Purpose: To report long-term results (with a minimum follow-up of 13 years) of GR construct [Luque-trolley (LT)] in EOS, to identify factors predictive of curve progression and to establish the timing of definitive fusion.

Method: The study cohort consisted of 37 patients (22M & 15F) who had primary LT between 1983–1995 were reviewed. Group I: 7 patients had LT alone and Group II: 30 had LT with convex fusion. Cobb at initial presentation, after first surgery, before definitive fusion and at the latest follow-up was recorded. Other radiological curve parameters recorded were rib spinal angle difference (RSAD), end vertebral tilts (EVT), apical vertebral rotation (AVR) and T1-S1 length. Complications with respect to development of junctional/apical kyphosis, implant failure, pseudoarthrosis (PA), sagittal/coronal profile and instrumented spinal segment growth at maturity were evaluated.

Results: The mean age at definitive fusion for study cohort was 12.5 years. Group I: Mean age at first surgery was 7.4 years (3.3–9.5y). Mean pre-op Cobb angle of primary curve was 600 (310–710) which was corrected to 280 (200–360). They underwent definitive segmental spinal instrumentation(SSI) with fusion at 13.9 years (9.8–15.1y) when the curve had worsened to 480 (400–650). Group II: Mean age at index surgery was 3.6 years (1.6–8.8y). Mean pre-op Cobb of primary curve was 580 (300–900) which corrected to 300 (100–620). 16/30 patients underwent definitive SSI with fusion at 11.5 years (8.5–14.2y) when the curve deteriorated to 600 (530–770). Instrumented segmental spinal growth was 3.2cms (SD±1.45; range 1–5cms). 14/30 maintained their correction till skeletal maturity. JK was observed in 8 cases [proximal(3), distal(2) & apical(3)] which were corrected at the time of definitive SSI. There was a linear relationship between Cobb angle at definitive fusion with concaveRSA and upperEVT.

Conclusion: Correlation and regression statistics revealed predictive factors of curve progression to be concave RSA (®=0.91 & p=0.001) and upper EVT (®=0.81 & p=0.0004). Patients with high concave RSA and upper EVT should be closely monitored for deterioration. Spinal growth that exceeds the capacity of LT to elongate leads to apical kyphosis. Timing of definitive fusion is influenced by growth velocity, clinico-radiological factors and complications.

Introduction: Patient questionnaires permit a direct measure of the value of care as perceived by the recipient. The Scoliosis Research Society outcomes questionnaire (SRS-22) has been validated as a tool for self-assessment. We investigated the correlation between SRS-22 and a detailed radiological outcome two-years following anterior correction of ThoracoLumbar Adolescent Idiopathic Scoliosis (TL-AIS).

Methods: The SRS-22 questionnaire was completed by 30 patients two-years following anterior correction of TL-AIS. Pre-operative, post-operative and two-year follow-up radiographs of all 30 patients were assessed. The following parameters were measured at each time point: 1) Primary Cobb angle, 2) Secondary Cobb angle, 3) Coronal C7-midsacral plumb line, 4) Apical Vertebra Translation (AVT) of primary curve, 5) AVT of the secondary curve, 6) Upper instrumented vertebra (UIV) translation, 7) UIV tilt angle, 8) Lower instrumented vertebra (LIV), 8) LIV tilt angle 9) Apical Vertebra Rotation (AVR) of the primary curve, 10) Sagittal C7-posterior corner of sacrum plumb line 11) T5–T12 angle, 12) T12-S1 angle, 13) shoulder height difference. The percentage improvements for each were noted. Correlation was sought between Total SRS score, each of the five individual domains and various radiographic parameters listed above by quantifying Pearson’s Correlation Coefficient (r).

Results: Percentage improvement in primary Cobb angle (r = 0.052), secondary Cobb angle (r = 0.165) and AVT of the primary curve (r = −0.353) showed little or no correlation with the SRS-22 total score or any of its five domains. Significant inverse correlation was found between the UIV tilt angle at two years and the SRS-22 (r = −0.516). Lateral radiographs however showed little or no correlation between thoracic kyphosis (r = 0.043) and SRS-22.

Conclusion: The SRS-22 outcomes questionnaire does not correlate with most of the radiographic parameters commonly used by clinicians to assess patient outcome.

Introduction We report the two-year clinical outcome of a prospective randomised trial comparing Femoral Ring Allograft (FRA) to a Titanium Cage (TC) in circumferential lumbar spinal fusion.

Methods 83 patients recruited to the study fulfilled strict entry requirements (> 6 months chronic discogenic low back pain, failure of conservative treatment, one or two-level discographically proven discogenic pain source). 38 patients were randomised to receive FRA, 45 patients were randomised to receive TC. Posterior stabilisation was achieved with translaminar or pedicle screws. Patients completed questionnaires including Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) and the Short-Form 36 (SF-36) pre-operatively and 6, 12 and 24 months post-operatively.

Results Results were available for all 83 patients with a mean follow-up of 26.5 months (range 24–75 months). Baseline demographic data (age, sex, smoking history, number of operated levels, pre-operative outcome measures) showed no statistical difference between groups (p< 0.05). For patients receiving the FRA, mean VAS (back pain) improved 2.0 points (p=0.01), mean ODI improved 14 points (p=< 0.01), and mean SF-36 scores improved by > 11 points in all domains (p< 0.03) except general health and emotional role. For patients receiving the TC, mean VAS improved 1.2 points (p=0.002), mean ODI improved 5 points (p=0.02); SF-36 improved significantly in only one of eight domains (bodily pain).

Discussion Clinical outcome following circumferential lumbar fusion with FRA readily achieves the accepted mean clinically important differences (MCID). Fusion with TC does not achieve the MCID. The use of TC for circumferential lumbar fusion appears not to be justified.

Background: Anterior scoliosis correctional surgery can result in screw pull out or pedicular fracture. This is more common in stiff curves where the instrumentation extends to the smaller, higher, thoracic levels. The fracture/intra-operative pull out usually occurs during the reduction maneuver. In all of our cases the curve was reduced in the standard cranial to caudal direction using a cantilever maneuver. We describe a salvage technique using circlage wires that can be used for this problem. We present seven cases and the final outcome.

Methods: The technique involves placing a longer screw into the damaged vertebrae so it protrudes 5mm proud. A 1.25mm circlage wire is then cut to length and passed around the tip of the screw. It is then looped in a figure of eight passed under the rod and tightened around the respective pedicle screw head. A case record and x- ray review of seven procedures performed was then carried out. The age of the patients was between 14 and 41 years (mean 20) at surgery. The pre-operative Cobb was between 72 and 43 (mean 58). One curve was flexible with a flexibility index of 70% but the remainder was stiffer (range 34%–40%). There was one thoracolumbar curve with a T11 fracture. All other curves were thoracic and the fracture levels were T5, T7, T7, T6+7, T6+7+8, and T6+7+8 respectively. Four out of seven were braced post operatively for three months. The Cobb angle over the instrumented levels immediately post surgery and at final follow up was measured. The technique was deemed to be successful if no significant loss of correction occurred.

Results: The technique held position in six out of seven of the subjects. The average loss of position in these patients was two degrees (range 0–4). In one subject the curve went from 28 degrees immediately post operatively to 38 degrees over 2 years. The four month post operative x ray showed no loss of position suggesting that this loss of position may not be due to the fracture. This patient remained pleased with his cosmetic result and went from 72 degrees pre operatively to 38 degrees at 2 year follow up.

Conclusion: Care should be taken in patients with stiff proximal curves. The use of larger 8mm screws may decrease pull out and consideration may be given to caudal to cranial reduction in some cases. Circlage wire rescue is a useful salvage procedure for inter-operative fracture or screw pull out during anterior scoliosis correction.

Objective. To evaluate the relation of ribs to the spine in the transverse plane (TP) at the curve apex in preoperative AIS using a real-time ultrasound method and radiographs (Burwell et al 2002).

Design. With the subject in a prone position and head supported, readings of laminal rotation (LR) and rib rotation (RR) were made on the back by one of two observers (RKA, ASK) using an Aloka SSD 500 portable u/s machine with a veterinary long (172mm) 3.5 MHz linear array transducer. The maximal difference between LR and RR about the curve apex was calculated as the apical spine-minus-rib rotation difference (SRRD). The SRRD eliminates the effect of any anterior chest wall asymmetry on the ultrasound measurements and, assuming no movement of ribs in the TP at the costotransverse joints, is considered to be a measure of TP rib deformity. The radiographic Cobb angle (CA), apical Perdriolle rotation (AR), and apical vertebral translation (AVT) were measured by one observer (RGB). In an attempt to separate mechanical axial vertebral rotation from axial vertebral deformity a derivative was calculated as Perdriolle rotation minus ultrasound LR with the latter corrected for the positional effect of lying prone and termed the axial vertebral difference (AVD) The correction factor (CF) used is maximal Scoliometer angle of trunk rotation obtained in the standing forward bending position minus that in the prone position.

Subjects. Thirty-three preoperative patients with AIS were studied (thoracic curves 20, thoracolumbar curves 8, double curves 5).

Results. The mean figures in degrees or mm (AVT) are shown in the Table.

All curves combined. The LR is significantly greater than the RR (p< 0.001) and correlates with RR (r=0.358, p=0.041), SRRD (r=0.713, P< 0.001) but not with CA (p=0.088), AR (p=0.166), AVT or AVD. AR does not correlate significantly with CA.

Thoracolumbar and thoracic curves. In the thoracolumbar curves the SRRDs are significantly greater than those in the thoracic curves (p=0.031) implying more TP rib deformity in the thoracolumbar curves. In the thoracic curves the SRRDs correlate negatively with the AVDs (r= −0.470, p=0.036) suggesting that rib deformity and intravertebral deformity contribute reciprocally and together with axial spinal rotation to determine the overall spinal deformity of AIS.

Conclusions. The findings are consistent with the hypothesis that in preoperative AIS the axial RR and TP rib deformities are adaptations to rotational and lateral forces imposed by the scoliotic spine (Wever et al 1999). Might surgical stiffening of the posterior ends of the apical convex ribs – in an attempt to prevent TP convex rib deformity – constrain axial spinal rotation, vertebral translation and intravertebral deformity and limit curve progression? #Supported by AO/ASIF Research Commission Project 96-W21

Objective: To evaluate the subjective clinical outcomes, radiographic results and complications associated with single solid rod anterior instrumentation in neuromuscular scoliosis.

Design: Retrospective clinical case series with a mean follow up of 30 months (range 24 – 42 months).

Subjects: 9 consecutive cases (6F, 3M) with a mean age 15 years (range 11 – 24 years), underwent single solid rod anterior instrumentation of their neuromuscular thoracolumbar scoliosis between 1994 and 2000. The heterogeneous patient group consisted of 5 spinal dysraphism, and 1 each of prune belly syndrome, arthrogryposis, myotonic dystrophy and congenital myopathic dystrophy (muscle eye brain syndrome). All patients were ambulatory and had minimal pelvic obliquity (< 15 degrees).

Outcome measures: Pre-operative, post-operative and final follow up measurements were collected for 1) Cobb angles, 2) apical vertebral translation (AVT), 3) thoracic kyphosis (T5-12) and 4) lumbar lordosis (L1-5). Operative complications, pseudarthrosis, metalwork failure and loss of correction were also recorded.

Results: There was 1 each of rod breakage and upper thoracic curve progression requiring supplementary posterior surgery. For the remaining 7 patients, the average follow-up corrections for Cobb angle was 56% (49 to 22 degrees), AVT was 49% (5.1 to 2.6 cms), and both the thoracic kyphosis and lumbar lordosis remained unchanged. No significant loss in correction occurred during the post-operative period to final follow-up in all the above parameters. No pseudarthrosis, vascular or neurological complications were encountered. Subjectively, there were 6 excellent and 1 good results.

Conclusions: In this limited case review, selective anterior instrumentation for neuromuscular scoliosis using a single solid rod system resulted in acceptable clinical and radiographic outcomes. Our results appear to compare favourably with those published for the recommended method of posterior instrumentation. Advantages include preservation of distal lumbar motion segments whilst maintaining segmental saggital and coronal alignment. We believe that this method of scoliosis correction has a definite yet select role in patients who are ambulatory, have minimal pelvic obliquity (< 15 degrees), non-progressive pathology and near normal mental function.

We studied prospectively 22 young athletes who had undergone surgical treatment for lumbar spondylolysis. There were 15 men and seven women with a mean age of 20.2 years (15 to 34). Of these, 13 were professional footballers, four professional cricketers, three hockey players, one a tennis player and one a golfer. Preoperative assessment included plain radiography, single positron-emission CT, planar bone scanning and reverse-gantry CT. In all patients the Oswestry disability index (ODI) and in 19 the Short-Form 36 (SF-36) scores were determined preoperatively, and both were measured again after two years in all patients. Three patients had a Scott’s fusion and 19 a Buck’s fusion.

The mean duration of back pain before surgery was 9.4 months (6 to 36). The mean size of the defect as determined by CT was 3.5 mm (1 to 8) and the mean preoperative and postoperative ODIs were 39.5 (sd 8.7) and 10.7 (sd 12.9), respectively. The mean scores for the physical component of the SF-36 improved from 27.1 (sd 5.1) to 47.8 (sd 7.7). The mean scores for the mental health component of the SF-36 improved from 39.0 (sd 3.9) to 55.4 (sd 6.3) with p < 0.001. After rehabilitation for a mean of seven months (4 to 10) 18 patients (82%) returned to their previous sporting activity.

We analysed the functional outcome (Oswestry Disability Index) after technically and radiologically successful lumbar fusion in 39 non-compensation seeking patients with chronic low back pain, who had a High Intensity Zone (HIZ) – positive MRI and subsequently underwent discography. The average follow-up was 33 months. The HIZ-positive, discogrampositive group was the only one with statistically significant improvement. The HIZ-positive, discogram-negative group had the worst outcome. Relying only on the HIZ fails to identify the group of patients who would have had negative discography at the same levels. Therefore the presence of HIZ alone should not dictate treatment plan without discography confirmation.

In a prospective non-randomised study, 28 patients underwent laparoscopic assisted transperitoneal anterior interbody fusion at the lumbosacral junction with the BAK cage over a 3-year period. In laparoscopic group, there were significantly lower blood losses (P< 0. 005), operating times [P< 0. 05], analgesic requirements [P< 0. 05] and postoperative rehabilitation [P< 0. 05). 8 patients developed post-operative nerve root pain, 5 of which settled with nerve root blocks, and there was 1 case of donor site infection. Intraoperative complications included 1 CIA tear, 2 CIV tears and 3 open conversions [11%]. 6 cases [24%] required further surgery at a mean of 14 months [range 4–29 months]. 20 laparoscopic cases completed a subjective self-assessment score with 4 [20%] excellent results, 5 [25%] good, 2 [10%] fair, 8 [40%] same and 1 [5%] worse.

The preoperative Visual Analogue Pain Score [VAPS] and Oswestry Disability Index [ODI] were set at 100 for the purposes of analysing the results [n=number in brackets]:

Results show an improvement in the overall pain and disability. However, at two years patients still continued with some 65% of symptoms.

Laparoscopic assisted anterior spinal fusion with the BAK device is safe and reliable with advantages that include reduced operating time, blood loss, post-operative analgesia requirements and hospitalisation. However, the clinical outcome does not appear to give superior results to other implants and we question whether it use as a stand-alone device is sufficient and would recommend posterior stabilisation to confer improved mechanical stability.

Objective: To assess the clinical and radiological outcome of isolated hemivertebrae and multiple vertebral anomalies in the very young.

Design: A cohort of patients with congenital scoliosis were identified on antenatal ultrasound and followed prospectively from twenty weeks in-utero (IU) for a mean of two years (range IU – five years).

Subjects: Twenty fetuses with congenital hemivertebrae were identified from 16, 000 routine antenatal scans over a five-year period. Each was X-rayed at six weeks and investigated for renal and cardiac abnormalities.

Outcome Measures: Clinical assessment included trunk balance, neurological abnormality and associated congenital abnormalities. Radiological assessment of curve magnitude and curve progression was performed using the Cobb method. The potential for progression (based on site, degree of incarceration, growth potential and presence of a congenital bar) was assessed. In all cases a clinical and radiological assessment was made at maximal follow-up.

Results: One of the twenty fetuses aborted spontaneously at 23 weeks, three remain in-utero, leaving 16 live births. Thirteen of 20 had an isolated hemivertebra, and seven of twenty had multiple vertebral abnormalities. Two fetuses had renal agenesis, two had VATER’s syndrome and one had rib and abdominal wall abnormalities. The mean antenatal Cobb angle was 30°. IU curve progression was noted in three. Seven of the 16 live births required surgery based on curve magnitude, curve progression, truncal imbalance and the potential for progression. Surgery included anterior and posterior convex hemi-epiphyseodesis in two, and hemivertebra excision with fusion in five. The mean pre-operative Cobb angle was 36° (range 25–42) reducing to a mean of 21° (range 0–45) at maximal follow-up.

Conclusions: Multiple vertebral abnormalities were more commonly associated with renal and cardiac abnormalities. If associated with the oligohyramnios sequence the fetus appeared to be at high risk. In general US detected isolated fetal hemivertebrae carry a good prognosis, nevertheless 38% of these cases at our institution underwent surgery within the first two years of life.

Objective: This study investigates whether fixation down to lumbar spine only can prevent pelvic tilt compared to pelvic fixation, in the surgical treatment of Duchenne Muscular Dystrophy (DMD).

Design: Retrospective and prospective clinical outcome study, with long-term follow up.

Materials and Methods: Nineteen cases of DMD with scoliosis had early stabilisation (mean age 11.5 years, range 9–16) with sublaminar wires and rods, and pedicle screws up to the lumbar spine. This cohort was followed up for a mean 4.2 years (3–10 years). 31 cases in another centre had late stabilisation (mean age 14.5 years, range 10–17), with Luque rod and sublaminar wire fixation, and pelvic fixation using L-rod (22 cases) configuration or Galveston technique (9 cases) and were followed up for 4.6 years (0.5–11.5 years). Post-op morbidity, Cobb angle correction and pelvic obliquity data were collected retrospectively and prospectively for comparison.

Results: In the lumbar fixation group FVC was 58%, the mean Cobb angle and pelvic obliquity were 19.8° and 9° preoperative, 3.2° and 2.2° direct postoperative, and 5.2° and 2.9° at final follow up respectively. The mean estimated blood loss was 3.3 litres and average hospital stay 7.7 days. In the pelvic fixation group FVC was 44%, the mean Cobb angle and pelvic obliquity were 48° and 19.8° preoperative, 16.7° and 7.2° direct postoperative, and 22° and 11.6° at final follow up respectively. The mean blood loss (4.1 litres) and the average hospital stay (17 days) were significantly higher (p< 0.05) compared to the lumbar fixation group. The pelvic fixation group had higher complication rate at the lower end of fixation. No progression of the pelvic obliquity was noted in the lumbar fixation group during follow up

Conclusion: Lumbar fixation may be adequate for scoliosis in DMD, if the stabilisation is performed early, before the pelvis becomes tilted, and scoliosis becomes significant. The caudal pedicular fixation in the lumbar spine stops rotation of the spine around the rods, and prevent pelvic tilt to occur. Pelvic fixation may be necessary in presence of established pelvic obliquity and larger scoliosis, but is associated with higher morbidity and complications.

Objective: To determine if a porous, coralline-derived hydroxyapatite block (ProOsteon 500^TM, Interpore, Irvine, CA) is a suitable substitute for tricortical iliac crest autograft in cervical interbody fusion.

Design: A prospective randomised trial with two-year follow-up comparing clinical and radiographic outcomes in patients receiving either iliac crest or hydroxyapatite grafts in cervical interbody fusion.

Subjects: Twenty-nine patients undergoing cervical fusion and anterior plating were randomised to receive either iliac crest (Group I) or hydroxyapatite (Group II) interbody grafts. Fourteen patients (19 grafts) in Group I and twelve patients (18 grafts) in Group II were available for final analysis. Both groups were similar with respect to age, sex, diagnosis and levels fused.

Outcome Measures: The SF-36 and Oswestry Disability Index were used to measure clinical outcome. Post-op and final follow-up radiographs were analysed for graft fragmentation, loss of height, loss of angular alignment and hardware failure to assess structural integrity of the graft. Computed or plain tomography was used to evaluate fusion.

Results: Groups I and II demonstrated improvement in preoperative scores for bodily pain (p=. 016 and. 016 respectively) and physical functioning (p=. 050 and. 016 respectively) at final follow-up. There was no significant difference in SF-36 and Oswestry scores between the two groups. Successful radiographic fusion was similar in both groups (79% in Group I and 76% in Group II). Graft fragmentation occurred in 89% of the hydroxyapatite grafts and 11% of the autografts (p=. 001). Greater than 2mm of graft height and 3° of segmental lordosis were lost in 55% of hydroxyapatite grafts vs. 11% of autografts (p=. 009). One patient in Group II and none in Group I required revision surgery for graft failure. The high rate of early radiographic failure in the hydroxyapatite grafts prompted suspension of further enrolment in the clinical trial.

Conclusions: ProOsteon 500 coralline hydroxyapatite blocks do not possess adequate structural integrity to resist axial loading and maintain disc height or segmental lordosis during cervical interbody fusion.

Objective: To evaluate the efficacy and safety of an expandable titanium cage for anterior column replacement after partial or total corpectomy in the thoracolumbar spine.

Design: A retrospective study evaluating the clinical and radiographic outcome following insertion of a novel implant.

Subjects: Twenty-three patients with anterior column insufficiency secondary to tumour, fracture, and infection were treated with a vertebral replacement capable of rapid and controlled in-situ expansion. Follow up consisted of a clinical and radiological review at a mean of 15.2 months (range 6–20 months).

Outcome Measures: The clinical outcome was measured by the degree of pain relief post-operatively, the ability to ambulate and the reliance on walking aids. Neurological deficit was measured using the Frankel Grade. Radiological follow-up compared preoperative radiographs with those taken at maximal follow-up. The degree of kyphosis and the degree of subsidence was measured.

Results: Twenty-three patients with a mean age of 43.6 years (range 20–72) underwent surgery. Indications included metastatic tumour in eight, acute fractures in five, infection in four, degenerative conditions in three, post-traumatic kyphosis in two and pseudathrosis in one. Nineteen patients underwent a single-level corpectomy and four patients a two-level corpectomy. Fourteen patients had a significant neurological deficit preoperatively. Supplementary instrumentation was used in 20 of 23 cases (anterior in nine, posterior in eleven). Excellent pain relief was observed in 19. Ten of 14 patients showed neurological improvement. Eleven patients improved their ambulatory status. There was no hardware failure. An average correction of 110 of kyphosis was observed. The average subsidence was 1.3 mm (range 0.2–2.3).

Conclusions: The use of an expandable vertebral body replacement with supplementary instrumentation following corpectomy appears to be safe and efficacious in correcting kyphosis. This implant appears to have a high resistance to subsidence.

Objective: To demonstrate possible advantages of combined (motor and sensory) versus single modality (either motor or sensory) intraoperative spinal cord monitoring

Design: Retrospective and prospective clinical study

Materials and Methods: One hundred and twenty-six consecutive operations in 97 patients had peroperative monitoring the lower limb motor evoked potentials (MEPs) to multi- pulse transcranial electrical stimulation (TES), and tibial nerve somatosensory evoked potentials (SEPs). Seventy-nine patients had spinal deformity surgery, and eighteen had surgery for trauma, tumor or disc herniation

Results: Combined motor and sensory monitoring was successfully achieved in 104 of 126 (82%) operations. Monitoring was limited to MEPs alone in two, and SEPs alone in eighteen cases. Neither MEPs nor SEPs were obtainable in two cases with Friedreich’s ataxia. Significant evoked potentials (EP) changes occurred in one or both modalities in 16 patients, in association with instrumentation (10) or systemic changes (6). After appropriate remedial measures, SEPs recovered either fully or partially in all cases (8/8) and MEPs in 10/15. New neurodeficits developed post-operatively in six of the sixteen patients with abnormal EPs, including two in whom SEPs had either not changed or recovered fully after remedial measures. One patient developed S3–5 sensory loss despite full recovery of both SEPs and MEPs. Two patients without neurological consequences had persistent MEP changes. Normal MEPs (but not SEPs) at the end of the operation correctly predicted the absence of new motor deficits. There were no false negative MEP changes.

Conclusion: MEPs are more sensitive than SEPs, but may rarely raise false positive alarm. SEPs are unaffected by anaesthetics and can be monitored more frequently. Combined monitoring is safe, complimentary to each other, and increases sensitivity and predictivity of adverse neorological consequences. True incidence of false positive MEP or SEP changes are difficult to define. Remedial measures after monitoring changes may help cord ischaemia to recover and absence of neurological deficit, therefore, may not indicate a false positive monitoring change.

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

Design: A retrospective case analysis

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

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

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

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

Objective: To assess the clinical outcome and return to sport following surgical treatment of spondylolysis in young sporting individuals.

Design: A prospective outcome analysis of consecutive surgically treated cases of lumbar spondylolysis in young sporting individuals.

Subjects: Twenty-two young sports persons (15M: 7F) with a mean age of 20.2 years (range 15–34 years) were surgically treated for radiographically confirmed spondylolysis between 1994 and 1999. Eleven patients were professional footballers and four were professional cricketers. Pre operative assessment included plain X-rays, SPECT imaging with planar bone scan and reverse gantry CT scans. All subjects had pre-operative Oswestry Disability Index (ODI) and SF36 scores recorded. Eighteen patients underwent Buck’s fusion and four patients underwent Scott’s fusion. A graduated exercise regime was commenced at 12 weeks. At two year follow-up nineteen patients had ODI and SF36 scores recorded.

Outcome Measures: The clinical outcome in individual patients supported by statistical analysis of the pre operative and post-operative data was performed using SPSS (ver 10). Return to the sporting activity at the previous level was regarded as a successful outcome.

Results: Eleven patients had bilateral spondylolysis at L5. Twenty patients had positive uptake on SPECT imaging and the remaining two were diagnosed to have lysis on CT scans alone. The average duration of back pain before the patients underwent surgery were 8.4 months (range 3–36 months). The mean lysis defect determined by CT was 3.5 mm (range 1–8 mm). The mean pre-operative and post-operative ODIs were 40.5 and 12.4 respectively (SEpreop = 2.06 and SEpostop = 3.05). The mean scores of physical health component of SF36 improved from 27.1 to 47.8 (SEmean = 1.1 and 1.7 respectively). The mean scores of mental health component of SF36 improved from 39.1 to 55.3 (SEmean = 0.9 and 1.4 respectively) [P < 0.001]. Eighteen patients returned to their previous active sporting career following an average of seven months of rehabilitation (range 4–10 months).

Conclusions: The surgical repair of bilateral spondylolysis with Buck’s fusion in professional sportsmen and women results in a significant improvement in Oswestry Disability scores (P< . 001) and in all domains of SF36 health questionnaire (P< . 001). 90% return to active sport seven months following surgery.

Objective: To study the long term operative and non-operative outcome in patients with diastematomyelia (DM).

Design: A prospectively acquired database of all spinal patients seen jointly by the senior authors (JKW, JLF), was searched for patients with DM. Their notes and the database were then reviewed.

Subjects: Thirty-six patients were identified; twenty-one (58%) had associated scoliosis. There were 60 associated abnormalities in the 36 patients, most common being ten (27%) with leg length inequality. Twelve patients (33%) had no radiological bony abnormality. Twenty-four (66%) had neurosurgery, eleven (31%) untethering of filum alone and eleven (31%) with removal of a spur and closure of the DM as well. Nineteen (53%) underwent some sort of neuraxial shortening scoliosis correction/surgery. Twenty-eight (78%) were deemed to have a normal/independent neurological outcome, seventeen (61%) having neurosurgery and twelve (43%) scoliosis surgery.

Conclusions: Patients with DM have been followed up for many years. Good neurological outcomes can be anticipated in cases with untethering and with scoliosis correction alone. This series raises the question as to whether any unthethering procedure is necessary in these cases when neuraxial shortening is carried out for scoliosis cases.

We describe an unusual injury to the upper cervical spine sustained during ejection from an aircraft. MRI provided an accurate and direct diagnosis of the severe ligamentous injuries.