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Highlights • Kyphotic deformity is common and can be associated with considerable morbidity. • Vertebral resection and reconstruction have been shown to preserve neurological function and decrease pain. • Two-stage, combined anterior and posterior approaches are performed to surgically address significant vertebral kyphotic. • The modified lateral extracavitary approach for reconstruction and instrumentation is an alternative to standard approach., Introduction Commonly, two stage combined anterior - posterior approaches were performed to treat significant kyphotic deformity, but potentially increase morbidity level. Recently, single - stage posterior approach for anterior column reconstruction have shown sagittal alignment improvement. The objective of this study is to describe a series of kyphotic deformity patients whom were treated using modified lateral extracavitary approach for anterior column reconstruction and posterior instrumentation. Methods Data collected from all kyphotic deformity patients whom treated with modified lateral extracavitary approach between 2016 until 2017 and this research work has been reported in line with the PROCESS criteria. In addition this technique could address kyphotic correction. Results 7 patients were reported, 4 males and 3 females with local and regional kyphotic more than 40 degrees. Procedures performed mostly on the right side to avoid the aorta with approximately 2 cm of the rib distal to the transverse processes. The average estimated blood loss and length of surgery were 1280 ml and 3.9 h. None of the patient had neurological deficit, and all of them have shown kyphotic improvement. Conclusion The modified lateral extracavitary approach for anterior column reconstruction and posterior instrumentation is a viable alternative to the standard combined approach. This approach continues to evolve as instrumentation development and possesses significant advantages.

Introduction: Tricortical iliac bone is the gold standard as an autograft for the reconstruction of the anterior column in tuberculosis (TB) of the thoracic spine. However, the quantity of graft needed is significant. It creates a considerable defect in the pelvic bone, causing graft site complications, including pain, pelvic instability, fractured ilium, herniated muscle, or abdominal contents. To prevent these donor site morbidities, ribs that were removed during the versatile approach were used for anterior reconstruction. The aim of this study was to assess the clinical and radiological results of the reconstruction of the anterior column of the spine with the help of an excised rib during the versatile approach. Subjects and Methods: This retrospective study was undertaken at a tertiary care center with a study duration of 14 years. Between January 2004 and December 2016, 52 patients with thoracic Koch's spine had anterior column reconstructed with multiple rib grafts. A single surgeon performed all operations. Indications for the surgery in these patients were the presence of neurologic deficit (49 patients) and vertebral column instability (3 patients). The preoperative kyphosis angle and visual analog scale (VAS) score were compared with postoperative values using a paired t-test. Results: All patients underwent a minimum follow-up of 18 months and were evaluated clinicoradiologically. Good bony fusion with neurological recovery was achieved in all cases. The VAS score for back pain improved significantly postsurgery. There was one case of graft buckling treated conservatively. Discussion: Appropriate anterior reconstruction forms the cornerstone of successful surgical management of spinal TB. The “Versatile approach” used offers anterior and posterior access in the lateral position. In these patients, we obviated the need for iliac crest graft using multiple segments of the rib for anterior column reconstruction. This meticulous rib grafting technique gives good functional outcome in terms of solid bony fusion. Conclusion: Meticulous rib grafting technique gives 360° bony fusion and good functional outcome in surgery for thoracic spinal TB. It has the advantage of avoiding the complications associated with a tricortical iliac crest graft.

Introduction In combined posterior–anterior stabilization of thoracolumbar burst fractures, the expandable vertebral body replacement device (VBRD) is typically placed bisegmentally for anterior column reconstruction (ACR). The aim of this study, however, was to assess feasibility, outcome and potential pitfalls of monosegmental ACR using a VBRD. In addition, clinical and radiological outcome of monosegmental ACR was related to that of bisegmental ACR using the same thoracoscopic technique. Methods Thirty-seven consecutive neurologically intact patients with burst fractures of the thoracolumbar junction (T11–L2) treated by combined posterior–anterior stabilization were included. Monosegmental ACR was performed in 18 and bisegmental ACR in 19 patients. Fracture type and extent of vertebral body comminution were determined on preoperative CT scans. Monosegmental and bisegmental kyphosis angles were analyzed preoperatively, postoperatively and at final radiological follow-up. Clinical outcome was assessed after a minimum of 2 years (74 ± 45 months; range 24–154; follow-up rate 89.2%) using VAS Spine Score, RMDQ, ODI and WHOQOL-BREF. Results Monosegmental ACR resulted in a mean monosegmental and bisegmental surgical correction of − 15.6 ± 7.7° and − 14.7 ± 8.1°, respectively. Postoperative monosegmental and bisegmental loss of correction averaged 2.7 ± 2.7° and 5.2 ± 3.7°, respectively. Two surgical pitfalls of monosegmental ACR were identified: VBRD positioning (1) onto the weak cancellous bone (too far cranially to the inferior endplate of the fractured vertebra) and (2) onto a significantly compromised inferior endplate with at least two (even subtle) fracture lines. Ignoring these pitfalls resulted in VBRD subsidence in five cases. When relating the clinical and radiological outcome of monosegmental ACR to that of bisegmental ACR, no significant differences were found, except for frequency of VBRD subsidence (5 vs. 0, P = 0.02) and bisegmental loss of correction (5.2 ± 3.7° vs. 2.6 ± 2.5°, P = 0.022). After exclusion of cases with VBRD subsidence, the latter did not reach significance anymore (4.9 ± 4.0° vs. 2.6 ± 2.5°, P = 0.084). Conclusions This study indicates that monosegmental ACR using a VBRD is feasible in thoracolumbar burst fractures if the inferior endplate is intact (incomplete burst fractures) or features only a single simple split fracture line (burst-split fractures). If the two identified pitfalls are avoided, monosegmental ACR may be a viable alternative to bisegmental ACR in selected thoracolumbar burst fractures to spare a motion segment and to reduce the distance for bony fusion.

Study D Design: Retrospective clinical series. Purpose: To assess whether titanium cages are an effective alternative to tricortical iliac crest bone graft for anterior column reconstruction in patients with active pyogenic and tuberculous spondylodiscitis. Overview oof L Literature: The use of metal cages for anterior column reconstruction in patients with active spinal infections, though described, is not without controversy. Methods: Seventy patients with either tuberculous or pyogenic vertebral osteomyelitis underwent a single staged anterior debridement, reconstruction of the anterior column with titanium mesh cage and adjuvant posterior instrumentation. The lumbar spine was the predominant level of involvement. Medical co-morbidities were seen in 18 (25.7%) patients. A significant neurological deficit was seen in 32 (45.7%) patients. At follow up patients were assessed for healing of disease, bony fuson, and clinical outcome was assessed using Macnab’s criteria. Results: Final follow up was done on 64 (91.4%) patients at a mean average of 25 months (range, 12 to 110 months). Pathologic organisms could be identified in 42 (60%) patients. Forty two (60%) patients had histopathological findings consistent with tuberculosis. Thirty of 32 (93.7%) patients showed neurological recovery. The surgical wound healed uneventfully in 67 (95.7%) patients. Bony fusion was seen in 60 (93.7%) patients. At final follow up healing of infection was seen in all patients. As per Macnab’s criteria 61 (95.3%) patients reported a good to excellent outcome. Conclusions: Inspite of the theoretical risks, titanium cages are a suitable alternative to autologous tricortical iliac crest bone graft in patients with active spinal infections.