Purposes: To determine the effect of gravity on outcome in sacral epidurals injected in the prone compared to the lateral position in patients with unilateral back related leg pain.

Methods: A randomised controlled trial with 2 arms. This pilot study was conducted to determine the standard deviation (SD) of the primary outcome measure to allow calculation of a final sample size. Forty patients who met the inclusion/exclusion criteria were randomly allocated to prone or lateral sacral epidural injection. Twenty patients were allocated to the prone and 20 to the left or right lateral position dependent on their radicular back pain. The primary outcome measure of back and leg pain severity was assessed using a visual analogue scale (VAS) (0= none, 10 = worst imaginable). The Oswestry disability index, SF-36 and straight leg raise were also measured. Outcomes were assessed at baseline and at 6 and 12 week follow-up. A repeated measures analysis using mixed model methodology was used to determine statistical significance.

Results: The 2 groups were comparable in gender and age. The prone group had a mean improvement in VAS back pain score at 6 weeks follow-up of 0.5 compared to 1.6 in the lateral group. At 12 weeks follow-up there was a negative response of 0.1 compared to baseline in the prone group and 1.4 improvement in the lateral group. Repeated measures analysis showed no significant difference in back pain scores between the groups at the 5% level (F2,38 = 3.24; P = 0.0797). Similarly mean improvement in VAS leg pain scores at 6 weeks follow-up were 1.4 in the prone group and 1.7 in the lateral group. At 12 weeks follow-up the scores were 1.1 for the prone and 2.4 for the lateral group. Repeated measures analysis showed no significant difference in leg pain scores between the groups (F1,38= 0.76; P = 0.3898). A post-hoc power calculation using the sample VAS SD showed we had reached only 65% power.

Conclusion: This pilot study has shown that sacral epidural injection for sciatica in the lateral position gives superior pain relief compared to the prone position but the difference is not statistically significant. More patients will now be recruited in order to minimise a type II error that may have occurred.

Introduction: Spinal deformities (scoliosis, kyphosis or kyphoscoliosis) in children under 10 years of age result from congenital, neuromuscular and idiopathic etiologies. The progression of the deformity is affected by its nature, location and age of onset. Spinal arthrodesis is the procedure of choice in patients with progressive deformities. The use of instrumentation facilitates curve correction and arthrodesis rates. Pediatric spinal surgery is technically demanding, and is still considered controversial. The advent of reduced size spinal instrumentation allowed surgeons to expand their use to pediatric patients. The use of spinal instrumentation in children with various spinal deformities has not been well documented.

Objective: To assess the safety and efficacy of spinal arthrodesis in young patients with progressive spinal deformities.

Patients and Methods: We retrospectively reviewed the medical charts and radiographs of 25 patients younger than 10 years of age who underwent corrective surgery for various spinal deformities. Radiographic outcome, fusion rates and complication were compared between instrumented and non instrumented patients.

Results: At two years of follow up instrumented corrective procedures resulted in superior correction compared to non-instrumented patients and in solid arthrodesis in all. Complications were infrequent.

Conclusions: The use of reduced size spinal instrumentation in young patients with progressive spinal deformities is safe and effective. Curve correction, length of bracing and fusion rates are all in favour of instrumentation, wile complication rates are acceptable. The use of spinal instrumentation in young patients requires expertise and patience.

Purpose: To describe the role of osteotomies in rigid spinal deformities

Patients and Methods: One hundred fifty six patients with spinal deformities undergoing surgery between March 1998 and August 2005 were identified from our spine registry. Our study cohort included 23 cases where osteotomies were performed for correction.

Corrective osteotomies were one of: 1) wedge osteotomy convex based; 2) wedge osteotomy dorsally based; 3) complex wedge or eggshell osteotomy for combined frontal and sagittal plane deformity. Patient’s demographics, type of deformity, underlying conditions, operative results, complications, and need for secondary procedures were documented.

Results: Twenty three patients (15%) with rigid curves underwent osteotomies as part of their corrective surgery. Mean age in this cohort was 11.3 years (2–26), 35% were males, 65% females. In 17 of the patients the main deformity was scoliosis, in 5 – kyphosis and in – 1 lordosis. MMC was the leading underlying condition in 4 cases, followed by VACTER syndrome (2), congenital myopathy (2), arthrogryposis and pterygium (2), Neuro-blastoma (1) and other congenital conditions. Operative results were satisfactory in terms of cosmetics, alignment and function. In 3 cases (13%) complications were encountered, with 2 infections requiring debridement, (one requiring hardware removal) and 1 Neurofibromatosis patient undergoing her 8^th surgical procedure, developing an intraoperative partial neurological injury with nearly full recovery.

Conclusions: Osteotomies are an important part of surgery in rigid spinal deformities. These deformities occur frequently in syndromatic children making peri-operative treatment more complex. Osteotomies facilitate better outcome in terms of correction, sagittal and coronal balance and cosmetics. These procedures are highly demanding technically. However, it is our opinion that adequate correction of rigid deformity with the benefit of spinal column shortening by way of osteotomy, is protective from significant neurological traction injuries that otherwise may occur.

Study Design: Prospective Cohort study.

Objective: To prospectively evaluate the Maverick Lumbar Disc Prosthesis (Medtronic, USA) at one year follow-up.

Methods: Prospective analysis of the Maverick Lumbar Disc Prosthesis implanted in the first 30 consecutive patients for the treatment of single-level degenerative disc disease of the lumbar spine resistant to conservative treatment for more than one year.

Subjects: Sixteen females and 14 males with an average age of 44 years and minimum follow-up of 1 year. The prosthesis was implanted at L4-L5 in 18 patients and at L5-S1 in 12.

Outcome Measures: Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) preoperatively and at routine scheduled follow-ups. Radiographic analysis included sagittal balance parameters on standing full length lateral radiographs of the spine and range of motion on flexion/extension dynamic radiographs.

Results: Clinical success (ODI improvement > 15), was 82% and 86%, at 6 months and one year follow-up respectively. The VAS showed an improvement in back pain from 7.1 (+/− 2) pre-operatively to 3.0 (+/− 1.8) post-operatively. At one year there were no device related complications. The measured range of motion in flexion-extension ranged from 3 to 12 degrees (mean range of motion, 6 +/− 4 degrees). There was no significant change in sacral tilt, pelvic tilt, or overall lordosis after disc replacement. In one case the ureter was injured during the approach.

Conclusions: The results of total disc arthroplasty presented here compare favourably with results reported in the literature following ALIF. It appears that the disc prosthesis has enough freedom of motion to allow the patient to maintain normal sagittal and spino-pelvic balance with radiographic evidence of normal range of motion. These early favourable clinical results and the influence on adjacent motion segments can be assessed only after long term follow-up.

Object: To study the incidence, etiology and management of patients with neuralgia following Posterior Lumbar Interbody Fusion (PLIF).

Design: A prospective study of 216 patients undergoing PLIF surgery from March 1996 to August 2003.

Subjects: 16 of the 225 patients (7.1%) undergoing PLIF surgery developed new leg pain following surgery.

Results In all patients, the distribution of the postoperative pain was different than the pre-operative pain. Nerve swelling with relative stenosis was the most common cause (9/16), followed by pedicular screw misplacement (2/16), nerve anomaly (2/16), loose posterior arch (2/16), and graft subsidence (1/16).

Nine patients with nerve swelling complained of pain with no neurological findings. One responded to a root block and 6 to re-exploration and further decompression. The patients with misplaced screws woke up from surgery with pain and neurology. The pain responded to removal of screws in both. Two patients with loose posterior arches complained of leg pain while lying down only. These symptoms disappeared after excision of the arches. In 2 patients conjoint roots were found intra-operatively. Both developed post operative pain, which settled down in one. In one patient subsidence of an iliac graft caused pain a few months following surgery and did not respond to further decompression.

Discussion: The overall incidence of post PLIF neuralgia was 7.1%, however by removing the whole facet, as performed in the last 122 patients, the incidence reduced from 9.7% (first 103 patients) to 4.9%. Based on our data we propose a classification system for Post PLIF Neuralgia, and a management plan. Using both, 11 of the 16 patients reported their leg pain disappeared, leaving only 5 patients with residual leg pain (< 3%). Key-stones in avoiding post PLIF neuralgia are generous decompression of the nerve roots, especially the lateral recess above the disc, total facetectomy and removal of graft pieces before closure.

Introduction: Vertebroplasty is an established minimally invasive technique, which provides consistent and sustained pain relief in patients with vertebral fractures. However cement extrusion remains a major problem and has been reported to occur in up to 70% of the cases in some reports. Cement extravasations may occur through the Basivertebral vein, the Segmental vein or through cortical defects. Cement leakage may be Epidural, Anterior, Para-vertebral, Intra-discal or distant. Most often cement leakage is asymptomatic but on occasion it may be a serious complication in the form of Cord compression, pulmonary embolism or Neuralgia.

The incidence of cement leakage can be reduced by the use of high viscosity cement, use of a low pressure injection system, injecting small volumes at each level, introducing the cement under visualization and waiting for cement to set before withdrawing the needle.

Patients and Methods: We describe another technique to help in reduction of cement extrusion.

After satisfactory placement of the Jamshidi needle (used for injecting cement), aspiration is attempted using a 20ml Syringe. A slurry, made of very fine pieces of Gel foam mixed with Omnipaque dye and saline, is injected into the vertebral body. This embolizes the blood channels, which are communicating with the needle. Once no more blood can be aspirated, and no dye is seen extruding into the veins, toothpaste consistency cement is injected under low pressure and fluoroscopic guidance. A post-procedure CT scan was performed in all cases to confirm cement location.

Results: 28 patients underwent PV, 24 of these patients had osteoporotic vertebral fractures and 4 had meta-static lesions. Vertebroplasty was done at 56 symptomatic levels. Using this method, Cement leakage was seen at 12 of the 56 levels operated on (21.4%); at 6 levels leakage was into the adjoining disc, leakage anteriorly was seen at 3 levels, there was 1 leakage into the paravertebral tissues and at 2 levels there was a streak of cement into the vertebral canal in 1 via the venous system and in the other through a cortical defect. None of the leakages were symptomatic. Epidural leakage was seen in 2 patients (3.57%).

Conclusion: A slurry of gelfoam, dye and saline injected prior to cement reduces the incidence of cement extrusion, therefore increasing the safety of this effective procedure.

Introduction: Total disc arthroplasty may offer the same clinical benefits as interbody fusion in symptomatic degenerative disc disease, while providing motion that may protect the adjacent level discs from the abnormal and undue stresses associated with fusion.

Objectives: To prospectively review the preliminary results of the Maverick Lumbar Disc Prosthesis (Medtronic, USA) at maximum 2 year follow-up.

Methods: The first 51 patients (26 M, 25F, age 45.5 mean, 53 levels implanted) were prospectively analyzed. Outcome data included the Oswestry Disability Score (ODI), Visual Analog Scale (VAS) for back and leg pain and SF-36 preoperatively and at routine scheduled follow-ups. Radiographic analysis included sagittal balance parameters and range of motion of the implanted level.

Results: Clinical success (ODI change > 15, FDA) was 82% and 86%, at 6 months and 1 year follow-up respectively. VAS (back) improved from 7.9 (±1.4) to 3.8 (±2.9), and VAS (leg) from (4.6 ± 3.2) to 3.1 (±3.2). All improvements were statistically significant. Two approach, 2 technique and 2 general related complications occurred. Implanted level range of motion ranged from 3 to 12 degrees (mean 6 ± 4 degrees). There was no significant change in any of the sagittal balance variables studied, but a local realignment of the L4-5 L5-S1 segments was found.

Conclusion: These results compare favorably with the short-term clinical outcomes associated with ALIF. It appears that the prosthesis has enough freedom of motion to allow the patient to maintain the natural sagittal and spino-pelvic balance, with normal range of motion. These early favorable clinical results or the influence on adjacent motion segments can be assessed only after a long term prospective randomized study comparing the Maverick to fusion procedures.

Background: The Achilles tendon is the strongest and thickest tendon in the human body, it is very commonly injured with significant clinical implications. The treatment of Achilles tendon rupture is a matter of controversy in orthopedics and sports medicine. Surgical repair compared with conservative treatment is debated constantly in the literature, without a conclusive decision. The diagnosis of Achilles tendon rupture is based usually on clinical examination, and may be reinforced by ultrasound or magnetic resonance imaging. The present study has been conducted in order to determine whether an ultrasound examination performed at the time of injury could be useful in deciding how to treat the patient.

Patients: Over a period of 5 years we treated 26 patients who had a clinical presentation of ruptured Achilles tendon with ultrasound diagnosis of either a partial tear or a full tear. Patients who were diagnosed by ultrasound as having a full tendon tear were operated on, and were not included in this study. Eight patients had partial tear of the tendon, six had a tear of the musculotendinous region, and twelve had a proximal tear. All patients were treated by means of a cast or a dressing, with limitation of weight bearing. The follow-up period ranged between six months to three years after the injury, and included up-to-date functional evaluation.

Results: Eighteen patients were available for evaluation. Excellent functional results were reported by five patients, twelve patients reported good results, and one patient complained of a bad result. None of our patients needed delayed surgery, and only one suffered from re-rupture of the tendon during his rehabilitation, and was treated conservatively with good results. No correlation was found between the location of the tear and the functional results.

Conclusions: 1. Ultrasound is an important and accurate tool in the diagnosis of Achilles tendon tear and is helpful in choosing the appropriate treatment. 2. Partial tear of Achilles tendon is not an indication for operative treatment, even when the clinical examination (Thompson test) is positive. The outcome of conservative treatment in this situation is as good or even better than surgical treatment.

Treatment of congenital kyphosis with severe angular dysplastic spine in children with myelomeningocele (MMC) is one of the most difficult spinal procedures. Most of the surgeons support kyphectomy with long segmental spinal instrumentation and postoperative immobilization by thoracolumbosacral orthosis.

Several spinal deformities are seen frequently in patients who have MMC. The deformity may be congenital or paralytic. Congenital lumbar kyphosis is less common, but most difficult in patients with MMC, occurring in 10–20% of patients. Most curves are congenital and rigid, often more than 80° at birth, and rapidly progresses.

With progression of kyphotic deformity, patients experience recurrent skin breakdown over the apex of the kyphos; impaired sitting balance; the necessity of using their hands for support; collapsing spine and decreasing of lumbar height reduce the capacity of the abdominal cavity and resulting in reduced respiratory capacity and malnutrition. The poor posture and short abdomen make it difficult to manage the patients’ urological needs. A severe deformity raises difficulties in social and psychological development.

Non-operative treatment with spinal orthoses may provide only temporary correction of a kyphotic deformity, but does not prevent progression and skin breakdown.

The goal of surgical treatment is correction of spinal deformity by long segmental instrumentation and achievement of a solid spine fusion in order to allow a balanced sitting position and to prevent complications.

From 1983 to 2001, 6 patients with thoracic level myelomeningocele and severe kyphotic deformity were referred for surgical correction. There were 5 males and 1 female patients with average age at the time of surgery of 8.3 years (range 4.3–13 years). All patients suffered from severe kyphosis, range 90° to 130°, average – 108°. All of them underwent posterior ligation of spinal cord during resection of lordotic segment of the kyphos, and segmental spinal fixation of the deformity from the thoracic spine to the sacrum. In all cases following the resection of the vertebrae it was possible to correct the deformity.

All patients were available for follow-up with range of 6–216 months, average 85 months. All of them were satisfied with the surgical outcome and presented in their final clinical examination with balanced and comfortable sitting, without soft tissue complications. In all cases a significant correction of the deformity was achieved (15°–30°) and enabled comfortable and stable sitting. Two patients suffered post-operative complications, one from surgical wound infection which required surgical debridement followed by soft tissue covering, and the other suffered from distal migration of the rod which was shortened later on.

Discussion: Kyphotic deformity in a patient who has MMC is a challenge for the orthopaedic surgeon and requires major surgical intervention. Resection of the kyphos with posterior instrumentation and fusion may solve patient’s functional problems.