Piotr Janusz

Cervical sagittal alignment in scheuermann disease

Study Design. Retrospective evaluation of radiographs. Objective. The aim of this study was to assess sagittal cervical balance in patients with the two types Scheuermann disease (SD). Summary of Background Data. The structural hyperkyphosis characterizing SD may be localized in the thoracic (SDT) or thoraco-lumbar (SDTL) spine segments. This may affect sagittal cervical balance. Methods. Seventy-one patients (41 males and 30 females), aged 16.3 ± 3.8 years with SD, were enrolled into the study. On standing lateral long-cassette radiographs, the following measurements were made: C0-2 angle, C2-7 angle (CL), C1-C2 angle, relative rotation angle (RRA)—measured at levels from C2 to C7, cervical tilt (CT), thoracic inlet angle (TIA), T1 slope, neck tilt (NT), C0-angle, cranial offset (CO), and cranial tilt (CRT). Comparison with t test was performed with significance level P < 0.05. Results. There were 38 SDT and 33 SDTL patients. In SDT, the T1 slope was significantly greater than that in SDTL (38.1° vs. 28.9°; P = 0.0002), and consequently CL (−19.8° vs. −8.9°; P = 0.0160), CT (29.8° vs. 24.3°; P = 0.0190), and TIA (81.9° vs. 71.1°; P = 0.0022) in SDT were significantly greater as well. The difference in CL was expressed mainly in C6-C5 (−4.8° vs. −1.4°; P = 0.0146) and C5-C4 (−4.4°; vs. −1.5° P = 0.0464) segments. There were no significant differences in proximal cervical lordosis: C0-2 angle (−21.6° vs. −20.8°; P = 0.7597), C1-C2 angle (−30.8°vs. −27.5°; P = 0.1746), C3-C2 (−5.4° vs. −5.1°; P = 0.7976), and C4-C3 (3.5° vs. −1.5°; P = 0.1464) segments. There was no significant difference in cranial parameters C0-angle, CRT, and CO. Conclusion. Scheuermann disease type has an influence on cervical sagittal balance. Localization of structural kyphosis affects the T1 slope as well as C2-C7 lordosis, cervical tilt, and thoracic inlet angle. Significant difference in C2-C7 lordosis in comparison to similar C0-2 lordosis demonstrates that compensation is present in subaxial cervical spine. Position of the head center of gravity is not dependent on the SD type. Level of Evidence: 4

Analysis of Anterior Trunk Symmetry Index (ATSI) in healthy school children based on 2D digital photography: normal limits for age 7-10 years

Background Digital photography for a 2-dimensional assessment of the body shape is a valuable method to both document the human posture and calculate the main quantitative parameters of it. Purpose The goal of this study was to assess the frontal plane symmetry of the anterior trunk in healthy school children based on the digital photography by measurement of the Anterior Trunk Symmetry Index (ATSI). . Methods The study comprised 421 school children, both sexes, aged 7-10 years, with no clinical evidence of scoliosis (Angle of Trunk Rotation <5o). One frontal photograph of anterior trunk in spontaneous standing position was taken with a digital camera in standardized manner. The semi-automatic software for calculation of photogrammetric parameters was developed in collaboration with an IT specialist. The photographs were analyzed to obtain a quantitative assessment of the ATSI parameter. The intra-observer error was calculated by the first author by measuring the pictures of 14 children three times, selected randomly, at the interval of at least two days. The inter-observer error was calculated by one surgeon and two experienced physiotherapists by measuring the pictures of 60 children, selected randomly. The normal upper value limit was calculated as mean + 2SD. Results

Complications in Adult Patients with Down Syndrome Undergoing Cervical Spine Surgery Using Current Instrumentation Techniques and rhBMP-2: A Long-Term Follow-Up

Introduction Cervical spine pathologies are common in Down syndrome (DS) patients. Cervical pathologies may cause cord compression and neurologic deterioration if left untreated. Complication rates of 73‐100% have been reported in DS patients after cervical spine surgery in historical studies. This study reports updated perioperative complications rates and long‐term outcome in patients with DS undergoing cervical spine surgery. Methods Retrospective review of patients with DS who have undergone cervical spine surgery from 1998 to 2011 (≥ 24 months of follow‐up) was undertaken. Series of 17 adults with preoperative diagnoses that included atlantoaxial instability, stenosis, spondylosis, or cervical spondylolisthesis were evaluated. Nine patients received recombinant human bone morphogenetic protein‐2 (rhBMP‐2). Neurologic and ambulatory status was evaluated at regular intervals included pre‐ and postoperative imaging, range of motion evaluation, strength/neurologic testing, ambulation observation, and patient and caretaker pain reporting. Results A total of 20 surgical procedures were performed in 17 patients. Average follow‐up was 78.7 months (range: 25‐156 months). Overall, 37 complications were observed including pneumonia, respiratory distress, reintubation, dysphagia, deep venous thrombosis, sepsis, wound infection, dehiscence, neurologic complications, loss of reduction (LOR), pseudarthrosis, and hardware failure. Postoperative pneumonia was most common (23.5%). Three patients developed pseudarthrosis (all in the rhBMP‐2 group); three demonstrated LOR. Neurologic complications (N = 3) included spasticity, loss of ambulation, and postoperative weakness with myelomalacia. Two were transient. Respiratory complications in the rhBMP‐2 group were the most common (N = 3). The anterior approach resulted in a higher likelihood of complications than the posterior (p = 0.032). Conclusions Current techniques may improve pseudarthrosis (p = 0.009), LOR (p = 0.043), and first attempt (p = 0.038) and overall fusion rates (p = 0.018) compared with historical studies. Complications continue to challenge most patients (82.4%). A total of 16 of 17 patients (94.1%) demonstrated stabilization or improvement in neurologic status. Apparent successful outcome in the majority appears to warrant the high complication risk associated with cervical spine surgery in DS patients. The anterior approach resulted in a higher risk of complications than posterior (p = 0.032). We report a higher than expected incidence of pseudarthrosis in DS patients receiving rhBMP‐2, putting its benefit in DS patients into question.

ESR1 and ESR2 genotypes and the age at menarche in idiopathic scoliosis

Background Environmental and genetic factors have influence on the age at menarche (AAM). Disturbance of the AAM in patients with idiopathic scoliosis (IS) were postulated [1]. Estrogen receptor genes 1 and 2 (ESR1, ESR2) single nucleotide polymorphisms (SNP) in IS were suggested to have some association with predisposition to IS [2]. ESR SNPs were reported to have association with AAM in healthily females [3].

The Four Fixation Points of the Axis: Technique and Case Report

ABSTRACT Background: Instrumentation of the axis can be accomplished through a variety of techniques including transarticular screw fixation, pars and pedicle screw fixation, translaminar screw fixation, and posterior wiring. We report on the evolution of the axial 4-screw technique. Methods: Retrospective case review. After exposure of posterior spinal elements, the medial and superior walls of the C2 pedicle were identified from within the spinal canal. A high-speed drill was then advanced under lateral fluoroscopy, which guided craniocaudal angulation. Medial angulation was based on anatomic landmarks and preoperative imaging. This was followed by placement of translaminar screws according to the technique described by Wright. When extending the construct into the subaxial spine or the occiput, lateral connectors are placed in translaminar screws, which are usually more offset. The rod is directly connected to the pedicle screws, which are usually more in alignment with the subaxial/occipital instrumentation. Results: Two male patients ages 56 and 58 underwent posterior instrumentation of the axis employing a combination of pedicle and laminar polyaxial screws. Indications included multilevel spinal cord compression and deformity in a patient with Down syndrome and cervical meningioma, respectively. Follow-up was 1 year and 5 years, respectively. Medical complications (N = 2) occurred in the patient with Down syndrome resulting in prolonged intubation with tracheostomy placement. Reduction was maintained in both patients at last follow-up. There were no neurologic, vascular, or instrumentation related complications. Conclusions: The axis serves as a versatile anchor point and offers 4 potential points of fixation. Lateral connectors play a crucial role and allow for incorporation of the C2 screws with the rest of the construct. Local anatomy will dictate the necessity and ability to place instrumentation and detailed preoperative planning is of paramount importance.

Estrogen receptors 1 and 2 genotypes and age at menarche in idiopathic scoliosis

Objectives The age at menarche (AAM) is commonly in use in patients with IS as one of the maturity indicator suggesting deceleration of the growth velocity. The AAM was suggested to be related to predisposition and curve progression potential of IS. The late age at menarche was reported to be associated with higher prevalence of adolescent idiopathic scoliosis. The age at menarche is determined by both genetic and environmental factors as well as their interactions. Estrogen receptors 1 and 2 polymorphism were reported to be associated with AAM: in ESR1 XbaI and PvuII site polymorphism and in ESR2 AluI site polymorphism. The purpose of the study was to investigate associations of the ESR1 and ESR2 polymorphisms with AAM in IS patients.

Estrogen receptor 2 polymorphism in idiopathic scoliosis.

Objectives In estrogen receptor 2 (ESR2) gene the rs1256120 polymorphism was described to be associated with predisposition to and severity of idiopathic scoliosis (IS) in Chinese population. This observation has not been confirmed in Japanese population. The ESR2 AluI and RasI site polymorphisms were described to present association with breast cancer, rheumatoid arthritis and bone mineral density, however the association with IS has not been evaluated. The purpose of the study was to investigate associations of the ESR2 polymorphisms with either predisposition to or progression of IS in Central European population.

Pathophysiology of Minimally Invasive Surgical Approaches: Current Concepts

Spine surgery is a continuously evolving field. Traditional posterior midline approaches to the lumbar spine are associated with muscle injury. Common mechanisms of injury include ischemia, denervation, and mechanical disruption of tendinous attachments of lumbar muscles. Muscle injury may be documented with chemical markers (creatinine kinase, aldolase, proinflammatory cytokines), by imaging studies, or with muscle biopsy. Minimally disruptive surgical approaches to the spine have the potential to minimize the trauma to muscular structures and thus improve the outcomes of surgery. The impact of minimally invasive spinal surgery on long-term clinical outcomes remains unknown. State-of-the-art pathophysiology of minimally invasive spine surgery is presented in this review.