Adult Spine Deformity (ASD) is a degenerative condition of the adult spine leading to altered spine curvatures and mechanical balance. Computational approaches, like Finite Element (FE) Models have been proposed to explore the etiology or the treatment of ASD, through biomechanical simulations. However, while the personalization of the models is a cornerstone, personalized FE models are cumbersome to generate. To cover this need, we share a virtual cohort of 16807 thoracolumbar spine FE models with different spine morphologies, presented in an online user-interface platform (SpineView). To generate these models, EOS images are used, and 3D surface spine models are reconstructed. Then, a Statistical Shape Model (SSM), is built, to further adapt a FE structured mesh template for both the bone and the soft tissues of the spine, through mesh morphing. Eventually, the SSM deformation fields allow the personalization of the mean structured FE model, leading to generate FE meshes of thoracolumbar spines with different morphologies. Models can be selectively viewed and downloaded through SpineView, according to personalized user requests of specific morphologies characterized by the geometrical parameters: Pelvic Incidence; Pelvic Tilt; Sacral Slope; Lumbar Lordosis; Global Tilt; Cobb Angle; and GAP score. Data quality is assessed using visual aids, correlation analyses, heatmaps, network graphs, Anova and t-tests, and kernel density plots to compare spinopelvic parameter distributions and identify similarities and differences. Mesh quality and ranges of motion have been assessed to evaluate the quality of the FE models. This functional repository is unique to generate virtual patient cohorts in ASD. Acknowledgements: European Commission (MSCA-TN-ETN-2020-Disc4All-955735, ERC-2021-CoG-O-Health-101044828)

Dislocations of the thoracolumbar spine, which account for 11% of injuries in the T10 to L2 region, follow a high-energy, flexion-distraction force. In this region, there is a transition from a fixed kyphosis to a mobile lordosis, an absence of costotransverse ligaments and a change of facet alignment from a coronal to a sagittal plane. In 1999, we treated 12 male and nine female patients with dislocations of the thoracolumbar spine. Their mean age was 30 years. Sixteen patients had been involved in motor vehicle collisions, four had fallen from a height and one had been assaulted with an iron bar. There were 14 Frankel grade-A injuries, one Frankel grade-C, two Frankel grade-D and four Frankel grade-E injuries. The site of injury was T12/L1 in 14 patients, L1/L2 in four, T11/T12 level in four and T10/T11 in one. Associated injuries included electrical burns and a fractured femur. None of the patients sustained visceral injuries. All patients were stabilised with transpedicular fixation. No disc sequestration was found. Following surgery, one of the 14 Frankel grade-A patients improved to Frankel grade C but 13 made no neurological recovery. The four patients graded Frankel E did not deteriorate. The remaining three patients with partial neurological deficit made a complete recovery. Postoperative sepsis resolved in one patient following debridement and antibiotic therapy. The thoracolumbar junction is anatomically and biomechanically predisposed to traumatic dislocation. The poor neurological outcome with dislocations at T11/T12 and T12/L1 may be attributed to cord injury, but injuries distal to this level have a better prognosis owing to cauda equina involvement

This study aims to 1) determine reported cannabis use among patients waiting for thoracolumbar surgery and to 2) identify demographics and health differences between cannabis-users and non-cannabis users. This observational cohort study is a retrospective national multicenter review data from the Canadian Spine Outcomes and Research Network registry. Patients were dichotomized as cannabis users and non-cannabis users. Variables of interest: age, sex, BMI, smoking status, education, work status, exercise, modified Oswestry Disability Index (mODI), the Numerical Rating Scales (NRS) for leg and back pain, tingling/numbness scale, SF-12 Quality of Life Questionnaire - Mental Health Component (MCS), use of prescription cannabis, recreational cannabis, and narcotic pain medication. Continuous variables were compared using an independent t-test and categorical variables were compared using chi-square analyses. Cannabis-use was reported by 28.4% of pre-operative patients (N=704), 47% of whom used prescription cannabis. Cannabis-use was reported most often by patients in Alberta (43.55%), British Colombia (38.09%) and New Brunswick (33.73%). Patients who reported using cannabis were significantly younger (mean=52.9 versus mean=61.21,). There was a higher percentage of concurrent narcotic-use (51.54 %) and smoking (21.5%) reported in cannabis-users in comparison to non-cannabis users (41.09%,p=0.001; 9.51%, p=0.001, respectively). There were significant differences in cannabis-use based on pathology (p=0.01). Patients who report using cannabis had significantly worse MCS scores (difference=3.93, p=0.001), and PHQ-8 scores (difference=2.51, p=0.001). There was a significant difference in work status (p=0.002) with cannabis-users reporting higher rates (20%) of being employed, but not working compared to non-cannabis users (11.13%). Non-cannabis users were more likely to be retired (45.92%) compared to cannabis-users (31.31%). There were no significant differences based on cannabis use for sex, education, exercise, NRS-back, NRS-Leg, tingling-leg, mODI, or health state. Thoracolumbar spine surgery patients are utilizing cannabis prior to surgery both through recreational use and prescription. Patients who are using cannabis pre-operatively did not differ in regards to reported pain or disability from non-users, though they did in demographic and mental health variables

This study aims to 1) determine reported cannabis use among patients waiting for thoracolumbar surgery and to 2) identify demographics and health differences between cannabis-users and non-cannabis users. This observational cohort study is a retrospective national multicenter review data from the Canadian Spine Outcomes and Research Network registry. Patients were dichotomized as cannabis users and non-cannabis users. Variables of interest: age, sex, BMI, smoking status, education, work status, exercise, modified Oswestry Disability Index (mODI), the Numerical Rating Scales (NRS) for leg and back pain, tingling/numbness scale, SF-12 Quality of Life Questionnaire - Mental Health Component (MCS), use of prescription cannabis, recreational cannabis, and narcotic pain medication. Continuous variables were compared using an independent t-test and categorical variables were compared using chi-square analyses. Cannabis-use was reported by 28.4% of pre-operative patients (N=704), 47% of whom used prescription cannabis. Cannabis-use was reported most often by patients in Alberta (43.55%), British Colombia (38.09%) and New Brunswick (33.73%). Patients who reported using cannabis were significantly younger (mean=52.9 versus mean=61.21,). There was a higher percentage of concurrent narcotic-use (51.54 %) and smoking (21.5%) reported in cannabis-users in comparison to non-cannabis users (41.09%,p=0.001; 9.51%, p=0.001, respectively). There were significant differences in cannabis-use based on pathology (p=0.01). Patients who report using cannabis had significantly worse MCS scores (difference=3.93, p=0.001), and PHQ-8 scores (difference=2.51, p=0.001). There was a significant difference in work status (p=0.002) with cannabis-users reporting higher rates (20%) of being employed, but not working compared to non-cannabis users (11.13%). Non-cannabis users were more likely to be retired (45.92%) compared to cannabis-users (31.31%). There were no significant differences based on cannabis use for sex, education, exercise, NRS-back, NRS-Leg, tingling-leg, mODI, or health state. Thoracolumbar spine surgery patients are utilizing cannabis prior to surgery both through recreational use and prescription. Patients who are using cannabis pre-operatively did not differ in regards to reported pain or disability from non-users, though they did in demographic and mental health variables

Introduction. Significant access morbidity with intercostal neuralgia and post-thoracotomy pain syndrome was reported in case that an anterior approach for spondylodesis of fractures of the thoracolumbar spine was used. We describe our experience with thoracoscopical fusion from anterior as a less invasive approach. Patients. Between 02/2007 and 09/2008 in a series of 32 patients (18 male; mean age 43, 17–74yrs) with fractures of the thoracolumbar spine (level Th11: n = 2, level Th12: n = 12, level L1: n = 18; fracture types: A3.1.1: n = 15, A3.2.1: n = 11, A3.3.1: n = 3, B2.1: n = 1 and B2.3: n = 2) thoracoscopical fracture stabilization was performed. A less invasive approach with three portals without an assistant was used facilitated by a new retractor system. In 16 patients fracture stabilization from anterior was supported by an additional spondylodesis using an dorsal approach. For reconstruction of the anterior column a VLIFT-system (n = 19), a Synex- (n = 11) or a Harms-Cage (n = 2) in combination with a MACS-TL (n = 16) or a Arcofix-system (n = 2) were used. Results. Thoracoscopical fusion from anterior was performed about 8 days after the injury (1–73 days), monosegmental in 11 and bisegmental in 21 out of 32 cases. The mean overall operating time was 201min (range 105–380min). The mean overall blood loss was 780ml, in 3/32 patients blood transfusions were required. In one patient epidural bleeding and in another a screw cut-out of the MACS system of the first lumbar vertebral body occurred intraoperatively. Revision surgery was necessary due to failure of the hardware (n = 2) or occurrence of hematothorax (n = 1). In the further follow up period no wound healing disorders, failure of the implants nor intercostal neuralgia were noted. Discussion. The endoscopic view is two-dimensional and may disorientate the less experienced surgeon, and thus, prolong operation time. However, the use of a retractor system allowed for bimanual operation increasing the depth perception, provided an optimal illuminated, and permanent and stable operation field, and was economic as an assistant was not required. Conclusion. The presented technique is a high demanding approach for anterior fusion of fractures of the thoracolumbar spine, however, with the potential to reduce the surgical access trauma to a minimum with an operation time comparable to open surgery. Patients might benefit from a shortened rehabilitation and a early reintegration into professional life

Abstract. Objectives. to evaluate the efficacy and safety of topically applied tranexamic acid (TXA) in thoracolumbar spinal tuberculosis surgery, posterior approach. Methods. Thoracolumbar spine tuberculosis patients who requiring debridement, pedicle screw fixation and fusion surgery were divided into two groups. In the TXA group (n=50), the wound surface was soaked with TXA (1 g in 100 mL saline solution) for 3 minutes after exposure, after decompression, and before wound closure, and in the control group (n=116) using only saline. Intraoperative blood loss, drain volume 48 hours after surgery, amount of blood transfusion, transfusion rate, the haemoglobin, haematocrit after the surgery, the difference between them before and after the surgery, incision infection and the incidence of deep vein thrombosis between the two groups. Results. EBL for the control group was 783.33±332.71 mL and for intervention group 410.57±189.72 mL (p<0.001). The operative time for control group was 3.24±0.38 hours and for intervention group 2.99±0.79 hours (p<0.695). Hemovac drainage on days1 and 2 for control group was 167.10±53.83mL and 99.33±37.5 mL, respectively, and for intervention group 107.03±44.37mL and 53.38±21.99mL, respectively (p<0.001). The length of stay was significantly shorter in the intervention group (4.8±1.1 days) compared to control group (7.0±2.3 days). There was bo different in incision side infection and DVT. Conclusions. Topical TXA is a viable, cost-effective method of decreasing perioperative blood loss in major spine surgery with fewer overall complications than other methods. Further studies are required to find the ideal dosage and timing

Study design: Prospective study after minimally invasive anterior approach of the thoracolumbar spine in scoliosis correction. Objective: To describe the technique and first results after minimally invasive anterior approach of the thoracolumbar junction with insertion of double rod and double screw instrumentation. Summary of Background Data: Minimally invasive techniques are used at many areas of surgery nowadays. Minimally invasive surgery should have the same correction potential as with conventional approaches. Possible advantages of minimally invasive surgery are small incisions, less tissue damage, less morbidity and an improved cosmetic appearance. Methods: In this study we describe the technique and the preliminary results of minimally invasive open approach of the thoracolumbar spine with insertion of double rod and double screw instrumentation. A consecutive series of seven patients were included. All patients were female with a mean age of 16.7 years (range 10–28). The cause of thoracolumbar scoliosis was mixed. Results: The thoracolumbar curve was 59° preoperatively and 22° at six months follow up (63% correction). The unfused thoracic curve was 40° preoperatively and 29° at six months follow-up. In the sagittal plane of the fused levels Cobb angle was 61° of lordosis preoperatively and 35° of lordosis at six months follow up. Lumbar lordosis of the unfused spine was 16° preoperative and 5° at six months follow up. Thoracic kyphosis was 33° preoperatively and 24° at six months follow-up. The average time of surgery was 6.6 hours (range 5.5–7hours). The average estimated blood loss was 764ml (range 350–1200ml). Average hospital stay was 11 days (range 5–14days), and average stay at the intensive care unit was 1.7 days (range 0–3 days). One minor neurological complication with complete recovery was observed. Conclusions: Minimally invasive surgery has the advantage of less tissue damage, less morbidity and a better cosmetic appearance. With newer implants a good correction of the scoliosis can be achieved

Introduction: The role of transpedicular bone graft for the stability after dorsal instrumentation of fractures of the thoracolumbar spine is still not clear whereas the morbidity of harvesting the bone from the iliac crest is evident. In a clinical study we examined the clinical outcome, radiological signs of instability and the vitality of the bone by MRI. Methods: We examined 45 patients who underwent posterior instrumention for fractures of the thoracolumbar spine between 1988 and 1997 and had removal of the implants more than 3 months ago. All patients had received a interspinal and interlaminar bone graft, 23 patients had received an additional transpedicular bone graft. We measured the clinical outcome by a standardized questionnaire and the stability of the spondylodesis by native and functional Xrays. The vitality of the transpedicular bone graft was examined by MRI. Results: There were not significant differences in both study-groups concerning the clinical outcome. In both groups we saw one case with radiological signs of instability. In the MRI-examination 18 of the 23 patients with a transpedicular bone graft showed a vital graft. In 5 cases the transpedicular bone graft showed no increase of the signal intensity after contrast media which was interpreted as a avital graft. Discussion: Although the support of the anterior column in the posterior instrumentation by a transpedicular bone graft is theoretically meaningful we saw no correlation to the clinical outcome. Considering our results and the donor site morbidity, the use of transpedicular bone graft must be discussed critically

Introduction: Diaphyseal femoral allograft is well suited to anterior column reconstruction of the thoracolumbar spine due to its inherent structural properties and bio-compatibility. The Bridwell system of interbody fusion assessment. 1. is based on plain x-rays and therefore lacks sensitivity. A new classification system of bony union is proposed using high-speed spiral CT imaging. Methods: Twenty-six patients who underwent anterior thoracolumbar reconstruction for burst fracture using femoral allograft were followed for a minimum of 2 years. Each subject underwent high speed spiral CT scanning through the reconstructed region of the thoracolumbar spine and a classification system of graft to endplate union and central cancellous autograft incorporation was established. The classification system reflects gradually increasing biological stability of the construct. Grade I (complete fusion) implies cortical union of the allograft and central trabecular continuity. Grade II (partial fusion) implies cortical union of the structural allograft with partial trabecular incorporation. Grade III (unipolar pseudarthrosis) denotes superior or inferior cortical non-union of the central allograft with partial trabecular discontinuity centrally and Grade IV (bipolar pseudarthrosis) suggests both superior and inferior cortical non-union with a complete lack of central trabecular continuity. Intra- and inter-observer error studies were carried out involving spinal surgeons, radiologists and trainees to examine reliability of the classification. Results: In this series 84% of cases demonstrated Grade I or Grade II characteristics. 1 case (4%) was identified as Grade IV. The classification showed good reliability with a kappa score of over 0.7. Discussion: Plain radiographs have always proved unsatisfactory for the accurate assessment of incorporation of grafts in the thoracolumbar spine. The use of CT imaging in the assessment of graft union has allowed a more accurate assessment of union. The classifi cation system presented allows a reproducible and relevant categorisation of allograft incorporation

Background. While the biomechanical properties of trans-pedicular screws have proven to be superior in the lumbar spine, little is known concerning pullout strength of trans-pedicle screws in comparison to different distal terminal constructs like sublaminar hooks alone, trans pedicular screws with sublaminar hooks and clow hooks alone in the thoracolumbar spine surgery. In vitro biomechanical pullout testing was performed to evaluate the axial pullout strength of four different distal terminal constructs in thoracolumbar spine surgery. Methods. 32 fresh-frozen lamb spines were used. The lamb spines were divided into four groups, each group is composed of eight lamb spine cadavers with a different distal fixation pattern was used to terminate the construct at L1. (Group 1) trans-pedicular screws alone, (Group 2) sublaminar hooks alone, (Group 3) trans-pedicular screws augmented with a sublaminar hooks via a domino connector and (Group 4) clow hooks alone. Results. The average pullout strength of group 1 was 927N, group2 was 626N, group 3 was 988N and group 4 was 972N. Group 3 and 4 showed the most significant pullout forces when compared to group 1 and group 2. However Group 3 and group 4 didn't show any significant statistical difference when compared to each others. Conclusion. Our study thus suggests that the strongest construct that may reduce the pullout phenomina in the distal fixation constructs are the trans-pedicular screw with laminar hooks. It is strongly advised to be used in osteoporotic bones and in conditions where pullout strength is required to be enhanced. But farther prospective clinical studies are needed to clearly demonstrate the beneficial effect of a trans-pedicular screw augmented with a laminar hooks in reducing the risk of distal instrumentation pullout. Level of Evidence. Level 5. Disclosure. The authors declare that no conflict of interests were associated with the present study

Introduction: Large anterior column defects of the thoracolumbar spine, after fracture decompression, tumour or other pathological resection, or spinal osteotomy present significant difficulties in respect to autograft procurement, donor site morbidity, graft instability and residual spinal instability. Titanium Mesh Cages for reconstruction thoracolumbar vertebral body defects (after corpectomy) offer an alternative to structural iliac crest autograft or allograft. The use of TMCs for inter-body reconstruction has been addressed yet the use of larger cages for corpectomy reconstruction has not. This study examines implant stability and deformity correction of TMCs following corpectomy reconstruction in the thoracolumbar spine. Methods: Independent radiological review before, after and at follow-up (one year) was performed for 27 patients having implantation of TMCs. Measurement of thoracolumbar kyphosis was performed before surgery, immediately post operatively, and at one year follow-up. Correction of kyphosis was expressed both as angular improvement and percentage improvement. Cage settling into adjacent vertebral bodies, translational deformities and any evidence of implant failure was sought. Results: Indications for reconstruction with TMC included burst fracture (13), post traumatic kyphosis (8), primary tumour resection (3), debridement of infection (1), and stabilisation of severe kyphotic deformity in achodroplasia with associated spinal stenosis requiring decompression (2). Desired resection and decompression was achieved as indicated. Correction of kyphosis was a mean of 12 deg / 61% (range 0 – 38 deg, 0–85%). No cage moved. One patient had kyphosis recurrence of > 5 deg (12 deg). Five patients demonstrated some settling of the cage within adjacent vertebral bodies (1–8%, mean 3.4% of height loss over construct length – the vertebral body above to the body below). Translational malposition of three cages occurred. One of these cases demonstrated the maximum settling and another was associated with the only case of instrumentation failure. Clinically significant spinal canal intrusion did not occur. One cage demonstrated buckling of the wall without evidence of other problem and the clinical result was excellent. Discussion: Use of TMCs is safe when managing vertebral body reconstruction. Significant kyphosis or translational deformity has not occurred, however minor cage settling within adjacent vertebra may occur. Fusion rate is unknown as the cage mesh obscures graft maturation. Construct failure has only occurred after pre operative translational malalignment could not be corrected. This demanding procedure offers a reconstructive option with superior structural stability and reduced bone grafting morbidity

Purpose. To investigate associations between sagittal thoracolumbar spine shape with sex and measures of adiposity throughout adulthood. Methods. Thoracolumbar spine shape was characterised using statistical shape modelling on lateral dual-energy x-ray absorptiometry images, recorded for vertebral fracture analysis, of the spine from 1529 participants of the MRC National Survey of Health and Development, acquired at age 60–64 years. Associations between spine shape modes (SM) and 1) sex, 2) contemporaneous measures of overall and central adiposity (indicated by body mass index and waist circumference, respectively), 3) changes in total and central adiposity during earlier stages of adulthood and age at onset of overweight, were investigated. Results. Four of the first eight spine modes (SM) describing lumbar spine shape differed by sex; on average, women had more lordotic spines than men with relatively smaller but caudally increasing anterior-posterior (a-p) vertebral diameters. Greater BMI and waist circumference and earlier onset of overweight were associated with uneven (or snaking) spinal curvatures (SM2) and larger a-p vertebral diameters (SM3). Central adiposity was also associated with larger caudal disc heights (SM4) in women, especially increases between 36–43 years. Conclusions. Sagittal spine shapes differed by sex and associations with overall and central adiposity also differed. Overweight and greater central adiposity earlier in adulthood were particularly important, and were associated with a straighter but more unevenly curved spine with larger vertebrae and caudal discs heights, possibly explained by a chronic effect of increased mechanical loading on the spine. Conflicts of interest: None. Funding received from MRC

Introduction: Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and show longer survival rates compared to other spinal metastatic disease. Adjuvant control by chemotherapy and hormonal therapy has been proven ineffective to treat this relatively radio resistant tumour, which can often present with both back pain and neurological deficit. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma. Methods: Four patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system to determine predictive life expectancy. Results: All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary in the nephrectomy bed. The other three are alive and well at 33, 40 and 54 months post-op with no radiological evidence of tumour recurrence in the spine. There were no major surgical complications. Discussion: Careful patient selection is required to justify this procedure. The indication is best limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence. Conclusion: TES can improve symptomatic control of isolated solitary spinal metastases of the thoracolumbar spine in Renal Cell Carcinoma

Purpose: Classifications of fractures of the thoracolumbar spine are theoretically designed to help make therapeutic decisions. Three classifications (J. Laulan, F. Denis, F. Magerl) were compared to assess reproducibility for use by a surgery team. Material and methods: The classifications were described during a SOFCOT symposium in 1995. Four observers examined 60 files reading them twice at a 1 month interval. The files included plain radiographs (AP and lateral view) and a scanner series and were read in random order. Intra- and interobserver concordance were measured with the kappa method. Results: Intra- and interobserver reproducibility was good for the classification proposed by F. Denis (kappa = 0.6229 and 0.0795) for classification groups but was weak for subgroups (kappa = 0.028 and 0.571). Reproducibility was moderate for the classification proposed by J. Laulin (interob-server kappa = 0.460, intraobserver kappa = 0.541). The Magerl classification produced low to negligible reproducibility for classification groups and subgroups (intra- and interobserver kappa = 0.138 to 0.0343). Discussion: Because of its low to negligible reproducibility, the Magerl classification would be difficult to use in clinical practice to make coherent therapeutic decisions or for scientific research to analyze series of fractures treated using this classification. The reproducibility of the F. Denis classification was good for groups but low for subgroups that include fractures resulting from different mechanisms requiring radically different treatment strategies. This is a good classification system for descriptive work but can lead to treatments poorly adapted to the causal mechanism of the fracture. The reproducibility of the J. Laulan classification is moderate but each group in this classification corresponds to fractures caused by the same mechanism. Therapeutic indications determined with this system would be more coherent

Objective: Effectiveness and safety of Balloon Kyphoplasty as a method of treatment for osteoporotic vertebral fractures of the thoracolumbar spine. Materials and Methods: From January 2003 to December 2008, 102 patients (27 males and 75 females), from 56 to 82 years old (mean age 72) were treated with balloon kyphoplasty procedures for 156 osteoporotic vertebral fractures of the thoracic or lumbar spine, in a mean follow up of 24 months (6 to 45 months). The patients had progressive and painful compression fractures more than 2 months. All fractures were analyzed for improvement in sagittal alignment (Cobb angle, kyphotic angle, sagittal index, vertebral height). The patients were evaluated using the visual analog scale (VAS) and the Oswestry Disability Score. Radiographs were performed postoperatively, and at 1, 3, 6, and 12 months. Results: The score according to pain, the patient’s ability to ambulate independently and without difficulty, and the need for medications improved significantly (P < 0.001) after kyphoplasty. Vertebral height significantly increased at all postoperative intervals, with ≥10% height increases in 88% of fractures. Morphometric height ratios for treated fractures also significantly increased. There were no severe kyphoplasty-related complications, such as neurological defects, cement leakage or narrowing of the spinal canal whereas additional fractures occurred at the adjacent vertebrae at a rate of 10%. Conclusions: Kyphoplasty provided a safe and effective treatment for pain and disability in patients with vertebral compression fractures due to osteoporosis

Purpose of the study: Titanium cases are used to achieve mechanical stable spinal reconstruction immediately after corpectomy. Bone grafts is often associated to ensure long-term success. Plain x-rays do not allow correct visualization of the graft within the cage, hindering evaluation of the fusion. The objectives of this study were to obtain a precise evaluation of the graft outcome within the cage using computed tomography (CT) and to search for factors affecting bone fusion. Materials and methods: This was a retrospective analysis of a consecutive series of patients undergoing anterior reconstruction of the thoracolumbar spine with a titanium cage and a bone autograft. 3D CT reconstructions were obtained at least three months after reconstruction surgery. Three independent observers (two surgeons and a radiologist) analyzed the images. Standard CT criteria for graft fusion are not described in the literature for this type of arthrodesis so the criteria used were based on a descriptive analysis of the CT slices. A statistical analysis was then conducted to search for factors affecting fusion: epidemiological features, etiology, type of graft, size of the case, number of levels reconstructed, associated posterior arthrodesis. The regional angle was analyzed postoperatively and at last follow-up to determine how the sagittal correction was maintained. Results: Twenty-eight cases were reviewed. Reconstructions had been performed for burst fractures, tumor resection, or deformed callus. CT analysis demonstrated three fusion zones to be examined: the upper, middle and lower part of the cases. Bony bridges were noted at the extremities in all cases. The middle part of the cage generally presented a heterogeneous image which was insufficient to confirm fusion. Loss of correction was not significant. No co-factors could be identified which influenced fusion. Discussion and conclusion: Most of the cases reviewed did not present a continuous bony bridge from one end to the other of the cage yet the sagittal correction was satisfactory and persistent. The structure of the cages might be modified with a solid intermediary zone which could «spare» graft material

Aims: To compare the efþcacy and possible complications of two approaches in the management of unstable burst fractures of the thoracolumbar spine. Methods: retrospective review of two consecutive series of patients with a minimum 2Y follow-up. Group 1, 22 patients operated up to 1998: isolated posterior approach using a rod-screw instrumentation, posterior grafting and correction of the kyphosis by in situ contouring of the rods. Group 2, 15 patients operated from 1998: isolated approach for strut grafting with rib, iliac crest or þbular fragments and a Z-Plate instrumentation. Results: preop, postop and 2Y FU kyphosis averaged respectively 11û/11.6û, 2.4û/-2û, 6.5û/5û in group 1 and 2. Initial correction was better with the posterior in-situ contouring of the rods but there was more loss of correction at þnal follow-up (7û). With the anterior approach, initial correction was more difþcult to obtain but loss of correction was less (4.1û). Though more invasive, the thoracic, thoracolumbar or lumbar anterior approaches did not lead to complications in our series. In 1/3 of the patients operated by anterior approach, a two level fusion could be performed instead of a three level fusion. Conclusions: the two procedures gave similar þnal results but an early surgery was necessary in the case of a posterior approach whereas correction remained possible after a greater delay with the anterior procedure. The anterior approach allowed a shorter fusion in cases where the inferior part of the vertebral body was not severely damaged

Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and survival rates compared to other spinal metastatic disease. Adjuvant therapy has been proven ineffective. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma. Five patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system. Recurrence of spinal metastasis and radiological failure of reconstruction. All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary. The other four are well at 24, 45, 52 and 66 months post-op without evidence of recurrence in the spine. There were no major surgical complications. Careful patient selection is required to justify this procedure. The indication is limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence

Introduction: Reported standardized functional outcome assessment of flexion distraction injuries of the thoracolumbar spinal column seems to be lacking in the literature. The primary focus of this study was the long term functional outcome in this patient population in view of the management employed in a tertiary spine referral center. In an attempt to overcome the lack of pre-injury Health Related Quality of Life (HRQOL) data, patient recall of the pre-injury state was used. Secondary outcomes included the long-term disease-specific HRQOL in these patients, the correlation between radiographic alignment and functional outcome, comparison of HRQOL between operative and non-operative care, and identifying potential prognostic factors influencing functional HRQOL. Method: A database generated retrospective cohort study with a cross-sectional outcome analysis was carried out for patients with a thoracolumbar (T11-L2) flexion-distraction injury treated at a tertiary care referral center between 1995 and 2000. Inclusion criteria were age over sixteen, and referral to our center for a traumatic thoracolumbar flexion-distraction injury within two weeks of the injury. Exclusion criteria were an associated spinal cord injury, a previous spine injury or a multi-level spine injury, a significant associated other system injury with an ISS > 50, or patient refusal or inability to complete the outcome questionnaires. Patients were followed for a minimum of two years. Injury classification, healing, and alignment were determined by radiographic analysis. Standing lateral x-rays at final follow-up were used to determine the amount of residual kyphosis by two independent observers. Results: A total of 87 patients were identified by the research database, of which 83 met inclusion and exclusion criteria. Twenty-eight patients were lost to follow-up, leaving 55 eligible patients. Eight refused to participate. Of the 47 remaining patients, 40 completed questionnaires representing a response rate of 85%. There were 26 males and 14 females with a mean age of 27.4 years (range 16–48). Average follow-up was 3.3 years (range 2.5–7). Twenty-five patients (64.9%) were treated operatively and fifteen patients (35.1%) underwent non-operative management. Complications in the surgical group included one non-union, three cases of painful instrumentation, and one infection. In the non-surgical group, two patients developed non-unions requiring surgical intervention. Comparing the follow-up mean SF-36 PCS and MCS scores to the recalled baseline SF-36 pre-injury scores, demonstrated the patients did not return to baseline physical component and mental component scores (p < 0.001). The mental component (MCS) and NASS pain scores showed significant statistical difference between the two groups with a trend of non-surgical patients scoring higher. There was no statistically significant difference in the SF-36 PCS between the two groups. Linear and multiple regression models identified “associated other system injuries” as the only useful predictor of outcome influencing the SF-36 PCS. Patients with associated injuries are likely to have a poorer prognosis with lower scores. Radiographically, there was no association between degree of kyphosis at last follow-up and outcome. Discussion: Long term functional outcome assessment in this patient population and comparison between the surgical and non-surgical groups, revealed a trend in the non-surgical group towards reporting higher scores on both the generic and disease-specific questionnaires. There were also a higher number of complications associated with the surgical group, as well as potential residual back pain related to instrumentation. Limitations of the study were the retrospective nature of the study, as well as the inherent absence of real time pre-injury quality of life assessment. The study is, however, strengthened by a homogeneous cohort and the use of validated outcome measures. It also involves a cross-sectional analysis and so has a prospective component. Conclusion: The health related quality of life in patients treated for flexion-distraction injuries without spinal cord injury is favorable overall, but does not return to normal after an average of two years following injury, with a trend in the non-surgical group towards reporting higher scores on both the generic and disease-specific questionnaires. Radiographically, no association was found between degrees of focal kyphosis at last follow-up and functional outcome

Study Design: Descriptive case series. Objective: To report on the outcome of 4 patients treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to hypernephroma. Summary of background data: Patients with solitary spinal metastases from renal cell carcinoma (RCC) have better prognosis and show longer survival rates as compared to other spinal metastatic disease. Adjuvant control by chemotherapy and hormonal therapy has been proven ineffective to treat this relatively radioresistant tumour, which can often present with both back pain and neurological deficit. Methods: Four patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system to determine predictive life expectancy. 3 of the 4 had pre-operative embolization and all had radical resection of the primary tumour. Results: All patients reported significant pain relief and demonstrated neurological improvement. One patient died at 11 months post-op due to a recurrence of the primary in the nephrectomy bed. 3 were alive and well at 18, 26 and 39 months post-op with no radiological evidence of tumour recurrence. There were no major surgical complications. Conclusions: Careful patient selection is required to justify this procedure. The indication is best limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence