Treatment of congenital kyphosis with severe angular dysplastic spine in children with myelomeningocele (MMC) is one of the most difficult spinal procedures. Most of the surgeons support kyphectomy with long segmental spinal instrumentation and postoperative immobilization by thoracolumbosacral orthosis. Several spinal deformities are seen frequently in patients who have MMC. The deformity may be congenital or paralytic. Congenital lumbar kyphosis is less common, but most difficult in patients with MMC, occurring in 10–20% of patients. Most curves are congenital and rigid, often more than 80° at birth, and rapidly progresses. With progression of kyphotic deformity, patients experience recurrent skin breakdown over the apex of the kyphos; impaired sitting balance; the necessity of using their hands for support; collapsing spine and decreasing of lumbar height reduce the capacity of the abdominal cavity and resulting in reduced respiratory capacity and malnutrition. The poor posture and short abdomen make it difficult to manage the patients’ urological needs. A severe deformity raises difficulties in social and psychological development. Non-operative treatment with spinal orthoses may provide only temporary correction of a kyphotic deformity, but does not prevent progression and skin breakdown. The goal of surgical treatment is correction of spinal deformity by long segmental instrumentation and achievement of a solid spine fusion in order to allow a balanced sitting position and to prevent complications. From 1983 to 2001, 6 patients with thoracic level myelomeningocele and severe kyphotic deformity were referred for surgical correction. There were 5 males and 1 female patients with average age at the time of surgery of 8.3 years (range 4.3–13 years). All patients suffered from severe kyphosis, range 90° to 130°, average – 108°. All of them underwent posterior ligation of spinal cord during resection of lordotic segment of the kyphos, and segmental spinal fixation of the deformity from the thoracic spine to the sacrum. In all cases following the resection of the vertebrae it was possible to correct the deformity. All patients were available for follow-up with range of 6–216 months, average 85 months. All of them were satisfied with the surgical outcome and presented in their final clinical examination with balanced and comfortable sitting, without soft tissue complications. In all cases a significant correction of the deformity was achieved (15°–30°) and enabled comfortable and stable sitting. Two patients suffered post-operative complications, one from surgical wound infection which required surgical debridement followed by soft tissue covering, and the other suffered from distal migration of the rod which was shortened later on. Discussion: Kyphotic deformity in a patient who has MMC is a challenge for the orthopaedic surgeon and requires major surgical intervention. Resection of the kyphos with posterior instrumentation and fusion may solve patient’s functional problems

Introduction: Minimally invasive augmentation techniques of vertebral bodies have been widely used in the treatment of painful osteoporotic vertebral compression fractures (VBCFs). Kyphoplasty seems to achieve pain relief and improvement in quality of life. However, the effect of kyphoplasty on the height and the kyphotic deformity of the vertebrae is now yet clear. The present study reports our experience in kyphoplasty procedures for osteoporotic VBCF’s. Materials and Methods: A total of 105 VBCF (45 thoracic and 60 lumbar vertebrae) in 56 patients (16 male, 40 female; mean age: 69 years, range 32–87 years) were treated with kyphoplasty between 2002–2005. All patients were preoperatively evaluated with radiographs, MRI and bone scintigraphy, and postoperatively immediately following the procedure and 6 months later with radiographs. Eight patients were treated within a week from their injury (new fractures). All patients completed the Oswestry Disability Index Questionnaire pre- and immediately post-operatively and at 6 months. The height of the treated vertebrae and the kyphotic deformity were measured before, after the kyphoplasty and at 6 months. All procedures were performed under general anaesthesia and fluoroscopy guidance. Results: 54 patients were included in the study; 2 patients expired from causes unrelated to the procedure. All patients experienced pain relief following the procedure and the average Oswestry Disability Index score decreased from 76% preoperatively to 12.4% postoperatively (P< 0.001) and to 18.5% (P< 0.001) at 6 months. The observed mean height restoration at 6 months was 3mm (range 0–15mm) (P=NS) and the kyphotic deformity correction was 3.70 (0–120) (P=NS). In the new fractures the height restoration was 7.1mm and the kyphotic correction 7.80 (P=0.01). There were no cases of pulmonary embolism nor were any significant cement leakages noted. Conclusion: The treatment of painful osteoporotic VBCFs with kyphoplasty is safe and reduces pain and disability. However, it does not lead to restoration of the vertebral height nor to correction of the kyphotic deformity, except in new fractures

To evaluate our results of treatment of kyphosis following osteoporotic fractures of the last 3 years. 28 women with a mean age of 63,2 years were treated for a painful kyphotic deformity of a mean Cobb angle 76,1°. They all had posterior fusion with pedicular screws and rods enhanced with autologous bone graft as well as allografts. Cement augmentation was used in a number of screws. A cell saver for auto transfusion and continuous neurophysiological monitoring was used intraoperatively in all cases. All patients fitted with a thoracolumbar brace for 3 months. The postoperative mean Cobb angle was 45,2° (40,6% improvement). Pain questionnaires at a mean postoperative follow up of 16 months showed excellent results in 10 patients (35,71%), good in 8 patients (28,57%), satisfactory in 6 patients (21,42%) and poor results in 4 patients (14,28%). All patients were satisfied with the cosmetic result. 2 patients presented a postoperative infection that was treated with debridement and antibiotics. Kyphotic deformity following osteoporotic fractures may treated satisfactory with rods and pedicular screws with cement augmentation

Twenty-one patients with rigid kyphosis treated by single stage vertebral column resection were evaluated retrospectively. The average age was 12 years and kyphosis was 75 degrees. Thirteen cases were due to tuberculosis while 8 had a congenital anomaly, 5 cases had neurologic deficit. Radiographs, CT and MRI scans were used for preoperative evaluation. The survey included transpedicular vertebral decancellisation, spinal column shortening, interbody fusion and segmental spinal instrumentation. At 36 months [36–60] follow up, the average correction was 61% and all cases adequately fused. Complications included one case with postoperative neurological deterioration and one patient with decompensated lordosis.

Aims

A variety of surgical methods and strategies have been demonstrated for Andersson lesion (AL) therapy. In 2011, we proposed and identified the feasibility of stabilizing the spine without curettaging the vertebral or discovertebral lesion to cure non-kyphotic AL. Additionally, due to the excellent reunion ability of ankylosing spondylitis, we further came up with minimally invasive spinal surgery (MIS) to avoid the need for both bone graft and lesion curettage in AL surgery. However, there is a paucity of research into the comparison between open spinal fusion (OSF) and early MIS in the treatment of AL. The purpose of this study was to investigate and compare the clinical outcomes and radiological evaluation of our early MIS approach and OSF for AL.

We report five children who presented at the mean age of 1.5 years (1.1 to 1.9) with a progressive thoracolumbar kyphosis associated with segmental instability and subluxation of the spine at the level above an anteriorly-wedged hypoplastic vertebra at L1 or L2. The spinal deformity appeared to be developmental and not congenital in origin. The anterior wedging of the vertebra may have been secondary to localised segmental instability and subsequent kyphotic deformity. We suggest the term ‘infantile developmental thoracolumbar kyphosis with segmental subluxation of the spine’ to differentiate this type of deformity from congenital displacement of the spine in which the congenital vertebral anomaly does not resolve. Infantile developmental kyphosis with segmental subluxation of the spine, if progressive, may carry the risk of neurological compromise. In all of our patients the kyphotic deformity progressed over a period of three months and all were treated by localised posterior spinal fusion. At a mean follow-up of 6.6 years (5.0 to 9.0), gradual correction of the kyphosis was seen on serial radiographs as well as reconstitution of the hypoplastic wedged vertebra to normality. Exploration of the arthrodesis was necessary at nine months in one patient who developed a pseudarthrosis

Introduction: Since 1989 vertebral resection with modified Luque fixation has been the procedure of choice for correction of myelomeningocele kyphotic deformity at this institution. The purpose of this study was to evaluate long-term results with this technique. Treatment or congenital kyphosis in myelomeningocele is a difficult problem. Current thinking supports kyphectomy and post-operative internal fixation. The majority of authors agree that kyphotic deformity in myelomeningocele should be treated with vertebral resection. There is less uniform consensus as to postoperative fixation. Literature reports appear to support fixation with modified segmental instrumentation. Methods and Results: 16 patients, followed for an average of 57.2 months (36–94 months), underwent vertebral resection from the proximal aspect of the apical vertebra cephalad into the compensatory lordotic curve. Fixation was segmental instrumentation wired to the thoracic spine and anterior to the sacrum. The average blood loss was 1121 cc (450–2580 cc.). Pre-operative kyphotic deformity averaged 111° (75–157°), postoperative 15° (−18° –36°) and latest follow-up of 20° (−17° –83°), with loss of correction of 6° (0–27°). Post-operative immobilisation was with a TLSO for 18 months. Complications occurred in eight of the 16 patients: (1) transient headache (2), superficial wound breakdown (2), supracondylar femur fractures (2), and one late infection secondary to skin breakdown necessitating early rod removal and some loss of correction. Conclusions: Kyphectomy is an excellent method of correcting rigid kyphotic deformity in the myelodys-plastic patient. Segmental spinal instrumentation provides three distinct advantages: rigidity of the construct, greater correction of the deformity and low-profile instrumentation

A combined anterior and posterior surgical approach is generally recommended in the treatment of severe congenital kyphosis, despite the fact that the anterior vascular supply of the spine and viscera are at risk during exposure. The aim of this study was to determine whether the surgical treatment of severe congenital thoracolumbar kyphosis through a single posterior approach is feasible, safe and effective. We reviewed the records of ten patients with a mean age of 11.1 years (5.4 to 14.1) who underwent surgery either by pedicle subtraction osteotomy or by vertebral column resection with instrumented fusion through a single posterior approach. The mean kyphotic deformity improved from 59.9° (45° to 110°) pre-operatively to 17.5° (3° to 40°) at a mean follow-up of 47.0 months (29 to 85). Spinal cord monitoring was used in all patients and there were no complications during surgery. These promising results indicate the possible advantages of the described technique over the established procedures. We believe that surgery should be performed in case of documented progression and before structural secondary curves develop. Our current strategy after documented progression is to recommend surgery at the age of five years and when 90% of the diameter of the spinal canal has already developed. Cite this article: Bone Joint J 2013;95-B:1527–32

Aim: Presentation of the technique, the mistakes and the results of a new minimal invasive surgical procedure for reduction and augmentation of pathological fractures of the vertebrae in spine. Patients and Methods: 12 patients (2 men / 10 women) with mean age 68 years (54–73) with pathological vertebral underwent kyphoplasty. The mean pain according to VAS was 7, 3 (6–10) and the mean follow up time is 8 months (5–14). 11/12 patients (20 vertebrae) had osteoporotic vertebral and 1/12 (1 vertebra) had metastatic lesion. 8/21 vertebrae were in thoracic spine and 13/21 in lumbar spine. In 20/21 the procedure was transcervical to the vertebra and in 1/21 was out of the cervix. 11/12 patients had kyphotic deformity in the plain x-ray and 18/21 vertebrae had decreased their height. To all patients was spilled PMMA. Results: 10/12 patients referred degrease of their pain in the first 48 hours and 2/12 in the 5th postoperative day. Correction of the kyphotic deformity was observed in 11/12 and reduction of the reduction of the fracture was occurred in 16/21 vertebrae. Leakage of PMMA was occurred in 5/21 vertebrae; in 2/5 the leakage was in the canal, in 1/5 in the intervertebral space and in 2/5 out of the vertebrae. 1/12 patient 2 moths postperatively had another vertebral fracture in a lower vertebra that was deled again with kyphoplasty. None of the patients had neurological deficit postoperatively. According to Oswestry questionnaire all the patients referred return to all their before fracture daily activities. Conclusions: Kyphoplasty in pathological vertebral fractures has as a result the immediate decrease of the pain and the return of the patient to his/her daily activities. Also there is correction of the kyphotic deformity decreases the possibility of a new vertebral fracture and the establishment of chronic back pain

Background: A 9- year-old child with osteogenesis imperfecta and severe cervical kyphosis associated with wedged vertebrae and progressive neurological deterioration is presented. There is no report of upper cervical kyphosis associated with wedged vertebrae in osteogenesis imperfecta in the literature. We discuss the methods and difficulties in the surgical management of this condition and to highlight the appropriate surgical approach. Methods: Methods:A 9-year-old girl presented with progressive cervical kyphosis and quadriparesis. At the age of 3 years she underwent posterior cervical fusion (C1–C6) for instability and deformity. Radiological and laboratory investigations confirmed the diagnosis of osteogenesis imperfecta. Radiographs of the cervical spine revealed a kyphotic deformity of 120° Magnetic Resonance Imaging (MRI) and Computerised Tomography (CT) scans showed anterior cord compression due to wedged vertebrae at C3 and C4. MRI-Angiography was performed pre-operatively to identify the anatomical position of the vertebral arteries. A modified anterolateral approach to the upper cervical spine was performed. Anterior C3 and C4 corpectomies with interbody fusion with cage and plate fixation was carried out. Results: Postoperatively the patient made a full neurological recovery and significant correction of the deformity was achieved and correction was maintained at final follow-up. Conclusion: Cervical kyphotic deformity in Osteogenesis Imperfecta is uncommon. Association of this condition with wedged vertebrae is rare. Surgical decompression of the upper cervical spine with severe kyphosis is a challenging problem. Which surgical approach should be used is controversial? There are difficulties exposing wedged vertebrae by a standard anterior or chin split approach to perform vertebrectomy. Costo-transversectomy has been used successfully in patients with Gibbous deformity in the thoracic spine but due the presence of vertebral artery in the cervical spine posterolateral approach is impossible. We have used a modified anterolateral approach to overcome this problem. Spinal stabilisation in children with Osteogenesis Imperfecta and poor bone quality is another challenge. We have used a small diameter MOSS cage with maxillofacial plate and screws to achieve stabilisation and fusion. The purpose of this report is to highlight the importance of diagnosis of progressive cervical kyphotic deformity in children with osteogenesis imperfecta and also to describe the difficulties encountered with surgical management of this condition

Introduction: To evaluate a three-stage procedure for the correction of symptomatic post-traumatic kyphotic deformity of the thoracic or lumbar spine. Methods: Over an 18-month period, five consecutive cases of post-traumatic kyphosis of the thoracic/lumbar spine were analysed. Indications for surgical correction were incapacitating back pain, progression of kyphotic deformity, persistent neurologic deficit and development of late spinal stenosis. All patients underwent a three-staged procedure using two surgeons. At first they were positioned prone for a posterior midline approach, with pedicle screw placement (USS), decompressive laminectomies and facetectomies. For the second stage, the patients were positioned either on left side (for upper thoracic spine) or on the right side (for the thora-columbar junction and lumbar spine). An open, minimal invasive access procedure using the SynFrame retractor was performed. The anterior column was reconstructed using expandable cages (Synex cages) with autologous bone for interbody fusion. Finally, the patient was again positioned prone for posterior compression, instrumentation and fusion. Results: The five patients comprised four males and one female. Age range was 26–51 years. Level of injury was T7–L3. Time since injury was two to10 years. Mean operating time was eight hours. One patient required a thoracic pedicle screw revision and another a posterior deep wound infection requiring wound debridement and lavage. Follow-up period was three to 15 months. All patients reported improvement in pain post-operatively. Lower rates of pain improvement correlated with longer standing symptomatic injuries. No worsening of neurological deficit occurred. Conclusion: Early correction of symptomatic kyphosis is recommended and aims to improve pain, deformity and function. Recognition of the correct type of injuries is essential to avoid late deformity. Correction of symptomatic post-traumatic kyphotic deformity is achieved by this three-staged approach. Minimal invasive anterior reconstruction using SynFrame and expandable Synex cages is safe and effective. Two surgeons working in conjunction is advantageous

Introduction. Pedicle subtraction osteotomy is a powerful technique for correcting sagittal imbalance in ankylosing spondylitis. There has been significant perioperative morbidity associated with this technique in the peer review literature. We present the Royal National Orthopaedic Hospital experience with a single surgeon retrospective study that was conducted to evaluate the outcomes in patients who underwent lumbar pedicle subtraction osteotomy for the correction of thoracolumbar kyphotic deformity in ankylosing spondylitis. Method. Twenty seven patients underwent a lumbar pedicle subtraction osteotomy and adjacent level posterior instrumentation between 1995 and 2010. There were 18 males and 9 females in the study. Events during the peri-operative course and post-operative complications were recorded. The radiological outcome and patient satisfaction were analysed with mean follow-up of one and a half years. Results. The mean operative time was three and half hours and the mean blood loss was 2290mls. Final follow-up radiograph showed an increase in lumbar lordosis angle from 17 degrees to 45 degrees. The sagittal imbalance improved by 85mm with the operation. Complications included loosening in two patients, one transient neurologic deficit and one infective non-union occurred overall. There were no mortalities from the surgery. Two patients developed junctional kyphosis and required a repeat operation. There was an improvement in the Oswestry Disability Score from a mean of 29 to 16 after the surgey. All (100%) of the patients were satisfied with the results of the procedure and would recommend the surgey to others. Conclusion. The study shows that pedicle subtraction extension osteotomy is effective for the correction of kyphotic deformity in ankylosing spondylitis

We reviewed 75 patients (57 men and 18 women), who had undergone tension-band laminoplasty for cervical spondylotic myelopathy (42 patients) or compression myelopathy due to ossification of the posterior longitudinal ligament (33 patients) and had been followed for more than ten years. Clinical and functional results were estimated using the Japanese Orthopaedic Association score. The rate of recovery and the level of postoperative axial neck pain were also recorded. The pre- and post-operative alignment of the cervical spine (Ishihara curve index indicating lordosis of the cervical spine) and the range of movement (ROM) of the cervical spine were also measured. The mean rate of recovery of the Japanese Orthopaedic Association score at final follow-up was 52.1% (. sd. 24.6) and significant axial pain was reported by 19 patients (25.3%). Axial pain was reported more frequently in patients with ossification of the posterior longitudinal ligament than in those with cervical spondylotic myelopathy (p = 0.027). A kyphotic deformity was not seen post-operatively in any patient. The mean ROM decreased post-operatively from 32.8° (. sd. 12.3) to 16.2° (. sd. 12.3) (p < 0.001). The mean ROM ratio was 46.9% (. sd. 28.1) for all the patients. The mean ROM ratio was lower in patients with ossification of the posterior longitudinal ligament than in those with cervical spondylotic myelopathy (p < 0.001). Compared to those with cervical spondylotic myelopathy, patients with ossification of the posterior longitudinal ligament had less ROM and more post-operative axial neck pain

Introduction. Vertebral osteoporotic fracture increases both elastic and time-dependent (‘creep’) deformations of the fractured vertebral body during subsequent loading. This is especially marked in central and anterior regions of the vertebral body, and could explain the development of kyphotic deformity in life. We hypothesise that vertebroplasty can reduce these creep deformations. Methods. Twelve pairs of spine specimens, each comprising three vertebrae and the intervening soft tissue, were obtained from cadavers aged 67-92 yr. They were compressed to failure, after which one of each pair underwent vertebroplasty with polymethylmethacrylate cement, the other with a resin (Cortoss). A 1kN compressive force was applied for 1 hour before fracture, after fracture, and after vertebroplasty, while creep deformation was measured in the anterior, middle, and posterior region of each vertebral body using a MacReflex optical tracking system. Results. Cement type had little influence on creep deformation, so data from all 24 specimens were pooled. After fracture, creep in the anterior vertebral body increased from 4,863 (STD 5060) to 57,674 (STD 57,663) microstrains (P<0.001), and creep in the central vertebral body increased from 738 (STD 5,643) to 37,025 (STD 43,519) microstrain (P<0.001). Vertebroplasty reduced creep deformations by 67% (P=0.002) and 66% (P=0.011) in the anterior and central regions respectively. Conclusion. Vertebroplasty reduces progressive creep deformations of a fractured vertebral body. These findings suggest that vertebroplasty may slow or prevent the development of kyphotic deformity following vertebral osteoporotic fracture

The K2M MESA Rail is a new implant with a unique beam-like design which provides increased rigidity compared with a standard circular rod of equivalent diameter potentially allowing greater control and maintenance of correction. The aim of this study was to review our early experience of this implant. We retrospectively reviewed the case notes and radiographs of all consecutive cases of spinal deformity correction in which at least one rail was used. All radiological measurements were made according to the Scoliosis Research Society definitions. Since June 2012 thirty-three cases of spinal deformity correction were performed using the K2M Rail system. One case was excluded as there were no pre-operative radiographs. Median age was 15 years; there were 23 females. There were 26 scoliosis cases of which two had associated Chiari malformation, three were neuromuscular, and the remainder were adolescent idiopathic cases. Six patients had kyphotic deformity secondary to Scheuermann's disease. Mean length of follow-up was 16 months. In the scoliosis cases the mean pre-operative Cobb angle of the major curve was 58.6° with a mean correction of 35.6°. The mean post-operative thoracic kyphosis was 21.1°. The median number of levels included in the correction was 13. Bilateral rails were used in four cases, the remainder had one rail on the concave side and a contralateral rod. No patients required an anterior release or staged surgery. All kyphosis cases had posterior apical corrective osteotomies. The mean pre-operative thoracic kyphosis was 75.5° with a mean correction of 31°. The median number of levels included in the correction was 11. Four patients had bilateral rails. No patients required anterior release. Complications: two patients had prominent hardware. One patient had a malpositioned screw causing nerve root irritation, which was removed. There were three superficial infections, which settled with antibiotics. There were no cases of implant breakage, screw pull-out, or loss of correction. The K2M MESA Rail is a powerful new implant design which helps to achieve and maintain satisfactory correction of complex spinal deformity, and is particularly strong at correcting kyphotic deformity. It also enables restoration of normal thoracic kyphosis, particularly in idiopathic thoracic curves, which tend to be lordosing. This may prevent thoracic flat back and potential long-term sequelae. Early results show that the system is as safe and effective as other posterior deformity correction implants on the market, however, it requires further prospective follow-up to ascertain its outcomes in the long-term

Introduction. Vertebral osteoporotic fracture increases both elastic and time-dependent ('creep') deformations of the fractured vertebral body during subsequent loading. The accelerated rate of creep deformation is especially marked in central and anterior regions of the vertebral body where bone mineral density is lowest. In life, subsequent loading of damaged vertebrae may cause anterior wedging of the vertebral body which could contribute to the development of kyphotic deformity. The aim of this study was to determine whether gradual creep deformations of damaged vertebrae can be reduced by vertebroplasty. Methods. Fourteen pairs of spine specimens, each comprising three vertebrae and the intervening soft tissue, were obtained from cadavers aged 67-92 yr. Specimens were loaded in combined bending and compression until one of the vertebral bodies was damaged. Damaged vertebrae were then augmented so that one of each pair underwent vertebroplasty with polymethylmethacrylate cement, the other with a resin (Cortoss). A 1kN compressive force was applied for 1 hr before fracture, after fracture, and after vertebroplasty, while creep deformation was measured in anterior, middle and posterior regions of each vertebral body, using a MacReflex optical tracking system. Results. Cement type had little influence on creep deformation, so data from all 28 specimens were pooled. After fracture, creep in the anterior vertebral body increased from 4,513 (STD 4766) to 54,107 (STD 54,845) microstrains (P<0.001), and creep in the central region of the vertebral body increased from 885 (STD 5,169) to 34,378 (STD 40,762) microstrain (P<0.001). (10,000 microstrains = 1% deformation.) Following vertebroplasty, creep deformations were reduced by 61% (P=0.002) and 66% (P=0.006) in anterior and central regions respectively. Conclusion. Creep deformations of the anterior and central regions of vertebral bodies increase markedly as a result of fracture but are then reduced by vertebroplasty. In life, vertebroplasty could help to slow or prevent the gradual development of kyphotic deformity following vertebral osteoporotic fracture, as well as increase vertebral stiffness and strength

This study prospectively compared the efficacy of kyphoplasty using a Jack vertebral dilator and balloon kyphoplasty to treat osteoporotic compression fractures between T10 and L5. Between 2004 and 2009, two groups of 55 patients each underwent vertebral dilator kyphoplasty and balloon kyphoplasty, respectively. Pain, function, the Cobb angle, and the anterior and middle height of the vertebral body were assessed before and after operation. Leakage of bone cement was recorded. The post-operative change in the Cobb angle was significantly greater in the dilator kyphoplasty group than in the balloon kyphoplasty group (−9.51° (. sd. 2.56) vs −7.78° (. sd. 1.19), p < 0.001)). Leakage of cement was less in the dilator kyphoplasty group. No other significant differences were found in the two groups after operation, and both procedures gave equally satisfactory results in terms of all other variables assessed. No serious complications occurred in either group. These findings suggest that vertebral dilator kyphoplasty can facilitate better correction of kyphotic deformity and may ultimately be a safer procedure in reducing leakage of bone cement

Introduction Anterior correction of cervical kyphotic deformity in traumatic and degenerative spine is a well established technique. The application of an anterior cervical plate is widely accepted, particularly in multilevel discectomies. However the placement of the cervical plate flush against the cortical margins of the spine remains challenging particularly when there is an underlying subluxation. Contouring the cervical plate with a plate bender is suggested. Others have described the use of an adjustable depth tap (. 1. ). We describe the technique of utilizing the Trimline™ Vertebral Body Distractor in correction of the sagittal plane deformity and maximizing the contact surface between plate and fusion construct. Methods The technique is described in a case each of cervical trauma and degenerative cervical spondylolisthesis. The Trimline™ distractor which utilizes cannulated legs, threaded pins and nuts is used as a direct reduction tool correcting the cervical lordosis, before discectomy. The distractor pins are placed bilaterally in the vertebral bodies at the level of the deformity, and at the level above and below. The distractors are applied bilaterally and reduction undertaken. The distraction device is locked in place whilst the discectomy is performed. Distraction device is removed once graft is in-situ and cervical plate is applied in routine manner. Results Bilateral application of pins and distraction device provides better reduction strength, and better distributes distraction forces minimizing further fracture. This optimizes correction of cervical kyphotic deformity and prevents obstruction of operative view for discectomy and fusion. Discussion Restoration of the normal cervical lordotic curve in traumatic and degenerative spinal disease remains challenging. Flush application of the anterior cervical plate to the anterior border of the spine and graft enhances spinal fusion, stability and alignment. The use of bilateral vertebral body distractor devices to reduce cervical subluxation and enhance implant-bone interface is a novel technique which is safe and not time consuming

Aims: To study the efþcacy of Texas Scottish Rite Hospital transpedicular screws versus laminar hooks in lumbar spine. Methods: 40 patients with unstable thoracolumbar fractures and spinal canal encroachment were randomly sampled into two groups: 20 patients received hooks in Òclaw conþgurationÒ in thoracic and lumbar spine (Group A), and 20 patients hooks in thoracic and transpedicular screws in the lumbar spine (Group B). Gardner kyphotic deformity; anterior vertebral body height (AVBH); Posterior vertebral body height (PVBH); and Spinal canal encroachment (SCE) were measured in roentgenograms and CT-scan. Results: All patients were followed for 52 months, (range, 42–71 months) postoperatively. Gardner angle was corrected at 45% and 48% with a loss of correction of 1.5û and 1û for Group A and B respectively. AVBH was corrected at 16% and 33% in Group A and B with loss of correction of 11% only in group A. PVBH was restored only in Group B at 3%, while the loss of correction was 4% and 1% for group A and B respectively. SCE was postoperatively decreased at 19% and 32% in group A and B respectively. On the latest evaluation there was an increase of SCE at 9% in group A, while it was furthermore decreased at 10.5% in-group B. All patients with incomplete neurologic lesions in-group A and B were postoperatively improved at 1.1 degrees and 1.7 degrees respectively. There was no screw failure, while there was two hook dislodgements in the thoracic spine (one in each group). There was neither pseudarthrosis nor neurologic deterioration in this series. Conclusions: The use of pedicle screws in the lumbar spine for stabilization of thoracolumbar injuries offers better correction of posttraumatic kyphotic deformity, restores and maintains better than hooks anterior and posterior vertebral body height of the fractured vertebra without loss of correction, and safeguard continuous remodeling of spinal canal resulting in increasing spinal canal clearance with time lapsed from operation

Rigid angular kyphotic deformities of the spine have been corrected by staged anterior and posterior procedures. This paper evaluates the efficacy of single stage transpedicular decancellation, vertebral column mobilization and spinal shortening in the correction of rigid THORACIC kyphotic deformities in adolescent patients. Between 1993 and 1999, 21 patients with rigid kyphosis underwent deformity correction using the above procedure. The deformity was thoracic in 6 patients, thoraco-lumbar in 14 and lumbar in one patient. This report focuses on 6 patients with thoracic deformity. The etiology in 5 patients was due to tuberculosis while one patient had a congenital anomaly. There were 4 females and 2 male patients. The average age was 12 years. The average kyphosis was 75 degrees (38 – 135 degrees). Of the 6 patients, 2 had preoperative paraplegia. All cases were assessed using CT and MRI scans in addition to plain radiographs. The surgical technique utilized the principle of transpedicular decancellation through a single posterior midline exposure in the prone position. Following complete decancellation of the apical vertebrae, the proximal and distal vertebral column was adequately mobilized to enable spinal shortening along with anterior translation. Segmental spinal instrumentation was used to achieve stable fixation.Intraoperatively, the wake-up test was used to assess the neurological function. This was followed by anterior interbody fusion and posterolateral fusion. At an average follow-up of 36 months, average kyphosis correction was 61% and all cases were adequately fused. Both cases with paraplegia recovered completely. The average loss of correction was 6 degrees. One patient developed hyperlordosis below the corrected level. This was revised by extending the spinal fixation to include the lower levels. In conclusion, the above procedure is used as a last resort for correction of rigid angular deformities. It is a safe but demanding procedure. Spinal column shortening is essential to avoid neurologic compromise and balance the column