Mohammad El-Sharkawi

Direct repair of spondylolysis presenting after correction of adolescent idiopathic scoliosis.

BACKGROUND CONTEXT Although spondylolysis is found in 6% of idiopathic scoliosis patients, very little was reported on management of pars defects in this group. These patients with painful spondylolysis are most eligible for direct repair of the defect rather than lumbosacral fusion in an attempt to save motion segments. PURPOSE The aim of this work was to analyze the clinical and radiologic outcome of pars repair in a group of adolescents who presented after surgical correction of their idiopathic scoliosis. STUDY DESIGN A prospective nonrandomized study. PATIENT SAMPLE Ten consecutive patients with spondylolysis presenting after an average of 3 months (range, 2-7 months) from correction of their idiopathic scoliosis with low back pain not responding to conservative therapy and interfering with everyday activities. The mean age at operation was 16 years (range, 14-19 years). OUTCOME MEASURES Total blood loss, operative time, and hospital stay were recorded. Clinical outcome was assessed by the Oswestry Disability Index (ODI), visual analog scale (VAS), and Scoliosis Research Society (SRS)-22 questionnaire. Fusion of the pars interarticularis was assessed using plain, lateral, and oblique radiographs and a computed tomography (CT) scan. METHODS The surgical technique consisted of thorough debridement of the defect, impacting the gap created with a tricortical iliac crest graft, and rigid fixation by either pedicle screws and a V-shaped rod (five patients) or a cable-screw construct (five patients). RESULTS Patients were followed up for an average of 4.5 years (range, 2-7 years). Nine patients had a good-to-excellent result, returned to normal everyday life, and participated in sports when desired. The mean ODI, VAS, and SRS total scores were 11 (range, 0-34), 1.1 (range, 0-2), and 92 (range, 61-108), respectively. Follow-up radiographs and CT scans revealed healing of all defects in nine cases, no signs of disc degeneration in any, and no implant-related complications. CONCLUSIONS The results of direct repair of spondylolysis in idiopathic scoliosis patients were very satisfactory both clinically and radiologically. Direct repair appears to be a logical alternative to spinal fusion; lumbar spine mobility was preserved, and precocious motion segments were saved with a relatively simple operation.

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.

Posterior Only Vertebral Column Resection (PVCR) for Fixed Angular Kyphosis (FAK)

Introduction VCR is the most suitable osteotomy for rigid angular kyphosis especially if the correction needed is high. The prospective cohort study assessed the efficacy of Posterior Vertebral Column Resection (PVCR) in management of Fixed Angular Kyphosis (FAK). Patients and Methods Thirteen cases of FAK managed by PVCR in Assiut University Hospital and followed up for a mean of 20.31 (12–48) months. Seven cases (53.8%) were females and six cases were males, the mean age was 13.77 years. Eleven cases were congenital (84.6%) and two cases were post tuberculous. Five cases (38.5%) affected the thoracic region, six cases (46.2%) affected thoracolumbar region and two cases (15.4%) affected lumbar region. VAS, ODI, SRS-22, and neurology together with local kyphotic angle were compared pre, post and at last follow up visit. One case suffered progressive paraplegia. Results Five osteotomies were at L1; four at D11, and one osteotomy at D10, D12, L2 and L3. The VAS improved from 6.57 ± 2.14 to 1.29 ± 0.75 (p = 0.001). The mean ODI improved from 56.22 ± 20.59 to 22.81 ± 11.33 (p = 0.001). Total SRS-22 score improved from 2.11 ± 0.60 to 3.35 ± 0.65 (p = 0.002). The mean local kyphotic angle improved from 65.38°±29.95 to 14.69°±19.78 (p = 0.001), the mean operative time was 465.38 ± 76.44 (320–600) minutes and the mean blood loss was 3323 ± 934.6 (1600–4500) cc. The preoperatively neurologically impaired case recovered completely. Four cases suffered complications (30%), one case suffered postoperative weakness of quadriceps which improved with physiotherapy, two cases suffered asymptomatic proximal junctional kyphosis and one case experienced pull out screws which was revised. Conclusion PVCR seems to be highly effective tool for correction of fixed angular kyphosis avoiding the morbidity of anterior or combined approaches.

Anterior Cervical Discectomy and Fusion Using an “Oversized” PEEK Cage: Radiological and Clinical Outcome

Introduction There has been controversial data about the effect of cage size on radiological and clinical outcome of anterior cervical discectomy and fusion (ACDF). Oversized cages have been linked to higher incidence of non-union, adjacent segment disease, and unfavorable clinical outcomes. The aim of this work is to evaluate the effect of an oversized PEEK cage on the radiological and clinical outcomes in ACDF. Patients and Methods Between January 2012 to July 2014, 57 patients (29 single level, 15 double levels, 8 three levels, 5 four levels) underwent ACDF using a stand-alone oversized PEEK cages. They were 35 males and 22 females with mean age 56 ± 13.5 years. The minimum follow up period is one year. The following parameters were measured preoperatively, postoperatively and at final follow up: cervical lordosis (in degrees), disc height (in mm), motion at operated level (in degrees), radiological ASD (present or not) and VAS for neck pain, VAS for arm pain. All complications were as well recorded. Results The mean cervical lordosis changed from 25°±5.5 postoperative to 7°±4.5 at final follow up. The mean disc height was 5± 2 mm preop, 7 ± 1.5 mm postop and 6 ± 1 mm at final follow up. Residual motion at operated level was observed at 1 year follow up X-rays in 2 patients (one double level and one 3-level) with average 5°. None of them had neck pain and no revision was required. In the postoperative X-rays, the suprajacent level was always observed to be slightly narrowed; this narrowing gradually diminished during the follow up. Radiological ASD developed in 9 patients (16%), all of them remained to date asymptomatic. The average improvement in VAS for neck pain was 27%±8.5 and the average improvement in VAS for arm pain was 33%±9.5. At the final follow up, fusion was achieved in 55 patients (96%) and clinical outcome was excellent. Radiological loss of the postoperative disc height and cervical lordosis and development of radiological ASD did not correlate to poor clinical outcome. No single case of cage dislodgement was observed in this series. Conclusion The use of a stand-alone oversized PEEK cage in ACDF seems to minimize the incidence of cage dislodgment even in multiple levels ACDF. Despite some radiological settlement and loss of cervical lordosis, an excellent clinical outcome was maintained.

Three Dimensional Correction of Severe Rigid Neurofibromatosis Scoliosis

Introduction The surgical management of severe rigid dystrophic neurofibromatosis curves is a demanding procedure with uncertain results. Several difficulties are present in such patients including a poor bone stock, sharp angulation of these curves and the delicate nature of the dural sac. The aim of this work is to review the clinical and radiographic outcome of three-dimensional correction of severe rigid neurofibromatosis curves analyzing its efficacy, safety and possible complications. Materials and Methods The results of 32 patients with severe rigid neurofibromatosis deformities were retrospectively reviewed. Patients were followed-up for a minimum of 3 years; an average of 6.5y (range 3 – 9y). The average age was 14 years (range 11 – 19y). All patients had typical dystrophic curves and the apex of the deformity was dorsal (13 patients); dorsolumbar (14 patients) and lumbar (5 patients). All patients had a two staged procedure; an anterior release followed by posterior instrumentation augmented by sublaminar wires. The wires were placed immediately below the proximal anchor and several sublaminar wires at the apex of the deformity. There were a total of 142 wires with an average of 6.5 wires/ patient (range 5 – 8 wires). Results The mean Cobb angle of the main curve was 102° before surgery corrected to an average of 39° and the loss of correction had an average of 4°. Sagittal alignment improved from an average of 12° to an average of 47° and rotation was corrected by an average of 34%. There were no dural tears during passage of the sublaminar wires and no neurological or implant related complications. Conclusions The use of extensive and vigorous anterior release with posterior hybrid instrumentation has proved useful and effective in the treatment of these difficult cases; sublaminar wires allow safe gradual correction and even distribution of forces over multiple anchor points improving the correction achieved and decreasing implant related complications.

Instrumented Circumferential Fusion for Tuberculosis of the Dorso-Lumbar Spine. A Single- or Double-Stage Procedure?

Introduction The purpose of this study was to present our experience in treating dorso-lumbar tuberculosis by one-stage posterior circumferential fusion and to compare this group with a historical group treated by anterior debridement followed by postero-lateral fusion and stabilization. Material and Methods Between 2003 and 2012, 43 patients with active spinal tuberculosis were treated by one-stage posterior circumferential fusion and prospectively followed for a minimum of two years. Pain severity was measured using Visual Analogue Scale (VAS). Neurological assessment was done using the Frankel scale. The operative data, clinical, radiological, and functional outcomes were also compared with a similar group of 25 patients treated with anterior debridement and fusion, followed 10–14 days later by posterior stabilization and postero-lateral fusion. Results The mean operative time and duration of hospital stay were significantly longer in the two-stage group. The mean estimated blood loss was also larger, though insignificantly, in the two-stage group. The incidence of complications was significantly lower in the one-stage group. At final follow-up, all 38 patients with pre-operative neurological deficits showed at least one Frankel grade of neurological improvement, all 68 patients showed significant improvement of their VAS back pain score, the mean kyphotic angle has significantly improved, all patients achieved solid fusion and 53 (78%) patients returned to their pre-disease activity level or work. Conclusion Instrumented circumferential fusion, whether in one or two stages, is an effective treatment for dorso-lumbar tuberculosis. One-stage surgery, however, is advantageous because it has lower complication rate, shorter hospital stay, less operative time and blood loss.

Pelvic Incidence is Not Constant

Introduction The pelvis is a very important component in the overall balance. It changes its orientation in space aiming at compensation for any sagittal imbalance. Three pelvic parameters were recognized as descriptive tools for pelvic status. Pelvic incidence (PI) is considered as a constant value after maturity which changes only in pelvic trauma. This work aims to evaluate if the surgical correction of the fixed sagittal imbalance has any effect on the pelvic incidence. Patients and Methods Twenty seven cases with fixed sagittal imbalance were corrected surgically by posterior spinal osteotomies and prospectively followed for at least one year. Pelvic Incidence (PI), Sacral Slope (SS), Pelvic Tilt (PT), Lumbar Lordosis (LL), Thoracic Kyphosis (TK) and Sagittal Vertical Axis (SVA) were compared between preoperative, postoperative and last follow up long standing lateral whole spine radiographs. Measurements were taken by three experienced spine surgeons independently. Results Twenty four cases were included, half of them were males, and the mean age was 16.3 (5–46) years. PI was fixed or changed by five degrees or less in seventeen cases (70%). PI increased in four patients (16%) by more than five degrees and decreased by more than five degrees in three cases (12,5%). The mean increase in the PI was 11.75° (6–20°) and 11.2° (7–23°) postoperatively and at last follow up respectively. Conclusions Despite that the PI is fixed or minimally changes (five degrees or less) in most of the cases of surgically corrected fixed sagittal imbalance, it is increased in some patients and decreased in others. The long term effect of this observation and its implication on surgical planning is yet to be determined.

Simultaneous Anterior Debridement and Posterior Instrumentation for Multiple Level Tuberculous Spondylodiscitis

Introduction The incidence of tuberculosis has rapidly increased in the last decade. The aim of this work is to compare the results of iliac crest and rib grafts and to assess the role of short segment posterior instrumentation in patients with multiple level affections. Materials and Methods The results of 48 patients with multiple level resistant tuberculous spondylodiscitis surgically treated were retrospectively reviewed. Patients were followed-up for an average of 6.5y. The average age was 47y and 27 patients had an associated neurologic deficit. The disease affected two levels (36 patients) and three levels (12 patients). All had anterior debridement and bone grafting by iliac crest autograft in 26 patients (Group 1) and rib autograft in 22 patients (Group 2); followed simultaneously by posterior short segment instrumentation. Results Postoperatively, the kyphotic deformity was corrected from an average of 41 degrees to an average of 5 degrees (Group 1) and from an average of 47 degrees to an average of 6 degrees (Group 2). At the last follow up, both groups had a similar fusion rate (95% and 96% respectively) and loss of correction (averaged 2.4 degrees and 2.1 degrees respectively). Group 1 patients had 7 donor site complications. All patients except one had an improvement in their neurologic status. Conclusions Radical anterior debridement of multiple level spondylodiscitis eradicated the infection; short segment posterior instrumentation applied immediate stability, allowed adequate graft uptake and long term correction of the kyphotic deformities.

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.

Surgical Treatment of Burst Fractures of the Dorsolumbar Spine by Short Segment Posterior Instrumentation. To Fuse or Not to Fuse

Introduction The concept of ‘Ligamentotaxis’ using short segment posterior instrumentation and fusion is widely accepted for managing unstable burst fractures of the dorsolumbar spine. The aim of this work is to study the possibility of performing this procedure without fusion. Materials and Methods This is prospective randomized study included 54 patients with burst fractures of the dorsolumbar spine treated with short segment posterior instrumentation without fusion (Group 1); compared with a similar group of 47 patients that were treated by the same technique with posterolateral fusion using iliac crest autograft. Patients were followed up for an average of 5y. Results In Group 1, all patients with neurological impairment improved 1 to 2 Frankel grades; the VAS improved from an average of 7.8 to 1.3 and the overall complications were 4/54. The kyphotic deformity was corrected from an average of 22.6 degrees to an average of 3.1 degrees; the average anterior height of the fractured vertebrae was corrected from an average of 65% to an average of 92% and the compromise of the spinal canal improved from an average of 42% to 14%. Implant failure occurred in 2 patients. There was no significant difference in these parameters between Groups 1 and 2. In Group 2 there was significantly more operative time, blood loss, hospital stay and 10/47 complications including 2 implant failures. Conclusion Short segment posterior instrumentation without fusion is a safe efficient procedure with significantly less operative time, blood loss, hospital stay and complications than when fusion was performed.