Background Data: Neuromuscular scoliosis (NS) causes disorders to the spinal cord, which affects the innervation and tone of the musculoskeletal system. NS can affect the quality of life by causing spinal deformity, sitting difficulties, and back pain. Progression of NS after skeletal maturity is common, and the incidence of surgery in NS is high. Whether posterior surgical strategy in the management of NS results in higher correction and fewer complications than other approaches, either anterior alone or combined, is a controversial issue. Study Design: Systematic review of the literature. Purpose: To determine if the management of NS via the posterior approach has better results and fewer complications or not. Methods: This study was conducted using the PubMed and Cochrane databases; it includes patients treated for NS deformity and the type of surgery, degree of correction achieved, and rate of complications were reported. Results: Our systematic review yielded 104 citations with 9 studies meeting the required criteria. Six studies focused on the comparisons of posterior-only approach (POA) and anteroposterior approach (APA) and three studies on POA only regarding postoperative outcomes and complications such as correction angle of scoliosis (Cobb's angle), pelvic obliquity, lordosis, kyphosis, amount of blood loss, hospital stay and ICU stay, and operative time. Conclusion: Posterior-only approach has the same results in correction of neuromuscular scoliosis deformity as anterior-posterior approach but with fewer complications. However, the anterior-posterior approach has more advantage in correcting severe rigid neuromuscular scoliosis. (2020ESJ215)

Background Data: Anterior approaches to the thoracic and thoracolumbar spine have several advantages including direct access to the lesion, less surgical bleeding, low risk of infection, and shorter segment fixation devices. It provides excellent visualization and access to the anterior thoracic spine, vertebral bodies, intervertebral disks, spinal canal, and nerve roots and may improve neurological outcome. Purpose: To evaluate various outcome parameters of the anterior approach to the thoracolumbar spine of various pathologies. Study Design: Prospective clinical case study. Patients and Methods: Thirty patients were included in this study. Patients with infections, malignancy, and trauma were included, while patients with medical comorbidities, extensive several spinal levels disease, posterior tension band injury and translational or rotational injury, and severe osteopenia or osteoporosis were excluded. The evaluation included the demographic data, clinical features, level of injury, and neurological status of these patients. All patients underwent operation through the anterior thoracolumbar approach. Outcome parameters included preoperative and perioperative data and postoperative ASIA, VAS, SCIM, and ODI. Results: The age of patients was 46.06±12.2 (range, 20–70) years. Twenty patients were males and 10 were females. Most patients were 41–50 and >50 years. Thirteen patients (43%) suffered from traumatic fractures (M:F 3.3:1), 14 (47%) tuberculous spondylodiscitis (M:F 1.8:1), and 3 (10%) metastatic compression fracture. Surgical time was 213.12 and 201.43 minutes in Rt and Lt side approach, respectively, while blood loss was 609.4 and 650 ml in Rt and Lt side approach, respectively. In the whole group, pre- and postoperative sensory ASIA score was 91.53 and 105.8; motor ASIA score was 66.2 and 77.13; VAS was 5.13 and 0.63; SCIM was 30.93 and 76.13; ODI was 74 and 16.53, respectively. Complications included wound infection (N=3), kyphosis (N=3), intraoperative vascular injury (N=2), new neurological deficit (N=2), and myocardial infarction (N=1). Conclusion: Anterolateral approach in thoracic and thoracolumbar pathologies achieves adequate decompression, pathological evaluation for tissue, the possibility for instrumentation, and favorable neurological outcome. The familiarity and experience of the surgeon with the approach will always remain a cornerstone for the success of the procedure. (2020ESJ204)

Background Data: Sickle cell disease (SCD) is the most common inherited blood disease that has obvious effects on the osteoarticular system and the spine. Despite Although vaso-occlusive crises and osteomyelitis are the most frequent complications requiring hospitalization for patients with SCD, the spinal involvement in adult patients with SCD has not been fully explored. Study Design: Retrospective clinical case series. Purpose: To elaborate on various types of spinal affection in adults with SCD and to discuss the effectiveness of conservative management in these patients. Patients and Methods: Between January 2018 and December 2019, a retrospective study was conducted on 21 adults with SCD who presented to the neurosurgery clinic with back pain. The mean age was 27.4±7.84 (range, 17–49) years, while 14 were females and 7 were males. The patients were divided into two groups according to the cause of back pain where Group I (N=12) included the patients who presented with back pain due to SCD related causes like osteonecrosis or infection, while Group II (N=9) included the patients who had back pain due to non-SCD etiologies such as vertebral disc protrusion or facet arthropathy. All patients were offered conservative management as a first-line treatment. Back pain was evaluated using the Wong–Baker Faces Pain Scale. Results: Group I of 12 patients (57.1%) had SCD related causes including 11 patients (91.7%) with vertebral osteonecrosis (4 of them (33.3%) had associated osteoporosis) and one patient (8.3%) with acute lumbar osteomyelitis. Of the 11 patients who presented with osteonecrosis, 7 patients (63.6%) had an acute painful crisis, and the remaining 4 (36.4%) presented with chronic pain due to bone infarcts. In 8 patients (72.7%), the osteonecrosis involved the lumbar spine, while the thoracic and lumbar spines were involved in 3 patients (27.3%). Group II of 9 patients (42.9%) had non-SCD etiologies, including 2 patients (22.2%) who had facet arthropathy, 4 patients (44.4%) disc protrusion, and 3 patients (33.3%) mixed pathology. All patients were managed conservatively. The mean follow-up was 15.2±5.38 (range, 3–24) months. Overall, the mean pre-management Wong–Baker Faces Pain Scale improved from 5.57±1.121 (range, 4–8) to 1.95±0.59 (range, 1–3) at the last follow-up. Conclusion: The most common SCD related spinal pathologies in adults are infarction, infection, and osteoporosis. The majority of SCD patients presenting with low back pain can be managed conservatively regardless of the associated pathology. (2020ESJ202)

Background Data: Intradural-extramedullary (IDEM) tumors represent two-thirds of spinal cord tumors. As IDEM tumors are mostly benign, advocated approaches for surgical excision of these lesions should aim for total excision of the lesion with avoiding unnecessary disruption of spinal stability. Study design: This is a retrospective case series. Purpose: To assess the feasibility and advantages of a minimally invasive hemilaminectomy approach for excising IDEM spinal tumors. Patients and Methods: This study was conducted in our institution to review retrospectively cases of IDEM spinal tumors that underwent a minimally invasive hemilaminectomy approach from January 2016 to January 2019. Twenty-six patients who presented with twenty-seven tumors fulfilled our criteria and were included in this study. The history of all patients was taken and they were subjected to clinical examination and preoperative MRI with contrast. Frankel scale was used to assess the neurological status of the affected limbs and Visual Analogue Scale (VAS) for the evaluation of associated radicular pain. Regular follow-up visits were arranged for our cases one month after surgery and then every three months for at least 6 months. Results: Twenty-six patients with 27 tumors were included in this study, 15 females (57.7%) and 11 males (42.3%). The mean age of patients was 42.3 ± 12.8 years. This study included 15 schwannomas (55.6%), 4 neurofibromas (14.8%), and 8 meningiomas (29.6%). Gross total excision was achieved in 26 tumors (96%). Early mobilization and short hospital stay (1.38 ± 1.09) days were reported in all these cases. Complications reported in this study included one case of wound infection, one patient developed a CSF leak, and one patient experienced a mild deterioration of motor power. Conclusion: This study suggests that a minimally invasive hemilaminectomy approach offers an adequate, safe, and convenient corridor for the total excision of IDEM tumors. However, good patient selection, accurate preoperative and intraoperative tumor localization, and meticulous microsurgical resection are mandatory. (2020ESJ208)

Background Data: Although most sacral fractures can be treated conservatively, several surgical options are available for highly unstable fractures. Surgery aims to provide sacral realignment, fixation, and maybe neural decompression with subsequent pain relief and early mobilization. Surgical options are variable depending on the type of fractures and surgeon’s experience. Spinopelvic fixation is one of the famous surgical procedures. Purpose: To evaluate the safety and efficacy of lumbopelvic fixation for the treatment of unstable traumatic spinopelvic sacral fractures. Study Design: Prospective cohort study. Patients and Methods: All patients with unstable spinopelvic sacral fractures excluding those with other types of sacral fractures were recruited for this study. All patients were submitted to lumbopelvic fixation. Patients were evaluated clinically and radiologically, including full lumbar and pelvis X-Ray and 3D MSCT scan at the pre- and postoperative period. Clinical parameters included a full neurological examination, VAS, ODI, and modified Rankin scale. Results: A total of 15 patients including 7 males and 8 females with mean age of 28±8.11 years were recruited for this study. All patients were suffering from unstable traumatic spinopelvic type C sacral fractures according to AO Spine sacral fractures classification system. Four patients suffered from type C0, 2 from C1, 4 from C2, and 5 from C3. Neural insults were reported in 13 patients. The mean follow-up period was 19.2±8.6 (range, 6–36) months. The mean preoperative VAS improved from 8.13±1.25 to 2.6±1.01 postoperatively, while the mean preoperative ODI improved from 88.53±2.24 to 16.8±3.16 postoperatively. According to the modified Rankin scale for functional recovery, 14 (93.3%) of the patients were categorized as excellent and good, while only one patient (6.6%) was categorized as fair outcome. Complete fractures’ healing was reported in all patients and none required any revision procedure. Deformity correction was incomplete in 40% without clinical effects on patients. Surgical site infection was reported in 3 patients and one of them necessitated debridement. Conclusion: Lumbopelvic fixation is a safe and effective procedure in the treatment of unstable traumatic spinopelvic sacral fractures. (2019ESJ196)

Background Data: Adolescent Idiopathic Scoliosis (AIS) is a spinal deformity that may interfere with patients’ quality of life. Many previous studies tried to assess the health-related quality of life (HRQoL) using the patient-reported outcome measures. The Arabic version of Scoliosis Research Society 22 (SRS-22r) questionnaire is known to be reliable and a valid tool to assess the quality of life in patients with AIS. Purpose: To evaluate quality of life of patients with AIS after surgical correction using the Arabic version of Scoliosis Research Society 22 (SRS-22r) questionnaire. Study Design: Prospective cohort study. Patients and Methods: Between 2016 and 2018, twenty-five patients were surgically treated for AIS with Cobb’s angle >45 degrees. All patients underwent posterior derotation and instrumented correction and fusion technique. In this study, we used the Arabic version of SRS-22 questionnaire to evaluate the clinical patient’s outcome. Whole spine plain X-ray was utilized to assess the radiological outcome. All patients underwent postoperative follow-up for at least 6 months with the SRS-22r questionnaire conducted in the last visit. Results: Twenty-five patients were recruited for this study including 22 females and 3 males with mean age of 14.7±1.7 (range, 11–18) years. Significant improvement was reported 6 months after surgical correction in the following radiological parameters: Cobb’s angle of the primary curve from 55.81±8.72 to 7.98±2.26; pelvic incidence from 62.24±7.33 to 57.96±6.14; pelvic tilt from 26.14±3.41 to 20.76±3.74; lumbar lordosis from 33.21±8.63 to 36.6±8.79. The scores of functional activity, pain, self-image/appearance, mental health, and satisfaction were 4.31±0.28, 4.57±0.27, 4.85±0.31, 4.85±0.17, and 4.96±0.21, respectively, at the last follow-up visit. The total SRS-22 score was 4.45±0.16. Correlation between different domains of SRS-22 questionnaire after surgical correction shows that only function/activity score revealed a positive significant correlation with the mental health domain (r=0.417) (P=0.038). Conclusion: The Arabic version of SRS-22 questionnaire was very useful in terms of measuring patients’ perceptions. Self-image domain was showing the highest increase among all other domains. (2019ESJ195)

Background Data: Foramen magnum (FM) meningiomas are always considered challenging cases for neurosurgeons. The challenge is even heftier with early experience with limited access to up-to-date neurosurgical gadgets. Besides the anatomical complexity of the region, FM meningiomas tend to grow in proximity to eloquent structures making the task even tougher. Multiple approaches have been advocated to manage these lesions; nevertheless, adopting an approach according to your experience and circumstances would be best. Purpose: To present our experience with 16 cases of FM meningiomas operated via posterior suboccipital approach and discuss the validity of this approach. Study Design: A retrospective cohort study. Patients and Methods: We reviewed our hospital records for patients where the posterior suboccipital approach was performed for foramen magnum meningiomas in the period between November 2014 and January 2019 at our institution. Lesions with anterior location or limited posterolateral extension and those with vertebral artery encasement were excluded. We could trace 16 patients with FM meningiomas operated upon using the midline suboccipital approach. Patients’ imaging included IV gadolinium-enhanced MRI brain and CT angiography including brain and neck for diagnostic and planning purposes. Recorded outcome variables were pre- and postoperative Japanese Orthopedic Association (JAO) scale, extent of tumor excision according to Simpson’s grading, operative blood loss, duration of surgery, hospital stay, and perioperative complications. Follow-up data were recorded from our outpatient clinic chart records. Results: Twelve patients were females and 4 were males with a mean age of 40.64±8.69 years (range, 29–56 years). The mean preoperative JOA score improved from 14.875±1.690 to 15.63±0.99 at the last postoperative follow-up. Total resection was achieved in 10 cases (6, grade I; 4, grade II), subtotal resection in 4 patients, and partial resection in 2 patients. Patients with residual lesions (N=6) were managed with Gamma Knife. The mean operative time was 261.25±55.33; the mean blood loss was 682.5±84.19; the mean hospital stay was 7.25±2.05 days. Transient CSF leak was the most common recorded complication (N=9). The mean follow-up period was 13±7.186 months. Conclusion: Our data suggest that the posterior midline suboccipital approach is a safe and effective option in the management of FM meningiomas that are mainly posterior or posterolateral. (2019ESJ203)

Background Data: Surgical management for high-grade spondylolisthesis is challenging and associated with high morbidity. There are many surgical techniques available for lumbosacral fixation and correction that differ in approaches and outcomes. The main concern during surgery is to decompress the neural element, correct focal kyphotic deformity, and restore or maintain global sagittal alignment. Purpose: The purpose of this study was to present a case series of patients with high-grade spondylolisthesis who were treated with reduction and fixation and compare the results to in situ fusion technique. Study Design: Retrospective observational study. Patients and Methods: We retrospectively reviewed patients with L5/S1 high-grade spondylolisthesis who underwent surgery at our institute in the period between March 2013 and March 2017. Patient’s demographic, preoperative, and postoperative data were collected. Taillard’s technique and Meyerding’s grade for spondylolisthesis were assessed for all cases. Additionally, we measured the pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT) pre- and postoperatively. The Bridwell grading system was used to assess the degree of radiographic fusion. Preoperative and postoperative clinical outcomes were evaluated using Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI). Complication rates were collected during the follow-up period. Results: We included 16 cases in the current study. Patients were divided into two groups: reduction group includes nine patients, and in situ group includes seven. There was no significant difference in demographics or radiological data between groups. Moreover, operative data demonstrated comparable results between the two groups (P<0.05). Reduction group showed significant increase in L5 palsy compared to the in situ fusion group (0.037), although reduction showed more significant changes regarding correction of deformity (PT and SS). Both techniques were efficient in relieving pain and improving disability at 3-month and last follow-up visits (P<0.001). Conclusion: The present study showed that both reduction and in situ fusion techniques are effective surgical tools in improving clinical outcomes for patients with L5/S1 high-grade spondylolisthesis. Attempt of complete reduction carries a high risk of L5 nerve root injury. Partial reduction under complete L5 nerve root decompression and visualization is crucial in reducing risk of injury. However, reduction technique demonstrated superior deformity correction at the index level of spondylolisthesis. (2019ESJ181)

Background Data: Optimal surgical approach for anterior cervical discectomy and fusion (ACDF) is still controversial. Some authors believe that addition of locking plate (ACDFP) has higher costs and longer operative time. Other surgeons believe that ACDFP have better clinical outcomes and more sound fusion. The debate is higher in single and double level ACDF. Purpose: To compare the clinical and radiological outcomes in patients with single or double level cervical disc herniation operated by ACDF versus those operated by ACDFP. Study Design: A retrospective, descriptive controlled, non-randomized, clinical case study. Patients and Methods: Forty patients underwent ACDF. They were divided into two groups; ACDF group and ACDFP fixation group. Each group included 20 patients. They were operated between 2010 and 2017. Participants were evaluated pre-operatively and post-operatively 1, 3, 6, 9 and 12 months after surgery. Operative time, hospital stay and complications were assessed. Pain was scored by a VAS for both upper arm and cervical pain. The clinical outcomes were compared using Odom’s criteria. Cervical fusion was assessed radiologically. Results: The demographic data of the two groups of patients were fairly homogeneous and comparable. ACDFP group showed slightly better clinical outcome parameters in comparison to ACDF group including VAS for cervical pain (9±5 versus 28±11) and Odom’s criteria scores (15 excellent outcome versus 10). Also ACDFP group showed slightly better radiological fusion rate (100%) in comparison to (85%) in ACDF group. Reported nonunion was higher in ACDF group (15%) in comparison to ACDFP group (0%). Conclusion: Our data suggest that the addition of cervical plate fixation to ACDF might leads to better clinical outcome and radiological fusion in single and double cervical disc disease. (2018ESJ155)

Background Data: Anterior cervical discectomy and fusion (ACDF) became the classic operation in treating degenerative cervical spondylosis. The application of anterior cervical plate helped fusion and stabilization; however, there were many reports of the complications, such as dysphagia and the possibility of adjacent segment degeneration that may develop after anterior cervical approach. Purpose: The aim of this study is to assess the outcome of the standalone anchoredcervical spacers in anterior cervical discectomy and fusion. Study Design: This is a retrospective study included 30 patients suffering from degenerative cervical disc disease. The outcome measures were: the visual analoguescore, Cobb’s angles for sagittal and segmental alignment, the Japanese orthopedic association score, Nurick score for myelopathic patients and the occurrence of postoperative dysphagia.Patients and Methods: 30 patients were included in this study. All these patients had an anterior approach for cervical discectomy. A standalone anchored cervical spacer was used for this purpose. All patients were regularly assessed through the follow up period of two years post surgical intervention. Results: The study included 30 patients, 22 patients had single level, and 8 patients had two levels cervical discectomy. Postoperative improvement of radicular painVAS were statistically significant (9.0 to 1.67) as well as the improvement in Cobb’s angle (1.39±5.69 to 6.78±3.83) were statistically significant (P=0.001). Postoperative improvement in the JOA Score was significant (7.12 to 14.65). Nurick score for myelopathy improvement was statistically significant (2.6 to 0.83). Postoperative improvement in the fused levels’ height was statistically significant (p=0.001) Conclusion: Stand-alone anchored spacer has a good result regarding relief of symptoms, fusion, and is simple to insert with less post-operative dysphagia. (2018ESJ156)