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Background: Few researchers have verified the clinical efficacy and safety of the modified unilateral extrapedicular approach (mUEP) applied to the percutaneous kyphoplasty (PKP) in comparative studies with other puncture techniques. Compared with the bilateral transpedicular approach (BTP), whether mUEP PKP is a preferred treatment for lumbar osteoporotic vertebral compression fracture (OVCF) remains unclear., Methods: Patients treated by PKP for single-level lumbar OVCF in our institution from September 2019 to December 2020 were retrospectively enrolled. Patients were grouped according to the puncture techniques. Clinical and radiologic outcomes were evaluated preoperatively, postoperatively, and at follow-up. The clinical evaluation was performed by using visual analog scale for pain relief and Oswestry Disability Index for health status. Radiologic measurements contained anterior vertebral height, kyphotic angle, and bone cement distribution., Results: In total, 76 patients with a mean follow-up duration of 16.6 months were enrolled, including 34 patients in the mUEP PK group and 42 patients in the BTP PKP group. In the mUEP group, operation time, fluoroscopy times, and injected cement volume were significantly less than that in the BTP group (P < 0.01). Both visual analog scale and Oswestry Disability Index scores of all patients decreased significantly after surgery (P < 0.01), with no significant differences between the 2 groups at each follow-up. Both mUEP PKP and BTP PKP showed significant anterior height restoration and kyphotic angle correction (P < 0.01), with no significant differences between the 2 groups at each follow-up. Meanwhile, the mUEP PKP reduced the incidence of intraspinal cement leakage (P < 0.05), and no facet joint violation was found in mUEP PKP., Conclusions: mUEP PKP could be clinically and radiographically equivalent to BTP PKP. However, it has advantages in reducing operation time and fluoroscopy times, lowering the risk of intraspinal cement leakage, and preventing the presence of facet joint violation. Compared with BTP PKP, the mUEP PKP seems to be an effective and alternative puncture technique for the treatment of lumbar OVCF after appropriate patient selection., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Our study aims to investigate the clinical outcome of 1-stage posterior vertebral column resection (PVCR) for adolescent thoracic and lumbar tuberculosis with severe kyphotic deformity (Cobb angle≥60°)., Methods: Between January 2008 and January 2016, we recorded 16 (9 male, 7 female) adolescent cases of thoracic and lumbar tuberculosis complicated with severe kyphotic deformity treated by 1-stage PVCR (average age: 15.38 ± 1.54 years; range: 13-18 years). The Cobb angle of kyphosis was 64.56° ± 3.41°. According to the American Spinal Injury Association (ASIA) classification, all patients were classified preoperatively. The lesions involved T4-T11 in 10 cases and T12-L2 in 6 cases., Results: The mean follow-up time was 19.06 ± 11.42 months (range: 12-48 months). Based on ASIA classification, postoperative grades were significantly increased compared with preoperative grades (P < 0.05), The mean Cobb angle was significantly corrected to 20.25° ± 13.83° at 1 week after surgery, when compared with preoperative Cobb angle (P < 0.05). There was no significant difference in Cobb angle between 1-week after operation and the last follow-up (20.69° ± 13.83°) (P > 0.05). All the patients achieved bony fusion at a mean time of 14 months (range: 10-20 months) postoperatively. No fixation loosening, displacement, or fracture was observed during follow-up., Conclusions: One-stage PVCR is an effective surgical method for the treatment of adolescent thoracic and lumbar spinal tuberculosis with severe kyphotic deformity, which can completely remove the lesion, effectively correct the kyphosis deformity, and prevent related complications., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Proximal junctional kyphosis (PJK) and proximal junction failure are common and costly complications after long-segment adult spinal deformity (ASD) correction. Although much research has focused on the concept of "softening the landing" to prevent proximal junction pathologies, long-segment constructs largely deviate from the force-deformation curve of the physiologic spine. Our novel distributed loading technique for ASD correction is described using multimaterial, long-segment constructs to create a biomechanically sound, yet physiologic, decremental stiffness toward the rostral end., Methods: Operative steps detail the custom-designed constructs of dual-headed pedicle screws and varied rod diameters and materials (cobalt chromium or titanium) for an initial 20 patients (mean 66.6 ± 4.8 years). Standing scoliosis films were obtained preoperatively and at regular intervals postoperatively to assess for PJK., Results: No patient had evidence of PJK or proximal junction failure at latest radiographic follow-up (mean 17.9 months, range 13-25 months). Radiographic findings for sagittal vertical axis averaged 11.2 ± 5.6 cm preoperatively and 3.6 ± 2.3 cm postoperatively. Compared with preoperative parameters, postoperative reductions in pelvic incidence-lumbar lordosis mismatch averaged 28.7 ± 12.9 degrees, and sagittal vertical axis averaged 7.6 ± 5.2 cm while PJA was essentially unchanged., Conclusions: Preliminary results suggest that the distributed loading technique is promising for prevention of PJK with stiffness gradients that mimic the force-deformation curve of the physiologic posterior tension band. Our technique may optimize the degree of stress at the proximal junction without overwhelming the anterior column bony while remodeling and mature arthrodesis takes place., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Pedicle screw fixation (PSF) has been considered the preferred surgery for the treatment of severe osteoporotic vertebral compression fracture (sOVCF), and sOVCF was traditionally regarded as a relative contraindication to minimally invasive percutaneous kyphoplasty (PKP). Debate has continued regarding the selection of the best surgical method for sOVCF. In the present study, we compared the efficacy and safety between PKP and PSF., Methods: PKP was performed in 376 patients in group 1 and PSF in 121 patients in group 2. The visual analog scale (VAS), Oswestry disability index (ODI), local kyphotic angle, fractured vertebral body height, and complications were evaluated., Results: In the immediate postoperative analysis, the mean VAS score for group 1 was 2.4, significantly lower than the VAS score of 4.7 for group 2. The mean ODI score was 44.4% for group 1, lower than the ODI score of 57.1% for group 2. In addition, group 1 had had a significantly better ODI score at 1 year of follow-up. The local kyphotic angle and fractured vertebral body height had recovered better in group 2. In group 1, 113 patients had experienced cement leakage, and 29 patients had undergone PKP for adjacent new vertebral fractures. In group 2, 2 patients had developed wound infections, 4 had developed pneumonia, 2 had developed urinary tract infection, 3 had experienced asymptomatic screw loosening, and 7 had undergone PKP to treat new vertebral fractures and 1 had undergone removal of internal fixation because of back pain., Conclusions: The results of the clinical and radiological evaluations showed that PKP is comparable to PSF for the treatment of sOVCF with kyphosis, with PKP having the advantages of minimal invasion, quick postoperative pain relief, and functional recovery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: We investigated the characteristics and revision rate of junctional failure after surgical correction for thoracolumbar kyphosis in patients with ankylosing spondylitis., Methods: A total of 230 patients had undergone surgical correction for thoracolumbar kyphosis from 2010 to 2019. The state of ankylosis between the uppermost instrumented vertebra (UIV) and UIV+1 and between the lowermost instrumented vertebra (LIV) and LIV-1 was analyzed using a modified Stoke ankylosing spondylitis spine score. Proximal junctional failure (PJF) and distal junctional failure (DJF) were defined as any type of symptomatic junctional failure., Results: Of the 230 patients, 23 (10.0%) had developed junctional failure. Of these 23 patients, 16 had had partial ankylosis and 7 had had complete ankylosis. PJF had developed in 10 patients and DJF in 13. The most common type of junctional failure was a junctional fracture, which developed in 12 patients. PJF had developed by UIV fracture in 4 patients, UIV+1 fracture in 1 patient, and UIV+2 in 1 patient. DJF had developed by LIV fracture in 6 patients, metallic failure in 5, and progression of DJF in 2 patients. The average time to the development of PJF and DJF was 13 months and 12.4 months, respectively. All 10 patients with PJF and 7 of 13 patients with DJF (53.8%) had required reoperation. Of the 12 patients with junctional fracture, 11 (91.7%) had undergone reoperation., Conclusions: Of the 23 patients with junctional failure, 16 had had immature ossification of the anterior longitudinal ligament. Therefore, to prevent junctional failure, the state of ankylosis seems to be important for selecting the fusion level after osteotomy. Once junctional failure has developed, however, reoperation should be considered owing to the stress concentration at the UIV or LIV., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Spinal osseous tuberculosis, or Pott's spine, although very common in endemic countries, has a lower incidence in very young children. However, the infection has the propensity to cause greater vertebral destruction in this age group, leading to severe structural kyphotic deformity and associated neurologic deficits. We report the case of a 19-month-old child with severe tubercular kyphotic deformity of the upper thoracic spine managed with posterior vertebral column resection (VCR) and nonfusion posterior pedicle screw instrumentation., Case Description: This 19-month-old boy presented with 1-month history of spontaneous-onset, progressive, painful rigid kyphotic deformity of the upper back associated with spastic paraparesis with bowel and bladder incontinence. Magnetic resonance imaging showed severe destruction of bodies of D4-D7 vertebrae with cord edema and draping of the spinal cord over the internal gibbus at D4-D7. Surgery was performed with a restricted anterior fusion via single-stage posterior VCR at D4-D7 with nonfusion pedicle screw instrumentation from D1 to D9, with subsequent extension of instrumentation to D10 after 4 months., Conclusions: Multilevel posterior VCR with a restricted fusion and nonfusion pedicle screw instrumentation beyond the resection site can be safely done in young children (age <3 years) requiring rigid tubercular kyphotic deformity correction. However, these patients require regular follow-up and may need multiple surgeries., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: We aimed to compare the clinical efficacy of titanium mesh cage with that of allogeneic bone graft to reconstruct the anterior column through posterior approach for the surgical management of patients with thoracolumbar spinal tuberculosis with kyphosis., Methods: From January 2011 to March 2013, 57 patients with single-segment or two-segments thoracolumbar spinal tuberculosis with kyphosis were treated by debridement, interbody graft, posterior instrumentation, and fusion via a posterior-only procedure. Twenty-four patients in group A were treated with allogeneic bone graft to reconstruct the anterior column, whereas 33 patients in group B were treated with titanium mesh cage. The clinical efficacy was evaluated by visual analog scale (VAS), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), neurologic function recovery, kyphotic Cobb angle, and postoperative complications., Results: The mean follow-up was 72.4 months. Neurologic function was significantly improved after surgery in all cases. There were significant differences of VAS, ESR, and CRP between preoperation and postoperation at the final follow-up, with no significant difference between the two groups. The kyphotic Cobb correction was significantly improved when compared with those in preoperation, but there was no significant difference between the two groups. One patient in group A with two segments involved experienced graft fracture. He had anterior bone graft with titanium mesh cage., Conclusions: Minimum 5-year follow-up outcomes showed that one-stage posterior focus debridement, interbody graft using titanium mesh cages, posterior instrumentation, and fusion is an effective treatment for patients with thoracolumbar spinal tuberculosis accompanied by kyphosis. It may obtain better clinical efficacy than allogeneic bone graft for treating two-segments thoracolumbar spinal tuberculosis., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Cervical kyphosis (CK) has been reported in patients with adolescent idiopathic scoliosis (AIS). The report about the incidence of CK between patients with AIS and normal populations was little. Patients included in previous studies often required scoliosis surgery (Cobb angle ≥40°), which does not represent all patients with AIS. The aims of this study were to compare incidence of CK between patients with AIS (Cobb angle >10°) and an age-matched normal population and to identify risk factors related to CK, especially coronal parameters that have rarely been studied in current literature., Methods: Patients with AIS (n = 112) and asymptomatic subjects from the general population (control group; n = 40) were retrospectively analyzed. Radiographic parameters of coronal and sagittal plane were measured on full-length spine x-rays. Patients with AIS were divided into 2 groups based on cervical lordosis angle: cervical lordosis and CK., Results: CK was observed in 14 of 40 (35%) subjects in the control group and 68 of 112 (60.7%) patients with AIS. Several parameters were related to CK, including major curve, proximal thoracic, and main thoracic Cobb angle; proximal thoracic kyphosis angle; main thoracic kyphosis angle; T1 slope; sagittal vertical axis; vertical distance between C7 plumb line and center sacral vertical line; apical vertebral translation; T1 coronal tilt; and lumbar pelvic relationship. Logistic regression identified main thoracic Cobb angle, main thoracic kyphosis angle, sagittal vertical axis, lumbar pelvic relationship, and apical vertebral translation as independent risk factors of CK., Conclusions: Incidence of CK increases in patients with AIS relative to normal subjects. Coronal parameters of the spine could influence cervical sagittal alignment., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Severe kyphoscoliosis associated with multiple giant spinal epidural arachnoid cysts (SEACs) is an extremely rare condition and remains a challenge in clinical practice. This study aimed to present a case of severe spinal deformity associated with multiple giant SEACs and to discuss strategies for the preoperative diagnosis and treatment., Case Description: A 22-year-old man with severe thoracolumbar kyphoscoliosis associated with multiple giant SEACs presented with progressive scoliosis, spastic paralysis, numbness, and abnormal gait. X-ray and magnetic resonance imaging revealed severe rigid kyphoscoliosis, extensive diffuse cystic space-occupying lesions, and diffuse spinal cord compression. After multidisciplinary consultation and discussion, the patient underwent a cyst-peritoneal shunting surgery followed by posterior vertebral column resection (PVCR) correction. The postoperative course was uneventful. Both kyphosis and scoliosis were significantly corrected, and muscle weakness of the lower extremities and sensory disturbance partially improved. At the 2-year follow-up visit, the patient could freely walk without the aid of crutches, but there were some residual neurologic deficits in both legs. A plain radiograph showed that bony fusion was achieved, and the correction was well maintained., Conclusions: Cyst-peritoneal shunting surgery followed by PVCR, as in our case, could be an alternative surgical strategy for multiple giant SEACs associated with severe rigid kyphoscoliosis., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: We assessed the contribution of a dynamic surgical guidance (DSG) probe in the accurate placement of thoracic and lumbar pedicle screws (PSs) in patients with spinal deformity., Methods: A retrospective review was performed of 98 patients (104 procedures) with various spinal deformities, who had received posterior instrumentation with PSs inserted using either DSG or the conventional free-hand (FH) technique. A total of 882 PSs were inserted using DSG (DSG group) and 603 using the FH technique (FH group). The DSG probe was preferably chosen for large osteosyntheses and severe deformities. Two neurosurgeons, unaware of the surgical groups, reviewed all the intraoperative computed tomography scans and assessed all the PS placements., Results: Of the PSs used, 95.4% in the DSG group and 92.2% in the FH group were correctly placed (P = 0.0136). The difference in screw placement accuracy was greater at the thoracic level (DSG group, 92.5%; vs. FH group, 87.0%; P = 0.0310) than at the lumbar level (DSG group, 98.0%; vs. FH group, 95.4%; P = 0.0385). Severe (>4 mm) lateral breaches occurred in 24 cases (4.0%) in the FH group but in only 5 (0.6%) in the DSG group (P < 0.0001). No severe medial breach was observed in either group., Conclusions: Despite having more patients with severe deformities in the DSG group, PS insertion was significantly more accurate with DSG. This technique also reduced the severe unacceptable lateral misplacement rate (>4 mm) and, consequently, the incidence of intraoperative screw revisions even in patients with severe deformities., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Thoracic ossification of the ligamentum flavum (OLF) is a common cause of thoracic myeloradiculopathy. Thoracolumbar kyphosis derived from abnormal embryonic development of the spine vertebrae often progresses continuously and causes neurologic deterioration. These conditions are presented separately in most cases. A diagnosis of both OLF and thoracolumbar kyphosis in the same patient is rare, and no definite principle of surgical strategy for this case could be found in the literature., Case Description: Here we report a 36-year-old woman who suffered from weakness and numbness of bilateral lower extremities for 2 years and urinary dysfunction for 1 month. On physical examination, the strength of muscles of lower limbs was grade 2 and the sensory system was bilaterally lost below the inguinal groove with numbness in the saddle area. Hyperreflexia was found in both lower limbs, and the Babinski sign was positive bilaterally. Thoracic OLF and thoracolumbar kyphosis were diagnosed on the basis of clinical presentation, radiograph, computed tomography, and magnetic resonance imaging. We performed 1-stage laminectomy and kyphosis correction by posterior vertebral column resection. The patient experienced postoperative paraplegia, and the strength of muscles of lower limbs recovered to the preoperative level at 1-year follow-up and stopped improving until the 5-year follow-up. However, the urinary dysfunction became normal at 3 months postoperative. Kyphotic deformity was corrected from preoperative 83.5 degrees to 35.0 degrees at the final follow-up, and bone fusion was achieved around the mesh cage without implantation failure., Conclusions: For patients with thoracic OLF and thoracolumbar kyphosis derived from wedged vertebrae, 1-stage laminectomy and kyphosis correction has a risk that may lead to a negative outcome. Staging operation should be taken into consideration when planning a surgical strategy for the treatment of kyphosis associated with concurrent compressive myelopathy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Thoracic kyphosis can result in neurologic deficits, pain, and cardiopulmonary dysfunction. Vertebral column resection (VCR) is a powerful technique that can be employed for large curves and fixed deformities. This study reports the outcomes of posterior VCR for adult spinal deformity with severe thoracic kyphosis., Methods: A retrospective review of all patients with adult spinal deformity who underwent posterior VCR for severe thoracic kyphosis (defined as segmental kyphosis greater than 80°) was performed. Patients with kyphosis secondary to trauma, tumor, or infection were excluded. Perioperative, radiographic, and minimum 2-year outcomes were assessed., Results: Nineteen patients were included. Mean age was 57.1 years and 31.6% were male. Mean preoperative sagittal vertical axis was 57.7 mm and thoracic kyphosis was 92.2°. Among 19 patients, 24 VCR were performed. Mean blood loss was 2188 mL. Perioperative complication rate was 36.8% and mortality rate was 5.3%. Mean postoperative sagittal vertical axis was 42.3 mm and thoracic kyphosis was 58.1°. Incidence of junctional failure at 2-year follow-up was 14.8%: 1 proximal and 2 distal. All patients with junctional disease required reoperation. At mean 35.7-month follow-up, 61.1% of patients reported a significant reduction of back pain and 50.0% were able to reduce their dose of opioid medications., Conclusions: Single-stage posterior VCR is a powerful technique for the correction of severe thoracic kyphosis. Perioperative morbidity can be high, but a majority of patients fare well at follow-up. Junctional disease occurs both proximal and distal; surgeons should continue to implement strategies to minimize distal junctional disease., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The optimal surgical procedure for degenerative cervical kyphosis with stenosis (DCKS) remains controversial. The purpose of this study is to describe the preliminary clinical and radiologic results of anterior controllable antedisplacement fusion (ACAF) as a surgical technique for DCKS., Methods: In the period from 2016 through 2017, a consecutive cohort of adults with degenerative cervical kyphosis (30° ≥ Cobb angles ≥5°) and stenosis (anteroposterior diameter of the spinal canal <12 mm) underwent ACAF, a technique making the vertebrae move forward in a hoisting manner. We retrospectively reviewed these patients, and primary outcomes of interest included operation duration, blood loss, hospital stay, kyphosis correction, decompression width, anteroposterior diameter of the spinal canal, morphology of the spinal cord, Japanese Orthopaedic Association (JOA) scores, and complications., Results: Thirty patients were included in the study. All patients were followed for a mean of 12 months. Mean operation duration and estimated blood loss were 104.8 minutes and 221.6 mL, respectively, and the mean length of hospital stay was 5.6 days. The decompression width reached 17.7 mm. The postoperative anteroposterior diameter of the spinal canal was 14.8 mm, with a significant improvement compared with preoperation (P < 0.01). There was also significant kyphosis correction after operation (20.4° vs. 4.8°, P < 0.01). The mean JOA score was significantly better than preoperation (15.0 vs. 9.3 points; P < 0.01). There were no surgery-related complications., Conclusions: ACAF, correcting cervical kyphosis and simultaneously enlarging the volume of the spinal canal, is a good choice for DCKS., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: We discuss the role of instability of multiple spinal segments including the atlantoaxial joint in the pathogenesis of cervical kyphotic deformity., Material and Methods: Two male patients (5 and 17 years old) had severe cervical kyphosis and presented with symptoms related to myelopathy. The patients underwent multisegmental spinal distraction and fixation that included atlantoaxial joint. No bone decompression was done., Results: At a follow-up of >30 months, both patients had significant neurologic recovery. Investigations at follow-up showed successful arthrodesis of treated spinal segments. Although incomplete, there was recovery in kyphosis., Conclusions: Multisegmental spinal distraction and fixation can lead to reduction in kyphosis and relief from symptoms related to myelopathy. Role of spinal instability in general and atlantoaxial joint instability in particular in pathogenesis of cervical kyphosis need to be assessed on the basis of studies with a larger number of patients., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Select patients with unremitting symptoms of cervical radiculopathy may be treated with indirect foraminal decompression and fusion via placement of a cervical cage placed bilaterally through a tissue sparing, posterior approach. Segmental fusion is known to affect adjacent segments. The aim of this study was to assess the affect of posterior fusion using bilateral cervical cages on adjacent segment degeneration (ASDegeneration) at 2 years postoperatively., Methods: Fifty-three patients enrolled in a prospective multicenter study who completed the imaging protocol were available for follow-up at 2 years. Lateral cervical radiographs were acquired preoperatively and at 1- and 2-years postoperatively. Imaging was evaluated for adjacent level degeneration using the following criteria: disk height ratio (DHR) defined as the ratio of the disk height and the lower vertebrae height measured at level above and below; proximal junctional kyphosis (PJK); Kellgren and Lawrence osteoarthritis severity grade (KLOSG); and heterotopic ossification (HO). The results were compared with a repeated analysis of variance test and Bonferroni correction; P < 0.05 was considered significant., Results: At 2 years postoperatively, there were no revision surgeries at the operated level or new surgeries at the adjacent levels. Of the 102 segments evaluated, ASDegeneration was identified at 21 levels cranial to and 21 levels caudal to the index level. At 2 years, new mild ASDegeneration signs developed at 3 levels: 1 in the level above and 2 in the level below the operated segment. In patients with pre-existing disk degeneration, mild progression of ASDegeneration signs developed in 6 upper and 2 lower segments. There were no significant changes in DHR and PJK in all patients; however, when patients with signs of ASDegeneration only were evaluated, a significant decrease of the DHR was found. The mean DHRs before surgery and 1 and 2 years after surgery in all patients were 44.0 ± 8.1, 44.0 ± 8.2, and 43.1 ± 8.4 (P = 0.1006) and in ASD patients were 43.8 ± 7.3, 41.9 ± 6.3, and 39.6 ± 8.3 (P = 0.0062), respectively. Overall, at 2 years postoperatively, ASDegeneration was identified in 9 patients (17.6% when compared with all evaluated patients before surgery)., Conclusions: In the current study, 5.9% of subjects treated with posterior cervical cages placed bilaterally between the facet joints developed adjacent segment degeneration at 2 years. Mild progression of existing degeneration was observed in 11.8% of subjects. Further evaluation to establish long-term incidence is needed., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Progressive rotational dislocation of the spine is rare and surgical treatment is challenging. Few reports have described surgical decompression, fusion, and partial correction by traditional 2-stage anterior decompression and the posterior fixation technique. The goal of this retrospective study was to report a series of 6 patients with this deformity and the outcome after treatment by posterior-only 2-level vertebral column resection (PVCR)., Methods: Between 2011 and 2014, 6 patients were treated for kyphoscoliotic deformities with progressive rotational dislocation. In these 6 patients (2 males and 4 females), the diagnosis included 4 cases of congenital kyphosis and 2 cases of neurofibromatosis; the distribution of spine level was from T4 to T11; the kyphosis angle of the patients was 115° (range, 107-125°); the scoliosis angle was 97° (range, 80°-117°); follow-up ranged from 13 to 51 months (mean, 27 months). Four patients developed progressive onset of neurologic deficit. All patients underwent surgery by 2-level PVCR for decompression and correction of kyphoscoliosis., Results: Postoperatively, the patients all had different kyphosis correction rates, from 49% to 72% (mean, 63%) and scoliosis correction rates, from 57% to 78% (mean, 65%). All patients achieved successful spinal fusion with less than 3° of loss of correction at the latest follow-up evaluation. The 4 patients with incomplete neurologic deficits improved 1 or 2 American Spinal Injury Association scales at follow-up of at least 6 months., Conclusions: Two-level PVCR is a safe and efficacious surgical option for the treatment of rotational dislocation in kyphoscoliosis and associated neurologic deficit., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Adult spinal deformity (ASD) surgery carries the risk of spinal cord injury. Spinal cord ischemia is often implicated in the pathogenesis but has not been directly investigated. Here we present our index case as a proof of concept for a study evaluating the role of spinal cord perfusion (SCP) changes in ASD correction., Methods: ASD surgery was performed in the usual fashion with the addition of 1) SCP monitoring, using laser Doppler probe fixated to the dura at the level of the pedicle subtraction osteotomy (PSO) and 2) intrathecal pressure monitoring, using a lumbar drain. Somatosensory evoked potential (SSEP) and motor evoked potential (MEP) were monitored throughout the case., Results: An 84-year-old male with kyphoscoliosis and progressive myelopathy causing diminished motor and sensory function was treated with T4 PSO and long segment reconstruction. At baseline, SSEP signals were detectable in all 4 extremities, MEP signals were present in the right foot only, intrathecal pressure was 4 mm Hg, and mean SCP was 21.2 perfusion units. The osteotomy was performed and reduced in 2 steps. After the first step of reduction, MEP signals appeared in the left leg and increased in amplitude in the right leg, and SCP simultaneously increased to 205.6. Further reduction led to MEP signal loss in both legs and decrease in SCP to 39.2. With partial reversal of the reduction, MEP signals returned in both legs and SCP improved to 76.0. Final reduction maneuvers were then performed in a delayed fashion before closure, with stable MEP signals and a final SCP of 42.9. SSEP signals, vital signs, and intrathecal pressure were stable throughout the case. Postoperatively the patient was neurologically stable., Conclusions: The present case provides the first direct evidence that fluctuations in SCP may contribute to neurologic changes during ASD surgery. Further investigation is under way to further elucidate the underlying mechanisms, with the ultimate goal of developing targeted strategies for spinal cord protection during these high-risk cases., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Surgical treatment for severe circumferentially fixed cervical kyphosis has been challenging. Both anterior and posterior releases are necessary to provide the cervical mobility necessary for fusion in a corrected position., Objective: In two case reports, we describe the circumferential osteotomy of anterior-posterior-anterior surgical sequence, and the efficacy of this technique when cervical pedicle screw fixation for severe fixed cervical kyphosis is used., Case Description: Etiology of fixed cervical kyphosis was unknown in one patient and neurofibromatosis in one patient. Both patients had severe fixed cervical kyphosis as determined by cervical radiographs and underwent circumferential osteotomy and fixation via an anterior-posterior-anterior surgical sequence and correction of kyphosis by pedicle screw fixation., Conclusion: Severe fixed cervical kyphosis was treated successfully by the use of circumferential osteotomy and pedicle screw fixation. The surgical sequence described in this report is a reasonable approach for severe circumferentially fixed cervical kyphosis and short segment fixation can be achieved using pedicle screws., (Copyright © 2013 Elsevier Inc. All rights reserved.)