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Purpose: Surgery of adult scoliosis was based upon coronal plane radiographical analysis using Cobb angle measurements, but recently it has been demonstrated that sagittal spinopelvic alignment plays a critical role in determining the final outcome. The aim of this paper is to compare the clinical and radiological results of 81 patients affected by adult scoliosis, treated with short or long fusions, and followed for 2-5 year follow-up.Materials and Methods: 81 patients affected by degenerative lumbar scoliosis managed by posterior-only surgery were retrospectively evaluated. Fifty-seven patients underwent to a short fusion procedure, while 24 had a long fusion. Clinical and radiographic coronal and sagittal spinopelvic parameters were compared between the two groups.Results: Coronal Cobb angle was 24° preoperatively and passed to 12° in the short fusion group, while changed from 45° to 10° in the long fusion group. Lumbar lordosis was 45° preoperatively and 60° at final follow-up in the short fusion group passed from 24° to 55° in the long fusion group. Sacral slope passed from 25° to 45° in the short fusion group, while from 10° to 40° in the long fusion group. Pelvic tilt passed from 24° to 13° in the short fusion group, and from 28° to 23° in the long fusion group.Conclusion: Surgical treatment of degenerative lumbar scoliosis improved balance and alignment of the spine, and also the coronal plane in terms of Cobb angle. These results were associated to a consistent clinical improvement and an acceptable rate of complications. [ABSTRACT FROM AUTHOR]

Introduction: Sacral chordoma is a rare low-to-intermediate grade malignant tumour. The mainstay of treatment is still surgery with en bloc and wide resection margins, which can grant the best chances of a long-term control or cure of this disease. The first aim of this paper is to collect data about survival, time to local recurrence and metastasis among patients affected by sacral chordoma and primarily treated with surgery. The second aim is to analyze the influence of level resection, tumor volume and surgical margins on local recurrence.Materials and Methods: The study population was composed of 14 patients treated with sacral chordoma resection at the National Tumour Institute of Naples-Pascale (Italy) from January 2000 to June 2013. The median follow-up was 84 months (range 24-132 months). The follow-up was characterized by: standard radiographs, MRI, and a CT scan of the chest annually. Time to recurrence or metastasis was calculated from the date of resection to the date of diagnosis of first recurrence or metastasis.Results: Out of all the patients, six died (42.86 %) during the follow-up; 6 (42.86 %) had local recurrence; 4 (28.57 %) had metastasis. At univariate analysis wide surgical margins (R0) were associated with increased survival up to a local recurrence (OR = 0.0286; 95 % CI = 0.0014-0.5739; P = 0.026); the level of resection (OR = 3.33; 95 % CI = 0.3619-30.7025; P = 0.592) and tumour volume (P = 1) did not show a statistically significant correlation.Discussion: Based on our experience, we hope all patients to be treated by surgery, the only good standard treatment of this disease. The resection should result in margins as wide as possible. For these reasons, it is essential for this disease to be treated in highly specialized centres because only a complete surgery can offer a chance to care for these patients.Conclusions: Solid survival at long-term follow-up can be achieved by a surgical resection performed with wide margins. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this retrospective study is to evaluate the efficacy and safety of posterior-only vertebral column resection (PVCR) for the treatment of angular and isolated congenital kyphosis.Methods: 24 patients with isolated angular congenital kyphosis treated by PVCR in our hospital were retrospectively studied. The patients' radiographs and hospital records were reviewed. Deformity in sagittal planes and global sagittal alignment were analyzed for correction and maintenance of the correction in preoperative, postoperative, and follow-up radiographs. The complications and related risk factors were analyzed.Results: The average age was 13.9 (4-40) years. Three of them were revision surgeries. Two patients have intraspinal anomalies. The mean follow-up is 56.9 (26-129) months. The mean operation time was 293.1 (170-480) min. The averaged blood loss was 993.8 (250-3000) ml. The segmental kyphosis was 87.3° before surgery, 17.6° post surgery and 20.4° at the latest the follow-up. And the sagittal vertical axis was improved from 43.1 mm to 9.2 mm. Mean total score of SRS-22 was 89.3. Complications occurred in 4 patients, including 1 screw pullout due to pseudarthrosis, 1 proximal junctional kyphosis, 1 incomplete spinal cord injury and 1 root injuries.Conclusion: Posterior-only vertebral column resection is an ideal procedure for severe rigid congenital kyphosis. However, it is still a highly technical demanding procedure. Neurological compromises still remain the biggest challenges. Sufficient height of anterior reconstruction, avoidance sacrifice of bilateral roots in the same level in the thoracic spine, avoidance of the sagittal translation of the upper and lower vertebras, intra-operative neuromonitoring, and preoperative surgical release of diastematomyelia and tethered cord may help to improve the safety. [ABSTRACT FROM AUTHOR]

Purpose: For adult spinal deformity (ASD) patients receiving operative (op) and non-operative (non-op) treatment, the relationship between HRQoL measures, complications and self-reported satisfaction remains unclear. The objective of this analysis is to study nonlinear association dynamics between ASD patient satisfaction, HRQoL, and complications over a two-year follow-up period.Methods: From a prospective multicenter international adult spinal deformity database, all patients with 2-year follow-up data on satisfaction (21st question of SRS-22r) were identified and included. A total of 12 LOESS (local polynomial fit) regressions were performed between patient satisfaction (SRS22 item 21) and HRQoL measures (ODI, SF36PCS and SRS22 subtotal) interacting with surgery at baseline, 6 months and 1 and 2 years of follow-up.Results: A total of 856 patients (527 op and 329 non-op) were included. At baseline, satisfaction was lower for patients scheduled for surgery even when HRQL was similar to those elected for conservative treatment. The nonlinear correlations showed that for similar PROMs, op patients reached higher satisfaction levels during follow-up, especially at six months. In fact, at six months operated patients with a deterioration of their initial PROMs had some improvement in their satisfaction, which could not be further observed at the end of follow-up.Conclusions: Satisfaction does not correlate well with other PROMs, and it might be subject to other external factors not directly related to treatment. Even if patient satisfaction is important in evaluating well-being and patient's experience with medical care, it should not be considered as an isolated proxy to measure quality of treatment. [ABSTRACT FROM AUTHOR]

Purpose: In the present prospective randomized controlled study, we compared the feasibility and effectiveness of our modified thoracoabdominal approach to anterior thoracolumbar spine surgery without cutting open the costal portion of diaphragm (extradiaphragmatic approach) with the traditional transdiaphragmatic thoracoabdominal approach. The traditional combined thoracoabdominal approach in anterior thoracolumbar surgery for spine tuberculosis is effective but seriously damages the diaphragm and causes various lung complications. We used an extradiaphragmatic approach for complete anterior debridement, bone grafting, and nerve decompression and compared its efficacy and complications with those of the traditional transdiaphragmatic thoracolumbar approach.Methods: The study included 106 patients with spinal tuberculosis. After a standard preoperative chemotherapy regimen, all patients underwent posterior deformity correction and internal fixation, anterior debridement, decompression, and bone grafting. Patients were divided into the modified extradiaphragmatic thoracolumbar approach group (the modified group) and the traditional transdiaphragmatic thoracolumbar approach group (the traditional group). During the treatment, we strictly followed the standard chemotherapy regimen.Results: The mean follow-up duration was 36.2 months (range 25-38 months). There were significant differences between the two groups in intraoperative blood loss, length of incision, recovery time, and postoperative complications but no significant differences in preoperative and postoperative erythrocyte sedimentation rates and C-reactive protein values, kyphosis, and neurologic function, recovery of ability to live and work, and postoperative healing of bone grafts.Conclusion: The modified extradiaphragmatic thoracolumbar approach for anterior thoracolumbar spine surgery is as effective as the traditional approach. However, associated surgical trauma is minimal, and the incidence of pulmonary complications is low. [ABSTRACT FROM AUTHOR]

Purpose: Patient-reported outcome measures (PROM) are used to measure treatment efficacy in clinical trials. The impact of the choice of a PROM and the cut-off values for 'meaningful important differences' (MID) on the study results in patients with lumbar spinal stenosis (LSS) is unclear.Objective: The objective is to study the consequences of applying different PROMs and values for MID for pain and disability on the proportions of patients with improvement.Design: Prospective multi-center cohort study.Methods: Proportions of patients with improvement using established MID cut-off values were calculated and compared for PROMs for pain and disability.Results: 466 patients with LSS completed a baseline and 6-month follow-up assessment and were analyzed. Treatment modalities included surgery (65 %), epidural steroid injections (15 %), or conservative care (20 %). The prevalence of patients fulfilling the criteria for MID ranged from 40 to 70 % across all outcome measures and cut-offs. The agreement of the spinal stenosis outcome measure (SSM) symptom subscale with other pain scales, and the SSM function subscale with other function scales was fair to moderate (Cohen's κ value between 0.24 and 0.5). Disagreement in the assessment of MID (MID reported by patients in one scale but not the other) was found in at least one-third of the patients.Conclusion: The MID in outcome scores for this population varied from 40 to 70 %, depending on the measure or cut-off score used. Further, the disagreement between domain specific measures indicates that differences between studies may be also related to the choice of an outcome measures. An international consensus on the use and reporting of outcome measures in studies on lumbar spinal stenosis is needed. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to compare the clinical outcome of spinal process osteotomy with two other midline-retaining methods, bilateral laminotomy and unilateral laminotomy with crossover, among patients undergoing surgery for lumbar spinal stenosis.Methods: This cohort study was based on data from the Norwegian Registry for Spine Surgery (NORspine). Patients were operated on between 2009 and 2013 at 31 Norwegian hospitals. The patients completed questionnaires at admission for surgery, and after 3 and 12 months. The Oswestry Disability Index (ODI) was the primary outcome. Secondary outcomes were duration of surgery and hospital stay, Numeric Rating Scale (NRS) for back pain and leg pain, and EQ-5D and EQ-VAS. The patients were classified into one of three treatment groups according to the surgery they had received, and a propensity score was utilized to minimize bias. The three treatment groups were divided into subgroups based on Propensity Scores, and the statistical analyses were performed with and within the Propensity Score stratified subgroups.Results: 103 patients had spinal process osteotomy, 966 patients had bilateral laminotomy, and 462 patients had unilateral laminotomy with crossover. Baseline clinical scores were similar in the three groups. There were no differences in improvement after 3 and 12 months between treatment groups. At 12 months, mean ODI improvement was 15.2 (SD 16.7) after spinous process osteotomy, 16.9 (SD 17.0) after bilateral laminotomy, and 16.7 (SD 16.9) after unilateral laminotomy with crossover. There were no differences in the secondary clinical outcomes or complication rates. Mean duration of surgery was greatest for spinal process osteotomy (p < 0.05). Length of stay was 2.1 days (SD 2.1) in the bilateral laminotomy group, 3.5 (SD 2.4) days for unilateral laminotomy, and 6.9 days (SD 4.1) for spinous process osteotomy group (p < 0.05).Conclusion: In a propensity scored matched cohort, there were no differences in the clinical outcome 12 months after surgery for lumbar spinal stenosis performed using the three different posterior decompression techniques. Bilateral laminotomy had shortest duration of surgery and shortest length of hospital stay. Surgical technique does not seem to affect clinical outcome after three different midline-retaining posterior decompression techniques. [ABSTRACT FROM AUTHOR]

Purpose: Determine impact of metal density on curve correction and costs in thoracic adolescent idiopathic scoliosis (AIS). Ascertain if increased metal density is required for larger or stiffer curves.Methods: Multicentre retrospective case series of patients with Lenke 1-2 AIS treated with single-stage posterior only surgery using a standardized surgical technique; constructs using >80 % screws with variable metal density. All cases had >2-year follow up. Outcomes measures included coronal and sagittal radiographic outcomes, metal density (number of instrumented pedicles vs total available), fusion length and cost.Results: 106 cases included 94 female. 78 Lenke 1. Mean age 14 years (9-26). Mean main thoracic (MT) Cobb angle 63° corrected to 22° (66 %). No significant correlations were present between metal density and: (a) coronal curve correction rates of the MT (r = 0.13, p = 0.19); (b) lumbar curve frontal correction (r = -0.15, p = 0.12); (c) correction index in MT curve (r = -0.10, p = 0.32); and (d) correction index in lumbar curve (r = 0.11, p = 0.28). Metal density was not correlated with change in thoracic kyphosis (r = 0.22, p = 0.04) or lumbosacral lordosis (r = 0.27, p = 0.01). Longer fusions were associated with greater loss of thoracic kyphosis (r = -0.31, p = 0.003). Groups differing by preoperative curve size and stiffness had comparable corrections with similar metal density. The pedicle screw cost represented 21-29 % of overall cost of inpatient treatment depending on metal density.Conclusions: Metal density affects cost but not the coronal and sagittal correction of thoracic AIS. Neither larger nor stiffer curves necessitate high metal density. [ABSTRACT FROM AUTHOR]

Purpose: Non-invasive distraction of magnetically controlled growing rods (MCGR) avoids repeated surgical lengthening in patients with early onset scoliosis, but it is not known how effective this technique is in previously operated children.Methods: In a retrospective, multicentre study, the data were obtained for 27 primary (P) patients [mean age 7.0 (2.4-10.7) years at surgery] and 23 conversion (C) patients [mean age 7.7 (3.6-11.0) years at conversion from standard growing rods] with 1-year follow-up.Results: The mean major curve was 63.9° in the P group and 46.5° in the C group at baseline (preoperatively, p = 0.0009) and 39.5° and 39.6°, respectively, at 1-year follow-up (p = 0.99). The mean percentage change of spinal growth from baseline to 1-year follow-up was 18.3 % in the P group and 6.5 % in the C group (p = 0.007). Comparing the spinal growth from postoperative to 1-year follow-up no statistical difference was observed between the study groups (1.8 % P vs -2.2 % C, p = 0.09).Conclusions: Scoliosis can be equally controlled after conversion from traditional growing rods into MCGR, but spinal growth from baseline is less in the conversion patients as compared with the primary group.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: The Dallas Pain Questionnaire (DPQ) assesses the impact of low back pain (LBP) on four components (0-100) of daily life. We estimated the minimal clinically important improvement (MCII) and the patient acceptable symptom state (PASS) values of DPQ in LBP patients.Methods: 142 patients with LBP lasting for at least 4 weeks completed a battery of questionnaires at baseline and 6 months later. Questions for MCII addressed patient-reported response to treatment at 6 months on a five-point Likert scale, while a yes/no question concerning satisfaction with present state was used to determine PASS. MCII was computed as the difference in mean DPQ scores between patients reporting treatment as effective vs. patients reporting treatment as not effective, and PASS was computed as the third quartile of the DPQ score among patients who reported being satisfied with their present state.Results: MCII values were 22, 23, 2 and 10 for daily activities, work and leisure, social interest, and anxiety/depression, respectively. PASS values were 29, 23, 20 and 21 for the four components, respectively. The PASS total score threshold of 24 correctly classified 84.1 % of the patients who reported being unsatisfied with their present state, and 74.7 % of patients reported being satisfied.Conclusions: These values give information of paramount importance for clinicians in interpreting change in DPQ values over time. Authors should be encouraged to report the percentage of patients who reach MCII and PASS values in randomized clinical trials and cohort studies to help clinicians to interpret clinical results. [ABSTRACT FROM AUTHOR]

Purpose Of the Study: To evaluate the results of a novel rigid-dynamic stabilization technique in lumbar degenerative segment diseases (DSD), expressly pointing out the preservation of postoperative lumbar lordosis (LL).Materials and Methods: Forty-one patients with one level lumbar DSD and initial disc degeneration at the adjacent level were treated. Circumferential lumbar arthrodesis and posterior hybrid instrumentation were performed to preserve an initial disc degeneration above the segment that has to be fused. Clinical and spino-pelvic parameters were evaluated pre- and postoperatively.Results: At 2-year follow-up, a significant improvement of clinical outcomes was reported. No statistically significant difference was noted between postoperative and 2-year follow-up in LL and in disc/vertebral body height ratio at the upper adjacent fusion level.Conclusions: When properly selected, this technique leads to good results. A proper LL should be achieved after any hybrid stabilization to preserve the segment above the fusion. [ABSTRACT FROM AUTHOR]

The aim of the present study was to assess the long-term clinical, functional, and radiographic outcome of direct repair of spondylolysis using cerclage wire fixation according to Scott in young patients with symptomatic spondylolysis or low-grade isthmic spondylolisthesis as compared to the outcome after uninstrumented posterolateral in situ fusion. Twenty-five out of 28 patients of the direct repair group (89%) and 23 out of 28 of the fusion group (82%) were available for follow-up examination. The assessment by independent observers included a structured interview (Oswestry questionnaire [ODI], visual analogue scale, SRS questionnaire), a clinical examination, functional testing, plain radiography, and MRI. The groups were comparable as to the mean age at operation (18.2 vs. 16.2 years.), the follow-up time (14.8 vs. 15.0 years), and the amount of preoperative slip (7.2 vs. 13.1%). The mean ODI and SRS total scores were significantly better in the fusion group (4.3 [0–16] and 96 [57–117]) as compared to the direct repair group (11.4[0–52] and 87[53–107]; P=0.02 and P=0.011, respectively). In functional testing, both groups reached normal values for abdominal and back muscle strength. The lumbar spine flexion and extension ROM was decreased in both groups showing no statistical difference between the groups. Significant progressive narrowing of the olisthetic disc was detected on the plain radiographs after direct repair. On the flexion-extension radiographs, in the direct repair group, the mobility in the lytic/olisthetic segment was decreased in comparison to normal values from the literature. The mobility at the level above the operated segment was decreased in the direct repair group as compared to the fusion group ( P=0.057). On T2-weighted MR images in the direct repair group, the signal intensity of the disc below the affected vertebra was decreased in 17/23 (74%) patients. There was no difference between the groups in the nucleus signal intensity of the adjacent disc above the operated segment. No association between the disc degeneration on MRI and the outcome of the patients could be established. In the direct repair group the following complications were seen: transient nerve root irritation (2), superficial infection (1), UTI (1); in the fusion group the complications were: subcutaneous seroma (2) and UTI (1). There were six re-operations, cerclage removal(4), conversion into segmental fusion(2) in the direct repair group, and one re-operation, instrumented respondylodesis, in the fusion group. In conclusion, the results of direct repair of the spondylolysis using cerclage wire fixation according to Scott were very satisfactory in 76% of the patients after a mean follow-up of 14.8 years. After direct repair, the ODI deteriorated with time leading to a clinically moderate but statistically significant difference in favour of segmental fusion. Lumbar spine mobility was decreased after direct repair. Secondary segmental instability above the spinal fusion was not detected. The procedure does not seem to be capable of preventing the olisthetic disc from degeneration. The theoretical benefits of direct repair could not be proven. [ABSTRACT FROM AUTHOR]

Five-lamina (C3-7) procedure is the most popular cervical laminoplasty and there have been no studies on the most appropriate number of laminae to be opened. We prospectively reduced the range of laminoplasty from C3-7 to C3-6 in 2002 and compared the outcome of C3-6 laminoplasty (n=37) to that of C3-7 laminoplasty (n=28). In both groups, neurological gain was satisfactory, radiographic changes were minimal, and postoperative MRI indicated sufficient expansion of the dura and the spinal cord. Average operating period was significantly shorter, and length of the operative wound was significantly less in the C3-6 group than in the C3-7 group. Postoperative axial neck pain was significantly rarer after C3-6 laminoplasty than after C3-7 laminoplasty (5.4% vs. 29%, P=0.015). Due to its simplicity and various benefits, C3-6 laminoplasty is a promising alternative to conventional C3-7 laminoplasty for treatment of multisegmental compression myelopathy. [ABSTRACT FROM AUTHOR]

For anterior correction and instrumentation of thoracic curves single rod techniques are widely used. Disadvantages of this technique include screw pullouts, rod fractures and limited control of kyphosis. This is a prospective study of 23 consecutive patients with idiopathic thoracic scoliosis treated with a new anterior dual rod system. Aim of the study was to evaluate the safety and efficacy of this new technique in the surgical treatment of idiopathic thoracic scoliosis. To the best knowledge of the authors, this is the largest series on dual rod dual screw instrumentation over the entire fusion length in thoracic scoliosis. Twenty-three patients with an average age of 15 years were surgically treated with a new anterior dual rod system through a standard open double thoracotomy approach. Average clinical and radiological follow-up was 28 months (24-46 months). Fusion was carried out mostly from end-to-end vertebra. The primary curve was corrected from 66.6 degrees to 28.3 degrees (57.5% correction) with an average loss of correction of 2.0 degrees at Cobb levels and of 1.3 degrees at fusion levels. Spontaneous correction of the secondary lumbar curve averaged 43.2% (preoperative Cobb angle 41.2 degrees ). The apical vertebral rotation was corrected by 41.1% with a consecutive correction of the rib hump of clinically 66.7%. The thoracic kyphosis measured 29.2 degrees preoperatively and 33.6 degrees at follow-up. In seven patients with a preoperative hyperkyphosis of on average 47.3 degrees thoracic kyphosis was corrected to 41.0 degrees . This new instrumentation enables an entire dual rod instrumentation over the whole thoracic fusion length. It offers primary stability without the need of postoperative bracing. Dual screw dual rod instrumentation offers the advantages of a high screw pullout resistance, an increased overall stability and satisfactory sagittal plane control. [ABSTRACT FROM AUTHOR]

The introduction of the titanium mesh cage (TMC) in spinal surgery has opened up a variety of applications that are realizable as a result of the versatility of the implant. Differing applications of TMCs in the whole spine are described in a series of 150 patients. Replacement and reinforcement of the anterior column represent the classic use of cylindrical TMCs. The TMC as a multisegmental concave support in kyphotic deformities and as a posterior interlaminar spacer or lamina replacement after wide laminectomy are additional applications. Implant subsidence, pseudarthrosis and implant loosening are the complications typically encountered with use of TMCs. The versatility of the implant permits its use in unusual surgical situations. [ABSTRACT FROM AUTHOR]

This single-blind randomised clinical trial compared osteopathic manipulative treatment with chemonucleolysis (used as a control of known efficacy) for symptomatic lumbar disc herniation. Forty patients with sciatica due to this diagnosis (confirmed by imaging) were treated either by chemonucleolysis or manipulation. Outcomes (leg pain, back pain and self-reported disability) were measured at 2 weeks, 6 weeks and 12 months. The mean values for all outcomes improved in both groups. By 12 months, there was no statistically significant difference in outcome between the treatments, but manipulation produced a statistically significant greater improvement for back pain and disability in the first few weeks. A similar number from both groups required additional orthopaedic intervention; there were no serious complications. Crude cost analysis suggested an overall financial advantage from manipulation. Because osteopathic manipulation produced a 12-month outcome that was equivalent to chemonucleolysis, it can be considered as an option for the treatment of symptomatic lumbar disc herniation, at least in the absence of clear indications for surgery. Further study into the value of manipulation at a more acute stage is warranted. [ABSTRACT FROM AUTHOR]

A total of 101 outpatients with acute or sub-acute low-back pain was randomly allocated to one of two treatment groups. One group was given standardised conventional and optimised activating treatment by primary health care teams. The other group received, according to a pragmatic approach, another treatment programme including manipulation, specific mobilisation, muscle stretching, autotraction and cortisone injections. The treatment effect was evaluated by standardised telephone interviews 3, 7, 14, 21 and 90 days after the start of treatment. The two groups were similar in most of the pretrial variables, including age, sex, occupation, education, previous low-back pain problems, previous treatment, sick-leave, findings at the physical examination, quality-of-life score, presence of common symptoms, disability rating and pain score. In the early phase as well as at the 90 days' follow-up, the group receiving manual therapy had significantly less pain, less disability, faster rate of recovery and lower drug consumption, indicating that this type of treatment is superior to conventional treatment. [ABSTRACT FROM AUTHOR]