Journal of Spine

During the last years in spine surgery has become more urgent the need for a safe method to improve pedicle screw placement. A safe and correct placement can have many important consequences, both clinical (development of new symptoms) and medico-legal. The most widespread and used tool is neuronavigation. In literature, many studies have compared the precision of screw placement between free-hand, fluoroscopic guided technique and neuronavigation.

The concept of vertebral instability has evolved in the last years, given the last scientific evidences on the degenerative cascade. Another concept has been developed in a parallel way to the one of the vertebral instability: it is the concept of microinstability, intended as biomechanical dysfunction of the motor spinal unit, responsible of symptoms but not showed by dynamic X-Rays. The introduction of the concept of microinstability has increased the diagnostic capacities towards low back pain and, subsequently, the therapeutic choices, but has increased the number of medico-legal issues related to the diagnostic and therapeutic pathway of this condition.

Many issues related to microinstability have to be explained, to guarantee to the patients the best treatment available and, at the same time, to uphold the surgeon to perform the treatment in a safe condition.

Our group has proposed a test, developed with the aim to furnish quantitative data on the basis of radiological examinations that can diagnose microinstability, giving indications on diagnosis and therapy of the dysfunctional phase of the degenerative cascade.

The retrospective analysis seems to validate the test, with a good predictive value, mainly towards Adjacent Segment Syndrome (ASD). The few cases analysed in a perspective manner, even if in preliminary phase and with a short follow-up, seem to confirm the data.

The spinal column is the most common site of skeletal secondary tumours. Metastatic tumours spreading to spine cause growing problem to the aging population. Patients suffer from immobilizing pain, instability of the spine and secondary neurologic deficits. In most patients treatment is palliative. By improving therapy of tumour-induced instability of the spine and tumour-induced pain, patients’ quality of life can be significantly improved and medical costs significantly lowered. In the past, the traditional therapy of metastatic spinal tumours was based on fractionated external beam radiotherapy. Surgical approach was limited to laminectomy (decompression). Nowadays, surgery focuses on preservation and restoration of neurologic function and stability of the spine by marginal resection, and immediate posterior and anterior stabilization. In addition, development of new surgical techniques such as radiofrequency thermoablation and kyphoplasty allowed surgeons address some of the problems related to lytic destruction of the vertebra without increasing morbidity and mortality of the patients associated with open surgery. However, proper treatment of the cervical spine metastases can be achieved only by multidisciplinary team work.

A 32 year old patient gravid with twins came in the 23th week of pregnancy; one of her fetus was small for date with polyhydramnion and a beginning feto-fetal transfusion syndrome. This is a very dangerous situation, in which one or both twins can die intrauterine because of the lack of nutrition and oxygen. One of the twins may become a donator and give all its nutrition to the other and won´t grow anymore itself. While the patient got continuous check-ups in the university clinic with ultrasound, she also got osteopathic treatments in short periods, first weekly and continuing with bigger pauses. This treatments were focussed on the uterus and its arterial nutrition and also the form of the uterus, to support the placenta of the twins to get as much oxygen as possible to nourish the babies. An additional focus was seeking for the healthy matrix of the babies intrauterine and if any osteopathic lesions could be found and get helped dissolved. The woman delivered healthy and equal weighted sons in the 38th week with section cesarean. The following case shows that an osteopathic treatment can effectively balance blood flow, growth and the well-being both of mother and children. A careful medical control and the ultrasound showed this effect.

Objective: To determine functional outcome of anterior cervical decompression and fusion using tricortical iliac bone graft (ACDF) for degenerative cervical spondylotic myelopathy with modified Japanese orthopedic association score (MJOA).
Materials and Methods: 60 diagnosed cases of one and two levels cervical myelopathy were prospectively analyzed preoperatively and at 3 months, 6 months, 1 year using MJOA.
Results: 46 patients underwent Single level ACDF with C5-C6 the commonest level to be affected. The correlation between Duration of Symptoms to Preoperative and postoperative MJOA was statistically significant. We noted statistically significant improvement in symptoms of axial neck pain, radicular arm pain, clumsy hand, and gait disturbances post operatively at one year. Statically significant difference was noted while comparison MJOA of Preoperative to 6 months and 1 year, and 3 months to 6 months and 1 year. Statistically significant difference in blood loss and anesthesia time for one level fusion compared with two level fusions was also noted. The fusion rate for single level ACDF was 95.65% compared to 71.42% for two levels.
Conclusion: Functional outcomes in operated patients at 1-year follow up are better if ACDF surgery is done early. Symptoms of axial neck pain; radicular arm pain, clumsy hand and gait disturbances show significant improvement at one year follow up. While bladder and bowel involvement showed the least recovery. Significant improvement in function occurs postoperatively between 3 and 6 months, and then it plateaus from 6 months to 1 year. Fusion rates for single level ACDF are better than two levels ACDF.

Background context: The ergonomic effects of headgear on spine surgeons are poorly understood. Assessment of cervical degenerative disease resulting from prolonged use of loupes and/or headlights was performed via data drawn from spine surgeons.
Methods: A questionnaire was distributed to 54 fellowship trained spine surgeons. Part one assessed the current level of neck pain compared to prior to residency. The amount of exposure to headgear usage was determined using this formula for headgear hours: Headgear Hours=Years in practice * Number of months per year of headgear usage * Number of cases per month * Number of hours per case. Part two assessed whether a specific diagnosis or treatment associated with neck symptoms was rendered or received. The respondents were placed into two groups for comparison: Group A (non- or infrequent users of headgear), Group B (frequent users).
Results: 28 of the 41 (68%) surgeons in Group B experienced worsening of their neck symptoms since the start of their residency versus 5 of the 13 (38%) in Group A (p=0.027). Only 1 surgeon from group A was diagnosed with a degenerative cervical disorder compared to 14 from Group B.
Conclusions: Neck pain among spine surgeons is not uncommon. Poor ergonomics during surgery combined with frequent headgear use may contribute to increased neck pain and cervical degenerative disease.

Study Background: Wrong level surgery remains one of the detrimental technical mistakes that can occur during a surgeon’s career. There is a higher frequency of wrong site surgery in the lumbar spine compared to the cervical spine. The authors aim to present a localization technique designed to aid in the prevention of wrong level surgery with the use of preoperative and intraoperative localization.

Methods: We prospectively followed 240 patients who underwent less exposure surgery for the lumbar spine. We identified the correct operative level using a combination of a 22-guage spinal needle placed under fluoroscopy in the lamina of the vertebra of the target intervertebral disc space prior to incision and then placing a hooked dilator between the spinous processes of the intervertebral space to provide actual confirmation within the operative space.

Results: Data showed that all 240 patients had surgery performed on the correct level using the described technique and the placement of the percutaneous needle assisted in minimizing the incision size to less than 5 cm for a single level fusion in all cases.

Conclusion: The described technique allows for localization prior to incision, smaller incision size, consistent and accurate localization when performing lumbar spinal surgery.

Study design: Cervical spine radiograms of 460 Jeju islanders, taken at the Cheju Halla General Hospital, Jeju, were the study materials.

Objectives: To investigate the age-matched incidences and severity of the cervical disc degeneration and associated pathologic findings.

Summary of background data: There exist several previous studies on the incidences of disc and Luschka’s and facet joint degeneration in the Europeans and Asians which provided the basic data for the interested clinicians.

Methods: Cervical radiographs of 460 (220 males and 240 females) patients of fourth to ninth decade were subjected to this prospective study. Ninety patients of third decade were excluded because none showed the spondylotic findings on radiograms. There were 76 patients (16.5%) in fourth decade, 107 patients (23.3%) in fifth decade, 112 patients (24.3%) in sixth decade, 85 patients (18.5%) in seventh decade, 64 patients (13.9%) in eighth decade, and 16 patients (3.5%) in ninth decade.

Results: Overall incidences of cervical spondylosis were 47.8% (220 patients out of 460 patients). The percentile incidences of spondylosis in fourth, fifth, sixth, seventh, eighth and ninth decade were 13.2%(10 out of 76 patients), 34.6%(37 out of 107 patients), 58.9%(66 out of 112 patients), 58.8%(50 out of 85 patients), 70.3% (45 out of 64 patients), and 75.0%(12 out of 16 patients).

The percentile incidences of one, two, three, four and five level spondylosis among 220 spondylosis patients were 45.5%(100 patients), 34.1%(75 patients), 15.0%(33 patients), 4.5%(10 patients), and 0.9%(2 patients). Severity of disc degeneration ranged from ± to ++++; ± in 6.0% (24 segments), + in 49.6% (198 segments), ++ in 35.3% (141 segments), +++ in 9.0% (36 segments) and ++++ in 0.25% (1 segment). Spurs and anterior ligament ossicle formed at the spondylotic segments, mostly at C4~6. Posterior corporal spurs formed in quite low rates. Olisthesis and OPLL rarely combined with spondylosis.

Cervical sagittal lordotic curve decreased gradually according to the progress of spondylosis, particularly over + disc degeneration.

Conclusion: It was evidently shown that the incidences of cervical spondylosis and numbers of spondylotic segments increased, and that degeneration became more severe gradually throughout the aging process.

Traditionally, back problems have been addressed from the biomedical area. For a long time the “radiologic-anatomy model” has been considered unusable because they have failed to respond to knowledge about the source of pain or therapeutic approaches used have solved the reduced chronic pain or disability

Background: Adolescents have a high prevalence of back problems. Some risk indicators are associated with sedentary lifestyle, the practice of inadequate physical activity, the physical contraindicated exercises, joint actions inadvisable, etc. For these reasons, there is a need to study the knowledge held by students about back health and sports to improve intervention programs and help them to improve their education and care of the back. Currently, there are no specific knowledge questionnaires on health and back care related to the practice of physical activity and exercise in adolescents. For these reasons, the aim of this study was to design and validate an assessment tool that measures such specific knowledge.

Methods: For this, the test-retest design was used with an interval of time of two weeks between each passes. The sample consisted of 230 students with a mean age of 15.31 (SD=1.52). Results: The internal consistency of Cronbach’s alpha coefficient was 0.80. The intraclass correlation coefficient (ICC) for average measurements was 0.80 with a significance of p<0.001. The t test for paired samples showed no statistically significant differences between the values of the first and second pass.

Conclusion: The COSACUES-AEF (in spanish cuestionario sobre “Conocimientos sobre la Salud y Cuidados de la Espalda relacionados con la Actividad y Ejercicio físico”) is a valid and reliable tool to evaluate the level of specific knowledge about health and back care related to physical activity and exercise in adolescents. The tool will let to compare the specific knowledge with other variables like presence or absence of LBP.

Objective: A variety of newly designed grafts for transforaminal lumbar interbody fusion (TLIF) have been introduced for clinical application. Biomechanical properties of the LOOP® PEEK cage (Medtronic GmbH, Meerbusch, Germany) have been shown in cadaver laboratory investigations, but not in clinical studies so far. In this study we analyze the safety, clinical and radiological outcome of the LOOP® PEEK cage implant in a clinical setting.

Methods: Forty one consecutive patients undergoing fluoroscopic-guided posterior pedicle screw fixation combined with TLIF using the LOOP® PEEK cage for degenerative spine diseases between January 2010 and December 2011 were included. Time intervals for follow-up, clinical and radiological outcome data collection were at 1, 3 and 12 months. Visual analog pain scales (VAS), neurological exam, patient-reported SF-12®, CT- scans and plain x-rays of the lumbar spine were used as clinical and radiologic outcome measures. Following data were recorded for safety evaluation: procedure duration, intraoperative blood loss, number of levels fused, intraoperative complications, hospitalization time, and postoperative complications.

Results: A total of 49 cages were implanted during 41 procedures with an average procedure time of 225.25 minutes. Four patients (9.8%) experienced a dural tear, While new sensory and motor deficits were seen in 2 (4.9%) and 1 (2.4%) patients respectively. complications were not associated with implant insertion. Significantly reduced pain scores (p<0.05, paired t-test) were reported by 29 patients (70%) at 1, 3 and 12 months. SF-12® results showed PCS and MCS scores below the healthy population average, one year post-op. Cage dislocation was observed in 2 (4.9%) patients, one required late revision. Implant fracture did not occur. Inchoate fusion of the vertebra was seen in 39 patients (95.1%) at one year.

Conclusion: TLIF procedure combined with lumbar fusion using LOOP®-PEEK cage, provides a safe and feasible intraoperative alternative as well as good clinical and radiologic outcome, without increasing the overall complication rate of TLIF procedures.

Study design: Retrospective review of monocentric database.

Objective: To determine the rate of late infection (LI) after surgical treatment for spinal deformities in children, to assess the risk factors and to follow them after treatment.

Summary of background data: Late infection is not very well documented. They are described as less frequent than early infection (EI) with a relatively good prognosis after implants removal. Review of a monocentric database with a long follow-up will address the questions.

Methods: We went through our database to look for any septic problem and compared the population with LI, without infection and with EI. Every spine deformity in children or adolescent treated between 1983 and 2010 were included with at least two years of follow up.

Results: During the study period, 1091 surgeries were performed. Nine EI occurred (8-33 days postoperatively) and sixteen LI (8 months-22 years).

If we compare LI surgeries versus no infection the risk factors we found are posterior instrumentation (0.05) especially subcutaneous rod insertion (0.0003), the type of implants we used, with more infection with stainless steel than titanium (0.013) and diamond-shape rod than smooth rod (0.013).

If we compare LI surgeries versus EI surgeries, fever, discharge, raised CRP are not seen frequently.

Cultures were positive in fourteen of the sixteen cases, frequently with low virulence organisms than in EI (0.003).

Removal of the implants and antibiotics were used as treatment. Infection resolved in all the cases after initial surgery more frequently than in EI (0.0002). In six cases we observed a loss of correction after implant removal.

Conclusion: LI are frequent. They may be due to low-virulence organisms. Smooth and titanium rods should be preferred. If removal of implants is the treatment of choice, reinstrumentation must be considered later. LI could be underestimated if the follow up is too short. Risk factor analysis could be done only if data are collected prospectively. This was done in our study.

Septum occupies a strategic position in limbic system and has been implicated in variety of behaviors. Present study was designed to evaluate the role of medial septum in modulation of pain and explore the role of neurotransmitters.

The present study was divided in two parts in first part the tail flick latencies were observed in rats with septal lesions and compared with sham operated ones. While in the second part, the effect of intraseptal injections of neurotransmitters and naloxone on tail flick latencies of cannulated rats was recorded after intraseptal lesions.

It was observed that the septal lesions decrease pain threshold. The interaseptal injection of Acetylcholine (5 μg to 20 μg) and Naloxone (5 μg to 20 μg) increases pain threshold. While the Interaseptal injection of Noradrenaline and Scopolamine decreases pain threshold.

The findings of the present study suggest that septum may be involved in modulation of pain. The neurotransmitters like Acetylcholine, Noradrenaline and opioid peptides may have an individual or collective role to play in the observed pain modulation.

Penetrating stab injuries of the spinal cord (PSISC) are extremely rare and typically associated with immediate neurological damages. However, some patients may represent with atypical and indistinct symptoms. Herein we report a case of atypical presentation of spinal canal penetration which was not detected in thorax computerized tomography (CT) scans performed in emergency room, but subsequently was revealed in thoracal CT and magnetic resonance imaging (MRI) scans. Initial neurological examination was normal except for the hypoesthesia in the right lower extremity. Surgical treatment was not performed since any foreign body or effusion consistent with hematoma and/or dural leak, or extrinsic cord compression was present. After administering a prophylactic tetanus shot and initiating a broad-spectrum antibiotic prophylaxis, patient was discharged with recommendations. On follow-up, he described that hypoesthesia was decreased, but still present at end of the first month of injury. To conclude, it is very important to scan the affected region with thin slice thickness-multislice CT or with MRI for proper diagnosis in patients with stab wounds presented with neurological symptoms.