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

Purpose: The rate of dislocation after revision total hip arthroplasty (RTHA) has varied from 8 to 28% in published series. Many causes are involved, but little work has been focused on the incidence of spinal disease in patients with postoperative dislocation. Material and methods: We performed a prospective analysis of 267 patients who had undergone RTHA in search of risk factors of postoperative dislocation. Chi-square test or Student’s t test were used for the statistical analysis as appropriate. P < 0.05 was considered significant. Results: We excluded 37 patients who had undergone first line THA with a restrained cup and who had not experienced dislocation. The 230 patients retained for analysis had undergone primary surgery with no intra or postoperative anti-dislocation measure. Among these, 31 (13.4% experienced dislocation). The cause was evident in ten cases (malposition, fracture of the greater trochanter, sciatic paralysis). For the other 21 patients, age, gender, types of surgery (uni or bipolary), surgical approach, size of the implant, and size of the femoral or acetabular defects were not found to influence the rate of postoperative dislocation. Conversely, a significant relationship was found between increased rate of dislocation and history of repeated dislocations (p < 0.001), prior surgery (p< 0.05), and association with spinal disease (p< 0.02). Characteristically, there was either radicular, or spinal disease, or both. Retrospective analysis of the radiograms showed that the measures of sacral incidence and inclination of lumbar lordosis were not predictive of dislocation. Inversely, the projection of a vertical line passing through the centre of rotation of the hips on L3 was different in patients who had experienced dislocation and those who had not (p< 0.02). Discussion: This study confirms the role of a history of dislocation and prior surgery in the risk of postoperative dislocation. It also shows that associated spinal disease, which may results from radicular disease, as well as altered spinal static can have an influence. A prospective study is currently under way to distinguish these features

Study purpose: Cancer patients presenting with symptomatic spinal metastases is an increasing problem. It is widely accepted that surgery plays an important role in the management of these patients and recent studies1 conclude that surgical treatment should be more frequently offered. However, who should be offered surgery remains controversial, largely because of a lack of information about outcome. Our study is a prospective analysis of survival and functional outcome in patients with metastatic spinal disease treated primarily by surgical decompression and stabilisation when indicated. Methods: Sixty two patients with radiologically suspected metastatic spinal disease, managed by one consultant neurosurgeon, were enrolled into a prospective cohort study. Patients presented with pain and or myelopathy. Survival, continence, walking, analogue pain scores and short form 36 (SF-36) scores were analysed. Results: Median age was 62 years (22–79 years, 35 female, 27 male) with the commonest primary tumours being breast (26%), lymphoma (13%) and prostate (10%). Lung cancer was poorly represented (1 patient). Survival rates were 56% at 1 year, 49% at 2 years and 28% at 3 years. Of 16 patients not walking pre-op, 8 gained the ability to walk, while 5 out of 7 incontinent patients gained continence following surgery. Conclusion: Our data indicate that long term survival and favourable functional outcomes can be achieved following surgery in patients with metastatic spinal disease. We strongly advocate that patients presenting with metastatic spinal disease be considered for primary surgical treatment but would highlight the importance of appropriate patient selection

There is currently no consensus about the mean volume of blood lost during spinal tumour surgery and surgery for metastatic spinal disease. We conducted a systematic review of papers published in the English language between 31 January 1992 and 31 January 2012. Only papers that clearly presented blood loss data in spinal surgery for metastatic disease were included. The random effects model was used to obtain the pooled estimate of mean blood loss. We selected 18 papers, including six case series, ten retrospective reviews and two prospective studies. Altogether, there were 760 patients who had undergone spinal tumour surgery and surgery for metastatic spinal disease. The pooled estimate of peri-operative blood loss was 2180 ml (95% confidence interval 1805 to 2554) with catastrophic blood loss as high as 5000 ml, which is rare. Aside from two studies that reported large amounts of mean blood loss (> 5500 ml), the resulting funnel plot suggested an absence of publication bias. This was confirmed by Egger’s test, which did not show any small-study effects (p = 0.119). However, there was strong evidence of heterogeneity between studies (I. 2. = 90%; p < 0.001). Spinal surgery for metastatic disease is associated with significant blood loss and the possibility of catastrophic blood loss. There is a need to establish standardised methods of calculating and reporting this blood loss. Analysis should include assessment by area of the spine, primary pathology and nature of surgery so that the amount of blood loss can be predicted. Consideration should be given to autotransfusion in these patients. Cite this article: Bone Joint J 2013;95-B:683–8

The aim of this study was to prospectively assess the outcome of patients with metastatic spinal disease who underwent minimally invasive fixation of the spine for intractable pain or spinal instability. This is a prospective audit of patients with metastatic spinal cord disease who have undergone minimally invasive fixation of the spine from August 2009 until the present date. This was assessed by pre and post-operative Oswestry Disability Index (ODI), EQ5D and Tokuhashi scores. Intra- and post-operative complications, time to theatre, length of inpatient stay, analgesia requirements, mobility, chest drain requirement and post-operative HDU and ITU stays were also recorded. So far, 10 patients have met the criteria. There were no intra-operative complications. Post-operatively, there were no complications, chest drains, increase in analgesia or stay on the HDU or ITU. All patients showed an improvement in mobility. The mean post-operative day of mobilisation was 2 days, post-operative days until discharge 5.3 days and length of inpatient stay was shorter than traditional surgery. Blood loss was minimum except one patient with metastatic renal cell carcinoma who needed transfusion intraoperatively. ODI, VAS and EQ-5D scores were calculated and were significantly improved compared to preoperatively. This novel approach to management of metastatic spinal disease has resulted in improved mobility, short inpatient stays without the need for chest drains, HDU or ITU and an improved the quality of life in pallliative patients. This is a completely new strategy to treat the pain in these patients without the usual associated risks of surgery and has major advantages over traditional surgical techniques which may preclude this group of patients having any surgical stabilisation procedure at all

Introduction: Metastatic spinal disease continues to be a challenge in the management of patients with advanced malignancy. Anterior en bloc spondylectomy and stabilisation, a more extensive procedure, is favoured as it is thought to provide a curative resection and improve the overall outcome (Tomita et al,2002; Wiegel, 1999). Aim: The aim of this study was to see if there is still a role for extensive posterior decompression (Wide laminectomy and transpedicular decompression) with stabilisation in the treatment of these patients which is the mode of treatment used in our institution and favoured by some others (Bauer, 1997). Patients and Methods: We retrospectively reviewed a cohort of patients treated in our institute by extensive posterior decompression and stabilisation between 2000 to 2006. We excluded patients having haematological primaries and anterior surgery and those with inadequate data. Outcome measures used were post operative mortality, Post operative improvement in Frankel score, level of pain perception, level of mobility and ability to perform activities of daily living. Results: 52 patients had posterior surgery with Colarado instrumentation being used in a majority. There was a slight male preponderance with an average age of 67 years. The mean length of follow up was 12 months.57% patients were dead at last review. 52 % patients showed an improvement in Frankel scores. There was a significant decrease in analgesic requirement post operatively with an improvement in pain scores. Similarly there was an improvement in the ability to perform activities of daily living and the level of mobility. No major surgical complications were noted bar a few superficial wound infections. Revision surgery was done in 6 cases. In 2 it was for a tumour recurrence, for broken rods in 2 and converted to anterior in 2. There were 4 immediate peri operative deaths. Conclusion: Our results are comparable to Bauer et al, 1997 and other series. Posterior spinal surgery is very much a viable treatment option to treat selected cases with metastatic spinal disease. It avoids all the complications and morbidity of anterior surgery while producing an overall improvement in pain, the quality of life, level of mobility and neurological status

Assessment and referral of spinal disease in a primary care setting is a challenge for the general practitioner. This has led to establishment of spinal assessment clinic to insure prompt access to the patient who requires treatment by a spinal surgeon. These clinics are run by a trained physiotherapist who liaises with a member of the spinal team and decides the need for referral to the spinal clinic on the bases of the patient’s history and clinical examination. In our clinic each patient is also assessed with Oswestry disability index, Short form-36, visual analogue score and hospital anxiety score (HADS), although these scores do not contribute to the clinical decision-making. The aim of this study is to assess the screening value of Oswestry disability score, Short form-36 scores in diagnosing acute spinal pathology. Sixty-nine patients who were referred to the spine clinic from the assessment clinic between March and December 2001 were recruited. Sixty-nine age and sex-matched patients were randomly chosen from five hundred and twelve patients who were seen in the spinal assessment clinic and did not need referral to the specialised spine clinic. The Oswestry disability score, Short form-36 scores and pain visual analogue scores between the two groups were statistically compared. The correlation between the level of psychological morbidity, length of symptoms and presence of past history of symptoms against the level of disability was statistically assessed. Although there was a significant increase in the level of disability in the referred group with each score (Oswestry Disability Score P< 0.001, SF-36 physical component score P=0.014, Visual analogue pain score P< 0.001). The variation in the scores makes the scoring system unspecific for use as a screening tool. We also found strong relationship between psychological disability and length of symptoms indicating the need for prompt treatment for back pain

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.

Back pain screening clinics are established to clinically screen patients with back pain for organic lumbar pathology. The aim of this study is to assess the relationship between clinical signs of organic pathology and the level of disability as measured by functional outcome scores. Methods: Notes from 581 consecutive patients who were seen in the back screening clinic was analyzed. Sixty-nine patients who were found to have clinical signs of organic pathology and 69 age and sex-matched patients from 512 patients who were found to have no signs of organic pathology in the same time period in the back pain screening clinic were selected. The Oswestry disability, Short form-36 and visual analogue (pain) scores between the two groups were statistically analyzed.

The correlation between the level of psychological morbidity, length of symptoms and presence of past history of symptoms against the level of disability was statistically assessed. Results: Although there was a signiþcant increase in the level of disability in the referred group with each score (Oswestry Disability Score P< 0.001, SF-36 physical component score P=0.014, Visual analogue pain score P< 0.001). We also found a strong relationship between psychological disability and the duration of back symptoms. Conclusions: High level of disability is associated with organic pathology. Acute back pain should be treated promptly to reduce it impact on the psychological disability.

Introduction. Treatment of spinal metastatic disease has evolved with the advent of advanced interventional, surgical and radiation techniques. Spinal Oligometastatic disease is a low volume disease state where en bloc resection of the tumour, based on oncological principles, can achieve maximum local control (MLC). Hybrid therapy incorporating Separation surgery (>2mm clearance of the thecal sac) and Stereotactic Ablative Radiotherapy (SABR) offer an alternative approach to achieving MLC. Hybrid therapy is also a viable option in patients eligible for SBRT who have failed conventional radiation therapy. En-bloc surgery may be a suitable option for those patients who are ineligible for or have failed SBRT. A multidisciplinary approach is particularly important in the decision-making process for these patients. Metal free instrumentation is aiding the optimization of these surgeries. The authors present a supra-regional centre's experience in managing spinal oligometastases. Methods. Retrospective review of oligometastatic spinal disease at a supra-regional centre between 2017 and 2021. Demographics, operative course, complications and Instrument type are examined. Results. Demographics: 24 patients with mean age 53.8y (range 12–77), 44% (40y–59y), 40% (60y–69y); 51% Male. Histology: Breast, Renal and Sarcoma accounted for 16.7% each; Thyroid, Prostate and Chordoma accounted for 8.3% each. Primary disease 7%, Synchronous 15%, Metachronous 78%. Instrumentation: Carbon-fibre (85%), TiAl (11%), Non-Instrumented (3%). Separation Surgery (70%), En-bloc resection/Tomita surgery (30%); SABR/Proton Beam Planned: 70%. Average length of hospital stays 19.1 days; twenty patients required intensive care admission for an average 2.7 days. 30 Day Mortality 8.3% (n=2: COVID-19 during admission and ventriculitis post discharge), 1y Mortality – 16.7%, 3y Mortality – 25%; Synchronous Mortality 75% (n=3) at 3 years. 30 Day infection rate 3%; 1y infection rate 7%. 1 Non-instrumented case developed proximal junctional failure post proton beam therapy and required a vascularised fibular strut graft. 2-year Revision for Local Recurrence 5% (Revision at 23 months). Conclusion. There are very few case series of oligometastatic spinal disease due to the relatively new concept of adjuvant SABR and its limited availability. Solid tumours pre-dominated the histology in our series with metachronous disease being the most commonly operated disease state. 92% of cases were eligible for SABR. The majority (85%) of cases were performed with Carbon-fibre instrumentation and has been shown to be safe with no mechanical failures in this series. Infection rates are in keeping with patients requiring radical radiotherapy with 3% early and 7% late. 30-day mortality was 8.3%, 1y=16.7% and 25% at last follow up. Mortality, as expected, is highest within the synchronous disease group and should be operated on sparingly. With the current management strategy, there was no local recurrence at 1 year and excellent local recurrence rate at 2 years (5%). Although radical en bloc surgery carries significant morbidity, it should be considered in selective cases to achieve MLC. All Oligometastatic cases deserve extra consideration and specialist MDT as not all are suitable for SABR. Multimodal Hybrid therapy, incorporating less invasive surgical techniques and SABR, represents a paradigm shift in achieving MLC in oligometastatic spinal disease

Spinal diseases such as unstable fractures, infections, primary or secondary tumors or deformities require surgical stabilization with implants. The long-term success of this treatment is only ensured by a solid bony fusion. The size of the bony defect, the often poor bone quality and metabolic diseases increase the risk of non-union and make the case a great burden for the patient and a challenge for the surgeon. The goal of spinal fusion can only be achieved if the implants used offer sufficient mechanical stability and the local biological regeneration potential is large enough to form sufficient bone. The lecture will present challenging clinical cases. In addition, implant materials and new surgical techniques are discussed. Local therapeutic effects are achieved through the release of osteopromotive or anti-resorbtive drugs, growth factors and antibiotics. By influencing biological pathways, basic orthopedic research has strong potential to further positively change future spinal surgery

During the pandemic of COVID-19, some patients with COVID-19 may need emergency surgeries. As spine surgeons, it is our responsibility to ensure appropriate treatment to the patients with COVID-19 and spinal diseases. A protocol for spinal surgery and related management on patients with COVID-19 has been reviewed. Patient preparation for emergency surgeries, indications, and contraindications of emergency surgeries, operating room preparation, infection control precautions and personal protective equipments (PPE), anesthesia management, intraoperative procedures, postoperative management, medical waste disposal, and surveillance of healthcare workers were reviewed. It should be safe for surgeons with PPE of protection level 2 to perform spinal surgeries on patients with COVID-19. Standardized and careful surgical procedures should be necessary to reduce the exposure to COVID-19

Several different algorithms attempt to estimate life expectancy for patients with metastatic spine disease. The Skeletal Oncology Research Group (SORG) has recently developed a nomogram to estimate survival of patients with metastatic spine disease. Whilst the use of the SORG nomogram has been validated in the international context, there has been no study to date that validates the use of the SORG nomogram in New Zealand. This study aimed to validate the use of the SORG nomogram in Aotearoa New Zealand. We collected data on 100 patients who presented to Waikato Hospital with a diagnosis of spinal metastatic disease. The SORG nomogram gave survival probabilities for each patient at each time point. Receiver Operating Characteristic (ROC) Area Under Curve (AUC) analysis was performed to assess the predictive accuracy of the SORG score. A calibration curve was also performed, and Brier scores calculated. A multivariate Cox regression analysis was performed. The SORG score was correlated with 30 day (AUC = 0.72) and 90-day mortality (AUC = 0.71). The correlation between the SORG score and 90-day mortality was weaker (AUC = 0.69). Using this method, the nomogram was correct for 79 (79%) patients at 30-days, 59 patients (59%) at 90-days, and 42 patients (42%) at 365-days. Calibration curves demonstrated poor forecasting of the SORG nomogram at 30 (Brier score = 0.65) and 365 days (Brier score = 0.33). The calibration curve demonstrated borderline forecasting of the SORG nomogram at 90 days (Brier score = 0.28). Several components of the SORG nomogram were not found to be correlated with mortality. In this New Zealand cohort the SORG nomogram demonstrated only acceptable discrimination at best in predicting life 30-, 90- or 356-day mortality in patients with metastatic spinal disease

Pelvic tilt can vary over time due to aging and the possible appearance of sagittal spine disorders. Cup position in total hip arthroplasty (THA) can be influenced due to these changes. We assessed the evolution of pelvic tilt and cup position after THA and the possible appearance of complications for a minimum follow-up of ten years. 343 patients received a THA between 2006 and 2009. All were diagnosed with primary osteoarthritis and their mean age was 63.3 years (range, 56 to 80). 168 were women and 175 men. 250 had no significant lumbar pathology, 76 had significant lumbar pathology and 16 had lumbar fusion. Radiological analysis included sacro-femoral-pubic (SFP), acetabular abduction (AA) and anteversion cup (AV) angles. Measurements were done pre-operatively and at 6 weeks, and at five and ten years post-operatively. Three measurements were recorded and the mean obtained at all intervals. All radiographs were evaluated by the same author, who was not involved in the surgery. There were nine dislocations: six were solved with closed reduction, and three required cup revision. All the mean angles changed over time; the SFP angle from 59.2º to 60º (p=0.249), the AA angle from 44.5º to 46.8º (p=0.218), and the AV angle from 14.7º to 16.2º (p=0.002). The SFP angle was lower in older patients at all intervals (p<0.001). The SFP angle changed from 63.8 to 60.4º in women and from 59.4º to 59.3º in men, from 58.6º to 59.6º (p=0.012). The SFP angle changed from 62.7º to 60.9º in patients without lumbar pathology, from 58.6º to 57.4º in patients with lumbar pathology, and from 57.0º to 56.4º in patients with a lumbar fusion (p=0.919). The SFP cup angle was higher in patients without lumbar pathology than in the other groups (p<0.001), however, it changed more than in patients with lumbar pathology or fusion at ten years after THA (p=0.04). Posterior pelvic tilt changed with aging, influencing the cup position in patients after a THA. Changes due to lumbar pathology could influence the appearance of complications long-term

Aims. As the population ages and the surgical complexity of lumbar spinal surgery increases, the preoperative stratification of risk becomes increasingly important. Understanding the risks is an important factor in decision-making and optimizing the preoperative condition of the patient. Our aim was to determine whether the modified five-item frailty index (mFI-5) and nutritional parameters could be used to predict postoperative complications in patients undergoing simple or complex lumbar spinal fusion. Methods. We retrospectively reviewed 584 patients who had undergone lumbar spinal fusion for degenerative lumbar spinal disease. The 'simple' group (SG) consisted of patients who had undergone one- or two-level posterior lumbar fusion. The 'complex' group (CG) consisted of patients who had undergone fusion over three or more levels, or combined anterior and posterior surgery. On admission, the mFI-5 was calculated and nutritional parameters collected. Results. Complications occurred in 9.3% (37/396) of patients in the SG, and 10.1% (19/167) of patients in the CG. In the SG, the important predictors of complications were age (odds ratio (OR) 1.036; p = 0.002); mFI-5 (OR 1.026 to 2.411, as score increased to 1 ≥ 2 respectively. ;. p = 0.023); albumin (OR 11.348; p < 0.001); vitamin D (OR 2.185; p = 0.032); and total lymphocyte count (OR 1.433; p = 0.011) . In the CG, the predictors of complications were albumin (OR 9.532; p = 0.002) and vitamin D (OR 3.815; p = 0.022). Conclusion. The mFI-5 and nutritional status were effective predictors of postoperative complications in the SG, but only nutritional status was successful in predicting postoperative complications in the CG. The complexity of the surgery, as well as the preoperative frailty and nutritional status of patients, should be considered when determining if it is safe to proceed with lumbar spinal fusion. Cite this article: Bone Joint J 2020;102-B(12):1717–1722

Background. Carbon fibre (CF) instrumentation is known to be radiolucent and has a tensile strength similar to metal. A specific use could be primary or oligometastatic cancer where regular surveillance imaging and Stereotactic Radiotherapy are required. CT images are inherently more prone to artefacts which affect Hounsfield unit (HU) measurements. Titanium (Ti) screws scatter more artefacts. Until now it has been difficult to quantify how advantageous the radiolucency of carbon fibre pedicle screws compared to titanium or metallic screws actually is. Methodology. In this retrospective study, conducted on patients from 2018 to 2020 in SGH, we measured the HU to compare the artifact produced by CF versus Ti pedicle screws and rods implanted in age and sex matched group of patients with oligometastatic spinal disease. Results. Eleven patients were included in each group. We compared the change of HU between preoperative and postoperative cases of both CF & Ti screws, which clearly shows Ti screws scatter lot more artefacts than CF screws. We are proposing a CT artefact grading system from grade 0 to grade 4 based on the percentage change of HU for unequivocal understanding of the CT artefacts. Conclusion. This study clearly shows the artefacts produced by the metallic implants are significantly higher than the carbon fibre implants. Considering the efficacy of the RT and the increased life expectancy as a consequence, carbon instrumentation MAY BE superior to titanium or metallic instrumentation. The artefact grading system will help the clinicians in describing and planning where the artefacts need to be factorized

Introduction. Instability remains a common complication following total hip arthroplasty (THA) and continues to account for the highest percentage of revisions in numerous registries. Many risk factors have been described, yet a patient-specific risk assessment tool remains elusive. The purpose of this study was to apply a machine learning algorithm to develop a patient-specific risk score capable of dynamic adjustment based on operative decisions. Methods. 22,086 THA performed between 1998–2018 were evaluated. 632 THA sustained a postoperative dislocation (2.9%). Patients were robustly characterized based on non-modifiable factors: demographics, THA indication, spinal disease, spine surgery, neurologic disease, connective tissue disease; and modifiable operative decisions: surgical approach, femoral head size, acetabular liner (standard/elevated/constrained/dual-mobility). Models were built with a binary outcome (event/no event) at 1-year and 5-year postoperatively. Inverse Probability Censoring Weighting accounted for censoring bias. An ensemble algorithm was created that included Generalized Linear Model, Generalized Additive Model, Lasso Penalized Regression, Kernel-Based Support Vector Machines, Random Forest and Optimized Gradient Boosting Machine. Convex combination of weights minimized the negative binomial log-likelihood loss function. Ten-fold cross-validation accounted for the rarity of dislocation events. Results. The 1-year model achieved an area under the curve (AUC)=0.63, sensitivity=70%, specificity=50%, positive predictive value (PPV)=3% and negative predictive value (NPV)=99%. The 5-year model achieved an AUC=0.62, sensitivity=69%, specificity=51%, PPV=7% and NPV=97%. All cohort-level accuracy metrics performed better than chance. The two most influential predictors in the model were surgical approach and acetabular liner. Conclusions. This machine learning algorithm demonstrates high sensitivity and NPV, suggesting screening tool utility. The model is strengthened by a multivariable dataset portending differential dislocation risk. Two modifiable variables (approach and acetabular liner) were the most influential in dislocation risk. Calculator utilization in “app” form could enable individualized risk prognostication. Furthermore, algorithm development through machine learning facilitates perpetual model performance enhancement with future data input

Cervical spinal arthrodesis is the standard of care for the treatment of spinal diseases induced neck pain. However, adjacent segment disease (ASD) is the primary postoperative complication, which draws great concerns. At present, controversy still exists for the etiology of ASD. Knowledge of cervical spinal loading pattern after cervical spinal arthrodesis is proposed to be the key to answer these questions. Musculoskeletal (MSK) multi-body dynamics (MBD) models have an opportunity to obtain spinal loading that is very difficult to directly measure in vivo. In present study, a previously validated cervical spine MSK MBD model was developed for simulating cervical spine after single-level anterior arthrodesis at C5-C6 disc level. In this cervical spine model, postoperative sagittal alignment and spine rhythms of each disc level, different from normal healthy subject, were both taken into account. Moreover, the biomechanical properties of facet joints of adjacent levels after anterior arthrodesis were modified according to the experimental results. Dynamic full range of motion (ROM) flexion/extension simulation was performed, where the motion data after arthrodesis was derived from published in-vivo kinematic observations. Meanwhile, the full ROM flexion/extension of normal subject was also simulated by the generic cervical spine model for comparative purpose. The intervertebral compressive and shear forces and loading-sharing distribution (the proportions of intervertebral compressive and shear force and facet joint force) at adjacent levels (C3-C4, C4-C5 and C6-C7 disc levels) were then predicted. By comparison, arthrodesis led to a significant increase of adjacent intervertebral compressive force during the head extension movement. Postoperative intervertebral compressive forces at adjacent levels increased by approximate 20% at the later stage of the head extension movement. However, there was no obvious alteration in adjacent intervertebral compressive force, during the head flexion movement. For the intervertebral shear forces in the anterior-posterior direction, no significant differences were found between the arthrodesis subject and normal subject, during the head flexion/extension movement. Meanwhile, cervical spinal loading-sharing distribution after anterior arthrodesis was altered compared with the normal subject's distribution, during the head extension movement. In the postoperative loading-sharing distribution, the percentage of intervertebral disc forces was further increased as the motion angle increased, compared with normal subject. In conclusion, cervical spinal loading after anterior arthrodesis was significantly increased at adjacent levels, during the head extension movement. Cervical spine musculoskeletal MBD model provides an attempt to comprehend postoperative ASD after anterior arthrodesis from a biomechanical perspective

Introduction. Pelvic tilt can vary over time due to aging and the possible appearance of sagittal spine disorders. Cup position in total hip arthroplasty (THA) can be influenced due to these changes. We assessed the evolution of pelvic tilt and cup position after THA and the possible appearance of complications for a minimum follow-up of ten years. Materials and methods. 343 patients received a cementless THA between 2006 and 2009. All were diagnosed with primary osteoarthritis and their mean age was 63.3 years (range, 56 to 80). 168 were women and 175 men. 250 had no significant lumbar pathology, 76 had significant lumbar pathology and 16 had lumbar fusion. Radiological analysis included sacro-femoral-pubic (SFP), acetabular abduction (AA) and anteversion cup (AV) angles. Measurements were done pre-operatively and at 6 weeks, and at five and ten years post-operatively. Three measurements were recorded and the mean obtained at all intervals. All radiographs were evaluated by the same author, who was not involved in the surgery. Results. There were nine dislocations: six were solved with closed reduction, and three required cup revision. All the mean angles changed over time; the SFP angle from 59.2º to 60º (p=0.249), the AA angle from 44.5º to 46.8º (p=0.218), and the AV angle from 14.7º to 16.2º (p=0.002). The SFP angle was lower in older patients at all intervals (p<0.001). The SFP angle changed from 63.8 to 60.4º in women and from 59.4º to 59.3º in men, from 58.6º to 59.6º (p=0.012). The SFP angle changed from 62.7º to 60.9º in patients without lumbar pathology, from 58.6º to 57.4º in patients with lumbar pathology, and from 57.0º to 56.4º in patients with a lumbar fusion (p=0.919). The SFP cup angle was higher in patients without lumbar pathology than in the other groups (p<0.001), however, it changed more than in patients with lumbar pathology or fusion at ten years after THA (p=0.04). Conclusions. Posterior pelvic tilt changed with aging, influencing the cup position in patients after a THA. Changes due to lumbar pathology could influence the appearance of complications at mid and long-term

Aims. This study aimed to evaluate the incidence and prognosis of patients with spinal metastasis as the initial manifestation of malignancy (SM-IMM). Patients and Methods. We retrospectively reviewed the electronic medical records of 338 patients who underwent surgical treatment for metastatic spinal disease. The enrolled patients were divided into two groups. The SM-IMM group included patients with no history of malignancy whose site of primary malignancy was diagnosed after the identification of spinal metastasis. The other group included patients with a history of treatment for primary malignancy who then developed spinal metastasis (SM-DTM). The incidence of SM-IMM by site of primary malignancy was calculated. The difference between prognoses after surgical treatment for SM-IMM and SM-DTM was established. Results. The median follow-up period was 11.5 months (interquartile range (IQR) 3.2 to 13.4) after surgical treatment. During the follow-up period, 264 patients died; 74 patients survived. The SM-IMM group consisted of 94 patients (27.8%). The site of primary malignancy in the SM-IMM group was lung in 35/103 patients (34.0%), liver in 8/45 patients (17.8%), kidney in 10/33 patients (30.3%), colorectum in 3/29 patients (10.3%), breast in 3/22 patients (13.6%), prostate in 3/10 patients (30%), thyroid in 4/8 patients (50%), and ‘other’ in 28/88 patients (31.8%). On Kaplan–Meier survival analysis, the SM-IMM group showed a significantly longer survival than the SM-DTM group (p = 0.013). The mean survival time was 23.0 months (95% confidence interval (CI) 15.5 to 30.5) in the SM-IMM group and 15.5 months (95% CI 11.8 to 19.2) in the SM-DTM group. Conclusion. Of the 338 enrolled patients who underwent surgical treatment for spinal metastasis, 94 patients (27.8%) underwent surgical treatment for SM-IMM. The SM-IMM group had an acceptable prognosis with surgical treatment. Cite this article: Bone Joint J 2019;101-B:1379–1384

Introduction. Although pelvic tilt does not significantly change after primary total hip arthroplasty (THA) at a short term, can vary over time due to aging and the possible appearence of sagittal spine disorders. Cup positioning relative to the stem can be influenced due to these changes. Purpose. We assessed the evolution of pelvic tilt and cup position after THA for a minimum follow-up of five years and the possible appearence of complications. Materials and methods. 47 patients underwent same single THA between 2008 and 2012. All were diagnosed with primary osteoarthritis and their mean age was 70.2 years (range, 63 to 75). There were 28 male patients, 19 had a contralateral THA, 17 were studied for lumbar pathology and three were operated for lumbo-sacral fusion. Radiological analysis included sacro- femoral-pubic and acetabular abduction angles on the anteroposterior pelvic view; and cup anteversion angle on the lateral cross-table hip view according to Woo and Morrey. All assessments were done pre-operatively and at 6 weeks, one, two and five years post-operatively. Three measurements were recorded and mean was obtained at all intervals All radiographs were evaluated by the same author, who was not involved in surgery. Results. There were four dislocations: one early and two contralateral dislocations which were solved wiith closed reduction, and one late recurrent dislocation five years after surgery which required cup revision. No other revision surgeries were performed. Mean sacro-femoral pubic angle decreased at all intervals from 60.6º preoperatively, to 60.0º at one year and 58.8 º at five years. This decrease was more significant in female, 63.3º preoperatively to 59.3º, than in male patients, 58.7º to 58.3º at five years. Mean acetabular abduction angle increased from 47.3º at 6 weeks to 48.2º at five years. Mean cup anteversion increased from 24.3º at 6 weeks to 26.4º at one year and 34.3º at five years. Conclusions. Posterior pelvic tilt increased with aging over time, particularly in women. These changes increased cup inclination and anteversion which may result in more dislocations after primary THA

Purpose: Analysis of the sagittal balance of the spine is a fundamental step in understanding spinal disease and proposing appropriate treatment. The objectives of this prospective study were to establish the physiological values of pelvic and spinal parameters of sagittal spinal balance and to study their interrelations. Material and methods: Two hundred fifty lateral views of the spine taken in the standing position and including the head, the spine and the pelvis were studied. The following variables were noted: lumbar lordosis, thoracic kyphosis, sagittal tilt at 9, sacral slope, pelvic incidence, pelvic version, intervertebral angle, and the vertebral wedge angle from T9 to S1. These measures were taken after digitalising the x-rays. Two types of analysis were performed. A descriptive univariate analysis was used to characterise angular parameters and a multivariate analysis (correlation, principal component analysis) was used to compare interrelations between the variables and determine how economic balance is achieved. Results and discussion: Mean angular values were: maximal lumbar lordosis 61±12.7°, maximal thoracic kyphosis 41.4±9.2°, sacral slope 42±8.5°, pelvic version 13±6°, pelvic incidence 55±11.2°, sagittal tilt at T9 10.5±3.1°. There was a strong correlation between sacral slope and pelvic incidence (r=0.8), lumbar lordosis and sacral slope (r=0.86), pelvic version and pelvic incidence (r=0.66), lumbar lordosis pelvic incidence pelvic version and thoracic kyphosis (r=0.9), and finally between pelvic incidence and sagittal tilt at T9, sacral slope, pelvic version, lumbar lordosis, and thoracic kyphosis (r=0.98). Multivariate analysis demonstrated three independent parameters influencing sagittal tilt at T9, reflecting the lateral balance of the spine. The first was a linear combination of the pelvic incidence, lumbar lordosis and sacral slope. The second was pelvic version and the third thoracic kyphosis. Conclusion: This work provides an aid for analysis and comprehension of anteroposterior imbalance observed in spinal disease and also to calculate with the linear regression equations describing the corrections to be obtained with treatment

1. Details are given of sixty-three consecutive cases with a history of pleural effusion seen at an orthopaedic hospital. 2. Twenty-four of these were post-primary effusions occurring before the onset of symptoms of the orthopaedic lesion. The bone and joint lesions ultimately developing in this group of patients were widely scattered throughout the skeleton. 3. Three others were secondary to adult-type pulmonary lesions. 4. Thirty-six patients had a pleural effusion after the beginning of their orthopaedic tuberculous history. Seven were certainly secondary to operative intervention, six in the thorax near the parietal pleura (costotransversectomy or antero-lateral decompression of the cord) and one from a haematogenous dissemination after fusion of a hip joint. 5. The remainder of this group with pleural effusion during the history of their orthopaedic tuberculous disease numbered twenty-nine. Of these, twenty-five suffered from disease of the thoracic spine; in two more details are defective. Only two definitely had neither pulmonary nor thoracic spinal disease; their lesions were in the lumbar spine. The conclusion is drawn that the overwhelmingly common cause of pleural effusion in patients with orthopaedic tuberculosis who have normal lungs and have not recently suffered spinal decompression is transpleural infection from thoracic spinal disease and that the sequence is by no means rare. It had occurred in approximately one in six of 145 patients with thoracic Pott's disease seen during this investigation. 6. Details are given of a group of cases with thoracic paravertebral abscess tracking laterally. When the abscess is well clear of the spine and spinal ligaments it may project forwards and radiologically it may appear in the antero-posterior chest film as a shadow in the middle of one or other lung field rather than as a shadow obviously connected with the central paravertebral abscess. Aspiration will yield pus from this posterior extra-pleural abscess extension. 7. The belief that Pott's disease most commonly follows direct spread from caseous paraaortic glands secondary to tuberculous pleurisy is discussed. It is concluded that the evidence is insufficient for so sweeping a statement

Patients may present with concurrent symptomatic hip and spine problems, with surgical treatment indicated for both. Controversy exists over which procedure, total hip arthroplasty (THA) or lumbar spine procedure, should be performed first. Clinical scenarios were devised for 5 fictional patients with both symptomatic hip and lumbar spine disorders for which surgical treatment was indicated. An email with survey link was sent to 110 clinical members of the NA Hip Society requesting responses to: which procedure should be performed first; the rationale for the decision with comments, and the type of THA prosthesis if “THA first” was chosen. The clinical scenarios were painful hip osteoarthritis and (1) lumbar spinal stenosis with neurologic claudication; (2) lumbar degenerative spondylolisthesis with leg pain; (3) lumbar disc herniation with leg weakness; (4) lumbar scoliosis with back pain; and (5) thoracolumbar disc herniation with myelopathy. Surgeon choices were compared among scenarios using chi-square analysis and comments analyzed using text mining. Complete responses were received from 51 members (46%), with a mean of 30.8 (± 10.4) years of practice experience. The percentages of surgeons recommending “THA first” were 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (χ. 2. =44.5, p<0.001). Surgeons were significantly more likely to choose “THA first” despite radicular leg pain (scenario 2), and less likely to choose “THA first” with the presence of myelopathy (scenario 5). The choice of “THA first” in scenarios 1, 3, and 4 were more equivocal, dependent on surgeon impression of clinical severity. For type of THA prosthesis, dual mobility component was chosen by: 12% in scenario 1; 16% in scenario 2; 8% in scenario 3; 24% in scenario 4; and 10% in scenario 5. Surgeons were more likely to choose dual mobility in scenario 4, but with the numbers available this was not statistically significant (χ. 2. =6.6, p=0.16). The analysis of comments suggested the importance of injection of the joint for decision making, the merit of predictable outcome with THA first, the concern of THA position with spinal deformity, and the urgency of myelopathy. With the presence of concurrent hip and spine problems, the question of “THA or lumbar surgery first” remains controversial even for a group of experienced hip surgeons. Outcome studies of these patients are necessary for appropriate decision making

Purpose. Patients may present with concurrent symptomatic hip and spine problems, with surgical treatment indicated for both. Controversy exists over which procedure, total hip arthroplasty (THA) or lumbar spine procedure, should be performed first, and does the surgeon's area of expertise influence the choice. Materials & Methods. Clinical scenarios were devised for 5 fictional patients with both symptomatic hip and lumbar spine disorders for which surgical treatment was indicated. An email with survey link was sent to 110 clinical members of the Hip Society and 101 experienced spine surgeons in the USA requesting responses to: which procedure should be performed first, and the rationale for the decision with comments. The clinical scenarios were painful hip osteoarthritis and (1) lumbar spinal stenosis with neurologic claudication; (2) lumbar degenerative spondylolisthesis with leg pain; (3) lumbar disc herniation with leg weakness; (4) lumbar scoliosis with back pain; and (5) thoracolumbar disc herniation with myelopathy. Surgeon choices were compared among scenarios and between surgical specialties using chi-square analysis and comments analyzed using text mining. Results. Complete responses were received from 51 hip surgeons (46%), with a mean of 30.8 (+ 10.4) years of practice experience, and 37 spine surgeons (37%), with a mean of 23.4 (+ 6.5) years of experience. The percentages of hip surgeons recommending “THA first” differ significantly among scenarios: 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (χ. 2. =44.5, p<0.001). The percentages of spine surgeons recommending “THA first” were 49% for scenario 1; 70% for scenario 2; 19% for scenario 3; 78% for scenario 4; and 0% for scenario 5. There were significant differences between the surgeon groups only for scenarios 3 and 4 (Fishers exact test, p=0.003 and p=0.006 respectively). Hip surgeons were significantly more likely to choose “THA first” despite radicular leg pain (scenario 2), and less likely to choose “THA first” with the presence of myelopathy (scenario 5). The choice of “THA first” in scenarios 1, 3, and 4 were more equivocal, dependent on surgeon impression of clinical severity. Spine surgeons were more likely to recommend THA first with back pain caused by spinal deformity, and spine surgery first with lumbar disc herniation with leg weakness. Surgeon comments suggested the utility of injection of the joint for decision making, the merit of predictable outcome with THA first, leg weakness as an indication for spine surgery, the concern of THA position with spinal deformity, and the urgency of myelopathy. Conclusion. With the presence of concurrent hip and spine problems, the question of “THA or lumbar surgery first” remains controversial in certain clinical scenarios, even for experienced hip and spine surgeons. Additional outcome studies of these patients are necessary for appropriate decision making

Introduction: Patients with malignant spinal disease who have neurologic symptoms are often considered poor surgical candidates. The aim of this paper is to review the effect on neurologic symptoms of surgical management of malignant spinal disease. Methods: A retrospective review of patients treated from January 1993 to June 2003 was undertaken. Pain status was assessed using patient statements and recorded analgesic requirements. Neurologic symptoms were assessed using Frankel’s grading. Results: There were 95 patients (32 females aged 26–83; 63 males aged 15–89). No patients were asymptomatic. 61 of 109 presentations were with multiple symptoms. The most common symptom was pain (99) – either localised (8), non-specific back (56) and/or radicular (57). The next most frequent symptom was weakness (54). The time course of onset varied from acute ward deterioration, with urgent surgery, to slow progression over weeks, prior to elective surgery. 8 cases had sphincteric dysfunction. There were 98 tumours treated. In females, the most common tumours were breast (8) and renal (4) and in males, prostate (13), multiple myeloma (12) and lung (10). The thoracic spine was involved in 62, the lumbar in 18, cervical in 16 and sacral in 2. The vertebral body was involved in 76. There were 109 operations. An instrumented fusion was performed in 82. Surgical approach was anterior in 17 (9 cervical, 8 thoracic) and posterior in 80 (5 cervical, 56 thoracic and 17 lumbar). Six patients had combined approaches (2 cervical, 3 thoracic and 1 lumbar). Two patients were treated for metachronous tumours. One patient had non-contiguous metastases treated separately. One patient was treated for local recurrence. One patient had revision for implant failure (anterior thoracic). One patient was explored after deterioration due to loss of autoregulation. Thoraco-abdominal approaches (12) were associated with ileus (2) and pneumonia (3). Of four cases with deep wound infections, three had received prior local irradiation. Two patients died of pulmonary embolus. 83 patients survived beyond three months. All patients demonstrated improvement in pain status. Thirteen of 29 non-ambulatory cases were able to mobilise postoperatively. There were 32 whose Frankel grades improved. Seventeen of these returned to normal (15 from Grade 4 and 2 from Grade 3). One patient with complete motor and sensory loss improved to useful but subnormal status, three others improved to residual motor function. 11 other patients improved one grade. Of those whose scores did not change (76), 53 remained normal, eight maintained useful but subnormal status, five were stabilised with residual motor function, three kept some sensory perception and two had complete motor and sensory loss. One patient deteriorated from residual motor function to complete motor loss. The outcome for sphincter dysfunction (8) was not clear from the notes. In no case was a specific change in function documented. Discussion: Surgical treatment of malignant spinal tumours is worthwhile. Posterior approaches are versatile and should be considered. Surgery is effective in the management of pain and preserves or may significantly improve neurologic function

Introduction. Facet joint osteoarthritis (FJOA) is a prominent clinical hallmark of degenerative spine disorders. During disease progression, cartilage and subchondral bone tissues undergo increased turnover and remodeling. The structural changes to the subchondral tissue of FJOA have not been studied thus far. In this study, we performed a micro computed tomography (µCT) study of the subchondral cortical plate (SCP) and trabecular bone (STB) in FJOA and determined osteoarthritis-specific alterations. Methods. Twenty-four patients (11 male, 13 female, median age 65) scheduled for decompression and stabilization surgery for degenerative spinal stenosis were included in this study. FJOA specimens were harvested during surgery and analyzed by µCT. Bone volume fraction (BV/TV), trabecular thickness (Tb.Th), trabecular separation (Tb.Sp) and trabecular number (Tb.N) were evaluated using CT Analyser. Lumbar facet joints without chondropathy from cadaveric specimens (9 male, 6 female, median age 57) served as healthy controls. Age-, gender- and disease-specific effects were identified by ANOVA (p<0.05) and significant differences confirmed by Bonferroni's post-test. Association between age and structural parameters was determined using correlation analysis. Results. Cortical and trabecular bone structural parameters of FJOA were similar between males and females. Compared to healthy controls, FJOA specimens demonstrated significantly greater trabecular Tb.N (1.97±0.11 vs 1.24±0.04 mm-1) and decrease of Tb.Sp (0.44±0.03 vs 0.69±0.03 mm). Conversely, subchondral cortical plate thickness (0.62±0.08 vs 1.60±0.08 mm) and porosity (22.9±1.9 vs 31.5±2.1%) were significantly less compared to healthy specimens. Tb.Th was equal between patients and controls. Age was positively correlated with Tb.N (r=0.48, p=0.02) and negatively correlated with Tb.Sp (r=−0.44, p=0.03) and cortical plate thickness (r=−0.52, p=0.04) in FJOA. Cortical and trabecular bone parameters did not associate in healthy and osteoarthritic facet joints. Conclusion. FJOA bone remodeling is characterized by thinning of the SCP and an increase in the number of subchondral trabeculae. Remodeling of cortical and trabecular bone might occur in an uncoupled fashion. Targeting elevated subchondral bone remodeling might slow progression of lumbar FJOA

Aims

The aim of this study was to evaluate the incidence of liner malseating in two commonly used dual-mobility (DM) designs. Secondary aims included determining the risk of dislocation, survival, and clinical outcomes.

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The presence of facet tropism has been correlated with an elevated susceptibility to lumbar disc pathology. Our objective was to evaluate the impact of facet tropism on chronic lumbosacral discogenic pain through the analysis of clinical data and finite element modelling (FEM).

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Patients with differentiated thyroid carcinomas (DTCs) have a favourable long-term survival. Spinal metastases (SMs) cause a decline in performance status (PS), directly affecting mortality and indirectly preventing the use of systemic therapies. Metastasectomy is indicated, if feasible, as it yields the best local tumour control. Our study aimed to examine the long-term clinical outcomes of metastasectomy for SMs of thyroid carcinomas.

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Spinopelvic pathology increases the risk for instability following total hip arthroplasty (THA), yet few studies have evaluated how pathology varies with age or sex. The aims of this study were: 1) to report differences in spinopelvic parameters with advancing age and between the sexes; and 2) to determine variation in the prevalence of THA instability risk factors with advancing age.

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.

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This study aimed, through bioinformatics analysis and in vitro experiment validation, to identify the key extracellular proteins of intervertebral disc degeneration (IDD).

Introduction. Idiopathic scoliosis is a spine disorder of unknown origin with a prevalence of 1·5-3% in the general population. Apart from the large multifactorial form sample of idiopathic scoliosis, there is a good evidence for the existence of a monogenic subgroup in which the disease is inherited in a dominant manner. However, results from published work suggest a strong heterogeneity in locations of the mutated genes. Methods. With a high resolution genome-wide scan, we undertook linkage analyses in three large multigenerational families with idiopathic scoliosis compatible with dominant inheritance, including 11–12 affected members or obligate carriers. Results. In two of these families, our results suggested intrafamilial genetic heterogeneity, whereas in the other we recorded a perfect marker disease co-segregation in two distinct chromosomal regions. We can state that one of these two locations is a novel idiopathic scoliosis disease gene locus, since the probability of having by chance this perfect co-segregation twice in the genome is very low (p=0·001). Lastly, in all three families studied, we excluded compatibility with linkage to the previously mapped dominant idiopathic scoliosis loci on chromosomes 19p13.3, 17p11.2, 9q34, 17q25, and 18q. Conclusions. Our findings confirm that there is a high genetic heterogeneity within the subgroup of dominant forms of idiopathic scoliosis

The revised Tokuhashi score has been widely used to evaluate indications for surgery and predict survival in patients with metastatic spinal disease. Our objective was to determine whether the score accurately predicted survival in those with MSCC. Retrospective analysis. All patients with MSCC presenting to our unit were included in this study from October 2003 to December 2009. Patients were divided into three groups – Tokuhashi score 0 – 8, 9 – 11 and 12 -15. Neurological outcome and survival. A total of 109 patients with MSCC were managed in our unit during this time. Mean age of patients was 61 years (range 7 - 86). Mean and median survival was 350 (5-2256) and 93 days in the 0-8 group, 439 (8-1902) and 229 days in the 9-11 group, and 922 (6-222) and 875 days in the 12-15 group; p = 0.01. All patients underwent decompression and stabilisation surgery. The rate of consistency between the prognostic score and actual survival was 64% (0-8), 64% (9-11) and 69% (12-15). Overall the consistency was 66%. There was no difference in neurological outcome between the 3 groups. There was a significant difference in the mean survival between groups. There was a moderate consistency between predicted and actual survival in this group of patients who all had cord compression. All patients had undergone some form of decompression and stabilisation surgery regardless of the overall revised Tokuhashi score

Aims

Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in recent years due to proposed benefits, including a lower risk of dislocation and improved early functional recovery. This study investigates the dislocation rate in a non-selective, consecutive cohort undergoing THA via the DAA without any exclusion or bias in patient selection based on habitus, deformity, age, sex, or fixation method.

To review indications, complications and outcome for revision surgery in metastatic spinal disease. Retrospective review of casenotes and radiographs. 13 patients (9 male, 4 female) identified from a cohort of 222 patients who underwent surgery for spinal tumours between 1994- 2001. Indication for revision, complications, survival. Further recurrence (same or different level). Further surgery, neurological grade and pain score. Of 13 patients (4 Renal, 6 breast, 2 prostate, 1 myeloma) one is alive 101 months following revision. Two have been lost to follow up, 10 have died (mean survival 25.3 months post op). The mean time between primary and revision surgery was 10 months (range 1- 32 months). 4 disease progression (same level), 4 new level disease, 3 loss of fixation, 1 radiological collapse, 1 progressive kyphus. Approaches used: 4 anterior, 8 posterior, 1 posterior + anterior. The mean number of levels which required instrumentation on revision was 5. Modal pain score pre op 5, modal post op 3, minimum one point improvement. Preop modal Frankel grade E, postoperatively all preserved or improved one grade. Modal Karnofsky score preop 70 (30- 90), postop 80 (40-90)- all but one at least 10 point increase. Complications: 1Dural tear, 1 bacteraemia, 1 chylothorax, 1 loss of fixation. 3 patients required further surgery (range 4 months- 18 months, mean 11 months). Patients with metastatic disease may benefit from second procedures for recurrent disease whether locally or distant with excellent survival, low complications and good function

Percutaneous vertebroplasty is an effective procedure for the treatment of osteoporotic vertebral compression fractures, spinal metastasis and other pathologic spinal diseases. However, there has been no mention in the relevant literature of the use of percutaneous vertebroplasty for the treatment of spinal pseudarthrosis in ankylosing sponyloarthritis. A 58-year-old male with a long standing ankylosing spondylitis presented with increasing, intolerable and non-intractable back pain. There was a 16- month-old history of a non-significant minor fall. Various radiological imaging technicques showed spinal pseudarthrosis with extensive discovertebral destruction and fracture of the posterior elements at the level T11–T12. Under local anaesthesia, and through a transpedicular approach with the guidance of CT, the cannula of a large bore needle was introduced into the level of spinal pseudarthrosis. Bone cement was then instilled into the affected spinal level. Results were documented by spiral CT and with sagittal reconstructions. Extraosseous cement leakage was seen at the puncture site of the vertebra and in the epidural veins and the paravertebral vessels. However, the patient did not present any immediate or late neurological and systemic complications. Percutaneous vertebroplasty of spinal pseudarthrosis in patients with ankylosing spondylitis is an effective procedure for stabilization of the affected spine segments and pain management

Spinal fusion still is considered to be the most appropriate treatment for lumbar spinal disease not responding to conservative measures. Various forms of lumbar instability require surgical stabilisation. As an alternative to fusion, mobile, dynamic stabilisation restricting segmental motion would be advantageous under certain conditions, allowing greater physiological function and reducing the inherent disadvantages of rigid instrumentation and fusion. The “Dynamic Neutralization System for thèeSpine” is a pedicle screw system for mobile stabilisation, consisting of titanium alloy screws connected by an elastic synthetic compound, controlling motion in any plane (non-fusion system). Clinical success after solid fusion is unpredictable because it does not necessarily prevent painful loading across the disc, and it may also interfere with maintenance of sagittal balance in various postures. This system reduces movement both in flexion and extension and appears to be better. These study results compare well with those obtained by conventional procedures; in addition to which, mobile stabilisation is less invasive than fusion. Long-term screw fixation is dependent on correct screw dimensions and proper screw positioning. The natural course of polysegmental disease in some cases necessitates further surgery as the disease progresses. Dynamic neutralisation proved to be a safe and effective alternative in the treatment of unstable lumbar conditions

The lumbar or sacral root compression is frequently associated with degenerative spinal diseases. It may be caused by the hypertrophic facets, hypertrophic ligamentum flavum, or protruding disc. Canal stenosis, epidural hematoma, the cyst of pseudo-joint from degenerative or lytic-type spondylolisthesis, or tumors are less common. We present one unusual case with the severe progressive symptom of bilateral S2-4 root compression. The 80-year-old active male suffered the intermittent claudication for 4 months and got the worse symptom including bilateral painful buttocks in recent one month. The bilateral radiation pain cannot be changed at any position and taking a rest. Plain x-ray showed the degenerative spondylolisthesis over L4-5 level. The magnetic resonance imaging showed the cyst-like mass indented the dura posteriorly. During the operation, one huge psudo-joint capsule created from the interspinous ligament compressed the dorsal side of the cauda equina. We performed the posterior decompression and removal of the pseudo-joint capsule and ligamentum flavum with posterolateral fusion. The patient was completely resolved from all the symptoms after surgery. Therefore we present the unusual case and discuss the differentiation from synovial or ganglion cysts of the spine

Summary. Metastatic spinal disease is a common entity of much debate in terms of ideal surgical treatment. The introduction of MIS can be a game-changer in the treatment of MSD due to less peri-operative morbidity and allowing earlier radiotherapy and/or chemotherapy. Introduction. Less invasive techniques have always been welcome for management of patients with ‘Metastatic Spinal Disorders’. This is because these patients can be poor candidates for extensive / major invasive surgery even though radiologically, there may be an indication for one. The aim of the treatment with Minimal Invasive Fixation (MIS) systems is mainly for ‘pain relief’ than to radically decrease tumour burden or to achieve near total spinal cord decompression, which could be major presentations in these patients. These procedures address the ‘spinal instability’ very well and they can address pain associated with compression fractures resulting from metastatic disease from a solid organ as well as multiple myeloma with minimal complications. These procedures can be combined with radiology and chemotherapy without much concern for wound problems in the way of infection or dehiscence. They also have a great advantage of timing of adjunct therapy closer to the index procedure. The disadvantage, however, are they do not allow thorough decompression of the spinal cord. There could also be problem in addressing patients who have severe vertebral height loss or loss of integrity of the anterior column where anterior column reconstruction may be required. There is a risk of inadequate fixation or implant loosening or failure. We aim to examine the results of MIS surgery in our department and support the rationale for its use. Patients and Methods. We prospectively collected data of patients who underwent MIS posterior instrumentation for MSD. Between June 2011 and December 2012, 10 patients presented with acute motor deficit, instability and/or threatening radiological features. Effectiveness of MIS was assessed in terms of operative parameters and clinical outcomes. Results. No patient suffered intra-operative complications. The median surgical time was 198 minutes (range: 149 – 403), median blood loss was 100 ml (range: 60 – 400). All patients maintained full neurological function and reported effective pain reduction. All patients were discharged with a median hospital stay was 13 days (range: 4 – 45) post-surgery. 9 patients started oncological treatment as planned. The median time in 7 patients who had radiotherapy post-surgery was 23 days (range: 20 – 40). Chemotherapy was initiated in 4 patients at a median of 9 days post-surgery (range: 6 – 23). No patient as yet has required open procedure due to progression of the disease. Discussion/Conclusion. We have shown that satisfactory outcomes are achievable with MIS in a selected group of patients with MSD. While our results are limited by small study size, we have been able to improve patient quality of living through minimally invasive intervention. By reducing surgical morbidity and enabling early implementation of oncological treatment, MIS has the potential to re-evaluate multi-disciplinary decision making for early surgery in MSD

Aims: The validation of two previously published prognostic scoring systems in relation to survival following surgery for metastatic disease of the spine. Methods: 169 patients operated upon for metastatic disease of the spine were retrospectively reviewed and prognostic scores calculated according to the systems of Tokuhashi and Tomita. Surgical approach and strategy, complications and reoperations were also recorded. Patient survival was compared by prognostic group and surgical strategy within and between the two systems. Results: 126 patients were conþrmed dead at a mean of 8.3 months and 43 alive at a mean 31.2 months. Patients with Tokuhashi scores of 9–12 had 50% survivial of 23 months compared to 5 months and 2 months for scores of 5–8 and 1–4 respectively (p< 0.05). Tomita scoring showed a similar trend with 50% survivals of 15 and 5 months for predicted long and medium term groups (p< 0.05). Each prognostic parameter was signiþcantly related to survival for both systems. There was no difference in survival within the better prognostic groups in relation to surgical stratergy. Tomitañs system was less sensitive to early mortality. Conclusions: Both systems are potentially useful in deciding the suitability for surgery in patients with metastatic spinal disease. There use in the emergency, unstaged patient has not been validated here. They may help in comparing patient status in future studies allowing more meaningful analysis of data

BACKGROUND. Many patients who underwent a THA, report a feeling of more “physiological” hip and of faster recovery when bigger heads are used. The aim of this study is to evaluate the walking recovery of patients after THA with different head diameters by the means of gait analysis. MATERIALS AND METHODS. A prospective, randomized, blind study was conducted on 60 patients operated by THA at our Institution. Inclusion criteria were: primary hip arthritis, women, age between 55 and 70 years. Exclusion criteria were: other problems influencing walking ability (previous operations of the lower limbs, spine disorders, knee or controlateral hip arthritis). The same uncemented stem, same uncemented press-fit cup, same surgical technique and approach (posterolateral), same surgeons, same postoperative protocol and rehabilitation were employed. The only difference was the head diameter. The patients were randomized into three groups, of twenty patients each one (28mm Cer-on-XPE, 36mm Cer-on-XPE, >42mm Met-on-Met). The gait evaluation have been performed at three temporal steps: preoperatively, two months postoperatively and four months postoperatively. Kinematic parameters were acquired with Elite opto-electronic system (BTS, Milan, Italy) equipped with 6 cameras at 100 Hz frame rate. The system is integrated with a force platform (Kistler, CH) and a synchronic video system using two cameras (BTS, Milan, Italy). Data acquisition and processing were carried out using passive markers positioned according to Davis protocol. At least ten trials for each session were collected in order to assess the repeatability of the results. Gait analysis included kinematic parameters (temporal-spatial parameters and joint angular values) and kinetic parameters (ground interaction forces during walking). Articular moments and powers were computed on the basis of data obtained from dynamometric platform along with those given by kinematic analysis. All patients were compared to a control group. Wilcoxon signed rank test was employed for statistical evaluation. RESULTS. At a preliminary evaluation (still in progress) and statistical analysis, temporal-spatial parameters show no significant differences among the three groups. All the variables of step length, stride length, cadence and velocity show statistical significant improvements towards the standard values, in the four months follow-up in all the groups, and the improvement does not depend on the side operated. CONCLUSIONS. The preliminary evaluation of this study shows that there is no statistical significant difference in standard gait analysis parameters in patients with different head diameters (28mm, 36mm, >42mm) after THA

Summary. Our meta-analysis showed that pooled mean blood loss during spinal tumour surgeries was 2180 ml. Standardised methods of calculating and reporting intra-operative blood loss are needed as it would be beneficial in the pre-operative planning of blood replenishment during surgery. Introduction. The vertebral column is the commonest site of bony metastasis, accounting for 18,000 new cases in North America yearly. Patients with spinal metastasis are often elderly, have compromised cardiovascular status, poor physiological reserve and altered immune status, all of which render them more susceptible to the complications of intra-operative blood loss and associated transfusion. Currently no consensus exists regarding the expected volume of blood lost during metastatic spine tumour surgery with various papers quoting anywhere between 1L to 6L. Knowledge of the expected blood loss prior to surgery however is important as it facilitates pre-operative planning, intra- and post-operative management of fluid balance and blood transfusion. We conducted a meta-analysis of published literature on spine tumour surgery to answer the question: “What is the expected blood loss in major spinal tumour surgery for metastatic spinal disease?”. Methods. A comprehensive online search of the English literature using Medline, Embase, and the Cochrane Central Register of Controlled Trials was performed. We included articles published from 31 January 1992 until 31 January 2012. This initial online search yielded 98 relevant articles. Two senior investigators independently reviewed all abstracts. The full text of articles that were deemed eligible for further consideration obtained and reviewed. Eighty five articles were excluded at this stage, largely due to lack of clear blood loss data, leaving 13 eligible articles. A hand search of the reference lists of relevant articles yielded 5 more articles. A total of 18 articles were included in the final meta-analysis of blood loss data. Disagreements regarding eligibility of articles for analysis were resolved by consensus. Selected articles for final analysis were independently graded according to the Centre for Evidence-Based Medicine (CEBM) Levels of Evidence. We evaluated the possibility of publication bias by obtaining a funnel plot (created by plotting the sample size against the effect estimate). The Egger's regression asymmetry test was used to assess the existence of publication bias. Results. Eighteen selected articles had a total of 785 patients who had undergone major spine tumour surgery for metastatic spinal disorders. The pooled estimate of the blood loss occurring during spinal tumour surgeries was calculated to be 2180ml (95%CI: 1805–2554ml). Apart from two studies which reported significant mean blood loss of more than 5500 ml, the resulting funnel plot suggested absence of publication bias. This was confirmed by Egger's test which did not show any small-study effects (p=0.119). However, there was strong evidence of heterogeneity between studies with I2=90% (p<0.001). Conclusions. The expected blood loss of a patient undergoing major surgery for spinal tumour constitutes more than a third of the circulating blood volume in a typical cancer patient with significantly impaired physiological reserve. Moreover, cases of catastrophic blood loss exceeding 5L exist in almost every series evaluated in this paper, with some reaching as much as 17–18L. Blood loss is a significant problem during spine tumour surgery and concerted effort is needed to address it

Aims: Acquired defects of the back primarily are the result of radiation injury, trauma, tumour ablation, or wound dehiscence and infection. The incidence of these defects is growing, since the demand of spinal operations for degenerative spinal diseases and tumour resections is increasing. The reconstructive techniques for posterior trunk defects have improved, because of the use of muscle ßaps. When there are extensive wounds, free ßap reconstruction may be the only option to assure durable coverage. We wanted to evaluate the outcome of these patients. Methods: We review our series of these reconstructions. Results: 16 patients with difþcult wounds of the posterior trunk were treated with various ßaps. The causes of posterior trunk defects were a post operative wound dehiscence or infection (13), tumour (2), meningomyelocele (1). Mean follow-up period was 63 months. The wound location was cervical area (4), upper and midthoracic area (3), lower thoracic and thoracolumbar area (5), lumbosacral area (2), and sacral area (2). The defects were closed by fasciocutaneous ßaps (3), musculocutaneous trapezius ßaps (4), trapezius muscle ßap (1), latissimus dorsi muscle ßap (1), paraspinous muscle ßaps (3), and gluteus muscle ßap (1). In addition, three patients underwent microvascular transfer of the latissimus dorsi muscle. The exposed orthopedic hardware could be left in place in þve out of seven cases. The muscle ßaps did not cause any major functional deþcit in the donor sites. Conclusions: A high rate of success is obtained in the management of posterior trunk defects with muscle ßaps. Adequate debridement of all devitalised tissues and coverage with well vascularized tissue to obliterate any residual dead space and to cover orthopedic hardware are mandatory and prerequisite

Introduction Anterior correction of cervical kyphotic deformity in traumatic and degenerative spine is a well established technique. The application of an anterior cervical plate is widely accepted, particularly in multilevel discectomies. However the placement of the cervical plate flush against the cortical margins of the spine remains challenging particularly when there is an underlying subluxation. Contouring the cervical plate with a plate bender is suggested. Others have described the use of an adjustable depth tap (. 1. ). We describe the technique of utilizing the Trimline™ Vertebral Body Distractor in correction of the sagittal plane deformity and maximizing the contact surface between plate and fusion construct. Methods The technique is described in a case each of cervical trauma and degenerative cervical spondylolisthesis. The Trimline™ distractor which utilizes cannulated legs, threaded pins and nuts is used as a direct reduction tool correcting the cervical lordosis, before discectomy. The distractor pins are placed bilaterally in the vertebral bodies at the level of the deformity, and at the level above and below. The distractors are applied bilaterally and reduction undertaken. The distraction device is locked in place whilst the discectomy is performed. Distraction device is removed once graft is in-situ and cervical plate is applied in routine manner. Results Bilateral application of pins and distraction device provides better reduction strength, and better distributes distraction forces minimizing further fracture. This optimizes correction of cervical kyphotic deformity and prevents obstruction of operative view for discectomy and fusion. Discussion Restoration of the normal cervical lordotic curve in traumatic and degenerative spinal disease remains challenging. Flush application of the anterior cervical plate to the anterior border of the spine and graft enhances spinal fusion, stability and alignment. The use of bilateral vertebral body distractor devices to reduce cervical subluxation and enhance implant-bone interface is a novel technique which is safe and not time consuming

Two hundred and eighty-three patients with tuberculosis of the thoracic and/or lumbar spine have been followed for 10 years from the start of treatment. All patients received PAS plus isoniazid daily for 18 months, either with streptomycin for the first three months (SPH) or no streptomycin (PH), by random allocation. There was also a second random allocation for all patients: in Masan to inpatient rest in bed (IP) for six months followed by outpatient treatment or to ambulatory outpatient treatment from the start (OP), and in Pusan to outpatient treatment with a plaster-of-Paris jacket (J) for nine months or to ambulatory treatment without any support (No J). A favourable status was achieved on their allocated regimen by 88% of patients at 10 years. Some of the remaining patients also attained a favourable status after additional chemotherapy and/or operation, and if these are included the proportion achieving such a status increases to 96%. There were five patients whose deaths were attributed to their spinal disease. A sinus or clinically evident abscess was present on at least one occasion in the 10-year period in 42% of the patients. Residual sinuses persisted at 10 years in two patients, at death at seven years in a third and at default in the seventh year in a fourth. Thirty-five patients had paraparesis at some time during the 10-year period, including two who died with paraplegia before five years. Complete resolution occurred in 26 patients (in six after additional chemotherapy and/or surgery). At 10 years two patients had severe paraplegia and one a moderate paraparesis.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of MRI or CT in the management of patients with LBP, for whom there is no clear clinical indication for the use of sophisticated imaging, is uncertain. The aim of The Scottish Back Trial was to determine whether early use of MRI or CT influences clinical management and outcome of patients with LBP and whether it is cost-effective. Elective patients were new referrals to orthopaedic or neurosurgeons with symptomatic lumbar spine disorders (without ‘red flags’). After obtaining informed consent, patients were randomised to ‘early imaging’ (imaging as soon as practicable) or ‘delayed, selective imaging’ (imaging only if an imperative clinical indication developed). Principal outcomes measures were the SF-36, questionnaire, the Aberdeen LBP Scale and the EQ-5D. Patients completed questionnaires at trial entry and after 8 and 24 months. From 15 hospitals, 2657 patients were assessed and 783 were recruited and randomised. Eight months and twenty-four months after trial entry, comparison of data abstracted from case notes indicated that, apart from the use of imaging, both groups had received similar clinical management. At follow-up, an improvement in health status, as measured by the SF-36 and Aberdeen LBP Scale, was reported by both groups. At 24 months, there was a statistically significant but small difference in favour of the ‘early imaging’ group (p=0. 002) as measured by the Aberdeen LBP Scale but no difference in the SF-36 except a marginal improvement in the bodily pain subscale. The use of MRI or CT imaging for this group of LBP patients did not significantly affect their management. The clinical significance of the marginal improvement in health status in the ‘early imaging’ group is uncertain. The results of the cost-effectiveness analysis may clarify whether a policy of ‘early imaging’ would be a cost effective use of resources

Spinal fusion surgery is a common procedure for the treatment of various spinal diseases. Several growth factors, including bone morphogenic protein-2 (BMP-2) and osteogenic protein-1 (OP-1) have been used in spinal fusion for the induction of bone formation. But complications have been reported due to the lack of suitable carrier. Here we hypothesis that Insoluble Bone Gelatin (ISBG) may be a good carrier for OP-1 in the induction of bone formation during spinal fusion. The aim of this study is to examine the efficacy of osteoconductive carrier, ISBG, for OP-1 in rabbit lumbar inter-transverse process fusion model. Adult New Zealand White rabbits (n=32) underwent bilateral lumbar intertransverse process fusion at L5-L6. The animals were divided into four groups based on the materials implanted:. Autograft group,. ISBG group,. OP-1 group and. ISBG+OP-1 group. Spinal fusion masses were evaluated by manual palpation, biomechanical testing, radiographic examination, micro-CT Scanning, and histological analysis six weeks after surgery. ISBG+OP-1 group demonstrated significantly higher fusion rates (7/7) than autograft (3/7), ISBG (2/8), and OP-1 groups (2/7) (P< 0.05) based on manual palpation. In biomechanical testing, given the same moment, the fusion masses of ISBG+OP-1 group had less range of motions than those of other groups (P< 0.05) in main direction motion. Radiographic examination and micro-CT demonstrated that continuous trabecular pattern within intertransverse process area in ISBG+OP-1 group than other groups, and radiographic scores and bone volume base on micro-CT were also higher than other groups. Mature new bone formation was observed covering the surface of transverse processes in all four groups in histological findings. Continuous trabeculae connected two transverse processes and endochondral bone formation was observed attached the surface of ISBG in ISBG+OP-1 group. However, in other three groups, obvious gaps were noted in fusion masses and fibrous tissue was filled in these gaps. In conclusion, OP-1 carried by ISBG results in more effective spinal fusion in posterolateral lumbar transverse fusion in rabbit model than autograft, ISBG or OP-1 alone

Introduction and Aims: Although PD has characteristic findings and stages of progression, neither the nature of operative spine problems occurring in patients with PD, nor their peri-operative complications, have been presented previously. Method: In this retrospective observational case series, we describe the nature of operative spine problems in patients with Parkinson’s disease (PD), and evaluate the incidence and types of peri-operative complications in spine surgery for patients with PD. A retrospective chart review was performed on 24 consecutive PD patients undergoing spine surgery in a six-year span at one institution. Nineteen were first surgeries, and five were first seen as failed back syndrome from surgery done elsewhere. Results: The mean patient age was 69 years. Spinal stenosis (10 patients) and cervical myelopathy (4 patients) were the predominant pre-operative diagnoses for the primary surgeries, with three patients operated upon for kyphoscoliosis (16%) and two for other conditions. Minor or transient complications were common, including delirium, arrhythmia, deep vein thrombosis, and dural tear; there were also two significant PD-specific complications, including aspiration pneumonia and global motor paresis post-operatively. Four of 19 primary cases were revised for recurrent stenosis (two patients) or pseudarthrosis (two patients). The overall number of poor patient-reported outcomes was only two of 14 primary cases (five patients had inadequate outcome measures) and zero of seven revisions (two had inadequate outcome measures), at a mean follow-up of 19 months. Conclusion: Symptoms and functional deficits of spinal disease were often masked by PD, posing diagnostic difficulty. However, outcomes and complications of spine surgery were similar to those of non-PD patients at the same institution. Spine symptoms improved concomitantly with successful surgery unless the PD progressed or significant complications ensued

Posterior lumbar fusion is a frequently performed procedure in spinal surgery. High percentages of good and excellent results are indicated by physicians. On the other hand patient-based outcomes are reported. Little is known about the correlations of these two assessment types. We aimed at their comparison. The analysis included 1013 patients with degenerative spinal disease or spondylolisthesis from an international spine registry, treated with posterior lumbar fusion. All patients were pre/postop assessed by physician-based McNab criteria (‘excellent’, ‘good’, ‘fair’, ‘poor’). Of these patients, 210 (mean age 61 years; 57% females) were in addition assessed by patient-based Oswestry Disability Index (ODI). The remaining 803 patients (mean age 59 years; 56% females) were assessed by patient-based Core Outcome Measure Index (COMI), including. Visual Analogue Scale (VAS) for back and leg pain as well as verbal self-rating (‘helped a lot’, ‘helped’, ‘helped only little’, ‘didn’t help’, ‘made things worse’). McNab criteria were compared to the Minimal Clinically Important Difference (MCID) in ODI (12.8), in VAS back (1.2) and leg pain (1.6). We investigated the correlations between McNab criteria and these patient-based outcomes. In the ‘excellent’ group as rated by physicians, the proposed MCID was reached in 83% of patients for ODI, in 69% for VAS back and in 83% for VAS leg pain. All patients said the treatment had ‘helped’ or ‘helped a lot’. In the ‘good’ group 56% (ODI), 66% (back pain) and 86% (leg pain) reached the MCID. 96% of patients perceived the treatment as positive. In the ‘fair’ group 37% (ODI), 55% (back pain) and 63% (leg pain) reached the MCID. 49% had positive treatment considerations. The ‘poor’ group revealed 30% (ODI), 35% (back pain) and 44% (leg pain) of patients with reached MCID. Only 15% rated the treatment as positive. The Spearman correlation coefficients between McNab criteria on the one hand and ODI, back and leg pain as well as patients’ verbal self-rating on the other hand were 0.57, 0.37, 0.36 and 0.46 respectively. The comparison of physician and patient-based outcomes showed the highest correlations between McNab criteria and ODI, somewhat weaker correlations with patients’ self-rating and the weakest correlations with back and leg pain. Based on these findings, physicians’ evaluation of patient outcomes can be considered a valuable part of patient assessment, corresponding very well with patients’ perceptions of success or failure of spinal surgery

There are increasing opportunity of operative treatment for advanced aged patients with degenerative spinal disease aiming for better quality of life. We have studied such patients concerning operative result, complication and problem in pre- and peri- operative management, and achievement of their aims. Patients and Results: 1) 26 patients were analyzed; 16 males and 10 females, av. aged 82.3, pts of 19 lumbar canal stenosis with marked intermittent claudication and 7 disc herniation. 2) Low back pain and neurogenic disabilities are evaluated on JOA scoring criteria excepting ADL points (full score:15). Results: 1) 25 of 26 pts had following complications before operation; hypertension in 16, neurogenic bladder 7, arrhythmia 6, prostata hypertrophy 6, cardiac ischemic disease 4, DM 3, cerebral infarction 3, advanced OA of the knee joints 3. asthma 2, pulmonary emphysema 2, Parkinsonism 1, respectively. 2) All patients underwent laminectomy of av. 2.2 segments(1~4), and 3 pts had PL fusion. 3) One had postlaminectomy haematoma complicated with neurologic deterioration 3 hrs after operaion. He underwent immediate revision which resulted complete recovery of neurology. 4) One pt with pulmonary emphysema was operated successfully with lumbar anaesthesia as general anaesthesia was refused. 5) Improvement evaluated with modified JOA pain score accounted for as follows; av. preoperative score showed 7.16 improved to 10.73 (45.8%), objective symptoms 4.23–4.66, subjective symptome 3.0–6.08 (51.3%), ambulant ability improved from 0.35–2.0 (62.3%), and pain ± numbness of L/E 0.96–2.04 (52.9%) resp. 6) 2 patient

Background: context: Length of hospital stay (LOS) varies widely within patients with posterior spinal fusion. So far there is little evidence on its co-variates. Purpose: This study examined which co-variates influence LOS in posterior spinal fusion. Study design: Prospective consecutive documentation of hospital based interventions in the international spine registry Spine Tango. Patient sample: Between 05/2005 and 11/2006 data of 3437 patients were documented in the registry. 790 patients with degenerative spinal disease (614) or spondylolisthesis (176), who had been treated with posterior decompression and spinal fusion, were included in this study. Median age was 62.8 yrs (min 13.2 yrs, max 89.8 yrs) with a female to male ratio of 2:1. Median LOS was 11 days (IQR 8–14 d). Outcome measures: LOS was chosen as dependent outcome variable. Methods: Multiple linear regression was performed on following independent variables: age, gender, main pathology, number of spinal segments of posterior fusion, level of fusion, number of previous spinal surgeries, operation time, clinic (number of fusions, academic status), surgeon credentials, type of fusion (sole fusion, fusion + instrumentation, fusion + instrumentation + cage). Results: Clinic (p< 0.0001) was found to be a highly significant co-variate for LOS (min 7 d, max 14 d). Number of fusions per clinic (min 25, max 434) and academic status of clinic had no influence on LOS. Further significant covariates were surgeon credentials (surgeons in training: 8.5 d, specialised spine surgeons: 11 d, orthopaedic or neurosurgeons: 12 d; p=0.001), number of spinal segments of posterior fusion (1 segment: 10 d, 2–3 segments: 12 d, 4–5 segments: 12.5 d, > 5 segments: 15 d; p=0.002), and age group (< 50 yrs: 9 d, 50–59 yrs: 11 d, 60–69 yrs: 12 d, ≥70 yrs: 13 d; p=0.01). Borderline significance was found for gender (women: 12 d, men: 10 d; p=0.05). All other variables showed no influence on LOS. Conclusion: Co-variates of LOS of patients with posterior spinal fusion are clinic, independent of number of spinal surgeries per clinic and academic status of clinic, surgeon credentials, number of segments of fusion, age group, and gender. A short LOS in surgeries performed by surgeons in training is explained by a smaller number of segments of fusions in these procedures. A subgroup analysis on the co-variate clinic should be performed assessing further explanatory variables. However, this goes beyond the possibilities of documentation in a spine registry

This study using digitized radiographs and custom software demonstrates that patients with spondylolysis and low-grade spondylolisthesis have increased Pelvic and L5 Incidence as well as a more vertically oriented L5-S1 intervertebral disc than patients without radiographic abnormality of the spine. We propose that shear across the more vertical L5-S1 disc may underlie the etiology of spondylolysis when Pelvic Incidence is high, while a “nutcracker” mechanism may be involved when Pelvic Incidence is low. The purpose of this study was to assess whether differences exist in sagittal alignment between normal controls and patients with spondylolysis or low-grade isthmic spondylolisthesis. Standing PA and lateral spine radiographs from eighty-two consecutive patients with spondylolysis or low-grade spondylolisthesis (Average age nineteen, range 15–44) were retrospectively compared with those from one hundred and sixty normal volunteers. The films were digitized with a VIDAR scanner and key landmarks were determined. Customized software was then used to measure geometric indices. Pelvic Incidence (PI), Sacral Slope (SS), Pelvic Tilt (PT), and L5-S1extension angle were compared between seventy-two patients with high PI (> 45°) versus ten patients with low PI (< 45°). Average high-PI vs. low-PI values were, respectively: PI (67.32° vs. 43.13°), SS (51.08° vs. 38.05°), PT (16.23° vs. 5.08°), and L5-S1ext (−8.69° vs. −9.57°). Furthermore, the range of values for L5-S1extension in the low-PI subgroup was much narrower (−17.81° to 0.93°) than that for the high-PI subgroup (−31.58° to 38.12°). This study demonstrates that patients with spondylolysis and low-grade spondylolisthesis have increased Pelvic and L5 incidence, a more vertically oriented L5-S1 intervertebral disc, and less segmental extension between L5 and S1 than patients without radiographic abnormality of the spine. We propose that different mechanisms underlie the etiology of spondylolysis depending on the magnitude of the Pelvic Incidence. These data highlight the importance of seeing localized lumbosacral spine disorders in the context of global alignment of the entire spine and pelvis. Funding: This research was assisted by support from the Spinal Deformity Study Group. This research was funded by an educational/research grant from Medtronic Sofamor Danek

Purpose of the study: To study clinical, radiological and pathological features of this rare condition and to observe the effect of surgery on the relief of presenting symptoms. Materials, Methods and Results: between February 1989 to May 1999, more than 200 spinal operations were carried out at Oswestry, amongst which we found 11 patients with 13 symptomatic lumbar synovial cysts. Nine patients were female and 2 were male. Among the symptoms produced, sciatica was present in 10 out of 11 patients, neurologic claudication was present in 6 patients and only one patient had neurologic deficit. All the patients suffered with back pain, which was either of facetal origin or mechanical back pain. Radiological investigations revealed that all patients had evidence of facet arthrosis. Seven patients had degenerative spondylolisthesis. Degenerative disc disease was also seen in 7 patients. The contents of the cysts varied from serous fluid to chalky white material to gelatinous grey material. One cyst contained calcium pyrophosphate crystals. Another cyst contained hydroxyapatite crystals. Seven cysts which contained deposition of bone debris in the cyst wall also revealed an (giant cell and macrophage) inflammatory reaction to this bone debris. In all patients complete resolution of sciatica, neurologic claudication and neurologic deficit was observed after surgery. However, after a minimum follow up of two years the back pain persisted in all but one patient. Conclusion: Lumbar synovial cyst is a rare condition, more common in females, elderly, and occurs most commonly in association with degenerative disease of the spine, although it can also be caused by other conditions like trauma, or rheumatoid arthritis. When they cause compression of the dura or nerve roots, they present with symptoms like sciatica and neurologic claudication, which resolve promptly after surgery. However, patients also have a long history of back pain from the associated degenerative spinal disease which usually does not resolve unless it is addressed separately and patients need to be warned regarding this

Introduction: This is a prospective study to determine the effectiveness of artificial disc replacements in the treatment of discogenic low back pain. There has been increasing interest in the possibility of preserving the motion of a diseased vertebral motion segment by various biomechanical designs. Preserving the motion of the segment, rather than opting for arthrodesis seems intuitively to be a more favourable treatment for several spine disorders. Up until now most spine surgery has been salvage (correcting the effects of trauma, stabilising correcting deformity, fusing degenerative segments) not restoration of normal function. As new alternatives to fusion come to fruition, we now have the ability to truly restore the spine to normal function. Spinal arthroplasty is a new concept and includes total disc replacement, nuclear replacement and there are efforts by investigators looking at posterior element reconstruction or facet replacement. Methods: The data have been collected from the surgical experience of one surgeon since commencement of this procedure in 1996. Data were collected from pre-operative, post-operative clinical and patient questionnaires (both pre- and post-operative) and radiological assessment.Patient questionnaires include Roland-Morris Questionnaire, Oswestry Questionnaire, Visual Analogue Scores, and SF36 Data. Results: 86 Patients have had implantation of the Charite artificial disc prosthesis “Link”; 113 levels have been instrumented; 42 males, 44 females; follow-up two months to five years, average follow-up 20 months. The results so far indicate good to excellent in 84% of cases. Complications have the potential to be catastrophic but attention to surgical detail results in minimal complications which will be discussed in the body of the presentation. Discussion: This paper is a prospective study. It also represents a personal surgical evolution and understanding of the role disc replacement plays in the treatment of discogenic low back pain. Disc replacement should be used as part of the armamentarium a spine surgeon can utilise in his practice. There are strict guidelines and criteria that need to be adhered to if optimal results are to be obtained. The artificial disc which has been most extensively used in the world is the Link SB Intervertebral Prosthesis. To date, over 2000 cases have been performed worldwide. The study is not intended to suggest that routine or indiscriminate use of the artificial disc replacement is warranted, but rather serves to provide a framework for further investigation to the utility of spinal arthroplasty with function intervertebral replacements

Introduction Locking plates are the most used devices for achieving anterior cervical spinal fusion and offer considerable advantages such as faster and easier implantation and fewer implant-related failures than older plate systems. Recently polyaxial locking screws were introduced to make the implantation of these plates even easier by facilitating the implantation of the screw in all directions. However polyaxial screws may have the disadvantage of losing the angular stability with subsequent failure of the plate. The aim of this study was the radiological follow up of the patients with polyaxial screw and to compare them with the conventional looking plates. Methods Patients underwent anterior cervical discectomy and fusion in which either ventral cervical locking plates or a polyaxial locking screw were used for indications including cervical spondylotic radiculopathy, disc herniation, trauma, and myelopathy. Patients underwent anterior cervical discectomy and interbody fusion and / or corpectomy. Preoperative and postoperative radiographic data included sagittal angle, translation, and settling of the graft. Results One hundred and forty patients were investigated (mean age of 49 years) with an average follow up period of 21.5 months (range from 4 to 50 months). All underwent anterior cervical plate fusion as a component of the surgical treatment for symptomatic degenerative cervical spinal disease (55%) or for vertebral destruction caused by trauma (45%).100 (71%) of patients were treated with a conventional locking plate and 29 % with a plate with polyaxial screw fixation. Besides plate fixation, 4 of the 140 patients had a combined ventrodorsal fusion. In 46 cases (25%), one or more vertebral bodies were removed and replaced with either iliac bone graft (two levels, 21% of all cases) or fibula strutgraft (4%). In the group with conventional locking plates no patient had to be revised, 3 showed a subluxation (up to 1/3 of the vertebral body diameter) and 2 screw back out posteriorly without clinical relevance. In the group with the plate with polyaxial screw fixation two patient had to be revised (posterior stabilisation) because of subluxation due to loss of angular stability of the screws and one patient developed subluxation of 1/3 of the vertebral body also due to loss of angular stability. Discussion The complication rate and the revision rate for anterior cervical discectomy and fusion with plates with and without polyaxial screw fixation were similarly low. Polyaxial screw may have the theoretical disadvantage of loosening with loss of the angular stability and subsequent failure necessitating revision

In two centres in Korea 350 patients with a diagnosis of tuberculosis of the thoracic and/or lumbar spine were allocated at random: in Masan to in-patient rest in bed (IP) for six months followed by out-patient treatment or to ambulatory out-patient treatment (OP) from the start; in Pusan to out-patient treatment with a plaster-of-Paris jacket (J) for nine months or to ambulatory treatment without any support (No J). All patients recieved chemotherapy with PAS with isoniazid for eighteen months, either supplemented with streptomycin for the first three months (SPH) or without this supplement (PH), by random allocation. The main analysis of this report concerns 299 patients (eighty-three IP, eighty-three OP, sixty-three J, seventy No J; 143 SPH, 156 PH). Pre-treatment factors were similar in both centres except that the patients in Pusan had, on average, less extensive lesions although in a greater proportion the disease was radiographically active. One patient (J/SPH) died with active spinal disease and three (all No J/SPH) with paraplegia. A fifth patient (IP/PH) who died from cardio respiratory failure also had pulmonary tuberculosis. Twenty-three patients required operation and/or additional chemotherapy for the spinal lesion. A sinus or clinically evident abscess was either present initially or developed during treatment in 41 per cent of patients. Residual lesions persisted in ten patients (four IP, two OP, one J, three No J; six SPH, four PH) at five years. Thirty-two patients had paraparesis on admission or developing later. Complete resolution occurred in twenty on the allocated regimen and in eight after operation or additional chemotherapy or both. Of the remaining four atients, all of whom had operation and additional chemotherapy, three died and one still had paraparesis at five years. Of 295 patients assessed at five years 89 per cent had a favourable status. The proportions of the patients responding favourably were similar in the IP (91 per cent) and OP (89 per cent) series, in the J (90 per cent) and No J (84 per cent) series and in the SPH (86 per cent) and PH (92 per cent) series

Aims

The aetiologies of common degenerative spine, hip, and knee pathologies are still not completely understood. Mechanical theories have suggested that those diseases are related to sagittal pelvic morphology and spinopelvic-femoral dynamics. The link between the most widely used parameter for sagittal pelvic morphology, pelvic incidence (PI), and the onset of degenerative lumbar, hip, and knee pathologies has not been studied in a large-scale setting.

1. Two hundred young Korean patients with a diagnosis of tuberculosis of the spine were allocated at random to in-patient rest in bed (IP) for six months followed by out-patient treatment, or to ambulatory out-patient treatment (OP) from the start. A second random allocation was made to chemotherapy with streptomycin for three months and PAS plus isoniazid for eighteen months (SPH), or to PAS plus isoniazid for eighteen months (PH). For various reasons twenty-nine patients had to be excluded from the study. The main analyses of this report therefore concern 171 patients, namely, forty IP/SPH, forty-six IP/PH, forty-two OP/SPH and forty three OP/PH. The comparisons made are a) of in-patient and out-patient treatment, and b) of the SPH and PH regimens. 2. The clinical and radiographic condition of the four groups on admission was similar. Many patients had extensive lesions. 3. Two in-patients died, probably from miliary tuberculosis, but neither had evidence of residual activity of the spinal lesion. 4. For the eighty-six in-patients the mean stay in hospital was 199 days and five were later readmitted. Of the eighty-five out-patients twenty-one (fourteen SPH, seven PH) were admitted to hospital in the first six months for complications of the spinal disease, for other medical conditions, or for domestic or geographical reasons; after the first six months eight more were admitted. 5. Three in-patients and five out-patients received chemotherapy beyond eighteen months for abscess or for paraparesis. 6. An abscess or sinus was either present initially or developed during treatment in 76 per cent of the in-patients and 72 per cent of the out-patients. Complete resolution occurred in most of the patients, some abscesses being aspirated. At three years 11 per cent of the in-patients and 5 per cent of the out-patients still had residual abscesses or sinuses. 7. On admission the mean total vertebral loss was 1·79 in the in-patients and 1·33 in the out-patients, and increased over the three-year period by 0·15 and 0·31 respectively. 8. The mean angulation of the spine at the start of treatment was 37 degrees for the in-patients and 27 degrees for the out-patients, the mean increase over the three-year period being 8 and 18 degrees respectively. 9. On admission six in-patients and four out-patients had incomplete motor paraplegia. This resolved completely within nine months in eight patients, as did the one cauda equina lesion. Only two patients (both out-patients) developed paraparesis during the course of the study; both recovered. 10. At eighteen months 66 per cent of the in-patients and 58 per cent of the out-patients had responded favourably. The corresponding percentages at thirty-six months were 84 and 88. 11. There was little difference in behaviour between the SPH and the PH series; at thirty-six months 82 per cent of eighty SPH and 90 per cent of eighty-eight PH patients had a favourable response. 12. A multiple regression analysis failed to identify any factor of clearly prognostic importance on admission

Aims

Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites.

There remains confusion in the literature with regard to the spinopelvic relationship, and its contribution to ideal acetabular component position. Critical assessment of the literature has been limited by use of conflicting terminology and definitions of new concepts that further confuse the topic. In 2017, the concept of a Hip-Spine Workgroup was created with the first meeting held at the American Academy of Orthopedic Surgeons Annual Meeting in 2018. The goal of this workgroup was to first help standardize terminology across the literature so that as a topic, multiple groups could produce literature that is immediately understandable and applicable. This consensus review from the Hip-Spine Workgroup aims to simplify the spinopelvic relationship, offer hip surgeons a concise summary of available literature, and select common terminology approved by both hip surgeons and spine surgeons for future research.

Cite this article: Bone Joint J 2019;101-B:808–816.

Aims

There is an increased risk of dislocation of the hip after the resection of a periacetabular tumour and endoprosthetic reconstruction of the defect in the hemipelvis. The aim of this study was to determine the rate and timing of dislocation and to identify its risk factors.

Aims

The aim of this study is to test the hypothesis that three grades of sagittal compensation for standing posture (normal, compensated, and decompensated) correlate with health-related quality of life measurements (HRQOL).

Aims

The aim of this study was to systematically compare the safety and accuracy of robot-assisted (RA) technique with conventional freehand with/without fluoroscopy-assisted (CT) pedicle screw insertion for spine disease.

Aims

Spinal tuberculosis (TB) remains an important concern. Although spinal TB often has sequelae such as myelopathy after treatment, the predictive factors affecting such unfavourable outcomes are not yet established. We investigated the clinical manifestations and predictors of unfavourable treatment outcomes in patients with spinal TB.

Aims

Studying the indications for revision total hip arthroplasty (THA) may enable surgeons to change their practice during the initial procedure, thereby reducing the need for revision surgery. The aim of this study was to identify and describe the potentially avoidable indications for revision THA within five years of the initial procedure.

Aims

The aims of this study were to measure sagittal standing and sitting lumbar-pelvic-femoral alignment in patients before and following total hip arthroplasty (THA), and to consider what preoperative factors may influence a change in postoperative pelvic position.

Aims

While previously underappreciated, factors related to the spine contribute substantially to the risk of dislocation following total hip arthroplasty (THA). These factors must be taken into consideration during preoperative planning for revision THA due to recurrent instability. We developed a protocol to assess the functional position of the spine, the significance of these findings, and how to address different pathologies at the time of revision THA.

Aims

It is important to consider sagittal pelvic rotation when introducing the acetabular component at total hip arthroplasty (THA). The purpose of this study was to identify patients who are at risk of unfavourable pelvic mobility, which could result in poor outcomes after THA.

Aims

The pelvis rotates in the sagittal plane during daily activities. These rotations have a direct effect on the functional orientation of the acetabulum. The aim of this study was to quantify changes in pelvic tilt between different functional positions.

Aims

Tuberculosis (TB) infection of bones and joints accounts for 6.7% of TB cases in England, and is associated with significant morbidity and disability. Public Health England reports that patients with TB experience delays in diagnosis and treatment. Our aims were to determine the demographics, presentation and investigation of patients with a TB infection of bones and joints, to help doctors assessing potential cases and to identify avoidable delays.

Aims

The aims of this study were to describe the prevalence of previous lumbar surgery in patients who undergo total hip arthroplasty (THA) and to investigate their patient-reported outcomes (PROMs) one year post-operatively.

Objectives

Pedicle-lengthening osteotomy is a novel surgery for lumbar spinal stenosis (LSS), which achieves substantial enlargement of the spinal canal by expansion of the bilateral pedicle osteotomy sites. Few studies have evaluated the impact of this new surgery on spinal canal volume (SCV) and neural foramen dimension (NFD) in three different types of LSS patients.

The December 2015 Spine Roundup360 looks at: Ketamine in scoliosis surgery; Teriparatide in osteoporotic spinal fractures; Trabecular metal in the spine?; Revision surgery a SPORTing chance?; The course of degenerative lumbar spondylolisthesis; Hip or lumbar spine: a common conundrum

Objectives

Normal sagittal spine-pelvis-lower extremity alignment is crucial in humans for maintaining an ergonomic upright standing posture, and pathogenesis in any segment leads to poor balance. The present study aimed to investigate how this sagittal alignment can be affected by severe knee osteoarthritis (KOA), and whether associated changes corresponded with symptoms of lower back pain (LBP) in this patient population.

Metastatic epidural compression of the spinal cord is a significant source of morbidity in patients with systemic cancer. With improved oncological treatment, survival in these patients is improving and metastatic cord compression is encountered increasingly often. The treatment is mostly palliative. Surgical management involves early circumferential decompression of the cord with concomitant stabilisation of the spine. Patients with radiosensitive tumours without cord compression benefit from radiotherapy. Spinal stereotactic radiosurgery and minimally invasive techniques, such as vertebroplasty and kyphoplasty, with or without radiofrequency ablation, are promising options for treatment and are beginning to be used in selected patients with spinal metastases.

In this paper we review the surgical management of patients with metastatic epidural spinal cord compression.

Pain catastrophising is an adverse coping mechanism, involving an exaggerated response to anticipated or actual pain.

The purpose of this study was to investigate the influence of pain ‘catastrophising’, as measured using the pain catastrophising scale (PCS), on treatment outcomes after surgery for lumbar spinal stenosis (LSS).

A total of 138 patients (47 men and 91 women, mean age 65.9; 45 to 78) were assigned to low (PCS score < 25, n = 68) and high (PCS score ≥ 25, n = 70) PCS groups. The primary outcome measure was the Oswestry Disability Index (ODI) 12 months after surgery. Secondary outcome measures included the ODI and visual analogue scale (VAS) for back and leg pain, which were recorded at each assessment conducted during the 12-month follow-up period

The overall changes in the ODI and VAS for back and leg pain over a 12-month period were significantly different between the groups (ODI, p < 0.001; VAS for back pain, p < 0.001; VAS for leg pain, p = 0.040). The ODI and VAS for back and leg pain significantly decreased over time after surgery in both groups (p < 0.001 for all three variables). The patterns of change in the ODI and VAS for back pain during the follow-up period significantly differed between the two groups, suggesting that the PCS group is a potential treatment moderator. However, there was no difference in the ODI and VAS for back and leg pain between the low and high PCS groups 12 months after surgery.

In terms of minimum clinically important differences in ODI scores (12.8), 22 patients (40.7%) had an unsatisfactory surgical outcome in the low PCS group and 16 (32.6%) in the high PCS group. There was no statistically significant difference between the two groups (p = 0.539).

Pre-operative catastrophising did not always result in a poor outcome 12 months after surgery, which indicates that this could moderate the efficacy of surgery for LSS.

Cite this article: Bone Joint J 2015;97-B:1546–54.

We undertook a retrospective study investigating the accuracy and safety of percutaneous pedicle screws placed under fluoroscopic guidance in the lumbosacral junction and lumbar spine. The CT scans of patients were chosen from two centres: European patients from University Medical Center Hamburg-Eppendorf, Germany, and Asian patients from the University of Malaya, Malaysia. Screw perforations were classified into grades 0, 1, 2 and 3. A total of 880 percutaneous pedicle screws from 203 patients were analysed: 614 screws from 144 European patients and 266 screws from 59 Asian patients. The mean age of the patients was 58.8 years (16 to 91) and there were 103 men and 100 women. The total rate of perforation was 9.9% (87 screws) with 7.4% grade 1, 2.0% grade 2 and 0.5% grade 3 perforations. The rate of perforation in Europeans was 10.4% and in Asians was 8.6%, with no significant difference between the two (p = 0.42). The rate of perforation was the highest in S1 (19.4%) followed by L5 (14.9%). The accuracy and safety of percutaneous pedicle screw placement are comparable to those cited in the literature for the open method of pedicle screw placement. Greater caution must be taken during the insertion of L5 and S1 percutaneous pedicle screws owing to their more angulated pedicles, the anatomical variations in their vertebral bodies and the morphology of the spinal canal at this location.

Cite this article: Bone Joint J 2015; 97-B:1111–17.

In patients with osteoporosis there is always a strong possibility that pedicle screws will loosen. This makes it difficult to select the appropriate osteoporotic patient for a spinal fusion. The purpose of this study was to determine the correlation between bone mineral density (BMD) and the magnitude of torque required to insert a pedicle screw. To accomplish this, 181 patients with degenerative disease of the lumbar spine were studied prospectively. Each underwent dual-energy x-ray absorptiometry (DEXA) and intra-operative measurement of the torque required to insert each pedicle screw. The levels of torque generated in patients with osteoporosis and osteopenia were significantly lower than those achieved in normal patients. Positive correlations were observed between BMD and T-value at the instrumented lumbar vertebrae, mean BMD and mean T-value of the lumbar vertebrae, and mean BMD and mean T-value of the proximal femur. The predictive torque (Nm) generated during pedicle screw insertion was [-0.127 + 1.62 × (BMD at the corresponding lumbar vertebrae)], as measured by linear regression analysis. The positive correlation between BMD and the maximum torque required to insert a pedicle screw suggests that pre-operative assessment of BMD may be useful in determining the ultimate strength of fixation of a device, as well as the number of levels that need to be fixed with pedicle screws in patients who are suspected of having osteoporosis.

Coccydynia is a painful disorder characterised by coccygeal pain which is typically exaggerated by pressure. It remains an unsolved mystery because of the perceived unpredictability of the origin of the pain, some psychological traits that may be associated with the disorder, the presence of diverse treatment options, and varied outcomes. A more detailed classification based on the aetiology and pathoanatomy of coccydynia helps to identify patients who may benefit from conservative and surgical management.

This review focuses on the pathoanatomy, aetiology, clinical features, radiology, treatment and outcome of coccydynia.

The April 2014 Spine Roundup³⁶⁰ looks at: medical treatment for ankylosing spondylitis; unilateral TLIF effective; peg fractures akin to neck of femur fractures; sleep apnoea and spinal surgery; scoliosis in osteogenesis imperfect; paediatric atlanto-occipital dislocation; back pain and obesity: chicken or egg?; BMP associated with lumbar plexus deficit; and just how common is back pain?

The cementless Oxford unicompartmental knee replacement has been demonstrated to have superior fixation on radiographs and a similar early complication rate compared with the cemented version. However, a small number of cases have come to our attention where, after an apparently successful procedure, the tibial component subsides into a valgus position with an increased posterior slope, before becoming well-fixed. We present the clinical and radiological findings of these six patients and describe their natural history and the likely causes. Two underwent revision in the early post-operative period, and in four the implant stabilised and became well-fixed radiologically with a good functional outcome.

This situation appears to be avoidable by minor modifications to the operative technique, and it appears that it can be treated conservatively in most patients.

Cite this article: Bone Joint J 2014;96-B:345–9.

We analysed the influence of the timing of surgery (< 48 hours, group 1, 21 patients vs > 48 hours, group 2, 14 patients) on the neurological outcome and restoration of mobility in 35 incomplete tetra- and paraplegic patients with metastatic spinal-cord compression.

Pain and neurological symptoms were assessed using the American Spinal Injury Association impairment scale. More improvement was found in group 1 than in group 2 when comparing the pre-operative findings with those both immediately post-operatively (p = 0.021) and those at follow-up at four to six weeks (p = 0.010). In group 1 the number of pre-operatively mobile patients increased from 17 (81%) to 19 patients (90%) whereas the number of mobile patients in group 2 changed from nine (64%) to ten (71%).

These results suggest that early surgical treatment in patients with metastatic spinal-cord compression gives a better neurological outcome even in a palliative situation.

We investigated the spinopelvic morphology and global sagittal balance of patients with a degenerative retrolisthesis or anterolisthesis. A total of 269 consecutive patients with a degenerative spondylolisthesis were included in this study. There were 95 men and 174 women with a mean age of 64.3 years (sd 10.5; 40 to 88). A total of 106 patients had a pure retrolisthesis (R group), 130 had a pure anterolisthesis (A group), and 33 had both (R+A group).

A backward slip was found in the upper lumbar levels (mostly L2 or L3) with an almost equal gender distribution in both the R and R+A groups. The pelvic incidence and sacral slope of the R group were significantly lower than those of the A (both p < 0.001) and R+A groups (both p < 0.001). The lumbar lordosis of the R+A group was significantly greater than that of the R (p = 0.025) and A groups (p = 0.014). The C7 plumb line of the R group was located more posteriorly than that of the A group (p = 0.023), but was no different from than that of the R+A group (p = 0.422). The location of C7 plumb line did not differ between the three groups (p = 0.068). The spinosacral angle of the R group was significantly smaller than that of the A group (p < 0.001) and R+A group (p < 0.001).

Our findings imply that there are two types of degenerative retrolisthesis: one occurs primarily as a result of degeneration in patients with low pelvic incidence, and the other occurs secondarily as a compensatory mechanism in patients with an anterolisthesis and high pelvic incidence.

Cite this article: Bone Joint J 2013;95-B:1244–9.

The identification of the extent of neural damage in patients with acute or chronic spinal cord injury is imperative for the accurate prediction of neurological recovery. The changes in signal intensity shown on routine MRI sequences are of limited value for predicting functional outcome. Diffusion tensor imaging (DTI) is a novel radiological imaging technique which has the potential to identify intact nerve fibre tracts, and has been used to image the brain for a variety of conditions. DTI imaging of the spinal cord is currently only a research tool, but preliminary studies have shown that it holds considerable promise in predicting the severity of spinal cord injury.

This paper briefly reviews our current knowledge of this technique.

In order to determine the epidemiology of adult scoliosis in the elderly and to analyse the radiological parameters and symptoms related to adult scoliosis, we carried out a prospective cross-sectional radiological study on 1347 adult volunteers. There were 615 men and 732 women with a mean age of 73.3 years (60 to 94), and a mean Cobb angle of 7.55° (sd 5.95).

In our study, 478 subjects met the definition of scoliosis (Cobb angle ≥10°) showing a prevalence of 35.5%. There was a significant difference in the epidemiological distribution and prevalence between the age and gender groups. The older adults showed a larger prevalence and more severe scoliosis, more prominent in women (p = 0.004). Women were more affected by adult scoliosis and showed more linear correlation with age (p < 0.001). Symptoms were more severe in those with scoliosis than in the normal group, but were similar between the mild, moderate and severe scoliosis groups (p = 0.224) and between men and women (p = 0.231).

Adult scoliosis showed a significant relationship with lateral listhesis, vertebral rotation, lumbar hypolordosis, sagittal imbalance and a high level of the L4–5 disc (p < 0.0001, p < 0.0001, p = 0.002, p = 0.002, p < 0.0001 respectively). Lateral listhesis, lumbar hypolordosis and sagittal imbalance were related to symptoms (p < 0.0001, p = 0.001, p < 0.0001 respectively).

We have examined the outcome in 19 professional rugby union players who underwent anterior cervical discectomy and fusion between 1998 and 2003. Through a retrospective review of the medical records and telephone interviews of all 19 players, we have attempted to determine the likelihood of improvement, return to professional sport and the long-term consequences. We have also attempted to relate the probability of symptoms in the neck and radicular pain in the arm to the position of play. Neck and radicular pain were improved in 17 patients, with 13 returning to rugby, the majority by six months after operation. Of these, 13 returned to their pre-operative standard of play, one to a lower level and five have not played rugby again. Two of those who returned to the game have subsequently suffered further symptoms in the neck, one of whom was obliged to retire. The majority of the players with problems in the neck were front row forwards.

A return to playing rugby union after surgery and fusion of the anterior cervical spine is both likely and safe and need not end a career in the game.

Thoracic back pain caused by osteoarthritis of a single costovertebral joint is a poorly recognised condition. We report a series of five patients who were successfully treated by resection arthroplasty of this joint.

Each had received a preliminary image-guided injection of local anaesthetic and steroid into the joint to confirm it as the source of pain. The surgical technique is described. There were no complications. The pain improved from a mean of 7.0 (6 to 8) on a visual analogue scale to 2.0 (0 to 4) post-operatively. The final post-operative Oswestry disability index was a mean of 19.4 (9 to 38).

Isolated osteoarthritis of a costovertebral joint is a rare but treatable cause of thoracic back pain. It is possible to obtain excellent short- and intermediate-term relief from pain with resection arthroplasty in appropriately selected patients.

The dismal outcome of tuberculosis of the spine in the pre-antibiotic era has improved significantly because of the use of potent antitubercular drugs, modern diagnostic aids and advances in surgical management. MRI allows the diagnosis of a tuberculous lesion, with a sensitivity of 100% and specificity of 88%, well before deformity develops. Neurological deficit and deformity are the worst complications of spinal tuberculosis. Patients treated conservatively show an increase in deformity of about 15°. In children, a kyphosis continues to increase with growth even after the lesion has healed. Tuberculosis of the spine is a medical disease which is not primarily treated surgically, but operation is required to prevent and treat the complications. Panvertebral lesions, therapeutically refractory disease, severe kyphosis, a developing neurological deficit, lack of improvement or deterioration are indications for surgery. Patients who present with a kyphosis of 60° or more, or one which is likely to progress, require anterior decompression, posterior shortening, posterior instrumented stabilisation and anterior and posterior bone grafting in the active stage of the disease. Late-onset paraplegia is best prevented rather than treated. The awareness and suspicion of an atypical presentation of spinal tuberculosis should be high in order to obtain a good outcome. Therapeutically refractory cases of tuberculosis of the spine are increasing in association with the presence of HIV and multidrug-resistant tuberculosis.

Cervical spinal disc replacement is used in the management of degenerative cervical disc disease in an attempt to preserve cervical spinal movement and to prevent adjacent disc overload and subsequent degeneration. A large number of patients have undergone cervical spinal disc replacement, but the effectiveness of these implants is still uncertain. In most instances, degenerative change at adjacent levels represents the physiological progression of the natural history of the arthritic disc, and is unrelated to the surgeon. Complications of cervical disc replacement include loss of movement from periprosthetic ankylosis and ossification, neurological deficit, loosening and failure of the device, and worsening of any cervical kyphosis. Strict selection criteria and adherence to scientific evidence are necessary. Only prospective, randomised clinical trials with long-term follow-up will establish any real advantage of cervical spinal disc replacement over fusion.