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Narrative review.Cervical decompressive laminectomy is a common posterior approach for addressing multilevel cervical spondylotic myelopathy. However, there is a concern that cervical laminectomy can lead to kyphotic deformity with subsequent neurological decline. In this context, cervical laminectomy with fusion using lateral mass instrumentation has become increasingly utilized with the aim of reducing the risk of developing postoperative kyphotic deformity, which is thought to predispose to poorer neurological outcomes in the long term.To compare the evidence for stand-alone cervical laminectomy with laminectomy with posterior fusion in terms of clinical outcomes and the incidence of adverse events, particularly the development of postoperative cervical kyphosis.Initial Medline search using MeSH terms yielded 226 articles, 23 of which were selected. An additional PubMed search and the reference list of individual papers were utilized to identify the remaining papers of relevance.Cervical laminectomy both with and without fusion offers effective decompression for symptomatic multilevel cervical spondylotic myelopathy. The incidence of postlaminectomy kyphosis is lower following posterior fusion; however, there seems to be no clinical-radiologic correlation given that patients who develop postoperative kyphosis often do not progress to clinical myelopathy. Furthermore, there are specific additional risks of posterior instrumentation that need to be considered.In carefully selected patients with normal preoperative cervical sagittal alignment, stand-alone cervical laminectomy may offer acceptably low rates of postoperative kyphosis. In patients with preoperative loss of cervical lordosis and/or kyphosis, posterior fusion is recommended to reduce the risk of progression to postoperative kyphotic deformity, bearing in mind that radiologic evidence of kyphosis may not necessarily correlate with poorer clinical outcomes. Furthermore, the specific risks associated with posterior fusion (instrumentation failure, pseudarthrosis, infection, C5 nerve root palsy, and vertebral artery injury) need to be considered and weighed up against potential benefits.

Background Bilateral extracavitary approach (BECA) is an option for decompression cases that require a more extended ventral approach. The clear advantage is increased accessibility to the most ventral aspects of the spine from a bilateral perspective. Objective To assess the safety and efficacy of thoracic and thoracolumbar decompression and/or reconstruction from BECA. Methods A retrospective chart review was performed reviewing all patients who underwent BECA for thoracolumbar decompression from 2003 to 2012 at our institution. We recorded patient baseline characteristics, physical exam, surgical indications, perioperative interventions, and outcomes. Results We performed 82 lateral extracavitary approaches and 10 BECAs. BECA indications included neoplasm, infection, and kyphotic deformity. Average patient age was 58 yr; 80% of BECA patients were male. Estimated blood loss was typically 1 to 3 L. Average length of stay postoperative was 12 d. Two patients required revisions; one for infection and one for revision of misplaced hardware. Eight patients improved at least one grade on the American Spinal Injury Association Impairment Scale (ASIA) or was originally ASIA E. Two patients declined 1 to 2 ASIA grades. Average length of follow-up was 16.8 mo. Conclusion BECA is an efficient technique with acceptable complication rates and similar risks to unilateral approaches. It should be considered when extensive bilateral decompression and/or reconstruction of the anterior thoracic or thoracolumbar spine is required.

A prospective randomized study.To introduce an operative technique that prevents proximal junctional kyphosis (PJK) in Scheuermann disease after a segmental posterior spinal instrumentation and fusion.PJK is the progression of kyphotic deformity at the proximal end of a construct10 degrees, and it can be seen up to 30% after posterior Scheuermann kyphosis surgery. After posterior fusion the biomechanics of the spine changes and the loss of motion at the fused levels is compensated by increased motion at other unfused segments. As a result significant amount of additional force is placed on the proximal junction. With our operative technique, we aimed to have a smooth passage from rigid to mobile segments and to decrease the stress on proximal junction during cantilever reduction to prevent PJK.A total of 60 consecutive patients (mean age: 18.27±3.19, male/female: 28/32) who were surgically treated for Scheuermann kyphosis in our institution were recruited into this study and were prospectively evaluated. Patients were divided into 2 groups according to upper-most screw fixation technique. In group 1, a standard screw insertion technique was used (ST group). The technique was modified in group 2 (MT group), leaving 2 threads out of the posterior cortex. There were 29 patients in group 1 (ST) and 31 patients in group 2 (MT). Patients had an average follow-up time of 24.2 months (range, 19-48 mo). Evaluated radiographic parameters were preoperative and postoperative kyphosis angle, and proximal junctional angle (PJA) at last visit. PJA was defined as the angle between the caudal endplate of the upper instrumented vertebra and the cephalad endplate of 2 suprajacent vertebrae above the upper instrumented vertebra. PJA exceeding 10 degrees was accepted as PJK. Quality of life measurement was assessed preoperatively and postoperatively with SF-36 questionnaire.Correction amounts in ST group and MT group were 46.8% and 43.7%, respectively, which was statistically insignificant. The mean PJA was 8.08±2.96 degrees and 4.44±1.55 degrees in ST and MT groups, respectively, which demonstrated a statistically significant difference (P=0.001). Five patients in ST group had a PJA exceeding 10 degrees (PJK), whereas PJK was not seen in MT group (P=0.022). The improvement in physical component summary of SF-36 was significantly better in MT group; however, mental component summary was similar in both groups.This study introduces a new technique that may have an effect in preventing PJK. Our results seem to be satisfactory, but additional studies with more patients and longer follow-up times are needed to further delineate the feasibility of this technique.

BACKGROUND: Because an idiopathic spinal extradural arachnoid cyst (SEAC) is rare, its optimal surgical treatment remains controversial. OBJECTIVE: To evaluate the results of surgical treatments for SEACs and to clarify features of the disease associated with poor outcomes. METHODS: Twelve patients with SEACs who underwent surgery at our hospital between 1988 and 2008 were examined retrospectively. The mean follow-up period was 4.7 years. Total resection of the cyst was performed in 7 patients and closure of the dural defect without cyst resection in 5 patients. Surgical outcomes were evaluated with regard to the duration of symptoms, the size of the cyst, and the surgical procedure used. RESULTS: Neurological recovery was observed in all patients, and there was no recurrence. Poor outcomes were observed in patients with a long duration of symptoms (>1 year, P 5 vertebrae, P < .05). The surgical procedure had no significant association with the postoperative neurological recovery. However, there was a significant difference in the degree of the mean postoperative kyphotic angle between the patients treated by total resection of the cyst (9.7 degrees) and those treated by closure of the dural defect without cyst resection through selective laminectomy (2.2 degrees) (P < .01). CONCLUSION: There was no significant difference in postoperative neurological recovery between the 2 surgical procedures. However, closure of the dural defect without cyst resection was less invasive, preventing postoperative kyphotic deformity of the thoracolumbar spine.

The aim of the present study is to identify factors correlated with kyphotic deformity after thoracolumbar spine injuries. We performed a retrospective case–control study with data from thoracolumbar spine fracture patients who were treated with posterior spinal fixation. Patients with a follow-up period shorter than 6 months and who experienced low-energy trauma were excluded. Intervertebral disc injuries (IDIs) were graded from 0 to 3 upon admission in accordance with Sander's classification of traumatic intervertebral disc lesions. Vertebral wedge angles (VWAs) and local kyphosis angles (LKAs) were also measured. Patients were allocated to kyphosis and control groups if they had LKA correction losses of ≥10° and

STUDY DESIGN Pedicle involvement in spinal tuberculosis (TB), the prevertebral abscess formation, severity of vertebral body, and disc collapse were evaluated from magnetic resonance imaging (MRI) of the patients. OBJECTIVE To study the pedicle involvement in spine TB in relation to the degree of vertebral body and disc collapse, prevertebral abscess collection, and degree of kyphosis; and to correlate the occurrence of pedicle involvement and the degree of spinal deformity. SUMMARY OF BACKGROUND DATA There are a few reports describing the posterior element involvement in spinal TB. Typically, the infection resides in the anterior part of the vertebral body endplates and rarely involved the pedicles. METHODS There were 31 patients, who had been diagnosed and treated for spinal TB from 2003 to 2007 at our center. Critical evaluation of each patient's MRI was carried out for the pedicle involvement, prevertebral abscess formation, severity of vertebral body, and disc collapse. RESULTS Spinal TB mostly involved the thoracic level (48.4%). Pedicle involvement was noted in 64.5% of patients, and the highest involvement was at thoracic level. The mean vertebral body, disc collapse, prevertebral abscess, and kyphosis were more severe in pedicle involved group. CONCLUSION The posterior spinal element, specifically the pedicle is not uncommonly involved in spinal TB. Pedicle involvement is part of the disease process and usually associated with relatively severe vertebral body and disc destruction, wide prevertebral abscess, and severe kyphosis. Pedicle involvement can be detected early from MRI and need to be documented as it may influence the treatment strategy.

STUDY DESIGN A 9-year-old boy with severe myelomeningocele kyphosis was treated by kyphectomy using a surgical threadwire. OBJECTIVE To describe a new method of kyphectomy for severe kyphotic deformity in a child with myelomeningocele using a surgical threadwire. SUMMARY OF BACKGROUND DATA Although several methods of kyphectomy for severe kyphotic deformity in children with myelomeningocele have been reported, few of these methods allow preservation of the nonfunctioning dural sac and cerebrospinal fluid flow, with the aim of reducing complications. METHODS The preoperative kyphotic angle was 113 degrees. There was repeated skin ulceration over the apex of the kyphos. Kyphectomy at the Th12 to L3 vertebral levels was performed using a surgical threadwire (T-saw, developed by Tomita and colleagues in 1996), preserving the entire dural sac. RESULTS The T-saw allowed anterior dissection of the dural sac over the length of the planned resection, thus preserving cerebrospinal fluid flow throughout the entire subarachnoid space. The kyphotic angle was decreased to 10 degrees after the operation, and the postoperative clinical course was uneventful. At the 2-year follow-up assessment, the kyphotic angle was 10 degrees according to plain radiograph. At this writing, the boy is able to maintain a sitting position without any difficulty. CONCLUSIONS For this child with myelomeningocele, kyphectomy using a surgical threadwire (T-saw) provided a satisfactory result without any major complication.

It is important to know the condition of neural spaces during the nonoperative treatment of thoracolumbar burst fractures. The goals of the current study were to identify the correlation between the degree of deformity of a fractured vertebra and the encroachment of neural spaces, and to determine how the encroachment and the deformity can be improved by the extension posture simulating the postural reduction. Experimental burst fractures were produced in L1 vertebrae of nine human thoracolumbar spine segments (T11-L3) with neural spaces lined with tiny steel balls. Lateral radiographs were taken in neutral and extended posture before and after the trauma. Anterior vertebral height, posterior vertebral height, vertebral height ratio, vertebral kyphotic angle, posterior vertebral body angle, and the cross diagonal angle were the geometric parameters used to describe the vertebral deformity. The canal diameter and superior and inferior intervertebral foramen areas were defined as the neural spaces. All parameters were measured on the scanned images of radiographs, as seen on the computer screen. Among the vertebral body parameters, the posterior vertebral height, posterior vertebral body angle, and cross diagonal angle showed significantly higher correlations with the canal encroachment. The extended posture did not improve the canal and intervertebral foramen encroachments. The kyphotic deformity (vertebral kyphotic angle and anterior vertebral height) was improved but the deformity of the vertebral posterior wall (posterior vertebral height and posterior vertebral body angle) was not improved because of the extended posture.

Transient kyphotic deformity arises in most infants with achondroplasia. In a minority, a fixed and angular kyphosis develops, which can cause serious neurologic sequelae later in life. We assessed a protocol for preventing development of such fixed kyphosis in a sequential, unselected series of 66 infants with achondroplasia. This study demonstrates the efficacy of early prohibition of unsupported sitting and, in those in whom such prohibition proves insufficient, use of bracing. When the proposed algorithm was followed, none of the infants had development of a progressive kyphotic deformity. On this basis, it appears that the secondary risks of angular kyphosis, previously estimated to be between 10 and 15% in individuals with achondroplasia, can be completely eliminated.

The results of resection of the lordotic segment cephalad to the apical vertebra of a kyphotic deformity in thirty-nine patients who had had a myelomeningocele were reviewed retrospectively. The operations were performed between 1973 and 1984, when the patients were an average of six years and ten months old (range, one year and five months to twenty years old). The average duration of follow-up was eleven years and one month (range, five years and one month to seventeen years and four months). The average preoperative kyphosis was 111 degrees (range, 77 to 151 degrees) and the average postoperative kyphosis was 40 degrees (range, 2 to 88 degrees). The preoperative deformity was reduced an average of 64 per cent (range, 0 to 98 per cent). At the latest follow-up evaluation, the average kyphosis was 62 degrees (range, -25 to 100 degrees). The measurements were obtained from lateral radiographs that were made with the patient sitting preoperatively, immediately postoperatively, at one year, and yearly until the time of the latest follow-up evaluation. At the most recent examination, thirty-four patients had a partial loss of correction, with twenty-five of them having maintained at least 50 per cent of the correction. The five remaining patients had an improvement in the alignment by an average of 26 degrees. Only two patients had an increase in kyphosis compared with the preoperative deformity. Thirty-seven patients had an average increase of 3.2 centimeters (range, 0.2 to 8.2 centimeters) in the height of the lumbar spine; the two remaining patients, who had a decrease in height, had operative intervention after reaching skeletal maturity.

Thirty-three patients with myelodysplasia had kyphectomies for correction of spinal deformities. Harrington compression instrumentation was used for fixation in 21 patients, with postoperative immobilization in a spinal orthosis for 6 months. Twelve patients had Luque rod instrumentation, with fixation through the first sacral foramina with a modification of the Dunn technique and with no postoperative immobilization. Kyphosis recurred in eight patients with Harrington rod instrumentation and in none of those with Luque rod instrumentation. Nine patients with Harrington compression rods required 15 procedures for instrumentation problems. Only five of the 21 patients with Harrington compression rods had no significant complications, although ultimately 20 of 21 patients had solid fusions without further progression of the kyphosis. All 12 patients with Luque rods had solid fusions with no recurrences of the kyphotic deformity. One patient required operation for instrumentation problems.

A 44-year-old woman presented with exertional dyspnea and atypical chest pain. On physical examination, severe kyphotic deformity was noted. The ECG demonstrated right-axis deviation and right ventricular hypertrophy. Echocardiography demonstrated normal left ventricular systolic function, …

A case is presented of a motorcyclist who crashed and suffered a fracture-dislocation of the mid-thoracic spine without any neurologic deficit. The injury was discovered 6 weeks after the crash. The patient underwent surgical stabilization and correction of the kyphotic deformity with Luque rods and sublaminar wires and had an uneventful recovery.

Fourteen patients with classic Marfan syndrome and spinal deformity treated at Texas Scottish Rite Hospital for Crippled Children (Dallas, TX) after 1975 have been conservatively treated to maturity or are at least 2 years after spinal fusion. Brace treatment was successful in one of nine patients. Nine patients underwent fusion. Three had a solid fusion, two lost 20 degrees of correction, and four required revision for multiple pseudarthroses. These latter four all had or developed a kyphotic deformity. Although Marfan syndrome patients can achieve solid fusion, they require massive bone graft, secure segmental internal fixation, and careful observation for pseudarthrosis. Kyphotic deformities require anterior fusion.

In an 18-year-old man and an 18-year-old woman, significant kyphotic deformity progressively developed in the course of the healing of apparently stable thoracic compression fractures. The common features were: (1) multiple adjacent fractures; (2) location in the thoracic spine; (3) associated thoracic injury; and (4) youth. The possibility of early progressive kyphotic deformity should be carefully monitored so that appropriate treatment can be instituted before the deformity becomes significant. Although both isolated fractures and multiple-level fractures of the thoracolumbar spine occur predominantly between T12 and L2, there is a secondary area that is predisposed to compression fractures in sequence from T5 to T7.