Purpose of the study

To investigate the efficacy of pedicle screw instrumentation in correcting thoracolumbar/lumbar idiopathic scoliosis in adolescent patients.

Background: To describe – Forced traction radiographs under GA for operative planning; The use of segmental orthogonal image-intensification for screw insertion in thoracic & lumbar pedicles; An audit of X-ray exposure during these procedures; The use of multiple Chevron osteotomies as an alternative to anterior release; The correction of scoliosis with convex cantilever, Cotrel-Debousset manoeuvre, segmental translation, segmental rotation,” lumbar-levelling”.

Methods: We present our operative technique in addressing deformity. This represents an eclectic evolution, which we feel is sufficiently dissimilar to current standards to merit presentation. Pedicle screws are inserted at multiple levels with no recourse to hook or wires. Five reduction techniques are used and repeated.

Results: The complications of 1500 thoracic pedicle screws; the predictive value of forced traction films under GA; the Fulcrum Bending Correction Index and operative parameters of our series are submitted separately.

Conclusion: We commend consideration of some or all of our techniques to the society.

Aim:. To review the use of traction x-rays under anaesthesia in Late Onset Scoliosis to correlate traction x-ray flexibility and postoperative correction using posterior nonsegmental all pedicle screw constructs. Methods:. Prospective study. Preoperative anteroposterior, lateral and side bending x-rays were done and Cobb angles were measured. Intraoperatively, traction anteroposterior x-rays were taken under anaesthesia and Cobb angles were measured. All patients underwent nonsegmental posterior all pedicle screw construct correction using Biomet implants. Cobb angles greater than 60 degees were included in the study. Calculations were done including correction rate, traction flexibility and traction correction index. Results were entered onto an excel spreadsheet and analyzed using Statistica software. Results:. 16 patients were studied, 3 boys and 13 girls, average age 14, ranging from 8 to 17 years. Preoperative Cobb angles were mean 82 (60 to 105) degrees. Traction x-rays mean Cobb angle was 42 degrees with mean traction flexibility rate 49%. Mean correction rate was 65% and mean traction correction index 106. Preoperative Cobb angles correlated with traction flexibility with a p value of 0.01. Traction x-rays Cobb angle correlated with the traction correction index (p = 0.003), postoperative x-rays (p = 0.000) and also with correction rate (p = 0.024). There was no correlation between preoperative Cobb angle and correction rate. Conclusion:. Traction x-rays under anaesthesia in late onset scoliosis are a good predictor of postoperative correction with posterior nonsegmental all pedicle screw constructs in curves greater than 60 degrees

The aim of this study was to report the restauration of the normal vertebral morphology and the absence of curve progression after removal the instrumentation in AIS patients that underwent posterior correction of the deformity by common all screws construct whitout fusion. A series of 36 AIS immature patients (Risser 3 or less) were include in the study. Instrumentation was removed once the maturity stage was complete (Risser 5). Curve correction was assessed at pre and postoperative, before instrumentation removal, just post removal, and more than two years after instrumentation removal. Epiphyseal vertebral growth modulation was assessed by a coronal wedging ratio (WR) at the apical level of the main curve (MC). The mean preoperative coronal Cobb was corrected from 53.7°±7.5 to 5.5º±7.5º (89.7%) at the immediate postop. After implants removal (31.0±5.8 months) the MC was 13.1º. T5–T12 kyphosis showed a significant improvement from 19.0º before curve correction to 27.1º after implants removal (p<0.05). Before surgery, WR was 0.71±0.06, and after removal WR was 0.98±0.08 (p<0.001). At the end of follow-up, the mean sagittal range of motion (ROM) of the T12-S1 segment was 51.2±21.0º. SRS-22 scores improved from 3.31±0.25 preoperatively to 3.68±0.25 at final assessment (p<0.001). In conclusion, fusionless posterior approach using a common all pedicle screws construct correct satisfactory scoliotic main curves and permits removal of the instrumentation once the bone maturity is reached. The final correction was highly satisfactory and an acceptable ROM of the previously lower instrumented segments was observed

Objective. The use of all pedicle screw constructs for the management of spinal deformities has gained widespread popularity. However, the placement of pedicle screws in the deformed spine poses unique challenges for the spinal surgeon. The purpose of this study was to evaluate the complications and radiological outcomes of surgery in 124 consecutive patients with spinal deformity. These patients underwent correction of coronal and sagittal imbalance with segmental pedicle screw fixation only. Background. All pedicle screw constructs have been associated with improved correction in all three planes. In patients with severe deformity, such constructs can obviate the need for anterior surgeries, and the higher implant cost is offset by the avoidance of dual anterior and posterior approaches. Pedicle screw fixation enables enhanced correction of spinal deformities, but the technique is still not widely applied for thoracic deformities for fear of neurological complications. This is a retrospective study that was carried out on 124 patients who underwent segmental screw fixation for coronal and sagittal spinal deformities. The purpose of this study was to evaluate the complications and outcomes of this technique and also assess the evidence of enhanced correction. Material and Methods. A total of 124 consecutive patients subjected to pedicle screw fixation for spinal deformities were analysed after a minimum period of follow-up of two years. Etiologic diagnoses were idiopathic scoliosis in 32, neuromuscular scoliosis 48, Scheuermann's kyphosis in 28 and others 16. They were reviewed using the medical records and preoperative, intraoperative and postoperative radiographs. Computed tomography was performed when screw position was questionable. Deformity correction was determined on preoperative and postoperative radiographs. The positions of the screws were evaluated using intraoperative and postoperative radiographs. There were 51 male and 73 female patients with the mean age of 17.2 years (range, 10-25 years). The average cobb angle for scoliosis and kyphosis were 55°(range 45°-85°) and 72° (range 68°-100°) respectively. Results. A total of 2784 pedicle screws were inserted and 1488 screws were inserted in the thoracic spine (18 screws/patient). Screw-related neurological complications occurred in two patients 0.4%; these comprised a transient paraparesis and dural tear. Other complications comprised six intraoperative pedicle fractures, 12 screw loosening, four postoperative infections and one haemothorax. There were no significant screw-related neurological or visceral complications. The average correction was 78% for scoliosis and 51% for kyphosis. The mean estimated blood loss was 653 ml (range, 510-850), the mean operation time was 148 minutes (range, 120-220). Conclusion. We were able to demonstrate that application of pedicle screw construct is safe and advantageous in the management of spinal deformities. Significant correction has been achieved with a single stage posterior surgery in all groups. Scoliosis and kyphotic deformity corrections were 78% and 51% respectively; this is far superior to correction achieved with one stage surgery with other constructs. This study showed that improved derotation has decreased the need for thoracoplasty, thus eliminating its risk of associated morbidity. Superior control of the deformity obviated the need for an anterior approach in severe curves. Improved correction, lower morbidity and shorter hospitalisation has compensated for higher implant cost. We believe using all pedicle screw fixation is a relatively safe procedure and offers an excellent correction. This correction was maintained throughout the follow up period. Despite our safety record in thoracic pedicle screw placement, we believe this technique can be potentially dangerous in inexperienced hands, and requires a long learning curve. Therefore, a thorough anatomical knowledge of pedicle morphology, a detailed analysis of pre-operative imaging coupled with experience is essential to avoid complications. Ethics approval None. Interest Statement None

Aim:. To evaluate the effect of a stiffer rod in normalising thoracic hypokyphosis in adolescent idiopathic scoliosis (AIS). Methods:. A retrospective review of AIS cases performed at our institution was carried out. In order to reduce variability, the analysis included only Lenke 1 cases which had all pedicle screw constructs, with similar constructs and implant density. Cases that underwent anterior release were excluded. All cases had the same implant (Expedium 5.5, Depuy-Synthes, Raynham, USA). The rod material differed in that some cases had 5.5 titanium, whilst others had 5.5 cobalt chrome. The preoperative and postoperative sagittal Cobb angle was measured. Results:. 35 patients met the inclusion criteria. 15 had titanium rods and 20 had cobalt chrome rods. The mean fulcrum correction index was similar between groups. The preoperative coronal and sagittal Cobb was similar between the two groups. There was no statistically significant difference in the postoperative sagittal Cobb between the two groups (ANOVA one way test). Discussion:. Despite the theoretical advantage of a stiffer construct improving the sagittal profile in AIS, this study identified no such benefit despite closely matching the two groups. All pedicle screw constructs do not seem to improve the sagittal profile despite the use of a stiffer rod. Conflict of interest:. Depuy-Synthes fund a fellow in this unit. Conflict Of Interest Statement: No conflict of interest

Aim:. To compare the ability of fulcrum bend and traction radiographs to predict correction of AIS using pedicle screw only constructs and to compare the fulcrum bending correction index (FBCI) with a new measurement: the traction correction index (TCI). Method:. Retrospective radiographic analysis of eighty patients, average age 14 yrs, who underwent posterior correction of scoliosis using pedicle screw only construct. Analysis was carried out on the pre-op and immediate post-op PA radiographs and the pre-op fulcrum bend and traction radiographs. Correction rate, fulcrum flexibility, traction flexibility, FBCI and TCI was calculated. Results:. Preoperative mean Cobb angle of 63.9 degrees was corrected to 25.8 degrees postoperatively. The mean fulcrum bending Cobb angle was 37.6 degrees and traction Cobb angle 26.6 degrees. The mean fulcrum flexibility was 41.1%, traction flexibility 58.4% and correction rate 59.6%. The mean FBCI was 144.9% and TCI was 102.1%. Discussion:. Radiographic correction of scoliosis based on correction rate does not take into consideration the curve flexibility. It has been suggested by Cheung et al, that fulcrum bending radiographs predict curve correction in AIS. Ibrahim et al, have questioned this, and they suggested that traction radiographs are more predictive in a mixed group of patients with hybrid and screw only constructs. Conclusions:. When comparing fulcrum bend and traction radiographs, we found the latter to be more predictive of curve correction in AIS using pedicle screw constructs. The TCI better takes into account the curve flexibility than the FBCI. Conflict Of Interest Statement: No conflict of interest

Pedicle screw constructs (PSC) in scoliosis are a recently established and widely accepted method of managing scoliotic curves posteriorly. There is a perceived improved coronal and rotational correction when compared to other posterior only constructs. With continued use of this method, the authors and deformity surgeons in general have become aware of persistent thoracic hypokyphosis. This review of 3 years of scoliosis cases using PSC looks at four different implant strategies utilised to manage this problem and our current practice. These strategies were:. All titanium 5.5 mm rod diameter (Expedium, Depuy spine). All titanium 5.5 mm rod diameter with periapical washers (Expedium, Depuy spine). All titanium 6.0 mm rod diameter (Pangea, Synthes). Titanium pedicle screws with 5.5 mm diameter cobalt chrome rods (Expedium Depuy spine). We have reviewed our outcomes with these strategies with respect to thoracic hypokyphosis. Strategy 1 had the highest rate of hypokyphosis on postoperative radiographs. Strategy 4 seems to have the best correction of coronal and sagittal plane abnormality post operatively. As a consequence, our current practice is the use of titanium pedicle screws and 5.5 mm diameter cobalt chrome rods when managing scoliosis with a pedicle screw construct

Introduction. Traditionally correction of idiopathic paediatric scoliosis is done by hybrid fixation. This involves a judicious combination of mono-axial and poly-axial screw constructs. This has inherent perceived advantages with better deformity correction and maintaining alignment without loss of correction over time. Study design. Single centre retrospective review of prospective collected data on the radiological analysis of idiopathic paediatric scoliosis corrections. The study compared hybrid screw constructs (poly-axial & mono-axial) to all poly-axial screw constructs over 28 months. Objective. Compare loss of correction between hybrid screw construct group (HSG) and all poly-axial screw construct group (PSG). Method. Retrospective review of preoperative, post-operative and latest follow-up radiographs on the cohort of 42 consecutive patients over a period of 28 months from a single surgeon series. Results. There were 19 patients (16 females, 3 male) in HSG and 23 (18 females, 5 male) in PSG. Average age at surgery was 14 years for HSG and 15.8 years for PSG. The average baseline Cobbs angle for HSG was 64.57°and 60.79° for PSG. In the HSG, on average 11.6 levels were fused and, in the PSG, it was 11.3 level. Mean screw density for HSG was 1.54 and PSG was 1.6. Mean correction from pre-op to immediate post-op was 46.06° (70.10%) in the HS group and 41.24 degrees (67.78%) in the PS group. At the last follow-up, mean correction was 45.12° (68.0%) for the HSG and 42.43° (70.39%) for PSG. Loss of correction from post-operative radiographs to latest follow up averaged 10.05% in HSG and 3.86% for PSG. Discussion. All poly-axial screw constructs has the advantage of minimal tray inventory, simple logistics, decreased surgical time and overall better efficiency. Rod application and derotation over poly-axial screw constructs is well controlled and we found no difference in the performance of these screws during and after the procedure. Conclusion. There was no statistically significant difference in the degree or loss of correction in HSG or PSG. No difference in radiological outcomes. In poly-axial pedicle screw construct, threading the rod and correction manoeuvres are easier and thereby reducing surgical times. There was no compromise on the derotation manoeuvre and correction of the apical rotation deformity. Our findings show that all poly-axial screw constructs in the management of idiopathic scoliosis corrections is emerging as a tangible alternative for the future

The purpose of this study was to investigate the efficacy and fusion rates of a unilateral pedicle screw construct supplemented with a translaminar screw in transforaminal lumbar interbody fusion (TLIF). The construct was used with an aim of providing suitable spine stiffness with minimal implant load for spinal fusion. Nineteen consecutive patients who underwent single level TLIF were included in the study. All patients had posterior spinal instrumentation using a unilateral pedicle screw construct with a contralateral translaminar screw. Patients were assessed preoperatively and at two, six, twelve and twenty-four weeks following surgery and at the end of one and two years. At every visit Oswestry disability index score,Visual analogue scale for pain and a pain diagram were recorded. A radiographic exam was also conducted and CT scan was done if there was concern about fusion. The average follow up was twenty-four months. There were twelve males and seven females with an average age of forty-eight years. All patients went on to clinical and radiographic union. Sixteen of nineteen patients had significant clinical improvement on VAS for pain, Oswestry scores and pain medication. Three patients had recurrence of radicular pain on the side of the TLIF leading to reexploration. In all three patients solid fusion was observed but scar tissue was evident and symptoms resolved following redecompression of the foramen. The biomechanical competence of a construct is evidenced by successful fusion. With the advent of minimally invasive techniques to achieve spinal fusion the goal is to use minimal instrumentation without compromising on the final stiffness of the spine. The construct of unilateral pedicle screws supplemented with a trans-laminar screw led to fusion in all our cases. It requires lesser soft tissue dissection and the posterior implants are 56% cheaper

RhBMP2 was used in thirty-six consecutive patients requiring interbody fusion with fifty-five levels (thirteen patients twenty levels ALIF, twelve patients seventeen levels TLIF, eleven patients eighteen levels ACDF) using anterior cervical locking plates and lumbar posterior pedicle screw constructs. All patients showed radiographic fusion at six months. Early lucency, subsidence, and increased pain occurred between six weeks and three months in 70% of ALIFS, 53% of TLIFS and 33% of ACDF’s. The average subsidence was 27% in ALIFS, 24% in TLIFS, and 53% in ACDF. Pain improved by the sixth month. We recommend alternative structural support when using RhBMP2. To determine effectiveness of RhBMP2 in interbody fusion with machined allograft spacers (MTF Synthes Spine USA femoral ring, TLIF and fibular ring cervical spacers). A prospective study of thirty-six consecutive patients requiring interbody fusion with fifty-five levels (thirteen patients twenty levels ALIF, twelve patients seventeen levels TLIF, eleven patients eighteen levels ACDF). Machined allograft spacers and RhBmp2 were supplemented with anterior locking plates in the cervical spine while the lumbar segments were supplemented posterior pedicle screws constructs. Patients were followed at two weeks, six weeks, three months, six months, one year. Patients were examined, had xrays, completed Oswestry scores, pain diagrams, and VAS for pain preoperatively and at every follow up appointment. All the patients showed radiographic evidence of fusion at six months after surgery. Early lucency and subsidence of allografts was observed in 70% of ALIFS, 53% of TLIFS and 33% of ACDF’s. The average subsidence was 27% (range13–42%) in ALIFS, 24% in TLIFS (range 13–40%), and 53% in ACDF. Subsidence and reporting of increased pain occurred between the six- week and three month follow up after which patients improved. Although high rates of early fusion can be accomplished with allograft spacers and rhBMP2 significant subsidence occurs in greater than 50% of lumbar cases and 30% of cervical cases due to early turnover and loss of structural support of the allograft. We recommend alternative structural support when using RhBMP2

To compare the ability of fulcrum bend and traction radiographs to predict correction of AIS using screw only implants and to assess the fulcrum bending correction index (FBCI) with a new measurement: the traction correction index (TCI). Retrospective radiographic analysis of case series (Level IV). Radiographic correction of scoliosis based on correction rate does not take into consideration the curve flexibility. It has been suggested that fulcrum bending radiographs predict curve correction in AIS [1]. This has been questioned [2] and has been suggested that traction radiographs are more predictive in a mixed group of patients with hybrid and screw only constructs. Twenty three patients average age 15, who underwent posterior correction of scoliosis using pedicle screw only construct. Analysis was carried out on the pre-op and immediate post-op AP radiographs and the pre-op fulcrum bend and traction radiographs. Correction rate, fulcrum flexibility, traction flexibility, FBCI and TCI was calculated. Preoperative mean Cobb angle of 66 degrees was corrected to 25 degrees postoperatively. The mean fulcrum bending Cobb angle was 38 degrees and traction Cobb angle 28 degrees. The mean fulcrum flexibility was 45%, traction flexibility 59% and correction rate 63%. The mean FBCI was 182% and TCI was112%. When comparing fulcrum bend and traction radiographs, we found the latter to be more predictive of curve correction in AIS using pedicle screw constructs. The TCI better takes into account the curve flexibility than the FBCI

Purpose of the study. To compare the effectiveness of unilateral and bilateral pedicle screw techniques in correcting adolescent idiopathic scoliosis. Summary of Background Data. Pedicle screw constructs have been extensively used in the treatment of adolescent patients with idiopathic scoliosis. It has been suggested that greater implant density may achieve better deformity correction. However, this can increase the neurological risk related to pedicle screw placement, prolong surgical time and blood loss and result in higher instrumentation cost. Methods. We reviewed the medical notes and radiographs of 139 consecutive adolescent patients with idiopathic scoliosis (128 female-11 male, prospectively collected single surgeon's series). We measured the scoliosis, thoracic kyphosis (T5-T12), and lumbar lordosis (L1-L5) before and after surgery, as well as at minimum 2-year follow-up. SRS 22 data was available for all patients. Results. All patients underwent posterior spinal arthrodesis using pedicle screw constructs. Mean age at surgery was 14.5 years. We had 2 separate groups: in Group 1 (43 patients) correction was performed over 2 rods using bilateral segmental pedicle screws; in Group 2 (96 patients) correction was performed over 1 rod using unilateral segmental pedicle screws with the 2. nd. rod providing stability of the construct through 2-level screw fixation both proximal and distal. Group 1. Mean Cobb angle before surgery for upper thoracic curves was 37°. This was corrected by 71% to mean 11° (p<0.001). Mean Cobb angle before surgery for main thoracic curves was 65°. This was corrected by 71% to mean 20° (p<0.001). Mean Cobb angle before surgery for thoracolumbar/lumbar curves was 60°. This was corrected by 74% to mean 16° (p<0.001). No patient lost >2° correction at follow-up. Mean preoperative thoracic kyphosis was 24° and lumbar lordosis 52°. Mean postoperative thoracic kyphosis was 21° and lumbar lordosis 50° (p>0.05). Mean theatre time was 5.5 hours, hospital stay 8.2 days and intraoperative blood loss 0.6 blood volumes. Complications: 1 transient IOM loss/no neurological deficit; 1 deep wound infection leading to non-union and requiring revision surgery; 1 rod trimming due to prominent upper end. Mean preoperative SRS 22 score was 3.9; this improved to 4.5 at follow-up (p<0.001). Pain and self-image demonstrated significant improvement (p=0.001, p<0.001 respectively) with mean satisfaction rate 4.9. Group 2. Mean Cobb angle before surgery for upper thoracic curves was 42°. This was corrected by 52% to mean 20° (p<0.001). Mean Cobb angle before surgery for main thoracic curves was 62°. This was corrected by 70% to mean 19° (p<0.001). Mean Cobb angle before surgery for thoracolumbar/lumbar curves was 57°. This was corrected by 72% to mean 16° (p<0.001). No patient lost >2° correction at follow-up. Preoperative scoliosis size for all types of curves correlated with increased surgical time (r=0.6, 0.4). Mean preoperative thoracic kyphosis was 28° and lumbar lordosis 46°. Mean postoperative thoracic kyphosis was 25° and lumbar lordosis 45° (p>0.05). Mean theatre time was 4.2 hours, hospital stay 8.4 days and intraoperative blood loss 0.4 blood volumes. Complications: 1 deep and 1 superficial wound infections treated with debridement; 1 transient brachial plexus neurapraxia; 1 SMA syndrome. Mean preoperative SRS 22 score was 3.7; this improved to 4.5 at follow-up (p<0.001). Pain, function, self-image and mental health demonstrated significant improvement (p<0.001 for all parameters) with mean satisfaction rate 4.8. Comparison between groups showed no significant difference in regard to age at surgery, preoperative and postoperative scoliosis angle for main thoracic and thoracolumbar/lumbar curves, as well as SRS scores and length of hospital stay. Better correction of upper thoracic curves was achieved in Group 1 (p<0.05), but upper thoracic curves in Group 2 were statistically more severe before surgery (p<0.05). Increased surgical time and blood loss was recorded in Group 1 (p<0.05, p=0.05 respectively). The implant cost was reduced by mean 35% in Group 2 due to lesser number of pedicle screws. Conclusion. Unilateral and bilateral pedicle screw instrumentation has achieved excellent deformity correction in adolescent patients with idiopathic scoliosis, which was maintained at follow-up. This has been associated with high patient satisfaction and low complication rates. The unilateral technique using segmental pedicle screw correction has reduced surgical time, intraoperative blood loss and implant cost without compromising surgical outcome for the most common thoracic and thoracolumbar/lumbar curves. The bilateral technique achieved better correction of upper thoracic scoliosis

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

Purpose of the study. To investigate the efficacy of pedicle screw instrumentation in correcting spinal deformity in patients with quadriplegic cerebral palsy. Also to assess quality of life and functional improvement after deformity correction as perceived by the parents of our patients. Summary of Background Data. All pedicle screw constructs have been commonly used to correct adolescent idiopathic scoliosis. There is limited information on their effectiveness in treating patients with cerebral palsy and neuromuscular scoliosis. Methods. We reviewed the medical records and serial radiographs of 45 consecutive patients with quadriplegia who underwent spinal arthrodesis using pedicle screw/rod instrumentation and a standardised surgical technique (prospectively collected single surgeon's series). All patients were wheelchair bound with collapsing thoracolumbar scoliosis and pelvic obliquity. Twenty-eight patients had associated sagittal deformities. A telephone survey was performed by an independent investigator to assess parents' perception on surgical outcome. Results. Thirty-eight patients underwent posterior-only and 7 staged anteroposterior spinal arthrodesis. Mean age at surgery was 13.4 years (range 9-18.3) and mean postoperative follow-up 3.5 years (range 2.8-5). Pedicle screw instrumentation extended from T2/T3 to L5 with bilateral pelvic fixation using iliac bolts. Scoliosis was corrected from mean 82.5° to 21.4° (74.1%). Pelvic obliquity was corrected from mean 24° to 4° (83.3%). In posterior-only procedures, average blood loss was 0.8 blood volumes, ICU stay 3.5 days, and hospital stay 17.6 days. In anteroposterior procedures, average blood loss was 0.9 blood volumes, ICU stay 8.9 days, and hospital stay 27.4 days. Major complications included one deep infection and one re-operation to remove prominent implants but no deaths, no neurological deficit and no detected pseudarthrosis. Parents' survey demonstrated 100% satisfaction rate. Conclusion. Pedicle screw instrumentation can achieve excellent correction of spinopelvic deformity in quadriplegic cerebral palsy with low complication and re-operation rates and high parent satisfaction. Our study has demonstrated that spinal correction using segmental pedicle screw/rod constructs can be performed safely and with lesser major complications and reoperations compared to the traditionally used Unit rod or hybrid instrumentation. The greater degree of deformity correction and lesser rate of complications and reoperations due to non-union, prominent instrumentation or failed pelvic fixation using a pedicle screw compared to the Unit rod technique should be balanced against the increased implant cost

Introduction This in-vitro biomechanical study was undertaken to compare the multi-directional flexibility kinematics of single versus multi-level lumbar Charité reconstructions and determine the optimal biomechanical method for surgical revision – posterior instrumentation alone or circumferential spinal arthrodesis. Methods A total of seven human cadaveric lumbosacral spines (L1 to Sacrum) were utilized in this investigation and biomechanically evaluated under the following L4-L5 reconstruction conditions: 1) Intact Spine; 2) Diskectomy Alone, 3) Charité, 4) Charité + Pedicle Screws, 5) Two Level Charité (L4-S1), 6) Two Level Charité + Pedicle Screws (L4-S1), 7) Charité L4-L5 with Pedicle Screws and Femoral Ring Allograft (L5-S1) and 8) Pedicle Screws and Femoral Ring Allograft (L4-S1). Multi-directional flexibility testing utilized the Panjabi Hybrid Testing protocol, which includes pure moments for the intact condition with the overall spinal motion replicated under displacement control for subsequent reconstructions. Hence, changes in adjacent level kinematics can be obtained compared to pure moment testing strategies. Unconstrained intact moments of ±7Nm were used for axial rotation, flexion-extension and lateral bending testing, with quantification of the operative and adjacent level range of motion (ROM) and neutral zone (NZ). All data was normalized to the intact spine condition. Results In axial rotation, single and two level Charité reconstructions produced significantly more motion than pedicle screw constructs combined with the Charité or femoral ring allograft (p< 0.05). There were no differences between the Charité augmented with pedicle screws or pedicle screws with femoral ring allograft (p> 0.05). Similar trends were observed under flexion-extension and lateral bending conditions with the Charité reconstructions demonstrating no significant differences compared to the intact spine (p> 0.05). However, the Charité combined with pedicle screws or pedicle screws with femoral ring allograft significantly reduced motion at the operative level compared to the Charité reconstruction (p< 0.05). The most pronounced changes in adjacent level kinematics were observed at the inferior level. The addition of pedicle screw fixation, in all cases, increased segmental motion at the inferior adjacent level (L5-S1) compared to the intact and Charité reconstruction groups (p< 0.05). Discussion Single and two level total disc arthroplasty using the Charité device preserved segmental motion at the operative and adjacent levels compared to pedicle screw stabilization constructs. In terms of revision strategies, posterior pedicle screw reconstruction combined with an existing Charité is not statistically different from pedicle screws combined with femoral ring allograft. As we enter an era of total disc replacement and the impending necessity for surgical revision, the current study provides a biomechanical basis for posterior re-stabilization alone in lieu of combined anteroposterior revision

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

Purpose. Retrospective review of fusion rates using Grafton DBM/allografts only in AIS. Methods. Medical records of 30 consecutive patients at an average age of 19(18-24)were reviewed. All patients had segmental fixation with dual rod and pedicle screw construct followed by decortication supplemented with matrix strips/allograft chips. Minimum follow up 1.5 years, average of 2 years (1.5-3). First follow up at 3 months postoperatively and than 6 months subsequently. All patients were evaluated using criteria described by Betz et al for “possible pseudoarthrosis” which included persistent back pain, defects in the fusion mass, loosening of pedicle screws, junctional kyphosis and curve progression of more than 10 degrees from initial standing postoperative PA views. There were no infections. Average time to clinically and radiographically evident fusion was 12 months (range 10-16). Radiographically visible unfused facet joints were encountered in 3 patients towards the end of the construct. One patient had extension of the construct to treat junctional kyphosis. Other two remained asymptomatic. None had Progression of deformity. One patient developed pars defect at level below construct and was treated with extension of fusion. Conclusion. Rate of fusion approaches 95% which favourably compares to that in literature. We acknowledge limitations inherent to retrospective design, lack of comparative group and CT analysis, nonetheless the study imparts information on the use of bone substitutes without autografts in a subset of spinal deformity patients

The requirements for a motion segment fusion for degenerative disc disease are relief from symptoms from a solid union with minimal damage to surrounding tissue. This is possible with the ‘Mini PLIF’ using the B Twin cages and facet screws. This procedure produces reliable relief of symptoms with a solid fusion. The use of facet screws mean that the nerve supply of the paraspinal muscles is protected. Between June 2002 and February 2006 35 patients underwent this procedure. There were 13 males and 22 females with an average age of 40 years from all walks of life. 30 patients had back and leg pain with only 5 having solely back pain. 28 patients had surgery at L5/ S1 with 4 patients at L4/5 and 3 at both. The median pre operation ODI was 53 (IQR 60–44) and at one year follow up the ODI was 24 (IQR 37–13). There were two complications of superficial infection and two pseudarthroses requiring pedicle screw constructs and revision bone grafting to achieve union. We believe this procedure demonstrates good relief from symptoms with a good fusion rate preserving the paraspinal muscles

Introduction: Studies suggest pedicle screw constructs are more effective than hybrid or hook constructs for AIS correction. This study assessed the efficacy of three methods of spinal instrumentation in patients treated at the WCH. Methodology: 30 AIS patients who underwent posterior spinal surgery were matched according to age, fusion levels, and Lenke curve. Three constructs were assessed, hook-exclusive, screw-exclusive and hybrid constructs, with 10 patients in each group. Endpoints included radiographic measures, operative time and complications. Results: Mean pre-operative Cobb angle was 56.1°, 52.2° and 56.7° for the screw, hybrid and hook group respectively. Structural curve correction was 63.6°, 60.2° and 58.5° for each group respectively. Compensatory curve correction favoured the hybrid and screw groups. Thoracic kyphosis correction was 20.7° (most improved), 19.9°, and 15.5° for the screw, hook, and hybrid groups respectively. Coronal alignment favoured the screw construct group. Comparison of operative time revealed no significant difference, and complication rates were similar in nature and incidence for all three groups. Conclusions: Results demonstrate improved correction of structural curve, kyphosis, and coronal alignment in the screw instrumentation group. No additional complications were observed with this method of AIS curve correction