Different pedicle osteosynthesis for thoracolumbar vertebral fractures in elderly patients

Is Force Control a Safe and Efficient Surgical Technology for Thoracolumbar Fusion Surgery? A Post Market Clinical Follow-Up Study

BACKGROUND

Early screw loosening, a relevant complication after posterior thoracolumbar fusion, indicates high mechanical stress during rod connection. Force Control is a surgical technology that goes beyond the usual to identify, control, and minimize intended and unintended, usually unnoticed forces to achieve the most stressless fixation. Optimized, extremely lightweight instruments support this principle on part of the pedicle screw system (PSS). The study objective is to evaluate the safety and efficacy of a novel PSS for Force Control fusion surgery.

METHODS

In this literature-controlled observational study, patients underwent surgery with a PSS that supports Force Control. Safety is demonstrated 1 year postoperatively by noninferiority in screw loosening rate and efficacy by noninferiority in Oswestry Disability Index (ODI) improvement. Secondary endpoints: 2-year ODI, spine-related adverse events, and outcomes. Statistical significance: P < 0.025 (Bonferroni correction 0.05/2).

RESULTS

75 patients enrolled, main diagnoses were trauma (73.3%), spinal stenosis (17.3%), and degenerative disc disease (6.7%). Screw loosening rate at 1 year was 2.7%, being not inferior (P = 0.005) to the control group at 9.2%. Mean ODI improvement of 49.3 showed noninferiority (P < 0.001) versus 35.2 in the control group. Mean 2-year ODI was 19, mean visual analog scale back pain improved from 80.3 to 24.1 (3 months) and 21.6 (1 year). The implant-related revision rate was 4.1%.

CONCLUSIONS

Force Control, aiming to go beyond the familiar by controlling intended and unintended forces to achieve the most stressless fixation, is a safe and efficient method. Lightweight instruments are designed to allow identifying, controlling, and reducing mechanical stress. Patients benefit from Force Control regarding screw loosening and clinical outcome.

Appropriate Use Criteria for Osteoporotic Compression Fractures

BACKGROUND CONTEXT

There is a lack of consensus regarding optimal indications for treatment of patients with osteoporotic vertebral fractures. An opportunity exists to improve outcomes if these indications can be clarified.

PURPOSE

The purpose of the North American Spine Society (NASS) Appropriate Use Criteria (AUC) was to determine the appropriate (i.e. reasonable) multidisciplinary treatment recommendations for patients with osteoporotic vertebral fractures across a spectrum of more common clinical scenarios.

STUDY DESIGN

A Modified Delphi process.

PATIENT SAMPLE

Modified consensus based guideline OUTCOME MEASURES: Final rating for treatment recommendations as either "Appropriate", "Uncertain", or "Rarely Appropriate" based on the median final rating among the raters.

METHODS

The methodology was based on the AUC development process established by the Research AND Development (RAND) Corporation. The topic of osteoporotic vertebral compression fracture was selected by NASS for its Clinical Practice Guideline development (CPG). In conjunction, the AUC committee determined key modifiers and adapted the standard definitions developed by the CPG with minimal modifications. A literature search and evidence analysis performed by the CPG were reviewed by the AUC work group. A separate multidisciplinary rating group was assembled. Clinical scenarios were generated based on a matrix of the modifiers, to rate the appropriateness of medical management, cement augmentation, or surgery. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions: once without discussion and again following discussion of the initial responses. The median rating for each scenario and level of agreement was then used to determine final indications as rarely appropriate with agreement (1 - 3), uncertain or disagreement (4-6), or appropriate with agreement (7-9). Consensus was not mandatory.

RESULTS

Medical management was appropriate across all scenarios. Cement augmentation was rarely appropriate in 60% of scenarios and uncertain or disagreement in 35% of scenarios. In the 5% of scenarios rated as appropriate with agreement for cement augmentation, high pain scores, acute duration, and simple fracture pattern were always present. Surgery was appropriate in 35% of scenarios and strongly influenced by instability and stenosis with neurological findings. Surgery was rarely appropriate in 18%, and uncertain or disagreement in 47% of scenarios.

CONCLUSIONS

Multidisciplinary appropriate treatment criteria for osteoporotic vertebral fractures were generated based on the RAND methodology. This document provides comprehensive evidence-based recommendations for evaluation and treatment of osteoporotic vertebral fractures. The document in its entirety will be found on the NASS website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of adults with osteoporotic vertebral compression fractures

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Adults with Osteoporotic Vertebral Compression Fractures features evidence-based recommendations for diagnosing and treating adult patients with osteoporotic vertebral compression fractures. The guideline is intended to reflect contemporary treatment concepts for osteoporotic vertebral compression fractures as reflected in the highest quality clinical literature available on this subject as of September 2020.

PURPOSE

The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with osteoporotic vertebral compression fractures. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

STUDY DESIGN

This is a guideline summary review.

METHODS

This guideline is the product of NASS' Clinical Practice Guidelines Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with a medical librarian. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.

RESULTS

Twenty-nine clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.

CONCLUSIONS

The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with osteoporotic vertebral compression fractures. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at http://www.spine.org/guidelines.

Efficacy and safety of hollow pedicle screw-anchored bone cement combined with posterior long-segment fixation for Stage III Kümmell's disease

OBJECTIVES

The study aimed to evaluate the efficacy and safety of hollow pedicle screw-anchored bone cement combined with posterior long-segment fixation (LSF) for the treatment of Stage III Kümmell's disease.

PATIENTS AND METHODS

The study retrospectively analyzed 23 patients (18 females, 5 males; mean age: 70.1±6.2 years; range, 58 to 80 years) with Stage III Kümmell's disease who underwent hollow pedicle screw-anchored bone cement combined with posterior LSF between March 2017 and April 2020. The clinical efficacy was evaluated using the Visual Analog scale (VAS), the Oswestry Disability Index (ODI), anterior vertebral height, kyphotic Cobb angle, and neurological function by Frankel classification. Complications, operation time, intraoperative blood loss, and complications were obtained from the hospital records. Data recorded at three time intervals (before the surgery, early postoperative period, and the last follow-up) were compared.

RESULTS

The mean follow-up time was 20.8±6.1 months. The mean operation time was 102±16.5 min, and the mean intraoperative blood loss was 225±41.3 mL. The VAS, ODI, anterior vertebral heights, and local kyphosis angle showed statistically significant differences between preoperative and postoperative values, as well as the preoperative and the final follow-up values (p<0.05). However, the differences between postoperative and final follow-up values were not statistically significant (p>0.05). Six patients (26%) had mild preoperative neurological deficits and normalized neurological function at the final follow-up evaluation. Asymptomatic leakage of cement occurred in five (22%) cases. There was no fixation failure (rod breakage or screw loosening).

CONCLUSION

Hollow pedicle screw-anchored bone cement combined with posterior LSF is a safe and effective surgical option for the treatment of Stage III Kümmell's disease.

Cardiopulmonary Cement Embolism Following Cement-Augmented Pedicle Screw Fixation: A Narrative Review

Fixation using cement-augmented pedicle screws (CAPS) is being increasingly performed. However, CAPS-associated cement leakage is a critical problem that can lead to cardiopulmonary cement embolism (CPCE). This narrative review aimed to explore the incidence of and risk factors and treatment strategies for CPCE and cement leakage-related complications after CAPS fixation. Data were extracted from each article, including characteristics of CPCE after CAPS fixation (incidence, location, diagnostic method and criteria, treatment, and outcome and prognosis). Overall, 28 case series and 14 case reports that met the inclusion criteria were included. Of the 1974 cases included in the review, CPCE was noted in 123, symptomatic CPCE in 35, and death in six, respectively. The frequencies of PCE and symptomatic PCE after CAPS fixation were 6% (range: 0-28.6%) and 1.3% (range: 0-26%), respectively. The range of frequencies of PCE and symptomatic PCE after CAPS fixation may have been wide because the definition of CPCE and data collection methods differed among the reports analyzed. Since PCE due to large cement emboli may be primarily related to the surgical technique, improved technique, such as minimizing the number of CAPSs by injecting low-volume high-viscosity cement at low velocity and pressure, and careful observation of cement leakage during CAPS insertion may reduce PCE associated with cement leakage. Spinal surgeons should pay more attention to the occurrence of CPCE during and after CAPS insertion, which can cause serious complications in some patients.

Study on the Optimal Surgical Scheme for Very Severe Osteoporotic Vertebral Compression Fractures

OBJECTIVE

Therapy of very severe osteoporotic compression fractures (VSOVCF) has been a growing challenge for spine surgeons. Opinions vary regarding the optimal surgical procedure for the treatment of VSOVCF and which internal fixation method is more effective is still under debate, and research on this topic is lacking. This retrospective study was conducted to compare the efficacy and safety of various pedicle screw fixation methods for treating VSOVCF.

METHODS

This single-center retrospective comparative study was conducted between January 2015 and September 2020. Two hundred and one patients were divided into six groups according to different surgical methods: 45 patients underwent long-segment fixation (Group 1); 39 underwent short-segment fixation (Group 2); 30 received long-segment fixation with cement-reinforced screws (Group 3); 32 received short-segment fixation with cement-reinforced screws (Group 4); 29 had long-segment fixation combined with kyphoplasty (PKP) (Group 5); and 26 cases had short-segment fixation combined with PKP (Group 6). The clinical records were reviewed and the visual analogue scale (VAS) score and the Oswestry Disability Index (ODI) score were used for clinical evaluation. The vertebral height (VH), fractured vertebral body height (FVBH), and Cobb's angle were objectively calculated and analyzed on lateral plain radiographs. Student's t-tests and one-way ANOVA among groups were conducted to analyze the continuous, and the chi-squared test was used to compare the dichotomous or categorical variables. The difference was considered statistically significant when the P-value was less than 0.05.

RESULTS

The six groups had similar distributions in age, gender, course of the disease, follow-up period, and injured level. In the postoperative assessment of the VAS score, the surgical intervention most likely to rank first in terms of pain relief was the short-segment fixation with cement-reinforced screws (Group 4). For the functional evaluation, the surgical intervention that is most likely to rank first in terms of ODI score was a short-segment fixation with cement-reinforced screws (Group 4), followed by long-segment fixation (Group 1). The long-segment fixation with cement-reinforced screws was the first-ranked surgical intervention for the maintenance of Cobb's angle and vertebral height, whereas the short-segment fixation performed the worst. The highest overall complication rate was in Group 6 with an incidence of 42.3% (11/26), followed by Group 2 with an incidence of 38.5% (15/39).

CONCLUSION

For the treatment of VSOVCF, the short-segment fixation with cement-reinforced screws is the most effective and optimal procedure, and should be used as the preferred surgical method if surgeons are proficient in using cemented screws; otherwise, directly and unquestionably use long-segment fixation to achieve satisfactory clinical results.

Influence on Therapeutic Decision-Making of Supine and Standing Radiographs after Traumatic Thoracolumbar Fracture in the Elderly

Background A standing X-ray is recommended for decision-making relative to the therapy for a traumatic thoracolumbar fracture (TLF). However, standing X-ray management can be demanding in elderly patients because of pain. The goal of this study was to determine whether supine radiograph is sufficient for proper therapeutic decision-making in patients older than 65 years with acute stable traumatic TLF.

Methods Patients older than 65 years who came to the emergency department diagnosed with an acute and stable traumatic vertebral fracture between T10 and L3 (both included) were included in the study. Initially, all the patients were studied with a supine radiograph and computed tomography (CT) scan. If the TLF was stable, a standing radiograph was performed. Segmental kyphosis (SK) and visual analog scale (VAS) score were collected and compared in both the supine and standing X-ray projections.

Results Twenty-seven patients with a mean age of 76.39 (range: 65–93) years were included; most were females. The mean supine SK was 10.14degrees (SD±7.22degrees). It increased to 12.97 (SD±8.61degrees) in the standing projection (p<0.001). In 37.1% of the patients, the SK increased from 13.22degrees (SD±7.21degrees) in supine X-ray to 19.96degrees (SD±5.34degrees) in the standing position in this group. When the initial supine projection showed an SK of ≥10degrees, the mean SK observed in the standing X-ray increased to 20.5degrees (SD±5.30, p=0.321).

Conclusion Stable traumatic TLF in patients older than 65 years showing ≥10degrees of SK in supine radiography may benefit from a standing radiography to make a proper therapeutic decision.

Pulmonary cement embolism following transpedicular screws placement for thoracolumbar fractures

Background

Symptomatic pulmonary cement embolism in patients undergoing thoracic transpedicular fenestrated screw placement is rare. Here, we have added a 64-year-old female undergoing transpedicular screw placement for a T11 fracture who developed a pulmonary cement embolism intraoperatively and add this case to 13 others identified in the literature.

Case Description

A 64-year-old female presented with a type "C", ASIA "E" T11 fracture. The thoracolumbar pedicle screw fixation was supplemented with bone cement due to her underlying severe osteoporosis. During the fluoroscopy-guided supplementation with bone cement, a leak through the paravertebral venous system was noted. Thirty minutes later, the patient acutely developed extreme respiratory failure and required mechanical ventilation for the next 2 days. The diagnosis of pulmonary embolism due to bone cement was confirmed on a contrast computed tomography study of the chest.

Conclusion

Symptomatic pulmonary cement embolization supplementing transpedicular screws placement for osteoporotic bone is rare. Here, we present a 64-year-old female who during transpedicular fixation of a T11 fracture developed an acute pulmonary embolism from the bone cement resulting in the need for 2 days of postoperative artificial ventilation.

Comparison of clinical effectiveness of fenestrated and conventional pedicle screws in patients undergoing spinal surgery: a systematic review and meta-analysis

INTRODUCTION

Pedicle screws are commonly used for spinal procedures for fusion stability, which is particularly important in osteoporotic patients, who are at an increased risk of requiring revision procedures.

AREAS COVERED

A systematic review and meta-analysis were conducted to compare clinical effectiveness of conventional pedicle screws (CPS) vs fenestrated pedicle screws (FPS) in patients undergoing spinal surgery. Primary outcomes included screw loosening, revision surgeries (involving an implant) and reoperations (not involving intervention on an implant) in patients treated with CPS vs FPS, sub-stratified by with and without osteoporosis. Secondary outcomes included changes in pain scores. Forty-eight studies with 8,302 patients were included, with 1,565 (19.18%) treated with FPS and 6,710 (80.82%) treated with CPS. FPS was associated with a lower risk of screw loosening (p = 0.001) vs CPS. In the general population, there was a non-significant trend of lower revision rate, but no difference in reoperation rate, between patients treated with FPS vs CPS. In osteoporotic patients, revision rates were significantly lower for FPS vs CPS (p = 0.009).

EXPERT OPINION

This review suggests that FPS are effective for surgical fixation and reduce rates of screw loosening, and in osteoporotic patients, revision surgeries, compared to CPS.

Therapeutic Efficacy of Transpedicular Impaction Bone Grafting with Long Segmental Posterior Instrumentation in Stage III Kümmell Disease

STUDY DESIGN

A retrospective review of clinical and radiological parameters.

OBJECTIVE

To evaluate the therapeutic efficacy of transpedicular impaction bone grafting (TIBG) with long segmental posterior instrumentation for the treatment of stage III Kümmell disease.

SUMMARY OF BACKGROUND DATA

The optimal treatment for stage III Kümmell disease remains controversial and unclear. Theoretically, transpedicular bone grafting can reconstruct anterior column support and reduce the failure of internal fixation, which is an intuitive method for the treatment of Kümmell disease. However, the use of this technique has rarely been reported for the treatment of this disease. This study reported the clinical and radiological results of TIBG with long segmental posterior instrumentation for the treatment of stage III Kümmell disease.

METHODS

Between August 2011 and December 2017, we retrospectively analyzed 24 patients with stage III Kümmell disease who underwent TIBG with long segmental posterior instrumentation. Anterior vertebral heights, kyphotic Cobb angle, visual analog scale (VAS), Oswestry disability index (ODI), and American Spinal Injury Association (ASIA) impairment scale were used to evaluate the effects of surgery.

RESULTS

The mean time to follow-up was 38.1 ± 10.2 months. The average operative duration was 136 ± 16.5 minutes, and the average intraoperative blood loss was 293 ± 41.3 mL. The VAS, ODI, anterior vertebral heights, and kyphotic Cobb angles were improved significantly at 1 week after surgery compared the preoperative examinations, and were well maintained at the final follow-up evaluation. Fourteen patients (58%) had mild neurological impairments before surgery, with neurological function returning to normal at the final follow-up evaluation. There was no instance of instrumentation failure.

CONCLUSION

TIBG combined with long segmental posterior instrumentation is a safe and effective surgical option for stage III Kümmell disease.Level of Evidence: 4.

Minimally Invasive Short-Segment Anteroposterior Surgery for Thoracolumbar Osteoporotic Fractures with Canal Compromise: A Prospective Study with a Minimum 2-Year Follow-up

Study Design

A prospective study with a minimum follow-up of 24 months.

Purpose

This study aimed to evaluate the results of minimally invasive anteroposterior surgery for osteoporotic vertebral fractures (OVFs) associated with bony spinal canal compromise in elderly patients.

Overview of Literature

There is a recent increase in the incidence of osteoporosis with OVFs, causing an increasing burden on medical systems.

Methods

The study included 47 patients, of whom 45 completed a minimum of 24-month follow-up. The inclusion criteria were OVF types 3 and 4 according to the osteoporotic fracture classification in patients aged ≥65 years with bony stenosis. The surgical management consisted of anterior corpectomy and decompression using a thoracoscopic or mini-laparotomy approach, together with posterior percutaneous cement-augmented short-segment fixation. Self-reported outcome measures included Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) in the preoperative phase and regular follow-up at a minimum of 24 months. Radiological measures included segmental lordosis, dual-energy X-ray absorptiometry for osteoporosis assessment, and radiological fracture healing.

Results

There were 33 patients with lumbar fracture and 12 patients with thoracic fracture. Thirteen patients had preoperative neurological deficits. The mean age was 77.4±8.3 years. The mean preoperative VAS score was 8.12±1.5, and the mean ODI score was 24.4±8.2. The mean preoperative sagittal Cobb angle was 6.3°±4.2° kyphosis. The mean operative time was 220.3±55.5 minutes, with a mean blood loss of 360.75±200.6 mL. After a mean follow-up of 32.6±6.4 months, the mean VAS significantly improved to 2.3, and the ODI to 12. Only three patients still had a partial neurological deficit. The mean final sagittal Cobb angle was significantly better, with 12.5°±4.3° of lordosis.

Conclusions

Short-segment percutaneous fixation with cement augmentation combined with minimally invasive anterior decompression and corpectomy is a less invasive and safe approach in elderly patients with OVF and canal compromise.

Back to the future in traumatic fracture shapes of lumbar spine: An analysis of risk of kyphosis after conservative treatment

Introduction:

Nonosteoporotic burst vertebral fracture could commonly be treated with conservative or surgical approach. Currently, decision-making process is based on thoracolumbar (TL) AO spine severity injury score. However, some factors could affect posttraumatic kyphosis (PTK) and could be taken into account. The aim of the present study is to identify if axial and sagittal fracture shape and initial kyphosis are the risk factors for PTK.

Materials and Methods:

All consecutive patients treated between 2016 and 2017 for TL vertebral fracture with conservative treatment were retrospectively evaluated in the study. Only type A3 and A4 vertebral fractures were included in the study. Patients suffering from osteoporosis or other metabolic bone disease, aged above 60 years old were excluded from the study. Initial and 6 months X-ray from injury were analyze to evaluate local kyphosis and region of injury while initial assessment was performed with computed tomography to better identify fracture type and in some cases magnetic resonance imaging to exclude posterior ligament complex injury. Axial and sagittal view of the vertebral plate was analyzed and classified in three shapes according to fragment comminution and dislocation. Statistical analysis was performed trough STATA13 software. Student's t-test was used to evaluate the differences between initial and follow up kyphosis; odds ratio (OR) was used to evaluate the role of initial kyphosis, vertebral sagittal and axial fracture shape as a risk factor for PTK. Kruskal–Wallis test was used to assess the differences among vertebral shape fractures and final kyphosis. Fisher's exact test was used to assess the differences between fracture patterns and final kyphosis.

Results:

An initial kyphosis >10° (OR 36.75 P = 0.015), shape c vertebral plate (OR 147 P = 0.0015), and sagittal shape 3 (OR 32.25 P = 0.0025) are strongly related with PTK. Kruskal–Wallis test revealed a statistically significant difference among axial fracture shape (P < 0.0001) and sagittal fracture shape (P = 0.004) and also for initial kyphosis >10° (P < 0.0001). Fisher's exact test showed a significant difference for final kyphosis among pattern c3 and other patterns of fracture (P = 0.0001).

Conclusions:

A burst type lumbar vertebral fracture affecting a patient with initial local kyphosis >10° and comminution and displacement of vertebral plate and vertebral body is at high risk to develop a local kyphosis >20° in the follow-up if treated conservatively.

Effectiveness and reliability of cannulated fenestrated screws augmented with polymethylmethacrylate cement in the surgical treatment of osteoporotic vertebral fractures

Background

Implants' stability, especially in osteoporosis patients, is a challenging matter. Nowadays, the adoption of cannulated fenestrated screws augmented with polymethylmethacrylate cement (PMMA CSF) is described by some authors. This single-center, retrospective observational study aims to evaluate the long-term effectiveness, reliability, and mechanical performances of this type of screws in osteoporotic fractures.

Materials and Methods

All the patients surgically treated from January 2009 to December 2019 with PMMA CSF were evaluated and submitted to the inclusion and exclusion criteria. Clinical and radiological evaluations were performed at pre- and post-surgery time and at the follow-up (FU). Loss of correction in the sagittal plane (bisegmental Cobb angle), kyphosis angle of the fracture (fractured vertebral angle), loosening of pedicle screws (screw's apex vertebral body's anterior cortex mean gap called SAAC gap and screw's apex vertebral body's superior endplate mean gap called SASE gap), visual analog scale, and Oswestry disability index scores were evaluated.

Results

One hundred and sixty-three patients (58 males and 105 females) aged over 65 years affected by vertebral osteoporotic fractures were included in the study. At FU, we do not found significant differences in radiological items in respect to the postoperative period. Only one case of loosening and 18 cases of cement leaking (without neurological impairments) were found. Clinical scores improvement was significant in the interval between preoperative and FU.

Conclusions

PMMA CSF seems to can guarantee good efficacy and effectiveness in the surgical treatment of vertebral fractures in osteoporosis.

Long versus Short Segment Instrumentation in Osteoporotic Thoracolumbar Vertebral Fracture

Study Design

Retrospective comparative study.

Purpose

This study aimed to compare clinical and radiological data and rate of mechanical complications in elderly patients treated with short segment (SSS) or long segment stabilization (LSS) for thoracolumbar junction osteoporotic vertebral fractures (OVFs).

Overview of Literature

A fervent debate is now focused on the treatment of OVF using SSS or LSS. High rate of complications is associated with pedicle screw fixation because of poor bone quality.

Methods

Patients over 65 years old with a T-score of <−2.5, affected by (T10–L2) vertebral fracture treated with LSS or SSS pedicle screw fixation, with at least 24 months of follow-up were evaluated. All patients were analyzed with conventional X-ray to evaluate bisegmental kyphotic angle (BKA) and clinically with Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and rate of mechanical complications at 2, 6, 12, and 24 months. Data were expressed as mean±standard deviation. Student t-test was used to compare clinical scores between populations. Mann-Whitney U-test was used to analyze clinical and radiological variable, whereas Fisher’s exact test was used to identify differences in the rate of complications between groups.

Results

A total of 37 patients met the inclusion criteria. Mean follow-up was 33.97±9.26 months. For both groups, ODI and VAS significantly decreased over time with good results (p<0.00001). At the final follow-up, no significant differences were found in terms of ODI and VAS. There was no difference in correction of BKA between groups; however, a significant difference was found in LSS group between pre- and postoperative BKA (p=0.046), whereas no difference was found in SSS group. A significant difference in the rate of mechanical complications was found between groups (p=0.011).

Conclusions

Both treatments showed good clinical and radiological results; however, LSS group showed better BKA correction and lower mechanical complications than SSS group.

Sublaminar fixation versus hooks and pedicle screws in scoliosis surgery for Marfan syndrome

Background:

In patients with Marfan syndrome (MFS), surgical correction of spinal deformities with hooks and/or pedicle screws involves a higher rate of complications than in patients with adolescent idiopathic scoliosis. Therefore, sublaminar instrumentation is often a last resort option. This study wants to assess the ability of sublaminar fixation to achieve three-dimensional scoliosis correction and spine stabilization compared with hook and/or pedicle screw systems.

Methods:

Twenty-one MFS patients who underwent posterior spinal fusion at a highly specialized medical center in 1995–2017 were divided into two different groups retrospectively evaluated at a minimum follow-up of 2 years. Group 1 (8 patients) was composed by hooks and screws instrumentation, while Group 2 (13 patients) was composed by hook or pedicle screw system associated to sublaminar wires/bands. Radiological (correction and long-term stability) and general endpoints (mean blood loss, surgery time, and complications) were compared between the groups.

Results:

The degree of correction compared with the preoperative status was satisfactory with both approaches, although the difference between them was not significant. No significant differences were found for general endpoints between groups.

Conclusion:

Our data suggest that scoliosis correction with sublaminar fixation is not inferior to treatment with hooks and/or pedicle screws.

Level of Evidence:

III.

Treatment of Aggressive Vertebral Hemangiomas with Poly Vinyl Alcohol (PVA) Microparticles Embolization, PMMA, and Short Segment Stabilization: Preliminary Results with at Least 5 Years of Follow-up

OBJECTIVE

Vertebral hemangiomas (VHs) are the most common incidental lesions of vertebral body, but they are very challenging to treat if they become symptomatic. Several treatments have been proposed but none was superior to others. The aim of this study is to analyze blood loss and long-term clinical and neurological results of aggressive VHs treated with arterial embolization the day before operation, followed by vertebroplasty, posterior decompression, and short segment stabilization.

METHODS

Ten patients (4 males and 6 females) were treated for aggressive VHs with polyvinyl alcohol microparticles embolization, posterior short segment stabilization, and poly methyl methacrylate. Clinical and neurological outcomes were assessed with visual analog, Nurick, and American Spinal Injury Association (ASIA) scales.

RESULTS

At last follow-up mean, visual analog scale was 1.8 ± 1.3, with a significant difference with preoperative values (P = 0.00018). Neurological deficits persisted in 4 patients (ASIA scale: C in 1 patient [10%], D in 3 patients [30%]), but they improved from baseline in all cases. Also, Nurick scale rating improved in all patients (0 in 3 patients [30%], 1 in 4 patients [40%], 2 in 2 patients [20%], and 3 in the last one [10%]). A statistically significant difference between pre- and postoperative values was observed for both scores (ASIA, P = 0.0102; Nurick, P = 0.026). Relapse of pathology was recorded in 2 patients.

CONCLUSIONS

Polyvinyl alcohol microparticles embolization, short segment fixation, and vertebroplasty is an effective treatment option for aggressive VHs, with a fast surgical time, poor blood loss, and improvement of preoperative clinical and neurological outcomes.

Over 70° thoracic idiopathic scoliosis: Results with screws or hybrid constructs

BACKGROUND

Adolescent idiopathic scoliosis is the most common type of scoliosis. High degrees curve can be treated with the anterior, posterior, or combined anterior-posterior approach. Contrarily to the anterior approach, the posterior one is widely used nowadays for its good correction outcomes and relatively low-complication rate.

MATERIALS AND METHODS

We evaluated retrospectively 27 patients, treated with posterior approach. Patients were divided into two groups, namely pedicle screws group (PSG) and hybrid group (pedicle screws + sublaminar bands). Radiographic measurements, including thoracic and lumbar Cobb° measurements of primary and secondary curves, coronal balance and sagittal balance, kyphosis and lordosis, curve flexibility, first and last vertebra included in the arthrodesis, and implant density were evaluated. Clinical patients' satisfaction was also evaluated with Scoliosis Research Society (SRS) 24 questionnaire.

RESULTS

Considering both groups, on preoperative X-rays, the average primary scoliotic curve angle was 83.56° ± 10.96° (range 70°-112°), whereas the global flexibility was 64° ± 7.63 (range 46°-72°). The curves were classified following the Lenke classification: 17 Type 1, 2 Type 2, and 8 Type 3. The primary curve resulted to be well corrected in both groups. In T0, the groups were homogeneous, but in T1 and follow-up, PSG stated a better mean value. No other significative differences can be found between groups for all other items (P > 0.05). Clinical results of SRS 24 were excellent in both groups.

CONCLUSIONS

The posterior approach proved to be an excellent technique for obtaining good clinical and radiographic results if the surgeon adopts the third-generation high-density implants.

LEVEL OF EVIDENCE

III.

Clinical comparison between simple laminectomy and laminectomy plus posterior instrumentation in surgical treatment of cervical myelopathy

BACKGROUND

Posterior stabilization in patients treated with laminectomy for spondylotic cervical myelopathy is still a debate. Despite both being reported in literature by several authors, some controversies still exist. The aim of this study is to compare clinical and radiological outcomes in patients treated with laminectomy or laminectomy with posterior stabilization.

MATERIAL AND METHODS

We retrospectively evaluated 42 patients affected by cervical myelopathy (mean age 70.43 ± 5.03 years), 19 treated with laminectomy (group A) and 23 with laminectomy and posterior instrumentation (group B). Neurological status was assessed with Nurick scale, pain with VAS and radiological parameters with C2-C7 SVA, T1 slope and C2-C7 lordosis, clinical function with modified Japanese Orthopaedic Association score (JOA). Also, surgery time and blood loss were recorded. Student's t test was used for continuous variables, while Kruskal-Wallis test was used for categorical values.

RESULTS

No differences were found in postoperative Nurick scale (p = 0.587), VAS (p = 0.62), mJOA (p = 0.197) and T1 slope (p = 0.559), while laminectomy with fusion showed better postoperative cervical lordosis (p = 0.007) and C2-C7 SVA (p < 0.00001), but higher blood loss (p < 0.00001) and surgical time (p < 0.00001). Both groups showed better Nurick scale (p = 0.00017 for group A and p = 0.00081 for group B), VAS (p = 0.02 for group A and p = 0.046 for group B) and mJOA (p < 0.00001 for both groups) than preoperative values.

CONCLUSIONS

Both treatments are a valuable choice, offering some benefits and disadvantages against each other. Each procedure must be carefully evaluated on the basis of patients' general status, preoperative pain, signs of instability and potential benefits from cervical alignment correction.

Is cast an option in the treatment of thoracolumbar vertebral fractures?

Background:

Thoracolumbar vertebral fractures are common in high-energy trauma and often are associated to other concomitant injuries. Currently, brace and Closed Reduction and Casting (CRC) are the two conservative treatments proposed by literature. Despite CRC was widely used in the past, today brace is preferred. The aim of our study is to evaluate clinical and radiographic outcomes of thoracolumbar type A fractures, not associated with other injuries, treated with CRC.

Materials and Methods:

We retrospectively evaluated all patients treated from 2008 to 2015, with a mean age of 26.69 years (range 15–45). All patients were affected by AO type A fracture: 26 type A1, 17 type A2, and 21 type A3. All patients were evaluated by X-ray, computed tomography, and magnetic resonance imaging. Radiological evaluations included vertebral kyphosis (VK), segmental kyphosis (SK), regional kyphosis (RK) angle, and vertebral ratio (VR) measures. Patients were clinically assessed through visual analog scale, Oswestry Disability Index, Roland–Morris Disability Questionnaire, and Short Form 36 Health Survey.

Results:

Seventy-four patients (41 males and 33 females) were included in the study. At follow-up (mean 28.48 months ± 5.16), we found significant improvements in VK (P = 0.000013), SK (P = 0.000455), and RK (P = 0.000016). No significant differences were observed in VR (P = 0.26). Good clinical results were reported in patients in all scores and 90.7% of patients returned to work.

Conclusions:

Closed reduction and casting is still a reliable treatment option in selected thoracolumbar fractures without spinal cord involvement. A correct fracture evaluation, patient compliance, and motivation are essentials.

Level of evidence:

IV.

Surgical treatment of spinal deformities in Marfan syndrome: Long-term follow-up results using different instrumentations

Background:

Scoliosis is the most frequent spinal deformity related to Marfan syndrome (MFS). Treatment with a brace is often ineffective, and surgical treatment is very challenging; many instrumentations were used along the years. Our retrospective study has the purpose of identifying the reliability of different devices in three-dimensional correction of the spine deformities in MFS.

Materials and Methods:

We reviewed retrospectively the records of patients surgically treated, in a single institution between 1999 and 2016, for spinal deformities in MFS. X-rays were reviewed for analyzing the magnitude of the curves in preoperative time (T0), the amount of correction in the immediate after surgery period (T1), and it's stability at follow-up (FU) (T2). The clinical outcomes were also evaluated with the Scoliosis Research Society 24.

Results:

A total of 21 patients with a mean age at surgery of 16 years met inclusion and exclusion criteria. Four different construct types were identified: hooks with sublaminar wires (G1), hooks and pedicle screws (G2), pedicle screws (G3), and pedicle screws with sublaminar wires (G4). The mean FU time was 8 years. The average major scoliosis curve had a mean value of 63.48° at T0 and was corrected to 28.81° at T2. Furthermore, minor curve, thoracic lordosis, and lumbar kyphosis (when associated to scoliosis) were also corrected. Student t-test showed significative differences (P < 0.05) for all curves between T0–T1 and T0–T2 while between T1 and T2, no differences were found. We also evaluated separately the results of each instrumentation, and G3 obtained the best performances.

Conclusions:

Our results shows that screws may guarantee a better correction of the deformities.

Level of Evidence:

III

Clinical and radiological union rate evaluation of type 2 odontoid fractures: A comparison between anterior screw fixation and halo vest in elderly patients

Purpose:

Odontoid fracture is a very common cervical injury, especially in elderly patients. Despite the high frequency, the appropriate management is still debated. The aim of this study is to evaluate clinical and radiological outcomes after anterior screw fixation or halo vest (HV) in type II odontoid fracture in elderly patients.

Materials and Methods:

Between January 2013 and December 2015, 135 consecutive patients affected by odontoid process were found. According to inclusion and exclusion criteria, 57 patients were included in the study. Patients were evaluated with visual analog scale (VAS), Smiley–Webster Scale (SWS), Italian Version of the Neck Disability Index (NDI), and patient satisfaction during follow-up. Furthermore, radiological data were evaluated for bone healing. Student's t-test or Fisher's exact test was used between groups, analyzing radiological and clinical results, and level of statistical significance was set at P < 0.05.

Results:

Seventeen patients were female and 40 were male. Twenty-seven patients were included in surgical group (SG) while 30 were included in HV group with a mean follow-up of 37.74 ± 10.52 months. A significant difference (P < 0.05) between groups was found for pseudoarthrosis, with a lower rate for SG. No significant differences in term of VAS, NDI, and SWS were found between groups (P > 0.05); SG reached higher satisfaction than HV group (P = 0.0271).

Conclusions:

Both treatments are equivalent in terms of clinical outcomes, and they are a valuable choice in the management of type II odontoid fracture. However, it must be considered that patients could slightly tolerate HV and may need a change of treatment.