The authors describe major trends and developments of experimental spinal surgery and neurosurgery at the Russian Ilizarov Scientific Center “Restorative Traumatology and Orthopaedics”.

Background Cervical spine injuries (CSI) are considered to be a major trauma with no well-established criteria for the choice of treatment technique. Objective Determine criteria for the choice of surgical technique to address CSI and review current tendencies in stabilization approaches used for CSI. Design Retrospective review and literature survey. Material and methods Retrospective review included 101 CSI cases with 24 craniocervical and 77 subaxial injuries, 48 CSI publications (9 books and guidelines, and 39 articles). The patients were treated with either anterior (ACDF, ACCF) or posterior fixation using screw constructs, or with 360° stabilization. Results Subaxial spine injury accounts for 75 % of all CSI. C2 vertebra injury is the most severe among craniocervical trauma. Posterior C1–C2 fixation with Harms and Magerl techniques remains the method of choice. SLIC and CSISS scoring systems are mostly used to assess subaxial injury. Anterior fixation is common for unstable subaxial injury. Posterior screw fixation has become more common. Conclusion Injuries to the cervical spine at the С2 vertebra fractures are most challenging, and posterior fixation is the method of choice for the operative stabilization. Subaxial injuries require a thorough assessment of posterior supporting complex integrity. Anterior fixation remains the most common method of treatment. Multipillar subaxial injuries require posterior fixation and 360° stabilization in the majority of the cases.

Study Design A descriptive study based on medical records of patients with congenital cervical spine abnormalities. Objective The hypothesis of the study was that patients with congenital cervical spine abnormalities could be divided according to the main pathological syndrome. Summary of Background Data Abnormalities of the cervical spine belong to embryopathies and are a very heterogeneous group. The variety of this pathology made it hard to create a general classification based on a morphological approach. Materials Medical records of 68 patients with congenital cervical spine abnormalities were analyzed and were a clinical material for working out the algorithm of their management. Computer tomography, magnetic resonance imaging (MRI) and selective angiography were used to specify the abnormality structure and preoperative planning. Use of functional positioning was an important feature in all these investigations. Various techniques of surgical treatment such as halo, anterior and posterior fusion, decompression of the cerebral, spinal cord and cervical vertebral arteries, revision of the spinal canal, neurolysis, and meningolysis were used in 28 patients aged from 2 to 47 years old. Results All patients were divided according to leading pathological syndromes. Those were instability, stenosis and brain ischemia. Each group had its own important subgroup. The main surgical steps in management of complex congenital anomalies of the cervical spine were bone fusion or (and) decompression of the brain and spinal cord. Conclusions Selection of the main pathological syndrome or combination of syndromes is a simple and effective way for making the right decision when treating patients with congenital cervical spine abnormalities. Syndromic approach can be used for prognosis as well.

Thematic justification Compression stress fractures of the vertebrae at the upper border with a metal structure are a serious problem, especially in extensive stabilization and in patients with osteoporosis. Nowadays, there is a lack of information on prevention of the fracture of the vertebrae adjacent to the metal structure. Purpose Compare experimentally the efficiency of cemented vertebroplasty and laminar band fixation of the cranial vertebra adjacent to the TPF level for prevention of fractures in osteoporosis. Study design Biomechanical cadaver study. Materials and methods We used the cadaver material obtained from females in the age from 66 to 81 years. The extension of the blocks withdrawn was from Th10 to L4 (7 vertebrae). L1 fracture was simulated in all the blocks by its mechanical destruction. A total of 15 blocks were studied divided into 3 groups of five units each: group 1 – controls (cemented TPF of Th12-L2); group 2 – cemented TPF of Th12-L2 + Th11laminar fixation with the «Universal Clamp»; group 3 – cemented TPF of Th12-L2 and preventive vertebroplasty of Th11 and L3. We used the axial load with a universal servo-hydraulic testing machine «Walter + bay ag» LFV-10-T50 (Switzerland). Compression was carried out until graphic signs of fracture were displayed. We took X-rays of blocks before and after the study. Results The control group revealed the appearance of vertebral fractures just above the metal structure (Th11). The first graphic signs of fracture were detected in the range of 0.78-0.94 kN (mean 0.86 ± 0.13784). The group with laminar fixation using the «Universal Clamp» revealed fractures of Th10 and Th11. The first graphic oscillations corresponding to a fracture were detected in the range of 1.12-1.48 kN (mean 1.21 ± 0.385227). The group with preventive vertebroplasty of Th11 and L3 revealed fractured vertebrae adjacent to the vertebroplasty (Th10). In this case, the first graphic oscillations corresponding to a fracture were detected in the range of 1.78-2.05 kN (mean 1.898 ± 0.222441). Conclusion The overlying vertebra is at increased risk of fracture when transpedicular fixation is used. The use of laminar fixation with the «Universal Clamp» does not prevent vertebral fracture over the pedicle system (Th11) but provides an increase of resistance to the vertebral fracture by 1.5 times. Preventive vertebroplasty of overlying vertebra is an effective way to prevent a pathological fracture (Th11), and also increases the resistance of the overlying (Th10) vertebra to fracture by 2–2.5 times.

Aim To analyze the immediate and long-term results of the surgical treatment of infectious spondylitis in children. Materials and methods A retrospective cohort design was implemented with the following inclusion criteria: 1) age below 18 years, 2) titanium mesh block cage for anterior spondylodesis, and 3) follow up period of 24 months. The mean age was 15.3 ± 2.8 years. The patients were divided into two groups according to diagnosis: active tuberculous spondylitis (n1 = 42) and chronic non-specific spondylitis and its consequences (n2 = 41). Results There were no complications or process aggravation within a period of 6 months after surgery. However, there was one case of mesh cage destabilization when tuberculous spondylitis progressed in the period from 6 to 12 months. The amount of kyphosis correction was 26.5° ± 10.1°. The postoperative deformity increase at 18 months after surgery did not exceed 5°. Bone block was estimated at 3 points in 95 % of cases 6 months after surgery and at 4 or 5 points in 97 % of cases 12 months after surgery. Neurological disorders, based on Frankel evaluation before surgery, were identified in 5 patients (Type D in 3 patients, Type B in 2 ), and complete regression was observed after surgery in 4 cases up to Type Е and 1 case up to Type D. Operative blood loss was M ± m = 207.9 ± 139.1. Conclusion The use of titanium mesh block cages in children with infectious spondylitis is a safe procedure that reduces the number of complications in the immediate and long-term postoperative period as well as maintains the stability of surgical correction of the spine deformity.

Objective of the work was to produce a comprehensive evaluation of the motor system, spine muscles and posture as effected by orthoses. Material and methods 28 children with scoliosis posture (mean age of 10 ± 0.4 years). Bilateral diagnostic transcranial magnet stimulation of m. abductor hallucis was performed for all the patients to assess latency and amplitude of evoked motor potential, voluntary activity of thoracolumbar muscles (m. latissimus dorsi) recorded at three locations with surface electromyography (EMG) evaluating mean amplitude and frequency of turns of interference pattern and posture in coronal and sagittal planes using optical topography assessing deviations of the spinal axis from the central line, kyphosis and lordosis angles. The studies were carried out prior to the usage of ORTO® orthosis and in 1 to 2 days on completion within 2 weeks during 8 hours daily. Results All children of the second series showed shorter latency in segmental MEPs, increased amplitude, increased amplitude of interference curve and low frequency, less deviations of the spinal axis from the central line, lordosis and kyphosis angles. Conclusions Pediatric application of ORTO® thoracic lumbosacral orthosis to improve posture showed no statistically significant decline in functional activity of the spinal muscles during 2 weeks. The usage of the brace resulted in a typical response in all the cases including better motor nerve conduction at periphery, increase in functional motor neuron activity, i.e. enhancement of neuroplasticity.

Background Surgical treatment is essential for patients with tuberculous spondylitis, abscess and compression of the spinal cord. Conservative treatment is practical for patients with tuberculous osteitis uncomplicated with compression of the spinal cord. Objective Make a comparative analysis of surgical treatment produced for pre-spondylitis and post-spondylitis patients with spine tuberculosis. Material and methods Surgical treatment was performed for 17 (28.8 %) patients with tuberculous osteitis and 42 (71.2 %) patients with progressing spondylitis. Debriding resection of tuberculous focus, decompression of the spinal cord, abscess drainage were followed by anterior spine fusion with mesh cages or porous constructs of memory metal nitinol, posterior spondylodesis with self-locking shape memory clamps or transpedicular system. Results Static and dynamic spine function, ability to work were restored in 16 (94.8 %) patients with tuberculous osteitis and 29 (69.1 %) patients with progressing spondylitis. Complications developed in 30.9 % of the patients with progressing spondylitis. Conclusions Application of combined spondylodesis allowed for restoration of static and dynamic function of the spine in 17 cases at 6-month follow-up. Early ambulation of patients with tuberculous osteitis and spondylitis was shown to provide regression of neurological deficit after stabilization of anterior and posterior supporting vertebral column. Surgical treatment combined with chemical therapy at early stages of spine tuberculosis appeared to prevent infection and neurological complications, and considerably reduce rehabilitation period

Introduction There is no unified opinion on the use of drains and their indication in spinal surgery. The main discussion focuses on the issue of infection rate reduction and its prophylaxis. It is believed that drains increase postoperative morbidity: infectious complications, anemia, and indications to blood transfusion. Material and methods One hundred and fifty patients that underwent surgical interventions on the spine from the posterior surgical approach were included into this study. According to surgical invasiveness, patients were divided in groups. Group 1 was 29 persons with lumbar dischernias. Group 2 were 85 patients with degenerative dystrophic diseases and posttraumatic deformities of the lumbar spine in one to three spine motor segments. Group 3 were 37 patients that had multilevel spinal deformities. Drains were not used in group 1 due to low invasiveness of the operation.Patients of groups 2 and 3 were divided into subgroups in which active drains were used or not used. Parameters for analysis were age, weight, duration of surgery, blood loss, length and deepness of wounds, duration of draining, amount of wound discharge, number of wound punctures and punctuate volume, duration of inpatient stay, associated diseases (arterial hypertension, diabetes, obesity and other chronic diseases in the remission stage), presence of infection complications in the postoperative period (superficial or deep), conduction of blood transfusion, neurologic deficits due to epidural hematoma. Method of variation statistics was used: calculation of mean (M) and its error (± m), r-Pierson correlation coefficient according to Chaddock scale; significance of statistical difference was assessed with Student’s t-test. Results and discussion Most studies that assess the efficiency of using drains show no difference in wound healing, infectious complication rates and epidural hematomas in spinal surgery. Different requirements are defined to wound drains according to volume, duration, techniques and instrumentation used in surgery. Discotomies and interventions of decompression stabilization at one to three levels do not require wound drains. Conclusion Treatment results and complication rate do not depend upon surgical wound drains. Draining used in multilevel stabilization operations on the thoracic and lumbar spine with the variants of vertebrotomies increases the frequency of hemotransfusion in the postoperative period and inpatient stay.

Objective Improve outcomes in patients treated for thoracolumbar spine injury based on updated methodological approaches to treatment tactics and analysis of stress-strain state (SSS) produced in a spinal fragment. Develop a technique for combined usage of percutaneous transpedicular spondylodesis and kyphoplasty for operative treatment of compression comminuted thoracolumbar spine injury being committed to minimally invasive technology. Material and methods Finite-element modeling (FEM) was performed to study SSS in an intact spinal motion segment with transpedicular stabilization in case of a traumatic injury to one vertebral body and also with combined application of transpedicular osteosynthesis and vertebroplasty in different loading regimes. Results Combined application of vertebroplasty and transpedicular fixation with metal systems has shown high efficacy with considerably decreased stress in intact vertebrae and decreased stress in the implanted metal construct. Conclusions The findings allowed for a new surgical technique developed by a concept of minimally invasive technology that is illustrated with a successful clinical instance.

Purpose To determine topographic manifestations and mobility criteria in spine deformities Materials and methods Twelve patients aged from 10 to 27 years with clinical and radiographic signs of scoliosis of grades 2 to 3 (according to V.D. Chaklin) were examined using computer optical topography. Inclusion group was patients with high positive results of conservative treatment and with a diagnostic mismatch between the methods of radiography and topography. Results It was established that on the scale of a live examination a topographic monitoring of the postural activity of the patient’s trunk in a standing position up to 3 minutes enables to reveal mobile manifestations of spine deformities in the form of arbitrary and involuntary variation of their angular characteristics in compensated and decompensated types with strengthening or weakening of the pathology signs. By instrumental control, high mobility was manifested by the following types of combinations of X-rays and topograms: 1) radiographic and topographic signs of spinal deformities coincided in location but significantly (more than 4º) differed in severity grade; 2) in the presence of radiographic signs of scoliotic deformity, their topographic analogs in orthostatics were either not detected or were recorded only at the end of a prolonged examination. Conclusion The degree of mobility of spinal deformities in orthostatics and its dynamics can be judged from the range of numerical values of the lateral asymmetry angle (S1_LA), the topographic analogue of the Cobb angle. The smaller is the range of its arbitrary and involuntary postural variations the lower is the mobility of spinal deformities. In a high mobility of spinal deformities, the lateral asymmetry angle varies over a range of values greater than 7°.

Purpose Evaluate the dynamics of the pyramidal pathway functional state in spinal deformity surgical correction in patients with genetically caused systemic skeletal pathology based on the formal criteria of a significance degree of the electrophysiological response to a surgical intervention which were developed at the RISC RTO. Materials and Methods The analyzed sample of patients included two groups for comparison. Group 1 (main group) were 28 patients with spinal deformities due to systemic hereditary diseases. Group 2 (control group) consisted of 126 patients with spinal deformities (51 subjects with idiopathic scoliosis, 71 subjects with deformities of congenital genesis, and 4 subjects of other etiology). All the patients underwent instrumental deformity correction with further fixation of the cervical, thoracic, thoracolumbar spine using different variants of internal transpedicular fixation systems. The changes in motor evoked potentials (MEP) were evaluated as ranks 0 to 7 according to the severity of the response observed. Results All the variants of changes in MEPs were observed both in the main group and in the control one. Five types of steady (reproduced in different patients) rank combinations were identified which conformed to the main types of the patient’s motor system response to spinal deformity surgical correction. Conclusion The use of the technology of MEP recording during surgical correction of spinal deformities in patients with systemic genetically caused skeletal pathology is a highly effective tool of preventing the development of intraoperative neurological complications. The proposed system of formal evaluation of the results of neuromonitoring allowed us to conduct a quantitative comparison of the character of intraoperative changes in the functional state of the pyramidal system in patients of different etiological groups depending on their age and intervention duration.

Purpose The purpose of the work was to study the clinical and neuroradiological features of segmental spinal dysgenesis (SSD), congenital anomaly with local hypogenesis of a spinal motion segment and the spinal cord; as well as the selection of an optimal tactics of treating this anomaly. Methods The authors reviewed the literature and present seven clinical cases of their own practice. Results The severity of clinical deficit correlates with the degree of morphological changes in the spinal cord, the level of dysgenesis, as well as with the presence of combined and concomitant developmental anomalies. Early decompression of neural structures and spine stabilization play an important role in improvement of treatment results but the immature bone structures in infants limit the possibilities of early instrumented fixation. Conclusion SSD is a specific developmental anomaly of the spine and spinal cord that features some clinical and radiological peculiarities. This anomaly fills the gap between the infant thoracolumbar kyphosis with segmental subluxation and the syndrome of caudal regression. Early diagnosis and individual approach to determination of an optimal period of surgical treatment and tactics are required in each case

Literature data were used to present the parameters of integral sagittal balance assessment. It is shown that the assessment of the sagittal balance should be performed taking into account the spatial position of the body and the use of the “cone of economy” concept and gravity line. Cervical spine and the pelvis are the key compensatory mechanisms in correction of the sagittal balance changes. The ratio of PI (pelvic incidence) and LL (lumbar lordosis) is the most significant as far as it correlates with the changes in the quality of life. Clinical interpretation of the changes in the sagittal balance should be conducted on the basis of their integration with a mandatory consideration of clinical manifestations and changes in the quality of life.

The authors presented a retrospective review and current tendencies of anterior spondylodesis used to treat spine diseases and injuries. The review includes advantages and disadvantages offered by surgical bio-implants and implants made of ceramics, carbon fiber, titanium nickelide and other alloys. Combined application of metal and autologous bone was shown to be the common tendency of spine stabilization. The development of osteoinductive materials has become essential in spine fusion.

The article presents an overview of embryonic and postnatal development of the chest wall describing current classification for a variety of chest wall and rib malformations. The clear identification of specific anomalies and a wider understanding of antenatal and postnatal development of the chest wall contribute to optimizing the choice of time and technique to treat the cohort of patients.

The authors presented a case of surgical treatment of a 16-year-old female patient who sustained a refracture of Th12 vertebral body eight years after conservative treatment of the same vertebra.

Purpose Our goal is to demonstrate a typical clinical situation that promotes the development of PJF and PJK, as well as a variant of surgical treatment of these complications. Material and methods A case of a fracture of the overlying vertebra above the level of metal fixation of the vertebra and development of proximal junctional kyphosis (PJF and PJK) in a patient operated for degenerative scoliosis of the lumbar spine. Repeated extended stabilization of the spine without cranial level protection resulted in the re-development of this complication. Vertebroplasty of the bodies of two vertebrae cranial from the fixed vertebral motor segment was performed in order to prevent the development of PJF and PJK and a hybrid fixation with a polymeric band on the cranial vertebral motor segment (VMS) was performed. Result Observation for a year confirms a good result of treatment. Conclusion Using vertebroplasty of two vertebrae cranial from the fixed vertebral motor segment with 7-8 ml of bone cement per vertebra prevented the possible development of PJF and PJK in the presented clinical observation and achieved a good clinical outcome. Laminar band fixation of the cranial VMS ensured the transition of the rigid system into a semi-rigid system in its proximal part, which also contributed to prevention of PJF and PJK.

Study Design Presentation of a clinical case. Object A clinical case of severe congenital kyphoscoliosis in an11-year-old child treated surgically. Method Vertebrotomy beyond the anomaly zone with the PSO technique and dynamic fixation of the spine. Result Correction of spinal deformity. Discussion Surgical treatment of congenital kyphoscoliosis with the PSO technique out the zone of congenital anomaly and implantation of dynamic systems achieve an orthopedic goal with a single intervention via a single approach.