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1.  Complications in patients undergoing combined transforaminal lumbar interbody fusion and posterior instrumentation with deformity correction for degenerative scoliosis and spinal stenosis 
Utilization of the transforaminal lumbar interbody fusion (TLIF) approach for scoliosis offers the patients deformity correction and interbody fusion without the additional morbidity associated with more invasive reconstructive techniques. Published reports on complications associated with these surgical procedures are limited. The purpose of this study was to quantify the intra- and postoperative complications associated with the TLIF surgical approach in patients undergoing surgery for spinal stenosis and degenerative scoliosis correction.
This study included patients undergoing TLIF for degenerative scoliosis with neurogenic claudication and painful lumbar degenerative disc disease. The TLIF technique was performed along with posterior pedicle screw instrumentation. The average follow-up time was 30 months (range, 15–47).
A total of 29 patients with an average age of 65.9 years (range, 49–83) were evaluated. TLIFs were performed at 2.2 levels on average (range, 1–4) in addition to 6.0 (range, 4–9) levels of posterolateral instrumented fusion. The preoperative mean lumbar lordosis was 37.6° (range, 16°–55°) compared to 40.5° (range, 26°–59.2°) postoperatively. The preoperative mean coronal Cobb angle was 32.3° (range, 15°–55°) compared to 15.4° (range, 1°–49°) postoperatively. The mean operative time was 528 min (range, 276–906), estimated blood loss was 1091.7 mL (range, 150–2500), and hospitalization time was 8.0 days (range, 3–28). A baseline mean Visual Analog Scale (VAS) score of 7.6 (range, 4–10) decreased to 3.6 (range, 0–8) postoperatively. There were a total of 14 (49%) hardware and/or surgical technique related complications, and 8 (28%) patients required additional surgeries. Five (17%) patients developed pseudoarthrosis. The systemic complications (31%) included death (1), cardiopulmonary arrest with resuscitation (1), myocardial infarction (1), pneumonia (5), and pulmonary embolism (1).
This study suggests that although the TLIF approach is a feasible and effective method to treat degenerative adult scoliosis, it is associated with a high rate of intra- and postoperative complications and a long recovery process.
PMCID: PMC3307239  PMID: 22439116
Adult scoliosis; complications; degenerative spine; lumbar stenosis; transforaminal lumbar interbody fusion
2.  Is Circumferential Minimally Invasive Surgery Effective in the Treatment of Moderate Adult Idiopathic Scoliosis? 
Outcomes for minimally invasive scoliosis correction surgery have been reported for mild adult scoliosis. Larger curves historically have been treated with open surgical procedures including facet resections or posterior column osteotomies, which have been associated with high-volume blood loss. Further, minimally invasive techniques have been largely reported in the setting of degenerative scoliosis.
We describe the effects of circumferential minimally invasive surgery (cMIS) for moderate to severe scoliosis in terms of (1) operative time and blood loss, (2) overall health and disease-specific patient-reported outcomes, (3) deformity correction and fusion rate, and (4) frequency and types of complications.
Between January 2007 and January 2012, we performed 50 cMIS adult idiopathic scoliosis corrections in patients with a Cobb angle of greater than 30° but less than 75° who did not have prior thoracolumbar fusion surgery; this series represented all patients we treated surgically during that time meeting those indications. Our general indications for this approach during that period were increasing back pain unresponsive to nonoperative therapy with cosmetic and radiographic worsening of curves. Surgical times and estimated blood loss were recorded. Functional clinical outcomes including VAS pain score, Oswestry Disability Index (ODI), and SF-36 were recorded preoperatively and postoperatively. Patients’ deformity correction was assessed on pre- and postoperative 36-inch (91-cm) standing films and fusion was assessed on CT scan. Minimum followup was 24 months (mean, 48 months; range, 24–77 months).
Mean blood loss was 613 mL for one-stage surgery and 763 mL for two-stage surgery. Mean operative time was 351 minutes for one-stage surgery and 482 minutes for two-stage surgery. At last followup, mean VAS and ODI scores decreased from 5.7 and 44 preoperatively to 2.9 and 22 (p < 0.001 and 0.03, respectively) and mean SF-36 score increased from 48 preoperatively to 74 (p = 0.026). Mean Cobb angle and sagittal vertical axis decreased from 42° and 51 mm preoperatively to 16° and 27 mm postoperatively (both p < 0.001). An 88% fusion rate was confirmed on CT scan. Perioperative complications occurred in 11 of the 50 patients (22%), with delayed complications needing further surgery in 10 more patients at last followup.
cMIS provides for good clinical and radiographic outcomes for moderate (30°–75°) adult idiopathic scoliosis. Patients undergoing cMIS should be carefully selected to avoid fixed, rigid deformities and a preoperative sagittal vertical axis of greater than 10 cm; surgeons should consider alternative techniques in those patients.
Level of Evidence
Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
PMCID: PMC4016423  PMID: 24658900
3.  Is the Lateral Transpsoas Approach Feasible for the Treatment of Adult Degenerative Scoliosis? 
Lumbar degenerative scoliosis is a common condition in the elderly. Open traditional surgical approaches are associated with high-morbidity complication rates. Less invasive options may carry fewer risks in this patient population. A minimally disruptive lateral transpsoas retroperitoneal technique to accomplish interbody fusion was developed to avoid the morbidity of traditional open surgery, but this approach as an anterior stand-alone construction has not been reported yet for the treatment of adult degenerative scoliosis.
We determined (1) the clinical outcomes (VAS scores for back and leg, Oswestry Disability Index), (2) the radiographic outcomes (Cobb angle, lumbar lordosis, sacral slope, high-grade subsidence, osseous fusion), and (3) the reoperation and complication rates in an older population undergoing this surgical approach.
Between 2004 and 2008, 62 patients were treated surgically for adult degenerative scoliosis, of whom 46 (74%) were treated with stand-alone lateral lumbar interbody fusion; 11 of these (24%) were lost to followup before 24 months, leaving the records of 35 patients (nine men, 26 women; mean ± SD age, 68 ± 10 years) available for this retrospective review. General indications for this approach included neurogenic claudication and radicular symptoms with history of chronic low-back pain. A total of 107 levels were treated (mean, three; range, one to seven). Clinical and radiographic outcomes were assessed at a followup of 24 months.
Mean VAS back pain scores improved from 85 mm preoperatively to 27 mm at latest followup (p < 0.001). VAS leg pain scores improved from 91 mm to 24 mm (p < 0.001). Oswestry Disability Index scores improved from 51 to 29 (p < 0.001). Coronal alignment improved from Cobb angles of 21° to 12° (p < 0.001). Lumbar lordosis improved from 33° to 41° (p < 0.001). Sacral slope was enhanced from 28° to 35° (p < 0.001). Fusion rate was 84% at final evaluation. High-grade subsidence was seen in 10 patients (29%). Three patients (9%) needed further surgical intervention.
Use of the lateral approach achieved reasonable coronal and sagittal correction, as well as improvements in pain and function, in mild scoliotic deformities; however, subsidence was a concern, occurring in 29% of patients. Questions still remain regarding the need for additional supplementation or the use of wider cages to prevent subsidence.
Level of Evidence
Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
PMCID: PMC4016469  PMID: 23996097
4.  Natural history of the aging spine 
European Spine Journal  2003;12(Suppl 2):S86-S89.
The unrelenting changes associated with aging progressively affects all structures of the spinal units. The degenerative process starts early during the first decade of life at the disc level. Discal degeneration is associated with biochemical changes followed by macroscopic alterations including tears and fissures, which may lead to discal herniation, the main cause of radiculopathy in the young adult. Moreover, nociceptive nerve fibers have been demonstrated in degenerated discs. They may be a source of nociception and of pure low-back pain. Facet joint changes are usually secondary to discal degeneration. They include subluxation, cartilage alteration and osteophytosis. Facet hypertrophy and laxity, associated with discal degeneration, and enlargement of the ligamentum flavum progressively create narrowing of the spinal canal as well as degenerative instabilities such as spondylolisthesis and scoliosis, which are the main causes of neurogenic claudication and radiculopathy in old persons. Vertebral bodies are the static elements of the spinal unit. With advancing age, osteoporosis weakens the bony structures and facilitates bone remodeling and rotatory deformities. Finally, aging of bone, discs, facets, ligaments, and muscles may ultimately lead to rotatory scoliosis, destabilization, and rupture of equilibrium.
PMCID: PMC3591827  PMID: 12961079
Lumbar disc degeneration; Age-related intervertebral changes; Disc herniation; Stenosis; Low-back pain
5.  Endoscopic Foraminal Decompression for Failed Back Surgery Syndrome under local Anesthesia 
The most common causes of failed back surgery are residual or recurrent herniation, foraminal fibrosis and foraminal stenosis that is ignored, untreated, or undertreated. Residual back ache may also be from facetal causes or denervation and scarring of the paraspinal muscles.1–6 The original surgeon may advise his patient that nothing more can be done on the basis of his opinion that the nerve was visually decompressed by the original surgery, supported by improved post-op imaging and follow-up studies such as EMG and conduction velocity studies. Post-op imaging or electrophysiological assessment may be inadequate to explain all the reasons for residual or recurrent symptoms. Treatment of Failed back surgery by repeat traditional open revision surgery usually incorporates more extensive decompression causing increased instability and back pain, therefore necessitating fusion. The authors, having limited their practice to endoscopic MIS surgery over the last 15-20 years, report on their experience gained during that period to relieve pain by endoscopically visualizing and treating unrecognized causative patho-anatomy in FBSS.7
Thirty consecutive patients with FBSS presenting with back and leg pain that had supporting imaging diagnosis of lateral stenosis and /or residual / recurrent disc herniation, or whose pain complaint was supported by relief from diagnostic and therapeutic injections (Figure 1), were offered percutaneous transforaminal endoscopic discectomy and foraminoplasty over a repeat open procedure. Each patient sought consultation following a transient successful, partially successful or unsuccessful open translaminar surgical treatment for disc herniation or spinal stenosis. Endoscopic foraminoplasty was also performed to either decompress the bony foramen for foraminal stenosis, or foraminoplasty to allow for endoscopic visual examination of the affected traversing and exiting nerve roots in the axilla, also known as the “hidden zone” of Macnab (Figure 2).8, 9 The average follow up time was, average 40 months, minimum 12 months. Outcome data at each visit included Macnab, VAS and ODI.
A diagnostic and therapeutic epidural gram may help identify unrecognized lateral recess stenosis underestimated by MRI. An excellent result from a therapeutic block lends excellent prognosis for a more lasting and “permanent” result from transforaminal endoscopic lateral recess decompression.
Kambin's Triangle provides access to the “hidden zone” of Macnab by foraminoplasty. The foramen and lateral recess is decompressed by removing the ventral aspect and tip of the superior articular process to gain access to the axilla between the traversing and exiting nerve. FBSS contains patho-anatomy in the axilla between the traversing and exiting nerve that hides the pain generators of FBSS.
The average pre-operative VAS improved from 7.2 to 4.0, and ODI 48% to 31%. While temporary dysesthesia occurred in 4 patients in the early post-operative period, all were happy, as all received additional relief of their pre-op symptoms. They were also relieved to be able to avoid “open” decompression or fusion surgery.
Conclusions / Level of Evidence 3
The transforaminal endoscopic approach is effective for FBSS due to residual/recurrent HNP and lateral stenosis. Failed initial index surgery may involve failure to recognize patho-anatomy in the axilla of the foramen housing the traversing and the exiting nerve, including the DRG, which is located cephalad and near the tip of SAP.10 The transforaminal endoscopic approach effectively decompresses the foramen and does not further destabilize the spine needing stabilization.11 It also avoids going through the previous surgical site.
Clinical Relevance
Disc narrowing as a consequence of translaminar discectomy and progressive degenerative narrowing and spondylolisthesis (Figure 3) as a natural history of degenerative disc disease can lead to central and lateral stenosis. The MRI may underestimate the degree of stenosis from a bulging or a foraminal disc protrusion and residual lateral recess stenosis. Pain can be diagnosed and confirmed by evocative discography and by clinical response to transforaminal diagnostic and therapeutic steroid injections.12 Foraminal endoscopic decompression of the lateral recess is a MIS technique that does not “burn bridges” for a more conventional approach and it adds to the surgical armamentarium of FBSS.
Cadaver Illustration of Foraminal Stenosis (courtesy of Wolfgang Rauschning). As the disc narrows, the superior articular process impinges on the exiting nerve and DRG, creating lateral recess stenosis, lumbar spondylosis, and facet arthrosis.
PMCID: PMC4325507  PMID: 25694939
Failed Back Surgery Syndrome(FBSS); Hidden zone; Foraminal decompression; Recurrent herniation; Lateral stenosis; Foraminal osteophyte
6.  Evaluation of operation outcomes in patients with degenerative lumbar scoliosis 
Journal of Injury and Violence Research  2012;4(3 Suppl 1): Paper No. 7.
Due to the increase of life expectancy, the prevalence of degenerative spine diseases such as adult degenerative lumbar scoliosis (ADLS) has been increasingly more than before which is required appropriate control and management. Therefore, the present study was aimed to survey the result of surgery in ADLS patients in Shiraz (Iran).
This is a preliminary report of 30 patients with ADLS who underwent pedicular screw fixation, posterolateral fusion, posterior decompression and correction of coronal plane deformity operation according to surgical indications in the Chamran and Kowsar hospitals during 2009-2011. The patients were followed up at 1, 6 and 12 months post operation. Radiologic changes were evaluated and the Oswestry low back pain disability (OLBP) scale and visual analogue scale (VAS) were used to evaluate functional and pain improvement, respectively. Data were analyzed using SPSS software version 15. We used Wilcoxon signed-rank test to compare the parameters of pain and LBP scale.
Primary analysis showed that 42.9% of operated patients were in 50-60 years age group. 71% of the patients were female and 29% were male. Prevalence of LBP from radicular pain among the patients was 95.2%. There was a significant difference between pre-operation and post-operation VAS and Oswestry LBP scale (P less than 0.001).
Our findings showed that posterior decompression combined with pedicular fixation, posterolateral fusion and correction of coronal plane deformity seems to be a suitable method for the relief of pain and improvement of function in ADLS patients. Only decompression can relieve low back pain but for the relief of radicular pain and correction of deformity, fixation and fusion are recommended.
Scoliosis, Degenerative, Low back pain, Adult lumbar, Radicular pain
PMCID: PMC3571533
7.  High failure rate of the interspinous distraction device (X-Stop) for the treatment of lumbar spinal stenosis caused by degenerative spondylolisthesis 
European Spine Journal  2007;17(2):188-192.
The X-Stop interspinous distraction device has shown to be an attractive alternative to conventional surgical procedures in the treatment of symptomatic degenerative lumbar spinal stenosis. However, the effectiveness of the X-Stop in symptomatic degenerative lumbar spinal stenosis caused by degenerative spondylolisthesis is not known. A cohort of 12 consecutive patients with symptomatic lumbar spinal stenosis caused by degenerative spondylolisthesis were treated with the X-Stop interspinous distraction device. All patients had low back pain, neurogenic claudication and radiculopathy. Pre-operative radiographs revealed an average slip of 19.6%. MRI of the lumbosacral spine showed a severe stenosis. In ten patients, the X-Stop was placed at the L4–5 level, whereas two patients were treated at both, L3–4 and L4–5 level. The mean follow-up was 30.3 months. In eight patients a complete relief of symptoms was observed post-operatively, whereas the remaining 4 patients experienced no relief of symptoms. Recurrence of pain, neurogenic claudication, and worsening of neurological symptoms was observed in three patients within 24 months. Post-operative radiographs and MRI did not show any changes in the percentage of slip or spinal dimensions. Finally, secondary surgical treatment by decompression with posterolateral fusion was performed in seven patients (58%) within 24 months. In conclusion, the X-Stop interspinous distraction device showed an extremely high failure rate, defined as surgical re-intervention, after short term follow-up in patients with spinal stenosis caused by degenerative spondylolisthesis. We do not recommend the X-Stop for the treatment of spinal stenosis complicating degenerative spondylolisthesis.
PMCID: PMC2226191  PMID: 17846801
Lumbar spinal stenosis; X-Stop; Degenerative spondylolisthesis
8.  High failure rate of the interspinous distraction device (X-Stop) for the treatment of lumbar spinal stenosis caused by degenerative spondylolisthesis 
European Spine Journal  2007;17(2):188-192.
The X-Stop interspinous distraction device has shown to be an attractive alternative to conventional surgical procedures in the treatment of symptomatic degenerative lumbar spinal stenosis. However, the effectiveness of the X-Stop in symptomatic degenerative lumbar spinal stenosis caused by degenerative spondylolisthesis is not known. A cohort of 12 consecutive patients with symptomatic lumbar spinal stenosis caused by degenerative spondylolisthesis were treated with the X-Stop interspinous distraction device. All patients had low back pain, neurogenic claudication and radiculopathy. Pre-operative radiographs revealed an average slip of 19.6%. MRI of the lumbosacral spine showed a severe stenosis. In ten patients, the X-Stop was placed at the L4–5 level, whereas two patients were treated at both, L3–4 and L4–5 level. The mean follow-up was 30.3 months. In eight patients a complete relief of symptoms was observed post-operatively, whereas the remaining 4 patients experienced no relief of symptoms. Recurrence of pain, neurogenic claudication, and worsening of neurological symptoms was observed in three patients within 24 months. Post-operative radiographs and MRI did not show any changes in the percentage of slip or spinal dimensions. Finally, secondary surgical treatment by decompression with posterolateral fusion was performed in seven patients (58%) within 24 months. In conclusion, the X-Stop interspinous distraction device showed an extremely high failure rate, defined as surgical re-intervention, after short term follow-up in patients with spinal stenosis caused by degenerative spondylolisthesis. We do not recommend the X-Stop for the treatment of spinal stenosis complicating degenerative spondylolisthesis.
PMCID: PMC2226191  PMID: 17846801
Lumbar spinal stenosis; X-Stop; Degenerative spondylolisthesis
9.  Surgical treatment of scoliosis in Rubinstein-Taybi syndrome type 2: a case report 
Rubinstein-Taybi syndrome is an autosomal dominant disorder resulting in congenital craniofacial deformities, and divided into types 1 and 2. Scoliosis has not been reported as one of the extra-cranial manifestations of Rubinstein-Taybi syndrome type 2.
Case presentation
We present a 14-year-old British Caucasian girl with Rubinstein-Taybi type 2 syndrome who developed a severe double thoracic scoliosis measuring 39° and 68° respectively. Her scoliosis was associated with thoracic hypokyphosis, causing a marked reduction in the anteroposterior diameter of her chest and consequent severe restrictive lung disease. The deformity was noted by her local pediatrician as part of a chest infection assessment when she was aged 13 years, and gradually progressed as the result of spinal growth. Our patient underwent a posterior spinal arthrodesis using a single concave pedicle hook and screw rod construct and locally harvested autologous graft supplemented by allograft bone. This spinal fixation technique was selected because of our patient’s low body weight to avoid prominence of the instrumentation causing skin healing problems and pain. Her scoliosis was corrected to 18° and 30° and we achieved a balanced spine in the coronal and sagittal planes. An underarm spinal jacket was provided for six months after surgery. During her latest follow-up at skeletal maturity, our patient had an excellent cosmetic outcome with no loss of deformity correction or detected pseudoarthrosis and a normal level of activities.
Scoliosis can develop in young children with Rubinstein-Taybi syndrome type 2, with the deformity deteriorating around the pubertal growth spurt. Surgical treatment can correct the deformity, balance the spine and prevent mechanical back pain. It can also stabilize the chest area and avoid respiratory complications developing as the scoliosis progresses, which can result in severe restrictive pulmonary disease. The use of single concave instrumentation is indicated in very slim patients with poor muscle bulk; in our patient, this produced satisfactory deformity correction and a favorable outcome at completion of growth. Peri-operative care in this group of patients can be very challenging because of associated co-morbidities as well as the presence of severe behavioral issues that result in poor patient compliance.
PMCID: PMC4334754  PMID: 25596810
Posterior spinal fusion; Rubinstein-Taybi syndrome; Scoliosis; Surgical treatment
10.  Spinaplasty following lumbar laminectomy for multilevel lumbar spinal stenosis to prevent iatrogenic instability 
Indian Journal of Orthopaedics  2011;45(5):396-403.
Iatrogenic instability following laminectomy occurs in patients with degenerative lumbar canal stenosis. Long segment fusions to obviate postoperative instability result in loss of motion of lumbar spine and predisposes to adjacent level degeneration. The best alternative would be an adequate decompressive laminectomy with a nonfusion technique of preserving the posterior ligament complex integrity. We report a retrospective analysis of multilevel lumbar canal stenosis that were operated for posterior decompression and underwent spinaplasty to preserve posterior ligament complex integrity for outcome of decompression and iatrogenic instability.
Materials and Methods:
610 patients of degenerative lumbar canal stenosis (n=520) and development spinal canal stenosis (n=90), with a mean age 58 years (33–85 years), underwent multilevel laminectomies and spinaplasty procedure. At followup, changes in the posture while walking, increase in the walking distance, improvement in the dysesthesia in lower limb, the motor power, capability to negotiate stairs and sphincter function were assessed. Forward excursion of vertebrae more than 4 mm in flexion–extension lateral X-ray of the spine as compared to the preoperative movements was considered as the iatrogenic instability. Clinical assessment was done in standing posture regarding active flexion–extension movement, lateral bending and rotations
All patients were followed up from 3 to 10 years. None of the patients had neurological deterioration or pain or catch while movement. Walking distance improved by 5–10 times, with marked relief (70–90%) in neurogenic claudication and preoperative stooping posture, with improvement in sensation and motor power. There was no significant difference in the sagittal alignment as well as anterior translation. Two patients with concomitant scoliosis and one with cauda equine syndrome had incomplete recovery. Two patients who developed disc protrusion, underwent a second operation for a symptomatic disc prolapse.
Spinaplasty following posterior decompression for multilevel lumbar canal stenosis is a simple operation, without any serious complications, retaining median structures, maintaining the tension band and the strength with least disturbance of kinematics, mobility, stability and lordosis of the lumbar spine.
PMCID: PMC3162674  PMID: 21886919
Decompression; laminectomies; lumbar canal stenosis; multilevel; posterior ligamentous complex; spinaplasty
11.  Cotrel–Dubousset instrumentation in neuromuscular scoliosis 
European Spine Journal  2011;20(Suppl 1):75-84.
The study design is retrospective. The aim is to describe our experience about the treatment of patients with neuromuscular scoliosis (NMS) using Cotrel–Dubousset instrumentation. Neuromuscular scoliosis are difficult deformities to treat. A careful assessment and an understanding of the primary disease and its prognosis are essential for planning treatment which is aimed at maximizing function. These patients may have pelvic obliquity, dislocation of the hip, limited balance or ability to sit, back pain, and, in some cases, a serious decrease in pulmonary function. Spinal deformity is difficult to control with a brace, and it may progress even after skeletal maturity has been reached. Surgery is the main stay of treatment for selected patients. The goals of surgery are to correct the deformity producing a balanced spine with a level pelvis and a solid spinal fusion to prevent or delay secondary respiratory complications. The instrumented spinal fusion (ISF) with second-generation instrumentation (e.g., Luque–Galveston and unit rod constructs), are until 1990s considered the gold standard surgical technique for neuromuscular scoliosis (NMS). Still in 2008 Tsirikos et al. said that “the Unit rod instrumentation is a common standard technique and the primary instrumentation system for the treatment of pediatric patients with cerebral palsy and neuromuscular scoliosis because it is simple to use, it is considerably less expensive than most other systems, and can achieve good deformity correction with a low loss of correction, as well as a low prevalence of associated complications and a low reoperation rate.” In spite of the Cotrel–Dubousset (CD) surgical technique, used since the beginning of the mid 1980s, being already considered the highest level achieved in correction of scoliosis by a posterior approach, Teli et al., in 2006, said that reports are lacking on the results of third-generation instrumentation for the treatment of NMS. Patients with neuromuscular disease and spinal deformity treated between 1984 and 2008 consecutively by the senior author (G.D.G.) with Cotrel–Dubousset instrumentation and minimum 36 months follow-up were reviewed, evaluating correction of coronal deformity, sagittal balance and pelvic obliquity, and rate of complications. 24 patients (Friedreich’s ataxia, 1; cerebral palsy, 14; muscular dystrophy, 2; polio, 2; syringomyelia, 3; spinal atrophy, 2) were included. According the evidence that the study period is too long (1984–2008) and that in more than 20 years many things changed in surgical strategy and techniques, all patients were divided in two groups: only hooks (8 patients) or hybrid construct (16 patients). Mean age was 18.1 years at surgery (range 11 years 7 months–max 31 years; in 17 cases the age at surgery time was between 10 and 20 years old; in 6 cases it was between 20 and 30 and only in 1 case was over 30 years old). Mean follow-up was 142 months (range 36–279). The most frequent patterns of scoliosis were thoracic (10 cases) and thoracolumbar (9 cases). In 8 cases we had hypokyphosis, in 6 normal kyphosis and in 9 hyperkyphosis. In 8 cases we had a normal lordosis, in 11 a hypolordosis and in 4 a hyperlordosis. In 1 case we had global T4–L4 kyphosis. In 8 cases there were also a thoracolumbar kyphosis (mean value 24°, min 20°–max 35°). The mean fusion area included 13 vertebrae (range 6–19); in 17 cases the upper end vertebra was over T4 and in 11 cases the lower end vertebra was over L4 or L5. In 7 cases the lower end vertebra was S1 to correct the pelvic obliquity. In 5 cases the severity of the deformity (mean Cobb’s angle 84.2°) imposed a preoperative halo traction treatment. There were 5 anteroposterior and 19 posterior-only procedures. In 10 cases, with low bone quality, the arthrodesis was performed using iliac grafting technique while in the other (14 cases) using autologous bone graft obtained in situ from vertebral arches and spinous processes (in all 7 cases with fusion extended until S1, it was augmented with calcium phosphate). The mean correction of coronal deformity and pelvic obliquity averaged, respectively, 57.2% (min 31.8%; max 84.8%) and 58.9% (mean value preoperative, 18.43°; mean value postoperative, 7.57°; mean value at last follow-up, 7.57°). The sagittal balance was always restored, reducing hypo or hyperkyphosis and hypo or hyperlordosis. Also in presence of a global kyphosis, we observed a very good restoration (preoperatory, 65°; postoperatory, 18° kyphosis and 30° lordosis, unmodified at last f.u.). The thoracolumbar kyphosis, when present (33.3% of our group) was always corrected to physiological values (mean 2°, min 0°–max 5°). The mean intraoperative blood lost were 2,100 cc (min 1,400, max 5,350). Major complications affected 8.3% of patients, and included 1 postoperative death and 1 deep infection. Minor complications affected none of patients. CD technique provides lasting correction of spinal deformity in patients with neuromuscular scoliosis, with a lower complications rate compared to reports on second-generation instrumented spinal fusion.
PMCID: PMC3087033  PMID: 21404030
Neuromuscular scoliosis; Cotrel–Dubousset; Spinal fusion
12.  Surgical Treatment of Adult Degenerative Scoliosis 
Asian Spine Journal  2014;8(3):371-381.
The rapid increase of elderly population has resulted in increased prevalence of adult scoliosis. Adult scoliosis is divided into adult idiopathic scoliosis and adult degenerative scoliosis. These two types of scoliosis vary in patient age, curve pattern and clinical symptoms, which necessitate different surgical indications and options. Back pain and deformity are major indications for surgery in adult idiopathic scoliosis, whereas radiating pain to the legs due to foraminal stenosis is what often requires surgery in adult degenerative scoliosis. When selecting a surgical method, major symptoms and underlying medical diseases should be carefully evaluated, not only to relieve symptoms but also to minimize postoperative complications. Surgical options for adult degenerative scoliosis include: decompression alone; decompression and limited short fusion; and decompression coupled with long fusion and correction of deformity. Decompression and limited short fusion can be applied to patients with a small Cobb's angle and normal sagittal imbalance. For those with a large Cobb's angle and positive sagittal imbalance, long fusion with correction of deformity is required. When long fusion is applied, a careful decision regarding the extent of fusion level should be made when selecting L5 or S1 as the distal fusion level and T10 or the thoracolumbar junction as the proximal fusion level. For the fusion extending to the sacrum, restoration of sagittal balance and rigid fixation with additional iliac screws should be considered. Any surgical procedures for adult degenerative scoliosis are known to have relatively high occurrences of complications; therefore, risks and benefits should be meticulously considered before selecting a surgical procedure.
PMCID: PMC4068860  PMID: 24967054
Osteoarthritis spine; Scoliosis; Lumbar vertebrae; Instrumentation; Postoperative complications
13.  Percutaneous Vertebroplasty in Adult Degenerative Scoliosis for Spine Support: Study for Pain Evaluation and Mobility Improvement 
BioMed Research International  2013;2013:626502.
We evaluate the efficacy-safety of percutaneous vertebroplasty (PV) as primary treatment in adult degenerative scoliosis. During the last 4 years, PV was performed in 18 adult patients (68 vertebral bodies) with back pain due to degenerative scoliotic spine. Under anaesthesia and fluoroscopy, direct access to most deformed vertebral bodies was obtained by 13G needles, and PMMA for vertebroplasty was injected. Scoliosis' inner arch was supported. Clinical evaluation included immediate and delayed studies of patient's general condition and neurological status. An NVS scale helped assessing pain relief, life quality, and mobility improvement. Comparing patients' scores prior to (mean value 8.06 ± 1.3 NVS units), the morning after (mean value 3.11 ± 1.2 NVS units), at 12 (mean value 1.67 ± 1.5 NVS units), and 24 months after vertebroplasty (mean value 1.67 ± 1.5 NVS units) treatment, patients presented a mean decrease of 6.39 ± 1.6 NVS units on terms of life quality improvement and pain relief (P = 0.000). Overall mobility improved in 18/18 (100%) patients. No complications were observed. During follow-up period (mean value 17.66 months), all patients underwent a mean of 1.3 sessions for facet joint and nerve root infiltrations. Percutaneous vertebroplasty in the inner arch seems to be an effective technique for supporting adult degenerative scoliotic spine.
PMCID: PMC3821888  PMID: 24260742
14.  Radiographic Progression of Degenerative Lumbar Scoliosis after Short Segment Decompression and Fusion 
Asian Spine Journal  2009;3(2):58-65.
Study Design
A retrospective study.
To assess the radiographic progression of degenerative lumbar scoliosis after short segment decompression and fusion without deformity correction.
Overview of Literature
The aims of surgery in degenerative lumbar scoliosis are the relief of low back and leg pain along with a correction of the deformity. Short segment decompression and fusion can be performed to decrease the level of low back and leg pain provided the patient is not indicated for a deformity correction due to medical problems. In such circumstance, the patients and surgeon should be concerned with whether the scoliotic angle increases postoperatively.
Forty-seven patients who had undergone short segment decompression and fusion were evaluated. The average follow-up period was more than 3 years. The preoperative scoliotic angle and number of fusion segments was 13.6±3.9° and 2.3±0.5, respectively. The preoperative, postoperative and last follow-up scoliotic angles were compared and the time of progression of scoliotic angle was determined.
The postoperative and last follow-up scoliotic angle was 10.4±2.3° and 12.1±3.6°, respectively. In eight patients, conversion to long segment fusion was required due to the rapid progression of the scoliotic angle that accelerated from 6 to 9 months after the primary surgery. The postoperative scoliosis aggravated rapidly when the preoperative scoliotic angle was larger and the fusion was extended to the apical vertebra.
The scoliotic angle after short segment decompression and fusion was not deteriorated seriously in degenerative lumbar scoliosis. A larger scoliotic angle and fusion to the apical vertebra are significant risk factors for the acceleration of degenerative lumbar scoliosis.
PMCID: PMC2852080  PMID: 20404949
Degenerative lumbar scoliosis; Short segment fusion; Radiographic progression
15.  Surgical treatment of scoliosis in Treacher Collins syndrome: a case report 
Treacher Collins syndrome is an autosomal dominant disorder resulting in congenital craniofacial deformities. Scoliosis has not been previously reported as one of the extracranial manifestations of this syndromic condition.
Case presentation
We present a 15-year-old British Caucasian girl with Treacher Collins syndrome who developed a severe double thoracic scoliosis measuring 102° and 63° respectively. The deformity was noted at age 14 years by the local general practitioner and gradually progressed until she was referred to our service and subsequently was scheduled for surgical correction. There were no congenital vertebral anomalies. As part of the condition, she had bilateral conductive hearing impairment. She also had reduced respiratory reserves and a restrictive lung disease. Both curves were rigid on supine maximum traction radiographs. She underwent a single-stage anterior and posterior spinal arthrodesis with pedicle hook/sublaminar wire/screw and rod instrumentation and autologous rib graft, supplemented by allograft bone and made a good postoperative recovery. Her scoliosis was corrected to 25° and 24° and a balanced spine in the coronal and sagittal planes was achieved. At latest follow-up beyond skeletal maturity (3 years post-surgery) she had an excellent cosmetic outcome with no loss of deformity correction, no detected pseudarthrosis and a normal level of activities.
Scoliosis can occur in patients with Treacher Collins syndrome with the deformity demonstrating significant deterioration around the adolescent growth spurt. A high index of awareness will allow for an early diagnosis and scoliosis correction at a stage when this can be safer and performed through a single-stage posterior procedure. If the deformity is detected at a later age and stage of growth as occurred in our patient, more complex surgery is required and this increases the risk for major morbidity and potential mortality. Surgical treatment can correct the deformity, balance the spine and restore cosmesis, as well as prevent mechanical back pain and respiratory complications if the scoliosis progressed to cause severe thoracic distortion. A thorough preoperative assessment can diagnose associated comorbidities and reduce the risk for postoperative complications.
PMCID: PMC4320598  PMID: 25524572
Posterior spinal fusion; Scoliosis; Surgical treatment; Treacher Collins syndrome
16.  Clinical and surgical outcomes after lumbar laminectomy: An analysis of 500 patients 
Surgical Neurology International  2015;6(Suppl 4):S190-S193.
The objective of this study is to determine the clinical and surgical outcomes following lumbar laminectomy.
We retrospectively reviewed medical records of neurosurgical patients who underwent first-time, bilateral, 1-3 level laminectomies for degenerative lumbar disease. Patients with discectomy, complete facetectomy, and fusion were excluded.
Five hundred patients were followed for an average of 46.79 months. Following lumbar laminectomy, patients experienced statistically significant improvement in back pain, neurogenic claudication, radiculopathy, weakness, and sensory deficits. The rate of intraoperative durotomy was 10.00%; however, 1.60% experienced a postoperative cerebrospinal fluid leak. The risk of experiencing at least one postoperative complication with a lumbar laminectomy was 5.60%. Seventy-two patients (14.40%) required reoperations for progression of degenerative disease over a mean of 3.40 years. The most common symptoms prior to reoperation included back pain (54.17%), radiculopathy (47.22%), weakness (18.06%), sensory deficit (15.28%), and neurogenic claudication (19.44%). The relative risk of reoperation for patients with postoperative back pain was 6.14 times higher than those without postoperative back pain (P < 0.001). Of the 72 patients undergoing reoperations, 55.56% underwent decompression alone, while 44.44% underwent decompression and posterolateral fusions. When considering all-time reoperations, the lifetime risk of requiring a fusion after a lumbar laminectomy based on this study (average follow-up of 46.79 months) was 8.0%.
Patients experienced statistically significant improvements in back pain, neurogenic claudication, radiculopathy, motor weakness, and sensory deficit following lumbar laminectomy. Incidental durotomy rate was 10.00%. Following a first-time laminectomy, the reoperation rate was 14.4% over a mean of 3.40 years.
PMCID: PMC4431053  PMID: 26005583
Fusion; laminectomy; lumbar; outcomes; reoperation; spine
17.  Artificial Cervical Disc Arthroplasty (ACDA): tips and tricks 
Journal of Injury and Violence Research  2012;4(3 Suppl 1): Paper No. 36.
Anterior cervical discectomy and fusion (ACDF) is currently treatment of choice for managing medical therapy refractory cervical degenerative disc disease. Numerous studies have demonstrated the effectiveness of ACDF; patients generally experience rapid recoveries, and dramatic improvement in their pain and quality of life. However, as several studies reported symptomatic adjacent segment disease attributed to fusions’ altered kinematics, cervical disc arthroplasty emerged as a new motion-sparing alternative to fusion. Fusion at one level increases motion at adjacent levels along with increased intradiscal pressures. This phenomenon can result in symptomatic adjacent level degeneration, which can necessitate reoperation at these levels. The era of cervical arthroplasty began in Europe in the late 1990s. In recent years, artificial cervical disc arthroplasty (ACDA) has been increasingly used by spine surgeons for degenerative cervical disc disease. There have been several reports of safety, efficacy and indications of ACDA.
Cervical arthroplasty offers several theoretical advantages over anterior cervical discectomy and fusion (ACDF) in the treatment of selected patients with medically refractory cervical radiculopathy. Preserving motion at the operated level, cervical TDR has the potential to decrease the occurrence of adjacent segment degeneration.
There are a few studies on the efficacy and effectiveness of ACDA compared to cervical fusion. However, the true scenery of cervical arthroplasty yet to be identified.
This study is intended to define patients' characteristics and outcomes of ACDA by a single surgeon in Iran.
This retrospective study was performed in two general Hospitals in Tehran, Iran from 2005 To 2010. All patients were operated by one senior neurospine surgeon. One hundred fifty three patients were operated in this period. All patients signed the informed consent form prior to surgery. All patients presented with cervical discopathy who had myelopathy or radiculopathy and failed conservative management, undergoing cervical disc arthroplasty by ACDA were included, consecutively. Patients were followed for at least 2 years.
Exclusion criteria was age greater than 60 years, non compliance with the study protocol, osteoporosis, infection, congenital or post traumatic deformity, malignancy metabolic bone disease, and narrow cervical canal (less than 12 mm). Heterotopic ossification and adjacent segment degenerative changes were assessed at 2 years follow up by means of neutral and dynamic xrays and CT/MRI if clinically indicated. Neck and upper extremity pain were assessed before the procedure and in the first post-operative visit and 3 months later by means of visual analogue scale.
A standard approach was performed to the anterior cervical spine. Patients were positioned supine while holding neck in neutral position. A combination of sharp and blunt dissection was performed to expose longus coli musculature and anterior cervical vertebrae. Trachea and esophagus were retracted medially and carotid artery and jugular vein laterally. After a thorough discectomy, the intersomatic space is distracted in a parallel way by a vertebral distracter. Followed by Caspar distractor is applied to provide a working channel into posterior disc space. In this stage, any remnant disc materials as well as osteophytes are removed and foraminal decompression is done. Posterior longitudinal ligament (PLL) opening and removal, although discouraged by some, is done next. In order to define the size of the prosthesis, multiple trials are tested. It is important not to exceed the height of the healthy adjacent disc to avoid facet joint overdistraction. An specific insertor is applied to plant the prosthesis in disc space. Control X-rays are advised to check the precise positioning of the implant.
one hundred-fifty three patients including 87 females and 66 males were included. The mean age was 41 for females and 42 for males. Affected level was C5-C6 in 81 cases, C6-C7 in 72 cases and C4-C5 in 10 cases. The most common applied ACDA was DiscoCerv which was inserted in 127 cases followed by prodisc-c in three patients and Baguera in thirty three psatients.Ten cases had two levels involvement. Both neck and upper extremity pain improved significantly in early and late post op assessments compared to pre-op. There was only one operative complication of quadriparesis which might be attributed to the iatrogenic cervical spinal trauma.
Cervical disc arthroplasty has been advocated to address drawbacks of fusion including loss of motion segment and adjacent level degeneration; our study along with several other reports provide considerable evidence in this regard. Cervical disc arthroplasty is a safe and effective alternative for fusion in cervical degenerative disc disease.
Cervical degenerative disc disease, Artificial cervical disc arthroplasty, Safety, Efficacy
PMCID: PMC3571562
18.  Differences between pre-existing type and de novo type left convex thoracolumbar / lumbar scoliosis 
Scoliosis  2015;10(Suppl 2):S6.
Lenke 5C type adolescent idiopathic scoliosis (AIS) with a Cobb angle of over 30 degrees has high risk of progression. The need for corrective surgeries for degenerative lumbar scoliosis has been increasing these days and some of those cases are pre-existing type scoliosis. However, it is said to be difficult to differentiate pre-existing type scoliosis from de novo type scoliosis. The purpose of this study is to analyze the relevant X ray metrics of degenerative lumbar scoliosis and to discover differences between pre-existing and de novo type scoliosis.
Of 54 consecutive patients who were diagnosed as candidates for corrective surgery for left convex thoracolumbar / lumbar scoliosis since December 2008, 19 patients over age 50 were included in this study. The average age was 60 years old (50-80 years old). All patients were female. Coronal and sagittal parameters were contrasted between two groups divided according to the existence of scoliosis in their adolescence; clear (AIS) and unclear (de novo).
Eleven were AIS, and 8 were de novo. The average age was 54.0 years old for AIS and 67.4 for de novo (p<0.05). Cobb angles (69°, 49°) and L4 tilt (30°, 22°) were found to be significantly greater in AIS. Nash-Moe rotation assessment showed that rotational deformity was greater in AIS type than in de novo type. Lumbar lordosis (28°, 32°), thoracolumbar kyphosis (24°, 12°), sagittal vertical axis (37mm, 58mm), and pelvic incidence (51°, 60°) showed no significant difference between the groups, however, pelvic tilt (24°, 33°) showed significant difference.
Among patients over 50 with degenerative thoracolumbar / lumbar scoliosis, those with pre-existing type scoliosis were found to have greater Cobb angle, greater L4 tilt, greater rotational deformity, less pelvic tilt, and were candidates for surgery at a younger age than those with de novo type scoliosis. In other words, those with de novo type scoliosis have less coronal deformity and worse sagittal pelvic alignment than those with pre-existing type scoliosis and are not considered candidates for surgery until a more advanced age. This study demonstrates some differences between pre-existing and de novo type scoliosis, contrasts the natural history of the two types of candidates for thoracolumbar / lumbar scoliosis surgery, and suggests the importance of performing surgery for Lenke 5C type adolescent idiopathic scoliosis at a younger age.
PMCID: PMC4331766  PMID: 25815049
19.  Safety and efficacy of a new percutaneously implantable interspinous process device 
Acta Neurochirurgica  2010;152(11):1961-1967.
Lumbar spinal stenosis is a degenerative disease of the elderly population. Although microsurgical decompression has shown good long-term results, percutaneous techniques could provide an alternative in the presence of significant comorbidities.
Eighty-seven interspinous process decompression devices (In-space; Synthes, Umkirch, Germany) were implanted percutaneously in up to three segments of 50 patients. Outcome was assessed directly after surgery, at 6–8 weeks, and at average follow-up of 1 year (11.8 ± 6 months). Assessment included complications, pain and spinal claudication, neurodeficit, time to recurrence of symptoms, and time to second surgery. Subgroups with additional low back pain at presentation and mild spondylolisthesis were analyzed separately.
Intraoperative complications were rare (one misplacement and two cases of failed implantation); average operation time was 16.4 ± 12.2 min per segment. Initial response was very good with 72% good or excellent relief of symptoms. After a 1-year follow-up, 42% reported of lasting relief from spinal claudication. Thirteen percent of these complained about lasting or new-onset low back pain. A second surgery had been performed in 22%. Subgroup analysis was performed for patients presenting with additional low back pain and spondylolisthesis patients. No significant differences could be noted between subgroups.
The In-space is a percutaneous treatment option of claudication in patients with lumbar spinal stenosis. Compared with microsurgical decompression surgery, recurrence rate within 1 year is, however, high and the device seems not suitable for the treatment of low back pain. Therefore, the authors suggest that the device should presently be used primarily in controlled clinical trials in order to get more information concerning the optimal indication.
PMCID: PMC3128705  PMID: 20635103
Interspinous process decompression (IPD); In-space; Lumbar spinal stenosis; Percutaneous
20.  Lumbar degenerative spinal deformity: Surgical options of PLIF, TLIF and MI-TLIF 
Indian Journal of Orthopaedics  2010;44(2):159-162.
Degenerative disease of the lumbar spine is common in ageing populations. It causes disturbing back pain, radicular symptoms and lowers the quality of life. We will focus our discussion on the surgical options of posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for lumbar degenerative spinal deformities, which include symptomatic spondylolisthesis and degenerative scoliosis. Through a description of each procedure, we hope to illustrate the potential benefits of TLIF over PLIF. In a retrospective study of 53 ALIF/PLIF patients and 111 TLIF patients we found reduced risk of vessel and nerve injury in TLIF patients due to less exposure of these structures, shortened operative time and reduced intra-operative bleeding. These advantages could be translated to shortened hospital stay, faster recovery period and earlier return to work. The disadvantages of TLIF such as incomplete intervertebral disc and vertebral end-plate removal and potential occult injury to exiting nerve root when under experienced hands are rare. Hence TLIF remains the mainstay of treatment in degenerative deformities of the lumbar spine. However, TLIF being a unilateral transforaminal approach, is unable to decompress the opposite nerve root. This may require contralateral laminotomy, which is a fairly simple procedure. The use of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) to treat degenerative lumbar spinal deformity is still in its early stages. Although the initial results appear promising, it remains a difficult operative procedure to master with a steep learning curve. In a recent study comparing 29 MI-TLIF patients and 29 open TLIF, MI-TLIF was associated with longer operative time, less blood loss, shorter hospital stay, with no difference in SF-36 scores at six months and two years. Whether it can replace traditional TLIF as the surgery of choice for degenerative lumbar deformity remains unknown and more studies are required to validate the safety and efficiency.
PMCID: PMC2856390  PMID: 20419002
Degenerative spine; lumbar spine fusion; minimally invasive transforaminal fusion
21.  The Clinical Effect of Gait Load Test in Two Level Lumbar Spinal Stenosis 
Asian Spine Journal  2009;3(2):96-100.
Study Design
This study is a prospective, clinical study assessing the efficacy of selective decompression of the level responsible in a two-level stenosis in accordance with the neurological findings defined by the gait load test with a treadmill.
To clarify the clinical features of multilevel lumbar spinal stenosis (LSS) regarding the neurological level responsible for the symptoms, neurogenic claudication, and outcomes of selective decompression.
Overview of Literature
Most spine surgeons have reported that multilevel compression of the cauda equina induces a more severe impairment of the nerve function than a single-level compression. However, the clinical effects of multilevel LSS on the cauda equine and nerve roots are unknown.
A total of 21 patients with lumbar spinal canal stenosis due to spondylosis and degenerative spondylolisthesis were selected. The level responsible for the symptoms in the two-level stenosis was determined from the neurological findings on the gait load test and functional diagnosis based on a selective nerve root block. All patients underwent a prospective, selective decompression at the level neurologically responsible only. The average follow-up period was 2.6 years (range, 1 to 6 years). The postsurgical outcome was defined using the Visual Analogue Scale (VAS) at the post-gait load test, 2 weeks after surgery, 3 months after surgery and at the last follow up.
Before surgery, the mean threshold distance and mean walking tolerance was 34.3 m and 113 m, respectively. All patients had neurogenic claudication and 19 of the patients had cauda equina syndrome, including hypesthesia in 11 cases, muscle weakness in 5 cases and radicular pain in 7 cases. Selective nerve blocks to determine the level responsible for the lumbosacral symptoms in 2 cases revealed a mean VAS score of 7.1, 2.61, 3.04, and 3.47 at the post-gait load test, 2 weeks after surgery, 3 months after surgery and at the last follow up, respectively. All subjects underwent surgery. After the operation, neurogenic claudication with or without cauda equna syndrome subsided in all patients.
The gait load test allows an objective and quantitative evaluation of the gait characteristics of patients with lumbar canal stenosis and is useful for determining the appropriate level for surgical treatment.
PMCID: PMC2852081  PMID: 20404954
Gait load test; Neurogenic claudication; Lumbar canal stenosis
22.  Outcomes of decompression surgery for lumbar spinal stenosis in elderly diabetic patients 
European Spine Journal  2003;13(1):32-37.
The purpose of this study was to assess and compare the outcome of surgical decompression for spinal stenosis in diabetic and non-diabetic elderly patients. This is a retrospective chart analysis conducted in a university affiliated referral hospital. The participants were consecutive patients, age 65 and older, undergoing laminectomy for spinal stenosis during 1990–2000. We assessed patients’ clinical and demographic data, procedures, perioperative complications, preoperative and postoperative pain intensity, basic activities of daily living (BADL), patients’ satisfaction, the need for repeated surgery, and overall mortality. A total number of 62 elderly diabetic group (DG) patients undergoing decompression surgery for spinal stenosis were compared with a sex and age-matched non-diabetic control group (CG) at baseline, and a mean of 40.3 months thereafter. We found that the DG patients had more pain (p=0.042), and suffered more frequently from neurogenic claudication (p=0.0018), motor weakness (p=0.021) and numbness of the affected limb (p=0.0069) than the CG patients. Nocturnal pain was reported in 24% of the DG patients. Pain relief was successfully achieved in both groups (p<0.001), but the patients’ satisfaction was greater in the non-diabetic patients (p=0.0067). Revision surgery was more frequently performed in the DG than the CG (non-significant difference), and the time interval for such a second intervention was shorter (p=0.04) in the DG. A higher rate of post-operative complications was observed in the DG (p<0.0001). It is concluded that surgical treatment of elderly diabetic patients suffering from spinal stenosis improves BADL and ameliorates pain, but the results remain worse than those observed in non-diabetics. The outcome of diabetic patients depends upon the presence of other comorbidities, concurrent diabetic neuropathy, duration of diabetes and insulin treatment. Successful postoperative pain reduction remained the strongest factor associated with patients’ satisfaction.
PMCID: PMC3468040  PMID: 14614597
Diabetes; Elderly; Laminectomy; Spine
23.  Current concepts and controversies on adolescent idiopathic scoliosis: Part I 
Indian Journal of Orthopaedics  2013;47(2):117-128.
Adolescent idiopathic scoliosis is the most common spinal deformity encountered by General Orthopaedic Surgeons. Etiology remains unclear and current research focuses on genetic factors that may influence scoliosis development and risk of progression. Delayed diagnosis can result in severe deformities which affect the coronal and sagittal planes, as well as the rib cage, waistline symmetry, and shoulder balance. Patient's dissatisfaction in terms of physical appearance and mechanical back pain, as well as the risk for curve deterioration are usually the reasons for treatment. Conservative management involves mainly bracing with the aim to stop or slow down scoliosis progression during growth and if possible prevent the need for surgical treatment. This is mainly indicated in young compliant patients with a large amount of remaining growth and progressive curvatures. Scoliosis correction is indicated for severe or progressive curves which produce significant cosmetic deformity, muscular pain, and patient discontent. Posterior spinal arthrodesis with Harrington instrumentation and bone grafting was the first attempt to correct the coronal deformity and replace in situ fusion. This was associated with high pseudarthrosis rates, need for postoperative immobilization, and flattening of sagittal spinal contour. Segmental correction techniques were introduced along with the Luque rods, Harri-Luque, and Wisconsin systems. Correction in both coronal and sagittal planes was not satisfactory and high rates of nonunion persisted until Cotrel and Dubousset introduced the concept of global spinal derotation. Development of pedicle screws provided a powerful tool to correct three-dimensional vertebral deformity and opened a new era in the treatment of scoliosis.
PMCID: PMC3654460  PMID: 23682172
Adolescent idiopathic scoliosis; natural history; clinical examination; radiological assessment; treatment
24.  Endoscopic Facet Debridement for the treatment of facet arthritic pain - a novel new technique 
Study design: Retrospective, observational, open label.
Objective: We investigated the efficacy of facet debridement for the treatment of facet joint pain.
Summary of background data: Facet joint disease, often due to degenerative arthritis, is common cause of chronic back pain. In patients that don't respond to conservative measures, nerve ablation may provide significant improvement. Due to the ability of peripheral nerves to regenerate, ablative techniques of the dorsal nerve roots often provide only temporary relief. In theory, ablation of the nerve end plates in the facet joint capsule should prevent reinnervation.
Methods: All patients treated with endoscopic facet debridement at our clinic from 2003-2007 with at least 3 years follow-up were included in the analysis. Primary outcome measure was percent change in facet-related pain as measured by Visual Analog Scale (VAS) score at final follow-up visit.
Results: A total of 174 people (77 women, 97 men; mean age 64, range 22-89) were included. Location of facet pain was cervical in 45, thoracic in 15, and lumbar in 114 patients. At final follow-up, 77%, 73%, and 68% of patients with cervical, thoracic, or lumbar disease, respectively, showed at least 50% improvement in pain. Mean operating time per joint was 17 minutes (range, 10-42). Mean blood loss was 40 ml (range, 10-100). Complications included suture failure in two patients, requiring reclosure of the incision. No infection or nerve damage beyond what was intended occurred.
Conclusions: Our results demonstrate a comparable efficacy of endoscopic facet debridement compared to radiofrequency ablation of the dorsal nerve branch, with durable results. Large scale, randomized trials are warranted to further evaluate the relative efficacy of this surgical treatment in patients with facet joint disease.
PMCID: PMC2880840  PMID: 20567612
vertebral arthritis; facet syndrome; back pain; minimally invasive; nerve ablation
25.  Partial Facetectomy for Lumbar Foraminal Stenosis 
Advances in Orthopedics  2014;2014:534658.
Background. Several different techniques exist to address the pain and disability caused by isolated nerve root impingement. Failure to adequately decompress the lumbar foramen may lead to failed back surgery syndrome. However, aggressive treatment often causes spinal instability or may require fusion for satisfactory results. We describe a novel technique for decompression of the lumbar nerve root and demonstrate its effectiveness in relief of radicular symptoms. Methods. Partial facetectomy was performed by removal of the medial portion of the superior facet in patients with lumbar foraminal stenosis. 47 patients underwent the procedure from 2001 to 2010. Those who demonstrated neurogenic claudication without spinal instability or central canal stenosis and failed conservative management were eligible for the procedure. Functional level was recorded for each patient. These patients were followed for an average of 3.9 years to evaluate outcomes. Results. 27 of 47 patients (57%) reported no back pain and no functional limitations. Eight of 47 patients (17%) reported moderate pain, but had no limitations. Six of 47 patients (13%) continued to experience degenerative symptoms. Five of 47 patients (11%) required additional surgery. Conclusions. Partial facetectomy is an effective means to decompress the lumbar nerve root foramen without causing spinal instability.
PMCID: PMC4119622  PMID: 25110591

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