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Abstract Purpose To evaluate the perioperative clinical outcomes of en bloc resection and anterior column reconstruction for thoracolumbar spinal tumors. Methods This study conducted a retrospective analysis of prospective data collection of 86 consecutive patients, including 40 males and 46 females, with an average age of 39 years (ranged from 10 to 71 years). There were 35 cases of a malignant primary tumor,42 cases of an aggressive benign tumor, and nine cases of metastases. The main lesions were located in 65 cases of thoracic spine, 17 cases of lumbar spine, and 4 cases of thoracolumbar spine. Tumors involved one level in 45 patients, two levels in 12 patients, three levels in 21 patients, four levels in five patients, five levels in two patients, and six levels in one patient. Results According to the Weinstein-Boriani-Biagini surgical staging system, all patients achieved en bloc resections, including 74 cases of total en bloc spondylectomy and 12 cases of sagittal resections. The mean surgical time was 559 min (210–1208 min), and the mean total blood loss was 1528 ml (260–5500 ml). A total of 122 complications were observed in 62(72.1%) patients, of which 18(20.9%) patients had 25 major complications and one patient (1.2%) died of complications. The combined approach (P = 0.002), total blood loss (P = 0.003), staged surgery (P = 0.004), previous surgical history (P = 0.045), the number of involved vertebrae (P = 0.021) and lumbar location (P = 0.012) were statistically significant risk factors for major complication. When all above risk factors were incorporated in multivariate analysis, only the combined approach (P = 0.052) still remained significant. Conclusions En bloc resection and anterior column reconstruction is accompanied by a high incidence of complications, especially when a combined approach is necessary.

This study aimed to evaluate the safety and efficacy of a novel Poly-Ether-Ether-Ketone (PEEK) expandable vertebral body replacement (VBR) for anterior cervico-thoracic vertebral column reconstruction in patients with metastatic, traumatic, or degenerative diseases. Radiographic and clinical outcomes, as well as complication rates, were analyzed in a retrospective analysis of 28 patients (61 ± 13 years; 64% female) who underwent an anterior cervical corpectomy and fusion (ACCF) with the Expandable Corpectomy Device (ECD) from DePuy/Synthes (2011–2020). Correction of the bisegmental kyphotic angle (BKA) was chosen as the primary outcome. Bony fusion, loss of device height, and implant subsidence were evaluated additionally. Clinical outcome was assessed using Odom’s criteria, the numerical pain rating scale (NRS), the American Spinal Injury Association Impairment Scale (AIS), and the Karnofsky Performance Status Scale (KPSS). Our study found a significant improvement in the BKA (12.3° ± 9.6°; p = 0.0002) at the last follow-up with no statistically relevant loss of device height (p = 0.96) or implant subsidence (p = 0.99). Successful bony fusion was observed in all patients. The KPSS significantly improved in patients with a tumorous disease at the time of discharge (p = 0.0009), and the sensation of pain showed significant improvement at six months post-operatively and at the final follow-up (p = 0.004; p = 0.021). However, four patients needed further secondary posterior stabilization, and one ECD was explanted due to a severe surgical site infection after an accidental esophageal lesion. In conclusion, the ECD proofed the radiographic stability for the anterior column reconstruction of the cervico-thoracic spine with significantly improved clinical outcome.

This study aimed to evaluate the safety and efficacy of a novel Poly-Ether-Ether-Ketone (PEEK) expandable vertebral body replacement (VBR) for anterior cervico-thoracic vertebral column reconstruction in patients with metastatic, traumatic, or degenerative diseases. Radiographic and clinical outcomes, as well as complication rates, were analyzed in a retrospective analysis of 28 patients (61 ± 13 years; 64% female) who underwent an anterior cervical corpectomy and fusion (ACCF) with the Expandable Corpectomy Device (ECD) from DePuy/Synthes (2011–2020). Correction of the bisegmental kyphotic angle (BKA) was chosen as the primary outcome. Bony fusion, loss of device height, and implant subsidence were evaluated additionally. Clinical outcome was assessed using Odom's criteria, the numerical pain rating scale (NRS), the American Spinal Injury Association Impairment Scale (AIS), and the Karnofsky Performance Status Scale (KPSS). Our study found a significant improvement in the BKA (12.3° ± 9.6°; p = 0.0002) at the last follow-up with no statistically relevant loss of device height (p = 0.96) or implant subsidence (p = 0.99). Successful bony fusion was observed in all patients. The KPSS significantly improved in patients with a tumorous disease at the time of discharge (p = 0.0009), and the sensation of pain showed significant improvement at six months post-operatively and at the final follow-up (p = 0.004; p = 0.021). However, four patients needed further secondary posterior stabilization, and one ECD was explanted due to a severe surgical site infection after an accidental esophageal lesion. In conclusion, the ECD proofed the radiographic stability for the anterior column reconstruction of the cervico-thoracic spine with significantly improved clinical outcome. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the perioperative clinical outcomes of en bloc resection and anterior column reconstruction for thoracolumbar spinal tumors. Methods: This study conducted a retrospective analysis of prospective data collection of 86 consecutive patients, including 40 males and 46 females, with an average age of 39 years (ranged from 10 to 71 years). There were 35 cases of a malignant primary tumor,42 cases of an aggressive benign tumor, and nine cases of metastases. The main lesions were located in 65 cases of thoracic spine, 17 cases of lumbar spine, and 4 cases of thoracolumbar spine. Tumors involved one level in 45 patients, two levels in 12 patients, three levels in 21 patients, four levels in five patients, five levels in two patients, and six levels in one patient. Results: According to the Weinstein-Boriani-Biagini surgical staging system, all patients achieved en bloc resections, including 74 cases of total en bloc spondylectomy and 12 cases of sagittal resections. The mean surgical time was 559 min (210–1208 min), and the mean total blood loss was 1528 ml (260–5500 ml). A total of 122 complications were observed in 62(72.1%) patients, of which 18(20.9%) patients had 25 major complications and one patient (1.2%) died of complications. The combined approach (P = 0.002), total blood loss (P = 0.003), staged surgery (P = 0.004), previous surgical history (P = 0.045), the number of involved vertebrae (P = 0.021) and lumbar location (P = 0.012) were statistically significant risk factors for major complication. When all above risk factors were incorporated in multivariate analysis, only the combined approach (P = 0.052) still remained significant. Conclusions: En bloc resection and anterior column reconstruction is accompanied by a high incidence of complications, especially when a combined approach is necessary. [ABSTRACT FROM AUTHOR]

Background: Vertebral osteomyelitis (VO) often necessitates surgical intervention due to bone loss-induced spinal instability. Anterior column reconstruction, utilizing expandable vertebral body replacement (VBR) implants, is a recognized approach to restore stability and prevent neurological compromise. Despite various techniques, clinical evidence regarding the safety and efficacy of these implants in VO remains limited. Methods: A retrospective cohort analysis, spanning 2000 to 2020, was conducted on 24 destructive VO cases at a Level 1 orthopedic trauma center. Diagnosis relied on clinical, radiological, and microbiological criteria. Patient demographics, clinical presentation, surgical interventions, and radiological outcomes were assessed. Results: The study included 24 patients (62.5% male; mean age 65.6 ± 35.0 years), with 58% having healthcare-associated infections (HAVO). The mean radiological follow-up was 137.2 ± 161.7 weeks. Surgical intervention significantly improved the bi-segmental kyphotic endplate angle (BKA) postoperatively (mean −1.4° ± 13.6°). However, a noticeable loss of correction was observed over time. The study reported a mortality rate of 1/24. Conclusions: Anterior column reconstruction using expandable VBR effectively improved local spinal alignment in destructive VO. However, the study underscores the necessity for prolonged follow-up and continuous research to refine surgical techniques and postoperative care. Addressing long-term complications and refining surgical approaches will be pivotal as the field progresses. [ABSTRACT FROM AUTHOR]

Introduction: Lateral anterior column release (ACR) is a minimally invasive option for the correction of sagittal plane deformity. To assemble a homogeneous picture of published research on ACR, an advanced bibliometric analysis was conducted to compile the top-ten most-cited articles on the topic of ACR. Methods: A keyword search using the Thomson Reuters Web of Knowledge was conducted to identify articles discussing the role of lateral ACR. The articles were then ranked based on the total number of citations to identify the ten most-cited articles published. A subjective appraisal of the findings of these articles was conducted to provide a ranked literature review and to examine trends in the study of ACR between 2012 and 2019. Results: The earliest published article on ACR was in 2012 by Deukmedjian et al. Three articles were in vitro biomechanical assessments of ACR, and seven articles were on outcome analyses, which were either case series or case controlled. The most-cited article was a biomechanical study authored by Uribe et al. The article with the highest rate of citations/year was authored by Manwaring et al. Uribe and the European Spine Journal were the most frequently cited author and journal, respectively. Conclusions: The lateral ACR approach has enjoyed significant scholarly attention since its advent. Higher-level analyses with robust control groups, larger sample sizes, and long-term follow-up are necessary to improve our understanding of this approach.

Introduction: Lateral anterior column release (ACR) is a minimally invasive option for the correction of sagittal plane deformity. To assemble a homogeneous picture of published research on ACR, an advanced bibliometric analysis was conducted to compile the top-ten most-cited articles on the topic of ACR. Methods: A keyword search using the Thomson Reuters Web of Knowledge was conducted to identify articles discussing the role of lateral ACR. The articles were then ranked based on the total number of citations to identify the ten most-cited articles published. A subjective appraisal of the findings of these articles was conducted to provide a ranked literature review and to examine trends in the study of ACR between 2012 and 2019. Results: The earliest published article on ACR was in 2012 by Deukmedjian et al. Three articles were in vitro biomechanical assessments of ACR, and seven articles were on outcome analyses, which were either case series or case controlled. The most-cited article was a biomechanical study authored by Uribe et al. The article with the highest rate of citations/year was authored by Manwaring et al. Uribe and the European Spine Journal were the most frequently cited author and journal, respectively. Conclusions: The lateral ACR approach has enjoyed significant scholarly attention since its advent. Higher-level analyses with robust control groups, larger sample sizes, and long-term follow-up are necessary to improve our understanding of this approach. [ABSTRACT FROM AUTHOR]

Background: Osteonecrosis with progressive collapse and segmental kyphosis can lead to intersegmental instability in some osteoporotic vertebral compression fractures (OVCFs). These conditions are known as Kümmell's disease and often require anterior column reconstruction in elderly patients. Methods: We attempted anterior column reconstruction by percutaneous transpedicular intracorporeal cage grafting (PTICG) with short-segment pedicle screw fixation and described the steps, with discussions on the surgical indications and pros and cons. Conclusion: PTICG is expected to be an alternative to vertebral anterior column reconstruction, which can preserve the thoracolumbar posterior arch and paravertebral musculature. [ABSTRACT FROM AUTHOR]

Background. One of the reasons for the lack of standardized approaches to treating lumbar and thoracolumbar spine traumatic injuries is inconclusive information on relative contribution of various factors to pedicle screw fixation stability.Objective. To determine risk factors that influence pedicle screw fixation stability in patients with unstable traumatic injuries of a lumbar spine and thoracolumbar junction.Material and Methods. This was a retrospective evaluation of 192 spinal instrumentations. Patients with type А3, A4, B1, B2 and C injuries of lumbar and thoracolumbar spine were enrolled. Pedicle screw fixation was used either as a stand-alone technique or in combination with anterior column reconstruction. If required, decompression of nerve roots and spinal cord was performed. Cases with pedicle screw fixation failure were registered. Logistic regression analysis was used to assess predictive significance of potential risk factors. Results. Complication rate growth was associated with a decrease in bone radiodensity, posterior decompression extensiveness, lumbosacral fixation and residual kyphotic deformity. Anterior column reconstruction and additional pedicle screw installation led to a decline in complication rate while anterior decompression and fixation length did not influence fixation stability. Conclusion. In most cases, pedicle screw fixation system failure is associated with altered bone quality; however, surgical approach may also impact complication rate and should be taken into account when planning surgical intervention. Anterior column reconstruction and additional pedicle screw installation are associated with the decline in complication rate; the influence of those options is comparable. Anterior decompression does not influence pedicle screw fixation stability; consequently, it is preferable in cases with considerable risk of pedicle screw fixation failure.

Study Design: Retrospective study. Aim: To retrospectively evaluate and compare the long-term outcome of anterior vertebral body reconstruction in tuberculosis (TB) of the dorsal spine by direct anterior-versus-posterior approach. Materials and Methods: A total of 127 patients operated by posterior approach, 118 by anterior for TB-thoracic spine with at least 1-year follow-up were included and retrospectively analyzed. Patients were assessed clinically, radiologically and data regarding age, sex, levels involved, surgical approach, operative time, blood loss, neurological recovery using Frankel grade, pre- and post-operative kyphosis, % correction of kyphosis, time for fusion, fusion grading using Bridwell criteria, % loss of correction, mobilization time and complications if any were collected, analyzed, compared in anterior-v/s-posterior approaches. Results: The mean age in anterior-approach was 36.03 and 39.83 years in posterior. Mean operative time in anterior-approach was 6.11 and 5 h in posterior. Mean blood loss of 1.6 L in anterior approach and 1.11 L in posterior. Mean preoperative kyphosis angle in posterior-approach was 34.803°and 11.286° (P < 0.001) at 3 months postopandtotal correction of 67.216%. Mean preoperative kyphosis angle in anterior-approach was 41.154° and 9.498° at 3 months postopandtotal correction of 77.467% (P < 0.001). Mean loss of correction at 1 year was 4.186°in posterior-approach and 6.184°in anterior. The mean time for fusion was 4.69 months in anterior-approach while 6.34 months in posterior as per Bridwell criteria. Meantime for mobilization in posterior-approach was 1.18 and 2.51 weeks in anterior. Significant improvement in neurology was seen in patients operated by either approach, slightly better in anterior. Complications were more in posterior-approach. Conclusions: Anterior-approach allows for thorough debridement, neural decompression, better anterior column reconstruction, and deformity correction under direct vision than posterior. Direct cord visualization while correcting kyphosis reduces the chances of neurological complications significantly. Both approaches have unique advantages and limitations. Though the posterior approach is easy to master, results shown by the anterior cannot be overseen. To conclude, better functional outcome and significantly better kyphosis correction are seen with anterior-approach, which are strong pointers favoring it. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate whether a new PEEK vertebral body replacement can maintain the sagittal alignment as an anterior column reconstruction device in thoracic and lumbar spinal defects due to trauma or tumor. Methods: Retrospective review of 48 patients who underwent a corpectomy between T5 and L5 due to trauma or tumor and were stabilized with the new PEEK vertebral body replacement, between 2013 and 2017. We excluded patients who underwent a corpectomy for infection or degenerative disease and patients without complete follow-up in our institution. The primary outcome was the bi-segmental kyphotic angle (BKA). Secondary outcomes were the assessment of pedicle screw loosening, cage height, and subsidence or tilting of the cage. The clinical outcomes were assessed through the COMI-Score, EuroQol-5D, and Karnofsky indexes. Bony fusion and complications were registered. Results: After the surgery BKA decreased by 12.1° (p < 0.001). At the end of the follow-up, we observed a mean loss of reduction of 1.6° (p = 0.002). This was accompanied by an increase in subsidence of 2.1 mm (p < 0.001) and mean tilting of the cage of 1.4° (p = 0.003). The height of the cage and other parameters did not experience any changes. Clinically, the COMI-Score (p = 0.02) and the EuroQol-5D Index (p = 0.012) showed significant improvement, same as Karnofsky-Index (p = 0.015) at final follow-up. The fusion rate according to Bridwell was 92.1%. The 2% late complications were related to implant malpositioning. Conclusion: The new PEEK expandable vertebral body replacement is effective and safe in thoracic and lumbar anterior column reconstruction in tumor and trauma diseases. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

• Spinal canal decompression through small laminectomy and percutaneous pedicle screw fixation offers excellent clinical and radiological improvement. • Furthermore, this can be safer and more effective surgical option compared to anterior corpectomy and fusion in the thoracolumbar burst fractures. • As far as I know, no paper has been directly compared these two methods. Thoracolumbar burst fractures (TLBFs) are the most common spinal trauma; however, their appropriate management has not yet been determined. In this study, we aimed to compare the clinical and radiological results of percutaneous pedicle screw fixation (PPSF) following posterior decompression technique versus anterior corpectomy and fusion technique for the treatment of TLBFs. A total of 46 patients (2002–2015) with TLBFs were included in this study. The inclusion criteria were a single-level Magerl type A3 burst fracture of the thoracolumbar junctional spine (T12–L2). The patients were divided into two groups; Group A (22 patients) underwent anterior corpectomy and fusion, and Group B (24 patients) underwent PPSF after posterior decompression. Anterior corpectomy and fusion surgery were performed in 22 cases before April 2009, and PPSF following posterior decompression technique was used in 24 cases since then. For radiological assessment, the kyphosis angle was measured preoperatively, early postoperatively, and at the last follow-up using the Cobb angle. Mean correction of the Cobb angle after surgery, and loss of correction between the immediate postoperative and final Cobb angle were calculated accordingly. All neurological deficits were identified in the initial evaluation and graded using the American Spinal Injury Association (ASIA) grading system. Perioperative parameters including operation time, amount of blood loss, and mean hospital stay were also evaluated. The patients comprised 17 males and 5 females in Group A and 13 males and 11 females in Group B. In terms of the involved levels, there were three cases of T12, twelve L1, and seven L2 in Group A and one case of T12, thirteen L1, and ten L2 in Group B. The mean follow-up duration was 44.9 months in Group A and 14.7 months in Group B. The kyphotic angle was significantly corrected after surgery by 6.4° in Group A (p = 0.001) and 9.2° in Group B (p < 0.001). Among patients with neurological deficit, 11 of 15 in Group A and 20 of 23 in Group B demonstrated improvement by at least one ASIA grade at the final observation. However, there was no significant difference in neurological improvement between the two groups (p = 0.13). Mean operation time was significantly shorter (p < 0.001) and mean blood loss was significantly less (p < 0.001) in Group B than in Group A. Mean hospital stay was also significantly shorter in Group B (p < 0.001). Spinal canal decompression through small laminectomy followed by PPSF in the treatment of TLBFs with neurological deficits offers excellent clinical and radiological improvement as well as biomechanical stability. Furthermore, this can be a safe and effective surgical option with the advantage of less invasiveness in the treatment of TLBFs. [ABSTRACT FROM AUTHOR]

Pyogenic vertebral osteomyelitis is a bacterial infection of the vertebral body often caused by hematogenous spread from a distant site with 3%–11% of cases affecting the cervical spine. 1,2 Patients at risk for osteomyelitis are intravenous drug users, patients with diabetes, patients in dialysis, and males older than 50 years of age. In severe cases where infection causes osseous destruction of the vertebral column lending to a loss of normal sagittal and coronal plane alignment, neurologic impairment, or spinal instability, surgical correction may be required. 3 A 38-year-old woman with a medical history of intravenous drug use presented with a 1-week history of progressive paresthesias, subjective loss of lower extremity sensation, and severe right upper extremity weakness. Neurologic examination was notable for significant weakness in the right deltoids, biceps, and triceps. Magnetic resonance imaging cervical spine revealed significant kyphosis at C4-C5 secondary to destruction of the C4 and C5 vertebral bodies and anterior and posterior epidural fluid collection at C2-C3 and C7-T1, respectively. Surgery was proposed through a combined anteroposterior approach with head and neck surgeons. Anteriorly, she underwent a C2-C3 and C6-C7 ACDF and C4, C5 corpectomies (Video 1). The patient was then transitioned to the prone position and underwent C3-T3 posterior fusion with instrumentation and C3-C7 laminectomies. Correction of sagittal imbalance should restore normal physiologic spinal alignment while promoting a successful fusion. 4 The patient was discharged to acute rehabilitation after an uneventful postoperative course. At 5-month follow-up, she has regained antigravity strength in right upper extremity and reports significant reduction in neck pain. [ABSTRACT FROM AUTHOR]

• Smaller cage-vertebral endplate interfaces increase the risk of cage subsidence. • Self-adjusting caps increase vertebral endplate engagement. • Flexibility maintains cage-endplate apposition through construct reduction. • Self-adjusting cage may decrease von Mises stress and subsidence risk. Destabilization of the vertebral column – as seen in trauma and metastatic spine disease – often requires corpectomy and anterior column reconstruction. Stresses applied to the implant can lead to subsidence, ultimately requiring in surgical revision. Here we report a cadaveric investigation of a novel expandable corpectomy cage with a self-adjusting, multiaxial end cap. Four cadaveric T11-sacrum spines (mean 67.3 yr; 75% female) were treated with L2 corpectomy and T12-L4 pedicle screw fusion. Pressure sensors were applied to the L1 and L3 endplates and anterior column reconstruction was performed with either a standard expandable corpectomy cage (T2A), an expandable corpectomy cage with a self-adjusting, multiaxial end cap (T2S), or the latter cage with oblong, extended end caps (T2S + EE). Total contact area was compared pre- and post-reduction using ANOVA general linear model. Pre-reduction, the T2S constructs had a trend of higher surface contact than the conventional T2A constructs, though the results were not significant (p = 0.068); however, T2S + EE constructs did produce significantly larger contact with vertebral endplates (p = 0.04). The difference was also significant for both conditions following compression (p < 0.01 for both constructs). The use of an expandable corpectomy cage with a self-adjusting, multiaxial end cap produces significant increases in vertebral endplate contact area. These in vitro data suggest that the self-adjusting, multiaxial end cap may serve to decrease the risk of subsidence in patients undergoing anterior column resection and reconstruction. Clinical data would be required to confirm the relationship between endplate contact area and risk of subsidence. [ABSTRACT FROM AUTHOR]

• 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. 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. 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. 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. 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. [ABSTRACT FROM AUTHOR]

Background Data: Short segment pedicular fixation is one of the most common operative techniques to treat unstable thoracolumbar burst fracture. However, it may be associated with pseudoarthrosis, progressive kyphosis, and a high rate of hardware failure. Different surgical techniques were described to deal with this failure. Biomechanical investigations have shown that anterior fusion provides superior stability as compared to single dorsal instrumentations. Study Design: A retrospective clinical case study. Purpose: To evaluate the outcomes of anterior column reconstruction for treatment of failed short segment pedicular fixation system in thoracolumbar fractures. Patients and Methods: This study included 25 patients with failed short segment pedicular fixation after acute thoracolumbar fracture. They were treated by anterior column reconstruction with strut iliac graft and fixed with either posterior long pedicular system or anterior locked system through simultaneous combined approaches. This study was done in the period between January 2009 to December 2013. Neurological status was classified using Frankel classification. All patients had been followed up by radiographs and CT-scans. Back pain and functional outcomes were assessed by VAS andODI respectively. Results: All patients were followed up for at least 24 months. The visual analogue scale (VAS) of back pain improved significantly from 6.20±0.94 preoperatively to 1.87±0.83 at the latest follow up. The mean Cobb angle improved significantly from 28.47±10.80o preoperatively to 2.07±9.39o immediate postoperatively and was maintained at 4.13±10.21o at latest follow up. According to Brantigan criteria, fusion was considered certain in all 25 patients (100%) and no failure of internal fixation occurred at latest follow up. The functional outcomes which measured by Oswestry disability index (ODI) improved significantly from 62.60±11.17% preoperatively to 24.00±6.04% at latest follow up.Conclusion: Anterior column reconstruction of the spine achieved significant improvement in radiological,clinical, and functional outcomes with few complications for treatment of failed short segment pedicular fixation in thoracolumbar fractures. (2015ESJ091)

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. [ABSTRACT FROM AUTHOR]

Background Data: The optimal treatment of unstable thoracolumbar spine due to trauma, tumors, and tuberculous spondylitis remains controversial. Treatment goals of thoracolumbar corpectomy are: to prevent neurological deterioration; enhance neurological recovery; stabilization, and to prevent late pain and deformity. Purpose: This retrospective study was conducted to determine the safety and efficacy of stabilization using titanium mesh cage reconstruction filled with autogenous bone graft and anterior plating after thoracolumbar corpectomy due to trauma, tumors or tuberculous spondylitis. Study Design: A retrospective clinical case study. Patients and Methods: A series of patients underwent reconstruction of the anterior column after thoracolumbar corpectomy between June 2006 and June 2011 were reviewed. Sixteen patients underwent reconstruction using titanium mesh cages, and retrospectively analyzed data from the medical records and radiographs including immediate postoperative and latest follow up. The etiology due to trauma in ten cases, tuberculosis in three cases, metastasis in two cases and myeloma in one case. An average duration of follow up was 18 months [ 8-58 months ], single level reconstruction done in trauma and tumor cases, two level corpectomy done in tuberculous spondylitis cases. The degree of kyphosis, construct height and the subsidence of the cage in relation to the vertebral endplates were measured preoperatively, early post operative, and at the latest follow up. The surgical approach was thoracoabdominal in 10 cases and retroperitoneal in 6 cases. Results: Neurological recovery in our study; 4 patients were neurologically intact, Frankel grade E on admission , and all of them remains intact postoperatively. Of the 6 patients with Frankel D on admission, all had recovered full motor and sensory function. Of the 6 patients with Frankel C on admission, three improved one grade, the other three improved two grades. The mean construct height of the involved vertebrae before surgery was 41 mm and the mean construct height immediate after surgery and at follow up were 47 and 44 mm respectively. Solid fusion was observed in all patients, there were no hardware failure. The sagittal alignment of the fractured segment was satisfactorily restored immediately after surgery as a significant decrease in the local kyphotic angle. Conclusion: Anterior instrumentation is an effective and safe treatment for thoracolumbar instability by demonstaring satisfactory clinical and radiological outcomes. (2012ESJ028)

A number of anterior reconstruction options are available in patients managed for symptomatic metastatic spinal column disease. Polymethylmethacrylate (PMMA) has been traditionally used as a reconstruction option in patients with limited life expectancy as an anterior fusion is not expected. In this article, we present the outcome of a 13-year follow-up of a long anterior reconstruction using PMMA of the upper thoracic spine in a myelopathic female secondary to a compressive breast metastasis affecting the upper 4 thoracic vertebrae. We discuss the use of PMMA in spinal oncological surgery and review the evidence pertinent to its use. [ABSTRACT FROM AUTHOR]

Study Design: A retrospective case series.Objective: The aim of this study was to evaluate patients with cervical spine osteomyelitis who underwent multilevel (≥2) subaxial corpectomies and anterior column reconstruction and plating.Summary Of Background Data: Neglected multilevel subaxial cervical osteomyelitis is a potentially dangerous disease. As it is rare, early radiographic and clinical outcomes after multilevel anterior corpectomy and reconstruction for subaxial cervical osteomyelitis are incompletely defined.Methods: Adults who underwent multilevel corpectomy and anterior plating/reconstruction for subaxial cervical osteomyelitis at two institutions were reviewed. Analysis of patient demographics, operative details, and radiographic cervical alignment parameters [segmental kyphosis, cervical lordosis, C2-7 sagittal vertical axis (SVA)] was performed.Results: Nineteen patients [15 males, four females; average age 48 years (20-81 yrs)] met inclusion criteria. The majority had pre-operative neurologic deficits or was immunosuppressed. All were treated with ≥6 weeks of intravenous antibiotics following operation. All had anterior plating/reconstruction with titanium cages (expandable-6; mesh-6) or structural bone graft (fibular allogaft-6; tricortical iliac crest-1). The average number of corpectomies was 2.4 (2-4). The average numbers of levels fused anteriorly was 4.4 (4-6) and posteriorly was 6.3 (4-9). The majority of patients (74%) was treated with an anterior/posterior approach. Average follow-up was 16 ± 9 months. There was significant improvement in all cervical alignment parameters (segmental kyphosis, C2-7 SVA, cervical lordosis). No intraoperative complications occurred and no patient deteriorated neurologically postoperatively. Postoperative complications included anterior cage/graft dislodgement (n = 2), recurrent neck hematomas requiring revision (n = 1), epidural hematoma (n = 1), and wound infection (n = 1). Sixty percent of patients had persistent neurologic dysfunction at final follow-up. None required reoperation for recurrent infection or pseudarthrosis.Conclusion: Although overall prognosis and neurologic recovery are guarded in medically fragile patients with multilevel subaxial cervical osteomyelitis, reconstruction with multilevel (≥2) corpectomy and anterior reconstruction/plating results in excellent restoration of cervical alignment and low rates of recurrent infection and pseudarthrosis.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Objective: The authors sought to assess the outcomes of lamina-sparing decompression using a posterior-only approach in patients with thoracolumbar spinal tuberculosis (TB). In patients with spinal TB with paraplegia, anterior decompression yields excellent results because it allows direct access to the diseased part of the vertebra, but the anterior approach has related morbidities. Posterior and posterolateral decompression mitigate approach-related morbidities; however, these approaches destabilize the already diseased segment. Lamina-sparing decompression through a posterior-only approach is a modification of posterolateral and anterolateral decompression that allows simultaneous decompression and instrumentation while preserving the posterior healthy bony structure as much as possible., Methods: Thirty-five patients with spinal TB underwent lamina-sparing decompression and instrumentation. Outcomes were determined by using a visual analog scale (VAS) and the Oswestry Disability Index (ODI) for functional assessment, the American Spinal Injury Association (ASIA) impairment grade for neurological assessment, blood loss and duration of surgery for surgical outcome assessment, and Cobb angles to measure kyphosis correction., Results: In total, 35 patients (12 men and 23 women) with an average age of 35.8 ± 18.7 (range 4-69) years underwent lamina-sparing decompression. Eight patients had dorsal, 7 had dorsolumbar, 7 had lumbar, 9 had multifocal contiguous, and 4 patients had multifocal noncontiguous spinal TB; 33 patients had paradiscal Pott's spine (tuberculous spondylodiscitis), and 2 had central-type disease. The average preoperative Cobb angle was 28.4° ± 14.9° (range 0°-60°) and the postoperative Cobb angle was 16.3° ± 11.3° (44° to -15°). There was loss of 1.6° ± 1.5° (0°-5°) during 16 months of follow-up. Average blood loss was 526 ± 316 (range 130-1200) ml. Duration of surgery was 228 ± 79.14 (range 60-320) minutes. Level of vertebral instrumentation on average was 0.97 ± 0.8 (range 0-4) vertebra proximal and 1.25 ± 0.75 (0-3) distal to the diseased segment. Neurological recovery during the immediate postoperative period occurred in 23 of 27 patients (85.1%). All patients had recovered at the final follow-up at 16 months. The preoperative ODI score improved from 76.4 ± 17.9 (range 32-100) to 6.74 ± 17.2 (0-60) at 16 months. The preoperative VAS score improved from 7.48 ± 1.16 (6-10) to 0.47 ± 1.94 (0-8). Surgical site infection occurred in 2 patients, and 1 patient had an intraoperative dural tear that was successfully repaired. One patient developed implant loosening at 3 months, which was managed by extended instrumentation., Conclusions: To achieve stability, lamina-sparing decompression allows fixation of lower numbers of vertebrae proximal and distal to the diseased segment. This method has a fair outcome in terms of kyphosis correction, good functional and neurological recovery, shorter surgical duration than conventional methods, and less blood loss.

Objective: To evaluate the effectiveness of pedicle subtraction osteotomy (PSO) assisted with anterior column reconstruction in the treatment of chronic osteoporotic vertebral compression fracture (OVCF)., Methods: Between January 2008 and October 2014, 11 cases of chronic OVCF were treated. There were 2 males and 9 females, aged 65-76 years (mean, 72.3 years). The vertebral compression fracture segment involved T 11 in 2 cases, T 12 in 2 cases, L 1 in 4 cases, L 2 in 2 cases, and L 3 in 1 case. At preoperation, the Oswestry disability index (ODI) score was 31.1±10.2; kyphosis Cobb angle of fractured vertebrae was (36.5±10.2)° on the lateral X-ray films of the spine; and distance between C 7 plumb vertical line (C 7 PL) and sagittal vertical axis (SVA) of the S 1 superior border was (5.2±2.5) cm. Six cases had spinal cord injury (SCI), including 4 cases of Frankel grade C and 2 cases of grade D. At last follow-up, ODI score, kyphosis Cobb angle of fractured vertebrae, and distance between C 7 PL and SVA were recorded and compared with preoperative values. Postoperative Frankle scores were recorded in SCI cases. X-ray film and CT scan were taken to evaluate bone fusion at 12 months after operation., Results: The operation was completed successfully without serious complications. Nerve root radiation symptoms occurred in 2 cases undergoing lumbar PSO, which was relieved after conservative treatment. Cerebrospinal fluid leakage occurred in 1 case and was cured after 2 weeks. All cases were followed up 12-24 months (mean, 15.6 months). No internal fixation failure or pseudarthrosis was found postoperatively.Screw loosening was found in 1 case (2 screws of the upper level) and titanium Cage cutting vertebral body was found in 1 case. Bone fusion was obtained in all cases at 12 months after operation. At last follow-up, ODI score was significantly improved to 13.7±5.7( t =4.417, P =0.018), kyphosis Cobb angle of fractured vertebrae to (7.0±15.2)° ( t =5.113, P =0.009), and the distance between C 7 PL and SVA to (2.8±2.2) cm ( t =3.285, P =0.032). In 6 SCI cases, Frankle grade was recovered to E (1 case), to D (1 case), and no improvement (2 cases) from C, and to E from D (2 cases)., Conclusions: PSO assisted anterior column reconstruction was an effective method in treatment of chronic OVCF.

Study 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 of 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.