Aims. 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. Methods. 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. Results. The Japanese Orthopaedic Association (JOA) score and recovery rate in the ACOE group were significantly higher than those in the PTLF group during two years postoperatively, provided that the canal occupying ratio (COR) was > 50%, or the K-line was negative. There was no significant difference in JOA scores and rate of recovery between the two groups in those in whom the COR was < 50%, or the K-line was positive. There was no significant difference in the Cobb angle between C2 and C7, sagittal vertical axis, cervical range of motion (ROM), and complications between the two groups. Conclusion. Compared with PTLF, ACOE is a preferred surgical approach for the surgical management of patients with cervical OPLL in that it offers a better therapeutic outcome when the COR is > 50%, or the K-line is negative, and it also preserves better cervical curvature and sagittal balance. The prognosis of ACOE is similar to that of PTLE when the COR is < 50%, or the K-line is positive. Cite this article: Bone Joint J 2023;105-B(4):412–421

We assigned 67 patients with central lumbar stenosis alternately to either multiple laminotomy or total laminectomy. The protocol, however, allowed multiple laminotomy to be changed to total laminectomy if it was thought that the former procedure might not give adequate neural decompression. There were therefore three treatment groups: group I consisting of 26 patients submitted to multiple laminotomy; group II, 9 patients scheduled for laminotomy but submitted to laminectomy; and group III, 32 patients scheduled for, and submitted to, laminectomy. The mean follow-up was 3.7 years. Bilateral laminotomy at two or three levels required a longer mean operating time than total laminectomy at an equal number of levels. The mean blood loss at surgery and the clinical results did not differ in the three groups. The mean subjective improvement score for low back pain was higher in group I but there was also a higher incidence of neural complications in this group. No patient in group I had postoperative vertebral instability, whereas this occurred in three patients in groups II and III, who had lumbar scoliosis or degenerative spondylolisthesis preoperatively. Multiple laminotomy is recommended for all patients with developmental stenosis and for those with mild to moderate degenerative stenosis or degenerative spondylolisthesis. Total laminectomy is to be preferred for patients with severe degenerative stenosis or marked degenerative spondylolisthesis

Study design. A retrospective study design. Objective. To comprehensively compare the 2-year clinical outcome of lumbar laminectomy alone versus lumbar laminetomy supplemented with dynamic stabilization (Dynesys system) in degenerative lumbar stenosis in elderly patients. Material and Methods. A total of 60 elderly patients with an average age of 65.1 years (range, 50 to 78 yrs) affected by lumbar stenosis that underwent lumbar laminectomy alone (30 cases) or lumbar laminectomy with supplementary Dynesys system (30 cases) at our Department were sorted and matched according to three criteria : similar patient age, similar degenerative lumbar desease, and identical operative methods (i.e. levels of laminectomy). Patients were compared according to Oswestry Disability Index (ODI), Roland Morris, SF-36 and VAS outcomes scores. Results. The two cohorts were well matched at 2-years follow-up. Patients treated with lumbar laminectomy alone presented reduced operative time and intraoperative blood loss and reduced postoperative complications, with better clinical outcome compared with patients that received laminectomy with supplementary Dynesys system, for ODI score (28.9 vs 31), Roland Morris (8.25 vs 9.1) and VAS scores (leg pain 36 vs 44.3; back pain 31 vs 38.7), while SF-36 scores resulted similar in both groups of patients. Conclusions. In degenerative lumbar stenosis, supplementary dynamic stabilization in addition to decompressive laminectomy did not presented significant advantages, with respect to functional outcome, in comparison to lumbar laminectomy alone

1 . Standard lumbar laminectomy was performed at multiple levels in thirty dogs, and manipulations were carried out in the spinal canal to observe their effects on periradicular adhesion formation. The canal was scarified, packed with Gelfoam, or treated with three varieties of Silastic membranes. The results were serially assessed from three days to twelve weeks by gross observation, nerve conduction studies, histological examination of transverse sections of the spine, myelin study of lumbar roots and micropaque study of the arterial supply to the roots. 2. The results were consistent biologically. The principal source of scar is dorsally in the fibrous tissue elements of the erector spinae muscle mass. This scar, the laminectomy membrane, covers the laminectomy defect and extends into the canal bilaterally to adhere to the dura and nerve roots. 3. Gelfoam does not contribute to scar formation, but instead acts as an effective interposing membrane. Silastic membranes are capable of providing protection against nerve root adhesions without interfering with the anatomical or physiological integrity of the nerves. 4. Certain clinical implications of the study are discussed

We have developed criteria to determine the appropriate indications for lumbar laminectomy, using the standard procedure developed at the RAND corporation and the University of California at Los Angeles (RAND-UCLA). A panel of five surgeons and four physicians individually assessed 1000 hypothetical cases of sciatica, back pain only, symptoms of spinal stenosis, spondylolisthesis, miscellaneous indications or the need for repeat laminectomy. For the first round each member of the panel used a scale ranging from 1 (extremely inappropriate) to 9 (extremely appropriate). After discussion and condensation of the results into three categories laminectomy was considered appropriate in 11% of the 1000 theoretical scenarios, equivocal in 26% and inappropriate in 63%. There was some variation between the six categories of malalignment, but full agreement in 64% of the hypothetical cases. We applied these criteria retrospectively to the records of 196 patients who had had surgical treatment for herniated discs in one Swiss University hospital. We found that 48% of the operations were for appropriate indications, 29% for equivocal reasons and that 23% were inappropriate. The RAND-UCLA method is a feasible, useful and coherent approach to the study of the indications for laminectomy and related procedures, providing a number of important insights. Our conclusions now require validation by carefully designed prospective clinical trials, such as those which are used for new medical techniques

Aims. The escalating demand for medical resources to address spinal diseases as society ages is an issue that requires careful evaluation. However, few studies have examined trends in spinal surgery, especially unscheduled hospitalizations or surgeries performed after hours, through large databases. Our study aimed to determine national trends in the number of spine surgeries in Japan. We also aimed to identify trends in after-hours surgeries and unscheduled hospitalizations and their impact on complications and costs. Methods. We retrospectively investigated data extracted from the Diagnosis Procedure Combination database, a representative inpatient database in Japan. The data from April 2010 to March 2020 were used for this study. We included all patients who had undergone any combination of laminectomy, laminoplasty, discectomy, and/or spinal arthrodesis. Results. This investigation included 739,474 spinal surgeries and 739,215 hospitalizations in Japan. There was an average annual increase of 4.6% in the number of spinal surgeries. Scheduled hospitalizations increased by 3.7% per year while unscheduled hospitalizations increased by 11.8% per year. In-hours surgeries increased by 4.5% per year while after-hours surgeries increased by 9.9% per year. Complication rates and costs increased for both after-hours surgery and unscheduled hospitalizations, in comparison to their respective counterparts of in-hours surgery and scheduled hospitalizations. Conclusion. This study provides important insights for those interested in improving spine care in an ageing society. The swift surge in after-hours spinal surgeries and unscheduled hospitalizations highlights that the medical needs of an increasing number of patients due to an ageing society are outpacing the capacity of existing medical resources. Cite this article: Bone Jt Open 2024;5(8):662–670

In currently used expansive laminoplasty (ELAP) for cervical spondylotic myelopathy (CSM), persistent axial pain, restriction of neck motion and loss of cervical l ordosis have been the significance postoperative problems. To prevent them, the author has developed skip laminectomy in which ordinary laminectomy at appropriate levels is combined with partial laminectomy of the cephalad half of laminae with preservation of the muscular attachments at adjacent levels. Since December 98, the author performed this procedure on 55 patients with CSM who required multilevel posterior decompressions. Twenty-one of these cases with follow-up period longer than 8 months, with an average of 12 months, were observed. In skip laminectomy, a consecutive four-level decompression between C3/4 and C6/7 as an example is accomplished by removing alternate laminae (C4 and C6), the cephalad half of the C5 and C7 lamina and the ligamentum flava at those four levels. The laminae to be removed were selected after analysis of the pre- and postoperative radiological findings. Intraoperative blood loss averaged 34 grams. The operation time averaged 128 minutes. The patients were allowed to sit up or walk on the first postoperative day without neck support of any kind. An average recovery rate according to the Japanese Orthopaedic Association score was 63%. None of these patients complained of residual axial pain. The postoperative ranges of neck motion on lateral X rays averaged 87% of the preoperative ranges. The spinal curvature index, according to Ishihara’s method, was reduced in only one of the 21 cases. Postoperative atrophy of the deep extensor muscles measured on T2 weighed axial MRI was minimal. Skip laminectomy is less damaging to the posterior extensor muscles and its use reduces the postoperative problems commonly seen after ELAP

AIM: To compare the outcomes between two different surgical techniques for cervical myelopathy (skip laminectomy vs laminoplasty). METHODS: Cervical skip laminectomy is a new technique described by Japanese surgeons in 2000. The advantage of this procedure over the other conventional techniques is it addresses multilevel problem in a least traumatic way without need for instrumentation. We are comparing the above two techniques with 25 patients in each group operated by 3 surgeons. The first group had conventional laminoplasty and the second group underwent the skip laminectomy. The groups were comparable in age, sex, pathology and clinical presentation. Both these group had clinical outcome measurements using SF 12 questionnaires, pre and postoperative clinical assessment with standard tools performed by independent surgeon and a specialist spinal physiotherapist. We also routinely performed pre and postoperative MRI scans to assess the adequacy of decompression. RESULTS & CONCLUSION: There was no significant difference in the outcome of these patients in terms of the operative technique, hospital stay, clinical and radiological outcome. However skip laminectomy is relatively a easier procedure to perform, while the laminoplasty does need instrumentation

Introduction & Aims: The X-stop interspinous process decompression system is being used as an alternative to laminectomy in the treatment of neurogenic claudication. To date the clinical outcomes are favourable, but the economic value has not been established within the NHS financial model. Objective: To compare the average hospital costs of performing an x-stop procedure (under general or local anaesthetic) to a laminectomy in patients with neurogenic claudication. Design: A retrospective analysis of average length of stay, anaesthetic and operative times, equipment and anaesthetic agent costs. Sources included theatre management systems, the British National Formulary and Leeds Teaching Hospitals Trust in-patient stay data. The study period was from April 2005 to October 2006. The number of patients in the two groups were 318 (laminectomy) and 75 (X-stop). Results: In comparison to laminectomy, patients under-going an X-stop procedure have a reduced average length of in-patient stay (3 versus 5 days), reduced anaesthetic time (25 versus 29 minutes) and operative duration (40 versus 128 minutes). The average cost for each procedure is £3346 for an X-stop under general anaesthetic (profit £119), £2835 for a laminectomy (profit £1177) and £2237 for an X-stop as a day case (profit £1228). Conclusions: Tariff reimbursement is an important consideration to ensure insertion of these devices is profitable for the hospital. Our results show that even with the additional cost of the implant device, an X-stop procedure under general anaesthetic remains profitable in comparison to a laminectomy, whilst a day-case X-stop procedure is more profitable. Additional savings are be made by reduced bed and theatre occupancy. Future studies will differentiate costs of 1- and 2-level X-stop procedures, complication rates and revision surgery

Introduction: Spinous process osteotomy (SPO) and multiple laminotomy can be used for multi-level lumbar decompression. We conducted an experimental study to compare the effects of these two methods on spinal kinetics. Method: Ten fresh calf spines (L2- sacrum) were mounted in dental stone and segmental motion of L3 relative to L5 was assessed using an electromagnetic 3-D motion detection system (FASTRAK, Polhemus, Colchester, VT, USA). Pure moments of 0, 2.5, 5, 7, and 10 Nm were used in flexion/extension, right/left lateral bending, and right/left axial rotation. The moments were generated by applying two equal and opposite forces (weights) to the perimeter of a plastic circular disc, which was fixed to the superior end plate of L3 by three screws. In five spines decompression was performed at L3/4 and 4/5 using standard laminotomy technique. Decompression using SPO was done at L3–5 through a unilateral approach in the rest. Segmental mobility between the two methods was compared using the Mann-Whitney test. Results: Mean range of motion in the specimens before intervention was-lateral bending (32.70 ± 7.6 SD), rotation (13.10 ± 4.8 SD), flexion/extension (19.30 ± 7.1 SD). There was statistically significant difference between mean increase in lateral bending after SPO to that following laminotomy (4.00 ± 1.5 SD vs 0.60 ± 1.6 SD; p=0.008). Mean increase in flexion- extension after SPO was not significantly different from that after laminotomy (4.50 ± 1.1 SD vs 3.90 ± 3.8 SD; p= 0.75). There was no difference in the mean increase in axial rotation after SPO compared to that following laminotomy (7.90 ± 3.6 SD vs 6.80 ± 5.0 SD; p= 0.75). Conclusions: Both laminotomy and SPO produced increased range of motion in a calf spine model. SPO produced significant increase in lateral bending although its clinical significance is unknown. Ethics approval: none. Interest Statement: Local grant (Research Fund, Centre for Spinal Studies, Robert Jones and Agnes Hunt Hospital, UK

Introduction and aims: Surgical decompression for lumbar stenosis entails a risk of iatrogenic instability. Consequently, laminectomy has been largely superseded by the more conservative procedure of fenestration, but the decompression may be compromised. We describe an additional technique of undercutting laminectomy, which conserves stability while maximising decompression, and the results are presented. Method: Forty-nine patients with lumbar spinal stenosis were treated by fenestration, medial facetectomy and removal with curved osteotomes of the ventral aspect of the lamina superior to the involved facets together with the attached ligamentum flavum. The results were assessed at a mean follow-up period of three years and four months using walking distance and a pain analogue scale as outcome measures, and surgical complications were recorded. The radiological results were assessed in 25 patients by measurement on MRI scan of the spinal canal cross-sectional area pre- and post-operatively. Results: Ten patients had undercutting laminectomy at one level, 19 at two levels, 14 at three levels and four at four levels. Medical co-morbidity was present in most patients; 11 were ASA 1, 25 ASA2 and 11 ASA 3. Pre-operatively, all patients reported leg pain or numbness and 20 patients reported back pain. All but one had limited walking distance, the mean being 564 metres (range 5m–8000m). Post-operatively the mean pain score was 3.3 and the mean walking distance 762 metres. Forty-one patients said they felt the operation had been worthwhile and six said they did not. Surgical complications occurred in five patients, consisting of dural tear in four patients (repaired with no sequelae) and a wound haematoma requiring drainage in one patient. The mean spinal canal cross-sectional area at the level of maximal stenosis pre-operatively was 28mm. 2. and postoperatively was 75mm. 2. , giving a mean increase of 133%. No patients had any evidence of iatrogenic instability as judged by the development of degenerative spondylolisthesis or scoliosis. Conclusion: The technique described achieves excellent decompression of the stenotic lumbar canal as measured radiologically, while largely preserving the facet joints. In relation to published reports on fenestration and medial facetectomy alone, the clinical results are at least as good

Purpose: The goal of laminectomy is to relieve spinal stenosis and improve radiculopathy. Back pain related to poor trunk muscular conditioning may negatively affect post-operative outcomes. A better understanding of this relationship is important to improve the selection of appropriate surgical candidates. The purpose of this study was to assess the association between cross-sectional lumbar paraspinal muscle area as measured by CT or MRI and outcomes following laminectomy. Method: Prospective observational study of 23 patients undergoing primary elective lumbar laminectomy without fusion who were assessed with pre-operative CT scans. Clinical outcomes were measured with Numerical Pain Scale (NPS) for back and leg pain and the Oswestry Low Back Disability Index (ODI) at baseline and follow-up at a minimum of one year. Lumbar paraspinal muscle cross-sectional area was measured using digital imaging software and adjusted for percent fat infiltration; CT scans evaluations were blinded to clinical outcomes. Results: There were significant improvements in clinical outcomes following laminectomy. ODI decreased from 53.9±11.8 (mean±standard deviation) at baseline to 27.3±20.6 after a follow-up of 15.2±3.5 months. A strong correlation existed between cross-sectional lumbar paraspinal muscle area after adjusting for infiltrating fat content an improvement in ODI (r=0.51, p< 0.02) or back pain NPS (r=0.55, p< 0.02). These relationships remained statistically significant after adjusting for age and body mass index. No significant associations were identified for improvements in leg pain NPS. Conclusion: This study suggests a possible relationship between cross-sectional lumbar paraspinal muscle area and outcomes following laminectomy. This raises important questions regarding the role of trunk muscular conditioning in the etiology of back pain and success of surgery. Further research is required to refine this measurement as a tool to improve patient selection for surgery

1. One hundred and sixty cases of incomplete or complete paraplegia due to extradural malignant tumour have been reviewed. Between 1959 and 1969 laminectomy for decompression of the cord was performed in 154 of these cases as an urgent measure and the results in 129 cases with full records have been assessed. 2. Immediate laminectomy, a palliative procedure, gave worthwhile improvement in 35 percent of cases of incomplete paraplegia; such patients could walk and had satisfactory control of bladder function at least six months after operation. 3. There were no satisfactory results when the paraplegia was complete. 4. The relief of pain following decompression may be gratifying, even if the patient does not improve sufficiently to fulfil the criteria of a satisfactory result. 5. The results emphasise the importance of early diagnosis, myelography and decompression if a patient with incomplete paralysis is to be offered any chance of relief

Purpose: To measure outcome in patients undergoing decompression for lumbar canal stenosis (LCS) by lami-nectomy. Methods: 100 patients (57 men, 43 women) under one consultant surgeon presenting with neurogenic claudication and MRI confirmed LCS were studied . 23 patients had pre –existing spondylolisthesis (21 Grade 1, 2 Grade-2) and were managed by laminectomy without fixation. Patients completed a set of outcome measure questionnaires (SF-36, Visual analogue scores for back pain, leg pain, leg sensory symptoms and the Roland-Morris back disability score) pre-operatively, 3 months post surgery and at longer term follow up (median 2 years). Outcome scores were analysed and for SF-36 compared to age matched normative data. Statistical significance was calculated using Wilcoxon’s matched pairs and correlations using Spearman’s rank test. Statistical analysis was performed using the SPSS statistical package. Results: Average age 68 years (inter-quartile range 60 – 77). For the cohort visual analogue scores and Roland scores showed significant improvement (p < 0.01) at both 3 months and at long term follow up compared to pre-operative scores. For the physical functioning domain of SF-36, outcome scores improved significantly (p< 0.01) at short and long term follow up with 80% of patients having better long term scores compared to pre-operative scores. The physical functioning domain of SF-36 was significantly correlated with the changes seen in the visual analogue pain scores and the Roland back pain score (p < 0.01). Outcome for the spondylo-listhesis subgroup was similar to the outcome in patients without pre existing spondylolisthesis. Conclusions: Laminectomy for lumbar canal stenosis is an effective treatment resulting in significant health gains which are maintained in the longer term. Our data validates SF-36 as a measurement of disease severity and outcome in this condition

1. The usual methods of posterior arthrodesis of the lumbo-sacral joint are not satisfactory in cases in which laminectomy has been performed. 2. Estimation of fusion by mobility radiographs is unreliable and cannot distinguish between fibrous ankylosis and bony fusion. 3. Bone grafts inserted from behind between the vertebral bodies almost invariably fail to become incorporated. 4. Intertransverse arthrodesis has given promising results and is probably the best method available at present

The purpose of this study was to evaluate whether epidural fibrosis formation around the spinal cord was affected by endogenous oestrogen deficient state after lumbar laminectomy in the rats. Thirty-six 12-month-old adult female Sprague-Dawley rats were used in this study. Bilaterally ooferectomy were done in 18 rats. Rats were divided into two groups: oophrectomised (oestrogen deficient) group and sham operated (oestrogen maintained) group. Three weeks after the ooferectomy each rat underwent complete bilaterally laminectomy at the L2 and L3 vertebral levels (two levels per rat). The rats were randomly divided into three equal groups (12 rats in each group). The rats were sacrificed at four, eight, and twelve weeks postoperatively and the lumbar spine excised en bloc, fixed and decalcified. Section stained with hematoxylin and eosin and Masson’s trichrome were used to evaluate epidural fibrosis, acute inflammatory cells, chronic inflammatory cells and vascular proliferation. Sections were analyzed by investigator blinded to the study and graded on a five-point grading system. Statistic were performed using Mann-Whitney U test when compare two variable and Kruskal-Wallis test when compare more than two variables. Compared with the oopherectomised group, the sham operated group showed decreased rate of epidural fibrosis and higher acute and chronic inflammatory cells response at four and eight weeks but this was no statistically significant (p> 0.05). The results of this study revealed that endogenous oestrogen may decrease epidural fibrosis formation after lumbar laminectomy in the rats

Aim: To compare the outcomes between two different surgical techniques for cervical myelopathy (skip laminectomy vs laminoplasty). Methods: Cervical skip laminectomy is a new technique described by Japanese surgeons in 2000. The advantage of this procedure over the other conventional techniques is it addresses multilevel problem in a least traumatic way without need for instrumentation. We are comparing the above two techniques with 25 patients in each group operated by 3 surgeons. The first group had conventional laminoplasty and the second group underwent the skip laminectomy. The groups were comparable in age, sex, pathology and clinical presentation. Both these group had clinical outcome measurements using SF 12 questionnaires, pre and postoperative clinical assessment with standard tools performed by independent surgeon and a specialist spinal physiotherapist. We also routinely performed pre and postoperative MRI scans to assess the adequacy of decompression. Results and Conclusion: here was no significant difference in the outcome of these patients in terms of the operative technique, hospital stay, clinical and radiological outcome. However skip laminectomy is relatively a easier procedure to perform, while the laminoplasty does need instrumentation

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 anterior decompression in conjunction with spinal fusion, which will achieve stabilisation and directly remove compression of the cord at multiple levels

1. The results of wide laminectomy of the fifth lumbar vertebra and disc excision in 132 patients are reviewed and compared with some published results of the interlaminar operation. 2. There was no significant difference in either the immediate or the long-term results of the two operations suggesting that post-operative morbidity was not related to operative technique. 3. The incidence of post-operative back pain was found to increase with age at operation, duration of pre-operative symptoms and length of follow-up, and supported the impression that backache is predominantly a feature of the underlying degenerative process rather than the incidental operation. 4. The significance of recurrent disc lesions is discussed. Recurrence usually occurred at the previously cleared disc space and was thought to indicate incomplete degeneration of the disc at the time of the original operation. 5. The place of fusion combined with disc excision is discussed. No reliable indications for coincident fusion were found in this series. 6. The value of radiography is discussed. Plain radiographs were essential before operation to exclude other causes of backache and sciatica; otherwise they were of little value. Motion radiographs were no more helpful and myelography was used only when the level of the lesion was in doubt. 7. The risk of an acute cauda equina lesion following manipulation of a prolapsed lumbar disc is noted and the danger of manipulation, unless facilities for emergency surgery are available, is stressed

1. A review of 204 cases of prolapsed intervertebral disc treated by the author by operation ten to twenty-five years before is presented. Injury was an etiological factor in only 14 per cent.

2. The decision to operate should be made after a clearly defined and controlled, but limited, period of closed treatment. The patients should not have to wait for operation. Treatment by closed methods should not be continued in the absence of detectable signs of improvement. Continuation under such circumstances delays recovery from paralysis, prolongs convalescence and delays return to work. Persistence of paraesthesia and numbness are other probable consequences of such delay.

3. A central disc prolapse is an indication for urgent operation if persistent sphincter disturbance or incomplete bladder evacuation is to be avoided.

4. A recurrence rate of sciatica less frequent than that associated with treatment by closed methods is noted in this and other reported series. True recurrence, as opposed to a prolapse at another level, is rare and is most probably due to continuation of the biochemical process of degeneration leading to further sequestration of disc tissue. On the other hand, the altered spinal mechanics, particularly local rigidity resulting from enucleation of a deranged intervertebral disc, may predispose to prolapse at a higher level or may themselves be the cause of symptoms of "recurrence".

5. Operation gives early and lasting relief of sciatic pain, reduces the need for the subsequent use of a corset and assists the patient to an early return to work.

6. Operation does not affect the decision to change work. This is decided by the length of history before operation and the amount of disc degeneration; and the need to change work is the same whether the patient is treated by closed means or by operation.

7. Apart from simple back raising exercises to strengthen the spinal extensor muscles, no physiotherapy need be given because it is not likely to improve the prognosis.

8. Backache is the most frequent disability after operation (17 per cent) and is related to the degree of degenerative change present before and after operation. Injury precipitated the onset of backache in three cases. Operation does not by itself produce backache. The amount of bone removed has no demonstrable effect on the late results of operation, nor on the subsequent development of degenerative changes.

9. Enucleation of the nucleus is not followed by fibrous ankylosis across the intervertebral space.

Prolonged length of stay (LOS) is a significant contributor to the variation in surgical health care costs and resource utilization after elective spine surgery. The primary goal of this study was to identify patient, surgical and institutional variables that influence LOS. The secondary objective is to examine variability in institutional practices among participating centers. This is a retrospective study of a prospectively multicentric followed cohort of patients enrolled in the CSORN between January 2015 and October 2020. A logistic regression model and bootstrapping method was used. A survey was sent to participating centers to assessed institutional level interventions in place to decrease LOS. Centers with LOS shorter than the median were compared to centers with LOS longer than the median. A total of 3734 patients were included (979 discectomies, 1102 laminectomies, 1653 fusions). The median LOS for discectomy, laminectomy and fusion were respectively 0.0 day (IQR 1.0), 1.0 day (IQR 2.0) and 4.0 days (IQR 2.0). Laminectomy group had the largest variability (SD=4.4, Range 0-133 days). For discectomy, predictors of LOS longer than 0 days were having less leg pain, higher ODI, symptoms duration over 2 years, open procedure, and AE (p< 0.05). Predictors of longer LOS than median of 1 day for laminectomy were increasing age, living alone, higher ODI, open procedures, longer operative time, and AEs (p< 0.05). For posterior instrumented fusion, predictors of longer LOS than median of 4 days were older age, living alone, more comorbidities, less back pain, higher ODI, using narcotics, longer operative time, open procedures, and AEs (p< 0.05). Ten centers (53%) had either ERAS or a standardized protocol aimed at reducing LOS. In this study stratifying individual patient and institutional level factors across Canada, several independent predictors were identified to enhance the understanding of LOS variability in common elective lumbar spine surgery. The current study provides an updated detailed analysis of the ongoing Canadian efforts in the implementation of multimodal ERAS care pathways. Future studies should explore multivariate analysis in institutional factors and the influence of preoperative patient education on LOS

The August 2024 Spine Roundup. 360. looks at: Laminectomy adjacent to instrumented fusion increases adjacent segment disease; Influence of the timing of surgery for cervical spinal cord injury without bone injury in the elderly: a retrospective multicentre study; Lumbar vertebral body tethering: single-centre outcomes and reoperations in a consecutive series of 106 patients; Machine-learning algorithms for predicting Cobb angle beyond 25° in female adolescent idiopathic scoliosis patients; Pain in adolescent idiopathic scoliosis; Teriparatide prevents surgery for osteoporotic vertebral compression fracture

Aims. The aim of this study was to investigate the clinical and radiographic outcomes of microendoscopic laminotomy in patients with lumbar stenosis and concurrent degenerative spondylolisthesis (DS), and to determine the effect of this procedure on spinal stability. Patients and Methods. A total of 304 consecutive patients with single-level lumbar DS with concomitant stenosis underwent microendoscopic laminotomy without fusion between January 2004 and December 2010. Patients were divided into two groups, those with and without advanced DS based on the degree of spondylolisthesis and dynamic instability. A total of 242 patients met the inclusion criteria. There were 101 men and 141 women. Their mean age was 68.1 years (46 to 85). Outcome was assessed using the Japanese Orthopaedic Association and Roland Morris Disability Questionnaire scores, a visual analogue score for pain and the Short Form Health-36 score. The radiographic outcome was assessed by measuring the slip and the disc height. The clinical and radiographic parameters were evaluated at a mean follow-up of 4.6 years (3 to 7.5). Results. There were no significant differences in the preoperative measurements between the group and no significant differences between the clinical parameters at the final follow-up. The mean percentage slip was 17.1% preoperatively and 17.7% at the final follow-up (p = 0.35). Progressive instability was noted in 13 patients (8.2%) with DS and 6 patients (7.0%) with advanced DS, respectively (p = 0.81). There was radiological evidence of restabilization of the spine in 30 patients (35%) with preoperative instability. The success rate of microendoscopic laminotomy was good/excellent in 166 (69%), fair in 49 (20%) and poor in 27 patients (11%) in both groups. Conclusion. Microendoscopic laminotomy is an effective form of surgical treatment for patients with DS and stenosis. Preservation of the stabilizing structures using this technique prevents postoperative instability. Cite this article: Bone Joint J 2018;100-B:499–506

Spinal stenosis is a condition resulting in the compression of the neural elements due to narrowing of the spinal canal. Anatomical factors including enlargement of the facet joints, thickening of the ligaments, and bulging or collapse of the intervertebral discs contribute to the compression. Decompression surgery alleviates spinal stenosis through a laminectomy involving the resection of bone and ligament. Spinal decompression surgery requires appropriate planning and variable strategies depending on the specific situation. Given the potential for neural complications, there exist significant barriers to residents and fellows obtaining adequate experience performing spinal decompression in the operating room. Virtual teaching tools exist for learning instrumentation which can enhance the quality of orthopaedic training, building competency and procedural understanding. However, virtual simulation tools are lacking for decompression surgery. The aim of this work was to develop an open-source 3D virtual simulator as a teaching tool to improve orthopaedic training in spinal decompression. A custom step-wise spinal decompression simulator workflow was built using 3D Slicer, an open-source software development platform for medical image visualization and processing. The procedural steps include multimodal patient-specific loading and fusion of Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) data, bone threshold-based segmentation, soft tissue segmentation, surgical planning, and a laminectomy and spinal decompression simulation. Fusion of CT and MRI elements was achieved using Fiducial-Based Registration which aligned the scans based on manually placed points allowing for the identification of the relative position of soft and hard tissues. Soft tissue segmentation of the spinal cord, the cerebrospinal fluid, the cauda equina, and the ligamentum flavum was performed using Simple Region Growing Segmentation (with manual adjustment allowed) involving the selection of structures on T1 and/or T2-weighted scans. A high-fidelity 3D model of the bony and soft tissue anatomy was generated with the resulting surgical exposure defined by labeled vertebrae simulating the central surgical incision. Bone and soft tissue resecting tools were developed by customizing manual 3D segmentation tools. Simulating a laminectomy was enabled through bone and ligamentum flavum resection at the site of compression. Elimination of the stenosis enabled decompression of the neural elements simulated by interpolation of the undeformed anatomy above and below the site of compression using Fill Between Slices to reestablish pre-compression neural tissue anatomy. The completed workflow allows patient specific simulation of decompression procedures by staff surgeons, fellows and residents. Qualitatively, good visualization was achieved of merged soft tissue and bony anatomy. Procedural accuracy, the design of resecting tools, and modeling of the impact of bone and ligament removal was found to adequately encompass important challenges in decompression surgery. This software development project has resulted in a well-characterized freely accessible tool for simulating spinal decompression surgery. Future work will integrate and evaluate the simulator within existing orthopaedic resident competency-based curriculum and fellowship training instruction. Best practices for effectively teaching decompression in tight areas of spinal stenosis using virtual simulation will also be investigated in future work

Instrumented fusion for lumbar degenerative spondylolisthesis (LDS) has been challenged recently with high impact trials demonstrating similar changes in health-related quality of life (HRQOL) and less morbidity/cost with laminectomy alone. Randomized trials often fail, however, to evaluate a heterogeneous population of patients. A standardized clinical assessment and management plan (SCAMP) was created as a decision aid for surgeons based on the radiographic stability and clinical presentation of patients. The purpose of this study was to compare outcomes of those patients who followed the decision aid with respect to fusion/no fusion to those who did not. Patients were prospectively enrolled from eleven different Canadian institutions and followed from 2015–2019. A degenerative spondylolisthesis instability classification system (DSIC) was created using best available evidence stratifying patients into three different subtypes (1. stable degenerative spondylolisthesis, 2. potentially unstable spondylolisthesis and 3. unstable spondylolisthesis). The decision aid recommends laminectomy alone for group 1 patients, posterolateral fusion with pedicle screws in type 2 patients and pedicle screw and interbody fusion for type 3 patients. One year changes in HRQOL, length of hospital stay (LOS), medication use and surgical time were compared between each group and in context of whether the treatment fell within the decision aid recommendation. Statistics were performed with STATA software. There were 394 patients initially enrolled and 334 (84.8%) with full one year data available for comparison. There were 95 type 1 (stable), 224 type 2 (potentially unstable) and 75 type 3 (unstable) patients initially classified. Baseline Ostwestry disability index (ODI), EQ-5D, and SF-12 MCS scores were significantly worse for type 3 patients versus type 1 patients. One hundred and eight patients were treated within the recommendations of the DSIC system (108/334, 32.3%). Surgeons performed interbody fusions in 141 patients (42%) rather than follow DSIC recommending a less invasive approach. There were no significant differences EQ-5D, SF-12 PCS/MCS, PHQ-9 or ODI at one year between patient groups. There was a trend towards shorter operating times for those patients following the DSIC system (195 minutes non-followers versus 180 followers, p=0.078) and reduced hospital stay (4.46 days non-followers versus 3.98 followers, p=0.065). There were no significant clinical differences in outcome at 1 year whether patients underwent decompression alone, decompression/posterolateral fusion or interbody fusion regardless of the stability classification. Surgeons were more likely to perform potentially unnecessary interbody fusions even in those patients with stable or potentially unstable spondylolisthesis. Although not statistically significant, there is some suggestion that following the DSIC system based on best evidence recommendations leads to more judicious/responsible use of hospital resources. Further study is required to determine why surgeons are more likely to choose more invasive, higher rigidity constructs in patients with LDS

Introduction: Wide laminectomy has been the accepted treatment of choice for stenosis in the lumbar spine. Recently, bilateral laminotomy has been proposed as an alternative decompressive technique for spinal canal stenosis. There have been no biomechanical studies to determine the in vitro difference in stability between these techniques. Objective: To determine the in vitro difference in stability in a functional spinal unit (FSU) following bilateral laminotomy, and compare it to the instability resulting from laminectomy. Methods: Six fresh human cadaver lumbar spines were injured sequentially at the L4-5 level: bilateral laminotomy and laminectomy. The normal and injured spines were subjected to flexion, extension, lateral bending and torsional moments. The three-dimensional motion behaviour of each spine before and after the two injuries was recorded using a magnetic motion sensor. The data from all five spines was pooled for statistical analysis. Results: With flexion and extension loading, bilateral laminotomy induced significantly less sagittal angulation and translation in the FSU than did laminectomy. Significant increases in coronal translation occurred with laminectomy in spines subjected to lateral bending loads. There were no significant differences between the two techniques in coronal plane angulation with lateral bending loads and torsional loads. Discussion: Adequate exposure of the lateral recesses requires limited medial facetectomy with both laminotomy and laminectomy. With laminotomy, the lamina and posterior ligamentous structures are preserved. This is aimed at decreasing the potential late development of spinal instability associated with laminectomy. The increase in motion seen with laminectomy in sagittal angulation / translation, and coronal translation in this in vitro model, may represent clinical instability, and may be responsible for continued symptomatology in these patients. Preservation of the lamina, spinous processes, and the posterior ligamentous structures significantly enhances the biomechanical stability of the FSU

Objective: To determine the in vitro difference in stability in a functional spinal unit (FSU) following bilateral laminotomy, and compare it to the instability resulting from laminectomy. Design: The normal and injured spines were subjected to flexion, extension, lateral bending and torsional moments. Subjects: Six fresh human cadaver lumbar spines were injured sequentially at the L4–5 level: bilateral laminotomy and laminectomy. Outcome measures: The three-dimensional motion behaviour of each spine before and after the two injuries was recorded using a magnetic motion sensor. The data from all five spines was pooled for statistical analysis. Results: With flexion and extension loading, bilateral laminotomy induced significantly less sagittal angulation and translation in the FSU than did laminectomy. Significant increase in coronal translation occurred with laminectomy in spines subjected to lateral bending loads. There were no significant differences between the two techniques in coronal plane angulation with lateral bending loads and torsional loads. Conclusion: The increase in motion seen with laminectomy in sagittal angulation/translation, and coronal translation in this in vitro model may represent clinical instability, and may be responsible for continued symptomatology in these patients. Preservation of the lamina, spinous processes, and the posterior ligamentous structures significantly enhances the biomechanical stability of the FSU

Objective: We prospectively compared the techniques of skip laminectomy and laminoplasty for the treatment of cervical spondolytic myelopathy in terms extent of decompression achieved, axial pain, postoperative range of cervical motion, patient and surgical outcomes. Methods and results: We studied fifty consecutive patients operated on for cervical spondolytic myelopathy and spinal cord compression as demonstrated on MRI between the levels C3–4 to C6–7. Each patient had a minimum follow-up of two years (2.2 – 4.3 years). Twenty-five patients underwent skip laminectomy and twenty-five patients underwent laminoplasty. Decompression was assessed by pre- and post-operative MRI. Cervical range of motion was assessed by pre- and postoperative flexion and extension radiographs. Patient outcomes were assessed by evaluation of pre-and postoperative neurology and SF12 scores for mental health, physical health and axial pain. Less blood loss and operative times were found with skip laminectomy. Similar degrees of decompression with both techniques. Significantly improved axial pain scores with skip laminectomy. Significantly improved preservation of range of movement with skip laminectomy. Conclusion: Skip laminectomy is an effective procedure for reducing the incidence of postoperative morbidities, such as persisting axial pain, and restriction of neck motion often seen after laminoplasty, and provides adequate decompression of the spinal cord as demonstrated on MRI for a minimum follow-up of two years

Introduction. Pulmonary Tuberculosis (TB) can be detected by sputum cultures. However, Extra Pulmonary Spinal Tuberculosis (EPSTB), diagnosis is challenging as it relies on retrieving a sample. It is usually discovered in the late stages of presentation due to its slow onset and vague early presentation. Difficulty in detecting Mycobacterium Tuberculosis bacteria from specimens is well documented and therefore often leads to culture negative results. Diagnostic imaging is helpful to initiate empirical therapy, but growing incidence of multidrug resistant TB adds further challenges. Methods. A retrospective analysis of cases from the Infectious Disease (ID) database with Extra Pulmonary Tuberculosis (EPTB) between 1. st. of January 2015 to 31. st. of January. Two groups were compared 1) Culture Negative TB (CNTB) and 2) Culture Positive TB (CPTB). Audit number was. Results. 31 cases were identified with EPSTB. 68% (n=21) were male. 55% (n=17) patients were Asian, (19% (n=6) were black and 16% (n=5) were of white ethnicity. 90.4% (n=28) patients presented with isolated spinal TB symptoms. No patient had evidence of HBV/HCV/HIV infections. CPTB Group was 51.6% (n=16) compared to CNTB Group with 48.4% (n=15) 48% (15) lumbar involvement, 42% (13) thoracic and 10% (3) cervical. 38.7% (12) patients presented with late neurology, equally in both groups. 56% CPTB patients showed signs of vertebral involvement on plain radiograph compared to 13.3% in CNTB patients. 68.7% CPTB patients had pathological changes or paraspinal collections seen on CT scan compared to 53.3% of CNTB patients. 81% of CPTB showed positive MRI findings compared to 86% in CNTB. Both groups were treated with Anti-TB medications according to local guidelines. 83% patients were followed up till the end of the treatment course. 22.5% (n=7) patients had Ultrasound guided aspiration. 29% (n=9) patients underwent surgical intervention. 3 patients had Laminectomy for decompression. 6 patients underwent Spinal Decompression and Fixation due to extensive bone destruction. No mortality occurred. Conclusion. TB continues to be a growing problem in the developed world with high numbers of patients travelling from endemic regions. 75% of our cases were from Asian or Black ethnicity. The thoracolumbar region was most commonly effected (90%). Approximately 50% of cases of extrapulmonary spinal TB were culture negative. Neurological deficit occurred in 40% patients and 30% of patients required surgery. Standard anti-TB treatment was however effective in all cases with no significant drug resistant variants noted. MRI and CT imaging remain the superior diagnostic tests in the presence of high CN EPSTB

A lumbar laminectomy is a commonly performed surgical procedure for the decompression of neural structures. The aim of this human cadaveric study is to establish the extent of pars interarticularis remaining at each lumbar level when a laminectomy is performed to the medial edge of the pedicle. Seven human cadavers with intact lumbar spines were obtained for this study. The lumbar spine was dissected from the body and segmental disarticulation of each level was performed. The isolated lumbar levels had laminectomies performed exposing the neural canal. The vertical alignment of the laminectomy was orientated in line with the medial aspect of the ipsilateral pedicle. The remaining lateral pars interarticularis was measured with a calliper. The procedure was performed bilaterally at each isolated lumbar segment. Five males and two female cadavers with an age range of sixty-eight years to ninety-five years at the time of death. Fourteen lumbar segments of each respective level were available for study except at L5, where only twelve was possible due the presence of a transitional vertebra in one of the specimens. Taken to the nearest mms, the average width of the remnant pars interarticularis at the L1 level was 4 mm, range 3–6 mm (SD 0.95); L2 6 mm, range 5–7 mm (SD 0.77); L3 8mm, range 4–9mm (SD 1.34); L4 11mm, range 9–14 mm (SD 1.31) and L5 16mm, range 13–17 mm (SD 1.15). One way analysis of variance for each of the groups were performed to establish that the difference recorded was greater than that expected by chance (p< 0.05). The results predictably established the gradual narrowing of the pars interarticularis as the levels ascend cranially from L5. The medial wall of the pedicle could be used as an indirect means to establish a satisfactory remnant of the pars interarticularis following a laminectomy in the lower lumbar spine, at the levels of L3 to L5. However in the upper two levels direct visualisation of the pars is recommended

Aims. Our aim was to perform a systematic review of the literature to assess the incidence of post-operative epidural haematomas and wound infections after one-, or two-level, non-complex, lumbar surgery for degenerative disease in patients with, or without post-operative wound drainage. Patients and Methods. Studies were identified from PubMed and EMBASE, up to and including 27 August 2015, for papers describing one- or two-level lumbar discectomy and/or laminectomy for degenerative disease in adults which reported any form of subcutaneous or subfascial drainage. Results. Eight papers describing 1333 patients were included. Clinically relevant post-operative epidural haematomas occurred in two (0.15%), and wound infections in ten (0.75%) patients. Epidural haematomas occurred in two (0.47%) patients who had wound drainage (n = 423) and in none of those without wound drainage (n = 910). Wound infections occurred in two (0.47%) patients with wound drainage and in eight (0.88%) patients without wound drainage. Conclusion. These data suggest that the routine use of a wound drain in non-complex lumbar surgery does not prevent post-operative epidural haematomas and that the absence of a drain does not lead to a significant change in the incidence of wound infection. Cite this article: Bone Joint J 2016;98-B:984–9

Purpose: Cervical laminoplasty has been used for the treatment of cervical arthrosic myelopathy in Japan. The purpose of this work was to assess clinical and radiological outcome at more than two years follow-up. Material: Thirty-one patients underwent laminoplasty of three levels or more for cervical arthrosic myelopathy and were reviewed more than two years after surgery. Methods: The Japanese Orthopaedic Association score was used to assess function preoperatively and at last follow-up. Preoperative and last follow-up standard strict lateral and flexion and extension x-rays of the cervical spine were available for all patients. The curvature was assessed on the lateral view in the neutral position (C2–C7 Cobb angle). Overall mobility was assessed on the dynamic views. Results: The mean preoperative score was 9.7, improving to 138 at last follow-up (p < 0.0001, paired t test). Mean relative gain was 52.9%. The mean Cobb angle was 17° preoperatively and 8.9° at last follow-up. Cervical spine curvature and overall mobility had no influence on the score at last follow-up. The postoperative Cobb score was only influenced by the preoperative angle (p < 0.0001). There were no reoperations for instability. Discussion: Guigui has demonstrated that mean loss of cervical lordosis in a series of extended laminectomies was 14°. In our series, mean loss of cervical lordosis was 8.1°. Laminoplasty enables a better preservation of cervical lordosis than laminectomy. Guigui also reported three patients requiring reoperation because of an unstable spine after laminectomy. Inversely, we did not have any cases requiring reoperation. During laminoplasty, a gutter is fashioned in a medial quarter of the articular masses to open the lamina, producing their fusion. This unexpected fusion diminishes overall mobility but also has a less destabilising effect on the spine than laminectomy

With the increase in the elderly population, there is a dramatic increase in the number of spinal fusions. Spinal fusion is usually performed in cases of primary instability. However it is also performed to prevent iatrogenic instability created during surgical treatment of spinal stenosis in most cases. In literature, up to 75% of adjacent segment disease (ASD) can be seen according to the follow-up time. 1. Although ASD manifests itself with pathologies such as instability, foraminal stenosis, disc herniation or central stenosis. 1,2. There are several reports in the literature regarding lumbar percutaneous transforaminal endoscopic interventions for lumbar foraminal stenosis or disc herniations. However, to the best our knowledge, there is no report about the treatment of central stenosis in ASD. In this study, we aimed to investigate the short-term results of unilateral biportal endoscopic decompressive laminotomy (UBEDL) technique in ASD cases with symptomatic central or lateral recess stenosis. The number of patients participating in the prospective study was 8. The mean follow-up was 6.9 (ranged 6 to 11) months. The mean age of the patients was 68 (5m, 3F). The development of ASD time after fusion was 30.6 months(ranged 19 to 42). Mean fused segments were 3 (ranged 2 to 8). Preoperative instability was present in 2 of the patients which was proven by dynamic lumbar x-rays. Preoperative mean VAS-back score was 7.8, VAS Leg score was 5.6. The preoperative mean JOA (Japanese Orthopaedic Association) score was 11.25. At 6th month follow-up, the mean VAS back score of the patients was 1, and the VAS leg score was 0.5. This improvement was statistically significant (p = 0.11 and 0.016, respectively). The mean JOA score at the 6th month was 22.6 and it was also statistically significant comparing preoperative JOA score(p = 0.011). The preoperative mean dural sac area measured in MR was 0.50 cm2, and it was measured as 2.1 cm. 2. at po 6 months.(p = 0.012). There was no progress in any patient's instability during follow-up. In orthopedic surgery, when implant related problems develop in any region of body (pseudoarthrosis, infection, adjacent fracture, etc.), it is generally treated by using more implants in its final operation. This approach is also widely used in spinal surgery. 3. However, it carries more risk in terms of devoloping ASD, infection or another complications. In the literature, endoscopic procedures have almost always been used in the treatment of ventral pathologies which constitute only 10%. In ASD, disease devolops as characterized by wide facet joint arthrosis and hypertrophied ligamentum flavum in the cranial segment and it is mostly presented both lateral recess and santal stenosis symptoms (39%). In this study, we found that UBEDL provides successful results in the treatment of patients without no more muscle and ligament damage in ASD cases with spinal stenosis. One of the most important advantages of UBE is its ability to access both ventral and dorsal pathologies by minimally invasive endoscopic aproach. I think endoscopic decompression also plays an important role in the absence of additional instability at postoperatively in patients. UBE which has already been described in the literature given successful results in most of the spinal degenerative diseases besides it can also be used in the treatment of ASD. Studies with longer follow-up and higher patient numbers will provide more accurate results

Background: A common complication of lumbar spine surgery is incidental tear of the dural sac and subsequent leakage of the cerebrospinal fluid intraoperatively. Studies have reported a wide variation in the rates of dural tears in spine surgery (1%–17%). The rates were higher after revision surgery. Objective: To establish a baseline rate of incidence of dural tears after lumbar surgery in Morriston Hospital Neurosurgical Unit and to compare it with the results reported in the literature. Methods and Results: A prospective review of the operation notes of 65 consecutive patients who had undergone lumbar surgery (Primary lumbar discectomy, primary lumbar laminectomy and revision lumbar discectomy) over a period of 3 months from Jan 2008. Patients were operated on by different neurosurgical consultants. 40 patients had primary lumbar discectomy of which 2 (5%) had dural tears. 20 patients had primary lumbar laminectomy of which 1 (5%) had a dural tear and 5 patients had revision lumbar discectomy of which 1 (20%) had a dural tear. All dural tears were repaired intraoperatively. Conclusion: This study shows that the highest percentage of incidental durotomy was in revision lumbar surgery which was also slightly higher than the reported rates (8.1%–17.4%). The percentage of dural tears after primary discectomy and primary laminectomy was within range of the percentages reported in the literature (1%–7.1%) and (3.1%–13%) respectively. A multicentre prospective larger study which includes all different surgical procedures performed on the lumbar spine is needed to establish a more accurate incidence rate for this common complication

Operative treatment was performed in nine patients with cervical spondylotic myelopathy complicating athetoid cerebral palsy. The first two patients were treated by laminectomy, and the other seven by anterior interbody fusion. The symptoms in both the laminectomy patients improved after operation, but became worse again when cervical instability developed; they then had to have an anterior fusion in addition. In six of the seven patients who had primary anterior fusion a halo-cast (or a halo-vest) was used to keep the cervical spine immobile, and good bony fusion was obtained with satisfactory results. However, in one patient no halo apparatus was used, bony union did not occur and the radiculopathy reappeared. In cervical myelopathy complicating athetoid cerebral palsy laminectomy is contra-indicated; anterior fusion combined with a halo apparatus is, however, satisfactory

Doubt remains as to the safest surgical approach to the prolapsed thoracic intervertebral disc. Laminectomy, lateral rhachotomy and the transthoracic approach all have their protagonists. Twenty-two patients from the National Hospital for Nervous Diseases, Queen Square, and Atkinson Morley's Hospital have been reviewed. Their clinical presentation is discussed and the ancillary aids to diagnosis assessed. The diagnostic value of disc space calcification is stressed, and the use of air myelography as an adjunct to positive contrast myelography is noted. Fifteen patients were subjected to laminectomy, and seven to lateral rhachotomy. Each group contained patients with a wide range of neurological deficit. Six of the patients who underwent laminectomy were improved, two were unchanged, six deteriorated and one died. Of the patients who had lateral rhachotomy, six were improved, one was unchanged and none deteriorated. The conclusion is drawn that lateral rhachotomy is a safer procedure

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Cite this article: Bone Joint J 2023;105-B(4):347–355.

Aims

Symptomatic spinal stenosis is a very common problem, and decompression surgery has been shown to be superior to nonoperative treatment in selected patient groups. However, performing an instrumented fusion in addition to decompression may avoid revision and improve outcomes. The aim of the SpInOuT feasibility study was to establish whether a definitive randomized controlled trial (RCT) that accounted for the spectrum of pathology contributing to spinal stenosis, including pelvic incidence-lumbar lordosis (PI-LL) mismatch and mobile spondylolisthesis, could be conducted.

We present a novel method of performing an ‘open-door’ cervical laminoplasty. The complete laminotomy is sited on alternate sides at successive levels, thereby allowing the posterior arch to be elevated to alternate sides. Foraminotomies can be carried out on either side to relieve root compression. The midline structures are preserved. We undertook this procedure in 23 elderly patients with a spondylotic myelopathy. Each was assessed clinically and radiologically before and after their operation. Follow-up was for a minimum of three years (mean 4.5 years; 3 to 7). Using the modified Japanese Orthopaedic Association scoring system, the mean pre-operative score was 8.1 (6 to 10), which improved post-operatively to a mean of 12.7 (11 to 14). The mean percentage improvement was 61% (50% to 85.7%) after three years. The canal/vertebral body ratio improved from a mean of 0.65 (0.33 to 0.73) pre-operatively to 0.94 (0.5 to 1.07) postoperatively. Alternating cervical laminoplasty can be performed safely in elderly patients with minimal morbidity and good results

A new technique of enlargement of the lumbar spinal canal (ELSC) and neural decompression in the treatment of any uni or multilevel segmental pathology causing stenosis with radicular or dural sac compression was performed by a standard laminectomy, posterior osteophytectomy and radical discectomy, leading to a widening of all the saggital and coronal sizes of the spinal canal, including the foraminal outlet of the root. No damage or excessive excision of facet joints are necessary to achieve the wide neural decompression. The outcome of patients that underwent conventional laminectomy and discectomy (Group A) and ELSC ( Group B) was compared. The only objective parameter used to compare between the groups was only the need for reoperation of the patients. The indications for the first surgery or a second reoperation (revision) were identical for both groups. Conventional laminectomy and discectomy (Group A) was performed in 317 patients between 1977 and 1989. In this group 193 (61%) were females and 124 (39%) males. Mean age 42.5 years (range 13 to 72). In this group reoperation at the same level was necessary in 24 patients (8%). ELSC (Group B) was performed in 231 patients between 1990 and 2002. In this group 133 (58%) were females and 98 (42%) males. Mean age 46.5 years (range 17 to 78). Only 3 patients needed reoperation at the same level in this group (1.3%). Using CT-scan cross sectional area measurements , the spinal canal was seen to be enlarged by 217% in average by using the ELSC surgical technique. The follow up for group A was from 1 to 8 years; group B was 3 to 11 years. All patients underwent the operations by the autor. Generous posterior osteophytectomy, scurving the anterior wall of the foramina in both sides, bypasses the pathway of the root, resulting in release of the overtensed, elongated and compressed nerve root at the encroached site of the foraminal outlet. An optimal enlargement of the lumbar spinal canal was achieved without affecting the spinal stability. No symptoms related to perineural scarring were seen in Group B. The ELSC technique can be aplied together with any kind of spinal instrumentation

Objective: Measuring outcomes from chronic disease in terms of generic, health-related quality of life (HRQoL) instruments is of increasing importance to allow valid comparison of interventions and to accurately assess efficacy of treatment from the patient’s perspective. In this context we sought to establish the role of the generic SF-36 health survey in measuring outcomes from spinal surgery. Method: A prospective observational study of patients undergoing elective cervical discectomy, lumbar discectomy, and lumbar laminectomy using both disease specific (Myelopathy Disability Index [MDI], Roland Morris Disability Scale [RMDS], Visual Analogue Scales [VAS], Hospital Anxiety and Depression Scales [HADS]) and SF-36 assessment pre-operatively and at 3 months and 12–24 months following surgery. The generic instrument was tested for the components of construct validity in comparison to the established specific measures. Analysis was performed with non-parametric statistics within SPSS. Results: Six-hundred and twenty patients were followed between 1998 and 2005 (median age 53 years; 203 lumbar discectomy, 177 lumbar laminectomy, 240 cervical discectomy). The principal SF-36 physical domains (Physical Functioning, Bodily Pain) strongly correlated with disease specific scores in all patients (Spearman’s ρ=0.5–0.74, p< 0.001) and similarly SF-36 mental domains correlated with the HADS subscales (ρ=0.30–0.45, p< 0.001) indicating concurrent/convergent validity. Discriminant validity was confirmed by the absence of significant correlation between SF-36 physical domains and the HADS (ρ=0.014–0.14, p> 0.05). In the lumbar laminectomy and cervical discectomy patients disease-specific physical scores prior to surgery strongly predicted early and late outcome (area under the receiver-operating characteristics curve [AUC] = 0.79–0.86, p< 0.001) and the same pattern was mirrored in the SF-36 physical domains (AUC = 0.76–0.78, p< 0.001) demonstrating the predictive validity of the generic measure. Physical Function and Bodily Pain SF-36 domains both had excellent response to change by Cohen’s criteria with effect sizes (standardised mean difference) of 0.86–1.57. Conclusion: The SF-36 has been shown to possess the necessary features of construct validity in relation lumbar and cervical surgery to be considered as a suitable adjunct or alternative to measuring outcome with disease specific scores. As a widely employed HRQoL instrument the SF-36 should be a convenient means of assessing patients with spinal morbidity in all healthcare settings and the generic measure will permit easier comparison of the clinical and economic efficacy of different interventions

Introduction: This study is a retrospective review of patients who underwent corticosteroid spinal injections and/or surgery for lumbar juxtafacet cysts to determine the effectiveness of corticosteroid injection and/or surgery for the treatment of lumbar juxtafacet cysts. Methods: The charts of 40 patients who underwent corticosteroid injection and/or surgery for the treatment of symptomatic juxtafacet cysts were reviewed and an outcome questionnaire was sent to each patient. All patients responded to the questionnaire (100%). Results: Forty-four juxtafacet cysts were treated in 40 patients. 28 cysts were initially treated with corticosteroid injection. 18 facet joints adjacent to the cysts were injected (4 were injected on two or more occasions), 13 underwent epidural injection and 5 underwent nerve sheath exit foraminal blocks. 18 obtained no Benefit from the use of corticosteroid injections and proceeded to surgical treatment. Of the 10 patients that did not undergo surgery, at follow-up 2 reported no clinical change and were considering surgical treatment. This represents a 71% failure rate for non-operative treatment with corticosteroid injections. 34 cysts were resected from 31 patients. Two (6%) were ligamental and 32 were facetal. 31 cysts were resected by laminectomy alone and 3 patients underwent laminectomy and bone only fusion. One cyst (3%) recurred and was managed by repeat laminectomy. One patient required instrumented lumbosacral fusion for increasing anterolisthesis. Incidental dural tear was the most common surgical complication occurring in two cases (6%). One patient demonstrated significant weakness of ankle and foot dorsiflexion which recovered incompletely. Average follow-up for the surgical group was 18 months (5–72 months). 27 scored an excellent or good outcome (79%), 3 scored a fair outcome, 3 were considered poor and one patient was worse. 30 (88%) patients were satisfied having complete improvement or improved with residual back or leg symptoms. Three responded as no change and one was worse. Discussion: Juxtafacet cysts are an uncommon cause of radiculopathy. Corticosteroid injection into the adjacent facet joints, epidural space or exit foraminae of the spine produces disappointing results. Surgical resection is the treatment of choice with low rates of complications, recurrences and residual complaints

Degenerative spondylolisthesis is consistently responsible for narrowing of the spinal canal, but only in a part of the cases it causes lateral or central stenosis. The presence, type and severity of stenosis is related to several factors, such as the constitutional dimensions of the spinal canal, the orientation and severity of degenerative changes of the facet joints, and the amount of vertebral slipping. The type of stenosis, that is whether stenosis is central or lateral, depends on the orientation of the articular processes, and the length of the pedicles. Usually stenosis is lateral initially and central in later stages. Instability, that is hypermobility on flexion-extension adiographs is one of the main characteristics of degenerative spondylolisthesis. However, in many cases there is no appreciable hypermobility of the slipped vertebra. We consider the latter condition as a potential instability, which can become a manifest instability as a result of surgery, or when destabilizing factors unable to destabilize a normal vertebra intervene, such as disc degeneration or severe degenerative changes of the facet joints. There is no indication for surgery in patients with no significant symptoms. In patients with an unstable motion segment who have only back pain it is usually sufficient to perform a fusion alone if stenosis is mild and asymptomatic. Neural decompression should be performed if stenosis is severe. Bilateral laminotomy, or even total laminectomy, may be carried out with no concomitant fusion in patients with mild olisthesis, no vertebral hypermobility on functional radiographs, mild central stenosis or any degree of isolated lateral stenosis, and mild or no back pain. The indications for monolateral laminotomy with no fusion are: moderate central stenosis in elderly patients with unilateral symptoms; lateral stenosis only on one side; and unilateral additional pathology, such as a synovial cyst. Patients with moderate or severe olisthesis, vertebral hypermobility even of mild degree, and/or severe central stenosis and chronic back pain should undergo decompression and fusion. The association of an arthrodesis allows decompression of the neural structures as widely as necessary. Posterolateral instrumented fusion, using pedicle screw fixation, is the most common procedure, that can be done at multiple level when olisthesis is present at more than one level. In both cases it requires no, or a short, postoperative immobilization Posterolateral fusion may be replaced by PLIF. This procedure, associated with pedicle screw instrumentation, gives excellent results and a high rate of solid fusion. The devices inserted in the disc space are normally represented by cages filled with bone chips. An alternative are the use of blocks of porous tantalum (hedrocel), the stiffness of which is very similar to that of subchondral bone. We are using blocks of hedrocel since 3 years with excellent results in terms of intersomatic fusion. In 20 cases followed for at least 2 years we never observed mobilization of the implant or loosening of the pedicle screws, and we almost consistently found a tight union between the implant and the adjacent vertebrae

Aims

This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures.

Percutaneous placement of pedicle screws is a well-established technique, however, no studies have compared percutaneous and open placement of screws in the thoracic spine. The aim of this cadaveric study was to compare the accuracy and safety of these techniques at the thoracic spinal level. A total of 288 screws were inserted in 16 (eight cadavers, 144 screws in percutaneous and eight cadavers, 144 screws in open). Pedicle perforations and fractures were documented subsequent to wide laminectomy followed by skeletalisation of the vertebrae. The perforations were classified as grade 0: no perforation, grade 1: < 2 mm perforation, grade 2: 2 mm to 4 mm perforation and grade 3: > 4 mm perforation. In the percutaneous group, the perforation rate was 11.1% with 15 (10.4%) grade 1 and one (0.7%) grade 2 perforations. In the open group, the perforation rate was 8.3% (12 screws) and all were grade 1. This difference was not significant (p = 0.45). There were 19 (13.2%) pedicle fractures in the percutaneous group and 21 (14.6%) in the open group (p = 0.73). In summary, the safety of percutaneous fluoroscopy-guided pedicle screw placement in the thoracic spine between T4 and T12 is similar to that of the conventional open technique. Cite this article: Bone Joint J 2015;97-B:1555–61

Introduction: Preliminary studies suggest that prolonged retraction of the paraspinal muscle during spinal surgery may produce ischaemic damage. We describe the continuous measurement of intramuscular pressures (IMP) during decompressive lumbar laminectomy and the relationship to back pain and disability. Methods: In this prospective interventional study, 28 patients undergoing surgery for lumbar canal stenosis were recruited. Back pain and function were assessed using the Visual Analogue Score (VAS), Oswestry Disability Index (ODI) and Short Form 36 (SF36) health survey. During surgery, IMP was continuously recorded from the multifidus muscle using a pressure transducer. The intramuscular perfusion pressure (IPP) was derived as the difference between the patient’s mean arterial pressure (MAP) and IMP (IPP = MAP − IMP). The data was analysed using repeated measures ANOVA (SPSS package). Results: The mean age was 60.4 ± 3 years and the mean duration of symptoms of 31.0 ± 6 months. The predominant symptoms were neurogenic claudication (14) and/or sciatica (13). Patients underwent 1 (N=3), 2 (N=20) or 3 (N=5) level laminectomies. The muscle retractors used were Norfolk and Norwich (N=16) and McCullock (N=12). The mean duration of deep muscle retraction was 68.5 ± 9 mins (range 19–240). On application of deep muscle retraction, there was a rapid and sustained increase in IMP (F=26.8; p< 0.001; repeated measures ANOVA), and overall the calculated mean IPP approached 0 mmHg or less during this period (F=36.8; p< 0.001). On release of deep muscle retraction there was a rapid decrease in IMP to pre-operative levels. The IPP was greater with Norfolk and Norwich than McCullock retractors (F=12.2; p< 0.001). Compared to pre-operative values, there was a decrease in ODI (F=18.6; p< 0.001) and VAS for back pain (F=9.9; p< 0.001) at discharge, 4–6 weeks and 6 months, post-operatively. Compared to pre-operative values, there was a decrease in SF36 scores at 6 months (F=26.7; p< 0.001). Total duration of muscle retraction over 60 mins was associated with higher VAS scores for back pain at 4–6 weeks and 6 months postoperatively (F=3.7; p< 0.01). There was no relationship between IPP and post-operative ODI or VAS for back pain. Conclusions: This study demonstrates a simple technique for the continuous monitoring of IMP during spinal surgery, from which the IPP can be derived. Comparison of two muscle retractors has shown that the McCullock retractor generates a higher IMP than Norfolk and Norwich retractor. Decompressive lumbar laminectomy improves the VAS for back pain and ODI and SF36 outcome scores in these patients. The results show that duration of muscle retraction, rather than extent of the pressure generated by the retractor, is related to postoperative back pain

Vertebral haemangiomas are usually asymptomatic and discovered fortuitously during imaging. A small proportion may develop variable degrees of pain and neurological deficit. We prospectively studied six patients who underwent eight surgical procedures on 11 vertebral bodies. There were 11 balloon kyphoplasties, six lumbar and five thoracic. The mean follow-up was 22.3 months (12 to 36). The indications for operation were pain in four patients, severe back pain with Frankel grade C paraplegia from cord compression caused by soft-tissue extension from a thoracic vertebral haemangioma in one patient, and acute bleeding causing Frankel grade B paraplegia from an asymptomatic vascular haemangioma in one patient. In four patients the exhibited aggressive vascular features, and two showed lipomatous, non-aggressive, characteristics. One patient who underwent a unilateral balloon kyphoplasty developed a recurrence of symptoms from the non-treated side of the vertebral body which was managed by a further similar procedure. Balloon kyphoplasty was carried out successfully and safely in all patients; four became asymptomatic and two showed considerable improvement. Neurological recovery occurred in all cases but bleeding was greater than normal. To avoid recurrence, complete obliteration of the lesion with bone cement is indicated. For acute bleeding balloon kyphoplasty should be combined with emergency decompressive laminectomy. For intraspinal extension with serious neurological deficit, a combination of balloon kyphoplasty with intralesional alcohol injection is effective

Introduction. MRI imaging is carried out to identify levels of degenerative disc disease, and in some cases to identify a definite surgical target at which decompression should take place. We wanted to see if repeat MRI scans due to a prolonged time between the initial diagnostic MRI scan of the lumbar sacral spine, and the MRI scan immediately pre-operatively, due for the desire for a ‘fresh’ MRI scan pre-operatively, altered the level or type of procedure that they would have. Methods. This was a retrospective observational cohort study. Inclusion criteria- all patients with more than one MRI scan before their surgical procedure on the lumbar sacral spine, these were limited to patients that had either, discectomy, microdiscectomy, laminotomy decompression, laminectomy decompression and fusion, and posterior lumbar interbody fusion. Exclusion criteria- all patients with anterior approaches, all patients without decompression and all non lumbar sacral patients. Outcome measures were if there was a change between the pre-operative MRI scans, which would have changed the operative level of decompression, added other levels of decompression or type of surgery than primarily decided. Results. 84 patients were identified with our inclusion criteria with two or more pre-operative MRI scans. The repeat MRI did not change the surgical target for all 84 patients. Conclusion. Repeat MRI scanning does not alter the surgical target level, and therefore does not change management. It can delay the initial primary procedure which can lead to progressive neurology, which may be irreversible and should be avoided unless the distribution of neurology has changed

The evaluation of results following posterior decompression and fusion for the management of cervical spondylotic myelopathy. Between July 2006 and May 2008, 68 patients with cervical myelopathy underwent posterior decompression with laminectomies and pedicle screw fixation of the cervical spine. All patients were selected based on the presence of multi-level degenerative disease and the correction of cervical lordosis on the pre-operative dynamic radiographs. Patient demographics, co-morbidities and post-operative complications were recorded and analysed. Functional outcome was assessed by using the Japanese Orthopaedic Association (JOA) score. There were 37 male and 31 female patients with an average age 67.4 years. The average follow up period was 18 months. The mean pre-operative JOA score was 8.7, whereas the mean post-operative score was 12.1 on the latest follow-up visit. 9 patients had unsatisfactory clinical results and consequently underwent anterior procedures with significant improvement. Complications included 1 epidural haematoma, 2 superficial infections and 4 cases of myofascial pain. In three cases there was mild dysfunction of the C5 nerve root which resolved spontaneously with conservative measures. In the present series of patients posterior decompression with laminectomies is an effective method for the management of cervical spondylotic myelopathy

Aims

We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences.

Purpose: To describe the diagnostic planning and treatment modalities of six patients with this rarest of sacral fractures. Due to the low incidence of these injuries, there is no literature evidence concerning their management. Materials and Methods: Six patients with a transverse fracture of the sacrum with anterior displacement. All patients were admitted with bowel and bladder dysfunction, perineal anesthesia, sensory and motor deficits at the lower extremities. Prompt diagnosis of the sacral fracture was obtained in five of the six patients. Results: Operative treatment including extensive lumbosacral laminectomies, spine instrumentation and fusion was performed in all cases. Neurological recovery was almost complete in one patient, partial in 4 patients and absent in one patient. Conclusions: A more favorable clinical outcome can be achieved when operative treatment is implemented using lumbosacral decompression by laminectomy, dural repair and posterolateral instrumented fusion with bone grafting. Although reduction of the fracture was not ideal in many of these patients, long term clinical and radiographic follow – up as well as neurological improvement were rewarding

Aims

The aims of this study were first, to determine if adding fusion to a decompression of the lumbar spine for spinal stenosis decreases the rate of radiological restenosis and/or proximal adjacent level stenosis two years after surgery, and second, to evaluate the change in vertebral slip two years after surgery with and without fusion.

Objectives. Neurogenic intermittent claudication secondary to lumbar spinal stenosis is a posture dependant complaint typically affecting patients aged 50 years or older. Various treatment options exist for the management of this potentially debilitating condition. Non-surgical treatments: activity modification, exercise, NSAIDs, epidural injections. Surgical treatment options include decompression surgery and interspinous process device surgery. Interspinous process decompression is a relatively new, minimally invasive, stand-alone alternative to conservative and standard surgical decompressive treatments. The aim of this review is to evaluate the use of the X-Stop interspinous implant in all patients with spinal stenosis who were managed using the device in Northern Ireland up to June 2009. Method. We performed a retrospective review of all patients who had the X-Stop device inserted for spinal stenosis by all consultant spinal surgeons in Northern Ireland. Patient demographics, clinical symptomatology, investigative modality, post-operative quality of life, cost effectiveness, complications and long-term outcomes were assessed. Information was collected from patients using a questionnaire which was posted to them, containing the SF-36 generic questionnaire and some additional questions. Results. A total of 23 patients underwent X-stop insertion in Northern Ireland at the time of this review, 19 patients returned their questionnaires and of these 17 were completed in full and therefore included. The mean age of the study population was 60.1 years and all patients included in the study had symptoms of neurogenic claudication secondary to lumbar spinal stenosis confirmed on MRI scan. The average hospital stay was 1.5 days compared to 7.5 days for decompressive laminectomy patients. Also, at a mean follow-up of 17.8 months, 2 patients suffered direct complications of device insertion requiring removal of the implant both of these patients agreed that they would undergo the operation again in the future. SF-36 scores indicate a quality of life improvement which equates to that of other popular orthopaedic operations such as total hip and total knee replacement. X-stop insertion has been shown to be much more cost-effective than decompressive laminectomy in previous studies. Conclusion. Decompression of the lumbar spine with the X-stop interspinous implant device is safe, cost-effective, minimally invasive, and at least as effective at improving symptomatology from lumbar spinal stenosis. It is obviously more invasive than non-surgical techniques, but is less invasive than lumbar decompression procedures, is less destructive to surrounding tissues and if it fails to produce the desired results can be removed easily and the option remains for the patient to under decompression

INTRODUCTION. Lumbar total disc replacement (TDR) is an alternative treatment to avoid fusion related adverse events, specifically adjacent segment disease. New generation of elastomeric non-articulating devices have been developed to more effectively replicate the shock absorption and flexural stiffness of native disc. This study reports 5 years clinical and radiographic outcomes, range of motion and position of the center of rotation after a viscoelastic TDR. Material and methods. This prospective observational cohort study included 61 consecutive patients with monosegmental TDR. We selected patients with intermediate functional activity according to Baecke score. Hybrid constructs had been excluded. Only cases with complete clinical and radiological follow-up at 3, 6, 12, 24 and 60 months were included. Mean age at the time of surgery was 42.8 +7.7 years-old (27–60) and mean BMI was 24.2 kg/m² +3.4 (18–33). TDR level was L5-S1 in 39 cases and L4-L5 in 22 cases. The clinical evaluation was based on Visual Analog Scale (VAS) for pain, Oswestry Disability Index (ODI) score, Short Form-36 (SF36) including physical component summary (PCS) and mental component summary (MCS) and General Health Questionnaire GHQ28. The radiological outcomes were range of motion and position of the center of rotation at the index and the adjacent levels and the adjacent disc height changes. Results. There was a significant improvement in VAS (3.3±2.5 versus 6.6±1.7, p<0.001), in ODI (20±17.9 versus 51.2±14.6, p<0.001), GHQ28 (52.6±15.5 versus 64.2±15.6, p<0.001), SF 36 PCS (58.8±4.8 versus 32.4±3.4, p<0.001) and SF 36 MCS(60.7±6 versus 42.3±3.4, p<0.001). Additional surgeries were performed in 5 cases. 3 additional procedures were initially planified in the surgical program: one adjacent L3-L5 ligamentoplasty above a L5S1 TDR and two L5S1 TDR cases had additional laminectomies. Fusion at the index level was secondary performed in 2 L4L5 TDR cases but the secondary posterior fusion did not bring improvement. In the 56 remaining patients none experienced facet joint pain. One patient with sacroiliac pain needed local injections. Radiological outcomes were studied on 56 cases (exclusion of 5 cases with additional surgeries). The mean location centers of the index level and adjacent discs were comparable to those previously published in asymptomatic patients. According to the definition of Ziegler, all of our cases remained grade 0 for disc height (within 25% of normal). Discussion. The silent block design of LP-ESP provides an interesting specificity. It could be the key factor that makes the difference regarding facets problems and instability reported with other implants experimentally or clinically. Unfortunately no other comparative TDR series are available yet in the literature. Conclusion. This series reports significant improvement in mid-term follow up after TDR which is consistent with previously published studies but with a lower rate of revision surgery and no adjacent level disease pathologies. The radiographic assessment of the patients demonstrated the quality of functional reconstruction of the lumbar spine after LP ESP viscoelastic disc replacement

The December 2022 Spine Roundup³⁶⁰ looks at: Deep venous thrombosis prophylaxis protocol on a Level 1 trauma centre patient database; Non-specific spondylodiscitis: a new perspective for surgical treatment; Disc degeneration could be recovered after chemonucleolysis; Three-level anterior cervical discectomy and fusion versus corpectomy- anterior cervical discectomy and fusion “hybrid” procedures: how does the alignment look?; Rivaroxaban or enoxaparin for venous thromboembolism prophylaxis; Surgical site infection: when do we have to remove the implants?; Determination of a neurologic safe zone for bicortical S1 pedicle placement; Do you need to operate on unstable spine fractures in the elderly: outcomes and mortality; Degeneration to deformity: when does the patient need both?

Purpose: Lumbar spinal stenosis is the most common indication for spine surgery in the elderly. XStop IPD is an attractive alternative to traditional laminectomy or laminectomy with fusion as it avoids a longer procedure and anaesthesia with significantly less blood loss. The purpose of this study is to prospectively evaluate clinical outcomes, complications and functional evaluation of symptom severity, physical function and patient satisfaction following XStop IPD procedure. Method: Preoperative and postoperative clinical data as well as SF 36, visual analog scale and Roland Morris questionnaire data collected on 16 consecutive patients over 60 years undergoing XStop IPD at L3-4 and L4-5 levels or both levels. All patients had symptomatic lumbar spine stenosis with intermittent neurogenic claudication. Evaluations were made pre-operatively and post-operatively at 3, 6, 12 and 24 months. All patients had clinical radiographic data as well as data on visual analog scale SF 36 and the Roland Morris back questionnaire. Results: Patients ages ranged from 58 to 86 years with an average age of 74.25 years. In 75 percent of patients there were two or more significant co-morbidities with 18.75 percent requiring 2 level surgery. Four of the 16 patients had lumbar degenerative scoliosis with cobb angle less than 25 degrees. 50.25% the patients had grade I spondylolisthesis. No patient had previous spine surgery. In 31.25 percent of patients there was a history of diabetes. BMI ranged from 20 to 40. Seventy five percent of patients were discharged home within 24 hours. Ninety percent of patients reported relief of their leg pain at their first follow up visit within two weeks of the surgery. There were no significant complications. One-year follow up in six patients demonstrated improvements in VAS, Roland Morris criteria and SF 36 while the remaining patients have up to nine months of follow-up clinical data. Conclusion: We present our early results of this prospective study. There were significant improvements in functional outcomes. We therefore recommend the use of XStop IPD for elderly patients with multiple co-morbidities suffering from symptomatic lumbar spine stenosis with neurogenic claudication

We reviewed 40 patients treated surgically for lumbar stenosis at an average time of 8.6 years after operation. In 32, total laminectomy had been performed and in eight bilateral laminotomy, both at one or more levels. Of the 16 patients with degenerative spondylolisthesis, ten had had a concomitant spinal fusion. Patients were assigned to one of four groups according to the amount of bone regrowth: group 0 had no regrowth and groups I, II, and III, had mild, moderate or marked regrowth, respectively. Only 12% of the patients showed no bone regrowth; 48% were assigned to group I, 28% to group II and 12% to group III. Imaging studies showed varying degrees of recurrent stenosis in patients with moderate or marked bone regrowth. All patients with degenerative spondylolisthesis showed bone regrowth, which was more severe in those who had not had a fusion. The clinical results were satisfactory in most of the patients with mild or no bone regrowth and significantly less good in those with moderate or marked regrowth. In the group with degenerative spondylolisthesis, the proportion of satisfactory results was significantly higher in patients who had had spinal fusion. The long-term results of surgery for lumbar stenosis depend both upon the amount of bone regrowth and the degree of postoperative vertebral stability

Aims

Ilium is the most common site of pelvic Ewing’s sarcoma (ES). Resection of the ilium and iliosacral joint causes pelvic disruption. However, the outcomes of resection and reconstruction are not well described. In this study, we report patients’ outcomes after resection of the ilium and iliosacral ES and reconstruction with a tibial strut allograft.

Aims

To identify variables independently associated with same-day discharge (SDD) of patients following revision total knee arthroplasty (rTKA) and to develop machine learning algorithms to predict suitable candidates for outpatient rTKA.

Purpose: There are a wide variety of operative procedures for lumbar spinal canal stenosis. Bilateral fenestration, preserving the continuity of the lamina and spinous processes, has widely been employed in our department and its affiliated hospitals. The following questions are raised: Are decompressive effects of fenestration and spinal stability maintained without spinal fusion or instrumentation? In order to answer the questions, we compared the rates of revision after fenestration with those after laminectomy alone and decompressive surgery with spinal fusion. Materials and methods: The registry of spinal surgeries of our university and affiliated hospitals from 1988 to 1997 was consulted. During the first 5-years period 1159 patients underwent decompressive surgery. 908 of them had spondylosis and 251 had degenerative spondylolisthesis (DO) as a contributing factors of neural compression. Fenestration was done in 740 (81%) of patients with spondylosis and in 176 (70%) of patients with DO. Results: Regarding the whole series 31 out of 1159 patients had a revision. The revision rate was 2.7%. 15 out of 908 patients (1.7%) with spondylosis and 16 out of 251 patients (6.4%) with DO underwent revisions. 11 out of 740 (1.5%) with spondylosis and 11 out of 176 (6.3%) with DO underwent revisions after fenestration. No significant differences were found among the revision rate of fenestration, laminectomy and decompressive surgery with spinal fusion. Conclusion: The decompressive effect of fenestration was maintained long enough, even for degenerative spondylolisthesis. As a first operation spinal fusion is not necessarily indicated for lumbar canal stenosis

Introduction and Aims: To evaluate the long-term results of an operation which does not involve instrumentation or fusion and which leaves the midline structures intact. Method: A retrospective clinical and radiological review of consecutive patients. Results: One hundred and sixty patients (87 females and 73 males) with a mean age at operation of 68 (range 40–90); the majority of patients (79%) had either a one or two level bilateral decompression. The most common level decompressed was the L4/5 level (91%). The mean post-operative follow-up was 22 months. Summary of background data: spondylosis, commonly involving a degenerative listhesis, is the most common cause of stenosis in the lumbar spine. The symptoms arise from root compromise of the stenotic level and surgery offers the only permanent cure. To date, the standard procedure remains a laminectomy with fixation and fusion in the presence of possible instability. A laminectomy, however, destabilises the spine and the instrumented fusion makes it a much bigger operation in patients often not best placed to cope with it. There has been, therefore, a need for an effective operation that does not compromise spinal stability. Conclusion: At six weeks post-operation, 141 patients (85%) reported relief of leg pain and this rose to 90% at six months. One hundred and fifty-three patients (96%) reported an increase in their walking distance. Of those patients who also presented with back pain pre-operatively, 79% reported an improvement. There were no significant post-operative complications. The results were sustained at follow-up. The operation of limited segmental decompression for degenerative lumbar spinal stenosis has been found to be effective, safe, and providing good long-term results, without compromising the existing spinal stability. Appropriate patient selection and attention to operative technique are of paramount importance

Aims

The aim of this study was to investigate the incidence and characteristics of instrumentation failure (IF) after total en bloc spondylectomy (TES), and to analyze risk factors for IF.

Introduction The precise contribution of the posterior longitudinal ligament (PLL) and disc annulus in the burst fracture setting and their potential relative roles during intra operative reduction manoeuvres remains unclear. The anatomical attachments of the posterosuperior fragment most often associated with canal occlusion and potential neurological compromise are not well described in a reproducible model. Methods Burst fractures were induced using a pendulum impact tester. The jig allowed for accurate positioning in all planes and for precise delivery of both the magnitude and vector of the impact force. This allowed for creation of fracture all three major groups of the AO classification. The A3 (burst fracture) was produced in 10 cadaveric sheep spines by delivering a neutral force vector on a physiologically flexed spine. The morphology of the fracture was confirmed by CT. Subsequent laminectomy was performed and the anatomical attachments of the large fragments were identified. Results The PLL was identified following laminectomy in each case. In six of the ten spines there had been significant disruption of the longitudinal structure of the PLL .In a further two cases there had been stripping of the PLL from the posterior aspect of the vertebral body in association with the retropulsed canal fragment. Subsequent excision of the PLL from the posterior aspects of vertebral body and discs did not compromise the attachment of the retropulsed fragment to the disc annulus in any case. Discussion This study confirms the anatomical relationship between disc fragment and disc annulus in the burst fracture setting. The strong attachment between fragment and disc facilitate rotation of the fragment about this hinge and into the canal. Subsequent intraoperative reduction of this fragment by restoration of disc height may require contribution both from this annular attachment and from tension set up in an intact PLL. The relative contributions of each of these structures in the reduction manoeuvre remains unclear

Between 1944 to 2003, eighty nine cases were registered with a diagnosis of Paget’s sarcoma in the Scottish Bone and Soft Tissue Tumour Registry. We found thirteen cases of sarcomatous degeneration of the spine (0.26% of the total bone tumour registry case) which were analysed in this study elaborating clinical, radiological and histopathological features. The mean age was 66.9 years (range 56 to 79 years). There were ten males and three females. There were seven cases involving sacral spine (63.6%), three cases involving lumbar vertebrae and two affecting dorsal spine. One case had diffuse dorso-lumbar involvement from D11 to L3 vertebrae. The mode of presentation was increasing low back pain (in all 13), unilateral sciatica (6, left sided-5, right sided-1), bilateral sciatica (2), lower limb weakness (8) and autonomic dysfunction (4, presented as chronic cauda equina syndrome). The majority of the cases (69.23%) were osteosarcomas. Out of these osteosarcomas, two showed giant cell rich matrix and one revealed predominant telengiectatic areas. Rest of the histological types was shared by chondrosarcoma, fibrosarcoma and malignant fibrous histiocytoma. Decompression laminectomy was performed in three cases. Eight patients had received radiotherapy. The mean survival was 3.93 months (range, 1 week to 7 months), nearly half to the whole Scottish Paget’s sarcoma series with a mean survival of 7.5 months. We found a constellation of symptomatology due to radiculo-medullary compression with a fatal evolution, predominantly lumbosacral involvement, predominantly osteosarcomatous histopathology with a poorest prognosis of all Paget’s sarcoma. Although, decompression laminectomy and adjuvant radiotherapy provided reasonable pain relief and palliation; however, there was no significant influence on the overall prognosis of the patients with Paget’s sarcoma of spine in the last six decades

Aims

Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in motor impairment affecting the upper limbs more than the lower, with occasional sensory impairment and urinary retention. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study was to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age.

Aims

Repeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort.

Background Data: Postoperative spondylothesis had been noted for many years, first reported by White in 1977. Biomechanic effect of the facetectomy was reported by Abumi in 1992. There were few reports about the results of surgical treatment for postoperative spondylolisthesis. Purpose: To assess the outcome of surgical treatment for postoperastive spondylolisthesis and examine the factors that might correlate with postoperative spondylolisthesis. Materials and Methods: This study retrospectively reviewed twenty seven patients (eleven male and sixteen female), from 1979 to 1996, who received pedicle screws instrumentation and posterolateral fusion for postoperative spondylolisthesis. Average age was 57.3 years old (from 36.6 to 79.5 years old). Average follow-up time was 40.0 months (from 24 months to 72 months). The grade of fcetectomy, percentage of vertebral slipping, and disc narrowing was checked by plain X-ray. End results were assessed using the modified Stauffer-Coventry’s evaluation criteria. Results: The mean period of postoperative instability was 49.3 months (from 6 months to 141 months) in whole group, 43.7 months (from 6 months to 129 months) in laminectomy group, 43.4 months (from 17months to 82 months) in laminectomy and disectomy groups, and 74.6 months (13 months to 141 months) in disectomy group. After an average follow-up period of 40 months, 29.6 % of patients had excellent results, 44.5% had good results, and 25.9 % had fair result. No complication was found in this study. Conclusions: Pedicle screw instrumentation with posterolateral fusion can get satisfactory result for postoperative spondylolisthesis

Background: To determine whether the operation of LSD destabilizes the lumbar spine and leads to an increase in any pre-existing scoliosis or spondylolisthesis. Lumbar spondylosis, which commonly includes a degenerative listhesis and a scoliosis, is the commonest cause for stenosis in the lumbar spine. The standard operation for spinal stenosis remains a laminectomy with fixation and fusion in the presence of possible instability. The laminectomy, however, destabilises the spine and the instrumented fusion makes it a much bigger operation in patients often not best placed to cope with it. The more limited operation of LSD, which has previously been reported to this society, avoids a simultaneous fusion or instrumentation and has been shown to give long term symptomatic relief (. 1. ) Its possible effect on the stability of the spine has not previously been reviewed. Methods: A retrospective clinical and radiological review of consecutive patients operated on for degenerative spinal canal stenosis with either a pre-existing scoliosis or degenerative listhesis or both. Sixty-one patients (44 female and 17 male) with a mean age at operation of 72.8ys (range: 54–85). Pre-operatively 35patients (57%) had a degenerative listhesis, 14 patients (23%) a lumbar scoliosis and 12 (20%) had both. The mean postoperative follow-up was three years (range from one to fourteen years). Results: None of the 47 patients with a preoperative degenerative spondylolisthesis had any change in grade of the listhesis. Also no patient developed a new spondylolisthesis. Of the 26 patients with a preoperative scoliosis, 10 progressed by a mean of 4.9° (range 2°–15°). Conclusion: The results show that the operation of LSD was not associated with the development of a spondylolisthesis or a further progression of a pre-existing listhesis, and no patient developed a scoliosis. In those who had a scoliosis pre-operatively, 38% progressed and this only to a degree which we believe falls within the natural progression to be expected in such a group of patients. We believe these results support the view that the operation of Limited Segmental Decompression for spinal stenosis does not significantly destabilize the spine, even in a group that would appear most vulnerable, and as such there is no indication in such cases to consider a simultaneous instrumentation and fusion

Objective: To evaluate the long term results of an operation developed to decompress the roots at the stenotic level, preserve the midline structures, and not use instrumentation or fusion. Design: A retrospective clinical and radiological review of consecutive patients operated on for spinal stenosis secondary to lumbar spondylosis. Subjects: One hundred and sixty patients (eighty seven female and seventy three male) with a mean age at operation of sixty eight (range 40–90). Sixty one patients (38%) had a degenerative listhesis causing stenosis. The mean post operative follow-up was twenty two months (range two months to fourteen years). Summary of background data: Lumbar spondylosis, commonly involving degenerative listhesis, is the commonest cause for spinal stenosis in the lumbar spine. Surgery offers the only permanent cure. The standard procedure remains a laminectomy with fixation and fusion in the presence of possible instability. The laminectomy destabilises the spine and the instrumented fusion makes it a much bigger operation in patients often not best placed to cope with it. There is a need, therefore, for an effective operation that does not compromise spinal stability. Results: At six weeks one hundred and forty one patient (85%) reported relief of leg pain and a further nine patients were improved at three to six months. 52% of the patients reported a concomitant improvement in back pain. The results were sustained at follow-up. The operation was not responsible for the development of a new spondylolisthesis. A minimal increase in an existing degenerative listhesis was seen in two patients only without compromise of their good results. There was no revision surgery at any of the operated levels. Conclusions: The operation of segmental spinal decompression for degenerative lumbar spinal stenosis has been found to be effective, safe, and give good long term results, without compromising the existing spinal stability. Patient selection and attention to operative technique are essential

Our knowledge regarding neurological recovery following spinal cord injury is like a tip of an iceberg. Spinal cord does not regenerate once damaged but nerve roots do so if an optimum environment is provided. Although distal neurological recovery is unlikely in ASIA Impairment Scale A (complete lesions), root recovery at the site of injury can occur. ASIA has recognized Zone of partial preservation & Zonal segmental recovery below the neurological level. Such a recovery in motor functions (Motor segmental recovery-MSR) of lumbar roots in paraplegia may make all the difference in final outcome of ambulation & functional status of the patient. 100 Thoracolumbar injuries in ASIA A underwent surgery. In 60, Posterior instrumentation alone (Gp1) and in 40 posterior instrumentation with laminectomy (Gp2) was done. Results of these were compared with randomly picked up 100 similar cases treated conservatively (Gp3). Meritsofsurgery(Gp1& Gp2)overconservative(Gp3) were many in terms of reduction & stability, pain-function scores, total hospital stay, ambulation mode and time. At 1 year follow-up, functional distal neurological recovery (FDNR) was said to be significant when ASIA A improved up to ASIA D/E and MSR was said to be significant (MSR-Sig) when key muscle had a power > III. In Gp3, FDNR was (7/100) 7% and MSR-Sig was (40/100) 40%. In Gp1 FDNR was(7/60) 11.67% and MSR-Sig (41/60) 68.33%. When laminectomy was added with instrumentation (Gp2) FDNR was (5/40) 12.5% and MSR-Sig was found in (37/40) 92% cases. This was especially beneficial in thoracolumbar injuries where MSR-Sig of the L2 & L3 roots made all the difference between an ambulatory life (with braces) and an otherwise permanent wheel chair bound life. Motor segmental recovery becomes a blessing in disguise in complete cases of spinal cord injury where distal recovery of spinal cord is unlikely to occur

A total number of 428 patients underwent surgical procedure due to different acquired spinal disorders. Conservative approaches were tried where it was indicated. When there was no improvement with conservative treatment then surgical procedures were adopted. It was a prospective study which was done in both Govt. and private hospitals irrespective of age & sex. Total period was from August 2002 to February, 2008. Age of the patients ranged between from 8–65 years. In this series male was more dominant than female. In this series main causes were traumatic, infective, degenerative & neoplastic disorders. Prolapsed Lumber Inter-vertibral Disc 202, prolapse cervical disc 15, unstable spinal injuries 86, Pott’s paraplegia 68, degenerative disc disease 18, spondilolisthesis 12 and neoplastic both primary & secondary were 9 cases. Fenestration & disectomy done in PLID and decompression and stabilization done in unstable spinal injuries. Instrumentation done as adjuvant to achieve early biological union of bone. In Pott’s disease when conservative treatment failed to improve, decompression and stabilization was done by thoracotomy specially in at thoraco-lumber tuberculosis. Clowards operation done in cervical disc prolapse & spinal canal stenosis. Laminectomy done in lumber spinal canal stenosis. In spondilolisthesis, laminectomy followed by stabilization done by bilateral pedicular screw fixation with or without inter-body bony fusion. Excellent and satisfactory results were achieved in incomplete unstable injuries. No neurological improvement detected in complete injuries. Maximum Pott’s paraplegia regained their neurological function and bowel bladder dysfunction except one who recovered her one limb function full but other limb become spastic. In PLID maximum patients improved immediately after surgery. Few patients required physiotherapy after surgery and improved later on. In Spondilolisthesis patients became symptoms free after decompression and in situ fusion by instrumentation. In complete spinal injuries no improvements were detected. Breaking of pedicular screws observed in two cases. Mal-position of screws in 5 cases observed in traumatic spinal injuries. Post operative discitis developed in 2 cases after PLID operation 2 cases required surgery second time due to recurrent PLID. Proper selection of cases is very important in spinal disorders. In incomplete spinal injuries satisfactory results can be achieved in maximum cases but in complete spinal injuries no neurological development are achieved but for early mobilization surgery is helpful. Maximum spinal disorders can be managed conservatively but surgical intervention should be done in earliest possible time when indicated

Purpose: We analysed retrospectively 32 cases of posterior cervicothoracic fixation for spinal tumours. We evaluated spinal stability, spinal alignment, and associated complications. Material and methods: Thirty-two patients underwent surgery: 27 men and five women, mean age 52 years, age range 17–72 years. We implanted 96 articular screws in C4 to C6, 54 screws in C7 and 180 pedicular screws in T1 to T8. Nineteen patients had primary lung cancer with spinal invasion, eleven had spinal metastases, one had a chondrosarcoma and one had a myeloma. For the first group of 19 patients, en bloc resection of the tumour with the vertebra was performed: four total vertebrectomies, 15 partial vertebrectomies. In a second group of 15 patients, palliative posterior fixation was performed with laminectomy decompression. Results: Follow-up ranged from three to 54 months with a mean of 15 months. Mean survival after total or partial vertebrectomy was 16 months (range 3 – 54 months). Survival after palliative decompression was eleven months with a range from five to 19 months. There were no changes in the sagittal alignment in 30 patients: two patients developed mechanical complications late after surgery requiring revision. We did not have any case of screw, plate or rod fracture. There were no neurological complications related to screw insertion either at the thoracic level (180 screws) or the cervical level (96 screws in C4C5C6 and 54 screws in C7). A control scan was available for 21 patients and revealed a malposition of the implanted screws for 2.5% of the screws with no clinical impact. Discussion: Posterior screw fixation is a good method to stabilise the cervicothoracic spine during tumour surgery. Articular cervical screws and transpedicular thoracic screws provide effective stability postoperatively. In addition, this type of instrumentation does not interfere should subsequent laminectomy or wider resection be necessary

Aims

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI).

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.

Purpose: The presence of a congenital anomaly of the lumborsacral unit must be taken into consideration during the preoperative planning for lumbosacral surgery. We present our clinical and surgical experience, analysing the pre-, per- and postoperative aspects. Material and methods: The clinical files,operative reports, and radiolographic results of 281 adult patients who had undergone lumbosacral surgery between March 1988 and January 2003 were analysed. Incomplete files were excluded. Clinical and radiological data were discordant in nine cases. These nine patients underwent extended laminectomy via a 3 cm posteromedial incision. Peroperative findings were noted with the Postacchini classification. Pain was assessed with a visual analogue scale. Results: Mean age of the nine patients (five men) was 44.2 years (range 17–69). Mean follow-up was 22.3 months (range 2–48). The symptomatic roots were: L5 (n=2), L5–S1 (n=1), S1 (n=2) and S1–S2 (n=1). Lasegue sign was positive in all patients. An anomaly was identified on the preoperative radiograms in three patients. The anomalies observed intraoperatively were type I (n=1), type II (n=1), type III (n=6), type IV (n=1). In addition to the laminectomy discectomy was performed in six patients and factetectomy in two. The neurological structures presented significant resistance to medial displacement in all cases. Pain was scored 8.6 preoperatively (range 7–10) and 1.4 in the early postoperative period (rang 0–3). Pain worsened after six months (sacralgia).There were no neurological or infectious complications. Discussion: For Kikuchi, presence of pain at two clinical levels can have four possible causes, nerve root anomalies being one of the potential causes. Aota proposed coronal MRI with fat suppression and Akbapak emphasised the need for ample exposure of the zone and pre-surgical diagnosis before percutaneous surgery to avoid catastrophic results. Conclusion: Nerve root anomalies should be suspected when the clinical presentation is in disagreement with the radiological findings. Frontal or oblique MR imaging should be obtained. Likewise, intraoperative resistance of the neurological structures is suggestive of nerve root anomalies. Unless identified before lumbosacral surgery, the presence of nerve root anomalies may lead to irreparable neurological damage, particularly for minimally invasive or percutaneous procedures

Purpose of the study: Surgery for lumbar canal stenosis is classically an intracanalar procedure with the risk of injury of the dura mater or nerve roots or of postoperative haematoma with secondary sequelae. Extracanalar surgery could be useful for the treatment of lumbar canal stenosis in older patients. Material and methods: The Farcy procedure is based on the observation that the root is compressed in the recessus by the tip of the upper facet. The foramen is too small. The tip can be cut with a chisel along a horizontal line plumb with the pedicle landmark on the upper border of the lateral mass. The tip of the facet and its osteophyte can be removed laterally to medially with a curette and separated from the capsule and the yellow ligament without exposing the root. Release of the foramen is verified with an elevator. From August 1999 to July 2000, 15 patients (ten women and five men) underwent the Farcy procedure in association with fusion-osteosynthesis. Mean age was 60.4 years (55–71). The patients had suffered a mean 8.5 years (1–30). All had lumbalgia. Radiculalgia involved one root in seven patients, two in four and three in four. The Beaujon score was 6.73 (0–14) before surgery. The procedure was performed at one level in five patients, at two in four, at three in four and at four in two. Laminectomy was associated in two patients early in our experience. Results: Postoperative Beaujon score was 15.2 (9–12) with cure of lumbalgia in eleven patients and cure of radiculalgia in ten patients. five patients had a 100% relative gain and only four had a gain of less than 50%. There were two failures explained by a history of stroke in two women (67 and 71 years). The only complications were one haematoma that was reoperated and one superficial infection. Discussion: These results are comparable with those obtained with intracanalar surgery. The procedure is equally effective and is more rapid without the risk of the classical complications. The one extradural haematoma observed was related to laminectomy which later was noted to be unnecessary. Conclusion: The Farcy procedure is a useful technique for the treatment of lumbar spine stenosis. Further experience is needed to determine whether this extracanalar technique should replace classical techniques with the risk of complications related to exposure of the canal

Objective: To assess the safety and outcome of laminectomy in patients with spinal stenosis operated at the age of 65 years or older. The relation between the duration of the symptoms and results was investigated. Study Design: A retrospective chart analysis with up to 10 years follow-up. Setting: The Spinal Care Unit, Meir Medical Center, Kfar Saba, Israel. Material and Methods: The medical records of all patients who had laminectomy for spinal stenosis at the age of 65 or more in a 10 years period were reviewed. Assessment of pain, ability to perform the basic activities of daily living, transferring dressing and basing before and after the operation was done by a telephone interview. Patient’s self-estimation of the final result of the surgery was also recorded. Results: Two hundred eight-three patients were eligible to participate in the study. They were allocated into 3 groups according to the duration of symptoms before surgery. Group A with symptoms lasting up to 24 months, B with 25–48 months and C with symptoms lasting for more than 48 months. The average age at the time of the operation was 68.9, 72.6 and 71.3 years, respectively. Forty-eight patients died and 18 refused or were not able to participate in the study. The average time of follow-up was 43.3 months, 42.2 in group A, 47.4 in B and 42.8 in C. No significant differences were noticed in the demographic, anesthetic and surgical parameters among the 3 groups. There were no mortality cases in the immediate postoperative period. The overall complication rate was 43.5%, nearly identical in all 3 groups. Two patients had cerebrovascular accident and 5 had myocardial ischemia but no one turned into infarction. Mild complications included 11 urinary retention, 24 urinary tract infections and 11 patients with superficial wound infection. Twenty-two patients were re-operated along the follow-up period. There was remarkable improvement in the perception of pain, walking distances and in the ability to perform basic activities of daily living in all 3 groups. Self-assessment of the final results disclosed 70% satisfied patients in group A, 67% in B and 67% in C. Conclusion: Surgery for spinal stenosis in elderly patients is safe and often lead to significant relief of pain and improvement in the quality of life. Delaying surgery had no deleterious effect on the operative results

Aims

The outcome following the development of neurological complications after corrective surgery for scoliosis varies from full recovery to a permanent deficit. This study aimed to assess the prognosis and recovery of major neurological deficits in these patients, and to determine the risk factors for non-recovery, at a minimum follow-up of two years.

Purpose: We report on the midterm clinical results in a retrospective series of 157 patients who have undergone PLIF with the Varilift expandable and lordotic cages, mostly stand alone. Material & methods: 157 consecutive patients, 80 men and 76 women, with a mean age of 44 (19 to 72); Single level procedure in 123 patients, 2 levels in 34 patients. Preoperative symptoms included chronic low back pain and/or sciatica for more than 6 months with failure of conservative treatment including epidural steroids. Primary surgical indications were degenerative disc disease (n = 76), spondylolisthesis (n = 33), failed back syndromes (n = 43 patients). Posterior fixation was added in 21 of the spondylolisthesis, 2 multi-level fusions and 3 other patients due to a previous wide laminectomies and a resultant instability. Surgical technique consisted of minimal bilateral laminotomy preserving the midline ligamentous structures and the conservation of most of the facets. Results: Follow ranged from 12 to 60 months. There were a 89.2% satisfactory results, 10 fair and 7 poor results, of which 2 required revision. Neither revision was due to implant failure. Fusion was deemed solid in 150 from the 157 patients, 7 showed an asymtomatic radiolucency around the cage, but without motion on bending films. 3 other patients needed a posterior fixation removal after one year. Of the 128 patients working pre-op, post-op 92 patients returned to their previous job, 18 returned to a less strenuous position and 18 patients did not return to work. No patient’s symptoms worsened. As major complications, we noted 3 cases of foot drop who had partial (1) or complete recovery (2), and one cases of unilateral thrombosis of the retinum central artery. there were no cage breakage or migration of the implants. Segmental lordosis, measured on the fused discs at the last follow up showed a mean angle of lordosis of 6.9o (4.8° on L4–L5, 8° on L5–S1). Conclusion: The VariLiftTM Cage confirms by its medium term result the stand alone feature in the appropriate indications. This PLIF technique resulted in a greater than 90% fusion rate, with a minimal of complications, good pain relief, and early recovery. No failure of the material was noted. The major advantages of this device are its intrinsic stability, the big inner volume for bone graft, the promoting of lordosis and the overall size saving that authorize a minimal invasive procedure

Objective: To report a new method for reduction and stabilisation of a high grade isthmic spondylolisthesis. Design: Case study. Subjects: A 14 year old boy presented with persistent low back pain from an L5/S1 grade 3 isthmic spondylolisthesis. MRI scan confirmed the L5/S1 spondylolisthesis with a degenerative disc at this level and healthy discs above. After discussion with the patient and his family, it was decided to attempt to reduce the spondylolisthesis. Operation: Surface SSEP and CMEP were performed throughout the procedure. The patient was positioned prone on a Montreal frame and a standard posterior, midline approach made from L4 to the sacrum with careful preservation of the L4/5 facet joints. Wide laminectomy at L5, with partial laminectomy of the superior aspect of S1 and the inferior aspect of L4 allowed visualisation of the L5, S1 and S2 nerve roots. The postero-superior aspect of S1 was removed with an osteotome from each side in preparation for the reduction of L5. An L5/S1 discectomy and end-plate preparation was performed in preparation for a PLIF. Reduction was not possible at this stage. The wound was closed and the patient re-positioned supine. A transperitoneal approach was made to L5/S1 allowing removal of the anterior disc protrusion and associated fibrosis. Following careful removal of this material, L5 could be translated posteriorly. The anterior approach was closed and the patient was repositioned prone with the posterior wound re-opened. Pedicle screws were inserted into S1 bilaterally but it was not possible to get pedicle screws into the deep seated and dysplastic L5 pedicles so screws were placed in the L4 pedicles. Contoured rods (5mm) were placed into the S1 screws. After very mild distraction, the screw in L4 on one side was reduced to the rod allowing placement of an L5 pedicle screw on the opposite side. This process was repeated to allow placement of a second L5 pedicle screw on the other side. The plan was to the remove the L4 pedicle screws to avoid fusing the L4/5 level. Unfortunately, due to the dysplastic pedicles, the L4/5 facet joints were destroyed by the pedicle screw insertion and an L4 to S1 fusion performed. Iliac crest bone graft was harvested for the posterolateral fusion and also used to fill two Rotafix cages inserted into the reduced L5/S1 disc space. A radiograph at this stage confirmed reduction of the L5/S1 spondylolisthesis. Total estimated blood loss was 4200ml and a cell saver system was used throughout the operation. The patient had no neurological deficit after surgery and made an uneventful recovery being discharged 4 days after surgery. There was a haematoma/seroma beneath a well healed wound noted at the six week clinic appointment but no other complications have been observed. He is delighted with his improved cosmetic appearance and his back pain has resolved. Conclusions: We feel this single operation, three stage procedure is a safe way of reducing a high grade spondylolisthesis

Aims

To evaluate the perioperative complications associated with total en bloc spondylectomy (TES) in patients with spinal tumours, based on the extent and level of tumour resection.

Aims

Iliosacral sarcoma resections have been shown to have high rates of local recurrence (LR) and poor overall survival. There is also no universal classification for the resection of pelvic sarcomas invading the sacrum. This study proposes a novel classification system and analyzes the survival and risk of recurrence, when using this system.

Introduction: Spinal fusions have been shown to be useful in correcting spinal deformities resulting from degenerative disc disease. We sought to produce a prospective analysis of functional outcomes following lumbar spinal fusion surgery for degenerative spondylolisthesis or degenerative scoliosis secondary to degenerative disc disease. We present the interim results from our case cohort of 74 patients. Methods: Over a period of 3 years (2005–2007), all patients who presented to this private practice with symptoms of canal stenosis or radicular pain secondary to degenerative spondylolisthesis or degenerative scoliosis were offered decompressive laminectomy and posterior lumbar interbody fusion (PLIF) surgery with interbody cages, pedicle screw instrumentation, bone morphogenic protein (BMP) and bicalcium phosphate (BCP). Patients who presented only with low back pain and did not have radicular pain or neurogenic claudication were excluded from this study. All patients who were offered spinal fusion surgery were consecutively offered the opportunity to enrol in this functional cohort analysis. Those patients who consented were prospectively entered into this functional analysis and were asked to complete Oswestry and SF-36 function questionnaires preoperatively and post-operatively. Post-operative data has been collected in some cases up to 16 months postoperatively. Patients were also assessed post-operatively by the surgeon and given an Odom clinical assessment score. Complications were also collated. Results: 102 patients were offered surgery with 18 patients not consenting to participate in this study. Of the 84 patients who consented to participate in this study, 10 patients failed to submit both pre-operative and postoperative questionnaires, leaving 74 patients who were followed for a median 7 months (range of 1.5–16 months). There were 30 males and 44 females in the study with a median age of 73 (range 46–89). Of these 74 patients, 63 had degenerative spondylolisthesis and 11 had degenerative scoliosis. 52 patients had sufficient follow-up to assess bony fusion, of which 1 patient failed to fuse. 32 of the patients who fused reported to have improved, but 16 did not and the remainder did not submit both pre-operative and post-operative questionnaires. For the SF-36 questionnaire, the median pre-operative SF-36 score was 30 (96.6% CI 26–35) and the median post-operative SF-36 score was 48 (95.3% CI 42–56). The mean difference between the preoperative and post-operative SF-36 scores was 14 (95% CI 11–18) (p< 0.0001. The median preoperative Oswestry score was 46 (96.6% CI 42–50) and the median post-operative Oswestry score was 30 (96.6% CI 24–40) and the median post-operative Oswestry score was 30 (96.6% CI 24–40). The mean difference between the preoperative and post-operative Oswestry scores was 14 (95% CI 10–19) (p= 0.0001). 45 patients (61%) reported improvements of greater than 20 between their pre-operative and post-operative scores in either their SF-36 or Oswestry questionnaires. Of these 45 patients, 40 (89%) were also given moderate or good Odom (clinical) scores. 29 patients (39%) reported that they had not experienced improvement in their symptoms based on either their SF-36 or Oswestry questionnaires, with 12 (41%) of those 29 patients scoring poorly on their Odom scores. In all, there were 18 complications ranging from wound collections (4) and breakdowns (2) to repositioning of screws (6) and nerve root injury (2), to DVT (1) and transfusion (3). Discussion: Interim results suggest that most patients undergoing PLIF and pedicle screw surgery with decompressive laminectomy for treatment of degenerative spondylolisthesis and degenerative scoliosis report significant improvements in function which correlate fairly well with clinical assessments performed by the surgeon at pre-operative and post-operative reviews. IInterestingly, patients generally reported either significant improvements (rather than borderline improvements) or that they had not improved at all, and that those who did report significant improvements also generally scored well on their Odom assessments. These reported improvements currently seem to be independent of whether bony fusion is achieved or not, as 16 of the 29 patients who did not report improvement actually achieved fusion. This is not unexpected as the initial PLIF procedure provides initial pre-fusion in situ rigid internal fixation

Aims

Psychoeducative prehabilitation to optimize surgical outcomes is relatively novel in spinal fusion surgery and, like most rehabilitation treatments, they are rarely well specified. Spinal fusion patients experience anxieties perioperatively about pain and immobility, which might prolong hospital length of stay (LOS). The aim of this prospective cohort study was to determine if a Preoperative Spinal Education (POSE) programme, specified using the Rehabilitation Treatment Specification System (RTSS) and designed to normalize expectations and reduce anxieties, was safe and reduced LOS.

Aims

This study, using a surgeon-maintained database, aimed to explore the risk factors for surgery-related complications in patients undergoing primary cervical spine surgery for degenerative diseases.

Aims

To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach.

Aims

Open discectomy (OD) is the standard operation for lumbar disc herniation (LDH). Percutaneous endoscopic lumbar discectomy (PELD), however, has shown similar outcomes to OD and there is increasing interest in this procedure. However despite improved surgical techniques and instrumentation, reoperation and infection rates continue and are reported to be between 6% and 24% and 0.7% and 16%, respectively. The objective of this study was to compare the rate of reoperation and infection within six months of patients being treated for LDH either by OD or PELD.

Purpose. To evaluate the efficacy of novel biodegradable MAACP/n-HA composite artificial lamina for the prevention of postlaminectomy adhesions and lamina reconstruction. Methods. Goats were randomly divided into three groups: an experimental group consisting of twelve goats that underwent cervical 4 laminectomies, followed by MAACP/n-HA composite artificial lamina implantations; a control group of nine goats whose cervical 4 vertebra plate were removed; and a normal group of three goats that did not receive any operations or treatments. On weeks 4, 12 and 24, two goats, two goats, three goats in the test group and two, two, two in the control group were selected using X-ray, CT, MRI and subsequently killed for histological examinations and SEM (scanning electronic microscopY). On week 24, the adhesion level of scar tissue was examined according to Rydell's degree of adhesion criteria. Biomechanical measurements were carried out at week 24 on 3 goats in the test group, 3 in the control group, and 3 in the normal group. Results. In the experimental group, the artificial lamina refrained from shifting, and no dural adhesion pressure was observed. New goat cervical natural bone formed in the defect and the bony spinal canal had reformed. In contrast, in the control group, fibrous scar tissue filled the defect and the scar tissue continued to exert pressure on the dura. Conclusions. Artificial lamina could prevent the epidural adhesions surrounding the defect and promote effectively bone tissue repair and new bone formation. MULTIPLE DISCLOSURES

Non-dysraphic intradural spinal cord lipomas are very rare lesions and the management remains controversial. We present our experience with five cases, review the literature and propose guidelines for their management. The case notes of the patients were retrospectively reviewed. An extensive literature search was done, and the relevant articles were analyzed. Between January 2004 and April 2009, we operated on five cases of non-dysraphic intradural spinal cord lipomas. The age at presentation ranged from 17 years to 52 years (mean 32.2). Minimum follow up was 6 months and maximum follow up 5 years. All patients underwent decompression with a laminectomy/ laminoplasty and debulking. The dura was primarily closed in one patient. All patients had regular clinical and radiological follow-up with serial MRI scans. Neurological improvement was noted in all patients. There was significant residual tumour on the MRI scan in all patients. Guidelines for management were formulated on the basis of our experience and literature review. The aim of surgery should be adequate decompression with preservation of neural structures. Aggressive debulking should be avoided. Onset of any neurological symptoms/signs, bowel or bladder symptoms or intractable local symptoms should be an indication for surgery

We report the technique and early results of the Dwyer-Hartshill method for segmental fixation of the spine. This uses pedicular screws wired to a rectangular frame and is indicated after laminectomy

Aims

Although lumbosacral transitional vertebrae (LSTV) are well-documented, few large-scale studies have investigated thoracolumbar transitional vertebrae (TLTV) and spinal numerical variants. This study sought to establish the prevalence of numerical variants and to evaluate their relationship with clinical problems.

Background. Surgical quality improvement has received increasing attention in recent years, yet it isn't clear where orthopaedic surgeons should focus their efforts for the greatest impact on peri-operative safety and quality. We sought to guide these efforts by prioritising orthopaedic procedures according to their relative contribution to overall morbidity, mortality, and excess length of stay. Methods. We used data from the American College of Surgeons' National Surgery Quality Improvement Program (ACS-NSQIP) to identify all patients undergoing an orthopaedic procedure between 2005 and 2007 (n=7,970). Patients were assigned to 44 unique procedure groups based on Current Procedural and Terminology codes. We first assessed the relative contribution of each procedure group to overall morbidity and mortality in the first 30 days, and followed with a description of their relative contribution to excess length of stay. Results. Ten procedures accounted for 70% of adverse events and 64% of excess hospital days. Hip fracture repair accounted for the greatest share of adverse events, followed by total knee arthroplasty, total hip arthroplasty, revision total hip arthroplasty, knee arthroscopy, laminectomy, lumbar/thoracic arthrodesis, and femur fracture repair. In contrast, no other procedure group accounted for more than 2% of morbidity and mortality. Conclusion. Only a few procedures account for the vast majority of morbidity and mortality in orthopaedic surgery. Concentrating quality improvement efforts on these procedures may be an effective way for surgeons and other stakeholders to improve peri-operative care and reduce cost in orthopaedic surgery

Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and survival rates compared to other spinal metastatic disease. Adjuvant therapy has been proven ineffective. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma. Five patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system. Recurrence of spinal metastasis and radiological failure of reconstruction. All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary. The other four are well at 24, 45, 52 and 66 months post-op without evidence of recurrence in the spine. There were no major surgical complications. Careful patient selection is required to justify this procedure. The indication is limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence