Introduction. Patients with metastatic spinal cord compression (MSCC) or unstable spinal lesions warrant early surgical consultation. In multiple myeloma, chemotherapy and radiotherapy have the potential to decompress the spinal canal effectively in the presence of epidural lesions. Mechanical stability conferred by bracing may potentiate intraosseous and extraosseous bone formation, thus increasing spinal stability. This study aims to review the role of non-operative management in myeloma patients with a high degree of spinal instability, in a specialist tertiary centre. Methods. Retrospective analysis of a prospectively collected database of 83 patients with unstable myelomatous lesions of the spine, defined by a Spinal Instability Neoplastic Score (SINS) of 13–18. Data collected include patient demographics, systemic treatment, neurological status, radiological presence of cord compression, most unstable vertebral level and presence of intraosseous and extraosseous bone formation. Post-treatment scores were calculated based on follow-up imaging which was carried out at 2 weeks for cord compression and 12 weeks for spinal instability. A paired t-test was used to identify any significant difference between pre- and post-treatment SINS and linear regression was used to assess the association between variables and the change in SINS. Results. A significant reduction in SINS was observed from a pre-treatment average score of 14 to a score of 9, following treatment for myeloma (p<0.001). A higher initial score and a younger age were associated with a larger overall reduction in SINS (p<0.001 and p=0.02 respectively). No single variable (bisphosphates, chemotherapy, radiotherapy and steroids) had a significant association with SINS reduction. 25 (30%) patients had spinal cord compression, all of which showed radiological resolution of cord compression at 2 weeks. No patients developed neurological deterioration during treatment and all patients had an improvement in their pain scores. 64 (77%) patients had evidence of intraosseous and/or extraosseous bone formation on their follow-up scan. Conclusion. Non-operative management in the form of bracing and systemic therapy is a safe and effective treatment for spinal instability and spinal cord compression in myeloma. Treatment of unstable myelomatous lesions of the spine with or without cord compression should not follow traditional guidelines for MSCC. The decision to adopt a non-operative approach in this cohort of patients should ideally be made in a tertiary centre with expertise in multiple myeloma and in a multidisciplinary setting

The evaluation of the lumbar spine by CT or MR in supine position provides excellent information about the morphology of the spinal structures (inside and outside the spinal canal) but of course cannot give dynamic information. By Newton’s Third Law we know that every axial vector acting on a functional spine unit corresponds a second vector of equal intensity but of opposite direction that counterbalances the first one and brings all the structures in a dynamic equilibrium. The definition of spinal instability by White and Panjabi is well known and X-ray plain film with dynamic testing is not always satisfactory for diagnosis. From April 2003 through May 2004 we evaluated 45 patients with with a dedicated device able to produce an axial load on the patient with a dynamometer to measure the load applied. The study can be performed in all patients in whom spinal instability is clinically suspected, even if the patients underwent spine surgery. The study was performed by CT or MR but always before in rest and stress conditions. The applied load is 60–70 % of body weight, based on literature data regarding orthostatic load at the L3 S1 level. A spiral multi-slice acquisition technique must be used to obtain thin scans with which excellent 2D multiplanar (MPR) and 3D reconstructions can then be achieved. Under normal conditions, under an axial loader, we do not see significant changes in spine morphology except for pseudo-protrusion of the disks. In pathologic conditions (38 patients) we must pay attention to the following: disc modifications (appearance or disappearance of vacuum phenomenon, volumetric increasing/appearance of protrusions or herniations); intersomatic findings (increment of the lysthesis, narrowing or widening of disc space, rotational movements, posterior translation of the vertebral body); interarticular joints modifications and neural foramina narrowing; and thickening of the ligamenta flava and narrowing of interspinous spaces and hypermobility of the spinous process. We believe the CT/MR axial loader currently represents the only way to gain dynamic information in patients in whom spinal instability is clinically suspected

Introduction: We hypothesise that disc degeneration is a major cause of segmental instability in elderly spines. Accordingly, we simulated two mechanical features of disc degeneration on cadaveric spines, and measured their effects on spinal movements. Methods: Twenty-one motion segments (T8–9 to L4–5) were obtained from spines aged 48–90yrs. Specimens were loaded rapidly to simulate full spinal bending movements in vivo, while vertebral movements were tracked using an optical MacReflex system. Intradiscal stresses were investigated using “stress profilometry”. Experiments were repeated following compressive creep loading (which reduced disc water content by an amount similar to the aging process) and again following a compressive overload cycle which fractured a vertebral endplate and decompressed the nucleus. MacReflex data were used to quantify the neutral-zone (NZ), the range of motion (ROM), and the range of translational (gliding) movements. Results Creep and endplate fracture both reduced disc height, and generated stress concentrations within the posterior annulus. Both treatments increased NZ, ROM and translational movements in flexion and lateral bending, but not in extension. Endplate fracture markedly increased the “instability index” (NZ/ROM) in flexion. Discussion Disc “degeneration” increased all measures of spinal instability during flexion and lateral bending. Disc decompression in particular created a large NZ in which the spine had negligible resistance to bending. In life, muscle action would prevent the spine “wobbling” within this range of movement. Results in extension suggest impaction between the neural arches. Back pain associated with spinal instability could arise from stress concentrations in the annulus and neural arches, or from abnormal muscle activity

The aim of this study was to assess the use of early ambulatory halo-thoracic immobilisation in paediatric patients with spinal instability. The case notes, radiographs and clinical findings at follow-up of 12 patients treated this way were reviewed. The mean age was 8.6 years (4 to 16). The aetiology was trauma in six, os odontoidium in one, tuberculosis in three, and Morquios syndrome and chronic granulomatous osteitis in one each. The instabilities were atlanto-axial rotatory subluxation in one patient, transverse ligament rupture in six, dens anomalies in two, anterior destruction by tuberculosis in two, and a dens fracture. The halo jackets were applied under general anaesthetic. In addition, posterior C1/2 fusions were performed in seven patients, posterior occipitocervical decompression and fusions in two, and posterolateral thoracotomies in two. No surgery was done on the patient with the dens fracture. Autograft was used in all cases except one posterior C1/2 fusion. This patient, who was HIV-positive, was the only one in whom union did not occur. There was one case of minor pin-tract sepsis. All patients mobilised in the halo jacket and, where possible, were managed as outpatients. Despite radiological nonunion in one patient, spinal stability was achieved in all. Early ambulatory halo jacket immobilisation is a useful, safe and well-tolerated technique in the paediatric patient group

Introduction: Wide laminectomy has been the accepted treatment of choice for stenosis in the lumbar spine. Recently, bilateral laminotomy has been proposed as an alternative decompressive technique for spinal canal stenosis. There have been no biomechanical studies to determine the in vitro difference in stability between these techniques. Objective: To determine the in vitro difference in stability in a functional spinal unit (FSU) following bilateral laminotomy, and compare it to the instability resulting from laminectomy. Methods: Six fresh human cadaver lumbar spines were injured sequentially at the L4-5 level: bilateral laminotomy and laminectomy. The normal and injured spines were subjected to flexion, extension, lateral bending and torsional moments. The three-dimensional motion behaviour of each spine before and after the two injuries was recorded using a magnetic motion sensor. The data from all five spines was pooled for statistical analysis. Results: With flexion and extension loading, bilateral laminotomy induced significantly less sagittal angulation and translation in the FSU than did laminectomy. Significant increases in coronal translation occurred with laminectomy in spines subjected to lateral bending loads. There were no significant differences between the two techniques in coronal plane angulation with lateral bending loads and torsional loads. Discussion: Adequate exposure of the lateral recesses requires limited medial facetectomy with both laminotomy and laminectomy. With laminotomy, the lamina and posterior ligamentous structures are preserved. This is aimed at decreasing the potential late development of spinal instability associated with laminectomy. The increase in motion seen with laminectomy in sagittal angulation / translation, and coronal translation in this in vitro model, may represent clinical instability, and may be responsible for continued symptomatology in these patients. Preservation of the lamina, spinous processes, and the posterior ligamentous structures significantly enhances the biomechanical stability of the FSU

A 22-year-old man was admitted to hospital after being assaulted. He complained of a painful neck and upper limbs, with weakness and numbness of his upper limbs.

Initial treatment was skull traction for six weeks, during which the motor power in the upper limbs recovered. CT scan of the cervical spine showed a lytic expanding bone lesion in the atlas. At 10 weeks he was transferred to a Spinal Centre, walking normally, with good bladder and bowel control. He was complaining of intermittent occipital headaches and pain at the cervicothoracic junction. He was wearing a cervical orthosis. His neck movements were guarded and markedly restricted. No neurological deficit was detected. A right-sided brachiocephalic artery angiogram showed no abnormality. MR scan showed definite narrowing of the spinal canal at the C2 vertebral level and stress studies some vertebral instability at the atlanto-axial level. Under general anaesthetic a transoral biopsy, curettage, and bone grafting of the atlas was carried out. The biopsy material comprised white membranous-type material, which had the histological features of hydatid cysts. A posterior spinal fusion with instrumentation was performed over posterior vertebral arches Cl to C3. Postoperatively ultrasound of the abdomen and radiograph of the chest did not reveal any further evidence of hydatid disease. Treatment with albendazole was commenced. The diagnosis was not anticipated preoperatively.

Objective: To determine the in vitro difference in stability in a functional spinal unit (FSU) following bilateral laminotomy, and compare it to the instability resulting from laminectomy.

Design: The normal and injured spines were subjected to flexion, extension, lateral bending and torsional moments.

Subjects: Six fresh human cadaver lumbar spines were injured sequentially at the L4–5 level: bilateral laminotomy and laminectomy.

Outcome measures: The three-dimensional motion behaviour of each spine before and after the two injuries was recorded using a magnetic motion sensor. The data from all five spines was pooled for statistical analysis.

Results: With flexion and extension loading, bilateral laminotomy induced significantly less sagittal angulation and translation in the FSU than did laminectomy. Significant increase in coronal translation occurred with laminectomy in spines subjected to lateral bending loads. There were no significant differences between the two techniques in coronal plane angulation with lateral bending loads and torsional loads.

Conclusion: The increase in motion seen with laminectomy in sagittal angulation/translation, and coronal translation in this in vitro model may represent clinical instability, and may be responsible for continued symptomatology in these patients. Preservation of the lamina, spinous processes, and the posterior ligamentous structures significantly enhances the biomechanical stability of the FSU.

Background. It has become increasingly important to conduct studies assessing clinical outcomes, reoperation rates, and revision rates to better define the indications and efficacy of lumbar spinal procedures and its association with symptomatic adjacent segment degeneration (sASD). Adjacent segment degeneration (ASD) is defined as the radiographic change in the intervertebral discs adjacent to the surgically treated spinal level. SASD represents adjacent segment degeneration which causes pain or numbness due to post-operative spinal instability or nerve compression at the same level. The most common reason for early reoperation and late operation is sASD, therefore is in our best interest to understand the causes of ASD and make steps to limit the occurrence. Method. A comprehensive literature search was performed selecting Randomized controlled trials (RCTs) and retrospective or prospective studies published up to December 2023. Meta-analysis was performed on 38 studies that met the inclusion criteria and included data of clinical outcomes of patients who had degenerative disc disease, disc herniation, radiculopathy, and spondylolisthesis and underwent lumbar fusion or motion-preservation device surgery; and reported on the prevalence of ASD, sASD, reoperation rate, visual analogue score (VAS), and Oswestry disability index (ODI) improvement. Results. When compared to fusion surgery, a significant reduction of ASD, sASD and reoperation was observed in the cohort of patients that underwent motion-preserving surgery. Conclusion. Dynamic fusion constructs are treatment options that may help to prevent sASD. Conflicts of interest. This research was funded by Paradigm Spine. Sources of funding. Paradigm Spine

Lumbar diseases have become a major problem affecting human health worldwide. Conservative treatment of lumbar diseases is difficult to achieve ideal results, and surgical treatment of trauma, complications, it is imperative to develop a new treatment method. This study aims to explore the regulatory mechanism of cartilage endplate ossification caused by abnormal stress, and design intervention targets for this mechanism, so as to provide theoretical reference for the prevention and treatment of lumbar degeneration. In vivo, we constructed spinal instability model in mice. In vitro, we used a mechanical tensile machine to simulate the abnormal stress conditions of the endplate cartilage cells. Through the high-throughput sequencing, we found the enrichment of Hippo signaling pathway. As YAP is a key protein in the Hippo signaling pathway, we then created cartilaginous YAP elimination mice (Col2::YAPfl/fl). The lumbar spine model was constructed again in these mice for H&E, SOFG and immunofluorescence staining. In vitro lentivirus was used to knock out YAP, immunofluorescence staining, WB and qPCR were performed. Finally, we conducted therapeutic experiments by using YAP agonist and AAV5 carrying YAP plasmids. We collected 8w samples from C57/BL6 mice after modeling. We found ossification of the endplate in mice similar to human disc degeneration. High-throughput sequencing of stretched cells demonstrated high enrichment of the Hippo signaling pathway. By immunofluorescence staining, it was confirmed that Col-II decreased and Col-X gradually increased in the endplate cartilage of mice. This was also confirmed at 7 days after an in vitro stretch of 5% and 12%. Meanwhile, we found that cartilaginous YAP elimination mice developed very severe endplate degeneration. However, the endplate was well protected by intraperitoneal injection of YAP agonist or AAV5-YAP endplate injection, and the results in vitro were consistent with that. In the process of cartilaginous ossification, abnormal stress regulates Col10a1 to promote cartilage endplate ossification through Hippo signaling pathway mediated YAP, and we expect to find potential drug targets for treatment through this mechanism

Background. Current clinical treatment for spinal instability requires invasive spinal fusion with cages and screw instrumentation. We previously reported a novel injectable hydrogel (Bgel), which supports the delivery and differentiation of mesenchymal stem cells (MSCs) to bone forming cells and supports bone formation in vivo. Here, we investigated whether this system could be utilised to induce bone formation within intervertebral disc tissue as a potential injectable spinal fusion approach. Methodology. Bovine and Human Nucleus pulpous tissue explants were injected with Bgel with and without MSCs. Tissue samples were cultured under hypoxia (5%) in standard culture media for 4 weeks. Cell viability, histological assessment of matrix deposition, calcium formation, and cell phenotype analysis using immunohistochemistry for NP matrix and bone markers. Results. Following injection of B-gel into tissue explants following culture for 4 weeks, cells were visualized within the regions of the B-gel. Demonstrating that native cells were able to migrate into regions of B-gel. Increased collagen deposition was seen in tissue explants injected with Bgel, with increased collagen type I and X but decreased collagen type II staining in explants injected with Bgel. Tissue explants, in the absence of Bgel, showed limited calcium deposition, which was increased in B-gel injected explants. Furthermore, disc cells increased expression of bone markers (alkaline phosphatase & osteocalcin), but decreased NP matrix (Aggrecan and Collagen type II) following Bgel injection. Conclusion. This system could have potential to support spinal fusion via direct injection into the disc. Conflict of interest: C Le Maitre & C Sammon are inventors on the hydrogel discussed. Funding: This work was funded by GrowMed Tech Proof of Concept funding

Aim. This study seeks to outline the clinical, laboratory, and imaging features of patients with pyogenic spondylitis. It aims to define a novel imaging sign that could indicate the severity of suppurative spondylitis, aiding in its early diagnosis and treatment. Method. This retrospective study included 137 patients from 2013 to 2023. Through the analysis and summary of imaging characteristics among all patients, we identified a distinct MRI sign known as ‘the Disc Penetration sign’ (DP). This sign is defined as an image finding on sagittal MRI depicting the anterior and posterior penetration of an abscess through the intervertebral disc space, affecting both the anterior margin of the vertebrae and the structures within the spinal canal. Observational parameters included WBC, ESR, CRP, hemoglobin, and albumin levels. Documentation of the study included location and segment of the lesion, presence or absence of spinal cord compression, and paravertebral abscesses. Results. 56 patients presented with the Disc Penetration sign(DP) and 81 did not. In both groups, there were no significant differences in gender ratio or age (P > 0.05). However, significant differences were observed in the presence of comorbid diabetes and chronic kidney disease (p < 0.05). The DP group had a significantly greater ESR level (74.30±33.79 mm/h vs. 51.46±30.46 mm/h, P < 0.001) and CRP level (47.28 mg/L vs. 26.18 mg/L, P = 0.003). Additionally, the DP group had a significantly lower Hb (100.66±19.82 g/L vs. 116.99±19.99g/L,P < 0.001) and the serum albumin level (28.81±6.59 g/L vs. 34.09±6.17 g/L,P < 0.001). Imaging results showed no significant differences in affected spinal segments or parts (p>0.05). Patients in the DP group showed a higher likelihood of developing paravertebral abscesses compared to those in the non-DP group (n = 54 [96.4%] vs. n = 33 [40.7%], P < 0.001), and also exhibited a higher incidence of spinal cord compression(n = 32 [57.1%] vs. n = 17 [21.0%], P < 0.001). Conclusions. The study suggests that the Disc Penetration sign in pyogenic spondylitis patients correlates with more severe inflammation and higher incidence of paraspinal abscess, pointing to worse stability of the spine, longer bone restructuring time, and potentially poorer prognosis. These findings enable clinicians to rapidly assess the severity of the disease and prognosticate outcomes more effectively We emphasize the need for early, pathogen-specific diagnosis and treatment, particularly considering surgical intervention for patients demonstrating substantial paraspinal abscesses or spinal instability

Introduction. Spine is a common site for haematological malignancies. Multiple myeloma affects the spine in 70% of cases. New guidelines were published in 2015 to help manage spinal haematological malignancies. Despite neural compression or spinal instability, instrumentation of the spine should be avoided. Surgery carries significant risks of wound complications and more importantly delaying the definitive chemotherapy and radiotherapy. Cement augmentation and bracing for pain and prevention of deformity is key to the new strategies. We aimed to evaluate the different treatment modalities adopted in the spine unit at St George's hospital for spinal haematological malignancies. We compared our practice to the current guidelines published in 2015. Methods. Retrospective review of all spinal haematological malignancy patients who were discussed in the spinal MDT and managed through the spine unit at St George's hospital in the period between April 2019 and February 2021. We analysed the demographics of the patients treated in this period and compared the management modalities adopted in the unit to the current British haematological guidelines. Results. 139 patients were included in this study, 61.9% of them were male. 70 cases came through the MSCC pathway. 15 patients had their spinal involvement in the lumbar spine only below the conus. The Bilsky Grades of the other 124 cases were B0: 35.97 % 1a: 4.31%%, 1b: 7.19%, 1c: 3.59%, 2: 5.75% 3: 32.37%. 43 patients (30.9 %) had neurological deficits on presentation. 70 cases were treated conservatively (50.35%), 21 were treated with brace only (15.1%), 25 had BKP (17.98%) and 23 were treated with instrumentation (16.54%). The number of instrumented cases was small and trending down and cement augmentation and bracing were more frequently chosen for these patients. This comes in accordance to the British haematological guidelines. Conclusion. Utilising BJH 2015 guidelines we have reduced our instrumented operative case load. There is a higher percentage of BKP and Bracing in accordance to the algorithm

Previous studies have shown improved outcome following surgery for spinal cord compression due to metastatic disease. Further papers have shown that many patients with metastatic disease are not referred for orthopaedic opinion. The aims of this paper are to study the survival and morbidity of patients with spinal metastatic disease who receive radiotherapy. Do patients develop instability and progressive neurological compromise? Can we predict which patients will benefit from surgery?. Retrospective review of patients receiving radiotherapy for pain relief or cord compression as a result of metastatic disease. Patients were scored with regards to Tomita and Tokuhashi, survival and for deterioration in neurology or spinal instability. 94 patients reviewed. All patients were followed up for a minimum of 1 year or until deceased. Majority of patients had a primary diagnosis of lung, prostate or breast carcinoma. Mean Tomita score of 6, Tokuhashi score 7, and mean survival following radiotherapy of 8 months. 11:94 patients referred for surgical opinion. Poor correlation with Tomita scores (-0.25) & Tokuhashi scores (0.24) to predict survival. Four patients developed progressive neurology on follow-up. One patient developed spinal instability. The remainder of the patients did not deteriorate in neurology and did not develop spinal instability. All patients with normal neurology at time of radiotherapy did not develop spinal cord compression or cauda equina at a later date. This study suggests that the vast majority of patients with spinal metastatic disease do not progress to spinal instability or cord compression, and that prophylactic surgery would not be of benefit. The predictive scoring systems remain unreliable making it difficult to select those patients who would benefit. The referral rate to spinal surgeons remains low as few patients under the care of the oncologists develop spinal complications

Previous studies have shown improved outcome following surgery for spinal cord compression due to metastatic disease. Further papers have shown that many patients with metastatic disease are not referred for orthopaedic opinion. The aims of this paper are to study the survival and morbidity of patients with spinal metastatic disease who receive radiotherapy. Do patients develop instability and progressive neurological compromise?. Do patients require surgery or are the majority adequately treated by oncologists?. Review of patients receiving radiotherapy for pain relief or cord compression as a result of metastatic disease. Patients were scored with regards to Tomita and Tokuhashi, survival and for deterioration in neurology or spinal instability. 94 patients reviewed. All patients were followed up for a minimum of 1 year or until deceased. Majority of patients had a primary diagnosis of lung, prostate or breast carcinoma. Mean Tomita score of 6, Tokuhashi score 7, and mean survival following radiotherapy of 8 months. 11:94 patients referred for surgical opinion. Four patients developed progressive neurology on follow-up. One patient developed spinal instability. The remainder of the patients did not deteriorate in neurology and did not develop spinal instability. All patients with normal neurology at time of radiotherapy did not develop spinal cord compression or cauda equina at a later date. This study suggests that the vast majority of patients with spinal metastatic disease do not progress to spinal instability or cord compression, and that prophylactic surgery would not be of benefit. The referral rate to spinal surgeons remains low as few patients under the care of the oncologists develop spinal complications

National Institute of Clinical Excellence guidelines on Metastatic Spinal Cord Compression recommend urgent consideration of patients with spinal metastases and imaging evidence of structural spinal failure with spinal instability for surgery to stabilise the spine and prevent Metastatic Spinal Cord Compression. We aimed to compare neurological outcomes of patients managed operatively and non-operatively. Prospective collection of 397 patients' data over a 4-year period. Males represented 59.2% of patients. Median age was 69 years. Non-operative intervention in 62.2% of patients. Prostate, lung, Breast, Myeloma, Renal Cell Carcinoma and Lymphoma accounted for over 75% of all primary tumours (n=305). Median Length of hospital stay was longer in the operative group of 15 days compared to 10 days in the non-operative group (p<0.0001). Patients who were ambulating on presentation maintained their ambulation in 70.2% of cases in the operative group compared to 90.9% in the non-operative group (p<0.0001). However, upon discharge 41% of patients managed operatively were ambulatory compared to the non-operative group rate of 36.5% (p<0.0001). In Prostate, Breast, Myeloma, RCC and Lymphoma 100% of patients managed non-operatively maintained ambulation. Lung primaries managed operatively had an 80% chance of maintaining ambulation compared to 76.9% in the non-operative group (p<0.05). A higher proportion of patients managed non-operatively maintained ambulation than those managed operatively. With operative intervention, more patients regained ambulatory status. Whilst we have mainly focused on ambulatory status in this paper there are other factors to consider including pain relief and spinal stability which may be an indication for surgical intervention

Purpose of study:. The question of prolonged bracing following injury in patients diagnosed with SCIWORA remains controversial. Proponents of the ‘Segmental Spinal Instability’ hypothesis claim that there is occult ligamentous injury leading to instability and a risk of recurrent injury. Published reports of recurrent SCIWORA involve patients with minor, transient neurological symptoms and normal MRI findings. The contradicting ‘differential stretch hypothesis’ is based on the premise that the spinal column will deform elastically, exceeding the elastic deforming potential of the more fragile spinal cord, but will return to its baseline stability. The purpose of this study is to evaluate the need for bracing in patients with SCIWORA based on MRI evidence of instability. Methods:. A retrospective chart review was performed for a series of eleven patients with documented SCIWORA that presented to Red Cross Children's Hospital over the past 8 years. Details regarding mode of injury, age at presentation, neurological deficit at presentation, MRI findings and long term prognosis were documented. MRI's were reviewed by the authors as well as a consultant radiologist. Results:. There were 9 males and 2 females. The average age was 4.5 years. All patients were victims of motor vehicle accidents and had multiple injuries. Five patients had cervical, five thoracic and one had both cervical and thoracic injuries. There were 1 monoplegia, 4 hemiplegias, 3 paraplegias and 3 triplegias. None of the MRIs performed on these patients demonstrated ligamentous or bony injury. Patients with only T2 changes demonstrated progressive neurological recovery within a few months following injury. There were no recurrences and none of the patients were braced following the diagnosis of SCIWORA. Conclusion:. Our results from this small series support the ‘differential stretch hypothesis’ and we maintain that patient's with SCIWORA does not demonstrate spinal instability and therefore does not require bracing following injury

Aims

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

Aims

Advances in treatment have extended the life expectancy of patients with metastatic bone disease (MBD). Patients could experience more skeletal-related events (SREs) as a result of this progress. Those who have already experienced a SRE could encounter another local management for a subsequent SRE, which is not part of the treatment for the initial SRE. However, there is a noted gap in research on the rate and characteristics of subsequent SREs requiring further localized treatment, obligating clinicians to extrapolate from experiences with initial SREs when confronting subsequent ones. This study aimed to investigate the proportion of MBD patients developing subsequent SREs requiring local treatment, examine if there are prognostic differences at the initial treatment between those with single versus subsequent SREs, and determine if clinical, oncological, and prognostic features differ between initial and subsequent SRE treatments.

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Cite this article: Bone Joint J 2023;105-B(4):347–355.

Aims

Implant-related postoperative spondylodiscitis (IPOS) is a severe complication in spine surgery and is associated with high morbidity and mortality. With growing knowledge in the field of periprosthetic joint infection (PJI), equivalent investigations towards the management of implant-related infections of the spine are indispensable. To our knowledge, this study provides the largest description of cases of IPOS to date.