Magnetically controlled growing rods (MCGRs) are an effective alternative to traditional growing rods (TGRs) in the treatment of early-onset scoliosis (EOS), with comparable deformity correction despite fewer planned reoperations. This case report presents a unique case of autofusion in a patient with tetraplegic cerebral palsy, thoracic myelomeningocele, and EOS who was treated with dual MCGR instrumentation and underwent serial lengthening procedures for four years. We detail the operative and radiographic findings in a novel case of autofusion encountered after MCGR placement to treat EOS. An eight-year-old female with tetraplegic cerebral palsy causing a 94° right thoracic neuromuscular scoliosis was treated with dual MCGRs; she then underwent serial lengthenings every four months. At 12 years of age, during MCGR explantation and posterior spinal fusion, dense heterotopic autofusion was encountered around the MCGR instrumentation, limiting further deformity correction. The benefits of MCGRs make them an appealing alternative to TGRs for the treatment of EOS. Although the theoretical risk of autofusion in MCGRs is low, recent case reports propose autofusion as a possible reason for MCGRs' failure to lengthen.

Study Design: Retrospective case series. Objective: To examine the incidence and risk factors for postoperative pain following anterior vertebral body tethering (AVBT) for adolescent idiopathic scoliosis (AIS). Summary of Background Data: Up to 78% of patients with AIS report preoperative pain; it is the greatest patient concern surrounding surgery. Pain significantly decreases following posterior spinal fusion, but pain following AVBT is poorly understood. Materials and Methods: We retrospectively reviewed 279 patients with a two-year follow-up after AVBT for AIS. We collected demographic, radiographic, and clinical data pertinent to postoperative pain at each time interval of preoperative and postoperative visits (6 wk, 6 mo, 1 y, and annually thereafter). Results: Within our cohort, 68.1% of patients reported preoperative pain. Older age (P=0.014) and greater proximal thoracic (P=0.013) and main thoracic (P=0.002) coronal curve magnitudes were associated with preoperative pain. Pain at any time point > 6 weeks postoperatively was reported in 41.6% of patients; it was associated with the female sex (P=0.032), need for revision surgery (P=0.019), and greater lateral displacement of the apical lumbar vertebrae (P=0.028). The association between preoperative and postoperative pain trended toward significance (P=0.07). At 6 months postoperatively, 91.8% had pain resolution; the same number remained pain-free at the time of last follow-up. The presence of a postoperative complication was associated with new-onset postoperative pain that resolved (P=0.009). Only 8.2% had persistent pain, although no risk factors were found to be associated with persistent pain. Conclusion: In our cohort of 279 patients with a minimum 2-year follow-up after AVBT, 68.1% reported preoperative pain. Nearly 42% reported postoperative pain at any time point, but only 8.2% had persistent pain. Postoperative pain after AVBT was associated with female sex, revision surgery, and Lenke lumbar modifier. AVBT is associated with a significant reduction in pain, and few patients report long-term postoperative pain.

Study Design. Retrospective review. Objective. To study risk factors for anterior vertebral body tether (VBT) breakage. Summary of Background Data. VBT is used to treat adolescent idiopathic scoliosis in skeletally immature patients. However, tethers break in up to 48% of cases. Materials and Methods. We reviewed 63 patients who underwent thoracic and/or lumbar VBT with a minimum five-year follow-up. We radiographically characterized suspected tether breaks as a change in interscrew angle >5°. Demographic, radiographic, and clinical risk factors for presumed VBT breaks were evaluated. Results. In confirmed VBT breaks, the average interscrew angle change was 8.1°, and segmental coronal curve change was 13.6°, with a high correlation ( r =0.82). Our presumed VBT break cohort constituted 50 thoracic tethers, four lumbar tethers, and nine combined thoracic/lumbar tethers; the average age was 12.1±1.2 years and the mean follow-up was 73.1±11.7 months. Of 59 patients with thoracic VBTs, 12 patients (20.3%) had a total of 18 breaks. Eleven thoracic breaks (61.1%) occurred between two and five years postoperatively, and 15 (83.3%) occurred below the curve apex ( P <0.05). The timing of thoracic VBT breakage moderately correlated with more distal breaks ( r =0.35). Of 13 patients who underwent lumbar VBT, eight patients (61.5%) had a total of 12 presumed breaks. Six lumbar breaks (50%) occurred between one and two years postoperatively, and seven (58.3%) occurred at or distal to the apex. Age, sex, body mass index, Risser score, and curve flexibility were not associated with VBT breaks, but the association between percent curve correction and thoracic VBT breakage trended toward significance ( P =0.054). Lumbar VBTs were more likely to break than thoracic VBTs ( P =0.016). Seven of the patients with presumed VBT breaks (35%) underwent revision surgery. Conclusions. Lumbar VBTs broke with greater frequency than thoracic VBTs, and VBT breaks typically occurred at levels distal to the curve apex. Only 15% of all patients required revision. Level of Evidence. 3.

STUDY DESIGN:Retrospective case series. OBJECTIVE:To examine the incidence and risk factors for postoperative pain following anterior vertebral body tethering (AVBT) for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA:Up to 78% of patients with AIS report preoperative pain; it is the greatest patient concern surrounding surgery. Pain significantly decreases following posterior spinal fusion, but pain following AVBT is poorly understood. MATERIALS AND METHODS:We retrospectively reviewed 279 patients with a two-year follow-up after AVBT for AIS. We collected demographic, radiographic, and clinical data pertinent to postoperative pain at each time interval of preoperative and postoperative visits (6 wk, 6 mo, 1 y, and annually thereafter). RESULTS:Within our cohort, 68.1% of patients reported preoperative pain. Older age ( P =0.014) and greater proximal thoracic ( P =0.013) and main thoracic ( P =0.002) coronal curve magnitudes were associated with preoperative pain. Pain at any time point > 6 weeks postoperatively was reported in 41.6% of patients; it was associated with the female sex ( P =0.032), need for revision surgery ( P =0.019), and greater lateral displacement of the apical lumbar vertebrae ( P =0.028). The association between preoperative and postoperative pain trended toward significance ( P =0.07). At 6 months postoperatively, 91.8% had pain resolution; the same number remained pain-free at the time of last follow-up. The presence of a postoperative complication was associated with new-onset postoperative pain that resolved ( P =0.009). Only 8.2% had persistent pain, although no risk factors were found to be associated with persistent pain. CONCLUSION:In our cohort of 279 patients with a minimum 2-year follow-up after AVBT, 68.1% reported preoperative pain. Nearly 42% reported postoperative pain at any time point, but only 8.2% had persistent pain. Postoperative pain after AVBT was associated with female sex, revision surgery, and Lenke lumbar modifier. AVBT is associated with a significant reduction in pain, and few patients report long-term postoperative pain.

Extradural atlantoaxial cysts are typically related to C1-2 degeneration. Intradural cysts may cause secondary syringobulbia depending on the size and cerebrospinal fluid flow obstruction. However, medullary syrinxes have not been previously described with extradural cysts. Treatment of symptomatic lesions involves surgical resection, often via a far-lateral approach, with consideration of fusion if C1-2 instability is present. We present a case of an extradural C1-2 cyst with intradural extension causing syringobulbia. Effective surgical resection was accomplished via a far-lateral, partial transcondylar approach without fusion. It is important to recognize that cysts of extradural origin may exhibit intradural extension and compress critical neurovascular structures.

A 79-year-old woman presented with acute-onset right leg pain in the setting of 3 months of progressive gait deterioration and bilateral leg weakness. On exam she had right lower extremity hyperreflexia and weakness. Lumbar spine magnetic resonance imaging demonstrated L3-L5 central canal stenosis with L4-L5 spondylolisthesis and a previously undiagnosed tethered cord. She underwent minimally invasive left segmental sublaminoplasty at L3-L4 and L4-L5 for spinal cord decompression with onlay arthrodesis resulting in resolution of her radicular pain and improved strength. This is a unique case of lumbar spinal stenosis presenting with myelopathy in the context of a previously asymptomatic and undiagnosed tethered cord.

BACKGROUND:Intracranial metastasis is a common complication of systemic malignancy. A rare subset of intracranial masses constitutes tumor-to-tumor metastasis, in which an extracranial neoplasm hematogenously spreads to an existing intracranial lesion.CASE DESCRIPTION:Here we present the unique case of a 59-year-old man with known hepatocellular carcinoma who presented with acute headaches, double vision, vertigo, and gait instability in the context of 2 years of right-sided hearing loss. Head imaging showed a heterogeneous right cerebellopontine angle mass extending into the porus acousticus with adjacent cerebellar edema. Histopathologic analysis after resection found coexisting hepatocellular carcinoma within a vestibular schwannoma.CONCLUSIONS:Tumor-to-tumor metastasis is an important consideration in the diagnostic work-up and treatment of patients with known systemic malignancy who present with a new intracranial lesion. This pathologic entity could be missed if this patient were treated with single-fraction radiosurgery such as Gamma Knife.