Complex spinal deformities can cause pain, neurological symptoms and imbalance (sagittal and/or coronal), severely impairing patients’ quality of life and causing disability. Their treatment has always represented a tough challenge: prior to the introduction of modern internal fixation systems, the only option was an arthrodesis to prevent worsening of the deformity. Then, the introduction of pedicle screws allowed the surgeons to perform powerful corrective manoeuvres, distributing forces over multiple levels, to which eventually associate osteotomies. In treating flexible coronal deformities, in-ternal fixation and corrective manoeuvres may be sufficient: the combination of high density pedicle screws and direct vertebral rotation revolutionized surgical treatment of scoliosis. However, spinal osteotomies are needed for correcting complex rigid deformities; the type of osteot-omy must be chosen according to the aetiology, type and apex of the deformity. When dealing with large radius deformities, spread over multiple levels and without fusion, multiple posterior column os-teotomies such as Smith-Petersen and Ponte (asymmetric, when treating scoliosis) can be performed, dissipating the correction over many levels. Conversely, the management of a sharp, angulated de-formity that involves a few vertebral levels and/or with bony fusion, requires more aggressive 3 col-umn osteotomies such as Pedicle Subtraction Osteotomies (PSO), Bone Disc Bone Osteotomies (BDBO) or Vertebral Column Resection (VCR). Sometimes the deformity is so severe that cannot be corrected with only one osteotomy: in this scenario, multilevel osteotomies can be performed

Aims

Magnetically controlled growing rods (MCGR) have been gaining popularity in the management of early-onset scoliosis (EOS) over the past decade. We present our experience with the first 44 MCGR consecutive cases treated at our institution.

Aims

The aim of this study is to introduce and investigate the efficacy and feasibility of a new vertebral osteotomy technique, vertebral column decancellation (VCD), for rigid thoracolumbar kyphotic deformity (TLKD) secondary to ankylosing spondylitis (AS).

The interaction between the lumbosacral spine and the pelvis is dynamically related to positional change, and may be complicated by co-existing pathology. This review summarises the current literature examining the effect of sagittal spinal deformity on pelvic and acetabular orientation during total hip arthroplasty (THA) and provides recommendations to aid in placement of the acetabular component for patients with co-existing spinal pathology or long spinal fusions. Pre-operatively, patients can be divided into four categories based on the flexibility and sagittal balance of the spine. Using this information as a guide, placement of the acetabular component can be optimal based on the type and significance of co-existing spinal deformity.

Cite this article: Bone Joint J 2015;97-B:1017–23.

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.

Few studies have examined the order in which a spinal osteotomy and total hip replacement (THR) are to be performed for patients with ankylosing spondylitis. We have retrospectively reviewed 28 consecutive patients with ankylosing spondylitis who underwent both a spinal osteotomy and a THR from September 2004 to November 2012. In the cohort 22 patients had a spinal osteotomy before a THR (group 1), and six patients had a THR before a spinal osteotomy (group 2). The mean duration of follow-up was 3.5 years (2 to 9). The spinal sagittal Cobb angle of the vertebral osteotomy segment was corrected from a pre-operative kyphosis angle of 32.4 (SD 15.5°) to a post-operative lordosis 29.6 (SD 11.2°) (p < 0.001). Significant improvements in pain, function and range of movement were observed following THR. In group 2, two of six patients had an early anterior dislocation. The spinal osteotomy was performed two weeks after the THR. At follow-up, no hip has required revision in either group. Although this non-comparative study only involved a small number of patients, given our experience, we believe a spinal osteotomy should be performed prior to a THR, unless the deformity is so severe that the procedure cannot be performed. Cite this article: Bone Joint J 2014;96-B:360–5

To determine extent of correction in spinal osteotomy for fixed sagittal plane deformity. Radiographic retrospective cohort analysis using standardised standing whole spine radiographs. Level III evidence. 24 patients (14 females/10 males, av. 53.6 yrs) with sagittal plane deformity due to either ankylosing spondylitis (4), idiopathic (12), congenital (1), tumour (2), infectious (1), or posttraumatic (4) aetiologies. Max. 4 yrs follow up. Sagittal balance, lumbar lordosis correction, osteotomy angle, pelvic indices. Chevron (3), pedicle subtraction (17), and vertebral column resection (4) osteotomies were performed with the majority at L3 (9) and L2 (8). The C7-S1 sagittal vertical axis demonstrated a preoperative decompensation averaging 12.0 cm (range -7 to 37) with 55% of patients achieving normal sagittal balance postoperatively. Lumbar lordosis increased from 28.9° (range -28 to 63) to 48.9° (range 12 to 69) (22.3° av. correction). L3 osteotomy angle was largest, average 31° (range, 16 to 47). There were 11 complications comprising; major (1) and minor (1) neurological, junctional kyphosis (3), metalwork problems (2), dural tear (2) and infection (2). Four patients required additional surgery at latest follow-up. Technical outcome was good 11(50%), fair 8(36%), poor 3(14%). Spinal osteotomy is a very effective technique to correct fixed sagittal imbalance and provide biomechanical stability. The high complication rate mandates a careful assessment of the risk/benefit ratio before undertaking what is a major reconstructive procedure. Most patients are satisfied, particularly when sagittal balance is achieved

The dismal outcome of tuberculosis of the spine in the pre-antibiotic era has improved significantly because of the use of potent antitubercular drugs, modern diagnostic aids and advances in surgical management. MRI allows the diagnosis of a tuberculous lesion, with a sensitivity of 100% and specificity of 88%, well before deformity develops. Neurological deficit and deformity are the worst complications of spinal tuberculosis. Patients treated conservatively show an increase in deformity of about 15°. In children, a kyphosis continues to increase with growth even after the lesion has healed. Tuberculosis of the spine is a medical disease which is not primarily treated surgically, but operation is required to prevent and treat the complications. Panvertebral lesions, therapeutically refractory disease, severe kyphosis, a developing neurological deficit, lack of improvement or deterioration are indications for surgery. Patients who present with a kyphosis of 60° or more, or one which is likely to progress, require anterior decompression, posterior shortening, posterior instrumented stabilisation and anterior and posterior bone grafting in the active stage of the disease. Late-onset paraplegia is best prevented rather than treated. The awareness and suspicion of an atypical presentation of spinal tuberculosis should be high in order to obtain a good outcome. Therapeutically refractory cases of tuberculosis of the spine are increasing in association with the presence of HIV and multidrug-resistant tuberculosis.

Segmental vessel ligation during anterior spinal surgery has been associated with paraplegia. However, the incidence and risk factors for this devastating complication are debated.

We reviewed 346 consecutive paediatric and adolescent patients ranging in age from three to 18 years who underwent surgery for anterior spinal deformity through a thoracic or thoracoabdominal approach, during which 2651 segmental vessels were ligated. There were 173 patients with idiopathic scoliosis, 80 with congenital scoliosis or kyphosis, 43 with neuromuscular and 31 with syndromic scoliosis, 12 with a scoliosis associated with intraspinal abnormalities, and seven with a kyphosis.

There was only one neurological complication, which occurred in a patient with a 127° congenital thoracic scoliosis due to a unilateral unsegmented bar with contralateral hemivertebrae at the same level associated with a thoracic diastematomyelia and tethered cord. This patient was operated upon early in the series, when intra-operative spinal cord monitoring was not available.

Intra-operative spinal cord monitoring with the use of somatosensory evoked potentials alone or with motor evoked potentials was performed in 331 patients. This showed no evidence of signal change after ligation of the segmental vessels.

In our experience, unilateral segmental vessel ligation carries no risk of neurological damage to the spinal cord unless performed in patients with complex congenital spinal deformities occurring primarily in the thoracic spine and associated with intraspinal anomalies at the same level, where the vascular supply to the cord may be abnormal.

Study Design: Retrospective chart review. Summary of Background Data: Spinal osteotomy in ankylosing spondylitis is performed to restore forward gaze and sagittal balance. Closing wedge lumbar osteotomy and polysegmental thoracic osteotomy in the same patient has not been reported. Objective: To study the factors affecting correction of sagittal balance. Subjects: 27 patients (23 male, 4 female) operated between 1989–2002: average age 46 years: minimum follow-up: 18 months. 19 patients had lumbar osteotomy alone, 6 had both lumbar and thoracic osteotomies and 2 had thoracic osteotomy alone. Three groups were identified: A) patients with decreased lumbar-lordosis and normal thoracic-kyphosis B) Normal / increased lumbar-lordosis and increased thoracic-kyphosis C) Decreased lumbar-lordosis and increased thoracic-kyphosis. Results: Preoperatively, mean sagittal balance was +103 mm, thoracic-kyphosis 61 degrees, and lumbar-lordosis 25 degrees. Three months postoperatively, sagittal balance was +36 mm, thoracic-kyphosis 55 degrees, and lumbar-lordosis 49 degrees. At final follow-up sagittal balance was +44 mm, thoracic-kyphosis 57 degrees and lumbar-lordosis 46 degrees. In patients who had thoracic osteotomies, thoracic-kyphosis of 78 degrees was corrected to 48 degrees. There were no spinal cord injuries or permanent nerve root palsies. Six patients had deterioration of sagittal balance (SB) (> 45 mm), 5 of them required cervical osteotomy. There was significant association between post-operative thoracic-kyphosis of > 60 degrees and SB deterioration (p-value < .001, sensitivity 100%, specificity 75%). Statistically there was no significant association between SB deterioration and post-operative sagittal balance, lumbar-lordosis, osteotomy-angle and extent of fixation. Conclusions: Correction of thoracic-kyphosis affected final sagittal balance significantly. Consideration should be given to the simultaneous performance of lumbar osteotomy and polysegmental thoracic osteotomies in selected patients to obtain greater correction and restoration of near normal sagittal balance

Purpose: Single-segment wedge osteotomy is classically proposed to correct for kyphosis subsequent to ankylosing spondylitits. We analysed the usefulness of this technique for other indications (revision procedures for flat back and deformed calluses of the lumbar spine) by studying the overall sagittal balance of the spine and tilt of the sacrum. Material and methods: Between 1980 and 1999, we retained 68 patients with complet clinical and radiological data (37 patients with ankylosing spondylitis and 31 patients with “post-operative” flat back, including nine trauma cases and 22 degenerative spines). Opening osteotomy was performed in the first 19 patients and closure osteotomy in the next 49. The correction level was L2L3 in 26 patients and lower in 42. Digitalised lateral views of the entire spine were obtained at minimum follow-up of three years to measure:. - posterior displacement of T9 (between the vertical line and a line joining the geometric centre of T9 and the femoral heads (normal 11±5°),. - tilt of the sacrum (angle between the horizontal line and a line tangent to the superior surface of the sacrum (normal 41±5°). Results and discussion: The overall angle of local correction was 44° and the correction of T9 displacement was 30.6°. For the low osteotomies, the local correction was 49° and the T9 displacement was +28° (−2° to +26°). Tilt of the sacrum varied from 4° to 7°. Tilt of the sacrum was influenced more and more for lower and lower osteotomies. T9 displacement stabilised between 12° and 26° (mean 19°) irrespective of the osteotomy level, although the angle of local correction was greater (up to 60°). This discordance was explained by adaptation of the pelvis. Seven patients developed secondary functional kyphosis (limited hip movement preventing the necessary adaptation to the overall correction of the sagittal balance). Conclusion: Single-segment spinal osteotomy remains difficult but offers very important correction possibilities affecting the position of the trunk and adaptation of the pelvis. The level for the correction must be chosen with care because it conditions final adjustment and function consequences affecting the pelvis

Introduction: Large anterior column defects of the thoracolumbar spine, after fracture decompression, tumour or other pathological resection, or spinal osteotomy present significant difficulties in respect to autograft procurement, donor site morbidity, graft instability and residual spinal instability. Titanium Mesh Cages for reconstruction thoracolumbar vertebral body defects (after corpectomy) offer an alternative to structural iliac crest autograft or allograft. The use of TMCs for inter-body reconstruction has been addressed yet the use of larger cages for corpectomy reconstruction has not. This study examines implant stability and deformity correction of TMCs following corpectomy reconstruction in the thoracolumbar spine. Methods: Independent radiological review before, after and at follow-up (one year) was performed for 27 patients having implantation of TMCs. Measurement of thoracolumbar kyphosis was performed before surgery, immediately post operatively, and at one year follow-up. Correction of kyphosis was expressed both as angular improvement and percentage improvement. Cage settling into adjacent vertebral bodies, translational deformities and any evidence of implant failure was sought. Results: Indications for reconstruction with TMC included burst fracture (13), post traumatic kyphosis (8), primary tumour resection (3), debridement of infection (1), and stabilisation of severe kyphotic deformity in achodroplasia with associated spinal stenosis requiring decompression (2). Desired resection and decompression was achieved as indicated. Correction of kyphosis was a mean of 12 deg / 61% (range 0 – 38 deg, 0–85%). No cage moved. One patient had kyphosis recurrence of > 5 deg (12 deg). Five patients demonstrated some settling of the cage within adjacent vertebral bodies (1–8%, mean 3.4% of height loss over construct length – the vertebral body above to the body below). Translational malposition of three cages occurred. One of these cases demonstrated the maximum settling and another was associated with the only case of instrumentation failure. Clinically significant spinal canal intrusion did not occur. One cage demonstrated buckling of the wall without evidence of other problem and the clinical result was excellent. Discussion: Use of TMCs is safe when managing vertebral body reconstruction. Significant kyphosis or translational deformity has not occurred, however minor cage settling within adjacent vertebra may occur. Fusion rate is unknown as the cage mesh obscures graft maturation. Construct failure has only occurred after pre operative translational malalignment could not be corrected. This demanding procedure offers a reconstructive option with superior structural stability and reduced bone grafting morbidity

An operation for radical resection of a tumour of the vertebral body and part of the neural arch is described. The approach is posterior and from both sides of the spine. The posterior approach is used to remove the healthy part of the neural arch, mobilise the dura, divide involved nerve roots and carry out the posterolateral parts of the spinal osteotomies or disc divisions. On one side, usually the right, the sides of the vertebral body or bodies are freed and the osteotomies or disc divisions are extended. Then from the other side, a posterolateral thoracotomy or lumbotomy allows completion of the dissection with radical resection by rolling the specimen away from the dura. Ten operations are reported in which up to three and a half vertebrae were resected. Spinal reconstruction was by internal fixation and grafting preferably with vascularised bone. The results were satisfactory after follow-up for as long as eight years

Fourteen patients with ankylosing spondylitis had an extension osteotomy for severe flexion deformity of the spine. The Smith-Petersen technique was modified by using a compression device which allows a slow, finely controlled closure of the osteotomy, and provides rigid internal fixation. There were no serious neurological complications. All the patients were able to see straight ahead after operation, and all had solid fusion at nine months, having maintained good correction.

1. Kyphosis and kyphoscoliosis associated with myelomeningocele are discussed. 2. It is suggested that the condition be treated by osteotomy of the spine, with removal of one or more vertebral bodies. 3. Sixteen patients treated by this method of spinal osteotomy are presented. 4. Although almost a third of the patients died, a high operative and post-operative mortality in this condition is considered acceptable

1. The management of severe kyphosis of the lumbar spine in association with myelomeningocele is discussed. 2. Neonatal spinal osteotomy-resection has been performed in six patients with partial correction of the deformity and a greatly improved ease of closure and healing of the skin defect. The severity of lower limb paralysis has been diminished compared with the complete paraplegia that almost always results from conservative management of closure of the defect without osteotomy. 3. In an older child who has not had the benefit of neonatal osteotomy and who has complete lower limb paralysis, transverse spinal osteotomy or excision of the prominent laminae and pedicles on each side of the midline makes possible the fitting of apparatus for walking and diminishes the liability to recurrent ulceration of the skin

1. The indications for correction of severe rigid kyphosis by lumbar osteotomy are described.

2. The fatal complications in a series of a hundred cases are listed. With more experience of this operation they should be considerably reduced.

3. Among the non-fatal complications the low incidence of recurrence of the deformity severe enough to require further operation is noteworthy.

1. The steps of the operation of spinal osteotomy, as carried out with the patient in the lateral posture, are described. 2. Details of post-operative management are given. 3. The major risks of the operation are discussed and precautions suggested