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Background data: The degenerative lumbar diseases form a burden on both the patients and the society. The development of the degenerative process is highly linked to the aging process as discussed by Kirkandly Willis where the degenerative spine passes through 3 phases of process that results in the degenerative diseases. The management of the degenerative spine deformities varies and depends on various factors. Traditional surgical management involves instrumentation, decompression and fusion processes. Oblique Lumbar interbody fusion ‘OLIF’ is a novel technique when used alone as in stand-alone OLIF ‘SA-OLIF’ it could achieve degenerative deformity correction along with neural decompression, however, the final aim of SA OLIF where solid fusion is required still is under evaluation and literature lacks the essential data for this approach. This study aims to assess the fusion of the SA-OLIF in the management of degenerative lumbar scoliosis. Study Design: A Prospective clinical case study. Objective: To assess the fusion rates in patients suffering from degenerative lumbar scoliosis ADS after SA-OLIF. Patients and Methods: Patients with ADS following a specific inclusion criterion underwent SA OLIF. Pre-, and Post-operative clinical data; back and leg pain ‘VAS score’ and ODI, radiological data; for fusion assessment. Intra-operative data: operative time, amount of blood loss, complications ‘intra-operative or post-operative’ and hospital stay were all analyzed and compared statistically. Results: A total of 28 patients and 30 levels were operated by SA OLIF, with mean age 50.54±6.05 included 14 males and 14 females. The mean operative time/min, blood loss/ml and hospital stay/day was 91.29±14.23, 195.54±42.299 and 2.78±0.875 respectively. The mean of Back Pain ‘VAS’, The mean of Leg Pain ’VAS’ and ODI changed from pre-operatively 7.36±0.98, 6.36±0.911and 68.615±8.72 to 4.07±1.01, 2.07±0.9 and 20.23±4.7 in 1-year respectively. In this study we had 92.9% fusion rates after 1-year. Operative complications occurred in 3 cases with segmental artery injury. Post-operative complications were 1 cage dislodgment immediately post-operative and 2 cases of cage subsidence after 1-year. Conclusion: SA OLIF can result in high rates of fusion. There are multiple factors that determine the rate of fusion such as the quality of the vertebrae and endplate preservation during the preparation procedure.

Study Design: Retrospective cohort study.Purpose: To evaluate the safety and efficacy of the far-lateral approach in the resection of ventral and ventrolateral upper cervical meningiomas.Overview of Literature: Upper cervical meningiomas are a common disease entity. These lesions can be surgically treated via many accesses. The far-lateral approach is a very appealing technique for these lesions.Methods: We assessed 23 patients with a mean age of 57.3±15 years. According to the Japanese Orthopedic Association (JOA) scale; eight patients had grade 0, nine had grade I, and six had grade II. All patients underwent plain radiography and magnetic resonance imaging of the cervical spine. The foramen magnum was involved in 10 patients, C1–2 in seven, C2–3 in four, and C3–4 in two. All patients were operated via the far-lateral approach.Results: Gross total resection was achieved in 21 patients. Sixteen lesions were psammomatous, five were fibroblastic, and two were meningothelial meningiomas. The mean operative duration was 135±40 minutes, while the mean operative blood loss was 450±210 mL, and the mean hospital stay was 4.3±2.2 days. At the final follow-up that was conducted at 27.6±21 months and as per the JOA score; 16 patients were classified into grade 0 and 7 into grade II. The condition of none of our patients deteriorated postoperatively. There was no significant correlation of the clinical outcome with tumor level, pathological subtype of the tumor, symptom duration, age, and sex. There was no significant correlation of tumor resection completeness with tumor level, tumor pathological subtype, or tumor topography (ventral or ventrolateral).Conclusions: The far-lateral approach is a safe and effective access for ventral and ventrolateral cervical meningiomas. It allows direct access to tumor with no spinal cord or nerve roots traction, and thus may yield a fairly better outcome than the standard posterior approach.

Study Design: Prospective randomized controlled cohort study. Objective: To compare the outcome of local autograft versus iliac crest bone graft (ICBG) stand-alone transforaminal lumbar interbody fusion (TLIF) in lumbar spondylolisthesis. Methods: One hundred eight patients with low-grade single-level spondylolisthesis underwent operation with pedicular screw fixation (PSF)-augmented stand-alone TLIF. Patients were randomly divided into groups according to bone graft: group I, autograft group; and group II, ICBG group, with 54 patients each. Fifty-nine patients had isthmic spondylolisthesis and 49 had degenerative spondylolisthesis. Clinical outcome parameters included Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and patient’s satisfaction, while the radiological parameters included fusion rate, slip reduction, segmental angle, and disc height. The mean follow-up period was 38 ± 19 months, with a minimum 24 of months. Results: The preoperative VAS of back pain improved from 8 ± 3.1 to 3.4 ± 2.9 and from 8 ± 3.2 to3.6 ± 2.6 in group I and group II, respectively. The preoperative ODI improved from 41.4 ± 8 to 12.3 ± 7 and from 39 ± 9 to 13 ± 8 in group I and group II, respectively. The fusion rate was 93% in group I and 94.5% in group II. The percentage of slip was reduced from 26.7 ± 7.1% to 16.5 ± 6.1% in group I and from 27.4 ± 8.25 to 15.8 ± 5.2% in group II. Intervertebral disc height increased from 25.27 ± 14.62 to 46.38 ± 15.41 in group I and from 22.29 ± 13.72 to 45.15 ± 16.77 in group II. Segmental angle improved from 10.5 ± 8.1° to 16.7 ± 5.4° in group I and from 11.6 ± 5.3° to 15.9 ± 6.2° in group II. There was no significant difference of the above-mentioned parameters between the 2 groups. Conclusion: Patients with single-level low-grade spondylolisthesis can be effectively treated with PSF-augmented stand-alone TLIF using either local autograft or ICBG with no outcome differences between the 2 groups.

Background Data: Anterior cervical discectomy and fusion (ACDF) has been the standard treatment for degenerative conditions of the cervical spine. Since the introduction of the procedure in the fifties, ACDF has become quite popular and a gold standard procedure. Autologous iliac crest bone grafts were used for fusion with associated drawbacks that mandated the introduction of new metallic substitutes with various fillers. Many improvements and enhancements to these cages were implemented with rising controversial issues. Purpose: To review the available data of cervical cages and the recent status of ACDF using standalone cages. Study Design: A narrative literature review. Patients and Methods: We reviewed the English literature through the last two decades for the most up-to-date available data of the cervical cages and reported the current status of ACDF outcomes using standalone cages. We ran a search using PubMed, Cochrane, and Google Scholar using different relevant keywords and extracted the most relevant researches according to our study aim. We focused on special titles that we thought were most relevant to the spinal surgeon's daily practice. Results: A great number of cervical cages with different shapes and designs are available for ACDF. Spinal surgeons are confronted with a huge array of cervical cages introduced every day by many medical industry competitors. Clinical and radiological outcomes are generally very satisfactory regardless of the type and material of cages used. Composite or titanium-coated PEEK cervical cages and 3D-printed and porous titanium cages are under evaluation. Self-locking standalone cages showed great advancement and development with promising outcomes. Conclusion: ACDF is a well-established surgical technique in the management of cervical spondylotic radiculopathy and/or myelopathy. Large numbers of cervical cages with different shapes, designs, and compositions are available in the market with generally satisfactory clinical and radiological outcomes. Spinal surgeons should be aware of the available cervical cages and choose the most suitable to their patient’s medical and socioeconomic status. New industrial technology has the potential to improve the load-bearing surface, lower cage dislocation and subsidence, and osteointegration. Composite cages, self-locking cages, and absorbable cages are fairly newly introduced cages and still under evaluation. Multicenter long-term prospective randomized controlled trials are mandatory for obtaining first-class evidence-based medical data on ACDF. (2020ESJ213) Abstract Background Data: Anterior cervical discectomy and fusion (ACDF) has been the standard treatment for degenerative conditions of the cervical spine. Since the introduction of the procedure in the fifties ACDF have become quite popular and gold standard procedures. Autologous iliac crest bone grafts were used for fusion with associated drawbacks that mandates the introduction of new metallic substitutes with various fillers. Lots of improvements and enhancements of these cages were supposed with arising controversial issues. Purpose: To review the available data of cervical cages and the recent status of ACDF using standalone cages. Study Design: narrative literature review. Patients and Methods: We reviewed the English literature for the most up-to-date available data of the cervical cages and reported the current status of ACDF outcomes using standalone cages. We ran a search using PubMed, Cochrane, and Google Scholar using different relevant keywords and extracted the most relevant researches according to our study aim. We focused on special titles that we thought they are most relevant to the spinal surgeon daily practice. Results: a great number of cervical cages with different shape and designs are available for ACDF. Spinal surgeons are confronted with a huge array of cervical cages introduced every day by many medical industrial competitors. Clinical and radiological outcomes are generally very satisfactory regardless the type and material of cages used. Composite or titanium coated PEEK cervical cages are under evaluation as well as 3D print and porous titanium cages. Self-locking standalone cages showed a great advancement and development with promising outcomes. Conclusion: ACDF is a well-established surgical technique in the management of cervical spondylotic radiculopathy and/or myelopathy. Large numbers of cervical cages with different shapes, designs, and compositions are available in the market with generally satisfactory clinical and radiological outcomes. Spinal surgeons should be aware of available cervical cages and choose the most suitable to their patient’s medical and socioeconomic status. New industrial technology has the potentials of improving load-bearing surface, lower cage dislocation and subsidence, and improve osteointegration. Composite cages, self-locking cages, absorbable cages are fairly introduced cages and still under evaluation. Multicenter long-term prospective randomized controlled trials are mandatory for first class evidence based medical data in ACDF. (2020ESJ213)

Background Data: In March 2020, WHO declared COVID-19 a pandemic and called for international effort to manage the disease. This pandemic has had many adverse effects on the globe. Spinal surgery and surgeons have dealt extensively with this pandemic. Purpose: To review the available data of COVID-19 and the recent status of spinal surgery. Study Design: Literature review. Patients and Methods: We reviewed the English literature for the most up-to-date available data of the COVOD-19 and reported the current status of spinal surgery and surgeons during the pandemic and how they have been affected by and handled the pandemic. Results: The COVID-19 pandemic resulted in the global reconstruction of the health care services of the spinal surgery. New guidelines and recommendations have been released by many health authorities during the pandemic to optimize the working conditions and make maximum use of the available resources; other guidelines are in progress depending on the altering nature of the disease. Maximizing the use of telemedicine and online education would decrease the spread of infection, continuing the health care and education. We have to continue this practice as the pandemic is expected to last for many months and to learn lessons from the current and previous pandemics to avoid another pandemic wave. Conclusion: Spinal surgeons have a crucial role as health care providers and society advocates. Optimizing the conditions for health care providers and patients in theatres, clinics, and inpatients would lessen the risk of spreading infections. Telemedicine and online education are playing a significant role during the pandemic. (2020ESJ134)

Background Data: Although most sacral fractures can be treated conservatively, several surgical options are available for highly unstable fractures. Surgery aims to provide sacral realignment, fixation, and maybe neural decompression with subsequent pain relief and early mobilization. Surgical options are variable depending on the type of fractures and surgeon’s experience. Spinopelvic fixation is one of the famous surgical procedures. Purpose: To evaluate the safety and efficacy of lumbopelvic fixation for the treatment of unstable traumatic spinopelvic sacral fractures. Study Design: Prospective cohort study. Patients and Methods: All patients with unstable spinopelvic sacral fractures excluding those with other types of sacral fractures were recruited for this study. All patients were submitted to lumbopelvic fixation. Patients were evaluated clinically and radiologically, including full lumbar and pelvis X-Ray and 3D MSCT scan at the pre- and postoperative period. Clinical parameters included a full neurological examination, VAS, ODI, and modified Rankin scale. Results: A total of 15 patients including 7 males and 8 females with mean age of 28±8.11 years were recruited for this study. All patients were suffering from unstable traumatic spinopelvic type C sacral fractures according to AO Spine sacral fractures classification system. Four patients suffered from type C0, 2 from C1, 4 from C2, and 5 from C3. Neural insults were reported in 13 patients. The mean follow-up period was 19.2±8.6 (range, 6–36) months. The mean preoperative VAS improved from 8.13±1.25 to 2.6±1.01 postoperatively, while the mean preoperative ODI improved from 88.53±2.24 to 16.8±3.16 postoperatively. According to the modified Rankin scale for functional recovery, 14 (93.3%) of the patients were categorized as excellent and good, while only one patient (6.6%) was categorized as fair outcome. Complete fractures’ healing was reported in all patients and none required any revision procedure. Deformity correction was incomplete in 40% without clinical effects on patients. Surgical site infection was reported in 3 patients and one of them necessitated debridement. Conclusion: Lumbopelvic fixation is a safe and effective procedure in the treatment of unstable traumatic spinopelvic sacral fractures. (2019ESJ196)

Background Data: Adolescent Idiopathic Scoliosis (AIS) is a spinal deformity that may interfere with patients’ quality of life. Many previous studies tried to assess the health-related quality of life (HRQoL) using the patient-reported outcome measures. The Arabic version of Scoliosis Research Society 22 (SRS-22r) questionnaire is known to be reliable and a valid tool to assess the quality of life in patients with AIS. Purpose: To evaluate quality of life of patients with AIS after surgical correction using the Arabic version of Scoliosis Research Society 22 (SRS-22r) questionnaire. Study Design: Prospective cohort study. Patients and Methods: Between 2016 and 2018, twenty-five patients were surgically treated for AIS with Cobb’s angle >45 degrees. All patients underwent posterior derotation and instrumented correction and fusion technique. In this study, we used the Arabic version of SRS-22 questionnaire to evaluate the clinical patient’s outcome. Whole spine plain X-ray was utilized to assess the radiological outcome. All patients underwent postoperative follow-up for at least 6 months with the SRS-22r questionnaire conducted in the last visit. Results: Twenty-five patients were recruited for this study including 22 females and 3 males with mean age of 14.7±1.7 (range, 11–18) years. Significant improvement was reported 6 months after surgical correction in the following radiological parameters: Cobb’s angle of the primary curve from 55.81±8.72 to 7.98±2.26; pelvic incidence from 62.24±7.33 to 57.96±6.14; pelvic tilt from 26.14±3.41 to 20.76±3.74; lumbar lordosis from 33.21±8.63 to 36.6±8.79. The scores of functional activity, pain, self-image/appearance, mental health, and satisfaction were 4.31±0.28, 4.57±0.27, 4.85±0.31, 4.85±0.17, and 4.96±0.21, respectively, at the last follow-up visit. The total SRS-22 score was 4.45±0.16. Correlation between different domains of SRS-22 questionnaire after surgical correction shows that only function/activity score revealed a positive significant correlation with the mental health domain (r=0.417) (P=0.038). Conclusion: The Arabic version of SRS-22 questionnaire was very useful in terms of measuring patients’ perceptions. Self-image domain was showing the highest increase among all other domains. (2019ESJ195)

Background Pediatric atlantoaxial instability (AAI) is not common and could be a serious clinical condition. The Goel-Harms technique is one of the most used techniques in adults and needs more evaluation in pediatric populations. This study reports the feasibility and safety of the Goel-Harms technique in the treatment of pediatric reducible AAI. Methods In this retrospective cohort study we reported all pediatric patients who underwent Goel-Harms technique for AAI with a minimum 1-year follow up. Patients were clinically assessed using the Japanese Orthopedic Association (JOA) score and radiologically with plain radiographs, computed tomography scan, and magnetic resonance imaging of the craniocervical region. Postoperatively, patients were followed up according to our clinical and radiographic imaging protocol. The following parameters were recorded: JOA score, construct stability, fusion, and abnormal events. Results A total of 25 patients have completed a 1-year follow-up and fulfilled our criteria. The mean age was 10.68 ± 4.47 (range, 3–17) years. Fifteen patients were male and 10 were female. The final diagnosis included Down syndrome (DS) in 8, type II dens fracture in 7, os odontoideum in 3, and atlantoaxial rotatory fixation in 7. The mean follow-up was 21.76 ± 8.22 months. The preoperative JOA score improved from 15.96 ± 1.46 to 16.76 ± 1.92 at the last follow-up. Sound bone fusion was reported in 92% of patients. Conclusions Our data suggest that the Goel-Harms technique is a safe, feasible, and effective procedure in managing pediatric reducible AAI. Special perioperative care should be offered to young AAI patients with DS.

Background Data: ACDF is one of the most commonly performed operations for degenerative spinal diseases. Traditionally, graft was harvested from iliac crest which was associated with donor site morbidity. This has led to the introduction of many synthetic implants such as PEEK cages to overcome this problem. Purpose: To evaluate the patterns of spinal fusion after ACDF with PEEK cage filled with HA. Study Design: Retrospective clinical study. Patients and Methods: Twenty-five patients that underwent ACDF with PEEK cage filled HA were enrolled in this study through the period from January to December 2017. All patients were submitted to pre- and postoperative clinical and radiological follow-up. Postoperative full neurological and images evaluations were done by independent observer on outpatients at 1, 2, 3, 6, and 12 months. Postoperative neck pain was evaluated using VAS. Radiological evaluation was done using cervical X-ray and images were evaluated using software SurgimapTM. Results: The mean age of our patients was 44.4±6.57 with 9 patients being males and 16 patients females. Total numbers of levels reported were 33 in 25 patients, with 17 patients (68%) undergoing single-level ACDF and 8 patients (32%) double-level ACDF. Five patients (20%) suffered from myeloradiculopathy and twenty patients (80%) had radiculopathy. The mean follow-up was 11.04±1.2. The mean preoperative neck pain VAS was 7.8±1.9, while postoperative VAS was 2.9±1.8. Continuous bridging bony trabeculae were reported in 29 levels (87.9 %) (N=21), while they were absent in 4 levels (12.1%) (N=4). Cage migration was reported in two patients (6%) and both showed >2 mm mobility in dynamic cervical X-ray indicating instability and nonunion. Conclusion: ACDF with PEEK cage filled with HA is a safe and effective method to achieve interbody fusion in patients with cervical disc disease. Although fusion occurred within usual time, remodeling took longer time than that previously reported with iliac graft (2018ESJ171).

Introduction: During the recent decade, many outbreaks of infectious diseases have been reported at increasing scales and frequency. The novel COVID-19 is the most recent lethal virus and has been declared to be a pandemic disease on March 11th, 2020. It has spread from China to most of the countries around the world causing a great burden on individuals and communities. The socioeconomic and professional profiles have been affected seriously by this pandemic. The aim of this study was to assess the short-term effects of COVID-19 on the socioeconomic profile of spinal surgeons in Egypt. Methods: We conducted a cross-sectional online survey study to address the effect of COVID-19 global pandemic on spine surgeons in Egypt, discussing the short-term socioeconomic effect of COVID-19 global pandemic on the professional and social profiles of the Egyptian spine surgeons. A SurveyMonkey® questionnaire was sent to 190 spine surgeons registered in the Egyptian spine association database. Results: Ninety male surgeons responded to our four-day survey. The responders included the following: 4 residents, 16 fellows, and 70 consultants working in different Egyptian hospitals. The partial country lockdown was associated with drop in monthly income and in number of both elective and emergency operations. Most surgeons either stopped surgery or limited the number of either elective or emergency surgeries as well as outpatient clinics. Most of them were not in the COVID-19 team or did not receive any training, working under immense physical and psychological stress of being exposed to transmission of infection. Discussion: COVID-19 global pandemic negatively affected spine surgeons in Egypt socioeconomically. The Health Authority and the community have to work jointly to help the health care professionals in overcoming this crisis.

Background Data: Thoracic and thoracolumbar fractures are commonly provoked by axial compression which disrupts the anterior column. In this setting, posterior stabilization using pedicle screws alone may lead to delayed kyphosis and hardware failure due to inadequate anterior column support. Application of thoracoscopic anterior column reconstruction while patient in prone position for posterior percutaneous instrumentation is a minimally invasive combined technique. Purpose: To evaluate the outcome of percutaneous pedicle screw instrumentation in combination with thoracoscopically assisted vertebral reconstruction using expandable titanium cage. Study Design: Prospective clinical case study. Patients and Methods: Eighteen patients with acute thoracolumbar fractures with different preoperative neurological status were recruited for this study. Patients were treated using a short segment percutaneous screw fixation construct combined with thoracoscopic corpectomy and insertion of expandable cage. Patients were followed for at least 6 months. Visual analogue scale (VAS), Oswestry disability index (ODI) and local kyphotic angle were recorded prospectively and compared to preoperative parameters. Intraoperative data including operative time, blood loss and perioperative complication was documented. Results: Patients were operated within 7 days after trauma using combined anterior and posterior stabilization technique. Mean operative time was 213±42 min (Range, 170-300). The mean blood loss was 225±79 ml (Range, 100-350). The mean VAS score improved significantly after surgery. The mean of ODI preoperatively was 74±6.9 preoperatively and improved after 6 months to become 17.5±14.6. The mean regional kyphotic angle was 22.6±6.82ᴼ preoperatively improved to 6.9±4.1ᴼ postoperatively and at final follow-up it became 8.67±4.8ᴼ. No patient had neurological deterioration or hardware failure during ≥6 months of follow up. Conclusion: our data suggest that thoracoscopic anterior reconstruction and decompression augmented with posterior percutaneous in prone position yield good clinical and radiological results with minimal complications in thoracolumbar trauma. (2018ESJ158)

Background Data: Upper cervical junction (UCJ) is a unique and complex structure because its discrete bony, ligamentous and vascular anatomy. Upper cervical instability (UCI) defined as loss of stability between the atlas and axis (C1–C2), resulting in loss of normal articulation that decrease the space for the lower brain stem and cervical cord and roots. It has different etiologies including; traumatic, inflammatory, idiopathic, or congenital abnormalities. Upon that UCJ have broad varieties of ultimate’s Clinical and radiological manifestations complex. In this study we consider the algorithm of safety and efficacy of polyaxial Screw-rod System Fixation in managing upper cervical instability by C1 Lateral mass (C1L) and C2 pedicle (C2P) screw fixation with or without occipital fixation either from congenital or acquired defect of the occipital bone, foramen magnum, or first two cervical vertebrae. Purpose: To evaluate safety and efficacy of C1L-C2P with or without occipital polyaxial screw-rod system fixation in managing craniocervical instability of various etiologies.Study Design: A retrospective descriptive clinical case study Patients and Methods: Forty-two patients with UCI due to various etiologies were reported. The primary upper cervical pathology (UCP) reported in this series was; type II dens Fracture (N=8), type-II Hangman fracture (N=10), AARF (N=9), Down’s syndrome (N=4), Os Odentadium (N=3), plasma cell cytoma (N=2), aneurysmal bone cyst (N=3), and atlanto-axial ligamentous instability (N=3). Those were treated surgically with reduction, decompression and internal fixation by poly axial screws and rods a within the atlanto-axial avenue. They were assessed pre- and postoperative radiographically by; full plain X-ray, MS 3D-Computed Tomography (MS 3D-CT), Magnetic Resonance Image (MRI), and clinically using Japanese Orthopedic Score (JOA). Results: Forty two patients including 26 males and 16 females with mean age 31.6±12 (range 4-52) years. None of the patients developed a new postoperative neurological deficit. The follow-up was 47±9 (range 12 to 72) months. All patients improve at least 1 grade according to the JOA Scale which was at the last follow-up as follow: 30 normal (71.5%), 9 grade-I (Excellent), and 3 grade-II (good) (7%). None of the patients had neurological worsening during the follow-up period.Conclusion: This prospective cohort suggested that Lateral mass C1 and transpedicular-C2 polyaxial screws fixation can be safely and effectively used in different entities of upper cervical instability, to achieve good purchase and fusion after decompression and reduction. Further prospective studies with longer follow-up are necessary to further establish its validity and safety. (2016ESJ109)

Background Data: Transforaminal Epidural Steroid Injection is one of the nonsurgical treatment methods for sciatic pain. The clinical outcome and predictive factors that affect its results are still under debate. Purpose: The purpose of this study is to evaluate the results of transforaminal epidural steroid injection and identify factors for predicting success. Study Design: A descriptive analytic cross sectional prospective study involving 45 patients with lumbar radiculopathy. Patients and Methods: Forty-Five patients with lumbar radiculopathy were prospectively followed up at 2 weeks and 6 months after Transforaminal Epidural Steroid Injection. The intensity of radicular pain was scored on the Visual Analog Scale (VAS). Outcome was classified as “respondent” when the pain diminished by 50% or more, “Non-respondent” for a diminution of less than 50%. Duration of symptoms, affected level, position of disc herniation, degree of nerve root compression, pain intensity, and body mass index were chosen as predictive factors to study. Results: The mean VAS scores were 7.381.11± before, 2.93 (SD 2.01) 2 weeks after the procedure, and 4.182.75± at 6 months follow-up. Outcome was graded as respondent in 31 patients (68.9%), and non-respondent in 14 patients (31.1%). Level and position of disc herniation, body mass index, and pain intensity were not predictive factors of radicular pain relief, whereas the symptom duration before the procedure and degree of nerve root compression were highly correlated with the pain relief outcome. Minor complications occurred in 2 patients. Conclusion: Transforaminal Epidural Steroid Injection is a simple, safe, and effective nonsurgical procedure. Patients with shorter duration of symptoms, and minimal degree of nerve root compressions shows better improvement. (2013ESJ036)

Background and Aim: Brachial plexus surgery is a complex surgery and multiple surgical techniques were advanced. The concept that patients who underwent surgery will obtain full recovery is still far from the truth. In this study, we show our results after usage some surgical techniques, aiming to describe them. Methods: Through case series study, the team operated 10 cases, including infants and adults (Seven males and three females) between January 2013 and June 2015. Detailed history, physical examinations, radiological imaging studies and electrophysiological studies were performed to confirm the nature and severity of the injury. Exclusion criteria, including individuals who spontaneously recovered after 4 months or those came after more than 12 months of injury. Neurolysis, nerve grafting and nerve transfer were done according to certain protocol performed for each case. Results:History of road traffic accident was reported in five cases, obstetric brachial plexus palsy in three cases, gunshot wound in two cases. They were diagnosed as upper brachial plexus injury (4 cases), lower brachial plexus injury (2 cases), and complete flail limb (4 cases). Four cases were submitted into neurolysis, three into nerve grafting, and three into the nerve transfer.Four cases showing functional motor outcome improvement (2 cases, Neurolysis and 2 cases, nerve transfer) but the other six cases do not show any improvement until now (3 nerve grafting, 2 neurolysis and 1 nerve transfer).Assessment of the motor power was done using the Medical Research Council scale. One case was complicated immediately post-operatively with pan plexopathy of the same limb of surgery and was improved one week after. Conclusion: Brachial plexus surgery renders satisfactory results for restoring the upper limb functions. The results shown that neurolysis and nerve transfer give better results than nerve grafting.

This study was conducted on 90 patients with symptomatic cervical disc disease with one or two-level disc pathology. Clinical and radiological outcome was compared to determine which technique was advantageous for patients with disc disease. Problems related to donor site as well as those related to fusion bed and grafts have stimulated investigators to avoid fusion. Patients were allocated at random for either the ACF (n=50) or the ACD (n=40) procedures. The standard Smith-Robinson technique was performed on all patients in this study. Patients were followed-up clinically and radiologically according to the study protocol. The clinical long-term outcome was comparable in both groups, though those who had ACF were more satisfied. There was significant incidence of kyphosis in the ACD group (P=0.02). Osseous union was slow and less satisfactory with ACD (64%) than with ACF (94%). Pain at the donor site was not a significant problem in the long-term. Hospital stay and operative time was shortened in ACD patients though not significantly. Spondylotic patients were less satisfied with ACD though not significantly. Conclusions. The issue of whether to fuse or not to fuse has not come to an end yet. The technique is still in need of more refinement of disc excision and graft harvesting and shaping, as well as more adequately controlled studies. Until that, ACD has to be limited to those patients with a soft single disc without spondylosis.

✓ Sixty-one patients treated with C1–2 transarticular screw fixation for spinal instability participated in a detailed clinical and radiological study to determine outcome and clarify potential hazards. The most common condition was rheumatoid arthritis (37 patients) followed by traumatic instability (15 patients). Twenty-one of these patients (onethird) underwent either surgical revision for a previously failed posterior fusion technique or a combined anteroposterior procedure. Eleven patients underwent transoral odontoidectomy and excision of the arch of C-1 prior to posterior surgery. No patient died, but there were five vertebral artery (VA) injuries and one temporary cranial nerve palsy. Screw malposition (14% of placements) was comparable to another large series reported by Grob, et al. There were five broken screws, and all were associated with incorrect placement. Anatomical measurements were made on 25 axis bones. In 20% the VA groove on one side was large enough to reduce the width of the C-2 pedicle, thus preventing the safe passage of a 3.5-mm diameter screw. In addition to the obvious dangers in patients with damaged or deficient atlantoaxial lateral mass, the following risk factors were identified in this series: 1) incomplete reduction prior to screw placement, accounting for two-thirds of screw complications and all five VA injuries; 2) previous transoral surgery with removal of the anterior tubercle or the arch of the atlas, thus obliterating an important fluoroscopic landmark; and 3) failure to appreciate the size of the VA in the axis pedicle and lateral mass. A low trajectory with screw placement below the atlas tubercle was found in patients with VA laceration. The technique that was associated with an 87% fusion rate requires detailed computerized tomography scanning prior to surgery, very careful attention to local anatomy, and nearly complete atlantoaxial reduction during surgery.

Introduction: various procedures for the management of atlantoxial instability have reviewed in the literatures. Advantages and disadvantages of these procedures have been stressed. Harms' procedure is one of the recently introduced techniques. This is a retrospective descriptive clinical case study to evaluate the safety and efficacy of Harms' technique. Patients and Methods: we reviewed our hospital medical records between 2009 and 2014. We were able to track 19 patients treated for atlantoaxial instability using Harms' technique with complete records. Patients' mean age was 19.6 years. Twelve were males and 7 were females. Surgical indications included: atlantoaxial ligamentous instability in 2, Os Odentadium in 2, Downs' syndrome in 3, type-II dens fracture in 5, atlantoaxia rotatory fixation in 7. All patients had plain radiography, CT scan, and MRI. According to the JOA-score 15 were normal, 3 were grade-1 and one was grade-2. All patients were operated with Hams' technique with iliac Bone graft. The following factors were evaluated; age, sex, pathology, neurological status, operative time, blood loss, hospital stay, morbidity, screw purchases, stability, fusion, and clinical outcome. Results: mean operative time was 125 minute. Mean blood loss was 350 ml. Hospital stay was 4 days. Screw purchase was adequate in all cases but one. Stability was adequate in all. Fusion was sound in all but two. All intact patients remained intact. Other patients improved at least one grade on JOA-Score. One patient had vertebral artery perforation by a low seated screw. There were no added neurological deficits in any of our patients. Conclusion: our experience demonstrates the safety and efficacy of the Harms' technique in the management of atlantoaxial instability. Meticulous technique and anatomical knowledge are mandatory for optimizing outcome.

The rheumatoid patient with atlanto-axial subluxation presents a major challenge to the spinal surgeon, owing to the poor wound healing and bone quality. Traditional wiring techniques are associated with a high complication and failure rate. Posterior transarticular screw ® xation of the atlanto-axial joint offers a credible alternative and when combined with a Gallie construct offers immediate true 3-point stability. It is, however, a dif® cult and demanding technique which carries a risk of vertebral artery, cranial nerve and spinal cord damage. The question that arises therefore is a Do the improved stability rates afforded by this technique really justify the risks of arterial and neurological damage?o To date there have been no studies of this technique dealing solely with the rheumatoid patient, with most reports dealing with a heterogeneous patient population, mainly trauma-related cases. The purpose of this report is to analyse critically our results with particular reference to the complications that we have encountered and the technical reasons for their occurrence. We analysed the clinical and radiological data of 38 rheumatoid patients (six males: 32 females, mean age of 54 years) with atlanto-axial subluxation who underwent transarticular screw ® xation. Our analysis centred on screw malposition and complications. Parametric and non parametric statistical analysis was performed. Signi® cance was accepted at the 5% level (p, 0.05). Our analysis revealed that three vertebral arteries were damaged. Two of these were recognized at the time of surgery, with the remaining case only suspected following postoperative CT to assess screw positioning. Vertebral artery occlusion was subsequently con® rmed by angiography. All three patients were asymptomatic from their arterial injury. There was only one neurological complication in this series, and this was caused by a high screw, which damaged the hypoglossal nerve with a temporary nerve palsy ensuing. Four screws broke, all were made of titanium, but more importantly, all were also associated with contralateral screw malposition. Stability was achieved in 95% of cases overall. The high stability rates afforded by this technique do appear to justify the inherent risks of this procedure. If unilateral screw ® xation only is achieved, we would recommend a period of halo immobilization until osseous union occurs.