1

Contents

Organising Committee 2

Malaysia Spine Society – Council 2015-2017

Message from the Right Honourable Chief Minister of Penang 3

Message from the President of the Malaysia Spine Society 4

Message from the Organising Chairman 5

Faculty 6

Programme Summary 7

Pre-Congress Workshop 8

Daily Programme 9 – 13

Post-Congress Workshop 13

Floor Plan & Trade Exhibition 14

Acknowledgements 15

Abstracts 16 – 56

• Symposia/Plenaries 16 – 22

• BestResearchAward(OralPresentations) 23 – 29

• FreePapers 30 – 40

• PosterPresentations 41 – 56

2

Organising Committee

Malaysia Spine Society Council 2015 – 2017

Chairman Dr K Parameshwaran

Scientific Chairman Assoc Prof Dr Chris Chan Yin Wei

BusinessManager Dato’ Dr K S Sivananthan

Hon Secretary Assoc Prof Dr Sabarul Afian Mokhtar

Hon Treasurer Prof Dr Kwan Mun Keong

Opening Ceremony and Gala Dinner Dr Nor Azlin Zainal Abidin

Publications and Publicity Dr Abdul Hadi Hussin

Audio Visual Dr Chiu Chee Kidd

Committee Members Assoc Prof Dr Abdul Halim Yusof

Dr Abdul Malik Hussein

President Dato’ Dr K S Sivananthan

Hon Secretary Assoc Prof Dr Sabarul Afian Mokhtar

Hon Treasurer Prof Dr Kwan Mun Keong

Committee Members Dr K Parameshwaran

Dr Nor Azlin Zainal Abidin

Dr Abdul Hadi Hussin

Dr Chiu Chee Kidd

Assoc Prof Dr Chris Chan Yin Wei

Dr Abdul Malik Hussein

Hon Auditor Assoc Prof Dr Abdul Halim Yusof

3

Message from the Right Honourable Chief Minister of Penang

My warmest congratulations to the Council of the Malaysia Spine Society for

choosing Penang for this international scientific meeting. Besides being a top

tourist destination, Penang is also well known as a health tourism hub.

This is due to the reasonable cost of treatment and the professionalism of its

medical workers. Of course, the most important factor is the high standard

of the care provided by the doctors and nurses. I urge the doctors to continue

to keep abreast with the latest advances by attending international medical

meetings like this one.

As Malaysia steers to attain international recognition, healthcare professionals

must focus on performance, productivity and proficiency, and ensure medical

care flourishes in the country. Penang is proud to control 60% of medical

tourism revenue in Malaysia, principally due to the excellent healthcare

provided at reasonable cost.

I have been informed that the Malaysia Spine Society also organises annual

scientific congress in collaboration with international bodies. This will help to

upgrade our spine surgeons with the latest medical inventions and technology.

While in Penang, I urge all of you to take time to experience the beautiful

Island with its varieties of culture and cuisine.

Thank you.

Lim Guan Eng

4

It gives me great pleasure to welcome you to the 4th International Malaysia

Spine Society Scientific Congress from 8th to 10th August 2016, at G Hotel,

Penang, Malaysia.

The scientific programme focuses on pre-congress workshops, plenaries,

symposia and instructional course lectures, to be given by distinguished

speakers from across the world. This conference will provide an invaluable

insight into the daily practice of spine surgery in the region, on a granular

level.

We hope that the meeting will enhance your interactions with the invited

experts to share and improve knowledge on the latest international research

and development in the field of spine surgery and pain management. The

Malaysia Spine Society is set up to provide continuing medical education,

fellowship and unity for the spine surgeons in Malaysia, and our annual

conference is an important part of this mission.

I hope you could make time to see the beautiful Penang Island and enjoy its

amazing local cuisine and culture.

Dato’ Dr K S Sivananthan

Message from the President of the Malaysia Spine Society

5

Message from the Organising Chairman

On behalf of the Organising Committee, I would like to extend a warm

welcome to all of you to the 4th International MSS Scientific Congress in this

fascinating and beautiful island of Penang, the Pearl of the Orient.

I am sure you will enjoy the scientific programme which will broaden your

academic interest in spinal surgery. You can learn the latest advances in spinal

surgery from a panel of experts in this field. The faculty of international

speakers from South East Asia, Indian Subcontinent, Far East and Australia

will present the latest developments in spinal surgery and also shine light

on how they handle these conditions and share tips on how to perform the

surgeries.

On the last day, we have included a pain control module which will enlighten

you on the different aspects of interventional pain control methods. To

top it all, there is also a life surgery workshop organised on epiduroscopic

decompression in one of our private medical centres.

Penang is one of the food havens of the world, so let your appetites go crazy

on the excellent and inexpensive food spreads. Also, do not forget to spend

time visiting some of the interesting places which have been designated as

UNESCO sites.

Dr K Parameshwaran

6

AustrAliAAustrAliA

Orso Osti

Stephan Schug

JApAnJApAn

Kuniyoshi Abumi

KoreAKoreA

Chung Jae Yoon

Lim Kang Taek

pAKistAnpAKistAn

Tariq Sohail

philippinesphilippines

Jose Manuel Ignacio

singAporesingApore

Wong Hee Kit

thAilAndthAilAnd

Wattana Mahattanakul

Warat Tassanawipas

Abdul Halim Yusof

Abdul Malik Hussein

Anwar Samhari bin Mat Arshad

AzmibinBaharudin

Chris Chan Yin Wei

Choong Leong Tong

Fazir Mohamad

Kwan Mun Keong

Lim Heng Hing

Mohd Hisam Muhamad Ariffin

Mohd Imran Yusof

Muralitharan Perumal

Sabarul Afian Mokhtar

K S Sivananthan

Wong Chung Chek

Faculty

internAtionAl

loCAl

7

Datetime

8th august 2016monDay

9th august 2016tuesDay

10th august 2016WeDnesDay

0700 – 0800 Meet-The-Experts Session Meet-The-Experts Session

0800 – 0830 Module 1 Fundamentals Of

Spine Surgery

Module 6 Debate Series

Plenary 2

0830 – 0900 Plenary 3

0900 – 0930 Plenary 1Module 7

Sagittal Balance

Coffee / Tea

0930 – 1000 Opening Ceremony

Module 12 Pain Management

1000 – 1030 Coffee / Tea Coffee / Tea

1030 – 1100

Module 2 Case Presentation And Operative Video Session

Module 8 Free Paper Presentations

1100 – 1130

1130 – 1200 Module 9 Cervical Degenerative

Diseases1200 – 1230 Module 3 Best Research Award (Oral Presentations)

Lunch1230 – 1300 Lunch Satel l i te Symposium(Baxter)

1300 – 1330Lunch Satel l i te Symposium

(S iemens)Lunch Satel l i te Symposium

(Pf izer)1330 – 1400

1400 – 1430

1430 – 1500Module 4

Spinal EmergenciesModule 10

Cervical Trauma1500 – 1530

1530 – 1600Module 5

Safety And Complications

Module 11 Common Conditions In My Spine Practice1600 – 1630

1630 – 1700 Tea Satel l i te Symposium (MSD)

Coffee / Tea

Coffee / Tea

1700 – 1730

7th august 2016 sunDay

10th august 2016 WeDnesDay

1400 – 1800Pre-Congress WorkshoP

Recent Advances in Spine Surgery1400 – 1900

PosT-Congress WorkshoPSacral Epiduroscopic Laser

Decompression (SELD), Live Workshop

Programme Summary

8

Pre-Congress Workshoprecent Advances in spine surgeryrecent Advances in spine surgery

Date : 7th August 2016 (Sunday)

Time : 1400 – 1800 hrs

Venue : Salon V, Level 2, G-Hotel Penang, Malaysia

Facilitators : K S Sivananthan

Abdul Malik Hussein

Programme

1400 – 1410 Opening Remarks

1410 – 1425 Adult deformity classification

1425 – 1440 Adult spinal deformity treatment options

1440 – 1500 Sacro pelvic fixation treatment options and techniques

1500–1520 mPACT(mediatizedPosteriorApproachCorticalboneTrajectory)

Biomechanicalstudyanditstechnique&casediscussion

1520 – 1530 Q & A

1530 – 1550 Tea

1550 – 1620 Hands-on session for S2Alar Iliac Fixation

1620 – 1650 Hands-on session for mPACT

1650 – 1700 Closing Remarks

Wong Chung Chek

K Parameshwaran

9

0700 – 0800 Meet-The-Experts SessionChung Jae Yoon, Tariq Sohail, Fazir Mohamad, Kwan Mun Keong

0800 – 0900 MODULE 1: MODULE 1: Fundamentals Of Spine SurgeryChairpersons: Abdul Hadi Hussin / Brian Teo

Plain radiological parameters in daily spine surgery practiceChiu Chee Kidd

Thoracolumbar fracture: Classification and management updateChris Chan Yin Wei

Magnetic resonance imaging: The basics and clinical correlation in lumbar degenerative disease [PAGE 16][PAGE 16]Kwan Mun Keong

Classification: Rules and regulation in Lenke classification and when it can be brokenWong Hee Kit

0900 – 0930 PLENARY 1PLENARY 1Chairperson: K S Sivananthan

Anterior surgery for AIS: Is it still relevant?Wong Hee Kit

0930 – 1000 Opening Ceremony

1000 – 1030 Coffee / Tea

1030 – 1200 MODULE 2: MODULE 2: Case Presentation And Operative Video SessionChairpersons: Nor Azlin Zainal Abidin / Chiu Chee Kidd

Over the top decompressionAbdul Halim Yusof

MIS TLIF [PAGE 17][PAGE 17]Mohd Hisam Muhamad Ariffin

CorrectionofdeformityinthecraniocervicaljunctionKuniyoshi Abumi

Reduction techniques in adolescent idiopathic scoliosisKwan Mun Keong

Posterior vertebral column resection for spinal deformitiesWong Chung Chek

1200 – 1300 MODULE 3: MODULE 3: Best Research Award (Oral Presentations) [PAGE 23 – 29][PAGE 23 – 29]Chairpersons: Chris Chan Yin Wei

Daily Programme8tH AuguSt 2016, MOnDAy

10

Daily Programme8tH AuguSt 2016, MOnDAy (continued)

1300 – 1430 Lunch Satel l i te Symposium (S iemens)

My experience with intra-operative 3D imagingWong Chung Chek

Advanced imaging applications for spine surgeryLouis Deleforge

1430 – 1530 MODULE 4: MODULE 4: Spinal EmergenciesChairpersons : Abdul Halim Yusof / Abdul Hadi Hussin

Acute cauda equina syndrome [PAGE 17][PAGE 17]Mohd Imran Yusof

Acute central cord syndromeFazir Mohamad

Metastatic epidural spinal cord compression with neurological deficitMohd Hisam Muhamad Ariffin

Spondylodiscitis with epidural abscessAbdul Malik Hussein

1530 – 1630 MODULE 5: MODULE 5: Safety and ComplicationChairpersons : Chong Chee Seang / Dzulkarnain Amir

How to minimise blood loss in spine surgeryFazir Mohamad

Safety of pedicle screw instrumentation in spinal surgery [PAGE 18][PAGE 18]Kwan Mun Keong

Management of neural complications after spinal surgeryWong Chung Chek

Surgical site infection: Avoidance and management tipsJose Manuel Ignacio

1630 – 1730 Tea Satel l i te Symposium (MSD)

1700 – 1730 Coffee / Tea

11

Daily Programme9tH AuguSt 2016, tueSDAy

0700 – 0800 Meet-The-Experts SessionWong Hee Kit, K S Sivananthan, Warat Tassanawipas, Abdul Malik Hussein

0800 – 0900 MODULE 6: Debate SeriesChairperson : Lim Heng Hing

Case 1: T12 burst fracture: Open vs percutaneous techniqueAbdul Malik Hussein , Tariq Sohail

Case 2: Degenerative scoliosis: Short vs long fusionWarat Tassanawipas, K S Sivananthan

0900 – 1000 MODULE 7: MODULE 7: Sagittal BalanceChairpersons : Saw Lim Beng / Lee Chee Kean

Importance of pelvic parameters in sagittal balanceWong Hee Kit

Surgical techniques to increase lumbar lordosis in degenerative kyphoscoliosisWong Chung Chek

Experience of multi-segmental osteotomy of ankylosing spondylitisChung Jae Yoon

Proximaljunctionalkyphosis [PAGE 19][PAGE 19]Warat Tassanawipas

1000 – 1030 Coffee / Tea

1030 – 1130 MODULE 8: MODULE 8: Free Paper PresentationsChairpersons : Jayamalar / Manoharan a/l Krishnan

1130 – 1230 MODULE 9: MODULE 9: Cervical Degenerative DiseasesChairpersons : Zamzuri Zakaria / Tariq Sohail

Cervical radiculopathy: Anterior vs posterior approachJose Manuel Ignacio

Cervical spondylotic myelopathy: Indications for surgeryChung Jae Yoon

OPLL: The strategic approach [PAGE 20][PAGE 20]Warat Tassanawipas

Managing complications in cervical spine surgeryKuniyoshi Abumi

1230 – 1300 Lunch Satel l i te Symposium (Baxter)Chairperson : Chris Chan Yin Wei

My experience: Flowable hemostat in MIS spine surgeriesWattana Mahattanakul

1300 – 1430 Lunch Satel l i te Symposium (Pf izer)

Multimodal analgesia: How to optimise combinations to manage post-operative painStephan Schug

12

Daily Programme9tH AuguSt 2016, tueSDAy (continued)

1430 – 1530 MODULE 10: MODULE 10: Cervical TraumaChairpersons : Zairul Anuar / Zamzuri Zakaria

Cervical facet dislocation: My approachWong Chung Chek

Cervical pedicle screws in the management of cervical fracturesKuniyoshi Abumi

UpdateinmanagementofspinalcordinjuryAzmi bin Baharudin

The patient with complete neurological deficit: Is decompression indicatedJose Manuel Ignacio

1530 – 1630 MODULE 11: MODULE 11: Common Conditions In My Spine PracticeChairpersons : Mazwar Sofiyan / Tariq Sohail

Lumbar disc herniation: Keys to success in conservative managementK S Sivananthan

Axial back pain management [PAGE 21][PAGE 21]Mohd Imran Yusof

Surgical decision in management of spondylolisthesisChung Jae Yoon

Pyogenic infection of the spine: Assessment and management Chris Chan Yin Wei

1630 – 1700 Coffee / Tea

13

0800 – 0830 PLENARY 2PLENARY 2Chairperson : K Parameshwaran

Pathophysiology and update on pain managementAnwar Samhari bin Mat Arshad

0830 – 0900 PLENARY 3PLENARY 3Chairperson : K Parameshwaran

Failed back syndrome Orso Osti

0900 – 0930 Coffee / Tea

0930 – 1200 MODULE 12: MODULE 12: Pain ManagementChairpersons : Deepak Ajit Singh / Orso Osti

0930 – 1000 Ultrasound guided spine interventions. The possibilities and advantagesChoong Leong Tong

1000 – 1030 Trans sacral epiduroscopic laser decompression in lumbar disc herniation [PAGE 22][PAGE 22]Lim Kang Taek

1030 – 1100 Nucleoplasty in disc desication – Mechanism, types and results Lim Heng Hing 1100 – 1130 Facet pathology – Medial branch block, radiofrequency or surgery Orso Osti 1130 – 1200 Coccydynia – Conservative treatment (ganglion impar block) and pyriformis syndrome (overview of diagnosis and treatment) Muralitharan Perumal

1200 – 1300 Lunch

Post-Congress Workshopsacral epiduroscopic laser decompression (seld), live Workshopsacral epiduroscopic laser decompression (seld), live Workshop

“A Frontier to Look at Back Pain”

Date : 10th August 2016 (Wednesday)

Time : 1400 – 1900 hrs

Guest Faculty : Lim Kang Taek

Facilitator : Lim Heng Hing

Venue : OT Conference Room 9th Floor & OT 5, Gleneagles Hospital Penang

Daily Programme10tH AuguSt 2016, WeDneSDAy

Programme

1300 – 1345 Registration

1345 – 1400 Opening Remarks by K Parameshwaran, Organising Chairman

Address by Lim Kang Taek

1400 – 1615 Live Cases 1 & Live Cases 2 Lim Kang TaekK Parameshwaran

1615 – 1645 Q & A

14

1 2

310

4

5

7 6

24

17

16

15

12

11

19

2120 22 2625

Shuttle LiftLobby

HotelLobby

BanquetManager

Office

Utility

Utility

Utility

SALON V

SALON IV

SALON III

SALON II

BALLROOM 1 BALLROOM 2

Floor Plan & trade exhibition

BOOTH NO COMPANY

1 Medi-CareProductsSdnBhd

2 NovamedikaGroupSdnBhd

3 SunPharmaceuticalsSdnBhd

4 SynergicEvolutionSdnBhd

5 & 6 Johnson & Johnson

7 SpineMatrixResourcesSdnBhd

10 BrainlabLtd,SouthEastAsia

11 MedcinPharmaSdnBhd12 BREGOLifeSciencesSdnBhd

15 Getz Health Care

16 PerintisMedikSdnBhd

17 CarlZeissSdnBhd

19 SutraMedi-EnvironSdnBhd

20 & 21 Medtronic International Ltd

22 SiemensHealthcareMalaysiaSdnBhd

24 BestContact(M)SdnBhd

25 TakedaMalaysiaSdnBhd

26 Humedical

15

The Organising Committee of the

4th International MSS Scientific Congress records its deepest appreciation

to the following for their support and contributions

BestContact(M)SdnBhd

BrainlabLtd,SouthEastAsia

BREGOLifeSciencesSdnBhd

CarlZeissSdnBhd

Getz Health Care

Humedical

Johnson & Johnson

MedcinPharmaSdnBhd

Medi-CareProductsSdnBhd

Medtronic International Ltd

MerckSharp&Dohme(Malaysia)SdnBhd

NovamedikaGroupSdnBhd

PerintisMedikSdnBhd

SiemensHealthcareMalaysiaSdnBhd

SpineMatrixResourcesSdnBhd

SunPharmaceuticalsSdnBhd

SutraMedi-EnvironSdnBhd

SynergicEvolutionSdnBhd

TakedaMalaysiaSdnBhd

Acknowledgements

16

Magnetic Resonance iMaging: the Basics and clinical coRRelation in luMBaR degeneRative disease

Mun-Keong Kwan Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

Magnetic Resonance Imaging (MRI) scan is a non-invasive radiological imaging which uses a powerful magnetic field and radio frequency pulses to produce detailed pictures of the internal body structures. MRI scan has revolutionized the management of different type of spinal pathology by improving the ability to make more accurate diagnosis and therefore an appropriate treatment can be instituted.

MRI lumbosacral spine i.e. axial views can be easily comprehended by understanding the concept of ‘Three Floor Anatomy House’ proposed by McCullough et al 1997. In the storey 1, intervertebral disc, facet joints and traversing nerve roots (vertebral below) will be well visualized. Occasionally, the far lateral disc compressing the exit nerve root (vertebral above) can be diagnosed. Whereas, in storey 2, the dorsal root ganglion (vertebral above) will be visualized over the foraminal region. In the storey 3, the pedicle (vertebral above) and the corresponding neural structures will be visualized. Based on this concept, the compression site of the neural structure can be easily identified and a proper surgical strategy can be carried out. In prolapsed disc, MRI will not only allow the identification of the severity but also location (i.e. axilla or shoulder) as well as type (i.e. extrusion or sequestration) of the prolapsed disc. In early lumbar stenosis resulting subarticular stenosis (i.e. lateral recess), MRI scan will allow visualization whether the traversing nerve root is trapped (compressed) or escaped (free). This information will allow us to avoid unnecessary surgical decompression.

MRI scan can be used to identify the conjoined nerve root in lumbosacral region prior to surgery. Identification of this anomalies is paramount important especially in MIS-TLIF where the conjoint nerve root will be potentially injured during this procedure if the diagnosis is missed. In addition to that, MRI scan can also use to diagnose synovial cyst, flavum cyst, facet arthrosis as well as Modic changes which can occurred during the unstable phase of the degenerative disc.

In conclusion, MRI has revolutionized the management of degenerative disc disease in lumbosacral spine. A good knowledge on the basic MRI scan is required for a sound and safe surgical decision.

MODULE 1MODULE 1Fundamentals Of Spine Surgery

17

Mis tliFMohd Hisam Muhamad Ariffin

Department of Orthopaedics, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia

One of the major principles of surgery is to perform the most efficient “target surgery” with minimum iatrogenic trauma resulting from the access. This requires meticulous pre operative planning, exact positioning and localization of the surgical target area to the entry level on the skin surface making it feasible to perform decompression and fusion through smaller incisions.

Incorporating bilateral decompression via a unilateral approach into this technique has enabled bilateral decompression to be done and not relying alone on the cage for indirect decompression.

In short, mIS approach minimized collateral injury or damage, standard treatment at the target site is possible despite the reduced access and this translates to excellent post operative recovery.

acute cauda equina syndRoMeMohd Imran Yusof

Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Kota Bharu, Kelantan, Malaysia

Cauda equina syndrome is a rare condition , forms 2-6% of all disc surgery or 1 in 30,000 to 100,000 incidences in a population.it is a serious, debilitating and potentially end up with medico legal implications. The treatment of patients with cauda equine syndrome is clear, however, the approach to treatment is quite controversial, as it is difficult to carry out definitive prospective studies with sufficient statistical power due to its rarity. It is possibly unethical to perform such study.

The most common causes of cauda equine syndrome are severe disc herniation and spinanl stenosis, traumatic, especially with lumbosacral fracture, infections, especially tuberculosis, tumor, especially sacral cordoma and spinal metastasis. Other uncommon causes include iatrogenically induced including following fat grafting and spinal anaesthesia. They may present with altered urinary sensation, unilateral saddle and genital sensory deficit, loss of desire to void or need to strain to micturate and with poor urinary stream. MRI is the most diagnostic investigation and should be arranged as soon as possible. It is indicated in all patients for suspected cauda equina syndrome. There are also proponents for early surgery and delayed surgery. Results are probably improved by relief within 24 h especially if they have incomplete syndrome and surgeons should aim to relieve neurological compression within 48 hours. In chronic or complete cauda equina syndrome, decompression can be carried out as an elective basis.

MODULE 2MODULE 2Case Presentation And Operative Video Session

MODULE 4MODULE 4Spinal Emergencies

18

saFety oF Pedicle scRew instRuMentation in sPinal suRgeRyMun-Keong Kwan

Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

Pedicle screw constructs have been shown to achieve better correction compared to older techniques. However, it is not without any risk of complications. The perforation rates for the conventional open method had been found to vary from 1.5% up to 29%.

In deformity surgery, the pedicle screw perforation rates were reported to be higher and ranges from 1.2% to 65.0%. We have performed a study to analyze our institutional database to investigate the accuracy and safety of pedicle screws placed in AIS surgery. This study investigates the accuracy and safety of 2020 pedicle screws placed in 140 AIS patients using CT scan. The overall total perforation rate was 20.3% (410 screws) with 8.0% (162 screws) grade 1, 2.1% (43 screws) grade 2 and 9.2% (186 screws) grade 3 perforations. Majority of the perforations was due to the lateral perforation (use of extrapedicular screw) in the thoracic region. When the lateral perforations of the thoracic region were excluded, the perforation rates were 6.4% (129 screws) grade 1, 1.4% (28 screws) grade 2, and 0.8% (16 screws) grade 3 perforations. There were only two symptomatic screws resulting radicular pain that subsided with conservative treatment. There was no spinal cord, aortic, esophageal, or lung injuries caused by malpositioned screws in this study.

MIS surgery has revolutionized the treatment of many spinal conditions. The use of the percutaneous pedicle screws has been increasing in the recent years. Our study group has performed a retrospective study to investigate the accuracy and safety of percutaneous pedicle screws placed using fluoroscopic guidance. We reviewed our intuitional database and a total 2000 percutaneous pedicle screws from 273 patients were analyzed. The total perforation rate was 9.4% with 151 (7.5%) Grade 1, 31 (1.6%) Grade 2, and 5 (0.3%) Grade 3 perforations. There were 3 distinct peaks in perforation rates (trimodal distribution) at T1, midthoracic region (T4–T7), and lumbosacral junction (L5 and S1). The highest perforation rates were at T1 (33.3%), S1 (19.4%), and T4 (18.6%). Percutaneous pedicle screws insertion using fluoroscopic guidance is safe and has the accuracy comparable to open techniques of pedicle screws insertion.

MODULE 5MODULE 5Safety And Complication

19

MODULE 7MODULE 7Sagittal Balance

PRoxiMal Junctional KyPhosisWarat Tassanawipas

Orthopaedics, Phramongkutklao Army Hospital, Bangkok, Thailand

Proximal Junction Kyphosis (PLK) is the complication after undergoing posterior semented instrumentation and fusion for spinal deformity PLK is defined by a 10 degree or more in kyphosis at the proximal Junction from the caudal endplate of the uppermost instrumented vertebrae (UIV) to the cephalad endplate of the vertebrae 2 segmented cranial to the UIV. PJK does not generate significant clinical or quality of life results and is often tolerated well and most cases do not need revision surgery. There were no significant differences in clinical outcome with SRS score or ODI scores in all studies. The development of PJK was most frequent in the first 8 weekly after surgery. The prevalence of PJK was between 20 – 35 degrees with the risk factors of age over 55 years, fusion to the sacrum, combined anterior and posterior fusion and sagittal malalignment.

Proximal junction Failure (PJF) is a subset of patients with more several failure of PJK which does seem to increase need to revision surgery because of pain neurologic deficit and increased deformity. The definition of PJF is proximal junctional acute collapse or fracture the vertebrae at the top of long pedicle screw constructs, pull – out of instrumentation at UIV and posterior – osseo – ligament disruption and weak muscular support. Risk factor of PJF are age, sagittal malalignments and increase thoracic kyphosis and greater requirement of correction of SVA.

PJF is increased in incidence due to increasing numbers of older patients undergoing reconstruction for better global sagittal as well alignment as the greater construct stiffness. Some patients with PJF may be successfully treated by conservative means but there is consistent relationship with PJF and early revision surgery for this complication.

20

oPll: the stRategic aPPRoachWarat Tassanawipas

Orthopaedics, Phramongkutklao Army Hospital, Bangkok, Thailand

Classification of Posterior Longitudinal Ligament (OPLL) which is most frequently found at the cervical spine region cause cervical myelopathy, radiculopathy and axial discomfort with pain and stiffness around the neck. OPLL is classified into four types on CT scan as:- Segmental, Continuous, Localized and Mixed type

The clinical syndrome of OPLL mostly develop insidiously and the formation and growth of OPLL occur slowly. Cervical OPLL has been found in 1.9 – 4.3% of the Japanese population which is higher than in the US and European nation. Some genetic background and male predomination 2:1 for cervical OPLL, but thoracic OPLL is more frequently seen in women. Report by 9-17% of patients with cervical OPLL have OPLL, OLF (ossified ligament flavum) or with at other spinal level.

The goal of surgical intervention for OPLL are to increase the space available for the cord or nerve roots and stability the cervical spine in order to hating the progressive of neurological dysfunction and OPLL. The choice of surgical approach is based on the location of OPLL compression, the number of involved cervical levels, the sagittal alignment, the severity of instability and the surgeon’s preferred.

For the anterior approach ACDF and ACCF or Hybride should be used in patients with kyphosis but in multilevel ACDF or ACCF, anterior plating decrease the risk of graft dislodgement or pseudathrosis but reported papers were 9% - 50% after two or three levels corpectomies. There is and increased dural tear especially if CT scan reveals a double layer sign indicative of dural penetration by the OPLL.

Laminoplasty can be used for multiple level myeoloradiculopathy but loss of lordosis are 10-50% and cervical ROM usually continue to decrease up to 18 months postoperatively Laminoplasty is contraindicated in patient who have less than 10๐ of lordosis or significant axial neck pain. Long term 10 – 14 years follow up also found spontaneous fusion in 85 – 97% of patients, frank kyphosis is 10% loss of lordosis in 40 – 50% and progressive of OPLL. In 60 – 70% OPLL progression has not been found to affect outcome. The complication of laminoplasty includes transient C5 – C6 radiculopathy in 7%, kyphosis in 10% and loss ROM in 12 – 18 as 97%.

Laminectomy with instrumentation and fusion provide decompression, correct alignment and halt the OPLL progression and is indicated for multilevel OPLL superimposed on congenital narrow spinal canal and kyphotic deformity.

Combined anterior – posterior procedure frequently recommend for a patient with fix kyphosis deformity requires extensive anterior released. Adding posterior instrumentation and fusion increases rigidity over an anterior plate alone in osteoporosis patients and multilevel ACDF or ACCF. This circumferential procedure achieved 360 degree for prevention of graft dislodgement.

MODULE 9MODULE 9Cervical Degenerative Diseases

21

axial BacK Pain ManageMentMohd Imran Yusof

Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Kota Bharu, Kelantan, Malaysia

There are a few issues related to axial low back pain. The origin of pain is difficult to determine most of the time. The patients usually present with unspecific symptoms.

Axial pain can be classified into two types, either mechanical or non-mechanical. Mechanical axial pain is either discogenic or non discogenic. Non discogenic pain is mainly from the facet arthritis, instability or sacro-iliac joint arthritis. Non mechanical pain is mainly due to infection or malignancy. Presence of red flags, yellow flags, issues related to compensation and secondary gain and psychological components of back pain must always be ruled out before treatment can be started.

The available investigation is not diagnostic. MRI may reveal features highly diagnostic for disc as the pain origin including high intensity zone in the annulus, on T2 weighted image. Many other abnormalities seen on MRI are clinically insignificant or of uncertain significance, including annular tears, Schmorl nodes, Modic changes and disc narrowing.

Treatment of axial back pain is fairly controversial because many tests are unspecific and not confirmative. The treatment is so personalized that even, the best treatment for a confirmed diagnosis is controversial. It depends so much on the training and belief of the doctors. Surgeon and non-surgeon approaches towards managing axial back pain are quite different. It may include regular analgesics, interventional procedures and spinal stabilization.

MODULE 11MODULE 11Common Conditions In My Spine Practice

22

tRans sacRal ePiduRoscoPic laseR decoMPRession in luMBaR disc heRniation

Kang Taek LimGood Doctor TeunTeun Spine Hospital, Department of Neurosurgery, Anyang City, Korea

PuRPoseTo investigate the effect of Trans Sacral Epiduroscopic Laser Decompression (SELD) in patients suffering from Herniated Lumbar Disc (HLD) including analysis of evidence based clinical data, comparing the changes of disc size on magnetic resonance image (MRI) scans, pain scores and functional capacity scores before and after the surgery.

MateRials and MethodsStudy was designed prospectively to determine the outcomes of SELD in regard to reduction of pain and improvements of functional status in patients with low back pain (LBP) and radiculopathy caused by definitive neural compression proven from MRI. A total of 1,400 patients with LBP and with simultaneous radiculopathy were operative with SELD technique applying Ho:Yag laser and 1.2mm flexible forceps. Clinical outcomes were evaluated using visual analogue scale (VAS) score for LBP and radiculopathy and functional status was measured with Oswestry disability index (ODI).

ResultsAt 2weeks after procedure, the average VAS score for leg pain fell to 3.6 from 7.1 (p-value < 0.01) and the average VAS score for back pain fell to 4.1 from 5.9 (p-value < 0.01). At three months the average leg and back pain VAS scores fell to 2.6, 2.7 respectively

Mean ODI improved from 50 to 19 at post-operative two weeks and further decreased to 12 at three months. Postoperative 2weeks MRI revealed sufficient removal of the HNP.

conclusionThe results of this study show significant improvements of VAS score and ODI after SELD for HNP patients with LBP and radiculopathy. MRI scan following the surgery revealed notable decrement of the size of HNP and reduction of neural compression. The SELD is suggested to be an effective therapeutic modality for patients with symptomatic HNP.

Key woRdsEpiduroscopy, Ho:Yag laser, lumbar disc herniation, adhesion of nerve root.

MODULE 12MODULE 12Pain Management

23

OP 1 Assessment Of Intra-Operative Blood Loss At Different Surgical OP 1 Assessment Of Intra-Operative Blood Loss At Different Surgical 2424 Stages Of Posterior Spinal Fusion Surgery In Adolescent Idiopathic Stages Of Posterior Spinal Fusion Surgery In Adolescent Idiopathic Scoliosis (Lenke Type 1 And 2): A Prospective Propensity Score-Matched Scoliosis (Lenke Type 1 And 2): A Prospective Propensity Score-Matched Cohort Study Comparing Between Single And Two Attending Surgeons Cohort Study Comparing Between Single And Two Attending Surgeons

Mun Keong Kwan1, Chee Kidd Chiu1, Siti Mariam Mohamad1, Mohd Shahnaz Hasan2, Chris Yin Wei Chan11Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia 2Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

OP 2 Safety Evaluation Of C1 Lateral Mass Screw Insertion In Three OP 2 Safety Evaluation Of C1 Lateral Mass Screw Insertion In Three 2525 Asian Ethnic Population Using 3-D Computed Tomography Analysis Asian Ethnic Population Using 3-D Computed Tomography Analysis

Chee Kean Lee, Tiam Siong Tan, Chris Yin Wei Chan, Mun Keong KwanDepartment of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia

OP 3 A Novel Trajectory Of C7 Screws: Evaluation Using 3-Dimentional OP 3 A Novel Trajectory Of C7 Screws: Evaluation Using 3-Dimentional 2626 Computed Tomography And Simulation Program To Compare Computed Tomography And Simulation Program To Compare With A Pre-Existing Trajectory With A Pre-Existing Trajectory

Chee Kean Lee1, Ho-Joong Kim2, Bong-Soon Chang2, Choon-Ki Lee2, Jin S Yeom21Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia 2Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul, Korea

OP 4 Lumbar Spinal Stenosis: The Reliability, Sensitivity And Specificity OP 4 Lumbar Spinal Stenosis: The Reliability, Sensitivity And Specificity 2727 Of The Nerve Root Sedimentation Sign Of The Nerve Root Sedimentation Sign

Yusof M I, H L Teh Hospital University Sains Malaysia, Kubang Kerian, Kelantan, Malaysia

OP 5 Pelvic Obliquity In Adolescent Idiopathic Scoliosis OP 5 Pelvic Obliquity In Adolescent Idiopathic Scoliosis 2828

Kyaw Soe Naing1, Chee Kidd Chiu2, Chris Yin Wei Chan2, Mun Keong Kwan21Institute of Medicine, Yangon Orthopaedic Hospital, Yangon, Myanmar 2Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia

OP 6 Cobb Angle Measurement Using Multiple Lines Technique For OP 6 Cobb Angle Measurement Using Multiple Lines Technique For 2929 Adolescent Idiopathic Scoliosis Adolescent Idiopathic Scoliosis

Elrofai Suliman Bashir1, Izzuddin Aziz2, Siti Mariam Mohamad2, Chee Kean Lee2, Chee Kidd Chiu2, Mun Keong Kwan2, Chris Yin Wei Chan21Elneelain University, Khartoum, Sudan 2Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia

MODULE 3Best Research Award (Oral Presentations)

24

assessMent oF intRa-oPeRative Blood loss at diFFeRent suRgical stages oF PosteRioR sPinal Fusion suRgeRy in adolescent idioPathic

scoliosis (lenKe tyPe 1 and 2): a PRosPective PRoPensity scoRe-Matched cohoRt study

coMPaRing Between single and two attending suRgeons Mun Keong Kwan1, Chee Kidd Chiu1, Siti Mariam Mohamad1,

Mohd Shahnaz Hasan2, Chris Yin Wei Chan11Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia

2Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

BacKgRoundKnowing the pattern of blood loss at different surgical stages between single and two surgeons may enable the surgical team to formulate a management strategy to reduce intra-operative blood loss.

oBJectiveTo assess the pattern of the intra-operative blood loss at various surgical stages comparing between single and two surgeons.

MethodsLenke 1 and 2 AIS patients who underwent instrumented posterior spinal fusion surgery from two centers between June 2014 and December 2015 were prospectively recruited into this study. The patients were grouped into Group 1 (single surgeon) and Group 2 (two surgeons). One to one matching analysis by using ‘propensity score-matched cohort patient sampling method’ was done. The operation was divided into 6 stages; stage 1 – exposure, stage 2 – screw insertion, stage 3 – release, stage 4 – correction, stage 5 – corticotomies and bone grafting and stage 6 – closure.

ResultsA total of 116 patients were recruited. Of 86 patients who were operated by the two surgeons, 30 patients were matched with 30 patients that were operated by a single surgeon. Operation duration was significantly longer in Group 1 (257.3 ± 51.4 min) compared to Group 2 (164.0 ± 25.7 min). The total blood loss was significantly more in Group 1 (1254.7 ± 521.5 mL) compared to Group 2 (893.7 ± 518.4 mL). Total blood loss/level fused was significantly more in Group 1 (117.5 ± 42.8 mL/level) compared to Group 2 (82.6 ± 39.4 mL/level). There were 7 patients (23.3%) in Group 1 that had allogenic blood transfusions but none in Group 2, (p

25

saFety evaluation oF c1 lateRal Mass scRew inseRtion in thRee asian ethnic PoPulation using

3-d coMPuted toMogRaPhy analysisChee Kean Lee, Tiam Siong Tan, Chris Yin Wei Chan, Mun Keong Kwan

Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia

BacKgRoundC1 lateral mass (C1LM) screw is a common procedure in spine surgery. However, Asian study has been lacking.

oBJectiveTo determine the safety of C1LM screw for the Chinese, Indians and Malays.

Methods3-Dimensional computed tomographies of 180 subjects (60 from each race) were analyzed. The length and angulations of C1LM screw and the location of ICA in relation to C1LM were assessed and classified according to the classification by Murakami et al. [1]. The incidence of PP was determined and racial differences were recorded.

ResultsThe average base length was 8.5 ± 1.4mm. The lengths within the lateral mass were between 14.7 ± 1.6 and 21.7 ± 2.3mm. The prevalence of PP was 8.3%. 55.3% (199) of ICA was located in Zone 0, 38.3% (138) in Zone 1-1, 6.4% (23) in Zone 1-2 and none in Zone 1-3 and Zone 2. The average angulation from the entry point to the ICA was 8.5 ± 6.4° laterally. The mean distance of ICA from C1 anterior cortex was 3.7 ± 1.7mm (range: 0.6~11.3). There was no difference in distribution of ICA in Zone 1 among the races (Chinese - 47%, Indians - 61% and Malays - 53%; p>0.05).

conclusionsNo ICA is located medial to C1LM’s screw entry point. If bicortical purchase of C1LM screw is needed, screw protrusion of less than 3mm or medially angulated is safe for ICA. The incidence of PP is 8.3% with higher prevalence among the Indian population.

OP 2OP 2

26

a novel tRaJectoRy oF c7 scRews: evaluation using 3-diMentional coMPuted toMogRaPhy and siMulation

PRogRaM to coMPaRe with a PRe-existing tRaJectoRyChee Kean Lee1, Ho-Joong Kim2, Bong-Soon Chang2, Choon-Ki Lee2, Jin S Yeom2

1Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia 2Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul, Korea

BacKgRoundThe old trajectory of C7 laminar screw has a horizontal or downward direction whereas the novel trajectory has an upward direction.

oBJectiveTo assess the feasibility of a novel trajectory for C7 laminar screw and to compare with an old trajectory.

MethodsAnalysis using 3-dimensional screw trajectory software and computed tomographic scans. Sequential C7 laminar screws were simulated using the new and old trajectories. The success rate, the causes of failure and the maximum allowable length of each trajectory were compared.

ResultsComputed tomographic scans of 100 patients were analyzed. Using the new trajectory, the success rates of the unilaminar and bilaminar screw were 93% and 83% respectively, which were significantly better than the old trajectory (80%, p

27

luMBaR sPinal stenosis: the ReliaBility, sensitivity and sPeciFicity oF the neRve Root sediMentation sign

Yusof M I, H L Teh Hospital University Sains Malaysia, Kubang Kerian, Kelantan, Malaysia

BacKgRoundSedimentation sign is an evaluation from standard lumbar MRIs and is a reliable sign to diagnose lumbar spinal stenosis(LSS) with high sensitivity and specificity.

oBJectiveTo identify the nerve root sedimentation sign in patients with degenerative LSS and to evaluate its reliability, sensitivity and specificity.

MethodologyThis is a retrospective study to determine the clinical presentation of LSS. It also determines the reliability, sensitivity and specificity of the nerve root sedimentation sign and evaluate the inter and intra observer reliability, sensitivity and specificity. 82 subjects were enrolled, 56 subjects were included in determining inter and intra observer reliability,sensitivity and specificity. A radiologist and orthopedic surgeon were assigned to independently elicit the sign.

ResultsThere were 43 patients in LSS group and 39 patients for control (non LSS group). There was significant association between spinal claudication and leg numbness with LSS (p

28

Pelvic oBliquity in adolescent idioPathic scoliosisKyaw Soe Naing1, Chee Kidd Chiu2, Chris Yin Wei Chan2, Mun Keong Kwan2

1Institute of Medicine, Yangon Orthopaedic Hospital, Yangon, Myanmar 2Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia

BacKgRoundPelvis obliquity (PO) in adolescent idiopathic scoliosis (AIS) patients is a radiographic parameter that is often overlooked. Failure in detection of PO prior to corrective scoliosis surgery may lead to coronal imbalance post-operatively. However, literatures of PO amongst AIS patients are still lacking.

oBJectiveThe objective of this study was to determine the prevalence and pattern of PO in AIS according to Lenke classification.

MethodA retrospective analysis of pre-operative radiographs of patients who were scheduled for corrective posterior spinal fusion surgery was carried out. It included the erect whole spine, supine side bending and lower limbs axis radiographs. Parameters that were measured were transilium pelvic height difference (TPHD), transilium pelvic angle (TPA) and direction of PO. TPHD was defined as the height difference in between two horizontal lines passing through the highest points of iliac crests. TPA was defined as the angle between the line joining both highest point of iliac crests and horizontal line. When the left iliac crest was higher than the right, the direction of PO was defined as positive direction (directed to right) and negative direction (directed to the left).

ResultsWe reviewed radiographs of 315 patients (286 females and 29 males) with average age of 15.08 ± 2.6 years and mean Cobb angle of 64.0 ± 17.2°. Only 70 (22.2%) patients had perfectly equal pelvis (TPHD=0). Of the remaining 245 patients (77.8%) with unequal pelvic height, 27.6% with the transilium pelvic height difference of ≤5mm, 30.2% between 6-10mm, 14.3% between 11-15mm, 4.8% between 16-20mm and 0.9% >20mm. The mean transilium height difference was 5.32 ± 4.9, 6.12 ± 5.5, 5.0 ± 3.9, 4.5 ± 6.4, 7.5 ± 5.1 and 9.59 ± 6.7 mm for Lenke 1-6 respectively. The mean transilium pelvic angle was 2.0 ± 1.7, 2.1 ± 1.9, 2.1 ± 1.4, 1.5 ± 2.1, 2.5 ± 1.8 and 3.7 ± 2.8 degrees for Lenke 1-6 respectively. There was equal number of each direction of pelvic obliquity (123 positive direction vs 122 negative direction). Lenke 1 and 2 had higher prevalence of positive direction PO (63.4% and 68.4% respectively) whereas Lenke 5 and 6 had higher prevalence of negative direction PO (77.6% and 87.0% respectively).

conclusionThe incidence of unequal pelvis in adolescent idiopathic scoliosis patients was found to be as high as 77.8%. Majority was ≤10mm and only 20.0% was >10mm. Lenke 6 had the highest mean transilium height difference and mean transilium pelvic angle. More thoracic major curve AIS had positive direction PO whereas more lumbar major curve AIS had negative direction PO. Therefore, the assessment of pelvic obliquity amongst adolescent idiopathic scoliosis patients is important and should not be neglected prior to corrective scoliosis surgery.

OP 5OP 5

29

coBB angle MeasuReMent using MultiPle lines technique FoR adolescent idioPathic scoliosis

Elrofai Suliman Bashir1, Izzuddin Aziz2, Siti Mariam Mohamad2, Chee Kean Lee2, Chee Kidd Chiu2, Mun Keong Kwan2, Chris Yin Wei Chan2

1Elneelain University, Khartoum, Sudan 2Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia

BacKgRoundAside from an accurate clinical evaluation, the Cobb angle measurement is one of the most important parameter to diagnose and to assess the severity of patients with scoliotic deformities. Failure to attain an accurate Cobb angle measurement may lead to wrong treatment. Wrongly measured Cobb angles by using the conventional method amongst clinicians are commonly encountered.

oBJectiveThis study evaluates the efficacy of Multiple Lines Technique (MLT) in the selection of end vertebrae and the measurement of the Cobb angle among orthopaedic trainees.

MethodsForty-five orthopaedic trainees were recruited to measure Cobb angles in 4 radiographs of various severities. Each trainee measured the radiographs 4 times with 3 weeks apart of each measurement; 2 measurements before and 2 measurements after they learned the MLT. The level of end vertebrae selected and the Cobb angles measured by the trainees were compared to the average measurements by 4 consultant spine surgeons. An accurate end vertebra selection is achieved when the selection by a trainee was similar to the selection by the consultant surgeons. An accurate Cobb angle measurement is achieved when the angle measured by a trainee was within 4° difference when compared to the angle measured by the consultant surgeons. Chi-square test was used for analysis.

ResultsFor UEV selection in X-rays 1~4, the accuracy were 57.8%, 71.1%, 71.1% and 30.0% before learning the MLT and it significantly improved to 77.8%, 85.6%, 86.7% and 36.7% after learning the MLT (p= 0.004, 0.02, 0.01 and 0.34 respectively).

For LEV selection in X-rays 1~4, the accuracy also improved significantly from 63.3%, 67.8%, 56.7% and 56.7% to 77.8%, 88.9%, 72.2% and 71.1% (p= 0.03, 0.001, 0.03 and 0.04 respectively).

For Cobb angle measurement of each X-rays, only 16.7%, 46.7%, 53.3% and 46.7% were accurate before leaning the MLT. The accuracy significantly increased to 37.8%, 62.2%, 77.8% and 60.0% after learning (p= 0.001, 0.04, 0.001 and 0.07 respectively).

conclusionMLT is effective in improving the accuracy of selection of end vertebrae and measurement of Cobb angle amongst the orthopaedic trainees.

OP 6OP 6

30

FP 1 A Morphometric Analysis Of The Pathoanatomy Of Cervical FP 1 A Morphometric Analysis Of The Pathoanatomy Of Cervical 3232 Spondylotic Myelopathy And The Correlation Between Magnetic Spondylotic Myelopathy And The Correlation Between Magnetic Resonance Imaging Findings And Clinical Presentation Of Patients Resonance Imaging Findings And Clinical Presentation Of Patients

Zamzuri Z1, Ariff M S1, Hishamudin D1, Azian A A2 1Department of Orthopaedics, Traumatology And Rehabilitation, Kulliyyah (Faculty) of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia 2Department of Radiology, Kulliyyah (Faculty) of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia

FP 2 2- 3 Level Thoracic Corpectomies And Expandable Cage Insertion FP 2 2- 3 Level Thoracic Corpectomies And Expandable Cage Insertion 3333 Via A Single-Stage Posterior Approach : A Case Series Via A Single-Stage Posterior Approach : A Case Series

S W Lim, M G Murali Govindasamy, Thuraikumar K, Z ZukiOrthopaedic and Traumatolgy Department, Sungai Buloh Hospital, Selangor, Malaysia

FP 3 Reduction Of Blood Loss During Posterior Spinal Instrumentation FP 3 Reduction Of Blood Loss During Posterior Spinal Instrumentation 3434 And Fusion Of Adolescent Idiopathic Scoliosis Utilising An And Fusion Of Adolescent Idiopathic Scoliosis Utilising An Ultrasonic Bone Scalpel : Hospital Kuala Lumpur Experience Ultrasonic Bone Scalpel : Hospital Kuala Lumpur Experience

Zakhiri M R, Dzulkarnain A, Manmohan S, J H Goh, Z A Norazlin, Fazir MOrthopaedic and Traumatolgy Department, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

FP 4 Early Outcome Of Discectomy With Interspinous Process Distraction FP 4 Early Outcome Of Discectomy With Interspinous Process Distraction 3535 Device. A Retrospective Cross-Sectional Study In Hospital Kuala Lumpur Device. A Retrospective Cross-Sectional Study In Hospital Kuala Lumpur

Zakhiri M R1, Hazli S S2, Manmohan S1, Dzulkarnain A1, J H Goh1, Z A Norazlin1, Fazir M11Hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2Universiti Kebangsaan Malaysia, Kuala Lumpur Malaysia

FP 5 Fluoroscopic Guided Percutaneous Pedicle Screws In The Thoracic FP 5 Fluoroscopic Guided Percutaneous Pedicle Screws In The Thoracic 3636 And Lumbosacral Spine, Is It Safe? And Lumbosacral Spine, Is It Safe?

Chee Kidd Chiu, Chris Yin Wei Chan, Mun Keong KwanDepartment of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia

FP 6 Feasibility Of Simultaneous Insertion Of Lumbar Pedicle And Cortical FP 6 Feasibility Of Simultaneous Insertion Of Lumbar Pedicle And Cortical 3737 Screw With 3 Dimensional Ct And Simulation Programme : Is It Possible Screw With 3 Dimensional Ct And Simulation Programme : Is It Possible To Insert Lumbar Double Screws At The Same Level? To Insert Lumbar Double Screws At The Same Level?

Chee Kean Lee1, Sung Shik Kang2, Ho-Joong Kim2, Jin S Yeom21Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia 2Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul, Korea

FP 7 Doctor! How Severe Is My Wound Pain After The Scoliosis Surgery? FP 7 Doctor! How Severe Is My Wound Pain After The Scoliosis Surgery? 3838

Mun Keong Kwan1, Chiu Chee Kidd1, Chong Kok Ian1, Chan Teik Seng1, Siti Mariam Mohamad1, Mohd Shahnaz Hasan2, Chris Yin Wei Chan11Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia 2Department of Anaesthesiology, University of Malaya, Kuala Lumpur, Malaysia

Free Papers

31

Free Papers (continued)

FP 8 Ground Reaction Force (GRF) Of The Hip, Knee And Ankle Joints FP 8 Ground Reaction Force (GRF) Of The Hip, Knee And Ankle Joints 3939 In Normal And Adolescent Idiopathic Scoliosis Before And After In Normal And Adolescent Idiopathic Scoliosis Before And After Spinal Fusion Spinal Fusion

Sivalingarajah P, Sm Lim, Yusof MiUniversity Sains Malaysia, Kubang Kerian, Kelantan, Malaysia

FP 9 Preliminary Report Of The Malaysian Scoliosis Registry : A Review FP 9 Preliminary Report Of The Malaysian Scoliosis Registry : A Review 4040 Of Scoliosis Cases Operated Between January – December 2015 Of Scoliosis Cases Operated Between January – December 2015

Mun Keong Kwan1, Siti Mariam Abd Gani1, Fazir Mohamad2, Nor Azlin Zainal Abidin2, Chung Chek Wong3, Zamyn Zuki Mohd Zuki4, Sivananthan K S5, Abdul Halim Yusof6, Heng Him Lim7, Abdul Malik8, Chris Yin Wei Chan11Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia 2Orthopaedic and Traumatology Department, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia 3Orthopaedic and Traumatology Department, University Malaysia Sarawak, Sarawak, Malaysia 4Othopaedic and Traumatology Department. Sungai Buloh Hospital, Selangor, Malaysia 5Othopaedic and Traumatology Department. Hospital Fatimah, Ipoh, Perak, Malaysia 6Department of Orthopaedic, University Sains Malaysia, Kelantan, Malaysia 7Sri Kota Specialist Medical Centre, Klang, Selangor, Malaysia 8KPJ Damanasara Specialist Hospital, Petaling Jaya, Selangor, Malaysia

32

a MoRPhoMetRic analysis oF the PathoanatoMy oF ceRvical sPondylotic MyeloPathy and the coRRelation Between Magnetic

Resonance iMaging Findings and clinical PResentation oF Patients Zamzuri Z1, Ariff M S1, Hishamudin D1, Azian A A2

1Department of Orthopaedics, Traumatology And Rehabilitation, Kulliyyah (Faculty) of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia

2Department of Radiology, Kulliyyah (Faculty) of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia

BacKgRoundCervical spondylotic myelopathy (CSM) is the commonest cause of spinal cord dysfunction and MRI remains the imaging of choice for CSM. However, its findings are not completely specific for clinically significant CSM.

oBJectivesThis cross-sectional study aimed to determine the pathoanatomy of CSM and analyze the correlation between clinical and MRI findings.

MethodsPatients aged 40 to 80 years old with CSM were recruited. Clinical parameters include myelopathic signs and other specific signs. MRI findings include level of compression, degenerative pathology, and parameters for cord compression.

ResultsThirty patients were recruited. Commonest (60%) myelopathic signs observed were positive Hoffmann’s sign and brachioradialis sign. 90% of patients had osteophyte formation, 36.7 % with single-level facet hypertrophy, and 23.3% had thickening of ligamentum flavum. Myelopathic signs and other specific signs significantly correlate with the cervical cord compression and observed in patients with smaller cord diameter. Positive correlation between the clinical key features with MRI parameters observed for canal and cord diameter. The transverse cord diameter, cord compression ratio and approximate cord area were the only independent variables related to almost all of the positive clinical signs. All have moderate to strong correlation with the clinical findings.

conclusionsThe MRI parameters with significant correlation reflect compression of the cord, indicating their major role in the pathophysiology of CSM. They may play significant roles in predicting the severity and outcome of CSM.

FP 1FP 1

33

FP 2FP 2

2- 3 level thoRacic coRPectoMies and exPandaBle cage inseRtion via a single-stage PosteRioR

aPPRoach : a case seRiesS W Lim, M G Murali Govindasamy, Thuraikumar K, Z Zuki

Orthopaedic and Traumatolgy Department, Sungai Buloh Hospital, Selangor, Malaysia

BacKgRoundExpandable Cage is gaining popularity especially in multilevel thoracic vertebral Column Resection due to relative ease in use and permits optimal fit.

Methods5 patients were operated on by same lead surgeon from June until December 2015. 4 had tuberculosis whilst 1 had lymphoma. 3 patients had 2 level while 2 had 3 level corpectomies done at various thoracic level. For all patients T2 altitude expandable cage by Medtronic was used. For each patient, operative time, repeat surgeries, and quality of life assessment were assessed ( Via SF 36 scale ) .

ResultsThe operating time for this procedure ranges from 6 hours – 7 hours. There is neurological improvement of atleast 1 Frankel grade for all the patients. No peri operative complications or repeat surgery were observed for all of the patients on latest follow up. Sequence x-rays show no hardware displacement or progressive angulation.

discussionIsada Thongtaran et al and Daniel met et al have shown good outcomes with expandable cage. Number of repeat surgeries & subsidence were minimal in their series.

Our operative time is comparable to those published in literature and no repeat surgeries show that this method of operation may indicate a low complication rate.

conclusionFrom this small case series, 2 to 3 Level thoracic corpectomies and Expandable Cage Insertion Via a single-stage Posterior Approach appears to be a safe and a viable approach for patients with the right indication.

34

FP 3FP 3

Reduction oF Blood loss duRing PosteRioR sPinal instRuMentation and Fusion oF adolescent idioPathic scoliosis utilising an

ultRasonic Bone scalPel : hosPital Kuala luMPuR exPeRienceZakhiri M R, Dzulkarnain A, Manmohan S, J H Goh, Z A Norazlin, Fazir MOrthopaedic and Traumatolgy Department, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

intRoductionBone scalpel is an ultrasonic powered bone cutting device. It is designed to provide clean cuts through osseus structures while preserving the underlying soft tissues. In posterior spinal fusion surgery, facetectomies are usually done using osteotomes and rongeurs. By using bone scalpel to perform facetectomies, this study discusses the beneficial impact this device has on improving surgical outcome and safety.

study designThis is a retrospective study of prospectively collected data utilizing patients’ medical records.

oBJectivesTo evaluate blood loss during posterior spinal instrumentation and fusion in adolescent idiopathic scoliosis patients performed with and without the use of ultrasonic bone scalpel.

Methods 30 patients with adolescent idiopathic scoliosis who underwent posterior spinal instrumentation and fusion using ultrasonic bone scalpel were compared with control group of 30 cases before using the bone scalpel, matched based on Cobb angles.

ResultsThe ultrasonic bone scalpel group showed less estimated blood loss (EBL) than control group.

discussion The use of an ultrasonic bone scalpel to perform bone cuts during facetectomies resulted in less bleeding compared with cuts made with standard osteotomes and rongeurs. Bone scalpel is a safe device for performing facetectomies in posterior spinal fusion surgeries.

35

eaRly outcoMe oF discectoMy with inteRsPinous PRocess distRaction device. a RetRosPective

cRoss-sectional study in hosPital Kuala luMPuRZakhiri M R1, Hazli S S2, Manmohan S1, Dzulkarnain A1, J H Goh1, Z A Norazlin1, Fazir M1

1Hospital Kuala Lumpur, Kuala Lumpur, Malaysia 2Universiti Kebangsaan Malaysia, Kuala Lumpur Malaysia

oBJectivesThe main aim of this retrospective study was to evaluate the usefulness and early outcome and radiological changes after discectomy with DIAM implant insertion for patients with herniation of nucleus pulposus.

MethodsThirty-three patients underwent discectomy with DIAM implant insertion for a herniation of nucleus pulposus between June 2009 and April 2014 in Hospital Kuala Lumpur, Malaysia were considered for this study. All datas were collected by reviewing the patient’s medical record. All patients had back pain and leg or buttock pain associated with radiological evidence of herniation of nucleus pulpous with failure to 3 months of conservative management. All patients had post-operative follow-up at 2 weeks, 3 months and 6 months after the surgery with documented VAS scores (back and leg pain) and Oswestry Disability Index preoperative and postoperatively. Disc height was measured on the preoperative and postoperative plain radiograph.

Results 23 male and 10 female were treated. The mean age was 39.82 years old. The most common level was L5/S1 (58%). Preoperative VAS score for leg pain and low back pain improved from 4.3±1.7 and 4.5±1.4 to 1.1±0.8 and 2.2±1.2 respectively at last clinic visit (p

36

FluoRoscoPic guided PeRcutaneous Pedicle scRews in the thoRacic and luMBosacRal sPine, is it saFe?

Chee Kidd Chiu, Chris Yin Wei Chan, Mun Keong KwanDepartment of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia

BacKgRoundSeveral studies had examined the accuracy and safety of percutaneous pedicle screws but provided large variations in their results.

oBJectiveTo investigate the safety and accuracy of percutaneous pedicle screws placed using fluoroscopic guidance in the thoracolumbosacral spine in a single center amongst the Malaysian population.

MethodsComputerized tomography scans of 128 patients who had surgery using fluoroscopic guided percutaneous pedicle screws were selected. Medial, lateral, superior, and inferior screw perforations were classified into Grade 0 (no violation), Grade 1 (< 2mm perforation), Grade 2 (2-4mm perforation) and Grade 3(> 4mm perforation). Anterior perforations were classified into Grade 0 (no violation), Grade 1 (< 4mm perforation), Grade 2 (4-6mm perforation) and Grade 3(> 6mm perforation). Grade 2 and Grade 3 perforation were considered as ‘critical’ perforation.

ResultsIn total, 1002 percutaneous pedicle screws from 128 patients were analyzed. The mean age was 52.7 ± 16.6. There were 70 male patients and 58 female patients. The total perforation rate was 11.3% (113) with 8.4% (84) Grade 1, 2.6% (26) Grade 2 and 0.3% (3) Grade 3 perforations. The overall ‘critical’ perforation rate was 2.9% (29 screws). However, there was no spinal cord injury, aortic injury, esophageal injury, lungs injury or other visceral injury caused by malposition screws. The highest perforation rates were at T4 (21.6%), T2 (19.4%) and T6 (19.2%).

conclusionsThe total perforation rate of 11.3% with the total ‘critical’ perforation rate of 2.9% (2.6% Grade 2 and 0.3% Grade 3 perforations). The highest perforation rates were found over the upper to mid thoracic region. Percutaneous pedicle screws insertion using fluoroscopic guidance amongst Malaysians has the safety and accuracy comparable to the current reported percutaneous pedicle screws and open pedicle screws techniques.

FP 5FP 5

37

FeasiBility oF siMultaneous inseRtion oF luMBaR Pedicle and coRtical scRew with 3 diMensional ct and siMulation PRogRaMMe : is it PossiBle to inseRt luMBaR douBle scRews at the saMe level?

Chee Kean Lee1, Sung Shik Kang2, Ho-Joong Kim2, Jin S Yeom21Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia 2Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seoul, Korea

BacKgRoundThere are only a few case reports about lumbar double screws at the same level, however feasibility of lumbar double screws insertion is still unknown.

oBJectiveTo evaluate the feasibility of simultaneous insertion of lumbar pedicle and cortical screws (lumbar double screws).

Methods: A simulation study using 3-dimensional screw trajectory software and computed tomography scans of 30 males and 30 females. Lumbar double screws were simulated for each level of lumbar spine from L1 to L5. The success rate, causes of failure, length of cortical screw and average trajectory of cortical screw were assessed.

ResultsWith 2~3mm cranially inserted pedicle screws compared to conventional entry point, the overall success rate of the cortical screw was 72.2%. There was decreasing success rate from L1 to L5; 95.8, 90.8, 80.8, 54.2 and 39.2%, respectively. Superior facet joint violation contributed to 17.2% of the overall failure rate, followed by inferior pedicle breach (9.3%) and combination of facet joint violation and pedicle breach (1.3%). Most of the failure in L4 and L5 were caused by facet joint violation. The average trajectory of cortical screw combined with modified pedicle screw insertion was 20.5±4.76° laterally and 10.6±3.98° cranially.

conclusionsThe success rate of lumbar double screws was 72.2%. The success rate would be higher at about 90% when superior facet joint violation was not a concern which was located within the fusion level. Decreasing success rate from L1 to L5 were caused due to increasing lordotic angle from L1-L5 (superior facet joint getting closer to entry point) and decreasing pedicle height from L1-L5 morphologically.

FP 6FP 6

38

doctoR! how seveRe is My wound Pain aFteR the scoliosis suRgeRy?Mun Keong Kwan1, Chiu Chee Kidd1, Chong Kok Ian1, Chan Teik Seng1, Siti Mariam Mohamad1, Mohd Shahnaz Hasan2, Chris Yin Wei Chan1

1Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia 2Department of Anaesthesiology, University of Malaya, Kuala Lumpur, Malaysia

BacKgRoundPosterior Spinal Fusion (PSF) surgery for AIS is a major surgery whereby patients will experience significant postoperative wound pain. The knowledge of surgical wound pain resolution trend will help the surgeon to advise the patients.

oBJectiveTo investigate the resolution trend of surgical wound pain after PSF surgery for AIS correction.

MethodForty patients with AIS who was planned for elective PSF surgery were recruited. The magnitude of postoperative wound pain was charted using the Visual Analogue Pain Score and was recorded in these intervals: 12 hours, 24 hours, 36 hours, 48 hours, day 3 to 14. The operative protocol, anaesthetic protocol, pain management regime and post-operative recovery regime was standardized. All operations were performed using a dual attending surgeon strategy.

ResultsThere were 36 females and 4 males with 16 Lenke 1, 7 Lenke 2, 3 Lenke 3, 2 Lenke 4, 8 Lenke 5 and 4 Lenke 6. The mean age was 15.7±3.6 years with the average Cobb angle of 66.5±16.0°. The average fusion levels were 9.8±2.2 with the average wound size was 28.9±5.7cm. The mean operation time was 162.4±59.4min with an average duration of stay of 91.2±0.7hours.The overall mean pain score for 12 hours, 24 hours, 36 hours, 48 hours, day 3, day 4, day 6, day 8, day 10, day12, and day 14 were 6.0±2.3, 5.9±2.5, 5.4±2.8, 4.7±2.7, 4.2±2.6, 3.9±2.2, 2.5±2.1, 2.1±1.9, 1.2±1.3, 0.9±1.3, and 0.7±1.1 respectively. Time taken for pain to reduce to a tolerable level (pain score ≤ 4) was 97.5±69.6 hours postoperatively (p

39

gRound Reaction FoRce (gRF) oF the hiP, Knee and anKle Joints in noRMal and adolescent idioPathic

scoliosis BeFoRe and aFteR sPinal Fusion Sivalingarajah P, Sm Lim, Yusof Mi

University Sains Malaysia, Kubang Kerian, Kelantan, Malaysia

intRoductionGround reaction force (GRF) is generated within the knee, hip and ankle, and may be altered by pathologies that transfigure the normal biomechanics of the human body such as adolescent idiopathic scoliosis (AIS). Fusion of the spinal segment to control the spinal deformity may restrict the normal ‘orchestraic’ movement of the human body and disturb the distribution of loads in the joints. This study aims to gauge the extent that this condition affects the pre-operative GRF compared to post-operative GRF and comparing each to the GFR of normal subjects.

oBJectiveThis study is expected to provide information on how scoliosis can affect the GRF of all major weight bearing joints.

MethodsWe measured GRF of the hip, knee and ankle of 42 subjects and made a comparative cross sectional study between normal individuals (n = 15), patients with AIS without fusion (n = 14) and patients AIS with fusion (n = 13). Study was conducted in USM Kelantan sports science biomechanics laboratory. These values were computed during walking on the gait platform over the force plate. Calculation of pertinent kinetic parameters allowed statistical comparison.

ResultsThe GRF revealed no significant difference on comparison for all x, y and z axis going through the point of equivalent force application at heel strike, midstance and toe off phases (p

40

FP 9FP 9

PReliMinaRy RePoRt oF the Malaysian scoliosis RegistRy : a Review oF scoliosis cases oPeRated Between JanuaRy – deceMBeR 2015Mun Keong Kwan1, Siti Mariam Abd Gani1, Fazir Mohamad2, Nor Azlin Zainal Abidin2,

Chung Chek Wong3, Zamyn Zuki Mohd Zuki4, Sivananthan K S5, Abdul Halim Yusof6, Heng Him Lim7, Abdul Malik8, Chris Yin Wei Chan1

1Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia 2Orthopaedic and Traumatology Department, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

3Orthopaedic and Traumatology Department, University Malaysia Sarawak, Sarawak, Malaysia 4Othopaedic and Traumatology Department. Sungai Buloh Hospital, Selangor, Malaysia

5Othopaedic and Traumatology Department. Hospital Fatimah, Ipoh, Perak, Malaysia 6Department of Orthopaedic, University Sains Malaysia, Kelantan, Malaysia

7Sri Kota Specialist Medical Centre, Klang, Selangor, Malaysia 8KPJ Damanasara Specialist Hospital, Petaling Jaya, Selangor, Malaysia

BacKgRoundDeformity surgery is a major operation which associated with a significant morbidities and mortalities. Local registry of scoliosis surgery will allow surgeons to analyze the epidemiology as well as the morbidities and moralities associated with this major surgery.

oBJectiveTo record and analyze the scoliosis surgery data performed in 8 major spine centers of Malaysia in 2015.

MethodProspective analysis of data collected by Malaysian Scoliosis Registry.

ResultsA total of 208 scoliosis surgeries comprising 186 adolescent idiopathic, 15 congenital, 4 neuromuscular, 4 juvenile idiopathic, 1 infantile idiopathic, 1 neurofibromatosis and 1 mesenchymal scoliosis cases were performed in 8 participating institutes from January 2015 to December 2015.There were 186 females and 22 males with 63 of them were Malays, 122 Chinese, 9 Indians and 14 Non-Malaysians. The mean age was 16.4 ± 4.6 years. The average number of fusion level was 10.2 ± 2.6 with an average number of screws inserted was 14.4 ± 3.1. Mean operation time was 198.1 ± 92.7 min with average blood loss volume was 951.8 ± 659.4 ml. The average length of ICU stays of 1.5 ± 0.9 day (23 patients require ICU stay) and the overall hospital stay of 6.0 ± 8.6 days. Most of the surgical approaches in these institutes were posterior open approach surgeries (98.2%) while only 1.8% surgeries performed anteriorly. Pedicle screws were inserted in 91.8% cases and only three and one cases use hooks and wires respectively. Autologous local bone graft was used in 95.2% surgeries.

There were two complications reported postoperatively i.e. 1 case of deep wound infection and 1case of lung collapse, which amounted to 1.0% of complication rate. There were no neurological deficit, blindness, visceral or vascular injuries reported.

conclusionsPosterior spinal fusion surgery using pedicle screw system and local bone graft is the most preferred surgery when treating scoliosis in Malaysia. Scoliosis surgery in Malaysia is remarkably safe with low complication rate comparable to the SRS morbidities and mortalities results.

41

PP 1 The Importance Of Accurate Spinal Level Enumeration In Symptomatic PP 1 The Importance Of Accurate Spinal Level Enumeration In Symptomatic 4343 Lumbosacral Transitional Vertebrae – A Case Report Lumbosacral Transitional Vertebrae – A Case Report

Bong C P, Lee C K, Chiu C K, Chris C Y W, Kwan M KUniversity of Malaya, Kuala Lumpur, Malaysia

PP 2 A Case Report Of C1-C2 Fusion Using Modified Magerl’s Technique PP 2 A Case Report Of C1-C2 Fusion Using Modified Magerl’s Technique 4444

Elrofai Suliman Bashir1, Chee Kean Lee2, Chris Yin Wei Chan2, Mun Keong Kwan21Elneelain University, Khartoum, Sudan 2Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia

PP 3 A Good Short-Term Outcome In Delayed Decompression Of Cauda PP 3 A Good Short-Term Outcome In Delayed Decompression Of Cauda 4545 Equina Syndrome In Klebsiella Pneumonia Spinal Epidural Abscess Equina Syndrome In Klebsiella Pneumonia Spinal Epidural Abscess

Hanifah J, Joehaimey J, Yusof M IDepartment of Orthopaedic Surgery, Universiti Sains Malaysia, Kubang Kerian, Malaysia

PP 4 Outcome Of Spinal Metastasis Treated With Total En Bloc Spondylectomy : PP 4 Outcome Of Spinal Metastasis Treated With Total En Bloc Spondylectomy : 4646 A Case Report A Case Report

Hisam M A, Kang Kai Lim, Kamalnizat I, Shaharuddin A B, Azmi BDepartment of Orthopaedic and Traumatology, Chancellor Tuanku Muhkriz Hospital, Kuala Lumpur, Malaysia

PP 5 Multiple Myeloma Mimicking As A Primary Solitary Tumour PP 5 Multiple Myeloma Mimicking As A Primary Solitary Tumour 4747 In The Posterior Element Of T7 Vertebra : A Rare Case Report In The Posterior Element Of T7 Vertebra : A Rare Case Report

E S Teoh, S W Lim, Thuraikumar K, Z Zuki Orthopaedic and Traumatology Department, Hospital Sungai Buloh, Selangor, Malaysia

PP 6 Management Of Iatrogenic L5 Nerve Root Injuries Caused By L5 Pedicle Screw PP 6 Management Of Iatrogenic L5 Nerve Root Injuries Caused By L5 Pedicle Screw 4848 Malposition : A Report Of 2 Cases Malposition : A Report Of 2 Cases

Chris Yin Wei Chan, Ling Xiu Wen, Chee Kean Lee, Mun Keong KwanDepartment of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia

PP 7 A Three-Year Follow Up Of Severe Scoliosis : Utilising Posterior Vertebra PP 7 A Three-Year Follow Up Of Severe Scoliosis : Utilising Posterior Vertebra 4949 Column Resection Technique Column Resection Technique

Zaim M R, Hisam M A, Kamalnizat I, Shaharudin A R, Azmi BHospital University Kebangsaan Malaysia, Kuala Lumpur, Malaysia

PP 8 Osteoradionecrosis Cervical Spine Following Thyroid Cancer Irradiation With PP 8 Osteoradionecrosis Cervical Spine Following Thyroid Cancer Irradiation With 5050 C3/C4 Anterolisthesis : Anterior And Posterior Fusion C3/C4 Anterolisthesis : Anterior And Posterior Fusion

Zaim M R, Hisam M A, Azmi B, Shaharudin A R, Kamalnizat IHospital University Kebangsaan Malaysia, Kuala Lumpur, Malaysia

PP 9 Case Series Of Tuberculous Spondylodiscitis With Asia Impairment Scale (AIS) A PP 9 Case Series Of Tuberculous Spondylodiscitis With Asia Impairment Scale (AIS) A 5151

Zakhiri M R, E P Su, T L Tie, Dzulkarnain A, Manmohan S, J H Goh, Z A Norazlin, Fazir MOrthopaedic and Traumatolgy Department, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

Poster Presentations

42

Poster Presentations (continued)

PP 10 How Common Is Epidural Haematoma Causing Neurological Deficit Post PP 10 How Common Is Epidural Haematoma Causing Neurological Deficit Post 5252 Epidural Pain Management In Children? What Is The Treatment Option?Epidural Pain Management In Children? What Is The Treatment Option?

Zakhiri M R, Dzulkarnain A, Manmohan S, J H Goh, Z A Norazlin, Fazir MOrthopaedic and Traumatolgy Department, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

PP 11 Generalized Tonic-Clonic Seizures During Posterior Correction And Fusion Surgery PP 11 Generalized Tonic-Clonic Seizures During Posterior Correction And Fusion Surgery 5353 For Adolescent Idopathic Scoliosis : A Case ReportFor Adolescent Idopathic Scoliosis : A Case Report

Nik Aizah Nabilla Faheem, Chris Yin Wei Chan, Mun Keong KwanDepartment of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia

PP 12 Spinal Epidural Hematoma, A Bleeding Paralysis PP 12 Spinal Epidural Hematoma, A Bleeding Paralysis 5454

Rahul L, Nishand, S Shamsher, Thurai K, Z ZukiHospital Sungai Buloh, Selangor, Malaysia

PP 13 Presumed Idiopathic Adolescent Scoliosis With Large Intraspinal Meningeal PP 13 Presumed Idiopathic Adolescent Scoliosis With Large Intraspinal Meningeal 5555 Cyst With Absent Channel Pedicles Undergoing Surgery – A Rare Case Report Cyst With Absent Channel Pedicles Undergoing Surgery – A Rare Case Report And Experience And Experience

Y Y Tan, S W Lim, K Thurai, Z ZamynHospital Sungai Buloh, Selangor, Malaysia

PP 14 A Good Clinical Outcome Of Indirect Decompression Surgery In Asia PP 14 A Good Clinical Outcome Of Indirect Decompression Surgery In Asia 5656 B Myelopathic Thoracic Ossified Posterior Longitudinal Ligament (Opll)B Myelopathic Thoracic Ossified Posterior Longitudinal Ligament (Opll)

Tunku Naziha T Z, Joehaimey J, Yusof M IDepartment of Orthopaedic Surgery, Universiti Sains Malaysia, Kubang Kerian, Malaysia

PP 15 Anterior And Posterior Fixation Of Cervical C5/C6 Bifacet Dislocation PP 15 Anterior And Posterior Fixation Of Cervical C5/C6 Bifacet Dislocation 5656

Wan-Yuhana W M Y, Joehaimey J, M I YusofHospital University of Science Malaysia, Kubang Kerian, Kota Bharu, Kelantan, Malaysia

43

the iMPoRtance oF accuRate sPinal level enuMeRation in syMPtoMatic luMBosacRal tRansitional veRteBRae – a case RePoRt

Bong C P, Lee C K, Chiu C K, Chris C Y W, Kwan M KUniversity of Malaya, Kuala Lumpur, Malaysia

BacKgRoundLumbosacral transitional vertebrae (LSTV) are common spine anomalies defined as either lumbarization of the uppermost sacral segment or sacralization of the lowest lumbar segment with reported prevalence of 7% - 30% in the general population[1]. The accurate assessment of spinal segmentation is crucial to avoid wrong level spine surgery or procedure[2].

RePoRtA 79 year-old lady, presented with 2 months history of worsening bilateral S1 radiculopathy without axial back pain despite trial of multiple spinal injections. She described her VAS as 9/10 and she only able to walk for 5 minutes duration. In view of worsening symptoms despite interventions, whole spine radiograph was obtained and noted she has lumbarization of her uppermost sacral segment. Her radiographs and MRI were thoroughly re-examined and conclude that her symptoms were due to the degeneration of the adjacent cephalad segment of LSTV, probably due to increasing mechanical connection of LSTV to the sacrum protects the disc at the traditional level and predisposes the adjacent cephalad segment to greater degeneration[3]. Posterior decompression of L4/L5 was performed uncomplicatedly. She was discharged home well. Upon follow up in clinic post-operative 2 weeks, her legs pain was completely resolved and she is able to walk without any restriction.

conclusionIdentification of spinal anomalies is crucial and accurate enumeration of spinal segment is essential to avoid an intervention or surgery at an incorrect level.

ReFeRences1. Delport, E.G., et al., Lumbosacral transitional vertebrae: incidence in a consecutive patient series. Pain Physician, 2006. 9(1): p. 53-6.

2. Konin, G.P. and D.M. Walz, Lumbosacral transitional vertebrae: classification, imaging findings, and clinical relevance. AJNR Am J Neuroradiol, 2010. 31(10): p. 1778-86.

3. Farshad-Amacker, N.A., et al., Associations between lumbosacral transitional anatomy types and degeneration at the transitional and adjacent segments. Spine J, 2015. 15(6): p. 1210-6.

PP 1PP 1

44

a case RePoRt oF c1-c2 Fusion using ModiFied MageRl’s techniqueElrofai Suliman Bashir1, Chee Kean Lee2, Chris Yin Wei Chan2, Mun Keong Kwan2

1Elneelain University, Khartoum, Sudan 2Department of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia

C1-C2 subluxation is usually due to congenital, traumatic, degenerative or inflammatory condition. Posterior C1/C2 fusion with C1 lateral mass and C2 pedicle screws construct is getting more popularity due to its superior biomechanical advantage as compared to other fixations. We report a case of C1-C2 subluxation in a 77 years old gentleman due to degenerative spine disease. Pre-operative CT revealed C1 posterior arch hypoplasia. A C1 lateral mass or posterior arch screw was not possible in this case. We performed a modified technique on Magerl’s transarticular C1/C2 screws bilaterally together with a C1 sublaminar wire. A good outcome was achieved by using this novel technique. Radiological union was achieved at 4 months post-operation.

PP 2PP 2

45

a good shoRt-teRM outcoMe in delayed decoMPRession oF cauda equina syndRoMe in KleBsiella PneuMonia sPinal ePiduRal aBscess

Hanifah J, Joehaimey J, Yusof M IDepartment of Orthopaedic Surgery, Universiti Sains Malaysia, Kubang Kerian, Malaysia

Spinal epidural abscess (SEA) represents a severe, generally pyogenic, infection of the epidural space of spinal cord or cauda equina. The abscess causes swelling in the area and threatens the spinal cord or cauda equina by compression or vascular disruption that requires urgent surgical decompression to avoid significant permanent disability. We present a rare case of klebsiella pneumonia spinal epidural abscess secondary to haematogenous spread of previous lung infection that presented late at our centre with cauda equine syndrome that shows good short-term outcome in delayed decompression. A 50-year-old female presented with one-week history of persistent low back pain with progressively worsening bilateral lower limb weakness for 7 days and urinary retention associated with saddle anesthesia of 2-day duration. Magnetic resonance imaging with contrast of the lumbo-sacral region showed intramuscular collection at left gluteus maximus and left multifidus muscle with a L3-L5 posteriorly placed extradural lesion enhancing peripherally on contrast, suggestive of epidural abscess that compress cauda equina. The pus was drained through the posterior lumbar approach. Tissue and pus culture revealed klebsiella pneumonia, suggestive of bacterial infection. The patient made immediate improvement of muscle power over bilateral lower limbs postoperative followed by ability to control micturition and defecation day 4 post operation. A good short-term outcome in delayed decompression of cauda equine syndrome is extremely rare. Aggressive surgical decompression combined with antibiotic lead to good short-term outcome in this patient despite delayed decompression more than 48 hours.

PP 3PP 3

46

outcoMe oF sPinal Metastasis tReated with total en Bloc sPondylectoMy : a case RePoRt

Hisam M A, Kang Kai Lim, Kamalnizat I, Shaharuddin A B, Azmi BDepartment of Orthopaedic and Traumatology, Chancellor Tuanku Muhkriz Hospital, Kuala Lumpur, Malaysia

BacKgRoundWe present a case of a T9 en bloc resection of an infiltrating ductal carcinoma metastasis.

RePoRtA 74-year-old lady presented with a 1-month history of progressive intractable back and leg pain with acute onset bilateral lower limb weakness and numbness for 2 days. She was diagnosed with left breast infiltrating ductal carcinoma with lymph nodes involvement 8 years prior and completed neoadjuvant chemotherapy with subsequent left mastectomy. The patient underwent a successful T9 en bloc spondylectomy using a Gigli saw, anterior stabilization with an expandable cage, and posterior instrumentation via a single posterior approach. Post-operatively the patient’s neurology was intact. There was no evidence of instrumentation failure at more than 2 years of follow-up. En bloc resection via a single posterior approach is a viable and effective treatment option for spinal metastasis. Although with a stage IV breast carcinoma, our patient had neurological improvement with spinal stability and improved quality of life 2 years post-operation.

PP 4PP 4

47

MultiPle MyeloMa MiMicKing as a PRiMaRy solitaRy tuMouR in the PosteRioR eleMent oF t7 veRteBRa : a RaRe case RePoRt

E S Teoh, S W Lim, Thuraikumar K, Z Zuki Orthopaedic and Traumatology Department, Hospital Sungai Buloh, Selangor, Malaysia

BacKgRoundMultiple myeloma commonly causes widespred osteolytic bone damage involving multiple vertebrae bodies. Solitary lesions involving posterior elements of a single vertebrae level is rare.

case RePoRtA 67 years old man presented with chief complaint of backache at thoracic region for 3 months with bilateral lower limb weakness and numbness, unable to walk or stand, Examination showed ASIA C neurological status. MRI showed a mass over posterior element of T7 vertebrae body with cord compression. Skeletal survey showed no evidence of lytic lesion from other parts of the body.

T7 vertebrectomy, expandable cage insertion and posterior spinal instrumentation and fusion done. through a single incision from posterior approach. HPE from vertebrectomy revealed plasma cell tumour. Bone marrow biopsy later noted 90% of plasma cells.

Patient showed remarkable neurological recovery to ASIA D two weeks post operatively.

discussionMultiple myeloma presenting as a solitary tumour involving posterior element of spine is rare.

Solitary Bone Plasmacytoma, different from Multiple myeloma as it has no bone marrow involvement (plasma cells less than 10 %).

Biopsy of lesion is mandatatory to get the definitive diagnosis.

PP 5PP 5

48

ManageMent oF iatRogenic l5 neRve Root inJuRies caused By l5 Pedicle scRew MalPosition : a RePoRt oF 2 cases

Chris Yin Wei Chan, Ling Xiu Wen, Chee Kean Lee, Mun Keong KwanDepartment of Orthopaedic Surgery (NOCERAL), University of Malaya, Kuala Lumpur, Malaysia

We report two patients with three L5 nerve root injuries caused by mal-positioning of pedicle screws. The first patient was a 58-year-old lady who presented with severe bilateral L5 radicular pain and right-sided foot weakness following posterior decompression and posterolateral fusion of L4-L5. CT scans confirmed bilateral L5 nerve roots impingement due to inferior perforation of L5 screws. The second patient was a 44-year-old gentleman who presented with worsening of left L5 radicular pain post L5 laminectomy and posterior instrumentation of L5-S1. CT scan showed grade 3 medial perforation of the left L5 pedicle screw. Both patients underwent repositioning of the screws and microsurgical neurolysis of the injured nerve roots through the pre-existing screw tracts of the mal-positioned screws. Both cases had good clinical recovery after one-year follow-up.

PP 6PP 6

49

a thRee-yeaR Follow uP oF seveRe scoliosis : utilising