Aims. Surgical approaches to cervical ossification of the posterior longitudinal ligament (OPLL) remain controversial. The purpose of the present study was to analyze and compare the long-term neurological recovery following
Multiple thoracic disc herniations are rare and there are few reports in the literature. Between December 1998 and July 2002, we operated on 12 patients with multiple thoracic disc herniations. All underwent an
Injury to the spinal cord and kyphosis are the two most feared complications of tuberculosis of the spine. Since tuberculosis affects principally the vertebral bodies,
Twenty-two patients with late onset Pott's paraplegia presenting at a mean of 18 years after initial symptoms were reviewed an average of seven years after treatment by
Seventeen patients with pathological fractures of the thoracolumbar spine which had not responded to conservative treatment are reported. All had compression of the spinal cord and/or severe pain. All (except one treated by lateral rhachotomy) were treated by
In this series, 15 patients with ossification of the posterior longitudinal ligament underwent
Ten patients who suffered iatrogenic injury to a vertebral artery during
A total of 39 HIV-infected adults with spinal tuberculosis underwent
Aim: To evaluate the outcome of late
The cervical spine is the most vulnerable segment in high velocity injuries. Bifacet dislocations are associated with significant soft tissue damage and neurological deficit. Management of delayed presentation of cervical facet dislocations, which are not uncommon, is varied. The aims of this study are to create awareness and to develop a management strategy. We retrospectively reviewed 14 patients (10 men and four women) with chronic dislocations treated over 4 years. The mean age was 42.5 years (23 to 62). The delay in presentation ranged from 15 to 135 days. Seven patients had neurological deficit. All patients underwent CT scan and MRI. Common areas of involvement were C6/7 (five patients) and C5/6 (four patients). Associated fracture of posterior elements was identified in 40% of patients. In two patients sequestrated disc ruptured into the canal. All patients underwent surgical reduction and stabilisation, with eight having one-stage and six two-stage surgery. The sequence of one-stage surgery was posterior release, reduction (facet reduction/facetectomy), anterior discectomy and anterior fusion. In three patients with sequestrated discs,
Summary: Twenty six consecutive patients with CSM were operated between Jan 2001–Dec 2004 with anterior corpectomy and reconstruction using strut graft/ lordotic cage and stabilization ACP. 10/26 were wheel chair bound/bought on stretcher. 16/26 had spastic lower limbs with myelopathic hands. Post operatively 20/26 had good gait improvement and are community ambulators. 3/26 house hold ambulators and 1 died. 18/26 had good improvement in hand function. Introduction: Cervical spondylotic myelopathy is a degenerative disease of old age. Patients present with severe disabiling symptoms of spastic gait/inability to walk and varied involvement in the hand. The degenerative spondylosis being the commonest cause, CSM is also caused by OPLL and soft disc herniation. Methods: 26 consecutive patients who had undergone
The dismal outcome of tuberculosis of the spine in the pre-antibiotic era has improved significantly because of the use of potent antitubercular drugs, modern diagnostic aids and advances in surgical management. MRI allows the diagnosis of a tuberculous lesion, with a sensitivity of 100% and specificity of 88%, well before deformity develops. Neurological deficit and deformity are the worst complications of spinal tuberculosis. Patients treated conservatively show an increase in deformity of about 15°. In children, a kyphosis continues to increase with growth even after the lesion has healed. Tuberculosis of the spine is a medical disease which is not primarily treated surgically, but operation is required to prevent and treat the complications. Panvertebral lesions, therapeutically refractory disease, severe kyphosis, a developing neurological deficit, lack of improvement or deterioration are indications for surgery. Patients who present with a kyphosis of 60° or more, or one which is likely to progress, require
The February 2013 Spine Roundup. 360 . looks at: complications with
Patient presenting with clinically significant cervical spinal cord compression have a variety of surgical strategies that may be appropriate. The common denominator for successful intervention is satisfactory decompression of the neural elements, while avoiding early or late complications. In general, one may think of situations with one or two motion segment involvement versus three or more foci of compression. As most applicable cervical pathology causes anterior cord compression, the logic of direct
Purpose: A descriptive cohort study of the surgical treatment of spinal tuberculosis in a single unit in the United Kingdom. Tuberculosis is a common disorder and may be increasing in prevalence. 83 cases of spinal involvement with TB occurred and of these 40 patients had a total of 61 interventional procedures. Indications for intervention were:. Progressive neurological deterioration. Failure to respond to treatment. Doubt about the diagnosis. Progressive deformity. Results: The age range was from 12 to 73. Sixteen patients had 17 closed biopsies to assist in establishing the diagnosis, of these four went on require further surgical procedures. There were five intermediate level procedures such as application of halo or removal of hardware. Two patients were Caucasian with no predisposing factors and delays occurred in the initial diagnosis. Diabetes was a significant associated co-morbidity particularly in Asian patients. Multiple procedures were required usually for staged stabilisation after
Several methods of surgical treatment for pyogenic spondylitis have been reported including anterior approach, staged and simultaneous
Purpose: The purpose of this study was to analyse the learning curve of video-assisted thoracoscopic surgery in a consecutive series of 70 interventions for decompression and intervertebral fusion with rib bone grafts. Material and methods: This series was composed of 70 patients followed for at least two years. The indication of video-assisted thoracoscopic surgery was idiopathic scoliosis (n=32), neuromuscular spinal malformation (n=13), neurofibromatosis (n=1), scoliosis secondary to Marfan disease (n=1), radiation-induced scoliosis (n=1), and nonunion (n=1). The first rib was resected in three patients due to compression. Resection of an intrath-roacic neurofibroma and a benign rib tumour was performed in two patients. Anterior fusion was necessary in one patient due to fracture-displacement of the thoracic spine. Results: Mean operative time for thoracoscopic
A retrospective review, comparing outcome following circumferential versus
The October 2023 Spine Roundup360 looks at: Cutting through surgical smoke: the science of cleaner air in spinal operations; Unlocking success: key factors in thoracic spine decompression and fusion for ossification of the posterior longitudinal ligament; Deep learning algorithm for identifying cervical cord compression due to degenerative canal stenosis on radiography; Surgeon experience influences robotics learning curve for minimally invasive lumbar fusion; Decision-making algorithm for the surgical treatment of degenerative lumbar spondylolisthesis of L4/L5; Response to preoperative steroid injections predicts surgical outcomes in patients undergoing fusion for isthmic spondylolisthesis.
The optimal procedure for the treatment of ossification of the posterior longitudinal ligament (OPLL) remains controversial. The aim of this study was to compare the outcome of anterior cervical ossified posterior longitudinal ligament en bloc resection (ACOE) with posterior laminectomy and fusion with bone graft and internal fixation (PTLF) for the surgical management of patients with this condition. Between July 2017 and July 2019, 40 patients with cervical OPLL were equally randomized to undergo surgery with an ACOE or a PTLF. The clinical and radiological results were compared between the two groups.Aims
Methods
The April 2023 Spine Roundup360 looks at: Percutaneous transforaminal endoscopic discectomy versus microendoscopic discectomy; Spine surgical site infections: a single debridement is not enough; Lenke type 5, anterior, or posterior: systematic review and meta-analysis; Epidural steroid injections and postoperative infection in lumbar decompression or fusion; Noninferiority of posterior cervical foraminotomy versus anterior cervical discectomy; Identifying delays to surgical treatment for metastatic disease; Cervical disc replacement and adjacent segment disease: the NECK trial; Predicting complication in adult spine deformity surgery.
Introduction: The management of patients with thoracolumbar burst fractures has evolved over the last 60 years from the days of conservative management through to the current era of
Aims. Cervical spondylosis is often accompanied by dizziness. It has
recently been shown that the ingrowth of Ruffini corpuscles into
diseased cervical discs may be related to cervicogenic dizziness.
In order to evaluate whether cervicogenic dizziness stems from the
diseased cervical disc, we performed a prospective cohort study
to assess the effectiveness of anterior cervical discectomy and
fusion on the relief of dizziness. Patients and Methods. Of 145 patients with cervical spondylosis and dizziness, 116
underwent
Introduction. Neurological involvement occurs in 10-30% cases of caries spine. Surgical debridement and stabilisation is needed to decompress the cord and prevent progression of deformity. This prospective study was undertaken to determine the efficacy of operative treatment in the management and neurological recovery in patients with caries spine with neural deficit. Material & methods. 20 patients, 14 male, 6 female, were included and followed up for 1 year after surgery. The mean age was 39.45 years. 10 patients had complete paraplegia and 9 patients had paraparesis. 1 patient with cervical involvement had quadriplegia.
Twenty-seven patients with neurological deficit due to burst fractures were treated with fresh frozen allografts following
Gram-negative infections are associated with comorbid patients, but outcomes are less well understood. This study reviewed diagnosis, management, and treatment for a cohort treated in a tertiary spinal centre. A retrospective review was performed of all gram-negative spinal infections (n = 32; median age 71 years; interquartile range 60 to 78), excluding surgical site infections, at a single centre between 2015 to 2020 with two- to six-year follow-up. Information regarding organism identification, antibiotic regime, and treatment outcomes (including clinical, radiological, and biochemical) were collected from clinical notes.Aims
Methods
Aims. The purpose of this retrospective study was to investigate the
clinical relevance of increased facet joint distraction as a result
of
The February 2023 Spine Roundup360 looks at: S2AI screws: At what cost?; Just how good is spinal deformity surgery?; Is 80 years of age too late in the day for spine surgery?; Factors affecting the accuracy of pedicle screw placement in robot-assisted surgery; Factors causing delay in discharge in patients eligible for ambulatory lumbar fusion surgery; Anterior cervical discectomy or fusion and selective laminoplasty for cervical spondylotic myelopathy; Surgery for cervical radiculopathy: what is the complication burden?; Hypercholesterolemia and neck pain; Return to work after surgery for cervical radiculopathy: a nationwide registry-based observational study.
Introduction. Aim was to compare the functional outcome of
Introduction. Aim was to compare the functional outcome of
Fresh-frozen allografts from the humerus were used to help to stabilise the spine after
Aim:. Historically,
Cervical myelopathy is an uncommon but potentially fatal complication of rheumatoid atlanto-axial subluxation. Computerised myelotomography with three-dimensional reconstruction shows that rheumatoid pannus, together with the odontoid peg, contributes significantly to anterior cervico-medullary compression. These findings were the basis for treatment by transoral
Acute myelopathy is a rare complication of Scheuermann's disease. Three patients are reported where spinal cord compression occurred at the apex of a kyphos. All were male, aged 14, 18 and 20 years, and each had a profound neurological defect associated with a short, sharp kyphos in the low thoracic region. Each patient underwent
Introduction. The resurgence of TB worldwide has several underlying causes, but HIV infection has undoubtedly been a key factor in the current TB epidemic. Since TB is endemic in the developing world the influence of HIV is of concern, particularly with the emergence of multi-drug-resistant strains. The remarkable susceptibility of patients with AIDS to develop TB has shown the critical role of CD4 lymphocytes in protective immunity. In the absence of immunological surveillance by CD4 cells, 5-10% of persons with latent foci of TB reactivate each year. Aim. This paper highlights the presentation and outcome following treatment in HIV patients with spinal TB. Methods. 81 HIV+ve patients with spinal tuberculosis were prospectively evaluated between 2006 and 2007. The mean age was 31 years and 63% were females. The thoracic spine was affected in 45, lumbar (33) and cervical (3). Non-contiguous lesions were noted in six patients. Sixty-six (81%) patients had neurological deficit. The mean Hb was (10.1gm/dl), mean WCC 4.9, mean lymphocyte count was 1.8, mean ESR 79mm/h and the mean CD4 count was 268 cell/cumm. Co-morbidities were seen in 68% of patients. All patients were optimised prior to treatment. Posterolateral decompression was performed in 29 cases,
We report the management of two children and 11 adults with paraplegia secondary to vertebral hydatidosis. Destruction of pedicles, posterior vertebral elements and discs as well as the vertebral bodies was common and all six patients with thoracic disease had involvement of adjacent ribs. The 13 patients had a total of 42 major surgical procedures; two patients died from postoperative complications and four from complications of the disease and paraplegia. All eight patients initially treated by laminectomy or
We have reviewed 41 patients with malignant extradural tumours of the spine treated by
Postoperative radiculopathy is a complication of posterior cervical decompression associated with tethering of the nerve root. We reviewed retrospectively 287 consecutive patients with cervical compression myelopathy who had been treated by multilevel cervical laminectomy and identified 37 (12.9%) with postoperative radiculopathy. There were 27 men and ten women with a mean age of 56 years at the time of operation. The diagnosis was either cervical spondylosis (25 patients) or ossification of the posterior longitudinal ligament (12 patients). Radiculopathy was observed from four hours to six days after surgery. The most frequent pattern of paralysis was involvement of the C5 and C6 roots of the motor-dominant type. The mean time for recovery was 5.4 months (two weeks to three years). The results at follow-up showed that the rate of motor recovery was negatively related to the duration of complete recovery of postoperative radiculopathy (γ = −0.832, p <
0.01) and that patients with spondylotic myelopathy had a significantly better rate of clinical recovery than those with ossification of the posterior longitudinal ligament (t = 2.960, p <
0.01). Postoperative radiculopathy may be prevented by carrying out an
Fractures and fracture dislocations involving the lower lumbar spine and lumbosacral junction are uncommon. These high velocity injuries are often associated with neurological deficit, incontinence and dural tears. The accepted treatment has been posterior stabilisation with fusion, but loss of reduction has often been reported. We reviewed our experience over the past four years in the management of eight male patients, two of whom sustained injuries in motor vehicle accidents and two in falls from a height. Two patients had L5/S1 traumatic spondylo-listhesis with no neurological deficit. Of the six patients with fracture dislocations of L3/4, four had translation in the sagittal and coronal planes and incomplete neurological deficit. Associated injuries in four patients included an ankle fracture, multiple rib fractures, dislocation of knee and hip, and a fracture dislocation of the midfoot. Following satisfactory reduction, seven patients were treated by posterior spinal fusion (PSF) with instrumentation. One patient had
Thoracic spine fractures and fracture dislocations often lead to neurological deficit, and associated injuries to morbidity and mortality. An audit conducted between January 1999 and December 2000 evaluated the outcome of 63 patients with fractures and fracture dislocations of the thoracic spine. The mean age of patients, 41 of whom were male, was 30 years. In 45 patients the injury was sustained in a motor vehicle accident, and 23 patients had associated injuries. We used the Margel radiological classification. There were 37 fracture dislocations and 23 pure fractures. Twenty patients had a type-A injury (flexion), of which 19 were type AIII (burst). There were 40 patients with a type-B injury, 35 of which were type BI (flexion distraction), and three type BIII (flexion and axial loading). In three patients there was a type-C injury (rotational). There was total neurological deficit in 39 patients, 10 with type-A, 26 with type-B and three with type-C injuries. Fifteen patients had partial neurological deficit and nine were neurologically intact. Posterior spinal fusion and bone graft was performed on 43 patients,
Thoracolumbar junction of the spinal column is the common site of spinal trauma and is often complicated by neurological dysfunction. From 1997 to 2000, there were 12 patients surgically stabilized. 8 of them were victims of major trauma while the rest was after a trivial fall in osteoporotic spine. Lengthen of follow-up ranged from 6 to 42 months. Ages of the patients in the major trauma group were from 22 to 65. Except the one who had anterior approach because of multiple level lesions, all fractures after major trauma were initially relocated and stabilized posteriorly. Subsequent anterior procedures were necessary in three of them because of significant residual spinal canal stenosis. All except one had satisfactory lower limb function on follow up. Two patients who were paralysed on admission were able to walk independently and 4 others had improved by at least one Frankel grade. Return of neurological function was usually observed within the first week after the procedure. Residual sphincter dysfunction was however, a common problem. The management of four osteoporotic spinal fractures in thoracolumbar junction was more unpredictable. Patients were from 66 to 92 years old.
Cervical Spondylotic Mielopathy (CSM) is the most common cause of spinal cord dysfunction in the adult population. Treatment implies surgical decompression as soon as possible after the diagnosis. In this study the authors present the long term results of minimal 10 years follow up of a prospective study of 98 patients that underwent
Cervical arthroplasty is usually performed for the treatment of soft disc herniation, but not for spondylotic radiculopathy. To our knowledge, there has no study to investigate the clinical and radiological results of cervical arthroplasty for spondylotic radiculopathy. We therefore performed the current study to evaluate clinical and radiological results of cervical arthroplasty for spondylotic radiculopathy with severe narrowing of the intervertebral disc space. Eight patients, who underwent
We investigated clinical features and surgical outcomes for compressive cervical myelopathy in patients over 75 years of age. Twenty-one patients who underwent surgical decompression for cervical myelopathy were reviewed. The average age at the time of operation was 78.0 years and the mean follow-up period was 5.7 years. Posterior decompression in 19 patients and
Introduction: Video assisted thoracoscopic surgery (VATS) is associated with good correction ability for spinal deformity and allow the reconstruction of the anterior column of the spine in tumors, deformity and trauma cases. Stand alone and instrumented procedures are possible. VATS has shown to be safe and can reduce the morbidities of traditional open anterior surgery but is a technically demanding procedure with a steep learning curve. The potential technique-related complication rate is low in experienced hands. Material and Methods: From 2006 till today, 22 thoracic vertebral fractures have been treated with thoracoscopic approach. The mean patients age was 32 years (24–58) and the levels treated between T6 and L1. Five fractures required only anterior approach, with corpectomy, implantation of an expandable cage (Obelisk, Ulrich, Germany) with autologous bone graft and an anterior Macs TL plate (Aesculap, Germany). The others seventeen fractures were treated by combined anterior – posterior approach in the same operating session or, the second, previously performed immediately after the admission. The endoscopic splitting of the diaphragm was performed in 9 cases to expose the L1/L2 levels. Seven patients received decompressive laminectomy during the first posterior approach performed in emergency settings. Endoscopic
Introduction and Aims: Socioeconomic deprivation and the HIV epidemic have accounted for the global increase in tuberculosis. Tuberculous spondylitis constitutes 60% of osteoarticular tuberculosis. Progressive kyphosis has been reported with rib grafts in spinal TB. We prospectively evaluated 45 patients treated with fresh frozen anterior cortical allografts for spinal TB. Method: The mean age was 28.6 years and all patients were HIV negative. The neurological status (Frankel grade) was (A)10, (B)18, (C)17 and the dorsal spine was affected in 37 patients. The kyphosis measured 540 (range 270–740). Following pre-operative nutritional support all patients underwent a radical
Purpose of the study: This study was conducted to assess short- and mid-term radiographic outcome of percutaneous posterior osteosynthesis (Sextant®)of thoracolumbar spine fractures and to identify indications and complications. Material and methods: The Sextant® material was used for 14 patients with a lumbar spine or low thoracic spine fracture. Mean patient age was 40 years (range 19–84). Outcome was reviewed retrospectively. Osteosynthesis was performed for 11 fractures Mager 1 A3, 2 B2, 1 C1 with no neurological deficit. A complementary graft and
Purpose: We report results obtained after surgical treatment of cervical myelopathy in 42 patients. Material and methods: This prospective study included 42 consecutive patients who underwent surgical treatment performed by the same operator between 1999 and 2002. Inclusion criteria were clinical expression of cervical cord suffering and radiological evidence (high-intensity intramedullary signal on the T2-weighted MRI). Anterior (corporectomy associated with autologous graft and plate-screw fixation) or posterior (laminoplasty or laminectomy) decompression was performed. The approach was chosen according to the number of levels requiring decompression and static disorders. The Japanese Orthopaedic Association (JAO) score was determined prepoperatively and at six months. Results: Forty-two patients (25 men and 17 women), mean age 65.7 years (38–80) were included, 18 anterior approaches and 24 posterior approaches. There were no neurological or infectious complications. One suffocating haematoma required early revision after an
Introduction and aims: Instrumentation in Spinal Tuberculosis is a controversial issue. The introduction of Pedicle screws in spinal fixation offered a new dimension to the management of this difficult problem. Method: We have operated on 147 patients with Spinal Tuberculosis between 1990 and 2001. Between 1990 and 1995 we treated 45 patients in the traditional manner with
Introduction and Aims: Instrumentation in spinal tuberculosis is a controversial issue. The introduction of Pedicle screws in spinal fixation offered a new dimension to the management of this difficult problem. Method: We operated on 147 patients with spinal tuberculosis between 1990 and 2001. Between 1990 and 1995, we treated 45 patients in the traditional manner with
Instrumentation in Spinal Tuberculosis is a controversial issue. The introduction of Pedicle screws in spinal fixation offered a new dimension to the management of this difficult problem. We operated on 127 patients with Spinal Tuberculosis between 1990 and 2000. Between 1990 and 1995, we treated 45 patients in the traditional manner with
Purpose: Access to the cervicothoracic junction is difficult both via a posterior and via an anterior approach. Tumour localisations or more rarely trauma however require access. Using the posterior approach,
Introduction: Treatment of thoracolumbar fractures remains controversial. The treatment options are conservative management or operative treatment, either through a posterior or anterior approach. Surgery through an anterior approach provides excellent decompression through vertebrectomy and the ability to correct the deformity. Stabilisation with Moss cage and Kaneda device remains unproven. Methods and Results: This is a retrospective study of 55 consecutive patients with thoracolumbar fractures operated on between 1993–99. Indications for surgery were: neurological deficit, two or three column injury causing instability or significant kyphotic deformity . There were 34 male and 21 female patients, mean age 33 years old. Trauma was caused by a fall from a height, either due to accident (30 patients) or suicide attempt (5), RTAs (14), sporting injury (6). Other injuries included multiple level spinal fractures (9 patients), pelvic (5), calcaneal (3), talar (1) and malleolar (1) fractures. Surgery was performed on the next available list unless there was an indication for emergency intervention, (mean 5 days post injury, range 1–19). Post-operative hospital stay averaged 17 days (7–59). Forty-seven patients underwent an anterior procedure alone, whilst eight patients had combined anterior and posterior instrumentation and fusion. Mean operative time was 207 minutes (150–360) and blood loss 2670 ml (985– 7000). Nineteen patients (35% of all) had neurological deficit. Neurological status improved post-op in 85% of these patients, remained the same in nine per cent and there was a nerve root injury in one patient (revision case) which has almost recovered. Other complications included five chest infections, three UTIs, one incisional hernia, four implant problems and eight patients with thigh pain. Results were analysed according to return to work and the Oswestry Disability Score with a mean follow-up of three years. Thirty-eight patients (69%) returned to the same occupation held before the injury, 11 patients (20% ) had a lighter job and six patients ( 11% ) are not working with litigation going on. Oswestry Disability Score post-op was 24% (4%–72%). Conclusion: Compared to the natural history of conservatively treated thoracolumbar fractures, surgical treatment with
The most appropriate classification of traumatic thoracolumbar (TL) spine injuries remains controversial and current systems can be cumbersome and difficult to apply. No classification aids decision making in clinical management. Clinical spine trauma specialists from institutions around the world were canvassed with respect to information deemed pivotal in the communication of TL spine trauma and the clinical decision making process. Traditional injury patterns were reviewed and reconsidered in light of these essential characteristics. The reliability and validity of an earlier version of this system has been demonstrated. The Thoracolumbar Injury Classification and Severity Score (TLICS) was devised based upon the three most important injury characteristics: 1) morphology of injury determined by radiographic appearance, 2) integrity of the posterior ligamentous complex, and 3) neurological status of the patient. These characteristics are largely independent of each other. A composite injury severity score can be calculated from these characteristics stratifying patients into surgical and non-surgical treatment groups. The three principal injury patterns are compression (including burst – 1 point each), translation/rotation (3 points) and distraction (4 points). Neurological status can be classified as a nerve root injury (1 point), a complete (ASIA A-2 points) or incomplete injury (3 points) to the spinal cord or conus, or injury of the cauda equina (3 points). Disruption of the posterior ligamentous complex and facet joint capsules results in instability. Disrupted posterior ligaments can be seen as subluxation or dislocation of a facet, interspinous widening, or MRI evidence of ligament discontinuity. Failure of the posterior ligamentous complex can be classified as indeterminate (2 points) or definitely disrupted (3points). Coexisting clinical factors (qualifiers) may alter decision making by virtue of their effect on stability, general management or effect on healing. Metabolic disorders such as ankylosing spondylitis, DISH, osteoporosis and age may influence treatment. Injury characteristics such as excessive kyphosis, severe vertebral body collapse and sternal fracture may influence outcome and modify treatment. Treatment options might be influenced in patients with head injuries or polytrauma. The impact of these clinical qualifiers on patient care must be evaluated. Once all the major variables have been assigned points, a total TLICS Score can be determined. Patients with 3 or less points are non-operative candidates while patients scoring 5 or more points should be considered for surgery. Clinical qualifiers may modify treatment. The morphology of the injury, neurological status, and integrity of the posterior ligamentous complex can help guide the management of TL injuries. Incomplete neurological injuries warrant
Purpose: When we treat burst fractures, we try to preserve the movable vertebra as much as possible and see to it that the instrument can be extracted finally. We have performed short-segment posterior spinal instrumentation and fusion (PSIF) for cases with no neurological symptoms, and combined short-segment posterior spinal instrumentation and fusion with
Study Design/Objective: Prospective two-leg cohort study on anterior cervical fusion versus cervical arthroplasty with emphasis on clinical outcome measures. Patients and Methods: Between August 2003 and May 2005 21 consecutive patients underwent anterior cervical fusion with or without
The aim of this study was to characterize the relationship between pre- and postoperative opioid use among patients undergoing common elective orthopaedic procedures Pre- and postoperative opioid use were studied among patients from a national insurance database undergoing seven common orthopaedic procedures using univariate log-rank tests and multivariate Cox proportional hazards analyses.Aims
Patients and Methods
Background: Cervical myelopathy and radiculopathy has been treated commonly with
Injuries of the cervical spine can be classified into six categories according to a mechanistic system describing the biomechanical deficiencies incurred in a cervical spine injury. However high velocity flexion compression loads cause multiple contiguous and noncontiguous fractures due to multiple force vectors. A universal classification system cannot be applied. Instability exists if there is greater than 3.5 mm of translation or greater than 11 degrees of angulation as compared to other segments. The degree of ligamentous injury on MRI correlates with instability in patients with lateral mass facet fractures, with rupture of multiple ligaments including the anterior longitudinal, posterior longitudinal, interspinous, or facet capsule. Patients with less than 13 mm of narrowing of the sagittal canal are predisposed to neurologic injury. Vertical compression injuries cause canal occlusion and vertebral column shortening. The timing of surgery in cases of spinal cord injury is controversial. There is no difference in outcome between early (<
72 hours) and late (>
5 days) surgery. However, there remains at least a theoretical benefit to early surgery. Compression-flexion injuries result in loss of the anterior column by compression followed by the posterior column in distraction. The injury is considered unstable if there is a vertical cleavage fracture of the vertebral body or displacement. Treatment includes a cervical orthosis or halo for minor injuries, depending on the degree of kyphosis. Major injuries with displacement should be treated surgically by anterior corpectomy and plate or an anterior/posterior fusion, depending on the degree of posterior instability. The most common level of vertical-compression injuries is at the C6 or C7 level. Minimally displaced injuries can be treated with a collar or halo. Fragmentation and peripheral displacement of the bony fragments needs a halo followed by surgery and this may include an anterior corpectomy and plating. Distraction-flexion injuries may result in facet sub-luxation with less than 25% displacement, or dislocation of one (UFD) or both (BFD) facet joints. When there is 3 mm of translation (25%), the canal is occluded 20–25%. With 6mm of translation (50%), there is 40–50% canal occlusion. MRI can help analyse the soft tissue and ligamentous injuries. In UFD, all posterior ligamentous structures including joint capsule, and half the disc annulus are disrupted. Disruption of ALL and PLL is not necessary to create a UFD. In addition to the posterior structures, the ALL, the PLL and disc are disrupted in BFD. Rupture of the intervertebral disc may include posterior herniation or circumferential disruption. All distraction flexion injuries should be reduced closed. The necessity of a preoperative MRI is undetermined. Preoperative MRI is recommended if there is an unreliable exam due to the patient being uncooperative, if there is neurological worsening with, or failure of closed reduction. If the patient is neurologically intact and closed reduction successful, a posterior cervical fusion is advocated if there is no evidence of an extruded disc on the post reduction MRI. If the closed reduction failed, or MRI indicated, and there is no evidence of a herniated disc, an open posterior reduction followed by fusion is performed. Anterior discectomy with reduction, a graft and a plate is performed for a herniated disc. Compression-extension injuries fail by compression of the posterior elements followed by distraction of the anterior elements. There are unilateral or bilateral fractures of the laminae/neural arch with degrees of displacement. Undisplaced neural arch fractures can be treated with a cervical orthosis or halo. Displaced neural arch fractures are treated with a posterior cervical fusion. There are two stages in the distraction-extension injury group. The anterior longitudinal ligament is disrupted with possibly a transverse fracture of the body. With more major injuries, there is a significant displacement injuring the posterior column. Stage 1 injuries can be treated with a halo and Stage 2 with an
The aim of this paper is to describe the impact of COVID-19 on spine surgery services in a district general hospital in England in order to understand the spinal service provisions that may be required during a pandemic. A prospective cohort study was undertaken between 17 March 2020 and 30 April 2020 and compared with retrospective data from same time period in 2019. We compared the number of patients requiring acute hospital admission or orthopaedic referrals and indications of referrals from our admission sheets and obtained operative data from our theatre software.Aims
Methods
Objective:. To observe the incidence of intra-operative vascular injuries during
Anterior only procedure for stable thoraco-lumbar burst fractures is controversial. Prospective collection of clinical and radiological data in stable burst fractures with neurological deficit undergoing
An operation which combined
Spinal tuberculosis (TB) remains an important concern. Although spinal TB often has sequelae such as myelopathy after treatment, the predictive factors affecting such unfavourable outcomes are not yet established. We investigated the clinical manifestations and predictors of unfavourable treatment outcomes in patients with spinal TB. We performed a multicentre retrospective cohort study of patients with spinal TB. Unfavourable outcome was defined according to previous studies. The prognostic factors for unfavourable outcomes as the primary outcome were determined using multivariable logistic regression analysis and a linear mixed model was used to compare time course of inflammatory markers during treatment. A total of 185 patients were included, of whom 59 patients had unfavourable outcomes.Aims
Patients and Methods
Nineteen patients with thoracic or thoracolumbar spinal tuberculosis and neurological deficits were treated by
Purpose: To assess the outcomes in consecutive 32 patients of two level cervical disc replacement. Methods: In this article, we report 2-year results of
Background. We present the results of a single centre, prospective study to evaluate the clinical and radiographic outcomes of
Introduction: In comparison to
The purpose of the study was to determine the effectiveness of rhBMP-2 when applied to an absorbable collagen sponge for interbody fusion with allograft spacers. Seventy-seven consecutive patients requiring inter-body fusion with one hundred and eighteen levels were included in the study. In thirty-six patients cervical or lumbar interbody fusions were performed using allograft and rhBMP-2. In the remaing allograft was used with demineralised bone matrix. In patients undergoing
Background: Smaller versions of threaded lumbar cages were developed for cervical spine to obviate the need for allograft, iliac autograft use and to provide initial stability before fusion. Clinical trials of threaded cervical fusion cages have shown higher fusion rates and lower rates of graft-donor site complications. Study design/Aims: Prospective. Radiological and clinical outcomes of an age, sex and diagnosis matched patient population who underwent cervical fusion with (A) BAK/C cages filled with autograft reamings (Center-pulse Spine-tech Inc., Minneapolis, MN) (N=50) were compared with (B)
Introduction.
Introduction and Aims: Autologous bone is the preferred method of providing structural support in spinal surgery. The disadvantages are donor site morbidity and limited bone available to reconstitute the anterior column. We evaluated fresh frozen femoral allografts following anterior column reconstruction for lumbar burst fractures with neurological deficit. Method: Twenty-seven patients with neurological deficit ( Frankel grade A(3), B(7), C(16) D (1) due to burst fractures of the dorsolumbar junction were treated with fresh frozen allografts following
To address the natural history of severe post-tuberculous (TB)
kyphosis, with focus upon the long-term neurological outcome, occurrence
of restrictive lung disease, and the effect on life expectancy. This is a retrospective clinical review of prospectively collected
imaging data based at a single institute. A total of 24 patients
of Southern Chinese origin who presented with spinal TB with a mean
of 113° of kyphosis (65° to 159°) who fulfilled inclusion criteria
were reviewed. Plain radiographs were used to assess the degree
of spinal deformity. Myelography, CT and MRI were used when available
to assess the integrity of the spinal cord and canal. Patient demographics,
age of onset of spinal TB and interventions, types of surgical procedure,
intra- and post-operative complications, and neurological status
were assessed. Aims
Patients and Methods
The aim of this study was to determine the efficacy of repeat epidural steroid injections as a form of treatment for patients with insufficiently controlled or recurrent radicular pain due to a lumbar or cervical disc herniation. A cohort of 102 patients was prospectively followed, after an epidural steroid injection for radicular symptoms due to lumbar disc herniation, in 57 patients, and cervical disc herniation, in 45 patients. Those patients with persistent pain who requested a second injection were prospectively followed for one year. Radicular and local pain were assessed on a visual analogue scale (VAS), functional outcome with the Oswestry Disability Index (ODI) or the Neck Pain and Disability Index (NPAD), as well as health-related quality of life (HRQoL) using the 12-Item Short-Form Health Survey questionnaire (SF-12).Aims
Patients and Methods
Introduction: While
Informed consent is a very important part of surgical treatment. In this paper, we report a number of legal judgements in spinal surgery where there was no criticism of the surgical procedure itself. The fault that was identified was a failure to inform the patient of alternatives to, and material risks of, surgery, or overemphasizing the benefits of surgery. In one case, there was a promise that a specific surgeon was to perform the operation, which did not ensue. All of the faults in these cases were faults purely of the consenting process. In many cases, the surgeon claimed to have explained certain risks to the patient but was unable to provide proof of doing so. We propose a checklist that, if followed, would ensure that the surgeon would take their patients through the relevant matters but also, crucially, would act as strong evidence in any future court proceedings that the appropriate discussions had taken place. Although this article focuses on spinal surgery, the principles and messages are applicable to the whole of orthopaedic surgery. Cite this article:
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:
Tuberculosis (TB) remains endemic in many parts
of the developing world and is increasingly seen in the developed world
due to migration. A total of 1.3 million people die annually from
the disease. Spinal TB is the most common musculoskeletal manifestation,
affecting about 1 to 2% of all cases of TB. The coexistence of HIV,
which is endemic in some regions, adds to the burden and the complexity
of management. This review discusses the epidemiology, clinical presentation,
diagnosis, impact of HIV and both the medical and surgical options
in the management of spinal TB. Cite this article:
The February 2015 Spine Roundup360 looks at: Paracetamol use for lower back pain; En-bloc resection of vertebra reported for the first time; Spinopelvic disassociation under the spotlight; Hope for back pain; Disc replacement and ACDF equivalent in randomised study; Interspinous process devices ineffective
There have been a few reports of patients with
a combination of lumbar and thoracic spinal stenosis. We describe six
patients who suffered unexpected acute neurological deterioration
at a mean of 7.8 days (6 to 10) after lumbar decompressive surgery.
Five had progressive weakness and one had recurrent pain in the
lower limbs. There was incomplete recovery following subsequent
thoracic decompressive surgery. The neurological presentation can be confusing. Patients with
compressive myelopathy due to lower thoracic lesions, especially
epiconus lesions (T10 to T12/L1 disc level), present with similar
symptoms to those with lumbar radiculopathy or cauda equina lesions.
Despite the rarity of this condition we advise that patients who
undergo lumbar decompressive surgery for stenosis should have sagittal
whole spine MRI studies pre-operatively to exclude proximal neurological
compression. Cite this article:
Many aspects of the surgical treatment of patients with tuberculosis
(TB) of the spine, including the use of instrumentation and the
types of graft, remain controversial. Our aim was to report the
outcome of a single-stage posterior procedure, with or without posterior
decompression, in this group of patients. Between 2001 and 2010, 51 patients with a mean age of 62.5 years
(39 to 86) underwent long posterior instrumentation and short posterior
or posterolateral fusion for TB of the thoracic and lumbar spines,
followed by anti-TB chemotherapy for 12 months. No anterior debridement
of the necrotic tissue was undertaken. Posterior decompression with
laminectomy was carried out for the 30 patients with a neurological
deficit.Aim
Patients and Methods
This study assessed the frequency of acute injury to the spinal cord in Irish Rugby over a period of ten years, between 1995 and 2004. There were 12 such injuries; 11 were cervical and one was thoracic. Ten occurred in adults and two in schoolboys. All were males playing Rugby Union and the mean age at injury was 21.6 years (16 to 36). The most common mechanism of injury was hyperflexion of the cervical spine and the players injured most frequently were playing at full back, hooker or on the wing. Most injuries were sustained during the tackle phase of play. Six players felt their injury was preventable. Eight are permanently disabled as a result of their injury.
This study evaluates factors related to myelopathic
symptoms in patients with ossification of the posterior longitudinal
ligament (OPLL). A total of 87 patients with OPLL were included.
Of these, 53 (Group I) had no symptoms or presented with neck pain
and radiculopathy and 34 (Group II) had myelopathic symptoms. Gender, age,
and history of trauma were evaluated in the two groups. The range
of movement of the cervical spine was measured using plain radiographs.
The number of involved segments, type of OPLL, and maximal compression ratio
were analysed using CT and signal change in the spinal cord was
evaluated using MRI. The patients’ age was found to be significant (p = 0.001). No
difference was found between gender and the range of movement in
the two groups. The maximum compression of the spinal canal showed
a difference (p = 0.03). The signal change of the spinal cord was
different between the two groups. In patients with OPLL of the cervical
spine, myelopathic symptoms are not related to the range of movement
or the number of involved segments.
We evaluated the efficacy of anterior fusion alone compared with combined anterior and posterior fusion for the treatment of degenerative cervical kyphosis. Anterior fusion alone was undertaken in 15 patients (group A) and combined anterior and posterior fusion was carried out in a further 15 (group B). The degree and maintenance of the angle of correction, the incidence of graft subsidence, degeneration at adjacent levels and the rate of fusion were assessed radiologically and clinically and the rate of complications recorded. The mean angle of correction in group B was significantly higher than in group A (p = 0.0009). The mean visual analogue scale and the neck disability index in group B was better than in group A (p = 0.043, 0.0006). The mean operation time and the blood loss in B were greater than in group A (p <
0.0001, 0.037). Pseudarthrosis, subsidence of the cage, and problems related to the hardware were more prevalent in group A than in group B (p = 0.034, 0.025, 0.013). Although the combined procedure resulted in a longer operating time and greater blood loss than with anterior fusion alone, our results suggest that for the treatment of degenerative cervical kyphosis the combined approach leads to better maintenance of sagittal alignment, a higher rate of fusion, a lower incidence of complications and a better clinical outcome.
We carried out a prospective study to determine whether the addition of a recombinant human bone morphogenetic protein (rhBMP-2) to a machined allograft spacer would improve the rate of intervertebral body fusion in the spine. We studied 77 patients who were to undergo an interbody fusion with allograft and instrumentation. The first 36 patients received allograft with adjuvant rhBMP-2 (allograft/rhBMP-2 group), and the next 41, allograft and demineralised bone matrix (allograft/demineralised bone matrix group). Each patient was assessed clinically and radiologically both pre-operatively and at each follow-up visit using standard methods. Follow-up continued for two years. Every patient in the allograft/rhBMP-2 group had fused by six months. However, early graft lucency and significant (>
10%) subsidence were seen radiologically in 27 of 55 levels in this group. The mean graft height subsidence was 27% (13% to 42%) for anterior lumbar interbody fusion, 24% (13% to 40%) for transforaminal lumbar interbody fusion, and 53% (40% to 58%) for anterior cervical discectomy and fusion. Those who had undergone fusion using allograft and demineralised bone matrix lost only a mean of 4.6% (0% to 15%) of their graft height. Although a high rate of fusion (100%) was achieved with rhBMP-2, significant subsidence occurred in more than half of the levels (23 of 37) in the lumbar spine and 33% (6 of 18) in the cervical spine. A 98% fusion rate (62 of 63 levels) was achieved without rhBMP-2 and without the associated graft subsidence. Consequently, we no longer use rhBMP-2 with allograft in our practice if the allograft has to provide significant structural support.
We present the case of a 15-year-old boy with
symptoms due to Klippel–Feil syndrome. Radiographs and CT scans demonstrated
basilar impression, occipitalisation of C1 and fusion of C2/C3.
MRI showed ventral compression of the medullocervical junction.
Skull traction was undertaken pre-operatively to determine whether
the basilar impression could be safely reduced. During traction,
the C3/C4 junction migrated 12 mm caudally and spasticity resolved.
Peri-operative skull-femoral traction enabled posterior occipitocervical
fixation without decompression. Following surgery, cervical alignment
was restored and spasticity remained absent. One year after surgery
he was not limited in his activities.
Young adults with hip pain secondary to femoroacetabular
impingement (FAI) are rapidly being recognised as an important cohort
of orthopaedic patients. Interest in FAI has intensified over the
last decade since its recognition as a precursor to arthritis of
the hip and the number of publications related to the topic has
increased exponentially in the last decade. Although not all patients
with abnormal hip morphology develop osteoarthritis (OA), those
with FAI-related joint damage rapidly develop premature OA. There
are no explicit diagnostic criteria or definitive indications for
surgical intervention in FAI. Surgery for symptomatic FAI appears
to be most effective in younger individuals who have not yet developed
irreversible OA. The difficulty in predicting prognosis in FAI means
that avoiding unnecessary surgery in asymptomatic individuals, while
undertaking intervention in those that are likely to develop premature
OA poses a considerable dilemma. FAI treatment in the past has focused
on open procedures that carry a potential risk of complications. Recent developments in hip arthroscopy have facilitated a minimally
invasive approach to the management of FAI with few complications
in expert hands. Acetabular labral preservation and repair appears
to provide superior results when compared with debridement alone.
Arthroscopic correction of structural abnormalities is increasingly becoming
the standard treatment for FAI, however there is a paucity of high-level
evidence comparing open and arthroscopic techniques in patients
with similar FAI morphology and degree of associated articular cartilage damage.
Further research is needed to develop an understanding of the natural
course of FAI, the definitive indications for surgery and the long-term
outcomes. Cite this article:
The February 2014 Spine Roundup360 looks at: single posterior approach for severe kyphosis; risk factors for recurrent disc herniation; dysphagia and cervical disc replacement or fusion; hang on to your topical antibiotics; cost-effective lumbar disc replacement; anxiolytics no role to play in acute lumbar back pain; and surgery best for lumbar disc herniation.
We reviewed 75 patients (57 men and 18 women), who had undergone tension-band laminoplasty for cervical spondylotic myelopathy (42 patients) or compression myelopathy due to ossification of the posterior longitudinal ligament (33 patients) and had been followed for more than ten years. Clinical and functional results were estimated using the Japanese Orthopaedic Association score. The rate of recovery and the level of postoperative axial neck pain were also recorded. The pre- and post-operative alignment of the cervical spine (Ishihara curve index indicating lordosis of the cervical spine) and the range of movement (ROM) of the cervical spine were also measured. The mean rate of recovery of the Japanese Orthopaedic Association score at final follow-up was 52.1% (
We have examined the outcome in 19 professional rugby union players who underwent anterior cervical discectomy and fusion between 1998 and 2003. Through a retrospective review of the medical records and telephone interviews of all 19 players, we have attempted to determine the likelihood of improvement, return to professional sport and the long-term consequences. We have also attempted to relate the probability of symptoms in the neck and radicular pain in the arm to the position of play. Neck and radicular pain were improved in 17 patients, with 13 returning to rugby, the majority by six months after operation. Of these, 13 returned to their pre-operative standard of play, one to a lower level and five have not played rugby again. Two of those who returned to the game have subsequently suffered further symptoms in the neck, one of whom was obliged to retire. The majority of the players with problems in the neck were front row forwards. A return to playing rugby union after surgery and fusion of the anterior cervical spine is both likely and safe and need not end a career in the game.
The purpose of this study was to investigate
the clinical predictors of surgical outcome in patients with cervical spondylotic
myelopathy (CSM). We reviewed a consecutive series of 248 patients
(71 women and 177 men) with CSM who had undergone surgery at our
institution between January 2000 and October 2010. Their mean age
was 59.0 years (16 to 86). Medical records, office notes, and operative
reports were reviewed for data collection. Special attention was
focused on pre-operative duration and severity as well as post-operative
persistence of myelopathic symptoms. Disease severity was graded
according to the Nurick classification. Our multivariate logistic regression model indicated that Nurick
grade 2 CSM patients have the highest chance of complete symptom
resolution (p <
0.001) and improvement to normal gait (p = 0.004)
following surgery. Patients who did not improve after surgery had
longer duration of myelopathic symptoms than those who did improve
post-operatively (17.85 months (1 to 101) vs 11.21 months (1 to
69); p = 0.002). More advanced Nurick grades were not associated
with a longer duration of symptoms (p = 0.906). Our data suggest that patients with Nurick grade 2 CSM are most
likely to improve from surgery. The duration of myelopathic symptoms
does not have an association with disease severity but is an independent
prognostic indicator of surgical outcome. Cite this article:
We report on two cases of infective spondylodiscitis
caused by We describe the clinical features, investigations and treatment
options.