Aims. Surgical approaches to cervical ossification of the posterior longitudinal ligament (OPLL) remain controversial. The purpose of the present study was to analyze and compare the long-term neurological recovery following anterior decompression with fusion (ADF) and posterior laminectomy and fusion with bone graft and internal fixation (PLF) based on > ten-year follow-up outcomes in a single centre. Methods. Included in this retrospective cohort study were 48 patients (12 females; mean age 55.79 years (SD 8.94)) who were diagnosed with cervical OPLL, received treatment in our centre, and were followed up for 10.22 to 15.25 years. Of them, 24 patients (six females; mean age 52.88 years (SD 8.79)) received ADF, and the other 24 patients (five females; mean age 56.25 years (SD 9.44)) received PLF. Clinical data including age, sex, and the OPLL canal-occupying ratio were analyzed and compared. The primary outcome was Japanese Orthopaedic Association (JOA) score, and the secondary outcome was visual analogue scale neck pain. Results. Compared with the baseline, neurological function improved significantly after surgery in all patients of both groups (p < 0.001). The JOA recovery rate in the ADF group was significantly higher than that in the PLF group (p < 0.001). There was no significant difference in postoperative cervical pain between the two groups (p = 0.387). The operating time was longer and intraoperative blood loss was greater in the PLF group than the ADF group. More complications were observed in the ADF group than in the PLF group, although the difference was not statistically significant. Conclusion. Long-term neurological function improved significantly after surgery in both groups, with the improvement more pronounced in the ADF group. There was no significant difference in postoperative neck pain between the two groups. The operating time was shorter and intraoperative blood loss was lower in the ADF group; however, the incidence of perioperative complications was higher. Cite this article: Bone Jt Open 2024;5(9):768–775

Multiple thoracic disc herniations are rare and there are few reports in the literature. Between December 1998 and July 2002, we operated on 12 patients with multiple thoracic disc herniations. All underwent an anterior decompression and fusion through a transthoracic approach. The clinical outcomes were assessed using the Frankel neurological classification and the Japanese Orthopaedic Association (JOA) score. Under the Frankel classification, two patients improved by two grades (C to E), one patient improved by one grade (C to D), while nine patients who had been classified as grade D did not change. The JOA scores improved significantly after surgery with a mean recovery rate of 44.8% ± 24.5%. Overall, clinical outcomes were excellent in two patients, good in two, fair in six and unchanged in two. Our results indicate that anterior decompression and fusion for multiple thoracic disc herniations through a transthoracic approach can provide satisfactory results

Injury to the spinal cord and kyphosis are the two most feared complications of tuberculosis of the spine. Since tuberculosis affects principally the vertebral bodies, anterior decompression is usually recommended. Concomitant posterior instrumentation is indicated to neutralise gross instability from panvertebral disease, to protect the anterior bone graft, to prevent graft-related complications after anterior decompression in long-segment disease and to correct a kyphosis. Two-stage surgery is usually performed in these cases. We present 38 consecutive patients with tuberculosis of the spine for whom anterior decompression, posterior instrumentation, with or without correction of the kyphus, and anterior and posterior fusion was performed in a single stage through an anterolateral extrapleural approach. Their mean age was 20.4 years (2.0 to 57.0). The indications for surgery were panvertebral disease, neurological deficit and severe kyphosis. The patients were operated on in the left lateral position using a ‘T’-shaped incision sited at the apex of kyphosis or lesion. Three ribs were removed in 34 patients and two in four and anterior decompression of the spinal cord was carried out. The posterior vertebral column was shortened to correct the kyphus, if necessary, and was stabilised by a Hartshill rectangle and sublaminar wires. Anterior and posterior bone grafting was performed. The mean number of vertebral bodies affected was 3.24 (2.0 to 9.0). The mean pre-operative kyphosis in patients operated on for correction of the kyphus was 49.08° (30° to 72°) and there was a mean correction of 25° (6° to 42°). All except one patient with a neural deficit recovered complete motor and sensory function. The mean intra-operative blood loss was 1175 ml (800 to 2600), and the mean duration of surgery 3.5 hours (2.7 to 5.0). Wound healing was uneventful in 33 of 38 patients. The mean follow-up was 33 months (11 to 74). None of the patients required intensive care. The extrapleural anterolateral approach provides simultaneous exposure of the anterior and posterior aspects of the spine, thereby allowing decompression of the spinal cord, posterior stabilisation and anterior and posterior bone grafting. This approach has much less morbidity than the two-stage approaches which have been previously described

Twenty-two patients with late onset Pott's paraplegia presenting at a mean of 18 years after initial symptoms were reviewed an average of seven years after treatment by anterior decompression and fusion. Fourteen patients had active disease, and in 12 of these, activity at the internal kyphus was the direct cause of the paraplegia. In the other two, a soft healing bony ridge was the cause. The eight patients with healed disease had hard bony ridges compressing the cord. The response to anterior decompression was faster, better and safer in patients with active disease: nine recovered completely and three significantly. In patients with healed disease, the anterior decompression was technically more difficult and the recovery less satisfactory. Significant complications included two cases with neurological deterioration, two with cerebrospinal fluid fistulae and four with neurapraxia of the cord

Seventeen patients with pathological fractures of the thoracolumbar spine which had not responded to conservative treatment are reported. All had compression of the spinal cord and/or severe pain. All (except one treated by lateral rhachotomy) were treated by anterior decompression followed by stabilisation; when the lesion was below T2 the spine was stabilised anteriorly, and when it was higher posterior instrumentation was used. Sixteen of the 17 patients benefited from the procedure

In this series, 15 patients with ossification of the posterior longitudinal ligament underwent anterior decompression to relieve moderate or severe myelopathy, which in 11 included urinary disturbance. The operation consisted of partial resection of the vertebrae, release of the ossified plaque from the surrounding tissue and the insertion of an iliac bone graft. The extent of ossification was confirmed by computerised tomography before and after operation. The plaque was completely detached and moved forward in half of the patients, but only partially moved in the remainder. Symptoms improved considerably. Urinary disturbance disappeared in all patients, but sensory disturbance was left in most. Two patients had prolonged symptoms which were not relieved despite the complete release of the ossified defect

Ten patients who suffered iatrogenic injury to a vertebral artery during anterior cervical decompression were reviewed to assess the mechanisms of injury, their operative management, and the subsequent outcome. All had been undergoing a partial vertebral body resection for spondylitic radiculopathy or myelopathy (4), tumour (2), ossification of the posterior longitudinal ligament (1), nonunion of a fracture (2), or osteomyelitis (1). The use of an air drill had been responsible for most injuries. The final control of haemorrhage had been by tamponade (3), direct exposure and electrocoagulation (1), transosseous suture (2), open suture (1), or open placement of a haemostatic clip (3). Five patients had postoperative neurological deficits, but most of them resolved. We found direct arterial exposure and control to be safe, quick and reliable. Careful use of the air drill, particularly in pathologically weakened bone, as in infection or tumour, is essential. Arterial injury is best avoided by a thorough knowledge of the anatomical relationships of the artery, the spinal canal, and the vertebral body

A total of 39 HIV-infected adults with spinal tuberculosis underwent anterior spinal decompression for neurological deficit. Fresh-frozen allografts were used in 38 patients. Antituberculous drugs were prescribed for 18 months, but antiretroviral therapy was not used. Six patients died within two years of surgery. Neurological recovery and allograft incorporation were observed at follow-up at a mean of 38 months, although the CD4/CD8 ratios were reversed in all patients. Adequate preoperative nutritional support and compliance with antituberculous treatment are essential in ensuring a satisfactory outcome

Aim: To evaluate the outcome of late anterior decompression in patients with dorsal and lumbar spinal injuries with neurological deficit. Background: Anterior decompression and bone graft stabilisation of the spinal injuries allows direct decompression of the spinal canal and provides favourable environment for neurological and functional recovery. Proponents of both early and delayed decompression have shown favourable results. However, what is unclear is the timing of the surgery. Methods: A prospective study of 12 patients with spinal injuries, who had anterior decompression a minimum of 4 weeks after the injury (mean 7.5 weeks). 5 had incomplete and 7 had complete neurological deficit at presentation. The indication for the operation was persistent neurological deficit with retropulsed fragment of bone causing canal compromise. Anterior stablisation after decompression was by means of a tri-cortical iliac crest graft or a rib graft. Results: 8 males, 4 females with average age 26.8 years. 7 lumbar and 5 dorsal spine injuries. Average follow-up of 5.5 years with minimum of 5 years. Post-operative improvement was seen only in patients who sustained injury at the lumbar level, with 6 of the 7 patients regaining normal bladder and bowel function after decompression. Immediate post-operative improvements obtained in the Kyphotic angle were not maintained probably due to the settling of the graft, so posterior or anterior stabilisation may be needed in addition to anterior bone grafting to prevent worsening of the kyphotic angle. Conclusion: Delayed anterior decompression of the lumbar spine in patients who had spinal fractures, is an effective procedure, which may help neurological recovery, especially of the bowel and bladder function

The cervical spine is the most vulnerable segment in high velocity injuries. Bifacet dislocations are associated with significant soft tissue damage and neurological deficit. Management of delayed presentation of cervical facet dislocations, which are not uncommon, is varied. The aims of this study are to create awareness and to develop a management strategy. We retrospectively reviewed 14 patients (10 men and four women) with chronic dislocations treated over 4 years. The mean age was 42.5 years (23 to 62). The delay in presentation ranged from 15 to 135 days. Seven patients had neurological deficit. All patients underwent CT scan and MRI. Common areas of involvement were C6/7 (five patients) and C5/6 (four patients). Associated fracture of posterior elements was identified in 40% of patients. In two patients sequestrated disc ruptured into the canal. All patients underwent surgical reduction and stabilisation, with eight having one-stage and six two-stage surgery. The sequence of one-stage surgery was posterior release, reduction (facet reduction/facetectomy), anterior discectomy and anterior fusion. In three patients with sequestrated discs, anterior decompression preceded posterior release and finally anterior fusion. The six patients who had staged surgery had a prolonged delay (over 3 months) in presentation. Posterior release was followed by an anterior decompression, then a 7 to 10-day period of traction reduction and finally anterior fusion. None of our patients developed neurological deficit. Three patients improved from Frankel-C to Frankel-D. We recommend that the sequence of surgery should be posterior release/reduction and then anterior decompression and anterior fusion. However, in chronic cases, staged reduction and fusion is a viable option

Summary: Twenty six consecutive patients with CSM were operated between Jan 2001–Dec 2004 with anterior corpectomy and reconstruction using strut graft/ lordotic cage and stabilization ACP. 10/26 were wheel chair bound/bought on stretcher. 16/26 had spastic lower limbs with myelopathic hands. Post operatively 20/26 had good gait improvement and are community ambulators. 3/26 house hold ambulators and 1 died. 18/26 had good improvement in hand function. Introduction: Cervical spondylotic myelopathy is a degenerative disease of old age. Patients present with severe disabiling symptoms of spastic gait/inability to walk and varied involvement in the hand. The degenerative spondylosis being the commonest cause, CSM is also caused by OPLL and soft disc herniation. Methods: 26 consecutive patients who had undergone anterior decompression and reconstruction were evaluated for recovery. The gait pattern, hand functions and return to activities were evaluated pre and postoperatively. No specific scoring system could be used in our studies due to practical reasons. Results: 18/26 patients had CSM, 5/26 had OPLL and 3/26 soft disc herniations. Soft disc herniation were at 2 levels and all underwent discectomy, tricortical bone grafting and stabilization with ACP. Other patients had corpectomy 1 level – 4, 2 levels – 9, 3 levels – 4, 4 levels – 1. OPLL was removed in 4/5 patients. Xx/10 patients who were wheel chair bound preoperatively became ambulatory, 3/10 had decrease in spasm but still could not walk postoperatively. At 1 year follow up 9/10 patients had good gait pattern and 1 was still wheel chair bound. 18/26 had good hand function recovery with improvement in hand writing, 16/26 returned to previous activity, 1 patient expired. Conclusion: Anterior decompression for CSN is an effective surgical option. It not only prevents further detoriation, but also improvement is seen in most of the patients. Significance: Anterior decompression is indicated for all patients with CSM, OPLL and disc herniation as the pathology is anterior based

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

The February 2013 Spine Roundup. 360 . looks at: complications with anterior decompression and fusion; lumbar claudication and peripheral vascular disease; increasing cervical instability in rheumatoids; kyphoplasty; cervical stenosis; exercise or fusion for chronic lower back pain; lumbar disc arthroplasty and adjacent level changes; and obese disc prolapses

Patient presenting with clinically significant cervical spinal cord compression have a variety of surgical strategies that may be appropriate. The common denominator for successful intervention is satisfactory decompression of the neural elements, while avoiding early or late complications. In general, one may think of situations with one or two motion segment involvement versus three or more foci of compression. As most applicable cervical pathology causes anterior cord compression, the logic of direct anterior decompression is very compelling. Thus anterior decompression and fusion procedures have been the mainstay of treatment in many quarters. On the other hand, complications with graft healing or displacement, speech and swallowing disturbance, etc. remain an issue. This is especially true for multi-level disease. Under these circumstances, indirect decompression with posterior surgery plays an important role. Laminoplasty, and to a lesser degree laminectomy and fusion, may prove every bit capable of spinal cord decompression and often with fewer complications. Each case must be evaluated on its own merits and the procedure chosen to optimize the likelihood of success

Purpose: A descriptive cohort study of the surgical treatment of spinal tuberculosis in a single unit in the United Kingdom. Tuberculosis is a common disorder and may be increasing in prevalence. 83 cases of spinal involvement with TB occurred and of these 40 patients had a total of 61 interventional procedures. Indications for intervention were:. Progressive neurological deterioration. Failure to respond to treatment. Doubt about the diagnosis. Progressive deformity. Results: The age range was from 12 to 73. Sixteen patients had 17 closed biopsies to assist in establishing the diagnosis, of these four went on require further surgical procedures. There were five intermediate level procedures such as application of halo or removal of hardware. Two patients were Caucasian with no predisposing factors and delays occurred in the initial diagnosis. Diabetes was a significant associated co-morbidity particularly in Asian patients. Multiple procedures were required usually for staged stabilisation after anterior decompression. 2 patients had four procedures, 2 had three procedures and 10 had two procedures 27 had a single procedure. Nine patients that underwent anterior decompression and strut grafting for neurological deterioration went on to have a second stage extra focal fixation and became ambulant. One death occurred from mesenteric infarction at 4 months post op in this group. Significant neurological recovery occurred after surgery in the neurologically impaired patients. Two revision procedures were required in the cervical spine for inadequate primary stabilisation. Conclusion: About half of the spinal TB cases come to interventional procedures. Surgery when required is often a complex decompression and staged reconstruction

Several methods of surgical treatment for pyogenic spondylitis have been reported including anterior approach, staged and simultaneous anterior decompression and posterior stabilisation. The use of anterior implants in the presence of infection presents still a challenge for spine surgeons. Retrospective analysis of the clinical and radiological outcome of patients suffering from pyogenic spondylitis of the cervical and lumbar spine necessitating surgical treatment for intractable pain, instability and neurologic impairment. Seventeen patients with spondylitis associated or not with paravertebral abscess were treated by one stage surgery (first: anterior decompression and placement of titanium mesh cage, filled with autologous iliac bone graft; second: posterior transpedicular instrumentation and fusion). The age of the patients was 54 ±15 years. Most of the patients had systematic problems such as lung tuberculosis, hepatic cirrhosis, diabetes mellitus or chronic renal failure. Patients were evaluated before and after surgery in terms of pain and neurological level, sagittal spinal balance and radiological fusion. All 17 patients were followed for 45 months. Average duration of both surgeries was 4.5 hours. The VAS score improved from 7 (preoperatively) to 2 (postoperatively). The correction of the segmental kyphotic deformity was 6o, without loss of correction or cage migration or instrumentation failure. All patients with incomplete neurologic impairment improved postoperatively. There was neither migration of mesh cage nor posterior instrumentation failure at the follow up observation. There was an approach-related abdominal hernia. This clinical study showed that patients with cervical and thoracolumbar osteomyelitis necessitating surgery for certain indications can successfully undergo instrumented combined, one-stage, same-day surgery. The presence of the mesh cage anteriorly at the site of infection had not negative but beneficial influence on the course of infection healing, and it additionally stabilised the affected segment, maintaining sufficient sagittal profile

Purpose: The purpose of this study was to analyse the learning curve of video-assisted thoracoscopic surgery in a consecutive series of 70 interventions for decompression and intervertebral fusion with rib bone grafts. Material and methods: This series was composed of 70 patients followed for at least two years. The indication of video-assisted thoracoscopic surgery was idiopathic scoliosis (n=32), neuromuscular spinal malformation (n=13), neurofibromatosis (n=1), scoliosis secondary to Marfan disease (n=1), radiation-induced scoliosis (n=1), and nonunion (n=1). The first rib was resected in three patients due to compression. Resection of an intrath-roacic neurofibroma and a benign rib tumour was performed in two patients. Anterior fusion was necessary in one patient due to fracture-displacement of the thoracic spine. Results: Mean operative time for thoracoscopic anterior decompression with discectomy and fusion was 256 minutes (range 150–405). On the average, eight discs were removed (range 4–11). Comparison of mean operative time per disc between the first interventions (n=31) and the later interventions (n=32) did not demonstrate any significant difference. Mean blood loss during thora-coscopic anterior decompression with discectomy and fusion was 285 ml (range 50–1300). Discussion: Definitive postoperative correction was achieved in 68% and 90% of the patients with scoliosis and kyphosis respectively. A thoracoscopy-related complication was observed in three patients. Video-assisted thoracoscopic surgery is an interesting alternative to conventional thoracotomy allowing effective safe treatment of infantile spinal malformations despite a long learning curve

A retrospective review, comparing outcome following circumferential versus anterior decompression and fusion for patients with cervical spondylotic myelopathy (CSM). To assess the safety and efficacy of the circumferential operation for CSM. Cervical spondylotic myelopathy has traditionally been managed by anterior or posterior decompression with/ without fusion. However, there is a considerable variation in neurological recovery and clinical outcome following these procedures. While circumferential decompression and fusion has been shown to provide superior neurological outcome in selected patients with cervical trauma and tumours, its role in the management of CSM has yet to be clearly defined. Fifteen patients who underwent a 360° operation (Groupl) for CSM were matched (age, number of levels operated and follow-up duration) with patients (Group 2, n=15), that underwent anterior decompression and fusion for the same problem. All patients were operated by a single surgeon and reviewed independently. Charts, radiographs, patient interviews and MODEMS Cervical Spine Outcome questionnaires were the basis for assessment. The operative time, blood loss, in-hospital stay and post-operative complications were higher in group l. The pseudoarthrosis rate was comparable though a trend towards increased graft and hardware problems was noted in group 2. Neurological improvement as measured by the mJOA Myelopathy Scale was significantly better (p = 0. 039) in group 1. 87% of those in group1 and 67% in group 2 showed improved function. Patients in group1 also performed better (p=0. 056) in the neurological domain and treatment expectation scales of the cervical spine questionnaire, though the incidence of post-op, neck pain was higher. Single stage circumferential spinal decompression and fusion permits consistent neurological recovery in selected patients with cervical spondylotic myelopathy and it can be performed with limited morbidity

The October 2023 Spine Roundup³⁶⁰ looks at: Cutting through surgical smoke: the science of cleaner air in spinal operations; Unlocking success: key factors in thoracic spine decompression and fusion for ossification of the posterior longitudinal ligament; Deep learning algorithm for identifying cervical cord compression due to degenerative canal stenosis on radiography; Surgeon experience influences robotics learning curve for minimally invasive lumbar fusion; Decision-making algorithm for the surgical treatment of degenerative lumbar spondylolisthesis of L4/L5; Response to preoperative steroid injections predicts surgical outcomes in patients undergoing fusion for isthmic spondylolisthesis.