Introduction: Treatment of unstable thoracolumbar burst fractures and fracture dislocations of thoracolumbar spine remains ever evolving. In this study we propose to study spinal fixation two levels above and one level below the fracture for the stabilization via posterior approach. Methods: We retro-prospectively reviewed the results of unstable thoracolumbar fractures with incomplete or intact neurology in 34 consecutive cases operated at our institute. Five cases were excluded due to incomplete follow up and remaining 29 patients were included for the study. Regular follow up in post-operative period at 3, 6 and 12 months was conducted. Data analysis was done by SPSS software version 22. Results: There were 16males and 13females. Average age was 36.3±1.4years. Average follow up duration was 14.3months. Average injury to surgery interval was 7.2±7.3days. On analysis via paired t-test, pre-operative kyphotic angle(mean=20.1±8.3ᴼ) improved to immediate post-operative (mean=8.4±5.7ᴼ, p=0.0001). Post-operative kyphotic angle at 12months follow-up showed significant stability (Mean=14.13±5.27ᴼ,p=0.0001). Median average pre-operative neurological compromise was ASIA-C and median average disability was ODI of 61-80%. At the end of 12months follow-up the median average neurological compromise improved to ASIA-D and median average disability improved to ODI of 21-40%. Conclusion: Two-levels above and one-level below hybrid pedicle screw fixation with decompression for the treatment of unstable thoracolumbar fractures with incomplete neurology was successful within the limited time frame we had for follow-up in preserving progressive post-operative kyphosis, preserving one-motion segment, improving the neurological outcome and disability of the patients without any major complications.

Introduction: Bracing is the standard nonoperative treatment for adolescent idiopathic scoliosis (AIS) with curve magnitude of ≥20°±5. The correction rate and flexibility of the curve can guide clinicians to the outcomes of bracing. We established a novel supine correction index for guiding brace treatment.

Methods: A prospective cohort of 207 braced AIS patients according to the SRS criteria were recruited and followed-up until brace weaning. Curve progression at the end of follow-up was used as outcome and defined by ≥5° increase of Cobb angle. The supine correction index (SCI) was defined as the ratio between correction rate and flexibility. ROC curve analysis was performed to assess the optimal thresholds for flexibility, correction rate and SCI in predicting lower risk of progression.

Results: Baseline Cobb angle was similar (p=0.374) between progressed (32.7°±10.7) and stable patients (31.4°±6.1). High supine flexibility (OR=0.947; 95%CI:0.910-0.984; p=0.006) and correction rate (OR=0.926; 95%CI: 0.890-0.964; p<0.001) were significantly predictive of lower incidence of progression. A cut-off of 18.1% for flexibility (sensitivity=0.682, specificity=0.704) and cut-off of 28.8% for correction rate (sensitivity=0.773, specificity=0.691) predicted lower risk of curve progression. SCI greater than 1.21 is significantly predictive of lower risk of progression (OR=0.4; 95% CI: 0.251-0.955; p = 0.036; sensitivity=0.583, specificity=0.591).

Conclusion: High supine flexibility (18.1%) and correction rate (28.8%) predicts lower risk of curve progression. A SCI of 1.21 was found to be predictive of bracing outcomes in patients with AIS. This may serve as a guide for achieving the target correction rate during brace fabrication to optimize brace outcome.

Introduction: The proximal humeral epiphyses can be conveniently viewed in routine spine radiographs, however its use for clinical decision-making remains unknown. This study aimed to investigate whether the timing of brace weaning in adolescent idiopathic scoliosis(AIS) can be determined by the proximal humeral epiphyseal ossification system(PHOS), as assessed by whether curve progressed post-weaning. Methods: A total of 107 patients with AIS who had weaned brace-wear at Risser stage ≥4, no bodily growth and post-menarche ≥2 years between 2014 and 2016 were studied. Any increase in major curve Cobb angle >5° between weaning and final follow-up at 2 years was considered curve progression. Skeletal maturity was assessed using PHOS, Distal radius and ulna classification, Risser and Sanders staging. Curve progression rate per maturity grading was examined. Results: After brace weaning, 12.1% of the patients experienced curve progression. Curve progression rate for weaning at PHOS Stage 5 was 0% for weaning Cobb <40⁰, and 20.0% for ≥40°. No curve progression when weaned at PHOS Stage 4 or 5 together with ≥R10 for curves <40°. Associating factors for curve progression were: Months post-menarche(p=0.021), weaning Cobb angle(p=0.002), curves <40° versus ≥40°(p=0.009), radius(p=0.006) and ulna(p=0.025) grades, Sanders stages(p=0.025), but not PHOS stages(p=0.454). Conclusion: PHOS can be a useful maturity indicator for brace-wear weaning in AIS, with weaning at PHOS Stage 5 having no post-weaning curve progression in curves <40°. However, the use of PHOS alone has limitations. Future investigation should focus on the use of PHOS with other readily visible maturity measures on spine radiographs.

Introduction: FBT would develop among Lenke 5 AIS patients following PSF surgery. The incidence and outcomes were unknown. Methods: 100 Lenke 5 AIS patients undergoing PSF with minimum 2-years follow-up were retrospectively reviewed. FBT was the angle between the longitudinal axis of the fusion block (line connecting the centroid of upper instrumented vertebra [UIV] and the centroid of lowest instrumented vertebra [LIV]) with the vertical axis. The calculated minimal detectable change of FBT was 1.131, therefore, we defined presence of FBT when the measured FBT was 2⁰ or more. Demographic, SRS-22r scores and radiological parameters were analyzed. Results: The incidence of FBT at 2-month postoperatively was 81.0%. At final follow-up, patients with FBT had larger main thoracic (MT) Cobb angle (18.0 ± 8.5⁰ vs. 13.1 ± 5.1⁰, p=0.018); twice larger MT apical vertical translation (MT-AVT) (13.7 ± 9.7 mm vs. 6.9 ± 4.8 mm, p=0.004); and larger disc wedge angle (DWA) (3.7 ± 3.4⁰ vs. 1.8 ± 2.3⁰, p=0.021) when compared to those without FBT. At final follow-up, 22% of patients with FBT developed unacceptable increase in main thoracic curve as compared to none in the non-FBT group. Among patients with FBT, 37.0% of patients had FBT progression of 2⁰ or more at final follow-up. However, there was no significant difference in radiological shoulder parameters. There was no significant difference in preoperative and final follow-up SRS-22r scores between both groups. Conclusion: Lenke 5 AIS patients would develop FBT following PSF surgery and some would progress over time.

Background: Between conventional microdiscectomy and tubular muscle splitting discectomy, later is believed to be less tissue traumatic, less blood loss, less post operative pain and lesser hospital stay. Prospective, randomized study to test this hypothesis was conducted.
Methods: Our study designed is prospective randomised study over at least 2 years of follow up. 63 patients with symptomatic lumbar intervertebral disc prolapse not relieved
by conservative management or those having neurological deficits, were randomly allocated to convention microdiscectomy(32) and tubular discectomy(31). Follow up
measurements were performed at 6 weeks, 3 months, 6 months, 12 months and 2 years. Outcomes were analysed with oswestry disability index (ODI) as primary and visual analogue scale (VAS) for back and leg pain as secondary outcome.
Results: Overall no significant difference was seen between the two procedures in terms of ODI or VAS at any point of time over 2 years of follow up. Mean ODI score at the end of 2 years for conventional microdiscectomy was 3.03+/-3.55 while it was 3.82+/-3.79 for tubular microdiscectomy. The mean± SD VAS-Back pain and VAS-Leg pain in the conventional microdiscectomy group was 0.4 +/- 0.71 and 0.4+/-0.91 respectively compared with 0.61 +/-0.71 and 0.38+/-0.71 respectively in tubular microdiscectomy. Postoperative length of hospital stays (8.22 ± 1.87 days) in the tubular microdiscectomy group were significantly shorter (p<0.001) compared with the conventional microdiscectomy (10.3 ± 2.57 days).
Conclusion: Overall outcome were similar for both conventional microdiscectomy and tubular discectomy despite hospital stay in tubular discectomy was significantly
shorter compared to microdiscectomy.

Introduction:The surgical management of high-grade(Meyerding grade III or more) dysplastic lumbosacral spondylolisthesis(HGDSL) is challenging due to the difficulty in achieving reduction of slip and restoring the global sagittal spinal alignment without causing neurological deficits.The various surgical techniques described in literature have their own benefits and disadvantages.Existing literature is limited by a low level of evidence with regards to the superiority of one technique over another.Methods:We analyzed the clinical, functional, and radiological outcomes of 10 patients(1 male, 9 females) with L5-S1 HGDSL with a balanced pelvis, treated with insitu fusion using L5-S1 transdiscal screw constructs. Results:The mean age at presentation was 36.7+/-9.4(range, 21 to 55) years.All patients presented with instability type back pain with normal neurology with 60% presenting with concomitant radiculopathy.At a mean follow-up was 38.9+/-20.7 months(range, 28 to 96 months), the meanVAS score[pre-op: 8.4+/-1.2(7 to 9) vs post-op: 2.2+/-1.0( 0 to 3) and ODI score [pre-op: 57.9+/-9.6 vs post-op: 14.9+/-3.8] showed significant improvement, p<0.05.CT scan showed evidence of fusion at a mean of 9.3+/- 4.1 months(range, 7 to 12 months), with no evidence of progression in slip percentage or slip angle at the final follow-up.There were no neurologic deficits, implant failure or pseudoarthrosis at final follow-up.There was one case of superficial wound infection which settled with antibiotics.Conclusion:In-situ fusion with posterior lumbosacral transfixation using transdiscal screws is a safe and effective technique, in the treatment of L5-S1 HGDSL with a balanced pelvis in as evidenced by the good clinical, functional and radiologic outcomes at mean follow-up of 38.9+/-20.7 months.

Introduction: The incidence and outcome of shoulder balance comparing AR/Non-AR Lenke 1 and 2 curves had not been widely reported. Methods: 168 AIS patients with Lenke 1 and 2 who underwent PSF surgery between 2013 and 2016 with minimum 2-year follow-up were reviewed. Propensity Score Matching analysis with match tolerance of 0.01 was performed. Predictors that were matched included Lenke curve type, main thoracic (MT) cobb angle, proximal thoracic cobb angle and preoperative T1 tilt. 31 patient pairs were matched. Patient demographics, pre-operative/ post-operative SRS scores and radiological parameters were analysed. The main outcome measures were clavicle angle (Cla-A), cervical axis (CA) and T1 tilt. Results: The mean age was 14.3 ± 2.3 years. There were 41 (66.1%) Lenke 1 curves and 21 (33.9%) Lenke 2 curves (p=0.788). Immediate post-operative and final follow up T1 tilt and MT correction rate was significantly different in patients with AR curves compared to non-AR curves (higher correction rate with more positive T1 tilt). Non-AR curves also had worse post-operative coronal balance compared to patients with AR curves. The number of fusion levels were higher in AR curves(p=0.022). The function domain of the SRS 22r HRQOL was lower among patients with AR curves whereas for the pain domain also demonstrated a tendency of lower scores among patients with AR curves. Conclusion: AIS patients with Lenke 1 and 2 AR curves were at a higher risk of post-operative medial shoulder imbalance. This could be contributed by overcorrection of the MT curve.

Introduction: Neurofibromatosis I (NF-1) is an autosomal dominant neurocutaneous disorder affecting both the axial and appendicular skeletal systems. Scoliosis in NF-1 can either mimic idiopathic scoliosis or have a distinct feature such as sharp curve, severe rotation, or wedging at the apex. In this study, we aim to evaluate the clinical, radiological, and functional outcomes of NF-1 patients with scoliosis who were operated in our institute. Methods: Records of 11 NF-1 patients with scoliosis who were operated in our institute between 2014 and 2019 were evaluated. Functional analysis done included the preoperative and postoperative SRS 22 functional scoring. Radiographically, the different parameters analyzed included preoperative and postoperative assessment of cobb's angle in the coronal and sagittal plane, T1-T12 length, and the T1-S1 lengths. Results: The mean age of patients at definitive procedure was 17.09 years with mean follow-up of 34.3 months. On radiographic evaluation, the mean coronal cobb’s correction of 42.57% ± 12.82(p<0.05) from preoperative cobb’s angle of 82.0 ± 30.2 to postoperative cobb’s angle of 49.2 ± 21.6, and mean sagittal cobb’s correction rate was 47.05% ± 21.69 (p<0.05). The mean preoperative SRS score was 2.43 ± 0.58 and mean postoperative SRS 22 score was 3.56 ± 0.7. There was significant improvement with function after surgery with a p-value less than 0.05. Conclusion: Surgery in NF-1 patients with scoliosis leads to good radiological and functional outcomes. Also, this can lead to arrest of further curve progression and hence should be considered at an early age to obtain good results.

Aim: To observe the altered morphology of multifidus in patients with LDH and to explore the correlation between multifidus fibrosis and TGF-β1 expression. Methods: 92 LDH patients with low back pain combined with unilateral leg radiation pain and/or numbness were selected. Patients were divided into four groups according to their medical histories. Group-1: duration of pain <6-months; group-2: 6–12month; group-3: m12–24 months; and group 4: >24months. Bilateral multifidus specimens were taken from compressed nerve root segments, and morphological changes in multifidus were determined. Multi-parameter changes in TGF-β1 expression in multifidus were observed by immunohistochemistry and immunofluorescence. Results: HE staining showed that the cross-sectional area of multifidus in the involved sides decreased and muscle fibers atrophied. Masson’s trichrome staining showed a decrease in the sectional area ratio of myofibers to collagen fibers in the involved side. In groups-1 and 2 no significant differences in the aforementioned parameters. In groups-3 and 4, statistically significant differences in the sectional area ratio of myofibers to collagen fibers. TGF-β1 expression was significantly enhanced in both muscle cells and the matrix of the involved side, while no expression or a little expression was found in the matrix on the uninvolved side. In group 1, there was no significant difference in TGF-β1 expression on both sides. In the remaining three groups, TGF-β1 expression in the involved sides was higher than were found in the uninvolved sides. Conclusions: Nerve root compression by LDH leads to multifidus atrophy, fibrosis, and increased TGF-β1 expression, which might promote multifidus fibrosis.

Introduction: For growing patients, it is ideal to have a growth plate visible in routine radiographs for skeletal maturity assessment without additional radiation. The proximal femoral epiphyseal ossification (PFMI) is in proximity to the spine; however, whether it can be used for assessing a patient’s growth status remains unknown.

Methods: A prospective study of 220 sets of radiographs of patients with idiopathic scoliosis were assessed for skeletal maturity and reliability testing. Risser staging, Sanders staging, distal radius and ulna (DRU) classification, the proximal humeral ossification system (PHOS), and the novel PFMI were used. The PFMI was newly developed on the basis of the radiographic appearances of the femoral head, greater trochanter, and triradiate cartilage. It consists of 7 grades (0-6) associated with increasing skeletal maturity. The PFMI was evaluated through its relationship with pubertal growth and with established skeletal maturity indices. Longitudinal growth data were assessed to detect peak growth using ROC curve analysis.

Results: The largest growth rate occurred at PFMI 3 (mean growth rates of 0.79±0.44 cm/mo for girls and 1.06±0.67 cm/mo for boys). Growth cessation occurred at PFMI 6 with growth rates of 0.12±0.23 cm/mo (girls) and 0±0 cm/mo (boys). Strong correlations were found with other skeletal maturity indices. Substantial to excellent interrater and intrarater reliabilities were observed. PFMI 3 was most predictive for peak growth based on ROC results.

Conclusion: The PFMI demonstrated clear pubertal growth phases with satisfactory reliability. Grade 3 indicates peak growth and grade 6 indicates growth cessation.

Aims: This study compares the radiological deformity correction of XLIF (Extreme Lateral Lumbar Interbody Fusion) with MIS Transforaminal Lumbar Interbody Fusion
(MIS-TLIF) in symptomatic degenerative conditions - lumbar scoliosis and spondylolisthesis, especially in multilevel surgeries, and correlates to clinical outcome measures.
Methods: We retrospectively analysed a
prospectively collected database of 22 XLIF cases, matched with 22 multilevel MIS-TLIF cases for age, sex, BMI and operated levels. All patients underwent multilevel spinal surgery for symptomatic mild to moderate spondylolisthesis or degenerative scoliotic disease
Both groups were compared by their radiological outcomes. Sagittal lumbar lordosis and segmental Cobb angle, as well as coronal Cobb angle were evaluated pre-operatively, 6 months and 2 years post-operatively.
Additionally, clinical outcome scores (ODI, NSS, SF-36 scores) were collected.
Results: Patients who underwent multilevel XLIF had significant improvement in sagittal segmental cobb angles and decrease in coronal angles.
There was no significant difference in outcome measures between the XLIF and MIS-TLIF group at 2 years despite a lower SF-36 preoperatively in the XLIF group, possibility reflecting the efficacy of XLIF in achieving fusion, foraminal decompression and thus better quality of life in this group of patients.
Conclusion: The study demonstrated the efficacy of XLIF in correcting sagittal and coronal segmental realignment which could contribute to more significant improvement in patient outcomes and functional scores at 2 years compared to MIS-TLIF.