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Previous studies of patient positioning during spinal surgery evaluated intraoperative or immediate postoperative outcomes after short-instrumented lumbar fusion. However, patient positioning during long-instrumented fusion for an adult spinal deformity (ASD) might be associated with differences in intraoperative parameters such as blood loss and longer-term outcomes such as spine alignment, and comparing types of surgical tables in the context of these larger procedures and evaluating longer-term outcome scores seem important.(1) Do blood loss and the number of transfusions differ between patients who underwent multi-level spinal fusion with a Wilson frame and those with a four-poster frame? (2) Does restoration of lumbar lordosis and the sagittal vertical axis differ between patients who underwent surgery with the use of one frame or the other? (3) Do clinical outcomes as determined by Numeric Rating Scale and Oswestry Disability Index scores differ between the two groups of patients? (4) Are there differences in postoperative complications between the two groups?Among 651 patients undergoing thoracolumbar instrumented fusion between 2015 and 2018, 129 patients treated with more than four levels of initial fusion for an ASD were identified. A total of 48% (62 of 129) were eligible; 44% (57 of 129) were excluded because of a history of fusion, three-column osteotomy, or surgical indications other than degenerative deformity, and another 8% (10 of 129) were lost before the minimum 2-year follow-up period. Before January 2017, one surgeon in this study used only a Wilson frame; starting in January 2017, the same surgeon consistently used a four-poster frame. Forty patients had spinal fusion using the Wilson frame; 85% (34 of 40) of these had follow-up at least 2 years postoperatively (mean 44 ± 13 months). Thirty-two patients underwent surgery using the four-poster frame; 88% (28 of 32) of these were available for follow-up at least 2 years later (mean 34 ± 6 months). The groups did not differ in terms of age, gender, BMI, type of deformity, or number of fused levels. Surgical parameters such as blood loss and the total amount of blood transfused were compared between the two groups. Estimated blood loss was measured by the amount of suction drainage and the amount of blood that soaked gauze. The decision to transfuse blood was based on intraoperative hemoglobin values, a protocol that was applied equally to both groups. Radiologic outcomes including sagittal parameters and clinical outcomes such as the Numerical Rating Scale score for back pain (range 0-10; minimal clinically important difference [MCID] 2.9) and leg pain (range 0-10; MCID 2.9) as well as the Oswestry Disability Index score (range 0-100; MCID 15.4) were also assessed through a longitudinally maintained database by two spine surgeons who participated in this study. Repeated-measures analysis of variance was used to compare selected radiologic outcomes between the two groups over time.Blood loss and the total amount of transfused blood were greater in the Wilson frame group than in the four-poster frame group (2019 ± 1213 mL versus 1171 ± 875 mL; mean difference 848 [95% CI 297 to 1399]; p = 0.003 for blood loss; 1706 ± 1003 mL versus 911 ± 651 mL; mean difference 795 [95% CI 353 to 1237]; p = 0.001 for transfusion). Lumbar lordosis and the sagittal vertical axis were less restored in the Wilson frame group than in the four-poster frame group (7° ± 10° versus 18° ± 14°; mean difference -11° [95% -17° to -5°]; p0.001 for lumbar lordosis; -22 ± 31 mm versus -43 ± 27 mm; mean difference 21 [95% CI 5 to 36]; p = 0.009 for the sagittal vertical axis). Such differences persisted at 2 years of follow-up. The proportion of patients with the desired correction was also greater in the four-poster frame group than in the Wilson frame group immediately postoperatively and at 2 years of follow-up (50% versus 21%, respectively; odds ratio 3.9 [95% CI 1.3 to 11.7]; p = 0.02; 43% versus 12%, respectively; odds ratio 5.6 [95% CI 1.6 to 20.3]; p = 0.005). We found no clinically important differences in postoperative patient-reported outcomes including Numeric Rating Scale and Oswestry Disability Index scores, and there were no differences in postoperative complications at 2 years of follow-up.The ideal patient position during surgery for an ASD should decrease intra-abdominal pressure and induce lordosis as the abdomen hangs freely and hip flexion is decreased. The four-poster frame appears advantageous for long-segment fusions for spinal deformities. Future studies are needed to extend our analyses to different types of spinal deformities and validate radiologic and clinical outcomes with follow-up for more than 2 years.III, therapeutic study.

Study design Retrospective case analyses. Objective The aim of this study was to investigate the incidence and characteristics of associated upper cervical spine injuries in 15 survival cases of traumatic atlanto-occipital dislocation (AOD). Summary of background data Traumatic AOD is a rare and generally fatal injury. Information regarding associated upper cervical spine injuries that may affect treatment methods, outcomes, and prognosis is limited. Methods Fifteen patients (11 patients with posterior-type AOD and four patients with vertical-type AOD) who survived traumatic AOD were included in this study. Plain radiographs, computed tomography, magnetic resonance imaging, and medical records were reviewed. The incidence and characteristics of associated upper and lower cervical spine and thoracolumbar spine injuries and brain injuries were evaluated. Results Thirteen patients with traumatic AOD (11 patients with posterior-type AOD and two patients with vertical-type AOD) showed associated upper cervical spine injuries; the overall incidence was 87% (100% in posterior-type AOD and 50% in vertical-type AOD). In posterior-type AOD, eight (72.7%) patients had C1 fractures (four patients had three-part fracture, three patients had two-part fracture, and one patient had four-part fracture), four (36.4%) patients had C1 lateral mass fractures, two (18.2%) patients had transverse atlantal ligament injuries. In vertical-type AOD, two (50%) patients had C1-C2 vertical subluxation with C1 anterior arch horizontal and sagittal split fractures. In posterior-type AOD, two (18%) patients had lower cervical spine injuries and one (9%) patient had brain injury. In vertical-type AOD, one (25%) patient had thoracic spine injury, and three (75%) patients had brain injuries additionally. Conclusion Survival cases with traumatic AOD showed a high incidence of associated upper cervical spine injuries and brain injuries. High index of suspicion and careful radiologic examination are needed to investigate the presence of associated upper cervical spine injuries and brain injuries in traumatic AOD, which affects treatment, outcome, and prognosis. Level of evidence 4.

STUDY DESIGN A retrospective study. OBJECTIVE The purpose of this study was to evaluate the morphology of rib regeneration and to analyze the influence of demographics and curve characteristics on regeneration potential after thoracoplasty in the treatment of adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA Studies on the physiological effects after thoracoplasty have been performed for several decades. However, rib cage anatomical regeneration patterns and reformation have been rarely studied. METHODS A total of 120 AIS patients who underwent thoracoplasty with deformity correction were included. Patients were followed for >12 months and radiographic assessment was done at 3, 6, and 12 months. Conventional or short apical rib resection thoracoplasty was performed and 543 ribs were resected. Demographic and curve parameters were recorded and a rib regeneration classification was used to analyze regeneration. Computed tomography (CT) scan was performed only in selected patients (n = 74). RESULTS At end of 3, 6, and 12 months, 23%, 45%, and 60% of the ribs had fused respectively. On multiple logistic regression analysis, age

Study design This was a retrospective comparative study. Objective The main objective of this article was to evaluate the clinical and radiologic efficacies of minimally invasive lateral lumbar interbody fusion (LLIF) for clinical adjacent segment pathology (ASP). Summary of background data Minimally invasive techniques have been increasingly applied for spinal surgery. No report has compared LLIF with conventional posterior lumbar interbody fusion for clinical ASP. Methods Forty patients undergoing LLIF with posterior fusion (hybrid surgery) were compared with 40 patients undergoing conventional posterior lumbar interbody fusion (posterior surgery). The radiologic outcomes including indirect decompression in hybrid surgery group, and clinical outcomes such as the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) were assessed. Postoperative major complications and reoperations were also compared between the 2 groups. Results Correction of coronal Cobb's angle and segmental lordosis in the hybrid surgery were significantly greater postoperatively (2.8 vs. 0.9 degrees, P=0.012; 7.4 vs. 2.5 degrees, P=0.009) and at the last follow-up (2.4 vs. 0.5 degrees, P=0.026; 4.8 vs. 0.8 degrees, P=0.016) compared with posterior surgery. As regards indirect decompression of the LLIF, significant increases in thecal sac (83.4 vs. 113.8 mm) and foraminal height (17.8 vs. 20.9 mm) were noted on postoperative magnetic resonance imaging. Although postoperative back VAS (4.1 vs. 5.6, P=0.011) and ODI (48.9% vs. 59.6%, P=0.007) were significantly better in hybrid surgery, clinical outcomes at the last follow-up were similar. Moreover, intraoperative endplate fractures developed in 17.7% and lower leg symptoms occurred in 30.0% of patients undergoing hybrid surgery. Conclusions Hybrid surgery for clinical ASP has advantages of segmental coronal and sagittal correction, and indirect decompression compared with conventional posterior surgery. However, LLIF-related complications such as endplate fracture and lower leg symptoms also developed. LLIF should be performed considering advantages and approach-related complications for the clinical ASP.

STUDY DESIGN This was a retrospective comparative study. OBJECTIVE To evaluate long-term outcomes of selective thoracic fusion (STF) using both rod derotation (RD) and direct vertebral rotation (DVR) with pedicle screw instrumentation (PSI) in the treatment of thoracic adolescent idiopathic scoliosis (AIS) with a minimum 10-year follow-up. SUMMARY OF BACKGROUND DATA Postoperative compensation and maintenance of the unfused lumbar curve after STF is very important factor for the satisfactory results in the treatment of thoracic AIS. PATIENTS AND METHODS Sixty-five patients with thoracic AIS treated with STF from the neutral vertebra (NV) to NV or NV-1 with RD and DVR were retrospectively analyzed with a minimum 10-year follow-up. Patients were divided into 2 groups: satisfactory (n=52) and unsatisfactory groups (n=13). Unsatisfactory results were defined as an adding-on, a lowest instrumented vertebra (LIV) tilt of >10 degrees, or coronal balance >15 mm. RESULTS No significant differences were observed in the main thoracic curve between the satisfactory and unsatisfactory groups postoperatively (P=0.218) and at the last follow-up (P=0.636). Significant improvements of LIV tilt and disk angle were observed in both groups, but these improvements deteriorated during the follow-up period in the unsatisfactory group. Significant differences of apical vertebra (AV) and end vertebra (EV) were observed postoperatively (AV: P=0.001, EV: P=0.001) and at the last follow-up (AV: P

A retrospective cohort study.To evaluate the clinical and radiological efficacies of supplementing minimally invasive lateral lumbar interbody fusion (LLIF) with open posterior spinal fusion (PSF) in adult spinal deformity (ASD).Minimally invasive techniques have been increasingly applied for surgery of ASD. Few reports have been published that directly compare LLIF combined with PSF to conventional PSF for ASD.To evaluate the advantages of minimally invasive LLIF for ASD, patients who underwent minimally invasive LLIF followed by open PSF (combined group) were compared with patients who only underwent PSF (only PSF group). The clinical and radiological outcomes for deformity correction and indirect decompression were assessed. The occurrence of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) were also evaluated.No significant differences were observed in the clinical outcomes of the Oswestry Disability Index (ODI), visual analog scale, and major complications including reoperations between the groups. No additional advantage was found for coronal deformity correction, but the restoration of lumbar lordosis in the combined group was significantly higher postoperatively (15.3° vs. 8.87°, P = 0.003) and last follow-up (6.69° vs. 1.02°, P = 0.029) compared to that of the only PSF group. In the subgroup analysis for indirect decompression for the combined group, a significant increase of canal area (104 vs. 122 mm) and foraminal height (16.2 vs. 18.5 mm) was noted. The occurrence of PJK or PJF was significantly higher in the combined group than in the only PSF group (P = 0.039).LLIF has advantages of indirect decompression and greater improvements of sagittal correction compared to only posterior surgery. LLIF should be conducted considering the above-mentioned benefits and complications including PJK or PJF in ASD.4.

Rationale Traumatic atlantoaxial anteroinferior subluxation associated with a dens fracture and a Hangman fracture is a very rare and complex injury. Therefore, appropriate surgical strategy is not established. Patient concerns An 85-year-old female presented with posterior neck pain and atypical neck position caused after rolling down a hill. Although neurological examinations for motor, sensory, gait, and reflex tests were normal, the patient complained of an abnormal neck posture. Diagnoses Radiological examinations revealed an atlantoaxial anteroinferior subluxation with kyphosis, a type IIA dens fracture (Anderson and D'Alonzo classification) with an anterolateral rotatory angulation of type IIA dens fracture fragment, and a type I Hangman fracture (Levine and Edwards classification). Nevertheless, the transverse atlantal ligament was intact. Interventions We considered that the intact transverse atlantal ligament and kinking of the type IIA dens fracture fragment into the left lateral mass of C1 prevented a spinal cord injury by blocking a further displacement of C1 to C2. Due to the patient's osteoporosis and the anterolateral rotatory angulated type IIA dens fracture fragment, a forceful reduction of the atlantoaxial anteroinferior subluxation with kyphosis could pose a high risk of fixation failure and spinal cord injury. Therefore, we performed in-situ posterior C1-2 fusion using a C1 lateral mass screw and C2 lamina screw fixations. Outcomes At 1 year after surgery, the bone union of all fractures was achieved in the kyphosis state. Furthermore, the patient's clinical symptoms were improved with no neurological deficit. Lessons A thorough radiological examination and appropriate surgical strategy are important for successful diagnosis and treatment of a complex C1-2 injury.

The surgical treatment of congenital scoliosis under 10 years is difficult as it involves resecting vertebrae. Moreover, patient follow-up after surgery is extremely important because the patient is a child whose growth has not been completed. However, there are very few long-term follow-up studies after surgical treatment of congenital scoliosis. Therefore, this study is designed to evaluate surgical outcomes after posterior hemivertebra resection in children under 10 years and its long-term effects.Twenty-one patients with congenital scoliosis who were younger than 10 years at the time of the surgery and received posterior hemivertebra resection and fusion using pedicle screw fixation were included in this study.There were significant improvements in the main curve, coronal balance, sagittal vertical axis, thoracic kyphosis, and lumbar lordosis after surgery (P < .001, .021, .047, .043, .006, respectively). Coronal balance, sagittal vertical axis, thoracic kyphosis, and lumbar lordosis remained within the normal range during the follow-up period; however, main curve deteriorated significantly (P = .005). Trunk appearance of perception scale improved significantly after surgery (P = .031) and was maintained during the follow-up period (P = .078).In conclusion, posterior hemivertebra resection and fusion using pedicle screw fixation in patients under 10 years old with congenital scoliosis is a safe and effective procedure that can achieve rigid fixation and deformity correction. Complete resection of the hemivertebra is important for deformity correction and prevention of curve progression, and careful long-term follow-up is necessary.

Rationale: To our knowledge, this is the first report of traumatic combined vertical atlanto-occipital dislocation (AOD) and atlanto-axial dislocation (AAD) with 2-part fracture of the atlas. Patient concerns: The first case was of a 31-year-old woman admitted to the emergency room comatose after a traffic accident. The second case was of a 21-year-old woman admitted to the emergency room comatose after a fall. Diagnoses: Traumatic combined vertical AOD and AAD with 2-part fractures of the atlas was diagnosed using plain radiography, 2-dimensional computed tomography, and/or magnetic resonance imaging of the cervical spine. Intervention: The first patient received immediate intubation and cardiopulmonary resuscitation in the emergency room. The second patient also received immediate intubation in the emergency room. After her vitals stabilized, she underwent occipitocervical fusion with instrumentation. Outcomes: The first patient died 2 days after the accident. The second patient remained quadriplegic in a ventilatory-dependent state at 1 year after surgery. She continues to receive comprehensive rehabilitation. Lessons: Immediate respiratory support and surgical stabilization are important for saving lives in this kind of extremely unstable and fatal complex upper cervical spine injury.

Rationale Traumatic AOD is rare but highly associated with upper cervical spine injuries. We found no references in the literature of traumatic posterior atlantooccipital dislocation (AOD) combined with type II dens fracture (Anderson-D'Alonzo classification) and C1 anterior arch fracture. Patient concerns The first case was a 93-year-old male patient who was admitted to the Emergency Department complaining of incomplete quadriplegia after a fall from a height. The second was a 53-year-old male patient who visited the emergency department complaining of posterior neck pain following a high-speed motor vehicle collision. Diagnosis Reconstructed computed tomography (CT) scans clearly demonstrated posterior AOD combined with type II dens fracture and C1 anterior arch fracture. In addition, magnetic resonance imaging (MRI) also revealed type II transverse atlantal ligament injury (Dickman's classification) in the first patient. Interventions The patients chose not to undergo surgery; instead, they were immobilized with a rigid cervical brace. Outcomes The patients were lost to follow-up. Lessons A thorough clinical evaluation and radiologic investigation (CT and MRI) on concomitant upper cervical injuries should be evaluated in traumatic AOD patients.

Unilateral sagittal split fracture (USSF) of the C1 lateral mass (LM) has been recently recognized as a rare variant of C1 atlas fracture. To date, there has been no study to investigate whether radiologic criteria can be applied to determine the presence or absence of transverse atlantal ligament (TAL) injury in USSF of the C1 LM. Twenty six consecutive cases of USSF of the C1 LM were included in this study. According to Dickman classification, 16 cases were TAL injury, and 10 cases were TAL intact. Radiologic parameters were measured and compared between the 2 groups. Total LM displacement (LMD) of the 2 sides (5.9 ± 2.0 mm vs 1.2 ± 2.0 mm), unilateral LMD of the fracture side (4.3 ± 1.2 mm vs 1.0 ± 1.1 mm), atlanto-dental interval (ADI) (2.0 ± 0.9 mm vs 1.5 ± 0.4 mm), and fracture gap (6.9 ± 2.7 mm vs 2.1 ± 1.1 mm) were statistically higher in the TAL injury group than the TAL intact group. However, basion-dental interval, clivus canal angle, and atlanto-occipital joint axis angle were not different between the 2 groups. Total LMD and unilateral LMD positively correlated with ADI and fracture gap. The incidence of fracture gap larger than 7 mm was statistically higher in the TAL injury group than the TAL intact group (81% vs 30%). In conclusion, total LMD > 5.9 mm or unilateral LMD > 4.3 mm suggests the presence of TAL injury in USSF of the C1 LM. The possibility of diagnostic error for TAL injury can be further reduced in USSF of the C1 LM by considering the fracture gap larger than 7 mm.

Study design Retrospective cohort study. Objective To identify the effect of cement augmentation for cephalad vertebral fracture after instrumented lumbar fusion. Summary of background data Osteoporosis may contribute to cephalad vertebral fractures by an altered biomechanics in the adjacent segments due to the loss of motion at the fused segments. However, few studies on the treatment for cephalad fractures using bone cement augmentation after instrumented lumbar fusion have been published. Methods Seventeen patients who had cephalad vertebral fractures after instrumented lumbar fusion underwent percutaneous vertebroplasty (PVP). All patients were divided into 2 groups according to the presence of intravertebral vacuum clefts (IVC) on plain radiographs and magnetic resonance imaging: group 1 consisted of 9 patients without an associated IVC and group 2 consisted of 8 patients with an IVC. The Oswestry Disability Index and the Visual Analogue Scale were recorded prospectively. The radiologic parameters of kyphotic deformity, vertebral height changes, and leakage of cement were studied. Results The Oswestry Disability Index and Visual Analogue Scale scores in group 1 decreased after PVP, but the mean score in group 2 was higher than in group 1 at the last follow-up. The mean kyphosis measured 15.7±7.4 degrees preoperatively and 15.6±7.1 degrees at the final follow-up in group 1, and 16.9±8.8 degrees preoperatively and 27.2±8.8 degrees at the final follow-up in group 2.The mean preoperative anterior and posterior vertebral height ratio measured 0.6±0.2 preoperatively and 0.6±0.2 at the final follow-up in group 1, and 0.6±0.2 preoperatively and 0.5±0.2 at the final follow-up in group 2.The mean preoperative middle and posterior vertebral height ratio measured 0.5±0.1 preoperatively and 0.6±0.1 at the final follow-up in group 1, and 0.5±0.1 preoperatively and 0.4±0.2 at the final follow-up in group 2. Four patients underwent revision surgery in group 2 and 1 in group 1. Conclusions Although PVP treatment may be a useful method for cephalad vertebral fractures after instrumented lumbar fusion in elderly patients with persistent unremitting back pain, recollapse of the vertebral body can occur after a PVP for cephalad or adjacent vertebral fractures with an IVC.

Rationale Traumatic bilateral facet dislocation in the lumbar (L) spine has rarely been reported. All reported cases were presented with acute facet dislocation. However, we present the first case of delayed bilateral facet dislocation at L4-5. Patient concerns A 34-year-old woman presented with back pain after a head-on collision. The patient was treated conservatively for 3 months with rigid orthosis and activity restriction. Even after this conservative treatment, she continued to suffer from persistent back pain that radiated down her left leg and a progressively kyphotic posture. Diagnoses Initial imaging studies revealed a fracture of the left L5 superior articular process with a posterior ligament complex (PLC) injury. Subsequent radiographs showed the locked facet dislocation with kyphotic changes. Interventions The patient underwent surgical reduction and fusion, and the operative findings revealed the L4-5 bilateral facet dislocation and rupture of the PLC at the index level. Outcomes After surgical reduction and fusion at L4-5 by posterior interbody fusion, we achieved a satisfactory clinical outcome. Lessons Injury of the PLC in the lower lumbar region deserves careful attention for the development of sequelae. The anatomic transition from lordosis to kyphosis, in the lumbosacral region may be related to this type of injury.

Rationale: To the best of our knowledge, this is an extremely rare case of traumatic C1–2 rotatory subluxation associated with multiple C2 fractures. Patient concerns: We report the case of a 63-year-old man with type 2 traumatic C1–2 rotatory subluxation (Fielding and Hawkins classification) associated with type III dens (Anderson and D’Alonzo classification) and bilateral articular facet fractures of C2. This injury occurred as a result of falling down in a drunken state. The patient complained of neck pain and mild degree of torticollis but did not show any neurologic abnormalities. Diagnoses: Plain radiographs of cervical spine showed extensive soft tissue swelling, a fracture fragment, disruption of spinolaminar line at C1–2 level, and bony overlapping of right side lateral joint of C1–2. Two- and three-dimensional reconstructed computed tomography scans clearly demonstrated complicated C1–2 combined injury. The atlantodental interval was normal. Intervention: By skull traction and derotation, closed reduction of C1–2 rotatory subluxation with a type III dens and bilateral articular facet fractures of C2 was successfully achieved. He was managed with halovest fixation for 3 months. Outcomes: At the 1-year follow-up visit solid fusion and improvement of clinical symptoms were achieved without C1–2 instability. Lessons: Despite traumatic C1–2 rotatory subluxation associated with multiple C2 fractures, trial of closed reduction should be considered as the first choice of treatment so as to preserve C1–2 motion.

Rationale: The management of congenital scoliosis concentrates on early diagnosis and proper surgical treatment before the development of severe deformities. Decision making regarding the appropriate fusion levels, proper surgical treatment, and reduction amount of kyphoscoliosis is very important but difficult in the treatment of congenital scoliosis, especially in young children. Patient concerns: We report an 11-year follow-up of revision surgery for fractional curve progression after combined anterior and posterior fusion without hemivertebra resection using pedicle screw fixation (PSF) in congenital kyphoscoliosis at age 4 years (a total 18-year follow-up). A T12 hemivertebra was documented in a 4-year-old girl and was treated by combined anterior and posterior fusion in two stages with PSF. The fusion mass was maintained but the distal compensatory curve progressed during the follow-up period. The patient underwent a posterior vertebral column resection (PVCR) with extended posterior fusion at the age of 11, 7 years after initial surgery. Outcomes: Eleven years after the revision surgery with PVCR, the patient showed satisfactory results and her spine was well balanced. Lessons: The cause of revision surgery for the curve progression may include inappropriate fusion level, incomplete hemivertebra resection, or failure of anterior and posterior fusion. Especially, inappropriate fusion level may result in deterioration of the compensatory curve even without progression of the fusion mass. Conclusion: Appropriate selection of fusion levels, complete resection of hemivertebra, and satisfactory reduction of scoliosis and kyphosis are important factors for deformity correction and prevention of progression of both main and compensatory curves (adding-on of structural curve or progression of compensatory curve) as well as reducing the influence of adjacent vertebral growth using as short a fusion as possible.