Purpose: To determine the incidence and outcome of late costoplasty in surgical management of IdS.

Methods and results: A retrospective review of prospectively collected data on patients with IdS who underwent costoplasty after definitive fusion during a 10 year period (1994–2004).

We reviewed surgical records of 318 patients who underwent instrumented spinal fusion for IdS at our centre. Amongst these, 15 patients had undergone late costoplasty. Pre-operative assessment included rib hump measurement, photographs and plain radiographs. 4 patients had computerised tomography to evaluate deformity. Outcome measures included patient satisfaction and clinical evaluation.

Results [Mean (SD)]: Age at primary operation was 12.3(3.3) years; age at costoplasty 17.1(2.7) years. Pre-operative Cobb angle was 64.1 (19.5) and postoperative Cobb 36.9 (15.7) degrees. Median time between primary operation and costoplasty was 4 years. Median follow up was 7 years. Indication for costoplasty was cosmetic deformity with prominent rib hump (n=9) and curve progression (n=6). Approach at primary operation was anterior 1 case, posterior 3 and combined 9 cases. Median length of stay was 5 days.

All patients except 1 had significant reduction in rib hump deformity. Complications included 1 case of surgical scar tenderness, 1 transient neuralgia and 1 patient required a chest drain due to haemothorax.

Discussion: Costoplasty is a cosmetic procedure for the correction of rib prominence in scoliosis. There is low incidence of late costoplasty (i.e. after definitive spinal fusion) in IdS. Following costoplasty, patients were satisfied with their cosmetic appearance; no major complications occurred and no further reoperation was needed.

Ethics approval: Audit/service standard in trust number: 1236

Interest Statement: None

Purpose: To determine frequency of reoperations after definitive spinal fusion in patients with AIS and identify factors responsible

Methods and results: We undertook a retrospective review of surgical logs of patients with AIS who underwent surgical fixation during 1994–2004 and detailed case notes review of patients who required > 1 operation after definitive fusion. Results were compared according to approach used during primary operation.

We reviewed surgical logs of 310 patients who underwent instrumented spinal fusion for AIS. Approach at primary operation was anterior 101, posterior 109 and combined 100. Of these, 33 patients underwent 58 reoperations (10.6 %) after definitive fusion. Median age was 14.7 years; median follow up 5.4 years. Amongst these, primary operation was Anterior in 5 patients (7 reoperations, 5%), Posterior 13 patients (25 re-ops, 11.9%) and Combined 15 patients (26 re-ops, 15%). 12 patients required more than 1 reoperation.

Common indications were infection (9), failure of fixation either due to curve progression (10), junctional kyphosis (7) or pseudoarthrosis (3). 16 revisions were undertaken due to implant related symptoms. 5 patients with posterior instrumentation requested removal of implant. Only 1 patient had a neurological deficit that required removal of implant. 13 patients required secondary costoplasty.

Discussion: Risk of reoperation after definitive fusion in AIS is 10.6 % in our institution. Reoperation rates were maximal with combined approach and least with anterior approach (15% v 5%). Common indication with posterior instrumentation was implant related and in anterior surgery due to curve progression (wrong level fixation).

Ethics approval: Audit/service standard in trust number: 1236

Interest Statement: None

Introduction: We report the result of cervical osteotomy in 11 patients using a controlled reduction technique and assess the safety and efficacy of this operation. Methods: Between 1993 and 2006, 11 patients with ankylosing spondylitis underwent correction of cervical kyphosis utilizing an extension osteotomy at the C7/T1 junction. The procedure was carried out under general anaesthesia with spinal cord monitoring. Lateral mass screws were placed from C3–C6 and thoracic pedicle screws placed from T2 to T5. After completion of the osteotomy, the reduction manoeuvre was carried out by the senior surgeon lifting the halo, while bilateral temporary malleable rods (fixed to cervical lateral mass screws) were allowed to pass through top loading thoracic pedicle screws, before tightening by the assistant when the desired position had been achieved. The temporary malleable rods were then replaced with definitive rods, thereby creating a solid internal fixation. A halo vest was maintained for 12 weeks to support the instrumentation and allow the fusion mass to develop.

Results: Surgery was performed on 10 males and one female. The mean age at surgery was 56 years (range 40–74). Duration of symptoms averaged 2.7 years (range 1–5 yrs). The average duration of surgery was 4.7 hours (range 3–6.5) with a mean blood loss of 1938cc (range 1000–3600). The mean follow up was 6.5 years (range 2–13). The mean pre-op chin brow vertical angle was 54º (range 20–70) reducing to 7º (range 2–20) at final follow-up. The mean pre-operative kyphotic angle was 19.2º reducing to minus 34º at final follow up. Restoration of normal forward gaze was achieved in all cases. No patient suffered spinal cord injury or permanent nerve root palsy.

Conclusion: Cervico-thoracic osteotomy is a potentially hazardous procedure. The technique described reduces the risk of translation during the reduction manoeuvre thereby reducing the risk of serious neurological injury.

Introduction: Conventional reduction techniques for high-grade isthmic spondylolisthesis do not address important anatomical constraints on the L5 and S1 nerve roots, thereby leading to a significant risk of neurological deficit. We describe a novel three-stage reduction technique carried out in one operative session that respects these anatomical constraints. We report the results in seven cases.

Methods: Between 2000 and 2006, four female and three male adolescents with high-grade spondylolisthesis (grade 3 or greater) underwent this 3 stage procedure which included: I) extensive posterior decompression of L5 and S1 nerve roots plus sacral dome osteotomy. II) anterior L5/S1 discectomy. III) reduction of spondylolisthesis with pedicle screw fixation and posterior lumbar interbody fusion using interbody cages. Somatosensory and motor evoked potentials were used during the procedure. Patients were followed up for a mean of 4 years (range1–6). Sagittal balance was restored and assessed by measuring sacral slope, lumbosacral angle, pelvic incidence and pelvic tilt.

Results: The mean age at surgery was 14.7 years (range 12–17) and average duration of symptoms was 13.7 months (range6–24). Mean operative time was 6.5 hours (range 5–8), with a mean blood loss of 2242cc (range1400–4200). The mean pre-op slip angle was 57°(range 45°–100°) and the mean post-op slip angle was 37.5°(range28°–57°). Anatomical reduction was achieved in six patients and one patient with spondyloptosis was reduced to grade 2. Sagittal balance was restored in all patients. There were no permanent neurological complications. One patient with grade 4 spondylolisthesis developed transient right L5 nerve root palsy which fully recovered within 3 months.

Conclusion: The safety and efficacy of this 3 stage reduction and stabilization procedure showed that immediate reduction of high grade spondylolisthesis with minimal risk of neurological deficit is possible. The procedure is technically demanding and should be performed by spinal surgeons familiar with the principles of anterior and posterior fusion.

Objective: To asses the outcome of hermivertebrectomy and fusion for symptomatic thoracic disc herniation.

Design: A retrospective case analysis

Subjects: Between 1993 and 1999, ten patients (M5, F5) were treated surgically for thoracic disc herniation by the two senior authors (JKW & SHM). The average age of patients at presentation was 5Oyears (range 32–77years). Two patients had two level disc herniations (total 12 disc herniation). The most common sites of disc herniation were at T10/11(4 patients). Duration of diffuse mid thoracic hock pain in eight patients varied from one week to six months. The initial neurological evaluation demonstrated weakness and spasticity of varying grades in eight patients, of which five had paraplegia and three had monoparesis. Sensory changes below the level of the lesion were found in eight patients. Sphincter dysfunction was noted in seven patients. Hemivertebrectomy followed by discectomy and fusion was carried out in all patients. Instrumentation with cages was performed in eight patients and only bone grafting in two patients. Spinal cord monitoring was used in all cases.

Outcome Measures: The average follow up was 24 months (range 13–36 months). Pre-operative and postoperative neurological grading was done using MRC grading for motor and sensory deficit. Asymptomatic patients with full activity were regarded as a successful outcome.

Results: Three patients had excellent, three had good, three had fair and one had poor outcome. Seven out of eight patients with cages had radiological fusion. The cage stabilises the segment and maintains the spinal height till bony fusion takes place. One patient with hone graft alone had recurrence of symptoms and had a re-surgery with a poor outcome. Six patients had residual back pain of varying degrees. One patient had atelectasis, which recovered within two days of surgery. One patient had suffered from complete paraplegia immediately after surgery detected by SSEPs. She underwent a MRI scan within the hour and was reoperated. She had complete corpectomy and instrumented fusion. At two years she was walking with a support.

Conclusion: Exposure of the norrnal tissue above and below herniated disc by hemivertebrectomy facilitates the safe removal of the disc and reduces the risk of further neurological damage. Cages were found to have advantages over autogenous strut only grafts. However, persistent back pain in some cases remains an unsolved problem.