Back ground:. The aim of this study is to evaluate the long-term outcome after posterior spinal stabilization surgery for the management of de novo non-tuberculous bacterial spinal infection. Method and Result:. Patients presenting to a single tertiary referral spinal centre between August 2011 and June 2014 were included in the study. 21 patients with nontuberculous bacterial infection were identified and included in the study. All patients were managed surgically with posterior stabilisation, with or without neural decompression, without debridement of the infected tissue. Neurological state was assessed using the frankel grading system before and after urgery. Long-term follow-up data was collected using SpineTango COMI questionnaires and Euro Qol EQ-5D system with a mean follow-up duration of 20 months postoperatively. The mean improvement in neurological deficits was 0.92 Frankel grade (range 0–4). At final followup, at a mean of 20 months, mean COMI score was 4.59, average VAS for back pain was 4.28. These symptoms were having no effect or only minor effect on the work or usual activities in 52%. 38% of patients reported a good quality of life. The average EQ-5D value was 0.569. There were no problems with mobility in 44% of patients. In 72% there were no problems with self-care. Conclusion:. Our study has shown that posterior surgery for the management of bacterial, nontuberculous spinal infection can improve neurological outcome in approximately half of the patients. However, at long term followup, only around 50% of patients was able to return their pre-morbid work or usual activities

Comparison of clinical, radiological & functional outcomes of corrective surgery for right thoracic AIS curves. There is a paucity of data relating functional outcomes to the radiological and surface measurement results of either posterior or anterior surgery for right thoracic AIS. Prospective, cohort study, mean follow up 35 months (range 9-115). 38 patients (6 males); 22 Lenke 2 posterior, 16 Lenke 1 anterior. Primary= rib hump, radiological (frontal Cobb correction, apical vertebral translation AVT, sagittal profile), Modified SRS Outcomes Instrument (MSRSI). Secondary= estimated blood loss (EBL), operative time, complications. No significant difference at P<0.005 with student t-test unless indicated. Rib Hump: 16° posterior 17 ° anterior, corrected to 8 ° (50%) and 6 ° (60%) respectively. Thoracic Cobb: 70° posterior 61 ° anterior, corrected to 27° (61%) and 22° (64%) respectively. No difference in preoperative curve flexibility or fulcrum bending correction index. Thoracic AVT 55% correction posterior, 70% anterior, Lumbar Cobb 59% correction posterior, 52% anterior. Thoracic kyphosis significantly reduced in posterior surgery (35 ° to 20 °) and significantly increased with anterior surgery (21° to 30°). Lumbar lordosis significantly reduced with posterior surgery (88° to 47°), no significant change with anterior surgery (60° to 53°). MSRSI; Domain scores similar preoperatively between groups. Difference scores (postop-preop), higher scores=better. Pain: +1.21 posterior +0.73 anterior. Self image: +1.02 posterior +0.71 anterior. Function/activity: +0.28 posterior +0.21 anterior. Mental health: +0.66 posterior +0.45 anterior. No significant difference in complication rate, operative time or estimated blood loss. Similar cohorts of AIS patients treated by either anterior or posterior surgery have no significant differences in radiological or functional outcomes. The different final sagittal profile in both groups did not affect the MSRSI outcomes. Both procedures deliver significant health gains as measured by the MSRSI

Scoliosis surgery has moved towards all posterior correction, as modern implants are perceived to be powerful enough to overcome stiffer and more severe curves. However, shortening of the anterior spinal column remains most effective in creating thoracic kyphosis, and may still have a role in correcting both coronal and sagittal deformities. Furthermore, anterior correction of lumbar and thoracolumbar curves can theoretically reduce the distal fusion level, and may have significant impact on patients' post-operative function. A single surgeon series of 62 patients with idiopathic scoliosis were examined retrospectively. Radiographs and operation notes were examined by 2 spinal surgeons, sagittal and coronal parameters were measured before and after the operation. The patients were divided into 4 groups: 16 anterior and posterior fusions (AP), 16 anterior thoracolumbar fusions (A), 5 anterior thoracic releases and posterior fusions (AR), and 25 posterior fusions only (P). The mean age was 15.3 (range 10 – 20). The mean main thoracic Cobb angle pre-operatively was: 54° (AP), 43° (A), 63° (AR), and 50° (P). The mean thoracolumbar Cobb angle was: 55° (AP) and 51° (A). There was no significant difference in lumbar lordosis. The mean post-operative main thoracic Cobb angle was: 9° (AP), 13° (A), 9° (AR) and 15° (P). There was significant difference between AR and P groups. The mean post-operative thoracolumbar Cobb angle was: 8° (AP) and 6° for (A). There was a significant difference in the post-operative thoracic kyphosis between AP (mean 14°), A (mean 38°), AR (mean 19°) and P (mean 14°). Overall, the lumbar lordosis for all 4 groups reduced from a mean of 67° to 50°, with no significant difference between the groups. The distal level of fusion for A and AP groups were L3 for all cases, whereas 2 cases had to extend to L4 in the P group. Anterior release improved both coronal and sagittal correction when compared to posterior only surgery, however it is of unknown clinical significance. Anterior thoracolumbar fusion with or without posterior spinal fusion appeared to produce adequate coronal correction if fused to L3. No difference was found between all groups in post-operative lumbar lordosis

Purpose: To identify patients in whom anterior scoliosis correction was not possible and to determine pre-operative factors that may predict such an outcome.

Methods: From 1999–2005, 257 patients were listed for anterior correction with the Kaneda Anterior Spine System (KASS). Of these 246 were completed successfully. However in 11 cases it was not possible to complete the procedure.

We performed a retrospective review of case notes and X-rays. A control group of 22 patients, in whom anterior surgery was completed, matched to age, sex and type of curve, was used.

Results: Two reasons for abandoning anterior instrumentation were identified; loss of cord signal (7) and failure to achieve adequate correction after anterior release and reduction (4).

Of the seven patients with lost signal three were syndromic and four were associated with syrinx. In all seven, loss of signal occurred on clamping of segmental vessels. All seven had no residual neurological deficit post-operatively and had uncomplicated posterior correction the following week.

All four patients in whom inadequate correction was achieved after anterior release and repositioning had idiopathic curves. Of these two were thoracic and two were thoracolumbar. Mean pre-operative Cobb angle was 67 (range 59–85) compared to a mean of 56 (range 42–68) in the control group. Mean pre-operative stiffness index was 91% (range 85%–100%) compared to a mean stiffness index of 65% (range 53–80) in the control population.

Conclusion: Whilst a successful outcome is achieved in a majority of KASS instrumentations we have identified two reasons why anterior surgery has to be abandoned. Whilst one often cannot pre-operatively anticipate intra-operative loss of cord signal, we found that in cases with an underlying syrinx there is a particular risk of this occurrence. Our experience has shown particularly stiff curves (Stiffness index ≥ 85%) may not be suitable for stand-alone anterior surgery.

The purpose was to compare the results of two different surgical techniques in the treatment of severe cerebral palsy scoliosis.

This is a retrospective review of 12 consecutive cerebral palsy patients with scoliosis greater than 90 degrees undergoing simultaneous anterior and posterior spinal fusion. The clinical notes were reviewed along with sequential radiographs. Twelve patients were operated on between March 1997 and October 2001. There were 6 patients who had anterior release and fusion followed by posterior fusion from T2 to the sacrum using the Luque-Galveston technique. (Group 1). The other 6 patients had identical surgery but with the addition of anterior instrumentation as well. (Group 2). There was no loss of fixation or metalware failure. There was no pseudarthrosis. One patient died at the time of rod removal for infection 2 years following their index operation.

These results show that a good outcome is achieved in this group of severely affected cerebral palsy patients using either of the techniques described. The addition of anterior instrumentation may make the surgery easier and was not associated with significant increase in complications.

Type of study: Case-series comparison.

Patients: 20 patients (2 males); average age 15.5 years; mean follow-up 22 months. 10 patients (Lenke type 1) had anterior correction and instrumentation; 10 patients (Lenke type 2) had posterior operations. All patients had a selective thoracic fusion (with the type 2 curves having instrumentation incorporating the proximal thoracic curve).

Outcome measures: Complications, radiological parameters (Cobb correction of major & compensatory curves); trunk shape (rib hump / scoliometer), and SRS-22 questionnaires.

SRS-22 outcomes: There was no significant difference in the pre-operative individual domain scores (pain, self-image, function, mental health, satisfaction) between the two groups. There were no differences in the postoperative results (including self-image) apart from pain. The anterior surgery group had more persistent pain, but at a similar level than preoperatively (3.2 [0.8] vs 4.6 [0.3], p~0.03).

Conclusion: For right thoracic (Lenke curve types 1& 2) late-onset idiopathic scoliosis both types of surgery deliver similar radiological and trunk-shape results. SRS-22 self-image and function post-operative results are also similar. The anterior procedure did not however improve the pre-operative pain score.

Aim of Study: The aim of the study was to investigate the effect of muscle retractors on intramuscular pressure in the posterior spinal muscles during posterior spinal surgery. Methods: Twenty patients undergoing posterior spinal surgery were recruited into this study and recordings of intramuscular pressure during surgery were performed using a Stryker® compartment pressure monitoring system, prior to insertion of retractors, 5, 30 and 60 minutes into surgery and on removal of retractors. Prior to and following use of the retractors, muscle biopsies were taken from the erector spinae muscle for analysis. Results: A significant increase in intramuscular pressure (p< 0.001) was observed during surgery, with pressure rising from 7.1±4.1 mmHg pre-operatively to 26.4±16.0 mmHg 30 minutes into the operation. On removal of retractors, this pressure returned to or near to the original value. Analysis of muscle biopsies using calcium-activated ATPase birefringence revealed a reduction in muscle function following prolonged use of self-retaining retractors. Discussion: This study demonstrates a substantial rise in pressure in the erector spinae muscle during posterior spinal surgery. Following retraction, marked changes were noted in the function of the muscles. This could be an important factor in the generation of operative scar tissue and post-operative dysfunction of the spinal muscles, and therefore, may be a cause of persistent back pain frequently observed in post-operative patients. Currently, this work is being extended to investigate the relationship between loss of muscle function and duration of retraction, and to study the long term implications of loss of muscle function with respect to surgical outcome and chronic back pain

Introduction: The principles of treatment of deep wound infection around bony implants involves appropriate antibiotics, drainage, repeat debridements, and secondary closure. This type of wound management can be difficult for nursing staff and uncomfortable for the patient. This paper discusses the results of debridement and immediate closure over drain tubes in eight cases from one surgeon’s practice in two tertiary hospitals. Methods: This is a retrospective review of patients from a personal database. Over a five year period, 178 instrumented posterior spine surgeries, in all regions of the spine, were performed. The indications for surgery included trauma, scoliosis, degenerative conditions, tumour, and other deformities in decreasing order of frequency. In this group, there were eight deep wound infections requiring debridement. All were in the thoracic and/or lumbar region. In two patients with non-fusion rods, the implants were removed. In six patients the implants were retained. All wounds were closed immediately over 16 Fr drain tubes. Follow-up times range from 4 years to 3 months. Results: No wounds required repeat debridement or developed subsequent breakdown. No patient had any further significant septic episodes. The drain tubes remained in situ for a time ranging from five days to three weeks. Of the two patients who had their implants removed at debridement, one remained on antibiotics for six weeks and the other for three months. Four patients remained on antibiotics for one year. One patient had removal of the implants before ceasing the antibiotics but the other three have not had a recurrence of infection despite retaining their implants. Two patients remain on lifelong antibiotics. Discussion: Debridement and immediate wound closure, in concert with the appropriate antibiotic, after post-operative deep wound infection can be successful with the benefit of less discomfort for the patient and greater ease of nursing care

INTRODUCTION: The principles of treatment of deep wound infection around bony implants involve appropriate antibiotics, drainage, repeat debridements, and secondary closure. This type of wound management can be difficult for nursing staff and uncomfortable for the patient. This paper discusses the results of debridement and immediate closure over drain tubes in eight cases from one surgeon’s practice in two tertiary hospitals. METHODS: This is a retrospective review of patients from a personal database. Over a five year period, 178 instrumented posterior spine surgeries, in all regions of the spine, were performed. The indications for surgery included trauma, scoliosis, degenerative conditions, tumour, and other deformities in decreasing order of frequency. In this group, there were eight deep wound infections requiring debridement. All were in the thoracic and/or lumbar region. In two patients with non-fusion rods, the implants were removed. In six patients the implants were retained. All wounds were closed immediately over 16 Fr drain tubes. Follow-up times range from four years to three months. RESULTS: No wounds required repeat debridement or developed subsequent breakdown. No patient had any further significant septic episodes. The drain tubes remained in situ for a time ranging from five days to three weeks. Of the two patients who had their implants removed at debridement, one remained on antibiotics for six weeks and the other for three months. Four patients remained on antibiotics for one year. One patient had removal of the implants before ceasing the antibiotics but the other three have not had a recurrence of infection despite retaining their implants. Two patients remain on lifelong antibiotics. DISCUSSION: Debridement and immediate wound closure, in concert with the appropriate antibiotic, after post-operative deep wound infection can be successful with the benefit of less discomfort for the patient and greater ease of nursing care

The use of cervical pedicle screws as anchors in posterior reconstruction surgery has not been widely accepted due to the neurological or vascular injury. We thus sought to investigate the accuracy of free-handed pedicle screw placement in the cervical and upper thoracic spine at the early stage of clinical application. Eight patients (five males and three females) were included in this study. Mean age was 63 years (31 to 78 years). There were three patients with rheumatoid arthritis, three with cervical fracture-dislocation, and two with spinal metastasis. Twenty-four pedicle screws (3.5 mm diameter: Vertex, Medtronic Sofamordanek) were placed into the pedicle from C2 to T2 level by free-handed technique2). Grade of breaching of pedicle cortex was divided into four groups (Grade 0–3). In addition, screw axis angle (SAA) were calculated from the horizontal and sagittal CT images and compared with pedicle transverse angle (PTA). Furthermore, perioperative complications were also examined. Our free-handed pedicle screw placement with carving technique is as follows: A longitudinal gutter was created at the lamina-lateral mass junction and then transverse gutter perpendicular to the longitudinal gutter was made at the lateral notch of lateral mass. The entry point of the pedicle screw was on the midline of lateral mass. Medial pedicle cortex through the ventral lamina was identified using the probes to create the hole within the pedicle. The hole was tapped and the screw was gently introduced into the pedicle to ensure the sagittal trajectory using fluoroscopy. In the transverse direction, 22 out of 24 screws (92%) were entirely contained within the pedicle (Grade 0). In contrast, only teo screws (8%) produced breaches less than half the screw diameter (Grade 1). In the sagittal direction, all screws were within the pedicle (Grade 0). Screw trajectories were not consistent with anatomical pedicle axis angle; the mean SAA were smaller than the mean PTA at all levels. The pedicle diameter ranged from 3.9 to 9.2 mm. The mean value gradually increased toward the caudal level. There were no neurological and vascular complications related to screw placement

Purpose: Purpose of this study was to evaluate the results of elective lumbar spinal surgery as it relates to patient expectations for outcome and outcome as quantified by patient derived generic and disease specific measures.

Methods: Prospectively collected patient derived generic health status (SF-36) and disease specific outcome measures (Oswestry) were quantified in all patients prior to surgery, and at serial postoperative clinical follow-ups. Patient expectations for their surgery were also measured; (pain relief, sleep, recreational and daily activities of living, return to work). Postoperatively, patients completed a questionnaire regarding the results of their spinal surgery as it related to meeting their expectations. Multivariate analysis of variance was used to evaluate for factors that influenced the results of surgery relating to patient expectations.

Results: Between 1998 and 2002 one hundred and forty three consecutive patients were evaluated. Average age was 52 (range 18–84). Diagnosis was disc herniation 43%, spondylitic spondylolisthesis 10%, degenerative spondylolisthesis 30%, spondylosis 6%, other 11%. The mean preoperative SF-36 mental component and physical component scores were 42.1 and 22.3 respectively (1.2 and 3.4 standard deviations below age and gender matched norms). Postoperative SF-36 scores were 48.1 and 38.6. The mean Oswestry disability scores were 48.7% preoperatively vs. 23.1% postoperatively. 81% (116/143) had their expectations met. Of the 19% (27 patients) who did not meet their expectations, they reported lower preoperative SF-36 general health and vitality domain scores. Patients were also less likely to have their expectations met if they had prior lumbar surgery, were involved in worker compensation or litigation. Patients who reported either back or back > leg symptoms were less satisfied than patients who presented with predominantly leg symptoms.

Conclusions: Patient factors inclusive of mental, (as measured by general health perception and vitality), physical (predominance of leg vs back pain), and social (presence of compensation, litigation), all contribute to patient satisfaction and outcomes following lumbar spinal surgery for degenerative conditions.

Late wound infection is a recognised complication of instrumented spinal deformity surgery. In most cases it is a benign complication which usually resolves after implant removal. However, some of our patients with late infection developed a pseudoarthrosis.

To investigate this further we undertook a retrospective review of all patients undergoing implant removal for deep infection between 1991 and 2000.

Twenty-one patients were identified, representing a late infection rate of at least 6%. They showed no specific pre- or intra-operative risk factors. Nine had some problems with early post-operative wound healing, which settled with minimal treatment. Late infection presented as localised swelling or a discharging sinus between 4 and 84 months (average 31 months) post-surgery. Blood parameters were abnormal in 15 cases, frank infection demonstrated in 19 cases, loosening of the implant in four cases and positive bacteriology culture in 14 cases. Wounds healed within 2 to 17 weeks (average 5 weeks) following implant removal, wound debridement and antibiotic therapy lasting 2 to 20 weeks (average 6 weeks). This was delayed until one year post-surgery in the three cases presenting early. Follow-up of between 6 and 92 months (average 38 months) revealed no persistent infection. Pseudoarthrosis developed in seven patients (33%). Four of these patients had progressive deformity warranting refusion and three produced minimal symptoms. Patients developing a pseudoarthrosis had an excess of post-operative wound problems, presented much earlier and had more severe infections compared to those without sequelae.

Late infection is confirmed as a relatively common complication of scoliosis surgery. Implant removal, aggressive debridement and primary closure is confirmed as effective treatment to eradicate the infection. A high rate of pseudoarthrosis is the only sequelae. The excess of early infections in these cases may indicate interference with a critical stage of the fusion process. Preservation of the implants until one year post surgery was unsuccessful at preventing a pseudoarthrosis.

Adolescent idiopathic scoliosis (AIS) is a complex three-dimensional deformity of the spine characterized by a Cobb angle of at least 10 degrees. The goal of surgery is to not only prevent progression but restore sagittal and coronal balance, protecting cardiopulmonary function and improving cosmesis. We reviewed the impact of deformity correction surgery in terms of radiology and patient reported outcome(PROMs). The senior authors prospectively maintained database from 2003 –2022 was retrospectively analysed in terms of pre- and post-operative patient reported outcome measures (SRS 22) as well as radiological parameters. 44 patients with AIS were identified with pre and post op PROMS. The average age at surgery was 15yrs with 84% female. 38% had a Lenke 1 curve and 3 patients had Lenke 6 curves. 73% had posterior surgery. There was a total improvement in SRS 22 scores by 7.8%. Patients reported significant satisfaction with treatment 4.8/5 and improvement in self-image with a change of 0.4 (p<0.001). However, no difference in function, pain and mental health were recorded. Overall, proximal thoracic (PT) curves improved from 24 degrees to 11 degrees (p<0.001), Main thoracic (MT) curve 55 degrees to 19 degrees and Thoracolumbar/Lumbar curves (TL/L) 45 degreesto 11 degrees. Pre-operative flexibility and post-operative correction were 0.40 and 0.41 respectively for PT curve. MT was 0.32 and 0.67. That for TL/L was 0.57 and 0.71 respectively. Surgery yields significant main curve correction correlating with high patient reported satisfaction rate. Although total SRS 22 score yielded 7.8% improvement, sub-analysis of self-image showed the most significant improvement

Aims. Traditionally, acetabular component insertion during total hip arthroplasty (THA) is visually assisted in the posterior approach and fluoroscopically assisted in the anterior approach. The present study examined the accuracy of a new surgeon during anterior (NSA) and posterior (NSP) THA using robotic arm-assisted technology compared to two experienced surgeons using traditional methods. Methods. Prospectively collected data was reviewed for 120 patients at two institutions. Data were collected on the first 30 anterior approach and the first 30 posterior approach surgeries performed by a newly graduated arthroplasty surgeon (all using robotic arm-assisted technology) and was compared to standard THA by an experienced anterior (SSA) and posterior surgeon (SSP). Acetabular component inclination, version, and leg length were calculated postoperatively and differences calculated based on postoperative film measurement. Results. Demographic data were similar between groups with the exception of BMI being lower in the NSA group (27.98 vs 25.2; p = 0.005). Operating time and total time in operating room (TTOR) was lower in the SSA (p < 0.001) and TTOR was higher in the NSP group (p = 0.014). Planned versus postoperative leg length discrepancy were similar among both anterior and posterior surgeries (p > 0.104). Planned versus postoperative abduction and anteversion were similar among the NSA and SSA (p > 0.425), whereas planned versus postoperative abduction and anteversion were lower in the NSP (p < 0.001). Outliers > 10 mm from planned leg length were present in one case of the SSP and NSP, with none in the anterior groups. There were no outliers > 10° in anterior or posterior for abduction in all surgeons. The SSP had six outliers > 10° in anteversion while the NSP had none (p = 0.004); the SSA had no outliers for anteversion while the NSA had one (p = 0.500). Conclusion. Robotic arm-assisted technology allowed a newly trained surgeon to produce similarly accurate results and outcomes as experienced surgeons in anterior and posterior hip arthroplasty. Cite this article: Bone Jt Open 2021;2(6):365–370

Aims

Surgical approaches to cervical ossification of the posterior longitudinal ligament (OPLL) remain controversial. The purpose of the present study was to analyze and compare the long-term neurological recovery following anterior decompression with fusion (ADF) and posterior laminectomy and fusion with bone graft and internal fixation (PLF) based on > ten-year follow-up outcomes in a single centre.

Posterior spinal surgery is associated with a significant amount of blood loss. The factors predisposing the patient to excessive bleeding-and therefore transfusion- are not well established nor is the effect of transfusion on the outcomes following spinal surgery. We had two goals in this study. First, we were to investigate any suspected risk factors of transfusion in posterior thoraco-lumbar fusion patients. Second, we wanted to observe the negative impact-if one existed- of transfusion on the outcomes of surgery. All adults undergoing posterior thoraco-lumbar spine fusion in our institution from May 2015 to May 2018 were included. Data collected included demographic data as well as BMI, preoperative hemoglobin, American Society of Anesthesiologists classification (ASA), delta Hemoglobin, estimated blood loss, incidence of transfusion, number of units transfused, number of levels fused, length of stay and re-admission within 30 days. The data was analyzed to correlate these variables with the frequency of transfusion and then to assess the association of adverse outcomes with transfusion. 125 patients were included in the study. Only 6 patients (4.8%) required re-admission within the first 30 days after discharge. Length of stay averaged 8.4 days (3–74). 18 patients (14.4%) required transfusion peri-operatively. When multiple variables were analyzed for any correlation, the number of levels fused, age and BMI had statistically significant correlation with the need for transfusion (P <0.005). Patients undergoing posterior thoraco-lumbar fusion are more likely to require blood transfusion if they were older, over-weight & obese or had a multi-level fusion. Receiving blood transfusion is associated with increased complication rates

Management of complex posterior malleolar fractures requires a detailed appreciation of ligamentous and bony anatomy for optimal fracture fixation and restoration of articular congruency. Pre operative planning is vitally important to determine the surgical strategy for complex ankle fractures. We evaluated pre operative planning strategy pre and post implementation of BOAST 12 guidelines (2016) focussing on pre operative CT scans prior to definitive fixation at a major trauma centre. A multi-surgeon retrospective review of prospectively collected data from 2013 to 2018 was performed at a major trauma centre. Patients who had sustained a posterior malleolar fracture and definitive fixation were identified. Information was collated from PICS, PACS, the trauma database and operative notes. 134 patients were identified over a 5 year period who had sustained a posterior malleolar fracture and had definitive fixation. (Pre BOAST guidelines = 61, Post BOAST guidelines = 73). Prior to the implementation of BOAST guidelines ¼ with posterior malleolar fractures did not have a pre operative CT scan (15/61). Post implementation of BOAST 12 90% (66/73)patients with fixation of posterior malleolus fractures had a pre operative CT scan. Posterior malleolus surgery most commonly took place In patients between 18–30 years. Following implantation of BOAST 12 guidelines there was a 15% increase in pre operative CT scanning for ‘complex ankle fractures'. Changes in national guidelines have heavily influenced pre operative planning strategy for ankle fractures at University Hospitals Birmingham. A detailed appreciation of fracture pattern pre operatively helps guide surgical strategy

Introduction: Surgical treatment is indicated in Scheuermann’s disease with severe kyphotic deformity, and/or unremitting pain. Proximal or distal junctional kyphosis and loss of correction have been reported in the literature, due to short fusion level, overcorrection, or posterior only surgery with failure to release anterior tethering. We reviewed surgically treated Scheuermann’s kyphosis cases, to evaluate the factors affecting the sagittal balance. Methods and results: 35 cases (22 male, 13 female) of Scheuermann’s kyphosis were treated surgically in this centre during 1993–1999. Mean age at operation was 21.5 years (14–53 years). The kyphosis was high thoracic (Gennari Type I) in two cases, mid thoracic (Type II) in 11 cases, low thoracic or thoraco-lumbar (Type III) in eight cases, and whole thoracic (Type IV) in 14 cases. Mean pre-operative kyphosis (Cobb angle) was 81° (range 70° to 110°). Ten cases (mean kyphosis 77°) had one stage posterior operation only with segmental instrumentation. Twenty-five cases had combined anterior and posterior (A-P) surgery. Fifteen cases (mean kyphosis 81°) had one stage thoracoscopic release and posterior instrumentation, and 10 cases (mean kyphosis 89°) had open anterior release, followed by second stage posterior instrumentation. Minimum follow-up was 14 months (mean 45 months, range 14–140 months). The mean post-operative kyphosis was 47.2°. Kyphosis correction achieved ranged from 39% after posterior surgery only, to 42% after thoracoscopic A-P surgery, and 48% after open A-P surgery. Mean loss of correction was 12° after posterior only surgery, 9.5° after thoracoscopic A-P surgery, and 6° after open A-P surgery. Four cases of open A-P surgery had additional anterior cages to stabilise the kyphosis before posterior instrumentation; a mean 55% kyphosis correction was achieved in this group, and there was no loss of correction. Younger cases, under 25 years (n=16) had significantly better kyphosis correction (p< 0.05). Two cases (6%) developed distal junctional kyphosis due to fusion short of the first lordotic segment, requiring extension of fusion. Four cases (12%) developed proximal junctional kyphosis requiring extension of fusion; all of them had primary posterior surgery only. Location of the curve (Gennari Type) had no significant influence on the initial curve, degree of immediate correction, or loss of correction. Complications included infection (4 cases), pneumothorax (1 case), haemothorax (1 case), instrumentation failure (3 cases); 3 cases had persistent back pain. Conclusion: Combined anterior release and posterior surgery achieves and maintains better correction of Scheuermann’s kyphosis. Loss of correction, and proximal junctional kyphosis are more frequent after posterior surgery only, and short fusion. Use of cages anteriorly prevents loss of correction. Correction is better achieved in younger patients, but is not influenced by the location of the curve

Purpose of the study. To review the primary bone tumours of the spine treated at our unit. Description of methods. Retrospective review of folders and x-rays of all the patients with primary bone tumours of the spine treated at our unit between 2005 and 2012. All haematological tumours were excluded. Summary of results. We treated 15 cases during this period. The median age at presentation was 36 years (8–65). There was a significant delay from onset of symptoms to diagnosis in most cases (median 7 months). Histological diagnoses included:. -Benign tumours.  Active. Hemangioma. 3. Osteoid osteoma. 1. Eosinophilic granuloma. 1.  Aggressive. Osteoblastoma. 1. Giant cell tumours. 2. Aneurysmal bone cysts. 4. -Malignant tumours.  Osteosarcomas. 2.  Leiomyosarcoma of bone. 1. A variety of definitive surgical methods were utilised. Seven patients had a debulking or intralesional resection of the tumour. Eight patients had an attempted marginal excision. This was achieved through anterior surgery only in 1 case, posterior only surgery in 6 cases and combination anterior and posterior surgery in 8 cases. The anterior and posterior surgery was performed in a single sitting in 5 cases and in a staged fashion in 3 cases. Adjuvant radiotherapy and chemotherapy were used where indicated. Three cases presented with significant neurological impairment. Of these 2 made a significant recovery. There were no cases of neurological deterioration following surgery. All 3 patients with malignant tumours died in the follow up period. We had 1 case of hardware failure due to chronic sepsis. Conclusion. Primary bone tumours of the spine are associated with a significant delay in diagnosis. Surgical treatment options and adjuvant therapy should be tailor made for each case depending on the diagnosis. Acceptable results with minimal complications can be achieved with this approach

To compare the effect of intraoperative red cell salvage on blood transfusion and cost in patients undergoing idiopathic scoliosis surgery. Retrospective. 37 patients (36 females, 1 male) underwent scoliosis surgery from February 2007 to October 2008. Intraoperative red cell salvage (Group 1) was used. They were compared with 28 patients (23 females, 5 males) operated from January 2005 to December 2006 without the use of cell salvage (Group 2). 36 patients in group 1 had posterior surgery and 1 had anterior surgery. In Group 2, 20 patients had posterior surgery, 7 anterior and 1 patient had anterior and posterior surgery. Both groups were comparable for age, number of levels fused, preoperative haemoglobin and haematocrit values. Amount of perioperative blood transfusion, costs. 14 patients (50%) in group 2 had blood transfusion whereas only 6 (16%) were transfused blood in group 1. Average blood loss in group 1 was 1076 mls (range 315-3000) and 1626mls (419-4275) in group 2. An average of 2 units of packed red blood cells per patient was processed by the cell salvage system. Postoperative haemoglobin, haematocrit and hospital stay were comparable in both groups. Cost analysis shows the use of cell salvage is cost beneficial by £116.60 per case. The use of red blood cell salvage reduces the amount of blood transfusion and is cost beneficial