Panagiotis Iliopoulos

Combined anterior plus posterior stabilization versus posterior short-segment instrumentation and fusion for mid-lumbar (L2-L4) burst fractures.

Study Design. Prospective randomized study. Objectives. To compare the results of the combined anterior-posterior surgery (Group A) with posterior “short-segment” transpedicular fixation (SSTF) (Group B) in mid-lumbar burst fractures. Summary of Background Data. There are no comparative randomized clinical studies on the outcome following operative treatment of mid-lumbar fractures. Methods. Forty consecutive patients with L2–L4 fresh single A3-type/AO burst fractures and load sharing score up to 6 were randomly selected to underwent either combined one-stage anterior stabilization with mesh cage and SSTF (Group A) or solely SSTF with intermediate screws in the fractured vertebra (Group B). Kyphotic Gardner angle, anterior and posterior vertebral body height (PVBHr, AVBHr), spinal canal encroachment (SCE), SF-36, VAS, and Frankel classification were used. Results. The follow-up observation averaged 46 and 48 months for Group A and B, respectively. Operative time, blood loss, and hospital stay were significant more in Group A. More surgical complications were observed in the Group A. After surgery, VAS was reduced to 4.3 and 3.6 for Group A and Group B, respectively. The SF-36 domains Role physical and Bodily pain improved significantly only in Group B (P = 0.05) and (P = 0.06), respectively. Correction of AVBHr, PVBHr, and spinal canal clearance was similar in both groups. Spinal canal clearance did not differ between the two groups, but it was continuous until the last evaluation in Group B. The final Gardner angle loss of correction averaged 2° and 5° for Group A and Group B, respectively. The posttraumatic Gardner deformity did not significantly improve by SSTF at the final evaluation in the spines of Group B. Gardner angle correlated significantly with SCE in Group B and Group A in all three periods and in the last evaluation, respectively. Frankel grade did not correlate with loss of correction of AVBHr and PVBHr in Group A, while it significantly correlated with loss of PVBHr correction and SCE in the patients of Group B. There was no neurologic deterioration after surgery in any patient. VAS and SF-36 scores did not significantly correlate with the loss of kyphotic angle correction and AVBHr, PVBHr at the final observation in any patient of both groups. Conclusions. SSTF offered similar significant short-term correction of posttraumatic deformities associated with mid-lumbar A3-burst fractures, but better clinical results as compared to combined surgery. However, SSTF did not significantly maintain the after surgery achieved correction of local posttraumatic kyphosis at the final evaluation. Thus, SSTF is not recommended for operative stabilization of fractures with this severity.

Anterior surgery with insertion of titanium mesh cage and posterior instrumented fusion performed sequentially on the same day under one anesthesia for septic spondylitis of thoracolumbar spine: is the use of titanium mesh cages safe?

Study Design. Retrospective study. Objective. To evaluate the outcome on patients with pyogenic spondylitis of the thoracolumbar spine following combined anterior and posterior surgery. Summary and Background Data. Several methods of surgical treatment of pyogenic spondylitis have been reported. These include anterior approach, staged and simultaneous anterior decompression, and posterior stabilization. The use of anterior implants in the presence of an infection presents a challenge for spine surgeons. This study analyzes the clinical and radiologic outcome of surgical intervention on patients with pyogenic spondylitis of the thoracolumbar spine who were treated surgically for intractable pain, instability, and neurologic impairment. Methods. Fourteen patients (6 women, 8 men) with thoracolumbar spondylitis were treated with anterior surgery with insertion of titanium mesh cage and posterior instrumented fusion performed sequentially on the same day under one anesthesia. The age (average, SD) of the patients at the time of surgery was 55 ± 16 years (range, 29–83 years). Most patients had also systemic diseases as lung tuberculosis, hepatic cirrhosis, diabetes mellitus, or chronic renal failure. Patients were evaluated before and after surgery in terms of pain, neurologic level, sagittal spinal balance, and radiologic fusion. Results. The average duration of the combined surgery was 4.5 hours. All patients were observed up for an average of 45 months (range, 37–116 months). The Visual Analog Scale score (average, range) improved from 7 (range, 4–10) before surgery to 2 (range, 0–5) after surgery. Correction (average, range) of segmental kyphotic deformity was 6° (range, 0°–11°) without loss of correction at the final observation. Neither a postoperative change of the position of mesh cage nor any posterior instrumentation failure was recorded. Patients with incomplete neurologic impairment showed improvement after surgery at an average 1.4 Frankel’s grade. There was one complication, an anterior wound abscess culminating in an abdominal hernia. Conclusions. This clinical study showed that patients with thoracolumbar osteomyelitis can successfully undergo anterior surgery with insertion of titanium mesh cage and posterior instrumented fusion performed sequentially on the same day under one anesthesia. The presence of the mesh cage anteriorly at the site of spondylitis had no negative influence on the course of infection healing, and additionally it stabilized the affected segment maintaining sufficient sagittal profile.

Direct reduction of thoracolumbar burst fractures by means of balloon kyphoplasty with calcium phosphate and stabilization with pedicle-screw instrumentation and fusion.

Study Design. Prospective consecutive series. Objective. To evaluate the outcomes of the treatment of acute thoracolumbar burst fractures by transpedicular balloon kyphoplasty with calcium phosphate cement and posterior instrumented fusion. Summary of Background Data. In the surgical treatment of thoracolumbar fractures, the major problem after posterior correction and transpedicular instrumentation is failure to support the anterior spinal column, leading to the loss of correction and instrumentation failure. Methods. Twenty-three consecutive patients with an average age of 48 years, who sustained thoracolumbar A3-type burst fracture with or without neurologic deficit were included in this prospective study. Twenty-one of 23 patients had single fractures and 2 had each one additional A1 compression contiguous fracture. On admission 5 (26%) of 23 patients had neurologic lesion (5 incomplete, 1 complete). Bilateral transpedicular balloon kyphoplasty was performed with quick hardening calcium phosphate cement to reduce segmental kyphosis and restore vertebral body height and supplementary pedicle-screw instrumentation [long including 4 vertebrae for T9–L1 fractures and short (3 vertebrae) for L2–L4 fractures]. Gardner kyphosis angle, anterior and posterior vertebral body height ratio, and spinal canal encroachment were calculated before to after surgery. Results. All 23 patients were operated within 2 days after admission and were followed for at least 24 months after index surgery. Operating time and blood loss averaged 70 minutes and 250 cc, respectively. The 5 patients with incomplete neurologic lesions improved by at least 1 American Spine Injury Association grade, whereas no neurologic deterioration was observed in any case. Overall sagittal alignment was improved from an average preoperative 16° to 1° kyphosis at final follow-up observation. The anterior vertebral body height ratio improved from 0.6 before surgery to 0.9 (P < 0.001) after surgery, whereas posterior vertebral body height was improved from 0.95 to 1 (P < 0.01). Spinal canal encroachment was reduced from an average 32% before surgery to 20% after surgery. No differences in preoperative values and postoperative changes in radiographic parameters between short and long group were shown. Cement leakage was observed in 4 cases: 3 anterior to vertebral body and 1 into the disc without sequela. In the last computed tomography evaluation, there was shown a continuity between calcium phosphate and cancellous vertebral body bone. Posterolateral radiological fusion was achieved within 6 to 8 months after index operation. There was no instrumentation failure or measurable loss of sagittal curve and vertebral height correction in any group of patients. Conclusion. Balloon kyphoplasty with calcium phosphate cement secured with posterior long and short fixation in the thoracolumbar and lumbar spine, respectively, provided excellent immediate reduction of post-traumatic segmental kyphosis and significant spinal canal clearance and restored vertebral body height in the fracture level in an equal amount both in the short and the long instrumentation.

Beneficial influence of titanium mesh cage on infection healing and spinal reconstruction in hematogenous septic spondylitis: a retrospective analysis of surgical outcome of twenty-five consecutive cases and review of literature.

Study Design. Single institution, single surgeon retrospective review. Objective. To investigate if the use of titanium mesh cage on the site of infection could be beneficial for successful outcome of the operative treatment for pyogenic spondylitis. Summary of Background Data. There is a controversy concerning the optimal treatment for pyogenic spondylitis regarding approach, instrumentation and staging. This large series reports on single-stage instrumented open and minimally invasive surgery for septic spondylitis. Methods. Twenty-four patients aged 57 ± 16 years suffering from persistent or complicated septic spondylitis were treated by a total of 25 single stage combined surgeries (first: anterior debridement/partial vertebrectomy plus mesh cage filled with autologous bone graft; second: pedicle screw fixation with open and minimal invasive techniques). The indications for surgery included neurologic compromise, significant vertebral body destruction with kyphosis associated with segmental instability, failure of medical treatment, and/or epidural/ paravertebral abscess formation. Needle biopsy was performed in all patients before surgery. Patients were evaluated before and after surgery in terms of pain and neurologic level, sagittal segmental spinal balance, radiologic fusion and recovery. Results. All but 1 tetraplegic patient with simultaneous cervical and lumbar spondylitis, who died because of massive clot lung embolism 2 months after surgery, were followed for 56 months (range, 31–116 months) The visual analogue scale score improved from 6.5 before surgery to 1.8 after surgery. The segmental kyphotic deformity was corrected at an average of 6°, without cage settling. An insignificant loss of kyphosis correction of an average 0.6° was measured in the thoracolumbar junctiononly. Blood loss, surgical time, and surgical complicationswere significant less in the patients who operated with minimal invasive technique. Patients with incomplete neurologic impairment improved after surgery. Physical function (SF-36) averaged 72 1 year after surgery. All operated patients had resolution of infection. There was neither migration of mesh cage nor posterior instrumentation failure at the last follow-up observation. Conclusion. The present study showed that radical debridement of spinal infection and anterior insertion of titanium cage, filled with autogenous bone graft, secured with pedicle screw instrumentation should have had a beneficial influence on the eradication of infection, segmental and global spinal reconstruction and fusion. Supplementary posterior minimal invasive pedicle screw fixation eliminates posterior soft tissue injury and preserves blood supply, and reduces surgical time, blood loss, and surgical complications.

One-stage combined surgery with mesh cages for treatment of septic spondylitis.

There is a controversy regarding most effective operative method for treatment of pyogenic spondylitis and whether to use metallic implants on the site of infection. This retrospective study reports on the outcome of 17 patients with persistent cervical and lumbar pyogenic spondylitis who had one-stage combined surgery and fusion with use of a titanium mesh cage for intractable pain, kyphosis, and neurologic impairment. All patients tolerated the combined operation and were followed up on for 45 months. Incomplete neurologic lesions improved postoperatively an average 1.4 Frankel grades. Visual analog pain score (mean) improved from 7 preoperatively to 2 postoperatively. Average correction of local kyphotic deformity was 6° without loss of correction at final observation. There was no expulsion or migration of any titanium mesh cage or loosening of the posterior instrumentation. There was an approach-related abdominal hernia after wound infection. At the final followup, the combined operation in combination with the use of the mesh cage improved sagittal alignment and resulted in eradication of the infection and attainment of solid fusion. The presence of the titanium mesh cage anteriorly at the site of infection had no adverse effect on the course of infection. Patients with cervical and lumbar osteomyelitis can successfully have instrumented-combined, one-stage surgery.Level of Evidence: Prognostic study, Level II (retrospective study). Please see the Guidelines for Authors for a complete description of levels of evidence.

Effect of sagittal spinal balance, levels of posterior instrumentation, and length of follow-up on low back pain in patients undergoing posterior decompression and instrumented fusion for degenerative lumbar spine disease: a multifactorial analysis.

Study Design. Prospective controlled clinical study on low back pain (LBP). Objective. To investigate the possible effects of radiographic and other related parameters on LBP in patients underwent decompression and posterolateral instrumented fusion for degenerative lumbar spine disease. Summary of Background Data. Sagittal balance of the spine after spine surgery has gained increasing interest regarding its correlation with LBP and fusion rate. To our knowledge, no advanced statistical analysis on the effects of sagittal roentgenographic and other parameters on LBP after lumbar surgery has been published. Methods. Forty-five patients with an average age of 63 years, who underwent pedicle-screw fixation in 2, 3, and 4 vertebrae for degenerative lumbar spine disease were selected to be included in this study. Radiographic and self-assessment (bodily pain, short form-36) data were evaluated using advanced statistics (multifactorial analysis) to investigate all possible correlations between a dependent parameter (LBP) and independent parameters (sex, extension of instrumentation, sagittal spinal balance, and angular motion at the adjacent free level above instrumentation). Results. All patients were observed for an average of 5.5 years (range, 5–7 years). Male patients showed significantly more improvement of LBP than female counterparts (P = 0.024). LBP improved after surgery by the first year (P < 0.000) and thereafter decreased (P < 0.000) at the final evaluation, but remained at levels significantly higher than before surgery (P < 0.000). The deviation of the apical lumbar vertebra from C7-plumbline was correlated with LBP (P < 0.000). Patients, who received third- and fourth- level instrumentation had less LBP (P = 0.0245) than their counterparts, who received second-level instrumentation. Conclusion. Improvement of sagittal deviation of apical lumbar vertebra, instrumentation of third or fourth vertebrae, male gender, and fusion success were correlated with postoperative improvement of LBP after posterior decompression and pedicle screw fixation for symptomatic degenerative lumbar spine disease. This research suggests that the methods directed at the improvement in sagittal spinal balance of the lumbar spine, careful selection of fusion levels, and improvement of fusion rate might be beneficial for decreasing LBP after surgery in degenerative lumbar spine disease.

Color Doppler Ultrasonography for Evaluation of Internal Mammary Artery Application in Adolescent Female Patients with Right-Convex Thoracic Idiopathic Scoliosis

Study Design. Prospective comparative study. Objective. To establish the use of Color Doppler Ultrasonography to investigate internal mammary artery. Summary of Background Data. Breast asymmetry in female adolescents with right convex idiopathic scoliosis was supposed to be linked with anatomic and functional asymmetry of the internal mammary artery that is the main supplier to the mammary gland. However, no measurements of anatomic and hemodynamic parameters of internal mammary artery have been made to justify or to reject the hypothesis of asymmetric blood flow volume to the breasts and costosternal junction in female adolescent scoliotics. Color Doppler Ultrasonography is a well established noninvasive method to assess vessel anatomy and hemodynamics. Methods. Twenty female adolescents with right thoracic scoliosis and 16 comparable female individuals without spine deformity were examined with Color Doppler Ultrasonography to measure at the origin of internal mammary artery lumen diameter, cross sectional area, time average mean flow and flow volume per minute and were compared each other. Results. The reliability of Color Doppler Ultrasonography was high and the intraobserver variability low (ANOVA, P = 0.92–0.94). There was no statistically significant difference in the ultrasonographic parameters of the internal mammary artery between right and left side in each individual as well as between scoliotics and controls. Conclusions. Color Doppler Ultrasonography applied to assess anatomic or hemodynamic blood flow parameters at the origin of internal mammary artery was proven a highly reliable method. Color Doppler Ultrasonography disclosed no side-differences, while there were no differences between scoliotics and controls. Thus, it seems that this study cannot justify previous theories for development of right thoracic scoliosis in female adolescents.

Evolution of Anterior Chest Wall Blood Supply in Female Adolescents With Progressive Right-convex Thoracic Idiopathic Scoliosis

Breast asymmetry was believed to be related to the asymmetry of anterior chest wall blood supply and subsequently to etiology of idiopathic thoracic scoliosis in female adolescents. Recent investigations on the anterior chest wall blood supply with colour Doppler ultrasonography in such individuals did not show anatomic and hemodynamic abnormalities. The present study investigated the evolution of anterior chest wall blood supply in these individuals over a 2-year period. Twenty female adolescents with progressive right-convex idiopathic thoracic scoliosis (scoliotics), who were during the study in therapy with thoracolumbosacral orthosis and 20 age-matched girls, without spine deformity (controls) were studied with colour Doppler ultrasonography [internal mammary artery (IMA)] twice within the 2-year period. IMA-anatomic parameters [lumen diameter (D) and cross sectional area (AR)] and also hemodynamic flow parameters [time average mean flow velocity (TAM) and flow volume per minute (FV)] were measured. In the 2-year period of observation, thoracolumbosacral orthosis prevented scoliosis progression (P=0.004), whereas IMA-AR decreased bilaterally in the individuals of both groups (P<0.03). In the last evaluation: in scoliotics right IMA FV decreased (P<0.04), whereas in controls IMA FV decreased bilaterally (P<0.03); left IMA FV was significantly higher (P<0.05) in scoliotics than in controls. The significant, within the 2-year period, decrease of IMA-diameter, cross-sectional area, and flow volume seems to be a physiologic ageing process because it was observed in all individuals (scoliotics and controls) and thus these anatomic and hemodynamic changes seem not to have been affected by bracing. The maintenance of left flow volume of IMA in the prebrace levels in scoliotics was the most significant finding of this investigation. In conclusion, this study provided evidences for abnormalities in the evolution of anterior chest wall blood supply in female adolescents with progressive right-convex female thoracic scoliosis. Further studies are needed to investigate if this asymmetric blood evolution contributes to the development of this pattern of scoliosis in girls.

Colour Doppler ultrasonography for evaluation of anterior chest blood supply: the possible role of arterial blood supply to the costosternal junction in the aetiology of idiopathic scoliosis in female adolescents

This prospective comparative study was carried out to investigate the blood supply to the anterior chest wall by measurement of several anatomical and haemodynamic flow parameters of the internal mammary artery, with the use of colour Doppler ultrasonography, in female scoliotics with idiopathic right convex scoliosis in adolescence. Previous investigations have postulated that asymmetry of the breasts in female adolescents may be linked with the development of right convex thoracic scoliosis. This breast asymmetry is supposed to be linked with anatomical and functional asymmetry of the internal mammary artery that is the main supplier to the mammary gland. However, no measurements of anatomical and haemodynamic parameters of the internal mammary artery have been made to justify or reject the hypothesis of asymmetric blood flow volume to the breasts and costosternal junction in female adolescent scoliotics. Twenty female adolescents with right convex thoracic scoliosis and 16 comparable female individuals without spine deformity were examined with roentgenograms (scoliotics only) to measure scoliosis curve, vertebral rotation and concave and convex rib–vertebra angle at three vertebrae (the apical, one level above and one below the apical vertebra). Doppler ultrasonography was used to measure, at the origin of the internal mammary artery, its lumen diameter, cross-sectional area, time average mean flow and flow volume per minute in scoliotics and controls, which were compared with each other. The roentgenographic parameters were compared with the ultrasonographic parameters in the scoliotics to disclose any relationship. The reliability of colour Doppler ultrasonography was high and the intra-observer variability low (ANOVA, P=0.92–0.94). There was no statistically significant difference in the ultrasonographic parameters of the internal mammary artery between right and left side in each individual as well as between scoliotics and controls. In scoliotics the right mammary artery time average mean velocity increases with the convex (P<0.05) and concave (P<0.01) rib–vertebra angle one level above the apical vertebrae and with the apical convex rib–vertebra angle (P<0.05). The right internal mammary artery flow volume per minute increases with convex (P<0.01) and concave (P<0.01) rib–vertebra angle one level above the apical vertebrae and with the apical convex rib–vertebra angle (P<0.05). Left internal mammary artery cross-sectional area increases with convex apical rib–vertebra angle (P<0.01) and concave rib–vertebra angle one level above the apical vertebra (P<0.01). Conclusively, this investigation showed that haemodynamic flow parameters of the right internal mammary artery and anatomical parameters of the left internal mammary artery are significantly correlated with the magnitude of rib–vertebra angles close to the apex of right thoracic scoliosis in female adolescents. This study did not find any evidence for side-difference in vascularity of the anterior thorax wall and, thus, it could not clearly justify previous theories for development of right thoracic scoliosis in female adolescents.