Study Design: Retrospective cohort study. Objective: Type III odontoid fractures are classically treated nonoperatively, yet, the current literature on Type III odontoid fractures includes fractures of multiple etiologies and fracture morphologies. We hypothesize that a subgroup of complex, Type III fractures caused by high-energy mechanisms are more likely to fail nonoperative treatment. Materials and Methods: Acute Type III odontoid fractures were identified at a single institution from 2008 to 2015. Fractures were categorized as high- or low-energy fracture with high-energy fractures defined as those with lateral mass comminution (>50%) or secondary fracture lines into the pars interarticularis or vertebral body. Patients were treated in either a hard collar orthosis or halo vest and were followed for fracture union and stability. Results: One hundred and twenty-five Type III odontoid fractures were identified with 51% classified as complex fractures. Thirty-three patients met the inclusion and exclusion criteria including 15 patients treated in a halo vest and 18 in a hard collar orthosis. Mean follow-up was 32 (±44) weeks. Seven patients demonstrated progressive displacement of either 2 mm of translation or 5° of angulation and underwent delayed surgical stabilization. Two additional patients required delayed surgery for nonunion and myelopathy. Initial fracture displacement and angulation were not correlative with final outcome. No statistical advantage of halo vest versus hard collar orthosis was observed. Conclusions: Complex Type III odontoid fractures are distinctly different from low-energy injuries. In the current study, 21% of patients were unsuccessfully treated nonoperatively with external immobilization and required surgery. For complex Type III fractures, we recommend initial conservative treatment, while maintaining close monitoring throughout patient recovery and fracture union.

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Introduction: High cervical myelopathy can be rarely caused by the developmental anomalies of atlas. Patients with C1 arch stenosis can present in early childhood or later in life. In symptomatic patients, posterior decompression at atlas is mandatory. We report the first clinical series of 20 patients of C1 arch stenosis in the English literature. Materials and Methods: This is retrospective case series having a cohort of 20 patients with congenital C1 arch stenosis. Results: There were 12 pediatric (age <18 years) and 8 adult patients. Mean age was 22.85 years. Syndromic association was seen in four patients. Following decompressive surgery, these patients noticed a symptomatic improvement. Conclusions: Isolated C1 arch stenosis is a surgically curable rare cause of high cervical myelopathy and responds well to surgery.

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Background: Scoliosis is defined as lateral curvature of the spine which is also associated with a change in the curves in sagittal plane and vertebral rotation. Various types of conservative treatment approaches have been recommended for the patients with scoliosis. The aim of this review article was to introduce the various methods of conservative treatment which can be used for the patients with scoliosis. Methods: A search was done in some databases including PubMed, ISI Web of knowledge, Google scholar, Ebsco, Embasco, and Scopus. Some keywords such as conservative treatment, orthosis, brace, exercise, and physical therapy were used in combination with scoliosis. As the aim of this paper was to introduce the conservative methods, no quality assessment was done in this review study. Results: Forty papers were found on various conservative treatments approaches which have been used for the patients with scoliosis, in which most of the papers focused on different designs of braces. There were a few studies on other interventions such as wedge, functional electrical stimulation, and yoga. Conclusion: Various treatment approaches have been used to treat scoliosis based on conservative approach. It is suggested that the efficiency of various methods be evaluated based on available literature.

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Study Design: This was a retrospective, observational study. Objectives: We hypothesize that the expandable transforaminal lumbar interbody fusion (TLIF) cage achieves satisfactory clinical outcomes while allowing for safe placement, improvement, and maintenance of foraminal and disc dimensions at 24 months postsurgery with low risk of cage migration, subsidence, and nerve injury. Methods: TLIF with expandable cages was performed in 54 patients (62 levels) over a 24-month-period using open midline or minimally invasive surgery techniques with placement of Globus Caliber, Rise, or Altera expandable cages. All patients underwent clinical and radiological assessment at 6 weeks, 6 months, 1, and 2 years postoperatively. Clinical outcome was measured by Oswestry disability index (ODI), visual analog pain score for both back and leg (visual analog scores [VASs]). Radiological assessment was done by X-ray standing lateral position. Results: There were significant clinical improvements in ODI, VAS leg, and VAS back at all postoperative time points. Disc height, foraminal height, focal Cobb angle, and global Cobb angle were significantly increased and maintained at all time points for 24 months (P < 0.001). Dural tear occurred in one patient (1.9%). There were neither intra- or postoperative neurological complications nor cage subsidence nor migration. Conclusions: These preliminary results indicate that the use of an expandable interbody cage achieves good clinical outcomes by improving and maintaining foraminal dimensions and disc height with minimal complication rate.

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Background: The development of high speed rotating burrs has greatly advanced spinal surgery in recent years. However, they produce unwanted frictional heat and temperature elevation during the burring process. We compare the misonix bone scalpel (MBS) and the Sonopet ultrasonic aspirator to assess which would be the safer device in terms of the risk of thermal injury following laminectomy. Methods: We describe an experimental nonrandomized study comparing two ultrasonic osteotomy devices. We use the device tip temperature and temperature of inner cortex of the lamina, following laminectomy, as the primary outcome. Our secondary outcome is to assess which device is associated with a lower risk of osteonecrosis and potential thermal injury to surrounding dura and nerves. Results: The average device tip temperature for the Sonopet ultrasonic aspirator following the process of laminectomy was 36.8 with a maximum temperature of 41.8°C. The average device tip temperature for the MBS following laminectomy was 48.6 with a maximum temperature of 85.3°C. Conclusion: Our results have demonstrated the safety of the Sonopet ultrasonic aspirator with the Nakagawa serrated knife with temperatures below the threshold for osteonecrosis and thermal neural injury. However, the MBS has shown to occasionally reach high temperatures above the threshold of potential thermal injury to surrounding nerves and dura for a very short period of time. We advise to withdraw and re-insert the ultrasonic tip repeatedly to re-establish adequate cooling and lubrication. Further studies should be carried out using cadaveric bone at body temperature to simulate more accurate results.

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Background: Normal sagittal cervical alignment has been associated with improved outcome after anterior cervical discectomy and fusion (ACDF). Objective: The aim of this study is to identify alterations of cervical sagittal balance parameters after single-level ACDF and assess correlations with postoperative functionality. Methods: A retrospective chart review was performed between January 2010 and January 2014 to identify adult patients with no previous cervical spine surgery who underwent ACDF at any one level between C2 and C7 for the single-level degenerative disease. Tumor, infection, and trauma cases were excluded from the study. For the included cases, the following data were recorded preoperatively and 6 months–1 year after surgery: sagittal balance-marker measurements of the C1–C2 angle, C2–C7 angle, C7 slope, segmental angle at the operated level, and sagittal vertical axis (SVA) distance between C2 and C7, as well as the neck disability index and visual analog scale of pain. Results: The present study included 47 patients (average age: 51.2 years; range: 28–86 years). A moderate negative correlation between a smaller C2–C7 angle and the presence of right arm pain before treatment was found (P = 0.0281). Postoperatively, functionality scores significantly improved in all patients. C1–C2 angle increased with statistical significance (P = 0.0255). C2–C7 angle, segmental angle, C7 slope, and SVA C2–C7 distance did not change with statistical significance after surgery. C7 slope significantly correlated with overall cervical sagittal balance (P < 0.05). Conclusions: Single-level ACDF significantly increases upper cervical lordosis (C1–C2) without significantly changing lower cervical lordosis (C2–C7). The C7 slope is a significant marker of overall cervical sagittal alignment (P < 0.05).

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Objective: The purpose of this study was to define the anatomy of the V3 segment of the vertebral artery (VA) from the posterior approach. Methods: Ten formalin-fixed cadavers were carefully dissected bilaterally using landmark features to identify and safely expose the VA from the posterior. Measurements regarding morphometric characteristics of landmark features and feasible resection quantifications were obtained and analyzed. The C2 pars was resected completely in all cadavers, averaging 15.03 ± 1.06 mm in thickness. Results: The average diameter of the VA at the midline of C2 on the right side was 4.66 ± 0.51 mm compared to the left 5.2 ± 0.49 mm (P = 0.002). The distance of the VA from the midline increased from caudal to rostral. The distance between the VA to the lateral edge of the dura in the middle of the window of approach was 9.67 ± 0.81 mm. The rostral-caudal length of the window of approach was 21.94 ± 1.60 mm. The percentage of C2 body removal was 28.04% ± 6.09% through each side (249.55 ± 55.5/898.2 ± 146.17 mm²). While carefully exposing the VA, a posterior approach can be feasible in cases of injury during C1–C2 instrumentation or during resection of tumors of the C2 pars with or without extension into the C2 body. Discussion: The posterior approach for a C2 partial corpectomy can also be used as an adjunct to anterior approaches when necessary to widen the extent of bone resection. Conclusion: Exposure of the V3 segment of the vertebral artery was defined as well as the extent of C2 corpectomy through the posterior approach.

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Background: Backing out and failure of pedicle screws in patients with osteoporosis is becoming a big problem due to wide use of these screws nowadays. Purpose: The aim of this study is to evaluate the purchase of fenestrated pedicle screws augmented with cement in patients with osteoporosis. Study Design: This was retrospective observational study. Patients and Methods: From May 2015 to January 2016, 25 patients with a poor bone stock condition underwent posterior fixation by fenestrated pedicle screws and cement augmentation. Assessment of pain improvement was done by visual analogue score (VAS) score while the long-term clinical outcome was assessed using Oswestry low back disability questionnaire (Oswestry disability index [ODI]). Implant stability was evaluated by plain radiography. Complications were evaluated in all cases. Results: All patients were followed up clinically and radiographically for a mean age of 24.84 months. There was a significant reduction in pain and improvement of the quality of life as detected using VAS scores and ODI questionnaire consecutively (P < 0.001). No radiological loosening or backing out of screws was observed. Cement leakage occurred in five cases. Conclusion: Augmentation of fenestrated screws with cement provided effective and lasting purchase in patients with osteoporosis. The only clinical complication strictly related to this technique was cement leakage.

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Background: Performing cervical laminoplasty after wide laminectomy may be technically demanding. The unique technique of cervical lift-up laminoplasty using titanium basket plates was applied for the reconstruction of cervical laminae after wide laminectomy for the resection of intradural tumors. Materials and Methods: This technical study included 14 cases that could be followed periodically for at least 6 months after surgery. Participants were 8 male and 6 female, with a mean age of 41.6 years (range, 13–71 years). Tumors were intramedullary in 11 cases and extramedullary in 3 cases. After resection of intradural tumors, custom-designed titanium baskets were fitted to expand the spinal canal. Combining baskets of different sizes are also possible for each side at one level. A mixture of hydroxyapatite granules and collagen was packed into the basket. The reconstructed posterior laminae were secured using titanium mini plates. The fascia of the paravertebral muscles was sutured to the spino-ligamentous complex to further stabilize the posterior elements of the cervical spine. Results: No wounds or implant problems requiring revision surgery were recognized. Imaging analysis demonstrated no significant change in C2–C7 angle cervical range of motion between before and after surgery, suggesting sequential spinal stability at the base of the laminae. Conclusions: This technical note suggests that cervical lift-up laminoplasty with titanium basket plates appears practical and useful as a procedure to reconstruct cervical laminae after wide laminectomy.

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Charcot spinal arthropathy (CSA) is a rare progressive disorder of vertebral joint degeneration that occurs in the setting of any condition characterized by decreased afferent innervation with loss of deep pain and proprioceptive sensation in the vertebral column. While surgical circumferential arthrodesis remains the most effective treatment modality, it is associated with multiple complications, including hardware construct failure. This manuscript represents an up-to-date narrative review of the treatment of CSA, its associated complications, and complication prevention.

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Background: Spinal cord involvement by schistosomiasis is considered to be rare. Clinical presentation of spinal schistosomiasis ranges from radicular pain to myelopathy causing flaccid paraplegia, bladder incontinence, and dysesthesia. We reported six cases with spinal schistosomiasis. Methodology: We did a retrospective analysis of the records in our department from March 1995 to March 2015, and we found that six cases of proved spinal schistosomiasis were documented, with follow-up period more than a year, aiming to find an assumption for a guideline for this ambiguous issue. Results: We found five cases from six were males and average age group was 26 years old (14–43). All had motor deficit (100%) which was variable, only two (33.33%) had dense weakness (G0) at time of presentation, three (50%) patients had sphincter disturbance also, and 50% of the patients presented with back pain as initial symptom. Only one of six patients had a positive history of the infestation. All patients went through surgical intervention, which was decompression laminectomy then biopsy or excision. Total excision was feasible only in two cases (33.33%), which had a well-defined lesion in imaging, while in others, lesion was ill defined and adherent, so biopsy was done. Steroids up to 2-month duration were used in all patients (100%) and praziquantel in repeated cycles after surgical excision or biopsy was used in all patients (100%). Conclusion: History of travelling to endemic areas should raise the suspicion which may be the cornerstone of diagnosis, particularly in conus/epiconus intramedullary lesions. Surgical excision and spinal canal decompression are the best line of treatment in cases of schistosomiasis even if this excision was not total but to confirm and exclude other forms of pathology. Steroids and oral Praziquantel in repeated cycles are the best medication regimen in case of myelitis and in postoperative treatment.

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Purpose: The relevance of the problem is caused by an increase in the number of spine-related diseases among children, including scoliosis. Currently, there are no methodologies for the treatment of scoliosis, which ensure an unambiguous positive result. The purpose of the article is to justify the spinal model as an elastic viscoplastic body for further mathematical modeling of the process of spine correction and search for its optimal conditions. Methodology: The leading approach to the study of this problem is the development of techniques for the surgical treatment of deformities of the vertebral column with the aid of an external fixation device for the spine, providing for a rigid connection of the elements of the apparatus with each other and with the spine. The rigid connection between the elements of the external fixation device increases the degree of static indeterminacy of the design, which leads to the occurrence of additional dangerous stresses in the details of the apparatus and in the vertebrae. The control actions in such devices do not provide an adequate result for the process of correction of the vertebral column. Results: The main result is the substantiation of the spine model as an elastic viscoplastic body. This will allow more detailed consideration of the medical and biological features of the spine and the physical and mechanical properties of human bone and soft tissues. The proposed model will allow developing an adaptive design of the device, taking into account specific features of the organism and more effectively managing the correction process. Value: The materials of the article can be useful for scientists, doctors and specialists in conducting scientific research on the problem of spine deformation correction and the development of appropriate technical means.

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Thoracolumbar burst fractures can frequently be treated either conservatively or surgically. Surgery is generally preferred when safe early mobilization with a reconstructed sagittal alignment is wanted without any external restraint. Various dedicated instruments are available on the market to perform reduction and distraction maneuvers on the spine intraoperatively to restore normal sagittal alignment after a fracture. The authors describe a simple but effective technique of proper patient positioning and preoperative on-table-traction that can effectively aid in the restoration of alignment and performance of surgery even with the most basic instrumentation.

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