Eur Spine J (2015) 24:872–903 DOI 10.1007/s00586-015-3885-2
ABSTRACTS
XXXVIII Italian Spine Society National Congress Roma, Italy 14th–16th May, 2015
ABSTRACTS
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Eur Spine J (2015) 24:872–903
CERVICAL SPINE RIGID INTERNAL FIXATION FOR OCCIPITO-CERVICAL ARTHRODESIS IN CHILDREN T. Odent Department of Pediatric Orthopedics, Hoˆpital Universitaire Necker Enfants Malades, Universite´ Sorbonne Paris, Paris, France Abstract: Traditional techniques (in situ bone grafting associated with a halo-cast ± wiring techniques) are associated with an important rate of non-fusion, in particular in patients having constitutional bone diseases, in trisomy 21 or in the presence of important bony defects. The aims of the study were to evaluate the effectiveness on the bony fusion and the safety of the use of a rigid internal fixation. Material and method: This is a retrospective study including 22 patients of mean age 10 years 10 months. Eight patients had a congenital malformation, six patients had a mucopolysaccharidoses, three patients had a trisomy 21, one patient had a vertebral tumor, one patient had a juvenile rheumatoid arthritis, one patient had EhlerDanlos disease, one patient had an iatrogenic instability after resection of an occipital chondrosarcoma, and one patient had osteogenesis imperfecta. The posterior instrumentation consisted of a precontoured titanium plate rod associating an occipital fixation by hooks or screws and a vertebral fixing by screws and hooks. Ten patients had C2 pedicle screws. The posterior iliac crest was used as a graft in 18 patients and the calvaria in 4 patients. The postoperative immobilization evolved with the experience of the surgeons from a halo-cast to an occipitocervical brace in young children and simply a rigid cervical collar in the older children. The mean follow-up was 50 months (2785 months). Results: Nineteen patients (91 %) had a complete fusion. There was no incidence of implant failure and there was no vertebral artery injury. We had four major complications, two due to deep wound infection, one due to post-operative hematoma, and one due to loss of reduction. All the patients, except one with the post-operative hematoma and one with the deep infection, had neurological improvement. Conclusion: Rigid internal fixation, in particular the use of C2 pedicle screws and occipital hooks, is safe in the young child without increase in surgical complications, and significantly increases the union rate of occipito-cervical arthrodesis.
SURGICAL TREATMENT OF OCCIPITO-ATLANTO-AXIAL COMPLEX LESIONS IN CHILDREN Pietro Spennato, Armando Rapana`°, Claudio Ruggiero, Giuliana Di Martino, Giuseppe Mirone, Giuseppe Cinalli Department of Pediatric Neurosurgery, AORN SantobonoPausillipon, Naples, Italy; °Department of Neurosurgery, P.O. S. Sebastiano, Caserta, Italy Introduction: The occipital-cervical junction (OCJ) may be affected by a wide spectrum of congenital, acquired and traumatic lesions. We report our experience with five pediatric cases. Materials and methods: Five patients aged 7 to 14 years affected by OCJ lesions were surgically treated at our department. Three patients had congenital syndromes with secondary instability (Goldenhar syndrome, Rubinstein-Taybi syndrome and mucolipidoses type I), 1 patient presented an acquired C1-C2 subluxation (Grisel’s
873 syndrome), and 1 patient presented a type 2 odontoid fracture. The OCJ were studied with MRI, CT and dynamic X-ray. The vertebral artery was studied with MR or CT angiography. All patients underwent surgery through a posterior approach. Rigid fixation was obtained with rods and screws in the lateral masses of C1, C2 interlaminar screws and C3 articular screws. The stabilization involved the occiput in 3 cases, and was limited to C1-C3 in two cases. The patients with acquired diseases had normal neurological examination. The patients with congenital syndromes presented clinical manifestations ranging from a mild hemiparesis with severe flaccid tetraplegia (patient with muculipidosis). Two patients presented severe psychomotor impairment. Results: The mean follow-up was 24 months (range 6-48 months). Bone fusion was achieved in all cases with stabilization and improvement of neurological deficits. In one case, of a quadriplegic patient with mucolipidosis, replacement of a C1 lateral mass screw was necessary as well as a temporary tracheostomy. Discussion and conclusion: The rigid stabilization of the OCJ with rods and screws appears to be the preferred strategy, even in childhood.
LEFT THORACIC OUTLET SYNDROME (TOS) IN A PATIENT WITH IPSILATERAL CERVICAL DISC HERNIATION: THE IMPORTANCE OF A DIFFERENTIAL DIAGNOSIS FOR A CORRECT SURGICAL STRATEGY V. Maiola, A. Landi, A.G. Ruggeri, R. Delfini Department of Neurology and Psychiatry, Division of Neurosurgery, Sapienza University of Rome, Rome, Italy Introduction: The thoracic outlet syndrome (TOS) is a clinical condition characterized by the compression of the nervous and vascular structures in the lateral region of the neck, of the clavicle and of the nerve roots of the upper limb. Various opinions on TOS are found in the literature. Often, however, the patients are not correctly diagnosed. The diagnosis is mainly clinical, so an accurate clinical and radiologic analysis of the patients with a suspect of TOS is mandatory. We describe the case of a patient with a left cervical disc herniation (C6-C7) and with positive TOS maneuvers in which we applied a specific diagnostic algorithm to make a differential diagnosis. Materials and methods: A 55 year old male patient complains of left cervicobrachialgy with paresthesia and hypoesthesia of the ipsilateral upper limb. Cervical X-Ray is positive for cervical arthrosis. A CT scan showed a paramedian and left intrforaminal cervical disc herniation at C6-C7. The neurologic examination revealed pain at the pressure applied to the suprascapular region and hyposthenia of the upper limb. The patient referred paresthesia to the whole left upper limb and to the first three fingers of the left hand and hypoesthesia. Wright-Allen test, Tinel’s test and EAST test were positive on the left side. Following the algorithm, the patient completed the study with a cervical MRI, a cervical CT, an electromyography and Magnetic Resonance Angiography (MRA) of the thoracic outlet. The patient underwent a surgical intervention for a TOS, where a neurolysis of the cords of the plexus, which appeared tense, fixed and constricted by fibrous bands. The patient underwent neurophysiological evaluations 5 months after surgery. Results: MRI scan revealed multiple cervical disc protrusions from C5 to C7 and a cervical disc herniation at C6-C7. The CT scan confirmed the MRI findings. Electromyography and electroneurography showed a neurogenic damage without active denervation with a
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874 metameric distribution in C7 on the left side. MRA of the thoracic outlet showed the left subclavian vein with a reduced diameter and post-stenosis dilatation due to constriction by scalene muscles. The vessel had a normal diameter with the arm in a resting position. At the discharge the patient had a complete regression of the symptoms. Five months after surgery the patient underwent neurophysiological and clinical examination with no pain or paresthesia. After 9 months of follow-up the clinical condition was maintained. Discussion and conclusions: TOS is often underestimated and undiagnosed. It raises the question if the TOS can be identified as a distinct clinical entity. In this case, the use of the algorithm was key in the correct differential diagnosis of what seemed to be a cervical disc herniation, and helped plan the correct surgical strategy. In our opinion, an accurate clinical and instrumental examination, together with the application of the clinical and radiological algorithm, can help in the differential diagnosis of TOS.
TREATMENT OF CERVICAL TRAUMA IN PEDIATRIC AND ADOLESCENT PATIENTS: OUR GUIDELINES
Eur Spine J (2015) 24:872–903 surgery is significantly associated with neurological improvement and reduced length of hospital stay. Methods: This is a retrospective analysis of case studies. We evaluated 283 patients with traumatic lesion of the lower cervical spine (C3-C7) operated on between January 95 and June 14. We considered gender, etiology of the trauma, the presence of other associated injuries, type of spinal injury, timing of surgery, surgical approach, and outcome. Results: Among patients with complete spinal cord lesion operated on within 24 h, 24 % showed a significant clinical improvement; among those operated on later, none showed clinical change. Among patients with partial spinal cord lesion operated on within 24 h, 88 % showed a significant clinical improvement; among those operated on later, a similar proportion (89 %) showed clinical improvement. Conclusions: there are currently no standards related to the role and timing of decompression in spinal cord trauma. Urgent decompression and stabilization is a reasonable solution and can be performed safely. Early surgery resulted in significant neurological improvement in patients with complete and partial lesions. In patients with partial lesions, surgery performed within and after 24 h yielded the same results.
Marco Crostelli, Osvaldo Mazza, Massimo Mariani, Dario Mascello Spine Disease Unit, Ospedale Pediatrico Bambino Gesu`, Rome, Italy Introduction: Cervical traumas are not frequent in paediatric and adolescent patients. They are usually caused by distortion or flexion– extension injuries and should be promptly and properly diagnosed and treated to avoid permanent damage. Materials and methods: In OPBG Spine Disease Unit we elaborated guidelines for diagnosis, immobilization, imaging and treatment of paediatric and adolescent patient cervical trauma, in order to increase treatment efficacy. From 2006 to 2013 we treated 210 patients with cervical trauma, mean age 10 years and 6 months, of which 70 were under 10 years of age. In 20 cases we performed instrumented arthrodesis by posterior approach, in 5 cases by sublaminar steel wires (2 patients under 36 months of age), and in 15 cases rigid instrumentation with rods, hooks and screws (5 patients under 10 years of age). Results: Mean follow up is 4 years. We had no major complications. In 2 cases we had sublaminar wires rupture and in 1 case one screw mobilized, without affecting the arthrodesis in any of the 3 cases. Discussion and conclusions: Surgical treatment on cervical instability in paediatric patients is challenging. Rigid instrumentation could obtain a more stable arthrodesis, but increases complication risks. In the past great part of the literature limited the use of rigid instrumentation to children over 10 years of age and the use of sublaminar wires to children over 3 years of age. In our experience the limit in the use of rigid instrumentation in children is set by anatomical dimensions and not by patient age.
CONSIDERATIONS ON THE TIMING OF SURGERY IN CERVICAL SPINAL TRAUMA Cappelletto B, Trevigne MA, Copetti E, Veltri C, Giorgiutti F Chirurgia Vertebro-Midollare e Unita` Spinale, Azienda OspedalieroUniversitaria ‘‘Santa Maria della Misericordia’’, Udine, Italy Introduction: Prevention is a key point in limiting traumatic spinal cord lesions. In the case of spinal cord damage, pharmacological therapy with high doses of methylprednisolone has proven dangerous and of uncertain efficacy. The role and timing of surgery remains controversial. Animal studies show that neurological recovery is better in the case of early decompression. In numerous studies, early
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CERVICAL CHORDOMA: OUR EXPERIENCE IN THE LAST 5 YEARS G. Beggio, L. Rossetto, L. Gazzola, M. Mazzetto, P. Cervellini U. O. Neurochirurgia, Ospedale San Bortolo, Vicenza, Italy Introduction: Chordoma is a neoplasm of low to intermediate malignancy characterized by an aggressive behavior. The surgical treatment should be based on an en bloc removal that is complicated in the cervical region due to anatomical peculiarities. Matherials and methods: In the last 5 years 2 patients affected by cervical chordoma were admitted to our Unit. The patients presented with involvement of 2 and 3 vertebral bodies, respectively. In both cases the chordoma caused a compression of the spinal cord and consequent myelopathy. Both patients underwent emergency and staged surgery. The surgical approach was characterized by vertebral somatectomy and consequent vertebral reconstruction, laminectomy and artrectomy with anterior and posterior arthrodesis. Results: The patients were followed up for 5 and 4 years respectively. One patient completed the treatment by adding radiotherapy and presented a recurrence of the chordoma with consequent neurosurgical reoperation by anterior approach. Discussion and conclusions: Chordoma is a neoplasm that requires a radical surgical treatment. In the reported cases this could have required bilateral vertebral ligation and contiguous cervical nerve roots exeresis with consequently unacceptable neurological deficits. Moreover a radical surgical removal was not predictable because of peridural localization of the disease. Based on the reported follow up we believe that the staged approach is a valid surgical option for the cervical localization of chordoma.
SIMPLE LAMINECTOMY VERSUS INSTRUMENTED LAMINECTOMY IN THE SURGICAL TREATMENT OF CERVICAL MYELOPATHY G. Gargiulo, M. Girardo, P. Cinnella, A. Coniglio, S. Aleotti Spine Unit, CTO Turin, Italy Introduction: Posterior decompression is the treatment of choice in multilevel cervical myelopathy. The authors report their experience in the treatment of cervical myelopathy with simple and instrumented
Eur Spine J (2015) 24:872–903 laminectomy to define indications and limits comparing late instability, progressive kyphosis and neurological deterioration. Material and method: Of 40 patients affected by cervical myelopathy, 20 were treated with simple laminectomy, and 20 by laminectomy and instrumentation. The mean age was of 71 years (5877). 31 were male, and 19 were female. Neurological status was assessed according to the Nurik scale (4 grade 2, 31 grade 3, 5 grade 4). Clinically 13 (30 %) had pain with a VAS score of 7 (5-9). Cervical lordosis (C2-C7) was 15°Cobb (2°-19°). Segmental instability was present in 7cases (17 %). 12 patients had a severe comorbidity. Surgical procedure was chosen based on the cervical lordosis (limit 10°), stability and patient’s general status. Laminectomy was extended from C3 to C7, as was the synthesis in the instrumented cases. Dural injury and facet joint violation without neurological consequences occurred in two cases (5 %) intraoperatively. One instrumented case (2 %) suffered delayed surgical wound healing. All patients used a brace for 45 and 30 days, respectively. Results: At the minimum follow-up of 5 years (5-8) 37 patients (92 %) improved in the neurological status (Nurik grade 0 in 15, grade 1 in 13, grade 2 in 7, grade 3 in 2). The neurological result worsened in 3 patients (8 %) that had undergone simple laminectomy (grade 2 in 1, grade 3 in 1, grade 4 in 1) with cervical pain in 2 (5 %) patients (VAS 7). These patients were older and presented severe neurological status and comorbidities. 5 cases (12 %), of which 3 instrumented, complained of cervical pain at cervico-thoracic junction (VAS 3). In simple laminectomy lordosis decreased by 11° while maintaining normal cervical spine excursion, whereas lordosis was preserved in the instrumented group. Neither junctional instability nor mobilization of the hardware was observed. Degree of arthrodesis was not measurable. Conclusions: No significant differences were observed between simple and instrumented laminectomy in terms of neurological outcome. In patients treated with simple laminectomy, degenerative changes ensured stability in older patients with or without comorbidity. Instrumentation should be reserved for cases with preoperative instability, reduced lordosis (below 10°) or mild flexible kyphosis, with significant neck pain, in combination with foraminotomy. Osteoporosis and poor bed for arthrodesis are not a contraindication for fixation. Instrumentation in younger patients may, however, increase the risk of junctional, late instability. The final choice must be tailored on an individual basis considering the benefits and risks of the two treatments.
875 Results corroborate that ACDF and TDA are feasible surgical techniques for the treatment of cervical herniated disc. Our experience shows similar short-term outcome and risk for the development of a degenerative ASD.
TWO-LEVEL CERVICAL CORPECTOMY, AUTOLOGOUS ILIAC CREST GRAFT AND RIGID PLATE SYNTHESIS: A RETROSPECTIVE STUDY WITH 3 YEAR FOLLOW-UP C. Doria, F. Milia, M. Gallo, A. Zachos , M. Balsano , G. Angiolini Orthopaedic Department, University of Sassari (Italy); Orthopaedic Department Santorso Hospital, AUSSL 4 Schio (Italy) Introduction: There is no clear evidence in the literature supporting two-level vertebral corpectomy with iliac crest graft rigid plate synthesis. We present our experience with the two-level cervical corpectomy and subsequent reconstruction. Materials and methods: Each patient was classified according to the ‘‘Nuricks Grade (1972)’’ and ‘‘Orthopaedic Association score (mJOA)’’ modified (1991). Recovery rates were calculated. All patients were subjected to a two levels vertebral corpectomy, autologous graft from the iliac crest and synthesis with titanium plate. Results: After surgery the score mJOA had risen to 15.5. The average recovery rate was 69 %. An average kyphosis correction of 25° was obtained in all patients (n. 8). Among the postoperative complications (25 %) we report two cases of vocal cord paralysis on the side of surgical access due to neuro-apraxia of the recurrent laryngeal nerve, and 2 patients (25 %) complained of transient pain at the donor site. Conclusion: Excellent results can be achieved with a two level corpectomy and autologous iliac crest graft. This technique is simple, convenient and secure. If the bone graft is harvested from the iliac crest following a standard approach between the anatomical landmarks, donor site pain, which is often only transient, is significantly reduced.
ON THE TREATMENT OF CERVICAL MULTIPLE DISCOPATHIES: WHAT EVIDENCE ON LEVEL SELECTION TO TREAT? M. Costaglioli, P. Sannais, C. Pani Casa di Cura Polispecialistica Sant’Elena, Cagliari, Italy
‘‘CERVICAL DISC ARTHROPLASTY: INDICATIONS AND LIMITS: OUR EXPERIENCE’’ Giovanni Andrea La Maida1, Marcello Ferraro1, Leoanrdo Zottarelli2, Donatella Peroni1, Francesco Luceri2, Bernardo Misaggi1 Orthopaedic Institute Gaetano Pini, Milan, Italy; 2Universita` degli Studi di Milano, Milan, Italy 1
Anterior cervical arthrodesis is the current gold standard for the surgical treatment of cervical degenerative disc disease. Over the past few years scientific publications highlight the importance of Adjacent Segment Disease (ASD) after Anterior Cervical Discectomy and Fusion (ACDF), and propose cervical disk replacement also known as Total Disc Arthroplasty (TDA) as a viable alternative to the use of cages in cervical herniated discs. In the view of current scientific background, the goal of this 10-year retrospective study is to compare ACDF and TDA. We retrospectively evaluated 35 middle-aged patients who underwent a surgery with an average follow up of 24 months. 20 patients underwent ACDF and 15 patients underwent TDA.
Keywords: Cervical fusion, Selective surgery, Anterior approach Objective: Cervical discectomy and arthrodesis by anterior approach is a widely used technique for the treatment of degenerative pathologies of the cervical spine. In a large number of cases, there are multiple levels of degeneration that characterize the disease. The aim of our study is to verify whether there is evidence that can guide the surgeon in the choice of selective surgery strategy in multiple levels disease to avoid overtreatment with increased invasiveness and potential complications. Materials and methods: This is a retrospective study of 37 patients treated for cervical disc disease on various levels, suffering from neck pain or cervicobrachialgia. Radiculopathy was due to herniated disc compression with foraminal and canal stenosis. Selective surgery was performed at the level considered symptomatic. A complete resolution of symptoms was achieved in 90.7 % of cases. Conclusion: The choice of what level requires surgery depends on several factors: the clinical and radiologic evidence must be studied carefully. Furthermore, alterations of the cervical spine in the sagittal plane in relation to the dorsal and lumbosacral curves must be taken into consideration.
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876 There is no established protocol that unequivocally guides the surgeon in choosing the number of level to treat. The literature increasingly supports treating only the symptomatic level, while avoiding unnecessary extensions of surgery, and respecting and restoring parameters of sagittal balance. References: Mauro Costaglioli, MD PhD C.D.C. Polispecialistica S’Elena U.O. Spine and Cervical and Mini Invasive Surgery Quartu S.E. Cagliari, Italy E.Mail:
[email protected]
Eur Spine J (2015) 24:872–903 was observed in 10 % of the patients; and clinical results are similar to historical fusion controls.
THE M6-C CERVICAL DISC PROSTHESIS: CLINICAL AND RADIOLOGICAL OUTCOMES WITH LONG-TERM FOLLOW-UP S. Forcato1, S. Trungu1, F.M. Polli1, M. Cimatti1, M. Miscusi2, A. Raco1 1
Sapienza of Rome, AO Sant’Andrea Hospital, Rome, Italy; Sapienza of Rome, ICOT, Latina, Italy
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CLINICAL AND RADIOLOGICAL STUDY AFTER BRYAN CERVICAL PROSTHESIS IMPLANTATION: FOLLOW-UP OF TEN YEARS Roberto Assietti, Chiara Liberati Divisione di Neurochirurgia, Ospedale Fatebenefratelli e Oftalmico, Milano, Italy Introduction: Anterior cervical disc fusion is considered the surgical treatment of choice for degenerative cervical disease. According to several studies, however, there are important restrictions related to the procedure, both in the kinematics and biomechanics of the cervical spine, as well as a potential acceleration of adjacent cervical segment degeneration. Cervical arthroplasty is an alternative to fusion that potentially offers advantages, which include the preservation of the cervical segmental motion and a potential absence of the disc degeneration of the adjacent segment. However, the literature refers only to short-term follow-up. Few long-term studies evaluating effectiveness, function and safety have been published. Materials and methods: From 2003 to 2008, 150 patients received cervical arthroplasty by means of Bryan prosthesis (Medtronic) at our hospital. Sixty patients were followed up clinically and radiologically. Pre and post-operative data with a follow-up of 10 years have been collected, including: Neck Disability Index, Visual Analogic Scale for pain and SF-36, standard and morphodynamic cervical X-rays using the classification published by McAfee for the lumbar spine for the heterotopic ossification. 3 points have been analyzed: the percentage of heterotopic ossification identifiable radiologically; the conservation and improvement of the motion at the treated cervical segment, and finally the percentage of degeneration of the adjacent segment. Results: Fifty-six patients out of 60 returned to their work activities without any limitation. The radiologic study showed heterotopic ossification in 18 patients out of 60 (30 %). At 120 months a degree 1 of ossification was found in 10 patients, a degree 2 in 2 patients, a degree 3 in 4 patients and a degree 4 in 2 patients, according to the McAfee classification. A positive correlation was observed between the degree of ossification and the number of operated levels: with 2 levels of arthroplasty the degree of heterotopic ossification was higher. The degree of movement of the treated segments was of about 8.5° in the pre-operation period and increased to about 9.8° in the follow-up period. The degeneration of the adjacent level was observed in 6 patients out of 60 (10 %): 5 of these patients already presented an asymptomatic beginning of adjacent disc degeneration. Discussion and conclusions: Ten years after the implantation of Bryan cervical prosthesis clinical and radiological data are not different from the data for short-term follow-up. It was possible to confirm the following points: in 30 % of the patients (18) heterotopic ossification of the treated segment was radiologically observed, 27 % of which (5) had undergone two-leve cervical arthroplasty; there is a lack of correlation between degree of cervical motion and degree of heterotopic ossification; the occurrence of adjacent level degeneration
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Introduction: Cervical disc arthroplasty (CDA) has been gaining popularity as a surgical alternative to anterior cervical discectomy and fusion. CDA is meant to preserve the range of motion (ROM) at the operated level while providing biomechanical stability and global neck mobility and may result in a reduction in adjacent-segment degeneration. The aim of this observational study is to evaluate the clinical outcomes and the preservation of ROM in patients who underwent CDA with the M6-CÒ cervical disc prosthesis (Spinal Kinetics, Sunnyvale, CA, USA) after 5 year follow up. Methods: Fifteen patients with single-level soft cervical disc hernation with radiculopathy were enrolled and underwent CDA with the M6-C disc prosthesis. Clinical outcomes included Neck Disability Index, the 36-Item Short-Form Health Survey, neck and arm pain scores. ROM was assessed with dynamic plain radiographs. Clinical and radiographic outcomes were evaluated preoperatively, and at 1, 6, 12, 24, 36 and 60 months postoperatively. Results: The mean patient age was 39.7 years (range 35–57 years) and all of them completed 5 years of clinical follow-up. ROM measurements demonstrated motion preservation at the operated level even after 5 years of follow-up (p \ 0.05). Significant clinical improvement in all outcome scores (p \ 0.05) both postoperatively or at all follow-up points were found. No major complications, infections, implant failure, or pull-outs were observed. Conclusions: M6-C disc prosthesis is a safe and effective treatment for CDA and has the potential to preserve motion with stable clinical improvement even at 5 years follow-up.
DEGENERATIVE PATHOLOGY UNILATERAL OBLIQUE PLIF USING POROUS TANTALUM CAGES L. Balla, N. Bellon, N. Isceri, A. Maron Ospedale di Monselice (PD), Monselice, Italy Background: The use of a unilateral PLIF associated with pedicle screws is know common in degenerative lumbar surgery, due to the continuous development of materials and shapes of cages. One of the most recent materials is trabecular metal (porous tantalum), which has a cellular structure similar to the bone and promotes osteointegration and osteoinduction. The low modulus of elasticity determines reduction of stress-shielding, while the high coefficient of friction prevents loosening. Methods: Between 2012 and 2014, we treated 26 patients (14 men and 12 women, aged between 29 and 64 years) with lumbar circumferential fusion, using unilateral oblique PLIF and pedicle screws. A single level was performed in 19 cases, and a two level fixation (always with PLIF in a single level) in the other 7 cases. We
Eur Spine J (2015) 24:872–903 performed a unilateral PLIF from the symptomatic side, using cages in porous tantalum (TM Ardis). Results: Patients were and will be checked at 3-6-12-24 months, assessed by VAS and ODI, and screened by standard x-ray. The follow-up at 12 months showed, in 19 patients, excellent or good results in 16 cases (84 %). We had two cases of dural lesion, repaired and healed without sequelae. Conclusions: Several authors highlighted the advantages of unilateral over bilateral PLIF, with reduced risk of radicular lesions, less extensive laminectomy, reduced surgical time and cost savings, and a similar rate of fusion. Cages in porous tantalum have characteristics that assure stability and osteointegration, they are self-distracting and anatomically fit to the biconcave shape of the disc space, allowing for satisfactory restoration of segmental lordosis.
INTERSOMATIC CAGES AND SAGITTAL BALANCE R. Bassani, R. Cecchinato, C. Morselli1, A. Sinigaglia, G. Casero, C. Lamartina IRCCS Istituto Ortopedico Galeazzi, Milano, Italy; 1Dipartimento di Neurologia e Psichiatria, Divisione Neurochirurgia, Universita` ‘‘Sapienza’’, Rome, Italy Introduction: Interbody fusion has become increasingly popular in the treatment degenerative disc treatment, given the advantages of immediate anterior support and higher fusion rate. In addition, there is rising interest on the effect of interbody fusion on sagittal balance and its corresponding effect on the clinical outcome of patients. Aim of the study: The aim of this study is to demonstrate how interbody cages can modify sagittal pelvic and lumbar parameters. In this retrospective study two homogeneous groups of patients treated in the same Division with interbody fusion through anterior (ALIF) or transforaminal (TLIF) approach were compared by evaluating pre and postoperative local and regional lordosis. Materials and methods: Pre and postoperative lumbosacral x-rays were retrospectively analyzed. A total of 108 patients (M = 48, F = 60, mean age of 49) treated in our division with ALIF were compared to a group of 90 patients (M = 48, F = 52, mean age of 56.5) treated with TLIF technique. Each group was divided in relation to treated levels: single level L3-4, single level L4-5, single level L5S1, multilevel. For each subgroup, lumbar lordosis, local lordosis, anterior and posterior disc height were measured on lumbosacral standing x-rays. All the measures were taken preoperatively, postoperatively and at 4 months follow-up. Results and conclusions: ALIF showed better results than TLIF in pelvic and spinal sagittal parameters restoration in our patients. This was particularly evident in local lordosis restoration, global lumbar lordosis and interbody height. A higher lordosis of the lower lumbar spine allows for better distribution of regional lumbar lordosis, with a higher efficacy on restoration of sagittal balance parameters and in recovery of pelvic parameters alteration.
DEGENERATIVE SPINE IN THE ELDERLY: SURGICAL OR CONSERVATIVE TREATMENT? V. F. Paliotta, B. Magliozzi, G. Martelli, A. Tucciarone Universita` Cattolica, Rome, Italy Introduction: The incidence of degenerative aging spine is increasing due to the population’s increasing mean age.
877 Materials and methods: Authors present a series of 843 cases. All patients complained of back pain due to spondilodiscoarthrosis, with a VAS score of 8, and mean age of 76 years. All patients underwent X-ray, MRI or multiplanar CT. In all cases degenerative changes were observed with severe lumbar stenosis in 27 %, foraminal stenosis in 32 %, scoliosis in 26 %, L5/S1 spondylolisthesis in 12 %, L4-L5 spondylolisthesis in 19 %. Neurological symptoms were present in 47 % of the patients; radiculopathy in 23 %, neurogenic claudication in 98 cases. All patients were treated conservatively for 1-6 months. Surgical treatment was needed only in 21 % of cases. In 27 % of the cases a minimally invasive treatment was performed, in 72 % decompression and fusion was carried out. In 5 patients only a focal decompression was carried out because of poor general conditions. Results: The mean follow-up was 3 years. Excellent results were reached in 91 % of the surgically treated patients and in 78 % of the conservatively treated patients. All patients with neurological symptoms recovered. Discussion and conclusions: Conservative treatment can be carried out in the degenerative aging spine, but results are not always good. Better results are obtained by means of decompression and fusion, but the general conditions of the elderly may contraindicate surgery. Decompression without fusion is to be performed only in a few selected cases.
LUMBAR SPINE DEGENERATIVE DISEASES: INFORMATION TO PATIENTS AS A TOOL OF THERAPY G. Barbanti Brodano, A. Gasbarrini, S. Bandiera, S. Terzi, R. Ghermandi, C. Griffoni, S. Boriani Struttura Complessa di Chirurgia Vertebrale Oncologica e Degenerativa, Istituto Ortopedico Rizzoli, Bologna, Italy Introduction: The growing evidence of the complexity of degenerative spine diseases, commonly associated with ‘‘back pain’’, has led us to develop a research project aimed to compare the surgical and non-surgical treatment of degenerative spine diseases. Within this project it was decided to make an informative movie for patients suffering from three common degenerative diseases: lumbar disc herniation, spondylolisthesis and lumbar stenosis. Its purpose is to inform about the characteristics of spinal pathologies, their possible treatments and related risks and benefits, in order to support a practice of shared decision between doctor and patient that leads to the best possible outcomes for the individual patient. Materials and methods: The movie consists of 5 macrosequences that the user/viewer can browse through: 1. General Introduction leading to the ‘‘menu page’’. 2., 3., 4. Specific sequences related to disc herniation, spinal stenosis, spondylolisthesis. At the end of each part a common conclusion is linked. 5. Conclusions, where the possible surgical and non-surgical treatments for these diseases are discussed and the relevance of a shared and active participation of the patient is highlighted. In the movie selected patients from a series of case studies lead the viewer through the story of their personal experiences, and through the process of personal decisions making, providing a wide range of different possibilities, sometimes even conflicting. Results and discussion: The movie turns out to be an effective instrument and guide for patients suffering from degenerative spine diseases in the choice of a therapeutic treatment, leading a satisfactory improvement in their quality of life.
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878 CRITICAL ANALYSIS OF A SERIES OF ADJACENT SEGMENT DISEASE AFTER TLIF AND PLIF PROCEDURES Carlo Formica, Matteo Formica Clinica Ortopedica dell’Universita` di Genova, Genova, Italy The purpose of the study is to critically reconsider different and widely used surgical techniques such as TLIF and PLIF in the treatment of lumbar degenerative pathologies, while trying to understand the importance of maintaining the correct sagittal alignment to avoid adjacent segment disease (ASD). We retrospectively evaluated a group of lumbar ASD next to lumbar arthrodesis obtained with TLIF/PLIF technique. In the last 3 years 32 patients were diagnosed with ASD after TLIF/PLIF procedures. All the patients were reintervened with an extension of the arthrodesis to the adjacent degenerated segment. When possible an anterior wide lordotic cage was implanted in the first third of the intervertebral space using XLIF (22 cases) or ALIF (3 cases) techniques. Only 7 patients underwent PLIF/TLIF techniques associated with posterior Smith Petersen osteotomies and posterior compression. VAS back/leg pain and ODI were evaluated at the follow up (minimum 9 months – maximum 3 years). Standing X-ray films after surgery corroborated preservation of sagittal alignment. In 19 patients an MRI at 1 year revealed no signs of disc degeneration above and below the instrumented area. Post-operative segmental LL and spino-pelvic parameters restoration play an important role in improving the clinical outcome. Furthermore, the insufficient segmental lordosis obtained with a TLIF or PLIF procedure produces a stressful adjacent compensatory lordosis that could lead to the development of a compensatory retrolisthesis. We consider these findings as the main possible cause of ASD.
BIOMECHANICAL AND CLINICAL STUDY OF SINGLE POSTERIOR OBLIQUE CAGE POLIF IN THE TREATMENT OF DEGENERATIVE DESEASES OF THE LUMBAR SPINE A. Zagra, L. Scaramuzzo, F. Galbusera, L. Minoia, M. Archetti, F. Giudici IRCCS Istituto Ortopedico Galeazzi, Milan, Italy Introduction: The aim of the study was to evaluate the biomechancal stability and the clinical efficacy of a lumbar intebody fusion obtained by single oblique cage implanted by a posterior approach. Method: Before the clinical application, POLIF was compared to PLIF and TLIF by means of 3 finite element mathematic models (FEM). From October 2013 to October 2014 94 patients (41 male, 53 female) underwent intebody fusion by POLIF with posterolateral fusion and pedicle screw fixation. Clinical outcome was evaluated by Visual Analog Scale (VAS) and SF-12. Radiographic evaluation included preoperative standard and dynamic X-ray, preoperative MRI, and X-ray immediately postoperatively and later at regular intervals. Cage positioning was evaluated by targeted CT scan. Results: 3 FEM showed no statistical significant differences for resistance to compression (PLIF = 7150 N/mm, TLIF = 8350 N/mm, POLIF = 8350 N/mm) and flexion–extension forces (PLIF = 65/130 Nm/°, TLIF = 87/163 Nm/°, POLIF = 65/130 Nm/°). Patients mean age was 50 years (24-77). Mean preoperative VAS score was 7.1 (5.98.3), which decreased to 2.1 (1-5) at 4 months minimum follow-up. Mean preoperative SF-12 value was 34.5 % (25.7 %-50.4 %), which increased to 75.4 % (68.2 %-99.4 %) at 4 months minimum follow-
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Eur Spine J (2015) 24:872–903 up. Cage positioning was optimal in 88 % of cases, satisfactory in 12 %. At last follow-up all patients showed a good fusion rate and no hardware failure. Discussion: POLIF associated to instrumented posterolateral fusion allows reduction of operative time, complications, and costs. It requires a short learning curve but provides a biomechanical stability comparable to other surgical techniques.
INTERSOMATIC AND POSTERIOR ARTHRODESIS IN THE MONOSEGMENTAL LUMBAR DEGENERATIVE DISEASE: PROSPECTIVE STUDY ON 27 PTS WITH A FOLLOW UP OF 18 MONTHS M. Cimatti, S. Forcato, A. Frati, A. Raco Sapienza of Rome, AO Sant’Andrea Hospital, Rome, Italy Introduction: Numerous surgical techniques for fusion in degenerative lumbar spine disease are described in the literature. They span from stand-alone devices to transpedicular screws fixation with or without anterior fusion. The aim of this prospective study is to analyze the clinical and radiologic outcome in patients with monosegmental lumbar degenerative disease treated by anterior fusion with intersomatic expandable cages in addition to posterior fusion with interspinous fusion devices. Materials and methods: The study included 27 patients affected by monosegmental lumbar degenerative disease. The exclusion criteria are spondylolysis, oncologic and trauma pathology, more than 2 levels interested. The patients were evaluated pre-operatively, postoperatively and up to 18 months of follow up using the SF-36 Questionnaire, Oswestry disability index, VAS, X-ray and MRI. Results: The patients’ mean age was 45.7 years old. Twelve patients were affected by DDD, 10 pts were affected by a degenerative anterolisthesis, while 5 patients presented a recurrent herniated disc. In 20 pts the interested level was L4-L5, in 4 cases L5-S1, and the interested level was L3-L4 in only 3 cases. ODI and SF-36 improvement was statistically significant (p \ 0.05). No implant was removed and no implant failure or infection occurred. Only one patient presented a CSF fistula, which was treated conservatively. Conclusion: This procedure resulted safe and effective. It can be considered a less invasive procedure compared to conventional open fixation, due the absence of exposition of the articular complex and preservation of the adjacent vertebra.
PRELIMINARY EXPERIENCE WITH A NOVEL SYSTEM OF LUMBAR PEDICLE LENGTHENING FOR SURGICAL TREATMENT OF MODERATE LUMBAR STENOSIS R. Maugeri*, L. Basile*, D. G. Anderson**, D. G. Iacopino* *Clinic of Neurosurgery, University of Palermo, Palermo, Italy; **Department of Orthopaedic and Neurological Surgery at Thomas Jefferson University, Philadelphia, USA Introduction: Lumbar spinal stenosis (LSS) is defined as a reduction in the diameter of the spinal canal and/or neural foramina. A variety of nonoperative measures have been advocated for treating LSS, including physical therapy, spinal injections, and medications. Open lumbar laminectomy is the primary surgical therapy for LSS.
Eur Spine J (2015) 24:872–903 Unfortunately, open laminectomy may pose an unacceptable risk to some older individuals with significant medical comorbidities and LSS, besides the risk of a future iatrogenic instability. A new procedure for LSS uses bilateral pedicle-lengthening osteotomies to expand the dimensions of the spinal canal and neural foramen moving the anterior elements away from the posterior elements, resulting in expansion of the spinal canal and neural foramen. The object of this study was to define the postoperative outcomes and complications of this surgical option. Methods: A cohort of 10 patients with symptomatic LSS was treated by pedicle-lengthening osteotomy procedures at 1 or 2 levels. Results: Clinically, significant improvement was observed in the mean values of each of the outcome scales. Most patients demonstrated an increase in the mean cross-sectional area of the spinal canals in the 6-month CT scans as compared with the preoperative CT scans. Conclusions: The pedicle-lengthening osteotomy is a new minimally invasive technique for correcting lumbar spinal canal stenosis. Longer-term follow-up is required.
CANNULATED LATERAL INTERBODY FUSION (‘‘CLIF’’): A NEW SURGICAL TECNIQUE L. Antonelli, L. Tarricone Department of Orthopaedic and Traumatology, Private Hospital ‘‘Domus Nova’’, Ravenna, Italy Abstract: A new surgical technique for the interbody fusion is presented. After discussing the theoretical basis, the anatomic studies and supporting bibliography, we present step by step the surgical technique and pearls. The key idea is that the instruments have to ‘‘slide’’ past the muscular, neural and vascular elements without creating any traction or compression. Materials and methods: In the past five years 35 patients requiring interbody fusion for degenerative disease of the spine were recruited for the study. In the first 25 patients the first version of surgical instrumentation (F.V.S.I.) was used, whereas the definitive version of surgical instrumentation (D.V.S.I.) was used in the last 10 cases. Each case was fully documented. The time of procedure, as well as complications, blood loss, global time (anterior and posterior) were recorded. Oswestry and VAS scores were obtained for all patients. Results: The mean time to insert the cage was 21 min with the F.V.S.I and 14 min with the D.V.S.I. The mean total blood loss (anterior and posterior phase) was 250 cc. The complications with F.V.S.I. included 2 cases with thigh pain, 1 case with paraesthesia and 3 cases with pain at lateral surgical site. Whereas the complications registered with D.V.S.I. were: 1 patient presenting paraesthesia on anterior thigh that has been resolved during the 3 weeks following surgery and 2 cases complaining of pain at the level of lateral surgical site. In both situations there were neither femoral nerve injuries nor other motor nerve injuries. The mean global time for anterior and posterior phases was 246 min with instrumented posterior arthrodesis and 152 min with dynamic posterior stabilization. Conclusion: The ‘‘CLIF’’ surgical technique is safe and reproducible. No major complications, such as femoral nerve injury, occurred. Only a few patients complained of temporary thigh pain. This technique provides many advantages. The patient can be positioned in the prone position during all the procedure time (anterior and posterior), allowing for control of lumbar lordosis during surgery. The mean time to insert the cage is only 14 min with D.V.S.I. Finally, the global costs of the surgery are significantly lower.
879 TRANSFACET SCREWS FIXATION WITH THE FACET-LINK: CLINICAL AND RADIOLOGIC OUTCOMES WITH 16 MONTHS FOLLOW-UP S. Forcato, A. Pietrantonio, S. Trungu, L. De Martino, A. Raco Sapienza of Rome, AO Sant’Andrea Hospital, Rome, Italy Introduction: Lumbar spinal stenosis, whether foraminal or central, and low-grade degenerative spondylolisthesis are frequently associated with facet joint effusion on MRI, defined as a measurable area of high signal intensity within the facet joint in the axial T2 images. These effusions denote facet joint degeneration, which can be considered cause of the low back pain. The aim of this prospective study is the evaluation of the clinical and radiologic outcome of patients treated with transfacet fixation. Materials and methods: Patients affected by radiologically-demonstrated mild or moderate monosegmental central lumbar stenosis were included in this prospective study. Exclusion criteria were: isthmic spondylolisthesis, grade II-IV degenerative spondylolisthesis, oncological disease with signs of progression, severe osteoporosis, and multilevel involvement. All patients underwent bilateral laminotomy, foraminotomy and one level facet fixation with two transfacet screws connected to a cross link (Facet-LinkÒ, Inc., NJ, USA). Pre and postoperative clinical (ODI, SF-36) and radiological (X-rays, MRI, CT) data were collected and analyzed. Results: 10 consecutive patients, mean age of 65.7 years, are included in this study. Mean follow-up was 16 months. L4-L5 level was involved in 7 patients and L5-S1 in 3. ODI and SF-36 indicated improvement at last follow-up (p \ 0.05). Only one patient (BMI [ 35.3 kg/m2) showed a partial pull-out of one screw that did not require reintervention. No implant failure or infection were detected. Conclusions: The Facet-LinkÒ proved to be a safe and effective treatment option in patients with single level lumbar spinal stenosis with clear signs of facet joints degeneration.
DO SURGICAL EXPECTATIONS CHANGE DEPENDING ON FIRST TIME SURGERY OR REOPERATION? A PROSPECTIVE COHORT STUDY IN LUMBAR SPINE SURGERY Francesco Ciccolo1, Gemma Vila Canet2, Augusto Atilio Covaro2, Ana Garcia De Frutos2, Maria Teresa Ubierna Garces2, Enric Caceres Palou2 1
Scuola di Specializzazione, Universita` di Messina, Messina, Italy; Hospital Universitari Quiron Dexeus, Barcelona, Barcelona, Spain
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Introduction: Patient satisfaction after spinal surgery can be influenced by the fulfillment of their expectations. The purpose of this study was to assess the difference in patient expectation depending on whether the patient was undergoing first time surgery or reoperation in degenerative lumbar spine procedures. Materials and methods: A consecutive prospective cohort of patients listed to be operated was selected including different lumbar degenerative etiologies. The study group was divided into two groups, patients going to be operated for the first time and patients that had already been operated, stratifying a sub-group based on recent surgery group (less than 1 year) or earlier surgery. All patients completed a set of questionnaires including: modified version of the NASS lumbar spine expectation questionnaire, lumbar and radicular VAS, ODI and Zung depression scale.
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880 Results: Sixty-six patients were enrolled, 22 were previously operated patients (15 due to a previous failed procedure) and 44 underwent first time lumbar surgery. Mean lumbar VAS score was 7 (dt 2.8), mean radicular VAS score was 7.2 (dt 2.8), mean ODI was 44 (dt 8), and mean Zung test 38 (dt 10). No differences were found in ODI, VAS and Zung results between two groups. We couldn’t find statistically significant differences in surgical expectations between reoperated and first time surgery groups (p [ 0.05). Both groups have really high expectations, expecting about 80 or 100 % improvement in most of the 8 questionnaire items. Discussion and conclusion: Previous failed lumbar surgical procedure doesn’t worsen patient expectations for the following operation. Both groups express high expectations for their surgery.
POSTERIOR INTERBODY FUSION IN SEVERE LUMBAR SPINAL STENOSIS
Eur Spine J (2015) 24:872–903 Matherials and methods: We retrospectively evaluated 80 patients aged between 20 and 77, with an average follow up of 4 years. All of them had performed standard and dynamic X-rays and MRI in the preoperative planning. In a selected group of patients post-operative MRI was performed at 1 year, to assess the state of disc hydration after dynamic neutralization. The clinical assessment scales used were ODI score and VAS. Results: We compared the objective and subjective results in the 15 % of the failures, defined by a severe ODI score (12.5 % of the sample) or serious score (4.3 %), with a VAS score between 6 and 8 points. The postoperative X-rays demonstrated a reduction of sagittal indexes greater than 3.5° in the levels treated, both in neutral position and in extension, with an unchanged or varied flexion within 0.6°, possibly the cause of sagittal imbalance. Discussion and conclusion: This study encouraged us to continue using DYNESYS. Mobile stabilization limits more the extension than flexion and neutralizes stress on the spine. A correct preoperative planning, a careful selection of the patients, and a meticulous execution of the technique are mandatory to avoid clinical failures.
A. Toscano, M. Nanni, D. Fabbri, M. Chehrassan*, F. Perna*, C. Calamelli*, C. Faldini Dipartimento Rizzoli-Sicilia, Bagheria, Italy; *Istituto Ortopedico Rizzoli, Bologna, Italy Introduction: Severe lumbar spinal stenosis typically occurs in the elderly, and determines low back pain, radiculopathy and neurogenic claudication, eventually leading to a progressively debilitating condition. It can be caused by facet joint hypertrophy or intervertebral disc degeneration, which reduce the volume of the vertebral canal, or by instability. Aim of the paper: The aim of this paper is to evaluate the results of 56 consecutive patients affected by lumbar spinal stenosis managed by spinal fusion by a posterior approach. Materials and methods: Fifty-six patients affected by severe lumbar spinal stenosis were treated by decompression, posterior stabilization and interbody fusion by posterior approach. The surgical treatment was planned according to the following factors: pain and neurological involvement, severity of the stenosis, presence of instability, or presence of foraminal stenosis. The fusion was performed at a single level in 8 cases, at two levels in 13 cases, and at three or more levels in 35 cases. Results: Preoperatively, the mean VAS score was 8 ± 2. At the fiveyear follow-up, the mean VAS score was 2.3 ± 1.9. Thirty-two patients showed excellent results, 16 good, 6 fair and 2 poor results. No major complications were reported in our series. Conclusion: Posterior stabilization associated with interbody fusion is a suitable surgical option for severe lumbar stenosis. A precise study is necessary to give correct surgical indication, and to better determine the number of fused levels.
FAILURES IN DYNAMYC/HYBRID SPINE STABILIZATION WITH DYNESYS/DTO FOR DEGENERATIVE DISC DISEASE Marcello Ferraro1, Giovanni Andrea La Maida1, Donata Peroni1, Leonardo Antonio Zottarelli2, Francesco Luceri2, Bernardo Misaggi1 1 Orthopaedic Institute Gaetano Pini, Milan, Italy; 2Universita` degli Studi di Milano, Milan, Italy
Introduction: DYNESYS (dynamic neutralization system for the spine) is a mobile stabilization recommended in slight but symptomatic vertebral instability. We have been using the hybrid stabilization Zimmer DTO system in patients selected by age, clinical presentation, standard and dynamics X-rays and MRI.
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CLINICAL OUTCOME IN 42 PATIENTS AFFECTED BY SPINAL LUMBAR STENOSIS AND OPERATED FOR LAMINECTOMY AND DYNAMIC STABILIZATION M. Dobran, M. Iacoangeli, L. M. G. Di Somma, R. Benigni, V. Liverotti, R. Colasanti, D. Nasi, D. Brunozzi, C. Vaira, M. Scerrati Clinic of Neurosurgery, University of Ancona, Italy Introduction: This study has been performed to evaluate the clinical outcome in a series of 42 patients operated for spinal lumbar stenosis with dynamic or hybrid stabilization device. Materials and methods: We included 42 patients (24 males and 18 females), mean age 64.3 y/o. (range 49-77) operated at the Neurosurgical Clinic of Ancona from September 2008 to May 2014. All 42 patients were affected by spinal lumbar stenosis, associating to, in nine patients, with grade I spondylolisthesis. The indication for dynamic stabilization was wide laminectomy in patients with stenosis and discopathy (excluding patients with Pfirrmann 5) or spondylolisthesis, in order to prevent the degeneration of the cranial disc adjacent to a multilevel fusion (Pfirrmann 2-3-4). Preoperative clinical and radiological evaluation consisted in neurological examination, Visual Analogis Scale (VAS) and Oswestry Disability Index (ODI), preoperative MRI and dynamic X-Ray (CT scan for some patients.). We operated 18 patients at L4-L5 level, 4 patients at L3-L4, 15 patients at L3-L4-L5 and only 2 patients at L2-L3-L4-L5. The follow-up was from 6 months to 3 years after surgery. Results: The mean preoperative ODI was 35.2 % the VAS score was 7.2 while in the postoperative the ODI was 18 and the VAS 3.3. The scores improved in 17 out of 19 patients treated with the hybrid device, and for 20 pts out of 23 treated with the dynamic device. Only 3 patients reported no improvement. We had no postoperative complications. Conclusions: The dynamic and hybrid devices are a valid option to prevent post-laminectomy instability and to prevent degeneration of the cranial adjacent disc to a multilevel fusion.
MINIMALLY INVASIVE APPROACHES IN CALCIFIED THORACIC DISC HERNIATIONS: OUR EXPERIENCE FROM 1997 P. Cervellini, L. Rossetto, L. Gazzola, G. Zambon Department of Neurosurgery, City Hospital of Vicenza, Vicenza, Italy
Eur Spine J (2015) 24:872–903 Introduction: Since 1997 we performed minimally invasive approaches in 58 thoracic disc herniations. We used a thoracoscopic approach in 24 cases, a transpedicular approach in 28 cases and a postero-lateral approach in 6 cases. Materials and methods: The levels operated in the 58 patients were from T5 to T12. The 24 patients operated with thoracoscopic approach all presented a calcified median disc and presented signs of myelopathy. 8 of these underwent thoracoscopic-micosurgical extrapleural approach. In these cases selective ventilation of the contralateral lung was not necessary. The 6 cases operated with postero-lateral microsurgical approach had a calcified postero-lateral disc herniation with myelopathy. In the 28 cases operated with transpedicular approach, the disc herniation was lateral o paramedian. The disc herniation was calcified in 22 cases and soft in 6 cases. Motor and sensory evoked potential monitoring was used for all surgeries. Results: Blood loss was less than 100 cc in all the surgeries, with a mean hospital stay of 5 days. Myelopathy improved in 18 cases, whereas one patient presented slight temporary deterioration. In 2 cases of thoracoscopic approach group, a liquoral fistula resolved after lumbar external drainage. In the transthoracic extrapleural approach group the hospital stay was of 4 days. In one case of transpedicular approach a second postero-lateral approach was necessary for complete removal of disc herniation. Conclusions: All thoracic disc herniations can be removed with a minimally invasive approach. Thoracoscopic discectomy allows the removal of giant calcified median herniations. These approaches significantly reduce hospital stay and postoperative pain.
LUMBAR MICROINSTABILITY AS A HIGHLY RELEVANT CLINICAL AND LEGAL ISSUE: PRELIMINARY CLINICAL AND RADIOLOGICAL CLASSIFICATION AND TREATMENT ALGORITHM
881 Results: The analysis of the radiological examinations, together with the clinical examination, has been transferred on a diagram; the score obtained by each exam is based on the positivity or negativity to specific anatomic-pathological alterations. The score obtained allows the classification of lumbar MI in three groups; each group can benefit from a different treatment. An accurate analysis of the radiological and MRI examinations, with negative dynamic X-Rays, allows a diagnosis of MI, with a discrete positive predictive value. This has given us the possibility, together with a clinical and symptomatic history and neurological examination, to plan, in all cases, a more correct surgical strategy. Discussion and conclusions: The diagnostic examinations used in our study initially include dynamic X-Rays (the only examination to give certain data about the presence of lumbar instability), followed by CT and MRI, capable of furnishing predictive data, but not diagnostic certainty. The diagnosis of lumbar MI is the result of an accurate analysis of the clinical and radiological situation of the patients. Often, in microinstable patients, the clinical positivity in not related to radiological evidence in dynamic X-Rays, posing the surgeon in a difficult situation: whether to perform fusion in a patient without spondylolisthesis. This situation has both an intrinsic decisional issue and important legal consequences. On the basis of the analysis of dynamic X-Rays and of CT and MRI scan, one can perform a stand-alone decompression in an apparently stable patient, that can worsen after surgery, due to a non-diagnosed MI. On the other hand, a patient with MI in an initial phase can be fused even if considerable improvement can be obtained with conservative treatment. Our study provides an interesting point of view in order to solve this controversial problem, trying to shed light in a situation with a high level of uncertainty.
THE DOMINANT VERTEBRA AS MECHANICAL RATIO OF THE MULTI-LEVEL STABILIZATION IN LUMBAR SPINE Developed by
A. Landi, V. Maiola, C. Mancarella, F. Gregori, E. Maccari, N. Marotta, R. Delfini Department of Neurology and Psychiatry, Division of Neurosurgery, Sapienza University of Rome, Rome, Italy Introduction: The function of the spinal motor unit is to allow the movement of the spine in the three planes of space, the passive and active cushioning of the axial loads and the elastic resistance to the extreme degrees of movement. The phase of instable dysfunction of the degenerative cascade, interpreted as the phase of microinstability (MI), is often characterized by clinical symptoms (CS) that are not related to movement alterations on radiological examinations. In this context there are two main problems: 1) is it possible to establish with absolute certainty the presence of MI and to correlate it to the CS? 2) is it possible to formulate a correct indication for treatment without incurring in legal problems? Our study aims to identify movement alterations typical of MI in patients with specific CS and with non-diagnostic dynamic X-Rays, in order to find out which patients present dysfunction as a pain generator, and to avoid undertreatment. Materials and methods: All patients treated in our institution for lumbar discartrosic disease in the period between July 2012 and July 2014 were reviewed. An accurate evaluation of clinical history, CS, detailed neurological examination, standard and dynamic X-Ray, CT and MRI scan of lumbar spine was obtained in all patietns. We included in our study all patients with low back pain (LBP) or LBP and radicular pain in which dynamic X-Rays were negative for lumbar instability. We applied our diagnostic test and then our therapeutic algorithm. All patients have a 6-months follow-up and have undergone postoperative radiological examinations.
Dr. Luigi Tarricone, Dr. Luca Antonelli Private Hospital Domus Nova, Ravenna, Italy Introduction: The revolutionary 3D Diagnostic System, defined as DOCS (Dynamic Orthopaedic Computer System) was first presented in Italian National Congress of 2003. The system is able to precisely display vertebral mobility during walking process. The study has been initially based on a monitored group of 246 patients and has revealed that 92 patients were affected by a rough movement in rotation at the level of craniocaudal axis involving L1, L2, and L3. A group of physicists working at the Physics Faculty – University of Salento have demonstrated that rotation energies at the higher lumbar segments were converted into energies damaging L4-L5 and L5-S1 vertebral disks. We have identified the vertebra showing the greatest rotation as the dominant vertebra. In 2003-2004, we treated 104 patients of the above group with multilevels dynamic stabilization. After 5 years of follow-up, 74 % of treated patients achieved good results, with some cases presenting excellent improvements. However, 60 % of the successful cases also demonstrated signs of sagittal imbalance. In 2011, we decided to stop using inter-spinal devices and start implanting inter-laminar prosthesis (Intraspine – Cousin Biomedical). Materials and surgical procedures: In 2013, retrospectively reviewed 30 cases treated by means of inter-laminar prosthesis. The indications for surgical procedures were in all those cases leg pain and back pain, with no benefit from conservative therapy or persistent after different surgical procedures.
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882 The follow-up varies from a minimum of 6 months to a maximum of 3 years. Each patient has been monitored clinically before and after surgical treatment by means of Oswestry Disability Index and VAS scale, and radiologically with lumbar x-rays and MRI. Results and achievements: The group of 30 patients consisted of 18 females and 12 males. The clinical results on 30 patients demonstrated absence of Lasegue test in all cases, symmetry of lower extremity reflexes, neural exam without deficit, and significant improvement of ODI and VAS values. Discussion: The adopted surgical procedure in all those 30 cases has always been based on the key principle of ‘‘dominant vertebra’’ and its stabilization. No discectomy was carried out, despite presence of expulsed hernia. In 13 of our patients, the MRI results have confirmed that at 8 months follow-up the vertebral discs are re-hydrated. Sagittal-balance was preserved in all cases. Our theory is that rotation energies at level L1-L2-L3 are the main cause of the degeneration of vertebral disk of L4-L5.
MISCELLANY ESTIMATING THE RISK FOR SYMPTOMATIC ADJACENT SEGMENT DEGENERATION AFTER LUMBAR FUSION: ANALYSIS FROM A COHORT OF PATIENTS UNDERGOING REVISION SURGERY Di Martino A1, Quattrocchi CC2, Scarciolla L2, Papapietro N1, Beomonte Zobel B2, Denaro V1 1
Department of Orthopaedics and Trauma Surgery, Center of Integrated Research, CIR, University Campus Bio-Medico of Rome, Via Alvaro del Portillo, 200, 00128, Rome, Italy; 2Department of Diagnostic Imaging, Center of Integrated Research, CIR, University Campus Bio-Medico of Rome, Via Alvaro del Portillo, 200, 00128, Rome, Italy Abstract Purpose: The aim of this study is to estimate the risk for symptomatic adjacent segment degeneration (ASD) and examine the association between spino-pelvic parameters and ASD. Methods: 22 patients with a previous instrumented lumbar or lumbosacral spinal fusion and re-operated for ASD were enrolled in the study. 83 consecutive patients with the same initial surgery and no further surgeries were included in the controls group. Pelvic incidence, sacral slope (SS), pelvic tilt (PT), and lumbar lordosis were measured. Results: Patients with ASD had significantly lower SS (p = 0.005) and higher PT values (p \ 0.001). Patients with SS \ 39° or PT [ 21°, were at higher risk for symptomatic ASD (relative risk 1.73 for SS and 3.663 for PT). Conclusions: In patients re-operated for ASD, pelvic retroversion and hyperlordosis are the main mechanisms of compensation for the unbalanced spine. Patients with PT above 21° and SS below 39° are at higher risk for symptomatic ASD.
PATIENT-SPECIFIC TEMPLATES FOR PEDICLE SPINE SCREW PLACEMENT: LITERATURE REVIEW AND PROPOSAL OF A NEW DESIGN Paolo Domenico Parchi1, Vincenzo Ferrari2, Sara Condino2, Marina Carbone2, Lorenzo Andreani1, Michele Novi1, Michele Lisanti1 1st Orthopedic Division University of Pisa, Pisa, Italy; 2Endocas Center University of Pisa, Pisa, Italy 1
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Eur Spine J (2015) 24:872–903 Introduction: Pedicle screw fixation to stabilize lumbar spine fusion has become the gold standard for posterior stabilization. Computerassisted systems allow to increase the accuracy of pedicle screw placement, but they are used only by few surgeons due to the costs and complexities related to their use. An alternative image guided approach, less expensive and less complex, is the Patient Specific Templates similar to the ones used for dental implants or knee prosthesis. Materials and methods: Preoperative planning and template developing is done using a modified version of an open source CT segmentation software ITK-SNAP 1.5. The templates are then created using a 3D Printer. We designed a single level template with multiple contact points on bone to guarantee high template stability and low soft tissue invasiveness. Preliminary ex vivo animal testing on 2 porcine specimens has been conducted to evaluate template performance in presence of the soft-tissue in place. A post-operative CT scan was performed to evaluate the Kirschner wire positioning. Results: The post-operative CT evaluation showed a discrepancy between the planned trajectory and the obtained trajectory of less than 1 mm in 93 % of the cases and between 1-2 mm in 7 % of the cases. We recorded one grade II pedicle cortex violation. Conclusions: Guide positioning is facilitated thanks to the using of the spinous processes contact point, while false stable positions can be avoided using four redundant contact points. The results obtained during our preliminary ex vivo animal tests encourage further studies comprising in vivo human evaluation.
APPLICATION OF A NEW WEARABLE VIDEO SEETHROUGH AUGMENTED REALITY SYSTEM BASED ON HEAD MOUNTED DISPLAYS TO AID PERCUTANEOUS PROCEDURE IN SPINE SURGERY Parchi P1, Piolanti N1, Andreani L1, Cervi V1, Zarattini G2, Cutolo F3, Carbone M3, Ferrari V3, Lisanti M1 1
1st Orthopedic Division University of Pisa, Pisa, Italy; 2Orthopedic Division University of Brescia, Italy; 3EndoCAS Center University of Pisa, Pisa, Italy Introduction: Mini-invasive surgery requires the surgeon to perform procedures under medical image intensifier radiology without a direct visualization of the patient’s anatomy. This has inspired the development of several research lines, of which the Augmented Reality (AR) systems are the most promising. The aim of the study was to evaluate the efficacy of a new wearable AR system to guide the position of a working cannula into the vertebral body through a transpedicular approach without the use X-Ray image guidance. Methods: We describe a video see-through system based on Head Mounted Displays (HMDs) that integrates video frames acquired by two cameras creating patient specific 3D models obtained from preoperative radiological volumetric images. Our system has been tested on an experimental setup that simulates access to a lumbar pedicle, similar to a vertebroplasty procedure. Experienced and young surgeons were asked to perform the percutaneous task wearing the HMDs with the AR guide running. The system accuracy was evaluated by a post-operative CT scan. Results: The preoperative and post-operative CT scans were compared and the trajectories obtained were compared to the theoretical trajectories. The maximum distance between the planned and obtained trajectories in the pedicle was considered to assess the quality of the guide system. The results obtained show a medium error of 1.48 ± 0.81 mm. Conclusions: The results of the in vitro tests were encouraging in terms of system usability and ergonomics rendering our system worthy of more extensive tests.
Eur Spine J (2015) 24:872–903 EPIDEMIOLOGIC AND ECONOMIC BURDEN OF SPINAL FUSION SURGERY FROM ADMINISTRATIVE DATA R. Assietti1, P. A. Cortesi2, F. Cuzzocrea3, D. Prestamburgo4, M. Pluderi5, L. G. Mantovani2, G. Cesana2 1 S.C. Neurochirurgia, Azienda Ospedaliera Fatebenefratelli e Oftalmico, Milan, Italy; 2Centro di Studio e Ricerca sulla Sanita` Pubblica, Universita` degli Studi Milano-Bicocca, Monza, Italy; 3 S.C. Ortopedia e Traumatologia, Fondazione, IRCCS Policlinico San Matteo, Pavia, Italy; 4U.O. Ortopedia e Traumatologia, Azienda Ospedaliera, Ospedale Civile di Legnano, Legnano, Italy; 5U.O. Neurologia, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Milan, Italy
Introduction: No adequate data are available about the epidemiology of spinal fusion surgery and its economic impact. The objective of this analysis was to assess the epidemiologic and economic burden of arthrodesis from a large population based-study. Methods: The study population was identified through the DENALI archive of the Italian Lombardy Region: with a probabilistic linkage DENALI matches demographic, clinical and economic data of different Healthcare Administrative databases. The study population included all subjects who, during the period January 2000–December 2010, underwent a spinal fusion surgery identified by one of the following ICD9-CM codes: 81.04 81.05, 81.06, 81.07 and 81.08. The first procedure was used as index date. We estimated the incidence of first spinal fusion surgery and healthcare costs (hospitalizations, drugs and outpatient examinations/visits) per patient-year from the National Health Service’s perspective. Results: During the study period, 18,751 (53.8 % female) spinal fusion surgeries were detected. The incidence of surgery showed an increasing trend during the observation time. The incidence rate of interventions has increased from 10.9 to 19 per 100,000 a year in the observational period between 2000 and 2006. During the last 4 years of observation, the incidence was close to 20 per 100,000 a year. The average cost during the index year showed an increasing trend during the observational period, from € 5.069 in 2000 up to € 11.072 in 2010. Conclusion: The study showed an increasing incidence of spinal fusion surgery and costs from 2000 to 2010 in the Italian Lombardy Region. These results can be used to better understand the epidemiological and economic burden of these types of interventions, and help to optimize the resources available considering the different surgical procedures available today.
APPROACH RELATED COMPLICATIONS OF THE MIDLINE ANTERIOR RETROPERITONEAL APPROACH TO THE LUMBAR SPINE PERFORMED BY THE SPINAL SURGEON: REPORT OF AN EXPERIENCE OF 15 YEARS A. Lovi*, A. Luca*, G. B. Marzo**, M. Brayda-Bruno* *IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; **AUO Policlinico, Giovanni XXIII di Bari, Bari, Italy Purpose: To expose the approach related complications of the anterior midline retroperitoneal approach to the lumbar spine performed by the spinal surgeon. Materials and methods: The retrospective study was on 141 consecutive patients who underwent lumbar anterior interbody fusion (ALIF) or total disc replacement (TDA), over a period of 15 years (2001-2014).
883 The same senior spinal surgeon always performed surgery. Intraoperative (vascular, visceral and neurological injuries) and early postoperative (retroperitoneal haematoma, iliac vein thrombosis, retrograde ejaculation and the lumbar post-sympathectomy syndrome) complications were considered. Results: 93 males and 48 females were included; the average age was 43,5 (23–71) years. 124 patients had single level surgery, and 17 cases had two level surgery. In 15 males, operated at the level L5-S1, the approach was performed from the right side, whereas the approach was from the left in the rest of cases. 2 procedures were performed at L3-4, 47 at L4-5 and 108 at L5-S1. The overall complication rate was 13.7 %. The most common intraoperative complication was left common iliac vein injury (5.6 %). In 1.4 % of cases a retroperitoneal hematoma was observed. 1.4 % had a left lumbosacral plexus lesion and 0.7 % presented with a sympathetic lesion. 8.3 % of males reported retrograde ejaculation, which was permanent in 2 cases. All complications occurred with the approach performed from the left side. Conclusions: The most frequent intraoperative complication was of vascular origin. Our preliminary experience confirmed that the anterior retroperitoneal approach for the level L5-S1 performed from the right side has a lower incidence of complications than from the left side.
PATIENT DOSES IN STANDING FULL SPINE RADIOLOGIC PROCEDURE: COMPARISON BETWEEN THREE IMAGING MODALITIES P. Ragucci+, N. Trenti+, G. Tosi*, D. D’Angelo+, L. Balzarini+ +
Radiology Department, Istituto Clinico Humanitas Rozzano Italia, *Medical Physics Department, Istituto Clinico Humanitas Rozzano Italia Aim: In this study we analysed entrance skin doses obtained by DAP (Dose Area Product) for a standing full spine radiological procedure, comparing three different radiological equipments: a DR radiological equipment (Siemens Axiom Aristos), a CR system (Philips Bucky Diagnost) and an EOS slot-scanner (Biospace EOS). Material and method: For every patient included in this study we acquired two projections (postero-anterior and lateral). DAP values were directly obtained from the various machines. Entrance skin dose (ESD) was calculated by multiplying DAP value, irradiation field dimension and backscattering factor. Result: The mean DAP and ESD values obtained for approximately 100 patients are: DR: DAP (mGy cm2) 1144 (PA), 1393 (LAT) ESD (lGy) 945 (PA), 1151 (LAT) CR: DAP (mGy cm2) 7360 (PA), 9105 (LAT) ESD (lGy) 2604 (PA), 3221 (LAT) EOS: DAP (mGy cm2) 535 (PA), 753 (LAT) ESD (lGy) 171 (PA), 271 (LAT) Conclusion: Patient doses are lower with EOS slot-scanner than with CR and DR radiological equipment. Moreover ESD is 80 % and 92 % lower, respectively, compared to the DR and CR system. EOS slot-scanner is therefore recommended for paediatric patients and for patients requiring regular and repeated radiologic control, as is the case in scoliosis.
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884 IS MINIMALLY INVASIVE DISCECTOMY STILL A VALID METHOD FOR THE TREATMENT OF SINGLE-LEVEL LUMBAR INTERVERTEBRAL DISC HERNIATION? A. Toscano, F. Traina, M. Nanni, F. Perna*, N. Stefanini*, M. Chehrassan*, C. Faldini Dipartimento Rizzoli-Sicilia, Bagheria, Italy; *Istituto Ortopedico Rizzoli, Bologna, Italy Introduction: Single-level lumbar intervertebral disc herniation is one of the most frequent diseases encountered in clinical practice. Indications for surgery are severe and persistent radiculopathy or the presence of neurological deficits. Objective: Aim of this study is to follow 40 patients with single level lumbar disc herniation managed by minimally invasive discectomy in order to assess whether the procedure can be associated with postsurgical instability. Materials and methods: Forty patients with single level lumbar disc herniation were managed by a minimally invasive approach. Patients had a mean age of 42 years; there were 29 men and 11 women. Levels were L5-S1 (18 patients), L4-L5 (18 patients) and L3-L4 (4 patients). All patients were preoperativelly evaluated using VAS scale and radiologic imagery. Post-operative evaluation was carried out by the VAS scale; at 1 year follow-up both the VAS scale and radiologic exam with standard and flexion–extension x-rays were performed. Results: Preoperatively, the mean VAS score was 8 ± 2. Postoperatively, it was 3 ± 1.5, while it reached 1 ± 1 at one-year followup. The complications encountered were 2 adjacent discs herniations, and 2 recurrences of disc herniation managed by discectomy and, in one patient by a single level instrumented fusion. The plain radiographs did not show signs of segmental instability either by standard or flexion–extension X-Rays. Conclusions: Minimally invasive discectomy has proved to be still an effective method for the treatment of single-level lumbar intervertebral disk herniation with a low rate of complications and risk of instability.
ADULT SCOLIOSIS SURGICAL TREATMENT OF DEGENERATIVE LUMBAR SCOLIOSIS C. Faldini, A. Toscano, R. Borghi*, C. Pungetti*, A. Sambri*, F. Perna*, F. Traina Dipartimento Rizzoli-Sicilia, Bagheria, Italy; *Istituto Ortopedico Rizzoli, Bologna, Italy Objective: Degenerative lumbar scoliosis occurs in the aging spine without previous history of scoliosis, and consists of an asymmetric narrowing of the intervertebral disc space producing lateral spine deviation and segmental stenosis. Degenerative lumbar scoliosis can lead to severe back pain and progressive radiculopathy due to segmental spinal instability and central or foraminal stenosis. The aim of this paper is to present the guidelines for surgical treatment of degenerative lumbar scoliosis based on 56 consecutive treated cases. Materials and methods: 56 patients affected by degenerative lumbar scoliosis were treated between 1997 and 2014. DLS involved one level in 12 cases, two in 27, and 3 or more levels in 17. Surgery was planned according to the following labelling factors: extension of the DLS, instability, presence of central or foraminal stenosis, neurological involvement and pain. Surgical treatment consisted of: minimally invasive hemilaminectomy and foraminotomy in 5 cases, posterior stabilization and decompression in 16 cases, posterior stabilization and intervertebral height restoration by PLIF in 35 cases.
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Eur Spine J (2015) 24:872–903 Results: Preoperative curve was 22° ± 5°, at follow-up was 7° ± 5° (p \ 0.05). Preoperative VAS pain was 7.5 ± 3, at follow-up was 2.9 ± 2 (p \ 0.05). At the last available follow up of 4 ± 2.5 years, 29 cases had excellent results, 18 good, 5 fair and 2 poor. 1 patient treated by foraminotomy required a second operation for posterior stabilization. Conclusion: Surgical treatment of degenerative lumbar scoliosis determined a positive effect on patient’s condition, both clinically and radiologically.
CLASSIFICATION OF DEGENERATIVE SEGMENT DISEASE IN ADULTS WITH DEFORMITY OF THE LUMBAR OR THORACOLUMBAR SPINE P. Berjano, R. Cecchinato, M. Damilano, M. Ismael, A. Sinigaglia, C. Lamartina IRCCS Istituto Ortopedico Galeazzi, Milan, Italy Introduction: Lumbar and thoraclumbar adult deformity is a pathology that causes loss of quality of life and may lead surgical treatment. In contrast with adolescent deformities where the curve magnitude plays a fundamental role in surgical indication, the relevant features of adult deformities are pain and dysfunction that correlate with segment degeneration and loss of sagittal alignment. Previous classifications of adult deformities are descriptive and have little or no utility for surgical planning. Materials and methods: A retrospective analysis of clinical and radiological features has been performed to present a classification based on degenerative disease segment distribution and on sagittal alignment of patients with adult deformities. Results: On the base of cases analysis four categories have been described: Type I (disc degeneration limited to a single segment, non apical), Type II (disc degeneration at the apex of the curve), Type III (multilevel disc degeneration, apical or non apical), Type IV (spine imbalance: IVa: sagittal imbalance; IVb: combined sagittal and coronal imbalance). Discussion and conclusion: A surgical indication is suggested for each type of deformity: Type I and II can be treated with a selective fusion of the pathologic level. In type III the fusion of the whole coronal curve is mandatory. Type IV usually requires aggressive corrective procedures, such as tricolumnar osteotomies (PSO, PVCRs). This classification allows the spinal surgeon to interpret the extension and significance of degenerative pathology, and plan surgery (selective fusion or major corrective surgeries). Further studies will be necessary to validate this classification.
SEVERE DEFORMITY OF THE ADULT: THE IMPORTANCE OF THE MEASUREMENTS OF SAGITTAL IMBALANCE AND ITS CORRECTION IN THE SURGICAL TREATMENT Carlo Ruosi, Silvia Casula*, Francesco Granata, Gianluca Colella, Pier Paolo Mura* Dipartimento di Sanita` Pubblica, Sezione di Ortopedia, Universita` degli studi Federico II di Napoli, Naples, Italy; *Divisione di Chirurgia Vertebrale, Clinica Quartu S. Elena Cagliari, Cagliari, Italy; E-mail:
[email protected] Severe spinal deformities in adults are often associated to severe sagittal imbalance with severe modification of physiological dorsal and lumbar curves. This imbalance, along with scoliosis and arthritic degeneration lead to a highly debilitating situation for the patients with acute pain, both in the lumbar region that the lower limbs, muscle spasms with increasing disabilities, leading to the inability to maintain the upright position and to walk in severe cases.
Eur Spine J (2015) 24:872–903 Patients with sagittal imbalance are unable to hold C7 over S1, or are able only by means of active compensation of pelvic retroversion, thoracic hyperkyphosis, lumbar hyperlordosis. Sagittal balance is achieved by means of the morphology of spine and pelvis that allow upright position without using flexor and extensor muscles. Sagittal imbalance is associated with a bad Quality of Life (QoL) in untreated patents, in patients treated for vertebral pathology, and in patients treated for degenerative disease. Having experience with angle measuring of sagittal imbalance is very important. Main parameters to evaluate are: Pelvic Tilt (PT), Sacral Slope (SS), Pelvic Incidence (PI), Thoracic Kyphosis (TK), Lumbar Lordosis (LL). Symptoms in vertebral pathology depend on various factors: neural compression, mechanical pain due to disc degeneration or vertebral joint degeneration, sagittal imbalance and coronal imbalance (fewer cases). Evaluating a standing lateral X-ray exam that includes C7 and femoral heads is fundamental. It is necessary to evaluate: SVA value (ideal value is 0), Pelvic Tilt (below 20-258, a lower value being of better prognosis); and lumbar lordosis. Moreover, the patient’s clinical evaluation must include neural damage signs, mechanical signs and signs of sagittal imbalance. Treatment of these severe deformities must take into account correction of sagittal balance. We recommend systematic accurate measurement of the parameters that characterize this imbalance for correct surgical planning.
MULTILEVEL XLIF WITH POSTERIOR OSTEOTOMIES FOR CORRECTION OF THE SAGITTAL IMBALANCE IN THE ADULT DEGENERATIVE SPINE: OUTCOMES IN THE FIRST 20 CONSECUTIVE CASES A. Ramieri, M. Miscusi**, S. El Boustany*, S. Forcato**, F.M. Polli**, A. Raco**, G. Costanzo* Don Gnocchi Foundation, Milan; *Orthopaedics, Polo Pontino Sapienza Rome University, Rome, Italy; **Neurosurgery, S. Andrea Hosp Sapienza Rome University, Rome, Italy Introduction: Sagittal imbalance in the adult degenerative spine requires surgical correction to improve pain, mobility and quality of life. Comorbidities and poor bone quality may increase the incidence of complications. XLIF is currently the less invasive alternative to open techniques for arthrodesis and recovery of the lumbar lordosis. Materials and methods: We treated consecutively by multilevel XLIF, Smith-Petersen osteotomies and pedicle instrumentation 20 cases of sagittal imbalance, associated or not to coronal deformity. All patients were submitted to X-ray screening (SLLP) during pre, postoperative and follow-up periods. Results: Mean age was 65.3 (47-74; M/F 1: 4). Six deformities were type II, 5 were type III, 4 were type IVa and 5 were type IVb. There were a total of 39 XLIF and 8 TLIF. Open or percutaneous posterior instrumentation was extended to S1 or S2 in 7 cases and the ileum in 5. The UIV was primarily T10. Osteotomies were performed at 6-7 levels in type IVa, in the apical zone in type III and IVb. Complications included 2 pleural tears, 1 retroperitoneal hematoma, 2 quadriceps weakness, and 3 psoas weakness. At FU (6-24mo; mean 10), we recorded no mobilization, junctional syndromes or infections. In 14 cases (70 %), improved postoperative spino-pelvic values were similar to those preoperatively calculated (SD ± 5°). VAS and ODI decreased in 100 % (p \ 0.05), with high patient satisfaction. Conclusions: The short follow-up does not allow for definitive conclusions. However, the approach adopted in this preliminary series of adult degenerative deformities seems to be a viable choice, avoiding risks and complications of more aggressive subtraction osteotomies.
885 PELVIC FIXATION IN ADULT DEFORMITY F. M. Finocchiaro, S. Costantini, U. Nena, V. Lo Scalzo, A. Bernabei, D. A. Fabris Monterumici Spinal Surgery Unit, Padua University General Hospital, Padua, Italy Introduction: Lumbosacral fusion presents many difficulties, which can often lead to failure and complications. The complex local anatomy, as well as the area-specific biomechanical forces and frequently poor bone quality, make this area difficult to treat. Materials and methods: 42 patients were included in the study, 39 women and 3 men, with a mean age of 66.97 ± 8.5 years (range 50-81). The follow-up period was of 14 ± 0.82 months (range 10-24). The pathologies treated were: 20 scoliosis, 11 global kyphosis, 3 lumbar kyphosis and 8 revision surgeries. The technique consisted of iliac fixation with two pairs of screws. The radiologic assessment included X-rays and CT scan, while the clinical assessment included the SF -36, Roland Morris (RM), and the visual analogic scale (VAS). Results: The average values for SF-36 were 28.7 % ± 13.8 preoperatively and 72.8 % ± 3.6 postoperatively. The average values for VAS were 8.9 preoperativly, and 3.3 at follow-up. The average values for RM were 19.2 preoperatively and 5.53 at follow-up. Results are not statistically significant. Patient satisfaction was 85.4 %. Non-union was observed in 2.4 %. Complications included 1 cerebrospinalfluid fistula, 3 cases of wound dehiscence, 1 paraparesis in recovery (following lumbar osteotomy), 1 broken connector, and 2 broken bars (in a case of non-union). Conclusions: The stabilisation of adult deformity provided by iliac fixation minimizes the risk of non-union of the lumbosacral junction. Sacral screws can suffer pull-out and cause movement of the implant. This technique, which is essential for corrective lumbar osteotomies and long fusions extending to the sacrum, allows the stress on the distal screws to be reduced and counteracts the lumbosacral bending moment. The choice of iliac fixation may be linked, not only to the size of the sagittal and coronal deformity, but also to a careful analysis of spinopelvic parameters and risk factors for possible bone fragility.
IMPLANT FAILURE AFTER PSO: HOW TO PREVENT IT? A FINITE ELEMENT ANALYSIS OF DIFFERENT HARDWARE CONSTRUCT AFTER LUMBAR PEDICLE SUBTRACTION OSTEOTOMY A. Luca1, A. Lovi1, C. Ottardi2, T. Villa2, F. Galbusera1, M. Sasso2, L. Prosdocimo2, G. B. Marzo2 M. Brayda-Bruno1 1 IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; 2Laboratory of Biological Structure Mechanics, Politecnico di Milano, Milan, Italy
Hardware failure after PSO remains a burning issue that should be overcome to make the procedure safer and more effective. The aim of the study was to investigate the biomechanical behavior of different hardware models and configurations. A validated finite element model (FEM) of the intact lumbar spine (L1-S1) was performed. Other models were created in order to simulate a Pedicle Subtraction Osteotomy (PSO) on L3 and L4. A standard spinal fixation was then simulated two levels above and below the osteotomy. Different configurations of the instrumentation were then studied: single vs. bilateral double rods, different rods diameters and different materials (TiAl4V vs. CrCo). The osteotomy caused a significant increase of the ROM in all the movement (25-90 %) while a decrease of about 55/80 % of the ROM was noticed after the fixation. Despite the absolute values of the stresses in the Cr-Co devices were 30-40 % higher with respect to the TiAl4 V ones at the osteotomy site, they provided a stronger stabilization without enhancing the risk of mechanical failure of the instrumentation
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886 due to their higher strength. Finally, the configuration with double bilateral rods exhibits a higher stress reduction near the treated level. The massive instability caused by a PSO in the lumbar spine partially explains the high rate of mechanical failure. The results indicate that Cr-Co implants have the best biomechanical performance and, secondarily, that the configuration with bilateral double parallel rods produces the higher stress reduction on the implants at the treated level, reducing the risk of hardware failure.
FINITE ELEMENT ANALYSIS OF PEDICLE SUBTRACTION OSTEOTOMY OF THE LUMBAR SPINE A. Luca1, C. Ottardi2, A. Lovi1, T. Villa2, F. Galbusera1, L. Prosdocimo2, M. Sasso2, G.B. Marzo2, M. Brayda-Bruno1 1 IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; 2Laboratory of Biological Structure Mechanics, Politecnico di Milano, Milan, Italy
The Pedicle Subtraction Osteotomy (PSO) is widely considered to be the selected procedure to correct flat-back deformity. The osteotomy involves all three columns of the spine producing a massive concentration of stress on the hardware. The aim of the study was to investigate, using a finite element model of the spine, the amount of biomechanical changes at the level of osteotomy. The study was conducted on a finite element model of the lumbar spine. The starting point was a model of the L1-S1 segment, complete of vertebrae, discs and ligaments. An osteotomy on L3 was then simulated, removing the posterior elements and the ligaments involved, increasing the lumbar lordosis of 30°. The same procedure was performed on L4. All the models were loaded with a follower load of 500 N (load imposed on the path connecting the vertebral bodies) and pure moments of 7.5 Nm in flexion–extension, lateral bending and axial rotation. Moreover, the contact between the fractured surfaces was modeled imposing a friction coefficient. Each FSU of the intact model was validated in flexion–extension, lateral bending and axial rotation (comparing the ROM with literature data). The model of the complete lumbar spine (L1-S1) therefore exhibits the typical flexibility of the lumbar spine. Both osteotomy models showed a significant increase of the flexibility, due to the destabilization. In particular, the simulation of the osteotomy on L3 produced the maximum increase of the ROM in extension of up to 74 % and in axial rotation of 95 %. The osteotomy in L4 caused an increase in extension of about 89 % and a variation of 85 % in lateral bending. The severe instability caused by a PSO in the lumbar spine may partially explain the high rate of mechanical failure. Hardware implementation (4 rods constructs) and combined approach (posterior and anterior) should be considered to reduce the risk of the procedure.
PEDIATRIC SCOLIOSIS TOTAL HEMIVERTEBRA RESECTION BY POSTERIOR APPROACH IN CONGENITAL SCOLIOSIS AND KYPHOSCOLIOSIS: RESULTS WITH 6 YEARS MEAN FOLLOW UP Marco Crostelli, Osvaldo Mazza, Massimo Mariani, Dario Mascello Spine Disease Unit, Ospedale Pediatrico Bambino Gesu`, Rome, Italy Introduction: Congenital vertebral deformities are caused by formation or segmentation defects in vertebras. They are generally treated by surgery due to high risk of curve progression and, in case of kyphosis and kyphoscoliosis, high risk of neural complications.
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Eur Spine J (2015) 24:872–903 Materials and Methods: Between 2006 and 2013 we operated 59 patients with congenital vertebral deformities (43 scoliosis and 16 kyphosis and kyphoscoliosis) by posterior approach using different techniques (subtraction osteotomy, hemivertebra resection) and instrumented arthrodesis with pedicle screws. Mean age at surgery was 8 years, and 22 patients was under 10 years of age. Mean kyphosis curve was 75° Cobb, mean scoliosis curve was 44°. Intraoperative neurophysiologic monitoring was used in surgeries after 2011. Results: Mean follow up was 5 years. The mean kyphosis curve after surgery was reduced to 20° and mean scoliosis curve was reduced to 11°. We had no major complication: neurologic, vascular or visceral injuries, instrumentation failure with loss of correction, or infections. Discussion and conclusions: Posterior approach interventions with pedicle screws instrumentation are less invasive than combined anterior–posterior approach interventions and they are well tolerated even by very young patients. Pedicle screws obtain important corrections that can be maintained using autologous bone obtained by osteotomy/resection to favour arthrodesis. If surgery is performed at an early age, before secondary curves are structured, the area of arthrodesis can be minimized. We believe that posterior approach procedures obtain excellent deformity correction in both frontal and sagittal plane, with optimal stability, and low risk of neural injury.
POSTERIOR APPROACH WITH COMPLETE L2 VERTEBRA RESECTION FOR CORRECTION OF SEVERE THORACICLUMBAR PROGRESSIVE KYPHOSIS IN A 6 YEARS OLD PATIENT AFFECTED BY TYPE 1 MUCOPOLYSACCHARIDOSIS Marco Crostelli, Osvaldo Mazza, Massimo Mariani, Dario Mascello Spine Disease Unit, Ospedale Pediatrico Bambino Gesu`, Rome, Italy Introduction: Type 1 mucopolysaccharidosis is a metabolic hereditary disease caused by alpha-l-iduronidase enzyme deficit that causes glycosaminoglycans accumulation in tissues. It causes typical skeleton deformities with hypoplastic, triangle shaped vertebras that cause severe kyphoscoliosis. Materials and methods: CR, with type 1 mucopolysaccharidosis, was affected by thoracic-lumbar kyphosis caused by hypoplastic L1 and L2 vertebras. Deformity increased despite brace treatment for 36 months. At the age of 6 years he presented 65° Cobb Kyphosis T11-L3 on standing x-rays. At 6 years and 1 month of age, 105.5 cm height and 19 kgs weight, CR was operated by posterior approach with complete total L2 vertebra resection, obtaining progressive deformity correction by two rods and pedicle screws in T11-T12-L1 and L3, and filling the resection gap with one cage with autologous bone. Intra operative neurophysiologic monitoring was used during surgery. Surgery lasted 11 h and 57 min, and total blood loss was 300 ml. Results: Kyphosis was reduced to 37° Cobb on standing x-rays. The patient had no major complication (infection, instrumentation failure, non union, nervous, visceral or vascular injuries). For about four weeks after surgery the patient complained of paresthesia in his right leg. Symptoms disappeared following steroid treatment. The patient was braced for 4 months after surgery. At 8 months follow up CTscan showed complete L1-L3 arthrodesis. At 1 year follow up there was no loss of correction. Discussion and conclusions: Posterior approach with total vertebra resection allows radical kyphosis correction while avoiding the complications of the anterior approach, and reducing the risk of neural injury.
Eur Spine J (2015) 24:872–903
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INSTRUMENTED CONVEX GROWTH ARREST AND HEMIVERTEBRA RESECTION IN THE SURGICAL TREATMENT OF NONSYNDROMIC CONGENITAL SCOLIOSIS: PERSONAL SERIES AND LITERATURE REVIEW
Conclusions: VEPTR is an effective device that can treat a variety of spine and thoracic deformities in the growing patients by fusion-less technique. Rib-vertebra VEPTR is more effective in scoliosis treatment.
G. Costanzo, U. Prencipe, E. Manauzzi, G. Ippolito, A. Ramieri*
JUVENILE SCOLIOSIS
Orthopaedics, Polo Pontino La Sapienza Rome University, Rome, Italy; *Don Gnocchi Foundation, Milan, Italy Introduction: Hemivertebrae are the most frequent cause of congenital scoliosis, while fused ribs are less frequent. Severity of the deformity depends on the type, level, number and relationship of hemivertebrae, as well as age of the patient. Surgery is indicated to prevent progression and different procedures are described. Materials and methods: From a retrospective series observed in 10 years, we enrolled 16 nonsyndromic congenital scoliosis; 7 being thoracic and 9 lumbar. The posterior surgical techniques applied were: 11 instrumented convex growth arrest and 5 instrumented ‘‘eggshell’’ hemivertebra resection. Cobb degrees at the end of growth and segmental kyphosis were measured. Results: In 10 males and 6 females (mean age 11.7 years; range 10-13), 14 scoliosis were associated with hemivertebra and 2 with fused ribs. The initial value of scoliosis was on average 34° (range 21-48). A segmental kyphosis was present in 14 cases, with mean value of 13° (range 10-21). After surgery, scoliosis improved on average 10° (range 11-30), as well as kyphosis (average 7; range 2-11). At follow-up (4 years; range 3-7), we detected two mechanical complications with loss of correction. We recorded no infections. At the end of growth, excluding re-operated cases with mechanical failure, the mean values of scoliosis and kyphosis were respectively 27° (range 15-35) and 5° (range 2-15). Conclusions: Despite two mechanical complications with significant development of kyphoscoliosis, the final results were mostly satisfactory in relation to correction and definitive deformity measured at the end of growth.
VERTICAL EXPANDABLE PROSTHETIC TITANIUM RIB (VEPTR) IN THE TREATMENT OF PAEDIATRIC, JUVENILE AND ADOLESCENT SCOLIOSIS Marco Crostelli, Osvaldo Mazza, Massimo Mariani, Dario Mascello Spine Disease Unit, Ospedale Pediatrico Bambino Gesu`, Rome, Italy Introduction: The thoracic expander Vertical Expandable Prosthetic Titanium Rib (VEPTR) was developed from 1988 by RM Campbell to treat severe thoracic deficiency in children. Its use has expanded to the treatment of early onset scoliosis associated with thoracic or ribs anomalies. The advantages of the device are the control of spine deformity acting on the thoracic wall and adaptation to patient growth. Materials and methods: From 2011 to 2014 we treated 15 patients by VEPTR, mean age 8 years 7 months: 2 scoliosis in VATER syndrome, 4 pediatric scoliosis, 6 congenital scoliosis associated with ribs anomalies/hemivertebras, 2 neurologic scoliosis and 1 progressive dorsal scoliosis in a patient previously treated for vertebral canal neoplasia that we treated by VEPTR to avoid interference with possible future posterior approach neurosurgery procedures. Each patient underwent an average of 4 lengthening procedures. The mean scoliosis curve was 56° Cobb. In 9 cases we used Rib-vertebra VEPTR. Results: Mean follow up was 25 months, mean scoliosis curve after surgery was 30° Cobb. We had no major complication (nervous, vascular or lung injuries, rib fracture, VEPTR failure). In 5 cases x-rays after surgery showed asymptomatic pleural effusion that was resolved by the pleural drainage routinely applied to all patients. We had 2 cases of superficial wound dehiscence, resolved with dressings.
ELONGATION X-RAYS TEST USE IN SURGICAL PLANNING OF ADOLESCENT IDIOPATHIC SCOLIOSIS: OUR EXPERIENCE Giovanni Andrea La Maida1, Leonardo Zottarelli2, Marcello Ferraro1, Francesco Negrini2, Bernardo Misaggi1 1 Orthopaedic Institute Gaetano Pini, Milan, Italy; 2Universita` degli Studi di Milano, Milan, Italy
Introduction: Choosing which segments will be included in the arthrodesis during scoliosis surgery is a real challenge for spine surgeons. The Lenke Scoliosis Classification is the only one approved by the scientific community. In our Institute, lateral Bending and Elongation X-rays Test (E.T.) are always taken before surgery. E.T. is an anteroposterior teleradiography of the patient in bipolar traction (maximum 1/3 of body weight). The aim of this trial is to analyze the role of E.T. in preoperative evaluation in adolescents affected by scoliosis. Materials and methods: The retrospective case–control trial included patients affected by Adolescent Idiopathic Scoliosis who underwent surgery with a 12-month follow-up. Cases reported an E.T. taken before surgery. Case and control groups had similar characteristics at baseline. Results: 124 patients (88 females and 36 males, mean age 15.8) were included: 62 cases and 62 controls. 60 patients (56.4 %) were Lenke Classification type 1. We analyzed 180 Major curves (90 in each group; cases group mean 55.4° - control group mean 59.1°) and 92 Minor curves (46 in each group, cases group mean 37.7° - control group mean 40.2°). Almost significant difference (p = 0.054) was observed in 1B and 1C Lenke curves (case group mean 16.7° - control group mean 19.3°). There were no other significant differences in postoperative outcome. Conclusions: E.T. is an efficient method to obtain preoperative evaluation of how flexible and correctable the scoliotic curves are. E.T. seems to be more effective than lateral bending radiographs in 1B and 1C Lenke curves.
COMPARISON OF TWO DIFFERENT STRATEGIES OF REDUCTION IN IDIOPATHIC SCOLIOSIS: CANTILEVER VERSUS SIMULTANEOUS TRANSLATION ON 2 RODS Federico Solla1, Virginie Rampal1, Ioana Oborocianu1, Vincent Lavoue´1, Souad Elbatti1, Edouard Chau1, Jean-Luc Cle´ment1 1
Ortopedia e Chirurgia delle scoliosi, Ospedale Lenval, Nizza, France
Introduction: Correction of hypokyphosis is a key component in the treatment of Adolescent Idiopathic Scoliosis (AIS). The goal of this study is to retrospectively compare the radiologic results for 2 consecutive series of AIS treated using 2 methods of reduction: sequential approximation by Cantilever Reduction (CR) and Simultaneous Translation technique on 2 Rods (ST2R). Methods: 40 patients with thoracic AIS (Lenke type 1, 2, 3) underwent a posterior spinal fusion and instrumentation (CR series: 20 patients - ST2R series: 20 patients). 2 groups of preoperative kyphosis were generated for each method (10 patients for each sub-group):
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888 patients with hypokyphosis (\20°) and with normal kyphosis (20°45°). Thoracic kyphosis (T4-T12) and Cobb angle measurements of major and minor curves were evaluated by an independent observer. The minimum follow-up was 2 years. Results: Density of implants was similar between groups (p [ 0.05). At final follow-up, in patients with preoperative hypokyphosis, the mean gain was 10° in the CR series (12° preoperative-22° postoperative) and 21° in the ST2R series (11°-32°). Postoperative values were different between groups (P \ 0.05). Concerning patients with normokyphosis, 3 patients of CR series had hypokyphosis whereas the patients of the ST2R series all had normal kyphosis. In coronal plane, the mean correction of scoliosis was similar for both groups (75 % vs. 69 %; P = 0.177). Conclusion: Simultaneous translation on 2 rods provides a better correction of thoracic kyphosis than the sequential approximation by CR on patients with preoperative hypokyphosis.
USE OF SUBLAMINAR DEVICES TO IMPROVE SAGITTAL BALANCE IN SCOLIOSIS SURGERY IN PATIENTS WITH MARFAN’S SYNDROME M. Palmisani, E. Dema, S. Cervellati
Eur Spine J (2015) 24:872–903 Background: Patients’ compliance in wearing braces is crucial for the effectiveness of the conservative treatment of juvenile idiopathic scoliosis (JIS) and kyphosis (KYP). It has been suggested that the adherence to the brace therapy in patients with JIS and KYP might improve after treatment with temporary cast braces. Purpose: The aim of this study is to explore the effect of wearing cast braces before the beginning of standard bracing on the correction of vertebral deformities, and on the patients’ compliance to the wearing of custom-fit braces. Materials and methods: The study population consisted of 41 female patients (12 ± 2 years), 9 of which were affected by HYP and 32 by JIS. Patients were further divided into two groups. One group treated with a cast brace for six months (renewed every two months), followed by a Milwaukee brace (n = 16) or an anti-gravity brace (n = 5). The second group consisted of patients directly treated by the Milwaukee brace (n = 16) or the anti-gravity brace (n = 4). Both treatments continued up to the end of skeletal growth. Patients were characterized radiologically and by the response to the Brace Questionnaire. Results: Patients treated with brace cast showed a significantly higher compliance to the subsequent wearing of the Milwaukee brace, as demonstrated by the improved results in the Brace Questionnaire. Conclusion: Preliminary results suggest that the use of cast before bracing treatment is associated to a better adherence to the brace treatment.
Hesperia Hospital, Modena, Italy Methods: Between 1999 and 2012, 18 patients with confirmed Marfan syndrome (according to the Ghent Criteria), 11 female and 5 male, with a mean age 16.5 years (range 12-29) underwent posterior segmental instrumentation using pedicle screws alone (5) and pedicle screws or hybrid constructs with sublaminar devices (13) at a single center. Before surgery the average curves in the thoracic spine were 70.3° (range 42°-89°), and 61° (range 45°-76°) in the lumbar spine. In the sagittal plane the curves either decreased or were reversed: 10° (range 5°-43°) of thoracic lordosis and the mean thoracolumbar kyphosis was 11.2° (range 5°-40°). Mean follow-up was 5.5 years (range 2-14 years). Patients were evaluated preoperatively, postoperatively and at the minimum 2-year follow-up. Results: The average curve correction was 30° (65 %), ranging from 12°-48°, in the thoracic spine and 25° (67 %), ranging from 10 to 35°, in the lumbar spine. The loss of coronal and sagittal correction at follow-up was 4 % and 2 %, respectively. There is a more significant correction in coronal planes in patients treated by pedicle screws alone, although patients with sublaminar devices (wires or bands) achieve a better correction in sagittal plan. There were no significant differences between pedicle screws alone and pedicle screws or hybrid constructs with sublaminar fixation in terms of blood loss, neurological deficit, hospital stay, or infection rate. Three complications were observed: 1 intraoperative dural tear, a superior mesenteric artery syndrome associated to significant correction in one of the patients, and 1 loss of correction without instrumentation failure in a patient treated with sublaminar bands.
CONSERVATIVE TREATMENT WITH RISSER CAST BEFORE BRACING IN SPINAL JUVENILE SPINAL DEFORMITIES A. Toscano, A. C. Di Martino*, R. Borghi**, M. Chehrassan**, F. Perna**, A. Mazzotti**, C. Faldini Dipartimento Rizzoli-Sicilia, Bagheria, Italy; *Universita` Campus Bio-Medico, Rome, Italy; **Istituto Ortopedico Rizzoli, Bologna, Italy
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ROBOTIC-GUIDED DEFORMITY CORRECTIONS: A PRELIMINARY TECHNICAL REPORT Pasquale Cinnella, Marco Muratore, Giosue` Gargiulo1, Massimo Girardo, Gabriele Dal Col, Stefano Aleotti Ospedale CTO-Maria Adelaide, Azienda Ospedaliera Citta` della Salute e della Scienza, Turin, Italy; 1Ospedale Molinette, Turin, Italy Background: Spinal deformity corrective surgeries can be technically challenging for the surgeon due to anatomical considerations such as rotation, hypoplastic pedicles and the frequent involvement of thoracic vertebrae. Robotic-guidance was introduced in recent years to assist surgeons to overcome such challenges and initial reports in the literature have been encouraging. In this report we review our preliminary experience with robotic guidance. Methods: This is a retrospective review of technical and clinical parameters of patients operated consecutively in our hospital by a single surgeon. The surgical technique required CT-based preoperative planning of the instrumentation. Intra-operatively an image intensifier-based registration process synchronized the location of the robot mounted on the patient’s spine with the CT and plan. Pedicle screws were placed manually after pilot holes were drilled in trajectories guided by the robotic system. Results: Two adults and one adolescent were operated between Sep 18th and Oct 30th. A total of 34 screws were placed accurately. Two trajectories were aborted due to technical reasons (colliding with mounting system). Two pilot holes were initially drilled low compared to the planning and were repositioned with the robotic system accurately. The inaccuracy stemmed from human error in locking the robot to its mounting platform. This was perceived and corrected intra-operatively. Exposure to fluoroscopy per screw ranged between 1.2-2.6 s per screw. No post-operative sequelae were recorded. Conclusions: Although still developing, robotic-guidance is a promising alternative allowing for predictable screw placement, regardless of the anatomical challenges, with reduced exposure to intra-
Eur Spine J (2015) 24:872–903 operative fluoroscopy. Prospective, controlled studies would be valuable to further assess this technology.
PEDICLE SUBTRACTION OSTEOTOMY FOR SURGICAL TREATMENT OF SEVERE ADOLESCENT CONGENITAL SPINE DEFORMITY Giovanni Andrea La Maida1, Leonardo Zottarelli2, Donatella Peroni1, Marcello Ferraro1, Francesco Luceri2, Bernardo Misaggi1 1 Orthopaedic Institute Gaetano Pini, Milan, Italy; 2Universita` degli Studi di Milano, Milan, Italy
Introduction: Congenital spine deformity is difficult to treat because of the severe stiffness of the anatomical structures. Pedicle subtraction osteotomy (PSO) is an effective tool for the correction of fixed deformities. The aim of the study is to report our experience relating to the use of PSO. Materials and methods: The study is a case-series with a level of evidence V. We evaluated every medical record of patients affected by congenital spine deformities and treated with PSO. Clinical and radiologic parameters were evaluated preoperatively and postoperatively (6-month and 1-year follow-up). Results: 5 congenital spine deformities (2 male, 3 female) were treated with PSO. 4 were angular thoraco-lombar scoliosis in hemivertebrae deformity, 1 was an angular thoraco-lombar hyperkyphosis in T12-L1 synostosis. The mean age was 15.2 years (range: 12-17 years old). The mean scoliosis Cobb angle at the diagnosis was 64.2° (range: 46.6°-78.0°). After PSO the Cobb angle improved to 23.6° (range: 12.5°-31.0°). In these cases, PSO achieved a mean correction of 60.7 % (range 48.0 %-73.1 %). The arthrodesis area included a mean of 7,4 spine levels (range 5-10). No major complications were observed. Discussion and conclusions: PSO in spine deformities can obtain a high correction rate in coronal and sagittal plane. Improvements up to 70 per cent of the preoperative curve values are reported in literature; these values are comparable to our experience. It is important to remember that the advantage of PSO is a significant angular correction with minimal number of vertebral levels involved in the arthrodesis.
NON FUSION PURE AND HYBRID LUMBOSACRAL DYNAMIC STABILIZATION: RESULTS IN 180 CASES WITH MINIMUM 2-YEAR FOLLOW-UP R. Mastrostefano*, A. Ramieri**, G. Ippolito°, M. Domenicucci§, G. Costanzo° *Neurosurgery, Canistro Hosp Avezzano, Avezzano, Italy; **Don Gnocchi Foundation, Milan, Italy; °Orthopaedics, Polo Pontino La Sapienza Rome University, Rome, Italy; §Neurosurgery, Umberto I Hosp. La Sapienza Rome University, Rome, Italy Introduction: Dynamic stabilization systems in lumbar degenerative diseases were introduced as an alternative to fusion techniques to decrease junctional problems. Given the similar biomechanical capacity with rigid instrumentation, indication for dynamic implants was later extended to degenerative and iatrogenic instabilities. Materials and methods: In 8 years, we have placed 180 dynamic implants, of which 40 pure and 140 hybrid. The procedure was applied mainly in younger patients: 137 young-adults (mean 39y, range 25-58), and 43 cases over 60 (mean 67y, range 60-76) suffering from
889 different degenerative manifestations unresponsive to conservative therapies for 1-6 months. Complications, junctional syndromes, changes in ODI and VAS and improvement of ROM were recorded at final follow-up (mean 93 months; range 24-180). Results: A poorly positioned screw was immediately relocated. Four mechanical complications were recorded. Two junctional syndromes were reintervened. Follow-up in 165 cases (15 lost) showed an improvement of ODI (15 % (0-51) vs 54.9 % (20-92) p = 0.031) and VAS (7.4 (range 6-10) vs 3.8 (range 0-7) p = 0.037). ROM was reduced in 38 cases (23 %), mainly when instrumentation included S1. Conclusions: The experience of almost ten years in the field of dynamic lumbar instrumentation seems to be positive for low complication rate and low occurrence of junctional syndromes. The final clinical condition in our series is satisfactory. In about 20 % of cases, however, the painful symptoms remain significant, limiting the range of motion. Further investigation in relation to indication and extension of these types of implants are still needed to reduce failure rate.
SACRO-ILIAC JOINT SYNDROME TEN YEARS AFTER LUMBAR ARTHROPLASTY: THE IMPORTANCE OF SPINOPELVIC ALIGNMENT Riccardo Ciarpaglini MD, Gianluca Maestretti MD Spinal Unit, Department of Orthopaedic Surgery, Cantonal Hospital Fribourg, Switzerland Abstract Introduction: Sagittal balance is an independent predictor of outcomes in spinal care and several authors focused their attention on the lumbar lordosis restoration as the key point to prevent secondary sacroiliac joint dysfunction (SIJD) after fusion. On the other hand, lumbar disc arthroplasty allows preservation of motion avoiding increased stress on the spinopelvic junction and preventing iatrogenic sagittal imbalance. Methods: We analyze the incidence of a secondary SIJD and the spinopelvic alignment on a series of 31 consecutive lumbar disc prosthesis with a 10 year follow-up. Results: Sagittal balance assessment showed no significant variation of preoperative spinopelvic parameters. Four patients (12 %) presented a symptomatic SIJD. Only 2 of them required a percutaneous SIJ fixation. Both of them presented a fused L5-S1 prosthesis. Conclusions: The low rate of SIJD 10 years after lumbar arthroplasty might be explained by the preservation of the spinopelvic balance.
LUMBAR TOTAL DISC REPLACEMENT (TDR): CLINICAL AND RADIOLOGICAL EVALUATION OF A SERIES WITH 10 YEARS OF MEAN FOLLOW-UP Francesco Ciccolo1, Augusto Atilio Covaro2, Gemma Vila Canet2, Ana Garcia De Frutos2, Maria Teresa Ubierna Garces2, Enric Caceres Palou2 1
Scuola di Specializzazione, Universita` di Messina, Messina, Italy; Hospital Universitari Quiron Dexeus, Barcelona, Barcelona, Spain
2
Introduction: This is a retrospective analysis of clinical and radiological results of 21 total disc replacements (TDR). The possible correlation between pain control and lumbar spine sagittal balance was also evaluated. Degenerative disc disease DDD has a high social impact. After the failure of all conservative treatment options, surgery should be considered.
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890 Materials and methods: 21 patients, mean age 40 years (range 37-46), treated between 2000 and 2010 by the same surgeon, were analysed. Mean follow-up was 9.28 years (DS 2.5). Inclusion criteria for TDR was respected. Pain assessment and clinical outcome was reviewed through VAS (Visual Analogue Scale) and ODI (Oswestry Disability Index) questionnaires. The radiological analysis was performed by two independent operators, assessing preoperative, postoperative, and last follow-up control. Parameters analysed were: disc height (DH), segmental lordosis (SL), and range of motion (ROM) of the surgery level. All complications were recorded. Results: Student-T analysis showed clinical improvement, with a 5.3 point average decrease of VAS, and 20.7 % decrease in ODI (p \ 0.05). TDR improved SL and DH at the level of surgery in the x-ray control. The mean ROM was 6.18° (range: 0-18). There was no correlation between clinical outcome, ROM and adjacent segment syndrome. Four complications were recorded. Discussion and conclusions: A good implant, in terms of SL and DH recovery, can restore lumbar spine segmental sagittal balance at medium-long term follow-up. Appropriate surgical indications and an adequate surgical technique significantly improve the outcome of TDR.
TRAUMATOLOGY CLINICAL AND RADIOLOGICAL RESULTS OF TREATMENT OF THORACOLUMBAR FRACTURES BY PERCUTANEOUS TRANSPEDICULAR SCREW INSTRUMENTATION: RETROSPECTIVE STUDY ON 101 PATIENTS TREATED CONSECUTIVELY P. Quaglietta, S. Aiello, G. Corriero Azienda Ospedaliera di Cosenza, Cosenza, Italy; O.U. of Neurosurgery Object: The aim of our study is to report clinical and radiological outcomes of patients undergoing the surgical treatment by percutaneous trans-pedicular fixation in thoraco-lumbar spine injury. Methods: One hundred and one consecutive patients were enrolled over a period of 3 years with thoraco-lumbar fracture (A3.1-A3.3 according to the AO/Magerl classification) in absence of neurological deficits or other significant injuries. The pain profile was assessed by a visual analog scale (VAS) and clinical outcome was assessed by the Oswestry Disability Index (ODI). The radiological follow-up was defined by the vertebral body index (VBI), vertebral body angle (VBA) and bisegmental Cobb angle. Results: The mean surgical time was 75 ± 15 min. Percutaneously treated patients had a significantly lower perioperative blood loss compared with open surgical treatment. VAS scores were relatively good with a significative pain reduction from the first postoperative day. Radiographic evaluation showed an immediate improvement in the postoperaive period while an angle worsening in the final followup even if not clinically significant. No implant failure was noted during follow-up and no new surgery was required. No perioperative medical complication was recorded. All patients were mobilized the day after surgery and discharged after third or fourth day withouth external brace. Our rresults are still in the short term and further studies are needed in the longer follow-up to highlight whether such satisfactory results are maintained over time. We intend to continue to follow this protocol and review the majority of our patients over time.
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Eur Spine J (2015) 24:872–903 EARLY SPINE TOTAL CARE VS SPINE DAMAGE CONTROL IN POLYTRAUMA PATIENTS SUFFERED BY A3’S MARGEL THORACO LUMBAR SPINE FRACTURES AND LONG BONES INJURIES. VALUTATION OF: METABOLIC SHOCK, OUTCOMES AND COMPLICATIONS A. Medici1, L. Meccariello2, E. De Blasio3, G. Falzarano1 1
U.O.C. Orthopedics and Traumatology, Azienda Ospedaliera ‘‘Gaetano Rummo’’, Benevento, Italy, Chief: Dott Gabriele Falzarano; 2Department of Medical and Surgical Sciences and Neuroscience, Section of Orthopedics and Traumatology, University of Siena, University Hospital ‘‘Santa Maria alle Scotte’’, Siena Italy, Chief: Prof. Paolo Ferrata; 3U.O.C Anesthesiology, Intensive Care and Treating Pain, Azienda Ospedaliera ‘‘Gaetano Rummo’’, Benevento, Italy, Chief: Elvio De Blasio Abstarct: The ideal timing and strategy for the fixation of unstable vertebral fractures in polytrauma patients remains controversial. Does the early surgical fixation in type A3 spine fractures reduce the metabolic shock, outcomes and complications? From March 1st 2013 to September 30th 2014, we recruited 17 polytrauma young adult patients with A3 spinal thoraco-lumbar fractures and long bones injuries (LBI). Of these, 7 patients had Early Spine Total Care (ESTC) associated with fixation of LBI. 10 patients had Delay Spine Total Care (DSTC) after an average of 7.8 days from the fixation of LBI. Intra-operative conditions and the surgeon’s training in vertebral fracture management dictated the choice of treatment. Patients underwent seriated screening in the emergency room, before and after surgery, during hospitalization and during the 6 months of follow up for monitoring inflammatory markers (LDH, CPK, IL-6, IL-1, IL-8, TNF-a, ALFA1G); thrombosis (Fibrinogen, D-dimer), infection (ESR, CRP, Procalcitonin) and number of complications. We also evaluated the clinical exams and XRays. The evaluation end-point was set at 6 months. From the admission in Emergency Room to third month after the surgery there were statistically significant higher values (p \ 0.05) of inflammatory and thrombosis markers for DSTC group. After the third month there was no statistically significant difference between ESTC and DSTC. We observed 3 complications in the DSTC group and 1 in the ESTC. From our data, we can corroborate that staged surgical treatment in polytrauma patients with vertebral fractures does not entail negative outcomes and catastrophic complications.
PERCUTANEOUS SHORT FIXATION (PESFIX) IN THE TREATMENT OF UNSTABLE THORACOLUMBAR FRACTURES: CLINICAL AND RADIOLOGIC OUTCOME AT LONG TERM FOLLOW UP S. Forcato1, M. Cimatti1, L. De Martino1, F. M. Polli1, A. Frati1, M. Miscusi2, A. Raco1 1
Sapienza of Rome, AO Sant’Andrea Hospital, Rome, Italy; Sapienza of Rome, ICOT, Latina, Italy
2
Introduction: MISS treatment for unstable thoracolumbar fractures is in discussion due to the risk of kyphosis, failure of the implant, pain and instability, especially in the long-term. The aim of this prospective study is to analyze the clinical and radiologic outcome in 50 unstable thoracolumbar fractures treated by percutaneous short segment fixation (PesFix). Materials and method: From 2010, fifty unstable thoracolumbar traumatic fractures are enrolled in this study. All the patients with neurological deficit and oncological pathologies were excluded from this study.
Eur Spine J (2015) 24:872–903 The fractures are classified from type A3 to type B3 according to the AO Classification. All patients are treated by PesFix within 24 h. The patients are evaluated pre-operative, post-operative and up to 5 years radiologically: MSI, Cobb´s angle and Sagittal Index (SI); and clinically: SF-36 Questionnaire, Oswestry disability index and return-to-work. Findings: All the patients, except for one patient, were mobilized in the first post-operative day without brace. No implant failure or infection occurred. Only two patients decided to remove the implant at 24 months and 32 months, respectively. All patients remained neurologically intact. There was only one minor wound revision. Restoration of MSI, Cobb’s angle and SI were obtained in all patients with significant differences in preoperative and follow-up (p \ 0.05), and maintained correction in the long-term. Scores for ODI and SF-36 improved significantly (p \ 0.05). Conclusion: The PeSFix technique can be considered safe and effective to treat type A and type B fractures in neurological intact patients, even in the long period follow-up. Introduzione: Le tecniche chirurgiche MISS per il trattamento delle fratture toracolombari sono oggi argomento di discussione soprattutto per i risultati a lungo termine di cifosi post-operatoria, failure dell’impianto, dolore e stabilita`. Presentiamo pertanto una serie di 50 fratture del segmento toracolombare trattate con tecnica percutanea pura senza artrodesi con un follow-up di 5 anni, analizzandone i risultati. Materiali e metodi: Sono state prese in considerazione dal 2010, 50 fratture comprese tra T11 e L4 con patogenesi traumatica. I criteri di esclusione sono le fratture patologiche e i pazienti con deficit neurologico. L’eta` media e` stata di 48 anni. I pazienti sono stati sottoposti ad intervento di stabilizzazione vertebrale short percutanea pura entro le prime 24 h dal trauma. Secondo la classificazione AO, le fratture trattate sono comprese tra i gradi A3 e B3. I pazienti sono stati seguiti con controlli radiologici e clinici mediante somministrazione di test di valutazione (Oswestry e SF-36) fino ad un follow-up 60 mesi. Risultati: Tutti i pazienti tranne uno sono stati mobilizzati in piedi senza busto nella prima giornata post operatoria. Non ci sono stati casi di infezione, loosening delle viti o failure dell’impianto. In un solo caso si e` avuto una lesione da pressione in corrispondenza della testa delle viti, risolta con revisione della ferita in anestesia locale. Due pazienti hanno richiesto la rimozione del sistema di fissaggio a 24 e 32 mesi per cattiva compliance con lo stesso. Infine in un singolo caso si e` evidenziato un peggioramento della cifosi a distanza di 30 mesi, in assenza di conseguenze clinico-neurologiche. In tutti i casi si e` assistito ad un netto e progressivo riassorbimento del frammento intracanalare a livello della vertebra fratturata. Discussione e conclusioni: La stabilizzazione pura percutanea senza artrodesi delle fratture toracolombari risulta efficace nel ridurre i rischi operatori per i pazienti politraumatizzati, velocizzare la mobilizzazione e correggere i valori della colonna vertebrale lesionata. Possiamo sottolineare come, suppur con modesto numero di pazienti trattati e un follow up di 5 aa, non si renda piu` necessario decomprimere il canale vertebrale o eseguire una procedura open.
MINIMALLY INVASIVE SURGICAL TREATMENT OF THORACO-LUMBAR BURST FRACTURES: IS USEFUL THE SCREW IN THE PEDICLE OF THE FRACTURED VERTEBRA ? C. Doria, M. Gallo, G. Angiolini, F. Milia, M. Balsano Orthopaedic Department, University of Sassari (Italy); Orthopaedic Department, Santorso Hospital AUSSL 4 Schio (Italy) Introduction: The goals of surgical treatment of unstable thoracolumbar fractures are early loading and recovery of gait as well as the
891 correction of spinal deformity with the restoration of the mechanical stability of the spine in order to prevent the onset of late deformity or neurological deficits. Short instrumentations are burdened by high failure rates that can be reduced by inserting a pedicle screw at the level of vertebra fracture site. Materials and methods: The aim of our work was to compare the outcome of surgical treatment of thoraco-lumbar burst fractures with or without screw placement in the pedicle of the fractured vertebra. In this study, we examined 26 patients (18 males, 8 females, with mean age 39.2 years), all suffering from burst fracture classified as B2 according Magerl and treated by reduction by ligamentotaxis and pedicle fixation with short instrumentation. In 12 cases we placed a pedicle screw into the fractured vertebra (group 1); in the remaining 14 cases, we placed two screws in the pedicles of the vertebra cranial and two screws in the pedicles of the vertebra caudal to the fracture (group 2). All patients underwent pre-operative X-rays, CT and MRI of the affected segment. Plain x-rays were carried out in the various post-operative controls at 3, 6 and 12 months to assess the segmental kyphosis and height of the vertebral body. In patients with poor clinical outcome TC scans were performed for a more precise measurement of the deformity. Results: The intra-operative blood loss and surgical times are comparable in both groups. No neurological deterioration was observed in any case. The loss of segmental kyphosis correction and reduction of the height of the vertebral body was more significant in group 2. Conclusions: The use of pedicle screw in the fractured vertebra improves the correction of kyphosis while maintaining the height of the vertebral body; this technique reduces also the incidence of fatigue fractures of the implants. In the results obtained a loss of correction of kyphosis from 3° to 8° in patients of group 2 with a loss of vertebral height from 3 % to 12 % was recorded.
THE TREATMENT OF THORACO-LUMBAR UNSTABLE VERTEBRAL FRACTURES BY PERCUTANEOUS TECHNIQUE: 3D CT EVALUATION AND CHROMEDENSITOMETRY ANALYSIS Daniele Vanni1,4, Renato Galzio2, Francesco Saverio Sirabella1, Matteo Guelfi1, Andrea Pantalone1, Antonio Sparvieri3, Vincenzo Salini1, Vincenzo Magliani4 1
Clinica Ortopedica e Traumatologica, Universita` ‘‘G.d’Annunzio’’, Chieti, Italy; 2Dipartimento di Neurochirurgia, Universita` degli Studi dell’ Aquila, L’Aquila, Italy; 3Dipartimento di Diagnostica per Immagini, Ospedale ‘‘Floraspe Renzetti’’, Lanciano, Italy; 4U.O. Chirurgia Vertebrale, ASL-2 Lanciano-Vasto-Chieti, Italy Introduction: The concepts of ‘‘tissue-sparing’’ and ‘‘minimally aggressive’’ surgery are gradually influencing surgical approach to vertebral pathology, both traumatic and degenerative. Materials and methods: The aim of the study is to evaluate the fracture healing model in case of unstable thoracolumbar vertebral fractures, treated by posterior percutaneous approach (PPA). Since March 2011, 89 patients with this fracture pattern were enrolled in the study. Patients were randomly divided into 2 homogeneous samples. PPA and standard posterior open approach were performed in patients of group A (46 patients) and B (43 patients, control), respectively. A clinical follow-up was performed at months 1, 3, 6 and 12 (using VAS and ODI), and a and radiographic follow-up was carried out at months 1, 6, 12. Twelve months after surgery a CT scan with 3D reconstruction and chrome-densitometry analysis was obtained. Results: The 3D reconstructions and the chrome-densitometry evaluation at 12 months showed a more homogeneous and organized trabecular architecture recovery in group A in comparison to group B. The PPA acts as an angular stability fixation system, allowing the
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892 ‘‘biological’’ healing process to follow its course (according to Wolf’s law), thus generating better clinical and radiographic results. Conclusion: Unstable thoracolumbar fracture PPA is an effective alternative to the classic open standard treatment. This treatment helps preserve the natural healing process, which may explain the better results and faster recovery times. This technique represents a safe and effective treatment, in terms of clinical and radiographic findings.
VERTEBROPLASTY AND KYPHOPLASTY: COMPARISON BETWEEN TWO TECHNIQUES FOR THE TREATMENT OF OSTEOPOROTIC VERTEBRAL FRACTURES G. Barbanti Brodano, S. Bandiera, A. Gasbarrini, R. Ghermandi, L. Babbi, C. Griffoni, L. Boriani, S. Colangeli, S. Terzi, S. Boriani Struttura Complessa di Chirurgia Vertebrale Oncologica e Degenerativa, Istituto Ortopedico Rizzoli, Bologna, Italy Introduction: Currently, there are two surgical techniques for the treatment of osteoporotic vertebral fractures: percutaneous vertebroplasty and kyphoplasty. Our study is a prospective, randomized study comparing the two surgical techniques, by analyzing their effects in terms of pain and quality of life. Materials and methods: We have randomly assigned treatment with kyphoplasty to 66 patients and treatment with vertebroplasty to 66 patients. The clinical status of the patients was examined by administering to patients, before and after surgery, self-assessment test on pain (VAS, visual analog pain score), function (ODI, Oswestry Disability Index) and quality of life (Euro QoL-5D). The radiographic results were evaluated in relation to the resolution of the fracture and the possible occurrence of further osteoporotic fractures during follow-up. Results: Overall, good results have been obtained following the surgical treatment of osteoporotic fractures with both techniques, both from the clinical point of view and from the radiographic point of view. The kyphoplasty group presented a VAS reduction of 39 %, an ODI reduction of 28.6 % and a QoL increase of 19 %. The vertebroplasty group presented a reduction in the VAS value of 26 %, an ODI reduction of 17 %, and a QoL increase of 15.2 %. Conclusion: The results indicate a good efficacy of both surgical procedures (vertebroplasty and kyphoplasty) in the treatment of osteoporotic vertebral fractures, in terms of reducing pain and improving function and quality of life. Analysis of these results and those of larger studies might question whether the economic burden of kyphoplasty on the National Health System is justified by better clinical results compared to those obtained using the simpler procedure of vertebroplasty.
EXPANDABLE PEDICLE SCREWS (OSSEOSCREW) FOR THE TREATMENT OF OSTEOPOROTIC SPINAL DISEASES Roberto Gazzeri MD, Massimiliano Neroni MD, Andrea Faiola MD, Claudio Fiore MD Department of Neurosurgery, San Giovanni Addolorata Hospital, Rome, Italy Introduction: Osteoporosis is a major global health problem with over 10 million people currently diagnosed with poor bone quality. Although 80 % of osteoporotic patients are women, a considerable number of men are also affected. Due to increasing life expectancy, the number of elderly patients with osteoporosis affected by spinal diseases will increase significantly. Despite all
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Eur Spine J (2015) 24:872–903 the advancements in spinal fusion, optimal pedicle screw fixation in low quality bone is still a concern. Pedicle screw instrumentation of the osteoporotic spine carries an increased risk of screw loosening, pull-out and fixation failure. Our preliminary study aims to investigate the efficiency of expandable pedicle screws (Osseoscrew, Scient’x – Alphatec Spine) in osteoporotic spinal patients. Materials: A total of 30 patients were enrolled in this study. All osteoporotic patients with degenerative and traumatic spinal disease admitted in our department performed a preoperative spinal X-Ray and MRI or CT. Preoperative clinical assessment of patients was based on VAS scale and ODI questionnaire. The subjects included 6 male and 24 female patients. The mean age was 61.4 years, with a mean follow up period of 35.2 months. Spinal disease on admission was osteoporotic compression/burst fracture in 14 patients, and degenerative disease in 16 patients. Results: At 2 years follow-up, there was no sign, of radiolucency around the pedicle screws on plain radiographs and spinal CT. There was no appreciable screw loosening or migration on spinal X-Ray and CT scans at 6 and 12 months follow-up. Functional capacity and pain evaluated by ODI and Visual Analogue Scale showed significantly improvement between preoperative and postoperative period including the 12 and 24 months follow-up. Complications: 2 patients presented subcutaneous CSF leakage after surgery. Conclusions: Osseoscrew expandable pedicle screws provide a significant stabilization in the osteoporotic spine because of its superior biomechanical properties. The energy required to fail the expanding screws is significantly greater than a standard screw, meaning there is greater grip after experiencing cyclic loads. The increased fixation strength may prevent screw pull-out in osteoporotic patients and in pedicle screw revision surgery.
VERY SHORT SEGMENT POSTERIOR INSTRUMENTATION IN THORACOLUMBAR SPINE FRACTURES Leonardo Antonio Zottarelli1, Giovanni Andrea La Maida2, Giorgio Lofrese3, Marcello Ferraro2, Bernardo Misaggi2 Universita` degli Studi di Milano, Milan, Italy; 2Orthopaedic Institute Gaetano Pini, Milan, Italy; 3Universita` Cattolica del Sacro Cuore, Rome, Italy 1
Introduction: Anatomy and biomechanics of thoracolumbar spine place these segments at high risk of trauma injuries. Treatment options are either conservative or surgical, and to this day there is lack of consensus about the right indication. Literature agrees only on basic surgical principles: vertebral stability, deformity correction, protection of neurologic structures and fast functional recovery. The most commonly used approach is the posterior one, allowing the best management of most vertebral fracture patterns. Matherials and methods: This is a retrospective clinical and radiologic study. We evaluated 120 consecutive patients treated with a monosegmental (Group A) or bisegmental (Group B) posterior peduncular instrumentation for thoracolumbar fractures. Fractures were classified by the new AO Spine TLIC system. Average follow up was 30 months. Clinical and radiologic results of both groups were compared statistically. Results and conclusions: Our study confirmed the validity of the short instrumentation, especially the monosegmental one, in the treatment of most vertebral fractures patterns, the A4 type included. In B type and C type fractures, correct surgical indications must be evaluated on an individual basis.
Eur Spine J (2015) 24:872–903 MID-TERM RESULTS OF A SURGICALLY TREATED THORACO-LUMBAR FRACTURE G. Calabro`1, G. Toro1, M. De Falco1, F. Nappi1, G. Landi2, A. Siano2, A. Toro1 1 Orthopaedic and Traumatology Unit, ‘‘Villa Malta’’ Hospital, Sarno, Italy; 2Orthopaedic and Traumatology Unit, ‘‘Santa Maria della Speranza’’ Hospital, Battipaglia, Italy
The thoracic and lumbar spines are the most common location of vertebral fractures, and in particular the thoraco-lumbar junction. It is clear that unstable fractures require surgical treatment, but the type and length of fixation are still controversial issues. We retrospectively evaluated all patients surgically treated between 2008 and 2012 who met the following criteria: single level thoraco-lumbar fracture in an age range of 18-60 years, excluding osteoporotic and pathologic fractures. All fractures were classified using the AO classification and evaluated according to the type and length of stabilization. 65 patients (53 male, 13 female) met inclusion criteria. A clinical evaluation was performed using VAS and Oswestry Disability Index, and the degree of local kyphosis and of vertebral collapse were calculated through an X-ray. We observed no clinical difference according to the type of fixation, however long constructs seemed to ensure a better result in term of preservation of anterior body height and the local kyphosis angle correction achieved. It still is unclear what fixation should be performed to stabilize thoraco-lumbar fracture in order to obtain the best clinical long-term result. More studies are needed to establish the most appropriate treatment.
KYPHOSIS EVALUATION OF SAGITTAL BALANCE AND QUALITY OF LIFE IN ACHONDROPLASTIC PATIENTS UNDERGOING LIMB LENGTHENING Francesco Ciccolo1, Augusto Atilio Covaro2, Gemma Vila Canet2, Ana Garcia De Frutos2, Maria Teresa Ubierna Garces2, Ignacio Ginebreda Martı`2, Enric Caceres Palou2 1
Scuola di Specializzazione, Universita` di Messina, Messina, Italy; Hospital Universitari Quiron Dexeus, Barcelona, Barcelona, Spain
2
Introduction: Bilateral lower limb lengthening remains controversial and its effects on sagittal spine parameters largely unknown. The aim of the study was to analyse sagittal spinal alignment, pelvic orientation and Quality of life (SF-36), in achondroplastic patients that underwent limb lengthening surgery. Materials and methods: A retrospective review was performed in 30 patients, who underwent limb lengthening protocol at 11 years of age, with a mean follow-up of 12 years. Standing full spine lateral x-rays including the hip joint were performed. The radiographic parameters examined were: sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), S1 overhang (OH), thoracic kyphosis (TK), lumbar lordosis (LL), T10-L2 kyphosis (TLJK), and sagittal balance (SB). Each patient was given a questionnaire for quality of life (QOL) by SF-36 scoring. Results Our radiographic parameters showed the following mean values: SS: 38.64° (SD 13.62°), PT: 22.13° (11.05°), PI: 61.27° (18.19°), OH: 30.22 (10.16), LL: 43.16° (23.69°), TK: 23.03° (14.86°), TLJK: 17.07° (13.91°), SB: -26.64 mm (34.61 mm). Physical and mental domains of SF-36 showed the following mean values: PC: 51.30 (SD 7.57), MC 51.69 (SD 7.15).
893 Discussion and conclusions: Our analysis corroborated that achondroplasic patients undergoing limb lengthening have a specific lumbo-pelvic morphology, that is more similar to a normal population than to an achondroplasic population without limb lengthening. Further research is necessary to clarify the possible relationship between spine sagittal balance and quality of life in achondroplasic patients undergoing limb lengthening.
CLASSIFICATION OF SAGITTAL IMBALANCE BASED ON SPINAL ALIGNMENT AND COMPENSATORY MECHANISMS C. Lamartina, R. Cecchinato, R. Bassani, G. Casero, M. Pejrona, P. Berjano IRCCS Istituto Ortopedico Galeazzi, Milan, Italy Introduction: Sagittal alignment of the spine is an independent predictive factor of clinical outcome after surgical treatment of spinal pathologies. Guidelines for surgical treatment are not currently based on a classification. A comprehensive classification of the sagittal alignment based on regional deformity and on compensational mechanisms is proposed to define deformity patterns. Even if sagittal alignment can change after degenerative pathologies or traumas, precise correlations between sagittal parameters and pelvic incidence (PI) have been described in literature. PI remains unchanged in adult life, being a constant source of information on original sagittal alignment of the spine. Materials and methods: 128 lateral full-standing x-rays of patients affected by different spinal pathologies have been analyzed and classified by an independent observer. 35 of these, randomly chosen, have been evaluated by two observers to define the inter-observer variability. Spinopelvic parameters have been measured in all the x-rays. Classification validity has been evaluated comparing sagittal parameter values among the different categories. Results: The following deformity patterns have been distinguished, considering deformity location and compensation mechanisms: Cervical Kyphosis, Thoracic Kyphosis, Thoracolumbar Kyphosis, Lumbar Kyphosis, Distal Lumbar Kyphosis, Global Kyphosis, Pelvic Kyphosis, Normal Sagittal Alignment. Inter-observer correlation was very high (k = 0.963). A statistically significant difference has been observed comparing the mean values of predetermined sagittal parameters in different deformity types: C2-7 SVA between Cervical Kyphosis and the other groups; TK-PI mismatch between Thoracic Kyphosis and the other groups; T11L2 kyphosis between Thoracolumbar Kyphosis and the other groups; global alignment (LL + TK-PI) and SVA between Lumbar and Global Kyphosis; Pelvic Tilt (PT) between Pelvic, Distal Lumbar and Global Kyphosis. Conclusions: In this study a general classification of sagittal balance is presented. This classification allows a better interpretation of deformity and of muscular strains on the spine, helping the spine surgeon in preoperative planning.
SURGICAL TREATMENT OF SEVERE SCHEUERMANN KYPHOSIS M. Palmisani, E. Dema, S. Cervellati Hesperia Hospital, Modena, Italy Introduction: The literature suggests that surgical treatment of severe Scheuermann kyphosis by posterior approach only, with pedicle
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894 screw fixation combined with Ponte osteotomies, allows for optimal correction. Objective: To evaluate our results of surgical treatment of Scheuermann kyphosis with pedicle screw fixation and Ponte technique in a posterior only approach. Methods: 32 patients (27 male and 5 female) with a Scheuermann kyphosis; 27 underwent a posterior only approach with segmental pedicle screw fixation at all fusion levels and 5 underwent combined anterior and posterior approach (4 in a single surgery and 1 in a staged surgery). In all severe cases we performed a Ponte technique at the apex of the deformities. Results: At the mean F.U. of 6 years (1-10 years) the correction of the instrumented levels was 56 %. The loss of correction at F.U. was 3*. Complications: 1 PJK (proximal junctional kyphosis) and 2 DJK (distal junctional kyphosis) recovered surgically with extension of arthrodesis. 2 neurological complication (1 anterior and 1 posterior cord injury) with a complete recovery. Conclusion: Surgical treatment of severe Scheuermann kyphosis by posterior only approach with segmental pedicle screw fixation and Ponte osteotomy allows for an optimal correction with a minimal loss of correction at follow-up.
SEVERE SCOLIOSIS AND SPONDYLOLISTHESIS ONE-STAGE POSTERIOR DECOMPRESSION, STABILIZATION AND TRANS-SACRAL INTERBODY FUSION AFTER PARTIAL REDUCTION FOR SEVERE L5-S1 SPONDYLOLISTHESIS: LONG TERM FOLLOW-UP D. Pasquetto, M. A. Marino, M. Scaglia, E. Donella, P. Bartolozzi, B. Magnan Ospedale Civile Maggiore, Verona, Italy Introduction: Various treatments are reported in literature, for high grade displastic spondylolisthesis. We present long term results in patients affected by severe L5-S1 spondylolisthesis treated with one-stage posterior decompression and circumferential stabilization with a trans-sacral cage. Methods and materials: Fifty patients (17 males and 33 females) affected by high grade displastic L5-S1 spondylolisthesis have been surgically treated, from 1997 to 2011. All patients suffered from low back pain, associated with radiculopathy in 38 cases. The average age at the time of surgery was 24 (range 11-59). Clinical outcomes were retrospectively studied and assessed with Oswestry Disability Index questionnaire and VAS (preoperative, postoperative and at follow-up). Radiologic study included standard X-Ray (preoperative, postoperative and at follow-up) and MRI (preoperative and at follow-up). Mean follow-up was of 10 years (range 3-16 years). 6 patients were lost to follow-up. Results: At follow-up all the patients were satisfied, with a mean ODI score of 7 % and VAS of 2/10. There were no cases of non-union, infection or implant failure. There was only a major complication due to an intraoperative lesion of an iliac vein. Discussion and conclusion: One-stage posterior decompression and partial reduction associated with circumferential stabilization combining pedicle fixation with trans-sacral titanium cage interbody fusion is an effective and safe technique for the management of severe spondylolisthesis.
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Eur Spine J (2015) 24:872–903 SPINO-PELVIC ALIGNMENT AFTER SURGICAL TREATMENT OF HIGH GRADE SPONDYLOLISTHESIS C. Faldini, A. C. Di Martino*, K. Martikos**, A. Toscano, F. Perna**, R. Borghi**, T. Greggi** Dipartimento Rizzoli-Sicilia, Bagheria, Italy; *Universita` Campus Bio-Medico, Rome, Italy; **Istituto Ortopedico Rizzoli, Bologna, Italy Introduction: Recent studies focused on the importance of evaluation of spinopelvic parameters (SPPs) in planning the surgical treatment of high-grade spondylolisthesis as a prognostic factor. Purpose: To analyze changes in spino-pelvic parameters (SPPs) after surgery of high-grade lumbar isthmic spondylolisthesis (HDIS). Methods: We analyzed 41 patients affected by HDIS treated by reduction and posterior spinal fusion with pedicle screw systems with or without interbody fusion. Pelvic tilt (PT), lumbar lordosis (LL), pelvic incidence (PI), and sacral slope (SS) were measured, and patients were further divided into balanced and unbalanced pelvis subgroups. Results: SS passed from 46.8° ± 9.8° preoperatively to 50.1° ± 10.1° (p = 0.02). PT passed from 26.7° ± 6.7° preoperatively to 22.9° ± 7.5° (p = 0.003). Unbalanced patients showed significantly higher PT and lower SS compared to the balanced patients preoperatively, and these corrected after surgery. Patients with instrumentation failure (n = 5) had significant increase in PT values postoperatively (p = 0.018). Conclusions: We confirmed the positive effect of surgery on the SPPs in patients affected by HDIS. Different patterns of correction were observed after surgery between balanced and unbalanced pelvis patients.
ONE STAGE SURGERY THROUGH POSTERIOR APPROACH FOR THE TREATMENT OF HIGH-GRADE DEVELOPMENTAL L5-S1 SPONDYLOLISTHESIS A. Bucciero, G.A. Piscopo, G.Olindo, G. Taddei, A. Zaccariello, G. Nicosia Department of Neurosurgery, Pineta Grande Hospital, Castel Volturno (CE), Italy Introduction: The purpose of this study was to evaluate the clinical and radiological outcomes of one-stage surgery through posterior approach for high-grade L5-S1 spondylolisthesis. Materials and methods: Fifteen consecutive patients (9 males and 6 females with an average age of 28.6 years) with high-grade developmental L5-S1 spondylolisthesis who underwent surgery at our institution between 2010 and 2014 were reviewed retrospectively. There were 13 Grade III, 1 Grade IV, and 1 Grade V slips. Follow-up ranged between 1 and 3 years with an average of 1 year. All of the surgical procedures were performed using the isolated posterior approach and a similar technique: laminectomy, transpedicle screw fixation, reduction of slippage, and posterolateral interbody fusion with a cage. Patients were clinically studied pre and postoperatively using VAS and ODI. Sagittal balance was evaluated measuring: SS, PT, LL and C7 plumb-line. Results: There were no perioperative complications. At follow-up all patients showed reduction of the degree of slippage, as well as a statistically significant improvement of mean VAS score and mean ODI score. The analysis of balancing parameters demonstrated a restore of sagittal balance with an increase of the SS, reduction of the PT and recovery of LL.
Eur Spine J (2015) 24:872–903 Conclusions: One-stage surgery through posterior approach is an effective procedure for the treatment of high-grade L5-S1 spondylolisthesis.
LOW DYSPLASIA SPONDYLOLISTHESIS TREATMENT IN PEDIATRIC AND ADOLESCENT PATIENTS Marco Crostelli, Osvaldo Mazza, Massimo Mariani, Dario Mascello Spine Disease Unit, Ospedale Pediatrico Bambino Gesu`, Rome, Italy Introduction: In the Marchetti and Bartolozzi classification low dysplasia spondylolisthesis is characterized by a relatively normal sagittal shape of the lumbosacral spine, rectangular shape of the L5 vertebra, flat S1 vertebra plate and absence of a vertical sacrum or hyperlordosis. Materials and methods: From 1995 to 2013 we treated 50 patients, mean age 12 years and 7 months, with symptomatic low dysplasia L5 spondylolisthesis. All patients had lumbar pain, in 25 cases with concomitant sciatic pain and paraesthesia in the lower limbs. 20 patients were treated by bracing for 6 weeks. 20 patients were operated by postero-lateral instrumented arthrodesis after reduction. 10 patients were operated by reduction and posterolateral instrumented arthrodesis in addition to L5-S1 intersomatic arthrodesis with cages and autologous bone. After surgery all patients were braced for a mean of 5 weeks. Patients with grade I and II lytic spondylolisthesis were first treated with bracing for 6 weeks. This treatment is successful in 70 % cases. In grade III spondylolisthesis with pars interarticularis intact we operated without previous bracing. Results: Mean follow up was 7 years and 6 months. No operated patient had major complications (nervous, vascular or visceral injuries, infection, non union, instrumentation failure). 85 % patients had optimal functional outcome with complete resolution of symptoms, 15 % had good results with pain reduction. 75 % patients that practiced sport continuously before surgery returned to the previous level of activity after surgery. Discussion and conclusions: Low dysplasia spondylolisthesis in pediatric and adolescent patients can be effectively treated by bracing and/or surgery depending on symptoms and vertebral slip severity.
A NEW NAVIGATION TOOL FOR PEDICLE SCREW PLACEMENT IN PATIENTS WITH SEVERE SCOLIOSIS C. Lamartina, R. Cecchinato, A. Zerbi, M. Putzier1, P. Strube1, E. Hoff1, P. Berjano IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; 1Klinik fu¨r Orthopa¨die, Centrum fu¨r Muskuloskeletale Chirurgie, Charite´, Universita¨tsmedizin Berlin, Berlin, Germany Introduction: Pedicle screws implant is a highly demanding technique in patients affected by severe scoliosis, with vertebral rotation and pedicle abnormalities. The aim of this study is the validation of the accuracy of a new custom-made navigation hardware for scoliosis surgery. Materials and methods: Pedicle screw implanting guides have been created for four patients affected by severe scoliosis. This procedure was based on a 3D reconstruction of a low dose CT scan. The design of the guides was different between the thoracic and the lumbar area according to the individual anatomy, with the aim of obtaining an optimal coupling between the hardware and the bony structures to maximize the stability of the guides. Screw position has been evaluated postoperatively with a CT scan, in order to compare the results with preoperative planning and identify any pedicle violation.
895 Results: A total of 76 pedicle screws have been implanted (56 thoracic, 20 lumbar). Two screws (2.6 %) were intraoperatively considered misplaced and were replaced immediately. At the CT scan, 84 % of screws were inside the pedicle; this value increased to 96.1 % when considering the screws that violated the lateral cortical bone less than 2 mm as valid. No medial violation or neurovascular lesion was observed. No implant-related complication was observed postoperatively. Conclusions: The new custom-made guides for pedicle screw implant demonstrated high accuracy in screw placement in severe scoliosis. Further studies are needed to validate these results.
MISCELLANY AND CASE REPORT LUMBAR DISC HERNIATION: COMPARISON OF CONSERVATIVE TREATMENT BY PULSED RADIO FREQUENCY AND SURGICAL TREATMENT Giovanni Barbanti Brodano, Giancarlo Facchini1, Alessandro Gasbarrini, Stefano Bandiera, Silvia Terzi, Riccardo Ghermandi, Ugo Albisinni1, Stefano Boriani Struttura Complessa di Chirurgia Vertebrale Oncologica e Degenerativa, Istituto Ortopedico Rizzoli, Bologna, Italy; 1Struttura Complessa di Radiologia Diagnostica e Interventistica, Istituto Ortopedico Rizzoli, Bologna, Italy Introduction: The surgical removal of a herniated disc is now a safe procedure when performed by experienced hands. Encouraging results are also reported with the use of a percutaneous procedure of pulsed radiofrequency (PRF). Materials and methods: We performed a pilot study for the comparison of the two treatments, radiofrequency and surgery, in patients with lumbar disc herniation for which the conservative therapy (medical therapy and physical therapy) failed. In the study 33 patients have undergone surgery and 18 patients have undergone PRF. For both groups radiographic and clinical outcomes were collected. Clinical outcomes were quantified using self-administered questionnaires for the assessment of pain (VAS) and function (ODI), before the treatments and at 3, 6, and 12 months of follow up. Results: A significant effect in terms of pain reduction was detected three months after treatment both in the surgery group (VAS pre 8.3; VAS post 2.6) and in the group receiving PRF (VAS pre 7.3; VAS post 3.7). This improvement was maintained after 12 months in the surgery group (VAS: 2.4) and it was further increased in the group treated with PRF (VAS: 1.9). Function significantly improved both after surgery (ODI pre 64; ODI post 21) and in the group receiving PRF (ODI pre 44; ODI post 22). The functional improvement continued in the course of follow-up for both groups. Discussion and conclusions: The results so far obtained indicate a good efficacy of surgery and PRF for the treatment of lumbar disc herniation in patients appropriately selected for the one or the other type of treatment.
RADIOFREQUENCY NEUROTOMY OF LUMBAR FACETS IN TREATING LOW BACK PAIN: BETTER RESULTS IN ASSOCIATION WITH PHYSICAL ACTIVITY? F. Sasso, M. Barbato, C. Piergentili Department of Orthopaedic and Trauma Surgery, University ‘‘Federico II’’ of Naples, Naples, Italy
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896 Background: The prevalence of low back pain is 60-90 % in the adult population. Of these, 15-52 % is caused by lumbar zygapophysial joint arthropathy. The medial branches of the dorsal rami of the spinal nerves innervate the lumbar facet joints, and pain relief can be obtained by radiofrequency thermal neurotomy. We report on the effects of this treatment applied to our cohort of patients. Methods: In this study, 79 patients with clinical signs of zygapophysial joint arthropathy, who had failed conservative treatment and had a favorable response to a diagnostic medial branch block, underwent radiofrequency neurotomy. The recommendation after treatment for all patients was to practice physical exercise. Visual analog scale (VAS) pain score, analgesic drugs assumption, incidence of complications and overall patient satisfaction were recorded. Results: Mean VAS score was evaluated preoperatively, at 1-month and at 1-year, being respectively 77.3, 31.7, and 37.5. After 1 year, the improvement of VAS score was better in patients who had exercised or had had physical therapy than in patients who hadn’t practiced any physical activity. 60 patients referred no analgesic requirements and 19 referred occasional requirement. 77 patients were satisfied with the results and only 2 were not satisfied. There were no complications from the procedure. Conclusions: The results of this study show that the radiofrequency neurotomy of lumbar facets is an effective, simple and safe treatment for low back pain caused by zygapophysial arthropathy. Better and longer lasting relief occurs when radiofrequency neurotomy treatment is combined with physical activity.
COSTOTRANSVERSE SCREW FIXATION IN A SEVERE CERVICOTHORACIC DEFORMITY DUE TO A TYPE-1 NEUROFIBROMATOSIS S. Paderni, M. Cappuccio, A. Corghi, L Amendola, L Mirabile, F. De Iure UOSD Chirurgia Vertebrale d’Urgenza e del Trauma, Ospedale Maggiore Bologna, Italy Introduction: Spinal implant placement may be challenging in cases of severe cervicothoracic spinal deformities and anatomical anomalies as in type 1 neurofibromatosis. Intralaminar screwing of the thoracic spine has been described in few cases in which pedicles were hypoplasic. The costovertebral joints have never been used before as an anchorage point for screws. Methods: An 18-year-old female with progressive tetraparesis caused by increasing deformity of the cervicothoracic spine underwent evaluation and surgical treatment: procedure and techniques were described. Clinical and radiologic features, and the outcome were assessed. Complications and local recurrences were also recorded. Results: Costotransverse joint screwing was successfully used in one case of severe cervicothoracic spine deformity with major hypoplasia of the pedicles. The posterior arch of one thoracic vertebra became mobile soon after periosteal stripping probably due to iatrogenic fracture of the only existent pedicle. The four-cortical trajectory of the screws resulted in a good bone purchase allowing the surgeon to complete the procedure. No local or general complications were recorded during two years of follow-up. Conclusion: The procedure was used as a salvage technique during a difficult surgery where a local complication forced a change of strategy. Although the implant remained stable long enough to achieve fusion, it still consists in placing a screw through a joint that remains slightly mobile. This could possibly result in a screw loosening in the long-term if fusion is not achieved. We suggest the use of
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Eur Spine J (2015) 24:872–903 this technique when all other options have been explored and excluded for anatomical reasons.
TUMORS VERTEBRAL METASTASES: GOALS OF TREATMENT AND PROGNOSTIC FACTORS M. Dobran, D. Brunozzi, M. Iacoangeli, V. Liverotti, R. Benigni, C. Vaira, R. Colasanti, C. Curzi, M. Scerrati Clinic of Neurosurgery, University of Ancona, Ancona, Italy Introduction: We analyze some prognostic factors that may influence survival in patients operated for spinal metastases by means of the univariate analysis (Kaplan–Meier test) and multivariate analysis (Cox Proportional Hazards Regression). Materials and methods: From January 2007 to December 2012, 77 patients with spinal metastases were operated (46 males and 31 females), mean age of 64 years old. The follow-up range spanned from 22 to 71 months. The origin of the primary tumors are breast (10), prostate (9), lung (10), kidney (7) and unknown (6). For 67.5 % of patients the tumor was located at the thoracic segment, 15.5 % at the lumbar level and 7.5 % at cervical level. 75 patients presented with neurological deficit and/or pain (97 %). Results: After surgery the median survival time was 7 months, the improvement of pain or neurological deficit was obtained in 75 % of patients while 25 % did not present any benefit. In our series histology of the primary tumor (p = 0.03), the post-operative Frankel score (p = 0.0011), presence of post-operative pain (p = 0.041), the extension of the disease (p = 0.03) and adjuvant therapy (p \ 0.0001) were significantly related to survival probability in the univariate analysis. In the multivariate analysis, histology of the primary tumor (p = 0.04), extension of disease (p = 0.008) and adjuvant therapy were confirmed as independent prognostic factors. Conclusions: Histology of the primary tumor, extension of disease and adjuvant therapy are confirmed as independent prognostic factors for survival in patients affected by spinal metastases. Our study corroborates that surgery of spinal metastases is essentially palliative, but may improve the quality of life of patients.
CYTOLOGY VERSUS HISTOLOGY IN THE DIAGNOSIS OF TUMOR LESIONS OF THE SPINE C. Ruosi1, G. Colella1, F. Granata1, S. Licardo1, F. Fazioli2 1 Department of Human Health, Univesity of Naples ‘‘Federico II’’, Naples, Italy; 2Division of Skeletal Muscles Oncology Surgery, I.N.T. ‘‘G. Pascale’’, Naples, Italy
The diagnostic approach of spine tumor lesions is still controversial. Although transpedicular biopsy represents the most sensitive diagnostic test, cytology biopsy by fine needle aspiration proves reliable in our experience in the diagnosis of 90 % of neoplastic lesions observed. The purpose of this work is to demonstrate that FNAB under image intensifier control is reliable and safe. Between January 2014 and May 2014 we have selected 20 cases of suspected spine neoplastic lesions (8 M, 12 F). Age was between 45 and 65 years old. The lesions were located in 9 cases at the dorsal spine and in 11 cases at the lumbar spine. Definitive diagnosis by histologic exam was made in 80 % of the analyzed samples. The cytology exam provided sufficient material in 80 % of the cases that led to diagnosis in 75 % of samples taken.
Eur Spine J (2015) 24:872–903 Regarding the complications, the histological biopsy led to the onset of 3 vagal reactions with vomiting, 1 neuromotor block, and 1 fever. There were no significant complications with FNAB. Transpedicular biopsy is advantages regarding the adequacy of the levy but however, requires surgery that can be risky in these patients with poor general conditions. We believe FNAB is simple, reliable and well accepted by the patient, as to be considered the routine examination in the first approach to suspected spine lesions.
RESIDUAL NEUROLOGICAL FUNCTION AFTER SACRAL ROOT SECTIONING DURING SACRECTOMY C. Zoccali, B. Rossi, M. Trevisan, A. A. Baaj1, R. Biagini IFO Regina Elena National Cancer Institute, Rome, Italy; Arizona Health Science Center, Tucson (USA)
1
Primitive sacral tumors are rare. Excisional surgery is the mainstay of the treatment, and may be combined with chemotherapy or radiotherapy. Unfortunately, it is correlated with loss of important functions depending on the resection level and the nerve roots sectioned. Information about residual function is provided by small series, so the aim of this paper is to perform a systematic review of literature looking for evidence to clarify the outcome after a sacrectomy. The search identified 15 papers for a total of 244 patients. They were distinguished based on the highest root cut. The patients who underwent a sacrectomy maintained a normal or almost normal deambulation in 3, 60, 61, or 100 % of cases, depending on whether S1, S2, S3 or S4 were the highest nerve roots cut, respectively. They maintained a normal bladder function in 0, 19.6 and 81.5 % of cases, depending on whether the highest sectioned root was S1/S2, S3 or S4, respectively. Bowel function was normal in the 0, 42 and 89.1 % cases, depending on whether the highest sectioned root was S1/S2, S3 or S4, respectively. In case of monolateral sacral nerve roots severing, bladder and bowel functions were normal in the 75 % and 82.6 % of cases, respectively. No sufficient data are available for sensitivity and sexual function.
THE HAZARDS OF SACRECTOMY: A CADAVER STUDY OF NEUROVASCULAR BUNDLES C. Zoccali, B. Rossi, J. Skoch1, A. Patel1, C. Walter1, A. A. Baaj1 IFO Regina Elena National Cancer Institute, Rome, Italy; 1Arizona Health Science Center, Tucson (USA) Abstract Background: Pelvic and sacral surgeries are considered technically difficult due to the complex tridimensional anatomy and the presence of significant, easily damaged, neurovascular structures. Knowledge of the key neurovascular anatomy is essential for safe and effective execution of partial and complete sacral resections, allowing the surgeon to minimize risk of damaging vessels, endangering the life of the patient, and the nerve roots proximal to the resection level. The goal of this anatomic, cadaveric study is to describe the pertinent neurovascular anatomy during these procedures. Materials and methods: Three embalmed human cadaveric specimens were used. Sacrectomies and sacro-iliac joint resections were simulated and the structures at risk were identified. Both anterior and posterior approaches were evaluated. Results: During sacro-iliac joint resection, L5 nerve roots are at high risk for iatrogenic injury. The blood vessels at highest risk are the common iliac vessels and internal iliac vessels with L5-S1 and S1-S2 high sacrectomies. Adjacent nerve roots proximal to the resection
897 level are also at high risk during higher sacrectomies. A less significant bleeding risk is associated with the S2-S3 osteotomy, resulting from damage to the superior gluteal vessels. The S3-S4 osteotomy presents a low risk of bleeding. Discussion: Several sacrectomy techniques are available and the choice often depends on the specific case and surgeon’s preference. Nevertheless, understanding the major neurovascular risks with standard anterior and posterior approaches in a normal anatomical model should aide in surgical planning for these often complex cases. Considering the highly variable anatomic relations of the vascular bundles, a preoperative evaluation with CT or MRI with vascular reconstruction may be helpful to decrease bleeding risk by preemptively ligating the internal iliac vessels in cases where rostral tumors are present. To decrease the risk of damaging nerve roots, it is recommended to perform the resection as close to the involved foramina as possible. Further anatomic studies with more numerous dissections would help better define the anatomy and normal variability between individuals.
MINI-INVASIVE TREATMENT OF SINGLE LEVEL DORSOLUMBAR METASTATIC LESIONS BY RADIO-FREQUENCY ABLATION AND AUGMENTATION: PRELIMINARY EXPERIENCE IN A SERIES OF 15 CASES R. Maugeri, L. Basile, C. Gulı`, G. Grasso, D. G. Iacopino Clinic of Neurosurgery, University of Palermo, Palermo, Italy Introduction: The authors analyzed the effectiveness and impact on quality of life in the short and medium term using radiofrequency ablation and injection of PMMA in the treatment of chronic low back pain in a series of 15 patients suffering from single level metastatic lesion of the dorso-lumbar spine. Materials and methods: 15 patients affected by dorsal-lumbar single level metastatic lesion were selected to undergo treatment of transpedicle radiofrequency ablation and injection of PMMA. 14 patients were treated by percutaneous technique. Only one patient came to our observation for the presence of low back pain and progressive weakness in the lower limbs and in this case an open surgery with decompression, posterior fusion and finally ablation with augmentation was performed. Results: Patients treated percutaneously showed an improvement in pain symptoms with a significant reduction in the VAS. The patient treated with ‘‘open surgery’’ had a reduction in pain with improvement of neurological function of the lower limbs. The follow-up included VAS, SF12, and analysis of morphin doses at 1, 3, and 6 month was satisfactory. Conclusions: The radiofrequency thermocoagulation with injection of PMMA represents a valid surgical strategy, in the context of palliative treatment, in patients with single level metastatic somatic lesion in advanced metastatic disease, with low back pain-back and in the absence of significant neurological deficit. It ensures effectiveness due to the neoplastic tissue removal and the augmentation.
DYNAMIC PERCUTANEOUS VERTEBROPLASTY SYSTEM IN PATIENTS WITH VERTEBRAL FRACTURES SECONDARY TO MULTIPLE MYELOMA A. Iozzelli Ospedale di Macerata, Macerata, Italy Aims and objectives: To demonstrate features and the efficacy of vertebroplasty using a dynamic system in patients with vertebral fractures secondary to multiple myeloma, leading to important pain reduction and vertebral body edema. Methods and materials: Thirty-three patients with 42 symptomatic thoracic-lumbar vertebral fractures secondary to multiple myeloma
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898 were selected after magnetic resonance examination showing stable somatic fractures and bone marrow edema. Patients underwent vertebroplasty procedure using a dynamic system (OsseoFlex kit), consisting in a flexible adjustable cannula for cement injection. Fluoroscopy guided percutaneous monolateral pedicle access was performed using a specific bone needle. 1 to 3 vertebrae were treated simultaneously per patient, under local anesthesia and nonsteroidal anti-inflammatory drugs. One-month follow-up with magnetic resonance was executed in all patients. The visual analogue scale (range 1 to 10 – minimum to maximum pain) was used to describe the pain level before, 24 h after and 1 month after the procedure. A score level of 5 or lower was considered consistent pain reduction. Results: The procedure was successful in all patients, with pain relief at 24 h (82 %) and at 1 month (100 %) follow-up, and showing no fracture progression in 100 % patients. Cement extravasation occurred in 7/42 (17 %) vertebrae: under the upper disc (10 %), perivertebral veins (2 %) or lateral side (5 %). One patient presented an adverse reaction to non-steroidal anti-inflammatory drugs. Conclusion: The dynamic vertebroplasty system allows easy access to the vertebral bodies, even in deep collapsed somas, allowing for important pain reduction in all patients without significant complications.
DEGENERATIVE LUMBAR THE BacJacÒ INTERSPINOUS DEVICE IN THE MANAGEMENT OF LUMBAR SPINE DEGENERATIVE DISEASE: MID-TERM (4 YEARS) FOLLOW-UP C. Irace, V. Amato, L. Giannachi, C. Corona Dept of Neurosurgery, ‘‘Igea’’ Hospital, Milan, Italy Introduction: In 2012 we reported our experience with surgical implantation of the BacJacÒ (Pioneer Surgical Technology) interspinous PEEK (polyetheretherketone) device in degenerative lumbar spine disease. In the current study we have re-examined this series in order to determine the clinical outcome at 4 years. Materials and methods: Between July 1st 2010 through November 1st 2011 forty devices were implanted. Patients presented central stenosis with or without instability (17), foraminal and/or lateral recess stenosis (14), and other (9). The mean follow-up in 39 cases was 4 years (3–4.6). Results: None of the patients deteriorated. Lumbar pain improved in 33 out of 39 patients, and remained unchanged in 6 patients. The radicular pain improved in 29 out of 33 cases, and remained unchanged in 4 patients. Claudication improved in 30 out of 39 cases and remained unchanged in 9. Four cases of partial fracture of the spinous process were observed, all of which were asymptomatic and diagnosed only by means of early postoperative CT scan. None of these required revision surgery. Four more patients have undergone surgery about three years later: lumbar microdiscectomy (2) and BacJac implant for stenosis at the adjacent level (1), BacJac removal ? interlaminospinous fusion for persistent lumbar pain (1). Final considerations: When re-examined at a follow-up ranging 3 to 4.6 years, the encouraging results reported in our former study are corroborated. Neuroradiological exams have confirmed the good correction of some signs of lumbar spine degeneration, maintaining of the initial right positioning of the device, and, above all, the absence of spinous process erosion. A longer follow-up is necessary before the use of this device in the treatment of well-identified degenerative lumbar spine disease can be established.
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Eur Spine J (2015) 24:872–903 MINIMALLY INVASIVE TREATMENT OF THE LUMBAR SPINE STENOSIS: PRELIMINARY STUDY ON 16 PATIENTS TREATED WITH PERCUTANEOUS STABILIZATION P. Quaglietta, S. Aiello, G. Corriero Azienda Ospedaliera di Cosenza, Cosenza, Italy; O.U. of Neurosurgery Object: Lumbar spinal canal stenosis affects a significant number of patients. It is estimated that this condition affects about 300,000 people each year with a greater incidence between 60 and 69 years. Most of these subjects present a slight or moderate stenosis while approximately 20 % suffer from a severe stenosis. In recent years minimally invasive techniques for the surgical treatment of this condition have been developed. Percutaneous stabilization was introduced in our department 3 years ago. Since then, we have treated 16 patients with lumbar canal stenosis after careful selection. We present in this study the preliminary clinical results obtained with a minimum follow-up of 6 months. Methods: The study includes 16 patients with neurogenic claudication secondary to moderate lumbar canal stenosis surgically treated with a percutaneous pedicle screws between June 2012 and October 2014. The data, which included clinical, surgical data, the Oswestry Disability Index (ODI) and the Short Form-36 Health Survey (SF-36), were collected preoperatively and at 3 and 6 months with a median follow-up final at 1 year. Results: Compared with preoperative data, surgery led to the improvement of all parameters considered. No significant complications were noted. Conclusions: According to our data it seems evident that a percutaneous approach in degenerative lumbar canal stenosis may have a role in the improvement of symptoms, especially in individuals not requiring decompression of neural structures. Vertebral instability is the principal cause of symptoms in these patients. Our study is retrospective and includes a small number of patients. Our results will be confronted with those of our following study which will include more groups of patients, longer follow-up, and comparison with other techniques.
PLF AND PLIF AS TREATMENT FOR RECURRENT LUMBAR DISC HERNIATIONS L. Balla, N. Bellon, N. Isceri, A. Maron Ospedale di Monselice (PD), Monselice, Italy Background: Recurrence of lumbar disc herniations is rated between 3 % and 18 %. The identification of the best treatment between several surgical techniques, including conventional discectomy, microdiscectomy, fusion and endoscopy, is still in discussion. Fusion techniques (PLIF, TLIF, PLF) provide a reduced incidence of low back pain and lower rates of residual neural damage, preventing instability and recurrences. Methods: Between 2009 and 2013 we treated 11 patients with late recurrent lumbar disc herniation (7 men and 4 women, aged between 28 and 57 years). In six cases we performed a discectomy with neurolysis, in the other five a circumferential fusion. We chose fusion in patients with significant low back pain, severe discopathy (Pfirrmann 4-5) associated with Modic 1, segmental kyphosis and with extensive fibrosis at MRI. Results: Follow up from 1 to 5 years, with good or excellent results in 10 cases out of 11 (according to VAS and ODI scores). A partial but persistent exacerbation occurred two years after treatment with PLIF L5-S1
Eur Spine J (2015) 24:872–903 in one obese patient with heavy work load and associated multiple discopathies. No sequelae were observed in the only case of dural lesion. Conclusions: In recurrent lumbar disc herniations, discectomy associated with fusion presents several theoretical advantages. It reduces mechanical stress on the degenerated disc, eliminating the risk of instability and new recurrence. We believe that fusion techniques are the best choice to treat recurrent disc herniation with significant low back pain, severe discopathy associated with Modic 1 and segmental kyphosis, especially in presence of extensive fibrosis.
DEGENERATIVE PATHOLOGY DE NOVO DEGENERATIVE SCOLIOSIS: TREATMENT WITH SPINECOR DYNAMIC CORRECTIVE BRACE. PRELIMINARY STUDY A. Sarchioto Azienda Ospedaliera ‘‘G. Rummo’’, Benevento, Italy Introduction: The increase in life expectancy and expectation of higher quality of life has brought interest to a disease rather neglected in the past: De Novo Degenerative Scoliosis (DDS). The lack of attention paid in respect of this condition to a little over a decade ago was also justified by the fact that the means of treatment available, including surgery, were limited. Available treatments included medical, physical and brace treatments. The SpineCor Corrective Dynamic Brace (CDB) should not be included in this last group. Materials and methods: In the past year and a half 7 women were treated, 6 with a true DDS and 1 with late onset symptomatic adolescent scoliosis, aged between 38 and 73 years. All complained of pain, previously treated with no benefit. One of them had used a rigid brace for few weeks, but was forced to discard it due to the appearance of bedsores. All of them were treated with the CDB used fulltime (20/24 h) for the first 6 weeks, then part-time, day and/or night, and for a number of hours independently and subjectively determined, as needed. The adjustment of the elastic band tension is made after 6-8 weeks from the first assembly of the brace. Clinical controls are provided every 3 months and a radiographic control, if necessary, every 6-12 months. Results: No patient abandoned the treatment and all have reported (and continue to report) exceptional - and unexpected - pain control requiring no further pain-relief by medication or other treatments. Quality of life has again become ‘‘normal’’ for their age. The continuous improvement in pain, due to permanent postural restructuring that is typical of this brace - induces patients to consider follow-up visits useless. Conclusion: The small number of cases are certainly an important limitation of the study, although the unexpected, positive results in all treated subjects and excellent compliance, make this very user-friendly, easily removable brace a valuable tool in the the nonoperative treatment of DDS. This brace should be taken into account as a helpful tool for conservative treatment of DDS, given the difficulties of conclusive surgery, particularly in elderly and osteoporotic subjects.
SURGICAL TREATMENT OF DISC DISEASE WITH BLOOD CELLS Gian Luigi Errico Ospedale Di Spoleto, Spoleto, Italy
899 Introduction: The purpose of this study is to evaluate improvement of biological and functional conditions of the intervertebral disk using blood cells (PRP or monocytes). Using MRI images (T2 sequences) we choose symptomatic patients (sciatica by slipped disc, disc protrusion or soft stenosis), presenting Pfirmann disc disease from 3 to 5. Materials and methods: A minimally invasive surgical treatment is performed on a special surgical bed with local anaesthesia, and under image intensifier control. Percutaneous decompression is executed using curved needle device, with inoculation of blood cells at the end of the operation. Inclusion criteria include patients presenting with sciatica or soft stenosis, with no response conservative treatment or epidural blocks. Patients are dismissed in the late evening with prescription to use a brace, rest for 15 days and permission to resume light sport activity (postural training, swimming or biking) after one month. Results: In 5 years we treated about 160 patients (from 20 to 60 years old) using PRP and about 20 using monocytes. For the first group we initially observed 60 % of good outcome (evaluation after 2 years made using MRI, VAS and Oswestry questionnaire). Presently we have 80-85 % of good outcome due to change in patient selection. The best outcome is obtained between 20 and 30 years of age, and good results until 40 years. Beyond this age the biological status of the disk must be evaluated. For the second group we have provisional results: 65 % of good outcome, from satisfying to excellent using VAS and Oswestry questionnaire. Discussion: A comparison of experiences is necessary to identify optimized protocols for this new procedure.
PATIENT SPECIFIC RODS FOR SURGICAL TREATMENT OF SPINE IMBALANCE IN ADULTS Vincent Fiere1, Federico Solla2, Alexis Faline1, Marc Szadkowski1 1
Chirurgia Vertebrale, Centre orthope´dique Santy, Lyon, Italy; Chirurgia delle scoliosi, Hopital Lenval, Nizza, Italy
2
Introduction: A good postoperative sagittal alignment results in an improvement of clinical outcomes and less complications. Two main reasons can explain realignment failure: insufficient surgical planning and poor execution. The authors propose to plan rod contouring and to manufacture rods specifically for each patient. Method: The proposed planning is based on a full-spine sagittal X-rays. First, pelvic parameters, lumbar lordosis and position of the apex of lordosis are evaluated. Then, surgical correction is simulated using specific software to reach the following aims: lordosis equal to pelvic incidence plus 10°, apex of the lordosis position in accordance with Roussouly’s classification and predefined distribution of lordosis around apex. From this virtually corrected spine, patient specific rods (PSR) contour and length are defined. These PSR are industrially contoured and delivered to the operating room in a one week leadtime. Post-operative sagittal parameters where measured. Recutting and additional contouring of rods were recorded. Results: This principle of rod contouring planning, manufacturing and supplying was prospectively applied in 20 cases, with good clinical outcomes and correct spinal alignment following pre-operative planning. There was no additional contouring on PSR; 4 pairs of rods needed to be recut. Discussion: Expected benefits include optimal execution of the plan, improved mechanical resistance of rods and reduced operating time. Further clinical evaluation are in progress to fine tune the process and confirm the added value to plan the shape of rod and to implant a PSR strictly bent in accordance with the planning.
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900 EVALUATION ON THE EFFECTIVENESS OF STANDARDS FOR PRECLINICAL MECHANICAL CHARACTERIZATION OF SPINAL FIXATORS L. La Barbera1, F. Galbusera2, H. J. Wilke3, T. Villa1 1
Laboratory of Biological Structure Mechanics, Department of Chemistry, Materials and Chemical Engineering ‘‘Giulio Natta’’, Politecnico di Milano, Milan, Italy; 2IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; 3Institut fu¨r Unfallchirurgische Forschung und Biomechanik Universitaet, Ulm (Germany) Introduction: Posterior spinal fixators are subjected to many load cycles after implantation due to walking, and failure events are continuously reported. To avoid this issue and evaluate preclinically the mechanical reliability of fixators a vertebrectomy (ASTM F1717 standard) and a physiological anterior support (ISO 12189) models are available. The aim of the study is to assess the international standards for the preclinical evaluation of posterior spinal fixators and to propose improvements. Materials and methods: Several anatomical/biomechanical parameters useful to describe the anatomy of the functional spine units were considered. Their value depending on the spinal level was obtained from literature or from direct measurements on biplanar stereoradiographies. Numerical models describing experimental setups were used to study the contribution of each parameter on the stress on the implant. The worst case condition was also determined. Results: Vertebrectomy condition may guarantee high safety of the implant once implanted in an average patient from a physiological population. The worst-case combination of parameters demonstrates higher loads than those reached using the current standard (screw: ?15 %; rod: ?9 % at L1). The physiological condition may not be safe enough: despite the anterior support characteristics lay within the literature range of values, it may lead to a stress increase even beyond 350 %. Discussion and conclusions: The study investigates the influence of biomechanical parameters on the stress on the fixator. Standards revision according to the anatomical worst-case condition (L1 level) would guarantee a higher safety for a greater range of patient population. Ongoing experimental testing partially corroborates numerical results.
PROJECT FOR THE DEVELOPMENT OF AN INFORMATIC PLATFORM FOR THE MANAGEMENT OF A HOSPITAL/ UNIVERSITY WARD OF SPINE SURGERY Alessandro Landi, Simone Landi*, Cristina Mancarella, Fabrizio Gregori, Roberto Delfini Department of Neurology and Psychiatry, Division of Neurosurgery, Sapienza University of Rome, Rome, Italy; *Software Architecture Engineer, freelance, Rome, Italy Introduction: The need for real time connection between doctors, nurses and technology is becoming a necessity in the management of any hospital ward, especially given the recent technological advancements in the field of communication. The use of smartphones, tablets and the development of the Android platform, with connections always more powerful, open new frontiers in the management of patients, and offer new possibilities for both the medical and nursing staff. The aim of our project is the development of an integrative system, using 2.0 technologies, for the management of a spinal surgery ward. Materials and methods: the materials needed are: tablet with Android operative system for each nurse and doctor, interfacing screen
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Eur Spine J (2015) 24:872–903 for each patient’s bed with an integrated webcam, wireless router in the ward, notifications on smartphone and tablet of events related to patients, visualization system of the ambulatory appointments. The main aspects needing development are: – Inserting medical records (clinical history, physical examination, insertion of radiological exams of the patient or other exams) with a personal tablet or smartphone – Direct modification of the clinical status of the patient by doctor (digital signature and date) – Variations of the current therapies, with notifications sent on the mobiles when a therapy has been modified – Requests for laboratory and radiological exams (integration with existing programs) with notification on all devices of the examinations requested and/or executed. – Release of signed documents with wireless access on the ward’s printer (registration of every activity executed and of the executing user) with digital signature – Storage of each patient’s data and documents in an institute digital archive. – Interaction of all the devices with the development of instant messaging and dedicated forums. This allows a real-time exchange of data and information. The doctor can be informed on patient’s condition even if not present in the department. – Every medical user has an access to the system with different privileges depending on the role (possibility to close the medical records, digital signatures for clinical records, etc.). – Visualization on every account of the number of patients in the ambulatory visits – Real time sharing of teaching material, directly produced by the department (videos, ppt presentations, videos of surgical interventions, scientific articles, etc.), allowing the consultation of a MyBOOK for studying purposes of the medical and training personnel (doctors and nurses) according to a programme written by the professors and that can be changed online. The patient’s sensible data will not be published outside the intranet system. The access to that data will be available only when the doctor will be using the intranet terminal. Outside the intranet the event will be notified only as related to the bed and not to the patient. The use of the bed number instead of the patient’s personnel data, guarantees the patient’s privacy. The notification would be ‘‘the therapy of bed 3 has been changed’’. Furthermore, the enabled users will be capable of visualizing the condition of the beds (free or occupied) and navigate inside the ward, visualizing each bed’s therapies and exams. Only the user with particular rights would be able to change the therapies. Every notification will be recorded and sent as ‘‘push notification’’ to all the devices registered. Similarly, examinations will be requested directly from the page relative to the patient’s bed. A section dedicated to all the appointments will be developed, so that the personnel can see how many and which visits have been planned for each day. The application will be developed with client server architecture, with fat clients installed on every android device (smartphone or tablet) and a web based portal accessible exclusively from the intranet by the authorized personnel. An ad hoc wireless net will be installed for the intranet interoperations between devices and server, with dedicated servers configured in place, while a cloud hosting will be defined for the access to the portal when the user is not inside the intranet, managing the notifications to the registered devices. Only the data codified per bed number will be available to the cloud hosting, never using the patients’ names. The association patient name – bed number will be available only on the server placed inside the ward, and will be consultable and modifiable only from the web portable that could be reached by the intranet. The project will have an estimated cost of about 25.000 €. The startup cost of the project is about 10.000 €, to cover the cost of
Eur Spine J (2015) 24:872–903 infrastructural and hardware costs installation and configuration. Those costs are related to a single ward, and can be considered as repeatable for every ward that needs to be configured. The further 15.000 € are used for the development of the application and its implementation. This part is defined by 5.000 € repeatable for configuration within each ward and 10.000 € as a one-time initial development cost of the application. Conclusions: Our aim is the development of an application allowing the real time interaction between clinical, laboratorial, radiological and surgical activity, to simplify and optimize the management of a spine surgery ward. The technological development of the Android operative system actually allows to use all the potentialities in terms of communication, so that the management could be easier and more efficient, with a relatively modest cost for its development and use.
HETEROCHRONIC PARABIOSIS: IS THERE A FACTOR THAT COULD REWIND THE HANDS OF THE WATCH FOR DISC DEGENERATION? D. Colangelo1, L. A. Nasto1, Nam Vo2, V. M. Formica1, V. Pambianco1, Niedernhofer3, P. Robbins3, E. Pola E1
901 the leading cause of low back pain in the elderly. We evaluated longterm outcomes of patients with severe lumbar stenosis treated surgically with posterior instrumented decompression. Materials and methods: 40 patients over 70 years old with radiological signs of lumbar stenosis on MRI and with severe neurogenic claudication were enrolled. All patients underwent posterior decompression and stabilization. Patients started to walk on the second post-operative day. Patients were evaluated preoperatively, and postoperatively at 5 days, 1,3,12, and 24 months. Clinical evaluation was based on VAS score, Japanese (SSL), SF-12, EQ5D and dynamic testing to evaluate walking capacity. Results: None of the patients had major complications. Average hospital stay was 7.4 days. All patients preserved the ability to walk for a distance greater than or equal to 900 meters within 3 months after surgery. VAS improved from 8.3 preoperatively to 3.2 1 month after surgery. The SSL increased from 93.3 preoperatively to 50.3 postoperatively; the scores at 6 months and 2 years were 20.1 and 6.2, respectively. There was no loosening or implant failure two years after surgery. Discussion and conclusions: Our data indicate that instrumented decompression in the treatment of patients with lumbar stenosis leads to a statistically significant improvement in walking capacity, physical state, and quality of life.
1 Clinica Ortopedica, Universita` Cattolica del Sacro Cuore, Rome, Italy; 2University of Pittsburgh, USA; 3University of Miami, USA
Introduction: 90 % of people worldwide will develop low back pain during their life. The purpose of this study was to determine whether blood chimerism with a young wild type mouse (WT) could delay or reverse the aging process in a prematurely aging mouse model (ERCC1/-D). Blood chimerism was obtained by way of parabiosis, an experimental method in which two animals have their circulatory systems surgically connected. Materials and methods: 3 kinds of parabiotic pairs were generated: WT ? WT at 40 days old (hisochronic), ERCC1/-D ? ERCC1/-D at 64 days old (hisochronic), and WT ? ERCC1/-D (heterochronic). Administration of a dye and fluorescent beads into a single symbiont was used to examine shared circulation and anastomosis in the parabiosis couples. Mice were sacrificed after 4 weeks, and lumbar discs from each mouse were analyzed histologically and for intervertebral protein content. Results: Compared to the hisochronic controls, ERCC1/-D mice heterochronically paired with young WT mice had significantly improved protein content in the disc (95 % CI). Histological analysis revealed an improvement in the disc for the ERCC1/-D individual in the heterochronic pair relative to hisochronic controls. Discussion and conclusions: These results indicate reversal of intervertebral disc degeneration in progeroid mice is possible through exposure to serum derived by younger organisms. The factor responsible for this, although currently unidentified, could potentially be used to as a treatment to combat intervertebral disc degeneration as well other pathologies connected to the aging process.
INSTRUMENTED DECOMPRESSION IN LUMBAR STENOSIS WITH SEVERE NEUROGENIC CLAUDICATION IN OVER SEVENTIES PATIENTS: RESULTS AT 2-YEAR FOLLOW-UP E. Pola, M. Genitiempo, G. Zirio, V. Pambianco, V. M. Formica, D. Colangelo, L. A. Nasto, F. C. Tamburrelli Clinica Ortopedica, Universita` Cattolica del Sacro Cuore, Rome, Italy Introduction: Spinal stenosis is increasingly common due to the aging of the general population. This condition is debilitating and is
THE TRANS-FORAMINAL INTERBODY FUSION IN THE TREATMENT OF LOW GRADE DEGENERATIVE LUMBAR INSTABILITY: COMPARISON BETWEEN TWO SURGICAL TECHNIQUES C. Doria, F. Milia, M. Gallo, G. Angiolini, F. Muresu , M. Balsano Orthopaedic Department, University of Sassari (Italy); Orthopaedic Department Santorso Hospital, AUSSL 4 Schio (Italy) Introduction: The aim of this study was to compare two surgical techniques of trans-foraminal interbody fusion (TLIF) in the treatment of low degree degenerative lumbar instability. Materials and methods: We conducted a prospective study with a mean follow-up of 24 months. Seventy-four patients (46 men and 28 women) were enrolled in the study. Forty-one patients (group A) were treated with traditional ‘‘open’’ approach through a midline incision and dissection of the sub-periosteal paraspinal muscles, while 33 patients (group B) underwent minimally invasive treatment by means of percutaneous pedicular system. Interbody fusion was performed by unilateral introduction of a cage after total or partial resection of the facet joint. Decompression of the spinal canal was obtained through partial resection of the hemilamina. We evaluated the operative time, blood loss and complications. The post-operative pain in the first week was assessed with the visual analog scale VAS. The VAS and the Oswestry Disabilty Index (ODI) were assessed during outpatient visits 6 weeks, 3, 6, 12 and 24 months after surgery. The time of the surgical procedure in group A was an average of 2h05 min. (1 h 40 min - 2 h 55 min); the time of the surgical procedure of the B group was on average of 1h50 min. (1 h 30 min - 2 h 25 min.). The average peri-operative blood loss was 700 ml (300-1100 ml) in group A and 150 ml (0-400 ml) in group B. Results: We had a slightly higher complication rate in group A than in group B. The value of VAS in the first few days after surgery was significantly higher in patients treated with an open procedure (group A); the difference in value of the VAS in both groups was no longer statistically significant (p \ 0.05) after the first week. The ODI at follow-up at two years showed similar values in both groups: 23.6 in group A and 22.3 in group B. Satisfactory results in the follow-up to two years were similar in each group: 73 % in group A and 74 % in group B.
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902 Conclusion: The long-term clinical and radiological results of TLIF in the treatment of degenerative instability of the lumbar spine are not related to the type of surgical approach. The use of minimally invasive percutaneous technique (group B) is associated with reduced pain immediately after surgery. The minimally invasive techniques have proven to be a viable alternative to traditional techniques in the treatment of lumbar spinal instability low grade.
MISCELLANY VARIATIONS IN CERVICAL LORDOSIS AND CRANIAL ALIGNMENT FOLLOWING SAGITTAL IMBALANCE SURGICAL CORRECTION WITH PEDICLE SUBTRACTION OSTEOTOMY R. Cecchinato1, P. Berjano1, F. Langella2, A. Redaelli1, C. Morselli3, C. Lamartina1 IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; 2Orthopaedic Department, Facolta` di Medicina e Chirurgia, Seconda Universita` degli Studi di Napoli, Naples, Italy; 3Dipartimento di Neurologia e Psichiatria, Divisione Neurochirurgia, Universita` ‘‘Sapienza’’, Rome, Italy 1
Introduction: Cervical lordosis variations after sagittal imbalance surgical correction has been poorly analyzed in scientific literature. The aim of this study is to verify eventual variations in cervical and cranial alignment after sagittal imbalance surgery. Materials and methods: 39 patients were enrolled in this study. Sagittal parameters and alignment of the cervical, thoracic and lumbar spine, pelvis and the lower limbs have been measured. Cranial alignment has been evaluated with a new parameter called Cranial Slope. Results: After sagittal balance corrective surgery we observed significant reduction of the cervical lordosis (from -43 degrees to -31.5 degrees) and of segmental upper and lower cervical lordosis (respectively from -24.1 to -20.2 degrees and from -18.1 to -9.2 degrees). A positive linear correlation has been noticed between T1slope and global and lower cervical lordosis variations. Cranial Slope didn’t show any statistically significant variation between preoperative and postoperative values. Conclusions: Cervical lordosis spontaneously reduces after surgical correction of sagittal imbalance with pedicle subtraction osteotomy, by a compensatory mechanism that maintains the head’s neutral position.
OZONE THERAPY AND DISC DISEASE: ALARM DATA AND NEED FOR REVISION OF THERAPEUTIC PROTOCOLS Daniele Vanni1,4, Renato Galzio2, Francesco Saverio Sirabella1, Matteo Guelfi1, Andrea Pantalone1, Antonio Sparvieri3, Vincenzo Salini1, Vincenzo Magliani4 1
Clinica Ortopedica e Traumatologica, Universita` ‘‘G.d’Annunzio’’, Chieti, Italy; 2Dipartimento di Neurochirurgia, Universita` degli Studi dell’ Aquila, L’Aquila, Italy; 3Dipartimento di Diagnostica per Immagini, Ospedale ‘‘Floraspe Renzetti’’, Lanciano, Italy; 4U.O. Chirurgia Vertebrale, ASL-2 Lanciano-Vasto-Chieti, Italy Introduction: Today ozone therapy is increasingly used to treat lumbar disc herniations that are not responsive to conservative management. In most cases this therapy is proposed as an alternative to surgery, although its effects are often only temporary.
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Eur Spine J (2015) 24:872–903 Materials and methods: Since June 2013, 23 patients (14 M and 9 F, mean age 51.3 years) have undergone spinal surgery for lumbar disc hernia or lumbar segmental stenosis. Each of them was previously subjected to ozone therapy in a period between 12 and 24 months prior to surgery. Standard preoperative protocol included M.R.I evaluation for all patients. Discussion: During surgery many strong adhesions between soft tissue and bony structures were noted. Specifically, the dural and periradicular adhesions required a more drastic approach in order to reach resolution of the disease. In one case, a iatrogenic dural cyst with invagination of the root was noticed (it only appeared after ozone therapy). It should be noted that none of these patients were previously subjected to spine surgery and that these specific pathologic adhesions are not observed in patients who did not received ozone therapy. Conclusion: Our observation is a crucial starting point. Although these data are preliminary and it is important not to create unnecessary alarms, it is mandatory to assert that ozone therapy may be associated with major complications. A review and update of guidelines in regard to ozone therapy application is necessary.
CERVICAL CORPECTOMY IN PATIENTS WITH SPONDYLODISCITIS B. Cappelletto, M. A. Trevigne, E. Copetti, C. Veltri, F. Giorgiutti Chirurgia Vertebro-Midollare e Unita` Spinale, Azienda OspedalieroUniversitaria ‘‘Santa Maria della Misericordia’’, Udine, Italy Introduction: Osteomyelitis of the vertebral column is a rare illness that affects approximately 1 to 7 % of all bone infections; only 3-6 % of spondylodiscitis are found in the cervical column. It can often be devastating at this level due to the serious neurological damage that may ensue. Methods: We have retrospectively examined 10 patients who were operated on for cervical osteomyelitis between January, 2000 and June, 2013. We evaluated the clinical history, surgical technique, antibiotic therapy, and neuroradiological images. Results: all patients presented with primary hematogenous spondylodiscitis. The micro-organisms isolated were in 6 cases staphylococcus aureus and in 2 cases mycobacteria. All the patients were treated with antibiotic therapy, on average for 13 weeks or with anti-tubercular drugs, on average for 54 weeks. They were re-evaluated with blood exams, CAT-PET and MRI according to protocols shared with the infectious disease department. All were operated on with an anterior approach; we performed a corpectomy, spinal cord decompression, graft or mesh insertion and stabilization with plate. In 4 cases we used a halo-system for 3 months; in 2 cases we also performed a posterior approach. All patients had neurological deficits; 5 patients had severe quadriplegia. In 6 cases we obtained a significant clinical improvement and in 4 cases we observed a complete regression of preoperative deficits. Conclusions: The anterior approach is the appropriate option in the treatment of patients with cervical osteomyelitis. This approach allows removal of inflammatory and necrotic tissue, and wide decompression of the spinal cord: neurological recovery is facilitated, and kyphotic deformity is prevented.
RESPIRATORY FUNCTION IN PATIENTS WITH CYSTIC FIBROSIS IN BRACE TREATMENT FOR SCOLIOSIS Carlo Ruosi*, Valerio Pipola, Gianluca Colella, Salvatore Liccardo, Francesco Granata
Eur Spine J (2015) 24:872–903 Dipartimento di Sanita` pubblica, Sezione di Ortopedia, Universita` degli studi Federico II di Napoli, Naples, Italy; *E-mail:
[email protected] The prevalence of scoliosis in CF patients aged from 4 to 16 years is 15.6 % with a M/F of 1/2.5, more than the prevalence of scoliosis in the normal population of the same age that is 0.67-2.5 %. The aim of this study is to evaluate the effects of conservative treatment of scoliosis on the respiratory function in CF patients. Twenty CF patients aged 6 to 18 years were enrolled and divided into three age groups: 6-10, 11-14 and 15-18 years. They have been observed for two years, from 2011 to 2013, with a spirometry test every three months and analysis of the main respiratory parameters: FEV1, FVC and FEV1/FVC.
903 In 11-14 years group there is an increase of respiratory parameters of 27.89 % for FEV1, 19.45 % for FVC and 7.41 % for FEV1/FVC in CF patients with conservative treatment against no treated patients of the same age group who show an improvement of 7.6 % for FEV1, 9.92 % for FVC and a reduction of 2.31 % for FEV1/FVC. In 15-18 years group there is a decrease of respiratory parameters in brace treatment patients compared to no treatment patients of the same age. The best results found in the 11-14 age group are due to the younger age of patients and the early intervention. These patients have not yet completed the process of skeletal maturity. Their unstructured scoliotic curves are more susceptible of correction with conservative treatment than the 15-18 age group in which patients present structured scoliotic curves that are less responsive to conservative treatment.
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