ABSTRACTS

XXXII

Italian Spine Society National Congress

Baia Samuele – Punta Sampieri, Ragusa

21–23 May, 2009

ABSTRACTS

123

Eur Spine J (2009) 18:727–780

DOI 10.1007/s00586-009-0962-4

ORAL PRESENTATIONS

DEFORMITY – Part 1

1

SPINAL DISORDERS IN PAEDIATRICS

(CLINICAL FINDINGS AND TREATMENT)

G. Stella

Genova, Italy

In 1968, there were two published books on scoliosis, one by Prof.

PierGiorgio Marchetti and one by Prof. Ugo del Torto. Both

reported the experience in new non-surgical and surgical treatments

of vertebral deformities and in particular of scoliosis. The efficacy

of surgical treatment of scoliosis according to Risser and the first

results of arthrodesis with Harrington distraction rod were con-

firmed. These books followed the monograph published by

Marchetti-Faldini in 1967 and the reports on scoliosis by V. Pie-

trogrande, L. Perugia, A. Maiotti, M. Pizzetti, P.G. Marchetti, A.

Faldini, A. Ponte and on kyphosis by L. Ranieri (LIII Congress of

the Italian Society of Orthopaedics and Traumatology, Chairman M.

Paltrinieri). After about 10 years, the Italian Study Group on Sco-

liosis (G.I.S.) was created and then became the Italian Society of

Vertebral Surgery-G.I.S. In a period of great confusion about the

therapeutic approaches to be adopted in this deformity considered

‘‘the cancer of orthopaedic surgery’’, rational indications in the

treatment of scoliosis were finally given. Other authors with a

special interest in vertebral deformities had already paved the way:

among the Americans, W. Blount, J. Cobb, P.R. Harrington, J.H.

Moe, J. Risser; among the Europeans, Y. Cotrel, J.I.P. James, R.

Roaf, P. Stagnara and many others highlighted the overlooked role

of vertebral deformities in orthopaedics. Honestly, all the Authors

considered their experience only as a starting point while waiting for

further improvements in the knowledge and treatment of these

severe deformities. In the space of 40 years, the great advances in

the fields of biomechanics, imaging of pathologic anatomy of

deformities and spinal diseases, and especially of surgical therapy

were not accompanied by parallel advances in understanding the

etiology of scoliosis, in particular of idiopathic scoliosis. Even in

congenital scoliosis, whose pathogenesis and morphogenesis have

already been well interpreted by Putti and Junghanns, most etiologic

agents of embryiopathies and fetopathies remain unknown. To quote

Haglund (1902), the etiology of idiopathic scoliosis and of spinal

congenital deformities is still ‘‘a large ink stain’’. For these reasons,

our treatments are still today often symptomatic, not causal. How-

ever, over the last few years, patients had better clinical results and

less discomfort during treatment. Many books and treatises, mainly

in the English language, were published on this topic, especially by

important American specialists, focusing also on exclusively

paediatric vertebral deformities. The ‘‘tone’’ of the book I am going

to present is a bit different. Without claiming to be exhaustive and

without forgetting the recent past, the author presents not only the

recent knowledge and surgical solutions that are useful to solve the

problems of our patients, but also to obtain an improved picture of

diseases causing vertebral deformities. Actually, these are the tip of

the inceberg consisting of diseases or syndromes causing spinal

deformity and possibly complicating its treatment. The book is

subdivided into 20 chapters, each illustrating underlying disease, in

some cases the possibility of prenatal diagnosis, the evolution of

spinal deformity, the possible non-surgical solutions (including, in

some cases, medical therapy) or surgical solutions, which makes the

book a prevalently practical tool. In my opinion, this book could be

useful for doctors who decide to focus their interest on the study and

treatment of diseases and vertebral deformities in children. In other

words, it is addressed not only to the beginner or to the orthopaedist

with little experience in paediatric diseases, but also to all those

doctors interested in the vertebral column in paediatric age. Since

this monograph is not an atlas of surgical techniques, only the

operative procedures most frequently used in children are syntheti-

cally reported. Several surgical techniques of historical importance

now superseded in the clinical practice are also reported since, in

my opinion, they can help the reader understand the evolution over

time of osteosynthesis in the treatment of vertebral deformities.

References include the major national and international papers on

different topics published up to the date of publication of the book.

2

THE CLASSIFICATION OF IDIOPATHIC

SCOLIOSIS: CRITICAL EVALUATION

M. Petruzzi, B. Cedron, C. Lamartina

I. R.C.C. S. IstitutoOrtopedicoGaleazzi –Chirurgia Vertebrale II,Milan, Italy

Ideally, the classifications of the disease serve for framing a clinical

entity, to allow to the surgeon to point out a specific treatment, and to

allow comparisons of different Methods of treatment. In 1983, King

et al. classified curves of idiopathic scoliosis on radiographies in antero-

posterior projection, describing therefore 5 types of curves and pointing

out the area of fusion. All the patients in their study were submitted to

vertebral fusion with Harrington rod with the purpose to correct the

deformity on the frontal plan. King et al. did not include in their clas-

sification the curved toracolumbar, lumbar, double or triple primary.

The classification of King has continued to always be used despite

the increasing general acceptance to consider the scoliosis as a three-

dimensional deformity and to use for the surgical treatment a seg-

mental fixation. Besides in base to a study performed to 2 different

groups of surgeons, in the 1998 Lenke et al. have shown a low degree

of reliability, validity and reproducibility of the King classification.

A classification of the idiopathic scoliosis should respond to the

followings requisite:

1. be comprehensive and include all curve types

2. emphasize consideration of sagittal alignment

3. help to define treatment that could be standardized

4. be based on objective criteria for each curve type

5. have good inter-intraobserver reliability

6. be easily understood and of practical value in the clinical setting

7. reflect the current concept of a 3-dimensional analysis of scoliotic

deformities

8. consider the skeletal age

Lenke et al. have published in 2001 a classification of the idio-

pathic scoliosis of the teen-ager, that tries to answer to these requisite

and that could be useful in the clinical practice.

The main advantage of King classification is the simplicity; the

principal disadvantage is that it has been made and concepted for the

Harrington instrumentation, so it’s connected to a monodimensional

correction. Lenke classification goes over this limit because it con-

siders the deformity also in the sagittal plane. The main disadvantage

is the complexity and the fact that it doesn’t consider the rotation.

This study shows the limits of both classifications on the base of some

examples.

728 Eur Spine J (2009) 18:727–780

123

3

POST-SURGICAL EVOLUTION OF THE

SAGITTAL ALIGNMENT IN ADOLESCENT

IDIOPATHIC SCOLIOSIS

A. Luca, G. De Giorgi, S. De Giorgi

Dip. di Metodologia Clinica e Tecnologie Medico Chirurgiche;U. O. Ortopedia e Traumatologia I Universita degli Studi di Bari,Italy. Chief: Prof. G. De Giorgi

Background: According the concept of the open linear chain pro-

posed by Berthonnaud the sagittal alignment of the spine is strictly

related to the shape and orientation of each anatomic segment of the

spinopelvic complex in order to maintain a normal posture with the

minimum of energy expenditure.

This relationship can be find out even in adolescent idiopathic

scoliosis and maintains its effectiveness in patients who undergo

surgery for the same pathology: in this case the modifications

in the alignment involve the segments not included in the fusion

area.

Aim of the Study: To evaluate the impact of the surgery on the global

sagittal alignment of the spine and pelvis.

Methods: Six sagittal parameters were evaluated on lateral radio-

graphs (preoperative, postoperative and follow up) of 65 patients with

adolescent idiopathic scoliosis surgically treated: C7 plumb line,

thoracic kyphosis, lumbar lordosis, sacral slope, pelvic tilt, pelvic

incidence. Two more parameters were evaluated on postoperative

radiographs: lumbar lordosis within the fusion (LLWF) and lumbar

lordosis below the fusion (LLBF).

The patients were classified according the caudal end of the fusion

in five different groups: 1 with caudal end on T12 (8 pts), 2 on L1 (6

pts), 3 on L2 (3 pts), 4 on L3 (27 pts), 5 on L4 (21).

For each patient, authors also evaluated social and functional

parameters in order to estimate quality of life after the surgery.

Results: No modifications about C7-plumbline alignment were seen

in preoperative, postoperative or FU radiographs.

No statistically SPSS significant changes in TK values were found

among the groups comparing the preoperative radiographs

(28�\TK\37,6�) with postoperative (30,1\TK\34) and F.U.

(34,2\TK\35).

Even LL does not show great differences comparing preoperative

data (50,8�\LL\57,2�) with postoperative (52,2�\LL\56�) and F.U.

(54�\LL\56�) ones. Considering the LLWF we found a slight decrease

after surgery. Looking at the F.U. in the group 5 the LLWF tends to

return to the preoperative value. Moderate changes were found even

considering the LLBF: it shows a progressive increase in all the groups

after surgery and at the F.U. The PI definitely increases after surgery and

at the follow up in each group with the exception of group 5 where no

changes were found.

The SS increases in all groups with the exception of group 3 (data

about group 3 could be affected by the meagre number of patients)

The PT tends to maintain its value unchanged or show a slight

increase not relevant from a statistical point of view.

Discussion: Our data show that surgery in adolescent idiopathic

scoliosis allows to achieve an optimal correction of the deformity in

both plane, coronal and sagittal. About lordosis, our data confirms a

correlation between LLWF and LLBF, as already stated in literature:

the decrease of LLWF is compensate by increase of LLBF.

Even the sacrum takes part in balancing the sagittal alignment

after surgery with a complex movement of anterior translation: this is

demonstrated by the increase of sacral slope.

No changes in PT were found: that suggests no changes in the

orientation of the pelvis relative to the hips.

According what we found a normal sagittal balance after surgery

can be easily reached just modifying the spine orientation without the

involvement of the hips

Conclusions: Our data show that in order to obtain a good results in

the middle-long follow up it is mandatory a detailed preoperative

selection of the fusion area in both plane, coronal and sagittal, and an

accurate tridimensional correction of the deformity during surgery

with implants of third generation.

If a good lumbar lordosis and thoracic kyphosis are achieved with

surgery it will be possible to reduce the overstress on the area below

fusion avoiding relevant changes in the pelvis.

4

ANALYSIS OF SAGITTAL BALANCE AFTER

POSTERIOR SURGERY IN ADOLESCENT

IDIOPATHIC SCOLIOSIS (AIS): HOOKS

VS. SCREWS

M. Balsano*, P. Parisini�, M. Di Silvestre�, G. Bakaloudis�

*U. O. C. Ortopedia e Traumatologia, Centro Regionale diRiferimento per la Chirurgia Vertebrale - Thiene-Schio, Vicenza,Italy; �Spinal Surgery Department - IOR, Bologna, Italy

Since the introduction of Cotrel-Dubousset instrumentation in 1984,

the techniques of correction in scoliosis’ surgery have changed from

Harrington principles of distraction of the concave side of the curve to

segmental realignment of the spine by using different Methods

(rotation, translation, cantilever, in situ bending, ecc).

In addition, the use of pedicles screws, at first in lumbar curves,

have enhanced correction and stabilization of scoliosis.

Various studies have showed significant better results and clini-

cal advantages of pedicle screws vs. conventional hook instru-

mentation.

Many Authors have focused their attention in the study of coronal

correction of scoliosis, and many papers have been written about this

theme, but not much about the behaviour of the sagittal curves pre and

post surgery.

The purpose of this study is to investigate the sagittal changes of

the curves of AIS (Adolescent Idiopathic Scoliosis) underwent sur-

gery correction and to compare segmental pedicle screw vs. hook

instrumentation.

Materials and Methods: We have selected 77 patients with Ado-

lescent Idiopathic Scoliosis (AIS) Lenke 1 and 2, operated in our

institutes with posterior fusion and instrumentation. The average age

was 16, 3 yrs. (11–25). The minimum follow-up has been 2 yrs., the

maximum 15 yrs. in 31 patients we have used only hook instru-

mentation (group A) and in 38 patients we have used only pedicles

screws (Group B).

The average of fused segments has been 7.7 segments in group A,

6.6 in the group B.

We have investigated the behaviour of sagittal curves, studyng the

kyphosis (T5-T12), Lumbar Lordosis (T12-S1), and Thoraco-lumbar

alignment (T10-L2).

Not significative differences between the 2 groups have been

noted related to age, pre operative magnitude of curves, length of

fusion (p\0.05).

Results: The pre-operative T5-T12 angle was similar in the 2 groups:

23,4 in the hook group and 21,4 in the screw group. The immediate

postoperative thoracic kyphosois averaged 25,6 in the hook group and

19,3 in the screw group. After a minimum f.up. of 2 yrs. the thoracic

kyphosis was 24,7 in grouip B and 29,8 in the group A.

Eur Spine J (2009) 18:727–780 729

123

The lumbar lordosis (T12-S1) was similar in both groups: -56.6 in the

hook group and –51,5 in the screw group. The immediate post. op.

lumbar lordosis demonstrated some slight but significant differences

(-55.1 in the hook goup and – 41,7 in the screw group). At the last f.up

Lumbar Lordosis was –56.1 in group A and – 45.7 in group B.

The thoraco-lumbar junction (T10-L2) has showed the same trend:

Group A 10.8 pre-op, 11.3 post.op. and 12.1 at f.up.; group B 9.7 pre-

op, 8.9 post.op and 9,3 at the last follow-up.

Discussion: In the screw group (Group B) thoracic kyphosis has

decreased after surgery and a slight decrease has been noted also in

lumbar lordosis.

On the contrary the hook group (Group A) have showed a slight

but significant increase in both the angles, especially in the thoracic

kyphosis.

These results can be probably explained with the different mate-

rials utilized (SS and titanium). The use of titanium rod (5.5 mm.

diameter) in the pedicle screw instrumentation achieve a great and

strong correction in the coronal plane but, in reason of its axial

flexibility, produces a straight spine in both the planes.

The use of hook instrumentation in SS with rods of 6.35 mm.

diameter achieve less correction in the coronal plane but a significant

better sagittal balance. This can be explained with the less memory’s

shape of the SS vs. titanium.

In addition the anterior disc height decrease because posterior hook

instrumentation allows anterior settling during the fusion process.

However the strong 3-column purchase in the screw group pre-

vented disc settling.

These differences, even if not clinically relevant, must be con-

sidered during the planning of surgery and during the correction

maneuvers of the deformity.

5

COTREL-DUBOUSSET INSTRUMENTATION

IN NEUROMUSCULAR SCOLIOSIS

A. Piazzolla, S. De Giorgi, G. Solarino, G. De Giorgi

Universita degli Studi di Bari – Italy. Dipartimento diMetodologia Clinica e Tecnologie Medico Chirurgiche –U.O. Ortopedia e Traumatologia I, Italy. Chief: Prof. G. De Giorgi

Study Design: Retrospective.

Aim: To describe our experience about the treatment of patients with

NMS (neuromuscular scoliosis) using Cotrel-Dubousset

instrumentation.

Summary of Background Data: Neuromuscular scoliosis are diffi-

cult 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 maximising 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 respi-

ratory complications. The instrumented spinal fusion (ISF) with

second-generation instrumentation (eg, Luque–Galveston and unit rod

constructs), are still considered the standard surgical technique for

neuromuscular scoliosis (NMS) even if the Cotrel-Dubousset (CD)

surgical technique, used since the beginning of the mid 1980 s has

represented the highest level achieved in correction of scoliosis by a

posterior approach. Today, 30 years after the introduction of CD,

reports are lacking on the results of third-generation instrumentation

for the treatment of NMS.

Methods: 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

6 months follow-up were reviewed, evaluating correction of coronal

deformity, sagittal balance and pelvic obliquity, and rate of

complications.

Materials: 24 patients (Friedreich’s ataxia: 1, Cerebral Palsy: 14,

Muscular dystrophy: 2, Polio: 2, Syringomyelia: 3, Spinal Atrophy:2)

were included. Mean age was 18,1 years at surgery (range 11y7 m -

max 31y). Mean follow-up was 118 months (range 8-259). The most

frequent patterns of scoliosis were thoracic (10 cases) and thoraco-

lumbar (9 cases). In 8 cases we had a hypokyphosis, in 6 a normal

kyphosis and in 9 a hyperkyphosis. In 8 cases we had a normal lordosis,

in 11 a hypolordosis and in 4 a hyperlordosis. In 1 case we have a global

T4-L4 kyphosis. In 8 cases there were also a thoracolumbar kyphosys

(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 preop-

erative 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 archs and spinous processes (in all 7 cases with fusion

extended untill S1, it was augmented with calcium phosphate).

Results: 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 hyper kyphosis and hypo or hyper

lordosis. 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 physio-

logical values (mean 2�. min 0� - max 5�).The mean intraoperative

blood lost were 2100 cc (min. 1400 max. 5350).

Major complications affected 8,3% of patients, and included 1 post-

operative death and 1 deep infection. Minor complications affected

none of patients.

Conclusions: CD technique provides lasting correction of spinal

deformity in patients with neuromuscular scoliosis, with a lower

complications rate compared to reports on second-generation instru-

mented spinal fusion.

Keywords: Neuromuscular scoliosis, Cotrel-Dubousset, spinal

fusion.

6

SURGICAL TREATMENT OF NEUROLOGICAL

SCOLIOSIS BY MEANS OF HYBRID CONSTRUCT:

LUMBAR TRANSPEDICULAR SCREWS PLUS

THORACIC UNIVERSAL CLAMPS

G. La Rosa, G. Giglio

Department of Paediatric Surgery-Orthopaedic Unit;Research Institute and Paediatric Hospital Bambino GesuPalidoro (Rome, Italy)

The segmental spine instrumentation (SSI) in the nineties had a good

validation by most spinal surgeons but the technique have been

730 Eur Spine J (2009) 18:727–780

123

progressively abandoned for the intrinsic implant difficulty and neu-

rological complication risk in favour of the Cotrel-Dobousset spinal

system. The C-D instrumentation, based on the segmentation of

curves, improves the angular correction but over all actuates the

sagittal profile. Sublaminar acrylic loops (Universal Clamp) have the

same stress resistance in comparison with steel or titanium alloy su-

blaminar wires. The simplicity of implant and tensioning of the strips

is associated with the possibility of re-tensioning and progressive

correction. The increase of the contact area gives an improvement of

the corrective forces with a reduction of the laminar fracture risk. Our

aim has been to verify the validity of this spinal fixation implant in the

surgical treatment of neurologic scolioses.

Methods: We treated surgically 24 patients by using universal clamps

associated with Socore TM spinal assembly, transpedicular lumbar

screws and apical thoracic hooks. The ethiology was cerebral palsy in

twenty-two cases and Friedreich ataxia in two cases. The median

angular pre-operative value was 92.4�. The median age was of

14 years for all the patients included in the study (range: 10–17 yrs).

The average follow-up consisted of 18.3 months and we implanted an

average of 6 clamps for each procedure (range: 3–8).

Results: The average percentage of correction has been of 72.2%+/-

8%. The mean loss of correction at follow-up of two years was 4�+/-

2� The learning curve period is shorter if the surgeon has experienced

the SSI procedure. The operating time is reduced in comparison with

surgical procedures in which we used screws at each level and fur-

thermore there is a better capacity of managing the kyphotic

component in case of thoracic lordosis.

Conclusions: The technique using universal clamps appears safe and

effective and represents a valid contribution in association with

lumbar screws, reduced number of dorsal screws or pedicle-transverse

hooks at the upper end of the curve. The assembly stability is satis-

fying in the post-operative period. It is mandatory to analyse the

results in the long term follow-up in terms of correction loss,

pseudoarthroses, mechanical failure of the strips.

Significance: The use of a hybrid assembly (lumbar screws, dorsal

acrylic clamps, apical dorsal hooks) showed a mechanical effi-

ciency as in case of the use of transpedicular screws at all level.

The advantages connected with a shorter operating time and

diminished risk of vascular or neurologic complications permit to

judge the technique as valid between the actual options of thera-

peutic planning.

DEFORMITY – Part 2

7

POSTERIOR EMISPONDILECTOMY

IN CONGENITAL SCOLIOSIS

M. Crostelli, O. Mazza, M. Mariani

Children Jesus Paediatric Hospital Palidoro-Roma, Italy

The authors present 7 cases of congenital scoliosis with lumbar

emivertebra. Patients have been treated by posterior emispondi-

lectomy and peduncolar screws stabilization. In the past, techniques

of choice used in emivertebra scoliosis have been in situ fusion,

posterior emiphisiodesis or anterior and posterior emiphisiodesis,

alternative procedures are arthrodesis and emivertebra resection by

combined antero-posterior approach. In our study 7 congenital

scoliosis cases have been treated only by posterior approach

with emivertebra resection and 2 levels stabilization, 3 levels

stabilitazion in the case of deformity above or under emispondilus.

All operated patients had worsening curves or pain from deformity.

Mean follow up was 18 m years. Mean scoliosis curve value has

been 41 cobb grades, reduced to 15 Cobb grades after surgery.

Mean kyphosis value has been 24 grades, reduced to 10 grades

after surgery. There was no major complication (infection, instru-

mentation mobilization or failure, neurological or vascular

impairment, peduncolar fracture). In authors opinion emispondi-

lectomy with posterior approach instrumentation is an effective

procedure with significative advantages over congenital deformity

control: excellent frontal and sagittal correction, best stability, short

segment arthrodesis, low neurological impairment risk, no necessity

of additional anterior surgical approach. Surgery should be con-

sidered as soon as possible in order to avoid severe deformity and

the use of long segment arthrodesis. In our experience youngest

patient was 2ys and 6 months old.

8

THORACIC PEDICLE SUBTRACTION

OSTEOTOMY IN THE TREATMENT OF SEVERE

PAEDIATRIC DEFORMITIES

G. Bakaloudis, M. Di Silvestre, A. Cioni, K. Martikos, P. Parisini

Spine Surgery Department - Istituti Ortopedici Rizzoli – Bologna,Italy

Purpose: To determine the safety and efficacy of posterior thoracic

pedicle subtraction osteotomy (PSO) in the treatment of severe

paediatric deformities.

Material and Methods: A retrospective review was performed on

12 consecutive paediatric patients (6 F, 6 M) treated by means of a

posterior thoracic PSO between 2002 and 2006 in a single Insti-

tution. Average age at surgery was 12,6 years (range, 9–16),

whereas the deformity was due to a severe adolescent idiopathic

scoliosis in 7 cases (average preoperative main thoracic 113�; 90–

135); an infantile idiopathic scolosis in 2 cases (preoperative main

thoracic of 95� and 105�, respectively); a post-laminectomy kypho-

scoliosis of 95� (for a intramedullar ependimoma); an angular

kypho-scoliosis due to a spondylo-epiphisary dysplasia (already

operated on 4 times); and a sharp congenital kypho-scoliosis

(already operated on by means of a anterior-posterior in-situ

fusion). In all patients a pedicle screws instrumentation was used,

under continuous intraoperative neuromonitoring (SSEP, NMEP,

EMG).

Results: At an average follow-up of 2.4 years (range, 2–6) the main

thoracic curve showed a mean correction of 61�, or a 62,3 % (range,

55%–70%), with an average thoracic kyphosis of 38,5� (range,

30�–45�), for an overall correction of 65% (range, 60%–72%). Mean

estimated intra-operative blood loss accounted 19,3 cc/kg (range,

7.7–27.27). In a single case (a post-laminectomy kypho-scoliosis) a

complete loss of NMEP occured, promtly treated by loosening of the

initial correction, and a final negative wake-up test. No permanent

neurologic damage, or instrumentation related complications, was

observed.

Conclusions: According to our experience, posterior-based

thoracic pedicle subtraction osteotomies represent a valuable tool in

the surgical treatment of severe paediatric spinal deformities, even in

revision cases. A dramatic correction of both the coronal and sagittal

profile may be achieved. Mandatory the use of a pedicle screws-only

instrumentation and a continuous intraoperative neuromonitoring to

obviate catastrophic neurologic complications.

Eur Spine J (2009) 18:727–780 731

123

9

LOW BACK PAIN IN PATIENTS WITH ADULT

IDIOPATHIC SCOLIOSIS: COMPARISON OF

THREE REHABILITATIVE METHODS OF

TREATMENT

V. Pavone, M. Privitera, F. Cosentino, G. Sessa

Orthopaedic Clinic, University of Catania, Italy;Chief of Department: Prof. G. Sessa

Introduction: The adult form of idiopathic scoliosis is less com-

monly recorded than its counterpart in the juvenile age. Clinically, it

often presents as invalidating painful phenomena. Several rehabili-

tative techniques are used as treatment strategies mainly for reducing

the low back pain but prospective comparative studies are lacking.

Aim of Study: Aim of present study is to evaluate in an homogeneous

cohort of adult patients, characterized by mild scoliosis, three reha-

bilitative approaches [e.g., Mezieres, Calliet and Proprioceptive

Vertebral Stimulation (PVS)], so as to determine the efficacy of the

different techniques.

Materials and Methods: The three different rehabilitative approa-

ches were applied blindly in a total number of 30 patients, divided

into three groups (each as homogeneously possible). Each group was

formed by ten subjects equally distributed re gender, age, and type of

scoliosis. Every single patient was evaluated both clinically and

radiographically. Only patients with the following features were

enrolled in the study and distributed in three groups: (1) age between

40/55 years; (2) Cobb degrees between 10 and 25; (3) moderate

physical activity; (4) frequent low back pain; (5) absence of neuro-

logical complications and absence of relevant osseous alterations. The

pain was evaluated through the VAS (Visual Analogical Scale) and

the disability (coupled with the Oswestry) Methods. Each study group

was treated over eight weeks. At the end of treatment all patients were

evaluated clinically by means of a questionnaire, which had been

filled at the beginning and at the end of the study.

Results: The patients - at the beginning of the study - before starting

treatment, presented a questionnaire with similar values both in the

VAS scale and in the Oswestry disability Index, as demonstrated by

Student test applied to the different groups. At the end of treatments

all groups of patients showed modest improvements concerning dis-

ability and pain statistically relevant in the group where the Mezieres

method was applied.

Discussion and Conclusions: The Mezieres method with its global

approach with the entire body structure seems to determine a re-

balance of the muscular tension and of the kinetic chain, this seems to

being reflected positively on the reduction of painful phenomena.

However, it would be important to test the trial in a more consistent

group of patients, also by extending the treatment’s period, in order to

precisely determine the period of real pain relief. None of the dif-

ferent Methods seem completely remittent. The rehabilitative therapy

should be transformed in a ‘‘life style’’ that the patients should adopt

continuously, to better cope with their pathology.

10

DEGENERATIVE LUMBAR SCOLIOSIS IN

ELDERLY PATIENTS: DYNAMIC STABILIZATION

WITHOUT FUSION VS POSTERIOR

INSTRUMENTED FUSION

F. Lolli, M. Di Silvestre, T. Greggi, F. Vommaro, P. Parisini

Spine Surgery Department - Istituti Ortopedici Rizzoli – Bologna,Italy

Purpose: To compare the results of dynamic stabilization without

fusion and posterior instrumented fusion in the treatment of degen-

erative lumbar scoliosis.

Study Design: A retrospective study.

Patient Sample: 54 elderly patients (46 F and 8 M; age 64.1 years,

range 61 to 78) were included. Exclusion criteria: scoliosis angle

[35�, sagittal imbalance, age \60 years, previous spinal fusion or

instrumentation.

Methods: Patients were divided into 2 groups according to surgical

treatment made. 23 patients (DS Group) were treated with dynamic

stabilization (Dynesys), 25 patients (PIF Group) with posterior

instrumented fusion (always titanium instrumentation). The two

groups were well matched according to age (65.3 vs 62.6 years),

gender (female: 75.9% vs 72%), scoliosis Cobb angle (16.9� vs

19.2�), instrumentation extension (3.7 vs 4.3 levels).

Results: At a mean FU of 54 months (range 39 to 67), the

questionnaires showed no statistically significant differences (P [0.05) between 2 groups. ODI score improved in DS Group from a

preop. score of 51.8% to 28% at last follow-up, in PIF Group from

52.7% to 30.2%. VAS score improved in DS Group from 6.7 to

3.4, in PIF Group from 6.5 to 3.8. There were differences

according to mean surgical time (190 vs 245 min), blood loss (935

vs 1425 cc) and hospital stay (4.9 vs 7.5 days). Major complica-

tions occurred in 2 cases (6.9%) in SD Group (a sciatica due to a

misplaced screw on L5, treated with screw replacement, and a

junctional disc degeneration, treated with extension of fixation), in

4 cases (16%) in PIF Group (2 flat-back, treated with an extension

of fixation to S1 in one case and with a correction through a PSO

in the other case; a junctional kyphosis, treated with extension of

fixation; a paraparesis due to a hematoma, treated by surgical

drainage, but without neurological recovery).

Conclusions: These results showed that dynamic stabilization is a

safe procedure in elderly patients with degenerative lumbar scoliosis.

This technique resulted less invasive with minor surgical time, blood

loss and complications rate (6.9% vs 16%) than instrumented pos-

terior fusion.

732 Eur Spine J (2009) 18:727–780

123

DEFORMITY – Part 3

11

SURGICAL TREATMENT OF DEGENERATIVE

SCOLIOSIS IN THE ADULTS (DE NOVO SCOLIOSIS)

M. Palmisani, S. Boriani

Department of Orthopaedics and Traumatology - OspedaleMaggiore, Bologna, Italy.Dir: Dr. S. Boriani

From January 1997 to December 2005 we treated surgically 49 sco-

liosis and degenerative scoliosis and cyphoscoliosi at the Orthopedics

and traumatology Department of the Ospedale Maggiore from

Bologna.

They were 13 male and 36 female with an average age of 66 years

(55–80).

All cases had low back pain resistant to medical and physical

treatment, that was associated with a sciatica in 15 cases, with a

claudicatio neurogena in 20cases, and in 20 was neurolgical deficit.

The scoliosis had a angular average value of 27� (10�–45�).

In all cases was taken, at all levels, an arthrodesis with pedicular

screws associated with laminectomy in the cases with sciatica or

lumbar spine stenosis and in the cases with serious intability of

postero lateral interbody fusion. In 44 cases arthrodesi is performed

up to sacrum.

After the surgery, before resignation, all the patients has been

studied with rx associating tac to highlight the correct posizioning of

the screws and the decompression of neural structure.

40 patients were monitored at a minium distance of 3 years and

maxium of 10 years from the surgery with rx, Tac o Rmm.

Clinic results were evalutated according Withe e Coll. (Spine

1987) and we record 10 (25%) excellent cases, 12 (30%) good, 14

(35%) fair and 4 (10%) poor.

Among other complications, we report 3 cases of dural lesion in 1

case that required a revision with a complete healing, 2 cases of a bad

positioned screws that required the review of the system.

12

SELECTIVE THORACIC FUSION IN LENKE

TYPE B,C LUMBAR MODIFIER ADOLESCENT

IDIOPATHIC CURVES

M. Di Silvestre, G. Bakaloudis, T. Greggi, S. Giacomini,P. Parisini

Spine Surgery Department - Istituto Ortopedico Rizzoli –Bologna, Italy

Purpose: To determine the efficacy of posterior selective tho-

racic fusion in the treatment of Lenke type B, C lumbar modifier

curves.

Material and Methods: A retrospective review was performed on

a consecutive series of 114 patients operated on, between 2000 and

2006 in a single Institution, by means of a selective pedicle screw

only thoracic fusion, with 45 (40 F, 5 M) responding to the fol-

lowing selection criteria: a main thoracic curve (Lenke type 1, 2,

3,and 4), with lumbar modifier type B (in 24 cases) and type C (in

21 cases). Average age at surgery was 15,4 years (range, 11–18),

with average Risser sign of 3,2 (range, 1–5). The lowest instru-

mented vertebra (LIV) was in 1 case T11, in 8 T12, in 18 L1, and

in 18 L2, corresponding to the stable vertebra (SV)-2 in one case,

to the SV-1 in 10 cases, in 31 cases was at the SV level, whereas

in the remaining 3 cases the LIV was the SV+1.

Results: At a mean follow-up of 4.5 years (range, 2–8), the main

thoracic curve presented an average correction of 60.2% (from

68.5� to 26.2�), while the secondary lumbar curve obtained a

spontaneous correction of 48% (from 40.8� to 22.4�), main thoracic

apical vertebra translation medially corrected from 4.8 cm to

1,9 cm (59 %), whereas the lumbar apical vertebra translation

remained unchanged (from 1.05 cm to 1,14 cm). Finally the lowest

instrumented vertebra tilt was corrected on average for a 67.63%

(from 18.19� to 5.8�). In nine cases we observed at latest follow-up

a mild decompensation of the secondary lumbar curve that didn’t

necessitated so far a revision surgery. In two cases, presenting a

lumbar modifier type B, an overcorrection of the main thoracic was

observed, whereas in the remaining 7 cases, being a Lenke 3C

curve, the LIV was always shorter than the SV.

Conclusions: According to our experience, selective thoracic fusion

in Lenke type B, C lumbar modifier curves, by means of pedicle

screw only instrumentations, present satisfactory results at a mid

term follow up. Lumbar spontaneous correction occurs mainly due

to upper lumbar vertebra’s tilt amelioration, and not as an apical

vertebra’s translation correction. A mild decompensation of the

lumbar secondary curve, observed in 20% of the present series, has

been found to be well tolerated and didn’t necessitated so far a

revision surgery.

13

THE CLAMP: AN EVOLUTION OF SUBLAMINAR

WIRE IN SURGICAL TREATMENT OF SPINAL

DEFORMITIES

P. P. Mura1, G. Costanzo2, D. Fabris Monterumici3, G. La Rosa2

Cagliari1, Roma2, Padova3, Italy

Scoliosis and other deformities are complex spinal problems that can

create many health problems for patients including pain, reduced

mobility and impaired organ function.

Surgical treatment of spinal deformities is considered when

medical treatment cannot control the deformity The absence of sur-

gical treatment might lead to an exacerbatio of the deformity, pain,

respiratory problems or, exceptionally, even paralysis. The surgical

procedures in question have two objectives. Correction or stabiliza-

tion of the deformity and preservation of the correction by means of

rods, hooks, screws or metal wires. To ensure the preservation of this

correction over time, bone grafts may be performed. Numerous

techniques have been developed to obtain fusion and correction:

system of hooks, steel wiring around a frame, and more recently

screws. The Universal Clamp is an innovative device that simplifies

the correction of scoliosis and other spinal disorders. The Universal

Clamp consists of a polyester band with titanium clamp and a set

screw. It may be used in place of, or in addition to screws, wires,

cables and hooks that are typical device in modern spine surgery and

permits surgical maneuvers including reduction, translation, distrac-

tion and compression to help anatomical alignment and balance. The

authors conducted a retrospective study on 12 patients who had

undergone operation operations for adolescent idiopathic scoliosis

with this device. The Clamp is an evolutional step in the scoliosis

treatment, with simple, safe and strong bone fixation.

Eur Spine J (2009) 18:727–780 733

123

14

THORACOLUMBAR KYPHOSIS IN

MUCOPOLYSACCHARIDOSIS TYPE 1:

AN EMERGING DISEASE

M. Carbone, F. Vittoria

S. C. O. Ortopedia e Traumatologia Pediatrica e Centro per ilTrattamento della Scoliosi; I. R. C. C. S.Burlo Garofolo – Trieste, Italy

Introduction: The Mucopolysaccharidosis type I (MPS I) is a serious

metabolic genetic disease; according to its seriousness, three variants

are distinguished.

In the worst form (Hurler syndrome or MPS I-H), the main

symptoms are a psychomotor delay and skeletal deformities, as a

result of which these patients show the morphologic features of

gargoylism, with grotesque facial features, a stature much shorter

than the average, severe joint stiffness and an evolutionary angular

thoracolumbar kyphosis, with the apex on one or more malformed

vertebrae and a progressive neurological involvement.

Until recently, these patients had a short life expectancy - less than

ten years of age - and a definitive etiologic cure does not exist as yet;

however, recent indications for bone marrow transplantation, or other

enzyme replacement therapies, show promising results on the mani-

festations of the disease, thus extending the survival of these patients.

Within a multidisciplinary team, the spinal surgeon has therefore to

deal with a ‘‘new’’ disease for which possible indications to the

treatment are to be assessed: joint stiffness responds well to medical

treatment, while the worsening of the kyphosis is unchanged.

Materials and Methods: From 2005 to the 2008, 3 patients with

MPS I-H have come to our observation. All of them had undergone

bone marrow transplantation.

• C.G., 4 years old, with kyphosis apex at the level of malformed

vertebrae L1 and L2 and an initial alteration of sensory evoked

potentials of the lower limbs, has undergone surgery in two stages:

at first a posterior instrumented arthrodesis T12-L4, later on an

anterior arthrodesis with insertion of a carbon cage.

• G.E., 5 years old, suffering from kyphosis with apex in L2, is

being treated with an extension corset and she undergoes periodic

orthopaedic and electrophysiological controls.

• N.N., 3 years old, with a similar deformity and a recent history of

bone marrow transplantation, is temporarily undergoing ortho-

paedic treatment.

Results: The one patient who has been surgically treated has an

excellent clinical, radiographic and electrophysiological outcome,

with a follow-up of only 6 months. In the two other patients, the

corset application is a procrastination treatment awaiting a surgical

correction, while the effects of bone marrow transplantation are

assessed under careful orthopaedic, radiological and electrophysio-

logical supervision.

Discussion and Conclusions: Kyphosis occurring in dysmorphic

syndromes and bone dysplasias often appear similar to congenital

forms. Particularly in MPS I-H, kyphosis deformity, owing to the lack

of development of the anterior part of the vertebral body, is similar to

a type I form. The same characteristics occur in the patients affected

by achondroplasia with evolutive toracolumbar kyphosis due to a

posterior hemivertebra.

Relying on this analogy, we have opted for circumferential

arthrodesis, with a satisfactory result on the sagittal spine equilibrium,

even if with short follow-up. The highest premature treatment allows

us to prevent the unavoidable neurological complications and to treat

less rigid and more easily correctable deformities.

15

LUMBO- SACRAL SPONDYLOLISTHESIS

EVOLUTION IN THE SURGICAL TREATMENT

OF IDIOPATHIC SCOLIOSIS

M. Crostelli, O. Mazza, M. Mariani

Children Jesus Paediatric Hospital Palidoro-Roma, Italy

The authors analyze lumbo-sacral spondylolisthesis evolution in

idiopathic scoliosis treated by posterior arthrodesis. There are 15 cases

treated by instrumented posterior arthrodesis, presenting grade 1 or grade

2 lumbo-sacral spondylolisthesis. In literature there is a significative

association between dorso-lumbar scoliosis and lumbo-sacral spondy-

lolysis, with or without vertebral listesis. Grade 1 or grade 2 listesis

without simptoms have no necessity of any tratment and their evolution is

not correlated to associated scoliotic curves severity. Our patients have

13ys and 4 months mean age, with mean Cobb grades value of major

scoliosis curve 50. They have been treated by posterior approach

arthrodesis with titanium instrumentation using peduncolar lumbar

screws and laminar hooks, or thoracic and lumbar screews. Mean main

curve value in Cobb grades after surgery has been 12�.

In all cases instrumentation was not after lithic level but arthrodesis

stopped 2 levels above. Mean follow up has been 5 years. No patient

presented in standard x-ray examination augmentation of vertebral

listesis and no patient had lumbar pain enhancement or neurologic

symptoms after surgery. There is no evidence of significative differences

between the two groups of listesis in the behaviour of olisthesis.

Above arthrodesis showed no sign of mobilization.

Avoiding long arthrodesis taking lower lumbar segment leave the

patient with good lumbar mobility, allowing him to attend daily

activities without pain and limitations. Even in grade 1 or 2 lumbo-

sacral spondylolysis our experience shows that functional overweight

on lower lumbar vertebrae caused by above arthrodesis does not

enhance listesis progression risk. The authors think that lumbar

spondylolysis presence should not modify surgical treatment of sco-

liosis and is not a cause to widen to the sacrum arthrodesis area.

FRACTURES AND VERTEBRO-KYPHOPLASTY

16

SPONTANEOUS LUXATION OF C1- C2 IN A CHILD

WITH TRISOMY 20

M. Broger, M. Campello, P. Rizzo, M. Tripodi, A. Schwarz

Dept. of Neurosurgery. Central Hospital of Bolzano, Italy

Introduction: Trisomy 20 is a genetic anomaly often responsible for

spontaneous abortion. In the surviving infants, psychomotor retarda-

tion and malformations involving multiple organs are easily

recognized soon after birth. Occipito-cervical malformations are

frequent spinal abnormalities for this group of patients.

Case Report: We report the case of an eight year-old girl, who came

to our attention with a history of persistent torticollis. No history of

neck trauma was reported. Upon physical examination she showed

diverging strabismus and a soft palate malformation; radiological

imaging displayed bony fusion at C1-C2 and C4-C5. An occipito-

cervical CAT scan showed complex changes involving C1 (absence

734 Eur Spine J (2009) 18:727–780

123

of the C1 articular facets), the C0-C1 complex (C1 retrolysthe-

sis[4 mm), and a C1-C2 fusion. Her torticollis was treated

conservatively by NSAIDs, muscle relaxants and a rigid cervical

collar, in order to achieve a relative, first-line stability to allow further

diagnostic and therapeutic steps.

Occipito-cervical MR imaging ruled out a spinal cord lesion and

misalignment of the vertebral levels (also due to the slight hyperex-

tension given by the collar), but did display a mild hyperintensity of

the apex of the C2 dens. This last finding is deemed to be the typical

indirect sign for an apex-ligament traumatic lesion, which per se has

no influence on segmental stability, but can be considered a warning

sign for a local derangement of bone-ligament structures.

Amongst the different therapeutic options we chose a posterior

stabilization procedure. A C0-C1-C2 instrumented posterior fusion,

strengthened with postero-lateral bone chips between the occiput, C1

and C2 was performed. The surgical procedure was uneventful.

Postoperative radiological control Xrays confirmed the correct

vertebral alignment without involvement of the spinal canal or

compression of the neurovascular structures. The postoperative neu-

rological condition was unremarkable. Due to ventilatory

disturbances a tracheostomy was put in place and kept in situ for three

weeks. At a six-month follow-up the patient’s neck stiffness was

improving. Control CT imaging showed strengthening of the postero-

lateral arthodesis.

Discussion: Patients affected by chromosomal abnormalities often

present with spinal malformations. This is true for rare genomic

variations, like in our patient’s case (trisomy 20), but also for the

more frequent syndromes (e.g. Down’s), mostly at the occipito-

cervical junction. For all of these patients the spinal ligaments

show a high tendency to give out under normal or slightly higher-

than-normal stress situations. In spite of these general issues, it is

common to reach a first-line diagnosis of ‘‘torticollis’’ because of

the patient’s young age, the absence of a previous history of

trauma and the difficulty to perform a complete examination due to

the patient’s associated psychomotor retardation. A misdiagnosed

and consequently untreated cervical instability bears a high mor-

tality rate (around 20% in trisomy 20).

Conclusion: Young patients with known cervical spine malfor-

mations and/or diagnosed chromosomal changes should be deemed

as ‘‘unstable’’ at the spinal level; in case of a prolonged, even if

minimally, axial cervical pain syndrome, with or without history of

a previous trauma (even if trivial), these subjects should undergo

prompt and complete CT and MR imaging (possibly coupled with

evoked-potential studies in selected cases). During this diagnostic

process all patients should wear a rigid cervical collar, or – when

forced by poor compliance – should be sedated and immobilized

until a spinal instability is ruled out.

17

THE TREATMENT OF FRACTURES

IN CHILDHOOD AND YOUTH

M. Palmisani, F. De Iure, G. B. Scimeca, A Gasbarrini,L. Boriani, S. Boriani

Department of Orthopaedics and Traumatology - OspedaleMaggiore, Bologna, Italy

From January 1997 to December 2007 came to our observation 2581

suffering from spine traumas. 83 (3,2%) younger than 16 years old. It

was of 38 cervical spine sprain traumas and 53 fractures (1,7%): 20

involving the cervical spine and 33 the thoracic and lumbar spine.

In the same period, we surgically treated 18 (2,2%) patients under

the age of 16 years old. In 10 cases was concerned the cervical spine and

in 8 cases the stretch of the thoracic and lumbar spine.

4 cases were SCIWORA: 1 case at cervical level with a incom-

plete neurological damage with a neurological recovery and 3 cases of

thoracic tract involvement with complete neurological damage

without neurological recovery.

In all the cases was reached a steady consolidation of the fracture

without major complications.

18

SHORT POSTERIOR PEDICLE SCREW FIXATION

WITHOUT FUSION FOR THE TREATMENT

OF THORACOLUMBAR BURST FRACTURES:

CLINICAL RESULTS OF 153 CASES TREATED

CONSECUTIVELY

P. Quaglietta, S. Aiello, G. Corriero

Azienda Ospedaliera di Cosenza - Dipartimento di Emergenza -U.O. di Neurochirurgia, Italy

Introduction: The treatment of burst fractures of the thoraco-lumbar

junction still remains controversial. The short posterior fixation

without fusion is one of the techniques used to treat these fractures.

This technique, extensively described in the literature, reduce and

stabilize the traumatic thoracolumbar fractures and it is easy to apply.

However, it may restore only indirectly the height of the vertebral

body and the reconstitution of the anterior column is quite limited.

The collapse of the system and the loss of kyphosis correction are the

major complications occurring in patients treated with this technique

because of the limit to support the anterior spinal column.

The aim of this retrospective study was to determine the clinical

results after surgical treatment with short posterior fixation without

fusion.

Methods: From September 1999 to December 2007 153 patients with

thoracolumbar unstable fractures (T11-L3) were operated with a short

posterior fixation. Mostly were young (mean age 30 years). The

average follow-up was 24.4 months. Their injuries, were due to

accidental falls from a height in 47.7% of cases, road traffic accident

in 32.7% of patients. In 8 cases (5.2%) following suicide attempts,

and in 13.1% of cases after working accidents. Finally, two cases

(1.3%) were due to other causes. In all patients was performed a X-

Ray and a spine CT scan while in 89 patients were performed MRI.

Twenty-six patients (16.9%) had multiple spinal trauma. Thirty

patients (20.2%) had abdominal and chest trauma and associated

fractures of other skeletal segments. Surgery was performed within 12

hours after injury in 17 cases (11.1%) with complete spinal cord

injury. In 115 patients (75.2%) surgery was performed between 24

and 72 hours. Finally, in 21 cases (13.7%) surgical procedure was

performed after 72 hours. We evaluated: neurological status (Frankel

Grade), spinal deformities, residual pain, and complications.

Results: At follow-up, 150 patients (98%) showed an postoperative

improvement. In agreement with the Frankel classification, all

patient classified as Frankel E remained stable. Three patients

(1.9%) presented an improvement of one degree (Frankel C). The

kyphosis angle was improved from 19.45 � to 11 � immediately

after surgery. In the follow-up there was a loss of 2 degrees with

an angle of 9 � of kyphosis. We had no operative mortality.

Complications occurred in 8 patients. In two cases wound infec-

tion, in 1 case liquoral fistula (treated surgically), in 3 cases screw

Eur Spine J (2009) 18:727–780 735

123

breakage where new surgery was no use and one patient required

implant removal because of implant dislocation after new motor

vehicle accident. Finally, in one case there was the early collapse

of the system with the complete loss of lordosis in which it was

necessary an anterior and posterior approach. The VAS at the final

follow-up was 2.2.

Conclusions: According to our experience, even compared with the

literature, patients with unstable burst fracture having [ 25 � of ky-

phosis,[50% loss of height of the vertebra or[40% impairment of

the channel can be treated with a short rigid stabilization without

posterior fusion. This technique can effectively restore and stabilize

the fractured vertebrae, can indirectly decompress the spinal cord,

maintain the stability of the column, reduce the risk of screw breakage

and the loss of height of the vertebral body. However, it is always

necessary to consider an anterior approach in fractures with initial

kyphosis angle greater than 30 degrees.

19

TREATMENT OF THORACOLUMBAR

VERTEBRAL FRACTURES WITH A NEW

PERCUTANEOUS TRANSPEDICULAR

STABILIZATION SYSTEM

G. Guizzardi, R. Morichi, A. Vagaggini, L. Paoli

Neurosurgery, University and City Hospital Careggi, Florence,Italy

Introduction: Within the last 30 years the management of thoracic

and thoracolumbar spinal fractures has evolved from one of conser-

vative management with external orthoses and bed rest to one of

operative intervention. The problem of invasiveness in the surgical

treatment of thoracolumbar vertebral fractures without neurological

deficits is well know to everyone. In the last few years a few authors

have proposed treatment, for type A1 and some A2 fractures,

according to Magerl through percutaneous Methods of vertebroplasty.

More recently we’ve seen appear the first treatments of even more

complex fractures with mininvasive percutaneous transpedicular

stabilization.

Material and Methods: We present the experience of the authors on

12 cases of thoracolumbar fractures without neurological defects,

treated between December 2008 and December 2009 with a new

screw-rod mininvasive percutaneous system (Silverbolt/Vertiflex).

This system is equipped with an extremely sophisticated instrumen-

tation set, but which is easy to use, which by means of the usual

distraction and compression mechanism, allows us to optimally

reduce even complex burst fractures.

Results: The follow up from 4 to 15 months has demonstrated a good

result in all cases both from a clinical point of view and the resto-

ration of the physiological alignment of the area and of the

preservation in time of the immediate result. We should highlight the

minimal haematic loss, the significantly reduces post-operative pain

in the patients and the rapidity of both the discharge from the hospital

and the resumption of work.

Discussions and Conclusions: Extremely positive appears our final

opinion, even if the cases are still limited, on this new path we have

taken and on which only a few already have a fairly good experience.

The brevity of the learning curve, the precision and the accuracy of

the instrumentation have surprised us and comforted us in continuing

and incrementing treatment of these fractures with mininvasive

percutaneous technique.

20

TREATMENT OF SPINAL FRACTURES IN

ANKYLOSING SPONDYLITIS

P. Viglierchio, L. Caruso, M. Girardo, P. Cinnella, S. Aleotti

Department of Spine Surgery – C. T. O. Turin, Italy

Introduction: Spinal fractures in Ankylosing Spondylitis (SA) are

characterized by an important instability, often result in neurolog-

ical deficits that necessitate early and aggressive surgical

management with a posterior or anterior and posterior fixation.

Aim of the study was evaluate the clinical, functional and radiological

outcomes in elderly patients with SA affected by cervical or dorsal

fracture treated with posterior or anterior and posterior stabilization.

Material and Methods: The present study is a retrospective review

and a radiological follow-up of 14 patients affected by SA treated at

our departement between 2000 and 2007, 11 were amielic and 3

mielic.8 male and 6 female were included with a mean age at surgery

of 65 years (47-82 years) Radiographs, magnetic resonance and CT

scan obtained before surgery, after surgery, and at the follow-up

evaluation were assessed for quality of fusion, sagittal balance and

kyphotic angle. Average follow-up time was 4,5 years (range 1–9).

Physical examination, spinal mobility, and nondynamometric trunk

strength measurements were used to assess, and Oswestry Disability

Index, SF-36 and Visual Analogic Score of pain (VAS) were used to

calculate outcome at the follow-up visit at the 1 month, 3 months,

6 months and at one year following treatment.

Results: In 10 patients the fracture level was the lower cervical

segment: (4:C6-C7, 3:C7-T1, 3:C5-C6).6 underwent posterior and

anterior fixation, 4 only long posterior fixation.

3 patients suffered a dorso-lumbar fracture (2:T10-T11, 1:T12-L1)

and were treated with a long posterior fixation

1 patient had 2 fractures non contiguous and concomitant (C2 and

T5) and received a double posterior fixation C1-C2 and T3, T4-T6, T7

All patients received immediate improvement in their pain. The

mean VAS reduction was 6.

All patients maintained stability or experienced improvement in

their neurological deficits after surgical intervention.

At the follow-up of 6 months there was demonstration, by CT, of

bone fusion.

There was no radiologic evidence of failure of fixation. There was

no new development of kyphosis deformity.

There were no complications.

Conclusion: Patients with AS are higly susceptible to extensive neu-

rological injury and deformity after spinal fracture caused by even

minor traumatic forces. These injuries are uniquely complex and

require considerable scrutiny and aggressive surgical management to

optimize spinal stability and functional outcomes. The result of the

present study indicate that a posterior fixation longer than commonly

used, or an anterior and posterior fixation is suited for treating spine

fractures in patients with ankylosing spondylitis.

736 Eur Spine J (2009) 18:727–780

123

21

PROPOSAL OF A NEW RISK SCORING SYSTEM

FOR OSTEOPOROTIC VERTEBRAL FRACTURES:

STUDY ON A POPULATION OF 400 PATIENTS

E. Pola, L. Proietti, L. A. Nasto, L. Scaramuzzo,C. A. Logroscino

Dipartimento di Scienze Ortopediche e Traumatologia – U.O.C.Chirurgia Vertebrale, Universita Cattolica del Sacro Cuore –Roma, Italy

Introduction: Osteoporosis is a disease characterized by a low bone

mass and the development of nontraumatic fractures, most commonly

in the spine. Approximately 500,000 elderly women in the United

States are newly diagnosed with vertebral fractures every year due to

the inability of the vertebral body to withstand the loads associated

with normal daily activities as skeletal mass and bone strength decline

with aging. Noninvasive measurements of bone mineral density

(BMD [g/cm2]) are central to the diagnosis and management of

osteoporosis. However, BMD alone is not completely satisfactory in

vertebral fracture risk assessment. Some others risk factors have been

identified for osteoporotic fractures but none, taken alone, is really

sufficient to predict for vertebral fractures. The aim of this study was

to identify clinical and laboratoristic factors associated with an

increased risk of vertebral fractures in osteoporotic Caucasian women

and to define a new clinically relevant scale of risk.

Methods: 400 patients (age: 55 – 87 years) consecutively admitted at

our ambulatory for the treatment of vertebral osteoporosis were inclu-

ded in the study. All patients were affected by post-menopausal

osteoporosis according to the WHO classification criteria. Exclusion

criteria were major infectious diseases, tumors, auto-immune diseases

and major diseases of sense organs. We attempted to determine whether

parameters such as age, body mass index, smoking and alcohol habi-

tudes, femoral and lumbar T-scores, femoral and lumbar Z-scores,

femoral and lumbar bone mineral density (BMD), total and bone

alkaline phosphatase and L3 and T7 vertebral volumes were associated

with the risk of vertebral fractures. The vertebral fractures were diag-

nosed by Morphometric CT and MRI for each patient. All bone

densitometric data were measured using an Hologic QDR 4500/A DXA

system. L3 and T7 vertebral volumes were calculated analyzing CT data

from patients without vertebral collapses in L3 and T7 with NIH Image

(Version 1.62, NIH, Bethesda, MD) and 3D Slicer (Version 3.2, NIH).

Results: 146 patients of the entire population presented at least one

vertebral fracture for a total of 411 fractures (201 thoracic and 210

lumbar collapses). When considered alone, age ([65 years -

p=0,0001), lumbar T-score (B -3,5 - p=0,0001), lumbar Z-score (B-

2,5 - p=0,0050), lumbar BMD (B 0,800 - p=0,0017), femoral T-score

(B -3,5 - p=0,0090), femoral Z-score (B -2,5 - p=0,0127), L3 volume

(B -2,0 SD – p=0,0023) and T7 volume (B -2,0 SD – p=0,0075) were

significantly associated with an increased risk of vertebral fractures.

Considering only the patients with two fractures or more, the same

parameters with the exception of the femoral T-score resulted

strongly associated with the risk of new vertebral fractures. Moreover,

there was a significantly increased risk of vertebral fractures when

two or more of these parameters were present together (p = 0.02). On

the base of the obtained data we have then defined a new scale of risk

(from grade I-low risk in patients without risk factors to grade IV-

very high risk in patients with 3 or more risk factors - p=0.0123)

confirmed in a prospective study conducted on 60 osteoporotic

patients followed for 2 years and that met the same inclusion and

exclusion criteria.

Discussion and Conclusions: Our findings indicate that clinical and

laboratoristic variables may have a synergistic effect on the risk of

vertebral fractures. Since the simultaneous analysis of these

parameters might help to stratify patients with different risks, we

propose a new clinical scale to easily identify the osteoporotic

patient with low, moderate, high or very high risk of new vertebral

fractures.

22

KYPHOPLASTY: ADVANCED INDICATIONS

AND RESULTS

P. Parchi, A. Poggetti, G. Calvosa, M. Lisanti

1st Orthopaedic Clinic University of Pisa, Italy. Chief: Prof.Michele Lisanti

Introduction: The use of mini-invasive percutaneous techniques for

the treatment of pain caused by vertebral collapse is increasingly

spreading in Italy. These techniques are designed to reduce pain, to

prevent the progression of vertebral collapse, and to restore quickly

the functional activity.

The was introduced by Mark Reiley in the late 90 s as an evolution

of vertebroplasty. This method, in fact, while still consists in a mini-

invasive augmentation the fractured vertebral body, allows a low

pressure cement injection due to the formation a balloon-created

cavity and the recovery of the height of the fracturated vertebral body.

The main indication of the kyphoplasty is the treatment of verte-

bral fractures from osteoporosis and from secondary osteolytic

lesions, but in recent years, the evolution of the technique resulted in a

widening scope of possible fields of application to include the treat-

ment of unstable thoraco-lumbar fractures are, in association with

spinal stabilization Methods

Also some contraindications to the use of this technique as the

painful vertebral pseudoarthrosis and the vertebral plane have become

advanced indications

Material and Methods: Aim of this study was to evaluate the

‘‘advanced indication’’ of kyphoplasty through the review of cases

treated at the Orthopedic Clinic of the University of Pisa in the period

between January 2004 and December 2008.

In this period were treated 90 patients of which 70% for osteoporotic

vertebral collapse and 30% for alternative indications (vertebra plana,

painful vertebral pseudoarthrosis, thoraco-lumbar fractures, meta-

static tumours and fractures in patients with an organ transplant).

Results: Patients were evaluated both clinically and radiographically.

From the review of our cases we obtained a high rate of positive

results (85-90% of cases) in terms of reduction of pain and in terms of

patient satisfaction without significant complications (leakage of

cement and cardio-pulmonary complications).

Discussion: Kyphoplasty is a mini-invasive treatment technique

that has proved both effective and safe in the treatment of recent

osteoporotic or osteolytic vertebral collapse, which represent its

main indication and in the treatment of certain pathological con-

ditions which were previously considered contraindications as the

vertebra plana, the vertebral pseudoarthrosis, metastatic tumours

and fractures in patients with an organ transplant and also in high-

energy fractures (in combination with Methods for transpeduncolar

stabilization). We consider essential to obtain good results and to

avoid unpleasant complications a careful and meticulous selection

of patients.

Eur Spine J (2009) 18:727–780 737

123

23

ACUTE THORACOLUMBAR BURST FRACTURES

TREATED BY BALLON-ASSISTED

KYPHOPLASTY PERFORMED

WITH CALCIUM PHOSPHATE

G. Caruso, V. Lorusso, E. Bassi, L. Massari

Ferrara University Department of Orthopaedic Surgery, Italy

Introduction: The progressive kyphosis and pain in patients with

acute thoracolumbar burst fractures treated conservatively so as the

recurrent kyphosis after posterior reduction and fixation were asso-

ciated to disc collapse rather than vertebral body compression. It

depends on redistribution of the disc tissue in the changed morphol-

ogy of the space after fractures of the endplate.

The aim of this study is to evaluate the safety and the efficacy of ballon

kyphoplasty with calcium phosphate, alone or associated to short posterior

instrumentation, in the treatment of acute thoracolumbar burst fractures.

Materials and Methods: eleven fractures in ten consecutive patients

with an average age of 48 years who sustained acute thoracolumbar

traumatic burst fractures without neurological deficits were included

in this study. The fractures were A1.2 (3), A3.1 (4) and A3.2 (4),

according to AO classification. In 7 fractures (A1.2 and A3.1) the

kyphopasty was performed alone in order to make the most of effi-

cacy in fracture reduction, anterior and medium column stabilization

and, as much as possible, segmental kyphosis correction. In the A3.2

fractures (4), that are unstable, the kyphoplasty was associated to a

short posterior instrumentation. To avoid the PMMA long run com-

plications in younger patients, we used a calcium phosphate cement.

VAS, SF-36, Roland-Morris questionnaire (RMQ) and Oswestry low

back pain disability questionnaire (ODQ) were used to evaluate pain,

state of health, functional outcomes and spine disability.

Results: To the average follow-up time of 15.5 months (range 8-31) we

did’nt observe statistically significant differences in 7 of 8 SF-36

domains in comparison to general healthy population of same sex and

age. At the same follow-up, the spine disability questionnaire showed a

functional restriction of 18% (ODQ) and 29,6% (RMQ) being 100% the

maximum of disability. No bone cement leakage, no implant failure and

no height correction loss was observed in any case.

Conclusion: Our data confirm the safety and the efficacy of ballon

kyphoplasty with calcium phosphate in the treatment of acute thoraco-

lumbar burst fractures. In this way we can reduce the possible

complications resulted from discal space collapse and obtain an early

functional restoration. When performed alone, this mini invasive surgical

technique offer the advantage of almost immediate return to daily

activities. When associated to a posterior instrumentation, it decreases the

long run complications and allows to reduce the number of stabilized

levels, maintaining, in part, the thoracolumbar junction movement.

24

EXPERIENCE OF VERTEBRAL FRACTURES

TREATED BY KYPHOPLASTY

B. A. Nannavecchia, F. Bigossi, P. F. Eugeni, F. Pineto, R. Sepe,V. Magliani, D. Lucantoni

Teramo - Unita Operativa di Neurochirurgia, Ospedale‘‘G. Mazzini’’, Italy

Authors analyze seventy patients with D/L vertebral fractures of

anterior wall treated by kyphoplasty since October 2005 to november

2008.

A review of an international litterature focalizes on the vertebral

stability concept and biomechanics features related to vertebral

fractures. These arguments are the introduction to definy the choise’s

reason of this technique.

After a short excursus about the etiopathogenesis of vertebral

fractures, authors describe the Methods used to select the fractures

divides in traumatic and onco-etiology.

An epidemiological study related to fracture’s level, fracture’s

tipology, sex and age is performed on this population of patients.

The paper describes the tecnique of the kyphoplasty and the

postoperatory managment.

The discussion is performed relating to the symptoms and to the

imaging of the follow-up.

EXPERIMENTAL STUDIES AND INFECTIONS

25

THE ROLE OF MELATONIN IN ADOLESCENT

IDIOPATHIC SCOLIOSIS

M. Girardo*, E. Dema, N. Bettini, S. Cervellati

*Chirurgia Vertebrale, Ospedale C.T.O., Torino; Centro diChirurgia Vertebrale-Hesperia Hospital, Modena, Italy

The cause of adolescent idiopathic scoliosis (AIS) in humans remains

obscure and probably multifactorial. At present there is no proven method

or test available to identify children or adolescent at risk of developing

AIS or identify which of the affected individuals are at risk of progres-

sion. Reported associations are linked in pathogenesis rather than

etiologic factors. A number of suggestions concerning its aetiology have

been proposed including neuromuscular, connective tissue structure,

vestibular dysfunction, melatonin secretion, platelet microstructure,

mechanical, growth related and developmental, asymmetry in the

brainstem, genetic factor, equilibrium dysfunction and impairment of

proprioception leading to the idea that a disturbance of postural control

but no single factor has been identified so far. Many authors think that a

relation exists between the origin of scoliosis and balance troubles.

Melatonin may play a role in the pathogenesis of scoliosis (neuro-

endocrine hypothesis) but at present, the data available cannot clearly

show the role of melatonin in producing scoliosis in humans. The data

regarding human melatonin levels is mixed at best and the melatonin

deficiency as a causative factor in the aetiology of scoliosis cannot be

supported. The biological relevance of melatonin in AIS is controver-

sial because: a) no significant decrease in circulating melatonin level

has been observed in a majority of studies, b) experimental pinealec-

tomy did not lead systematically to a scoliosis in all pinealectomised

chicken, c) melatonin injections in pinealectomised animals did not

always prevent the formation of scoliosis.

Melatonin the ‘‘light of night’’ is not a simple hormone. It has many

complex functions, which are only recently being defined. In compar-

ison with other signalling molecules the numerous actions that have

been attributed to melatonin are exceptional. Unfortunately there are

differences in the pharmacology of melatonin between the species and

different biological circadian rhythms. Chicken model cannot be simply

extrapolated to humans. No permanent deficiency of secretion of mel-

atonin occurs in patients with AIS. Evidence for a transient deficiency

before and/or during development of scoliosis is scant and requires

confirmation in a large number of subjects. The diurnal variations in

melatonin levels and the circadian rhythm of secretion play an impor-

tant role. There is now evidence that melatonin may have a role in

biologic regulation of circadian rhythms, sleep, mood, and perhaps

738 Eur Spine J (2009) 18:727–780

123

reproduction, tumour growth, cardiovascular system and aging. How-

ever, uncertainties and doubts still surround the role of melatonin. It will

be an important issue of future research to investigate the role of mel-

atonin in human biology, the clinical efficacy and safety of melatonin

under different pathological situations.

26

LATE-DEVELOPING INFECTION FOLLOWING

POSTERIOR INSTRUMENTED SURGERY FOR

ADOLESCENT IDIOPATHIC SCOLIOSIS

M. Di Silvestre, T. Greggi, A. Cioni G. Barbanti-Brodano,M. Spina, P. Parisini

Spine Surgery Department - Istituto Ortopedico Rizzoli –Bologna, Italy

Introduction: A retrospective clinical and radiographic review of

patients with adolescent idiopathic scoliosis who were surgically re-

visioned due to a late-developing post-operative infection.

Methods: From a total of 540 patients who underwent posterior-only

fusion from 1993 through 2005, fifteen (2,77%) were surgically re-

visioned due to a late-developing post-operative infection. The

implant alloy used was a stainless-steel instrumentation in 11 patients

(4,56% of 241/540), and in 4 patients in titanium (1,33% of 299/540).

Comparing the two groups, there was a statistically significant dif-

ference on the incidence of late developing infection (p\0.0001).

There were 6 males and 9 females, average age at initial surgery

15,8 years (range,12-18), with infection occurred at a mean

70 months (15-195) after the index procedure.

Results: The clinical signs of infection included mild back pain,

spontaneous sinus drainage, and a fluctuance mass. Complete removal

of instrumentation was performed in 9 patients. In six patients an attempt

to save/replace the previous instrumentation was performed. A complete

removal of the instrumentation had to be performed 11,6 months later

(3-24) for the persistence or recurrence of infection. All healed

uneventfully at a minimum 2 years follow up (25-70). Intra-operative

cultures were obtained in all 15 patients, being positive in 13 (S. Epi-

dermidis in 5, S.Aureus in 3, Propionibacterium Acnes in 1, Serratia

Marcescens in 1, Propionibacterium Acnes+ S.Epidermidis in 1,

S.Aureus+S.Epidermidis in 1, coagulase-negative Staphylococci in 1).

Conclusions: According to our experience, late-developing postoper-

ative infection in adolescent idiopathic scoliosis surgery should be

treated only by means of a complete removal of the implant, continuous

drain and short-term adequate antibiotic therapy. To our findings, this

entity is sustained by a polimicrobic flora, always necessitating an

antibiogram-based post-operative antibiotic treatment. Our results

suggest that titanium alloy spinal instrumentations are less subject to

late post-operative infection, when compared to stainless-steel one.

27

THORACOSCOPIC APPROACH FOR THE

TREATMENT OF ADULT SPONDYLODISCITIS

A. Sinigaglia, R. Bassani

Ortopedia e Traumatologia - IRCCS Policlinico S. Matteo, Pavia,Italy

Pyogenic spinal infections encompass a large number of clinical

entities: spondylodiscitis, septic discitis, vertebral osteomyelitis and

epidural abscess. Pyogenic vertebral discitis and osteomyelitis are

uncommon entities with an incidence of 1 in 100,000 but this number

is rising up because of longer life expectancy for patients with

chronic debilitating diseases (immunocompromise, steroids thera-

pies, tumors, HIV, recent spinal surgery). The diagnosis of pyogenic

spinal infection is frequently delayed as symptoms are often non

specific. Spine is involved up to 7% of the cases of pyogenic infec-

tions: most of all the vertebral body (95%), then the posterior

elements (5%).

In this paper is presented a case report of a Thoracic discitis (T10-

T11) managed operatively by a minimal invasive thoracoscopic sur-

gery reducing morbility and morbidity compared to standard

thoracotomy.

A 42 years old male, complaining of chronic pain in thoracic spine

since six years was managed operatively.

Five years before this surgery diagnosis of discitis T10-T11 was

done. He was just treated by oral antibiotics (Cotrimoxazole and

Rifampicin) with partial relief of the symptoms. In the last year he

complained of worsening. MRI, CT scan and blood samples were

showing active inflammatory disease in T10-T11 disc.

In January 2008 he was operated by minimal invasive left tho-

racoscopic approach. Selective intubation and left lung complete

deflation were done. During the procedure the surgeon performed a

complete T10-T11 discectomy as well as removed the end plates

obtaining bloody healty bone. Blood and and disc samples were

collected for colture. To achieve a good fusion hydroxiapatite and

BMP was implanted in the empty space. The procedure was com-

pleted with a posterior approach for screws fixation and postero

lateral bone grafting. Patient was observed in subintensive care for 24

hours and discharged in 6 day post op. Intra Venous antibiotics were

delivered just in the following 15 days post op (Teicoplanin) followed

by oral cotrimoxazole and rifampicine for one month. No germs were

isolated from intraop colture.

Xrays and CT scan showed six months later complete fusion as

well as symptoms disappeared.

This clinical result is showing the feasibility and efficacy of this

minimal invasive technique for the treatment of discitis in thoracic

spine reducing morbidity and morbidity compared to standard

thoracotomy.

28

MORPHOLOGY AND TGF-BETA1

CONCENTRATION’S ANALYSIS OF FLAVUM

LIGAMENTUM OF PATIENT WITH LUMBAR

CANAL STENOSIS AND/OR LUMBAR DISC

HERNIATION

R. Rispoli, R. Mastrostefano

Neurosurgery, Avezzano (AQ), Italy

The study’s objective is to analyse the flavum ligamentum of patients

with lumbar canal stenosis and / or lumbar disc herniation to evaluate

the morphology and the concentration of the transforming growth

factor-beta 1 (TGF-beta 1).

The study is characterised by three phases:

• Measurement of the thickness of the flavum ligamentum of

patients with lumbar stenosis and/or herniated lumbar disc

through the sagittal, T1 weighted images of the lumbo-sacral

MRI;

• Removal of flavum ligamentum in patients undergoing interven-

tion for lumbar stenosis and / or lumbar disc herniation;

Eur Spine J (2009) 18:727–780 739

123

• Optical microscopy study of the morphology of degenerated

ligamentum and immunohistochemical analysis to assess the

concentration of TGF-beta 1 in the same.

The analysis of the morphology of the ligamentum (meant as the

increase of the fibers number or distension and relaxation of the same

as a result of degenerative processes) and the presence or absence of a

high concentration of TGF-beta1 (then more fibroblasts involved in

the degenerative process) can be important in the choice of surgical

treatment of stenosis and / or lumbar disc hernia, particularly:

• The removal or preservation of the ligament itself;

• The use of interspinous or interlaminar devices.

29

USE OF PLATELET GEL IN POSTEROLATERAL

FUSION: PRELIMINARY RESULTS IN 14

PATIENTS

A. Landi, R. Tarantino, N. Marotta, L. Giudice, S. Martini1,E. Rastelli1, G. Ferrazza2, N. De Luca2, F. Tomei2, R. Delfini

Department of Neurological Science, division of Neurosurgery,University of Rome Sapienza; 1Department of NeurologicalScience, division of Neuroradiology, University of RomeSapienza; 2Department of Hematology, University of RomeSapienza, Italy

Introduction: actually hematological research is based on already

known role of platelets in the mechanisms of tissue repair. The

combination of ultraconcentration of platelets with fibrin glue

(fibrinogen, XIII factor, fibronectin) in presence of activated trombin,

determines the formation of platelet gel, applied alone or in combi-

nation with scaffold for the repair of ‘‘hard’’ wounds. This

haematological component is assuming an important role in regen-

erative medicine. Authors took into account the possibility of using a

preparation of ultraconcentrate of autologous platelets to be applied in

addition to autologous or synthetic bone during the posterolateral

fusion in order to induce an higher degree of bone fusion.

Patients and Methods: have been assessed 14 patients (mean age

60.2 aa, 8 M and 5 F) underwent laminectomy, spinal fixation and

posterolateral fusion, from November 2007 to November 2008 there

were performed five 2-level stabilization, five 3-level, one 4-level and

one 5-level.

In our cases the platelet gel has been obtained taking 16 ml of peripheral

venous blood from patients, using for each surgical procedure two

tubes, each one with a capacity of 8 ml. Both of them are the REGEN-

THT� system (Thrombocyte, Harvesting Tube) that allows us to take in

40’-45’ from the sampling, 8 ml of autologous platelet gel. The process

requires the addiction of Ca-gluconate and ethanol at 95%, obtaining a

preparation of plasma rich in platelets and activated trombin, at a

concentration of platelets with an average of 5 times higher than blood.

The PRP is joined in the operating field with suitably fragmented

autologous and synthetic bone. To allow a comparative assessment

between the degree of fusion with platelet preparation and in his

absence, for each patient was arbitrarily decided to use the platelet gel in

a single surgical field, the right one. Patients underwent CT scans at 3

and 6 months after surgery, and RX scans at 6 months after surgery. CT

axial scans, allow a proper assessment of the degree of spinal fusion and

bone growth, by measuring the increase in bone density through the e

ROI (HU) evaluation in the newly-formed bone and comparing the

density between the bony callus formed only by autologous and syn-

thetic bone and the one with addition of platelet gel.

Results: in all cases we found a good bone fusion. In addition CT

evaluation at 3 and 6 months and RX evaluation at 6 months after surgery

showed an increase of bone density in the fusion stimulated by platelet gel

compared to the fusion stimulated only by autologous-heterologous

bone. These preliminary results confirm the objective of our study.

Discussion: the newly formed bone in areas where performed pos-

terolateral fusion, is well evident three months after surgery and

continued gradually in the subsequent 18-24 months. The autologous

platelet gel used by us seems to promote bone repair and regeneration

by increasing bone density at the same level of posteolateral fusion.

Moreover this preparation has a low production cost and is easy to

apply and use.

30

FOCUS ON RESEARCH ABOUT CELLS

MECHANISMS INVOLVED IN BONE

REGENERATION FOR ARTHRODESIS

C. Ruosi1, G. F. Tajana2, D. Maglione1, L. Pastore3

1Dipartimento di Scienze Chirurgiche, Ortopediche,Traumatologiche ed Emergenze, Universita degli Studi di Napoli,‘‘Federico II’’, Napoli, Italy; 2Cattedra di Anatomia e IstologiaUniversita degli Studi di Salerno; 3Dipartimento di Biochimica eBiotecnologie Avanzate, Universita degli Studi di Napoli,‘‘Federico II’’, Napoli, Italy

The aim of this study was the evaluation of molecular and micro-

molecular mechanisms on which the healing of bony callus of

arthrodesis is based.

In particular the aim was to investigate the way of recruitment,

proliferation and migration of undifferentiated cell populations

towards a differentiation in osteoblasts and ostocytes but in particular

towards a special organization precise enough to fill in bony gaps only

in defined points and not in others and only in proper quantity.

The study started from the identification of which stem cells were

involved in these processes and why. Subsequently, the cell mecha-

nisms determining the development of the phenomenon ‘‘bony

callus’’ were noticed and studied.

These fundamental mechanisms for the development of the bony

callus include four defined stadiums, either for the treatment of

fractures or of arthrodesis from bony micro-fragments:

The adhesion, the migration with its strategies, the cell movement

and the gene regulation.

Adhesion: It’s the fundamental condition for the bony healing and

only after this phase the processes of cell restyling, proliferation and

differentiation take place. In this phase the cells can receive precise

information about what to do, divided in positional and differentiative

information. This information derives from signal molecules that can

affect the formation of proteins that can activate the extracellular

matrix through genes called ‘‘architects’’.

Migration: It takes place thanks to chemo-attracted proteins like

BMP-2 and BMP-4 that recognize cell surface proteins; the interac-

tion between these two elements leads to the creation of ‘‘molecular

rails’’ to define the spatial orientation and the cell is also stimulated to

produce ‘‘sub-signals’’ that can mean both prosecution of the process

and stop of the process for the following cells.

These mechanisms have a direct influence of migration strategies.

Actually, according to their position and role, the proliferating cells

are divided in Analyzers, Marginators and Erasing.

Cellular Movement: This mechanism, that can be defined cell mi-

crobiomechanic, takes place thanks to a series of ultra-structures on

740 Eur Spine J (2009) 18:727–780

123

the cellular surface like the tractor pseudopods and the anchorage

plaque, together defined ‘‘lamellopods’’.

These structures allow a characteristic ‘‘jumping’’ or better rolling

movement of the cell in the environment.

The anchorage ties to the lamellopod and then the cellular cyto-

skeleton will stretch giving propulsion to the (long) part of the cell,

called uropod.

Gene Regulation: The differentiation of mesenchimal stem cells

(MSCs) in osteoblasts was widely studied and investigated in the last

years.

Recently a number of genes involved in this process has been

identified. In details the genes necessary to determine the differenti-

ation from stem cells to osteoblasts can be divided in extrinsic and

intrinsic.

The first group (extrinsic) includes the genes that codify for bony

morphogenetic proteins (BMPs) that lead to differentiation in osteo-

blasts with high efficiency; these proteins are very important both in

physiologic processes like the development of skeletal structure, and

in pathological ones, like the reparation of fractures. The BMP-2 in

particular demonstrated to be necessary for the recovery of fractures

in human being.

Nevertheless, many other factors take part in the building of post-

fracture callus like VEGF, FGFs and so on.

The necessary inner factors for the differentiation in osteoblasts,

instead, include essentially transcription factors and molecules

working as transduction signals.

In particular the transcription factor Runx2 (which causes, if

mutated, human cleido-cranial dysplasia) is absolutely necessary for

the differentiation in osteoblasts and for the deposition of the matrix.

More recently other factors involved in the pre-osteoblastic prolifer-

ation (e.g. Osterix) and in the mineralization of the matrix (e.g. Dkk2)

have been identified and isolated even in our laboratories.

Recently several studies have shown the importance of Periostina

in the induction of differentiation of osteoblasts. This researches

confirmed that there is a series of cellular mechanisms controlling the

bone building that are codified and ruled by special genes. Everyone

of them is responsible of a different aspect of those important pro-

cesses represented by induction, building, development and

consolidation of a repairing bony callus.

INTERSPINOUS DEVICES AND MOTIONPRESERVATION – Part 1

31

OUR EXPERIENCE OF EFFICACY AND SAFETY

OF DEVICE FOR INTERVERTEBRAL ASSISTED

MOTION (DIAM�) IN PATIENT UNDERWENT

SIMPLE LUMBAR SURGERY

(MICRODISCECTOMY): CORRELATION

BETWEEN CLINICAL AND RADIOGRAPHIC

IMAGING PATTERN: FOLLOW-UP EVALUATION

A. Villaminar, M. Comisso, M. Balsano

Ospedale ‘‘ C. De Lellis’’ Schio (Vicenza) - Centro di RiferimentoRegionale per le Patologie del Rachide, Italy

Object: To assess the safety and efficacy of device for intervertebral

assisted motion (DIAM�). For this we compared patients underwent to

microdiscectomy with DIAM placement against patients underwent

lumbar surgery only. We also correlated clinical with radiological

pattern (sagittal angulation and pain outcome). Four years follow – up.

Methods: Between 2004 to 2008, in our department, 60 patients

were operated of herniated disk. 35 patients underwent concomitant

surgical placement of DIAM interspinous spacer (group A), the

other 25 underwent only microdiscectomy (group B). Radiographic

imaging, pain score (VAS), clinical assessments (ODI), were

obtained pre and postoperatively to a mean 25 months (range 12 –

48 months).

In group A, no statistically significant differences were noted

compared with group B in visual analog scale (VAS) and ODI at a

mean of 12 mounths; differences, without a statistical relevance, were

noted in VAS and ODI at the end of the 24 months between the two

groups.

In group A, no statistically significant differences were noted

in anterior or posterior disc height when comparing patients pre

and postoperatively during all follow up. Differences were noted

in Group B in anterior and posterior disc height after 12 months,

no statistical relevance. In Group A was relevated a relative

Kyphosis (less than 4�) in postoperative images compared with

group B. Complications in group A included one infection treated

with antibiotic therapy, and two reoperation for hernia

recedivation.

Conclusions: After microdiscectomy, the placement of a interspinous

process spacer (DIAM�) did not alter the disc height or sagittal

alignment at the mean 24-36 months of follow up. No statistically

differences in VAS and ODI were noted between the groups treated

with or without the interspinous spacer at the mean 12 months follow

up, after 12 months were noted differences between the two groups

but not statistical relevance.

32

INTERSPINOUS DEVICES IN THE TREATMENT

OF LUMBAR SPINAL STENOSIS: OUR

EXPERIENCE WITH APERIUS

A. P. Fabrizi, R. Maina, M. Galarza, R. Parisotto

Neurosurgery, Villa Maria Pia Hospital (Torino), VillalbaHospital (Bologna), Italy

Introduction: Aperius represents a new treatment option for patients

with neurogenic intermittent claudication (NIC) for degenerative

lumbar spinal stenosis (DLSS). Traditionally, DLSS were treated with

unilateral or bilateral laminectomy with wellknown possible post-

operative complications.

Material and Methods: From April 2007 to September, 260 DLSS

patients underwent APERIUS PercLID (Percutaneous stand-alone

Lumbar Interspinous Decompression System) mono- or multi-level

surgical implantation.

Results: 240 patients reported satisfactory improvement with rapid

return to their working and domestic activities. Clinical improve-

ment was detectable in early post-operative period in 200 of these

patients.

Only 20 patients reported unchanged or unsatisfactory clinical status.

Conclusions: A longer follow-up period is needed but clinical results

are good and promising. We preset Aperius percLID system as a good

option for the treatment of DLSS.

Keywords: interspinous devices, APERIUS PercLID, neurogenic

intermittent claudication, degenerative lumbar spinal stenosis.

Eur Spine J (2009) 18:727–780 741

123

33

APERIUS COMPARED TO OPEN SURGERY

IN LUMBAR STENOSIS: A RETROSPECTIVE

MULTICENTRE STUDY

F. Postacchini*, P.P.M. Menchetti**, E. Ferrari*,S. Faraglia*, R. Postacchini***

*Department of Orthopaedic Surgery, University Sapienza,Rome, Italy; **Rome American Hospital, Rome, Italy; ***Department of Orthopaedic Surgery, University Tor Vergata,Rome, Italy

In the last few years numerous interspinous spacers have been

developed, some of which are specifically indicated for the treatment

of lumbar stenosis. The latter include X-Stop, which is inserted by

open surgery, and Aperius and Superion which can be introduced by a

percutaneous approach. The clinical efficacy, the indications and the

anatomical effects of these devices, particularly those that can be

inserted percutaneously, are still unclear.

This aim of this study was to evaluate the results of Aperius

compared with open surgery in the treatment of various forms of

central or lateral lumbar stenosis and to try to determine the clinical

indications for this spacer.

Materials and Methods: We analysed two groups of patients with

lumbar stenosis: Group I, consisting of 30 patients in whom Aperius

was used, and Group II, including 30 patients who underwent open

surgery with or without the use of the opearating microscope.

Group I included 14 males and 16 females, aged on average 72 years.

Mild degenerative spondylolisthesis was present in 2 cases. 20

patients were operated at L4-L5 level, 5 at L3-L4, 2 at L2-L3 and 3 at

L3-L4 and L4-L5. No patients had motor deficits. In most cases the

thickness of the spacer was 12 mm. Patients were followed for 6-

14 months (mean 8.2)

Group II included 13 males and 17 females with a mean age of

67 years, who underwent surgery in the period 2006-2008. Three had

degenerative spondylolisthesis, but none underwent fusion. The level

most frequently involved was L4-L5, follewed by L3-L4. Four

patients had motor deficits. One of the following types of decom-

pression was performed: unilateral laminotomy, bilateral laminotomy

at one or two levels, bilateral decompression by a unilateral approach,

bilateral laminectomy. Patients were followed for 8 to 30 months

(mean 1.4 years) after surgery.

In both groups clinical evaluation was carried out using VAS

and ODI by two orthopaedic surgeons not involved in the treat-

ment. Based on the preoperative MRI or CT, four degrees of

severity of stenosis were identified: mild, moderate, severe and

very severe.

Results: In Group I, 25 patients (83%) had an improvement of rad-

iucular symptoms, while five (17%) had a poor result; in two of the

latter, who had degenerative spondylolisthesis, the spacer was

removed and decompression and fusion was carried out. The mean

VAS score decreased from 73 to 20 and ODI from 63 to 11. Most

patients in this group had mild or moderate stenosis.

In Group II, 26 patients (87%) improved, while four (13%) had a poor

result. The mean VAS score decreased from 82 to16 and ODI from 69

to 12. Patients in this Group had moderate to very severe stenosis.

Conclusions: Open surgery gave better results than Aperius, but the

difference was not significant. However, in the Aperius group most

patients had mild to moderate stenosis, whereas in the surgery group

stenosis was consistently moderate to very severe. Aprius appears to

be indicated particularly in patients in whom stenosis is due to

hypertrophy of ligamenta flava. The poor results with Aperius were

mainly ascribed to poor selection of patients.

34

INTERSPINOUS IMPLANTS FOR DEGENERATIVE

LUMBAR SPINE DISEASE: EXPERIENCE WITH

DIAM AND APERIUS DEVICES

A. P. Fabrizi, M. Galarza, R. Maina

Torino, Italy

Introduction: The insertion of posterior lumbar dynamic devices is

common procedure for the treatment of degenerative spine disease

and lumbar stenosis. Clinical and radiographic results were assessed

to determine the clinical outcomes and fusion rate in 1575 consecu-

tive selected patients

Methods: From 2000 through 2008, 1315 consecutive patients

underwent ‘‘Device for Intervertebral Assisted Motion (DIAM)’’ and

260 had APERIUS PercLID ‘‘Percutaneous stand-alone Lumbar

Interspinous Decompression System’’. The main surgical indications

included: symptomatic degenerative disc disease with foraminal ste-

nosis (1060 patients), black disk and facet syndrome (240 patients),

foraminal stenosis with disc herniation (211 patients) and topping-off

syndrome (64 patients).

Results: 1100 patients underwent a single level implant and 475 had a

multiple level implant. Mean operating time was 35 minutes for

DIAM and 7 minutes for APERIUS. At the mean 12-month follow-up

assessment, all patients had solid bone fusions across the interspace.

There was no sign of heterotopic ossification in any patient. No

patient experienced migration of the intervertebral distracting implant

on follow- up imaging. Complications were detected in 20 patients

(10 cases of infections, 10 fractures of the posterior spinous process).

40 patients were subsequently treated with posterior arthrodesis

(n=30) or total disk replacement (n=10). Patient’s postoperative

clinical status was rated according to the modified Macnab criteria:

symptoms resolution or improvement was achieved in 1505 patients;

and unchanged or unsatisfactory results in 70 in a mean postoperative

time of 56 months.

Conclusions: We present our experience in DIAM implant over a

decade and with APERIUS in patients with degenerative lumbar

spine. Both techniques are safe, simple and less technically

demanding. These approaches appear to be an effective alternative in

selected cases, although conventional posterior lumbar decompres-

sion and fusion still may be required.

Learning Objectives: Keywords: Posterior lumbar dynamic devices

DIAM implant APERIUS PercLID

35

DYNAMIC INTERSPINOUS STABILIZATION

WITH COFLEX�: OUR EXPERIENCE IN 53 CASES

WITH 7 MONTHS TO 29 MONTHS FOLLOW-UP

G. Maida*, F. Garofano*, S. Sarubbo*, M. A. Cavallo*

*University-Hospital S. Anna - Division of Neurosurgery -Ferrara, Italy

We undergone 53 patients to dynamic stabilization with interspinous

device (Coflex�) for lumbar stenosis, joint facet syndrome, ‘‘black

disc’’ (with or without disc herniation and/or Modic degeneration),

recurrence of herniated disk, epidural scar, I grade lumbar listhesys

not reducible and without spondilolisys, all clinical manifest and after

failure of conservative treatment. The mean follow-up is twelve

742 Eur Spine J (2009) 18:727–780

123

months and fifty patients reported complete pain and neurological

recovery and motion preservation. Three patients did not experience a

pain improvement and resulted unsatisfied. We did not report infec-

tions, hematomas, neural lesions or spinous process ruptures. In three

cases with severe lumbar stenosis we produced a dural perforation

sutured and covered with fat patch and fibrine glue without

any CSF leakage. Just in one case, with very severe lumbar stenosis,

we observed a cauda equina’s syndrome and we undergone the patient

to the interspinous device removal and cages’ implantation stand

alone.

We consider dynamic interspinous stabilization with Coflex�device less invasive and really useful, safe and effective specially

considering the large surgical indications, low complications’ rate and

the good clinical outcomes reported. However, the ability in the

lumbar canal ‘‘reaclibrage’’ and the possible need to shift surgical

strategy ‘‘in itinere’’, we suggest this technique, in I� lumbar listhesys

and sever lumbar stenosis, for expert spinal surgeon alone.

INTERSPINOUS DEVICES AND MOTION PRESERVATION –Part 2

36

LUMBAR SPINE STENOSIS TREATMENT

BY PERCUTANEOUS VIA AND IN LOCAL

ANESTHESIA WITH INTERSPINAL DEVICES ‘‘IN

SPACE’’. PRELIMINARY RESULTS ON 60 CASES

L. Genovese, M. Muto, G. Anceschi

Napoli, Italy

The author reports the preliminary data on 60 patients treated with

interspinal spacers ‘‘IN SPACE (Synthes) type, applied by percuta-

neous local anestesia.

Indications: Patients treated were those presenting sympotms

chacaterized by low-back pain and/or radiculopathy and Neurologic

Intermittent Claudication.

The clinical evaluation of the symptoms occurred before and sfter

surgical operation via VAS and ZGQ.

The neuro-radiologic datum (Rx lumbo-sacral in AP,LL and

through dynamic tests, TC and RM lumbo-sacral) showed in all the

patients stenosis of the lumbar central canal and/or foraminal mono,

bi or tri-segmental, generated by the district conflict, secondare to the

osteo-artrhosis and disc degeneration and also to one or more ana-

tomical pathological conditions associated with it; such as disc

protusion, disc hernia not expelled, lower spondylolisthesis of grade

I�, events of arthrosis of the articular facets, hypertrophy or folding of

the yellow ligaments, reduction of the intersomatic space linked to

dessiccation phenomena of intervertebral discs and also results of

post-operative fibrous scarring recurrence of herniated disc

uncompressed.

The duration of symptoms, recent (continuing for at least 6 weeks)

and remote (for at least 6 years) and the failure of conservative

treatment were essential elemento for the indication of this kind of

treatment.

Materials and Methods: From January 2008 to end of December

2008, 60 patients, includine 36 male and 24 female were recruited and

treated.

The most treated levels in order of frequency were L4-L5, L5-S1 and

L3-L4, and properly:

• 3 cases at 3 levels (L3-L4, L4-L5, L5-S1)

• 10 cases at 2 levels (L3-L4, L4-L5)

• 16 cases at 2 levels (L4-L5, L5-S1)

• 31 cases at 1 level (L4-L5)

Surgical cutaneous access via a skin incision of 1 cm has been the

same procedure used for all the patients.

Device used: interspinal spacer ‘‘In Space’’ SYNTHES type of

8,10,12 14 mm.

Technique: Patient in prone position on an OR table with variable

aperture and head on antidecubito cushion, legs slightly bent.

Checking of the radiological level in the treated segments.

Side guide wire is applied to identify the line of the articular pro-

cesses. Then proceed with radiological checking for the identification

of the cavuum at the base of the interspinal ligament through which

the device (using the dedicated instruments annexed) must be added.

Local Anesthesia: Interspinal lumbar puncture is done using a 20 G

needle at the pre-chosen level and by proceeding gradually, until

reaching the base of the interspinal ligament when it crosses the

yellow ligament and release local anesthetic consisting of hydro-

chloride levobupivacaina 0,75 ml.

The duration of the operation is approximately 20 minutes.

Results: Clinical post-operative controls with VAC and ZCQ in all

the patients have showed positive results.

The VAS fell from 7.8 to 2.3 immediately after the operation and

remained unchanged in the controls at 1,3,6 and 9 months.

ZCQ showed an improvement of the severity of the symptoms, a

good functional recovery and a greater patient satisfaction for theb

treatment received.

37

INTERSPINOUS SPACER LIMITS AND FAILURE

M. Tenucci*, C. Giannetti**, M. Lisanti**, G. Calvosa**

*Ortopedia e Traumatologia USL2 LUCCA - Primario Prof. A.Fornaciai; **Ia Clinica Ortopedica Universitaria Cisanello –Direttore: Prof. M. Lisanti

Introduction: The objective of this study is to retrace the history of

the devices from their conception to their development and use in

relation to their design and different materials.

We do an analysis of the spacer from a mechanical point of view,

emphasizing the different technical characteristics. Observe their

effects on the biomechanics of the lumbar sacral spine. From these

observations we perform a critical review of our cases.

Materials and Methods: Review of 50 cases treated with interspi-

nous spacer in patients with central stenosis and lumbar sacral spine,

the disc hernia, some cases of recurrence of disc herniation syndrome

junctional in rigid stabilization and /or dynamic.

Thirty percent of patients were over 65 with associated diseases that

contraindicated major surgery. For these patients we decided to a

treatment in local anesthesia.

Results: All patients complained of progressive low back pain with

neurogenic claudication, radiculopathy and a diminished walking

distance. Anteroposterior, lateral and flexion/extension plain

radiographs, were performed in all cases. The patients were

investigated pre and post operative with Osvestry Disability Index,

VAS score; magnetic resonance imaging (MRI) pre and post

operative. A total of 80% were very satisfied with the outcome of

the operation.

Conclusions: Critical review of our case studies reveal considerations

on indications, contraindications and complications and limitations of

the treatment of degenerative disease of the lumbar sacral spine with

interspinous spacers.

Eur Spine J (2009) 18:727–780 743

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38

INTERSPINOUS PROCESS DECOMPRESSION

SYSTEMS: INDICATIONS AND CONTROVERSIES

M. Costaglioli, M. Piredda, D. Castangia, S. Casula, S. Caboni,P.P. Mura

Cagliari, Italy

Introduction: A growing number of interspinous process devices

have been introduced to the lumbar spine implant market. Implant

designs vary from static spacers to dynamized devices. Despite being

made of different materials, the common link between them is the

mechanical goal of distracting the spinous processes to affect the inter-

vertebral relationship. In contrast, the purported clinical goals are more

variable, ranging from treatment of degenerative spinal stenosis, disco-

genic low back pain, facet syndrome, disk herniations, and instability.

Posterior element distraction with an ISP device is intended to cause

restore of posterior tension band of the instrumented segment. By

doing so, infolding of the ligamentum flavum is somewhat reversed,

causing less intrusion into the spinal canal. Furthermore, longitudinal

distraction between 2 vertebrae can increase the neural foramina

dimensions and partially unload the facet joints and posterior portion

of the disk. Another advantage is the ease of revision. In case of

failure, these devices can easily be revised or removed.

Patients and Methods: Between 2002 and 2007 we treated 145

patients with various devices (Diam, Wallis, Back jak, X Stop, A-

perius). a mean age of 35,3, minimum follow up one years.

Patients were evaluated preoperatively, intraoperatively and postop-

eratively at 1, 3 and 12 months

Conclusion: Defining the indications for these minimally invasive

procedures will be crucial and should emerge from thoughtful con-

sideration of data from randomized controlled studies. Though few

published data exist, this paper will review the available clinical

results of the various devices and ours experience with some of these

(Diam, Wallis, Back jak, X Stop, Aperius).

39

BIOMECHANICAL CONSIDERATIONS ON

POSTERIOR MOTION PRESERVATION SYSTEMS :

INTERSPINOUS VERSUS INTERLAMINAR

P. Petrini�, G. Guizzardi*

�Orthopaedics, Hospital of Citta di Castello, Perugia, Italy*Neurosurgery. University and City Hospital Careggi, Florence,Italy

Introduction: In the last few year the market has been literally

invaded by interspinous/interlaminar systems for motion preservation.

The type of material, the surgical technique and moreover the

placement of these devices (interspinous or interlaminar) substantially

influence the ROM, but in different ways.

Material and Methods: The authors, that have been using these

devices for about 10 years, through static and dynamic radiographic

examinations and biomechanical tests, analyse both the segmental

mobility and the sagittal balance after these devices have been

implanted. We present a new device (INTRA Spine) for the treatment of

degenerative pathology of the lumbar spine. The device, in medical

silicone 65 shore coated by a pure poliester therephthalate sleeve, has

with respect to other posterior devices the advantange that it may be

implanted more anteriorily (interlaminar) and thus gets placed even

closer to the center of instantaneous rotation of the segment. The fun-

damental feature in the design of this new device is that of overturned

anvil with the anterior part to be placed between the laminae and whose

frontal extremity is covered by a silicone film that prevents adhesion to

the surrounding structures. The surgical instrumentation, designed ad

hoc, allows us to perform the procedure with a mininvasive monolateral

approach and with the maximum respect for the anatomical structures.

Finally, the difference in compression ratio between the anterior and

posterior parts of the device, do not limit the ROM.

Results: The results are undoubtedly in favour of interlaminar rather

than interspinous systems and this seems obvious if we consider

simply the different distances of the two types of implants from the

axis of instantaneous rotation.

Conclusions: The path we must take has yet to come to an end, but

the consciousness and understanding of this data by all those who use

these devices appears fundamental for their correct use, but most of

all so that the correct system be used for the various situations. We

nevertheless feel we should recommend the use of this device after

failure of conservative treatment, as a first choice over more invasive

surgical operations and especially in the first phases of degenerative

cascade in order to slow down its natural evolution.

40

SPINAL STABILIZATION USING AN ‘‘HYBRID’’

RIGID / DYNAMIC SYSTEM: PRELIMINARY

RESULTS

B. Misaggi1, P. Vigano’1, G. Fava1, D. Peroni1, M. Ferraro2,A. Trapletti3, M. Colombo3, W. Albisetti4

1U.O. Scoliosis and Vertebral Disease – Orthopaedic Institute G.Pini – Milan; 2S.C. II Division - Orthopaedic InstituteG. Pini – Milan; 31� Residency Program in Orthopaedics andTraumatology - Universita degli Studi – Milan; 4Universita degliStudi - Milan, Italy

Introduction: On the basis of the good results obtained with the

elastic stabilization, we decided to combine the elastic to the rigid

stabilization, especially in consideration of the fact that the disc

adjacent to the arthrodesis area undergoes excessive stresses which

can significantly accelerate its physiological aging process. If the disc

already has original degenerative problems, overstress will aggravate

its condition. Zimmer recently developed the DTO system, a new

hybrid stabilization system indicated for the treatment of degenerative

lumbar spine disc with or without instability.

The goal of the treatment is to obtain the fusion of the seriously

damaged segment, while preserving the adjacent segments with a

Dynesys dynamic stabilization.

Material and Method: We reviewed the early cases treated at our

Institute with the Zimmer DTO system, a peduncular hybrid system.

We selected the patients by age and by clinical situation, all the

patients were investigated with standard and dynamic x-ray exami-

nation and NMR study.

We performed a prospective study on 16 patients aged between 25

and 52 years, with an average follow-up of 10 months. In 80% of the

cases a 2-level stabilization was performed, in 20% of the cases a 3-

level stabilization was performed. The clinical rating scales used were

the Oswestry and the VAS

Results: In the 87.5% of the cases we obtained an important reduction

of the pain with a good / great satisfaction of the patients. Post-

surgery imaging investigations are also encouraging.

Discussion and Conclusions: Preliminary results indicate that a

hybrid stabilization using the Zimmer DTO system may offer real

advantages in patients affected by low back pain, reducing the

744 Eur Spine J (2009) 18:727–780

123

concentration of stress on the border disc, preserving it and reducing

the risk of its degeneration. This improves patients’ quality of life and

activity. However it is important to remember that the results

obtained, although encouraging, require further studies to confirm the

preliminary data and a statistically significant clinical evaluation.

LUMBAR SPINE – Part 1

41

MONOLATERAL IMPINGEMENT ROOT

SYNDROMES: TREATMENT OPTIONS

M. Cassini, G. Gioia

Orthopaedic and Traumatology Department; AULSS 21 MaterSalutis Hospital Legnago-Verona, Italy

Background: Monolateral impingement root syndromes may

manifest mainly with two aspects: monolateral pain to a leg with

or without motor sensitive deficit during rest or walking and pain

only during walking: this condition is named ‘‘claudicatio’’. Disc

hernia is often associated with the first situation while lateral ste-

nosis is more frequently responsible in the second condition.

Considering the frequency of these clinical syndromes and the

treatment options up today available (microdiscectomy, microde-

compression, interspinous devices) the right indication is

indispensable for a good outcome.

Methods: From November 2005 to July 2008, 112 patients (aver-

age age 54 yrs range 19-71) affected by root impingement

syndrome underwent to surgery. Disc hernia was responsible of

radicular pain in 101 cases with association of lateral stenosis in 21

cases (intraoperative evidence). We performed a microdiscectomy

(Caspar technique) in case of protruded or extruded disc hernia, a

microdecompression with high speed drill in the cases with lateral

stenosis associated, a microdecompression in the symptomatic side

plus DIAM interspinous device (11 cases) in those cases with

asymptomatic controlateral stenosis. All cases were revised at 2

mths and 6 mths after surgery.

Results: We observed an improvement of the radicular symptoms

in all the patients with complete recovery in over 90% of the

cases. The microdiscectomy and microdecompression group had the

best results in the short time after few days or weeks post surgery

with an earlier functional restore due to the MIS technique (Mini

Invasive Surgery). On the contrary the DIAM group presented in

the immediate postoperative period more pain and disability with a

longer hospital stay probably due to the more invasive approach

and the adaptation to the device.

Nevertheless the few cases treated with this kind of spacers don’t

allow conclusive considerations.

We had 1 case of durotomy during a microdiscectomy treated with

fibrin glue that lead to a prolonged bed rest of 3 days. 2 disc hernia

recurrence reoperated with micro technique. One case of disc hernia

1 year after surgery in a patient treated with DIAM device without

discectomy at the level involved. One case of persistent low back pain

in a patient treated with microdecompression plus interspinous spacer.

The MIS group patients was discharged from the hospital in the first

or second day after surgery while the DIAM group needed a pro-

longed hospital stay (4 or 5 days).

Discussion and Conclusion: The frequence of lumboradicular

syndroms is a common occurrence in the daily clinical practice.

Much of these improve with conservative treatment. Surgery in

case of disc hernia was usually considered after 4 or 6 weeks

following the guide lines (earlier in case of neurologic worsening

or intractable pain). Patients affected from ‘‘claudicatio’’ were

generally treated after months because of delay in the diagnosis

and prolonged conservative treatment. From the results of our

revision the majority of the procedures were effective because the

indication and the patient selection were accurate. In our opinion

the interspinous spacers, allowing an indirect opening of the

radicular canal, could be utilized in selective cases without mic-

rodecompression (stand alone). But the wide utilize of such

devices, too frequent from our point of view, will be revised

considering the rate of complications (spinous processes breakeage,

lower tolerance in the postoperative period) and higher costs in

confront of selective microdecompression.

42

SURGICAL TREATMENT OF INTRA-

EXTRAFORAMINAL LUMBAR DISC HERNIATION

WITH BI-RADICULAR INVOLVEMENT: OUR

EXPERIENCE AND REVIEW OF LITERATURE

A. Barbanera1, G. P. Longo1,2, E. Serchi1, A. Andreoli1,D. Rossi 1

1Unita Operativa di Neurochirurgia D’Urgenza e del TraumaOspedale Bellaria-Maggiore Bologna; 2Unita Operativa diNeurochirurgia AOU Policlinico ‘‘ G. Rodolico ‘‘ Catania, Italy

Intra-Extraforaminal lumbar disc herniations may cause a compres-

sion of both intracanalar ed extraforaminal roots.

The surgical treatment of this condition is still controversial.

Surgical procedures described in literature are intracanalar, extra-

canalar or combined.

At our institution we have decided to treat these patient through an

unilateral artrectomy, that allows a good decompression of both roots

even in the foraminal region, followed by a transforaminal interbody

fusion (TLIF).We performed this approach using both open and

minimally invasive technique.

Between May 2007 and April 2008 16 patients (16 women, 10

men), aged 39 to 73, with bi-radicular symptoms underwent surgery

through this approach.

The herniations were located at L4-L5 in 9 patients, at L3-L4 in 3

patients and L5-S1 in three.

Two patients were previously treated through an intracanalar

interlaminar approach with a partial resolution of radiculopathy.

Minimally invasive tecnique was used in 5 patients.

Operating time was beetween 2 and 2.30 hours, depending if

minimally invasive tecnique was used.

After a follow up period from 2 to 18 months, fifteen patients

showed an almost complete resolution of the symptoms, with a pre-

operative VAS in 8 and post-operative VAS in 2, without any evi-

dence of pseudoarthrosis or malpositioning of devices.

Taking into account the shortness of the follow up there isn’t any

evidence of adjacent segment pathology.

Even if others studies are needed we believe this tecnique is a

feasible method to obtain a complete decompression of both

roots with an almost circumferential arthrodesis (270�) in

single stage procedure. Frequently with a minimally invasive

approach.

Eur Spine J (2009) 18:727–780 745

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43

SURGICAL TREATMENT WITH

TRANSFORAMINAL LUMBAR INTERBODY

FUSION (TLIF) IN RECURRENT LUMBAR DISC

HERNIATION: INDICATION AND RESULTS

S. Astolfi, L. Scaramuzzo, V. Del Bravo, C. A. Logroscino

Departement of Orthopaedic Science and Traumatology SpineSurgery Division Catholic University Rome

Introduction: Recurrent disc herniation is a major cause of surgical

failure in spine surgery. The optimal technique choice in treating this

disease is, nowadays, controversial. A repeated discectomy and a

wide decompression increased the risk of segmental instability, dural

tear and nerve injuries due to the presence of scar tissue. Need to

prevent these complications and the growing facility in approaching

posteriorly the anterior lumbar vertebral column, make the trans-

foraminal lumbar interbody fusion a valid surgical treatment

possibility in recurrent disc herniation.

Methods: From January 2005 to January 2008 by Spine Surgery

Division of Department of Orthopaedic Science and Traumatology

of Catholic University 25 patients, 14 male and 9 female, with a

mean age of 47 years (range 34-67 years) affected by recurrent

disc herniation underwent transforaminal lumbar interbody fusion

combined with pedicle screw fixation. All patients were evaluated

post-operative with an antero-posterior and lateral X-ray 1 m, 3 m,

6 m, 12 m and then every year and with a CT scan of the treated

levels to evaluate the cages’ positioning and the fusion rate.

Clinical outcome was evaluated by SF-36 questionnaire, Oswestry

Disability Index and VAS Score.

Results: All the patients demonstrated a significant and progressive

improvement, in term of pain, especially radicular pain and inde-

pendence in daily life. CT scan control at 1 year minimum follow-

up exhibited a good fusion rate in 100% of cases. Cages’

positioning was very good in 85% of cases, good in 15% of cases.

There was no hardware failure at two years median follow-up.

Discussion: The gold standard in surgical treatment of recurrent

disc herniation is, nowadays, a subject of controversy. In our

opinion the transforaminal lumbar interbody fusion combined with

pedicle screw fixation has several advantages. It allows to perform

a wide decompression with complete release of neurological

structures, reduces or eliminates segmental motion and helps to

restore the physiological lordosis of the affected lumbar segment.

A transforaminal approach to the disc space allows to perform

decompression limiting the damages to neurological structures,

greatly increased in revision surgery due to the presence of a great

number of adhesions and fibrotic scar tissue.

44

STAND-ALONE CAGE FOR POSTERIOR LUMBAR

INTERBODY FUSION IN THE TREATMENT OF

HIGH DEGREE DEGENERATIVE DISC DISEASE

(DDD): DESIGN OF A NEW DEVICE FOR AN

‘‘OLD’’ TECHNIQUE. A PROSPECTIVE STUDY

ON A SERIES OF 119 CASES

M. Fornari, F. Costa, M. Sassi, A. Cardia, A. Ortolina, R. Assietti*

Istituto IRCCS Galeazzi, Milano; *Ospedale Fatebenefratelli,Milano, Italy

Introduction: Chronic lumbar pain due to Degenerative Disc Disease

(DDD) is a very common entity affecting a large amount of people

often in the full activity ages. Considering that the usual self-repair

system observed in nature is a spontaneous temptative of arthrodesis

leading in most of the cases to pseudoartrosis, many possible surgical

treatment of fusion have been proposed and introduced during the

recent years, such as PLIF.

Due to the growing interest toward minimally invasive surgery and the

unsatisfactory results present in Literature (mainly to the high incidence

of morbidity and complications) a new titanium made lumbar interbody

cage (I-Fly) has been developed in order to achieve a solid bone fusion

by a stand alone posterior device. This cage presents a modify head,

(blunted and thinned), in a way it can be used as a blunt spreader and a

small size core, leading an easier self-positioning of the cages.

Matherial and Methods: Between 2003 and 2007 119 patients were

treated for chronic lumbar discopathy (Modic III grade and V grade in

Pfirman classification) with I-Fly uses as stand-alone cage.

All the patients were clinically evaluated pre-operatively and at 1 and

2 years follow-up with a neurological evaluation, VAS and Prolo

Economic and Functional Scale. Radiological results were evaluated

with a polyaxial CT scan and flexion-exstension x-rays. Fusion is

defined as absence of segmental instability at dynamic x-ray and

Bridwel grade I or II at Ct scan. Patients were considered clinically

‘‘responders’’ with any improvement at VAS evaluation (comparing

to baseline values), and a PROLO value [ 7.

Results: At the last follow-up the rate of clinical success was assesed

in 93.9% patients while the rate of bony fusion was 99.1% evaluated

with flexion-extension x-ray and 92.2% evaluated with CT scan. The

rate of morbidity (no nerve root injury, no dural lesion) and com-

plications (subsidence and pseudoarthrosis) is minimal.

Conclusion: PLIF with stand-alone I-Fly cage can be considered as a

possible surgical treatment of chronic low-back pain due to high degree

DDD. This technique is not demanding and can be considered safe and

effective as showed by the excellent clinical and radiological success rates.

746 Eur Spine J (2009) 18:727–780

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45

THE DIFFERENTIATED STABILIZATION IN THE

LUMBAR DEGENERATIVE DESEASE

M. Petruzzi, M. Laccisaglia, B. Cedron, C. Lamartina

I.R.C.C.S. Istituto Ortopedico Galeazzi – Chirurgia Vertebrale II,Italy

Introduction: The treatment of degenerative disk disease remains one

of the most controversial topics in the spine literature. The spine surgery

strategies depend on the clinical and radiological manifestation of the

degenerative lumbar disk disease. The fusion eliminates motion of the

functional spinal segment and may overload the adjacent segments,

thereby generating the transition syndrome and sometimes the need of

reinterventions. These disadvantages led to alternative procedures and

techniques for stabilization without fusion. Mobile stabilization systems

have to neutralize noxious forces and restore normal function of the

spinal segments and protect the adjacent segments. Very frequently in

the same patient different degrees of lumbar degenerative cascade are

observed. We often see one motion segment with an advanced degen-

eration (disk collapse) neighboring one or more segments with just a

mild discopathy (black disk/annular tear ‘‘HIZ’’). The symptoms can be

tied up to the different levels. Long fusion has a bad reputation and the

modern non-fusion techniques are not designed to address all multilevel

disease. In these cases, when the surgery is suitable, it is necessary to

differentiate and to adjust the stabilization to the degree of degeneration.

In this way an instrumentated fusion can be suitable to a level (laminar

screws or pedicular screws) and a stabilization without fusion to another

(pedicular dynamic neutralization). This study shows different surgical

strategies with or without fusion in relationship to the different level of

lumbar degenerative cascade.

Materials and Methods: We report our experience on 15 patients

suffereing from lumbar degenerative disease, registered in Spine Tango

Registry, treated surgically between January 2007 and December 2008.

We evaluated pre- and follow-up pain and fusion in a consecutive series

of 15 patients (6 male/9 female) with a mean age of 50.8 years (40-66) at

the time of the surgery. The mean follow-up time was 10.6 months (6-

19). Twelve patients received a three-level of instrumentation, 1 patient

had a four level of instrumentation, 1 patient had a five level of

instrumentation and 1 six-level of instrumentation. Three patients

received a TLIF, 2 a PLIF, 1 an interspinous spacer, 12 a fusion with

pedicular screws, 3 a fusion with laminar screws.

Results: Pre-op VAS was 8.4, f.up VAS was 2.06. We found a solid

fusion in all patients at the last follow-up.

Conclusion: Hybrid stabilization is a relatively new concept in spinal

stabilization procedures with the combination of a rigid stabilization

with fusion and non-fusion techniques in the same patient. Pre-

liminary clinical results suggest that these procedures benefit patients

with spinal disorders, varying stiffnes of the systems. The goals of this

procedure is to preserve the adjacent segment to the fusion.

46

TRANSFORAMINAL LUMBAR INTERBODY

FUSION: A RETROSPECTIVE STUDY OF 114

PATIENTS

P. P. Mura, M. Costaglioli, M. Piredda, D. Castangia, S. Casula,S. Caboni

Cagliari, Italy

Introduction: The goal of a fusion of the lumbar spine is to obtain a

primary solid arthrodesis so as to alleviate pain. Different circumferential

or ‘‘360’’ fusion techniques have been described such as combined

anterior–posterior fusion (APF), instrumented posterior lumbar

interbody fusion (PLIF) and transforaminal lumbar interbody fusion

(TLIF).

The TLIF procedure has rapidly gained popularity in these last few

years. Because of its posterolateral extracanalar discectomy and

fusion, it has been reported as a safe technique, without the potential

complications described when using combined APF and PLIF

techniques.

Patients and Methods: 114 patients operated from 2003 to 2008

• 60 patients operated between 2003 and 2006

• All patients operated in the same center

• All patients operated by the same surgeon

Patients were evaluated preoperatively, intraoperatively and postop-

eratively at 1 and 3 and 12 months.

Operation Technique: The spine was approached through a

classic posterior midline incision and subperiosteal muscular

detachment. The side of facetectomy was chosen according to the

subject’s symptoms of leg pain if present. A posterolateral annuloto-

my was made and subtotal discectomy was performed and the hyaline

cartilage of endplates was removed. Once the surgeon was satisfied

with endplate preparation, a banana shaped allograft spacer was

inserted through the annulotomy and placed anteriorly, along the

anterior apophyseal ring. Additional autograft locally harvested from

decompression was packed behind the allograft spacer in all cases.

Laminae and the remaining contralateral facet joint were decorticated,

and packed with bone graft (local autologous and allograft chips in all

cases). Finally, the posterior fusion was instrumented with pedicle

screws and rods.

No major surgical complication was observed.

Results: The TLIF procedure had led to shortened surgical times, less

neurologic injury, and improved overall outcomes. The introduction of

the transforaminal lumbar interbody fusion procedure has allowed

surgeons to achieve successful fusion without the risk of nerve root

tethering that is seen so frequently with standard PLIF techniques.

47

CLASSIFICATION OF LUMBAR STABILIZATION

DEVICES: A BIOMECHANICAL CRITERION

M. Brayda-Bruno1, A. Lovi1, M. Teli1, F. Anasetti2,C. M. Bellini2, F. Galbusera2

1Department of Spine Surgery III, IRCCS Istituto OrtopedicoGaleazzi, Milan, Italy; 2LaBS, IRCCS Istituto OrtopedicoGaleazzi, Milan, Italy

Introduction: The surgical devices currently used for the treatment of

lumbar disc degenerative disease can be divided into three categories:

fusion devices (rigid or semirigid rods), devices aimed to the reduc-

tion of the flexibility (flexible rods) and load-bearing devices which

preserve the physiological spine flexibility (very flexible rods, inter-

spinous devices, disc prostheses). However, devices belonging to the

latter two categories are difficult to be sorted. In this paper, the

authors propose a classification system based on the residual mobility

of the implanted segment.

Materials and Methods: The motion-limiting effect of several

devices was evaluated by means of a finite element model of the L2-

L5 segment. The following devices were considered: stainless steel

rods, titanium rods, PEEK rods, composite rods, and some dynamic

pedicular devices currently available on the market. Both single level

(L4-L5) and double level (L3-L5) stabilizations were considered. The

Eur Spine J (2009) 18:727–780 747

123

models were loaded with pure moments of 7.5 Nm in flexion,

extension, lateral bending and axial rotation.

Results: The spine flexibility after the implantation of the stabiliza-

tion devices resulted extremely sensitive to the mechanical properties

of the device materials. All the rods (steel, titanium, PEEK, com-

posite) induced a significant reduction of the flexibility (more than

70% in flexion and extension). The dynamic devices partially pre-

served the segment mobility. However, the stiffness of the implanted

spine models resulted strongly dependent on the device biomechanics

(flexibility reduction between 7% and 72% in flexion and extension).

Discussion and Conclusions: Based on the present results, the

authors suggest the use of a classification system for the stabilization

devices based on the residual flexibility of the implanted spine,

independently on the design of the device (e.g. pedicular or inter-

spinous). The devices able to preserve only partially (for example less

than 70%) the segment flexibility may be defined ‘‘flexible’’.

‘‘Dynamic’’ devices should be able to preserve a nearly physiological

flexibility (at least 70%).

48

ITALIAN MULTICENTRIC STUDY ABOUT THE

USE OF A NEW INTERBODY DEVICE WITH

PROGRAMMABLE LORDOSIS: FIRST RESULTS

ON 25 CASES

T. C. Russo1, M. Balsano2, P. Bruni3, R. Greco4, B. Misaggi5,P. P. Mura6, G. Rizzo7, C. Ruosi8

1Ragusa, 2Schio-Tiene, VI, 3Viterbo, 4Roma, 5Milano, 6Cagliari,7Bari, 8Napoli, Italy

The present study concerns the use of an expansion cage to the

lumbar level. Were evaluated 25 patients with degenerative lumbar

disease: 13 degenerative spondylolisthesis of L4 (Mayerding 1), 9

steno-instability and 3 litic spondylolisthesis of L5 (Mayerding 1).

The cage has been always used in association with posterior sta-

bilization. In most cases (22 of 25) was preferred implant a

monocage with PLIF or TLIF access in the more symptomatic side.

We also discussed some known surgical technique and presented the

first results.

ISOLATED INTERBODY FUSION WITH A

POSTERIOR TRANSFORAMINAL MONOPORTAL

ACCESS IN LUMBAR DEGENERATIVE

PATHOLOGY

C. Formica, L. Cavaleri, M. Formica, G. Buzzi

SONG - Spinal Orthopaedical Neurosurgical Group; Alessandria– Clinica Salus - Gruppo Policlinico di Monza; Genova - ClinicaMontallegro – Universita di Genova, Italy

Purpose of the Study: To evaluate the results and the complications

of lumbar interbody fusion, even known as ‘‘stand-alone’’. Interbody

arthrodesis in primitive or secondary intervertebral disc degeneration

has still today a biomechanical and biological validity despite the

prosthesis coming. In the last years the posterior surgical procedures

have been changed looking for less invasive techniques than the

traditional PLIF (Posterior Lumbar Interbody Fusion) such as TLIF

(Transforaminal Lumbar Interbody Fusion). This open surgical

technique is less invasive on the dura madre and respects the bone as

well as the capsular-ligamentous structures of the opposite vertebral

lumbar side.

Material and Methods: From 2002 we began the isolated lumbar

interbody fusion (without pedicular screws) using a device with a

‘‘banana shape’’ in carbonium or titanium in a selection of patients.

The indications are very limited: monosegmental primitive or post-

surgical disc degeneration with no or less instability, close to a

physiological stabilization and with a good disc above and below. In

the case of a radicular pain the transforaminal approach was per-

formed on the same side of the nervous sufferance, apart when an

important scar tissue due to previous surgery was found. In the last

situation a traditional TLIF with pedicular screws and an interbody

fusion from the opposite side of the previous access would have been

done. Age and sex were discriminating; indeed in young or middle

age patients we like best disc prosthesis, also in males at level L4L5.

Results: From January 2002 to December 2007 we treated with the

isolated monoportal interbody fusion technique 148 patients: 93

males, 55 females. Minimum age 23 years old, maximum age

78 years old (average 42,7 y.o.). In 6 cases the levels treated were

L3L4, in 52 cases L4L5, in 90 cases L5S1. The complications

occurred were 2 lesions of the dura madre, sutured in first instance.

Pre-operatory VAS was 7.1 and post-operatory 2.7. Oswestry dis-

ability index improved from 84% to 22%.

Conclusions: These indications are not definitive. We are sure

enough that no absolute truth could be found in degenerative vertebral

diseases. The advantage of this procedure is the less invasion of the

nervous structures (dura madre and nerve roots) thanks to a mono-

lateral mobilization. The weight bearing is granted the day after

surgery and the average stay in hospital is 2/3 days. The microscope

or enlarger glasses are used as well as in herniated disc operations. As

a disadvantage a lesion of the dura madre might occur as well as the

formation of scar tissue around the foraminal root. If well seen and

checked, the root is never damaged nor stretched. Products against

adhesions or a fat patch could be used to protect the nerve root. The

venous plexus is probably the worse problem if responsible of a

compressive haematoma. For this reason we bring particular attention

to a precise haemostasis using bipolar forceps, collagenous layers and

drainage hoses after surgery.

LUMBAR SPINE – Part 2

49

SURGICAL TREATMENT OF ADULT LOW GRADE

LYTIC SPONDYLOLISTHESIS

G. Gargiulo, A. Solini

U.O. Ortopedia - A.S.O. S. Giovanni Battista Molinette, Italy

Introduction: Surgical treatment of 1th – 2th grade adult lytic

spondilolisthesis presents some controversies. Articolar rand disc

degeneration at the level of lysis, foraminal stenosis and istmic

traction spurs, degenerative changes at adjacent level and possible

concomitatant stenosis, osteoporosis in aged patient and different

surgical options available (Gill decompression, posterolateral, ante-

rior or circumferential fusion, with or without instrumentation, open

or mininvasive surgery) don’t give a general interpretation of the

surgical treatment when indicated. Authors report their experience in

these partiets discussing surgical strategies.

Material and Method: During the period of 1992-2004 63 patient 33

males, 30 females) of mean age of 39 y. (28-57) were treated at the

748 Eur Spine J (2009) 18:727–780

123

Orthopaedic Division of A.S.O. S. Giovanni Battista Molinette of

Turin for a simptomatic low grade spondylolistesis. Low back pain

affected 61 patients (VAS 8), in 2 cases radicolopathy pain was the

main symptom for surgical treatment. However radicular pain was

present in 59 cases with deficit in 21 and claudicazio in 9. All the

patients have been submitted to standard and functional rx, TC and

RNM. In 43 cases the lysis was in L5, in 13 in L4, in 4 in L3 and in 2

in L3 and L4. The surgical treatment was of simple decompression

according to Gill in 2 cases, of decompression and posterolateral

instrumented in situ fusion with transpedicular screws in 37 cases, of

alone instrumented posterolateral in situ fusion in 24 cases (Wiltse

access).

Results: Satisfactory results were achieved in most patients. At a mean

8 y. f.up (4 -12) they have been good in 51 cases (VAS 2), fair in 13

(VAS 5) for the irregular assumption of FANS for the treatment of a

residual light back pain but with significant improvement of day life

activities. In any case the worsening of the preoperative symptoms was

observed. A homogeneous callus of artrodesis has been clearly evident

in RX in 53 patients. Among the complications of the treatment we

observed pedicle violation of the lytic vertebra in 3 cases, of which in 2

has not been possible to insert screws, a transitory nerve root compro-

mise from excessive manipulation of the root in 5 cases. One case in

which the screw repositioning was been necessary in S1 after 7 days

from surgery was complicated by the appearance of a pulmonary

embolism without residual functional damages. In 3 cases the instru-

mentation has been removed for the appearance of a lombalgia after

4 years in average from surgery in a good fusion, with regression of the

symptoms. In a case of instrumented L5-S1 artrodesis has been nec-

essary to extend proximally the artrodesis after 6 years for the

reappearence of the lumbar and peripheral simptoms following a seri-

ous lumbar trauma with partial regression of the signs at last control. A

junctional syndrome treated with medical cares and physical therapy

has been observed in 3 cases after 7 years in average.

Conclusions: In our experience surgical treatment of low grade istmic

spondylolistehesis in adults was commensurate to the symptoms

complained by the patients. The nerve root decompression, also as the

only surgical action, has been performed always in presence of a

radicular compromise confirmed by an imaging that shows the central

or lateral stenosis at the level of lysis or at the adjoining levels. The

posterolateral instrumented fusion has allowed to adequately treat the

local instability and mechanical lombalgia with good clinical results

any degenerative characteristic of the articular tripode and any degree

of lysthesis.

50

SPONDYLOLYSIS OR FIRST-DEGREE

ISTHMICAL SPONDYLOLISTHESIS: ISTHMICAL

RECONSTRUCTION OR ARTHRODESIS?

B. Misaggi1, P. Vigano’1, G. Fava1, D. Peroni1,M. Ferraro2, A. Trapletti3, F. Spreafico3, W. Albisetti4

1U.O. Patologie Vertebrali e Scoliosi - Istituto Ortopedico G. Pini– Milano; 2S.C. II Divisione - Istituto Ortopedico G. Pini –Milano; 3I Scuola di Specializzazione in Ortopedia eTraumatologia – Universita degli Studi di Milano; 4Universitadegli Studi di Milano, Italy

Introduction: In young patients affected by lumbar pain due to

spondylolysis or first degree spondylolisthesis, if conservative treat-

ment failed, it’s better to choose a surgical solution consisting in

isthmical recontruiction.

The vertebral arthrodesis is obliged only in cases of severe instability

and discal degeneration.

The isthmical reconstruction is obtained by different techniques

Materials and Methods: In our experience, we used Buck and Gillet

techniques, indicated if there is not discal degeneration.

In our retrospective, uncontrolled study, we reviewed 88 patients;

patients aged from 11 to 36 year; the mean follow up was 8 years; the

operated level was L2 in 62 patients, L4 in 20 patients and L3 in 6

patients.

Oswestry and VAS scale were used for clinical evaluation. RX

evaluation was performed at 3,6,12, and 24 months after surgery; a

MR was performed in 65% of the cases at 18 months after surgery.

Results: The results of surgery were satisfactory; only in 11% of the

patients pain persisted after the intervention. At RX a complete

consolidation was observed in 93% of cases, with the complete

restored function in 90%.

At RM evaluation there were no signs of discal degeneration in 90%

of patients.

Discussion and Conclusion: Isthmical reconstruction is surely

advantageous respect to arthrodesis: it consents an anathomical rec-

ontruction, it saves the vertebral segment and the functional unit.

That’s why we consider it as functional surgery.

51

LONG TERM RESULTS OF THE DIRECT REPAIR

OF SPONDYLOLISTHESIS

F. Giudici1, L. Minoia, M. Archetti, A. S. Corriero, A. Zagra

1Istituto Ortopedico Galeazzi, Milano, Italy

Isthmic repair is an effective surgical procedure in lumbar spondy-

lolysis and spondylolisthesis with slipping less than 15% in patients

under 25 years old with painful symptoms resistant to conservative

treatment.

Isthmic repair of the lumbar spondylolisthesis was first proposed

by Buck in 1970. The Author performed the isthmic repair by iliac

bone graft and two trans-isthmic screws. Nicol and Scott (1986)

performed the fixation by two steel wirings that proceeded anterior

to the transverse process and were anchored to the spinous process.

Morscher et al. (1984) described a technique for the surgical

treatment of spondylolysis by bone grafting and direct stabilization

by means of a hook and a screw for each side. Salib and Pettine

(1993), Songer and Rovine (1998) proposed a fixation by pedicular

screws, segmental wire and bone grafting. Takuhashi and Matsu-

zaki (1996) proposed repairing the deficit in spondylolysis by

segmental pedicular screws and laminar hook fixation.

58 patients were operated for isthmic repair at Istituto Ort-

opedico Galeazzi of Milan, according to different techniques from

1994 to 2006. The males were 39 (67.2%), the females were 19

(32.8%). The mean age of the patients was 18 years (range 10-26

y.). The symptoms were: backache in 47 cases (81%), back and

radicular pain in 7 cases (12.1%), no pain in 4 cases (6.9%). The

defect was in L5 in 55 cases (94.8%) and in L4 in 3 cases (5.2%).

The slipping was from 0 to 15% (average 8%). An iliac bone

graft was applied in the lysis in all cases. The Buck technique

was performed in the first 7 cases (12.1%), the Scott technique

was performed in 12 cases (20.7%) and the modified Scott tech-

nique (pedicular screws and wiring) was performed in 39 cases

(67.2%).

The results of 52 cases were analysed from 2 to 14 years after

operation (average 7 years); 6 were lost to follow-up. The clinical

result of 7 patients operated by the Buck technique was good in 3

Eur Spine J (2009) 18:727–780 749

123

cases (42.8%), whereas backache was present in 4 cases (57.2%).

The x-rays showed in these patients: no change of the slipping in 6

cases (86%), increasing in 1 case (14%); bone graft absorption was

observed in 3 cases (42.8%); no loosening and no breakage of the

screws occurred. A second operation was performed in 5 patients

(71.4%). The removal of the screws in 1 case, the removal of the

screws and a posterior-lateral fusion without instrumentation in 4

cases. The clinical result of 11 patients operated by the Nicol and

Scott technique was good in 9 cases (81.8%), whereas backache

was present in 2 cases (18.2%). The x-rays showed in these

patients: no change of the slipping in 10 cases (91%), increasing in

1 case (9%), bone graft absorption only in the last case; breakage

and loosening of the wirings, but complete repair of defect, was

observed in 1 case (9%). A second operation was performed in 2

patients (18.2%): the removal of the wires in 1 case, the removal

of the wires and a posterior-lateral fusion without instrumentation

in 1 case. The clinical result of 34 patients operated by the

modified Scott technique was good in 30 cases (88.2%), whereas

backache was present in 4 cases (11.8%). The x-rays showed in

these patients: no change of the slipping in 33 cases (97%),

increasing in 1 case (3%) (bone graft absorption only in this case);

breakage and loosening of the fixation were observed in 2 cases

(5.9%). A second operation was performed in 2 patients (5.9%):

the removal of the implant in 1 case, the removal of the implant

and a posterior-lateral fusion in 1 case.

The data show a significant statistical difference among the

three groups of patients operated with different techniques

(p=0,025, Fisher’s exact test). The Scott and modified Scott tech-

niques, with respectively 81.8% e 88.2% of good clinical results,

seem to provide a better outcome than the Buck technique (42.8%).

In conclusion, these results demonstrate that the pars defect

repair is a helpful, easier and faster technique in lumbar spondy-

lolysis and spondylolisthesis treatment, especially the modified

Scott technique.

52

INSTRUMENTAL ARTHRODESIS WITH

TRANSPEDUNCOLAR SCREWS AND ONE

INTERBODY DEVICE IN THE TREATMENT OF

DEGENERATIVE LUMBAR SPONDYLOLISTHESIS

G. Incatasciato, C. Casamichele, M. Quartarone, A. Tumino,G. Giuca, T. C. Russo

Unit of Orthopaedics and Traumatology Major Hospital ofModica, Italy

Introduction: The increase in the average age involves an increasing

number of degenerative spinal diseases. These included degenerative

spondylolisthesis is one of the most frequent and disabling. In the

literature are numerous surgical procedures that are adopted by

decompression alone, decompression associated to the segmental ar-

trodesis, with or without instrumentation.

Materials and Methods: At Unit of Orthopedics and Traumatology

of the Major Hospital of Modica from 2007 to date 24 degenerative

spondylolisthesis have been treated by circumferential arthrodesis

with one interbody device by plif or tlif. The average age was 60 aa

(range 48-79), 17 women and 7 men, the most involved vertebra was

L4. The symptoms presented were backache, neurogenic claudication,

the mono / pluriradicolapatie paintings and mixed. All patients had

performed conservative treatment for a period of not less than

3 months. All interventions were performed by the same surgeon,

with an average time of 120 min, with contained blood loss (130 cc).

Patients with an average follow up of 12 months (range 3-24) and

were evaluated with controls at 1, 3, 6.12 months, bringing the

intensity of pain according to VAS scale and evaluating the results of

the SF 36 specially administered. Of all the patients we have obtained

x-rays in AP, LL and dynamic.

Results: The amount of pain, assessed with the VAS scale decreased

significantly to 23 (range 0-82) (P = 0.00001). SF-36 in 74% patients

have described their health good to excellent. Was not observed any

failure of the plant, while in 24% of patients show signs of degen-

eration of segments adjacent asymptomatic. The segmental lordosis

was maintained at fusion segment as well as lumbar lordosis.

Discussion and Conclusions: Treatment with one interbody device

reduces the surgery time and invasiveness of intervention itself. The

clinical and radiological results confirm the validity and effectiveness.

Keywords: degenerative spondylolisthesis, instrumental arthrodesis,

one interbody device, plif, tlif

53

DIRECT SCREW REPAIR OF SPONDYLOLYSIS:

AN ‘‘OLD’’ DYNAMIC SOLUTION

S. Casula, M. Costaglioli, M. Piredda, D. Castangia, S. Caboni,P. P. Mura

Cagliari, Italy

Introducion: Lumbar spondylolysis is not an infrequent finding and

has been reported in approximately 6% of the adult population.

Although most of patients affected by the disorder are asymptomatic, a

small number of patients experience chronic disabling low back pain,

sometimes radiating to the buttocks or thighs. Direct repair of the lesion

in the pars interarticularis is an appropriate and reasonable alternative to

fusion in those patients who have minimal spondylolisthesis and an

intact disc. The Buck technique proved to be the most stable method

among several techniques for the direct repair of a pars defect.

Patients and Methods: Between January 2005 and January 2007 we

treated 15 patients with a mean age of 22,3 years for bilateral bilateral

defect of the pars interarticularis (spondylolysis) at L5 level, opera-

tions were performed for persistent disabling low back pain. Direct

repair is indicated only in the absence of disc degeneration or radi-

culopaty. Each patient had an MRI which included T1- and T2-

weighted scans with axial views of the pedicles. Direct repair of a

defect in the pars interarticularis was performed with use of bone-

grafting and internal fixation with a pedicle screw, rod, and laminar

hook in order to achieve a higher prevalence of osseous union than

that achieved with commonly used procedures.

Conclusion: This technique offers the advantage of being a dynamic

motion preservation solution, it can be performed using a great

number of available spinal instrumentations using rods and pedicle

screws. There is no violation of the neural canal. No postoperative

brace was used, return to everyday life avoiding low back stress was

immediate, and return to work or sports was possible 3 to 6 months

after the procedure. This technique seems safe and effective but needs

careful selection of patients, as do all other techniques for direct

repair of pars interarticularis screw fixation is a safe and reliable

method of treatment for painful spondylolysis

750 Eur Spine J (2009) 18:727–780

123

54

LUMBAR SYNOVIAL CYST: OUR EXPERIENCE

AND METANALISYS OF LITERATURE

M. Ganau, F. Ennas*, G. Bellisano�, G. Faa�, A. Maleci

Chair of Neurosurgery, *Dept of Orthopaedics,�Institute of Anatomic Pathology - University of Cagliari, Italy

Introduction: Symptomatic lumbar synovial cysts (LSC) are rare

(incidence: 0,02-0,8%), their diameter may range between 5 mm and

2-3 cm, contributing significantly to the narrowing of the spinal canal,

and lateral thecal sac or nerve root compression. From a histological

perspective true synovial cysts have a thick wall lined by synovial

cells, containing granulation tissue, numerous histiocytes, and giant

cells; in contrast pseudo cysts lack a specialised epithelium, they have

a collagenous capsule filled with a mixoid material and may be

classified into ganglion cysts: originating from periarticular fibrous

tissues, and ligamentous cysts: arising from ligamentum flavum or

even from posterior longitudinal ligament.

Pathogenesis and biomechanics implications of LSC are not well

elucidated; moreover there is still a lack of consensus over the best

management since conservative treatment or surgical indication are

still controversial. Clinical results are reported in the form of small

series or case reports, while we see an ever growing number of facet

joint steroid injections, sometimes without a clear rationale, and

generally responsible for poor long lasting benefits (pain resolution in

only 1=3 of patient at 6 mos).

Herein we describe the surgical series of the Chair of Neurosur-

gery at the University of Cagliari, and match our results with those

from a metanalysis of the literature.

Materials and Methods: Between 2000 and 2006, we have surgically

treated fourteen LSC (7 women and 5 men; age: 58-76 years) pre-

senting with chronic low back pain (9), motor deficits (2) or cauda

equina syndrome (1). Diagnosis was obtained by MRI or CT scans,

showing LSC located at: L4-L5 (9), L3-L4 (3), L5-S1 (2); two

patients presented contiguous cysts on adjacent spine levels, no cases

of bilateral cysts were encountered. Facet sparing excision of LSC

was achieved by small hemilaminectomy in all patients.

Results: Our cohort experienced a complete resolution of symptoms

(MacNab: excellent), without perioperative complications, nor

regrowth of cysts or vertebral instability at follow up (*28 mos).

Diagnosis was confirmed by histological specimen examination

which detected the typical synovial epithelium, the intracystic pres-

ence of haemosiderin, histiocytes and calcifications. Immuno-

histochemical investigation revealed a positive stain for CK 5, 6,

AE1-AE3.

Metanalysis of literature was conducted from 1987 up to the

present: we were able to collect a total of 719 LSC surgically

treated and histologically confirmed. LSC appear to be correlated

to degenerative spondilolisthesis (Meyerding: I), rheumatoid

arthritis, and condrocalcinosis. Low back pain or radiculopathy are

often the only clinical findings (45%), less frequently patients

complain of motor deficits (35%) or cauda equina syndromes (5%);

lastly the onset with intra-cystic haemorrhage is rare: only 24 cases

described

Surgical excision seems to guarantee excellent results in 80-90%

of patients, with complication rate\3%. Arthrodesis rate account for

7% of all procedures, and is performed only in case of facetectomy or

evidence of preoperative instability. We did not find significant dif-

ferences in clinical outcomes between en bloc vs gross total cysts

excision, nor between endoscopic vs open surgery, or fusion vs

laminectomy/laminotomy alone.

Conclusions: Both clinical and histological findings described

in our study contribute to enrich the still limited amount of data

found in literature. Moreover our experience confirms the efficacy

of open surgical removal of symptomatic LSC, and particularly we

advocate the facet sparing technique as the one of choice.

55

MODIFIED WILTSE APPROACH FOR DTO

IMPLANTATION

P. Cervellini, L. Rossetto, L. Gazzola, G. Zambon

Department of Neurosurgery City Hospital, Vicenza, Italy

Introduction: Early degeneration of a adjacent disc to a fused area

may occur.

To avoid this problem many surgeons extend fusion to adjacent grade

2-3 Pfirmann disc degeneration.

We are using DTO for degenerative discopathy with a modified

Wiltse approach since 2007.

Materials: Surgical indicatin was:

1) Grade 1 spondylolisthesis

2) Severe discopathy

3) FBSS

All them associated with 1 or 2 discs degenerated.

Results: All the patients underwent VAS (visual analogue scale) test

before and after surgery with pain reduction, even after 6 months.

We also noticed a reduction in blood loss during this kind of surgery

and a minimal muscular trauma at MRI controls.

56

PLIF WITH TRABECULAR METAL: LONG-TERM

RESULTS

F. Postacchini*, G. Cinotti*, E. Ferrari*, S. Faraglia*, R.Postacchini**

*Department of Orthopaedic Surgery, University ‘‘Sapienza’’,Rome, Italy; **Department of Orthopaedic Surgery, University‘‘Tor Vergata’’, Rome, Italy

In the last 15 years, interbody fusions (PLIF or TLIF) have usually

been performed using intersomatic cages of various materials, filled

with autologous bone graft. In most cases, satisfactory clinical results

have been obtained. However, several experimental studies have

shown that interbody fusion may not occur with cages since the bone

graft may be replaced by dense fibrous tissue, probably due to the

stress-shilding to which it is submitted because of the rigidity of the

implant. An alternative to cages is represented by implants of tra-

becular metal (tantalum), which has a modulus of elasticity very

similar to that of bone, thus being able to undergo a good

osteointegration.

This study was aimed at evaluating the long-term clinical and

imaging (x-ray and MRI) results of PLIF carried out with trabecular

metal.

Materials and Methods: Between 1996 and 2002, an instru-

mented PLIF using blocks of tabecular metal was performed in 22

patients (14 males and 8 females, with a mean age of 52 years)

who had degenerative spondylolisthesis with or without lumbar

stenosis (14 cases), degenerative disc disease (5 cases) or isthmic

spondylolisthesis (3 cases). Interbody fusion was carried out at L4-

Eur Spine J (2009) 18:727–780 751

123

L5 in 15 cases, L3-L4 in 5 and L5-S1 in 3. One patient was fused

at 2 levels.

Patients were evaluated every 3 months in the first postoperative

year and most of them every 2 years successively. In 2008, 14

patients, who represent the clinical material of this study, were

evaluated at an average of 8,3 years after surgery. At the latter follow-

up, patients underwent clinical examination, imaging studies (x-rays

and MRI) and were asked to fill in the SF-36 and Oswestry

questionnaires.

Results: In all patients, x-rays and MR images showed a solid

fusion with no evidence of radiolucency at the bone-implant

interface or abnomalities of signal intensity of the vertebral

bones adjacent to the implant. The clinical results were rated as

excellent in 9 cases, good in 3, and fair and poor in 2, respec-

tively. In the postoperative period, out of the 14 patients, 3, who

had had a single level fusion, underwent degenerative diseases at

the vertebral level above or below the fusion after a mean interval

of 4.2 years after surgery. The 3 patients developed lumbar

stenosis, associated to degenerative spondylolisthesis in 1, at the

level above the fusion. All 3 patients underwent repeat surgery,

consisting in decomopression in 2 and decompression and fusion

in 1.

Conclusions: Intersomatic implants of trabecular metal appear to be

highly effective in obtaining fusion in the lumbar spine. The low

rigidity of the material appears to allow better osteointegration

compared to the cages. The incidence of degenerative diseases at the

levels adjacent to the arthrodesis is higher compared to that occurring,

in our experience, following posterolateral fusion; based on the

numbers available, we cannot determine whether it is also higher than

instrumented interbody fusion with cages.

57

140 CASES OF LUMBAR SPINAL FUSION

WITH SFS INSTRUMENTATION: PRELIMINARY

RESULTS OF A MULTICENTRIC STUDY

C. Ruosi1, D. Maglione1, M. Balsano2, M. Crostelli3,M. Costaglioli4, P. P. Mura4, B. Misaggi5, T. C. Russo6,S. Savino7

1Napoli; 2Schio-Thiene (VI); 3Roma; 4Cagliari; 5Milano; 6Ragusa;7Latina, Italy

SFS by Blackstone is one of the different spine instrumentations for

back surgery, performed both for short fusions (degenerative lumbar

pathologies, spondilolystesis, dorsolumbar fractures or metastasis)

and long fusions (scoliosis and kifosis).

It’s made of alloy titanium and is composed by self-tapping tulip

mono and multi- axial tulip screw and a large choice of hooks. The

longitudinal bars have a diameter of 5,5 mm with a length range from

40 to 200 mm., and, if necessary, there is the possibility to have a

measure of 450 mm and 600 mm for longer stabilizations.

Together with a group of orthopaedics and neurosuregeons from

several Italian centers we decided to define a study protocol to

demonstrate the reliability and the versatility of these new instru-

ments too.

The multicentric non-randomized controlled study started in 2007

and concerned the surgical treatment of lumbar degenerative pathol-

ogies with back fusion. The aim is to evaluate the results of the treated

patients in a short (3 months), medium (one year) and long term

(3-5 years).

Among 140 patients treated in the various centers between July

2007 and November 2008, 80 of them with at least 6 months of

follow-up have been chosen. We report the preliminary results related

to this group of patients that were evaluated after about 10 months

from the operation (range: 6 to 16 months)

We performed a clinical (Oswestry Scale, low back pain/disabil-

ity, l’SF-36 e il VAS score), radiological, and MR evaluation.

LUMBAR SPINE – Part 3

58

UP TO 2-YEAR FOLLOW-UP RESULTS OF NUBAC

DISC ARTHROPLASTY: A PROSPECTIVE

WORLDWIDE MULTICENTER CLINICAL STUDY

M. Balsano1, D. Coric2, M. Songer3, H. Yuan4, L. Pimenta5,A. Reyes-Sanchez6, D. Werner7, U. Agrillo8, A. Bucciero9

1MD, UO Ortopedia, Centro Regionale di Riferimento inch.Vertebrale, Schio, Vicenza, Italy; 2MD, Carolina MedicalCenter, Charlotte, NC, USA; 3MD, Ken Davenport, MD;Orthopaedic Surgery Associates of Marquette, Marquette, MI,USA; 4MD, SUNY Upstate Medical University, Syracuse, NY,USA; 5MD, PhD, Santa Rita Hospital, Sao Paulo, Brazil; 6MD,Instituto de Ortopedia, Division de Cirugia Especial, Mexico City,Mexico; 7MD, Arkade Private Hospital, Breitungen, Germany;8MD, Sandro Petrini Hospital, Rome, Italy; 9MD, Clinica PinetaGrande, Casturno, Italy

Introduction: Disc arthroplasty is gaining popularity in treating low

back pain caused by degenerative disc disease. Disc arthroplasty can

be divided into total disc replacement and nucleus replacement or

intradiscal arthroplasty. Comparing to total disc replacement, nucleus

replacement could have the advantages of less invasive, less surgical

risk, faster post-operative recovery and non-bridge-burning. NU-

BACTM is the first PEEK-on-PEEK articulating intradiscal

arthroplasty device. After successful completion of pre-clinical design

verification and validation, this study has been initiated to assess the

clinical and economic outcomes of this PEEK-on-PEEK intradiscal

arthroplasty device.

Methods: An ongoing prospective, worldwide multi-center clinical

study which includes patients enrolled both outside of US and inside

of US as a part of an IDE study.

All inclusive 219 patients with main indication of discogenic back

pain caused by DDD.

Intra-operative and post-operative vascular and neurological

complications as well as ODI and VAS scores at pre-op, 6w, 3 m,

6 m, 12 m and 24 m were recorded. In addition, operation time and

the length of hospital stay were recorded to gain preliminary

knowledge on the economic benefits. A total of 225 NUBAC devices

have been implanted in 219 patients since December 2004. The

average age was approximately 41 years with a near even distribution

between males (49%) and females (51%). All three different surgical

approaches, posterior (52%), lateral (14%), and anterolateral (34%),

were used in this series. Six patients had two-level implantation and

the remaining had single level implantation. The majority of

implantations were on L4/5 (52%) and L5/S1 (42%) levels with the

remaining on L3/4 and L2/3 levels.

Results: The average operating time was 103 minutes and average

EBL 71 cc. No major intra-operative and post-operative vascular and

neurological complications occurred in this series. Most patients were

discharged from the hospital within1-2 days. Early clinical results

showed that good pain relief and improvement in function was

752 Eur Spine J (2009) 18:727–780

123

established and maintained from six weeks through 2 years (Fig-

ure 1). Disc height and the segment mobility and stability were also

maintained.

Conclusions: The early clinical experience demonstrated that

NUBAC performed as intended. The pain relief, improvement in

function, lack of intra-operative and postoperative neurological

complications and maintenance of the disc height suggests that NU-

BAC is a viable alternative to fusion and total disc replacement

surgery. The preliminary data on operative time and hospital dis-

charge time suggests this procedure also has economic benefits over

fusion and total disc replacement.

59

LUMBAR DISC REPLACEMENT. A 10-YEAR

EXPERIENCE

C. Formica, L. Cavaleri, M. Formica, G. Buzzi

SONG - Spinal Orthopaedical Neurosurgical Group;Alessandria – Clinica Salus - Gruppo Policlinico di Monza;Genova - Clinica Montallegro – Universita di Genova, Italy

Introduction: The treatment of low back pain due to a disc pathology

has been changed in the last years thanks to the improvement of the

biomechanical knowledge and therefore to the role of the intervertebral

disc in the segment of motion. However prosthesis and instrumentations

have had important improvements. Arthrodesis is still a diffused tech-

nique in vertebral surgery but the overloading of the discs above and

below is a common complication. The segment of motion preservation

is becoming imperative not only in young patients.

Material and Methods: From November 1998 to November 2008 we

implanted 84 lumbar disc prosthesis in 80 patients. 74 were females

and 10 males. The minimum age was 21 years old and the maximum

60 years old. The average was 40. We have never treated patients

over 60 years old neither patients with poor subcondral bone quality.

Most of the cases were primitive lumbar disc degeneration, only 14 of

the patients treated were suffering for low back pain and radicular

pain after previous surgery. In 6 cases the levels were L3L4, in 56

L4L5 and in 22 L5S1. In 4 patients we performed a 2 level disc

replacement. Charite was used in 4 cases, Prodisc in 10 and Maverick

in the remaining 70 cases (62 frontal and 8 oblique implants). The

follow up starts from a minimum of 7 months to a maximum of

10 years and 7 months.

Results: VAS and Oswestry disability index were used to evaluate the

clinical outcomes. In 95% of the cases we had excellent results with

the remission of the symptoms. We had 3 cases of abdominal muscles

paresis and 1 of these underwent an abdominal plastic reconstruction.

In 4 patients we had a paravertebral simpatic suffering with an

alteration of the thermical sensibility of the lower limb. No problems

linked to the irritation of the sacral plexus were found, neither in

males. In only 6 cases a radiological asymmetric positioning was

found, even if without symptoms. There was an important remission

of the radicular pain in the 14 cases of secondary surgery. The

complications might have been linked to the first operations since we

never have found them in the most recent cases. The weight bearing

was allowed the day after surgery with an abdominal bandage. In

most of the patients the feeling of an important and immediate clinical

changing was found. All of the patients returned back to work and

practicing sports.

Conclusions: We consider that the prosthesis with a fixed metal on

metal insert are easier to handle especially considering the surgical

implantation technique, furthermore the one with the oblique insertion

allows a less invasive mobilization of the iliac vessels above all

approaching L4L5. Despite this is an apparent invasive surgery, all of

the patients were able to walk the day after the operation and they

were discharged after 2 or 3 days. We are very satisfied of this

technique, even if a severe selection of the patients and a long

learning curve is requested.

60

DEGENERATIVE LUMBAR DISC DISEASE:

TOTAL DISC ARTHROPLASTY VS POSTERIOR

INSTRUMENTED FUSION

M. Di Silvestre, F. Lolli, A. Cioni, G. Barbanti-Brodano,S. Giacomini, P. Parisini

Spine Surgery Department; Istituti Ortopedici Rizzoli – Bologna,Italy

Background Context: Artificial disc replacement has been proposed

as a substitute for spinal fusion for the treatment of degenerative

lumbar disc disease.

Purpose: To compare the results of total disc arthroplasty and pos-

terior instrumented fusion in the treatment of monosegmental

degenerative disc disease.

Study Design: A retrospective study.

Patient Sample: A total of consecutive 46 patients (32 females and

14 males; mean age 40.9 years), all affected by monosegmental

degenerative disc disease, were included in the study.

Methods: Patients were divided into 2 groups according to surgical

treatment made. 22 patients (TDA Group) were surgically treated

with total disc arthroplasty (Maverick), 24 patients (PIF Group: 13

females and 11 male; average age 41.8 years) with a posterior

instrumented fusion (19 XIA, 5 Claris; always titanium instru-

mentation). The two groups were well matched according to age

(39.9 vs 41.8 years), gender (female: 86.4% vs 82.3%), level

treated (always L5-S1), type of degenerative disc disease (Pfirr-

mann 2 77.3% vs 75%, Pfirrmann 3 22.7% vs 25%) and follow-up

(36 vs 39 months).

Results: At an average follow-up of 38 months (range: 24 to 51),

the questionnaires showed no statistically significant differences (P

[ 0.05) between 2 groups. ODI score improved in TDA Group

from a preoperative score of 64.7% to 21.8% at last follow-up, in

PIF Group from 66.3% to 24.6%. VAS score improved in TDA

Group from 7.8 to 2.3, in PIF Group from 8.0 to 2.8. Major

complications occurred in 1 case (4.5%) in TDA Group (a per-

sistent low back pain, that required a posterior instrumented

fusion), in 2 cases (8.3%) in PIF Group (a junctional disc degen-

eration, that required an extension of fixation, and a persistent low

back pain, that required instrumentation removal).

Conclusions: These results showed that total disc arthroplasty is a

safe and effective procedure to treat the monosegmental lumbar

degenerative disc disease, ensuring clinical results superimposable to

those obtained with posterior instrumented fusion, but preserving

vertebral motion at the operated levels and with a lower complications

incidence (4.5 % vs 8.3%).

Eur Spine J (2009) 18:727–780 753

123

61

EARLY AND LATE COMPLICATION IN TDR

CHARITE’. ANTERIOR REVISION SURGERY

AFTER 7 YEARS

R. Bassani, A. Sinigaglia

Ortopedia e Traumatologia - IRCCS Policlinico S. Matteo,Pavia, Italy

The use of intervertebral disc prostheses as an alternative to spinal

fusion has been advocated to preserve segmental motion and to pre-

vent adjacent segment disease. The purpose of this paper is to

consider early (fracture of the vertebral body) and late complication

(migration) in Total disc replacement using Charite I.

A 42 years old female complained about serious low back pain

since 15 years. No benefit from medical treatment and physiotherapy

(ODI 68% - VAS 9). MRI: DDD L5-S1

She was operated in June 1999 for TDR (Charite I) L5-S1.

Immediately in the post op period complained of persistent sciatica

without any benefit from NSAID and Steroids. Plain films showed a

bad positioning of the prostheses (too much posterior) and a minimal

posterior body fracture with a small fragment displaced in the canal.

In 5� day post op she was operated from posterior: flavectomy, nerve

root decompression and minimal repositioning toward of the front

with partial resolution of the symptoms.

Because of severe low back pain and leg pain the patient was again

operated in 2004 from posterior with monolateral PL fusion without

relief of pain. Plain Xrays showed from 1999 to 2004 progressive

anterior migration of the prostheses. No evidence of fusion after the

last posterior surgery.

In 2006 the patient came to our Department. VAS was 8 and ODI

75%. Plain films showed no evidence of fusion and further migration

of the prostheses.

Our strategy was anterior revision: removal of the prostheses and

anterior interbody fusion with tantalum implant, BMP and Calcibone

(TCP).

Fusion was complete one year later, well shown by Xrays and

MRI as well as pain desappeared.

Follow up is now 2 years and half. VAS is 2 and ODI 20%.

Total disc replacement implant revisions occurs largely as a result

of technical errors in positioning and sizing of the implant. Anterior

revision surgery for TDR failure is a challenging and demanding

procedure. Anyway an interbody fusion, after removal of the pros-

theses, could lead to a good primary stability and healing. Tantalum

implants, according to literature, require less bone graft and less time-

in presence of a stable construct-to achieve bone healing.

References:

1. Regan JJ. Clinical results of Charithe lumbar TDR. Othop Clin

North Am 2005;36: 323-40

2. David T, Lemaire JP, Moreno P, Lumbar disc prostheses: an

analysis of long term complications for 272 SB Charite disc

prostheses with minimum 10 year follow up. Spine J 2004; 4

(suppl):50-1

3. Scott-Young M. Revision strategies for total lumbar disc

replacement. Spine J 2004; 4 (suppl) 115

4. McAfee PC, Geisler FH, Saiedy S, et al Revisability of the

Charithe artificial disc replacement: an analysis of 688 patients

enrolled in the US. IDE study of the Charithe artificial disc. Spine

2006; 31:1217-26

5. Steiber JR, Donald GD III, Early failure of lumbar disc

replacement: case report and review of the literature. J Spinal

Disord Tech 2006; 19: 55-60

62

NUCLEUS DISC ARTHROPLASTY WITH THE

NUBACTM DEVICE: PRELIMINARY CLINICAL

EXPERIENCE

F. Milia, C. Doria, M. Balsano1, L. Tidu, A. Zachos,A. Ruggiu, P. Tranquilli-Leali

Orthopaedic Department - University of Sassari – Italy;1Orthopaedic Department - Hospital of Schio - Italy

Introduction: Back pain due to degenerative disc disease is a com-

mon condition that can be treated along a continuum of care: from

conservative therapies to several surgical choices. Conservative care

focuses on pain relieving that can be achieved by drugs administration

(NSAIDS-steroidal drugs), physical therapy and orthesis. The basic

goal in decompression procedures is to reduce or stop the pain by

taking off pressure on pinched nerves and, eventually, providing

fusion of the affected segment. Nucleus replacement is an intriguing

technology that could potentially fill part of the gap in the spine

continuum of care. The introduction of recent technologies that allow

the replacement of the degenerated disc nucleus using prosthetic

systems, may be considered an additional therapeutic tool that can be

used by the surgeon in selected cases of back pain due to degenerative

disc disease. Nucleus replacement products are designed to treat early

stage degenerative disc disease, which is one of the most common

spine disorders in the population under 65 years of age. This, com-

bined with an increasing desire to move away from invasive, motion

limiting procedures such as fusion, and a growing patient base in an

aging population, may propel this technology to the forefront of spine.

Nucleus replacement could help redefine the continuum of care by

broadening the focus to include not only early diagnosis of degen-

erative disc disease, but also a reduction in the need for surgical

procedures performed further down the continuum of care.

Materials and Methods: NUBAC is the first articulating nucleus disc

prosthesis, designed to optimally respect the lumbar anatomy, kine-

matics and biomechanics, constructed in a unique two-piece design of

a polyetheretherketone (PEEK) with an inner ball/socket articulation.

The racetrack geometry provides a large contact area designed to

distribute the load, reduce the contact stress and, subsequently, mit-

igate the risk of subsidence. The optimal indications for NUBAC

implantation are: disc height[9 mm, degenerative disc changes at an

early stage (Pfirmann 1-2 - max 3), single level affection, integrity of

articular posterior elements, lack of local anatomical contraindication,

patient non responder to conservative treatment for at least 6 months.

Results: From December 2006 to January 2008, a total of 16 patients

underwent nucleus disc arthroplasty with the NUBAC device. There

have been no major intra-operative or post-operative vascular or

neurological complications in this series. The data showed that there

were significant decreases in both VAS and ODI after the procedure,

expression of a significant improvement of symptoms in all patients.

The average VAS score increased from a preoperative value of 7.1 to

a post-operative of 1.0 after 24 months. The average ODI score

increased from a preoperative value of 58 to a post-operative of 7.0

after 24 months.

Conclusions: Although preliminary, the initial results are very

encouraging. The absence of any major intra-operative and post-

operative vascular and neurological complications supports the design

rationale of the NUBAC being less invasive and of less surgical risk.

The initial effectiveness data as seen in the significant improvements

on both VAS and ODI have also suggested that the NUBAC could be

a viable treatment option for patients with low-back pain caused by

degenerative disc disease.

754 Eur Spine J (2009) 18:727–780

123

CERVICAL SPINE – Part 1

63

FIVE-YEAR OUTCOME OF STAND-ALONE

FUSION USING CARBON CAGES IN CERVICAL

DISK ARTHROSIS

N. Marotta, A. Landi, G. Rocchi, R. Tarantino, C. Mancarella,C. Delfinis, R. Delfini

Department of Neurological Science, Division of Neurosurgery,University of Rome ‘‘Sapienza’’, Italy

From 1 January 2001 to 31 December 2003, In the Neurosurgery

Department of Rome University o ‘‘Sapienza’’, 167 patients under-

went anterior surgery for cervical spondylodiscoarthrosis

Materials and Methods: The levels treated by the anterior stand-

alone technique were: C3-C4 (11%), C4-C5 (19%), C5-C6 (40%),

C6-C7 (30 %). All patients underwent left anterior presternocleido-

mastoid - precarotid approach, microdiskectomy and interbody fusion

using a carbon fiber cage filled with hydroxyapatite. All patients were

discharged within 48 hours after surgery with cervical orthosis. In one

case a hematoma of the surgical site occurred within 12 hours of

surgery; for this reason the patient underwent surgical revision and

was discharged 4 days later. All patients have worn cervical orthosis

for a mean period of 7 weeks and underwent radiological follow-up

with cervical RX at 1 month and 3 months after surgery. All patients

underwent follow-up from 54 to 90 months after surgery, and all of

them underwent cervical RX, cervical CT scans for the estimate of

fusion, and evaluation of neurological status using VAS and NDI.

Results: Of 167 patients, 119 were cooperative for this study, 18 were

non-cooperative, and 17 died. The estimation of fusion made by

cervical CT scans with sagittal reconstruction, showed complete os-

teointegration of the cage in 103 patients (83%), while it showed

pseudoarthrosis in 24 patients (17%). In 24 patients we observed

adjacent segment degeneration, and 13 of these underwent new sur-

gical procedures in our institute or in another hospital. Clinical

evaluation with VAS and NDI showed a good outcome, with poorest

benefit in patients over 60 years.

Conclusions: Our clinical analysis showed a good fusion rate in

according with literature, 13% of non fusion rate without clinical

evidence and 20% of ASDegeneration but only 10% had required new

surgery. We also observed that patients over 60’s had less satisfactory

outcome, probably related with the evolution of pathophysiological

degeneration of the cervical spine. In our opinion pseudoarthrosis is

caused by malpositioning of the carbon fiber cage.

64

SPINAL SURGERY OF THE CERVICO-THORACIC

JUNCTION: MULTICENTRIC EXPERIENCE

A. Ramieri, M. Domenicucci*, P. Ciappetta**, G. Costanzo***

Orthopaedics, The Don Gnocchi Foundation; * Neurosurgery,Rome University ‘‘La Sapienza’’; ** Neurosurgery, BariUniversity; *** Orthopaedics, Rome University ‘‘La Sapienza’’,Italy

Surgical treatment of the cervico-thoracic junction (CTj) in the

spine requires special evaluation due to the anatomical and

biomechanical characteristics of this spinal section. The transitional

zone between the mobile cervical spine and the relatively rigid

thoracic spine is the site of serious unstable traumas or neoplastic

lesions, frequently associated with neurological impairment due to

the smaller canal caliber and/or the spinal cord vascular insuffi-

ciency. We considered 32 lesions of the CTj (trauma=22,

tumour=8, infection=2) treated by means of different type of pos-

terior instrumentation (hooks, transarticular and traspedicular

screws, wires, dual diameter rods). All cases had significant neu-

rological deficits. The surgical procedure was posterior in 28 cases

and combined in 4. Follow-up evaluation showed an improvement

of neurological deficits in 19 patients (60%), with good stability of

all implants and without significant back pain.

In our experience, neurological results in the surgical treatment of

CTj lesions are often unsatisfactory, due to the initial serious impair-

ment. On the contrary, the recovery of the spinal stability seems to be

essential to avoid disability due to back pain. There is no type of

instrumentation more effective than other. In each single lesion, the

most suitable type of instrumentation should be employed, considering

the familiarity of the spinal surgeon with different types of implants and

the morphological and biomechanical features of the damage.

65

ANTERIOR CERVICAL FUSION WITH A BIO-

RESORBABLE COMPOSITE CAGE (BETA TCP –

PLLA): CLINICAL AND CT SCAN RESULTS FROM

A PROSPECTIVE STUDY ON 20 PATIENTS AT 3

YEARS FOLLOW-UP

S. Aunoble1, F. Debusscher1, D. Clement2, J. C. Le Huec1

Bordeaux 2 University, spine unit 2, CHU Pellegrin, Amelie-RabaLeon state 33000 Bordeaux, DETERCA surgical lab,BORDEAUX Cedex France; 2SBM, ZI du Monge, 65100Lourdes, France

Background: A resorbable composite material (40 % PLLA and 60%

beta TCP) with a high breaking strength and capacity to withstand

plastic and elastic strain has been developed for cervical interbody

fusion.

Objective: To evaluate clinical and radiological results of 20 patients

implanted with 27 cages (mean follow-up: 27 months).

Methods: Clinical (neck disability index, VAS, neurological evalu-

ation) and radiological (anteroposterior, lateral, bending X rays) data

were assessed before and after surgery. At the end of the study, CT

scan was performed to evaluate fusion, resorption of the cage and

density of new tissue substituting the cage.

Results: The mean patient age was 50.3 years (range 18 to79 y). The

average improvement was 55% for neck pain, 83% for arm pain and

65% for NDI, with 85% good or excellent results at final outcomes.

Radiologically, lordosis was significantly improved (mean gain of

5.4� and 3.7� for overall and segmental lordosis respectively). This

correction was conserved in 95% of cases. Fusion was obtained in

96% (CT evaluation). Resorption was started in all cases and com-

pleted in an average of 36 month after surgery.

The mean density of tissue substituting the cage was 659 UH with a

range of 455 to 911 UH (compatible with bone nature). Over time the

amount of bony tissue increased and the graft remodelled with an

increase in density value. This demonstrates a biological activity and

changing bone mineral content of this tissue.

Conclusion: The new composite cage under investigation provides

long term fusion without loss of correction or inflammatory reaction.

Eur Spine J (2009) 18:727–780 755

123

The ceramic block guarantees the maintenance of the disc height and

its slow resorption allows long term fusion and stability with good

and reliable clinical and radiological outcomes.

CERVICAL SPINE – Part 2

66

TRANSPEDUNCULAR SCREW FIXATION

FOR CERVICAL STABILIZATION

M. Ganau, F. Ennas*, A. Medda, A. Maleci

Chair of Neurosurgery and *Dept of Orthopaedics -University of Cagliari, Italy

Introduction: For decades cervical instability related to degenerative,

neoplastic or traumatic diseases has been managed by anterior sur-

gical approaches, but the recent availability of specific

instrumentation has opened new frontiers also for posterior approa-

ches. When compared from a biomechanical perspective, posterior

approaches appear to be more appropriate, especially for the treat-

ment of two or more vertebral segments. Nevertheless, while

transarticular screw placement, as described by several authors, does

not provide an optimal stability, particularly in case of bone fragility,

transpeduncular screw fixation seems to be more effective, as estab-

lished by experimental studies that have confirmed their higher

biomechanical stability.

Even though, up to 1991, Roy Camille has stated that transpe-

duncular screw fixation harboured an unacceptable risk of

neurovascular complications, since the late nineties many authors

have described their experience with this technique reporting excel-

lent results with few drawbacks.

This retrospective study, conducted at the Chair of Neurosurgery

at the University of Cagliari, focuses on the surgical results obtained

with transpeduncular screw fixation for cervical instability.

Materials and Methods: Between 2001 and 2008, 42 patients

admitted at our institution have required posterior stabilization for

cervical instability related to: degenerative mielopathy (C 3 levels) in

31 cases, post-traumatic instability in 7 cases, and bone metastasis in

4 cases.

Every patient underwent axial CT scan preoperatively, in order to

evaluate orientation and width of peduncles, and postoperatively to

confirm the correct screw placement. Arthrodesis was always performed

with Neon system (Ulrich, Germany) without neuronavigation; during

surgery sagittal orientation of the screws was assessed by radiofluores-

cence control, while a specific protractor guided their lateral orientation.

Results: In every case peduncles were large enough to allow the

placement of 3,5 mm screws, for a total of 196 screws. Inclination

of peduncles ranged between 30� to 48� at C3-C6, and between

21� to 33� at C7. No intraoperative complications were encoun-

tered; but 7 patients complained of transitory radicular deficits.

Postoperative CT scans detected incorrect positioning of 17 screws,

without any need for replacement. Every patient showed an optimal

cervical stability at follow-up radiographic examination (range 6-78

mos).

Conclusions: Our experience confirms the feasibility and efficacy

of transpeduncular screw fixation for cervical instability. The risk

of iatrogenic neurovascular damage, even if not higher than other

posterior techniques, has always to be considered; since only a

tailored presurgical planning can reduce it.

67

ANALYSIS OF THE PERIOPERATIVE

COMPLICATIONS DURING THE CERVICAL DISC

PROSTHESIS SURGERY

A. A. Rocca, L. Attuati, M. Medone, P. Castellazzi – IRCCS SanRaffaele – Milan – Italy

Introduction: The increasing number of the operation for cervical

disc prosthesis is based on the need to preserve a range of motion after

discectomy. To day, mobile cervical prosthesis allow an easy posi-

tioning without increasing of surgical time. But as in the classic

discectomy and arthrodesis so this operation may cause complications

in the perioperative periods.

Methods: In our opinion and according to Goffin et al. a classification

of complications shoul consider five main ‘‘steps’’ :

1. the ‘‘step’’ of indications (=wrong indications)

2. the surgical ‘‘step’’ conditioning the intra-operative conplications

(1 to 30 days) represented by dysphagia, laryngeal nerve palsy,

soft-tissue hematoma, esophageal or dural perforation

3. the ‘‘step’’ of the early complications (1 to 6 months) represented

by wound infection, prosthesis migration, worsening of the

symptoms.

4. The ‘‘step’’ of the intermediate follow-up (6 to 60 months) with

complications represented by subsidence, osteolysis, heterotopic

ossification.

5. For the five ‘‘step’’ or ‘‘long time follow up’’, literature lack of a

consistent number of reports

Results: In a period lasting from 2003 to 2007 we have operated

on 23 patients with herniated cervical disc by a discectomy and

cervical disc prosthesis positioning with Bryan prosthesis in 16

cases and Mobi C prosthesis in 7 cases. Median age of the patients

was 45 years (range 29-56) and male:female ratio was 11:12.

Indications to operation were: age between 20 and 70 years, her-

niated cervical disc (at 1 level between C3 and T1) showed at MRI

or CT scan images, cervical radicular pain consistent with level

and side of the disc affected and not responsive to at least 6 weeks

of steroid or analgesic drugs.

In our experience there were no main complications. In 1 patient we

observed prosthesis migration after 4 months by implant.

Conclusions: We analyzed literature data and the results of our

experience

Intermediate follow-up after treatment of degenerative disc disease

with the Bryan Cervical Disc Prosthesis: single-level and bi-level.

Goffin J, Van Calenbergh F, van Loon J, Casey A, Kehr P, Liebig

K, Lind B, Logroscino C, Sgrambiglia R, Pointillart V. Spine. 2003

Dec 15; 28(24):2673-8.

68

HETEROTOPIC OSSIFICATION FOLLOWING

CERVICAL ARTHROPLASTY. ANALYSIS OF 30

PATIENTS WITH 2-3 YEARS FOLLOW-UP

V. Albanese, L. Corbino, G. Olindo, V. Russo, N. Platania,G. Barbagallo

Department of Neurosurgery, Azienda Ospedaliero-UniversitariaPoliclinico, Catania, Italy

Introduction: It remains uncertain whether or not heterotopic ossi-

fication (HO) after arthroplasty retains any clinical relevance.

756 Eur Spine J (2009) 18:727–780

123

Materials and Methods: 30 patients (18 males), with a mean age of

40.9 years, underwent cervical arthroplasty because of radiculopathy

(n. 13), myelopathy (n.4) or myeloradiculopathy (n.13) due to disc

hernia (n.17), spondylosis (n.8) or both of them (n.5). We treated 1

level in 19 cases, 2 levels in 7 patients and three levels in 4 patients,

with a total of 45 disc prostheses (7 Prestige LP e 38 Prodisc C). The

distribution of devices/level is as follows: C3-C4:5; C4-C5:4; C5-

C6:23; C6-C7:13. SF-36 and NDI questionnaires were used, before

and after surgery, for clinical and functional assessment. Preopera-

tively, all patients were assessed by x-rays, with flexion-extension

views, CT and MR. Patients were followed-up by x-rays and CT scan,

when clinically required.

Follow-up ranges from 24 months (16 patients) to 4 years (1 patient),

mean 36.1 months.

The McAfee classification was used to quantify the presence of

HO/level. The surgical technique used in both groups of patients is the

standard one described for each disc prosthesis.

Results: 19 levels (in 16 patients) presented different degrees of HO

(42.2%): grade 2 in 8 levels, grade 3 in 10 levels and grade 4 in one

level only.

In 10 patients we observed HO’s progression over the months; in 6

patients HO presented de novo several months after surgery (from 23

to 46 months, mean 33.3 months).

In patients without HO (n.14), preoperative SF-36 values were PH:

39.4 e MH:44.3; the NDI value was 43.1. At 36-month-follow-up the

same values were 83.9, 74.1 and 7.3.

In 16 patients with HO, preoperative values were PH: 42.5,

MH:7.1; NDI was 32.7. At 36-month-follow-up the same values were

PH:71.7, MH: 68.9; NDI:8.8.

No patients required further surgery, neither for revision nor for

adjacent segment disease.

Discussion and Conclusions: No specific protocols to prevent HO

was used in our series. In most of the cases, HO was shown anteriorly

to disc prostheses. No signficant differences were demonstrated

between disc hernia vs spondylosis in patients with or without HO.

HO’s causes remain uncertain. No significant clinical and functional

differences were demonstrated in patients with or without HO.

In 15/16 patients (93.75%) with HO disc prostheses remain mobile.

Therefore, HO does not seem to alter the clinical and functional

results and, hence, the indications to arthroplasty.

We analyse potential causes for HO with reference to the surgical

technique and discuss possible surgical strategies to prevent HO.

69

60 PATIENTS FOLLOW-UP, FROM 6 MONTHS

TO 2 YEARS, IN PATIENTS TREATED

WITH DISCOVER� ARTHROPLASTY

AFTER DISCECTOMY AND PRELIMINARY

COMPARISON WITH DISCECTOMY AND FUSION

AND DISCECTOMY ALONE

G. Maida*, F. Garofano*, S. Sarubbo*, M. A. Cavallo*

*University-Hospital S.Anna - Division of Neurosurgery -Ferrara – Italy

The fusion procedure, after anterior cervical decompression, seems to

allow the better neuroradiological and clinical results in the treatment

of cervical discoarthrosis, even if the debate is still opened. The

anterior cervical fusion, performed with bone, cages or locking plates,

avoids kyphosis but can produce immobilization of the interested

cervical tract and symptomatic junctional disease. So, many authors

suggest cervical arthroplasty may be the best solution to preserve

motion and lordosis of the cervical tract.

We present our case series of 60 patients undergone to cervical

discectomy and arthroplasty (Discover �) with follow-up ranging

between 6 to 29 months. We obtained a good and steady clinical

outcome in all the patients with arthroplasty after discectomy. In all

patients the two-years morphodynamic X-rays and MRIs showed

preservation of motion and physiological cervical lordosis, absence of

junctional disease without foraminal narrowing. After 24 months, we

didn’t find any significant clinical and neuroradiological difference in

the results obtained in patients treated with discectomy and arthro-

plasty vs discectomy and fusion. The kyphosis discovered in

discectomy and fusion was clinical manifest only in 1 of 60 patients,

with junctional disease too. Yet Patients treated with atrhroplasty

referred, instead, the best satisfaction. Moreover, we found significant

better outcome in respect to patients treated with discectomy alone, in

which we reported seven cases of kyphosis clinical manifest (about

11.6%). In the patients underwent atrhroplasty we didn’t report any

surgical complication or artificial cervical disc displacement.

Our follow-up is, of course, too short to be conclusive and the

debate remain opened but we consider cervical atrhroplasty a good,

safe and really effective option to fusion and the best treatment in

respect to cervical discectomy alone.

70

A NEW SOMATIC CERVICAL PROSTHESIS.

PRELIMINAR EXPERIENCE

A. Solini, G. Gargiulo

U.O. Ortopedia - A.S.O.S. Giovanni Battista Molinette, Turin,Italy

The Authors bring the results to short and middle term of a new

prosthesis of the cervical vertebral body replacement that finds indi-

cation in the somatectomies for the treatment of degenerative

pathologies (mielopaty or foraminal stenosis of two adjacent levels),

for primitive os secondary tumors, for cervical deformities results of

fractures or infections and in the treatment of somatic fractures. The

prosthesis represents the evolution with innovative characteristics of

the conceived one and described by the elderly author in 1994 already

applied in more than 200 cases. The prosthesis is constituted by a rigid

titanium body, full or cable, that allows the simple reconstruction of

the size of the vertebra and to perform an interbody fusion, available in

different dimensions in length and width. Of simple and rapid appli-

cation the prosthesis is inserted after preparing the lodging in the

vertebral body and determined the dimensions with a witness of test.

The prosthesis is definitely fixed to the adjoining vertebral segments

by 4 screws endowed through 2 holes in the anterior proximal and

distal fins with which the prosthesis takes contact with the anterior

surface of the neighboring vertebral bodies. In the cases of cable

prosthesis the fusion is performed through bone chips from iliac crest

or vertebral body resected pushed in the empty body, taking rela-

tionships with the neighboring vertebral dishes through the open

proximal and distal surfaces of the prosthetic body.The prosthesis has

been used in 23 patients of age middle 53 years (31 -71) affected from

metastasis (11), degenerative pathology (8), deformity from infection

(1), somatic fractures (3). The patients have been mobilized in 2� p-op.

day wearing a collar for 30 ggs in cases with fusion. At a 3 y, f.up (1 -5)

in all the cases the prosthesis appeared stable. In the patients fused the

osseous continuity has been underline in TC with the neighboring

levels. In conclusion the new cervical prosthesis has dimostrated at

short and medium term to give stability to cervical spine trough a

Eur Spine J (2009) 18:727–780 757

123

simple and fast surgical procedure like the previous one but it offers a

wider surgical application concurring to carry out fusion when indi-

cated assuring stability in the time.

TUMOURS

71

PERCUTANEOUS TREATMENT OF VERTEBRAL

OSTEOID OSTEOMA WITH RADIOFREQUENCY

THERMAL ABLATION

U. Albisinni, M. Chiatante, M. C. Malaguti

Department of Diagnostic and Interventional Radiology,Bologna, Italy

Introduction: The percutaneous treatment of osteoid osteoma (OO)

with thermal ablation with radiofrequency (RFTA) is actually the first

choice in the treatment of non-vertebral OO.

In this work we present our experience in the treatment of vertebral

localization of this pathology.

Material and Methods: From November 2002 until June 2007 we

have treated at Rizzoli Orthopaedic Institute 34 patients (23 male and

11 female) with vertebral OO, never treated before.

The patients were between 8 and 48 years old (middle age: 23,4).

The diagnosis was made on clinical and radiological (RX, bone

scan, CT, MRI) examinations; it was confirmed histologically in 18

cases.

The percutaneous treatment of vertebral OO with RFTA needs to

pay attention to the narrowness of vasculo-nervous structures and

spinal cord. Therefore we performed this procedure only under deep

general sedation and local infiltration of anesthetics; the mean dura-

tion was around 90 minutes.

We used under CT guidance a bone bioptic set with 14G cannula

to place the monopolar needle electrode into the ‘‘nidus’’. We

delivered RF for 2 minutes at 60�C. The time of RF delivery was

between 8 and 30 minutes with a temperature not below 90�C.

Our tools include a non cooled monopolar electrode, 0.35 mm

calibre, 145 mm length with active tip of 5,10 or 15 mm with dis-

posable cannula of 20G.

Results: 31 patients have been treated successfully after the first time;

a second procedure was necessary in 3 cases and was successful

twice. In the remaining case, the recurrence occurred because a

suitable dose of RF could not be delivered due to the impossibility to

the patient to bear the pain.

Conclusions: The first treatment with percutaneous RFTA of OO was

made by Rosenthal and his experience has been exhaustively reported

in literature since 1992.

Since then a lot of similar experience have been reported in literature

about the treatment of non-vertebral OO with good results.

The treatment with RFTA of vertebral OO is still uncommon

because of the narrowness of structure like vessels, nerves and spinal

cord and their high risk of damage.

The experience made on over 400 patients with OO allowed us to

create some particular technical devices to treat safely also vertebral

OO.

Our experience allows us to claim that also in vertebral OO

treatment with RFTA is a safe and effective procedure with a lot of

advantages: it is less invasive, there are fewer complications, the

patient can resume daily living activities in about 2-3 weeks, the rate

of recurrence is very low and hospital and procedure costs are lower.

72

MORBIDITY OF EN BLOC RESECTIONS IN THE

SPINE

S. Bandiera*, F. De Iure, A. Gasbarrini, M. Cappuccio,L. Amendola, R. Donthineni**, S. Boriani

*Presenting author; Ospedale Maggiore ‘‘C.A.Pizzardi’’, Bologna(Italy); **Spine & Orthopaedic Oncology, Alta Bates SummitMedical Center (USA)

Introduction: Spine tumour surgery has often a high risk of com-

plications, worse than other surgical procedures and this is

particularly true for en bloc resections.

A retrospective review of a large series of en bloc resections could be

helpful to identify risk factors and therefore to reduce the rate of

complications and to improve the outcome.

Methods: A retrospective study of 1035 patients affected by spine

tumours treated from 1990 to 2007 identified 134 patients (53.0%

male, age 44±18 years) who were submitted to en bloc resection for

primary tumours (90) and for bone metastases (44). All the clinical,

histological and radiological data were recorded since the beginning

in a specifically built database.

The prospective study was set up to correlate diagnosis, staging and

treatment with the oncologic and functional outcome recorded for all

the patients at periodical controls (follow-up from 0 to 211 months,

av. 47 months, 25th-75th percentile 22-85 months)

Results: Forty-seven on 134 patients (34.3%) encountered a total of 70

complications: 32 patients (68.1%) had one complication, while the rest

had 2 or more. There were 41 major and 29 minor complications. Three

patients (2.2%) died from complications. Sixteen (45.7%) of the 35

patients with a recurrent or contaminated tumor suffered at least one

complication; by contrast, complications appeared in 31 (31.3%) of the

99 patients who had had no previous treatment. A local recurrence was

recorded in 21 cases (15.7%). The rate of deep infection was higher in

patients who had previously undergone radiation therapy (RT), but the

global incidence of complications was lower. Re-operations were

mostly due to tumor recurrences, but also to hardware failures, wound

dehiscence, hematomas and aortic dissection.

Conclusions: En bloc resection can improve the prognosis of

aggressive benign and low-grade malignant tumors of the spine, even

if with high related morbidity, sometimes fatal.. Re-operations have

higher risks due to the dissection through scar from previous surgeries

and possibly from radiation.

The treatment of recurrent cases and planned transgression to reduce

surgical aggressiveness is associated with higher rate of local recur-

rence, the most severe complication

In terms of survival and quality of life complicated cases have

better outcomes than recurrent events. Careful planning for the

treatment and referral to a specialty center in case of uncertainty.

73

VESSEL-X IN THE TREATMENT OF VERTEBRAL

OSTEOLISI

M. Quartarone, C. Casamichele, A. Tumino, G. Incatasciato,G. Giuca, T. C. Russo

Unit of Orthopaedics and Traumatology Major Hospital ofModica, Italy

Introduction: Plastic somatic performed using a mini spinal access

(vertebrates and cifoplastica) has been widely used in the treatment of

758 Eur Spine J (2009) 18:727–780

123

vertebral compression fractures (VCFs) to neoplastic etiology, oste-

oporotic and / or traumatic. Starting in 2003 we used the technique of

cifoplastica and since 2004 we used the vertebroplastica in cases with

osteoporotic collapse with severe somatic deformities. The latter

technique, however, presents a significant risk of leakage. In recent

years in order to remedy this complication has developed a new

technique represented by Vessel-x that can be considered a valid

alternative to vertebroplastica. Since 2007 we have used the vessel-x

with selective indications such as spinal osteolisi.

Materials and Methods: From January 2007 until today, in our Unit

were performed 22 vessel-x for osteolisi kind of tumor. The average

age of patients was 64 years (55-80), 10 women and 4 men. The

primary locations were 9 and in 13 cases this was secondary locations.

In 14 cases the localization was to a single vertebra, were involved in

the remaining 2 or more vertebrae. Each patient was evaluated at 1, 3,

6, 12 months after surgery. Were assessed: location of pain, intensity

of pain according to VAS scale, neurological symptoms, spinal

motility, complications caused by surgery. For each control were

made rx-spellings control AP, LL. 5 of these patients have died of

complications related to the pathology of the primitive tumor

Results: The intensity of pain according to VAS scale was signifi-

cantly decreased (27 with range from 0 to 83). There were no cases of

posterior Leakage

Discussion and Conclusions: Based on the clinical and radiographic

results obtained it can be said that the vessel-x is effective and safe in

the treatment of osteolisi with and without vertebral collapse.

74

ANEURYSMAL BONE CYST OF THE MOBILE

SPINE

L. Amendola, S. Bandiera, F. De Iure, M. Cappuccio,A. Gasbarrini, S. Boriani

Ospedale Maggiore ‘‘C. A. Pizzardi’’, Bologna, Italy

Introduction: Fifty cases of aneurysmal bone cyst (ABC) of the

mobile spine were retrospectively reviewed. Our aim is to evaluate

the role of surgical and non-surgical treatment of ABC of the spine.

ABC is a pseudo-tumoral condition typical of the younger patients

and frequently involving the mobile spine. The progression of disease

and the type of treatment depends on the aggressiveness of the tumor.

Intralesional excision, radiotherapy, selective arterial embolization

(SAE), used alone or in combination, seem to be an effective

treatment.

Methods: From 1952 to 2008, fifty cases of ABC of the spine were

treated and 42 patients have follow-up greater than 24 months.

Treatment must be based on Diagnosis, Oncologic Staging (Enne-

king) and Surgical Staging (Weinstein-Boriani-Biagini). Diagnosis

can be achieved by X-ray, MRI and CT in most cases with high

reliability; biopsy is mandatory in the remaining cases. Fourteen

patients were submitted to SAE (3 of them followed by radiotherapy),

26 received radiotherapy alone (2 cases combined to palliative sur-

gery), 9 patients underwent curettage (3 of them followed by

radiotherapy) and one underwent Enbloc excision.

Results: All patients were found alive: 48 without evidence of des-

ease and two, treated by SAE, alive with desease. In this 2 cases the

residual cyst is maintained under control and not progressive any-

more. One local recurrence appeared 5 months after an incomplete

curettage and was successfully treated by radiotherapy. In our series,

curettage and radiotherapy, although effective, showed the greatest

incidence of late axial deformity.

Conclusion: Despite SAE was totally curative in 12 of 14 cases in our

series, it seems to be the first option for spine ABC. SAE is the

treatment with the best cost-to-benefit ratio and is indicated when

diagnosis is certain, when technically feasible and safe, and when no

pathologic fracture nor neurologic involvement are found. If SAE

fails, other options for treatment would still be available. In case of

pathologic fracture, neurologic involvement, high technical impossi-

bility of performing embolization, or local recurrence after at least

two embolization procedures, complete intralesional excision would

be the therapy of choice.

MINIMALLY INVASIVE TREATMENT ANDMISCELLANEOUS

75

MINIMALLY INVASIVE TREATMENT OF

THORACO-LUMBAR FRACTURES IN THE

YOUNG ADULT: OUR EXPERIENCE WITH

THE PERCUTANEOUS PROCEDURES

S. Caserta, G. A. La Maida

Hesperia Hospital. Modena, Italy; Orthopaedic Dpt. NiguardaHospital – Milan, Italy

The incidence of spinal injuries has been increasing over the last

decade and the vast majority of these are the consequence of high-

energy trauma due to a road traffic accidents, falls and sports

injuries.

Mechanical failure of the spinal column following a trauma fre-

quently occurs at the thoracolumbar junction as a result of its

transitional anatomy and biomechanical environment.

In order to well analyse and consequntly understand a spinal

fracture, it is very important to apply a comprehensive and prog-

nostic classification system. In our opinion the most useful

classification is the one proposed by Magerl et Al in 1994. The AO

classification associated with the McCormack classification points

system are, in our hand, the best way to better analyse and con-

sequently treat a spine fracture.

We report our experience in the treatment of thoracolumbar spine

fractures in the young adult by using a percutaneous approach.

We selected all the type A fractures of Patients up to 45 years of

age considering only the percutaneous approaches and we found

about twenty procedures. The surgical techniques we consider were

percutaneous vertebral augmentation by using a kyphoplasty or a

intravertebral mesh with morcelized bone graft (allograft or bone

substitutes) or bone substitute (calcium phosphate).

All Patients underwent a clinical and radiographic follow-up at 3,

6 and 12 months post-op with a minimum follow-up of six months.

The group treated with kiphoplasty had also a CT scan view of the

treated level at six months post-op.

All Patients had a good clinical and radiographic results with no

complication related to the material injected.

We concluded that very selected type A fractures of the thoraco-

lumbar spine in the young adult can be very well treated with a

percutaneous augmentation by using bone substitutes.

Eur Spine J (2009) 18:727–780 759

123

76

XLIF: A NEW MINIMAL INVASIVE TECHNIQUE

TO ACHIEVE LUMBAR INTERBODY FUSION.

INDICATIONS AND PRELIMINARY RESULTS

M. Balsano, S. Caserta*, A. Villaminar, M. Comisso

U. O. Ortopedia e Traumatologia - Centro Regionale diRiferimento in Chirurgia Vertebrale - Ospedale Civile Thiene eSchio (VI); *Clinica Capitanio, Milan, Italy

Introduction: Lumbar interbody fusion represents nowadyas the

‘gold standard’ to treat different pathologies of the lumbar spine.

Scientific research has lead to find new surgical techniques that allows

to minimize the rate of complications and the length of recovery.

Xlif means Extreme Lateral Interbody Fusion. This is a new mini-

mally invasive approach to the anterior spine that avoids an incision

that traverses the abdomen and also avoids cutting the posterior

muscles of the lumbar spine.. In this fusion technique, named ALPA

approach, the disk space is accessed from a very small incision on the

flank of the patient, a couple of inches in length, occasionally with

another small incision (one inch long) just behind the first incision.

Special monitoring equipment is used to determine the proximity of

the working instruments to the nerves of the spine, because the

instruments are introduced through the psoas muscle.

With this technique the lumbar spine can be approached from L1

to L5, excluding L5-S1 for anatomic limits (iliac wings). The indi-

cations are degenerative spondylolisthesis, degenerative lumbar

scoliosis, and severe disc degeneration, or other conditions that needs

an interbody fusion of the lumbar spine.

Methods: A clinical series of 9 patients with 11 implants have been

included in this study. Patients ranged in age from 27-71 yrs. (ave

55.2). For achieving lumbar fusion and to provide primary stabil-

ization a Peek Cage (Coerent, Nuvasive, S.Diego, USA) filled with

allograft has been used.

Results: All of them showed lumbar segmental stabilization with

radiographic signs of fusion.

Surgical operative time ranged between 50-60 minutes per device

implanted. Length of stay I hospital ranged from 2 to 4 days. Median

preoperative ODI was 64 to baseline, improving to 13 at 6 months.

VAS improved from 8.5 preoperatively to 1.9 at 6 months.

No major complications have been noted. One case of femoral

neuroapraxia has occurred, with complete recovery after 10 days.

Conclusions: XLIF provides access to multiple lumbar levels through

small lateral incisions and retroperitoneal dissection, minimizing

approach-related morbidity while providing anterior column access

for large cage placement, good disc height and alignment restoration.

Initial results in the treatment of lumbar spine disease are very

favourable with the advantage of a low rate of complications and a

shorter hospital stay. This is a novel technique that may avoid more

invasive surgery in many patients but a formal prospective random-

ised control trial and further user experience are welcomed to

establish its benefits in this respect.

77

MINIMALLY INVASIVE POSTERIOR LUMBAR

INTERBODY FUSION AND PERCUTANEOUS

PEDICLE SCREWS FIXATION FOR

DEGENERATIVE LUMBAR SPINE DISEASE

C. A. Logroscino, L. Proietti, E. Pola, S. Astolfi, F. R. Frasso,L. Scaramuzzo

Departement of Orthopaedic Science and Traumatology SpineSurgery Division Catholic University Rome, Italy

Introduction: The aim of the study was to evaluate the feasibility and

safety of mini-open transforaminal lumbar interbody fusion for

instabilities and degenerative disc disease.

Methods: All patients who underwent mini-open lumbar interbody

fusion(TLIF) combined with percutaneous pedicle screw fixation of

the lumbar spine were studied retrospectively. Transforaminal lumbar

interbody fusion was performed at L3-L4 in 4 patients, L4-L5 in 9

patients, L5-S1 in 7 patients. Surgical time, intraoperatrative blood

loss, preoperative diagnosis, number of stabilized levels, mean hos-

pital stay, complications and fusion rate were recorded at routine

intervals. In all patients pedicle screw postion was studied with

postoperative CT scan. Clinical outcome was assessed using the

Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and

SF-36.

Results: From May 2005 to October 2008 20 patients, 14 males

and 6 females (age range 28-59 yr; mean 46 yr) underwent mini-

open TLIF procedure for degenerative disc disease or degenerative

spondylolisthesis. The mean follow-up was 24 months. The mean

estimated blood loss was 230 ml, the mean length of stay was

5,3 days, the meantime needed before ambulation was 3,2 days.

The mean pre-operative VAS score was 7,1 (range 5,9-8,3),

decreasing to a mean of 2,1 (range 1-3,5) at 6 months minimum

follow-up, mean pre-operative Oswestry Disability Index was

52,8% (range 40,2%-72,7%) decreasing to a mean of 27,1% (range

11,2%- 34,8%) at 6 months minimum follow-up, mean pre-opera-

tive SF-36 questionnaire was 34,5% (50,4% - 25,7%) improving to

a mean of 75,4% (range 68,2%- 99,4%) at 6 months minimum

follow-up. 80 screws were implanted in 20 patients. Screws’

positioning was excellent in 85% (68 screws) of cases, acceptable

in 13,75 % (11 screws), and unacceptable 1,25% (1 screw)

according to the criteria published by Yokulis et al. [1]. We

observed 1 case of misplaced screw that required revision. At mid

term follow-up all patients exhibited a good intersegmental stability

and no hardware failure.

Discussion: In our opinion mini-open TLIF is a valid and safe

alternative in the treatment of low-grade lumbar instability and

degenerative disc disease. The use of mini-open technique for pedicle

screw instrumentation with spinal fusion procedure provides good

clinical results and may be a definite indication in selected patients.

Advantages of this surgical technique are reduced soft tissue damage,

reduced estimated blood loss and length of stay.

760 Eur Spine J (2009) 18:727–780

123

78

CLINICAL AND RADIOLOGICAL REVIEW

OF PATIENTS OPERATED WITH MINIMALLY

INVASIVE ARTHRODESIS WITH CANNULATED

SCREWS AND TLIF

P. Cervellini, L. Rossetto, L. Gazzola, G. Zambon

Department of Neurosurgery City Hospital of Vicenza, Italy

Introduction: We use since 2004 the minimally invasive systems

with cannulated screws and transforaminal lumbar interbody fusion

(TLIF).

The indication were: grade 1 isthmic spondylolisthesis, degenerative

spondylolisthesis, discopathy and FBSS.

We operated 80 cases, the follow-up was from 6 months to

4 years.

Materials and Methods: 50 patients operated at least 6 months

before were controlled with VAS, x-rays and CT Scan.

Results: All the patients had reduction of the pain.

Only in 10 radiological studies the fusion was evident.

In many cases we noted small subsidence.

In 3 cases there was a migration of the cage, 1 anteriorly with

loss of the correction of the listhesis; 2 posteriorly, without

radicular problems.

Conclusions: The minimally invasive systems with cannulated

screws and TLIF, in degenerative pathology, are valid in the cases in

which the indication is correct. The small surface of the cages for the

transforaminal approaches doesn’t allow the radiologic optimal result

however.

e-POSTERS

1

OUTCOMES ON THE FIRST CASES OF BALLOON

KYPHOPLASTY WITH KYPHOS IN YOUNG

PATIENTS WITH VERTEBRAL FRACTURES

R. Partescano

U.O. Ortopedia e traumatologia - P. O. S. M. Annunziata - ASL10 Firenze, Italy

Introduction: Since 2006 we have begun treating young selected

patients with the Balloon Kyphoplasty using KyphOs cement (Cal-

cium Triphosphate).

With this kind of procedure it is possible to also treat those patients

that cannot be treated with PMMA as for their young age.

The procedure using the KyphOs differs from the one using the

PMMA as for the following:

Limited time of introduction of the KyphOs in the Vertebral Body

Patient must remain in prone position for half an hour after the

conclusion of the procedure

Patient must have bed rest for 18-24 hours after surgery

Patient must avoid hard activities for almost 3 months after

surgery.

Materials and Methods: We treated 8 patients aged between 27 and

43 with wedge vertebral fractures, type A1.1 and A1.2 in the thoraco-

lumbar segment, levels between D10 and L2.

In all cases we made pre-operative X-Rays and CT.

Periodical clinical Follow Up has been made. 1 year Follow Up

controls have been made through X-Rays and MRI

Conclusions: We consider the Balloon Kyphoplasty with Calcium

Triphosphate a good alternative to the Conservative Medical Man-

agement of the wedge vertebral fracture[30� in a well informed and

motivated patient.

The outcomes show how the procedure presents remarkable benefits

in patient management. 24 hours after surgery the patient can stand up

right without using any brace or plaster devices.

The procedure can restores the vertebral body height.

2

MULTIDISCIPLINAR TREATMENT OF GIANT

CELL TUMOUR OF THE CERVICAL SPINE: CASE

REPORT

P. Rocco, E. D’Avella, R. Tarantino, R. Delfini

Neurological Sciences Department, U.O.C. of Neurosurgery ofPoliclinico Umberto I in ROME ‘‘Sapienza’’ University, Italy

Introduction: Giant cell tumours of the bone are rare and benign

neoplasms. Spinal localization is most common at the sacrum, while

cervical giant cell tumours are extremely rare. The treatment of

choice of cervical giant cell tumour is complete surgical excision.

However the high vascularization and the adherence to surrounding

structures make complete excision of the tumour often impossible.

The role of adjuvant radioterapy is still controversial because of the

associated risk of malignant transformation. We present the case of a

30 year old woman with giant cell tumour of C2 who was treated

successfully with endovascular embolization, surgery and

radiotherapy.

Case Report: A 30 year old woman presented to another institution

with a three month history of pain in the neck. A RM scan of the

cervical spine revealed a destructive slightly hyperdense mass lesion

completely occupying the body of C2 and the odontoid process. The

patient underwent a biopsy trough a transoral approach and the

histopatological examination showed a giant cell tumour with asso-

ciated aneurismal bone cyst. The patient was surgically treated with

vertebroplasty and occipito-cervical stabilization.

Four month later the patient presented to our attention because of

worsening of the sintomatology. The woman complained of neck pain

radiating to both arms, more severe at the right side, progressive

dispnea, swalling difficulty and voice disturbance. A RM scan

revealed a contrast enhancing mass with anterior extraosseous

extension from the body of C2, compressing farinx, larinx and tra-

chea, and lateral extension reaching the right vertebral artery. The

patient underwent surgery trough a lateral cervical approach. Com-

plete removal of the tumour was impossible because of massive

bleeding. One week later, the patient underwent an endovascular

procedure of embolization of the tumour to reduce intraoperative

bleeding. Second surgery trough a transoral approach was successful

and complete removal of the tumour was accomplished. The patient

underwent post operative radiotherapy. At 40 month follow-up, MR

scan showed no recurrence of the tumour and the patient is relieved

from symptoms.

Conclusion: Giant cell tumours of the spinal axis have an aggressive

and unpredictable behaviour and therefore their management is con-

troversial. Although frequently difficult, wherever possible radical

microsurgical resection in required for treatment. The use of adjuvant

therapy is not very well defined. The world literature about cervical

giant cell tumours is rather sparse, due to the rarity of these lesions.

We report our experience of a successful multimodal treatment of

Eur Spine J (2009) 18:727–780 761

123

cervical giant cell tumour to add more information to the present

literature.

3

TRANSITION DYNAMIC FIXATION SYSTEM

IN THE LUMBO-SACRAL SPINE: SELECTION

CRITERIA AND PRELIMINARY RESULTS

A. Ramieri, G. Costanzo

Orthopaedics, The Don Gnocchi Foundation and RomeUniversity ‘‘La Sapienza’’ Polo Pontino, Italy

Above or below lumbar fusion disorder is a worrying long-term

complication, often yelding to revision surgery. A particular lumbo-

sacral stabilization system has become available, coupling both rigid

and dynamic rods by a transition zone.

From 2007, we perspectively treated 12 consecutive adult patients

with severe L5-S1 DDD together with L4-L5 moderate degeneration

and disc herniation. Patients complained chronic LBP and unilateral

radicular symptoms. Surgery included discectomy, rigid L5-S1 fixa-

tion and fusion and dynamic neutralization of L4-L5 level.

Outcomes were evaluated by means of x-ray and Oswestry Dis-

ability score. After a maximum follow-up of 14 months, all implants

seemed stable with a good fusion of L5-S1 level and without L3-L4

degenerative changes. Sagittal alignment (pre-operative kyphosis)

improved as well. LBP improved too.

Dynamic transition fixation seems to show biomechanical and

clinical advantages in our group of selected patients. However, the

effect in protecting from adjacent level disease, as it appears from our

short and mid-term results, still remains theoretical and should be

validated with further studies.

4

BACJAC� AND TREATMENT OF LOW BACK

PAIN: STARTING EXPERIENCE

E. Amoroso, A. Guarracino, M. Genovese

U. O. C. di Neurochirurgia - Ospedale ‘‘Umberto I’’- NoceraInferiore (SA), Italy

Introduction: BacJac� is an interspinous spacer. Made of peek, this

device is biocompatible, and radiolucent, except for a fine metal

thread passing through its structure. Impiantable, by local anaesthesia,

with unilateral minimally invasive open approach, tissue sparing and

sopraspinous ligament preserving, the spacer would reduce subacute

or chronic low back pain (resistant both drug’s treatment and phys-

iotherapy), in selected cases. Available in 5 heights (from 8 to

16 mm) and 2 A/P widths (small and medium), it would adapt to both

individual needs for interspinous strain and different length of spinous

process, resulting easily to implant in case of short process too.

Purpose: To determine the safety and effectiveness of this new

spacer.

Materials and Methods: We have selected 8 patients, in the first six-

month period 2008, (5 male e 3 female; mean age 58 years) with sub-

acute or chronic low back pain (4 patients) or with intermittent

neurogenic claudication (4 patients), refractory to the best not surgical

treatments, but all presenting clear improvement of the painful symp-

tomatology when they bend (flexion) lumbar spine segment (score

decrement [ 5 of Visual Analogue Scale of pain). Pre-operative

imaging (standard and dynamic L/S spine x-ray, lumbar CT or MRI)

showed typical findings of spondylosis (bulging of intervertebral disk,

slight retro-listhesis, ‘‘kissing spine’’, facet subluxing, ‘‘soft- stenosis’’

of the spinal canal, black disc, Modic 1-2). In no case there was anterior

spondylolisthesis. The average operating time was 42 min., under local

anaesthesia with lidocaine and ropivacaine. All cases were followed for

6 months after surgery with clinical examination, L/S spine x-ray,

Oswestry Disability Index (ODI) and VAS scale.

Results: All patients achieved reduction of both intermittent neuro-

genic claudication and low back pain, in orthostasis (pre-operative

VAS average 8, post-operative 2; pre-operative ODI average 52%,

post- operative 28%). No adverse events occurred. In second post-

operative day, all patients were discharged from the hospital with

lumbar corset.

Conclusions: Although shortage of the surgical cases and brevity of

the ‘‘follow-up’’ don’t allow conclusions about long term effective-

ness of BacJac�, this device appears safe, fast and easy to implant,

and it finds both patient favour and approval, in selected cases, with

subacute or chronic low back pain and with or without intermittent

neurogenic claudication.

5

TWO-YEAR RESULTS OF FLEXIS INTERSPINOUS

IMPLANT FOR THE TREATMENT OF LUMBAR

SPINAL STENOSIS. THE VENIZELEIO-HOSPITAL

EXPERIENCE

N. Syrmos, V. Valadakis, Ch. Iliadis, K. Grigorio, D. Arvanitakis

Neurosurgical Department, Venizeleio General Hospital.Heraklion, Crete, Greece

Aim: Aim of our study was to investigate the clinical outcome of

patients with symptomatic lumbar spinal stenosis before and at

periodic intervals after FLEXIS implantation

Material and Methods: The FLEXIS Interspinous Device is a rela-

tively new interspinous implant designed for patients with

symptomatic spinal stenosis particularly neurogenic claudication. 63

consecutive patients were enrolled and surgically treated with

FLEXIS implantation. The FLEXIS device was implanted at the

stenotic segment, which was either at 1 or 2 levels in each patient.

They were clinically evaluated at the preoperative 1 month, 3-month,

6-month, 9 month and 1-year stage with clinical questionnaires (VAS,

Zurich Claudication Questionnaire, Oswestry Disability Index, SF-

36,JOA,AO SPINE)

Results: 13 patients failed to complete all the questionnaires at

all time intervals and hence were excluded, leaving 50 patients who

had completed all questionnaire at all time interval. By 12 months,

80% of these 50 patients reported clinically significant improvement

in their symptoms, 5% reported clinically significant improvement

in physical function, and 5% expressed satisfaction with the

procedure.

Conclusions: The advantages of the FLEXIS interspinous device are:

• Low Risk Operation

• Shorter Surgical Time

• Minimally Invasive Surgery

• Preserve Flexibility and Mobility

• Faster Rehabilitation

762 Eur Spine J (2009) 18:727–780

123

6

CERVICAL MYELOPATHY DUE TO OPLL AND

OLF ASSOCIATED WITH DISH, CRANIO-

VERTEBRAL JUNCTION MALFORMATION AND

C2-C3 SYNOSTOSIS. CASE REPORT

V. Russo, F. Graziano, D. Romano, M. Giarrusso, V. Albanese

Universita degli Studi di Catania, Dipartimento di Neuroscienze,Clinica Neurochirurgica, Italy;Direttore: Prof. V. Albanese

Diffuse Idiopathic Skeletal Hyperostosis (DISH) is characterized by

calcification and ossification of soft tissues. It has been found to

involve the axial skeleton and, in up to 76% of patients, the cervical

spine. The disease is characterized by ossification of the anterior

longitudinal ligament and production of flowing osteophytes with

preservation of the intervertebral disc space. The prevalence of DISH

varies in different populations: 25% and 15% in men and women over

50 years old respectively and 35% and 26% in men and women over

70 years old, respectively. The association with the ossification of the

posterior longitudinal ligament (OPLL) has been described in up to

50% of cases. Whereas it has been rarely reported the association with

ossification of ligamentum flavum (OLF) or congenital malforma-

tions. The difference with ankylosing spondylitis is the absence of

inflammatory changes in facets or sacroiliac joints. Patients with

DISH are mainly asymptomatic. Dysphagia is the most common

clinical manifestation in symptomatic patients.

We report the case of a 72-years-old man with a severe cervical

myelopathy and neck pain due to OPLL and OLF with concomitant

DISH, cranio-vertebral junction malformation and C2-C3 synostosis.

X-Rays revealed a flowing ossification of the anterior aspect of the

cervical spine. Magnetic resonance imaging revealed cranio-vertebral

junction malformation, C2-C3 synostosis and, on T2-weithed images,

intramedullary high signal intensity at C3-C4 level. CT of the cervical

spine showed narrowing of spinal canal primarily at C3-C4 level due

to OPLL and OLF. The patient underwent a C3-C6 decompressive

laminectomy. Postoperative course was uneventful and carachterized

by progressive and rapid improvement of the pre-op symptomatology.

To the best of our knowledge this is the first report on a patient with

DISH associated with OPLL, OLF and congenital malformations. In the

present case a posterior approach has been choosen because of the

absence of dysphagia and preserved cervical spine lordosis. In conclu-

sion, only patients with dysphagia need resection of the anterior

ossification. A posterior approach has to be performed in case of absence

of dysphagia in patients with a physiological cervical spine lordosis.

7

EXTRAOSSEOUS EXTENSION OF T5 VERTEBRAL

HEMANGIOMA: A RARE CAUSE OF SPINAL

CORD COMPRESSION

F. Graziano, V. Russo, D. Romano, M. Giarrusso, N. Platania

Universita degli Studi di Catania, Dipartimento di Neuroscienze,Clinica Neurochirurgica;Direttore: Prof. V. Albanese, Italy

Vertebral hemangiomas are relatively common benign dysplasias or

vascular tumours affecting the vertebral column. They account for

approximately 2 to 3% of all spinal tumours and occur with an

estimated incidence of 10 to 12% in the population as based on large

autopsy series and review of plain spine radiographs. These lesions

are usually asymptomatic and often present as incidental findings on

plain radiographs and on magnetic resonance images. Rarely, they

may cause pain or neurological deficits because of spinal cord com-

pression, vertebral body or arch expansion, or pathological fracture.

Radiation therapy or decompressive surgery with or without postop-

erative irradiation have been the traditional means for treating these

lesions.

We report the case of a 75-year-old woman with a severe thoracic

myelopathy due to extraosseous extension of a thoracic vertebral

hemangioma. The MRI revealed mild anterior wedging of the T5

vertebral body with extensive signal abnormality throughout the body

extending into the pedicle, the transverse process and the spinous

process. An extraosseous extension of this lesion, that appeared as an

extradural soft tissue mass encroaching on the posterior aspect of the

spinal canal with a marked cord compression, was found. A bilateral

paravertebral soft tissue mass laying between the T4–T5 and T5–T6

intervertebral discs was also seen. Axial T1-weithed images showed

the characteristic ‘‘polka dot’’ pattern of trabecular thickening

involving most of the vertebral body, the pedicle and the spinous

process. The patient underwent a posterior decompression through a

Th2-Th6 laminectomy and osteosynthesis with rods and laminar

hooks, to prevent progressive neurologic deterioration and potential

instability with the risk of vertebral collapse. The extraosseous

extension of the tumor was removed. The histologic examination

revealed a benign capillary hemangioma. Postoperative course was

unenventful and carachterized by progressive and rapid improvement

of the pre-op symptomatology.

It is generally agreed that surgical decompression should be

undertaken if significant or progressive neurological deficit is present.

The choice of surgical procedure is determined by the location of the

hemangioma and by the severity of neurological condition. In this

case a decompressive laminectomy with posterior fixation was per-

formed in order to avoid a progressive neurological decline due to

neural canal stenosis caused by osseous tumor growth involving the

vertebral body and posterior elements.

8

SPINAL EPIDURAL ABSCESS

D. Romano, V. Russo, F. Graziano, M. Giarrusso, N. Platania

Department of Neurosurgery, Neuroscience Institute, Universityof Catania, Catania, Italy

Spinal epidural abscess (SEA) (described for the first time by Ber-

gamaschi in 1820) is an uncommon disease with a frequency of 0.2 to

2 cases per 10.000 hospital admissions and a mortality rate of 10-

30%.

Predisposing factors of SEA include infections, diabetes, chronic

liver disease, intravenous drug abuse, AIDS, immunocompromised

condition, alcohol abuse, spinal surgery or trauma, cancer and steroid

use, however 20% of patients will have no clear predisposing factor.

The classic triad is composed by three typical symptoms: spine

pain, fever, and neurological abnormalities, but this triad is present in

only 10-15% of SEA patients.

In a patient with SEA the value of surgical intervention versus

antimicrobial therapy alone is controversial.

We report a patient with SEA treated successfully with a medical

regimen.

Case Report: A 74 years old female was admitted because sudden

neck pain, left superior arm hypostenia, dizziness, dysphagia.

Eur Spine J (2009) 18:727–780 763

123

On admission the physical examination showed weakness in the

abduction movements of the left superior arm, hypoesthesia in C5

nerve root distribution, weakness of left deltoid muscle, patellar and

achilles hyperreflexia, bilateral Hoffmann sign, spontaneous and

evocated neck pain.

Laboratory examination revealed: leukocytosis with white cell

count of 10.67 x 10^3/mmc, elevated C-reactive protein of 7.23 g/dl

and elevated VES of 49 mm/h. Blood cultures were negative.

Cervical Spine Magnetic resonance imaging (MRI) demonstrated

spinal compression along the anterior aspect of the thecal sac at the

C5-C6 level, with an epidural mass.

The patient was started on intravenous vancomycin and Glazidim

(ceftazidima) for 45 days.

This prompt antimicrobial therapy resulted in excellent, relativily,

early neurologic outcome, in fact the neurological disorders and RCP

(Reactive C Proteine) and VES values in this patient normalized, and

a post therapy MRI exam showed a unmistakable improvement.

In conclusion SEA is a rare disease usually associated with spe-

cific predisposing factors; however, patients may present atypically.

Diagnostic delays lead to adverse neurological outcomes. Magnetic

resonance imaging is now the diagnostic procedure of choice.

The decision to treat the patients with SEA medically was

based on the short duration of the cord dysfunction, the gradual

improvement of neurological signs within the first 24 hours of the

initiation of therapy and the absence of immunodeficiency. The

medical (antimicrobial) therapy should be reserved to those cases

in which there is a high surgical risk related to unfavorable clinical

circumstances.

This case suggest that surgery may not be required in all cases

with cervical spinal epidural abscess causing epidural compression

and neurological involvement, conservative treatment with antibiotic

therapy (Glazidim and Vancomicyn) may be sufficient.

9

TARLOV’S CYST-RETROSPECTIVE REVIEW

OF 5 CASES

N. Syrmos, C. Iliadis, V. Valadakis, K. Grigoriou, D. Arvanitakis

Neurosurgical Department, Venizeleio General Hospital.Heraklion, Crete, Greece

Introduction: Tarlov’s cyst or perineurial cyst is disease on portion of

the posterior nerve root in lumbo-sacral region. The lack of knowledge

of physicians around the world about Tarlov’s cyst as to their nature,

significance and treatment also with differential diagnostics to radic-

ulopathy in legs. The pathogenesis Tarlov’s cyst remains unclear;

several cases have history of the trauma, old hemorrhage, congenital

and iatrogenic. Cysts provoke low back pain, sacral radiculopathy,

dyspareunia, urinary incontence. The magnetic resonance imaging is

now the gold standard to diagnose cysts. The treatment is clinic or

surgery depending neurologics finding and neuroimage.

Aim: 5 perineurial cysts cases (Tarlov’s cysts) are reported

Material and Method: The evaluation was performed among 198

adult patients with symptoms of radiculopathy, sacral pain, low back

pain

Results: The diagnosis was made by magnetic resonance imag-

ing.Following surgery, the claudication pain resolved with no motor

or sensory deficits. Tarlov’s cysts should be considered as a differ-

ential diagnosis of sacral radiculopathy, sacral or lumbar pain

syndromes and mainly to the lumbar disc prolapse. The goal of the

surgical treatment is to relieve the neural compression and stop bone

erosion.

10

SPINE INJURIES AND ROAD TRAFFIC

ACCIDENTS RETROSPECTIVE REVIEW

N. Syrmos, C. Iliadis, V. Valadakis, K. Grigoriou, D. Arvanitakis

Neurosurgical Department, Venizeleio General Hospital.Heraklion, Crete, Greece

Aim: Aim of our study was to investigate the causes and the conse-

quence of the spine injuries, with and without neurological injuries,

who were treated in our hospital

Material and Method: We retrospectively reviewed data for 210

patients who were admitted to our hospital after road traffic accidents,

between 2001 and 2007. Spine injuries nd other factors were stud-

ied(Age, helmet status, alcohol and drug use, head injuries, length of

stay, disposition, hospital costs).

Results: 81,4%(171) of victims were male, with an average age of

33.5 years. 18,5(39) of all patients were wearing helmets.99 patients

(47,1%) sustained spinal injuries. There were a total of 17 deaths

(8%)

Conclusions: It is estimated that the annual incidence of spinal cord

injury, not including those who die at the scene of the accident, is

approximately 40 cases per million population in the U. S. or

approximately 12,000 new cases each year. In Europe some 330 000

people suffer from spinal cord injuries, with more than 10 000 new

cases occurring each year. Young people between the age of 25 and

35 are most affected by these injuries. Spine and brain injuries

occurred in 80% of fatal crashes. Crete has a fatality high rate. We

conclude that safety legislation would save lives.

11

MYELOPATHY HAND. CLINICAL SIGN OF CORD

DAMAGE

G. A. La Maida

Orthopaedic Dpt. Niguarda Hospital – Milan, Italy

The myelopathy hand is a characteristic dysfunction that has been

observed in various cervical spinal disorders when there is

involvement of the spinal cord. The most frequent causes of

myelopathy hand are cervical disk herniation, spinal stenosis,

tumours or syringomyelia. The most important clinical signs are

the loss of power of adduction and extension of the ulnar two or

three fingers and an inability to grip and release rapidly with these

fingers. Very characteristic is the escape finger test that is a loss of

adduction of the fifth finger of the hand. The muscular strength

reduction begins in most cases in the intrinsic muscles of the hand.

The sensitive impairment is often absent or very light. These

changes have been termed ‘‘myelopathy hand’’ and appear to be

due to pyramidal tract involvement. The Author would like to

underline a very characteristic clinical sign that can be easily

checked in the Patient and that could be expression of a very

important cord damage.

764 Eur Spine J (2009) 18:727–780

123

12

RISKS OF THE CEMENT IN SPINE SURGERY

G. A. La Maida

Orthopaedic Dpt. Niguarda Hospital – Milan, Italy

During the last years we observed an increased in the use of the

cement in spine surgery. The cement can be very useful especially in

some pathological conditions characterized by bone mass loosening,

like osteoporosis or some osteolytic lesions and so up to now a lot of

vertebral augmentations were done all over the world. Some surgeons

try now also to use cement in order to treat the traumatic fractures of

the young adult, with excellent results reported also in type A3

fractures.

I personally regularly use both the vertebroplasty and kyphoplasty

procedures to treat some type A fractures of the elderly patients but

I’m as many convinced that the use of the cement must be limited to

treat only very selected cases of the elderly age.

I report the case of a Patient of 69 years old affected by osteolytic

pathological fractures of T5 and L3, with a limited involvement of the

posterior wall in both levels

I planned a double spine short segment stabilization by using

pedicular instrumentation, combined with a vertebroplasty procedure

of the fracturated vertebral body in order to have an anterior support.

During the procedure of vertebroplasty in T5 there was a massive

cement extravasion into the canal with high grade stenosis and

compression of the spinal cord. The cord compression was immedi-

ately demonstrated by the suddently reduction of the evoked potential

and an emergency procedure of cord decompression was done in

addition to an immediate methilprednisolone infusion according to

the NASCIS III protocol. The decompression of the canal was

achieved by bilateral lamino-artrectomy and by direct removal of the

cement from the canal. At the end of the procedure the Patient was

neurologically intact without any peripheral pain and without any

sensitive or motor damage.

Cement leakage during vertebral augmentation procedures is

reported to be very useful, with rate ranging from 8 to 60% in the

litterature.

Additionally the cement, when used to treat spine fractures, is not

able to lead to a biologic healing of the bone and so it should be

contraindicated in young Patients.

I’m finally convinced that the use of the cement must be very

useful in spine surgery but it must be indicated in very selected

pathologies and Patients. I also think that any kind of vertebral aug-

mentation procedure should be performed in general anesthesia and in

operating room in order to immediate decompress the Patient if a

leakage complication is seen. I’m sure if my Patient had had to wait

the necessary time to organize an urgent decompression from the

angiographic room to the operating room, she would have had a

neurologic consequence.

The indiscriminate use of the cement, like in fractures with pos-

terior wall involvement or in young Patients, could easily lead to a

dangerous consequences for the Patient.

13

THE DISC PROSTHESIS IN TREATMENT OF

CERVICAL DEGENERATION DISC PATHOLOGY

A. Tumino, T. C. Russo, C. Casamichele, M. Quartarone,G. Incatasciato, G. Giuca, D. Pitino

Unit of Orthopaedics and Traumatology Major Hospitalof Modica, Italy

Introduction: Anterior Cervical Discectomy and interbody fusion

(ACDF) has for years been the gold-standard in the treatment of

symptomatic degenerative disease of the cervical disc. Despite the

good results obtained, after the merger intersomatic cervical discec-

tomy addition to causing a limitation of the range of motion leads to a

acceleration of the degenerative discs adjacent to fusion. In this work

we evaluate the radiographic and clinical results obtained following

cervical arthroplasty that assess the efficacy of this treatment.

Materials and Methods: Were evaluated 8 patients with implanted

prosthetic 9, 5 males and 3 females. In one case it is the level C4-C5,

in 3 cases of C5-C6 level, in 2 cases of C6-C7 and in one case of a

double level C5-C6 and C6-C7. Patients were evaluated both clini-

cally (Vas scale and ASIA) and radiographically with x ray in

standard projections and those dynamics.

Results: The results obtained showed that the emergence of the

prosthetic disc, while maintaining the benefits of ACDF (decom-

pression, restoration of stability and the height of intervertebral

space), keeping the movement, protects the disc levels adjacent to

fusion overload which will accelerate the degeneration.

14

A CASE OF ATYPICAL SPONDYLODISCITIS:

CASE REPORT

G. Giuca, T. C. Russo, A. Davı, C. Casamichele, M. Quartarone,A. Tumino, G. Incatasciato, M. Stamilla

Unit of Orthopaedics and Traumatology Major Hospital ofModica, Italy

Introduction: We present the case of a patient of 60 years suffer

from pain ingravescent symptoms a dorsal location, hyperthermia and

a history to recent right basal pleurisy with pleural payment agree-

ment. For this reason the same was subjected to repeated admissions

to other healthcare centers with final diagnosis of septicemia from S.

Aureus suspected spondylodiscitis D8 and D9-and antibiotic therapy

was carried out without resolution of pain symptoms will febrile

episodes.

Materials and Methods: The patient then came to our observation,

and during hospitalization at our UOC chose a multidisciplinary

approach with involvement of the infectious disease specialist and the

Eur Spine J (2009) 18:727–780 765

123

microbiologist and after excluding a spondylodiscitis of tubercular or

brucella nature, the patient was treated with antibiotic therapy with

broad spectrum and surgical stabilization of D7-D10 with biopsy with

negative results.

Results: In post-operating there was a marked improvement in pain

symptoms, the hyperthermia does not reappear and control to one

month the patient had resumed normal ambulation. The state of

welfare remained unchanged over time even with the new controls at

three, six months and a year with permanent normalization of bio-

chemical parameters.

Discussion and Conclusions: This is an atypical case because the

basal pleurisy may have been the cause for contiguity of vertebral

localization. From this case shows how the multidisciplinary

approach is the ‘‘gold standard’’ in the treatment of bone diseases of

infectious nature even more atypical.

15

PRELIMINARY REPORT ON PERCUTANEOUS

TRANSPEDICULAR SCREW INSTRUMENTATION

COMBINED WITH MINIMAL ALIF APPROACH

J. Buric, D. Bombardieri, M. Pulidori

Functional unit for Spinal Surgery - cdc Valdisieve – Pelago (FI)- Italy

Objective: This study was performed to compare the minimally

invasive circumferential fusion to standard open circumferential

fusion for low back pain in lumbar degenerative disc disease.

Background: Standard open circumferential fusion is associated with

better clinical and radiological results than PLIF or TLIF fusion

procedures but has a higher degree of intraoperative and post-oper-

ative complications. Minimally invasive ALIF and XLIF combined

with percutaneous trenaspedicular screw instrumentation has the

potential of reducing the disadvantages of the procedure.

Methods: Twenty-five affected by low back and leg pain due to

degenerative disc disease from L3 to S1 levels were submitted to

surgery during 2007 and 2008 using this minimally invasive

approach. Posterior part of the procedure was performed using the

percutaneous transpedicular screws (Pathfinder, Abbott Spine) and

(Silverbolt, Vertiflex) while the ALIF was performed in by minimally

invasive retroperitoneal approach implanting anterior full-body cage

(Perimeter, Medtronic) or by lateral percutaneous approach using

XLIF cage (Nuvasive).

Results: All of 25 patients improved upon surgery. The mean

improvement was of 5,7 points on VAS scale and 7 points on the

Roland Morris Disability Quetionnaire. The mean operating time

for the posterior part of the procedure (skin to skin) was as fol-

lows: 55 minutes for one level and 80 minutes for two levels. The

mean operating time for the anterior approach was 90 minutes for

one level and 110 minutes for two levels. The total amount of time

for both approaches, including the turn-up time for patient repo-

sitioning ranged from 160 minutes for one level till 300 minutes

for double level. Just one case of common iliac vein rupture was

encountered and successfully resolved. No other minor or major

intra-operative complications were encountered. The mean blood

loss per surgery was approximately 250 milliliters and in no

patient, except the one with vein rupture, blood transfusion was

indicated. Surgical wound drainage was never used. All the patients

were raised from the bed between 12 to 18 hours after the surgery.

The longest hospital stay was 6 days. As compared to standard

circumferential fusion, the reported post-operative pain was 3-fold

less and the use of post-operative opioids and painkillers was 60%

less. No wound or systemic infection was ever encountered. There

were no complications observed due to pulmonary embolism.

Conclusion: Minimally invasive ALIF or XLIF combined with pos-

terior percutaneous transpedicular screw instrumentation seems an

equally usefull system as compared to standard open circumferential

fusion with the advantage of less blood loss, fewer complication rate,

shorter operation time and shorter hospital stay. It is not indicated in

cases of 2� or more of lysthesis as well as when laminectomy is

planned, too.

16

FIVE YEAR FOLLOW-UP ON INTRADISCAL

OZONE INJECTION FOR DISC HERNIATION

J. Buric*, L. Rigobello#, B. Frankel’’, D. Hooper^

*CDC Villanova – Florence, Italy; #Dpt for Neurosurgery – Univ.of Padua, Italy; ‘‘Dpt. of Neurosurgery, Med Univ of SouthCarolina, USA; ^Minimus Spine-Austin, USA

Objective: This study was performed to collect five-year follow-up

on patients with lumbar disc herniation treated with intradiscal

injection of ozone gas.

Background: Disc herniation is the most common cause for spinal

surgery, and many clinicians emply epidural steroid injections with

limited success. In numerous countries, intradiscal injection of

ozone gas has been used as an alternative to epidural steroid and

surgical discectomy. Early results are positive, but long-term data

are limited.

Buric JosipNinety-five patients with confirmed contiguous disc

herniation were treated with intradiscal injection of ozone in 2002.

Eighty-seven patients were available for telephone follow-up at five

years and a chart review was performed. Patients were asked to

describe their clinical outcome since the injection. Surgical inter-

ventions were documented. Available MRI films were

collectively reviewed to assess the reduction in disc herniation at

six months.

Results: of the 87 responders at five years, 63 (72%) reported being

‘‘much better’’, three (3%) were ‘‘better’’, eight (9%) had no

improvement and 13 (15%) went on to surgery. There were 12

discectomies and one fusion, with ten of the 13 surgeries occuring

during the first year. Two patients had a second intradiscal ozone

injection for an average of 1.02 injections per patient. MRI films

demonstrated a consistent reduction in the size of the disc herniation.

Seventy-nine percent of patients had a reduction in herniation volume

and the average reduction was 56%. Other than subsequent surgeries

typically associated with these patients, no complications were

experienced.

Conclusion: Ozone is a conservative alternative to surgical discec-

tomy for many patients. The gas reduced the size of the disc

herniation. Randomized trials are required to gain wider acceptance

of this treatment option.

This work was published as a Clinical review article in Orthopedic

Product News, May/June 2008 pp 66-9

766 Eur Spine J (2009) 18:727–780

123

17

NEW COMPRESSION VERTEBRAL FRACTURES

AFTER VERTEBROPLASTY OR KYPHOPLASTY:

MYTH OR REALITY?

G. Caruso, V. Lorusso, E. Zamagni, S. Poggiali, L. Massari

Ferrara University Department of Orthopaedic Surgery, Italy

Introduction: Percutaneous vertebroplasty and baloon asissted

kyphoplasty are efficient and safe procedures to improve quality of

life and to treat pain due to osteoporotic vertebral compression

fractures (OVCFs). To date, literature data did’nt clarify an etio-

logical potential correlation among these mini invasive surgery

techniques and new osteoporotic vertebral fractures incidence.

Materials and Methods: In this retrospective study we have evalu-

ated incidence and spine distribution of new OVCFs in 124 patients

previously treated for 193 OVCFs with percutaneous vertebroplasty

(105 vertebra) or balloon assisted kyphoplasty (88 vertebra), from

2003 to 2007 in our Orthopaedic Clinic.

Results: We observed that 16,5% of patients have developed new

OVCFs at an average time of 8,6 months (1-35) from surgery. The

28,1% of these fractures incurred in an immediately adiacent level to

the previously treated vertebra whereas the 71,9% in the distance.

Also in this case the number of new compression fracture decreases

drifting away from the previously treated vertebra. Vertebroplasty

was most often associated to this complication (68,75%).

Conclusion: The biomechanical alterations resulting from poly-

methylmethacrylate injection in vertebral body involve the risk to

develop new OVCFs in adiacent level to the previously treated ver-

tebra. This event does not seem to be higher than that resulting from

the presence of the fracture itself. As a matter of fact, literature data

show a new OVCFs incidence in 12 months, following the first

OVCFs of 19,2%; this percentage is correlated to the osteoporosis

progression and to biomechanical modification depending from the

fracture itself.

18

SCOLIOSIS SURGERY: TREATMENT

OF SURGICALS FAILURES

C. A. Logroscino, S. Astolfi, F. C. Tamburrelli, L. Scaramuzzo,L. Oggiano

Department of Orthopaedics and Traumatology, UniversitaCattolica del Sacro Cuore School of Medicine, Rome, Italy

Scoliosis operative planning and surgical technique can be considered

very challenging. Technical and clinical success of treatment are

defined by the occurrence of a three-dimensional correction of

deformity, an accurate postural balance and an improvement of pain.

Revision surgery can be considered even more demanding; it would

be necessary to correct a failure or mobilization of instrumentation or

a wrong assessment of the fusion area leading to structural imbalances

and to treat involvement of adjacent segments not instrumented.

Between January 2006 and September 2008 fourteen patients previ-

ously treated for scoliosis were submitted to revision surgery. In 2

cases they had been treated for an adolescent idiopathic scoliosis, in

10 cases for adult scoliosis and 2 were scoliosis in children with spina

bifida. Surgical treatment consisted of 9 osteosynthesis revisions with

pedicle screw instrumentation and proximal or caudal extension of

fusion area, 1 anterior approach revision and 4 osteotomies (PSO) to

restore a correct sagittal balance. Patients were evaluated by clinical

and radiographic examination, ODI-2 and SF-36 questionnaires

administration to assess functional disability degree. No death

occurred in the present case series. Complications included blood loss

more than 1500 ml in 4 cases, wound infection in 1 case and deep

venous thrombosis in 1 case.

19

LUMBAR STENOSIS TREATED BY X-STOP

DEVICE: PRELIMINARY RESULTS OF AN

EXPERIENCE OF 30 MONTHS

B. A. Nannavecchia, F. Bigossi, P. F. Eugeni, F. Pineto, R. Sepe,V. Magliani, D. Lucantoni

Unita Operativa di Neurochirurgia, Ospedale ‘‘G. Mazzini’’ -Teramo, Italy

Authors describe a clinical retrospective of 65 patients with lumbar

stenosis treated by X-Stop device since october of 2006 to november

2008.

After a review of an international litterature of lumbar stenosis

pathology, it focalizes on the epidemiology and the traditional sur-

gical treatments; then, the study analyzes the age, the life outcome,

the preoperatory clinical aspects and the levels of stenosis.

The paper describes the Methods used to select the patients, all the

steps to implante the device and the postoperatory managment.

The follow-up based to the results related to the symptoms and to

the imaging is discussed.

The conclusions of this preliminary experience highights a man-

agment standard to treat this type pathology of cervical disc able to

resolve by a surgical procedure minimally invasivity the disfunction

and no the microinstability.

20

CERVICAL MICRODISCECTOMY WITH DISCO-

CERV DEVICE: OUR PRELIMINARY

EXPERIENCE

B. A. Nannavecchia, F. Bigossi, P. F. Eugeni, F. Pineto, R. Sepe,V. Magliani, D. Lucantoni

Unita Operativa di Neurochirurgia, Ospedale ‘‘G. Mazzini’’ -Teramo, Italy

Authors describe six clinical cases of patients with soft slipped disc

surgically treated by cervical microdiscectomy and implante of disco-

cerv device since June 2007 to June 2008.

After a review of an international litterature of cervical disc

pathology, it focalizes on the epidemiology and the traditional sur-

gical treatments; then, the study analyzes the age, the life outcome,

the preoperatory clinical aspects and the slipped disc levels of

selected patients.

Topics related to the device’s system are the biomechanics fea-

tures and its relationship to a biologically young cervical disc.

The paper describes the Methods used to select the patients, all the

steps to implante the device and the postoperatory managment.

The follow-up based to the results related to the symptoms and to

the imaging is discussed.

Eur Spine J (2009) 18:727–780 767

123

The conclusions of this preliminary experience highight a man-

agment standard to treat a soft slipped disc disease in patients with a

biologically young age.

21

SHORT INSTRUMENTATION IN THE FRACTURES

OF THE THORACIC-LUMBAR JUNCTION: OUR

EXPERIENCE

B. Cappelletto, F. Giorgiutti, C. Veltri, P. Facchin, P. Del Fabro

The thoracic-lumbar junction is the part of the column most fre-

quently involved in traumatic lesions: it is, in biomechanics, the most

susceptible zone because there is a passage without transition from

the rigid and kyphotic portion of the dorsal column to the mobile and

lordotic portion of the lumbar column.

The objective of surgical treatment is to obtain a stable column,

pain-free and flexible, and to gain the best possible neurological

result.

There is controversy regarding which is the preferred method for

achieving these goals. It has been demonstrated that short posterior

fixation causes a high incidence of failure of the hardware and of the

correction. We argue that the choice of the treatment should be based

on the classification of the fracture and, from this, one should carry

out as short a fusion as possible.

The purpose of this study is to analyze our case records in com-

parison to those reported in the literature. From January 1994 until

December 2007, we performed stabilization with short instrumenta-

tion on 175 patients with fracture of L1 (117 cases) or T12 (58 cases).

In 36 cases the patients presented a neurological deficit due to spinal

cord or root lesion while in 139 cases there was no deficit. We carried

out laminectomy in 68 cases and put two screws in the fractured

vertebra in 156 cases.

All patients were examined 3 and 12 months after the operation

with X-rays. We observed a neurological improvement in 67% of

the cases. In no case was it necessary to remove the hardware, and

in no case did hardware breakage occur. Patients tolerated the short

instrumentation well and never requested removal.

In conclusion, our view is that the insertion of two pedicle screws

in the fractured vertebra adds a crucial element of stability. In selected

patients, short instrumentation brings about good stability, permits

good mobility, and is well tolerated.

22

VASCULAR INJURIES IN CERVICAL SPINE

TRAUMAS

M. Campello, M. Broger, P.C. Cecchi, M. Baldassa, N.Vezzali1,A. Schwarz

Neurosurgical Unit and Radiology1, General Hospital – Bolzano -Italy

Injuries of the main cervical and cephalic arteries, following cer-

vical spine traumas, can result in significant, possibly devastating,

neurological sequelae. Extra-cranial dissections can cause ischemic

accidents, sometimes in more than one vascular territory. Recent

advances in multiplanar reformatting of the axial images at CT-

scan and the availability of MR scans, even in emergency settings,

facilitate early diagnosis of these vascular injuries, more often than

previously done. Aim of the present study is to review our policy

in detecting and treating suspected – then confirmed – carotid and

vertebral arteries post-traumatic injuries in order to avoid ischemic

complications. Since fall 2004, in our hospital, a comprehensive

multiple trauma management protocol is routinely performed;

according to this protocol a total-body CT with angio-CT scans are

done; MR and angio-MR are done in selected cases. Our experi-

ence stems from 531 consecutive traumatized patients (time span:

November 2004 - November 2008) in which that protocol was

applied. We used the 5-points Denver grading scale as a tool to

classify the diagnosed vascular injuries, from mild wall damages

till a complete vascular transection. We found 11 patients (2,07%

of the total population) with 13 vascular lesions. It is of note that

all eight patients with vertebral arteries damages had a concomitant

osseous spinal lesion, but only one third of carotid arteries lesions

were associated to a bone fracture. We analyze pathogenesis,

pathological and radiological spectrum, clinical features and ther-

apy – when delivered – of these positive cases.

23

SPONDYLOLISTHESIS REDUCTION WITH UNI-

THREAD� SPL SYSTEM

M. Piredda, M. Costaglioli, D. Castangia, S. Casula, S. Caboni, P.P. Mura

Cagliari, Italy

Introduction: Spondylolisthesis occurs when one vertebra slips for-

ward in relation to an adjacent vertebra, usually in the lumbar spine.

The symptoms that accompany a spondylolisthesis include pain in the

low back, thighs, and/or legs, muscle spasms, weakness, and/or tight

hamstring muscles. Some people are symptom free and find the dis-

order exists when revealed on an x-ray.

The latest developments in spondylo-implantology have increased

interest in operative treatment of slip. The reduction of slip, however,

remains controversial and is broadly discussed.

Spondylolisthesis reduction effectively relieves clinical com-

plaints, and reconstitutes physiological spinal load bearing and

spino-pelvic balance. Stabilization eliminates segmental instability

and improves conditions for spondylodesis. Currently, one-seg-

mental interbody stabilization with transpedicular fixation is a

recommended method. Broad and complete decompression of

neural elements and its control during the reduction procedure is

recommended in order to avoid neurological complications.

Patients and Methods: Eight patients with lumbar spondylolisthesis

were collected from January to December 2008, they were treated by

posterior restoration and fixation with UNI-Thread� SPL system.

This device permits unconstrained anteroposterior reduction of the

listhesis and gradual, fully controlled correction of the profile.

Conclusion: The UNI-Thread� SPL device provides a true mono-

segmental micrometric reduction and a 360� fusion with interbody

cages (TLIF o PLIF procedures).

768 Eur Spine J (2009) 18:727–780

123

24

SELECTIVE SEGMENTAL STABILIZATION WITH

A NEW DYNAMIC/HYBRID CONSTRUCT

P. P. Mura, C. Formica*, M. Balsanoo, M. Costaglioli,L. Cavaleri*, A. Villaminar

Cagliari; *Alessandria; oSchio-Thiene (VI), Italy

Introduction: In the last few years, there was a shift from rigid to

dynamic fixation of spinal segments.

Dynamic stabilization system decrease the load of intervertebral disc

of corresponding movement segments and provide a good environ-

ment for the recovery of intervertebral disc and soft tissues. It also

delays the degeneration of small facet and reconstructs the biome-

chanical function of spine at instrumented level.

Patients experiencing pain and biomechanical instability at one

level may also present with radiographic or other indicators of

early degeneration at an adjacent level. Clearly, fusion would be

warranted at the symptomatic level, but the treatment plan for the

adjacent level remains controversial. Additionally, the effects on

adjacent motion segments above a fusion level are currently not

well understood.

The varying degrees of functional spinal unit (FSU) degeneration

have led to recent discussion of tailored treatments at multiple levels

in a single-stage operation. Bertagnoli et al have defined the use of

motion-preserving technologies combined with fusion as a multilevel

hybrid construct category.

Patients and Methods: In this article we analyze the first 100

patients operated with a new dynamic/hybrid construct: FlexPLUS

(Spinevision). The FlexPlus system is unique because it offers various

degrees of stabilization, rigid, hybrid and dynamic, 3 types of rods

compatible with the same bone anchorage screw mechanism and

instruments.

FlexPLUS allow to apply Selective Segmental Stabilization during

the procedure and therefore adapt to multiple disc-degeneration

stages: dynamic one-level posterior stabilization constructs to one-

level rigid rod fixation constructs.

Conclusion: This original construct requires no more surgical steps

than a normal fusion, and allows easy conversion to fusion in case of

revision surgery or construct extension

25

ORTHELIUS: A NON INVASIVE DIAGNOSTIC

SYSTEM IN EVALUATION OF SPINAL

DEFORMITIES

P. P. Mura, M. Costaglioli, M. Piredda, D. Castangia, S. Casula,S. Caboni

Cagliari, Italy

Introduction: Accurate and non-invasive measurements are essential

for deformity diagnosis and assessment of curve progression.

Although the standard procedure for diagnosis and follow-up of the

progression of scoliosis is the Cobb method of radiographic mea-

surement, there is much concern related to the multiple exposures to

ionizing radiation.

Modern technologies for assessing spinal deformities are based on

assessment of the surface topography of the back in various ways.

Ortelius 800TM is a unique device that allows radiation-free, simple

and accurate assessment of spinal deformities.

Ortelius 800TM is based on direct measurement of the patient’s

back with a fingertip scanner. The fingertip scanner is equipped

with sensors, a fusion of varied technological elements. The

scanner is worn over the examiner’s index finger while leaving the

tip of the finger exposed. This maintains the palpation at the bare

fingertip to enable accurate recognition and recording of the ver-

tebral spinous processes. The examination is extremely concise and

the system provides very accurate recording of the spine coordi-

nate. The recorded positions are used to reconstruct the 3D contour

of the spine and to calculate the location of each verterbra as well

as deformity angle, graphically presented by the system on the

LCD monitor in real time.

The data is then digitized and stored and Ortelius 800TM provides

a novel method for plotting and analyzing the spine. Details regarding

the patient history and examination results are stored in the patient log

for comparisons with follow-up visits required for monitoring.Patients and Methods: 1500 Ortelius examens were collected and

retrospectively reviewed and analyzed.

Conclusion: Follow-up of the scoliotic patients with the Orte-

lius800�, provides the managing orthopaedic surgeon with a

radiation-free accurate Cobb angle measurement.

We propose the Ortelius 800 as a clinical tool for the routine follow-

up measurements of patients affected by spinal deformities such as

scoliosis and kyphosis, thus enabling a significant reduction of radi-

ation exposure.

26

THE ANTERIOR CERVICAL ARTHRODESIS

BY PLATE – CAGE

M. Quartarone, T. C. Russo, C. Casamichele, A. Tumino,G. Incatasciato, G. Giuca

Unit of Orthopaedics and Traumatology Major Hospital ofModica, Italy

Introduction: The anterior cervical arthrodesis is a procedure used

for the treatment of degenerative and post-traumatic diseases.

The present work aims to evaluate the cervical arthrodesis obtained

through the use of the plate-cage (PCB) that is a titanium- made

implant introduced recently in spinal surgery. It has a plate attached to

the anterior surface of the cage.

Materials and Methods: Were assessed 9 plates cage in 8 patients (6

males and 2 females), mean age 67 years. The follow-up has averaged

24 months. Patients were evaluated clinically, by VAS scale, ASIA

and SF36, which radiologically. It was valued in the local cervical

lordosis and general.

Results: This work has showed good stabilizations, which led to an

increase in cervical lordosis of levels treated in 100% of cases.

Conclusions: This technique allows to obtain stable arthrodesia,

while maintaining the advantages of cage or plate (restoring the

height of the interbody space and physiologic lordosis), has reduced

the complications related primarily to the mobilization of the implant.

Given that the final aim is segmental arthrodesis, the long-term status

of the adjacent mobile segments must be assessed.

Eur Spine J (2009) 18:727–780 769

123

27

OUTCOME ASSESSMENT IN SCOLIOTIC

PATIENTS OPERATED ON VERTEBRAL

ARTHRODESIS

A. Accardo*, C. Latte*, G. Parente*, C. Gioia*, A. Toro**,S. Gatto***

*Medico in formazione specialistica Clinica Ortopedica S. U. N.Napoli; ** Direttore U. O. C. Ortopedia e Traumatologia ‘‘G.Fucito’’ Mercato San Severino (Sa); ***Professore e Direttore U.O. C. di Chirurgia riabilitativa del traumatizzato S. U. N. Napoli,Italy

Introduction: The follow-up of scoliotic patients operated on ver-

tebral arthrodesis shows excellent clinical and imaging results.

Nowadays there are few publications about life quality out come after

surgery. The aim of this work is to estimate trought a specific eval-

uation scale named SRS-22 the surgical correction on the life quality

in patients suffered by idiopathic scoliosis.

Materials and Methods: We checked 23 patients with idiopathic

scoliosis (7 males, 16 females) operated on vertebral arthrodesis.

Patients have been subdivided: 21 with idiopathic scoliosis; 1 case

with secondary scoliosis based on neurological disorders; 1 of

congenital kyphoscoliosis based on hemivertebra. The mean age is

16,9 years (range 14 - 25). The mean follow-up time after surgery

is 3,4 years (range 1 - 8). Every patients had SRS-22 which

includes five subjects (function/physical activties,pain, aspect,self-

esteem, mental health, treatment satisfaction),inside of these

subjects there are 5 items;the answers for each item goes from 1 to

5, the scale foresees points for every subjects,a satisfying result

will be more than 3

Results: In these three subjects function/physical activity, pain and

mental health, most of patients had a score more [ 3 while about

aspect/selfsteem and therapy satisfaction the 25% of them had a mean

score \ 3.

Discussion and Conclusions: We consider necessary to carry out an

outcome assessment about the life quality before and after surgical

treatment in order to estimate a right evaluation of scoliotic patients

operated on vertebral arthrodesis.

28

LUMBAR INTERSOMATIC ARTHRODESIS

WITH ‘‘B-TWIN’’ EXPANDIBLE CAGES

N. Ronchini, T. Godowicz, F. Kalfas, T. Capuzzo, P. Severi

Department of Neurosurgery, Galliera Hospitals, Genova, Italy

Lumbar intersomatic arthrodesis with ‘‘B-Twin’’ expandible cages is

an effective and simple surgical technique for symptomatic vertebral

instability.

This technique is particularly suggested in cases of degenerative

dynamic unstable I grade vertebral spondylolisthesis (with or without

the presence of spinal stenosis), and in cases of degenerative inter-

somatic vertebral instability (radiologic evidence of dynamic

disalignment of vertebral somatic plates, also without the presence of

spondylolisthesis), with the presence of symptomatic discal pathology

and/ or spinal stenosis.

In the last five years (2003-2007) we surgically treated with in-

tersomatic ‘‘B-Twin’’ expandible cages 40 patients (mean age:

63 years old, with a range of 39-82 years old).

Of these patients, 36 presented a I grade dynamic unstable

spondylolisthesis (associated to spinal stenosis in 27 cases, without

spinal stenosis in 9 cases), 4 presented degenerative intersomatic

vertebral instability without spondylolisthesis, but associated to

symptomatic herniated disk (3 cases) and to symptomatic spinal

stenosis (1 case).

‘‘B-Twin’’ cages were positioned in L4-L5 discal space in 32

cases, in L3-L4 in 11 cases, in L5-S1 in 1 case; in 4 patients we

positioned B-Twin in two different discal levels (L3-L4 and L4-L5).

We observed (mean follow-up = 18 months) a symptomatic

improvement in 90% of these patients.

In one case we found the mobilization of one cage.

In our opinion lumbar intersomatic arthrodesis with ‘‘ B-Twin’’

expandible cages is the surgical technique of choice in symptomatic I

grade spondylolisthesis, particularly when is also necessary to per-

form a discectomy for the presence of an herniated disk or when is

simultaneously necessary to perform a mono/bilateral laminectomy

for the presence of a spinal stenosis.

To achieve a correct positioning of ‘‘B-Twin’’ expandible cages is

mandatory the intraoperative Rx-scopy.

29

KYPHOPLASTY: DISTANT EFFECTS

A. Nicoletti, N. Giuffrida

U.O.C. Ortopedia e traumatologia P.O. Bronte - Azienda USL 3Catania, Italy

Percutaneous kyphoplasty is a procedure used for the treatment of

osteoporotic vertebral compression fractures. It is an injection of a

radiopaque bone cement into a cavity created in the vertebral body by

a balloon introduced through percutaneous way.

Compared with the vertebroplasty, kyphoplasty allows a restora-

tion of the vertebral body height and a reduction of kyphosis.

Moreover, applying this procedure, the risk of a venous embolization

caused by cements is lower, since cement is injected into a preformed

cavity.

The percutaneous kyphoplasty has reached a broad consensus,

particularly in USA where about 18.000 surgeries been performed in

2002.

Objective: To evaluate the effectiveness of the kyphoplasty on the

improvement of the quality of life in patients affected by osteoporotic

vertebral compression fractures.

Materials and Methods: Since November 2003, 46 patients (30

women and 16 men) have been treated. In 8 cases the surgery has

been implemented contemporaneously on 2 vertebral body. The other

cases have been operated at a single level.

About half of the treated fractures were at the lumbosacral level (D12

and L1). We have assessed the pain (VAS), the degree of kyphosis

(%), the quality of life (Owestry Disability Index), the vertebral

height restoration and the return to daily life.

All patients have been treated with the medical therapy for oste-

oporosis with bisphosphonates, PTH, or strontium ranelatic associated

with calcium and vitamin D.

Results: After the surgery, all patients have shown a remission of

pain and a rapid return to the everyday activities with a good quality

of life.

The three-year follow-up shows the maintenance of the vertebral

body height in the 70% of cases with low segmental kyphosis. In the

other cases, we have noticed a deformity of the operated vertebral

body (further crushing) or more osteoporotic fractures at the adjacent

levels.

770 Eur Spine J (2009) 18:727–780

123

Conclusions: The kyphoplasty perfomed in patients with vertebral

compression fractures reduces the pain, improves the static spine,

through a restoration of the vertebral body height, and improves the

quality of life.

It is a quick method of easy implementation. We currently perform it

in local anesthesia with mild sedation.

It offers the possibility to restore, at least in part, the alignment of

the spine if it is performed by the end of the first 2-3 months after the

fractures.

30

THE TREATMENT OF OSTEOPOROTIC VCFs

WITH BALLOON KYPHOPLASTY (BK): OUR

EXPERIENCE

A. Piazzolla, S. De Giorgi, M. W. C. Damato, G. De Giorgi

Azienda Ospedaliero Universitaria ‘‘Policlinico’’ - Bari –Dipartimento di metodologia Clinica e Tecnologie Medico-Chirurgiche, I Clinica Ortopedica, Italy.Direttore: Prof. G. De Giorgi

Background: The International Osteoporosis Foundation declares

one woman each three and one man each eight aged 50 and above are

affected with osteoporosis with an high risk of vertebral compression

fractures of spine (VCFs) after minimal or no trauma. Traditionally,

VCFs caused by osteoporosis have been treated with bed rest, narcotic

analgesics, brace, and physical therapy. In the time new possibilities

of treatment are enveloped: Vertebroplasty and Kyphoplasty. Ver-

tebroplasty is a medical procedure where bone cement is

percutaneously injected into the body vertebra in order to stabilize it

and fill the defect: polimethylmethacrylate (PMMA) cement is used.

Kyphoplasty involves the use of a device called a ballon tamp to

restore the height and shape of the vertebral body; this is followed by

application of bone cement (PMMA) to strengthen the vertebra. The

technique kyphoplasty can be performed within 60 days from the

fracture. A known complication of these minimally invasive proce-

dures is cement extravasation with lower risk in the kyphoplasty than

in vertebroplasty. Worldwide, over 95,000 VCFs in 75,000 patients

have been treated with balloon kyphoplasty. Results with the tech-

nique have been reported in prospective and retrospective studies in

patient with osteoporotic VCFs and in patients with fractures sec-

ondary to multiple myeloma.

Object: Aim of this study is to confirm the safety effectiveness of

balloon kyphoplasty (BK) in the treatment of VCF.

Patients and Methods: Between September 2001 and September

2008, 63 transpedicular BK in 61 patients with VCFs are performed

by our institute. The site of fractures was T12 (10), L1 (31), L2 (15)

and L3 (7). The mean time from the trauma was 6 days (min 2 max

15). The bilateral approach was done in 61 cases. The unilateral was

instead indicated in two cases with monolateral vertebral body

compression fracture. In 2 patients we treated double (2 levels) VCF.

The men age was 67,7 y.o. (min 62-max 89). Preoperative AP and

lateral X- Rays, MRI (T1-T2-STIR sequences) and CT scans of the

fractured vertebral body were always performed in all patients and

read always by the first author. In all patients, on lateral X-Rays scan,

we have measured the central and anterior vertebral body height,

valued as the ratio compared to posterior vertebral body height (Index

AH/PH=anterior vertebral body height/posterior vertebral body

height; index MH/PH=middle vertebral body height/posterior verte-

bral body height). We have also valued the Vertebral kyphosis (VK)

and the Regional kyphosis (RK). Vertebral kyphosis was measured

from the superior endplate to the inferior endplate of the fractured

vertebra. Regional kyphosis was measured from the inferior endplate

of the intact adjacent-distal vertebra to the superior endplate of intact

adjacent-proximal vertebra. Post-operative and 2-4-6-12 months-after

surgery Cobb angle, central and anterior height of the fractured ver-

tebral body, vertebral kyphosis (VK) and regional kyphosis (RK)

were assessed with radiographs and CT study, read always by the first

author. Also pain intensity was evaluated with a visual analogical

scale (VAS) preoperative, postoperative and 2-4-6-12 months-after

surgery.

Results: In our study, mean Vertebral kyphosis was 18,8 degrees

preoperatively (min 0-max 24), 7,34 degrees postoperatively (min 1-

max 22) and the same postoperatory degrees at the 2-4-6-12 months

follow-up. At the same time the mean Regional kyphosis angles were

respectively 12,84 (min 0-max 44), 10,65 (min 1-max 45) and the

same postoperatory degrees. The mean middle height ratio (MH/PH)

was 0,58 (min 0,24-max 0,82) preoperatively, 0,69 (min 0,52-max 1)

postoperatively and 0,67 (min 0,53-max 1) at the 12 months follow-

up. The mean anterior height ratio (AH/PH) was 0,77 (min 0,25-max

1) preoperatively, 0,85 (min 0,43-max 1) postoperatively and 0,84

(min 0,56-max 1) at 12 months follow-up. The average VAS (visual

analogical scale) score decreased from 8 (+/- 2) preoperatively, to 2

(+/- 1) one day after surgical procedure, to 0 (+/- 1) at 12 months

follow up.

Conclusions: In conclusion our results confirm the balloon kyp-

hoplasty improved multiple measurements of quality of life, back pain

and disability that last at least one year after the procedure.

31

IMPLANTS REMOVAL IN SPINE SURGERY:

FROM CAUSES TO CONSEQUENCES

S. De Giorgi, A. Piazzolla, A. Luca, G. De Giorgi

Dipartimento Di Metodologia Clinica E Tecnologie Medico-Chirurgiche - U.O. Ortopedia E Traumatologia I, Policlinico Bari.Chief: Prof. Giuseppe De Giorgi

Introduction: Metal implants removal in spine surgery is not usual, it

is performed in failures and complications and in fractures according

to the surgical programme.

Instrumentation removal can be definitive or temporary as the first

step of following surgeries.

This kind of removal can be intraoperative (neurological compli-

cation, revision surgery, etc.) or postoperative. The last one is early if

it is performed before the ripening of fusion or late.

Aim of the Study: Aim of our study was to evaluate the most

common causes of implants removal in our experience, the conse-

quences of the removal and the strategies we used to solve the most

complex cases.

Materials and Methods: The implants we removed were four Har-

rington, one Dove instrumentation, fifteen CD and similars

instrumentations.

There were three males and seventeen females, age at surgery

between 14 and 72 years old.

The most common diseases were adolescent idiopathic scoliosis

(4), and adult idiopathic scoliosis (5), congenital deformities (1),

postinfectious ones (2), secondary scoliosis (1), segmental instabili-

ties (1), tumours (1), spondylolysthesis (2), fractures (3).

Etiological causes were infections, implants breakage, cranial or

caudal hooks dislodgement, pseudoarthrosis, screws pull-out, wrong

choice of the fusion area, wrong strategy of instrumentation, pain

persistence without an apparent cause, early or late neurological

complications. In many subjects more causes were found.

Eur Spine J (2009) 18:727–780 771

123

In many cases implants were removed only to be implanted again

in the same surgery or in a second time, after a good radiological

study (CAT, MRI). This occurred to better correct the deformity, to

extend fusion, to repair the pseudoarthrosis, to solve neurological

complications, while it was not effective in solving pain without

infections and pseudoarthrosis.

We observed in two subjects operated by adding collagenous

matrix as bone substitutes, an increasing of curve values in the fol-

lowing months after surgery, in spite of the implant removal after

more then two years from fusion, even in the absence of

pseudoarthrosis.

Conclusions: Our analysis shows that:

1. Normally, current implants are not removed, because they

perfectly integrate in the fusion and guarantee a good arthrodesis

evolution when it is performed without bone substitutes.

2. Implant removal and its reapplication to ameliorate the fusion

area and/ or to recover the compromised stability is the base for a

good result.

3. Pain disappearance is not always guaranteed by the implant

removal.

4. Definitive removal has to be realized in case of infection, but only

when fusion is recognized as mature, that is at nearly two years

after surgery.

5. In multisegmentary fusion realized in major surgery (scoliosis)

and performed by adding bone substitutes (collagenous matrix),

late metal implant removal equally exposes to the curve

worsening. In our opinion it occurs for a slow and late mass

fusion ripening.

32

ALGODISTROPHY OF THE SPINE: DIAGNOSIS,

PATHOGENESIS AND TREATMENT

A. Ramieri*, G. Costanzo*, V. Barci*, V. Petrozza*,C. della Rocca*

*Orthopaedics, The Don Gnocchi Foundation and RomeUniversity ‘‘La Sapienza’’ Polo Pontino; **Experimental Medicineand Pathology, Rome University ‘‘La Sapienza’’ Polo Pontino,Italy

Even without fractures, an osteoporotic vertebral body may develop

some structural modifications with dystrophic aspects, defined by the

literature as ‘‘intravertebral clefts’’ and ‘‘intravertebral vacuum’’.

Such phenomena can be painful and the MRI is the imaging technique

of choice for their evaluation. This is one of the forms of ‘‘Kummel-

Verneuil syndrome’’, a clinical entity which has been unjustly

neglected for 30 years, characterized by ischemic necrosis of the

vertebral body. The positive diagnosis is based on specific criteria but

one must always rule out spinal affections of inflammatory, infectious

and neoplastic nature. Recently, histological features of these lesions

are represented by blood accumulation with progressive trabecular

resorption. We observed and perspectively treated by biopsy and

vertebral percutaneous augmentation 16 algodistrophyc lesions of the

thoraco-lumbar spine (MRI hyperintensity = 7; vacuum = 9). Histo-

logic aspects during hyperintesity without vertebral body deformity

were neoangiogenesis, inflammation and blood gaps. During vacuum,

trabecular resorption prevailed. Vertebral augmentation achieved

good results on VAS and Oswestry score.

We assume that have identified three stages of the same disease.

During the first stage, the vertebral body is not deformed and it

appears with signal hyperintensity on MRI. The second stage is

characterized by intravertebral vacuum with initial vertebral body

deformity and ‘‘impending collapse’’ condition. Kummel’s disease

with complete vertebral body collapse due to osteonecrosis represents

the third stage. In our hand, vertebral percutaneous augmentation

seems to avoid the final vertebral collapse blocking these histological

and biomechanical cascades.

33

PHYSICAL-MATHEMATICAL MODELS

OF LUMBAR SPINE SEGMENTS SUBJECTED

TO TORSION

G. De Nunzio1, L. Tarricone2

1Materials Science Dept. – University of Salento – Lecce, Italy;2DOCstudio srl – Lecce, Italy

Introduction: Qualitative and quantitative understanding of stress

distribution in an intervertebral disc (IVD) is fundamental in order to

estimate the solicitations to which the disc is subjected. This infor-

mation is useful, in case of disc degeneration pathology, both in the

diagnostic phase and at therapeutic level.

This work deals with physical-mathematical models of a lumber spine

segment composed of two vertebrae (L5 and S1) and a IVD, and then

extends the model to a larger spine segment (from L4 to S1).

The purpose of our research is the analysis of tangential stress in

discs subjected to torsion because of the rotation of one or more adjacent

vertebrae.

Materials and Methods: In the first case study (L5/IVD/S1 system)

the inferior vertebra is fixed, while the superior one can axially rotate

around its equilibrium position. An intervertebral disc is situated

between the vertebrae, with its faces rigidly connected to L5 and S1.

In this model, L5 acts by transmitting the axial rotation movement to

the disc, while S1 exercises a constraint reaction on the disc, pre-

venting it from spinning, and subjecting it to torsion. This causes in

the disc a distribution of cross-sectional stress, whose strength varies

point by point and depends on L5 rotation angle and on the elasticity

parameters of the IVD fibers.

Our work delves into various simulation models, starting from an

elementary disc scheme like a hollow cylindrical structure with cir-

cular or elliptic section, of solid, elastic, approximately homogenous

material (the fibrous ring or annulus fibrosus) containing the nucleus

pulposus. This model has the advantage of being intuitive and

didactically effective, and shows how a rotation movement of L5

vertebra necessarily transmits torsional motion to the disc below,

which is thus subjected to tangential forces.

For a deeper description of the disc mechanics, it is however nec-

essary to resort to numerical simulations with finite element techniques.

These experiments are currently in progress at our Research Group,

both on the L5-IVD-S1 segment, and on a larger lumbar-spine segment

starting from L4, with the aim of putting in evidence the phenomena

happening in the system, and the distribution of disc stresses.

Preliminary Results and Conclusions: Being elementary models

approximated, surface stress values deduced from them are overes-

timated, if compared to experimental measurements in the literature.

The intervertebral-disc shape and its inner structure (an aggregate of

inhomogeneously distributed collagen fibrils) allow the absorption of

torque, and therefore of cross-sectional tensions on the annulus fibers,

more effectively than circular sections, though tangential stress is

however high and causes usury. More elaborated models show better

correspondence with experimental measures.

In particular, we are studying the distribution of stress in a lumbar

spine segment containing a degenerative disc, in order to understand

772 Eur Spine J (2009) 18:727–780

123

how the stress, than the degenerative disc cannot absorb any more, is

transferred to the nearby (superior) spine segments.

34

PERCUDYN: A NEW DEVICE FOR

PERCUTANEOUS TREATMENT OF LUMBAR

DEGENERATIVE DISC DISEASE (DDD)

M. Balsano, C. Doria*, A. Villaminar, M. Comisso

UO Ortopedia e Traumatologia – Centro Regionale diRiferimento per la Chirurgia Vertebrale - Schio, Vicenza, Italy;* Clinica Ortopedica Universita di Sassari, Italy

Objectives: To report the benefits of outpatient treatment for lumbar

DDD at 1-2 levels with a novel percutaneous facet augmentation device.

Methods: This is a prospective, non-randomized study to investi-

gate safety and efficacy of a new percutaneous device, PercuDyn, for

patients presenting mild/moderate DDD and concordant X-ray/MRI

who have failed conservative treatment for at least 6 months. The

mechanism of pain relief is by preserving disc height. Using percuta-

neous over-the-wire techniques and a 15 mm incision, the Teleport

dilator establishes a posterior working port at the base of the inferior

facet. Each device has a titanium Anchor and a PCU/titanium Stabilizer

that are serially introduced and mechanically connected in vivo via a

secure locking mechanism. Once the Anchor is driven through the pars

into the pedicle, the Stabilizer is ratcheted over the serrated shaft and

wedged between the inferior facet and the pars/lamina. One size

accommodates all patients with working lengths of 28-35 mm. Devices

are placed bilaterally at each treatment level. No additional rods or

connecting hardware are required. The procedure is reversible with

minimal anatomic impact on the spine.

Results: A clinical series of 34 patients with 96 implants have been

included in the study. We reported short operative times, discharge

from hospital within 4 to 24 hours, no significant complications and

marked improvement in ODI and VAS scores that were sustained at

6-18 month follow-up. Our initial series of outpatients were had

conscious sedation and did not require an airway intubation. 5-10 cc

of local anesthetic with epinephrine was administered.All patients

received intra-procedural antibiotics. Marked improvement in ODI

and VAS scores were noted on early follow-up.

Conclusions: Lumbar back pain and functional disability, measured by

VAS and ODI, can be successfully treated in ambulatory patients using

percutaneous techniques. Patients benefit from short procedure and

recovery times, and require fewer medications. Complication rates are

low.

35

THE ROLE OF SURGERY IN THE TREATMENT

OF VERTEBRAL METASTASIS

F. Tancioni, P. Navarria1, M. Lorenzetti, P. Pisano, P. Gaetani,A. Di Ieva, D. Levi, E. Aimar, S. Serra, A. Santoro2,M. Scorsetti1, R. Rodriguez y Baena

Department of Neurosurgery, 1Department of Radiotherapy,2Department of Oncology and Haematology, IRCCS IstitutoClinico Humanitas, Rozzano (Milano), Italy

Introduction: Increasingly effective oncology protocols have, on one

hand, raised average survival rate in patients with solid tumors, on the

other hand raised cases with secondary vertebral localizations. The

misconception by which a patient with secondary lesions of the

vertebral column is to be considered terminal rather than a candidate

for surgery, leads to grant and often dramatic developments which

could be avoided or at least better managed if planned ahead rather

than treated in emergency. Whereas we agree on the diagnostic-

therapeutic approach for primitive vertebral tumors, we can’t rely on

a common guidance universally accepted for the treatment of sec-

ondary lesions of the spine. 2.5% to 5% of patients affected by

malignant tumor, develop a compression of the spinal cord within the

last two years of life. Surgical techniques have evolved from simple

laminectomy, already practiced at the beginning of the century, to

modern decompression techniques such as stabilization, somatectomy

and vertebrectomy which are carried out through anterior, posterior

and combined anterolateral approaches. At present we do not have a

reference scale or classification applicable in clinical practice, only

clinical and instrumental references for the choice of the more

appropriate therapy.

Materials and Methods: In our study carried out at Istituto Clinico

Humanitas from 2004 to 2007 we reviewed 89 patients treated for

spinal cord compression affected by vertebral metastasis, for a total

number of 98 vertebral surgical procedures performed. 76 of them

have also undergone radiotherapy in the periooperative period. All 89

patients followed a multidisciplinary therapeutic course with onco-

logical, radiotherapeutic and neurosurgical approaches. The

considered characteristics were: ASA, KPS, spread of systemic dis-

ease (osseous and visceral), age, radiological and clinical evidence of

vertebra-compressive metastasis. Great importance was given to

clinical aspects (VAS and Frankel scale) and to the disease localized

evolution, obtaining further results from cross survival evaluations

between istotype and type of surgery.

Results: Global survival has resulted in 43.5% in a 12 months peri-

od; pain remission in almost every patient for an average remission

period of 12 months; neurologic recovery in 30/36 patients with

deficit before treatment. Local relapse disease was inferior to 11%,

with an average time to progression period of 7 months. We had

complications on 5 cases. Among 61 deaths on the follow up, 85%

were caused by primitive tumor disease.

Conclusions: Surgery has a substantially palliative significance in the

global process of treatment in patients affected by vertebral metas-

tasis. A multidisciplinary evaluation is vital to a correct patient

selection and to concretely carry out a therapeutic timing which takes

into account course and modalities of the natural evolution of the

compressive vertebral metastatic pathology. According to the study,

we conclude that a particular attention to the indications and thus to

the choice of the more appropriate surgical procedure/technique

results in a significant improvement in local control. If this element

may have an indirect effect on survival remains to be demonstrated. It

is still necessary to apply more comprehensive and universally

approved guidelines in order to obtain an advantageous homogeneity

in the treatment of vertebral metastasis.

36

TECHNOLOGICAL INNOVATION AND

PERCUTANEOUS VERTEBROPLASTY

F. Tancioni, P. Pisano, P. Gaetani, D. Levi, E. Aimar, A. Di Ieva,M. Lorenzetti, R. Rodriguez Y Baena

Department of Neurosurgery. Istituto Clinico Humanitas,Rozzano (MI), Italy

The vertebral fracture is the most common complication of the

ostheoporotic disease; in a significant percentage pain is

Eur Spine J (2009) 18:727–780 773

123

invalidating in spite of the forced rest, the use of orthesis devices

or bed setting which are, moreover cause of cardiorespiratory

complications. The evidence of a vertebral fracture is common in

tumoral pathology both in benign and malignant tumours) such as

a conseguence of direct or indirect traumas or in degenerative

diseases (i.e. Metabolic disorders) From years the different repair

techniques (vertebroplasty and cifoplasty) had permitted a quick

regression of pain and a fast functional recovery, becoming com-

monly used procedures in those centers equipped for vertebral-

fractured patients management.

However these procedures aren’t risk free: cement lickage from

the vertebral body, asymptomatic in most cases, may beco me a real

problem for the related clinical consequences. Since one year we have

been using a new device (Viscosafe Viscometer – Synthes) actually

available, that measures the real resin viscosity avoiding the viscosity

evaluation to be dependant upon the operator’s experience. This

because the the correct viscosity of the resin, that may be altered by

different variables such as temperature in particular, is very important

in the final result (distribution within the vertebral body, leackage

etc.) In our 40 patient-treated experience the percentage of resin

leackage, even if asymptomatic, fell from 40% to less than 20 %. This

percentage is even lower than those reported in the international lit-

erature. It’s to note that the high viscosity resin does not only reduce

the leackage from the vertebral body but also improves the distribu-

tion inside of it creating a radial distribution from the tip of the

injecting needle, thus avoiding further failures of the vertebral body

treatment. Last, but not least, the dedicated needles are fenestrated on

their side to permit a better control and the guidance of the distri-

bution of the cement limiting the necessity of a bipedicular approach

to the vertebral body.

37

TREATMENT OF THORACIC AND LUMBAR

FRACTURE WITH VERTEBRAL AUGMENTATION

BY BONE GRAFT

M. Girardo, A. Bruno, L. Caruso, M. Muratore, P. Viglierchio,S. Aleotti

Department of Spine Surgery; C.T.O., Torino, Italy

Introduction: Percutaneous vertebral augmentation (BVA) is an

emerging technology for the management of osteoporotic, traumatic

and neoplastic vertebral compression fractures (VCF). The reco-

struction with intravertebral polyethylene mesh sac (Optimesh) and

morcelized bone graft provided a minimally invasive efficacious and

controlled delivery mechanism to stabilize the fractures and treat the

pain.

Aim of the study was evaluate the evolution of single level frac-

ture after augmentation in non osteoporotic patients.

Material and Methods: 18 patients consecutive (11 men, 7 women),

with average of 38 +/- 14 years, underwent one level percutaneous

kyphoplasty for treatment of vertebral fracture at the thoraco-lumbar

spine. We managed fractures type A and B (Magherl’s classification).

All patients were radiologically examinated with X-Ray (2 P),

Computer Tomography (CT), and MR imaging. Follow –up was

carried out at the 1 month, 3 months, 6 months and at one year fol-

lowing treatment. We recorded and analysed the sagittal balance, the

vertebral body height, the kyphotic angle and the evidence of osseous

union of the bone graft. Pain assessment was carried out using a

patient-administered questionnaire as well as VAS scores determined

during the patient visits.

Results: Kyphoplasty was performed between T12 and L5. A total of

18 vertebral bodies were augmented. All patients was treated in one

time. All patients received immediate improvement in their pain. The

mean VAS reduction was 6. There were no cases of adjacent seg-

mental fracture seen on CT. At the last follow-up (one year), there

was demonstration, by CT, of bone remodelling and persistence of the

construct with the mesh and its contents still discernible and no

resorption of graft surrounding bone. There was no radiologic evi-

dence of hardware failure or subsequent re-kyphosis by CT and X-

Ray imaging. There was no new development of kyphosis deformity,

or loss of 5 degree. There were no complications.

Conclusion: The kyphoplasty with biological vertebral augmentation

in the treatment of compression fracture is a safe and efficacious

method to provide pain and increase function. There has been no

evidence of promotion of adjacent segment fracturing

38

SECOND GENERATION CERVICAL BI-

ARTICULAR DISC PROSTHESIS IN THE

TREATMENT OF CERVICAL DISC HERNIATION

R. Mastrostefano, R. Rispoli, M. Fontana

Neurosurgical Department, Avezzano, Italy

Discectomy, decompression, and interbody fusion are the traditional

surgical treatment of disc disease with neural element compression.

However2, it has been proved that fusion may cause or increase

adjacent level degeneration.

Cervical disc replacement has been considered as alternative

surgical solution to the fusion, for the symptomatic relief of pain by

neural decompression, without the resulting loss of motion associated

with a fusion procedure.

The present study analyses the results of 25 consecutive cases of

single level symptomatic cervical disc herniation, without important

osteophytosis, treated by a second generation cervical bi-articular disc

prosthesis.

All selected patients (15 $, 10 #, age 26-39, average 31), were

submitted to discectomy by anterior cervical approach, with simul-

taneous implant of bi-articular semi-constrained prosthesis Mobi-C�.

All the patients were pre-operatively submitted to cervical MRI and to

standard and dynamic plain x-rays films, to exclude instability. Effi-

cacy was assessed by evaluating pre and post-operative Neck

Disability Index, VAS score, Radiologic Range of Motion, and, at

follow-up, Odom’s criteria.

After the operation, all the patients improved, as confirmed by

VAS and NDI scores. Average follow-up was 20 months (range: 3-

36): primary stability of the implant was excellent at latest follow-up,

and no spontaneous ossification was noticed at operated levels. Ex-

cellents clinical results was observed in 24 cases. Only one case had

post-operative minor complication (transient dysphonia), but had

relief of radicular pain. ROM also improved in 80% of cases. All the

patients came back to their work.

The second generation prosthesis permits the self positioning of

the superior plate versus the inferior plate, through the controlled

mobility of the mobile insert, limits the constraints on the bone/

implant interface (origin of dislocation), and favors the decrease of

the constraints on the posterior facet joints. The self centering of the

mobile insert favors the respect of the instantaneous rotation centers,

and also gives back to the treated intervertebral segment its natural

physiological movement within the respect of the cervical lordosis.

This prosthesis present a surprendent simplicity of insertion (one

774 Eur Spine J (2009) 18:727–780

123

step), which is similar to a cage, in opposite to the first generation

prosthesis.

39

RIGID VS. HYBRID THORACIC AND/OR LUMBAR

STABILIZATION

N. Koumpouros, R. Rispoli

Department of Neurosurgery, ‘‘SS. Filippo e Nicola’’ Hospital,Avezzano, Italy

The indications for thoracic and lumbar dorsal instrumentation are

evolving. The most common current use for thoracolumbar instru-

mentation systems is in the setting of degenerative lumbosacral

instability. The stabilizing effect of dorsal instrumentation allows for

earlier mobilization of patients with traumatic or neoplastic spinal

instability. The role of fusion and instrumentation for the treatment of

dysfunctional motion segments remains somewhat controversial.

However the improvement of materials and implant systems has

permitted the extension of the indications. The introduction of hybrid

systems has ameliorated the biomechanical properties of the instru-

mented spine. The combination of rigid instrumentation with dynamic

or elastic systems may offer response to complex biomechanical

problems. Hybrid stabilizing systems reduce the incidence of adjacent

segment syndrome. Hybrid solutions permit customizing and patient-

tailored solutions. However still remain several controversial aspects

concerning the appropriate use of rigid or hybrid systems for thora-

columbar stabilization.

In the current presentation we present our experience in the use of

either rigid or hybrid stabilizing systems. The latter ones include

different dynamic or elastic solutions. We discuss biomechanical

advantages of different systems and present our results.

Although no benefit regarding neurologic outcome has been

demonstrated, the use of hybrid stabilizing systems has improved the

biomechanical behaviour of the instrumented spine and reduced

adjacent segment incidence in selected cases.

40

HIATROGENIC STENOSIS OF THE FORAMEN

MAGNUM DUE TO FIBROSIS AND ADHESIONS,

WITH CONGENITAL STENOSIS OF C2 IN THE

ACHONDROPLASIA: MULTIDISCIPLINARY

APPROACH AND SURGICAL TREATMENT

F. Guarnera, A. Florio, M. Furnari, M. Giuffrida, G. Ponzo,G. F. Nicoletti

Catania, Italy

Introduction: in the paediatric population with achondroplasia, ste-

nosis and compression at the level of the foramen magnum commonly

occurs and can give rise to lethal neurological complications also due

to a cervico-medullary compression. Stenosis is osteo-fibrous’ type:

reduction of diameter of the foramen magnum coexists and there is

almost always a thickened reactive fibrous tissue band overlooking

the dura mater. The appearance of specific neurological deficits due to

the chronic compression of the cervico-medullary region, the evi-

dence of stenosis to the imaging (compression of the cervico-

medullary region, lack of CSF space at the level of foramen magnum

etc.), represents an indication to the surgical treatment.

Materials and Methods: the AA. report a case of three and half years

old child operated on already at the age of fourth months, at another

neurosurgical center, with C1 laminectomy only, because of frequent

and serious fits of dyspnea and cyanosis. He came to our observation

subsequently to progressive clinical impairment from about

15 months. The indication to a surgical procedure of wide occipito-

cervical decompression has been valued with multidisciplinary

approach (pediatricians, neuroradiologists, paediatric anesthetists,

neurosurgeons). The surgical procedure was performed on with a

bony decompression at the level of occiput and the midline posterior

arch of C1 and C2. The bone removed was limited to approximately

3 cm. in width to avoid the complications of cerebellar sagging or

craniocervical instability. Also the thickened reactive fibrous tissue

band was carefully separated from the underlying dura mater at the

level of the previous laminectomy of C1. The patient in the immediate

post-operative course, was transferred in the department of intensive

care where he was observed carefully for improvement of his pre-

operative neurological symptoms.

Results: the following post-operative course was very good. The follow

up has shown an important improvement of the neurological findings.

Conclusions: the surgical treatment of the cervico-medullary com-

pression according to the data of the literature stays controversial

because of different opinions: the one believes that it deal with a

surgery that doesn’t give up of hazards in terms of mortality and

morbidity and that the stenosis would go toward to a progressive

resolution following the growth of the child owed to a physiological

widened of the foramen magnum, the other favorable to an early

surgical operation with the purpose to prevent irreversible or cata-

strophic neurological damages (‘‘sudden death’’).

The AA. they share such thought as many other Authors. We think

to propose a clinical multidisciplinary assessment with a complete

neuroradiological study at the first year of lifetime. In cases of

important stenosis we propose bony and fibrous decompression

(suboccipital craniectomy with opening of the foramen magnum,

C1 laminectomy and if necessary also C2, removal of the thickened

reactive tissue band), as in the symptomatic patients as in the

patients without symptoms that have alterations of the evoked

potential or cervico-medullary signs of compression on RM. The

C1 laminectomy only in such patients is not ufficient in to deter-

mine a meaningful clinical improvement, also in the time, of thel

patients.

41

PEDUNCOLAR SCREWS INSERTED BY FREE

HAND TECNIQUE IN THE TREATMENT OF 120

SCOLIOSIS CASES

M. Crostelli, O. Mazza, M. Mariani

Children Jesus Pediatric Hospital Palidoro-Roma, Italy

The authors present 120 dorso-lumbar scoliosis cases treated by

posterior instrumented arthrodesis with the use of peduncolar screws

inserted by free hand tecnique, without using navigator or exploring

laminectomy and with limited x-ray aid.

In the cases there are idiopatic scoliosis, neurological scoli-

osis, and scoliosis associated with dismorphic and congenital

diseases.

In 60% of cases the authors used ibrid instrumentation with

lumbar and dorso-lumbar screws, dorsal hooks and laminar wires,

while in 40% of patients they used only dorsal or lumbar screws.

In patients treated by hybrid instrumentation (pedicle

screws + laminar hooks) mean age has been 14 years and 6 months

Eur Spine J (2009) 18:727–780 775

123

(12 years 3 months–20 years 8 months), mean follow up 46 months

(24 months–134 months). Mean Cobb angle value of scoliosis curve

treated by laminar hooks has been 73� before surgery (63�–96�).

Mean curve correction has been 43% (27�–66�). Mean curve value

after surgery in scoliosis treated by laminar hooks has been 37,5�(16�–46�), with 49% bettering.

Mean Cobb angle value of scoliosis curve treated by peduncolar

screws has been 50,2� (30�–65�) before surgery. Mean value after

surgery in scoliosis treated by screws has been 19,2� (15�–30�), with

60% bettering.

In patients treated by all screws instrumentation mean age has

been 14 years and 9 months (12 years 5 months–21 years), with

mean follow up of 30 months (24 months–48 months).

Mean Cobb angle value of scoliosis in these patients has been 79�before surgery (48�–97�); curve correction has been 40%. After sur-

gery mean curve value has been 27� (9�–46�).

There was no case of major complication (infection, neurological

lesion of any type, vascular lesion, or other kind of iatrogen lesion). In

10 patients in standard X-ray examination there was defective posi-

tion of screws, without any complication and without consequence on

arthrodesis and on correction obtained or on patient clinical condition.

There was no necessity of more accurate examination like CAT.In

authors opinion use of peduncolar screws leads to best correction and

balancing of vertebral bodies, with better results after time on man-

taining the correction.

Free hand technique with screws at every level has longer surgical

timing than ibrid constructs, and if x-ray are use during surgery

exposition by patients and phisicians is enhanced. In the personal

experiences of authors this risk is reduced by the terminal check when

the screws are all placed. Blood loss, tissues exposition is slightly

wider, in the personal experiences the mean is about 45.The radiations

absorbed by operators, patient and operatory room personnel are

reduced using the terminal check. Free hand tecnique, even at thoracic

level, is an affordable procedure but, having potential severe com-

plications, should be used only by experienced operators, with

peculiar expertise in vertebral surgery and moreover in vertebral

deformity surgery. Learning curve is very long and execution must be

accurate.

42

TRANSFORAMINAL ENDOSCOPIC DISCECTOMY

S. Scopetta, N. Calabrese, R. De Vizia, U. De Crescenzo,M. Vollaro

Casa di Cura ‘‘GE.P.O.S.’’ Telese Terme (Benevento), Italy

Since 1960, there has been a development in minimally invasive

percutaneous techniques for treating lumbar discal hernias, bearing in

mind, the different ways of operating. In the 70 Kambin e Hijikata

performed the first percutaneous nucleotomy without direct vision

check. The approach of transforaminal description was a great step

forward in disc lumbar surgery. In 1994 Matthews and Kambin in

1996 started treating lumbar hernias with the transforaminal

approach. We have been using Thomas Hoogland technique since

June 2006 but is still not common in Italy.

Materials and Methods: Since June 2006 to October 2008, we have

treated 30 patients, of which 16 male and 14 female, aged 25 to 65

with back pain, and or radiculopathy for the most part the latter. Were

all tested with VAS (back and leg), ODI and MacNab questionnaire.

The radiological diagnosis has been of 20 intraforaminal and 10

postero-lateral. Treated levels: 17 L4-L5; 8 L5-S1; 5 L3-L4.

The uniportal system (Thessis e Max-More) has allowed discal her-

nias to be removed using the transforaminal approach under

simultaneous visual check in surgical manoeuvres.

It is made of a foraminoscope (6,5 mm Ø) light, camera, cannula,

drills, bipolar, forceps and monitor. The patient lies on his side, local

anaesthesia about 10 cc and Remifentanil (Ultiva). Operating time is

60-80 minutes, all patients were discarged a few hours later.

There have been no immediate or tardy complications. Follow-up

1 year: excellente and good in 81,4 % (MacNab).

Conclusions: The transforaminal approach with direct and concurrent

vision, allows the treatment of non contained LDH intraforaminal and

postero-lateral.

Cranially or caudally herniated fragments and those that take up more

than 50 % of spinal canal cannot be reached by this approach.

The limits of this technique,is mainly due to the localization and

dimension of the hernia and sometimes to anatomic problems.

The transforaminal approach has some advantages with other per-

cutaneous techniques, and has also some important characteristics such

as the removal of non contained LDH and the possibility to operate

under direct vision check. This procedure should be taken into con-

sideration whenever possible to standard surgery.

43

ASSOCIATION BETWEEN ABLATION WITH

RADIO-FREQUENCY AND VERTEBROPLASTY

IN VERTEBRAL METASTASES TREATMENT

A. Toro, G. Calabro, G. Iervolino, G. F. Trinchese

Divisione Ortopedia e Traumatologia – Ospedale ‘‘G.Fucito’’ – Mercato S. Severino (SA), Italy

Summary: The contemporary use of these two techniques is reported

only by few studies with similar encouraging results. 14 patients

affected by lumbago or dorsalgy from vertebral metastases, have been

selected from those referring to our center from March 2004 to

October 2006. Patients have also been given a pain evaluation scale

(verbal numerical scale) and an evaluation scale of their quality of life

(SF-36). While the patient was lying on the operating table, face

down, the trocar was placed in the relative vertebral body in a trans-

peduncular way. Once the tip was taken off, some small bone samples

were taken for the bioptic exam and then for the ablation in radio-

frequency; once this phase was over, the bone cement was prepared

and then injected in the vertebral body.

Of the 14 patients treated, all have reported a decrease of the pain

within one week. The average score in the Verbal Numeric Scale

decreased from 9.1±0.6/10 in the pre-operation period to 4.3±0.8/10

in the after operation period, with a statistically significant decrease

(p\0.0001) of the pain perception.

In the same way, it was possible to record a statistically significant

average improvement (p\0.0001) of the SF-36 scores, which went

from an average value of 22.5±0.2 to 59.4±0.6.

Similarly to the results of other works, 100% of the patients

we treated had a drastic decrease of the pain perception in one week.

In literature there are few works on the association of radio

frequencies and vertebroplasty in the treatment of vertebral metasta-

ses, but, as in our study, the results are very encouraging.

776 Eur Spine J (2009) 18:727–780

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44

TREATMENT OF DEGENERATIVE DISC DISEASE

AND INSTABILITY OF THE LUMBAR SPINE BY

MEANS OF LUMBAR INTERBODY FUSION

VIA LATERAL PERCUTANEOUS APPROACH

ASSOCIATED WITH MINIMALLY INVASIVE

PEDICLE-SCREW FIXATION. TECHNICAL NOTE

U. Agrillo, K. Panagiotopoulos, L. Corbino, G. Schettini,F. Puzzilli, M. Giarrusso*

Neurosurgical Division, Sandro Pertini Hospital, Rome, Italy;*Neurosurgical Department, University of Catania, Italy

In recent years minimally invasive techniques for lumbar interbody

fusion and lumbar fixation gained popularity worldwide. Herein, we

present a personal technique for lumbar interbody fusion via a lateral,

true percutaneous unilateral approach, associated with minimally

invasive pedicle-screw fixation for the treatment of degenerative disc

disease and instability of the lumbar spine. We provide a step-by-step

description of the procedure along with preliminary clinical and

radiological outcome, and we discuss indications and limitations of

the procedure. We believe that the present technique may offer a

valuable alternative to other anterior and posterior interbody fusion

procedures in terms of minimal invasiveness, operative duration and

surgical risks.

45

PATHOMORFOLOGY OF THE LIGAMENTA

FLAVA IN LUMBAR SPINAL STENOSIS

E. Ferrari*, S. Faraglia*, R. Postacchini**

*Department of Orthopaedic Surgery, University ‘‘Sapienza’’,Rome, Italy; ** Department of Orthopaedic Surgery, University‘‘Tor Vergata’’, Rome, Italy

Numerous studies have shown that the ligamenta flava play a sig-

nificant role in the compression of the neural structures in patients

with lumbar stenosis. However, it is still unclear whether structural

modifications of these ligaments are present in stenotic patients.

The aim of this study was to analyse the microscopic and ultra-

structural changes of the ligamenta flava in patients undergoing

surgery for lumbar stenosis and to compare them with those in

patients operated for vertebral fractures. The clinical relevance of this

study is related to the use of interspinous spacers in the treatment of

lumbar stenosis.

Materials and Methods: Ligamenta flava obtained from 10 patients

with stenosis of the lumbar spinal canal, aged 46 to 82 years (mean,

64), were studied at histological, histochemical and ultrastructural

level. The control group was represented by ligamenta flava excised

from 6 patients (mean age, 46 years) who underwent surgery for

thoracolumbar fractures.

Results: The ligamenta flava of the control group consisted of

numerous, extremely thick elastic fibres, thin bundles of collagen

fibres and few fibrocytes containing with a scarce amount of cyto-

plasm. Near the attachment of the ligaments to the laminae, the tissue

showed fibrocartilaginous features with cells which had intermediate

features between fibrocytes and condrocytes. In subjects in the control

group aged more than 50 years, the cells were less numerous and

showed poorly developed cytoplasmic organelles.

The ligamenta flava of stenotic patients showed large areas in which

the elastic fibres were few in number and thin, and were separated by

abundant collagen tissue. In some cases, elastic fibres consisting only

of microfibrils were observed. In these areas, the fibrocytes were more

numerous and had the features of actively synthesizing cells.

Degenerated elastic fibres and aggregates of amourphous electron

dense material were occasionally seen in the intercellular matrix

Conclusion: With advancing age, the ligamenta flava undergo grad-

ual fibrotic and chondrometaplasic changes. In stenotic patients, the

decrease in elastic fibres, the increase in size of the fibrotic areas and

those of chondroid metaplasia lead to a considerable decrease in

elasticity of the ligaments. As a result, they become less thinner in

flexion of the spine and protrude more in the spinal canal in the

standing position, and particularly in extension of the spine, due to the

inability to shorten with no thichening as occurs in the presence of a

normal elasticity of the tissue. This holds when the ligament is either

thickened and of normal thickness.

These findings may be of relevant importance to understand the role of

distraction of the spine, and thus of the ligaments, obtained by inter-

spinous spacers, which extend and put in flexion the vertebrae of the

motion segment by increasing the intervertebral distance posteriorly.

46

PROSPECTIVE CLINICAL RESULTS OF 1 LEVEL

CERVICAL ARTHROPLASTY WITH THE

PRESTIGE DEVICE: PRELIMINARY RESULTS

A. P. Fabrizi, M. Galarza, R. Maina

Torino, Italy

Introduction: The rate of symptomatic adjacent cervical level that

may occur after Anterior Cervical Discectomy and Fusion (ACDF) is

up to 30% is concerning. The cervical disc replacement provides an

option for the treatment of radiculopathy and myelopathy degenera-

tive anterior cervical spine, while it may prove to provide an impact

on the development of adjacent segment disease.

Methods: To check the preliminary results about efficacy and safety

of the Prestige cervical replacement.

This is a prospective study of 35 patients with cervical arthroplasty at

a single institution with the Prestige device for 1 disc level. There

were 20 sole implants and 15 associated with other ACDF. Follow-up

is up to 2 years now, and the results are reported in terms of Visual

Analog Scale (VAS) for pain, VAS for patient satisfaction, and

flexion-extension range of motion.

Results: Improvements in neuropathy, pain, and patient satisfaction is

noted in 90% of patients. There is a trend to increased benefit in cases

with multi-level fusion, which correlates to increased preoperative

disability. At the mean 12-month follow-up imaging all patients had

solid bone fusions with device. There was no sign of heterotopic

ossification in any patient and no patient experienced migration of the

cervical replacement. There have been no re-operations for continued

pain. No adjacent segment problems have been detected at final

follow up imaging.

Conclusions: Cervical disc replacement had good clinical results as

measured by preoperative and postoperative VAS. Radiographic study

suggested normal motion at implanted site and restrictive postoperative

management is not required. In our opinion, Prestige cervical disc

replacement is a stable implant in reconstructing cervical spine after

anterior discectomy. This study represents the largest number and longest

follow-up of single level cervical disc replacement in Italy. Final effec-

tiveness will be determined after long-term follow-up studies.

Learning Objectives: Keywords: Anterior Cervical Discectomy and

Fusion (ACDF) cervical disc replacement Prestige

Eur Spine J (2009) 18:727–780 777

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47

INTERSPINOUS PROCESS DECOMPRESSION

WITH THE BACJAC DEVICE FOR LUMBAR

SPINAL STENOSIS: PRELIMINARY CLINICAL

EXPERIENCE

A. Zachos, C. Doria, A. Ruggiu, F. Milia, L Tidu P. Lisai,P. Tranquilli-Leali

Orthopaedic Department – University of Sassari, Italy

Background: The BacJac is a new interspinous process decompres-

sion device designed to distract the posterior elements of a stenotic

lumbar segment and place it in flexion in those patients with neuro-

genic intermittent claudication. Materials and

Methods: We present 8 months follow-up data on the BacJac

patients. The inclusion criteria for the trial were leg, buttock, with

back pain relieved during flexion and claudication (being able to walk

at least 100 meters). The exclusion criteria were fixed motor deficit,

cauda equina syndrome, previous lumbar surgery or spondylolisthesis

greater than grade I at the affected level. From April 2008 to

November 2008 nineteen patients have been included in this study (8

women and 11 men). The average follow-up was 4 months and the

average age was 57 years. Thirteen patients had the BacJac implanted

at either L3-L4, L4-L5 or L5-S1 levels. Five patients had the BacJac

implanted at both L3-4 and L4-5 levels and one at three levels L2-L3,

L3-L4 and L4-L5. Two patients had a grade 1� spondylolisthesis, the

other seventeen single or multi level spinal degenerative stenosis.

Results: The mean preoperative Oswestry score was 47. The mean

postoperative Oswestry score was 16. The mean preoperative VAS

score was 8.7 and the mean postoperative one was 3.8. Our results

have demonstrated a very good success rate in the BacJac interspi-

nous process decompression group at an average of 5 months

postoperatively.

Conclusion: The initial effectiveness data as seen in the significant

improvements on both VAS and ODI have also suggested that the

BacJac could be a viable treatment option for patients with low-back

pain caused by degenerative disc disease and low grade spondylo-

listhesis. Furthermore, the characteristic feature of this device is the

low invasiveness and the possibility of use it in L5-S1 thanks to the

variety of sizes and its simple surgical approach.

48

PERCUTANEOUS AXIAL LUMBOSACRAL

INTERBODY FUSION: PRELIMINARY CLINICAL

AND RADIOLOGICAL RESULTS

A. Zachos, C. Doria, L. Tidu, F. Milia, A. Ruggiu, P. Lisai,P. Tranquilli-Leali

Istituto di Clinica Ortopedica – Universita degli Studi di Sassari,Italy

Background: Anterior access to the L5-S1 disc space for interbody

fusion can be technically challenging, frequently requiring the use of

an approach surgeon for adequate exposure. We reviewed our expe-

rience with a novel minimally invasive technique for L5-S1 interbody

fusion (Trans1) that exploits the pre-sacral space and its relative

dearth of critical structures.

Materials and Methods: 4 patients were included in this analysis.

Average follow-up was 6 months. Back pain was secondary to

lumbar degenerative disc disease (DDD) in 2 cases, failed-back

surgery syndrome in 1 case and lytic spondylolistesis in another 1

case. All patients had radiographic evidence of L5-S1 degenera-

tion and underwent percutaneous fusion with Trans1 cage and

local bone autograft. Trans1 was followed by percutaneous ped-

icle screw-rod fixation in 2 patients; in the remaining 2 patients

facet joint screw fixation devices were implanted. Clinical eval-

uation was performed using a visual analogue scale (VAS) and

Oswestry form.

Results: Mean operative time for the Trans1 procedure was 55

minutes. All patients had radiographic evidence of stable L5-S1

interbody cage placement and fusion at last follow-up. The VAS

scores assessing back pain improved significantly from 7.20 to 2.65.

The mean Oswestry score improved significantly from 58.3% to

31.5%. No device related complications were identified.

Conclusion: The percutaneous paracoccygeal approach to the L5-S1

interspace provides a minimally invasive corridor through which

discectomy and interbody fusion can safely be performed. It can be

used alone or in combination with minimally invasive or traditional

open fusion procedures. It may provide an alternative route of access

to the L5-S1 interspace in those patients who may have unfavourable

anatomy for or contraindication to traditional open anterior approach

to this level.

49

CLINICAL AND RADIOLOGICAL OUTCOME

AFTER TREATMENT OF CERVICAL

DEGENERATIVE DISEASE WITH STAND-ALONE

CAGE: LONG-TERM FOLLOW-UP STUDY OF 116

PATIENTS

P. Quaglietta, S. Aiello, G. Corriero

Azienda Ospedaliera di Cosenza; Dipartimento di Emergenza -U.O. di Neurochirurgia, Italy

Aim Of The Study: anterior cervical discectomy and fusion

(ACDF) with cage is currently the gold standard for surgical

treatment of patients with symptomatic single- or two-level cervical

degenerative disc disease. The purpose of this study was to eval-

uate the long-term results in these patients taking into account of

clinical signs changes and symptomatic disc disease appearances on

adjacent segments.

Methods: From December 2001 to December 2007 one hundred and

sixteen consecutive patients underwent to anterior cervical discec-

tomy and fusion with CBK cage (ACDF) (82 males and 34 females,

average age 49.8 years) for a total of 130 implants. The clinical and

radiological data are based on standard and dynamics X-ray and on

MRI images. The follow-up was conducted with a telephone

questionnaire, ambulatory clinical examination, with the VAS scale

for pain and Oswestry scale for disability. Have also been per-

formed cervical spine static and dynamic X-ray at 1, 3, 6 and

12 months after surgery to assess the spine stability, sagittal

alignment, mobility of the treated segment and any presence of

antero or retrolisthesis. In 20 patients MRI was performed 2 years

after surgery to assess the change of disc space height at operated

level and at adjacent levels, the spondylosis progression, the

improvement of the area of the anterior spinal canal and appearance

of disease in adjacent segments.

778 Eur Spine J (2009) 18:727–780

123

Results: The average follow-up was 3 years. There were no intra-

operative complications and no cage subsidence. All patients were

discharged within 72 hours with a cervical orthosis to be weared for

30 days. Radiographic follow-up showed the cervical spine good

stability without evidence of collapse or cage subsidence. Two

patients showed a slight anterolisthesis on operated level following a

mothorvehicle accident. In any case, the cervical spine showed a

mobility in adjacent segments in the functional tests. The follow-up

MRI showed, in all cases, good decompression in the treated levels. In

sixteen patients (13.8%) MRI showed new diseases in adjacent seg-

ments (osteophithosis, disc disease, spinal stenosis). In four of these

cases (3.4%) new surgery was necessary. In 15% of the patients there

was a clinical worsening. In only one case was observed ossification

of posterior longitudinal ligament. At follow-up we had eighty-five

percent of patients with an excellent or good results according to

Odom’s criteria, while in 15% of cases the results have been poor.

Eighty-two percent of patients have resumed their work. At the final

follow-up the VAS rating was 2.1 and Oswestry average score was

23.1.

Conclusions: The outcome of ACDF has good clinical results during

long-term follow-up. The cervical spine stabilization, which for us

was the most important parameter, has been ensured in all patients.

The incidence of the adjacent-segment disease in our experience is in

line with those published in the literature even if the percentage of

patients who had to undergo to further surgery is lower than the

literature. Indeed we believe that surgery does not cause a variation in

the natural history of degenerative disease of the cervical spine, but at

most result in a stop of symptoms progression.

Of course, our results, also compared with those in the literature,

can not be considered conclusive taking into account that this is a

retrospective study with a small number of patients remotely

controlled with MRI and also relation to the follow-up period still

short.

50

THE PALLIATIVE TREATMENT OF VERTEBRAL

METASTATIC LESIONS: VESSELPLASTY

G. Guizzardi*, D. Fabris Monterumici�

*Neurosurgery, University and City Hospital Careggi, Firenze;�Spine Surgery Department, University Hospital, Padova, Italy

Introduction: The Vesselplasty is relatively new method of the

percutaneous transpedicolar Kyphoplasty, which allows to fill the

cement directly in to a container cutting down the risk of leakage.

Materials and Methods: The Authors present their experiences of

using such a method in metastatic Vertebral Compression Fractures

and general form, myeloma multiple, etc., in cases where the sur-

gical intervention is not indicated and the patients were negative for

the neurological point of view. This method is preferred in many of

these cases where it was very important solution of continuity the

cortical of the vertebrae. 30 patients have been treated with 35

levels.

Results: The result has been really excellent, relatively to pain relieve

and even for the percent of vertebral leakage (4.5%).The truthful of

such a percent is absolutely verified by all the patients, because they

were examined after the surgery by CT. In none of cases the leakage

was clinically significant, and nobody had complications.

Conclusions: In our opinion this method is particularly indicated in

cases where the risk of leakage is high.

51

THE USE OF THE NEOADJUVANT MALIGNANT

TUMOURS OF THE SACRUM

M. A. Rosa, G. Maccauro*, G. Giuca

Section of Orthopaedics - Surgical Specialties Department -Policlinico Universitario ‘‘G. Martino ‘‘- Messina; *Department ofOrthopaedic Science - Orthopaedics and Traumatology -Universita Cattolica Sacro Cuore – Roma, Italy

Introduction: The authors report their experience on 28 cases of

malignant tumors in sacred location which includes 21 primary

tumors (5 Cordomi, 3 Giant Cell Tumors, 2 Ewing’s sarcoma, 1

Condrosarcoma) and 7 secondary locations (3 from Breast k,2 from

Prostate k,1 from Renal k, 1 from Pulmonary k).

Materials and Methods: Malignant lesions observed showed a dif-

ferent clinical disease under the seat (sacrum proximal: region S1-S2,

sacrum distal: region S3, S4, S5), the size and the histological

aggressiveness. Outside of Myelomas in which the act diagnostic

biopsy was followed always and exclusively by chemotherapy anti-

blastic, all other histological type, after closure biopsy, have

undergone surgery that included the use of ‘‘ curettage ‘‘ associated

with the use of liquid nitrogen and in three cases, the use of

methylmethacrylate.

The selective arterial embolization was performed in pre-operative

in order to reduce the vascularization in the three cases of giant cell

tumours and in two cases of Ewing’s sarcoma, since the Cordoma and

Condrosarcoma, poorly vascularised tumours.

Conclusions: With regard to the metastatic embolization was per-

formed in secondary injury of Renal K, in the one Lung k and in two

out of three cases the lesions secondary to Breast K.

The surgical ‘‘en block’’ was not in ‘experience of the authors never

performed for high risk traders and serious neurological deficits as

possible especially in proximal locations. In the authors’ use of liquid

nitrogen has a greater impact of surgical treatment with a subsequent

extension in the range free from disease. This ‘‘disease free intervall’’

is different when tumors are distinguished for local aggressiveness,

although with different biological nature, such as Giant Cell

Tumors, the Cordoma and Condrosarcoma I and II grade, highly

malignant tumors such as secondary locations and the Ewing’s Sar-

coma in which the surgical action is always associated with a

multidisciplinary treatment involving the use of chemotherapy and /

or radiotherapy.

52

OUR EXPERIENCE USING EBPM (PARNAPERIN)

ON VERTEBRAL SURGERY

C. Casamichele, T. C. Russo

Modica (RG), Italy

Since one year, on our orthopaedic department (Ospedale Maggiore

Modica and Ospedale Busacca Scicli), we have done antitrombotic

Prophilaxisis on 20 patients underwent major vertebral surgery with

EBPM (parnaparin) for 30 days.

Aim of our study is to check, using ematochimic Exams and

doppler of lower legs, efficacy of this drugs in order to avoid TVP and

lung embolya.

Eur Spine J (2009) 18:727–780 779

123

We had a control group of 20 patients with the same kind of

surgery and deseases without EBPM.

Material and Methods: 20 patients were treated with parnaparin in

order toh ve tromboembolyc prophilaxisys (10 man – 10 woman)

mean age 40 years using a personal evaluation score involving ematic

coagulation elements, risk factors, associated desease, other terapy

and collaterals effect. We didn’t advise, since today any embolic

complication or lung embolysm.

780 Eur Spine J (2009) 18:727–780

123