Aim. A retrospective review of the management of adjacent level discectomy and fusion using a Zero-P (Synthes) cage and report of ease of technique and outcomes. Method. Surgical approach to adjacent level cervical disc protrusion with previous anterior cervical discectomy and fusion (ACDF) can be difficult. We review 4 patients who had previous ACDF with cage and plate who developed new onset adjacent level cervical disc prolepses causing myelopathy. A retrospective review of demographic data, symptoms, details of surgery, pre and post operative radiology, pre and postoperative ODI and pain score, length of stay, complications and follow-up data were collected in all patients. Results. Previous ACDF with plate was performed in all 4 patients an average of 11.6 years ago. Two patients had bilateral approaches previously and both had previous vascular injuries. The average duration of current symptoms was 9 months with a mean age of 65 years. All patients presented with myelopathy and two also had radiculopathy. Multiple level ACDF were operated in 2 patients previously. Revision surgery and dissection on the disc level was restricted by the previous plate. Screws from the previous plate fusion were removed adjacent to the level of surgery and discectomy was performed using distractor pins through the screw sites. Following discectomy a Zero-P cage was used to fusion with DBX under image intensifier guidance. The advantage was not to remove the previous plate and keep the dissection over the scar tissue to the minimal. All patients improved in their radicular symptoms with improvement of their hand function in the myelopaths. There was no complication and post operative radiographs were satisfactory. Conclusions. Use of the Zero-P cage for adjacent level discectomy and fusion was safe without disturbing the previous cage and plate fusion or stability

Aims. The aims of this study were first, to determine if adding fusion to a decompression of the lumbar spine for spinal stenosis decreases the rate of radiological restenosis and/or proximal adjacent level stenosis two years after surgery, and second, to evaluate the change in vertebral slip two years after surgery with and without fusion. Methods. The Swedish Spinal Stenosis Study (SSSS) was conducted between 2006 and 2012 at five public and two private hospitals. Six centres participated in this two-year MRI follow-up. We randomized 222 patients with central lumbar spinal stenosis at one or two adjacent levels into two groups, decompression alone and decompression with fusion. The presence or absence of a preoperative spondylolisthesis was noted. A new stenosis on two-year MRI was used as the primary outcome, defined as a dural sac cross-sectional area ≤ 75 mm. 2. at the operated level (restenosis) and/or at the level above (proximal adjacent level stenosis). Results. A total of 211 patients underwent surgery at a mean age of 66 years (69% female): 103 were treated by decompression with fusion and 108 by decompression alone. A two-year MRI was available for 176 (90%) of the eligible patients. A new stenosis at the operated and/or adjacent level occurred more frequently after decompression and fusion than after decompression alone (47% vs 29%; p = 0.020). The difference remained in the subgroup with a preoperative spondylolisthesis, (48% vs 24%; p = 0.020), but did not reach significance for those without (45% vs 35%; p = 0.488). Proximal adjacent level stenosis was more common after fusion than after decompression alone (44% vs 17%; p < 0.001). Restenosis at the operated level was less frequent after fusion than decompression alone (4% vs 14%; p = 0.036). Vertebral slip increased by 1.1 mm after decompression alone, regardless of whether a preoperative spondylolisthesis was present or not. Conclusion. Adding fusion to a decompression increased the rate of new stenosis on two-year MRI, even when a spondylolisthesis was present preoperatively. This supports decompression alone as the preferred method of surgery for spinal stenosis, whether or not a degenerative spondylolisthesis is present preoperatively. Cite this article: Bone Joint J 2022;104-B(12):1343–1351

Aims. The aim of this study was to determine the influence of developmental spinal stenosis (DSS) on the risk of re-operation at an adjacent level. Patients and Methods. This was a retrospective study of 235 consecutive patients who had undergone decompression-only surgery for lumbar spinal stenosis and had a minimum five-year follow-up. There were 106 female patients (45.1%) and 129 male patients (54.9%), with a mean age at surgery of 66.8 years (. sd. 11.3). We excluded those with adult deformity and spondylolisthesis. Presenting symptoms, levels operated on initially and at re-operation were studied. MRI measurements included the anteroposterior diameter of the bony spinal canal, the degree of disc degeneration, and the thickness of the ligamentum flavum. DSS was defined by comparative measurements of the bony spinal canal. Risk factors for re-operation at the adjacent level were determined and included in a multivariate stepwise logistic regression for prediction modelling. Odds ratios (ORs) with 95% confidence intervals were calculated. Results. Of the 235 patients, 21.7% required re-operation at an adjacent segment. Re-operation at an adjacent segment was associated with DSS (p = 0.026), the number of levels decompressed (p = 0.008), and age at surgery (p = 0.013). Multivariate regression model (p < 0.001) controlled for other confounders showed that DSS was a significant predictor of re-operation at an adjacent segment, with an adjusted OR of 3.93. Conclusion. Patients with DSS who have undergone lumbar spinal decompression are 3.9 times more likely to undergo future surgery at an adjacent level. This is a poor prognostic indicator that can be identified prior to index decompression surgery

We evaluated the impact of lumbar instrumented circumferential fusion on the development of adjacent level vertebral compression fractures (VCFs). Instrumented posterior lumbar interbody fusion (PLIF) has become a popular procedure for degenerative lumbar spine disease. The immediate rigidity produced by PLIF may cause more stress and lead to greater risk of adjacent VCFs. However, few studies have investigated the relationship between PLIF and the development of subsequent adjacent level VCFs. . Between January 2005 and December 2009, a total of 1936 patients were enrolled. Of these 224 patients had a new VCF and the incidence was statistically analysed with other covariants. In total 150 (11.1%) of 1348 patients developed new VCFs with PLIF, with 108 (72%) cases at adjacent segment. Of 588 patients, 74 (12.5%) developed new subsequent VCFs with conventional posterolateral fusion (PLF), with 37 (50%) patients at an adjacent level. Short-segment fusion, female and age older than 65 years also increased the development of new adjacent VCFs in patients undergoing PLIF. In the osteoporotic patient, more rigid fusion and a higher stress gradient after PLIF will cause a higher adjacent VCF rate. Cite this article: Bone Joint J 2015;97-B:1411–16

Aim. The purpose of this study is to compare the pre and post-operative magnetic resonance image clarity of titanium and PEEK based cervical arthroplasty devices at the level of implantation and adjacent level discs. Methodology and Results. This is a prospective, blinded, randomised study on imaging of cervical arthroplasty devices. The pre and postoperative MRI images of 16 patients who underwent cervical arthroplasty using Prestige LP(r) (Medtronic Sofamor Danek) and NuNec(tm) Cervical Arthroplasty System (Pioneer Surgical Technology, Marquette, Mich., USA) were assessed. Two independent radiologists who were blinded and provided with a sets of random images to score using a four point Jarvick grading system. Statistical analysis was completed using SPSS 16.0 statistical package (SPSS Inc, Chicago, IL) and analysis included comparing MR image quality before and after cervical arthroplasty at the operated and adjacent levels, and in between two types of implant. The pre-operative MR image quality at operated and adjacent levels was excellent in both groups. In the post-operative images, the adjacent level visualisation was adequate in both groups without much difference in average scores. However, at operated level, the quality of MR images in the NuNec group (PEEK on PEEK articulating disc) was excellent and clear visualisation of the cord, central canal, foramen and disc. Conclusion. Previous studies have shown that titanium devices allow satisfactory monitoring of adjacent and operated levels by providing good quality MRI images. Our studies confirm that using titanium based cervical arthroplasty implants provide clear visualisation of the adjacent level, however, provide less than satisfactory images at operated level. But the PEEK devices provide excellent quality images even at the operated level, with clear visualisation of neural structures and are valuable, if one wishes to assess the adequacy of neural decompression at operated level

Following studies in 2007-08 comparing cervical discs devices, satisfaction and accuracy of operated and adjacent levels was observed with titanium devices. Patients were followed up and surgical assessments recorded. MRI with 12 patients were first assessed for imaging quality. Two independent radiologists scored twice sagittal and axial T2 – weighted images using the Jarvik four point scale. Statistical analysis was performed on operated and adjacent levels and between devices. Length of surgery, blood loss, approach and time of exposure to radiation were recorded. Patients were followed up at two years. BAGUERA C containing titanium metal allowed satisfactory visualization of the canal, exit foramina, cord and adjacent levels. PCM and PRODISC C visualization was significantly impaired at operated level and in both spinal cord and neural foramina. At adjacent levels, image quality was statistically poorer for those two devices. 6 patients were operated at C5-C6 and 6 at C6-C7. Mean age was 49. Approach was from the right, length of surgery and blood loss were: mean 46 min and 16.25 cc for BAGUERA C; mean 70 min and 27.5 cc for PCM and mean 63 min with 26.25 cc for PRODISC C. Exposure to radiation presented also significant difference between devices. Clinical outcomes reveal similar VAS and patient's satisfaction scores. Titanium device with polyethylene allow for satisfactory monitoring with adequacy in the assessment of neural decompression. BAGUERA C surgical outcomes indicate potential benefits that may be related to technique and simplicity of implantation

Aims. To address the natural history of severe post-tuberculous (TB) kyphosis, with focus upon the long-term neurological outcome, occurrence of restrictive lung disease, and the effect on life expectancy. . Patients and Methods. This is a retrospective clinical review of prospectively collected imaging data based at a single institute. A total of 24 patients of Southern Chinese origin who presented with spinal TB with a mean of 113° of kyphosis (65° to 159°) who fulfilled inclusion criteria were reviewed. Plain radiographs were used to assess the degree of spinal deformity. Myelography, CT and MRI were used when available to assess the integrity of the spinal cord and canal. Patient demographics, age of onset of spinal TB and interventions, types of surgical procedure, intra- and post-operative complications, and neurological status were assessed. . Results. All except one of the 24 patients were treated with anti-TB chemotherapy when they were first diagnosed with spinal TB. They subsequently received surgery either for neurological deterioration, or deformity correction in later life. The mean follow-up was 34 years (11 to 59) since these surgical interventions. Some 16 patients (66.7%) suffered from late neurological deterioration at a mean of 26 years (8 to 49) after the initial drug treatment. The causes of neurological deterioration were healed disease in nine patients (56.2%), re-activation in six patients (37.5%) and adjacent level spinal stenosis in one patient (6.3%). The result of surgery was worse in healed disease. Eight patients without neurological deterioration received surgery to correct the kyphosis. The mean correction ranged from 97° to 72°. Three patients who were clinically quiescent with no neurological deterioration were found to have active TB of the spine. Solid fusion was achieved in all cases and no patient suffered from neurological deterioration after 42 years of follow-up. On final follow-up, six patients were noted to have deceased (age range: 47 years to 75 years). Conclusion. Our study presents one of the longest assessments of spinal TB with severe kyphosis. Severe post-TB kyphosis may lead to significant health problems many years following the initial drug treatment. Early surgical correction of the kyphosis, solid fusion and regular surveillance may avoid late complications. Paraplegia, restrictive lung disease and early onset kyphosis might relate to early death. Clinically quiescent disease does not mean cure. . Cite this article: Bone Joint J 2017;99-B:1381–8

We evaluated the efficacy of anterior fusion alone compared with combined anterior and posterior fusion for the treatment of degenerative cervical kyphosis. Anterior fusion alone was undertaken in 15 patients (group A) and combined anterior and posterior fusion was carried out in a further 15 (group B). The degree and maintenance of the angle of correction, the incidence of graft subsidence, degeneration at adjacent levels and the rate of fusion were assessed radiologically and clinically and the rate of complications recorded. The mean angle of correction in group B was significantly higher than in group A (p = 0.0009). The mean visual analogue scale and the neck disability index in group B was better than in group A (p = 0.043, 0.0006). The mean operation time and the blood loss in B were greater than in group A (p < 0.0001, 0.037). Pseudarthrosis, subsidence of the cage, and problems related to the hardware were more prevalent in group A than in group B (p = 0.034, 0.025, 0.013). Although the combined procedure resulted in a longer operating time and greater blood loss than with anterior fusion alone, our results suggest that for the treatment of degenerative cervical kyphosis the combined approach leads to better maintenance of sagittal alignment, a higher rate of fusion, a lower incidence of complications and a better clinical outcome

Aims

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

Aims

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

Aims

Lumbar disc prolapse is a frequent indication for surgery. The few available long-term follow-up studies focus mainly on repeated surgery for recurrent disease. The aim of this study was to analyze all reasons for additional surgery for patients operated on for a primary lumbar disc prolapse.

Establish the positive predictive value of clinical examination predicted radicular level to MRI. To identify the value of the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) assessment tool in the assessment of patients presenting with radicular symptoms of lumbar spine source. 8 patients attending the ESP Orthopaedic triage service, presenting with radicular pain in which MRI is clinically indicated. Prospective study on patients attending ESP Orthopaedic triage service. Patients were clinically examined, both parts LANSS score was completed. Following the assessment a radicular level was selected. Following MRI the results were compared. Positive predicted values (PPV) for clinical examination and sensitivity and specificity of a LANSS score>12 was calculated. LANSS score. MRI report. PPV of 75% of therapist predicted level being same level or adjacent level to MRI stated level. 66% specificity and 100% sensitivity of patients in study with LANNS>12 having MRI evaluated radicular nerve root compression. This pilot suggests that clinical examination and the LANSS score is useful in establishing the presence of radicular nerve root compression. This evidence supports the need for further research

PURPOSE. This study aims to identify the incidence and factors influencing readmissions following scoliosis surgery over a period of 19 years. METHODS. A search was conducted in the hospital database between 7. th. January 1992 and 29. th. December 2010. 73 diagnostic codes were used to identify all scoliosis patients within this period. Repetitions of hospital codes were identified and these represent readmission episodes. Each readmission episode was manually classified using hospital diagnostic/procedural codes, clinic letters, or radiographs. The average costs of the implants used were calculated using the hospital costing database. RESULTS. 4528 primary scoliosis operations were identified. In the 19 year period, 596 readmissions episodes were recorded. 101 (2.2% of all primary operations) were metalwork revisions for pseudarthrosis, further/residual deformity, and adjacent level degeneration. 193 (4.2%) were removal or trimming of prominent metalwork. Other reasons for readmissions were: infection (2%), costoplasty (2.1%) injection (2.4%), scar revision (0.1%). There were no clear correlations with the year of the primary surgery, or the cost of the implants used. CONCLUSION. The recorded complication rate remained constant over a 19 year period, despite changes in surgical techniques, peri-operative care, implant types and cost. A national spinal implant registry is called for

The purpose of this retrospective study, is to demonstrate the survivorship and clinical effectiveness of the Wallis implant, against low back pain and functional disability in patients with degenerative lumbar spine disease. The Wallis Interspinous implant, was developed as a minimally invasive and anatomically conserving procedure, without recourse to rigid fusion procedures. The initial finite element analysis and cadaver biomechanical studies showed that the Wallis ligament improves stability in the degenerate lumbar motion segment. Unloading the disc and facet joints reduces intradiscal pressures at same and adjacent levels allowing for the potential of the disc to repair itself. A total of 157 patients who had wallis ligament insertion between 2003 and 2009 were reviewed, with a mean age of 54 and were followed for 48 months on average. Patients were assessed pre-operatively and post-operatively every 6 months by VAS pain score, Oswestry Disability Index and SF-36. 90% of patients improved, to show a minimal clinical difference, compared to the pre-operative evaluation. There is overall 75-80% good clinical outcome. Low infection rate of 1.1%. Two cases of prolapsed discs at the same level requiring further discectomy, 7 required fusion. No fractures or expulsions. The Wallis implant represents a safe non-fusion stabilisation device in the treatment of degenerative lumbar spine disease with canal stenosis. There is less soft tissue damage, quick rehabilitation, less morbidity and associated low complication rate

Patients with neurogenic claudication from lumbar canal stenosis non-responsive to non-surgical treatment are usually managed with spinal decompression with or without fusion. Flexion at stenotic segments relieves symptoms by increasing canal cross-sectional area, intervertebral foraminal height. Interspinous spacers work by causing flexion at the treated segement. We used COFLEX¯ [Paradigm Spine] a titanium interspinous spacer along with interlaminar decompression where indicated. To compare the clinical and radiological results of patients undergoing interlaminar decompression with or without use of COFLEX¯. Pre and post-operative assessment and comparison of clinical outcomes of Oswestry disability index(ODI), Visual analog Scale(VAS), Short Form-36(SF-36) and radiological outcomes of disc heights of operated and adjacent levels, intervertebral foraminal heights, sagittal angles of the operated segment. All consecutive patients undergoing spinal decompression at one or more levels from Jan to Dec 2008 were included. Patients with clinically symptomatic back pain for a duration longer than claudication pain were offered interspinous spacer at L4/5 level or above. In first group(n-20), patients were treated with inter-laminar decompression and COFLEX¯ with a standard posterior approach. In second group(n-25) inter-laminar decompression for the involved segment was performed. All patients are on follow-up. Clinical and radiological outcomes were compared at 6 months and 1 year. Statistically significant(p<0.001) improvements in ODI, VAS(back), VAS(leg) and SF-36 in patients in whom COFLEX¯ was used. Radiological parameters also showed significant improvements(p<0.05). Use of COFLEX¯ spacer is justified in patients with symptomatic disc degeneration with neurogenic claudication when treated operatively

Background. Degenerative spondylolisthesis (DS) with stenosis is now typically treated by decompression and instrumented fusion. This treatment method does produce predictable results at the spondylolisthetic level, but later stenosis will occur commonly at the adjacent level due to the rigidity of the construct. Pedicle screw fusion may also be a significantly invasive procedure for an elderly patient. Aim. To evaluate the clinical potential of a new, non-screw based, posterior dynamic flexion-restricting stabilization system (FRSS). Method. 17 patients (15f, 2m; mean age 68 (45-78yr)) presenting with leg pain, with or without low back pain, and MR evidence of spinal stenosis with DS were treated by uni- or bilateral laminotomy and FRSS. Microdiscectomy was performed for one patient with a concomitant disc prolapse. The FRSS was placed at L4/5 in 13 patients and at L3/4 in four. Results. Follow up data was available for 12 patients at 3 months and 9 patients at 6 months. At 3 months the mean pain scores (VAS) for both back and leg pain (p<0.05) and ODI (>10 point) had improved and 82% were satisfied. Three patients had adverse events unrelated to the device or procedure. At 6 months the improvements were maintained in 8 patients. One complained of transient leg neuralgia (78% overall group satisfaction). There was no evidence of vertebral translation on flexion radiography. Mean blood loss at surgery was 220ml (50-1400ml) and instrumentation time 23min (10-54min). Discussions and Conclusion. Early data demonstrates good clinical outcomes in patients with DS treated with decompression and FRSS. Further follow up is necessary to evaluate whether stabilization with the FRSS can help to maintain the benefits of decompression over the longer-term. REC: 10/MRE00/9

We do know that the use of stand-alone cage with no plate is prone to subsidence and segmental kyphosis. Cage and plate construct are prone to adjacent level ossification. Zero P (Synthes, UK) cage combines the functionality of spacer and anterior plate. Radiological evaluation of subsidence of cervical spine after anterior cervical interbody fusion using Zero P cage system. Method: Retrospective review of radiographic records of patients undergoing surgery between June 2008- Oct 2009. We evaluated lateral cervical standing radiographs before, after, 6 weeks, 3, 6 months of surgery. We measured subsidence (using Total Intervertebral Height (TIH). All measurements were done using Web 1000 (Impax Agfa). Two level was treated as single segment. Subsidence > 3mm was considered significant. 20 patients (11 male: 9 female) with median age of 51 yrs (40-65) underwent one (n=10) or two level (n= 10) cervical fusion. Immediately post-op there was increase in TIH in one and two level group by 1.74mm (1.61 and 4.25mm (1.48 respectively, which at 6 months reduced to 1.05mm (0.24 (p< 0.003) and 1.32mm (1.29 (p< 0.085) at 6 months respectively. Subsidence was seen in all cases and was rapid in first 3 months and then tailed off. It was significant (> 3mm) only in 2/20 (2%) patients at 6 months. Early results indicate that spine alignment is maintained radiologically with no associated complications as screw loosening, cage extrusion etc

Introduction. Osteoporotic fracture reduces vertebral stiffness, and alters spinal load-sharing. Vertebroplasty partially reverses these changes at the fractured level, but is suspected to increase deformations and stress at adjacent levels. We examined this possibility. Methods. Twelve pairs of three-vertebra cadaver spine specimens (67-92 yr) were loaded to induce fracture. One of each pair underwent vertebroplasty with PMMA, the other with a resin (Cortoss). Specimens were then creep-loaded at 1.0kN for 1hr. In 15 specimens, either the uppermost or lowest vertebra was fractured, so that compressive stress distributions could be determined in the disc between adjacent non-fractured vertebrae. Stress was measured in flexion and extension, at each stage of the experiment, by pulling a pressure-transducer through the disc whilst under 1.0kN load. Stress profiles quantified intradiscal pressure (IDP), stress concentrations in the posterior annulus (SP. P. ), and compressive load-bearing by the neural arch (F. N. ). Elastic deformations in adjacent vertebrae were measured using a MacReflex tracking system during 1.0kN compressive ramp loading. Results. No differences were found between Cortoss and PMMA so data was pooled. Following fracture, IDP fell by 27% in extension (P=0.009), and SP. P. increased by 277% in flexion (P=0.016). F. N. increased from 17% to 30% of the applied load in flexion, and from 23% to 37% in extension (P<0.05). Vertebroplasty partially reversed these changes without inducing any increase in elastic deformation of the adjacent vertebrae. Conclusion. Vertebral fracture increases stress concentrations acting on the vertebral bodies and neural arches of adjacent (non-fractured) vertebrae, and these increases can be partially reversed by vertebroplasty

Introduction. We present our experience of 22 patients with low grade degenerative lumbar spondylolysthesis with stenosis (21 Grade I and 1 Grade II) who were treated using new stabilization systems {Scient'x IsoBar TTL Dynamic Rod Stabilization and the Inlign™ Multi-Axial pedicle Screws (Disc Motion Technologies - DMT)}. Methodology and Results. The pain intensity was evaluated using the Visual Analogue Score for back pain (VAS-BP) and leg pain (VAS-LP) and functional outcomes using Oswestry Disability Score (ODS). Overall improvement in general patient's health was assessed using the Bodily Pain (SF36-BP) component of the SF -36 questionnaires. Data was analysed with the SPSS 16.0 for Windows (SPSS Inc, Chicago, IL). Statistical significance was designated at p < 0.05 and appropriate parametric (Paired sample t-test) and non parametric tests (Wilcoxon signed-rank test) were used. There were 3 male and 19 female patients and average age at operation was 68.95 years (57-79 years). The average duration of follow up was 16.18 months (8-37 months). Most common level of surgery was L4/5 (n=18). Decompression and instrumentation involved 1 level (7 cases), 2 levels (9 cases), 3 levels (1 case) and 4 levels (5 cases). There was statistically significant improvement in all clinical outcomes. The ODS improved from 49.45 ±14.35 pre-operatively to 22.91 ± 6.38 post operatively (p< 0.001). There was statistically significant improvement noted in VAS-BP (p< 0.001), VAS-LP (p<0.001) and SF36-BP (p=0.002). Conclusion. The recent dynamic stabilisation systems were developed with an intention to stabilise the spondylolisthetic segment and preventing adjacent level degeneration. The study results clearly demonstrate that central decompression and dynamic stabilization using TTL/DMT system for degenerative lumbar spondylolysthesis is a safe, reliable method and offers excellent clinical outcomes. This technique obviates the need of bone graft and hence the graft site pain

Aims

The aim of this study was to determine the differences in spinal imaging characteristics between subjects with or without lumbar developmental spinal stenosis (DSS) in a population-based cohort.