PSS RESEARCH ABSTRACTS

Abstracts submitted to the PSS Research activities since 2014

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Text Results

Determinants of Good Outcome for Patients with Degenerative Spondylolisthesis treated Surgically

Gilbert Ola, MD

Introduction: Degenerative spondylolisthesis affects patients aged 50 and above. Previous studies indicated that that condition is common in women and frequently affects the L4-L5 level. The etiology is multifactorial. Patients often complain of low back pain associated with neurologic deficits. Initial treatment is by non-surgical means.


Methods: Twenty patients were recruited in this study. Baseline patient characteristics and questionnaires were taken prior to surgery. Surgical treatment was grouped under Posterolateral fusion group and Inter body fusion group. Outcome measures used were the Owestry Disability index (ODI) and the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABEPQ) at 5 given time intervals: Preoperative, 3 months post op, 6 months post op, 12 months post op and 18 months post op.


Results: Of the 20 patients included in the study, 10 were male and 10 were female. Mean age was 60.8 and average BMI was 26.9 kg/m2. Majority of the participants were obese. Forty percent of the patients were under the high-grade spondylolisthesis group. Significant improvements were observed in almost all patients in the preoperative and postoperative scores. Gender, BMI, and Slip severity showed a direct relationship in the rate of improvement in terms of Disability, social function, mental function, walking ability, lumbar function and low back pain while age, gender, type of surgery and time to intervention did not show any statistically significant effect.


Conclusion: Gender, BMI and Slip Severity appears to have a strong relationship to a good outcome

Outcomes of Vertebrectomy with Anterior Cage Reconstruction and Posterior Instrumentation by Single Posterior Approach for Thoracic Vertebral Compression

Consuelo Amparo G. de Vera, MD; Larry Acuña, MD

Objective. To present a case series of patients who underwent vertebrectomy and reconstruction by anterior cage reconstruction and instrumented fusion by single posterior approach for various etiology of vertebral collapse. The surgical results using this technique are reviewed.


Methods. Chart review of 6 patients treated in a single institution from 2008 to 2013, by a single surgeon, ranging from 11 to 68 years of age. Details of surgery including level of involvement, duration of surgery, and blood loss, and post-operative management and outcomes were reviewed.

Results. Six procedures have been performed: 3 for metastatic tumor, 2 post-infectious kyphosis and 1 for Pott’s infection with kyphosis. The levels involved ranged from T3 to L1. Of the six patients, five improved neurologically postoperatively. Mean operative time was 7 hours. Average blood loss was 925cc. There were no operative complications encountered. Immediate post-operative pain control allowed high back rest to ambulation with brace or walker assistance.


Conclusion. The paper presents a method of vertebrectomy, with circumferential stabilization using pyramesh cage for the anterior, pedicle screws and rods for the posterior, and local bone grafts for fusion through a single posterior approach. This is an alternative to anterior approaches and combined anterior and posterior approaches.

Cervical Artificial Disc Replacement: A Three Year Follow Up on Functional Outcome and Radiographic Evidence Of Adjacent Segment Disease for Single And Multilevel Surgery

Dyan Pangilinan, MD; Mario Ver MD, FPOA

Background: The primary goal of cervical decompression Artificial Disc Replacement (C-ADR) is to remove the pathologically herniated disc while maintaining disc height and preserving motion, thereby decreasing the incidence of adjacent segment disease (ASD). The benefit of single-level C-ADR is well described in literature, however, the role of multi-level C-ADR is less clear.


Objective: The purpose of this study is to provide a three year follow-up on clinical outcome and radiographic evidence of ASD on patients who underwent single and multi- level C-ADR .


Study Design: This is a retrospective review of records of 28 patients with symptomatic single and multi-level (two - four level) cervical disc disease who underwent C-ADR from February 2006 – December 2012 in a tertiary hospital.


Methods: Out of the 28 patients, 9 underwent the single-level and 19 underwent multilevel C-ADR. Preoperative diagnosis was either radiculopathy or myelopathy. Mean follow up period was 3 years. All procedures were done by one surgeon using Cervical Artificial Disc Prosthesis-Prestige LP. Visual analogue scale (VAS) for arm and neck pain, neck disability index (NDI), neurological and overall success using Odom’s criteria, return to work and surgical complications were evaluated. Radiographic evaluation of ASD above or below the operative level was done.


Results: A significant improvement in the NDI (>30% reduction) and VAS scores (p-values<0.05) was observed from preoperative to postoperative follow-up periods. 95-100% showed an overall success at immediate follow-up and neurological symptoms were completely improved for most patients at 6 months. 11% of single-level C-ADR patients and 16% of multilevel C-ADR patients developed radiographic changes for ASD.


Conclusions: There is statistically significant relief of symptoms from pre-operative and different follow-up thereafter. Multilevel C-ADR seems to have similar results to single level ADR but may have higher rates of ASD and dysphagia however did not affect overall outcomes.


Keywords: cervical artificial disc replacement, adjacent segment disease, prestige LP

What are the risk factors in the development of low back pain among high school students in Dasmarinas, Cavite from June-September 2010?

Adrian P. Alaras, MD

Objective: To determine the risk factors in the development of low back pain among high school students of Dasmariñas, Cavite.


Study Design: A cross-sectional prospective analytical study among high school students in Dasmariñas, Cavite during June to September 2010.


Summary of Background Data: Nonspecific low back pain (NSLBP) is a fairly frequent condition in children, whose pathophysiology remains unclear. Studies have revealed that back pain is quite common in this population, with many risk factors being implicated.


Methods: A semi-structured questionnaire, based on the Fairbank questionnaire, was asked among high school students in Dasmariñas, Cavite during June to September 2010. Questions concerning demographics, family history, mechanical and lifestyle factors and school-environmental factors were assessed.


Results: There were a total of 421 respondents. The point prevalence was noted to be 54.37%. It is higher compared to most international studies. Sixteen variables were noted to be statistically significant in the bivariate analysis. These are the year level, school type, gender, age, student’s height, a family history of a parent suffering from LBP, exercise frequency, seating arrangement in class, neck twisting, trunk twisting or chair turning during class, height of the backrest of the chair, presence of lockers in school, type of bag, the strapping used, and the pain noted during recess activities. In the multiple logistic regression and forward logistic regression analysis 4 variables were noted to be statistically significant. These are school, gender, family history of a parent suffering from LBP, and LBP noted during recess.


Conclusion: There is a consensus that LBP in children, particularly adolescents, is indeed prevalent and requires attention. This study adds support to the prevalence of low back pain among children even in our local setting with its own risk factors.

Artificial Disk Replacement versus Fusion for Multi-level Cervical Spondylotic Radiculopathy: A Prospective Study

Miguel Rafael Ramos, MD; Mario Ver, MD

Background. C-ADR has been proven to be an equally successful alternative to ACDF, which was the current standard of care among patients with cervical degenerative disc disease manifesting with radiculopathy. Most studies have dealt with single-level C-ADR surgeries with much room for discussion regarding its theoretical use in multi-level disc disease.


Methods. The subjects in this study were a cohort of patients who underwent either multi-level ACDF, or multilevel C-ADR from January 2006 to July 2009. Neck Disability Index (NDI) and neck and arm pain (VAS) scores were measured pre-operatively and at 6 weeks, 3, 6, 12, 24, and 36 months post-operatively. Patient satisfaction and overall success of surgery was evaluated at the most recent follow-up using Odom’s criteria. Complications among the patients of both treatment groups were also recorded.


Results. A total of 37 patients diagnosed with cervical spondylotic radiculopathy were included: 22 (59%) underwent ACDF, and 15 (41%) underwent C-ADR. Surgical parameters such as peri-operative blood loss, operative time and post-operative length of hospital stay were all found to be similar in both ACDF and C-ADR groups (p>0.05). Patients of both treatment groups were observed to have significant improvement in function and pain compared to baseline values at 6 weeks, 3, 6, 12, 24, and 36 months post-operatively. There were no noted significant differences with regards to clinical outcome measures (neck VAS, arm VAS, NDI score) among the treatment groups. A total of four post-operative complications were apparent from both groups.


Conclusion. Our study supports current evidence of the use of artificial disc replacement as an alternative to fusion for the treatment of multi-level cervical degenerative disc disease. In our local setting, from 6 weeks to 36 months postoperatively, patients who underwent multi-level C-ADR had comparable function, pain, and satisfaction with those patients that underwent multi-level ACDF

Functional Outcome After a Single Level Percutaneous Indirect Decompression Using the DTRAX facet Screw System for the Treatment of Patients with Cervical Degenerative Disc Disease

Yehlen Francis R. Saligumba MD; Mario Ver MD

The DTRAX facet screw system is a minimally invasive option for cervical disc disease. The study’s aim is to establish the improvement in the functional outcome after one year of undergoing decompression facet fusion using DTRAX. Study design is a descriptive, prospective, single-center, non-randomized study. A total of 24 subjects were included ages ranging from 40 to 75 years old. Mean of VAS score for the neck and arm at baseline and at 1 year follow-up markedly decreased. Mean score of the NDI at baseline and after 1 year follow-up is also noted improvement. All the subjects claimed that their general health and wellbeing markedly improved using the SF12v2TM health survey questionnaire. The DTRAX facet screw system is effective in improving the functional outcome for patients with a single level cervical degenerative disc disease.

A rare case of Klippel-Feil syndrome Complicated with Bilateral Sprengel’s Deformity

Candice Elaine C. Lim; MD Carlo Emmanuel J. Sumpaico, MD; Daniel V. Dungca; MD Jose Bayani O. Aliling, MD

A 4-year old female presents with congenital shoulder deformity and shortening of the neck. She was born full-term with an apparently uneventful perinatal course. Developmental Milestones were at par with age. At 7 months, her neck was observed to be shortened with deformity of the upper back and shoulders. As the years progressed, these deformities became more apparent, with limitation of motion of the neck and shoulders. Physical examination at 4 years old reveals a shortened neck, low-lying posterior hairline, and elevation and tilting of both scapulae. Range of motion of the neck is limited on extension, rotation and lateral flexion. Bilateral shoulder range of motion is limited on forward flexion and isolated abduction. Radiographs of the cervical spine showed congenital fusion of the spinous process of C3 to C4 and C5 to C6, with several bifid vertebrae. Radiographs and CT scan of the shoulders showed bilateral elevation of the scapulae and bilateral omovertebrae from the superomedial scapula to the C6 spinous process. She was diagnosed with Sprengel’s deformity with Klippel-Feil Syndrome.


Sprengel’s deformity is a congenital elevation of the scapula, such that it lies more superiorly in relation to the thoracic cage. It is a rare condition, with an incidence of less than 1 in 10,000, with unilateral involvement more common. Very little literature is available documenting the incidence of bilateral Sprengel’s deformity. Sprengels deformity also present in around 20% of cases of Klippel-Feil syndrome, which has an incidence of 1 in 40,000 births. Since bilateral Sprengel’s deformity is unusual, there are no recommendations regarding surgical correction in such cases. Thus, we are reporting a rare case of Sprengel’s deformity in a 4-year-old female with Klippel-Feil syndrome treated with a single stage bilateral Woodward procedure.

The Comparison of the Clinical Outcome of Patients Undergoing Scoliosis Surgery Under Fluoroscopy Guidance versus Image Guidance System

Oliver Ong, MD; Jose Joefrey Arbatin, MD, FPOA

Background: Scoliosis is a complex deformity of the spine. The main goal of surgical intervention is to prevent its progression. Prior to the advent of image guidance system (IGS), fluoroscopy was used to confirm the placement of pedicle screws. IGS increased the precision of pedicle insertion. This study was conducted to determine the clinical outcome of these two techniques.


Objectives: To determine the difference in clinical outcome among patients who underwent scoliosis surgery under fluoroscopy guidance vs. image guidance system.

Materials and Methods: This is a retrospective cross-sectional study done in a tertiary institution. Data on age, gender, operative times, blood loss, and length of fusion were recorded. The rate of correction was determined using the difference in the preoperative and postoperative Cobb’s angle. Cobb’s angle was measured by either the surgeon as recorded or by the author.


Results: There were 31 patients included in this study. The average operative time for the fluoroscopy group (n=18) was 373.78 minutes and 372.31 minutes for the image guidance group (n=13) (p=0.965). The average blood loss for the fluoroscopy group was 611.11 ml and 557.69 ml for the image guidance group (p=0.664). The rate of correction for the fluoroscopy group was 58.74%, and 70.8% for the IGS group. Statistical difference in both groups in terms of rate of correction was significant (p=0.044). The average length of fusion for the fluoroscopy group was 10.89 segments and 10.25 segments for the IGS group (p=0.295).


Conclusion: There is a significant difference in the rate of correction among patient undergoing scoliosis surgery under fluoroscopy guidance vs. image guidance system (p=0.044). The age and sex distribution were similar in both groups. There was no statistical difference in terms of operative time, blood loss and length of fusion.


Keywords: scoliosis, fluoroscopy, c-arm, image intensifier, image guidance system, IGS, CASS, spine, operative time, duration, blood loss, rate of correction

A Comparative Study on MIS TLIF with Unilateral Versus Bilateral Pedicle Screw Fixation

Christopher C. Balaba MD, Agustin Miguel G. Morales MD, Jose Joefrey F. Arbatin MD, Oliver Y. Ong MD

Chong Hua Hospital

Bilateral pedicle screw fixation (BPSF) after Minimally Invasive Surgery, Transforaminal Lumbar Interbody Fusion (MIS TLIF) as adjunct to discectomy in patients who presented with lumbar axial pain and sciatica has revealed higher fusion rate and better clinical outcome. However, early adjacent segment degeneration was suspected due to the rigidity of BPSF. And together with an increased in blood loss, operative time, approach-related morbidity, cost and postoperative pain in BPSF, Unilateral PSF was investigated as a practical alternative. This retrospective study aims to compare clinical and radiographic outcomes of single level Herniated Disc who underwent MIS TLIF between UPSF versus BPSF from January 2011 to December 2012 in a single institution. With a mean follow up of 30months, early result showed comparable outcome as to Visual Analog Scale(VAS) & Oswestry Disability Index(ODI), and radiographic fusion and sagittal profile. Significant decrease in operative time and blood loss was seen in UPSF. Longer hospital stay noted in BPSF but wasn't found to be significant statistically. Therefore, in properly selected patients, UPSF is a practical alternative for BPSF.

Prognostic Factors for the Necessity of Surgical Debridement in Adult Patients with Tuberculous Spondylitis

Pamela Gervacio, MD, Samuel Grozman, MD

Philippine General Hospital

BACKGROUND: Conservative therapy alone with the five first-line anti-tuberculous drugs, namely isoniazid, rifampicin, pyrazinamide, streptomycin and ethambutol has been an effective means of treatment of tuberculous spondylitis. Despite this, some patients treated conservatively worsen and eventually cross over to the surgical group. 


OBJECTIVE: This study aims to determine the prognostic factors for the necessity of surgical debridement in tuberculous spondylitis cases. 


METHODS: Using 23 different clinical, laboratory and radiographic parameters, a multiple logistic regression analysis was done. This data was based on 42 previously managed cases of tuberculous spondylitis. The Spinal Instability Neoplastic Score (SINS) was taken for each patient. T-test analysis was used to determine the correlation of the SINS with surgical debridement. 


RESULTS: Data that were found to be statistically significant (p<0.05), with a 95% confidence interval, in predicting whether the patient should undergo conservative therapy or surgical intervention, were 6 out of 23 variables. These are onset to weakness, rate to non-ambulatory status, the SINS, location of affected vertebra, abnormal alignment, and involvement of posterolateral elements. The SINS had a positive correlation with the need for surgical management, (P=0.060) with 95% confidence interval. Specific MRI findings were not found to be significantly related to necessity for surgical management. 


CONCLUSIONS: Some clinical and radiographic parameters may be helpful in determining the necessity of surgical debridement in patients with tuberculous spondylitis. The SINS may be used in determining spinal instability in tuberculous spondylitis and may be helpful in surgical decision-making. We recommend prospective and larger scale studies for more accurate data collection to determine which patients will need surgical intervention.

Midterm Functional and Radiologic Outcome of Single Level Percutaneous Indirect Decompression and Fusion for the Treatment of Patients with Cervical Disc Disease

Miguel Rafael Ramos, MD, Yehlen Francis Saligumba, MD, Ai Gamboa, MD, Mario Ver, MD

St Luke's Medical Center

Cervical radiculopathy resulting from cervical spondylosis and/or cervical disc disease is often disabling condition common among the aging population. Surgical options include anterior cervical discectomy and fusion (ACDF), total disc replacement (TDR), and posterior laminoforaminotomy. The basic aim of all these surgical treatment is decompression of the neural structures. ACDF and TDR procedures are safe and has reliable outcome but with complications that include implant failure and dislodgement, excessive or incomplete bone healing, spinal deformity and instability, neurological complications, dysphagia, esophageal injury, and recurrent laryngeal nerve palsy and adjacent level degeneration. Development of minimally invasive procedure to address cervical radiculopathy is thought to decrease the chance of adjacent level degeneration and disease. The DTRAX facet screw system is a minimally invasive surgical option for patients with cervical radiculopathy. This paper aims to present the midterm outcome of this novel minimally invasive procedure of facet distraction-fusion for patients who are diagnosed with cervical radiculopathy.

Validation of the Cebuano Version of the Oswestry Disability Index (ODI)

Jan Chiu, MD, Agustin Miguel G. Morales MD, Jose Joefrey F. Arbatin MD, Oliver Y. Ong MD

Chong Hua Hospital

Background: The Oswestry Disability Index is a self-administered questionnaire that consists of ten items to assess the extent of the patient's back pain and difficulty in carrying out ten different activities of daily life. Presently, no validated Cebuano version exists at the time the study will be initiated. 


Objective: To translate and cross-culturally adapt the Oswestry Disability Index (ODI) Version 2.1a to the Cebuano language, and to evaluate its reliability and construct validity to the Cebuano population. Study Design: Prospective Longitudinal Validation Study. 


Methods: The ODI was translated to Cebuano language using established guidelines in three stages: first, was translation to Cebuano language; second, a pilot study of the pre-final version was conducted to fifteen (15) randomly selected patients to assess the comprehensibility and for additional modification; third, to test for reliability and validity of the final version. Forty-nine (49) patients were given the final questionnaire of the Cebuano version 2.1b of ODI, twenty-five of which were advised to answer the same set of questionnaires twice for the test-retest validity. 


Results: The test-retest correlations of Cebuano version ODI revealed that all the correlations are directly proportional. Moreover, there was an item between both tools which showed strong correlation, namely Item No. 1 (r=0.76, p<0.01). It was reflected that both test-retest of Cebuano versions' tools have acceptable or ideal items. Thus, both versions showed acceptable validity. In testing whether ODI score or ratings changed or did not change in test retests, only Item No. 6 ratings significantly changed. The rest of the other items including the overall scores did not show significant differences, thus, this would imply consistency of the translated patient-reported outcome measuring tool (PROM's). 


Conclusion: We have translated and validated one of the most commonly used PROM's on spine-related disability to the Cebuano language and can be used in everyday clinical practice. The Cebuano version of the ODI proved to be reliable and a valid measurement tool that can be used to measure subjective outcomes of pain and disability in Cebuano speaking patients with low back pain.

A Novel Patient-Specific Drill Template for Pedicle Screw Insertion of the Subaxial Cervical Spine Using Stereolithography: An In Vitro Study

Giogio Delgado, MD, Rafael Bundoc, MD

Philippine General Hospital

Cervical pedicle screw fixation is an invaluable tool for posterior cervical fixation owing to its sound biomechanical advantages. Its major drawback is its narrow corridor that leaves very little clearance for neural and vascular injuries. This study describes a unique high technology but low cost do-it-yourself procedure that can provide an accurate means of inserting pedicle screws in the subaxial cervical spine. 


Fifty subaxial cervical vertebrae from five cervical cadavers were scanned into thin slices using computed tomography. DICOM images of the cadaver spine were digitally processed in a DICOM reader software and images were exported as ".stl" file. Latter was printed using an office desktop 3D printer to produce 1:1 scale ABS plastic models. Kirschner wires were carefully inserted into the pedicles of the entire 3D printed plastic spine models. A mold was created to incorporate the Kirschner wires over the posterior elements of the 3D printed plastic spine models using polymethylmethacrylate cement. Each of these molds provided us the specific trajectory of the pedicles of every 3D printed models that correspond to a cadaveric vertebra. Latter served as our drill guide template. The molds were then used to insert pedicle screws in each of the fifty cadaveric cervical vertebrae. 


The instrumented cadaveric spines were again subjected to computed tomography to assess the accuracy of our pedicle placement by an external observer. Our case-specific drill guide template showed an accuracy of 92% in allowing us to insert cervical pedicle screws.

Factors affecting quality of life among adult Filipino Pott’s patients

Jewel Sadiang-Abay, MD, Ferdinand Bernal. MD

Philippine Orthopedic Center

In the Philippines, a study by Vianzon reported a total of 1 379 390 diagnosed cases of tuberculosis from 2003 to 2011. Of these, extra-pulmonary tuberculosis comprise 1.1%. Among the forms of extra-pulmonary tuberculosis, Potts can be most devastating with the threat of spinal cord compression and deformity. 


WHO defines Quality of Life as an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. 


This study aimed to identify the factors that define the quality of life of patients suffering from spinal TB. 


This was a cross sectional study of patients who consulted at Philippine Orthopaedic Center. Forty seven patients were asked to answer the WHO BREF QOL. The factors that were investigated include age, gender, spinal level of disease, level of education, marital status, hospital admission and length of stay, time interval from onset of symptoms to initial consult, months of anti-Kochs medication among others. 


The questionnaire was administered in the outpatient and inpatient setting by the primary investigator and spine surgery residents. The data were tabulated, mean scores and demographics were obtained, odds ratio and relative risk ratio were computed. 


The mean age of patients was 38 years old. There were 24 males and 23 females. Thirty three of these patients have Potts in the thoracic level, 11 on the lumbar and 3 on the cervical. Thirty one patients were high school graduate or undergraduate; 5 were elementary graduate or undergraduate; 11 were either college graduate or undergraduate. Twenty eight patients were admitted. The average hospital stay was 3 months. The average time interval from onset of symptoms to initial consult was 6 months. Twelve months was the average length of time the patients have used Anti-Kochs treatment. 


Higher level of education, less than 3 months hospital stay, less than 6 months interval of onset of symptoms to initial consult, intact bowel and bladder continence were positively associated with good quality of life. Level of spine affected (cervical), prolonged hospital admission and less than 12 months of treatment brings about poor quality of life. 


This paper presented the factors that define the quality of life of Filipino patients with Potts disease that can be explained in the socio cultural context of a developing country.

The Urgency of Early Intervention on Traumatic Cervical Spine Injuries: Comparative Study of Early vs Delayed Surgery

Angelica Lee Real, MD, Mary Ruth Padua, MD

East Avenue Medical Center

BACKGROUND: Early decompression of acute cervical spinal cord injuries (SCI) is associated with improved outcomes. However, due to logistical limitations, there are numerous cases of delayed management in our setting. The outcome of these cases remain uncertain. 


STUDY DESIGN: Retrospective cohort study. 


STUDY OBJECTIVE(S): Evaluate the (1) outcome of early (? 7 days after injury) versus late (>7 days after injury) decompression surgery after traumatic cervical SCI using the ASIA Impairment Scale (AIS), and (2) mortality rates. 


METHODOLOGY AND RESULTS: All patients with traumatic cervical spine injuries seen at the emergency room from January 2014 to May 2016 were included in this study. A total of 34 patients with acute cervical SCI were included in this study. Mean duration of injury to date of consult or admission is at 1.0  8.49 days. Mean time to operative management for the patients who underwent surgery (n=24, 68.57%) was at 7.10  16.0 days. Patients were further stratified into early (?7 days after injury) and late (>7days after injury) surgical management based on the computed mean. Improvements of ? 1-grade were reported in 9 patients (39.13%) and 3 patients (13.04%) who underwent early surgical management and late surgical management respectively, with odds ratio of 2.5000, with confidence interval of (0.4279 to 14.6070) p = 0.3090. Increased survival rates (N=14, 60.87%) were observed in patients who underwent early surgery (versus patients who underwent late surgery N= 6, 26.09%), with odds ratio of OR: 4.6667, CI (0.3552-61.8336) p =0.2426. 


CONCLUSION: Early surgical decompression (?7 days after injury) is associated with at least one-grade AIS improvement and increased survival rates at 12 weeks follow up.

Anterior Cervical Osteophyte (C1-C2) and Dysphagia

Ralph Dennis A. Vicente, MD, Adrian B. Catbagan, MD

Armed Forces of the Philippines Medical Center

Anterior cervical osteophytes are common in elderly patients, being found in up to 20-30% of the geriatric population. While in the younger population, certain conditions predispose to osteophyte formation. The development of anterior cervical osteophytes mainly involves the cartilage-periosteum attachment and capsule ligament traction areas. There are several causes of cervical osteophytes, and most are due to degenerative causes. There are factors responsible for the local osteogenesis, notably mechanical factors. Anterior cervical osteophytes can be isolated or diffuse; they are most often idiopathic and part of a form called Forestier disease (diffuse idiopathic skeletal hyperostosis). This condition may be due to a trauma or iatrogenic cause (particularly following spinal surgery). It can be a common finding but patients are rarely symptomatic. Dysphagia is typically the presenting symptom. It is usually caused by a mechanical obstruction of the esophagus. We present the case of a patient with marked anterior cervical osteophytes that resulted in dysphagia.

Thoracic Radiculopathy secondary to Ossified Ligamentum Flavum in a Young Caucasian Female: A Case Report

Miguel Rafael Ramos, MD, Mario Ver, MD

St Luke's Medical Center

Background. Ossification of the ligamentum flavum (OLF) is described as the replacement of the ligamentum flavum with lamellar bone and is an uncommon cause of thoracic myelopathy1, predominantly in East Asian populations. However, OLF remains a rare cause of thoracic radiculopathy in this population, and even more so in non-East Asian individuals2. We present a rare case of thoracic radiculopathy caused by OLF in a Caucasian female, and the consequent operative management that afforded complete relief of her symptoms. 


Case Report. A 36-year old Caucasian female presented with severe, intractable mid-back pain radiating sharply to her left subcostal area without preceding trauma. Neurological examination revealed a mild sensory deficit at the left side of her abdomen along the T10 dermatome. There was no muscle weakness, sensory deficits, nor myelopathic signs in the lower extremities and she displayed normal deep tendon reflexes. 


Surgical Procedure. The patient underwent posterior spinal decompression of T9-T12 levels via laminectomies without facetectomies nor subsequent instrumentation. Excision of the visible OLF was also performed. Post-operatively, her pain was relieved and was without the previous T10 sensory deficit upon her successful discharge. 


Discussion. Functionally, the ligamentum flavum provides a static, elastic force to aid the spinal column in its return to neutral position after flexion and extension. Despite the knowledge on its anatomy and function for almost a century, the exact pathophysiology of OLF has not been elucidated yet and only theories on extrinsic and intrinsic causes have been the basis of its occurrence. Clinically, thoracic OLF would predominantly present with myelopathy and not radiculopathy. It has been suggested that thoracic OLF would rarely cause radicular pain precisely due to the pattern of the disease progression, which would leave the neural foramen without compromise. 


Conclusion. This case represents the only documented Caucasian female who presented with thoracic radiculopathy due to OLF. Although a rare cause, thoracic OLF should be remain a differential diagnosis when chest or abdominal radicular pain presents even without the presence of myelopathic symptoms. If a trial of conservative treatment results in persistence of debilitating pain, surgical intervention must be entertained.

Progressive Local Anesthesia for Lumbar Microdiscectomy in a Pregnant Patient with Cauda Equina Syndrome: A Case Report

Mannuel Alican, MD, Miguel Rafael Ramos, MD, Mario Ver, MD

St Luke's Medical Center

Introduction. Symptomatic lumbar disc herniation is a rare occurrence during gestation despite the fact that low back pain complicates around 56% of pregnant patients. In line with this, cauda equina during pregnancy have only been documented in literature twice and considered as extremely rare. Advancements in surgical technique coupled with the proven safety of magnetic resonance imaging has made lumbar discectomy a viable and justifiable procedure at any stage of pregnancy. This paper was created to present a rare case of a pregnant patient with cauda equina syndrome treated surgically with lumbar microdiscectomy employing progressive local anesthesia as a novel alternative to neuraxial anesthesia. 


Case. A 30-year old multigravid primiparous woman with a seven month history of intermittent low back pain sought consult at 14 weeks' gestation because of severe right leg pain which confined her to bed rest at home. The pain was associated with saddle anesthesia of the perineum, urinary incontinence and constipation without any recalled precipitating factors. Physical examination revealed weakness of the right foot everters and plantar flexors, loss of sensation in the L5-S1 nerve root distributions, and positive straight leg raise bilaterally. MRI confirmed an extruded disc at L5-S1. 


Surgery. The patient underwent right-sided L5S1 foraminotomy, laminotomy and discectomy L5S1 under microscopic guidance. Immediately post-operatively, the patient experienced relief of her leg pain and later on delivered a premature male at 33 weeks' gestation by normal spontaneous delivery. At one year follow-up, patient denied any low back pain, residual paresthesia or motor weakness of both lower extremities, saddle anesthesia, nor urinary or bowel disturbances. 


Discussion. The surgical and anesthetic technique used in the study resulted in the desired outcome of decompression of the spinal cord and involved nerve roots, relief of patient pain post-operatively, disappearance of symptoms of cauda equina syndrome, and, ultimately, the uncomplicated delivery of a healthy infant. 


Conclusion. This case represents the only documented use of progressive local anesthesia in lumbar surgery in a pregnant patient suffering from cauda equina syndrome. A rare condition in its own right, cauda equina syndrome is just as debilitating in the pregnant patient as it is in the normal population and still constitutes an orthopedic emergency that should be managed promptly without hesitation. As highlighted in this report, progressive local anesthesia may be a quick, effective, and non-expensive anesthetic option for these cases and in cases where neuraxial anesthesia is contraindicated.

Failed Back Surgery Syndrome and Failed Neck Surgery Syndrome in One Patient: A Case Report

Kathryn Jimenez, MD, Antonio Sison, MD

Veterans Memorial Medical Center

Failed back surgery syndrome (FBSS) is the term used to describe patients who experience chronic lower back pain and/or leg pain after spinal surgery. The pain can be physically disabling, emotionally depressing and financially draining. Revision surgery is a treatment option but the 2nd operation has a 50% success rate and succeeding reoperations are expected to give worse results. This grim scenario poses a major challenge to the surgeon. Therefore, a careful patient evaluation which includes the history, symptomatology, past operations, imaging studies, and psychological behavior is crucial in formulating a treatment plan strategy. Similarly, in failed neck surgery syndrome (FNSS), the presentation is much the same but this time, patients complain of persistent, recurrent or worsened neck pain and/or arm pain after cervical spinal surgery. The case of a 36/male patient who suffered from both FBSS and FNSS is presented. He has undergone 4 lumbar spine operations in a 12 year period and 4 cervical spine operations including a shoulder arthroscopy in a span of 4 years. In both instances, conservative treatment was attempted first before deciding to do another revision surgery, knowing that the overall outcome is less favorable.

C1-C2 Pott’s Disease: A Unique Picture of Spine Tuberculosis

Angelica Lee Real, MD, Mary Ruth Padua, MD, Adrian B. Catbagan, MD

East Avenue Medical Center

Study Design: Case report and literature review. 


Objective: To report the case, clinical course, management, and outcome of a 49 year old female who was diagnosed with Pott's Disease at the C1  C2 level.


Case Presentation: We present a 49 year old female seamstress who experienced gradual onset lower and upper extremity weakness and numbness, bowel and bladder incontinence, and progressive right neck pain of two months duration. Open biopsy of the C2 level was then performed revealing chronic granulomatous inflammation with Langhan's type Giant cells and casseation necrosis. Patient was started on anti Koch's treatment and underwent posterior decompression, occipitocervical fusion and instrumentation C0 to C6. Neurologic status was then monitored regularly postoperatively, with marked improvement of neurologic status, disappearance of cervical pain, and eventual return to previous functional occupation as a seamstress.

Posterior-only one level vertebral column resection (VCR) without anterior column reconstruction for post-tuberculous kyphosis: a case report

Anthony A. Suguitan, M.D., Ryan Conrad A. Carnero, M.D., Reggie A. Torredes, M.D., Ferdinand R. Bernal, M.D, Franklin M. Dizon III, M.D, Mark U. Pasion, M.D.

Philippine Orthopaedic Center

Objectives: To describe a local experience in using posterior-only one level vertebral column resection without anterior column reconstruction for post-tuberculous kyphosis of the lumbar spine. The technique has been reported in literature but to our knowledge, no local paper has been published about it. 


Methods: A 24-year-old female with a rigid lumbar angular kyphotic deformity of 600 (-300 lordosis) had presented with low back pain and numbness on lateral aspect left thigh after completion of 1-year anti-Koch's regimen for L1-L3 TB spondylodiscitis. She underwent posterior-only vertebral column resection of L2, laminectomy of T12-L4, and posterior instrumented corrective fusion of T11-L5 with autogenous anterior bone grafting of adjacent levels post-resection. 


Results: Patient was able to walk with brace 1 week after surgery. Successive follow-ups up to 5 months showed signs of bony fusion with no signs of implant failure or loosening. Oswestry Disability Index improved from 28.9 to 5 at last follow-up. 


Conclusion: Our initial results show that posterior-only one level vertebral column resection without anterior column reconstruction is safe and efficacious but challenging in lumbar post-tuberculous kyphosis correction.