Aims

The aim of this study was to investigate whether the type of cervical disc herniation influences the severity of symptoms at the time of presentation, and the outcome after surgical treatment.

Aims. Some patients presenting with hip pain and instability and underlying acetabular dysplasia (AD) do not experience resolution of symptoms after surgical management. Hip-spine syndrome is a possible underlying cause. We hypothesized that there is a higher frequency of radiological spine anomalies in patients with AD. We also assessed the relationship between radiological severity of AD and frequency of spine anomalies. Methods. In a retrospective analysis of registry data, 122 hips in 122 patients who presented with hip pain and and a final diagnosis of AD were studied. Two observers analyzed hip and spine variables using standard radiographs to assess AD. The frequency of lumbosacral transitional vertebra (LSTV), along with associated Castellvi grade, pars interarticularis defect, and spinal morphological measurements were recorded and correlated with radiological severity of AD. Results. Out of 122 patients, 110 (90.2%) were female and 12 (9.8%) were male. We analyzed the radiographs of 122 hips (59 (48.4%) symptomatic left hips, and 63 (51.6%) symptomatic right hips). Average age at time of presentation was 34.2 years (SD 11.2). Frequency of LSTV was high (39% to 43%), compared to historic records from the general population, with Castellvi type 3b being the most common (60% to 63%). Patients with AD have increased L4 and L5 interpedicular distance compared to published values. Frequency of pars interarticularis defect was 4%. Intraclass correlation coefficient for hip and spine variables assessed ranged from good (0.60 to 0.75) to excellent (0.75 to 1.00). Severity of AD did not demonstrate significant correlation with frequency of radiological spine anomalies. Conclusion. Patients with AD have increased frequency of spinal anomalies seen on standard hip radiographs. However, there exists no correlation between radiological severity of AD and frequency of spine anomalies. In managing AD patients, clinicians should also assess spinal anomalies that are easily found on standard hip radiographs. Cite this article: Bone Joint J 2021;103-B(8):1351–1357

Aims. Although lumbosacral transitional vertebrae (LSTV) are well-documented, few large-scale studies have investigated thoracolumbar transitional vertebrae (TLTV) and spinal numerical variants. This study sought to establish the prevalence of numerical variants and to evaluate their relationship with clinical problems. Methods. A total of 1,179 patients who had undergone thoracic, abdominal, and pelvic CT scanning were divided into groups according to the number of thoracic and lumbar vertebrae, and the presence or absence of TLTV or LSTV. The prevalence of spinal anomalies was noted. The relationship of spinal anomalies to clinical symptoms (low back pain, Japanese Orthopaedic Association score, Roland-Morris Disability Questionnaire) and degenerative spondylolisthesis (DS) was also investigated. Results. Normal vertebral morphology (12 thoracic and five lumbar vertebrae without TLTV and LSTV) was present in 531 male (76.7%) and 369 female patients (75.8%). Thoracolumbar transitional vertebrae were present in 15.8% of males and 16.0% of females. LSTV were present in 7.1% of males and 9.0% of females. The prevalence of the anomaly of 16 presacral mobile vertebrae (total number of thoracolumbar vertebrae and TLTV) without LSTV was 1.0% in males and 4.1% in females, and that of the anomaly of 18 vertebrae without LSTV was 5.3% in males and 1.2% in females. The prevalence of DS was significantly higher in females with a total of 16 vertebrae than in those with normal morphology. There was no significant correlation between a spinal anomaly and clinical symptoms. Conclusion. Overall, 24% of subjects had anomalies in the thoracolumbar region: the type of anomaly differed between males and females, which could have significant implications for spinal surgery. A decreased number of vertebrae was associated with DS: numerical variants may potentially be a clinical problem. Cite this article: Bone Joint J 2021;103-B(7):1301–1308

Introduction. Developments in the use of ultrasound during pregnancy for assessment of fetal spine abnormalities indicate a need for accurate information about the antenatal development of the vertebral column. The published work is deficient in this regard, with available data examining only the period of 8–26 weeks. The aims of this study are to establish antenatal spine growth curves with fetal radiographs, to establish growth velocity curves for each anatomical spinal, region and to calculate the multiplier factor during antenatal life. Methods. 75 anteroposterior spine radiographs were retrieved from the fetal pathology unit. Cases with spinal anomalies were excluded from analysis. Individual vertebral regions were measured from radiographs with the method of Bagnall and colleagues,1 with use of DICOM software. Polynomial regression analysis was applied to each measurement with PASW statistics 18 (SPSS, Chicago, IL, USA). Results. 47 cases were included in the analysis. Gestational age ranged from 14–40 weeks. Growth velocity was greatest in the thoracic region and least in the sacral region. The table shows regression equations for each spinal region. Conclusions. Regression equations from this study will have direct clinical application in the antenatal ultrasound assessment of fetal maturity and normality, particularly the third trimester data. Use of the standard error of the estimate as an approximation to normal values will allow antenatal identification of anomalies, particularly in cases of scoliosis, spina bifida, and anencephaly

Study Design: A retrospective analysis of patients with spinal disorders using Magnetic Resonance Imaging (MRI) results. Objective: To review the clinical and MRI results of patients with various scoliotic deformities. Background: Insufficient reports exist regarding the MRI’s of scoliotic deformities. MRI’s can offer vital information in the diagnosis of various types of scoliosis and their concomitant disorders. Methods: MRI reults of a total of 277 patients with various types of scoliosis/kyphoscoliosis were reviewed. All patients met the cobb angle criteria: > or = 20 degrees. 65 (23.46%) patients were male and 212 (76.53%) were female. 224 (80.86%) patients received conservative treatment and 53 (19.14%) underwent surgical treatments. 107 (38.62%) patients had adolescent idiopathic scoliosis, mean age: 13.7 (7–18) years, 76 (27.43%) adult idiopathic, mean age: 29.53 (19–79) years, 48 (17.32%) congenital, mean age: 12.6, (1–46) years, 29 (10.46%) neuromuscular, mean age: 12.86 (2–30) years, 15 (5.41%) syndromic, mean age: 13.6 (1–29) years, 2 (0.72%) tumor related, mean age:10.5 (8–13) years. Results: MRI results revealed the spinal cord of 169 (61.01%) patients as normal: no spinal cord anomalies, tumors, or congenital problems. Of the remaining patients 108 (38.98%) the following irregularities were diagnosed: 39 (36.11%) syringohydromyeli in various spinal locations, 29 (26.85%) butterfly vertebrae, 19 tethered cord (17.59%), 10 (9.2%) split cord, 10 diastometamyelia, 10 cleft vertebrae, 14 (12.96%) myelomeningocele, 7 (6.48%) grade one spondilolisthezis, 5 (4.62%) caudal regression syndromes, 6 (5.55%) vertebra partial fusion, 4 (3.7%) cranio-cervical problems, 4 cerebellar tonsillar ectopia, 3 (2.77%) block vertebra, 3 chiari typ2 II, 3 TIS, 2 (1.85%) tumors on the spinal column, 2 neurofibromatosis, 2 introdural lipoma, 2 myelomalacia of the spinal cord, 2 spinal cord injuries, 1 (0.92%) arachnoid cyst, 1 neuroanteric, 1 spina bifida, 1 scheuermann, 1 vertebral artery hypoplasia, 1 sacral dermal sinus, 1 cervical rib, 1 interpedicullar cyst, 1 high scapula, 1 sphenoid sinus retention cyst, 1 paravertebral cyst, 1 Schmorl’s node, 1 Tarlow cyst and 1 intercranial pineal cyst. Conclusion: Our study revealed how MRI analysis can lead to the accurate diagnosis of scoliotic deformities. In many cases tumors, neuromuscular pathology and syndromic conditions can be misdiagnosed as scoliotic. Careful MRI review can offer vital information for diagnosis and help determine the classification of scoliosis and subsequent treatment

Structural defects of the posterior arch of the atlas are rare, and range from clefts of variable location and size to more extensive defects such as complete agenesis. These abnormalities are usually incidental radiological findings. We present a case of a fracture of the anterior arch of the atlas associated with a congenital abnormality of the posterior arch.

We describe a case of a three year old girl with Caudal Regression Syndrome (CRS) at the ninth thoracic vertebral level with termination of the spinal cord at the unusually high level of the third thoracic vertebra. We describe this rare condition and discuss the challenging management in an extremely rare case where there is termination of the spinal cord at a high thoracic level. CRS is a severe congenital neural and skeletal deficiency that is characterized by absence of the entire sacrum and of variable amounts of the lumbar and occasionally thoracic spine with associated neural elements. This is accompanied by a number of congenital visceral abnormalities. Controversy belies the optimal orthopaedic management of the spinal anomaly and the associated lower extremity deformities in this condition. Affected children have multiple musculoskeletal abnormalities, including foot deformities, knee and hip flexion contractures, dis-located hips, spino-pelvic instability, and scoliosis. We believe the care of these complex patients should be highly individualized. Patients with types I and II lumbosacral agenesis have an excellent chance of becoming community ambulators and early interventions should be taken to correct the associated orthopaedic deformities. Treatment of types III and IV lumbosacral agenesis is controversial. In these severe forms of agenesis periodic examinations of the spine for scoliosis should be performed and the patient must be monitored for spinopelvic instability as indicated by a worsening posture. The management of these and other orthopaedic deformities is controversial but we do advocate the surgical correction of fixed deformities of the lower extremities which interfere with sitting or with the wearing of braces or shoes thereby avoiding amputation and maintaining body image

Bertolotti’s syndrome is characterised by anomalous enlargement of the transverse process(es) of the most caudal lumbar vertebra which may articulate or fuse with the sacrum or ilium and cause isolated L4/5 disc disease.

We analysed the elective MR scans of the lumbosacral spine of 769 consecutive patients with low back pain taken between July 2003 and November 2004. Of these 568 showed disc degeneration. Bertolotti’s syndrome was present in 35 patients with a mean age of 32.7 years (15 to 60). This was a younger age than that of patients with multiple disc degeneration, single-level disease and isolated disc degeneration at the L4/5 level (p ≤ 0.05). The overall incidence of Bertolotti’s syndrome in our study was 4.6% (35 of 769). It was present in 11.4% (20 patients) of the under-30 age group.

Our findings suggest that Bertolotti’s syndrome must form part of a list of differential diagnoses in the investigation of low back pain in young people.

We reviewed retrospectively 45 patients (46 procedures) with bladder exstrophy treated by bilateral oblique pelvic osteotomy in conjunction with genitourinary repair.

The operative technique and post-operative management with or without external fixation are described. A total of 21 patients attended a special follow-up clinic and 24 were interviewed by telephone. The mean follow-up time was 57 months (24 to 108).

Of the 45 patients, 42 reported no pain or functional disability, although six had a waddling gait and two had marked external rotation of the hip. Complications included three cases of infection and loosening of the external fixator requiring early removal with no deleterious effect. Mid-line closure failed in one neonate managed in plaster. This patient underwent a successful revision procedure several months later using repeat osteotomies and external fixation.

The percentage pubic approximation was measured on anteroposterior radiographs pre-operatively, post-operatively and at final follow-up. The mean approximation was 37% (12% to 76%). It varied markedly with age and was better when external fixation was used. The wide range reflects the inability of the anterior segment to develop naturally in spite of close approximation at operation.

We conclude that bilateral oblique pelvic osteotomy with or without external fixation is useful in the management of difficult primary closure in bladder exstrophy, failed primary closure and secondary reconstruction.

Between 1964 and 2002, 26 pairs of conjoint twins were recorded at the Red Cross Hospital. The available radiographs and notes were reviewed, with specific attention to the incidence of spinal anomalies that result in scoliosis. Structural scoliosis was noted to occur only in the ischiopagus and pygopagus subsets, namely those joined by the pelvic outlet and the rump respectively. The abnormalities were largely those of failure of formation, with early onset of severe deformity. The hemi-vertebrae were often remote to the area of conjunction, mostly in the thoracic area. All six ischiopagi had vertebral abnormalities, with two of the four pygopagi demonstrating abnormalities. There were associated lower limb neurological abnormalities in the ischiopagi. The association of conjoint twinning and vertebral anomaly is currently thought to be due to non-specific teratogenic insult with hypoxia. The fact that the ischiopagus and pygopagus are involved is important: these groups constitute up to 45% of survivors and are reported to have a longer life expectancy. Because they will later develop severe deformities, they need early active management

Objective To assess the validity of Somatosensory Evoked Potential (SSEP) monitoring in identifying potential spinal cord vascular damage resulting from segmental artery ligation in anterior spinal deformity correction. Design SSEP monitoring was undertaken in patients deemed at risk of spinal cord vascular injury during corrective surgery. The segmental vessels of the vertebral bodies to be instrumented were identified. Baseline SSEPs were obtained prior to application of non-crushing microvascular clamps. After ten minutes of occlusion, further SSEP recordings were made. Surgery proceeded with either, vessel ligation and division allowing anterior instrumentation, or vessel sparing anterior release. Subjects 22 patients were included; 7 had Scheuermann’s hyperkyphosis and 15 had scoliosis (11 idiopathic, 3 syndromic, 1 neuromuscular). Perceived risk was defined by the presence of hyperkyphosis, abnormal neurological examination or radiologically identified spinal cord anomaly. Outcome Measures A drop of 30% from baseline reading was taken as significant. Post-operative neurological outcome was correlated with intra-operative signal change and alteration in planned surgery. Results There was no significant drop in post-clamping SSEPs in the hyperkyphotic patients. In 3 scoliosis patients anterior instrumentation was abandoned and a release was performed. Staged posterior instrumentation followed. In a further 2, anterior instrumentation proceeded but in a modified fashion. The remaining 10 patients had no significant drop and underwent the surgery as planned. No patient sustained a neurological injury. Conclusions SSEP monitoring is safe in assessing the apparent contribution of segmental vessel blood supply to the spinal cord in spinal deformity surgery. It has allowed timely alteration of planned surgical procedures that potentially may have caused vascular spinal cord injury

Introduction: Although there are several known causes of scoliosis, most are of unknown cause and develop during adolescence, making adolescent idiopathic scoliosis (AIS) the most common form. It has long been hypothesised that unilateral closure of the neurocentral junction accompanied by continued growth on the opposite side could lead to vertebral rotation and subsequent lateral curvature. However, autopsy studies of neurocentral junction closure in children has revealed that these joints close at approximately six years of age consequently excluding this hypothesis as a cause of AIS. In contrast, a recent MRI study has suggested that in some children at least, the NCJ does not close until much later in development around the time of puberty thereby resurrecting this hypothesis as a potential cause of AIS. This study was designed to investigate closure time and pattern of closure of the NCJ in normal patients to determine whether further examination of this hypothesis might be warranted. Methods and results: The morphology of the NCJs in 20 patients between the ages of 3 and 15 were observed in MR images taken for purposes other than spinal anomaly. The structure of individual NCJs were observed and reconstructed in 3-dimensions. The age at which NCJs became closed was determined and pattern of closure of a typical NCJ was created using the reconstructed images. The pattern of closure of the NCJs along the vertebral column was also determined and any differences between right and left sides at the same level was also noted. The results showed that there was a sequence of closure along the vertebral column for the NCJs with those in the cervical and lumbar regions being the first to close and those at the approximate level of T8 being the last to close. While the NCJs in the cervical and lumbar regions close at 5–6 years of age, those in the thoracic region, that are the last to close, do so at approximately 12 years of age. No significant difference between the stage of closure of the left and right sides was seen at any level. Conclusion: The results of this study have shown that the closure of the NCJs in those vertebrae that form at approximately the most common level for the apical vertebra associated with AIS (midthoracic) does not occur until the time of puberty. This contrasts sharply with previously held views on the age of closure. Although no significant difference in closure between left and right sides was seen among these particular patients it does not exclude unilateral closure as a cause of AIS at least in some patients. These results suggest that examination of this hypothesis should be resurrected and that further study is well warranted. MR examination of young patients with small, initial curves could be well worthwhile

There is a close link between the embryological development of the musculoskeletal system and all other main organ systems. We report a prospective series of 202 patients with congenital vertebral abnormalities and document the associated abnormalities in other systems. There were 100 boys and 102 girls. In 153 there were 460 associated abnormalities, a mean of 2.27 abnormalities for each patient. Intravenous pyelography was carried out on 173 patients (85.6%) and ultrasonography on the remaining 29 (14.4%). Patients with genitourinary anomalies were more likely to have musculoskeletal (p = 0.002), gastrointestinal (p = 0.02) and cardiac abnormalities (p = 0.008) than those without genitourinary involvement. A total of 54 (26.7%) had at least one genitourinary abnormality, the most frequent being unilateral renal agenesis. There was urinary obstruction in six (3%). There was no association between genitourinary abnormality and the place of birth, parental age, birth order, level of spinal curvature, or the number, type and side of spinal anomaly. There was, however, a statistically significant association (p = 0.04) between costal and genitourinary abnormalities. The incidence of genitourinary abnormalities (26.7%) was similar to that of previously reported series. The diagnosis of a congenital vertebral abnormality should alert the clinician to a wide spectrum of possible associated anomalies most of which are of clinical importance