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

Lowest instrumented vertebra (LIV) selection is critical to preventing complications following posterior spinal arthrodesis (PSA) for thoracolumbar/lumbar adolescent idiopathic scoliosis (TL/L AIS), but evidence guiding LIV selection is limited. This study aimed to investigate the efficacy of PSA using novel unilateral convex segmental pedicle screw instrumentation (UCS) in correcting TL/L AIS, to identify radiographic parameters correlating with distal extension of PSA, and to develop a predictive equation for distal fusion extension using these parameters. We reviewed data (demographic, clinical, radiographic, and SRS-22 questionnaires) preoperatively to 2-years' follow-up for TL/L AIS patients treated by PSA using UCS between 2006 to 2011. 53 patients were included and divided into 2 groups: Group-1 (n=36) patients had PSA between Cobb-to-Cobb levels; Group-2 (n=17) patients required distal fusion extension. A mean curve correction of 80% was achieved. Mean postoperative LIV angle, TL/L apical vertebra translation (AVT), and trunk shift were lower than previous studies. Six preoperative radiographic parameters significantly differed between groups and correlated with distal fusion extension: thoracic curve size, thoracolumbar curve size, LIVA, AVT, lumbar flexibility index, and Cobb angle on lumbar convex bending. Regression analysis optimised an equation (incorporating the first five parameters) which is 81% accurate in predicting Cobb-to-Cobb fusion or distal extension. SRS-22 scores were similar between groups. We conclude that TL/L AIS is effectively treated by PSA using UCS, six radiographic parameters correlate with distal fusion extension, and a predictive equation incorporating these parameters reliably informs LIV selection and the need for fusion extension beyond the caudal Cobb level

Introduction

This study compares outcomes of vertebroplasty(VP) and kyphoplasty(KP) in 125 consecutive female Asian patients above 65 years with L1 osteoporotic vertebral compression fractures

Scheuermann's kyphosis is a structural deformity of the thoracic or thoracolumbar spine, which can result in severe pain, neurological compromise and cosmetic dissatisfaction. Modern surgical techniques have improved correction through a posterior-only or antero-posterior approach but can result in significant morbidity. We present our results of the surgical management of severe Scheuermann's kyphosis by a single surgeon with respect to deformity correction, global balance parameters, functional outcomes and complications at latest follow-up. We included 49 patients, of which 46 had thoracic and 3 had thoracolumbar kyphosis. Surgical indications included persistent back pain, progressive deformity, neurological compromise and poor self-image. Fourty-seven patients underwent posterior-only and 2 antero-posterior spinal arthrodesis utilising Chevron-type osteotomies and hybrid instrumentation. Mean age at surgery was 16.0 years with mean postoperative follow-up of 4.5 years. Mean kyphosis corrected from 92.1o to 46.9o (p<0.001). Concomitant scoliosis was eliminated in all of the 28 affected patients. Coronal and sagittal balance was corrected in all patients. Mean blood loss was 24% total blood volume. Mean operation time was 4.3 hours with mean inpatient stay of 9 days. SRS-22 questionnaire improved from a mean preoperative score of 3.4 to 4.6 at 2 years, with high treatment satisfaction rates. Complications included one toxic septicaemia episode but otherwise no wound infections, no junctional deformity, no loss of correction and no requirement for re-operation. Posterior spinal arthrodesis with the use of hybrid instrumentation can safely achieve excellent correction of severe Scheuermann's kyphosis helping to relieve back pain, improve functional outcomes and enhance self-image

Introduction. Surgical treatment of spinal metastasis belongs to the standards of oncology. The risk of spinal cord compression represents an operative indication. Intraoperative bleeding may vary, depending on the extent of the surgical technique. Some primary tumors, such as the renal cell carcinoma, present a major risk for hemorrhage and preoperative embolisation is mandatory. The purpose of this study is to evaluate the possible benefit of embolisation in different types of primary tumors. Material and Methods. The charts of 93 patients (42 women, 51 men, mean age 60.5 years) who were operated for spinal metastasis, 30 cases with multiple levels, were reviewed. Surgical procedures were classified as: (1) thoracolumbar laminectomy and instrumentation, (2) thoracolumbar corpectomy or vertebrectomy, (3) cervical corpectomy. A preoperative microsphere embolisation was performed in 35 patients. The following parameters, describing blood loss, were evaluated: hemoglobin variation from beginning to end of surgery, blood volume in suction during the intervention, number transfused packed red blood cells units until day 5 after surgery. A Poisson model was used for statistical evaluation. Results. The origins of spinal metastasis were: 28 breast cancer (30.1%), 19 pulmonary carcinoma (20.4%), 16 renal cell carcinoma (17.2%), 30 other cancers (32.3%). An embolisation was always performed in metastasis of renal cell carcinoma. An embolisation was performed in 8 cases in breast, 3 in pulmonary and 9 in other cancers. In the breast cancer group, there was no difference between embolisation versus non-embolisation concerning intraoperative blood loss and transfusion (P=0.404). In the pulmonary group, no difference was found either, but the number of embolisation cases was limited. For other metastasis types, the embolisation had no significant influence (P=0.697). The type of surgical intervention (2) increased intraoperative bleeding significantly in all groups: breast (P=0.002), pulmonary (P=0007), others (P=0.001). The average intraoperative hemoglobin decrease was: 2.3 in renal, 2.5 in breast, 3.0 in pulmonary, 1.9 in other metastasis (P=0.692). Conclusion. Several studies have clearly shown that the preoperative embolisation of renal cell carcinoma is recommended because of their risk of hemorrhage. However, the benefits of this procedure have been less described for other metastatic vertebral lesions. For breast cancer and other carcinoma (mainly digestive and prostate), the results of this study do not indicate a clear benefit for patients who received an embolisation. The same tendency was observed for pulmonary metastasis. The extent of the operation (corpectomy or vertebrectomy) represents the main factor that influences intraoperative bleeding

Introduction. The risk factors for new adjacent vertebral compression fracture (NAVCF) after Vertebroplasty (VP) or Kyphoplasty (KP) for osteoporotic vertebral compression fractures (VCFs) were investigated. Materials and methods. The authors retrospectively analyzed the incidence of NAVCFs in 135 patients treated with VP or KP for osteoporotic VCFs. Study period was from 2004 to 2008 with minimum follow-up of 2 years. Possible risk factors were documented: age, gender, body mass index, bone mineral density (BMD), co-morbidities, location of treated vertebra, treatment modality and amount of bone cement injected. Anterior-posterior vertebral body height ratio, intra-discal cement leakage into the disc space and pattern of cement distribution of the initial VCF and adjacent vertebral bodies were assessed on lateral thoracolumbar radiographs by 2 independent assessors. Results. 21 patients (15.6%) had subsequent symptomatic NAVCFs with a median time to new fracture was of 125 days. There was no difference in incidence of NAVCF between VP and KP groups (P>0.05). Significant differences were found between patients with and without NAVCF in terms of age, BMD, and the proportion of cement leakage into the disc space (P < 0.05). Greater age, intra-discal cement leakage and low BMD were found in patients with NAVCF. Conclusion. The most important risk factors affecting NAVCFs were age, osteoporosis and intra-discal cement leakage

The reported results of compression fractures are poor. These results are not influenced by the severity of compression, the fracture site or the residual deformity. Otherwise, the factors that determine a patient's recovery are unknown. This study wants to identify the factors determining a patient's recovery after surgical treatment of compression fractures of the thoracolumbar spine. Therefore, in 31 surgically treated patients the pre-injury versus the 12-month follow-up differences in back pain, in global outcome and in participation were prospectively recorded. For this, the visual analogue scale for pain (VAS scale) and the Greenough and Fraser low back outcome scale were used. Of the latter scale, the 3 questions pertaining to participation were combined to create a participation subscale. For these differences and for time lost from work multiple linear regressions with combinations of 16 possible predictors were performed. At one year patients who smoke report a 25% less favorable global outcome and return 2.8 points (out of 10) less closely to their pre-injury pain level than patients who do not smoke. Patients with a fracture at the thoraco-lumbar junction return 3.3 points less closely to their pre-injury level on the VAS scale than those with a lumbar fracture. For each decrease in 1 of the 3 education levels, the patients stay away from work 15 weeks longer. Per degree of sagittal index at follow-up, patients stay 9 days longer at home. For each increase in level of occupation the return to the pre-injury participation level is 10% less favorable. The variability of time lost from work and of recovery of global outcome, pain and participation level explained by our models is 73%, 37%, 25% and 13% respectively. Smoking, localization of the fracture at the thoraco-lumbar junction and a high pre-existent level of occupation are strong negative predictors for recovery. A lower education level and sagittal fracture deformity at follow-up are negative predictors for sick leave but might also reflect the concerns of the physician when deciding about return to work

Introduction. The main symptoms in multiple myeloma are the result of skeletal destruction mainly the vertebral column. The current treatments for multiple myeloma include radiotherapy and chemotherapy but unfortunately it is still incurable. However, the symptoms and quality of life of these patients can be improved by cement augmentation which has gained popularity in the recent years. Aim. To analyse the efficacy and safety of cement augmentation and to assess the survival and outcome of the patients with vertebral fractures secondary to multiple myeloma. Material and Methods. In this retrospective study, we reviewed the data over the last 3 years. Medical records review included correction of vertebral angle (VA), assessment of disability, survival and postoperative improvement in pain and functional status. Results. We reviewed 12 patients with 48 vertebral compression fractures including 9 male and 3 female patients. Mean age was 62.5 years (41–85). 5 patients had single vertebral involvement while 7 had multiple fractures at different levels in thoracolumbar spine. Average length of follow-up was 20.3 months (14–33 months). Based on Modified Tokuhashi score, the expected survival was less than 12 months in 2 patients and more than 12 months in the remaining patients. 11 patients are alive till date with average survival of 26 months (18–42 months) while 1 patient died, 23 months after the initial correction surgery. Prior to correction, the average vertebral angle (VA) was 10.60 (2.30 to 25.20) and after cement augmentation the average VA was 7.00 (1.60–22.80). Mean correction achieved was 3.60. There was no loss of vertebral height in any patient until their latest follow-up. Karnofsky performance score was more than 70 in 5 patients, 50–70 in 6 and less than 50 in 1 patient preoperatively while it improved to more than 70 in all patients postoperatively which indicates improvement in their functional status. All patients reported improvement in their pain level after surgery. No cement leakage or major complication occurred in these patients. Conclusion. Cement augmentation is a safe and effective way of treating the symptoms of multiple myeloma which occur due to vertebral metastases. It results in excellent pain control and improvement in quality of life

PURPOSE OF THE STUDY. The anterior approach to the thoracic and lumbar spine is used with increasing frequency for various indications. With the advent of prosthetic intervertebral disc replacement, its use has become even more frequent and has often been associated with serious complications. The aim of this study was to evaluate vascular complications in patients who underwent anterior spinal surgery of the thoracic and lumbar spine. MATERIAL. We performed a total of 531 operations of the thoracolumbar spine from the anterior approach. In 12 cases, after exposure of the body of the first or second thoracic vertebrae, we employed the Smith-Robinson technique to expose the cervical spine. We used sternotomy in six, posterolateral thoracotomy in 209, pararectal retroperitoneal approach in 239, anterolateral lumbotomy in 58 and the transperitoneal approach in seven patients. The aim of surgery was somatectomy in 190 patients and discectomy in 341 patients. Sternotomy and transperitoneal approaches were carried out by a thoracic or vascular surgeon and all the other procedures were done by the first author. The indications for spinal surgery included an accident in 171, tumour in 56, spondylodiscitis in 43 and a degenerative disease in 261 patients. METHODS. The Smith-Robinson approach was used for exposure of T1 or T2. Sternotomy was indicated for treatment of T2–T4 and also T1 in the patients with a short, thick neck. Access to T3–L1 was gained by posterolateral thoracotomy, in most cases performed as a minimally invasive transpleural procedure. For access to the lumbar spine we usually used the retroperitoneal approach from a pararectal incision or lumbotomy. We preferred the pararectal retroperitoneal approach in L2–S1 degenerative disease, L5 fractures, and L5–S1 spondylodiscitis. We carried out lumbotomy in patients with trauma, tumors and L1–L4 spondylodiscitis. The transperitoneal approach from lower middle laparotomy was used only in tumors at L5 or L4. The patients were followed up for 2 to 96 months (average, 31.4 months) after anterior spinal surgery. RESULTS. In 12 patients treated by the Smith-Robinson procedure and in six patients undergoing sternotomy, neither early nor late signs of any injury to major blood vessels or internal organs were recorded. The 209 patients with posterolateral thoracotomy were also free from any signs of vascular injury, but trauma to the thoracic duet was recorded in one case. We found injury to major blood vessels in three patients in the group treated by the pararectal retroperitoneal procedure. In the total of 531 anterior spinal surgery procedures this accounts for 0.56 %; of the 304 lumbar operations and 239 pararectal retroperitoneal operations it is 0.99 % and 1.26 %, respectively. In one patient the vascular injury was associated with trauma to the ureter. CONCLUSIONS. The technique of anterior approach is safe only in the hands of experienced spinal surgeons with long experience. In institutions where anterior spinal surgery is not a routine method it is advisable to involve a vascular or cardiac surgeon. However, the most important point is to know when not to operate

Introduction. Primary malign tumors and solitary metastatic lesions of the thoracic and thoracolumbar spine are indications for radical en bloc resections. Extracompartimental tumor infiltration makes the achievement of adequate oncological resection more difficult and requires an extension of the resection margins. We present a retrospective clinical study of patients that underwent chest wall resection in combination with vertebrectomy due to sarcomas and solitary metastases for assessing the clinical outcome especially focusing on onco-surgical results. Method. From 01/2002 to 01/2009 20 patients (female/male: 8/12; mean age: 52 (range of age: 27–76yrs)) underwent a combined en bloc resection of chest wall and vertebrectomy for solitary primary spinal sarcoma and metastatic lesions. The median follow-up was 20,5 (3–80) months. Histological analysis revealed 17 primary tumors and 3 solitary metastatic lesions. In the group of primary tumors 10 sarcomas, 1 giant cell tumor, 2 PNET, 1 histiocytoma, 1 aggressiv fibrous dysplasia, 1 pancoast tumor and 1 plasmocytoma were histologically documented. We included 1 rectal carcinoma, 1 breast cancer metastases and 1 renal cell carcinoma. All patients underwent a chestwall resection en bloc with multilevel (1/2/3/4 segments: n=4/6/6/4) hemi (n=7) or total vertebrectomy (n=13) with subsequent defect reconstruction. Reconstruction of the spinal defect following total resections was accomplished by combined dorsal stabilization and carbon cage interposition. The chest wall defects were closed with a goretex ® -patch. One patient also received a musculocutaneus latissimus dorsi flap. Results. The surgical margins were R0 in 19 (wide in 14, marginal in 5) and one R1 resection. Marginal/R1 resections were due to extracompartimental sarcoma invasion (spinal canal) and dural involvement. In these patients postoperative radiotherapy was performed. Surgical complications requiring revision occurred in 1 patient due to injury of the ductus thoracicus and persisting chylothorax. Temporary subileus or mild pneumonia appeared in 3 patients. No superficial/deep infection or neurological deficits (except those related to oncologically required dissection of thoracic nerve roots) were observed. At follow up 2 patients died due to the disease after 7,5 months. Local recurrences were seen in 3 patients at median 24 months (13–43). Pulmonary metastases necessitating polychemotherapy were seen in 7 patients after median 17 months (7–44). Conclusion. Despite the only midterm follow up, the combined en bloc resection of chest wall and multilevel en bloc spondylectomy/hemivertebrectomy is a challenging but safe and effective technique in order to achieve adequate margins and local control in selected with spinal sarcomas extending to the dorsolateral chest wall

INTRODUCTION. Spinal injuries in children are rare and account for a low proportion of all childhood injuries. Because of higher mobility and elasticity of the spine and a lower body mass in children, spinal injuries are not frequent and represent only 2 to 5 % of all spinal injuries. MATERIAL. All patients from birth to the completed 18th year of age treated in our departments between 1996 and 2005 were included in this study. The patients, evaluated in three age categories (0–9, 10–14, 15–18), were allocated to two groups according to the method of treatment used (conservative or surgical). The information on patients treated conservatively was drawn from medical records; the surgically treated patients were invited for a check-up. RESULTS. During 1996 through 2005, we treated a total of 15 646 patients with injury to the skeleton, aged 0 to 18 years. The spine was affected in 571 cases, which is 3.6 %. We used conservative treatment in 528 (92.5 %) and surgery in 43 (7.5 %) children. The group of patients treated conservatively consisted of 292 boys (55. 3 %) and 236 girls (44.7 %); of these 219 (41.5 %) were in the 0–9 year category, 251 (47.5 %) were between 10 and 14 years and 58 (11 %) were 15 to 18 years old (mean age 10.2 years). The most frequent cause of injury was a fall (277; 52.2 %), then sports activity or games (86; 16.3 %), car accidents (34; 6.4 %) and diving accidents (30; 5.7 %). Pedestrians were injured on 25 occasions (4.7 %) and other causes in 76 patients (14.4 %). Thoracic spine was most frequent (340; 64.4 %), multi-segment injury in 124 patients (23.5 %). The TL spine was affected in 22 patients (4.2 %), and lumbar vertebrae were injured in 28 patients (5.3 %). Injury to the cervical spine, both upper and lower, was least frequent, including 4 (0.8 %) and 10 (1.9 %) patients, respectively. None showed neurological deficit. The surgically treated group included 29 (67.4 %) boys and 14 (32.6 %) girls; two (4.7 %) children were between 0 and 9 years, nine (20.9 %) between 10 and 14 years, and 32 (74.7 %) between 15 and 18 years (mean age 15.1 years). The frequent causes of injury were car accidents and falls in 21 (48.8 %) and 14 (32.6 %) children, respectively. Other causes were infrequent. The upper cervical spine was operated on in five (11.6 %), lower cervical spine in eight (18.6 %), thoracic spine in 13 (30.2 %), TL spine in five (11.6 %) and lumbar vertebrae in 12 (27.9 %) patients. Thirty-six (83.7 %) patients had fractures, five had dislocated fractures (11.6 %) and two (4.7 %) had a dislocation. Neurological deficit was recorded in nine (20.9 %). CONCLUSIONS. Childhood spinal injuries account for only 2 to 5 % of all spinal injuries and for 3.6 % of all skeletal injuries in children. The cervical spine is affected most often in younger children, while the thoracolumbar spine in older children. Multi-segment injuries are typical in the childhood spine, particularly in smaller children. Typically, children show SCIWORA and a more rapid improvement of neurological deficit than adults. Conservative treatment is preferred; surgery before 12 years of age is strictly individual, while after 12 years therapy is similar to that used in adults

Epidemiological studies enhance clinical practice in a number of ways. However, there are many methodological difficulties that need to be addressed in designing a study aimed at the collection and analysis of data concerning fractures and other injuries. Most can be managed and errors minimised if careful attention is given to the design and implementation of the research.

Cite this article: Bone Joint J 2014;96-B:863–7.

We describe the results of 287 intra-articular fractures of the calcaneum in 247 patients treated by minimally-invasive reduction and K-wire fixation between 1994 and 2003. There were 210 men (85%) and 37 women (15%). The most common cause of injury was a fall from a height in 237 patients (96%). Fracture classification was based on the method described by Sanders and Essex-Lopresti. All patients were operated on within 21 days of injury and 89% (220) within 48 hours. The reduction was graded as nearly anatomical (less than 2 mm residual articular displacement and satisfactory overall alignment) in 212 (73.9%) fractures.

There were 20 cases (7%) of superficial pin-track infection and five (1.7%) of deep infection. All healed at a mean of 6 weeks (3 to 19). Loss of reduction was observed in 13 fractures (4.5%) and a musculocutaneous flap was needed in three (1%).

The results were evaluated in 176 patients (205 fractures) with a mean age of 44.3 years (13 to 67), available for follow-up at a mean of 43.4 months (25 to 87) using the Creighton-Nebraska Health Foundation Assessment score. The mean score was 83.9 points (63 to 100). There were 29 (16.5%) excellent, 98 (55.7%) good, 26 (14.8%) fair and 23 (13%) poor results. A total of 130 patients (73.9%) were able to return to their original occupation at a mean of 5.6 months (3.2 to 12.5) after the injury.

Semi-open reduction and percutaneous fixation is an effective treatment for displaced intra-articular fractures of the calcaneum.