The effects of patient related factors on hidden and total blood loss in single-level open transforaminal lumbar interbody fusion surgery.

OBJECTIVE: The aim of this retrospective study was to identify the amount of TBL and HBL and analyse the risk factors using multivariate linear regression analysis during single-level OTLIF surgery. METHODS: In this study 62 patients (32 male, 30 female, mean age 49.22 ± 13.26) who underwent single-level interbody fusion proce dures by a single surgeon between 2015 and 2021 were included. Retrospectively, relevant statistics regarding body mass index (BMI), American Society of Anesthesiologist Score (ASA), preoperative mean arterial pressure (MAP), and age were gathered. Preoperative MR images were used to assess and measure radiological parameters such as skin-disc distance (SDA), canal area (CA), paravertebral muscle area (PVMA),lumbosacral maximum subcutaneous fat thickness (LSMSF), operation level subcutaneous fat thickness (OPSF) and spi nous process length (SPL).Total blood loss (TBL) was calculated according to Nadler's formula. Hidden blood loss (HBL) was measured by deducting the measured (visible) blood loss from TBL. TBL, HBL and their relationship with preoperative parameters were assessed. RESULTS: HBL was determined to be significantly higher in older patients (P = 0.012). MAP was seen to have a statistically significant cor relation with operating time (P = 0.002), operative bleeding (P = 0.002), TBL (P = 0.006), and HBL (P = 0.001), and an inverse correlation with postoperative drainage (P = 0.007). The ASA scores were observed to be statistically significantly correlated with TBL (P = 0.001), and HBL (P = 0.001). LSMSF showed a significant correlation with TBL (P = 0.005) and HBL (P = 0.002). OPSF was determined to be correlated with TBL (P = 0.011), HBL (P = 0.009) and length of stay in hospital (P =0.034). SDD was correlated with TBL (P =0.043), and SPL with HBL (P = 0.013). It was shown that age (P =0.012), MAP (P =0.001), ASA (P =0.001), LSMFS (P = 0.002), OPSF (P = 0.009), SPL (P = 0.013) were risk factors for HBL. According to multivariate logistic regression analysis; two anatomical factors LSMSF and SPL were independent risk factors for HBL (P < 0.05). CONCLUSION: This results of this study have revealed that most patient-related parameters have a significant effect on HBL and TBL.The study has also demonstrated that LSMSF and SPL are independent risk factors for HBL. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Cervical and thoracic/lumbar motion and muscle strength in surgically treated adolescent idiopathic scoliosis patients.

BACKGROUND: To date, only one study assessed the spinal mobility and muscle strength of patients who were treated either with fusion or brace treatment. OBJECTIVE: The aim of this retrospective study was to evaluate the range of motion (ROM) and strength of the cervical and thoracic/lumbar spine in patients who underwent spinal fusion for the treatment of adolescent idiopathic scoliosis (AIS) in comparison to healthy individuals. METHODS: Patients (n= 28) who were treated surgically for AIS were included in the study. An age and gender matched control group (n= 22) was included that consisted of healthy individuals. DAVID® Lumbar/Thoracic Extension, Lumbar/Thoracic Rotation, and Cervical Extension/Lateral Flexion devices were used to measure cervical and lumbar/thoracic ROM as well as muscle strength. RESULTS: Significant differences were observed between groups in all ROM measurements except thoracic/lumbar sagittal flexion ROM measurement (p= 0.198). There were significant differences between groups in terms of muscle strength, except thoracic lumbar left rotation strength (p= 0.081). CONCLUSIONS: The findings of the current study demonstrated that cervical and thoracic/lumbar range of motion, as well as muscle strength, were significantly decreased in surgically treated adolescent idiopathic scoliosis patients compared to healthy counterparts. However, trunk (thoracic/lumbar) flexion range of motion and trunk left rotation muscle strength were not significantly different.

Preservation of Spine Motion in the Surgical Treatment of Adolescent Idiopathic Scoliosis Using an Innovative Apical Fusion Technique: A 2-Year Follow-Up Pilot Study.

BACKGROUND: This trial reports the 2-year and immediate postremoval clinical outcomes of a novel posterior apical short-segment (PASS) correction technique allowing for correction and stabilization of adolescent idiopathic scoliosis (AIS) with limited fusion. METHODS: Twenty-one consecutive female AIS patients were treated at 4 institutions with this novel technique. Arthrodesis was limited to the short apical curve after correction with translational and derotational forces applied to upper and lower instrumented levels. Instrumentation spanned fused and unfused segments with motion and flexibility of unfused segments maintained. The long concave rods were removed at maturity. Radiographic data collected included preoperative and postoperative data for up to 2 years as well as after long rod removal. RESULTS: All 21 patients are beyond 2 years postsurgery. Average age at surgery was 14.2 years (11-17 years). A mean of 10.5 ± 1 levels per patient were stabilized and 5.0 ± 0.5 levels (48%) were fused. Cobb angle improved from 56.1° ± 8.0° to 20.8° ± 7.8° (62.2% improvement) at 1 year and 20.9° ± 8.4°, (62.0% improvement) at 2 years postsurgery. In levels instrumented but not fused, motion was 26° ± 6° preoperatively compared to 10° ± 4° at 1 year postsurgery, demonstrating 38% maintenance of mobility in nonfused segments. There was no report of implant-related complications. CONCLUSIONS: PASS correction technique corrected the deformity profile in AIS patients with a lower implant density while sparing 52% of the instrumented levels from fusion through the 2-year follow-up.

Results of Posterior Vertebral Column Resection: Surgical Modification of Suk Technique.

STUDY DESIGN: Consecutive, retrospective review. OBJECTIVES: To evaluate and report a modified posterior vertebral column technique. METHODS: We present a retrospective analysis of 20 patients. Patients having severe 3-dimensional deformity with flexibility less than 20% and managed by posterior vertebral body resection (PVCR) between 2011 and 2014 were included in this study. There were 12 female and 8 male patients, with a mean age of 18 year (range = 3-63 years). RESULTS: The average follow-up was 3.5 years (2-5 years). The preoperative coronal plane deformity was 84° (70° to 120°) and corrected to 42° (28° to 68°), showing 60% scoliosis correction. Average preoperative local kyphotic angle was 92° (82° to 110°). Correction rate for kyphosis was 62%. All patients after surgery showed their baseline neurological status, and no complications were encountered. The mean estimated blood loss was 1072 mL (350-2000 mL). Thirty-nine percent (33% to 50%) of total blood loss occurred after vertebral body resection, and 61% (50% to 67%) blood loss occurred after the removal of posterior elements. The ratio of estimated blood loss to estimated body blood volume was 26% (range = 19% to 52%). CONCLUSION: We found that 60% of total bleeding occurs during and after posterior bone resection. Spinal cord is open to possible iatrogenic direct spinal cord injury with surgical instruments for a much shorter period of time compared with the original technique.

Analysis of Segmental Mobility Following a Novel Posterior Apical Short-Segment Correction for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: A prospective, nonrandomized, multicenter study. OBJECTIVES: The purpose of this study was to evaluate the amount of motion present at instrumented but unfused segments and at motion segments adjacent to the instrumentation following application of a new posterior apical short-segment correction technique for correcting adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: High-density pedicle screw instrumentation and posterior arthrodesis of all instrumented levels is the most common surgical treatment for AIS stabilization. The consequence of long fusion is an abnormal load on adjacent levels with an increased risk of future adjacent segment degeneration. METHODS: This new system applied translational and derotational forces over a short apical segment. The short apical region was prepared for fusion while maintaining motion of unfused vertebral segments. Radiographic data were collected pre-operatively, at surgery, and at 3, 6, and 12 months after surgery. RESULTS: Twenty-one female patients, mean age of 14.2 years (10.6-16.9 years) with Lenke 1A/1B curves, were enrolled. The range of motion in the unfused instrumented segment was significantly higher than the apical fused segment (11 vs. 0.9, P < 0.001). The range of motion of unfused vertebral levels distal to the construct at one year did not differ significantly from their respective pre-op values. When the analysis was extended to understand the impact of lower instrumented vertebra (LIV) on motion of unfused segments distal to the construct, it appeared that (1) the change in motion from pre-op to 12 months post-op as a function of LIV is not statistically significant; and (2) The motion of the unfused distal vertebral segments at 12 months does not statistically increase with a lower LIV. CONCLUSION: Through one year, this novel technique achieved and maintained similar AIS correction to current posterior fusion techniques while maintaining the mobility of unfused motion segments with less implant density. LEVEL OF EVIDENCE: 4.

Posttraumatic Charcot (Neuropathic) Spinal Arthropathy at the Cervicothoracic Junction.

BACKGROUND: Charcot spine arthropathy (posttraumatic neuroarthropathy of the spine) has been reported to be a very late and rare complication of spinal cord injury. Charcot of the cervicothoracic and upper thoracic region rarely is reported in the literature. Charcot spinal arthropathy is a cause of progressive deformity and may present as late as 30 years after the original spinal cord injury. This is more common in paraplegic patients who are actively ambulating. CASE DESCRIPTION: A 56-year-old patient with complete paraplegia for approximately 20 years after spinal cord injury presented with severe kyphous deformity and instability of thoracolumbar spine. His sensory level to deep pain was at thoracic (D4). He kept developing new neuroarthropathies at different segments within a span of 5-6 months after every decompression and fusion with anterior cage and posterior instrumentation done. A total of 3 surgeries had been done in span of 2 years, initially thoracic, then lumbar and finally cervicothoracic junction. CONCLUSIONS: We present this case because of the challenges in surgery for instrumentation of new Charcot spinal arthropathy. Reports of neuroarthropathy developing above the level of spinal cord injury and at the cervicothoracic junction are rare. The treating surgeon should be cognizant of the possibility of developing secondary levels of neuroarthropathy above and below a previously successful fusion.

Traumatic lumbosacral spondyloptosis: a case report and review of the literature.

Study Design Case report and review of the literature. Objective To report a case of traumatic L5-S1 spondyloptosis and review the literature. Method A 28-year-old man presented with severe low back pain, numbness at the soles of feet, and bowel and bladder dysfunction. Two days before admission, a tree trunk fell on his back while he was seated. A two-stage posterior-anterior procedure was performed. At the first stage, posterior decompression, reduction, and fusion with instrumentation were performed. At the second stage, which was performed 6 days after the first stage, the patient underwent anterior lumbar interbody fusion. The patient received physical therapy 1 week after the second stage. Results The patient's numbness improved immediately after the first posterior surgery. His fecal and urinary incontinence improved 6 months after discharge. He has been pain-free for a year and has returned to work. Conclusion A PubMed search was performed using the following keywords: lumbosacral spondyloptosis, lumbosacral dislocation, and L5-S1 traumatic dislocation. The search returned only nine reported cases of traumatic spondyloptosis. Traumatic spondyloptosis at the lumbosacral junction is a rare ailment that should be suspected in cases of high, direct, and posterior impact on the low lumbar area, and surgical treatment should be the standard choice of care.

Iliosacral fixation after type-1 hemipelvectomy: a novel technique.

Involvement of the iliac bone and a sacroiliac joint with malignant tumours is not uncommon; treatment is difficult due to the anatomy of the pelvis. Resection of the tumour mass must be extensive in order to achieve safe margins, but this may lead to instability and poor results. We present a new technique for reconstruction after resection of the iliac bone and sacroiliac joint including a sacral ala, and we present two illustrative cases, with 2 years follow-up. Following en bloc resection of a chondrosarcoma in the iliac bone, two or three polyaxial pedicle screws were placed transversly into the sacrum. Two polyaxial pedicle screws were also inserted into the remaining pubic and ischial bone respectively. After completion of the construct with rods, a cortical strut graft from the ipsilateral fibula was placed between the rods. Next a split mesh was placed around the implants and was filled with 60 cc bone chips allografts. Both patients were mobilized with crutches and partial weight bearing for 4 weeks and then full-weight bearing. After two years follow-up, they were ambulatory without external support and their radiological results remained satisfactory. This technique for reconstruction after type I pelvic resection is advantageous in that it saves mobile lumbar segments.

Validation of the Turkish version of the visual analog scale spine score in patients with spinal fractures.

OBJECTIVE: The visual analog scale spine score (VASSS) is a valid and reliable instrument for outcome assessment of patients with thoracic and lumbar spine fractures. The aim of this study was to prepare a Turkish version of the VASSS and to validate its use for assessing treatment outcomes in Turkish patients with spinal trauma. METHODS: The German version of the VASSS was blindly and independently translated into Turkish by three translators and modified by a team. Fifty patients who had been surgically treated for thoracic or lumbar fracture and a group of 50 healthy controls were evaluated using the VASSS, Oswestry Disability Index (ODI), Roland-Morris Disability Questionnaire (RMDQ), and Short Form 36 (SF-36). The Cronbach's alpha was performed to test the internal consistency of the score. RESULTS: The Cronbach's alpha coefficient was calculated as 0.965 in the overall assessment of the scale. Criterion validity measured by comparing the VASSS responses with the results of ODI, RMDQ, and SF-36 physical component (for ODI r=0.881, p<0.001; for RMDQ r=0.882, p<0.001; for SF-36 r=0.824, p<0.001). Construct validity tested by factor analysis yielded a factorial structure of the questionnaire with 64.7% of cumulative percentage of explained variance, and Turkish version of the VASSS showed a similar structure than the original version. CONCLUSION: The Turkish version of the VASSS is a reliable and valid instrument to assess the outcome in patients with thoracic or lumbar spinal fractures in the Turkish population.

Long-term outcome after surgical treatment of thoracolumbar fractures versus a control group of healthy volunteers.

The authors conducted a retrospective study on the long term outcome (+/- 9 years) after instrumentation for thoracolumbar fractures. This study is probably unique in that it compares the surgical group with a control group of healthy volunteers, rather than with a group of conservatively treated patients. All classical outcome measures were used: ODI, RMDQ, VASSS, VAS, Denis Pain scale, SF-36 Bodily Pain, SF-12 Bodily Pain, the remaining SF-36 and SF-12 scores, and the Denis Work Scale. As expected, the large majority of the scores was better in the healthy group. The difference was significant, except as far as the SF-tests were concerned.

The comparison of the negative effect of autoclaving and pasteurization on bone healing.

OBJECTIVES: The aim of this study was to compare the effects of autoclaving and pasteurization on bone healing. METHODS: Twenty-five full-grown male rabbits were included in the study; all 25 had bone blocks resected and reimplanted. In group 1, bone blocks were autoclaved; in group 2, bone blocks were pasteurized; and in group 3 (controls), resected bone blocks were reimplanted without sterilization. RESULTS: Heiple scores of the proximal parts of the fusion surfaces in group 1, group 2, and group 3 were 12.8±0.4, 6.8±1.2, and 10.2±1.9, respectively. Heiple scores of the distal parts of the fusion surfaces in group 1, group 2, and group 3 were 10.8±0.8, 6.0±1.1, and 9.8±1.5, respectively. Differences in radiologic scores were not statistically significant between the groups for proximal or distal fusion surfaces at 3 and 6 weeks. CONCLUSION: In conclusion, pasteurization has a less negative effect on bone healing than autoclaving, and can be considered for bone sterilization in certain circumstances.

Surgical treatment of odontoid fractures with C1 hook and C2 pedicle screw construct.

A number of approaches have been attempted to address the treatment of acute odontoid fractures, spanning from conservative treatment with an external orthotic device to posterior C1-C2 arthrodesis or anterior screw fixation. The current report describes stabilisation of such fractures with a C1 supralaminar hook and a C2 pars interarticularis screw construct. Two patients with odontoid fracture were treated by this technique. Two-year follow-up of both patients revealed complete union without complications. The authors stress that this technique avoids the hazards of C1 lateral mass screws.

Interobserver reliability in evaluation of pedicle screw positions inserted with a modified technique.

The aim of this study was to evaluate a new technique for insertion of pedicle screws. The position of the screws was assessed on postoperative plain radiographs and computed tomography (CT) scans, and the interobserver reliability in evaluation of the pedicle screw positions was studied. The technique was applied to insert 201 pedicle screws in 27 patients with various spine conditions. The positions of the screws were evaluated blindly by two independent orthopaedic surgeons and two independent radiologists. Interobserver reliability was evaluated separately for analysis of plain radiographs and CT scans, as well as for the different spinal segments and for the different spine conditions treated. The rate of malpositioned screws was between 6.5% and 32.8% in plain radiographs and between 3.5% and 6.5% in CT scans according to the different observers. In plain radiographs, the rates of malpositioned screws in the upper thoracic, lower thoracic and lumbosacral spine segments were between 3.8%-39.6%, 10.0%-36.3%, 4.4%-23.5%, respectively. In CT scans, the rates of malpositioned screws in the upper thoracic, lower thoracic and lumbosacral spine segments were between 3.8%-13.2%, 2.5%-8.8%, and 0%, respectively. Interobserver reliability was found to be poor in radiographs and fair in CT scans. The technique used for insertion of pedicle screws was found to be simple and reproducible. Assessment of the screw positions with only plain radiographs was not found reliable. A detailed and standard classification system should be developed in order to improve interobserver reliability in assessing the positions of the screws.

Brown tumor of the sacral spine in a patient with low-back pain.

We present a case of a 44-year-old woman with an unusual location of a brown tumor in the sacral vertebrae due to parathyroid adenoma. She was admitted to our clinic with the complaint of low-back pain and was later diagnosed to have a brown tumor. The patient underwent surgery and partial sacrectomy and iliac wing resection was performed in Orthopedic Surgery Department. Subsequently the patient underwent parathyroid adenoma excision in General Surgery Department. On her control examination at postoperative 3 months, she had no pain and was able to perform daily activities without any problem. We believe it is an interesting clinical case both because it shows a very rare localization of brown tumor and points out the importance of employing a wide clinical scope in the differential diagnosis of back pain.

Simultaneous versus sequential one-stage combined anterior and posterior spinal surgery for spinal infections (outcomes and complications).

To compare simultaneous with sequential one-stage (same anaesthesia) combined anterior and posterior spinal surgery in the treatment of spinal infections in terms of the operation time, blood loss and complication rate. Fifty-six patients who underwent one-stage (same anaesthesia) simultaneous or sequential anterior decompression and posterior stabilisation of the involved vertebrae for spinal infection from January 1994 to December 2002 were reviewed. In group I (n=29), sequential anterior and posterior surgery was performed. In group II (n=27), simultaneous anterior and posterior spinal surgery was performed. With regard to age and gender, there was no statistical difference between both groups (P=0.05). The analysed and compared data between the two groups included the age, gender, blood loss, operation time and postoperative complications. There was a statistically significant difference between the two groups in terms of the duration of surgery, amount of blood transfusion needed and occurrence of major postoperative complications (P<0.05). The mean correction of the kyphotic deformity was similar in both groups (P>0.05) without a subsequent loss of correction on follow-up radiographic films at a mean follow-up of 6.5 years (range, 3 to 11 years). Simultaneous anterior and posterior surgery is a good alternative procedure. It provides the ability to manipulate both anterior and posterior aspects of the spine at the same time and appears to result in less blood loss, a shorter operative time and fewer complications. However, gaining experience and the availability of two surgical teams are important factors in the success of the procedure.

Evaluation of lung cancer metastases to the spine.

Most metastatic spinal lesions (70%) are found at the thoracic level, 20% in the lumbar region, and 10% in the cervical region. A variety of benign and malignant tumours may arise in the lung, but the vast majority is bronchogenic carcinomas (90 to 95%). The aim of this study was to evaluate the lung cancer metastases to the vertebral column in terms of type, localisation and metastasis pattern. Between the years 1995 and 2003, 168 lung cancer patients with metastatic spinal tumour who had received radiotherapy and chemotherapy were retrospectively evaluated. The total number of vertebrae in which metastases were detected was 328. The most common site for metastasis was the thoracic spine. In 49 (29%) patients, there was only one vertebral involvement. Additional extravertebral bony metastases were present in 37 (22%) patients; the femur (20 patients) was the most common site. Only 25 of 168 patients were operated due to spinal cord compression leading to neurological deficit. The rest of the patients were treated by appropriate chemotherapy and radiotherapy protocols. The mean survival after diagnosis of vertebral metastasis was 7.1 months. Squamous cell carcinoma and adenocarcinoma are the lung cancers that mostly metastasise to vertebrae. Most of the metastases involve multiple spinal levels. After the diagnosis of vertebral metastasis, the mean survival is seven months. Pain relief and maintaining quality of life must be balanced with the patient's life expectancy, comorbidities and immunological, nutritional and functional status in treatment decision.

A new material for prevention of epidural fibrosis after laminectomy: oxidized regenerated cellulose (interceed), an absorbable barrier.

Epidural fibrosis, which may cause persistent back and leg pain, may develop after laminectomy. Several materials have been used in attempts to minimize epidural fibrosis, with varying results. We evaluated the efficacy of an absorbable cellulose adhesion barrier in preventing epidural fibrosis. In 25 New Zealand white rabbits, laminectomies were performed at L3 and L5 vertebrae. The dura mater was covered by the adhesion barrier (Interceed, TC7, Johnson & Johnson, USA) at L3 laminectomy site (group 1), with L5 laminectomy site serving as an internal control (group 2) in each animal. There was no neurological deficit in any of the animals during the postoperative period. Animals were sacrificed at postoperative day 28. The lumbar spine was removed en bloc and placed in neutral, buffered formalin for 72 h. The specimens were then decalcified and embedded in paraffin. Permanent sections of 5 to 7 microm were stained with hematoxylin and eosin and Masson trichrome dye. Epidural fibrosis was evaluated in a double-blinded manner. The extent of epidural fibrosis was graded as 0, no reaction seen; 1, mild reaction; 2, moderate reaction; 3, extensive reaction, and 4, severe reaction. The histological findings of each group were compared. For the statistical analysis, Wilcoxon signed rank test was used. In group 1, the fibrotic tissue formation was minimal in 19 and moderate in 6 laminectomy sites. In group 2, the fibrotic tissue formation was determined as being extensive in 17 and moderate in 8 laminectomy sites. Statistical analysis showed significant decrease in epidural fibrosis in group 1 (P<0.05). This study showed that Interceed, which is commercially available in the market, especially for abdominal and gynecological surgeries, could be used to prevent epidural fibrosis.

Kyphoplasty for pregnancy-associated osteoporotic vertebral fractures.

We report a case of pregnancy-associated osteoporotic vertebral fracture treated by kyphoplasty. This case is important for being the first case of postpregnancy osteoporotic vertebral fracture treated with kyphoplasty. Although kyphoplasty is a very successful procedure in short-term pain relief for osteoporotic vertebral fractures, there is a critical need for randomized controlled trials demonstrating short-term complications of kyphoplasty including new vertebral fractures.

A new autogenous graft choice in pelvic reconstructions: free vascularized rib (a case report).

Primary or secondary bone tumours are not uncommon in pelvic girdle. In some cases, after radical resection, there is a big bony defect where the prosthesis is not applicable; arthrodesis is the only choice for good functional results. In this instance, the major problem is to achieve the fusion. In this case report, we focused on easy harvesting and minimal time consumption with free vascularized rib graft to achieve the fusion between the resected segments. Two year follow up showed fusion with good functional result.

Surgical treatment of sprengel's deformity: a modified Green procedure.

Twelve cases of Sprengel's deformity were treated surgically by a modification of Green's procedure. After clavicular osteotomy, all muscular attachments to the scapula were freed; an omovertebral band if present was cut and the scapula was rotated and moved caudal to a more normal position, to be sutured into a pocket of the latissimus dorsi. The patients included 10 female and 2 male patients (age range at the time of operation: 3 to 9 years; mean: 5.2 years). The deformity involved the left shoulder in 8 patients, the right shoulder in 4. All patients were followed for an average of 2 years (range: 6 months to 4.5 years). The range of flexion improved from an average of 95 degrees to 105 degrees and the range of abduction from an average of 81 degrees to 97 degrees. Cosmesis was improved in all 12 patients but three patients had an unsightly surgical scar. Surgical treatment by a modified Green procedure for patients with Sprengel's deformity is indicated when the patient and family want cosmetic or functional improvement.