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✓There are many potential risks associated with spinal deformity correction procedures including transient and/or permanent neurological deficits. Typically, neurological deficits caused by the surgical correction of spinal kyphosis occur acutely during surgery or immediately after surgery. Delayed postoperative neurological deficits are extremely rare. The authors report a case of delayed neurological deficit that occurred 48 hours after surgical correction of thoracic hyperkyphosis. An 18-year-old man with myotonic dystrophy presented with a 110° T7–L1 kyphosis. The patient underwent an uneventful two-stage correction procedure of the hyperkyphotic deformity. First, anterior discectomies and fusion were performed from T-7 to L-1 using rib autograft, and all segmental vessels were preserved. Subsequently, on the same day, the patient underwent posterior Smith–Petersen osteotomies and T7–L2 pedicle screw fixation. Intact somatosensory and motor evoked potentials were maintained throughout both operations. Postoperatively, he remained neurologically intact without sequelae for nearly 48 hours. On postoperative Day 2, the patient developed delayed monoplegia of the left leg and sensory level loss below T-10. Medical management enabled complete reversal of the patient's monoplegia and sensory loss. At 2-year follow-up, the patient had no adverse neurological sequelae. In this case, a delayed postoperative neurological deficit occurred following spinal hyperkyphosis correction. The authors discuss the possible etiological mechanisms behind this complication and suggest strategies for its management.

Background Burst fractures account for more than half of all thoracolumbar fractures, which often cause a neurologic deficit and present a significant economic burden to the family and society. Accepted methods of treatment of thoracolumbar burst fractures include conservative therapy, posterior reduction and instrumentation, and anterior decompression and instrumentation. However, the management of thoracolumbar burst fractures has been the subject of much controversy. Methods Publications reporting clinical data relating to the thoracolumbar burst fractures were reviewed. These articles were determined via review of the results of PubMed searches and articles gathered through compilation of references from those articles. Results There exist different criteria for the choice of the management based on the severity of kyphotic deformity, canal compromise, vertebral height loss, and neurologic status. To our knowledge, none of the existing criteria for the treatment of thoracolumbar burst fractures are generally accepted. Conclusions In thoracolumbar burst fractures without a neurologic deficit, there is no superiority of conservative therapy over operative therapy. When the neurologic involvement is significant, the choice of operative management is advised. Also, there is no obvious superiority of one approach over the other.

A systematic review and meta-analysis.To compare the efficacy and safety outcomes of Smith-Petersen osteotomy (SPO) and pedicle subtraction osteotomy (PSO) for patients with ankylosing spondylitis (AS) with thoracolumbar kyphotic deformity.Both SPO and PSO are used to correct thoracolumbar kyphotic deformity due to AS. Evidence is insufficient to determine which has better efficacy and safety outcomes.A systematic literature search was performed. Studies concentrating on treating thoracolumbar kyphotic deformity due to AS with SPO and/or PSO were included. Efficacy was determined with radiographical outcomes, including sagittal vertical axis and lumbar lordosis. Safety was determined with complication rates. The data were analyzed with Review Manager and R software.Twenty-three studies were included. Among them, 5 were comparative studies and were used for a meta-analysis. All 23 studies were pooled to evaluate the radiographical correction and incidence of complications. The meta-analysis of the 5 comparative studies showed no significant difference between groups in either correction of sagittal vertical axis and lumbar lordosis or incidence of complications. The pooled data also showed similar radiological correction and complication rates between SPO and PSO. SPO was found to have potential risk of aortic rupture and slightly higher risk of permanent neurological deficit without statistical significance, whereas PSO was shown longer operative time and more blood loss.This systematic review and meta-analysis demonstrates that both SPO and PSO are effective in correcting thoracolumbar kyphotic deformity in AS and have similar risk of most complications. Aortic rupture and related death during correction is reported in SPO and should be taken into consideration for decision making.4.

We report the outcome of 30 patients with multilevel noncontiguous spinal fractures treated between 2000 and 2005. Ten cases were treated conservatively (group A), eight cases were operated on at only one level (group B), and 12 cases were treated surgically at both levels (group C). All cases were followed up for 14-60 months (mean 32 months). Initial mobilisation with a wheelchair or crutches in group A was 9.2 +/- 1.1 weeks, which was significantly longer than groups B and C with 6.8+/-0.7 weeks and 3.1 +/- 0.4 weeks, respectively. Operative time and blood loss in group C were significantly more than group B. The neurological deficit improved in six cases in group A (60%), six in group B (75%) and eight in group C (80%). Correction of kyphotic deformity was significantly superior in groups C and B at the operated level, and increasing deformity occurred in groups A and B at the non-operated level. From the results we believe that three treatment strategies were suitable for multilevel noncontiguous spinal fractures, and individualised treatment should be used in these patients. In the patients treated surgically, the clinical and radiographic outcomes are much better.

Objective. To define the effective surgical management of posttraumatic kyphotic deformities in the thoracic spine basing on experimental biomechanical and clinical studies Material and Methods. Experimental biomechanical study was performed in 30 spine specimens. Anterior wedge osteotomy and fixation of a specimen in a kyphotic position modeled kyphotic deformity. Deformity correction with various instrumentation systems was firstly performed by maximal extension of segments adjacent to kyphosis-producing block, and carried on after crossing of intervertebral anatomical structures. Clinical study consisted in X-ray and instrumental examinations of 80 patients operated on for thoracic spine trauma. The magnitude of true posttraumatic deformity was defined as a difference between measured Cobb angle and mean physiological kyphosis value in the studied spine level. Results. Deformity rigidity, character of spine mobilization at the level of correction and size of posttraumatic deformity are the most significant factors determining the efficacy of thoracic posttraumatic kyphosis correction. The study resulted in defining rational approach to surgical correction of posttraumatic deformities in the thoracic spine. Conclusion. Minor kyphotic deformities in the thoracic spine are effectively corrected by instrumentation without mobilization of the spine. Large unfixed kyphosis sometimes requires anterior mobilization. Cases with rigid posttraumatic kyphotic deformity should be operated on with combined mobilization of the spine.

The prognosis for vertebral fracture is discussed in this study. The patients were divided into two groups: early treatment group and late treatment group. It was found that early treatment prevents kyphotic deformity and low back pain. It was difficult to asses prognosis only by fracture type. We found clear correlation between the number of NTx and onset of multiple vertebral compression fracture. Patients complaining of back pain despite being under appropriate recumbency indicated aggravation of kyphotic deformity. Steroids adversely enhanced the deformity of compressed vertebral compression fracture. Moreover kyphotic deformity and incomplete fusion appeared when T1 weighted MRI showed clear low band.

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

Object. Cervical kyphotic deformation may develop after surgery involving either the ventral or dorsal approach. Regardless of the cause, the development of a cervical kyphotic deformity should be avoided, if possible, and corrected if present, when appropriate. The authors describe their experience with a technique for the ventral correction of iatrogenic (postoperative) cervical kyphosis. Methods. A retrospective review of cases involving correction of postoperative iatrogenic cervical kyphosis via an ventral approach was performed. The authors conducted an ventral approach to kyphosis correction. The procedure required specific head positioning (in extension), convergent distraction pins, and an ventrally placed implant (axially dynamic when appropriate) with multiple points of fixation including at least one point of intermediate fixation. The pre- and postoperative sagittal angle and clinical status were evaluated. During a nearly 14-month period, 12 patients met the inclusion criteria. Ten patients underwent a minimum of 6 months of follow up. They comprised the study population. Most patients presented with mechanical neck pain as part of their symptom profile. The mean magnitude of deformity correction (pre- to postoperative) was 20° of lordosis. The mean postoperative sagittal angle was 6° of lordosis. The mean change in the sagittal angle during the follow-up period was 2.2° of lordosis. Conclusions. The ventral approach to correction of cervical deformity led to the achievement of lordosis in all but one patient. This posture was effectively maintained during the follow-up period. All patients exhibited improvement postoperatively; three experienced complete resolution of their preoperative symptoms. When symptoms are related to postsurgical kyphosis, deformity correction should be considered. Such a procedure may be performed effectively via an ventral approach in most circumstances.

For anatomical and biomechanical reasons, thoracolumbar fractures are very common injuries. Although the surgical management of these fractures is still an open issue, the main goals of the treatment are always represented by restoration of vertebral stability, correction of kyphotic deformity, decompression and protection of neurological structures and a fast functional improvement.

Ankylosing spondylitis (AS) is a chronic inflammatory disease, generally involving the sacroiliac joints and spinal column from caudal to cranial vertebrae as pathogenesis develop [1, 2]. Thoracolumbar kyphosis is the most common deformity which causes hard standing, walking, looking horizontally, and lying flat on the back.

Both Smith-Peterson osteotomy (SPO) and Ponte osteotomy (PO) are the simplest and the most useful posterior-column-only wedge osteotomy technique. The middle column functioning as a pivot point during correction of sagittal imbalance or kyphotic deformity with SPO or PO results in the least change of the length and risk of injury of neural tissue comparing with pedicle subtraction osteotomy and vertebral column resection. Using PO results in closing wedge of posterior column without opening wedge of anterior column like SPO does. Vascular injury due to open wedge of anterior column by SPO is very rare. PO and SPO are the simplest surgical technique of osteotomy and should always be considered to be applied to achieve a balance spine.

To describe a successful five-level cervical corpectomy and circumferential reconstruction in a patient with a plexiform neurofibroma causing a severe kyphotic deformity.Case report.43-year-old man with history of Neurofibromatosis presented with signs and symptoms of myelopathy with spastic lower extremities and gait difficulties. Imaging studies demonstrated a severe kyphotic deformity of the cervical spine with associated cord compression secondary to an anteriorly positioned plexiform neurofibroma. Two-stage surgical procedure was designed to treat this lesion. Stage I consisted of tracheostomy placement, transmandibular, circumglossal approach to the anterior cervical spine, C2-C6 corpectomies, and C1-C7 reconstruction with a custom titanium cage/plate. Stage II consisted of suboccipital craniectomy, C1-C2 laminectomies, and occipital-cervical thoracic instrumented fusion (O-T8). There were no operative complications, but the patient did develop a small pulmonary embolism post-operatively treated with anticoagulation. Patient required two-weeks of inpatient rehabilitation following surgery. Gastrostomy tube and tracheostomy were successfully discontinued with preserved swallowing and respiratory function. Patient-reported outcome measurements revealed significant and sustained improvement post-operatively.Five-level cervical corpectomy including C2 can be safely and successfully performed via a transmandibular, circumglossal approach. Circumferential reconstruction utilizing a custom anterior titanium cage and plate system manufactured from a pre-operative CT scan was utilized in this case. Long segment occipital-cervical-thoracic reconstruction is recommended in such a case. Using such a technique, improvement in myelopathy, correction of deformity, and improved quality of life can be achieved.

Study Design. Retrospective analysis of kinematic magnetic resonance images. Objective. To provide baseline data on the segmental angular and translational motion of the degenerated cervical spine by subtype of kyphotic cervical deformity and to elucidate the relationship between motion and degree of spinal cord compression. Summary of Background Data. Kyphotic deformities of the cervical spine are relatively common and are classified as either global or focal. Nevertheless, the effects of kyphotic subtype on cervical segmental motion and degree of spinal cord compression are unknown. Methods. A total of 1171 symptomatic patients (618 females, 553 males) underwent cervical kinematic magnetic resonance imaging in the neutral, flexion, and extension positions. Cervical spines demonstrating kyphosis were included and classified into 3 groups: (1) “global kyphotic deformity” (C-type) (n = 54); (2) “sigmoid deformity” (S-type) with kyphotic upper and lordotic lower cervical segments (n = 29); and (3) “reverse sigmoid deformity” (R-type) with lordotic upper and kyphotic lower cervical segments (n = 39). Translational motion, angular motion, and degree of spinal cord compression were evaluated for each cervical level along with the changes associated with flexion and extension. Results. In the C- and R-types, angular motion with extension was increased in the upper cervical spine, where there was kyphosis; when compared with the S-type, in which there was lordosis in the upper segments. The results were opposite for flexion angular motion. R-type displayed more translational motion at C3–C4 and C5–C6. Degree of static spinal cord compression of R-type was higher than the others at C3–C4. The dynamic spinal cord compression increased in extension more than flexion in all subtypes. Conclusion. Cervical spine studies that aim to investigate kyphotic deformities should make efforts to discern the different subtypes of kyphotic deformities to more accurately characterize and study the effects that the sagittal alignment has on the kinematics of the spine and the degree of spinal cord compression. Conclusion. Level of Evidence: 3

Surgical treatment for cervical kyphotic deformity is still controversial. Circumferential approach has been well described in the literature but long terms outcomes are not well reported. Important to decide the correct treatment option is the preoperative radiological exams to value the type of deformity (flexible or fixed). We report the case of a 67-year-old woman affected by a severe cervical kyphotic deformity who underwent combined anterior/posterior surgical approach, getting a good reduction of the deformity and an optimal stability in a long term follow up.

Posturology studies disorders of the central nervous system (CNS), thanks to the categories of space and time. Indeed, at the end of the nineteenth century, Jean-Marie Charcot and the Salpetriere’s French school suggested to isolate the disorders of the CNS that were caused by a lesion—i.e., belonged to a spatial, anatomic category. That fertile suggestion led to the foundation of neurology.

To avoid severe kyphotic deformity due to multi-level osteoporotic vertebral fractures, an inter-spinous processes fixation technique using several instruments at the thoraco-lumbar region was employed in 9 cases. The extension of the motor segment is believed to decrease the compression force on the anterior column and the approach of faced each spinous processes. In the first 2 early cases, 2 segments were fused by wiring, and were followed up for 14 years and 12 years, the fixation levels remained on unchanged in spite of many vertbral fractures occured apart from the fixation lelvels. In another 7 cases, more than 2 levels were fixed using the Apophix Hook system in 2 cases, the Isola system was combined with wiring in 4, and only the Isola system was used in 1.Complaints resulting from the thoraco-lumbar fracture decreased in all cases after surgery.The average kyphotic deformity level of 33.5 degrees at the local levels could be corrected to 18.4 degrees after surgery, but within 6 months after surgery, an average loss of correction of 6 degrees was seen, after which conditions stabilized.This technique is considered the effective for preventing severe deformity by the simple and mild fixation of the selected levels.In the future, a combination of vertbroplasty and this technique may be recommended for preventing the loss of correction.

A clinical case of single-step posterior-only approach in surgical treatment of a patient with severe kyphotic deformity.Surgery resulted in reduction of neurological deficit and pain, and restoration of proper trunk balance.

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

Chance fracture is an unstable vertebral fracture, which usually results from a high velocity injury. An elderly lady with a previously healed osteoporotic fracture of the T12 and L1 vertebra which resulted in a severe kyphotic deformity subsequently sustained a Chance fracture of the adjacent L2 vertebrae after a minor fall. The previously fracture left her with a deformity which resulted in significant sagittal imbalance therefore predisposing her to this fracture. This case highlights the importance of aggressive treatment of osteoporotic fractures in order to prevent significant sagittal imbalance from resultant (i.e. kyphotic) deformity.

The disease mainly affects the sacroiliac joints and spine. It ischaracterised by inflammation and ossification of the interverteb-ral discs, ligamentous structures and facet joints. Over time thespine tends to become rigid and kyphotic deformity is common.This may result in a long rigid lever arm, and is particularlyvulnerable to fracture. Osteoporosis associated with reducedfunctional activity and comorbidities add further to the vulner-ability of the spine. Spinal fracture in this condition is associatedwith a high rate of neurological injury.

A retrospective review of six patients treated nonoperatively for severe burst fractures of the lumbar spines with mild neurological deficits was performed. In five patients considered to have good functional outcome; kyphotic deformity averaged 10 at injury (-14 to 21) and 3.6 at follow-up (-6-15), and spinal canal compromise averaged 54.4% at injury (46.9-62.0) and 34.1% at follow-up (22.2-42.4). One patient with laminar fracture had a mild back pain, requiring surgery. Nonoperative treatment should be considered an alternative in the treatment of severe burst fractures of the lumbar spine with mild neurological deficit and normal posterior column.

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

Correction of kyphotic deformity of the spine is quite complex, especially in the thoracic spine. A variety of techniques exist for correction of thoracic kyphotic deformity; however, the controversy continues regarding the most efficacious approaches toward improving adequate sagittal balance, obtaining successful fusion of the construct, and providing an adequate scaffold anteriorly to tolerate the forces placed upon the anterior spine. Additionally, these goals must be accomplished while minimizing patient neurological morbidity. The use of an expandable thoracic cage to reconstruct the anterior and middle columns has proven to be a successful method of correcting thoracic kyphotic deformity, especially since 80 % of the axial vector load placed upon the spine is specifically along these particular columns [1].

Kyphosis is a difficult topic of spinal surgery, and its management contains many controversies. Surgical management needs consideration of different aspects of the kyphotic deformity such as neurological status, the presence of spinal cord compression, angle of the kyphosis, the quality of bone, and accompanying diseases. In case of significant cord compression and neurological compromise, anterior surgery should have the priority. However, in smooth-angled kyphosis and ankylosing spondylitis patients, deformity can easily be reduced by a posterior-only approach. Since they have no neurological deficits, and large spinal canals, most suitable patients for pedicle subtraction osteotomy are the patients with ankylosing spondylitis.

Infections of the spine can be rapidly progressive and often cause significant neurologic deficits and even death. Unfortunately, they are also often difficult to diagnose, as they can mimic a number of other conditions. With rising numbers of patients who are immunosuppressed due to HIV, diabetes mellitus, and organ transplantation, these infections are becoming increasingly prevalent. Thus, it is important to know how to efficiently diagnose and initiate treatment for these patients.

Low back pain is a common musculoskeletal disorder affecting 60–80 % of people at some point in their lives. In the USA it is the most common cause of job-related disability, a leading cause of missed work. Low back pain is classified as acute (less than 4 weeks), subacute (4–12 weeks), or chronic (greater than 12 weeks).

Background Corpectomy is a frequently performed procedure for pathologies of the anterior spine including neoplasms, fractures, deformities, and osteomyelitis. Traditional approaches to the anterior thoracic spine and thoracolumbar junction are associated with significant perioperative pulmonary complications and morbidity. Posterior and posterolateral approaches minimize some of these complications but are somewhat limited in visualization of the anterior elements. Patient and Methods Here we report the case of a 49-year-old man with a remote thoracolumbar fracture and subsequent focal deformity treated with a minimally invasive lateral retroperitoneal corpectomy and open posterior arthrodesis. Conclusion Minimally invasive lateral corpectomy is a safe and effective option for deformity correction. We discuss the relative advantages and disadvantages of this approach and review the relevant literature.

The present study was performed to establish an animal model of cervical kyphosis after laminectomy (C2-C5), and to determine the role of endplate chondrocytes apoptosis in cervical kyphosis after laminectomy.Twenty-four 3-month-old sheep were randomly divided into two groups: the laminectomy group (n = 12), and the control group (n = 12). The cervical spine alignment was evaluated on a lateral cervical spine X-ray using Harrison's posterior tangent method before surgery and at follow-up. Cartilaginous endplate chondrocyte apoptosis was confirmed using transmission electron microscopy and terminal deoxyribonucleotidyl transferase (TdT)-mediated dUTP nick-end labelling.The mean preoperative cervical curvature (C2-5) in the surgery group was -15.8°. The cervical curvature was 19.1° at 3 months post-operation and decreased to 20.2° at the final follow-up postoperatively. The cervical curvature was significantly decreased in the laminectomy group compared with the control group at the last follow-up (P0.001), which was a direct indication of kyphotic change. The incidence of apoptotic cells in the surgery group was significantly higher at the 3- and 6-month follow-up than the incidence in the control group.The frequency of endplate chondrocyte apoptosis in the laminectomy group was significantly higher than in the control group, indicating that chondrocyte apoptosis may play a pivotal role in the progress of post-laminectomy cervical kyphosis.

Growth modulation changes occur in pediatric spines and lead to kyphotic deformity during discitis infection from mechanical forces. The present study was done to understand the consequences of discitis by simulating inflammatory puss at the T12/L1 disc space using a validated eight-year-old thoracolumbar spine finite element model. Changes in the biomechanical responses of the bone, disc and ligaments were determined under physiological compression and flexion loads in the intact and discitis models. During flexion, the angular-displacement increased by 3.33 times the intact spine and localized at the infected junction (IJ). The IJ became a virtual hinge. During compression loading, higher stresses occurred in the growth plate superior to the IJ. The components of the principal stresses in the growth plates at the T12/L1 junction indicated differential stresses. The strain increased by 143% during flexion loading in the posterior ligaments. The study indicates that the flexible pediatric spine increases the motion of the infected spine during physiological loadings. Understanding intrinsic responses around growth plates is important within the context of growth modulation in children. These results are clinically relevant as it might help surgeons to come up with better decisions while developing treatment protocols or performing surgeries.

Goal of Surgery Cure of a bacterial osteomyelitis of the spine and correction of the kyphotic deformity.

IntroductionOsteoporotic vertebral fractures commonly result in increased kyphotic angle. Several studies have shown that compared with controls increasing severity of osteoporotic kyphosis signifi...