Enhanced technique of dural closure using autologous fat graft and Gelfoam for effective management of dural tear following interlaminar endoscopic lumbar spine surgery.

BACKGROUND: Incidental dural tears are common complications in lumbar spine surgery, particularly in endoscopic procedures where primary closure via suturing is challenging. The absence of a standardized approach for dural closure in endoscopic spine surgery necessitates exploring alternative techniques. OBJECTIVE: This study introduces a surgical technique for dural closure utilizing fat graft and Gelfoam, offering an effective alternative to standard approaches in endoscopic spine surgery. METHODS: Surgical data from patients who underwent interlaminar endoscopic discectomy or stenosis decompression at Lerdsin Hospital from October 2014 to October 2021 were analyzed. RESULTS: Among 393 cases, dural tears occurred in 2% (8 patients). Our technique achieved successful closure in all these cases, with no incidents of cerebrospinal fluid leakage or wound complications. The majority of patients showed favorable clinical outcomes, except for one case involving concomitant nerve root injury. CONCLUSION: This study demonstrates that using fat graft and Gelfoam for dural closure is a simple, reliable, and safe technique, particularly effective for challenging-to-repair areas in interlaminar endoscopic lumbar spine surgery.

Does computed tomography-guided percutaneous catheter drainage is effective for spinal tuberculous abscess: a midterm results.

STUDY DESIGN: Retrospective cohort study. PURPOSE: To evaluate an effectiveness and report a midterm clinical outcome in pain and neurological status in spinal tuberculous abscess after treated by CT-guided percutaneous catheter drainage. OVERVIEW OF LITERATURE: Spinal tuberculosis is one of the destructive forms of tuberculosis infection, which can cause undesirable consequences. The gold standard of surgical treatment of spinal tuberculosis with tuberculous abscess is radical debridement, abscess drainage, and bone grafting of the defect via anterior approach. However, this treatment may lead to several serious complications. CT-guided percutaneous catheter drainage is an alternative procedure for this condition and may reduce the serious complications from standard surgical treatment. MATERIALS AND METHODS: The medical record of the patients with spinal tuberculosis with tuberculous abscess who underwent CT-guided percutaneous catheter drainage (CT-guided PCD) from 2015 to 2021. The visual analog pain scale (VAS), Frankel grading scale, duration of drainage, amount of spinal tuberculous abscess, and complications were evaluated. RESULTS: Twenty-nine patients (mean age 44 years old) were included in the study. All patients were followed up for 24 to 72 months with an average of 36 months. Level involvements were mostly found in L1-L2 followed by L2-L3 and T12-L1 levels. A 14-Fr catheter was the mostly use followed by 16-Fr catheter. Amount of abscess drainage ranged from 110 to 2,490 ml (mean 599 ml). The drainage duration ranged from 6 to 42 days (mean 17 days). Additional surgery was performed in three patients due to subsequent mechanical instability developed despite successful drainage of abscess. At the last follow-up, VAS, Frankel grading scale were improved significantly in all patients without complications. CONCLUSIONS: CT-guided percutaneous catheter drainage is a safe and effective alternative procedure in the treatment of spinal tuberculous abscess patients with high success rate, less complications, and satisfied midterm outcomes.

Comparison of post-operative wound pain between interlaminar and transforaminal endoscopic spine surgery: which is superior?

STUDY DESIGN: Prospective cohort study PURPOSE: The objective is to compare post-operative wound pain in patients treated by endoscopic surgery between interlaminar and transforaminal approach at lumbar region. OVERVIEW OF LITERATURE: There are two common approaches for endoscopic lumbar spine surgery, interlaminar and transforaminal approach. The wound size of these two approaches is about the same. However, post-operative wound pain may differ according to the entrance area. METHODS: We conducted a prospectively cohort study including all patients underwent full endoscopic lumbar spine surgery by single surgeon between January 2016 to October 2019. Wound pain using visual analog scale (VAS) at post-operative day 1 and day 14 were collected. VAS back pain, VAS leg pain, Oswestry Disability Index (ODI), modified McNab criteria and complications were also collected. RESULTS: There were 313 patients included in the study. There was no significant difference in VAS wound pain between interlaminar and transforaminal group. Interestingly, subgroup analysis in interlaminar group found statistically significant higher VAS for wound pain at post-operative day 1 when significant bone resection was done by power burr. VAS back-leg pain and ODI have improved significantly between pre-operative and last follow up in both approaches. CONCLUSIONS: Wound pain from endoscopic spine surgery is minimal. This study found no difference in wound pain between endoscopic interlaminar and transforaminal approach. Both approaches show favorable clinical outcomes with few serious complications rate. Further study with long term follow up is needed.

Comparison between 1 g and 2 g of Intrawound Vancomycin Powder Application for Prophylaxis in Posterior Instrumented Thoracic or Lumbosacral Spine Surgery: A Preliminary Report.

BACKGROUND: Surgical site infection (SSI) after instrumented spinal surgery is one of the most serious complications in spite of the routine use of prophylactic intravenous (IV) antibiotics. Many studies have suggested that intrawound vancomycin powder, applied during the intraoperative period, may decrease the incidence of SSI after surgery. However, the appropriate dose of vancomycin has not yet been reported. PURPOSE: The purpose of the study is to compare between the use of 1 g and 2 g intrawound vancomycin powder and to find out which of these two groups can reduce the rate of deep wound infection in posterior instrumented thoracic or lumbosacral spine surgery. MATERIALS AND METHODS: The preliminary study was conducted from July 2013 to July 2015 at Lerdsin Hospital. A total of 400 patients were enrolled in the study, and their individual demographics were recorded. All patients underwent posterior instrumented thoracic or lumbosacral spine surgery. Of these, 131 patients received IV cefazolin and 2 g of vancomycin powder intrawound application, 134 patients received 1 g of intrawound vancomycin powder in addition to IV cefazolin, and 135 patients were given only IV cefazolin and were assigned as the control group. RESULTS: One hundred and thirty-one patients were treated with posterior instrumented thoracic or lumbosacral fusions using IV cefazolin and adjuvant 2 g of intrawound vancomycin powder. Five patients in this group developed deep infections (3.8%). One hundred and thirty-four patients were treated with posterior instrumented thoracic or lumbosacral fusions using IV cefazolin and adjuvant 1 g of intrawound vancomycin powder. Of these, four patients developed deep infections (2.98%). One hundred and thirty-five patients in the control group were treated with posterior instrumented thoracic or lumbosacral using only IV cefazolin as prophylaxis. Of these, four patients developed deep infections (2.96%). Coagulase-negative staphylococcus was the most common isolated organism. There were no adverse clinical outcomes or wound complications due to local application of vancomycin powder. CONCLUSION: The preliminary result could not state the relation of intrawound vancomycin powder to the deep infection; further study with adequate sample size is required.

Comparison of Segmental Mobility in Lumbar Extension Radiographs between a New Technique ("Fulcrum Bending Position") and Conventional Standing Position in Spondylolisthesis Patients.

STUDY DESIGN: Cross-sectional study. PURPOSE: This was carried out to evaluate the benefit of a 'fulcrum bending position' compared with the standing position for evaluation of sagittal translation and sagittal rotation in symptomatic patients with spondylolisthesis. OVERVIEW OF LITERATURE: In lumbar X-ray, the standing position is the most common position used in determining abnormalities in lumbar movement. Lack of standardized method is one of the pitfalls in this technique. We hypothesized that the new technique, that is, fulcrum bending position, may reveal a higher translation and rotation in spondylolisthesis patients. METHODS: The extension lumbar radiographs of 36 patients with low-grade spondylolisthesis were included in the analysis and measurement. Sagittal translation and sagittal rotation were measured in both the routine standing position and in our new technique, the fulcrum bending position, which involves taking lateral cross-table images in the supine position wherein the patient lies on a cylindrical pipe to achieve maximum passive back extension by the fulcrum principle. RESULTS: Results of the measurement of sagittal translation in both positions revealed that compared with the extension standing position, the fulcrum bending position achieved a statistically significant increase of 1.57 mm in translation of the vertebra position (95% confidence interval [CI], 0.52-2.61; p=0.004). The measurement of sagittal rotation in both positions revealed that when compared with the extension standing position, the fulcrum bending position achieved a statistically significant increase of 3.47° in the rotation of the vertebra (95% CI, 1.64-5.30; p<0.001). CONCLUSIONS: For evaluation of both sagittal translation and sagittal rotation in symptomatic patients with spondylolisthesis, compared with the extension standing position, the fulcrum bending position can achieve an increased change in magnitude. Our technique, that is, the fulcrum bending position, may offer an alternative method in the detection or exclusion of pathological mobility in patients with spondylolisthesis.

Extended Posterior Decompression and Instrumented Fusion for Spinal Tuberculosis.

STUDY DESIGN: Retrospective cohort. PURPOSE: To evaluate clinical outcomes, including pain and neurologic status, and to evaluate radiographic outcomes of patients treated with extended posterior decompression, posterior fixation, and fusion in different vertebral segments. OVERVIEW OF LITERATURE: The standard surgical treatment of spinal tuberculosis is radical debridement via anterior approach. However, this approach may lead to several serious complications. Meanwhile, extended posterior approach, the posterior surgical approach, involving the removal of posterior elements, ribs, and pedicles, is an alternative option that can achieve the aims of treatment in this disease and may reduce the serious complications from anterior approach. METHODS: The medical records and imaging of 50 patients admitted with spinal tuberculosis from January 2010 to June 2016 were reviewed. The Visual Analog Scale (VAS), Frankel grading scale, and kyphotic Cobb angle between the pre- and postoperative periods were used to evaluate the patients. RESULTS: The patients had significant improvement of VAS score in all the groups. The T/T-L, L, and L-S group scores improved from 7.2±1.5 to 1.7±1.2 (p<0.01), from 8.1±1.8 to 1.7±1.4 (p<0.01), and from 7.9±2.2 to 1.7±0.8 (p<0.01), respectively, and overall, the patient scores (n=50) improved from 7.8±1.4 to 1.7±1.3 (p<0.01). Ten patients (20%) had Frankel grade E preoperatively, which was improved to 38 patients (76%) postoperatively. A significant improvement of the kyphotic Cobb angle was observed when compared at the preoperative, early postoperative, and final follow-up period in the T/T-L, L, and L-S groups. The loss of correction angle in the LS group was 7.7°±4.3° at the final follow-up compared with the early postoperative correction angle at 9.1°±5.8°, with no statistically significant difference. CONCLUSIONS: Extended posterior decompression, posterior instrumentation, and fusion are effective methods of surgery for treatment of spinal tuberculosis involved in the thoracic, thoracolumbar, lumbar, and lumbosacral regions.

Congenital Spinal Canal Stenosis with Ossification of the Ligamentum Flavum in an Achondroplastic Patient: A Case Report and Literature Review.

Achondroplasia has an effect on intracartilaginous ossification during the development of the spine resulting in a narrow spinal canal. This abnormal anatomy could make an achondroplastic patient tend to have spinal canal stenosis. We reported a case of congenital spinal canal stenosis with achondroplasia combined with ossified ligamentum flavum (OLF) at the thoracolumbar and lumbar spine, which was treated by decompressive surgery. We reported a 52-year-old Thai male with achondroplasia presented with progressive myelopathy and neurogenic claudication due to spinal canal stenosis. Spinal canal stenosis was observed at T10/11 and L1-L5 and OLF at T10/11 through L5 varying in size. Laminectomy and removal of the OLF were performed at T11 and L1-L5. The patient's neurological symptom improved after the surgery. He could walk with a walker at the time of 6-month follow-up postoperatively. In this report, we describe a rare case of achondroplasia with OLF presenting with progressive myelopathy and claudication symptoms from multiple levels of spinal canal stenosis. Laminectomy, removal of the ossified ligament, and fusion with instrumentation resulted in the improvement of the patient's neurological symptoms and function.

Chronic posterior atlantoaxial subluxation associated with os odontoideum: a rare condition. A case report and literature review.

Introduction: Os odontoideum is a rare cervical lesion. This unusual condition is sometimes associated with atlantoaxial subluxation, which is mostly anterior subluxation. Posterior atlantoaxial subluxation due to os odontoideum is extremely rare. Case presentation: We report an unusual case of a 60-year-old Thai female, who was diagnosed as having chronic posterior atlantoaxial subluxation associated with os odontoideum with progressive myelopathy. The patient underwent posterior arch of C1 laminectomy and an occipito-C3 fusion using an occipital plate, C2 pedicle screws, C3 lateral mass screws and autologous iliac crest strut bone graft arthrodesis. During three years of follow-up, she was clinically significantly improved and postoperative radiographs showed a solid osseous fusion without loss of correction or implant failure. Discussion: Chronic posterior atlantoaxial subluxation associated with os odontoideum is rare. This condition can cause occipital-cervical pain, myelopathy, intracranial symptoms, or death. Surgical decompression and stabilization is the treatment of choice. Principles of treatment are to prevent sudden death from neurological compromise, improve neurological status, stabilize the cervical spine, and improve quality of life. Surgical options include atlantoaxial fusion, occipito-C2 fusion, and occipito-C3 fusion. Decision making depends on the location of spinal cord compression, area for arthrodesis, and bone quality.

Variation of C1 spinolaminar line and prevalence of C1 stenosis in normal population.

BACKGROUND: The variation of C1 spinolaminar line in normal population is not fully understood. The relative position of C1 lamina to C3-C2 spinolaminar line is reported as good screening tool for determination of C1 canal stenosis. OBJECTIVE: To determine the variation of C1 spinolaminar line and find the prevalence of C1 canal stenosis in normal population using C3-C2 spinolaminar test. MATERIALS AND METHODS: Three hundred and fifteen lateral cervical radiographs from 315 volunteers without neurological symptoms were analyzed. The relative position of C1 spinolaminar line was determined by C3-C2 spinolaminar and considered positive if C1 lamina lay ventral to C3-C2 line. C1 space available for cord (SAC) was measured from posterior border of dens to the C1 lamina to determine the sagittal diameter. RESULTS: The mean sagittal spinal canal diameter of C1 was 22.2 mm (13-26 mm). Of 315, 14 (4.4%) had positive, 184 (58.4%) had neutral, and 117 (37.1%) had negative C1 spinolaminar line in relation to C3-C2 line. The mean SAC among positive group was 14.9 mm compared to neutral and negative groups which were 22.2 and 23.3 mm, respectively. 21.4% of positive group had SAC of less than 12 mm. The 92.8% of positive C1 spinolaminar line was found in age ≥ 60 years. CONCLUSION: In a normal population, 4.4% has positive C1 spinolaminar line. The C1 stenosis is more prevalent in positive C1 spinolaminar line group.

Concomitant mycotic abdominal aortic aneurysm and lumbartuberculous spondylitis with cauda equina syndrome: a rare condition - a case report and literature review.

INTRODUCTION: Concomitant mycotic abdominal aortic aneurysm and lumbar tuberculous spondylitis with psoas abscess and cauda equina syndrome is extremely rare. This condition can cause serious life-threatening problems if not diagnosed and treated properly. CASE PRESENTATION: We report an unusual case of a 79-year-old Thai male, who was diagnosed with concomitant mycotic abdominal aortic aneurysm and lumbar tuberculous spondylitis at the L2-L3 level with left psoas abscess and cauda equina syndrome. The surgical plan was radical surgical debridement via transpsoas approach and the defect was filled with iliac crest strut graft and posterior decompressive laminectomy and fusion with a pedicle screws and rods system. During the operation, an abdominal aortic aneurysm was iatrogenically ruptured and then was emergently treated with endovascular stent graft implantation. Subsequently, hemostasis was achieved and the patient remained hemodynamically stable. A few days later, he underwent posterior decompressive laminectomy L2-L3, fusion and instrumentation with a pedicle screws and rods system at T11-L5. After surgery, the patient recovered well and his motor power improved gradually. He was continually treated with anti-tuberculous chemotherapy for 12 months. DISCUSSION: Concomitant mycotic aortic aneurysm and lumbar tuberculous spondylitis with psoas abscess and cauda equina syndrome is an extremely rare condition that requires prompt diagnosis and management. Its consequences can lead to serious complications such as permanent neurological damage, paralysis or even death, if left untreated. The aims of the treatment are to eradicate infection, to prevent further neurological compromise, to stabilize the spine and to protect the aortic aneurysm from rupture.

Metastatic Basal Cell Adenocarcinoma of Submandibular Gland to the Spine: An Extremely Rare Condition.

BACKGROUND: Basal cell adenocarcinomas are rare malignant neoplasms of salivary glands, accounting for <1% of salivary gland tumors. Few cases of distant metastases have been reported. CASE DESCRIPTION: A 50-year-old Thai man was diagnosed with basal cell adenocarcinoma of the submandibular gland with pulmonary and cervical spine metastases with progressive myelopathy. He was treated with wide surgical resection of the soft tissue tumor and modified radical neck dissection, anterior cervical total corpectomy with fusion combined with posterior decompression and fusion of the cervical spine, and surgical wound coverage by anterolateral thigh free tissue transfer, followed by adjuvant radiotherapy. At 18-month follow-up, the patient remained in good condition, and no signs of local recurrence or contiguous spreading were detected. Postoperative radiographs showed solid osseous fusion without loss of correction or implant failure. CONCLUSIONS: This case highlighted an extremely rare condition of metastatic basal cell adenocarcinoma of the submandibular gland to the lung and spine, which, to our knowledge, has not been previously reported in the literature.

Postoperative Kinetics of C-Reactive Protein and Erythrocyte Sediment Rate in One-, Two-, and Multilevel Posterior Spinal Decompressions and Instrumentations.

STUDY DESIGN: Prospective study. OBJECTIVE: To characterize the normal pattern of kinetics of postoperative C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) after decompression, spinal instrumentation, and posterolateral fusion in 1, 2, and more than 2 levels. METHODS: Blood specimens were obtained from patients who underwent posterior decompression, instrumentation with pedicular screws, and posterolateral fusion from June 2009 to January 2011. CRP and ESR levels were measured on the day before surgery and on postoperative days 1, 3, 7, 11, 14, 28, and 42. RESULTS: Mean CRP levels peaked on the third day postoperatively in all groups. By day 7 postoperatively, it had dropped rapidly. At the 14th and 28th postoperative days, decreases to normal CRP levels were found in 16% and 80% of all patients, respectively. The pattern of decline in CRP was similar among groups. Values of ESR increased and peaked between the third and seventh postoperative days. ESR values gradually decreased. At the 42 day postoperatively, ESR level still remain above normal values in all groups. CONCLUSIONS: We compared conventional operation groups of 1-, 2-, and more than 2-level posterior instrumentation and found no statistically significant differences in the peak of CRP level, the ESR value, and the pattern of decline. CRP levels of 80% of the patients returned to normal within 4 weeks.

Primary leiomyosarcoma of the spine treated with total en bloc spondylectomy: the first case in Thailand-a case report and literature review.

Leiomyosarcoma is a rare type of malignant soft tissue tumor and also one of the most aggressive soft tissue sarcomas. It commonly occurs in uterus, abdominal viscera, retroperitoneal space and soft tissue of the extremities. Primary osseous leiomyosarcoma is a rare condition. Furthermore, primary leiomyosarcoma of the spine is extremely rare. Only few cases have been reported. However, the treatment and outcomes remains controversial. Therefore, the objective of this case report is to illustrate the management of this extremely rare disease by using total en bloc spondylectomy (TES) procedure, which is one of a suitable option for surgical resection of the spinal tumors. In this study, we presented an unusual case of a 61-year-old female, who was diagnosed as primary leiomyosarcoma of the twelfth thoracic spine with liver metastasis, treated with total en bloc spondylectomy of the twelfth thoracic vertebra followed by chemotherapy. On last follow-up, 6 months after the surgery, the clinical outcome remained in good condition and no signs of local recurrence. In conclusion, primary leiomyosarcoma of the spine is an extremely rare and difficult to diagnosis. Immunohistochemistry studies are very important for confirmation of the diagnosis. Standard treatment remains controversial. However, surgical resection is still treatment of choice. One of the most effective surgical options is TES, which give the better outcome and minimize local recurrence, if indicate.

What Are the Functional Outcomes After Total Sacrectomy Without Spinopelvic Reconstruction?

BACKGROUND: After total sacrectomy, many types of spinopelvic reconstruction have been described with good functional results. However, complications associated with reconstruction are not uncommon and usually result in further surgical interventions. Moreover, less is known about patient function after total sacrectomy without spinopelvic reconstruction, which may be indicated when malignant or aggressive benign bone and soft tissue tumors involved the entire sacrum. QUESTIONS/PURPOSES: (1) What is the functional outcome and ambulatory status of patients after total sacrectomy without spinopelvic reconstruction? (2) What is the walking ability and ambulatory status of patients when categorized by the location of the iliosacral resection relative to the sacroiliac joint? (3) What complications and reoperations occur after this procedure? METHODS: Between 2008 and 2014, we performed 16 total sacrectomies without spinopelvic reconstructions for nonmetastatic oncologic indications. All surviving patients had followup of at least 12 months, although two were lost to followup after that point (mean, 43 months; range, 12-66 months, among surviving patients). During this time period, we performed total sacrectomy without reconstruction for all patients with primary bone and soft tissue tumors (benign and malignant) involving the entire sacrum with no initial metastasis. The level of resection was the L5-S1 disc in 14 patients and L4-L5 disc in two patients. We classified the resection into two types based on the location of the iliosacral resection. Type I resections went medial to or through or lateral but close to the sacroiliac joint. Type II resections were far lateral (more than 3 cm from the posterior iliac spine) to the sacroiliac joint. Musculoskeletal Tumor Society (MSTS) scores, physical function assessments, and complications were gleaned from chart review performed by the treating surgeons (PK, BS). Video documentation of patients walking was obtained at followup in eight patients. RESULTS: The mean overall MSTS scores was 17 (range, 5-27). Thirteen patients were able to walk, five without walking aids, two with a cane and sometimes without a walking aid, three with a cane, and three with a walker. Thirteen of 14 patients who had bilateral Type I resections or a Type I resection on one side and Type II on the contralateral side were able to walk, five without a walking aid, and had a mean MSTS score of 19 (range, 13-27). Two patients with bilateral Type II resection were only able to sit. Complications included wound dehiscences in 13 patients (which were treated with reoperation for drainage), sciatic nerve injury in seven patients, a torn ureter in one patient, and a rectal tear in one patient. CONCLUSIONS: Without spinopelvic reconstruction, most patients in this series who underwent total sacrectomy were able to walk. Good MSTS scores could be expected in patients with bilateral Type I resections and patients with a Type I on one side and a Type II on the contralateral side. Total sacrectomy without spinopelvic reconstruction should be considered as a useful alternative to reconstructive surgery in patients who undergo Type I iliosacral resection on one or both sides. LEVEL OF EVIDENCE: Level IV, therapeutic study.

A new method for measurement of occipitocervical angle by occiput-C3 angle.

BACKGROUND: The description of the measurement technique of the posterior occiput-third cervical spine (OC3) angle-before performing occipitocervical fusion is still controversial. Setting an appropriate alignment in occipitocervical instrumentation is important for successful fixation surgery. Several methods were used for quantifying occipitocervical alignment on the lateral radiograph. This study was performed to describe a measurement technique of OC3 angle and comparing reliability and reproducibility in the measurement of occipitocervical angle with previous method. The purpose of this study was to determine the best technique for assessing this angle. MATERIALS AND METHODS: Three hundred and twenty-six lateral cervical spine radiographs from volunteers without spinal disorder were taken in neutral position and collected from June 2011 to December 2012. Analysis consisted of measurement of the OC3 angle and posterior occipitocervical angle. Inter- and intra-observer reliabilities were assessed using limit agreement test. RESULTS: The mean OC3 angle measurements were approximately 107 (94-120) degrees. Intra- and inter-observer error assessed by 95% limit agreement was approximately ±5.5 and ±7.5, while the POCA measurements were approximately 108 (94-120) degrees. Intra- and inter-observer error assessed by 95% limit agreement was approximately ±13.3 and ±18.2. CONCLUSION: The OC3 angle measurement is a simple method, good inter- and intra-observer reliabilities to measure of the occipitocervical angle. That can be useful to setting the patient's position and facilitate confirmation of the occipitocervical neutral position during occipitocervical fusion.

The Treatment of Flexion Myelopathy of the Thoracic Spine in Pierre Robin Sequence: A Case Report.

BACKGROUND: A few studies had reported the spinal deformity associated with neurological symptoms in PRS patients. OBJECTIVE: To report the management of myelopathy fromflexible thoracic kyphoscoliosis in Pierre Robin sequence (PRS) patient. MATERIAL AND METHOD: A 15-year-old PRS patient with thoracic kyphoscolsis developed myelopathy symptom for 4 months. Posterior instrumentation (Cotrel-Dubousset) from T1-T9 was done to correct her deformity without decompression. RESULTS: Her motor power improved to grade 5/5 two months after operation. Her urological symptom returned to normal at 4-month postoperatively. CONCLUSION: Myelopathy from flexible kyphotic deformity in PRS patients can be successfully treated by posterior correction and fusion without decompression.

A comparative study of radiographic results using HEALOS collagen-hydroxyapatite sponge with bone marrow aspiration versus local bone graft in the same patients undergoing posterolateral lumbar fusion.

BACKGROUND: Autologous bone harvested from the iliac crest is the gold standard for lumbar spinal fusion. However postoperative donor site pain and morbidity have been reported. Local bone graft is insufficient and contains some soft-tissue attachment. Therefore, Healos (DePuy Spine, Raynham, MA, USA) is currently bone graft substitute that was introduced for spinal fusion with good results but radiographic fusion rate has not been clearly defined yet. OBJECTIVE: To assess the radiographic fusion rate of HEALOS with bone marrow aspiration versus autologous bone graft in the same patients undergoing posterolateral lumbar fusion. MATERIAL AND METHOD: A retrospective radiographic outcome study of radiographic fusion rate from plain radiographs in 55patients indicatedforposterolateral lumbar fusion in Lerdsin General Hospital between April 2005 and December 2006 was done. The patients were implanted with HEALOS collagen-hydroxyapatite sponge with bone marrow aspiration and local bone graft on each side of Posterolateral Lumbar Fusion. Twenty-seven patients were included in the present study according to the authors'inclusion criteria. Plain radiographs were collected and radiographic fusion rate was assessed for at least two years follow-up. RESULTS: The two years post operative radiographic fusion rate was 29.63% (8/27) in Healos/BMA group and 62.96% (17/27) in LBG group. At three-years follow-up, radiographic fusion rate of 36.84% (7/19) was achieved in the Healos/ BMA group and 78.93% (15/19) in the LBG group. CONCLUSION: In the present study, Healos collagen-hydroxyapatite sponge with bone marrow aspiration had lower radiographic fusion rate when compared to local bone graft in posterolateral lumbar fusion at two years post operative. The results of the Healos/BMA group was increased fusion rate with time but remained lower than LBG group at three and four years follow-up.

A preliminary study of three and four levels degenerative cervical spondylosis treated with peek cages and anterior cervical plate.

OBJECTIVE: A retrospective study was performed in case with three and four levels degenerative cervical spondylosis that underwent anterior cervical discectomy and fusion (ACDF) with polyetheretherketone (PEEK) cages and anterior cervical plate to evaluate the efficacy and outcome. MATERIAL AND METHOD: Clinical and radiographic results of 16 patients (6 women and 10 men) between January 2006 and June 2009 with follow-up more than 24 months were evaluated Spinal curvature, segmental sagittal angulations, construct height and the radiographic fusion success rate were measured Odom's criteria, visual analog scale (VAS), Nurick and modified JOA (Japanese Orthopedic Association) score were used to assess the clinical results. RESULTS: There was significant difference between pre- and post-operative in degree of lordosis, segmental Cobb angle and clinical outcomes (p < 0.01). Clinical outcomes were classified as 'excellent' or 'good' according to Odom's criteria in 14 patients (success rate: 87.5%). Mean follow-up period was 36 months. Flexion and extension lateral radiographs showed 100% fusion rate. The construct height and sagittal alignment were maintained on the final follow-up observations. No cage failure, subsiding or dislodgement was showed on follow-up radiographs. CONCLUSION: Interbody fusion with PEEK cages packed with bone substitute and aspirated bone marrow which additions of cervical plate eliminate the complications of graft harvest and is a good option for the treatment of patients with three and four levels degenerative cervical spondylosis.

Validity and reliability of an adapted Thai version of Scoliosis Research Society-22 questionnaire for adolescent idiopathic scoliosis.

STUDY DESIGN: Cross-sectional observational study to investigate psychometric properties of an adapted Thai version of the refined Scoliosis Research Society-22 (SRS-22) questionnaire. OBJECTIVE: To evaluate the reliability and validity of the adapted Thai version of the refined SRS-22 questionnaire. SUMMARY OF BACKGROUND DATA: The SRS-22 questionnaire is a valid instrument for assessing the health-related quality of life for patients with adolescent idiopathic scoliosis. Recently, the questionnaire has been translated and validated in many languages for non-English-speaking countries. METHODS: Translation/retranslation of the English version of the SRS-22 was conducted, and the cross-cultural adaptation process was performed. The Thai version SRS-22 and previously validated Thai version Short-Form survey version 2.0 (SF-36V2) questionnaires were administered to 77 patients with adolescent idiopathic scoliosis who had surgical treatment. Fifty-eight patients (52 adolescent girls) had filled out the first set of questionnaires. Thirty patients of the first-time responders completed the second set of questionnaires. The mean age at the time of operation was 14.6 years and the mean age at the time of the final follow-up was 18.7 years. The mean preoperative scoliosis curve magnitude was 55.4° (range, 30°-95°) and postoperative curve magnitude was 20.1° (range, 0°-60°). Internal consistency was determined with Cronbach α coefficient. Intraclass correlation coefficient was used for test-retest reliability. Concurrent validity was evaluated by comparing SRS-22 domains with relevant domains in the SF-36V2 questionnaire, using the Pearson correlation coefficient. RESULTS: The mean overall Cronbach α coefficient of the adapted Thai version SRS-22 was 0.76. The 2 of corresponding domains (mental health = 0.80 and self-image = 0.83) had satisfactory internal consistency and the remaining domains (pain = 0.78; function/activity = 0.74; and satisfaction = 0.76) were good. The intraclass correlation coefficient for 5 domains was ranged from 0.79 to 0.90, which demonstrated the satisfactory test/retest reproducibility. The concurrent validity, determined by the Pearson correlation coefficient between SRS-22 and SF-36V2 domains, had a good correlation for 15 relevant comparisons (r = 0.50-0.75). CONCLUSION: The adapted Thai version of the SRS-22 questionnaire had validity and reliability, which can be used to assess the outcome of treatment among Thai-speaking patients with adolescent idiopathic scoliosis.

Variations of the iliolumbar and ascending lumbar veins.

STUDY DESIGN: A cadaveric retrospective study. OBJECTIVE: To verify the variation of tributaries draining into the iliac system at the lumbosacral junction. SUMMARY OF BACKGROUND DATA: Special attention to vascular anatomy at the great venous bifurcation during anterior lumbar surgery is needed as more tributaries may increase the rate of operative bleeding. Although important, there have been very few detailed anatomic studies about variations of the ascending and iliolumbar veins. The latter tributary forms a horizontal system draining blood into the iliac vein. METHODS: A total of 116 formaldehyde-preserved specimens (61 male and 55 female) were studied. All specimens were dissected and simply classified into patterns and subpatterns according to the similar or different tributaries and their entry points. RESULTS: There were 2 patterns of tributaries: symmetric and asymmetric. More variants were found in the asymmetric group. Each pattern comprising 58 specimens was further classified into 3 subpatterns according to their main tributary trunks. One to 3 tributaries may enter into any trunk of the iliac vein. The most common trunk was the common iliac vein seen in 75.9% of specimens. Draining into the external and internal veins was found in 21.6% and 2.6% of specimens, respectively. One common drainage of the ascending and iliolumbar veins on 1 or both sides was found in 0.9% and > 50% of specimens, respectively (right, 51.7%; left, 56%), whereas 2 or more tributaries were seen in < 50% of specimens (right, 47.4%; left, 43.1%). There was no significant statistical difference among sexes and body sides. CONCLUSIONS: Draining into the iliac system has a high frequency of variations through a number of tributaries and their entry points. The iliolumbar vein will mainly drain into the common iliac vein with frequently 2 or 3 tributaries, whereas drainage into the external iliac or the internal vein is less often observed.