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Introduction The incidence of junctional kyphosis (JK) varies in the literature from 7% to 40%. We here present our experience with JK. The aim of this work is investigate the incidence of JK after long spinal segment fusion, to identify the underlying factors leading to its development, and to discuss treatment outcome. Patients and Methods This combined retrospective/prospective cohort study included sixty-four consecutive patients (40 women and 24 men) with a mean age of 20.7 years, who underwent long segment spinal fusion (≥ 5 vertebrae) for treatment of spinal deformity. The average length of follow-up was 2 years. Risk factors analyzed included patients’ factors, surgical factors, and radiographical parameters such as thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis, pelvic tilt, and pelvic incidence. Results Radiological JK occurred in 14 patients (22%). Ten cases were proximal junctional kyphosis (PJK), two cases were intercalary junctional kyphosis (IJK), and two cases were distal Junctional Kyphosis (DJK). Only seven patients (50%) out of the 14 with JK were symptomatic. Six cases have undergone revision surgery. In nine cases, the original deformity was kyphosis (1 Ankylosing spondylitisS, 1 post-tuberculous, 3 Sheuermann's kyphosis, 4 congenital kyphosis). The other 5 cases were scoliosis (3 idiopathic and 2 congenital). Preoperative TK more than 40 ° was associated with PJK. In all cases PI, PT, SS, SVA were within normal range, but it was noticed that SVA had negative values in 5 cases. LIV in the dorsolumbar junction was associated with DJK. Conclusion Pre-existing TK more than 40°was identified as an independent risk factor. Negative sagittal balance may be a risk factor for PJK. A surgical strategy to minimize Junctional kyphosis may include careful preoperative planning for reconstructions with a goal of optimal postoperative alignment.

Introduction The incidence of junctional kyphosis (JK) varies in the literature from 7% to 40%. We here present our experience with JK. The aim of this work is investigate the incidence of JK after long spinal segment fusion, to identify the underlying factors leading to its development, and to discuss treatment outcome. Patients and Methods This combined retrospective/prospective cohort study included sixty-four consecutive patients (40 women and 24 men) with a mean age of 20.7 years, who underwent long segment spinal fusion (≥ 5 vertebrae) for treatment of spinal deformity. The average length of follow-up was 2 years. Risk factors analyzed included patients’ factors, surgical factors, and radiographical parameters such as thoracic kyphosis (TK), lumbar lordosis (LL), sagittal vertical axis, pelvic tilt, and pelvic incidence. Results Radiological JK occurred in 14 patients (22%). Ten cases were proximal junctional kyphosis (PJK), two cases were intercalary junctional kyphosis (IJK), and two cases were distal Junctional Kyphosis (DJK). Only seven patients (50%) out of the 14 with JK were symptomatic. Six cases have undergone revision surgery. In nine cases, the original deformity was kyphosis (1 Ankylosing spondylitisS, 1 post-tuberculous, 3 Sheuermann's kyphosis, 4 congenital kyphosis). The other 5 cases were scoliosis (3 idiopathic and 2 congenital). Preoperative TK more than 40 ° was associated with PJK. In all cases PI, PT, SS, SVA were within normal range, but it was noticed that SVA had negative values in 5 cases. LIV in the dorsolumbar junction was associated with DJK. Conclusion Pre-existing TK more than 40°was identified as an independent risk factor. Negative sagittal balance may be a risk factor for PJK. A surgical strategy to minimize Junctional kyphosis may include careful preoperative planning for reconstructions with a goal of optimal postoperative alignment.

Introduction There has been controversial data about the effect of cage size on radiological and clinical outcome of anterior cervical discectomy and fusion (ACDF). Oversized cages have been linked to higher incidence of non-union, adjacent segment disease, and unfavorable clinical outcomes. The aim of this work is to evaluate the effect of an oversized PEEK cage on the radiological and clinical outcomes in ACDF. Patients and Methods Between January 2012 to July 2014, 57 patients (29 single level, 15 double levels, 8 three levels, 5 four levels) underwent ACDF using a stand-alone oversized PEEK cages. They were 35 males and 22 females with mean age 56 ± 13.5 years. The minimum follow up period is one year. The following parameters were measured preoperatively, postoperatively and at final follow up: cervical lordosis (in degrees), disc height (in mm), motion at operated level (in degrees), radiological ASD (present or not) and VAS for neck pain, VAS for arm pain. All complications were as well recorded. Results The mean cervical lordosis changed from 25°±5.5 postoperative to 7°±4.5 at final follow up. The mean disc height was 5± 2 mm preop, 7 ± 1.5 mm postop and 6 ± 1 mm at final follow up. Residual motion at operated level was observed at 1 year follow up X-rays in 2 patients (one double level and one 3-level) with average 5°. None of them had neck pain and no revision was required. In the postoperative X-rays, the suprajacent level was always observed to be slightly narrowed; this narrowing gradually diminished during the follow up. Radiological ASD developed in 9 patients (16%), all of them remained to date asymptomatic. The average improvement in VAS for neck pain was 27%±8.5 and the average improvement in VAS for arm pain was 33%±9.5. At the final follow up, fusion was achieved in 55 patients (96%) and clinical outcome was excellent. Radiological loss of the postoperative disc height and cervical lordosis and development of radiological ASD did not correlate to poor clinical outcome. No single case of cage dislodgement was observed in this series. Conclusion The use of a stand-alone oversized PEEK cage in ACDF seems to minimize the incidence of cage dislodgment even in multiple levels ACDF. Despite some radiological settlement and loss of cervical lordosis, an excellent clinical outcome was maintained.

Background Data: Far lateral lumbar disc herniation accounts for 1-12% of all lumbar disc herniations. Every aspect of management of this unique type of lumbar disc herniation is challenging for spine surgeons, and no consensus has been reached for the best surgical approach and technique to use. Purpose: The purpose of this study is to evaluate the extraforaminal approach, which is a less invasive approach, for the treatment of far lateral lumbar disc herniation. Study Design: A prospective case series. Patients and Methods: Of 501 lumbar disc prolapse patients treated surgically in our department between September 2013 and August 2015, 15 patients presented with far lateral lumbar disc herniation. These 15 patients (11 males and 4 females, mean age 46.80 ± 8.08 years) were treated surgically using the extraforaminal approach and were prospectively followed for 1 year. The study was approved by the Institution Ethical Committee, and all patients signed an informed consent form. Clinical and functional outcomes were assessed using VAS and ODI scores and MacNab’s criteria. Follow-up MRI was performed at 1 year. Results: Far lateral lumbar disc herniation accounted for 3% of all lumbar disc herniation patients treated surgically in our department. The mean back pain VAS score improved from 6.46 preoperatively to 1.06 at the 1-year follow-up evaluation (P=0.001). The mean leg pain VAS score improved from 7.40 preoperatively to 1.06 at the 1-year follow-up evaluation (P=0.001). The mean ODI score improved from 30.20 preoperatively to 2.80 at the 1-year follow-up evaluation (P=0.001). According to MacNab’s criteria, 12 patients (80%) had excellent outcomes, 3 (20%) had good outcomes, and no patients showed fair or poor outcomes at the final follow-up evaluation at 1 year. Conclusion: The extraforaminal approach seems to be a safe, less traumatic and less destabilizing approach for managing far lateral lumbar disc herniation and can lead to a better outcome than traditional approaches. (2017ESJ129)

Background Data: Far lateral lumbar disc herniation accounts for 1-12% of all lumbar disc herniations. Every aspect of management of this unique type of lumbar disc herniation is challenging for spine surgeons, and no consensus has been reached for the best surgical approach and technique to use. Purpose: The purpose of this study is to evaluate the extraforaminal approach, which is a less invasive approach, for the treatment of far lateral lumbar disc herniation. Study Design: A prospective case series. Patients and Methods: Of 501 lumbar disc prolapse patients treated surgically in our department between September 2013 and August 2015, 15 patients presented with far lateral lumbar disc herniation. These 15 patients (11 males and 4 females, mean age 46.80 ± 8.08 years) were treated surgically using the extraforaminal approach and were prospectively followed for 1 year. The study was approved by the Institution Ethical Committee, and all patients signed an informed consent form. Clinical and functional outcomes were assessed using VAS and ODI scores and MacNab’s criteria. Follow-up MRI was performed at 1 year. Results: Far lateral lumbar disc herniation accounted for 3% of all lumbar disc herniation patients treated surgically in our department. The mean back pain VAS score improved from 6.46 preoperatively to 1.06 at the 1-year follow-up evaluation (P=0.001). The mean leg pain VAS score improved from 7.40 preoperatively to 1.06 at the 1-year follow-up evaluation (P=0.001). The mean ODI score improved from 30.20 preoperatively to 2.80 at the 1-year follow-up evaluation (P=0.001). According to MacNab’s criteria, 12 patients (80%) had excellent outcomes, 3 (20%) had good outcomes, and no patients showed fair or poor outcomes at the final follow-up evaluation at 1 year. Conclusion: The extraforaminal approach seems to be a safe, less traumatic and less destabilizing approach for managing far lateral lumbar disc herniation and can lead to a better outcome than traditional approaches. (2017ESJ129)

Background Data: Far lateral lumbar disc herniation accounts for 1-12% of all lumbar disc herniations. Every aspect of management of this unique type of lumbar disc herniation is challenging for spine surgeons, and no consensus has been reached for the best surgical approach and technique to use. Purpose: The purpose of this study is to evaluate the extraforaminal approach, which is a less invasive approach, for the treatment of far lateral lumbar disc herniation. Study Design: A prospective case series. Patients and Methods: Of 501 lumbar disc prolapse patients treated surgically in our department between September 2013 and August 2015, 15 patients presented with far lateral lumbar disc herniation. These 15 patients (11 males and 4 females, mean age 46.80 ± 8.08 years) were treated surgically using the extraforaminal approach and were prospectively followed for 1 year. The study was approved by the Institution Ethical Committee, and all patients signed an informed consent form. Clinical and functional outcomes were assessed using VAS and ODI scores and MacNab’s criteria. Follow-up MRI was performed at 1 year. Results: Far lateral lumbar disc herniation accounted for 3% of all lumbar disc herniation patients treated surgically in our department. The mean back pain VAS score improved from 6.46 preoperatively to 1.06 at the 1-year follow-up evaluation (P=0.001). The mean leg pain VAS score improved from 7.40 preoperatively to 1.06 at the 1-year follow-up evaluation (P=0.001). The mean ODI score improved from 30.20 preoperatively to 2.80 at the 1-year follow-up evaluation (P=0.001). According to MacNab’s criteria, 12 patients (80%) had excellent outcomes, 3 (20%) had good outcomes, and no patients showed fair or poor outcomes at the final follow-up evaluation at 1 year. Conclusion: The extraforaminal approach seems to be a safe, less traumatic and less destabilizing approach for managing far lateral lumbar disc herniation and can lead to a better outcome than traditional approaches. (2017ESJ129)

Background: Early Onset Scoliosis (EOS) is defined as scoliosis occurring before the age of 5 years. It affects not only the growing spine but also has a direct influence on the cardiopulmonary development and function of the child. Cardiopulmonary function is compromised as a result of decreased size of the thoracic cavity, which has a negative effect on lung alveolar development. The goal in the management of EOS is to control the deformity and allow continued growth of the spine and thoracic cavity. Non-fusion instrumentation facilitates this and allows ongoing respiratory development and optimal cardiopulmonary functions. However some authors describe that early onset scoliosis is that scoliosis starts before the age of 10 years. The debate in these definitions is made because of the differ-ence in spine growth and cardiopulmonary compromise before and after age of five.

Background: Early Onset Scoliosis (EOS) is defined as scoliosis occurring before the age of 5 years. It affects not only the growing spine but also has a direct influence on the cardiopulmonary development and function of the child. Cardiopulmonary function is compromised as a result of decreased size of the thoracic cavity, which has a negative effect on lung alveolar development. The goal in the management of EOS is to control the deformity and allow continued growth of the spine and thoracic cavity. Non-fusion instrumentation facilitates this and allows ongoing respiratory development and optimal cardiopulmonary functions. However some authors describe that early onset scoliosis is that scoliosis starts before the age of 10 years. The debate in these definitions is made because of the differ-ence in spine growth and cardiopulmonary compromise before and after age of five.

Introduction: The aim of this prospective case series study is to document safety and effectiveness of high density pedicle screws through posterior only approach with intraoperative wake-up test in correction of adolescent idiopathic scoliosis (AIS). Methods: Between 2011 and 2015, all surgically treated patients for AIS were followed up for a minimum of 2 years. Clinical outcomes were evaluated using scoliosis research society-22 (SRS) questionnaire. All patients were classified according to Lenke classification. Major and minor curves Cobb angle as well as sagittal parameters were measured on whole spine X-rays. All patients underwent an intra-operative wake-up test after deformity correction and a minimum of 80% metal density of implants was used. Results: This study included 50 patients. The mean age at time of surgery was 16.8 years. The mean follow-up period was 38.1 months. The mean correction rate for the coronal Cobb angle of the major curve was 79.12%, while that of the minor curve was 68.9%. The mean thoracic kyphosis angle was 38.4 degrees preoperatively, 29.76 degrees postoperatively and 30.36 degrees at the last follow-up. The mean SRS-22 questionnaire scores improved significantly at the last follow-up (P > 0.001). There were no neurological deficits at the wake-up test. No cases of pseudarthrosis or metal failure were encountered. Conclusion: This is a prospective study of at least 80% metal density pedicle screws technique and intra-operative wake-up test in Egyptian patients with AIS. It proved to be an effective and safe technique in correction of radiological parameters, with no neurological or implant related complications. It allowed excellent scoliotic and kyphotic curves correction with minimal loss of correction. On the whole it led to better quality of life.