Mohamed El-Meshtawy

Management of burst thoracic and thoracolumbar fractures with thoracoscopically assisted anterior corpectomy and posterior short segment percutaneous stabilization

Study design This was a prospective observational study. Objective The aim of this study was to evaluate the role of thoracoscopically assisted corpectomy of burst thoracic and thoracolumbar fractures combined with posterior percutaneous transpedicular instrumentation. Summary of background data Because of the associated morbidities related to the combined open anterior and posterior approaches to thoracic and thoracolumbar spine, some surgeons prefer either the anterior-only or the posterior-only approach that is sometimes not sufficient to achieve the goals of surgery. The combination of two minimally invasive techniques enables the achievement of treatment goals and minimizes the associated morbidities. Patients and methods Between January 2008 and December 2008, 26 patients with acute burst spinal fractures were operated upon in our hospital. These patients underwent posterior percutaneous stabilization plus anterior thoracoscopically assisted corpectomy and fusion in the prone position. Clinical and radiological outcomes were evaluated after a minimum follow-up period of 2 years. The Oswestry Disability Index combined with clinical examination was used for clinical evaluation. Plain radiography in two views was used for the radiological evaluation. Results The mean operative time was 240 min. The average blood loss was 745 ml. Ten patients had preoperative neurological deficits ranging from Frankel A to Frankel D. One patient did not show any neurological improvement at the final follow-up. The mean Oswestry Disability Index at the final follow-up was about 7. The mean preoperative kyphosis angle was 26.2°, and improved to 9.2° postoperatively and to 14° at the final follow-up. One patient had a superficial wound-healing problem. Conclusion Thoracoscopic decompression and fusion plus short segment posterior percutaneous instrumentation showed good clinical outcomes and can be considered as an alternative to open procedures, with decreased rates of morbidities in the management of burst thoracic and thoracolumbar fractures.

Posterior-only surgical correction of adolescent idiopathic scoliosis: an Egyptian experience

Introduction: The aim of this prospective case series study is to document safety and effectiveness of high density pedicle screws through posterior only approach with intraoperative wake-up test in correction of adolescent idiopathic scoliosis (AIS). Methods: Between 2011 and 2015, all surgically treated patients for AIS were followed up for a minimum of 2 years. Clinical outcomes were evaluated using scoliosis research society-22 (SRS) questionnaire. All patients were classified according to Lenke classification. Major and minor curves Cobb angle as well as sagittal parameters were measured on whole spine X-rays. All patients underwent an intra-operative wake-up test after deformity correction and a minimum of 80% metal density of implants was used. Results: This study included 50 patients. The mean age at time of surgery was 16.8 years. The mean follow-up period was 38.1 months. The mean correction rate for the coronal Cobb angle of the major curve was 79.12%, while that of the minor curve was 68.9%. The mean thoracic kyphosis angle was 38.4° preoperatively, 29.76° postoperatively and 30.36° at the last follow-up. The mean SRS-22 questionnaire scores improved significantly at the last follow-up (P > 0.001). There were no neurological deficits at the wake-up test. No cases of pseudarthrosis or metal failure were encountered. Conclusion: This is a prospective study of at least 80% metal density pedicle screws technique and intra-operative wake-up test in Egyptian patients with AIS. It proved to be an effective and safe technique in correction of radiological parameters, with no neurological or implant related complications. It allowed excellent scoliotic and kyphotic curves correction with minimal loss of correction. On the whole it led to better quality of life.

Junctional Kyphosis after Long Segment Fusion

Introduction The incidence of junctional kyphosis (JK) varies in the literature from 7% to 40%. We here present our experience with JK. The aim of this work is investigate the incidence of JK after long spinal segment fusion, to identify the underlying factors leading to its development, and to discuss treatment outcome. Patients and Methods This combined retrospective/prospective cohort study included sixty-four consecutive patients (40 women and 24 men) with a mean age of 20.7 years, who underwent long segment spinal fusion (≥ 5 vertebrae) for treatment of spinal deformity. The average length of follow-up was 2 years. Risk factors analyzed included patients’ factors, surgical factors, and radiographical parameters such as thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis, pelvic tilt, and pelvic incidence. Results Radiological JK occurred in 14 patients (22%). Ten cases were proximal junctional kyphosis (PJK), two cases were intercalary junctional kyphosis (IJK), and two cases were distal Junctional Kyphosis (DJK). Only seven patients (50%) out of the 14 with JK were symptomatic. Six cases have undergone revision surgery. In nine cases, the original deformity was kyphosis (1 Ankylosing spondylitisS, 1 post-tuberculous, 3 Sheuermanns kyphosis, 4 congenital kyphosis). The other 5 cases were scoliosis (3 idiopathic and 2 congenital). Preoperative TK more than 40 ° was associated with PJK. In all cases PI, PT, SS, SVA were within normal range, but it was noticed that SVA had negative values in 5 cases. LIV in the dorsolumbar junction was associated with DJK. Conclusion Pre-existing TK more than 40°was identified as an independent risk factor. Negative sagittal balance may be a risk factor for PJK. A surgical strategy to minimize Junctional kyphosis may include careful preoperative planning for reconstructions with a goal of optimal postoperative alignment.

Transpedicular Wedge Opening (TWO) Osteotomy for Post-Traumatic Kyphosis (PTK): Own Technique and Preliminary Results

Introduction Management for symptomatic post-traumatic kyphosis always has presented a challenge to orthopedic surgeons. The management for post-traumatic kyphosis remains controversial: Anterior, posterior, or combined anterior and posterior procedures have been advocated by different authors and show various degrees of success. All of these techniques end in abnormal morphology of the affected vertebra, so in this technique we try to restore the normal sagittal balance by restoring the normal morphology of the affected vertebra (natural kyphoplasty). Material and Methods Between May 2010 and Jun 2014 30 patients with symptomatic kyphotic deformity were treated with TWO osteotomy. Twenty-two are males and eight are females. The mean age of patients was 37 years (range 18- 62 years). All patients had history of old trauma with time lag till surgerical interferance was 10 months in average (3m- 12y.). They underwent TWO osteotomy of the wedged VB bisegmental TPSF through posterior-alone approach The clinical evaluation throughout the study entailed visual analogue scale (VAS) and Oswestry disability index. The local kyphotic angel (LKA), sagittal balance (SB) and sagittal index (SI) were measured preoperatively, postoperatively and during the follow up visits. Radiographic bony healing of the v-shaped VB defect which left after the TWO osteotomy is confirmed by MSCT. Results The mean follow up period was 26.5 months (range12- 48 m.). TWO osteotomy was done for wedged VB between D10 and L2. The mean operative time was 110 minutes (range 70- 180 minute.) and the mean intraoperative blood loss was 625 cc (range 400- 1700 cc). The mean preoperative LKA was 28.7° (range 20- 56°) that had been improved to -2° (range 8°- (−10°)) postoperatively. Lordotic correction of 30.8° (range 22–48°) was achieved with minimum loss of correction (range 0- 8°) through the period of follow up. The mean period required for radiographic bony healing of the osteotomy was 7 months (range 3–15m.). The VAS &ODI had been improved significantly (p.005) in comparison to preoperative values. Excellent clinical and radiographic outcomes were achieved in 92% of cases with no major complications. Conclusion Spontaneous bony healing after TWO of wedged VB occurs without doubt. This study evoked the concept of “Natural Kyphoplasty” for treatment of certain cases of PTK. Although it is a newly described technique, it was proved to be safe and effective method for treatment of symptomatic thoracolumbar PTK.

Safety and Efficacy of Percutaneous Non-Canulated Transpedicular Screws Fixation (TPSF) in the Management of Thoracolumbar Fractures

Background Data: The use of pedicle screws for spinal stabilization has become increasingly popular worldwide. Standard open techniques for pedicle screw placement, however, require extensive tissue dissection to expose entry points and to provide lateral to medial orientation for optimal screw trajectory. Minimal invasive techniques (MIT) are widely accepted as being the less aggressive procedure in any kind of surgery. Purpose: The aim of this study was to describe and evaluate a new alternative percutaneous technique using the usual economic non-canulated screws in thoracolumbar fractures. Study Design: A prospective clinical case study. Patients and Methods: Between January 2007 and December 2012, 42 patients (31 males and 11 females) with thoracolumbar fractures were admitted to emergency department of Assiut University Hospital. The mean age of the patients was 37 years (range, 19 to 57). All fractures were classified according to Magerl’s classification. According to American Spinal injury Association (ASIA) Impairment Scale (AIS), all patients were neurologically free (ASIA grade E) preoperatively. Surgery was done within 72 hours after injury. All patients underwent ligamentotaxis through percutaneous posterior approach using non-canulated transpedicle screws. The kyphotic angle was measured according to Cobb method preoperatively, postoperatively, and at latest follow up. Postoperative CT was done for all patients to verify screw position and recording of pedicle violations. Results: The mean operative time was 65 minutes (range, 55 to 120). The mean operative blood loss was 54 ml (range, 35 to 90). The mean preoperative local kyphotic angle (LKA) improved from 12° to -2° postoperatively and 2° at latest follow up. Neurological deterioration occurred in one patient. The average hospital stay was 1.5 days (average, 1 to 3). Misplacement of the screws (3 screws violated the medial wall of the pedicle, 7 violated the lateral wall) was recorded in 10 of 186 screws (5.4%). Conclusion: The percutaneous pedicle screw insertion using non-canulated technique in thoracolumbar spine fracture is safe, economic, and reliable minimal invasive technique. (2013ESA047)

The Efficacy of Stand-Alone PEEK Cages versus Locking Plate in Three or More-Level Anterior Cervical Discectomy and Fusion

Background Data: Anterior cervical discectomy and fusion (ACF) is currently the gold standard for surgical treatment of cervical degenerated disease (CDD). For many years, patients were treated with ACF using tricortical autogenous bone graft augmented with anterior cervical locking plate. Later, Cages packed with calcium triphosphate bone substitute were the treatment of choice. Study Design: A comparative clinical case study. Purpose: Compare the outcomes of ACF using stand-alone PEEK cages packed with calcium triphosphate bone substitute compared with tricortical iliac autograft augmented with anterior locking plate in treatment of three or more-level CDD in 47 patients. Patients and Methods: We evaluated 47 patients (22 patients in the locking plate group and 25 patients in the cage group) at our institution from January 2007 to September 2010. They were followed up for minimum 2 years. The clinical outcomes (Nurick grade and JOA score), radiographic changes (local kyphotic angle (LKA), fusion, subsidence, and adjacent disc degeneration), and complications were compared between the 2 groups. Results: The blood loss was significantly less in cage group (388 cc) than plate group (529.6cc).Both groups showed significant improvement in LKA postoperatively and at latest follow up with no significant difference. Fusion was 94.1% and 94.4% in cage and plate groups in order. There was insignificant more subsidence in cage (21.4%) than plate group (11.3 %). There was significant improvement in Nurick grading of both cage and plate groups as it improved from 3.32 and 3.68 preoperatively to 0.84 and 1.05 at latest follow up in order with no significant difference between the two groups. Final outcome was comparable in both groups: In cage group: excellent in 7 patients, good in 16, and fair in 2. In plate group, excellent in 8 patients, good in 11, and fair in 3. Conclusion: In multiple levels (three or more) ACF, the use of stand-alone PEEK cages results in less blood loss, less adjacent disc degeneration, less complications than the use of autograft augmented with locking plate but unfortunately, more incidence of subsidence. However, there is no significant difference in the postoperative and latest follow up LKA, fusion rate, clinical, and functional outcomes between the cage and plate groups. (2013ESJ049)