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A 70-year-old man presented with severe lower-back pain and left L5 radiculopathy that was resistant to all forms of conservative treatment. Imaging showed a grade 1 unstable degenerative listhesis at L4/5 that resulted in severe left lateral recess stenosis. To this end, he underwent an uneventful minimally invasive L4/5 unilateral transforaminal lumbar interbody fusion (TLIF), and he was discharged 3 days later with complete relief of leg pain. But 2 weeks later, he presented to the emergency room with a recurrence of severe left leg pain. A plain X-ray obtained in the ER showed a displaced interbody cage (backout). The patient underwent revision surgery, where the cage was removed. A larger cage was reinserted, and right-sided pedicle screw and rod fixation was performed. This resulted in complete pain relief until 2 weeks later, when the patient experienced yet another recurrence of cage migration. This time, the cage was removed, and the interbody space was successfully impacted with a bone graft. Since then, he has been pain-free over a 6-month period. The possible reasons for cage backout and strategies to prevent it are discussed., (© 2025. The Author(s).)

Purpose: To compare 3D postoperative deformity correction using two distinct commonly utilized techniques for the treatment of adolescent idiopathic scoliosis (AIS)., Methods: AIS patients with major thoracic (Lenke 1-2) curves at two sites who underwent deformity correction via posterior spinal instrumented fusion using one of two distinct techniques were retrospectively reviewed. Patients were matched 1:1 between sites for Lenke type (95% Lenke 1) and follow-up time. The "band site" performed posteromedial translation using thoracic sublaminar bands and 5.5-mm rods. The "screw site" performed spine derotation using differential rod contouring with pedicle screws and 5.5-mm rods. 3D measures of deformity from spinal reconstructions were compared between sites., Results: Preoperatively, the groups had similar thoracic curve magnitudes (band, 55 ± 12° vs. screw, 52 ± 10°; p > 0.05); the "screw site" had less T5-T12 kyphosis (2 ± 14° vs. 7 ± 12°, p = 0.05) and greater thoracic apical rotation (- 19 ± 7° vs. - 14 ± 8°, p = 0.007). Postoperatively, the "screw site" had greater percent correction (61% vs. 76%, p < 0.001) and kyphosis restoration (p = 0.002). The groups achieved a similar amount of apical derotation (p = 0.9). The "band site" used cobalt chromium rods exclusively; the "screw site" used cobalt chromium (3%) and stainless steel (97%; p < 0.001). The "band site" performed significantly longer fusions., Conclusions: Significant variations were found between two commonly utilized techniques in AIS surgery, including rod material, correction mechanisms, and fusion levels. Significantly, a greater 3D deformity correction of the coronal and sagittal planes was observed at the "screw site" compared to the "band site", but with no difference in axial plane correction.

Study Design: Multicenter retrospective., Objective: To determine the long-term complication rate associated with surgical treatment of spondylolisthesis in adolescents. There is limited information on the complication rate associated with posterior spinal fusion (PSF) of spondylolisthesis in the pediatric and adolescent population., Methods: Patients who underwent PSF for spondylolisthesis between 2004 and 2015 at four spine centers, < 21 years of age, were included. Exclusion criteria were < 2 years of follow-up or anterior approach. Charts and radiographs were reviewed., Results: 50 patients had PSF for spondylolisthesis, 26 had PSF alone, while 24 had PSF with trans-foraminal lumbar interbody fusion (TLIF). Mean age was 13.9 years (range 9.6-18.4). Mean follow-up was 5.5 years (range 2-15). Mean preoperative slip was 61.2%. 20/50 patients (40%) experienced 23 complications requiring reoperation at a mean of 2.1 years (range 0-9.3) for the following: implant failure (12), persistent radiculopathy (3), infection (3), persistent back pain (2), extension of fusion (2), and hematoma (1). In addition, there were 22 cases of radiculopathy (44%) that were transient. Rate of implant failure was related to preoperative slip angle (p = 0.02). Reoperation rate and rates of implant failure were not associated with preoperative % slip (reoperation: p = 0.42, implant failure: p = 0.15), postoperative % slip (reoperation: p = 0.42, implant failure: p = 0.99), postoperative kyphosis of the lumbosacral angle (reoperation: p = 0.81, implant failure: p = 0.48), change in % slip (reoperation: p = 0.30, implant failure: p = 0.12), change in slip angle (reoperation: p = 0.42, implant failure: p = 0.40), graft used (reoperation: p = 0.22, implant failure: p = 0.81), or addition of a TLIF (reoperation: p = 0.55, implant failure: p = 0.76)., Conclusion: PSF of spondylolisthesis in the adolescent population was associated with a 40% reoperation rate and high rate of post-operative radiculopathy. Addition of a TLIF did not impact reoperation rate or rate of radiculopathy.

Study Design: Retrospective monocentric study., Objectives: To report radiologic outcomes of a consecutive series of AIS patients, operated with a bivertebral autostable claw for the upper instrumentation over a 5-year period. The upper fixation represents the weakest part of long constructs because of local anatomy and the high pull-out forces. Various implants have been proposed, but proximal junctional failures (PJF) and shoulder imbalance still occur with variable incidence. The autostable claw is a new implant, safe, and low profile, combining the mechanical strength of hooks with the initial stability of pedicle screws., Methods: All AIS patients operated between January 2010 and July 2015 for a Lenke 1 or 2 curve with the bivertebral autostable claw were included. A minimum 2-year follow-up was required. Full-spine biplanar stereoradiographs were performed preoperatively, within 8 weeks postoperative and at latest examination. Local and global sagittal and coronal parameters were analyzed and complications were reported., Results: 237 patients (191 Lenke 1 and 46 Lenke 2) were included, with a mean follow-up of 4.1 ± 0.6 years. PJF occurred in 2 patients (0.8%), and radiologic PJKs were observed in 8.4% of the series. Shoulder balance was efficiently restored or maintained in 88.2%., Conclusions: The bivertebral autostable claw is a safe and robust alternative to pedicle screws for proximal fixation in AIS long constructs. Compression and/or distraction can be applied to level shoulders, and mechanical failures remain rare at 4-year follow-up., Level of Evidence: IV.

Study Design: Retrospective monocentric database study., Objectives: To describe the "frame" reduction technique and report the 3D quantitative analysis of postoperative corrections in a consecutive series of thoracic adolescent idiopathic scoliosis (AIS) patients., Summary of Background Data: Posteromedial translation technique using sublaminar bands have been proved to be efficient and safe for 3D correction of the deformity and overall cosmetic aspect of the trunk. However, the ability to correct the axial plane may tend to rotate the vertebra clockwise instead of counterclockwise, thus increasing apical vertebra axial rotation (AVR) and the rib hump. A technical improvement was developed to emphasize axial correction., Methods: 60 thoracic AIS patients consecutively operated by posteromedial translation using the "frame" reduction technique were included with a minimum 2-year follow-up. Precontoured rods were connected with fixed transverse connectors according to a personalized preoperative planning. Rods were first inserted distally in the pedicle screws to achieve lumbar correction, and then in the upper anchors, and finally sublaminar bands were connected to their corresponding rods to progressively bring the concave lamina to the concave rod to correct the thoracic deformity. Sagittal and coronal 3D measures were performed preoperatively and at the latest follow-up using SterEOS (EOS Imaging, Paris, France) to assess the efficiency of the technique., Results: The distance from the center of the apical vertebra to the reference axis in the frontal plane was reduced from 4.7 to 1.1 cm, traducing the efficient medial translation of the spine during correction. T1-T12 kyphosis significantly increased after surgery (28°-35°). 3D location of the upper instrumented vertebra (UIV) was not affected. The apical rotation was significantly reduced after surgery (19°-11°), and the AVR correction rate averaged 42.2%., Conclusion: The "frame" technique is an innovative way of using polyester bands, optimizing axial correction while respecting sagittal alignment., Level of Evidence: Level IV., (Copyright © 2018. Published by Elsevier Inc.)

Purpose: Major concern during surgery for high-grade spondylolisthesis (HGS) is to reduce lumbosacral kyphosis and restore sagittal alignment. Despite the numerous methods described, lumbosacral fixation in HGS is a challenging technique associated with high complication rate. Few series have described outcomes and most of the results are limited to lumbosacral correction without global sagittal alignment analysis. This study aims at analyzing clinical and radiological outcomes of HGS patients treated with intrasacral rods on full spine radiographs., Methods: HGS patients (Meyerding III or higher) operated between 2004 and 2014 were reviewed. All patients underwent full spine stereoradiographic images. After L5 and S1 decompression, reduction and circumferential fusion with intrasacral rod fixation and fusion up to L4 were performed under fluoroscopy. The entry points for S1 screws were located 3-5 mm above and 5 mm lateral to the first sacral hole, toward the promontory. The two short distal fusion rods were then positioned into the sacrum guided by anteroposterior fluoroscopy using Jackson's technique. Then, sacral dome resection was performed and a PEEK cage was impacted in L5S1 after reduction. Postoperatively, the hip and knee were kept flexed at 45° for 1 week and extended progressively. Preoperative, 3 months postoperative and last follow-up (> 2 years minimum) clinical and radiographic data were collected. Sagittal parameters included lumbosacral angle (LSA), olisthesis, T1 spinopelvic inclination (T1SPi) and spinopelvic parameters., Results: 20 HGS patients were included (8 ptosis, 5 Meyerding IV). The mean age was 14 years. At final FU (7.2 years ± 3), LSA kyphosis and olisthesis were reduced (65° ± 14 vs 99° ± 11, p < 0.001 and 81% ± 19 vs 45% ± 18, p < 0.001, respectively). While L1L5 lordosis decreased, T1T12 kyphosis increased. At FU, global alignment with T1SPi was - 6° ± 3. No significant loss of correction was observed. Regarding complications, ten patients presented transient L5 motor deficit that occurred when patients were put in standing position. However, all recovered before 3 months postoperatively., Conclusion: Intrasacral rod fixation appears to be an effective technique to correct LSA kyphosis, compensatory hyperlordosis and restore global sagittal alignment with a postoperative T1SPi corresponding to the value of the asymptomatic subject and achieve fusion. However, it remains a demanding technique with high risk of transient neurologic complications.

Introduction: The comparison of implants and correction methods remain controversial in AIS. Excellent frontal and axial correction rates have been reported with all-screw constructs, but at the expense of sagittal alignment, which has a tendency to flatten postoperatively. Posteromedial translation using hybrid constructs seems to preserve and improve thoracic kyphosis (TK), but no series exist to date with a significant number of hypokyphotic patients. In addition, the measures of TK in 2D are often wrong in severe AIS due to axial rotation. The goals of this study were therefore to analyze the 3D radiological outcomes of a group of hypokyphotic AIS patients operated with sublaminar bands., Methods: 35 consecutive AIS hypokyphotic patients (T4T12 <15°) operated in three centers were included, with a minimum 2-year follow-up. The surgical technique was similar in all centers, associating lumbar pedicle screws and thoracic sublaminar bands. Posteromedial translation was the main correction technique, and no patient underwent prior anterior release. 3D spinal reconstructions were performed preoperatively, postoperatively and at the latest follow-up by an independent observer using SterEOS (EOS imaging, Paris, France), and 2D and 3D measurements were compared. In addition, a new 3D parameter [sagittal shift of the apical vertebra (SSAV)], reflecting the translation of the apical vertebra of the main curve in the patient sagittal plane, was described and reported., Results: The age of the cohort was 16 years and the number of sublaminar bands used for correction averaged 6 (±1.5). T1T12 and T4T12 sagittal Cobb angles appeared to be overestimated on 2D postoperatively (3°, p = 0.002 and 4°, p < 0.001, respectively). Hence, only 3D measurements were kept for the quantitative analysis of the postoperative correction. T4T12 TK significantly increased after surgery (average 8° ± 7°, p < 0.001), but 11 patients (31.4%) remained hypokyphotic. Seven out of the eight patients (87.5%) who presented a thoracic lordosis (i.e., T4T12 <0°) preoperatively were corrected after surgery (mean gain 16° ± 4°). A posterior shift (positive SSAV) of the apical vertebra was reported in 24 patients (68.6%). In this subgroup, the mean SSAV was +2 cm (±1). Good correlation was found between the SSAV and the postoperative change in 3D T4T12 kyphosis (r = 0.62)., Conclusion: Measures in 2D tend to overestimate sagittal alignment and are not sufficient to evaluate postoperative correction. SSAV is a new 3D parameter reflecting the TK change that needs to be further investigated and used in the future. This series confirms that sublaminar bands should be considered in hypokyphotic patients, since thoracic sagittal alignment was restored in 68.6% of the cases.

Background: The incidence of surgical site infections (SSI) after adolescent idiopathic scoliosis (AIS) surgery ranges from 0.5% to 7%. There is currently a regain of interest in hybrid constructs, combining lumbar pedicle screws and thoracic sublaminar bands, but some authors have raised concerns about the risk of SSI and the difficulty of bacterial eradication. The goal of this study was therefore to assess the outcomes of SSI after AIS surgery using sublaminar bands., Methods: A total of 524 consecutive patients operated for AIS using sublaminar bands between June 2006 and June 2014 were included. SSI cases were identified and analyzed retrospectively. Radiologic and functional outcomes were evaluated at follow-up using EOS imaging and SRS 30 scores, and compared with a control group., Results: The overall SSI rate was 5.3%, with a majority of monomicrobial (86%) infections occurring in the first 6 weeks postoperative (93%). The most frequent pathogens were skin germs (Staphylococcus aureus and Propionibacterium acnes) with a community profile. Patients were treated successfully with surgical debridement without implants removal, associated with 6 weeks of antibiotherapy. However, 25% of patients required >1 surgical debridement. Instrumentation removal was decided in the 2 cases with late SSI, and performed uneventfully. Radiologic and functional outcomes at follow-up were not affected by the occurrence of SSI., Conclusions: Sublaminar bands are not associated with a higher risk of infection. However, the SSI rate in the current study stands in the upper range of the literature, and other preventive strategies should be considered. In case of early infection, bands removal is not necessary to obtain pathogen eradication, but the sublaminar implants can be pulled out safely in case of late SSI. The occurrence of SSI does not alter the outcomes at follow-up., Level of Evidence: Level III.

Purpose: Cobalt chromium (CoCr) rods have recently gained popularity in adolescent idiopathic scoliosis (AIS) surgical treatment, replacing titanium (Ti) rods, with promising frontal correction rates in all-screw constructs. Posteromedial translation has been shown to emphasize thoracic sagittal correction, but the influence of rod material in this correction technique has never been investigated. The aim of this study was to compare the postoperative correction between Ti and CoCr rods for the treatment of thoracic AIS using posteromedial translation technique., Methods: 70 patients operated for thoracic (Lenke 1 or 2) AIS, in 2 institutions, between 2010 and 2013, were included. All patients underwent posterior fusion with hybrid constructs using posteromedial translation technique. The only difference between groups in the surgical procedure was the rod material (Ti or CoCr rods). Radiological measurements were compared preoperatively, postoperatively and at last follow-up (minimum 2 years)., Results: Preoperatively, groups were similar in terms of coronal and sagittal parameters. Postoperatively, no significant difference was observed between Ti and CoCr regarding frontal corrections, even when the preoperative flexibility of the curves was taken into account (p = 0.13). CoCr rods allowed greater restoration of T4T12 thoracic kyphosis, which remained stable over time (p = 0.01). Most common postoperative complication was proximal junctional kyphosis (n = 4). However, no significant difference was found between groups regarding postoperative complications rate., Conclusion: CoCr and Ti rods both provide significant and stable frontal correction in AIS treated with posteromedial translation technique using hybrid constructs. However, CoCr might be considered to emphasize sagittal correction in hypokyphotic patients.

Purpose: Recent literature has reported that the ]progression risk of Lenke 5 adolescent idiopathic scoliosis (AIS) during adulthood had been underestimated. Surgery is, therefore, proposed more to young patients with progressive curves. However, choice of the approach and fusion levels remains controversial. The aim of this study was to analyze the influence of the length of posterior fusion on clinical and radiological outcomes in Lenke 5 AIS., Methods: All Lenke 5 AIS operated between 2008 and 2012 were included with a minimum 2-year follow-up. Patients were divided into two groups according to the length of fusion. In the first group (selective), the upper instrumented level (UIV) was the upper end vertebra of the main structural curve and distally the fusion was extended to the stable and neutral vertebra, according to Lenke's classification. In the second group (hyperselective), shorter fusions were performed and the number of levels fused depended on the location of the apex of the curve (at maximum, 2 levels above and below, according to Hall's criteria). Apart from the fusion level selection, the surgical procedure was similar in both groups. Radiological outcomes and SRS-22 scores were reported., Results: 78 patients were included (35 selective and 43 hyperselective). The number of levels fused was significantly higher in the first group (7.8 ± 3 vs 4.3 ± 0.6). None of the patients was fused to L4 in selective group. No correlation was found between length of fusion and complication rate. Eight patients had adding-on phenomenon among which 6 (75%) had initially undergone hyperselective fusions and had significantly higher postoperative lower instrumented vertebra (LIV) tilt. In the adding-on group, LIV was located above the last touching vertebra (LTV) in 62.5% of the cases and above the stable vertebra (SV) in 87.5%. Patients in the selective group reported a significantly lower score in the SRS function domain., Conclusion: Coronal alignment was restored in both groups. Hyperselective posterior fusions can be considered in Lenke 5 AIS, preserving one or two mobile segments, with similar clinical and radiological outcomes. However, selection of the LIV according to SV and LTV need to be accurately analyzed in order to avoid adding-on during follow-up.

Purpose: The surgical treatment of severe adolescent spinal deformities is challenging and carries substantial risks of mortality and morbidity. To mitigate this risk, surgeons have employed various methods as this study designed to evaluate the safety and effectiveness of preoperative halo-femoral or halo gravity traction (HGT) followed by posterior-only surgery in the management of severe scoliosis., Method: A total number of 23 patients with severe scoliosis treated by preoperative skeletal traction (halo gravity or halo femoral) followed by posterior fusion and instrumentation in one stage. All patients were followed for a minimum of 2 years after surgery., Results: The average age of the patients was 12.7 years at the time of surgery. Mean of the Cobb angle improved from 99.9° ± 8.2° preoperatively to 75.3° ± 8° post-traction and 49.5° ± 7.7° postoperatively. Kyphosis angle corrected from 56.4° ± 9.5° to 38.6° ± 5.8°. The preop-FVC% was 41 ± 6.1% and after 1 year follow-up FVC% was 45.7 ± 7.7%. No patients required an anterior release due to amount of their deformity., Discussion: Despite the benefits of modern instrumentation procedures, the treatment of severe scoliosis can be very competing. We think that by applying preoperative halo femoral traction and halo-gravity traction, managing severe scoliosis will be in safe and easy manner and can lead to better deformity correction and less neurological complications and facilitate to avoid anterior operation for severe scoliosis and its related complications.

Introduction: Anterior lumbar interbody fusion (ALIF) is a well-established technique to achieve lumbar spine fusion with various indications including degenerative disk disease, spondylolisthesis, recurrent disk herniation, adjacent level disease, pseudoarthrosis, as well as being used as part of the overall strategy to restore sagittal balance. ALIF can be an extremely useful tool in any spine surgeon's armamentarium. However, like any surgical procedure, proper patient selection is key to success. A solid understanding of the biomechanics, careful surgical planning, along with clear knowledge of the advantages and disadvantages of stand-alone ALIF will ensure optimal clinical outcome. Stand-alone ALIF may be a suitable surgical option in carefully selected patients that can provide good clinical results and adequate fusion rates without the need for posterior instrumentation. Areas covered: A brief overview of the indications, techniques, biomechanics, surgical outcome and complications of stand-alone ALIF is provided in this article with a review of the pertinent literature. Expert commentary: In this review we discuss the clinical evidence of using a stand-alone ALIF compared to other fusion techniques of the lumbar spine. The development of interbody cages with integrated screws has increased the arthrodesis rate and improved clinical outcomes while decreasing morbidity and operative time.

Purpose: Thoracic adolescent idiopathic scoliosis (AIS) curves (Lenke 1-4) are often characterized by hypokyphosis. Sagittal alignment remains challenging to correct, even with recent posterior segmental instrumentation. Some authors recommend anterior endoscopic release (AER) to reduce anterior column height, and facilitate thoracic kyphosis correction. The aim of this study was to assess the contribution of AER to sagittal correction in hypokyphotic AIS., Methods: Fifty-six hypokyphotic (T4T12<20°) AIS patients were included. In group 1 (28 patients), patients first underwent AER, followed by posterior instrumentation and correction 5-7 days later. In group 2 (28 patients), patients underwent the same posterior procedure without AER. Posterior correction was performed in all cases using posteromedial translation and hybrid constructs consisting of lumbar pedicle screws and thoracic sublaminar bands. From radiological measurements performed using low-dose EOS radiographs, the correction of thoracic kyphosis was compared between the two groups., Results: Groups 1 and 2 were comparable regarding demographic data and preoperative thoracic kyphosis (group 1: 11.7° ± 6.9° vs group 2: 12.1° ± 6.3°, p = 0.89). Postoperative thoracic kyphosis increase averaged 18.3° ± 13.6° in group 1 and 15.2° ± 9.0° in group 2. The benefit of anterior release was not statistically significant (p = 0.35)., Conclusion: Although previous studies have suggested that thoracoscopic release improved correction compared to posterior surgery alone, the current study did not confirm this finding. Moreover, results of the current series showed that no significant benefit can be expected from AER in terms of sagittal plane improvement when the posteromedial translation technique is used, even in challenging hypokyphotic patients.

Purpose: Sublaminar polyester bands have been used in hybrid construct to achieve correction of adolescent idiopathic scoliosis since 2003. Despite the reported safety of the bands, some surgeons remain reluctant at the idea of approaching the canal because of the potential neurological complications reported with the Luque wiring. Sub transverse bands might be an alternative. The present study is the first to compare sublaminar polyester band fixation to fixation of polyester bands around the transverse processes in hybrid constructs used to treat AIS., Methods: Two cohorts of consecutive patients treated for thoracic AIS were retrospectively reviewed, with a minimum 2-year follow-up. Posteromedial translation was used for main curve correction in all cases. Sublaminar polyester bands were used in group 1 (20 patients). In group 2 (20 patients), the same implant was used, but the bands were passed around the transverse process instead of the lamina. Radiographic analysis included frontal Cobb angle measurements for each curve, thoracic kyphosis and rotation of the apical vertebra (RVA)., Results: Mean operative time was similar in groups 1 and 2 (235±35 and 240±30minutes, respectively). Mean frontal correction achieved for the main curve was similar in both groups, 62.5±17.4% in group 1 and 54.1±19.4% in group 2. Sagittal correction was similar, with a final mean thoracic kyphosis of 30.9°±9.7° and 27.8°± 6.8° in group 1 and 2, respectively. Correction of RVA was similar in both groups postoperatively, 65.8% (±29.1) and 54.4% (±42.7) in group 1 and 2 respectively. No transverse process or lamina fracture was observed during insertion of the bands or curve correction in any of the groups., Conclusion: This study confirms that anchorage of Universal clamps (UCs) around transverse processes is a safe and efficacious technique in both the frontal and sagittal planes, providing a useful alternative for the correction of moderate AIS. UCs attached to transverse processes can achieve correction of moderate AIS similar to that obtained with sublaminar UCs while further reducing risks of vertebral canal complications., Level of Evidence: Level IV., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Purpose: This paper reports the authors' 19 years experience with pediatric intrasacral rod fixation., Methods: After insertion of two cannulated screws in S1 with and an original template guiding them into the anterior third of the endplate, two short fusion rods were inserted into the sacrum according to Jackson's technique distally to S3. In neuromuscular scoliosis, pelvic obliquity was reduced by connecting the proximal and distal constructs, distraction or compression, and in situ rod bending. In children with high-grade spondylolisthesis, lumbosacral kyphosis was reduced by rotation of the sacrum and in situ bending., Results: There were no direct neurological or vascular injuries. The main complication was infection (7%). No pseudarthrosis or significant loss of correction at the lumbosacral junction was observed during follow-up., Conclusions: Intrasacral rod fixation appears to be safe and reliable for lumbopelvic fusion in pediatric patients.

Unlabelled: The Universal Clamp (UC) equipped with a soft sublaminar band is a relatively new thoracic anchor that can be used in hybrid constructs. A dedicated reduction tool that applies traction to the sublaminar band permits gentle translation of the thoracic curve to the pre-contoured fusion rods, which have been previously anchored distally by pedicle screws and proximally by hooks in a claw configuration., Methods: A literature review concerning the use of UC in adolescent idiopathic Scoliosis was performed., Results: The results confirm the efficacy with the UC hybrid constructs, the good correction (71-66%) of the main thoracic curve and low loss of correction at 2-year follow-up (3-4%). The thoracic curve correction achieved and maintained in the AIS patients appears to be substantially higher than that reported for all hook and hook hybrid techniques. Regardless of the deformity correcting method employed with all-screw constructs, the Cobb angle correction achieved is equivalent to that achieved with UC hybrid devices. Among the present AIS patients who had normal values of thoracic kyphosis pre-operatively, there was almost no change in average thoracic kyphosis at the latest follow-up. However, among the patients with low pre-operative values of T5-T12 kyphosis, the average T5-T12 kyphosis improved., Conclusion: Hybrid construct with UC is safe, with reduced operative time and blood loss. While achieving deformity correction in the coronal and axial planes equivalent to the best-reported results of all screw or previous hybrid constructs, the UC hybrid technique appears to provide superior correction in the sagittal plane. The excellent outcome is maintained at the 2-year follow-up.

Purpose: To analyze postoperative changes in the cervical sagittal alignment (CSA) of patients with AIS treated by posteromedial translation., Methods: 49 patients with thoracic AIS underwent posterior arthrodesis with hybrid constructs, combining lumbar pedicle screws and thoracic universal clamps. Posteromedial translation was the main correction technique used. 3D radiological parameters were measured from low-dose biplanar radiographs. CSA was assessed using the C2C6 angle, and the central hip vertical axis (CHVA) was used as a reference axis to evaluate patients' balance., Results: Preoperatively, 58 % of patients had thoracic hypokyphosis, and 79 % had a kyphotic CSA. Significant correlation was found (r = 0.45, P = 0.01) between thoracic hypokyphosis and cervical kyphosis. Increase in T4-T12 thoracic kyphosis (average 14.5° ± 10°) was associated with significant decrease in cervical kyphosis in the early postoperative period. The CSA further improved spontaneously during follow-up by 7.6° (P < 0.0001). Significant positive correlation (r = 0.32, P = 0.03) was found between thoracic and cervical improvements. At latest follow-up, 94 % of the patients were normokyphotic and 67 % had a CSA in the physiological range. Sagittal balance of the thoracolumbar spine was not significantly modified postoperatively. However, the procedure significantly changed the position of C2 in regard to the CHVA (C2-CHVA), which reflects headposition (P = 0.012). At last follow-up, the patients sagittal imbalance was not significantly different from the preoperative imbalance (P = 0.34)., Conclusions: Thoracic hypokyphosis and cervical hypolordosis, observed in AIS, can be improved postoperatively, when the posteromedial translation technique is used for correction. The cervical spine remains adaptable in most patients, but the proportion of patients with physiological cervical lordosis at final follow-up remained low (24.5 %).

Background: The Universal Clamp (UC) is a novel vertebral anchor consisting of a sublaminar polyester band connected to fusion rods by a titanium jaw locked with a screw. The authors prospectively studied patients treated for thoracic or lumbar burst fractures with short pedicle screw constructs reinforced with UCs to prevent screw pullout., Methods: Eleven patients below 18 years of age underwent 2-stage circumferential fusion for complete burst fractures (Magerl A 3.3). Two pedicle screws reinforced by 2 UCs were inserted in the vertebra proximal to the fracture and 2 pedicle screws reinforced by 2 UCs were inserted in the vertebra distal to the fracture. Within 7 days, cages filled with cancellous bone graft were added for anterior column support. T12 was fractured in 3 patients, L1 in 4, L3 in 2, and L4 in 2 patients. Preoperatively, 10 patients were neurologically intact (Frankel E) and 1 patient had an incomplete spinal cord injury (Frankel C)., Results: Mean operative duration for the posterior and anterior procedures was 110±24 and 120±35 minutes, respectively. Average intraoperative blood loss was 355±60 mL. Mean hospital stay was 11±2 days and follow-up averaged 36.1±5 months. Mean kyphotic deformity was corrected from 25±9 to 5.3±4.5 degrees postoperatively (79%), without subsequent loss of correction (P=0.17). Regional kyphosis improved by 20±8 degrees postoperatively, without subsequent loss of correction (P=0.09). No intraoperative complication was observed. There was no neurological deterioration. The patient who had a Frankel C lesion recovered 1 Frankel level (Frankel D) at final follow-up. None of the patients exhibited significant correction loss during follow-up, and there was no pseudarthrosis., Conclusions: Thoracic and lumbar complete burst fractures in skeletally immature patients can be treated using anterior bone graft cages and posterior instrumented fusion augmented with UCs to prevent pedicle screw pullout. With these constructs, which are short to preserve mobile intervertebral segments, kyphosis was corrected, fusion achieved, and correction maintained in all subjects without neurological worsening., Level of Evidence: Level IV.

Background: Thoracoscopy is now considered a safe and feasible method for surgical management of spinal disorders in both adults and children. Nevertheless, a weight less than 20 kg has been reported as a relative contraindication because of the small volume of the thoracic cage and the anticipated difficulties of single-lung ventilation. The aim of this study was to evaluate the feasibility, as well as the safety and efficacy, of thoracoscopic procedures in such patients., Methods: This study was a retrospective analysis of a consecutive group of patients less than 20 kg weight, who underwent a thoracoscopy between 1998 and 2005. Results were evaluated radiologically, and intraoperative and postoperative complications were reported. A minimum 2-year follow-up was required., Results: Seventeen patients were included. Age at surgery averaged 3 years and 4 months (±1.25). The mean weight was 13.3 kg (±2.8). Fourteen of the patients had congenital scoliosis, 9 due to hemivertebrae and 5 due to segmentation failures. The other 3 suffered from evolutive kyphosis, 2 caused by Pott disease, and 1 caused by congenital anterior failure of segmentation. The mean follow-up was 6 years and 9 months (±1.5). Lung exclusion time averaged 114 minutes (±20). The intended procedure was possible in all cases and no conversion to open thoracotomy was required. The mean operating time was 139 minutes (±10). A posterior arthrodesis was associated and performed during the same anesthesia in 15 cases. The selective breathing was efficient and well tolerated in all cases. No intraoperative respiratory complication was observed. For patients with congenital scoliosis, the average improvement of the main curve between preoperative and latest follow-up was 55%, with an average Cobb angle improvement of 19.1 degrees (±10.5). For the 3 cases of kyphosis, the curve progression stopped, with a mean reduction of the regional kyphosis of 6 degrees (±11.5). Fusion was obtained radiologically in all cases., Conclusions: This study confirms the feasibility, safety, and efficacy of thoracoscopy for the management of spinal disorders in children less than 20 kg weight. Thoracoscopy can still be considered as an option in very young children, even though the small chest cavity creates additional technical challenges and the diminutive bronchial tree necessitates a dedicated method of single-lung ventilation., Level of Evidence: IV.

Study Design: A literature-based review., Objective: To summarize the clinical and morphologic findings leading to diagnosis, the etiologic factors, and principles of management. To identify the strengths and limits of past studies., Summary of Background Data: There are considerable controversies regarding etiologic factors, diagnosis, and management of adjacent segment disease in patients instrumented for idiopathic scoliosis., Methods: Summarized is past literature and, to some extent, personal experience of the authors., Results: Several factors participating to this complex pathophysiology are reported. The clinical presentation, occurring after symptom free interval, can vary, and modern morphologic investigations help for diagnosis. Management is often surgical and remains challenging., Conclusions: Long-term consequences of spinal fusions are now major concerns, especially in young patients undergoing surgical correction for idiopathic scoliosis. Adjacent segment disease is defined by a combination of clinical symptoms and morphologic findings. Several etiologic factors have been reported, but need to be further studied to prevent and improve the surgical management of this complication.

Background: Lumbosacral fusion is often needed in cases of pediatric neuromuscular spinal deformities. Despite the numerous fixation techniques described, the procedure remains challenging. Jackson has described a method of intrasacral fixation providing immediate 3-dimensional stability and promising clinical results. The purpose of this study was to report our experience with long spinal fusion using Jackson intrasacral fixation in pediatric patients., Methods: All patients with at least 5 years of follow-up were reviewed. No brace was used postoperatively. Clinical data and radiographs were collected and analyzed preoperatively, postoperatively, and at latest follow-up. Intraoperative and postoperative complications were reported. Paired t test was used for statistical analysis., Results: Fifty-six patients were included. The average age at surgery was 15.3 years. Mean follow-up period was 10.3 years and no patient was lost to follow-up. All radiographic parameters (frontal balance, frontal Cobb angle of the primary curve, iliolumbar angle, pelvic obliquity, sagittal balance, lumbosacral lordosis, and sacral slope) were significantly improved postoperatively (P<0.001), without significant loss of correction at latest follow-up. Four early infections, 1 pressure sore, and 4 cases of radicular pain, which resolved without intervention, were reported postoperatively. At latest follow-up, no patient complained of lumbar pain, and neither ambulatory status nor activity level ability worsened in any case. Sixteen of the 20 patients who needed a sitting orthosis preoperatively achieved a functional sitting posture without bracing., Conclusions: Jackson fixation is a safe and reliable technique providing immediate stability. In our series, no mechanical complication occurred and no loss of correction was observed, despite immediate unprotected mobilization. The method provides reliable good sacral fixation for pediatric neuromuscular spinal deformities, especially when the correction of severe pelvic obliquity is necessary., Level of Evidence: This consecutive series provides level IV evidence.

Correction of adolescent idiopathic scoliosis (AIS) has been reported with various systems. All-screw constructs are currently the most popular, but they have been associated with a significant decrease in thoracic kyphosis, with a potential risk of junctional kyphosis, not observed with hybrid constructs in the literature. In addition, it is important to weigh potential advantages of pedicle screw fixation against risks specific to its use. Because hybrid constructs are associated with a lower risk of complications and better sagittal correction than all-screw constructs, at present we use lumbar pedicle screws combined with a new sublaminar connection to the spine (Universal Clamps) at thoracic levels. The purpose of this study was to determine the efficacy and safety of the Universal Clamp (UC) posteromedial translation technique for correction of AIS. Seventy-five consecutive patients underwent posterior spinal fusion and hybrid instrumentation for progressive AIS. Correction was performed at the thoracic level using posteromedial translation. At the lumbar level, correction was performed using in situ contouring and compression/distractions maneuvers. A minimum 2-year follow-up was required. Medical data and radiographs were prospectively analyzed and compared using a paired t test. The average age at surgery was 15 years and 4 months (+/-19 months). The average number of levels fused was 12+/-1.6. The mean follow-up was 30+/-5 months. The average preoperative Cobb angle of the major curve was 60 degrees+/-20 degrees. The immediate postoperative major curve correction averaged 66+/-13%. The average loss of correction of the major curve between the early postoperative assessment and latest follow-up was 3.5 degrees+/-1.4 degrees . The mean Cincinnati correction index was 1.7+/-0.8 postoperatively, and 1.57+/-1 at last follow up. The mean rotation of the apical vertebra was corrected from 23.3 degrees+/-9 degrees preoperatively to 7.3 degrees+/-5 degrees at last follow up (69% improvement, P<0.0001). In the sagittal plane, the mean thoracic kyphosis improved from 23.8 degrees+/-14.2 degrees preoperatively to 32.3 degrees+/-7.3 degrees at last follow up. For the 68 patients who had a normokyphotic or a hypokyphotic sagittal modifier, thoracic kyphosis increased from 20.5 degrees+/-9.9 degrees to 31.8 degrees+/-7.4 degrees, corresponding to a mean kyphosis correction of 55% at last follow up. No intraoperative complication occurred and none of the patients developed proximal junctional kyphosis during the follow up. The principal limitation of the UC technique was the rate of proximal posterior prominence (14.6%), leading us to recommend the use of conventional claws at the upper extremity of the construct. The technique was safe, and reduced operative time, radiation exposure, and blood loss. While achieving correction of deformity in the coronal and axial planes equivalent to the best reported results of all-screw or previous hybrid constructs, the UC hybrid technique appears to provide superior correction in the sagittal plane. The excellent outcome in all three planes was maintained at 2 year follow up.

Background: The selection of fusion levels continues to be controversial in adolescent idiopathic scoliosis (AIS). The classifications of King and Lenke remain the most widely used, but recent studies have demonstrated their shortcomings, including poor interobserver reproducibility. We propose a method of preoperative planning that is independent of anatomical classifications, based on the anticipated effect of curve reduction. The objectives of this preoperative strategy are (1) to achieve satisfactory T1 tilt and shoulder balance and (2) to restore balance in the coronal and sagittal planes. The purpose of the present study was to evaluate the results of our strategy of deciding the proximal level of arthrodesis in Lenke types 1 and 2 AIS., Methods: We included 132 adolescents operated on for thoracic AIS by posterior instrumentation. The choice of the proximal fusion level was based on preoperative analysis of the rigidity of the proximal curvature, T1 tilt, and shoulder balance. The preoperative, postoperative, and last follow-up radiographs were digitized then analyzed using computer software. Radiological parameters were compared using paired t tests., Results: Average age at the time of surgery was 15.2 years (SD, 1.7 years). Mean follow-up was 30.2 months. The clavicle angle and T1 tilt were significantly improved in both Lenke types 1 and 2 curves. No correlation was found between T1 tilt and shoulder balance. At last follow-up, 89% of the patients satisfied all criteria for balance., Conclusions: The results of the present preoperative strategy, to which we adhered in 97% of cases, are encouraging and show that the systematic instrumentation of the entire proximal curvature is not justified in Lenke type 2 curves. However, long-term consequences of the residual T1 tilt need to be studied further.

Purpose of the Study: Determining the level of fusion remains a highly debated topic in adolescent isiopathic scoliosis. The King and Lenke classifications are used, but have their limitations, particularly the weak interobserver reproducibility. We describe the method we use which is independent of the anatomic classification, based on the predictable reduction of the different curvatures. The goal is to achieve good balance of T1 and the shoulders and reestablish spinal balance in the frontal and sagittal planes. The purpose of this work was to assess the midterm results of this strategy for determining the upper level of instrumentation., Material and Methods: The series included 103 adolescents who underwent surgery for idiopathic thoracic scoliosis using a posterior segmental instrumentation. The upper level of fusion was determined by analyzing the rigidity of the proximal curvature and the inclination of T1 and the shoulder. X-rays (preop, postop, last follow-up) were digitalized for computer processing. Comparisons were made with the t test for paired series., Results: Mean age at surgery was 15.2+/-1.7 years (range 10.8-19.3). Mean follow-up was 30.2 months. The clavicular angle and T1 inclination were improved significantly, both for the unique thoracic curvatures and for double thoracic curvatures. No correlation could be found between T1 inclination and shoulder balance. At last follow-up, 86.5% of the patients satisfied all balance criteria., Discussion: The results of our method, which was carried out fully in 97% of patients, are encouraging and show that systematic instrumentation of the entire proximal curvature is not warranted for double thoracic curvatures. The long-term consequences for the residual T1 inclination remain to be assessed.

Background: Iliac crest autograft is currently the gold standard material for spinal fusion. However, its use is limited by additional operative time, increased blood loss, and morbidity. Recently, a synthetic osteoconductive bone graft material composed of bioactive glass has been described, with high effectiveness in animal models. Its ability to achieve spinal fusion in human has never been reported. The aim of this study was to compare bioactive glass and iliac crest autograft as bone substitutes in the treatment thoracic adolescent idiopathic scoliosis (AIS)., Methods: Eighty-eight consecutive patients underwent posterior spinal fusion for progressive thoracic AIS. There were 2 study groups based on the type of bone graft used: iliac crest autograft (n = 40) or bioglass (n = 48). A minimum 2-year follow-up was required. Medical data and radiographs were retrospectively analyzed and compared using unpaired t test and Mann-Whitney U test., Results: Mean follow-up was 40 months in the autograft group and 38 months in the bioglass group. In the autograft group, there were 2 infections (5%) and 3 mechanical failures (7.5%). One infection (2%) and 1 early mechanical failure (2%) occurred in the bioglass group. Loss of correction of the main thoracic curve between immediate postoperative and latest follow-up averaged 15.5% for autograft group and 11% for the bioglass group (P = 0.025). The mean (+/-SD) gain of frontal balance between immediate postoperative latest follow-up was 0.8 (+/-9.3) mm in the autograft group and 8.1 (+/-12) mm for the bioglass group (P = 0.005)., Conclusions: Results of this retrospective study suggest that bioglass is as effective as iliac crest graft to achieve fusion and maintain correction in AIS. Less complications were seen in the bioactive glass group, but the difference did not reach statistical significance. Bioactive glass can be proposed in the treatment of AIS, avoiding the morbidity of iliac crest harvesting. However, clinical and radiological outcomes need to be confirmed at long-term follow-up., Level of Evidence: Level III.

Study Design: This study directly measures the ideal point of insertion and direction of sacral screws in the Jackson intrasacral fixation., Objective: To design a template for safe positioning of transpedicular endplate screws that does not require fluoroscopy., Summary of Background Data: Screw and rod insertion into the sacrum as described by Jackson requires careful intraoperative fluoroscopic or radiographic control. The technique can *be difficult and demanding, especially in the case of severe pelvic obliquity. No anatomic data based on cadaveric studies are available to aid in the described technique for screw insertion., Methods: Fifty dry sacrums were used. On each bone, the length of the intrasacral portion and the ideal direction of transpedicular endplate pins introduced at the originally described point of insertion were measured in reference to the plane formed by the two posterior sacral foramen and the posterior arch of S1. The limit angles in each direction, where the pin perforated the cortex outside of the S1 endplate, were noted. Then, the point of insertion of a pin with the ideal angles was progressively modified to determine the limits of the safe insertion area. The 95% confidence interval was reduced to the smallest safe angle., Results: The safe angles were 54.3 degrees to 57.9 degrees for the sagittal plane, 47 degrees to 50 degrees for the coronal plane, and between 46.9 degrees and 49.7 degrees for the horizontal plane., Conclusions: A "cylinder of safety" for the transpedicular endplate screws was determined. Its coordinates are related to the sacrum and not to the sacral position. This allowed for a template to be designed, the efficiency of which will have to be confirmed by anatomic and clinical studies.

The article presents summaries of articles on neuroscience, published as of March 2018. Topics include impact of postoperative bracing on pain and quality of life after posterior spinal instrumented fusion (PSIF), implantation of an empty polyetheretherketone cage in anterior cervical discectomy and fusion, and comparison between tubular discectomy and conventional microdiscectomy for the treatment of lumbar disc herniation.