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CLINICAL SCIENCE
Posterior-only spinal fusion without rib head resection for treating type I neurofibromatosis with intra-canal rib head dislocation
Dong Sun#, Fei Dai#, Yao Yao Liu, Jian-Zhong Xu
Corresponding author
xjzslw@163.com

Tel.: 011 86 23 65340297
Third Military Medical University, Orthopedic Department of Southwest Hospital, Chongqing, China.
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          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">True axial CT images of pre- &#40;A&#41; and 24 months post-operation &#40;B&#41; showed the method of recording intra-canal rib head position&#58; Line &#8220;bo&#8221; is the bisecting line of the vertebral body&#59; line &#8220;a&#8221; is the perpendicular line of &#8220;bo&#8221;&#59; line &#8220;L&#8220;&#40;red line&#41;is the distance between the tip of intra-canal rib head and the bisecting line of vertebral body&#46; The comparison of A and B demonstrated definite intra-canal rib head dislocation before the surgery and significant extraction after the surgery&#44; which was maintained for 24 months after the surgery&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle60">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">Neurofibromatosis type 1 &#40;NF1&#41;&#44; also known as von Recklinghausen disease&#44; involves the spine in 26&#37; to 50&#37; of patients &#40;<a class="elsevierStyleCrossRef" href="#bib1">1</a>&#44;<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#41;&#46; The spinal deformity can be divided into two categories&#58; dystrophic and non-dystrophic&#46; Non-dystrophic forms mimic idiopathic scoliosis and are treated as such&#46; Dystrophic deformities&#44; on the other hand&#44; are characterized by relentless curve progression with short segmental and sharply angulated curves&#44; which are often accompanied by severe vertebral body wedging and neural foraminal enlargement &#40;<a class="elsevierStyleCrossRef" href="#bib3">3</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib6">6</a>&#41;&#46; These dystrophic curves are usually corrected via combined anterior and posterior fusion&#44; which is also known as circumferential fusion &#40;<a class="elsevierStyleCrossRef" href="#bib7">7</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib9">9</a>&#41;&#46; In some dystrophic cases&#44; the deformities are so severe that the rib heads on the convex side of the curve penetrate into the spinal canal through the enlarged neural foramen&#46; If unrecognized&#44; the dislocated rib heads could lead to catastrophic injuries by impinging on the spinal cord after corrective procedures &#40;<a class="elsevierStyleCrossRef" href="#bib6">6</a>&#44;<a class="elsevierStyleCrossRef" href="#bib10">10</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib14">14</a>&#41;&#46; Unfortunately&#44; current knowledge about the diagnosis and surgical management of NF-1 scoliosis with intra-canal rib penetration is insufficient due to the rarity of the condition &#40;<a class="elsevierStyleCrossRef" href="#bib6">6</a>&#44;<a class="elsevierStyleCrossRef" href="#bib10">10</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib15">15</a>&#41;&#46; Thus far&#44; only 19 cases have been reported in the English literature &#40;<a class="elsevierStyleCrossRef" href="#t1-cln_68p1521">Table&#160;1</a>&#41;&#46; The purpose of our study is to share our systematic experience with the diagnosis and surgical treatment of this rare and highly risky situation&#46;</p><elsevierMultimedia ident="t1-cln_68p1521"></elsevierMultimedia></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">METHODS</span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle80">Patient data</span><p id="para20" class="elsevierStylePara elsevierViewall">Following the approval of the Institutional Review Board &#40;IRB&#41; of Southwest Hospital&#44; the records of six patients &#40;2 males&#44; 4 females&#59; 10&#8211;16 years&#41; diagnosed with Neurofibromatosis- type I &#40;NF-1&#41; with rib head dislocation into the spinal canal at our institution between 2008 to 2011 were reviewed&#46; The patient data are shown in <a class="elsevierStyleCrossRef" href="#t1-cln_68p1521">Table&#160;1</a>&#46;</p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle90">Measurements</span><p id="para30" class="elsevierStylePara elsevierViewall">The following parameters were measured pre- and post-operatively for correction assessment&#58; the coronal and sagittal Cobb angles on plain films&#44; the apex rotation and distance between the intra-canal rib head tip and the line bisecting the vertebral body by computed tomography &#40;CT&#41; scan&#46; The coronal and sagittal deformities were measured by the Cobb method &#40;<a class="elsevierStyleCrossRef" href="#bib16">16</a>&#44;<a class="elsevierStyleCrossRef" href="#bib17">17</a>&#41;&#46; The coronal Cobb angle was defined by the angles between the two end vertebrae &#40;the last vertebra that tilted into the curve&#41;&#46; Sagittal kyphosis was defined by the angles between the endplates of T2 and T12&#46; The apex rotation was measured using the Aaro-Dahlborn method on a true axial slice &#40;<a class="elsevierStyleCrossRef" href="#bib18">18</a>&#41;&#44; in which the axial slices were adjusted to parallel the orientation of the superior endplate&#46; The distance between the intra-canal rib head tip and the line bisecting the vertebral body was measured on a true axial CT slice&#46; It was represented by its absolute value and direction&#59; the distance was recorded as positive if the intra-canal rib head tip passed the bisecting line of the body&#59; otherwise&#44; it was negative &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure&#160;1</a>&#41;&#46; Finally the correction rate of the coronal Cobb angle&#44; kyphosis and the apex rotation and distance of the intra-canal rib head being retracted out of the canal were calculated&#46; Magnetic resonance imaging &#40;MRI&#41; of the whole spine was performed on all patients to reveal any intra-spinal lesions and assess the relationship between the rib head and the dural sac&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia></span><span id="cesec50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle100">Reliability tests</span><p id="para40" class="elsevierStylePara elsevierViewall">The measurements were performed by two orthopedic residents &#40;D&#46;S&#46; &#38;Y&#46;Y&#46;L&#46;&#41; on our PACS system and were confirmed by a senior spine specialist &#40;F&#46;D&#46;&#41;&#46; The parameters for each patient were measured five times by each observer&#44; and reliability was determined by intra-observer and inter-observer interclass coefficients&#46;</p></span><span id="cesec60" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle110">Surgical Procedures</span><p id="para50" class="elsevierStylePara elsevierViewall">The procedure was performed with multimodality spinal cord monitoring&#46; The patient was in the prone position&#44; and a midline incision was made&#46; After satisfactory exposure&#44; pedicle screws were carefully placed bilaterally at all levels within the two neutral vertebrae except for the apex and its cranial- and caudal-adjacent levels&#46; Afterwards&#44; multi-level Smith-Peterson osteotomy was performed and followed by simultaneous rod rotation on the convex side and translation maneuver on the concave side&#46; Spinal cord status was closely monitored by both transcranial electric motor-evoked potential &#40;MEP&#41; and somatosensory-evoked potential &#40;SEP&#41;&#46; Alterations in which the MEP wave amplitude decreased more than 75&#37; and SEP amplitude decreased more than 50&#37; compared to baseline were diagnosed as positive changes&#46; Any correction maneuvers were stopped or even reversed if any indication of neurological impairment was noted&#46; In addition&#44; intra-operative &#8220;wake-up&#8221; tests were performed at the end of the reduction procedure to confirm&#46; The spinal fusions were accomplished in an extended fashion&#44; which means that the one or two levels above and below the neutral vertebrae at each end were instrumented and grafted with autograft and allograft bones&#46; A cell saver was used in all surgeries&#46; After being discharged&#44; the patients were required to wear a thoracic-lumbar vest for at least four months to protect the fusion site&#46;</p></span><span id="cesec70" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle120">Statistical analysis</span><p id="para60" class="elsevierStylePara elsevierViewall">The measurements were analyzed with SPSS 13&#46;0 &#40;SPSS Inc&#44; Chicago&#44; IL&#41;&#46; Paired t-tests were used to determine the difference of parameters&#46; Significance was defined as a <span class="elsevierStyleItalic">p</span>&#60;0&#46;05 and reported as such&#46;</p></span><span id="cesec80" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle130">Ethics</span><p id="para70" class="elsevierStylePara elsevierViewall">This study was approved by the Institutional Review Board &#40;IRB&#41; of Southwest Hospital&#44; Third Military Medical University&#46; All procedures in the study were in accordance with the ethical standards of the IRB of Southwest Hospital and with the Helsinki Declaration&#46;</p></span></span><span id="cesec90" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle140">RESULTS</span><span id="cesec100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle150">Pre-operative examination</span><p id="para80" class="elsevierStylePara elsevierViewall">All six patients displayed multiple cafe au lait spots on the skin and were neurologically asymptomatic&#46; Intra-canal rib head dislocation was detected by pre-operative CT and MRI examinations &#40;<a class="elsevierStyleCrossRef" href="#fig2">Figure&#160;2</a>&#41;&#46; There were no signs of cord compression or intra- or para-spinal neurofibromatosis on the pre-operative MRI&#46;</p><elsevierMultimedia ident="fig2"></elsevierMultimedia></span><span id="cesec110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle160">Surgical outcomes</span><p id="para90" class="elsevierStylePara elsevierViewall">All six NF-1 patients with rib head dislocation underwent posterior-only approach correction and instrumentation without rib head resection&#46; The average blood loss was 1020&#177;80 ml&#44; and the average surgery time was 238&#177; 63 minutes&#46; Three of the patients required an intra-operative transfusion&#44; which averaged 667&#177;56 ml&#46; No neurological impairment&#44; intra-canal hematoma&#44; dural tear or other form of complication was reported after surgery&#46;</p><p id="para100" class="elsevierStylePara elsevierViewall">The spinal deformity parameters&#44; radiology and patients&#39; postures at pre-operation&#44; immediately post-operation and 24 months post-operation are shown in <a class="elsevierStyleCrossRef" href="#t2-cln_68p1521">Table&#160;2</a>&#44; <a class="elsevierStyleCrossRefs" href="#fig3">Figures&#160;3 and 4</a>&#46;</p><elsevierMultimedia ident="t2-cln_68p1521"></elsevierMultimedia><elsevierMultimedia ident="fig3"></elsevierMultimedia><elsevierMultimedia ident="fig4"></elsevierMultimedia><p id="para110" class="elsevierStylePara elsevierViewall">To evaluate the efficacy of the surgical correction&#44; we compared the deformity parameters pre-operation and immediately after the operation &#40;<a class="elsevierStyleCrossRef" href="#t2-cln_68p1521">Table&#160;2</a> and <a class="elsevierStyleCrossRef" href="#fig3">Figure&#160;3A&#44; B&#44; D&#44; E</a>&#41;&#46; The coronal Cobb angle&#44; kyphosis and axial rotation were significantly reduced after the surgery in all patients&#46; The average correction rate of the coronal Cobb angle was 47&#46;4&#37;&#44; and that of kyphosis was 58&#46;6&#37;&#46; The correction rate of apex rotation was 44&#46;4&#37;&#46; These improvements corresponded to a change in the patients&#39; posture before and after the surgery &#40;<a class="elsevierStyleCrossRef" href="#fig4">Figure&#160;4A&#44; B&#44; D&#44; E</a>&#41;&#46; In addition&#44; the intra-spinal rib head tips were retracted away from canals by 5&#46;18&#177;2&#46;6 cm&#46; These results suggested that our procedures significantly corrected the spinal deformity and the intra-canal rib head dislocation&#46;</p><p id="para120" class="elsevierStylePara elsevierViewall">Because dystrophic NF-1 patients are more likely to develop pseudoarthrosis after posterior-only spinal fusion&#44; all patients were followed up for at least 24 months&#46; All of the deformity parameters at 24 months post-operation were compared with those immediately after surgery &#40;<a class="elsevierStyleCrossRef" href="#t2-cln_68p1521">Table&#160;2</a> and <a class="elsevierStyleCrossRef" href="#fig3">Figure&#160;3B&#44; C&#44; E&#44; F</a>&#41;&#44; and there was no significant difference between the two groups&#46; There was also no significant difference in the relative position of the rib heads being extracted from the canal&#46; The maintenance of deformity corrections was also supported by the patients&#39; posture 24 months after surgery &#40;<a class="elsevierStyleCrossRef" href="#fig4">Figure&#160;4C&#44; F</a>&#41;&#46; Solid fusion was confirmed on radiology at 24 months after surgery&#44; and implant failure and screw pull-out &#40;<a class="elsevierStyleCrossRef" href="#fig3">Figure&#160;3 C&#44; F</a>&#41; were not observed&#46; These results indicated that solid spinal fusions were achieved and all of the corrections were well-maintained 24 months after the surgery&#46;</p></span><span id="cesec120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle170">Reliability</span><p id="para130" class="elsevierStylePara elsevierViewall">The repeated measurements demonstrated good inter-operator reliability and intra-observer reliability &#40;<a class="elsevierStyleCrossRef" href="#t3-cln_68p1521">Table&#160;3</a>&#41;&#46;</p><elsevierMultimedia ident="t3-cln_68p1521"></elsevierMultimedia></span></span><span id="cesec130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle180">DISCUSSION</span><p id="para140" class="elsevierStylePara elsevierViewall">Multiple manifestations are associated with NF-1&#44; and 26&#37; to 50&#37; of individuals with this disorder show spinal abnormalities&#46; Two general curve patterns have been widely recognized&#58; Type I curves are characterized by scoliosis of 20 to 40 degrees and normal sagittal curvatures &#40;kyphosis less than 50 degrees&#41;&#44; which is known as an idiopathic scoliosis-like curve pattern&#59; Type II curves are short&#44; angulated dystrophic curves with angles of kyphosis more than 50 degrees&#46; The latter type is accompanied by rib-penciling&#44; vertebral scalloping&#44; severe apical wedging and rotation&#44; enlargement of the foramina&#44; and para-vertebral tumors &#40;<a class="elsevierStyleCrossRef" href="#bib1">1</a>&#44;<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#44;<a class="elsevierStyleCrossRef" href="#bib8">8</a>&#44;<a class="elsevierStyleCrossRef" href="#bib19">19</a>&#8211;<a class="elsevierStyleCrossRef" href="#bib21">21</a>&#41;&#46; Occasionally&#44; the rib heads dislocate into the spinal canal and lead to subsequent neurological impairment &#40;<a class="elsevierStyleCrossRef" href="#bib10">10</a>&#44;<a class="elsevierStyleCrossRef" href="#bib12">12</a>&#44;<a class="elsevierStyleCrossRef" href="#bib14">14</a>&#44;<a class="elsevierStyleCrossRef" href="#bib15">15</a>&#41;&#46; Due to the rarity of this particular condition&#44; evidence-based diagnosis and surgical treatments on this deformity have been insufficient&#44; which presents risks to patients with this condition &#40;<a class="elsevierStyleCrossRef" href="#bib20">20</a>&#44;<a class="elsevierStyleCrossRef" href="#bib24">24</a>&#41;&#46;</p><p id="para150" class="elsevierStylePara elsevierViewall">So far&#44; only 12 studies with a total of 19 involved patients have been previously reported &#40;<a class="elsevierStyleCrossRef" href="#t1-cln_68p1521">Table&#160;1</a>&#41;&#46; These included 11 males and 8 females with a mean age at presentation of 14&#46;1 years &#40;range&#58; 5 to 16 years&#41;&#46; Rib head dislocation occurred on the convex side of the curve&#44; usually around its apex&#46; The mean curvature was 68 degrees &#40;range&#58; 29 to 92 degrees&#41;&#46; Eight patients showed preoperative neurologic signs or symptoms&#44; whereas 11 did not&#46; All patients underwent rib head resection&#44; and 11 had combined or staged anterior and posterior spinal fusion and segmental spinal instrumentation&#46; Eight patients underwent stabilization with only a posterior spinal fusion and segmental spinal instrumentation&#46; Among all of the reported cases&#44; only a few were followed up over a long term to evaluate the outcomes&#46;</p><p id="para160" class="elsevierStylePara elsevierViewall">The diagnosis of NF-1 dystrophic scoliosis can be made based on typical clinical features&#44; such as multiple cafe au lait spots on the skin and a characteristic curve pattern on radiology &#40;<a class="elsevierStyleCrossRef" href="#bib10">10</a>&#44;<a class="elsevierStyleCrossRef" href="#bib14">14</a>&#44;<a class="elsevierStyleCrossRef" href="#bib15">15</a>&#44;<a class="elsevierStyleCrossRef" href="#bib24">24</a>&#41;&#46; It is fairly important that clinicians are able to identify this disease early&#46; In contrast&#44; the neurological symptoms of NF-1 with intra-spinal rib head dislocation are varied&#44; ranging from mild sensory and motor deficits to paraplegia and paraparesis&#44; with approximately 60&#37; of documented cases being asymptomatic &#40;<a class="elsevierStyleCrossRef" href="#bib12">12</a>&#41;&#46; Therefore&#44; we believe intensive radiology examinations are most reliable for finding intra-canal dislocations&#46; CT myelography may have added benefit in detecting intra-canal dislocations but should be weighed against the risks by the clinician&#44; as these risks include adverse reactions to the contrast&#44; iatrogenic headache&#44; nerve injury&#44; or bleeding due to the spinal needle&#46; In our study&#44; we included several steps to aid with the diagnosis and surgical decision-making&#46; First&#44; thin slice &#40;1 mm&#41; CT and 3D reconstruction of the entire spine was performed before and after surgery to detect the dislocation pre-operatively and confirm rib head retraction post-operatively&#44; as it has been reported that the rib penetration can be missed pre-operatively even with CT scanning &#40;<a class="elsevierStyleCrossRef" href="#bib10">10</a>&#41;&#46; The CT gantry was adjusted individually to parallel the superior endplate of the scoliotic vertebral body&#44; as the intra-canal rib head can be easily under-recognized in routine CT examinations &#40;<a class="elsevierStyleCrossRef" href="#bib24">24</a>&#41;&#46; In addition&#44; whole spine MRI was also performed to demonstrate intra-canal and paraspinal soft tissue details&#46; Rib head dislocations were detected on the axial CT slice and 3D reconstruction&#46; All of the dislocated ribs were on the convex side of the curve and were from the levels at the peri-apical regions&#46; Therefore&#44; we suggest that slices from these regions should be carefully inspected&#46; Furthermore&#44; MRI scanning demonstrated the relationship between the cord and intra-canal rib heads&#44; which was also important to clarify the intra-canal deformity and assist with surgical decision-making&#46;</p><p id="para170" class="elsevierStylePara elsevierViewall">It is generally accepted that if any neurological symptoms are present due to spinal cord compression from intra-canal rib head dislocation&#44; it is necessary to resect the compressing part&#46; In contrast&#44; if the patient shows no neurologic symptoms&#44; whether to resect the dislocated rib head in the canal remains controversial&#46; As a result&#44; current surgical approaches to this situation vary greatly among surgeons&#46; Crawford &#40;<a class="elsevierStyleCrossRef" href="#bib21">21</a>&#44;<a class="elsevierStyleCrossRef" href="#bib22">22</a>&#41; and Abdulian et al&#46; &#40;<a class="elsevierStyleCrossRef" href="#bib10">10</a>&#41; believed that the rib head would impale the spinal cord in the correction process&#59; therefore&#44; intra-spinal rib heads needed to be resected before the correction procedure&#46; It was also reported that patients with dislocated rib heads were predisposed to spinal cord injury after a traumatic event &#40;<a class="elsevierStyleCrossRef" href="#bib23">23</a>&#41;&#46; The only case without resection of the rib head was reported by Yalcin et al&#46; &#40;<a class="elsevierStyleCrossRef" href="#bib14">14</a>&#41;&#44; who claimed that the intra-canal rib head had moved away from the spinal cord while the apex was translated to the concavity&#46; However&#44; the reliability of this claim was questioned because it was based on a single case without any long-term follow up&#46; In our study&#44; we had six consecutive patients with at least 24 months of follow-up&#46; We feel our study guides identification and care of patients with such a deformity&#46; To quantify the extraction effect on the intra-canal rib head&#44; we used the line bisecting the vertebral body on a true axial CT cut as the reference line and measured the distance between this line and the intra-canal rib head&#46; As demonstrated in our postoperative results&#44; the rib head had been extracted out of the canal significantly and remained extracted 24 months after surgery&#46; The benefit of reduction without rib head resection was that we could avoid the risk of impaling the spinal cord or tearing the dural sac while achieving good reduction&#46;</p><p id="para180" class="elsevierStylePara elsevierViewall">Another innovation in the surgical management of our study was that we used a posterior-only approach for spinal fusion and segmental instrumentation&#46; A high incidence of pseudarthrodesis has been reported in dystrophic NF-1 scoliosis&#44; and circumferential spinal fusion via a combined anterior and posterior approach was recommended as the standard treatment &#40;<a class="elsevierStyleCrossRef" href="#bib1">1</a>&#41;&#46; At least three groups have reported alarmingly high failure rates &#40;63&#37;&#8211;72&#37;&#41; with posterior-only fusion of dystrophic NF-1 scoliosis &#40;<a class="elsevierStyleCrossRef" href="#bib8">8</a>&#41;&#46; However&#44; those surgeries frequently involved forms of internal fixation now considered biomechanically inferior to pedicle screw-rod systems &#40;<a class="elsevierStyleCrossRef" href="#bib25">25</a>&#41;&#46; An anterior and posterior combined approach necessitates more extensive surgery and therefore carries a higher risk of complications&#44; including decreased respiratory function and excessive bleeding from the plexiform venous channels that are sometimes associated with neurofibromatosis&#46; Several authors &#40;<a class="elsevierStyleCrossRef" href="#bib8">8</a>&#44;<a class="elsevierStyleCrossRef" href="#bib18">18</a>&#44;<a class="elsevierStyleCrossRef" href="#bib26">26</a>&#44;<a class="elsevierStyleCrossRef" href="#bib27">27</a>&#41; have proposed and performed posterior vertebral body resection &#40;pVCR&#41; and circumferential spinal fusion in treating dystrophic scolio-hyperkyphosis&#46; However&#44; this procedure utilizes a challenging technique and should only be performed by a highly experienced surgical team &#40;<a class="elsevierStyleCrossRef" href="#bib28">28</a>&#41;&#46; Therefore&#44; the posterior-only approach with extended fusion levels in our study has the advantage of being less invasive and less technique demanding&#46; In our study blood loss and surgery time was limited to approximately 1020 ml and 238 min with a posterior-only approach&#44; which was relatively less invasive than the combined approach &#40;<a class="elsevierStyleCrossRef" href="#bib9">9</a>&#44;<a class="elsevierStyleCrossRefs" href="#bib29">29-31</a>&#41;&#46; The corrections on three planes were also significant&#44; as demonstrated by the results&#44; and were well maintained at the two-year post-operative follow-up&#46; These outcomes validated the efficacy and reliability of the posterior-only approach in treating NF-1 dystrophic scoliosis&#46;</p><span id="cesec140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle190">Limitations and future directions</span><p id="para190" class="elsevierStylePara elsevierViewall">Our study is not without limitations&#46; Due to the rarity of NF-1 dystrophic scoliosis with rib head dislocation&#44; more extensive studies should be conducted to better understand the natural history&#44; diagnosis and management of this deformity&#46; In addition&#44; the parameters describing intra-canal rib head dislocation still need further verification and improvement&#46; Our study did&#44; however&#44; include more cases of this unique situation than have been previously reported in the English literature&#59; we feel this study was strong enough to provide some primary guidelines in caring for NF-1 dystrophic scoliosis patients without any neurological symptoms&#46;</p><p id="para200" class="elsevierStylePara elsevierViewall">NF-1 dystrophic curves with rib head dislocation into the canal can be treated by extended segmental instrumentation and fusion without rib head resection via a posterior-only approach&#46; Appropriate surgical candidates should be carefully selected prior to any procedure&#59; inclusive pre-operative evaluation and sufficient intra-operative exposure and monitoring are necessary to improve surgical outcomes&#46;</p></span></span></span>"
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          "titulo" => "INTRODUCTION"
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          "titulo" => "METHODS"
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              "titulo" => "Patient data"
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              "titulo" => "Measurements"
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              "titulo" => "Reliability tests"
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              "titulo" => "Surgical Procedures"
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              "titulo" => "Ethics"
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        3 => array:3 [
          "identificador" => "cesec90"
          "titulo" => "RESULTS"
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            0 => array:2 [
              "identificador" => "cesec100"
              "titulo" => "Pre-operative examination"
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            1 => array:2 [
              "identificador" => "cesec110"
              "titulo" => "Surgical outcomes"
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            2 => array:2 [
              "identificador" => "cesec120"
              "titulo" => "Reliability"
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        4 => array:3 [
          "identificador" => "cesec130"
          "titulo" => "DISCUSSION"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "cesec140"
              "titulo" => "Limitations and future directions"
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          "titulo" => "REFERENCES"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-05-06"
    "fechaAceptado" => "2013-06-20"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "KEYWORDS"
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          "palabras" => array:3 [
            0 => "Neurofibromatosis"
            1 => "Rib Head Protrusion"
            2 => "Posterior Spinal Fusion"
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    "resumen" => array:1 [
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        "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">OBJECTIVES&#58;</span><p id="spara90" class="elsevierStyleSimplePara elsevierViewall">Patients with Type I neurofibromatosis scoliosis with intra-canal rib head protrusion are extremely rare&#46; Current knowledge regarding the diagnosis and treatment for this situation are insufficient&#46; The purpose of this study is to share our experience in the diagnosis and surgical treatments for such unique deformities&#46;</p></span> <span id="ceabs20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">METHODS&#58;</span><p id="spara100" class="elsevierStyleSimplePara elsevierViewall">Six patients with Type I neurofibromatosis scoliosis with rib head dislocation into the spinal canal were diagnosed at our institution&#46; Posterior instrumentation and spinal fusion without intra-canal rib head resection via a posterior-only approach was performed for deformity correction and rib head extraction&#46; The efficacy and outcomes of the surgery were evaluated by measurements before&#44; immediately and 24 months after the surgery using the following parameters&#58; coronal spinal Cobb angle&#44; apex rotation and kyphosis of the spine and the intra-canal rib head position&#46; Post-operative complications&#44; surgery time and blood loss were also evaluated&#46;</p></span> <span id="ceabs30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">RESULTS&#58;</span><p id="spara110" class="elsevierStyleSimplePara elsevierViewall">Patients were followed up for at least 24 months post-operatively&#46; The three dimensional spinal deformity was significantly improved and the intra-canal rib head was significantly extracted from the canal immediately after the surgery&#46; At follow-up 24 months after surgery&#44; solid fusions were achieved along the fusion segments&#44; and the deformity corrections and rib head positions were well maintained&#46; There were no surgery-related complications any time after the surgery&#46;</p></span> <span id="ceabs40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">CONCLUSIONS&#58;</span><p id="spara120" class="elsevierStyleSimplePara elsevierViewall">Systematic examinations are needed to identify patients with Type I neurofibromatosis scoliosis with rib head dislocation into the canal who can be treated by posterior-only spinal fusion without rib head resection&#46;</p></span>"
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            "titulo" => "RESULTS&#58;"
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        "nota" => "<p class="elsevierStyleNotepara" id="cenpara70">co-first authors</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="cenpara50">Sun D and Dai F contributed equally to the study and are considered co-first authors&#46; Sun D drafted the manuscript&#46; Dai F and Xu JZ performed surgery and commented on the manuscript&#46; Sun D and Liu YY collected and analyzed the data&#46;</p> <p class="elsevierStyleNotepara" id="cenpara60">No potential conflict of interest was reported&#46;</p>"
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          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">True axial CT images of pre- &#40;A&#41; and 24 months post-operation &#40;B&#41; showed the method of recording intra-canal rib head position&#58; Line &#8220;bo&#8221; is the bisecting line of the vertebral body&#59; line &#8220;a&#8221; is the perpendicular line of &#8220;bo&#8221;&#59; line &#8220;L&#8220;&#40;red line&#41;is the distance between the tip of intra-canal rib head and the bisecting line of vertebral body&#46; The comparison of A and B demonstrated definite intra-canal rib head dislocation before the surgery and significant extraction after the surgery&#44; which was maintained for 24 months after the surgery&#46;</p>"
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          "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Pre-operation radiology examination detected intra-canal rib head dislocation&#46; A&#41; Preoperative CT sagittal image showed the intra-canal portion of dislocated rib head &#40;white arrow&#41;&#59; B&#41; 3D reconstruction image of the same patient showed rib head&#40;R&#41; dislocation into the canal&#59; C&#41; MRI demonstrated the intra-canal rib head&#40;R&#41; did not compress on the cord&#40;C&#41;&#44; and the boundary&#40;white arrow&#41; between the rib head and the cord was clear&#46;</p>"
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          "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">Pre-operative&#44; immediate post-operative and 24 month post-operative radiographs&#46; The coronal Cobb angles &#40;A-C&#41; were defined by the angles between the two end vertebra&#40;yellow lines&#41;&#44; and sagittal kyphosis &#40;D-F&#41; was defined by the angles between T2 and T12&#40;yellow lines&#41;&#46; A and D&#41;The preoperative coronal and sagittal images showed sharp and short segmental coronal deformity and significant sagittal hyperkyphosis in the thoracic region&#59; B and E&#41; The immediate post-operative coronal and sagittal images showed significant correction of the deformity in both planes&#59; C and F&#41; The 24 month post-operative coronal and sagittal images showed the well-maintained correction of deformity in both planes&#44; solid fusion within the fused regions was achieved&#44; and all the implants remained in position&#46;</p>"
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          "en" => "<p id="spara40" class="elsevierStyleSimplePara elsevierViewall">Pre-operative&#44; immediately post-operative and 24 month post-operative photos of patient postures&#46; A and D&#41; The preoperative anterior and posterior&#40;AP&#41; views and lateral view showed multiple cafe au lait spots on the patient&#39;s skin and significant hyperkyphosis posture&#59; B and E&#41; The immediate post-operative AP and lateral view showed significant improvement of postures&#59; C and F&#41; 24 month post-operative AP and lateral view showed well-maintained body posture in both views&#59; the incision healed well&#46;</p>"
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          "leyenda" => "<p id="spara60" class="elsevierStyleSimplePara elsevierViewall">ASF&#58; anterior spinal fusion&#59; CT-M&#58; CT myelography&#59; HT&#58; halo traction&#59; PSF&#58; posterior spinal fusion&#59; R&#58; rib head resection&#59; SSI&#58; segmental spinal instrumentation&#59; VCR&#58; vertebral column resection&#46;</p>"
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                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Age &#40;y&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Signs &#38; symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Radiology Exam&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Follow-up time&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abdulian et al&#46; &#40;<a class="elsevierStyleCrossRef" href="#bib10">10</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">R&#44;ASF&#44;HT&#44;PSF&#44;SSI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Capella et al&#46; &#40;<a class="elsevierStyleCrossRef" href="#bib15">15</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No pre-operative symptoms&#59; postoperative weakness and paraparesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT&#44; MRI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">R&#44;ASF&#44;PSF&#44;SSI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dacher et al&#46; &#40;<a class="elsevierStyleCrossRef" href="#bib6">6</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bilateral ankle clonus and daytime micturition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT-M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">R&#44;ASF&#44;PSF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Deuchi et al&#46; &#40;<a class="elsevierStyleCrossRef" href="#bib11">11</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weakness of the lower extremities&#44; difficulty walking with eventual paraparesis&#44; hyperesthesia below waist&#44; ankle clonus and knee&#47;ankle hyperreflexia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT-M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HT&#44;VCR&#44;R&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Flood et al&#46; &#40;<a class="elsevierStyleCrossRef" href="#bib5">5</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Knee &#38; ankle clonus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT-M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">R&#44;ASF&#44;PSF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not mentioned&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gkioka et al&#46; &#40;<a class="elsevierStyleCrossRef" href="#bib4">4</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Painful rib hump&#44; gait difficulty&#44; bilateral Bobinski&#44; ankle clonus&#44; right foot drop&#44; decreased sensation&#47;hyperreflexia in lower limbs&#44; and daytime micturition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT&#44;MRI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">R&#44;PSF&#44;SSI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Kamath et al&#46; &#40;<a class="elsevierStyleCrossRef" href="#bib12">12</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ASF&#44;PSF&#44;SSI&#44;R&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not mentioned&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Koshhal et al&#46; &#40;<a class="elsevierStyleCrossRef" href="#bib32">32</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No pre-operative symptoms&#59; postoperative T5 paraparesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ASF&#44;PSF&#44;R&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Major et al&#46; &#40;<a class="elsevierStyleCrossRef" href="#bib33">33</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Transient loss of sensation below the waist and inability to move lower extremities after fall on rib hump&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT-M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ASF&#44;PSF&#44;SSI&#44;R&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not mentioned&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ASF&#44;PSF&#44;SSI&#44;R&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not mentioned&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT-M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PSF&#44;R&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not mentioned&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mukhtar et al&#46; &#40;<a class="elsevierStyleCrossRef" href="#bib3">3</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right leg weakness and radiculopathy down to toes when he rolled to his right side&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT-M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">R&#44;PSF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yalcin et al&#46; &#40;<a class="elsevierStyleCrossRef" href="#bib14">14</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">R&#44;PSF&#44;SSI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not mentioned&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT&#44; MRI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">R&#44;PSF&#44;SSI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not mentioned&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Radiographs &#38;CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PSF&#44;SSI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not mentioned&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ton et al&#46; &#40;<a class="elsevierStyleCrossRef" href="#bib24">24</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mild lower limb hyperreflexia and ankle clonus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT&#44; MRI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PSF&#44;SSI&#44;R&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not mentioned&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT&#44;MRI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">R&#44;PSF&#44;SSI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not mentioned&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT&#44;MRI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">R&#44;ASF&#44;PSF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not mentioned&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right foot weakness&#44; hyperreflexia and clonus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CT&#44;MRI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">R&#44;ASF&#44;PSF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not mentioned&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara50" class="elsevierStyleSimplePara elsevierViewall">Previous Reports of Spinal Canal Rib Penetration in Patients With Neurofibromatosis Type-1&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "t2-cln_68p1521"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Cobb angle&#40;&#176;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Kyphosis&#40;&#176;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Apex Rotation&#40;&#176;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Distance of rib extraction&#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pre-operation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">76&#46;6&#177;20&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">58&#46;8&#177;26&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;2&#177;2&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Post-operation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#46;6&#177;21&#46;5<a class="elsevierStyleCrossRef" href="#tfn2-cln_68p1521">&#42;</a>&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#46;8&#177;4&#46;3<a class="elsevierStyleCrossRef" href="#tfn2-cln_68p1521">&#42;</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;1&#177;2&#46;6<a class="elsevierStyleCrossRef" href="#tfn2-cln_68p1521">&#42;</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">5&#46;18&#177;2&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 Months post-operation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">26&#46;4&#177;6&#46;8<a class="elsevierStyleCrossRef" href="#tfn3-cln_68p1521">&#42;&#42;</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;6&#177;2&#46;6<a class="elsevierStyleCrossRef" href="#tfn3-cln_68p1521">&#42;&#42;</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;23&#177;2&#46;1<a class="elsevierStyleCrossRef" href="#tfn3-cln_68p1521">&#42;&#42;</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            1 => array:3 [
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Coronal Cobb angle</th><th class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Sagittal Cobb angle</th><th class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t" scope="col">Apex rotation</th><th class="td" title="\n
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                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Distance of rib extraction &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col">Pre-OP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col">Post-OP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col">Pre-OP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col">Post-OP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col">Pre-OP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">ICC<a class="elsevierStyleCrossRef" href="#tfn4-cln_68p1521">1</a>&#41;&nbsp;\t\t\t\t\t\t\n
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Spinal deformity in neurofibromatosis type-1&#58; diagnosis and treatment"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => """
                              AI Tsirikos \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              A Saifuddin \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              MH Noordeen \n
                              \t\t\t\t\t\t\t\t
                              """
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                    0 => array:2 [
                      "doi" => "10.1007/s00586-004-0829-7"
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                        "tituloSerie" => "Eur Spine J"
                        "fecha" => "2005"
                        "volumen" => "14"
                        "numero" => "5"
                        "paginaInicial" => "427"
                        "paginaFinal" => "439"
                        "link" => array:1 [
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                      "titulo" => "Prevalence of scoliosis in neurofibromatosis"
                      "autores" => array:1 [
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                          "autores" => array:4 [
                            0 => """
                              BA Akbarnia \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              KR Gabriel \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              E Beckman \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              D Chalk \n
                              \t\t\t\t\t\t\t\t
                              """
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                      "doi" => "10.1097/00007632-199208001-00005"
                      "Revista" => array:7 [
                        "tituloSerie" => "Spine"
                        "fecha" => "1992"
                        "volumen" => "17"
                        "numero" => "8 Suppl"
                        "paginaInicial" => "S244"
                        "paginaFinal" => "S248"
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                      "titulo" => "Spinal cord impingement by a displaced rib in scoliosis due to neurofibromatosis"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => """
                              IA Mukhtar \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              M Letts \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              K Kontio \n
                              \t\t\t\t\t\t\t\t
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                      "Revista" => array:7 [
                        "tituloSerie" => "Can J Surg"
                        "fecha" => "2005"
                        "volumen" => "48"
                        "numero" => "5"
                        "paginaInicial" => "414"
                        "paginaFinal" => "415"
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                      "titulo" => "Painful rib hump&#58; a new clinical sign for detecting intraspinal rib displacement in scoliosis due to neurofibromatosis"
                      "autores" => array:1 [
                        0 => array:2 [
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                            0 => """
                              A Gkiokas \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              S Hadzimichalis \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              E Vasiliadis \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              M Katsalouli \n
                              \t\t\t\t\t\t\t\t
                              """
                            4 => """
                              G Kannas \n
                              \t\t\t\t\t\t\t\t
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Article information
ISSN: 18075932
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos