Recovery with posterior decompression and dural suturing in a patient with cauda equina syndrome caused by lamina entrapment in an unstable burst fracture: A case report.

INTRODUCTION: This report investigates Cauda Equina Syndrome (CES), a critical neurological condition from lumbar and sacral nerve root compression that arises from trauma, such as unstable burst fractures leading to interlaminar entrapment. This study highlights the effective management and recovery of a young woman with CES following a traumatic fall, offering new insights into the condition's treatment and recovery process. CASE PRESENTATION: A 24-year-old female experienced severe lower back pain, bilateral lower limb weakness, saddle anesthesia, and bladder dysfunction after a 3-m fall. The neurological assessment showed reduced sensation and motor function in the lower extremities. Diagnostic imaging revealed an unstable L2 burst fracture with cauda equina entrapment. She underwent emergency posterior decompression and dural repair, followed by a tailored rehabilitation program, which is a novel aspect of this study. DISCUSSION: This report underscores the critical need for immediate surgical intervention in CES to avert lasting neurological damage. The case represents the significance of early decompression for improving prognosis and explores the complexities of managing CES with unstable spinal fractures and dural tears. It demonstrates the challenges in surgical intervention and postoperative rehabilitation, offering a new perspective on the integrative approach to treatment. CONCLUSION: This case exemplifies the imperative CES management post-spinal trauma. Despite severe initial deficits, an innovative multidisciplinary approach involving surgery and early rehabilitation resulted in remarkable functional recovery. This study contributes to a new understanding of CES management in acute trauma settings and calls for further research to advance treatment protocols and enhance predictive outcomes.

Surgical management of posterior ligament complex stripping in an adolescent spinal flexion distraction injury: A case report and literature review.

INTRODUCTION: Adolescent spinal injuries such as flexion-distraction injuries with posterior ligament complex (PLC) stripping require specialized management because of the unique interplay between injury mechanics and spinal growth. This case report sheds light on these rare occurrences and their management. PRESENTATION OF CASE: An 11-year-old boy sustained spinal flexion-distraction injuries resulting in posterior ligament complex stripping following a passenger traffic accident. He underwent a meticulously planned surgical intervention involving urgent posterior fusion with pedicle screw fixation at the L1-2-3 levels and allograft bone grafting. This approach was chosen considering the unique challenges posed by his adolescent spinal anatomy and the nature of his injuries. Postoperative management included using thoracolumbar-sacral orthosis (TLSO), facilitating early ambulation and recovery. DISCUSSION: The rarity of PLC stripping in adolescents underscores the importance of case studies for guiding care. This instance validates the surgical approach and highlights the importance of postoperative management with TLSO for early mobility and prevention of growth-related deformities. This case emphasizes the need for vigilant surgical and postoperative strategies in adolescent spinal injury management. CONCLUSION: An early surgical approach complemented by strategic postoperative management, including the use of TLSO for early mobilization, is vital for the treatment of adolescent spinal injuries. Effective recovery and careful consideration of spinal growth are essential during treatment. Documenting such cases contributes to the body of knowledge necessary to enhance the care strategies for patients with similar injuries.

Spontaneous spinal epidural abscess in an adolescent patient: A case report and literature review.

INTRODUCTION: Spinal epidural abscess (SEA), particularly the spontaneous variant, is a severe and rare condition often associated with vertebral osteomyelitis, hematogenous infections, and spinal interventions, leading to severe neurological damage and disabilities. Although more common in adults, spontaneous SEA (SSEA) in adolescents is extremely rare but represents a significant risk, as presented here. PRESENTATION OF CASE: A 16-year-old boy presented with progressive back pain, uncontrolled fever, and paresthesia in the right lower extremity. Despite the absence of common risk factors, SEA was diagnosed at the L4-L5 level. Laboratory results revealed leukocytosis and elevated levels of inflammatory markers. Magnetic resonance imaging (MRI) confirmed the diagnosis of SEA, and surgery revealed Group A Streptococcus in the abscess. The patient showed significant improvement after laminectomy and a six-week course of intravenous cefazolin. DISCUSSION: SSEA often presents with nonspecific symptoms, leading to delayed diagnosis and treatment. The gold standard for diagnosis is MRI, and typical treatment involves antibiotic administration and surgical decompression. The importance of maintaining a high index of suspicion for SEA in adolescent patients presenting with back pain and fever, even in the absence of common risk factors or sources, is highlighted. CONCLUSION: We report the infrequent manifestation of SEA in an adolescent patient, and the difficulties in the diagnosis and treatment thereof. Despite these common risk factors, SEA should be considered as a differential diagnosis in adolescents with back pain and uncontrolled fever. Prompt diagnosis, early surgical intervention, and appropriate antimicrobial therapy are vital to improve patient outcomes and prognosis.

Atypical intradural extramedullary spinal schwannoma causing cauda equina syndrome: A case report and literature review.

INTRODUCTION: Spinal schwannomas are slow-growing benign tumors that are generally asymptomatic. However, we describe an atypical case in which an intradural extramedullary schwannoma presented as an acute cauda equina syndrome. PRESENTATION OF CASE: This was a 58-year-old woman with a 2-month history of severe low back pain and worsening neurological deficits and a 2-day period of acute onset of lower extremity numbness and urinary incontinence. Physical and neurological examination revealed significant lower extremity weakness, tenderness on palpation of the spine, positive straight leg test bilaterally, decreased sensation below the L4 dermatome, reduced sphincter tone, saddle anesthesia, decreased deep tendon reflexes, and loss of sphincter control, consistent with compression of the cauda equina. Magnetic resonance imaging revealed a large mass of heterogeneous composition at the level of L3 lumbar, intruding into the cauda equina. Wide decompression was successfully performed, and histopathological examination confirmed the diagnosis. With rehabilitation, there was some recovery of lower extremity motor function. DISCUSSION: Spinal schwannomas are rare, accounting for only about 2 % of spinal tumors. Cauda equina syndrome is also rare, with an incidence of 0.08-0.27 % among patients presenting with low back pain. Therefore, it is important for clinicians to have an awareness of the possible association between spinal schwannoma and cauda equina syndrome and to complete a comprehensive assessment of patients with back pain, including magnetic resonance imaging. CONCLUSION: Early recognition and treatment of a spinal schwannoma causing neurological symptoms can improve patient outcomes.

Complete bone fusion in failed back surgery syndrome using teriparatide in neurosyphilis: A case report.

INTRODUCTION AND IMPORTANCE: Syphilis is a sexually transmitted disease that appears in various organs. Neurosyphilis in the spine is infrequent, and report of failed spinal arthrodesis surgery is rare. We report the first presentation of complete bone fusion in failed back surgery syndrome with teriparatide. CASE PRESENTATION: A 65-year-old man presented to the outpatient clinic after being admitted to the spine department. The patient visited the neurology department 30 years prior for syphilitic myelitis and had been walking with a cane. He underwent an L5-S1 stenosis operation earlier. Severe proximal adjacent L4-L5 level stenosis was observed due to syphilitic gumma with cauda equina syndrome. A posterior decompression and posterolateral fusion to S1 were performed. Four weeks post-surgery, bilateral lower extremity muscle weakness recurred, and a radiographic examination revealed bilateral posterior screw loosening and fracture of the fourth lumbar vertebrae body. After the stagnant fluid and metal removal, for the augmentation of bone union, teriparatide was used for six months, and a complete bone union was confirmed by radiography without pain. CLINICAL DISCUSSION: Spinal syphilitic gumma has been rarely reported, most of which undergo surgical treatment. Surgical decompression and fixation with a pedicle screw are usually needed. There are complications after spinal surgery using a pedicle screw fixation, and parathyroid hormone (PTH) might be suitable for application in the prevention of nonunions or to augment bone fusion. CONCLUSION: This case report is the first description of complete spinal bone fusion in failed back surgery syndrome using teriparatide in tertiary syphilis.

Delayed cauda equina syndrome by nerve root incarceration after caudal epidural block: A case report.

INTRODUCTION AND IMPORTANCE: Caudal epidural block has been commonly practiced in recent years and is used for management of pain before surgery and chronic back pain in adult spine diseases. CASE PRESENTATION: A 58-year-old man visited the outpatient clinic complaining of recently aggravated severe low back pain, saddle anesthesia, and unbearable radiating pain in his left leg, with a previous history of caudal epidural block. He had problems with bladder and bowel function. Emergency exploration for cauda equina syndrome (CES) was performed. Decompression, extradural herniation, and entrapment of a cauda equina filament through a dural defect were observed, and surgical reduction with dural repair was performed. CLINICAL DISCUSSION: The clinical signs at onset suggested cauda equina dysfunction after caudal epidural block. Magnetic resonance imaging showed spinal canal stenosis with a paracentral herniated intervertebral disc at the L4-L5 level without any other dural or nerve root abnormality. Exploration was the only option to identify the lesion. CONCLUSION: This is the first case report of CES caused by extradural nerve root herniation and strangulation after caudal epidural block.

Intraoperative finding and management of complete spinal cord transection after thoracolumbar traumatic fracture-dislocation: A case report.

RATIONALE: We report the first case of the management of spinal cord transection due to thoracolumbar fracture-dislocation in human beings. There are several case reports of cord transection, but only radiological findings have been reported; we report intraoperative findings and management. PATIENT CONCERNS: A 53-year-old man presented to the hospital after falling. He had no motor power or sensation below T10 (below the umbilicus area) dermatome level. American Spinal Injury Association (ASIA) impairment scale was grade A. Magnetic resonance imaging and computed tomography demonstrated a fracture and translation of the vertebral body at the T11-T12 level and anterior displacement of T11 on T12, with complete disruption of the spinal cord. DIAGNOSIS: Complete spinal cord resection due to T11-T12 fracture-dislocation. INTERVENTIONS: We performed spinal fusion with pedicle screw instrumentation (T10-L1) and autobone graft and decompression and repaired the dural sac to prevent cerebrospinal fluid leakage. There was no neurological recovery either immediately or 4 years post-operation at follow-up. CONCLUSION: To the best of our knowledge, this report is the first on the intraoperative finding and management of the complete transection of the spinal cord in thoracolumbar spine injury. Perfect fusion is required to facilitate rehabilitation and daily living, prevent neurogenesis, and prevent unnecessary pain such as phantom pain.

Intoxication by hand sanitizer due to delirium after infectious spondylitis surgery during the COVID-19 pandemic: A case report and literature review.

INTRODUCTION: Alcohol-containing hand sanitizers are part of the strategy to prevent person-to-person transmission during the COVID-19 pandemic. The purpose of this report was to present a case of ethanol-induced hand sanitizer intoxication after spine surgery in a patient with a postoperative delirious state. PRESENTATION OF CASE: A 63-year-old man was admitted to the spine department with intractable back pain as the main symptom and diagnosed with infectious spondylitis with discitis. The patient suddenly showed mental changes, resulting in a semi-comatose mental state the first day after surgery, without seizure-like activity and asphyxia. We subsequently discovered the patient had consumed half of an ethanol hand sanitizer bottle (about 300-400 mL) which was placed at the foot of the bed to prevent infection transmission during the COVID-19 pandemic. The patient did not tend to depend on alcohol or psychiatric medication in the past, and had no addiction. After seven months, the patient had complete bone union and independent ambulation. DISCUSSION: Acute ethanol intoxication can result in life-threatening clinical effects. One of the major problems after orthopedic surgery is delirium, with the largest number appearing after spine surgery. CONCLUSION: Hand sanitizer, mainly composed of ethanol, did not cause abnormal findings or interfere with the course of treatment of infectious spondylitis. However, it is expected that such accidents will increase, due to the increase in the use of hand sanitizers caused by COVID-19. It is, therefore, necessary to avoid potential patient abuse, especially after spinal surgery in patients at risk of delirium.

Delayed symptomatic spinal adhesive arachnoiditis after surgery for thoracolumbar flexion-distraction injury: A case report.

BACKGROUND: Adhesive arachnoiditis is an uncommon lesion caused by an inflammatory reaction in spinal nerves. Reports of substantial symptomatic thoracolumbar (TL) adhesive arachnoiditis after spinal surgery are rare. To the best of our knowledge, this is the first presentation of delayed adhesive arachnoiditis with cauda equina syndrome after decompression and fusion for a traumatic TL flexion-distraction injury. PRESENTATION OF CASE: A 51-year-old man presented to the emergency room with absence of lower extremity muscle power and partial sensation preservation below T12 after slipping. Magnetic resonance imaging (MRI) and computed tomography demonstrated a flexion-distraction injury at T12-L1 and unstable burst fracture at L1 with posterior fragment displacement and cauda equina compression. Emergency decompression, fracture reduction, and posterior fusion with pedicle screw instrumentation (T11-L2) were performed. After the surgical wound completely healed, the patient was transferred to the rehabilitation department. Three months after surgery, the patient complained of severe pain around the anal and testis area and had absent anal sensation and sphincter tone. We re-evaluated the spine MRI and diagnosed the patient with adhesive arachnoiditis in the previous injury site. After gabapentin was administered, the symptoms dramatically subsided. CONCLUSION: To the best of our knowledge, this is the first description of delayed spinal adhesive arachnoiditis after TL spinal surgery due to trauma. Developments in technology and resolution and the fact that titanium instrumentation produces less artifacts make MRI a useful tool to evaluate previously operated lesions. Gabapentin may be a good option in the treatment for delayed-onset postoperative adhesive arachnoiditis.

Posterior lumbar interbody fusion graft penetrated the lumbar thecal sac in a patient with rheumatoid arthritis: A case report.

INTRODUCTION: Intradural foreign bodies have been reported to be associated with disc material, tumors, and bullets following spinal gunshot injuries. In this report, we describe a case of non-union with minor trauma that caused interbody bone graft material to migrate into the intrathecal area in a patient with RA. PRESENTATION OF CASE: We present the case of a 65-year-old woman visited an outpatient clinic of our hospital after experiencing progressive lower extremity weakness, and voiding and defecation difficulty after fell down several times in the past. She had a history of two spinal decompression with fixation surgeries due to spinal stenosis with a herniated intervertebral disc. She was prescribed steroids and methotrexate for the RA. The results of MRI and CT demonstrated an intradural bone graft material migration with cauda equina syndrome after revision lumbar stenosis surgery. Calcified material protruded to the intracanal area and compressed the cauda equina fiber. After the removal of fragments operation, she recovered from cauda equina symptoms. A follow-up examination two years postoperatively revealed clinical resolution of cauda equina symptoms and a return to partial walking with a cane. DISCUSSION: The patient had a minor or major trauma, such as a fall, after the revision surgery. After that trauma, the patient presented with some dural injury, kyphotic position, or non-union state causing the dural penetration of the interbody fusion material. CONCLUSION: The first report describing displaced PLIF graft material that penetrated the dural sac and caused cauda equina symptoms in a patient with RA. Establishing strategies to minimize these complications is indicated when treating degenerative lumbar spine conditions in patients with RA.

A Comparison of Percutaneous Endoscopic Lumbar Discectomy and Open Lumbar Microdiscectomy for Lumbar Disc Herniation in the Korean: A Meta-Analysis.

BACKGROUND: Among the surgical methods for lumbar disc herniation, open lumbar microdiscectomy is considered the gold standard. Recently, percutaneous endoscopic lumbar discectomy is also commonly performed for lumbar disc herniation for its various strong points. OBJECTIVES: The present study aims to examine whether percutaneous endoscopic lumbar discectomy and open lumbar microdiscectomy show better results as surgical treatments for lumbar disc herniation in the Korean population. METHODS: In the present meta-analysis, papers on Korean patients who underwent open lumbar microdiscectomy and percutaneous endoscopic lumbar discectomy were searched, both of which are surgical methods to treat lumbar disc herniation. The papers from 1973, when percutaneous endoscopic lumbar discectomy was first introduced, to March 2018 were searched at the databases of MEDLINE, EMBASE, PubMed, and Cochrane Library. RESULTS: Seven papers with 1254 patients were selected. A comparison study revealed that percutaneous endoscopic lumbar discectomy had significantly better results than open lumbar microdiscectomy in the visual analogue pain scale at the final follow-up (leg: mean difference [MD]=-0.35; 95% confidence interval [CI]=-0.61, -0.09; p=0.009; back: MD=-0.79; 95% confidence interval [CI]=-1.42, -0.17; p=0.01), Oswestry Disability Index (MD=-2.12; 95% CI=-4.25, 0.01; p=0.05), operation time (MD=-23.06; 95% CI=-32.42, -13.70; p<0.00001), and hospital stay (MD=-4.64; 95% CI=-6.37, -2.90; p<0.00001). There were no statistical differences in the MacNab classification (odds ratio [OR]=1.02; 95% CI=0.71, 1.49; p=0.90), complication rate (OR=0.72; 95% CI=0.20, 2.62; p=0.62), recurrence rate (OR=0.83; 95% CI=0.50, 1.38; p=0.47), and reoperation rate (OR=1.45; 95% CI=0.89, 2.35; p=0.13). LIMITATIONS: All 7 papers used for the meta-analysis were non-RCTs. Some differences (type of surgery (primary or revisional), treatment options before the operation, follow-up period, etc.) existed depending on the selected paper, and the sample size was small as well. CONCLUSION: While percutaneous endoscopic lumbar discectomy showed better results than open lumbar microdiscectomy in some items, open lumbar microdiscectomy still showed good clinical results, and it is therefore reckoned that a randomized controlled trial with a large sample size would be required in the future to compare these two surgical methods.

Epidural lipomatosis with cauda equina syndrome in chronic alcoholic patient: A case report.

INTRODUCTION: Epidural lipomatosis of the lumbar spine is a rare condition, which is described as the accumulation of fat in the extradural territory. PRESENTATION OF CASE: We report the case of a 60-year-old, non-obese, and chronic alcoholic man who was transferred to our spine department with cauda equina syndrome (CES) for 4 months. On magnetic resonance imaging (MRI), spinal epidural lipomatosis (SEL) was confirmed in the multilevel lumbar lesion. A decompression surgery was performed and the patient recovered significantly. DISCUSSION: The patient was not obese, had no abnormal liver laboratory test results, and no history of steroid injection or administration. The clinical signs at onset suggested bilateral lower cauda equina dysfunction, indicating a more diffuse involvement, consistent with lumbosacral epidural lipomatosis. CONCLUSION: This case report is the first description of SEL in a non-obese, chronic alcoholic patient who was neither receiving steroids nor had any kind of endocrinopathy.

Acute airway obstruction due to postoperative retropharyngeal hematoma after anterior cervical fusion: a retrospective analysis.

BACKGROUND: Acute airway obstruction (AAO) after anterior cervical fusion (ACF) can be caused by postoperative retropharyngeal hematoma, which requires urgent recognition and treatment. However, the causes, evaluation, and appropriate treatment of this complication are not clearly defined. The purpose of this retrospective review of a prospective database was to investigate etiologic factors related to the development of AAO due to postoperative hematoma after ACF and formulate appropriate prevention and treatment guidelines. METHODS: Cervical spinal cases treated at our academic institutions from 1998 to 2013 were evaluated. Demographic data, including factors related to hemorrhagic tendency, and operative data were analyzed. Patients who developed a hematoma were compared with those who did not to identify risk factors. Cases complicated by hematoma were reviewed, and times until development of hematoma and surgical evacuation were determined. Degrees of airway compromise and patient behavior were classified and evaluated. Treatment was selected according to the patient's status. RESULTS: Among 785 ACF procedures performed, there were nine cases (1.15%) of AAO. None of these nine patients had preoperative risk factors. In six patients (67%), the hematoma occurred within 24 h, whereas three patients (33%) presented with hematoma at a median of 72 h postoperatively. Four of the nine patients with AAO underwent evacuation of the hematoma. Two patients with inspiratory stridor, anterior neck swelling, and facial edema progressed to respiratory distress and their hematomas were removed by surgery, during which, sustained superficial venous bleeding was confirmed. Intubation was attempted several times in one patient with cyanosis, but is unsuccessful; cricothyroidotomy was performed in this patient and pumping in the small muscular arterial branches was confirmed in the operating room. All of the patients recovered without any complications. CONCLUSIONS: With rapid recognition and appropriate treatment, there were no long-term complications caused by postoperative hematoma. There were no specific preoperative risk factors for hematoma. Systematic evaluation and appropriate management can be helpful for preventing serious complications after development of a postoperative hematoma.

Ultrasound versus fluoroscopy-guided cervical medial branch block for the treatment of chronic cervical facet joint pain: a retrospective comparative study.

OBJECTIVE: To compare the mid-term effects and advantages of the ultrasound (US)-guided with fluoroscopy(FL)-guided cervical medial branch blocks (CMBBs) for chronic cervical facet joint pain through assessment of pain relief, functional improvement, and injection efficiency. METHODS: Patients with chronic cervical facet joint pain who received US- (n = 68) or FL-guided CMBBs (n = 58) were included in this retrospective study. All procedures were performed using a FL or US. The complication frequencies, treatment effects, functional improvement, and injection efficiency of CMBBs were compared at 1, 3, and 6 months after the last injection. RESULTS: Both the NDI and VNS scores showed improvements at 1, 3, and 6 months after the last injection in both groups, with no significant differences between groups (p < 0.05). Furthermore, the treatment success rate at all time points was not significantly different between groups. Logistic regression analysis revealed that the injection method (US- or FL-guided), the number of injections, sex, analgesic use, and age were not independent predictors of treatment success. Compared with FL-guided CMBB, US-guided CMBB was associated with a shorter administration duration and fewer needle passes. CONCLUSIONS: Our results suggest that, compared with FL-guided CMBBs, US-guided CMBBs require a shorter administration duration and fewer needle passes, while providing similar pain relief and functional improvements. Therefore, US-guided CMBBs can be considered as an effective alternative for the conservative management of chronic cervical facet joint pain.

How to improve shoulder balance in the surgical correction of double thoracic adolescent idiopathic scoliosis.

STUDY DESIGN: A retrospective comparative study. OBJECTIVE: To evaluate the shoulder balance resulting from the correction of double thoracic adolescent idiopathic scoliosis (AIS) comparing rod derotation (RD) with direct vertebral rotation (DVR) and RD only after pedicle screw instrumentations. SUMMARY OF BACKGROUND DATA: This is the first report on the effect of DVR on the shoulder balance using segmental pedicle screw instrumentation in the treatment of double thoracic AIS with minimum 5-year follow-up. METHODS: Patients with double thoracic AIS (n = 57) were treated by fusing both thoracic curves with RD and DVR (n=35), or RD (n=22) methods and retrospectively studied with a minimum 5 years of follow-up. RESULTS: In the RD with DVR group, the preoperative proximal thoracic curve of 40.2° improved to 17.9° postoperatively and 19.9° at the last follow-up. In the RD group, the preoperative proximal thoracic curve of 37.5° improved to 22.4° postoperatively and 23.2° at the last follow-up. In the RD with DVR group, the preoperative distal thoracic curve of 56.6° improved to 16.1° postoperatively and 16.7° at the last follow-up. In the RD group, the preoperative distal thoracic curve of 50.6° improved to 17.8° postoperatively and 18.2° at the last follow-up. In the RD with DVR group, the average preoperative shoulder height difference of 16.3 mm had improved to 7.2 mm postoperatively and was 7.0 mm at the last follow-up. In the RD group, the average preoperative shoulder height difference of 15.1 mm had changed to 7.5 mm postoperatively and was 7.3 mm at the last follow-up. CONCLUSION: Shoulder balance had not significantly improved even with additional correction method of DVR using segmental pedicle screw instrumentation in double thoracic AIS. The proximal thoracic curve was rigid and corrected less in both groups. Therefore, less correction of the distal thoracic curve effectively achieves better shoulder balance. LEVEL OF EVIDENCE: 3.

Determination of the distal fusion level in the management of thoracolumbar and lumbar adolescent idiopathic scoliosis using pedicle screw instrumentation.

STUDY DESIGN: A retrospective study. PURPOSE: To determine the exact distal fusion level in the management of thoracolumbar/lumbar adolescent idiopathic scoliosis (TL/L AIS) using pedicle screw instrumentation (PSI). OVERVIEW OF LITERATURE: The selection of distal fusion level remains controversial in TL/L AIS. METHODS: Radiographic parameters of 66 TL/L AIS patients were analyzed. The patients were grouped according to the distal fusion level; L3 group (fusion to L3, n=58) and L4 group (fusion to L4, n=8). The L3 group was subdivided into L3A (L3 crosses the mid-sacral line with rotation of less than grade II, n=33) and L3B (L3 does not cross the mid-sacral line or rotation is grade II or more, n=25) based on both bending radiographs. All of the patients in the L4 group had the same location and rotation of L3 in bending films as that of patients in the L3B group. An unsatisfactory result was defined as a lowest instrumented vertebral tilt (LIVT) of more than 10° or coronal balance of more than 15 mm. RESULTS: Among the 3 groups, there was a significantly lesser correction in the TL/L curve and LIVT in the L3B group. Unsatisfactory results were obtained in 3 patients (9.1%) of the L3A group, in 15 patients (68.2%) of the L3B group, and in 1 patient (12.5%) of the L4 group with a significant difference. CONCLUSIONS: In TL/L AIS treatment with PSI, the curve can be fused to L3 with favorable radiographic outcomes when L3 crosses the mid-sacral line with rotation of less than grade II in bending films. Otherwise, fusion has to be extended to L4.

Complications of posterior vertebral resection for spinal deformity.

STUDY DESIGN: Retrospective study. PURPOSE: To evaluate the incidence and risk factors of complications following posterior vertebral resection (PVR) for spinal deformity. METHODS: A review of 233 patients treated with PVR at one institution over a nine-year period (1997 to 2005) was performed. The average age was 33.5 years. Complications were assessed in terms of surgical techniques (posterior vertebral column resection [PVCR] and decancellation osteotomy) and etiologies of deformity. RESULTS: Local kyphosis was corrected from 51.4° to 2.7°, thoracic scoliosis 63.9° to 24.5° (62.6% correction), and thoracolumbar or lumbar scoliosis 50.1° to 17.1° (67.6%). The overall incidence of complications was 40.3%. There was no significant difference between PVCR and decancellation osteotomy in the incidence of complications. There were more complications in the older patients (>35 years) than the younger (p < 0.05). Hig her than 3,000 ml of blood loss and 200 minutes of operation time increased the incidence of complications, with significant difference (p < 0.05). More than 5 levels of fusion significantly increased the total number of complications and postoperative neurologic deficit (p < 0.05). Most of the postoperative paraplegia cases had preoperative neurologic deficit. Preoperative kyphosis, especially in tuberculous sequela, had hig her incidences of complications and postoperative neurologic deficit (p < 0.05). More than 40° of kyphosis correction had the tendency to increase complications and postoperative neurologic deficit without statistical significance (p > 0.05). There was 1 mortality case by heart failure. Revision surgery was performed in 15 patients for metal failure or progressing curve. CONCLUSIONS: The overall incidence of complications of PVR was 40.3%. Older age, abundant blood loss, preoperative kyphosis, and long fusion were risk factors for complications.

Pedicle screw instrumentation in adolescent idiopathic scoliosis (AIS).

INTRODUCTION: Pedicle screw instrumentation in AIS has advantages of rigid fixation, improved deformity correction and a shorter fusion, but needs an exacting technique. MATERIALS AND METHODS: The author has been using the K-wire method with intraoperative single PA and lateral radiographs, because it is safe, accurate and fast. Pedicle screws are inserted in every segment on the correction side (thoracic concave) and every 2-3 on the supportive side (thoracic convex). After an over-bent rod is inserted on the corrective side, the rod is rotated 90° counterclockwise. This maneuver corrects the coronal and sagittal curves. Then the vertebra is derotated by direct vertebral rotation (DVR) correcting the rotational deformity. The direction of DVR should be opposite to that of the vertebral rotation. A rigid rod has to be used to prevent the rod from straightening out during the rod derotation and DVR. The ideal classification of AIS should address all curve patterns, predicts accurate fusion extent and have good inter/intraobserver reliability. The Suk classification matches the ideal classification is simple and memorable, and has only four structural curve patterns; single thoracic, double thoracic, double major and thoracolumbar/lumbar. Each curve has two types, A and B. When using pedicle screws in thoracic AIS, curves are usually fused from upper neutral to lower neutral vertebra. Identification of the end vertebra and the neutral vertebra is important in deciding the fusion levels and the direction of DVR. In lumbar AIS, fusion is performed from upper neutral vertebra to L3 or L4 depending on its curve types. CONCLUSIONS: Rod derotation and DVR using pedicle screw instrumentation give true three dimensional deformity correction in the treatment of AIS. Suk classification with these methods predicts exact fusion extent and is easy to understand and remember.