abstracts: poster presentations for eurospine annual meeting 2013

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ABSTRACTS Abstracts: Poster Presentations for Eurospine Annual Meeting 2013 ADULT THORACOLUMBAR SPINE, DEGENERATIVE P1 INTERSPINOUS PROCESS IMPLANT APERIUS PERCLID CAUSES WEAR OF THE SPINOUS PROCESSES - EXPERIMENTAL STUDY AND CLINICAL CASE REPORTS Adad Baranto, Lars Ekstro ¨m, Helena Brisby, Klas Halldin, Jonas Hvannberg Department of Orthopedics, Gothenburg, Sweden Background: There are few biomechanical studies on interspinous process implants but none that have investigated the amount of wear caused to the spinous processes. Purpose: To investigate the effect of repetitive loading of the interspi- nosus implant Aperius on the spinous processes in a biomechanical porcine model. We also present three clinical cases operated with Aperius followed with X-rays and CT up to one year. Study design: Biomechanical analysis of cyclic loading of lumbar spinal segments operated with Aperius implants. Three patients operated with Aperius are also presented. Study sample: Eight lumbar segments from porcine were operated in vitro with the interspinous process implants Aperius (6), and as controls the interspinous implants X-Stop (1) and DIAM (1). Methods: Four lumbar spines from 6 months old porcinis were divided into eight segments, which received interspinous implants. The segments were then exposed to 20.000 cyclical loads where after the deformation (wear) of the segments was registered. The wear of the spinous processes was measured in mm on the following CT-scan. Additionally, three patients treated with interspinous implants were followed between one and two years postoperatively. The wear of the spinous processes on CT-scans or X-ray were presented together with the clinical results. Results: The mean maximal deformation of all specimens was 1.8 (SD 0.24) mm where the largest deformation occurred in the first quarter of the loading ( \ 5000 cycles). The mean wear of the spinous processes after loading was 5.75 mm in the Aperius cases and 3.00 mm in the X-Stop cases. No wear was found in the DIAM segment. Wear of the spinous processes was detected in the clinical cases already after three months postoperatively and interestingly two of the patients had recurrence of their symptoms and planned for decompression surgery. Conclusions: In an experimental biomechanical study under cyclical loading the interspinous titanium implant Aperius causes significant wear of the spinous processes. Also the X-Stop implant caused wear of the spinous process. No wear was detected on the segment with an implant made of silicon (DIAM). Wear of the spinous process is also present in clinical cases already at three months post-operatively. The clinical importance of these findings is still not clarified but indicates that the material the implant is made of is of importance for the clinical durability. Further clinical studies are needed. P2 IS AUTOGENOUS BONE GRAFT REALLY STRUCTURALLY INFERIOR TO A CAGE IN INSTRUMENTED LUMBAR INTERBODY FUSIONS Alexander Durst, Andrew Cook, Shaishav Bhagat, Am Rai, Robert Crawford Norfolk and Norwich Hospital, Norwich, UK Objectives: We aimed to compare loss of disc fusion height in patients undergoing a pedicle screw stabilised Posterior Lumbar Interbody Fusion (PLIF) using local autogenous bone graft to those using synthetic cages. Methods: 99 patients underwent instrumented PLIF (one level or two level) between 2007 and 2011 at our tertiary spinal unit. 36 using bone graft and 63 using a age. Loss of disc height was calculated by comparing post- operative radiographs with those at a minimum of 6 months follow-up. Results: In the graft group mean loss of height was 2.67 mm (95 % CI 1.82-3.52) with a mean follow-up of 14.7 months. The mean in the cage group 2.54 mm (95 % CI 1.94-3.14) with a mean follow-up of 18.2 months. There was no significant difference between the 2 groups (p = 0.798). Loss of disc fusion height was statistically greater for men than women in both groups (p = 0.044). Conclusion: Previous studies have suggested that use of bone graft alone in instrumented PLIFs may result in loss of fusion height. We have shown that a technique of packed bone graft with a block of bone placed posteriorly in the disc space creates a mechanical construct providing comparable structural support to that of a cage. This technique has clear financial advantages in an era of spiralling spinal surgical costs. P3 DEVELOPMENT AND FACE VALIDITY OF CRITERIA FOR ASSESSING THE APPROPRIATENESS OF SURGERY FOR LUMBAR DEGENERATIVE SPONDYLOLISTHESIS Anne F Mannion, Valerie Pittet, Felix Steiger, Hans-Ju ¨rgen Becker, John-Paul Vader, Franc ¸ois Porchet, and the Zurich Appropriateness of Spine Surgery (ZASS) Group Spine Center, Schulthess Klinik, Zu ¨rich, Switzerland 123 Eur Spine J (2013) 22 (Suppl 5):S720–S766 DOI 10.1007/s00586-013-2947-6

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Page 1: Abstracts: Poster Presentations for Eurospine Annual Meeting 2013

ABSTRACTS

Abstracts: Poster Presentations for Eurospine Annual Meeting2013

ADULT THORACOLUMBAR SPINE, DEGENERATIVE

P1

INTERSPINOUS PROCESS IMPLANT APERIUS

PERCLID CAUSES WEAR OF THE SPINOUS

PROCESSES - EXPERIMENTAL STUDY

AND CLINICAL CASE REPORTS

Adad Baranto, Lars Ekstrom, Helena Brisby, Klas Halldin,

Jonas Hvannberg

Department of Orthopedics, Gothenburg, Sweden

Background: There are few biomechanical studies on interspinous

process implants but none that have investigated the amount of wear

caused to the spinous processes.

Purpose: To investigate the effect of repetitive loading of the interspi-

nosus implant Aperius on the spinous processes in a biomechanical

porcine model. We also present three clinical cases operated with Aperius

followed with X-rays and CT up to one year.

Study design: Biomechanical analysis of cyclic loading of lumbar

spinal segments operated with Aperius implants. Three patients

operated with Aperius are also presented.

Study sample: Eight lumbar segments from porcine were operated

in vitro with the interspinous process implants Aperius (6), and as

controls the interspinous implants X-Stop (1) and DIAM (1).

Methods: Four lumbar spines from 6 months old porcinis were

divided into eight segments, which received interspinous implants.

The segments were then exposed to 20.000 cyclical loads where after

the deformation (wear) of the segments was registered. The wear of

the spinous processes was measured in mm on the following CT-scan.

Additionally, three patients treated with interspinous implants were

followed between one and two years postoperatively. The wear of the

spinous processes on CT-scans or X-ray were presented together with

the clinical results.

Results: The mean maximal deformation of all specimens was 1.8 (SD

0.24) mm where the largest deformation occurred in the first quarter of the

loading (\ 5000 cycles). The mean wear of the spinous processes after

loading was 5.75 mm in the Aperius cases and 3.00 mm in the X-Stop

cases. No wear was found in the DIAM segment. Wear of the spinous

processes was detected in the clinical cases already after three months

postoperatively and interestingly two of the patients had recurrence of

their symptoms and planned for decompression surgery.

Conclusions: In an experimental biomechanical study under cyclical

loading the interspinous titanium implant Aperius causes significant

wear of the spinous processes. Also the X-Stop implant caused wear

of the spinous process. No wear was detected on the segment with an

implant made of silicon (DIAM). Wear of the spinous process is also

present in clinical cases already at three months post-operatively. The

clinical importance of these findings is still not clarified but indicates

that the material the implant is made of is of importance for the

clinical durability. Further clinical studies are needed.

P2

IS AUTOGENOUS BONE GRAFT REALLY

STRUCTURALLY INFERIOR TO A CAGE

IN INSTRUMENTED LUMBAR INTERBODY FUSIONS

Alexander Durst, Andrew Cook, Shaishav Bhagat, Am Rai,

Robert Crawford

Norfolk and Norwich Hospital, Norwich, UK

Objectives: We aimed to compare loss of disc fusion height in

patients undergoing a pedicle screw stabilised Posterior Lumbar

Interbody Fusion (PLIF) using local autogenous bone graft to those

using synthetic cages.

Methods: 99 patients underwent instrumented PLIF (one level or two

level) between2007 and 2011 at our tertiary spinal unit. 36 using bone graft

and 63 using a age. Loss of disc height was calculated by comparing post-

operative radiographs with those at a minimum of 6 months follow-up.

Results: In the graft group mean loss of height was 2.67 mm (95 %

CI 1.82-3.52) with a mean follow-up of 14.7 months. The mean in the

cage group 2.54 mm (95 % CI 1.94-3.14) with a mean follow-up of

18.2 months. There was no significant difference between the 2

groups (p = 0.798). Loss of disc fusion height was statistically

greater for men than women in both groups (p = 0.044).

Conclusion: Previous studies have suggested that use of bone graft

alone in instrumented PLIFs may result in loss of fusion height. We have

shown that a technique of packed bone graft with a block of bone placed

posteriorly in the disc space creates a mechanical construct providing

comparable structural support to that of a cage. This technique has

clear financial advantages in an era of spiralling spinal surgical costs.

P3

DEVELOPMENT AND FACE VALIDITY

OF CRITERIA FOR ASSESSING

THE APPROPRIATENESS OF SURGERY

FOR LUMBAR DEGENERATIVE

SPONDYLOLISTHESIS

Anne F Mannion, Valerie Pittet, Felix Steiger, Hans-Jurgen Becker,

John-Paul Vader, Francois Porchet, and the Zurich Appropriateness

of Spine Surgery (ZASS) Group

Spine Center, Schulthess Klinik, Zurich, Switzerland

123

Eur Spine J (2013) 22 (Suppl 5):S720–S766

DOI 10.1007/s00586-013-2947-6

Page 2: Abstracts: Poster Presentations for Eurospine Annual Meeting 2013

Introduction: In spine surgery, treatment failures are often attributed

to poor patient selection and inappropriate treatment. However, for

many spinal disorders there is little consensus on the precise indica-

tions for surgery, and gold standards based on RCTs are lacking. We

addressed one such gap in the evidence-base by using the RAND

Appropriateness Method (RAM; detailed literature review and mod-

ified Delphi expert panel) to develop criteria for the appropriateness

of surgery (AoS) in lumbar degenerative spondylolisthesis (LDS).

Methods: Clinical scenarios were generated comprising combinations

of signs and symptoms in LDS and other relevant parameters

(‘‘variables’’). 12 multidisciplinary international experts rated each

scenario on a 9-point scale (1 highly inappropriate, 9 highly appro-

priate) with respect to doing decompression only, fusion, and

instrumented fusion. Surgery for each scenario was classified as

appropriate, inappropriate, or uncertain based on the median values

and disagreement in the ratings. Multiple regression was used to

examine: 1) the extent to which the different variables influenced the

median ratings in a logical way (‘‘face validity’’); 2) the variables

most strongly associated with ‘‘appropriate’’ scenarios.

Results: 744 hypothetical scenarios were generated; overall, surgery

(of some type) was appropriate in 27 %, uncertain in 41 % and inap-

propriate in 31 %. Frank panel disagreement was low (7 % scenarios).

90 % of the variance in median ratings was explained by the variables

neurogenic claudication, radicular pain, stenosis, LBP, yellow flags,

instability, neurological deficit, comorbidity, disability (each

p \ 0.05). Face validity was shown by the logical relationship between

each variable’s subcategories and the ratings, e.g., compared with no/

mild disability, having moderate or severe disability increased the

average ratings by 2.7 and 4.3 points, respectively. The three variables

most likely (p \ 0.0001) to be components of scenarios considered

‘‘appropriate’’ were: severe disability, no yellow flags, and severe

neurological deficit.

Conclusion: This is the first study to report AoS criteria for LDS

developed by a multidisciplinary international panel using a validated

method (RAM). The panel ratings followed logical clinical rationale,

indicating good face validity. The criteria should be evaluated for

predictive validity on a prospective basis to examine whether patients

treated ‘‘appropriately’’ do indeed have better clinical outcomes.

P4

VERTEBRAL RETROLISTHESIS

AND ANTEROLISTHESIS OF DEGENERATIVE

LUMBAR SPINE: THEIR DIFFERENT

CONTRIBUTIONS IN SPINE SAGITTAL BALANCE

BAO Hong-da, ZHU Feng, LIU Zhen, ZHU Ze-zhang, XU Lei-lei,

QIAO Jun, QIU Yong

Spine Surgery, Nanjing, China

Introduction: Lumbar instability is one of the common degenerative

changes of spine in which forwards slippage of one vertebral body on

another, known as spondylolisthesis or anterolisthesis, and backward

translational deformity, namely retrolisthesis, were included. In clinical

practice, retrolisthesis is considered as one of the compensatory

mechanisms of sagittal unbalance in aging spine. To the best of our

knowledge, however, few studies have focused on the contribution that

retrolisthesis made to sagittal balance. The objective of the present

study is to compare sagittal alignment between anterolisthesis and

retrolisthesis, as well as to elucidate their different contribution to

sagittal balance.

Methods: This study was a retrospective review of 26 retrolisthesis

patients (19 females and 7 males) and 20 anterolisthesis patients (3

males and 17 females). 17 of the retrolisthesis patients and 6 of the

anterolisthesis patients were associated with adult scoliosis. Long-

cassette standing upright radiographs were taken; Sagittal parameters

including sagittal vertical axis (SVA), thoracic kyphosis (TK), lumbar

lordosis (LL), the spinosacral angle (SSA), pelvic incidence (PI),

pelvic tilt (PT), sacral slope (SS) were measured through digital

analysis software. Independent samples t-tests were performed to

compare radiographic parameters between retrolisthesis group and

anterolisthesis group. Spinopelvic sagittal alignments in both groups

were also classified into four types defined by Roussouly et al.

Results: In the present study, PI, SS, LL, SVA in retrolisthesis group

were significantly smaller than those in anterolisthesis group

(p \ 0.05). In contrast, PT, TK and SSA were not different between

the two groups. Retrolisthesis patients were mostly classified into

Type 1 or 2 (low PI and SS), and patients with anterolisthesis tended

to be classified into Type 3 or 4 (high PI and SS).

Conclusion: The results confirmed that retrolisthesis permitted to limit

anterior translation of the axis of gravity since PT and TK were similar

in both groups. It is also hypothesized that low PI may contribute to

development and progression of different slip direction of vertebrae.

Keywords: Retrolisthesis, anterolisthesis, sagittal balance, pelvic

incidence, compensatory mechanism

P5

THE EFFECT OF THE LENGTH OF THE PEDICLE

SCREW FIXATION LEVEL FOR LUMBAR

DEGENERATIVE SPONDYLOLISTHESIS:

PRELIMINARY RESULTS OF ONE YEAR

FOLLOW-UP

Bora Gurer, Ahmet M. Sanli, Erhan Turkoglu, Hayri Kertmen,

Erdal R. Yilmaz, Zeki Sekerci

Ministry of Health, Diskapi Yildirim Beyazit Education and Research

Hospital, Neurosurgey Clinic, Ankara/Turkey, Ankara, Turkey

Introduction: Lumbar degenerative spondylolisthesis is a disease of

the older ages, and characterized by displacement of one vertebral body

over another due to disc degeneration and facet arthropathy, most

commonly combined with spinal canal stenosis at the affected levels.

The purpose of this study is to evaluate whether the length of the seg-

mental stabilization has any effect on quality of life, disability and pain.

Materials and methods: This retrospective study comprised 43 patients

who were operated due to lumbar degenerative spondylolisthesis. The

patients were divided into two groups by the length of the posterior sta-

bilization levels: Group I (short-segment group): operated for only two-

level posterior stabilization; Group II (long-segment group): operated for

three and four-level posterior stabilization. The medical outcomes study

36-Item short form general health survey, oswestry disability index and

visual analogue scale were used to analyze the outcome.

Results: It was clearly shown that, posterior segmental stabilization

increased the postoperative quality of health in the both groups, by all

parameters of Short Form -36 survey. Evermore in the group I, the dif-

ference between the preoperative and postoperative scores of the role

limitations due to physical health problems, bodily pain, general health

perceptions, social functioning, mental health, vitality and mental com-

ponent summary were better than group II, predisposing a better quality of

life results were obtained with short-segmental stabilization. Postoperative

Oswestry Disability Index and Visual Analogue Scale of the both groups

decreased postoperatively. The decrease of the Oswestry Disability Index

and Visual Analogue Scale was better in group I than group II.

Conclusions: Our study showed that both short- and long-segmental

posterior stabilization caused a significant better quality of health

Eur Spine J (2013) 22 (Suppl 5):S720–S766 S721

123

Page 3: Abstracts: Poster Presentations for Eurospine Annual Meeting 2013

results, disability scores and less pain scores postoperatively for the

lumbar degenerative spondylolisthesis. The most important result of

our study is that, short-segmental stabilization caused significantly

better Short Form-36 scores, Oswestry Disability Index and Visual

Analogue Scale.

P6

LACK OF PRECISION IN CODING LUMBAR DISC

PROLAPSE SIZE

Bruce S. Watson, Philip Nie, J.N. Alastair Gibson

Orthopaedic Surgery, Edinburgh, UK

Objective: Investigators assessing outcomes following lumbar disc

prolapse usually attempt to categorize prolapse type, but this is fre-

quently only a simple intra-operative assessment of site. Seldom is

size data from MR imaging provided. Neither a full classification

from NASS & Am Soc of Spine Radiol. (1) or an axial classification

(2) have been universally adopted by spinal surgeons. The aim of this

study was to define whether a combined MR classification had ade-

quate inter-observer reliability for comparative analyses.

Study design: We searched PubMed, Cinahl and Google using relevant

MESH headings for all classifications of disc prolapse in common clinical

usage. Taking this data we then constructed a composite scoring system

factoring site (central, lateral, foraminal, extra-foraminal) and size.

Outcome measures: MR scans of 120 consecutive patients with a

disc prolapse were analysed and scored independently by three sur-

geons. An online calculator was used to determine Randolph’s free-

marginal multi-rater Kappa (chance adjusted measure of agreement).

Results: 60 articles were analysed providing 3 classification systems

that were modified to 5 domains: level, site relative to the pedicle in

the axial plane, lateral extension, canal compromise and vertical

extent. This produced site (54 % L5/S1, 43 % L4/5, 3 % other) and

numerical size descriptors of which the commonest was: L.2.1.2

(central and lateral herniation (2), with prolapse at disc level

extending 1/3 across canal (1), and small vertical extension (2). The

three surgeons however, only agreed on the position of maximal

prolapse in 24 % of cases (Kappa = 0.27) and in calculated total size

score in 13 % (Kappa = 0.15). Two surgeons agreed in 92 % and

54 % respectively. There was a 25 % agreement for lateral extent,

60 % for degree of canal compromise and 58 % for vertical extent.

Conclusion: From the available literature data we produced a simple

coding system. However, the results were not sufficiently reproduc-

ible to be of value in comparative scientific data analyses. A better

3-D reconstruction method of size assessment is required.

1 Fardon D, Millette PC. Spine 2001;26(5):E93-113.

2 Mysliwiec LW, Cholewicki J, Wingelpleck MD, Eis GP. Eur Spine

J 2010;19:1087-93.

P7

MINIMALLY INVASIVE SPINE SURGERY IT’S

RATIONALE, BENEFITS AND EFFECTS

ON PATIENT OUTCOMES A COMPARISON

OF THE CLASSIC OPEN APPROACH

VERSUS MUSCLE SPARRING MINIMALLY

DISRUPTIVE APPROACH FOR MIS SURGERY

Donald Kucharzyk, Dushan Budimir

Orthopaedics, Crown Point, USA

Minimally Invasive Surgery for instrumented lumbar fusion is an

attractive concept with obvious advantages for the surgeon and patient

but the questions arises does it effect the outcomes of the patient. The

impetus for this technique centers on the wish to avoid paraspinal muscle

damage as seen with the classic open approach. One also questions the

approach in MIS as to whether a muscle splitting percutaneous approach

as seen with most MIS systems is more beneficial than a muscle sparring

minimally disruptive approach as offered with the MiniMax MIS system

and does this affect the patients’ outcomes as well?

A Study was undertaken to compare MIS surgery thru a muscle

splitting percutaneous approach and also a muscle sparring approach

versus the standard open approach spine fusion surgery.

Results revealed: In the Open Group: OR time(110 min), blood

loss(300 ml), duration of hospitalization(3.3 days), duration of nar-

cotic use(51 h), and fusion rate(92.8 %).

In the MIS I group: OR time (125 min), blood loss (100 ml), duration

of hospitalization (2.0 days), duration of narcotic use (25 h), and

fusion rate (93.3 %). In the MIS II groups: OR time (90 min,), blood

loss (75 ml) duration of hospitalization (1.5 days), duration of nar-

cotic use (12 h), and fusion rate (94.5 %).

Outcomes measurements revealed the following:

ODI: open 52.5 preop, 28.4 postop MIS I 53.9 preop, 19.2 postop MIS

II 54.1 preop 12.2 postop

BPS: open 16.4 preop, 8.1 postop MIS I 15.9 preop 5.1 postop MIS II

17.1 preop 2.0 postop

LPS: open 14.0 preop 6.7 postop MIS I 15.8 preop 3.7 postop MIS II

16.2 preop 1.0 postop

SF-36: open 27.6 preop, 39.7 postop MIS I 21.7 preop, 48.6 postop

MIS II 27.1 preop 49.6 postop.

These outcome measurement point to the positive effect of an MIS

approach to spine fusion but even better outcome measurements were

seen with the muscle sparring minimally disruptive approach via

MiniMax MIS System.

Conclusions: MIS has shown improvements in all outcome mea-

surements evaluated when compared to the classic open approach.

When further separated by MIS muscle splitting percutaneous

approach versus MIS muscle sparring approach minimally disruptive

approach, the muscle sparing approach performed even better and

when compared to the classic open approach it was more dramatic

and the outcome measurements were even more significant. Finally,

the most important conclusion for the surgeon was that similar fusion

rates were seen in all three studied groups.

P8

THE EFFECT OF LOCAL STEROID APPLICATION

COMBINED WITH PREEMPTIVE SURGICAL SITE

INFILTRATION IN REDUCING IMMEDIATE

POSTOPERATIVE PAIN AND OPIOID

CONSUMPTION FOLLOWING LUMBAR

MICRODISCECTOMY. A PROSPECTIVE

RANDOMISED CONTROLLED TRIAL

Efthimios Samoladas, Stavros Stavridis

2nd Orthopaedic Dpt, Aristotle University of Thessaloniki,

Thessaloniki, Greece

Aim of the study: To investigate whether preemptive surgical site

infiltration with local anaesthetic combined with before closing local

steroid application would be more effective compared to infiltration

alone in reducing immediate postoperative back pain and opioid

consumption, following lumbar microdiscectomy.

S722 Eur Spine J (2013) 22 (Suppl 5):S720–S766

123

Page 4: Abstracts: Poster Presentations for Eurospine Annual Meeting 2013

Patients and Methods: 60 patients undergoing one or two-level

discectomy were randomized to either Group A (infiltration + steroid,

30 patients) or Group B (infiltration only, 30 patients). After defining

the correct level under fluoroscopic guidance, all patients received a

preemptive infiltration of the surgical site with 10 ml of a 2 % lido-

caine and 1/10000 adrenaline solution. In Group A patients, a solution

consisting of 9 ml 2 % ropivacaine and 1 ml 3 mg/ml betamethasone

acetate was applied just before wound closure both intraforaminally

and retrograde epidurally with use of a small catheter. A standard

postoperative analgesic regime including the administration of 1 gr

paracetamol 9 3 i.v. was applied to all patients. 100 mg Tramadol

i.v. were administered at 3 h postop to those patients who required

further analgesia. Postoperative back pain was evaluated with use of

the VAS score at 1, 2, 3, 4, 6, 8, 12 and 24 h post-surgery. Patients’

opioid consumption was also recorded. Statistical analysis was per-

formed with use of the t Test for discrete variables and Fisher’s exact

test for categorical variables.

Results: There were no complications regarding neither the pre-

emptive infiltration, nor the steroid application. Overall none of the

Group A patients required further analgesia; while 12 Group B

patients received upon request 100 mg Tramadol i.v. 3 h postop

(P = 0.01). At 2 and 3 h postop the VAS score was significantly

lower in Group A (mean VAS = 1.6 at 2 h, 1.8 at 3 h) compared to

Group B (mean VAS = 2.3 at 2 h, 2.7 at 3 h) (P \ 0.05). Following

the Tramadol application, mean VAS score decreased in Group B up

4 h postop, while it remained low in Group A without any significant

difference among the two groups for the remaining time points tested.

Conclusions: Our results indicate that local corticosteroid application

combined with preemptive surgical site infiltration with local anaes-

thetic is more effective than infiltration alone in reducing immediate

postoperative back pain and opioid consumption, following lumbar

microdiscectomy. Both are also safe and easy to perform procedures

with no related complications.

P9

PREDICTORS FOR DURAL LESIONS REQUIRING

SURGICAL MEASURES IN THE TREATMENT

OF LUMBAL SPINAL STENOSIS: COMPARISON

OF A SINGLE CENTER WITH THE ‘‘RELIABLE’’

AND ALL OTHER SPINE TANGO CLINICS

Everard Munting, Christoph Roder, Rolf Sobottke, Emin Aghayev

Institute for Evaluative Research in Medicine, Bern, Switzerland

Background: Lumbar spinal stenosis is one of the most frequently

treated spinal diseases and a dural lesion is its most frequent com-

plication. We aimed at finding predictors for dural lesions requiring a

surgical intervention by analysing the Spine Tango registry data (form

versions 2005/06).

Methods: Inclusion criterion was a lumbar spinal stenosis with pos-

terior decompression (deco) surgery. A total of 9545 patients was

identified: n = 645 from the first author‘s center, n = 1962 from five

international ‘‘reliable’’ clinics with known and credible recording of

all surgical complications, and n = 6938 from all other Spine Tango

participants. The target variable was a dural lesion that required a

surgical measure.

Multivariate logistic regression was applied to adjust for differences

in patient age and gender, previous surgery (yes/no), extension of

lesion (1/2-3/4-5/C 5 segments) and type of surgical treatment (deco

only/deco with instrumented fusion).

Results: The raw dural lesion rate was higher in the single center

(11.2 %), followed by the reliable (6.6 %) and all other clinics

(3.0 %). The multivariate regression analysis revealed several pre-

dictors for the outcome. Deco alone had an odds ratio (OR) 1.65

(CI95 % 1.1-2.4) for dural lesion compared with deco and instru-

mented fusion. Patients with previous surgery had an OR 1.67 (1.2-

2.3) for a dural lesion compared with those without. Larger extensions

of lesion had an OR 1.65 (1.2-2.4), 1.84 (1.1-3.2), and 4.06 (1.8-9.1)

for 2-3, 4-5, [ 5 segments compared with 1-2 segments. Patients

from the single center and the reliable clinics had similar (single

center OR 1.59, 1.0-2.5; reliable clinics OR 1.63, 1.1-2.3) and higher

odds for dural lesions than patients in other clinics.

Discussion: Documentation of surgical complications in the Spine

Tango registry relies on individual surgeons‘ and clinics‘ honesty.

A Spine Tango code of conduct will be introduced in 2013 to foster

honest, transparent and monitored documentation. The difference in

proportions of relevant dural tears between the single center and

reliable clinics was not significant and even reversed after case mix

adjustment, which shows the importance of adjusted analyses. Dural

lesion rates of the reliable Spine Tango centers can probably serve as

authentic benchmark. Deco alone, previous spinal surgery and larger

extension of lesion were revealed as significant predictors for relevant

dural lesions in spinal canal stenosis surgery in the Spine Tango

dataset.

P10

DOES THE NEW SRS-SCHWAB CLASSIFICATION

SUFFICE TO DEFINE ADULT SPINAL DEFORMITY?

Ferran Pellise, Montse Domingo-Sabat, Emre Acaroglu,

Francisco J S Perez-Grueso, Ahmet Alanay, Ana Garcıa de Frutos,

Alba Vila-Casademunt, Joan Bago, ESSG European Spine Study Group

Spine Unit Vall Hebron Hospital, Barcelona, Spain

Background: The new Scoliosis Research Society Adult Spinal

Deformity (ASD) classification, published in May 2012 and based on

radiological criteria, has been shown to be reliable. The incidence and

patient’s characteristics for each curve type are still unknown. We

hypothesized that this classification may not identify homogeneous

groups of patients.

Patients and Methods: Radiological and health related quality of life

(HRQL) baseline data of patients with degenerative (DG) or idio-

pathic (ID) deformity, consecutively enrolled in a prospective

European multicenter database, was analyzed. Inclusion criteria:

age [ 18 ys and scoliosis [ 208, SVA [ 5 cm, pelvic tilt [ 258 or

thoracic kyphosis [ 608. Patients’ characteristics and incidence were

evaluated for each coronal curve type

Results: 368 patients, mean age 44.1 years (18 to 88), 83.9 % female,

were evaluated. Incidence of curve types: T 14.3 %, L 16.3 %, D

40.4 % and N 28.9 %. In N curve pattern 56.6 % of cases had minor

(20-308) coronal and 43.4 % pure sagittal deformity without coronal

deformity. ASD was idiopathic in 73.1 % of cases and degenerative in

26.9 %. Diagnostic groups had different mean ages (p \ 0.0001) (ID

36.2 y/DG 65.4 y). Idiopathic and degenerative curves had different

(p \ 0.0001) curve pattern distribution: T curve: 92 % ID vs 8 % DG;

L curve: 42.1 % ID vs 57.8 % DG; D curve: 95.6 % ID vs 4.3 % DG;

N curve: 54.4 % ID vs 45.5 % DG. Sagittal modifiers’ scores differed

(p \ 0.0001) among diagnostic groups too: Score 0: 86-88 % ID vs

11-13 % DG; Score +: 38-53 % ID vs 47-61 % DG; Score ++:

22-34 % ID vs 65-77 % DG.

We found clinically and statistically significant differences in SF36

PCS (p \ 0.01), ODI (p \ 0.001) and SRS-subtotal (p \ 0.01)

between T or D and L curves, L curves having worse HRQL scores.

These differences were found to disappear when idiopathic and

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degenerative curves were analyzed separately. DG L and N patients

had worse HRQL scores compared to L and N ID patients: SF36 PCS

L curve 41.2 ID vs 33.4 DG (p \ 0.001); SF36 PCS N curve 45.4 ID

vs 34.2 DG (p \ 0.0001); ODI L curve 25.2 ID vs 49.5 DG

(p \ 0.0001); ODI N curve 18.3 ID vs 51.8 DG (p \ 0.0001); SRS22

subtotal L curve 3.3 ID vs 2.6 DG (p = 0.0002); SRS22 subtotal N

curve 3.6 ID vs 2.9 DG (p \ 0.0001).

Conclusion: In the new SRS-Schwab ASD classification D and N

patterns are predominant. This classification does not identify

homogeneous groups of patients. Adding the etiology parameter to

that of coronal curve pattern increases homogeneity of patient

subgroups.

P11

DO ‘‘DOERS’’ AND ‘‘REFERRERS’’ DIFFER

IN THEIR RATINGS OF THE APPROPRIATENESS

OF SURGERY FOR LUMBAR DEGENERATIVE

SPONDYLOLISTHESIS?

Francois Porchet, Felix Steiger, Valerie Pittet, Hans-Jurgen Becker,

John-Paul Vader, Anne F Mannion, and the Zurich Appropriateness

of Spine Surgery (ZASS) group

Spine Center, Schulthess Klinik, Zurich, Switzerland

Introduction: The RAND Appropriateness Method (RAM) is one of

the most respected methods for defining appropriate medical care.

Given the paucity of evidence from RCTs in spine surgery, the RAM

may represent a reliable, unbiased and clinically relevant approach to

assessing the appropriateness of treatment in various spinal patholo-

gies. It combines a detailed literature review with a modified Delphi

panel approach to gauge collective expert opinion. The panel should

be multidisciplinary, to reflect the variety of specialties involved in

treatment decisions. This study evaluated the difference in ‘‘appro-

priateness of surgery’’ (AoS) ratings between surgeons (‘‘doers’’) and

non-surgeons (‘‘referrers’’) participating in a RAM expert panel to

develop criteria for the surgical management of lumbar degenerative

spondylolisthesis (LDS).

Methods: The risks/benefits of treatment were summarised in a sys-

tematic review. Clinical scenarios comprising combinations of signs,

symptoms and other clinical parameters in LDS were then generated.

The AoS for each scenario was rated on a 9-point scale (1, inappropriate

to 9, appropriate) by an international, multidisciplinary group of 12

experts (8 surgeons, 4 non-surgeons (physiatrists/rheumatologist/

internist)). The ratings were analysed with respect to the appropriateness

of any type of surgery (decompression ± fusion ± instrumentation).

Results: 744 hypothetical scenarios were generated. Overall, sur-

geons gave significantly (p \ 0.0001) higher ratings than non-

surgeons (+0.68 points difference), especially for the scenarios in the

category ‘‘back pain only’’ (+0.97 points). The least discrepancy was

found for the scenarios in the category ‘‘radicular pain with no LBP

and no instability’’ (+0.12 points). Multiple regression revealed that

significant (p \ 0.0001) factors influencing the surgeon vs non-sur-

geon difference in ratings were the presence of yellow flags

(difference narrowed) and severe disability (difference increased).

Discussion: The study quantified the more conservative stance of

non-surgeons in relation to the appropriateness of surgery for LDS.

The findings may reflect the different case mixes typically seen by

surgeons and non-surgeons and their respective appreciation of the

risks and benefits of surgery compared with alternative treatments.

The results emphasise the importance of having a mix of ‘‘doers’’ and

‘‘referrers’’ when developing treatment appropriateness criteria.

P12

SPONTANEOUS REDUCTION TECHNIQUE

OF MODERATE TO HIGH GRADE

SPONDYLOLISTHESIS VIA MINIMALLY

INVASIVE, MINI-OPEN POSTERIOR LUMBAR

INTERBODY FUSION

Hyeun Sung Kim, Ki Hyun Jeon, Chang Il Ju

Neurosurgery, Daejeon, Korea (ROK/South Korea)

Purpose: The purpose of this study was to achieve the safe and

easy technique for minimizing the neurologic deterioration and

maximizing the reduction of spondylolisthesis using mini-open,

posterior-lumbar interbody fusion under circumferential releasing

technique.

Material & Methods: This study involved 54 cases who received mini-

open PLIF with percutaneous screwing, due to more than Mayerding

Grade II spondylolisthesis. Mean age was 60.19 year, mean follow-up

period was 32.67 months. According to the rate of slippage, 37 cases

included in Grade II (25 % * 49 %), 14 cases included in Grade III

(50 %-74 %) and 3 cases included in Grade IV (75 % *). The mean rate

of slippagewas 45.85 %. All patient received mini-open, posterior-lumbar

interbody fusion under epidural anaesthesia using the rimmed head screw

type percutaneous screw system. A circumferential releasing technique

was performed according to the following sequence: 1. Intraoperative

postural reduction position; 2. facet joint mobilization decompression; 3.

Segmental Mobilization; 4. Increasing sacral slope; and 5. Increasing the

anterior disc height. The clinical results were evaluated by visual analogue

scale (VAS) and Oswestry Disability Index, and Radiological results were

evaluatedby degreeof slippage reduction, degreeof disc height restoration

and postoperative neurological complications.

Results: The degree of slippage rate preoperative was: 45.85 % to

postoperative: 9.35 %. The degree of disc space was preoperative:

5.37 mm to postoperative: 12.15 mm. Back/Leg Visual Analogue

Scale and Oswestry Disability Index decreased from 6.28/7.83 to

1.85/1.41, 68.37 to 16.46, respectively.

There was no definite motor weakness after operation. However, 2

cases (3.70 %) suffered only transient, mild, motor weakness and 4

cases (7.41 %) suffered transient sensory change. There were no signs

of instrumentation failure or fusion failure.

Conclusion: According to the results, we could obtain maximal

reduction of spondylolisthesis under minimal neurologic deterioration

in the cases of a moderate to high grade of spondylolisthesis using the

circumferential segmental releasing technique.

P13

PATTERNS OF LUMBAR PAIN: AN EFFECTIVE

APPROACH TO LUMBAR AND SCIATIC PAIN

IN PRIMARY CARE IN OCCUPATIONAL

MEDICINE. COMPARATIVE STUDY OF TWO

RETROSPECTIVE COHORTS OF 3627 PATIENTS

Jaime Diaz de Atauri Bosch, Oscar Zabalza Mantilla, Mikel Ayala Garcia

Clinica Ercilla - Mutualia Vizcaya. Spine Unit, Bilbao, Spain

Patterns of lumbar pain: An effective approach to lumbar and sci-

atic pain in primary care in occupational medicine. Comparative

study of two retrospective cohorts of 3627 patients.

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Objective: We present a new approach to lumbar and sciatic pain in

primary care by grouping patients according to different pain patterns

noted during history-taking and physical examination. The aim is to

assess whether differences exist between managing lumbar and sciatic

pain in the working population when grouping patients according to

pain patterns and the possible health repercussions of not doing so.

Materials and methods: We performed a retrospective study of two

cohorts of patients treated for lumbar and sciatic pain at the accident

insurance company, Mutualia, in the provinces of Alava and Vizcaya

(Spain) in 2012. In Alava (G1), patients were managed according to

pain patterns, while in Vizcaya (G2), they received conventional

treatment. Diagnosis, number of sick days and mean duration, number

of additional tests, hospital admissions, surgical interventions and

referrals to rehabilitation (and duration) were studied. Statistical

analysis was performed using SPSS software (Chi squared and Stu-

dent t) with a sensitivity of 95 %.

Results We reviewed 3627 cases: 593 for G1 and 3032 for G2. The

sick leave rate was 38.78 % (G1) and 44.95 % (G2); the statistical

difference was significant (P \ 0.01). Average sick leave was 14.36

(G1) and 19.98 (G2) days (P \ 0.01). Rehabilitation sessions totalled

14.95 (G1) and 21.28 (G2) (P \ 0.01). We found no significant dif-

ferences in the number of additional tests per patient (0.16 vs 0.17),

percentage of hospital admissions (2.36 % vs 3.49 %), inpatient bed

days (3.92 vs 1.72) or in the percentage of surgical interventions

(2.02 % vs 2.20 %).

Conclusions: A marked difference in pain management was observed

after patients were grouped according to pain patterns. In primary

care, this is an effective way to indicate the duration of sick leave and

rehabilitation therapy. These results have already modified treatment

in G2, given the resulting financial and health care repercussions for

Mutualia.

P14

POSTERIOR TRANS-PEDICULAR FIBULAR

GRAFTS AND INTERFERENTIAL SCREWS

TO TREAT L5-S1 SPONDYLOPTOSIS. REPORT

ON FOUR CASES WITH 9.5 YEAR FOLLOW-UP

Javier Pizones, Alberto Nunez, Felisa Sanchez-Mariscal,

Patricia Alvarez-Gonzalez, Lorenzo Zuniga, Enrique Izquierdo

Spine Unit. Orthopaedic surgery. Hospital Universitario de Getafe,

Madrid, Spain

Introduction: Several techniques have been described to treat high-

grade spondylolisthesis. Reported historical complications are neuro-

logic injuries, pseudarthrosis, progression of slip, and instrumentation

failure. We present a posterior-only approach with partial reduction

and instrumentation to treat spondyloptosis. Interbody fusion is pro-

vided by trans-pedicular fibular struts inserted through S1 capturing

L5, avoiding central neural manipulation. Graft stress is protected

using interferential screws placed through these same pedicles.

Methods: Retrospective revision of four cases with grade V spond-

ylolisthesis. We analyzed preoperative, postoperative and final

follow-up clinical and radiographic data, with final SRS-22 outcomes.

Pelvic Incidence (PI), Sacral Slope (SS), Pelvic Tilt (PT), L5 Inci-

dence (L5I), Lumbar Lordosis (LL), L5 Slip Angle (L5SA),

Lumbosacral Kyphosis (LSK), and Sagittal Vertical Axis (SVA) were

measured. Fusion and complications were recorded.

Results: The mean age was 25.7 ± 5.7 yr. All were men with istmic

spondyloptosis (Meyerding grade V; type 5/6 SDSG classification).

One revision and three primary surgeries. The median fused levels

were 3 (3, 3.75), the mean operative time was 6.1 ± 0.8 h, the

median transfusion units were 2 (2, 5). The median follow-up was

114 months (45, 147.7). The lumbar/radicular pain assessed by VAS

reduced from preoperative 7.1 ± 2.4 to postoperative 1.3 ± 1.3. PT

improved 9.78, L5I improved 158, LSK and L5SA improved over 308and maintained over time. SVA improved 1.6 cm but lost them at

final follow-up. The SRS global satisfaction was 4.6 ± 0.2. We have

not seen any neurological complications, graft fractures, pseudar-

throsis, progression of slip, or instrumentation failure.

Conclusion: This technique yielded satisfactory clinical results in the

treatment of L5-S1 spondyloptosis. It provided stable anterior support

and high fusion rate by means of the transpedicular fibular grafts

while interferential screws protected from graft failure. It avoided

anterior approach related complications and mid-body inserted grafts

neurologic risks.

P15

IS PELVIC INCIDENCE AS CONSTANT

AS EVERYONE KNOWS?: CHANGE OF PELVIC

INCIDENCE IN SURGICALLY BALANCED ADULT

SAGITTAL DEFORMITY

Jung-Hee Lee, Jin-Soo Kim, Il-Heon Choi, Hyun-Seok Oh,

Chul-Hee Lee, Dae-Hyun Tak

Orthopaedic Surgery, Seoul, Korea (ROK/South Korea)

Objectives: To analyze the disparity of pelvic incidence (PI) before

and after surgery and to evaluate the its effect on final sagittal balance

in the surgically fixed lordosis with immediate postoperative optimal

sagittal balance following correction of adult sagittal deformity.

Summary of Background Data: Previous investigations have been

recognized pelvic parameters as a critical role in the setting of fixed

sagittal deformity. PI is as constant as everyone knows. PI might be

changed reciprocally because increased shear force following over-

corrected fixed lumbar lordosis on mobile sacroiliac joint. The

disparity of PI after surgery according to surgical methods and its

effect on final follow-up have not been reported.

Methods: A prospective study of 29 subjects with adult spinal

deformity (average age 67.9 years) who resulted optimal sagittal

balance at final follow-up following consecutive sagittal correction

with a minimum 2-year follow-up was carried out. The surgical change

of spinopelvic parameters were analyzed including PI, sacral slope,

pelvic tilt, lumbar lordosis, thoracic kyphosis and sagittal balance.

Results: The mean lumbar lordosis was 0.2 ± 19.3� before surgery, -

59.3 ± 10.9� after surgery with PSO (n = 20), ALIF (n = 20, 33

segments) and PLIF (n = 19, 36 segments) and -57.5 ± 11.4� at final

follow-up. The sagittal vertical axis was +14.8 Cm before surgery, -

0.7 Cm after surgery and 2.2 Cm at final follow-up. The mean PI was

increased in 49.4� before surgery, 55.2� after surgery, 57.5� at post-

operative 1-years and 58.8� at final follow-up (p = 0.02). The mean

disparity of PI preoperative and final follow-up was 11.4� without

sacropelvic fixation (n = 18) and 6.0� with sacropelvic fixation

(n = 11) (p = 0.002). Analysis revealed the disparity of PI to be

significantly higher in non-sacropelvic fixation and correlated with

follow-up period (r = 0.442, p = 0.016) but no to age, BMD, number

of fused segments, correction methods, corrected lumbar lordosis or

sagittal balance.

Conclusions: PI was increased in all patients with optimal sagittal

balanced adult sagittal deformity following overcorrection of lumbar

lordosis. The disparity of PI after surgery was significantly higher in

non-sacropelvic fixation and was shown to possess significant

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correlation to follow-up period, but there are no influence on sagittal

balance at final follow-up.

P16

ANALYSIS OF THE OPTIMAL SCREW DENSITY

FOR CORRECTION OF ADOLESCENT

IDIOPATHIC SCOLIOSIS

Kensuke Shinohara, Yoshihisa Sugimoto, Tomoyuki Takigawa,

Shinya Arataki, Masato Tanaka, Toshifumi Ozaki

Orthopaedics, Okayama city, Japan

Introduction: We have performed surgical correction of adolescent

idiopathic scoliosis (AIS) using thoracic pedicle screw (TPS). We

usually insert pedicle screw as many screws as possible in order to

archive good correction. However, optimal screw density for correction

of AIS is unknown. The purpose of this study is to analyze optimal screw

density for correction of AIS based on flexibility of spinal curve.

Materials and methods: Forty patients with AIS were retrospectively

reviewed for this study. Inclusion criteria: (1) Patients who were

treated by TPS at our department; and (2) a minimum follow-up of

one year. There were five males and 35 females, with and average age

of 16 years (range, 13 to 23 years) at the time of operation. We

measured the pre- and postoperative Cobb angle in the upright

position, preoperative traction Cobb angle, screw density and rigidity

of curve (RC). The measurements were performed between the upper

and lower end vertebra, and defined as follows:

Screw density: number of inserted screw/(number of vertebra body 2)

100 (%)

Rigidity of curve (RC): traction Cobb angle/preoperative standing

Cobb angle 100 (%)

We calculated Spearman’s correlations between the screw density and

RC, and correction rate.

Results: Average pre- and postoperative standing Cobb angle were 58

degrees (range 38 to 89) and 15 degrees (range 0 to 40), respectively.

The mean correction rate was 75 percent. The average screw density

and RC were 80 percent (range, 14 to 100) and 63 percent (range, 36

to 91), respectively. Calculation of Spearman’s correlations between

the screw density and RC, and correction rate gave coefficients 0.23

and 0.48, respectively. Regardless of number of screws, average

correction rate of patients with non-rigid curve (RC was 50 percent or

less) was 85 percent.

Conclusions: Our study demonstrates that RC correlated well and

more closely with the correction rate, than did the screw density.

Increasing number of pedicle screw did not always mean good cor-

rection. Patients who had non-rigid curve (RC: 50 percent or less) can

be treated with fewer pedicle screws.

P17

LUMBAR DECOMPRESSION FOR CENTRAL

CANAL STENOSIS IN THE ELDERLY

Matthew George Stovell, Tim Pigott, Chris Barrett

Neurosurgery, Liverpool, UK

Objective: Lumbar canal stenosis due to a combination of anterior

compression from disc bulges and posterior compression from

hypertrophy of the ligamentum flavum and facet joints can cause

pain, sensory disturbance, reduced mobility and autonomic dysfunc-

tion. These processes deteriorate with increasing age, which will have

an increasing impact on the aging population of Europe. With the

improvement of surgical techniques and the safety of anaesthesia,

surgery is being performed on a larger proportion of increasingly

elderly patients. We compared the post-operative outcome and

complication rate of primary lumbar laminectomy in very elderly

patients, to their younger cohort.

Methods: Data were collected prospectively using the Spine Tango

database. All patients who underwent primary lumbar decompression

during 2012 for central stenosis were included. Patients undergoing

instrumentation were excluded. Only patients with both pre-operative

and post-operative COMI scores were included. Patients were split

into two groups (C 75 years old & \ 75 years old).

Results: Complete data were available for 43 patients \ 75 years old

and 16 patients C 75 years old. In the younger group, pre-operative

COMI score was 8.0 ± 1.6 (mean, S.D.) and post-operative

improvement was 3.4 ± 2.6 (mean, S.D.). In the more elderly group,

pre-operative COMI score was 8.1 ± 1.5 (mean, S.D.) with a post-

operative improvement of 4.0 ± 2.1 (mean, S.D.). There were 7

unintentional durotomies in the younger group (16 %) and 1 in the

elderly group (6 %). There were no other intra-operative complica-

tions in either group. Intra-operative mortality was zero.

Conclusions: The reduction in COMI score in the more elderly group

was greater than that in the younger group (although not statistically

significant). The rate of complication (durotomies) was also lower.

We believe that when patients are appropriately selected, lumbar

laminectomy for lumbar canal stenosis is an effective surgical inter-

vention in extreme age.

P18

POSTERIOR VERTEBRAL COLUMN RESECTION

FOR ADULT SPINAL DISORDERS: EFFICACY,

COMPLICATIONS AND RISK FACTORS

Meric Enercan, Gurkan Gumussuyu, Sinan Kahraman,

Cagatay Ozturk, Tunay Sanli, Bekir Yavuz Ucar, Ramazan Soydan,

Burak Abay, Azmi Hamzaoglu, Ahmet Alanay

Istanbul Spine Center, Istanbul, Turkey

ABSTRACT BODY:

Summary: (80 words max): PVCR provides satisfactory radiographic

outcome for the treatment of complex spinal disorders.

Introduction: Aim is to analyze the results, complications and related

risk factors of PVCR performed on a consecutive series of adult pts

with spinal disorders.

Methods: 56 adult patients (27 f, 29 m) managed by PVCR having

more than 2 years follow-up were included. Indications were scoliosis

(9), acute fracture (15), posttraumatic kyphosis (8), kyphosis (9), PJK

(7), spondylodiscitis (6), ankylosing spondylitis (2). Preop, postop

and f/up X-Rays were evaluated to measure deformity, to reveal

mechanical complications. Hospital charts were evaluated for medical

complications. Risk factors and their correlation with complications

were analyzed.

Results: v age was 45 (19 - 85) years at the time of the operation.

Mean f/up was 4.6 (2-10) years. PVCR was performed at T level (23),

TL level (29) and L level (4). Av. operation time was 441 (240-900)

minutes and blood loss was 2452 (1000-6100) ml. Av instrumentation

levels were 9 (4-18). Preop mean coronal plane curve was corrected

from 87.6 degree (46-120) to 47.3 degree (5-77) (46 %). Preoperative

thoracic kyphosis was corrected from 65.1 degree (24-110) to 47.6

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degree (29-84) (27 %). There was no significant loss of correction at

final f/up (p [ 0.05). Overall complication rate was 55.4 %, including

29 patients had 35 minor complications (51.8 %) and 4 patients had 4

major complications (7.1 %). Major complications were pneumonia

(2), pulmonary embolism (1) and superior mesenteric artery syn-

drome (1). There was no neurological complication. Patient age,

PVCR level, etiology and revision surgery were not associated with

major complications (p [ 0.05). Etiology (acute trauma) was asso-

ciated with major complications (p = 0.045). Total and minor

complications were found higher in males (p = 0.014, p = 0.025,

respectively). Fusion was observed in all patients.

Conclusion: PVCR provides satisfactory radiographic outcome for

the treatment of complex spinal disorders. However, it is a technically

demanding procedure with high complication rates (major: 7.1 %,

minor: 51.8 %) and should be selected only when other alternatives

are not appropriate.

P19

AUGMENTATION OF PEDICLE SCREWS

WITH CEMENT HELPS TO PREVENT

MECHANICAL FAILURE IN ELDERLY PATIENTS

WITH [ 5 LEVELS INSTRUMENTATION: A CT

ANALYSIS OF 688 PEDICLE SCREWS

Meric Enercan, Sinan Kahraman, Cagatay Ozturk, Gurkan

Gumussuyu, Tunay Sanli, Bekir Yavuz Ucar, Levent Ulusoy,

Azmi Hamzaoglu, Ahmet Alanay

Istanbul Spine Center, Istanbul, Turkey

Introduction: Cement augmentation of pedicle screws (PS) is one of

the several measures to prevent screw failure in elderly patients with

osteoporosis. The aim of this study is to analyse the efficacy and

complications of cement augmentation in elderly patients with long

([ 5 levels) instrumentation.

Methods: A retrospective analysis of 55 patients who had cement

augmented PS was performed. All patients had CT scans taken

minimum 2 years after index operation. CT’s were analysed to

determine PS loosening, cement leakage and fusion rates at aug-

mented levels. Standard vertebroplasty technique was used for

augmentation. Prior to cement injection, mechanical aspiration of the

vertebral bodies was done through working cannula to prevent cement

emboli. Cement injected was 4 cc/lumbar and 2 cc/thoracic vertebrae.

Screws were placed immediately after cement injection.

Results: There were 688 cement augmented PS with a mean f/up of

45 (24-116) months. Average age (40 F, 15 M) was 69 (50-85) years.

Diagnosis were spinal stenosis in 41, trauma in 1, infection in 5 and

revision surgey in 8 patients. Av. number cement-augmented screw/

patient was 13 (4-32). Interbody fusion was done in 37 patients (100

levels). There were 10 (1.4 %) loose screws in 7 (%12.7) patients.

None had pulled out. Screw loosening was at fused levels in all except

one with pseudoarthrosis. All loosed screws were at the levels without

interbody fusion. One patient with pseudoarthrosis had rod breakage

and underwent a revision operation. There was no vertebral body

fracture at the augmented levels. Extravasation of cement was seen in

7 (%12.7) patients, none in spinal canal. 3 (%5.4) patients had

asymptomatic pulmonary cement emboli. 3 (%5.4) patients had deep

wound infection, they were treated successfully with debridement and

antibiotic therapy with no need to instrument removal.

Conclusion: Cement augmentation of PS in elderly osteoporotic

patients prevents screw pull-out. Screw loosening can be seen with a

very low rate and at the levels without interbody fusion.

P20

COHORT STUDY OF RISK FACTORS RELATED

TO REOPERATION AFTER MICROSURGICAL

BILATERAL DECOMPRESSION VIA A UNILATERAL

APPROACH (MBDU) FOR TREATMENT

OF DEGENERATIVE LUMBAR DISEASE

Minori Kato, Hiroaki Nakamura, Koji Tamai, Kazunori Hayashi,

Akira Matsumura, Sadahiko Konishi

Orthopaedic Surgery, Osaka, Japan

Purpose: Some authors have reported good clinical outcomes follow-

ing microsurgical bilateral decompression via a unilateral approach

(MBDU). This approach entails a less invasive technique that preserves

the posterior elements. Some studies have also reported the good results

of MBDU for LCS in cases with instability or scoliosis. However, few

reports examine the risk factors that might preclude certain patients

from MBDU. The purpose of this research was to evaluate the radio-

graphic risk factors of required reoperations after MBDU.

Methods: Between 2007 and 2010, 255 patients underwent MBDU our

institution. Of them, 48 were lost follow up. A total of 207 patients (309

discs; 88 women 119 men; age range, 40-86 years; mean age, 70 years)

were included in this study (follow-up ratio: 81.2 %), and the duration of

the follow-up was 24 months. The radiological indications were lumbar

spinal stenosis, degenerative lumbar spondylolisthesis with slip-

page\ Meyerding Grade I, or degenerative lumbar scoliosis with\ 20�Cobb’s angle. We investigated the prevalence of cases that required

reoperation, these cases’ clinical characteristics, and the risk factors

associated with reoperation after MBDU.

Results: Reoperation after MBDU was needed in 13 cases (6.3 %). The

cause of reoperation was radicular pain due to intraforaminal stenosis in 6

cases, development of disc herniation in 4 cases, exacerbation of disc

degeneration in 2 cases, and low back pain due to intraspinal facet cyst in

1 case. The duration from the initial operation to reoperations for radic-

ular pain due to intraforaminal stenosis or due to the development of disc

herniation was 6 months, which is very short for this condition. The

Japanese Orthopedic Association (JOA) Scores of the cases was 9.8

points preoperatively. It aggravated to 7.8 points before the second

operation, and reached 12.8 points at the final follow up. The L4/5 cases

with reoperation were significantly associated with scoliotic disc wedg-

ing and lateral listhesis in the prone position. The odds ratio of scoliotic

disc wedging and lateral listhesis was 9.88 and 12.6, respectively.

Conclusions: There is no consensus about the inclusion criteria of

MBDU for LCS in cases involving AP slippage, lateral listhesis, or

scoliotic disc wedging, such as spondylolisthesis and degenerative sco-

liosis. From this study, surgeons should be cautious about indicating

MBDU for cases with scoliotic disc wedging or lateral listhesis in L4/5.

P21

CLINICAL CHARACTERISTICS OF INTRASPINAL

FACET CYSTS FOLLOWING MICROSURGICAL

BILATERAL DECOMPRESSION VIA A UNILATERAL

APPROACH FOR TREATMENT OF DEGENERATIVE

LUMBAR DISEASE

Minori Kato, Hiroaki Nakamura, Koji Tamai, Kazunori Hayashi,

Akira Matsumura, Sadahiko Konishi

Orthopaedic Surgery, Osaka, Japan

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Purpose: Primary intraspinal facet cysts in the lumbar spine are

uncommon, but it is unclear whether cyst incidence increases following

decompression surgery and if these cysts negatively impact clinical

outcome. We examined the prevalence, clinical characteristics, and the

risk factors associated with intraspinal facet cysts after microsurgical

bilateral decompression via a unilateral approach (MBDU) which

entails a less invasive technique that preserves the posterior elements,

including the paravertebral muscle, facet joints, and lamina.

Methods: We studied 230 patients treated using MBDU for lumbar

degenerative disease (133 men and 97 women; mean age, 70.3 years).

Clinical status, as assessed by the Japanese Orthopedic Association

(JOA) score and findings on X-ray and magnetic resonance images,

was evaluated prior to surgery and at both, 3 months and 1 year after

surgery. The prevalence of intraspinal facet cysts was determined and

preoperative risk factors defined by comparing presurgical findings

with clinical outcomes.

Results: Thirty-eight patients (16.5 %) developed intraspinal facet cysts

within 1 year postoperatively, and 24 exhibited cysts within 3 months.

In 10 patients, the cysts resolved spontaneously 1 year postoperatively.

In total, 28 patients (12.2 %) had facet cysts 1 year postoperatively. The

most common sites in all groups were L3–4 and L4–5; few cysts

developed at L2–3 and L5–S1. The mean JOA score of patients with

cysts 1 year postoperatively was significantly lower than that of patients

without cysts. This poor clinical outcome resulted from low back pain

that was not improved by conservative treatment. Most cases with

spontaneous cyst disappearance were symptom-free 1 year later. The

preoperative risk factors for postoperative intraspinal facet cyst forma-

tion were instability (OR: 2.47, P = 0.026), scoliotic disc wedging (OR:

2.23, P = 0.048), and sagittal imbalance (OR: 2.22, P = 0.045).

Conclusions: Postoperative intraspinal cysts should be recognized as

a common cause of postoperative symptom deterioration following

MBDU. Postoperative intraspinal facet cyst formation is a common

cause of poor clinical outcome in patients treated using MBDU. We

suggest caution in using MBDU for patients with instability, scoliotic

disc wedging, or sagittal imbalance, because a fusion operation

should be considered as an alternative in such situations.

P22

DEVELOPMENT OF A CLINICAL DECISION TOOL

TO SUPPORT SPINE SURGEONS IN THE TRIAGE

OF CHRONIC LOW BACK PAIN PATIENTS

Miranda van Hooff, Jan van Loon, Jacques van Limbeek,

Marinus de Kleuver

Sint Maartenskliniek Research, Nijmegen, Netherlands

Introduction: Chronic Low Back Pain (CLBP) is the most common

complaint for patients to visit a spine surgeon. International guide-

lines recommend developing a system that helps to direct both

surgical and non-surgical interventions. In Sint Maartenskliniek in the

Netherlands, a specialized hospital for spine care, a clinical decision

tool has been developed to support patient-triage. The tool is based on

evidence and professional consensus (Delphi procedure) and consists

of a web-based screenings questionnaire and a decision algorithm.

Patients presenting with CLBP are systematically followed over time.

We speculate that different patient profiles might be identified likely

to benefit from different recommended interventions such as surgery

or a Combined Physical and Psychological (CPP) program.

Purpose: To evaluate pre-intervention patient profiles based on

indicators predicting favorable outcome in spine surgery or the evi-

dence-based CPP program.

Methods: To attend a first consult, new patients have to complete an

extensive web-based screenings questionnaire (based on 48 predictive

indicators in 5 domains: sociodemographic, pain, somatic [red flags],

psychological [yellow flags], and functioning & quality of life). The spine

surgeons follow their decision making process as usual. Between April

2012 and March 2013 1,106 new CLBP patients completed the screen-

ings questionnaire: 82 (7.4 %) were indicated for spinal surgery and 97

(8.8 %) for the CPP program. A cross-sectional study on the screening

data was performed. Chi square tests for categorical variables and inde-

pendent Students’t tests for continuous variables were used to evaluate

differences in patient characteristics.

Results: Significant differences for: ‘age’, ‘leg pain intensity’, ‘pre-

vious back surgery’, ‘pension income’, ‘compensation sick leave’,

‘pain duration’(over 2 years), ‘yellow flags’, ‘expectations work

return’, and ‘expectations recovery’. Surgery patients e.g. reported

more leg pain, more previous surgeries, and shorter pain duration.

Although expected, surprisingly no significant differences between

cohorts were found for red flags and co-morbidities.

Discussion: Although some differences were found, large cohorts

with long follow-up periods are needed to be conclusive about the

probability of success in different treatment modalities. If indeed

these profiles can be identified, it would help practitioners to triage

the right patients to the spine surgery clinics. This would potentially

increase the effectiveness of these clinics, improve outcomes, and

lead to more appropriate use of limited health care resources. To our

knowledge this is a first attempt to find differences in profiles, based

on a wide range of indicators predicting treatment outcome. Since the

patient flow and assignment is still on-going, we will present the most

recent results at the time of the meeting.

P23

CLINICAL OUTCOMES OF A COMBINED

PHYSICAL AND PSYCHOLOGICAL PROGRAM

IN A LARGE COHORT OF LONGSTANDING

CHRONIC LOW BACK PAIN

Miranda van Hooff, John O’Dowd, M Spruit, Marinus de Kleuver,

Jeremy Fairbank, Jacques van Limbeek

Sint Maartenskliniek Research, Nijmegen, Netherlands

Introduction: Combined physical and psychological (CPP) programs

are widely recommended in international guidelines for Chronic Low

Back Pain (CLBP), but not often implemented. A two-week CPP

program is delivered in partnership with the spine surgeons of Sint

Maartenskliniek, the Netherlands. In a previous study the participants

(n = 107) learned to manage CLBP, improved in functional status

and quality of life at one-year follow up. After two years, the same

cohort showed maintenance of this improvement. As systematic

outcome measurement is part of the program, a large database

(n = 955) with one-year data is available.

Purpose: Review of the one-year follow-up clinical outcomes of a

large cohort (n = 848) and compared the results with previously

published results (n = 107).

Methods: Pre-treatment age (43.4 years [SD 8.4]), CLBP duration

(12.3 years [SD 10.9]), patients at work (70 %), and spinal surgery

before (32 %) were compared. Primary outcome: functional status

(Oswestry Disability Index [ODI; 0-100]). Secondary outcomes: self-

efficacy (Pain Self Efficacy Index [PSEQ; 0-60]), and Quality of Life

(SF36 Physical Component Scale [SF36PCS; 0-100])). Chi square

tests for categorical variables and independent Student’s t tests for

continuous variables were used to evaluate differences in pre-

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treatment characteristics. For the outcomes a Repeated Measures

analysis of variance was used to identify changes over time (within-

subject factor; R2) and to compare differences between cohorts

(between-subject factor). The one-year follow-up proportion of CLBP

patients reaching a functional status equivalent to an acceptable or

‘normal’ value (ODI B 20), is calculated.

Results: Except for age (48.0 [SD 11.6], t = -4.0, p \ 0.001), no

significant differences in pre-treatment characteristics were found.

The mean primary outcome score showed a similar pattern:

improvement immediately after following the program and mainte-

nance of results over time (ODI df(1,848), F = 917.0, p \ 0.001,

R2 = 0.52). Secondary outcomes showed the same pattern. Com-

pared to previously reported (n = 107), all outcomes showed

significantly more improvement over time. One-year follow-up pro-

portion reaching ODI ‘satisfactory’ value: 50.1 %.

Conclusion: The study results contribute to the evidence for the

efficacy of this CPP program. Patients improve during the pro-

gramme, have further improved at one year follow up, and half of the

patients improve such that their function is not significantly restricted

to a normal range.

P24

CAUDA EQUINA SYNDROME, TIMING

OF SURGERY AND AUTONOMIC OUTCOME

Nisaharan Srikandarajah, Simon Clark, Tim Pigott, Martin Wilby

Neurosurgery, Liverpool, UK

Objectives: Cauda equina syndrome (CES) is a severe neurological

disorder most commonly due to lumbar disc herniation with signifi-

cant compression on the cauda equina. The most distressing

consequence generally is loss of bladder control. There is much

debate regarding timing of surgery. Our aim was to analyse if oper-

ating within the 48 h actually made any difference to bladder

function.

Methods: We retrospectively reviewed 50 patients who had under-

gone surgery for CES due to herniated lumbar disc between 2000 and

2007 at a single neurosurgical centre. All cases were verified with

MRI lumbar spine. Data collected included age, pain distribution, date

of hospital admission and operation, level of operation, length of

autonomic symptoms before operation, time to initial follow up and

autonomic outcome. Presentation was categorized into cauda equina

syndrome with retention (CESR) and cauda equina syndrome

incomplete (CESI). Outcome measures of were documented at initial

follow up.

Results: 50 patients of whom 30 were female and 20 were male with

an average age of 42 years. All patients had emergency decompres-

sive surgery within 24 to 48 h of admission to the neurosurgical unit.

37 patients presented with unilateral leg pain and 13 with bilateral leg

pain. Average follow up time was 81 days. 32 patients presented with

CESI and 18 patients presented with CESR. For all the 15 CESI

patients operated within 48 h of onset of autonomic symptoms normal

bladder function was seen at follow up however with 15 CESI

patients operated after 48 h 2 had a negative outcome of bladder

dysfunction. For the 18 CESR patients operating within 24 h, within

48 h or after made no significant difference to the outcome.

Conclusions: In our study emergency decompressive surgery within

48 h of onset of autonomic symptoms in CESI patients can prevent

bladder dysfunction. This encourages prompt referral and surgical

management within 48 h of patients presenting with CESI to reduce

the possibility of bladder dysfunction. For CESR patients operating

within 48 h made no difference to their outcome.

P25

RELATIONSHIP BETWEEN SEDIMENTATION

SIGN AND MORPHOLOGICAL GRADE

IN SYMPTOMATIC LUMBAR SPINAL STENOSIS

Pietro Laudato, Gerit. Kulik, Katarzyna Pierzchala,

Constantin Schizas

Orthopedics, Centre Hospitalier Universitaire Vaudois and the

University of Lausanne, Lausanne, Switzerland

Introduction: Dural sac cross sectional area has been the main

radiological measurement used in clinical practice. The morphologi-

cal grading of stenosis (rootlet/cerebrospinal fluid) consists of 4

grades (A to D), better presents the degree of entrapment of the neural

structures and carries a prognostic value, with C and D grades being

likely to fail conservative measures. Another team described the

sedimentation sign, measured on axial MRI images to discriminate

patients with neurological claudication from asymptomatic subjects.

Our objective was to find the relationship between those two

descriptions.

Methods: 137 patients were divided in three groups: patients with

symptomatic lumbar spinal stenosis (LSS); 69 treated surgically and

41 conservatively, and low back pain (LBP) control group of 27

subjects. We studied the morphological grade of stenosis at disc level

and evidence of positive sedimentation sign.

Results: Sedimentation sign was positive in none of Grade A levels, in

58 % of grade B, in 69 % of grade C and 76 % of grade D levels. The

sedimentation sign was positive in 66 % of the surgically and in 39 % of

the conservatively treated patients and only in 8 % of the LBP patients.

Comparing LSS and LBP patients, presence of a sedimentation sign in

the LSS group had a sensitivity of 56 %, a specificity of 93 %, a positive

predictive value 97 % and a negative predictive value of 34 % (odds

ratio (OR) of 16 between those two groups). In the group of patients with

LSS who were either treated surgically or conservatively the presence

of a sedimentation sign in the surgical group carried a sensitivity of

66 %, a specificity of 60 %, a positive predictive value 74 % and a

negative predictive value of 52 %. (OR of 3.13 between the two LSS

groups). C or D morphological grades were present in 97 % of the

surgical group, in 41 % (17/41) of the conservative group and in 18 %

of the LBP group. The presence of a C or D grade was a strong predictor

of surgical treatment in the LSS group (OR 47, P \ 0.001).

Discussion: In this patient cohort presence of a C or D stenosis grade

was a stronger predictor of failure of conservative treatment than the

positive sedimentation sign. Sedimentation sign might be more useful

to identify patients to the claudicating or non-claudicating population

than for deciding which patient needs surgical treatment. Being

measured at pedicle level it is probably not suited in deciding which

levels need to be surgically decompressed.

P26

NEUROLOGICAL MANIFESTATIONS

OF THORACIC MYELOPATHY IN 203 PATIENTS

Shota Takenaka, Takashi Kaito, Noboru Hosono, Toshitada Miwa,

Takenori Oda, Shinya Okuda, Tomoya Yamashita,

Kazuya Kazuya Oshima, Kazuo Yonenobu

Orthopaedic Surgery, Osaka, Japan

Study Design: Retrospective, multi-institutional study.

Eur Spine J (2013) 22 (Suppl 5):S720–S766 S729

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Objective: To identify clues for the early diagnosis of thoracic mye-

lopathy by detailed investigation of the preoperative manifestations.

Summary of Background Data: Detailed investigation of the pre-

operative manifestations of thoracic myelopathy in a large population

has not been reported.

Methods: The subjects were 203 patients (142 men, 61 women; mean

age, 62.2 years; range, 21-87 years) with thoracic myelopathy who

underwent surgery at our affiliate institutions from 2000 to 2010. The

disease distribution was ossification of the ligamentum flavum (OLF)

in 106 patients, ossification of the posterior longitudinal ligament

(OPLL) in 16, OLF with OPLL in 17, disc herniation (DH) in 22,

OLF with DH in 3, and spondylosis in 39. Assessments were made of

(1) the earliest complaints and preoperative complaints, (2) neuro-

logical findings, (3) Japanese Orthopaedic Association score (full

score, 11 points), (4) the compressed segments, and (5) preoperative

duration. Multivariate analyses were performed to examine the rela-

tionships between the preoperative manifestations and causative

diseases or compressed segments.

Results: The multivariate analyses revealed relationships between:

lower limb muscle weakness and T10/11 anterior compression; low

back pain and T11/12 compression; lower limb pain and T10/11 or

T11/12 anterior compression; drop foot and T12/L1 anterior com-

pression; and hyporeflexia in the patellar tendon reflex and T11/12

compression or T12/L1 anterior compression.

Conclusions: This study demonstrated that there are characteristic

relationships between several preoperative manifestations and com-

pressed segments among a variety of symptoms caused by thoracic

myelopathy. These relationships can be helpful in the initial investi-

gation of thoracic diseases, though additional modalities such as MRI

or CT are necessary for definitive diagnosis.

P27

GENDER DIFFERENCES IN LUMBAR

DEGENERATIVE SPONDYLOLISTHESIS: IMAGE

ANALYSIS

Kosuke Tateishi, Shota Takenaka, Yoshihiro Mukai, Noboru Hosono,

Takeshi Fuji

Department of Orthopaedic Surgery, Osaka Koseinenkin Hospital,

Osaka, Japan

Introduction: The incidence of degenerative spondylolisthesis is 4

times more in women than in men. Although this gender difference

has long been recognized, the reasons underlying the difference have

not been elucidated. We performed image analysis to address this

issue.

Materials and methods: We divided 124 patients (age, more than

50 years) who underwent posterior lumbar interbody fusion for L4

spondylolisthesis between 2009 and 2011 into 2 groups: Group M (50

men) and Group F (74 women). We measured the vertebral slip (mm),

lamina inclination (degree) of L4, and intervertebral angle (degree)

between L4/5 and L5/S in flexion radiographs. The L4/5 and L5/S

intervertebral height and L5 vertebral height were measured using

computed tomography (CT), and then the ratio of the intervertebral

height to the L5 vertebral height was calculated. We also measured

the angle of the L4/5 facet joints on the CT scans, as described by

Grobler and Wiltse. Facet sagittalization was defined as the sum of

the right and left facet angles. The pre-operative clinical findings were

evaluated using the Japan Orthopedic Association (JOA) score. Sta-

tistical significance of the data was evaluated using Student’s t test. A

p value of \ 0.01 was considered significant.

Results: No significant age-related differences were observed in the

pre-operative JOA scores of the patients in Groups M and F. The

vertebral slip and lamina inclination were significantly greater in

Group F (M vs. F: 5.9 mm vs. 7.7 mm, 114.7� vs. 118.4�, p \ 0.01).

Although there was no significant difference in the ratio of the L4/5

intervertebral height to L5 vertebral height between Groups M and F,

the ratio of the L5/S intervertebral height to the L5 vertebral height

was significantly greater in Group F (0.48 vs. 0.3, p \ 0.01). There

was no significant difference in facet sagittalization between Group M

and Group F.

Discussion/Conclusion: The ratio of the L5/S height to the L5 height

was significantly smaller in Group M. This study suggested that the

degenerative change of L5-S1, which could lead to less mobility, might

promote L4 spondylolisthesis in men. In contrast, the vertebral slip

between L4 and L5 was greater in Group F, although the ratio of L5/S to L5

did not decrease. These data suggest that the pathology of spondylolis-

thesis differs in men and women. It is possible that L4 spondylolisthesis in

men is an adjacent segment disease of L5/S spondylosis.

P28

NEGATIVE BELIEFS AND PSYCHOLOGICAL

DISTURBANCE IN SPINE SURGERY PATIENTS:

A CAUSE OR CONSEQUENCE OF A POOR

TREATMENT OUTCOME?

Sina Havakeshian, Anne F Mannion

Spine Center, Schulthess Klinik, Zurich, Switzerland

Introduction: Chronic musculoskeletal pain is often associated with

psychological distress/maladaptive beliefs and these may have a negative

impact on surgical outcome. The influence of a surgical intervention, and

its outcome, on the course of change in psychological status has been

poorly documented. We prospectively examined the dynamic interplay

between psychological factors and outcome in patients undergoing

decompression for spinal stenosis/herniated disc.

Methods: Before and 12 mo after surgery, 159 patients (100 M, 59 F;

65 ± 11 y) completed questionnaires enquiring about socio-demo-

graphics, medical history, pain characteristics, psychological

disturbance, catastrophising, disability (Roland & Morris), general health

and Fear Avoidance Beliefs about physical activity (FABQ-PA). The

global outcome of surgery at 12 mo was rated using a 5-point Likert scale

and dichotomised as ‘‘good’’ (operation helped/helped a lot) or ‘‘poor’’

(operation helped only little/didn’t help/made things worse).

Results: Questionnaire data were available for 148 patients at 12mo

follow-up: 113 (76.4 %) reported a good outcome and 35 (23.6 %) a

poor outcome. In univariate analyses the following each significantly

(p \ 0.05) predicted a good 12mo global outcome: no disability

claim, and lower values for LBP frequency, average pain score,

FABQ-PA, and catastrophising. In multiple logistic regression, only

lower FABQ-PA scores (OR 0.877 (95 %CI 0.809-0.949), p = 0.001)

and lower LBP-frequency (OR 0.340 (1.249-1.783), p \ 0.0001)

significantly predicted a good outcome at 12mo. A second ‘‘explan-

atory’’ logistic regression model revealed that a good outcome at 12

mo was significantly associated with improvements (pre-op to 12mo)

in: average pain score (OR 1.6879 (1.187- 2.398), general health (OR

1.246 (1.004-1.545), psychological disturbance (OR 1.073 (1.006-

1.144), and Roland Morris (OR 1.243 (1.074-1.439).

Conclusion: In a multivariable predictive model, FABQ-PA was the

only psychological factor that significantly predicted outcome. Future

studies should assess whether preoperative cognitive-behavioural

therapy in patients with maladaptive beliefs improves treatment out-

come. Psychological disturbance did not predict outcome, but

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improved in patients with a good outcome and worsened in those with

a poor outcome. Rather than being a risk factor for poor outcome, it

appeared to be a consequence of long-standing, unremitting pain that

improved when symptoms were resolved after successful surgery.

P29

COMPLICATIONS AND RISK FACTORS

IN PATIENTS WITH AGE [ 50 AFTER SURGICAL

TREATMENT WITH INSTRUMENTATION [ 5

LEVELS: A SINGLE SURGEON EXPERIENCE

Sinan Kahraman, Gurkan Gumussuyu, Cagatay Ozturk,

Bekir Yavuz Ucar, Tunay Sanli, Wael Elkasem, Alaa Zakaout,

Azmi Hamzaoglu, Ahmet Alanay

Istanbul Spine Center, Istanbul, Turkey

Introduction: Aims were to evaluate relevance of patient’s and surgical

characteristics in development of postoperative complications following

surgical treatment of pts over age 50 and with [ 5levels of instrumen-

tation and fusion.

Methods: 137 consecutive pts (93F and 44 M), av age 67 years (50-

85) were included. All procedures performed by single surgeon in a

single center. Hospital charts were reviewed to analyze comorbidities,

intraoperative blood loss, operative time, ICU stay, hospital stay,

minor and major complications. ODI scores were used to assess

preoperative and follow up outcomes.

Results: Av f/up was 45 months (24-120). Etiologies were degenerative

spinal stenosis (111), adult scoliosis (14), spondylodiscitis (8), and

fracture (4). Sixty-six (48.1 %) patients had at least 1 comorbidity. Av

intraoperative blood loss was 2369 cc (200-8000). Av. number of

instrumented levels/patient was 7.6 (5-16)0.44 (%32.1) patients had

operations more than 10 h. Av. ICU stay was 1.82 (1-6) and hospital stay

was 19.6 (6-47) days. 46 patients (%33.5) had at least 1 prior spinal

surgery. Overall complication rate was 48.2 % including 9.49 % major

(deep infection, pneumonia, pseudoarthrosis, vascular injury) and

38.7 % minor complications (arytmia, dural tear, DVT, hematoma,

wound detachment, gastrointestinal, urinary infection, screw loosening)

0.22 (16 %) pts had re-interventions to treat complications. ODI

improved from 51.2 to 26.7 (%52.1) (p\ 0.001). Hypertension

(P = 0.001), male gender (P = 0.025) obesity (P = 0.02) and revision

surgery (P = 0.001) were risk factors for minor complications. Obesity

(P = 0.002) was found to be a risk factor for major complications.

Complications had no effects on ODI.

Conclusion: There is a high complication rate after spinal operations with

long ([5 levels) instrumentation in elderly patients ([50 years). Obesity,

hypertension, male gender and revision surgery are risk factors. However,

the outcome improves significantly despite high complication rates.

P30

PROPHYLACTIC VERTEBROPLASTY OF ADJACENT

NON-FUSED SEGMENT(S). ITS EFFECT

ON ADJACENT DISCS AND THE INFLUENCE

OF SAGITTAL MALALIGNMENT ON ITS

EFFICACY? AN MRI STUDY

Sinan Kahraman, Meric Enercan, Gurkan Gumussuyu,

Cagatay Ozturk, Levent Ulusoy, Azmi Hamazaoglu, Ahmet Alanay

Istanbul Spine Center, Istanbul, Turkey

Introduction: Prophylactic vertebroplasty (PV) has been used to

prevent failure of non-fused adjacent segment failure (ASF) over the

long-construct fusions in elderly osteoporotic pts. However, there is

still concerns that PV may not be protective against ASF if there is

sagittal malalignment after surgery. One other concern is the

decreased nutrition of the disc below the augmented level due to

cement in the vertebral body causing adjacent segment disc degen-

eration (ASD) and PJK. The aim of this study was to analyse the

efficacy of PV, its effects on adjacent discs and the effect of residual

sagittal malalignment on the success rate of PV. To our knowledge

this is the first study, analysing the adjacent discs by MRI minimum

2 years after PV procedure.

Methods: 48 (35F,13 M) elderly osteoporotic pts. (mean age

68;range 52-85) treated with minimum 5 levels instrumentation and

one or more levels PV with at least 2 years f/up (mean 42.5; range24-

70 months) were included. Amount of cement injected was 2 cc. in

upper thoracic spine and 3 cc. in lower thoracic spine. All patients

had preop and F/up ([ 2 years) MRI’s. All discs at PV levels were

evaluated in terms of disc degeneration by using Phirmann classifi-

cation. Sagital plane x-ray measurements were done to classify post-

op and f/up sagittal plane alignment according to Schwab sagittal

modifiers. PJK was determined as the cobb measurement between the

UIV and 2 levels above. All adjacent segments were analysed to

determine ASF.

Results: Av. instrumentation level was 7.35 (5-16). Av level of PV

was 1.25 (1-3). PV was performed at upper thoracic spine (T2-5) in 3

pts and lower thoracic spine in 45 pts. 60 % of pts had perfect sagittal

alignment while 40 % had abnormal sagittal alignment at f/up

according to Schwab sagittal modifiers. PJK was observed in 10 % of

pts. ASD below the PV level was observed in 20 % of pts. None of

the patients had adjacent segment collapse/fracture. There was no

correlation between the sagittal malalignment and adjacent segment

degeneration, PJK or ASF (p [ 0.05).

Conclusions: PV is effective to prevent ASF. ASD after PV below the

PV level is comparable to ASD incidence after long fusions with no PV.

Less than optimal sagittal alignment has no effect on the efficacy of PV.

P31

HOW DO ADOLESCENTS WITH IDIOPATHIC

SCOLIOSIS PERCEIVE THEIR EXPERIENCE

OF BRACING? AN EVIDENCE BASED QUESTION

Sriram Harish Srinivasan, Cheryl Honeyman

Orthopaedics and (2)South Tees Hospital NHS Trust, Leicester, UK

Introduction: Bracing is considered when the curvature of spine is

between 20� to 50�, the patient is skeletally immature and the curve is

progressing (Bono, 2007). There is level II evidence suggest that

bracing can reduce curves. Braces need to be worn full time for them

to be effective (Negrini et al., 2010), Poor compliance is strongly

correlated with brace treatment failure and appropriate support pro-

mote compliance of treatment.

Self-esteem is very unstable during early adolescence and particularly

low self-esteem has been linked to stress. We identified a lack of

support given to adolescents needing brace therapy for idiopathic

scoliosis.

The aim of the study was to explore adolescents’ feelings about their

experience of wearing a spinal brace, and their opinions on support

provided by professionals and families. There is evidence of literature

linking bracing to low body image and reduced quality of life.

Eur Spine J (2013) 22 (Suppl 5):S720–S766 S731

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Methods: We searched the literature for evidence and databases such

as Medline, Pubmed and Cochrane. Individual articles were looked

one by one sequentially. We reviewed wide range of publications.

Only one paper by Sapountzi-Krepia et al., 2006 was appropriate, and

appraisal of the paper was done.

Results: There is evidence available that there is lack of support given

to adolescents with idiopathic scoliosis undertaking a bracing pro-

gramme which was identified as a source of concern.

Conclusion: The evidence is to recommend changes in practice, that

ensure support to be given to adolescents undergoing a bracing pro-

gramme, including input from psychologists and regular monitoring

of patient satisfaction.

P32

DOES THE FUSION STATUS AFTER POSTERIOR

LUMBAR INTERBODY FUSION AFFECT

THE PATIENT-BASED QOL OUTCOMES? -AN

EVALUATION USING PATIENT-BASED

OUTCOME MEASURE (JOABPEQ)

Takahiro Makino, Takashi Kaito, Hiroyasu Fujiwara, Takahiro Ishii,

Kazuo Yonenobu

Department of Orthopaedic Surgery, National Hospital Organization

Osaka Minami Medical Center, Kawachinagano, Japan

Purpose: Delayed union or non-union is one of the major complications

of posterior lumbar interbody fusion (PLIF). However, little has been

known about the effect of fusion status on patients’ quality of life (QOL).

The purpose of this study was to investigate the effect of fusion status

after PLIF on patient-based QOL outcomes using Japanese Orthopaedic

Association Back Pain Evaluation Questionnaire (JOABPEQ).

Methods: A total of 57 patients (33 men, 24 women) who underwent

single level PLIF (including the patients with laminectomy combined

with PLIF at other levels) for lumbar spinal canal stenosis were

included. The mean age at the surgery was 65.3 years (range,

29-89 years). Fusion status was evaluated from dynamic lateral plain

radiographs at 6 month after surgery. Overall clinical severity was

assessed using Japanese Orthopaedic Association Score for Low Back

Pain (JOA score) before and 6 months after surgery. The patients

answered JOABPEQ (patient-based evaluation questionnaire referred

to the Japanese editions of SF-36 and the Roland-Morris Disability

Questionnaire, which consists of 25 questions and is calculated for

five functional scores for corresponding domains according to the

provided calculating formulas) before and 6 months after surgery.

The amounts of changes (postoperative scores - preoperative scores)

in all 5 subscales of JOABPEQ (low back pain, lumbar function,

walking ability, social life function, and mental health) were calculated

and compared between fusion and incomplete fusion groups.

Results: The fusion rate was 71.9 % (41 of 57 patients). The age,

gender, presences of laminectomy, number of laminectomy level,

fusion level, pre- and post-operative JOA score, or recovery rate of JOA

score were not different between fusion (n = 41) and incomplete fusion

(n = 16) group. However, the amount of changes in the subscales of

low back pain and social life function in fusion group were significantly

greater than incomplete fusion group (low back pain, 56.7 vs. 16.5,

p \ 0.01; social life function, 40.0 vs. 22.8, p = 0.01).

Conclusions: This study using patient-based QOL outcome measure

(JOABPEQ) revealed that incomplete fusion after PLIF correlated

with disability from low back pain and lack of social life function,

though the clinical severity assessed by physician (JOA score) did not

have significant correlation with fusion status. Fusion status had an

adverse impact on patients’ QOL after PLIF.

P33

A MINIMALLY INVASIVE SURGICAL APPROACH

REDUCES CRANIAL ADJACENT SEGMENT

DEGENERATION IN PATIENTS UNDERGOING

POSTERIOR LUMBAR INTERBODY FUSION

Takahiro Tsutsumimoto, Mutsuki Yui, Shota Ikegami, Masashi

Uehara, Hidemi Kosaku, Hiroshi Ohta, Hiromichi Misawa

Spine Center, Yodakubo Hospital, Nagano, Japan

Background: The multifidus (MF) muscle plays a role in lumbar seg-

mental stability. Posterior lumbar interbody fusion (PLIF) using the

Wiltse approach (minimally invasive surgery for PLIF; MIS-PLIF) does

not involve the detachment of the MF from the cranial adjacent facet

joints and spinous process; thus, this procedure has a theoretical advan-

tage over conventional open PLIF in that it reduces iatrogenic cranial

adjacent segment degeneration (ASD). To examine this hypothesis, we

compared the incidence of cranial ASD after MIS-PLIF and open PLIF.

Methods: From 2004-2006, 23 consecutive patients had undergone L4-

L5 PLIF with cages and pedicle screws (PS) through the Wiltse

approach: all procedures including cages and PS insertion were per-

formed through expandable tubular retractors placed in the gap between

the MF and the longissimus on both sides. Of the 23 patients, 1 with

Parkinsonism was excluded and the remaining 22 (mean age,

61.2 years) were retrospectively reviewed (MIS group). The mean

follow-up period was 5.7 years (range, 2-8.5 years). The open group

comprised 19 age- and gender-matched patients who had undergone

PLIF through the conventional midline approach before 2004. All

patients were followed up every 6 months after surgery. Surgical results

were evaluated using the MacNab criteria. ASD at the L3-L4 level was

assessed using plain radiography and magnetic resonance imaging,

irrespective of the presence or absence of clinical symptoms. Any

deterioration of the preoperative University of California at Los

Angeles Grading Scale or the postoperative development of stenosis,

herniation, vertebral compression fractures, spondylolisthesis, or

instability at the adjacent levels was considered indicative of ASD.

Result: Fusion was achieved in all patients in both groups. Excellent or

good outcomes were observed in 86 % (19/22) of the patients in the MIS

group. Postoperative segmental angle at the L4-L5 level was not signif-

icantly different between the 2 groups (P = 0.2). Cranial ASD developed

in 3 cases in the MIS group and in 9 cases in the open group. Kaplan–

Meier analysis showed that 94 % of the patients in the MIS group and

68 % of the patients in the open group survived for [ 3 years, while

88 % of the patients in the MIS group and 51 % of the patients in the open

group survived for [ 5 years (log-rank test, P = 0.04).

Conclusion: MIS approach potentially contributes to a lower risk of

cranial ASD in patients undergoing PLIF.

P34

CLINICAL VALUE OF RADIOGRAPHIC

SAGITTAL PARAMETERS IN ADULT SCOLIOSIS

GREATER THAN 408 FOR PATIENTS OLDER

THAN 40 YEARS

Tamara Rodriguez Lopez, Felisa Sanchez-Mariscal,

Ana Nunez-Garcia, Alejandro Gomez-Rice, Patricia Alvarez-Gonzalez,

Lorenzo Zuniga-Gomez, Javier Pizones, Enrique Izquierdo-Nunez

Spine Unit, Getafe, Spain

Introduction/Aim: Sagittal plane alignment is increasingly recog-

nized as a critical parameter in the setting of adult spinal deformity. A

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positive sagittal balance (SVA), an increased pelvic tilt (PT) and a

reduced lumbar lordosis are prognostic factors for poor clinical out-

come for adult scoliosis.

The present study was carried out in an attempt to answer this question:

In older than 40 years patients with a mainly frontal deformity (‘‘no N’’

type, Schwab 2012) what is the role of sagittal parameters?

Methods: 40 patients (35 female), 55 years old (41-74) at surgery

time. Scoliosis greater than 408 (28 idiopathic, 12 degenerative).

Mean postoperative follow-up 7.4 years.

-New full length standing radiographs were obtained and every patient

completed SRS 22 and SF36 questionnaires at the time of enrollment.

-Thoracic kyphosis (TK), Thoracolumbar Kyphosis (TLK), LL, SVA,

Spinosacral angle (SSA), Spinal Tilt (ST), pelvic sagittal parameters,

pelvic incidence-lumbar lordosis discordance (PILL)), needed lumbar

lordosis (ideal -measured) and main curve Cobb angle were measured.

Results: 1) Preoperatively an increased TLK was found (13.88), as

well a pelvic tilt near to the superior limit of the normal ranges (20.

98) and a reduced LL (LL = 488 and needed lordosis = 148).28) Through postoperative follow-up significant changes in some

radiographic parameters were identified, mainly towards a worse

sagittal profile (except TLK).

38) Patients were asked the following: ‘‘Do you think surgery was

worth it?’’ 82.5 % yes; 10 % No; 7.5 % in doubt.

48) At final follow-up there was a significant correlation (Pearson

coefficient) between the SRS activity domain an ST (p = 0.001;

r = 0.54), PT (p = 0.008; r = -0.42) and PILL (p = 0 047 r = -

0.32). After multiple linear regression only ST persisted as possible

predictor for worse SRS activity scores.

Some other less significant correlations were found.

Conclusion: Although some sagittal parameters are preoperatively

altered in adult scoliosis, they don’t seem sufficient to indicate sur-

gery, since their worsening through time does not seem to have an

impact in patient satisfaction with surgery.

-Through time, the only sagittal parameter that correlates with SRS

activity is ST.

-Sagittal plane does not seem to have a significant role as a prognostic

factor in adult patients with a mainly frontal deformity.

P35

SURGICAL TREATMENT FOR LUMBAR

DEGENERATIVE DE NOVO SCOLIOSIS

WITH SPINAL STENOSIS

Wei-feng HAN, Bao-ge LIU

orthopedic, Beijing, China

Objective: To investigate clinical effects of surgical treatment for

lumbar degenerative de novo scoliosis with spinal stenosis.

Methods: From June 2007 to January 2012, 26 patients of degener-

ative scoliosis with spinal stenosis were treated by operation, the

involved segments were determined by clinical manifestations,

radiographic documents and findings intra-operation. We carried out

posterior decompression on the segments and selected fusion on the

segments with preoperative instability or probably iatrogenic post-

operative unstable. Measured Cobb’s angle, focal lordosis angle, the

distance between C7 plumb line (C7PL) and upper edge of S1 ver-

tebral body (SVA), and the distance between C7PL and center sacral

vertical line (CSVL) after operation and final follow up were com-

pared with preoperative data. JOA score system were used to evaluate

clinical effects. The SF-36 questionary was used to evaluate the

patients’ life quality before and after operation as well.

Results: All the patients were followed up from 1.3 to 5 years with an

average of 2.5 years. Preoperative, postoperative and final follow up,

Cobb’s angle was (22.1 ± 10.5)�, (10.2 ± 7.3)�, (8.3 ± 4.8)�,

respectively; focal lordosis angle was (21.2 ± 10.3)�, (25.7 ± 12.2)�,

(31.5 ± 12.3)�, respectively; SVA was (7.5 ± 6.1) cm, (0.6 ± 3.1)

cm, (6.9 ± 5.3) cm, (-1.3 ± 2.4) cm, respectively; CSVL was

(2.7 ± 1.2) cm, (1.5 ± 1.1) cm, respectively. There was significant

difference in data before and after operation. Preoperative, instantly

postoperative, final follow up, JOA score was 10.8 ± 1.4, 21.3 ± 2.4,

23.5 ± 2.3, respectively; All domains of SF-36 score were signifi-

cantly improved postoperatively (P \ 0.05).

Conclusion: Surgical treatment with limited decompression, pedicle

screw fixation and fusion is effective method for degenerative scoli-

osis with spinal stenosis, individualized surgery design should be

made according to clinical symptoms, signs and imaging features.

Key words: lumbar scoliosis, degeneration, spinal stenosis, operation,

P36

A NOVEL CAUSE FOR CAUDA EQUINA

SYNDROME WITH A NEW RADIOLOGICAL SIGN

William Singleton, Devindra Ramnarine, Crispin Wigfield,

Nitin Patel

Department of Neurosurgery, Frenchay Hospital, Bristol, UK

Introduction: We present a case series of symptomatic, post lumbar

surgery cauda equina compression due to formation of a dissecting

subdural extra-arachnoid CSF collection (hygroma) under tension.

Surgical re-exploration and formal durotomy confirmed a tension

subdural extra-arachnoid hygroma due to one-way flow of CSF

through a pinhole puncture in the arachnoid. The diagnosis was made

surgically and is associated with a new clinically important and

pathognomonic radiological sign.

Methods: Prospective case series.

Results: In all 4 cases the MRI findings were identical. Axial images

showed central clumping of the nerve roots surrounded by a normal

CSF signal. The roots were gathered along a horizontal plane due to

lateral tethering of the dentate ligament. Surgical exploration was

successful in all cases with normal post-operative nerve function and

restoration of normal radiological anatomy.

Conclusions: Inadvertent durotomy during routine lumbar spinal

surgery is often uncomplicated if successfully repaired. However, if a

patient develops post operative diffuse lower limb or cauda equina

neurological symptoms, the rare entity of a dissecting subdural extra-

arachnoid tension hygroma should be considered in the differential.

The MRI appearances of this condition are unique and not previously

described by another group. If the diagnosis is suspected, surgical

exploration to decompress the cyst through wide opening of the

arachnoid should be considered and in this series proves successful.

ADULT THORACOLUMBAR SPINE,

NON-DEGENERATIVE

P37

ADJACENT SEGMENT INFECTION

AFTER SURGICAL TREATMENT

OF SPONDYLODISCITIS. A SERIES OF 23 CASES

AND REVIEW OF LITERATURE.

Ahmed Ezzat Siam, Heinrich Boehm

Spinal Surgery, Bad Berka, Germany

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Purpose: First series describing and analysing adjacent segment

infection (ASI) after surgical treatment of spondylodiscitis (SD).

Methods: Retrospective review summarising clinical, laboratory and

radiological findings. All patients with primary diagnosis as spondylo-

discitis, spondylitis and/or epidural, psoas abscess have been included,

who have been surgically treated and returned to our institution with SD

of the adjacent level. Between 1994-2012, 1187 patients have been sur-

gically treated of SD in our institution; 23 patients (10 M,13F) have

returned with ASI (1.94 %), with a mean age of 65.1 years. Primary

affection was lumbar in 13 (56.5 %), thoracolumbar in 4, thoracic in 3,

cervical in one and combined thoracic and lumbar in 2. Single level

affection was found in 16 patients (65.6 %), double level in 4 and 3-levels

in 3. Five patients had epidural abscess. Mean FU was 67.6 months after

primary surgery. Comorbidities were found in 19 (82.6 %); hypertension

(12), DM (7), osteoporosis (5) and IHD (5). Mean preoperative ASA

score was 2.7 indicating poor general condition. Seven patients had

coinciding infections elsewhere.

Results: Most common primarily involved levels were L3-4 (7), L4-5

(7) and L2-3 (5), while ASI involved most commonly L3-4 (7), T12-

L1 (5) and L2-3 (4). ASI affected cranial segment in 10, caudal

segment in 10, segment between two fused segments in two patients

and adjacent segments cranially and caudally in one patient.

Mean interval between operations of primary infection and ASI was

40.9 months. All cases needed surgical intervention; debridement and

fusion with longer instrumentation; with culture-sensitivity-based

postoperative antimicrobial therapy. Mean operative time was

201 min, with a mean blood loss of 1222,9 mL. Five patients died

within postoperative six months after ASI operation (21.7 %). No

organism was isolated in 11 patients.

At last FU, Eight patients (34.8 %) were mobilised in wheelchair with

a varying degree of paraplegia. (two had preexisting paralysis).

Conclusions: ASI after surgical treatment of SD is a rare complica-

tion (1.94 %), that has been previously only as sporadic cases

reported. This is the largest series describing this phenomenon. It is

associated with multimorbid conditions. This rare complication shows

a high postoperative mortality rate (21.7 %) and a high neurological

affection rate (34.8 %). Further studies are recommended for more

analysis, prevention and treatment methods of the condition.

P38

PERCUTANEOUS KYPHOPLASTY

VERSUS CONSERVATIVE TREATMENT

IN ACUTE AND SUBACUTE OSTEOPOROTIC

VERTEBRAL COMPRESSION FRACTURES

(OVCF): A DOUBLE-BLINDED, RANDOMIZED

CONTROLLED CLINICAL TRIAL (RCT)

IN THE POPULATION OF WESTERN CHINA

Ding Jun Hao, En Xie, Qi Ning Wu

Department of Orthopedic Surgery, Hong Hui Hospital, Jiaotong

University College of Medicine, Xi’an, China

Study Design: Double-blinded, randomized controlled clinical trial

(RCT).

Objective: Clinical efficacy comparisons between percutaneous

kyphoplasty (PKP) and conservative treatment (CT) for osteoporotic

vertebral compression fractures (OVCF) are reported.

Summary of Background Data: This is the first RCT to compare

percutaneous kyphoplasty with conservative treatment in acute and

subacute osteoporotic vertebral compression fractures (OVCF) in

Chinese population.

Methods: Between July 2007 and July 2010, 164 patients with acute

(within 2 weeks) or sub-acute (2 to 8 weeks) OVCF were enrolled in

this study. They were randomly assigned to CT and PKP. In the PKP

group, there were 47 men and 30 women, aged from 57 to 77 years

(average, 67 years); In the CT group, there were 43 men and 44

women, aged from 60 to 82 years (average, 67 years). Improvement

of symptoms, restoration of vertebral body height, correction of ky-

phosis, bone cement leakage, pain, physical and psychological

outcomes were reported. Visual analog scale (VAS), SF-36 form and

the Dallas questionnaire were used to evaluate the physiological and

psychological changes of patients.

Results: The patients had an average follow-up of 9 months (from 6

to 12 months). A considerable degree of pain relief was obtained in

both groups at post-operation and 3-month follow-up (P \ 0. 05).

There was no significant difference between the 2 groups in terms of

VAS scores at either preoperation or the last follow-up (P[ 0.05).

However, a significant difference of VAS scores was observed at the

24-hour postoperation (P\ 0.05). In the PKP group, the average anterior

vertebral body height was restored by 27.9 % (P \ 0. 05) and the average

vertebral kyphosis correction was 12.6� (P \ 0.05). There were no sig-

nificant differences between the 2 groups in postoperative scores in

Health Survey Short Form (standard physical components and standard

psychological components), Dallas Pain Questionnaire (activities of

daily living, work and play, anxiety and depression, social interests),

Barthel index, Mini-Mental State Examination (P[ 0.05).

Conclusion: Compared to the CT, application of PKP for acute and sub-

acute PVCF has advantages such as immediate pain relief, early return to

active lifestyle, restoration of the vertebral body height, correction of the

kyphosis, and reduction of complication. Although CT could also

improve the symptoms after 3 to 6 months treatment, the restoration of

vertebral body height and vertebral kyphosis correction is not ideal.

Vertebral compression fracture (VCF) was one of the commonest

cause osteoporosis fractures. There are over 700,000 VCF patients

yearly. Percutaneous kyphoplasty, PKP was a minimally invasive

surgical approach that uses interventional radiology technique and

involves the fluoroscopically guided injection of polymethylmeth-

acrylate (PMMA) through a needle inserted into a weakened

vertebral body. PKP and conservative treatment of the controversy

was big focus disputed problem by medical expert. In China, there

was no randomized controlled study reported in this regard. It was

still controversial to choose between PKP and conservative treat-

ment for VCF patients. In this study, we treated 164 osteoporotic

VCF (OVCF) patients with either PKP or CT method under a

double-blinded, randomized controlled study between July 2007 and

July 2010. In china, this study was Level I evidence according to

U.S. Preventive Services Task Force. The results were reported below.

Keywords: Osteoporotic vertebral fractures, kyphoplasty, PKP,

conservative treatment, randomized study

P39

A PROSPECTIVE STUDY OF PERCUTANEOUS

BALLOON KYPHOPLASTY WITH CALCIUM

PHOSPHATE CEMENT IN TRAUMATIC

VERTEBRAL FRACTURES: 10 YEARS RESULTS

Gianluca Maestretti, Patrick Sutter, Riccardo Ciarpaglini,

Monnard Etienne, wahl Peter, Emmanuel Gautier

Department of Orthopaedic Surgery, Spinal unit, Fribourg,

Switzerland

Study design: This is a a prospective study to investigate the clinical

and radiological results 10 years after percutaneous balloon

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kyphoplasty and cement augmentation with Calcium Phosphate

Cement (CPC) in traumatic vertebral fractures type A.

Objectives: Evaluation of a 10 year follow up with radiological and

computed tomography results, calculated by 2 independent radiolo-

gists, VAS, Roland Morris score, ODI score and Denis work scale and

clinical examination in patients with traumatic compression fractures

type A, who were treated with a balloon kyphoplasty with CPC

(CalcibonTM; from Biomed).

Methods: In this study we evaluated 21 patients (8 female and 13

male) clinically and radiologically 10 years postoperative and com-

pared them with the same group of 28 patients we operated between

August 2002 and August 2003 for traumatic vertebral fractures type A

with balloon kyphoplasty and CPC. Over the 10 years 7 patients were

untraceable. 3 of them were not clinically impaired but didn’t want to

participate in the study and 4 patients we didn’t found. All 21 patients

underwent standard X-ray (standing) and a CT. We measured the

volume of the cement, the resorption the last 10 years and the disc

height in the CT and the segmental and vertebral kyphosis angle in the

X ray and compared them with the X-ray (standing) and CT done

directly postoperatively. To assess the pain level we used the VAS,

ODI score, Roland Morris score and the Denis work scale and

compared them with the same scores we recorded in the past.

Results: The VAS score demonstrated an increase over time from a

mean of 1 (0-5) at the 2 year follow up to 2.3 (0-8) at the 10 years

follow up. The Roland Morris disability score also increased over

time from 2 (0-8) 2 years postoperative to a mean of 3.6 (0-18) at the

10 years follow up. We recognized no complications and no reoper-

ations were necessary.

We recognized an increase of the median value for the vertebral

kyphosis angle about 1� (0� - 4�). The median value of the disc height

diminution over the 10 years was 0.7 mm (0 - 3.9). For the anterior

wall of the fractured VB the decrease of the median value was about

1 mm (0-3) and for the posterior wall it was 0 mm (0-2). So the Beck

Index decreased from 0.80 (0.65 - 0.97) to 0.77 (0.62 - 0.97) at the

10 year follow up which means a decrease of the median value of

0.03 (0 - 0.07). We noticed a median value for the cement volume of

4.2 cc (2.0-8.6) postoperative and at the 10 year follow up of 3.2 cc

(1.3-7.8) which means a resorption of the cement volume about

22.9 % (0.8 % - 55.5 %).

Conclusions: In our 10 year follow up we didn’t recognize any sig-

nificant loss of correction of the vertebral and segmental kyphosis

angle. We also didn’t recognized a significant diminution of the disc

height without degeneration of the disc over the last 10 years. There

was a partial resorption of the cement but not as much as we expected

with variable bone formation. In summary the long follow up about

10 years of kyphoplasty show us very good clinical and radiological

results and in our opinion we consider this to be a treatment option for

traumatic selected vertebral type A fractures also in young patients.

P40

MOTOR FUNCTION OF LOWER EXTREMITIES

AFTER TOTAL EN BLOC SPONDYLECTOMY

WITH SACRIFICE OF BILATERAL L2 NERVE ROOTS

Hideki Murakami, Satoru Demura, Satoshi Kato, Katsuhito Yoshioka,

Hiroyuki Hayashi, Kazuya Shinmura, Noriaki Yokogawa,

Xiang Fang, Hiroyuki Tsuchiya

Department of Orthopaedic Surgery, Graduate School of Medical

Sciences, Kanazawa University, Kanazawa, Japan

Introduction: During total en bloc spondylectomy (TES), the nerve

root is often sacrificed to perform en bloc corpectomy. Preservation of

the nerve root requires wide lateral exposure or posterior-anterior

combined surgery. According to the strategy adopted at our institute,

the L2 and upper nerve roots are sacrificed and the L3 and lower

nerve roots are preserved during TES of the lumbar spine. However,

since sacrificing the L2 root also affects the branch to the femoral

nerve, the effect on femoral nerve motor dysfunction is uncertain.

This study aimed to investigate the relationship between L2 root

sacrifice and postoperative leg motor function.

Patients and methods: Ten patients (6 men, 4 women; mean age,

49.3 years) who underwent TES with sacrifice of bilateral L2 roots were

included. The motor function of the lower extremities was determined

using a modified Frankel classification and Manual Muscle Testing

(MMT) of iliopsoas (IP) and quadriceps femoris (QF) preoperatively,

1 week post-surgery, 1 month post-surgery, and on the last follow-up

day. The results from the weaker side were used when MMT showed a

laterality difference.

Results: The preoperative IP MMT score decreased to 4 in 1 patient;

however, the Frankel classification was D3, meaning she had no gait

disturbance. Compared with preoperative investigation, at 1 week post-

surgery, IP MMT was the same in 3 patients, decreased by 1 point in 6

patients, and decreased by 2 points in 1 patient, and QF MMT was the

same in 4 patients, and decreased by 1 point in 6 patients. Compared

with preoperative investigation, at 1 month post-surgery, IP MMT was

the same in 6 patients and decreased by 1 point in 4 patients, and QF

MMT at 1 month post-surgery was the same in 9 patients and decreased

by 1 point in 1 patient. On the last follow-up day, IP MMT decreasing

remained in 3 patients, and QF MMT improved in all patients. The

Frankel classification was E in 3 patients, D3 in 1 patient, and D2 in 6

patients 1 month post-surgery, and E in 6 patients and D3 in 4 patients

on the last follow-up day. No patient had gait disturbance.

Conclusion: All patients whose bilateral L2 roots were sacrificed

during TES were able to walk without assistance, although mild

weakness of IP remained in 3 patients. Although the MMT of IP and

QF may be slightly affected by L2 roots sacrifice, it should be noted

that walking function remains intact. Sacrifice of L2 roots appears to

be an acceptable procedure in TES.

P41

PREVENTION OF SURGICAL SITE INFECTION

USING IODINE-COATING SPINAL INSTRUMENTS

Hideki Murakami, Toshiharu Shirai, Satoru Demura, Satoshi Kato,

Katsuhito Yoshioka, Hiroyuki Hayashi, Takashi Ota,

Kazuya Shinmura, Noriaki Yokogawa, Hiroyuki Tsuchiya

Department of Orthopaedic Surgery, Kanazawa, Japan

Introduction: Surgical site infection (SSI) associated with spinal

instruments remains a serious complication in spine surgeries. We

newly developed antimicrobial coating spinal instruments for pre-

vention and treatment of spinal infection. This instrument has

povidoneiodine-containing surface. In basic study using white rabbits,

iodine-coating titanium has antibacterial activity, biocompatibility,

and no cytotoxicity. We have performed a clinical trial of iodine-

coating spinal instruments which suppress microbial activities of

bacteria, virus and fungus. Our purpose is to evaluate the effective-

ness of iodine-coating spinal instruments for preventing SSI.

Methods: We have treated 122 compromised patients under immu-

nosuppressive condition such as cancer (96 cases), hemodialysis (8

cases), diabetes (7 cases), steroid administration (4 cases), and so on,

using iodine-coating instruments to prevent SSI. The age of the

patients was 55.2 years (range, 18-75 years) on average. Sixty-four

patients were male and 58 were female. To confirm whether iodine

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from the instruments influenced the body, thyroid hormone levels in

the blood were examined. After the operation radiological evaluations

were performed regularly.

Results: SSI was perfectly prevented in 119 of 122 compromised

hosts except for 3 cases. In one case with a huge synovial sarcoma of

back, wide excision of the tumor with latissimus dorsi flap was per-

formed. However, SSI occurred around polypropylene mesh for chest

wall reconstruction after postoperative intensive chemotherapy. After

exchange of the mesh, SSI was cured. In one case with gastric cancer

metastasis at L4, SSI occurred after total en bloc spondylectomy.

However, SSI was cured by antibiotics only without revision surgery.

In the other case which had decompression and stabilization surgery

for multiple spinal metastases from breast cancer, SSI was cured by

curettage and irrigation. In all 3 cases, SSI was cured without removal

of instruments. Abnormalities of thyroid gland function and instru-

mentation failure were not detected.

Discussion and Conclusion: We newly developed a procedure for the

anodization of iodine-containing surfaces that can be directly-coating

to existing titanium implants, and iodine-coating spinal instruments

were invented. The iodine-coating spinal instruments had a great

effect on preventing SSI in compromised patients. Moreover, there

were no cytotoxicity and adverse effects detected.

P42

TEMPORARY PEDICLE SCREW FIXATION

WITHOUT AUGMENTATION

FOR THORACOLUMBAR BURST FRACTURES

Hiroyuki Aono, Hidekazu Tobimatsu, Yukitaka Nagamoto

Orthopedic Surgery, Osaka, Japan

Introduction: Short-segment posterior spinal instrumentation for

thoracolumbar burst fracture has its merit based on superior correc-

tion of kyphosis by indirect reduction technique. However, failure of

this procedure in loss of kyphosis correction has been frequently

reported. As the materials and configuration of spinal instrumentation

advanced considerably compared with the research period of these

failure reports, we performed this procedure without augmentation.

Methods: This study included 24 consecutive patients with thoraco-

lumbar burst fracture (T11-L3) who underwent surgery by

ligamentotaxis procedure using Schanz screws without augmentation.

Their implants were removed around 1 year after operation after

confirming union of the fracture. We have measured local vertebral

body angle (VBA) and superior-inferior endplate angle SIEA) before

and just after operation, approximately 1 year after initial operation

and 6 to 12 months after removal. We also evaluated fracture severity

according to load sharing classification.

Results: Operation was performed 0 to 9 (mean 3.5) days after injury.

Mean operating time was 100 min and mean blood loss was 131 ml. After

surgery, all 11 patients with neurologic deficit had improvement equiva-

lent to at least one ASIA grade. One patient had screw breakage 8 months

after operation but collapse of injured vertebra was not accelerated.

VBA was corrected from 17.3� before surgery to 6.5� after surgery. Loss

of correction was 0.5� before removal, which deteriorated by another 0.2�after removal. Total loss of correction was 0.7� from the initial surgery.

SIEA was corrected from 13� before surgery to 1� after surgery. Loss of

correction was 2.2� before removal, which deteriorated by another 7.6�after removal. Total loss of correction was 9.8� from the initial surgery.

Taken together, these results indicate that postoperative kyphotic

change was related to disc level not fractured vertebra; maintenance

of reduced vertebral body height was successful regardless of load

sharing classification.

Conclusion: Temporary short-segment fixation without augmentation

yielded satisfactory results. Maintenance of fractured vertebra was

independent of load sharing classification. Kyphotic change was

observed due to loss of disc height mostly after removal of implants.

Such change might be inevitable, as adjacent discs can be injured at

the onset. Kyphotic change may thus be a limitation of this surgical

procedure.

P43

EVALUATION OF THE INTERVERTEBRAL DISC

IN TYPE A THORACOLUMBAR FRACTURES

Hugues Pascal-Moussellard, Philippe Loriaut, Guillaume Mercy,

Patrick Boyer, Yves Catonne

Department of Orthopaedic Surgery, Hospital Pitie Salpetriere,

PARIS, France

Introduction: Despite a sizable amount of literature, the optimal

management of thoracolumbar fractures remains controversial. Many

authors assume the existence of disc lesions in Magerl type A frac-

tures. The aim of this study was to assess changes in the intervertebral

discs adjacent to type A thoracolumbar fractures.

Methods: 56 patients with 95 type A thoracolumbar fractures were

studied with a median follow-up of 25 months (range 18-37). The

patients received conservative or surgical treatment during four years at

our institution. Radiological assessment included CT-scan and MRI

realized initially, then within 1 week of trauma and at final follow-up.

CT-scan study involved characterization of Magerl/AO subtypes frac-

tures, measurements of adjacent vertebral body and disc heights in

millimeters. MRI was performed for the evaluation of disc signal, height

and morphology modifications and compared to Oner classification.

Results: Mean disc height was 1.03 ± 0.36 initially, 0.98 ± 0.23

after treatment and 0.97 ± 0.35 at last follow-up. Mean vertebral

height was 0.88 ± 0.2 initially, 0.86 ± 0.26 after treatment and

0.85 ± 0.24 at last follow-up. No signal intensity modification was

identified. Disc morphology was either normal or altered with redis-

tribution of discal tissue in the vertebral end-plate depression. Mean

values and observations did not differ at last follow up.

According to Oner, 38 suprajacent discs were type 1, 1 was type 2, 25

type 3, 1 type 4 and 1 type 5. All subjacent discs were type 1 except

from 12 discs which were cranial to a second fracture corresponding

type 3 pattern.

Conclusions: In this study, CT-scan imaging showed that no loss of

height occurred in adjacent discs to fractured vertebra whereas there

was a vertebral end-plate depression, more important in A3 than in

A1. MRI showed no major alteration of the intervertebral disc in

terms of signal intensity and morphology.

P44

THE PREDICTIVE VALUE OF THE SPINAL

INSTABILITY NEOPLASTIC SCORE (SINS)

SYSTEM FOR ADVERSE EVENTS

OF PATHOLOGIC FRACTURE AND SPINAL CORD

COMPRESSION IN PATIENTS WITH SINGLE

SPINAL METASTASIS

Hyoungmin Kim, Choon-Ki Lee, Jin S. Yeom, Jae-Hyup Lee

Department of Orthopaedic Surgery, Seoul, Korea (ROK/South

Korea)

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Introduction: The SINS, developed to assess the spinal instability in

patients with metastatic spinal tumor, seems to have a potential pre-

dictive value for the adverse event of pathologic fracture (Fx) and

epidural spinal cord compression (ESCC). This study was performed

to evaluate the predictive value of the SINS system for spinal adverse

events in patients with a single spinal metastatic tumor.

Methods: The pain, location, quality of bone lesion, spinal alignment,

collapse of vertebral body, involvement of posterior spinal elements

were assessed according to the SINS system for a consecutive series

of 78 patients with a single spinal metastasis. The attribution of the

each and total score of the SINS was assessed to the spinal events of

Fx and ESCC after detection of spinal metastasis by Cox proportional

hazard model.

Results: Average age of patients when the primary disease was

diagnosed was 55 years and they lived mean of 43 months after the

diagnosis. Spinal events occurred at the mean of 8 months after

diagnosis of the primary disease. Gastrointestinal system was the

most common site of primary disease and breast was the second one.

The survival after the diagnosis of the spinal metastasis was different

according to the primary cancer: patients with breast cancer lived for

mean of 6.5 years and for only 0.5 years with lung cancer since the

detection of the spinal metastasis. Cox regression analysis found that

the pain (p = 0.008) and posterior involvement score (p = 0.002)

was significantly related with the event of ESCC. The scores of the

pain (p = 0.009), alignment (p = 0.008) and location (p = 0.036)

were also related with the event Fx. With the higher score in the

related components was related with higher rate of spinal adverse

events except for the location components. Lesions in mid-thoracic

location (1 point of the SINS) showed higher hazard ratio of Fx than

the mobile spine (2 points) or junctional area (3 points). The sum of

SINS was not related with the spinal adverse events.

Conclusion: Among the components of the SINS system, the

mechanical pain, location, and alignment showed significant corre-

lation with the event of Fx, and with the event of ESCC, mechanical

pain and posterior involvement were related in patients with single

spinal metastasis.

P45

A RETROSPECTIVE ANALYSIS INVESTIGATING

THE CAUSES OF NEUROLOGICAL DEFICITS DUE

TO OSTEOPOROTIC VERTEBRAL FRACTURES

Itaru Oda, Eihiro Murota, Hirohito Takeuchi, Shigeki Oshima,

Masanori Fujiya

Department of Orthopaedic Surgery, Hokkaido Orthopaedic

Memorial Hospital, Sapporo, Japan

Purpose: To select appropriate treatments for osteoporotic vertebral

fractures, the causes of neurological deficits must be understood. The

purpose of this study was to investigate the causes of neurological

deficits associated with osteoporotic vertebral fractures.

Methods: A total of 83 patients who underwent surgeries for neu-

rological symptoms associated with osteoporotic vertebral fractures

were reviewed. There were 65 female and 18 male patients with an

average age of 74.9 years. Intraoperative findings, neurological and

radiographic examinations were reviewed and the responsible region

for neurological symptoms was detected. Neurological symptoms

were categorized into myelopathy, cauda equina syndrome, and

radiculopathy. Also, causes of neurological symptoms were classified

into two types including ‘‘Compression’’ and ‘‘Instability’’. The

Compression type was defined as neurological symptoms with neural

compression on the MRIs, and the symptoms did not improve by

preoperative bed rest. The Instability type was defied as neurological

deficit with slight or no neural compression on the MRIs, and it

improved by preoperative bed rest.

Results: Fifty-five of 83 patients presented myelopathy. Thirty-three

of them (62 %) were Compression type. Four patients indicated

preexisting spinal cord compression at the segment above the fracture,

and delayed myelopathy was detected during conservative treatments.

Twenty patients of myelopathy (38 %) were Instability type and all

patients showed intravertebral cleft. Thirty of 83 patients presented

cauda equina syndrome or radiculopathy. Twenty-seven of them

(90 %) were Compression type, while 3 cases (10 %) were Instability

type. Only four patients demonstrated radiculopathy at the neural

foramen, and all four cases showed neural compression by the lower

endplate fracture.

Conclusions: In approximately 40 % of myelopathy cases, instability

was the main pathology and surgical treatments should be stabiliza-

tion without decompression. As a preexisting spinal cord compression

at the level above the fracture may result in progressive myelopathy,

conservative treatments must be carefully performed even if the

patient is neurologically intact. In 90 % of the patients with cauda

equina syndrome or radiculopathy, neural compression was the main

pathology and stabilization with decompression should be considered.

Although not common, foraminal stenosis should be assessed in case

of lower end-plate fractures.

P46

TWO-YEAR CLINICAL AND RADIOLOGICAL

OUTCOMES IN A PROSPECTIVE COHORT

OF PATIENTS WITH VERTEBRAL FRACTURES

Javier Pizones, Lorenzo Zuniga, Patricia Alvarez-Gonzalez,

Felisa Sanchez-Mariscal, Enrique Izquierdo

Spine Unit, Department of Orthopaedic Surgery. Hospital

Universitario de Getafe, Madrid, Spain

Introduction: The aim of the study was to prospectively evaluate the

2-year clinical and radiologic results in a cohort of patients with acute

thoracolumbar fracture.

Materials and methods: Patients hospitalized during a two-year

period for an acute traumatic thoracolumbar fracture, excluding

pathological fractures, were prospectively included in the study. An

analysis was performed with age, gender, AO fracture type, type of

treatment, and local and regional kyphosis (preoperative and 1 month

postoperative). At 2 years, the following data were collected: local

and regional kyphosis, SF-36 and Oswestry Disability Index (ODI)

results, and complications. A comparative study was performed

between the conservative group and surgical group using the Chi

square and Mann–Whitney U tests.

Results: Thirty-one patients were included in the study, 3 were lost to

follow-up; response rate 90.3 %. Total sample description was as

follows: 50 % were males; mean age 39.8 ± 14.4 years; fracture

localization was: 21 % thoracic area, 71 % thoracolumbar, and 8 %

lumbar; L1 was the most often affected level (32 %); according to the

AO classification: 53 % were type A, 39 % type B, and 8 % type C.

Surgical treatment was used in 50 % (Sx Group), the majority by

posterior instrumented fusion; the other half were managed conser-

vatively (C Group).

Statistically significant differences (p \ 0.05) were found for local

preoperative kyphosis (C: 12.28 ± 3.7 vs Sx: 17.68 ± 4); local

kyphosis at 1 month (C: 12.58 ± 3.2 vs Sx: 6.48 ± 5.4); and final

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local kyphosis (C: 14.88 ± 6.8 vs Sx: 6.48 ± 6.6). At the end of

follow-up, patients undergoing conservative management showed a

+3.18 ± 4 increase in kyphosis, whereas those with surgical treatment

showed a -11.28 ± 0 (63 %) correction.

At two years there was a non-significant trend favoring conservative

treatment in all SF-36 domains except emotional role (Table).

Patients who underwent conservative treatment showed less final

disability on the ODI (C: 13.5 % vs Sx: 29.8 % p = 0.006).

Two conservatively treated patients had a [ 208 increase in kyphosis

at final follow-up and one required surgery. In the Sx group, the

reoperation rate was 28 %.

Conclusion: Patients with stable fractures treated conservatively had

residual kyphosis, but an acceptable quality of life. In patients with

unstable fractures that required surgical fixation, normal kyphosis was

restored, but the clinical outcome was less satisfactory.

P47

RADIOLOGICAL RESULTS OF SHORT SEGMENT

INSTRUMENTATION AND FUSION IN TYPE C AO

THORACOLUMBAR FRACTURES

Jose Fleiderman, Sergio Ramırez, Alberto Telias, Javier Lecaros,

Francisco Ilabaca, Alejandro Urzua, Juan Zamorano,

Vicente Ballesteros, Ratko Yurac, Miguel Lecaros

Traumatologia, Santiago, Chile

According to Magerl’s classification, type C thoracolumbar spine frac-

tures are those produced by rotational and shearing mechanisms,

affecting both columns. This type of injuries require surgical treatment in

order to achieve decompression of the neural structures together with

fracture reduction and stabilization through spinal instrumentation until

spinal fusion occurs. Traditionally, long segment instrumentations and

fusions have been used in the treatment of these lesions. Short segment

instrumentations are those including, at the most, one segment above and

one below the injured one. Monosegmental instrumentations represent

the maximum preservation of moving spinal segments. In this way, we

consider that knowledge about the radiological evolution, both in the

short and long term, of this short instrumentations and fusions is very

useful, as it can further validate them in the management of these patients

with highly unstable spine fractures. The objective of this study is to

evaluate the radiological results, by establishing the failure rate, of short

segment instrumentations and fusions in the treatment of patients with

type C AO thoracolumbar fractures.

Materials and Methods: Retrospective case series of 31 patients with

type C AO thoracolumbar spine fractures, operated at our institution

with a short segment instrumentation and fusion (bisegmental or

monosegmental), with a minimum follow-up of 2 years. Those

patients who required a complimentary anterior fusion and/or those

who used a brace during follow-up were excluded. Hardware fracture,

loosening and/or progression of segmental kyphosis of 108 or more

were considered as failure of the instrumentation.

Results: Patients’ mean age at the moment of surgery was 39 years.

Forty-one percent of the patients presented subtype C3 AO fractures,

29 % subtype C2 and 29 % subtype C1. The mean progression of the

segmental kyphosis in the study group was 4.58, and only three

patients presented instrumentation failure during follow-up, according

to the previously described criteria: two cases of hardware fracture,

while one patient evolved with progression of 108 of the segmental

kyphosis.

Conclusion: The use of short segment instrumentations and fusions in

the treatment of type C AO thoracolumbar spine fractures is a suitable

alternative in selected patients. In our case series, we report a failure rate

of 9.6 %.

P48

THE CLINICAL IMPORTANCE OF POSTERIOR

VERTEBRAL HEIGHT LOSS IN OSTEOPOROTIC

VERTEBRAL FRACTURE

Jun-Yeong Seo, Kwang Woo Nam, Sungwook Choi, Kee-Yong Ha,

Kyu Bum Seo

Orthopaedic surgery, Jeju, Korea (ROK/South Korea)

Introduction: In patients with vertebral fracture, the height loss of the

fractured vertebra occurred inevitable after starting ambulation, even

if they wear orthosis. The pulposes of this study is to investigate the

correlation of the posterior height loss with vertebral canal

compromise.

Materials and methods: From June 2010 to January 2012, patients

who suffered from thoracolumbar vertebral fractures were investi-

gated. After 2 weeks of bed rest, tolerable ambulation was permitted

in wearing custom molded orthoses. Orthoses were kept for 12 weeks.

Radiological assessment including anterior, posterior height of ver-

tebral body of affected level and superior and inferior adjacent level

were measured at initial, 2, 4, 6, 12 weeks, 6 months, 9 months,

12 months. The height loss(%) were calculated from the estimated

loss of fractured vertebral height by the mean of superior and inferior

vertebrae. Magnetic resonance imaging (MRI) were performed to

assess vertebral fracture. The MRI findings of fractured vertebrae

were divided to 3 types by enhancing pattern. In patients with sig-

nificant height loss in follow up x-ray were evaluated by computed

tomography(CT) or MRI.

Results: 97 patients were enrolled for this study. 15 patients were

male, 82 patients were female. Mean age at initial visit were

70.25 ± 14.6. The mean t-score of lumbar spine was -2.95 ± 1.03.

At initial visit, the average anterior height loss was 25.2 ± 3.5 % and

the average posterior height loss was 7.78 ± 2.1 %. 42 out of 97

patients showed posterior vertebral body involvement. The mean

canal encroachment at initial visit was 11.79 ± 4.9 %. MRI findings

showed 16 cases of type 1(17 %), 68 cases type 2(70 %) and 13 cases

of type 3(13 %). During the follow-up period, significant posterior

height loss was noticed in 32 patients and CT or MRI was performed

to evaluated canal encroachment. Newly developed canal encroach-

ment was found in 8 patients. The mean canal encroachment was

15.3 ± 7.6 %. Of them, neurologic complication was found in 4

patients. All of the 4 cases showed type 3 MRI pattern at initial.

Conclusions: In thoraco-lumbar vertebral fractures, the posterior

vertebral body height loss was important findings during follow up

period, because they usually followed by spinal canal encroachment.

In patients with simple compression fracture, great attention to the

posterior vertebral height should be paid to detect the spinal canal

compromise which could be followed by devastating result.

P49

SURGICAL MANAGEMENT FOR SPINAL CORD

INJURY IN PATIENTS WITH ANKYLOSING

SPINAL DISORDERS

Kazuhiro Takeuchi

Orthopaedic Surgery, National Okayama Medical Center, Okayama,

Japan

The ankylosing spinal disorders include ankylosing spondylitis (AS),

ankylosing spinal hyperostosis (ASH) and diffuse idiopathic skeletal

S738 Eur Spine J (2013) 22 (Suppl 5):S720–S766

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hyperostosis (DISH). AS is a chronic rheumatic disease. Bone for-

mation around paraspinal structure reduces bone mineral and bone

quality of vertebra. AS is a great risk factor for spinal fracture because

of mechanical stress due to loss of spinal flexibility and bone fragility.

Minor trauma can easily lead to spinal fracture with subsequent

severe spinal cord injury (SCI). The purpose is to discuss about the

specific features of AS fracture and review the surgical outcomes.

We report 24 AS cases (mean age: 75.7 yrs.) with SCI following

spinal fracture. This study was composed with clinical and image

analysis. The clinical records were retrospectively reviewed about

pain status and neurological functions.

CT and MRI showed great view of fracture. MRI identified 3-columns

injury including both transdiscal and transvertebral.

Thoracolumbar spine was most commonly affecting level in 17/24

cases. Low energy trauma caused SCI in 16 cases. Neurological

deficits were revealed in 20 cases (ASIA A:1, B:3, C:10, D:6). 13

patients (65 %) had delayed diagnosis or late onset neurological

deficits before admission.

Posterior fusion was performed in 17 cases. Pedicle screw fix-

ation was convenient. However these screws were not enough to

control spinal instability due to bone fragility. Image analysis

revealed two nonunion cases. Screw loosening and pull out was

detected in 8/17 cases. We applied supplemental procedures

using sublaminar wiring to secure fixation. A successful stabil-

ization required a combined anterior and posterior fusion for 7

delayed union cases.

Surgical outcomes were reliable in this series. Back pain was reduced

in all cases. Neurological improvement was shown in 8/20 cases.

However there was no improvement in severe paraplegic cases. No

patient experienced neurological deterioration with surgery.

Spinal fracture in AS is unique and different from common fracture.

The fracture always extends completely across the vertebral segment

leading to unstable 3-column injury. It requires careful imaging

assessment and aggressive surgical management to prevent secondary

neurological deterioration. Multilevel screw fixation is one of the

great options. The correction is essential for this maneuver. Open

wedge is prohibited at fracture site. Sublaminar wiring or banding and

massive bone graft is a key to get solid fusion.

P50

ARE PERCUTANEOUS PEDICLE SCREWS MORE

ACCURATE THAN OPEN?

Matthew George Stovell, Martin Wilby, Chris Barrett

Neurosurgery, Liverpool, UK

Objective: To assess the accuracy of pedicle screw insertion by five

spinal surgeons in a regional neurosciences centre and compare

results using the open and percutaneous technique.

Methods: All pedicle screws inserted between March 2011-2013

were recorded on a prospectively collected database (Spine Tango) by

five spine specialist consultants using systems from three major

companies. Pathology included trauma, malignancy and degenerative

spine disease. Open screws were inserted using anatomical land-

marks, pedicle probing and biplanar fluoroscopy. Percutaneous

screws were inserted using biplanar fluoroscopy alone. 3D image

guidance was not used. Accuracy was assessed using the Zdichavsky

scoring system 1 on post-operative CT imaging when available.

Zdichavsky 1a was considered optimal; 1b & 2a acceptable, 2b & 3a

poor and 3b very poor.

Results: 163 patients were included on the database. Post-operative

CT imaging was performed on 89(55 %). 66 of these had an open

procedure and 23 underwent percutaneous fixation. Optimal screw

position was achieved in 85.5 %(283) of the open screw insertions

and 88.8 %(87) of percutaneous screw insertions (not statistically

significant, p = 0.408 Fisher’s Test). An acceptable position was

attained in 8.2 %(28) of the open group and 8.2 %(8) of the percu-

taneous group. Of the open group, 5.1 %(14) were poor and 0.9 %(3)

were very poor. Of the percutaneous group, 3 %(3) were poor and

none were very poor.

Conclusions: The accuracy of pedicle screw insertion in both groups

was comparable to that reported previously in the literature1.

Although it did not reach statistical significance, our series may

suggest greater accuracy of pedicle screw placement using a percu-

taneous technique rather than an open technique. Importantly, there

were no percutaneous screws inserted with a ‘very poor’ trajectory

(Zdichavsky 3b). We advocate the use of percutaneous fixation of the

thoracic and lumbar spine for trauma, malignancy and degenerative

spinal disorders.

References: 1 Zdichavsky M et al. Accuracy of Pedicle Screw

Placement in Thoracic Spine Fractures Part I. Eur J Trauma 30:234-

240, 2004

P51

RISK FACTORS FOR POSTOPERATIVE

CEREBROSPINAL FLUID LEAKAGE

ASSOCIATED WITH TOTAL SPONDYLECTOMY

Noriaki Yokogawa, Satoru Demura, Murakami Hideki, Satoshi Kato,

Katsuhito Yoshioka, Hiroyuki Hayashi, Takashi Ota,

Kazuya Shinmura, Xiang Fang, Hiroyuki Tsuchiya

Department of Orthopaedic Surgery, Graduate School of Medical

Sciences, Kanazawa University, Kanazawa, Japan

Introduction: Cerebrospinal fluid (CSF) leakage is a serious post-

operative complication associated with spine surgery. CSF leakage

can lead to surgical site infection, pyogenic meningitis, intracranial

hypotension, and prolonged hospitalization. In total spondylectomy,

the dura mater is dissected circumferentially. Therefore, great care

must be taken to prevent CSF leakage after total spondylectomy. In

this study, we examined the incidence and risk factors for CSF

leakage after total spondylectomy.

Patients and Methods: A total of 70 patients underwent total

spondylectomy between May 2010 and February 2012. Of the 70

patients, 63 were selected for the study, and 7 patients with dural

injury during operation were excluded. The patients included 35 men

and 28 women with a mean age of 53.7 years (range, 16-75 years) at

the time of surgery. We examined the association between postop-

erative CSF leakage and the following parameters: age, sex, smoking,

diabetes, radiotherapy at the surgical site, chemotherapy, revision

surgery, surgical level of the spine, surgical approach, number of

vertebral bodies resected, and number of nerve roots sacrificed. We

also assessed the course of treatment for CSF leakage in each patient.

In this study, C 250 ml/day of serous drainage after postoperative

day 5 was defined as postoperative CSF leakage.

Results: Postoperative CSF leakage was observed in 11 of the 63

patients (17.5 %). Our multivariate analysis demonstrated that

radiotherapy at the surgical site was a significant risk factor for

postoperative CSF leakage. Six of 15 (40 %) of patients with a history

of radiotherapy experienced postoperative CSF leakage. An age of

more than 60 years was a significant risk factor in the univariate

analysis but not in the multivariate analysis. Eight of 27 (29.6 %)

patients aged more than 60 years experienced postoperative CSF

leakage. Although all 11 patients with CSF leakage were treated using

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factor XIII concentrate, 1 patient required reoperation. This patient

had a history of radiotherapy at the surgical site.

Discussion and Conclusions: The incidence of postoperative CSF

leakage associated with total spondylectomy was 17.5 %. Among

patients with a history of radiotherapy at the surgical site, this inci-

dence was particularly high (40.0 %). Our results suggest that

irradiation may result in histological changes, such as increased

permeability and fragility of the dura mater, which contribute to the

high incidence of CSF leakage.

P52

DOES GERIATRIC STATUS IMPACT

THE PRESENTATION AND MANAGEMENT

OF ACUTE FRACTURES OF THE

LUMBAR SPINE?

Osa Emohare, Alison Dittmer, Robert Morgan, Julie Switzer

Department of Orthopaedics, St Paul, USA

Introduction: The frequency of lumbar spine surgery has increased

by an order of magnitude over the last 20 years. This increase has

been particularly marked in geriatric patients. Specific changes in the

spine are known to be associated with the process of aging. While the

majority of fusions occur for degenerative disease, a relatively non-

controversial indication for fusion is trauma to the lumbar spine.

Given the physiological differences associated with aging, we sought

to review the impact of age on the patterns, management and out-

comes of acute lumbar fractures.

Methods: Following IRB approval, all patients who had presented with

acute fractures involving any of their lumbar vertebrae were identified.

We collected details of consecutive patients presenting to a level I

trauma center with between June 2010 and December 2012. Patients

were stratified into an index population (18 and 64 years) and a study

population ([ 65 years) and comparisons were made between both

groups.

Results: A total of 88 patients were reviewed; 50 were \ 65 years

and 38 were [ 65 years. Patients presented with a total of 164

fractures, with 92 fractures in the younger cohort and 72 in the

older cohort. There was concomitant neurological injury in 13

patients (26 %) under 65; this figure was only 5 (13 %) of those

aged 65 or over. The most common mechanism in younger patients

was motor vehicle collision; in the older population, falls from

standing height or lower were most common. In the younger

cohort, most were managed surgically, 39 (78 %); fewer of the

older patients underwent surgery, 17 (44 %) (p = 0.001). Most

patients under 65 were able to return home after injury 33 (66 %)

whereas in those 65 years or older this was only, 12 patients

(32 %) (p = 0.001).

Discussion: The preponderance of high velocity mechanisms is a

feature that differentiates the etiology of trauma in younger patients

from that in older patients. The most frequent mechanism in older

patients suggested suggesting some underlying impairment in bone

quality; differences in mechanism may relate the to the frequency

with which neurological injury occurs, as lower velocity injuries

would, would likely be associated with less damage to neighboring

structures. The frequency of surgical management also differed

significantly. These data point to some fundamental differences in

the two patient cohorts under consideration, and should inform the

approach to management, especially in older patients.

P53

A COMPARISON OF THE EFFECT OF AGING

ON THE PRESENTATION AND MANAGEMENT

OF ACUTE FRACTURES OF THE THORACIC

SPINE

Osa Emohare, Alison Dittmer, Robert Morgan, Julie Switzer

Department of Orthopaedic Surgery, St Paul, USA

Introduction: There has been a large rise in the frequency of spinal

procedures over the last two decades. In patients over 65, this has

occurred at a frequency higher than rate of increase in the proportion of

the total US population that is over 65. In the geriatric spine, factors like

hormone levels, nutrition and degenerative change combine to produce

unique changes. The thoracic spine is pivotal role in providing axial sup-

port. This study aims to comparatively elucidate the patterns, management

and outcomes specific to acute fractures of the thoracic spine.

Methods: An Institutional Review Board approved review was con-

ducted of patients who presented between June 2010 and December

2012. Details of consecutive patients presenting to a level I trauma

center with acute fractures of the thoracic spine were collected. Patients

were stratified by age into an index group: 18-64 years, and study

group: over 65 years. The two groups were compared using parameters

which included Charlson score, management, injury characteristics and

outcome.

Results: One hundred and nine patients presented with a total of 212

fractures; the most common mechanism of injury in the younger

group were motor vehicle collisions, 20 patients (41 %); In older

patients, falls from standing height or less comprised the majority of

fractures. Most fractures in the older patient cohort were at the level

of T11 and T12, with a total of 34 fractures (39 %) at these two levels,

compare with a more even distribution across the upper thoracic and

lower thoracic levels in younger patients. In younger patients, 32

fractures (65 %) were associated with neurological injury; this figure

was 8 (13 %) in older patients (p \ 0.001). Surgery was required in

39 patients (79 %) \ 65 years and 27 patients (45 %) 65 years or

older (p \ 0.001). 30 day mortality was 1 (2 %) and 4 (7 %) in the

younger and older groups respectively.

Discussion: The impact of age on acute spine fractures is reflected in

the location, type of injury and mechanism involved. Younger

patients are frequently injured by falls from height and MVCs; these

involve significant force. In contrast, older patients, who may have a

concomitant degenerative process, were noted to sustain injuries most

frequently in the lower thoracic spine. The difference in mechanism is

also noted when the presence of associated neurological injuries is

considered. These results demonstrate significant age related differ-

ences in the nature of thoracic spine trauma.

P54

TREATMENT OF THE THORACOLUMBAR

TRAUMA BY SHORT SEGMENT PERCUTANEOUS

TRANSPEDICULAR SCREW INSTRUMENTATION.

PROSPECTIVE COMPARATIVE STUDY

WITH MINIMUM 2 YEAR FOLLOW UP

Petr Vanek, Ondrej Bradac, Renata Konopkova, Vladimir Benes

Department of Neurosurgery, Charles University, 1st Faculty of

Medicine, Central Military Hospital, Prague, Prague, Czech Republic

S740 Eur Spine J (2013) 22 (Suppl 5):S720–S766

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Introduction: In an effort to minimalize soft tissue injury percuta-

neous transpedicular systems were developed. These were originally

constructed for the treatment of degenerative conditions. The

expectation regarding better long-term outcome was not confirmed

until now. The main aim of our study is to compare clinical and

radiological outcome after stabilization by percutaneous transpedic-

ular system and stabilization from the standard open approach for

thoracolumbar spine injury.

Outcome Pain profile was assessed by the Visual analogue scale

(VAS). Two years after the surgery overall satisfaction and pain were

assessed by a simple 4-staged scale. Working ability and return to

original occupation were also monitored. Radiographic follow up was

defined by the indexes: vertebral body index (VBI), vertebral body

angle (VBA) and bisegmental Cobb angle. The accuracy of screw

placement was examined using computer tomography.

Methods: 37 consecutive patients were enrolled in the study. The

inclusion criteria were: 1. one thoracolumbar fracture classified from

A3.1-A3.3 (AO-Magerl), 2. absence of neurological deficit, 3. no other

significant injury. 18 patients were treated by short-segment minimally

invasive percutaneous pedicle screw instrumentation. The control group

was constituted from 19 patients whom were stabilized by short-segment

transpedicular construct from the standard open approach.

Results: Mean surgical time in percutaneous group was 53 ± 10 min

against 60 ± 9 min in control group (p = 0.032). In comparison of

per-operative blood loss, the percutaneous treatment group reached

better results: 56 ± 17 ml against 331 ± 149 ml in control group

(p \ 0.001). Patients in the percutaneous group scored on VAS dur-

ing the first 7 post-operative days significantly lower than those in the

control group (p \ 0.001). There was no significant difference in

values of VBI, VBA and Cobb angle between the groups during the

follow up. There was no difference in the screw placement accuracy

between the groups and no patients needed surgical revision. There

was no significant difference found at two year overall satisfaction in

both group (p = 0.402). Working ability was insignificantly better in

the percutaneous group - previous working position was achieved in

17 patients and in the control group in 12 cases (p = 0.088).

Conclusions: Percutaneous transpedicular screw technique represents

a viable option in the treatment of pre-selected thoracolumbar frac-

tures. A significant reduction in blood loss, postoperative pain and

surgical time are the main advantages associated with this minimally

invasive technique. Clinical, functional and radiological results are at

least the same as those achieved in the open technique after a two year

follow up. Short term benefits look to be apparent and long term

results have to be studied in another well designed studies.

P55

SURGICAL MANAGEMENT AND OUTCOME

OF NONTUBERCULOUS BACTERIAL

SPONDYLODISCITIS OF THE AXIAL SPINE

Renjit Krishna Kumar

Department of Orthopaedics, EDAPPALLY, COCHIN, India

Introduction: Infection of the spinal column is rare and often rec-

ognized and treated too late. Spondylodiscitis is an infection of the

intervertebral disc space, vertebral bodies, can be a serious disease

because of diagnostic delay and inadequate treatment. Presentation

can be vague and highly variable but usually includes pain and ten-

derness over the involved vertebrae and fever.

Objective: To analyze the bacteriology, pathology, complications,

management and outcome of pyogenic discitis treated in a tertiary

care referral centre by review of medical records.

Materials and Methods: Total of 42 patients were included in the

study with the range of age from 16 to 75 years and mean age being

51.61 years, male 33 and female 9. All the cases were confirmed to

have pyogenic discitis by pus culture report or histopathological

examination. Mean follow-up period was 9.6 months, with a range

from 6 to 26 months. Five patients (11.9 %) presented with neuro-

logical deficits and 13 patients (30.95 %) had other co-morbidities

like diabetes mellitus, renal failure, chronic obstructive pulmonary

disease (COPD), heart diseases, and malignancies. Five cases

(11.9 %) had previous operation of the involved level and three

(7.14 %) cases had history of vertebral fractures. Three patients

(7.14 %) were operated for gynaecological problems and four cases

(9.52 %) had history of urological surgery.

Results: Lumbar spine was the most frequent site of pyogenic discitis

(29 cases, 69.04 %) followed by dorsal and cervical spine respec-

tively. The most common bacteria isolated was Staphylococcus

aureus in 19 cases (45.23 %) followed by E coli (4 cases, 9.52 %) and

Klebsiella pneumoniae (3 cases, 7.14 % %). Debridement and pos-

terior lumbar interbody fusion (PLIF) was done in 17 cases

(40.47 %), transforaminal lumbar interbody fusion (TLIF) was done

in 8 cases (19.04 %), anterior cervical discectomy and fusion (ACDF)

was done in 7 cases (16.66 %) and anterior lumbar interbody fusion

(ALIF) was done in 5 cases (11.9 %). Five patients were treated

conservatively.

Conclusion: The pyogenic discitis should be suspected for people

having pain and local tenderness in spinal region with rise of

inflammatory parameters in blood investigations. Although the most

common bacteria were S aureus but there were still greater number of

patients infected by the other types of bacteria. Therefore antibiotics

therapy should be started only after obtaining laboratory evidence of

the involved bacteria and the drug sensitivity.

Key words: pyogenic infection, spondylodiscitis, spinal instrumen-

tation, antibiotics

P56

THIRTY DAY MORTALITY RATE

IN THE SURGICAL TREATMENT

OF METASTATIC SPINAL CORD COMPRESSION

Sakthivel Rajan Rajaram Manoharan, Nasir Quraishi,

Deepshri Sureshkumar, Hussein Mehdian, Bronek Boszczyk

Centre for Spinal Studies and Surgery, Queens Medical Centre,

Nottingham, UK

Objectives: Emergency surgical treatment in MSCC has been shown

to improve function and neurological outcome. Inpatient patient

mortality is of course devastating. Our aim was to review our 30 day

inpatient mortality rate in patients undergoing surgery for MSCC,

with the intention of analysing the causes and to further scrutinise our

patient selection for surgical intervention.

Methods: We reviewed all patients treated surgically from our

comprehensive database. All data was collected retrospectively from

October 2004-October 2009, then prospectively from October

2009-October 2011 (7 years). We reviewed all patient records held on

the database, including patient demographics, primary tumour, neu-

rological outcome (Frankel grade) and survival.

Results: During the 7 year study period, in total 302 patients who

underwent emergency surgery for MSCC in our institution, 243 were

included in whom complete information was available. There were 29

patients who died within 30 days of surgery (12 %; mean age

Eur Spine J (2013) 22 (Suppl 5):S720–S766 S741

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65.2 years, 17 M, 12 F) with an average survival of 19.6 days (from

index operation).

The reasons for the mortality were respiratory complications (n = 12)

sepsis (n = 6), rapid disease progression (n = 3), stroke (n = 1),

gastrointestinal bleed (n = 1) and cerebral metastases causing intra-

cranial bleed (n = 1). The cause of death was unknown in 5 patients.

When comparisons were made with patients who survived at least

6 months(n = 80), then were significantly lower revised Tokuhashi

score 7.2 vs 9.7; (p \ 0.05), older patient group 65.4 vs 59.5

yrs(p \ 0.03) and more lung tumour primaries in the 30 day mortality

group(n = 9) vs (n = 3) in the other group.

Conclusions: Our 30 day mortality rate following emergency surgery

for MSCC was 12 % and most of the patients died within 3 weeks of

surgery. Older patients with lower revised Tokuhashi and lung

primaries were the poorest survivors. This study may help to assist

with better patient selection for surgical intervention in these patients.

P57

POSTOPERATIVE URINARY TRACT INFECTION

AND SURGICAL SITE INFECTION

IN INSTRUMENTED SPINAL SURGERY: IS THERE

A LINK?

Susana Nunez-Pereira, Rodrıguez-Pardo Dolors, Pellise Ferran,

Carles Pigrau, Joan Bago, Enric Caceres

Spine Surgery St Franziskus Hospital, Cologne, Germany

Introduction: Urinary tract infection (UTI) and surgical site infection

(SSI) are the most common minor and major complications following

posterior spinal fusion and instrumentation (PSFI). Quinolones (i.e.

ciprofloxacin), often used for treatment of UTI are, in combination

with other agents, one of the treatments of choice for implant asso-

ciated infections, especially against Staphylococcus aureus resistent

to methicillin and against gram negative bacteria.

Objectives: The aims of this study were to analyze a potential rela-

tionship between UTI and SSI, and to evaluate the possible effects of

using quinolones for treatment of UTI in further development of

antibiotic resistances at SSI.

Materials and methods: Retrospective study of prospectively col-

lected data from consecutive patients who underwent PSFI in a single

centre. Demographic, clinical and microbiological data were col-

lected. UTI occurring in the first 4 weeks, SSI (superficial and deep)

occurring in the first 12 weeks after PSFI and antibiotic treatments

were recorded. Statistical analyses used the Chi square test to com-

pare proportions and logistic regression to study risk factors for SSI.

Results: 446 patients were included: 58.6 % women, mean age 50.3 (SD

19.5), 40.8 % ASA Score [ 2, and 49.8 % fusion of more than 3 seg-

ments. Eighty-nine patients had confirmed UTI, 54 had SSI, and 22

presented both infections. In only 9 of these 22 cases were the two

infections caused by the same microorganism. Multivariate analysis

identified fusion of more than three segments (OR = 3.0, 95 % CI 1.5-

6.0; p = 0.003) and UTI (OR = 2.9, 95 % CI 1.4-5.7; p = 0.002) as

independent risk factors for SSI. Patients receiving ciprofloxacin for UTI

showed higher resistance rates to quinolones at the surgical site cultures

(46.13 %) compared to patients who did not take ciprofloxacin before SSI

(21.9 %). The difference did not reach statistical significance (p = 0.1),

but the power of the analysis was very low due to the small sample size.

Discussion: UTI is a significant risk factor for SSI after PSFI. Further

efforts to reduce the incidence of UTI and to provide adequate

empirical antibiotic therapy that avoids quinolones may help to

reduce the incidence of SSI and potential microbiological resistances.

P58

RADIOLOGIC FINDING OF FAILED

PERCUTANEOUS VERTEBROPLASTY

Wei-Chiang Liu, Sang-Ho Lee, Won Gyu Choi, Dong-Yeob Lee,

Sung Suk Paeng, Amy Kwon

Radiology, Seoul, Korea (ROK/South Korea)

Objective: Vertebroplasty is extensively performed worldwide for the

treatment of thoracic and lumbar osteoporotic compression fractures.

Although percutaneous vertebroplasty is considered a minimally

invasive procedure, it may result in several complications. The pur-

pose of this study was to evaluate the etiology of failed percutaneous

vertebroplasty.

Materials and Methods: We retrospectively reviewed the clinical

data and imaging findings of 23 patients (4 men and 19 women) who

were treated with corpectomy after percutaneous vertebroplasty for

compression fracture from 2007 through 2012. The average age of the

patients at the time of admission was 71.8 years (range, 61-86 years).

To diagnose the etiology of failed percutaneous vertebroplasty, we

evaluated the preoperative magnetic resonance (MR) images findings

such as fracture type, avascular necrosis, fluid collection in the

fracture segment, kyphosis, interspinous ligament injury, adjacent

interbody fusion, compression fracture with infection and poor-

quality of the image.

Results: The average length of days from percutaneous vertebroplasty

to corpectomy was 140.3 days. Among the 23 patients with failed

percutaneous vertebroplasty, 11 (47.8 %) had confirmed compression

fracture and 12 (52.2 %) had confirmed bursting fracture. Eight of the

23 patients (34.8 %) had missed diagnosis of interspinous injury, 5

patients (21.7 %) had poor-quality MR image for the evaluation of

interspinous ligament injury, and 3 patients (13.0 %) had no fat-sat-

urated T2-weighted images for the evaluation of interspinous

ligament injury. Avascular necrosis, kyphosis, compression fracture

with infection, and adjacent interbody fusion were observed in 10

(43.5 %), 3 (13.0 %), 1 (4.3 %), and 5 (21.7 %) of the 23 patients,

respectively.

Conclusion: We reported the MR findings of failed percutaneous

vertebroplasty. Evaluation of the interspinous ligament using high-

quality MR images is important before performing percutaneous

vertebroplasty for the treatment of osteoporotic compression

fractures.

P59

RECONSIDERATION OF THE TREATMENT

STRATEGY FOR THORACOLUMBAR

FRACTURES CAUSED BY HIGH ENERGY FORCE

Yasunori Sorimachi, Kanako Tsuihiji, Takashi Nakajima,

Eiji Takasawa, Ryoichi Kobayashi, Yoichi Iizuka, Haku Iizuka,

Kenji Takagishi

Orthopaedic and Spine Surgery, Japanese Red Cross Maebashi

Hospital, Gunma, Japan

Introduction: Thoracolumbar spine injury is usually caused by high

energy force, so it often occurs as a component of multiple trauma.

Therefore, early mobilization is required to prevent complications of

bed rest such as venous thromboembolism and atelectasis, to facilitate

nursing care. This study investigated clinical results of thoracolumbar

S742 Eur Spine J (2013) 22 (Suppl 5):S720–S766

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fractures in recent years, and evaluated the previous treatment strat-

egy for these fractures.

Methods: 53 consecutive patients with thoracolumbar fractures (T11-

L2) caused by high energy trauma treated in our hospital between

October 2006 and September 2011 were reviewed. Age, AO classi-

fication, ASIA impairment scale, load sharing classification (LSC)

and thoracolumbar injury classification and severity score (TLICS),

local kyphosis angle (LKA), immobility period and residual back pain

were investigated. For the statistical analysis, the subjects were

divided into three groups: operative group (O); conservative group

with TLICS 3 or less (C1); conservative group with TLICS 4 or more

(C2).

Results: In 14 cases of Group O (the average age was 37.6 years, AO

A3: 1 case, B1: 5 cases, B2: 8 cases, LSC 6.4, TLICS 6.9), 22 cases of

Group C1 (50.0 years, A1: 3, A2: 1, A3: 18, LSC 4.0, TLICS 1.8) and

17 cases of Group C2 (44.0 years, B1: 9, B2: 8, LSC 4.3, TLICS 5.6),

the most common level injured was L1. All 5 cases with neurological

deficit (ASIA A: 1, C: 3, D: 1) were recognized in Group O. The LKA

at the injury was 15.8� in Group O, 10.3� in Group C1 and 13.1� in

Group C2. There was no difference between conservative groups

(Cs). The LKA at the final follow-up was 11.7� in Group O, 14.1� in

Group C1 and 22.2� in Group C2. The LKA in Group C2 significantly

increased between Group Cs. The immobility period was 7.6 days in

Group O, 26.1 days in Group C1 and 30.9 days in Group C2. There

was no difference between Group Cs. The residual back pain was

revealed in 3 cases (21.4 %) of Group O, 9 cases (40.9 %) of Group

C1 and 10 cases (58.8 %) of Group C2. Prevalence rate was signifi-

cantly higher in Group C2 than in Group O.

Conclusion: Previously, we adopted conservative treatment for

patients without instability and paralysis, and determined the duration of

bed rest for 2 to 8 weeks. However, this study showed that the severity

of the fracture did not reflect conventional determination of bed rest

period. Moreover, conservative therapy with prolonged immobility, in

cases of TLICS 4 or more, did not prevent kyphotic deformity.

BASIC SCIENCE

P60

A SINGLE NUCLEOTIDE POLYMORPHISM

IN THE HUMAN BMP-2 GENE (109T [ G)

AFFECTS SMAD SIGNALING PATHWAY

AND THE PREDISPOSITION TO OSSIFICATION

OF POSTERIOR LONGITUDINAL LIGAMENT

OF SPINE

Baorong He, Dingjun Hao, Liang Yan

Hong Hui Hospital, Xi’an Jiaotong University College of Medicine,

Xi’an, China

Objective: To investigate whether BMP-2 is a candidate gene to

modify the susceptibility of OPLL and the mechanism of ossification

in signal transduction.

Methods: A total of 420 OPLL patients and 506 age- and sex-mat-

ched controls were studied. The complete coding sequence of the human

BMP-2 gene were analysed through PCR and direct sequencing, all the

SNPs were detected and genotype. The BMP-2 expression vectors

containing positive polymorphisms were constructed and transfected to

the C3H10T1/2 cell. The expression of BMP-2 and Smad signal path-

way in positive cell clones were detected by western blotting. The ALP

activity was detected by quantitative detection kits.

Results: The frequencies for the 109T [ G and 570A [ T poly-

morphisms were difference between the case and control group. The

‘‘TG’ genotype in 109T [ G polymorphism is associated with the

occurrence of OPLL. The ‘‘AT’ genotype in 570A [ T polymorphism

is associated with the occurrence of OPLL. The expression of Smad4

protein transfected by wild-type or mutant expression vectors were

significantly higher than control groups (P \ 0.05), the expression of

Smad4 protein transfected by pcDNA3.1-BMP2 (109G) and

pcDNA3.1-BMP2 (109G, 570T) were significantly higher than the

other experimental groups(P \ 0.05). The ALP activity increase has

been detected in pcDNA3.1-BMP2 (109G) and pcDNA3.1-BMP2

(109G, 570T) transfected cells to 4 weeks after stably transfection.

The activity ALP results were (30.56 ± 0.46) nmol/minute/mg pro-

tein and (29.62 ± 0.68) nmol/minute/mg protein, respectively. There

was a statistical difference compared with the other experimental

groups (P \ 0.05).

Conclusions: The BMP-2 is the predisposing gene of OPLL. The

‘‘TG’ genotype in the 109T [ G and the ‘‘AT’ genotype in the

570A [ T polymorphisms are associated with the occurrence of

OPLL. In the intracellular signalling transduction, the 109T [ G

polymorphism in exon-2 of BMP-2 gene is positively associated with

the level of Smad4 protein expression and the activity of ALP. Smad

mediated signalling pathway plays an important role during the

pathological process of OPLL induced by SNPs of BMP-2 gene.

P61

POSTEROLATERAL SPINAL FUSION USING

ESCHERICHIA COLI-DERIVED RHBMP-2

WITH HYDROXYAPATITE GRANULE

Chang-Bae Kong, Choon-Ki Lee, Jin Sup Yeom, Jae-Hyup Lee,

Hyoungmin Kim, Bong-Soon Change

Department of Orthopaedic Surgery, Seoul, Korea (ROK/South Korea)

Introduction: Mini-pig posterolateral spinal fusion model was used

to analyze the osteoinductivity of rhBMP-2 using HA granules as a

carrier, which can be potentially applicable in a clinical setting for the

treatment of human spinal diseases.

Methods: Thirty-one adult male mini-pigs underwent a single level

laminectomy followed by bilateral intertransverse process arthrodesis.

Those were randomized into control (HA 3 g), low dose (HA

3 g + rhBMP-2.1 mg) and high dose (HA 3 g + rhBMP-2.3 mg)

groups. Each animal was euthanized at 3 months after surgery. Fusion

status and degree of bony mass formation were evaluated by radio-

logic and histologic examinations.

Results: Three mini-pigs were dead and exlcluded for analysis. The

fusion rate were 37.5 % for control group, 71.4 % for low dose group and

84.6 % for igh dosed group (p = 0.031). The volume of fusion mass

determined by 3D CT and micro CT showed largest in high dose group

(p\ 0.001). The HA volume was not different but the new bone volumes

showed significant differnece: 9590 ± 1105 mm3 for control group,

14898 ± 2540 mm3 for low dose group and 23831 ± 8015 mm3 for high

dose group (P\ 0.001). The bone volume fractions (bone volume/tissue

volume), trabecular thicknesses, trabecular numbers and trabecular

separations were also analyzed and the differences between groups were

not statistically significant.

Histologic analysis showed that solid bridging bone was seen in the

19 mini-pigs in which fusion was achieved, as measured by palpation

and radiographs. Normal appearing mature osteoblast-lined trabecular

bone was present between the proximal and distal transverse pro-

cesses. There was no evidence of inflammatory cells or other reaction

to the carrier.

Eur Spine J (2013) 22 (Suppl 5):S720–S766 S743

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Seven animals developed wound complications. One is from con-

trol group, 2 from low dose group and 4 from high dose group.

There was no statistical difference between groups according to the

infection development (P = 0.623). When further stratified by deep

or superficial wound infections, 3 subjects from high dose group

were classified as superficial ones and they achieved solid bony

union.

Conclusion: The E-coli-derived rhBMP-2 in usage with carrier of HA

granule induced successful posterolateral fusion in mini-pigs.

P62

CONSTRAINED INTERVERTEBRAL DISC ORGAN

CULTURE FOR SIMULATION OF CELL THERAPY

APPROACHES

Cornelia Neidlinger-Wilke, Antje Boldt, Graciosa P.Q. Teixeira,

Christopher Jahn, Jurgen A. Mollenhauer, Hans-Joachim Wilke,

Anita Ignatius, Mario Barbosa, Raquel Goncalves

Institute of Orthopaedic Research and Biomechanics, Ulm, Germany

Introduction: Purpose of the study was to establish a bovine disc

organ culture model with simulation of pro-inflammatory conditions.

This model system was characterized with regard to its suitability for

testing the fate of injected cells under simulation of a degenerative

disc environment.

Materials and methods: Bovine caudal disc punches (each 5-6 discs

from 12 tails) cultured at constrained conditions were exposed to

needle-puncture treatment and/or application of pro-inflammatory

molecules (LPS, IL1b and TNFa) or maintained as untreated controls.

At day 2 after culture initiation, part of the discs was injected with

fluorescence labeled cells (PKH-67/26) within an albumin-based

hydrogel. The induction of a pro-inflammatory response was evalu-

ated by quantification of prostaglandin (PGE2) production in the

conditioned media and by gene expression analysis of pro-inflam-

matory cytokines and MMPs from isolated disc cells. The metabolic

profile of cultured discs was traced by glucose consumption. Discs

with injected cells were analyzed after 1, 2 and 4 weeks of incubation

by histomorphology, immuno-histochemistry and by determination of

glycosaminoglycan content.

Results: Treatment of needle-punctured disc organ cultures with LPS

or IL1b increased PGE2 12-fold in conditioned media of the disc

explants. Glucose consumption levels indicate that cultured discs

were not starving (above 0.2 g/l) and the LPS-treated samples showed

higher glucose consumption than controls. Annulus and Nucleus cells

treated with LPS or IL1b showed a strong up-regulation of MMP3,

MMP13, IL-6, and IL8 expression. GAG contents decreased

(62.4 ± 9 %) within 2 weeks in culture. Though only small volumes

of cell-seeded hydrogels could be injected into the discs, fluorescent

cells were detected at each sampling time point. Disc matrix around

cells close to the injection site showed a more intense Alcian blue

staining suggesting a locally increased GAG deposition.

Discussion: Through simulation of degenerative and/or inflammatory

environment conditions under controlled organ culture conditions this

model is suitable with regard to in vitro testing of regenerative or anti-

inflammatory treatment strategies of disc degeneration. The moni-

toring of injected fluorescence-labelled cells allows continuous

characterization of cell reactions in this organ culture environment.

Supported by HEALTH-F2-2008-201626, CP-IP 213904 and Deut-

sche Wirbelsaulenstiftung.

No conflict of interest to declare.

P63

END PLATE TRANSITION FROM CARTILAGE

TO BONE IN THE AGEING MURINE

INTERVERTEBRAL DISC: ROLE FOR BMP2

Esmeralda Blaney Davidson, Elly Vitters, Wim van den Berg,

Peter van der Kraan

Rheumatology Research & Advanced Therapeutics, Nijmegen,

Netherlands

Purpose: Degeneration of the intervertebral disc (IVD) is considered a

source of back pain and affects 80 % of the ageing population. Mech-

anisms underlying age-related IVD degeneration remain unclear. We

studied age-related changes in IVD gene expression to find clues

explaining age-related IVD degeneration. We show that with age the

end plate underwent terminal differentiation followed by bone forma-

tion accompanied by high osteocalcin mRNA expression and intense

BMP2 staining.

Methods: We isolated lumbar spines of C57Bl/6 mice aged

2-20 months for RNA isolation or histology. Spines were decalcified

with EDTA, IVD were isolated, followed by RNA isolation and RT-

PCR. Q-PCR was performed for aggrecan, collagen type I, collagen

type II, collagen type X and osteocalcin and Id1. Values were cor-

rected for GAPDH and compared to 4 months of age. For histology,

paraffin sections were stained with Safranin O and Fast Green.

Immunohistochemistry was performed for BMP2.

Results: In the IVD aggrecan mRNA decreased 1.9-fold by

20 months. Collagen type II increased 3.7 fold by 12 months of age

and remained stable thereafter. Collagen type I also increased up to

4.5 fold by 12 months of age and slightly reduced again to 3.3 fold

increase. The most striking change was increased osteocalcin of 3.2,

5.4 and 6.1 fold, by 8, 12 and 20 months respectively. This indicated

bone formation with an onset even before 8 months of age.

We investigated the potential cause of the osteocalcin increase his-

tologically. Already at 6 months, end plate chondrocytes underwent

hypertrophic differentiation and were eventually replaced by bone

resulting in a bone layer covering the growth plate. As BMP2 is a

major inducer of bone we investigated its presence and found

increased staining with age especially intense in the terminally dif-

ferentiating end plate chondrocytes. These increased BMP2 levels

resulted in downstream alterations as well as we found Id1 mRNA

levels increased 1.4 fold by 8 months and 2.8 fold by 12 months and

was stable thereafter.

Conclusions: Our data show that with age, end plate chondrocytes

undergo terminal differentiation and are eventually replaced by bone.

This is accompanied by an intense increase in BMP2 staining in the

hypertrophic cells and a sustained increase in osteocalcin levels and

increased Id1 expression. Our data strongly suggesting a role for

BMP2 in bone formation in the IVD end plate. This phenomenon will

contribute to age-related degeneration of the IVD.

P64

MAPK INHIBITION SELECTIVELY MITIGATES

INFLAMMATORY MEDIATORS PRODUCTION

IN DISC CELLS CO-CULTURED WITH ACTIVATED

MACROPHAGE-LIKE THP-1 CELLS

Joo Han Kim

Department of Neurosurgery, Seoul, Korea (ROK/South Korea)

S744 Eur Spine J (2013) 22 (Suppl 5):S720–S766

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Recent data have suggested that macrophages are involved in the

pathogenesis of intervertebral disc (IVD) degeneration and enhance

the secretion of inflammatory mediators in co-cultured disc cells. The

purpose of these studies is to determine the role of mitogen-activated

protein kinase (MAPK) signaling in the interactions between mac-

rophage and IVD cells.

Human annulus fibrosus (AF) cells and nucleus pulposus (NP) cells

were co-cultured with phorbol myristate acetate-stimulated macro-

phage-like THP-1 cells with and without SB202190 (p38 MAPK

inhibitor), SP600125 (JNK MAPK inhibitor), and PD98059 (ERK

MAPK inhibitor). Conditioned media from co-cultured cells were

assayed for tumor necrosis factor (TNF)-a, interleukin (IL)-1b, -6, -8,

and nitric oxide (NO). Human AF cells and NP cells were also cul-

tured with proinflammatory cytokine to find the activation of NF-kb

and MAPKs.

IL-6, IL-8, and NO were secreted in greater quantities by cells

maintained in co-culture compared to macrophages (M) cultured

alone. TNF-a and IL-6 production in NP co-culturing with M were

significantly lower than AF co-culturing with M. SB202190 dose-

dependently suppressed IL-6 secretion in AF-M and NP-M co-culture

while did not significantly suppressed TNF-alpha, IL-1beta, and IL-8.

10 uM SP600125 and PD600125 suppressed the TNF-alpha, IL-8 in

the AF-M and NP-M co-culture. 1 ng/mL IL-1b and 10 ng/mL TNF-

a, which are major proinflammatory cytokines of macrophage, acti-

vated NF-kB and MAPKs (p38, JNK1/2, and ERK 1/2) protein. in the

AF and NP cells. IL-6 production from macrophage-exposed NP was

significantly strikingly blunted by p38 and ERK MAPK inhibition

while IL-8 production was significantly blunted to p38 MAPK

inhibition,

Symptomatic IVD degeneration can result in macrophage infiltration

at the AF and NP, and this can cause enhanced inflammatory medi-

ators from AF and NP. The MAPK pathway signals are selectively

responsible for cytokines secretion in disc cells with macrophage-like

cells and p38 MAPK are more responsible for IL-6 and IL-8 pro-

duction in previous macrophage-exposed disc cells than JNK and

ERK MAPK pathway, suggesting that selective blockade of these

signals may serve as a therapeutic approach to symptomatic disc

degeneration.

P65

THE EFFECT OF BIPHASIC ELECTRICAL

CURRENT STIMULATION ON IL-1B STIMULATED

ANNULUS FIBROSUS CELLS USING IN VITRO

MICRO-CURRENT GENERATING CHAMBER

SYSTEM

Joo Han Kim, Jae Hee Shin

Department of Neurosurgery, Seoul, Korea (ROK/South Korea)

Symptomatic disc degeneration is an important cause of chronic

intractable lumbar pain, which is associated with macrophage-

mediated inflammation in the AF. Although some studies suggest

that in vitro electrical stimulation can up-regulate collagen pro-

duction and diminished inflammatory mediators in osteoarthritis,

their effects on human AF inflammation remain unknown. To

identify the effect of a biphasic electrical current on ECM regu-

lated enzymes and inflammatory mediators in IL-1b stimulated AF,

we evaluated the influence of biphasic electrical field stimulation

on the expression of inflammatory mediators and ECM regulated

enzymes in IL-1b stimulated annulus fibrosus (AF) using in vitro

culture system.

Human AF (hAF) cells were cultured with micro-current generating

chamber (MCG) system (0, 50, 250, 500 mV/mm) in presence of

1 ng/mL IL-1b. Conditioned media from cells were assayed for

MMP-1,-3, TIMP-1, -2, IL-6, -8, NO, VEGF, and IGF-1 by ELISAs.

Gene expression in AF pellets was assay for COX-2 and COL1A2 by

real time reverse transcriptase polymerase chain reaction (RT-PCR).

IL-1b stimulated hAF produced significantly higher levels of MMP-1,

-3, IL-6, IL-8, NO, and VEGF, and lower levels of TIMP-1 and -2. IL-

6, NO, MMP-1, TIMP-1, VEGF, and IGF-1 were time-dependently

increased through 72 h under 250 mV/mm. MMP-1, TIMP-1, IL-6,

and VEGF were not changed at 0, 50, and 250 mV/mm while

decreased at 500 mV/mm compared to control (MMP-1,

17.2 ± 4.7 ng/mL, p \ 0.05;TIMP-1, 12.4 ± 3.3 ng/mL, p \ 0.02;

IL-6, 2.5 ± 0.9 ng/mL, p \ 0.05 and VEGF, 0.1 ± 0.04, ng/mL,

p \ 0.03). MMP-3, IL-8, and IGF-1 were not significantly influenced

according to intensity of electrical field stimulation. NO were not

changed between 0, 50, 250 mV/mm while strikingly increased at

500 mV/mm (p \ 0.0001).

In present study, we confirmed that electrical field stimulation suc-

cessfully suppressed MMP-1, IL-6, and VEGF on 500 mV/mm while

did not influence to MMP-3, IL-8 and IGF-1. Furthermore, electrical

field stimulation significantly suppressed the TIMP-1 on 500 m/mm,

suggesting the selective efficacy of electrical field stimulation to blunt

symptomatic cervical disc degeneration.

P66

LONG-TERM IN VIVO KINEMATICS

OF THE LUMBAR INTERVERTEBRAL DISC

TRANSPLANTATION IN A GOAT MODEL

Keith Luk, Yong-can Huang, Jun Xiao, William Lu, Victor Leung

Orthopaedics and Traumatology, Pokfulam, Hong Kong

Purpose: Intervertebral disc (IVD) allograft transplantation in the

human cervical spine is able to restore segmental kinematics.

Extending this technique to the lumbar spine remains a challenge

because of the difference in anatomy and loading mechanics. This

study evaluated the long-term in vivo kinematics of the spinal seg-

ment following IVD transplantation in the goat lumbar spine model.

Methods: Twelve male goats between 6 and 9 months weighing

between 17.5 and 25 kg were used in this study. Two goats served as

allografts donor, 5 as allograft recipients where a graft was trans-

planted into L4-5, and the remaining 5 as untreated controls. Post-

operation lateral radiograph of the lumbar spine in the neutral, flexion

and extension positions were taken at 1, 3, 6, 9 and 12 months. Disc

height (DH) of the allograft and the adjacent levels were measured

and the range of motion (ROM) of the transplanted segment, the

adjacent levels, and the global lumbar spine were measured using the

Cobb’s method.

Results: All the disc allografts were well seated without subluxation

or dislocation. Immediately post-operation, the average DH of the

allograft was 3.04 ± 0.57 mm. This decreased slightly to

2.51 ± 0.54 mm after 1 m which is not significant statistically. The

DH further decreased to 1.91 ± 0.28 mm at 3 months post-op but

stabilized thereafter (One-way ANOVA, P [ 0.05). The DH of the

adjacent levels exhibited no significant change throughout the

observation period.

At 1 m post-operation, the average ROM of the allograft segments

was 6.4� ± 1.8� while that of the cranial and caudal adjacent seg-

ments were 6.7� ± 3.4� and 6.1� ± 2.4� respectively. At the final

follow-up, the respective ROMs were 6.7� ± 4.2�, 5.2� ± 2.2� and

Eur Spine J (2013) 22 (Suppl 5):S720–S766 S745

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10.1� ± 4.4�. When compared with the average ROM of the two

adjacent segments considered together, the mean ROM of the trans-

planted segment it was not statistically significant (Paired-Samples T

test, P [ 0.05). It was also comparable to that of the L4-5 disc in the

untreated controls (5.5� ± 2.5�). The global ROM of the lumbar spine

after disc transplantation was well preserved when compared to that

of the untreated goats (P [ 0.05).

Conclusion: Lumbar intervertebral disc transplantation could restore

the global and segmental mobility after 12 months despite a mean

reduction of the allograft height at the initial three months. A study on

the center of rotation at the grafted segment is underway.

P67

DNA DAMAGE IN INTERVERTEBRAL DISC

CELLS ACCELERATES DISC DEGENERATION

THROUGH MATRIX LOSS IN A MOUSE MODEL

OF HUMAN PROGERIA

Luigi Aurelio Nasto, Enrico Pola, Debora Colangelo,

Andria Robinson, Gwendolyn Sowa, Peter Roughley,

Laura Niedernhofer, James Kang, Nam Vo

Division of Spine Surgery, Department of Orthopaedic Surgery,

Catholic University of Rome, Rome, Italy

Introduction: Deficiency in DNA repair induces rapid biological

ageing which invariably associates with disc matrix proteoglycan

loss. Thus we hypothesize that DNA damage, when not repaired,

can promote disc aging and matrix loss. To test our hypothesis, we

challenged wild-type mice and their DNA repair deficient Ercc1-/Dlittermates with the genotoxic cross-linking agent mechlorethamine

(MEC) or chronic ionizing radiation (IR) to induce DNA damage.

Methods: Ercc1-/D mice (n = 6) and their wild-type littermates were

chronically exposed to genotoxic stress beginning at 8 weeks by

subcutaneous administration of a subtoxic dose of MEC (8 lg/kg

once per week for 6 weeks) or & 10 % radiotherapeutic dose of

ionizing radiation (0.5 Gy 1 9 per week for 10 weeks). Safranin O

histological staining for proteoglycan and Masson’s Trichrome for

collagen were performed. Disc aggrecan, ADAMTS4, and ADAMTS-

generated G1 aggrecan fragments terminating in NITEGE-373 were

analyzed by immunohistochemistry (IHC). Proteoglycan synthesis

was measured by 35S-sulfate incorporation using disc organ cultures.

Results: Histological staining revealed substantial reduction in matrix

collagen, proteoglycan and endplate cellularity in the discs of MEC-

exposed and irradiated mice. IHC analysis showed decreased aggre-

can content and increased levels of ADAMTS4 and NITEGE-373

containing aggrecan proteolytic fragments. Disc PG synthesis was

reduced 2-3 folds in MEC-treated mice. The overall effect of the

treatment on disc matrix and endplate cartilage was more severe in

Ercc1-/D mice than in wild-type mice.

Conclusion: MEC and IR treatment resulted in loss of disc matrix

proteoglycan and collagen in adult wild-type and Ercc1-/D mice

through a combination of decreased matrix synthesis and increased

breakdown. The finding that loss of matrix proteoglycan was greater

in the DNA repair deficient mice strongly supports the conclusion that

DNA damage can drive disc degeneration. These results implicate

DNA damage as a contributor to disc aging and degeneration. Thus

Ercc1-/D mice, a novel and rapid murine model of age-related disc

degeneration, are useful for exploring the molecular mechanisms by

which DNA damage promotes age-related disc matrix loss and

degeneration. The results of this work may have important implica-

tions for long-term cancer survivors patients treated with genotoxic

agents.

P68

FRICTION MEASUREMENT OF A METAL-ON-

POLYETHYLENE TOTAL DISC REPLACEMENT

Philip Hyde, John Fisher, Richard Hall

Mechanical Engineering, Leeds, UK

Introduction: Compared to total hip replacements (THR), articulat-

ing total disc replacements (TDR) typically utilise bearing materials

that are reversed (i.e. a polymer head on a metallic cup). This has

resulted in unexpected wear phenomena such as edge-loading [1] and

debris re-attachment [2] that have highlighted the differences between

TDR and THR bio-tribology. The replacement of a natural visco-

elastic intervertebral disc with an articulating TDR is a fundamental

change in design rationale when compared to hip and knee replace-

ment theory. Further, pull-out torque was once a concern in THR and

may be of issue for TDR.

Aim: To investigate the effect of loading and serum concentration on

the frictional behaviour of a semi-constrained TDR.

Method: TDR components (n = 3) were mounted in a pendulum

friction simulator in a bath of lubricant of bovine serum diluted to

25 % (v/v). Constant loadings were applied in a pseudo-random order

to avoid bias caused by the preceding test over a range from 500 to

2750 N and FE inputs of ± 4.58 were used. Serum concentration was

then tested between 0 % (full water) to 100 % serum at a constant

1500 N load.

Results: Frictional torque varied from 0.6 Nm (500 N load) to 2.4 Nm

(2750 N load), giving friction factors of 0.082 to 0.060. The constant

load friction factors were proportional to the load raised to index

power -0.28. No significant difference was observed between friction

measurements using serum concentrations from 0-100 % (p = 0.9,

ANOVA). Increasing the serum concentration increased the friction

slightly, but this trend was also not significant (Pearson’s linear

correlation, p = 0.17).

Discussion: The friction factors were equivalent to those reported for

MoP and CoP hips [3].Typical torque developed was * 1.5 Nm

(1500 N axial load). This is below the torque developed in the natural

IVD per 18 flexion (1.7 Nm/8 [4]) and so pull-out concerns are

minimal. The decrease in friction with increasing load (L-^0.28) is

typical of dry friction in polymers and may indicate poor lubrication.

References:

1. Hyde et al., Journal of ASTM International, 2011. 9(2): p. 51-65.

2. Vicars et al., European Spine Journal, 2010. 19(8): p. 2010,

1356-1362.

3. Brockett et al., J Biomed Mater Res B Appl Biomater, 2007. 81(2):

p. 508-15.

4. Panjabi et al., Spine, 1984. 9(7): p. 707-713.

P69

DYNAMIC STATE AND LOCALIZATION

OF MICROGLIA IN INJURED SPINAL CORD

BY THE PERIPHERAL BENZODIAZEPINE

RECEPTOR LIGAND PK11195

Shuji Watanabe, Kenzo Uchida, Hideaki Nakajima, Takayuki Hirai,

Hisatoshi Baba

Department of Orthopaedic Surgery, University of Fukui, Fukui,

Japan

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Introduction: In acute spinal cord injury (SCI), the primary

mechanical injury is followed by post-traumatic inflammation and

various inflammatory cells are migrated around the lesion site. In

these cells, resident microglia is commonly known that mainly

associated with repair of spinal cord, but there is no precise method of

quantification activated microglia in injured spinal cord. The present

study was aimed to investigate the benefits of peripheral benzodiaz-

epine receptor (PBR), known as a marker of glial activation in central

nervous system, and autoradiography using PK11195, known as

specific antagonist of PBR, for evaluation of microglial activation in

SCI mice.

Methods: We used C57BL/6 mice (8-12 weeks old), and we also

made chimeric mice transplanted EGFP + bone marrow cells from

CAG-EGFP transgenic mouse in order to distinguish from hematog-

enous macrophages. Mice were subjected to T9-T10 SCI by

contusion. In 7, 14, 28 days after injury, mice spinal cord was

resected and the part of 2 mm caudal side was cut into serial 20-lm

thick axial frozen section. For immunofluorescence, the sections were

incubated with CD11b, Iba-1, PBR antibodies. For autoradiography,

the sections were incubated in PBS containing 1nM [3H](R)-

PK11195 and developed after a few weeks. Cellular localization and

quantification analysis of PK11195 was evaluated and compared to

results of immunofluorescence.

Results: In immunofluorescence, PBR positive cells are located in

gray matter and almost cells were merged with CD11b, Iba-1 positive

cells. The cell counting of PBR was performed on a semiquantitative

level, so PBR positive cells increased from 4 days up to more than

14 days post injury and a lot of PBR positive cells were not merged

with GFP + cells, hematogenous cells. In autoradiography, accumu-

lation of PK11195 was identified in gray matter and were up from

4 days to 7 days post injury. In chronic phase, accumulation

decreased.

Conclusion: Our results suggest that PBR is mainly located in resi-

dent microglia and hematogenous macrophage in injured spinal cord.

From the results of double staining with GFP positive cells. PBR is

dominantly located in resident microglia than hematogenous macro-

phage. Therefore, autoradiography of PK11195 has potential to be

able to evaluate the activation of microglia.

P70

LUMBAR FLEXOR–EXTENSOR RATIO DOES

NOT CHANGE WITH AGE DESPITE

A REDUCTION IN MULTIFIDUS VOLUME

Stephanie Valentin, James Elliott, Theresia Licka

Movement Science Group Vienna, Vienna, Austria

Introduction: Trunk musculature is an important contributor to spinal

stability. In a healthy population, ageing leads to generalised muscle

volume loss. Whilst the benefits of synergistic muscle activity for a

supported spine are well reported, age-related changes of relative

muscle volume are less well-documented. Therefore, the aim of this

preliminary study was to identify trunk muscle volume and ratio of

flexors to extensors in a young and mature group of healthy

participants.

Method: Ten healthy asymptomatic males free from back pain, spinal

fracture or surgery were included, consisting of a young group (YG,

n = 5) and mature group (MG, n = 5). Axial T1-weighted magnetic

resonance images were obtained (1.5T Siemens, slice thickness

10 mm, TR/TE: 253/7.1 ms, rectangular field of view 80 %). Muscle

volumes (left and right sides) of erector spinae (ES), multifidus (M),

rectus abdominis (RA), psoas (PS) and lateral abdominal musculature

(LA) of the lumbar spine were measured using Analyze V. 11.0

software. The ratio of combined flexor volume (FV - RA, LA, PS) and

extensor volume (EV - ES, M) was calculated. Data were statistically

analysed using paired and independent t-test or their non-parametric

equivalent.

Results: Mean age was 22.4 years (± 0.9) for the YG and 51.0 years

(± 6.2) for the MG. Height or weight were not significantly different.

There were no significant differences between left and right sided

volumes for any muscle in the YG but the left RA was significantly

greater than the right in the MG. Muscle volume in the MG was

significantly reduced in left RA (by 19 %), left PS (by 21 %), right PS

(by 19 %), left M (by 21 %) and right M (by 23 %) compared to the

YG (100 %). FV was significantly reduced in the MG compared to

the YG, but EV was not. The ratio between FV and EV was not

significantly different between the YG and MG.

Discussion: Even though multifidus volume was reduced in the MG

compared to the YG, FV to EV ratio was not different, indicating that

the balance between flexor and extensor volume is maintained with

age in a healthy population. This ratio may not be maintained in back

pain patients, and the resulting imbalance could cause further dys-

function or pain recurrence. Loss of the specific stabilisation capacity

of multifidus with age may predispose to age related instability and

thus contribute to the development of associated lesions. Cause and

effect however is unknown at this time.

P71

AN ATTEMPT FOR LOW-DOSE MYELO-

TOMOSYNTHESIS

Takao Nakajima, Yong Kim, Kazuhumi Minami

Department of Orthopedic Surgery, Nippon Medical School, Chiba

Hokusoh Hospital, Inzai-City, Chiba, Japan

Objective: Since we reported an attempt for low-dose whole-spine

imaging to reduce exposure. In orthopedics, tomosynthesis is being

increasingly used as well, which combines digital image processing

and tomography techniques. We are also working to reduce patient

exposure by using low-dose imaging in tomosynthesis-based mye-

lography called myelo-tomosynthesis (MTS). This report introduces

our attempt for low-dose MTS and indicates the efficacy evaluation

results.

Subjects and Methods: We compared surface doses (SDs) between

front and lateral plain X-ray and MTS of the thoracic and lumbar

vertebrae at our hospital. Surface doses were calculated by the

Numerical Dose Determination (NDD) method. In addition, the

usefulness of MTS was compared to that of conventional myelogra-

phy (M-G), computed tomography myelography (CTM), or magnetic

resonance imaging (MRI). At our hospital, MTS involves use of a

0.1 mm Cu filter for total filtration during the imaging procedure and

an X-ray tube swing angle of 30�. The reconstruction technique after

the imaging procedure is the Filtered Back Projection (FBP) method.

The reconstruction filter is of the greatest thickness (Thickness ++)

(Metal 6). To facilitate visualization of reconstructed images even at a

low dose, specific signal components are enhanced by using an image

processing technique called Multi-objective Frequency Processing,

and the contrast and density are adjusted to optimize the images.

Results and Discussion: With plain X-ray, the front and lateral SDs

were 2.19 and 2.73 mGy for the thoracic vertebrae and 2.37 and

4.75 mGy for the lumbar vertebrae. With MTS, the front and lateral

SDs were 2.15 and 3.07 mGy for the thoracic vertebrae, and 2.73 and

3.90 mGy for the lumbar vertebrae. The SDs with MTS were

approximately 1/4 to 1/2 of the targeted depreciation values with plain

Eur Spine J (2013) 22 (Suppl 5):S720–S766 S747

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X-ray specified in the JART Guideline (1/8 to 1/4 of guidance levels

of International Atomic Energy Agency). The advantages of MTS are:

(1) enables tomography in various positions and even under various

dynamic stress thereby providing more detailed information; (2) more

useful than M-G in delineating lesions such as deformed joints,

destroyed bones, and vertebral canal stenoses; (3) less subject to metal

artifacts than CT and MRI; (4) requires a shorter imaging time and is

less distressing to the patient than CT and MRI. MTS at our hospital

has sufficiently reduced patient exposure and can be an effective

alternative to M-G.

P72

PORCINE MODEL FOR EARLY ONSET

SCOLIOSIS CREATED WITH A POSTERIOR MINI-

INVASIVE METHOD

WANG Bin, ZHENG Xin, QIU Yong, QIAN Bang-ping, SUN Xu,

ZHU Zezhang, YU Yang

Spine Surgery, Nanjing, China

Introduction: Nonfusion techniques for the treatment of EOS require a

reliable animal model to test new devices preclinically. However, cur-

rently available models either took a long tethering period for model

creation or had the spinal elements violated to a great degree, which

called for a reliable model created in a shorter period with less invasion.

Methods: This study included ten female Yorkshire pigs (age,

5-6 weeks; weight, 5-7 kg) in which scoliosis was created with posterior

asymmetric tethering at the left side from T5 to L3. At the index surgery,

three separated incisions was used and ipsilateral rib tethering from the

10th to 13th ribs were also performed without disruption of the spinal

elements. Progressive deformity was documented with monthly radio-

graphs. Frontal and sagittal profiles were assessed using the Cobb

method. After 8-week tethering, all the instrumentations were removed,

and the pigs were observed for an additional 8-week period with serial

radiographs to document progression of the deformity.

Results: All pigs developed rapidly progressive, structural, idio-

pathic-type curves with convex to the right in the lower thoracic

spine. The mean coronal Cobb angle was 29� immediately postop-

eratively and progressed to 65� after 8-week tethering period. After

removal of the tethering, the scoliosis progressed to 68� on average

(range, 58� to 78�). On the saggittal plane, a mean lordosis of 32� at

the thoracic spine and a thoracolumbar kyphosis of 63� was also

observed at final follow-up. Apical vertebra rotation increased from

12� postoperatively to 39� after 8-week tethering period.

Conclusion: Using a mini-invasive tethering method, a rapidly pro-

gressive spinal deformity can be created in immature pigs. This

method avoids violation of the spinal elements throughout the cur-

vature and provides an ideal EOS model with great growth potential

for further study of new nonfusion therapies.

Keywords: animal model, early onset scoliosis, nonfusion.

P73

BIOMECHANICAL COMPARISON

OF VERTEBRAL AUGMENTATION

WITH SILICONE AND PMMA CEMENT AND TWO

FILLING GRADES

Werner Schmoelz, Alexander Keiler, Felix Riechelmann, Tobias Schulte

Trauma Surgery, Innsbruck, Austria

Introduction: Vertebral augmentation with PMMA is a widely

applied treatment of vertebral osteoporotic compression fractures.

Subsequent fractures are a common complication, possibly due to the

relatively high stiffness of PMMA in comparison with bone. Silicone

as an augmentation material has biomechanical properties closer to

those of bone and might therefore be an alternative. The study aimed

to investigate biomechanical differences, especially stiffness, of ver-

tebral bodies with two augmentation materials and two filling grades.

Methods: Forty intact human osteoporotic vertebrae (T10-L5, mean

age 75.3 ± 13.9 years, mean trabecular BMD 74.4 ± 22.5 mg/ccm)

were evenly distributed in 4 groups. Wedge fractures were produced

in a standardized manner. For treatment, PMMA and silicone at two

filling grades (16 % and 35 % vertebral body fill) were assigned to

four groups. Each specimen received 5000 load cycles with a high

load range of 20-65 % of fracture force, and stiffness was measured.

Additional low-load stiffness measurements (100-500 N) were per-

formed for intact and augmented vertebrae and after cyclic loading.

Results: Low-load stiffness testing after cyclic loading normalized to

intact vertebrae showed increased stiffness with 35 % and 16 %

PMMA (115 % and 110 %) and reduced stiffness with 35 % and

16 % silicone (87 % and 82 %). After cyclic loading (high load

range), the stiffness normalized to the untreated vertebrae was 361 %

and 304 % with 35 % and 16 % PMMA, and 243 % and 222 % with

35 % and 16 % silicone augmentation. For both high and low load

ranges, the augmentation material had a significant effect on the

stiffness of the augmented vertebra (p = 0.021), while the filling

grade did not significantly affect stiffness (p = 0.17).

Conclusions: The results indicate that fractured vertebrae undergoing

vertebroplasty achieve a significantly lower stiffness using VK100

compared to PMMA. Both materials have higher stiffness results in

case of 35 % augmentation compared to 16 %, this difference was not

significant but more pronounced for the PMMA.

P74

IN VIVO PHARMACODYNAMICS OF P2K,

A PEPTIDE THAT REGULATES TGF-BETA

SIGNALLING ON DISC DEGENERATION

Young-joon Kwon, Je-wook Lee, Eun-joung Moon, Ok-soon Kim,

Hae-jin Kim

Department of Neurosurgery, Seoul, Korea (ROK/South Korea)

Purpose: In a previous study, we demonstrated that P2 K, a novel

peptide that regulates TGF-beta signaling, showed an anabolic effect

on degenerated disc using rabbit model.

The purpose of this study was to investigate in vivo pharmacody-

namics of P2K in rabbit degenerated disc and determines the maximal

effective dose in in vivo.

Materials and methods: In 15 New Zealand white rabbits, disc

degeneration was induced by annular needle puncture and confirmed

4 weeks after the puncture by the decrease in disc height in X ray.

Then the rabbits divided into 5 treatment groups according to P2K

dose (0, 3ug, 10ug, 30ug, 60ug). Three consecutive discs in each

rabbit were then treated with lactose (5 % in saline) or P2 K at var-

ious doses. Twelve weeks after treatment (16 weeks from initial

annular puncture), the regenerative activity in the disc was examined

by X-ray radiography, magnetic resonance imaging (MRI), and his-

tological analyses. Statistical analyses were performed by repeated

measures ANOVA, ANCOVA, and Mann–Whitney test.

Result: The disc height index (DHI) in X ray of P2 K treatment

groups were gradually increased during time course and increased

12 weeks after treatment, compared to control group. The P2K

S748 Eur Spine J (2013) 22 (Suppl 5):S720–S766

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injection of dose 30ug per disc resulted in significant increase of

%DHI (p \ 0.001) during the time course, followed by 10ug/disc

(p \ 0.05). At 12 weeks after treatment, two doses of P2K (30 lg and

10 lg, sequentially) showed significant increase of %DHI, compared

to control group. The MR grade was significantly increased in 10 lg/

disc treated group (p \ 0.05). Histologic grades using H&E/Safranin

O stain were also improved in P2K treated groups and correlated with

the MR grade.

Conclusion: The results show that range of maximal effective dose of

P2K would be 10 to 30ug/disc. Based on these results, adjustment of

P2K dose would be important in maximizing the regulation of TGF

b1 signaling on degenerated disc.

CERVICAL SPINE

P75

FACETECTOMY IS MORE EFFECTIVE

THAN FORAMINOTOMY TO PREVENT

IATROGENIC FORAMINAL STENOSIS

AFTER PEDICLE SCREW FIXATION

IN THE CERVICAL SPINE

Akiyoshi Yamazaki, Tomohiro Izumi, Hirokazu Shoji, Yu Sato,

Tatsuki Mizouchi

Spine Center, Orthopaedic Surgery, Niigata, Japan

Introduction: The incidence of iatrogenic foraminal stenosis (IFS),

which is not directly attributable to cervical pedicle screw (PS)

insertion, is reported to be 0.6- 50 %. The use of posterior forami-

notomy is recommended for preventing IFS. However, in some cases,

IFS occurs even after foraminotomy. The purpose was to compare the

effectiveness of foraminotomy with that of facetectomy in preventing

IFS after PS fixation.

Methods: PS fixation was indicated in 43 patients for instability or

kyphotic deformities from C4/5 to C7/T1. Of these 43 patients (total

190 nerve roots in the fusion area), 16 underwent PS fixation without

foraminotomy, 17 underwent foraminotomy, and 10 underwent fac-

etectomy. The average patient age was 62 years. Investigated factors

included the incidence of IFS, Manual Muscle Test score worsening

by [ 1 grade, and the preoperative foraminal diameter on axial CT

images.

Results: The incidence of IFS was 4.3 % (5/117 roots; C5 in 2 patient, C6

in 1, and bilateral C8 in 1) without foraminotomy, 8.4 % (4/48 roots; C5

in 4 patients) with foraminotomy, and 0 % (0/25 roots) with facetectomy

(p = 0.197). Without foraminotomy, the average foraminal diameter in 5

roots with IFS was 1.3 mm (0.8- 1.7 mm), while that in 112 roots without

IFS was 3.6 mm (0.8- 7.1 mm) (p\ 0.001). Five out of 13 roots (38 %)

with foraminal diameter less than 1.7 mm presented IFS. With forami-

notomy, the average foraminal diameter was 1.7 mm (1.3- 1.8 mm) in 4

roots with IFS and 2.1 mm (0.5- 5.9 mm) in 44 roots without IFS

(p\ 0.05). Four out of 22 roots (18 %) with foraminal diameter less than

1.8 mm presented IFS even after foraminotomy. With facetectomy, the

average foraminal diameter was 2 mm (0.8- 4.6 mm). According to

receiver operating characteristic analysis, the cut-off value was estimated

as 1.7 mm without foraminotomy and 1.8 mm with foraminotomy.

Discussion: Foraminotomy is not sufficient to prevent IFS. In con-

trast, IFS did not occur after facetectomy. Foraminotomy primarily

decompresses the inlet of the foramen. Therefore, it may cause IFS by

creating rigid fixation, changes in sagittal alignment, or unexpected

posterior translation. However, facetectomy decompresses the entire

foramen from the inlet to the outlet, allowing clinicians to fully

observe the nerve roots. IFS occurred even after foraminotomy,

especially when the foraminal diameter was \ 1.8 mm. Therefore,

prophylactic facetectomy rather than foraminotomy is recommended,

especially at the C4/5 level.

P76

‘‘SKIP’’ CORPECTOMY IN TREATMENT

OF MULTILEVEL CERVICAL SPONDYLOTIC

MYELOPATHY CAUSING BY OSSIFIED

POSTERIOR LONGITUDINAL LIGAMENT

Alexander Barysh, Stanislav Kozyryev

Orthopedic, Kharkiv, Ukraine

Objective: According to existing literature sources, results of corp-

ectomy on one and two levels are usually considered to be good. At the

same time, multilevel corpectomy is associated with a high complication

rate, such as graft migration, screw and plate breakage, pseudoartrosis

and screw loosening. The skip corpectomy technique is one of modern

ways of decompression and stabilization of cervical spine in patients with

cervical spondylotic myelopathy (CSM) and ossified posterior longitu-

dinal ligament (OPLL). Theoretically it can lessen the rate of

complications, associated with grafts and implants. This retrospective

study evaluated the outcomes of skip corpectomy by clinical and radio-

logical criteria in patients with CSM causing by OPLL.

Methods: There were evaluated outcomes of 15 consecutive patients

(11:73.3 % men and 4:26.7 % women among them) who were treated

during 2008 - 2013 years. Age of patients was from 57 to 76 years.

All patients had undergone surgical treatment - subtotal corpectomy

of C4 and C6 vertebras, resection of osteophytes on C 5 vertebra,

decompression of spinal canal, interbody fusion with autografts from

iliac crest bone and ventral fixation by cervical plate of own con-

struction. The clinical outcomes we evaluated using JOA scale before

and after surgery, and at the final follow-up. We performed X-ray and

CT examination preoperatively and postoperatively accessing signs of

fusion by Bridwell and cervical lordosis.

Results: The mean preoperative JOA score was 12.2 ± 1.7, after

surgery it was 13,1 ± 0.8, at the final follow up it was 14.3 ± 2.2.

The cervical lordosis was 1.8 ± 10.5 degrees preoperatively,

16.4 ± 2.3 after surgery and 14.5 ± 6.5 degrees at the final follow

up. Fusion signs grade 1 had 4 patients, grade 2 was in 8 cases, grade

3 had 2 patients, grade 4 was in 1 case. We met the following

complications : transient dysphagia in 2 cases, C-5 nerve palsy in 1

case, C-7 partial screw pullout in 1 case, temporary hoarseness in 1

case. Two patients had pain in iliac crest donor site for 3 weeks.

Conclusion: Skip corpectomy is an effective technique in OPLL and

CSM treatment, evidenced by good fusion rate and proper clinical

outcomes. Preservation of the C-5 vertebra provide an additional

stability and strengthening of the construct.

P77

POSTOPERATIVE COMPLICATIONS

OF CERVICAL SPONDYLOTIC MYELOPATHY

Antonia Matamalas, Xavier Plano, Ferran Pellise,

Ana Garcia de Frutos, Jose Casamitjana

Orthopaedic Surgery, Barcelona, Spain

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Objective: To assess the rate of complications associated with cer-

vical spondylotic mielopathy (CSM) surgery and to evaluate the

influence of the approach on complication rates.

Methods: A retrospective single-center study. All patients operated

because of CSM between 2005 and 2010 with at least one year fol-

low-up were reviewed. Demographic data; preoperative co-

morbidities; medical, surgical and mechanical complications and re-

intervention during follow up were collected in a standardized

manner.

Results: 237 surgeries on 221 patients (mean age 52.2 years; 66.5 %

men). 78.3 % of patients has at least one associated co-morbidity

(mean co-morbidities per patient = 2.07). The mean hospital stay

duration was 9.8 days (SD = ±8.3).

26.6 % of patients had complications during the postoperative period

(14.8 % minor and 11.8 % major complications). The most common

perioperative complications included respiratory insufficiency

(4.2 %), dysphagia (4.2 %) and urinary tract infection (3.4 %).

Wound complication rate was 6.8 %: of which 3.8 % were dehiscence

and 3 % infectious (2.1 % deep). Only one case of perioperative

worsening of myelopathy was detected (0.4 %).

Mechanical complication rate during follow-up was 3.8 % and 9.3 %

of patients needed a new surgery during follow-up (2.5 % debride-

ment; 6.3 % progression of myelopathy; 0.4 % instrumentation

failure). Mortality rate was 0.4 %.

When we compared anterior (n = 157) and posterior (n = 75)

approaches, 9.6 % and 16 % of patients had major complications.

Patients operated on by posterior approach were older (62.7 vs 55.8),

a larger number of levels of interventions (3.3 vs 2.2) and longer

hospital stays (11.6 vs 5.8 days). Compared with the anterior

approach, posterior approach patients had a higher incidence of

medical complications (p = 0.004), wound complications (p = 0.03)

and radicular complications (pain 8.1 % vs 1.3 %;p = 0.01 and

neurological impairments 5.4 % vs 0.6 %;p = 0.04). The most fre-

quently affected roots were C6 (1.9 %) and C5 (1.5 %).

We didn0t find differences between the number of levels of inter-

vention and different kinds of complications analyzed. Older patients

had higher rates of medical complications postoperatively

(p = 0.001).

Conclusions: One quarter of patients operated on because of CSM

developed some kind of postoperative complication. Older patients

had a higher risk of medical complications, while patients operated on

by posterior approach had a higher risk of wound complications.

P78

COMBINATION OF FUSION AND MOTION

PRESERVATION IN THE SURGICAL TREATMENT

OF DEGENERATIVE CERVICAL DISC DISEASE

Bank Andras, Szollosi Balazs, Varga Peter Paul

National Center For Spinal Disorders, Budapest, Hungary

Introduction: Our clinical study design was prospective, concur-

rently enrolled and single-center trial of the combination of fusion

(intervertebral cage with or without ventrofixation) and cervical disc

prosthesis implantation in the treatment of patients with multiple level

degenerative disc disease. The cervical disc arthroplasty become more

and more popular in the surgical treatment of the degenerativ cervical

disc disease. The goals of the cervical disc arthroplasty are to

maintain or restore intervertebral height, spinal balance and mobility

and to avoid adjacent segment degeneration. However, in most of the

patients with multisegmental degenerative disc disease the certain

segments show different stage of degeneration and instability. The

study was designed to investigate the clinical effects of the combi-

nation of cervical fusion and arthroplasty and to observe the stability,

range of motion, and the cervical spine sagittal balance in the follow

up period.

Materials and methods: Since December 2007 to September 2010,

24 patients with symptomatic cervical radiculopathy and/or myelop-

athy underwent surgery with this combined method. In 7 cases the

surgery involved two level, in 14 cases was three level, and 2 cases

was four level. At the follow-up period the patients pain, neurologic

function, and the radiographic parameters (range of motion at the

level of prosthesis and the adjacent segments, the intervertebral disc

height of the adjacent segments, lordosis of the whole cervical spine,

heterotopic ossification) was evaluated.

Results: Early clinical experiences are promising. The segment of the

prosthesis ultimately showed preservation of motion when compared

with preoperative levels. The preop. average ROM was 8.2� (flexion/

extension), the postop. average ROM 7.6�. The whole cervical spine

lordosis was preop. 1.7� the postop. 16.2�. We have no implant related

failure.

Conclusions: The most important potential advantages of this method

that we can treat the multisegmental degeneration in each segment

with the proper method including motion preservation and fusion, and

restore the sagittal balance of the cervical spine. Although early

results are promising, long-term follow up studies required to prove

its efficacy in the surgical treatment of the multisegmental degener-

ative cases.

P79

THE EFFICACY OF RHBMP-2 VERSUS ILIAC

CREST BONE GRAFT FOR POSTERIOR

C1-2 FUSION IN PATIENTS OVER 60 YEARS

OF AGE

Baorong He, Liang Yan, Dingjun Hao

Hong Hui Hospital, Xi’an Jiaotong University College of Medicine,

Xi’an, China

Few studies have specifically examined the efficacy of rhBMP-2/ACS

for posterolateral lumbar spine fusion. The purpose of this study is to

report on clinical outcomes, in elderly patients treated posterior C1-2

fusion with ICBG plus rhBMP-2/ACS versus ICBG alone. One

hundred and forty patients were enrolled in a prospective randomized

trail and underwent instrumented C1-2 fusion in patients over

60 years old. All the patients were divided into two groups based on

fusion material. The ICBG group consisted of patients who received

ICBG alone. The rhBMP-2/ACS group was composed of patients

with ICBG plus rhBMP-2/ACS. A comparison was made based on

OR time, EBL, LOS, clinical results, perioperative complication,

fusion rate, fusion time, and revision rates. There were no significant

differences in OR time, EBL, LOS and intraoperative surgical com-

plications between the two groups. The improvement in VAS, JOA

scores over the 2-year follow-up period was similar in both groups.

The fusion rate was 82.4 % (56/68) in the rhBMP-2/ACS group and

78.7 % (52/66) in the ICBG group (P = 0.782). The fusion time was

significantly greater in the rhBMP-2/ACS group (81.8 ± 29.4 days)

than in the ICBG group (92.9 ± 23.7 days, P = 0.034). There were

more wound complications requiring treatment in the rhBMP-/ACS

group (6, 8.8 %) versus the ICBG group (2, 3.0 %), although this was

not statistically significant (P = 0.118). the use of rhBMP-2/ACS for

posterior C1-2 fusion appears to generate relatively greater fusion rate

and fusion time, but there may be an increased risk of posterior

cervical wound complications.

S750 Eur Spine J (2013) 22 (Suppl 5):S720–S766

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P80

MANAGEMENT OF TYPICAL AND ATYPICAL

HANGMAN’S FRACTURES

Christopher Beagrie, Eleanor Woolley, Rafid Al-Mahfoudh,

Rasheed Zakaria, Mark Radon, Robin Pillay, Martin Wilby

Neurosurgery, Liverpool, UK

Aims: Although most authors agree that Hangman’s fractures can be

managed conservatively a degree of uncertainty still exists. Variants

of fractures of the ring of the axis have been recorded but no agreed

classification system exists. Our aim was to retrospectively review

management and outcomes of these fractures and compare to the

existing literature.

Methods: Retrospective analysis of 282 patient records treated

between 2004 and 2013 with C2 cervical spine fractures was per-

formed. Forty-one patients with typical and atypical hangman’s

fractures of the C2 vertebra were identified. Typical hangman’s

fractures were defined by Francis et al. as traumatic spondylolisthesis

of the axis causing a bilateral pars interarticularis fracture[3]. Frac-

tures involving the posterior cortex of C2 on one or both sides have

been defined as Atypical. [4][5].

The radiological records were reviewed and graded by an independent

radiologist according to the modified Effendi system[1] (modified by

Levine[2]).

Results: Forty-one adult patients with a mean age of 59.7 years were

included (seventeen male and twenty-four females). There were

twelve (29 %) typical hangman’s fractures and twenty-nine (71 %)

atypical hangman’s fractures.

Five typical Hangman’s fractures (38 %) were managed with a rigid

collar and five (38 %) were managed with a halo orthosis. In the

atypical group, six (21 %) were managed with rigid collar, twenty

two (76 %) using halo orthosis and one (3 %) surgically.

Surgical fixation was performed in two patients with typical Hangmans

fractures, one for C3 associated injuries and one for progression of

fracture whilst in halo orthosis. One patient in the atypical fracture series

underwent surgery following failure of conservative management.

Bony union was achieved in all patients on radiological follow up. No

new neurological deficits were documented. Neck pain and stiffness

were more commonly reported in the atypical group with 9 (33 %)

experiencing mild-moderate symptoms compared to one (8 %) in the

typical group. Three atypical hangman’s fracture patients were lost to

follow up.

Conclusions: The management of atypical Hangman’s fractures are

very similar to the classically described bilateral pars fracture. The

majority of Hangman type fractures can be treated conservatively.

Radiological follow up is essential to identify cases of non union. In

our series three patients underwent surgical fixation after failure of

conservative management.

P81

CENTRAL CORD SYNDROME: DOES EARLY

SURGICAL INTERVENTION IMPROVE

NEUROLOGICAL OUTCOME?

Ciara Stevenson, Jonathan Warnock, Suzanne Maguire, Niall Eames

Royal Victoria Hospital, Belfast, UK

Central cord syndrome: does early surgical intervention improve

neurological outcome?

Background: Historically the treatment of central cord syndrome has

been conservative however recovery is often incomplete. Surgery

remains controversial and there is no uniform consensus in the lit-

erature about treatment.

Aim: To review management and outcomes of patients with central

cord syndrome in Northern Ireland in 1 year.

Methods: Patients were identified using the Fracture Outcome

Research Database cross-referenced with the spinal MDT register.

Information gathered included demographics, mechanism of injury,

length of hospital stay and functional status. ASIA scores calculated

at injury, pre-operatively, post-operatively and at follow up.

Results: 27 cords identified, 5 managed conservatively and 22 with

surgery. Average age 62 years. 85 % were male. 85 % of patients had

a simple fall with neck hyperextension.

Average Asia motor score in operated patients improved from injury,

pre-operatively, post-operatively and at follow up from 51, 81, 83 and

90 respectively. 86 % patients independent at follow up.

Average Asia motor score in conservative patients improved from

time of injury to day 10 from 57 to 86 however at follow up fell to 84.

Only 20 % were independent at follow up.

Patients operated on within 10 days of injury had improved motor

function compared with those operated on after day 10. 82 % of their

improvement occurred prior to surgery.

Conclusions: This review suggests that patients treated with surgery

have improved Asia scores and functional outcomes. Three patterns

of recovery have been identified and timing of surgery is crucial. For

the majority of patients operated on late, the role of surgery maybe to

prevent deterioration.

P82

CLINICAL OUTCOMES OF MULTI-LEVEL

POSTERIOR CERVICAL FORAMINOTOMY

FOR THE TREATMENT OF CERVICAL

RADICULOPATHY

Dong Chan Lee, Choon Keun Park, Dong Geun Lee, Jong Yang Oh,

Dong Hwan Lim, Dong Hwa Heo, Jang Hoe Hwang,

Hyoung Sub Kim, Huk Keun Lee

Neurosurgery, Suwon, Korea (ROK/South Korea)

Objective: The benefits of one-level posterior cervical foraminotomy

have been recognized by several papers. However, reports of the

efficacy of multi-level posterior cervical foraminotomy are rare. The

aim of this study was to analyze the surgical outcomes of multi-level

posterior cervical foraminotomy in patients with multi-level unilateral

cervical radiculopathy..

Material and Method: Forty six patients were surgically treated

with multi-level posterior cervical foraminotomy with or without

discectomy for cervical radiculopathy. All patients had radiculopa-

thy with or without neck pain. Among those 46 patients, 36 patients

could be followed-up for at least 3 year. The mean follow-up period

was 44.4 ± 10.9 months(ranged 36-64 months). Sex, age, symptom

period, preoperative and postoperative neck pain, motor weakness,

level of operation, and combined discectomy were analyzed. Clin-

ical outcomes were retrospectively assessed according to

VAS(visual analogue scale), NDI(neck disability index) and Odom’s

criteria.

Results: There were 32 men and 4 women. The mean age was

55.4 years old (range 42-71 years). The mean symptom period was

17.5 months (range 1-72 months). Ten patients had preoperative neck

pain. Four patient had transient postoperative neck pain. Eight patients

had preoperative motor weakness. Two level foraminotomy was

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performed in 33 cases, three level in 2 cases and four level in 1 case. We

performed foraminotomy with discectomy in 14 levels. Clinically,

90 % patients had improved or resolved radicular symptoms. The

patients had taken foraminotomy with discectomy was better clinical

outcomes. The preoperative VAS for arm pain was 8.08 ± 0.69. The

mean postoperative VAS for arm pain was decreased to 1.82 ± 1.16.

The clinical outcome was excellent in 16 cases (44.4 %), good in 16

cases (44.4 %), fair in 3 case (8.3 %), and poor in 1 case (2.8 %). One

patient took ACDF at same level after 1 year. We confirmed that

foraminal space was widened by postoperative MRI in 32 cases. There

were no surgery-related complications in any cases.

Conclusion: Most patients treated with the posterior cervical for-

aminotomy have good to excellent outcomes. It appears to be a good

alternative procedure for carefully selected patients with unilateral

cervical radiculopathy and avoids a fusion of the disc space. Espe-

cially, we suggest that the operator must make efforts to seek a

possible ruptured disc.

P83

POOR OUTCOME AFTER WHIPLASH INJURY.

A STUDY WITH 4 YEARS FOLLOW UP

Georgios Mouzopoulos, Ioannis Skevofilax, Aris Adraktas,

Aggeliki Paragi, Georgios Nomikos, Vasilios Vasiliadis

Orthopaedic Department of Chios Hospital, Chios, Greece, Chios,

Greece

Purpose: The aim of our study was to identify the prognostic factors

associated with a poor response to treatment in the early stages of a

whiplash injury of cervical spine.

Methods: A study cohort of 231 patients with acute or subacute

whiplash injury, presenting to our department, during the period

between January 2002 and May 2008, were investigated for factors

associated with poor outcome according to the Canadian Back

Institute Questionnaire (CBIQ) score. Demographic data were col-

lected. Lag time between injury date and presentation for treatment

and initial pain intensity according to VAS score were also evaluated.

All patients were assessed on admission and 4 years after injury.

Statistical analysis was performed by statistical packet STATA 8.0.

Results: Logistic regression analysis revealed the following prognostic

factors associated with a negative outcome: 1) older age [ 65ys (odds

ratio = 2.01; 95 %CI:1.16-3.49), 2) female gender (odds ratio = 3.91;

95 %CI:2.12-4.79), 3) increasing lag time between injury date and pre-

sentation for treatment, more than 5 days (odds ratio = 2.81;

95 %CI:1.56-3.71), 4) higher initial pain intensity, more than 7 according

to VAS score (odds ratio = 1.91; 95 %CI:1.06-3.69).

Conclusion: Older age, female gender, late therapy onset and intense

initial pain are important prognostic factors for a 4-year handicap

after acute whiplash.

P84

MOTION PRESERVING PROCEDURE

FOR THE TREATMENT OF HANGMAN’S

FRACTURE

Gohsuke Hattori, Takahiro Miyahara, Hisaaki Uchikado,

Motohiro Morioka

Department of Neurosurgery, Kurume University School of

Medicine, Kurume, Fukuoka, Japan

Object: Opinions have varied regarding the optimal treatment of an

unstable Hangman’s fracture. C2 pedicle screw instrumentation is a

biomechanically strong fixation witch although done through a simple

posterior approach. The purpose of this study is to determine the

effectiveness of C2 pedicle screw fixation on Hangman’s fracture

management.

Methods: This prospective study included 6 consecutive patients with

displaced type II or IIA traumatic spondylolisthesis of the axis. There

were three males and three females with mean age of 58 years at

surgery. The cause of injury was a road traffic accident in 3 patients

and a fall from height in 3 patients. All patients had a single stage

reduction and direct transpedicular screw fixation through the C2

pedicles. Two patients required additional fixation with the C3 lateral

mass screw. During follow-up, clinical evaluation and plain X-rays

were performed at each visit; at 3, 6, and 12-month follow-up,

additional dynamic lateral flexion/extension views and a CT scan

were performed.

Results: Mean follow-up period was 37 months (range of

15-52 months). At final follow-up, all patients were asymptomatic

and regained a good functional outcome with no limitation of range of

motion; all the patients showed solid union with no implant failure.

There were no neurological complications. At 6-month follow-up, CT

evaluation showed fusion in all patients and an adequate position of

12 screws.

Conclusions: Transpedicular screw fixation through the C2 pedicles

is a safe and effective method in the treating type II traumatic

spondylolisthesis of the axis, resulting in good clinical and radio-

logical outcomes. Adequate reduction was achieved and motion

segments were preserved with its use.

P85

ASSESSING QUICKNESS OF UPPER LIMB

AND HAND FUNCTION FOR PATIENTS

WITH CERVICAL SPINAL CORD INJURY

WITHOUT BONE INJURY USING SIMPLE TEST

FOR EVALUATING HAND FUNCTION

Jun Shinbo, Masaya Mimura, Hiroaki Sameda, Sumio Ikenoue,

Kan Takase, Eiko Hashimoto, Aya Kanazuka, Takahiro Enomoto

Orthopedic Department, Funabashi Municipal Medical Center,

Funabashi, Japan

Objective: It has been reported that in assessing tools for evaluating

spinal cord injury (SCI) outcomes, further validation studies are

required to identify the most appropriate tools for specific targets in a

human SCI study. Moreover, there are few reports on evaluation

methods of upper limb and hand motor skill including manual speed.

Simple test for evaluating hand function (STEF) is designed in Japan

in 1974 to objectively evaluate the speed of carrying objects to an

arranged area and inserting sticks into holes or turning over cloths,

which has come to the market in Japan. The aim was to evaluate

quickness of upper limb and hand function for patients with cervical

spinal cord injury without bone injury (CSCIWBI) using STEF and

compare the improvement rate of quickness between surgical and

conservative treatment retrospectively.

Materials-Methods: Eighteen patients with CSCIWBI were enrolled.

Ability of manipulating the objects by the upper limb and hand was

assessed using STEF (The maximum score is 100 points.) at each

hand at 2, 4, 6, 8, 12, 24 and 24 weeks. Laminoplasty was performed

3 weeks after injury in cases with delayed neurological recovery. At

2 weeks after injury, all the upper arms were categorized based on the

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treatment and STEF score (border point: 60) into four groups: Con-

servative-Low STEF group (CL), High STEF group (CH), Operative-

Low STEF group (OL) and Operative-High STEF group (OH). The

rate of improvement was calculated as the amount of STEF score

improvement or deterioration per week. Data analyses were per-

formed using Mann–Whitney U-test.

Results: The numbers of upper limb in CL, CH, OL and OH were 3,

9, 17 and 7 respectively. There was no statistical difference of the average

STEF score in comparison between the CL and OL at all the examined

time points. No statistical difference of the average STEF score between

CH and OH was also found in comparison at all the examined time points.

The average rate of improvement from 2 to 4 weeks in CL and OL were

9.83 and 8.47 respectively and no statistical difference was found

between them. Whereas, the average rate from 4 to 48 weeks in the CL

and OL were 0.24 and 0.78 respectively and statistical difference was

observed between them. (P \ 0.05).

Conclusion: STEF could be a useful tool for the evaluation of upper

arm function of patients with CSCIWBI. Surgical treatment could

have positive impact on the improvement of quickness of upper limb

and hand function.

P86

PEDICLE-HINGED UNILATERAL POSTERIOR

ARCH RECAPPING TECHNIQUE FOR DUMBBELL-

SHAPED CERVICAL SPINAL CORD TUMORS

Kazuya Kitamura, Tateru Shiraishi, Ryoma Aoyama,

Jun-ichi Yamane, Ken Ninomiya, Seiji Ueda

Department of Orthopedic Surgery, Hiratsuka City Hospital,

Kanagawa, Japan

Introduction: For safe and secure excision of cervical spinal cord

tumors, we have performed muscle-preserving Unilateral Posterior

Arch Recapping Technique (UPART) in 11 cases, in which unilateral

posterior arches pivoted on the lateral gutter of the laminae with all

their attached muscles preserved. For dumbbell-shaped cervical spinal

cord tumors, anterior or posterior one-way approach can injure vital

organs including vertebral artery and spinal cord. To prevent these

vital complications and excise the tumor securely, we developed a

new procedure in which the unilateral posterior arches pivoted on the

divided pedicles (P-UPART) and macro-totally excised 4 dumbbell-

shaped cervical neurinomas.

Methods: Microscopic surgical technique: (UPART) The spinous

processes were sagittaly split and lateral gutters were created on the

laminae with the attached muscles undisturbed. Then, the epidural

space was exposed by opening unilateral laminae. After excising

tumor, the opened unilateral laminae were reduced to their counter-

parts with stitches. (P-UPART) First, by antero-lateral approach, the

outer wall of the foramen transversarium was removed to dislodge the

vertebral artery, then the inner wall, the pedicle, was divided after

excising anterior tumor component. Second, by posterior approach,

unilateral laminae pivoted on the divided pedicle after sagittally

splitting the spinous processes. After excising posterior tumor com-

ponent, the opened laminae were reduced in the same way as UPART.

Evaluation: This study included 11 cases of UPART and 4 cases of

P-UPART. Cervical curvature and flexion–extension range of motion

were measured on plain X-rays, and bone union examined on CT. Cross-

sectional area of the deep extensor muscles on the affected side was

compared with that on the opposite side on postoperative axial MRI.

Results and discussions: All tumors were successfully excised.

Postoperative MRI showed no evidence of muscle damage.

Undamaged muscles and landmarks can make revision surgeries safer

as well as minimize dead space formation and incidence of infection.

Furthermore, P-UPART has following advantages; 1. the anterior

tumor component is securely excised with the vertebral artery kept in

control, 2. the unilateral laminae opened on the divided pedicle pro-

vide wider epidural space for safer tumor excision avoiding spinal

cord damage, 3. the posterior musculature is kept completely undis-

turbed as lateral gutter is unnecessary.

P87

POTENTIAL USE OF DIFFUSION TENSOR IMAGING

FOR LEVEL DETERMINATION IN MULTILEVEL

CERVICAL SPONDYLOTIC MYELOPATHY

Keith Luk, Xiang Li, Jiao-Long Cui, Kin-Cheung Mak, Yong Hu

Orthopaedics and Traumatology, Pokfulam, Hong Kong

Background: Cervical spondylotic myelopathy (CSM) resulting from

multilevel canal stenosis commonly presents with complex neuro-

logical signs which makes level localization difficult. While Magnetic

Resonance Imaging (MRI) could identify the level(s) of compression

anatomically, it is unable to reveal the pathological changes inside the

compressed cord leading to discrepancies between the MRI level and

the clinical findings. Diffusion tensor imaging (DTI) is recently found

to be able to assess the microstructural changes of the white matter

caused by cord compression and may be a useful tool for level

determination in multilevel CSM.

Method: 16 CSM patients with multilevel compression were recrui-

ted for this study. The level(s) responsible for the clinical symptoms

were determined by: (1) a detailed clinical neurological examination,

(2) T2-weighted MRI, and (3) DTI analysis (Orientation Entropy,

OE). On the T2 W MRI the anterior-posterior compression ratio

(APCR) of the compressed cord and the presence of a high-intensity

signal (HIS) were used to determine the affected level(s). The level

estimation results from T2 W MRI and DTI analysis were correlated

to that of the clinical neurological examination on a level-to-level

basis. The agreement rate, sensitivity and specificity were calculated.

Results: When correlated with the clinical level determination, the

OE based DTI analysis was found to have higher agreement rate than

the APCR (80.00 % versus 77.5 %) but they have almost equal

sensitivity (81.58 % versus 78.26 %) and specificity (59.09 % versus

59.09 %). The HIS has the highest agreement rate (95.45 %) and

specificity (95.45 %) but the lowest sensitivity (58.33 %).

Conclusion: DTI can be a useful tool to determine the pathological

spinal cord levels in multilevel CSM. This information from OE based

DTI analysis, in addition to the clinical neurologic assessment, should

help the spine surgeons in deciding the optimal surgical strategy.

P88

ANATOMIC FEASIBILITY OF C2 PEDICLE

SCREW FIXATION: A MULTIDIMENSIONAL

COMPUTED TOMOGRAPHY STUDY

Lauren Burke, Anthony Ho, Timothy Wagner, Joseph O’Brien,

Warren Yu

O’BrienOrthopaedic Surgery, Washington, USA

Objective: Anatomic variability of the C2 pedicle is well documented

and poses a challenge for C2 fixation. The use of multidimensional

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computed tomography (CT) is not widely used, but may be an asset to

preoperative planning. This study evaluated the suitability of C2 pedicle

screws by using Osirix software to change the gantry angle of CT angi-

ograms in order to measure the anatomic dimensions of the C2 pedicle.

Methods: Retrospective review of CT angiograms of the head and

neck from 47 consecutive trauma patients at our institution. Data

collection included length and width of each C2 pedicle from 47

patients, allowing 94 samples, by 3 independent observers. This was

performed using Osirix (Pixmeo, Switzerland), a DICOM viewer that

allows navigation and visualization in multidimensional imaging,

such as 3D, which was utilized here. Vertebral anatomy was also

studied to determine if aberrant anatomy would preclude pedicle

fixation. Statistical analysis was performed.

Results: Of the 47 consecutive CT angiograms that were reviewed, 20

were of female patients and 27 were male. Overall mean C2 pedicle

width and length were 8.272 ± 1.364 mm and 27.052 ± 3.471 mm,

respectively. Gender-specific measurements were also determined.

The average width and length of pedicle in females was

8.040 ± 1.262 mm and 27.241 ± 2.731 mm, respectively. The

average width and length of pedicle in males was 8.444 ± 1.414 mm

and 26.913 ± 3.933 mm, respectively. The gender difference was

statistically significant for width (p = 0.012) but not for length

(p = 0.41). 98 % and 97 % of pedicles could tolerate a 3.5 mm and

4.0 mm screw, respectively, based on width. Only three patients had

vertebral anatomy that precluded screw length greater than 14 mm.

Conclusion: Careful preoperative planning is imperative for instru-

mentation at C2. Fine-cut, noncontrast CT is a useful tool to delineate

anatomy; however, the axis of images is not always along the ana-

tomical axis of the vertebra in question. With multidimensional CT or

3D imaging, we found that over 90 % of patients could tolerate both

3.5 mm and 4.0 mm pedicle screws at C2. Only 6 % of patients (3 of

47) have vertebral anatomy that precludes the use of screw lengths

greater than 14 mm. We conclude that the C2 pedicle may be more

tolerant of fixation than previously reported.

P89

CERVICAL MULTIFIDUS CONTRACTION IS

ASSOCIATED WITH ISOMETRIC CONTRACTION

OF SHOULDER MUSCLES

Leila Rahnama, Asghar Rezasoltani, Farhang Noorikochi,

Minoo Khalkhali, Alireza Akbarzadeh Baghban

Physiotherapy, Tehran, Iran

Background: Deep neck muscles provide the stability of cervical

spine either in rest or during neck movements. But whether it is

activated during upper extremities’ task to provide the stability of the

neck is unknown to us.

Objective: The aim of this study is ultrasonographic evaluation of

cervical multifidus (CM) thickness in response to isometric contrac-

tion of shoulder muscles.

Methods: A total of 23 healthy subjects were participated voluntarily

in this cross sectional study. Ultrasonographic imaging of CM has been

taken at level C4 while subjects were at rest and during 25, 50, 75 and

100 % maximal voluntary contraction of right shoulder muscles.

Results: Our results showed CM thickness increased as isometric

contraction of shoulder muscles increased (P = 0.00). This changes

of thickness was also larger at right CM (P = 0.047). However there

was no significant difference among effects of force directions on the

muscle thickness (P [ 0.05).

Conclusion: Cervical multifidus is contracted in isometric contraction

of shoulder muscles to provide the stability of cervical spine. It may

lead to design an indirect method for CM training in conditions in

which the direct contraction of CM is impossible or prohibited

because of pain or injury.

P90

DEGENERATIVE CERVICAL KYPHOTIC

DEFORMITY RECONSTRUCTION. IS RADICAL

SURGICAL CORRECTION EFFECTIVE?

Lukas Bobinski, John Michael Duff, Marc Levivier

Neurosurgical Department Lausanne, CHUV, Lausanne, Switzerland

Background and aims: Severe, fixed degenerative cervical deformity

is a rare condition. There are no current guidelines how to treat this

challenging disease. The goal of this report was to review the surgical

strategy, technique and the outcome in 5 patients after surgical

correction.

Methods: Among 14 retrospectively reviewed cases of severe cervical

kyphotic deformity, 5 (4 man and 1 women) were due to severe

degenerative changes. The average age was 66 years (49-78). All

subjects presented with signs of myelopathy and were treated with two

stage 360� correction. The Ishihara index and the Cobb angle at the apex

of deformity were measured on pre- and postoperative images. The

mJOA myelopathy score was calculated before surgery and during

clinical follow-up. The anterior approach (two or three level corpec-

tomy) was performed to achieve ventral release, decompression and

height restoration of anterior column. Anterior plating was used for

fixation. In the second stage of correction we used posterior instru-

mentation with pedicle screws (inserted using 3D fluoroscopy with

navigation) with compression across the construct to shorten the pos-

terior column. In one case, at the level of C4/C5 and C5/C6 we

performed posterior osteotomy to enhance correction. Each case was

under neurophysiologic surveillance, which remained unchanged.

Results: The mean clinical and radiological follow-up was 6 months

(1-12 months). The mean preoperative mJOA score improved from

average 13.2 (10-16) to 15.2 at follow-up (10-18).

In four patients we achieved the average correction of 12 points

measured by Ishihara index. One patient improved from -9 to plus 22

but during 6 months of the follow-up lost 11 points of correction. The

average pre-operative Cobb angle changed from kyphotic 17.1� to

kyphotic 4.2�.

Conclusions: Degenerative, fixed, cervical kyphotic deformity with

myelopathy requires complex treatment including: decompression,

anterior column height restoration and shortening of posterior column.

The 360� procedure enable all of these steps. The use of cervical pedicle

screws provides biomechanical advantage, which help maintain the

correction. Despite the fact we did not achieve full correction to lordosis,

our clinical outcome was good. However, these findings require long

term follow-up to ensure that deformity correction is maintained.

P91

SELECTIVE LAMINOPLASTY FOR CERVICAL

SPONDYLOTIC MYELOPATHY: A COMPARATIVE

STUDY WITH A MINIMUM 5-YEAR FOLLOW-UP

Minori Kato, Hiroaki Nakamura, Koji Tamai, Kazunori Hayashi,

Akira Matsumura, Sadahiko Konishi

Orthopaedic Surgery, Osaka, Japan

S754 Eur Spine J (2013) 22 (Suppl 5):S720–S766

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Purpose: Less invasive methods for laminoplasty such as selective

decompression laminoplasty decrease postoperative complications

and are reportedly effective for treating cervical spondylotic mye-

lopathy (CSM). To our knowledge, no comparative study has

evaluated the medium-term clinical outcome of selective laminopl-

asty vs. conventional C3-7 laminoplasty. The purpose of this study is

to examine the medium-term clinical outcome of selective lamin-

oplasty (C4-7 laminoplasty and C3-6 laminoplasty) in comparison

with conventional C3-7 laminoplasty for treating CSM over a mini-

mum follow-up of 5 years.

Methods: Medium-term (minimum follow-up: 5 years) clinical out-

comes of selective (C4-7 and C3-6) for CSM were compared with

those of C3-7 laminoplasty in 73 CSM patients. The extent of lam-

inoplasty was C3-7 in 42 cases (Group A), C4-7 in 16 (Group B), and

C3-6 in 15 (Group C). Clinical outcomes were evaluated by com-

paring the Japanese Orthopedic Association (JOA) Scores, axial

symptom (neck pain), and X-ray findings [cervical sagittal alignment

and range of motion (ROM) of cervical spine] before, at 2 years after

surgery, and at the final follow-up among 3 groups.

Results: Neurological recovery following selective laminoplasty (C4-

7: 51.9 % and C3-6: 53.4 %) was similar to that of C3-7 laminoplasty

(59.8 %). Among all the cases, the postoperative axial pain was

observed in 11 patients, with its incidence being 15.1 % at 2 years

after surgery. At final follow-up, 9 patients had postoperative axial

pain (12.3 %). In Group A, 9 patients had postoperative axial pain

2 years after surgery and 7 patients had axial pain at the final follow-

up. In Groups B and C, only 1 patient had postoperative axial pain at

2 years after surgery and at final follow-up. The percentage of cer-

vical spine ROM retained after surgery was significantly higher in

Groups B (59 %) and C (63 %) than in Group A (48 %) at final

follow-up. C4-7 laminoplasty retained the muscle attachments on the

C2 spinous process, which helped in maintaining cervical alignment

(4� increase in cervical lordosis).

Conclusions: Medium-term neurological recovery following selec-

tive laminoplasty was satisfactory compared with that following

conventional C3-7 laminoplasty. In addition, selective laminoplasty

decreased axial pain (neck pain) and ameliorated restriction of the

cervical spine ROM. Selective laminoplasty was effective in

improving the surgical outcomes in CSM patients, and medium-term

results were satisfactory.

P92

CERVICAL INJURIES - A TEN YEAR EXPERIENCE

FROM BELFAST, NORTHERN IRELAND

Rakesh Dhokia, Niall Eames

Royal Victoria Hospital, Belfast, UK

Objectives: To record our experience in the management of cervical

trauma. In particular compare the patterns of management of Atlanto-

axial, Sub-axial and isolated PEG injuries.

Methods: A retrospective review of the Fracture Outcome Research

Database (FORD) for Northern Ireland (NI). We reviewed 2395

patients admitted with cervical injuries to Royal Victoria Hospital,

Belfast, between January 2000 and December 2010. Cervical trauma

represented a mean 46 % of all spinal trauma admissions per year.

1251 were male and 783 female. 33 % patients were aged 65 + .

Results: NI population has increased 9 %, (1.81 million, 2011), There

is no significant increase in cervical trauma admissions. There is no

significant change in conservative (71 %) and surgical (29 %) man-

agement. The average proportion per year of Atlanto-axial trauma

was 31 % and Subaxial trauma was 69 %. There was a total of 365

PEG and associated segment injuries. Of these 266 were isolated PEG

fractures (Mean,24/year). Those treated conservatively 182(68 %)

and Surgical 84(32 %). Surgical treatment was 51 Halo, 4 Anterior

and 29 posterior fixations. All isolated PEG fractures surgically fixed

were aged under 65. For isolated PEG fractures the Mean age of

surgical fixation was 42 and those treated conservatively 69.

Conclusions: Cervical trauma admissions in NI represent a steady but

significant proportion of spinal trauma. In cases of isolated PEG

fractures all patients aged greater than 65 have been treated conser-

vatively with a cervical orthotic and surgical fixation has been

employed to patients aged 65 or under. Surgically treated patients

with multi segment atlanto-axial injury aged over 65 had posterior

fusion.

P93

IS IT SIGNIFICANT TO PRESERVE C7 OR C6

POSTERIOR ARCHES WITH THEIR

ATTACHMENTS OF NUCHAL LIGAMENT

FOR MAINTAINING CERVICAL CURVATURE

AND REDUCING NECK PAIN AFTER CERVICAL

LAMINOPLASTY?

Ryoma Aoyama, Tateru Shiraishi, Junichi Yamane, Ken Ninomiya,

Kazuya Kitamura, Satoshi Nori, Seiji Ueda, Ukei Anazawa,

Hiraku Hotta, Takeru Arai

Orthopaedics, Chiba, Japan

Introduction: Purpose of this study is to elucidate significance of

preserving C7 or C6 posterior arches with their attachments of the

nuchal ligament to maintain cervical curvature and to reduce neck

pain after posterior cervical laminoplasty. Previous papers, which

emphasized the significance of C7 preservation, compared results

between C3-7 laminoplasty sacrificing 5 extension units of the spi-

nous process and its attached muscles bilaterally and C3-6

laminoplasty sacrificing 4 units. Their study designs were inadequate

because the former was more invasive to cervical extension mecha-

nism than the latter. Avoiding the influence of surgical invasion, we

compared surgical results between the groups, each of which had the

same number of extension unit sacrificed.

Materials and Methods: Since 2002, 77 patients with cervical

spondylotic myelopathy (CSM) underwent adjacent two-level or one-

level laminoplasty. Among 32 patients who underwent two-level

laminoplasty sacrificing 2 extension units, attachment of nuchal lig-

ament was compromised in 10 patients (N2) while preserved in the

remaining 22 (P2). Among 45 patients who underwent one-level

laminoplasty sacrificing one unit, attachment of nuchal ligament was

compromised in 7 patients (N1) while preserved in the remaining 38

(P1). To evaluate surgical outcomes, Japanese Orthopaedic Associa-

tion (JOA) scores and Visual Analog Scale (VAS) were recorded for

each patient pre- and postoperatively. On the lateral radiographs with

the neck in neutral position, C2-7 angles were measured pre- and

postoperatively according to Cobb’s method.

Results: Improvement rate calculated with JOA scores averaged

63.7 % for N2, 43.2 % for P2, 48.3 % for N1, and 40.7 % for P1

respectively. Pre- and postoperative VAS scores of neck pain aver-

aged 2.0 and 0.6 for N2, 1.3 and 0.6 for P2, 1.3 and 1.3 for N1, and

2.7 and 1.6 for P1 respectively. Pre- and postoperative C2-7 angles

averaged 5.3� and 7.7� for N2, 11.4� and 11.5� for P2, 0.3� and 4.5�for N1, and 12.5� and 14.8� for P1 respectively. There was no sta-

tistical difference in pre- and postoperative JOA scores, VAS scores,

and C2-7 angles between the groups.

Eur Spine J (2013) 22 (Suppl 5):S720–S766 S755

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Conclusion: Preservation of the integrity of the cervical posterior

arches with their attachments of the nuchal ligament does not have

significant influence over postoperative neck pain and cervical curvature.

P94

IS CERVICAL LAMINOPLASTY REALLY ABLE

TO PRESERVE THE MOTION OF CERVICAL

SPINE? : MINIMUM 2 YEARS FOLLOW-UP

AFTER OPEN-DOOR LAMINOPLASTY

AND ADJACENT SEGMENT DEGENERATION

Sang Gu Lee, Keun Lee, Seong Son, Chan Woo Park,

Woo Kyung Kim

Neurosurgery, Gachon University, Gil medical center, Incheon, Korea

(ROK/South Korea)

Introduction: Several studies have reported on the decrease of range

of motion (ROM) associated with laminoplasty. The purpose of this

study was to compare the changes in ROM of whole cervical spine,

laminoplasty segment and adjacent segment after cervical unilateral

open-door laminoplasty between OPLL(ossification of posterior lon-

gitudinal ligament) and CSM (cervical spondylotic myelopathy) and

evaluate the adjacent segment degeneration in cranial and caudal

aspect of laminoplasty segment.

Material and Method: 41 patients (33 males and 8 females, mean

age: 53.2 years) who underwent unilateral open-door laminoplasty

were enrolled. The average follow-up period was 46.2 months. 22

patients had OPLL and 19 patients had CSM. Radiography was per-

formed before surgery, at 1-year follow-up and at the last follow-up. A

retrospective radiologic review of cervical alignment in the neutral and

flexion–extension view were measured by the Cobb method.

Results: Cervical ROM was decreased after laminoplasty from

37.2 ± 9.0� at preoperative state to 28.5 ± 2.6� at 1-year follow-up,

25.9 ± 13.1�at the final follow-up, showing a significant decrement of

11.2�(30.1 %). Laminoplasty segment ROM was decreased from

28.1 ± 8.3� at preoperative state to 18.3 ± 8.4� at 1-year follow-up,

16.2 ± 8.1� at the final follow-up. Upper segment ROM was 4.7 ± 2.6�at preoperation, 4.9 ± 4.0� at 1-year follow-up, 5.7 ± 4.1� at last follow-

up and this decrement was not significant statistically. Lower segment

ROM was 5.4 ± 2.5� at preoperation, 7.5 ± 2.6� at 1-year follow-up and

9.4 ± 3.0� at the last follow-up. 4 cases developed postoperative ky-

phosis (OPLL 3 vs. CSM 1) and 13 cases showed interlaminar bony

fusion at the last follow-up (OPLL 9 vs. CSM 4).

Conclusions: The study about ROM after cervical laminoplasty

showed that the postoperative cervical ROM decreased notice-

ably(30.1 %). Laminoplasty segment became stiff and adjacent

segment received more abnormal stress which increased more motion

in the caudal adjacent segment than in the cranial segment. Fortu-

nately, none of them developed into adjacent segment disease and

needed additional operation.

P95

RECONSIDERATION OF LAMINECTOMY

REGARDING THE PRESERVATION

OF THE SPINE CONSTRUCTION IN PATIENTS

WITH CERVICAL MYELOPATHY

Tatsuya Ohtonari, Nobuharu Nishihara, Katsuyasu Suwa, Taisei Ota,

Tsunemaro Koyama

Department of Spinal Surgery, Brain Attack Center Ota Memorial

Hospital, Fukuyama, Japan

Objective: To present a positive outlook for the replacement of open-

door laminoplasty, developed by Hirabayashi in 1977, by a lami-

nectomy that allows for mioarchitectonic preservation. Until recently,

we have performed open-door laminoplasty on patients with cervical

myelopathy. The concern about excessive stripping of the posterior

cervical muscles has led us to reconsider the long established

approach and change to the laminectomy that pays due attention to

the preservation of the cervical spine construction. This presentation

aims to introduce our surgical method and to report its short- and mid-

term results. We also report the mid-term results of open-door lam-

inoplasty to hint at the prospect of its outcome based replacement by

the laminectomy.

Methods: This laminectomy was performed on a total of 19 patients

with cervical myelopathy since February 2010, 16 were followed up

(10 males and 6 females, age 68.8 ± 9.1 years). The details regarding

the diseases of these patients were as follows: spondylosis, 7 cases;

canal stenosis, 8 cases; and discopathy, 1 case. The median value of

the preoperative JOA score was 12.0 (range: 3-16). The surgical

procedure was the following. Pursuant to a midline skin incision, a

paramedian approach to the symptom dominant side was taken to

strip the posterior cervical muscles up to the medial line of the facet

joint, while preserving the continuity of the nuchal ligament. The

spinous process in the target area for decompression was cut, and the

cervical muscles on the contralateral side were removed just slightly

beyond the edge of the cut section of the spinous process. Laminec-

tomy was performed with deviation to the dominant side of symptom.

Results: The median value of the JOA scores in the early or middle

postoperative phase (mean 218.3 days, range: 99-463 days) has

improved to 15.0, and the recovery rate of the JOA scores was

46.9 %. On the other hand, 60 patients with cervical myelopathy due

to non-OPLL underwent laminoplasty. Of these, 44 were followed

(mean 892.9 days, range: 311-2048 days, the median value of the

preoperative JOA score was 12.0) and the recovery rate of the JOA

scores was 52.9 %.

Conclusion: The laminectomy that enables the preservation of the

cervical spine construction might turn out to be the more preferable

one with less damage to the posterior cervical muscles if the mid- and

long-term outcome proves to be equivalent to that of open-door

laminoplasty.

P96

RELATIONSHIPS BETWEEN SURGICAL

OUTCOMES OF LAMINOPLASTY

AND POSTOPERATIVE RANGE OF MOTION

OF THE CERVICAL SPINE IN PATIENTS

WITH CERVICAL SPONDYLOTIC MYELOPATHY

Yuto Ogawa, Morio Matsumoto, Masaya Nakamura, Ken Ishii,

Yoshiaki Toyama

Department of Orthopedic Surgery, Saitama-shi, Japan

Several factors related to neurological recovery after expansive

laminoplasty (ELAP) for cervical spondylotic myelopathy (CSM)

have been reported. However, an impact of postoperative range of

motion(ROM) of cervical spine on surgical outcomes has not been

addressed. This study was retrospectively conducted to elucidate

relationship between postoperative cervical ROM and surgical out-

comes of ELAP for CSM.

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Methods: Between 1993 and 2011, 163 patients with CSM were

operated and followed for at least 1 year. To exclude surgery-related

factors and other factors unrelated to this disease which might affect

surgical outcomes, patients with CSM whose symptoms were

improved or unchanged after surgery were included into analyses

(130 patients).

Japanese Orthopedic Association score (JOA score), recovery rate

(RR: (postoperative JOA score - preoperative JOA score)/(17 -

postoperative JOA score) x 100), age at the time of surgery,

gender, preoperative morbidity period, ROM of cervical spine,

diminution rate of ROM (DR: 100 - postoperative ROM/preoper-

ative ROM x 100), alignment of cervical spine, level of affected

segment and antero-posterior diameter at affected segment, number

of segments where compression of spinal cord was observed were

assessed. Parameters were assessed before and 1 year after surgery.

Results: Preoperative mean JOA score of 9.8 ± 2.7 points improved

to 13.8 ± 2.3 points at 1 year after surgery. Mean RR was

50.6 ± 32.0 %. Significant correlation with RR was observed in age

(p \ 0.001), preoperative morbidity period (p = 0.04), postoperative

ROM (p = 0.02), and DR (p = 0.006). Significant difference in RR

was not observed in any categorical parameters. Multilinear regres-

sion analysis using parameters which have significant correlation with

RR revealed that age, preoperative morbidity period and DR were

associated with RR (p \ 0.001, R2 = 0.21).

Conclusions: Recently, preservation of ROM of cervical spine after

ELAP has been preferred to prevent development of postoperative

axial pain and to minimize ADL disturbance. However, results of this

study suggest that mobility of cervical spine could impair postoper-

ative neurological recovery. It has been reported in several literatures

that the degree of diminution of ROM after ELAP depended on the

period and the mode of postoperative external immobilization.

Therefore, the importance of the postoperative external immobiliza-

tion should be reconsidered to obtain the maximum postoperative

neurological recovery.

GROWING SPINE DEFORMITIES

P97

CORRELATION ANALYSIS BETWEEN DIGITAL

PHOTOGRAPHY MEASUREMENT OF TRUNK

DEFORMITY AND SELF-IMAGE PERCEPTION

IN PATIENTS WITH IDIOPATHIC SCOLIOSIS

Antonia Matamalas, Elisabetta D0Agata, Ferran Pellise, Juan Bago,

Enric Caceres

Orthopaedic Surgery, Barcelona, Spain

Introduction: It has been suggested that some measures of trunk

deformity obtained in digital photography can be useful in the

assessment of trunk deformity. The relationship between these mea-

sures and patients’ self-image perception has not been established.

Study design: Concurrent validity between postural indexes obtained

from digital photographs and self-assessed appearance questionnaires.

Objective: To assess the validity of a clinical assessment tool of the

trunk deformity based on photographs as compared to self-assessed

appearance questionnaires.

Methods: Front and back digital photographs of patients with idio-

pathic scoliosis (Cobb angle [ 258) were obtained. Shoulder, armpit

and waist angles in addition to trunk asymmetry indices were cal-

culated on front and back photographs with Surgimap software. All

patients completed SRS-22, SAQ, QLSDP and TAPS questionnaires.

The Pearson correlation coefficients (r) were used to estimate con-

current validity between both methods.

Results: 80 consecutive patients (68 females and 12 males) aged 12 to

40 years old (average 20.3 years old) were included. Mean Cobb

angle was 45.98 (range 25.18 to 77.28).A significant correlation was found between waist height angle and

TAPS (r = -0.31 to -0.34); SAQ appearance subscale (r = 0.27 to

0.35) and SAQ total score (r = 0.25 to 0.29). No correlation between

TAPS, SAQ and other photography measurements was found. No

correlations between photographs and total SRS-22 score or its sub-

scales and QLSDP were found.

Conclusion: Waist height angle measured with digital photography is

moderately correlated with perceived trunk appearance. Trunk

asymmetry is poorly correlated with self-assessed appearance. Pic-

ture scales are better correlated with photographs than verbal rating

scales.

P98

THE NORTHERN IRELAND EXPERIENCE

WITH GROWTH RODS: IMPROVING

SIGNIFICANT SCOLIOSIS DEFORMITY

David Spence, Deirdre Fee, Eugene Verzin, Gregory McLorinan,

Alistair Hamiliton, Niall Eames

Trauma & Orthropaedics, Belfast, UK

Objectives: Growth rods are being used increasingly worldwide in

the treatment of scoliosis. We report the Northern Ireland experience,

with a series of 25 patients over 8 years, and the effectiveness of the

growth rods in improving deformity.

Methods: Between June 2004 and October 2012, a consecutive series

of 25 patients have had growth rods inserted and subsequently

lengthened. Notes and X-rays were reviewed with demographic data

and Cobb angles recorded.

Results: Of the 25 patients, 17 were male and 8 female with an

average age at time of surgery 6.6 years (range 2 - 12 years).

Nine patients had a single growing rod inserted with 6 requiring

conversion to dual rods. 15 patients had dual rods inserted primarily

and 1 patient underwent the VEPTR procedure.

The levels instrumented ranged from T2 - L5 with hooks used

superiorly in 12 cases and only screws in the remainder.

The average Cobb angle pre-op was 70� (range 40� - 108�). At initial

follow-up, the Cobb angle had reduced to 44� (range 26�- 74�). At last

review the average Cobb angle was 40� (range 19� - 66�).

On average 3.91 lengthening procedures per patient were carried out

(range 1 - 10).

Complications were two broken rods and one rod that cut out

requiring revision.

Conclusion: This case series showed that growth rods can dramati-

cally improve significant scoliosis deformity, and improvement is

maintained with consequent lengthening procedures. The majority of

improvement occurs at the initial lengthening procedure, with the

insertion of dual rods the preferred technique.

The data suggests that the use of growing rods in the immature spine

is a safe and effective method for improving and maintaining the

corrected Cobb angle, in the Northern Ireland population.

Eur Spine J (2013) 22 (Suppl 5):S720–S766 S757

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P99

THE NOTTINGHAM QUESTIONNAIRE, A NEW

TOOL TO ASSESS QUALITY OF LIFE

IN NEUROMUSCULAR SCOLIOSIS

Hoda Mohajer-Bastami, Ann Marriott, George Arealis, Bev Beeson,

Nasir A Quraishi, Hossein Mehdian

QMC, London, UK

Introduction: There is limited literature regarding the use of a ded-

icated questionnaire to assess the outcome of spinal deformity

correction in patients with neuromuscular scoliosis. A multidisci-

plinary steering group were instrumental in designing an outcome

questionnaire in our unit for use in patients with Cerebral Palsy (CP)

and Duchenne Muscular Dystrophy (DMD).

Purpose: The purpose of this study was to assess the quality of life

(QOL) in patients with neuromuscular scoliosis following spinal surgery

using the newly devised Nottingham Questionnaire for Neuromuscular

scoliosis (NQNMS) with particular reference to CP and DMD patients.

Methods: Our questionnaire was developed by the steering committee

and granted ethical approval. The parameters assessed include sitting

posture/balance, arm use, head control, breathing, chest infections, pain,

eating, drinking, reflux, mobility, transferring, washing, dressing, daily

living, skin integrity before and after surgery. All answers were given by

the carers, parents or patients. Statistical analysis was performed using

the SPSS 17 and statistical significance was set at p = 0.5

Results: Between 2001 and 2011, 20 patients with NMS were treated

with posterior segmental screw fixation - 10 with (CP) and 10 with

(DMD). A total of 17/20 (85 %) carers responded - 9/10 patients with

CP and 8/10 with DMD.

At final follow-up (mean f/u 6.4 years (range 2-10), the parameters

that improved in both groups were sitting posture (p = 0.01), eating

and drinking and reflux (p = 0.33).

With mobility and transferring, and washing and dressing, there was

no difference before or after the operation for both CP and DMD

patients (p = 1.00) and the same happened with arm use (CP

p = 0.75, DMD p = 0.81).

Head control (p = 0.41) and breathing (DMD p = 0.28, CP

p = 0.62), improved in DMD patients only whilst pain improved in

CP patients (p = 0.17).

Post-operatively, there was 1 patient with superficial wound infection.

Conclusion: Our questionnaire is simple and easy to use for the

assessment of QOL in CP and DMD patients and had a good response

rate (85 %). Our study shows that spinal stabilization does improve

QOL through improvements in sitting posture, breathing, reflux,

mobility and transfer, washing, dressing and arm use. Validation of

the questionnaire in a larger group of patients is under way.

P100

IT IS POSSIBLE TO SPACE OUT THE TIME

BETWEEN GROWING RODS LENGTHENINGS

IN PATIENTS WITH JUVENILE SCOLIOSIS

AND STILL OBTAIN LONGITUDINAL CHEST

GROWTH

Javier Pizones, Tamara Rodrıguez, Patricia Alvarez-Gonzalez,

Lorenzo Zuniga, Felisa Sanchez-Mariscal, Enrique Izquierdo

Spine Unit. Orthopaedic Surgery. Hospital Universitario de Getafe,

Madrid, Spain

Introduction: Serial lengthening is recommended every six months

for the treatment of early onset scoliosis with growing rods. The

objective is to evaluate the longitudinal growth of the thorax and the

deformity control if the time between lengthening is spaced out, in a

series of patients with juvenile scoliosis.

Materials and methods: Retrospective study of eight patients with

juvenile scoliosis treated with growing rods whose lengthenings were

spaced more than six months apart. During the follow-up we mea-

sured: the Cobb angle, the apical vertebra traslation, the coronal

balance, the thoracic T1-L1 length, the thoracic T5-T12 kyphosis, the

proximal junctional kyphosis (PJK) angle, and the lumbar lordosis.

Complications were collected.

Results: Five idiopathic and three syndromic scoliosis. All had Risser

0 sign and open triradiate cartilage. Mean age 9.4 ± 1.5 years. Mean

follow-up of 78 months. Number of levels fused 12.4 ± 3.1. Mean

time between distractions 15.7 months, with an average of two dis-

tractions per patient. Four definitive fusions.

-Preoperative Cobb 56.5�, postoperative 24.75�, and final 23.75�(58 % correction). 16.8� were lost before the first lengthening and

11.5� before the second.

-Preoperative apical translation 4.8 cm and final 1.9 cm.

-Preoperative coronal balance 1.7 cm and final 1 cm.

-The thoracic (T1-L1) preoperative length was 20.8 cm, postoperative

24.3 cm, and final 26 cm. The initial surgery got to stretch 3.5 cm, the

first lengthening 3 cm and the second 2.6 cm, losing an average of

1.5 cm between elongations. At the end, the thorax’s average growth

was 5.2 cm.

-The preoperative (T5-T12) kyphosis was 33.5�, postoperative 23.4�,

and final 32�. 108 were corrected in the first surgery, 5.3� in the

second and 48 in the third surgery. An average of 6.4� were corrected

with each lengthening, losing an average of 5� between elongations.

-The change in PJK angle was 2.5� at final follow-up.

Conclusions: Spacing out lengthenings more than a year, in juvenile

scoliosis patients treated with growing rods, can spare surgeries while

still controlling the deformity and allowing longitudinal thoracic

growth.

P101

DOES INTRAOPERATIVE CELL SALVAGE

SYSTEM EFFECTIVELY DECREASE THE NEED

FOR ALLOGENEIC TRANSFUSIONS

IN SCOLIOTIC PATIENTS UNDERGOING

POSTERIOR SPINAL FUSION: A PROSPECTIVE

RANDOMIZED STUDY

Jianxiong Shen, Jinqian Liang, Sooyong Chua

Department of Orthopedic Surgery, Peking Union Medical College

Hospital, Beijing, China

Objective: To evaluate the safety and efficacy of intraoperative cell

salvage system in decreasing the need for allogeneic transfusions in a

cohort of scoliosis patients undergoing primary posterior spinal fusion

with segmental spinal instrumentation.

Background: Scoliosis patients undergoing posterior spinal fusion

can experience significant intraoperative blood loss and often require

perioperative blood transfusions. Cell saver can possibly obviate the

need for additional predonated autologous or allogeneic red blood cell

transfusion. However, there is conflicting evidence in the literature

regarding cell salvage system usage in pediatric orthopedic surgery.

Methods: A total of 92 consecutive scoliosis patients undergoing

posterior instrumented spinal fusion were randomized into 2 groups

S758 Eur Spine J (2013) 22 (Suppl 5):S720–S766

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according to whether a Cell Saver machine for intra-operative blood

salvage was used or not. Data included age, body mass index, perioper-

ative hemoglobin levels, surgical time, levels fused, perioperative

estimated blood loss, perioperative transfusions and incidence of trans-

fusion related complications. A Chi square test and t tests were performed

for intraoperative and perioperative allogeneic transfusion between

groups. A regression analysis was performed between selected covariates

to investigate the predictive factors of perioperative transfusion.

Results: Perioperative allogenic blood transfusion rate were lower in

the cell saver group (10 % vs. 28.6 %, P = 0.022). Mean intraoper-

ative red blood cell transfusion requirement were also lower (0.16

U/pt vs. 0.52 U/pt, P = 0.041). The mean Hb and hematocrit levels in

the cell saver group were significantly higher in the first three days

(P \ 0.05). No marked differences were observed in transfusion

related complications between both groups (p = 0.292). A multi-

variate analysis demonstrated that preoperative hemoglobin value

(OR: 0.849; p = 0.008), surgical time (OR: 1.041; p = 0.019),

intraoperative estimated blood loss (OR: 1.011; p = 0.001) and the

use of cell saver system (OR: 0.007; p = 0.003) had a trend toward

significance in predicting likelihood of transfusion.

Conclusions: Cell saver use significantly reduces the need for allo-

geneic blood in spine deformity surgery, particularly in patients with

low preoperative hemoglobin or longer operation time. This study

confirms the utility of routine cell saver use during PSF with seg-

mental spinal instrumentation for scoliosis patients.

P102

PREOPERATIVE SKULL-FEMORAL TRACTION

WITH POSTERIOR VERTEBRAL COLUMN

RESECTION (PVCR) TO TREAT SEVERE RIGID

SPINAL DEFORMITY WITH ANGULAR

CURVES [ 150�

Jingming Xie, Zhi Zhao, Tao Li, Yingsong Wang, Ying Zhang, Ni Bi

Department of Orthopaedics, Kunming, China

Summary: To explore the significance of preoperative skull-femoral

traction in severe rigid spinal deformity with angular curves [ 150�.

Introduction: Based on the angulation, rotation of the spinal cord, the

extremely severe rigid spinal deformity with angular curves can be

effectively corrected by PVCR, but the high risk of it has also been

reached a consensus in the world. If the curves can be improved preop-

eratively, the safeties of PVCR and the spinal cord will be increased.

Methods: From 2004 * 2012, 98 consecutive cases with severe

spinal deformity were successfully treated by PVCR in authors’

institution, in which, 12 cases with extremely severe rigid deformities

and angular curves were treated by skull-femoral traction before

PVCR. For the 12 cases, the average preoperative major scoliosis

curve and kyphosis was 153�(110�-168�) and 109�(61�-180�). The

continuous skull-femoral traction in the supine position was started

from preoperative 4 weeks. In the process of traction, the tolerance

(diet, sleeping, pain, etc.), neurologic status, deformity changes, etc.

were documented for analysis. The surgical correction through PVCR

was performed at the end of the post-traction 4th week.

Results: For the 12 cases, the final traction force was 63 % of body

weight (47 %-75 %). After 4 weeks traction, the deformity was

improved both on coronal and sagittal planes (F = 64.196,

P = 0.000): the major scoliosis curve and kyphosis were decreased

34 % and 31 %. At the end of the 1st week, the major scoliosis curve

and kyphosis were decreased 19 % and 15 %. In the 2nd week, the

major scoliosis curve was decreased 11 % (Fig. 1), but kyphosis was

unexpected increased 4 %. The deformities improvement in the last

2 weeks was less obvious than the first 2 weeks (P = 0.000). After

PVCR, the major scoliosis curve and kyphosis were improved 69 %

and 66 %. No spinal cord injury occurrence.

Conclusions: Preoperative skull-femoral traction is effective to decrease

the risks of spinal cord displacement in PVCR. Along with the traction,

the scoliosis can be improved more obviously and much earlier than

kyphosis. Following the traction force exceeding 63 % of the body

weight, the tolerance of the patients will be obviously decreased. In the

process of traction, the rigid deformity is rotated from coronal to sagittal

planes so as to decrease the risks and difficulties of PVCR.

P103

NON-SEGMENTAL LOW IMPLANT DENSITY

PEDICLE SCREW CONSTRUCT IN LENKE TYPE 1

AND 2 ADOLESCENT IDIOPATHIC SCOLIOSIS-

DOES IT HAVE AN IMPACT ON DEGREE OF CURVE

CORRECTION AND THORACIC KYPHOSIS?

Renjit Krishnakumar

Orthopaedics, Cochin, Kerala, India

Study Design: Retrospective cohort study of 36 consecutive patients

with Lenke I an 2adolescent idiopathic scoliosis, at a single centre,

using all posterior non-segmental pedicle screw instrumentation.

Objective: To evaluate the coronal and sagittal correction of main

thoracic adolescent idiopathic scoliosis using all-pedicle screw non

segmental instrumentation with low implant density in.

Summary of Background Data: There is an increasing trend in the

use of bilateral segmental pedicle screw construct in scoliosis cor-

rection surgery which increases the implant load, decreases thoracic

kyphosis and increases the cost of surgery.

Methods: Thirty seven consecutive patients with Lenke 1 and 2

adolescent idiopathic scoliosis curve pattern underwent single stage

posterior correction and instrumented spinal fusion with non seg-

mental pedicle screw fixation between 2004 and 2011. Pre- and

postoperative radiographs were analyzed. Mean patient age at the

time of operation was 15 years.

Results: Minimum follow-up was 2 years. The mean preoperative

thoracic curve was 58.80 degrees and 14.8 degrees at final follow-up,

resulting in a mean correction of 74.7 % (p \ 0.001) The preopera-

tive thoracic kyphosis of 15.7 degrees increased to 23.1 degrees. The

mean screw density was 1.13.

Conclusion: Even with non segmental pedicle screw construct with

low implant density of 1.13 we could achieve 74 % of curve cor-

rection with improvement of thoracic kyphosis.

P104

SAGITTAL SPINO-PELVIC ALIGNMENT IN EARLY

THORACIC VERSUS EARLY (THORACO)LUMBAR

ADOLESCENT IDIOPATHIC SCOLIOSIS

Tom Schlosser, Suken Shah, Samantha Reichard, Kenneth Rogers,

Koen Vincken, Rene Castelein

Orthopedic Surgery, Utrecht, Netherlands

Background: Rotational stiffness of spinal segments is decreased by

posteriorly directed shear loads. Posterior shear loads act on

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backwardly inclined segments of the spine as determined by the indi-

vidual’s inherited sagittal profile. Accordingly, it can be inferred that: (1)

certain sagittal spinal profiles are more prone to develop a rotational

deformity that may lead to idiopathic scoliosis; (2) lumbar scoliosis

develops on a different sagittal spinal profile than thoracic scoliosis.

Purpose: To compare the sagittal alignment and vertebral inclination

of early thoracic versus early (thoraco)lumbar scoliosis versus con-

trols in a systematic and reproducible way, and to examine the role of

sagittal alignment in the etiology of different types of idiopathic

scoliosis.

Design: Multicenter, cross-sectional study.

Methods: Standardized lateral radiograph of the spine of adolescent

idiopathic scoliosis patients with thoracic (n = 128) and lumbar

(n = 64) curves with a Cobb’s angle less than twenty degrees were

studied. Subjects who underwent scoliosis screening and had a normal

spine were included in the control cohort (n = 95). A systematic,

semi-automatic measurement of nine sagittal spino-pelvic parameters,

parameters describing the backwardly inclined segment and inclina-

tion of each individual vertebra between C7 and L5 was performed

for each subject using in-house developed computer software.

Results: Thoracic kyphosis was significantly smaller in thoracic

scoliosis than in lumbar scoliosis or controls. For thoracic scoliosis, a

significantly longer backwardly inclined segment and steeper back-

ward inclination of C7-T8 was observed compared to both lumbar

scoliosis and controls (Figure 1). In lumbar scoliosis, the backwardly

inclined segment was shorter and located lower in the spine, and T12-

L4 was more backwardly inclined than in the thoracic group. Lumbar

lordosis, pelvic tilt and incidence and sacral slope were similar for the

two scoliotic subgroups as well as controls.

Conclusions: This study demonstrates that the sagittal profile already

at an early stage of development of thoracic adolescent idiopathic

scoliosis differs significantly from lumbar scoliosis and controls. This

supports the theory that differences in sagittal profile play a role in the

development of different types of idiopathic scoliosis.

P105

IS THE KYPHECTOMY

FOR MYELOMENINGOCELE BENEFICIAL?

Yukitaka Nagamoto, Hidekazu Tobimatsu, Hiroyuki Aono,

Yukari Imajima, Motohiro Kitano

Orthopaedics, Osaka, Japan

Introduction: Severe kyphosis of myelomeningocele is a complex

disorder that usually requires kyphectomy. Although surgical correction

offers the possibility of restoring spinal alignment, kyphectomy is tech-

nically demanding and many complications can occur as result of the

surgery. Given the aforementioned facts, we wondered if the patents and

parents are really satisfied with the result of kyphectomy. The purpose of

our study is first to investigate our surgical results and perioperative

complication rates and second to elucidate patient and parent satisfaction

of kyphectomy for myelomeningocele.

Materials and methods: We reviewed 6 patients (3 male and 3

female) with myelomeningocele who had kyphectomy. The median

age at surgery was 9.5 years (4-19) and the median follow-up period

was 5.5 years (1-9.5). Outcome measures include radiographic mea-

surement (kyphotic angle and sacral slope), complication, and patient

and parent satisfaction. The patient and parent satisfaction was

assessed by mailing an original satisfaction questionnaire.

Results: In our case series, 3 were short fusions using plate and 3

were long fusions using spinal instrument. On an average, 2.7 (1-4)

vertebrae were resected. The mean kyphotic angle was 132�

preoperatively, 56� postoperatively, and 66� at the final follow-up. The

mean sacral slope was -38� preoperatively, -13� postoperatively, and -6�at the final follow-up. We identified 8 postoperative complications

including recurrence of kyphosis at adjacent segment, protruding hard-

ware, deep infection due to postoperative cast ulceration, and spinal fluid

leakage. Due to these complications, 22 additional surgeries were needed

in 3 of 6 patients. As for the satisfaction, 5 of 6 patients were answered

‘‘satisfied’’ including ‘‘satisfied a little’’ despite these all complications.

Especially, all patients were satisfied with the improvement of sitting

balance and prominent deformity in the low back.

Discussion: In previous studies, the percentage correction ranges

from 37 % to 96 % and complication rate remains greater than 50 %.

In our results, the percentage correction and complication rate were

50 % and 66 %, respectively and the results were equivalent as

compared with previous studies. Despite these all complications,

almost all patients and parents were satisfied with surgical results.

Given the results, it is very important to give fully informed consent

including all assumed risks and benefits before surgery.

P106

BRACE TREATMENT VERSUS OBSERVATION

ALONE FOR SCOLIOSIS ASSOCIATED

WITH CHIARI I MALFORMATION FOLLOWING

POSTERIOR FOSSA DECOMPRESSION: A CASE

CONTROL STUDY

ZHU Ze-zhang, SHA Shi-fu, SUN Xu, JIANG Long,

QIAN Bang-ping, QIU Yong

Spine Surgery, Nanjing, China

Objective: To investigate whether brace treatment subsequent to

posterior fossa decompression (PFD) produces better outcomes than

observation alone for scoliosis secondary to Chiari I malformation.

Methods: The clinical and radiographic data of all CMS patients who

underwent PFD at our center between January 1998 and November 2010

were retrospectively reviewed. Following PFD, 21 patients refused

bracing due to psychological concerns and were treated with observation

alone (Ob group), whereas 33 patients who received brace treatment were

assigned into the braced (Br) group. Evolution of scoliosis was defined as

progression if Cobb angle of the primary curve increased[ 5�, in

comparison with that at brace initiation; otherwise it was considered

improvement (decreased[ 5�) or stabilization (varied within 5�).

Results: The initial primary curve magnitude in the Br and Ob groups

averaged 33.3� ± 6.6� and 32.5� ± 7.8�, respectively. Duration of fol-

low-up in the Br group averaged 70.3 ± 22.4 months and in the Ob

group 61.9 ± 27.3 months. By the final visit, progression of primary

curve [ 5� occurred in 10/33 (30 %) of braced patients and 13/21 (62 %)

of observed patients (P = 0.022). Overall, 8 (24 %) patients in the Br

group and 9 (43 %) in the Ob group underwent corrective surgery

(P = 0.151). When analysis was restricted to those who had reached

skeletal maturity or undergone spinal fusion surgery, decreased curve

progression and surgical rates were also observed in the braced group but

did not meet the criteria for statistical significance (P [ 0.05). Results of

the survival analysis, however, demonstrated a significantly increased

survival proportion in the braced group (0.63 versus 0.35, P = 0.014).

Conclusion: Compared with observation alone, bracing subsequent to

PFD indeed reduces the rates of curve progression and scoliosis

surgery in patients with Chiari malformation-associated scoliosis.

Nonetheless, children and their parents should be informed that almost a

third of brace-treated patients still resort to surgery ultimately.

Keywords: Chiari malformation, posterior fossa decompression,

brace treatment, observation.

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OTHERS

P107

OUTCOMES OF SACRECTOMY FOR PRIMARY

SACRAL TUMORS

Ana Marıa Morales Codina, Sonia Munoz Donat, Diego Valverde

Belda, Susanne Eschenbach, Rafael Aguirre Garcıa, Maria Jesus

Molina Aguilar, Juan Antonio Martın Benlloch

Orthopaedic and Traumatology Department, Valencia, Spain

Introduction: The sacrectomy is an uncommon procedure indicated

in primary sacral tumors. They are diagnosed in advanced stages,

making more difficult a complete resection. Sacrectomy is associated

with a high complication rate. However, in some tumors is the only

effective treatment.

Objectives: Analyze the functional outcomes, complications, rate of

recidive and mortality of patients who underwent sacrectomy for

primary sacral tumor.

Materials and methods: Retrospective study of patients who under-

went sacrectomy between 1997 and 2012 for primary sacral tumor.

Diagnosis, type of sacrectomy, reconstruction, complications, oper-

ating time, recidive and mortality were documented.

Results: 16 patients (9 males), mean age at surgery 46 years (range,

28-90 years) with a diagnosis of primary sacral tumor underwent en bloc

sacrectomy.

The mean follow-up was 7 years (range: 1 - 13 years).

Chordoma was the most common primary tumor (12 patients). Other diag-

nosis included 1 osteochondroma, 1 leiomyosarcoma and 1 ependymoma.

We performed 7 total sacrectomies and 9 subtotal sacrectomies (13

combined anterior and posterior approach and 3 a single posterior

approach).

Of total sacrectomies, 4 were stabilized with double-rod and single

iliac screw, 3 with single-rod and single iliac screw.

Of subtotal sacrectomies, 3 were stabilized with single-rod and single

iliac screw.

At the first postoperative month all patients had paresis of lower

extremities, gait disturbance and sphincter dysfunction. At the last

chek, all patients had improved motor activity and gait disturbance

but remains sphincter dysfunction.

2 of the lumbopelvic instrumentation failed, requiring surgical revisions.

3 patients had recurrences (2 in intralesional resections), 2 metastasis

and 3 deaths.

Overall survival was 84 % at 5 years.

Conclusions: Sacrectomy is an aggressive procedure with a high com-

plication rate. Although patient’s quality of life depends on the extent of

sacral root resection and the establishment of sacroiliac stability, sacrectomy

can be performed successfully in the treatment of primary sacral tumors.

P108

SURGICAL MANAGEMENT OF CHORDOMA

IN THE SPINE

Ana Marıa Morales Codina, Sonia Munoz Donat,

Diego Valverde Belda, Carles Martınez Perez, Rafael Aguirre Garcıa,

Marıa Jesus Molina Aguilar, Juan Antonio Martın Benlloch

Orthopaedic and Traumatolgy Department, Valencia, Spain

Introduction: Chordoma is a rare primary bone tumor accounting for

1-4 % of all primary bone neoplasms. It is a relatively slow-growing,

low-grade malignancy tumor. However, due to their invasive nature

and rate of recurrence, they are considered malignant.

En bloc resection with negative margins results in improved local

disease control and have reported prognostic role in local recurrence

and improved survival.

Objectives: To analyze the surgical treatment results of chordoma in

terms of complications, local recurrence, metastasis and mortality.

Materials and methods: Retrospective study of patients who

underwent surgical treatment between 1997 and 2012 for chordoma in

spine.

Inclusion criteria for the current study were patients with diagnosis of

chordoma without history of prior surgical or nonsurgical treatments

of the neoplasm. Patients were excluded from the study if they had

undergone prior radiation treatment and if they had prior surgery with

recurrent tumor requiring secondary salvage tumor excision.

Results: We analyzed 19 patients (12 men), mean age at surgery

48 years (range, 28-90 years).

The mean postoperative follow-up was 7 years (range: 1 - 13 years).

The location is 13 sacro-coccygeal, 4 lumbar, 1 thoracic, 1 cervical.

2 patients underwent intralesional resection and 17 patients was

performed en bloc resection of the tumor and surgical reconstruction

(12 patients).

2 of the cases had contaminated surgical margins.

In the early postoperative period (first month) 16 patients had motor

deficits in extremities and all had undergone a sacrectomy had

sphincter and sexual dysfunction. At the last visit extremity motor

deficit had improvement but remains sphincter dysfunction, for sacral

location.

2 of the lumbopelvic instrumentation failed, requiring surgical

revisions.

3 patients had recurrences (2 in intralesional resections), 1 metastasis

and 3 deaths.

Overall survival was 84.5 % at 5 years.

Conclusions: Despite the complications and consequences involved

en bloc resection of these tumors is the procedure of choice in the

treatment of chordomas because of its high survival rate and low

number of recurrences.

P109

INTER-TESTER AGREEMENT AND VALIDITY

OF IDENTIFYING LUMBAR PAIN PROVOCATIVE

MOVEMENT PATTERNS USING ACTIVE

AND PASSIVE ACCESSORY MOVEMENT TESTS

Benjamin Hidalgo, Toby Hall, Henri Nielens, Christine Detrembleur

Faculty of Motor Sciences, University of Louvain, Brussels, Belgium

Background and objectives: Clinical examination comprises pain

provocation tests including active trunk movements and passive

accessory intervertebral motion (PAIVM). These tests help to deter-

mine a pain provocative movement direction, which in turn helps

determine manual therapy management of low back pain (LBP). To

date there is little evidence regarding the inter-examiner agreement

and validity of this combined process. The purpose of this study was

to evaluate the inter-examiner agreement and validity of these com-

bined pain provocation tests.

Method: Two blinded raters examined 36 subjects, 18 of whom were

asymptomatic while 18 reported subacute non-specific LBP. Two

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types of pain provocation tests were carried out: Physiological

movements in single (flexion/extension) and, when necessary, com-

bined planes; and PAIVMs of each lumbar spine vertebra in prone

with the lumbar spine in neutral, flexion, and extension position.

Inter-observer agreement was assessed by percentage of agreement,

as well as Kappa and prevalence adjusted bias adjusted Kappa (PA-

BAK). Validity was determined by comparing findings in

asymptomatic subjects to those with LBP.

Results: The inter-observer agreement in both populations was good

to excellent for the identification of flexion [K = 0.87 - 1] or

extension [K = 0.65 - 0.74] as the most painful pattern of spinal

movement. In healthy subjects 0 % were identified as having a flexion

provocative pattern and 8.8 % were identified as having an extension

provocative pattern. In the LBP group, 20 % were identified as having

a flexion provocative pattern versus 60 % with an extension pro-

vocative pattern. The average inter-examiner agreement for PAIVMs

in both groups was moderate to excellent [K = 0.42 - 0.83]. The

lower lumbar vertebrae showed a significant (p \ 0.001) higher

prevalence of positive pain responses to PAIVMs than the upper

lumbar vertebrae. The examiners showed good sensitivity [0.67 -

0.87] and specificity [0.82 - 0.85] to distinguish subjects with LBP

using this combined examination procedures.

Conclusions: The use of a combination of pain provocative tests was

found to have acceptable inter-examiner reliability and good validity to

identify the main pain provocative movement pattern and the lumbar

segmental level of involvement. These tests can be used with confidence

by clinician’s to aid in the manual therapy management of LBP.

P110

DIFFUSION-WEIGHTED MAGNETIC RESONANCE

(DW-MR) NEUROGRAPHY OF THE LUMBAR

PLEXUS IN THE PREOPERATIVE PLANNING

OF LATERAL ACCESS LUMBAR SURGERY

Cristiano Menezes, Luciene Andrade, Marcello Nogueira-Barbosa,

Carlos Fernando Herrero, Helton Defino, Willian Blake-Rodgers

Spine Surgery - Lifecenter Hospital, BELO HORIZONTE, Brazil

Introduction: Lateral access lumbar surgery has rapidly increased in

popularity in the last several years. However, the technique remains

limited by the risk of injury to the lumbar plexus, most commonly the

femoral nerve near the L4L5 level. While real-time neural monitoring

can decrease the incidence of such injuries, postoperative deficits can

still occur. Magnetic resonance (MR) neurography has been used to

evaluate abnormal conditions of entire nerves and nerve bundles by

providing better contrast between the nerves and the surrounding

tissues. The purpose of this study is to introduce and assess DW-MR

neurography for imaging of the lumbar plexus in the preoperative

planning of lateral access surgery. By providing the surgeon with a

preoperative roadmap of the lumbar plexus, DW-MR may improve

the safety profile of lateral access procedures.

Methods: Sixty patients (120 sides) with degenerative spine disorders

and history of low back pain underwent a DW-MR examination of the

lumbar plexus in relation to the L3L4 and L4L5 disc spaces and

superior third of the L5 vertebral body. Images were reconstructed in

axial plane using high-resolution 10 mm MIP slabs over the disc

space and 22 mm MIP slabs in L3-L4 and L4-L5 interspace to mimic

the working zone of standard lateral access retractors. L4 spinal nerve

and femoral nerve position were analyzed relative to the L4L5 disc

and this position was confirmed in sagittal planes.

Results: In all subjects the plexus was successfully mapped. At L3L4,

all components of the plexus (except the genitofemoral nerve) were in

zone 4. The L3 and L4 roots coalesced into the femoral nerve below

the L4L5 disc space in all subjects. Side to side variation was noted,

with 51 (84.7 %) of plexa in zone 4 on the right vs 44 (72.9 %) on the

left. At the superior third of L5, the plexus was found in zone 3 in 13

(22 %) and 24 (33.9 %), respectively; and at zone 2 in 3 (5.1 %) on

the right and 2 (3.3 %) on the left.

Conclusion: DW-MR neurography appears to afford a noninvasive

method of mapping the lumbar plexus preoperatively.

P111

NEUROPHYSIOLOGIC APPROACH

FOR INTRAOPERATIVE IDENTIFICATION

OF THE INJURY LEVEL AFTER SPINAL CORD

DAMAGE DURING SPINE SURGERY. A NEW

METHOD EXPERIMENTALLY TESTED IN PIGS

Jesus Burgos, Gema de Blas, Lidia Cabanes, Javier Cervera,

Eduardo Hevia, Carlos Barrios, Carlos Correa

Institute for Research on Musculoskeletal Disorders, Valencia

Catholic University, Valencia, Spain

Introduction: Intraoperative spinal cord injury is a complication that

may have important clinical consequences. In most instances, the

intraoperative identification of the injury level might allow immediate

spinal decompression, increasing the chance for later recovery. This

study presents a new neurophysiologic method that was experimen-

tally tested in a pig model.

Materials and methods: Five industrial pigs were included in the

experiment. Bilateral laminectomies were performed to expose the

spinal cord at T4-T5, T7-T9 and T12-T13 segments. Pedicle screws

were inserted left at T5, T7, T9 and T12. Four epidural catheters were

placed sublaminar for neurophysiologic recording in T3, T6, T11 and

L1. The neurophysiologic techniques performed were: a) cord-to-cord

motor spinal-evoked potentials between the epidural catheters; b)

recording of the sensory epidural potential after stimulation of a

mixed nerve of the lower limb; c) recording of the motor D-wave in

the epidural catheters after transcranial stimulation; d) Pulse-train

stimulation of the four screws and recording of the responses in

epidural catheters. After basal recording, the spinal cord was sec-

tioned with a scalpel at T8 pedicle level and the neurophysiologic

study was repeated for determining the level of injury.

Results: In all cases, there was a lack of caudal cord-to-cord motor

potential when the spinal cord was stimulated just above the section.

The epidural sensory potentials were normal in the two levels caudal

to the medullary section and absent in the two segments craneal to the

section. The motor D-wave was completely normal at the levels

above the injury, and absent int the two caudal segments. Pulse-train

stimulation of the screws craneal to the spinal cord section showed

caudal response in the distal epidural catheters in three cases.

Conclusions: It is feasible to identify intraoperatively the level of

an spinal cord injury by neurophysiologic methods. Cord-to-cord

stimulation techniques, epidural sensory evoked potentials and

the D-wave recorded at various levels permit to identify the

exact location of the spinal cord injury. The pulse-train screw

stimulation technique is less accurate in identifying the level of

injury.

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P112

IDENTIFICATION OF OBSTACLES

TO RECOVERY IN SECONDARY CARE

Kwang Chear Lee, Shakil Patel, Philip Sell

Orthopaedics, Leicester, UK

Introduction: Yellow flags are psychosocial indicators which are

associated with a greater likelihood of progression to persistent pain

and disability. The yellow flags are referred to as obstacles to

recovery. It is not known how effective clinicians are in detecting

them. Our objective was to determine if clinicians were able to detect

them in secondary care.

Methods: 88 new referrals in a specialist spine clinic completed the

Oswestry Disability Index and a range of other validated question-

naires including the yellow flag questionnaire adapted from the

psychosocial flags framework. Clinicians blinded to the patient data

completed a standardized form to determine which and how many

yellow flags they had identified.

Results: The average number of yellow flags per patient was 4.8

(range: 0-9). Clinician sensitivity in detecting yellow flags was poor,

identifying on average only 41 % of flags. The most common yellow

flag reported by patients was fear of movement or injury (n = 78) and

this was correctly reported by clinicians in 39 patients. Patient cata-

strophising (‘‘Do you think pain is terrible and will never get better?’’)

was most frequently missed by clinicians (n = 41) and the most com-

monly misidentified was the lack of coping strategies and patient

uncertainty (both n = 25). Patients who reported more yellow flags were

more likely to score higher on the modified somatic perception score

(Pearson correlation = 0.53, p \ 0.01) and had poorer Low Back Out-

come Scores (LBOS) (Pearson correlation = -0.461, p \ 0.01).

Conclusion: Clinician sensitivity in detecting yellow flags is poor.

Improved identification of obstacles to recovery may improve out-

comes. Clinicians may improve detection of these obstacles by having

a simple set of questions completed by the patient.

P113

THE USE OF CEMENT AUGMENTED SCREWS

IN LUMBAR SPINAL FUSION IN OSTEOPOROTIC

PATIENTS. DOES IT ADD ANY CLINICALLY

RELEVANT MORBIDITY?

Luis Alvarez, Angel R Pinera, Felix Tome, Belen Lopez San Roman,

Carmen Duran, Daniela Vlad, Ignacio Mahillo

Fundacion Jimenez Dıaz. Spine Unit, Madrid, Spain

Introduction: Pedicle screws encounter difficulty in achieving and

maintaining fixation in osteoporotic vertebrae, and have been shown

to loosen in these patients.. As a result, some spine surgeons may

refuse to perform instrumentation on osteoporotic patients with

lumbar instability. The use of cement to augment pedicle screw fix-

ation yields increased resistance to pullout and/or toggle failure in the

cephalad-caudad direction as reported in numerous studies. However

there is a concern in its used because associated potential morbidities.

In our knowledge, no clinical study has analyzed these potential

complications. The purpose of this study is to analyzed the possible

complications related with the cement augmented screws.

Materials and methods: This is a retrospective study including all

the patients treated in one Center with cement augmented screws

since November 2006 until November 2012. We include 225 patients,

with a mean age of 73.7 years old, and a mean follow-up of

31.8 months. Indication for fusion was degenerative disease in 168

cases, fracture in 37 cases, deformity in 18 cases and tumor in 2

patients. Leakages were classified as epidural, foraminal, intradiscal,

venous paravertebral, canal, and extravertebral on a post-operative

CT scans. Clinical charts were analysed for clinical complications,

including radicular pain related with cement leakages, infection,

extraction of screws and failure of the instrumentation.

Results: 598 vertebrae were instrumented with 1134 cemented

screws. Cement leakage was observed in 53.5 % of the vertebrae;

Four vertebra had a canal leakage, with no clinical relevance.

Radicular pain was observed only in 4 patients, all of them with a

foraminal leakage at S1. There were 20 patients (8 %) with a deep

infection that required surgical debridement. In none of these cases

removal of instrumentation was necessary. Thirty patients (13.3 %)

required a revision surgery. Twenty for the treatment of the adjacent

level and 10 pseudoarthrosis. None of the 103 screws removed a

extraction torque required was difficult. All pseudoarthosis were

found in long fusion constructs (more than 4 levels), and in 6 cases a

broken rod was observed.

Conclusion: This study demonstrates that the use of cement to aug-

ment pedicle screws is a safe procedure. Augmentation with cement

allows an excellent attachment of the screws, so in case of pseudo-

arthrosis there is a failure of the rod first.

P114

THE LOCAL APPLICATION OF VANCOMYCIN

FOR THE PREVENTION OF LUMBAR SPINE

WOUND INFECTION

Martin Komzak, Radek Hart, David Nahlık, Filip Buek,

Vojtch Prochazka

Department of Orthopaedics and Traumatology, Znojmo, Czech

Republic

Introduction: Postoperative spinal wound infections are relatively

common. They are associated with significant morbidity, increased

costs, and poor long-term outcomes. As the use of spinal instru-

mentation has become common, infection rates in elective

instrumented cases as high as 3 % to 6 % have been reported. The

aim of this prospective study was to evaluate the incidence of surgical

site infection following elective instrumented lumbar spine operations

supplied with locally poured vancomycin.

Methods: Between September 2008 and September 2012, 200

patients (112 men, 88 women) in the mean age of 59 years (range, 30 to

87 years) were included in the study. In all cases, transpedicular screw

instrumentation (S4�, B/Braun-Aesculap, Tuttlingen, Germany) was

used. Other procedures were often added (fusion, decompression). In the

end of the surgery, vancomycin powder (vancomycin hydrochloride

0.5 g; Edicin�, Sandoz, Ljubljana, Slovenia) was poured into the wound.

Antibiotic prophylaxis was used in all patients consisting of 1 g of

intravenous cefazolin within 1 h before the operation and additional six

doses every 4 h. Incidence of risk factors was:

1) obesity (BMI C 26): 178 patients (89 %), mean value 29 (range,

21-43), median 28.5;

2) old age (C 70 years): 84 patients (42 %);

3) diabetes mellitus: 36 patients (18 %);

4) smoking: 36 patients (18 %);

5) cardiovascular disease: 122 patients (61 %);

6) bronchopulmonary disease: 30 patients (15 %);

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7) malignancy: 8 patients (4 %);

8) steroid use: 6 patients (3 %).

Results: Postoperative wound infection didn0t occur in any case.

Aseptic haematoma developed in 4 cases and was treated with revi-

sion and drainage.

Discussion and conclusions: Despite the administration of prophy-

lactic antibiotics, surgical site infections are not uncommon following

lumbar spine operations. The additional local application of vanco-

mycin is the reliable measure for preventing this complication also in

cases at risk.

P115

INCOMPLETE CORRECTION OF SAGITTAL

SPINAL ALIGNMENT AFTER HIP FLEXION

CONTRACTURE TREATMENT WITH THR

Martin Komzak, Radek Hart, Martin Feranec, David Nahlık, Petr Mıd

Department of Orthopaedics and Traumatology, Znojmo, Czech

Republic

Introduction: It has become well recognised that sagittal balance of

the spine is the result of an interaction between the spine, the pelvis and

the hip. Flexion contracture is a frequent finding in patients with osteo-

arthrosis of the hip. Only few studies have insisted on the relationship

between spinopelvic parameters and hip flexion parameters.

Methods: A prospective study was carried out on 40 patients with

flexion contracture of the hip. The test of Thomas was used to identify

and measure (pre- and postoperatively) the deformity. The parameters

of pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS) and lumbar

lordosis (LL) were analysed on lateral standing radiographs of the

lumbosacral spine before and one year after the flexion contracture

release and the short stem total hip replacement (Metha, B/Braun-

Aesculap, Tuttlingen, Germany).

Results: The average value of the flexion contracture of the hip was

preoperatively 17� (range, 5� to 30�) and postoperatively 4� (range, 0�to 10�) (p = 0.018). PI didn0t change after the surgery (as expected)

with a mean value of 57� (range, 37� - 72�). Compensatory balance

parameters (PT, SS) changed postoperatively in all but one case.

Preoperative and postoperative average value was for PT 14� (range,

1� to 30�) and 18� (range, 3� to 32�), respectively (p = 0.25); for SS

43� (range, 26� - 56�) and 39� (range, 23� - 54�), respectively

(p = 0.31). LL changed less than 1� at average.

Discussion and Conclusions: This is one of the first series analysing

the hip flexion contracture as a cause of sagittal spinal imbalance. The

compensatory pelvic parameters (PT, SS) of the spine balance adjust

postoperatively after hip joint flexion reduction at one year follow-up,

but not significantly.

P116

POSSIBILITIES OF SEQUELAE SPINAL CORD

INJURY TREATMENT

Nataliia Sych

Cell Therapy Center EmCell, Kiev, Ukraine

Goal: study clinical efficacy in patients with sequelae of spinal cord

injury (SSCI) treatment under the influence of fetal stem cells (FSC)

treatment.

Materials and methods: The paper contains the results analysis of 23

patients with consequences of SSCI, 15 man, 8 women, with the age

range between 25 to 60 years old. Duration of injury to an average of

4.2 ± 0.34 years. The 9 patients had an injury of the cervical spine in

14 patients - the thoracic spine. All patients had a spinal injury was

confirmed by magnetic resonance imaging. All patients underwent

clinical, neurological research, assessment of the scale, the assess-

ment of quality of life on a scale of SF-36. Patients with SSCI were

timely monitored at 0, 1, 3 months after the stem cell transplantations.

Patients underwent transplantation of fetal hematopoietic and non-

hematopoietic mesenchymal and ectodermal stem cells harvested

from germ layers of internal organs of 5-8 weeks old legally aborted

fetuses and routine therapy.

Results: According to the scale independence spinal 34.78 % of patients

showed improvement in the area of ‘‘control sphincter’’ at 1 month after

treatment with FSC and 52.17 % of patients after 3 months after treat-

ment with FSC. Marked improvement in gait and 26.08 % of patients at

1 month after treatment with FSC and 47.82 % of patients after

3 months. In 17 patients with trauma were identified pressure ulcers in the

sacral region. 1 month after treatment, six patients had a decrease in

diameter and pressure ulcers in 11 patients at 3 months after treatment,

we observed FSC also reduce pressure ulcers in diameter, two patients

healed pressure ulcers. Analysis of the results according to the scale of the

SF-36 showed that in patients with SSCI with improvements in the fol-

lowing subtests 1 month after treatment FSC: of physical functioning,

mental health, and emotional role functioning, vitality and social role

functioning, but the degree of reliability achieved no, p [ 0.05. 3 months

after FSC therapy, significant improvement was reported in the emotional

role functioning, social role functioning, p \ 0.05.

Conclusions: The results indicate a significant clinical efficacy of this

variant cell therapy in patients with a history of SSCI. The use of

cellular technology in the treatment of patients with SSCI demon-

strated its significance and perspective.

P117

DOES SPINAL CORD DECOMPRESSION REDUCE

SPASTICITY IN PATIENTS WITH SPINAL CORD

INJURY AND RESIDUAL COMPRESSION?

Ratko Yurac, Sergio Ramırez, Sergio Mandiola, Miguel Lecaros,

Juan Zamorano, Carlos Tapia, Francisco Ilabaca, Alejandro Urzua,

Jose Fleiderman

Traumatologia, Santiago, Chile

Introduction: Spasticity, a disorder resulting from a superior moto-

neuron injury, is characterized by involuntary muscle activation, both

intermittent and sustained, which can be very bothersome for some

patients. It can affect up to 70 % of spinal cord injury (SCI) patients

and may appear months or years after the acute injury. While selec-

tive posterior rhizotomy is the main surgical procedure used to reduce

spasticity; orthopaedic procedures, such as tenotomies, myotomies,

tendon transpositions and elongations are used to correct deformities,

prevent muscular contractions and bone complications in patients

with advanced spasticity. Other procedures like myelotomies present

good results in selected patients that have no chance of recovering

voluntary motor function.

We have observed that some SCI patients evolve with progressive

spasticity, resistant to pharmacological treatment, due to residual

spinal cord compression. The objective of this study is to describe the

clinical results of surgical spinal cord decompression for the treatment

of refractory spasticity in this type of patients.

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Materials and Methods: We reviewed our institution’s database of

patients with traumatic SCI treated between 1992 and 2009 (196

patients), identifying three patients who evolved with spasticity

resistant to pharmacological treatment. They were studied with CT

and MRI, revealing focal spinal cord compression due to bone spurs.

Surgical decompression through a posterior approach was performed

in all three patients. Baseline and post surgery modified Ashworth

scale and drug requirements were used to assess the intervention’s

effect on their spasticity.

Results: Three patients with ASIA A SCI (two thoracic and one

thoracolumbar injury, mean age at the time of decompressive surgery

40 years) and Ashworth grade 3 spasticity in spite of maximum doses

of baclofen in two of them. The three patients presented a reduction of

their spasticity after the procedure (two to grade 1 and one to grade 2),

allowing all of them to discontinue pregabalin and even benzodi-

azepines in one patient. Baclofen doses remained unchanged.

Conclusion: In our experience, spinal cord decompression surgery

presents good results in patients with a previous traumatic SCI and

refractory spasticity in the context of spinal cord compression due to

bone spurs. This procedure should be considered as a less aggressive

alternative to cord surgeries in these patients.

P118

THE EFFECT OF PSYCHOLOGICAL STATUS

ON POSTOPERATIVE SATISFACTION

AND CLINICAL OUTCOMES IN SPINAL SURGERY

PATIENTS

Wan-Sik Seo, Sang-Hyun Lee, Hong-Sik Kim, Seung-Wook Baek,

Ye-Soo Park

Orthopaedic Surgery, Guri city, Korea (ROK/South Korea)

Purpose: The purpose was to evaluate the effect of psychological

status on postoperative satisfaction and clinical outcomes of patients

who received surgical treatment for degenerative spine disease.

Methods: Among patients who received short segment spinal fusion

in two or less segments for degenerative spine disease between Jan-

uary 2007 and February 2010, 206 patients for whom follow-up

observation was possible for at least 2 years were selected as subjects.

Psychological status of subjects before surgery such as depression,

anxiety and optimism were evaluated using Hospital Anxiety and

Depression Scale(HADS) and Revised Life Orientation Test(LOT-R).

Clinical evaluation was performed by measuring the degree of

improvement according to changes in Visual Analogue Scale(VAS)

and Oswestry Disability Index(ODI) before and after surgery. Their

correlation was evaluated, and satisfaction of subjects after surgery

was comparatively analyzed with psychological status before surgery

after dividing subjects into satisfied group and dissatisfied group.

Results: VAS and ODI showed statistically significant reduction after

surgery (P \ 0.0001), suggesting a clinically satisfactory outcome. In the

correlation analysis on psychological status and clinical outcomes,

optimism showed positive correlation (P\ 0.0001) with improvement in

ODI after surgery. Anxiety and depression showed negative correlation

(P \ 0.0001) with improvement in ODI after surgery. However,

improvement in VAS after surgery did not show significant correlation

with optimism, anxiety and depression before surgery. In comparison of

satisfaction among groups, satisfied group had significantly higher value

for optimism (P \ 0.0001) and significantly lower values for anxiety and

depression(P\ 0.0001, 0.0058) compared to dissatisfied group.

Conclusion: Psychological status of patients according to anxiety,

depression and optimism before surgery was found to be related with

the degree of improvement in Oswestry Disability in terms of satis-

faction and clinical outcomes after surgery. Accordingly, in order to

increase clinical outcomes and satisfaction of patients, careful eval-

uation and proper management of psychological status before surgery

are deemed necessary.

P119

RADIOGRAPHIC ANALYSIS OF SPINO-PELVIC

SAGITTAL ALIGNMENT IN CHINESE

ASYMPTOMATIC SUBJECTS

Weishi Li, Zhuoran Sun, Zhongqiang Chen

Orthopaedic Department of Peking University Third Hospital,

Beijing, China

Objective: To determine the physiological values of spinal-pelvic

sagittal parameters in asymptomatic Chinese adults, and to describe

the normal patterns of spinal-pelvic alignment in a Chinese

population.

Methods: This was a prospective radiological analysis. Whole spine,

standing lateral radiographs of 171 Chinese volunteers were taken.

The pelvic and spinal parameters (pelvic incidence, pelvic tilt, sacral

slope, lumbar lordosis, thoracic kyphosis, cervical lordosis, sagittal

vertical axis, apex of total lumbar lordosis, total lumbar lordosis,

upper arc of total lumbar lordosis, lower arc of total lumbar lordosis,

junctional level, apex of total thoracic kyphosis, total thoracic ky-

phosis, total cervical lordosis, lordosis tilt) were measured and the

correlations of all parameters were analyzed.

Results: Total of 171 volunteers were identified (94 males and 77

females), had a mean age of 23.0 years (18 to 28 years). The mean

value of pelvic incidence was 44.7 ± 9.5�, significantly less than that

reported in western subjects, even less than that reported in a Korean

population. Total lumbar lordosis has a significant correlation with

pelvic incidence, sacral slope, total thoracic kyphosis, cervical lor-

dosis and sagittal vertical axis. Apex of total lumbar lordosis showed

a significant correlation with pelvic incidence, sacral slope, junctional

level, lordosis tilt, sagittal vertical axis. The volunteers were classified

into four patterns according to their apex of total lumbar lordosis.

Conclusions: The pelvic sagittal morphology of Chinese adults was

significantly different from that of western and Korean. Lumbar lor-

dosis turned into a core in regulating spinal sagittal balance by pelvis.

As apex of total lumbar lordosis moved cranially, the lordosis tilt

decreased, whereas the lower lumbar lordosis, pelvic incidence, and

sacral slope increased .

Keywords: pelvic incidence, spinal-pelvic, sagittal alignment

P120

A NOVEL AUGMENTED REALITY ASSISTED

PERCUTANEOUS VERTEBROPLASTY

TECHNIQUE

Yuichiro Abe, Shigenobu Sato, Hiroyuki Yasuda

Eniwa Hospital, Eniwa, Japan

Augmented reality (AR) is an imaging technology for overlaying virtual

objects onto the images of real objects captured by a web-camera in real

time. We developed a novel AR guidance system for percutaneous

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vertebroplasty, called Virtual Protractor with Augmented Reality

(VIPAR). The aim of this study was to introduce an AR guidance system

to visualize 3-dimensional needle trajectory in percutaneous verteb-

roplasty (PVP).

Methods: This AR system consists of a head mount display (HMD)

with a web-camera and AR software. AR software created the aug-

mented scene by overlaying the preoperatively generated needle

trajectory onto the detected marker on the patient surface, and pro-

vided the surgeon an augmented image through the HMD in real-time.

With looking the augmented needle trajectory, surgeon can insert the

needle into the fractured vertebra safely. Accuracy of the system was

evaluated using a computer generated simulation model in the spine

phantom. The error of inserted angle (EIA) was defined as the dif-

ference between attempted angle and inserted angle, was evaluated by

3D CT scans. Five patients with osteoporotic vertebral fracture

received PVP under the guidance of VIPAR from October 2011

to May 2012, and EIA was also evaluated using postoperative CT

scans.

Results: CT analysis of a total of 40 trials in the spine phantom

showed that EIA in the axial plane significantly improved from

4.34 ± 2.36 degrees in without guidance group to 0.96 ± 0.61

degrees in VIPAR group. EIA in the sagittal plane also significantly

improved from 2.55 ± 1.93 (w/o) to 0.61 ± 0.70 (VIPAR) degrees.

The clinical result of the five patients showed that EIA in all 10

needle insertions was 2.09 ± 1.3 degrees in the axial plane and

1.98 ± 1.8 degrees in the sagittal plane. There was no pedicle breach

or leakage of PMMA.

Conclusion: VIPAR demonstrated success in assisting needle inser-

tion in PVP as a virtual protractor by providing the surgeon an ideal

incision point and the needle trajectory through the HMD. AR

guidance technology could become a useful assistive device for spine

surgeries requiring percutaneous procedures.

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