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Aims

To provide normative data that can assess spinal-related disability and the prevalence of back or leg pain among adults with no spinal conditions in the UK using validated questionnaires.

Methods

A total of 1,000 participants with equal sex distribution were included and categorized in five age groups: 20 to 29, 30 to 39, 40 to 49, 50 to 59, and 60 to 69 years. Individuals with spinal pathologies were excluded. Participants completed the Scoliosis Research Society-22 (SRS-22r), visual analogue scale (VAS) for back/leg pain, and the EuroQol five-dimension index (EQ-5D/VAS) questionnaires, and disclosed their age, sex, and occupation. They were also categorized in five professional groups: doctors, nurses, allied health professionals, office workers, and manual workers.


The Bone & Joint Journal
Vol. 103-B, Issue 6 | Pages 1133 - 1141
1 Jun 2021
Tsirikos AI Wordie SJ

Aims

To report the outcome of spinal deformity correction through anterior spinal fusion in wheelchair-bound patients with myelomeningocele.

Methods

We reviewed 12 consecutive patients (7M:5F; mean age 12.4 years (9.2 to 16.8)) including demographic details, spinopelvic parameters, surgical correction, and perioperative data. We assessed the impact of surgery on patient outcomes using the Spina Bifida Spine Questionnaire and a qualitative questionnaire.


Bone & Joint Open
Vol. 2, Issue 3 | Pages 163 - 173
1 Mar 2021
Schlösser TPC Garrido E Tsirikos AI McMaster MJ

Aims

High-grade dysplastic spondylolisthesis is a disabling disorder for which many different operative techniques have been described. The aim of this study is to evaluate Scoliosis Research Society 22-item (SRS-22r) scores, global balance, and regional spino-pelvic alignment from two to 25 years after surgery for high-grade dysplastic spondylolisthesis using an all-posterior partial reduction, transfixation technique.

Methods

SRS-22r and full-spine lateral radiographs were collected for the 28 young patients (age 13.4 years (SD 2.6) who underwent surgery for high-grade dysplastic spondylolisthesis in our centre (Scottish National Spinal Deformity Service) between 1995 and 2018. The mean follow-up was nine years (2 to 25), and one patient was lost to follow-up. The standard surgical technique was an all-posterior, partial reduction, and S1 to L5 transfixation screw technique without direct decompression. Parameters for segmental (slip percentage, Dubousset’s lumbosacral angle) and regional alignment (pelvic tilt, sacral slope, L5 incidence, lumbar lordosis, and thoracic kyphosis) and global balance (T1 spino-pelvic inclination) were measured. SRS-22r scores were compared between patients with a balanced and unbalanced pelvis at final follow-up.


The Bone & Joint Journal
Vol. 103-B, Issue 1 | Pages 148 - 156
1 Jan 2021
Tsirikos AI Carter TH

Aims

To report the surgical outcome of patients with severe Scheuermann’s kyphosis treated using a consistent technique and perioperative management.

Methods

We reviewed 88 consecutive patients with a severe Scheuermann's kyphosis who had undergone posterior spinal fusion with closing wedge osteotomies and hybrid instrumentation. There were 55 males and 33 females with a mean age of 15.9 years (12.0 to 24.7) at the time of surgery. We recorded their demographics, spinopelvic parameters, surgical correction, and perioperative data, and assessed the impact of surgical complications on outcome using the Scoliosis Research Society (SRS)-22 questionnaire.


Bone & Joint Open
Vol. 1, Issue 3 | Pages 19 - 28
3 Mar 2020
Tsirikos AI Roberts SB Bhatti E

Aims

Severe spinal deformity in growing patients often requires surgical management. We describe the incidence of spinal deformity surgery in a National Health Service.

Methods

Descriptive study of prospectively collected data. Clinical data of all patients undergoing surgery for spinal deformity between 2005 and 2018 was collected, compared to the demographics of the national population, and analyzed by underlying aetiology.


The Bone & Joint Journal
Vol. 99-B, Issue 8 | Pages 1080 - 1087
1 Aug 2017
Tsirikos AI Mataliotakis G Bounakis N

Aims

We present the results of correcting a double or triple curve adolescent idiopathic scoliosis using a convex segmental pedicle screw technique.

Patients and Methods

We reviewed 191 patients with a mean age at surgery of 15 years (11 to 23.3). Pedicle screws were placed at the convexity of each curve. Concave screws were inserted at one or two cephalad levels and two caudal levels. The mean operating time was 183 minutes (132 to 276) and the mean blood loss 0.22% of the total blood volume (0.08% to 0.4%). Multimodal monitoring remained stable throughout the operation. The mean hospital stay was 6.8 days (5 to 15).


The Bone & Joint Journal
Vol. 98-B, Issue 2 | Pages 229 - 237
1 Feb 2016
Roberts SB Dryden R Tsirikos AI

Aims

Clinical and radiological data were reviewed for all patients with mucopolysaccharidoses (MPS) with thoracolumbar kyphosis managed non-operatively or operatively in our institution.

Methods

In all 16 patients were included (eight female: eight male; 50% male), of whom nine had Hurler, five Morquio and two Hunter syndrome. Six patients were treated non-operatively (mean age at presentation of 6.3 years; 0.4 to 12.9); mean kyphotic progression +1.5o/year; mean follow-up of 3.1 years (1 to 5.1) and ten patients operatively (mean age at presentation of 4.7 years; 0.9 to 14.4); mean kyphotic progression 10.8o/year; mean follow-up of 8.2 years; 4.8 to 11.8) by circumferential arthrodesis with posterior instrumentation in patients with flexible deformities (n = 6).


The Bone & Joint Journal
Vol. 98-B, Issue 1 | Pages 88 - 96
1 Jan 2016
Tsirikos AI Sud A McGurk SM

Aims

We reviewed 34 consecutive patients (18 female-16 male) with isthmic spondylolysis and grade I to II lumbosacral spondylolisthesis who underwent in situ posterolateral arthodesis between the L5 transverse processes and the sacral ala with the use of iliac crest autograft. Ten patients had an associated scoliosis which required surgical correction at a later stage only in two patients with idiopathic curves unrelated to the spondylolisthesis.

Methods

No patient underwent spinal decompression or instrumentation placement. Mean surgical time was 1.5 hours (1 to 1.8) and intra-operative blood loss 200 ml (150 to 340). There was one wound infection treated with antibiotics but no other complication. Radiological assessment included standing posteroanterior and lateral, Ferguson and lateral flexion/extension views, as well as CT scans.


The Bone & Joint Journal
Vol. 97-B, Issue 7 | Pages 982 - 987
1 Jul 2015
Ganesan S Karampalis C Garrido E Tsirikos AI

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.


The Bone & Joint Journal
Vol. 96-B, Issue 8 | Pages 1082 - 1089
1 Aug 2014
Roberts SB Tsirikos AI Subramanian AS

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.


The Bone & Joint Journal
Vol. 96-B, Issue 7 | Pages 943 - 949
1 Jul 2014
Duckworth AD Mitchell MJ Tsirikos AI

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.


The Bone & Joint Journal
Vol. 96-B, Issue 6 | Pages 800 - 806
1 Jun 2014
Karampalis C Tsirikos AI

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.


The Journal of Bone & Joint Surgery British Volume
Vol. 94-B, Issue 12 | Pages 1670 - 1677
1 Dec 2012
Tsirikos AI Subramanian AS

We reviewed 212 consecutive patients with adolescent idiopathic scoliosis who underwent posterior spinal arthrodesis using all pedicle screw instrumentation in terms of clinical, radiological and Scoliosis Research Society (SRS)-22 outcomes. In Group 1 (51 patients), the correction was performed over two rods using bilateral segmental pedicle screws. In Group 2 (161 patients), the correction was performed over one rod using unilateral segmental pedicle screws with the second rod providing stability of the construct through two-level screw fixation at proximal and distal ends. The mean age at surgery was 14.8 years in both groups. Comparison between groups showed no significant differences with regard to age and Risser grade at surgery, pre- and post-operative scoliosis angle, coronal Cobb correction, length of hospital stay and SRS scores. Correction of upper thoracic curves was significantly better in Group 1 (p = 0.02). Increased surgical time and intra-operative blood loss was recorded in Group 1 (p < 0.001 and p = 0.04, respectively). The implant cost was reduced by mean 35% in Group 2 due to the lesser number of pedicle screws.

Unilateral and bilateral pedicle screw techniques have both achieved excellent deformity correction in adolescent patients with idiopathic scoliosis, which was maintained at two-year follow-up. This has been associated with high patient satisfaction and low complication rates.


The Journal of Bone & Joint Surgery British Volume
Vol. 94-B, Issue 10 | Pages 1399 - 1402
1 Oct 2012
Tsirikos AI Tome-Bermejo F

An eight-week-old boy developed severe thoracic spondylodiscitis following pneumonia and septicaemia. A delay in diagnosis resulted in complete destruction of the T4 and T5 vertebral bodies and adjacent discs, with a paraspinal abscess extending into the mediastinum and epidural space. Antibiotic treatment controlled the infection and the abscess was aspirated. At the age of six months, he underwent posterior spinal fusion in situ to stabilise the spine and prevent progressive kyphosis. At the age of 13 months, repeat imaging showed lack of anterior vertebral body re-growth and he underwent anterior spinal fusion from T3 to T6 and augmentation of the posterior fusion. At the age of five years, he had no symptoms and radiographs showed bony fusion across the affected levels.

Spondylodiscitis should be included in the differential diagnosis of infants who present with severe illness and atypical symptoms. Delayed diagnosis can result in major spinal complications with a potentially fatal outcome.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXI | Pages 35 - 35
1 Jul 2012
Tsirikos AI
Full Access

Purpose of the study

Two patients with very severe thoracolumbar Scheuermann's kyphosis who developed spontaneous bony fusion across the apex of the deformity are presented and their treatment, as well as surgical outcome is discussed.

Summary of Background Data

Considerable debate exists regarding the pathogenesis, natural history and treatment of Scheuermann's kyphosis. Surgical correction is indicated in the presence of severe kyphosis which carries the risk of neurological complications, persistent back pain and significant cosmetic deformity.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXI | Pages 12 - 12
1 Jul 2012
Tsirikos AI Subramanian AS
Full Access

Purpose of the study

We report septic shock as postoperative complication following an instrumented posterior spinal arthrodesis on a patient with multiple body piercings. The management of this potentially catastrophic complication and outcome of treatment is been discussed.

Summary of Background Data

Body piercing has become increasingly more common due to change in culture or as a fashion statement. This has been associated with local or generalized ill effects including tissue injury, skin and systemic infections, and septic shock. There is no clear guideline pathway regarding removal and reinsertion of body piercings in patients who undergo major surgery. Complications following Orthopaedic or Spinal procedures associated with body piercing have not been reported.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXI | Pages 11 - 11
1 Jul 2012
Tsirikos AI Mains E
Full Access

Purpose of the study

To investigate the efficacy of pedicle screw instrumentation in correcting spinal deformity in patients with quadriplegic cerebral palsy. Also to assess quality of life and functional improvement after deformity correction as perceived by the parents of our patients.

Summary of Background Data

All pedicle screw constructs have been commonly used to correct adolescent idiopathic scoliosis. There is limited information on their effectiveness in treating patients with cerebral palsy and neuromuscular scoliosis.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXI | Pages 13 - 13
1 Jul 2012
Subramanian AS Tsirikos AI
Full Access

Purpose of the study

To investigate the efficacy of pedicle screw instrumentation in correcting thoracolumbar/lumbar idiopathic scoliosis in adolescent patients.

Summary of Background Data

Thoracolumbar/lumbar scoliosis has been traditionally treated through an anterior approach and instrumented arthrodesis with the aim to include in the fusion the Cobb-to-Cobb levels and preserve distal mobile spinal segments. Posterior instrumentation has been extensively used for thoracic or thoracic and lumbar scoliosis. In the advent of all-pedicle screw constructs there is debate on whether thoracolumbar/lumbar scoliosis is best treated through an anterior or a posterior instrumented arthrodesis.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXI | Pages 10 - 10
1 Jul 2012
Subramanian AS Tsirikos AI
Full Access

Purpose of the study

To compare the effectiveness of unilateral and bilateral pedicle screw techniques in correcting adolescent idiopathic scoliosis.

Summary of Background Data

Pedicle screw constructs have been extensively used in the treatment of adolescent patients with idiopathic scoliosis. It has been suggested that greater implant density may achieve better deformity correction. However, this can increase the neurological risk related to pedicle screw placement, prolong surgical time and blood loss and result in higher instrumentation cost.


The Journal of Bone & Joint Surgery British Volume
Vol. 94-B, Issue 5 | Pages 684 - 689
1 May 2012
Tsirikos AI Smith G

We reviewed 31 consecutive patients with Friedreich’s ataxia and scoliosis. There were 24 males and seven females with a mean age at presentation of 15.5 years (8.6 to 30.8) and a mean curve of 51° (13° to 140°). A total of 12 patients had thoracic curvatures, 11 had thoracolumbar and eight had double thoracic/lumbar. Two patients had long thoracolumbar collapsing scoliosis with pelvic obliquity and four had hyperkyphosis. Left-sided thoracic curves in nine patients (45%) and increased thoracic kyphosis differentiated these deformities from adolescent idiopathic scoliosis. There were 17 patients who underwent a posterior instrumented spinal fusion at mean age of 13.35 years, which achieved and maintained good correction of the deformity. Post-operative complications included one death due to cardiorespiratory failure, one revision to address nonunion and four patients with proximal junctional kyphosis who did not need extension of the fusion. There were no neurological complications and no wound infections. The rate of progression of the scoliosis in children kept under simple observation and those treated with bracing was less for lumbar curves during bracing and similar for thoracic curves. The scoliosis progressed in seven of nine children initially treated with a brace who later required surgery. Two patients presented after skeletal maturity with balanced curves not requiring correction. Three patients with severe deformities who would benefit from corrective surgery had significant cardiac co-morbidities.