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1.  Comparison of Clinical and Radiologic Results between Expandable Cages and Titanium Mesh Cages for Thoracolumbar Burst Fracture 
A thoracolumbar burst fracture is usually unstable and can cause neurological deficits and angular deformity. Patients with unstable thoracolumbar burst fracture usually need surgery for decompression of the spinal canal, correction of the angular deformity, and stabilization of the spinal column. We compared two struts, titanium mesh cages (TMCs) and expandable cages.
33 patients, who underwent anterior thoracolumbar reconstruction using either TMCs (n=16) or expandable cages (n=17) between June 2000 and September 2011 were included in this study. Clinical outcome was measured by visual analogue scale (VAS), American Spinal Injury Association (ASIA) scale and Low Back Outcome Score (LBOS) for functional neurological evaluation. The Cobb angle, body height of the fractured vertebra, the operation time and amount of intra-operative bleeding were measured in both groups.
In the expandable cage group, operation time and amount of intraoperative blood loss were lower than that in the TMC group. The mean VAS scores and LBOS in both groups were improved, but no significant difference. Cobb angle was corrected higher than that in expandable cage group from postoperative to the last follow-up. The change in Cobb angles between preoperative, postoperative, and the last follow-up did not show any significant difference. There was no difference in the subsidence of anterior body height between both groups.
There was no significant difference in the change in Cobb angles with an inter-group comparison, the expandable cage group showed better results in loss of kyphosis correction, operation time, and amount of intraoperative blood loss.
PMCID: PMC4024813  PMID: 24851149
Thoracolumbar; Lumbar; Fracture; Corpectomy; Cage; Kyphosis
2.  Spinal shortening and monosegmental posterior spondylodesis in the management of dorsal and lumbar unstable injuries 
Patients with spinal injuries have been treated in the past by laminectomy in an attempt to decompress the spinal cord. The results have shown insignificant improvement or even a worsening of neurologic function and decreased stability without effectively removing the anterior bone and disc fragments compressing the spinal cord. The primary indication for anterior decompression and grafting is narrowing of the spinal canal with neurologic deficits that cannot be resolved by any other approach. One must think of subsequent surgical intervention for increased stability and compressive posterior fusion with short-armed internal fixators.
To analyze the results and efficacy of spinal shortening combined with interbody fusion technique for the management of dorsal and lumbar unstable injuries.
Materials and Methods:
Twenty-three patients with traumatic fractures and or fracture-dislocation of dorsolumbar spine with neurologic deficit are presented. All had radiologic evidence of spinal cord or cauda equina compression, with either paraplegia or paraparesis. Patients underwent recapping laminoplasty in the thoracic or lumbar spine for decompression of spinal cord. The T-saw was used for division of the posterior elements. After decompression of the cord and removal of the extruded bone fragments and disc material, the excised laminae were replaced exactly in situ to their original anatomic position. Then application of a compression force via monosegmental transpedicular fixation was done, allowing vertebral end-plate compression and interbody fusion.
Lateral Cobb angle (T10–L2) was reduced from 26 to 4 degrees after surgery. The shortened vertebral body united and no or minimal loss of correction was seen. The preoperative vertebral kyphosis averaged +17 degrees and was corrected to +7 degrees at follow-up with the sagittal index improving from 0.59 to 0.86. The segmental local kyphosis was reduced from +15 degrees to −3 degrees. Radiography demonstrated anatomically correct reconstruction in all patients, as well as solid fusion.
This technique permits circumferential decompression of the spinal cord through a posterior approach and posterior interbody fusion.
PMCID: PMC3122988  PMID: 21716869
Injury; laminoplasty; spine; shortening; spondylodesis
3.  Posterior short segment pedicle screw fixation and TLIF for the treatment of unstable thoracolumbar/lumbar fracture 
Currently, Posterior Short Segment Pedicle Screw Fixation is a popular procedure for treating unstable thoracolumbar/lumbar burst fracture. But progressive kyphosis and a high rate of hardware failure because of lack of the anterior column support remains a concern. The efficacy of different methods remains debatable and each technique has its advantages and disadvantages.
A consecutive series of 20 patients with isolated thoracolumbar/lumbar burst fractures were treated by posterior short segment pedicle screw fixation and transforaminal thoracolumbar/lumbar interbody fusion (TLIF) between January 2005 and December 2007. All patients were followed up for a minimum of 2 years. Demographic data, neurologic status, anterior vertebral body heights, segmental Cobb angle and treatment-related complications were evaluated.
The mean operative time was 167 minutes (range, 150–220). Blood loss was 450 ~ 1200 ml, an average of 820 ml. All patients recovered with solid fusion of the intervertebral bone graft, without main complications like misplacement of the pedicle screw, nerve or vessel lesion or hard ware failure. The post-operative radiographs demonstrated a good fracture reduction and it was well maintained until the bone graft fusion. Neurological recovery of one to three Frankel grade was seen in 14 patients with partial neurological deficit, three grades of improvement was seen in one patient, two grades of improvement was observed in 6 patients and one grade of improvement was found in 6 patients. All the 6 patients with no paraplegia on admission remained neurological intact, and in one patient with Frankel D on admission no improvement was observed.
Posterior short-segment pedicle fixation in conjunction with TLIF seems to be a feasible option in the management of selected thoracolumbar/lumbar burst fractures, thereby addressing all the three columns through a single approach with less trauma and good results.
PMCID: PMC3930337  PMID: 24517217
Short segment fixation; Thoracic vertebrae; Lumbar vertebrae; Unstable burst fractures; Pedicle screw; TLIF
4.  First aid and treatment for cervical spinal cord injury with fracture and dislocation 
Indian Journal of Orthopaedics  2007;41(4):300-304.
Traumatic cervical spinal cord injury with subaxial fracture and dislocation not only indicates a highly unstable spine but can also induce life-threatening complications. This makes first aid critically important before any definitive operative procedure is undertaken. The present study analyzes the various first aid measures and operative procedures for such injury.
Materials and Methods:
Two hundred and ninety-five patients suffered from cervical spinal cord injury with fracture and dislocation. The average period between injury and admission was 4.5 days (range 5 h-12 weeks). The injury includes burst fractures (n = 90), compression fractures with herniated discs (n = 50), fractures and dislocation (n = 88) and pure dislocation (n = 36). Other injuries including developmental spinal canal stenosis and/or multi-segment spinal cord compression associated with trauma (n = 12), lamina fractures compressing the spinal cord (n = 6), ligament injuries (n = 7) and hematoma (n = 6) were observed in the present study. The injury level was C4 (n = 17), C5 (n = 29), C6 (n = 39), C7 (n = 35), C4-5 (n = 38), C5-6 (n = 58), C6-7 (n = 49), C4-6 (n = 16) and C5-7 (n = 14). According to the Frankel grading system, grade A was observed in 20 cases, grade B in 91, grade C in 124 and grade D in 60. One hundred and eighteen (40%) patients had a high fever and difficulty in breathing on presentation. First aid measures included early reduction and immobilization of the injured cervical spine, controlling the temperature, breathing support, and administration of high-dose methylprednisolone within eight hours of the injury (n = 12) and administration of dehydration and neurotrophy medicine. Oxygen support was given and tracheotomy was performed for patients with serious difficulty in breathing. Measures were taken to prevent bedsores and infections of the respiratory and urological systems. Two hundred and thirty six patients were treated with anterior decompression, 31 patients were treated by posterior approach surgery and combined anterior and posterior approach surgery was performed in a single sitting on 28 patients.
All patients were followed for 0.5-18 years (mean 11.8 years). At least one Frankel grade improvement was observed in 178 (60.3%) patients. In the anterior surgery group, the best results were observed in the cases with slight compressive fracture with disc herniation (44/50 patients, 88.0%). In the posterior surgery group, one Frankel grade improvement was observed in the cases with developmental spinal canal stenosis with trauma, lamina fractures, ligament injuries and hematoma (27/31, 87.1%). Most of the patients in the Frankel D group recovered normal neurological function after surgery. The majority of the patients with Frankel C neurological deficit (102/124) had the ability to walk postoperatively, while most of the seriously injured patients (Frankel A and B) had no improvement in their neurological function. Radiolographic fusion of the operated segments occurred in most patients within three months. Loss of intervertebral height and cervical physiological curvature was observed to varying degrees in 30.1% (71/236) of the cases in the anterior surgery group.
First aid measures of early closed reduction or realignment and immobilization of the cervical spine, breathing support and high-dose methylprednisolone were most important in the treatment for traumatic spinal cord injury. Surgery should be performed as soon as the indications of spinal injury appear. The choice of the approach—anterior, posterior or both, should be based on the type of the injury and the surgeon's experience. Any complications should be actively prevented and treated.
PMCID: PMC2989519  PMID: 21139782
Cervical spine; first aid; spinal cord injury; surgical treatment
5.  Long-term results of transpedicle body augmenter in treating burst fractures 
Indian Journal of Orthopaedics  2007;41(4):362-367.
Short-segment fixation alone to treat thoracolumbar burst fractures is common but it has a 20-50% incidence of implant failure and rekyphosis. A transpedicle body augmenter (TpBA) to reinforce the vertebral body via posterior approach has been reported to prevent implant failure and increase the clinical success rate in treating burst fracture. This article is to evaluate the longterm results of short-segment fixation with TpBA for treatment of thoracolumbar burst fractures.
Materials and Methods:
Patients included in the study had a single-level burst fracture involving T11-L2 and no distraction or rotation element with limited neurological deficit. Patients in the control group (n = 42) were treated with short-segment posterior instrumentation alone, whereas patients in the augmented group (n = 90) were treated with a titanium spacer designed for transpedicle body reconstruction. The followup was 48-101 months. The radiographic and clinical results were evaluated and compared by Student's t test and Fisher's exact test.
The blood loss, operation time and hospitalization were similar in both the groups. The immediate postoperative anterior vertebral restoration rate of the augmented group was similar to that of the control group (97.6% ± 2.4% vs. 96.6% ± 3.2%). The final anterior vertebral restoration was greater in the augmented group than in the control group (93.3% ± 3.4% vs. 62.5% ± 11.2%). Immediate postoperative kyphotic angles were not significantly different between the groups (3.0° ± 1.8° vs. 5.1° ± 2.3°). The final kyphotic angles were less in the augmented group than the control group (7.3° ± 3.5° vs. 20.1° ± 5.4°). The augmented group had less (P < 0.001) implant failure [0% (n=0) vs. 23.8% (n=10)] for the control group) and more patients (P < 0.001) with no pain or minimal or occasional pain (Grade P1 or P2) than the control group [90.0% (n=81) vs. 66.7% (n=28)]. All patients in the augmented group and 39 (92.8%) patients in the control group experienced neurological recovery to Frankel Grade E. Three patients in the control group had improvement to Frankel Grade D from Frankel Grade C, but later had deterioration to Frankel Grade C because of loosening and dislodgement of the implant.
Posterior body reconstruction with TpBA can maintain kyphosis correction and vertebral restoration, prevent implant failure and lead to better clinical results.
PMCID: PMC2989517  PMID: 21139792
Burst fractures; kyphosis; posterior instrumentation; spinal trauma; thoracolumbar injury; transpedicle body augmenter
6.  Single stage corpectomy and instrumentation in the treatment of pathological fractures in the lumbar spine 
International Orthopaedics  2011;36(1):111-117.
Corpectomy and implantation of titanium cages is standard in pathological fracture treatment but additional single ventral instrumentation remains controversial with regard to rotational stability.
This study included 45 patients suffering from vertebral metastases with spinal stenosis, instability and/or neurological deficits secondary to pathological lumbar spine fractures and bone mineral density (BMD) ≥1.20 g/cm2. The clinical results of a single stage anterior decompression with corpectomy defect restoration with titanium cage and single double rod system in patients were evaluated at mean 36 months postoperatively with follow-up neurological and radiological exams at three months then every six months.
Evaluation of neurological recovery included grading following a modified Frankel scale. Contentment, disability and actual pain were evaluated using the visual analogue scale (VAS) and Oswestry disability index (ODI). BMD was measured using dual-energy X-ray absorptiometry (DXA).
Postoperative neurological evaluations showed improvement in all patients. In the radiological follow-up in 40 patients (89%) findings were similar compared to the postoperative control. In five patients (11%) a loss of correction at a mean of 8° degrees (Cobb angle) secondary to cage subsidence occurred. No breakage of the device or displacement of the instrumentation was seen. Overall the Frankel scale improved 0.65 points (p < 0.05) and the ODI improved 40.69 points (p < 0.05).
In lumbar spine fractures of metastatic origin with stenosis, instability and/or neurological deficit, a single stage ventral decompression and instrumentation in patients with BMD ≥1.20 g/cm2 should be considered.
PMCID: PMC3251684  PMID: 21643685
7.  Neurological L5 burst fracture: posterior decompression and lordotic fixation as treatment of choice 
European Spine Journal  2012;21(Suppl 1):119-122.
We report our experience and literature review concerning surgical treatment of neurological burst fractures of the fifth lumbar vertebra.
Materials and methods
Nineteen patients with L5 neurological burst fractures were consecutively enrolled; 6 patients had complete motor deficits, and 12 had sphincter dysfunction. We performed 18 posterior and one combined approaches. To avoid kyphosis, posterior internal fixation was achieved by positioning patients on the operating table with hips and knees fully extended. At the latest follow-up (mean 22 months, range 10–66), neurological recovery, canal remodeling and L4–S1 angle were evaluated.
Vertebral body replacement was difficult, which therefore resulted in an oblique position of the cage. Vertebral bodies still remained deformed, even though fixation allowed for an acceptable profile (22°, range 20–35). We observed three cases of paralysis, five complete, and three incomplete recoveries. In the remaining eight patients, sphincter impairment was the only finding. In 15 patients, pain was absent or occasional; in four individuals, it was continuous but not invalidating. Remodeling was visible by X-ray and/or CT, without significant secondary stenosis.
The L5 burst fractures are rare and mostly due to axial compression. Cauda and/or nerve root injuries are absolute indications for surgery. If an anterior approach is technically difficult, laminectomy can allow for decompression, and it can be easily combined with transpedicular screw fixation. Posterior instrumented fusion, also performed with the aim to restore sagittal profile, when associated with an accurate spinal canal exploration and decompression, may be looked at as an optimal treatment for neurological L5 burst fractures.
PMCID: PMC3325385  PMID: 22407264
Burst fracture; Low lumbar spine; Neurologic deficit; Internal fixation; Lordosis
8.  Shortening spinal column reconstruction through posterior only approach for the treatment of unstable osteoporotic burst lumber fracture: a case report 
Study design
Case report.
Clinical question
This study reports if shortening reconstruction procedure through posterior approach only can be used in osteoporotic unstable fracture as well as post-traumatic burst fracture.
An 80-year-old female patient with unstable burst osteoporotic fracture of L1 underwent posterior approach corpectomy and shortening reconstruction of the spinal column by non-expandable cages.
The surgery was uneventful, with average blood loss. Using of small profile cages has helped us to avoid root injury. Augmentation of the screw with cement and the compressive force applied to the spine column aids in obtaining a rigid construct with good alignment without any neurological complication.
Shortening reconstruction procedure through only posterior approach is a viable option in treating unstable osteoporotic fracture as well as post-traumatic fractures. Using non-expandable cage is advocated to avoid cage subsidence.
PMCID: PMC3550702  PMID: 23179477
Osteoporotic fracture; Posterior corpectomy; Shortening reconstruction; Unstable burst fracture; Thoracolumbar fracture
9.  Titanium cages in the surgical treatment of severe vertebral osteomyelitis 
European Spine Journal  2003;12(6):606-612.
The role of spinal implants in the presence of infection is critically discussed. In this study 20 patients with destructive vertebral osteomyelitis were surgically treated with one-stage posterior instrumentation and fusion and anterior debridement, decompression and anterior column reconstruction using an expandable titanium cage filled with morsellised autologous bone graft. The patients' records and radiographs were retrospectively analysed and follow-up clinical and radiographic data obtained. At a mean follow-up of 23 months (range 12–56 months) all cages were radiographically fused and all infections eradicated. There were no cases of cage dislocation, migration or subsidence. Local kyphosis was corrected from 9.2° (range −20° to 64°) by 9.4° to −0.2° (range −32° to 40°) postoperatively and lost 0.9° during follow-up . All five patients with preoperative neurological deficits improved to Frankel score D or E. Patient-perceived disability caused by back pain averaged 7.9 (range 0–22) in the Roland–Morris score at follow-up. In cases of vertebral osteomyelitis with severe anterior column destruction the use of titanium cages in combination with posterior instrumentation is effective and safe and offers a good alternative to structural bone grafts. Further follow-up is necessary to confirm these early results.
PMCID: PMC3467979  PMID: 12961081
Vertebral osteomyelitis; Spinal infection; Spondylodiscitis; Cages; Spinal fusion
10.  The Safety and Efficacy of Cadaveric Allografts and Titanium Cage as a Fusion Substitutes in Pyogenic Osteomyelitis 
The safety and efficacy of various fusion substitutes in pyogenic osteomyelitis has not been investigated. We evaluated and compared the cadaveric allograft and titanium cages used to reconstruct, maintain alignment and achieve fusion in the management of pyogenic spinal infection.
There were 33 patients with pyogenic osteomyelitis underwent fusion in this study. Fifteen of the 33 patients were operated on by fusion with allografts (cadaveric patella bones) and 18 of those were operated with titanium mesh cages filled with autologous cancellous iliac bone. After the affected disc and vertebral body resection with pus drainage, cadaveric allograft or titanium cages were inserted into the resected space. Posterior transpedicular screw fixation and rod compression in resected space, where cadaveric allograft or titanium cages were inserted, was performed to prevent the malposition in all patients except in 1 case. Recurrent infection was identified by serial erythrocyte sedimentation rate and cross reactive protein follow-up. Osseous union and recurred infection available at a minimum of 2 years following operation was identified. The amount of kyphosis correction and the subsidence were measured radiographically.
Spinal fusion was achieved in 29 of 33 patients. In the cadaveric allograft group, 93.3% of patient (14 of 15) showed the osseous union while 83.3% of patient (15 of 18) in the titanium cage group showed union. Subsidence was noted in 12 of the patients. Twelve patients (36.3%) showed unsettling amounts of subsidence postoperatively whereas 46.6% of patients in the cadaveric allograft group and 37.7% of patients in the titanium cage group showed similar subsidence, respectively. There were statistical difference in the fusion rate (p=0.397) and subsidence rate (p=0.276) between the two groups. There was significant statistical difference in the postoperative improvement of segmental kyphosis between the two groups (p=0.022), that is the improvement in sagittal alignment was greater in the titanium cage group than in the cadaveric allograft group. There was no case of recurred infection.
The cadaveric allograft and titanium cages are effective and safe in restoring and maintaining sagittal plane alignment without increased incidence in infection recurrence in pyogenic osteomyelitis. The postoperative improvement of segmental kyphosis was better in the cage group.
PMCID: PMC3243839  PMID: 22200018
Allograft; Fusion; Spinal infection; Titanium cage
11.  Clinical application of the paraspinal erector approach for spinal canal decompression in upper lumber burst fractures 
Percutaneous pedicle screw fixation is commonly used for upper lumber burst fractures. The direct decompression remains challenging with this minimally invasive surgery. The objective was to evaluate a novel paraspinal erector approach for effective and direct decompression in patients with canal compromise and neurologic deficit.
Patients (n = 21) with neurological deficiency and Denis B type upper lumbar burst fracture were enrolled in the study, including 14 cases in the L1 and 7 cases in the L2. The patients underwent removal of bone fragments from the spinal canal through intervertebral foramen followed by short-segment fixation. Evaluations included surgery-related, such as duration of surgery and blood loss, and 12-month follow-up, such as the kyphotic angle, the height ratio of the anterior edge of the vertebra, the ratio of sagittal canal compromise, visual analog scale (VAS), Oswestry Disability Index (ODI), and Frankel scores.
All patients achieved direct spinal canal decompression using the paraspinal erector approach followed by percutaneous pedicle screw fixation. The mean operation time (SD) was 173 (23) min, and the mean (SD) blood loss was 301 (104) ml. Significant improvement was noted in the kyphotic angle, 26.2 ± 8.7 prior to operation versus 9.1 ± 4.7 at 12 months after operation (p <0.05); the height ratio of the anterior edge of the injured vertebra, 60 ± 16% versus 84 ± 9% (p <0.05); and the ratio of sagittal canal compromise, 46.5 ± 11.4% versus 4.3 ± 3.6% (p <0.05). Significant improvements in VAS (7.3 ± 1.2 vs. 1.9 ± 0.7, p <0.05), ODI (86.7 ± 5.8 vs. 16.7 ± 5.1, p <0.05), and Frankel scores were also noted.
The paraspinal erector approach was effective for direct spinal canal decompression with minimal injury in the paraspinal muscles or spine. Significant improvements in spinal function and prognostics were achieved after the percutaneous pedicle screw fixation.
PMCID: PMC4240844  PMID: 25387608
Erector spinae; Direct spinal canal decompression; Minimally invasive spine surgery; Surgical approach; Upper lumber burst fractures
12.  Posterior Direct Decompression and Fusion of the Lower Thoracic and Lumbar Fractures with Neurological Deficit 
Asian Spine Journal  2011;5(3):146-154.
Study Design
A retrospective study.
To analyze the treatment outcome of patients with lower thoracic and lumbar fractures combined with neurological deficits.
Overview of Literature
Although various methods of the surgical treatment for lower thoracic and lumbar fractures are used, there has been no surgical treatment established as a superior option than others.
Between March 2001 and August 2009, this study enrolled 13 patients with lower thoracic and lumbar fractures who underwent spinal canal decompression by removing posteriorly displaced bony fragments via the posterior approach and who followed up for more than a year. We analyzed the difference between the preoperative and postoperative extents of canal encroachment, degrees of neurologic deficits and changes in the local kyphotic angle.
The average age of the patients was 37 years. There were 10 patients with unstable burst factures and 3 patients with translational injuries. Canal encroachment improved from preoperative average of 84% to 9% postoperatively. Local kyphosis also improved from 20.5° to 1.5°. In 92% (12/13) of the patients, neurologic deficit improved more than Frankel grade 1 and an average improvement of 1.7 grade was observed. Deterioration of neurologic symptoms was not observed. Although some loss of reduction of kyphotic deformity was observed at the final follow-up, serious complications were not observed.
When posteriorly displaced bony fragments were removed by the posterior approach, neurological recovery could be facilitated by adequate decompression without serious complications. The posterior direct decompression could be used as one of treatments for lower thoracic and lumbar fractures combined with neurologic injuries.
PMCID: PMC3159062  PMID: 21892386
Lower thoracic and lumbar; Unstable burst fracture; Posterior direct decompression; Neurologic manifestations
13.  Multiple revisions of a L2 burst fracture in a suicide jumper: a retrospective analysis of what went wrong 
European Spine Journal  2009;18(7):927-934.
A 35-year-old female patient sustained three contiguous vertebral fractures at the thoracolumbar junction while jumping off the third floor in a suicide attempt. Initial fracture treatment occurred in the setting of a multiple injury scenario. While the Th12 and the L1 vertebral fractures were considered stable, the L2 fracture exhibited a complete burst configuration with 80% canal compromise due to a posterior wall fragment causing paraplegia. A posterior pedicle screw stabilisation with indirect fracture reduction was carried out initially from T12 to L3. At 1 year follow-up the patient presented to us for new onset radiculopathy L2, and loss of correction. A circumferential revision surgery with an expandable cage was carried out to restore the anterior and posterior columns. Unfortunately again loss of reduction with kyphosis occurred, this time at the upper instrumented vertebra, which made another revision necessary. In this situation a longer construct was chosen using a combined approach and a Mesh cage. This later procedure was complicated by a postoperative paraparesis believed to be vascular in origin. Six months later a further complication involving MSSA deep wound infection required a series of irrigation debridement for healing. At the 2.5 years follow up the spine was stable and the patient had a neurologic recovery allowing her to ambulate with crutches. This Grand Round Case raises the question on the initial management of multiply injured patients with spine fracture, the classification of these fractures, the optimal initial internal fixation, the need for complementary anterior column reconstruction and the strategy when all these fails.
PMCID: PMC2899590  PMID: 19495813
14.  Patients With Cervical Metastasis and Neoplastic Pachymeningitis are Less Likely to Improve Neurologically After Surgery 
Although many patients with cervical spine metastases are treated surgically, it is unknown whether certain subsets achieve better pain relief and improvement of neurologic function.
(1) Does tumor removal with reconstruction improve the neurologic status? (2) Is any subset of patients more likely to have neurological recovery from palliative surgery? (3) What is the rate of surgery-related complications?
Patients and Methods
We retrospectively reviewed 46 patients who had palliative surgery for metastatic solid tumor metastases of the subaxial cervical spine. Indications were neurologic deficits, life expectancy longer than 6 months, and a Karnofsky Performance Score of 50 to 70. Surgery consisted of anterior tumor removal and reconstruction with titanium mesh cages and/or tricortical iliac crest allograft plus plate fixation or of a combined procedure with adjunctive posterior decompression and stabilization with lateral mass screw fixation. Postoperatively, neurologic Frankel score grade, Karnofsky Performance Score, and complications were recorded.
Five of 18 nonambulatory patients (Frankel B/C) became ambulatory again (Frankel D). No patients were Frankel Grade E preoperatively, whereas 19 of 46 gained Frankel Grade E after surgery. One patient worsened neurologically and died 4 months after surgery. Patients with neoplastic pachymeningitis had less neurologic recovery than those without. Complications included dural tears (three), wound infection (three), and tumor relapse at the same or an adjacent level (four). Two of these four patients had instrumentation-related complications.
Surgery improved clinical and neurologic status according to Frankel score; patients with neoplastic pachymeningitis are likely to experience less neurologic recovery.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3032852  PMID: 20945121
15.  Single-stage closing–opening wedge osteotomy of spine to correct severe post-tubercular kyphotic deformities of the spine: a 3-year follow-up of 17 patients 
European Spine Journal  2009;19(4):583-592.
The correction of severe post-tubercular kyphosis (PTK) is complex and has the disadvantage of being multiple staged with a high morbidity. Here, we describe the procedure and results of closing–opening osteotomy for correction of PTK which shortens the posterior column and opens the anterior column appropriately to correct the deformity without altering the length of the spinal cord. Seventeen patients with PTK (10 males; 7 females) with an average age of 18.3 ± 10.6 years (range 4–40 years) formed the study group. There were ten thoracolumbar, one lumbar and six thoracic deformities. The number of vertebrae involved ranged from 2 to 5 (average 2.8). Preoperative kyphosis averaged 69.2° ± 25.1° (range 42°–104°) which included ten patients with deformity greater than 60°. The average vertebral body loss was 2.01 ± 0.79 (range 1.1–4.1). The neurological status was normal in 13 patients, Frankel’s grade D in three patients and grade C in one. Posterior stabilization with pedicle screw instrumentation was followed by a preoperatively calculated wedge resection. Anterior column reconstruction was performed using rib grafts in four, tricortical iliac bone graft in five, cages in six, and bone chips alone and fibular graft in one patient each. Average operating time was 280 min (200–340 min) with an average blood loss of 820 ml (range 500–1,600 ml). The postoperative kyphosis averaged 32.4° ± 19.5° (range 8°–62°). The percentage correction of kyphosis achieved was 56.8 ± 14.6% (range 32–83%). No patient with normal preoperative neurological status showed deterioration in neurology after surgery. The last follow-up was at an average of 43 ± 4 months (range 32–64 months). The average loss of correction at the last follow-up was 5.4° (range 3°–9°). At the last follow-up, the mean preoperative pain visual analogue scale score decreased significantly from 9.2 (range 8–10 points) to 1.5 (range 1–2 points). There was also a significant decrease in mean preoperative Oswestry’s Disability Index from 56.4 (range 46–68) to 10.6 (range 6–15). Complications were superficial wound infections in two, neurological deterioration in one, temporary jaundice in one and implant failure requiring revision in one. Single-stage closing–opening wedge osteotomy is an effective method to correct severe PTK. The procedure has the advantage of being a posterior only, single-stage correction, which allows for significant correction with minimal complications.
PMCID: PMC2899834  PMID: 20013004
Tuberculosis; Kyphosis; Closing–opening wedge; Osteotomy
16.  Study of Vertebral Body Replacement with Reconstruction Spinal Cages in Dorsolumbar Traumatic and Koch's Spine 
Asian Spine Journal  2014;8(6):786-792.
Study Design
Retrospective and prospective case series.
The aim of this study was to assess the results of reconstruction of anterior column, fusion and complications related to cages.
Overview of Literature
Literature shows that corpectomy has become a common surgical procedure for spinal infection, trauma, deformity, instability and metastasis. Also the use of reconstructive spinal cages is common after corpectomy.
Study was carried out in patients with dorsolumbar traumatic and Koch's spine. We assessed 25 patients (13 traumatic/12 tuberculous) who were treated with cages with/without any other instrumentation. Radiographs were obtained before and after the surgery. A preoperative magnetic resonance imaging was obtained in every patient.
Fourteen patients underwent 1 level of corpectomy, 9 patients underwent 2 levels and 2 patients underwent 3 levels of corpectomy. Anterior reconstruction alone was performed in 8 patients; 360° reconstruction was performed in 17 patients and 2 of them underwent reconstruction through single posterior approach only. The mean kyphotic angulation improved from 21.2° preoperatively to 9.3° postoperatively and to 12° at final follow up. 8 patients with neurological deficits had improvement by at least one or more Frankel grade. No migration/displacement of cage was seen in any patients.
The present study demonstrates that the vertebral body replacement after corpectomy by reconstructive cages provides a reconstruction of the anterior column, good correction of the mean kyphotic angle, and a correction maintained with cage without any cage related complication at long term follow up. The fusion can be achieved with reconstructive cage plus bone graft with or without posterior instrumentation.
PMCID: PMC4278984  PMID: 25558321
Spinal fusion; Reconstructive surgical procedure; Autografts; Spinal Injuries; Tuberculosis, spinal; Tuberculosis, multi drug resistant
17.  Is Titanium Mesh Cage Safe in Surgical Management of Pyogenic Spondylitis? 
To report our experience with pyogenic spondylitis treated with anterior radical debridement and insertion of a titanium mesh cage and to demonstrate the effectiveness and safety of the use of a titanium mesh cage in the surgical management of pyogenic spondylitis.
We retrospectively analyzed the clinical characteristics of 19 patients who underwent surgical treatment in our department between January 2004 and December 2008. The average follow-up period was 11.16 months (range, 6-64 months). We evaluated risk factors, cultured organisms, lab data, clinical outcomes, and radiographic results. Surgical techniques for patients with pyogenic spondylitis were anterior radical debridement and reconstruction with titanium mesh cage insertion and screw fixation. All patients received intravenous antibiotics for at least 6 weeks postoperatively, and some patients received oral antibiotics.
The infections resolved in all of the patients as noted by normalization of their erythrocyte sedimentation rates and C-reactive protein levels. The mean pain score on a Visual Analog Scale was 7.8 (range, 4-10) before surgery and 2.4 (range, 1-5) after surgery. The Frankel grade was improved by one grade in seven patients. After surgery, the average difference of the angle was improved about 6.96° in all patients. At the last follow-up, the mean loss of correction was 4.86°.
Anterior radical debridement followed by the placement of instrumentation with a titanium mesh cage may be a safe and effective treatment for selected patients with pyogenic spondylitis. This surgical therapy does not lead to recurrent pyogenic spondylitis.
PMCID: PMC3243840  PMID: 22200019
Pyogenic spondylitis; Corpectomy; Titanium
18.  Anterior Dislodgement of a Fusion Cage after Transforaminal Lumbar Interbody Fusion for the Treatment of Isthmic Spondylolisthesis 
Transforaminal lumbar interbody fusion (TLIF) is commonly used procedure for spinal fusion. However, there are no reports describing anterior cage dislodgement after surgery. This report is a rare case of anterior dislodgement of fusion cage after TLIF for the treatment of isthmic spondylolisthesis with lumbosacral transitional vertebra (LSTV). A 51-year-old man underwent TLIF at L4-5 with posterior instrumentation for the treatment of grade 1 isthmic spondylolisthesis with LSTV. At 7 weeks postoperatively, imaging studies demonstrated that banana-shaped cage migrated anteriorly and anterolisthesis recurred at the index level with pseudoarthrosis. The cage was removed and exchanged by new cage through anterior approach, and screws were replaced with larger size ones and cement augmentation was added. At postoperative 2 days of revision surgery, computed tomography (CT) showed fracture on lateral pedicle and body wall of L5 vertebra. He underwent surgery again for paraspinal decompression at L4-5 and extension of instrumentation to S1 vertebra. His back and leg pains improved significantly after final revision surgery and symptom relief was maintained during follow-up period. At 6 months follow-up, CT images showed solid fusion at L4-5 level. Careful cage selection for TLIF must be done for treatment of spondylolisthesis accompanied with deformed LSTV, especially when reduction will be attempted. Banana-shaped cage should be positioned anteriorly, but anterior dislodgement of cage and reduction failure may occur in case of a highly unstable spine. Revision surgery for the treatment of an anteriorly dislodged cage may be effectively performed using an anterior approach.
PMCID: PMC3809439  PMID: 24175028
Cage; Transforaminal lumbar interbody fusion; Spondylolisthesis; Lumbosacral spine; Transitional vertebra
19.  Outcome of single level instrumented posterior lumbar interbody fusion using corticocancellous laminectomy bone chips 
Indian Journal of Orthopaedics  2011;45(6):500-503.
Interbody fusion surgery has been considered by many to be a treatment of choice for instability in lumbar degenerative disc disease. A posterior lumbar interbody fusion (PLIF) has the advantages of spinal canal decompression, anterior column reconstruction, and reduction of the sagittal slips from a single posterior approach. The PLIF using double cage was a standard practice till many studies reported comparable results and lesser complications with single cage. Iliac crest was considered as an appropriate source of bone graft until comparable spinal fusion rates using local bone graft and cage emerged. Till date, there has been no report of corticocancellous laminectomy bone chips alone being used for spinal fusion. In this paper, we present radiologic results of single level instrumented PLIF, where in only corticocancellous laminectomy bone chips were used as a fusion device.
Materials and Methods:
It is a retrospective cohort study of 35 consecutive patients, who underwent single level instrumented PLIF surgery, wherein only locally obtained bone chips was used for spinal fusion. The average follow-up was 26 months. The indications for the surgery were as follows: 19 patients had disc herniations, with back pain of instability type, normal disc height on radiology. Ten patients had grade 1 spondylolisthesis, with significant back pain and translational instability on radiography. Three patients were redo spine surgeries, and three patients had healed spondylodiscitis with significant back pain and instability. All patients were regularly followed up and decision of spinal fusion or no fusion was taken at 2 years using modified criteria of Lee.
Of total 35 patients, there were 24 males and 11 females, with a mean age of 41 years. There were 16 patients with definitive fusion, 15 patients with probable fusion, 04 patients with possible pseudoarthrosis, and no patient had definitive pseudoarthrosis. The mean time for fusion to occur was 18 months. The average loss of disc height, over 2 year follow up, was only 3 mm in 8 patients. Three patients had a localized kyphosis of more than 3° at the fusion level. The average blood loss was 356 ml and average operating time was 150 min.
Corticocancellous laminectomy bone chips alone can be used as a means of spinal fusion in patients with single level instrumented PLIF. This has got a good fusion rate.
PMCID: PMC3227352  PMID: 22144741
Corticocancellous laminectomy bone chips; Interbody cage; posterior lumbar interbody fusion
20.  The Extended Posterior Circumferential Decompression Technique in the Management of Tubercular Spondylitis with and without Paraplegia 
Asian Spine Journal  2014;8(6):711-719.
Study Design
Retrospective clinical series.
To study the clinical, functional and radiological results of patients with tuberculous spondylitis with and without paraplegia, treated surgically using the "Extended Posterior Circumferential Decompression (EPCD)" technique.
Overview of Literature
With the increasing possibility of addressing all three columns by a single approach, posterior and posterolateral approaches are gaining acceptance. A single exposure for cases with neurological deficit and kyphotic deformity requiring circumferential decompression, anterior column reconstruction and posterior instrumentation is helpful.
Forty-one patients with dorsal/dorsolumbar/lumbar tubercular spondylitis who were operated using the EPCD approach between 2006 to 2009 were included. Postoperatively, patients were started on nine-month anti-tuberculous treatment. They were serially followed up to thirty-six months and both clinical measures (including pain, neurological status and ambulatory status) and radiological measures (including kyphotic angle correction, loss of correction and healing status) were used for assessment.
Disease-healing with bony fusion (interbody fusion) was seen in 97.5% of cases. Average deformity (kyphosis) correction was 54.6% in dorsal spine and 207.3% in lumbar spine. Corresponding loss of correction was 3.6 degrees in dorsal spine and 1.9 degrees in the lumbar spine. Neurological recovery in Frankel B and C paraplegia was 85.7% and 62.5%, respectively.
The EPCD approach permits all the advantages of a single or dual session anterior and posterior surgery, with significant benefits in terms of decreased operative time, reduced hospital stay and better kyphotic angle correction.
PMCID: PMC4278975  PMID: 25558312
Extended posterior approach; Circumferential spinal canal decompression; Kyphosis correction; Interbody fusion; Neurological recovery
21.  Operative treatment of 733 patients with acute thoracolumbar spinal injuries: comprehensive results from the second, prospective, internet-based multicenter study of the Spine Study Group of the German Association of Trauma Surgery 
European Spine Journal  2010;19(10):1657-1676.
The second, internet-based multicenter study (MCSII) of the Spine Study Group of the German Association of Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie) is a representative patient collection of acute traumatic thoracolumbar (T1–L5) injuries. The MCSII results are an update of those obtained with the first multicenter study (MCSI) more than a decade ago. The aim of the study was to assess and bring into focus: the (1) epidemiologic data, (2) surgical and radiological outcome, and (3) 2-year follow-up (FU) results of these injuries. According to the Magerl/AO classification, there were 424 (57.8%) compression fractures (A type), 178 (24.3%) distractions injuries (B type), and 131 (17.9%) rotational injuries (C type). B and C type injuries carried a higher risk for neurological deficits, concomitant injuries, and multiple vertebral fractures. The level of injury was located at the thoracolumbar junction (T11–L2) in 67.0% of the case. 380 (51.8%) patients were operated on by posterior stabilization and instrumentation alone (POSTERIOR), 34 (4.6%) had an anterior procedure (ANTERIOR), and 319 (43.5%) patients were treated with combined posteroanterior surgery (COMBINED). 65% of patients with thoracic (T1–T10) and 57% with lumbar spinal (L3–L5) injuries were treated with a single posterior approach (POSTERIOR). 47% of the patients with thoracolumbar junction (T11–L2) injuries were either operated from posterior or with a combined posterior–anterior surgery (COMBINED) each. Short angular stable implant systems have replaced conventional non-angular stable instrumentation systems to a large extent. The posttraumatic deformity was restored best with COMBINED surgery. T-spine injuries were accompanied by a higher number and more severe neurologic deficits than TL junction or L-spine injuries. At the same time T-spine injuries showed less potential for neurologic recovery especially in paraplegic (Frankel/AISA A) patients. 5% of all patients required revision surgery for perioperative complications. Follow-up data of 558 (76.1%) patients were available and collected during a 30-month period from 1 January 2004 until 31 May 2006. On average, a posterior implant removal was carried out in a total of 382 COMBINED and POSTERIOR patients 12 months after the initial surgery. On average, the rehabilitation process required 3–4 weeks of inpatient treatment, followed by another 4 months of outpatient therapy and was significantly shorter when compared with MCSI in the mid-1990s. From the time of injury until FU, 80 (60.6%) of 132 patients with initial neurological deficits improved at least one grade on the Frankel/ASIA Scale; 8 (1.3%) patients deteriorated. A higher recovery rate was observed for incomplete neurological injuries (73%) than complete neurological injuries (44%). Different surgical approaches did not have a significant influence on the neurologic recovery until FU. Nevertheless, neurological deficits are the most important factors for the functional outcome and prognosis of TL spinal injuries. POSTERIOR patients had a better functional and subjective outcome at FU than COMBINED patients. However, the posttraumatic radiological deformity was best corrected in COMBINED patients and showed significantly less residual kyphotic deformity (biseg GDW −3.8° COMBINED vs. −6.1° POSTERIOR) at FU (p = 0.005). The sagittal spinal alignment was better maintained when using vertebral body replacement implants (cages) in comparison to iliac strut grafts. Additional anterior plate systems did not have a significant influence on the radiological FU results. In conclusion, comprehensive data of a large patient population with acute thoracolumbar spinal injuries has been obtained and analyzed with this prospective internet-based multicenter study. Thus, updated results and the clinical outcome of the current operative treatment strategies in participating German and Austrian trauma centers have been presented. Nevertheless, it was not possible to answer all remaining questions to contradictory findings of the subjective, clinical outcome and corresponding radiological findings between different surgical subgroups. Randomized-controlled long-term investigations seem mandatory and the next step in future clinical research of Spine Study Group of the German Trauma Society.
PMCID: PMC2989217  PMID: 20499114
Spinal injuries; Fracture; Treatment; Spine; Prospective; Multicenter study; Online database; Epidemiology; Complications; Spine Study Group (SSG) of the German Association of Trauma Surgery (DGU); Radiological findings; Follow-up; Rehabilitation; Activities of daily living; Outcome
22.  Cage subsidence does not, but cervical lordosis improvement does affect the long-term results of anterior cervical fusion with stand-alone cage for degenerative cervical disc disease: a retrospective study 
European Spine Journal  2011;21(7):1374-1382.
Clinical outcomes of the stand-alone cage have been encouraging when used in anterior cervical discectomy and fusion (ACDF), but concerns remain regarding its complications, especially cage subsidence. This retrospective study was undertaken to investigate the long-term radiological and clinical outcomes of the stand-alone titanium cage and to evaluate the incidence of cage subsidence in relation to the clinical outcome in the surgical treatment of degenerative cervical disc disease.
A total of 57 consecutive patients (68 levels) who underwent ACDF using a titanium box cage for the treatment of cervical radiculopathy and/or myelopathy were reviewed for the radiological and clinical outcomes. They were followed for at least 5 years. Radiographs were obtained before and after surgery, 3 months postoperatively, and at the final follow-up to determine the presence of fusion and cage subsidence. The Cobb angle of C2–C7 and the vertebral bodies adjacent to the treated disc were measured to evaluate the cervical sagittal alignment and local lordosis. The disc height was measured as well. The clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) score for cervical myelopathy, before and after surgery, and at the final follow-up. The recovery rate of JOA score was also calculated. The Visual Analogue Scale (VAS) score of neck and radicular pain were evaluated as well. The fusion rate was 95.6% (65/68) 3 months after surgery.
Successful bone fusion was achieved in all patients at the final follow-up. Cage subsidence occurred in 13 cages (19.1%) at 3-month follow-up; however, there was no relation between fusion and cage subsidence. Cervical and local lordosis improved after surgery, with the improvement preserved at the final follow-up. The preoperative disc height of both subsidence and non-subsidence patients was similar; however, postoperative posterior disc height (PDH) of subsidence group was significantly greater than of non-subsidence group. Significant improvement of the JOA score was noted immediately after surgery and at the final follow-up. There was no significant difference of the recovery rate of JOA score between subsidence and non-subsidence groups. The recovery rate of JOA score was significantly related to the improvement of the C2–C7 Cobb angle. The VAS score regarding neck and radicular pain was significantly improved after surgery and at the final follow-up. There was no significant difference of the neck and radicular pain between both subsidence and non-subsidence groups.
The results suggest that the clinical and radiological outcomes of the stand-alone titanium box cage for the surgical treatment of one- or two-level degenerative cervical disc disease are satisfactory. Cage subsidence does not exert significant impact upon the long-term clinical outcome although it is common for the stand-alone cages. The cervical lordosis may be more important for the long-term clinical outcome than cage subsidence
PMCID: PMC3389116  PMID: 22205113
Anterior cervical discectomy and fusion; Stand-alone cage; Cervical spine; Complication; Subsidence; Cervical alignment
23.  Anterolateral Corrective Lumbar Corpectomy and Interbody Fusion by Using Extended Screw Fixation without Posterior Instrumentation for Posttraumatic Kyphosis 
Case Reports in Orthopedics  2013;2013:614757.
A 26-year-old paraplegic schizophrenic Japanese woman suffered from severe kyphosis and back pain derived from lumbar burst fractures caused by jumping. She had already undergone resection of the L1 and L2 spinous processes for sharp angular kyphosis, but she still had severe kyphosis and back pain at the L1 and L2. Radiographical examination revealed fused anterior columns at L1 and L2 with severe local kyphosis and a significantly decreased percutaneous distance in the back. The patient underwent anterior instrumented bony resection including an L2 vertebral osteotomy: bilateral L2-L3 facetectomy and partial posterior osteotomy of the L2 vertebrae via a posterior approach followed by an anterior corpectomy of the L2 vertebrae and insertion of a cylindrical cage. No posterior instrumentation was used owing to the presence of atrophied paraspinal soft tissues. Lumbar interbody fusion was performed with vertebral body screws extending from T12 to L4 and corresponding anterior distension and posterior compression. The procedure corrected the kyphosis by 15° and enhanced local stability. Postsurgical visual analogue scale improved from 9.0 to 2.0 and Oswestry Disability Index from 40 to 17.8, respectively. In conclusion, we have demonstrated that anterolateral interbody fusion using extended fixation can compensate for posterior corrective surgery.
PMCID: PMC3732620  PMID: 23970987
24.  Posterior instrumented fusion without neural decompression for incomplete neurological deficits following vertebral collapse in the osteoporotic thoracolumbar spine 
European Spine Journal  2008;18(1):69-76.
Previous reports have emphasized the importance of neural decompression through either an anterior or posterior approach when reconstruction surgery is performed for neurological deficits following vertebral collapse in the osteoporotic thoracolumbar spine. However, the contribution of these decompression procedures to neurological recovery has not been fully established. In the present study, we investigated 14 consecutive patients who had incomplete neurological deficits following vertebral collapse in the osteoporotic thoracolumbar spine and underwent posterior instrumented fusion without neural decompression. They were radiographically and neurologically assessed during an average follow-up period of 25 months. The mean local kyphosis angle was 14.6° at flexion and 4.1° at extension preoperatively, indicating marked instability at the collapsed vertebrae. The mean spinal canal occupation by bone fragments was 21%. After surgery, solid bony fusion was obtained in all patients. The mean local kyphosis angle became 5.8° immediately after surgery and 9.9° at the final follow-up. There was no implant dislodgement, and no additional surgery was required. In all patients, back pain was relieved, and neurological improvement was obtained by at least one modified Frankel grade. The present series demonstrate that the posterior instrumented fusion without neural decompression for incomplete neurological deficits following vertebral collapse in the osteoporotic thoracolumbar spine can provide neurological improvement and relief of back pain without major complications. We suggest that neural decompression is not essential for the treatment of neurological impairment due to osteoporotic vertebral collapse with dynamic mobility.
PMCID: PMC2615122  PMID: 19005689
Neurological deficit; Osteoporosis; Vertebral collapse; Thoracolumbar spine; Posterior fusion
25.  Posterior transpedicular approach with circumferential debridement and anterior reconstruction as a salvage procedure for symptomatic failed vertebroplasty 
Complications and failure of vertebroplasty, such as cement dislodgement, cement leakage, or spinal infection, usually result in spinal instability and neural element compression. Combined anterior and posterior approaches are the most common salvage procedure for symptomatic failed vertebroplasty. The purpose of this study is to evaluate the feasibility and efficacy of a single posterior approach technique for the treatment of patients with symptomatic failed vertebroplasty.
Ten patients with symptomatic failed vertebroplasty underwent circumferential debridement and anterior reconstruction surgery through a single-stage posterior transpedicular approach (PTA) from January 2009 to December 2011 at our institution. The differences of visual analog scale (VAS), neurologic status, and vertebral body reconstruction before and after surgery were recorded. The clinical outcomes of patients were categorized as excellent, good, fair, or poor based on modified Brodsky’s criteria.
The symptomatic failed vertebroplasty occurred between the T11 and L3 vertebrae with one- or two-level involvement. The average VAS score was 8.3 (range, 7 to 9) before surgery, significantly decreased to 3.2 (range, 2 to 4) after surgery (p < 0.01), and continued to decrease to 2.4 (range, 2 to 3) 1 year later (p < 0.01). The average correction of Cobb’s angle after surgery was 17.3° (range, 4° to 35°) (p < 0.01). The mean loss of Cobb’s angle correction after 1 year of follow-up was 2.7° (range, 0° to 5°). The average allograft subsidence at 1 year after surgery was 1 mm (range, 0 to 2). The neurologic status of Frankel’s scale significantly improved after surgery (p = 0.014) and at 1 year after surgery (p = 0.046). No one experienced severe complications such as deep wound infection or neurologic deterioration. All patients achieved good or excellent outcomes after surgery based on modified Brodsky’s criteria (p < 0.01).
Single-stage PTA surgery with circumferential debridement and anterior reconstruction technique provides good clinical outcomes and low complication rate, which can be considered as an alternative method to combined anterior and posterior approaches for patients with symptomatic failed vertebroplasty.
PMCID: PMC4332747
Cement dislodgement; Cement leakage; Failed vertebroplasty; Posterior transpedicular approach; Spinal infection

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