Eur Spine J (2014) 23:248–288 DOI 10.1007/s00586-013-3090-0
ABSTRACTS
Abstracts for GEER-SILACO—Congreso in Valencia, Spain, June 2013
ORAL COMMUNICATION 1 CORRELATION BETWEEN PATIENT-REPORTED INTENSITY OF LOW BACK OR LEG PAIN AND THE SUBJECTIVE WALKING ABILITY EVALUATED WITH THE SWISS SPINAL STENOSIS QUESTIONNAIRE (SSSQ) Principal Author: Lombao Iglesias, Domingo
ODI
SSSQ
Group 1
40.7
2.2
Group 2
41.9
2.5
Group 3
42.9
2.3
2 PREVALENCE OF THE NERVE ROOT SEDIMENTATION SIGN IN PATIENTS SHOWING NO SYMPTOMS OF LUMBAR SPINAL STENOSIS
Center: Hospital Universitario Lucus Augusti, Lugo, Spain Additional Authors: Bago´ Granell, Joan1; Vilor Rivero, Teresa2 Centers: 1Hospital Vall d’Hebro´n, Barcelona, Spain; Universitario Lucus Augusti, Lugo, Spain
2
In cases of canal stenosis, the Swiss Spinal Stenosis Questionnaire (SSSQ) results correlate significantly with the patients’ actual walking capacity. However, the relationship between SSSQ and the patientreported pain intensity has not been analyzed. Material: The study included 84 patients (51 women, 33 men; mean age 58 years) with degenerative lumbar spine disease and pain intensity of at least 5 on the visual analog scale (VAS). Patients completed a VAS for low back pain and leg pain, the Oswestry Disability Index (ODI), and the SSSQ. Method: An adaptation of the SSSQ to Spanish was carried out and subsequently validated. Based on the intensity of low back and leg pain, patients were divided into 3 groups: group 1 (low back pain 2 points C leg pain), group 2 (leg pain 2 points C low back pain) and group 3 (low back pain 2 points B leg pain). Results: Mean low back pain was 6.6 and leg pain was 6.6. Mean ODI score was 42.5 and SSSQ score was 2.3. The Spanish version of SSSQ showed adequate internal consistency (alpha coefficient 0.82). SSSQ results correlated with those of the ODI (r = 0.67). There were 18 patients in group 1, 15 in group 2, and 50 in group 3. Mean ODI and SSSQ scores did not differ between the three groups. However, the correlation of SSSQ with leg pain (r = 0.39) was somewhat higher than with low back pain (r = 0.23). Conclusions: The Spanish version of SSSQ is a valid instrument that significantly correlates with the ODI. Walking capacity determined with SSSQ correlated with the intensity of both low back pain and leg pain. SSSQ cannot differentiate between patients classified according to the values for low back versus leg pain. These data suggest that the leg pain reported by patients may not correspond to pain caused by neurological compression.
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Principal Author: Lombao Iglesias, Domingo
Hospital Center: Hospital Universitario Lucus Augusti, Lugo, Spain Additional Authors: Bago´ Granell, Joan Center: Hospital Universitario Vall d0 Hebro´n, Barcelona, Spain The nerve root sedimentation sign has been considered a characteristic MR finding in patients with symptoms of lumbar canal stenosis. Whether this sign is present in individuals without such symptoms is unknown. Aim: To determine the prevalence of the sedimentation sign in MR studies requested for conditions other than spinal disease in patients with no symptoms of stenosis. Materials and Methods: In patients undergoing MR examination for non-spinal conditions, all of whom denied having symptoms of radicular pain or claudication, an MR slice was acquired at L4–L5 to determine the presence or not of the sedimentation sign. Results: Thirty-two patients (19 women) were studied, with a mean age of 63.4 years. MR was performed for the following reasons: gastrointestinal, 15 cases; gynecological, 6; urological, 5; and miscellaneous, 6. A sedimentation sign was found in 15.6 % of cases (95 % CI 5.2 %–32.7 %). The reported prevalence of the sign in patients with symptomatic canal stenosis is 94 % (Barz et al., Spine, 2010, 35:892). The difference in the prevalence percentages was statistically significant (Chi square 78.8 p = 0.0001). Conclusions: The nerve root sedimentation sign seems highly characteristic of patients with symptomatic lumbar canal stenosis, although it can also be seen in individuals without symptoms of stenosis. A larger sample size is needed to determine the true prevalence of this sign in patients without symptomatic stenosis.
Eur Spine J (2014) 23:248–288
3 10-YEAR RESULTS OF CIRCUMFERENTIAL LUMBAR FUSION, DETERMINED WITH THE OSWESTRY DISABILITY INDEX Principal Author: Orts Garcı´a, Javier Center: Hospital Universitario de la Ribera, Alzira, Valencia, Spain Additional Authors: Bas Hermida, Teresa1; Bas Hermida, Paloma1; Maruenda Garcı´a, Francisco Borja2 Centers: 1Hospital Universitario y Polite´cnico La Fe, Valencia, Spain; 2 Hospital Universitario de la Ribera, Alzira, Valencia, Spain Aim and Introduction: Circumferential fusion is suggested to be the treatment of choice for some degenerative conditions and disc diseases, both as primary surgery and particularly, in salvage procedures. We performed a study to demonstrate that an extensive transforaminal approach with anterior and posterior fusion provides good long-term results in patients with lumbar or radicular pain, as measured by the Oswestry Disability Index (ODI). Materials and Methods: Observational study of 43 patients with a mean age of 45.3 years, operated on by the same surgeon between 2000 and 2003, with translateral interbody fusion (TLIF) of the lumbar spine at one, two, and three levels. Patients initially presented low back or radicular pain with moderate or severe disability due to spondylolisthesis and postdiscectomy sequelae. The degree of disability related to low back pain was determined before the procedure and 10 years after, using the ODI (version 2.0) validated for the Spanish language (Florez et al. 1995), considered the reference standard among low back pain scales. Results: There were no complications or sequelae following surgery. Two patients required proximal extension of the fusion. Comparison of the percentage of disability before and 10 years after the procedure yielded a significant difference of more than 10 points ([ 20 %, p \ 0.05), which implies a considerable clinical improvement. Conclusions: In our series, TLIF applied to patients with low back or radicular pain and moderate-severe disability due to spondylolisthesis and postdiscectomy sequelae resulted in a long-term (more than 10 years) improvement in pain and consequently, in function, as determined by the ODI. We believe this outcome may be related to the more extensive surgical approach used, which releases more structures, and to the larger area of fusion achieved, which provides greater stability to the treated segment.
249 Centers: 1Facultad de Medicina, Badajoz, Spain; 2Hospital Universitario Fundacio´n Hospital Alcorco´n, Unidad de Columna, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Madrid, Spain; 3 Hospital Universitario Fundacio´n Hospital Alcorco´n, Unidad de Columna, Madrid, Spain Introduction: The visual analog scale (VAS) enables measurement of patient-reported pain intensity with maximum interobserver reproducibility. The scale consists of a 10-cm horizontal line whose endpoints denote extreme limits of a symptom, and it provides a fast measurement method. The Oswestry Disability Index (ODI) (together with the Roland-Morris Disability Scale) is the most widely used and recommended instrument worldwide for predicting pain chronicity, duration of sick leave from work, and the outcome of treatment. The ODI is somewhat more difficult to administer than the VAS, mainly because it is more time-consuming. Aims: To study the relationship between the VAS and ODI and their correlational fit, in order to design a predictive algorithm based on the existing relationship. Materials and Methods: The study sample included 200 patients, 108 women (49.89 ± 8.91) and 92 men (44.01 ± 8.64), with chronic low back pain and degenerative lumbar spine disease, receiving conservative treatment in a university hospital. Data were collected from January 2004 to December 2007, through purposive sampling. The measurement instruments included the ODI and VAS, administered preoperatively, postoperatively, and at 2 years. Simple linear regression models were performed to determine the relationships between variables. Results: The best fit was obtained between the variable postoperative lumbar VAS and preoperative lumbar ODI (r = 0.811) as well as postoperative lumbar ODI (r = 0.957) (p \ 0.001 in both cases). The variables preoperative lumbar ODI and postoperative lumbar ODI showed a significant positive correlation (r = 0.779; p \ 0.001). Conclusions: Given that the VAS has considerable implications, taking into account its speed of administration and self-evaluating nature, we propose use of the linear regression equation adjusted to these variables as the postoperative predictor of the ODI (for use in situations where the ODI cannot be evaluated or its administration would be complicated). Can we avoid use of the postoperative ODI questionnaire?
5 INFLUENCE OF PHYSICIANS’ BELIEFS AND ATTITUDES ON THEIR TREATMENT RECOMMENDATIONS FOR LOW BACK PAIN. CONTROLLED CLINICAL TRIAL
4
Principal Author: Ezzedine Angulo, Aida
PREDICTING OSWESTRY DISABILITY INDEX SCORES FROM VISUAL ANALOG SCALE SCORES IN PATIENTS UNDERGOING SURGERY FOR LOW BACK PAIN
Center: Hospital Arnau de Vilanova, Valencia, Spain
Principal Author: Egea Ga´mez, Rosa Marı´a Center: Hospital Universitario Fundacio´n Hospital Alcorco´n, Unidad de Columna, Madrid, Spain Additional Authors: Guerrero Bonmatty, Rafael1; Gonza´lez Dı´az, Rafael2; Losada Vin˜as, Jose´ Isaac3; Rodrı´guez Velasco, Francisco Jose´1; Gil Ferna´ndez, Guadalupe1
Additional Authors: Domenech Ferna´ndez, Julio1; Cabanes Soriano, Francisco1; Liso´n Parraga, Juan Francisco2; Segura Ortı´, Eva2; Buj Pascual, Javier3 Centers: Hospital Arnau de Vilanova, Valencia, Spain; 2Universidad Cardenal-Herrera CEU, Valencia, Spain; 3Hospital Universitario Dr. Peset Aleixandre, Valencia, Spain Physicians’ beliefs and attitudes regarding low back pain can reinforce maladaptive behavior and limit their adherence to clinical practice guidelines (CPG), with a significant impact on patients. Aim: To investigate the influence that physicians’ beliefs and attitudes have on their treatment recommendations related to activity and
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250 work. To determine whether an educational module based on the biopsychosocial model will modify physicians’ beliefs and attitudes and lead to a change in their recommendations and the number of patients prescribed sick leave. Methods: Eighty-four physicians were randomly assigned to one of two groups and followed-up for two years: 39 received an educational module based on the biopsychosocial model and 45 received placebo educational sessions. The participants completed the FABQ and HCPAIRS questionnaires and described their treatment recommendations regarding activity and work for three clinical scenarios at the start of the study and one year later. The number of sick leaves from work due to low back pain prescribed by each participating physician one year before and one year after the intervention were recorded. Results: Before receiving the educational module, participants showed high fear-avoidance beliefs and the conviction that pain justifies disability in low back pain. In many cases, their recommendations did not conform to those in clinical practice guidelines (CPGs). The recommendations for activity and work significantly correlated with the FABQ and HC-PAIRS scores. Physicians with high fear-avoidance beliefs tended to be more restrictive in their recommendations. Those who received the biopsychosocial module showed a significant improvement in their fear-avoidance and pain-disability ideas that persisted at one year. Their recommendations for patients were better adapted to the CPGs. In comparison to the control group, the intervention group showed a significant reduction in the number of sick leaves prescribed one year after the intervention relative to one year before. Conclusion: Clinicians’ orientations toward low back pain have an impact on their recommendations to patients and adherence to CPGs. In addition to transmitting knowledge, strategies for continuing medical education in low back pain should focus on changing maladaptive beliefs and attitudes.
6 LOW BACK PAIN RELATED TO TRAINING IN THE GYM Principal Author: Godoy Adaro, Alfredo Center: CETEC, Entre Rios, Argentina Additional Authors: Taleb Pabon, Cristian Center: CETEC, Entre Rios, Argentina Aim and Introduction: To investigate the relationship between spinal lesions and physical preparation in players of juvenile rugby. Materials and Methods: This is a retrospective study performed in 69 male rugby players, focussing on the following variables: age 13-20 years (16.72), time working out in the gym 0–10 years (1.85), height 1.53–1.95 m (1.74), weight 47–120 kg (79.3), weight lifted 0–150 kg (74.8), history of back pain, and whether treatment was received. In treated patients: the diagnosis and evaluation by additional studies. The exercises involved were squats and dead lifts, and the relationship between load and lumbar spine lesions was analyzed. Trainers’ technical indications: load should never exceed 50 % of the body weight; at age 15 and 16 years, maximal effort methods are not used. At 17 years, the submaximal effort test can be taken; formulas are then used to determine the FMax and athletes can work at percentages of 80 % to 85 %. At 19 years, the athletes’ possibility to work at all levels of effort is complete. Results: Among the total, 86 % had episodes of back pain and 74 % of episodes were low back pain. On more than one occasion, 43 % received some type of treatment. All carried out gym activities with excessively heavy loads that exceeded 50 % of their body weight
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Eur Spine J (2014) 23:248–288 without strict, specialized monitoring. Among the total, we detected 3 extruded disc herniations, 11 symptomatic lysis, with 3 grade 1 listhesis that required treatment. Of the 43 %, all showed some type of disc lesion on MRI. We excluded deformities, tumors, and infection. Conclusions: Strength training in the gym is common practice in our setting. Repeated use of excessively heavy weights may be a determinant factor in the development of spinal disease.
7 TREATMENT OF EARLY-ONSET SPINAL DEFORMITIES: COMPLICATIONS Principal Author: Legarreta, Carlos Center: Hospital de Nin˜os Ricardo Gutie´rrez, Buenos Aires, Argentina Additional Authors: Rositto, Gabriel Center: Hospital de Nin˜os Ricardo Gutie´rrez, Buenos Aires, Argentina Introduction: Complications are commonly associated with treatment for early-onset spinal deformities (EOSD). The main objectives of surgery for this condition are to control the spinal deformity and achieve adequate thoracic growth with the lowest incidence of complications. Aims: To analyze our experience in the treatment of EOSD, using non-fusion techniques. To evaluate the preoperative risk factors and the complications arising during the course of treatment. Materials and Methods: Retrospective case series study (level of evidence IV). We evaluated 13 patients treated using non-fusion surgical techniques and growth by distraction. Patients had the following conditions: 5 MMC, 2 infantile idiopathic scoliosis, 1 vertebral dysplasia, 1 SCIWORA, 1 Marfan syndrome, 1 ‘‘Escobar syndrome’’, 1 neurofibromatosis type I, 1 thoracogenic scoliosis. Mean age at the time of surgery was 4.10 years. Mean preoperative angular value was 83.7 (R: 50–135). We analyzed preoperative risk factors, type of construct, sequence of distractions, and complications. In the 13 patients, 27 distraction procedures were carried out. On individual analysis of the cases, we found that the mean frequency of distractions was one procedure per each 11 months (R: 7–17 months), and that 23 % of patients had definitive surgery (fusion) following 3.5 years of distraction treatment (R: 2.10–3.10). Among the total, 69 % of patients had complications during treatment; these included superficial infections (6.6 %), deep infections (10 %), rib fractures (10 %), spontaneous fusion (3.3 %), and prosthesis loosening and failure of the material (10 %). Conclusions: When treating ESOD, the spinal surgeon should be prepared to manage various complications during the course of treatment. Based on our experience, we consider this a high-risk condition.
8 COORDINATION OF THE SUPERFICIAL SPINAL MUSCULATURE AND DEEP ROTATOR IN IDIOPATHIC SCOLIOSIS. INTRAMUSCULAR ELECTROMYOGRAPHIC STUDY IN DIFFERENT SPINAL MOVEMENTS Principal Author: Barrios Pitarque, Carlos
Eur Spine J (2014) 23:248–288 Center: Instituto de Investigacio´n en Enfermedades Mu´sculo-Esquele´ticas, Universidad Cato´lica de Valencia, Spain Additional Authors: Zena, Vı´ctor1; De Blas Beorlegui, Gema2; Garcı´a Casado, Javier1; Caban˜es Martı´nez, Lidia2; Catala´n, Benedicta3; Burgos Flores, Jesu´s2; Noriega, David3; Saiz, Javier1 Centers: 1Group de Bioelectro´nica, Universidad Polite´cnica de Valencia, Spain; 2Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 3Hospital Clı´nico Universitario de Valladolid, Spain Introduction: An imbalance in myoelectric activity between the musculature at the convexity and concavity has been described in patients with idiopathic scoliosis. These studies base their findings on the EMG patterns recorded in surface electrodes, which do not differentiate between the superficial and deep muscles. The aim of this study was to separately analyze the findings of the superficial and deep paraspinal musculature in subjects with idiopathic scoliosis. Material: Sixteen patients with idiopathic scoliosis (Cobb angle, 208358) underwent electromyography of the paraspinal musculature using monopolar intramuscular electrodes. At the level of the apex, 4 electrodes were inserted on both sides of the curve (2 in the deep rotator muscles and 2 others in the superficial paraspinal muscles). Electric activity was recorded simultaneously in the 4 muscle groups with the patient standing and in flexion, extension, right and left lateral bending, and rotation toward the side of the concavity and the side of the concavity. The recordings were compared with those obtained in 4 healthy subjects in the same age range with no spinal deformity. Results: In standing position, the activity of the deep muscles was greater than that of the superficial ones, with no imbalance between the concavity and convexity. Greater activity of the deep muscles over the superficial was also evident during anterior spinal flexion, with the deep muscles of the concavity showing higher activity than those of the convexity. None of the 4 muscle groups actively participated in spinal extension movements, although the activity of the deep rotators was always greater. On lateral flexion toward the convexity, the deep rotator muscles on the side of the concavity showed hyperactivity. During rotation movements, the most active musculature was the contralateral, with clear inhibition of the deep muscles of the concavity in rotations toward this side. Conclusion: Patients with idiopathic scoliosis present signs of deficient motor coordination between the superficial paraspinal muscles and the deep rotators. The study findings do not clearly define whether this lack of coordination is primary or secondary to the presence of the deformity.
9 IMPACT OF THE TECHNIQUE USED FOR SURGICAL CORRECTION OF CERVICAL AND THORACIC SAGITTAL ALIGNMENT IN ADOLESCENT IDIOPATHIC SCOLIOSIS. COMPARATIVE STUDY OF TWO CORRECTIVE MANEUVERS
251 Centers: 1Departamento de Ortopedia Infantil, Hospital de Nin˜os Ricardo Gutie´rrez, Buenos Aires, Argentina; 2Hospital Clı´nico Universitario, Valencia, Spain; 3Hospital Son Espases, Palma de Mallorca, Spain; 4Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 5Hospital La Fraternidad-Muprespa, Madrid, Spain Introduction and Aims: In recent years, there has been an increasing interest in the consequences of posterior fusion on the cervical sagittal plane in adolescent idiopathic scoliosis (AIS). The aim of this study is to compare the effect of two different techniques for AIS correction on cervical and sagittal alignment. Methods: Two series of 25 patients with Lenke type 1 AIS treated surgically and with at least 2 years of follow-up were retrospectively reviewed. In one series, patients underwent correction using the vertebral coplanar alignment (VCA) maneuver, which involves en bloc vertebral derotation from the convex side. In the other series, correction consisted in derotation from the concavity (DC). Preoperative and 2-year follow-up radiologic studies were evaluated by measuring the following parameters: C2–C7 sagittal angle, C2–C7 plumbline sagittal balance, T1 sagittal inclination, T1–T5 and T5– T12 kyphosis, and global C7–S1 sagittal balance. Results: In the coronal plane, the VCA technique provided a higher percentage of curve correction than DC (71.2 % vs 62.1 %). In both groups, T5-T12 experienced a lordosing effect following surgery, with a mean loss of 6.1 for DC and 7.7 for VCA. After 2 years of follow-up, differences between the groups were only found in the C2– C7 sagittal plane, which showed a mean kyphosing tendency of -5.2 in the VCA group and a mean lordosing tendency of 1.8 in the DC group (p \ 0.05). In patients whose upper instrumented vertebra (UIV) was at or below T4 in both techniques, a lordosing effect was more evident in the DC group (+9.4 vs 0.3). In patients in whom the UIV was at T3 or higher, both techniques showed a kyphosing effect, which was more pronounced in the VCA group (-7.0 vs -2.8). Conclusions: Regardless of the surgical technique used, the cervical spine has a tendency toward kyphosing decompensation of the sagittal profile. The kyphotic changes in C2–C7 sagittal alignment induced by scoliosis correction closely correlated with the level of the upper instrumented vertebra.
10 EFFICACY OF INTRAOPERATIVE AND POSTOPERATIVE RADIOLOGY FOR POSITIONING DORSAL PEDICLE SCREWS IN AIS: INTRA- AND INTEROBSERVER REPRODUCIBILITY Principal Author: Demonti, Hernan He´ctor Center: Sanatorio Mapaci-Assist Sport, Rosario, Argentina Additional Authors: Fiorillo, Pablo1; Ferrer, Alejandro2 Centers: 1Sanatorio Mapaci-Assist Sport, Rosario, Argentina; 2 Hospital Provincial del Centenario, Rosario, Argentina
Principal Author: Barrios Pitarque, Carlos Center: Instituto de Investigacio´n en Enfermedades Mu´sculo-Esquele´ticas, Universidad Cato´lica de Valencia, Spain Additional Authors: Reviriego, Juan1; Legarreta, Carlos1; Rositto, Gabriel1; Maruenda Paulino, Jose´ I2; Escalada, Marı´a1; Piza´ Vallespir, Gabriel3; Burgos Flores, Jesu´s4; Hevia Sierra, Eduardo5
Introduction: In recent years, there has been a major surge in the use of pedicle screws in the thoracic spine as another option in spine surgery for AIS. This technique is associated with better anchorage, fewer cases of pull out, and greater corrective force. Data from the literature has shown that a slight displacement of screw position (e.g., medial perforation of 2 mm or less) is biomechanically acceptable and within the safety limits. CT has proven useful for postoperative
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252 assessment of pedicle screw placement. The aim of this study was to evaluate the intraoperative and postoperative efficacy of radiography in dorsal pedicle screw placement and its relationship with CT. Materials and Methods: We evaluated 280 dorsal pedicle screws (4.5-mm polyaxial titanium screws) in 36 patients with AIS. Three observers classified screw placement as well positioned, inconclusive, or malpositioned. These responses were then compared to the CT findings using the following classification: •
•
•
TYPE 1: Positioned within the pedicle, (a) completely within, (b) within, but touching cortical, (c) penetration less than 2 mm, (d) screw in the costovertebral space (in–out–in) TYPE 2: Asymptomatic: (a) penetration greater than 2 mm, (b) perforation of anterior cortical. No neurovascular complications. TYPE 3: Screw outside, neurovascular complications.
Results: A total of 280 pedicle screws were evaluated. Three observers assessed each patient. Interobserver evaluation was 0.56 (moderate agreement). Intraobserver evaluation was 0.79 (good agreement). No vascular or neurologic lesions occurred in any case. Conclusions: According to the intra- and interobserver findings, use of intraoperative and postoperative radiography is not highly effective for diagnosing dorsal pedicle screw malposition. CT was very useful for determining the position of dorsal pedicle screws.
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Eur Spine J (2014) 23:248–288 underwent a descriptive analysis. The Student t test for paired data was used to assess differences between scores on the two questionnaires, and the Pearson correlation coefficient was applied to evaluate the relationship between the magnitude of correction and quality of life. Results: The demographic and clinical data in this review are consistent with those reported in the international literature. A statistically significant difference was found in the mean quality of life scores obtained with the SRS-22 preoperatively and postoperatively, as well as in the activity and self-image domains. There was no correlation between Cobb angle correction and quality of life. Conclusion: The validated Spanish version of the SRS-22 questionnaire is reliable and applicable to surgically treated AIS patients. Surgery resulted in an improvement in the quality of life of this population.
12 TRANSCULTURAL ADAPTATION AND VALIDATION OF THE SPANISH VERSION OF THE EOSQ-24 Principal Author: Farrington, David M Center: Hospital Infatil Virgen del Rocı´o, Seville, Spain
QUALITY OF LIFE AT 2 YEARS IN SURGICALLY TREATED PATIENTS WITH ADOLESCENT IDIOPATHIC SCOLIOSIS
Additional Authors: Vitale, Michael1; Matsumoto, Hiroko2; Tatay ´ ngela3 Dı´az, A
Principal Author: Valenzuela Candia, Carlos Felipe
Centers: 1Morgan Stanley Children’s Hospital of New York, USA; 2 Columbia University, New York, USA; 3Hospital Infantil Virgen del Rocı´o, Spain
Center: Hospital Dipreca, Santiago de Chile, Chile Additional Authors: Otto San Martı´n, Juan Pablo; Miranda Osorio, Guillermo Center: Hospital Carlos Van Buren, Valparaı´so, Chile Introduction: Adolescent idiopathic scoliosis (AIS) is a permanent, three-dimensional structural deformity of the vertebral spine. The quality of life concept and its measurement are currently considered essential in the evaluation of treated AIS patients. Aims General: To investigate whether there are differences in preoperative and 24-month postoperative quality of life in AIS patients who underwent surgical correction. Specific: (1) Describe the demographic and clinical characteristics of the population studied; (2) Report the pre- and postoperative SRS-22 questionnaire results. (3) Determine whether there is a correlation between the magnitude of the curve correction and quality of life changes. Materials and Methods: Prospective, quantitative, longitudinal, observational research study performed in 30 patients with AIS treated surgically between 2007 and 2010. All patients were evaluated clinically and all completed the validated Spanish version of the SRS22 questionnaire preoperatively and at 24 months postoperatively. The inclusion criteria were: (1) AIS with an indication for surgery, (2) 24 months of follow-up, (3) pre- and postoperative SRS-22, (4) surgical treatment by the same team, (5) a single surgical technique, and (6) a complete imaging study. Demographic and clinical variables
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Aims: To perform a translation and transcultural adaptation of the Early Onset Scoliosis Questionnaire-24 (EOSQ-24) to the Spanish language, and test its validity. Methods: The Spanish version of the EOSQ-24 was developed according to internationally accepted guidelines that included preparation, forward translation, reconciliation, back translation, review of back translation and harmonization, cognitive debriefing, review of cognitive debriefing results, and proofreading. The parents of 38 patients with early onset scoliosis (2–10 years) completed this new translated version of the EOSQ-24. Each subscale of the Spanish EOSQ-24 was analyzed in terms of internal consistency, discriminative validity, reliability of internal consistency (Cronbach alpha), and ceiling and floor effects. Results: The Spanish version of EOSQ-24 seems to provide excellent psychometric performance that is equivalent to the original EOSQ-24. All the subscales show adequate internal consistency (Cronbach alpha [ 0.7), the item-scale correlations were generally high, and the floor and ceiling effects were limited. Conclusions: The Spanish version of EOSQ-24 can be used to evaluate disease-specific health-related quality of life (HRQOL) in Spanish-speaking families of patients with early onset scoliosis. Significance: The Spanish version of the EOSQ-24 as a measure of HRQOL seems to be equivalent to the original version in English and enables collection of information from Spanish-speaking families. This will expand the number of patients available for recruitment in various studies and avoids the selection bias associated with excluding patients unable to complete a questionnaire in English. Level of Evidence: Diagnostic Level I.
Eur Spine J (2014) 23:248–288
13 TYPE II ODONTOID FRACTURES TREATED WITH SCREWS IN YOUNG ADULTS AND IN THOSE OLDER THAN 70 YEARS Principal Author: Rocca Siri, Carlos Antonio Center: Servicio Cirugı´a de Columna CASMU, Montevideo, Uruguay Additional Authors: Rodrı´guez Satler, Lisandro Center: Servicio Cirugı´a de Columna CASMU, Montevideo, Uruguay Introduction and Aims: Anterior screw fixation for type II odontoid fractures is mainly recommended for treating young patients; its use in the elderly population is controversial. Our aim was to carry out a retrospective study of the functional outcome in younger and older patients who presented type II odontoid fractures (Anderson and D’Alonzo) surgically treated with solid and cannulated screws, by anterior approach. Materials and Methods: We evaluated the clinical and radiological results of 16 patients between 2004 and 2012, including 14 men and 2 women, with a mean age of 64.5 years. Seven patients were older than 70 years and 9 younger than 70. Mean follow-up was 18 months. All procedures were performed by the same surgeon using an anterior approach, placing one or two 4-mm cancellous screws for small fragments in 14 patients and cannulated screws in 2 patients. The clinical and radiologic results between patients younger and older than 70 years were compared. Results: Among the total, 93.7 % had a follow-up to 8 years. Fourteen patients (87.5 %) returned to their preoperative activity. The Smiley-Webster scale showed an overall functional outcome score of 1.61, 1.49 for patients younger than 70 years and 1.74 for those older. Bone consolidation (solid union or fibrous union) was achieved in 13 patients (81 %); a reduction defect occurred in 2 cases. Consolidation was achieved in all the younger patients. Pseudoarthrosis developed in one older patient. There were no reinterventions or neurological lesions. Conclusion: The results obtained with surgical stabilization of type II odontoid fractures using anterior screw fixation were satisfactory in both older and younger patients, with a good cervical spine functional outcome, and 90 % satisfaction with treatment. As to morbidity and mortality, younger patients had better results.
14 EPIDEMIOLOGICAL STUDY OF BACK PAIN IN RUNNERS
253 Aims: The aims of this study were to assess the effect that running, as a sports activity, has on back pain, and to determine the prevalence of back pain in runners. Materials and Methods: The study data were obtained by providing a questionnaire to all participants in a half marathon that took place in 2012; 771 participants responded. The following variables were recorded: age, sex, BMI, years as a regular runner, number of kilometers covered in the previous week, last time running activity had to be stopped because of back pain, type of training surface used, rank in the last half marathon, and subjective opinion of the effect running has on back pain. A descriptive statistical analysis was performed on the total of participants. In those reporting back pain, the different variables were crossed with the effect running has on back pain. Finally, multivariate analysis was performed. Results: Age and sex of the 771 participants who responded were comparable to the demographics of the total; hence, the sample was considered representative. Of the 771 participants, 420 had experienced back pain (54.47 %). The patients’ subjective perception of the effect of running on back pain was improvement in 48.8 %, worsening in 27.4 %, and no impact in 23.8 %. The subjective effect of running on back pain was crossed with the remaining variables, and associations were found for age (p \ 0.001), sex (p = 0.045), and a history of previous treatment (p = 0.001). On multivariate analysis, the variable age was significantly associated with back pain, and subjects who reported an improvement were older (p = 0.018). Conclusions: 1. Approximately half the participants reported having experienced back pain. 2. Most runners with back pain, particularly those who are older, believe that running has a beneficial effect. 3. The presence of back pain in runners was not associated with the BMI, sex, ranking, kilometers covered, or the training surface. 4. We found no grounds to prohibit running in patients with back pain. Individual assessment is required.
Variables
Crossed with variable effect running has on back pain
Age
Association: the older, the Association: the older, the greater the improvement greater the improvement (p \ 0.001) (p = 0.018)
Sex
Association: more improvement in men (p = 0.045) No association
No association
Years running
No association
No association
KM covered
No association
No association
Treatment
Association: history of previous treatment significantly associated with the influence of running on back pain (p = 0.001)
No association
Stop
Association: those who reported worsening had stopped running most recently (p \ 0.001)
Association: those who reported worsening had stopped running most recently (p = 0.001)
Surface
No association
No association
Ranking
No association
No association
Center: Hospital Universitari de Bellvitge, Barcelona, Spain
Centers: 1Hospital de Friburg, Servicio de Reumatologı´a; 2Hospital Universitari de Bellvitge, Barcelona, Spain; 3IDIBELL, Servicio de estadı´stica, Barcelona, Spain
Trend: more improvement in men (p = 0.125)
BMI
Principal Author: Garreta Catala`, Iago
Additional Authors: Balague´ Gea, Federico1; Font Vila`, Frederic2; Bustos Bedoya, Paloma2; Cuadras Palleja`, Daniel3; Gonza´lez Can˜as, Lluı´s2; Pereira, David2
Multivariate analysis
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15
Center: Facultad de Medicina, Universidad de Extremadura, Me´rida, Badajoz
SURVEY REGARDING THE SKILLS OF SPECIALIZED ORTHOPEDIC SURGEONS IN EUROPE
Additional Authors: Gonza´lez Dı´az, Rafael1; Rodrı´guez Velasco, Francisco Jose´2; Gil Ferna´ndez, Guadalupe2; Losada Vin˜as, Jose´ Isaac3; Egea Ga´mez, Rosa Marı´a3
Principal Author: Nu´n˜ez Pereira, Susana Center: St. Franziskus Hospital, Ko¨ln, Germany Additional Authors: Okoro, Tosan1; Luca, Andrea2; Boszczyk, B.M.3; Sell, Philip4 1
2
Centers: Dept. Orthopaedics, Ysbyty Gwynedd, Bangor, UK; Clı´nica Ortopedica, Universita´ degli Studi di Bari, Bari, Italy; 3Centre for Spinal Studies and Surgery, Queens Medical Centre, Nottingham, UK; 4Dept. Orthopaedics, Leicester General Hospital, Leicester, UK Introduction: Spine surgery societies are implementing specialized educational programs to guarantee the quality and consistency of training in this line. However, data are lacking on the specialists’ perception of their knowledge, skills, and potential training needs. Materials and Methods: An online questionnaire was sent by e-mail to residents and specialists in orthopedic-trauma surgery (OTS) participating in the European Spine Foundation educational program, and to the members of AO Spine. The questionnaire was a modified version of the one used by the European Association of Neurosurgical Societies (EANS) to assess the theoretical and practical skills acquired during medical training. In addition to queries regarding demographic data, there were 24 questions on the participant’s theoretical and practical skills in 12 specific techniques, evaluated with a 4-item Likert scale. A descriptive analysis was performed, as well as a comparative study of the results obtained with those from neurosurgeons on the EANS questionnaire (Fischer exact test). Results: There were 205 responses (57 residents, 148 specialists). As compared to neurosurgery residents, OTS felt they had less ability to perform anterior cervical stabilization (62 % vs. 80 %, p = 0.35) and craniocervical stabilization (39 % vs 53 %, p = 0.38), and greater ability to treat deformities (61 % vs 13 %, p = 0.0021). Among the total of residents, 14 % felt they were unable to treat a lumbar disc herniation under supervision and 21.1 % felt unable to carry out conservative treatment for low back pain and sciatic pain. In the group of specialists, fewer orthopedic surgeons felt capable of treating cervical stenoses than neurosurgeons (88.3 % vs 98.5 %, p = 0.003), but a greater number considered they were able to perform posterior thoracolumbar instrumentations (98.6 % vs. 44.7 %, p \ 0.05) and treat spinal deformities (90.3 % vs. 37.9 %, p \ 0.001). There were no significant differences in the capability to perform posterior stabilization, craniocervical stabilization, tumor surgery, or surgery for degenerative lumbar spine disease. Conclusion: The knowledge obtained during the period of medical training seems insufficient in some basic areas (low back pain), and this should be rectified during the residency period. Spine surgery societies can help in correcting other deficiencies in training, taking into consideration the specialty of origin.
16 RELATIONSHIP BETWEEN THE ABSTRACTS SENT TO GEER AND THOSE ULTIMATELY ACCEPTED. IS THERE A DIFFERENCE ACCORDING TO THE CONDITION STUDIED? Principal Author: Guerrero Bonmatty, Rafael
123
Centers: 1Hospital Universitario Fundacio´n Alcorco´n, Unidad de Columna, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Madrid, Spain; 2Facultad de Medicina, Universidad de Extremadura, Me´rida, Badajoz, Spain; 3Hospital Universitario Fundacio´n Alcorco´n, Unidad de Columna, Madrid, Spain Aim: This study proposes an analysis of the abstracts (oral communications, wall posters, and electronic posters) sent to the GEER Scientific Committee, corresponding to the XX to XXVI Congress of the Society (2006–2012), with the aim of estimating the current status of research in spinal diseases and evaluating the submission and acceptance rates according to the medical condition studied or the specialty. Materials and Methods: Cross-sectional, observational, descriptive study. A total of 748 studies were presented to the Scientific Committee in the form of oral communications, wall posters, and electronic posters for the XX to XXVI GEER Congress (2006–2012). The following information related to the studies was recorded for each abstract: sent, accepted, accepted by year, by center, by condition, by affected level, type of study, and best studies competing for the prizes. Results: Of the 748 abstracts evaluated, 534 (71.4 %) were accepted. Most studies accepted by year, 2006 (N = 89) and 2011 (N = 91), and by center, H.U. de Getafe (N = 47), Ramo´n y Cajal (N = 41), Vall d’Hebro´n (N = 35), and I.U. Dexeus (N = 35). Condition predominantly accepted: deformity (Table 1); of 211 studies presented, 153 (20.7 %) were accepted. This condition was also the one most often competing for the prizes (12 studies, 5 won a prize). Nonetheless, when abstracts from the group of research studies were in the competition, one or more always won a prize (9 of 66 studies presented). The second most common condition was degenerative disease: of 159 studies presented, 98 (13.3 %) were accepted, with the lumbar region being most often the subject of the study. For cervicalthoracic-lumbar involvement (Table 2), among 311 studies, 243 (32.6 %) were accepted, and for lumbar involvement, 238 were sent and 156 accepted (20.9 %). Among the clinical studies presented, 22.6 % were retrospective (N = 130). Conclusions: The analysis showed that the groups of conditions most often presented and accepted were deformities and degenerative disease. Although it was not the aim of the present study, it would be interesting to know how many of the studies presented at the GEER congress are published in national and international medical journals, with or without an impact factor.
17 SINGLE APPROACH FOR THORACIC SPINE DISEASE. CLINICAL OUTCOME AND COMPLICATIONS Principal Author: Kahl, Guillermo Center: Sanatorio de la Trinidad Mitre, Buenos Aires, Argentina Additional Authors: Rudt, Toma´s; Zisuela, Roberto; Santi, Maximiliano; Recchia, Sebastia´n Center: Sanatorio de la Trinidad Mitre, Buenos Aires, Argentina
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255
Introduction: The costotransversectomy approach has been used for drainage of tuberculous spondylitis since the early 1900s. However, it has taken almost 60 years to extend its indication to other thoracic spine diseases. Aim: The aim of this study is to present the clinical results and complications of treatment for thoracic spine disease by a single approach. Material and Method: Retrospective study of 17 patients with spinal disease surgically treated by a circumferential technique with a single incision between 2009 and 2011. The sample included adult patients of both sexes with tumors, infectious diseases, and osteoporotic fractures of the thoracic spine. Results: An improvement in neurological status was documented in 88.2 %, whereas 11.8 % showed no changes following surgery. Mean Oswestry score was 68.80 % preoperatively and 11.2 % postoperatively. Conclusion: This technique provides absolute control of the spine and avoids the use of double or triple approaches in complex conditions, decreasing patient morbidity. Age Sex
Location Disease
Complications Oswestry Oswestry Frankel Frankel Preop
Postop
(%)
(%)
48
4
Preop
Postop
C
E
65
Fem
T6
Met breast CA
62
Fem
T8
Met lung CA
60
10
C
D
72
Fem
T7
Met thyroid CA
78
30
B
B
75
Fem
T11
Multiple myeloma
84
2
C
E
55
Male T2–T3
Spondylitis
52
2
C
E
73
Male T9
Met renal CA
78
38
B
B
70
Male T10
Met colon CA
71
Fem
T8
Met breast CA
68
Fem
T12
Met lung CA
70
12
C
E
65
Male T10– T11
Met prostate CA
82
24
B
D
74
Fem
T7–8
Met breast CA
62
8
D
E
72
Fem
T5–6
Met lung CA
58
8
C
D
59
Fem
T7–T8
Angiosarcoma Pneumothorax 82
24
B
D
67
Fem
T9
Multiple myeloma
68
8
D
E
55
Fem
T10– T11
Met breast CA
74
10
C
E
68
Fem
T7
Osteoporosis
56
Male T8
Spondylitis
Acute infection
60
4
C
E
78
18
B
C
Additional Authors: Ferraris, Luis; Meier, Oliver; Koller, Heiko Center: German Scoliosis Center Werner-Wicker-Klinik, Germany Aim and Introduction: Anterior column reconstruction in thoracolumbar burst fractures can be done by thoracotomy or by videoassisted thoracoscopic surgery (VATS). Recent studies in scoliosis patients have not reported less approach-related morbidity (ArM) with VATS than with the surgical approach. The aim of this study is to assess the differences in ArM between these two techniques in patients with thoracolumbar fractures. Materials and Methods: Over 24 months in the VATS group, patients prospectively completed questionnaires on ArM in all T12 o L1 burst fractures treated by VATS. We included patients with satisfactory reconstruction, no neurological deficits, no complications, and age from 16 to 70 years. In the thoracotomy group, patients were collected from a database of 223 thoracolumbar fractures. The same questionnaire was administered. Cases were matched according to the level of the fracture (T12/L1), age (± 5 years), sex, and follow-up (± 0 months in patients with follow-up between 6 and 24 months and a greater difference in patients with more than 24 months). Results: In the VATS group, 21 cases met the inclusion criteria; 39 patients con thoracotomy were compatible. Thirteen pairs were included, 9 of men and 4 of women. In the VATS and thoracotomy groups, mean age was 34.5 ± 10.2 and 35.5 ± 9.1 years, respectively, fused levels were 2.2 ± 0.4 and 2.1 ± 0.3, 5 and 4 patients had T12 fractures, and 8 and 9 had L1 fractures. With a follow-up of 45.8 ± 21.3 and 55.8 ± 32.6 months, the ArM was 22.2 ± 26.5 % in the VATS group and 16.4 ± 15.1 % in the thoracotomy group. The number of patients with intercostal neuralgia (INC) was 4 and 1. As to satisfaction with the surgical wound, 6 patients in the VATS group and 5 in thoracotomy were very satisfied and 7 and 8 were satisfied, respectively. There was a statistically significant relationship between the clinical result and satisfaction with the wound (p = 0.0005, r = 0.6). In this study, the presence of INC was not related with ArM or the clinical outcome. There were no significant differences between the groups with regard to ArM or the incidence of INC. Conclusion: In our series, no differences were found with regard to ArM, and therefore, we should not use it as a criterion for choosing the approach to use in anterior column reconstruction.
19 Pull-out
60
8
D
E
76
10
D
E
RADIOLOGIC RESULTS OF SHORT INSTRUMENTATION AND FUSION FOR AO TYPE C THORACOLUMBAR FRACTURES Principal Author: Fleiderman Valenzuela, Jose´
18 Center: Hospital del Trabajador, Santiago, Chile
DIFFERENCES IN SURGICAL ACCESS-RELATED MORBIDITY IN ANTERIOR COLUMN RECONSTRUCTION OF THORACOLUMBAR FRACTURES USING OPEN TECHNIQUES VERSUS VIDEO-ASSISTED THORACOSCOPIC SURGERY. RESULTS OF A PAIRED ANALYSIS IN TWO CENTERS Principal Author: Iba´n˜ez Aparicio, Natalia Center: Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
Additional Authors: Ramı´rez Pittaluga, Sergio1; Telias Neira, Alberto1; Lecaros Bahamondes, Javier2; Ilabaca Grez, Francisco1; Urzua Bacciarini, Alejandro1; Zamorano Pe´rez, Juan Jose´1; Ballesteros Plaza, Jose´ Vicente1; Yurac Barrientos, Ratko1; Lecaros Larenas, ´ ngel1; Munjin Leo´n, Milan1; Tapia Pe´rez, Carlos1 Miguel A Centers: 1Hospital del Trabajador, Santiago, Chile; 2Universidad de Los Andes, Santiago, Chile Introduction: Type C fractures of the thoracolumbar spine are unstable injuries associated with a high incidence of neurological deterioration. These injuries require stabilization by spinal instrumentation and fusion including two or more levels above and below
123
256
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the level of the lesion. Because of the better understanding of the biomechanics of the spine, more detailed and precise classification systems, and the development of new techniques for pedicle instrumentation, we can now consider short instrumentation treatments, in which only one segment above and below the injured level is fused, preserving the adjacent mobile segments. Our study will enable evaluation of the radiologic results by establishing the failure rate in short-segment instrumentation and fusion in the treatment of patients with AO type C thoracolumbar fractures. Materials and Methods: Retrospective case series study of 31 patients with AO type C thoracolumbar fractures surgically treated with short instrumentation and fusion (bi-segmental or mono-segmental). Minimal postoperative follow-up was 2 years. Patients requiring anterior fusion and those using a brace during follow-up were excluded. Instrumentation failure was established based on fracture or loosening of the osteosynthesis material, or progression of segmental kyphosis greater than 108 (using the Cobb method). Results: Mean age was 39 years. Fracture subtype was C3 in 41 % of patients, C2 in 29 %, and C1 in 30 %. The most frequent mechanism of injury was a fall from a height (48 %), followed by traffic accidents (29 %). Mean progression of segmental kyphosis in the study group was 4.58 (08-108), and only 3 patients (9.6 %) presented instrumentation failure during follow-up: 2 cases of fractured osteosynthesis material, and 1 case of segmental kyphosis progression greater than 108. Conclusion: The use of short-segment instrumentation and fusion in the treatment of type C thoracolumbar spine fractures is an adequate alternative for selected patients. The failure rate of this approach was 9.6 % in our series.
women (21.8 %), mean age 44 years (18–71 years). Patients had undergone spine surgery in our center involving instrumentation and fusion with the use of autologous bone graft and additional demineralized bone matrix. Radiologic evaluation with a minimum of 2 years’ postoperative follow-up. Fusion status was assessed by a radiologist using the Lenke fusion scale, as follows:
20
Principal Author: Baza´n Lizarraga, Pedro Luis
OUTCOME OF FUSION USING DEMINERALIZED BONE MATRIX AUGMENTATION IN THORACOLUMBAR SPINE FRACTURES
Center: Higa San Martı´n-Hospital Italiano, La Plata, Argentina
a. b. c. d.
Definitely solid masses, bilateral fusion Possibly solid unilateral masses, moderate contralateral fusion Probably not solid bilateral fusion masses Definitely not solid bilateral (bilateral graft resorption or fusion mass with obvious bilateral pseudarthrosis)
Grades A and B were considered a satisfactory radiologic outcome. Results: Case series of 78 patients; only 1 patient lost to follow-up. According to the Lenke classification, 26 patients (34.21 %) were considered grade A, 22 (28.95 %) grade B, 10 (13.16 %) grade C, and the remaining 18 patients (23.68 %) were classified as grade D at the last radiologic assessment. Satisfactory results (grades A and B) were obtained in 63.16 % of patients. There were no cases of instrumentation failure. Conclusion: A satisfactory radiologic outcome was achieved in 58.14 % of patients. Nevertheless, instrumentation failure did not occur in any patient.
21 PREDICTIVE FACTORS IN ADULT SCIWORA SYNDROME
´ lvaro Enrique; Medina, Martin Additional Authors: Borri, A Center: Higa San Martı´n-Hospital Italiano, La Plata, Argentina
Principal Author: Fleiderman Valenzuela, Jose´ Center: Hospital del Trabajador, Santiago, Chile Additional Authors: Tapia Pe´rez, Carlos1; Innocenti Dı´az, Piero1; Larrain Garces, Cristian1; Navarrete Zavala, Jose´2; Munjin Leo´n, Milan1; Urzua Bacciarini, Alejandro1; Yurac Barrientos, Ratko1; Ballesteros Plaza, Vicente1; Zamorano Pe´rez, Juan Jose´1; Ilabaca Grez, Francisco1 Center: Hospital del Trabajador, Santiago, Chile; 2Universidad de Los Andes, Santiago, Chile Introduction: Thoracolumbar spine fractures are severe injuries that require a prompt and precise diagnosis to establish adequate treatment. Conservative therapy is one option, but surgery is needed in some cases, including spinal instrumentation and fusion of the injured segment. Autologous bone graft is the reference standard to achieve spinal fusion, but it is associated with donor site complications. Demineralized bone matrix is an adequate alternative material for this purpose because of its osteoinductive and osteogenic properties. The aim of this study is to evaluate the radiologic outcome in terms of degree of bone fusion and number of instrumentation failures in patients who have undergone bone graft augmentation with demineralized bone matrix. Materials and Methods: Retrospective case series including 78 patients with thoracolumbar spine fractures, 61 men (78.2 %) and 17
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Introduction: SCIWORA syndrome in adulthood occurs in up to 15 % of spinal cord injuries. It seems most commonly related to a container-content problem that becomes decompensated following a low-energy injury. Magnetic resonance imaging (MRI) can diagnose intramedullary and extramedullary lesions. Aims: To analyze kinematics, recognize the presenting clinical picture, describe imaging findings, consider therapeutic options, and assess the evolution. Material and Method: Thirteen patients (all men) who presented SCIWORA between 2005 and 2012 were analyzed. We evaluated the clinical signs and symptoms, treatment, complications, and evolution. Results: Ten patients older than 45 years presented signs of spondyloarthrosis with mild symptoms. Among the 3 younger patients, only one presented an asymptomatic constitutional narrow spinal canal. All had sustained a low-energy trauma. MRI predominantly showed intramedullary hematoma, and clinically, all patients presented a spinal cord injury, which was severe (ASIA A-B) in those older than 45. Seven patients were initially treated with conservative management: one worsened and required surgery 18 months later, another died in the first hours, and the remaining patients had a good evolution. Six patients underwent surgery (laminoplasty) in the first 10 days; 3 died and the remaining patients improved by at least one ASIA level. Conclusions: Younger age, a less severe clinical picture, and intramedullary edema are factors associated with a good prognosis; these patients are helped by conservative treatment. Older age,
Eur Spine J (2014) 23:248–288
257
spondyloarthrosis and severe or progressive conditions carry a poor prognosis and may require surgical treatment. Table 1 Age, kinematics, and associated injuries Patient
Age
Kinematics
Associated lesions Head and chest trauma
Table 4 Evolution of Japanese Orthopedic Association (JOA) score PATIENT
6 months
1 year
2 years
3 years
4 years
Final JAO
1
14
11
12
13
13
13
2
10
12
12
12
12
12
3
15
15
16
16
16
16
4
8
Death 10
13
15
15
15
1
55
Driver without a seat belt
5
14
2
46
Driver
6
Death
3
60
Passive rotation
7
11
4
75
Driver without a seat belt
8
Death
5
53
Driver with a seat belt
9
12
14
14
14
6
84
Fall from height
10
16
16
16
16
7
63
Passive flexion–extension
11
16
16
8
63
Bicycle
12
17
17
9
65
Fall from height
13
15
15
10
20
Driver with a seat belt
11
27
Front seat passenger
12
16
Rugby
13
58
Back seat passenger
Age
Radiography
VERTEBRAL RESTORATION FOLLOWING TYPE A FRACTURE: MEDIUM-TERM FOLLOW-UP IN A PROSPECTIVE, MULTICENTER CLINICAL STUDY
MRI In tramedullary
Affected
Diameter
lesion
levels
compromise
1
55
Spondyloarthrosis
Hematoma
C4–C6
[50
2
46
Spondyloarthrosis
Edema
C5–C6
\50
3
60
Spondyloarthrosis
Edema
C5–C7
\50
4
75
Spondyloarthrosis
Hematoma
C3–C5
[50
5
53
Spondyloarthrosis
Edema
C4–C6
\50
6
84
Spondyloarthrosis
Hematoma
C3–C6
[50
7
63
Spondyloarthrosis
Hematoma
C4–C5
\50
8
63
Spondyloarthrosis
Hematoma
C3–C6
[50
9
65
Spondyloarthrosis
Hematoma
C2–C3
[50
10
20
Normal
Hematoma
C3–C4
[50
11
27
Constitutional narrow canal
Mixed
C3–C5
[50
12
16
Normal
Hematoma
C5–C6
\50
13
58
Spondyloarthrosis
Mixed
C3–C4
[50
Initial
Surgery
Asia
Principal Author: Rodrı´guez-Monsalve Milano, Fiona Center: Hospital Clı´nico Universitario de Valladolid, Spain Additional Authors: Luengos Pen˜a, Vero´nica1; Ardura Arago´n, Francisco1; Herna´ndez Ramajo, Rube´n1; Beyerlein, J.2; Hansen-Algenstaedt, N.2; Hassel, F.3; Barreau, X.4; Noriega Gonza´lez, David Ce´sar1 Centers: 1Hospital Clı´nico Universitario de Valladolid, Spain; 2University Medical Center Hamburg-Eppendorf, Germany; 3LorettoKrankenhaus, Freiburg, Germany; 4Interventional Neuroradiology Department CHU, Bordeaux, France
Table 3 Evolution of neurologic symptoms according to the ASIA scale Patient
16
22
Table 2 Imaging findings Patient
Death
6
1
2
3
4
Final
months
year
years
years
years
Asia
1
C
X
D
C
D
D
D
D
2
B
X
C
C
C
C
C
C
3
C
E
E
E
E
E
E
4
A
X
A
Death
5
D
X
D
C
D
E
E
E
6
A
7
B
X
C
8
A
X
Death
9
B
X
E
E
E
10
B
E
E
E
11
C
E
E
12
C
E
E
13
C
E
E
Death Death
E E E
Introduction: The aim is to evaluate the ability of minimally invasive surgery with a titanium implant associated with high-viscosity cement to control the clinical symptoms in treatment for vertebral compression fractures. Materials and Methods: Prospective, multicenter study, performed in 4 European hospitals, including 28 patients (26 women, 2 men), mean age 70.2 years (SD = 10.7). There were 22 osteoporotic fractures and 6 traumatic fractures. Data recorded included VAS, ODI and quality of life (EQ-5D) scores, analgesic use, and radiologic parameters. Values were collected preoperatively, in the immediate postoperative period, and at 6 and 12 months postoperatively. Cement leaks were analyzed by CT. Results: The group of patients followed-up to 12 months (n = 21) presented a mean VAS reduction of 6 points, from 7.2 (SD = 2.5) to 1.2 (SD = 1.9). The ODI decreased from 68 % preoperatively to 8.6 % at one year. On the EQ-5D quality of life questionnaire, the preoperative value of 35.2 increased to 76.9 at one year. The percentage of patients who required analgesics dropped from 63.6 % at the preoperative assessment to 9.0 % at one year. The changes in the clinical parameters were statistically significant (p \ 0.001). The cement leak rate was 28.6 %, and all cases were asymptomatic. CT diagnosed 50 % of leaks. Adverse events: none of the events occurring during follow-up (2 deaths, 1 degenerative lumbar syndrome, diaphragmatic paralysis, 1 hypophyseal adenoma, 1 blood pressure disorder, 1 cerebral infarction) were related to the implant or the procedure.
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258 Discussion and Conclusions: The clinical status was significantly better during follow-up and remained stable. The cement leak rate of 28.6 % was comparable to the 27 % reported in the FREE study, with the consideration that being assessed by CT, there was a correction factor of 1.5 with respect to plain radiography studies.
Eur Spine J (2014) 23:248–288 cement (e.g., vertebroplasty). Most leaks were asymptomatic. This study shows that use of cement-augmented screws does not imply associated comorbidity.
24
DOES CEMENT USE TO REINFORCE PEDICLE SCREWS POSE AN ADDITIONAL RISK?
IS THERE A RELIABLE CUT-OFF AGE TO DIFFERENTIATE BETWEEN HEALTHY AND NON-HEALTHY SUBJECTS INCLUDED IN AN ADULT SCOLIOSIS REGISTRY?
´ ngel Ramo´n Principal Author: Pin˜era Parrilla, A
Principal Author: Bago´ Granell, Juan
Center: Fundacio´n Jime´nez Dı´az, Madrid, Spain
Center: Hospital Universitari Vall d’Hebro´n, Barcelona, Spain
Additional Authors: Tome´ Bermejo, Fe´lix; Lo´pez San Roma´n, Bele´n; ´ lvarez, Carmen; Vlad, Marı´a Daniela; A ´ lvarez Galovich, Dura´n A Luis
Additional Authors: Domingo Sabat, Montse1; Pellise´ Urquiza, Ferra´n2; Sa´nchez Pe´rez-Grueso, Fco. Javier3; Vila Casademunt, Alba1; Alanay, Ahmed4; Acaroglu, Emre5
Center: Fundacio´n Jime´nez Dı´az, Madrid, Spain
Centers: 1Institut de Recerca Vall d’Hebro´n, Barcelona, Spain; 2 Hospital Universitari Vall d’Hebro´n, Barcelona, Spain; 3Hospital Universitario La Paz, Madrid, Spain; 4Acibadem Maslak Hospital, Istanbul, Turkey; 5Ankara Spine Center, Ankara, Turkey
23
Aim and Introduction: Pedicle instrumentation in patients with osteoporosis may pose problems related to safety and anchorage strength. Some reports have shown that reinforcing the bone around the screw with PMMA cement is the best method to avoid pullout/cutout problems. Its use has been limited by concerns that it may increase morbidity. To date, there are no studies demonstrating the clinical safety of this instrumentation. The aim of this study is to analyze the potential morbidity of this type of instrumentation. Materials and Methods: Retrospective analysis of 225 consecutive patients treated with cement-augmented cannulated pedicle screws. Indication for instrumentation: degenerative disease (168 cases), fracture (37 cases), deformity (18 cases), tumor (2 cases). The presence of cement leaks, leak-related clinical complications, infection, implant loosening and failure, and extraction difficulties in case of instrumentation revision were analyzed. Cement leaks were detected and classified by CT (epidural, lateral plexus, disc, extravertebral and foraminal). Mean age of patients was 73.7 years. Mean follow-up was 31.8 months. Results: A total of 598 vertebrae were instrumented with 1134 cement-augmented screws. Some type of cement leak occurred in 53.5 % of vertebrae. In 4 vertebrae (0.67 %), cement leaked to the canal, with no clinical repercussions in any case. Four patients (1.7 %) presented radicular pain, which was always associated with a leak to the S1 foramen. Twenty patients (8.8 %) presented a deep infection that required wound revision; removal of the material was not necessary in any case. Thirty patients (13.3 %) needed revision surgery: 20 of the adjacent segment (8.8 %), and 10 cases of pseudoarthrosis (4.4 %). Despite cement augmentation, none of the 103 screws requiring replacement caused any difficulty at removal. Pseudoarthrosis developed in long instrumentations, and in 6 cases, rod breakage occurred without screw loosening. Conclusion: Cement-augmented pedicle screws are a safe instrumentation option in patients with osteoporosis. The cement leak rate is much lower than the rates described in other techniques using
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Adult scoliosis (AS) databases usually include individuals older than 18 years, and all subjects are considered useful for analyzing the effect of interventions in this population. Nonetheless, it is known that the quality of life of many individuals with scoliosis is not significantly different from that of the non-scoliotic population. Aim: To determine whether there is a cut-off age that enables separation of healthy persons with EA from non-healthy ones based on distribution of the SF-36 and SRS-22 questionnaires in the normal population. Material: Patients incorporated in a multicenter AS database. The study included women older than 18 years diagnosed with idiopathic or degenerative scoliosis, who had not received surgical treatment. Patients below the 25th percentile of SF-36 or the 20th percentile of SRS-22 were assigned to the Non-healthy group and the remaining patients to the Healthy group. Method: An analysis of ROC curves was performed, and the area under the curve (AUC), sensitivity, and specificity were determined. Results: A total of 174 women (mean age 44.5 y, mean Cobb angle 51.28) were analyzed. The percentage of Non-healthy individuals was 48.8 % in the SF-36 mental component summary (MCS) and 57.4 % in the physical component summary (PCS). For the SRS-22, the percentage of Non-healthy subjects was 58.6 % in Function, 78.7 % in Pain, 85.1 % in Self-image, 71.8 % in Mental health, and 79.3 % for the subtotal. In SF-36, the best predictive values were for PCS (age 42, AUC 0.78), Physical function (age 42, AUC 0.77) and Physical role (age 41, AUC 0.81). In SRS-22, the most robust values were in Function (age 46, AUC 0.77) and Pain (age 44, AUC 0.75). Of note, significance was lacking in the cut-offs for the Mental health and Self-image scales. Conclusions: An age of 40 years is a reliable cut-off for classifying individuals with AS when the analysis is focussed on pain and/or
Eur Spine J (2014) 23:248–288
259
function. A reliable cut-off was not found for assessing mental health or self-image.
26 EFFECT OF NON-FUSION TECHNIQUES ON VERTEBRAL ROTATION AND THE RIB CAGE IN EARLY-ONSET SCOLIOSIS
25 COMPARATIVE STUDY OF THE SENSITIVITY TO CHANGE OF TAPS VERSUS SRS-22 FOLLOWING SURGERY FOR IDIOPATHIC SCOLIOSIS AND RELATIONSHIPS WITH THE PERCENTAGE OF CURVE CORRECTION Principal Author: Bago´ Granell, Juan
Principal Author: Pe´rez Martı´n-Buitrago, Mar Center: Hospital Universitario La Paz, Madrid,Spain Additional Authors: Sa´nchez Pe´rez-Grueso, Francisco J.; Sa´nchez Ma´rquez, Jose´ Miguel; Garcı´a Ferna´ndez, Alfredo; Ferna´ndez-Baillo, Nicomedes; Quinta´ns Rodrı´guez, Jose´ Center: Hospital Universitario La Paz, Madrid, Spain
Center: Hospital Universitari Vall d’Hebro´n, Barcelona, Spain Additional Authors: Sa´nchez Pe´rez-Grueso, Fco. Javier1; Sa´nchez Raya, Judith2; Les, Esther2; Pe´rez Buitrago, Mar1; Vila Casademunt, Alba2; Pellise´ Urquiza, Ferra´n2 Centers: 1Hospital Universitario La Paz, Madrid, Spain; 2Hospital Universitari Vall d’Hebro´n, Barcelona, Spain There is a lack of correlation between the magnitude of change in SRS-22 scores and the percentage of scoliosis correction following instrumented vertebral fusion. Aim: To compare the sensitivity to change of the SRS-22 questionnaire and the TAPS scale and correlations between the magnitude of the change and the scoliotic curve. Material and Method: The study included 73 patients (62 females) who underwent surgery for idiopathic scoliosis. Mean age at the time of surgery was 16.9 years. In all cases, a complete radiography study, and SRS-22 and TAPS scores were available preoperatively and at the follow-up visit (mean duration of follow-up, 23.5 months). Results: Mean magnitude of the major curve was 63.88 preoperatively and 27.48 at follow-up (mean correction 56.5 %). The table shows mean preoperative and follow-up values as well as the effect size (Glass delta) of the radiologic magnitude of the major curve and the mean scores on the TAPS and SRS-22 questionnaires. All differences between preoperative and follow-up values were statistically significant (Student t test 2.6-25, p \ 0.05). The correlation between percentage of scoliosis correction and improvement on the SRS-22 Self-image score was not significant, whereas the correlation with improvement on the TAPS scale was statistically significant (r = 0.3, p = 0.009). Conclusions: The TAPS scale was more sensitive to change than the SRS-22, specifically the Self-image subscale. The improvement in the TAPS score after surgical treatment correlated with the percentage of scoliosis correction.
Preop
Follow-up
Glass D
Cobb
63.8
27.4
2.52
TAPS Self-image
2.55 2.94
4.24 4.02
1.94 1.42
Non-fusion techniques to treat early-onset scoliosis (EOS) have proven effective for controlling the angular deformity, and additionally, provide a gain in vertebral height close to physiological parameters. Nonetheless, there is little information regarding their effect in controlling vertebral rotation and its repercussions on the rib hump. One hypothesis has proposed that these instrumentations act as a posterior tether and could aggravate the rotational deformity. Aim: To evaluate whether these techniques avert progression of vertebral rotation and the rib deformity. Material and Method: Retrospective review of prospectively recorded preoperative, and immediate and late postoperative data in a series of patients with EOS treated by non-fusion techniques and fulfilling the following requisites: idiopathic pattern of curves treated with growing rods or VEPTR and two years of follow-up. Exclusion criteria: congenital cause, dysplasia, neuromuscular. Radiologic Data: (1) vertebral: coronal and sagittal Cobb. (2) rotation: RVAD (Mehta). Convex apical rib spread (ARS). Space available for the lung (SAL) in convexity. Clinical Data: Rib hump (scoliometer). Trunk imbalance. Statistical analysis used the Mann–Whitney and Wilcoxon tests, and ANOVA. Results: Eighteen of 43 patients met the inclusion criteria. Initial mean age 6 +7 years and follow-up of 4 years. Analysis of the results (Table) confirmed a maintained improvement in Cobb angle, but not in the vertebral rotation values and their effect on the ribs. There was a significant increase in RVAD (Metha) (p \ 0.05) between the postoperative and follow-up. The rib hump improved significantly following surgery (p \ 0.05), but relapsed to preoperative values during follow-up (p \ 0.05). The ARS showed no significant differences over time except for left curves, where there was significant narrowing (p \ 0.05) at the thoracic convexity. The vertical diameter of the convex hemithorax (SAL) increased with time, without being affected by the rotational component. Conclusions: Non-fusion techniques for EOS do not seem to avert the rotational deformity and its aesthetic impact. Studies with longer follow-up at a more collaborative age would enable analysis of the repercussions on respiratory function.
27
SRS 22 subtotal
3.73
4.26
0.86
Pain
3.87
4.42
0.57
Function
4.18
4.43
0.36
Mental health
3.94
4.16
0.3
WHAT IS THE CLINICAL VALUE OF SAGITTAL RADIOGRAPHIC PARAMETERS IN [408 SCOLIOSIS IN ADULTS [40 YEARS OF AGE? Principal Author: Rodrı´guez Lo´pez, Tamara Center: Hospital Universitario de Getafe, Madrid, Spain
123
260
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Additional Authors: Nu´n˜ez Garcı´a, Ana; Sa´nchez-Mariscal Dı´az, ´ lvarez Gonza´lez, Patricia; Zu´n˜iga Felisa; Go´mez Rice, Alejandro; A Go´mez, Lorenzo; Pizones Arce, Javier; Izquierdo Nu´n˜ez, Enrique
continued
Center: Hospital Universitario de Getafe, Madrid, Spain Aim and Introduction: • The sagittal plane is gaining increasingly greater interest in adult deformity. It is considered that a positive sagittal balance (SB), increased pelvic tilt (PT), and decreased lumbar lordosis are prognostic factors of a poor outcome in adult scoliosis (AS). • The question is: In patients older than 40 (degenerative changes expected) with predominantly frontal spinal deformity (Schwab 2012, type NON), what are the sagittal parameters for? Materials and Methods: • Forty patients (35 women) 55 years old (41–74) at the time of surgery. Scoliosis [ 408 (idiopathic 28, degenerative 12). Mean postoperative follow-up 7.4 years. • Updated radiographic studies, and SRS-22 and SF-36 questionnaires. Patients were asked if they felt it was worthwhile to have undergone surgery. • We evaluated: thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), LL, SB, spinal sacral angle (SSA), spinal tilt (ST), sagittal pelvic parameters, pelvic incidence/lumbar lordosis mismatch (PILL), necessary lumbar lordosis (ideal-real), and major frontal Cobb curve. Results: (1) Preoperatively (Table) we observed an elevated TLK (13.88), pelvic retroversion at the upper limit (20.98), and loss of LL (LL = 488 and necessary lordosis = 148); (2) In the postoperative follow-up, there was a statistically significant change (Table) in some radiographic parameters, but it was toward a worsening in the sagittal plane (except TLK); (3) Was it worthwhile to operate?: 82.5 % yes; 10 % no; 7.5 % not sure. (4) At final follow-up, there was a significant correlation (Pearson coefficient) between the SRS activity subscale and ST (p = 0.001; r = 0.54), PT (p = 0.008; r = -0.42), and PI-LL (p = 0.047 r = -0.32). Following multiple linear regression analysis, only ST remained as a possible predictor of poorer results on the SRS-22 Activity scale. There were also other, less significant, correlations. • Conclusions: In AS, some sagittal parameters show preoperative changes, but we cannot say that they serve to indicate surgery because they worsen over follow-up; nonetheless, the patient is satisfied with the outcome of the procedure. • The only sagittal parameter that correlated with SRS-22 Activity during follow-up was ST. • The sagittal plane does not seem to have an evident prognostic role when the main deformity is frontal.
Preoperative
Final
p
43.2 ± 19.4
44.9 ± 16.6
NS
TLK, 8
13.8 ± 15.06
7.04 ± 10.8
0.023
LL, 8
48 ± 18.7
42.8 ± 13.6
0.045 0.003
TK, 8
SB, cm
1.5 ± 4
4.8 ± 6.8
T1 inclination, 8
-5 ± 4.4
-2.8 ± 6.2
0.016
Pelvic incidence (PI), 8
56 ± 11.6
57.5 ± 11
NS 0.018
Sacral slope (SS), 8
34.6 ± 12.3
28.9 ± 9.1
Pelvic tilt (PT), 8
20.9 ± 10.9
30.78 ± 11.8
0.000
SSA, 8
123.2 ± 11.1
117.3 ± 12.6
0.005
123
Preoperative
Final
p
ST, 8
91.2 ± 5.1
89.4 ± 7.3
NS
PI-LL mismatch, 8
7.2 ± 20.3
14.5 ± 18.5
0.008
Necessary lordosis, 8
14. 1 ± 18.5
20.6 ± 15.4
0.14
Frontal Cobb, 8
59.2 (38–120)
28.9 (4–80)
0.000
28 IMPACT OF PELVIC PARAMETERS ON THE DEVELOPMENT OF PROXIMAL JUNCTIONAL KYPHOSIS AND INFLUENCE OF THE UPPER LIMIT OF THE MEASURE Principal Author: Sacramento Domı´nguez, Ma Cristina Center: Hospital Ruber Internacional, Madrid, Spain ´ lvarez Sala-Walther, Fernando1; Areta Jime´Additional Authors: A nez, Francisco Javier1; Berna´cer Lo´pez, Jose´ Luis1; Castrillo Amores, ´ ngel1; Cobo Soriano, Javier1; Jime´nez Sosa, Alejandro2 Miguel A Centers: 1Hospital Ruber Internacional, Madrid, Spain; 2Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain Introduction: Anterior sagittal imbalance of the vertebral segments above a fusion is a major long-term complication of long spinal fusions. The aim of this study is to determine the influence of spinopelvic parameters on the development of this complication and the impact of the upper limit of the Cobb angle on measurement of the proximal junctional kyphosis. Materials and Methods: The study included 24 patients who underwent surgery for scoliosis and kyphosis using posterior instrumentation with pedicle screws between 2005 and 2011. We measured sagittal balance, pelvic incidence, and sacral and pelvic inclination. To measure the proximal junctional kyphosis, we first used the standard Cobb angle, from the inferior plate of the upper last instrumented vertebra to the superior plate of the second vertebra above. We then measured proximal kyphosis at a somewhat more distant area, three levels above the upper last instrumented vertebra. Digital radiography was used for the preoperative evaluation and at completion of follow-up to determine the parameters evaluated. The statistical analysis was performed with the means of the quantitative variables, and correlations were determined with the Spearman Rho test. Results: Demographic characteristics as follows: age, 43.29 ± 23.11; females, 19; diagnosis scoliosis/kyphosis, 18/6; fusion levels, 10.41 ± 1.74. Conclusions: The analysis showed that a smaller preoperative pelvic incidence correlates with the development of greater proximal junctional kyphosis at completion of follow-up (Rho = -0.391 P = 0.032 and Rho = -0.528 P = 0.007), and that measurement of the proximal junctional kyphosis angle at an area farther from the upper last instrumented vertebra is a more valid instrument for evaluating the positive influence of anterior sagittal imbalance on the development of greater proximal junctional kyphosis (Rho = 0.362, P = 0.045).
Eur Spine J (2014) 23:248–288
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Spinopelvic parameters Preoperative Sacral inclination
35.94 ± 11.82
Pelvic inclination
20.60 ± 10.89
Pelvic incidence
55.22 ± 13.9
Sagittal balance
24.04 ± 79.94
End follow-up Sacral inclination
35.75 ± 9.44
Pelvic inclination
21.99 ± 10.79
Pelvic incidence
57.69 ± 13.27
Sagittal balance
-2.79 ± 58.02
Proximal junctional kyphosis (PJK) angle Preoperative Standard (2 levels above)
5.58 ± 7.73
Distant (3 levels above)
7.41 ± 11.04
End follow-up Standard (2 levels above) Distant (3 levels above)
14.67 ± 9.55 16.88 ± 9.50
End follow- Preoperative End follow-up Preoperative up PJK sagittal balance sagittal pelvic incidence balance Distant PJK Rho = 0.362, P = 0.045 Standard Rho = 0.236, PJK P = 0.395
Rho = 0.353, P = 0.049 Rho = 0.193, P = 0.195
Rho = -0.391, P = 0.032 Rho = -0.528, P = 0.007
retrolisthesis), LF surgery-related factors (number of levels, ending in L5 or S1, screw length, laminectomies), and factors related to spinopelvic parameters following LF (PI, SS, LL, L4–S1 angle, L4– L5 angle, L2–L4 angle, disc height ratios, L4–L5/LL ratio and SS/PI ratio). Variables in the two groups were compared (Student t for quantitative, Chi square for categorical), and the odds ratio (OR) was estimated as a measure of association. Results: Mean follow-up was 67.46 months (SD 3.7) in controls and 57.92 months (SD 46.3) in cases to the development of SASD. Patient-related RFs did not differ between cases and controls. Facet inclination was greater in cases (p = 0.039; dif. means 7.758, 95 %CI 1.38-14.138, if [458 p = 0.013; OR = 2.205) and previous disc disease was more frequent in this group (p = 0.013). RFs identified included finalizing LF in a level other than S1 (p \ 0.05; OR = 1.39), presence of long screws (p = 0.001; OR = 2.023), and adjacent laminectomy (p = 0.005; OR = 1.57). PI was similar between groups, but cases showed a smaller SS (p = 0.004; dif. means -6.258, 95 % CI -10.428 to -2.028), LL (p = 0.001; dif. means -11.188, 95 % CI -17.368 to -5.058), L4–S1 angle (p = 0.018; dif. means -6.28, 95 % CI -11.38 to -1.48), L4–L5 angle (p = 0.001; dif. means -10.548, 95 % CI -14.88 to -6.288), L4–L5/LL ratio \0.33 (p = 0.000; OR = 3.59), and SS/PI ratio \0.5 (p = 0.005; OR = 8.615). Sixty percent of SASDs occurred in \45 months following LF. These cases were older (p \ 0.001; dif. means 21.2 months, 95 % CI 27–14 months), facet inclination was [458 (p = 0.007; OR = 3.055), and there was a larger number of multilevel LFs (p = 0.004; OR = 2.75) than in the remaining SASD cases. Conclusions: The RFs identified for the development of SASD included aspects related to the degenerative disease, the surgery, and unfavorable spinopelvic parameters. Exposure to these last RFs showed a greater association with the development of SASD.
30 29 RISK FACTORS FOR THE DEVELOPMENT OF SYMPTOMATIC ADJACENT SEGMENT DISEASE IN LUMBAR FUSION
DIAGNOSTIC ERROR IN DURAL LESIONS IN DEGENERATIVE LUMBAR SPINE DISEASE: MANAGEMENT AND TREATMENT Principal Author: Sirna, Pablo Mario
Principal Author: Herna´ndez Ferna´ndez, Alberto
Center: Instituto Dupuytren-Casa Hospital San Juan de Dios, Buenos Aires, Argentina
Center: Hospital Universitario Donostia, San Sebastia´n, Spain
Additional Authors: Sisi, Tamara1; Bernasconi, Juan Pablo2; Seltzer, German1; Rudt, Toma´s3; Ramı´rez, Gustavo Valentı´n4
Additional Authors: Gabarain Morcillo, Imanol1; Case Martı´nez, Jose´1; Lersundi Artamendi, Ana1; Abdul-Sayed Valdeolmillos1, Amal; Iza Beldarrain, Jon1; Villanueva Leal, Carlos2 Centers: 1Hospital Universitario Donostia, San Sebastia´n, Spain; 2 Clı´nica del Pilar, Barcelona, Spain Aims: To identify risk factors (RF) for the development of symptomatic adjacent segment disease (SASD) in lumbar spine fusion (LF) and estimate the degree of association between RF exposure and development of SASD. Materials and Methods: Case–control study: 39 cases surgically treated for SASD (2010-2012) and 28 controls undergoing surgical LF (2006–2007) without developing SASD. We studied potential patient-related RFs (age, sex, ASA, weight, smoking habit, rheumatic diseases), factors related to the degenerative disease before LF (adjacent disc disease, facet arthrosis, facet inclination, and
Centers: 1Instituto Dupuytren, Buenos Aires, Argentina; 2Instituto Dupuytren-Sanatorio Sarmiento, Buenos Aires, Argentina; 3Sanatorio Mitre- Instituto Dupuytren, Buenos Aires, Argentina; 4Instituto Dupuytren-Casa Hospital San Juan de Dios, Buenos Aires, Argentina Aim and Introduction: Intraoperative dural sac lesions are not uncommon. Nonetheless, those that go unnoticed during the primary surgery and those that are diagnosed at a later time point have not been fully described. Materials and Methods: This is a retrospective, descriptive, multicenter study including 3860 patients who underwent degenerative lumbar spine surgery between January 2006 and January 2012, and presented fistulas and/or CSF collections that were diagnosed at least 2 weeks following the procedure. Results: Among the 3860 surgically treated patients, 7 received a late diagnosis of a fistula and/or CSF collection, accounting for 0.18 %, of
123
262 the sample. The most common clinical presentation was an unstable wound: 4 cases (57.14 %). Two patients (28.58 %) presented a CSF fistula that was interpreted as a secretion. Of the 7 patients, 4 (57.14 %) were treated by placing them in the Trendelenburg position. This measure failed in 100 % of cases. With regard to surgical treatment of the fistula or dural lesion, examination of the laminectomized area and sealing with biological glue was carried out in 6 cases (85.72 %). Success was obtained in only 1 case (16.66 %), a patient who had undergone simple discectomy. The fistula was not visualized intraoperatively in any case. In the 5 cases of sealant failure, 2 patients (40 %) were reoperated 3 times and 3 patients (60 %) 2 times. The 2 patients requiring 3 surgeries were the ones in whom there was an erroneous interpretation of contaminated secretion and CSF fistula was not suspected. In all cases, the definitive treatment was drainage to the exterior. CSF culture was negative in all cases. Conclusions: In our experience, an accurate diagnosis of late fistula is provided by (1) clinical suspicion (unstable wound), (2) physical– chemical examination of the fluid or secretion, and (3) gadoliniumenhanced MRI. Based on the results of this series, treatment should consist in drainage from the dural sac to the exterior.
Eur Spine J (2014) 23:248–288 p = 0.056, respectively). Satisfaction with surgery was similar in the 2 groups (76.2 % and 72.4 %, respectively, p = 0.3956). Although the complication rate was higher in group I, this factor did not seem to have an impact on the functional outcome. Conclusion: This study demonstrates that the benefit patients older than 75 years can obtain from lumbar spine fusion is comparable to that of younger patients. Hence, age in itself should not be considered an absolute contraindication.
32 EFFECT OF LUMBOSACRAL INSTRUMENTATION AND OBSERVER EXPERIENCE IN THE MEASUREMENT OF PELVIC PARAMETERS Principal Author: Vila Casademunt, Alba Center: Hospital Universitari Vall d’Hebro´n, Barcelona, Spain
31 LUMBAR FUSION IN PATIENTS OLDER THAN 75 YEARS. IS IT WORTHWHILE? STUDY INVESTIGATING THE IMPROVEMENT IN QUALITY OF LIFE COMPARED TO YOUNGER PATIENTS Principal Author: Tome´ Bermejo, Fe´lix Center: Fundacio´n Jime´nez Dı´az, Madrid, Spain ´ ngel R.; Dura´n A ´ lvarez, CarAdditional Authors: Pin˜era Parrilla, A men; Lo´pez San Roma´n, Bele´n; Vlad, Marı´a Daniela; Mahillo ´ lvarez Galovich, Luis Ferna´ndez, Ignacio; A Center: Fundacio´n Jime´nez Dı´az, Madrid, Spain Aim and Introduction: Despite the prevalence of back problems in elderly patients, most related studies focus on investigating the complications. Our aim is to analyze the improvements in function and quality of life obtained in this population following treatment with lumbar spine fusion and compare the results with those obtained in a younger patient group. Materials and Methods: This is a retrospective study in 194 consecutive patients treated by lumbar fusion of 1 or 2 segments, with more than one year of follow-up. Patients were divided into 2 groups: I, 67 patients older than 75 years and II, 127 patients younger than 65 years. We analyzed the changes on the visual analog scale (VAS), Oswestry Disability Index (ODI) and Core Outcome Measure Index (COMI), as well as the clinical complications and radiologic results. Functional results were analyzed based on the mean increase and the percentage of patients reaching the threshold of a clinically significant difference. Results: The mean age was 77.8 years (75–86) in group I and 47 years (24–65) in group II. A clinically significant improvement was found in all functional parameters at 6 months and 1 year in the 2 groups. The mean ODI improvement was 31.6 points in group I and 30 points in group II. For COMI items 2 and 3, elderly patients presented a greater improvement than younger ones (p \ 0.001 and
123
Additional Authors: Pellise´ Urquiza, Ferra´n1; Acaroglu, Emre2; Sa´nchez Pe´rez-Grueso, Francisco J.3; Pe´rez Buitrago, Mar3; Sanli, Tunay4; Yakici, Sule2; Garcı´a de Frutos, Ana1; Matamalas Adrover, Antonia1; Sa´nchez Ma´rquez, Jose´ Miguel3; Obeid, Ibrahim5; Bago´ Granell, Joan1; European Spine Study Group ESSG1 Centers: 1Hospital Universitari Vall d’Hebro´n, Barcelona, Spain; 2 Ankara Spine Center, Istanbul, Turkey; 3Hospital Universitario La Paz, Madrid, Spain; 4Florence Nightingale Hospital, Istanbul, Turkey; 5 Hospital Pellegrin, Burdeos, France Measurement of pelvic parameters (PPs) is necessary to determine the surgical strategy. Instrumented flatback is a common cause of sagittal imbalance. The reliability of PP measurement has never been evaluated in the instrumented lumbosacral spine. Aims: To analyze the reliability of PP measurement using the new computerized tool recommended by the Scoliosis Research Society (SurgimapSpine). To compare the reliability of measurement between instrumented and non-instrumented patients and between professionals with various levels of experience in the measurement technique. To compare the results obtained with published findings. Materials and Methods: Sixty-three full-spine standing radiographs, 31 of them with lumbosacral instrumentation were measured twice by 13 observers. The observers were divided into three levels of experience: high (4 investigators), intermediate (5 senior surgeons), and low (4 junior surgeons). Previously, the investigators trained all the surgeons in handling of the software during a maximum of 30 min, using a series of practice cases. The parameters analyzed included pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). The statistical analysis to estimate reliability used the intraclass correlation coefficient (ICC, 95 %CI) and the standard error of measurement (SEM). Results: Thirteen observers and 63 radiographs generated 817 observations (2 system losses). The overall interobserver and intraobserver reliability was excellent (ICC [ 0.85) (Table). Lumbosacral instrumentation did not change the intraobserver reliability, but it significantly reduced the interobserver reliability for PT (p = 0.006) (ICC 0.92, SEM 2.28) and SS (p = 0.007) (ICC 0.77, SEM 4.48) measurement. Experience did not change intraobserver reliability. However, interobserver reliability was lower in the group of experts (p \ 0.05) than in those with intermediate or low experience. Conclusions: The reliability of PP measurement using SurgimapSpine is equal to or better than reported reliability values.
Eur Spine J (2014) 23:248–288
263
Lumbosacral instrumentation decreased interobserver reliability from excellent to moderate in the sacral slope measurement. Less experienced observers can reliably measure PPs following a simple training session.
ICC (95 % CI)
PI
PT
SS
Interobserver (overall)
0.86 (0.81–0.90)
0.95 (0.93–0.96)
0.86 (0.81–0.90)
Intraobserver (overall)
0.89 (0.83–0.93)
0.99 (0.98–0.99)
0.90 (0.84–0.93)
Interobserver (not Instrumented)
0.87 (0.81–0.92)
0.97 (0.95–0.98)
0.90 (0.84–0.93)
Interobserver (instrumented)
0.83 (0.75–0.89)
0.92 (0.88–0.95)
0.77 (0.66–0.85)
Intraobserver (not Instrumented)
0.88 (0.78–0.94)
0.99 (0.98–0.99)
0.89 (0.79–0.94)
Intraobserver (instrumented)
0.89 (0.80–0.94)
0.99 (0.98–0.99)
0.88 (0.79–0.94)
33 RELATIONSHIP BETWEEN SPINOPELVIC PARAMETERS AND LUMBAR SPINE DISEASE ON MRI IN WORKING-AGE PATIENTS Principal Author: Vila` Canet, Gemma Center: Institut Universitari Dexeus, Barcelona, Spain Additional Authors: Ubierna Garce´s, Ma Teresa; Garcı´a de Frutos Ana; Salo´ Bru, Guillem; Arias Baile, Ainhoa; Ca´ceres Palou, Enric Center: Institut Universitari Dexeus, Barcelona, Spain Aim and Introduction: Some authors have described a certain relationship of lumbar lordosis and/or sagittal balance with lumbar spine pathologies. Our aim was to determine whether there is any relationship between the spinopelvic parameters of patients with lumbar and/or radicular pain and their disease according to MRI findings. Materials and Methods: Prospective observational study including 191 consecutive patients consulting for the first time in our center, and manifesting lumbar and/or radicular pain of at least 2 months’ duration. We recorded epidemiologic data (age, sex, work activity, sports activity) and pain location (lumbar and/or radicular). All patients underwent measurements in the full-spine lateral view and MRI study of the lumbar spine. The radiographic measurements included lumbar lordosis, sagittal balance (positive, negative, neutral), sacral slope, pelvic incidence, and lumbar morphotype according to Roussouly. MR findings were divided into 7 groups: normal, mild disc disease at one level, disc disease at one level with MODIC changes, disc herniation, multiple disc disease, canal stenosis, and isthmic or degenerative spondylolisthesis Results: Among a total of 191 patients (85 men, 106 women) with a mean age of 45 years (18–66), 66 % manifested lumbar pain and 44 % radicular pain. Mean lumbar lordosis was 558 (188–818), pelvic incidence 528 (288–788), and sacral slope 358 (148–518); 49 % had negative sagittal balance and 45 % neutral. Roussouly types 2 (45 %) and 3 (39 %) predominated. The predominant MRI findings were multiple disc disease, disc herniation, and disc disease at one level with MODIC changes. There was no statistically significant relationship of MRI findings with the type of sagittal balance, pelvic
incidence values, or Roussouly morphotype. There was a non-significant trend to greater radicular pain in patients with higher pelvic incidence values. Conclusions: Sagittal balance with a predominance of neutral and negative cases concurs with the literature in healthy patients at least 40 years old. We found no relationships between the spinopelvic parameters in our patient sample and specific lumbar disease according to MR findings.
34 INTRAOPERATIVE NEUROPHYSIOLOGICAL MONITORING IN SPINAL CORD INJURY. EXPERIMENTAL STUDY Principal Author: Cervera, Javier Center: Hospital Virgen de la Salud, Toledo, Spain Additional Authors: Burgos Flores, Jesu´s1; De Blas Beorlegui, Gema1; Caban˜es Martı´nez, Lidia1; Hevia Sierra, Eduardo2; Barrios Pitarque, Carlos3; Correa Gorospe, Carlos1; Sanpera Trigueros, Ignacio4; Barriga Martı´n, Andre´s5; Collazos Castro, Jorge5 Centers: 1Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 2 Hospital La Fraternidad, Madrid, Spain; 3Universidad Cato´lica de Valencia, Spain; 4Hospital Son Espases, Palma de Mallorca, Spain; 5 Hospital Nacional de Paraple´jicos de Toledo, Spain Aim and Introduction: Patients with spinal cord injury often require urgent surgical treatment. Surgery without intraoperative neurophysiological monitoring in these patients may lead to additional cord lesions or aggravate the previous injury. The aim of this study is to experimentally ascertain the reliability of intraoperative neurophysiological monitoring in spinal cord injury. Materials and Methods: Three groups of 5 industrial pigs were studied: In Group 1 (n = 3), using a posterior approach and laminectomies, the dural sac was exposed at T4–T5 and sublaminar epidural catheters were placed cranially and caudally. Progressive cord compression at T5 was carried out using an adjustable compression device with two parallel rods placed on both sides of the cord. The spinal cord was compressed at a rate of 0.5 mm every 2 min. Animals were electrophysiologically monitored using cord– cord evoked potentials with proximal stimulation and distal recording, until complete disappearance of potentials. In Group 2 (n = 3), the same approach was used at the T12–T13 level, with compression at T12. In Group 3 (n = 5), the spinal cord was exposed at T4–T5, T8, and T12–T13. Catheters were placed cranially and caudally at both T4–T5 and T13–T12. The cord was sectioned at T8, and compression was applied at T5 and T12 using the same technique. Results: In Group 1 (mean cord diameter 7.1 ± 0.3 mm), complete disappearance of potentials occurred at 4.6 ± 1.2 mm of cord compression. In Group 2 (mean cord diameter 7.6 ± 0.5 mm), potentials disappeared at 4.8 ± 0.4 mm of compression. In Group 3, in which the cord was sectioned, loss of potentials occurred after 5 ± 0.8 mm of compression, but at T12, only 3.1 ± 0.7 mm of compression was required. Conclusions: Neurophysiological monitoring of the spinal cord above and below the lesion is feasible in patients with acute cord injury. This study shows that the spinal cord is more susceptible to proximal
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264 compression following an injury than the uninjured cord. Therefore, intraoperative neurophysiological monitoring is feasible and necessary in patients with spinal cord injuries requiring surgery.
35 STUDY INVESTIGATING INTRAOPERATIVE SPINAL CORD FLOW MONITORING. VALUE OF NEUROPHYSIOLOGICAL MONITORING Principal Author: Hevia Sierra, Eduardo Center: Hospital La Fraternidad-Muprespa, Madrid, Spain Additional Authors: Burgos Flores, Jesu´s1; Barrios Pitarque, Carlos2; De Blas Beorlegui, Gemma1; Mun˜oz Nu´n˜ez, Laura3; Caban˜as Martı´nez, Lidia1; Collazos, Jorge4; Barriga Martı´n, Andre´s4; Sanpera Trigueros, Ignacio5 Centers: 1Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 2 Universidad Cato´lica de Valencia, Spain; 3Hospital La FraternidadMuprespa, Madrid, Spain; 4Hospital Nacional de Paraple´jicos de Toledo, Spain; 5Hospital Universitario de Son Espases, Palma de Mallorca, Spain Aims and Introduction: Intraoperative measurement of spinal cord blood flow (CF) using high-resolution laser Doppler (HRLD) imaging could improve intraoperative cord monitoring. In this study, we determined the CF decrease needed to produce changes in neurophysiological monitoring (NM). Materials and Methods: Laminectomies were used to expose the dural sac from T3 to T13 in 6 domestic pigs (mean weight 31 kg). Progressive compression was applied at a rate of 1 mm/2 min using a 5-mm wide lateral rods. CF was recorded by HRLD, and NM was performed using epidural catheters above and below the spinal cord injury (SSEPs involved nerve stimulation in the lower limbs, and MEPs transcranial stimulation with D wave). The CF and NM changes were measured following each compression step. The study ended when potentials completely disappeared in neurophysiological monitoring. Results: At T8, the cord had a diameter of 7.3 mm. When a 2 mm compression was applied, the distal CF increased with no changes in NM potentials. When compression reached 5 mm, CF disappeared at the area of compression and decreased distally; potentials were present, although decreased and slower. By 6 mm compression, potentials fully disappeared. The CF changes were detected only at a distance of 2.3 cm from the compressed area; being CF normal in the remainder of the cord. Conclusions: CF changes secondary to compression and measured by HRLD were only detectable at a distance of 2.3 cm from the lesion. The extensive network of vascular perfusion may explain the fact that when compression is applied locally it is reflected only in a small portion of the spinal cord. These findings question the role of ischemia in the development of spinal cord lesions. Conventional NM only detects major changes in CF; but it is unable to detect subtle changes.
36 IMPACT OF PERIOPERATIVE MEASURES TO DECREASE INFECTION RATES IN SPINAL SURGERY. PRELIMINARY STUDY Principal Author: Gonza´lez Murillo, Manuel
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Eur Spine J (2014) 23:248–288 Center: Hospital Universitario de Getafe. Madrid. Spain ´ lvarez Gonza´lez, Patricia; Moreno Gomila, Additional Authors: A Carolina; Pizones Arce, Javier; Sa´nchez-Mariscal Dı´az, Felisa; Zu´n˜iga Go´mez, Lorenzo; Izquierdo Nu´n˜ez, Enrique Center: Hospital Universitario de Getafe, Madrid, Spain Aim and Introduction: Our aim was to decrease the postoperative infection rate in spinal surgery by applying a protocol of intraoperative and postoperative multidisciplinary measures. Currently, surgical site infection is the most common complication and one of the most important in spinal surgery. Reported infection rates vary from 0.3 % to 20 %. Materials and Methods: Comparison of two groups of patients consecutively undergoing surgical treatment: group 1 (January– August 2011) patients operated without use of the perioperative protocol; group 2 (September 2011–April 2012) patients in whom the following protocol of perioperative measures was implemented: intraoperative measures included washing skin with chlorhexidine gluconate, use of closed-circuit washing with saline and iodinated povidone, glove changes every 3 h, application of local antibiotic (1 g vancomycin in powder form) at the suprafascial plane, and application of 240-mg gentamicin solution in the autologous bone graft; postoperative measures were sterile dressing of the surgical wound only if stained and drain removal at 48 h without changing the dressing. Results: In group 1, the surgical wound infection rate was 10.2 % (11 patients) in 108 spinal surgeries, requiring 9 cases of reinterventions. In group 2, the infection rate decreased to 3.1 % (4 patients) in 128 procedures with 4 cases of reintervention. The difference in infection rates was statistically significant (p = 0.019). Conclusion: Although surgical wound infections have a multifactorial etiology, there are several modifiable elements that can maximally decrease the infection rate, and along with it, morbidity, reinterventions, hospital stay and therefore, related costs. Nonetheless, separate study of each of the variables would be needed to determine their individual significance.
37 SURGICAL TREATMENT OF POTT DISEASE BY ANTERIOR APPROACH Principal Author: Ramı´rez Rojas, Elio Center: Hospital Eugenio Espejo, Quito, Ecuador Additional Authors: Ochoa Valarezo, Marcelo; Ordo´n˜ez, Fausto; ´ ngel Cabezas Roma´n, A Center: Hospital Eugenio Espejo, Quito, Ecuador Aim: To evaluate kyphotic deformity correction, stability, and fusion with titanium implants by anterior approach in spinal tuberculosis. Introduction: Tuberculosis is a granulomatous systemic disease caused by the bacillus Mycobacterium tuberculosis. Tuberculosis continues to be endemic in developing countries. Kyphosis and neurological deterioration are the main residual problems of spinal tuberculosis. The surgical indications for this condition are severe pain due to an expansive abscess, neurological deterioration caused by spinal cord compression, bone and disc sequestration, progressive kyphotic deformity, and instability. Anterior debridement and fusion is the classic surgical treatment for Pott disease.
Eur Spine J (2014) 23:248–288 Materials and Methods: This is a retrospective study performed between January 2010 and August 2012 and including 8 patients with Pott disease. Surgery consisted of debridement of the affected segment and instrumentation-fusion, with autologous rib graft. The indication for surgery was neurological deficit and segmental kyphosis. Previously, patients received antituberculosis treatment for 3 weeks. We used the clinical history, and imaging studies, such as pre- and postoperative AP and lateral radiographs and MRI, to evaluate kyphosis. Results: Eight patients, 5 men and 3 women, with a mean age of 51.63 years. All patients had a neurological deficit. Six with incomplete lesions improved neurologically, whereas the remaining 2 patients showed no change in neurological status. Mean kyphosis was 14.388 preoperatively and 6.88 postoperatively. The most commonly affected level was T12 with 3 cases (37.5 %), followed by the T12-L1 segment with 2 cases (25 %); T8–T9, L1, and L3: one case each. Mean duration of surgery was 222.5 min and mean operative blood loss was 391.5 cc. There were no cases of significant correction loss or recurrent disease. The surgical interventions were performed in conjunction with the Cardiothoracic Service. There were no immediate or middle-term postoperative complications. Conclusions: Anterior surgery with instrumentation is an effective method for the management of vertebral tuberculosis.
38 SPINAL INFECTIONS Principal Author: Romano, Osvaldo Anı´bal Center: Hospital El Cruce, Buenos Aires, Argentina Additional Authors: Bacaloni, Nicola´s; Bustamante, Jorge Luis; Lambre, Jorge; Bassani, Julio; Posadas, Dolores Center: Hospital El Cruce, Buenos Aires, Argentina Introduction: Spinal infections continue to have an important healthcare and economic impact. The aim of this study is to review the epidemiologic characteristics and treatment of adult patients hospitalized for vertebral infections in a single center. Materials and Methods: Retrospective review of the clinical records of patients hospitalized with a diagnosis of vertebral infection between October 2008 and December 2011. On an Excel spreadsheet, we recorded demographic data (name, age, sex), clinical signs and symptoms, neurological compromise, type of infection, culture findings, microorganism, complementary studies, days hospitalized on a ward and in intensive care, type of treatment, and sequelae. Results: The study included 67 patients (38 males), with a mean age of 51.2 (17–84) years. In 59 patients, the causal microorganism was identified, and 8 cases showed more than one causal agent. Treatment consisted in surgery + antibiotic therapy in 59 patients. Hematogenous infections, 24 (7 females and 17 males) mean age 43.6. Most common microorganisms: MRSA 8, MSSA 5, Pseudomonas 3. Fever 21, axial pain 17, Frankel A/B in 4. Mean duration of hospitalization 26.6 days (ICU 5.9, ward 20.6). Localization; 12 peridural abscess, 9 spondylodiscitis, 1 spondylitis, 1 facet arthritis, and 1 paravertebral myositis. Postoperative infections, 43 (22 females and 21 males), mean age 55.3. Most common microorganisms: MSSA 12, MRSA 9, Proteus and Klebsiella in 4. Fever in 27, axial pain in 18, without paralysis. Mean duration of hospitalization 39 days (ICU 2.3, ward 36.7), 27 surgeries with implant. Conclusions: Spinal infections have a great impact on the health of affected patients and on healthcare expenditure. Knowledge of the characteristics of these infections in each healthcare center is the basis for better control.
265
39 PULMONARY DYSFUNCTION IN PATIENTS WITH ADOLESCENT IDIOPATHIC SCOLIOSIS AND LOSS OF THORACIC KYPHOSIS Principal Author: Nu´n˜ez Pereira, Susana Center: St. Franziskus Hospital, Cologne, Germany Additional Authors: Ferraris, Luis1; Koller, Heiko1; Bullmann Viola2; Hempfing, Axel1 Centers: 1German Scoliosis Center, Bad Wildungen, Germany; 2 St. Franziskus Hospital, Cologne, Germany Introduction: In adolescent idiopathic scoliosis, hypokyphosis (\108) has been related to a mild restrictive change in lung function (forced vital capacity [FVC] B80 % and [65 %), according to the criteria of the American Thoracic Society. Nonetheless, there are no studies investigating whether severe hypokyphosis or thoracic lordosis may be associated with more severe lung function abnormalities (moderate B65 % and [50 %, or severe B50 %). Materials and Methods: Prospective study. Preoperative data collection in consecutive patients about to undergo surgery for adolescent idiopathic scoliosis in a single center over one year (June 2011–June 2012). Radiologic study and respiratory function testing. Exclusion criteria: history of any type of respiratory disease and Lenke type 5 curves (absence of a structural thoracic deformity). For the statistical analysis, patients were divided into 2 groups: thoracic lordosis (TL) if T5–T12 B 0, and thoracic kyphosis (TK) if T5–T12 [0. Statistical analysis: correlation study and comparison of means using the Student t test. Results: A total of 52 patients, 42 female (80.7 %), mean age 16.3 ± 2.4. TL group (9 patients): main coronal thoracic curve (Cobb) 57.0 ± 10.4, T5/T12 kyphosis -5.8 ± 5.0, apex in T8 or T9 in 66.7 %, FVC (%) 53.8 ± 14.5 (range 35–71). TK group (43 patients): main coronal thoracic curve (Cobb) 57.05 ± 11.4, T5/T12 kyphosis 20.9 ± 11.1, apex in T8 or T9 in 86.0 %, FVC (%) 79.1 ± 9.4 (range 63–101). The mean difference in FVC between the two groups was 25.4 (95 % CI 14.05–36.7, p = 0.001). Correlation study demonstrated a significant association between the sagittal thoracic deformity and FVC r = 0.465, p = 0.001. Coronal deformity was similar in the two groups (p = 0.991) and did not correlate with FVC (r = -0.18, p = 0.201). Conclusion: Severe deformity in the sagittal plane is associated with a moderate/severe lung function abnormality. In patients with lordotic thoracic curves, we recommend prompt respiratory function testing for early detection of pulmonary dysfunction and establishment of appropriate treatment.
40 CLINICAL RESULTS AT 3–5 YEARS AFTER LUMBAR FUSION OF ONE LEVEL FOR DEGENERATIVE DISC DISEASE. COMPARATIVE STUDY OF THE CLASSIC APPROACH VS. THE ‘‘MINI-OPEN’’ MINIMALLY INVASIVE APPROACH Principal Author: Pen˜a Jime´nez, Diego
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Center: Hospital Universitario ‘‘Miguel Servet’’, Zaragoza, Spain 1
continued 1
Additional Authors: Rodrı´guez Vela, Javier ; Loste Ramos, Antonio ; Tabuenca Sa´nchez, Antonio1; Sun˜e´n Sa´nchez, Enrique1; Izquierdo Enguita, Marı´a2; Soriano Guille´n, Antonia1; Velilla Marco, Jose´1
SF-36
Type of
physical
surgery
Centers: 1Hospital Universitario ‘‘Miguel Servet’’, Zaragoza, Spain; 2 Universidad de Zaragoza, Spain
Walk 1 km
Introduction: The clinical results of minimally invasive approaches are better than those of classic approaches in the pre- and postoperative period. Our aim is to determine whether these results are maintained during follow-up. Materials and Methods: We reviewed two groups of patients included in a prospective study comparing lumbar fusion for degenerative disc disease at one level, followed-up for 3–5 years (50 cases). All patients underwent circumferential fusion (interbody device with a single-port transforaminal approach [TLIF] and pedicle screws). The following questionnaires were used: Oswestry Disability Index (ODI), SF-36, and visual analogue scale (VAS) for lumbar and sciatic pain. There were no preoperative differences regarding age, sex, level, or in questionnaire scores. Twenty-one cases operated by mini-invasive technique (bilateral mini-open) (Group MO) and 20 operated using a classic approach (Group Cl) responded to the questionnaires sent out. Nonparametric tests were used (Mann–Whitney U) with SPSS 16.0. Results: There were no significant differences in the overall questionnaire scores: ODI (p = 0.073), SF-36 (p = 0.302), SF-36 Physical scale and VAS lumbar (p = 0.194), and VAS sciatic (p = 0.427). However, the mean values for many of the parameters evaluated were better in the MO group: standing, lifting, walking, picking up or carrying groceries, and bathing or dressing oneself. Conclusions: We found no statistically significant differences dependent on the type of approach (mini-open or classic). However, at 3–5 years of follow-up, patients in the MO group had less low back and sciatic pain (VAS) and showed better performance in daily life activities, particularly those requiring moderate effort (e.g., lifting, standing, carrying groceries, walking, bathing, dressing). According to our hypothesis, the clinical results become more similar because the impact of operative muscle injury has less effect.
Walk several blocks
Type of
physical
surgery
scale Vigorous
Moderate
N
Mean
Standard
Standard
deviation error
Walk one block
Bathe, dress
Classic
20 37.5000 39.31988 8.79219
MiniOpen
21 23.8095 33.98179 7.41543
Classic
20 37.5000 39.31988 8.79219
MiniOpen
21 47.6190 33.45217 7.29986
Lift, carry groceries Classic
20 55.0000 32.03616 7.16350 21 76.1905 25.58832 5.58383
Climb several flights
Classic
20 47.5000 44.35206 9.91742
MiniOpen
21 61.9048 26.94792 5.88052
Climb one flight
Classic
20 70.0000 41.03913 9.17663
MiniOpen
21 88.0952 21.82179 4.76190
123
MW U
0.239
0.241
0.379
Mean_SF_ physical
ODI
0.221*
0.260
Classic
20 32.5000 33.54102 7.50000
MiniOpen
21 50.0000 35.35534 7.71517
Pain intensity
Personal care
Walking
Sitting
Social life
Traveling
0.161 ODI Index
0.112
0.111
MW
20 62.5000
39.31988
8.79219
21 61.9048
31.24405
6.81801
Classic
19 65.7895
33.55191
7.69734
MiniOpen
21 80.9524
29.47961
6.43298
Classic
20 75.0000
38.04430
8.50696
MiniOpen
21 92.8571
17.92843
3.91230
Classic
20 70.0000
37.69685
8.42927
MiniOpen
21 88.0952
26.94792
5.88052
20 550.0000 273.38040 61.12972
U 0.957
0.831
0.136
0.122
0.067(*)
0.095
0.087*
0.074
0.114
0.157
0.114
0.157
21 671.4286 186.79630 40.76229
Classic
20 55.3335
27.44273
6.13638
MiniOpen
21 67.1429
18.67963
4.07623
Type of
N
Mean
Standard
Standard
P, Student
Non-parametric
deviation
error of
t
MW U
0.352
0.536
0.125
0.178
0.066
0.081
0.038*
0.069
0.348
0.356
0.075*
0.097
0.065
0.067
0.153*
0.123
0.328
0.352
0.243
0.349
0.073*
0.140
0.073*
0.140
the mean
Sex life 0.091*
t
Classic
surgery
0.330
0.033
P, Student P,
error
*Welch correction: Levine test \0.5 (equal variances not assumed)
Sleeping 0.024
Standard
MiniOpen
MiniOpen
Standing
MiniOpen
Bend, kneel
t
Standard deviation
of the mean
Sum_SF_ physical Classic
P, Student P,
of the mean
Mean
scale
Lifting SF-36
N
Osw_100
Classic
20
1.9000
1.62707
.36382
Mini-Open
21
1.4762
1.23972
.27053
Classic
20
1.1000
1.02084
.22827
Mini-Open
21
.6667
.73030
.15936
Classic
20
2.6500
1.59852
.35744
Mini-Open
21
1.7619
1.41084
.30787
Classic
20
1.2000
1.15166
.25752
Mini-Open
21
.5714
.59761
.13041
Classic
20
1.7000
1.21828
.27242
Mini-Open
21
1.3810
.92066
.20090
Classic
20
1.8000
1.36111
.30435
Mini-Open
21
1.1429
.85356
.18626
Classic
20
2.1000
1.86096
.41612
Mini-Open
21
1.0952
1.51343
.33026
Classic
20
2.1500
1.87153
.41849
Mini-Open
21
1.3810
1.46548
.31979
Classic
20
1.9000
1.44732
.32363
Mini-Open
21
1.4762
1.28915
.28132
Classic
20
1.6000
1.42902
.31954
Mini-Open
21
1.1429
1.01419
.22131
Classic
20
18.1000
12.45053
2.78402
Mini-Open
21
12.0952
7.59707
1.65782
Classic
20
36.2000
24.90107
5.56805
Mini-Open
21
24.1905
15.19414
3.31563
Eur Spine J (2014) 23:248–288
41 SEVERE IDIOPATHIC SCOLIOSIS. DOES THE APPROACH AND INSTRUMENTATION MODIFY THE RESULTS? Principal Author: Sa´nchez Ma´rquez, Jose´ Miguel Center: Hospital Universitario La Paz, Madrid, Spain Additional Authors: Sa´nchez Pe´rez-Grueso, Francisco J.; Pe´rez Buitrago, Mar; Garcı´a Ferna´ndez, Alfredo; Ferna´ndez-Baillo, Nicomedes; Quinta´ns Rodrı´guez, Jose´ Center: Hospital Universitario La Paz, Madrid, Spain For years the combined approach has been the reference standard treatment for severe idiopathic scoliosis. However, recent studies on the posterior only approach have questioned the need for combined surgery. The aim of this study is to evaluate the radiographic results and complications associated with surgical treatment for adolescent idiopathic scoliosis greater than 758 by a double approach (DA), or a posterior only approach with hybrid instrumentation (PH) or an allscrew construct (PA-S). Materials and Methods: Retrospective review of 69 patients fulfilling the following inclusion criteria: curve[758, more than 2 years’ follow-up, and preoperative, postoperative, and follow-up radiographs, in addition to perioperative clinical data. There were 24 patients in the DA group, mean age 13.8 years and mean Cobb angle 898 (758–1178); 20 patients in the PH group, mean age 14 years and mean Cobb 838 (758–1008); and 25 patients in the PA-S group, mean age 14 years and mean Cobb 838 (758–1108). The following were analyzed: flexibility, correction, surgical procedure, and complications. Statistical analysis with the Kruskal–Wallis test for nonparametric variables. Results: There were no statistically significant differences (p [ 0.05) between the three groups for preoperative, immediate postoperative, or final Cobb angle values (Table). Nor were there differences in the final percentage of correction (DA = 60 %, PH = 57 %, PAS = 60 %; p [ 0.05), although curve flexibility was significantly greater (p = 0.002) in the PA-S group. Sagittal correction and the number of fused levels were similar in the 3 groups. The percentage of procedure-related complications was 20.8 % in DA, 10 % in PH, and 20 % in PA-S. Two patients in the PA-S group had spinal cord monitoring changes with no neurological lesion, and 1 patient in the same group had an incomplete, deferred, transient lesion. Conclusions: There were no significant differences in severe idiopathic scoliosis correction between patients treated with a double approach or a single posterior approach, regardless of the type of instrumentation used. According to these results, the combined approach may no longer be the reference standard technique for treating these severe deformities.
267 Additional Authors: Burgos Flores, Jesu´s1; De Blas Beorlegui, Gemma1; Barrios Pitarque, Carlos2; Anto´n Rodriga´lvarez, Miguel1; Hevia Sierra, Eduardo3; Correa Gorospe, Carlos1; Caballero Garcı´a, Alberto3; Piza´ Vallespir, Gabriel4 Centers: 1Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 2 Instituto de Investigacio´n en Enfermedades Musculo-esquele´ticas, Universidad Cato´lica de Valencia, Spain; 3Hospital La FraternidadMuprespa, Madrid, Spain; 4Hospital Universitario Son Espases, Palma de Mallorca, Spain Introduction and Aims: The spinal cord commonly undergoes manipulation during spinal surgery. The aim of this experimental study was to establish the degree of compression required to produce a neurological spinal cord lesion as assessed with neurophysiological monitoring, and to define whether these limits vary depending on the speed with which compression is applied. Materials and Methods: In two groups of 5 industrial pigs with a mean weight of 35 kg, the spinal cord was exposed from T7 to T11 by posterior laminectomy and compression was applied to the cord at T9 by approximating two 5-mm diameter rods placed on both sides. In one group, compression was gradually applied at a rate of 0.5 mm every 2 min, and in the other, abrupt compression of 2.5 mm was applied (acute compression). Spinal cord neurophysiological recording using two epidural catheters on either side of the compression area was performed each time compression was applied. Results: The mean cord diameter at T9 was 7.1 mm. When gradual compression was applied, neurophysiological cord monitoring changes of increased latency and decreased amplitude appeared after a mean compression of 3.2 ± 0.9 mm; potentials completely disappeared after 4.6 ± 1.2 mm of maintained pressure. After releasing compression, potentials returned in all cases at a mean of 16.8 ± 3.2 min. When acute compression was applied, potentials completely disappeared at 2.5 ± 0.3 mm, and they did not recover following a 30-min wait after releasing compression. Conclusion: The thoracic spinal cord shows a marked sensitivity to acute compression, which causes complete, irreversible injury. In contrast, slow, gradual compression is better tolerated: neurophysiological changes appear later and at greater compression, and rapidly recover when pressure is removed. From the clinical viewpoint, it seems recommendable to avoid maneuvers leading to abrupt movements of the thoracic spinal cord and particularly direct jolts, even minor ones.
43 EVALUATION OF THE APGAR SURGICAL SCORE IN SPINAL SURGERY Principal Author: Urrutia, Julio Center: Pontificia Universidad Cato´lica de Chile, Santiago, Chile
42 SPINAL CORD TOLERANCE TO ABRUPT AND GRADUAL INTRAOPERATIVE COMPRESSION. EXPERIMENTAL STUDY Principal Author: Montes Ferna´ndez, Elena Center: Hospital Universitario Ramo´n y Cajal, Madrid, Spain
Additional Authors: Valde´s, Macarena; Zamora, Toma´s; Canessa, Valentina; Bricen˜o, Jorge Center: Pontificia Universidad Cato´lica de Chile, Santiago, Chile Aim and Introduction: A simple, objective postoperative score that can identify patients at risk of morbidity-mortality would be useful in clinical practice and research. The Surgical Apgar Score (SAS), developed in general and vascular surgery, enables prediction of the 30-day morbidity-mortality risk. This 10-point instrument, inspired by
123
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the obstetric Apgar score, is calculated based on the estimated intraoperative blood loss, lowest mean blood pressure, and lowest heart rate. High scores are associated with a lower risk of morbiditymortality and vice versa. The SAS has not been evaluated in spinal surgery. This prospective study attempts to determine it usefulness in these procedures. Materials and Methods: Prospective study of 268 consecutive patients undergoing major and intermediate spinal surgery in a university hospital over an 18-month period. Intraoperative parameters were recorded and we calculated the SAS at completion of surgery. Complications and mortality were recorded over a 30-day follow-up. The relationship between the SAS and morbidity-mortality was analyzed by calculating the relative risk (RR) and the likelihood ratio (LR) for different sets of patients grouped according to score. Univariate logistic regression analysis was carried out and we estimated the predictive capacity of the SAS by calculating a C-statistic (area under the ROC curve). Finally, the cohort was divided into 2 groups: low-risk patients (SAS C7) and high risk (SAS \7); the Fischer test was used to analyze differences between groups. Results: Eighteen patients presented at least one complication (6.72 %). Among patients with SAS 9-10 there was 1.64 % complication rate (RR = 1; LR = 0.23), which increased monotonically as the score decreased (SAS 7–8 = 2.75 %; RR = 1.68; LR = 0.39), (SAS 5–6 = 13.33 %; RR = 8.13; LR = 2.14), (SAS B4 = 17.39 %; RR = 10.61; LR = 2.92). The odds ratio of logistic regression was 0.66 (95 % CI 0.54–0.82) p \ 0.01. The C-statistic to predict morbidity-mortality was 0.77 (95 % CI 0.66–0.88), which was considered good discriminatory capability. Four of 170 patients with SAS C7 presented complications, versus 14/98 patients with SAS \7 (p \ 0.01). Conclusions: The SAS enables stratification of postoperative risk, and it has good discriminatory capacity for predicting 30-day morbidity-mortality in spinal surgery.
Table 1 Surgical Apgar Score (10 points) Number of points 0
1
2
3
4
Estimated blood loss, cc [1,000 601–1,000 101–600 B100 – \40
40–54
55–69
B70
Lowest heart rate, bpm [85
76–85
66–75
56–65 B55
Lowest mean blood pressure, mmHg
–
Table 2 Morbidity-mortality, relative risk, and likelihood ratio for the different categories of the score Score
0–4
5–6
7–8
9–10
Number of patients
23
75
109
61
Major complications and deaths, N (%)
4
10
3
1
Relative risk (95 % CI)
10.61 (1.25–90)
Likelihood ratio (95 % CI)
2.92 2.14 (1.09–8.49) (1.32–7.84)
123
(17.39 %)
(13.33 %)
(2.75 %)
(1.64 %)
44 LUMBAR FUSION, STIFFNESS OF THE SYSTEM, AND IMPACT ON ADJACENT DISCS Principal Author: Lax Pe´rez, Raquel Center: Hospital Santa Lucı´a, Cartagena, Murcia, Spain Additional Authors: Murcia Asensio, Antonio1; Sua´rez Sua´rez, ´ ngel2; Vega, Jose´ Antonio3; Garcı´a Sua´rez, Olivia3; Ferrero Miguel A Manzanal, Francisco1 Centers: 1Hospital Santa Lucı´a, Cartagena, Murcia, Spain; 2Hospital de Cabuen˜es, Gijo´n, Asturias, Spain; 3Universidad de Oviedo, Departamento de Anatomı´a, Asturias, Spain Aim and Introduction: The aims of vertebral fusion are to stabilize the affected segment and prevent displacement of the devices used. Ideally, the flexibility of the fused segment should be close to that of a healthy specimen. However, the optimal stiffness of the construct to achieve consolidation without causing a detrimental effect on the fixed and adjacent segments remains to be determined. The aim of our study is to assess the effect produced by the stiffness of different configurations used in transforaminal fusion (3608 and 2708) on the superior and inferior mobile adjacent segments. Materials and Methods: Using a healthy volunteer, we created an original finite elements model (FEM) from L2 to the sacrum. This ‘‘intact’’ model, which was validated with the literature, was modified to simulate two configurations of L4–L5 transforaminal fusion (3608 and 2708). The disc was divided into 5 intervals (not anatomical areas of the disc) according to the load they support when various movements are performed in space (flexion, extension, torsion, and lateral bending). Relative graphs were used to compare the two models with the values found in the healthy spine, sharing the assumption that less rigid systems will lead to a smaller increase in stress on the discs adjacent to a lumbar fusion. Results: We found that the amount of disc submitted to high stress (interval 5) was lower with the TLIF 2708 model than TLIF 3608, in all the trials and in both discs. The reductions exceeded 50 % and were especially significant in the tests that most challenged the disc (torsion and lateral bending). Conclusions: Performance of the TLIF 2708 fusion model was midway between that of circumferential fusion and healthy spine in terms of transferring load onto the mobile adjacent segments. Since the mathematical model still has little clinical relevance, studies in patients are needed to correlate the anatomical-clinical findings with the qualitative differences seen between the different fusion configurations.
45 HYBRID CONSTRUCTS FOR THE LUMBOSACRAL SPINE. PRELIMINARY STUDY IN 20 CASES Principal Author: Castelli, Roberto
8.13 1.68 1 (1.07–61.78) (0.18–15.79) (reference) 0.39 (0.09–0.98)
0.23 (0.03–1.47)
Center: Hospital Militar Central, Buenos Aires, Argentina Additional Authors: Steverlynck, Alejandro Center: Hospital Militar Central, Buenos Aires, Argentina
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269
Introduction: Spinal fusion has been the classic reference standard for surgical management of symptomatic degenerative lumbar spine disease. Currently, adjacent disc degenerative syndrome would be a theoretical sequela of conventional fusion. Aim: To present the philosophy we use: How and why we have decided to protect the level adjacent to a fusion. Materials and Methods: Among 620 patients evaluated for surgery between January 2007 and August 2011 for degenerative disease, instability, and lumbosacral canal stenosis, we selected 30 patients (Pfirmann stages 3 and 4). Among these, 6 were lost to postoperative consultation and 4 refused surgical treatment, which left 20 patients, (11 men, 55 %, and 9 women, 45 %) who underwent surgery. Mean age was 46 years (range 22–71 years). Results: Follow-up ranged from 2 to 6 years. To date, there has been no clinical/radiologic evidence of worsening or instrumentation loosening in any case. Discussion: Advantages and disadvantages should be evaluated when implementing these novel techniques to develop flexible pedicle screw systems. There is evidence suggesting that radiologic degeneration of the upper adjacent segment does not correlate with the clinical outcome. Conclusions: We believe that protecting the adjacent level with the use of semirigid PEEK rods would be a good option for protection because it preserves the ligaments and pedicles in the level adjacent to the fusion.
between the screws of the dynamic segment 2.538, and of the adjacent segment 5.58 preoperatively and 7.878 postoperatively. There were no cases of breakage of the material or underlying rod end/screw head contact in flexion–extension in any segment. There were, however, three cases of lysis around the screws in the proximal vertebra and two cases of lysis in the distal vertebra. Adjacent disc syndrome in the segment adjacent to the dynamic segment developed in 4 patients, one of whom had severe stenosis that required a reintervention. The mean improvement on the Oswestry Index was 30 %. Conclusions: Dynamic fixation preserves motion in the index segment at a range smaller than the physiological range. The adjacent segment showed an increase in the mean range of motion in flexion– extension, which led to the development of lysis around the screws and adjacent disc syndrome in the segment adjacent to the dynamic segment, despite partial preservation of motion. Because of the development of implant complications and failure to prevent adjacent segment disease, we believe that use of this type of system should be excluded.
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Principal Author: Rovira Gutie´rrez, Manuel
HYBRID VERTEBRAL INSTRUMENTATION IN DEGENERATIVE LUMBAR SPINE DISEASE: CLINICAL-RADIOLOGIC OUTCOME AT MINIMUM 2-YEARS’ FOLLOW-UP Principal Author: Iba´n˜ez Aparicio, Natalia Center: Hospital de la Santa Creu i Sant Pau, Barcelona, Spain ´ scar Additional Authors: Garcı´a Casas, O Center: Hospital de la Santa Creu i Sant Pau, Barcelona, Spain Aim: Dynamic radiologic evaluation of the motion of instrumented vertebral segments and the upper adjacent segment, and assessment of mechanical complications and clinical outcome. Materials and Methods: Prospective observational study. Inclusion criteria: consecutive patients during the year 2009 with an indication for surgical treatment of established transitional syndrome, long instrumentation for degenerative disease or simple instrumentation for incipient adjacent disc disease, all of whom underwent posterior fusion with dynamic instrumentation of the adjacent segment. The system used pedicle screws and a dynamic rod with an integrated bumper element. Radiographic analysis (lateral films in neutral and flexion–extension) of the degree of motion in the index and adjacent segments preoperatively and at last control (24–48 months); mean of two measurements by two different observers. In addition, we evaluated the development of mechanical complications, disease in the segment adjacent to the dynamic segment, lysis around the screw, and the reintervention rate. The Oswestry Disability Index was used to assess the clinical evolution. Results: Fifteen patients were included (1 L1–L3, 1 L2–L4, 3 L2–S1, 1 L3–L5, 3 L3–S1 and 6 L4–S1). Mean range of motion of the dynamic segment was 8.668 preoperatively and 3.78 postoperatively,
47 USE OF A NEW EXPANDABLE SCREW IN PATIENTS WITH POOR BONE QUALITY. MULTICENTER STUDY
Center: Hospital Universitario Virgen Macarena, Seville, Spain Additional Authors: Ferna´ndez Gonza´lez, Manuel1; Villar Pe´rez, Julio1; Pe´rez Varela, Luis2; Herna´ndez Pascual, Luis2; Alia Benı´tez, Jose´3; Domı´nguez Esteban, Ignacio3; Quintana Cruz, Jose´ Jaime4; Zu´n˜iga Go´mez, Lorenzo5; Izquierdo Nu´n˜ez, Enrique5 Centers: 1Complejo Asistencial Universitario de Leo´n, Spain; 2Hospital Universitario Sagrat Cor, Barcelona, Spain; 3Hospital Clı´nico San Carlos, Madrid, Spain; 4Hospital Universitario Virgen Macarena, Seville, Spain; 5Hospital Universitario de Getafe, Madrid, Spain Introduction: Expandable screws are an alternative to cement-augmented screws for fusion in poor quality bone. We used two screws with an expandable middle section that are anchored beyond the pedicle, the area of maximum strength, to avoid pullout. Currently there are no studies focussed on the clinical use of this type of expandable screws; hence, we were prompted to present this study. Aim: To observe the performance of expandable screws in patients with poor bone quality in terms of safety, technique, management, and complications (percentage of loosening, breakage, pullout, and pseudoarthrosis). Materials and Methods: Prospective multicenter study in 99 patients with poor bone quality, mean age 73 years (67 % women, 33 % men), with degenerative disease, fractures, or deformity, and 579 implanted screws. Patients underwent fusion with these expandable screws and mean follow-up was 21 months (12–36). We studied patient-related risk factors, VAS scores, duration of surgery, blood loss, screw positioning, and implant-related complications at discharge, and at 3, 12 and 24 months. Results: Among the total, 99 % of patients had no permanent, implant-related complications. There was only one case of unresolved radiculopathy. 95 % of implants were placed without complications. Complications related to malposition or incorrect expansion of the screw occurred in 5 %, and were resolved during the procedure (1 partial pedicle breakage, 3 non-expanded screws, 1 screw
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270 malposition). Mean operating time per level 56 min; mean duration of surgery 2 h 35 min; mean blood loss per level 211 cc. There were three cases of pullout. Lumbar and radicular VAS showed significantly favorable changes, with mean decreases of 4.6/10 and 5.8/10, respectively. The study will continue to 5 years; these are the preliminary results. Conclusions: Expandable screws provide a new anchoring system for patients with poor bone quality. They are safe, effective, and easy to place, Rx exposure is reduced, and when screws must be removed, they leave the way clear for a new procedure.
Eur Spine J (2014) 23:248–288
49 OUTCOME OF SURGICAL TREATMENT FOR SPINAL CHORDOMA Principal Author: Morales Codina, Ana Marı´a Center: Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain Additional Authors: Mun˜oz Donat, Sonia; Valverde Belda, Diego; Aguirre Garcı´a, Rafael; Molina Aguilar, Ma Jesu´s; Martı´n Benlloch, Juan Antonio
48 RETROSPECTIVE COMPARATIVE STUDY OF LUMBAR FUSION USING INTERBODY DEVICES OF DIFFERENT MATERIALS IN DEGENERATIVE DISEASE Principal Author: Isart Torruella, Anna Center: Institut Universitari Dexeus, Barcelona, Spain Additional Authors: Marlet Jordana, Ma Teresa; Ubierna Garces, Maite; Garcı´a de Frutos, Anna; Vila Canet, Gemma; Arias Baile, Ainhoa; Ca´ceres Palou, Enric Center: Institut Universitari Dexeus, Barcelona, Spain Introduction: Circumferential fusion combining interbody cages with pedicle instrumentation has been extensively used in the last decade to treat degenerative lumbar disease, with the objective of enhancing fusion and recovering lordosis and disc height. Aim: To analyze the impact of using cages made of different materials (titanium/PEEK) on the radiologic outcome of posterior circumferential fusion (TLIF). Materials and Methods: Retrospective study of 162 patients, 68 men and 94 women, mean age 49 years (23–76), surgically treated with transforaminal lumbar interbody fusion using two different types of interbody cages (titanium/PEEK) in patients with lumbar disease and a mean follow-up of 5 years (2002–2010). In all cases, autologous iliac crest graft was used. Preoperative radiography and MRI studies were available in all patients. The following variables were studied: preoperative radiology, and postoperative radiology and CT (fusion was assessed using the parameters described by Kanemura 2011). Complete bone fusion was defined by continuous bony bridges within or outside the implant. We evaluated imaging features of osteolysis/ sclerosis around the cage. Results: Of 162 patients studied, 52 had titanium cages and 110 PEEK cages. In 94 cases, the L4–L5 segment was treated and in 68, L5–S1. Titanium/PEEK fusion rates were 100 %/85.3 % for L4–L5 and 90.9 %/77.5 % for L5–S1. A greater degree of osteolysis/sclerosis was observed at the inferior vertebral plate in patients who received PEEK interbody cages than those receiving titanium cages, with a statistically significant relationship. The posterior height of the intervertebral space and the segmental lordosis showed significant differences between the two materials. Conclusions: The fusion rate was higher in patients with titanium implants relative to PEEK, although the difference was not statistically significant. There was greater presence of inferior vertebral plate subchondral sclerosis in patients treated with the more recent (PEEK) technique.
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Center: Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain Introduction: Chordoma is an uncommon primary bone tumor (1 %– 4 % of bone tumors). These lesions are classically described as lowgrade, locally invasive tumors that are slow growing and have little tendency to metastasize. Nonetheless, they often recur locally, in a manner similar to malignant tumors. En bloc resection with tumorfree margins has been shown to decrease the percentage of recurrent disease and improve the prognosis of these patients. Aims: To analyze the clinical evolution and results of surgical treatment in terms of complications, recurrences, and mortality in patients with spinal chordoma. Materials and Methods: Retrospective observational study of patients undergoing surgery from 1997 to 2012 for spinal chordoma. We included patients whose first treatment was surgery without adjuvant radiotherapy. Patients who had received previous radiotherapy were excluded. Results: Nineteen cases (12 men) were analyzed, with a mean age of 48 years (28–90 years). Mean postoperative follow-up was 7 years (1–15 years). Tumor location: 1 cervical, 1 thoracic, 4 lumbar, and 13 sacral-coccygeal. Two patients were treated with tumor resection, and the 17 remaining patients underwent en bloc tumor resection and reconstruction when necessary (12). The margins of 2 surgical specimens showed tumor contamination. In the early postoperative period (first month), 16 patients presented a motor deficit of the extremities, and all those undergoing sacrectomy had sphincter and sexual dysfunction. At the last control, the motor deficit had improved, but sphincter dysfunction persisted in patients with sacral involvement. There were two cases of material breakage in spinopelvic stabilization. In 1 patient, dehiscence of the rectal stump from a previous colostomy occurred. There were 3 cases of recurrence (2 in the patients with tumor resection), 2 bone and muscle metastases, and 3 deaths. Five-year survival was 84.5 %. Conclusions: Despite the complications and sequelae associated with en bloc resection of vertebral chordomas, we believe it is the treatment of choice for these tumors because of the high survival rates and low number of recurrences.
50 OUTCOME OF SACRECTOMY FOR PRIMARY SACRAL TUMORS Principal Author: Morales Codina, Ana Marı´a Center: Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain
Eur Spine J (2014) 23:248–288 Additional Authors: Valverde Belda, Diego; Eschenbach, Susanne; Mun˜oz Donat, Sonia; Aguirre Garcı´a, Rafael; Molina Aguilar, Ma Jesu´s; Martı´n Benlloch, Juan Antonio Center: Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain Introduction: Sacrectomy is an uncommon procedure indicated for the treatment of primary sacral tumors resistant to radiotherapy or chemotherapy. These tumors are often diagnosed in advanced stages, which makes resection more problematic. Sacrectomy is associated with a high complication rate. However, it is the only effective treatment for some tumors. Aims: To analyze the functional outcome, complications, relapses, and mortality in patients undergoing sacrectomy for a primary sacral tumor. Materials and Methods: Retrospective observational study. Patients treated with a sacrectomy for a primary sacral tumor between 1997 and 2012 were analyzed. Patients who had received any previous treatment were excluded. We analyzed the type of sacrectomy, the stabilization performed, attainment of surgical specimens with disease-free margins, complications, recurrence, and mortality. Results: Sixteen patients (9 men), with a mean age of 46 years (28–90) were analyzed. Mean postoperative follow-up was 7 years (1–13). There were 12 chordomas, 1 osteochondroma, 1 leiomyosarcoma, and 1 ependymoma. Seven complete sacrectomies and 9 partial sacrectomies (3 posterior approach and 13 double approach) were carried out. In complete surgeries, lumboiliac stabilization with a double rod to the ilium was performed in 4 patients, lumboiliac stabilization with a U-shaped double rod and connectors in 3 patients, and no instrumentation in 1 case. In partial sacrectomies, iliac screws and rods were used in 3 patients. Mean intraoperative bleeding was 3572 cc (2000–4800). Eight patients presented wound complications, and there were 5 deep infections. At one month postoperatively, all patients presented paresis of at least one motor group of the lower extremities, gait abnormality, and sphincter dysfunction. At the last control, motor activity and gait had improved in all cases, but sphincter abnormality persisted. Material breakage occurred in two lumbopelvic stabilizations. In 3 cases, tumor-free margins were not obtained. There were 3 cases of recurrence, 2 of metastasis, and 3 deaths. Five-year survival was 84 %. Conclusions: Sacrectomy is an aggressive procedure with a high percentage of complications. Studies are needed to establish the appropriate reconstruction system. Nonetheless, this surgery is associated with greater survival and a good quality of life relative to tumor resection.
271 and 1 iliac tumor affecting the sacroiliac joint, treated over an 11-year period. Materials and Methods: Retrospective review of intra- and postoperative complications in 16 patients with primary sacral tumors and 1 iliac tumor affecting the sacroiliac joint, including 10 men and 7 women, with a mean age of 49.5 years, in the period of 2000–2011, with a mean follow-up of 5 years (1–11 years). The surgical technique consisted in tumor resection by a posterior approach in 14 cases, and complete sacrectomy by a double approach in 2 cases. En bloc resection was carried out in 10 cases, intralesional excision in 6 cases, and radiofrequency treatment in 1 case. Postoperative neurological changes were not considered complications, but rather a direct consequence of sacral tumor excision. Results: Complications were recorded in 12 of the 16 patients treated (75 %). The most important were surgical wound infections that required various debridements and lengthy hospitalization in 8 cases (50 %). Two patients had chronic persistent suppuration; a new surgery was not contemplated, and treatment with long-term antibiotic therapy was continued. Intraoperative vascular complications occurred in 3 cases (18.75 %): 1 right iliac artery lesion that was resolved in collaboration with the Vascular Surgery Department, and 2 gluteal artery lesions. Five patients relapsed: 2 chordomas, 1 melanocytic schwannoma, 1 hemangiopericytoma, and 1 iliac tumor involving the sacroiliac joint. En bloc resection had not been performed in any of the relapsing cases. Conclusions: 1. Treatment of sacral tumors is associated with a high incidence of intra- and postoperative complications, mainly infections and vascular lesions. 2. The treatment that best guarantees favorable long-term results is en bloc resection. 3. Treatment of sacral tumors is complex and requires a multidisciplinary approach.
52 ADJUSTING VERTEBRAL METASTASIS TREATMENT TO THE TOKUHASHI SCALE Principal Author: Cano Go´mez, Claudio Center: Hospital Puerta del Mar, Ca´diz, Spain Additional Authors: Sa´nchez de las Matas Pena, Santiago; Garcı´a Guerrero, Gaspar; Vela Panes, Toma´s; Brun Romero, Francisco; Vela Manzano, Laura
51 Center: Hospital Puerta del Mar, Ca´diz, Spain
REVIEW OF POSTOPERATIVE COMPLICATIONS IN PRIMARY SACRAL TUMORS Principal Author: Ezagui Bentolila, Jaime Leo´n Center: Hospital Universitario de Bellvitge, Barcelona, Spain Additional Authors: Font Vila, Federic; Gonza´lez Can˜as, Lluis; Celi, Sergio Center: Hospital Universitario de Bellvitge, Barcelona, Spain Aims: The aim of this study was to review the postoperative complications occurring in surgical treatment for 16 primary sacral tumors
Aim: To analyze adherence to treatment (percentage of patients who followed treatment indications recommended by the Tokuhashi scale) and prognostic consistency (percentage of patients whose survival was estimated by the Tokuhashi scale) in patients diagnosed with vertebral metastasis in our hospital. Material and Method: Retrospective study of vertebral metastases diagnosed in our center between 2006 and 2010. Study variables: mean age, sex, Karnofsky score, Tokuhashi score, pathologic fracture, treatment, and survival since the diagnosis. In patients treated with surgery or radiotherapy, we evaluated improvements in pain and the Karnofsky score following treatment. The adherence to treatment and prognostic consistency was measured in relation to the scale. Cases with incomplete data and those lost to follow-up were excluded.
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272 Results: We analyzed 279 cases, mean age 65 years, 60 % men. Mean survival, 12.8 months. Adherence to the Tokuhashi scale, 64.8 % of cases. Overall prognostic consistency, 71.6 %. Distribution by Tokuhashi prognostic groups was as follows: 62 % Group I (0–8 points and estimated survival 6 months), 26.6 % Group II (9–11 points and estimated survival 6–12 months), and 11.4 % Group III (12–15 points and estimated survival [1 year). Group I: adherence to Tokuhashi scale in 95.4 %, who received conservative treatment; prognostic consistency, 68.7 % and mean survival 6.15 months. In those who did not adhere to the scale and underwent surgery: survival 9 months and prognostic consistency 33 %. Group II: adherence to the Tokuhashi scale in 13.4 %, who underwent palliative surgery; prognostic consistency, 42.8 %, with mean survival of 22.7 months. In patients who did not adhere to the scale and were not operated, mean survival was 19.5 months. Group III: adherence to the scale in 22.7 %, who underwent surgery for curative purposes; prognostic consistency in 80 %, and mean survival 30.8 months. In patients who did not adhere to the scale in this group, one had palliative surgery and the remaining conservative treatment; mean survival was 28.9 months. Conclusions: • Poor adherence to Tokuhashi scale recommendations did not result in a decrease in prognostic consistency in our series; in group I, survival even increased. The surgical indication in Group I (neurology or pathological fracture) may have increased survival. • Adherence was greater when the recommendation according to the Tokuhashi score was conservative management and poorer when the recommendation was surgery.
Eur Spine J (2014) 23:248–288 daily life (Karnofsky [80), 33.7 % required assistance (Karnofsky 50–70), and 10.7 % were bedridden (Karnofsky 10–40). Among the total, 75.5 % presented two or more vertebral metastases, 80.4 % had extravertebral bone lesions, 58.7 % had internal organ involvement, and more than one major organ was affected in 15.9 %. Most common primary tumors: lung 26.1 % (n = 73), breast 21.8 % (n = 61), and prostate 10.7 % (n = 30). Spinal cord lesion in 16 % (30 partial and 17 complete). 10.2 % debuted with a pathological fracture, and pain was the initial symptom in 82.8 % Thirty patients (10.7 %) underwent surgery, 9 with intent to cure and 21 palliative. The remaining patients received conservative treatment: symptomatic pharmacological treatment (33.3 %), radiotherapy (17.9 %), chemotherapy (16.3 %), and radiotherapy-chemotherapy (11.7 %). Surgical complications in 26.6 %, most commonly surgical wound infection (25 %). In operated patients, pain improved in 76.2 % and Karnofsky score in 71.4 %; in those receiving radiotherapy, 65.2 % and 51.4 %, respectively. In 64.8 % of cases, the Tokuhashi criteria were used for the therapeutic decision, with 71.6 % of consistent prognoses. Conclusions: • In our setting, the most common vertebral metastases were from lung, breast and prostate. • Operated patients showed greater pain improvement and functionality than patients treated with radiotherapy. • Adherence to the criteria and prognostic consistency of the Tokuhashi scale: 64.8 % and 71.6 %, respectively.
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53 ANALYSIS OF THE EPIDEMIOLOGIC AND CLINICAL CHARACTERISTICS OF PATIENTS WITH VERTEBRAL METASTASES Principal Author: Cano Go´mez, Claudio
DECISION MAKING IN THE TREATMENT OF VERTEBRAL METASTASES Principal Author: Issa Benı´tez, Daniela Center: Hospital Universitario Vall d’Hebro´n, Barcelona, Spain Additional Authors: Pellise´ Urquiza, Ferran; Matamalas Adrover, Antonia; Frascheri, Laura; Verge`s Capdevila, Ramo´na; Pijoan Bueno, Joan; Garcı´a de Frutos, Ana; Bago Granell, Joan; Ca´ceres Palou, Enric
Center: Hospital Universitario Puerta del Mar, Ca´diz, Spain Center: Hospital Universitario Vall d’Hebro´n, Barcelona, Spain Additional Authors: Sa´nchez de las Matas Pena, Santiago; Garcı´a Guerrero, Gaspar; Vela Pane´s, Toma´s; Brun Romero, Francisco Manuel; Vela Manzano, Laura Center: Hospital Universitario Puerta del Mar, Ca´diz, Spain Aims: To analyze the epidemiologic and clinical characteristics of patients diagnosed with vertebral metastasis in our hospital, and assess the therapeutic procedure applied based on the recommendations of the Tokuhashi scale. Material and Method: Retrospective study of vertebral metastases in our hospital between 2006 and 2010 (minimal follow-up, 1 year). Variables: mean age, sex, Karnofsky score, number of vertebral metastases, number of bone metastases other than vertebral, number of metastases to internal organs, major organ involvement (brain, lung, liver, kidney), primary tumor, neurological lesion, pathological fracture, type of treatment, survival, improvements in pain and Karnofsky score following treatment. Adherence to the Tokuhashi scale criteria and prognostic consistency were also assessed. Cases with incomplete data and those lost to follow-up were excluded. Results: We analyzed 279 cases, mean age 65 years (SD ± 13) and 60 % men. At the time of the diagnosis, 55.6 % were leading a normal
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The aim of this study is to identify the most important criteria to use when making treatment decisions in patients with vertebral metastatic disease. Patients and Methods: Retrospective analysis of all patients treated for non-hematological vertebral metastatic disease in a third-level hospital between January 2010 and September 2012, with the following inclusion criteria: (1) Radiotherapy treatment (RT) and MR of the thoracolumbar spine, (2) Assessment for spinal surgery by the consulting physician or in a multidisciplinary committee. The following variables were studied: primary tumor, start of RT, date of first assessment for surgery, neurological deficit, radiologic cord compression, number of affected vertebrae, SINS (Spinal Instability Neoplastic Score), and survival. Decision making was analyzed: (1) at the start of the process, identifying differences between patients treated with RT and those referred for surgery; (2) comparing patients referred for surgery from RT with those not referred; (3) comparing patients referred for surgery and ultimately operated with those not operated. Results: Among a total of 299 patients, 182 (mean age 64.8, SD 12.4; 50 % women) met the inclusion criteria. Most common primary tumors were lung (29.1 %), breast (25.8 %), and colorectal (9.9 %). Mean survival since the start of treatment was 9.33 (SD 8.8) months.
Eur Spine J (2014) 23:248–288 The 33 patients who debuted with a neurological deficit had a higher SINS (p = 0.04). Initially, 116 patients were treated with RT and 66 referred for surgery. Patients treated with RT had a larger number of affected vertebrae (p = 0.001), tumors that were more highly radiosensitive (p = 0.000), and a debut with neurological deterioration (p = 0.016). The 21 patients treated initially with RT and referred to surgery had a higher SINS (p = 0.016) than those who continued with RT. Spinal cord compression was the only parameter that differentiated between the 22 patients who underwent surgery and the 65 patients who were referred but not operated (p = 0.005). Conclusions: The SINS is useful for identifying patients with a higher neurological risk and those referred for surgery from RT, but it is not a determinant factor in decision making at the start of the therapeutic process. The most important factors for that purpose are extension of the vertebral disease and radiosensitivity of the tumor.
273 57.9 % ± 9.5. Preoperative proximal thoracic curve was 38.38 ± 11.78 and final postoperative, 258 ± 12.5 (p \ 0.05), with a mean correction of 34.1 % ± 14.5. Preoperative clavicular angle was -2.48 ± 3.48 and postoperative, 1.78 ± 2.98 (p \ 0.05). Preoperative shoulder height was -12.7 ± 14.1 mm and final postoperative, 4.4 ± 9.5 mm (p \ 0.05). In the preoperative assessment, 2 patients presented shoulder balance greater than 3 cm, 8 patients 2–3 cm, 6 patients 1–2 cm, and 5 patients less than 1 cm. Postoperatively, shoulder balance was 1–2 cm in 7 patients and less than 1 cm in 14 patients. SRS-22 score was 3.6 ± 0.6 preoperatively and 4.4 ± 0.3 postoperatively (p \ 0.05). Conclusions: In this series, patients with posterior instrumentation obtained a smaller percentage of correction in the proximal thoracic curve than in the main curve. In most cases, it is not necessary to include the entire proximal curve in the instrumentation to achieve adequate shoulder balance.
N First Triage
182 Radiotherapy = 95
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Consultation/Committee = 66 (A) Second Triage
116 (RT) Only RT = 95 Consultation/Committee = 21 (B)
Third Triage
87 (A + B)
CORRECTION IN ADOLESCENT IDIOPATHIC SCOLIOSIS COMPARING PEDICLE SCREW AND HYBRID SYSTEMS. ANALYSIS OF IMPLANT DENSITY AND CURVE CORRECTION
No surgery = 65 Surgery = 22
Principal Author: Rubio Belmar, Pedro
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Center: Hospital Universitario y Polite´cnico La Fe, Valencia, Spain
THE STRUCTURAL PROXIMAL THORACIC CURVE AND SHOULDER BALANCE IN ADOLESCENT IDIOPATHIC SCOLIOSIS TREATED WITH POSTERIOR INSTRUMENTATION
Additional Authors: Pe´rez Vergara, Silvia; Morales Valencia, Jorge; Cruz Miranda, Daniel; De la Calva Ceinos, Carolina; Soler, Susana; Bas Hermida, Paloma; Bas Hermida, Teresa
Principal Author: Ferna´ndez Varela, Tito Center: Hospital Universitario Dr. Negrı´n, Las Palmas de Gran Canaria, Spain Additional Authors: Mhaidli Hamdan, Hani; Montesdeoca Ara, Arturo; Lorenzo Rivero, Jose´ Augusto Center: Hospital Universitario Dr. Negrı´n, Las Palmas de Gran Canaria, Spain Aim and Introduction: The structural proximal thoracic curve was analyzed in a group of patients with Lenke type 2 and 4 curves surgically treated for adolescent idiopathic scoliosis (AIS) by posterior instrumented fusion. Materials and Methods: Retrospective analysis of data from a prospective database on 21 patients with AIS, 19 females and 2 males. Mean age 15.6 years (13–18); mean follow-up 48 months (24–122); 12 type 2 curves and 9 type 4. Proximal fixation was at D3 in 13 cases (62 %), D2 in 4 cases (19 %), and D4 in 4 cases (19 %). In 80 % of cases, the entire structural curve was not instrumented. Standing and bending whole-spine A-P and lateral Rx were obtained preoperatively. Pre- and postoperative evaluation with VAS and SRS-22, and A-P and lateral Rx at 3, 6, and 12 months, and yearly thereafter. Results: Preoperative main curve was 68.38 ± 15.2 and final postoperative, 29.1 ± 9.9 (p \ 0.05), with a mean correction of
Center: Hospital Universitario y Polite´cnico La Fe, Valencia, Spain Aim: To compare the clinical and radiographic evolution of a cohort of patients surgically treated for adolescent idiopathic scoliosis (AIS) using a pedicle screw system (PS) or a hybrid system (HS). To determine the implant density, degree of correction, and one-year correction loss in surgically treated AIS. Materials and Methods: Retrospective paired comparison of data on PS and HS instrumentation from a prospective database. We reviewed AIS patients, analyzing age, sex, magnitude of the curve (preoperative and postoperative), and correction (bending). Twelve-month data on correction magnitude and loss were compared between the two instrumentation systems. Implant density was determined by screw density. All types of curves were included. Results: The study included 67 patients, 13 males and 54 females, mean age 16 years. Distribution by sex, age, and preoperative curve magnitude was similar in the two groups. In the group treated with HS (n = 28), preoperative curve magnitude was 498 (bending 29), postoperative curve correction 18, and one-year correction 23. The group treated with PS (n = 39) presented a preoperative curve magnitude of 54 (bending 30), postoperative curve correction of 18, and one-year correction, 21. Preoperative kyphosis correction was 22 in the HS group and 24 in the PS group. Postoperative kyphosis was 21 with HS and 18 with PS. Mean implant density was 1.7 screws/level: low density defined as \1.7, high density [1.7. The relationship according to curve magnitude and kyphosis is shown in the Table. Conclusion: Pedicle screw implantation at all levels does not result in a higher degree of curve correction or greater hypokyphosis than hybrid systems. Hybrid systems show a tendency to correction loss,
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and therefore, require more intense follow-up. There were no significant differences in kyphosis or curve reduction in the immediate postoperative period or at 12 months in the comparison between high and low pedicle screw density.
Preop Cobb
Postop
1-year
Preop
Postop
1-year
Cobb
Cobb
Kyphosis
Kyphosis
Kyphosis
High 53.2 ± 11.1 19.8 ± 8.5 22.9 ± 8.6 24.2 ± 7.6 density
19 ± 7.3
20.8 ± 7.7
Low 51.6 ± 5.6 density
17.7 ± 9.5
19.7 ± 9.6
17.2 ± 8
19.8 ± 8.4 23.5 ± 10.6
•
No clear patterns were found for the relationship between last instrumented lumbar vertebra and correct postoperative coronal balance.
58 POSTOPERATIVE AND LONG-TERM RESULTS OF A MINI-INVASIVE APPROACH FOR SCOLIOSIS CORRECTION Principal Author: Burgos Flores, Jesu´s Center: Hospital Universitario Ramo´n y Cajal, Madrid, Spain
57 ANALYSIS OF CORONAL BALANCE AND LAST FUSED LEVEL IN LENKE 5 IDIOPATHIC SCOLIOSIS: SPECIFIC RADIOGRAPHIC PARAMETERS Principal Author: Siderakis, Nicola´s Center: Hospital de Nin˜os Dr. Ricardo Gutie´rrez, Buenos Aires, Argentina Additional Authors: Ludzky, La´zaro; Rosado Pardo, Jose´; Aguilar, Ariel; Dinelli, Dino; Reviriego, Juan; Escalada, Marı´a; Rositto, Gabriel; Legarreta, Carlos Center: Hospital de Nin˜os Dr. Ricardo Gutie´rrez, Buenos Aires, Argentina Aim and Introduction: To determine the postoperative changes in coronal balance in AIS patients with Lenke type 5 curves. Pre- and postoperative analysis of the following radiographic parameters: last fused vertebral level, L4 tilt, apical vertebral translation (AVT), lumbosacral oblique take-off angle (LSOTA), and previous coronal balance. This study analyzes specific radiographic parameters of the lumbar spine pre-and postoperatively to determine how they affect the patients’ final coronal balance. Materials and Methods: Retrospective radiographic study of a case series with at least 2 years’ follow-up. Twenty patients with a diagnosis of AIS and Lenke type 5 curves were evaluated; mean follow-up was 36 months (R: 24–48 months). Specific radiographic measurements were carried out in all patients pre- and postoperatively. Results: Our series showed a direct correlation of the AVT and LSOTA with postoperative coronal balance, both in the group of patients who improved (14 patients) and the group in whom coronal balance worsened (6 patients). Conclusions: • • •
•
In the patient group that experienced less LSOTA correction, coronal imbalance did not improve or increased. In the patient group that experienced less AVT correction, coronal imbalance did not improve or increased. In our series, AVT and LSOTA were the two specific radiographic parameters that had the most impact on the patients’ final coronal balance. The inclination of the last instrumented vertebra experienced less angular correction in patients whose coronal imbalance did not improve or increased.
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Additional Authors: Hevia Sierra, Eduardo1; Sanpera Trigueros, Ignacio2; Del Olmo Herna´ndez, Teresa3; Maruenda Paulino, Jose´4; Barrios Pitarque, Carlos5; Dome´nech Ferna´ndez, Pedro6; Anto´n Rodriga´lvarez, Miguel3; Garcı´a, Vicente7 Centers: 1Hospital La Fraternidad-Muprespa, Madrid, Spain; 2Hospital Universitario Son Espases de Palma de Mallorca, Spain; 3 Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 4Hospital Clı´nico de Valencia, Spain; 5Universidad Cato´lica de Valencia, Spain; 6Hospital General Universitario de Alicante, Spain; 7Hospital La Mancha Centro, Alca´zar de San Juan, Ciudad Real, Spain Aims and Introduction: Posterior approaches in scoliosis surgery are extensive and may cause significant morbidity. Mini-invasive approaches (MIA) are less aggressive and may lower blood loss, analgesic requirements, complications, and duration of hospital stay. The technique presented here can facilitate placement of the most difficult pedicle screws (PS) at the concavity. Materials and Methods: Two similar groups of 10 AIS patients were compared. Group 1: mean age 14.3 years (12.1–16.8), with Cobb 60 (53–71) and T5–T12 thoracic kyphosis +258 (11–40), treated by posterior approach using the following MIA technique: posterior longitudinal midline incision; in the lumbar region, Wiltse technique and in the thoracic spine, longitudinal section of the thoracic longissimus muscle fibers, reaching the posterior vertebral elements; PS placement at the convexity with coplanar correction. Subsequently, PS placement at the concavity using a freehand technique. In group 2, 15.3 years (11.0–17.4), Cobb 56 (45–66) and T5–T12 kyphosis +20 (10–36), surgical correction of scoliosis was performed using a conventional approach and freehand pedicle screw placement. Results: Operative time: 6.1 h (5.1–7.9) in group 1 and 3.4 h (2.9–4.7) in group 2. Blood loss: 270 cc (220–600) in group 1 and 720 cc (450–1160) in group 2. Analgesic requirements were slightly higher in group 1. On postoperative CT in 101 PS in the concavity in group 1, 6 % were outside the limits of the pedicle; in 89 PS in group 2, 12.3 % were outside. Duration of hospitalization was similar in the 2 groups. After a follow-up of more than 26 months, final correction was 81 % in group 1 and 80 % in group 2. T5–T12 kyphosis was 17 in group 1 and 22 in group 2. There were no cases of significant correction loss, implant failure, or nonunion in either group. Conclusions: In AIS patients, MIA resulted in longer operative time, less blood loss, and no significant differences in analgesic requirements relative to the conventional technique. Initial correction of scoliosis at the convexity with MIA decreased the percentage of malpositioned PSs in the concavity. This MIA technique did not lead to correction loss, implant loosening, or nonunion.
Eur Spine J (2014) 23:248–288
59 SET-SCREW LOOSENING AT THE LOWER INSTRUMENTED LEVEL IN LONG SPINAL CONSTRUCTS FOR ADOLESCENT IDIOPATHIC SCOLIOSIS Principal Author: Piza Vallespir, Gabriel Center: Hospital Universitari Son Espases, Palma de Mallorca, Spain Additional Authors: Sanpera Trigueros, Ignacio1; Serrano Pastor, Ricardo1; Burgos Flores, Jesu´s2 Centers: 1Hospital Universitari Son Espases, Palma de Mallorca, Spain; 2Hospital Universitario Ramo´n y Cajal, Madrid, Spain Introduction: Screw–rod connection failure, particularly at the ends of long instrumentations, is a known complication, but there are few related reports in the literature. Materials and Methods: Retrospective review of 67 patients who consecutively underwent surgery for AIS in a single center, with a follow-up of C24 m. We selected cases with evidence of screw–rod connection failure at the lower instrumented level (LIL). Results: Eleven cases were identified (10F/1 M, mean age 14.1 years). Classification: Lenke type 1 (4), 3 (3), and 6 (4). Mean Cobb angle: MT 63 and TL/L 61. CIL: T-11 (2), L-1 (1), L-3 (3), and L-4 (5). Correction by coplanar alignment (9) or in situ contouring (2). Mean correction: MT 53 % and TL/L 54 %. LIL inclination decreased from 30 to 14. Loosening was detected at 7 m (1–17) as complete separation of the locking screw (6) or rod sliding within the screw (4). Seven patients were asymptomatic and 4 presented mild low back pain. Loosening was always at the screw on the convexity: right in 4 (right Lenke type 1) and left in 7 (left lumbar Lenke types 3 and 6). There was one case of distal curve worsening with an increase in LIL inclination (mean 6) and Cobb angle (mean 6). In cases instrumented to T-11, caudal junctional kyphosis occurred. As compared to cases showing no instrumentation failure, loosening occurred more often in the absence of transverse connectors and all were fixed screws, although these differences were not statistically significant. Eight cases required revision (1 pending); nonunion was found at 1 or 2 caudal levels. Instrumentation was extended caudally only in the 2 patients with junctional kyphosis. In 3 cases, revision was excluded because there was no progression or symptoms. In the revision cases, final correction was similar to that obtained following the initial surgery. Conclusions: Screw–rod connection loosening in the LIL was observed in 16 % of cases in this series, and revision was required in 12 %. Loosening always occurred at the side of the convexity and in monoaxial screws.
275 Additional Authors: Grass Pedral, Jose´ Center: Hospital Luis Calvo Mackenna, Santiago, Chile Introduction: The rods used for scoliosis surgery have undergone modifications to achieve better balance. Aims: To compare coronal and sagittal balance in patients with adolescent idiopathic scoliosis undergoing posterior instrumented fusion using chrome-cobalt or titanium rods. Materials and Methods: Prospective study of 2 groups of 10 consecutive patients who underwent posterior surgery for adolescent idiopathic scoliosis. The same osteosynthesis materials were used in all patients, with titanium rods in one group (TG) and chrome-cobalt rods in the other (CCG). We evaluated coronal and sagittal balance in whole-spine AP and lateral radiographs preoperatively, in the immediate postoperative period, and at one year. Curve flexibility was measured in bending and traction; flexible was defined as correction greater than 50 % of the curve. Radiographs were taken in the same center by the same technician. Microsoft Excel was used for tabulation. The Welsch two-sample t test, Chi square test, and Wilcoxon test were used for the statistical analyses, with a p-value \ 0.001. Results: There were no significant differences in sex, age, Lenke type, degree of scoliosis, number of fused levels, surgical technique, operating time (3.6 h in both groups), or days hospitalized. Braces were used only in CCG (30 %). Statistically significant differences between preoperative and postoperative status were found for each individual group with regard to Cobb angle and kyphosis; lordosis was not significant in CCG; there were no significant differences in pelvic incidence, sacral slope, or pelvic tilt. The more flexible was the curve, the greater the correction, regardless of the material used. In more rigid curves, CCG achieved significantly greater correction. There was no significant loss of correction between immediate postoperative and 1-year in either group. Significant differences in Cobb angle, kyphosis, and lordosis, but not in the other variables studied, were found between the groups. Conclusions: Use of chrome-cobalt rods results in better coronal y sagittal balance in patients undergoing posterior surgery for adolescent idiopathic scoliosis. The flexibility of the curve and stiffness of the material have a significant impact on correction.
61 PEDICLE SCREWS VERSUS EXTRAPEDICULAR SCREWS IN THE THORACIC SPINE. COMPARATIVE CADAVERIC STUDY Principal Author: Anto´n Rodriga´lvarez, Luis Miguel Center: Hospital Universitario Ramo´n y Cajal, Madrid, Spain
60 STUDY COMPARING CHROME-COBALT RODS AND TITANIUM RODS FOR CORRECTION OF ADOLESCENT IDIOPATHIC SCOLIOSIS Principal Author: Weissmann Marcuson, Karen Andrea Center: Hospital Exequiel Gonza´lez Cortes, Regio´n Metropolitana, Chile
Introduction and Aims: Placement of pedicle screws in the thoracic vertebrae enables greater capacity for correction, being the single implant that fixates the three vertebral columns. Nonetheless, pedicle screw placement is complex and not free of risk. Several techniques have been developed to optimize thoracic screw placement. In this study, the safety and accuracy of vertebral screw implantation by two different techniques are compared in cadaveric thoracic vertebrae. Materials and Methods: Thoracic spine instrumentation at T1–T10 was carried out in 14 cadavers. In the extrapedicular technique, the reference for insertion was the intersection of the exterior border of the facet joint with the midpoint of the transverse apophysis,
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276 performed in 7 cadavers (140 screws). A conventional freehand technique was used for inserting pedicle screws in the other 7 cadavers (140 screws). At completion of surgery, the spinal columns were resected and studied by conventional radiography, computed tomography, and anatomic dissection. Invasion of the spinal canal and foramen, lateral malpositioning, and nerve lesions were evaluated. Results: Spinal canal invasion by less than 2 mm was observed in 32 screws, 27/140 pedicle screws (19.3 %) and 5/140 extrapedicular (3.6 %), yielding a significant difference (p \ 0.001). Spinal canal invasion [2 mm was found in 5 screws, 3 pedicle screws and 2 extrapedicular, with non-significant differences. In 15 cases, screws were found partially (9) or completely (6) lateral to the vertebral body. Among them, 8/140 were extrapedicular (5.7 %) and 7/140 pedicle screws (9.7 %). Differences were not significant. In 18 cases, screws were completely caudal to the pedicle, occupying the foramen: 16/140 extrapedicular (11.4 %) and 2/140 pedicle screws (1.4 %), also yielding a statistically significant difference (p \ 0.001). Conclusions: Extrapedicular screw placement provides better results in terms of lower risk of canal invasion and better anchoring in the vertebral body. However, since the screw course is partially extraosseous, there is a higher risk of foramen invasion, with the consequent risk of radicular lesion.
62 IN VITRO INTERACTION OF MESENCHYMAL STEM CELLS WITH BIOLOGICAL CEMENTS USED IN SPINAL SURGERY Principal Author: Pino Minguez, Jesu´s
Eur Spine J (2014) 23:248–288 death (caspase-3), alkaline phosphate production, and possible differentiation to osteoblasts. Statistical study with SPSS 15. Results: Greatest cell growth was obtained at concentrations of 15 % and 20 %, with values of 0.801 ± 0.064 and 0.793 ± 0.005. Caspase3 expression showed a gradual decline as the HA:PMMA ratio increased, with 20 % being the optimal concentration. Alkaline phosphatase production showed values up to 0.645 ± 0.0227303 at concentrations greater than 15 % versus baseline values of 0.247 ± 0.03. Optimum cell adhesion was seen at concentrations of 10 % or more. TRAIL values showed a considerable decrease at the 20 % concentration (Student t 0.05; p [ 0.01). Discussion and Conclusions: This study shows that HA/PMMA mixtures with HA concentrations of 15 % to 20 % enhance MSC proliferation and adhesion, with a lower toxic effect and reductions in cell death. The local inflammatory reaction decreases at concentrations around 20 % and differentiation of MSCs to osteoblasts is enhanced at concentrations higher than 15 %.
63 LOCAL DIFFUSION OF ANTINEOPLASTIC AGENTS FOLLOWING VERTEBROPLASTY, USING ACRYLIC CEMENT WITH CISPLATIN OR METHOTREXATE. EXPERIMENTAL STUDY IN PIGS Principal Author: Llombart Blanco, Rafael Center: Clı´nica Universidad de Navarra, Pamplona, Spain
Center: Departamento de Cirugı´a Facultad de Medicina Universidad Santiago de Compostela, Spain
Additional Authors: Alfonso Olmos, Matı´as1; Villas Tome´, Carlos1; ´ lvaro2; Aldaz Pastor, Azucena1; Navarro, I´n˜igo3; Silva Gonza´lez, A ´ Martın Algarra, Salvador1
Additional Authors: Couceiro Otero, Ramiro1; Dı´ez Ulloa, Ma´ximo Alberto2; Otero Ferna´ndez, Marı´a3; Garcı´a Santiago, Carlota4; Freire Garabal, Manuel4
Centers: 1Clı´nica Universidad de Navarra, Pamplona, Spain; 2Clı´nica Alemana de Santiago de Chile, Chile; 3Facultad de Ciencias de la Universidad de Navarra
Centers: 1Cell and Developmental Biology, School of Medicine, UNC Chapel Hill, North Carolina, USA; 2Departamento de Cirugı´a, Facultad de Medicina, Universidad Santiago de Compostela, Spain; 3 Complejo Hospitalario Universitario Santiago de Compostela. Spain; 4 Departamento de Farmacologı´a, Facultad de Medicina, Universidad Santiago de Compostela, Spain
Introduction: Among the uses of acrylic cement (PMMA), is the possibility to employ it as a vehicle for drug diffusion. This capability is of interest in the treatment of pathological fractures: The curative effects of the cement (cytotoxicity of the monomer and increased temperature) are added to the antineoplastic effect of the drugs. Aims: To determine the efficacy of cisplatin- or methotrexate-containing acrylic cement for local and systemic antineoplastic drug diffusion. Materials and Methods: Two groups of 10 pigs each were studied. The first group underwent vertebroplasty using cisplatin-containing cement and the second group, cement containing methotrexate. Vertebroplasty was performed in two non-consecutive lumbar vertebrae with bipedicular cement injection. Transpedicular bone biopsy was performed weekly to measure levels of antineoplastic agent in bone tissue, and plasma levels of the drugs were determined. Cisplatin was studied by atomic absorption spectrometry and methotrexate by fluorescence polarization immunoassay. In addition to clinical monitoring of the animals, renal and hepatic function and hemogram analysis were performed weekly. Results: Cisplatin and methotrexate levels were found in bone tissue at more than 5 weeks following surgery. The cisplatin peak occurred at week 3 (1269 lg/g bone) and the methotrexate peak at week 1 (862.76 lg/g bone). Therapeutic plasma levels of cisplatin and methotrexate were found at more than 72 h, with a peak at 24 h for cisplatin
Introduction and Aims: PMMA has been used in spinal surgery since 1987. Studies on this material over more than 50 years have shown no biocompatibility. Commercial hydroxyapatite (HA) is a highly reactive, osteoconductive synthetic ceramic, but it does not have ideal mechanical properties. Schwartz reported that mesenchymal stem cells (MSCs) can migrate and adhere to an implant with osteogenic capacity, and can even differentiate to an osteoblast phenotype, secreting their own extracellular matrix. The aim of this study was to assess the osteogenic potential of a PMMA/HA composite at different concentrations on MSCs. Material and Method: Characterized HA powder (=2.0 g/cm3) was mixed with cement (A Kyphon HV-R) before polymerization. HA concentrations were 5 %, 10 %, 15 %, and 20 %. MSCs were cultured and isolated using the Ficoll-Paque technique. Cells were then cultured on PMMA/HA discs with HA at the concentrations established. The following variables were studied: cell proliferation, cell adhesion, local inflammatory reaction (TRAIL), cell
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Eur Spine J (2014) 23:248–288 (0.23 lmol/L) and at 30 min for methotrexate (0.92 lmol/L). None of the animals died during the study. Animals with intracanal cement leaks showed no neurological involvement. AST, ALT, creatinine, hemoglobin, platelet, and leukocyte levels remained within normal limits. Conclusions: There is local diffusion of antineoplastic agents from the cement to bone and plasma. We found methotrexate and cisplatin levels in bone at up to 5 weeks, comparable to previous in vitro reports. At the doses administered, there were no cases of myelosuppression, hepatotoxicity, or nephrotoxicity.
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65 BIOMECHANICAL AND IN VIVO STUDY OF THE EFFECT OF PILOT HOLE SIZE ON THE PEDICLE SCREW-BONE INTERFACE Principal Author: Defino, Helton Center: Faculdade de Medicina de Ribeira˜o Preto-USP, Brazil
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Additional Authors: Silva, Patricia; Shimano, Antonio Carlos; Rosa, Rodrigo
BIOMECHANICAL TESTING COMPARING TITANIUM AND PEEK TRANSLAMINAR FACET SCREWS
Center: Faculdade de Medicina de Ribeira˜o Preto-USP, Brazil
Principal Author: Wanderley Velho, Jose Guilherme Center: Rio de Janeiro University-Neurosurgery Department. Brasil Additional Authors: Ribeiro Telles, Carlos Roberto Center: Rio de Janeiro University-Neurosurgery Department. Brasil Introduction and Aim: In 1983, Magerl improved Boucher’s transfacet screw fixation technique, changing the starting point for the contralateral spinal process lamina junction, increasing its stiffness and safety. The aim of this study is to show a novel biomechanical testing protocol comparing the titanium and a new PEEK screw device through Magerl’s trajectory in a stand alone and TLIF construct. Materials and Methods: Three spinal functional units were utilized: one with a bilateral titanium screw construct, one with a bilateral PEEK screw construct, and the third with bilateral PEEK screws combined with a TLIF cage construct. All units underwent an intact, pre-fatigue static test, a fatigue test, and a post-fatigue static test. During the pre-fatigue and post-fatigue tests, moments were applied in steps of 0.25, 5, 7.5, 10, and zero Nm, in flexion, extension, left and right lateral bending, and axial rotation. A preload of 400 N was applied and moments were applied in steps of 0.25, 5, 7.5, 10, and zero Nm in extension and flexion. The position of each vertebra was recorded using an OPTOTRAK motion measurement system. During the dynamic testing or fatigue, each instrumented segment was fixed on an XY table attached to an MTS load cell. The test was conducted by applying cyclic loads of 75 N at 10 cm from the COR up to 50 000 cycles of 2 HZ frequency. This loading created extension and flexion motion. Load displacement data was collected. Results: All the pre-fatigue tests confirmed the efficacy of Magerl’s technique in decreasing the spinal segment motion in all directions. The post-fatigue test with the Ti screw construct showed increased motion, mainly during flexion and extension, and increased screw hole diameter. The post-fatigue test with the PEEK screw remained stable during all tests, without damage to the surrounding bone. The TLIF construct combined with bilateral PEEK screws showed initial displacement, but it did not increase after 50 000 cycles. Conclusion: The PEEK features of stiffness and elasticity, very similar to those of real bone, may explain its better results. This opens a door for clinical application, mainly in elderly patients with poor bone quality and in motion preservation constructs.
Objective: To experimentally study the influence of pilot hole diameter (smaller than or equal to the internal screw diameter [core]) on biomechanical variables (insertion torque and pullout strength) and histomorphometric parameters of the screw–bone interface immediately after pedicle screw insertion and 8 weeks later. Methods: Fifteen sheep underwent surgery with bilateral insertion of pedicle screws from L1 to L3. The pilot hole was smaller (2.0 mm) than the internal diameter of the screw (core) in pedicles on the left side and equal to the internal diameter of the screw (2.8 mm) in pedicles on the right side. Ten animals were immediately sacrificed (5 were assigned to pull-out strength trials and 5 were used for histomorphometric assessment of the screw–bone interface). The remaining 5 animals were sacrificed 8 weeks after pedicle screw insertion for histomorphometric evaluation of the screw–bone interface. Results: Insertion torque and pullout strength were significantly greater in pedicle screws inserted in pilot holes with a diameter smaller than the internal screw diameter. Histomorphometric assessment of the screw–bone interface showed that the percentage of boneimplant contact, the area of bone inside the screw thread, and area of bone outside the screw thread were significantly higher for screws inserted in pilot holes smaller than the internal diameter of the screw, both immediately following insertion and at 8 weeks. Conclusion: A pilot hole diameter smaller than the internal pedicle screw diameter led to better insertion torque and pull-out strength immediately after screw insertion, and improved the screw–bone interface in the pedicle immediately after screw placement and 8 weeks later.
66 MINIMALLY INVASIVE TREATMENT FOR DEGENERATIVE CERVICAL SPINE DISEASE Principal Author: Ramı´rez Leo´n, Jorge Felipe Center: Clı´nica Reina Sofı´a-Colsanitas, Bogota´, Colombia Additional Authors: Rugeles Ortiz, Jose´ Gabriel Center: Clı´nica Reina Sofı´a-Colsanitas, Bogota´, Colombia Aim and Introduction: The aim of this study was to report 14 years’ experience with minimally invasive surgery (MIS) to treat degener-
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278 ative cervical spine disease (CSD). CSD is characterized by axial pain. An estimated 66 % of the adult population has experienced neck pain at some point in life. The percentage of women is higher than men and the C6–C7 segment is most commonly affected. Various open surgery techniques are available, all of which have certain disadvantages and associated complications. Since the first report of MIS in 1994 and further studies indicating its efficacy and safety, this technique has become a new option for treating spinal diseases, including CSD. Currently there are two approaches, the anterior and posterior, each with specific indications and advantages. Our 14-year experience is focused on the anterior technique. Materials and Methods: Retrospective study of CSD patients treated with MIS by anterior approach. The evaluation instruments used were the MacNab criteria, modified Oswestry Disability Index, and visual analogue scale (VAS). Results: During the period of 1997–2012, the MIS technique was used in 236 patients with CSD. All surgeries were ambulatory procedures, performed under local anesthesia and sedation. Maximum follow-up was 13 years. The MacNab classification was excellent to good in 90 %, fair in 7 %, and poor in 3 %. The modified Oswestry rating was excellent to good in 63 %, improvement in 30 %, poor in 6 %, and worsening in 1 %. Preoperative VAS was 8/10 preoperatively and 2/10 postoperatively. Complications included cervical hematoma 3 cases, carotid lesion 2 cases, and transient dysphonia 3 cases. Conclusions: MIS to treat the cervical spine is a safe and effective procedure, with a low complication rate. Since it is performed with local anesthesia and sedation, and a small incision is used, it can be done on an outpatient basis with prompt return to work activity. The results found were very satisfactory and comparable to open microsurgery procedures.
67 INFLUENCE OF TIME OF EVOLUTION AND AGE ON CERVICAL SPONDYLOTIC MYELOPATHY Principal Author: Ferna´ndez de Rota Conde, Antonio Center: Hospital Universitario Virgen de la Victoria, Malaga, Spain Additional Authors: Ferna´ndez de Rota Avecilla, Juan Jose´; Meschian Coretti, Stephan; Urbano Labajos, Vı´ctor; Baro´n Romero, Manuel Center: Hospital Universitario Virgen de la Victoria, Malaga, Spain Introduction and Aim: The prognosis of cervical spondylotic myelopathy (CSM) poses numerous questions. We present a study that attempts to elucidate the influence of age and duration of symptoms on the prognosis of this condition following surgery. Material and Method: Prospective study in 66 patients who underwent surgery for CSM, evaluated (JAO scale) pre- and postoperatively. Follow-up, 2 years. The variables analyzed were age and time of clinical evolution (TE), the latter divided into two groups: long evolution ([1 year), 35 cases, and short evolution (\1 year), 31 cases. In addition, we included the variable recent aggravation (RA) as follows: if the condition progressed gradually without any major ups and downs, it was rated NO (15 cases), whereas if there was an acceleration in progression of the disease before surgery, it was rated YES (20 cases). Results: Age showed a negative correlation with the preoperative (CI -0.38) and postoperative (CI -0.30) situation (p \ 0.01). There was no correlation between age and the recovery rate. The TE did not correlate with the preoperative clinical status. There was a negative correlation between the TE and the postoperative clinical status (CI -
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Eur Spine J (2014) 23:248–288 0.29), as well as the recovery rate (CI -0.4) (p \ 0.01). The recovery rate was 20.51 % higher in patients with a short clinical evolution. With regard to the variable RA, there was greater preoperative clinical involvement, with a mean score of 1.44 points (JAO) (p \ 0.05), and poorer postoperative clinical status. Furthermore, RA YES patients had poorer recovery rates than patients classified as RA NO, with a trend approaching significance. Analysis of the relationship between RA YES patients (20 cases) and RA NO patients with a long evolution (15 cases), showed a poorer preoperative clinical status in RA YES (p \ 0.05), and a non-significant trend to a better recovery rate in this group. Conclusions: Age had a negative influence on the preoperative and postoperative clinical status, but was not predictive of the capacity to improve. The time of disease evolution had prognostic value for the capacity to improve, showing a negative influence.
68 NEED FOR INTRAOPERATIVE NEUROPHYSIOLOGICAL MONITORING (INM) IN SURGICAL POSITIONING OF PATIENTS WITH SEVERE CERVICAL MYELOPATHY Principal Author: Pe´rez Lorensu, Pedro Javier Center: Hospital Universitario de Canarias, Neurofisiologı´a Clı´nica, Santa Cruz Tenerife, Spain Additional Authors: Corte´s Garcı´a, Pedro1; De´niz Rodrı´guez, Bernabe´1; Arnau Santos, Amelia2; Rolda´n Delgado, He´ctor3; Garcı´a Conde, Mario3; Febles Garcı´a, Pablo3; Pe´rez Orribo, Luis3; Garcı´a Marı´n, Vı´ctor3 Centers: 1Hospital Universitario de Canarias, Santa Cruz Tenerife, Spain; 2Hospital Universitario La Candelaria, Traumatologı´a, Santa Cruz Tenerife, Spain; 3Hospital Universitario de Canarias, Neurocirugı´a, Santa Cruz Tenerife, Spain Aim and Introduction: The scientific literature recognizes a risk of producing a severe cord lesion with postoperative paraplegia in more than 1 % of patients undergoing surgery for cervical myelopathy during maneuvers to position the patient or during the surgical act. INM techniques are used to detect and prevent this potential iatrogenic injury. Materials and Methods: The study included 66 consecutive patients (39 F and 27 M; 17–81 years of age, mean 68 years) with severe cervical myelopathy (degenerative and traumatic) who required posterior stabilization surgery. Anesthesia consisted in TIVA and neuromuscular block reversion (Sugammadex), which was carried out before moving and positioning the patient for surgery. INM used transcranial electrical stimulation (TcMEP) to study the motor pathway and somatosensory evoked potentials (SSEPs) for the sensory pathway, following induction of anesthesia, and during positioning of the patient and surgery. When INM changes were seen during patient positioning, repositioning was carried out, and if the signals did not improve, the spinal cord protection protocol (raise blood pressure and steroids) was implemented. Results: Of the 66 patients in the series, INM changes were seen in 4 patients during surgical positioning. The changes reverted following repositioning in 3 cases: 1 patient had transient postoperative paraparesis of the lower extremities (2/5), and the others had no
Eur Spine J (2014) 23:248–288 postoperative symptoms. In the remaining patient, the INM changes did not recover following repositioning or with the cord injury protection protocol. The patient had transient postoperative tetraparesia (2/5 in upper and 1/5 in lower extremities) that recovered in 72 h. Conclusion: In our series, INM illustrated the efficacy of monitoring techniques during preoperative positioning of patients with severe cervical myelopathy who require a posterior approach and instrumentation. A risk of cord lesion was detected in 6.06 % of cases, enabling repositioning and rapid establishment of cord protection measures.
69 OUTCOME OF SURGERY FOR DEGENERATIVE CERVICAL MYELOPATHY, AND PATIENT SATISFACTION Principal Author: Matamalas Adrover, Antonia Center: Hospital Universitario Vall d’Hebro´n, Barcelona, Spain Additional Authors: Plano Jerez, Xavier; Ferna´ndez Bautista, Alejandro; PellisE` Urquiza, Ferran; Garcı´a de Frutos, Ana; Casamitjana Ferra´ndiz, Jose´ Center: Hospital Universitario Vall d’Hebro´n, Barcelona, Spain Aim: To assess the subjective satisfaction and clinical outcome of surgery in patients operated for cervical myelopathy, and the repercussions of complications. Materials and Methods: Retrospective analysis of patients surgically treated for degenerative cervical myelopathy between 2005 and 2010 (minimum follow-up [1 year). We collected data on demographics, complications, and reinterventions. The repercussions of the complications were analyzed using a 15-point scale (GOS) to evaluate the perceived overall effect and a satisfaction scale at the end of followup. Results: Of the 221 patients initially recruited (mean age 52.2 years; 66.5 % men), 12 (5.4 %) had died at completion of follow-up (0.4 % surgery-related). Of the remaining patients, 82.3 % completed the questionnaires at the end of the study. Mean follow-up was 44.9 ± 19.4 months. Among patients responding to the questionnaires, 45.34 % were very satisfied with the results of surgery and 27.9 % were reasonably satisfied. The mean GOS score (0–15 points) was 11.26 (SD ± 3.3); 75.6 % of patients considered that surgery had improved their health status and 11.04 % considered that it had worsened their health. Of the 19 patients reporting a worsening, only 2 had been reoperated during the follow-up period. Among the total, 14.8 % of patients presented minor complications and 11.8 % major complications postoperatively. Some type of neurological radicular lesion (pain and/or paresis) occurred in 7.7 % of patients. There were 7.6 % of surgical wound complications and 9.3 % of reinterventions (2.5 % debridements, 6.3 % myelopathy progression, 0.4 % instrumentation failure). There were no differences with regard to satisfaction and GOS score between patients with postoperative complications (medical, neurological, and/or wound) and those without. Nor was there a difference between patients reoperated for any cause and those who were not reoperated.
279 Conclusions: More than 60 % of patients undergoing surgery for degenerative cervical myelopathy were satisfied with the outcome of surgery and had a subjective impression of symptoms improvement. The development of postoperative complications did not seem to have an influence on the results of the procedure.
70 COMPLICATIONS OF SURGERY IN PATIENTS WITH DEGENERATIVE CERVICAL MYELOPATHY Principal Author: Plano Jerez, Xavier Center: Hospital Universitario Vall d’Hebro´n, Barcelona, Spain Additional Authors: Matamalas Adrover, Antonia; Ferna´ndez Bautista, Alejandro; Pellise´ Urquiza, Ferran; Garcı´a de Frutos, Ana; Casamitjana Ferra´ndiz, Jose´ Center: Hospital Universitario Vall d’Hebro´n, Barcelona, Spain Aim: To analyze the complications secondary to cervical surgery in patients with degenerative myelopathy and evaluate the influence of the type of approach used on development of complications. Materials and Methods: Retrospective analysis of patients surgically treated for degenerative cervical myelopathy between 2005 and 2010 (minimum follow-up[1 year). Data were collected on demographics, preoperative comorbidity, complications (medical, surgical, and mechanical), and reinterventions in the immediate postoperative period and during follow-up. Results: A total of 237 procedures were reviewed in 221 patients (mean age 52.2 years; 66.5 % men). At least one associated comorbidity was recorded in 78.3 % of patients (mean number of comorbid conditions/patient 2.07). Mean duration of hospitalization was 9.8 days (SD ± 8.3). Among the total, 26.6 % of patients presented at least one postoperative complication (minor 14.8 % and major 11.8 %). The most common medical complications were respiratory failure (4.2 %), dysphagia (4.2 %), and urinary infection (3.4 %). Surgical would complications occurred in 6.8 %: 3.8 % dehiscences and 3 % infections (2.1 % deep). Preoperative myelopathy deterioration occurred in 1 case (0.4 %). Mechanical complications developed in 3.8 %. Reinterventions were needed in 9.3 % (2.5 % debridements, 6.3 % myelopathy progression, 0.4 % instrumentation failure). Mortality was 0.8 %. Among patients treated with an anterior (n = 157) or posterior (n = 75) approach, 9.6 % and 16 %, respectively, experienced major complications. Patients treated by posterior technique were older (62.7 vs. 55.8), had a larger number of operated levels (3.3 vs. 2.2), and longer hospitalization (11.6 vs. 8.5 days). As compared to the anterior approach, posterior surgery was associated with a higher rate of medical complications (p = 0.04), wound complications (p = 0.03), and neurological radicular complications (pain 8.1 % vs. 1.3 %, p = 0.01; and deficit 5.4 % vs. 0.6 %, p = 0.04). C6 (1.9 %) and C5 (1.5 %) paresis were the most common. There were no differences with regard to the number of levels treated or the different types of complications. Older patients had a larger number of postoperative medical complications (p = 0.001).
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Conclusions: One quarter of patients surgically treated for cervical myelopathy develop some type of postoperative complication. Older patients have a higher risk of medical complications, whereas those operated by posterior approach have more surgical wound complications.
Center: Hospital Mancha-Centro, Alca´zar de San Juan, Ciudad Real, Spain
71
Centers: 1Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 2 Universidad Cato´lica de Valencia, Spain; 3Hospital La Fraternidad de Madrid, Spain; 4Hospital Son Espases de Palma de Mallorca, Spain
EVOLUTION OF PATIENTS MORE THAN 21 MONTHS ON THE WAITING LIST FOR LUMBAR MICRODISCECTOMY (2004–2010) Principal Author: Bosch Garcı´a, David Center: Hospital Universitari Mu´tua Terrassa, Barcelona, Spain Additional Authors: Morera Domı´nguez, Carles; Yela Verdu´, Chris´ lvarez, Saioa tian; Quintas A Center: Hospital Universitari Mu´tua Terrassa, Barcelona, Spain Introduction: Most patients with radiculopathy due to disc herniation cure spontaneously without the need for surgery. Surgery for disc herniation is indicated in hyperalgesic patients, those refractory to treatment, and those with a progressive neurological lesion. The aim of our study is to assess the clinical status of a group of patients who had been on the waiting list for microdiscectomy treatment for more than 21 months. Materials and Methods: The study group for clinical review was comprised of 48 patients (22 women and 26 men), with a mean age of 51.3 years, and on the waiting list for a simple microdiscectomy procedure from January 2004 to December 2010. Eighteen patients were excluded from the study group (4 could not be located, 10 declined, and 4 underwent surgery in other centers). Hence, the final group included 30 patients, in whom their current clinical status was evaluated with the VAS, ODI, and SF-12 instruments. Results: Of the 30 patients on the microdiscectomy waiting list reviewed, 15 patients were removed (9 mild low back pain and 6 without current pain), in 9 patients the surgical indication was changed (8 fusion and 1 laminectomy), and in 6 the same indication was maintained. In the 15 patients with a surgical indication, the mean ODI value was 41 %, mean lumbar VAS 5.6, mean radicular VAS 4.5, and mean SF-12 scores were 27 for the physical component and 43.25 for the mental component. None of the patients had a neurological lesion during their time on the waiting list. Conclusion: We found that the clinical status improved without the need for surgery in more than 50 % of patients. Among those in whom an indication for surgery remained, the type of surgical indication changed in 60 % during the time on the waiting list.
Additional Authors: Burgos Flores, Jesu´s1; Del Olmo, Teresa1; Barrios Pitarque, Carlos2; Hevia Sierra, Eduardo3; Anto´n Rodriga´lvarez, Miguel1; De Blas Beorlegui, Gema1; Sanpera Trigueros, Ignacio4
Aim and Introduction: There are reports of radicular lesions that go unnoticed in neurophysiological and conventional radiologic controls in vertebral deformities. The aim of this study is to assess a neurophysiological examination that will identify these cases intraoperatively. Materials and Methods: In 294 patients surgically treated between 2004 and 2010 by a posterior approach with pedicle screws using a freehand technique, 6765 pedicle screws were implanted, 1550 lumbar and 5088 thoracic. Eight of these patients (2.7 %), with a mean age of 24 years, presented radicular pain. On postoperative CT, 10 lumbar pedicle screws (2 L1, 3 L2, 4 L3, 1 L4) were found to slightly protrude in the inferior part of the pedicle. The EMG thresholds of the screw and screw tract were evaluated. Results: During the initial surgery, no anomalies were detected on palpation of the screw trajectory or by radioscopic control, and there were no changes on screw stimulation (s-EMG). All patients presented radicular pain when standing and sitting that remitted with bedrest. Screws were removed without repositioning at a mean of 37 days (R: 4–182). In this procedure, screw stimulation was repeated, and again, normal values were obtained (C11 mA). Following pedicle screw removal, stimulation of the screw tract was performed, and thresholds below normal values (3.9–10.7 mA) were found in the middle portion. After a mean follow-up of 4.4 years (R: 2.0–6.8), 5 patients reported occasional radicular discomfort and a minimal motor deficit in the affected leg. Conclusions: This study presents a type of lumbar pedicle screw malposition producing radicular pain on standing–sitting that is not detected by conventional monitoring. Stimulation in the middle area of the tract after removing the pedicle screw produced low stimulation thresholds. Routine stimulation of the screw tract is recommended before insertion of lumbar screws.
73 LUMBOSACRAL FUSION IN POSTDISCECTOMY SYNDROMES Principal Author: Bermu´dez Santos, Washington
72
Center: CE.DEF.CO (Centro de Deformidades de Columna) Montevideo, Uruguay
LUMBAR PEDICLE SCREW MALPOSITION WITH NORMAL NEUROPHYSIOLOGICAL STIMULATION PRODUCING POSTOPERATIVE MECHANICAL RADICULAR PAIN: VALUE OF NEUROPHYSIOLOGICAL STIMULATION OF THE SCREW TRACT
´ lvaro; Pereyra Baison, Additional Authors: Rocchietti Infante, A Leo´nardo
Principal Author: Garcı´a Gonza´lez, Vicente
123
Center: CE.DEF.CO (Centro de Deformidades de Columna), Montevideo, Uruguay Aim: To evaluate the efficacy of lumbosacral fusion in postdiscectomy syndromes. Periodic assessments of our surgical results over the years (1978–2008) marked a turning point in this subject. We now present an updated evaluation.
Eur Spine J (2014) 23:248–288 Material and Method: In the period of January 1998 to December 2008, 2363 patients underwent surgery in our center, and 1141 procedures were lumbosacral fusions. All patients were operated on by the same surgical team. Fifty-five patients had a history of one or more surgeries for disc herniation (DH), and 36 had complete medical records and could be contacted. All patients were interviewed by telephone, and outcome was rated according to Odom’s criteria. In addition, the psychosocial status of the sample was analyzed. Results: The 36 clinical histories reviewed were from 22 women and 14 men. More than 40 % had been operated at least twice for DH. Follow-up of the sample ranged from 5 to 15 years, with a mean of 10 years. Outcome based on Odom’s criteria was excellent or good in 52 % and regular or poor in 48 %; patients were analyzed by category. In those who underwent two or more DH surgeries, the outcome changed to 40 % and 60 % respectively. Analysis by cohorts showed that values worsened as postoperative time increased, with no regular pattern, until the values mention above were reached. As to the patients’ psychosocial status, 70 % of patients had histories of psychiatric treatment, which were analyzed. Conclusions: 1) 2)
3)
4)
It is clear that the procedure used did not achieve the expected outcome, even considering that it was a salvage procedure. The more times patients underwent DH surgery, the poorer was the outcome. Based on these findings, salvage surgery should be reconsidered according to other, more complex factors than simply mechanical ones. In this line, presence of the psychosocial component in the profile of these patients. Despite the results of earlier internal evaluations and efforts to eliminate factors related to a poor prognosis, unsatisfactory outcomes continue to occur. The most rational measure is to increasingly limit the HISTORY, that is, surgery for DH.
281 Our aim was to evaluate the results of surgical treatment of recurrent lumbar disc herniation in patients within the workers’ compensation program. Materials and Methods: Retrospective case series study. We identified patients in the workers’ compensation program who had undergone surgery for recurrent lumbar disc herniation between June 1994 and May 2011. Their medical records were reviewed, pertinent data were collected, and a descriptive statistical analysis was performed. Results: A total of 109 patients were identified, 106 males (97.2 %). The median time between the primary discectomy and that for the recurrent herniation was 62.3 months (5–226.5). Sixty-four percent of the patients were operated at L5-S1, 34.9 % at L4–L5, and only one required a second surgery at L3-L4 (0.9 %). A new discectomy alone was required in 99 patients (90.8 %), whereas 9.2 % (10 patients) needed lumbar fusion due to excessive resection of the facet joint or preoperative diagnosis of segmental instability. The mean operative time was 123 min (105 min for the discectomy group and 299 min for discectomy plus fusion). Three patients (2.8 %) presented surgeryrelated complications. Patients returned to work at a mean of 73.5 days (22–315, median 64 days). Disability compensation due to chronic pain was granted to 24 of the 109 patients (22 %). Median follow-up was 110.8 months (15.4–217.3). According to our previous reports, these results are comparable to those of the primary discectomy in compensated patients, considering time out of work (73.5 and 57.7 days respectively) and surgery related complications (2.8 % and 2 % respectively), but not regarding the need for disability compensation (22 % and 8 % respectively). Conclusion: The results of surgical treatment for recurrent lumbar disc herniation in a population of patients under a workers’ compensation program are comparable to those of primary discectomy, particularly regarding time out of work and surgery-related complications.
74 75 SURGICAL TREATMENT OF RECURRENT LUMBAR DISC HERNIATION IN PATIENTS WITHIN A WORKERS’ COMPENSATION PROGRAM
LUMBAR FUSION AND INSTRUMENTATION IN PATIENTS WITH A SECOND RECURRENCE OF LUMBAR DISC HERNIATION
Principal Author: Zamorano Pe´rez, Juan Jose´
Principal Author: Urzua Bacciarini, Alejandro
Center: Hospital del Trabajador, Santiago, Chile
Center: Hospital del Trabajador, Providencia, Chile
Additional Authors: Lira Prado, Fernando; Ballesteros Plaza, Jose´; Yurac Barrientos, Ratko; Urzua Bacciarini, Alejandro; Ilabaca Grez, Francisco; Fleiderman Valenzuela, Jose´; Lecaros Larenas, Miguel ´ ngel; Munjin Leo´n, Milan; Ramı´rez Pittaluga, Sergio; Tapia Pe´rez, A Carlos
Additional Authors: Valiente Valenzuela, Diego; Zamorano Pe´rez, Juan; Ballesteros Plaza, Jose´; Yurac Barrientos, Ratko; Ilabaca Grez, Francisco; Fleiderman Valenzuela, Jose´; Munjin Leo´n, Milan; Lecaros Larenas, Miguel; Tapia Pe´rez, Carlos; Ramı´rez Pittaluga, Sergio Center: Hospital del Trabajador, Providencia, Chile
Center: Hospital del Trabajador, Santiago, Chile Introduction: Recurrent disc herniation refers to the presence of disc material within the spinal canal from a previously operated disc. The reported incidence for this entity ranges between 3 % and 18 %. The workup of these patients involves gadolinium-enhanced magnetic resonance imaging, electromyography of the lower extremities, and dynamic lumbar spine radiography. Surgical resection of a recurrent herniation is technically more demanding, due to the presence of scar tissue, and altered anatomy, so it is usually associated to a higher complication rate (up to 14.3 % of the patients present dural tears).
Introduction: The incidence of primary recurrence of lumbar disc herniation is 3 % to 18 %. There are no data on the incidence and treatment of second recurrent hernias. In most patients, surgical treatment of a second recurrent hernia includes discectomy and fusion of the affected lumbar segment. Treatment is more complex in these cases and the results differ from those of patients treated for a primary recurrence. The aim of this study is to evaluate the results of instrumented fusion of the lumbar spine for treating a second hernia recurrence in a group of patients included in the workers’ compensation program.
123
282 Materials and Methods: Retrospective case series study. Patients within the workers’ compensation program who underwent surgery in the spinal unit for a second recurrent disc herniation between June 1994 and May 2011 were identified. We reviewed their clinical histories, recorded pertinent data, and performed a descriptive statistical analysis. Results: Twelve patients were identified, 11 men (91.7 %). Mean age at the second recurrent hernia procedure was 44 years (34–58). Median time between surgery for the first and second hernia recurrence was 24.6 months (2.5–95.5). The levels treated were L5–S1 in 77 % of patients and L4–L5 in the remaining 33.3 %. One patient (8.3 %) presented a surgery-related complication (dural tear). The mean time to return to work was 130.5 days (58–330, median 113 days). Disability compensation due to chronic pain was awarded to 7 patients (58.3 %). Median follow-up was 65.6 months (16–158.6). Conclusion: Surgical treatment for a second lumbar disc herniation in a population within a workers’ compensation program was only needed at levels L4–L5 and L5–S1. These patients take longer to recover and present a higher incidence of chronic low back pain requiring compensation than patients undergoing surgery for a primary recurrence of lumber disc herniation.
Eur Spine J (2014) 23:248–288 measures and the TAPS or SAQ. There were no correlations between the SRS-22 and the photographic measures. Conclusion: The height of the waist folds measured by digital photography showed a moderate correlation with the self-perceived trunk deformity. Trunk asymmetry correlated poorly with self-perceived body image. Pictorial scales correlated better with the photographic images than verbal scales.
77 ENDOCRINE DISEASE AS A RISK FACTOR FOR VERTEBRAL FRACTURES Principal Author: De la Calva Ceinos, Carolina Center: Hospital Universitario y Polite´cnico La Fe, Valencia, Spain Additional Authors: Jover Jorge, Nadia; Cruz Miranda, Daniel; Bonete Lluch, Daniel; Bas Hermida, Paloma; Bas Hermida, Teresa Center: Hospital Universitario y Polite´cnico La Fe, Valencia, Spain
76 ANALYSIS OF THE CORRELATION BETWEEN TRUNK DEFORMITY MEASUREMENT WITH DIGITAL PHOTOGRAPHY AND SELF-PERCEIVED BODY IMAGE IN PATIENTS WITH IDIOPATHIC SCOLIOSIS (IS) Principal Author: Matamalas Adrover, Antonia Center: Hospital Universitario Vall d’Hebro´n, Barcelona, Spain Additional Authors: Bago´ Granell, Juan; D’Agata, Elisabetta; Pellise´ Urquiza, Ferran; Garcı´a de Frutos, Ana; Ca´ceres Palou, Enric Center: Hospital Universitario Vall d’Hebro´n, Barcelona, Spain Introduction: It has been suggested that some measures of trunk deformity by digital photography may be useful for clinically assessing the deformity. The relationship between these measurements and patients’ perception of their body image has not been analyzed. Aim: To evaluate the validity of a clinical measure of trunk deformity based on digital photography compared with the self-perceived body image. Methods: Photographs were taken of the front and back views of IS patients (Cobb [25). Five different angles were calculated at the level of the shoulders, axillas, and waist, and two trunk asymmetry scores were determined in both photographic views, using the Surgimap software. All patients completed the SRS-22, SAQ, QLSDP, and TAPS questionnaires. Correlations were determined using the Pearson correlation coefficient. Results: Eighty consecutive patients were included (68 females and 12 males), aged 12 to 40 years (mean 20.3 y). Mean Cobb was 45.9 (range 25.1–77.2). A statistically significant correlation was found between the angle formed by the height of the waist folds and TAPS (r = 0.26–0.32), SAQ-image (r = 0.31–0.36), and SAQ total (r = 0.29–0.33). There were no further correlations between the remaining photographic
123
Introduction: Endocrine diseases are related with bone metabolism abnormalities. Recent studies have demonstrated an association between osteoporotic vertebral fractures and this type of disease. Aim: Prospective study of the relationship between endocrine disease and osteoporotic vertebral fractures following a low-energy trauma. Materials and Methods: Prospective enrollment of 23 patients hospitalized for acute vertebral fracture following a low-energy trauma. We analyzed age, sex, location of the fracture, and history of endocrine disease and omeprazole treatment. Radiologic studied included plain radiography, CT and MRI, with analysis of the anterior, middle and posterior spine involvement, and loss of height and kyphosis angle. Analysis of bone metabolism markers was performed (betaCTX, P1NP, AP, vitamin D and PTH). Results: All patients were hospitalized for a low-energy acute vertebral fracture. Distribution by sexes was 91.3 % women and 8.7 % men. The affected vertebral level was thoracolumbar in 65.2 %, lumbar 21.7 %, and thoracic 13 %. Mean age was 72.43 ± 9.05 years. The incidence of endocrine abnormalities was 56.53 %, among them thyroid metabolism changes, DM, Addison syndrome, suprarenal incidentaloma, and a double adnexectomy. Among the total, 34.78 % of patients were receiving omeprazole treatment. Analysis of bone metabolism markers showed a vitamin D decrease in 80 % of patients. The radiographic results according to the presence or absence of endocrine abnormality are shown in the Table. There were no cases of posterior spine involvement. Conclusion: There is an association between endocrine disease and vertebral fractures. Among the lesions affecting patients with endocrine abnormalities, there were more cases of anterior and middle column involvement, greater loss of height, and a larger kyphosis angle. Patients with vertebral fractures present a vitamin D deficit.
Endocrine abnormality
No endocrine abnormality
Anterior column
46.1 %
60 %
Anterior and middle column
53.8 %
40 %
Height loss
19.19 ± 19.6 %
19.04 ± 13.35 %
Kyphosis
12.32 ± 8.768
5.02 ± 5.528
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78
Center: Hospital Universitario Rı´o Hortega, Valladolid, Spain
HISTOLOGIC STUDY IN A SERIES OF CHORDOMAS. PROGNOSTIC FACTORS
Additional Authors: Ramos Galea, Rafael; Escudero Marcos, Roberto; Paredes Herrero, Elena; Garcı´a Garcı´a, Javier Minaya; Alonso Garcı´a, Noelia; Garcı´a Alonso, Manuel Francisco
Principal Author: Rosello´ Sastre, Esther
Center: Hospital Universitario Rı´o Hortega, Valladolid, Spain
Center: Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain Additional Authors: Martı´n Benlloch, Juan Antonio1; Martı´nez Ciarpaglini, Carolina2; Morales Codina, Ana Marı´a1; Molina Aguilar, Ma Jesu´s1 Centers: 1Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain; 2Hospital Clı´nico Universitario de Valencia, Spain Introduction: Chordoma is an uncommon, low-grade, malignant primary bone tumor that is locally aggressive, but has low metastasizing capacity, and is commonly recurrent. Symptoms often manifest at a late stage, when there is advanced local destruction, making their removal difficult. Nonetheless, only complete resection with wide margins guarantees lengthy disease-free survival. The need for associated radiotherapy worsens the prognosis. Materials and Methods: Eleven chordomas surgically treated between 2002 and 2012. Histological study of all samples: initial biopsy, surgery, and biopsied recurrent disease or metastasis. Results: Complete initial resection was achieved in 7 cases. In 3 patients, the margins were affected and in one, palliative surgery was performed. These 4 cases received radiotherapy. Three died due to loco-regional problems, there were 3 cases of local recurrence, and 2 cases of osteomuscular metastasis with no response to Imatinib. The 8 remaining patients were disease-free. The most common histological and immunohistochemical patterns were conventional chordoma, multilobulated pattern of clear cells (9), neural infiltrative, glandular differentiation, and positive for EMA (9), cytokeratins AE1/AE3 (10), S-100 (9), and vimentin (11). Uncommon histological features related to greater tumor aggressiveness included focal dedifferentiation on conventional chordoma, sarcomatoid dedifferentiation as the single pattern in recurrent chordoma, foci of greater cell density in conventional chordoma with elevated proliferative activity (Ki-67); infiltration of margins at a distance from the resection margin, supported by low molecular weight cytokeratin (CK 8–18). Three patients had a history of oncologic disease: 1 cutaneous melanoma, 1 prostate cancer treated with radiotherapy, and 1 rectal adenocarcinoma, synchronous with the chordoma. Conclusions: Chordoma is an aggressive, slow growing local tumor with metastatic capability. Extensive surgery facilitates longer disease-free survival. The histology does not modify the prognosis if the resection is performed with wide disease-free margins. Incomplete resection is associated with recurrence at 3–5 years. Complete study of the surgical specimen is needed to estimate the prognosis. The presence of other synchronous or metachronous malignant tumors was common in our series, although it is unusual in the literature.
Introduction: Discectomy and interbody fusion is the most commonly used technique to treat cervical spondylosis; fusion with iliac crest graft is the reference standard. Interbody devices have been used for years to avoid associated complications. Our aim, in addition to evaluating the results of tantalum use, is to investigate the need for complementary internal fixation. Material and Method: Retrospective study including 32 patients with cervical myeloradiculopathy unresponsive to conservative management for at least 6 months, surgically treated between March 2008 and February 2012 by discectomy and cervical fusion using a tantalum device at one or two levels. Internal screw and plate fixation was additionally used in 15 cases. We performed a clinical evaluation (pre- and postoperative Neck Disability Index [NDI] and Odom’s criteria) and radiographic study (functional views at the time the study was designed). Results: Mean follow-up was 27.7 months. Mean age was 46.81 years and 64.71 % were men in the group receiving fusion with the tantalum device, and 52.6 years and 66.6 % men in the group with tantalum device and plates. In both groups, there was a significant improvement in the previous clinical-functional status according to the NDI. Rating was good or excellent according to the Odom criteria in 72 % of cases, with no significant differences between the groups. Complications were detected in the implant alone group: one case of early device mobility, one case of pseudoarthrosis, and one inferior plate collapse requiring a reoperation using the Smith-Robinson technique. There were no significant differences regarding radiologic spondylosis progression in levels adjacent to the fusion and in sagittal alignment. Conclusions: The results in both groups were satisfactory in most cases and comparable to reported results in similar series. In osteoporotic patients, use of internal fixation seems to provide primary stability and may favor fusion and avoid complications such as implant mobility or vertebral plate collapse.
80 ANTERIOR CERVICAL DISCECTOMY. COMPARATIVE STUDY OF FUSION VERSUS CERVICAL ARTHROPLASTY Principal Author: Mostaza Saavedra, Antonio Center: Complejo Asistencial Universitario de Leo´n, Spain Additional Authors: Iglesias, Elena; Robla, Javier; Iba´n˜ez Plagaro, Javier Center: Complejo Asistencial Universitario de Leo´n, Spain
79 CERVICAL DISCECTOMY AND FUSION WITH TANTALUM IMPLANTS. IS INTERNAL FIXATION NECESSARY? Principal Author: Pe´rez Bermejo, Diego
Aim: Anterior cervical decompression and fusion (ACDF) is a common cervical procedure that yields good clinical results. The aim of total cervical disc replacement (TDR) is to treat radicular pain and preserve cervical function. The objective of this study is to compare the safety and efficacy of cervical TDR with that of anterior cervical discectomy and fusion (ACDF) at one level between C3 and C7. Materials and Methods: Ninety-four patients with degenerative cervical disc disease were treated (endoscopic approach) between 2004
123
284 and 2012 by fusion (51 patients) and TDR (43 patients). Age: TDR group 41.4 ± 7.4 years, 43.8 % men; fusion group 47.5 ± 8.1 years, 45.6 % men. Most commonly treated level, C5–C6 (TDR 57.3 %, fusion 54.5 %). Patients were evaluated with the VAS, Neck Disability Index (NDI), standardized questionnaire (SF-36), neurologic examination, and adjacent space assessment. Evaluations before and after surgery, at 6 weeks, and at 6, 12, 18 and 24 months. Results: Patients treated with a disc prosthesis returned to work 3 weeks before those treated with fusion (P = 0.015). The 12-month analysis demonstrated an improvement in both groups; nonetheless, at 24 months, patients treated with TDR showed a statistically significant increase in the variables NDI (P \ 0.025) and VAS (P = 0.010). There were no complications in either group. The fusion group required 4 reoperations (adjacent space syndrome). Although progression of disc degeneration was demonstrated in both patient groups over 8 years, ACDF patients had a significantly higher incidence than those with a disc implant, whereas progression of adjacent segment degeneration was not always related with development of new symptoms. Conclusions: Cervical disc arthroplasty is a new method under development for surgical treatment of cervical disc disease. There is a reduction in the rate of secondary surgeries as compared to ACDF. At two years of follow-up, cervical arthroplasty is a viable alternative to anterior cervical discectomy with fusion in patients with degenerative cervical disc disease.
Eur Spine J (2014) 23:248–288 Results: Duration of surgery (min) was shorter in the SPO group relative to PSO and VCR (420 ± 347 vs. 578 ± 459 vs. 533 ± 435) (p \ 0.00). Intraoperative blood loss (cc) was also lower in SPO than in PSO or VCR (1341 ± 804 vs. 2364 ± 1459 vs. 2134 ± 1335) (p \ 0.03). Thirty-eight percent presented complications, with no significant differences between the groups. There were no differences in the mean correction of segmental kyphosis, but differences were seen for SVA correction (cm), with the SPO group showing a smaller correction than PSO or VCR (3.95 vs. 8.3 vs. 8.33) (p \ 0.00). Nonetheless, the preoperative SVA was significantly greater in the PSO and VCR groups (4.83 ± 3.20 vs. 13.4 ± 11.0 vs. 13.0 ± 12.3). In the SRS-22, significant changes were seen in the 3 groups in all dimensions with respect to the preoperative status, with no significant differences between the groups. Conclusions: There were no differences regarding complications, although the condition was more severe in the PSO and VCR groups. Although there were no differences in correction of segmental kyphosis, PSO and VCR obtained better results for SVA change. There were no differences in the patients’ quality of life between the groups.
83 LONG SPINOPELVIC FUSIONS: FACTORS WITH AN IMPACT ON THE INCIDENCE OF NON-UNION
82
Principal Author: Burgos Flores, Jesu´s
COMPARISON OF THE OUTCOMES OF SMITHPETERSEN OSTEOTOMIES, PEDICLE SUBTRACTION OSTEOTOMIES, AND VERTEBRECTOMY IN THE TREATMENT OF SAGITTAL IMBALANCE
Center: Hospital Universitario Ramo´n y Cajal, Madrid, Spain
Principal Author: Morales Codina, Ana Marı´a Center: Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain Additional Authors: Valverde Belda, Diego; Mun˜oz Donat, Sonia; Sa´nchez Monzo´, Carlos; Aguirre Garcı´a, Rafael; Molina Aguilar, Ma Jesu´s; Martı´n Benlloch, Juan Antonio Center: Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain Introduction: Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), and vertebral column resection (VCR) are widely used for correcting sagittal imbalance. Few studies have compared the outcome of these three procedures. Aims: To compare the clinical and radiologic results of three types of osteotomies in patients with fixed sagittal imbalance. Materials and Methods: Observational retrospective study, comparing 42 patients who underwent more than 2 SPOs (n = 14), PSOs (n = 16), or VCRs (n = 12) and posterior instrumentation for fixed sagittal imbalance in the period of 2003–2012. The sample included 71.4 % men and mean age was 43 years (17–74). The mean follow-up time was 5 years (2–10). Intraoperative and postoperative complications were recorded. All patients completed the SRS-22 questionnaire preoperatively and at the end of follow-up. The segmental kyphosis angle, and the sagittal vertical axis (SVA) were measured in the preoperative period and at 2 years postoperatively.
123
Additional Authors: Vera Ibars, Pablo1; Barrios Pitarque, Carlos1; Sa´nchez Ru´as, Jaime2; Hevia Sierra, Eduardo3; Anto´n Rodriga´lvarez, Miguel2; Dome´nech Ferna´ndez, Pedro4; Sanpera Trigueros, Ignacio5; Piza´ Vallespir, Gabriel5 Centers: 1Universidad Cato´lica de Valencia, Spain; 2Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 3Hospital La Fraternidad de Madrid, Spain; 4Hospital General Universitario de Alicante, Spain; 5 Hospital Son Espases de Palma de Mallorca, Spain Aims and Introduction: A large percentage of non-unions occur in long spinopelvic fusions due to the high mechanical demands in the lumbosacral region, and the incidence persists when iliac screws are used. The aim of this study is to identify the factors implicated in nonunion, to decrease this complication. Materials and Methods: Forty-four patients with scoliosis and no previous surgical treatment, who completed the protocol of this retrospective study, were treated by a posterior only approach in a single surgical stage. Instrumentation was performed to T2 or T3, with bilateral placement of pedicle screws and iliac screws. Radiographic non-union was defined as rod breakage and/or connection loosening and/or lysis around the screws. Results: Mean age 23.9 years. Etiologies: CP (27 %), adult idiopathic (16 %) congenital (14 %); 34 % were unable to walk. Mean followup 57 months (25–124). Preoperative Cobb of the main curve 74.28 (40–135), final correction 67 %; T5–T12 kyphosis 208 to 408 initially in 32 % and final in 89 %. T12–S1 lordosis -20 to -608 initially in 73 % and final in all patients except one. Preoperative pelvic inclination [15 in 11 and final \158 in all. 41 % presented lumbosacral non-union, with a significantly lower incidence in patients \17 years of age and non-ambulatory cases. One iliac screw was used at each side in 24 patients, and non-union occurred in 42 %, with 50 % of lysis around the iliac screw or distal loosening. In cases with two or more iliac screws at each side, rod
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breakage occurred in 45 %, with no other implant failures. In 5 patients with L3–S1 interbody fusion and in 7 ambulatory patients with a third rod and compression hooks, non-union did not occur. Conclusions: In long spinopelvic fusions, placement of more than one iliac screw at each side did not decrease the incidence of nonunion. Use of interbody implants in the three levels distal to the fusion or a third rod with compression hooks associated with more than 2 iliac screws significantly decreased this complication. These lumbosacral reinforcement techniques are particularly indicated in ambulatory patients and those older than 17 years, because this population has a higher incidence of non-union.
Conclusion: Corrective osteotomy treatment by for FSPD in patients with major disability results in a significant functional improvement and a high degree of satisfaction, despite older age and the high percentage of complications. Age should not be considered an absolute contraindication.
84
Radicular VAS Pre
SURGICAL TREATMENT OF RIGID SAGITTAL DEFORMITIES IN PATIENTS OLDER THAN 70 YEARS. IS A RISK JUSTIFIED? ´ lvarez Galovich, Luis Principal Author: A
Variable Lumbar VAS
ODI
CORE 2
Center: Fundacio´n Jime´nez Dı´az, Madrid, Spain ´ ngel R; Tome´ Bermejo, Fe´lix; Additional Authors: Pin˜era Parrilla, A ´ lvarez, Carmen; Vlad, Marı´a Lo´pez San Roma´n, Bele´n; Dura´n A Daniela; Mahillo Ferna´ndez, Ignacio
CORE 3
Center: Fundacio´n Jime´nez Dı´az, Madrid, Spain
CORE 6a
Aim and Introduction: The incidence of fixed sagittal plane deformity (FSPD) increases with age. Various types of corrective osteotomies have been developed to treat this condition. This is demanding surgery with a high rate of complications; hence, it is rarely indicated in the elderly population. The aim of this study is to evaluate the clinical and radiologic results, and complications of this procedure in patients older than 70 years. Materials and Methods: This is a retrospective study including 24 patients older than 70 years consecutively treated for FSPD by corrective osteotomy, and with more than 1 year of follow-up (mean 28.7 months). We analyzed the following: scores on the visual analogue scale (VAS), Oswestry Disability Index (ODI), and Core Outcome Measure Index (COMI), clinical complications, and radiologic results, including the pelvic incidence, lumbar lordosis, pelvic tilt, and sagittal axis. Functional results were analyzed based on the mean increase and the percentage of patients reaching the threshold of a clinically significant difference. Results: Mean age was 74.3 years (70–81). A significant improvement was seen in all the functional parameters and quality of life at 6 months, and in yearly follow-up visits. Mean ODI improvement at 1 year was 40.86 points. There was a significant improvement in the lumbar and radicular VAS (p \ 0.001). Among the total, 74 % of patients were satisfied or very satisfied with the procedure; 95 % of patients used opioid drugs before surgery, and only 12 % at the end. There were 10 major preoperative complications (41.6 %), the most common being deep infection (29 %). One death occurred, due to a respiratory complication. During follow-up, 33 % required a second surgery.
CORE 6b
Variable Lumbar VAS
Situation N Mean SD
Median P25
P75
Pre
23 8.09
2.71
9.00
7.50
10.00
6 months 21 4.52 1 year 23 3.00
3.08 1.68
4.00 3.00
2.00 2.00
6.00 4.50
23 5.83
3.13
6.00
3.50
8.00
6 months 21 3.24
2.51
2.00
2.00
4.00
1 year
23 2.96
2.55
2.00
1.00
5.00
Pre
23 69.85 11.72 73.33
64.44 81.11
6 months 21 39.15 17.35 36.00
26.00 55.56
1 year
23 28.99 13.79 26.00
23.11 36.00
Pre
23 3.91
0.29
4.00
4.00
4.00
6 months 20 1.95
1.15
2.00
1.00
3.00
1 year
23 1.57
1.08
1.00
1.00
2.50
Pre
23 0.09
0.42
0.00
0.00
0.00
6 months 20 1.35
1.09
1.50
0.00
2.00
1 year
21 1.86
1.31
2.00
1.00
3.00
Pre
22 0.82
1.22
0.00
0.00
1.00
6 months 20 3.00
1.30
3.00
3.00
4.00
1 year Pre
23 3.13 22 0.59
1.06 1.05
3.00 0.00
3.00 0.00
4.00 1.00
6 months 20 3.00
0.92
3.00
3.00
4.00
1 year
0.83
3.00
2.50
4.00
Comparison N Median P25
CORE 2
CORE 3
P75
p
Pre-6 m
20 -42.22 -68.75 -25.00 0.0019
Pre-1y
22 -61.25 -80.00 -50.00 0.0001
6 m-1y
19 -16.67 -53.57 0.00
Radicular VAS Pre-6 m Pre-1y ODI
23 3.17
0.0633
20 -63.33 -78.33 -18.12 0.0275 22 -56.25 -82.50 -5.56 0.0011
6 m-1y
19 -20.00 -55.00 0.00
Pre-6 m
21 -47.09 -61.08 -24.32 0.0000
0.0432
Pre-1y
23 -61.08 -70.57 -45.45 0.0000
6 m-1y
21 -13.33 -33.33 0.00
Pre-6 m
20 -50.00 -75.00 -25.00 0.0002
Pre-1y
23 -75.00 -75.00 -29.17 0.0000
6 m-1y
18 0.00
Pre-6 m
1
-50.00 -50.00 -50.00
Pre-1y
1
-50.00 -50.00 -50.00
6 m-1y
13 0.00
0.0799
-50.00 0.00
0.00
0.00
0.4112
0.7835
123
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Eur Spine J (2014) 23:248–288
85
continued
IS ADULT VERTEBRAL DEFORMITY ADEQUATELY DEFINED USING THE SRSSCHWAB CLASSIFICATION? Principal Author: Domingo Sa`bat, Montse Center: Hospital Universitari Vall d’Hebro´n, Barcelona, Spain Additional Authors: Pellise´ Urquiza, Ferra´n1; Acaroglu, Emre2; Sa´nchez Pe´rez-Grueso, Francisco J.3; Alanay, Ahmet4; Garcı´a de Frutos, Ana1; Vila Casademunt, Alba1; Bago´ Granell, Joan1; European Spine Study Group ESSG1
Idiopathic
Degenerative
p
Sagittal modifier 0 (%)
86–88
11–13
\0.0001
Sagittal modifier? (%)
38–53
47–61
Sagittal modifier?? (%)
22–34
65–77
Age (years)
36.2
65.4
\0.0001
SF-36 PCS curve L
41.2
33.4
\0.001
SF-36 PCS curve N
45.4
34.2
\0.0001
Oswestry curve L
25.2
49.5
\0.0001
Oswestry curve N
18.3
51.8
\0.0001
SRS-22 Subtotal curve L
3.3
2.6
0.0002
SRS-22 Subtotal curve N
3.6
2.9
\0.0001
Centers: 1Hospital Universitari Vall d’Hebro´n, Barcelona, Spain; 2 Ankara Spine Center, Istanbul, Turkey; 3Hospital Universitario La Paz, Madrid, Spain; 4Acibadem Maslak Hospital, Istanbul, Turkey Introduction: The only available published data on the SRS-Schwab adult spinal deformity (ASD) classification is related to the reliability of the instrument. The aims of this study are to determine the incidence of the different types of curves and to evaluate the homogeneity of the patients included in each subgroup. Patients and Methods: The radiologic data (coronal and sagittal) and quality of life data (QOL) (ODI, SRS-22, SF-36) were analyzed in all patients with degenerative or idiopathic deformity, consecutively recruited in a prospective multicenter database. Inclusion criteria: age [18 years and coronal Cobb [208, vertical sagittal axis [5 cm, pelvic inclination [258 or thoracic kyphosis [608. Patients were classified according to the SRS-Schwab criteria. Distribution of patients was compared according to age and diagnosis. Patients’ QOL was compared according to the curve type and sagittal modifier, taking into account the diagnosis of the deformity. Non-parametric tests (Mann–Whitney, Kruskal–Wallis) and the Dunn test were used for the comparisons, (significance p \ 0.05). Results: We evaluated 368 patients (83.9 % women), with a mean age of 44.1 years (18–88), 73.1 % idiopathic and 26.9 % degenerative. The overall incidence of each type of curve was as follows: T 14.3 %, L 16.3 %, D 40.4 %, and N 28.9 %. Among patients included in type N, 56.6 % presented a minor coronal deformity (208–308) and 43.4 % only a sagittal deformity. The distribution of the type of coronal curve and sagittal modifiers differed between patients with idiopathic or degenerative disease (Table). Overall, clinically and statistically significant differences in QOL were found between type T or D curves and type L: SF-36-PCS adjusted by age and sex (p \ 0.01), ODI (p \ 0.001), and SRS-subtotal (p \ 0.01). Patients with type L curves had poorer QOL. The differences in QOL disappeared when the different types of curves were compared in patients with the same diagnosis. In type L and N curves, patients with a diagnosis of degenerative disease had poorer QOL scores than those with an idiopathic diagnosis (Table). Conclusions: In the SRS-Schwab classification, curve types D and N predominated. The classification is insufficient to adequately define ASD. The parameter diagnosis seems essential to identify the more homogeneous patient groups. Idiopathic
Degenerative
p
Curve type T (%)
92
8
\0.0001
Curve type L (%)
42.1
57.8
Curve type D (%)
95.7
4.3
Curve type N (%)
54.4
45.5
123
ELECTRONIC POSTER 1 LONG-TERM OUTCOME OF POSTEROLATERAL VERSUS CIRCUMFERENTIAL FUSION IN CHRONIC LOW BACK PAIN. PROSPECTIVE STUDY Principal Author: Ortega Garcı´a, Paula Center: Hospital Universitario Marque´s de Valdecilla, Santander, Spain Additional Authors: Pe´rez Nu´n˜ez, Marı´a Isabel; Laguna Bercero, Esther; Moro Pascual, Laura; Rodrı´guez Lo´pez, Tamara Center: Hospital Universitario Marque´s de Valdecilla, Santander, Spain Introduction and Aim: Lumbar fusion is indicated in patients with degenerative lumbar disease, spondylolisthesis, or degenerative disc disease that does not respond to conservative treatment. The aim of this study, performed in a hospital Rehabilitation Department, is to investigate functional disability and pain in patients who have undergone instrumented lumbar fusion by the same surgical team, after at least 4 years’ follow-up. Materials and Methods: Prospective study. We reviewed 66 patients treated with instrumented lumbar fusion between March 2006 and December 2008, 35 posterolateral and 31 circumferential. Before the intervention, a questionnaire was conducted, which included a visual analog scale for lumbar and radicular pain and the Oswestry Disability Index, version 2.0; these questionnaires were repeated for the present study. Statistical analyses used SPSS 19.0, the Wilcoxon test for nonparametric variables, and the Student t test for parametric variables. The sample included 20 men and 46 women, with a mean age of 56 years. Mean follow-up was 4 years. Results: A statistically significant improvement in both groups was seen in the disability and pain parameters: 69.2 % of patients reached the minimal clinically important difference (MCID) for the Oswestry score, 67.6 % reached the MCID for VAS lumbar pain, and 56.7 % for VAS radicular pain. There were no statistically significant
Eur Spine J (2014) 23:248–288 differences between the groups according to the type of fusion, number of fused levels, or fixation to the sacrum or not. Three patients developed complications: screw loosening in one patient in the posterolateral fusion group and two cases of severe radiculopathy with a need for prompt reoperation in the group with circumferential fusion. Conclusions: At long term, patients with chronic low back pain treated with circumferential fusion did not have a better outcome regarding functional disability and lumbar and radicular pain than patients undergoing posterolateral fusion.
287 and 20 %, with considerable differences relative to the control group receiving PMMA alone.
3 IMPACT OF SPINOPELVIC PARAMETERS ON QUALITY OF LIFE AND LUMBAR FUNCTION IN WORKING-AGE PATIENTS CONSULTING FOR PAIN
2 Principal Author: Vila` Canet, Gemma
OSTEOBLAST VIABILITY AND ADHESIVENESS ON BONE CEMENT MIXED WITH HYDROXYAPATITE AT VARIOUS CONCENTRATIONS USED IN VERTEBRAL AUGMENTATION TECHNIQUES Principal Author: Pino Minguez, Jesu´s Center: Complejo Hospitalario Universitario Santiago de Compostela, Spain Additional Authors: Couceiro Otero, Ramiro1; Dı´ez Ulloa, Ma´ximo Alberto2; Otero Ferna´ndez, Marı´a2; Garcı´a Santiago, Carlota3; Freire Garabal, Manuel3 Centers: 1Cell and Developmental Biology, School of Medicine, UNC Chapel Hill, North Carolina, USA; 2Complejo Hospitalario Universitario Santiago de Compostela, Spain; 3Departamento de Farmacologı´a, Facultad de Medicina, Santiago de Compostela, Spain Introduction: The PMMA used in vertebral surgery differs from conventional cements in viscosity, a lower exothermic capacity, and the fact that it is radio-opaque, but the osteointegration capacity of PMMA does not seem better than that of conventional material. The aim of the present study is to assess the osteogenic capacity of PMMA mixed with hydroxyapatite (HA) at different concentrations. Materials and Methods: HA at various concentrations (5 %, 10 %, 15 %, and 20 %) was mixed with PMMA (A Kyphon HV-R). HA powder was examined with a particle analyzer and mixed with the monomer; it was then scanned with electron microscopy (SEM, Hitachi S-2400). Mapping of the chemical composition of the mixture was carried out using energy dispersive X-ray. MG63 human osteoblasts were seeded at a density of 6 9 105 cell/ mL on discs with PMMA and HA at the concentrations indicated. Cell proliferation was determined using MTT (Sigma). Specific markers of osteoblast proliferation, osteocalcin and alkaline phosphatase (MedSystems Bender), were investigated. Cell death was determined by caspase-3 levels. Results: Osteoblast proliferation increased in parallel with the HA concentration in PMMA. Maximum growth peaks were obtained at concentrations of 15 % and 20 %, with values of 0.86 ± 0.026 and 0.90 ± 0.008. As to caspase-3, there was a progressive decrease as HA concentration increased, showing an optimum apoptotic index at 20 % HA. Cell adhesiveness was optimum at 15 %. Alkaline phosphatase activity and osteocalcin also increased in parallel with HA concentration. Maximum bone growth peaks were obtained at HA concentrations of around 15 % and 20 %, with values of 0.801 ± 0.064 and 0.793 ± 0.005. There seemed to be a clear turning point in proliferation at concentrations between 10 % and 15 %. Conclusions: The optimal HA concentration in PMMA in terms of cell adhesiveness, viability, and proliferation is approximately 15 %
Center: Institut Universitari Dexeus, Barcelona, Spain Additional Authors: Ubierna Garce´s, Ma Teresa; Garcı´a de Frutos, Ana; Salo´ Bru; Guillem; Arias Baile, Ainhoa; Ca´ceres Palou, Enric Center: Institut Universitari Dexeus, Barcelona, Spain Aim and Introduction: Over the last years, there has been a growing interest in determining the link between spinopelvic parameters and the patient’s quality of life and lumbar spine function. The aim of this study was to evaluate the relationship of quality of life and lumbar function with sagittal balance and spinopelvic parameters in workingage patients consulting for low back pain or radicular pain. Material and Method: Prospective observational study including 191 consecutive patients consulting for the first time in our center for symptoms of lumbar or radicular pain of at least 2 months’ duration. We determined epidemiologic data (age, sex, work activity, sports activity) and pain location. All patients underwent complete measurements in lateral spinal radiographs and MRI of the lumbar spine. The SF-12 questionnaire and Roland Morris Disability Questionnaire (RMDQ) were administered. In the radiologic studies, the following were determined: lumbar lordosis, sagittal balance (positive, negative, neutral), sacral slope, pelvic incidence, and Roussouly type. Results: The study included 191 patients (85 men, 106 women), mean age 45 (18–66) years; 66 % had lumbar pain and 44 % radicular pain. Mean score was 36 on the SF-12 physical component and 43 on the mental component, and mean RMDQ value was 6.4. Pelvic incidence, lumbar lordosis, Roussouly morphotype, and sagittal profile showed no statistically significant relationships with quality of life. There was a non-significant trend to poorer RMDQ results in Roussouly type IV patients. Quality of life showed a significant relationship with the RMDQ score, but not with the severity of MR findings. Conclusions: In the patients studied, quality of life was particularly affected in the physical aspect (SF-12), although it was not significantly related to any of the spinopelvic parameters or MR findings. It seems that patients classified as Roussouly morphotype IV have poorer lumbar function according to the RMDQ.
4 HEMIVERTEBRA RESECTION BY POSTERIOR APPROACH AND INSTRUMENTATION WITH PEDICLE SCREWS AND SUBLAMINAR HOOKS (THREE-ROD APPROACH). A STUDY OF 9 CASES Principal Author: Ventura Go´mez, Norberto Center: Hospital Sant Joan de De´u, U.B, Barcelona, Spain
123
288
Eur Spine J (2014) 23:248–288
Additional Authors: Ey Batlle, Ana
Center: Hospital de Nin˜os Pedro Elizalde, Buenos Aires, Argentina
Center: Hospital Sant Joan de De´u, U.B, Barcelona, Spain
´ scar1; Majluf, Rodolfo2 Additional Authors: Reynier, Mariano O
Introduction: Hemivertebra resection by a posterior only approach and pedicle screw instrumentation in young children has been associated with a high number of complications due to implant failure. Objective: To demonstrate the efficacy of pedicle screws combined with sublaminar hooks (three-rod technique) in treatment by hemivertebra resection. Material and Method: Retrospective clinical-radiological study of 9 patients who underwent surgery in our hospital between July 2007 and January 2012, consisting in posterior hemivertebra resection and instrumentation with pedicle screws and sublaminar hooks. Results: Time of review 2.5 years (5–1), 5 boys, age 34 months (26–48), weight 14 kg (12–18), operative time 3.4 h (3–4), 7 received a perioperative transfusion, 7 left hemivertebrae, 2 right, 4 lumbar hemivertebrae, 4 thoracolumbar, 3 thoracic (2 patients with 2 hemivertebrae), 3 patients with mixed thoracic malformations, all with rib abnormalities. Preoperative Cobb values: 508 (36/67), dorsal kyphosis 368 (25/52), lumbar lordosis 398 (30/46). Postoperative Cobb values: 198 (7/35), postoperative kyphosis 298 (25/34), postoperative lordosis 338 (16/54). One patient had asymptomatic syringomyelia. Resection levels: T10–T11 (1), T11–T12 (2), T12–L1 (4), L1–L2 (1), L2–L3 (1), L3–L4 (2); in 2 patients two hemivertebrae were resected in the same surgical act. All patients wore a brace for 6 months. Complications: one case of prominent instrumentation. Conclusions: The lamina is mechanically more resistant than the pedicle (neurocentral cartilage) in young children. For this reason, the space remaining after hemivertebra resection can be closed, decreasing the stress on the pedicle screws.
Centers: 1Hospital de Nin˜os Pedro Elizalde, Buenos Aires, Argentina; 2 Hospital de Nin˜os R. Gutie´rrez, Buenos Aires, Argentina
5 LIMITED AXILLARY THORACOTOMY FOR TREATING HIGH (T1–T4) THORACIC HEMIVERTEBRAE RESECTION Principal Author: Orellano, Armando
123
Introduction: Various approaches have been developed (anterior– posterior or combined), for treating hemivertebrae; the superior thoracic sector (T1–T4) is difficult to access using a posterolateral thoracotomy. Bianchi et al. in 1998 and Kalman in 2002 used a limited axillary thoracotomy for superior thoracic lesions. The objective of this study is to evaluate the usefulness of this approach in high thoracic hemivertebra resection. Materials and Methods: We retrospectively evaluated 2 patients with a diagnosis of congenital scoliosis, operated on in our hospital by hemivertebra resection. The procedure was carried out by limited axillary thoracotomy associated with posterior instrumentation to correct and stabilize the curve. Postoperative curve correction and wound cosmesis were assessed. Results: Clinical Case 1: 10-year-old girl with a diagnosis of congenital hemivertebra/scoliosis, at T2, preoperative Cobb angle T1–T3 35, Risser 2, menarche negative. Following limited axillary thoracotomy in the axillary fold, costal resection, and T2 hemivertebra resection, we carried out bilateral posterior T1–T3 instrumentation plus laminectomy of the hemivertebra. Postoperative Cobb angle 15. Clinical Case 2: Twelve-year-old girl with a diagnosis of congenital hemivertebra/scoliosis at T3. Preoperative Cobb T2-T4 52, Risser 4, menarche 0 ? 6. Limited axillary thoracotomy in the axillary fold, costal resection, and T3 hemivertebra resection were carried out and subsequently, bilateral posterior T1-T5 instrumentation plus hemivertebra laminectomy. Postoperative Cobb 10. Conclusion: In children, incision in the axillary fold provides good visibility of the high thoracic spine, even up to T1, and enables complete vertebral resection, which is often difficult through a posterior only approach. Several authors have described this approach for the treatment of esophageal atresia, and pulmonary and mediastinal lesions. We believe it should be considered as an option in the treatment of high thoracic spine conditions, since it provides good visibility and is cosmetically invisible in the axillary fold.
ABSTRACTS
Abstracts for GEER-SILACO—Congreso in Valencia, Spain, June 2013
ORAL COMMUNICATION 1 CORRELATION BETWEEN PATIENT-REPORTED INTENSITY OF LOW BACK OR LEG PAIN AND THE SUBJECTIVE WALKING ABILITY EVALUATED WITH THE SWISS SPINAL STENOSIS QUESTIONNAIRE (SSSQ) Principal Author: Lombao Iglesias, Domingo
ODI
SSSQ
Group 1
40.7
2.2
Group 2
41.9
2.5
Group 3
42.9
2.3
2 PREVALENCE OF THE NERVE ROOT SEDIMENTATION SIGN IN PATIENTS SHOWING NO SYMPTOMS OF LUMBAR SPINAL STENOSIS
Center: Hospital Universitario Lucus Augusti, Lugo, Spain Additional Authors: Bago´ Granell, Joan1; Vilor Rivero, Teresa2 Centers: 1Hospital Vall d’Hebro´n, Barcelona, Spain; Universitario Lucus Augusti, Lugo, Spain
2
In cases of canal stenosis, the Swiss Spinal Stenosis Questionnaire (SSSQ) results correlate significantly with the patients’ actual walking capacity. However, the relationship between SSSQ and the patientreported pain intensity has not been analyzed. Material: The study included 84 patients (51 women, 33 men; mean age 58 years) with degenerative lumbar spine disease and pain intensity of at least 5 on the visual analog scale (VAS). Patients completed a VAS for low back pain and leg pain, the Oswestry Disability Index (ODI), and the SSSQ. Method: An adaptation of the SSSQ to Spanish was carried out and subsequently validated. Based on the intensity of low back and leg pain, patients were divided into 3 groups: group 1 (low back pain 2 points C leg pain), group 2 (leg pain 2 points C low back pain) and group 3 (low back pain 2 points B leg pain). Results: Mean low back pain was 6.6 and leg pain was 6.6. Mean ODI score was 42.5 and SSSQ score was 2.3. The Spanish version of SSSQ showed adequate internal consistency (alpha coefficient 0.82). SSSQ results correlated with those of the ODI (r = 0.67). There were 18 patients in group 1, 15 in group 2, and 50 in group 3. Mean ODI and SSSQ scores did not differ between the three groups. However, the correlation of SSSQ with leg pain (r = 0.39) was somewhat higher than with low back pain (r = 0.23). Conclusions: The Spanish version of SSSQ is a valid instrument that significantly correlates with the ODI. Walking capacity determined with SSSQ correlated with the intensity of both low back pain and leg pain. SSSQ cannot differentiate between patients classified according to the values for low back versus leg pain. These data suggest that the leg pain reported by patients may not correspond to pain caused by neurological compression.
123
Principal Author: Lombao Iglesias, Domingo
Hospital Center: Hospital Universitario Lucus Augusti, Lugo, Spain Additional Authors: Bago´ Granell, Joan Center: Hospital Universitario Vall d0 Hebro´n, Barcelona, Spain The nerve root sedimentation sign has been considered a characteristic MR finding in patients with symptoms of lumbar canal stenosis. Whether this sign is present in individuals without such symptoms is unknown. Aim: To determine the prevalence of the sedimentation sign in MR studies requested for conditions other than spinal disease in patients with no symptoms of stenosis. Materials and Methods: In patients undergoing MR examination for non-spinal conditions, all of whom denied having symptoms of radicular pain or claudication, an MR slice was acquired at L4–L5 to determine the presence or not of the sedimentation sign. Results: Thirty-two patients (19 women) were studied, with a mean age of 63.4 years. MR was performed for the following reasons: gastrointestinal, 15 cases; gynecological, 6; urological, 5; and miscellaneous, 6. A sedimentation sign was found in 15.6 % of cases (95 % CI 5.2 %–32.7 %). The reported prevalence of the sign in patients with symptomatic canal stenosis is 94 % (Barz et al., Spine, 2010, 35:892). The difference in the prevalence percentages was statistically significant (Chi square 78.8 p = 0.0001). Conclusions: The nerve root sedimentation sign seems highly characteristic of patients with symptomatic lumbar canal stenosis, although it can also be seen in individuals without symptoms of stenosis. A larger sample size is needed to determine the true prevalence of this sign in patients without symptomatic stenosis.
Eur Spine J (2014) 23:248–288
3 10-YEAR RESULTS OF CIRCUMFERENTIAL LUMBAR FUSION, DETERMINED WITH THE OSWESTRY DISABILITY INDEX Principal Author: Orts Garcı´a, Javier Center: Hospital Universitario de la Ribera, Alzira, Valencia, Spain Additional Authors: Bas Hermida, Teresa1; Bas Hermida, Paloma1; Maruenda Garcı´a, Francisco Borja2 Centers: 1Hospital Universitario y Polite´cnico La Fe, Valencia, Spain; 2 Hospital Universitario de la Ribera, Alzira, Valencia, Spain Aim and Introduction: Circumferential fusion is suggested to be the treatment of choice for some degenerative conditions and disc diseases, both as primary surgery and particularly, in salvage procedures. We performed a study to demonstrate that an extensive transforaminal approach with anterior and posterior fusion provides good long-term results in patients with lumbar or radicular pain, as measured by the Oswestry Disability Index (ODI). Materials and Methods: Observational study of 43 patients with a mean age of 45.3 years, operated on by the same surgeon between 2000 and 2003, with translateral interbody fusion (TLIF) of the lumbar spine at one, two, and three levels. Patients initially presented low back or radicular pain with moderate or severe disability due to spondylolisthesis and postdiscectomy sequelae. The degree of disability related to low back pain was determined before the procedure and 10 years after, using the ODI (version 2.0) validated for the Spanish language (Florez et al. 1995), considered the reference standard among low back pain scales. Results: There were no complications or sequelae following surgery. Two patients required proximal extension of the fusion. Comparison of the percentage of disability before and 10 years after the procedure yielded a significant difference of more than 10 points ([ 20 %, p \ 0.05), which implies a considerable clinical improvement. Conclusions: In our series, TLIF applied to patients with low back or radicular pain and moderate-severe disability due to spondylolisthesis and postdiscectomy sequelae resulted in a long-term (more than 10 years) improvement in pain and consequently, in function, as determined by the ODI. We believe this outcome may be related to the more extensive surgical approach used, which releases more structures, and to the larger area of fusion achieved, which provides greater stability to the treated segment.
249 Centers: 1Facultad de Medicina, Badajoz, Spain; 2Hospital Universitario Fundacio´n Hospital Alcorco´n, Unidad de Columna, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Madrid, Spain; 3 Hospital Universitario Fundacio´n Hospital Alcorco´n, Unidad de Columna, Madrid, Spain Introduction: The visual analog scale (VAS) enables measurement of patient-reported pain intensity with maximum interobserver reproducibility. The scale consists of a 10-cm horizontal line whose endpoints denote extreme limits of a symptom, and it provides a fast measurement method. The Oswestry Disability Index (ODI) (together with the Roland-Morris Disability Scale) is the most widely used and recommended instrument worldwide for predicting pain chronicity, duration of sick leave from work, and the outcome of treatment. The ODI is somewhat more difficult to administer than the VAS, mainly because it is more time-consuming. Aims: To study the relationship between the VAS and ODI and their correlational fit, in order to design a predictive algorithm based on the existing relationship. Materials and Methods: The study sample included 200 patients, 108 women (49.89 ± 8.91) and 92 men (44.01 ± 8.64), with chronic low back pain and degenerative lumbar spine disease, receiving conservative treatment in a university hospital. Data were collected from January 2004 to December 2007, through purposive sampling. The measurement instruments included the ODI and VAS, administered preoperatively, postoperatively, and at 2 years. Simple linear regression models were performed to determine the relationships between variables. Results: The best fit was obtained between the variable postoperative lumbar VAS and preoperative lumbar ODI (r = 0.811) as well as postoperative lumbar ODI (r = 0.957) (p \ 0.001 in both cases). The variables preoperative lumbar ODI and postoperative lumbar ODI showed a significant positive correlation (r = 0.779; p \ 0.001). Conclusions: Given that the VAS has considerable implications, taking into account its speed of administration and self-evaluating nature, we propose use of the linear regression equation adjusted to these variables as the postoperative predictor of the ODI (for use in situations where the ODI cannot be evaluated or its administration would be complicated). Can we avoid use of the postoperative ODI questionnaire?
5 INFLUENCE OF PHYSICIANS’ BELIEFS AND ATTITUDES ON THEIR TREATMENT RECOMMENDATIONS FOR LOW BACK PAIN. CONTROLLED CLINICAL TRIAL
4
Principal Author: Ezzedine Angulo, Aida
PREDICTING OSWESTRY DISABILITY INDEX SCORES FROM VISUAL ANALOG SCALE SCORES IN PATIENTS UNDERGOING SURGERY FOR LOW BACK PAIN
Center: Hospital Arnau de Vilanova, Valencia, Spain
Principal Author: Egea Ga´mez, Rosa Marı´a Center: Hospital Universitario Fundacio´n Hospital Alcorco´n, Unidad de Columna, Madrid, Spain Additional Authors: Guerrero Bonmatty, Rafael1; Gonza´lez Dı´az, Rafael2; Losada Vin˜as, Jose´ Isaac3; Rodrı´guez Velasco, Francisco Jose´1; Gil Ferna´ndez, Guadalupe1
Additional Authors: Domenech Ferna´ndez, Julio1; Cabanes Soriano, Francisco1; Liso´n Parraga, Juan Francisco2; Segura Ortı´, Eva2; Buj Pascual, Javier3 Centers: Hospital Arnau de Vilanova, Valencia, Spain; 2Universidad Cardenal-Herrera CEU, Valencia, Spain; 3Hospital Universitario Dr. Peset Aleixandre, Valencia, Spain Physicians’ beliefs and attitudes regarding low back pain can reinforce maladaptive behavior and limit their adherence to clinical practice guidelines (CPG), with a significant impact on patients. Aim: To investigate the influence that physicians’ beliefs and attitudes have on their treatment recommendations related to activity and
123
250 work. To determine whether an educational module based on the biopsychosocial model will modify physicians’ beliefs and attitudes and lead to a change in their recommendations and the number of patients prescribed sick leave. Methods: Eighty-four physicians were randomly assigned to one of two groups and followed-up for two years: 39 received an educational module based on the biopsychosocial model and 45 received placebo educational sessions. The participants completed the FABQ and HCPAIRS questionnaires and described their treatment recommendations regarding activity and work for three clinical scenarios at the start of the study and one year later. The number of sick leaves from work due to low back pain prescribed by each participating physician one year before and one year after the intervention were recorded. Results: Before receiving the educational module, participants showed high fear-avoidance beliefs and the conviction that pain justifies disability in low back pain. In many cases, their recommendations did not conform to those in clinical practice guidelines (CPGs). The recommendations for activity and work significantly correlated with the FABQ and HC-PAIRS scores. Physicians with high fear-avoidance beliefs tended to be more restrictive in their recommendations. Those who received the biopsychosocial module showed a significant improvement in their fear-avoidance and pain-disability ideas that persisted at one year. Their recommendations for patients were better adapted to the CPGs. In comparison to the control group, the intervention group showed a significant reduction in the number of sick leaves prescribed one year after the intervention relative to one year before. Conclusion: Clinicians’ orientations toward low back pain have an impact on their recommendations to patients and adherence to CPGs. In addition to transmitting knowledge, strategies for continuing medical education in low back pain should focus on changing maladaptive beliefs and attitudes.
6 LOW BACK PAIN RELATED TO TRAINING IN THE GYM Principal Author: Godoy Adaro, Alfredo Center: CETEC, Entre Rios, Argentina Additional Authors: Taleb Pabon, Cristian Center: CETEC, Entre Rios, Argentina Aim and Introduction: To investigate the relationship between spinal lesions and physical preparation in players of juvenile rugby. Materials and Methods: This is a retrospective study performed in 69 male rugby players, focussing on the following variables: age 13-20 years (16.72), time working out in the gym 0–10 years (1.85), height 1.53–1.95 m (1.74), weight 47–120 kg (79.3), weight lifted 0–150 kg (74.8), history of back pain, and whether treatment was received. In treated patients: the diagnosis and evaluation by additional studies. The exercises involved were squats and dead lifts, and the relationship between load and lumbar spine lesions was analyzed. Trainers’ technical indications: load should never exceed 50 % of the body weight; at age 15 and 16 years, maximal effort methods are not used. At 17 years, the submaximal effort test can be taken; formulas are then used to determine the FMax and athletes can work at percentages of 80 % to 85 %. At 19 years, the athletes’ possibility to work at all levels of effort is complete. Results: Among the total, 86 % had episodes of back pain and 74 % of episodes were low back pain. On more than one occasion, 43 % received some type of treatment. All carried out gym activities with excessively heavy loads that exceeded 50 % of their body weight
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Eur Spine J (2014) 23:248–288 without strict, specialized monitoring. Among the total, we detected 3 extruded disc herniations, 11 symptomatic lysis, with 3 grade 1 listhesis that required treatment. Of the 43 %, all showed some type of disc lesion on MRI. We excluded deformities, tumors, and infection. Conclusions: Strength training in the gym is common practice in our setting. Repeated use of excessively heavy weights may be a determinant factor in the development of spinal disease.
7 TREATMENT OF EARLY-ONSET SPINAL DEFORMITIES: COMPLICATIONS Principal Author: Legarreta, Carlos Center: Hospital de Nin˜os Ricardo Gutie´rrez, Buenos Aires, Argentina Additional Authors: Rositto, Gabriel Center: Hospital de Nin˜os Ricardo Gutie´rrez, Buenos Aires, Argentina Introduction: Complications are commonly associated with treatment for early-onset spinal deformities (EOSD). The main objectives of surgery for this condition are to control the spinal deformity and achieve adequate thoracic growth with the lowest incidence of complications. Aims: To analyze our experience in the treatment of EOSD, using non-fusion techniques. To evaluate the preoperative risk factors and the complications arising during the course of treatment. Materials and Methods: Retrospective case series study (level of evidence IV). We evaluated 13 patients treated using non-fusion surgical techniques and growth by distraction. Patients had the following conditions: 5 MMC, 2 infantile idiopathic scoliosis, 1 vertebral dysplasia, 1 SCIWORA, 1 Marfan syndrome, 1 ‘‘Escobar syndrome’’, 1 neurofibromatosis type I, 1 thoracogenic scoliosis. Mean age at the time of surgery was 4.10 years. Mean preoperative angular value was 83.7 (R: 50–135). We analyzed preoperative risk factors, type of construct, sequence of distractions, and complications. In the 13 patients, 27 distraction procedures were carried out. On individual analysis of the cases, we found that the mean frequency of distractions was one procedure per each 11 months (R: 7–17 months), and that 23 % of patients had definitive surgery (fusion) following 3.5 years of distraction treatment (R: 2.10–3.10). Among the total, 69 % of patients had complications during treatment; these included superficial infections (6.6 %), deep infections (10 %), rib fractures (10 %), spontaneous fusion (3.3 %), and prosthesis loosening and failure of the material (10 %). Conclusions: When treating ESOD, the spinal surgeon should be prepared to manage various complications during the course of treatment. Based on our experience, we consider this a high-risk condition.
8 COORDINATION OF THE SUPERFICIAL SPINAL MUSCULATURE AND DEEP ROTATOR IN IDIOPATHIC SCOLIOSIS. INTRAMUSCULAR ELECTROMYOGRAPHIC STUDY IN DIFFERENT SPINAL MOVEMENTS Principal Author: Barrios Pitarque, Carlos
Eur Spine J (2014) 23:248–288 Center: Instituto de Investigacio´n en Enfermedades Mu´sculo-Esquele´ticas, Universidad Cato´lica de Valencia, Spain Additional Authors: Zena, Vı´ctor1; De Blas Beorlegui, Gema2; Garcı´a Casado, Javier1; Caban˜es Martı´nez, Lidia2; Catala´n, Benedicta3; Burgos Flores, Jesu´s2; Noriega, David3; Saiz, Javier1 Centers: 1Group de Bioelectro´nica, Universidad Polite´cnica de Valencia, Spain; 2Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 3Hospital Clı´nico Universitario de Valladolid, Spain Introduction: An imbalance in myoelectric activity between the musculature at the convexity and concavity has been described in patients with idiopathic scoliosis. These studies base their findings on the EMG patterns recorded in surface electrodes, which do not differentiate between the superficial and deep muscles. The aim of this study was to separately analyze the findings of the superficial and deep paraspinal musculature in subjects with idiopathic scoliosis. Material: Sixteen patients with idiopathic scoliosis (Cobb angle, 208358) underwent electromyography of the paraspinal musculature using monopolar intramuscular electrodes. At the level of the apex, 4 electrodes were inserted on both sides of the curve (2 in the deep rotator muscles and 2 others in the superficial paraspinal muscles). Electric activity was recorded simultaneously in the 4 muscle groups with the patient standing and in flexion, extension, right and left lateral bending, and rotation toward the side of the concavity and the side of the concavity. The recordings were compared with those obtained in 4 healthy subjects in the same age range with no spinal deformity. Results: In standing position, the activity of the deep muscles was greater than that of the superficial ones, with no imbalance between the concavity and convexity. Greater activity of the deep muscles over the superficial was also evident during anterior spinal flexion, with the deep muscles of the concavity showing higher activity than those of the convexity. None of the 4 muscle groups actively participated in spinal extension movements, although the activity of the deep rotators was always greater. On lateral flexion toward the convexity, the deep rotator muscles on the side of the concavity showed hyperactivity. During rotation movements, the most active musculature was the contralateral, with clear inhibition of the deep muscles of the concavity in rotations toward this side. Conclusion: Patients with idiopathic scoliosis present signs of deficient motor coordination between the superficial paraspinal muscles and the deep rotators. The study findings do not clearly define whether this lack of coordination is primary or secondary to the presence of the deformity.
9 IMPACT OF THE TECHNIQUE USED FOR SURGICAL CORRECTION OF CERVICAL AND THORACIC SAGITTAL ALIGNMENT IN ADOLESCENT IDIOPATHIC SCOLIOSIS. COMPARATIVE STUDY OF TWO CORRECTIVE MANEUVERS
251 Centers: 1Departamento de Ortopedia Infantil, Hospital de Nin˜os Ricardo Gutie´rrez, Buenos Aires, Argentina; 2Hospital Clı´nico Universitario, Valencia, Spain; 3Hospital Son Espases, Palma de Mallorca, Spain; 4Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 5Hospital La Fraternidad-Muprespa, Madrid, Spain Introduction and Aims: In recent years, there has been an increasing interest in the consequences of posterior fusion on the cervical sagittal plane in adolescent idiopathic scoliosis (AIS). The aim of this study is to compare the effect of two different techniques for AIS correction on cervical and sagittal alignment. Methods: Two series of 25 patients with Lenke type 1 AIS treated surgically and with at least 2 years of follow-up were retrospectively reviewed. In one series, patients underwent correction using the vertebral coplanar alignment (VCA) maneuver, which involves en bloc vertebral derotation from the convex side. In the other series, correction consisted in derotation from the concavity (DC). Preoperative and 2-year follow-up radiologic studies were evaluated by measuring the following parameters: C2–C7 sagittal angle, C2–C7 plumbline sagittal balance, T1 sagittal inclination, T1–T5 and T5– T12 kyphosis, and global C7–S1 sagittal balance. Results: In the coronal plane, the VCA technique provided a higher percentage of curve correction than DC (71.2 % vs 62.1 %). In both groups, T5-T12 experienced a lordosing effect following surgery, with a mean loss of 6.1 for DC and 7.7 for VCA. After 2 years of follow-up, differences between the groups were only found in the C2– C7 sagittal plane, which showed a mean kyphosing tendency of -5.2 in the VCA group and a mean lordosing tendency of 1.8 in the DC group (p \ 0.05). In patients whose upper instrumented vertebra (UIV) was at or below T4 in both techniques, a lordosing effect was more evident in the DC group (+9.4 vs 0.3). In patients in whom the UIV was at T3 or higher, both techniques showed a kyphosing effect, which was more pronounced in the VCA group (-7.0 vs -2.8). Conclusions: Regardless of the surgical technique used, the cervical spine has a tendency toward kyphosing decompensation of the sagittal profile. The kyphotic changes in C2–C7 sagittal alignment induced by scoliosis correction closely correlated with the level of the upper instrumented vertebra.
10 EFFICACY OF INTRAOPERATIVE AND POSTOPERATIVE RADIOLOGY FOR POSITIONING DORSAL PEDICLE SCREWS IN AIS: INTRA- AND INTEROBSERVER REPRODUCIBILITY Principal Author: Demonti, Hernan He´ctor Center: Sanatorio Mapaci-Assist Sport, Rosario, Argentina Additional Authors: Fiorillo, Pablo1; Ferrer, Alejandro2 Centers: 1Sanatorio Mapaci-Assist Sport, Rosario, Argentina; 2 Hospital Provincial del Centenario, Rosario, Argentina
Principal Author: Barrios Pitarque, Carlos Center: Instituto de Investigacio´n en Enfermedades Mu´sculo-Esquele´ticas, Universidad Cato´lica de Valencia, Spain Additional Authors: Reviriego, Juan1; Legarreta, Carlos1; Rositto, Gabriel1; Maruenda Paulino, Jose´ I2; Escalada, Marı´a1; Piza´ Vallespir, Gabriel3; Burgos Flores, Jesu´s4; Hevia Sierra, Eduardo5
Introduction: In recent years, there has been a major surge in the use of pedicle screws in the thoracic spine as another option in spine surgery for AIS. This technique is associated with better anchorage, fewer cases of pull out, and greater corrective force. Data from the literature has shown that a slight displacement of screw position (e.g., medial perforation of 2 mm or less) is biomechanically acceptable and within the safety limits. CT has proven useful for postoperative
123
252 assessment of pedicle screw placement. The aim of this study was to evaluate the intraoperative and postoperative efficacy of radiography in dorsal pedicle screw placement and its relationship with CT. Materials and Methods: We evaluated 280 dorsal pedicle screws (4.5-mm polyaxial titanium screws) in 36 patients with AIS. Three observers classified screw placement as well positioned, inconclusive, or malpositioned. These responses were then compared to the CT findings using the following classification: •
•
•
TYPE 1: Positioned within the pedicle, (a) completely within, (b) within, but touching cortical, (c) penetration less than 2 mm, (d) screw in the costovertebral space (in–out–in) TYPE 2: Asymptomatic: (a) penetration greater than 2 mm, (b) perforation of anterior cortical. No neurovascular complications. TYPE 3: Screw outside, neurovascular complications.
Results: A total of 280 pedicle screws were evaluated. Three observers assessed each patient. Interobserver evaluation was 0.56 (moderate agreement). Intraobserver evaluation was 0.79 (good agreement). No vascular or neurologic lesions occurred in any case. Conclusions: According to the intra- and interobserver findings, use of intraoperative and postoperative radiography is not highly effective for diagnosing dorsal pedicle screw malposition. CT was very useful for determining the position of dorsal pedicle screws.
11
Eur Spine J (2014) 23:248–288 underwent a descriptive analysis. The Student t test for paired data was used to assess differences between scores on the two questionnaires, and the Pearson correlation coefficient was applied to evaluate the relationship between the magnitude of correction and quality of life. Results: The demographic and clinical data in this review are consistent with those reported in the international literature. A statistically significant difference was found in the mean quality of life scores obtained with the SRS-22 preoperatively and postoperatively, as well as in the activity and self-image domains. There was no correlation between Cobb angle correction and quality of life. Conclusion: The validated Spanish version of the SRS-22 questionnaire is reliable and applicable to surgically treated AIS patients. Surgery resulted in an improvement in the quality of life of this population.
12 TRANSCULTURAL ADAPTATION AND VALIDATION OF THE SPANISH VERSION OF THE EOSQ-24 Principal Author: Farrington, David M Center: Hospital Infatil Virgen del Rocı´o, Seville, Spain
QUALITY OF LIFE AT 2 YEARS IN SURGICALLY TREATED PATIENTS WITH ADOLESCENT IDIOPATHIC SCOLIOSIS
Additional Authors: Vitale, Michael1; Matsumoto, Hiroko2; Tatay ´ ngela3 Dı´az, A
Principal Author: Valenzuela Candia, Carlos Felipe
Centers: 1Morgan Stanley Children’s Hospital of New York, USA; 2 Columbia University, New York, USA; 3Hospital Infantil Virgen del Rocı´o, Spain
Center: Hospital Dipreca, Santiago de Chile, Chile Additional Authors: Otto San Martı´n, Juan Pablo; Miranda Osorio, Guillermo Center: Hospital Carlos Van Buren, Valparaı´so, Chile Introduction: Adolescent idiopathic scoliosis (AIS) is a permanent, three-dimensional structural deformity of the vertebral spine. The quality of life concept and its measurement are currently considered essential in the evaluation of treated AIS patients. Aims General: To investigate whether there are differences in preoperative and 24-month postoperative quality of life in AIS patients who underwent surgical correction. Specific: (1) Describe the demographic and clinical characteristics of the population studied; (2) Report the pre- and postoperative SRS-22 questionnaire results. (3) Determine whether there is a correlation between the magnitude of the curve correction and quality of life changes. Materials and Methods: Prospective, quantitative, longitudinal, observational research study performed in 30 patients with AIS treated surgically between 2007 and 2010. All patients were evaluated clinically and all completed the validated Spanish version of the SRS22 questionnaire preoperatively and at 24 months postoperatively. The inclusion criteria were: (1) AIS with an indication for surgery, (2) 24 months of follow-up, (3) pre- and postoperative SRS-22, (4) surgical treatment by the same team, (5) a single surgical technique, and (6) a complete imaging study. Demographic and clinical variables
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Aims: To perform a translation and transcultural adaptation of the Early Onset Scoliosis Questionnaire-24 (EOSQ-24) to the Spanish language, and test its validity. Methods: The Spanish version of the EOSQ-24 was developed according to internationally accepted guidelines that included preparation, forward translation, reconciliation, back translation, review of back translation and harmonization, cognitive debriefing, review of cognitive debriefing results, and proofreading. The parents of 38 patients with early onset scoliosis (2–10 years) completed this new translated version of the EOSQ-24. Each subscale of the Spanish EOSQ-24 was analyzed in terms of internal consistency, discriminative validity, reliability of internal consistency (Cronbach alpha), and ceiling and floor effects. Results: The Spanish version of EOSQ-24 seems to provide excellent psychometric performance that is equivalent to the original EOSQ-24. All the subscales show adequate internal consistency (Cronbach alpha [ 0.7), the item-scale correlations were generally high, and the floor and ceiling effects were limited. Conclusions: The Spanish version of EOSQ-24 can be used to evaluate disease-specific health-related quality of life (HRQOL) in Spanish-speaking families of patients with early onset scoliosis. Significance: The Spanish version of the EOSQ-24 as a measure of HRQOL seems to be equivalent to the original version in English and enables collection of information from Spanish-speaking families. This will expand the number of patients available for recruitment in various studies and avoids the selection bias associated with excluding patients unable to complete a questionnaire in English. Level of Evidence: Diagnostic Level I.
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13 TYPE II ODONTOID FRACTURES TREATED WITH SCREWS IN YOUNG ADULTS AND IN THOSE OLDER THAN 70 YEARS Principal Author: Rocca Siri, Carlos Antonio Center: Servicio Cirugı´a de Columna CASMU, Montevideo, Uruguay Additional Authors: Rodrı´guez Satler, Lisandro Center: Servicio Cirugı´a de Columna CASMU, Montevideo, Uruguay Introduction and Aims: Anterior screw fixation for type II odontoid fractures is mainly recommended for treating young patients; its use in the elderly population is controversial. Our aim was to carry out a retrospective study of the functional outcome in younger and older patients who presented type II odontoid fractures (Anderson and D’Alonzo) surgically treated with solid and cannulated screws, by anterior approach. Materials and Methods: We evaluated the clinical and radiological results of 16 patients between 2004 and 2012, including 14 men and 2 women, with a mean age of 64.5 years. Seven patients were older than 70 years and 9 younger than 70. Mean follow-up was 18 months. All procedures were performed by the same surgeon using an anterior approach, placing one or two 4-mm cancellous screws for small fragments in 14 patients and cannulated screws in 2 patients. The clinical and radiologic results between patients younger and older than 70 years were compared. Results: Among the total, 93.7 % had a follow-up to 8 years. Fourteen patients (87.5 %) returned to their preoperative activity. The Smiley-Webster scale showed an overall functional outcome score of 1.61, 1.49 for patients younger than 70 years and 1.74 for those older. Bone consolidation (solid union or fibrous union) was achieved in 13 patients (81 %); a reduction defect occurred in 2 cases. Consolidation was achieved in all the younger patients. Pseudoarthrosis developed in one older patient. There were no reinterventions or neurological lesions. Conclusion: The results obtained with surgical stabilization of type II odontoid fractures using anterior screw fixation were satisfactory in both older and younger patients, with a good cervical spine functional outcome, and 90 % satisfaction with treatment. As to morbidity and mortality, younger patients had better results.
14 EPIDEMIOLOGICAL STUDY OF BACK PAIN IN RUNNERS
253 Aims: The aims of this study were to assess the effect that running, as a sports activity, has on back pain, and to determine the prevalence of back pain in runners. Materials and Methods: The study data were obtained by providing a questionnaire to all participants in a half marathon that took place in 2012; 771 participants responded. The following variables were recorded: age, sex, BMI, years as a regular runner, number of kilometers covered in the previous week, last time running activity had to be stopped because of back pain, type of training surface used, rank in the last half marathon, and subjective opinion of the effect running has on back pain. A descriptive statistical analysis was performed on the total of participants. In those reporting back pain, the different variables were crossed with the effect running has on back pain. Finally, multivariate analysis was performed. Results: Age and sex of the 771 participants who responded were comparable to the demographics of the total; hence, the sample was considered representative. Of the 771 participants, 420 had experienced back pain (54.47 %). The patients’ subjective perception of the effect of running on back pain was improvement in 48.8 %, worsening in 27.4 %, and no impact in 23.8 %. The subjective effect of running on back pain was crossed with the remaining variables, and associations were found for age (p \ 0.001), sex (p = 0.045), and a history of previous treatment (p = 0.001). On multivariate analysis, the variable age was significantly associated with back pain, and subjects who reported an improvement were older (p = 0.018). Conclusions: 1. Approximately half the participants reported having experienced back pain. 2. Most runners with back pain, particularly those who are older, believe that running has a beneficial effect. 3. The presence of back pain in runners was not associated with the BMI, sex, ranking, kilometers covered, or the training surface. 4. We found no grounds to prohibit running in patients with back pain. Individual assessment is required.
Variables
Crossed with variable effect running has on back pain
Age
Association: the older, the Association: the older, the greater the improvement greater the improvement (p \ 0.001) (p = 0.018)
Sex
Association: more improvement in men (p = 0.045) No association
No association
Years running
No association
No association
KM covered
No association
No association
Treatment
Association: history of previous treatment significantly associated with the influence of running on back pain (p = 0.001)
No association
Stop
Association: those who reported worsening had stopped running most recently (p \ 0.001)
Association: those who reported worsening had stopped running most recently (p = 0.001)
Surface
No association
No association
Ranking
No association
No association
Center: Hospital Universitari de Bellvitge, Barcelona, Spain
Centers: 1Hospital de Friburg, Servicio de Reumatologı´a; 2Hospital Universitari de Bellvitge, Barcelona, Spain; 3IDIBELL, Servicio de estadı´stica, Barcelona, Spain
Trend: more improvement in men (p = 0.125)
BMI
Principal Author: Garreta Catala`, Iago
Additional Authors: Balague´ Gea, Federico1; Font Vila`, Frederic2; Bustos Bedoya, Paloma2; Cuadras Palleja`, Daniel3; Gonza´lez Can˜as, Lluı´s2; Pereira, David2
Multivariate analysis
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15
Center: Facultad de Medicina, Universidad de Extremadura, Me´rida, Badajoz
SURVEY REGARDING THE SKILLS OF SPECIALIZED ORTHOPEDIC SURGEONS IN EUROPE
Additional Authors: Gonza´lez Dı´az, Rafael1; Rodrı´guez Velasco, Francisco Jose´2; Gil Ferna´ndez, Guadalupe2; Losada Vin˜as, Jose´ Isaac3; Egea Ga´mez, Rosa Marı´a3
Principal Author: Nu´n˜ez Pereira, Susana Center: St. Franziskus Hospital, Ko¨ln, Germany Additional Authors: Okoro, Tosan1; Luca, Andrea2; Boszczyk, B.M.3; Sell, Philip4 1
2
Centers: Dept. Orthopaedics, Ysbyty Gwynedd, Bangor, UK; Clı´nica Ortopedica, Universita´ degli Studi di Bari, Bari, Italy; 3Centre for Spinal Studies and Surgery, Queens Medical Centre, Nottingham, UK; 4Dept. Orthopaedics, Leicester General Hospital, Leicester, UK Introduction: Spine surgery societies are implementing specialized educational programs to guarantee the quality and consistency of training in this line. However, data are lacking on the specialists’ perception of their knowledge, skills, and potential training needs. Materials and Methods: An online questionnaire was sent by e-mail to residents and specialists in orthopedic-trauma surgery (OTS) participating in the European Spine Foundation educational program, and to the members of AO Spine. The questionnaire was a modified version of the one used by the European Association of Neurosurgical Societies (EANS) to assess the theoretical and practical skills acquired during medical training. In addition to queries regarding demographic data, there were 24 questions on the participant’s theoretical and practical skills in 12 specific techniques, evaluated with a 4-item Likert scale. A descriptive analysis was performed, as well as a comparative study of the results obtained with those from neurosurgeons on the EANS questionnaire (Fischer exact test). Results: There were 205 responses (57 residents, 148 specialists). As compared to neurosurgery residents, OTS felt they had less ability to perform anterior cervical stabilization (62 % vs. 80 %, p = 0.35) and craniocervical stabilization (39 % vs 53 %, p = 0.38), and greater ability to treat deformities (61 % vs 13 %, p = 0.0021). Among the total of residents, 14 % felt they were unable to treat a lumbar disc herniation under supervision and 21.1 % felt unable to carry out conservative treatment for low back pain and sciatic pain. In the group of specialists, fewer orthopedic surgeons felt capable of treating cervical stenoses than neurosurgeons (88.3 % vs 98.5 %, p = 0.003), but a greater number considered they were able to perform posterior thoracolumbar instrumentations (98.6 % vs. 44.7 %, p \ 0.05) and treat spinal deformities (90.3 % vs. 37.9 %, p \ 0.001). There were no significant differences in the capability to perform posterior stabilization, craniocervical stabilization, tumor surgery, or surgery for degenerative lumbar spine disease. Conclusion: The knowledge obtained during the period of medical training seems insufficient in some basic areas (low back pain), and this should be rectified during the residency period. Spine surgery societies can help in correcting other deficiencies in training, taking into consideration the specialty of origin.
16 RELATIONSHIP BETWEEN THE ABSTRACTS SENT TO GEER AND THOSE ULTIMATELY ACCEPTED. IS THERE A DIFFERENCE ACCORDING TO THE CONDITION STUDIED? Principal Author: Guerrero Bonmatty, Rafael
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Centers: 1Hospital Universitario Fundacio´n Alcorco´n, Unidad de Columna, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Madrid, Spain; 2Facultad de Medicina, Universidad de Extremadura, Me´rida, Badajoz, Spain; 3Hospital Universitario Fundacio´n Alcorco´n, Unidad de Columna, Madrid, Spain Aim: This study proposes an analysis of the abstracts (oral communications, wall posters, and electronic posters) sent to the GEER Scientific Committee, corresponding to the XX to XXVI Congress of the Society (2006–2012), with the aim of estimating the current status of research in spinal diseases and evaluating the submission and acceptance rates according to the medical condition studied or the specialty. Materials and Methods: Cross-sectional, observational, descriptive study. A total of 748 studies were presented to the Scientific Committee in the form of oral communications, wall posters, and electronic posters for the XX to XXVI GEER Congress (2006–2012). The following information related to the studies was recorded for each abstract: sent, accepted, accepted by year, by center, by condition, by affected level, type of study, and best studies competing for the prizes. Results: Of the 748 abstracts evaluated, 534 (71.4 %) were accepted. Most studies accepted by year, 2006 (N = 89) and 2011 (N = 91), and by center, H.U. de Getafe (N = 47), Ramo´n y Cajal (N = 41), Vall d’Hebro´n (N = 35), and I.U. Dexeus (N = 35). Condition predominantly accepted: deformity (Table 1); of 211 studies presented, 153 (20.7 %) were accepted. This condition was also the one most often competing for the prizes (12 studies, 5 won a prize). Nonetheless, when abstracts from the group of research studies were in the competition, one or more always won a prize (9 of 66 studies presented). The second most common condition was degenerative disease: of 159 studies presented, 98 (13.3 %) were accepted, with the lumbar region being most often the subject of the study. For cervicalthoracic-lumbar involvement (Table 2), among 311 studies, 243 (32.6 %) were accepted, and for lumbar involvement, 238 were sent and 156 accepted (20.9 %). Among the clinical studies presented, 22.6 % were retrospective (N = 130). Conclusions: The analysis showed that the groups of conditions most often presented and accepted were deformities and degenerative disease. Although it was not the aim of the present study, it would be interesting to know how many of the studies presented at the GEER congress are published in national and international medical journals, with or without an impact factor.
17 SINGLE APPROACH FOR THORACIC SPINE DISEASE. CLINICAL OUTCOME AND COMPLICATIONS Principal Author: Kahl, Guillermo Center: Sanatorio de la Trinidad Mitre, Buenos Aires, Argentina Additional Authors: Rudt, Toma´s; Zisuela, Roberto; Santi, Maximiliano; Recchia, Sebastia´n Center: Sanatorio de la Trinidad Mitre, Buenos Aires, Argentina
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Introduction: The costotransversectomy approach has been used for drainage of tuberculous spondylitis since the early 1900s. However, it has taken almost 60 years to extend its indication to other thoracic spine diseases. Aim: The aim of this study is to present the clinical results and complications of treatment for thoracic spine disease by a single approach. Material and Method: Retrospective study of 17 patients with spinal disease surgically treated by a circumferential technique with a single incision between 2009 and 2011. The sample included adult patients of both sexes with tumors, infectious diseases, and osteoporotic fractures of the thoracic spine. Results: An improvement in neurological status was documented in 88.2 %, whereas 11.8 % showed no changes following surgery. Mean Oswestry score was 68.80 % preoperatively and 11.2 % postoperatively. Conclusion: This technique provides absolute control of the spine and avoids the use of double or triple approaches in complex conditions, decreasing patient morbidity. Age Sex
Location Disease
Complications Oswestry Oswestry Frankel Frankel Preop
Postop
(%)
(%)
48
4
Preop
Postop
C
E
65
Fem
T6
Met breast CA
62
Fem
T8
Met lung CA
60
10
C
D
72
Fem
T7
Met thyroid CA
78
30
B
B
75
Fem
T11
Multiple myeloma
84
2
C
E
55
Male T2–T3
Spondylitis
52
2
C
E
73
Male T9
Met renal CA
78
38
B
B
70
Male T10
Met colon CA
71
Fem
T8
Met breast CA
68
Fem
T12
Met lung CA
70
12
C
E
65
Male T10– T11
Met prostate CA
82
24
B
D
74
Fem
T7–8
Met breast CA
62
8
D
E
72
Fem
T5–6
Met lung CA
58
8
C
D
59
Fem
T7–T8
Angiosarcoma Pneumothorax 82
24
B
D
67
Fem
T9
Multiple myeloma
68
8
D
E
55
Fem
T10– T11
Met breast CA
74
10
C
E
68
Fem
T7
Osteoporosis
56
Male T8
Spondylitis
Acute infection
60
4
C
E
78
18
B
C
Additional Authors: Ferraris, Luis; Meier, Oliver; Koller, Heiko Center: German Scoliosis Center Werner-Wicker-Klinik, Germany Aim and Introduction: Anterior column reconstruction in thoracolumbar burst fractures can be done by thoracotomy or by videoassisted thoracoscopic surgery (VATS). Recent studies in scoliosis patients have not reported less approach-related morbidity (ArM) with VATS than with the surgical approach. The aim of this study is to assess the differences in ArM between these two techniques in patients with thoracolumbar fractures. Materials and Methods: Over 24 months in the VATS group, patients prospectively completed questionnaires on ArM in all T12 o L1 burst fractures treated by VATS. We included patients with satisfactory reconstruction, no neurological deficits, no complications, and age from 16 to 70 years. In the thoracotomy group, patients were collected from a database of 223 thoracolumbar fractures. The same questionnaire was administered. Cases were matched according to the level of the fracture (T12/L1), age (± 5 years), sex, and follow-up (± 0 months in patients with follow-up between 6 and 24 months and a greater difference in patients with more than 24 months). Results: In the VATS group, 21 cases met the inclusion criteria; 39 patients con thoracotomy were compatible. Thirteen pairs were included, 9 of men and 4 of women. In the VATS and thoracotomy groups, mean age was 34.5 ± 10.2 and 35.5 ± 9.1 years, respectively, fused levels were 2.2 ± 0.4 and 2.1 ± 0.3, 5 and 4 patients had T12 fractures, and 8 and 9 had L1 fractures. With a follow-up of 45.8 ± 21.3 and 55.8 ± 32.6 months, the ArM was 22.2 ± 26.5 % in the VATS group and 16.4 ± 15.1 % in the thoracotomy group. The number of patients with intercostal neuralgia (INC) was 4 and 1. As to satisfaction with the surgical wound, 6 patients in the VATS group and 5 in thoracotomy were very satisfied and 7 and 8 were satisfied, respectively. There was a statistically significant relationship between the clinical result and satisfaction with the wound (p = 0.0005, r = 0.6). In this study, the presence of INC was not related with ArM or the clinical outcome. There were no significant differences between the groups with regard to ArM or the incidence of INC. Conclusion: In our series, no differences were found with regard to ArM, and therefore, we should not use it as a criterion for choosing the approach to use in anterior column reconstruction.
19 Pull-out
60
8
D
E
76
10
D
E
RADIOLOGIC RESULTS OF SHORT INSTRUMENTATION AND FUSION FOR AO TYPE C THORACOLUMBAR FRACTURES Principal Author: Fleiderman Valenzuela, Jose´
18 Center: Hospital del Trabajador, Santiago, Chile
DIFFERENCES IN SURGICAL ACCESS-RELATED MORBIDITY IN ANTERIOR COLUMN RECONSTRUCTION OF THORACOLUMBAR FRACTURES USING OPEN TECHNIQUES VERSUS VIDEO-ASSISTED THORACOSCOPIC SURGERY. RESULTS OF A PAIRED ANALYSIS IN TWO CENTERS Principal Author: Iba´n˜ez Aparicio, Natalia Center: Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
Additional Authors: Ramı´rez Pittaluga, Sergio1; Telias Neira, Alberto1; Lecaros Bahamondes, Javier2; Ilabaca Grez, Francisco1; Urzua Bacciarini, Alejandro1; Zamorano Pe´rez, Juan Jose´1; Ballesteros Plaza, Jose´ Vicente1; Yurac Barrientos, Ratko1; Lecaros Larenas, ´ ngel1; Munjin Leo´n, Milan1; Tapia Pe´rez, Carlos1 Miguel A Centers: 1Hospital del Trabajador, Santiago, Chile; 2Universidad de Los Andes, Santiago, Chile Introduction: Type C fractures of the thoracolumbar spine are unstable injuries associated with a high incidence of neurological deterioration. These injuries require stabilization by spinal instrumentation and fusion including two or more levels above and below
123
256
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the level of the lesion. Because of the better understanding of the biomechanics of the spine, more detailed and precise classification systems, and the development of new techniques for pedicle instrumentation, we can now consider short instrumentation treatments, in which only one segment above and below the injured level is fused, preserving the adjacent mobile segments. Our study will enable evaluation of the radiologic results by establishing the failure rate in short-segment instrumentation and fusion in the treatment of patients with AO type C thoracolumbar fractures. Materials and Methods: Retrospective case series study of 31 patients with AO type C thoracolumbar fractures surgically treated with short instrumentation and fusion (bi-segmental or mono-segmental). Minimal postoperative follow-up was 2 years. Patients requiring anterior fusion and those using a brace during follow-up were excluded. Instrumentation failure was established based on fracture or loosening of the osteosynthesis material, or progression of segmental kyphosis greater than 108 (using the Cobb method). Results: Mean age was 39 years. Fracture subtype was C3 in 41 % of patients, C2 in 29 %, and C1 in 30 %. The most frequent mechanism of injury was a fall from a height (48 %), followed by traffic accidents (29 %). Mean progression of segmental kyphosis in the study group was 4.58 (08-108), and only 3 patients (9.6 %) presented instrumentation failure during follow-up: 2 cases of fractured osteosynthesis material, and 1 case of segmental kyphosis progression greater than 108. Conclusion: The use of short-segment instrumentation and fusion in the treatment of type C thoracolumbar spine fractures is an adequate alternative for selected patients. The failure rate of this approach was 9.6 % in our series.
women (21.8 %), mean age 44 years (18–71 years). Patients had undergone spine surgery in our center involving instrumentation and fusion with the use of autologous bone graft and additional demineralized bone matrix. Radiologic evaluation with a minimum of 2 years’ postoperative follow-up. Fusion status was assessed by a radiologist using the Lenke fusion scale, as follows:
20
Principal Author: Baza´n Lizarraga, Pedro Luis
OUTCOME OF FUSION USING DEMINERALIZED BONE MATRIX AUGMENTATION IN THORACOLUMBAR SPINE FRACTURES
Center: Higa San Martı´n-Hospital Italiano, La Plata, Argentina
a. b. c. d.
Definitely solid masses, bilateral fusion Possibly solid unilateral masses, moderate contralateral fusion Probably not solid bilateral fusion masses Definitely not solid bilateral (bilateral graft resorption or fusion mass with obvious bilateral pseudarthrosis)
Grades A and B were considered a satisfactory radiologic outcome. Results: Case series of 78 patients; only 1 patient lost to follow-up. According to the Lenke classification, 26 patients (34.21 %) were considered grade A, 22 (28.95 %) grade B, 10 (13.16 %) grade C, and the remaining 18 patients (23.68 %) were classified as grade D at the last radiologic assessment. Satisfactory results (grades A and B) were obtained in 63.16 % of patients. There were no cases of instrumentation failure. Conclusion: A satisfactory radiologic outcome was achieved in 58.14 % of patients. Nevertheless, instrumentation failure did not occur in any patient.
21 PREDICTIVE FACTORS IN ADULT SCIWORA SYNDROME
´ lvaro Enrique; Medina, Martin Additional Authors: Borri, A Center: Higa San Martı´n-Hospital Italiano, La Plata, Argentina
Principal Author: Fleiderman Valenzuela, Jose´ Center: Hospital del Trabajador, Santiago, Chile Additional Authors: Tapia Pe´rez, Carlos1; Innocenti Dı´az, Piero1; Larrain Garces, Cristian1; Navarrete Zavala, Jose´2; Munjin Leo´n, Milan1; Urzua Bacciarini, Alejandro1; Yurac Barrientos, Ratko1; Ballesteros Plaza, Vicente1; Zamorano Pe´rez, Juan Jose´1; Ilabaca Grez, Francisco1 Center: Hospital del Trabajador, Santiago, Chile; 2Universidad de Los Andes, Santiago, Chile Introduction: Thoracolumbar spine fractures are severe injuries that require a prompt and precise diagnosis to establish adequate treatment. Conservative therapy is one option, but surgery is needed in some cases, including spinal instrumentation and fusion of the injured segment. Autologous bone graft is the reference standard to achieve spinal fusion, but it is associated with donor site complications. Demineralized bone matrix is an adequate alternative material for this purpose because of its osteoinductive and osteogenic properties. The aim of this study is to evaluate the radiologic outcome in terms of degree of bone fusion and number of instrumentation failures in patients who have undergone bone graft augmentation with demineralized bone matrix. Materials and Methods: Retrospective case series including 78 patients with thoracolumbar spine fractures, 61 men (78.2 %) and 17
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Introduction: SCIWORA syndrome in adulthood occurs in up to 15 % of spinal cord injuries. It seems most commonly related to a container-content problem that becomes decompensated following a low-energy injury. Magnetic resonance imaging (MRI) can diagnose intramedullary and extramedullary lesions. Aims: To analyze kinematics, recognize the presenting clinical picture, describe imaging findings, consider therapeutic options, and assess the evolution. Material and Method: Thirteen patients (all men) who presented SCIWORA between 2005 and 2012 were analyzed. We evaluated the clinical signs and symptoms, treatment, complications, and evolution. Results: Ten patients older than 45 years presented signs of spondyloarthrosis with mild symptoms. Among the 3 younger patients, only one presented an asymptomatic constitutional narrow spinal canal. All had sustained a low-energy trauma. MRI predominantly showed intramedullary hematoma, and clinically, all patients presented a spinal cord injury, which was severe (ASIA A-B) in those older than 45. Seven patients were initially treated with conservative management: one worsened and required surgery 18 months later, another died in the first hours, and the remaining patients had a good evolution. Six patients underwent surgery (laminoplasty) in the first 10 days; 3 died and the remaining patients improved by at least one ASIA level. Conclusions: Younger age, a less severe clinical picture, and intramedullary edema are factors associated with a good prognosis; these patients are helped by conservative treatment. Older age,
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257
spondyloarthrosis and severe or progressive conditions carry a poor prognosis and may require surgical treatment. Table 1 Age, kinematics, and associated injuries Patient
Age
Kinematics
Associated lesions Head and chest trauma
Table 4 Evolution of Japanese Orthopedic Association (JOA) score PATIENT
6 months
1 year
2 years
3 years
4 years
Final JAO
1
14
11
12
13
13
13
2
10
12
12
12
12
12
3
15
15
16
16
16
16
4
8
Death 10
13
15
15
15
1
55
Driver without a seat belt
5
14
2
46
Driver
6
Death
3
60
Passive rotation
7
11
4
75
Driver without a seat belt
8
Death
5
53
Driver with a seat belt
9
12
14
14
14
6
84
Fall from height
10
16
16
16
16
7
63
Passive flexion–extension
11
16
16
8
63
Bicycle
12
17
17
9
65
Fall from height
13
15
15
10
20
Driver with a seat belt
11
27
Front seat passenger
12
16
Rugby
13
58
Back seat passenger
Age
Radiography
VERTEBRAL RESTORATION FOLLOWING TYPE A FRACTURE: MEDIUM-TERM FOLLOW-UP IN A PROSPECTIVE, MULTICENTER CLINICAL STUDY
MRI In tramedullary
Affected
Diameter
lesion
levels
compromise
1
55
Spondyloarthrosis
Hematoma
C4–C6
[50
2
46
Spondyloarthrosis
Edema
C5–C6
\50
3
60
Spondyloarthrosis
Edema
C5–C7
\50
4
75
Spondyloarthrosis
Hematoma
C3–C5
[50
5
53
Spondyloarthrosis
Edema
C4–C6
\50
6
84
Spondyloarthrosis
Hematoma
C3–C6
[50
7
63
Spondyloarthrosis
Hematoma
C4–C5
\50
8
63
Spondyloarthrosis
Hematoma
C3–C6
[50
9
65
Spondyloarthrosis
Hematoma
C2–C3
[50
10
20
Normal
Hematoma
C3–C4
[50
11
27
Constitutional narrow canal
Mixed
C3–C5
[50
12
16
Normal
Hematoma
C5–C6
\50
13
58
Spondyloarthrosis
Mixed
C3–C4
[50
Initial
Surgery
Asia
Principal Author: Rodrı´guez-Monsalve Milano, Fiona Center: Hospital Clı´nico Universitario de Valladolid, Spain Additional Authors: Luengos Pen˜a, Vero´nica1; Ardura Arago´n, Francisco1; Herna´ndez Ramajo, Rube´n1; Beyerlein, J.2; Hansen-Algenstaedt, N.2; Hassel, F.3; Barreau, X.4; Noriega Gonza´lez, David Ce´sar1 Centers: 1Hospital Clı´nico Universitario de Valladolid, Spain; 2University Medical Center Hamburg-Eppendorf, Germany; 3LorettoKrankenhaus, Freiburg, Germany; 4Interventional Neuroradiology Department CHU, Bordeaux, France
Table 3 Evolution of neurologic symptoms according to the ASIA scale Patient
16
22
Table 2 Imaging findings Patient
Death
6
1
2
3
4
Final
months
year
years
years
years
Asia
1
C
X
D
C
D
D
D
D
2
B
X
C
C
C
C
C
C
3
C
E
E
E
E
E
E
4
A
X
A
Death
5
D
X
D
C
D
E
E
E
6
A
7
B
X
C
8
A
X
Death
9
B
X
E
E
E
10
B
E
E
E
11
C
E
E
12
C
E
E
13
C
E
E
Death Death
E E E
Introduction: The aim is to evaluate the ability of minimally invasive surgery with a titanium implant associated with high-viscosity cement to control the clinical symptoms in treatment for vertebral compression fractures. Materials and Methods: Prospective, multicenter study, performed in 4 European hospitals, including 28 patients (26 women, 2 men), mean age 70.2 years (SD = 10.7). There were 22 osteoporotic fractures and 6 traumatic fractures. Data recorded included VAS, ODI and quality of life (EQ-5D) scores, analgesic use, and radiologic parameters. Values were collected preoperatively, in the immediate postoperative period, and at 6 and 12 months postoperatively. Cement leaks were analyzed by CT. Results: The group of patients followed-up to 12 months (n = 21) presented a mean VAS reduction of 6 points, from 7.2 (SD = 2.5) to 1.2 (SD = 1.9). The ODI decreased from 68 % preoperatively to 8.6 % at one year. On the EQ-5D quality of life questionnaire, the preoperative value of 35.2 increased to 76.9 at one year. The percentage of patients who required analgesics dropped from 63.6 % at the preoperative assessment to 9.0 % at one year. The changes in the clinical parameters were statistically significant (p \ 0.001). The cement leak rate was 28.6 %, and all cases were asymptomatic. CT diagnosed 50 % of leaks. Adverse events: none of the events occurring during follow-up (2 deaths, 1 degenerative lumbar syndrome, diaphragmatic paralysis, 1 hypophyseal adenoma, 1 blood pressure disorder, 1 cerebral infarction) were related to the implant or the procedure.
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258 Discussion and Conclusions: The clinical status was significantly better during follow-up and remained stable. The cement leak rate of 28.6 % was comparable to the 27 % reported in the FREE study, with the consideration that being assessed by CT, there was a correction factor of 1.5 with respect to plain radiography studies.
Eur Spine J (2014) 23:248–288 cement (e.g., vertebroplasty). Most leaks were asymptomatic. This study shows that use of cement-augmented screws does not imply associated comorbidity.
24
DOES CEMENT USE TO REINFORCE PEDICLE SCREWS POSE AN ADDITIONAL RISK?
IS THERE A RELIABLE CUT-OFF AGE TO DIFFERENTIATE BETWEEN HEALTHY AND NON-HEALTHY SUBJECTS INCLUDED IN AN ADULT SCOLIOSIS REGISTRY?
´ ngel Ramo´n Principal Author: Pin˜era Parrilla, A
Principal Author: Bago´ Granell, Juan
Center: Fundacio´n Jime´nez Dı´az, Madrid, Spain
Center: Hospital Universitari Vall d’Hebro´n, Barcelona, Spain
Additional Authors: Tome´ Bermejo, Fe´lix; Lo´pez San Roma´n, Bele´n; ´ lvarez, Carmen; Vlad, Marı´a Daniela; A ´ lvarez Galovich, Dura´n A Luis
Additional Authors: Domingo Sabat, Montse1; Pellise´ Urquiza, Ferra´n2; Sa´nchez Pe´rez-Grueso, Fco. Javier3; Vila Casademunt, Alba1; Alanay, Ahmed4; Acaroglu, Emre5
Center: Fundacio´n Jime´nez Dı´az, Madrid, Spain
Centers: 1Institut de Recerca Vall d’Hebro´n, Barcelona, Spain; 2 Hospital Universitari Vall d’Hebro´n, Barcelona, Spain; 3Hospital Universitario La Paz, Madrid, Spain; 4Acibadem Maslak Hospital, Istanbul, Turkey; 5Ankara Spine Center, Ankara, Turkey
23
Aim and Introduction: Pedicle instrumentation in patients with osteoporosis may pose problems related to safety and anchorage strength. Some reports have shown that reinforcing the bone around the screw with PMMA cement is the best method to avoid pullout/cutout problems. Its use has been limited by concerns that it may increase morbidity. To date, there are no studies demonstrating the clinical safety of this instrumentation. The aim of this study is to analyze the potential morbidity of this type of instrumentation. Materials and Methods: Retrospective analysis of 225 consecutive patients treated with cement-augmented cannulated pedicle screws. Indication for instrumentation: degenerative disease (168 cases), fracture (37 cases), deformity (18 cases), tumor (2 cases). The presence of cement leaks, leak-related clinical complications, infection, implant loosening and failure, and extraction difficulties in case of instrumentation revision were analyzed. Cement leaks were detected and classified by CT (epidural, lateral plexus, disc, extravertebral and foraminal). Mean age of patients was 73.7 years. Mean follow-up was 31.8 months. Results: A total of 598 vertebrae were instrumented with 1134 cement-augmented screws. Some type of cement leak occurred in 53.5 % of vertebrae. In 4 vertebrae (0.67 %), cement leaked to the canal, with no clinical repercussions in any case. Four patients (1.7 %) presented radicular pain, which was always associated with a leak to the S1 foramen. Twenty patients (8.8 %) presented a deep infection that required wound revision; removal of the material was not necessary in any case. Thirty patients (13.3 %) needed revision surgery: 20 of the adjacent segment (8.8 %), and 10 cases of pseudoarthrosis (4.4 %). Despite cement augmentation, none of the 103 screws requiring replacement caused any difficulty at removal. Pseudoarthrosis developed in long instrumentations, and in 6 cases, rod breakage occurred without screw loosening. Conclusion: Cement-augmented pedicle screws are a safe instrumentation option in patients with osteoporosis. The cement leak rate is much lower than the rates described in other techniques using
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Adult scoliosis (AS) databases usually include individuals older than 18 years, and all subjects are considered useful for analyzing the effect of interventions in this population. Nonetheless, it is known that the quality of life of many individuals with scoliosis is not significantly different from that of the non-scoliotic population. Aim: To determine whether there is a cut-off age that enables separation of healthy persons with EA from non-healthy ones based on distribution of the SF-36 and SRS-22 questionnaires in the normal population. Material: Patients incorporated in a multicenter AS database. The study included women older than 18 years diagnosed with idiopathic or degenerative scoliosis, who had not received surgical treatment. Patients below the 25th percentile of SF-36 or the 20th percentile of SRS-22 were assigned to the Non-healthy group and the remaining patients to the Healthy group. Method: An analysis of ROC curves was performed, and the area under the curve (AUC), sensitivity, and specificity were determined. Results: A total of 174 women (mean age 44.5 y, mean Cobb angle 51.28) were analyzed. The percentage of Non-healthy individuals was 48.8 % in the SF-36 mental component summary (MCS) and 57.4 % in the physical component summary (PCS). For the SRS-22, the percentage of Non-healthy subjects was 58.6 % in Function, 78.7 % in Pain, 85.1 % in Self-image, 71.8 % in Mental health, and 79.3 % for the subtotal. In SF-36, the best predictive values were for PCS (age 42, AUC 0.78), Physical function (age 42, AUC 0.77) and Physical role (age 41, AUC 0.81). In SRS-22, the most robust values were in Function (age 46, AUC 0.77) and Pain (age 44, AUC 0.75). Of note, significance was lacking in the cut-offs for the Mental health and Self-image scales. Conclusions: An age of 40 years is a reliable cut-off for classifying individuals with AS when the analysis is focussed on pain and/or
Eur Spine J (2014) 23:248–288
259
function. A reliable cut-off was not found for assessing mental health or self-image.
26 EFFECT OF NON-FUSION TECHNIQUES ON VERTEBRAL ROTATION AND THE RIB CAGE IN EARLY-ONSET SCOLIOSIS
25 COMPARATIVE STUDY OF THE SENSITIVITY TO CHANGE OF TAPS VERSUS SRS-22 FOLLOWING SURGERY FOR IDIOPATHIC SCOLIOSIS AND RELATIONSHIPS WITH THE PERCENTAGE OF CURVE CORRECTION Principal Author: Bago´ Granell, Juan
Principal Author: Pe´rez Martı´n-Buitrago, Mar Center: Hospital Universitario La Paz, Madrid,Spain Additional Authors: Sa´nchez Pe´rez-Grueso, Francisco J.; Sa´nchez Ma´rquez, Jose´ Miguel; Garcı´a Ferna´ndez, Alfredo; Ferna´ndez-Baillo, Nicomedes; Quinta´ns Rodrı´guez, Jose´ Center: Hospital Universitario La Paz, Madrid, Spain
Center: Hospital Universitari Vall d’Hebro´n, Barcelona, Spain Additional Authors: Sa´nchez Pe´rez-Grueso, Fco. Javier1; Sa´nchez Raya, Judith2; Les, Esther2; Pe´rez Buitrago, Mar1; Vila Casademunt, Alba2; Pellise´ Urquiza, Ferra´n2 Centers: 1Hospital Universitario La Paz, Madrid, Spain; 2Hospital Universitari Vall d’Hebro´n, Barcelona, Spain There is a lack of correlation between the magnitude of change in SRS-22 scores and the percentage of scoliosis correction following instrumented vertebral fusion. Aim: To compare the sensitivity to change of the SRS-22 questionnaire and the TAPS scale and correlations between the magnitude of the change and the scoliotic curve. Material and Method: The study included 73 patients (62 females) who underwent surgery for idiopathic scoliosis. Mean age at the time of surgery was 16.9 years. In all cases, a complete radiography study, and SRS-22 and TAPS scores were available preoperatively and at the follow-up visit (mean duration of follow-up, 23.5 months). Results: Mean magnitude of the major curve was 63.88 preoperatively and 27.48 at follow-up (mean correction 56.5 %). The table shows mean preoperative and follow-up values as well as the effect size (Glass delta) of the radiologic magnitude of the major curve and the mean scores on the TAPS and SRS-22 questionnaires. All differences between preoperative and follow-up values were statistically significant (Student t test 2.6-25, p \ 0.05). The correlation between percentage of scoliosis correction and improvement on the SRS-22 Self-image score was not significant, whereas the correlation with improvement on the TAPS scale was statistically significant (r = 0.3, p = 0.009). Conclusions: The TAPS scale was more sensitive to change than the SRS-22, specifically the Self-image subscale. The improvement in the TAPS score after surgical treatment correlated with the percentage of scoliosis correction.
Preop
Follow-up
Glass D
Cobb
63.8
27.4
2.52
TAPS Self-image
2.55 2.94
4.24 4.02
1.94 1.42
Non-fusion techniques to treat early-onset scoliosis (EOS) have proven effective for controlling the angular deformity, and additionally, provide a gain in vertebral height close to physiological parameters. Nonetheless, there is little information regarding their effect in controlling vertebral rotation and its repercussions on the rib hump. One hypothesis has proposed that these instrumentations act as a posterior tether and could aggravate the rotational deformity. Aim: To evaluate whether these techniques avert progression of vertebral rotation and the rib deformity. Material and Method: Retrospective review of prospectively recorded preoperative, and immediate and late postoperative data in a series of patients with EOS treated by non-fusion techniques and fulfilling the following requisites: idiopathic pattern of curves treated with growing rods or VEPTR and two years of follow-up. Exclusion criteria: congenital cause, dysplasia, neuromuscular. Radiologic Data: (1) vertebral: coronal and sagittal Cobb. (2) rotation: RVAD (Mehta). Convex apical rib spread (ARS). Space available for the lung (SAL) in convexity. Clinical Data: Rib hump (scoliometer). Trunk imbalance. Statistical analysis used the Mann–Whitney and Wilcoxon tests, and ANOVA. Results: Eighteen of 43 patients met the inclusion criteria. Initial mean age 6 +7 years and follow-up of 4 years. Analysis of the results (Table) confirmed a maintained improvement in Cobb angle, but not in the vertebral rotation values and their effect on the ribs. There was a significant increase in RVAD (Metha) (p \ 0.05) between the postoperative and follow-up. The rib hump improved significantly following surgery (p \ 0.05), but relapsed to preoperative values during follow-up (p \ 0.05). The ARS showed no significant differences over time except for left curves, where there was significant narrowing (p \ 0.05) at the thoracic convexity. The vertical diameter of the convex hemithorax (SAL) increased with time, without being affected by the rotational component. Conclusions: Non-fusion techniques for EOS do not seem to avert the rotational deformity and its aesthetic impact. Studies with longer follow-up at a more collaborative age would enable analysis of the repercussions on respiratory function.
27
SRS 22 subtotal
3.73
4.26
0.86
Pain
3.87
4.42
0.57
Function
4.18
4.43
0.36
Mental health
3.94
4.16
0.3
WHAT IS THE CLINICAL VALUE OF SAGITTAL RADIOGRAPHIC PARAMETERS IN [408 SCOLIOSIS IN ADULTS [40 YEARS OF AGE? Principal Author: Rodrı´guez Lo´pez, Tamara Center: Hospital Universitario de Getafe, Madrid, Spain
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260
Eur Spine J (2014) 23:248–288
Additional Authors: Nu´n˜ez Garcı´a, Ana; Sa´nchez-Mariscal Dı´az, ´ lvarez Gonza´lez, Patricia; Zu´n˜iga Felisa; Go´mez Rice, Alejandro; A Go´mez, Lorenzo; Pizones Arce, Javier; Izquierdo Nu´n˜ez, Enrique
continued
Center: Hospital Universitario de Getafe, Madrid, Spain Aim and Introduction: • The sagittal plane is gaining increasingly greater interest in adult deformity. It is considered that a positive sagittal balance (SB), increased pelvic tilt (PT), and decreased lumbar lordosis are prognostic factors of a poor outcome in adult scoliosis (AS). • The question is: In patients older than 40 (degenerative changes expected) with predominantly frontal spinal deformity (Schwab 2012, type NON), what are the sagittal parameters for? Materials and Methods: • Forty patients (35 women) 55 years old (41–74) at the time of surgery. Scoliosis [ 408 (idiopathic 28, degenerative 12). Mean postoperative follow-up 7.4 years. • Updated radiographic studies, and SRS-22 and SF-36 questionnaires. Patients were asked if they felt it was worthwhile to have undergone surgery. • We evaluated: thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), LL, SB, spinal sacral angle (SSA), spinal tilt (ST), sagittal pelvic parameters, pelvic incidence/lumbar lordosis mismatch (PILL), necessary lumbar lordosis (ideal-real), and major frontal Cobb curve. Results: (1) Preoperatively (Table) we observed an elevated TLK (13.88), pelvic retroversion at the upper limit (20.98), and loss of LL (LL = 488 and necessary lordosis = 148); (2) In the postoperative follow-up, there was a statistically significant change (Table) in some radiographic parameters, but it was toward a worsening in the sagittal plane (except TLK); (3) Was it worthwhile to operate?: 82.5 % yes; 10 % no; 7.5 % not sure. (4) At final follow-up, there was a significant correlation (Pearson coefficient) between the SRS activity subscale and ST (p = 0.001; r = 0.54), PT (p = 0.008; r = -0.42), and PI-LL (p = 0.047 r = -0.32). Following multiple linear regression analysis, only ST remained as a possible predictor of poorer results on the SRS-22 Activity scale. There were also other, less significant, correlations. • Conclusions: In AS, some sagittal parameters show preoperative changes, but we cannot say that they serve to indicate surgery because they worsen over follow-up; nonetheless, the patient is satisfied with the outcome of the procedure. • The only sagittal parameter that correlated with SRS-22 Activity during follow-up was ST. • The sagittal plane does not seem to have an evident prognostic role when the main deformity is frontal.
Preoperative
Final
p
43.2 ± 19.4
44.9 ± 16.6
NS
TLK, 8
13.8 ± 15.06
7.04 ± 10.8
0.023
LL, 8
48 ± 18.7
42.8 ± 13.6
0.045 0.003
TK, 8
SB, cm
1.5 ± 4
4.8 ± 6.8
T1 inclination, 8
-5 ± 4.4
-2.8 ± 6.2
0.016
Pelvic incidence (PI), 8
56 ± 11.6
57.5 ± 11
NS 0.018
Sacral slope (SS), 8
34.6 ± 12.3
28.9 ± 9.1
Pelvic tilt (PT), 8
20.9 ± 10.9
30.78 ± 11.8
0.000
SSA, 8
123.2 ± 11.1
117.3 ± 12.6
0.005
123
Preoperative
Final
p
ST, 8
91.2 ± 5.1
89.4 ± 7.3
NS
PI-LL mismatch, 8
7.2 ± 20.3
14.5 ± 18.5
0.008
Necessary lordosis, 8
14. 1 ± 18.5
20.6 ± 15.4
0.14
Frontal Cobb, 8
59.2 (38–120)
28.9 (4–80)
0.000
28 IMPACT OF PELVIC PARAMETERS ON THE DEVELOPMENT OF PROXIMAL JUNCTIONAL KYPHOSIS AND INFLUENCE OF THE UPPER LIMIT OF THE MEASURE Principal Author: Sacramento Domı´nguez, Ma Cristina Center: Hospital Ruber Internacional, Madrid, Spain ´ lvarez Sala-Walther, Fernando1; Areta Jime´Additional Authors: A nez, Francisco Javier1; Berna´cer Lo´pez, Jose´ Luis1; Castrillo Amores, ´ ngel1; Cobo Soriano, Javier1; Jime´nez Sosa, Alejandro2 Miguel A Centers: 1Hospital Ruber Internacional, Madrid, Spain; 2Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain Introduction: Anterior sagittal imbalance of the vertebral segments above a fusion is a major long-term complication of long spinal fusions. The aim of this study is to determine the influence of spinopelvic parameters on the development of this complication and the impact of the upper limit of the Cobb angle on measurement of the proximal junctional kyphosis. Materials and Methods: The study included 24 patients who underwent surgery for scoliosis and kyphosis using posterior instrumentation with pedicle screws between 2005 and 2011. We measured sagittal balance, pelvic incidence, and sacral and pelvic inclination. To measure the proximal junctional kyphosis, we first used the standard Cobb angle, from the inferior plate of the upper last instrumented vertebra to the superior plate of the second vertebra above. We then measured proximal kyphosis at a somewhat more distant area, three levels above the upper last instrumented vertebra. Digital radiography was used for the preoperative evaluation and at completion of follow-up to determine the parameters evaluated. The statistical analysis was performed with the means of the quantitative variables, and correlations were determined with the Spearman Rho test. Results: Demographic characteristics as follows: age, 43.29 ± 23.11; females, 19; diagnosis scoliosis/kyphosis, 18/6; fusion levels, 10.41 ± 1.74. Conclusions: The analysis showed that a smaller preoperative pelvic incidence correlates with the development of greater proximal junctional kyphosis at completion of follow-up (Rho = -0.391 P = 0.032 and Rho = -0.528 P = 0.007), and that measurement of the proximal junctional kyphosis angle at an area farther from the upper last instrumented vertebra is a more valid instrument for evaluating the positive influence of anterior sagittal imbalance on the development of greater proximal junctional kyphosis (Rho = 0.362, P = 0.045).
Eur Spine J (2014) 23:248–288
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Spinopelvic parameters Preoperative Sacral inclination
35.94 ± 11.82
Pelvic inclination
20.60 ± 10.89
Pelvic incidence
55.22 ± 13.9
Sagittal balance
24.04 ± 79.94
End follow-up Sacral inclination
35.75 ± 9.44
Pelvic inclination
21.99 ± 10.79
Pelvic incidence
57.69 ± 13.27
Sagittal balance
-2.79 ± 58.02
Proximal junctional kyphosis (PJK) angle Preoperative Standard (2 levels above)
5.58 ± 7.73
Distant (3 levels above)
7.41 ± 11.04
End follow-up Standard (2 levels above) Distant (3 levels above)
14.67 ± 9.55 16.88 ± 9.50
End follow- Preoperative End follow-up Preoperative up PJK sagittal balance sagittal pelvic incidence balance Distant PJK Rho = 0.362, P = 0.045 Standard Rho = 0.236, PJK P = 0.395
Rho = 0.353, P = 0.049 Rho = 0.193, P = 0.195
Rho = -0.391, P = 0.032 Rho = -0.528, P = 0.007
retrolisthesis), LF surgery-related factors (number of levels, ending in L5 or S1, screw length, laminectomies), and factors related to spinopelvic parameters following LF (PI, SS, LL, L4–S1 angle, L4– L5 angle, L2–L4 angle, disc height ratios, L4–L5/LL ratio and SS/PI ratio). Variables in the two groups were compared (Student t for quantitative, Chi square for categorical), and the odds ratio (OR) was estimated as a measure of association. Results: Mean follow-up was 67.46 months (SD 3.7) in controls and 57.92 months (SD 46.3) in cases to the development of SASD. Patient-related RFs did not differ between cases and controls. Facet inclination was greater in cases (p = 0.039; dif. means 7.758, 95 %CI 1.38-14.138, if [458 p = 0.013; OR = 2.205) and previous disc disease was more frequent in this group (p = 0.013). RFs identified included finalizing LF in a level other than S1 (p \ 0.05; OR = 1.39), presence of long screws (p = 0.001; OR = 2.023), and adjacent laminectomy (p = 0.005; OR = 1.57). PI was similar between groups, but cases showed a smaller SS (p = 0.004; dif. means -6.258, 95 % CI -10.428 to -2.028), LL (p = 0.001; dif. means -11.188, 95 % CI -17.368 to -5.058), L4–S1 angle (p = 0.018; dif. means -6.28, 95 % CI -11.38 to -1.48), L4–L5 angle (p = 0.001; dif. means -10.548, 95 % CI -14.88 to -6.288), L4–L5/LL ratio \0.33 (p = 0.000; OR = 3.59), and SS/PI ratio \0.5 (p = 0.005; OR = 8.615). Sixty percent of SASDs occurred in \45 months following LF. These cases were older (p \ 0.001; dif. means 21.2 months, 95 % CI 27–14 months), facet inclination was [458 (p = 0.007; OR = 3.055), and there was a larger number of multilevel LFs (p = 0.004; OR = 2.75) than in the remaining SASD cases. Conclusions: The RFs identified for the development of SASD included aspects related to the degenerative disease, the surgery, and unfavorable spinopelvic parameters. Exposure to these last RFs showed a greater association with the development of SASD.
30 29 RISK FACTORS FOR THE DEVELOPMENT OF SYMPTOMATIC ADJACENT SEGMENT DISEASE IN LUMBAR FUSION
DIAGNOSTIC ERROR IN DURAL LESIONS IN DEGENERATIVE LUMBAR SPINE DISEASE: MANAGEMENT AND TREATMENT Principal Author: Sirna, Pablo Mario
Principal Author: Herna´ndez Ferna´ndez, Alberto
Center: Instituto Dupuytren-Casa Hospital San Juan de Dios, Buenos Aires, Argentina
Center: Hospital Universitario Donostia, San Sebastia´n, Spain
Additional Authors: Sisi, Tamara1; Bernasconi, Juan Pablo2; Seltzer, German1; Rudt, Toma´s3; Ramı´rez, Gustavo Valentı´n4
Additional Authors: Gabarain Morcillo, Imanol1; Case Martı´nez, Jose´1; Lersundi Artamendi, Ana1; Abdul-Sayed Valdeolmillos1, Amal; Iza Beldarrain, Jon1; Villanueva Leal, Carlos2 Centers: 1Hospital Universitario Donostia, San Sebastia´n, Spain; 2 Clı´nica del Pilar, Barcelona, Spain Aims: To identify risk factors (RF) for the development of symptomatic adjacent segment disease (SASD) in lumbar spine fusion (LF) and estimate the degree of association between RF exposure and development of SASD. Materials and Methods: Case–control study: 39 cases surgically treated for SASD (2010-2012) and 28 controls undergoing surgical LF (2006–2007) without developing SASD. We studied potential patient-related RFs (age, sex, ASA, weight, smoking habit, rheumatic diseases), factors related to the degenerative disease before LF (adjacent disc disease, facet arthrosis, facet inclination, and
Centers: 1Instituto Dupuytren, Buenos Aires, Argentina; 2Instituto Dupuytren-Sanatorio Sarmiento, Buenos Aires, Argentina; 3Sanatorio Mitre- Instituto Dupuytren, Buenos Aires, Argentina; 4Instituto Dupuytren-Casa Hospital San Juan de Dios, Buenos Aires, Argentina Aim and Introduction: Intraoperative dural sac lesions are not uncommon. Nonetheless, those that go unnoticed during the primary surgery and those that are diagnosed at a later time point have not been fully described. Materials and Methods: This is a retrospective, descriptive, multicenter study including 3860 patients who underwent degenerative lumbar spine surgery between January 2006 and January 2012, and presented fistulas and/or CSF collections that were diagnosed at least 2 weeks following the procedure. Results: Among the 3860 surgically treated patients, 7 received a late diagnosis of a fistula and/or CSF collection, accounting for 0.18 %, of
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262 the sample. The most common clinical presentation was an unstable wound: 4 cases (57.14 %). Two patients (28.58 %) presented a CSF fistula that was interpreted as a secretion. Of the 7 patients, 4 (57.14 %) were treated by placing them in the Trendelenburg position. This measure failed in 100 % of cases. With regard to surgical treatment of the fistula or dural lesion, examination of the laminectomized area and sealing with biological glue was carried out in 6 cases (85.72 %). Success was obtained in only 1 case (16.66 %), a patient who had undergone simple discectomy. The fistula was not visualized intraoperatively in any case. In the 5 cases of sealant failure, 2 patients (40 %) were reoperated 3 times and 3 patients (60 %) 2 times. The 2 patients requiring 3 surgeries were the ones in whom there was an erroneous interpretation of contaminated secretion and CSF fistula was not suspected. In all cases, the definitive treatment was drainage to the exterior. CSF culture was negative in all cases. Conclusions: In our experience, an accurate diagnosis of late fistula is provided by (1) clinical suspicion (unstable wound), (2) physical– chemical examination of the fluid or secretion, and (3) gadoliniumenhanced MRI. Based on the results of this series, treatment should consist in drainage from the dural sac to the exterior.
Eur Spine J (2014) 23:248–288 p = 0.056, respectively). Satisfaction with surgery was similar in the 2 groups (76.2 % and 72.4 %, respectively, p = 0.3956). Although the complication rate was higher in group I, this factor did not seem to have an impact on the functional outcome. Conclusion: This study demonstrates that the benefit patients older than 75 years can obtain from lumbar spine fusion is comparable to that of younger patients. Hence, age in itself should not be considered an absolute contraindication.
32 EFFECT OF LUMBOSACRAL INSTRUMENTATION AND OBSERVER EXPERIENCE IN THE MEASUREMENT OF PELVIC PARAMETERS Principal Author: Vila Casademunt, Alba Center: Hospital Universitari Vall d’Hebro´n, Barcelona, Spain
31 LUMBAR FUSION IN PATIENTS OLDER THAN 75 YEARS. IS IT WORTHWHILE? STUDY INVESTIGATING THE IMPROVEMENT IN QUALITY OF LIFE COMPARED TO YOUNGER PATIENTS Principal Author: Tome´ Bermejo, Fe´lix Center: Fundacio´n Jime´nez Dı´az, Madrid, Spain ´ ngel R.; Dura´n A ´ lvarez, CarAdditional Authors: Pin˜era Parrilla, A men; Lo´pez San Roma´n, Bele´n; Vlad, Marı´a Daniela; Mahillo ´ lvarez Galovich, Luis Ferna´ndez, Ignacio; A Center: Fundacio´n Jime´nez Dı´az, Madrid, Spain Aim and Introduction: Despite the prevalence of back problems in elderly patients, most related studies focus on investigating the complications. Our aim is to analyze the improvements in function and quality of life obtained in this population following treatment with lumbar spine fusion and compare the results with those obtained in a younger patient group. Materials and Methods: This is a retrospective study in 194 consecutive patients treated by lumbar fusion of 1 or 2 segments, with more than one year of follow-up. Patients were divided into 2 groups: I, 67 patients older than 75 years and II, 127 patients younger than 65 years. We analyzed the changes on the visual analog scale (VAS), Oswestry Disability Index (ODI) and Core Outcome Measure Index (COMI), as well as the clinical complications and radiologic results. Functional results were analyzed based on the mean increase and the percentage of patients reaching the threshold of a clinically significant difference. Results: The mean age was 77.8 years (75–86) in group I and 47 years (24–65) in group II. A clinically significant improvement was found in all functional parameters at 6 months and 1 year in the 2 groups. The mean ODI improvement was 31.6 points in group I and 30 points in group II. For COMI items 2 and 3, elderly patients presented a greater improvement than younger ones (p \ 0.001 and
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Additional Authors: Pellise´ Urquiza, Ferra´n1; Acaroglu, Emre2; Sa´nchez Pe´rez-Grueso, Francisco J.3; Pe´rez Buitrago, Mar3; Sanli, Tunay4; Yakici, Sule2; Garcı´a de Frutos, Ana1; Matamalas Adrover, Antonia1; Sa´nchez Ma´rquez, Jose´ Miguel3; Obeid, Ibrahim5; Bago´ Granell, Joan1; European Spine Study Group ESSG1 Centers: 1Hospital Universitari Vall d’Hebro´n, Barcelona, Spain; 2 Ankara Spine Center, Istanbul, Turkey; 3Hospital Universitario La Paz, Madrid, Spain; 4Florence Nightingale Hospital, Istanbul, Turkey; 5 Hospital Pellegrin, Burdeos, France Measurement of pelvic parameters (PPs) is necessary to determine the surgical strategy. Instrumented flatback is a common cause of sagittal imbalance. The reliability of PP measurement has never been evaluated in the instrumented lumbosacral spine. Aims: To analyze the reliability of PP measurement using the new computerized tool recommended by the Scoliosis Research Society (SurgimapSpine). To compare the reliability of measurement between instrumented and non-instrumented patients and between professionals with various levels of experience in the measurement technique. To compare the results obtained with published findings. Materials and Methods: Sixty-three full-spine standing radiographs, 31 of them with lumbosacral instrumentation were measured twice by 13 observers. The observers were divided into three levels of experience: high (4 investigators), intermediate (5 senior surgeons), and low (4 junior surgeons). Previously, the investigators trained all the surgeons in handling of the software during a maximum of 30 min, using a series of practice cases. The parameters analyzed included pelvic incidence (PI), pelvic tilt (PT), and sacral slope (SS). The statistical analysis to estimate reliability used the intraclass correlation coefficient (ICC, 95 %CI) and the standard error of measurement (SEM). Results: Thirteen observers and 63 radiographs generated 817 observations (2 system losses). The overall interobserver and intraobserver reliability was excellent (ICC [ 0.85) (Table). Lumbosacral instrumentation did not change the intraobserver reliability, but it significantly reduced the interobserver reliability for PT (p = 0.006) (ICC 0.92, SEM 2.28) and SS (p = 0.007) (ICC 0.77, SEM 4.48) measurement. Experience did not change intraobserver reliability. However, interobserver reliability was lower in the group of experts (p \ 0.05) than in those with intermediate or low experience. Conclusions: The reliability of PP measurement using SurgimapSpine is equal to or better than reported reliability values.
Eur Spine J (2014) 23:248–288
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Lumbosacral instrumentation decreased interobserver reliability from excellent to moderate in the sacral slope measurement. Less experienced observers can reliably measure PPs following a simple training session.
ICC (95 % CI)
PI
PT
SS
Interobserver (overall)
0.86 (0.81–0.90)
0.95 (0.93–0.96)
0.86 (0.81–0.90)
Intraobserver (overall)
0.89 (0.83–0.93)
0.99 (0.98–0.99)
0.90 (0.84–0.93)
Interobserver (not Instrumented)
0.87 (0.81–0.92)
0.97 (0.95–0.98)
0.90 (0.84–0.93)
Interobserver (instrumented)
0.83 (0.75–0.89)
0.92 (0.88–0.95)
0.77 (0.66–0.85)
Intraobserver (not Instrumented)
0.88 (0.78–0.94)
0.99 (0.98–0.99)
0.89 (0.79–0.94)
Intraobserver (instrumented)
0.89 (0.80–0.94)
0.99 (0.98–0.99)
0.88 (0.79–0.94)
33 RELATIONSHIP BETWEEN SPINOPELVIC PARAMETERS AND LUMBAR SPINE DISEASE ON MRI IN WORKING-AGE PATIENTS Principal Author: Vila` Canet, Gemma Center: Institut Universitari Dexeus, Barcelona, Spain Additional Authors: Ubierna Garce´s, Ma Teresa; Garcı´a de Frutos Ana; Salo´ Bru, Guillem; Arias Baile, Ainhoa; Ca´ceres Palou, Enric Center: Institut Universitari Dexeus, Barcelona, Spain Aim and Introduction: Some authors have described a certain relationship of lumbar lordosis and/or sagittal balance with lumbar spine pathologies. Our aim was to determine whether there is any relationship between the spinopelvic parameters of patients with lumbar and/or radicular pain and their disease according to MRI findings. Materials and Methods: Prospective observational study including 191 consecutive patients consulting for the first time in our center, and manifesting lumbar and/or radicular pain of at least 2 months’ duration. We recorded epidemiologic data (age, sex, work activity, sports activity) and pain location (lumbar and/or radicular). All patients underwent measurements in the full-spine lateral view and MRI study of the lumbar spine. The radiographic measurements included lumbar lordosis, sagittal balance (positive, negative, neutral), sacral slope, pelvic incidence, and lumbar morphotype according to Roussouly. MR findings were divided into 7 groups: normal, mild disc disease at one level, disc disease at one level with MODIC changes, disc herniation, multiple disc disease, canal stenosis, and isthmic or degenerative spondylolisthesis Results: Among a total of 191 patients (85 men, 106 women) with a mean age of 45 years (18–66), 66 % manifested lumbar pain and 44 % radicular pain. Mean lumbar lordosis was 558 (188–818), pelvic incidence 528 (288–788), and sacral slope 358 (148–518); 49 % had negative sagittal balance and 45 % neutral. Roussouly types 2 (45 %) and 3 (39 %) predominated. The predominant MRI findings were multiple disc disease, disc herniation, and disc disease at one level with MODIC changes. There was no statistically significant relationship of MRI findings with the type of sagittal balance, pelvic
incidence values, or Roussouly morphotype. There was a non-significant trend to greater radicular pain in patients with higher pelvic incidence values. Conclusions: Sagittal balance with a predominance of neutral and negative cases concurs with the literature in healthy patients at least 40 years old. We found no relationships between the spinopelvic parameters in our patient sample and specific lumbar disease according to MR findings.
34 INTRAOPERATIVE NEUROPHYSIOLOGICAL MONITORING IN SPINAL CORD INJURY. EXPERIMENTAL STUDY Principal Author: Cervera, Javier Center: Hospital Virgen de la Salud, Toledo, Spain Additional Authors: Burgos Flores, Jesu´s1; De Blas Beorlegui, Gema1; Caban˜es Martı´nez, Lidia1; Hevia Sierra, Eduardo2; Barrios Pitarque, Carlos3; Correa Gorospe, Carlos1; Sanpera Trigueros, Ignacio4; Barriga Martı´n, Andre´s5; Collazos Castro, Jorge5 Centers: 1Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 2 Hospital La Fraternidad, Madrid, Spain; 3Universidad Cato´lica de Valencia, Spain; 4Hospital Son Espases, Palma de Mallorca, Spain; 5 Hospital Nacional de Paraple´jicos de Toledo, Spain Aim and Introduction: Patients with spinal cord injury often require urgent surgical treatment. Surgery without intraoperative neurophysiological monitoring in these patients may lead to additional cord lesions or aggravate the previous injury. The aim of this study is to experimentally ascertain the reliability of intraoperative neurophysiological monitoring in spinal cord injury. Materials and Methods: Three groups of 5 industrial pigs were studied: In Group 1 (n = 3), using a posterior approach and laminectomies, the dural sac was exposed at T4–T5 and sublaminar epidural catheters were placed cranially and caudally. Progressive cord compression at T5 was carried out using an adjustable compression device with two parallel rods placed on both sides of the cord. The spinal cord was compressed at a rate of 0.5 mm every 2 min. Animals were electrophysiologically monitored using cord– cord evoked potentials with proximal stimulation and distal recording, until complete disappearance of potentials. In Group 2 (n = 3), the same approach was used at the T12–T13 level, with compression at T12. In Group 3 (n = 5), the spinal cord was exposed at T4–T5, T8, and T12–T13. Catheters were placed cranially and caudally at both T4–T5 and T13–T12. The cord was sectioned at T8, and compression was applied at T5 and T12 using the same technique. Results: In Group 1 (mean cord diameter 7.1 ± 0.3 mm), complete disappearance of potentials occurred at 4.6 ± 1.2 mm of cord compression. In Group 2 (mean cord diameter 7.6 ± 0.5 mm), potentials disappeared at 4.8 ± 0.4 mm of compression. In Group 3, in which the cord was sectioned, loss of potentials occurred after 5 ± 0.8 mm of compression, but at T12, only 3.1 ± 0.7 mm of compression was required. Conclusions: Neurophysiological monitoring of the spinal cord above and below the lesion is feasible in patients with acute cord injury. This study shows that the spinal cord is more susceptible to proximal
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264 compression following an injury than the uninjured cord. Therefore, intraoperative neurophysiological monitoring is feasible and necessary in patients with spinal cord injuries requiring surgery.
35 STUDY INVESTIGATING INTRAOPERATIVE SPINAL CORD FLOW MONITORING. VALUE OF NEUROPHYSIOLOGICAL MONITORING Principal Author: Hevia Sierra, Eduardo Center: Hospital La Fraternidad-Muprespa, Madrid, Spain Additional Authors: Burgos Flores, Jesu´s1; Barrios Pitarque, Carlos2; De Blas Beorlegui, Gemma1; Mun˜oz Nu´n˜ez, Laura3; Caban˜as Martı´nez, Lidia1; Collazos, Jorge4; Barriga Martı´n, Andre´s4; Sanpera Trigueros, Ignacio5 Centers: 1Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 2 Universidad Cato´lica de Valencia, Spain; 3Hospital La FraternidadMuprespa, Madrid, Spain; 4Hospital Nacional de Paraple´jicos de Toledo, Spain; 5Hospital Universitario de Son Espases, Palma de Mallorca, Spain Aims and Introduction: Intraoperative measurement of spinal cord blood flow (CF) using high-resolution laser Doppler (HRLD) imaging could improve intraoperative cord monitoring. In this study, we determined the CF decrease needed to produce changes in neurophysiological monitoring (NM). Materials and Methods: Laminectomies were used to expose the dural sac from T3 to T13 in 6 domestic pigs (mean weight 31 kg). Progressive compression was applied at a rate of 1 mm/2 min using a 5-mm wide lateral rods. CF was recorded by HRLD, and NM was performed using epidural catheters above and below the spinal cord injury (SSEPs involved nerve stimulation in the lower limbs, and MEPs transcranial stimulation with D wave). The CF and NM changes were measured following each compression step. The study ended when potentials completely disappeared in neurophysiological monitoring. Results: At T8, the cord had a diameter of 7.3 mm. When a 2 mm compression was applied, the distal CF increased with no changes in NM potentials. When compression reached 5 mm, CF disappeared at the area of compression and decreased distally; potentials were present, although decreased and slower. By 6 mm compression, potentials fully disappeared. The CF changes were detected only at a distance of 2.3 cm from the compressed area; being CF normal in the remainder of the cord. Conclusions: CF changes secondary to compression and measured by HRLD were only detectable at a distance of 2.3 cm from the lesion. The extensive network of vascular perfusion may explain the fact that when compression is applied locally it is reflected only in a small portion of the spinal cord. These findings question the role of ischemia in the development of spinal cord lesions. Conventional NM only detects major changes in CF; but it is unable to detect subtle changes.
36 IMPACT OF PERIOPERATIVE MEASURES TO DECREASE INFECTION RATES IN SPINAL SURGERY. PRELIMINARY STUDY Principal Author: Gonza´lez Murillo, Manuel
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Eur Spine J (2014) 23:248–288 Center: Hospital Universitario de Getafe. Madrid. Spain ´ lvarez Gonza´lez, Patricia; Moreno Gomila, Additional Authors: A Carolina; Pizones Arce, Javier; Sa´nchez-Mariscal Dı´az, Felisa; Zu´n˜iga Go´mez, Lorenzo; Izquierdo Nu´n˜ez, Enrique Center: Hospital Universitario de Getafe, Madrid, Spain Aim and Introduction: Our aim was to decrease the postoperative infection rate in spinal surgery by applying a protocol of intraoperative and postoperative multidisciplinary measures. Currently, surgical site infection is the most common complication and one of the most important in spinal surgery. Reported infection rates vary from 0.3 % to 20 %. Materials and Methods: Comparison of two groups of patients consecutively undergoing surgical treatment: group 1 (January– August 2011) patients operated without use of the perioperative protocol; group 2 (September 2011–April 2012) patients in whom the following protocol of perioperative measures was implemented: intraoperative measures included washing skin with chlorhexidine gluconate, use of closed-circuit washing with saline and iodinated povidone, glove changes every 3 h, application of local antibiotic (1 g vancomycin in powder form) at the suprafascial plane, and application of 240-mg gentamicin solution in the autologous bone graft; postoperative measures were sterile dressing of the surgical wound only if stained and drain removal at 48 h without changing the dressing. Results: In group 1, the surgical wound infection rate was 10.2 % (11 patients) in 108 spinal surgeries, requiring 9 cases of reinterventions. In group 2, the infection rate decreased to 3.1 % (4 patients) in 128 procedures with 4 cases of reintervention. The difference in infection rates was statistically significant (p = 0.019). Conclusion: Although surgical wound infections have a multifactorial etiology, there are several modifiable elements that can maximally decrease the infection rate, and along with it, morbidity, reinterventions, hospital stay and therefore, related costs. Nonetheless, separate study of each of the variables would be needed to determine their individual significance.
37 SURGICAL TREATMENT OF POTT DISEASE BY ANTERIOR APPROACH Principal Author: Ramı´rez Rojas, Elio Center: Hospital Eugenio Espejo, Quito, Ecuador Additional Authors: Ochoa Valarezo, Marcelo; Ordo´n˜ez, Fausto; ´ ngel Cabezas Roma´n, A Center: Hospital Eugenio Espejo, Quito, Ecuador Aim: To evaluate kyphotic deformity correction, stability, and fusion with titanium implants by anterior approach in spinal tuberculosis. Introduction: Tuberculosis is a granulomatous systemic disease caused by the bacillus Mycobacterium tuberculosis. Tuberculosis continues to be endemic in developing countries. Kyphosis and neurological deterioration are the main residual problems of spinal tuberculosis. The surgical indications for this condition are severe pain due to an expansive abscess, neurological deterioration caused by spinal cord compression, bone and disc sequestration, progressive kyphotic deformity, and instability. Anterior debridement and fusion is the classic surgical treatment for Pott disease.
Eur Spine J (2014) 23:248–288 Materials and Methods: This is a retrospective study performed between January 2010 and August 2012 and including 8 patients with Pott disease. Surgery consisted of debridement of the affected segment and instrumentation-fusion, with autologous rib graft. The indication for surgery was neurological deficit and segmental kyphosis. Previously, patients received antituberculosis treatment for 3 weeks. We used the clinical history, and imaging studies, such as pre- and postoperative AP and lateral radiographs and MRI, to evaluate kyphosis. Results: Eight patients, 5 men and 3 women, with a mean age of 51.63 years. All patients had a neurological deficit. Six with incomplete lesions improved neurologically, whereas the remaining 2 patients showed no change in neurological status. Mean kyphosis was 14.388 preoperatively and 6.88 postoperatively. The most commonly affected level was T12 with 3 cases (37.5 %), followed by the T12-L1 segment with 2 cases (25 %); T8–T9, L1, and L3: one case each. Mean duration of surgery was 222.5 min and mean operative blood loss was 391.5 cc. There were no cases of significant correction loss or recurrent disease. The surgical interventions were performed in conjunction with the Cardiothoracic Service. There were no immediate or middle-term postoperative complications. Conclusions: Anterior surgery with instrumentation is an effective method for the management of vertebral tuberculosis.
38 SPINAL INFECTIONS Principal Author: Romano, Osvaldo Anı´bal Center: Hospital El Cruce, Buenos Aires, Argentina Additional Authors: Bacaloni, Nicola´s; Bustamante, Jorge Luis; Lambre, Jorge; Bassani, Julio; Posadas, Dolores Center: Hospital El Cruce, Buenos Aires, Argentina Introduction: Spinal infections continue to have an important healthcare and economic impact. The aim of this study is to review the epidemiologic characteristics and treatment of adult patients hospitalized for vertebral infections in a single center. Materials and Methods: Retrospective review of the clinical records of patients hospitalized with a diagnosis of vertebral infection between October 2008 and December 2011. On an Excel spreadsheet, we recorded demographic data (name, age, sex), clinical signs and symptoms, neurological compromise, type of infection, culture findings, microorganism, complementary studies, days hospitalized on a ward and in intensive care, type of treatment, and sequelae. Results: The study included 67 patients (38 males), with a mean age of 51.2 (17–84) years. In 59 patients, the causal microorganism was identified, and 8 cases showed more than one causal agent. Treatment consisted in surgery + antibiotic therapy in 59 patients. Hematogenous infections, 24 (7 females and 17 males) mean age 43.6. Most common microorganisms: MRSA 8, MSSA 5, Pseudomonas 3. Fever 21, axial pain 17, Frankel A/B in 4. Mean duration of hospitalization 26.6 days (ICU 5.9, ward 20.6). Localization; 12 peridural abscess, 9 spondylodiscitis, 1 spondylitis, 1 facet arthritis, and 1 paravertebral myositis. Postoperative infections, 43 (22 females and 21 males), mean age 55.3. Most common microorganisms: MSSA 12, MRSA 9, Proteus and Klebsiella in 4. Fever in 27, axial pain in 18, without paralysis. Mean duration of hospitalization 39 days (ICU 2.3, ward 36.7), 27 surgeries with implant. Conclusions: Spinal infections have a great impact on the health of affected patients and on healthcare expenditure. Knowledge of the characteristics of these infections in each healthcare center is the basis for better control.
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39 PULMONARY DYSFUNCTION IN PATIENTS WITH ADOLESCENT IDIOPATHIC SCOLIOSIS AND LOSS OF THORACIC KYPHOSIS Principal Author: Nu´n˜ez Pereira, Susana Center: St. Franziskus Hospital, Cologne, Germany Additional Authors: Ferraris, Luis1; Koller, Heiko1; Bullmann Viola2; Hempfing, Axel1 Centers: 1German Scoliosis Center, Bad Wildungen, Germany; 2 St. Franziskus Hospital, Cologne, Germany Introduction: In adolescent idiopathic scoliosis, hypokyphosis (\108) has been related to a mild restrictive change in lung function (forced vital capacity [FVC] B80 % and [65 %), according to the criteria of the American Thoracic Society. Nonetheless, there are no studies investigating whether severe hypokyphosis or thoracic lordosis may be associated with more severe lung function abnormalities (moderate B65 % and [50 %, or severe B50 %). Materials and Methods: Prospective study. Preoperative data collection in consecutive patients about to undergo surgery for adolescent idiopathic scoliosis in a single center over one year (June 2011–June 2012). Radiologic study and respiratory function testing. Exclusion criteria: history of any type of respiratory disease and Lenke type 5 curves (absence of a structural thoracic deformity). For the statistical analysis, patients were divided into 2 groups: thoracic lordosis (TL) if T5–T12 B 0, and thoracic kyphosis (TK) if T5–T12 [0. Statistical analysis: correlation study and comparison of means using the Student t test. Results: A total of 52 patients, 42 female (80.7 %), mean age 16.3 ± 2.4. TL group (9 patients): main coronal thoracic curve (Cobb) 57.0 ± 10.4, T5/T12 kyphosis -5.8 ± 5.0, apex in T8 or T9 in 66.7 %, FVC (%) 53.8 ± 14.5 (range 35–71). TK group (43 patients): main coronal thoracic curve (Cobb) 57.05 ± 11.4, T5/T12 kyphosis 20.9 ± 11.1, apex in T8 or T9 in 86.0 %, FVC (%) 79.1 ± 9.4 (range 63–101). The mean difference in FVC between the two groups was 25.4 (95 % CI 14.05–36.7, p = 0.001). Correlation study demonstrated a significant association between the sagittal thoracic deformity and FVC r = 0.465, p = 0.001. Coronal deformity was similar in the two groups (p = 0.991) and did not correlate with FVC (r = -0.18, p = 0.201). Conclusion: Severe deformity in the sagittal plane is associated with a moderate/severe lung function abnormality. In patients with lordotic thoracic curves, we recommend prompt respiratory function testing for early detection of pulmonary dysfunction and establishment of appropriate treatment.
40 CLINICAL RESULTS AT 3–5 YEARS AFTER LUMBAR FUSION OF ONE LEVEL FOR DEGENERATIVE DISC DISEASE. COMPARATIVE STUDY OF THE CLASSIC APPROACH VS. THE ‘‘MINI-OPEN’’ MINIMALLY INVASIVE APPROACH Principal Author: Pen˜a Jime´nez, Diego
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Center: Hospital Universitario ‘‘Miguel Servet’’, Zaragoza, Spain 1
continued 1
Additional Authors: Rodrı´guez Vela, Javier ; Loste Ramos, Antonio ; Tabuenca Sa´nchez, Antonio1; Sun˜e´n Sa´nchez, Enrique1; Izquierdo Enguita, Marı´a2; Soriano Guille´n, Antonia1; Velilla Marco, Jose´1
SF-36
Type of
physical
surgery
Centers: 1Hospital Universitario ‘‘Miguel Servet’’, Zaragoza, Spain; 2 Universidad de Zaragoza, Spain
Walk 1 km
Introduction: The clinical results of minimally invasive approaches are better than those of classic approaches in the pre- and postoperative period. Our aim is to determine whether these results are maintained during follow-up. Materials and Methods: We reviewed two groups of patients included in a prospective study comparing lumbar fusion for degenerative disc disease at one level, followed-up for 3–5 years (50 cases). All patients underwent circumferential fusion (interbody device with a single-port transforaminal approach [TLIF] and pedicle screws). The following questionnaires were used: Oswestry Disability Index (ODI), SF-36, and visual analogue scale (VAS) for lumbar and sciatic pain. There were no preoperative differences regarding age, sex, level, or in questionnaire scores. Twenty-one cases operated by mini-invasive technique (bilateral mini-open) (Group MO) and 20 operated using a classic approach (Group Cl) responded to the questionnaires sent out. Nonparametric tests were used (Mann–Whitney U) with SPSS 16.0. Results: There were no significant differences in the overall questionnaire scores: ODI (p = 0.073), SF-36 (p = 0.302), SF-36 Physical scale and VAS lumbar (p = 0.194), and VAS sciatic (p = 0.427). However, the mean values for many of the parameters evaluated were better in the MO group: standing, lifting, walking, picking up or carrying groceries, and bathing or dressing oneself. Conclusions: We found no statistically significant differences dependent on the type of approach (mini-open or classic). However, at 3–5 years of follow-up, patients in the MO group had less low back and sciatic pain (VAS) and showed better performance in daily life activities, particularly those requiring moderate effort (e.g., lifting, standing, carrying groceries, walking, bathing, dressing). According to our hypothesis, the clinical results become more similar because the impact of operative muscle injury has less effect.
Walk several blocks
Type of
physical
surgery
scale Vigorous
Moderate
N
Mean
Standard
Standard
deviation error
Walk one block
Bathe, dress
Classic
20 37.5000 39.31988 8.79219
MiniOpen
21 23.8095 33.98179 7.41543
Classic
20 37.5000 39.31988 8.79219
MiniOpen
21 47.6190 33.45217 7.29986
Lift, carry groceries Classic
20 55.0000 32.03616 7.16350 21 76.1905 25.58832 5.58383
Climb several flights
Classic
20 47.5000 44.35206 9.91742
MiniOpen
21 61.9048 26.94792 5.88052
Climb one flight
Classic
20 70.0000 41.03913 9.17663
MiniOpen
21 88.0952 21.82179 4.76190
123
MW U
0.239
0.241
0.379
Mean_SF_ physical
ODI
0.221*
0.260
Classic
20 32.5000 33.54102 7.50000
MiniOpen
21 50.0000 35.35534 7.71517
Pain intensity
Personal care
Walking
Sitting
Social life
Traveling
0.161 ODI Index
0.112
0.111
MW
20 62.5000
39.31988
8.79219
21 61.9048
31.24405
6.81801
Classic
19 65.7895
33.55191
7.69734
MiniOpen
21 80.9524
29.47961
6.43298
Classic
20 75.0000
38.04430
8.50696
MiniOpen
21 92.8571
17.92843
3.91230
Classic
20 70.0000
37.69685
8.42927
MiniOpen
21 88.0952
26.94792
5.88052
20 550.0000 273.38040 61.12972
U 0.957
0.831
0.136
0.122
0.067(*)
0.095
0.087*
0.074
0.114
0.157
0.114
0.157
21 671.4286 186.79630 40.76229
Classic
20 55.3335
27.44273
6.13638
MiniOpen
21 67.1429
18.67963
4.07623
Type of
N
Mean
Standard
Standard
P, Student
Non-parametric
deviation
error of
t
MW U
0.352
0.536
0.125
0.178
0.066
0.081
0.038*
0.069
0.348
0.356
0.075*
0.097
0.065
0.067
0.153*
0.123
0.328
0.352
0.243
0.349
0.073*
0.140
0.073*
0.140
the mean
Sex life 0.091*
t
Classic
surgery
0.330
0.033
P, Student P,
error
*Welch correction: Levine test \0.5 (equal variances not assumed)
Sleeping 0.024
Standard
MiniOpen
MiniOpen
Standing
MiniOpen
Bend, kneel
t
Standard deviation
of the mean
Sum_SF_ physical Classic
P, Student P,
of the mean
Mean
scale
Lifting SF-36
N
Osw_100
Classic
20
1.9000
1.62707
.36382
Mini-Open
21
1.4762
1.23972
.27053
Classic
20
1.1000
1.02084
.22827
Mini-Open
21
.6667
.73030
.15936
Classic
20
2.6500
1.59852
.35744
Mini-Open
21
1.7619
1.41084
.30787
Classic
20
1.2000
1.15166
.25752
Mini-Open
21
.5714
.59761
.13041
Classic
20
1.7000
1.21828
.27242
Mini-Open
21
1.3810
.92066
.20090
Classic
20
1.8000
1.36111
.30435
Mini-Open
21
1.1429
.85356
.18626
Classic
20
2.1000
1.86096
.41612
Mini-Open
21
1.0952
1.51343
.33026
Classic
20
2.1500
1.87153
.41849
Mini-Open
21
1.3810
1.46548
.31979
Classic
20
1.9000
1.44732
.32363
Mini-Open
21
1.4762
1.28915
.28132
Classic
20
1.6000
1.42902
.31954
Mini-Open
21
1.1429
1.01419
.22131
Classic
20
18.1000
12.45053
2.78402
Mini-Open
21
12.0952
7.59707
1.65782
Classic
20
36.2000
24.90107
5.56805
Mini-Open
21
24.1905
15.19414
3.31563
Eur Spine J (2014) 23:248–288
41 SEVERE IDIOPATHIC SCOLIOSIS. DOES THE APPROACH AND INSTRUMENTATION MODIFY THE RESULTS? Principal Author: Sa´nchez Ma´rquez, Jose´ Miguel Center: Hospital Universitario La Paz, Madrid, Spain Additional Authors: Sa´nchez Pe´rez-Grueso, Francisco J.; Pe´rez Buitrago, Mar; Garcı´a Ferna´ndez, Alfredo; Ferna´ndez-Baillo, Nicomedes; Quinta´ns Rodrı´guez, Jose´ Center: Hospital Universitario La Paz, Madrid, Spain For years the combined approach has been the reference standard treatment for severe idiopathic scoliosis. However, recent studies on the posterior only approach have questioned the need for combined surgery. The aim of this study is to evaluate the radiographic results and complications associated with surgical treatment for adolescent idiopathic scoliosis greater than 758 by a double approach (DA), or a posterior only approach with hybrid instrumentation (PH) or an allscrew construct (PA-S). Materials and Methods: Retrospective review of 69 patients fulfilling the following inclusion criteria: curve[758, more than 2 years’ follow-up, and preoperative, postoperative, and follow-up radiographs, in addition to perioperative clinical data. There were 24 patients in the DA group, mean age 13.8 years and mean Cobb angle 898 (758–1178); 20 patients in the PH group, mean age 14 years and mean Cobb 838 (758–1008); and 25 patients in the PA-S group, mean age 14 years and mean Cobb 838 (758–1108). The following were analyzed: flexibility, correction, surgical procedure, and complications. Statistical analysis with the Kruskal–Wallis test for nonparametric variables. Results: There were no statistically significant differences (p [ 0.05) between the three groups for preoperative, immediate postoperative, or final Cobb angle values (Table). Nor were there differences in the final percentage of correction (DA = 60 %, PH = 57 %, PAS = 60 %; p [ 0.05), although curve flexibility was significantly greater (p = 0.002) in the PA-S group. Sagittal correction and the number of fused levels were similar in the 3 groups. The percentage of procedure-related complications was 20.8 % in DA, 10 % in PH, and 20 % in PA-S. Two patients in the PA-S group had spinal cord monitoring changes with no neurological lesion, and 1 patient in the same group had an incomplete, deferred, transient lesion. Conclusions: There were no significant differences in severe idiopathic scoliosis correction between patients treated with a double approach or a single posterior approach, regardless of the type of instrumentation used. According to these results, the combined approach may no longer be the reference standard technique for treating these severe deformities.
267 Additional Authors: Burgos Flores, Jesu´s1; De Blas Beorlegui, Gemma1; Barrios Pitarque, Carlos2; Anto´n Rodriga´lvarez, Miguel1; Hevia Sierra, Eduardo3; Correa Gorospe, Carlos1; Caballero Garcı´a, Alberto3; Piza´ Vallespir, Gabriel4 Centers: 1Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 2 Instituto de Investigacio´n en Enfermedades Musculo-esquele´ticas, Universidad Cato´lica de Valencia, Spain; 3Hospital La FraternidadMuprespa, Madrid, Spain; 4Hospital Universitario Son Espases, Palma de Mallorca, Spain Introduction and Aims: The spinal cord commonly undergoes manipulation during spinal surgery. The aim of this experimental study was to establish the degree of compression required to produce a neurological spinal cord lesion as assessed with neurophysiological monitoring, and to define whether these limits vary depending on the speed with which compression is applied. Materials and Methods: In two groups of 5 industrial pigs with a mean weight of 35 kg, the spinal cord was exposed from T7 to T11 by posterior laminectomy and compression was applied to the cord at T9 by approximating two 5-mm diameter rods placed on both sides. In one group, compression was gradually applied at a rate of 0.5 mm every 2 min, and in the other, abrupt compression of 2.5 mm was applied (acute compression). Spinal cord neurophysiological recording using two epidural catheters on either side of the compression area was performed each time compression was applied. Results: The mean cord diameter at T9 was 7.1 mm. When gradual compression was applied, neurophysiological cord monitoring changes of increased latency and decreased amplitude appeared after a mean compression of 3.2 ± 0.9 mm; potentials completely disappeared after 4.6 ± 1.2 mm of maintained pressure. After releasing compression, potentials returned in all cases at a mean of 16.8 ± 3.2 min. When acute compression was applied, potentials completely disappeared at 2.5 ± 0.3 mm, and they did not recover following a 30-min wait after releasing compression. Conclusion: The thoracic spinal cord shows a marked sensitivity to acute compression, which causes complete, irreversible injury. In contrast, slow, gradual compression is better tolerated: neurophysiological changes appear later and at greater compression, and rapidly recover when pressure is removed. From the clinical viewpoint, it seems recommendable to avoid maneuvers leading to abrupt movements of the thoracic spinal cord and particularly direct jolts, even minor ones.
43 EVALUATION OF THE APGAR SURGICAL SCORE IN SPINAL SURGERY Principal Author: Urrutia, Julio Center: Pontificia Universidad Cato´lica de Chile, Santiago, Chile
42 SPINAL CORD TOLERANCE TO ABRUPT AND GRADUAL INTRAOPERATIVE COMPRESSION. EXPERIMENTAL STUDY Principal Author: Montes Ferna´ndez, Elena Center: Hospital Universitario Ramo´n y Cajal, Madrid, Spain
Additional Authors: Valde´s, Macarena; Zamora, Toma´s; Canessa, Valentina; Bricen˜o, Jorge Center: Pontificia Universidad Cato´lica de Chile, Santiago, Chile Aim and Introduction: A simple, objective postoperative score that can identify patients at risk of morbidity-mortality would be useful in clinical practice and research. The Surgical Apgar Score (SAS), developed in general and vascular surgery, enables prediction of the 30-day morbidity-mortality risk. This 10-point instrument, inspired by
123
268
Eur Spine J (2014) 23:248–288
the obstetric Apgar score, is calculated based on the estimated intraoperative blood loss, lowest mean blood pressure, and lowest heart rate. High scores are associated with a lower risk of morbiditymortality and vice versa. The SAS has not been evaluated in spinal surgery. This prospective study attempts to determine it usefulness in these procedures. Materials and Methods: Prospective study of 268 consecutive patients undergoing major and intermediate spinal surgery in a university hospital over an 18-month period. Intraoperative parameters were recorded and we calculated the SAS at completion of surgery. Complications and mortality were recorded over a 30-day follow-up. The relationship between the SAS and morbidity-mortality was analyzed by calculating the relative risk (RR) and the likelihood ratio (LR) for different sets of patients grouped according to score. Univariate logistic regression analysis was carried out and we estimated the predictive capacity of the SAS by calculating a C-statistic (area under the ROC curve). Finally, the cohort was divided into 2 groups: low-risk patients (SAS C7) and high risk (SAS \7); the Fischer test was used to analyze differences between groups. Results: Eighteen patients presented at least one complication (6.72 %). Among patients with SAS 9-10 there was 1.64 % complication rate (RR = 1; LR = 0.23), which increased monotonically as the score decreased (SAS 7–8 = 2.75 %; RR = 1.68; LR = 0.39), (SAS 5–6 = 13.33 %; RR = 8.13; LR = 2.14), (SAS B4 = 17.39 %; RR = 10.61; LR = 2.92). The odds ratio of logistic regression was 0.66 (95 % CI 0.54–0.82) p \ 0.01. The C-statistic to predict morbidity-mortality was 0.77 (95 % CI 0.66–0.88), which was considered good discriminatory capability. Four of 170 patients with SAS C7 presented complications, versus 14/98 patients with SAS \7 (p \ 0.01). Conclusions: The SAS enables stratification of postoperative risk, and it has good discriminatory capacity for predicting 30-day morbidity-mortality in spinal surgery.
Table 1 Surgical Apgar Score (10 points) Number of points 0
1
2
3
4
Estimated blood loss, cc [1,000 601–1,000 101–600 B100 – \40
40–54
55–69
B70
Lowest heart rate, bpm [85
76–85
66–75
56–65 B55
Lowest mean blood pressure, mmHg
–
Table 2 Morbidity-mortality, relative risk, and likelihood ratio for the different categories of the score Score
0–4
5–6
7–8
9–10
Number of patients
23
75
109
61
Major complications and deaths, N (%)
4
10
3
1
Relative risk (95 % CI)
10.61 (1.25–90)
Likelihood ratio (95 % CI)
2.92 2.14 (1.09–8.49) (1.32–7.84)
123
(17.39 %)
(13.33 %)
(2.75 %)
(1.64 %)
44 LUMBAR FUSION, STIFFNESS OF THE SYSTEM, AND IMPACT ON ADJACENT DISCS Principal Author: Lax Pe´rez, Raquel Center: Hospital Santa Lucı´a, Cartagena, Murcia, Spain Additional Authors: Murcia Asensio, Antonio1; Sua´rez Sua´rez, ´ ngel2; Vega, Jose´ Antonio3; Garcı´a Sua´rez, Olivia3; Ferrero Miguel A Manzanal, Francisco1 Centers: 1Hospital Santa Lucı´a, Cartagena, Murcia, Spain; 2Hospital de Cabuen˜es, Gijo´n, Asturias, Spain; 3Universidad de Oviedo, Departamento de Anatomı´a, Asturias, Spain Aim and Introduction: The aims of vertebral fusion are to stabilize the affected segment and prevent displacement of the devices used. Ideally, the flexibility of the fused segment should be close to that of a healthy specimen. However, the optimal stiffness of the construct to achieve consolidation without causing a detrimental effect on the fixed and adjacent segments remains to be determined. The aim of our study is to assess the effect produced by the stiffness of different configurations used in transforaminal fusion (3608 and 2708) on the superior and inferior mobile adjacent segments. Materials and Methods: Using a healthy volunteer, we created an original finite elements model (FEM) from L2 to the sacrum. This ‘‘intact’’ model, which was validated with the literature, was modified to simulate two configurations of L4–L5 transforaminal fusion (3608 and 2708). The disc was divided into 5 intervals (not anatomical areas of the disc) according to the load they support when various movements are performed in space (flexion, extension, torsion, and lateral bending). Relative graphs were used to compare the two models with the values found in the healthy spine, sharing the assumption that less rigid systems will lead to a smaller increase in stress on the discs adjacent to a lumbar fusion. Results: We found that the amount of disc submitted to high stress (interval 5) was lower with the TLIF 2708 model than TLIF 3608, in all the trials and in both discs. The reductions exceeded 50 % and were especially significant in the tests that most challenged the disc (torsion and lateral bending). Conclusions: Performance of the TLIF 2708 fusion model was midway between that of circumferential fusion and healthy spine in terms of transferring load onto the mobile adjacent segments. Since the mathematical model still has little clinical relevance, studies in patients are needed to correlate the anatomical-clinical findings with the qualitative differences seen between the different fusion configurations.
45 HYBRID CONSTRUCTS FOR THE LUMBOSACRAL SPINE. PRELIMINARY STUDY IN 20 CASES Principal Author: Castelli, Roberto
8.13 1.68 1 (1.07–61.78) (0.18–15.79) (reference) 0.39 (0.09–0.98)
0.23 (0.03–1.47)
Center: Hospital Militar Central, Buenos Aires, Argentina Additional Authors: Steverlynck, Alejandro Center: Hospital Militar Central, Buenos Aires, Argentina
Eur Spine J (2014) 23:248–288
269
Introduction: Spinal fusion has been the classic reference standard for surgical management of symptomatic degenerative lumbar spine disease. Currently, adjacent disc degenerative syndrome would be a theoretical sequela of conventional fusion. Aim: To present the philosophy we use: How and why we have decided to protect the level adjacent to a fusion. Materials and Methods: Among 620 patients evaluated for surgery between January 2007 and August 2011 for degenerative disease, instability, and lumbosacral canal stenosis, we selected 30 patients (Pfirmann stages 3 and 4). Among these, 6 were lost to postoperative consultation and 4 refused surgical treatment, which left 20 patients, (11 men, 55 %, and 9 women, 45 %) who underwent surgery. Mean age was 46 years (range 22–71 years). Results: Follow-up ranged from 2 to 6 years. To date, there has been no clinical/radiologic evidence of worsening or instrumentation loosening in any case. Discussion: Advantages and disadvantages should be evaluated when implementing these novel techniques to develop flexible pedicle screw systems. There is evidence suggesting that radiologic degeneration of the upper adjacent segment does not correlate with the clinical outcome. Conclusions: We believe that protecting the adjacent level with the use of semirigid PEEK rods would be a good option for protection because it preserves the ligaments and pedicles in the level adjacent to the fusion.
between the screws of the dynamic segment 2.538, and of the adjacent segment 5.58 preoperatively and 7.878 postoperatively. There were no cases of breakage of the material or underlying rod end/screw head contact in flexion–extension in any segment. There were, however, three cases of lysis around the screws in the proximal vertebra and two cases of lysis in the distal vertebra. Adjacent disc syndrome in the segment adjacent to the dynamic segment developed in 4 patients, one of whom had severe stenosis that required a reintervention. The mean improvement on the Oswestry Index was 30 %. Conclusions: Dynamic fixation preserves motion in the index segment at a range smaller than the physiological range. The adjacent segment showed an increase in the mean range of motion in flexion– extension, which led to the development of lysis around the screws and adjacent disc syndrome in the segment adjacent to the dynamic segment, despite partial preservation of motion. Because of the development of implant complications and failure to prevent adjacent segment disease, we believe that use of this type of system should be excluded.
46
Principal Author: Rovira Gutie´rrez, Manuel
HYBRID VERTEBRAL INSTRUMENTATION IN DEGENERATIVE LUMBAR SPINE DISEASE: CLINICAL-RADIOLOGIC OUTCOME AT MINIMUM 2-YEARS’ FOLLOW-UP Principal Author: Iba´n˜ez Aparicio, Natalia Center: Hospital de la Santa Creu i Sant Pau, Barcelona, Spain ´ scar Additional Authors: Garcı´a Casas, O Center: Hospital de la Santa Creu i Sant Pau, Barcelona, Spain Aim: Dynamic radiologic evaluation of the motion of instrumented vertebral segments and the upper adjacent segment, and assessment of mechanical complications and clinical outcome. Materials and Methods: Prospective observational study. Inclusion criteria: consecutive patients during the year 2009 with an indication for surgical treatment of established transitional syndrome, long instrumentation for degenerative disease or simple instrumentation for incipient adjacent disc disease, all of whom underwent posterior fusion with dynamic instrumentation of the adjacent segment. The system used pedicle screws and a dynamic rod with an integrated bumper element. Radiographic analysis (lateral films in neutral and flexion–extension) of the degree of motion in the index and adjacent segments preoperatively and at last control (24–48 months); mean of two measurements by two different observers. In addition, we evaluated the development of mechanical complications, disease in the segment adjacent to the dynamic segment, lysis around the screw, and the reintervention rate. The Oswestry Disability Index was used to assess the clinical evolution. Results: Fifteen patients were included (1 L1–L3, 1 L2–L4, 3 L2–S1, 1 L3–L5, 3 L3–S1 and 6 L4–S1). Mean range of motion of the dynamic segment was 8.668 preoperatively and 3.78 postoperatively,
47 USE OF A NEW EXPANDABLE SCREW IN PATIENTS WITH POOR BONE QUALITY. MULTICENTER STUDY
Center: Hospital Universitario Virgen Macarena, Seville, Spain Additional Authors: Ferna´ndez Gonza´lez, Manuel1; Villar Pe´rez, Julio1; Pe´rez Varela, Luis2; Herna´ndez Pascual, Luis2; Alia Benı´tez, Jose´3; Domı´nguez Esteban, Ignacio3; Quintana Cruz, Jose´ Jaime4; Zu´n˜iga Go´mez, Lorenzo5; Izquierdo Nu´n˜ez, Enrique5 Centers: 1Complejo Asistencial Universitario de Leo´n, Spain; 2Hospital Universitario Sagrat Cor, Barcelona, Spain; 3Hospital Clı´nico San Carlos, Madrid, Spain; 4Hospital Universitario Virgen Macarena, Seville, Spain; 5Hospital Universitario de Getafe, Madrid, Spain Introduction: Expandable screws are an alternative to cement-augmented screws for fusion in poor quality bone. We used two screws with an expandable middle section that are anchored beyond the pedicle, the area of maximum strength, to avoid pullout. Currently there are no studies focussed on the clinical use of this type of expandable screws; hence, we were prompted to present this study. Aim: To observe the performance of expandable screws in patients with poor bone quality in terms of safety, technique, management, and complications (percentage of loosening, breakage, pullout, and pseudoarthrosis). Materials and Methods: Prospective multicenter study in 99 patients with poor bone quality, mean age 73 years (67 % women, 33 % men), with degenerative disease, fractures, or deformity, and 579 implanted screws. Patients underwent fusion with these expandable screws and mean follow-up was 21 months (12–36). We studied patient-related risk factors, VAS scores, duration of surgery, blood loss, screw positioning, and implant-related complications at discharge, and at 3, 12 and 24 months. Results: Among the total, 99 % of patients had no permanent, implant-related complications. There was only one case of unresolved radiculopathy. 95 % of implants were placed without complications. Complications related to malposition or incorrect expansion of the screw occurred in 5 %, and were resolved during the procedure (1 partial pedicle breakage, 3 non-expanded screws, 1 screw
123
270 malposition). Mean operating time per level 56 min; mean duration of surgery 2 h 35 min; mean blood loss per level 211 cc. There were three cases of pullout. Lumbar and radicular VAS showed significantly favorable changes, with mean decreases of 4.6/10 and 5.8/10, respectively. The study will continue to 5 years; these are the preliminary results. Conclusions: Expandable screws provide a new anchoring system for patients with poor bone quality. They are safe, effective, and easy to place, Rx exposure is reduced, and when screws must be removed, they leave the way clear for a new procedure.
Eur Spine J (2014) 23:248–288
49 OUTCOME OF SURGICAL TREATMENT FOR SPINAL CHORDOMA Principal Author: Morales Codina, Ana Marı´a Center: Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain Additional Authors: Mun˜oz Donat, Sonia; Valverde Belda, Diego; Aguirre Garcı´a, Rafael; Molina Aguilar, Ma Jesu´s; Martı´n Benlloch, Juan Antonio
48 RETROSPECTIVE COMPARATIVE STUDY OF LUMBAR FUSION USING INTERBODY DEVICES OF DIFFERENT MATERIALS IN DEGENERATIVE DISEASE Principal Author: Isart Torruella, Anna Center: Institut Universitari Dexeus, Barcelona, Spain Additional Authors: Marlet Jordana, Ma Teresa; Ubierna Garces, Maite; Garcı´a de Frutos, Anna; Vila Canet, Gemma; Arias Baile, Ainhoa; Ca´ceres Palou, Enric Center: Institut Universitari Dexeus, Barcelona, Spain Introduction: Circumferential fusion combining interbody cages with pedicle instrumentation has been extensively used in the last decade to treat degenerative lumbar disease, with the objective of enhancing fusion and recovering lordosis and disc height. Aim: To analyze the impact of using cages made of different materials (titanium/PEEK) on the radiologic outcome of posterior circumferential fusion (TLIF). Materials and Methods: Retrospective study of 162 patients, 68 men and 94 women, mean age 49 years (23–76), surgically treated with transforaminal lumbar interbody fusion using two different types of interbody cages (titanium/PEEK) in patients with lumbar disease and a mean follow-up of 5 years (2002–2010). In all cases, autologous iliac crest graft was used. Preoperative radiography and MRI studies were available in all patients. The following variables were studied: preoperative radiology, and postoperative radiology and CT (fusion was assessed using the parameters described by Kanemura 2011). Complete bone fusion was defined by continuous bony bridges within or outside the implant. We evaluated imaging features of osteolysis/ sclerosis around the cage. Results: Of 162 patients studied, 52 had titanium cages and 110 PEEK cages. In 94 cases, the L4–L5 segment was treated and in 68, L5–S1. Titanium/PEEK fusion rates were 100 %/85.3 % for L4–L5 and 90.9 %/77.5 % for L5–S1. A greater degree of osteolysis/sclerosis was observed at the inferior vertebral plate in patients who received PEEK interbody cages than those receiving titanium cages, with a statistically significant relationship. The posterior height of the intervertebral space and the segmental lordosis showed significant differences between the two materials. Conclusions: The fusion rate was higher in patients with titanium implants relative to PEEK, although the difference was not statistically significant. There was greater presence of inferior vertebral plate subchondral sclerosis in patients treated with the more recent (PEEK) technique.
123
Center: Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain Introduction: Chordoma is an uncommon primary bone tumor (1 %– 4 % of bone tumors). These lesions are classically described as lowgrade, locally invasive tumors that are slow growing and have little tendency to metastasize. Nonetheless, they often recur locally, in a manner similar to malignant tumors. En bloc resection with tumorfree margins has been shown to decrease the percentage of recurrent disease and improve the prognosis of these patients. Aims: To analyze the clinical evolution and results of surgical treatment in terms of complications, recurrences, and mortality in patients with spinal chordoma. Materials and Methods: Retrospective observational study of patients undergoing surgery from 1997 to 2012 for spinal chordoma. We included patients whose first treatment was surgery without adjuvant radiotherapy. Patients who had received previous radiotherapy were excluded. Results: Nineteen cases (12 men) were analyzed, with a mean age of 48 years (28–90 years). Mean postoperative follow-up was 7 years (1–15 years). Tumor location: 1 cervical, 1 thoracic, 4 lumbar, and 13 sacral-coccygeal. Two patients were treated with tumor resection, and the 17 remaining patients underwent en bloc tumor resection and reconstruction when necessary (12). The margins of 2 surgical specimens showed tumor contamination. In the early postoperative period (first month), 16 patients presented a motor deficit of the extremities, and all those undergoing sacrectomy had sphincter and sexual dysfunction. At the last control, the motor deficit had improved, but sphincter dysfunction persisted in patients with sacral involvement. There were two cases of material breakage in spinopelvic stabilization. In 1 patient, dehiscence of the rectal stump from a previous colostomy occurred. There were 3 cases of recurrence (2 in the patients with tumor resection), 2 bone and muscle metastases, and 3 deaths. Five-year survival was 84.5 %. Conclusions: Despite the complications and sequelae associated with en bloc resection of vertebral chordomas, we believe it is the treatment of choice for these tumors because of the high survival rates and low number of recurrences.
50 OUTCOME OF SACRECTOMY FOR PRIMARY SACRAL TUMORS Principal Author: Morales Codina, Ana Marı´a Center: Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain
Eur Spine J (2014) 23:248–288 Additional Authors: Valverde Belda, Diego; Eschenbach, Susanne; Mun˜oz Donat, Sonia; Aguirre Garcı´a, Rafael; Molina Aguilar, Ma Jesu´s; Martı´n Benlloch, Juan Antonio Center: Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain Introduction: Sacrectomy is an uncommon procedure indicated for the treatment of primary sacral tumors resistant to radiotherapy or chemotherapy. These tumors are often diagnosed in advanced stages, which makes resection more problematic. Sacrectomy is associated with a high complication rate. However, it is the only effective treatment for some tumors. Aims: To analyze the functional outcome, complications, relapses, and mortality in patients undergoing sacrectomy for a primary sacral tumor. Materials and Methods: Retrospective observational study. Patients treated with a sacrectomy for a primary sacral tumor between 1997 and 2012 were analyzed. Patients who had received any previous treatment were excluded. We analyzed the type of sacrectomy, the stabilization performed, attainment of surgical specimens with disease-free margins, complications, recurrence, and mortality. Results: Sixteen patients (9 men), with a mean age of 46 years (28–90) were analyzed. Mean postoperative follow-up was 7 years (1–13). There were 12 chordomas, 1 osteochondroma, 1 leiomyosarcoma, and 1 ependymoma. Seven complete sacrectomies and 9 partial sacrectomies (3 posterior approach and 13 double approach) were carried out. In complete surgeries, lumboiliac stabilization with a double rod to the ilium was performed in 4 patients, lumboiliac stabilization with a U-shaped double rod and connectors in 3 patients, and no instrumentation in 1 case. In partial sacrectomies, iliac screws and rods were used in 3 patients. Mean intraoperative bleeding was 3572 cc (2000–4800). Eight patients presented wound complications, and there were 5 deep infections. At one month postoperatively, all patients presented paresis of at least one motor group of the lower extremities, gait abnormality, and sphincter dysfunction. At the last control, motor activity and gait had improved in all cases, but sphincter abnormality persisted. Material breakage occurred in two lumbopelvic stabilizations. In 3 cases, tumor-free margins were not obtained. There were 3 cases of recurrence, 2 of metastasis, and 3 deaths. Five-year survival was 84 %. Conclusions: Sacrectomy is an aggressive procedure with a high percentage of complications. Studies are needed to establish the appropriate reconstruction system. Nonetheless, this surgery is associated with greater survival and a good quality of life relative to tumor resection.
271 and 1 iliac tumor affecting the sacroiliac joint, treated over an 11-year period. Materials and Methods: Retrospective review of intra- and postoperative complications in 16 patients with primary sacral tumors and 1 iliac tumor affecting the sacroiliac joint, including 10 men and 7 women, with a mean age of 49.5 years, in the period of 2000–2011, with a mean follow-up of 5 years (1–11 years). The surgical technique consisted in tumor resection by a posterior approach in 14 cases, and complete sacrectomy by a double approach in 2 cases. En bloc resection was carried out in 10 cases, intralesional excision in 6 cases, and radiofrequency treatment in 1 case. Postoperative neurological changes were not considered complications, but rather a direct consequence of sacral tumor excision. Results: Complications were recorded in 12 of the 16 patients treated (75 %). The most important were surgical wound infections that required various debridements and lengthy hospitalization in 8 cases (50 %). Two patients had chronic persistent suppuration; a new surgery was not contemplated, and treatment with long-term antibiotic therapy was continued. Intraoperative vascular complications occurred in 3 cases (18.75 %): 1 right iliac artery lesion that was resolved in collaboration with the Vascular Surgery Department, and 2 gluteal artery lesions. Five patients relapsed: 2 chordomas, 1 melanocytic schwannoma, 1 hemangiopericytoma, and 1 iliac tumor involving the sacroiliac joint. En bloc resection had not been performed in any of the relapsing cases. Conclusions: 1. Treatment of sacral tumors is associated with a high incidence of intra- and postoperative complications, mainly infections and vascular lesions. 2. The treatment that best guarantees favorable long-term results is en bloc resection. 3. Treatment of sacral tumors is complex and requires a multidisciplinary approach.
52 ADJUSTING VERTEBRAL METASTASIS TREATMENT TO THE TOKUHASHI SCALE Principal Author: Cano Go´mez, Claudio Center: Hospital Puerta del Mar, Ca´diz, Spain Additional Authors: Sa´nchez de las Matas Pena, Santiago; Garcı´a Guerrero, Gaspar; Vela Panes, Toma´s; Brun Romero, Francisco; Vela Manzano, Laura
51 Center: Hospital Puerta del Mar, Ca´diz, Spain
REVIEW OF POSTOPERATIVE COMPLICATIONS IN PRIMARY SACRAL TUMORS Principal Author: Ezagui Bentolila, Jaime Leo´n Center: Hospital Universitario de Bellvitge, Barcelona, Spain Additional Authors: Font Vila, Federic; Gonza´lez Can˜as, Lluis; Celi, Sergio Center: Hospital Universitario de Bellvitge, Barcelona, Spain Aims: The aim of this study was to review the postoperative complications occurring in surgical treatment for 16 primary sacral tumors
Aim: To analyze adherence to treatment (percentage of patients who followed treatment indications recommended by the Tokuhashi scale) and prognostic consistency (percentage of patients whose survival was estimated by the Tokuhashi scale) in patients diagnosed with vertebral metastasis in our hospital. Material and Method: Retrospective study of vertebral metastases diagnosed in our center between 2006 and 2010. Study variables: mean age, sex, Karnofsky score, Tokuhashi score, pathologic fracture, treatment, and survival since the diagnosis. In patients treated with surgery or radiotherapy, we evaluated improvements in pain and the Karnofsky score following treatment. The adherence to treatment and prognostic consistency was measured in relation to the scale. Cases with incomplete data and those lost to follow-up were excluded.
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272 Results: We analyzed 279 cases, mean age 65 years, 60 % men. Mean survival, 12.8 months. Adherence to the Tokuhashi scale, 64.8 % of cases. Overall prognostic consistency, 71.6 %. Distribution by Tokuhashi prognostic groups was as follows: 62 % Group I (0–8 points and estimated survival 6 months), 26.6 % Group II (9–11 points and estimated survival 6–12 months), and 11.4 % Group III (12–15 points and estimated survival [1 year). Group I: adherence to Tokuhashi scale in 95.4 %, who received conservative treatment; prognostic consistency, 68.7 % and mean survival 6.15 months. In those who did not adhere to the scale and underwent surgery: survival 9 months and prognostic consistency 33 %. Group II: adherence to the Tokuhashi scale in 13.4 %, who underwent palliative surgery; prognostic consistency, 42.8 %, with mean survival of 22.7 months. In patients who did not adhere to the scale and were not operated, mean survival was 19.5 months. Group III: adherence to the scale in 22.7 %, who underwent surgery for curative purposes; prognostic consistency in 80 %, and mean survival 30.8 months. In patients who did not adhere to the scale in this group, one had palliative surgery and the remaining conservative treatment; mean survival was 28.9 months. Conclusions: • Poor adherence to Tokuhashi scale recommendations did not result in a decrease in prognostic consistency in our series; in group I, survival even increased. The surgical indication in Group I (neurology or pathological fracture) may have increased survival. • Adherence was greater when the recommendation according to the Tokuhashi score was conservative management and poorer when the recommendation was surgery.
Eur Spine J (2014) 23:248–288 daily life (Karnofsky [80), 33.7 % required assistance (Karnofsky 50–70), and 10.7 % were bedridden (Karnofsky 10–40). Among the total, 75.5 % presented two or more vertebral metastases, 80.4 % had extravertebral bone lesions, 58.7 % had internal organ involvement, and more than one major organ was affected in 15.9 %. Most common primary tumors: lung 26.1 % (n = 73), breast 21.8 % (n = 61), and prostate 10.7 % (n = 30). Spinal cord lesion in 16 % (30 partial and 17 complete). 10.2 % debuted with a pathological fracture, and pain was the initial symptom in 82.8 % Thirty patients (10.7 %) underwent surgery, 9 with intent to cure and 21 palliative. The remaining patients received conservative treatment: symptomatic pharmacological treatment (33.3 %), radiotherapy (17.9 %), chemotherapy (16.3 %), and radiotherapy-chemotherapy (11.7 %). Surgical complications in 26.6 %, most commonly surgical wound infection (25 %). In operated patients, pain improved in 76.2 % and Karnofsky score in 71.4 %; in those receiving radiotherapy, 65.2 % and 51.4 %, respectively. In 64.8 % of cases, the Tokuhashi criteria were used for the therapeutic decision, with 71.6 % of consistent prognoses. Conclusions: • In our setting, the most common vertebral metastases were from lung, breast and prostate. • Operated patients showed greater pain improvement and functionality than patients treated with radiotherapy. • Adherence to the criteria and prognostic consistency of the Tokuhashi scale: 64.8 % and 71.6 %, respectively.
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53 ANALYSIS OF THE EPIDEMIOLOGIC AND CLINICAL CHARACTERISTICS OF PATIENTS WITH VERTEBRAL METASTASES Principal Author: Cano Go´mez, Claudio
DECISION MAKING IN THE TREATMENT OF VERTEBRAL METASTASES Principal Author: Issa Benı´tez, Daniela Center: Hospital Universitario Vall d’Hebro´n, Barcelona, Spain Additional Authors: Pellise´ Urquiza, Ferran; Matamalas Adrover, Antonia; Frascheri, Laura; Verge`s Capdevila, Ramo´na; Pijoan Bueno, Joan; Garcı´a de Frutos, Ana; Bago Granell, Joan; Ca´ceres Palou, Enric
Center: Hospital Universitario Puerta del Mar, Ca´diz, Spain Center: Hospital Universitario Vall d’Hebro´n, Barcelona, Spain Additional Authors: Sa´nchez de las Matas Pena, Santiago; Garcı´a Guerrero, Gaspar; Vela Pane´s, Toma´s; Brun Romero, Francisco Manuel; Vela Manzano, Laura Center: Hospital Universitario Puerta del Mar, Ca´diz, Spain Aims: To analyze the epidemiologic and clinical characteristics of patients diagnosed with vertebral metastasis in our hospital, and assess the therapeutic procedure applied based on the recommendations of the Tokuhashi scale. Material and Method: Retrospective study of vertebral metastases in our hospital between 2006 and 2010 (minimal follow-up, 1 year). Variables: mean age, sex, Karnofsky score, number of vertebral metastases, number of bone metastases other than vertebral, number of metastases to internal organs, major organ involvement (brain, lung, liver, kidney), primary tumor, neurological lesion, pathological fracture, type of treatment, survival, improvements in pain and Karnofsky score following treatment. Adherence to the Tokuhashi scale criteria and prognostic consistency were also assessed. Cases with incomplete data and those lost to follow-up were excluded. Results: We analyzed 279 cases, mean age 65 years (SD ± 13) and 60 % men. At the time of the diagnosis, 55.6 % were leading a normal
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The aim of this study is to identify the most important criteria to use when making treatment decisions in patients with vertebral metastatic disease. Patients and Methods: Retrospective analysis of all patients treated for non-hematological vertebral metastatic disease in a third-level hospital between January 2010 and September 2012, with the following inclusion criteria: (1) Radiotherapy treatment (RT) and MR of the thoracolumbar spine, (2) Assessment for spinal surgery by the consulting physician or in a multidisciplinary committee. The following variables were studied: primary tumor, start of RT, date of first assessment for surgery, neurological deficit, radiologic cord compression, number of affected vertebrae, SINS (Spinal Instability Neoplastic Score), and survival. Decision making was analyzed: (1) at the start of the process, identifying differences between patients treated with RT and those referred for surgery; (2) comparing patients referred for surgery from RT with those not referred; (3) comparing patients referred for surgery and ultimately operated with those not operated. Results: Among a total of 299 patients, 182 (mean age 64.8, SD 12.4; 50 % women) met the inclusion criteria. Most common primary tumors were lung (29.1 %), breast (25.8 %), and colorectal (9.9 %). Mean survival since the start of treatment was 9.33 (SD 8.8) months.
Eur Spine J (2014) 23:248–288 The 33 patients who debuted with a neurological deficit had a higher SINS (p = 0.04). Initially, 116 patients were treated with RT and 66 referred for surgery. Patients treated with RT had a larger number of affected vertebrae (p = 0.001), tumors that were more highly radiosensitive (p = 0.000), and a debut with neurological deterioration (p = 0.016). The 21 patients treated initially with RT and referred to surgery had a higher SINS (p = 0.016) than those who continued with RT. Spinal cord compression was the only parameter that differentiated between the 22 patients who underwent surgery and the 65 patients who were referred but not operated (p = 0.005). Conclusions: The SINS is useful for identifying patients with a higher neurological risk and those referred for surgery from RT, but it is not a determinant factor in decision making at the start of the therapeutic process. The most important factors for that purpose are extension of the vertebral disease and radiosensitivity of the tumor.
273 57.9 % ± 9.5. Preoperative proximal thoracic curve was 38.38 ± 11.78 and final postoperative, 258 ± 12.5 (p \ 0.05), with a mean correction of 34.1 % ± 14.5. Preoperative clavicular angle was -2.48 ± 3.48 and postoperative, 1.78 ± 2.98 (p \ 0.05). Preoperative shoulder height was -12.7 ± 14.1 mm and final postoperative, 4.4 ± 9.5 mm (p \ 0.05). In the preoperative assessment, 2 patients presented shoulder balance greater than 3 cm, 8 patients 2–3 cm, 6 patients 1–2 cm, and 5 patients less than 1 cm. Postoperatively, shoulder balance was 1–2 cm in 7 patients and less than 1 cm in 14 patients. SRS-22 score was 3.6 ± 0.6 preoperatively and 4.4 ± 0.3 postoperatively (p \ 0.05). Conclusions: In this series, patients with posterior instrumentation obtained a smaller percentage of correction in the proximal thoracic curve than in the main curve. In most cases, it is not necessary to include the entire proximal curve in the instrumentation to achieve adequate shoulder balance.
N First Triage
182 Radiotherapy = 95
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Consultation/Committee = 66 (A) Second Triage
116 (RT) Only RT = 95 Consultation/Committee = 21 (B)
Third Triage
87 (A + B)
CORRECTION IN ADOLESCENT IDIOPATHIC SCOLIOSIS COMPARING PEDICLE SCREW AND HYBRID SYSTEMS. ANALYSIS OF IMPLANT DENSITY AND CURVE CORRECTION
No surgery = 65 Surgery = 22
Principal Author: Rubio Belmar, Pedro
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Center: Hospital Universitario y Polite´cnico La Fe, Valencia, Spain
THE STRUCTURAL PROXIMAL THORACIC CURVE AND SHOULDER BALANCE IN ADOLESCENT IDIOPATHIC SCOLIOSIS TREATED WITH POSTERIOR INSTRUMENTATION
Additional Authors: Pe´rez Vergara, Silvia; Morales Valencia, Jorge; Cruz Miranda, Daniel; De la Calva Ceinos, Carolina; Soler, Susana; Bas Hermida, Paloma; Bas Hermida, Teresa
Principal Author: Ferna´ndez Varela, Tito Center: Hospital Universitario Dr. Negrı´n, Las Palmas de Gran Canaria, Spain Additional Authors: Mhaidli Hamdan, Hani; Montesdeoca Ara, Arturo; Lorenzo Rivero, Jose´ Augusto Center: Hospital Universitario Dr. Negrı´n, Las Palmas de Gran Canaria, Spain Aim and Introduction: The structural proximal thoracic curve was analyzed in a group of patients with Lenke type 2 and 4 curves surgically treated for adolescent idiopathic scoliosis (AIS) by posterior instrumented fusion. Materials and Methods: Retrospective analysis of data from a prospective database on 21 patients with AIS, 19 females and 2 males. Mean age 15.6 years (13–18); mean follow-up 48 months (24–122); 12 type 2 curves and 9 type 4. Proximal fixation was at D3 in 13 cases (62 %), D2 in 4 cases (19 %), and D4 in 4 cases (19 %). In 80 % of cases, the entire structural curve was not instrumented. Standing and bending whole-spine A-P and lateral Rx were obtained preoperatively. Pre- and postoperative evaluation with VAS and SRS-22, and A-P and lateral Rx at 3, 6, and 12 months, and yearly thereafter. Results: Preoperative main curve was 68.38 ± 15.2 and final postoperative, 29.1 ± 9.9 (p \ 0.05), with a mean correction of
Center: Hospital Universitario y Polite´cnico La Fe, Valencia, Spain Aim: To compare the clinical and radiographic evolution of a cohort of patients surgically treated for adolescent idiopathic scoliosis (AIS) using a pedicle screw system (PS) or a hybrid system (HS). To determine the implant density, degree of correction, and one-year correction loss in surgically treated AIS. Materials and Methods: Retrospective paired comparison of data on PS and HS instrumentation from a prospective database. We reviewed AIS patients, analyzing age, sex, magnitude of the curve (preoperative and postoperative), and correction (bending). Twelve-month data on correction magnitude and loss were compared between the two instrumentation systems. Implant density was determined by screw density. All types of curves were included. Results: The study included 67 patients, 13 males and 54 females, mean age 16 years. Distribution by sex, age, and preoperative curve magnitude was similar in the two groups. In the group treated with HS (n = 28), preoperative curve magnitude was 498 (bending 29), postoperative curve correction 18, and one-year correction 23. The group treated with PS (n = 39) presented a preoperative curve magnitude of 54 (bending 30), postoperative curve correction of 18, and one-year correction, 21. Preoperative kyphosis correction was 22 in the HS group and 24 in the PS group. Postoperative kyphosis was 21 with HS and 18 with PS. Mean implant density was 1.7 screws/level: low density defined as \1.7, high density [1.7. The relationship according to curve magnitude and kyphosis is shown in the Table. Conclusion: Pedicle screw implantation at all levels does not result in a higher degree of curve correction or greater hypokyphosis than hybrid systems. Hybrid systems show a tendency to correction loss,
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and therefore, require more intense follow-up. There were no significant differences in kyphosis or curve reduction in the immediate postoperative period or at 12 months in the comparison between high and low pedicle screw density.
Preop Cobb
Postop
1-year
Preop
Postop
1-year
Cobb
Cobb
Kyphosis
Kyphosis
Kyphosis
High 53.2 ± 11.1 19.8 ± 8.5 22.9 ± 8.6 24.2 ± 7.6 density
19 ± 7.3
20.8 ± 7.7
Low 51.6 ± 5.6 density
17.7 ± 9.5
19.7 ± 9.6
17.2 ± 8
19.8 ± 8.4 23.5 ± 10.6
•
No clear patterns were found for the relationship between last instrumented lumbar vertebra and correct postoperative coronal balance.
58 POSTOPERATIVE AND LONG-TERM RESULTS OF A MINI-INVASIVE APPROACH FOR SCOLIOSIS CORRECTION Principal Author: Burgos Flores, Jesu´s Center: Hospital Universitario Ramo´n y Cajal, Madrid, Spain
57 ANALYSIS OF CORONAL BALANCE AND LAST FUSED LEVEL IN LENKE 5 IDIOPATHIC SCOLIOSIS: SPECIFIC RADIOGRAPHIC PARAMETERS Principal Author: Siderakis, Nicola´s Center: Hospital de Nin˜os Dr. Ricardo Gutie´rrez, Buenos Aires, Argentina Additional Authors: Ludzky, La´zaro; Rosado Pardo, Jose´; Aguilar, Ariel; Dinelli, Dino; Reviriego, Juan; Escalada, Marı´a; Rositto, Gabriel; Legarreta, Carlos Center: Hospital de Nin˜os Dr. Ricardo Gutie´rrez, Buenos Aires, Argentina Aim and Introduction: To determine the postoperative changes in coronal balance in AIS patients with Lenke type 5 curves. Pre- and postoperative analysis of the following radiographic parameters: last fused vertebral level, L4 tilt, apical vertebral translation (AVT), lumbosacral oblique take-off angle (LSOTA), and previous coronal balance. This study analyzes specific radiographic parameters of the lumbar spine pre-and postoperatively to determine how they affect the patients’ final coronal balance. Materials and Methods: Retrospective radiographic study of a case series with at least 2 years’ follow-up. Twenty patients with a diagnosis of AIS and Lenke type 5 curves were evaluated; mean follow-up was 36 months (R: 24–48 months). Specific radiographic measurements were carried out in all patients pre- and postoperatively. Results: Our series showed a direct correlation of the AVT and LSOTA with postoperative coronal balance, both in the group of patients who improved (14 patients) and the group in whom coronal balance worsened (6 patients). Conclusions: • • •
•
In the patient group that experienced less LSOTA correction, coronal imbalance did not improve or increased. In the patient group that experienced less AVT correction, coronal imbalance did not improve or increased. In our series, AVT and LSOTA were the two specific radiographic parameters that had the most impact on the patients’ final coronal balance. The inclination of the last instrumented vertebra experienced less angular correction in patients whose coronal imbalance did not improve or increased.
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Additional Authors: Hevia Sierra, Eduardo1; Sanpera Trigueros, Ignacio2; Del Olmo Herna´ndez, Teresa3; Maruenda Paulino, Jose´4; Barrios Pitarque, Carlos5; Dome´nech Ferna´ndez, Pedro6; Anto´n Rodriga´lvarez, Miguel3; Garcı´a, Vicente7 Centers: 1Hospital La Fraternidad-Muprespa, Madrid, Spain; 2Hospital Universitario Son Espases de Palma de Mallorca, Spain; 3 Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 4Hospital Clı´nico de Valencia, Spain; 5Universidad Cato´lica de Valencia, Spain; 6Hospital General Universitario de Alicante, Spain; 7Hospital La Mancha Centro, Alca´zar de San Juan, Ciudad Real, Spain Aims and Introduction: Posterior approaches in scoliosis surgery are extensive and may cause significant morbidity. Mini-invasive approaches (MIA) are less aggressive and may lower blood loss, analgesic requirements, complications, and duration of hospital stay. The technique presented here can facilitate placement of the most difficult pedicle screws (PS) at the concavity. Materials and Methods: Two similar groups of 10 AIS patients were compared. Group 1: mean age 14.3 years (12.1–16.8), with Cobb 60 (53–71) and T5–T12 thoracic kyphosis +258 (11–40), treated by posterior approach using the following MIA technique: posterior longitudinal midline incision; in the lumbar region, Wiltse technique and in the thoracic spine, longitudinal section of the thoracic longissimus muscle fibers, reaching the posterior vertebral elements; PS placement at the convexity with coplanar correction. Subsequently, PS placement at the concavity using a freehand technique. In group 2, 15.3 years (11.0–17.4), Cobb 56 (45–66) and T5–T12 kyphosis +20 (10–36), surgical correction of scoliosis was performed using a conventional approach and freehand pedicle screw placement. Results: Operative time: 6.1 h (5.1–7.9) in group 1 and 3.4 h (2.9–4.7) in group 2. Blood loss: 270 cc (220–600) in group 1 and 720 cc (450–1160) in group 2. Analgesic requirements were slightly higher in group 1. On postoperative CT in 101 PS in the concavity in group 1, 6 % were outside the limits of the pedicle; in 89 PS in group 2, 12.3 % were outside. Duration of hospitalization was similar in the 2 groups. After a follow-up of more than 26 months, final correction was 81 % in group 1 and 80 % in group 2. T5–T12 kyphosis was 17 in group 1 and 22 in group 2. There were no cases of significant correction loss, implant failure, or nonunion in either group. Conclusions: In AIS patients, MIA resulted in longer operative time, less blood loss, and no significant differences in analgesic requirements relative to the conventional technique. Initial correction of scoliosis at the convexity with MIA decreased the percentage of malpositioned PSs in the concavity. This MIA technique did not lead to correction loss, implant loosening, or nonunion.
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59 SET-SCREW LOOSENING AT THE LOWER INSTRUMENTED LEVEL IN LONG SPINAL CONSTRUCTS FOR ADOLESCENT IDIOPATHIC SCOLIOSIS Principal Author: Piza Vallespir, Gabriel Center: Hospital Universitari Son Espases, Palma de Mallorca, Spain Additional Authors: Sanpera Trigueros, Ignacio1; Serrano Pastor, Ricardo1; Burgos Flores, Jesu´s2 Centers: 1Hospital Universitari Son Espases, Palma de Mallorca, Spain; 2Hospital Universitario Ramo´n y Cajal, Madrid, Spain Introduction: Screw–rod connection failure, particularly at the ends of long instrumentations, is a known complication, but there are few related reports in the literature. Materials and Methods: Retrospective review of 67 patients who consecutively underwent surgery for AIS in a single center, with a follow-up of C24 m. We selected cases with evidence of screw–rod connection failure at the lower instrumented level (LIL). Results: Eleven cases were identified (10F/1 M, mean age 14.1 years). Classification: Lenke type 1 (4), 3 (3), and 6 (4). Mean Cobb angle: MT 63 and TL/L 61. CIL: T-11 (2), L-1 (1), L-3 (3), and L-4 (5). Correction by coplanar alignment (9) or in situ contouring (2). Mean correction: MT 53 % and TL/L 54 %. LIL inclination decreased from 30 to 14. Loosening was detected at 7 m (1–17) as complete separation of the locking screw (6) or rod sliding within the screw (4). Seven patients were asymptomatic and 4 presented mild low back pain. Loosening was always at the screw on the convexity: right in 4 (right Lenke type 1) and left in 7 (left lumbar Lenke types 3 and 6). There was one case of distal curve worsening with an increase in LIL inclination (mean 6) and Cobb angle (mean 6). In cases instrumented to T-11, caudal junctional kyphosis occurred. As compared to cases showing no instrumentation failure, loosening occurred more often in the absence of transverse connectors and all were fixed screws, although these differences were not statistically significant. Eight cases required revision (1 pending); nonunion was found at 1 or 2 caudal levels. Instrumentation was extended caudally only in the 2 patients with junctional kyphosis. In 3 cases, revision was excluded because there was no progression or symptoms. In the revision cases, final correction was similar to that obtained following the initial surgery. Conclusions: Screw–rod connection loosening in the LIL was observed in 16 % of cases in this series, and revision was required in 12 %. Loosening always occurred at the side of the convexity and in monoaxial screws.
275 Additional Authors: Grass Pedral, Jose´ Center: Hospital Luis Calvo Mackenna, Santiago, Chile Introduction: The rods used for scoliosis surgery have undergone modifications to achieve better balance. Aims: To compare coronal and sagittal balance in patients with adolescent idiopathic scoliosis undergoing posterior instrumented fusion using chrome-cobalt or titanium rods. Materials and Methods: Prospective study of 2 groups of 10 consecutive patients who underwent posterior surgery for adolescent idiopathic scoliosis. The same osteosynthesis materials were used in all patients, with titanium rods in one group (TG) and chrome-cobalt rods in the other (CCG). We evaluated coronal and sagittal balance in whole-spine AP and lateral radiographs preoperatively, in the immediate postoperative period, and at one year. Curve flexibility was measured in bending and traction; flexible was defined as correction greater than 50 % of the curve. Radiographs were taken in the same center by the same technician. Microsoft Excel was used for tabulation. The Welsch two-sample t test, Chi square test, and Wilcoxon test were used for the statistical analyses, with a p-value \ 0.001. Results: There were no significant differences in sex, age, Lenke type, degree of scoliosis, number of fused levels, surgical technique, operating time (3.6 h in both groups), or days hospitalized. Braces were used only in CCG (30 %). Statistically significant differences between preoperative and postoperative status were found for each individual group with regard to Cobb angle and kyphosis; lordosis was not significant in CCG; there were no significant differences in pelvic incidence, sacral slope, or pelvic tilt. The more flexible was the curve, the greater the correction, regardless of the material used. In more rigid curves, CCG achieved significantly greater correction. There was no significant loss of correction between immediate postoperative and 1-year in either group. Significant differences in Cobb angle, kyphosis, and lordosis, but not in the other variables studied, were found between the groups. Conclusions: Use of chrome-cobalt rods results in better coronal y sagittal balance in patients undergoing posterior surgery for adolescent idiopathic scoliosis. The flexibility of the curve and stiffness of the material have a significant impact on correction.
61 PEDICLE SCREWS VERSUS EXTRAPEDICULAR SCREWS IN THE THORACIC SPINE. COMPARATIVE CADAVERIC STUDY Principal Author: Anto´n Rodriga´lvarez, Luis Miguel Center: Hospital Universitario Ramo´n y Cajal, Madrid, Spain
60 STUDY COMPARING CHROME-COBALT RODS AND TITANIUM RODS FOR CORRECTION OF ADOLESCENT IDIOPATHIC SCOLIOSIS Principal Author: Weissmann Marcuson, Karen Andrea Center: Hospital Exequiel Gonza´lez Cortes, Regio´n Metropolitana, Chile
Introduction and Aims: Placement of pedicle screws in the thoracic vertebrae enables greater capacity for correction, being the single implant that fixates the three vertebral columns. Nonetheless, pedicle screw placement is complex and not free of risk. Several techniques have been developed to optimize thoracic screw placement. In this study, the safety and accuracy of vertebral screw implantation by two different techniques are compared in cadaveric thoracic vertebrae. Materials and Methods: Thoracic spine instrumentation at T1–T10 was carried out in 14 cadavers. In the extrapedicular technique, the reference for insertion was the intersection of the exterior border of the facet joint with the midpoint of the transverse apophysis,
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276 performed in 7 cadavers (140 screws). A conventional freehand technique was used for inserting pedicle screws in the other 7 cadavers (140 screws). At completion of surgery, the spinal columns were resected and studied by conventional radiography, computed tomography, and anatomic dissection. Invasion of the spinal canal and foramen, lateral malpositioning, and nerve lesions were evaluated. Results: Spinal canal invasion by less than 2 mm was observed in 32 screws, 27/140 pedicle screws (19.3 %) and 5/140 extrapedicular (3.6 %), yielding a significant difference (p \ 0.001). Spinal canal invasion [2 mm was found in 5 screws, 3 pedicle screws and 2 extrapedicular, with non-significant differences. In 15 cases, screws were found partially (9) or completely (6) lateral to the vertebral body. Among them, 8/140 were extrapedicular (5.7 %) and 7/140 pedicle screws (9.7 %). Differences were not significant. In 18 cases, screws were completely caudal to the pedicle, occupying the foramen: 16/140 extrapedicular (11.4 %) and 2/140 pedicle screws (1.4 %), also yielding a statistically significant difference (p \ 0.001). Conclusions: Extrapedicular screw placement provides better results in terms of lower risk of canal invasion and better anchoring in the vertebral body. However, since the screw course is partially extraosseous, there is a higher risk of foramen invasion, with the consequent risk of radicular lesion.
62 IN VITRO INTERACTION OF MESENCHYMAL STEM CELLS WITH BIOLOGICAL CEMENTS USED IN SPINAL SURGERY Principal Author: Pino Minguez, Jesu´s
Eur Spine J (2014) 23:248–288 death (caspase-3), alkaline phosphate production, and possible differentiation to osteoblasts. Statistical study with SPSS 15. Results: Greatest cell growth was obtained at concentrations of 15 % and 20 %, with values of 0.801 ± 0.064 and 0.793 ± 0.005. Caspase3 expression showed a gradual decline as the HA:PMMA ratio increased, with 20 % being the optimal concentration. Alkaline phosphatase production showed values up to 0.645 ± 0.0227303 at concentrations greater than 15 % versus baseline values of 0.247 ± 0.03. Optimum cell adhesion was seen at concentrations of 10 % or more. TRAIL values showed a considerable decrease at the 20 % concentration (Student t 0.05; p [ 0.01). Discussion and Conclusions: This study shows that HA/PMMA mixtures with HA concentrations of 15 % to 20 % enhance MSC proliferation and adhesion, with a lower toxic effect and reductions in cell death. The local inflammatory reaction decreases at concentrations around 20 % and differentiation of MSCs to osteoblasts is enhanced at concentrations higher than 15 %.
63 LOCAL DIFFUSION OF ANTINEOPLASTIC AGENTS FOLLOWING VERTEBROPLASTY, USING ACRYLIC CEMENT WITH CISPLATIN OR METHOTREXATE. EXPERIMENTAL STUDY IN PIGS Principal Author: Llombart Blanco, Rafael Center: Clı´nica Universidad de Navarra, Pamplona, Spain
Center: Departamento de Cirugı´a Facultad de Medicina Universidad Santiago de Compostela, Spain
Additional Authors: Alfonso Olmos, Matı´as1; Villas Tome´, Carlos1; ´ lvaro2; Aldaz Pastor, Azucena1; Navarro, I´n˜igo3; Silva Gonza´lez, A ´ Martın Algarra, Salvador1
Additional Authors: Couceiro Otero, Ramiro1; Dı´ez Ulloa, Ma´ximo Alberto2; Otero Ferna´ndez, Marı´a3; Garcı´a Santiago, Carlota4; Freire Garabal, Manuel4
Centers: 1Clı´nica Universidad de Navarra, Pamplona, Spain; 2Clı´nica Alemana de Santiago de Chile, Chile; 3Facultad de Ciencias de la Universidad de Navarra
Centers: 1Cell and Developmental Biology, School of Medicine, UNC Chapel Hill, North Carolina, USA; 2Departamento de Cirugı´a, Facultad de Medicina, Universidad Santiago de Compostela, Spain; 3 Complejo Hospitalario Universitario Santiago de Compostela. Spain; 4 Departamento de Farmacologı´a, Facultad de Medicina, Universidad Santiago de Compostela, Spain
Introduction: Among the uses of acrylic cement (PMMA), is the possibility to employ it as a vehicle for drug diffusion. This capability is of interest in the treatment of pathological fractures: The curative effects of the cement (cytotoxicity of the monomer and increased temperature) are added to the antineoplastic effect of the drugs. Aims: To determine the efficacy of cisplatin- or methotrexate-containing acrylic cement for local and systemic antineoplastic drug diffusion. Materials and Methods: Two groups of 10 pigs each were studied. The first group underwent vertebroplasty using cisplatin-containing cement and the second group, cement containing methotrexate. Vertebroplasty was performed in two non-consecutive lumbar vertebrae with bipedicular cement injection. Transpedicular bone biopsy was performed weekly to measure levels of antineoplastic agent in bone tissue, and plasma levels of the drugs were determined. Cisplatin was studied by atomic absorption spectrometry and methotrexate by fluorescence polarization immunoassay. In addition to clinical monitoring of the animals, renal and hepatic function and hemogram analysis were performed weekly. Results: Cisplatin and methotrexate levels were found in bone tissue at more than 5 weeks following surgery. The cisplatin peak occurred at week 3 (1269 lg/g bone) and the methotrexate peak at week 1 (862.76 lg/g bone). Therapeutic plasma levels of cisplatin and methotrexate were found at more than 72 h, with a peak at 24 h for cisplatin
Introduction and Aims: PMMA has been used in spinal surgery since 1987. Studies on this material over more than 50 years have shown no biocompatibility. Commercial hydroxyapatite (HA) is a highly reactive, osteoconductive synthetic ceramic, but it does not have ideal mechanical properties. Schwartz reported that mesenchymal stem cells (MSCs) can migrate and adhere to an implant with osteogenic capacity, and can even differentiate to an osteoblast phenotype, secreting their own extracellular matrix. The aim of this study was to assess the osteogenic potential of a PMMA/HA composite at different concentrations on MSCs. Material and Method: Characterized HA powder (=2.0 g/cm3) was mixed with cement (A Kyphon HV-R) before polymerization. HA concentrations were 5 %, 10 %, 15 %, and 20 %. MSCs were cultured and isolated using the Ficoll-Paque technique. Cells were then cultured on PMMA/HA discs with HA at the concentrations established. The following variables were studied: cell proliferation, cell adhesion, local inflammatory reaction (TRAIL), cell
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Eur Spine J (2014) 23:248–288 (0.23 lmol/L) and at 30 min for methotrexate (0.92 lmol/L). None of the animals died during the study. Animals with intracanal cement leaks showed no neurological involvement. AST, ALT, creatinine, hemoglobin, platelet, and leukocyte levels remained within normal limits. Conclusions: There is local diffusion of antineoplastic agents from the cement to bone and plasma. We found methotrexate and cisplatin levels in bone at up to 5 weeks, comparable to previous in vitro reports. At the doses administered, there were no cases of myelosuppression, hepatotoxicity, or nephrotoxicity.
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65 BIOMECHANICAL AND IN VIVO STUDY OF THE EFFECT OF PILOT HOLE SIZE ON THE PEDICLE SCREW-BONE INTERFACE Principal Author: Defino, Helton Center: Faculdade de Medicina de Ribeira˜o Preto-USP, Brazil
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Additional Authors: Silva, Patricia; Shimano, Antonio Carlos; Rosa, Rodrigo
BIOMECHANICAL TESTING COMPARING TITANIUM AND PEEK TRANSLAMINAR FACET SCREWS
Center: Faculdade de Medicina de Ribeira˜o Preto-USP, Brazil
Principal Author: Wanderley Velho, Jose Guilherme Center: Rio de Janeiro University-Neurosurgery Department. Brasil Additional Authors: Ribeiro Telles, Carlos Roberto Center: Rio de Janeiro University-Neurosurgery Department. Brasil Introduction and Aim: In 1983, Magerl improved Boucher’s transfacet screw fixation technique, changing the starting point for the contralateral spinal process lamina junction, increasing its stiffness and safety. The aim of this study is to show a novel biomechanical testing protocol comparing the titanium and a new PEEK screw device through Magerl’s trajectory in a stand alone and TLIF construct. Materials and Methods: Three spinal functional units were utilized: one with a bilateral titanium screw construct, one with a bilateral PEEK screw construct, and the third with bilateral PEEK screws combined with a TLIF cage construct. All units underwent an intact, pre-fatigue static test, a fatigue test, and a post-fatigue static test. During the pre-fatigue and post-fatigue tests, moments were applied in steps of 0.25, 5, 7.5, 10, and zero Nm, in flexion, extension, left and right lateral bending, and axial rotation. A preload of 400 N was applied and moments were applied in steps of 0.25, 5, 7.5, 10, and zero Nm in extension and flexion. The position of each vertebra was recorded using an OPTOTRAK motion measurement system. During the dynamic testing or fatigue, each instrumented segment was fixed on an XY table attached to an MTS load cell. The test was conducted by applying cyclic loads of 75 N at 10 cm from the COR up to 50 000 cycles of 2 HZ frequency. This loading created extension and flexion motion. Load displacement data was collected. Results: All the pre-fatigue tests confirmed the efficacy of Magerl’s technique in decreasing the spinal segment motion in all directions. The post-fatigue test with the Ti screw construct showed increased motion, mainly during flexion and extension, and increased screw hole diameter. The post-fatigue test with the PEEK screw remained stable during all tests, without damage to the surrounding bone. The TLIF construct combined with bilateral PEEK screws showed initial displacement, but it did not increase after 50 000 cycles. Conclusion: The PEEK features of stiffness and elasticity, very similar to those of real bone, may explain its better results. This opens a door for clinical application, mainly in elderly patients with poor bone quality and in motion preservation constructs.
Objective: To experimentally study the influence of pilot hole diameter (smaller than or equal to the internal screw diameter [core]) on biomechanical variables (insertion torque and pullout strength) and histomorphometric parameters of the screw–bone interface immediately after pedicle screw insertion and 8 weeks later. Methods: Fifteen sheep underwent surgery with bilateral insertion of pedicle screws from L1 to L3. The pilot hole was smaller (2.0 mm) than the internal diameter of the screw (core) in pedicles on the left side and equal to the internal diameter of the screw (2.8 mm) in pedicles on the right side. Ten animals were immediately sacrificed (5 were assigned to pull-out strength trials and 5 were used for histomorphometric assessment of the screw–bone interface). The remaining 5 animals were sacrificed 8 weeks after pedicle screw insertion for histomorphometric evaluation of the screw–bone interface. Results: Insertion torque and pullout strength were significantly greater in pedicle screws inserted in pilot holes with a diameter smaller than the internal screw diameter. Histomorphometric assessment of the screw–bone interface showed that the percentage of boneimplant contact, the area of bone inside the screw thread, and area of bone outside the screw thread were significantly higher for screws inserted in pilot holes smaller than the internal diameter of the screw, both immediately following insertion and at 8 weeks. Conclusion: A pilot hole diameter smaller than the internal pedicle screw diameter led to better insertion torque and pull-out strength immediately after screw insertion, and improved the screw–bone interface in the pedicle immediately after screw placement and 8 weeks later.
66 MINIMALLY INVASIVE TREATMENT FOR DEGENERATIVE CERVICAL SPINE DISEASE Principal Author: Ramı´rez Leo´n, Jorge Felipe Center: Clı´nica Reina Sofı´a-Colsanitas, Bogota´, Colombia Additional Authors: Rugeles Ortiz, Jose´ Gabriel Center: Clı´nica Reina Sofı´a-Colsanitas, Bogota´, Colombia Aim and Introduction: The aim of this study was to report 14 years’ experience with minimally invasive surgery (MIS) to treat degener-
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278 ative cervical spine disease (CSD). CSD is characterized by axial pain. An estimated 66 % of the adult population has experienced neck pain at some point in life. The percentage of women is higher than men and the C6–C7 segment is most commonly affected. Various open surgery techniques are available, all of which have certain disadvantages and associated complications. Since the first report of MIS in 1994 and further studies indicating its efficacy and safety, this technique has become a new option for treating spinal diseases, including CSD. Currently there are two approaches, the anterior and posterior, each with specific indications and advantages. Our 14-year experience is focused on the anterior technique. Materials and Methods: Retrospective study of CSD patients treated with MIS by anterior approach. The evaluation instruments used were the MacNab criteria, modified Oswestry Disability Index, and visual analogue scale (VAS). Results: During the period of 1997–2012, the MIS technique was used in 236 patients with CSD. All surgeries were ambulatory procedures, performed under local anesthesia and sedation. Maximum follow-up was 13 years. The MacNab classification was excellent to good in 90 %, fair in 7 %, and poor in 3 %. The modified Oswestry rating was excellent to good in 63 %, improvement in 30 %, poor in 6 %, and worsening in 1 %. Preoperative VAS was 8/10 preoperatively and 2/10 postoperatively. Complications included cervical hematoma 3 cases, carotid lesion 2 cases, and transient dysphonia 3 cases. Conclusions: MIS to treat the cervical spine is a safe and effective procedure, with a low complication rate. Since it is performed with local anesthesia and sedation, and a small incision is used, it can be done on an outpatient basis with prompt return to work activity. The results found were very satisfactory and comparable to open microsurgery procedures.
67 INFLUENCE OF TIME OF EVOLUTION AND AGE ON CERVICAL SPONDYLOTIC MYELOPATHY Principal Author: Ferna´ndez de Rota Conde, Antonio Center: Hospital Universitario Virgen de la Victoria, Malaga, Spain Additional Authors: Ferna´ndez de Rota Avecilla, Juan Jose´; Meschian Coretti, Stephan; Urbano Labajos, Vı´ctor; Baro´n Romero, Manuel Center: Hospital Universitario Virgen de la Victoria, Malaga, Spain Introduction and Aim: The prognosis of cervical spondylotic myelopathy (CSM) poses numerous questions. We present a study that attempts to elucidate the influence of age and duration of symptoms on the prognosis of this condition following surgery. Material and Method: Prospective study in 66 patients who underwent surgery for CSM, evaluated (JAO scale) pre- and postoperatively. Follow-up, 2 years. The variables analyzed were age and time of clinical evolution (TE), the latter divided into two groups: long evolution ([1 year), 35 cases, and short evolution (\1 year), 31 cases. In addition, we included the variable recent aggravation (RA) as follows: if the condition progressed gradually without any major ups and downs, it was rated NO (15 cases), whereas if there was an acceleration in progression of the disease before surgery, it was rated YES (20 cases). Results: Age showed a negative correlation with the preoperative (CI -0.38) and postoperative (CI -0.30) situation (p \ 0.01). There was no correlation between age and the recovery rate. The TE did not correlate with the preoperative clinical status. There was a negative correlation between the TE and the postoperative clinical status (CI -
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Eur Spine J (2014) 23:248–288 0.29), as well as the recovery rate (CI -0.4) (p \ 0.01). The recovery rate was 20.51 % higher in patients with a short clinical evolution. With regard to the variable RA, there was greater preoperative clinical involvement, with a mean score of 1.44 points (JAO) (p \ 0.05), and poorer postoperative clinical status. Furthermore, RA YES patients had poorer recovery rates than patients classified as RA NO, with a trend approaching significance. Analysis of the relationship between RA YES patients (20 cases) and RA NO patients with a long evolution (15 cases), showed a poorer preoperative clinical status in RA YES (p \ 0.05), and a non-significant trend to a better recovery rate in this group. Conclusions: Age had a negative influence on the preoperative and postoperative clinical status, but was not predictive of the capacity to improve. The time of disease evolution had prognostic value for the capacity to improve, showing a negative influence.
68 NEED FOR INTRAOPERATIVE NEUROPHYSIOLOGICAL MONITORING (INM) IN SURGICAL POSITIONING OF PATIENTS WITH SEVERE CERVICAL MYELOPATHY Principal Author: Pe´rez Lorensu, Pedro Javier Center: Hospital Universitario de Canarias, Neurofisiologı´a Clı´nica, Santa Cruz Tenerife, Spain Additional Authors: Corte´s Garcı´a, Pedro1; De´niz Rodrı´guez, Bernabe´1; Arnau Santos, Amelia2; Rolda´n Delgado, He´ctor3; Garcı´a Conde, Mario3; Febles Garcı´a, Pablo3; Pe´rez Orribo, Luis3; Garcı´a Marı´n, Vı´ctor3 Centers: 1Hospital Universitario de Canarias, Santa Cruz Tenerife, Spain; 2Hospital Universitario La Candelaria, Traumatologı´a, Santa Cruz Tenerife, Spain; 3Hospital Universitario de Canarias, Neurocirugı´a, Santa Cruz Tenerife, Spain Aim and Introduction: The scientific literature recognizes a risk of producing a severe cord lesion with postoperative paraplegia in more than 1 % of patients undergoing surgery for cervical myelopathy during maneuvers to position the patient or during the surgical act. INM techniques are used to detect and prevent this potential iatrogenic injury. Materials and Methods: The study included 66 consecutive patients (39 F and 27 M; 17–81 years of age, mean 68 years) with severe cervical myelopathy (degenerative and traumatic) who required posterior stabilization surgery. Anesthesia consisted in TIVA and neuromuscular block reversion (Sugammadex), which was carried out before moving and positioning the patient for surgery. INM used transcranial electrical stimulation (TcMEP) to study the motor pathway and somatosensory evoked potentials (SSEPs) for the sensory pathway, following induction of anesthesia, and during positioning of the patient and surgery. When INM changes were seen during patient positioning, repositioning was carried out, and if the signals did not improve, the spinal cord protection protocol (raise blood pressure and steroids) was implemented. Results: Of the 66 patients in the series, INM changes were seen in 4 patients during surgical positioning. The changes reverted following repositioning in 3 cases: 1 patient had transient postoperative paraparesis of the lower extremities (2/5), and the others had no
Eur Spine J (2014) 23:248–288 postoperative symptoms. In the remaining patient, the INM changes did not recover following repositioning or with the cord injury protection protocol. The patient had transient postoperative tetraparesia (2/5 in upper and 1/5 in lower extremities) that recovered in 72 h. Conclusion: In our series, INM illustrated the efficacy of monitoring techniques during preoperative positioning of patients with severe cervical myelopathy who require a posterior approach and instrumentation. A risk of cord lesion was detected in 6.06 % of cases, enabling repositioning and rapid establishment of cord protection measures.
69 OUTCOME OF SURGERY FOR DEGENERATIVE CERVICAL MYELOPATHY, AND PATIENT SATISFACTION Principal Author: Matamalas Adrover, Antonia Center: Hospital Universitario Vall d’Hebro´n, Barcelona, Spain Additional Authors: Plano Jerez, Xavier; Ferna´ndez Bautista, Alejandro; PellisE` Urquiza, Ferran; Garcı´a de Frutos, Ana; Casamitjana Ferra´ndiz, Jose´ Center: Hospital Universitario Vall d’Hebro´n, Barcelona, Spain Aim: To assess the subjective satisfaction and clinical outcome of surgery in patients operated for cervical myelopathy, and the repercussions of complications. Materials and Methods: Retrospective analysis of patients surgically treated for degenerative cervical myelopathy between 2005 and 2010 (minimum follow-up [1 year). We collected data on demographics, complications, and reinterventions. The repercussions of the complications were analyzed using a 15-point scale (GOS) to evaluate the perceived overall effect and a satisfaction scale at the end of followup. Results: Of the 221 patients initially recruited (mean age 52.2 years; 66.5 % men), 12 (5.4 %) had died at completion of follow-up (0.4 % surgery-related). Of the remaining patients, 82.3 % completed the questionnaires at the end of the study. Mean follow-up was 44.9 ± 19.4 months. Among patients responding to the questionnaires, 45.34 % were very satisfied with the results of surgery and 27.9 % were reasonably satisfied. The mean GOS score (0–15 points) was 11.26 (SD ± 3.3); 75.6 % of patients considered that surgery had improved their health status and 11.04 % considered that it had worsened their health. Of the 19 patients reporting a worsening, only 2 had been reoperated during the follow-up period. Among the total, 14.8 % of patients presented minor complications and 11.8 % major complications postoperatively. Some type of neurological radicular lesion (pain and/or paresis) occurred in 7.7 % of patients. There were 7.6 % of surgical wound complications and 9.3 % of reinterventions (2.5 % debridements, 6.3 % myelopathy progression, 0.4 % instrumentation failure). There were no differences with regard to satisfaction and GOS score between patients with postoperative complications (medical, neurological, and/or wound) and those without. Nor was there a difference between patients reoperated for any cause and those who were not reoperated.
279 Conclusions: More than 60 % of patients undergoing surgery for degenerative cervical myelopathy were satisfied with the outcome of surgery and had a subjective impression of symptoms improvement. The development of postoperative complications did not seem to have an influence on the results of the procedure.
70 COMPLICATIONS OF SURGERY IN PATIENTS WITH DEGENERATIVE CERVICAL MYELOPATHY Principal Author: Plano Jerez, Xavier Center: Hospital Universitario Vall d’Hebro´n, Barcelona, Spain Additional Authors: Matamalas Adrover, Antonia; Ferna´ndez Bautista, Alejandro; Pellise´ Urquiza, Ferran; Garcı´a de Frutos, Ana; Casamitjana Ferra´ndiz, Jose´ Center: Hospital Universitario Vall d’Hebro´n, Barcelona, Spain Aim: To analyze the complications secondary to cervical surgery in patients with degenerative myelopathy and evaluate the influence of the type of approach used on development of complications. Materials and Methods: Retrospective analysis of patients surgically treated for degenerative cervical myelopathy between 2005 and 2010 (minimum follow-up[1 year). Data were collected on demographics, preoperative comorbidity, complications (medical, surgical, and mechanical), and reinterventions in the immediate postoperative period and during follow-up. Results: A total of 237 procedures were reviewed in 221 patients (mean age 52.2 years; 66.5 % men). At least one associated comorbidity was recorded in 78.3 % of patients (mean number of comorbid conditions/patient 2.07). Mean duration of hospitalization was 9.8 days (SD ± 8.3). Among the total, 26.6 % of patients presented at least one postoperative complication (minor 14.8 % and major 11.8 %). The most common medical complications were respiratory failure (4.2 %), dysphagia (4.2 %), and urinary infection (3.4 %). Surgical would complications occurred in 6.8 %: 3.8 % dehiscences and 3 % infections (2.1 % deep). Preoperative myelopathy deterioration occurred in 1 case (0.4 %). Mechanical complications developed in 3.8 %. Reinterventions were needed in 9.3 % (2.5 % debridements, 6.3 % myelopathy progression, 0.4 % instrumentation failure). Mortality was 0.8 %. Among patients treated with an anterior (n = 157) or posterior (n = 75) approach, 9.6 % and 16 %, respectively, experienced major complications. Patients treated by posterior technique were older (62.7 vs. 55.8), had a larger number of operated levels (3.3 vs. 2.2), and longer hospitalization (11.6 vs. 8.5 days). As compared to the anterior approach, posterior surgery was associated with a higher rate of medical complications (p = 0.04), wound complications (p = 0.03), and neurological radicular complications (pain 8.1 % vs. 1.3 %, p = 0.01; and deficit 5.4 % vs. 0.6 %, p = 0.04). C6 (1.9 %) and C5 (1.5 %) paresis were the most common. There were no differences with regard to the number of levels treated or the different types of complications. Older patients had a larger number of postoperative medical complications (p = 0.001).
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Conclusions: One quarter of patients surgically treated for cervical myelopathy develop some type of postoperative complication. Older patients have a higher risk of medical complications, whereas those operated by posterior approach have more surgical wound complications.
Center: Hospital Mancha-Centro, Alca´zar de San Juan, Ciudad Real, Spain
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Centers: 1Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 2 Universidad Cato´lica de Valencia, Spain; 3Hospital La Fraternidad de Madrid, Spain; 4Hospital Son Espases de Palma de Mallorca, Spain
EVOLUTION OF PATIENTS MORE THAN 21 MONTHS ON THE WAITING LIST FOR LUMBAR MICRODISCECTOMY (2004–2010) Principal Author: Bosch Garcı´a, David Center: Hospital Universitari Mu´tua Terrassa, Barcelona, Spain Additional Authors: Morera Domı´nguez, Carles; Yela Verdu´, Chris´ lvarez, Saioa tian; Quintas A Center: Hospital Universitari Mu´tua Terrassa, Barcelona, Spain Introduction: Most patients with radiculopathy due to disc herniation cure spontaneously without the need for surgery. Surgery for disc herniation is indicated in hyperalgesic patients, those refractory to treatment, and those with a progressive neurological lesion. The aim of our study is to assess the clinical status of a group of patients who had been on the waiting list for microdiscectomy treatment for more than 21 months. Materials and Methods: The study group for clinical review was comprised of 48 patients (22 women and 26 men), with a mean age of 51.3 years, and on the waiting list for a simple microdiscectomy procedure from January 2004 to December 2010. Eighteen patients were excluded from the study group (4 could not be located, 10 declined, and 4 underwent surgery in other centers). Hence, the final group included 30 patients, in whom their current clinical status was evaluated with the VAS, ODI, and SF-12 instruments. Results: Of the 30 patients on the microdiscectomy waiting list reviewed, 15 patients were removed (9 mild low back pain and 6 without current pain), in 9 patients the surgical indication was changed (8 fusion and 1 laminectomy), and in 6 the same indication was maintained. In the 15 patients with a surgical indication, the mean ODI value was 41 %, mean lumbar VAS 5.6, mean radicular VAS 4.5, and mean SF-12 scores were 27 for the physical component and 43.25 for the mental component. None of the patients had a neurological lesion during their time on the waiting list. Conclusion: We found that the clinical status improved without the need for surgery in more than 50 % of patients. Among those in whom an indication for surgery remained, the type of surgical indication changed in 60 % during the time on the waiting list.
Additional Authors: Burgos Flores, Jesu´s1; Del Olmo, Teresa1; Barrios Pitarque, Carlos2; Hevia Sierra, Eduardo3; Anto´n Rodriga´lvarez, Miguel1; De Blas Beorlegui, Gema1; Sanpera Trigueros, Ignacio4
Aim and Introduction: There are reports of radicular lesions that go unnoticed in neurophysiological and conventional radiologic controls in vertebral deformities. The aim of this study is to assess a neurophysiological examination that will identify these cases intraoperatively. Materials and Methods: In 294 patients surgically treated between 2004 and 2010 by a posterior approach with pedicle screws using a freehand technique, 6765 pedicle screws were implanted, 1550 lumbar and 5088 thoracic. Eight of these patients (2.7 %), with a mean age of 24 years, presented radicular pain. On postoperative CT, 10 lumbar pedicle screws (2 L1, 3 L2, 4 L3, 1 L4) were found to slightly protrude in the inferior part of the pedicle. The EMG thresholds of the screw and screw tract were evaluated. Results: During the initial surgery, no anomalies were detected on palpation of the screw trajectory or by radioscopic control, and there were no changes on screw stimulation (s-EMG). All patients presented radicular pain when standing and sitting that remitted with bedrest. Screws were removed without repositioning at a mean of 37 days (R: 4–182). In this procedure, screw stimulation was repeated, and again, normal values were obtained (C11 mA). Following pedicle screw removal, stimulation of the screw tract was performed, and thresholds below normal values (3.9–10.7 mA) were found in the middle portion. After a mean follow-up of 4.4 years (R: 2.0–6.8), 5 patients reported occasional radicular discomfort and a minimal motor deficit in the affected leg. Conclusions: This study presents a type of lumbar pedicle screw malposition producing radicular pain on standing–sitting that is not detected by conventional monitoring. Stimulation in the middle area of the tract after removing the pedicle screw produced low stimulation thresholds. Routine stimulation of the screw tract is recommended before insertion of lumbar screws.
73 LUMBOSACRAL FUSION IN POSTDISCECTOMY SYNDROMES Principal Author: Bermu´dez Santos, Washington
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Center: CE.DEF.CO (Centro de Deformidades de Columna) Montevideo, Uruguay
LUMBAR PEDICLE SCREW MALPOSITION WITH NORMAL NEUROPHYSIOLOGICAL STIMULATION PRODUCING POSTOPERATIVE MECHANICAL RADICULAR PAIN: VALUE OF NEUROPHYSIOLOGICAL STIMULATION OF THE SCREW TRACT
´ lvaro; Pereyra Baison, Additional Authors: Rocchietti Infante, A Leo´nardo
Principal Author: Garcı´a Gonza´lez, Vicente
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Center: CE.DEF.CO (Centro de Deformidades de Columna), Montevideo, Uruguay Aim: To evaluate the efficacy of lumbosacral fusion in postdiscectomy syndromes. Periodic assessments of our surgical results over the years (1978–2008) marked a turning point in this subject. We now present an updated evaluation.
Eur Spine J (2014) 23:248–288 Material and Method: In the period of January 1998 to December 2008, 2363 patients underwent surgery in our center, and 1141 procedures were lumbosacral fusions. All patients were operated on by the same surgical team. Fifty-five patients had a history of one or more surgeries for disc herniation (DH), and 36 had complete medical records and could be contacted. All patients were interviewed by telephone, and outcome was rated according to Odom’s criteria. In addition, the psychosocial status of the sample was analyzed. Results: The 36 clinical histories reviewed were from 22 women and 14 men. More than 40 % had been operated at least twice for DH. Follow-up of the sample ranged from 5 to 15 years, with a mean of 10 years. Outcome based on Odom’s criteria was excellent or good in 52 % and regular or poor in 48 %; patients were analyzed by category. In those who underwent two or more DH surgeries, the outcome changed to 40 % and 60 % respectively. Analysis by cohorts showed that values worsened as postoperative time increased, with no regular pattern, until the values mention above were reached. As to the patients’ psychosocial status, 70 % of patients had histories of psychiatric treatment, which were analyzed. Conclusions: 1) 2)
3)
4)
It is clear that the procedure used did not achieve the expected outcome, even considering that it was a salvage procedure. The more times patients underwent DH surgery, the poorer was the outcome. Based on these findings, salvage surgery should be reconsidered according to other, more complex factors than simply mechanical ones. In this line, presence of the psychosocial component in the profile of these patients. Despite the results of earlier internal evaluations and efforts to eliminate factors related to a poor prognosis, unsatisfactory outcomes continue to occur. The most rational measure is to increasingly limit the HISTORY, that is, surgery for DH.
281 Our aim was to evaluate the results of surgical treatment of recurrent lumbar disc herniation in patients within the workers’ compensation program. Materials and Methods: Retrospective case series study. We identified patients in the workers’ compensation program who had undergone surgery for recurrent lumbar disc herniation between June 1994 and May 2011. Their medical records were reviewed, pertinent data were collected, and a descriptive statistical analysis was performed. Results: A total of 109 patients were identified, 106 males (97.2 %). The median time between the primary discectomy and that for the recurrent herniation was 62.3 months (5–226.5). Sixty-four percent of the patients were operated at L5-S1, 34.9 % at L4–L5, and only one required a second surgery at L3-L4 (0.9 %). A new discectomy alone was required in 99 patients (90.8 %), whereas 9.2 % (10 patients) needed lumbar fusion due to excessive resection of the facet joint or preoperative diagnosis of segmental instability. The mean operative time was 123 min (105 min for the discectomy group and 299 min for discectomy plus fusion). Three patients (2.8 %) presented surgeryrelated complications. Patients returned to work at a mean of 73.5 days (22–315, median 64 days). Disability compensation due to chronic pain was granted to 24 of the 109 patients (22 %). Median follow-up was 110.8 months (15.4–217.3). According to our previous reports, these results are comparable to those of the primary discectomy in compensated patients, considering time out of work (73.5 and 57.7 days respectively) and surgery related complications (2.8 % and 2 % respectively), but not regarding the need for disability compensation (22 % and 8 % respectively). Conclusion: The results of surgical treatment for recurrent lumbar disc herniation in a population of patients under a workers’ compensation program are comparable to those of primary discectomy, particularly regarding time out of work and surgery-related complications.
74 75 SURGICAL TREATMENT OF RECURRENT LUMBAR DISC HERNIATION IN PATIENTS WITHIN A WORKERS’ COMPENSATION PROGRAM
LUMBAR FUSION AND INSTRUMENTATION IN PATIENTS WITH A SECOND RECURRENCE OF LUMBAR DISC HERNIATION
Principal Author: Zamorano Pe´rez, Juan Jose´
Principal Author: Urzua Bacciarini, Alejandro
Center: Hospital del Trabajador, Santiago, Chile
Center: Hospital del Trabajador, Providencia, Chile
Additional Authors: Lira Prado, Fernando; Ballesteros Plaza, Jose´; Yurac Barrientos, Ratko; Urzua Bacciarini, Alejandro; Ilabaca Grez, Francisco; Fleiderman Valenzuela, Jose´; Lecaros Larenas, Miguel ´ ngel; Munjin Leo´n, Milan; Ramı´rez Pittaluga, Sergio; Tapia Pe´rez, A Carlos
Additional Authors: Valiente Valenzuela, Diego; Zamorano Pe´rez, Juan; Ballesteros Plaza, Jose´; Yurac Barrientos, Ratko; Ilabaca Grez, Francisco; Fleiderman Valenzuela, Jose´; Munjin Leo´n, Milan; Lecaros Larenas, Miguel; Tapia Pe´rez, Carlos; Ramı´rez Pittaluga, Sergio Center: Hospital del Trabajador, Providencia, Chile
Center: Hospital del Trabajador, Santiago, Chile Introduction: Recurrent disc herniation refers to the presence of disc material within the spinal canal from a previously operated disc. The reported incidence for this entity ranges between 3 % and 18 %. The workup of these patients involves gadolinium-enhanced magnetic resonance imaging, electromyography of the lower extremities, and dynamic lumbar spine radiography. Surgical resection of a recurrent herniation is technically more demanding, due to the presence of scar tissue, and altered anatomy, so it is usually associated to a higher complication rate (up to 14.3 % of the patients present dural tears).
Introduction: The incidence of primary recurrence of lumbar disc herniation is 3 % to 18 %. There are no data on the incidence and treatment of second recurrent hernias. In most patients, surgical treatment of a second recurrent hernia includes discectomy and fusion of the affected lumbar segment. Treatment is more complex in these cases and the results differ from those of patients treated for a primary recurrence. The aim of this study is to evaluate the results of instrumented fusion of the lumbar spine for treating a second hernia recurrence in a group of patients included in the workers’ compensation program.
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282 Materials and Methods: Retrospective case series study. Patients within the workers’ compensation program who underwent surgery in the spinal unit for a second recurrent disc herniation between June 1994 and May 2011 were identified. We reviewed their clinical histories, recorded pertinent data, and performed a descriptive statistical analysis. Results: Twelve patients were identified, 11 men (91.7 %). Mean age at the second recurrent hernia procedure was 44 years (34–58). Median time between surgery for the first and second hernia recurrence was 24.6 months (2.5–95.5). The levels treated were L5–S1 in 77 % of patients and L4–L5 in the remaining 33.3 %. One patient (8.3 %) presented a surgery-related complication (dural tear). The mean time to return to work was 130.5 days (58–330, median 113 days). Disability compensation due to chronic pain was awarded to 7 patients (58.3 %). Median follow-up was 65.6 months (16–158.6). Conclusion: Surgical treatment for a second lumbar disc herniation in a population within a workers’ compensation program was only needed at levels L4–L5 and L5–S1. These patients take longer to recover and present a higher incidence of chronic low back pain requiring compensation than patients undergoing surgery for a primary recurrence of lumber disc herniation.
Eur Spine J (2014) 23:248–288 measures and the TAPS or SAQ. There were no correlations between the SRS-22 and the photographic measures. Conclusion: The height of the waist folds measured by digital photography showed a moderate correlation with the self-perceived trunk deformity. Trunk asymmetry correlated poorly with self-perceived body image. Pictorial scales correlated better with the photographic images than verbal scales.
77 ENDOCRINE DISEASE AS A RISK FACTOR FOR VERTEBRAL FRACTURES Principal Author: De la Calva Ceinos, Carolina Center: Hospital Universitario y Polite´cnico La Fe, Valencia, Spain Additional Authors: Jover Jorge, Nadia; Cruz Miranda, Daniel; Bonete Lluch, Daniel; Bas Hermida, Paloma; Bas Hermida, Teresa Center: Hospital Universitario y Polite´cnico La Fe, Valencia, Spain
76 ANALYSIS OF THE CORRELATION BETWEEN TRUNK DEFORMITY MEASUREMENT WITH DIGITAL PHOTOGRAPHY AND SELF-PERCEIVED BODY IMAGE IN PATIENTS WITH IDIOPATHIC SCOLIOSIS (IS) Principal Author: Matamalas Adrover, Antonia Center: Hospital Universitario Vall d’Hebro´n, Barcelona, Spain Additional Authors: Bago´ Granell, Juan; D’Agata, Elisabetta; Pellise´ Urquiza, Ferran; Garcı´a de Frutos, Ana; Ca´ceres Palou, Enric Center: Hospital Universitario Vall d’Hebro´n, Barcelona, Spain Introduction: It has been suggested that some measures of trunk deformity by digital photography may be useful for clinically assessing the deformity. The relationship between these measurements and patients’ perception of their body image has not been analyzed. Aim: To evaluate the validity of a clinical measure of trunk deformity based on digital photography compared with the self-perceived body image. Methods: Photographs were taken of the front and back views of IS patients (Cobb [25). Five different angles were calculated at the level of the shoulders, axillas, and waist, and two trunk asymmetry scores were determined in both photographic views, using the Surgimap software. All patients completed the SRS-22, SAQ, QLSDP, and TAPS questionnaires. Correlations were determined using the Pearson correlation coefficient. Results: Eighty consecutive patients were included (68 females and 12 males), aged 12 to 40 years (mean 20.3 y). Mean Cobb was 45.9 (range 25.1–77.2). A statistically significant correlation was found between the angle formed by the height of the waist folds and TAPS (r = 0.26–0.32), SAQ-image (r = 0.31–0.36), and SAQ total (r = 0.29–0.33). There were no further correlations between the remaining photographic
123
Introduction: Endocrine diseases are related with bone metabolism abnormalities. Recent studies have demonstrated an association between osteoporotic vertebral fractures and this type of disease. Aim: Prospective study of the relationship between endocrine disease and osteoporotic vertebral fractures following a low-energy trauma. Materials and Methods: Prospective enrollment of 23 patients hospitalized for acute vertebral fracture following a low-energy trauma. We analyzed age, sex, location of the fracture, and history of endocrine disease and omeprazole treatment. Radiologic studied included plain radiography, CT and MRI, with analysis of the anterior, middle and posterior spine involvement, and loss of height and kyphosis angle. Analysis of bone metabolism markers was performed (betaCTX, P1NP, AP, vitamin D and PTH). Results: All patients were hospitalized for a low-energy acute vertebral fracture. Distribution by sexes was 91.3 % women and 8.7 % men. The affected vertebral level was thoracolumbar in 65.2 %, lumbar 21.7 %, and thoracic 13 %. Mean age was 72.43 ± 9.05 years. The incidence of endocrine abnormalities was 56.53 %, among them thyroid metabolism changes, DM, Addison syndrome, suprarenal incidentaloma, and a double adnexectomy. Among the total, 34.78 % of patients were receiving omeprazole treatment. Analysis of bone metabolism markers showed a vitamin D decrease in 80 % of patients. The radiographic results according to the presence or absence of endocrine abnormality are shown in the Table. There were no cases of posterior spine involvement. Conclusion: There is an association between endocrine disease and vertebral fractures. Among the lesions affecting patients with endocrine abnormalities, there were more cases of anterior and middle column involvement, greater loss of height, and a larger kyphosis angle. Patients with vertebral fractures present a vitamin D deficit.
Endocrine abnormality
No endocrine abnormality
Anterior column
46.1 %
60 %
Anterior and middle column
53.8 %
40 %
Height loss
19.19 ± 19.6 %
19.04 ± 13.35 %
Kyphosis
12.32 ± 8.768
5.02 ± 5.528
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78
Center: Hospital Universitario Rı´o Hortega, Valladolid, Spain
HISTOLOGIC STUDY IN A SERIES OF CHORDOMAS. PROGNOSTIC FACTORS
Additional Authors: Ramos Galea, Rafael; Escudero Marcos, Roberto; Paredes Herrero, Elena; Garcı´a Garcı´a, Javier Minaya; Alonso Garcı´a, Noelia; Garcı´a Alonso, Manuel Francisco
Principal Author: Rosello´ Sastre, Esther
Center: Hospital Universitario Rı´o Hortega, Valladolid, Spain
Center: Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain Additional Authors: Martı´n Benlloch, Juan Antonio1; Martı´nez Ciarpaglini, Carolina2; Morales Codina, Ana Marı´a1; Molina Aguilar, Ma Jesu´s1 Centers: 1Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain; 2Hospital Clı´nico Universitario de Valencia, Spain Introduction: Chordoma is an uncommon, low-grade, malignant primary bone tumor that is locally aggressive, but has low metastasizing capacity, and is commonly recurrent. Symptoms often manifest at a late stage, when there is advanced local destruction, making their removal difficult. Nonetheless, only complete resection with wide margins guarantees lengthy disease-free survival. The need for associated radiotherapy worsens the prognosis. Materials and Methods: Eleven chordomas surgically treated between 2002 and 2012. Histological study of all samples: initial biopsy, surgery, and biopsied recurrent disease or metastasis. Results: Complete initial resection was achieved in 7 cases. In 3 patients, the margins were affected and in one, palliative surgery was performed. These 4 cases received radiotherapy. Three died due to loco-regional problems, there were 3 cases of local recurrence, and 2 cases of osteomuscular metastasis with no response to Imatinib. The 8 remaining patients were disease-free. The most common histological and immunohistochemical patterns were conventional chordoma, multilobulated pattern of clear cells (9), neural infiltrative, glandular differentiation, and positive for EMA (9), cytokeratins AE1/AE3 (10), S-100 (9), and vimentin (11). Uncommon histological features related to greater tumor aggressiveness included focal dedifferentiation on conventional chordoma, sarcomatoid dedifferentiation as the single pattern in recurrent chordoma, foci of greater cell density in conventional chordoma with elevated proliferative activity (Ki-67); infiltration of margins at a distance from the resection margin, supported by low molecular weight cytokeratin (CK 8–18). Three patients had a history of oncologic disease: 1 cutaneous melanoma, 1 prostate cancer treated with radiotherapy, and 1 rectal adenocarcinoma, synchronous with the chordoma. Conclusions: Chordoma is an aggressive, slow growing local tumor with metastatic capability. Extensive surgery facilitates longer disease-free survival. The histology does not modify the prognosis if the resection is performed with wide disease-free margins. Incomplete resection is associated with recurrence at 3–5 years. Complete study of the surgical specimen is needed to estimate the prognosis. The presence of other synchronous or metachronous malignant tumors was common in our series, although it is unusual in the literature.
Introduction: Discectomy and interbody fusion is the most commonly used technique to treat cervical spondylosis; fusion with iliac crest graft is the reference standard. Interbody devices have been used for years to avoid associated complications. Our aim, in addition to evaluating the results of tantalum use, is to investigate the need for complementary internal fixation. Material and Method: Retrospective study including 32 patients with cervical myeloradiculopathy unresponsive to conservative management for at least 6 months, surgically treated between March 2008 and February 2012 by discectomy and cervical fusion using a tantalum device at one or two levels. Internal screw and plate fixation was additionally used in 15 cases. We performed a clinical evaluation (pre- and postoperative Neck Disability Index [NDI] and Odom’s criteria) and radiographic study (functional views at the time the study was designed). Results: Mean follow-up was 27.7 months. Mean age was 46.81 years and 64.71 % were men in the group receiving fusion with the tantalum device, and 52.6 years and 66.6 % men in the group with tantalum device and plates. In both groups, there was a significant improvement in the previous clinical-functional status according to the NDI. Rating was good or excellent according to the Odom criteria in 72 % of cases, with no significant differences between the groups. Complications were detected in the implant alone group: one case of early device mobility, one case of pseudoarthrosis, and one inferior plate collapse requiring a reoperation using the Smith-Robinson technique. There were no significant differences regarding radiologic spondylosis progression in levels adjacent to the fusion and in sagittal alignment. Conclusions: The results in both groups were satisfactory in most cases and comparable to reported results in similar series. In osteoporotic patients, use of internal fixation seems to provide primary stability and may favor fusion and avoid complications such as implant mobility or vertebral plate collapse.
80 ANTERIOR CERVICAL DISCECTOMY. COMPARATIVE STUDY OF FUSION VERSUS CERVICAL ARTHROPLASTY Principal Author: Mostaza Saavedra, Antonio Center: Complejo Asistencial Universitario de Leo´n, Spain Additional Authors: Iglesias, Elena; Robla, Javier; Iba´n˜ez Plagaro, Javier Center: Complejo Asistencial Universitario de Leo´n, Spain
79 CERVICAL DISCECTOMY AND FUSION WITH TANTALUM IMPLANTS. IS INTERNAL FIXATION NECESSARY? Principal Author: Pe´rez Bermejo, Diego
Aim: Anterior cervical decompression and fusion (ACDF) is a common cervical procedure that yields good clinical results. The aim of total cervical disc replacement (TDR) is to treat radicular pain and preserve cervical function. The objective of this study is to compare the safety and efficacy of cervical TDR with that of anterior cervical discectomy and fusion (ACDF) at one level between C3 and C7. Materials and Methods: Ninety-four patients with degenerative cervical disc disease were treated (endoscopic approach) between 2004
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284 and 2012 by fusion (51 patients) and TDR (43 patients). Age: TDR group 41.4 ± 7.4 years, 43.8 % men; fusion group 47.5 ± 8.1 years, 45.6 % men. Most commonly treated level, C5–C6 (TDR 57.3 %, fusion 54.5 %). Patients were evaluated with the VAS, Neck Disability Index (NDI), standardized questionnaire (SF-36), neurologic examination, and adjacent space assessment. Evaluations before and after surgery, at 6 weeks, and at 6, 12, 18 and 24 months. Results: Patients treated with a disc prosthesis returned to work 3 weeks before those treated with fusion (P = 0.015). The 12-month analysis demonstrated an improvement in both groups; nonetheless, at 24 months, patients treated with TDR showed a statistically significant increase in the variables NDI (P \ 0.025) and VAS (P = 0.010). There were no complications in either group. The fusion group required 4 reoperations (adjacent space syndrome). Although progression of disc degeneration was demonstrated in both patient groups over 8 years, ACDF patients had a significantly higher incidence than those with a disc implant, whereas progression of adjacent segment degeneration was not always related with development of new symptoms. Conclusions: Cervical disc arthroplasty is a new method under development for surgical treatment of cervical disc disease. There is a reduction in the rate of secondary surgeries as compared to ACDF. At two years of follow-up, cervical arthroplasty is a viable alternative to anterior cervical discectomy with fusion in patients with degenerative cervical disc disease.
Eur Spine J (2014) 23:248–288 Results: Duration of surgery (min) was shorter in the SPO group relative to PSO and VCR (420 ± 347 vs. 578 ± 459 vs. 533 ± 435) (p \ 0.00). Intraoperative blood loss (cc) was also lower in SPO than in PSO or VCR (1341 ± 804 vs. 2364 ± 1459 vs. 2134 ± 1335) (p \ 0.03). Thirty-eight percent presented complications, with no significant differences between the groups. There were no differences in the mean correction of segmental kyphosis, but differences were seen for SVA correction (cm), with the SPO group showing a smaller correction than PSO or VCR (3.95 vs. 8.3 vs. 8.33) (p \ 0.00). Nonetheless, the preoperative SVA was significantly greater in the PSO and VCR groups (4.83 ± 3.20 vs. 13.4 ± 11.0 vs. 13.0 ± 12.3). In the SRS-22, significant changes were seen in the 3 groups in all dimensions with respect to the preoperative status, with no significant differences between the groups. Conclusions: There were no differences regarding complications, although the condition was more severe in the PSO and VCR groups. Although there were no differences in correction of segmental kyphosis, PSO and VCR obtained better results for SVA change. There were no differences in the patients’ quality of life between the groups.
83 LONG SPINOPELVIC FUSIONS: FACTORS WITH AN IMPACT ON THE INCIDENCE OF NON-UNION
82
Principal Author: Burgos Flores, Jesu´s
COMPARISON OF THE OUTCOMES OF SMITHPETERSEN OSTEOTOMIES, PEDICLE SUBTRACTION OSTEOTOMIES, AND VERTEBRECTOMY IN THE TREATMENT OF SAGITTAL IMBALANCE
Center: Hospital Universitario Ramo´n y Cajal, Madrid, Spain
Principal Author: Morales Codina, Ana Marı´a Center: Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain Additional Authors: Valverde Belda, Diego; Mun˜oz Donat, Sonia; Sa´nchez Monzo´, Carlos; Aguirre Garcı´a, Rafael; Molina Aguilar, Ma Jesu´s; Martı´n Benlloch, Juan Antonio Center: Hospital Universitario Doctor Peset Aleixandre, Valencia, Spain Introduction: Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), and vertebral column resection (VCR) are widely used for correcting sagittal imbalance. Few studies have compared the outcome of these three procedures. Aims: To compare the clinical and radiologic results of three types of osteotomies in patients with fixed sagittal imbalance. Materials and Methods: Observational retrospective study, comparing 42 patients who underwent more than 2 SPOs (n = 14), PSOs (n = 16), or VCRs (n = 12) and posterior instrumentation for fixed sagittal imbalance in the period of 2003–2012. The sample included 71.4 % men and mean age was 43 years (17–74). The mean follow-up time was 5 years (2–10). Intraoperative and postoperative complications were recorded. All patients completed the SRS-22 questionnaire preoperatively and at the end of follow-up. The segmental kyphosis angle, and the sagittal vertical axis (SVA) were measured in the preoperative period and at 2 years postoperatively.
123
Additional Authors: Vera Ibars, Pablo1; Barrios Pitarque, Carlos1; Sa´nchez Ru´as, Jaime2; Hevia Sierra, Eduardo3; Anto´n Rodriga´lvarez, Miguel2; Dome´nech Ferna´ndez, Pedro4; Sanpera Trigueros, Ignacio5; Piza´ Vallespir, Gabriel5 Centers: 1Universidad Cato´lica de Valencia, Spain; 2Hospital Universitario Ramo´n y Cajal, Madrid, Spain; 3Hospital La Fraternidad de Madrid, Spain; 4Hospital General Universitario de Alicante, Spain; 5 Hospital Son Espases de Palma de Mallorca, Spain Aims and Introduction: A large percentage of non-unions occur in long spinopelvic fusions due to the high mechanical demands in the lumbosacral region, and the incidence persists when iliac screws are used. The aim of this study is to identify the factors implicated in nonunion, to decrease this complication. Materials and Methods: Forty-four patients with scoliosis and no previous surgical treatment, who completed the protocol of this retrospective study, were treated by a posterior only approach in a single surgical stage. Instrumentation was performed to T2 or T3, with bilateral placement of pedicle screws and iliac screws. Radiographic non-union was defined as rod breakage and/or connection loosening and/or lysis around the screws. Results: Mean age 23.9 years. Etiologies: CP (27 %), adult idiopathic (16 %) congenital (14 %); 34 % were unable to walk. Mean followup 57 months (25–124). Preoperative Cobb of the main curve 74.28 (40–135), final correction 67 %; T5–T12 kyphosis 208 to 408 initially in 32 % and final in 89 %. T12–S1 lordosis -20 to -608 initially in 73 % and final in all patients except one. Preoperative pelvic inclination [15 in 11 and final \158 in all. 41 % presented lumbosacral non-union, with a significantly lower incidence in patients \17 years of age and non-ambulatory cases. One iliac screw was used at each side in 24 patients, and non-union occurred in 42 %, with 50 % of lysis around the iliac screw or distal loosening. In cases with two or more iliac screws at each side, rod
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breakage occurred in 45 %, with no other implant failures. In 5 patients with L3–S1 interbody fusion and in 7 ambulatory patients with a third rod and compression hooks, non-union did not occur. Conclusions: In long spinopelvic fusions, placement of more than one iliac screw at each side did not decrease the incidence of nonunion. Use of interbody implants in the three levels distal to the fusion or a third rod with compression hooks associated with more than 2 iliac screws significantly decreased this complication. These lumbosacral reinforcement techniques are particularly indicated in ambulatory patients and those older than 17 years, because this population has a higher incidence of non-union.
Conclusion: Corrective osteotomy treatment by for FSPD in patients with major disability results in a significant functional improvement and a high degree of satisfaction, despite older age and the high percentage of complications. Age should not be considered an absolute contraindication.
84
Radicular VAS Pre
SURGICAL TREATMENT OF RIGID SAGITTAL DEFORMITIES IN PATIENTS OLDER THAN 70 YEARS. IS A RISK JUSTIFIED? ´ lvarez Galovich, Luis Principal Author: A
Variable Lumbar VAS
ODI
CORE 2
Center: Fundacio´n Jime´nez Dı´az, Madrid, Spain ´ ngel R; Tome´ Bermejo, Fe´lix; Additional Authors: Pin˜era Parrilla, A ´ lvarez, Carmen; Vlad, Marı´a Lo´pez San Roma´n, Bele´n; Dura´n A Daniela; Mahillo Ferna´ndez, Ignacio
CORE 3
Center: Fundacio´n Jime´nez Dı´az, Madrid, Spain
CORE 6a
Aim and Introduction: The incidence of fixed sagittal plane deformity (FSPD) increases with age. Various types of corrective osteotomies have been developed to treat this condition. This is demanding surgery with a high rate of complications; hence, it is rarely indicated in the elderly population. The aim of this study is to evaluate the clinical and radiologic results, and complications of this procedure in patients older than 70 years. Materials and Methods: This is a retrospective study including 24 patients older than 70 years consecutively treated for FSPD by corrective osteotomy, and with more than 1 year of follow-up (mean 28.7 months). We analyzed the following: scores on the visual analogue scale (VAS), Oswestry Disability Index (ODI), and Core Outcome Measure Index (COMI), clinical complications, and radiologic results, including the pelvic incidence, lumbar lordosis, pelvic tilt, and sagittal axis. Functional results were analyzed based on the mean increase and the percentage of patients reaching the threshold of a clinically significant difference. Results: Mean age was 74.3 years (70–81). A significant improvement was seen in all the functional parameters and quality of life at 6 months, and in yearly follow-up visits. Mean ODI improvement at 1 year was 40.86 points. There was a significant improvement in the lumbar and radicular VAS (p \ 0.001). Among the total, 74 % of patients were satisfied or very satisfied with the procedure; 95 % of patients used opioid drugs before surgery, and only 12 % at the end. There were 10 major preoperative complications (41.6 %), the most common being deep infection (29 %). One death occurred, due to a respiratory complication. During follow-up, 33 % required a second surgery.
CORE 6b
Variable Lumbar VAS
Situation N Mean SD
Median P25
P75
Pre
23 8.09
2.71
9.00
7.50
10.00
6 months 21 4.52 1 year 23 3.00
3.08 1.68
4.00 3.00
2.00 2.00
6.00 4.50
23 5.83
3.13
6.00
3.50
8.00
6 months 21 3.24
2.51
2.00
2.00
4.00
1 year
23 2.96
2.55
2.00
1.00
5.00
Pre
23 69.85 11.72 73.33
64.44 81.11
6 months 21 39.15 17.35 36.00
26.00 55.56
1 year
23 28.99 13.79 26.00
23.11 36.00
Pre
23 3.91
0.29
4.00
4.00
4.00
6 months 20 1.95
1.15
2.00
1.00
3.00
1 year
23 1.57
1.08
1.00
1.00
2.50
Pre
23 0.09
0.42
0.00
0.00
0.00
6 months 20 1.35
1.09
1.50
0.00
2.00
1 year
21 1.86
1.31
2.00
1.00
3.00
Pre
22 0.82
1.22
0.00
0.00
1.00
6 months 20 3.00
1.30
3.00
3.00
4.00
1 year Pre
23 3.13 22 0.59
1.06 1.05
3.00 0.00
3.00 0.00
4.00 1.00
6 months 20 3.00
0.92
3.00
3.00
4.00
1 year
0.83
3.00
2.50
4.00
Comparison N Median P25
CORE 2
CORE 3
P75
p
Pre-6 m
20 -42.22 -68.75 -25.00 0.0019
Pre-1y
22 -61.25 -80.00 -50.00 0.0001
6 m-1y
19 -16.67 -53.57 0.00
Radicular VAS Pre-6 m Pre-1y ODI
23 3.17
0.0633
20 -63.33 -78.33 -18.12 0.0275 22 -56.25 -82.50 -5.56 0.0011
6 m-1y
19 -20.00 -55.00 0.00
Pre-6 m
21 -47.09 -61.08 -24.32 0.0000
0.0432
Pre-1y
23 -61.08 -70.57 -45.45 0.0000
6 m-1y
21 -13.33 -33.33 0.00
Pre-6 m
20 -50.00 -75.00 -25.00 0.0002
Pre-1y
23 -75.00 -75.00 -29.17 0.0000
6 m-1y
18 0.00
Pre-6 m
1
-50.00 -50.00 -50.00
Pre-1y
1
-50.00 -50.00 -50.00
6 m-1y
13 0.00
0.0799
-50.00 0.00
0.00
0.00
0.4112
0.7835
123
286
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85
continued
IS ADULT VERTEBRAL DEFORMITY ADEQUATELY DEFINED USING THE SRSSCHWAB CLASSIFICATION? Principal Author: Domingo Sa`bat, Montse Center: Hospital Universitari Vall d’Hebro´n, Barcelona, Spain Additional Authors: Pellise´ Urquiza, Ferra´n1; Acaroglu, Emre2; Sa´nchez Pe´rez-Grueso, Francisco J.3; Alanay, Ahmet4; Garcı´a de Frutos, Ana1; Vila Casademunt, Alba1; Bago´ Granell, Joan1; European Spine Study Group ESSG1
Idiopathic
Degenerative
p
Sagittal modifier 0 (%)
86–88
11–13
\0.0001
Sagittal modifier? (%)
38–53
47–61
Sagittal modifier?? (%)
22–34
65–77
Age (years)
36.2
65.4
\0.0001
SF-36 PCS curve L
41.2
33.4
\0.001
SF-36 PCS curve N
45.4
34.2
\0.0001
Oswestry curve L
25.2
49.5
\0.0001
Oswestry curve N
18.3
51.8
\0.0001
SRS-22 Subtotal curve L
3.3
2.6
0.0002
SRS-22 Subtotal curve N
3.6
2.9
\0.0001
Centers: 1Hospital Universitari Vall d’Hebro´n, Barcelona, Spain; 2 Ankara Spine Center, Istanbul, Turkey; 3Hospital Universitario La Paz, Madrid, Spain; 4Acibadem Maslak Hospital, Istanbul, Turkey Introduction: The only available published data on the SRS-Schwab adult spinal deformity (ASD) classification is related to the reliability of the instrument. The aims of this study are to determine the incidence of the different types of curves and to evaluate the homogeneity of the patients included in each subgroup. Patients and Methods: The radiologic data (coronal and sagittal) and quality of life data (QOL) (ODI, SRS-22, SF-36) were analyzed in all patients with degenerative or idiopathic deformity, consecutively recruited in a prospective multicenter database. Inclusion criteria: age [18 years and coronal Cobb [208, vertical sagittal axis [5 cm, pelvic inclination [258 or thoracic kyphosis [608. Patients were classified according to the SRS-Schwab criteria. Distribution of patients was compared according to age and diagnosis. Patients’ QOL was compared according to the curve type and sagittal modifier, taking into account the diagnosis of the deformity. Non-parametric tests (Mann–Whitney, Kruskal–Wallis) and the Dunn test were used for the comparisons, (significance p \ 0.05). Results: We evaluated 368 patients (83.9 % women), with a mean age of 44.1 years (18–88), 73.1 % idiopathic and 26.9 % degenerative. The overall incidence of each type of curve was as follows: T 14.3 %, L 16.3 %, D 40.4 %, and N 28.9 %. Among patients included in type N, 56.6 % presented a minor coronal deformity (208–308) and 43.4 % only a sagittal deformity. The distribution of the type of coronal curve and sagittal modifiers differed between patients with idiopathic or degenerative disease (Table). Overall, clinically and statistically significant differences in QOL were found between type T or D curves and type L: SF-36-PCS adjusted by age and sex (p \ 0.01), ODI (p \ 0.001), and SRS-subtotal (p \ 0.01). Patients with type L curves had poorer QOL. The differences in QOL disappeared when the different types of curves were compared in patients with the same diagnosis. In type L and N curves, patients with a diagnosis of degenerative disease had poorer QOL scores than those with an idiopathic diagnosis (Table). Conclusions: In the SRS-Schwab classification, curve types D and N predominated. The classification is insufficient to adequately define ASD. The parameter diagnosis seems essential to identify the more homogeneous patient groups. Idiopathic
Degenerative
p
Curve type T (%)
92
8
\0.0001
Curve type L (%)
42.1
57.8
Curve type D (%)
95.7
4.3
Curve type N (%)
54.4
45.5
123
ELECTRONIC POSTER 1 LONG-TERM OUTCOME OF POSTEROLATERAL VERSUS CIRCUMFERENTIAL FUSION IN CHRONIC LOW BACK PAIN. PROSPECTIVE STUDY Principal Author: Ortega Garcı´a, Paula Center: Hospital Universitario Marque´s de Valdecilla, Santander, Spain Additional Authors: Pe´rez Nu´n˜ez, Marı´a Isabel; Laguna Bercero, Esther; Moro Pascual, Laura; Rodrı´guez Lo´pez, Tamara Center: Hospital Universitario Marque´s de Valdecilla, Santander, Spain Introduction and Aim: Lumbar fusion is indicated in patients with degenerative lumbar disease, spondylolisthesis, or degenerative disc disease that does not respond to conservative treatment. The aim of this study, performed in a hospital Rehabilitation Department, is to investigate functional disability and pain in patients who have undergone instrumented lumbar fusion by the same surgical team, after at least 4 years’ follow-up. Materials and Methods: Prospective study. We reviewed 66 patients treated with instrumented lumbar fusion between March 2006 and December 2008, 35 posterolateral and 31 circumferential. Before the intervention, a questionnaire was conducted, which included a visual analog scale for lumbar and radicular pain and the Oswestry Disability Index, version 2.0; these questionnaires were repeated for the present study. Statistical analyses used SPSS 19.0, the Wilcoxon test for nonparametric variables, and the Student t test for parametric variables. The sample included 20 men and 46 women, with a mean age of 56 years. Mean follow-up was 4 years. Results: A statistically significant improvement in both groups was seen in the disability and pain parameters: 69.2 % of patients reached the minimal clinically important difference (MCID) for the Oswestry score, 67.6 % reached the MCID for VAS lumbar pain, and 56.7 % for VAS radicular pain. There were no statistically significant
Eur Spine J (2014) 23:248–288 differences between the groups according to the type of fusion, number of fused levels, or fixation to the sacrum or not. Three patients developed complications: screw loosening in one patient in the posterolateral fusion group and two cases of severe radiculopathy with a need for prompt reoperation in the group with circumferential fusion. Conclusions: At long term, patients with chronic low back pain treated with circumferential fusion did not have a better outcome regarding functional disability and lumbar and radicular pain than patients undergoing posterolateral fusion.
287 and 20 %, with considerable differences relative to the control group receiving PMMA alone.
3 IMPACT OF SPINOPELVIC PARAMETERS ON QUALITY OF LIFE AND LUMBAR FUNCTION IN WORKING-AGE PATIENTS CONSULTING FOR PAIN
2 Principal Author: Vila` Canet, Gemma
OSTEOBLAST VIABILITY AND ADHESIVENESS ON BONE CEMENT MIXED WITH HYDROXYAPATITE AT VARIOUS CONCENTRATIONS USED IN VERTEBRAL AUGMENTATION TECHNIQUES Principal Author: Pino Minguez, Jesu´s Center: Complejo Hospitalario Universitario Santiago de Compostela, Spain Additional Authors: Couceiro Otero, Ramiro1; Dı´ez Ulloa, Ma´ximo Alberto2; Otero Ferna´ndez, Marı´a2; Garcı´a Santiago, Carlota3; Freire Garabal, Manuel3 Centers: 1Cell and Developmental Biology, School of Medicine, UNC Chapel Hill, North Carolina, USA; 2Complejo Hospitalario Universitario Santiago de Compostela, Spain; 3Departamento de Farmacologı´a, Facultad de Medicina, Santiago de Compostela, Spain Introduction: The PMMA used in vertebral surgery differs from conventional cements in viscosity, a lower exothermic capacity, and the fact that it is radio-opaque, but the osteointegration capacity of PMMA does not seem better than that of conventional material. The aim of the present study is to assess the osteogenic capacity of PMMA mixed with hydroxyapatite (HA) at different concentrations. Materials and Methods: HA at various concentrations (5 %, 10 %, 15 %, and 20 %) was mixed with PMMA (A Kyphon HV-R). HA powder was examined with a particle analyzer and mixed with the monomer; it was then scanned with electron microscopy (SEM, Hitachi S-2400). Mapping of the chemical composition of the mixture was carried out using energy dispersive X-ray. MG63 human osteoblasts were seeded at a density of 6 9 105 cell/ mL on discs with PMMA and HA at the concentrations indicated. Cell proliferation was determined using MTT (Sigma). Specific markers of osteoblast proliferation, osteocalcin and alkaline phosphatase (MedSystems Bender), were investigated. Cell death was determined by caspase-3 levels. Results: Osteoblast proliferation increased in parallel with the HA concentration in PMMA. Maximum growth peaks were obtained at concentrations of 15 % and 20 %, with values of 0.86 ± 0.026 and 0.90 ± 0.008. As to caspase-3, there was a progressive decrease as HA concentration increased, showing an optimum apoptotic index at 20 % HA. Cell adhesiveness was optimum at 15 %. Alkaline phosphatase activity and osteocalcin also increased in parallel with HA concentration. Maximum bone growth peaks were obtained at HA concentrations of around 15 % and 20 %, with values of 0.801 ± 0.064 and 0.793 ± 0.005. There seemed to be a clear turning point in proliferation at concentrations between 10 % and 15 %. Conclusions: The optimal HA concentration in PMMA in terms of cell adhesiveness, viability, and proliferation is approximately 15 %
Center: Institut Universitari Dexeus, Barcelona, Spain Additional Authors: Ubierna Garce´s, Ma Teresa; Garcı´a de Frutos, Ana; Salo´ Bru; Guillem; Arias Baile, Ainhoa; Ca´ceres Palou, Enric Center: Institut Universitari Dexeus, Barcelona, Spain Aim and Introduction: Over the last years, there has been a growing interest in determining the link between spinopelvic parameters and the patient’s quality of life and lumbar spine function. The aim of this study was to evaluate the relationship of quality of life and lumbar function with sagittal balance and spinopelvic parameters in workingage patients consulting for low back pain or radicular pain. Material and Method: Prospective observational study including 191 consecutive patients consulting for the first time in our center for symptoms of lumbar or radicular pain of at least 2 months’ duration. We determined epidemiologic data (age, sex, work activity, sports activity) and pain location. All patients underwent complete measurements in lateral spinal radiographs and MRI of the lumbar spine. The SF-12 questionnaire and Roland Morris Disability Questionnaire (RMDQ) were administered. In the radiologic studies, the following were determined: lumbar lordosis, sagittal balance (positive, negative, neutral), sacral slope, pelvic incidence, and Roussouly type. Results: The study included 191 patients (85 men, 106 women), mean age 45 (18–66) years; 66 % had lumbar pain and 44 % radicular pain. Mean score was 36 on the SF-12 physical component and 43 on the mental component, and mean RMDQ value was 6.4. Pelvic incidence, lumbar lordosis, Roussouly morphotype, and sagittal profile showed no statistically significant relationships with quality of life. There was a non-significant trend to poorer RMDQ results in Roussouly type IV patients. Quality of life showed a significant relationship with the RMDQ score, but not with the severity of MR findings. Conclusions: In the patients studied, quality of life was particularly affected in the physical aspect (SF-12), although it was not significantly related to any of the spinopelvic parameters or MR findings. It seems that patients classified as Roussouly morphotype IV have poorer lumbar function according to the RMDQ.
4 HEMIVERTEBRA RESECTION BY POSTERIOR APPROACH AND INSTRUMENTATION WITH PEDICLE SCREWS AND SUBLAMINAR HOOKS (THREE-ROD APPROACH). A STUDY OF 9 CASES Principal Author: Ventura Go´mez, Norberto Center: Hospital Sant Joan de De´u, U.B, Barcelona, Spain
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Additional Authors: Ey Batlle, Ana
Center: Hospital de Nin˜os Pedro Elizalde, Buenos Aires, Argentina
Center: Hospital Sant Joan de De´u, U.B, Barcelona, Spain
´ scar1; Majluf, Rodolfo2 Additional Authors: Reynier, Mariano O
Introduction: Hemivertebra resection by a posterior only approach and pedicle screw instrumentation in young children has been associated with a high number of complications due to implant failure. Objective: To demonstrate the efficacy of pedicle screws combined with sublaminar hooks (three-rod technique) in treatment by hemivertebra resection. Material and Method: Retrospective clinical-radiological study of 9 patients who underwent surgery in our hospital between July 2007 and January 2012, consisting in posterior hemivertebra resection and instrumentation with pedicle screws and sublaminar hooks. Results: Time of review 2.5 years (5–1), 5 boys, age 34 months (26–48), weight 14 kg (12–18), operative time 3.4 h (3–4), 7 received a perioperative transfusion, 7 left hemivertebrae, 2 right, 4 lumbar hemivertebrae, 4 thoracolumbar, 3 thoracic (2 patients with 2 hemivertebrae), 3 patients with mixed thoracic malformations, all with rib abnormalities. Preoperative Cobb values: 508 (36/67), dorsal kyphosis 368 (25/52), lumbar lordosis 398 (30/46). Postoperative Cobb values: 198 (7/35), postoperative kyphosis 298 (25/34), postoperative lordosis 338 (16/54). One patient had asymptomatic syringomyelia. Resection levels: T10–T11 (1), T11–T12 (2), T12–L1 (4), L1–L2 (1), L2–L3 (1), L3–L4 (2); in 2 patients two hemivertebrae were resected in the same surgical act. All patients wore a brace for 6 months. Complications: one case of prominent instrumentation. Conclusions: The lamina is mechanically more resistant than the pedicle (neurocentral cartilage) in young children. For this reason, the space remaining after hemivertebra resection can be closed, decreasing the stress on the pedicle screws.
Centers: 1Hospital de Nin˜os Pedro Elizalde, Buenos Aires, Argentina; 2 Hospital de Nin˜os R. Gutie´rrez, Buenos Aires, Argentina
5 LIMITED AXILLARY THORACOTOMY FOR TREATING HIGH (T1–T4) THORACIC HEMIVERTEBRAE RESECTION Principal Author: Orellano, Armando
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Introduction: Various approaches have been developed (anterior– posterior or combined), for treating hemivertebrae; the superior thoracic sector (T1–T4) is difficult to access using a posterolateral thoracotomy. Bianchi et al. in 1998 and Kalman in 2002 used a limited axillary thoracotomy for superior thoracic lesions. The objective of this study is to evaluate the usefulness of this approach in high thoracic hemivertebra resection. Materials and Methods: We retrospectively evaluated 2 patients with a diagnosis of congenital scoliosis, operated on in our hospital by hemivertebra resection. The procedure was carried out by limited axillary thoracotomy associated with posterior instrumentation to correct and stabilize the curve. Postoperative curve correction and wound cosmesis were assessed. Results: Clinical Case 1: 10-year-old girl with a diagnosis of congenital hemivertebra/scoliosis, at T2, preoperative Cobb angle T1–T3 35, Risser 2, menarche negative. Following limited axillary thoracotomy in the axillary fold, costal resection, and T2 hemivertebra resection, we carried out bilateral posterior T1–T3 instrumentation plus laminectomy of the hemivertebra. Postoperative Cobb angle 15. Clinical Case 2: Twelve-year-old girl with a diagnosis of congenital hemivertebra/scoliosis at T3. Preoperative Cobb T2-T4 52, Risser 4, menarche 0 ? 6. Limited axillary thoracotomy in the axillary fold, costal resection, and T3 hemivertebra resection were carried out and subsequently, bilateral posterior T1-T5 instrumentation plus hemivertebra laminectomy. Postoperative Cobb 10. Conclusion: In children, incision in the axillary fold provides good visibility of the high thoracic spine, even up to T1, and enables complete vertebral resection, which is often difficult through a posterior only approach. Several authors have described this approach for the treatment of esophageal atresia, and pulmonary and mediastinal lesions. We believe it should be considered as an option in the treatment of high thoracic spine conditions, since it provides good visibility and is cosmetically invisible in the axillary fold.
