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.

To assess implant performance, to evaluate fusion and to assess clinical and radiologic outcome of circumferential fusion using porous tantalum cages for ALIF in a 360-degree fusion.

A retrospective cohort study was performed over a 4-year period that included the implantation of 280 tantalum cages in 98 patients by the technique of anterior lumbar interbody fusion (ALIF) and posterolateral spondylodesis. Radiographic follow-up was performed to document any implant related problems. Preoperative and postoperative clinical outcome measures were assessed.

No neurological, vascular or visceral injuries were reported. There were no rod breakages and no symptomatic non-unions. One revision procedure was performed for fracture. Mean VAS back pain score in our patient cohort improved from 7.5 preoperatively to 1.9 at latest follow-up, mean VAS leg pain score improved from 6.2 to 1.1 and mean ODI score improved from 51.1 to 18.3.

Porous tantalum cages have high strength and flexibility, in addition to having similar biomaterial properties to cancellous bone. Their use in 360-degree spondylodesis to treat degenerative lumbar spine deformity has been demonstrated to be very safe and effective, with excellent clinical and functional outcomes.

To evaluate the incidence of complications and the radiographic and clinical outcomes from 2-stage reconstruction including 3-column osteotomy for revision adult spinal deformity.

A prospective cohort study performed over 2 years at a major tertiary referral centre for adult spinal deformity surgery. All consecutive patients requiring 2-stage corrective surgery for revision adult spinal deformity were included. Radiographic parameters and clinical outcome measures were collected preoperatively and at 6 weeks, 6 months, 1 year and 2 years postoperatively. Radiographic parameters analysed included pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, thoracic kyphosis and sagittal vertical axis. Clinical outcome measures collected included EQ-5D, ODI, SRS 22 and VAS Pain Scores.

Performing anterior column reconstruction followed by 3-column osteotomy and extension of instrumentation for revision spinal deformity resulted an excellent correction of sagittal alignment, minimal surgical complications and significant improvements in HRQOL. Restoration of lumbar lordosis, pelvic tilt and sagittal vertical axis were observed in addition to postoperative improvements in EQ-5D, ODI, SRS 22 and VAS Pain Scores at follow-up.

Performing anterior column reconstruction prior to a 3-column osteotomy minimises complications associated with 3-column osteotomy and extension of posterior instrumentation. We propose a treatment algorithm for safe and effective treatment in revision adult deformity surgery.

To assess the clinical and radiologic outcome of MM patients with thoracic spine involvement and concomitant pathologic sternal fractures with a resultant severe sagittal plane deformity.

A prospective cohort study (n=391) was performed over a 7-year period at a national tertiary referral centre for the management of multiple myeloma with spinal involvement. Clinical, serological and pathologic variables, radiologic findings, treatment strategies and outcome measures were prospectively collected. Pre-treatment and post-treatment clinical outcome measures utilised included EQ-5D, VAS, ODI and RMD scoring systems.

13 MM patients presented with a severe symptomatic progressive sagittal plane deformity with a history of pathologic thoracic compression fractures and concomitant pathologic sternal fracture. All patients with concomitant sternal fractures displayed the radiographic features and spinopelvic parameters of positive sagittal malalignment and attempted clinical compensation. All patients had poor health related quality of life measures when assessed.

Pathologic sternal fracture in a MM patient with thoracic compression fractures is a risk factor for the development of a severe thoracic kyphotic deformity and sagittal malalignment. This has been demonstrated to be associated with a very poor health related quality of life.

To examine the impact of a structured rehabilitation programme as part of an integrated multidisciplinary treatment algorithm for adult spinal deformity patients.

A prospective cohort study was performed over a 2-year period at a major tertiary referral centre for adult spinal deformity surgery. All consecutive patients requiring 2-stage corrective surgery for sagittal malalignment were included (n=32). Details of physiotherapy initial evaluation, inpatient rehabilitation progress, details of bracing treatment and time to discharge were collected. Clinical outcome scores were measured preoperatively and at 6 weeks, 6 months and 1 year postoperatively.

After second stage corrective surgery, the mean time to standing without assistance was 2.1 days, mean time to independent ambulation was 4.2 days, mean time to competent ascending and descending stairs was 5.6 days and mean time to moulded orthosis application 7.1 days. Successful progression through the structured rehabilitation programme was associated with high clinical outcome scores and improved health related quality of life (HRQOL).

The introduction of this programme contributed to the development of an enhanced recovery pathway for patients having adult spinal deformity surgery, reducing inpatient length of stay and optimising clinical outcomes.

To evaluate the differences between spinopelvic parameters before and after sagittal malalignment correction and to assess the relationship between these radiologic parameters and clinical outcome scores.

A prospective cohort study was performed over a 2-year period at a major tertiary referral centre for adult spinal deformity surgery. All consecutive patients requiring 2-stage corrective surgery were included (n=32). Radiographic parameters and clinical outcome measures were collected preoperatively and at 6 weeks, 6 months, 1 year and 2 years postoperatively. Radiographic parameters analysed included pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, thoracic kyphosis and sagittal vertical axis. Clinical outcome measures collected included EQ-5D, ODI, SRS 22 and VAS Pain Scores.

Correction of sagittal malalignment was associated with significant improvements in HRQOL. Restoration of lumbar lordosis, pelvic tilt and sagittal vertical axis correlated with postoperative improvements in EQ-5D, ODI, SRS 22 and VAS Pain Scores at follow-up.

This study demonstrates that the magnitude of sagittal plane correction correlates with the degree of clinical improvements in HRQOL. This further underlines the need for spinal surgeons to target complete sagittal plane deformity correction if they wish to achieve the highest rates of HRQOL benefit in patients with marked sagittal malalignment.

To assess screw malposition rates and complications associated with pedicle screw insertion using 3D navigation technology.

A retrospective study was undertaken for all cases where O-arm® and StealthStation® systems were used over a 2-year period. The primary outcome measure was return to theatre rates for pedicle screw malposition.

A total of 938 screws were inserted (934 thoracolumbar and 4 cervical), and 103 patients underwent spinal fixation using O-arm® and StealthStation® navigation. 64 were revision cases and 39 primary cases. Average number of levels was 4.6. There were a total of 10 complications: 3 infections, 1 DVT, 1 PE, 1 fast atrial fibrillation (AF), 1 screw malposition, 1 non-union, 1 undisplaced vertebral body fracture and 1 nerve root compression following osteotomy. The percentage return to theatre for screw malposition using 3D navigation was 1% of patients and 0.1% of pedicle screws. No patients developed permanent neurological compromise.

These systems provide accuracy that is comparable to traditional 2D fluoroscopic techniques. We advocate their use in the safe insertion of pedicle screws in complex revision deformity cases where original anatomical landmarks are absent or obscured. We also believe that radiation exposure is considerably less with navigation especially in these complex and revision cases.

Retrospective review of blood loss during posterior instrumented fusion in Adult Deformity Surgery before and after the introduction of the ultrasonic bone cutter into routine surgical technique

We retrospectively reviewed a large series of adult patients undergoing four or more levels of posterior instrumented fusion (+/− osteotomies/decompressions) over an eight year period. The senior surgeon (SM) switched to using the ultrasonic bone cutter instead of conventional cutting techniques at a specific point in time. We reviewed the clinical records of cases performed both before and after this time point and were able to identify blood loss from the clinical records. We reviewed actual blood loss by evaluating several aspects, including suction volumes, swab weights, re-infusion volumes, pre- and post- operative haemoglobin values and the type and amount of haemostatic agents used.

We demonstrated that a significant reduction in blood loss intra-operatively occurred with reduced use of haemostatic agents following introduction of the ultrasonic bone cutter as the method of bone removal.

Significant reductions in blood loss were achieved with implications in terms of patient mortality and morbidity, improved surgical field and reduced amount and cost of haemostatic agents.

To describe a staged surgical technique to correct significant progressive sagittal malalignment, without the need for 3-column osteotomy, in patients with prior long thoracolumbar instrumentation for scoliosis and to evaluate the radiographic and clinical outcome from this surgical strategy.

A small cohort study (n=6) of patients with significant sagittal malalignment following extensive thoracolumbar instrumented fusions for scoliotic deformity. Radiographic parameters analysed included pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, thoracic kyphosis and sagittal vertical axis. Clinical outcome measures collected included EQ-5D, ODI, SRS 22 and VAS Pain Scores.

3 patients had 2-stage anterior release and instrumented fusion followed by a posterior instrumented fusion 3 patients with a large sagittal plane deformity had a 3-stage surgical technique. All patients achieved an excellent correction of sagittal alignment, with no surgical complications and excellent health related quality of life (HRQOL) outcome measures at follow-up. There was no symptomatic non-unions or implant failures including rod breakages.

We present a safe and effective surgical strategy to treat the complex problem of progressive sagittal malalignment in the previously instrumented adult deformity patient, avoiding the need for 3-column osteotomies in the lumbar spine.

This study assesses whether balloon kyphoplasty (BKP) can safely restore height and correct deformity for cancer-related vertebral compression fractures (VCFs) involving the posterior vertebral body wall (PVBW), which is normally considered a relative contraindication.

Retrospective cohort study of 158 patients (99M:59F; mean age 63 years) with 228 cancer-related VCFs, who underwent BKP. 112 had VCFs with PVBW defects, and 46 had VCFs with no PVBW defect. Data was assessed preoperatively and at 3 months.

In the PVBW defect group, mean pain score decreased from 7.5 to 3.6 (p<0.001). There was a significant decrease in kyphotic angle (p<0.01), anterior vertebral body height (AVBH) (p<0.01) and mid-vertebral body height (MVBH) (p<0.05). In the PVBW intact group, mean pain score decreased from 7.3 to 3.3 (p<0.001). There was a significant improvement in AVBH and MVBH (p<0.001). When comparing groups, kyphotic angle, AVBH and MVBH were significantly worse in the PVBW defect group (P<0.05). More cement leaks occurred in the PVBW defect group.

BKP can alleviate pain but does not restore height or correct kyphosis in patients with cancer-related VCFs and PVBW defects. There is no appreciable increase in surgical risk.

Aim:

To simplify sagittal plane spinal assessment by describing a single novel angle in the lumbar spine equivalent to the difference between pelvic incidence (PI) and lumbar lordosis (LL) and evaluate its reliability.

Aim:

To establish whether there is a direct relationship between pelvic morphology and lumbar segmental angulation in the sagittal plane.

Objective: In 1989 Mirels published a scoring system for identifying impending pathological fractures in long bones. However, the spine is the most common site of skeletal metastases. A MR-based scoring system is proposed to quantify the risk of sustaining a pathological fracture through a metastatic lesion in a vertebral body.

Methods: A retrospective analysis of 101 vertebral body metastatic lesions was carried out. The metastases were identified through the onco-radiology database. Only lesions with a MR scan and subsequent imaging within 24-months of the index scan were included. Variables potentially predictive of impending fracture were analysed for significance. The significant variables were then statistically weighted. The original MR scans were scored, and the subsequent imaging was used to identify which lesions fractured. The scores were compared between the fracture and non-fracture group. Analysis was carried out for each predictive variable to establish whether they were individually as good as the scoring system alone in predicting fracture. Intra and inter-observer variability was assessed using kappa statistics.

Results: Twenty-one of the 101 lesions fractured within 24 months. A mean score of 0.65 was identified in the non-fracture group, whilst the fracture group had a mean score of 6.52 (p< 0.0001). The percentage risk of a lesion sustaining a pathological fracture was calculated for any given score. As the score increased above 4, so did the percentage risk of fracture (sensitivity 85.7%, specificity 97.5%). Very good intra and inter-observer agreement was present, showing the scoring system to be reliably reproducible.

Conclusions: The authors propose that all painful vertebral body metastatic lesions be evaluated by MR scanning. Lesions with a score of 3 or less can be left untreated. Lesions with scores of 4 or higher are at risk of fracture and should be considered for prophylactic cement augmentation.

The aim of the study was to assess the safety of a novel anatomical landmark in the placement of thoracic pedicle screws. It is our clinical observation that the sagittal plane of the screw trajectory is perpendicular to the plane of the superior articular facet, when the entry point is in the lateral half of the articular surface of the corresponding superior facet.

Using SECTRA software on a PACS digital imaging system, morphometric analysis was performed on thoracic vertebrae imaged using computed tomography (CT). For inclusion, the scan had to have no reported bony abnormality. It was determined whether a trajectory as described at 90 degrees to the articular facet, with an entry point just caudal to the lateral half of the facet to a depth of 25mm would breach either the medial wall of the pedicle or lateral vertebral body wall anterior to the costovertebral facet.

Sixty-two CT scans (744 segments, 1488 pedicle-facet complexes) were reviewed. 1154 complexes were suitable for full analysis. Exclusions were due to the lumbarisation of the T12 facet joints (62) or inability to clearly define the facet surface due to the plane of the CT slice (272). Of 1154 entry points assessed, 1154 (100%) were safe to be entered at 90 degrees to a depth of at least 25mm.

We have demonstrated the safety and reliability of a novel anatomical landmark in normal thoracic pedicles. We believe this will improve sagittal plane alignment and reduce further the risk of medial pedicle breach.

Acute osteoporotic vertebral compression fractures (VCFs) are frequently misdiagnosed as there is often no history of preceding trauma. VCFs not only cause back pain, but can also result in a loss of function, spinal deformity and increased mortality. Cement augmentation has been shown to effectively treat these fractures. It is impossible to diagnose an acute fracture on plain x-ray and therefore identify those likely to benefit from this treatment. The definitive investigation to determine the presence of an acute fracture is a MR scan, but this is a limited resource. The aim of this paper is to evaluate 2 new clinical signs which we believe aid in the diagnosis of an acute VCF: firstly closed fist percussion at the level of an acute VCF resulting in a severe, sharp fracture pain, and secondly the inability of a patient to lie supine. This was a prospective study of 78 patients with suspected acute VCFs.

48/78 had an acute fracture on MR. 42/45 patients who were positive for closed fist percussion, had an acute fracture on their MR scan. There were 6 patients who were negative for closed fist percussion who had an acute fracture (sensitivity 87.5%, specificity 90%).

39/41 patients who were positive for the supine sign had an acute fracture on their MR scan. There were 9 patients who were comfortably able to lay supine who had an acute fracture (sensitivity 81.25%, specificity 93.33%).

Either a positive closed fist percussion sign or a positive supine sign is a reliable indicator of the presence of an acute VCF. By incorporating these signs into our routine clinical assessment we are better able to predict which patients have an acute fracture, and therefore decide which patients need a MR scan.

Objective: In 1989 Mirels published a scoring system for identifying impending pathological fractures in long bones, and it is now standard practice that long bones with metastases at risk of fracture are treated with prophylactic internal fixation. The spine is the most common site of skeletal metastases, with spinal metastases present in up to 36% of patients with terminal cancer. A pathological fracture through a vertebral body can result in paralysis, incontinence and severe pain. However, there is no equivalent of the Mirels’ scoring system to aid the spinal surgeon in determining the probability of an impending spinal fracture.

A weighted scoring system is proposed to quantify the risk of sustaining a pathological fracture through a metastatic lesion in a vertebral body. This system analyzes and combines four magnetic resonance (MR) risk factors into a single score.

Methods: A retrospective analysis of 100 vertebral body metastatic lesions was carried out. The original MR scans were scored, and the subsequent imaging was used to identify which vertebral body lesions fractured. Patients with no subsequent imaging within 12 months were excluded.

Results: Twenty of the 100 lesions fractured within 12 months. A mean score of 0.64 was identified in the non-fracture group, where as the fracture group had a mean score of 6.80. The percentage risk of a lesion sustaining a pathological fracture was calculated for any given score. As the score increased above 3, so did the percentage risk of fracture (sensitivity 90%, specificity 91%).

Conclusions: The authors propose that all painful vertebral body metastatic lesions be evaluated by MR scanning. Lesions with a score of 2 or less can be left untreated, while lesions with scores of 3 or higher should be considered for prophylactic balloon kyphoplasty.

Introduction: Cervical spine pedicle morphology has been assessed by direct measurement and by CT in cadavers. We have assessed reproducibility and produced data for normal ranges in live subjects from the UK.

Method: 54 axial CT scans were examined. All subjects were scanned for the exclusion of fracture between December 2003 and December 2004. The digitised images were analysed on the Philips PACS system using SECTRA software. 168 individual vertebrae were assessed between C3 and C7. The following were measured; the angle of the pedicle relative to the sagittal plane, the smallest internal and external diameter, the angle of the lamina and the distance from the lateral mass to the anterior vertebral body (LMAVB) in the line of the pedicle. Reproducibility was assessed in a subset of 10 individuals with paired measures using the FDA approved formula for CV%.

Results: Angular measures had a CV% of 3.9%. The re-measurement error for distance was 0.5mm. 338 pedicles were assessed in 25 females and 29 males. Average age was 48.2 years (range 17–85). Our data from live subjects was comparable to previous cadaveric data. Mean pedicle external diameter was 4.9mm at C3 and 6.6mm at C7. Females were marginally smaller than males. Left and right did not significantly differ. Mean LMAVB was 34mm (min 21mm). In no case was the pedicle narrower than 3.2mm. Mean pedicle angle was 130 deg at C3 and 140 deg at C7.

Conclusions: CT measurement has acceptable reproducibility. Previous cadaveric measurements have been validated in live subjects in the UK. Although there is some variation in morphology, instrumentation no wider than 3.0mm and no longer than 20mm is unlikely to prove too large for an adult pedicle.

Introduction: We have assessed the clinical observation that the angle of the contralateral lamina matches the angle required from the sagittal plane for the placement of pedicle screws in the subaxial cervical spine.

Method: 54 axial CT scans were examined. All subjects were scanned for the exclusion of fracture between December 2003 and December 2004. The digitised images were analysed on the Philips PACS system using SECTRA software. 168 individual vertebrae were assessed between C3 and C7. The following were measured; the angle of the pedicle relative to the sagittal plane, the smallest internal and external diameter, the angle of the lamina and the distance from the lateral mass to the anterior vertebral body (LMAVB) in the line of the pedicle. Reproducibility was assessed in a subset of 10 individuals with paired measures using the FDA approved formula for CV%.

Results: Angular measures had a CV% of 3.9%. The re-measurement error for distance was 0.5mm. 336 pedicles were assessed in 25 females and 29 males. Average age was 48.2 years (range 17–85). Our morphologic data from live subjects was comparable to previous cadaveric data. Mean pedicle external diameter was 4.9mm at C3 and 6.6mm at C7. Females were marginally smaller than males. Left and right did not significantly differ. In no case was the pedicle narrower than 3.2mm. Mean pedicle angle was 130 deg at C3 and 140 deg at C7. The laminar angle correlated well at C3,4,5 (R2> 0.7) and was within 1 deg of pedicle angle. At C6,7 it was within 11 deg. In all cases a line parallel to the lamina provided a safe corridor of 3mm for a pedicle implant.

Conclusions: The contralateral lamina provides a reliable intraoperative guide to the angle from the sagittal plane for subaxial cervical pedicle instrumentation in adults.

Background: There are conflicting reports regarding the effect of scoliosis surgery on respiratory function in Duchenne Muscular Dystrophy (DMD)^1,2. Galasko et al² found that the Percentage Predicted Forced Vital Capacity (%PFVC), remained static for thirty six months following surgery, in patients with DMD that underwent spinal stabilisation for scoliosis. The aim of the current study was to support or refute the above finding in a large series of patients with DMD.

Methods: A retrospective analysis of data on 55 consecutive patients with DMD that underwent single stage posterior surgical correction for scoliosis. We analysed the data of 55 boys with DMD who underwent scoliosis surgery between 1990 and 2002. Age at surgery, pre-operative Cobb angles, pre-operative %PFVC, and post-operative %PFVC at 6 months, 12-18 months and 2–3 years were collected. We documented the pre-operative Cobb angle ± SD to assess the difficulty level of our surgical cases. Percentage PFVC was used as our outcome measure to assess respiratory function. The mean pre-operative %PFVC was compared to the post –operative mean %PFVC at three different time intervals; at 6 months, 12 to 18 months and at 2 to 3 years.

Results: The mean age was 14.6 years (range 11.2–18yrs). The mean pre-operative Cobb angle was 65.4 degrees ± 14.8. The mean %PFVC pre-operatively was 33.9 ± 10.4. The mean post-operative %PFVC’s were: 6 months (29.1 ± 10.4), 12 to 18 months (27.6 ± 12.1) and 2 to 3 years (25.4 ± 8.7). Therefore the mean % PFVC following surgery at 6 months, 12 to 18 months and 2 to 3 years decreased from the mean pre-operative % PFVC by 4.8%, 6.3% and 8.5% respectively.

Conclusion: The natural history of patients with DMD is a gradual decline in respiratory function. In the current study the mean post –operative %PFVC was less than the mean pre-operative %PFVC at 6 months, 12 to 18 months and at 2 to 3 years post surgery. Our series would suggest that respiratory function declines post-operatively, even in the short term, in patients with DMD that undergo spinal stabilisation. The decline in respiratory function in our study was progressive over the 3 year follow up period.

Background: Sacral tumours are commonly diagnosed late and therefore are often large and at an advanced stage before treatment is instituted. The late presentation means that curative surgical excision is technically demanding¹. Total en-bloc sacrectomy is fraught with potential complications: deep infection, substantial blood loss, large bone and soft tissue defects, bladder, bowel and sexual dysfunction, spinal-pelvic non-union, and gait disturbance². The aim of the current study was two-fold: firstly to detail the technique used by the senior author and chronicle how this has evolved; and secondly to present the complications and outcome of nine total en bloc sacrectomies.

Methods: We retrospectively analysed of total en-bloc sacrectomies between 1991 and 2004. Nine patients (2M, 7F, mean age at surgery 39 years, range 21 – 64yrs) with a diagnosis of primary sacral tumour underwent total en-bloc sacrectomy under the care of the senior author. The mean follow-up was 50.2 months (range: 3.5 – 161 mths). Patients’ functional outcome was evaluated using the Functional Independence Measure (FIM) instrument and the SF-36. Intra-operative and postoperative complications (including disease progression) were documented.

Results: Surgical technique has evolved from single stage surgery without and with colostomy to two stage surgery with colostomy. Currently, the first stage includes an anterior lumbar interbody fusion at L4/L5 retaining the L5 nerve roots. In the second stage an L4 to pelvic fusion is performed posteriorally. The dura is tied and divided just below the L5 roots. The mean total operating time was 13.3 hrs (range: 8 – 20.1hrs); the mean total blood loss 14.1 ltrs (range: 4.2 – 33 ltrs). There were two revision L4 to pelvic fusions for pseudoarthroses. The mean length of hospital stay was 8.9mths (range: 2 – 36mths). One patient had a recurrence and died 2 years after her surgery. Of the surviving 8 patients the results from the functional outcome scores were variable. Three patients are able to walk independently; the remaining 5 are all mobile but require differing degrees of assistance to walk.

Conclusion: Total en bloc sacrectomy is a major surgical undertaking but our series has shown that it is probably justified in view of the fact that 8 out of 9 patients have had no tumour recurrence and all are able to walk.