Aims. Surgical approaches to cervical ossification of the posterior longitudinal ligament (OPLL) remain controversial. The purpose of the present study was to analyze and compare the long-term neurological recovery following anterior decompression with fusion (ADF) and posterior laminectomy and fusion with bone graft and internal fixation (PLF) based on > ten-year follow-up outcomes in a single centre. Methods. Included in this retrospective cohort study were 48 patients (12 females; mean age 55.79 years (SD 8.94)) who were diagnosed with cervical OPLL, received treatment in our centre, and were followed up for 10.22 to 15.25 years. Of them, 24 patients (six females; mean age 52.88 years (SD 8.79)) received ADF, and the other 24 patients (five females; mean age 56.25 years (SD 9.44)) received PLF. Clinical data including age, sex, and the OPLL canal-occupying ratio were analyzed and compared. The primary outcome was Japanese Orthopaedic Association (JOA) score, and the secondary outcome was visual analogue scale neck pain. Results. Compared with the baseline, neurological function improved significantly after surgery in all patients of both groups (p < 0.001). The JOA recovery rate in the ADF group was significantly higher than that in the PLF group (p < 0.001). There was no significant difference in postoperative cervical pain between the two groups (p = 0.387). The operating time was longer and intraoperative blood loss was greater in the PLF group than the ADF group. More complications were observed in the ADF group than in the PLF group, although the difference was not statistically significant. Conclusion. Long-term neurological function improved significantly after surgery in both groups, with the improvement more pronounced in the ADF group. There was no significant difference in postoperative neck pain between the two groups. The operating time was shorter and intraoperative blood loss was lower in the ADF group; however, the incidence of perioperative complications was higher. Cite this article: Bone Jt Open 2024;5(9):768–775

Aim: To evaluate the outcome of late anterior decompression in patients with dorsal and lumbar spinal injuries with neurological deficit. Background: Anterior decompression and bone graft stabilisation of the spinal injuries allows direct decompression of the spinal canal and provides favourable environment for neurological and functional recovery. Proponents of both early and delayed decompression have shown favourable results. However, what is unclear is the timing of the surgery. Methods: A prospective study of 12 patients with spinal injuries, who had anterior decompression a minimum of 4 weeks after the injury (mean 7.5 weeks). 5 had incomplete and 7 had complete neurological deficit at presentation. The indication for the operation was persistent neurological deficit with retropulsed fragment of bone causing canal compromise. Anterior stablisation after decompression was by means of a tri-cortical iliac crest graft or a rib graft. Results: 8 males, 4 females with average age 26.8 years. 7 lumbar and 5 dorsal spine injuries. Average follow-up of 5.5 years with minimum of 5 years. Post-operative improvement was seen only in patients who sustained injury at the lumbar level, with 6 of the 7 patients regaining normal bladder and bowel function after decompression. Immediate post-operative improvements obtained in the Kyphotic angle were not maintained probably due to the settling of the graft, so posterior or anterior stabilisation may be needed in addition to anterior bone grafting to prevent worsening of the kyphotic angle. Conclusion: Delayed anterior decompression of the lumbar spine in patients who had spinal fractures, is an effective procedure, which may help neurological recovery, especially of the bowel and bladder function

The cervical spine is the most vulnerable segment in high velocity injuries. Bifacet dislocations are associated with significant soft tissue damage and neurological deficit. Management of delayed presentation of cervical facet dislocations, which are not uncommon, is varied. The aims of this study are to create awareness and to develop a management strategy. We retrospectively reviewed 14 patients (10 men and four women) with chronic dislocations treated over 4 years. The mean age was 42.5 years (23 to 62). The delay in presentation ranged from 15 to 135 days. Seven patients had neurological deficit. All patients underwent CT scan and MRI. Common areas of involvement were C6/7 (five patients) and C5/6 (four patients). Associated fracture of posterior elements was identified in 40% of patients. In two patients sequestrated disc ruptured into the canal. All patients underwent surgical reduction and stabilisation, with eight having one-stage and six two-stage surgery. The sequence of one-stage surgery was posterior release, reduction (facet reduction/facetectomy), anterior discectomy and anterior fusion. In three patients with sequestrated discs, anterior decompression preceded posterior release and finally anterior fusion. The six patients who had staged surgery had a prolonged delay (over 3 months) in presentation. Posterior release was followed by an anterior decompression, then a 7 to 10-day period of traction reduction and finally anterior fusion. None of our patients developed neurological deficit. Three patients improved from Frankel-C to Frankel-D. We recommend that the sequence of surgery should be posterior release/reduction and then anterior decompression and anterior fusion. However, in chronic cases, staged reduction and fusion is a viable option

Summary: Twenty six consecutive patients with CSM were operated between Jan 2001–Dec 2004 with anterior corpectomy and reconstruction using strut graft/ lordotic cage and stabilization ACP. 10/26 were wheel chair bound/bought on stretcher. 16/26 had spastic lower limbs with myelopathic hands. Post operatively 20/26 had good gait improvement and are community ambulators. 3/26 house hold ambulators and 1 died. 18/26 had good improvement in hand function. Introduction: Cervical spondylotic myelopathy is a degenerative disease of old age. Patients present with severe disabiling symptoms of spastic gait/inability to walk and varied involvement in the hand. The degenerative spondylosis being the commonest cause, CSM is also caused by OPLL and soft disc herniation. Methods: 26 consecutive patients who had undergone anterior decompression and reconstruction were evaluated for recovery. The gait pattern, hand functions and return to activities were evaluated pre and postoperatively. No specific scoring system could be used in our studies due to practical reasons. Results: 18/26 patients had CSM, 5/26 had OPLL and 3/26 soft disc herniations. Soft disc herniation were at 2 levels and all underwent discectomy, tricortical bone grafting and stabilization with ACP. Other patients had corpectomy 1 level – 4, 2 levels – 9, 3 levels – 4, 4 levels – 1. OPLL was removed in 4/5 patients. Xx/10 patients who were wheel chair bound preoperatively became ambulatory, 3/10 had decrease in spasm but still could not walk postoperatively. At 1 year follow up 9/10 patients had good gait pattern and 1 was still wheel chair bound. 18/26 had good hand function recovery with improvement in hand writing, 16/26 returned to previous activity, 1 patient expired. Conclusion: Anterior decompression for CSN is an effective surgical option. It not only prevents further detoriation, but also improvement is seen in most of the patients. Significance: Anterior decompression is indicated for all patients with CSM, OPLL and disc herniation as the pathology is anterior based

The February 2013 Spine Roundup. 360 . looks at: complications with anterior decompression and fusion; lumbar claudication and peripheral vascular disease; increasing cervical instability in rheumatoids; kyphoplasty; cervical stenosis; exercise or fusion for chronic lower back pain; lumbar disc arthroplasty and adjacent level changes; and obese disc prolapses

Patient presenting with clinically significant cervical spinal cord compression have a variety of surgical strategies that may be appropriate. The common denominator for successful intervention is satisfactory decompression of the neural elements, while avoiding early or late complications. In general, one may think of situations with one or two motion segment involvement versus three or more foci of compression. As most applicable cervical pathology causes anterior cord compression, the logic of direct anterior decompression is very compelling. Thus anterior decompression and fusion procedures have been the mainstay of treatment in many quarters. On the other hand, complications with graft healing or displacement, speech and swallowing disturbance, etc. remain an issue. This is especially true for multi-level disease. Under these circumstances, indirect decompression with posterior surgery plays an important role. Laminoplasty, and to a lesser degree laminectomy and fusion, may prove every bit capable of spinal cord decompression and often with fewer complications. Each case must be evaluated on its own merits and the procedure chosen to optimize the likelihood of success

Purpose: A descriptive cohort study of the surgical treatment of spinal tuberculosis in a single unit in the United Kingdom. Tuberculosis is a common disorder and may be increasing in prevalence. 83 cases of spinal involvement with TB occurred and of these 40 patients had a total of 61 interventional procedures. Indications for intervention were:. Progressive neurological deterioration. Failure to respond to treatment. Doubt about the diagnosis. Progressive deformity. Results: The age range was from 12 to 73. Sixteen patients had 17 closed biopsies to assist in establishing the diagnosis, of these four went on require further surgical procedures. There were five intermediate level procedures such as application of halo or removal of hardware. Two patients were Caucasian with no predisposing factors and delays occurred in the initial diagnosis. Diabetes was a significant associated co-morbidity particularly in Asian patients. Multiple procedures were required usually for staged stabilisation after anterior decompression. 2 patients had four procedures, 2 had three procedures and 10 had two procedures 27 had a single procedure. Nine patients that underwent anterior decompression and strut grafting for neurological deterioration went on to have a second stage extra focal fixation and became ambulant. One death occurred from mesenteric infarction at 4 months post op in this group. Significant neurological recovery occurred after surgery in the neurologically impaired patients. Two revision procedures were required in the cervical spine for inadequate primary stabilisation. Conclusion: About half of the spinal TB cases come to interventional procedures. Surgery when required is often a complex decompression and staged reconstruction

Several methods of surgical treatment for pyogenic spondylitis have been reported including anterior approach, staged and simultaneous anterior decompression and posterior stabilisation. The use of anterior implants in the presence of infection presents still a challenge for spine surgeons. Retrospective analysis of the clinical and radiological outcome of patients suffering from pyogenic spondylitis of the cervical and lumbar spine necessitating surgical treatment for intractable pain, instability and neurologic impairment. Seventeen patients with spondylitis associated or not with paravertebral abscess were treated by one stage surgery (first: anterior decompression and placement of titanium mesh cage, filled with autologous iliac bone graft; second: posterior transpedicular instrumentation and fusion). The age of the patients was 54 ±15 years. Most of the patients had systematic problems such as lung tuberculosis, hepatic cirrhosis, diabetes mellitus or chronic renal failure. Patients were evaluated before and after surgery in terms of pain and neurological level, sagittal spinal balance and radiological fusion. All 17 patients were followed for 45 months. Average duration of both surgeries was 4.5 hours. The VAS score improved from 7 (preoperatively) to 2 (postoperatively). The correction of the segmental kyphotic deformity was 6o, without loss of correction or cage migration or instrumentation failure. All patients with incomplete neurologic impairment improved postoperatively. There was neither migration of mesh cage nor posterior instrumentation failure at the follow up observation. There was an approach-related abdominal hernia. This clinical study showed that patients with cervical and thoracolumbar osteomyelitis necessitating surgery for certain indications can successfully undergo instrumented combined, one-stage, same-day surgery. The presence of the mesh cage anteriorly at the site of infection had not negative but beneficial influence on the course of infection healing, and it additionally stabilised the affected segment, maintaining sufficient sagittal profile

Purpose: The purpose of this study was to analyse the learning curve of video-assisted thoracoscopic surgery in a consecutive series of 70 interventions for decompression and intervertebral fusion with rib bone grafts. Material and methods: This series was composed of 70 patients followed for at least two years. The indication of video-assisted thoracoscopic surgery was idiopathic scoliosis (n=32), neuromuscular spinal malformation (n=13), neurofibromatosis (n=1), scoliosis secondary to Marfan disease (n=1), radiation-induced scoliosis (n=1), and nonunion (n=1). The first rib was resected in three patients due to compression. Resection of an intrath-roacic neurofibroma and a benign rib tumour was performed in two patients. Anterior fusion was necessary in one patient due to fracture-displacement of the thoracic spine. Results: Mean operative time for thoracoscopic anterior decompression with discectomy and fusion was 256 minutes (range 150–405). On the average, eight discs were removed (range 4–11). Comparison of mean operative time per disc between the first interventions (n=31) and the later interventions (n=32) did not demonstrate any significant difference. Mean blood loss during thora-coscopic anterior decompression with discectomy and fusion was 285 ml (range 50–1300). Discussion: Definitive postoperative correction was achieved in 68% and 90% of the patients with scoliosis and kyphosis respectively. A thoracoscopy-related complication was observed in three patients. Video-assisted thoracoscopic surgery is an interesting alternative to conventional thoracotomy allowing effective safe treatment of infantile spinal malformations despite a long learning curve

A retrospective review, comparing outcome following circumferential versus anterior decompression and fusion for patients with cervical spondylotic myelopathy (CSM). To assess the safety and efficacy of the circumferential operation for CSM. Cervical spondylotic myelopathy has traditionally been managed by anterior or posterior decompression with/ without fusion. However, there is a considerable variation in neurological recovery and clinical outcome following these procedures. While circumferential decompression and fusion has been shown to provide superior neurological outcome in selected patients with cervical trauma and tumours, its role in the management of CSM has yet to be clearly defined. Fifteen patients who underwent a 360° operation (Groupl) for CSM were matched (age, number of levels operated and follow-up duration) with patients (Group 2, n=15), that underwent anterior decompression and fusion for the same problem. All patients were operated by a single surgeon and reviewed independently. Charts, radiographs, patient interviews and MODEMS Cervical Spine Outcome questionnaires were the basis for assessment. The operative time, blood loss, in-hospital stay and post-operative complications were higher in group l. The pseudoarthrosis rate was comparable though a trend towards increased graft and hardware problems was noted in group 2. Neurological improvement as measured by the mJOA Myelopathy Scale was significantly better (p = 0. 039) in group 1. 87% of those in group1 and 67% in group 2 showed improved function. Patients in group1 also performed better (p=0. 056) in the neurological domain and treatment expectation scales of the cervical spine questionnaire, though the incidence of post-op, neck pain was higher. Single stage circumferential spinal decompression and fusion permits consistent neurological recovery in selected patients with cervical spondylotic myelopathy and it can be performed with limited morbidity

Introduction: The management of patients with thoracolumbar burst fractures has evolved over the last 60 years from the days of conservative management through to the current era of anterior decompression combined with either anterior or posterior stabilisation. There is no doubt that surgical outcomes have improved markedly with the more modern techniques. Nevertheless, there are still technical and other difficulties, which the surgeon may encounter. Based upon his experience with posterior vertebrectomy and reconstruction for thoracolumbar tumours, the author has used this technique for the management of acute burst fractures in this region. This paper presents a review of 10 patients with severe thoracolumbar burst fracture or fracture dislocation managed since 1997, using a single stage posterior decompression, realignment and stabilisation/interbody fusion. Methods: Data were acquired prospectively on consecutive patients between June 1997 and October 2000. All patients underwent single stage posterior decompression via laminectomy and then a subtotal eggshell vertebrectomy with removal of any herniated bone fragment(s) or partial vertebrectomy/ pedicle subtraction osteotomy. Pedicle screw stabilisation was performed to include one or two vertebrae above and below the involved vertebra(e). The intervertebral discs adjacent to the fractured vertebra were removed prior to realigning the vertebral column and performing inter-body fusion using carbon fibre spacers and autograft (4 patients) or vertebral body reconstruction with Titanium mesh cages and autograft (6 patients). Results: The mean age was 37 years (21–52 years). There were six males and four females. Three patients had no neurological deficit. Seven had incomplete paraplegia, three of which were severe with no or only a flicker of leg movement. The principal fracture involved L1 in 6 patients, L2 in 2, L4 in 1 and L5 in 1. Seven had herniated bone fragments occupying 90+% of the spinal canal. Of the seven patients with incomplete paraplegia, all recovered the ability to walk. Two with conus lesions still self catheterize. There were no serious early complications. A serious late complication was the development at three months of a severe deep wound infection, which required debridement and subsequent anterior/ posterior revision surgery. One patient with severe polytrauma and an L4 burst fracture/dislocation has developed a chronic pain syndrome. Discussion: The decompression, realignment, interbody reconstruction and stabilisation of thoracolumbar burst fractures/dislocations using a single stage posterior technique is technically demanding but the neurological outcome and restoration of spinal balance in these 10 patients was gratifying. The procedure appears to have two advantages over an anterior decompression and reconstruction combined with anterior or posterior stabilisation: first, it appears to provide easier access and improved visualisation for lumbar burst fractures where the psoas muscle may be swollen and contused, and second, it allows for easier realignment of any coronal or sagittal deformity

Introduction. Neurological involvement occurs in 10-30% cases of caries spine. Surgical debridement and stabilisation is needed to decompress the cord and prevent progression of deformity. This prospective study was undertaken to determine the efficacy of operative treatment in the management and neurological recovery in patients with caries spine with neural deficit. Material & methods. 20 patients, 14 male, 6 female, were included and followed up for 1 year after surgery. The mean age was 39.45 years. 10 patients had complete paraplegia and 9 patients had paraparesis. 1 patient with cervical involvement had quadriplegia. Anterior decompression and stabilisation was done in all the cases. Objective of surgery was adequate debridement of diseased foci, decompression of cord and stabilisation of spine with correction of deformity. In 19 (95%) patients there with thoraco-lumbar involvement. This was addressed with a titanium mesh cage filled with impacted bone graft and supplemented with 2 Moss Miami screws and a rod construct. In the cervical spine, cervical spine locking plate was used for stabilisation after decompression and bone grafting (tricortical iliac crest graft). Results. Fifteen patients had complete and 5 patients had incomplete neurologic recovery. Neurological recovery started as early as first post-op week (range 3 days to 12 weeks). The ASIA motor score improved from 60.80 (60.80 +/− 20.206) before surgery to 73.55 (73.55 +/− 13.828) at 1 month and 95.30 (95.30+/−11.934) at 6 months after surgery. The ASIA sensory score improved from 173.30 (173.30 +/− 50.689), to 186.85 (186.65 +/− 37.452) at one month and 218.45 (218.45 +/−11.843) at 6 months. All 8 patients with bladder and bowel involvement recovered normal bladder and bowel functions at 6 months. There was no recurrence of infection. Bony fusion was achieved in all patients and there were no implant failures. Conclusion. Anterior debridement, decompression, stabilisation and anti-tubercular chemotherapy resulted in neurological recovery in the majority of the patients

Twenty-seven patients with neurological deficit due to burst fractures were treated with fresh frozen allografts following anterior spinal decompression. Their mean age was 28 years. In 19 patients the injury was due to motor vehicle accidents and in five to falls. The mean preoperative kyphosis was 19° (4° to 33°). Three patients with laminae fractures, which resulted in entrapment of the dura, underwent posterior decompression and transpedicular fixation before anterior decompression. Corpectomy was performed in all patients. An appropriate length of femoral allograft was positioned by interference fit and the spine was stabilised with an anterior rod screw construct in 21 patients. The follow-up ranged from 29 to 72 months. Bridwell grade-I fusion was seen in 23 patients at two years. Subsequent follow-up revealed no fracture, resorption or collapse. The mean neurological recovery was 1.4 Frankel grades. Nine patients (37%) made a complete recovery but in four (16%) there was no improvement. The mean postoperative kyphosis was 9° and at two years the mean loss of correction was 3°. One patient presented with a psoas abscess at two-year follow-up. At surgery the graft was partially resorbed but was stable. At six-year follow-up the patient was asymptomatic with a grade-II fusion. The use of allografts saves considerable time in surgery and avoids potential donor site morbidity. They are versatile and are easily available

Aims

Gram-negative infections are associated with comorbid patients, but outcomes are less well understood. This study reviewed diagnosis, management, and treatment for a cohort treated in a tertiary spinal centre.

Introduction. Aim was to compare the functional outcome of anterior cervical decompression and fusion (ACDF) with stand-alone tricotical iliac crest auto graft verses stand-alone PEEK cage. Material and methods. Prospectively collected data of 60 patients in each group was compared. Results. There was statistically significant improvement noted in postoperative Modified Japanese Orthopaedic Association scores at one year follow up for both the groups. Perioperative complications were significantly higher in the autograft group when compared with the PEEK cage group. Among the 94 patients who underwent single level non-instrumented ACDF only 4 (4.25%) had psuedoarthrosis. The fusion rate for single level ACDF in our series was 95.74%. Among the 25 patients operated for two level non-instrumented ACDF, 6 patients (24.00%) had pseudoarthrosis. The fusion rate for two levels ACDF in our series is 76.00%. There was no significant difference in fusion rates of the PEEK cage when compared to auto graft group. Conclusion. Fusion rates in ACDF are independent of interbody graft material. Fusion rates for single level ACDF is significantly higher than two levels ACDF. ACDF with PEEK is the fusion technique of choice with fewer complications and better functional recovery

Introduction. Aim was to compare the functional outcome of anterior cervical decompression and fusion (ACDF) with stand-alone tricotical iliac crest auto graft verses stand-alone PEEK cage. Material and methods. Prospectively collected data of 60 patients in each group was compared. Results. There was statistically significant improvement noted in postoperative Modified Japanese Orthopaedic Association scores at one year follow up for both the groups. Perioperative complications were significantly higher in the autograft group when compared with the PEEK cage group. Among the 94 patients who underwent single level non-instrumented ACDF only 4 (4.25%) had psuedoarthrosis. The fusion rate for single level ACDF in our series was 95.74%. Among the 25 patients operated for two level non-instrumented ACDF, 6 patients (24.00%) had pseudoarthrosis. The fusion rate for two levels ACDF in our series is 76.00%. There was no significant difference in fusion rates of the PEEK cage when compared to auto graft group. Conclusion. Fusion rates in ACDF are independent of interbody graft material. Fusion rates for single level ACDF is significantly higher than two levels ACDF. ACDF with PEEK is the fusion technique of choice with fewer complications and better functional recovery

Aim:. Historically, anterior decompression followed by posterior fusion has been the surgical management of choice in spinal tuberculosis. Due to theatre time being at a premium, we have evolved to performing anterior only debridement, allograft strut reconstruction and instrumentation for tuberculosis in the adult thoracic spine. The aim of this study is to review the safety and the efficacy of this treatment. Methods:. Twenty-eight adult thoracic tuberculosis patients were identified where anterior only surgery had been performed. These were all in the mid-thoracic spine as circumferential surgery is still favoured in thoracolumbar disease. The surgery was performed by a single surgeon at a tertiary hospital. Following transthoracic aggressive debridement, allograft humeral shafts were cut to size and inserted under compression and the spines instrumented with the use of screw-rod constructs into the body above and below. A retrospective review of clinical notes and radiological studies was performed. Results:. Twenty-seven of the patients presented with altered neurology; 2 had only sensory changes while 25 presented with paraparesis; 22 of these patients were unable to walk. The average surgical time was 2 hours 20 minutes with a median blood loss of 726 ml. The majority of patients had 2 vertebral bodies involved and required an average of a 4 body fusion. Surgical complications included inadvertent opening of the diaphragm in 1 patient and 1 patient deteriorated neurologically post operatively. 21 of 28 patients recovered to independent mobility at their latest follow-up appointment. 1 patient showed no recovery, 3 had some motor recovery that was not useful, 1 had some sensory but no motor recovery. 16 of 28 patients have documented bony fusion with no evidence of instrumentation failure in any patients. Conclusion:. Anterior only debridement, allograft strut reconstruction and instrumented fusion for the treatment of thoracic spinal tuberculosis is a safe and effective alternative to circumferential surgery in the adult patient

Introduction. The resurgence of TB worldwide has several underlying causes, but HIV infection has undoubtedly been a key factor in the current TB epidemic. Since TB is endemic in the developing world the influence of HIV is of concern, particularly with the emergence of multi-drug-resistant strains. The remarkable susceptibility of patients with AIDS to develop TB has shown the critical role of CD4 lymphocytes in protective immunity. In the absence of immunological surveillance by CD4 cells, 5-10% of persons with latent foci of TB reactivate each year. Aim. This paper highlights the presentation and outcome following treatment in HIV patients with spinal TB. Methods. 81 HIV+ve patients with spinal tuberculosis were prospectively evaluated between 2006 and 2007. The mean age was 31 years and 63% were females. The thoracic spine was affected in 45, lumbar (33) and cervical (3). Non-contiguous lesions were noted in six patients. Sixty-six (81%) patients had neurological deficit. The mean Hb was (10.1gm/dl), mean WCC 4.9, mean lymphocyte count was 1.8, mean ESR 79mm/h and the mean CD4 count was 268 cell/cumm. Co-morbidities were seen in 68% of patients. All patients were optimised prior to treatment. Posterolateral decompression was performed in 29 cases, anterior decompression (25), needle biopsy (13), incision and drainage 5 and 9 were treated non-operatively. Medication included ARV (72 patients) and anti-TB in all patients. Results. The mean follow-up was 21 months. Eleven (13.5%) patients developed wound infection and one child died. Complete recovery occurred in 23 patients (35%). The mean CD4 count was 341 cell/cumm. Conclusion. The short term results are encouraging. These patients are best managed by a multidisciplinary team to monitor potential complications from dual therapy, to ensure compliance and adequate nutrition

Fractures and fracture dislocations involving the lower lumbar spine and lumbosacral junction are uncommon. These high velocity injuries are often associated with neurological deficit, incontinence and dural tears. The accepted treatment has been posterior stabilisation with fusion, but loss of reduction has often been reported. We reviewed our experience over the past four years in the management of eight male patients, two of whom sustained injuries in motor vehicle accidents and two in falls from a height. Two patients had L5/S1 traumatic spondylo-listhesis with no neurological deficit. Of the six patients with fracture dislocations of L3/4, four had translation in the sagittal and coronal planes and incomplete neurological deficit. Associated injuries in four patients included an ankle fracture, multiple rib fractures, dislocation of knee and hip, and a fracture dislocation of the midfoot. Following satisfactory reduction, seven patients were treated by posterior spinal fusion (PSF) with instrumentation. One patient had anterior decompression, strut-grafting and posterior instrumentation. Three patients had dural tears. In three patients treated by single segment PSF, reduction was not maintained. The maintenance of alignment was attributed to stable facet joints in one patient, two-segment instrumentation in three, and anterior strut grafting in one. One patient developed postoperative wound sepsis, which settled after repeated debridement and antibiotic treatment. Symptoms of nerve root compression improved in two of the four patients with neurological deficit. Posterior reduction and instrumentation alone did not maintain reduction in these severe injuries. Anterior column support and multisegmental instrumentation may be required where there is marked vertebral body compression and neurological deficit

Thoracic spine fractures and fracture dislocations often lead to neurological deficit, and associated injuries to morbidity and mortality. An audit conducted between January 1999 and December 2000 evaluated the outcome of 63 patients with fractures and fracture dislocations of the thoracic spine. The mean age of patients, 41 of whom were male, was 30 years. In 45 patients the injury was sustained in a motor vehicle accident, and 23 patients had associated injuries. We used the Margel radiological classification. There were 37 fracture dislocations and 23 pure fractures. Twenty patients had a type-A injury (flexion), of which 19 were type AIII (burst). There were 40 patients with a type-B injury, 35 of which were type BI (flexion distraction), and three type BIII (flexion and axial loading). In three patients there was a type-C injury (rotational). There was total neurological deficit in 39 patients, 10 with type-A, 26 with type-B and three with type-C injuries. Fifteen patients had partial neurological deficit and nine were neurologically intact. Posterior spinal fusion and bone graft was performed on 43 patients, anterior decompression and bone graft without instrumentation on seven, and combined anterior and posterior surgery on one. The remaining 12 were treated conservatively with orthoses. The neurological status of eight patients improved by a single grade following surgery and the neurological status of two following conservative treatment. Of the 54 patients with neurological deficit, 52 were wheelchair-bound. The poor neurological outcome was comparable to that in other studies