Deep Surgical-Site Infection Following Thoracolumbar Instrumented Spinal Surgery: The Experience of 25 Years.

BACKGROUND: Deep surgical-site infection following thoracolumbar instrumented spinal surgery (DSITIS) is a major complication in spine surgery and its impact on long-term morbidity and mortality is yet to be determined. This article describes the characteristics and evolution of DSITIS in our center over a period of 25 years. METHODS: This single-center, retrospective cohort study included patients diagnosed with DSITIS between January 1992 and December 2016 and with a minimum follow-up after infection diagnosis of 1 year. The Infectious Diseases Society of America criteria and/or Centers for Disease Control and Prevention criteria were used to define DSITIS. Patient data (epidemiological and health status), surgical data, infection characteristics and presentation, isolated microorganisms, required surgical debridements, implant removal, and major complications linked to infection were evaluated. RESULTS: A total of 174 patients (106 females) were included in the analysis. Mean follow-up after infection diagnosis was 40 months (56 patients with over 5 years follow-up). Adolescent idiopathic scoliosis, adult deformity, and degenerative lumbar stenosis were the most frequent etiologies for primary surgery. Presentation of infection was considered early (0-3 months since first surgery) in 59.2% of the cases, delayed (3-24 months) in 11.5%, and late (more than 24 months) in 29.3%. All patients were treated by surgical debridement. More than 1 surgical debridement was necessary in 20.7% of cases. Implants were removed in 46.6% of the patients (72.83% in the first surgical debridement). Most frequently isolated microorganisms were Staphylococcus spp, Enterobacteriaceae, and Cutibacterium acnes. Major complications appeared in 14.3% of the patients, and over 80% of them required major surgeries to resolve those complications. CONCLUSIONS: Late DSITIS is more frequent than previously reported. In DSITIS culprits, Staphylococcus spp, Enterobacteriaceae, and Cutibacterium acnes predominate. DSITIS produce a high rate of major complications that usually require major surgery for treatment. LEVEL OF EVIDENCE: 3.

Long-term Pulmonary Function After Open Anterior Thoracolumbar Surgery in Thoracolumbar/Lumbar Idiopathic Adolescent Scoliosis.

STUDY DESIGN: A prospectively updated, long-term case series analysis. OBJECTIVE: The aim of this study was to report the effect of thoracolumbar anterior open surgery performed during adolescence on adult pulmonary function. SUMMARY OF BACKGROUND DATA: There seems to be subclinical impairment of pulmonary function in the mid-term (2-5 years) in patients who underwent thoracotomy or thoraco-phreno-laparotomy after adolescent idiopathic scoliosis (AIS) surgery. However, long-term results when patients reach adulthood are lacking. METHODS: Prospective data of pulmonary function tests (PFTs) on adult patients who underwent anterior open surgery during adolescence due to main thoracolumbar/lumbar curves were collected. Forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and the Tiffeneau index (TI: FEV1/FVC) with a 12-year minimum follow-up were recorded. These figures were compared with reference (predicted) values and preoperative data. RESULTS: Twenty-four patients were included. All patients had undergone a thoraco-phreno-laparotomy. None of the patients had pulmonary disease. Mean age was 15.83 years at the time of surgery and the mean follow-up was 18.26 years (12-29 years).Long-term results of the 24 operated patients (mean ±â€ŠSD: FVC = 3.3 ±â€Š0.39; FEV1 = 2.6 ±â€Š0.38; TI = 80.3 ±â€Š5.7) showed a similar FVC and slightly worse FEV1 than reference values (FVC = 3.4 ±â€Š0.48; FEV1 = 3.03 ±â€Š0.42; TI = 82.4 ±â€Š1.3), (P = 0.21; P = 0.02; P = 0.3, respectively). Nevertheless, the values were within the normal percent-predicted range for FVC (93.5% ±â€Š11.2) and FEV1 (91.4% ±â€Š12.8). In 14 patients, long-term figures (median ±â€ŠIQR): FVC = 3.2 ±â€Š0.6; FEV1 = 2.54 ±â€Š0.42; TI = 81.5 ±â€Š11.2) were compared with preoperative values (median ±â€ŠIQR: FVC = 2.9 ±â€Š0.8; FEV1 = 2.47 ±â€Š0.93; TI = 84.8 ±â€Š34.2), (P = 0.08, P = 0.92, P = 0.026, respectively). Only the TI showed significant differences due to disproportionate improvement of FVC and FEV1 during the follow-up years. CONCLUSION: Thoracolumbar/lumbar AIS patients who underwent a thoraco-phreno-laparotomy during adolescence showed, in the long-term (18 years follow-up), a similar FVC compared with the reference values that was slightly superior than the values before surgery. Despite the lower FEV1 than the reference values and taking into consideration our limitations, the percent-predicted values were within the normal range, indicating no major pulmonary impairment in the long run. LEVEL OF EVIDENCE: 4.

Selective Anterior Thoracolumbar Fusion in Adolescent Idiopathic Scoliosis: Long-Term Results After 17-Year Follow-Up.

STUDY DESIGN: Prospectively updated long-term data and retrospective case series analysis. OBJECTIVE: To report the long-term results of selective anterior instrumented thoracolumbar (ThL) fusion in adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: The results of anterior selective fusion in AIS have been reported up to 2 and 5 years follow-up. However, there is a lack of evidence of long-term results of this surgical approach. METHODS: Forty-two consecutive patients with main thoracolumbar/lumbar AIS who had undergone surgery for a selective anterior ThL instrumented fusion with more than 12 years of follow-up met inclusion criteria. Preoperative, postoperative (1-yr), and final updated radiographic parameters were recorded. Final ODI and SRS-22 questionnaires were evaluated. RESULTS: Thirty-five patients were finally recruited (5 were lost and 2 refused). The mean age at surgery was 16.6 years. The mean final follow-up was 17.3 years (12-24 yr).The ThL preoperative Cobb was 49.5°â€Š±â€Š9, obtaining a postoperative correction of 79%±13 and final correction of 72% ±â€Š18. The preoperative thoracic curve (31.4°â€Š±â€Š14.2) obtained a spontaneous postoperative correction to 18.4°â€Š±â€Š11.9, maintained at final follow-up (17.8°â€Š±â€Š10.8). Apical vertebral rotation improved from 25.8°â€Š±â€Š7.8 to 9.2°â€Š±â€Š5.5 and finally to 8°â€Š±â€Š5.2 (P = 0.001). Sagittal parameters (T5-T12 = 27.2° and L1-S1=56.9°) did not change significantly postoperatively nor by final follow-up. Coronal balance improved from 2.4 cm to 1.6 cm postoperatively and 0.8 cm at final follow-up (P = 0.006). The disc angulation below the last instrumented vertebra improved with follow-up from 7.6° to 5.7° (P = 0.012).There were no revision surgeries or infections. One patient showed a symptomatic lower disc degeneration requiring lumbar pain surgery. Final SRS-22 global score was 4.3/5. The final ODI scored 6/100. CONCLUSION: In the long term, selective anterior thoracolumbar instrumentation with a single solid rod in AIS maintained good corrections on the three planes with no major complications or infections, no revision surgeries, and with satisfactory final functional and clinical outcomes. LEVEL OF EVIDENCE: 4.

Preoperative and postoperative sagittal plane analysis in adult idiopathic scoliosis in patients older than 40 years of age.

BACKGROUND CONTEXT: Most of the papers correlate sagittal radiographic parameters with health-related quality of life (HRQOL) scores for patients with scoliosis. However, we do not know how changes in sagittal profile influence clinical outcomes after surgery in adult population operated for mainly frontal deformity. PURPOSE: This study aimed to analyze spinal sagittal profile in a population operated on adult idiopathic scoliosis (AS) and to describe variations in sagittal parameters after surgery and the association between those variations and clinical outcomes. DESIGN/SETTING: This is a historical cohort study. PATIENT SAMPLE: We included in this study 40 patients operated on AS, older than 40 at the time of surgery (mean age 54.9), and with more than 2-year follow-up (mean 7.4 years). OUTCOME MEASURES: Full-length free-standing radiographs, Scoliosis Research Society 22 (SRS22) and Short Form 36 (SF36) instruments, and satisfaction with outcomes were available at final follow-up. METHODS: Sagittal preoperative and final follow-up radiographic parameters, radiographic correlation with HRQOL scores at final follow-up, and association between satisfaction and changes in sagittal profile were analyzed. A multivariate analysis was performed. No funds were received for this article. RESULTS: Preoperatively, the spinal sagittal plane tended to exhibit kyphosis. Most sagittal parameters did not improve at final follow-up with respect to preoperative values. We saw, after univariate analysis, that worse sagittal profile leads to worse HRQOL, but after multivariate analysis, only spinal tilt (ST) persisted as possible predictor for worse SRS activity scores. Frontal Cobb significantly improved. Most patients (82%) were satisfied with final outcomes. Variations in sagittal profile parameters did not differ between satisfied and dissatisfied patients. CONCLUSIONS: Although most sagittal plane parameters did not improve after surgery, surgical treatment in AS achieves a high satisfaction rate. Good clinical results do not correlate with improving sagittal plane parameters. Sagittal profile measurements are not helpful to decide surgical treatment in patients with mainly frontal deformity.

The effect of sublaminar wires on the rib hump deformity during scoliosis correction manoeuvres.

INTRODUCTION: During thoracic curve correction, the tightening of the sublaminar wires through concavity creates a medial and a dorsal translation of the spine. However, little is known about the effect of the sublaminar wires on the axial plane. METHODS: This is prospective case series analysis of 30 consecutive surgical patients with main thoracic adolescent idiopathic scoliosis. All of the patients were fused with hybrid instrumentation (apical concavity-sublaminar wires) and differential rod contouring (over-kyphosis concavity/under-kyphosis convexity). The degrees of the rib hump were measured with a scoliometer placed at the apex of the deformity at five different times: (1) preoperatively through the Adam's test, and during surgery (sterilised scoliometer), (2) with the patient lying prone, (3) after the Ponte osteotomies, (4) after the apical sublaminar tightening, and (5) after convexity apical derotation and compression manoeuvres. RESULTS: (1) Preoperatively, the Adam's test was 16.3° ± 4.6. (2) Lying prone and under general anaesthesia, it decreased to 11.4° ± 3.9. (3) After exposure and Ponte osteotomies, it was 7.1° ± 4. (4) After the wire tightening, it was 10.8° ± 4.7. (5) After the convexity manoeuvres, it was 4.8° ± 3.7. The degrees of the rib hump final correction were 11.6° ± 4 (70 % correction). The tightening of the sublaminar wires increased the rib hump by 3.5°. CONCLUSIONS: The sublaminar wire tightening towards the concave rod seemed to create an effect opposite of the desired effect, increasing the apical rotation and the thoracic rib hump deformity. Convexity manoeuvres (apical screw derotation and compression) are necessary and must be coupled with an under-bending of the convex rod to neutralise this effect.

Relationship between the different torsion-related thoracic deformity parameters of adolescent idiopathic scoliosis.

INTRODUCTION: Torsion has recently become essential in curve evaluation, not only to assess the degree of clinical deformity that can influence decision making, but also to predict curve progression. Since torsion cannot be currently measured using plain X-rays, our aim was to study the relationships between the different torsion-related parameters measured on 2D radiographs that can indirectly guide the clinician about the torsion of a given curve. METHODS: This is a cross-sectional study analyzing prospectively registered data of a consecutive cohort of 113 AIS patients with progressive main thoracic deformity. Demographic data, the Adams test and eight radiographic torsion-related coronal and sagittal deformity parameters [apical vertebral rotation (AVR)-Stokes method, Mehta angle (RVAD), main thoracic Cobb side-bending, T5-T12 kyphosis, T5-T8 kyphosis, T9-T12 kyphosis, kyphotic change and double rib contour sign (rib index)] were correlated between each other and with the main thoracic Cobb angle (MTCobb). Univariate linear regression and multiple linear stepwise regression analyses were performed as well. RESULTS: The radiographically measurable deformity parameters that best correlated with the MTCobb angle in idiopathic curves were: side-bending, RVAD, AVR and the Adams test. Sagittal variables were correlated the least with MTCobb. Coronal parameters as AVR, RVAD, side-bending and Adam test are highly intercorrelated. Sagittal variables are related between each other but are not directly related to coronal parameters. CONCLUSIONS: There is a strong relationship between the Cobb angle, curve bending, the Mehta angle and the apical vertebral rotation. Together with the clinical Adams test, these are the most important radiographic torsion-related parameters to measure when assessing scoliosis in 2D. LEVEL OF EVIDENCE: 3.

Thoracic sagittal plane variations between patients with thoracic adolescent idiopathic scoliosis and healthy adolescents.

PURPOSE: To analyze the sagittal thoracic parameters of different types of progressive thoracic adolescent idiopathic scoliosis (AIS) patients and compare them with healthy adolescents. METHODS: 115 AIS patients with main thoracic curves (Cobb: 59.4 ± 12.7) were prospectively compared with 116 healthy adolescents. The AIS and control (C) groups were homogeneous in terms of age and gender. Standing sagittal radiographs were analyzed for differences in T5-T12 kyphosis, T5-T8 and T9-T12 segmental kyphosis, the change between these two angles, and the double rib contour sign. Statistical analyses were performed using the χ 2, one-way ANOVA, Mann-Whitney U and Student's t tests. RESULTS: The sagittal parameters of Lenke 1 curves did not differ from healthy adolescents (T5-T8: 17.1 ± 10 vs C: 16 ± 7; T9-T12: 6.3 ± 7 vs C: 7.9 ± 5; T5-T12: 23.9 ± 14 vs C: 23.9 ± 8). Compared with the controls, Lenke type 3 curves were globally more hypokyphotic (T5-T12: 18.9 ± 12 vs C: 23.9 ± 8, P = 0.027) due to a "lordosis" of the lower thoracic segment (T9-T12: 0.9 ± 10 vs C: 7.9 ± 5, P = 0.001). Type 2 curves tended to exhibit more pronounced upper thoracic kyphosis (T5-T8: 20.7 ± 12 vs C: 16 ± 7). Both types 2 and 3 require a marked TK changes in the transition between the upper and lower thoracic segments to compensate for global (T5-T12) kyphosis. CONCLUSIONS: In this 2D analysis of moderate AIS, Lenke 1 curves exhibited normal thoracic sagittal parameters, which brings into question the effect of lordosis on the development of single thoracic curves. Lenke 3 curves exhibited lower thoracic segmental hypokyphosis, and the type 2 showed upper segmental hyperkyphosis. These results should be considered when planning a surgical strategy.

Ponte osteotomies to treat major thoracic adolescent idiopathic scoliosis curves allow more effective corrective maneuvers.

PURPOSE: There is controversy regarding the effect of the Ponte osteotomies in the improvement of coronal correction, its maintenance during follow-up, and the restoration of thoracic kyphosis in adolescent idiopathic scoliosis (AIS). METHODS: Seventy-three AIS patients with Lenke type 1-4 curves were included. A prospective description of 43 consecutive patients who underwent apical Ponte osteotomies and sublaminar wires with hybrid instrumentation was retrospectively compared to a historical cohort of 30 patients without "Ponte osteotomies". The surgical details and complications were recorded. We evaluated the radiological measurements and SRS-22 Questionnaire scores over a 2-year follow-up. RESULTS: The Ponte group achieved better postoperative (70 vs 57 %) and final (62 vs 50 %) main curve correction P < 0.001, with no significant loss of correction (4.2° vs 2.5°) P = 0.2 at the final follow-up (48 vs 106 months). We did not find a difference in thoracic (T5-T12) postoperative (22° vs 24°) and final (25° vs 26°) mean kyphosis angle. However, the "Ponte osteotomies" helped to achieve a normal sagittal profile, increasing preoperative hypokyphotic curves (<10°) from 6° to 17° (control: 9°-12°; P = 0.01); and preoperative hyperkyphotic curves (>40°) from 52° to 26° (control: 46°-39°; P = 0.01). The length of surgery was similar (4.3 vs 4.6 h), as were the SRS-22 scores. No major complications were found. CONCLUSIONS: Ponte osteotomies in major thoracic AIS curves treated by sublaminar wires allowed more effective corrective maneuvers, which improved coronal correction without a significant loss during follow-up. The sagittal profile appears to be determined by other variables; however, "Ponte osteotomies" facilitate the contouring of the desired kyphosis.

Survivorship analysis after primary fusion for adult scoliosis. Prognostic factors for reoperation.

BACKGROUND CONTEXT: Adult scoliosis surgery is a challenging procedure with high rate of complications and reoperations. Reoperation rates vary widely. Long-term survival for this surgery still remains unknown, and the prognostic factors for reoperation are not well defined. PURPOSE: To assess adult scoliosis surgery survival (without the need of reoperation) after primary fusion in adults with mainly frontal deformity and to define prognostic factors for reoperation. STUDY DESIGN: Survival analysis of a cohort of consecutive adult patients, primarily operated on scoliosis using segmental instrumentation (retrospective cohort study). PATIENT SAMPLE: Fifty-nine patients older than 21 years at primary surgery (median age, 42 years), who presented idiopathic or degenerative curves with frontal Cobb >40° (median preoperative frontal Cobb 59°), more than four-level fusion, and a 2-year minimum postoperative follow-up (median, 8.5 years; 41% patients had a longer than 10-year follow-up). OUTCOME MEASURES: Clinical and preoperative radiographic parameters were analyzed preoperatively and evaluated as prognostic factors for reoperation. METHODS: Survival was estimated using Kaplan-Meier method. Prognostic factors (clinical and radiographic) for reoperation were evaluated. Logistic regression using backward elimination was used for multivariate analysis. RESULTS: Survival was 89.8% at 1 year, 79.4% at 2 years, 73.4% at 3 years, 64% at 5 years, and 60.9% at 10 years. Overall, 21 patients (35.6%) underwent revision surgery. The most common reasons for reoperation were painful/prominent implants, adjacent-segment degeneration, and infection. American Society of Anesthesiologists Type II patients and double surgical approach were associated with a higher revision rate. Preoperative thoracic kyphosis was significantly higher in reoperated patients. CONCLUSIONS: The 10-year survival rate of primary scoliosis surgery in adult patients is 61%. Risk factors identified for reoperation included patients with higher morbidity, double surgical approach, and preoperative thoracic hyperkyphosis.

MRI reliability in classifying thoracolumbar fractures according to AO classification.

The vertebral fracture patterns of AO classification have been established historically via radiograph and computed tomography analysis, achieving modest reproducibility values. The authors hypothesize that magnetic resonance imaging may improve reliability because it better indicates posterior ligamentous complex damage. They conducted a retrospective analysis of a prospective recruited cohort of patients using radiographs and magnetic resonance images with fat saturation sequences to classify 37 traumatic vertebral fractures. Five spine surgeons, 2 orthopedic residents, 2 musculoskeletal radiologists, and 2 radiodiagnosis residents classified the morphological pattern of each fracture per AO classification in 2 separate sessions that occurred 6 weeks apart. Inter- and intraobserver reproducibility for AO classification types A, B, and C were assessed using the kappa test (pairwise method), and standard error was assessed using the jackknife method. Quantitative comparisons were performed using the Student's t test, and the kappas were performed using normal approximation. Mean interobserver agreement was kappa=0.53 and 0.47 for the first and second sessions, respectively, for all evaluators. Greater interobserver agreement was observed between the senior doctors (kappa=0.59 and 0.54 for the first and second sessions, respectively) vs residents (kappa=0.45 and 0.31 for the first and second sessions, respectively) (P=.02) and between orthopedic surgeons vs radiologists (kappa=0.71 vs 0.48, respectively) (P=.008). Mean intraobserver agreement was kappa=0.58 (range, 0.38-0.76). Evaluators more familiar with the classification obtained higher kappas. Magnetic resonance imaging offers moderate reproducibility in assessing vertebral fractures pursuant to AO classification, and results are slightly better than those reported with computed tomography. Reliability increases in the hands of experiened spine surgeons and improves with greater familiarization with the classification.

Prospective analysis of magnetic resonance imaging accuracy in diagnosing traumatic injuries of the posterior ligamentous complex of the thoracolumbar spine.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To study magnetic resonance imaging (MRI) accuracy in diagnosing posterior ligamentous complex (PLC) damage, when applying the new dichotomic instability criteria in a prospective cohort of patients with vertebral fracture. SUMMARY OF BACKGROUND DATA: Recent studies dispute MRI accuracy to diagnose PLC injuries. They analyze the complex based on 3 categories (intact/indeterminate/rupture), including the indeterminate in the ruptured group (measurement bias) in the accuracy analysis. Moreover, fractures with conservative treatment (selection bias) are not included. Both facts reduce the specificity. A recent study has proposed new criteria where posterior instability is determined with supraspinous ligament (SSL) rupture. METHODS: Prospective study of patients with acute thoracolumbar fracture, using radiography and MRI (FS-T2-w/short-tau inversion-recovery sequences). 1. The integrity (ruptured/unruptured) of each isolated component of the PLC (facet capsules, interspinous ligament, SSL, and ligamentum flavum) was assessed via MRI and surgical findings. 2. PLC integrity as a whole was assessed, adopting the new dichotomic stability criteria from previous studies. In the MR images, PLC is considered ruptured when the SSL is found discontinued, and intact when not (this excludes the "indeterminate" category). In surgically treated fractures, PLC stability as a whole was assessed dynamically (ruptured/unruptured). In conservative fractures, PLC stability was assessed according to change in vertebral kyphosis measured with the local kyphotic angle at 2-year follow-up (ruptured if difference is > 5°/unruptured if difference is < 5°).3. Comparative analysis among findings provided MRI accuracy in diagnosing PLC damage. RESULTS: Fifty-eight vertebral fractures were studied (38 surgical, 20 conservative), of which 50% were in males; average age, 40.4 years. MRI sensitivity for injury diagnosis of each isolated PLC component varied between 92.3% (interspinous ligament) and 100% (ligamentum flavum). Specificity varied between 52% (facet capsules) and 100% (SSL). PLC integrity sensitivity and specificity as a whole were 91% and 100%, respectively. CONCLUSION: Adopting the new stability criteria, MRI accuracy in PLC injury diagnosis increases. Specificity is increased (true positives) both in isolated component analysis and PLC as a whole.

Delayed Tetraplegia After Thoracolumbar Scoliosis Surgery in Stuve-Wiedemann Syndrome.

OBJECTIVE: We present 2 patients with Stuve-Wiedemann syndrome (SWS) who suffered delayed tetraparesis following posterior spinal surgery for scoliosis. BACKGROUND SUMMARY: Delayed tetraparesis after a syndromic thoracic scoliosis correction has never been reported. A cord injury distant from the surgical site is rare, and intraoperative neuromonitoring should be used to detect and prevent neurologic impairment. METHODS: Review of medical charts. RESULTS: Two patients with SWS suffered delayed tetraparesis 20 and 40 hours respectively after thoracolumbar posterior surgery. In one patient distal motor evoked potentials fell and recovered partially during surgery. In both patients, early postoperative neurologic examination was normal (in one of them except for the extensor hallucis 2/5). CT scan showed correct instrumentation placement and no compressive haematoma. MRI ruled out cord anomalies, but revealed in both patients identical cervical edema that was most likely secondary to ischemia. Angiogram revealed an absence of anterior cord vascular supply. CONCLUSIONS: Correction of severe deformities in syndromic patients may lead to stretch injuries of the spinal cord and its vascular supply. This in turn may lead to a neurological deficit extending beyond the limits of the spinal instrumentation. Abrupt postoperative neck pain may be an alert to this impending development. Close surveillance in the early postoperative period should be maintained in patients with SWS because a delayed neurological deficit can be present even hours afterwards and may be cranial to the surgical level.

Posterior Transpedicular Fibular Grafts and Interferential Screws for the Surgical Treatment of L5-S1 Spondyloptosis: Case Report of Four Patients With 8.5 Years' Follow-Up.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To present long-term results using partial reduction and instrumented fusion adding an L5-S1 transpedicular fibular plus interferential screw construct to treat spondyloptosis. SUMMARY OF BACKGROUND DATA: Several techniques have been described to treat high-grade spondylolisthesis. Reported complications include neurologic injuries, pseudarthrosis, slip progression, and instrumentation failure. We present a posterior-only approach with partial reduction and instrumentation to treat spondyloptosis. Interbody fusion is provided by fibular struts inserted through the S1 pedicles capturing L5, avoiding neural manipulation. Graft stress is supported using interferential screws placed through these same pedicles. METHODS: Retrospective revision of 4 cases with grade V spondylolisthesis. Information analyzed was preoperative, postoperative, and final follow-up clinical and radiographic data, with final Scoliosis Research Society Questionnaire-22 outcomes. Pelvic incidence, sacral slope, pelvic tilt, L5 incidence, lumbar lordosis, L5 slip angle, lumbosacral angle, and sagittal vertical axis were measured. Fusion and complications were recorded. RESULTS: Mean age was 25.7 ± 5.7 years. All men with isthmic spondyloptosis (Meyerding V; type 5/6, Spinal Deformity Study Group classification). There were 3 primary surgeries and 1 revision. Median fused levels were 2 (range, 2-2.75); mean operative time was 6.1 ± 0.8 hours and median transfusion units were 2 (percentile 2-5). Mean follow-up was 102 months (range, 24-157 months). Postoperative pain using Visual Analog Score decreased from 7.1 ± 2.4 to 1.3 ± 1.3. Pelvic tilt improved 9.7°, whereas L5 incidence improved 15° and lumbosacral angle and L5 slip angle improved over 30°, which was maintained over time. Sagittal vertical axis improved by 1.6 cm; however, the improvement was lost by the final follow-up. The Scoliosis Research Society global satisfaction scale was 4.6 ± 0.2. No major complications were observed. CONCLUSIONS: This technique yielded satisfactory clinical results in the treatment of L5-S1 spondyloptosis, resulting in stable anterior support and complete radiographic fusion. It avoided the complications reported from the use of previous posterior techniques such as graft fractures, pseudarthrosis, slip progression, and neurologic injuries.

MRI study of post-traumatic incompetence of posterior ligamentous complex: importance of the supraspinous ligament. Prospective study of 74 traumatic fractures.

PURPOSE: Posterior ligamentous complex (PLC) components have an orderly sequence of rupture. However, it is still unclear how many structures have to be damaged to consider it disrupted. We aim to establish imaging criteria, which can define the complex as competent or incompetent. METHODS: Prospective study of 74 consecutive vertebral acute traumatic fractures, using X-rays and MRI scan (FS-T2-w/STIR sequences). We analyzed the association between MRI signal (intact, edema, disruption) of each PLC component-facet capsules (FC), interspinous ligaments (ISL), supraspinous ligaments (SSL) and ligamentum flavum (LF)-and the variables: AO/TLICS classification, treatment, surgical findings, interspinous diastasis index (IDI), local kyphosis (LVK) and ISS (TLICS) score. χ2 test and U Mann-Whitney were used for statistics. RESULTS: MR images of ISL edema correlated surgically with intact ligaments or laxity, and were associated with 87.5% of facet distraction, LVK: 11.6º, IDI: 1.2. Images of ISL, SSL or LF disruptions showed in all cases ruptures under surgical examination. Images of SSL disruption associated with LVK: 14.5º, IDI: 1.8. Images of ISL disruption associated with SSL/LF rupture, LVK: 16º, and IDI: 2; while LF disruption showed LVK: 18º, IDI: 1.9. When comparing "competent PLC" (images of facet distraction and ISL edema) with "incompetent PLC" (images of SSL disruption ± ISL or LF disruption) the latest showed more severe scores in every variable (p < 0.001), except neurologic status. CONCLUSION: Following PLC rupture sequence, ISL edema with facet distraction seems not to be enough to define a posterior tension band incompetence. It is the further step of SSL rupture what gives the key to PLC incompetence.

Correlation of radiographic and functional measurements in patients who underwent primary scoliosis surgery in adult age.

STUDY DESIGN: Prospective radiographic and clinical analysis. OBJECTIVE: To evaluate whether radiographic spinopelvic parameters correlate with health-related quality of life (HRQOL) measures, in the long run, in patients operated on scoliosis in adult age. SUMMARY OF BACKGROUND DATA: There are papers that correlate sagittal radiographic parameters with HRQOL scores for healthy spine as well as for some spinal disorders. However, there are limited studies evaluating correlations between HRQOL measures, radiographic spinopelvic parameters, and age in patients operated on scoliosis in adult age. METHODS: Fifty-nine patients, older than 21 years at surgery time (median: 50.2 years), were operated upon at a single center. All of them suffered mainly frontal deformity, idiopathic or degenerative curves, and long fusions, with more than a 2-year follow-up (median:8.5 years). Full-length freestanding radiographs, including the spine and pelvis, and SRS22 and SF36 instruments, were available for every patient at final follow-up. Sagittal and frontal radiographic parameters and age were analyzed for correlation with HRQOL. A multivariate analysis was performed. RESULTS: No significant correlation was found between frontal parameters and HRQOL measures. Spearman rank order test showed correlation (P < 0.001) between Scoliosis Research Society (SRS) activity and sagittal vertical axis (SVA) (r = -0.44), pelvic tilt (PT) (r = -0.49), and age (r = -0.5). SRS total was correlated (P < 0.004) with PT (r = -0.32) and age (r = -0.41). SF36 physical function correlated (P < 0.001) with SVA (r = -0.44), PT (r = -0.45), and age (r = -0.56). After multivariate analysis, only age and PT persisted as possible predictors of worse SRS activity scores. CONCLUSION: After primary surgery for adult scoliosis, frontal radiographic parameters did not correlate with HRQOL measures. In univariate analysis, patient age, SVA, and PT correlated with activity scores, although the correlation coefficients did not reach high values. After multivariate analysis, SVA was not a predictor of function.

Sequential damage assessment of the different components of the posterior ligamentous complex after magnetic resonance imaging interpretation: prospective study 74 traumatic fractures.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To study whether there is a sequential pattern in the posterior ligamentous complex (PLC) rupture caused by deforming traumatic forces by analyzing magnetic resonance (MR) images in a consecutive prospective cohort of patients with traumatic vertebral fracture. SUMMARY OF BACKGROUND DATA: PLC plays an important role in vertebral stability. However, the sequence in which the different components of the PLC tear, in the face of traumatic forces, has not been yet described. METHODS: Prospective study of 74 consecutive vertebral acute traumatic fractures analyzed using radiography and magnetic resonance imaging (MRI) (FS-T2-w/short-tau inversion-recovery [STIR] sequences). Fracture morphology was classified according to the AO classification. Integrity of each PLC component-facet capsules, interspinous ligament (ISL), supraspinous ligament (SSL), and ligamentum flavum (LF)-was assessed and classified as intact, edema, or disruption. ISL edema was further subdivided depending on the extension (>50%/<50%). We analyzed the association between MRI signal and the AO progressive scale of morphological damage. RESULTS: AO type A1/A2 fractures associated with only facet distraction. A3 fractures showed additional ISL edema, usually less than 50%, with neither SSL nor LF disruption. Type B1 fractures associated with facet distraction, ISL edema or disruption, and low rate of SSL/LF disruptions; B2 fractures increased SS/LF disruption rates. Type C fractures associated with facet fracture or dislocation and ISL, SSL, or LF complete rupture. We found high association (P < 0.001) between AO progressive scale and MRI signal. MRI analysis showed that posterior distraction forces begin in the facets and extend throughout the ISL, starting at its posterosuperior margin (finally disinserting the SSL superiorly) and traveling diagonally toward anteroinferior border, finally tearing the LF. CONCLUSION: MR images correlated with AO progressive scale of morphological damage, which showed a progressive orderly rupture sequence among the different PLC components as traumatic forces increased.

Impact of magnetic resonance imaging on decision making for thoracolumbar traumatic fracture diagnosis and treatment.

INTRODUCTION: The role of magnetic resonance imaging (MRI) has recently been enhanced in the diagnosis of thoracolumbar fractures due to its ability to examine soft tissue injury. MATERIAL AND METHODS: We conducted a prospective study to analyze the usefulness of MRI in fracture diagnosis and its influence on treatment decision making. Thirty-three patients were enrolled after suffering an acute traumatic thoracolumbar fracture. Osteoporotic or pathologic fractures were excluded. Fractures were initially classified using X-ray and CT scan following the AO classification. Afterward, a selective MRI protocol was performed with T1 and T2-weighted FS/STIR sequences. Subsequently, fractures were classified according to the TLICS system and reclassified following the AO system. Analysis was performed before and after MRI, focusing on: diagnostic changes, occult fractures and differences in treatment decision making. RESULTS: Thirty patients (15 males, 15 females) with an average age of 39.9 years were studied. Forty-one fractures were initially diagnosed using plain X-rays and CT scans, while MRI diagnosed 50 fractures and 9 vertebral contusions. MRI modified our diagnosis in 40% of our patients (discovering 18 occult injuries), the classification of fracture pattern in 24% of the fractures (mostly upgrading type A to type B patterns) and the therapeutic management in 16% of our patients. CONCLUSIONS: MRI seems to be a useful tool in the evaluation of thoracolumbar acute fractures, as it allows a better visualization of the posterior complex integrity and of the levels involved, offering additional information compared to traditional diagnostic tools.