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Background Progressive spinal deformity following laminectomy and resection surgery of spinal tumor has been well-documented. However, the postlaminectomy deformity in adolescent patients often bring challenge to clinical treatment, which may be subjected to rapid progression of kyphosis during the growth spurt. The aim of this study is to investigate the clinical outcome of long fusion correction surgery for thoracic or thoracolumbar kyphotic deformity secondary to laminectomy and tumor resection in adolescent patients. Methods Records of 12 cases underwent correction surgery of postlaminectomy thoracic (n=6) or thoracolumbar (n=6) kyphotic deformity were reviewed. The Cobb angle of sagittal and coronal curve before surgery, immediately after surgery, and at the final follow-up were measured to evaluate the correction of deformity and loss of correction. Neurological function was evaluated using the Frankel grading system. Back pain was assessed by using the visual analog score (VAS). Disability status was evaluated by the Oswestry Disability Index (ODI). Patients' satisfaction to surgery was assessed by the patient satisfactory index. Results The mean kyphosis angle reduced from 76±20 degrees before surgery to 34±18 degrees immediately after surgery and remained at 39±17 degrees at the final follow-up with the average correction rate of 58.6% and 51.0%, respectively. For 7 patients with concomitant scoliosis, the Cobb angle of major curve reduced from 52±21 degrees before surgery to 16±9 degrees immediately after surgery and 20±9 degrees at the final follow-up. The average corrective rate was 69.5% and 62.4%, respectively. The mean ODI score improved from 19.9±7.5 to 10.8±8.0, whereas the mean VAS score improved from 5.3±2.0 to 1.5±1.4. The sagittal and coronal balance of the spine, Frankel grading, ODI, and VAS were improved, and the patient satisfactory index was 100%. One patient had inferior paraplegia recovered to Frankel grade E after treatment. Conclusions Satisfactory clinical outcomes can be achieved after long fusion surgery for thoracic or thoracolumbar kyphotic deformity secondary to laminectomy for spinal tumor. Due to the high risk of secondary kyphotic deformity in adolescent patients, internal fixation should be performed simultaneously with the resection of spinal tumor, especially for the cases in the thoracic or thoracolumbar region. Level of evidence Level III.

STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to investigate the impact of cervical to thoracolumbar ratios on poor outcomes in cervical deformity (CD) corrective surgery. SUMMARY OF BACKGROUND DATA Consideration of distal regional and global alignment is a critical determinant of outcomes in CD surgery. For operative CD patients, it is unknown whether certain thoracolumbar parameters play a significant role in poor outcomes and whether addressing such parameters is warranted. METHODS Included: surgical CD patients (C2-C7 Cobb >10°, cervical lordosis [CL] >10°, C2-C7 sagittal vertical axis (cSVA) >4 cm, or chin-brow vertical angle >25°) with baseline and 1-year data. Patients were assessed for ratios of preop cervical and global parameters including: C2 Slope/T1 slope, T1 slope minus C2-C7 lordosis (TS-CL)/mismatch between pelvic incidence and lumbar lordosis (PI-LL), cSVA/sagittal vertical axis (SVA). Deformity classification ratios of cervical (Ames-ISSG) to spinopelvic (SRS-Schwab) were investigated: cSVA modifier/SVA modifier, TS-CL modifier/PI-LL modifier. Cervical to thoracic ratios included C2-C7 lordosis/T4-T12 kyphosis. Correlations assessed the relationship between ratios and poor outcomes (major complication, reoperation, distal junctional kyphosis (DJK), or failure to meet minimal clinically important difference [MCID]). Decision tree analysis through multiple iterations of multivariate regressions assessed cut-offs for ratios for acquiring suboptimal outcomes. RESULTS A total of 110 CD patients were included (61.5 years, 66% F, 28.8 kg/m2). Mean preoperative radiographic ratios calculated: C2 slope/T1 slope of 1.56, TS-CL/PI-LL of 11.1, cSVA/SVA of 5.4, CL/thoracic kyphosis (TK) of 0.26. Ames-ISSG and SRS-Schwab modifier ratios: cSVA/SVA of 0.1 and TS-CL/PI-LL of 0.35. Pearson correlations demonstrated a relationship between major complications and baseline TS-CL/PI-LL, Ames TS-CL/Schwab PI-LL modifiers, and the CL/TK ratios (P

Spinal tumors are rare, of which intradural-extramedullary lesions form the majority of primary spinal tumors. Occasionally these may even be large, dumbbell shaped, with both intraspinal and extraspinal components. Complete gross total resection is the gold standard in the removal of these tumors since most are benign in nature. Traditionally this has been achieved using large open midline approaches that involve significant muscle dissection, extensive laminectomy, and even facetectomy. This may lead to instability, requiring stabilization to prevent deformity. Minimally invasive surgical approaches using fixed tubular retractors may obviate this need by minimizing the amount of muscle stripping and bony resection required for complete tumor excision. By utilizing facet sparing corridors, the authors describe a novel 2-incision minimally invasive surgical technique that combines a paramedian and a far-lateral approach to access both the intraspinal and extraforaminal, paraspinal portions of the tumor for achieving complete excision. Three illustrative cases are discussed with tumors in 2 different spinal locations that highlights the versatility of this technique-1 in the cervical region and the other 2 in the thoracolumbar region.

Study design A case report. Objective The aim of this study was to outline the potential risks of late bleeding from the segmental vessels following less invasively dorsolateral approaches to the thoracolumbar spine. Summary of background data A low risk of major intraoperative bleeding, associated traditional dorsolateral approach to the lumbar spine is reported, but segmental arteries and great vessels may be rarely damaged. Spine surgeons who are involved with these approaches should be aware of this rare but potential dangerous vascular complication because it could be life-threatening, particularly in elderly patients with increased morbidity, and/or metastatic disease to the spine. Methods A 76-year-old white woman with a comminuted osteoporotic fracture of the L1-vertebrae with spinal canal encroachment underwent a corpectomy and a 360° fusion with the use of a titanium mesh cage, through a less invasively dorsolateral approach. Results Despite the lack of visible intraoperative bleeding and uneventful postoperative period, the patient died on the seventh postoperative day as a result of massive bleeding from a segmental artery at the level of L3 vertebrae body, two levels below our intervention area. Conclusion This article describes a rare complication of delayed and fatal bleeding of the segmental L3 left vertebral artery following less invasively L1 corpectomy, mesh cage insertion, and pedicle screw fixation in a elderly female patient with history of two malignancies. Although injury to large vessels must always be prevented during these procedures, an injury to the segmental vessels occurs more frequently. The dorsolateral approach and other retroperitoneal approaches to the thoracolumbar region are established methods for the surgical stabilization of comminuted vertebral body fractures, especially on the hands of experienced spine surgeons. Great care should be given postoperatively for signs of bleeding and hematoma and the surgeon should be aware for these life-threatening complications. Level of evidence 5.

Osteoporotic vertebral fractures constitute at least 50% of the osteoporotic fractures that happen worldwide. Occurrence of osteoporotic fractures make the elderly patient susceptible for further fractures and increases the morbidity due to kyphosis and pain; the mortality risk is also increased in these patients. Most fractures occur in the thoracic and thoracolumbar region and are often stable. Different descriptive and prognostic classification systems have been described, but none are universally accepted. Radiographs, computed tomography, and magnetic resonance imaging are useful in imaging the fracture and evaluating the bone density. In acute stages, the fractures are well treated with conservative measures including short bed rest, analgesics, bracing, and exercises. Although most fractures heal well, up to 30% of fractures can develop painful nonunion, progressive kyphosis, and neurological deficit. For patients who develop severe pain not responding to nonoperative measures and painful nonunion, percutaneous cement augmentation procedures including vertebroplasty or kyphoplasty have been suggested. For fractures with severe collapse and that lead to neurological deficit and increasing kyphosis, instrumented stabilization is advised. Prevention and management of osteoporosis is the key element in the management of osteoporotic fractures in the elderly. Guidelines for essential adequate dietary and supplemental calcium and vitamin D, and antiosteoporotic medications have been described.

STUDY DESIGN Controlled radiological study. OBJECTIVE Ascertain if a difference exists in the mechanical effects on the cord between the unilateral and bilateral straight leg raise (SLR) and to verify whether the effect on the spinal cord may be cumulative between the two. SUMMARY OF BACKGROUND DATA To the authors' knowledge these are the first data on noninvasive, in vivo, normative measurement of spinal cord displacement with bilateral SLR test. METHODS Sixteen asymptomatic volunteers were scanned with 1.5-T magnetic resonance scanner (Siemens Avanto, Erlangen, Germany) using T2-weighted turbo spin-echo fat-saturation sequence. The displacement of the medullar cone relative to the vertebral endplate of the adjacent vertebra during the passive bilateral SLR was quantified and compared with the position of the conus in the neutral (anatomic) position and with unilateral SLR. Each movement was performed twice for evaluation of reproducibility. The measurements were repeated by 2 observers. Four practitioners performed the maneuvers in a random sequence to avoid series effects. RESULTS Compared with the neutral (anatomic) position, the medullar cone displaced caudally in the spinal canal by 2.33 ± 1.2 mm (μ ± SD) with unilateral (P ≤ 0.001) and 4.58 ± 1.48 mm with bilateral SLR (P ≤ 0.001). Statistical significance was also reached for bilateral versus unilateral SLR (P ≤ 0.001). Spearman correlations proved higher than 0.99 for intra and interobserver reliability, and 0.984 for results reproducibility in bilateral SLR. CONCLUSION The caudal displacement of the medullar cone was significantly greater (almost double) with the bilateral SLR than the unilateral SLR. We hypothesize that this greater movement may be because more force was transmitted to the cord through a larger number nerve roots with the bilateral than unilateral SLR. The high correlation values in this study show that these movements are consistent and reproducible. This study offers baseline measurements on which further studies in diagnosis and treatment of lumbar disc protrusion and radiculopathy may be developed.

Review question/objective The objective of this review is to compare anterior versus posterior surgical approaches for instrumented thoracolumbar fusion in adolescent idiopathic scoliosis. The reviewers seek to critically evaluate available evidence to provide an evidence-based appraisal of the comparative safety, effectiveness and cost effectiveness of alternative surgical approaches for thoracolumbar spinal fusion in adolescent idiopathic scoliosis. Inclusion criteria Types of participants A comprehensive and exhaustive literature search will be conducted for studies that satisfy the following inclusion criteria: •Children (10 to 18 years) undergoing instrumented spinal fusion for adolescent idiopathic scoliosis. •Scoliosis curves that involve a curve apex that approaches the thoracolumbar region The following participant limitations and exclusion criteria will also be implemented: •Combined anterior/posterior surgical procedures or two-staged procedures •Congenital or neuromuscular or syndromic scoliosis •Studies that report considerable curve characteristic heterogeneity (pure thoracic and lumbar) will be excluded. Types of intervention(s)/phenomena of interest This review will consider studies that evaluate anterior approaches for instrumented spinal fusion for adolescent idiopathic scoliosis. Comparator: posterior approach Type of outcome (if any) Outcomes of interest will be stratified into safety and effectiveness categories as outlined below. Safety: Complications Blood loss Infection Neurological injury Revision rate Systemic metal ion levels Effectiveness: Number of levels fused Total operating time Deformity correction (coronal and sagittal) Pulmonary function preservation Length of hospital stay Time to return to full physical activity (regarded as participation in regular sport) Patient satisfaction Patient pain scores Cost minimization

Study design Retrospective analysis of prospectively collected follow-up data for 2.9 years. Objective To determine the natural history of subsequent morphometric fracture rates at adjacent levels (one level above or below a previous known baseline fracture) in a large patient database. Summary of background data The long-term risk and risk factors for adjacent-level vertebral fractures in patients with osteoporosis are unknown. Methods The fracture intervention trial is a large randomized, placebo-controlled trial of alendronate treatment for osteoporosis. Data from both bisphosphonate-treated and bisphosphonate-naive patients (N = 1950, vertebral fracture arm) was analyzed to detect incident morphometric fracture rates. Results During a mean follow-up of 2.9 years, 3.4% of patients in the alendronate group and 7.4% in the placebo group experienced adjacent-level vertebral fractures. The annual rate of adjacent-level vertebral fractures was 1.2% in the alendronate group, and 2.5% in the placebo group (overall, 1.8% per year in both groups combined). As expected, the thoracolumbar region (defined as T11, T12, and L1) seemed to be the most prone to new adjacent-level fractures. Among females with baseline prevalent fractures at the thoracolumbar junction, who subsequently experienced at least one new fracture anywhere along the spine (N = 124), 40.3% had a new adjacent-level fracture in this region. Older age at randomization, lower bone mineral density, inactivity, and placebo therapy were significantly associated with the development of adjacent-level fractures in univariate analysis (P ≤ 0.05). Multivariate analysis indicated decreased odds of adjacent-level fractures with bisphosphonate therapy and higher bone mineral density, and increased odds with older age at randomization (P ≤ 0.05). Conclusion New vertebral fractures adjacent to prevalent fractures occurred relatively infrequently in this treatment trial of alendronate in females with osteoporosis, and were more common with older age at randomization, lower bone mineral density and placebo treatment.

STUDY DESIGN Multicenter, retrospective series. OBJECTIVE To analyze the incidence, mode, and location of acute proximal junctional failures (APJFs) after surgical treatment of adult spinal deformity. SUMMARY OF BACKGROUND DATA Early proximal junctional failures above adult deformity constructs are a serious clinical problem; however, the incidence and nature of early APJFs remain unclear. METHODS A total of 1218 consecutive adult spinal deformity surgeries across 10 deformity centers were retrospectively reviewed to evaluate the incidence and nature of APJF, defined as any of the following within 28 weeks of index procedure: minimum 15° post-operative increase in proximal junctional kyphosis, vertebral fracture of upper instrumented vertebrae (UIV) or UIV + 1, failure of UIV fixation, or need for proximal extension of fusion within 6 months of surgery. RESULTS Sixty-eight APJF cases were identified out of 1218 consecutive surgeries (5.6%). Patients had a mean age of 63 years (range, 26-82 yr), mean fusion levels of 9.8 (range, 4-18), and mean time to APJF of 11.4 weeks (range, 1.5-28 wk). Fracture was the most common failure mode (47%), followed by soft-tissue failure (44%). Failures most often occurred in the thoracolumbar region (TL-APJF) compared with the upper thoracic region (UT-APJF), with 66% of patients experiencing TL-APJF compared with 34% experiencing UT-APJF. Fracture was significantly more common for TL-APJF relative to UT-APJF (P = 0.00), whereas soft-tissue failure was more common for UT-APJF (P < 0.02). Patients experiencing TL-APJF were also older (P = 0.00), had fewer fusion levels (P = 0.00), and had worse postoperative sagittal vertical axis (P < 0.01). CONCLUSION APJFs were identified in 5.6% of patients undergoing surgical treatment of adult spinal deformity, with failures occurring primarily in the TL region of the spine. There is evidence that the mode of failure differs depending on the location of UIV, with TL failures more likely due to fracture and UT failures more likely due to soft-tissue failures.

OBJECTIVE To investigate the morphology of pedicle in thoracic and lumbar spine in scoliosis associated with Chiari malformation/Syringomyelia-comparison with adolescent idiopathic scoliosis (AIS). MATERIAL AND METHODS Twenty-three patients of Lenke type 1 AIS and 21 patients of scoliosis associated with Chiari malformation/Syringomyelia with the similar curve type to Lenke 1 AIS underwent preoperational computed tomographic scans. Anatomic parameters were measured from T1 to L4, which included pedicle width, transverse pedicle angle, and chord length. Statistical comparison was performed within and between 2 groups. RESULT Pedicle width of patients with scoliosis associated with Chairi malformation/Syringomyelia ranged from 3 to 10.9 mm; pedicle width of convex side was wider than concave side in apex region and upper end vertebrae region (P

The treatment of an unusual case with severe kyphoscoliotic deformity of the thoracolumbar spine, in association with a ganglioneuroblastoma invading the adjacent diaphragm, is presented in this report. Severe scoliotic deformity of the spine, associated with ganglioneuroblastoma of the diaphragm is a rare combination and treatment can be very challenging, as both entities require extensive surgery. To the best of our knowledge, only two reports related to a similar condition have been published in the literature so far. A 9-year-old girl had been treated in another institution since the age of 5 years for thoracolumbar kyphoscoliosis with bracing. She was referred to our department with a stiff right kyphoscoliotic curve at the thoracolumbar region (T8-L2), with measurements of 105 and 90° for the scoliotic and kyphotic elements, respectively. There were no neurological signs detected at the preoperative work-up, which included clinical and radiological evaluation (plain X-rays and computed tomographic scan). The patient was treated with a two-stage spinal fusion. During the anterior approach through a right thoracotomy, a tumor was discovered infiltrating half of the diaphragm and extended to the frontal surface of the lower thoracic vertebral bodies. The vertebrae were cleared of the tumorous masses and anterior discectomies (T8-L2) were successfully carried out according to the preoperative plan. The histopathology report indicated ganglioneuroblastoma in both the prevertebral material and the speciments excised from the diaphragm. A week later a T3-L4 posterior fusion was carried out and the deformity was corrected and fixed with an SFS instrumentation system. Both the scoliotic and the kyphotic curves were reduced to 46°. Postoperatively the patient was referred to the oncology department of another hospital for the treatment of the diaphragm tumor. During the last follow-up (4 years), the scoliotic curve remains steady and the tumor shows no recurrence. Although there are cases of ganglioneuroblastoma associated with scoliotic deformity, the combination of this tumor infiltrating the diaphragm and a very severe deformity of the spine is extremely rare. Nevertheless, the treatment undertaken has proven to be successful so far.

Study Design. A qualitative and semiquantitative study of the morphology of the human thoracolumbar transversospinal (TSP) muscles. Objective. To further define the functional morphology of the thoracolumbar TSP muscles. Summary of Background Data. The TSP muscle group plays an important role in vertebral function but few studies have rigorously investigated their morphology throughout the thoracolumbar region and details on the location of motor endplates (MEPs) and fiber types are sparse. Methods. Thoracolumbar TSP muscles were examined by microdissection in five cadavers (seven sides). MEPs were identified using acetylcholinesterase histochemistry in muscles between T5 and S4 unilaterally in two cadavers. The relative proportions of type I and type II skeletal muscle fibers were determined using immunohistochemistry on whole cross sections of every TSP muscle from one side of one cadaver (T5–S4). Results. TSP morphology was homogeneous and consistent throughout the thoracolumbar region. Notable differences to standard descriptions included: (1) consistent attachments between muscles; (2) no discrete cleavage planes between muscles; and (3) attachment sites over the sacrum and to lumbar zygapophysial joints. Previously undescribed small muscles were found attaching to the medial sacrum. All TSP muscles were multipennate, with fibers arranged in parallel having one MEP per muscle fiber. Muscles were highly aerobic (mean proportion of type I fibers 89%), with the proportion of type I fibers decreasing caudally. A significantly greater proportion of type I fibers were found in the midthoracic compared to the low lumbar regions. Conclusion. The complex morphology of the TSP muscles indicates that they would be better classified as spinotransverse muscles. They are multipennate, highly aerobic, with fibers organized in parallel, an arrangement lending itself to “fine-tuning” of vertebral movements. Understanding their morphology has implications for investigation, treatment, motor control, and biomechanics.

Study design Retrospective case series. Objective To make clinicians aware of this unusual natural history. Summary of background data Nonprogressive and progressive scolioses due to hemivertebrae have been abundantly documented in the literature. There has been no article describing spontaneous improvement. Two case reports have been described elsewhere in a general article on natural history. Methods From a previous review of 1250 patients with congenital spine deformity of all types, 7 patients were identified with spontaneous improvement of their scoliosis due to a hemivertebra during growth. Results The mean curve at start of observation was 31 degrees (range: 24 degrees -43 degrees), and at the end of observation was 19 degrees (range: 10 degrees -30 degrees). Six of the curves were at the thoracolumbar region (T11-L2), and the other at T1. The average duration of follow-up was 9 years. Conclusion Spontaneous curve improvement is rare, but possible. In view of the difficulty of prediction for curves due to a hemivertebra, careful observation with careful curve measurement is recommended. Inappropriate early, aggressive surgery should be avoided.

Computerized tomography (CT) analysis of in vivo pedicle screw placement to determine their exact position in relation to the pedicle in thoracolumbar region (T10-L3).To evaluate the clinical accuracy of the placement of thoracolumbar pedicle screws with a free hand technique after reviewing preoperative imaging.CT scans have been used in research clinical settings to evaluate pedicle screw placement in thoracolumbar spine.Ninety-eight consecutive patients who underwent posterior stabilization using 640 transpedicular screws by 1 surgeon from T10 to L3 were analyzed. The mean age was 36.1+/-15.1 (13 to 73) years at the time of surgery. Pedicle screws were inserted using anatomic landmarks; specific entry sites, preoperative anteroposterior/lateral radiographs, and CT imaging were used to guide the surgeon. After preparation of entry point, a pedicle probe was carefully advanced free hand down the pedicle into the body. Careful palpation of all bony borders (flour and 4 pedicle walls) was performed before placement the screw. Postoperative CT scans were used to evaluate the position of all pedicle screws inserted. Screw cortical penetration was graded on the basis of anatomy (the wall penetrated) and distance of the penetration, with 2 mm of interval.The number of screws inserted at each level were as follows: T10 (n=55), T11 (n=124), T12 (n=118), L1 (n=91), L2 (n=146), and L3 (n=106). Analysis of these pedicle screws using postoperative CT scans confirmed 37 (5.8%) violated screws, including 12 medial, 18 lateral, 2 superior, 1 inferior, and 4 anterolateral vertebral body penetrations. No neurologic, vascular, or pleural injuries occurred. No screws required postoperative repositioning.Pedicle screw placement with a free hand technique after reviewing preoperative imaging seems to be accurate, reliable, and safe adjunct for the placement of thoracolumbar spine screws.

Although vehicular trauma traditionally has accounted for the majority of spinal cord injuries, gunshot wounds are the second most common cause. Furthermore, the proportion of spinal cord injuries caused by gunshot wounds are increasing although the proportion of injuries caused by high-speed vehicular trauma is decreasing. Gunshot wounds to the spine commonly are thought to be stable injuries. There is, however, a potential for instability if the bullet passes transversely through the spinal canal and fractures pedicles and facets. Injuries to the thoracic region of the spine are the most common, followed by the thoracolumbar area and the cervical spine. Completeness of injury is related to the anatomic region. Patients with incomplete injuries and patients with injuries in the thoracolumbar region have the greatest improvement in motor function. Approximately (1/4) of individuals are able to ambulate 1 year after injury. Surgical decompression of bullets from the spinal canal has been shown to improve neurologic recovery below the T12 level. Improvement of neurologic recovery after bullet removal has not been shown in other regions of the spine. Rare instances of late neurologic decline because of retained bullet fragments have been documented.

STUDY DESIGN Use of a rule-based automated algorithm to determine sources of variability in radiographic classification. OBJECTIVES To determine whether unambiguous rules encoded in a computer program would ensure reliable classification. SUMMARY OF BACKGROUND DATA Reliability problems have been identified in classifications used in surgical planning for patients with thoracic idiopathic scoliosis, but the sources of unreliability are not understood. METHODS Objective classification methodology was tested on the King et al (1983) scheme. There were two novel components: 1) positions of the corners of vertebrae in radiographs were digitized relative to a defined axis system and used in automated evaluation of spinal shape parameters required for classification; and 2) the assignment of a classification was done with a rule-based algorithm. The algorithm was implemented after some ambiguities and absence of precise definitions in the King et al classification scheme had been resolved. The algorithm was tested with radiographs of patients having adolescent idiopathic scoliosis. RESULTS The automated procedure could encounter reliability problems in cases in which a lumbar curve was very close to crossing the midline, thoracic and lumbar curves were of approximately equal value, when the apex level in the thoracolumbar region was ambiguous, when a Cobb angle was close to 10 degrees, or when the flexibility index was close to unity. CONCLUSION Objective measurements and rule-based algorithms can eliminate some sources of interobserver and intraobserver errors in classification of spinal deformity. When classification parameters fall close to the boundaries for classification, reliability problems will persist.

Study Design. Ex vivo biomechanical study using osreoporotic cadavetic vertebral bodies. Objective. To determine the association between the volume of compent injected during percutaneous vertebroplasty and the restoration of strength and stiffness in osteoporotic vertebral bodies, two investigational cements were studied: Orthocomp (Orthovita, Malvern, PA) and Simplex 20 (Simplex P with 20% by weight barium sulfate content: Stryker-Howmedica-Osteonics, Rutherford, NJ). Summary of Background Data. Previous biomechanical studies have shown that injections of 8-10 mL of cement during vertebroplasty restore or increase vertebral body strength and stiffness; however, the doseresponse association between cement volume and restoration of strength and stiffness is unknown. Methods. Compression fractures were experimentally created in 144 vertebral bodies (T6-L5) obtained from 12 osteoporotic spines harvested from female cadavers. After initial strength and stiffness were determined, the vertebral bodies were stabilized using bipedicular injections of cement totaling 2, 4, 6, or 8 mL and recompressed, after which post-treatment strength and stiffness were measured. Strength and stiffness were considered restored when post-treatment values were not significantly different from initial values. Results. Strength was restored for all regions when 2 mL of either cement was injected. To restore stiffness with Orthocomp, the thoracic and thoracolumbar regions required 4 mL, but the lumbar region required 6 mL. To restore stiffness with Simplex 20, the thoracic and lumbar regions required 4 mL, but the thoracolumbar region required 8 mL. Conclusion. These data provide guidance on the cement volumes needed to restore biomechanical integrity to compressed osteoporotic vertebral bodies.

The Quantec Spinal Imaging System (QSIS) is a raster stereography used to measure three-dimensional trunk images. The Q angle, a coronal plane measurement generated by the Quantec Spinal Imaging System (QSIS), was compared with the Cobb angle in assessment of scoliosis curve magnitude. One hundred forty-nine patients with idiopathic scoliosis were evaluated using both the Quantec system and plane radiographs. The Cobb and Q angles demonstrated significant correlation in the thoracic region (r = 0.65, p < 0.05), lumbar region (r = 0.63, p < 0.05), and in the thoracolumbar region (r = 0.70, p < 0.05). The difference between the Q and Cobb angles was small when the Cobb angle was

Coverage of midline posterior wounds presents a challenge to the reconstructive surgeon, especially when spinal stabilization hardware has been present and exposed in the wound. Most commonly those wounds that involve the mid to upper thoracic spine have been covered by latissimus dorsi muscle or musculocutaneous flaps. Lower midline wounds, especially in the thoracolumbar region, have needed more complex means of coverage. These have included reversed latissimus dorsi flaps, free flaps, extended intercostal flaps, or fasciocutaneous rotation flaps. We have utilized a far simpler and effective muscle flap: the paraspinous muscle flap. We have raised paraspinous muscle flaps bilaterally and have been able to cover a number of difficult wounds. The wounds were presented by 8 patients with exposed Harrington rods, 3 patients with cerebrospinal fluid leaks, and 1 patient with exposed spinous processes. The wounds in 5 of these 12 patients were in the upper thoracic region, where a latissimus flap was utilized as an additional layer of muscle coverage. The other seven patients had wounds in the lower midline region below the potential reach of the latissimus dorsi. In the latter patients the only flaps employed were paraspinous muscle flaps. We had only one failure in all patients, which involved a recurrent cerebrospinal fluid leak in which there was no decompression of the cerebrospinal fluid pressure utilized in the immediate postoperative period to protect the dural repair. In that instance, a leak recurred. This paper presents the method of flap elevation and the results of our series.

STUDY DESIGN A case report of aggressive multilevel Charcot spinal arthropathy treated with staged spinal instrumentation. OBJECTIVES To report an unusual case of Charcot spinal arthropathy, given the rapidity of progression and extent of tissue destruction, and present the results of successful spinal instrumentation and stabilization. SUMMARY OF BACKGROUND DATA Charcot spinal arthropathy in the long-standing paraplegic patient is more commonly seen in those who have undergone prior spinal surgery and is usually restricted to 2 spinal levels. METHODS A 36-year-old amateur weight lifter with T6 complete paraplegia presented with lower thoracic back pain, a kyphotic deformity of the thoracolumbar region, and gross spinal instability on transferring. Imaging revealed extensive bony destruction from T10-T12 and complete absence of spinal tissue over the affected levels. Staged anterior and posterior spinal instrumentation from T3 to L4 was performed. RESULTS Spinal stabilization was achieved, and the patient was pain free and able to resume light training at 6-month follow-up. CONCLUSIONS We would advise a high index of suspicion of Charcot arthropathy in the active paraplegic patient presenting with back pain caudal to their sensory level. Staged spinal instrumentation is an effective treatment for multilevel Charcot spinal arthropathy.

Primary osteosarcoma of the spine is rare. The reported prevalence of osteosarcoma of spinal origin is less than 3 per cent of all osteosarcomas1,2,7; Shives et al., for example, reported such a lesion in only twenty-seven of 1122 patients who had a primary osteosarcoma. We believe that en bloc resection with a wide margin is the ideal treatment for any osteosarcoma; however, this procedure is very difficult to perform for an osteosarcoma of the spine because of the proximity of the spinal cord and the major vessels. Because it is difficult to excise the spinal tumor completely7,9, the prognosis after treatment of an osteosarcoma of the spine continues to be poor compared with that after treatment of an osteosarcoma in an extremity. We report the case of a patient who was managed successfully with total en bloc spondylectomy10,11 for a primary osteosarcoma of the spine involving the eleventh thoracic through second lumbar vertebral levels. A sixteen-year-old boy was seen because of a four-month history of stiffness and severe pain in the thoracolumbar region of the back. Physical examination demonstrated tenderness in the area of the posterior elements of the eleventh and twelfth thoracic and first lumbar vertebrae, without neurological deficit. Plain radiographs showed increased bone density at the level of the twelfth thoracic vertebra and diffuse sclerotic changes in the paravertebral soft tissues at the levels of the eleventh thoracic through second lumbar vertebrae (Figs. 1-A and 1-B). The computerized tomography scan demonstrated that the tumor included the entire twelfth thoracic vertebra as well as segments of the eleventh thoracic vertebra. There was extensive paravertebral and epidural involvement in the region of the eleventh thoracic through first lumbar vertebrae as well as bilateral invasion of the paraspinous …

Study design A retrospective study to review the results of unstable thoracolumbar burst fractures managed with casting or bracing and early ambulation in neurologically healthy patients. Objectives To determine the clinical outcome of patients with unstable burst fractures of the thoracolumbar spine treated without surgery, and to identify any variables that may adversely influence the final outcome. Summary of background data The management of unstable fractures of the thoracolumbar spine as described by Bedbrook involves a period of recumbency for 6-8 weeks followed by gradual mobilization. Newer techniques of surgical stabilization of the fracture and decompression of the neural elements have become popular because immediate stability of the spine is created and because the need for prolonged bedrest and hospitalization is eliminated. There have been only three reports in the literature describing the nonoperative management of these fractures with early mobilization; some authors believe that this is appropriate only if the posterior column is intact. The results reported in the literature of nonoperative management of thoracolumbar burst fractures have indicated that this is an effective method of management. Methods A retrospective review of 26 patients with unstable burst fractures in the thoracolumbar region (T11-L2) was performed; follow-up evaluation was obtained from 24 patients. Clinical follow-up examination was performed by the use of a questionnaire in which the patients were asked to rate their pain, ability to work, ability to perform in recreational activities, and their overall satisfaction with treatment. Results Mean follow-up time for the 24 patients was 34.3 months. Mean duration of hospitalization was 8.2 days; those patients who did not have injuries other than their spine fracture had a mean hospitalization time of 5.9 days. Kyphotic deformity could be corrected with hyperextension casting but tended to recur during the course of mobilization and healing. No correlation was found between kyphosis and clinical outcome. At final follow-up evaluation, 19 patients (79%) had little or no pain; 18 patients (75%) had returned to work; 18 (75%) stated that they had little or no restrictions in their ability to work, and 16 (67%) stated that they had little or no restrictions in their ability to participate in recreational activities. Only one patient (4%) reported being dissatisfied with the initial nonoperative treatment of his spine fracture. Ten patients were found to have evidence of spinous process widening on plain films; there was no significant difference in the clinical or radiographic outcome of these 10 patients when compared with the 14 others who did not have interspinous widening. Conclusions Nonoperative management of thoracolumbar burst fractures with hyperextension casting or bracing was proven to be a safe and effective method of treatment in selected patients. Clinical results were favorable; no neurologic deterioration was observed; hospitalization times were minimized, and patient satisfaction was high. The authors do not believe that ligamentous injury of the posterior column is a contraindication to nonoperative management of thoracolumbar burst fractures.

The aim of this study was to identify the prevalence of proximal junctional kyphosis (PJK) in degenerative lumbar scoliosis (DLS) following long instrumented posterior spinal fusion, and to search for predictable risk factors for the progression of junctional kyphosis. In total 98 DLS patients with a minimum 2-year follow-up were reviewed prospectively. According to the occurrence of PJK at the last follow-up, patients were divided into 2 groups: PJK group and non-PJK group. To investigate risk values for the progression of PJK, 3 categorized factors were analyzed statistically: patient characteristics—preoperative data of age, sex, body mass index (BMI), bone mineral density (BMD) were investigated; surgical variables—the most proximal and distal levels of the instrumentation, the number of instrumented levels; pre- and postoperative radiographic parameters include the scoliotic angle, sagittal vertical axis, thoracic kyphosis, thoracolumbar junctional angle, lumbar lordosis, pelvic incidence, pelvic tilt, and sacral slope. PJK was developed in 17 of 98 patients (17.3%) until to the final follow-up and were enrolled as the PJK group, and 81 patients without PJK at final follow-up were enrolled as the non-PJK group. There was no statistically significant difference between the 2 groups in age at operation (P = 0.900). The patient's sex was excluded in statistical analysis because of the predominance of female patients. There were statistically significant difference between the 2 groups in BMI ([25.5 ± 1.7] kg/m2 in the PJK group and [23.6 ± 1.9] kg/m2 in the non-PJK group, P 25 kg/m2, osteoporosis, and UIV at thoracolumbar junction were independently associated with PJK. In conclusion, osteoporosis, obesity, and UIV at thoracolumbar junction are risk factors for the development and progression of PJK in DLS patients following long instrumented posterior spinal fusion. Antiosteoporosis treatment extends the fusion level above the thoracolumbar region and controlling body weight before and after surgery could provide opportunities to reduce the rate of PJK and to improve therapeutic outcomes.

Study Design. Case report. Objectives. To report a rare case of purely extradural spinal meningioma in a patient with previous history of malignant disease and to discuss the potential pitfalls in differential diagnosis and treatment of intraspinal extramedullary masses. Summary and Background Data. Spinal meningiomas located purely in the extradural space are rare, and they may easily be confused with malignant neoplasms that are much more common in this location. Methods. An asymptomatic intraspinal extramedullary mass in the thoracolumbar region was detected by magnetic resonance imaging in a 75-year-old woman with previous history of malignant disease. Results. The purely extradural lesion was completely excised via a dorsal approach. The intraoperative and postoperative histologic examination revealed a meningioma. The patient is symptom free 18 months after surgery without radiologic recurrence. Conclusion. Extradural spinal meningiomas may mimic metastatic disease. Attention needs to be drawn to this dangerous preoperative and intraoperative misinterpretation, which may easily entail an inadequate therapy. Intraoperative histology is mandatory for optimal surgical decision-making.

Paragangliomas are benign tumors arising from the heterotopic sympathetic ganglion. They occur more often in the carotid body, glomus jugulare, mediastinum, and paraaortic region; central nervous system locations include the petrous ridge, pineal region, and sella turcica. We report the clinical and imaging features of an unusual case of paraganglioma of the cauda equina. Magnetic resonance imaging (MRI) of the thoracolumbar region should be performed in cases of increased intracranial pressure whenever the head examination does not reveal the exact cause of the problem.

The present study is the first that reports the prevalence of scoliotic changes in the island of Crete. We examined 21,220 children (10,942 boys and 10,278 girls), which corresponds to 87.8% of the 6-12-year-old children living in the Iraklion district (city and rural areas). Of the examined population, 9.6% were referred for radiological examination; 1.7% of the screened children were found to have spine deformities with angular values > 10 degrees. The prevalence of severe abnormalities (> 20 degrees) requiring conservative treatment was 0.06%. Thirty percent of the scoliotic deformities involved the thoracolumbar region, whereas 48 and 22% of curves were confined to the thoracic or lumbar area, respectively. The cost of the screening per child during the 1st year was estimated to be $10 (U.S.), but it was reduced by 42% during the 2nd year. The screening program is continuing to include all four districts of the island of Crete and assess the impact of scoliosis screening programs and of conservative treatment on the natural history of the disease. Scoliometers are used for the selection of children who should be referred for radiological evaluation (> 7 degrees). The screening includes children older than 8 years of age.

Bone imaging demonstrated diffuse and intense radionuclide concentration in multiple intervertebral disc spaces. This was unexplained by history a physical examination. Films of the thoracolumbar region, taken during the hospitalization, did not show any evidence of disc disease a calcification. Radiographs of the area, two years previously, also did not detect any abnormalities of the intervertebral disc spaces

We examined cord motion and cord-spine coupling associated with the axial tension and dorsal impact models of spinal cord injury. In 20 cats, distraction forces up to 15 kg were applied. Five microliters of radiopaque agent was injected into the central cord at C4-C7 (14 cats) and T6-L1 (6 cats) at 2-mm intervals. In 20 cats, 300 g/cm impacts were delivered after injection of contrast at 2-mm intervals from the impact point. Trials were conducted under fluoroscopy. At 5-kg distraction, vertebral motion averaged 2.12 mm and cord motion averaged 1.03 mm (coupling ratio = .49). At 10-kg coupling increased to .75. Between 10 and 15-kg distraction, the amount of increase in cord length slowed, as did the ratio (.59). Differences in length between load groups were significant at most levels, and motion corresponded with histologic injury reported previously. In the thoracolumbar region, minimal spine motion and no cord motion occurred. Spine motion was not seen with dorsal impact although cord motion at 2 mm from impact averaged 1.3 mm/300 g/cm, which decreased away from the impact point. The spinal cord has limited elasticity, which may be related to injury. Because spine and cord motion occur in clinical injury, experimental models need to incorporate this element.