The axis is anatomically, developmentally and biomechanically unique from the five lower cervical vertebrae as well as the axis above it. The pars interarticularis is a transitional structure and a thin tube of cortical bone with small amount of cancellous bone. The canal-to-cord ratio is extremely large, hence the minimal risk of neurological deficit after injury.

HIV and musculoskeletal trauma have reached epidemic proportions in the developing world especially in sub Saharan Africa. The epidemic has adversely affected health care delivery in limited resource settings. We assessed the outcome of HIV+ patients following spinal surgery for fractures and dislocations.

Forty seven HIV+ patients were treated surgically over the past three years. The mean age was 32 years (19–53 years) and included 39 males. The dorsolumbar region was affected in 28 patients and the cervical spine in 19. Motor vehicle collisions (34) accounted for 72% of the injuries. Neurology occurred in 49% of patients (23). The mean CD4 count was 426 (range 98–742). The albumen was 29 gm/d? (range 26–34) and the lymphocyte count was 1.6c/cumm range 1.4–1.9). Twenty eight patients had generalized lymphadenopathy and recent weight loss was noted in 11 patients. Fifteen patients were treated for pulmonary TB and seven patients were on ARVs.

The dislocations at the cervical spine commonly occurred at C5/6 (8). Three patients required a posterior cervical release with facetectomy prior to anterior cervical plating which was performed in all patients. The dislocations and unstable burst fractures of the dorsolumbar spine were treated by a one/two level posterior fusion.

Post-operative sepsis due to S. aureus occurred in 8 (17%) patients. In four patients with deep infection vacuum dressings were used to clear the sepsis. Post-operative sepsis is best avoided by optimization of patients and meticulous surgery.

The incidence of MRSA infection is increasing worldwide. Costs incurred in treating MRSA infection are over twice that of normal patients, and the duration of hospital stay is up to 10 times longer. Risk factors are age, previous MRSA infection, prolonged hospitalization, patients from convalescent homes, immunocompromised states, vascular and pulmonary disease.

Background:

The reported prevalence of sciatica ranges from 1.2% to 43%. Epidural injections are the most commonly performed interventions for sciatica

Objective

To determine the incidence, distribution and associated organ damage in patients that sustained multilevel spinal injuries presenting to a level 1 trauma unit. Is the standard trauma series adequate?

Controversy exists as to whether burst fractures without neurological deficit should be treated operatively or non operatively. We assessed the functional outcomes of non operative treatment of burst fractures using the Oswestry disability index (ODI).

57 Patients who were treated non operatively (bed rest for one week and a corset for 3 months) were assessed using the Oswestry disability index (ODI) over a 6 month period. Assessments were done at an average of 4.8 years (range 18 months–7 years) post injury. There were 37 males and 22 females with an average age of 39 years. Fifty-three percent (31) injuries were due to a fall and twenty-two percent (22) followed an MVA. 90% Of fractures occurred between T12 and L2. Plain x-rays and CT scans were obtained to evaluate the burst fracture.

The initial average Cobb angle was nineteen degrees (19⁰) (range 6⁰–53⁰) with an average progression in Cobb angle was 7⁰ and the average final Cobb angle was 26⁰ (9⁰–71⁰) The average ODI was 17.32% (range 0 48%). Personal care, sexual activity and sleeping were not significantly affected (ODI : 0 or 1 each). Fifty-five percent (11/20) who were previously unemployed returned to work and none of those patients who were previously unemployed, were employed at a later date. All 11 housewives experienced no difficulty with household chores. This study revealed that 31 patients occasionally used analgesia (paracetamol).

The authors conclude that non operative treatment of burst fractures is a viable option in neurologically intact patients.

40% Of the cases of tuberculous (TB) spondylitis involve the lumbar spine. Despite the large forces borne by the lumbar spine and subsequent disability that may result from the TB infection, no studies have reported on the functional outcome. We review the clinical, radiological and patient-orientated functional outcomes using the Oswestry Disability index (ODI) following treatment of lumbar spine TB.

The final radiological and ODI assessment was undertaken at follow-up during October 2005 and March 2006 in 37 patients, treated non-operatively for TB of the lumbar spine. The diagnosis was established following a closed needle biopsy.

The mean age at follow-up was 35 (range 16 to 76 years). The average duration of symptoms prior to presentation was 9 months (range 2 to 24 months). All patients presented with low backache and night pain but only 42% had constitutional symptoms. 92% had 2-body involvement and L3/4 segment was most commonly involved (35%). The kyphosis measured 13⁰ (range 40⁰ kyphosis to 13⁰ lordosis) and the mean overall lumbar curve was +1⁰ (range 26⁰ kyphosis to 36⁰ lordosis). Ten patients had coronal plane deformity averaging 10⁰ (0⁰ to 22⁰). All patients had a minimum of 6 months of anti-TB treatment (6 to 24 months), 76% used spinal brace for a mean of 5 months (2 to 24 months). At the last follow-up the kyphosis was 17⁰ (38⁰ kyphosis to 8⁰ lordosis) with overall average lumbar curve of +3⁰ (18⁰ kyphosis to 36⁰ lordosis). 11 Had mean coronal deformity of 9⁰ (0⁰ to 14⁰). 34 Of the patients showed full radiological fusion. The mean ODI was 19% (0 to 55%).

We conclude that a favourable functional outcome can be expected with conservative treatment of lumbar spine TB, despite the deformity.

The majority of spinal tumours are due to metastasis, however the most common primary tumour is multiple myeloma. This is a retrospective study of patients presenting with tumours of the spine, determining the incidence of malignant and benign tumours presenting at King George V spinal unit.

All admissions from January 2004 to April 2006 were reviewed. Age, gender, presenting complaint, clinical presentations, and tumour type were evaluated. The tumour type was diagnosed by laboratory, radiological and histological investigations. Histology was obtained by either closed or open biopsy. Laboratory investigations included a full blood count, liver function tests, urea and electrolytes, serum and urine protein electrophoresis.

Of the 42 patients diagnosed, 25 were male (59.5%) and 17 were female (40.5%). The average age was 50 (range 10 to 82). All patients presented with pathological pain and 34 patients presented with neurology ranging from mild weakness to complete paralysis (frankel D to A). 8 had no neurology. 16 Patients (38.1%) were diagnosed by closed biopsy, 23 (54.8%) by open biopsy, and 3 patients (7.1%) were diagnosed by clinical biochemical, and radiological investigations as multiple myeloma (they demised prior to biopsy). 9 Patients had a benign tumour (21.4%) and 33 had a malignant tumour (78.6%). 12 Patients had a primary tumour (36.4%), and 21 had secondary deposits (63.6%). The benign tumours included 2 Aneurysmal bone cysts, 2 Giant cell tumours, 3 haemangioma’s, 1 osteoblastoma and 1 osteochondroma. The primary malignant tumours included 1 Ewings sarcoma, 1 lymphoma, 1 ependymoma, and 9 myeloma. The secondary tumours included 17 undifferentiated metastatic adenocarcinomas, 2 renal cell cancers, 1 nephroblastoma, and 1 follicular thyroid cancer. Patients were managed by a multi-disciplinary team.

Malignant spinal tumours are most likely due to metastasis. Males have a greater risk than females with a peak incidence in the 5^th decade.

The purpose of this prospective study was to assess the patient referrals to King Edward V111 hospital with respect to communication, quality of referral letters, transfer times, investigations, diagnostic accuracy, initial management, associated and missed injuries.

88 Patient referrals were assessed prospectively over 4 months by a single investigator utilizing a questionnaire. The average age was 41 years. Eighteen (20%) were compound fractures. The average transfer time of closed injuries was 10h08 and compound injuries 4h20. 20 Patients (23%) were not discussed prior to transfer and 1 (1%) patient did not present with a referral letter. Referring physician details were deficient in name 10 (11%), contact details 58 (66%) and designation 82 (93%). No receiving physician was listed in 23 (26%) referrals. Mechanism of injury was provided in 51 (58%) referrals, time of injury in 41 (47%), type of splinting in 53 (60%) and type of analgesia in 11 (12%) referrals. Referrals of compound fractures showed a description of wound care in 11 (61%) referrals, antibiotic therapy in 9 (50%) and tetanus prophylaxis in 3 (16%). 53 (60%) referrals presented without haematological investigations and 84 (95%) presented with radiological investigations of which 54 (64%) were inadequate. Splinting was satisfactory in 35 (40%) and analgesia was adequate in 9 (10%). Wound care was appropriate in only 5 (27%) and antibiotics were administered in 7 (39%) compound fractures. Diagnostic errors emerged in 14 (16%) of referrals with a missed injury rate of 10% (9 pts). 1 Patient required urgent intervention due to blunt abdominal trauma.

Supervision, training and regular assessment of junior doctors is essential to improve the quality of patient care by the referring hospitals.

Orthopaedic pathology at the craniocervical junction (CCJ) is uncommon. This is a retrospective analysis of 37 patients who underwent transoral surgery. The indications were fixed rotatory subluxation in 12 patients, myelopathy following nonunion of the dens in 15, tuberculous abscesses in seven, congenital anomalies in two and chordoma in one. There were 29 males and the mean age was 24 years (3 to 57). Neurological deficit was present in 19 patients. Other symptoms included hoarseness, difficulty swallowing, neck pain and limitation of movement. All patients had a CT scan, MR angiography, MRI and dental consultation to exclude oral sepsis. After the transoral release, 29 patients underwent atlanto-axial fusion and two occipito-axial fusion. Following nasal intubation the skull was immobilised in tongs with 2-kg traction. A Jacques catheter was used to retract the uvula. The CCJ was located with an image intensifier and the posterior pharyngeal wall was infiltrated with 5 cc of local anaesthetic and Por-8. The atlanto-axial joints (AAJ) were released and in children with fixed rotatory subluxation the atlantodentate interval was cleared of fibrous tissue. The 15 patients with non-union of the dens underwent anterior release of the AAJs and the fracture site. The seven patients with abscesses had incision and drainage. Two patients with basilar invagination required excision of the dens. The chordoma was partially excised. One patient required a partial excision of the dens to reduce a posterior dislocation of the AAJ. A patient with chronic atlanto-axial subluxation owing to a type-I fracture required a partial excision of the superior part of atlas. Two patients with CSF leaks were treated successfully. There were cases of sepsis. Two patients developed occipital pressure sores. One patient died 5 days after surgery because of pulmonary embolus.

The transoral approach is safe and effective in treating pathology at the CCJ.

Introduction and Aims: Autologous bone is the preferred method of providing structural support in spinal surgery. The disadvantages are donor site morbidity and limited bone available to reconstitute the anterior column. We evaluated fresh frozen femoral allografts following anterior column reconstruction for lumbar burst fractures with neurological deficit.

Method: Twenty-seven patients with neurological deficit ( Frankel grade A(3), B(7), C(16) D (1) due to burst fractures of the dorsolumbar junction were treated with fresh frozen allografts following anterior spinal decompression. The average age was 28 years, and 19 patients sustained the injury following a road traffic accident.

The mean pre-operative kyphosis measured 190. A corpectomy was performed in all patients and femoral allografts were positioned by interference fit and the spine stabilised with an anterior rod screw construct. The radiographs were reviewed at three-monthly intervals and the fusion graded by an independent radiologist.

Results: The follow-up in 24 patients ranged from 29 to 72 months (mean 43 months) and three patients were excluded due to inadequate follow-up. Allograft incorporation was assessed by criteria of Bridwell et al grade 1 fused with remodelling with cross trabeculae into the adjacent vertebral bodies, grade 11 graft intact, not fully remodelled and incorporated, no lucenies, grade 111 graft intact, but a definite lucency at the top or bottom of the graft, grade 1V not fused with resorption and collapse of graft. The allografts were stable and evidence of graft incorporation and remodelling were observed between eight and 24 months. Grade 1 fusion was seen in 23 patients at two years and subsequent follow-up revealed no fracture, resorption or collapse.

The average neurological recovery, which was 1.4 Frankel grades (range 0–2 grades), occurred within seven weeks following surgery (range 11–74 days).

Nine patients (37%) made a complete recovery and in four patients (16%) there was no improvement. The mean post-operative kyphosis at two years was 80 (range 2–180). At seven-year follow-up one patient had an asymptomatic grade 11 fusion following secondary infection due to TB which was successfully treated.

Conclusion: The indications for the operative treatment of thoracolumbar burst fractures remains controversial. The increased compressive strength of allografts, the large surface of contact, and the stability with instrumentation created a stable construct, which permitted early mobilisation. Allografts were inexpensive biological alternatives to reconstruct the anterior column in burst fractures.

Introduction and Aims: Socioeconomic deprivation and the HIV epidemic have accounted for the global increase in tuberculosis. Tuberculous spondylitis constitutes 60% of osteoarticular tuberculosis. Progressive kyphosis has been reported with rib grafts in spinal TB. We prospectively evaluated 45 patients treated with fresh frozen anterior cortical allografts for spinal TB.

Method: The mean age was 28.6 years and all patients were HIV negative. The neurological status (Frankel grade) was (A)10, (B)18, (C)17 and the dorsal spine was affected in 37 patients. The kyphosis measured 540 (range 270–740). Following pre-operative nutritional support all patients underwent a radical anterior decompression and the granulation tissue tethering the cord to the apex of the deformity was released. An appropriate length of fresh frozen cortical allograft was positioned by interference fit and stabilised with an anterior rod screw construct. Anti-tuberculosis treatment was prescribed for one year.

Results: Post-operatively, four patients developed pulmonary atelectasis and three patients had superficial wound infections, which resolved with physical therapy and antibiotics respectively. Four patients were excluded due to inadequate follow-up. At 12 months complete neurological recovery occurred in 32 patients, partial in five and no recovery in four patients. There was no radiological evidence of infection or fracture of the allografts. The criteria of Bridwell et al was used to classify the incorporation of allografts. The earliest radiological evidence of fusion and remodelling occurred between 12 and 18 months post-operatively. At the last follow-up (mean 7.8 years, range 6.5–9.2 years) the allografts had incorporated in 33 cases and in eight cases the remodelling was incomplete. Although the incorporation is slow, there were no cases of non-union. The kyphosis measured 220 (range 14–460) at the most recent follow-up.

Conclusion: The weakness of rib grafts is attributed to the unfavourable length, width ratio and the small surface area of contact. Allografts are biological and the stability is enhanced by a large surface area of contact and instrumentation.

Tuberculous sacro-iliitis occurs in fewer than 10% of cases of skeletal tuberculosis. The diagnosis is usually delayed as more common causes of low back pain are sought. Treatment is mainly conservative, with very few patients requiring surgery.

In a retrospective analysis from 1994 to 2004, we reviewed 15 patients, ranging in age from 15 to 60 years, 13 of whom presented with lower back pain and difficulty with walking. Two patients had an abscess over the affected sacro-iliac joint. All patients had tenderness over the sacro-iliac joint. The Gaenslen and FABER stress tests were positive in all patients. Radiographs showed joint space widening, marginal sclerosis of the joints and peri-articular osteopoenia. Technetium 99 bone scan revealed increased uptake in the region of the sacro-iliac joint. CT scan revealed joint space widening, sclerosis and sequestra in the joint space. Only one patient had bilateral tuberculous infection. Two had had an associated lumbar spine lesion. All 15 patients underwent open biopsy. Histological and microbiological reports revealed chronic infection, with Mycobacterium tuberculosis the causative organism. An 18-month program of antituberculous medication was initiated. Ambulation followed wound healing. Follow-up ranged from 5 to 8 years. All 15 patients responded well to this conservative approach.

In patients with low back pain, sacro-iliac disease should always be included in the differential diagnosis. Thorough clinical and radiological examination and laboratory diagnosis is essential to exclude pyogenic infection and tumours.

The cervical spine is the most vulnerable segment in high velocity injuries. Bifacet dislocations are associated with significant soft tissue damage and neurological deficit. Management of delayed presentation of cervical facet dislocations, which are not uncommon, is varied. The aims of this study are to create awareness and to develop a management strategy.

We retrospectively reviewed 14 patients (10 men and four women) with chronic dislocations treated over 4 years. The mean age was 42.5 years (23 to 62). The delay in presentation ranged from 15 to 135 days. Seven patients had neurological deficit. All patients underwent CT scan and MRI.

Common areas of involvement were C6/7 (five patients) and C5/6 (four patients). Associated fracture of posterior elements was identified in 40% of patients. In two patients sequestrated disc ruptured into the canal. All patients underwent surgical reduction and stabilisation, with eight having one-stage and six two-stage surgery. The sequence of one-stage surgery was posterior release, reduction (facet reduction/facetectomy), anterior discectomy and anterior fusion. In three patients with sequestrated discs, anterior decompression preceded posterior release and finally anterior fusion. The six patients who had staged surgery had a prolonged delay (over 3 months) in presentation. Posterior release was followed by an anterior decompression, then a 7 to 10-day period of traction reduction and finally anterior fusion. None of our patients developed neurological deficit. Three patients improved from Frankel-C to Frankel-D.

We recommend that the sequence of surgery should be posterior release/reduction and then anterior decompression and anterior fusion. However, in chronic cases, staged reduction and fusion is a viable option.

Twenty-seven patients with neurological deficit due to burst fractures were treated with fresh frozen allografts following anterior spinal decompression. Their mean age was 28 years. In 19 patients the injury was due to motor vehicle accidents and in five to falls. The mean preoperative kyphosis was 19° (4° to 33°). Three patients with laminae fractures, which resulted in entrapment of the dura, underwent posterior decompression and transpedicular fixation before anterior decompression. Corpectomy was performed in all patients. An appropriate length of femoral allograft was positioned by interference fit and the spine was stabilised with an anterior rod screw construct in 21 patients.

The follow-up ranged from 29 to 72 months. Bridwell grade-I fusion was seen in 23 patients at two years. Subsequent follow-up revealed no fracture, resorption or collapse. The mean neurological recovery was 1.4 Frankel grades. Nine patients (37%) made a complete recovery but in four (16%) there was no improvement. The mean postoperative kyphosis was 9° and at two years the mean loss of correction was 3°. One patient presented with a psoas abscess at two-year follow-up. At surgery the graft was partially resorbed but was stable. At six-year follow-up the patient was asymptomatic with a grade-II fusion.

The use of allografts saves considerable time in surgery and avoids potential donor site morbidity. They are versatile and are easily available.

One hundred and thirty-eight patients from South Africa were part of an international study aimed to determine whether the rate of healing of compound tibial fractures treated with intramedullary nails improved with recombinant human bone morphogenetic protein-2 (rhBMP-2). There were 118 men and 20 women, with a mean age of 33.3 years. According to the Gustilo-Anderson classification, there were 32 type-I, 50 type-II, 38 type-IIA and 18 type-IIIB fractures.

Patients were randomised to one of three groups: the standard care (SC) group, in which 47 patients were treated with intramedullary nail fixation and soft-tissue management, the group treated with SC and 0.75 mg/ml of rhBMP-2, which comprised 50 patients, and the group treated with SC and 1.50 mg/ml of rhBMP-2, which comprised 40 patients.

At 20 and 26 weeks, there was a significant difference (p < 0.027) in the rate of fracture healing in the three groups. At one year follow-up union was achieved in 30 patients (63.8%) in the SC group and in 27 patients (54%) and 30 patients (73.2%) in the two rhBMP-2 groups respectively. All patients with type-IIIB fractures developed nonunion in the SC group, but 56% in the 0.75-mg/ml rhBMP-2 group and 50% in the 1.5-mg/ml rhBMP-2 group achieved union.

Secondary intervention and medical costs were reduced in patients treated with rhBMP-2.

Injuries at the occipitocervical junction are commonly due to high velocity trauma. Because of severe injury to the cervicomedullary junction and concomitant cerebral trauma, they are usually fatal. We describe our experience in the management of five patients who initially survived the injuries.

Between 1995 and 2000 we treated four men and one woman, ranging in age from 23 to 47 years, injured in motor vehicle accidents. All patients had head injuries, three with cranial nerve involvement, and four had polytrauma. Although initial radiographs of the skull included the occipitocervical junction, the traumatic disruption of the occipitocervical junction was not diagnosed for between two days and five weeks. One patient, who had no neurological deficit, developed periodic weakness of the lower limbs with rotation of the neck. In three patients the dislocation was posterior and in two it was anterior to Wackenheim’s line.

Three of four patients who required ventilatory support died before surgical stabilisation. The dislocation was reduced in only one of the remaining two, both of whom underwent a successful occipitocervical fusion (O-C2), with subsequent complete neurological recovery.

In patients with polytrauma, meticulous clinical evaluation and appropriate radiographic investigations of the occipitocervical junction are essential for early recognition and management of this potentially fatal injury.

Atlanto-axial rotatory fixation (AARF) is uncommon and is usually associated with a history of trauma to the neck or an upper respiratory tract infection. In patients who present early, correction of the deformity with traction and orthoses has been reported.

Owing to failure of reduction, patients presenting late (more than a month after the condition developed) have been treated with an in situ C1/C2 fusion. Follow-up of in situ fusions has shown both progression of the deformity and correction through compensatory mechanisms.

Over a five-year period seven AARF patients (16%), ranging in age from 5 to 11 years, presented more than three months after injury. All patients had a ‘cock robin’ posture and were neurologically intact. In three patients the injury was sustained in a fall from a tree and in four it was due to a motor vehicle accident. Two patients sustained additional fractures.

All patients had CT scans. In four patients MR scans and MR angiography were used to evaluate the pathology in the atlanto-axial complex, including the vertebral artery, and revealed soft-tissue interposition in the atlanto-axial joint and atlantodental interval. There was thrombosis of the vertebral artery in two patients. Clinical and radiological correction of the deformity was achieved with transoral release and skull traction, followed by fusion.

While in previous studies there has been speculation on the causes of failure of closed reduction, MRI and the transoral procedure identified the pathology in this uncommon condition.

Fractures and fracture dislocations involving the lower lumbar spine and lumbosacral junction are uncommon. These high velocity injuries are often associated with neurological deficit, incontinence and dural tears. The accepted treatment has been posterior stabilisation with fusion, but loss of reduction has often been reported.

We reviewed our experience over the past four years in the management of eight male patients, two of whom sustained injuries in motor vehicle accidents and two in falls from a height. Two patients had L5/S1 traumatic spondylo-listhesis with no neurological deficit. Of the six patients with fracture dislocations of L3/4, four had translation in the sagittal and coronal planes and incomplete neurological deficit. Associated injuries in four patients included an ankle fracture, multiple rib fractures, dislocation of knee and hip, and a fracture dislocation of the midfoot.

Following satisfactory reduction, seven patients were treated by posterior spinal fusion (PSF) with instrumentation. One patient had anterior decompression, strut-grafting and posterior instrumentation. Three patients had dural tears.

In three patients treated by single segment PSF, reduction was not maintained. The maintenance of alignment was attributed to stable facet joints in one patient, two-segment instrumentation in three, and anterior strut grafting in one. One patient developed postoperative wound sepsis, which settled after repeated debridement and antibiotic treatment. Symptoms of nerve root compression improved in two of the four patients with neurological deficit.

Posterior reduction and instrumentation alone did not maintain reduction in these severe injuries. Anterior column support and multisegmental instrumentation may be required where there is marked vertebral body compression and neurological deficit.