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4.  Improvement in low back pain following spinal decompression: observational study of 119 patients 
European Spine Journal  2013;23(1):135-141.
Study design
Prospective clinical observational study of low back pain (LBP) in patients undergoing laminectomy or laminotomy surgery for lumbar spinal stenosis (LSS).
To quantify any change in LBP following laminectomy or laminotomy spinal decompression surgery.
Patients and methods
119 patients with LSS completed Oswestry Disability Index questionnaire (ODI) and Visual Analogue Scale for back and leg pain, preoperatively, 6 weeks and 1 year postoperatively.
There was significant (p < 0.0001) reduction in mean LBP from a baseline of 5.14/10 to 3.03/10 at 6 weeks. Similar results were seen at 1 year where mean LBP score was 3.07/10. There was a significant (p < 0.0001) reduction in the mean ODI at 6 weeks and 1 year postoperatively. Mean ODI fell from 44.82 to 25.13 at 6 weeks and 28.39 at 1 year.
The aim of surgery in patients with LSS is to improve the resulting symptoms that include radicular leg pain and claudication. This observational study reports statistically significant improvement of LBP after LSS surgery. This provides frequency distribution data, which can be used to inform prospective patients of the expected outcomes of such surgery.
PMCID: PMC3897808  PMID: 23963487
Spine; Back pain; Laminectomy; Spinal stenosis
5.  Clinical outcomes following sublaminar-trimming laminoplasty for extensive lumbar canal stenosis 
European Spine Journal  2013;23(1):80-86.
Current surgical approaches for treatment of lumbar canal stenosis are often associated with relatively high rates of reoperation and recurrent stenosis. We have developed a new approach for treatment of this condition: sublaminar-trimming laminoplasty. To describe the surgical approach of sublaminar-trimming laminoplasty and to assess associated outcomes.
Patients with extensive lumbar canal stenosis who received sublaminar-trimming laminoplasty from 2006 to 2008 were considered for inclusion in the study. The surgery comprised aspects of laminotomy and laminectomy. The following were assessed before surgery and 3 years after surgery: leg and back pain by visual analog scale (VAS), extent of disability by Oswestry Disability Index (ODI), severity of back pain by Japanese Orthopedic Association Score for Back Pain (JOA), walking tolerance, and leg numbness. Complications were noted.
A total of 49 patients were included in the study (mean age 65.6 ± 10.6 years). VAS leg and back pain, ODI, and JOA scores significantly changed from before surgery to 3 years after surgery (P < 0.001). Mean changes (95 % confidence interval) were −6.2 (−6.7, −5.7), −4.3 (−4.8, −3.8), −21.4 (−23.4, −19.5), and 13.4 (12.1, 14.7) for leg pain, back pain, ODI, and JOA scores, respectively. Patients experienced significant improvements in walking tolerance and leg numbness (P < 0.001). There were no instances of recurrent stenosis or postoperative spinal instability. Complications included intraoperative dural tear (n = 2), postoperative urinary tract infection (n = 2), and inadequate decompression and junctional stenosis during follow-up (both n = 1).
Sublaminar-trimming laminoplasty shows promise as an effective treatment for extensive lumbar canal stenosis.
PMCID: PMC3897809  PMID: 23852436
Laminoplasty; Lumbar canal; Stenosis; Sublaminar-trimming; Treatment
6.  Dynamic changes in the dural sac of patients with lumbar canal stenosis evaluated by multidetector-row computed tomography after myelography 
European Spine Journal  2013;23(1):74-79.
Some reported studies have evaluated the dural sac in patients with lumbar spinal stenosis (LSS) by computed tomography (CT) after conventional myelography or magnetic resonance imaging (MRI). But they have been only able to evaluate static factors. No reports have described detailed dynamic changes in the dural sac during flexion and extension observed by multidetector-row computed tomography (MDCT). The aim of this study was to elucidate or demonstrate, in detail, the influence of dynamic factors on the severity of stenosis.
One hundred patients with LSS were enrolled in this study. All underwent MDCT in both flexion and extension positions after myelography, in addition to undergoing MRI. The anteroposterior diameter (AP-distance) and cross-sectional area of the dural sac (D-area) were measured at each disc level between L1–2 and L5–S1. The dynamic change in the D-area was defined as the absolute value of the difference between flexion and extension. The rate of dynamic change (dynamic change in D-area/D-area at flexion) in the dural sac at each disc level was also calculated.
The average AP-distance in flexion/extension (mm) was 9.2/7.4 at L3–4 and 8.3/7.4 at L4–5. The average D-area in flexion/extension (mm2) was 96.3/73.6 at L3–4 and 72.3/61.0 at L4–5. The values were significantly lower in extension than in flexion at all disc levels from L1–2 to L5–S1. AP-distance was narrowest and D-area smallest at L4–5 during extension. The rates of dynamic changes at L2–3 and L3–4 were higher than those at L4–5.
MDCT clearly elucidated the dynamic changes in the lumbar dural sac. Before surgery, MDCT after myelography should be used to evaluate the dynamic change during flexion and extension, especially at L2–3, L3–4, and L4–5.
PMCID: PMC3897810  PMID: 23817960
Lumbar spinal stenosis (LSS); Dynamic factor; Multidetector-row computed tomography (MDCT); Dural sac
7.  The relevance of sacral and sacro-pelvic morphology in developmental lumbosacral spondylolisthesis: are they equally important? 
European Spine Journal  2013;23(1):157-162.
Study design
Retrospective study of the importance of sacral and sacro-pelvic morphology in developmental L5–S1 spondylolisthesis.
To determine and compare the importance of sacral and sacro-pelvic morphology in developmental L5–S1 spondylolisthesis.
Summary and background data
Recent studies have shown abnormalities in sacral and sacro-pelvic morphology in spondylolisthesis. However, it is still unclear if sacral and sacro-pelvic morphology are correlated and if they are equally important in the progression of spondylolisthesis.
Lateral radiographs of 120 controls and 131 subjects with developmental L5–S1 spondylolisthesis were analyzed. Sacral table angle (STA) and pelvic incidence (PI) were compared using Student t tests. The relationship between STA and PI was assessed separately in the control and spondylolisthesis groups using Pearson’s coefficients. The proportion of subjects with high PI but average STA was compared to the proportion of subjects with low STA but average PI using χ2 tests.
STA was significantly lower and PI was significantly higher in the spondylolisthesis group. STA was statistically related to PI in both control (r = −0.43) and spondylolisthesis (r = −0.57) groups. In the spondylolisthesis group, STA (r = −0.45) and PI (r = 0.35) were significantly related to slip percentage. STA remained statistically related to slip when controlling for PI. A significantly greater proportion of subjects in the spondylolisthesis group had average STA and high PI, rather than average PI and low STA.
The significant relationship between PI and STA validates that geometrically sacral morphology depends on sacro-pelvic morphology. This study failed to demonstrate a clear predominant role of either STA or PI in the presence of spondylolisthesis.
PMCID: PMC3897811  PMID: 23712627
Spondylolisthesis; Pelvic incidence; Sacral table angle; Sacro-pelvic morphology; Sacral morphology; Pelvic morphology
9.  The risk factors of neurologic deficits of one-stage posterior vertebral column resection for patients with severe and rigid spinal deformities 
European Spine Journal  2013;23(1):149-156.
To determine the risk factors of neurologic deficits during PVCR correction, so as to help improve safety during and after surgery.
A consecutive series of 76 patients with severe and rigid spinal deformities who were treated with PVCR at a single institution between October 2004 and July 2011 were included in our study. Of the 76 patients, 37 were male and 39 female, with an average age of 17.5 years (range 10–48 years). There were 52 adolescent patients (with an age <18 years) and 24 adult patients (with an age ≥18 years). Preoperatively, postoperatively and 6 months after surgery, we performed systemically neurologic function evaluations of each patients through meticulous physical examination. Any new abnormality or deterioration in evaluation of neurologic function than preoperative is reckoned postoperative neurologic deficits. Ten variables that might affect the safety of neurologic deficits during PVCR procedures, including imaging factors, clinical factors and operational factors, were analyzed using univariate analysis. Then the variables with statistical difference were analyzed by using multi-factor unconditional logistic regression analysis.
No patient in this series had permanent paraplegia and nerve root injury due to operation. Change of neurologic status was found in six patients after surgery. Results of single-factor comparison demonstrated that the following seven variables were statistically different (P < 0.05): location of apex at main curve (X3), Cobb angle at the main curve at the coronal plane (X4), scoliosis associated with thoracic hyperkyphosis (X5), level of vertebral column resected (X6), number of segmental vessels ligated (X7), preexisting neurologic dysfunction (X8), and associated with intraspinal and brain stem anomalies (X9). The multi-factor unconditional logistic regression analysis revealed that X8 (OR = 49.322), X9 (OR = 18.423), X5 (OR = 11.883), and X6 (OR = 8.769) were independent and positively correlated with the neurologic deficit.
Preexisting neurologic dysfunction, associated with intraspinal and brain stem anomalies, scoliosis associated with thoracic hyperkyphosis and level of vertebral column resected are independent risk factors for neurologic deficits during PVCR procedure.
PMCID: PMC3897813  PMID: 23619771
Spinal deformity; Vertebral column resection; Surgical procedures; Neurologic deficits; Risk factor
10.  Abstracts for GEER-SILACO—Congreso in Valencia, Spain, June 2013 
European Spine Journal  2013;23(1):248-288.
PMCID: PMC3897814  PMID: 24311020
11.  Progression of lumbar spinal stenosis is influenced by polymorphism of thrombospondin 2 gene in the Korean population 
European Spine Journal  2013;23(1):57-63.
The aim of this study is to determine the contribution of thrombospondin 2 (THBS2) polymorphisms to the development and progression of lumbar spinal stenosis (LSS) in the Korean population.
We studied 148 symptomatic patients with radiographically proven LSS and 157 volunteers with no history of back problems from our institution. Magnetic resonance images were obtained for all the patients and controls. Quantitative image evaluation for LSS was performed to evaluate the severity of LSS. All patients and controls were genotyped for THBS2 allele variations using a polymerase chain reaction-based technique.
We found no causal single nucleotide polymorphism (SNPs) in THBS2 that were significantly associated with LSS. Two SNPs (rs6422747, rs6422748) were over-represented in controls [P = 0.042, odds ratio [OR] = 0.55 and P = 0.042, OR = 0.55, respectively]. Haplotype analysis showed that the ‘‘AGAGACG’’ haplotype (HAP4) and ‘‘AAGGACG’’ haplotype (HAP5) were over-represented in severe LSS patients (P = 0.0147, OR = 2.02 and P = 0.0137, OR = 2.48, respectively). In addition, the ‘‘AAAGGGG’’ haplotype (HAP1) was over-represented in controls (P = 0.0068, OR = 0.30).
Although no SNPs in THBS2 were associated with LSS, haplotypes (HAP4 and HAP5) were significantly associated with progression of LSS in the Korean population, whereas another haplotype (HAP1) may play a protective role against LSS development.
PMCID: PMC3897815  PMID: 23807322
Genetic study; Haplotype; Lumbar spinal stenosis; Polymorphism; Thrombospondin gene
12.  Two-level pedicle subtraction osteotomy for severe thoracolumbar kyphotic deformity in ankylosing spondylitis 
European Spine Journal  2013;23(1):234-241.
Study design
A retrospective clinical study.
To evaluate the outcomes of two-level (T12 and L3) pedicle subtraction osteotomy (PSO) for severe thoracolumbar kyphosis in ankylosing spondylitis (AS), and to discuss the surgical strategies of this surgery.
Cases were limited on the results of two-level PSO for correction of severe kyphosis caused by AS, nor on surgical strategies of this type of surgery.
From March 2006 to December 2010, nine consecutive AS patients with severe kyphotic deformity, underwent T12 and L3 PSOs. Chin-brow vertical angle (CBVA) and radiographic assessments which contain thoracic kyphosis (TK), lumbar lordosis (LL), global kyphosis (GK), and sagittal vertical axis were carefully recorded pre and postoperatively to evaluate the sagittal balance. Intra and postoperative complications were also registered. All patients were asked to fill out Oswestry Disability Index before surgery and at the last follow-up visit.
All nine patients (8M/1F), averaged 41.4 years old (range 35–51 years), were received two-level (T12 and L3) PSO, and were followed up after surgery for a mean of 39.9 months (range 24–68 months). Good cosmetic results were achieved in all patients. Mean correction at two-level PSO was 67.9 ± 5.5°. All CBVA, TK, LL, and GK were changed significantly after surgery (P < 0.05), the mean amount of correction of which were 59.5 ± 13.8, 34.7 ± 3.8, 33.2 ± 2.4, and 54.0 ± 14.8 degrees, respectively, and with a small loss of correction at the last follow-up visit. Sagittal imbalance was significantly improved from 27.3 ± 4.4 to 3.4 ± 0.7 cm postoperatively. Neither mortalities nor any major neurological complications were found. The mean ODI score was significantly improved from 53.4 ± 15.5 before surgery to 8.2 ± 4.7 at the last visit.
The outcomes of follow-up showed that two-level (T12 and L3) PSO can effectively and safely correct severe thoracolumbar kyphosis in AS.
PMCID: PMC3897816  PMID: 23771578
Ankylosing spondylitis; Kyphosis; Pedicle subtraction osteotomy; Spine; Sagittal deformity
13.  Announcements for issue 1, 2014 
European Spine Journal  2013;23(1):289.
PMCID: PMC3897817
14.  Coexisting lumbar and cervical stenosis (tandem spinal stenosis): an infrequent presentation. Retrospective analysis of single-stage surgery (53 cases) 
European Spine Journal  2013;23(1):64-73.
Study design
Retrospective analysis of 53 patients who underwent single stage simultaneous surgery for tandem spinal stenosis (TSS) at single centre.
To discuss the presentation of combined cervical and lumbar (tandem) stenosis and to evaluate the safety and efficacy of single-stage simultaneous surgery.
Summary of background data
Combined stenosis is an infrequent presentation with mixed presentation of upper motor neuron and lower motor neuron signs. Scarce literature on its presentation and management is available. There is a controversy in the surgical strategy of these patients. Staged surgeries are frequently recommended and only few single-stage surgeries reported.
All the patients were clinico-radiologically diagnosed TSS. Surgeries were performed in single stage by two teams. Results were evaluated with Nurick grade, modified Japanese Orthopedic Association score (mJOA), oswestry disability index (ODI), patient satisfaction index, mJOA recovery rate, blood loss and complication.
The mJOA cervical and ODI score improved from a mean 8.86 and 68.15 preoperatively to 13.00 and 30.11, respectively, at 12 months and to 14.52 and 24.03 at final follow-up. The average mJOA recovery rate was 48.23 ± 26.90 %. Patient satisfaction index was 2.13 ± 0.91 at final follow-up. Estimated blood loss of ≤400 ml and operating room time of <150 min showed improvement of scores and lessened the complications. In the age group below 60 years, the improvement was statistically significant in ODI (p = 0.02) and Nurick’s grade (p = 0.03) with average improvement in mJOA score.
Short-lasting surgery, single anaesthesia, reduced morbidity and hospital stay as well as costs, an early return to function, high patient satisfaction rate with encouraging results justify single-stage surgery in TSS. Age, blood loss and duration of surgery decide the complication rate and outcome of surgery. Staged surgery is recommended in patients above the age of 60 years.
PMCID: PMC3897818  PMID: 23793607
Tandem; Combined; Cervical; Lumbar; Single stage surgery
15.  Radiographic evaluation of ventral instability in lumbar spondylolisthesis: do we need extension radiographs in routine exams? 
European Spine Journal  2013;23(1):96-101.
To determine the usefulness of acquiring extension radiographs for the evaluation of the degree of spondylolisthesis.
Routine radiographs of the lumbar spine were retrospectively evaluated in 87 patients (mean-age 63, range 32–86) by two independent radiologists. All patients received radiographs in standing neutral, flexion and extension position. Vertebral body depth, sagittal translational displacement and lordosis angle were measured and slip percentage (SP) was calculated on standing neutral, flexion and extension radiographs. Statistical analysis was performed with a two-sided t test. Inter- and intraobserver reliability was assessed using the kappa-coefficient.
There was no statistically significant SP-difference between neutral standing and extension images. Ventral instability was diagnosed in 25–34 % (cut-off >8 % SP-difference) for neutral versus flexion comparison. The detection rate of flexion–extension radiographs representing the extremes of motion was lower with 15–22 %. Inter- and intraobserver reliability was good to excellent.
Slip percentage in routine standing extension radiography ultimately does not differ from that obtained in a static neutral standing view. Extension radiography may therefore be omitted in a routine work-up of ventral instability in lumbar spondylolisthesis.
PMCID: PMC3897819  PMID: 23912887
Radiography; Back pain; Spondylolisthesis; Vertebral instability
16.  Sagittal spinopelvic alignment in adolescent thoracic scoliosis secondary to Chiari I malformation: a comparison between the left and the right curves 
European Spine Journal  2013;23(1):226-233.
To investigate whether the sagittal morphology differs between the left and right thoracic curves in patients with Chiari malformation-associated scoliosis (CMS).
Thirty-four patients with a left thoracic curve constituted the CM-L group, whereas 44 patients with a right thoracic curve were assigned into the CM-R group. Another cohort of 90 age- and gender-matched asymptomatic adolescents was enrolled to serve as the control group. Seven sagittal parameters were evaluated on standing lateral radiographs, including thoracic kyphosis (TK), lumbar lordosis (LL), thoracolumbar junctional kyphosis (TJK), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS).
Compared to the normal controls, the TK, LL and SS were significantly greater in the CM-L group, along with a significantly decreased PT. Similar changes in SS and PT were also demonstrated in the CM-R group, while the TK and LL were found to be relatively normal compared with the control group. Concerning CMS patients with different curve directions, significantly increased TK and LL were observed in the CM-L group, whereas all three pelvic parameters were similar for the two groups. In addition, no significant differences were noted between the three groups in PI, TJK or SVA. Moreover, the LL was strongly related to the TK and SS in all three groups, but to the PI only in the control and CM-R groups. A significant correlation was also noted between TK and SS in the CM-L group.
Significant differences in sagittal profiles indeed exist between CMS patients and healthy adolescents, as well as between CMS patients with different curve directions. In CMI patients with a left thoracic curve, compensatory alterations appear to occur in LL in response to the increased TK to maintain a balanced posture.
PMCID: PMC3897820  PMID: 24026168
Chiari I malformation; Scoliosis; Curve direction; Sagittal spinopelvic alignment; Sagittal balance
17.  Correlation between clinical outcome and spinopelvic parameters in ankylosing spondylitis 
European Spine Journal  2013;23(1):242-247.
Little data are available on the relationship between sagittal spinopelvic parameters and health related quality of life (HRQOL) in ankylosing spondylitis (AS) patients. The aim of this study was to identify the relationships between spinopelvic parameters and HRQOL in AS.
The study and control groups comprised 107 AS patients and 40 controls. All underwent anteroposterior and lateral radiographs of the whole spine including hip joints and completed clinical questionnaires. The radiographic parameters examined were sacral slope, pelvic tilt, pelvic incidence, thoracic kyphosis, lumbar lordosis, and sagittal vertical axis. A Visual Analogue Scale (VAS: 0–10) score for back pain, the Oswestry disability index (ODI) questionnaire, Scoliosis Research Society (SRS-22) questionnaire and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) were administered to evaluate QOL. Statistical analysis was performed to identify significant differences between the study and control groups. In addition, correlations between radiological parameters and clinical questionnaires were sought.
The AS patients and controls were found to be significantly different in terms of sagittal vertical axis, sacral slope, pelvic tilt, pelvic incidence, and lumbar lordosis. However, no significant intergroup difference was observed for thoracic kyphosis (P > 0.05). Of the 107 AS patients, there were 18 women and 89 men. Correlation analysis revealed significant relationships between radiographic parameters and clinical outcomes. Multiple regression analysis was performed to identify predictors of clinical outcome, and the results obtained revealed that sagittal vertical axis and sacral slope significantly predicted VAS, ODI and BASDAI scores and that sagittal vertical axis and lumbar lordosis predicted SRS-22 scores.
AS patients and normal controls were found to be significantly different in terms of sagittal spinopelvic parameters. Correlation analysis revealed significant relationships between radiographic parameters and clinical outcomes. In particular, sagittal vertical axis, sacral slope and lumbar lordosis were found to be significant parameters in prediction of clinical outcomes in AS patient.
PMCID: PMC3897821  PMID: 23900687
Ankylosing spondylitis; Sagittal parameters; Quality of life
18.  Classification system of the sagittal standing alignment in young adolescent girls 
European Spine Journal  2013;23(1):216-225.
The purpose of this cohort study was to classify sagittal standing alignment of pre-peak height velocity (pre-PHV) girls, and to evaluate whether identified subgroups were associated with measures of spinal pain. This study further aimed at drawing attention to similarities and differences between the current postural classification and a previous system determined among pre-PHV boys.
557 pre-PHV girls [mean age, 10.6 years (SD, 0.47 years)] participated in the study. Three gross body segment orientation parameters and five specific lumbopelvic characteristics were quantified during habitual standing. Postural subgroups were determined by cluster analysis. Logistic regression was applied to assess the relationship between postural subgroups and spinal pain measures (pain and seeking care, assessed by self-administered questionnaire). Chi-square statistics, independent samples T test, and distribution-based methods were used for comparison with postural categorization in pre-PHV boys.
Results and conclusion
Among pre-PHV girls, clinically meaningful posture clusters emerged both on the gross body segment and specific lumbopelvic level. The postural subtypes identified among pre-PHV girls closely corresponded to those previously described in pre-PHV boys, thereby allowing the use of the same, working nomenclature. In contrast to previous findings among pre-PHV boys, no associations between posture clusters and spinal pain measures were significant in girls at pre-PHV age. When comparing discrete ‘global’ alignment scores across corresponding posture types, some intriguing differences were found between genders which might involve different biomechanical loading patterns. Whether habitual posture forms a risk factor for developing spinal pain up to adulthood needs evaluation in prospective multifactorial follow-up research.
PMCID: PMC3897822  PMID: 23955370
Posture; Sagittal balance; Classification; Adolescent; Spinal pain
19.  Management of catastrophising and kinesiophobia improves rehabilitation after fusion for lumbar spondylolisthesis and stenosis. A randomised controlled trial 
European Spine Journal  2013;23(1):87-95.
To evaluate the effect of a rehabilitation programme including the management of catastrophising and kinesiophobia on disability, dysfunctional thoughts, pain, and the quality of life in patients after lumbar fusion for degenerative spondylolisthesis and/or lumbar spinal stenosis.
This was a parallel-group, randomised, superiority-controlled study in which 130 patients were randomly assigned to a programme consisting of exercises and cognitive-behavioural therapy (experimental group, 65 subjects) or exercises alone (control group, 65 subjects). Before treatment (T1), 4 weeks later (post-treatment analysis, T2) and 12 months after the end of treatment (follow-up, T3), all the patients completed a booklet containing the Oswestry Disability Index (ODI, primary outcome), the Tampa Scale for Kinesiophobia, the Pain Catastrophising Scale, a pain Numerical Rating Scale, and the Short-Form Health Survey. A linear mixed model for repeated measures was used for each outcome measure.
The ODI linear mixed model revealed significant main effects of group (F(1,122.8) = 95.78, p < 0.001) and time (F(2,120.1) = 432.02, p < 0.001) in favour of the experimental group. There was a significant group × time interaction effect (F(2,120.1) = 20.37, p < 0.001). The analyses of all of the secondary outcome measures revealed a significant effect of time, group and interaction in favour of the experimental group.
The rehabilitation programme, including the management of catastrophising and kinesiophobia, was superior to the exercise programme in reducing disability, dysfunctional thoughts, and pain, and enhancing the quality of life of patients after lumbar fusion for degenerative spondylolisthesis and/or LSS. The effects lasted for at least 1 year after the intervention ended.
PMCID: PMC3897823  PMID: 23836299
Spondylolisthesis; Lumbar stenosis; Lumbar fusion; Rehabilitation; Kinesiophobia
20.  Single segment of posterior lumbar interbody fusion for adult isthmic spondylolisthesis: reduction or fusion in situ 
European Spine Journal  2013;23(1):172-179.
We prospectively compared surgical reduction or fusion in situ with posterior lumbar interbody fusion (PLIF) for adult isthmic spondylolisthesis in terms of surgical invasiveness, clinical and radiographical outcomes, and complications.
From January 2006 to June 2008, 88 adult patients with isthmic spondylolisthesis who underwent surgical treatment in our unit were randomized to reduced group (group 1, n = 45) and in situ group (group 2, n = 43), and followed up for average 32.5 months (range 24–54 months). The clinical and radiographical outcomes were compared between the two groups.
The average operative time and blood loss during surgery showed insignificant difference (p > 0.05) between two groups. The radiological outcomes were significantly better in group 1, but there was no significant difference between two groups of clinical outcomes, depicting as VAS, ODI, JOA and patients’ satisfaction surveys. Incident rate of surgical complications was similar in two groups, but in group 1 the complication seemed more severe because of two patients with neurological symptoms.
For the adult isthmic spondylolisthesis without degenerative disease in adjacent level, single segment of PLIF with pedicle screw fixation is an effective and safe surgical procedure regardless of whether additional reduction had been conducted or not. Better radiological outcome does not mean better clinical outcome.
PMCID: PMC3897824  PMID: 23764766
Isthmic spondylolisthesis; Surgical reduction; Single segment; Sagittal balance; PLIF
21.  The prevalence of depressive symptoms before and after surgery and its association with disability in patients undergoing lumbar spinal fusion 
European Spine Journal  2013;23(1):129-134.
The aim of this study was to evaluate the prevalence of depressive symptoms and disability pre-operatively, at 3 months and at 1 year after lumbar spine fusion surgery.
Data was extracted from a dedicated lumbar spine fusion register, giving 232 patients (mean age 62 years, 158 females) who had undergone instrumented lumbar spine fusion. The frequency of depressive symptoms and disability was evaluated using the Depression Scale (DEPS) and Oswestry Disability Index (ODI).
Depressive symptoms were found in 34, 13, and 15 % of the patients pre-operatively, at 3 months and at 1 year after surgery, respectively. The mean DEPS score decreased from 16.2 to 8.6 (p < 0.001) in patients who had depressive symptoms pre-operatively, and from 6.1 to 3.8 (p < 0.001) in those patients without pre-operative depressive symptoms. The mean ODI values pre-operatively, at 3 months and at 1 year after surgery were 53, 30, and 23, respectively, in patients with pre-operative depressive symptoms and 41, 23, and 20 in those patients without pre-operative depressive symptoms. The differences between the groups were statistically significant at all time points (p < 0.001).
One-third of our patients with chronic back pain undergoing spinal fusion had depressive symptoms pre-operatively. The prevalence of depressive symptoms decreased after surgery. Although disability remained higher in those patients who had reported depressive symptoms pre-operatively, disability did decrease significantly in both groups post-operatively. Thus, there is no need to exclude depressive patients from operation, but screening measures and appropriate treatment practises throughout both pre-operative and post-operative periods are encouraged.
PMCID: PMC3897825  PMID: 23880866
Depressive symptoms; Depression scale DEPS; Disability; Lumbar spine fusion; Surgery
22.  Total spondylectomy for solitary bone plasmacytoma of the lumbar spine in a young woman: a case report and review of literature 
European Spine Journal  2013;23(1):35-39.
Solitary bone plasmacytoma (SP) is a rare diagnosis for which the primary treatment is local radiotherapy. There is no established consensus suggesting a total spondylectomy in spinal SP.
Materials and Methods
We report the case of a 43-year-old woman with solitary plasmacytoma of the lumbar spine treated with complete vertebral resection. Radiographs, CT scan and MRI showed a single osteolytic lesion of the third lumbar vertebra. Further diagnostics following recommended algorithm for tumour screening were negative. Two times, biopsy showed no histological pathologies. Due to the instability of the spine with suspicious unknown lesion, we decided to perform a dorsal lumbar approach and instrumentation with complete resection of the posterior parts to prepare for a complete resection if mandatory. Resamples were taken and the bone surfaces sealed. Consecutive findings were positive for plasma cell infiltration of the respective vertebra, however not on the first pass, but after diagnostic pathological reference. Surgery was completed by total spondylectomy. Reference histological findings with restaging and cytogenetic risk analysis confirmed a non-high-risk solitary bone plasmacytoma, and the patient was scheduled for localized radiotherapy with 40 Gy.
Follow-up examinations (53 months) showed no local recurrence or disease progression.
There is no consensus in the literature regarding appropriate surgical approach and perioperative strategies in the treatment of solitary plasmacytoma. The finding of a solitary plasmacytoma of the spine was the determining factor for our decision to perform radical surgery with subsequent radiotherapy. The rationale for the chosen approach was to minimize the risk of local recurrence and to avoid conversion into multiple myeloma. The follow-up with 53 months is limited. However, discussion remains, if radical surgery in addition to local radiotherapy could be an alternative therapeutic approach depending on paraclinical parameters, age and cytogenetic risk analysis.
PMCID: PMC3897826  PMID: 23989739
Solitary plasmacytoma; Osteolytic lesion; Total spondylectomy; Radiotherapy
23.  Synovial sarcoma of the spine: a case involving paraspinal muscle with extensive calcification and the surgical consideration in treatment 
European Spine Journal  2013;23(1):27-31.
Synovial sarcoma is a rare malignant tumor of the spine. This tumor may present as a painless mass of the spine or slowly enlarge, causing pain or neurologic deficits. As it is difficult to differentiate this lesion from other soft tissue tumors, synovial sarcoma requires histologic confirmation for definite diagnosis. Thus, the treatment strategy is often planned in the final step depending on the pathologic results. Despite its rare incidence, a few cases of primary or metastatic synovial sarcoma involving the spinal cord, foramen, vertebral body, or paraspinal muscles have been reported in the literature.
Materials and methods
We present the case of a 29-year-old man with a synovial sarcoma in the paraspinal muscle of the cervical spine. The patient was evaluated radiologically and histologically. Plain radiography, computed tomography, and magnetic resonance imaging were performed as part of the preoperative workup, and immunohistochemical and cytogenetic studies were additionally performed to identify the histologic features of the tumor. The patient underwent marginal resection followed by adjuvant radiation therapy. The patient has been followed up for 2 years.
This article highlights the features of synovial sarcoma of the spine via a comprehensive review. Synovial sarcoma of the spine is uncommon, but it is a challenging issue in both diagnostic and therapeutic aspects. The currently available evidence suggests the use of a multidisciplinary approach in the treatment of synovial sarcoma, which includes complete resection and radiation therapy.
PMCID: PMC3897827  PMID: 24121750
Synovial sarcoma; Cervical spine; Paraspinal muscle
24.  Posterior approach lumbar and thoracolumbar hemivertebra resection in congenital scoliosis in children under 10 years of age: results with 3 years mean follow up 
European Spine Journal  2013;23(1):209-215.
The authors present 15 cases of congenital scoliosis with lumbar or thoracolumbar hemivertebra in children under 10 years of age (mean age at the time of surgery was 5.5 years). Patients were treated by posterior hemivertebra resection and pedicle screws two levels stabilization or three or more levels stabilization in the case of deformity above or under hemivertebra or for severe curve deformities.
Materials and methods
All operated patients had worsening curves; mean follow up was 40 months. The mean scoliosis curve value was 44° Cobb, and reduced to a mean 11° Cobb after surgery. The mean segmental kyphosis value was 19.7° Cobb, and reduced to a mean −1.8° Cobb after surgery. We did not consider total dorsal kyphosis value as all hemivertebras treated were at lumbar or thoracic lumbar level. No major complications emerged (infections, instrumentation mobilization or failure, neurological or vascular impairment) and only one pedicle fracture occurred.
Our findings show that the hemivertebra resection with posterior approach instrumentation is an effective procedure, which has led to significant advances in congenital deformity control, which include excellent frontal and sagittal correction, excellent stability, short segment arthrodesis, low neurological impairment risk, and no necessity for further anterior surgery.
Surgery should be considered as soon as possible in order to avoid severe deformity and the use of long segment arthrodesis. The youngest patient we treated, with a completed dossier at the end the follow up was 24 months old at the time of surgery; the youngest patient treated by this procedure was 18 months old at the time of surgery.
PMCID: PMC3897828  PMID: 23934348
Hemivertebra; Posterior approach lumbar hemivertebra resection; Congenital scoliosis
25.  Posterior vertebral column resection in early onset spinal deformities 
European Spine Journal  2013;23(1):198-208.
Early onset spinal deformities (EOSD) can be life-threatening in very young children. In the growing spine, surgical intervention is often unavoidable and should be carried out as soon as possible. A deformed section of the spine not only affects the development of the remaining healthy spine, but also that of the chest wall (which influences pulmonary function), the extremities and body balance. Posterior vertebral column resection (PVCR) represents an effective surgical solution to address such problems. However, reports in the literature concerning PVCR are mostly limited to its use in adolescents or adults. The purpose of this study was to illustrate our experience with PVCR in EOSD and to describe the surgical technique with respect to the unique anatomy of young children.
Materials and methods
Four children [mean age 3.7 (range 2.5–5.2) years] with severe spinal deformity underwent PVCR through a single approach. Multimodal intraoperative monitoring was used in all cases. Surgery included one stage posterior circumferential resection of one vertebral body along with the adjoining intervertebral discs and removal of all posterior elements. A transpedicular screw-rod system was used for correction and stabilisation. Fusion was strictly limited to the resection site, allowing for later conversion into a growing rod construct at the remaining spine, if necessary. Relevant data were extracted retrospectively from patient charts and long spine radiographs.
The mean operation time was 500 (range 463–541) min, with an estimated blood loss of 762 (range 600–1,050) ml. Mean follow-up time was 6.3 (range 3.5–12.4) years. After PVCR, the mean Cobb angle for scoliosis was reduced from 69° (range 50–99°) to 29° (5–44°) and the sagittal curvature (kyphosis) from 126° (87–151°) to 61° (47–75°). The mean correction of scoliosis was 57 % (18–92°) and of kyphosis, 51 % (44–62°). There were no spinal cord-related complications. In three patients, spinal instrumentation for growth guidance (fusion less growing rod technique) was applied. Two patients had complications: one patient had a complication of anesthesia, halo pin failure, and revision surgery with extension of the instrumentation cranially due to loss of correction; the second patient had a postoperative infection, which required plastic reconstructive measures.
PVCR appears to be an effective technique to treat severe EOSD. There are important differences in its use in young children when compared with older patients. In patients with EOSD, additional surgical procedures are often necessary during growth, and hence non-fusion instrumentation beyond the vertebral resection site is advantageous, as it permits spinal growth and the later addition of fusion.
PMCID: PMC3897829  PMID: 23978993
Early onset spinal deformity; Early onset scoliosis; Posterior vertebral column resection; Growing rod instrumentation; Surgical technique; Multimodal intraoperative monitoring; Surgical complications; Paediatric spine surgery

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