Context: Thoracolumbar injuries are common manifestations of spinal trauma. While non-operative therapy is indicated in certain cases of isolated injury, operative therapy via open approaches are widely utilized. Recently, minimally invasive surgical (MIS) approaches have been adapted for the management of thoracolumbar trauma in an effort to avoid the operative morbidity of open thoracolumbar procedures.
Purpose: The purpose of this review is to perform a critical analysis of the literature regarding the clinical efficacy and safety of MIS procedures in the management of thoracolumbar trauma.
Evidence Acquisition: PubMed and MEDLINE databases were searched for articles published on the topic of MIS treatment of traumatic thoracolumbar injuries. Studies included in this review were comprised of clinical case series, retrospective cohort studies, non-randomized prospective cohort studies, prospective randomized controlled trials, and meta-analyses.
Results: The majority of published studies were retrospective clinical case series comprising level IV evidence. The majority of studies demonstrated the viability of MIS approaches as a treatment modality for thoracolumbar trauma in regards to clinical outcomes, radiographic outcomes, and complication rates. Additionally, MIS procedures were associated with reductions in operative time, intraoperative blood loss, and immediate postoperative pain.
Conclusions: MIS approaches to thoracolumbar trauma are viable treatment strategies in regards to clinical efficacy and safety. While the results for MIS procedures are promising, more high-quality prospective studies are necessary in order to make definitive conclusions regarding the superiority of MIS over open surgical strategies.

Background: Nerve repair with microsurgical techniques is the gold standard and the most widely used surgical treatment for nerve reconstruction. However, the optimum number of microsutures for approximation of nerve ends has not been investigated thoroughly, as the focus of previous studies has been on in vitro examination of biomechanical strength of the repaired nerve.
Objectives: In this study, we investigated the effect of the number of suture on nerve repair, concerning mechanical, functional, and morphometric aspects.
Methods: Twenty-four male Wistar rats were subjected to tibial nerve transection and randomly divided into three groups: control with no repair; repair with 1 suture; and repair with 3 sutures. Tibial functional index (TFI) was determined weekly for two months to assess the functional recovery. At the end of the study, macroscopic and microscopic evaluations as well as adhesive strength quantification at the site of the injury were performed.
Results: There was no significant difference in the TFI measures between 1-suture and 3-suture groups during 8 weeks (P > 0.05). Adhesive strength was not significantly different between three groups (P > 0.05); however, it was higher in both suture groups compared with the control group. Scar index was 0.50 (SD = 0.06, n = 2) in control, 0.54 (SD = 0.08, n = 4) in 1-suture, and 0.58 (SD = 0.13, n = 4) in 3-suture groups. The comparison of the mean of differences in scar index and vascular index did not imply significant differences (P > 0.05).
Conclusions: Repair of rat’s tibial nerve with one or three microsutures gave comparable outcomes. This may suggest that for functional recovery of the fine nerves, simple approximation with minimum number of sutures is sufficient.

Background: Supracondylar humerus fracture is the most common elbow fracture in children. While closed reduction and percutaneous pining is the standard treatment method, the ideal pin arrangement is controversial.
Objectives: The current study aimed at evaluating the outcome of the closed lateral cross-pinning to treat displaced supracondylar humeral fractures. Patients and method: After closed parallel lateral pin fixation, reduction was unstable in 35 patients, who underwent cross- pinning from lateral entry point. The mean follow-up period was 6 months and all patients were evaluated for the loss of reduction, iatrogenic ulnar nerve injury, and elbow range of motion.
Results: The mean age of the patients was 7 years. All fractures were type III according to the Gartland classification. There was no case of reduction loss or iatrogenic ulnar nerve injury. Elbow range of motion was full. Two patients had malreduction.
Conclusions: Although medial and lateral cross-pinning has the highest stability of pinning techniques, the risk of iatrogenic ulnar nerve injury is significant. Total lateral entry cross-pin fixation method of pediatric supracondylar humerus fractures has similar results to the conventional cross-pin methods regarding the fixation stability, but with lower ulnar nerve injury cases.

Background: Medical tourism is one of the most influential factors in industrial growth and development. To increase medical tourism, it is crucial to promote the quality of medical care and facilities to the level of international standards. This study aimed at identifying service quality as perceived by medical tourists admitted to the children’s Medical center of Tehran.
Methods: All patients admitted to the children’s Medical center between years 2014 and 2015, in all hospital wards, were included. For data collection, a 24-item questionnaire and the Likert scale for scoring were used. The reliability of the questionnaire was assessed with Cronbach’s Alpha coefficient, which was 0.87. The data was presented as descriptive measures.
Results: The findings revealed that therapeutic care and facilities were rated as “good”, by 56.67% and 65% of the patients, respectively. The clarity of medical costs was rated as “very poor” by 50% of the patients. Furthermore, payment system was clearly causing problems for a large percentage of patients (48.33%), mainly due to the weak currency exchange capability.
Conclusions: The findings of this study suggest that the center has satisfactory medical services and therapeutic care, however, it fails to provide a good payment service and enough currency exchange counters for the patients, which need proper planning and monitoring.

Background: Fibular fractures are the most common associated fractures with tibia injuries. The current study aimed at collecting data on segmental fibular fractures in the patients and investigating the prognostic and functional significance of this injury pattern in outcomes.
Methods: The charts were retrospectively reviewed from 2013 to 2016 to find patients with segmental fibular fractures. Patients’ history, physical examinations, initial radiographic findings, surgical reports, and follow-up data were evaluated. The patients were also assessed for union status, infection, limb shortening, and complications. Fractures were defined as segmental when the bone was disrupted in 2 points and a segment of bone with circumferential cortices was apart from the main bone proximally and distally.
Results: During the 3-year period of the current study, out of 212 patients with leg fracture (tibiofibular fracture) treated in Imam Khomeini hospital, 17 patients (8%) had segmental fibular fractures. In the observed fibular fractures, the number of fracture fragments was between 3 and 6 segments. After 6 months, the rate of union was 70% in the tibia and 88% in the fibula. Overall, 6 patients needed re-operation, 1 of them had below knee amputation, and 5 other had surgeries because of tibial nonunion.
Conclusions: The current study results showed that presence of a segmental fibular fracture may be associated with higher rates of complications. Fixation of the fibula in this situation can lead to nonunion. However, more studies are needed to approve or reject this conclusion.

Introduction: Ewing sarcoma of bone represents the second most common primary malignant tumor of the bone in children and adolescents. The most common primary bony sites include the long bones, pelvis, chest wall, and spine. However, it is responsible for only 3% to 5% of cases in bones of the hands and feet.
Case Presentation: The case was a 13-year-old girl, who attended our clinic with a complaint of 8 months of left ankle swelling and pain. Eight months earlier, she recalled an ankle torsion for which treatment was performed with long leg splint. Her pain was better, but, her swelling remained. The X ray showed a sclerotic lesion in the calcaneus with soft-tissue mass. Next, she underwent open biopsy, and was diagnosed with Ewing’s sarcoma. She underwent chemoradiotherapy and obtained below knee amputation. She was followed up at our clinic.
Conclusions: There are a few articles about early diagnotic effects of Ewing's sarcoma prognosis. Therefore, this study aimed at presenting an anatomical-rare case of Ewing’s sarcoma as preliminary diagnosis could help the patient and lead to better outcomes.

Spontaneous fractures occur in patients with Paget disease, Multiple myelomas, and osseous metastasis. Furthermore, spontaneous fractures may be the result of physiological pressure and stress on bones with reduced elastic tenacity. In this report, we have introduced an elderly patient with multiple significant fractures without any history of a major trauma. In the discussion, we have considered important issues around the topic.

Introduction: Bone cement leakage is the most common, however, it can have potentially disastrous complications during vertebroplasty and balloon kyphoplasty (BK). Polymethylmethacrylate (PMMA) is the most commonly used bone filler, however, calcium phosphate (CP) has been successfully used in spine surgery as a vertebral filler because it is not associated with exothermal reaction and is biologically very close to the vertebral bone. CP leakage during vertebral augmentation is extremely rare.
Case Presentation: A 72-year-old woman with an A2/AO type fracture of L1-vertebra underwent a transpedicular BK at the L1-vertebra with CP plus short segment pedicle screw construct (T12-L2) by minimally invasive surgery (MIS). Continuous neuromonitoring and fluoroscopy were used in this case, although no pathological signs were recorded because of the low radiopacity of CP. Two days later, incomplete paraplegia was presented due to intra and extradural cement leakage. The patient underwent an emergency T12-L2 wide decompression for removal of an epidural leak of CP plus durotomy for intradural CP removal. After removal of the cement, there was improvement of neurologic function. CP leakage should have occurred because of a violation of the medial right pedicle wall by the BK trockar and subsequently CP injection both intra and extradural. Since no direct intraoperative nerve root injury occurred, there was no pathologic sign during intraoperative neuromonitoring.
Conclusions: PMMA leakage is well documented in the literature as a common complication during BK. Calcium phosphate leakage during vertebral augmentation is rare. Furthermore, delayed onset of neurologic deficit due to CP leakage has never been reported in the current literature. Spine surgeons and interventional radiologists should always be aware of this potential disastrous complication.