Introduction: Total lumbar disc replacement (TLDR) is a motion-preserving alternative to lumbar spinal fusion for degenerative disc disease. Although in vitro cadaveric studies have provided invaluable information in preserving motion and possibly prevent abnormal loading at the adjacent level for TLDR, there is still lack evidence of in vivo consequences for sagittal balance and movement.

Purpose: Aim of our prospective non-randomized clinical study was to analyze the consequences for segmental and sagittal balance and movement of TLDR.

Materials and Methods: From October 2001 trough December 2006, 1-year minimum follow-up, 78 TLDR were implanted in 57 patients. 31 (54.4%) were female, 26 (45.6%) male. Mean age at surgery was 41.77±7.46 ys (30–57). 36 (63.2%) had single level TLDR, 15 (26.4%) 2-level, 3 (5.2%) 3-level, and 3 (5.2%) hybrid constructs. Replaced discs were L3–L4 in 5 (6.4%) cases, L4–L5 in 32 (41%), and L5-S1 in 41 (52.6%). AP, lateral, and flexion-extension periodical lumbar X-rays allowed to measure segmental lordosis, lumbar lordosis, segmental motion, and lumbar motion pre-, post-op, and at follow-ups. Analyses were performed using 9.2 STATA statistical software, and 12.0 SPSS version. Differences were assessed using t or Mann-Whitney tests. Samples of 3-level and hybrid constructs were too small for comparative analysis.

Results: Mean follow-up was 35.02±17.58 ms. Lumbar lordosis passed from 43.87°±11.82° pre-op to 46.42°±10.83° post-op (P=0.062379), and 47.98°±11.97° at last follow-up (P=0.008544). L3–L4 segmental lordosis passed from 6.90°±3.51° pre-op to 10.85°±5.22° post-op (P=0.026971), and 11.80°±2.59° at last f-u (P=0.064873). L4–L5 segmental lordosis passed from 9.86°±5.06° pre-op to 13.83°±6.21° post-op (P=0.000611), and 13.21°±6.11° at last f-u (P=0.000631). L5-S1 segmental lordosis passed from 17.02°±5.32° pre-op to 22.46°±6.27° post-op (P=0.000001), and 23.03±6.81° at last follow-up (P= P=0.000000). Concerning movement, there was no differences between pre- and post-op L3–L4 (P=0.656045), L4–L5 (P=0.458793), or L5-S1 (P=0.157879) ROM. Even lumbar motion had no difference between pre- and post-op. There was no differences between single and double level replacement about lumbar and segmental lordosis, and about lumbar and segmental ROM.

Conclusion: In vivo implanted TLDR affected sagittal balance, increasing segmental and lumbar lordosis. TLDR avoid spinal fusion maintaining normal motion, both segmental and lumbar. Single and double level disc arthroplasty have similar effects.

Object. Our purpose is to describe a new surgical technique, the transoral kyphoplasty, that we performed in 3 cases of tumors in C2.

Materials and Methods. From February 2004 to January 2006 3 cases of C2 tumoral localizations did not show healing after 6 months of conservative treatments. To reduce pain and avoid both C2 collapse and prolonged immobilization transoral kyphoplasties were performed.

Results. There were no complications and/or complaints related to the procedure. There were no C2 related symptoms or neurological problems. The first patient died 8 months after surgery due to unrelated causes. The second and the third are alive and, follow ups of 2 years and 8 months respectively, reveal good and pain-free cervical motion, with no findings regarding pathologic mobility/instability on X-ray and CT.

Discussion. The management of tumors of the C2 body is still controversial. In cancer patients non-operative treatment could fail. In these cases the literature recommends internal fixation (anterior or posterior), percutaneous vertebroplasty, or transoral vertebroplasty [1–4]. Anatomically, the transoral route is the most straightforward percutaneous access to the C2 body [4]. In our cases, after conservative treatment failure, we performed the transoral kyphoplasty to avoid major surgical procedures, and considering kyphoplasty an improvement of the vertebroplasty. While maintaining the normal cervical spine anatomy, and avoiding arthrodesis or fixation that reduce the cervical spine range of motion, in the thoracolumbar spine kyphoplasty versus vertebroplasty is correlated with a reduction in the complication rate [5].

Conclusions. Transoral kyphoplasty could be considered a safe, quick and effective treatment in reducing pain and avoiding vertebral collapse in patients with tumors in C2, not responding to non-operative treatment.

Object. Our purpose is to evaluate early benefits and complications of pedicle subtraction osteotomy (PSO) for patients with fixed thoracolumbar kyphotic deformities.

Background. The fixed sagittal imbalance is a syndrome in which the patient is only able to stand with the weight-bearing line in front of the sacrum [1]. Its etiology could be very different, but usually it is due to idiopathic scoliosis or degenerative sagittal imbalance [2]. Different techniques are reported in the literature for its correction [3]. In particular, in the last few years, the PSO is affirming as a good technique in correcting the fixed thoracolumbar sagittal deformity, with its three column osteotomy [1–3].

Materials and Methods. From December 2005 to July 2006 the first 10 PSOs for patients with fixed symptomatic thoracolumbar sagittal deformity were performed in our Spine Center. All 10 were female (100%). Mean age was 63.8±5.3 (55–71). The diagnosis was idiopathic scoliosis in 7 cases (70%), degenerative sagittal imbalance in 3 (30%). Patients had undergone a mean of 1.5±0.97 (0–3) operative procedures prior to the PSO.

Results. A pedicle subtraction was always performed between the level L1 and L4. An average of 10±2.9 (7–16) vertebral levels were included in the spinal fusion. Intraoperative estimated blood loss was 1300±305 (800–1800) mL, operative time was 298.5±37.5 (250–360) minutes. An average increase in lumbar lordosis of 28.3±12.1 (8–51) degree was established with this technique: the transpedicular wedge resection contributed 73.5%±25.4% (19.4±6.1 degree) of this correction; the remaining correction came from multilevel facetectomy. The average improvement in the sagittal plumb line was 4.3±5.1 (from −5 to +15) cm. There were 8 (80%) perioperative complications: 4 major (1 subdural hematoma; 1 pulmonary embolism; 1 fracture of the upper end vertebrae; 1 pemanent neurologic deficit); 4 minor (1 transient neurologic deficit; 3 wound dehiscences). Most patients reported improvement in terms of pain and self image as well as overall satisfaction with the procedure.

Conclusions. Pedicle subtraction osteotomy is a useful procedure in correcting fixed sagittal thoracolumbar imbalance. Often it is well-tolerated, but certainly this is a technically demanding procedure with high perioperative complication rates.