Aims. A variety of surgical methods and strategies have been demonstrated for Andersson lesion (AL) therapy. In 2011, we proposed and identified the feasibility of stabilizing the spine without curettaging the vertebral or discovertebral lesion to cure non-kyphotic AL. Additionally, due to the excellent reunion ability of ankylosing spondylitis, we further came up with minimally invasive spinal surgery (MIS) to avoid the need for both bone graft and lesion curettage in AL surgery. However, there is a paucity of research into the comparison between open spinal fusion (OSF) and early MIS in the treatment of AL. The purpose of this study was to investigate and compare the clinical outcomes and radiological evaluation of our early MIS approach and OSF for AL. Methods. A total of 39 patients diagnosed with AL who underwent surgery from January 2004 to December 2022 were retrospectively screened for eligibility. Patients with AL were divided into an MIS group and an OSF group. The primary outcomes were union of the lesion on radiograph and CT, as well as the visual analogue scale (VAS) and Oswestry Disability Index (ODI) scores immediately after surgery, and at the follow-up (mean 29 months (standard error (SE) 9)). The secondary outcomes were total blood loss during surgery, operating time, and improvement in the radiological parameters: global and local kyphosis, sagittal vertical axis, sagittal alignment, and chin-brow vertical angle immediately after surgery and at the follow-up. Results. Data for 30 patients with AL were evaluated: 14 in the MIS group and 16 in the OSF group. All patients were followed up after surgery; no nonunion complications or instrumentation failures were observed in either group. No significant differences in the VAS and ODI scores were identified between the two groups. Mean ODI improved from 51 (SE 5) to 17 (SE 5) in the MIS group and from 52 (SE 6) to 19 (SE 5) in the OSF group at the follow-up. There were significant improvements in total blood loss (p = 0.025) and operating time (p < 0.001) between the groups. There was also no significant difference in local kyphosis six months postoperatively (p = 0.119). Conclusion. Early MIS is an effective treatment for AL. MIS provides comparable clinical outcomes to those treated with OSF, with less total blood loss and shorter operating time. Our results support and identify the feasibility of solid immobilization achieved by posterior instrumentation without bone graft via MIS for the treatment of AL. Cite this article: Bone Jt Open 2024;5(10):886–893

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

Aims

The aim of this study was to investigate the safety and efficacy of 3D-printed modular prostheses in patients who underwent joint-sparing limb salvage surgery (JSLSS) for malignant femoral diaphyseal bone tumours.

Background:. Severe kyphosis in myelomeningocoele patients results in seating problems, early satiety and ultimately pressure sores over the prominence. Kyphectomy and sagittal correction can improve these morbidities. Aim:. To evaluate the outcome of kyphectomy surgery in meningomyelocoele children. Methods:. A retrospective review was performed of a single surgeon series of paediatric myelomeningocele patients who underwent kyphectomy surgery. All the patients had posterior fusion, employing pedicle screws and sub laminar wiring. All the posterior fusions extended to the pelvis either to include S1 or the ilium. Prior to surgery, three children had open wounds over the apex of the deformity. Despite prone nursing, these failed to heal. These were closed primarily intra-operatively without the requirement of flaps. Results:. Seven children (four males, three females) were identified with an average age of 9.5 (8–13) years. The kyphosis was corrected from a mean range of 110° (88°–180°) to post-operative range of 5°–45°. The operative time averaged 240 min (165–284 min) with an estimated blood loss average of 957 ml (500–2550 ml). All the patients recovered well and no short-term complications were experienced except one transient CSF leak intra operatively. Two patients presented with sub-acute delayed infection requiring removal of instrumentation once the spine had fused. There was one case of instrumentation failure. All patients had improved wheel chair seating. Conclusion:. Kyphectomy in myelomeningocele is an infrequently required procedure which is effective in sagittal correction and improved seating with an acceptable complication rate

Purpose. To review the outcome of multilevel (≥4) instrumented lumbar fusion to sacrum / pelvis performed for degenerative conditions. Methods. Clinical data of 47 consecutive patients from 2002 to 2012 were reviewed retrospectively. Inclusion criteria included fusion from at least L2 to S1 / pelvis, i.e. minimum of 4 levels. Imaging was assessed for restoration of normal sagittal profile as well as subsequent fusion. EQ5D, OSD and VAS scores pre-op and at 6 months post op were analysed. Average age at surgery was 64 years (50–78). Thirteen cases were primary and 34 revisions. Indications were axial back pain either associated with sagittal imbalance (40%) or leg pain (36%) and leg pain alone in 10%. Results. The intra-operative blood loss averaged 2222 (250–7000) ml with 40% re-infusion from cell-saver. The average surgical duration was 268 minutes. Proximal extent of instrumentation was T2 (1), T3 (1), T4 (2), T8 (1), T9 (1), T10 (17), T11 (2), T12 (5), L1 (4) and L2 (13). TLIF's were done in 20 cases mostly at the base of the construct. Pedicle subtraction osteotomies were performed in 14 revision cases. Dural tears occurred in 14 cases, all revision cases except one. Wound infection occurred in 3 cases. Except for transient quadriceps weakness related to osteotomy, no neurological complications occurred. One patient deceased peri-operatively. Subsequent revision was required in 13 cases for instrumentation failure. OSD score improved by 15.3 points on average, which is clinically and statistically significant. Conclusion. Long lumbar fusions remain technically demanding with a high incidence of adverse events. This is due to the nature of revision surgery and high biomechanical demands on constructs. Surgical intervention can however be justified by the desperation of the cohort in terms of pain and poor function which can be modestly improved with this intervention. NO DISCLOSURES

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

Purpose of study: There is a controversy in the surgical treatment of unstable thoracolumbar burst fractures scoring high on the Load Sharing Classification (LSC). We have been treating unstable thoracolumbar fractures with postero-lateral fusion using short segment instrumentation and in this study we investigated our complication rate. Methods and results: We retrospectively reviewed notes and radiographs of patients presenting with thoracolumbar burst fractures and stabilised with a short-segment instrumented postero-lateral fusion between 1998 and 2007. We identified 31 patients who had adequate documentation and radiographs. Twenty patients had a high (> =7) LSC score and none of these fixations failed. Overall early and late complication rate was low (one wound infection, one dehiscence and four unrelated infections), the one metalwork failure related to infection. Fifty-five percent of patients returned to full-time work. Approximately 50% of correction of kyphosis was lost but the average kyphosis at final follow-up was 11 degrees that we thought was acceptable. Conclusion: We concluded that treating unstable burst fractures with posterior instrumented fusion alone using a pedicle screw construct does not result in late instrumentation failure, high complication rate or unacceptable final deformity. Ethics approval: None. Interest Statement: None

To define how pre-operative evaluation guides surgical planning in patients with atlanto-axial subluxation secondary to rheumatoid arthritis and to measure clinical outcome for the same group. Prospective evaluation of a consecutive cohort of 26 patients undergoing C1/2 fusion over 5 years (2004-2009). Pre-operative evaluation of posterior atlanto-dens interval (PADI), C1 lateral mass and C2 pedicle dimensions. Pre- and post-op Ranawat scores and visual analogue scores for neck and C2 pain. C1/2 instability resulted from rheumatoid arthritis (21), trauma (4) and infection (1). C1 lateral mass mean height 4.4mm, C2 pedicle mean height 5.1mm and mean width 3.4mm (30% width <3mm). Ranawat scale improved Grade II to Grade I (p=0.07). Neck pain (pre-op mean 5.5, s.d. 2.8; post-op mean 1.6, s.d. 2.1, t<0.05) and C2 pain (pre-op mean 2.1, s.d. 3.3; post-op mean 0.5, s.d. 1.2, t<0.05) improved. No instrumentation failure. In the rheumatoid group, 17/21 patients had C1 lateral mass and C1/2 transarticular screws. 1 patient had a cranio-cervical fusion and 3 patients had other constructs. 3 patients had C2 numbness. No other neurological deficit. In a rheumatoid population, pre-operative evaluation often precludes the use of C2 pedicle screws. Rigid fixation with a C1 lateral mass and C1/2 transarticular polyaxial screw-rod system is associated with good clinical outcomes

A combined posterior-anterior approach is usually proposed for the fixation of highly unstable spinal lesions. A monocortical anterior fixation seems to become more and more popular. In the period from 1993 to 1998, 43 patients with minimally anterior and middle column destruction of thoracolumbar spine were anteriorly instrumented. There were 23 tumors, 11 specific infections, 5 posttraumatic conditions with failed posterior instrumentation, 4 acute fractures. Anterior instrumentation (45Nm rod-screw rotation rigidity) were used in all cases. A four screws principle with two non connected rods were bicortically applied to correct the deformity and to fix the corpectomy gap. No postoperative bracing was necessary. There was one pseudarthrosis 2yrs post op. due to poor anterior fusion in a posttraumatic case. In one case instrumentation failure occurred due to widespreading of the prostatic tumor. The study revealed no complications due to bicortical screw fixation in thora-columbar region. It is suggested that combined anterior and posterior procedure is only exceptionally necessary

Introduction: Historically segmental sublaminar wiring (SLW) fixation has been used for the correction of spinal deformity in neuromuscular scoliosis, however pedicle screw (PS) fixation is gaining popularity. We compared the results of both techniques in patients with Duchenne Muscular Dystrophy (DMD). Methods: Two groups of patients with DMD were matched according to the age at surgery, magnitude of deformity and vital capacity. Indications for surgery included loss of sitting balance, rapid decline of vital capacity and curve progression. In Group 1 (22 patients) SLW fixation was used from T2 to S1 with the Galveston technique. In Group 2 (18 patients) PS fixation was used from T2 to L5. Minimum follow-up was 2 years (range 2–13 years). Radiographs, SRS-22 and lung function tests were performed at standardised intervals. Results: Mean Cobb angle in Group 1 improved from 47° (range 26°–75°) to 23.5° (range10°–36°) and mean pelvic obliquity improved from 15° (range8°–25°) to 2.4° (range0°–8°). Mean Cobb angle in Group 2 improved from 46° (range28°–82°) to 8.5° (range 0°–18°) and mean pelvic obliquity improved from 15° (range7°–30°) to 1.1° (range 0°–6°) [p< 0.05]. Mean operating time and blood loss were less in Group 2 [p< 0.05]. In Group 1, the infection rate and instrumentation failure was higher, and SRS-22 outcomes showed no significant difference between the groups. Interestingly the mean Body Mass Index (BMI) in Group 2 was much higher than group 1. Conclusions: PS fixation resulted in superior correction and controlled pelvic obliquity to a large extent without the need for pelvic fixation. Lower rates of infection and failure of instrumentation were noted with PS fixation, despite high BMI of patients presumably due to steroid therapy. We recommend the use of PS instrumentation for the correction of spinal deformity in DMD

Purpose: Lumbosacral dislocation injuries are rare. Severe trauma disrupts the mechanically stable lumbosacral junction, rendering the injuries particularly unstable. Aggressive surgical management has been recommended. We present a review of our experience with these uncommon injuries defining injury patterns, surgical strategies and outcomes. Methodology: Six patients were treated at Auckland Hospital in the last decade. Thorough review and literature search were performed to revise recommendations for management. Results: All injuries were associated with high-energy trauma. In two cases there was evidence of previous spondylolysis, with dramatic progression after injury. All cases were surgically treated with decompression, reduction as indicated, and fusion with instrumentation. The only instrumentation failure occurred when reduction reconstituted disc height without attention to reconstruction of the severely mechanically compromised intervertebral disc. Satisfactory recovery of nerve root injury occurred in all but one case. Major cauda equina damage did not occur. Correlations with previously described classification systems for this injury were poor, and often showed injuries to span grades. Conclusions: These highly unstable injuries require a high index of suspicion, and aggressive surgical management of these highly unstable injuries is warranted, yielding satisfactory outcomes. Existing classification systems are of little value prognostically, or in planning treatment, and it is better to classify and treat these injuries specifically relating to the anatomical injury patterns. The severe disruption to the intervertebral disc warrants special consideration with attention to a stable reduction position or three-column reconstruction. Spondylolysis may represent a predisposing factor

Lumbosacral dislocation injuries are rare. Severe trauma disrupts the mechanically stable lumbosacral junction, rendering the injuries particularly unstable. Aggressive surgical management has been recommended. We present a review of our experience with these uncommon injuries defining injury patterns, surgical strategies and outcomes. Six patients were treated at Auckland Hospital in the last decade. Thorough review and literature search were performed to revise recommendations for management. All injuries were associated with high-energy trauma. In two cases there was evidence of previous spondylolysis, with dramatic progression after injury. All cases were surgically treated with decompression, reduction as indicated, and fusion with instrumentation. The only instrumentation failure occurred when reduction reconstituted disc height without attention to reconstruction of the severely mechanically compromised intervertebral disc. Satisfactory recovery of nerve root injury occurred in all but one case. Major cauda equina damage did not occur. Correlations with previously described classification systems for this injury were poor, and often showed injuries to span grades. These highly unstable injuries require a high index of suspicion, and aggressive surgical management of these highly unstable injuries is warranted, yielding satisfactory outcomes. Existing classification systems are of little value prognostically, or in planning treatment, and it is better to classify and treat these injuries specifically relating to the anatomical injury patterns. The severe disruption to the intervertebral disc warrants special consideration with attention to a stable reduction position or three-column reconstruction. Spondylolysis may represent a predisposing factor

PURPOSE: Lumbosacral dislocation injuries are rare. Severe trauma disrupts the mechanically stable lumbosacral junction, rendering the injuries particularly unstable. Aggressive surgical management has been recommended. We present a review of our experience with these uncommon injuries defining injury patterns, surgical strategies and outcomes. METHODOLOGY: Six patients were treated at Auckland Hospital in the last decade. Thorough review and literature search were performed to revise recommendations for management. RESULTS: All injuries were associated with high-energy trauma. In two cases there was evidence of previous spondylolysis, with dramatic progression after injury. All cases were surgically treated with decompression, reduction as indicated, and fusion with instrumentation. The only instrumentation failure occurred when reduction reconstituted disc height without attention to reconstruction of the severely mechanically compromised intervertebral disc. Satisfactory recovery of nerve root injury occurred in all but one case. Major cauda equina damage did not occur. Correlations with previously described classification systems for this injury were poor, and often showed injuries to span grades. CONCLUSIONS: These highly unstable injuries require a high index of suspicion, and aggressive surgical management of these highly unstable injuries is warranted, yielding satisfactory outcomes. Existing classification systems are of little value prognostically, or in planning treatment, and it is better to classify and treat these injuries specifically relating to the anatomical injury patterns. The severe disruption to the intervertebral disc warrants special consideration with attention to a stable reduction position or three-column reconstruction. Spondylolysis may represent a predisposing factor

Introduction: We have compared the results of pedicle screw (PS) construct only with a hybrid sublaminar wire and pedicle screw construct (HS) in a matched cohort of CP patients, to establish which technique is superior in view of deformity correction and its maintenance. Methods: 22 male and 14 female CP patients with average age of 16 years (range 8–25 years) underwent surgical correction for spinal deformity. Indications for surgery included loss of sitting balance, progression of spinal deformity, pelvic obliquity and back pain. Group 1 (18 patients) had PS construct only and Group 2 (18 patients) had HS constructs. 32 patients (90%) required sacral fixation. 5 patients in Group 2 required anterior release. All patients had a minimum follow-up of 2 years (range 2–13 years). Clinical and radiographic analyses were performed in both groups. Results: Mean Cobb angle in Group 1 improved from 650 (range 120–950) to 18.50 (range 0–280) and in Group 2 from 77.60 (range 400–1050) to 34.80 (range 100–620) [p < 0.05]. Mean pelvic obliquity in Group 1 improved from 14.30 (range 00–420) to 2.50 (range 00–50) and in Group 2 from 24.70 (100–510) to 9.70 (range 20–180) [p< 0.05]. Mean surgical time in Group 1 was 224 minutes as compared to 260 minutes in Group 2 [P< 0.05]. 6 patients in Group 2 had proximal junctional kyphosis and implant failure requiring revision. One patient in each group had infection treated with antibiotic therapy. Conclusions: PS fixation in CP patients, allowed significant correction of large curves without anterior release, eliminated proximal junctional kyphosis and instrumentation failure. Correction of pelvic obliquity was also superior due to three-dimensional corrective force of pedicle screws. Although PS fixation is expensive and technically demanding, it outweighs the costs incurred by two-stage surgery because of its superior durability correction

Aim: To present our experience concerning late infections in operated scoliosis. Methods: 118 patients were treated surgically using multiple hook and screw instrumentation systems over the last 10 years. 103 patients had idiopathic (mean age 22.1) and 15 had neuromuscular scoliosis (mean age 12.2 years). All patients were instrumented posteriorly. Bovine xenografts were used were used in all cases where fusion was the goal. Additional anterior fusion was necessary in 8 patients. To date 10 patients (7 idiopathic and 3 neuromuscular) presented late deep wound postoperative infections. None of these patients had signs of generalized septic condition. The latent period of the infection varied from 1 to 5 years. Two patients presented rod failure. Initial pus cultures were negative in 5 patients. A common þnding was pus lining on the instrumentation surface with increased concentration under the cross-links. All patients had at least one loose cross-link nut. Local corrosion of the hardware and metal inþltration of the surrounding tissues was also present. The instrumentation was removed in all cases. All patients but one had satisfactory bony fusion. A variety of pathogens were cultured from intra-operative specimens (5 CNS, 2 A. baumannii, 1 peptostreptococcus, 2 St. epidermidis). A continuous irrigation system was used for 5 days in all patients, combined with antibiotics IV for 7 days and po for 45 days. Results: Protocol treatment was successful in all patients. No recurrence of the infection was observed after the removal of the instrumentation. Conclusions: The exact etiology of those infections seems to be an interesting subject for investigation. The extended surface and bulky nature of the construct are a probable predisposing factor, as is instrumentation failure and loosening. No bone involvement was noticed. Removal of instrumentation appears to be effective treatment

Summary. Pyogenic spondylodiscitis is an uncommon but severe spinal infection. In majority of cases treatment is based on intravenous antibiotics and rigid brace immobilization. Posterior percutaneous spinal instrumentation is a safe alternative procedure in relieving pain, preventing deformity and neurological compromise. Introduction. Pyogenic spondylodiscitis (PS) is an uncommon but severe spinal infection. Patients affected by a non-complicated PS and treatment is based on intravenous antibiotics and rigid brace immobilization with a thoracolumbosacral orthosis (TLSO) suffices in most cases in relieving pain, preventing deformity and neurological compromise. Since January 2010 we started offering patients percutaneous posterior screw-rod instrumentation as alternative approach to TLSO immobilization. The aim of this study was to evaluate safety and effectiveness of posterior percutaneous spinal instrumentation for single level lower thoracic (T9-T12) or lumbar pyogenic spondylodiscitis. Materials and Methods. Retrospective cohort analysis on 27 patients diagnosed with PS who were offered to choose between 24/7 TLSO rigid bracing for 3 to 4 months and posterior percutaneous screw-rod instrumentation bridging the infection level followed by soft bracing for 4 weeks after surgery. All patients underwent antibiotic therapy. Fifteen patients chose conservative treatment, 12 patients chose surgical treatment. Patients were seen at 1, 3, 6, 9 months after diagnosis. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and complete blood count were measured at each follow-up visit. Segmental kyphosis was measured at diagnosis and at 9 months. VAS, SF-12, and EQ-5D questionnaires were recorded at each follow-up visit. Baseline groups’ demographic characteristics were assessed using independent sample t-tests for continuous variables and χ2 tests for frequency variables. Results. Complete healing was achieved in all patients, no difference was observed in healing time between the two groups (77.3±7.2 days vs 80.2±4.4). Instrumentation failure and screw loosening was not observed in any patient. In both group CRP and ESR decreased accordingly with response to antibiotic therapy. Surgically treated patients had significantly lower VAS scores at 1 month (3.05±0.57 in surgery group vs 5.20±1.21 in TLSO group) and 3 months (2.31±0.54 in surgery group vs 2.85±0.55 in TLSO group) post-diagnosis. Both groups had similar trends toward fast recovery in both mental (MCS) and physical components (PCS) of SF-12 questionnaire, surgically treated patients showed steeper and statistically significative improvement at 1 month (37.83±4.57 MCS in surgery group vs 24.52±3.03 MCS in TLSO group and 35.46±4.43 PCS in surgery group vs 27.07±4.45 PCS in TLSO group, p<0.001), 3 months (52.94±3.82 MCS in surgery group vs 39.45±4.92 MCS in TLSO group and 44.93±3.73 PCS in surgery group vs 35.33±6.44 PCS in TLSO group, p<0.001), and 6 months (54.93±3.56 MCS in surgery group vs 49.99±5.82 MCS in TLSO group) post-diagnosis, no statistically significant differences were detected at the other time points (9 months post-diagnosis). EQ-5D index was significantly higher in surgery patients at 1 month (0.764±0.043 in surgery group vs 0.458±0.197 in TLSO group) and 3 months (0.890±0.116 in surgery group vs 0.688±0.142 in TLSO group); no statistically significant changes were observed in segmental kyphosis between the two groups. Conclusion. Posterior percutaneous spinal instrumentation is a safe, feasible, and effective procedure in relieving pain, preventing deformity and neurological compromise. Surgical stabilization was associated with faster recovery, lower pain scores, and improved quality of life compared with TLSO conservative treatment at 1 and 3 months after diagnosis

Introduction: Titanium mesh cages (TMC) for the reconstruction of thoracolumbar vertebral body defects offer an alternative to structural iliac crest autograft or allograft. The stability and safety of these cages has not been addressed. Aim: To assess the stability and safety of titanium mesh cages in the reconstruction of thoracolumbar vertebral body defects. Method: Independent radiological review before and after surgery, and at follow-up was performed for 27 patients having implantation of TMCs. Measurements of thoracolumbar kyphosis, cage settling, translational deformities and any evidence of implant failure were recorded. Results: Indications for reconstruction with TMC included burst fracture (13), post-traumatic kyphosis (8), primary tumour resection (3), debridement of infection (1) and stabilisation of severe kyphotic deformity in achondroplasia with spinal stenosis (2). Kyphoses were corrected by a mean of 12 degrees (61%, range: zero degrees to 38 degrees, 0% to 85%). No cage moved. One patient had a recurrence of the kyphosis of more than five degrees (12 degrees). Five patients demonstrated some settling of the cage within adjacent vertebral bodies (1% to 8%, mean = 3.4% of height loss over length). Translational malposition of three cages occurred. One of these cases demonstrated the maximum settling and another was associated with the only case of instrumentation failure. Spinal canal intrusion did not occur. Conclusions: We found that the use of TMCs was safe when managing vertebral body reconstruction. Significant kyphosis or translational deformity did not occur, however minor cage settling within adjacent vertebra did. The fusion rate is unknown as the mesh cage obscured graft maturation. Construct failure only occurred after pre-operative translational malalignment could not be corrected. This demanding procedure offers a reconstructive option with superior structural stability and reduced bone grafting morbidity

Objective. To evaluate the outcomes of the treatment of acute thoracolumbar burst fractures by transpedicular balloon kyphoplasty with Calcium phosphate cement and posterior instrumented fusion. Methods: Twenty-three consecutive patients (average age 48 years) who sustained thoracolumbar A3-type burst fracture with or without neurologic deficit were included in this prospective study. Twenty-one out 23 patients had single fractures and the left 2 had each one additional A1 compression contiguous fracture. On admission 5(26%) out 23 patients had neurologic lesion (5 incomplete, one complete). Bilateral transpedicular balloon kyphoplasty was performed with quick hardening calcium phosphate cement to reduce segmental kyphosis and restore vertebral body height and supplementary pedicle screw instrumentation (long including 4 vertebrae for T9-L1 fractures and short (3 vertebrae) for L2 to L4 fractures. Gardner kyphosis angle, anterior and posterior vertebral body height ratio and spinal canal encroachment were calculated pre–to postoperatively. Results: All 23 patients were operated within two days after admission and were followed for at least 24 months after index surgery. Operating time and blood loss averaged 70 minutes and 250 cc respectively. The 5 patients with incomplete neurologic lesions improved by at least one ASIA grade, while no neurological deterioration was observed in any case. Overall sagittal alignment was improved from an average preoperative 16o to one degree kyphosis at final follow up observation. The anterior vertebral body height ratio improved from 0.6 preoperatively to 0.9 (P< 0.001) postoperatively, while posterior vertebral body height was improved from 0.95 to 1 (P< 0.01). Spinal canal encroachment was reduced from an average 32% preoperatively to 20% postoperatively. No differences in preoperative values and postoperative changes in radiographic parameters between short and long group were shown. Cement leakage was observed in 4 cases: three anterior to vertebral body and one into the disc without sequalae. In the last CT evaluation, continuity was shown between calcium phosphate and cancellous vertebral body bone. Posterolateral radiological fusion was achieved within 6–8 months after index operation. There was no instrumentation failure or measurable loss of sagittal curve and vertebral height correction in any group of patients. Conclusions: Balloon kyphoplasty with calcium phosphate cement secured with posterior long and short fixation in the thoracolumbar and lumbar spine respectively provided excellent immediate reduction of posttraumatic segmental kyphosis and significant spinal canal clearance and restored vertebral body height in the fracture level in an equal amount both in short and long instrumentation

Objective: To assess the radiological and back surface correction achieved following anterior USS in the treatment of thoracic adolescent idiopathic scoliosis (AIS). Design: Prospective study of back surface correction, retrospective radiological review. Subjects: 14 patients with thoracic AIS (age 11–18 yrs) were treated with anterior USS between 1995 and 2000. There are 12 females and 2 males, all with 2 year follow-up. 8 patients have complete surface data. Data from a further 6 patients will shortly be available as they reach 2 year follow-up. Outcome measures: Cobb angle, apical vertebral rotation (AVR), apical vertebral translation (AVT), frontal plane imbalance, kyphosis and lordosis were measured from the radiographs. A Scoliometer was used to assess the maximal angle of trunk inclination (max ATI) in the thoracic region. All measurements were obtained before surgery and at 8 weeks, 1 year and 2 years after surgery. Complications were recorded. Results: Significant initial corrections are observed for each of: Cobb angle (51%, p< 0.001), AVR (40%, p=0.003),AVT (64%,p< 0.001),maxATI (47%,p=0.001). There is no significant correction loss during the 2 year follow-up. Three patients had spinal imbalance (> 2cm) before surgery with one patient after surgery. The kyphosis significantly increased from 24° to 29° immediately after surgery with no significant change during follow-up. There was no change in lordosis. There were no neurological complications and no instrumentation failures were observed. In two cases the upper screw partially pulled out of T5 with some loss of correction. Conclusions: Anterior scoliosis correction for thoracic AIS achieves good and stable radiological and particularly back surface corrections (max ATI – 47% compared with 22% correction after posterior surgery). Rigid anterior instrumentation has eliminated the 20% rod failure seen with Zielke. New techniques for preventing upper screw pull out will be discussed and new retractor systems allow smaller thoracotomies. There remains a small but significant increase in kyphosis which is less of a problem in the thoracic spine than at the thoracolumbar junction where anterior scoliosis correction is most commonly advocated. Anterior instrumentation for thoracic AIS has advanced to a point where it can be widely adopted, particularly if the patient expresses concerns regarding the rib hump or is hypokyphotic

Introduction: Large anterior column defects of the thoracolumbar spine, after fracture decompression, tumour or other pathological resection, or spinal osteotomy present significant difficulties in respect to autograft procurement, donor site morbidity, graft instability and residual spinal instability. Titanium Mesh Cages for reconstruction thoracolumbar vertebral body defects (after corpectomy) offer an alternative to structural iliac crest autograft or allograft. The use of TMCs for inter-body reconstruction has been addressed yet the use of larger cages for corpectomy reconstruction has not. This study examines implant stability and deformity correction of TMCs following corpectomy reconstruction in the thoracolumbar spine. Methods: Independent radiological review before, after and at follow-up (one year) was performed for 27 patients having implantation of TMCs. Measurement of thoracolumbar kyphosis was performed before surgery, immediately post operatively, and at one year follow-up. Correction of kyphosis was expressed both as angular improvement and percentage improvement. Cage settling into adjacent vertebral bodies, translational deformities and any evidence of implant failure was sought. Results: Indications for reconstruction with TMC included burst fracture (13), post traumatic kyphosis (8), primary tumour resection (3), debridement of infection (1), and stabilisation of severe kyphotic deformity in achodroplasia with associated spinal stenosis requiring decompression (2). Desired resection and decompression was achieved as indicated. Correction of kyphosis was a mean of 12 deg / 61% (range 0 – 38 deg, 0–85%). No cage moved. One patient had kyphosis recurrence of > 5 deg (12 deg). Five patients demonstrated some settling of the cage within adjacent vertebral bodies (1–8%, mean 3.4% of height loss over construct length – the vertebral body above to the body below). Translational malposition of three cages occurred. One of these cases demonstrated the maximum settling and another was associated with the only case of instrumentation failure. Clinically significant spinal canal intrusion did not occur. One cage demonstrated buckling of the wall without evidence of other problem and the clinical result was excellent. Discussion: Use of TMCs is safe when managing vertebral body reconstruction. Significant kyphosis or translational deformity has not occurred, however minor cage settling within adjacent vertebra may occur. Fusion rate is unknown as the cage mesh obscures graft maturation. Construct failure has only occurred after pre operative translational malalignment could not be corrected. This demanding procedure offers a reconstructive option with superior structural stability and reduced bone grafting morbidity