Study Design: Descriptive case series.

Objective: To report on the outcome of 4 patients treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to hypernephroma.

Summary of background data: Patients with solitary spinal metastases from renal cell carcinoma (RCC) have better prognosis and show longer survival rates as compared to other spinal metastatic disease. Adjuvant control by chemotherapy and hormonal therapy has been proven ineffective to treat this relatively radioresistant tumour, which can often present with both back pain and neurological deficit.

Methods: Four patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system to determine predictive life expectancy. 3 of the 4 had pre-operative embolization and all had radical resection of the primary tumour.

Results: All patients reported significant pain relief and demonstrated neurological improvement. One patient died at 11 months post-op due to a recurrence of the primary in the nephrectomy bed. 3 were alive and well at 18, 26 and 39 months post-op with no radiological evidence of tumour recurrence. There were no major surgical complications.

Conclusions: Careful patient selection is required to justify this procedure. The indication is best limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence.

Objective: To assess the effectiveness of total disc replacement (TDR) (Charité SB III) for treatment of lumbar discopathy and to report the preliminary clinical results after a minimum follow-up period of two years

Materials and Methods: From 49 patients who underwent lumbar TDR, 31 patients fulfilled the criteria for clinical evaluation at least 2 years after surgery. The mean age was 39ys (range 29 – 48). Preoperative diagnosis included degenerative disc disease in 27 patients and 4 patients had post discectomy back pain. 44 disc prosthesis were implanted, 18 patients had a single level disc replacement and 13 patients had two level replacement. All patients were studied prospectively and clinical results evaluated by assessing preoperative and postoperative Oswestry Disability Index questionnaire and Visual Analogue Scale for back pain. Pre and postoperative patients’ work status as well as patient satisfaction were also assessed. The mean postoperative follow up was 3.3years (range 2 – 8 years). Statistical analysis of the results was done with the Wilcoxon Signed Ranks Test.

Results: There were significant improvements of the clinical outcome measures. Mean post operative ODI compared to mean preoperative scores of 19 and 53 respectively (p< 0.0001) and mean postoperative VAS compared to mean preoperative scores of 2.5 and 7.5 respectively (p< 0.0001). Success rates showed 51.6% of patients had an excellent result (relative improvement of ODI score, > 75%), 19.4% had a good result (relative improvement of ODI score, 60% to74%), and 29% had a fair and poor results (relative improvement of ODI score, < 60%). No major or approach related complications were encountered.

Conclusions: TDR is an effective method of treating discopathic low back pain. The medium term results are comparable to those obtained following traditional lumbar arthrodesis. Yet longer term results are still needed to comment on adjacent segment load transfer and progression of degenerative changes.

Objective: To evaluate the long term results of an operation developed to decompress the roots at the stenotic level, preserve the midline structures, and not use instrumentation or fusion.

Design: A retrospective clinical and radiological review of consecutive patients operated on for spinal stenosis secondary to lumbar spondylosis.

Subjects: One hundred and sixty patients (eighty seven female and seventy three male) with a mean age at operation of sixty eight (range 40–90). Sixty one patients (38%) had a degenerative listhesis causing stenosis. The mean post operative follow-up was twenty two months (range two months to fourteen years).

Summary of background data: Lumbar spondylosis, commonly involving degenerative listhesis, is the commonest cause for spinal stenosis in the lumbar spine. Surgery offers the only permanent cure. The standard procedure remains a laminectomy with fixation and fusion in the presence of possible instability. The laminectomy destabilises the spine and the instrumented fusion makes it a much bigger operation in patients often not best placed to cope with it. There is a need, therefore, for an effective operation that does not compromise spinal stability.

Results: At six weeks one hundred and forty one patient (85%) reported relief of leg pain and a further nine patients were improved at three to six months. 52% of the patients reported a concomitant improvement in back pain. The results were sustained at follow-up.

The operation was not responsible for the development of a new spondylolisthesis. A minimal increase in an existing degenerative listhesis was seen in two patients only without compromise of their good results. There was no revision surgery at any of the operated levels.

Conclusions: The operation of segmental spinal decompression for degenerative lumbar spinal stenosis has been found to be effective, safe, and give good long term results, without compromising the existing spinal stability. Patient selection and attention to operative technique are essential.

Objectives: To establish the side incidence of acute lumbar disc prolapse and to determine whether there is a correlation between the side of the prolapse and hand dominance.

Design: A retrospective study of consecutive cases of acute lumbar disc prolapse in which the diagnosis was confirmed at operation and the patients contacted about hand dominance.

Summary of background data: The side incidence of operatively confirmed disc herniation does not appear to have been reported.

Lifting and turning with the trunk in the flexed position is the commonest cause of an acute disc prolapse. Flexion and rotation of the lumbar spine, under load, may also give rise to unilateral fractures in the lumbar spine in fast bowlers in cricket and in eighty percent of these cases the fracture occurs on the opposite side to the bowling arm (ref 1.) Given that the majority of the population (eighty nine percent) are right handed it was speculated that the incidence of lumbar disc prolapse might not be equal and might be greater on the side opposite the dominant hand.

Methods: From a review of case notes one hundred and twenty six patients were identified in which a sequestrated disc fragment was confirmed at operation. The side of the prolapse was noted. These patients were contacted to determine their hand dominance.

Results: Fifty nine patients (47%) had a disc prolapse on the right side and sixty seven (55%) had a disc prolapse on the left side. There was no statistically significant difference in the numbers.

Ninety two of the one hundred and twenty six patients contacted about their hand dominance responded: eighty three patients (90.2%) were right handed, eight (8.7%) were left handed and one patient (1.1%) was ambidextrous. Of the eighty three right handed patients, forty (48.2%) had a left sided disc prolapse and forty three (51.8%) had a right sided disc prolapse.

Conclusion: This study revealed no difference in the side incidence of lumbar disc prolapse. There was no correlation either with the side of the prolapse and hand dominance.

The findings are considered to support the view that a disc prolapse, and the side on which it occurs, is not a consequence of a single unilateral action but an end product of pre-existing disc degeneration in a midline structure.