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April-June 2021
Volume 12 | Issue 2
Page Nos. 103-211

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EDITORIAL  

Indicators of atlantoaxial instability Highly accessed article p. 103
Atul Goel
DOI:10.4103/jcvjs.jcvjs_55_21  
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REVIEW ARTICLE Top

Spondylectomy in the treatment of neoplastic spinal lesions – A retrospective outcome analysis of 582 patients using a patient-level meta-analysis Highly accessed article p. 107
Alexander Spiessberger, Nicholas Dietz, Varun Arvind, Mansoor Nasim, Basil Gruter, Edin Nevzati, Silvia Hofer, Samuel K Cho
DOI:10.4103/jcvjs.jcvjs_211_20  
This study aims at identifying predictors of postoperative complications, lesion recurrence, and overall survival in patients undergoing en bloc spondylectomy (EBS) for spinal tumors. For this purpose a systematic review of the literature was conducted and patient-level data extracted. Linear-regression models were calculated to predict postoperative complications, lesion recurrence and overall survival based on age, tumor etiology, surgical approach, mode of resection (extra- vs. intralesional), tumor extension, and number of levels treated. A total of 582 patients were identified from the literature: 45% of females, median age 46 years (5–78); most common etiologies were: sarcoma (46%), metastases (31%), chordoma (11%); surgical approach was anterior (2.5%), combined (45%), and posterior (52.4%); 68.5% underwent EBS; average levels resected were 1.6 (1–6); average survival was 2.6 years; Complication rate was 17.7%. The following significant correlations were found: postoperative complications and resection mode (Odds ratio [OR] 1.35) as well as number of levels treated (OR 1.35); tumor recurrence and resection mode (OR 0.78); 5-year survival and age (OR 0.79), tumor grade (OR 0.65), tumor stage at diagnosis (OR 0.79), and resection mode (OR 1.68). EBS was shown to improve survival, decreases recurrence rates but also has a higher complication rate. Interestingly, the complication rate was not influenced by tumor extension or tumor etiology.
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ORIGINAL ARTICLES Top

Minimally invasive surgery for spinal fractures due to multiple myeloma Highly accessed article p. 117
Rui Reinas, Djamel Kitumba, Leopoldina Pereira, Oscar L Alves
DOI:10.4103/jcvjs.jcvjs_2_21  
Background: Multiple myeloma (MM) presents with spinal lesions in 60% of cases. The combination of osteolytic lesions with multifactorial osteopenia raises specific surgical treatment challenges. Minimally invasive spine surgery (MISS) could be a potential option for MM spinal lesions treatment. Objective: The objective of this study is to evaluate MISS techniques to treat patients presenting with spine fractures due to MM Methods: Retrospective analysis of consecutive patients with histology-proven pathological fractures caused by MM treated with MISS between 2009 and 2018. We collected the data from the clinical records on epidemiology, topography of spine lesions, surgical techniques, blood loss, operation time, complications, mean in-hospital time, and clinical evolution. Results: Twenty-one patients were studied – 13 males and 8 females, with a mean age of 64 years (range 43–83). Mean preoperative spinal instability neoplastic score was 9.8 ± 6 (range 5–16). All cases had a thoracolumbar location – 15 patients underwent kyphoplasty (KP) or vertebroplasty (VP) and 6 were treated with other more complex procedures. All patients had a reduction of pain and/or analgesic load. Vertebral body height increased by a mean of 2.9 mm after VP/KP. Mean hospital stay was 1.3 days for KP/VP and 5.0 days for other MISS procedures. Three patients had complications. Conclusions: The heterogeneity of techniques used reflected the variety of spine involvement by MM. KP and VP led to shorter hospital stays and less complications, being adequate for lesions without major instability. More complex MISS techniques offer an effective treatment with short delay for starting MM adjuvant treatment.
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Lumbar canal stenosis in “young” - How does it differ from that in “old” - An analysis of 116 surgically treated cases p. 123
Atul Goel, Sagar Bhambere, Abhidha Shah, Saswat Dandpat, Ravikiran Vutha, Survendra Kumar Rajdeo Rai
DOI:10.4103/jcvjs.jcvjs_53_21  
Objective: Patients treated for lumbar canal stenosis (LCS) were retrospectively analyzed to evaluate the differences in clinical management in those below (Group A) and those above (Group B) the age of 50 years. All patients were treated with the premise that instability is the nodal point of the pathogenesis of LCS and “only-stabilization” is the surgical treatment. Materials and Methods: During the period June 2014 to June 2020, 116 cases were diagnosed to have LCS and surgically treated by the Goel modification of Camille's transarticular screw fixation technique. Results: Twenty-four patients in Group A and six patients in Group B had a history of “significant” injury to the back at the onset of clinical symptoms. The indices suggested that the intensity of symptoms was relatively more severe in Group A than in Group B. Unilateral leg symptoms were more common in Group A (68%) than in Group B (31.8%). Neurological motor deficits were more common in Group A (28%) than in Group B (12%) patients. Spinal segments surgically treated in Group A ranged from 1 to 4 (average 2 levels) and in Group B it ranged from 2 to 5 (average 3 levels). During the follow-up period that ranged from 6 to 72 months (average 37 months), 100% of patients had varying degrees of relief from symptoms. Conclusions: LCS is confined to a lesser number of spinal segments in the Group A patients. The symptoms were radicular in nature and relatively severe in Group A than in Group B patients.
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Anthropometric evaluation for surgical feasibility of C1–C2 transarticular screw stabilization in Indian population p. 129
Saijyot Raut, Vishal G Kundnani, Mohit Kumar Meena, Jwalant Y Patel, Sanjeev Asati, Ankit Patel
DOI:10.4103/jcvjs.jcvjs_175_20  
Study Design: This study was a radiographic observational study for C1–C2 anthropometry. Purpose: The purpose of the study was to understand the anatomic relationship of C1–C2 in view of transarticular screw (TAS) fixation, to overcome the difficulties related with TAS placement, and to minimize the technique-related complications. Materials and Methods: It was an anthropometric observational study with retrospectively obtained anatomical data of randomly selected 116 patients from a single center. The anatomical measurements such as pars width, pars height, screw trajectory, and length were evaluated on the axial, sagittal, and three-dimensional reconstructed cervical CT scan using the radiant DICOM viewer software by the two fellowship trained spine surgeons which were blind to the study group details. The intra- and interobserver reliability with regard to the measured parameters was statistically analyzed. Results: The mean age of male and female was 28 and 29 years. The average BMI was calculated to be 23.5 and 25 for males and females, respectively. The mean right pars width in males was 5.78 ± 0.93 (range: 3.1–6.5 mm), while in female, it was 5.84 ± 0.95 (range: 3.1–6.5). The mean left pars width in males was 5.95 ± 1.13 (range: 3.8–8.1 mm), while in females, it was 5.70 ± 1.18 (range: 3.7–8.1 mm). Right side mean pars height in males was 5.90 ± 1.2 (range: 3.7–9.4 mm), and in females, it was 6.11 ± 1.04 (range: 3.8–9.3 mm). Left-sided mean pars height in males was 6.0 ± 1.1 (range: 3.2–9.4 mm) as compared to females, in which it was 5.77 ± 1.23 (range: 4.1–9.3 mm). The mean lateral angulation angle in males was 9.99° ± 1.70° (8.1°–15°), while in females, it was 10.15° ± 1.73° (8.1°–15°). The mean sagittal angulation in males was 26.33° ± 3.32° (21.0°–32.80°), while in females, it was 27.18 ± 3.05 (21.0°–32.10°). The average screw length in males was 41.74 ± 5.63 (34–54.8 mm), whereas in females, it was 41.35 ± 4.77 (34–54.8 mm). Conclusion: This study provides a morphometric database which is characteristic of the C1–C2 vertebrae in the normal Indian population with regard to the anatomic feasibility of the TAS fixation for various C1–C2 pathologies. The C2 pars width and height measured in the current study can guide the selection of TAS screws in the Indian population. This study could serve in providing the baseline anatomic parameters assessed in the healthy individuals to design and develop customized screws and related implant assembly which might provide wider clinical applicability.
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Convolutional neural network-based automated segmentation and labeling of the lumbar spine X-ray p. 136
Sandor Konya, T R Sai Natarajan, Hassan Allouch, Kais Abu Nahleh, Omneya Yakout Dogheim, Heinrich Boehm
DOI:10.4103/jcvjs.jcvjs_186_20  
Purpose: This study investigated the segmentation metrics of different segmentation networks trained on 730 manually annotated lateral lumbar spine X-rays to test the generalization ability and robustness which are the basis of clinical decision support algorithms. Methods: Instance segmentation networks were compared to semantic segmentation networks based on different metrics. The study cohort comprised diseased spines and postoperative images with metallic implants. Results: However, the pixel accuracies and intersection over union are similarly high for the best performing instance and semantic segmentation models; the observed vertebral recognition rates of the instance segmentation models statistically significantly outperform the semantic models' recognition rates. Conclusion: The results of the instance segmentation models on lumbar spine X-ray perform superior to semantic segmentation models in the recognition rates even by images of severe diseased spines by allowing the segmentation of overlapping vertebrae, in contrary to the semantic models where such differentiation cannot be performed due to the fused binary mask of the overlapping instances. These models can be incorporated into further clinical decision support pipelines.
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Factors affecting functional outcome after anterior cervical discectomy and fusion: A multicenter study p. 144
Alba Scerrati, Antonino Germano', Nicola Montano, Jacopo Visani, Fabio Cacciola, Giovanni Raffa, Ilaria Ghetti, Fabrizio Pignotti, Michele Alessandro Cavallo, Alessandro Olivi, Pasquale de Bonis
DOI:10.4103/jcvjs.jcvjs_1_21  
Background: Although anterior cervical discectomy and fusion (ACDF) represents a standardized procedure for surgical treatment of a cervical herniated disc, several variables could affect patients' clinical and radiological outcome. We evaluated the impact of sex, age, body mass index (BMI), myelopathy, one- or two-level ACDF, and the use of postoperative collars on functional and radiological outcomes in a large series of patients operated for ACDF. Materials and Methods: Databases of three institutions were searched, resulting in the enrollment of 234 patients submitted to one- or two-level ACDF from January 2013 to December 2017 and followed as outpatients at 6- and 12-month follow-up. The impact of variables on functional and radiological outcomes was evaluated using univariate and multivariate logistic regression analysis. Results: At univariate analysis, female sex, higher BMI, two-level ACDF, and postoperative collar correlated with a significantly worse early and late Neck Disability Index (NDI). Multivariate analysis showed that male patients had a lower risk of worse early (P = 0.01) and late NDIs (P = 0.009). Patients with myelopathy showed better early NDI (P = 0.004). Cervical collar negatively influenced both early and late NDIs (P < 0.0001), with a higher risk of early nonfusion (P = 0.001) but a lower risk of late nonfusion (P = 0.01). Patients operated for two-level ACDF have a worse early NDI (P = 0.005), a worse late NDI (P = 0.01), and a higher risk of early nonfusion (P = 0.048). BMI and age did not influence outcome. Conclusions: Female sex, two-level surgery, and the use of postoperative collars significantly correlate with worse functional outcomes after one- or two-level ACDF.
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Roy-Camille Type 3 suicidal jumper's fractures: Case series and review of the literature p. 149
Giuseppe Emmanuele Umana, Marco Teli, Bipin Chaurasia, Maurizio Passanisi, Gianfranco Longo, Angelo Spitaleri, Marco Fricia, Santino Ottavio Tomasi, Giancarlo Ponzo, Giovanni Federico Nicoletti, Salvatore Cicero, Massimiliano Visocchi, Gianluca Scalia
DOI:10.4103/jcvjs.jcvjs_185_20  
Background: Roy-Camille reported only three patients in their Type 3 posttraumatic transverse sacral fracture (TSF) classification. A modified Roy-Camille classification has been already proposed by other authors suggesting further categorization of the TSFs as partially displaced or completely displaced to predict the rate of neurological recovery following lumbopelvic fixation. Materials and Methods: We reported three adult cases of surgical fixation of fracture–dislocation (3A and 3B) of the sacrum due to traumatic injuries and submitted to lumbopelvic posterior reconstruction. A case of a 15-year-old male patient affected by Type 3C with vascular pelvic injury was also reported. A comprehensive literature search was performed on evaluation and management of Type 3 TSFs. Results: In Type 3A, there is a minimal anterior dislocation and the reduction is feasible with good chance of recovery. In Type 3B, the anterior dislocation is severe, neurological deficits are present, reduction is difficult, and there is a risk of vascular injury both at the trauma and during the surgical reduction. In Type 3C, the anterior dislocation is massive, and the risk of vascular injury is very high requiring prompt vascular or endovascular treatment. Open reduction and posterior instrumentation are technically feasible in patients affected by Type 3 high TSFs. Conclusions: In our opinion, a modified Roy-Camille classification could be useful in the assessment of prognostic and therapeutic aspects of such fractures, In our opinion, a modified Roy-Camille classification could help assess the prognostic and therapeutic aspects of such fractures, in which the severity of the dislocation affects the surgical technique, the chance of neurological recovery, and the patient's life expectancy.
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Redefining cervical spine deformity classification through novel cutoffs: An assessment of the relationship between radiographic parameters and functional neurological outcomes p. 157
Peter Gust Passias, Katherine E Pierce, Avery E Brown, Cole A Bortz, Haddy Alas, Renaud Lafage, Virginie Lafage, Breton Line, Eric O Klineberg, Douglas C Burton, Robert Hart, Alan H Daniels, Shay Bess, Bassel Diebo, Themistocles Protopsaltis, Robert Eastlack, Christopher I Shaffrey, Frank J Schwab, Justin S Smith, Christopher Ames
DOI:10.4103/jcvjs.jcvjs_22_21  
Purpose: The aim is to investigate the relationship between cervical parameters and the modified Japanese Orthopedic Association scale (mJOA). Materials and Methods: Surgical adult cervical deformity (CD) patients were included in this retrospective analysis. After determining data followed a parametric distribution through the Shapiro–Wilk Normality (P = 0.15, P > 0.05), Pearson correlations were run for radiographic parameters and mJOA. For significant correlations, logistic regressions were performed to determine a threshold of radiographic measures for which the correlation with mJOA scores was most significant. mJOA score of 14 and <12 reported cut-off values for moderate (M) and severe (S) disability. New modifiers were compared to an existing classification using Spearman's rho and logistic regression analyses to predict outcomes up to 2 years. Results: A total of 123 CD patients were included (60.5 years, 65%F, 29.1 kg/m2). For significant baseline factors from Pearson correlations, the following thresholds were predicted: MGS (M:-12 to-9° and 0°–19°, P = 0.020; S: >19° and <−12°, χ2 = 4.291, P = 0.036), TS-CL (M: 26°to 45°, P = 0.201; S: >45°, χ2 = 7.8, P = 0.005), CL (M:-21° to 3°, χ2 = 8.947, P = 0.004; S: <−21°, χ2 = 9.3, P = 0.009), C2-T3 (M: −35° to −25°, χ2 = 5.485, P = 0.046; S: <−35°, χ2 = 4.1, P = 0.041), C2 Slope (M: 33° to 49°, P = 0.122; S: >49°, χ2 = 5.7, P = 0.008), and Frailty (Mild: 0.18–0.27, P = 0.129; Severe: >0.27, P = 0.002). Compared to existing Ames- International Spine Study Group classification, the novel thresholds demonstrated significant predictive value for reoperation and mortality up to 2 years. Conclusions: Collectively, these radiographic values can be utilized in refining existing classifications and developing collective understanding of severity and surgical targets in corrective surgery for adult CD.
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Lateral mass intra-pedicular screw fixation for subaxial cervical spines - An alternative surgical technique p. 165
Kota Kojima, Masayuki Ishikawa, Takahiro Endo, Jun Muto, Yasuyuki Fukui, Shunji Asamoto
DOI:10.4103/jcvjs.JCVJS_17_21  
Background: Lateral mass screw (LMS) and transpedicular screw (TPS) techniques are the two major options for performing posterior cervical fusion of the subaxial cervical spine. Although these two techniques can cover the vast majority of patients who require posterior fixation of the cervical spine, they are not without their limitations. Objective: The objective of this study is to introduce a novel technique, lateral mass intrapedicular screw (LMIS) fixation, for posterior subaxial cervical spine (C3–C6) fixation. Materials and Methods: The starting point of the screw is defined as the midpoint of the lateral mass. In the axial plane, the screw is angled at 20°–25° with respect to the midline of the spinous process. In the sagittal plane, the screw is directed toward the rostral quarter (zone 1) of the vertebral body and placed within the pedicle. A preliminary, proof-of-concept experiment was performed using a bone model created with synthetic bone and computed tomography images before performing the operation on a patient. Results: During the preliminary experiment, insignificant breaching of the inner cortex of the pedicle was observed with one of the screws. However, no other screws breached the inner cortex in the same manner during the preliminary experiment or during the operation, and the intraoperative fixation was strong. Conclusion: LMIS is a relatively simple and safe technique that can be performed for the fixation of subaxial cervical spines with screws that are longer than those used in LMS. We believe that this technique may join the two existing techniques to become a common alternative technique, particularly for patients with poor bone quality.
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Repair of spondylolysis using a pedicle screw U-shaped rod construct: A preliminary study of 25 young patients with a mean follow-up of 24 months p. 170
Ahmed Samir Barakat, Wessam Samir Soliman, Amr Farahat Elgharabawy, Khaled Fawaz, Nader M Diab, Wissam Gaber Alinani, Akram Azzam, Ahmed Maher Sultan
DOI:10.4103/jcvjs.jcvjs_36_21  
Study Design: Prospective case series, therapeutic Level IV. Objectives: Functional and radiographic outcome evaluation of patients with spondylolysis treated with pars interarticularis defect repair with iliac bone grafting and application of a construct consisting of a pair of polyaxial pedicle screws connected by a U-shaped rod passing beneath the spinous process. Methods: Twenty-five patients (27 operated lumbar levels) with an average of 20 months of follow-up (range 12–24 m) with spondylolysis who met our inclusion criteria were treated with the above-mentioned technique. Functional assessment was by the Visual Analog Score (VAS) for low back pain (LBP) and Oswestry Disability Index (ODI). Fusion was confirmed with plain x-rays and when indicated with computed tomography scan. Return to activities of daily living (ADL) was also assessed. Results: There were 16 males (64%) and 9 females (36%), with a mean age of 18 ± 3 years at surgery, with a mean operating time of 79 ± 13 min and a mean blood loss of 186 ± 57 ml. ODI significantly improved from a mean of 63 ± 7 preoperatively to 10 ± 4 at 12 months postoperatively (P < 0.001). The mean preoperative LBP VAS score 8 ± 1 showed also a statistically significant decrease of values to 1 ± 1 at 12 months, (P < 0.001). At 12 m, all patients returned to unrestricted ADL. Pars healing was present in 19 patients (76%) at 6 months and in all patients at 12 months. Conclusions: Polyaxial pedicular screws with a U-shaped rod offer an effective and reproducible treatment for spondylolysis with an appropriate fusion rate, predictable return to daily activities, and good pain relief in young adults.
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Morphometric analysis of posterior cranial fossa and surgical implications p. 178
Dan Zimelewicz Oberman, Matias Baldoncini, Nicollas Nunes Rabelo, Pablo Ajler
DOI:10.4103/jcvjs.jcvjs_205_2  
Background: Posterior cranial fossa (PCF) is an important area in terms of anatomy and surgery. It is a common site of many neoplastic, vascular, and degenerative lesions. Craniovertebral surgeries require special attention regarding detailed information about the morphology and morphometry of this region. The aim of this study was to analyze the morphometric characteristics of PCF and distances between the inner base of the skull. Materials and Methods: An observational, retrospective cross-sectional study was made. Fifty-five dry human skulls of unknown sex were measured ascertained using digital Vernier caliper with 0.01 mm precision. Results: The morphometric analysis of the mean length and width of the FM was 34.51 mm and 29.85 mm, respectively. We found a significant difference (P < 0.05) among the distance between the posterior tip of occipital condyle and basion of the right and left sides. Conclusion: According to our observations, the present study yielded detailed morphometry of the PCF and neurovascular relationship. It can facilitate successful instrumentation and minimize neurovascular injuries. Furthermore, it provides safe and suitable data for guiding neurosurgical procedures. The major limitation of this study was the lack of knowledge regarding the age and gender of the participants whose skull base was studied.
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Changes in cervical sagittal alignment and the effects on cervical parameters in patients with cervical spondylotic myelopathy after laminoplasty p. 183
Ali Fahir Ozer, Ozkan Ateş, Onder Çerezci, Mehdi Hekimoğlu, Ahmet Levent Aydın, Tunç Öktenoğlu, Mehdi Sasani
DOI:10.4103/jcvjs.jcvjs_213_20  
Objective: To monitor changes in cervical parameters before and after laminoplasty surgery. Cervical parameters and health-related quality-of-life (HRQOL) values that may be affected after laminoplasty were examined before and after surgery. The clinical and radiological course of these values was monitored, and their interaction with all spinal radiological parameters was revealed. Materials and Methods: Nineteen patients who underwent clinical and radiological evaluation for 2 years were followed in this study. Neck disability index, visual analog scale, and short form 36 scores were determined to evaluate HRQOL. For radiological parameters, the C0-C2 angle, C2-C7 angle, cervical sagittal vertical axis, T1 slope angle, neck tilt (NT) and thoracic inlet angle were used. The results of the 4-month, 1 year and 2-year follow-ups were statistically evaluated. Results: Both the HRQOL and cervical radiological parameters deteriorated in the first 4 months and returned to normal in the 2nd year. Statistically, all parameters were meaningful (P < 0.05), except for NT. Conclusion: Cervical parameters and HRQOL values, which deteriorated in the early period, recovered in the late period in the long-term follow-up of patients undergoing laminoplasty. The important point is that preoperative cervical parameters suitable for laminoplasty should be present, and spinopelvic parameters should be normal.
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An alternative way of C1 screwing: Supralaminar C1 lateral mass screws p. 191
Alexander V Burtsev, Olga M Sergeenko, Alexander V Gubin
DOI:10.4103/jcvjs.jcvjs_45_21  
Study Design: This study involves literature review, technical note, and case series. Objectives: The objectives were to analyze indications and contraindications, advantages, and disadvantages for C1 lateral mass screw (LMS) insertion above or partially above the arch, to descript technical features, and to give examples of the practical application of this technique and investigated its safety. Methods: A literature review was carried out in English and Russian in PubMed, Google Scholar, and eLibrary databases. We selected four patients, treated in our clinic, which was carried out partially supralaminar C1 LMS. Results: Only three descriptions of supralaminar C1 LMS were found in the literature. Four adult patients underwent posterior C1–C2 screw fixation with C1 LMS along the superior edge of the C1 arch at our clinic. Partially supralaminar C1 screws were inserted on one of the sides due to the difficulties of using classical techniques. The main reasons for supralaminar screw fixation were narrow C1 lamina, hypertrophied venous plexus, and intraoperative failures of classic techniques application (broken screw trajectory, profuse venous bleeding from the plexus). The average follow-up time for the patients was 2.7 years, no complications were noted, and all had a satisfactory spinal fusion. Conclusions: The proposed types of C1 LMS above or partially above the C1 arch can be useful alternative method of C1 screwing in selected patients. Indications for the use of the supralaminar C1 LMS method can be narrow C1 posterior arch and pedicle, pronounced C1-C2 venous plexus, some V3 segment anomalies at C1 level, small arthritic inferior part of lateral mass, and intraoperative failures of classic techniques application.
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Increased cautiousness in adolescent idiopathic scoliosis patients concordant with syringomyelia fails to improve overall patient outcomes p. 197
Katherine E Pierce, Oscar Krol, Nicholas Kummer, Lara Passfall, Brooke O'Connell, Constance Maglaras, Haddy Alas, Avery E Brown, Cole Bortz, Bassel G Diebo, Carl B Paulino, Aaron J Buckland, Michael C Gerling, Peter G Passias
DOI:10.4103/jcvjs.jcvjs_25_21  
Background: Adolescent idiopathic scoliosis (AIS) is a common cause of spinal deformity in adolescents. AIS can be associated with certain intraspinal anomalies such as syringomyelia (SM). This study assessed the rate o f SM in AIS patients and compared trends in surgical approach and postoperative outcomes in AIS patients with and without SM. Methods: The database was queried using ICD-9 codes for AIS patients from 2003–2012 (737.1–3, 737.39, 737.8, 737.85, and 756.1) and SM (336.0). The patients were separated into two groups: AIS-SM and AIS-N. Groups were compared using t-tests and Chi-squared tests for categorical and discrete variables, respectively. Results: Totally 77,183 AIS patients were included in the study (15.2 years, 64% F): 821 (1.2%) – AIS-SM (13.7 years, 58% F) and 76,362 – AIS-N (15.2 years, 64% F). The incidence of SM increased from 2003–2012 (0.9 to 1.2%, P = 0.036). AIS-SM had higher comorbidity rates (79 vs. 56%, P < 0.001). Comorbidities were assessed between AIS-SM and AIS-N, demonstrating significantly more neurological and pulmonary in AIS-SM patients. 41.2% of the patients were operative, 48% of AIS-SM, compared to 41.6% AIS-N. AIS-SM had fewer surgeries with fusion (anterior or posterior) and interbody device placement. AIS-SM patients had lower invasiveness scores (2.72 vs. 3.02, P = 0.049) and less LOS (5.0 vs. 6.1 days, P = 0.001). AIS-SM patients underwent more routine discharges (92.7 vs. 90.9%). AIS-SM had more nervous system complications, including hemiplegia and paraplegia, brain compression, hydrocephalous and cerebrovascular complications, all P < 0.001. After controlling for respiratory, renal, cardiovascular, and musculoskeletal comorbidities, invasiveness score remained lower for AIS-SM patients (P < 0.001). Conclusions: These results indicate that patients concordant with AIS and SM may be treated more cautiously (lower invasiveness score and less fusions) than those without SM.
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A comparative study of L4-L5-S1 and L5-S1 vertebral fusion in high-grade L5-S1 spondylolisthesis p. 202
Majid Rezvani, Masih Sabouri, Mehdi Mahmoodkhani, Ali Mokhtari, Donya Sheibani Tehrani
DOI:10.4103/jcvjs.jcvjs_41_21  
Introduction: One of the most common types of spinal diseases is spondylolisthesis, which in advanced cases requires surgical intervention. This study aimed to compare the results of L4-L5-S1 and L5-S1 vertebral fusion treatment in high-grade L5-S1 spondylolisthesis. Methods: A study design that randomized controlled trial. A total of 70 consecutive patients who underwent surgery for the treatment of spondylolisthesis at Al-Zahra Hospital in Isfahan, Iran, were evaluated from July 2020 to February 2021 (35 patients underwent L4-L5-S1 and 35 received L5-S1 vertebral fusion treatment). The radicular and low back pain (LBP) intensity (Vanguard Australian Shares), blood loss, wound infection, reduction, and quality of life (SF-12 scores) were quantified before the surgery, 1, 3, and 6 months after surgery in two groups. Results: Patients involved in the two groups had similar baseline demographic characteristics. The percent slip in L4-L5-S1 and L5-S1 group, respectively, postoperative 81.11% and 57.89%, P = 0.0001. Intraoperative blood loss and postoperative were higher in the L4-L5-S1 group when compared to the L5-S1 group (P < 0.05). The wound infection rate of the L4-L5-S1 group was similar to that of the L5-S1 group (8.6% vs. 2.9%, P = 0.303). There was no difference in radicular and LBP intensity, SF-12 scores among patients with L4-L5-S1 and L5-S1 groups (P < 0.05). Conclusion: Both L4-L5-S1 and L5-S1 were equally beneficial in improving short-term functional outcomes for patients with high grade L5-S1 spondylolisthesis. However, L4-L5-S1 was associated with statistically significant higher incidences of blood loss, but it was accompanied by a better reduction. Therefore, caution should be exercised when considering L4-L5-S1.
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CASE REPORT Top

A report of two cases of familial occipitalization of the atlas in a father and his daughter p. 209
Shaveen Jayalathge, Lauren Tollefson, David Mackenzie, Siddharth Patel
DOI:10.4103/jcvjs.jcvjs_4_21  
Occipitalization of the atlas (OA) (atlantooccipital assimilation) is a rare congenital anomaly that results in fusion of the C0-C1 complex. Here, we report the two cases of familial OA occurring in a father and his daughter and describe the pathologic features of this rare developmental anomaly. A 70-year-old father and his 30-year-old daughter seeking conservative care for musculoskeletal complaints presented to a chiropractic clinic. Radiographs of the cervical spine demonstrated OA. This represents a novel example of this anomaly in two patients with a direct familial relationship.
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