0.7 had a better clinical outcome. Conclusions: Sagittal parameters correlate with clinical outcome. Values C2-C7 SVA, Introduction: The importance of sagittal cervical alignment has recently been linked with clinical outcomes in spinal deformity surgery. Despite of the increasing number of studies showing the relationship of these radiographic parameters with postoperative clinical outcome, there is a lack of data correlating sagittal cervical alignment with health related quality of life (HRQOL) considering patients in nonsurgical treatment for cervical spondylosis. The aim of the present study is to evaluate the impact of the sagittal cervical alignment on neck pain and disability in patients in nonsurgical treatment for cervical spondylosis. Material and Methods: This is a transversal study considering patients with symptomatic cervical spondylosis, including only patients with no prior spine procedures. The patients were divided into three groups: axial pain, radiculopathy and myelopathy. Sagittal upright full spine radiographs were obtained and the cervical radiographic parameters considered were: CSVA, CL, TS and TS minus CL (TS-CL). The radiographic parameters were correlated with the HRQOL, assessed by the neck disability index (NDI) score and the visual analogue scale (VAS) for neck pain, using ANOVA. Results: Fifty-two patients were included. There was no significant difference in the cervical sagittal parameters between the three groups. The mean of the radiographic parameters in the total sample was: CL, 22.4° (±8.8°); TS, 29.3° (±6.6°); CSVA, 17.8 mm (±8.3 mm); TS-CL, 7.0° (±7.4°). There was a significant inverse correlation between CL and NDI (r = 0.3, P = .039), but there was not significant correlation between CL and VAS (r = 0.0, P = .989). CSVA (r = 0.1, P = .541), TS (r = −0.2, P = .287) and TS-CL (r = 0.2, P = .287) did not significantly correlated with NDI and VAS. Conclusion: Considering patients in nonsurgical treatment for cervical spondylosis, increasing CL is correlated with worst neck disability, but not with pain. There was not correlation between CSVA, TS and TS-CL with neck disability and pain in those patients., Introduction: There is borad spectrum of surgical options to treat foraminal stenosis from simple decompressive microscopic foraminotomy to lumbar interbody fusion for foraminal height reduction. Nowadays, several trials of endoscopic foraminal decompression have been reported. But, its’ usefulness and durability was not proved to the extent to satisfy most spine surgeons. Objective of study is to evaluate the clinical efficacy and safety of endoscopic foraminal decompression in lumbar foraminal stenosis. Materials and Methods: Total 52 Patient underwent endoscopic lumbar foraminal decompression from August 2012 to May 2015. Inclusion criteria were single level, unilateral lumbar foraminal stenosis (Wildermuth Gr 2, 3) regardless of disc herniation with symptoms of NIC and radiculopathy. Remarkable instability, listhesis, ASD cases were excluded in this study. FSVNA (foraminoplastic superior vertebral notch approach) with reamers and several kinds of endoscopic drills was performed for the foraminal decompression. Radiologic parameter (disc height, dynamic x-ray, displacement) were investigated preoperatively and postoperatively and compared. Clinical outcome (VAS, ODI, MacNab criteria) were also evaluated. Complications and failed cases were analyzed. Results: The mean age of the 28 female and 24 male patients was 65.2 years. Mean follow-up period was 24.6 months. The mean VAS for leg, back pain and the mean ODI improved from 8.12, 5.24, 63.8% at baseline to 5.32 (P < .001), 3.36 (P < .001), 47.5% (P < .001) at final follow-up. Based on the modified MacNab criteria, excellent or good results were obtained in 80.7% of the patients. Radiologically, disc height and segmental stability was preserved compared to preoperative status. There were 3 cases of transient postoperative dysthesia. 4 patients received revision surgery (1 Endoscopic revision surgery, 2 Interbody fusion, 1 Artificial disc replacement). No patient had postoperative infection, dura tear, postoperative hematoma. Major causes of unsuccessful outcome were remnant leg pain by incomplete decompression and postoperative dysthesia. Conclusion: Percutaneous endoscopic foraminal decompression under local anesthesia could be an efficacious and safe surgical procedure for the treatment of foraminal stenosis. Complete decompression of exiting root by thorough understanding of endoscopic lumbar foraminal structure is the key of successful outcome., Introduction: Minimally invasive endoscopic assisted spinal surgery allows a lower complication rate as well as less morbidity than the classical extended thoracotomy. Thoracoscopic surgery in the prone position facilitates the ventrodorsal operations in spine surgery, without the need to change the patient’s position during combined approaches. Publications about re-thoracoscopy for spine surgery are scanty. Material/Methods: Between August 1996 and June 2014, a total of 2004 patients (mean age 49.9 years) (51% males) underwent thoracoscopic assisted spinal surgery in our department. The indications for surgery were as follows: Trauma in 609 patients (30.4%), Deformity in 578 Patients (28,8%), Spondylodiscitis in 384 Patients (19%), degenerative diseases in 270 Patients (13.5%) and Tumor in 163 Patients (8.3%). All 2004 patients were operated in the prone position using a two-portal technique. Simultaneous posterior (revision) surgery in the same position was performed in 82 of the 91 reinterventions of this study. Analysis of the prospectively collected Data revealed 83 patients (4.1%) in whom a thoracoscopically assisted reintervention, surgery using the same technique has been performed. The data of these 83 patients were analysed with a minimum follow-up of two years. Results: The majority of the 83 patients had one thoracoscopic reintervention. In seven patients (8.4%), thoracoscopic surgery was performed more than twice. The mean age was 55.3 years (average 15 and 86 years). The majority were males (61.4%). The mean time lapse between the primary and revision surgery was 20.6 months. The indication for re-thoracoscopic assisted surgery was mostly mechanical in 89% of the cases (such as pseudoarthrosis and adjacent segment disease), followed by recurrent pathology (such as recurrent tumor or spondylodiscitis). In 52 patients (62.7%), the same incisions as the primary surgery have been used. In the rest of the patients new incisions were done to address pathology at other spinal segments. The mean total operation time ( = including the posterior reintervention and bone graft-taking) was recorded to be 5.1 hours in the primary surgery and 3.8 hours in the revision including the re-thoracoscopy. Conclusion: Thoracoscopic assisted spinal surgery became a well-established procedure despite the high learning curve. Performing this technique in the prone position has many advantages, since it allows several anterior and posterior surgical steps in one postioning and draping. The complication rates as well the operation time were not higher in the revision cases than in the primary cases. Mainly due to the minimal amount of adhesions associated with this procedure, revision surgery in the same thoracoscopic technique proofed possible, safe and effective., Introduction: In case of the recurred herniated nucleus pulposus after open lumbar discectomy (OLD), revision surgery is technically demanding because dural retraction and nerve root mobilization are difficult to operate due to the massive epidural scar. That’s why wide laminectomy followed by fusion surgery is generally performed. However, since Kambin’s triangle is still remained freely, it could be possible to perform transforaminal percutaneous endoscopic lumbar discectomy (PELD) without fusion surgery as a virgin surgery. Material and Methods: We retrospectively analyzed 83 cases who underwent revision surgery (Group A: transforaminal PELD: 35 cases, Group B: Microscopic Lumbar Discectomy: 48 cases) for recurred HNP between March 2010 and April 2014. All of the patients were followed for more than 12 months. Results: In group A and B, respectively, the mean age was 50.2 ± 12.9 years and 50.1 ± 11.6 years, sex ratio was male 25 cases: female 10 cases and male 30 cases: female 18 cases, the mean follow-up period was 24.2 ± 11.8 and 33.7 ± 7.9. The operated level of L2-3 / L3-4 / L4-5 were 3 cases / 5 cases / 27 cases in group A and 4 cases / 9 cases / 35 cases in group B. The mean VAS (Visual Analogue Score) prior to surgery was decreased at the 1 weeks, 1 months, 6 months after surgery, from 8.2 ± 0.6 to 2.3 ± 0.8, 1. 9 ± 0.6, 1.6 ± 0.7 and from 8.2 ± 0.7 to 4.5 ± 0.9, 3.3 ± 0.7, 2.4 ± 0.9 in group A and B, respectively. The mean ODI (Oswestry Disability Index) score prior to surgery was decreased at the 1 weeks, 1 months, 6 months after surgery, from 39.2 (78.3%) ± 2.8 to 13.5 ± 2.2, 11.8 ± 1.9, 10.3 ± 2.0 and from 39.0 ± 2.4 to 26.6 ± 3.6, 20.5 ± 3.4, 16.8 ± 3.4 in group A and B, respectively. 1 case (2.9%) of Surgery-related complication of dural tear (1 case: 2.9%), infection (0), hematoma (0) and 9 cases (18.8%) of dural tear (6 cases: 12.5%), infection (1 case: 2.1%), hematoma (2 cases: 4.2%) were occurred in group A and B, respectively. However, surgery-related neurology happened to 2 cases (5.7%) and 7 cases (14.6%) in group A and B, respectively. During the follow-up period, 2 cases (5.7%) and 8 cases (16.7%) of recurrence occurred in group A and B, respectively. Conclusion: According to the result, transforaminal PELD reveal the good clinical result of recovery after operation compare to the OLD in recurrent lumbar disc herniation. Transforaminal PELD also had a less chance of the surgery related complication and neurology as a virgin surgery. In conclusion, transforaminal PELD could be considered as one of the minimally invasive surgical options for revision surgery after OLD as a virgin surgery., Introduction: Minimally invasive techniques for instrumenting the lumbar spine are common in the modern hospital setting, however the same is not true for the cervical spine. Stripping the posterior ligamentous tension band and paraspinal musculature for the placement of lateral mass screws may contribute to development of postoperative kyphosis and chronic pain. The purpose of this study was to investigate and evaluate the feasibility of minimally invasive lateral mass fixation of the cervical spine in a controlled setting. Materials and Methods: Lateral mass screws were placed bilaterally into each level from C3 to C7 of 4 cadaveric specimens. Fluoroscopic guidance in the AP plane was utilized to plan an incision one vertebral body below the level of interest, just medial to the lamina-facet junction. Incision through skin and fascia allowed sequential dilation to accommodate a 14 mm tubular retractor. Exposure of the lateral mas allowed visualization of a central starting point that was confirmed with a lateral fluoroscopic image. A starting hole was then created using a bur and followed by a cannulated drill, guidewire and placement of a cannulated 2.5 mm screw. Screw trajectory and accuracy were assessed using fluoroscopy and 3D fluoroscopic reconstructions. Results: Lateral mass screws were completely within the substance of the lateral mass 87.5% of the time, with a 12.5% incidence of lateral or anterior breach of the cortical margins. The typical angle of divergence achieved was 12.8 degrees with 45.5 degrees of cranial angulation. There was no incidence of penetration into the transverse foramen or spinal canal. Conclusion: Minimally invasive placement of lateral mass screws through a tubular retractor is a viable technique for instrumenting the posterior cervical spine. Despite restrictions from the soft tissues and spinous process, we were able to achieve a trajectory through the tubular retractor that is within the range of techniques described for the open placement of lateral mass screws. Further refinement of the technique is warranted including clinical trials comparing patient outcomes with traditional open techniques., Rationale: Freehand placement iliac screws can be difficult for novices. Typically it requires dissecting the posterior superior iliac spine (PSIS), the use of connectors and may leave palpable screw heads. Choosing a more medial and inferior entry point eliminates these problems, but makes correct positioning more challenging. Despite its advantages, this technique has found only limited acceptance. Methods: In a human pelvis the medial and lateral cortices of the ilium were marked with pieces of wire and a CT scan was obtained. The pelvis was placed on a carbon operating table and a C-arm was positioned in the same way as in a surgical situation to achieve a proper projection of the iliac teardrop. Correlated photographic and C-arm images were obtained. The CT data was entered into the SpineAssist software. Virtual screws were placed through the defined entry point and along the visual axis. The trajectory was evaluated in all three anatomical planes as well as in a drive-through mode. Results: In the teardrop view, the lateral iliac cortex becomes almost one solid line, leaving a visual safety margin towards the hip joint and the correct entry point is located very close to the PIIS. In the simulation, we placed virtual screws (120 x 8 mm). Their position was examined in the 3 planes and always exhibited a trajectory that was completely within the ilium. It is possible by means of this technique to position a screw very tightly along the lateral and the inferior iliac cortices, thus providing superior anchoring. Conclusions: The outline of the iliac teardrop figure is made up entirely by the iliac cortices, making iliac screw placement using the teardrop technique safe and reproducible. It requires only a C-arm and even novices should be able to safely place iliac screws in this way. Screws placed according to this technique can easily be connected without offset connectors. Supported by this data, the teardrop technique should be taught to residents., Introduction: The laminotomy with flavectomy for lumbar canal or lateral recess stenosis evolved from open laminectomy, to the microscope, followed by micro-endoscopic laminectomy In MISS trend. The objective of this study was to evaluate the clinical feasibility and safety of Percutaneous Endoscopic Laminotomy with Flavectomy for the Lumbar Canal or Lateral Recess Stenosis. Material and Methods: Total 42 Patients underwent Uniportal Percutaneous Endoscopic Laminotomy and Flavectomy with/without discectomy from August 2012 to May 2015. Procedure was performed with several endoscopic instruments such as drill, punch and dissector in the way similar to conventional microscopic laminotomy and flavectomy. Clinical outcomes (VAS, ODI, modified MacNab criteria) were evaluated. Surgical outcomes including operative time, hospital stay and complications were also investigated. Results: Total 44 lumbar levels were decompressed for spinal canal or lateral recess stenosis (Unilateral laminotomy: 29, Bilateral laminotomy via unilateral app: 15). The mean age of the 28 female and 14 male patients was 64.2 years. Mean follow-up period was 13.45 months. The mean VAS for leg pain, back pain and the mean ODI improved from 7.12, 6.24, 69.8% at baseline to 4.32 (P < .001), 3.56 (P < .001), 46.5% (P < .001) at final follow-up. Based on the modified MacNab criteria, excellent or good results were obtained in 90.9% of the patients. Average operation time was 95 ± 27 minutes. In the late period of the learning curve, operation time was shortened by 2/3. Hospital stay was 1.45 days. There were 1 case of transient postoperative dysthesia, 1 case of motor weakness and 2 case of dura tear. One patient experienced the recurrence of combined HDs and underwent secondary endoscopic revision surgery. There was 1 case of intraoperative conversion to classic microscopic laminotomy due to breakage of lens of endoscope. No patient had postoperative infection, hematoma or revision surgery for the incomplete decompression. Conclusion: Percutaneous endoscopic laminotomy with flavectomy is the least invasive and clinically feasible surgical technique for lumbar canal or lateral recess stenosis., Introduction: Symptomatic adjacent vertebral fracture AVF is a common complication after kyphoplasty. It usually happens within 6 months after operation, and constitutes majority of new fracture. Intra-disc leakage is as an important risk factor, but there were no studies reported on prophylactic vertebral augmentation in high-risk patients. The aim of the study is to evaluate the clinical outcome of prophylactic vertebral augmentation in selected patients, and identify the risk factors of early adjacent vertebral fracture (AVF). Material and Methods: We conducted a retrospective cohort study. Eighty-two patients with intra-disc leakage after kyphoplasty were enrolled and divided into two groups based on whether they received prophylactic vertebral augmentation at the superior level. General conditions, operative details, and complications were recorded. The minimum follow-up was 6 months to ensure that any possible early complications were included. Results: In the non-prophylactic group, 9 of 59 (15.3%) patients had an AVF superior to the level of intra-disc leakage, and 8 of 9 (88.9%) occurred within 6 months post-operatively. Overall, 14 (23.7%) patients had a new fracture. In the prophylactic group, no patients had an AVF, but 3 (13.0%) had remote fractures (P = .047 and 0.284, respectively). There were no complications associated with vertebral augmentation. The parameters were comparable between the two. General conditions, osteoporosis, and radiological analysis were not significantly correlated with early AVF. Patients with comorbidities, including diabetes and hypertension, and corticoid use history had a higher risk of fracture (odds ratios: 12.0, 95% confidence interval [CI]: 1.0–143 and 34.3, 95% CI: 3.2–364.5, respectively). Conclusion: Prophylactic vertebral augmentation can prevent AVF and associated second surgery, and it can reduce the overall new fracture rate, although this was not statistically confirmed. Patients with comorbidities and corticoid use have a higher risk of AVF. Therefore, we recommend prophylactic vertebral augmentation for intra-disc cement leakage with those conditions., Introduction: Two-dimensional radiographic measurement methods have been proposed to evaluate the radiographic outcome after foraminal and central canal decompression through extreme lateral interbody fusion (ELIF). However, the assessment of neural decompression in a single plane may underestimate the effect of volumes on a particular area and current techniques fail to predict the effect of “ligamentotaxis” on central canal, foramen and lateral recess decompression. Material and Methods: 7 patients (9 levels) undergoing ELIF were included in a retrospective study. Three independent, blind raters using Osirix-MD software performed volumetric measurements pre- and postoperatively to determine central canal and foraminal volumes. Intra-rater and Inter-rater reliability tests were performed to assess the reliability and repeatability of this novel volumetric method. Two-dimensional measurements of foraminal height and disc height were also measured and compared pre- and postoperatively. Results: The inter-rater reliability ranged between 0.800 to 0.952 for each volume measurement (ICC range P < .0001 for all comparisons). The test-retest analysis on a randomly selected subset of three patients was 0.78 – 1.00 (range of 0.78 – 1.00) for all three raters. There was a significant increase in right foramen (25.46% ± 6.61), left foramen (20.79% ± 5.06), and central canal volumes (20.69% ± 1.33) after the surgery (P = .0472, P = .0066; and P = .0003, respectively). Additionally, anterior disc height, posterior disc height, left foramen height, and right foramen height increased significantly after ELIF (P = .0002; P < .0001; P < .0001; and P = .0025, respectively). Conclusions: Here we demonstrate a volumetric analysis technique that is feasible, reliable, and reproducible amongst independent raters for assessing important radiological factors such as central canal and foraminal volume in the lumbar spine. Our results demonstrate that two- and three-dimensional radiographic measures significantly increase in an equivalent amount after performing ELIF surgery. This method may help to understand why current radiological techniques fail to predict the effect of “ligamentotaxis” after ELIF on central canal, foramen and lateral recess volumes., Introduction: Minimally disruptive posterior cervical fusion is a surgical option for treating cervical radicular pain in select patients. To achieve stabilization until fusion occurs, a posterior cervical cage is deployed bilaterally between the facet joints, distracting the joints and freeing the nerve root (Figure 1). The cervical cages prevent translation of the motion segment and support fusion in conjunction with standard posterior fusion techniques such as decortication of the lateral masses, rasping of the articular processes, and the application of bone graft. The authors present intra-operative and clinical outcome data for 76 patients with single or multiple-level cervical radiculopathy treated with posterior cervical cages placed bilaterally in the facet joints. Materials & Methods: Between 2014 and 2016, 76 patients were treated with a posterior cervical fusion and decompression between two surgical centers. All patients had single or multiple-level symptomatic cervical radiculopathy that had failed conservative management and/or other surgical treatment modalities. In this retrospective study, the patient’s NDI score, VAS arm and neck pain scores, neurological status, imaging studies, and adverse events at baseline and post-operative follow-ups scheduled at intervals of 2- and 6-weeks, 3-, 6-,12-, and 24-months were reviewed. The patient’s operative time from initial skin incision to skin closure, length of hospital stay, and intra-operative blood loss were also reviewed. Results: This cohort of 76 patients had a mean follow-up of 8.22 months (0.5-24 months). The mean age of this cohort was 57 years (34-87 years) and consisted of 40 males and 36 females. Thirty-eight patients had one-level disease treated with this construct, thirty-one had 2-level disease treated, and seven patients had three levels treated. Bilateral posterior cervical cages were placed at the level of C3-C4 in nine patients, twenty-four at C4-C5 (one patient had a unilateral cage placed at this level), fifty-eight at C5-C6, and twenty-eight at C6-C7 for a total of 119 levels amongst all patients. One patient also had a single-level ACDF performed concurrently. All NDI scores (n = 8), VAS arm pain (n = 76), and VAS neck pain (n = 76) scores significantly improved by final follow-up (Figure 2), with a mean NDI improvement of 14.81 (±0.17; P = .018), and mean VAS arm and neck pain improvements of 5.54 (±2.52; P < .001) and 8.16 (±2.23; P < .001), respectively. The mean operative time from initial incision to skin closure was 90.89 minutes (43-248 minutes; n = 9), mean blood loss was 24 cubic centimeters (9-48 cc; n = 9) and mean hospital stay was 25.61 hours (6-96 hours; n = 76). Conclusion: Bilateral posterior cervical fusion can treat single or multiple-level cervical radiculopathy via a safe and effective minimally disruptive approach. The use of this posterior cervical cage system to perform a posterior cervical fusion and decompression shows favorable results and offers the surgeon an additional treatment option for cervical radiculopathy in select patients., Introduction: Limited data exists characterizing risk factors for blood transfusion in elective thoracolumbar spine surgery. Additionally, effects of blood transfusion on inpatient outcomes and health care-resource utilization in this population has not been well established. Material and Methods: Utilizing data from the National Inpatient Sample from 2002 to 2012, an estimated 2,483,779 patients undergoing elective thoracolumbar surgery for degenerative conditions or deformity correction were identified. The sample was divided into two cohorts based on whether or not they received a blood transfusion while in the hospital. Risk factors for transfusion, post-operative complications, and health care resource utilization (length of stay, hospital charges, and discharge disposition) were analyzed. Additionally, complications were classified as major or minor. Major complications included acute myocardial infarction, cardiac arrest, septicemia, septic shock, stroke, and pulmonary embolism. Minor complications included deep vein thrombosis, pneumonia, surgical complications, post-operative anemia, and urinary tract infections. Results: 290,849 patients (mean age 57.7) received a blood transfusion during their hospitalization and 2,192,930 patients (mean age 57.9) did not; P < .001. Multi-level fusion ≥9 levels was the most important independent risk factor for transfusion (OR 5.28; 95% CI 5.16 to 5.41; P < .001) followed by underlying coagulopathy (OR 2.58; 95% CI 2.51 to 2.66; P < .001) and baseline anemia (OR 2.39; 95% CI 2.36 to 2.43; P < .001). Blood transfusions were strongly associated with inpatient mortality (0.2% versus 0.1%; p < 0.001) and major complications (0.8% versus 2.5%; P < .001) including a greater than two-fold increase in rates of myocardial infarction, cardiac arrest, stroke, and pulmonary embolism, and a greater than three-fold increase in rates of septicemia and shock when compared to patients who did not receive a blood transfusion. Blood transfusion status was an independent risk factor for major complications (OR 1.79; 95% CI 1.64 to 1.86; P < .001) and inpatient mortality (OR 1.41; 95% CI 1.32 to 1.51; P < .001). Patients who received a blood transfusion had longer hospital stays (mean 5.4 compared to 3.3), significantly increased total hospital charges, and were twice as likely to need discharge to a facility other than home (P < .001). Conclusion: Blood transfusions are associated with poorer inpatient outcomes and a significant increase in consequent health-care resource utilization. Extra efforts should be made to minimize blood loss in those at risk of needing a subsequent blood transfusion following elective spine surgery., Introduction: Based on the US census, the population of those aged 65 and over is projected to experience the greatest increase in size over the next decade, increasing by approximately 18 million in the United States and more than doubling by 2060. Large studies analyzing the effect of advanced age on inpatient outcomes in patients undergoing elective lumbar surgery are limited. Material and Methods: An analysis of the National Inpatient sample from 2002 to 2012 was performed. An estimated 2,483,167 patients >25 years old who underwent elective primary or revision fusion or decompression alone for degenerative lumbar conditions were identified. A comparison of demographic information, inpatient outcomes, hospital resource utilization, and discharge disposition was performed for groups of increasing age. Complications were classified as major or minor. Major complications included acute myocardial infarction, cardiac arrest, septicemia, septic shock, stroke, and pulmonary embolism. Minor complications included deep vein thrombosis, pneumonia, surgical complications, post-operative anemia, and urinary tract infections. Specific analysis of outcomes in patients >70 and >80 was additionally performed. There was no source of external funding. Results: 734,909 patients (mean age 76.3) over the age of >70 and 1,751,989 patients ≤70 (mean age 54.0) were identified in this patient sample; P < .001. Patients >70 were more likely to have associated comorbidities (1.90 compared to 1.42; P < .001). Patients >70 were twice as likely to experience a major complication (2% compared to 0.8%; P < .001) and fatality (0.2% versus 0.1%; P < .001). While length of stay was similar between the elderly and younger patients (3.9 compared to 3.6; P < .001), patients >70 were more likely to require a discharge to another facility (32.9% compared to 9.3%). Age >70 was an independent risk factor for major post-operative complications (OR = 1.95; 95% 1.89 to 2.01; P < .001), inpatient mortality (OR 2.45; 95% CI 2.18 to 2.75; P < .001), and need for transfer (OR = 5.10; 95% CI 5.05 to 5.15; P < .001). These increases in inpatient complications, mortality, and need for transfer were further magnified when the same analysis was performed in patients >80. Conclusion: The elderly represents a quickly growing patient population in the United States. Advanced age is associated with increased post-operative complications, inpatient mortality, and a substantial increase in the need for transfer to another facility in patients undergoing elective lumbar surgery., Introduction: Sagittal balance is expected to influence functional results after spine surgery. Transforaminal lumbar interbodyc fusion (TLIF), first described in 1988 by Harns et al, is one of the treatment options for disk heigh improval. There are several papers that describe clinical results from TLIF, but few explore the relationship between sagittal balance and clinical results. Our aim was to evaluate radiological parameters variation between pre and postoperative periods and to determine its correlation with postoperative clinical results. Material and Methods: Between January 2011 and December 2015, 35 patients were submitted to TLIF. We selected 18 patients with complete radiological study and at least 12 months of follow-up. The present data was retrospectively collected by phone interview and clinical and imagiological data consultation. Pain analogue scale, Short-Form Health Survey-36 (SF-36) and Oswestry Disability Index (ODI) were used. Statistical analysis was performed with GraphPad Prism version 6.0 para Windows 8. Results: We obtained 6 men and 12 women with 55.50 ± 11.09 years old by average, a mean follow-up period of 38.44 ± 14.28 months and a mean hospital stay of 4.13 ± 2.698 days. Lumbar and radicular pain were significantly lower in postoperative period (2.00 ± 2.64 versus 6.78 ± 2.21 and 2.50 ± 3.00 versus 5.50 ± 1.78, respectively; P < .05). Mean postoperative value for SF-36 was 66.84 ± 5.24 and 70.0 ± 4.83 for Physical and Mental Component, respectively. Average postoperative ODI value was 25.78% ± 20.71. Global satisfaction was 80%. We obtained a significantly higher postoperative disk height (7.83 ± 3.05 versus 10.37 ± 2.83; P < .05). Pelvic tilt values increased in general (PT; 18.33 ± 8.75 versus 24.05 ± 7.82; P < .05), there was a slight increase in lumbar lordosis (LL) for 72% of the patients (60.06 ± 15.44 versus 60.72 ± 12.21) and a slight decrease in sacral slope (SS), although normal range values were maintained for the latter (40.89 ± 8.86 versus 39.06 ± 11.67). Definitive symptoms remission occured for 55% of the patients. From those patients who maintained a normal postoperative pelvic incidence – lumbar lordosis ratio (PILL), 60% had no symptoms at all, when compared with 38% patients that exibited PILL mismatch. We were not able to obtain a correlation between cage position and lumbar lordosis variation before and after surgery. All patients obtained objective bone fusion in computed tomography at 12 months of follow-up. Conclusion: TLIF does seem to lead to efficacious disk height correction and might influence, even though in a slight manner, sagittal balance correction and consequent clinical parameters, as it was observed in our findings. Global variations obtained in lumbar lordosis values might be derived from modest influences that TLIF triggers in sagittal balance, as current evidence recall; also, pelvic tilt increases might translate global compensation from sagittal balance. Present data shows that PILL mismatch might be related with residual symptoms, which overlaps current literature. However, in our results, cage position did not correlate with individual variations of sagittal balance, as previously thought, specifically for lumbar lordosis. Future work with larger number of patients and longer follow-up periods are needed to corroborate these findings and extend it to general population., Introduction: The accuracy of robot-guided pedicle screws has been proven to be high, but little is known on revision rates. No reports include long-term patient-reported clinical outcomes. A clinical benefit for the patient is unknown. This is the first report on long-term outcomes of robot-guided pedicle screw fixation for single level spondylolisthesis. Literature data were used to compare surgical revision rates and patient-reported outcomes. Material and Methods: We retrospectively analyzed prospectively collected data from patients undergoing Minimally Invasive Transforaminal/Posterior Lumbar Interbody Fusion (MI-T/PLIF). Patients were followed up at 6 weeks, 12 months, 24 months and by mailed questionnaires in March 2016 as a final follow up. Visual Analog Scale (VAS) for back and leg pain severity, Oswestry Disability Index (ODI), peri- and postoperative revision rates and socio-demographic factors were analyzed. Results: 72 patients fit our inclusion criteria, and had a mean follow up of 32 ± 17 months. Mean improvements in VAS back pain (49.3%), leg pain (63.4%) and ODI (61.2%) were consistent with previous reports. Length of stay was 2.4 days and operating time was 161 minutes. 89.1% of patients indicated they would choose this treatment again. Ability to work increased from 38.9% to 78.2% (P < .001). No instrumentation-related complications occurred, and no revision surgery was needed. Intraoperative screw repositioning was significantly lower compared to navigated and free hand techniques (P < .001). PLIF, high BMI, smoking status, and preoperative ability to work were identified as predictors of reduction in back pain. Conclusion: Minimally invasive robot-guided pedicle screw fixation is a safe and effective means to treat spondylolisthesis. It lowers intraoperative screw revisions when compared to published evidence on both free hand and navigated procedures. Moreover, it significantly reduces the revision rate for pedicle screw malposition compared to freehand procedures., Introduction: As US healthcare expenditures continue to rise, there is a substantial incentive to reduce the cost of inpatient services. While pre-operative testing requires an estimated 3 billion dollars each year, several studies have suggested that lab results have a minimal impact on clinical decision-making in surgery. Despite the widespread use of pre-operative testing in spine surgery and the large volume of posterior lumbar fusions (PLF) being performed each year, no study has assessed the ability of pre-operative labs to predict adverse events following PLF. The purpose of this study was to explore the relationship between commonly obtained preoperative lab results and post-operative complications following 1-2 level PLF. Material and Methods: The 2006-2013 ACS-NSQIP database was employed to identify all patients who underwent 1-2 level PLF. Emergent procedures and patients undergoing unrelated interventions were excluded. Demographic information, pre-operative co-morbidities, and intraoperative characteristics were collected for each patient. Pre-operative labs included sodium, BUN, creatinine, albumin, bilirubin, SGOT, alkaline phosphatase, white blood count, hematocrit, platelet count, prothrombin time, INR, and partial thromboplastin time. Patients were determined to have normal or abnormal values. Incidence of major, minor, and total complications was documented. Patient demographics, pre-operative comorbidities, surgical characteristics, and lab values for the entire cohort were explored for potential associations with the development of postoperative complications using bivariate Chi-squared analysis. Variables resulting in P < 0.1 in this analysis were subsequently incorporated into a backward, binary logistic regression model with the presence of a complication as the dependent variable. Three regressions were performed for total complications, minor complications, and major adverse events. Model performance was assessed using the c-statistic and the H-L test was utilized to evaluate model calibration. Results: 6788 patients were identified as having undergone PLF, 6507 of which underwent elective 1-2 level fusion. After controlling for age, ASA score, length of surgery, and all significant comorbidities, abnormal sodium (P = .001, OR = 2.47, 95CI: 1.45-4.19) and abnormal INR (P = .029, OR = 2.33, 95CI: 1.09-4.98) were significantly associated with the development of any complication. Sodium (P = .04, OR = 1.61, 95CI: 1.01-2.54) and platelets (P = .04, OR = 1.58, 95CI: 1.02-2.44) were associated with minor complications. Meanwhile, creatine (P = .04, OR = 1.74, 95CI: 1.02-2.99) and platelets (P = .04, OR = 1.71, 95CI: 1.02-2.89) were significantly predictive of major adverse events. All of the models fit the data well (H-L test > 0.5) and exhibited good discrimination (c-statistic values of 0.66, 0.704, and 0.704). Conclusion: This study represents the first attempt to assess the utility of pre-operative labs in predicting post-operative complications in PLF. Although the majority of labs were not significantly associated with adverse events, abnormal sodium values, INR, creatinine, and platelets were shown to be predictive of various complications., Introduction: Several treatments have been proposed to reduce the symptoms of spinal stenosis with the caudal injection of corticosteroids and ropivacain being the most dominant. The purpose of this prospective study is to evaluate the effectiveness of this treatment in our clinic. Material and Methods: The sample consisted of 148 patients (108 female, 40 male). All inclusion and exclusion criteria were taken into account and the patients signed a written consent form. Apart from demographics, the duration of the symptoms was registered and a MRI of the spine was made in order to evaluate the severity of the condition, how many levels are involved and which level has the largest stenosis. A caudal injection was made in each patient consisted of 2 ml ropivacain +2 ml betamethasone. Visual Analog Scale (VAS), Standing Tolerance Scale (STS), Walking Tolerance Scale (WTS), Patient Satsisfaction Scale (PSS) and Oswestry Disability Index (ODI) were used to evaluate the pain and disability of the patients. All the above parameters (with the exception of PSS) were measured before, 6 weeks after and 6 months after the caudal injection. Statistic tests as Wilcoxon, Mann – Whitney U and Kendall’s tau were used in the SPSS 20.0 software to detect possible worsening or improvement of the symptoms as well as the existence of possible predisposing factors. Results: 6 weeks after the injection a statistically significant improvement was noticed in all the tests: VAS (P = .013), STS (P = .02), WTS (P = .003), PSS (ΜΟ = 2.46 ± 1.129), ODI (P < .001). However, after 6 months only VAS and ODI showed statistically significant difference (P = .08 and P = .001 respectively). A statistically significant negative correlation was noticed between the duration of the symptoms and VAS (P = .035) and PSS (P = .002) in 6 months after the injection was made. No more statistically significant differences were noticed. Conclusion: Patients with spinal stenosis can be relieved significantly after caudal injections of corticosteroids but for a short amount of time. Large duration of the symptoms before the injections seems to play a negative role on the middle-term effectiveness of the injections., Introduction: Lumbar spinal stenosis is defined as the narrowing of either the spinal canal or neural foramina.1 Underlying causes for the stenosis are hypertrophy of the ligament flavum and facet joints, osteophytes, spondylolisthesis, disc protrusion. The Aspen device is a new interspinous process decompression device designed to distract the posterior elements of a stenotic lumbar segment and place it in order to enlarge the foraminal and central canals in those patients with neurogenic intermittent claudication.2-3 Material and Methods: We present 4 years follow-up data on the Aspen patients. The inclusion criteria for the trial were leg, buttock, with back pain relieved during flexion and claudication. The exclusion criteria were chronic motor deficit, cauda equina syndrome, previous lumbar surgery or spondylolisthesis greater than grade I at the affected level. From April 2010 to January 2014, 38 patients have been included in this study. The average age was 57 years. 26 patients had the Aspen implanted at either L3-L4, L4-L5 or L5-S1 levels. 10 patients had the Aspen implanted at both L3-L4 and L4-L5 levels. 2 patients had a grade I spondylolisthesis, the other single or multilevel spinal degenerative stenosis. Results: The mean preoperative Oswestry score was 47. The mean postoperative Oswestry score was 16. The mean preoperative VAS score was 8.7 and the mean postoperative one was 3.8. Our results have demonstrated a successful rate in the Aspen interspinous process decompression group at an average of 4 years postoperatively. Conclusions: The initial effectiveness data as seen in the significant improvements on both VAS and ODI have also suggested that the Aspen device could be a viable treatment option for patients with low-back pain caused by degenerative disc disease and low grade spondylolisthesis. Furthermore, the characteristic feature of this device is the low invasiveness and the possibility of use it in L5-S1 thanks to the variety of sizes and its simple surgical approach. Herno A, Saari T, Suomalainen O, Airaksinen O. (1999) The degree of decompressive relief and its relation to clinical outcome in patients undergoing surgery for lumbar spinal stenosis. Spine 24:1010-1014. Schnake KJ, Putzier M, Haas NP, Kandziora F (2006) Mechanical concepts for disc regeneration. European Spine Journal, 15 (suppl. 3), S354-S360. Oppenheimer JH, DeCastro I, McDonnell DE. (2009) Minimally invasive spine technology and minimally invasive spine surgery: a historical review. Neurosurg Focus;27(3): E9., Introduction: Lumbar spinal stenosis is frequent diagnosis especially in the elderly. Clinical signs are very variable, but graphical findings are typical. But are they really so typical? Can we rely on our clinical and graphical results? And can we find some rules for the decision about the treatment? When continue in conservatively and when go to surgical surgical treatment. Are there any borders or rules? We decided to study morphological, clinical and patients self-assessment classifications to find corrleations and importance. Materials and Methods: Retrospective study, 60 patients selected for surgery for the lumbar spinal stenosis Inclusion criteria were preoperative MR, visual analog scale (VAS), Oswestry disability index (ODI), Swiss Spinal Stenosis Questionnaire and neurological score - (NIS-LSS). We measured MR axial pictures: area of the spinal canal, area of dural sac, Schizas nerve root compression score. The results were statistically processed to study correlation between all categories. Results: We have found no correlation between both self-assessment scores and morphological and clinical scales. We have found only weak correlation between clinical scale (NIS-LSS) and Schizas score and area of the dural sac. There is no correlation between clinical scale and area of the spinal canal. Conclusion: Our hypothesis - in such a selected group of patients there should be strong evidence of correlation between morphological, clinical scores and self-assessment questionnaires - was disproved. The decision about the way of treatment of the lumbar spinal stenosis remains the same - it depends on the agreement of the surgeon and the patients. There are no classification schemes that can help with the decision. Only the Schizas nerve root compression score has some value and can show some relations between MR and clinical findings, although it is not statistically reliable in our study., Purpose: Recovering of individual lumbar lordosis (LL), especially lower lumbar lordosis (L-LL) is mandatory in spine fusion surgery. Pelvic incidence (PI) minus lumbar lordosis, or PI-LL value to predict ideal lumbar lordosis has been known to be a fixed parameter around 9°. However there are several reports that PI – LL is variable according to the value of PI. The study of normal subjects using PI calculating ideal LL and L-LL, where most lumbar surgery are performed, was not reported. The purpose of this study was to present the correlation formula for optimum LL and L-LL by PI value. Materials and Methods: Standing sagittal radiographs of the whole spine including the pelvis in 150 adult male volunteers (average age: 64.1 ± 6.4) without back pain, or surgery in spine or lower extremity was analyzed. Volunteers with scoliosis, spondylolisthesis, 1–3 segmental disc space narrowing, and/or compression fractures in radiographs were excluded. The following parameters were included: C7 Plumbline (C7 PL), Thoracic kyphosis (TK, T5 upper endplate (UEP) - T12 lower endplate (LEP)), LL (T12 LEP − S1 UEP), L-LL (L4 UEP − S1 UEP), pelvic parameters including PI. The values PI - LL, and PI - L-LL were calculated, and the formula using simple linear regression analysis was performed. A P value of, Introduction: Patients with a greater degree of deformity, those with neuromuscular or congenital deformity, and those undergoing more complex procedures including 3 column osteotomies have an increased rate of major complications. In this complex cohort, accurate preoperative risk assessment is even more important. A deformity-specific frailty index (ASD-FI) has been validated in less complex cohorts and was strongly associated with major complication incidence and hospital length of stay (LOS). Material and Methods: The Scoli-Risk 1 database only included patients with severe deformity (eg >80ϒ Cobb curvature or congenital deformities) undergoing complex procedures (eg 206/272 patients had 3-column osteotomies). The recently developed ASD-FI was used to calculate frailty scores for all patients. Patients were classified as not frail (, Introduction: The neurologic complication rate following complex adult spinal deformity (ASD) surgery is quite variable due to several factors. Most series are retrospective with heterogeneous patient populations & have non-uniform neurologic assessments performed &/or documented before & after surgery. We hypothesized that the neurologic complication rate would be higher than previously reported due to strict prospective grading of the Lower Extremity Motor Score (LEMS) by Asia-Certified evaluators at specific postoperative time points, with gradual improvement over time. Material and Methods: The Scoli-Risk 1 trial enrolled 272 patients from 15 centers (9 North American, 3 European, 3 Asia-Pacific) with ASD having primary or revision surgery with a major Cobb of >80° (n = 79), a revision including an osteotomy (n = 165), and/or a complex 3-Column Osteotomy (3-CO, n = 206, 76%). All patients had a complete Lower Extremity ASIA exam performed preoperatively and at specific postoperative time points up to 2 yr follow-up which generated a Lower Extremity Motor Score (LEMS, Max. 50 points = Normal LE Motor function). Results: 196 (72%) patients had preoperative & all postoperative time point LEMS available. The patients with normal scores of 50 points preoperatively statistically declined at discharge (49.04, P < .001), 6 weeks (49.00, P < .001), 6 months (49.62, P = .001) & 2 year follow-up (49.66, P = .002). Those starting with a motor deficit preoperatively (n = 68; LEMS 43.79), had statistical improvement in their LEMS at 6 months (47.21, P < .001) & 2 years postoperative (46.12, P = .003). The overall rate of postoperative decline in LEMS was 23% at discharge, 17.1% at 6 weeks postoperative, 9.9% at 6 months, & 10.1% at 2 years postoperative. Conclusion: The rate of postoperative motor function decline in ASD patients undergoing complex spinal reconstructive surgery was 23% at hospital discharge improving to 17% at 6 weeks postoperative then further improving to 10% at the 6 months & 2 year follow-up time points. This rate is higher than previously reported due to the prospective, strict nature of LEMS testing in these challenging pts., Introduction: In geriatrics literature, the concept of frailty as a physiologic diagnosis was developed as an improved measure of aging. In general surgery cohorts, frailty has been shown to be a better predictor of major complications than age. One validated method of determining frailty is by using a frailty index, which is based on the concept that frailty is an accumulation of deficits. With each deficit, frail patients become increasingly vulnerable to acquiring additional deficits and of having adverse outcomes following surgery. Material and Methods: All preoperative variables in a prospective ASD database were analyzed to select those meeting previously validated criteria. 40 variables were identified, the ASD-FI score was calculated as the average of the variables, and this score was used to stratify patients into 3 frailty score cohorts with cut off scores previously defined in the literature: not frail (NF) 0.5. The frailty model was then validated in a prospective ASD database with identical inclusion criteria. We then performed a multivariate logistic regression to determine the relationship between ASD-FI cohorts, incidence of major complications, and hospital length of stay (LOS), adjusted for important preoperative and surgical covariates such as operative time and blood loss. Results: In the ESSG database, of 266 patients with at least 2 years follow up, the average ASD-FI score was 0.29 (0-0.8). The adjusted odds of incurring a major intraoperative or postoperative complication were 4.5 [2.0-10.0] (P < .001) times greater, those of having a reoperation were 3.8 [1.7-8.9] (P < .01) times greater, and the LOS was 9.3 [5.4-13.2] (P < .001) days longer for SF (n = 83) compared to NF (n = 80) patients. SF patients were also more likely to develop PJK (4.6), wound infections (5.7, adjusted 10.2), implant related (3.4), and neurologic 4.7) complications than NF patients (P < .05). Conclusion: The ASD-FI score is associated with increased LOS and risk of major complications, especially medical complications, wound infections, and PJK. This indicates that frailty assessment could be applied to improve the accuracy of preoperative risk stratification and assist with patient counseling., Introduction: A multi surgeon retrospective review looking at postoperative deep space infections after posterior spinal fusion can be difficult to manage and potentially devastating. The overall rate of infection after posterior spinal fusion has been reported as high as 23% in patients with neuromuscular scoliosis. A multilayered plastic surgery closure decreases potential dead space, protecting the spinal instrumentation. We compared surgically treated neuromuscular scoliosis patients with and without plastic surgery multilayered wound closure. Materials/Methods: All neuromuscular scoliosis patients treated with posterior spinal fusion from 2008 to 2014 were analyzed. Patients with 2-year follow-up and completed charts were reviewed. Patients were categorized into 2 Groups: Group 1 [Plastic Closure (PC)] – included patients with a multilayered closure and advancement flaps when necessary; Group 2 - Standard Closure (SC). Differences in demographic, radiographic, and clinical parameters were analyzed. Results: 50 patients met inclusion criteria for the database, of which 39 had complete 2-year data. Group 1 had 11 patients, each having a multilayered plastic surgery wound closure. Group 2 included 28 patients who had a standard wound closure. There was no difference in age, male gender, number of levels fused, or postop max coronal Cobb angles between the Groups (Table 1). There was a significant difference in deep space infections (0 vs 7, P = .0057), revision surgeries (0 vs 7, P = .0057), EBL (2425 vs 644 cc, p = 1.46E-06), OR time (467 vs 245 min, p = 1.97E-08), iliac screw fixation (58% v. 21%, P = .022), and preop max coronal Cobb angle (58.29 vs 71.99°, P = .043) in the PC vs SC Groups, respectively. Conclusion: Plastic surgery closure resulted in a statistically significant decrease in infection and revision surgery rates despite this patient cohort having significant increases in blood loss, operative time, and iliac screw fixation, all of which have been shown to increase the risk of infection. Utilizing a plastic surgery closure can reduce dead space, providing better soft-tissue coverage of the spinal instrumentation reducing infections and revision surgery rates. Table 1. PC SC p N 11 29 Age (yrs) 15.28 17.39 0.255 Male 57% 41% 0.38 # levels fused 14.38 15.5 0.197 Preop Cobb Max 58.29° 71.99° 0.043 Postop Cobb Max 26.88° 25.13° 0.704 EBL (ml) 2425 644 1.46E-06 OR time (min) 467 245 1.97E-08 Iliac screw fixation 58% 21% 0.022 Deep Space infections 0 7 0.0057 Revision surgery 0 7 0.0057, Introduction: Although three-column osteotomies (3CO), including pedicle subtraction osteotomy (PSO) and vertebral column resection (VCR), can provide powerful alignment correction and disability improvement in adult spinal deformity (ASD) treatment, these procedures are complex and associated with high rates of complications. Previous reports on complications associated with 3CO have been primarily based on retrospective complication collection, which may substantially underestimate the true rates. Our objective was to provide a retrospective review of a prospectively collected multicenter consecutive case series of thoracolumbar 3COs performed for ASD. Materials and Methods: ASD patients treated with 3CO and eligible for 2-year follow-up were identified from a prospectively collected multicenter ASD database. Early (intraoperative and 6 weeks after surgery) complications were collected using standardized forms and onsite study coordinators. Results: Of 106 ASD patients treated with 3CO, 82 (77%; 68 PSO/14 VCR) had 2-year follow-up (76% women, mean age 61 years, previous fusion in 80%, and mean Charlson Comorbidity Index of 2.1). The mean number of posterior instrumented fusion levels was 13, and 17% also had an anterior fusion. A total of 101 early (43 minor/58 major) and 63 delayed (14 minor/49 major) complications were reported, with 53 (65%) and 44 (54%) patients affected, respectively. Overall, 67 (82%) patients had at least one complication. The most common complications were rod breakage (31%), excessive blood loss (>4 L, 29%), dural tear (21%), new radiculopathy (10%), new motor deficit (10%), proximal junctional kyphosis (PJK,10%) and pleural effusion (9%). The most common early complications were excessive blood loss and dural tear, and the most common delayed complication was rod breakage. 27 (33%) patients had from 1-11 re-operations (total of 44 re-operations). The most common indications for re-operation were rod breakage (n = 15), deep wound infection (n = 15) and PJK (n = 6). Notably, the early complication rate (50%, 9 minor/4major) and types of early and delayed complications reported among the 24 patients that did not achieve 2-year follow-up were similar to the 82 patients that achieved 2-year follow-up. Compared with patients that achieved 2-year follow-up, those lost to follow-up did not differ with regard to age, comorbidity index, number of fusion levels, or length of hospital stay (P > .18). Conclusions: Among 82 ASD patients treated with 3CO, 67 (81.7%) patients had at least one complication (57 minor/107 major). The most common complications were instrumentation failure, excessive blood loss (>4 L), neurologic deficit, and PJK. This study represents one of the most complete and detailed reports to date of early and delayed complications associated with surgical treatment for ASD that includes 3CO. These findings may prove useful for treatment planning, patient counseling, benchmarking of complication rates, and ongoing efforts to improve the safety and cost-effectiveness of patient care., Introduction: PJK is a well-known complication occurring in patients (pts) that undergo surgical ASD correction. Acute PJK (aPJK) occurs within the first six weeks, and chronic PJK (cPJK) more than 1 yr after surgery. Both PJK deformities can require surgical treatment. In this study, we aimed to first report the incidence of PJK, and contributing factors to either acute or chronic PJK. Materials and Methods: This is a retrospective review of prospectively collected database of consecutive ASD patients. Pts were included if they were >18y, ≥5 levels fused including the pelvis and 2y f/u. Using Glattes criteria, pts were stratified according to timing of PJK: aPJK 1y. Pts demographics, radiographic parameters, clinical outcomes (HRQL), operative data, complications and revisions rates were studied using univariate and multivariate analyses to identify independent predictors of aPJK. Results: 176 pts (61.8 yo) were included. 71 pts (40.3%) developed aPJK, and 39 pts (22%) cPJK. Both groups were similar in age, baseline deformity, and HRQL. aPJK pts were more likely to have Charlson score >2 (39.4% vs. 20.5%), depression (34% vs. 16.2%), greater # of co-morbidities (2.7 vs. 2.0), all P < .05. aPJK pts were more likely to have an abnormal neurologic exam (30% vs. 10.5%), and unable to perform toe-walking test (17% vs.0%), all P < .05. aPJK had higher revision rate (21 vs. 10.3%), peri-operative complication rate (14.1% vs. 0%) all P < .05. Both groups underwent similar amounts of sagittal correction, # of level fused, #/type of osteotomies, however, aPJK had more proximal LL apex restoration vs more caudal apex restoration in cPJK. aPJK occurred in 50/70 (71.4%) of posterior only approaches vs. 21/40 (52.5%) in combined approaches, P < .05. On multivariate analysis depression (OR: 2.99), and abnormal neurologic exam (OR: 4.15) increased the likelihood of aPJK. Conclusions: Compared to chronic PJK, Acute PJK pts have more co-morbidities, neurologic deficits, depression, and higher lumbar apex corrections with less caudal correction. In addition, aPJK pts had significantly higher peri-operative complication rates, and were more likely to be revised., Introduction: The reported incidence of complications after spine surgery varies widely, although many strategies have being developed to make this surgery safer, there is still a high rate of complications. The objective of this study is to determine the complication rates associated with surgical treatment of scoliosis and to assess variables associated with these complications. The literature to date was reviewed on risk factors for spine surgery and a risk stratification is proposed. Material and Methods: A retrospective review of hospital charts of patients with scoliosis who underwent surgical correction at a tertiary hospital between 2010-2014 was performed. Demographic variables, surgery characteristics and perioperative complications rates were assessed. Central tendency measures were made, a bivariate analysis and finally a logistic regression was performed. The literature to date was reviewed and a risk stratification was developed. Taking in to account the etiology, patient characteristics like age and weight, the radiological measurements, lab values and the patient past records, the potential risk for the major types of complications can be determined and therapeutic interventions are proposed to prevent them. Results: A total of 318 Cases fulfilled inclusion criteria. The most common etiology for scoliosis was idiopathic (47%) followed by neuromuscular (27%) and congenital (23%). The main rates of complications according to the bivariate analysis with the etiology are as follows: for neuromuscular scoliosis, pneumonia (23.8%), pleural effusion (15.87%) and urinary tract infection (6.34%); for idiopathic scoliosis was pneumonia (2,77%) and for congenital scoliosis was urinary tract infection (1.88%). All these results with a P < .05. A logistic regression was made and age was a significant risk factor to present complications. The risk stratification that was designed consist in a section subdivided by the major types of complications, the risk factors associated to each complication were listed as a checklist so that they can be compared with patient information. Based on these results the next section of therapeutic interventions can be interpreted to choose the proper action. Conclusions: The rates of complications after scoliosis correction surgery remain high; risk stratification assesses the particular risks of each patient to present specific complications and therapeutic interventions can be made in time to reduce complication rates. This risk stratification can also provide appropriate preoperative counseling on the risks and benefits of surgery., Introduction: Safety culture as a concept emerged from examining organizations that have been successful in minimization of adverse events in hazardous working conditions, such as the aviation. An adverse event is defined as “any unfavourable and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of a medical treatment or procedure that may or may not be considered related to the medical treatment or procedure. In medicine, safety culture is gaining more and more importance as an outcome to improve clinical practice. In 1999, for example, The Institute of Medicine published the report ‘To Err is Human’ which established that improving safety culture was as a crucial element in improving the quality of health care in the US. Organizational factors such as safety climate, work environment factors such as staffing, team factors such as teamwork, and staff factors such as overconfidence are factors influencing risk and safety in clinical practice. Purpose of this study is to evaluate these factors among spinal professionals worldwide. Material and Methods: An online survey was distributed to members of AOSpine International in 2016. The survey consisted out of three parts: (1) demographics of the respondents; (2) the Safety Attitude Questionnaire (SAQ) and (3) expectations of who is responsible for improving the safety culture. The SAQ measured the job satisfaction, teamwork climate, safety climate, the perceptions of management, stress recognition and the working conditions of the respondents. Multivariate logistic regression was performed to identify factors associated with safety attitudes. Results: A total of 356 respondents, majorly spine surgeons, responded. Gender, continent, occupation, tenure, and the amount of employees in the clinic were all not associated with the team climate, safety climate, stress recognition or management perceptions of the respondents (P > .05). Respondents in Africa have a significant lower score (OR: 0.19, P < .05) on working conditions, compared to spine professionals in Asia. Respondents in North America had the highest odds to have a significantly higher score (OR: 4.04, P < .05) than respondents in Asia. Overall, the majority expected the surgeon to be mainly responsible for improving the safety culture in the OR and at management level. Conclusion: Surgeons were expected to play a central role in improving the safety culture. The continent of the responders is a factor that may affect the safety attitudes among spinal professionals., Introduction: Dislodgement of a bone graft after anterior cervical corpectomy and fusion is one of the most severe complications which should be avoided because it may cause to compression of spinal cord. The purpose of this study is to clarify risk factors for graft dislodgement after cervical corpectomy and fusion. Material and Methods: Between April 2013 and May 2016, thirty seven patients (twenty three men; mean age, sixty four yr) who underwent anterior cervical corpectomy and fusion combined with corpectomy for two vertebra, grafting fibula and plating for cervical spondylotic myelopathy or ossification of posterior longitudinal ligament were investigated retrospectively. All patients put on cervical collar after surgery. Three type of graft position were defined as neutral postion: distance between posterior surface of vetebra and proximal edge of bone graft are similar to distance between posterior surface of vetebra and distal edge of bone graft, Z position: proximal edge of graft is located posteriorly to distal edge of bone graft, reverse Z position: distal edge of graft is located posteriorly to proximal edge of bone graft by measuring on lateral view of X-ray or on sagittal view of CT scan. Results: There were four cases of graft dislodgement (10.8%) which proximal edges of grafts were migrated posteriorly. Then three patients of them required halo vest without neurological symptoms progressed, one who complained progressive symptoms of myelopathy required posterior decompression and instrumentation as a revision surgery. Regarding graft position in patients without graft dislodgement, twelve cases showed neutral position, nineteen showed Z position, two showed reverse Z position, and all of four graft dislodgement cases showed Z position. Conclusion: We clarified risk factors for dislodgement of bone graft after anterior cervical corpectomy and fusion. Z position of bone graft is a possible risk factor of graft dislodgement., Introduction: Anterior cervical discectomy and fusion (ACDF) is one of the most commonly-performed surgical spine procedures, typically used to alleviate or halt progression of myeloradiculopathy. However, ACDF inherently decreases motion between the two fused vertebral segments, which has led to the advent of non-fusion techniques such as cervical disc replacement (CDR). Long-term analysis studies have shown that CDR is generally associated with either similar or lower complication rates than ACDF, including post-operative pain, adjacent segmental degeneration, segmental range of motion, and neurological degeneration. However, there is limited data on the short-term outcome of ACDF vs. CDR, particularly in terms of early reoperation or readmission rates. Thus, the purpose of this article is to compare 30-day readmissions and reoperations between patients who underwent single-level ACDF vs. CDR. Material and Methods: We used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2013 to 2014. Inclusion criteria were adult patients who underwent single level ACDF or CDR for cervical spondylosis. Primary outcome measures were 30-day readmissions and reoperations. Data analyses were performed in Stata SE 12. Logistic regression analysis was used to assess the independent effect of procedure (ACDF vs. CDR). Results: A total of 7019 patients met inclusion criteria; 6,468 patients (92.1%) underwent single-level ACDF and 551 patients (7.9%) underwent CDR. Readmission rates were 2.6% for ACDF versus 0.5% for CDR (P = .002). When stratified by age groups, only patients between the ages of 41 to 60 who underwent ACDF had significantly higher readmission rates when compared to CDR (2.5% vs. 0.6%, P = .037). Reoperation rates were 1.3% for ACDF and 0.5% for CDR (P = .130). After controlling for patient age, sex, BMI, smoking status, history of COPD, diabetes, hypertension, steroid use, and ASA class, patients who underwent CDR were significantly less likely to undergo a 30-day readmission compared to patients who underwent ACDF (OR 0.31; 95% CI, 0.09 – 0.98; P = .048). On the other hand, also after multivariate analysis, CDR was not associated with lower odds of reoperation (OR 0.72; 95% CI, 0.22 – 2.39; P = .603). Conclusion: Patients who underwent single-level ACDF had a higher readmission rate than single-level CDR due to related complications. When stratified by age, this was also seen only in the 41 to 60 years old age group. No significant difference in 30-day single-level ACDF or single-level CDR related reoperation rates were found., Introduction: Anterior cervical discectomy and fusion (ACDF) is considered a standard surgical treatment for cervical disc disease that is non-responsive to conservative treatments. ACDF provides decompression of the neural structures, segmental stabilization, restoration and maintenance of the normal lordotic curvature of the cervical spine.Despite the success of the ACDF procedure, long term outcome studies increasingly focused on multiple adverse effects in both short and long terms. Cervical fusion reduces motion at the fused segment resulting in increased motion and increased intradiscal pressure at adjacent levels with up to 25% of operated patients may develop recurrent radicular symptoms from adjacent level disease within 10 years of operation. Pseudarthrosis, dysphagia and complications associated with autologous graft site are other adverse outcomes reported as well.To overcome ACDF drawbacks, Cervical disc arthroplasty was designed to preserve motion at the desired segment thereby reducing mechanical changes at the adjacent segments, avoid limitations of fusion, and allow faster return to daily activities. Materials and Methods: A systematic literature review was done using electronic databases and reference lists of key articles searching for randomized controlled trials comparing cervical arthroplasty versus ACDF. The inclusion criteria were prospective, randomized controlled trials comparing arthroplasty and fusion with minimum follow up of 2 years. The exclusion criteria were studies that didn’t have a prospective, randomized controlled design, those with follow up time less than 2 years, retrospective studies, and case series. Studies were evaluated for level of bias. Results: Twenty three randomized controlled trials were identified that met the inclusion criteria. With a minimum follow up period of 2 years and maximum follow up period of 7 years. Patient reported clinical outcomes were assessed using the Neck Disability index (NDI), Visual Analog Scale (VAS) of neck and arm pain, short form 36 (SF-36). Overall success, implant-related complications, secondary surgeries, and return to work were compared as well.At short term follow up, cervical arthroplasty wasn’t inferior to ACDF at all postoperative measures. However, at long term follow up, cervical arthroplasty had better overall success, better NDI score, lower VAS of neck and arm pain, better range of motion at the operated level, fewer secondary surgical procedures, and faster return to work. Some of the differences were not statistically significant. Conclusion: ACDF is considered a standard surgical treatment for cervical disc disease. It has some drawbacks, like increased motion and increased intradiscal pressure at adjacent levels, leading to a higher rate of adjacent segments degeneration.Our review suggests that cervical arthroplasty is a safe and effective method for treating cervical disc disease and is a viable alternative to ACDF with at least equivalent (2 years follow up) or even better clinical outcome (>4 years follow up). Cervical arthroplasty patients have superior spine kinematics at the operative and adjacent levels, theoretically minimizing adjacent level disease.Although the majority of cervical arthroplasty patients had a clinically significant overall success, some studies showed similar outcomes.Future studies are necessary before strong recommendations can be made to prove that this technology supersedes ACDF., Introduction: Anterior cervical discectomy and fusion (ACDF) results in loss of mobility at the index segment and creates increased stress on adjacent segments, resulting more rapid disc degenerations. Symptomatic adjacent segment disease (ASD) occurs in 25% of patients, within 10 years after the initial ACDF surgery. Multi-level fusion leads to a substantially greater increase in intradiscal pressure than single level surgery. As a promising alternative, artificial disc replacement (ADR) has emerged and it has been demonstrated that ADR can maintains motion at the index level and decreases strain on the adjacent segments for prevention of ASD. The optimal surgical technique for 3-level cervical disc disease (CDD) remains uncertain. Hybrid surgery, consisting of ADR combined with ACDF, has been reported with favorable results for 2-level cervical disease. In this context, hybrid surgery (2-level ACDF/ADR) for 3-level CDD may be a reasonable alternative to multi-level ACDF to prevent symptomatic ASD. The objective of this study was to compare clinical and radiologic outcomes of 3-level ACDF and hybrid surgery in terms of postoperative adjacent segment degenerations. Material and Methods: Between May 2008 and September 2012, 18 patients with 3 consecutive levels CDD between C3/4 and C6/7 who underwent hybrid surgery were retrospectively reviewed. Study group were matched paired to 18 patients of 3-level ACDF group based on age, gender and the operated levels. All patients were followed clinically and radiologically for a minimum of 24 months. All operations were conducted with two surgeons with the same surgical protocols. For ACDF surgery, allograft spacers were inserted and anterior cervical plate was placed over the entire fused segments. In hybrid group, ADR was performed in the segment that had less degenerative changes and had greater physiologic motion (C5–C6 > C4–C5 > C6–C7 > C3–C4). Either Prodisc-C or Prestige artificial disc was implanted according to the surgeon’s preferences. Retrospective analysis of perioperative parameters included factors such as operative time, fluoroscopic time, postoperative opioid use, blood loss, length of hospital stay, surgical drainage, transfusion and complications. Neck Disability Index (NDI) and visual analogue scale (VAS) scores for neck and arm pain were obtained before surgery, 1, 3, 6, 12 and 24 months after surgery for each group. Radiological analysis was conducted via lateral radiographs in flexion, extension, and in neutral position before surgery and routine postoperative intervals. Radiological measurements including angular range of motion (ROM) of C2–C7 and adjacent segments and cervical lordosis were measured using the Cobb method with PACS software. The radiological evidence of adjacent level changes including new osteophyte formation, narrowing of disc space, end-plate sclerosis and anterior longitudinal ligament (ALL) calcification was assessed. Results: The demographic and perioperative data showed no statistical differences between 2 groups. Both groups showed significant improvement in NDI and VAS scores postoperatively and continued improvements were observed in both groups until 2 years. Although no significant differences in NDI scores existed between 2 groups at 3 and 6 month postoperatively (P = .333,.055 respectively), hybrid group experiences a trend towards better results at 12 and 24 months (P = .001, .018 respectively). VAS scores for postoperative neck pain were significantly less in the hybrid group at 6 and 12 months (4.7 ± 1.6 vs 3.3 ± 1.3; P = .018, 3.5 ± 1.6 vs 2.3 ± 1.7; P = .045 respectively), but there was no differences at the final follow-up (2.5 ± 1.6 vs 2.2 ± 1.9; P = .110). There was no difference in arm pain relief between the groups. Both group exhibited decreased C2-C7 ROM when compared with preoperative values. The cervical motion was significantly limited immediately after surgery and then gradually recovered. The hybrid group showed greater C2-C7 ROM recovery compared to ACDF group at the final follow-up (36.3 ± 7.9° vs 29.5 ± 7.4°; P = .034). Although, superior adjacent segment ROM for ACDF group was significantly increased from 12 month after the surgery, the hybrid group remained hypo-mobile during the follow-up periods. The ACDF group exhibited hyper-mobility at inferior adjacent segment ROM from 6 month after the surgery; however, the hybrid group showed no difference during the follow-up periods except final follow-up. Significantly increased ROM at inferior adjacent segments was observed in both groups compared with preoperative values at the final follow-up, but the compensatory ROM was less in hybrid group. Significant recovery of cervical lordosis was observed in both group compared with preoperative values (P = .004, P = .009 respectively). But no statistical difference was found between two groups (P = .937). Adjacent disc space narrowing was observed equally in both groups. New osteophyte formations were found only in ACDF groups (11%. 2/18). Other degenerative changes were not observed in both groups. One patient with dysphagia and one with hoarseness were found in each group. In Hybrid group, 1 patient underwent emergency re-operation for epidural hematoma. Heterotopic ossification was found among 11.1% (2 out of 18) of patients in hybrid group. No other complications such as implant failure, infection or C5 palsy was developed in both groups. Conclusion: In this study, hybrid surgery consisting of 2-level ACDF and ADR was shown to be safe and effective for 3-level CDD. Compared with ACDF, the hybrid surgery exhibited better neck pain improvement, C2-C7 ROM and less impact at adjacent level. The hybrid surgery may be a promising alternative to fusion surgery for 3-level CDD. Longer-term follow-up is warranted., Background: Despite being the gold standard treatment for cervical disc herniation, ACDF may be considered a non-physiological procedure as it results in loss of segmental motion and induces biomechanical changes at adjacent disc levels. The purpose of this study is to investigate the effect of cervical arthroplasty on cervical spine disc center of rotation and range of motion at instrumented and adjacent levels. Material and Methods: Thirty-one patients were submitted to one or more cervical arthroplasties with M6. Radiological parameters were measured preoperatively and postoperatively at 6 months, and 1-year FU. Ranges of motion (ROM), global and segmental, and center of rotations (CORs) at instrumented and adjacent levels were analyzed using specific validated motion analysis software (SpineView 2.4). Results: Thirty-one patients with a mean age of 51.7 (range 35-69) were implanted with forty-six M6 cervical disc prosthesis. Mean FU is 12 months. Fourteen were pure M6 cases, whereas seventeen were hybrid constructs adding fusion to M6. In single level cervical disc prosthesis, CORs at index level tend to locate superior and posterior at 6-months post-operatively normalizing at 1-year. Measuring the distance to an elliptic distribution of normalized asymptomatic confirms the same tendency, from 7% to the ellipse pre-OP to 12% at 6-month (P < .05), and 6% at 12-year (P > .05). Minimal changes at adjacent levels CORs were observed in different time-points. At instrumented level, the mean X-COR was pre- operatively calculated to 34.8% versus 30.2% at 6-months and 33.4% at 1-year (P > .05); the mean Y-COR was preoperatively calculated to -23.5% versus -2% at 6.months (P < .05), and −31.6% at 1-year (P > .05). At index level, an increase of ROM from a mean pre-OP of 6° (4-7°) to 11° (6-15°) at 6-months, and 14° (16-12°) at 1-year was observed (P < .05), with a non significant decrease at inferior adjacent level ROM from a mean of 7° to 5° and no change at superior adjacent level (mean 11 to 12°) (P > .05). Implanting a single level cervical disc prosthesis did improve without statistical significance the global range of motion (C2-C7) from 40 to 45°, at pre-OP to 1-year post-OP, respectively (P > .05). When inserted adjacent to a fusion, M6 arthroplasty tended to normalized the CORs of the index level at 6 months, without affecting the location of CORs of the superior natural level. The ROM remained unchanged both at index and superior adjacent level at 1-year. The decrease at 12months of global ROM (mean 46 to 47°) equals the decrease of ROM at the fusion level (P > .05). These changes are observed whether M6 is implanted above or below a fusion. In multilevel M6, index levels ROM changes from a mean of 9° to 11° and from 11° to 9° with minimal decrease in ROM at natural superior level (12° to 11ª) (P > .05). Conclusions: M6 tends to considerably restore qualitative kinematics in the cervical spine at the index level at 1-year, with minimal changes at adjacent levels. Restoring mobility and CORs at index level and at adjacent levels may elude hypermobility and biomechanical stresses at adjacent levels. The extent of motion was preserved along with quality of motion., Introduction: Cervical radiculopathy and myelopathy are common pathologies in adult patients and have been shown to cause significant disability. Surgical options include posterior decompression and fusion, anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA). To date, ACDF is the most accepted treatment with a satisfactory clinical outcome. Such a procedure is highly effective in terms of resolving symptoms, improving nerve function, and restoring the physiological curvature of the cervical spine. It has been pointed out that fusion may result in acceleration of adjacent segment degeneration (ASD). In this scenario, CDA has been proven to be beneficial in terms of preserving motion of the cervical spine and possibly reducing ASD. Controversy exists as to the ideal surgical techniques that could benefit patients with multilevel cervical disc diseases (MLDDD). Hybrid surgery (HS) that incorporates ACDF and CDA at different levels can be considered a possible option since it combines the advantages of both techniques in terms of vertebral stability and spine motion preservation. Methods: This prospective study enrolled patients with MLCDDD who underwent HS. Thirty consecutive patients who underwent HS were compared with patients who underwent ACDF and CDA at the same level of surgery. Patients were followed up for more than 3 years. Intraoperative parameters, clinical features and outcome scores were recorded. Radiological assessments included overall range of motion (ROM), disc height (DHI), and changes in adjacent disc spaces. Results: Duration of surgery was significantly shorter for ACDF compared with HS and CDA (P < .05). The VAS, SF-36, JOA, and NDI scores improved significantly after surgery in all the patients without significant differences among the groups. Cervical ROM increased significantly in CDA and HS groups as compared with ACDF-treated patients (P < .05). The mean DHI at the treated level was significantly restored after surgery in all the groups. The HS group returned to work faster (28 days) when compared with both ACDF (59 days) and CDA (63 days) (P < .05). Conclusions: The findings provided suggest that hybrid construct is a safe and effective surgical strategy for decompression in patients with multilevel cervical disc diseases. Studies with larger sample sizes and longer follow-up periods are required to confirm the results of the present study., Introduction: Arthrodesis is the established gold standard for the surgical treatment ofrefractory low back pain due to lumbar degenerative disc disease. 32 years ago it resurfaces treatment by lumbar arthroplasty SB Charite, showing that non-fusion allows closer to the physiology of the disc treatment and reducing complications. Current technological development has enabled a better design and evolution of lumbar arthroplasty. Material and Methods: Retrospective longitudinal study were included 80 patients who had low back pain with or without radicular component and met the radiographic criteria including the loss of disc height, low intensity RM-T2, changes cymbals and disc protrusion. All patients underwent arthroplasty ProDisc or Activ between 2000 and 2008. The age was between 23 and 56 years. They were evaluated before and after surgery at 3, 6, 12 and 24 months. Demographics and clinical parameters were collected if it had only low back pain or lumbar pain associated with radicular component, values disability index Oswestry (ODI and analog-visual scale (VAS), level of patient satisfaction, the success criteria and radiographic analysis of disc height, range motion of the operated segment. Security also proceed analyzing complications was evaluated. Results: 18 men and 62 women. Average age of 38 years. Thirteen patients (16%) had been previously operated via posterior discectomy technique on the same site. They were treated as follow: L5-S1 level 60 patients (75%), L4-L5 level19 patients (23.7%) and one patient L3-L4 level (1.3%). ODI was compared between preoperatively and 24 months postoperatively, noting an average reduction of 53.86%. The average reduction for VAS back pain in the period of 24 months compared to the preoperative was 63.83% and a low back pain with radicular component also fell by 60.20%. These changes were statistically significant (P ≤ .05). Levels of patient satisfaction: 82% completely satisfied and satisfied 18% of patients. After surgery disc height was increased to an average of 12 mm (P < .001). The movement in the affected segment increased from 4 degrees to 7 degrees on average after surgery (P < .004). There were no cases of displacement, dislocation, migration or component failure of the prosthesis. Complications related to the approach presented in 11 patients, accounting for 13.75%. Conclusion: Arthroplasty is recommended on one segment as an effective treatment so much safe for patients with degenerative disc disease who meet the inclusion criteria: both low back pain alone or low back pain with radicular component. The benefits were significant and were maintained through 24 months after total disc replacement. There seems to be differences in outcomes among patients with previous surgery and without this, nor among patients with chronic low back pain and those with associated radicular component. The two prostheses used L4-L5 vs L5-S1 level is not influenced the results. No complications related to the implanted device is presented. The careful and proper patient selection is essential in planning an optimal surgical outcome, Introduction: To illustrate 10 years experience andclinical follow-up data of 70 Italian patients treated with BRYAN cervical spine system for degenerative disc disease. To prospectively assess the intermediate and long-term radiographic characteristics of disk replacement surgery with the Bryan Cervical Disc and to correlate these results with clinical outcome. Materials and Methods: A cross-sectional retrospective study was designed. We studied NRS and NDI using a “Do It Yourself” web-survey method. Time-points were pre-operative and 6 months, 2, 5, 10 years post-operative. Results: 70 patients were included in this retrospective study. Pre-operative NRS and NDI mean values were 6.34 ± 1.44 and 40.74 ± 9.03%. 6 months post-operative were 2.16 ± 1.37 and 16.17 ± 10.24%. 2 years post-operative were 2.16 ± 1.37 and 16.17 ± 10.24%. 5 years post-operative were 2.07 ± 1.34 and 15.66 ± 11.08%. 10 years post-operative were 1.87 ± 1.49 and 14.50 ± 11.44%. Pre-operative NRS and NDI mean values were lower than 2 years post-operative values (P < .0001) using U test of Mann-Whitney. There was no stastistically difference of NRS and NDI mean values between all other time points. Conclusion: The majority of patients had excellent clinical outcome. After 2 years post-operative there is no statistical increase in clinical outcome and it is highly prognostic of long-term results., Introduction: The position of cervical disk arthroplasty (CDA) in spinal practice is controversial. This is probably due to the lack of studies with a large sample sizes and long-term outcomes. Therefore we aimed to evaluate the opinions of spine surgeons towards the use of CDA in the current treatment of cervical disk herniation (CDH). Material and Methods: A web-based survey was sent to all the members of AOSpine International by email using Survey Monkey on July 18, 2016. A single reminder was sent on August 18, 2016. Questions included geographic location, specialty, associated practice site, amount of operations performed annually and the use and expectations of three frequently applied surgical techniques. Results: A total of 387 surgeons responded. Almost all (97.9%) of the responders were male with a mean of 15.0 ± 9.7 years of clinical experience. The majority of our responders were orthopedic surgeons (54.6%). 84.3% of our responders use ACDF as the standard operation technique for treatment of CDH. Only 7.3% performs CDA as standard approach, whereas 47.8% surgeons perform CDA at all. The most common arthroplasty device used is the Pro-Disc C. Low evidence for benefits and costs were the most important reasons for not offering CDA. The risk of adjacent level disease was considered smaller for CDA as compared to ACDF. The biggest disadvantage was the costs of CDA. Conclusion: In this survey, CDA is not considered to be the treatment of choice for CDH, but is claimed to reduce the risk of adjacent level disease. Lack of enough evidence on the effectiveness and higher costs were disadvantages and considered reasons for not offering CDA., Study Design: Prospective observational cohort study. Objective: To determine the long-term clinical results and prosthesis survival in patients treated with lumbar total disc replacement (TDR). Summary of Background Data: Fusion has become the current standard surgical treatment for lumbar degenerative disease. TDR is an alternative treatment that seeks to avoid fusion-related adverse events, specifically adjacent segment disease. Methods: Sixty-eight consecutive patients treated with TDR from 2003-2008 were invited to follow-up and complete a Visual Analog Scale (VAS) for back and leg pain, the Dallas Pain Questionnaire (DPQ) and the Short Form-36. These surveys were also administered to the subjects prior to their index TDRs. Data on re-operation were collected from the patients’ medical records. Results: Fifty-seven (84%) patients were available for follow-up at a mean 10.6 years post-operative (range, 8.1-12.6 years). There was a significant improvement from pre-op to latest follow-up in VAS (6.8 vs 3.2, P < .000) and DPQ (63.2 vs 45.6, P = .000) in the entire cohort. Nineteen patients (33%) had a revision fusion surgery after their index TDR. Patients who had a revision surgery and statistically significant worse outcome scores at last follow-up compared to patients who had no revision. Thirty patients (52.6%) would choose the same treatment again if they were faced with the same problem. Conclusion: This study demonstrated significant improvement in long-term clinical outcomes, similar to previously published studies, and 2/3 of the discus prostheses were still functioning at follow-up. However, there is still a lack of well-designed long-term studies, thus requiring further investigation., Introduction: Conventional spinal sagittal deformity correction procedures involve significant risk, morbidity and cost. An osteotomy site at the level of the pelvis may provide a viable alternative. Theoretically, the more distal osteotomy site produces a longer lever arm to correct sagittal vertical axis (SVA). This study investigated the relationship between pelvic osteotomy opening angle (OA) and effect on spinopelvic sagittal parameters using a mathematical predictive model. Materials and Methods: Virtual BPO (anterior inferior iliac spine to the sciatic notch) was created on full-length lateral x-ray of a sagittally deformed spine. Predictive equations correlating OA with spinopelvic parameters were derived using geometric relationships. Fixed spinal curvature was assumed. Image was rotated to reduce pelvic tilt (PT) to 10° and neutralize its compensatory effect. A geometric model (MATLAB) calculated spinopelvic parameters (SVA, pelvic incidence [PI], PT and T1 pelvic angle [TPA]) produced by progressively increasing the OA. These values were compared to optimal balance criteria in the literature. Results: Osteotomy OA correlated negatively with PI, TPA and SVA, and positively with PT. From baseline SVA of 22 cm, OA 21° reduced SVA to 5 cm. OA 23° reduced TPA to 14°. OA 30° increased PT to 20°. OA 26° decreased PI-LL to 10°. Thus, OA range of 26°-30° resulted in optimal sagittal deformity correction. Within this range, PI decreased 19°-21° from baseline. Conclusions: Predictive relationships between pelvic osteotomy OA and spinopelvic parameters were shown, thus providing proof of concept that sagittal balance may be achieved via pelvic osteotomy. Demonstrating negative correlation between OA and PI refutes conventional notion that PI is a fixed parameter. In patients with fixed lumbar lordosis (LL), correction may be achieved by decreasing PI to match LL. Since baseline abnormal PT causes partial SVA correction, rotation of the image during planning for BPO is necessary to neutralize the compensatory PT and unmask the true extent of deformity., Introduction: Ankylosing spondylitis (AS) is a seronegative spondyloarthritis that can severely alter the normal spinal sagittal balance resulting in functional and social disability. Although the traditional open corrective surgeries have provided radiographic correction, they are associated with relatively high morbidity and mortality. Therefore, a new less invasive technique has been developed in an attempt to achieve both radiographic and clinical improvement while minimizing the possible surgical risks of conventional open approaches. The aim of this study is to describe and evaluate this innovative technique for management of thoraco-lumbar sagittal imbalance (TLSI) in AS. Material and Methods: Fifty-one patients (43 males and 8 females) with TLSI due to AS, who underwent 360 degree deformity correction through this technique in our hospital between 2008 and 2013 with a minimum of 2-year follow-up were retrospectively analyzed and included in the study. The main steps of the technique are: (1) Posterior percutaneous spinal instrumentation (2) Posterior mini-open microscopic-assisted osteotomy. (3) Anterior thoracoscopically- and / or retroperitoneoscopically-assisted osteotomy and reconstruction. All steps are done in the same prone position. Sagittal vertical axis (SVA), T1 pelvic angle (TPA), osteotomy angle (OA), angle of fusion levels (AFL) and chin-brow vertical angle (CBVA) were used to evaluate radiographic outcomes and degree of correction. Clinical outcomes were assessed by Oswestry Disability Index (ODI) and visual analogue scale (VAS). Results: The patients had a mean age at operation of 49.02 years. The mean total operative time was 419.31 ± 100.23 minutes (163.53 ± 52.51 minutes for anterior procedures and 253.75 ± 69.32 minutes for posterior procedures) while the intraoperative blood loss ranged from 50 to 2100 ml with a mean of 698.24 ml. In one third of the patients, two or even three osteotomies were performed. SVA, TPA and CBVA showed a statistically significant improvement after surgery (P < .0001). The mean correction was 28.93 ± 8.02° for patients with single osteotomy and 46.58 ± 13.16° for patients with more than one osteotomy, while the mean loss of correction was 1.05 ± 1.70°. In the present study, not only the mean ODI improved significantly from 48.67 ± 7.86 preoperatively to 19.25 ± 10.22 at the latest follow up (P < .0001), but also 94% of the patients showed >30% improvement from the baseline ODI. Moreover, the changes in ODI were significantly related to the changes in SVA, TPA, AFL, OA, and CBVA. Dural tear and transient radiculopathy were the most common reported complications. Conclusions: The idea behind the implementation of minimally invasive technologies in the correction of AS deformity is not to reduce muscle damage in an already damaged non-functioning muscle but to minimize the extent of surgical trauma to an already vulnerable patient with several medical comorbidities. The ability to perform 360 degree deformity correction through a less invasive anterior and posterior approaches has significantly reduced blood loss and facilitated post-operative course and in the same time provided a well maintained correction with satisfactory clinical outcomes. We believe that this novel technique, although technically demanding, dose offer a safe and effective alternative for traditional open surgery in managing TLSI due to AS., Introduction: Pseudarthrosis is a common complication following spine fusions in ASD and has a major impact on patient morbidity. Both surgical strategy, such as the use of interbody fusion (IBF) and choice of biologics (BMP-2, iliac crest bone graft, bone marrow aspirate, etc), and patient characteristics (age, smoking status, osteoporosis) have been associated with pseudarthrosis rate in previous studies. Material and Methods: Four surgeons determined fusion grades at 2 yrs postoperatively for all patients in a prospective, multi-center, ASD database. All patients who exhibited pseudarthrosis posteriorly or, if anterior IBF performed, both posteriorly and anteriorly were considered pseudarthrosis. IBF, type of biologic, osteoporosis, age, smoking status, and frailty, assessed using the ASD Frailty Index (ASD-FI) and split into three cohorts (not frail NF, frail F, and severely frail SF), were analyzed for association with fusion rate. Results: In a multivariate regression model of frailty and various preoperative and operative characteristics, odds of pseudarthrosis in F was 2.8 [1.1-7.0] (P < .05) and in SF was 3.4 [1.0-11.2] (P < .05) times less than for NF patients. Patients who had IBF had a much lower risk of pseudarthrosis (OR 0.17 [0.08-0.39] P < .001), those who had BMP-2 also had a lower risk (OR 0.39 [0.19-0.79] P < .05), and female patients had a higher risk (OR 4.5 [1.2-17.7] P < .05). On univariate analysis, smoking status had an increased risk of pseudarthrosis (OR 1.9), however it was not significant. Osteoporosis had a decreased risk (OR 0.77), which was also not significant. Pseudarthrosis rate with only autologous biologics was 25.8% whereas the rate with bmp-2 was 12.1% (Pearson’s chi2 = 9.1, P < .01). Increasing age had a decreased risk of pseudarthrosis (by decade OR 0.72 [0.61-0.87] P < .001), which was no longer significant on multivariate analysis controlling for surgical parameters. Conclusion: Surgical factors (IBF and BMP-2 usage) had the greatest protective impact on pseudarthrosis rate. While osteoporosis and increasing age were also shown to have a protective impact on univariate analysis, these were likely confounded by surgical parameters. This was supported by the lack of significance on multivariate analysis. Frailty, as measured by the ASD-FI, was the strongest predictor of pseudarthrosis, followed by smoking status. While patient factors such as frailty, osteoporosis, and smoking status, have an impact on pseudarthrosis rates, surgical factors can mostly mitigate this effect., Introduction: The purpose of our research is to study the incidence of distal adjacent segment disease (DASD) and to evaluate the health-related quality of life (HRQOL) parameters after long fusion with or without pelvis fixation including L5-S1. Material and Methods: A retrospective study was held on 75 patients with thoracolumbar spine deformation operated from 2009 to 2011. Inclusion criteria were the following: age 44-60 years, adolescent idiopathic scoliosis (AIS), normal L5-S1 (Pfirrmann grade 1-2) and satisfactory global spine alignments after operation. Patients were divided into two groups according to preoperative difference in sagittal and coronal spinopelvic parameters. The first group included 39 patients who underwent long fusion from upper thoracic spine (T3-4) to the pelvis. The second group consisted of 36 patients, who were treated using long fusion from upper thoracic spine to L5 without pelvic fixation. Groups were evaluated with HRQOL-scales including VAS, SF36 and SRS-24. Radiographical assessment included Cobb coronal angle, thoracic kyphosis, lumbar lordosis, sagittal vertical axis, central sacral vertical line. Radiographical, HRQOL-parameters and complications with a 3-year minimum follow-up were analyzed and compared between two groups. The comparisons were done using independent sample Student t-test. A p-value of less than 0.05 was Results: In both groups satisfactory global spine alignments were achieved. After 3 years significant difference was not found (P > .05). In early postoperative period the HRQOL-scores (VAS, SF36, SRS-24) of the patients were slightly higher in the first group, but we did not get statistical difference between groups (P > .05). In the first group no cases of DADS occurred after 3 months. The second group showed a higher number of DASD (n = 8, 22%). Finally, after 3 years the second group had significantly worse results (P < .05) of HRQOL-scores and numbers of DASD (n = 14, 39%). Conclusion: Despite good condition of L5-S1 before operation in both groups, after 3 years follow-up long fusion with extending to the pelvis provided better outcome than long fusion with extending only to L5., Introduction: Three-column osteotomy (3CO) for complex spinal deformity is a technique that involves bony resection of the anterior, middle, and posterior columns of the spine with associated reconstruction in an effort to restore spinal alignment. In recent years, the rate of utilization of 3CO has significantly increased, with a reported 3.2-fold increase in the use of PSO between 2008 and 2011 alone. The purpose of this study is to report the 30-day readmission and reoperation rate after 3CO for complex spinal deformity using a large multicenter prospective database, and identify risk factors for these occurrences. Material and Methods: The prospectively-collected American College of Surgeons National Surgical Quality Improvement Program database (2012 – 2014) was reviewed. Inclusion criteria were adult patients who underwent 3CO. The rate of 30-day readmission/reoperation was examined, and the association between patient/operative characteristics and outcome was investigated via univariate analysis. Readmissions were categorized as related or unrelated to the primary procedure. Results: There were 299 patients who underwent a 3CO for spinal deformity. The rate of 30-day readmission and reoperation was 11.0% and 8.4%, respectively; 7.7% of readmissions were related to the primary procedure and 3.3% were unrelated. The most common unique cause for readmission was wound infection in 27.2% of cases. Among reoperations, the most common unique indications were wound infection (20.0%) and implant-related complications (20.0%). Patients who experienced a readmission were significantly more likely to be obese (60.6% vs. 37.6%, P = .011) and have a history of chronic obstructive pulmonary disease (COPD; 18.2% vs. 4.1%, P = .001). Likewise, patients who needed reoperation were more likely to have COPD (16.0% vs. 4.7%, P = .020) and a history of chronic steroid use (20.0% vs. 5.8%, P = .008). Interestingly, revision procedures, multilevel 3CO, or number of levels fused was not associated with readmission nor reoperation. Conclusion: Wound complications and short-term implant-related complications are important causes of readmission and/or reoperation after 3CO. Preoperative factors such as obesity, chronic lung disease, and chronic steroid use may significantly increase the risk of 30-day morbidity following these procedures., Introduction: Minimally invasive surgery (MIS) is becoming an alternative tool in the treatment of adult spinal deformity (ASD) with the aim to reduce perioperative complications due to surgical access morbidity. However, when you have to treat a moderate or severe deformity, MIS techniques cannot often be employed alone. Hybrid surgical approach refers to the MIS techniques associated with traditional posterior open surgery that includes segmental instrumentation, decompression and/or osteotomies. Material and Methods: We performed a prospective study analyzing data collected from 27 patients (21 women and 6 men, mean age 66 years) underwent hybrid surgical approach, involving minimally invasive lateral interbody fusion and supplementary posterior open approach by performing various degrees of segmental decompression, posterior column osteotomies and instrumented fusion. The inclusion criteria were: age >45 years; lumbar spine deformity with at least one parameter among coronal Cobb angle >20°, pelvic tilt (PT) > 25°, mismatch between pelvic incidence (PI) and lumbar lordosis (LL) greater than 10°, sagittal vertical axis (SVA) > 60 mm; Oswestry Disability Index (ODI) greater than 20 (moderate disability or more). Clinical outcomes were assessed by using ODI and visual analog score (VAS) for back and leg pain while radiographic measurements included coronal cobb, LL, PT, PI-LL mismatch, SVA and disc angle (DA) at each level of cage application, evaluated preoperatively, 6 month and 1 year postoperatively. Mean operative time (OT), estimated blood loss (EBL) and any complications were reported. Results: Strumented levels were in mean 6 for patient (range 4-10), with a total number of 49 cages implanted through the lateral trans-psoas approach. The mean cages for patient were 1,8 (1-3). At 1-year follow-up, the patients achieved statistically significant mean improvement in VAS back pain (from 7.9 to 4.7, P < .01), VAS leg pain (from 5.8 to 2.8, P < .01), ODI (from 49 to 26, P < .01). Mean radiographic data changed as follow: coronal cobb from 33.1° to 7.9° (P < .01), LL from 32,7° pre-op to 49,6° post-op (P < .01), PT from 23,8° to 20,2°, PI-LL mismatch from 15.8° to 4.6° (P < .01), SVA from 53.8 mm to 33.1 mm (P < .01). DA at each level of cage application changed from −0.5° to −6.2° at last follow-up (P < .01). Mean operative time was 370 min (range 190 – 440) and EBL was 1220 ml (range 600 – 1750). There were 1 major (postoperative proximal junctional kyphosis) and 9 minor complications. Conclusion: Minimally-invasive lateral lumbar interbody fusion combined with posterior open approach is an effective method to achieve a good correction of the radiographic parameters improving quality of life in patients with adult lumbar deformity., Introduction: There exists a growing literature to support aggressive surgical corrections including osteotomies to correct sagittal malalignment in adult spinal deformities. However, there is a dearth of literature to guide the extent of contribution of forward stoop or sagittal malalignment secondary to physical compression on neural structures per se. The present study was aimed at carrying out a prospective cohort study to assess the impact of lumbar surgical decompression without fusion on sagittal profile. Materials and Methods: Consecutive patients undergoing lumbar decompression surgeries for symptomatic spinal canal stenosis and/ or disk herniations at a single center during the time period from May 2014-May 2015 were included in the study. Patients with unequivocal evidence of instability and revision surgeries were excluded. All patients had detailed clinical and radiological evaluation prior to the surgery and three months following the surgery. Radiological evaluation included standard anteroposterior view, lateral views in flexion and extension and whole-length spine radiographs in the standing position. Radiological parameters studied were segmental lordosis over the operated motion segments [SL], global lumbar lordosis [GL], sacral slope [SS], sagittal vertical axis [SVA] and disk heights at involved levels. Disk heights were measured using distortion compensated roentgen analysis [DCRA]. Involved levels were considered to have a collapsed disk if the height was less than 50% of the cranial adjacent healthy segment. Clinical outcome was assessed using Macnab’s criteria. Results: Sixty-three patients with mean age 47.33 + 15.06 years included [21 males and 42 females]. Decompression was carried out at one, two and three levels in n = 45, 15 and 3 patients, respectively. SL improved from 15.33 + 12.23° to 17.82 + 11.54° [two-tailed P = .0009, paired t-test]. GL improved from median 53° [-19° to 66°] to 56° [1° to 74°] [two-tailed P < .0001, Wilcoxon matched-pairs test]. SS improved from 33.43 + 11.23° to 36.21 + 11.42° [two-tailed P = .01, paired t-test]. SVA improved from +3.92 + 68.64 mm to -15.88 + 44.32 mm [two-tailed P = .01, paired t-test]. Subset analysis was done in patients with and without disk collapse. SL, GL and SS showed a statistically higher improvement in patients without disk collapse [0.05°, 1.34° and 0.37° improvement in SL, GL and SS in patients with disk collapse vis-à-vis 3°, 7.73° and 3.82°, respectively] [two-tailed P = .002, .002 and .01, respectively]. Though SVA too, had a higher improvement in patients without disk collapse [23.48 + 37.08 mm] as compared to those with disk collapse [10.63 + 15.15 mm], it did not approach statistical significance [two-tailed P = .46, Mann-Whitney test]. Barring one patient with a fair result, all others had an excellent/good outcome on Macnab’s criteria. There was no statistically significant correlation noted between clinical and radiological outcomes. No correlation was found between the number of levels operated upon and radiological outcomes. Conclusions: Lumbar decompression surgery without fusion too, can lead to improvement in sagittal profile. This improvement is muted though, in patients with disk collapse. Though preliminary, this data can be helpful in templating decisions in adult spinal deformities., Introduction: Over the last decade, XLIF has been also used to improve coronal curves by its ability to generate high corrective symmetrical forces due to lateral, deep insertion of large interbody cages. The recommended procedure, based on anatomical observations provides for access from the concave side of the curve. Material and Methods: We enrolled 25 adult scoliosis with Cobb angle > 30°. All XLIFs from T11 to L5 was performed by a convex side approach. Complications were compared with those reported in the pertinent literature. Results: We observed no major vascular, intestinal or ureteral injuries. Our complications were: 2 pleural lacerations; 1 hematoma; 4 transient weaknesses; 1 permanent genito-femoral damage; 1 deep vein thrombosis. These complications did not differ significantly (Chi square [0.05]) with those reported in the literature or were less severe. The coronal correction was on average 10.8 (8-18), with no significant differences between 3 or 4 cages (P = .061). Conclusion: Reasons that support XLIF from the concave side of spine deformities are questionable. In our experience, approach from the convex side did not result in serious complications: moreover, they may appeared fewer and less severe. When the curve is more than 30°, surgical technique may be more simple and quick, because the apical rotated vertebra is more posterior and extremely superficial in the convex side. By a transverse skin incision of 3-4 cm, centered on the VB, 2 disks can be removed. Psoas manipulation, actions on the contralateral annulus and osteophyte, foraminal decompression and deformity correction are similar to those described for the concave approach., Introduction: Giant cell tumor of the spine is a rare primary bone tumor known for its local aggressiveness. Optimal surgical treatment remains to be determined. This is a multicenter, ambispective observational study with the objective to quantify local recurrence and mortality rates after surgical treatment of spinal giant cell tumor and to determine whether en bloc resection with wide/marginal margins is associated with improved prognosis compared to an intra-lesional procedure. Material and Methods: The AOSpine Knowledge Forum Tumor developed a comprehensive multicenter database including demographics, presentation, diagnosis, treatment, mortality, and recurrence rate data for giant cell tumor of the spine. Patients were analysed based on surgical margins, including Enneking appropriateness. Results: Between 1991 and 2011, 82 patients underwent surgery for spinal giant cell tumor. According to Enneking classification, 59 tumors (74%) were classified as S3-aggressive and 21 as S2-active (26%). The surgical margins were wide/ marginal in 27 (36%) patients and intra-lesional in 48 (64%) patients. 39/77 (51%) underwent Enneking appropriate (EA) treatment and 38 (49%) underwent Enneking inappropriate (EI) treatment. 18 (22%) patients experienced local recurrence (LR). LR occurred in 11 (29%) EI-treated patients and six (15%) EA-treated patients (P = .151). There was a significant difference between wide/marginal margins and intra-lesional margins for LR (P = .029). Seven (9%) patients died. LR is strongly associated with death (RR 8.9, P < .001). Six (16%) EI-treated patients and one (3%) EA-treated patient died (P = .056). With regards to surgical margins, all patients that died underwent intra-lesional resection (P = .096). Conclusion: En bloc resection with wide/marginal margins should be performed when technically feasible as it is associated with decreased LR. Intra-lesional procedure is associated with increased LR. Mortality strongly correlates with LR., Introduction: Symptomatic Metastatic Epidural Spinal Cord Compression (MESCC) afflicts up to 10% of all cancer patients and is associated with shortened survival and worsened quality of life. This study aims to identify the key survival predictive factors in MESCC patients who were surgically treated for a single symptomatic lesion. Material and Methods: 142 MESCC patients were enrolled in a prospective North American multi-center study and followed postoperatively to death or at least 12 months. Using univariate analyses, Kaplan-Meier methods, and log-rank tests the predictive value of various clinical variables were assessed. Non-collinear predictors with P < .05 in univariate analyses were included in the final Cox proportional hazards model. Results: The overall median survival was 7.7 months (range: 3 days – 35.6 months); breast cancer had the longest median survival (12.1 months). Eight patients (7%), whose primary cancer were lung (3), kidney (3), sarcoma (2), prostate (1), and breast (1), died within 30-days postoperatively and 88 had died at 12 months (62%). Univariate analyses yielded eight significant predictors for survival: the growth of primary tumor (Tomita Grade 1 vs Grade 2 and 3), BMI, gender, preoperative SF-36 physical component, EQ-5D, and ODI scores as well as the presence of either visceral or extraspinal bony metastasis. The multiple regression analysis revealed that the Tomita grade (Grade 1 vs Grade 2 and 3; HR: 2.81, P = .007), the absence of visceral metastasis (HR: 2.01; P = .0044), and higher score on SF-36 physical component (HR: 0.95, P < .0001) were independent predictors for longer survival. Conclusion: Slow growing tumor (Tomita Grade 1), absence of visceral metastasis, and lower degree of preoperative physical disability, as reflected by a higher score on the SF-36 physical component questionnaire, are good predictive factors for survival in selected patients who underwent surgical treatment for a focal symptomatic MESCC lesion., Introduction: Evaluating health related quality of life (HRQOL) has become increasingly important especially in oncology. Therefore, the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ) was developed as the first spinal oncology specific measure. With previous confirmation of the content validity the purpose of this study is to test the construct validity and reliability of the SOSGOQ. Methods: The AOSpine Knowledge Forum Tumor conducted a multicenter prospective observational study where patients underwent surgery and/or radiotherapy for the treatment of spinal metastases. Patient demographic, diagnostic, treatment, and quality of life data were collected. Construct validity was assessed at 12 weeks post-treatment by correlating the subdomains of the SOSGOQ to the relevant subdomains of the SF-36 or the NRS score using Spearman’s rank correlation. The SOSGOQ score is inverse to the SF-36 score. Reliability of the SOSGOQ was assessed using the Intraclass Correlation Coefficient (ICC) between 12 weeks post-treatment and the re-assessment after 4-9 days. The Cronbach’s alpha was used to test for internal consistency. Results: A total of 238 eligible patients were included in the observational study in the nine participating centers. Thirty-six patients in two centers also participated in the sub-study to test the reliability of the SOSGOQ. Twenty-six patients underwent radiotherapy alone and ten underwent surgery with or without additional radiotherapy. Correlation of the SOSGOQ subdomains to the relevant SF-36 subdomains showed a strong to very strong correlation (Spearman’s rank range -0.61 to -0.83). Correlation of the subdomain pain to the NRS score was strong (Spearman’s rank = 0.72). The reliability for the total SOSGOQ score demonstrated to be excellent with an ICC of 0.84. Conclusion: Construct validity of the SOSGOQ was confirmed by correlation of the SOSGOQ to the relevant subdomains of the SF-36 and the NRS score. Furthermore, the SOSGOQ showed excellent reproducibility. The SOSGOQ is a valid and reliable tool to measure HRQOL outcomes in patients undergoing treatment for spinal metastases., Introduction: Pelvic fixation via iliac-screws is a crucial technique in stabilizing metastatic lumbosacral deformity. MIS iliac-screw fixation avoids complications of an open approach and is a viable palliative option in treating patients with painful instability and advanced disease, unsuited for major reconstruction. In this study we share our clinical experience in the use of MIS iliac-screw fixation in treatment of painful metastatic LSJ deformity. Material and Methods: Seven patients with lumbosacral metastatic deformity who underwent MIS lumbopelvic stabilization using iliac-screws were prospectively studied. At presentation these patients had severe axial back pain in erect posture with significant resolution when supine, indicating underlying mechanical instability. Results: Mean cohort age was 58 years (27-73). Median preop SIN and Tokuhashi scores were 13 and 9 respectively. All patients were instrumented successfully without conversion to open technique. Mean preoperative and postoperative Cobb angle was 10° and 4.2° respectively. There were no neurological deficits or wound complications postop. Postoperative CT scans showed no iliac-screw and sacroiliac joint bony violation. Mean time for commencement of adjuvant therapy was 2.6 weeks. At 6-month follow-up the visual analogue score (VAS) for each case was considerably better than at preop (median scores for back and leg were 3 and 2 respectively) Average follow-up was 12 months (8-20). No screw breakage, wound complication, symptomatic implant prominence and SI joint pain were noted at last spine surgery follow-up. Conclusion: MIS iliac-screw fixation is feasible, reproducible and can be employed without complications in metastatic spine without dynamic neurological deficits. This opens a new avenue of surgical management for metastatic lumbosacral disease patients, who otherwise may be inoperable and provide better soft-tissue control and earlier postoperative adjuvant treatment opportunity., Introduction: Neoplastic spinal instability is defined as movement-related pain, deformity or neurologic compromise under physiologic loads with SINS developed in order to facilitate the diagnosis. While data supporting SINS validity and reliability exist, there is paucity of evidence that mechanical instability correlates with patient-reported pain and disability and that surgical stabilization significantly improves these patient-reported outcomes (PRO). Establishment of association between SINS and PRO supports the validity of SINS as a diagnostic instrument and confirms the benefit of surgical stabilization in the setting of neoplastic mechanical instability. Materials and Methods: PRO, including Brief Pain Inventory (BPI) and MD Anderson Symptom Inventory – Spine Tumor (MDASI-SP), were prospectively collected. Patients who underwent instrumented surgical stabilization for spinal tumor treatment between July 2014 and August 2016 and who had pre-operative and post-operative PRO data available were included. Age, gender, primary tumor, surgical stabilization technique, epidural spinal cord compression (ESCC) grade, pre-operative SINS data, duration of follow-up and survival were collected. SINS was analyzed as a continuous and ordinal categorical variable (Stable 0-6, Low Indeterminate 7-9, High Indeterminate 10-12, Unstable 13-18). Association between SINS and pre-operative symptom burden was analyzed using Spearman Rank Coefficient (ρ) and an extension of the Cochran-Armitage trend test. The association between symptom change after surgery and pre-operative SINS categories was also analyzed. P-values less than 0.05 were considered statistically significant. Analyses were performed in SAS (version 9.4) and Stata (version 13.0). Results: A total of 150 surgeries were performed on 134 patients (mean 61.8 years old). 118 patients had both pre- and postoperative PRO data. 119 patients underwent open stabilization and 31 had percutaneous stabilization. The average time of first postoperative assessment was 34.7 days (6-279 days) after surgery. The most common primary tumors were non-small cell lung (N = 33), renal cell carcinoma (N = 19), breast (N = 14), prostate (N = 13), and sarcoma (N = 13). 2 patients had primary spine tumors (1 hemangioma, 1 chordoma). There was a statistically significant positive correlation between increasing pre-operative SINS and the severity of pre-operative pain as measured by BPI worst pain (ρ = 0.18, p = 0.02), BPI average pain (ρ = 0.23, p = 0.005), and MDASI pain (ρ = 0.2, p = 0.01) items. Increasing pre-operative SINS also correlated with increasing severity of pre-operative functional impairment measured by BPI walking (ρ = 0.23, p = 0.006), MDASI activity (ρ = 0.28, p = 0.0006), and MDASI walking (ρ = 0.22, p = 0.009) items. Similar associations were noted when SINS was analyzed as an ordinal categorical variable. The magnitude of symptom relief after surgery positively correlated with pre-operative SINS, with patients with higher pre-operative SINS experiencing greater symptom relief as measured with BPI worst pain (p = 0.03), BPI average pain (p = 0.02), BPI activity (p = 0.04), and MDASI pain (p = 0.04) instruments. Conclusion: The association between increasing SINS and symptom burden provide PRO-based validation of SINS as an instrument for diagnosis of spinal instability. The larger decrease in the severity of pain and activity interference experienced by patients with pre-operative neoplastic spinal instability supports the role of surgical stabilization for pain relief and improved functional status in the setting of mechanically unstable spines., Introduction: We investigated the ability of intraoperative neurophysiological monitoring to predict postoperative neurological recovery in intradural-extramedullary spinal cord tumors. Material and Methods: From 2010 to 2014, we operated on 173 intradural-extramedullary spinal cord tumor patients with intraoperative neurophysiological monitoring. We retrospectively compared preoperative and postoperative clinical status using a modified McCormick grading scale and correlated with intraoperative neurophysiological monitoring. We followed patients for at least 1 year and correlated neurological outcomes with intraoperative changes in intraoperative neurophysiological monitoring. We then compared the degree of intraoperative neurophysiological monitoring change with the duration of the neurological deficit. Results: Monitorability was 92% and 57% with transcranial motor-evoked potential and somatosensory-evoked potential modalities, respectively. Waveform attenuation on transcranial motor-evoked potentials was detected in 8.17% of cases. For somatosensory-evoked potentials, waveform attenuation was detected in 7% of the patients. A multimodality approach incorporating any transcranial motor-evoked potential changes had a sensitivity of 0.91 and a specificity of 0.98. The McCormick grade scale increased until 1 month in patients with alarm criteria on transcranial motor-evoked potentials (P < .05). Conclusion: Patients suffered neurological deterioration in case of abolishment or >50% irreversible attenuation of the waveform in transcranial motor-evoked potentials. All patients gradually recovered after 1 postoperative month with alarm criteria from 50% to 80% irreversible amplitude drop on transcranial motor-evoked potentials., Introduction: The major problems performing a spinal wide resection are the proximity, contiguity, and sometimes invasion of the great vessels, the parenchymatous organs, the chest wall and the central and peripheral nervous system. In children, in addition to all that, we meet the difficulties of choosing the length of the instrumentation, the small size of the pedicles and vertebral bodies, the fragile hemodynamic balance and the management of post-operative pain. Material and Methods: Over the past 12 years we have performed 18 total spondilectomy single or multilevel (one to five vertebrae in en block excision), 6 cervical, 4 thoracic and 8 lumbar, with a resection of a minimum of 2.8 to a maximum of 12 cm. The age of our patients was between 4 and 16 years old with a mean follow-up of 26 months. The pathologies treated were primary aggressive bone lesions: 6 osteosarcomas, 4 Ewing’s sarcoma, 3 malignant high grade schwannomas, 1 leiomyosarcoma, 1 high grade rhabdoid tumor, 1 giant cell tumor (aggressive), 1 chordoma, 1 osteoblastoma osteosarcoma-like. Results: We systematically performed a 360° circumferential reconstruction, connecting the anterior artrodesis with the posterior fixation, compressing the entire instrumentation at the end of the surgery. The final stability over the time has been systematically carried out by an anterior interbody fusion between the adjacent vertebrae to the resection, always made with the iliac autograft with which we have filled the different anterior cages used (carbon, titanium, homograft massive bone bank). The choice of the length of the posterior instrumentation was always very difficult, preferring short strumentations, whenever possible, to save spine for future growth. We had a distal junctional kyphosis due to breakage of the instrumentation (successfully re-operated), an distal junctional kyphoscoliosis due to failure of the arthrodesis (successfully re-operated), two neurological worsening (one completely healed, one with only partial recovery), 4 local recurrences (9, 12, 34 and 39 months) with systemic progression of the disease. Conclusion: The high complication rate in our series is explained by the complexity of this type of surgery in children, which any how permits to obtain satisfactory oncological results. Based on our results we can say that even in pediatric patients with multilevel vertebral primary aggressive tumors it is possible to perform correct oncological resections with a final positive outcome higher than 70%., Introduction: The spine is the prime target organ in the skeletal system as a metastatic site for the majority of primary tumours of epithelial origin. Surgery has an established role in management of metastatic spine disease (MSD). Spinal oncologic surgeries aimed at decompression and stabilization of the neural and osseous elements respectively remains an integral part in maintaining the quality of life in the terminal years of these patients. Due to the vast spectrum of patterns and severity of spinal metastases, a multitude of surgical techniques are employed. In analyzing variables influencing surgical outcomes, comparing data between institutions, and weighing clinical options of treatment, a standardized scoring system that compares the extent of surgery with outcome variables will be useful for surgeons and patients alike in both research and treatment planning. Methods: Surgery for MSD can include anterior, posterior or combined approaches to the spinal column. We devised a metastatic spine surgery scoring system based on surgical intrusion of the vertebral column. The score is based on number of vertebrae instrumented posteriorly or anteriorly, the number of levels decompressed by posterior approach, extent of anterior decompression dictated by total/partial corpectomy, posterior fusion and vertebroplasty. The index was validated by the retrospective analysis of patients undergoing metastatic spinal surgery from 2005-2014. Data collected included patient demographics, type of primary tumour, type and extent of surgery, blood loss and transfusion, surgical duration and complications. The relationship between the intrusion score and outcome measures such as blood loss, blood transfusion, operative time and post-operative complications were analyzed. Results: A total of 241 patients were included in the analysis. The median age was 60 years (range:25-87) with gender distribution of 127 males(53%) and 114 females(47%). The median score of Intrusiveness Index was 7 (range:1-20). Multivariate analyses revealed that the Intrusiveness Index score was independently associated with increased amount of blood loss, increased odds of blood transfusion and prolonged operative time after adjusting for a number of potential confounders. With every one score increase in Intrusiveness Index, there was a 42 ml increase in mean blood loss (95%CI:29-51, P = .01), 10 minutes increase in mean operative time (95%CI:5-18, P = .01) and 1.1 times increased odds of blood transfusion (95%CI:1.05 -1.19, P = .03). There was a tendency towards increased odds of developing postoperative complications with an increase Intrusiveness Index score in but this was not significant (OR = 1.06, 95%CI:0.91 -1.23, P = .08). Conclusion: This novel Intrusiveness Index correlates well with surgical outcomes, in particular with blood loss, transfusion requirements and operative time. We believe that it will have significant utility in clinical practice for clinical decision making and predicting risks and potential complications. In addition, this index would facilitate research by allowing fair comparisons between different types of operative procedures and operative outcomes between institutions., Introduction: The role of intraoperative monitoring (IOM) in the resection of spinal tumors is understudied compared to its use in other conditions of the spine. The aim of this study was thus to assess the utility of Somatosensory-Evoked Potentials (SSEP) and Transcranial Electric Motor-Evoked Potentials (MEP) in the resection of intramedullary, intradural extramedullary, and extradural spinal tumors and evaluate the ability of both single and multi-modal monitoring to predict post-operative neurological deficits. Materials and Methods: A retrospective analysis of consecutive patients who underwent a spine tumor resection with the use of IOM at a single institution between August 2009 and March 2013 was performed. Demographic, clinical and neuromonitoring data were collected pre-operatively, during surgery, at the moment of discharge, and at a six-month follow-up visit. Three cohorts were established based on the anatomical location of the tumor: intramedullary, intradural extramedullary, and extradural. Patients with significant bilateral or unilateral loss of amplitude in SSEPs or MEPs during surgery were identified and the rate of neurological deficits was assessed. Results: A total of 52 patients were analyzed. All of the patients underwent surgery using a posterior approach. The average age of the cohort was 46 years (SD of 21 years) with 25 (48.1%) males and 27 (51.9%) females. A significant change in intraoperative SSEPs or MEPs was detected in 14 cases. Fourteen patients (26.9%) developed permanent post-operative neurological deficits. SSEPs significantly predicted post-operative deficits in the resection of intramedullary tumors (P = .015; AUC = 0.83) as well as intradural extramedullary tumors (P = .048; AUC = 0.70). MEP monitoring did not predict post-operative deficits in the resection of intramedullary (P = .20; AUC = 0.69) or intradural extramedullary tumors (P = .308; AUC 0.63). Neither SSEPs nor MEPs predicted post-operative deficits in the resection of extradural tumors. Conclusion: The efficacy of intraoperative neuromonitoring during spine tumor resection surgery is highly dependent on tumor location relative to the spinal cord and dura. In spinal tumors approached primarily via a posterior approach, the accuracy of SSEPs and their ability to predict post-operative deficits increases the closer the lesion is located to the spinal cord, thus demonstrating greatest accuracy and predictive capacity for post-operative deficits in the resection of intramedullary tumors. For spine tumor resections employing a posterior approach, MEP and multi-modal monitoring may not confer a benefit in predicting permanent neurological deficits., Introduction: The results of surgery for thoracic myelopathy caused by multilevel OPLL have been unfavorable. All the existing surgical decompressive methods, including posterior circumferential decompression and anterior decompression, are technically demanding and associated with a high rate of complications. This study is to evaluate the feasibility and surgical outcomes in patients with multilevel OPLL of the thoracic spine treated by one-stage posterior selective and localized circumferential decompression with dekyphosis and instrumented fusion. Material and Methods: This is an one-stage posterior operative procedure. The circumferential decompression level is selected before surgery following two standards: being the most stenotic level of the spinal canal and locating at the apex of the kyphosis of the stenotic segments. During the operation, instrumented fixation and wide laminectomy is performed firstly. At the already selected level, bilateral facetectomy and transforaminal localized extirpation of the OPLL is performed, followed by appropriate V-shaped osteotomy, compressing to reduce thoracic kyphosis by approximately 10 degrees (dekyphosis) and to shorten the spinal cord by approximately 10 mm. Twelve patients who underwent posterior selective and localized circumferential decompression with dekyphosis were included in this study. Japanese Orthopedic Association (JOA) scores and recovery rates were used to evaluate the outcomes. Twenty one cases who suffered from thoracic spinal stenosis due to multilevel OPLL were surgically treated before December 2015, among which 5 were male and 16 were female, with an average age of 48.2 (32∼59) years old. The average segment number of OPLL was 6.9 (3∼11). The preoperative Japanese Orthopaedic Association (JOA) score was 4.1 averagely (1∼8). Results: The average operation time was 4.2 hours (range 3.0∼7.0 h) and the average blood loss was 1510 m1 (range 400∼6000 ml). The segment number of laminectomy was 8.0 averagely (range 5∼13). The segment number of selective circumferential decompression and dekyphosis was two in 2 cases, and one in 19 cases. The average dekyphotic degree of all decompression levels was 9.1° (range 2∼25°).The shortened length of vertebral canal was 3.9mm (0∼6.9 mm). All 21 cases were followed up for more than 6 months, and the latest average JOA score was 9.3 (range 1∼11), while the recovery rate was 74.1% averagely (range -100%∼100%). Conclusion: In cases of thoracic myelopathy due to multilevel OPLL, a dramatic degree of neurologic recovery can be obtained by one-stage posterior selective and localized circumferential decompression with dekyphosis and instrumented fusion, despite the other levels of OPLL remaining, even for those patients in whom the spinal cords are severely damaged before surgery. We recommend this one-stage posterior decompression and dekyphosis procedure be selected for patients whose thoracic spinal cord are impinged anteriorly by multilevel OPLL, especially when the physiological kyphosis is relatively severe., Introduction: A new method for the management of early-onset scoliosis (EOS) has been recently introduced: it consists of a magnetically controlled growing rod (MCGR) that allows gradual outpatient distractions under control of an external remote device. We present a series of 14 patients with EOS managed with MCGR (Ellipse TM MAGEC System, Irvine, CA). Material and Methods: We implanted MCGR in 14 patients affected by EOS with various aetiology. Scoliosis and kyphosis angles, T1-T12 and T1-S1 length were evaluated preoperatively, postoperatively, and at the last follow-up. A visual analogue scale score was used to evaluate pain during outpatient rod distraction procedures. The mean follow-up is 34 months. All patients attended distractions of the magnetic rod through an external remote control every 3 months. The mean predicted distraction was 3 mm at each lengthening session. Results: The mean Cobb angle value was 64.7±17.4 degrees (range, 45 to 100 degrees) preoperatively and 28.5 ± 13.9 degrees (range, 15 to 59 degrees) at the latest follow-up. The mean T1-S1 length value was 27.1 ± 5.4 cm (range, 16 to 34.8 cm) preoperatively and 32.8±4 cm (range, 26.5 to 39 cm) at the latest follow-up. The mean T1-T12 length value was 16.2 ± 2.7 cm (range, 10 to 19 cm) preoperatively and 20.6 ± 2.9 cm (range, 15.5 to 23.5 cm) at the latest follow-up. The average monthly T1-T12 height increase was 0.8 mm, whereas the average monthly T1-S1 increase was 0.9 mm. Two patients experienced a rod breakage and 1 patient had a pull-out of the apical hooks. In cases of rod breakage, the magnetic rod was removed and replaced. In case of pull-out, apical pedicle screws have been positioned in substitution of hooks. Conclusion: Although implant-related complications could occur, as in all EOS growing rods procedures, MCGR can be effectively used in patients with EOS. This spinal instrumentation can overcome many of the complications related with the traditional growing rods implants. In our experience, rod breakage occurred only in patients with a single magnetic rod instrumentation. First case was a patient with a severe thoracic kyphosis. In effect, the management of kyphosis with the MCRG is quite challenging. Moreover, a marked kyphosis was also the cause of pull-out of the apical hooks. Instead, in the second case of rod breakage, we reported a failure of the internal magnet of the rod. This procedure can be effectively used in outpatient settings, minimizing surgical scarring, surgical site infection, and psychological distress due to multiple surgeries needed in the traditional growing rods system, improving quality of life, and saving health care costs. Because of progressive ankylosis, avoiding final surgical fusion at skeletal maturity is a viable option for patients treated with growing rods who have satisfactory final alignment and trunk height, a minimal gain in length at the last distraction, and no clinical or radiographic evidence of implant-related problems., Introduction: Pedicle screw systems are very useful for the treatment of spinal diseases. As their use has increased significantly, so has the rate of related complications due to screw malpositioning. New technologies have been applied to spinal instrumentation to increase the accuracy of pedicle implant, and thus decrease the rate of screw related complications. CT navigation and robotics are two alternatives to improve screw precision. However, the amount of radiation given to the patient in CT navigation is considerably high, and in this phase robotics can significantly increase surgical time. Alternatively, 3D printed tubular guides are more frequently used in operating theater for thoracolumbar spine surgery. This kind of hardware is usually patient-specific, following vertebral anatomy acquisition from a preoperative CT scan. Among the different available systems, Medacta MySpine uses a preoperative low-dose protocol CT to obtain spinal images of the patient and create custom-made guides. These are helpful in driving the preparing instruments and the pedicle screws in the correct position, maximizing length and decreasing the risk of pedicle wall violation and of related complications. Material and Methods: Patients with idiopathic and adult thoracolumbar deformity were included in this prospective study. A preoperative low dose CT scan according to the MySpine protocol was performed to create custom-made guides for the insertion of pedicle screws at the instrumented levels. After surgery, the patients underwent a control low dose CT scan to determine the accuracy of the pedicle screws placement and to measure violation of the pedicles. Results: In this series a total of 143 pedicle screws were implanted using the 3D stamped custom guides. Of these, 87.4% of the screws were completely intrapedicular, and this value rose up to 93.7% considering the screws with less than 2 millimeters of pedicle violation. Violation between 2-4 mm occurred in 4.9% of the screws. Only 1.4% of the screws presented a violation greater than 4 mm, although no medial violation of the pedicle was observed in any of these cases. Conclusion: The MysSpine Medacta system provides reduction of x-ray exposure of the patients and surgeons. In addition, the precision of the 3D printer allows a perfect fit between the guide and the corresponding vertebra, increasing the accuracy of the system. Our study suggests high accuracy of screw positioning inside the pedicles using the MySpine Medacta system, allowing for a reduction of complications related to screw misplacement., Introduction: Anterior corpectomy and fusion (ACF) with or without the floating method for cervical ossification of the posterior longitudinal ligament (OPLL) is known to be associated with a higher incidence of surgery-related complications including cerebrospinal fluid (CSF) leakage and neurologic deterioration. To avoid these complications, we have developed a novel anterior decompression technique (vertebral body sliding osteotomy; VBSO). Its basic concept is to expand the spinal canal by anteriorly translating the involved vertebral bodies as well as ossified masses. The purpose of this study is to attest the efficacy and safety of VBSO by comparing its postoperative outcomes to those of conventional anterior corpectomy and fusion (ACF). Material and Methods: Twenty-four consecutive patients who needed anterior decompression for cervical myelopathy with OPLL underwent VBSO by a single surgeon. Other 38 patients consecutively underwent ACF by another single surgeon. In 16 out of 38 ACF patients, OPLL masses were partly remained by the floating method due to severe dural adhesion. All the patients were followed for more than 2 years after surgery and their medical records and radiographic data were analyzed. Operation time, estimated blood loss (EBL), postoperative neurologic outcomes by Odom’s criteria, and the incidence of surgery-related complications were investigated. Various radiographic parameters including the spinal canal widening on CT axial images, the degree of remaining cord compression on MRI, and pre- and post-operative sagittal alignment were also measured. The clinical and radiographic outcomes were statistically compared between the two groups. Results: The mean operation time and EBL in VBSO group were significantly smaller than those in ACF group. Sixteen patients in ACF group (42.1%) showed various surgery-related complications (neurologic deficit in 2 patients, CSF leak in 4, graft migration in 3, and pseudarthrosis in 7). On the contrary, there was no neurologic deterioration, no dural tear, and no graft migration except 2 pseudarthrosis (8.3%) in VBSO group (P < 0.05). Neurologic improvements showed no significantly difference between the two groups (P = 0.128). On radiographic data, the mean canal widening was significantly greater in VBSO group than in ACF group (4.79±1.34 mm vs. 3.21±1.76 mm, P < .05). Preoperatively, VBSO group had a significantly less mean lordotic curve, which was improved postoperatively much more than that of ACF group (−2.17±9.21° → −10.78±9.07° in VBSO, −9.56±10.36° → −6.71±9.58° in ACF, P < .01). Conclusion: The vertebral body sliding osteotomy could provide similar neurologic outcomes with shorter operation time and less bleeding compared with the conventional corpectomy procedure for cervical myelopathy with OPLL. Since surgeons do not need to directly manipulate the OPLL mass or dissect the interspace between the OPLL and dura mater, this technique could significantly decrease the complications such as dural tear, CSF leak, and neurologic deterioration. Furthermore, as it is based on the multi-level discectomy and fusion technique, it would be more helpful to correct a less lordotic or kyphotic sagittal curve into a physiologic lordosis., Background and Purpose: Vertebral body compression fractures due to osteoporosis is the most common fracture in patients with osteoporosis (1). Kyphoplasty surgical procedure were introduced and performed to stop the pain caused by pathologic spinal fractures, to stabilize the bone, and to restore some or all of the lost vertebral body height due to the compression fracture. One of the major concerns with the technique is extravasation of the cement material. This was reported to a range of 4.8% - 39% in some reports (2). We tested the feasibility of a Cement Encapsulation Biodegradable Balloon Catheter in Kyphoplasty therapy over 14 days in healthy animal model. Synthetic biodegradable polymers have been investigated for the above applications. Poly (glycolic acid) (PGA), Poly (lactic acid), (PLA) and their copolymers have been researched for a wider range of applications. Materials and Methods: Cement Encapsulation Biodegradable Balloon Catheter System comprised of five components: 1) Biodegradable Shaft made from the balloon materials to support the balloon; non-compliant Biodegradable Balloon to inflate inside the vertebral body and accumulate the cement; Silicone Inflation Valve, one-way valve to hold cement inside balloon catheter after inflation shaft is removed; Delivery Stainless Steel Shaft, temporary inflation shaft removed from balloon catheter after inflation; Balloon Catheter Release Shaft, push shaft to push balloon forward while inflation shaft is removed. Balloons were percutaneously implanted, under X-Ray guidance, into the vertebral body of 4 levels L1-L4. Two animals undergo standard Kyphoplasty therapy followed by Cement Encapsulation Biodegradable Balloon Catheter implementation inflated with contrast medium to mimic PMMA inflation. Animal model used; Sheep, 2 Females with weight ranging between: 75-90 kg. There was no significant difference between the performances of the system between the two animals. One animal was deadened post procedure and the harvested spine was sent to CT scanning to learn about the balloon and catheter formation. Second animal was kept alive to examine balloon degradation process over time. Every other day the live animal was X-Rayed to examine the balloon integrity by examining the content of contrast medium inside the balloon. Results: Two animals were tested and implanted with 8 Biodegradable Balloon Catheters. The balloons degraded over a period of 12-14 days in the live animal model. The implant procedure was accepted by Kyphoplasty therapies trained physicians. No infections or thromboembolic events occurred during the implant procedure or during the examination period. No adverse events were recorded throughout the study period. Conclusion: A pre-clinical diagnosis of the biodegradable balloon inflation on the vertebral body was performed. Although it was a small sample size, but it was shown that the material and procedure was safe in-vivo. Further investigation is required with cement to investigate the mechanics of fluid dynamics of bone reconstruction under X-Ray. Synthetic polymers can be prepared with chemical structures tailored to optimize physical properties of the biomedical materials and with well-defined purities and compositions to enhance performance and reduce crossing profile of the balloon catheter. Tools Animal Catheter and Insertion Tools CT Scan of Balloon X-Ray Imaging: Balloons Implanted in Spine. References 1. Marcy B. Bolster, Consternation and questions about two vertebroplasty trials, Clevelend clinic journal of Medicine, Volume 77, number 1 Jan 2010. 2. Fernando Ruiz Santiago, Alicia Santiago Chinchilla, Luis Guzmán Álvarez, Antonio Luis Pérez Abela, Maria del Mar Castellano García, Miguel Pajares López, Comparative review of vertebroplasty and kyphoplasty. World J Radiol 2014 June 28; 6(6): 329-343., Object: To present our experience using a new system for the treatment of adolescent idiopathic scoliosis and the first outcomes. Material and Methods: A new system (Apifix) has been used in 8 adolescents with progressive scoliosis of 32°-52°. This system corrects the scoliosis without fusion. No blood transfusion was needed. The surgical time was about 1 hour, and the hospital stay was 3 days. After three weeks, a special program of physiotherapy was started to expand further the system. The Cobb angle, the parameters of sagittal balance and the vertebra rotation (using Nash-Moe technique and spinometry), has been evaluated during a follow-up of 3 years. Results: A spontaneous vertebra derotation average of 35% was noted using Nash-Moe evaluation. The Cobb angle average improved from 37° to 17.2°. Immediately postoperatively a scoliosis improvement of 13° (range: 17°-4°) was noted, and after the physiotherapy other 5° (range: 1°-8°) of improvement was achieved. The sagittal balance parameters remained unchanged. Conclusions: A spontaneous derotation of the vertebra is documented in our cases but further research in more patients, and in longer follow-up is needed. This system offers an option between conservative treatment and spinal posterior fusion to be used as an internal brace., Introduction: Aim of the study was the evaluation of the efficacy of the use of a new wearable AR video see-through system based on Head Mounted Displays (HMDs) to guide the position of a working cannula into the vertebral body through a transpedicular approach without the use X-Ray images guidance. Material and Methods: We describe a head mounted stereoscopic video see-through display that allows the augmentation of video frames acquired by two cameras with the rendering of patient specific 3D models obtained on the basis of pre-operative radiological volumetric images. The system does not employ any external tracker to detect movements of the user or of the patient. User’s head movements and the consistent alignment of the virtual patient with the real one, are accomplished through machine vision methods applied on pairs of live images. Our system has been tested on an experimental setup that simulate the reaching of lumbar pedicle as in a vertebral augmentation procedure avoiding the employment of ionizing radiation. Aim of the study is to evaluate the ergonomics and the accurancy of the systems to guide the procedure. We performed 4 test sessions with a total of 32 kirschner wire implanted by a single operator wearing the HMD with the AR guide. The system accurancy was evaluated by a post-operative CT scan. Results: The most ergonomic AR visualization comprise the use of a pair of virtual viewfinders (one at the level of the skin entry point and one at the level of the trocar’s bottom) aligned according to the planned direction of the trocar insertion. With such AR guide the surgeon must align the tip of the needle to the center of the first viewfinder placed on the patient’s skin. indeed the viewfinder barycenter provides a 2 degrees of freedom (DoFs) positioning guide corresponding to the point of insertion preoperatively planned over the external surface of the model. The second viewfinder is used by the surgeon to rotate and align the trocar according to the planned direction of insertion (2 rotational DOFs). After the first test series a clamping arm has been introduced to maintain the reached trocar’s trajectory. The post-operative CT scan was registered to the preoperative one and the trajectories obtained with the AR guide were compared to the planned one. The overal results obtained in the 4 test session show a medium error of 1.18+/-0.16 mm. Conclusions: In the last year there was a growing interest to the use of Augmented Reality systems in which the real scene watched by the surgeon is merged with virtual informations extracted from the patient’s medical dataset (medical data, patient anatomy, preoperative plannig). Wearable Augmented Reality (WAR) with the use of HDMs allows the surgeon to have a “natural point of view” of the surgical field and of the patient’s anatomy avoiding the problems related to eye-hand coordination. Results of the in vitro tests are encouraging in terms of precision, system usability and ergonomics proving our system to be worthy of more extensive tests., Introduction: Accurate measurement of spine motion is challenging due to the complex anatomy and motion of the spine. Presently, clinical assessments of spine motion are limited to subjective observations and static goniometric measurements or radiographic measurements. More advanced techniques, such as three-dimensional motion analysis, allow for quantitative assessment of spine motion. These techniques are the gold standard in spine motion analysis, but are cost, size, and time-prohibitive for everyday use. Recently, alternative technologies of motion analysis have emerged and may be appropriate for measuring motion of the spine in a clinic setting. The utility of clinical motion analysis can be found in both pre-operative assessment and biomechanical coaching postoperatively. This study presents the application of the Microsoft Kinect system to measure motion of the thoracolumbar spine static and functional tasks. This system represents a low-cost alternative to measure spinal balance and range of motion in a clinic setting. Material and Methods: Prospective case series of five patients with adult spinal deformity after multilevel spinal fusion and two patients with lumbar disc herniation. Surface reflective markers were affixed to bony landmarks of the thoracolumbar spine. Motion of the markers was captured by the Microsoft Kinect system and custom MATLAB software for neutral, flexion extension, and sit-to-stand activities. Sagittal alignment, coronal alignment, and segmental motion of each functional spinal unit were calculated post-hoc using custom MATLAB software. Alignment parameters were compared to radiographs. Data were compared using a t-test (P < .05). Results: The mean positive sagittal balance for Kinect and radiographic data was 5.8 ± 1.9 cm and 4.2 ± 1.9 cm, respectively (P = .27). The mean thoracic alignment is 41.5 ± 8.2 degrees of kyphosis and the mean lumbar alignment is 5.8 ± 12.4 degrees of lordosis in neural position. Implementation in clinic was not obstructive to clinic flow. Conclusion: The Microsoft Kinect system can be used to measure clinically-relevant spine parameters in a clinic setting. Soft tissue overlying the bony anatomy may limit accuracy. Future studies will apply this technique to measure spine motion in a spectrum of spine disorders before and after intervention., Introduction: Distraction of the atlanto-axial joints for treatment of basilar invagination has become an option in recent years. The posterior approach described in literature has a small but definite risk of injury to the vertebral arteries, C2 root ganglion and can be associated with difficult hemorrhage from the sub occipital paravertebral venous plexus. The unilateral anterior retropharyngeal approach offers a safe and simple corridor to expose both the atlanto-axial joints for adequate preparation and manipulation for distraction and fixation for the ultimate goal of joint fusion. Material and Methods: Since Jan 2012 till Sept 2016 25 patients of basilar invagination with or without atlantoaxial dislocation have been treated by unilateral right sided anterior extrapharyangeal wedge shaped titanium cage distraction with bilateral fixation of lateral mass of atlas to body of axis. Results: The odontoid process migrated downwards in all cases with relief of the cervicomedullary compression. Spasticity improved in all cases. Transient deviation of the tounge due to retraction neurapraxia of the hypoglossal nerve and weakness of lower lip due to marginal mandibular nerve stretch were tha only complications in 3 patients. Follow up has been for 3 years in 12 patients. Vertebral artery, venous plexus and C2 root were not injured in any case. Conclusion: Basilar invagination can be reduced by spacer in the atlanto-axial joint. Recently this technique has been recommended for syringomyelia and Chiari malformation. However posterior surgery has inherent difficulties such as risk vertebral artery injury, paravertebral venous plexus hemorrhage and necessity of sacrificing the C2 ganglion in most cases.1 The anterior extrapharyangeal approach offers a safe corridor to achieve all the aims of the posterior operation without the problems of posterior approach.3 The surgery is performed in supine position with extension which aids in reduction of the atlanto-axial dislocation after opening of the joints and excising the pannus behind the anterior arch of the atlas. Unlike the posterior approach which disrupts the sub occipital and C2 spinous process muscle attachments, the anterior approach, is through muscle planes preserving muscle attachments which are essential for craniovertebral stability. Wedge shaped cage distracts the joint and reduces the atlantoaxial dislocation. The large bone mass of the atlas and body of axis allow ample opportunity for easy, safe and rigid fixation of the atlanto-axial joint. The unilateral anterior retropharyngeal approach offers a safe corridor to both the atlanto-axial joints, for distraction and fixation for fusion. References 1. Anterior facetal realignment and distraction for atlanto-axial subluxation with basilar invagination…. a technical note. Sushil Patkar. Neurological Research (Ahead of Print). 2. Goel A, Shah A. Atlantoaxial joint distraction as a treatment for basilar invagination: A report of an experience with 11 cases. Neurol India [serial online] 2008 [cited 2015 Sep 23];56:144-50. 3. S Patkar. Anterior Retropharyangeal Titanium Cage Distraction Of The Atlantoaxial Joints For Reducing Basilar Invagination: A First Report In The Literature. The Internet Journal of Spine Surgery. 2015 Volume 10 Number 1.