Aims

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

We studied the use of autologous pre-donated blood transfusion in surgery for scoliosis in 45 patients who were divided into two groups; 27 who pre-donated autologous blood (group 1) and 18 who were planned recipients of allogenic blood (group 2). Normovolaemic haemodilution and intra-operative blood salvage was used in six patients in group 1 and three patients in group 2. The two groups did not differ significantly with respect to age, American Society of Anaesthesiologists score, mean operative time, number of vertebral segments fused, total blood loss, length of stay in intensive care and length of stay in hospital. The risk of requiring allogenic blood transfusion was found to be significantly less in group 1 (7.4% ν 88.9%, p < 0.001). Only 5.21% of autologous units were wasted. Although intra-operative blood salvage reduced the total blood loss in both groups, it did not affect the need for subsequent allogenic transfusion or reduce the number of pre-donated autologous units which were given (p < 0.67). Autologous blood transfusion required extra time, personnel, resources and cost £28.88 per patient more than allogenic transfusion, however, the projected costs at May 2002 make this programme cost-effective by £51.54 per patient. Pre-donated autologous blood transfusion is acceptable and safe in scoliosis surgery. It significantly reduces the subsequent requirement of allogenic transfusion. Although the cost is currently more than allogenic transfusion, with the increase in the costs of the latter and the decrease in potential donors which is anticipated, pre-donation of autologous blood will become comparatively cost-effective

Purpose of the study. Two patients with very severe thoracolumbar Scheuermann's kyphosis who developed spontaneous bony fusion across the apex of the deformity are presented and their treatment, as well as surgical outcome is discussed. Summary of Background Data. Considerable debate exists regarding the pathogenesis, natural history and treatment of Scheuermann's kyphosis. Surgical correction is indicated in the presence of severe kyphosis which carries the risk of neurological complications, persistent back pain and significant cosmetic deformity. Methods. We reviewed the medical notes and radiographs of 2 adolescent patients with severe thoracolumbar Scheuermann's kyphosis who developed spontaneous posterior and anteroposterior fusion across the apex of the deformity. Results. Patient 1. A male patient aged 17 years and 11 months underwent kyphosis correction when the deformity measured 115o and only corrected to 100o on supine hyperextension radiograph against the bolster; he had a small associated scoliosis. The surgery involved a combined single-stage anterior and posterior spinal arthrodesis T4-L3 with the use of posterior pedicle hook/screw/rod instrumentation and autologous rib graft. The anterior longitudinal ligament was ossified from T10 to L1 with bridging osteophytes extending circumferentially from T11 to T12 at the apex of kyphosis and displacing the major vessels anteriorly. The intervertebral discs from T9 to T12 were very stenotic and immobile. The osteophytes were excised both on the convexity and concavity of the associated thoracolumbar scoliosis. The anterior longitudinal ligament was released and complete discectomies back to the posterior longitudinal ligament were performed from T7 to L1. During the posterior exposure, the spine was found to be spontaneously fused across the apex of the kyphosis from T9 to L1. There were no congenital vertebral anomalies. Extensive posterior apical closing wedge osteotomies were performed from T7 to T12. The fused facets and ossified ligamentum flavum were excised and the spine was mobilised at completion of the anterior and posterior osteotomies. The kyphosis was corrected using a cantilever maneuver from proximal to distal under spinal cord monitoring. Excellent correction to 58o was achieved and maintained at follow-up. Autologous rib graft was used to enhance a solid bony fusion. Patient 2. A female patient aged 18 years and one month underwent kyphosis correction when the deformity measured 115o and only corrected to 86o on supine hyperextension radiograph against the bolster; she had a small thoracolumbar scoliosis. The surgery involved a single-stage posterior spinal arthrodesis T2-L4 with the use of posterior pedicle hook/screw/rod instrumentation and autologous iliac crest bone. The spine was spontaneously fused across the apex of kyphosis from T9 to L1. There were no congenital vertebral anomalies. Extensive posterior apical closing wedge osteotomies were performed from T6 to T12. The fused facets and ossified ligamentum flavum were excised and the spine was mobilised at completion of the osteotomies. The kyphosis was corrected using a cantilever maneuver from proximal to distal under spinal cord monitoring. Excellent correction to 60o was achieved and maintained at follow-up. Autologous iliac crest graft was used to achieve a solid bony fusion. In both patients the preoperative MRI assessed the intraspinal structures but failed to diagnose the solid fusion across the posterior bony elements at the apex of kyphosis. A CT scan with 3D reconstruction would have illustrated the bony anatomy across the kyphosis giving valuable information to assist surgical planning. This is recommended in the presence of rigid thoracolumbar Scheuermann's kyphosis which does not correct in hyperextension, especially if the plain radiograph shows anterior bridging osteophytes. Conclusion. Spontaneous posterior or anteroposterior fusion can occur across the apex of severe thoracolumbar Scheuermann's kyphosis; this should be taken into account when surgical correction is anticipated. The bony ankylosis may represent the natural history of an extreme deformity as an attempt of the spine to auto-stabilise. A combination of factors including a rigid deformity, which limits significantly active movement of the spine, as well as anterior vertebral body wedging with severe adjacent disc stenosis which induces bridging osteophyte formation may result in the development of spontaneous fusion across the apex of the kyphosis either posteriorly or anteroposteriorly. In the presence of an isolated posterior fusion, segmental posterior closing wedge osteotomies with complete excision of the ossified ligamentum flavum and fused facets should mobilise the thoracolumbar spine and allow for kyphosis correction. An additional anterior spinal release including complete discectomies, resection of the anterior longitudinal ligament and osteophytes is required if the bony fusion extends anteroposteriorly. Patients with Scheuermann's kyphosis should be ideally treated at an earlier stage and with a lesser degree of deformity so that this ossification process is prevented

This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review.

We studied 70 consecutive patients with adolescent idiopathic scoliosis who underwent corrective surgery. They were divided into two groups. In the study group of 38 patients one or more modern blood-conservation measures was used peri-operatively. The 32 patients in the control group did not have these measures. Both groups were similar in regard to age, body-weight, the number of levels fused and the type of surgery. Only two patients in the study group were transfused with homologous blood and these transfusions were ‘off-protocol’. Wastage of autologous pre-donated units was minimal (6 of 83 units). By contrast, all patients in the control group were transfused with homologous blood. In the study group there was a significant decrease (p = 0.005) in the estimated blood loss when all the blood-conservation methods were used. The use of blood-conservation measures, the lowering of the haemoglobin trigger for transfusion and the education of the entire team involved in the care of the patient can prevent the need for homologous blood transfusion in patients undergoing surgery for adolescent idiopathic scoliosis

Background. For bone grafting procedures, the use of autologous bone is considered the gold standard, as it is has a better healing capacity compared to other alternatives as allograft and synthetic bone substitutes. However, as there are several drawbacks related to autografting (infection, nerve- or vascular damage, chronic pain problems, abdominal herniation), there has been a targeted effort to improve the healing capacities of synthetic bone substitutes. Aim. To evaluate the performance of a carbonated osteoionductive hydroxyapatite (CHA) scaffold of clinical relevant size (Ø=15mm, H=50mm) in a sheep model of multi level posterolateral intertransverse lumbar spine fusion after activation with autologous bone marrow nuclear cells (BMNC) in a flow perfusion bioreactor. Method. Two groups were included in the study, autograft (n=6) and CHA scaffold (n=6) CHA. A paired design was used between and within the groups as lumbar posterolateral arthrodesis was performed in sheep on two levels (L2-L3, L5-L6) +/− BMNC, respectively. Before implantation, the CHA scaffold was cultured in a flow perfusion bioreactor system with BMNC for 21 days, and the autograft group was supplemented with isolated BMNC during the procedure. Micro tomography was used to evaluate fusion rate and the microarchitectural properties of the explants after an observation period of four months. Results. In the autograft group, the healing rate was 83.3% irrespective of the presence BMNC, and in the CHA group, 66.7% fused in the presence of BMNC, and 33.3% without. The microarchitectural data suggested the autograft group to be superior to the CHA scaffold regarding mechanical properties, however porosity decreased significantly (p=0.001) in the CHA scaffold group suggesting deposition of mineralized bone matrix. Conclusion. Based on the fusion rate and micro architectural properties, we consider the CHA scaffold fully capable of new bone formation, and that the presence of BMNC has a positive effect on the fusion rate in a challenging model of bone healing

To assess radiological fusion rates in posterolateral fusions using SiS-CaP. Retrospective, radiological follow-up study. Single surgeon series of 76 consecutive patients were evaluated, in a regional spinal unit. All patients had clinical and radiological (MRI) spinal canal stenosis secondary to degenerative spondylosis or spondylolisthesis. Surgery consisted of instrumentation, decompression and meticulous preparation of the posterolateral graft bed by removal of all soft tissues posterior to the inter-transverse membrane and decortication of transverse processes (TPs). SiS-CaP putty was injected into this gutter and moulded around the instrumentation. Good quality, well prepared bone chips from the posterior decompression were seeded into the putty. Patient radiographs were reviewed at 3-6 months, 1 year and 2 years. Radiographs were assessed using a protocol to examine granularity, bone formation and evidence of pseudarthrosis, based upon previously reported literature . 1. and our personal experience. Of the 76 patients, 26 were excluded. M:F was 21:29. Mean age was 58yrs. Average number of motion segments fused per case was 2.2. There was one pseudarthrosis with metalwork fracture, and thus a total fusion rate of 98%. In addition, one patient had scanty bridging of TPs, and one patient had lucency around the S1 screws. SiS-CaP, as a bone graft substitute in posterolateral instrumented fusions, gives comparable results to published fusion rates using autologous iliac crest grafting and/or Bone Morphogenic Protein . 2. Moreover, it avoids the associated morbidity of iliac bone harvest

To determine the current practice of scoliosis surgery in the UK. A 10 point questionnaire was constructed to identify the philosophy of surgeons on various aspects of scoliosis surgery such as choice of implant, bone graft, autologous blood transfusion (ABT), cord monitoring and computer assisted surgery. Results are compared with the current best evidence. Consultants and Fellows attending the 2009 British Scoliosis Society meeting. 50 questionnaires were completed: 45 Consultants and 5 Fellows. All pedicle screw construct favored by 25/50, hybrid 24/50 (one undecided). Posterior construct of less than 10 levels, 20/50 would not cross-link, 11/50 used one and 19/20 used two or more. More than ten levels 17/50 considered cross-links unnecessary, 4/50 used one and 29/50 used two or more. 88% preferred titanium alloy implants, while a mixture of stainless steel and cobalt chrome was used by others. For bone graft, substitutes (24), iliac crest (14), allograft (12) and demineralised bone matrix (9) in addition to local bone. 10/50 would use recombinant bone morphogenetic protein (3 for revision cases only). 39/50 routinely used intra-operative cell salvage or ABT drains and 4/50 never used autologous blood. All used cord monitoring, Sensory (19/50), Motor (2/50) and combined (29/50). None used computer-aided surgery. 26 operated alone 12 operated in pairs and 12 varied depending on type of case. This survey has brought to light interesting variations in scoliosis surgery in UK. It may reflect the conflicting evidence in the literature

We conducted a prospective, randomised study of 42 cervical interbody fusions undertaken with either an autologous tricortical graft or a cage. The factors assessed in the two groups were: (1) time taken to achieve fusion; (2) neck disability index; (3) pain score; (4) interbody height ratio; (5) interbody angle and (6) the influence of smoking on fusion. No statistical difference was seen in the time taken to achieve fusion, neck disability index, interbody height ratio, or interbody angles. Smoking did not have any effect on the fusion process. The pain score was significantly lower in the tricortical graft group at six months. We conclude that both methods of fusion give similar results, although tricortical graft fusion is cheaper than cage fusion, and is more effective in reducing the pain score

Purpose of the study. We report septic shock as postoperative complication following an instrumented posterior spinal arthrodesis on a patient with multiple body piercings. The management of this potentially catastrophic complication and outcome of treatment is been discussed. Summary of Background Data. Body piercing has become increasingly more common due to change in culture or as a fashion statement. This has been associated with local or generalized ill effects including tissue injury, skin and systemic infections, and septic shock. There is no clear guideline pathway regarding removal and reinsertion of body piercings in patients who undergo major surgery. Complications following Orthopaedic or Spinal procedures associated with body piercing have not been reported. Methods. We reviewed the medical notes and radiographs of an adolescent patient with severe Scheuermann's kyphosis and multiple body piercings who underwent an uneventful posterior spinal arthrodesis with pedicle hook/screw/rod instrumentation and autologous iliac crest bone graft and developed septic shock. Results. Septic shock developed on postoperative day 2 after reinsertion of all piercings following patient's request. The patient became systemically very unwell and required intensive medical management, as well as a total course of antibiotics of 3 months. The piercings remained in situ. She did not develop a wound infection despite the presence of bacteraemia (coagulase-negative Staphylococci/Streptococci warneri) and spinal instrumentation. The patient had no new piercings subsequent to her deformity procedure. Two and a half years after spinal surgery she reported no medical problems, had a balanced spine with no loss of kyphosis correction and no evidence of nonunion or recurrence of deformity. Conclusion. The development of septic shock as a result of piercing reinsertion in the postoperative period has not been previously reported. This is an important consideration to prevent potentially life-threatening complications following major spinal surgery. Despite the wide array of complications associated to body art there are no clear guidelines for body piercing. There is growing public awareness and several countries are laying regulations which have not yet been internationally standardized. A clear practice guideline in the perioperative management of piercings is needed as the incidence of body piercing and associated complications is rising. There is need for surgeons to be aware of the hazards of body piercing and its implications. We propose that multiple piercings should not be reinserted after major surgery and appropriate counseling should be provided to the patients as part of the consent process

Aims

It is uncertain whether instrumented spinal fixation in nonambulatory children with neuromuscular scoliosis should finish at L5 or be extended to the pelvis. Pelvic fixation has been shown to be associated with up to 30% complication rates, but is regarded by some as the standard for correction of deformity in these conditions. The incidence of failure when comparing the most caudal level of instrumentation, either L5 or the pelvis, using all-pedicle screw instrumentation has not previously been reported. In this retrospective study, we compared nonambulatory patients undergoing surgery at two centres: one that routinely instrumented to L5 and the other to the pelvis.

Aims

In a multicentre, randomised study of adolescents undergoing posterior spinal fusion for idiopathic scoliosis, we investigated the effect of adding gelatine matrix with human thrombin to the standard surgical methods of controlling blood loss.

Aims

Minimally invasive transforaminal lumbar interbody fusion (MITLIF) has been well validated in overweight and obese patients who are consequently subject to a higher radiation exposure. This prospective multicentre study aimed to investigate the efficacy of a novel lumbar localisation system for MITLIF in overweight patients.

Aims

We present the results of correcting a double or triple curve adolescent idiopathic scoliosis using a convex segmental pedicle screw technique.

Aims

Clinical and radiological data were reviewed for all patients with mucopolysaccharidoses (MPS) with thoracolumbar kyphosis managed non-operatively or operatively in our institution.

Aims

We reviewed 34 consecutive patients (18 female-16 male) with isthmic spondylolysis and grade I to II lumbosacral spondylolisthesis who underwent in situ posterolateral arthodesis between the L5 transverse processes and the sacral ala with the use of iliac crest autograft. Ten patients had an associated scoliosis which required surgical correction at a later stage only in two patients with idiopathic curves unrelated to the spondylolisthesis.

Objectives

We performed a systematic review of the literature to determine the safety and efficacy of bone morphogenetic protein (BMP) compared with bone graft when used specifically for revision spinal fusion surgery secondary to pseudarthrosis.

Mesenchymal stem-cell based therapies have been proposed as novel treatments for intervertebral disc degeneration, a prevalent and disabling condition associated with back pain. The development of these treatment strategies, however, has been hindered by the incomplete understanding of the human nucleus pulposus phenotype and by an inaccurate interpretation and translation of animal to human research. This review summarises recent work characterising the nucleus pulposus phenotype in different animal models and in humans and integrates their findings with the anatomical and physiological differences between these species. Understanding this phenotype is paramount to guarantee that implanted cells restore the native functions of the intervertebral disc.

Cite this article: Bone Joint Res 2013;2:169–78.

This article reviews the current knowledge of the intervertebral disc (IVD) and its association with low back pain (LBP). The normal IVD is a largely avascular and aneural structure with a high water content, its nutrients mainly diffusing through the end plates. IVD degeneration occurs when its cells die or become dysfunctional, notably in an acidic environment. In the process of degeneration, the IVD becomes dehydrated and vascularised, and there is an ingrowth of nerves. Although not universally the case, the altered physiology of the IVD is believed to precede or be associated with many clinical symptoms or conditions including low back and/or lower limb pain, paraesthesia, spinal stenosis and disc herniation.

New treatment options have been developed in recent years. These include biological therapies and novel surgical techniques (such as total disc replacement), although many of these are still in their experimental phase. Central to developing further methods of treatment is the need for effective ways in which to assess patients and measure their outcomes. However, significant difficulties remain and it is therefore an appropriate time to be further investigating the scientific basis of and treatment of LBP.

We reviewed 212 consecutive patients with adolescent idiopathic scoliosis who underwent posterior spinal arthrodesis using all pedicle screw instrumentation in terms of clinical, radiological and Scoliosis Research Society (SRS)-22 outcomes. In Group 1 (51 patients), the correction was performed over two rods using bilateral segmental pedicle screws. In Group 2 (161 patients), the correction was performed over one rod using unilateral segmental pedicle screws with the second ^{rod providing stability of the construct through two-level screw fixation at proximal and distal ends. The mean age at surgery was 14.8 years in both groups. Comparison between groups showed no significant differences with regard to age and Risser grade at surgery, pre- and post-operative scoliosis angle, coronal Cobb correction, length of hospital stay and SRS scores. Correction of upper thoracic curves was significantly better in Group 1 (p = 0.02). Increased surgical time and intra-operative blood loss was recorded in Group 1 (p < 0.001 and p = 0.04, respectively). The implant cost was reduced by mean 35% in Group 2 due to the lesser number of pedicle screws.}

Unilateral and bilateral pedicle screw techniques have both achieved excellent deformity correction in adolescent patients with idiopathic scoliosis, which was maintained at two-year follow-up. This has been associated with high patient satisfaction and low complication rates.