Khaled M. Kebaish

Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis.

Study Design. Prospective multicenter study evaluating operative (OP) versus nonoperative (NONOP) treatment for adult spinal deformity (ASD). Objective. Evaluate correlations between spinopelvic parameters and health-related quality of life (HRQOL) scores in patients with ASD. Summary of Background Data. Sagittal spinal deformity is commonly defined by an increased sagittal vertical axis (SVA); however, SVA alone may underestimate the severity of the deformity. Spinopelvic parameters provide a more complete assessment of the sagittal plane but only limited data are available that correlate spinopelvic parameters with disability. Methods. Baseline demographic, radiographical, and HRQOL data were obtained for all patients enrolled in a multicenter consecutive database. Inclusion criteria were: age more than 18 years and radiographical diagnosis of ASD. Radiographical evaluation was conducted on the frontal and lateral planes and HRQOL questionnaires (Oswestry Disability Index [ODI], Scoliosis Research Society-22r and Short Form [SF]-12) were completed. Radiographical parameters demonstrating highest correlation with HRQOL values were evaluated to determine thresholds predictive of ODI more than 40. Results. Four hundred ninety-two consecutive patients with ASD (mean age, 51.9 yr) were enrolled. Patients from the OP group (n = 178) were older (55 vs. 50.1 yr, P < 0.05), had greater SVA (5.5 vs. 1.7 cm, P < 0.05), greater pelvic tilt (PT; 22° vs. 11°, P < 0.05), and greater pelvic incidence/lumbar lordosis PI/LL mismatch (PI-LL; 12.2 vs. 4.3; P < 0.05) than NONOP group (n = 314). OP group demonstrated greater disability on all HRQOL measures compared with NONOP group (ODI = 41.4 vs. 23.9, P < 0.05; Scoliosis Research Society score total = 2.9 vs. 3.5, P < 0.05). Pearson analysis demonstrated that among all parameters, PT, SVA, and PI-LL correlated most strongly with disability for both OP and NONOP groups (P < 0.001). Linear regression models demonstrated threshold radiographical spinopelvic parameters for ODI more than 40 to be: PT 22° or more (r = 0.38), SVA 47 mm or more (r = 0.47), PI − LL 11° or more (r = 0.45). Conclusion. ASD is a disabling condition. Prospective analysis of consecutively enrolled patients with ASD demonstrated that PT and PI-LL combined with SVA can predict patient disability and provide a guide for patient assessment for appropriate therapeutic decision making. Threshold values for severe disability (ODI > 40) included: PT 22° or more, SVA 47 mm or more, and PI − LL 11° or more.

Analysis of the risk factors for the development of post-operative spinal epidural haematoma

In order to identify the risk factors and the incidence of post-operative spinal epidural haematoma, we analysed the records of 14 932 patients undergoing spinal surgery between 1984 and 2002. Of these, 32 (0.2%) required re-operation within one week of the initial procedure and had an International Classification of Diseases (ICD)-9 code for haematoma complicating a procedure (998.12). As controls, we selected those who had undergone a procedure of equal complexity by the same surgeon but who had not developed this complication. Risks identified before operation were older than 60 years of age, the use of pre-operative non-steroidal anti-inflammatories and Rh-positive blood type. Those during the procedure were involvement of more than five operative levels, a haemoglobin < 10 g/dL, and blood loss > 1 L, and after operation an international normalised ratio > 2.0 within the first 48 hours. All these were identified as significant (p < 0.03). Well-controlled anticoagulation and the use of drains were not associated with an increased risk of post-operative spinal epidural haematoma.

Pelvic Fixation In Spine Surgery: Historical Overview, Indications, Biomechanical Relevance, And Current Techniques

F usions of the lumbosacral spine continue to be a challenging area in spine surgery. The complex local anatomy, unique biomechanical forces, and poor bone quality of the sacrum are just a few of the many reasons why fusions of the lumbosacral spine have been notoriously difficult to perform. The goals of this review were (1) to familiarize the reader with the complicated anatomy of the lumbosacral region, the specific pathological entities that involve this region, and the biomechanical forces that lead to high pseudarthrosis rates; (2) to discuss the various types of lumbosacral and spinopelvic implants and their respective advantages and disadvantages; (3) to review the most common clinical indications for lumbosacral and spinopelvic fusions; and (4) to emphasize that iliac screw placement is a safe and reproducible technique for achieving stable caudad pelvic fixation that minimizes the risk of pseudarthrosis at the lumbosacral junction. T he sacrum, which functions as the keystone that unites the two hemipelves, consists of five fused vertebrae with transverse processes that merge into a thick, continuous lateral mass. Its anteroposterior diameter tapers rapidly from 47 mm at S1 to 28 mm at S2 in women and from 50 to 31 mm in men1. For the most part, the sacrum has a cancellous osseous architecture, but areas of increased bone density are present in the sacral alae and particularly in the sacral promontory2. Therefore, it is best that pedicle screws be directed toward the midline. The sacrum is connected to each hemipelvis by the sacroiliac joint, which is the largest joint in the axial skeleton. The sacroiliac joint contains a synovial membrane but has minimal motion because of the matching interdigitating contours of the sacral and iliac bones and the strong interosseous, dorsal, ventral, and accessory ligaments3. It …

Functional outcome after open supracondylar fractures of the humerus

We reviewed 26 patients who had had internal fixation of an open intra-articular supracondylar fracture of the humerus. All operations were performed using a posterior approach, 13 with a triceps split and 13 with an olecranon osteotomy. The outcome was assessed by means of the Mayo Elbow score, the Disability of the Arm, Shoulder and Hand (DASH) score and the SF-36 Physical Function score. Patients with an olecranon osteotomy had less good results.

Low profile pelvic fixation: anatomic parameters for sacral alar-iliac fixation versus traditional iliac fixation.

Study Design. Three-dimensional computed tomography (CT) radiographic analysis. Objective. To describe the parameters for a trajectory through a sacral starting point as a method of pelvic fixation in spinal deformity and to compare this technique with insertion from the posterior superior iliac spine (PSIS). Summary of Background Data. Long anchors projecting into the ilium provide optimal pelvic fixation. The traditional starting point in the PSIS requires muscle dissection and connectors or rod bends. Methods. Twenty pelvic CTs of mature adolescents were analyzed using InSpace, a three-dimensional CT program, by 2 surgeons. Trajectory with maximal length and width through the sacral ala and iliac wing was obtained through CT imaging plane manipulation. Trajectory and starting-point parameters were measured. Parameters were evaluated and compared for insertion from the PSIS. Results. Based on the ideal trajectory, the mean starting point in S2 was 25 mm caudal to the superior endplate of S1 and 22 mm lateral to the sacral midline (S2 alar-iliac [S2AI] path). Maximal mean S2AI distance was 105 mm (range, 74–129 mm; SD = 11 mm). Maximal mean length for PSIS insertion was 118 mm (range, 99–147 mm; SD = 13 mm). Mean angulation was 40° (SD = 6°) laterally in the transverse plane and 39° (SD = 6°) caudally in the sagittal plane. The mean difference between surgeons in selecting the trajectory was 2° and 1° in the transverse and sagittal plane, respectively. The S2AI pathway traversed 35 mm of sacral ala. The narrowest mean width of the ilium along this path was 12 mm (range, 6–18 mm). The starting point for the S2AI was 19 mm deep to the PSIS. The distance from skin for S2AI versus PSIS techniques was 52 and 37 mm, respectively. Conclusion. Iliac fixation through the S2 ala provides a reproducibly chosen starting point in line with S1 pedicle anchors. Implant prominence is minimized because the starting point is 15 mm deeper than the PSIS entry. It is less likely to be affected in cases using iliac crest bone graft harvest because of the more anterior position of the anchor in the ilium.

Sacropelvic Fixation : Techniques and Complications

Study Design. Literature-based topic review. Objective. To review the indications and techniques for different sacropelvic fixation methods and to outline important associated complications. Summary of Background Data. Despite all the advances and new developments in spinal instrumentation techniques, fixation at the lumbosacral junction continues to be one of the important challenges to spine surgeons. The poor bone quality of the sacrum, the complex regional anatomy, and the tremendous biomechanical forces at the lumbosacral junction contribute to the high rates of instrumentation-related problems. Although many techniques for sacropelvic fixation have been attempted, only a few are still widely used because of the high rate of complications associated with some of those techniques. Methods. Review of literature and expert opinion. Conclusion. There are many indications for sacropelvic fixation. Long fusions to the sacrum are the most common reasons for extending the instrumentation to the pelvis. Spinal surgeons performing complex spinal reconstruction should be familiar with the currently available techniques, including their potential risks and complications. Surgical treatment decisions should be based on an individual patients anatomy and abnormalities, and on the surgeons experience.

An anatomic study of the S2 iliac technique for lumbopelvic screw placement.

Study Design. An anatomic study conducted on cadaveric specimens. Objectives. The objectives of the study were (1) to determine course of S2 lumbopelvic screws with reference to the articular cartilage of the sacroiliac joint, (2) to determine the length and trajectory of screws placed using anatomic placement techniques, and (3) to determine vital structures at risk using this technique. Summary of Background Data. Multiple techniques exist for fixation distal to S1 including alar screws, iliac post bolts, and transiliac rods. Distal fixation is crucial in adult deformity surgery when fusion to the sacrum is indicated. Methods. Five female and 5 male cadaveric specimens were instrumented with S1 promontory screws and S2 iliac lumbopelvic screws. The specimens then underwent computed tomography scanning to determine structures at risk, cortical violations, and characteristics of screws placed. The sacroiliac joints were opened to examine articular cartilage penetration. Results. Articular violation occurred in 60% of screws placed. Average length was 84 mm. No vital structures were at risk from screw placement. No intrapelvic cortical violations occurred. Conclusion. S2 iliac technique is a potential option for distal fixation in spine surgery. Biomechanical and clinical data are required to fully evaluate the potential of this technique.

Scoliosis in Adults Aged Forty Years and Older: Prevalence and Relationship to Age, Race, and Gender

Study Design. Retrospective study. Objective. To identify the prevalence of lumbar scoliosis in adults ≥40 years old; to investigate relationships between scoliosis prevalence and 3 parameters (age, race, gender); and to determine any effect of those parameters on curve severity. Summary of Background Data. As the population ages, the incidence of degenerative spine conditions increases. More patients are being diagnosed with and treated for spinal deformities, including scoliosis. Methods. We examined dual-energy x-ray absorptiometry lumbar spine images of 3185 individuals ≥40 years old (average, 60.8 years; range, 40–97 years), obtained July 2002 to June 2005, to determine the presence of scoliosis (i.e., a curvature of ≥11.0°) by digitally measuring Cobb angles. Patients with a history of previous lumbar spinal surgery were excluded, leaving 2973 individuals for final evaluation. We used SAS system software, version 9.1 (SAS Institute, Inc., Cary, NC) to investigate the relationship between the prevalence of scoliosis and the variables of age, race, and gender, we then examined for any effect that these variables had on curve severity. Results. We identified scoliosis (i.e., a Cobb angle of ≥11°) in 263 of 2973 patients. Age was associated with an increased prevalence of scoliosis, e.g., 40 to 50 years old, 3.14%; ≥90 years old, 50%. Prevalence rates differed among races (e.g., 11.1% for whites and 6.5% for African Americans) but were similar for men and women. Most patients had mild curves (80.6%), there was no difference in the distribution of curve severity by gender or age, and African Americans were more likely to have mild curves (94.3%) than were other races. Conclusion. The prevalence of scoliosis in our patients ≥40 years old was 8.85% and was associated with age and race, but not with gender. Most curves in our population were mild; curve severity was associated with race but not with age or gender.

Functional Outcome and Radiographic Correction After Spinal Osteotomy

STUDY DESIGN A prospective clinical trial to study the radiographic parameters and functional outcome in patients undergoing spinal osteotomy. OBJECTIVES To determine whether correction of specific radiographic parameters is associated with improved functional outcome. SUMMARY OF BACKGROUND DATA Although vertebral osteotomies have been shown to improve functional outcome in patients with spinal deformity, no prospective reports have studied whether correction of specific radiographic parameters is associated with improvement in functional outcome. METHODS Eighty-three patients with fixed sagittal and/or coronal deformity were followed over a 7-year period. Patients were evaluated clinically and radiographically and completed a SF-36 Health Survey and American Academy of Orthopedic Surgeons Modems Instrument questionnaire. Spearman correlation analysis was used to determine the association between correction of radiographic parameters and functional outcome. RESULTS Mean preoperative lumbar lordosis measured -14.2 degrees (i.e., kyphosis) with an average postoperative correction of 27.9 degrees. Mean preoperative lumbar scoliosis measured 40.1 degrees with an average postoperative correction of 15.1 degrees. Mean preoperative plumb sagittal and coronal plane alignment was 8.37 cm and 4.22 cm, respectively; after surgery they improved to 3.33 cm and 2.31 cm, respectively. A significant association was found between sagittal angular correction and physical function (P = 0.034) and role-physical (P = 0.01) when postoperative lumbar lordosis was >25 degrees. A significant association was also found between plumb coronal correction and physical function (P = 0.041), vitality (P = 0.05), and social function (P = 0.047) when postoperative plumb coronal alignment was <2.5 cm. CONCLUSIONS Correction of sagittal and coronal deformity is important in the treatment of spinal deformity. A significant association was found between outcomes and radiographic correction of coronal and/or sagittal deformity if postoperative sagittal lordosis was >25 degrees and if postoperative plumb coronal alignment was <2.5 cm. Therefore, these radiographic parameters should be the goal of a spinal osteotomy. The surgery has a relatively high complication rate.

Incidence, mode, and location of acute proximal junctional failures after surgical treatment of adult spinal deformity.

Study Design. Multicenter, retrospective series. Objective. To analyze the incidence, mode, and location of acute proximal junctional failures (APJFs) after surgical treatment of adult spinal deformity. Summary of Background Data. Early proximal junctional failures above adult deformity constructs are a serious clinical problem; however, the incidence and nature of early APJFs remain unclear. Methods. A total of 1218 consecutive adult spinal deformity surgeries across 10 deformity centers were retrospectively reviewed to evaluate the incidence and nature of APJF, defined as any of the following within 28 weeks of index procedure: minimum 15° post-operative increase in proximal junctional kyphosis, vertebral fracture of upper instrumented vertebrae (UIV) or UIV + 1, failure of UIV fixation, or need for proximal extension of fusion within 6 months of surgery. Results. Sixty-eight APJF cases were identified out of 1218 consecutive surgeries (5.6%). Patients had a mean age of 63 years (range, 26–82 yr), mean fusion levels of 9.8 (range, 4–18), and mean time to APJF of 11.4 weeks (range, 1.5–28 wk). Fracture was the most common failure mode (47%), followed by soft-tissue failure (44%). Failures most often occurred in the thoracolumbar region (TL-APJF) compared with the upper thoracic region (UT-APJF), with 66% of patients experiencing TL-APJF compared with 34% experiencing UT-APJF. Fracture was significantly more common for TL-APJF relative to UT-APJF (P = 0.00), whereas soft-tissue failure was more common for UT-APJF (P < 0.02). Patients experiencing TL-APJF were also older (P = 0.00), had fewer fusion levels (P = 0.00), and had worse postoperative sagittal vertical axis (P < 0.01). Conclusion. APJFs were identified in 5.6% of patients undergoing surgical treatment of adult spinal deformity, with failures occurring primarily in the TL region of the spine. There is evidence that the mode of failure differs depending on the location of UIV, with TL failures more likely due to fracture and UT failures more likely due to soft-tissue failures.