Introduction. Recently published results suggest insertion of shorter screws in L5/S1 stand-alone anterior interbody fusion, fearing S1 nerve root violation. However, insertion of shorter screws led to screw fixation failure and new onset of S1 body fractures. Material and Methods. Retrospective review of patients with L5/S1 stand-alone anterior interbody fusion, focussing on screw length, radiological outcomes (especially metal work failure, screw fixation and S1 body fractures) and new onset of S1 nerve root irritation. Results. 38 patients were included (mean age 46.2±13.3 years, 21 females, 17 males). Fusion of the L5/S1 segment was performed in between 2003-2010; postoperative follow-up ranged from 2-24 months. 15 patients had multilevel surgery (7 multiple segmental fusion, 8 hybrid procedures). Screw length ranged from 20-30 mm. No patient had new postoperative S1 nerve root irritation. Interestingly, 2 patients out of the hybrid group had a new onset of L5 radiculopathy, concordant to the level of disc-replacement. Follow-up x-ray review showed no fracture of S1 body fractures in all patients. No evidence of screw loosening, migration or metal work failure was reported. Conclusion. In our opinion, this review showed that insertion of longer screws for stand-alone anterior interbody fusion in L5/S1 is safe. Longer screws offer better stabilization and seem to minimize risks like S1 body fractures. Short and long-term follow-ups were satisfactory regarding screw placement, migration and positioning of implants in all patients

Introduction. Iatrogenic spondylolisthesis occurs infrequently after posterior decompression. Posterior surgery is challenging due to altered anatomy and scarring. Anterior lumbar interbody fusion (ALIF) allows indirect decompression, restoration of lordosis and fusion. Material and Methods. Retrospective review of 6 patients (5 female, 1 male, mean age 64±5.8 years) with iatrogenic spondylolisthesis (5 L4/L5; 1 L4/L5) treated with stand-alone ALIF (Synfix, BMP2). Assessment of pelvic incidence, listhesis, pre- and post-operative ODI, VAS, global lumbar lordosis and segmental lordosis as outcome measurements. Results. The slippage was grade II at L4/L5 in 3 patients and grade I in 2 patients at L4/L5 and 1 patient at L5/S1. Average ODI dropped from 49±11% pre-operatively to 30±9% at 6 and to 25±6% at 12 months follow-up. VAS average dropped from 7±1 to 3±1 at 6 and 12 months follow-up. Average pelvic incidence was 54.6±8.0°. Global lordosis of 44.6±5.2° increased to 49.0±8.6°; Segmental lordosis in L4/5 was increased from 12.1±8.2° to 22.4±3.7° at 6 and 20.5±7.9° at 12 months. Cage migration due to severe osteoporosis occurred in 1 case after 5 months. Conclusion. Anterior interbody fusion offers good stabilization and restoration of lordosis in iatrogenic spondylolisthesis. In our group, ODI and VAS scores were improved. These early results encourage further investigations regarding long-term follow-ups and prospective studies in larger patient groups

Introduction: The initial promise of stand-alone threaded anterior interbody fusion cages to treat chronic low back pain has not been maintained. In an attempt to overcome some of the problems associated with threaded fusion devices (endplate subsidence, failure to re-establish lordosis and displacement) a two-part ALIF cage was devised. The device consists of a rectangular frame that accommodates a threaded, open-weave cylinder holding bone graft material. The device addresses the biomechanical issues required for successful ALIF whilst providing a large area for bone in-growth and is a less invasive solution than a formal 3600 fusion. Methods: From August 2001 to December 2002, 41 patients who fulfilled selection criteria for a single or two-level 3600 spinal fusion for low back and leg symptoms underwent ALIF using Stabilis. All patients had failed to improve with all non-invasive and minimally invasive treatments available to them. Prospective follow-up has continued for all cases using the Low Back Outcome Score and a Patient Satisfaction Score. Plain x-rays were taken at 3, 6 and 12 months post-operatively and the 12-month series included flexion and extension films. Results: Ten patients (24.4%) have completed more than 12 months follow-up; 18 (43.9%) are between six and twelve months post surgery and the rest (31.7%) have less than six months follow-up. LBOS results for the first 10 showed 9 (90%) as excellent or good. LBOS results for the second group of 18 were excellent or good in 15 (83.3%). All but two of the 28 patients, would be prepared to undergo the procedure again and all would recommend the operation to a friend with similar trouble. Radiographic assessment at 6 months showed 16 patients had at least a partial anterior or posterior sentinel sign. Using motion criteria, all 10 cases at one year were fused on flexion and extension lateral x-rays. No devices migrated anteriorly or posteriorly and no lucent lines have been seen around the implants. Three of the two-level procedures showed some subsidence of the L4/5 implant into the L5 vertebral body, but none were symptomatic. No clear reasons have emerged to explain the clinical failure of 14% of the patients given the radiological success. In only one was there a mismatch in the LBOS outcome measure and the satisfaction rating. Conclusions: Stabilis is a useful standalone ALIF device that not only addresses the theoretical biomechanical failures of anterior threaded interbody fusion cages, but has been shown in this early clinical and radiological evaluation to be effective, objectively and subjectively. It is likely that in the medium term future, fewer patients will require fusion to treat back and leg pain as the results from lumbar spine arthroplasty become established and non-fusion technologies become accepted. Until that time, experience in the UK and USA suggests that Stabilis is a good alternative to 3600 fusion

INTRODUCTION: The initial promise of stand-alone threaded anterior interbody fusion cages to treat chronic low back pain has not been maintained. In an attempt to overcome some of the problems associated with threaded fusion devices (endplate subsidence, failure to re-establish lordosis and displacement) a two-part ALIF cage was devised. The device consists of a rectangular frame that accommodates a threaded, open-weave cylinder holding bone graft material. The device addresses the biomechanical issues required for successful ALIF whilst providing a large area for bone in-growth and is a less invasive solution than a formal 360° fusion. METHODS: From August 2001 to December 2002, 41 patients who fulfilled selection criteria for a single or two-level 360° spinal fusion for low back and leg symptoms underwent ALIF using Stabilis. All patients had failed to improve with all non-invasive and minimally invasive treatments available to them. Prospective follow-up has continued for all cases using the Low Back Outcome Score and a Patient Satisfaction Score. Plain X-rays were taken at three, six and 12 months post-operatively and the 12-month series included flexion and extension films. RESULTS: Ten patients (24.4%) have completed more than 12 months follow-up; 18 (43.9%) are between six and twelve months post surgery and the rest (31.7%) have less than six months follow-up. LBOS results for the first 10 showed nine (90%) as excellent or good. LBOS results for the second group of 18 were excellent or good in 15 (83.3%). All but two of the 28 patients, would be prepared to undergo the procedure again and all would recommend the operation to a friend with similar trouble. Radiographic assessment at six months showed 16 patients had at least a partial anterior or posterior sentinel sign. Using motion criteria, all 10 cases at one year were fused on flexion and extension lateral X-rays. No devices migrated anteriorly or posteriorly and no lucent lines have been seen around the implants. Three of the two-level procedures showed some subsidence of the L4/5 implant into the L5 vertebral body, but none was symptomatic. No clear reasons have emerged to explain the clinical failure of 14% of the patients given the radiological success. In only one was there a mismatch in the LBOS outcome measure and the satisfaction rating. CONCLUSIONS: Stabilis is a useful stand-alone ALIF device that not only addresses the theoretical biomechanical failures of anterior threaded interbody fusion cages, but has been shown in this early clinical and radiological evaluation to be effective, objectively and subjectively. It is likely that in the medium term future, fewer patients will require fusion to treat back and leg pain as the results from lumbar spine arthroplasty become established and non-fusion technologies become accepted. Until that time, experience in the UK and USA suggests that Stabilis is a good alternative to 360° fusion

From April 2001 to January 2003, 60 patients were selected for a circumferential fusion with an ALIF Brantigan cage and posterior titanium instrumentation. The aim of this study was to analyse the complications and the effects of circumferential fusion on functional outcome and lumbar lordosis. Circumferential fusion restored lordosis, provided a higher fusion rate, and showed a tendency towards better functional outcome and reduced back and leg pain.

Aim: To determine the incidence of adjacent level osteophytes in patients who have had anterior cervical fusion using an anterior cervical plate as compared to those who are fused without an anterior cervical plate. Design: We retrospectively reviewed the lateral radiograms of sixty two patients who have had an anterior cervical fusion with a minimum follow up of twelve months. Materials and methods: We looked for the development of adjacent level osteophytes in these patients at their final follow up, which was generally at the time radiological fusion. There were 27 patients in the first group who had an anterior cervical plate used to fix the vertebrae in addition to the Cervios cage, while the 35 patients in the second group in whom only a Rabea cage was used for the fusion. The mean follow-up was 20.6 months (range 12–48). Results: 64.3% of the patients who had an anterior cervical plate developed adjacent level osteophytes while none of the patients who have had the fusion without the cage developed the osteophytes. Conclusion: We found the patients who had an anterior cervical interbody fusion using a plate had a significant risk of developing adjacent level osteophytes while this is not seen in patients who do not have the plate for the fixation

Anterior decompression and adequate spine fixation in patients with cervical radiculopathy and myelopathy are essential for functional restoration of cervical spine. In this study, we performed evaluation and comparative radiological assessment of several types of spinal implants in terms of bone block formation, sagittal alignment and effectiveness as a structural support.

Materials and Methods: From 1993 to 2003, 165 patients with radiculopathy and myelopathy due to degenerative disease of cervical spine were operated on. The age of patients was 32–74 years (mean age 57, 8). The interbody fusion was performed by several methods.

Group1. Autograft – 91 patients

Group 2. TiNi alloy cages – 74 patients.

Group 3. Varilift expandable cages without plate fixation – 22 patients

Group 4. Verilift cages with plate fixation – 8 patients

Group 5. Bone substitute spacer and plate fixation – 3 patients.

Results: In groups 1 and 2, the bone and bone-metal block was formed during the first 3–4 months after surgery in all patients. There were no cases of bone resorbtion around the TiNi cages or loosening of the device. In patients with one-level (15 patients) interbody fusion by Varilift cages (group 3); formation of the bone block during the same time period was observed in 14 out of 15 patients. In cases with two-level fusion (7 patients), the bone block at the second level was not formed for longer than 6 months. There were 7 cases of subsiding and segmental kyphosis. In group 4, we did not detect any cases of loosening, subsiding or segmental kyphosis. In group 5, no bone block formation was observed after 6 months despite plate fixation.

Conclusions: A high fusion rate was achieved after a single or multi-level discectomy and interbody fusion by autograft and TiNi cages, which did not subside due to their design and superelasticity and can therefore be used without plate fixation. Varilift cages were also very effective, but if used without plate fixation may be associated with subsiding effect. The use of the bone substitute spacer is questionable in cervical spine surgery. Cervical plate fixation is effective as a prophylactic measure against segmental kyphosis in all types of interbody fusion.

Purpose: To investigate the potential value of titanium anterior interbody cages compared to morselized rib graft for anterior interbody fusion in combination with posterior instrumentation, correction and fusion for Scheuermann’s kyphosis. Methods and Materials: A Non-Randomised historic cohort study of two surgical techniques in matched subjects was carried out.15 patients with identical pre-operative radiographic and physical variables (age, gender, height, weight, BMI ) were managed with combined anterior release, interbody fusion, posterior instrumentation, correction and fusion . Group A (n=8) had morsilized rib graft inserted into each intervertebral disc space. Group B (n=7) had titanium interbody cages packed with bone graft inserted at each level. The posterior instrumentation extended from T2 to L2 in both groups. Pre- and post-operative curve morphometry was studied on plain radiographs by two independent observers. The indices studied included Cobb angle, Ferguson’s angle(FA) , Voutsinas index(VI), Sagittal Vertical Axis (SVA), Sacral Inclination (SI) and Lumbar Lordosis (LL). Interbody Fusion was assessed at final follow up. Each patient was reviewed at 3, 6, 12, 24, 48 and 60 months following surgery with standing radiographs. Wilcoxon-matched pairs test and Mann-Whit-ney test were used for statistical analysis. Results: The average follow-up for groups A was 70 and Group B,66 months. For the whole group, the pre-operative : postoperative median Cobb angle, FA, VI, SVA and SI were 86: 42degrees, 50 : 28.4degrees, 28.7 :13, −3.5 : −4.0 centimetres and 40 : 34 degrees respectively. There were significant differences for all variables [p< 0.01] indicating good correction. At four-year follow-up, fusion criteria were satisfied in 12 / 15 cases (80%). Three patients had distal junctional kyphosis. There was no significant difference with respect to the variables between the two groups and both retained the post-operative correction achieved. Conclusion: There was no significant advantage in the use of anterior titanium interbody cages over the use of morselized rib graft in the surgical management of Scheuermann’s Kyphosis

Aims: Presentation and evaluation of clinical outcomes of patients with cervical degenerative disc disease treated by Smith – Robinson method with interbody fusion by Cornerstone Carbon Cage (CCS) in own clinical experience. Methods: We operated 37 patients by anterior cervical discectomy with interbody stabilisation by CCS in the last 11 months. 31 patients were operated for the first time. In 6 cases, patients were reoperated after surgical treatment in other hospitals. The Smith – Robinson cervical discectomy with anterior interbody fusion by CCS was performed in all patients. Additionally, in 12 patients titan cervical plates were used. Follow-up examinations were performed in 2 and 6 months after the treatment. Results: All treated patients experienced total pain termination. In patients with posttraumatical discopathy and heavy cervical spondylosis with ligamental instability (33% all patients) additional internal stabilisation by cervical plate was performed. Neurological or local long-term postoperative complications were not observed. Conclusions: Patients who underwent treatment by anterior cervical discectomy met. S-R with interbody stabilisation by CCS benefited from the treatment and present good clinical outcome with pain termination and gradual disappearance of neurological disabilities. Using of cornerstone carbon cage allows to obtain good stabilisation without the necessity of allogenic bone graft insertion. This kind of stabilisation is sufficient without external collar stabilisation

Introduction and Aims: Trans-laminar screw fixation is a popular method of posterior stabilisation when performing a 360-degree lumbar fusion, but many have concerns over the biomechanical stability of this construct. The objective of this paper is to compare the fusion rate and clinical outcome of this method with pedicle screw fixation. Method: During 2001, 31 patients underwent combined anterior and posterior fusion by the two senior surgeons for the treatment of discogenic low back pain. Anterior interbody fusion was performed using the Syncage LR in all patients. Sixteen patients underwent trans-laminar screw fixation posteriorly and 15 underwent pedicle screw fixation. Fusion was assessed by fine cut CT scan at one year post-operatively. Function was assessed with pre- and post-operative Low Back Outcome Score and visual analogue pain scores. Results: The average follow-up was 15.5 months. The incidence of pseudarthrosis in the trans-laminar screw group was approximately 80% (15 out of 19 levels), compared to 20% (4 of 21 levels) in the pedicle screw group (p < 0.05). There were trends towards greater improvements in the LBOS and VAS scores in the pedicle screw group. There were two surgical complications in the trans-laminar screw group and one in the pedicle screw group. Conclusion: The use of trans-laminar screws is associated with a significantly higher rate of pseudarthrosis compared to pedicle screw fixation. Assessing fusion with fine cut CT scans has revealed a higher rate of pseudarthrosis with trans-laminar screw fixation than has previously been reported

In a prospective non-randomised study, 28 patients underwent laparoscopic assisted transperitoneal anterior interbody fusion at the lumbosacral junction with the BAK cage over a 3-year period. In laparoscopic group, there were significantly lower blood losses (P< 0. 005), operating times [P< 0. 05], analgesic requirements [P< 0. 05] and postoperative rehabilitation [P< 0. 05). 8 patients developed post-operative nerve root pain, 5 of which settled with nerve root blocks, and there was 1 case of donor site infection. Intraoperative complications included 1 CIA tear, 2 CIV tears and 3 open conversions [11%]. 6 cases [24%] required further surgery at a mean of 14 months [range 4–29 months]. 20 laparoscopic cases completed a subjective self-assessment score with 4 [20%] excellent results, 5 [25%] good, 2 [10%] fair, 8 [40%] same and 1 [5%] worse. The preoperative Visual Analogue Pain Score [VAPS] and Oswestry Disability Index [ODI] were set at 100 for the purposes of analysing the results [n=number in brackets]:. Results show an improvement in the overall pain and disability. However, at two years patients still continued with some 65% of symptoms. Laparoscopic assisted anterior spinal fusion with the BAK device is safe and reliable with advantages that include reduced operating time, blood loss, post-operative analgesia requirements and hospitalisation. However, the clinical outcome does not appear to give superior results to other implants and we question whether it use as a stand-alone device is sufficient and would recommend posterior stabilisation to confer improved mechanical stability

Spondylolytic spondylolisthesis is one of the common causes of mechanical low back pain in adults. Conservative treatment of such cases, particularly for the low grade slips, remains the mainstay of management. When patients’ symptoms are marked and not responsive to conservative therapy, the surgical option can be considered. Up to the time of writing this abstract [January 2003], arthrodesis of the affected motion segment with or without instrumentation is the standard surgical option for treating mechanical low back pain. Results of different types of arthrodesis for treating such condition had been reported in literature, including posterior fusion, posterolateral fusion, and posterior and anterior interbody fusion. Between 1993 and 1998, seventy- five adult patients with grade I or II lytic spondylolisthesis were treated by in situ posterolateral fusion and segmental instrumentation using the Oswestry Pedicle Screw System, with or without extended Gill’s procedure. The indications for surgical intervention in these cases were significant reduction in the quality of life with persistent low back pain and/or leg pain after a minimum of six months conservative therapy. Confirmatory imaging studies consistent with the clinical data should also be obtained before deciding the surgical option. The average operative time was 2.5 hours [range 2–4 hours). The average blood loss was 850 mls (range 300–2300 mls). After an average follow-up of 60.7 months (range 24–95 months) clinical results were excellent and good in 92%, and radiological union was achieved in 94% of patients. Complications included 2 cases with superficial wound infection, one case with deep wound infection, and four of the patients went to non-union. In conclusion, with a careful patient selection, patients with instrumental insitu posterolateral fusion gained a satisfactory clinical and radiological outcome and the results were maintained for an adequate postoperative period

Objective: To report a consecutive series of patients who underwent staged reduction and fusion with the Magerl External Fixator and 360° fusion for high grade slips and spondyloptosis. Design: Prospective observational study. Patients & methods: There were 11 patients, average age 17 years (range 9–25 years). All these patients had equal or greater than Meyerding grade III slips. Clinical presentation included severe back pain with disability and a severe cosmetic deformity (including flexed knees, proptotic abdomen and loin creases). The indications for surgery were pain relief and neurological symptoms/signs, and to improve the sagittal alignment. Surgery consisted of first stage Gill procedure, L5 root decompression, and insertion of Schanz pins into L4 pedicles and ilium, and application of the fixateur-externe. Second stage consisted of gradual correction of kyphosis and translation (average 1 week duration). Third stage entailed anterior interbody fusion, removal of fixator and instrumented fusion L5 to sacrum. Outcome measures: Functional out comes (pain scores [VAS], activities of daily living) cosmesis, complications (including neurologic status) and radiographic parameters. Results: Average follow-up was 3 years and 3 months. Postoperatively none of these patients developed a neurological deficit. Imaging confirmed solid fusion in all patients. In terms of reduction, 1 patient failed to reduce (fusion in-situ) and 1 patient developed subsequent L4 on L5 spondylolisthesis. There was no case of permanent neurologic deficit. Nine (82%) patients reported improved pain scores on the VAS, improved quality of life and cosmetic appearance. There was significant reduction of the translation (in most cases to grade II) and correction of the lumbosacral kyphosis. All patients went on to a solid arthrodesis and there was no late loss of correction. Conclusions: Staged reduction and Fusion not only improves a severe cosmetic deformity but also restores sagittal balance. We recommend this technique as there is negligible risk of neurological complications, and avoids fusion involving two motion segments

Objectives: To evaluate the clinical and radiological outcome following anterior interbody fusion using a femoral cortical allograft packed in the centre with autogenous iliac graft combined with posterior pedicle fixation. Design: A prospective study of 30 consecutive adult patients diagnosed with lumbar degenerative disc disease. Summary of background data: Various fusion options have been described in the literature with various clinical and radiological outcomes. Narrowing of the disc space is thought to be the primary cause of all the potential secondary spondylotic changes; the ideal corrective surgery would be one that reconstitutes the disc space interval. A hybrid graft consisting of a femoral cortical allograft (FCA) ring packed in the centre with autogenous cancellous iliac graft seems to be an ideal option as one should capitalize on the mechanical strength of the cortical ring and the biological strength of the cancellous autogenous graft. Methods: 15 patients with failed back surgery, 15 patients with primary degenerative disc disease. Mean age was 43 years. All patients had preoperative radiographs, MRI scanning, discography was not used in this study. All femoral allografts were processed by freeze drying and sterilized using ethylene oxide. The protocol for surgery consisted of: . * Left sided retroperitoneal muscle splitting approach. * Anterior hybrid interbody grafting. * Pedicle screw fixation without grafting. Results: There were no complications from using the allograft. Intraoperative and postoperative complications were seen in 3 patients. After a minimum follow up of 2 years good clinical outcome was achieved in 83 % using Ricciardi et al criteria, solid fusion was achieved in 98%. Conclusion: The results in this study continue to support the efficacy of using hybrid interbody grafts to achieve a successful fusion, however there is discrepancy between the radiological and clinical outcome which merits additional investigations

Introduction: Two total disc replacement devices have been used in Europe for more than 10 years. However, there are few, if any, prospective studies evaluating their results. The purpose of this prospective study using standardized outcome evaluations was to evaluate surgical outcome following implantation of an artificial disc. Methods: This study is based on the consecutive series of the first 57 patients undergoing total disc replacement using the SB Charité (Link) disc prosthesis. Indications included single-level symptomatic disc degeneration, failure of at least 6 months of non-operative treatment including active rehabilitation, and no previous surgery at the operated segment. Data were collected prospectively pre-operatively and at 6 weeks, 3, 6, and 12 months post-operatively (24 month follow-up data collection is continuing). Primary outcome measures included visual analog scales (VAS) assessing pain and the Oswestry Low Back Pain Disability Questionnaire. Results: The mean operative time was 78.5 minutes and the mean estimated operative blood loss was 134.3 cc. Estimated blood loss and operating time were both significantly less for disc replacements at the L5-S1 level than at L4–5 (p< 0.05; t-test). As seen in Figures 1 and 2, there was a significant improvement in the VAS and Oswestry scores (p< 0.05) at the 6-week follow-up visit, and the improvements were maintained during subsequent follow-up visits. There were no cases of device failure, displacement, or migration. Complications were comparable to those encountered with anterior interbody fusion. Discussion: The results of this prospective study, using patient self-report questionnaires, demonstrated significant improvement at 6 weeks and the improvement was maintained during the 12 month follow-up period (24-month data is being collected). The disc prosthesis can be implanted safely, with complications similar to those encountered with anterior lumbar interbody fusion

INTRODUCTION: Two total disc replacement devices have been used in Europe for more than 10 years. However, there are few, if any, prospective studies evaluating their results. The purpose of this prospective study using standardised outcome evaluations was to evaluate surgical outcome following implantation of an artificial disc. METHODS: This study is based on the consecutive series of the first 57 patients undergoing total disc replacement using the SB Charité (Link) disc prosthesis. Indications included single-level symptomatic disc degeneration, failure of at least six months of non-operative treatment including active rehabilitation, and no previous surgery at the operated segment. Data were collected prospectively pre-operatively and at six weeks, three, six, and 12 months post-operatively (24 month follow-up data collection is continuing). Primary outcome measures included visual analog scales (VAS) assessing pain and the Oswestry Low Back Pain Disability Questionnaire. RESULTS: The mean operative time was 78.5 minutes and the mean estimated operative blood loss was 134.3 cc. Estimated blood loss and operating time were both significantly less for disc replacements at the L5-S1 level than at L4-5 (p< 0.05; t-test). As seen in Figures 1 and 2, there was a significant improvement in the VAS and Oswestry scores (p< 0.05) at the six week follow-up visit, and the improvements were maintained during subsequent follow-up visits. There were no cases of device failure, displacement, or migration. Complications were comparable to those encountered with anterior interbody fusion. DISCUSSION: The results of this prospective study, using patient self-report questionnaires, demonstrated significant improvement at six weeks and the improvement was maintained during the 12 months follow-up period (24-months data is being collected). The disc prosthesis can be implanted safely, with complications similar to those encountered with anterior lumbar inter-body fusion

Rigid angular kyphotic deformities of the spine have been corrected by staged anterior and posterior procedures. This paper evaluates the efficacy of single stage transpedicular decancellation, vertebral column mobilization and spinal shortening in the correction of rigid THORACIC kyphotic deformities in adolescent patients. Between 1993 and 1999, 21 patients with rigid kyphosis underwent deformity correction using the above procedure. The deformity was thoracic in 6 patients, thoraco-lumbar in 14 and lumbar in one patient. This report focuses on 6 patients with thoracic deformity. The etiology in 5 patients was due to tuberculosis while one patient had a congenital anomaly. There were 4 females and 2 male patients. The average age was 12 years. The average kyphosis was 75 degrees (38 – 135 degrees). Of the 6 patients, 2 had preoperative paraplegia. All cases were assessed using CT and MRI scans in addition to plain radiographs. The surgical technique utilized the principle of transpedicular decancellation through a single posterior midline exposure in the prone position. Following complete decancellation of the apical vertebrae, the proximal and distal vertebral column was adequately mobilized to enable spinal shortening along with anterior translation. Segmental spinal instrumentation was used to achieve stable fixation.Intraoperatively, the wake-up test was used to assess the neurological function. This was followed by anterior interbody fusion and posterolateral fusion. At an average follow-up of 36 months, average kyphosis correction was 61% and all cases were adequately fused. Both cases with paraplegia recovered completely. The average loss of correction was 6 degrees. One patient developed hyperlordosis below the corrected level. This was revised by extending the spinal fixation to include the lower levels. In conclusion, the above procedure is used as a last resort for correction of rigid angular deformities. It is a safe but demanding procedure. Spinal column shortening is essential to avoid neurologic compromise and balance the column

Introduction: Sports injuries to the cervical spine account for about one in ten of all cervical spine injuries. They occur at all levels of participation. Fortunately, the number of patients suffering spinal cord injury is relatively small. Neurological injuries may range from transient quadriparesis through to complete quadriplegia. The decision to allow sportsmen to return to sport following a cervical spine injury is complex. It is based on such factors as history, clinical examination, the nature of the injury, as well as age and other psychosocial factors. The evidence that exists to aid this decision process is at times conflicting. The aim of this presentation is to review some of the contentious issues that exist in the decision making by reference to case presentations of high level sportsmen who were treated following a variety of cervical spine injuries. Methods: Four high-level rugby players (22–31 years old) presented with different cervical spine injuries sustained during sporting activities. Two subjects sustained a “stinger” and two a transient quadriparesis which rapidly resolved. Radiological evaluation included assessment of spinal canal diameter. 1. Results: Two had a C5-6 disc bulge with developmental spinal stenosis. A third had a congenital fusion C2-3 with a disc bulge and developmental stenosis at C3-4. Case 4 had degenerative disc disease at C5-6. All were treated non-operatively and returned to sport. All suffered a recurrence of the neurological symptoms and subsequently underwent an anterior interbody fusion (Case 4 for subluxation of C6-7). Three successfully resumed rugby six months after surgery while one elected not to continue. Discussion: The decision to allow a patient to return to contact sports following a cervical spine injury may be difficult. The four cases presented highlight some of these contentious issues such as transient neurological deficit and the effect that surgery may have on a patient’s ability to return safely to sport. A review of the literature may assist in the decision making. 1,. 2. This may be conflicting and difficult to interpret. Neurological signs, instability, displacement, fusion of more than one level and occipito-atlanto-axial pathologies are considered absolute contraindications. 3

Introduction: 360 degree combined anterior and posterior fusion is an accepted surgical treatment for the management of discogenic back pain. Controversy exists to the optimal technique of posterior fixation. Proponents of translaminar screw fixation cite lower morbidity as a result of less dissection. Despite reports of high fusion rates with this technique, there are concerns over the biomechanical inferiority of this construct compared to pedicle screw fixation. Previous studies on translaminar screws have used only plain radiographs to assess fusion. The objective of this paper is to compare radiographic outcomes, using high definition CT scans, and clinical outcomes between these two methods of posterior fixation. Methods: During 2001, 31 patients underwent combined anterior and posterior fusion by the two senior surgeons for the management of back pain. Anterior interbody fusion was performed using the Syncage in all patients. 16 patients underwent translaminar screw posterior fixation and 15 underwent pedicle screw posterior fixation. Fusion was assessed by high definition CT scan at one year postoperatively. Function was assessed with pre- and postoperative Low Back Outcome Score and visual analogue scores. Results: Minimum follow-up was 12 months. The incidence of pseudarthrosis in the translaminar group was over 75% which was five times greater than that seen in the pedicle screw group (p = 0.01). There were trends towards greater improvements in the LBOS and VAS scores in the pedicle screw group and amongst those patients who achieved a successful fusion. There were two surgical complications in the translaminar screw group and one in the pedicle screw group. Discussion: With the numbers that are available, there are no clinical differences between the two methods of fixation, although there were trends towards improved function and reduced pain in the pedicle screw group. Furthermore there does not appear to be any difference in regards to complications. However, translaminar screws are associated with a significantly higher rate of pseudarthrosis compared to pedicle screws

INTRODUCTION: 360 degree combined anterior and posterior fusion is an accepted surgical treatment for the management of discogenic back pain. Controversy exists to the optimal technique of posterior fixation. Proponents of translaminar screw fixation cite lower morbidity as a result of less dissection. Despite reports of high fusion rates with this technique, there are concerns over the biomechanical inferiority of this construct compared to pedicle screw fixation. Previous studies on translaminar screws have used only plain radiographs to assess fusion. The objective of this paper is to compare radiographic outcomes, using high definition CT scans, and clinical outcomes between these two methods of posterior fixation. METHODS: During 2001, 31 patients underwent combined anterior and posterior fusion by the two senior surgeons for the management of back pain. Anterior interbody fusion was performed using the Syncage in all patients. 16 patients underwent translaminar screw posterior fixation and 15 underwent pedicle screw posterior fixation. Fusion was assessed by high definition CT scan at one year post-operatively. Function was assessed with pre- and post-operative Low Back Outcome Score and visual analogue scores. RESULTS: Minimum follow-up was 12 months. The incidence of pseudarthrosis in the translaminar group was over 75% which was five times greater than that seen in the pedicle screw group (p = 0.01). There were trends towards greater improvements in the LBOS and VAS scores in the pedicle screw group and amongst those patients who achieved a successful fusion. There were two surgical complications in the translaminar screw group and one in the pedicle screw group. DISCUSSION: With the numbers that are available, there are no clinical differences between the two methods of fixation, although there were trends towards improved function and reduced pain in the pedicle screw group. Furthermore there does not appear to be any difference in regard to complications. However, translaminar screws are associated with a significantly higher rate of pseudarthrosis compared to pedicle screws