Randomised controlled trials (RCTs) that assessed the efficacy of bracing for adolescent idiopathic scoliosis have suffered from small sample sizes, low compliance and lack of willingness to participate. The aim of this study was to assess the feasibility of a comprehensive cohort study for evaluating both the efficacy and the effectiveness of bracing in patients with adolescent idiopathic scoliosis. Patients with curves at greater risk of progression were invited to join a randomised controlled trial. Those who declined were given the option to remain in the study and to choose whether they wished to be braced or observed. Of 87 eligible patients (5 boys and 63 girls) identified over one year, 68 (78%) with mean age of 12.5 years (10 to 15) consented to participate, with a mean follow-up of 168 weeks (0 to 290). Of these, 19 (28%) accepted randomisation. Of those who declined randomisation, 18 (37%) chose a brace. Patients who were more satisfied with their image were more likely to choose bracing (Odds Ratio 4.1; 95% confidence interval 1.1 to 15.0; p = 0.035). This comprehensive cohort study design facilitates the assessment of both efficacy and effectiveness of bracing in patients with adolescent idiopathic scoliosis, which is not feasible in a conventional randomised controlled trial.

Cite this article: Bone Joint J 2015; 97-B:973–81

Acute angulation at the thoracolumbar junction with segmental subluxation of the spine occurring at the level above an anteriorly hypoplastic vertebra in otherwise normal children is a rare condition described as infantile developmental thoracolumbar kyphosis. Three patient series with total of 18 children have been reported in the literature. We report five children who presented with thoracolumbar kyphosis and discuss the treatment algorithm. We reviewed the medical records and spinal imaging at initial clinical presentation and at minimum two-year follow-up. The mean age at presentation was eight months (two to 12). All five children had L2 anterior vertebral body hypoplasia. The kyphosis improved spontaneously in three children kept under monitoring. In contrast, the deformity was progressive in two patients who were treated with bracing. The kyphosis and segmental subluxation corrected at latest follow-up (mean age 52 months; 48 to 60) in all patients with near complete reconstitution of the anomalous vertebra. The deformity and radiological imaging on a young child can cause anxiety to both parents and treating physicians. Diagnostic workup and treatment algorithm in the management of infantile developmental thoracolumbar kyphosis is proposed. Observation is indicated for non-progressive kyphosis and bracing if there is evidence of kyphosis and segmental subluxation deterioration beyond walking age. Surgical stabilisation of the spine can be reserved for severe progressive deformities unresponsive to conservative treatment.

Cite this article: Bone Joint J 2015;97-B:982–7.

We assessed the frequency and causes of neurological deterioration in 59 patients with spinal cord injury on whom reports were prepared for clinical negligence litigation. In those who deteriorated neurologically we assessed the causes of the change in neurology and whether that neurological deterioration was potentially preventable. In all 27 patients (46%) changed neurologically, 20 patients (74% of those who deteriorated) had no primary neurological deficit. Of those who deteriorated, 13 (48%) became Frankel A. Neurological deterioration occurred in 23 of 38 patients (61%) with unstable fractures and/or dislocations; all 23 patients probably deteriorated either because of failures to immobilise the spine or because of inappropriate removal of spinal immobilisation. Of the 27 patients who altered neurologically, neurological deterioration was, probably, avoidable in 25 (excess movement in 23 patients with unstable injuries, failure to evacuate an epidural haematoma in one patient and over-distraction following manipulation of the cervical spine in one patient). If existing guidelines and standards for the management of actual or potential spinal cord injury had been followed, neurological deterioration would have been prevented in 25 of the 27 patients (93%) who experienced a deterioration in their neurological status.

Cite this article: Bone Joint J 2015;97-B:527–31.

Minimal clinically important differences (MCID) in the scores of patient-reported outcome measures allow clinicians to assess the outcome of intervention from the perspective of the patient. There has been significant variation in their absolute values in previous publications and a lack of consistency in their calculation.

The purpose of this study was first, to establish whether these values, following spinal surgery, vary depending on the surgical intervention and their method of calculation and secondly, to assess whether there is any correlation between the two external anchors most frequently used to calculate the MCID.

We carried out a retrospective analysis of prospectively gathered data of adult patients who underwent elective spinal surgery between 1994 and 2009. A total of 244 patients were included. There were 125 men and 119 women with a mean age of 54 years (16 to 84); the mean follow-up was 62 months (6 to 199) The MCID was calculated using three previously published methods.

Our results show that the value of the MCID varies considerably with the operation and its method of calculation. There was good correlation between the two external anchors. The global outcome tool correlated significantly better.

We conclude that consensus needs to be reached on the best method of calculating the MCID. This then needs to be defined for each spinal procedure. Using a blanket value for the MCID for all spinal procedures should be avoided.

Cite this article: Bone Joint J 2015;97-B:366–71.

The aim of this study was to evaluate the feasibility of using the intact S1 nerve root as a donor nerve to repair an avulsion of the contralateral lumbosacral plexus. Two cohorts of patients were recruited. In cohort 1, the L4–S4 nerve roots of 15 patients with a unilateral fracture of the sacrum and sacral nerve injury were stimulated during surgery to establish the precise functional distribution of the S1 nerve root and its proportional contribution to individual muscles. In cohort 2, the contralateral uninjured S1 nerve root of six patients with a unilateral lumbosacral plexus avulsion was transected extradurally and used with a 25 cm segment of the common peroneal nerve from the injured leg to reconstruct the avulsed plexus.

The results from cohort 1 showed that the innervation of S1 in each muscle can be compensated for by L4, L5, S2 and S3. Numbness in the toes and a reduction in strength were found after surgery in cohort 2, but these symptoms gradually disappeared and strength recovered. The results of electrophysiological studies of the donor limb were generally normal.

Severing the S1 nerve root does not appear to damage the healthy limb as far as clinical assessment and electrophysiological testing can determine. Consequently, the S1 nerve can be considered to be a suitable donor nerve for reconstruction of an avulsed contralateral lumbosacral plexus.

Cite this article: Bone Joint J 2015; 97-B:358–65.

Introduction

Research has suggested baby wearing results in happier healthier babies [1]. Various designs of carrier are available, is there one which has less impact on the biomechanics of the cervical spine?

Purpose and background

Over two-thirds of pregnant women experience low back pain (LBP) that interferes with everyday activities, work and sleep. Acupuncture appears a safe, promising intervention but there are no high quality trial data, regarding its clinical or cost-effectiveness in comparison to standard care.

Background

Emerging research has indicated that ‘significant others’ (spouses/relatives) may have important influences on continued work participation for individuals with chronic non-specific musculoskeletal pain (CMP). In order to expand on this novel area of research, data from studies conducted in The Netherlands and the UK were assimilated.

Purpose and background

To explore the cost-utility of implementing stratified care for low back pain (LBP) in general practice, compared with usual care, within patient risk subgroups (low, medium and high risk of persistent disabling pain determined by the STarT Back tool).

Background

Medical Research Council (MRC) guidelines recommend applying theory within interventions to explain how behaviour change occurs. Guidelines endorse self-management of chronic low back pain (CLBP) and osteoarthritis (OA), but evidence for its effectiveness is weak. This literature review aimed to determine the use of behaviour change theory and techniques within group-based self-management randomised controlled trials for chronic musculoskeletal pain, including CLBP and OA.

Background

Stratifying patients with Low Back Pain (LBP) using the STarT Back Tool and delivering targeted treatment has demonstrated efficacy in individual physiotherapy settings. Physiotherapy interventions for LBP patients are often delivered in groups. This study aimed to explore the sustainability and cost effectiveness of a group stratified intervention in primary care.

This study examined spinal fractures in patients admitted to a Major Trauma Centre via two independent pathways, a major trauma (MT) pathway and a standard unscheduled non-major trauma (NMT) pathway. A total of 134 patients were admitted with a spinal fracture over a period of two years; 50% of patients were MT and the remainder NMT. MT patients were predominantly male, had a mean age of 48.8 years (13 to 95), commonly underwent surgery (62.7%), characteristically had fractures in the cervico-thoracic and thoracic regions and 50% had fractures of more than one vertebrae, which were radiologically unstable in 70%. By contrast, NMT patients showed an equal gender distribution, were older (mean 58.1 years; 12 to 94), required fewer operations (56.7%), characteristically had fractures in the lumbar region and had fewer multiple and unstable fractures. This level of complexity was reflected in the length of stay in hospital; MT patients receiving surgery were in hospital for a mean of three to four days longer than NMT patients. These results show that MT patients differ from their NMT counterparts and have an increasing complexity of spinal injury.

Cite this article: Bone Joint J 2015;97-B:235–9.

Purpose of the study and background

Patients' beliefs about the origin of their pain and their cognitive processing of pain-related information have both been shown to be associated with poorer prognosis in low back pain (LBP), but the relationship between specific beliefs and specific cognitive processes is not known. The aim of this study was to study the relationship between diagnostic uncertainty and recall bias in two groups of chronic LBP patients, those who were certain about their diagnosis, and those who believed that their pain was due to an undiagnosed problem.

Background and Aim

Spinal stability is associated with low back pain and affects the spines ability to support loads. Stability can be achieved if the applied force follows the curvature of the spine, passing close to the vertebral centroids. Previously we showed that calculated muscle forces required for stability in an idealised model increased with increasing and more evenly distributed lumbar curvatures. The purpose of this study was to calculate the muscle forces required for stability in standing in a group of healthy adults.

Purposes of the study and background

Characteristics of muscle activity, represented by surface electromyography (EMG), have shown differences between patients with low back pain and healthy adults; how they relate to functional/clinical scales remains unclear. The purpose of the current study was to examine the correlation between frequency characteristics of EMG and patients' self-rated score of disability using continuous wavelet transform (CWT) analysis.

Purpose of study and background

The use of NRB (Nerve Root Block) in radicular pain caused by stenosis is considered controversial in some centres, whereas its indication in radiculitis caused by disc herniation is widely accepted. Most studies evaluating NRB have combined disc herniation and stenosis pathologies in their inclusion criteria. This study explores the efficacy of NRB in different categories of stenosis: lateral recess, foraminal and combined.

Purpose

To study the relationship between Zygoapophysial Joint Tropism and pathologic fractures affecting lumbar and thoracic vertebrae in elderly patients.

Purpose of the study and background

In the majority of low back pain (LBP) patients a definitive cause for back pain cannot be established; consequently, many patients report feeling uncertain about their diagnosis. They also experience pain-related guilt, which can be divided into: social guilt, managing pain guilt and verification of pain guilt. This study aimed to test a theoretical (causal) model, which proposed that diagnostic uncertainty leads to pain-related guilt, which leads to depression, anxiety and finally to disability.

Background

Leg pain frequently accompanies low back pain and is associated with increased levels of disability and higher health costs than simple low back pain. Distinguishing between different types of low back- related leg pain (LBLP) is important for clinical management and research applications.

The aim of this systematic review was to identify, describe and appraise papers that classify or subgroup populations with LBLP.

Introduction

Orthopaedic Spinal Rapid Access Service (OSRAS) was developed in our institute to provide a structured pathway for management of urgent spinal pathologies during working hours of Monday to Friday. It was delivered through a published rota by a multi displinary team of Extended Scope Practitioner carrying a bleep and a Spinal Surgeon.

Purposes of Study and Background

This study investigates the role of the patient and the therapeutic relationship with their medical practitioner in resolving CLBP (chronic low back pain). Many cases of chronic pain persist due to the stress response. The body is equipped with natural self-healing mechanisms that must be activated by the patient. This needs facilitation by someone trained to engage the patient in this process. Evidence shows that conventional medication; surgery and physical rehabilitation do not always resolve chronic pain. To ensure that the stress response doesn't sabotage biomedical intervention the patient may need to address any problems obstructing a healthy lifestyle. This means supporting healthy relationships, and good health in other areas such as: professional life, financial matters, beliefs and creativity.

Aim

To use Patient Reported Outcome Measures (PROMs) to determine the effectiveness of lumbar spinal surgery at a single UK institution.

Aim

To assess the safety of Zero Profile Interbody fusion (Zero P) device in Anterior Cervical Decompression and fusion (ACDF) for degenerative cervical stenosis.

Purpose

To measure the prevalence, type and instigator of verbal interruptions during initial consultations between clinicians and patients with low back pain.

Background

Implementation fidelity is the extent to which an intervention is delivered as intended by intervention developers, and is extremely important in increasing confidence that changes in study outcomes are due to the effect of the intervention itself and not due to variability in implementation. Growing demands on healthcare services mean that multiple condition interventions involving highly prevalent musculoskeletal pain conditions such as chronic low back pain (CLBP) and/or osteoarthritis (OA) are of increasing clinical interest. This is the first in-depth review of implementation fidelity within self-management interventions for any musculoskeletal pain condition.

Aim

The primary aim of this pilot study was to assess and evaluate the SpineCor Pain Relief Brace as a method of reducing the pain experienced by patients diagnosed with degenerative scoliosis

Background

Osteoarthritis (OA) and chronic low back pain (CLBP > 12 weeks duration) are two of the most common and costly chronic musculoskeletal conditions globally. Healthcare service demands mean that group-based multiple condition interventions are of increasing clinical interest and a priority for research, but no reviews have evaluated the effectiveness of group-based physiotherapy-led self-management interventions (GPSMI) for both conditions concurrently. Rapid review methodologies are an increasingly valid means of expediting knowledge dissemination and are particularly useful for addressing focused research questions.

Aim

To assess the safety of day case lumbar decompressive surgery

Purpose of the study and background

This audit report outlines a physiotherapy lead spinal triage program for inpatients in a private hospital. The reason to trial this model was proposed as a way to expedite the assessment of inpatients presenting with back pain and implement an appropriate and prompt management plan.

Background

60% of back pain patients report pain radiation in the leg(s), which is associated with worse symptoms and poorer recovery. The majority are treated in primary care, but detailed information about them is scarce. The objective of this study is to describe the characteristics of patients with back and leg pain-seeking treatment in primary care.

Purpose and Background

Low birth weight is related to decreased lumbar spine vertebral canal size and bone mineral content later in life, suggesting that antenatal factors affect spine development. The purpose of this study was to explore associations between antenatal factors and lumbar spine morphology in childhood.

Background

The factors influencing normal spine curvature in midlife are unknown. We performed an MR and plain radiograph study on well characterised, unselected twin volunteers from the TwinsUK register (www.twinsuk.ac.uk) to determine the relative contributions of genetic and environmental factors to spine curve.

Introduction

The authors recognised that patients presenting to the Orthopaedic Spinal Rapid Access Service with symptoms and or signs of cauda equina syndrome may not have the diagnosis confirmed radiologically. Altered sensation in the ‘saddle area’, bilateral sciatica, urinary incontinence or retention, altered bowel habit, and sexual dysfunction are well recognised symptoms of cauda equina syndrome. Recognised side-effects of neuropathic medications commonly prescribed for radicular pain include: altered sensation, urinary incontinence or retention, and sexual dysfunction. We have undertaken a retrospective cohort analysis in order to identify the relationship between prescribed medications and presenting symptoms and signs.

Background and purpose

To identify methods used to measure free living sedentary behaviour in people with back pain and review the validity and reliability of identified measures.

Background and Purpose of Study:

Differences in regional lumbar angles in sitting have been observed between subgroups of NSCLBP patients exhibiting motor control impairments (MCI) (O'Sullivan, 2005; Dankaerts et al, 2006). However, differences in standing posture and other spinal regions are unknown. This study aimed to compare regional spinal angles in healthy and MCI subgroups in sitting and standing.

Background

Low back pain (LBP) is widespread in all populations and is a worldwide health problem, which poses substantial challenges for clinical management. Individuals with LBP may reduce their symptoms by implementing self-managed at-home interventions. The theoretical design of the LumbaCurve™ promotes the principles of a passive gravity-assisted traction (PGAT) stretch of the lumbar and sacral region in order to reduce LBP. This study aimed to assess the clinical effectiveness of the LumbaCurve™ in the management of LBP when compared to a control group of standardised care.

Purpose and Background

Back pain impinges upon all aspects of life, has a reported UK lifetime prevalence as high as 84% and considering approximately a third of our lives are spent asleep the paucity of research into the effect a mattress has on back pain and sleep is surprising. Mood changes, effecting an increase in pain perception, due to sleep loss may also lead to a downward spiral of increasing back pain and greater sleep loss. A controllable factor in this spiral, affecting both aspects, is the mattress but to the authors' knowledge none currently available on the market have any robust, published research to objectively support any claims made and at best being ‘endorsed’ by experts. This may lead to possible misinterpretation of efficacy and leave professionals at a loss with what to advise when questioned.

Background

Being involved in litigation is associated with poor outcomes, higher levels of pain, disability, catastrophising, fear-avoidance and other psychological factors. Poor access to treatments can contribute to chronicity of symptoms and poor outcomes, especially in patients involved in litigation with a longer time since the accident.

Background and Purpose

Chronic low back pain (CLBP) can be constant or episodic. Fluctuations are common. We present two different pictures of the CLBP experience; timelines illustrating back pain over time and ‘web diagrams’ showing a snapshot of a phase in time.

Objectives

This paper describes the outcomes obtained from a 12 hour group based multidisciplinary functional restoration programme for patients with persistent low back pain who presented with psychosocial obstacles to recovery. The programme was designed to address modifiable psychosocial obstacles to recovery over a four week period, reduce pain related disability, improve pain self-efficacy and reduce patients' reliance on analgesic medication.

Hypovitaminosis D has been identified as a common risk factor for fragility fractures and poor fracture healing. Epidemiological data on vitamin D deficiency have been gathered in various populations, but the association between vertebral fragility fractures and hypovitaminosis D, especially in males, remains unclear. The purpose of this study was to evaluate serum levels of 25-hydroxyvitamin D (25-OH D) in patients presenting with vertebral fragility fractures and to determine whether patients with a vertebral fracture were at greater risk of hypovitaminosis D than a control population. Furthermore, we studied the seasonal variations in the serum vitamin D levels of tested patients in order to clarify the relationship between other known risk factors for osteoporosis and vitamin D levels. We measured the serum 25-OH D levels of 246 patients admitted with vertebral fractures (105 men, 141 female, mean age 69 years, sd 8.5), and in 392 orthopaedic patients with back pain and no fractures (219 men, 173 female, mean age 63 years, sd 11) to evaluate the prevalence of vitamin D insufficiency. Statistical analysis found a significant difference in vitamin D levels between patients with vertebral fragility fracture and the control group (p = 0.036). In addition, there was a significant main effect of the tested variables: obesity (p < 0.001), nicotine abuse (p = 0.002) and diabetes mellitus (p < 0.001). No statistical difference was found between vitamin D levels and gender (p = 0.34). Vitamin D insufficiency was shown to be a risk factor for vertebral fragility fractures in both men and women.

Cite this article: Bone Joint J 2015;97-B:89–93.

Total en bloc spondylectomy (TES) is the total resection of a vertebra containing a tumour. Many authors have investigated patient-reported outcomes after routine spinal surgery and surgery for tumours in general. However, this is the first report of patient-reported outcomes, including health-related quality of life (HRQoL) and satisfaction, after en bloc vertebral resection for a spinal tumour.

Of the 54 patients who underwent TES for a primary tumour between 1993 and 2010, 19 died and four were lost to follow-up. In January 2012, a questionnaire was sent to the 31 surviving patients. This included the short form-36 to assess HRQoL and questions about the current condition of their disease, activities of daily living (ADL) and surgery. The response rate was high at 83.9% (26/31 patients). We found that most patients were satisfied and maintained good performance of their ADLs.

The mental health status and social roles of the HRQoL scores were nearly equivalent to those of healthy individuals, regardless of the time since surgery. There was significant impairment of physical health in the early post-operative years, but this usually returned to normal approximately three years after surgery.

Cite this article: Bone Joint J 2014;96-B:1693–8.

Neural axis anomalies in idiopathic scoliosis (AIS) are well documented, with prevalence of 7% in adolescents; 20% in early-onset and up to 40% in congenital, the case for pre-operative MRI of brainstem to sacrum is well made in these groups. SK is rarer than AIS and the prevalence of anomalies is not defined. The case for routine MRI scan is unclear. A recent report concluded that routine MRI was not indicated, although this was based on only 23 MRI scans in 85 patients. At our institution all patients are undergo whole spine MRI following a diagnosis of SK. We aimed to assess the incidence of significant neural anomalies in Scheuermann's Kyphosis.

Using a keyword search for “Scheuermann”, we reviewed all SK patients' MRI reports over the past 6 years.

117 MRI scans were identified. 13 patients did not fulfil the radiological criteria for SK and thus 104 (73M: 31F) scans were reviewed. 14 (13%) of 104 scans showed unexpected Significant abnormal findings. There were 8 (8%) with neural axis anomalies: 4 syrinxes; 1 cord anomaly; 2 cerebellar descents and 1 cerebellar tumour. All these patients had normal neurological examination except one with examination consistent with a known diagnosis of Parkinson's. A further 6 patients had non-neural anomalies.

The presence of neural axis anomalies may influence the management of a patient with SK. Neurological compromise during correction is higher in patients with neural axis anomalies and this risk can often be partially mitigated by a preceding neurosurgical procedure (such as foramen magnum decompression or shunt). Furthermore it is well described that these anomalies often occur in patients who demonstrate a normal neurological examination. This study confirms this. Given that MRI is widely available and considering the devastating life implications of neurological injury, we advise pre-operative MRI scan in all SK patents.

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.

This study aimed to verify the accuracy of the DIERS Formetric Scan when assessing vertebral rotation of the apical vertebrae in Adolescent Idiopathic Scoliosis (A.I.S) patients, to determine whether the DIERS Formetric Scans can be used instead of or alongside radiographs when assessing A.I.S patients.

Both the radiographs and the DIERS Formetric Scans of 60 Preoperative A.I.S patients. All patients included in our study had predominant thoracic curves using the Lenke classification method, Cobb angle range 33° – 85°. Each radiograph was categorised into groups according to the severity of Nash-Moe rotation score of the apical vertebrae. Three groups were formed Nash-Moe +1 (20 patients), Nash-Moe +2 (27 patients), Nash-Moe +3 (13 patients). Each result was then compared to the maximal rotation analysed by the DIERS Formetric Scan, which took place on the same day as the radiographs. The results were then assessed using a Pearson Correlation Coefficient and a One-Way ANOVA with Post-Hoc Tukey HSD Analysis.

The Nash-Moe +1 Group scored a mean maximal rotation of 14.65° ±6.56 (11.82 – 17.48) (95% Confidence Interval), Nash-Moe +2 mean maximal rotation was 19.6° ±7.1 (16.92 – 22.28) and Nash-Moe +3 scored 21.53° ±8.9 (16.99 – 26.37). The Pearson Correlation Coefficient of this assessment was +0.342 (p value 0.07) demonstrating a weak positive correlation. The One-Way ANOVA analysis with Post-Hoc Tukey HSD analysis. The results of this analysis was an F value score of +4.115 (p Value 0.021) for the overall One-Way ANOVA test. The Post-Hoc Tukey HSD tests demonstrate that there is a statistical difference between Group 1 and Group 3 (p value 0.030) but there is no statistical difference between Group 1 and Group 2 (p value 0.068) as well as no statistical difference between Group 2 and Group 3 (p value 0.716).

DIERS Formetric Scan assessment of vertebral rotation shows a positive correlation with the Nash-Moe method. This allows us to rely on the Formetric scans and thus a possible reduction in radiographs when assessing A.I.S, this reduces the exposure to ionising radiation in A.I.S patients.

Costoplasty remains useful in the treatment of adolescent idiopathic scoliosis, rib hump and associated chest wall deformities. However traditional costoplasty increases morbidity and blood loss. We examine the feasibility and possible effectiveness of a more conservative costoplasty using an animal model.

4 fresh half Ovine rib cages from separate animals were obtained, stored at +4 °C and warmed to room temperature before testing. Each rib cage was randomly assigned to group 1, 2, 3 or 4. Ribs 2–10 were dissected out for testing. The ribs then underwent stepwise deconstruction according to their group. Beginning at the convexity, removing first the convex cortex, then the cancellous, then the cranial and caudal cortices to leave just the concave cortex. Testing for stiffness was by three-point bending on the concave side of each rib with the rib fixed at the head of the rib and 5 cm from the resected area. The ribs were deformed at a constant rate of 0.5 mm.sec ⁻1 up to a maximum load of 9.99 kg or until fracturing. Then stress was plotted against strain to find the Young's modulus of each group and statistics carried out with an ANOVA test. The ribs in each group were as follows: Group 1= control, group 2= 30 mm long convex side cortical bone removed 10 mm from lateral tubercle, group 3= convex, cortical and cancellous bone removal and group 4= removal of convex, caudal and cranial cortices with cancellous removal.

The Young's Modulus of the groups were: 1= 3.38 N-m (+/− 0.84), 2= 2.65 N-m (+/− 1.58), 3= 1.55 N-m (+/− 0.55) and 4= 0.74 N-m (+/− 0.55). Groups 3 and 4 were significantly less stiff than group 1 (p< 0.01.) No ribs in groups 1, 2 and 4 fractured under the maximum load. 5/8 ribs in group 3 fractured before the maximum load was administered.

By deconstructing the rib down to only the concave side it becomes significantly more flexible by approximately 4.5 times than the control Ribs. Coupled with its increase in flexibility it still retains its ability to withstand up to 10 kg of load without fracture. It may be possible to perform a costoplasty whilst preserving ventilatory integrity. This may improve rib hump correction, and curve correction due to increased flexibility of the stiff thoracic cage.

Increasing health care costs, limited resources and increased demand makes cost-effective and cost-efficient delivery of Adolescent Idiopathic Scoliosis (AIS) management paramount. Rising implant costs in deformity surgery have prompted justification of high implant density. The objective of this study was to analyse the costs of thoracoscopic scoliosis surgery, comparing initial learning curve costs with those of the established technique and to the costs involved in posterior instrumented fusion from the literature.

189 consecutive cases from April 2000 to July 2011 were assessed with a minimum of 2 years follow-up using a prospective database covering perioperative factors, clinical and radiological outcomes, complications and patient-reported outcomes. The patients were divided into three groups to allow comparison; 1. A learning curve cohort, 2. An intermediate cohort and 3. A third cohort using our established technique. Hospital finance records and implant manufacturer figures were corrected to 2013 costs. A literature review of AIS management costs and implant density in similar curve types was performed.

The mean pre-op Cobb angle was 53°(95%CI 0.4) and was corrected postop to mean 22.9°(CI 0.4). The overall complication rate was 20.6%, primarily in the first cohort, with a rate of 5.6% in the third cohort. The average total costs were $46,732, operating room costs of $10,301 (22.0%) and ICU costs of $4620 (9.8%). The mean number of screws placed was 7.1 (CI 0.04) with a single rod used for each case giving average implant costs of $14,004 (29.9%). Comparison of the three groups revealed higher implant costs as the technique evolved to that in use today, from $13,049 in Group 1 to $14577 in Group 3 (P<0.001). Conversely operating room costs reduced from $10,621 in Group 1 to $7573 (P<0.001) in Group 3. ICU stay was reduced from an average of 1.2 to 0 days. In-patient stay was significantly (P=0.006) lower in Groups 2 and 3 (5.4 days) than Group 1 (5.9 days).

Our thoracoscopic anterior scoliosis correction has evolved to include an increase in levels fused and reduction in complication rate. Implant costs have risen, however, there has been a concurrent decrease in those costs generated by operating room use, ICU and in-patient stay with increasing experience. Literature review of equivalent curve types treated posteriorly shows similar perioperative factors but higher implant density, 69–83% compared to the 50% in this study. Thoracoscopic Scoliosis surgery presents a low density, reliable, efficient and effective option for selected curves.

The use of serial casting in the management of early onset scoliosis (EOS) has been well described. Our aim was to evaluate outcomes of plaster jacket therapy in patients with EOS from a tertiary referral centre.

A retrospective review of hospital records and PACS images of 27 patients to identify patients treated with serial casting over a five year period. The primary outcome measure was the need for surgical intervention, with change in Cobb angle used as a secondary outcome measure

Mean age at presentation was 14 months (range 10 – 42), including 14 male and 13 female patients, with an average follow-up of 34 months. Curves were categorised according to aetiology: 16 idiopathic, 6 syndromic, 3 congenital and 2 neuromuscular curves. The mean Cobb angle at diagnosis was 43.7° (range 22 – 115) and mean rib vertebral angle difference (RVAD) was 22.2° (8 – 70). Duration of treatment was 9.9 months (range 3 – 27), with an average of two plaster jacket changes per child. At the time of review, patients fell into one of three groups. Group one (10 patients) failed conservative treatment due no improvement in Cobb angle (mean 48.4° compared with pre-op 53.9°, p value 0.55) and either had insertion of growing rods or had been listed for this procedure, at a mean age of 51.8 months. Group two (12 patients) had a mean Cobb angle of 38.9° pre-treatment which improved to 23.5° (p value <0.05) and were either treated in a brace or had discontinued treatment. The mean RVAD at initial diagnosis was 36.6° in group 1 compared with 13.8° in group 2 (p<0.05). All patients in group one requiring surgical treatment had an RVAD of greater than 20°. Serial casting is on-going for five patients (group three). Complications occurred in 30% of patients including pressure sores, chest infection and respiratory compromise requiring intubation.

Current NICE guidance recognises that serial casting ‘rarely corrects scoliosis’ but recommends it may be used ‘to allow growth before a more permanent treatment is offered’. In our experience, serial casting did not allow any patients with a progressive scoliosis (determined by an RVAD of greater than 20°), to reach a single definitive fusion. However serial casting appeared to halt to curve progression until the child was suitable for the insertion of a growing rod system.

There are limited data on scoliosis in cystic fibrosis (CF), and the two most recent studies came to opposite conclusions. Reported prevalence ranges from 2% (within the normal range for the general population) to 15.5%. We felt that a recent study under-estimated the prevalence due to a very young population (mean age 10.9 years), since scoliosis develops most commonly in adolescents. We hypothesised that scoliosis is more prevalent in adolescents with CF compared to the general population. The aim of our study was to determine the incidence of scoliosis in adolescents with CF followed to and beyond skeletal maturity and describe the type of spinal deformity. We included all patients in our CF clinic aged >10 years, and those who have transitioned to adult services in the last 10 years. Patients with a co-existent neuromuscular condition were excluded.

We conducted a retrospective observational study. Most recent chest radiographs at end of spinal growth, or those taken at transition to adult services, were reviewed by a Consultant Radiologist and a Consultant Spine Surgeon. Scoliosis was defined as a Cobb angle of >10° in the coronal plane. Demographics and characteristics of the curves were recorded.

Our cohort included 143 CF patients (48% male) with a mean age at the time of chest radiograph of 18 years (range 15–22 years). 16 (6 male) subjects were noted to have scoliosis with a mean (range) Cobb angle of 14° (10–38°) giving a prevalence of 11%. 13 were single thoracic curves, 2 double and 1 triple. The majority were non-progressive short mid-thoracic curves, convex to the right. 5 curves were progressive, only one of which was significant and required bracing to the end of growth but no surgical treatment.

We found a prevalence of scoliosis in our adolescent CF population that is significantly greater than the general population. Only one curve was significant and progressive requiring bracing, the remainder being minor and non-progressive. A strength of our study is that all patients had achieved skeletal maturity at the time of latest X-ray and, therefore, development or further progression of scoliosis is unlikely. The negative effect of scoliosis on lung function is well-documented. With the progressive nature of CF lung disease, scoliosis may have further deleterious effects. Bone disease is increasingly recognised in CF patients, with osteopenia and osteoporosis occurring earlier and more frequently than in the general population (38% & 24% respectively in 18–32 year old CF patients). To date, studies have failed to show a correlation between scoliosis, lung function and bone mineral density. The paradigm of a radiologically significant (Cobb angle >10°) versus a clinically important scoliosis remains.

The current trend in kyphosis correction is for “every level” instrumentation to achieve intraoperative stability, correction, fusion and implant longevity.

We evaluate the medium term follow up of a low implant density (LID) construct.

All patients with adolescent kyphosis (idiopathic or Scheurmann's) on our deformity database were identified. Radiographs and records were analysed for neurological complications, correction and revision.

The constructs included were all pedicle screw anchors with multiple apical chevron osteotomies and a proximal and distal “box” of 6 to 8 screws. A four rod cantilever reduction manoeuvre with side to side connectors completed the construct. Kyphosis for any other cause was excluded. Follow up less than 12 months was excluded.

23 patients were identified with an average follow up 27 months (72 to 12 months) and a mean implant density of 1.1 (53.5% of “available” pedicles instrumented).

There was 1 false positive neurophysiological event without sequelae (4%).

There were no proximal junctional failures (0%).

There were no pseudarthroses or rod breakages (0%).

There was 1 loss of distal rod capture (early set screw failure) (4%). This was revised uneventfully.

There were 4 infections requiring debridement (early series).

Average initial correction was 44% (77.7 degrees to 43.5 degrees) with a 1% loss of correction at final follow up (43.5 to 44.0 degrees). The fulcrum bending correction index was 107% (based on fulcrum extension radiographs). 85% of curves had a fulcrum flexibility of less than 50%.

The average cost saving compared to “every level “instrumentation was £5700 per case.

This paper shows that a LID construct for kyphosis has technical outcomes as good as high density constructs. The obvious limitation of the study is the small number of patients in the cohort.

The infection rates have improved with changes to perioperative process in the later series of patients. We do not believe these are a consequence of the construct itself.

An often neglected component of sagittal balance in adolescent idiopathic scoliosis (AIS) is the cervical spine. The cervical spine is capable of compensating for large sagittal deformities by altering head position, but in doing so may give rise to symptoms when the extremes of cervical compensatory mechanisms are reached. This paper seeks to define whether AIS patients have a different cervical lordosis pre and post corrective surgery when compared to normal adolescents.

A review of the literature was carried out in order to define normal cervical lordosis in adolescents. A retrospective analysis of 81 patients with a confirmed diagnosis of idiopathic scoliosis who had received corrective surgery was carried out, and pre and post op cervical lordosis of C1– C7 and C2– C7 were independently measured and recorded using full length sagittal spine radiographs. This data was compared to the 95% confidence interval (95% CI) of cervical lordosis in controls to show if AIS patients showed different cervical spine lordosis before or after corrective surgery.

A literature search showed that normal cervical spine lordosis values are poorly described. However, some values have been published. One study (paper A) gives values of −16° (95%CI −12–20°) for male C2– C7 lordosis and −15° (95% CI −12.5–17.5°) for female C2– C7 adolescents. Another reference (paper B) gives values of −8.4 (95%CI −6.7–10.1°) for male and −1.9 (95%CI −0.5–3.3°) for female adolescents for the same C2– C7 measurements. Our values for male patients for pre op C2– C7 lordosis was −1.2 (95%CI −8.5–6.1°) and 9° (95%CI 2.9– 15.1°) for females. Post op values were 10.6° (95%CI 2.4–18.8°) for males and 8.3° (95%CI 4.8–11.8°) for females.

The values of cervical lordosis in our series show that patients with AIS have a significantly different cervical lordosis when compared to normal values both pre and post deformity correction (p < 0.05). A complete understanding of how the cervical spine is positioned prior to surgery is critical, as flattening the thoracic spine during corrective surgery could give rise to cervical pain and sagittal imbalance if the ability of the cervical spine to compensate for the new spinal position is exceeded.

We describe the prevalence of spondylolisthesis in Scheuermann's Kyphosis (SK) from retrospective review of 104 SK patients over 6 years.

All patients referred to our institution for symptomatic SK undergo MRI scan from hindbrain to sacrum. Our MRI database was reviewed for all SK patients. All scans with spondylolisthesis were re-analysed.

117 scans were identified, 13 patients did not fulfil the MRI criteria for SK and thus 104 (74M: 31F) scans of SK are reported. There were 5 spondylolisthesis (1 cervical and 4 lumbosacral). Of the 4 lumbosacral there were 2 Meyerding grade-1; 1 grade-2 and 1 grade-5 spondyloptosis). An overall rate of 5% for listhesis was therefore found.

The prevalence of spondylolisthesis is around 3% in the general population based on a CT study of 510 patients (Belfi 2006) and Fredrickson's (1984 and 2003) prospective study of 500 children. We describe the prevalence in SK patients being higher at 5%. This may be related to the adaptive change of increased lumbar lordosis in SK, certainly it supports the previous description higher rates of spondylolysis in SK.

To identify the most cited British author, unit and country within Great Britain among the scoliosis and spinal deformity literature.

Using methods as described by Skovrlj (2014), a search of the Thomson Reuters Web of Science was performed using the terms ‘scoliosis’ and ‘spine deformity’ from 1900 to 2013 published from authors in the following countries: UK, England, Scotland, Ireland, Wales. Additional citations searches were performed using PubMed and Google scholar. Results were sorted according to number of citations; papers applicable to scoliosis or spinal deformity were chosen.

The Top 25 citations from British authors were established. 80% of papers were published before 2000. Citation counts and therefore rankings varied for each of the three citation searches, producing differences in rank of as great as 28 for the same paper. Ruth Wynne-Davies from Edinburgh ranked number one in all three searches, followed by SG Boyd, R Dickson, and M McMaster. Half of the top ten papers were published by authors from Edinburgh.

The most cited author in Great Britain from all citation searches is Ruth Wynne Davies. However, the citation count of all papers varied depending on the search platform used, producing varying ranks for all other papers.

Scoliosis surgery has moved towards all posterior correction, as modern implants are perceived to be powerful enough to overcome stiffer and more severe curves. However, shortening of the anterior spinal column remains most effective in creating thoracic kyphosis, and may still have a role in correcting both coronal and sagittal deformities. Furthermore, anterior correction of lumbar and thoracolumbar curves can theoretically reduce the distal fusion level, and may have significant impact on patients' post-operative function.

A single surgeon series of 62 patients with idiopathic scoliosis were examined retrospectively. Radiographs and operation notes were examined by 2 spinal surgeons, sagittal and coronal parameters were measured before and after the operation. The patients were divided into 4 groups: 16 anterior and posterior fusions (AP), 16 anterior thoracolumbar fusions (A), 5 anterior thoracic releases and posterior fusions (AR), and 25 posterior fusions only (P).

The mean age was 15.3 (range 10 – 20). The mean main thoracic Cobb angle pre-operatively was: 54° (AP), 43° (A), 63° (AR), and 50° (P). The mean thoracolumbar Cobb angle was: 55° (AP) and 51° (A). There was no significant difference in lumbar lordosis.

The mean post-operative main thoracic Cobb angle was: 9° (AP), 13° (A), 9° (AR) and 15° (P). There was significant difference between AR and P groups. The mean post-operative thoracolumbar Cobb angle was: 8° (AP) and 6° for (A). There was a significant difference in the post-operative thoracic kyphosis between AP (mean 14°), A (mean 38°), AR (mean 19°) and P (mean 14°). Overall, the lumbar lordosis for all 4 groups reduced from a mean of 67° to 50°, with no significant difference between the groups.

The distal level of fusion for A and AP groups were L3 for all cases, whereas 2 cases had to extend to L4 in the P group.

Anterior release improved both coronal and sagittal correction when compared to posterior only surgery, however it is of unknown clinical significance. Anterior thoracolumbar fusion with or without posterior spinal fusion appeared to produce adequate coronal correction if fused to L3. No difference was found between all groups in post-operative lumbar lordosis.

The SRS-22 instrument was developed to assess quality of life in adolescent idiopathic scoliosis patients (AIS). The aim of our study was to evaluate the impact of surgical treatment on quality of life in neurologically normal patients with complex spinal deformity of a range of aetiologies using the SRS-22 questionnaire.

We analysed prospectively collected SRS-22 data on 407 consecutive patients (315 females-92 males) treated from 2006–2012 under the care of the senior author. 97.6% of patients had a posterior (PSF), 1.3% an anterior (ASF) and 1.1% an anterior-posterior (A/PSF) spinal fusion. Questionnaires were completed at 4 stages of treatment: preoperatively, 6-months, 12-months and 24-months postoperatively. Other variables included age at surgery, gender, diagnosis and year of surgery. 9 diagnoses were included in the study: 271 patients had AIS; 39 Scheuermann's kyphosis; 31 spondylolisthesis; 16 congenital scoliosis; 13 JIS; 6 IIS; 13 scoliosis associated with intraspinal anomalies; 11 syndromic scoliosis; 7 scoliosis associated with congenital cardiac disease. Mean age at surgery was 15.14±2.07 years. Age at surgery was divided in 3 groups to compare outcomes against previous studies: 10–12, 13–15, and 15–19 years.

Mean total SRS-22 scores for the whole group were: preoperative 3.62±0.66; 6-month 4.12±0.44; 12-month 4.39±0.40; and 24-month 4.52±0.37 (p<0.0001). Individual preoperative scores for the whole group were: function 3.77±0.75; pain 3.7±0.97; self-image 3.14±0.66; mental 3.86±0.77. Mean 24-month postoperative scores for the whole group were: function 4.39±0.42; pain 4.59±0.56; self-image 4.39±0.51; mental 4.43±0.56; satisfaction 4.81±0.40. All changes observed at 2-year follow-up were statistically significant (p<0.0001). Male preoperative total score (3.64±0.66) did not have a significant difference compared to female (3.62±0.66); however 24-month total score improvement was significant, with males (4.62±0.25) performing better than females (4.49±0.39) including satisfaction (p=0.004). Spondylolisthesis patients performed worse preoperatively (2.93±0.26) compared to other diagnoses (p<0.0001); AIS 3.67±0.64, congenital 3.81±0.57, syndromic 3.80±0.54, Scheuermann's 3.48±0.75, JIS 3.90±0.63, scoliosis with congenital cardiac disease 4.04±0.41 or intraspinal anomalies 3.71±0.66, and IIS 3.58±0.80. No change in total and individual scores was observed at 24-month review across diagnoses (p>0.05). There were no significant changes between each year of surgery in the study period and the total values at each stage (p>0.05). There were no significant changes between the 3 age ranges at each stage (p>0.05). Patients undergoing ASF performed significantly better at preoperative function (4.7±0.27) compared to PSF (3.76±0.74) and A/PSF (3.68±0.72), (p=0.19). All values at 2-years were not significant in comparison regarding type of operation (p>0.05).

All individual domains and total SRS-22 scores improved after surgical correction of spinal deformity in our young patient cohort with an incremental change between preoperative, 6-month, 12-month and 24-month postoperative. Our 24-month postoperative outcomes in all diagnoses compare favourably to reported SRS-22 scores in healthy adolescents (function: 4.31±0.54; pain: 4.44±0.67; image: 4.41±0.64; mental health: 3.96±0.81; total 4.26±0.54). We are planning to continue this study with longer follow-up in order to allow comparison of our SRS-22 outcomes after surgical treatment to those obtained in patients treated with bracing or patients who were followed untreated (previous reports SRS-22 total scores: 4.2 for braced patients and 4.1 for observed patients).

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 describe complications and reoperation rates associated with degenerative spinal deformity surgery

A retrospective review of prospectively collected data from a single spinal surgeon in the United Kingdom. A total of 107 patients who underwent surgery, of 5 or more levels, for primary degenerative kyphoscoliosis between 2006 and 2012 were identified. Clinical notes were reviewed and post-operative complications, reoperation rates, length of follow up and mortality were analysed.

A total of 107 patients, average aged 66.5 years (range 52 – 85), with 80% women. 105 patients underwent posterior surgery, two patients required both anterior and posterior surgery. The average number of instrumented levels was 8.3; 10% 5 levels, 15% 6 levels, 11% 7 levels, 14% 8 levels, 15% 9 levels and 35% had fusions of 10 levels and above. 58% included fixation to sacrum or pelvis. 93% had a decompression performed and 30% had an osteotomy. There were 40 complications recorded within the follow-up period. Infection occurred in 7 patients (6.5%). All were successfully managed with debridement, antibiotic therapy and retention of implants. There were 4 dural tears (3.7%). One patient developed a post-operative DVT (0.9%). No patients sustained cord level deficits. Prevalence of mechanical complications requiring re-operation was 26% (28 patients). 5 patients (4.7) required revision surgery for symptomatic pseudarthrosis, 7 patients (6.5%) underwent revision fixation for metal work failure (broken rods/screw pull-out) and 16 patients (14.9%) underwent revision surgery to extend fixation proximally or distally due to adjacent segment disease (symptomatic proximal junction kyphosis 4.7%; osteoporotic fracture 3.7% and junctional/nerve root pain 6.5%). Overall reoperation rate was 32.5% at an average of 1.9 years following primary surgery (range 1 week–6 years). 37% patients remain on regular outpatient review (average 3.8 years following first surgery; range 2–6 years). 52% have been discharged after a mean follow-up of 2.3 years. 11 patients had died since their surgery (10.2%) at an average 4.1 years following their spinal surgery (range 1 –5.9 years).

Overall complication rate was 37.3%. 32.5% of patients were re-operated for infective or mechanical complications. 52% of patients had been discharged at an average of 2.3 years following their surgery. 10.2% of patients had died within 6 years of surgery.

The exact prevalence of scoliosis remains unknown however it appears to be stable over time. In contrast the surgical management of spinal deformity has evolved considerably. In the UK this can be observed by examining recorded hospital statistics. Specifically the volume of procedures undertaken and preferred technique to correct deformity can be analysed and trends captured providing a comprehensive picture of changing UK practice.

Annual data tables from 2000 to 2013 were downloaded from the health information and social care UK website which contains Hospital Episode Statistics (HES) data online. Numbers of completed consultant episodes for the four character primary procedure codes V41.1 (posterior attachment of correctional instrument to spine), V41.2 (anterior attachment of correctional instrument to spine), V41.4 (Anterior and posterior attachment of correctional instrument to spine), V41.8 and V41.9 (other specified and other non-specified instrumental correction of spinal deformity respectively) as main procedure where recorded.

The total number of attachment of correctional instrument procedures listed as main procedure has increased significantly. The increase consists of higher numbers of posterior attachment procedures over this time from 352 in 2011–2012 to 1967 in 2012–2013 with data demonstrating a year on year increase to 2009–2010 before plateauing. Unspecified and other specified instrumental correctional spinal procedures have also contributed to the overall rise increasing from 206 in 2000–2001 to 447 in 2012–2013. Anterior attachment procedures listed as the main procedure are currently declining in number from a peak of 230 in 2005–2006 to 89 in 2012–2013. Combined posterior and anterior attachment procedures have also decreased marginally from 27 in 2009–2010 to 19 in 2012–2013.

Unfortunately combined anterior and posterior procedures were not uniquely coded until 2009–2010. There is also some inherent variability in accuracy of coding which may distort HES data. Despite these limitations these results are likely to represent genuine changes in practice for the surgical correction of spinal deformity over the time period examined.

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.

Boys affected by Duchenne Muscular Dystrophy (DMD) often develop significant scoliosis in the second decade of life and require scoliosis surgery. Our aim was to establish whether cardiac MRI (CMR) improves the preoperative risk assessment in DMD patients and evaluate the current risk of surgery.

Case records were retrospectively reviewed for 62 consecutive DMD boys who underwent pre-surgical evaluation at a single tertiary neuromuscular centre between 2008–2013.

62 DMD patients aged 7–18 years underwent pre-operative assessment for a total of 70 procedures (45 spinal, 19 foot, 6 gastrostomy). Echocardiography data were available for 68 procedures. Echo revealed a median left ventricular (LV) shortening fraction (SF) of 29% (range: 7–44). 34% of boys (23/68) had abnormal SF <25%, 48% (31/65) showed dyskinesia and 22% (14/64) had LV dilatation. CMR was routinely performed on 35 patients. Of those who underwent CMR, median left ventricular ejection fraction (LVEF) was 52% (range: 27–67%), 71% of boys (25/35) had dyskinesia. Echocardiography shortening fraction (SF) correlated significantly with CMR LVEF (r_s = 0.67; p<0.001). Increasing severity of dyskinesia on CMR correlated with reduced CMR LVEF (r_s = −0.64; p<0.001) and reduced echo SF (r_s = −0.47; p = 0.004). Although functional echocardiography and CMR data tended to correlate in 35 DMD boys who underwent both imaging modalities nine (26%) had discrepant results. Seven (20%) had evidence of dysfunction on CMR (LVEF < 55%) not detected on echocardiography (SF ≥ 27%); in two cases echocardiogram measured worse function than CMR.

Based on multi-disciplinary risk assessment, surgery was considered too high risk in 23 out of 67 (34%) cases. In 21 cases (91%) this was due to underlying cardiomyopathy. The highest risk among older boys assessed for spinal surgery; 21 out of 43 (49%). Of 19 boys undergoing spinal surgery, six (32%) experienced complications: two wound infections; three patients required readmission to intensive care; one patient died in the post-operative period with acute heart failure.

AIS is present in 3–5% of the general population. Large curves are associated with increased pain and reduced quality of life. However, no information is available on the impact of smaller curves, many of which do not reach secondary care. The objective of this project was to identify whether or not there is any hidden burden of disease associated with smaller spinal curves.

The Avon Longitudinal Study of Parents and Children (ALSPAC) is a population-based birth cohort that recruited over 14,000 pregnant women from the Bristol area between 1991–1992 and has followed up their offspring regularly. At aged 15 presence or absence of spinal curvature ≥6degrees was identified using the validated DXA Scoliosis Measure in 5299 participants. At aged 18 a structured pain questionnaire was administered to 4083 participants. Chi-squared was used to investigate any association between presence of a spinal curve at aged 15 and self-reported pain at aged 18 years. Sensitivity analyses were performed by rerunning analyses after excluding those who were told at aged 13 they had a spinal curve (n=27), and using a higher spinal curve cut-off of ≥10degrees.

Full data was available for 3184 participants. Of these, 56.8% were female, and 4.2% non-white reflecting the local population. 202 (6.3%) had a spinal curve ≥6degrees and 125 (3.9%) had a curve ≥10degrees. The mean curve size was 12degrees. 140/202 (69.3%) had single curves, and 57.4% of these were to the right. In total 46.3% of the 3184 participants reported aches and pains that lasted for a day or longer in the previous month, consistent with previous literature. 16.3% reported back pain. Those with spinal curves ≥6degrees were 42% more likely to report back pain than those without (OR 1.42, 95%CI 1.00 to 2.02, P=0.047). In addition, those with spinal curves had more days off school, were more likely to avoid activities that caused their pain, were more likely to think that something harmful is happening when they get the pain, and were more afraid of the pain than people without spinal curves (P<0.05). Sensitivity analyses did not change results.

We present the first results from a population-based study of the impact of small spinal curves and identify an important hidden burden of disease. Our results highlight that small scoliotic curves that may not present to secondary care are nonetheless associated with increased pain, more days off school and avoidance of activities.

The magnetically controlled growing rod (MCGR) system allows growth maintenance without the risk of anaesthesia, implant and wound complications associated with repeated surgeries. This is a medium-term report of the complications of MCGR from a multicentre study.

Twenty-six patients from 6 spine institutes that are part of a multicentre study with prospectively collected data of minimum 24 months follow-up were assessed. Pre-operative, immediate post-operative and most recent spine radiographs were reviewed to measure the Cobb angle and the rod lengthening distance. The causes and any associated risk factors for re-operations were examined.

Eleven patients required re-operation within the follow-up period, with a mean time to re-operation of 17 months after the initial surgery. Five were due to failure of rod distractions; 3 were due to failure of proximal foundation implants; 2 were due to rod breakage; and one case of superficial wound infection with failure of proximal fixation. Proximal junctional kyphosis occurred in 5 patients. Three had proximal anchor dislodgement and all five constructs were revised.

This is the largest series with the longest follow-up to date. Our series show that the perception that using MCGR may reduce the frequency of re-operations may not be entirely true. This is the first report to examine the need for re-operation after MCGR implantation, and highlights the inherent risks of any surgical treatment in this group of patients despite the advantages of this new implant. Longer-term studies and comparisons with traditional growing rods are required.

During the last decade or more, the anchors used for instrumentation in scoliosis surgery are predominantly transpedicular screws, according to Suk. The long term radiographical feature of screw fixation after scoliosis surgery is not previously studied.

A consecutive series of 81 cases with AIS operated on with an all screw construct has been studied by means of low dose CT postoperatively and at 2 years postoperatively. There were 67 females and 14 males, with a mean age of 18.3 ± 3 years.

In 26 / 81 (32 %) there were signs of loosing of one or more screws, at a maximum 3 screws. We observed loosened screws in the upper thoracic region in 16 cases, in the thoracolumbar 6 and in lumbar area in 4. Mean pre-op Cobb angle was 56 in cases of loosening and 53 of intact screw fixation (n.s.), the correction rate was 69% in loosened vs 70% among intact screws (n.s.). In males there were signs of loosening in 8/14 (57%) and in females 18/67 (27%). Among cases with loosening, 14% had suboptimal screw positioning postoperatively, in intact cases it was observed in 11% (n.s.). In the whole group there were signs of suboptimal screw positioning 12%. Clinically, 1 case had a loosened L4 screw replaced; and at all 21/26 had no complaints and 5/26 reported minor pain or discomfort. 1/26 had a minor proximal junctional kyphosis about 10°, in 3/26 there was a pull-out of some few mms. With plain radiography loosening could be observed in 11/26 cases; 5 were in the lumbar region.

In a consecutive series of 81 adolescents with idiopathic scoliosis who had underwent scoliosis surgery according to Suk, one third showed, 2 years after the intervention, some minor screw loosening, assessed by low dose CT. One patient had one lumbar screw replaced and only 5 patients reported minor discomfort. Males were more prone to develop screw loosening.

The purpose of this study is to investigate what effect cross links have on scoliosis constructs and whether cross links may be used instead of pedicle screws at the apex of the deformity

The rotational stiffness of six different construct designs was investigated on scoliotic sawbone models with zero, one or two cross links. In three of the constructs the screws at the apex were removed. Testing was performed to an average torque of 3Nm and ration was detected using electromagnetic motion tracking system.

The stiffness in axial rotation of all constructs increased with the number of cross links, however the difference was not statistically significant. In constructs with apical screws the stiffness increased by 3.01% and 12.9% for one and two cross links respectively. In constructs without apical screws the increase was 1.64% and 14.3% for one and two cross links respectively.

The total stiffness of the construct increased with the addition of apical screws by 20%, 21.7% and 18.8% for zero, one and two cross links respectively. This increase was statistically significant using a paired t-test (p= 0.01142).

On the basis of these results we conclude that the use of cross links in scoliosis correction surgery is not necessary. Pedicle screws positioned at the apex of the scoliosis curve statistically increase the stiffness in axial rotation and are therefore necessary to promote an environment suitable for bony fusion.

To present the results of surgical correction in patients with double or triple thoracic/lumbar AIS (Lenke types 2,3,4) with the use of a novel convex/convex unilateral segmental screw correction technique in a single surgeon's prospective series.

We reviewed the medical records and spinal radiographs of 92 consecutive patients (72 female-20 male). We measured scoliosis, thoracic kyphosis, lumbar lordosis, scoliosis flexibility and correction index, coronal and sagittal balance before and after surgery, as well as at minimum 2-year follow-up. SRS-22 data was available preoperatively, 6-month, 12-month and 2-year postoperatively for all patients. Surgical technique. All patients underwent posterior spinal fusion using pedicle screw constructs. Unilateral screws were placed across the convexity of each individual thoracic or lumbar curve to allow for segmental correction. ‘Corrective rod’ was the one attached to the convexity of each curve with the correction performed across the main thoracic scoliosis always before the lumbar. Maximum correction of main thoracic curves was always performed, whereas the lumbar scoliosis was corrected to the degree required to achieve a balanced effect across the thoracic and lumbar segments and adequate global coronal spinal balance. Concave screws were not placed across any deformity levels. Bilateral screws across 2 levels caudally and 1–2 levels cephalad provided proximal/distal stability of the construct.

Mean age at surgery was 14.9 years with mean Risser grade 2.8. The distribution of scoliosis was: Lenke type 2–26 patients; type 3–43 patients; type 4–23 patients. Mean preoperative Cobb angle for upper thoracic curves was 45°. This was corrected by 62% to mean 17° (p<0.001). Mean preoperative Cobb angle for main thoracic curves was 70°. This was corrected by 69% to mean 22° (p<0.001). Mean preoperative Cobb angle for lumbar curves was 56°. This was corrected by 68% to mean 18° (p<0.001). No patient lost >2° correction at follow-up. Mean preoperative thoracic kyphosis was 34° and lumbar lordosis 46°. Mean postoperative thoracic kyphosis was 45° (p<0.001) and lumbar lordosis 46.5° (p=0.69). Mean preoperative coronal imbalance was 1.2 cm. This corrected to mean 0.02 cm at follow-up (p<0.001). Mean preoperative sagittal imbalance was −2 cm. This corrected to mean −0.1 cm at follow-up (p<0.001). Mean theatre time was 187 minutes, hospital stay 6.8 days and intraoperative blood loss 0.29 blood volumes (1100 ml). Intraoperative spinal cord monitoring was performed recording cortical and cervical SSEPs and transcranial upper/lower limb MEPs and there were no problems. None of the patients developed neurological complications, infection or detected non-union and none required revision surgery to address residual or recurrent deformity. Mean preoperative SRS-22 score was 3.6; this improved to 4.6 at follow-up (p<0.001). All individual parameters also demonstrated significant improvement (p<0.001) with mean satisfaction rate at 2-year follow-up 4.9.

The convex-convex unilateral pedicle screw technique can reduce the risk of neurological injury during major deformity surgery as it does not require placement of screws across the deformed apical concave pedicles which are in close proximity to the spinal cord. Despite the use of a lesser number of pedicle fixation points compared to the bilateral segmental screw techniques, in our series it has achieved satisfactory scoliosis correction and restoration of global coronal and sagittal balance with improved thoracic kyphosis and preserved lumbar lordosis. These results have been associated with excellent patient satisfaction and functional outcomes as demonstrated through the SRS-22 scores.

The prevalence of degenerative spondylolisthesis (DS) increases with age. With an ageing population there will be increasing demands for adult deformity surgery, with associated significant financial and complication costs. The prevalence of lytic spondylolisthesis (LS) is 6–8%. Our clinical observation is that it is extremely rare to see LS in the presence of DS and therefore the objective was to formally describe the prevalence of LS in combination with DS to assess the hypothesis that 6–8% of patients with DS should also have LS. If this is not the case it may further our understanding of the pathogenesis of DS, which could aid in future prevention or treatment.

A retrospective review of erect lateral lumbar radiographs demonstrating lumbar spondylolisthesis was performed. Radiographs were identified and analysed on the hospital Synapse Picture Archiving and Communication System (PACS). Search criteria were radiographs requested by primary care and patients aged over 60.

101 patients with spondylolisthesis were identified. 89% were requested for back or leg pain. There were 89 patients with DS (69.7% women) and 12 with LS (83% men). The average age of DS and LS patient was 75 and 70 respectively (not significant). There were no cases found with both DS and LS. This was significantly different to the expected amount of 6% (p=0.03). The level of DS was at L3/4 in 11.2% (n=10), L4/5 in 79.8% (n=71) and L5/S1 in 16.9% (n=15). 2 levels were involved in 7 patients. 94.4% (n=84) demonstrated a Meyerding grade 1 slip and 5.6% (n=5) grade 2 slip. For LS the slipped level was at L5/S1 in all cases. 66.7% (n=8) had a grade 1 slip and 33.3% (n=4) a grade 2 slip.

We found no cases of lytic spondylolisthesis in the presence of degenerative spondylolisthesis. We hypothesis that the presence of spondylolysis or lytic spondylolisthesis may be protective against development of degenerative spondylolisthesis. More work is needed to explore this further.

There is a wide range of reports on the prevalence of neurological injuries during scoliosis surgery, however this should depend on the subtypes and severity of the deformity. Furthermore, anterior versus posterior corrections pose different stresses to the spine, further quantifications of neurological risks are presented.

Neuromonitoring data was prospectively entered, and the database between 2006 and 2012 was interrogated. All deformity cases under the age of 21 were included. Tumour, fracture, infection and revision cases were excluded.

All “red alerts” were identified and detailed examinations of the neuromonitoring records, clinical notes and radiographs were made. Diagnosis, deformity severity and operative details were recorded.

2290 deformity operations were performed: 2068 scoliosis (1636 idiopathic, 204 neuromuscular, 216 syndromic, and 12 others), 89 kyphosis, 54 growing rod procedures, and 80 operations for hemivertebra. 696 anterior and 1363 posterior operations were performed for scoliosis (8 not recorded), and 38 anterior and 51 posterior kyphosis correction.

67 “red alerts” were identified, there were 14 transient and 6 permanent neurological injuries. 62 were during posterior stage (24 idiopathic, 21 neuromuscular, 15 syndromic (2 kyphosis), 1 growing rod procedure, 1 haemivertebra), and 5 were during anterior stage (4 idiopathic scoliosis and 1 syndromic kyphosis). Average Cobb angle was 88°. 1 permanent injuries were during correction for kyphosis, and 5 were for scoliosis (4 syndromic, 1 neuromuscular, and 1 anterior idiopathic).

Common reactions after “red alerts” were surgical pause with anaesthetic interventions (n=39) and the Stagnara wake-up test (n=22). Metalwork was partially removed in 20, revised in 12 and completely removed in 9. 13 procedures were abandoned.

The overall risk of permanent neurological injuries was 0.2%, the highest risk groups were posterior corrections for kyphosis and scoliosis associated with a syndrome. 4% of all posterior deformity corrections had “red alerts”, and 0.3% resulted in permanent injuries; compared to 0.6% “red alerts” and 0.3% permanent injuries for anterior surgery. The overall risk for idiopathic scoliosis was 0.06%.

The K2M MESA Rail is a new implant with a unique beam-like design which provides increased rigidity compared with a standard circular rod of equivalent diameter potentially allowing greater control and maintenance of correction. The aim of this study was to review our early experience of this implant.

We retrospectively reviewed the case notes and radiographs of all consecutive cases of spinal deformity correction in which at least one rail was used. All radiological measurements were made according to the Scoliosis Research Society definitions.

Since June 2012 thirty-three cases of spinal deformity correction were performed using the K2M Rail system. One case was excluded as there were no pre-operative radiographs. Median age was 15 years; there were 23 females. There were 26 scoliosis cases of which two had associated Chiari malformation, three were neuromuscular, and the remainder were adolescent idiopathic cases. Six patients had kyphotic deformity secondary to Scheuermann's disease. Mean length of follow-up was 16 months. In the scoliosis cases the mean pre-operative Cobb angle of the major curve was 58.6° with a mean correction of 35.6°. The mean post-operative thoracic kyphosis was 21.1°. The median number of levels included in the correction was 13. Bilateral rails were used in four cases, the remainder had one rail on the concave side and a contralateral rod. No patients required an anterior release or staged surgery. All kyphosis cases had posterior apical corrective osteotomies. The mean pre-operative thoracic kyphosis was 75.5° with a mean correction of 31°. The median number of levels included in the correction was 11. Four patients had bilateral rails. No patients required anterior release. Complications: two patients had prominent hardware. One patient had a malpositioned screw causing nerve root irritation, which was removed. There were three superficial infections, which settled with antibiotics. There were no cases of implant breakage, screw pull-out, or loss of correction.

The K2M MESA Rail is a powerful new implant design which helps to achieve and maintain satisfactory correction of complex spinal deformity, and is particularly strong at correcting kyphotic deformity. It also enables restoration of normal thoracic kyphosis, particularly in idiopathic thoracic curves, which tend to be lordosing. This may prevent thoracic flat back and potential long-term sequelae. Early results show that the system is as safe and effective as other posterior deformity correction implants on the market, however, it requires further prospective follow-up to ascertain its outcomes in the long-term.

The objective of this study was to assess the reliability and appropriateness of statistical shape modelling for capturing variation in thoracic vertebral anatomy for future use in assessing scoliotic vertebral morphology.

Magnetic resonance (MR) images of the thoracic vertebrae were acquired from 20 healthy adults (12 female, 8 male) using a 1.5 T MR scanner (Intera, Philips). A T1 weighted spin-echo sequence (repetition time = 294 ms, echo time = 8 ms, number of signal averages = 3) was used. A set of slices (number = 27, thickness = 1.9 mm, gap = 1.63 mm, pixel size = 0.5 mm) were acquired for each vertebrae, parallel to the mid-transverse plane of the vertebral body. Repeated imaging, including participant repositioning, was performed for T4, T8 and T12 to assess reliability. Landmark points were placed on the images to define anatomical features consisting of the vertebral body and foramen, pedicles, transverse and spinous processes, inferior and superior facets. A statistical shape model was created using software tools developed in MATLAB (R2013a, The MathWorks Inc.). The model was used to determine the mean vertebral shape and ‘modes of variation’ describing patterns in vertebral shape. Analysis of variance was used to test for differences between vertebral levels and subjects and reliability was assessed by determining the within-subject standard deviation from the repeated measurements.

The first three modes of variation, shown below (green = mean, red and blue = ±2 standard deviations about the mean), accounted for 70% of the variation in thoracic vertebral shape (Mode 1 = 44%, Mode 2 = 19%, Mode 3 = 4%). Visual inspection indicated that these modes described variation in anatomical features such as the aspect ratio of the vertebral bodies, width and orientation of the pedicles, and position and orientation of the processes and facet points. Variation in shape along the thoracic spine, characterised by these modes of variation, was consistent with that reported in the literature. Significant differences (p< 0.05) between vertebral levels and between some subjects were found. The reliability of the method was good with low relative error (Mode 1 = 5%, Mode 2 = 8%, Mode 3 = 19%).

Statistical shape modelling provides a reliable method for characterizing many anatomical features of the thoracic vertebrae in a compact number of variables. This is useful for robustly assessing morphological differences between scoliotic and non-scoliotic vertebrae and in assessing entry points and trajectories for pedicle screws.

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.

The lack of an accurate, rapid diagnostic test for mycobacterium tuberculosis (TB) is a major handicap in the management of spinal TB. GeneXpert, a new, rapid molecular diagnostic test is recommended as the first line investigation for suspected pulmonary TB in areas with a high prevalence of HIV or drug resistance, yet it has not been validated for the diagnosis of musculoskeletal TB.

The aim of this study was to assess the accuracy of GeneXpert in diagnosing spinal TB.

A prospective clinical study of 69 consecutive adults with suspected spinal TB was conducted at a tertiary hospital in an area with the highest incidence and prevalence of TB in the world. GeneXpert was used on tissue samples of the enrolled patients and its diagnostic accuracy compared with a reference standard of tissue in liquid culture. A total of 71 spine samples from 69 patients (two re-biopsies) were included in the study.

The GeneXpert test showed a sensitivity of 95.6% and specificity of 96.2% for spinal TB. The results of the GeneXpert test were available within 48 hours compared with a median of 35 days (IQR 15 to 43) for cultures. All cases of multi-drug resistant TB (MDR TB) were diagnosed accurately with the GeneXpert test. The MDR TB rate was 5.8%.

Cite this article: Bone Joint J 2014;96-B:1366–9.

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.

To determine whether neurophysiological electrical pedicle testing (EPT) is a useful aid in the detection of malpostioned pedicle screw tracts

EPT data from 246 screws in 32 spinal operations on 32 patients over a 5 year period (2009–2014) were recorded and analysed. In addition to physical palpation, a ball-tipped electrode delivered stimuli and the output was recorded by evoked electromyogram (EMG). When breach threshold values were recorded, the surgeon rechecked the tract for breaches and responded appropriately. In addition, standard motor evoked potential (MEP) and sensory evoked potential(SEP) spinal cord monitoring was performed.

There were 24(9.8%) pedicle breaches by tract testing and 8(3.3%) by screw testing. In 11 instances in 7 patients where the tract testing showed a breach, the tract was redirected and subsequent screw testing showed adequate integrity of the pedicle. The total time for tract and screw testing was 25 seconds.

There were no associated changes in MEP or SEP monitoring with any of the recorded pedicle breaches and none of the patients had any post-operative neurological deficit.

EPT for the pedicle screw and tract is a safe, simple, practical and reliable technique which improves the accuracy of screw placement. Further studies would be required to confirm (and possibly revise) the threshold levels and to demonstrate whether EPT reduces the risk of misplaced screws or post-operative neurological deficit.

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.

The purpose of this study was to evaluate the long-term outcome of adults with spina bifida cystica (SBC) who had been treated either operatively or non-operatively for scoliosis during childhood.

We reviewed 45 patients with a SBC scoliosis (Cobb angle ≥ 50º) who had been treated at one of two children’s hospitals between 1991 and 2007. Of these, 34 (75.6%) had been treated operatively and 11 (24.4%) non-operatively. After a mean follow-up of 14.1 years (standard deviation (sd) 4.3) clinical, radiological and health-related quality of life (HRQOL) outcomes were evaluated using the Spina Bifida Spine Questionnaire (SBSQ) and the 36-Item Short Form Health Survey (SF-36).

Although patients in the two groups were demographically similar, those who had undergone surgery had a larger mean Cobb angle (88.0º (sd 20.5; 50.0 to 122.0); versus 65.7º (sd 22.0; 51.0 to 115.0); p < 0.01) and a larger mean clavicle–rib intersection difference (12.3 mm; (sd 8.5; 1 to 37); versus 4.1 mm, (sd 5.9; 0 to 16); p = 0.01) than those treated non-operatively. Both groups were statistically similar at follow-up with respect to walking capacity, neurological motor level, sitting balance and health-related quality of life (HRQOL) outcomes.

Spinal fusion in SBC scoliosis corrects coronal deformity and stops progression of the curve but has no clear effect on HRQOL.

Cite this article: Bone Joint J 2014; 96-B:1244–51

Whiplash injury is surrounded by controversy in both the medical and legal world. The debate on whether it is either a potentially serious medical condition or a social problem is ongoing. This paper briefly examines a selection of studies on low velocity whiplash injury (LVWI) and whiplash associated disorder (WAD) and touches upon the pathophysiological and epidemiological considerations, cultural and geographical differences and the effect of litigation on chronicity. The study concludes that the evidence for significant physical injury after LVWI is poor, and if significant disability is present after such injury, it will have to be explained in terms of psychosocial factors.

Clinical, radiological, and Scoliosis Research Society-22 questionnaire data were reviewed pre-operatively and two years post-operatively for patients with thoracolumbar/lumbar adolescent idiopathic scoliosis treated by posterior spinal fusion using a unilateral convex segmental pedicle screw technique. A total of 72 patients were included (67 female, 5 male; mean age at surgery 16.7 years (13 to 23)) and divided into groups: group 1 included 53 patients who underwent fusion between the vertebrae at the limit of the curve (proximal and distal end vertebrae); group 2 included 19 patients who underwent extension of the fusion distally beyond the caudal end vertebra.

A mean scoliosis correction of 80% (45% to 100%) was achieved. The mean post-operative lowest instrumented vertebra angle, apical vertebra translation and trunk shift were less than in previous studies. A total of five pre-operative radiological parameters differed significantly between the groups and correlated with the extension of the fusion distally: the size of the thoracolumbar/lumbar curve, the lowest instrumented vertebra angle, apical vertebra translation, the Cobb angle on lumbar convex bending and the size of the compensatory thoracic curve. Regression analysis allowed an equation incorporating these parameters to be developed which had a positive predictive value of 81% in determining whether the lowest instrumented vertebra should be at the caudal end vertebra or one or two levels more distal. There were no differences in the Scoliosis Research Society-22 outcome scores between the two groups (p = 0.17).

In conclusion, thoracolumbar/lumbar curves in patients with adolescent idiopathic scoliosis may be effectively treated by posterior spinal fusion using a unilateral segmental pedicle screw technique. Five radiological parameters correlate with the need for distal extension of the fusion, and an equation incorporating these parameters reliably informs selection of the lowest instrumented vertebra.

Cite this article: Bone Joint J 2014;96-B:1082–9.

We report the incidence of and risk factors for complications after scoliosis surgery in patients with Duchenne muscular dystrophy (DMD) and compare them with those of other neuromuscular conditions.

We identified 110 (64 males, 46 females) consecutive patients with a neuromuscular disorder who underwent correction of the scoliosis at a mean age of 14 years (7 to 19) and had a minimum two-year follow-up. We recorded demographic and peri-operative data, including complications and re-operations.

There were 60 patients with cerebral palsy (54.5%) and 26 with DMD (23.6%). The overall complication rate was 22% (24 patients), the most common of which were deep wound infection (9, 8.1%), gastrointestinal complications (5, 4.5%) and hepatotoxicity (4, 3.6%). The complication rate was higher in patients with DMD (10/26, 38.5%) than in those with other neuromuscular conditions (14/84, 16.7% (p = 0.019). All hepatotoxicity occurred in patients with DMD (p = 0.003), who also had an increased rate of deep wound infection (19% vs 5%) (p = 0.033). In the DMD group, no peri-operative factors were significantly associated with the rate of overall complications or deep wound infection. Increased intra-operative blood loss was associated with hepatotoxicity (p = 0.036).

In our series, correction of a neuromuscular scoliosis had an acceptable rate of complications: patients with DMD had an increased overall rate compared with those with other neuromuscular conditions. These included deep wound infection and hepatotoxicity. Hepatotoxicity was unique to DMD patients, and we recommend peri-operative vigilance after correction of a scoliosis in this group.

Cite this article: Bone Joint J 2014; 96-B:943–9.

C5 nerve root palsy is a rare and potentially debilitating complication of cervical spine surgery. Currently, however, there are no guidelines to help surgeons to prevent or treat this complication.

We carried out a systematic review of the literature to identify the causes of this complication and options for its prevention and treatment. Searches of PubMed, Embase and Medline yielded 60 articles for inclusion, most of which addressed C5 palsy as a complication of surgery. Although many possible causes were given, most authors supported posterior migration of the spinal cord with tethering of the nerve root as being the most likely.

Early detection and prevention of a C5 nerve root palsy using neurophysiological monitoring and variations in surgical technique show promise by allowing surgeons to minimise or prevent the incidence of C5 palsy. Conservative treatment is the current treatment of choice; most patients make a full recovery within two years.

Cite this article: Bone Joint J 2014;96-B:950–5.

We describe 13 patients with cerebral palsy and lordoscoliosis/hyperlordosis of the lumbar spine who underwent a posterior spinal fusion at a mean age of 14.5 years (10.8 to 17.4) to improve sitting posture and relieve pain. The mean follow-up was 3.3 years (2.2 to 6.2).

The mean pre-operative lumbar lordosis was 108^° (80 to 150^°) and was corrected to 62^° (43^° to 85^°); the mean thoracic kyphosis from 17^° (-23^° to 35^°) to 47^° (25^° to 65^°); the mean scoliosis from 82^° (0^° to 125^°) to 22^° (0^° to 40^°); the mean pelvic obliquity from 21^° (0^° to 38^°) to 3^° (0^° to 15^°); the mean sacral slope from 79^° (54^° to 90^°) to 50^° (31^° to 66^°). The mean pre-operative coronal imbalance was 5 cm (0 cm to 8.9 cm) and was corrected to 0.6 cm (0 to 3.2). The mean sagittal imbalance of -8 cm (-16 cm to 7.8 cm) was corrected to -1.6 cm (-4 cm to 2.5 cm). The mean operating time was 250 minutes (180 to 360 minutes) and intra-operative blood loss 0.8 of estimated blood volume (0.3 to 2 estimated blood volume). The mean intensive care and hospital stay were 3.5 days (2 to 8) and 14.5 days (10 to 27), respectively. Three patients lost a significant amount of blood intra-operatively and subsequently developed chest or urinary infections and superior mesenteric artery syndrome.

An increased pre-operative lumbar lordosis and sacral slope were associated with increased peri-operative morbidity: scoliosis and pelvic obliquity were not. A reduced lumbar lordosis and increased thoracic kyphosis correlated with better global sagittal balance at follow-up. All patients and their parents reported excellent surgical outcomes.

Lordoscoliosis and hyperlordosis are associated with significant morbidity in quadriplegic patients. They are rare deformities and their treatment is challenging. Sagittal imbalance is the major component: it can be corrected by posterior fusion of the spine with excellent functional results.

Cite this article: Bone Joint J 2014;96-B:800–6.

Using the United States Nationwide Inpatient Sample, we identified national trends in revision spinal fusion along with a comprehensive comparison of comorbidities, inpatient complications and surgical factors of revision spinal fusion compared to primary spinal fusion.

In 2009, there were 410 158 primary spinal fusion discharges and 22 128 revision spinal fusion discharges. Between 2002 and 2009, primary fusion increased at a higher rate compared with revision fusion (56.4% vs 51.0%; p < 0.001). In 2009, the mean length of stay and hospital charges were higher for revision fusion discharges than for primary fusion discharges (4.2 days vs 3.8 days, p < 0.001; USD $91 909 vs. $87 161, p < 0.001). In 2009, recombinant human bone morphogenetic protein (BMP) was used more in revision fusion than in primary fusion (39.6% vs 27.6%, p < 0.001), whereas interbody devices were used less in revision fusion (41.8% vs 56.6%, p < 0.001).

In the multivariable logistic regression model for all spinal fusions, depression (odds ratio (OR) 1.53, p < 0.001), psychotic disorders (OR 1.49, p < 0.001), deficiency anaemias (OR 1.35, p < 0.001) and smoking (OR 1.10, p = 0.006) had a greater chance of occurrence in revision spinal fusion discharges than in primary fusion discharges, adjusting for other variables. In terms of complications, after adjusting for all significant comorbidities, this study found that dural tears (OR 1.41; p < 0.001) and surgical site infections (OR 3.40; p < 0.001) had a greater chance of occurrence in revision spinal fusion discharges than in primary fusion discharges (p < 0.001). A p-value < 0.01 was considered significant in all final analyses.

Cite this article: Bone Joint J 2014;96-B:807–16.

Back pain is a common symptom in children and adolescents. Here we review the important causes, of which defects and stress reactions of the pars interarticularis are the most common identifiable problems. More serious pathology, including malignancy and infection, needs to be excluded when there is associated systemic illness. Clinical evaluation and management may be difficult and always requires a thorough history and physical examination. Diagnostic imaging is obtained when symptoms are persistent or severe. Imaging is used to reassure the patient, relatives and carers, and to guide management.

Cite this article: Bone Joint J 2014;96-B:717–23.

Little information is available about the incidence and outcome of incidental dural tears associated with microendoscopic lumbar decompressive surgery. We prospectively examined the incidence of dural tears and their influence on the outcome six months post-operatively in 555 consecutive patients (mean age 47.4 years (13 to 89)) who underwent this form of surgery. The incidence of dural tears was 5.05% (28/555). The risk factors were the age of the patient and the procedure of bilateral decompression via a unilateral approach. The rate of recovery of the Japanese Orthopaedic Association score in patients with dural tears was significantly lower than that in those without a tear (77.7% vs 87.6%; p < 0.02), although there were no significant differences in the improvement of the Oswestry Disability Index between the two groups. Most dural tears were small, managed by taking adequate care of symptoms of low cerebrospinal fluid pressure, and did not require direct dural repair. Routine MRI scans were undertaken six months post-operatively; four patients with a dural tear had recurrent or residual disc herniation and two had further stenosis, possibly because the dural tear prevented adequate decompression and removal of the fragments of disc during surgery; as yet, none of these patients have undergone further surgery.

Cite this article: Bone Joint J 2014;96-B:641–5.

Aim:

Right-Handed Girls With Rt-Ais Measured Using Holtain Equipment Have Upper Arm Length Asymmetry (Right-Minus-Left) Which Is: 1) Relatively Longer On Scoliosis Curve Convexity; 2) Significantly Associated With Scoliosis Curve Severity (Cobb Angle And Apical Vertebral Rotation); And 3) Transient, Decreasing With Age And Years After Menarche [1,2]. The Aim Is To Test Whether The Right Upper Arm Length Relative Overgrowth And Spinal Deformity Severity Were Associated With Right Or Left Upper Arm Length Size-For-Age.

Aim:

The purpose of this study was to identify factors (radiographic and MRI) which may be important in determining whether a degenerative spondylolisthesis at L4/5 is mobile.

Aim:

The Magnetic Expansion Control Rod Device (Magec) allows controlled distraction of the immature spine for the treatment of early onset scoliosis. There disparity between the reported distraction on the external adjustment device (EAD) and true distraction achieved has not been commented on to date. This study aims to determine the disparity between ‘true’ (T) and ‘apparent’ (A) distraction. Our secondary aim was to assess truncal growth and development.

Aim:

To present the results of multi-modal IOM in 298 patients who underwent spinal deformity correction.

Aim:

The aim of this study was test the amount of corrosion occurring at the (Ti) /cobalt chrome (CoCr) interface comparing this with Ti and Ti interfaces. This was compared with retrieved metal work visualised under a scanning electron microscope (SEM).

Aim:

To Determine Whether Maximal Rib Prominence Measured On Lateral Radiographs Can Be Used As A Surrogate To Rib Rotation Determined By Surface Tomography (Quantecscanning) In Assessment Of Spinal Rotation.

Introduction:

Shoulder balance after surgery is one main attribute of the cosmetic outcome. It has been difficult to assess on 2D images. The balance results from the interaction of rib cage, shoulder joint and scapular positions, spinal alignment and rotation, muscle size and co-ordination and pain interaction. Attempts have been made to predict shoulder balance from radiograph measurements. There is no consensus on this.

Background:

Long-Term Follow-Up Of Lung Function And Quality Of Life (Qol) In Those Undergoing Combined Anterior And Posterior Spinal Fusion (A/Psf) For Ais Is Not Well Documented With Only One Study Extending Beyond 2 Years.

Aim:

The introduction of novel systems for correction of scoliosis should be subject to critical analysis and based on patient benefit.

Aim:

To evaluate the effect of intraoperative manoeuvres on the rib hump.