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

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. Methods. The Swedish Spinal Stenosis Study was a multicentre randomized controlled trial with recruitment from September 2006 to February 2012. A total of 247 patients with one- or two-level central lumbar spinal stenosis, stratified by the presence of DS, were randomized to decompression alone or decompression with fusion. The five-year Oswestry Disability Index (ODI) was the primary outcome. Secondary outcomes were the EuroQol five-dimension questionnaire (EQ-5D), visual analogue scales for back and leg pain, and patient-reported satisfaction, decreased pain, and increased walking distance. The reoperation rate was recorded. Results. Five-year follow-up was completed by 213 (95%) of the eligible patients (mean age 67 years; 155 female (67%)). After five years, ODI was similar irrespective of treatment, with a mean of 25 (SD 18) for decompression alone and 28 (SD 22) for decompression with fusion (p = 0.226). Mean EQ-5D was higher for decompression alone than for fusion (0.69 (SD 0.28) vs 0.59 (SD 0.34); p = 0.027). In the no-DS subset, fewer patients reported decreased leg pain after fusion (58%) than with decompression alone (80%) (relative risk (RR) 0.71 (95% confidence interval (CI) 0.53 to 0.97). The frequency of subsequent spinal surgery was 24% for decompression with fusion and 22% for decompression alone (RR 1.1 (95% CI 0.69 to 1.8)). Conclusion. Adding fusion to decompression in spinal stenosis surgery, with or without spondylolisthesis, does not improve the five-year ODI, which is consistent with our two-year report. Three secondary outcomes that did not differ at two years favoured decompression alone at five years. Our results support decompression alone as the preferred method for operating on spinal stenosis. Cite this article: Bone Joint J 2024;106-B(7):705–712

Aims. Degenerative cervical spondylosis (DCS) is a common musculoskeletal disease that encompasses a wide range of progressive degenerative changes and affects all components of the cervical spine. DCS imposes very large social and economic burdens. However, its genetic basis remains elusive. Methods. Predicted whole-blood and skeletal muscle gene expression and genome-wide association study (GWAS) data from a DCS database were integrated, and functional summary-based imputation (FUSION) software was used on the integrated data. A transcriptome-wide association study (TWAS) was conducted using FUSION software to assess the association between predicted gene expression and DCS risk. The TWAS-identified genes were verified via comparison with differentially expressed genes (DEGs) in DCS RNA expression profiles in the Gene Expression Omnibus (GEO) (Accession Number: GSE153761). The Functional Mapping and Annotation (FUMA) tool for genome-wide association studies and Meta tools were used for gene functional enrichment and annotation analysis. Results. The TWAS detected 420 DCS genes with p < 0.05 in skeletal muscle, such as ribosomal protein S15A (RPS15A) (PTWAS = 0.001), and 110 genes in whole blood, such as selectin L (SELL) (PTWAS = 0.001). Comparison with the DCS RNA expression profile identified 12 common genes, including Apelin Receptor (APLNR) (PTWAS = 0.001, PDEG = 0.025). In total, 148 DCS-enriched Gene Ontology (GO) terms were identified, such as mast cell degranulation (GO:0043303); 15 DCS-enriched Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways were identified, such as the sphingolipid signalling pathway (ko04071). Nine terms, such as degradation of the extracellular matrix (R-HSA-1474228), were common to the TWAS enrichment results and the RNA expression profile. Conclusion. Our results identify putative susceptibility genes; these findings provide new ideas for exploration of the genetic mechanism of DCS development and new targets for preclinical intervention and clinical treatment. Cite this article: Bone Joint Res 2023;12(1):80–90

Introduction. Degenerative cervical myelopathy (DCM) is associated with progressive neurological deterioration. Surgical decompression can halt but not reverse this progression. The Modified Japanese Orthopaedic Assessment (MJOA) tool is recommended by international guidelines to grade disease severity into mild, moderate and severe, where moderate and severe are both recommended to undergo surgical intervention. During Covid-19 Nottingham University Hospitals (NUH) NHS Trust, identified DCM patients as high risk for sustaining permanent neurological damage due to surgical delay. The Advanced Spinal Practitioner (ASP) team implemented a surveillance project to evaluate those at risk. Methods. A spreadsheet was compiled of all DCM patients known to the service. Patients were telephoned (Oct-Nov 2021) by an ASP. MJOA score was recorded and those describing progressive deterioration were reviewed by the ASP team on a spinal same day emergency assessment unit. Incident forms were completed for clinical deterioration and recorded as severe harm. Acute, progressive neurological deterioration was fast tracked for emergency surgical decompression. Results. 45 patients were telephoned, 18 (40%) had deteriorated. Of the 18, 9 underwent urgent surgical decompression, 6 still await surgery and 3 continue to be monitored. Those who had deteriorated were sent a formal apology and duty of candour letter. Conclusion. It appears that patients with a diagnosis of DCM deteriorate over time. Delays to timely surgical intervention can have a deleterious effect on patient's neurological function. Baseline assessment should be clearly documented and scoring system such as MJOA considered for effective monitoring. Safety netting for deterioration should be standard practice, and a clear pathway for emergency presentation identified. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Purpose of Study and Background. Degenerative cervical myelopathy resulting in cord compromise is a progressive condition that results in significant quality of life limitations. Surgical treatment options available are anterior and/or posterior decompression of the affected levels. Patients are counselled pre-operatively that the aim of surgical intervention is to help prevent deterioration of neurology. Anecdotal evidence suggested improvements in both EMS and PROMs in this cohort of patients. A 2-year prospective study tested this hypothesis. Methodology and Results. 67 patients undergoing anterior cervical surgery were followed up to two years. Myelopathic features, radiological cord compression, myelomalacia change and levels of surgery were recorded. Pre/post intervention myelopathy scores/grades, and PROM's were recorded. Paired t-test was performed when comparing pre/post intervention scores and Annova test when comparing results across levels. Our prospective study identified statistically significant improvements in European myelopathy scores and grade and patient reported clinical outcomes in the said population. Conclusions. DCSM patients undergoing anterior surgery demonstrated statistically significant improvement in PROMs and EMS scores and grades. This has been demonstrated irrespective of number of surgical levels. Conflicts of Interest: None. Sources of Funding: None. Previously presented as a poster at Cervical Spine Research Society, Paris 2020-Virtual Meeting

Introduction. Degenerative spondylosis (DS) represents a challenging condition to diagnose and treat. There are multiple modalities to investigate DS including X-ray, MRI and CT, but symptoms may not be equivocal to DS to support the clinical findings. The investigation of metastases commonly utilises SPECT/CT for identification of areas of increased osteoblastic activity to denote disease. The aim of the study was to analyse the prevalence of asymptomatic DS in a consecutive hospital cohort of oncology patients who had SPECT/CT for investigation of metastases. Methods. Oncology patients who underwent SPECT/CT at St. George's Hospital were analysed between 2015–2019. Exclusion criteria: back pain, inflammatory disorders, metastases, trauma, infection. Radiology reports were examined for DS and anatomical distribution of tracer uptake. Results. A total of 1182 patients had a Whole-Body SPECT CT used for the spinal analysis. After exclusions (age >80 [n=260], non-cancer [n=318], back pain [n=72]), 522 reports with cancer were utilised. Mean age was 65 (4–80). Age and distribution of DS are given in the table. Conclusion. The prevalence of radiological asymptomatic DS is prevalent in large proportions of patients without back pain, and its incidence increases with age. Approximately 60% of 60 year old and 70% of 70 years old patients have asymptomatic DS in the lumbosarcal region. We conclude that SPECT/CT will detect radiographic degenerative spondylosis in an asymptomatic hospital cohort and this prevalence increase with age. Therefore, this modality of imaging must be utilised with caution when investigating potential pain generators. For any figures or tables, please contact the authors directly

Aims. Chronic low back pain due to degenerative disc disease is sometimes treated with fusion. We compared the outcome of three different fusion techniques in the Swedish Spine Register: noninstrumented posterolateral fusion (PLF), instrumented posterolateral fusion (IPLF), and interbody fusion (IBF). Patients and Methods. A total of 2874 patients who were operated on at one or two lumbar levels were followed for a mean of 9.2 years (3.6 to 19.1) for any additional lumbar spine surgery. Patient-reported outcome data were available preoperatively (n = 2874) and at one year (n = 2274), two years (n = 1958), and a mean of 6.9 years (n = 1518) postoperatively and consisted of global assessment and visual analogue scales of leg and back pain, Oswestry Disability Index, EuroQol five-dimensional index, 36-Item Short-Form Health Survey, and satisfaction with treatment. Statistical analyses were performed with competing-risks proportional hazards regression or analysis of covariance, adjusted for baseline variables. Results. The number of patients with additional surgery were 32/183 (17%) in the PLF group, 229/1256 (18%) in the IPLF group, and 439/1435 (31%) in the IBF group. With the PLF group as a reference, the hazard ratio for additional lumbar surgery was 1.16 (95% confidence interval (CI) 0.78 to 1.72) for the IPLF group and 2.13 (95% CI 1.45 to 3.12) for the IBF group. All patient-reported outcomes improved after surgery (p < 0.001) but were without statistically significant differences between the groups at the one-, two- and 6.9-year follow-ups (all p ≥ 0.12). Conclusion. The addition of interbody fusion to posterolateral fusion was associated with a higher risk for additional surgery and showed no advantages in patient-reported outcome. Cite this article: Bone Joint J 2019;101-B:1526–1533

Degenerative spondylolisthesis is four times more common in women than in men. Although this gender difference has long been recognised there has been no explanation for it. We have examined the radiographs and CT scans of 118 patients over the age of 55 years and of a control group under the age of 46 years. Our findings confirmed the presence of more sagittally-orientated facet joints in patients with degenerative spondylolisthesis but did not show that the gender difference can be explained by the morphology of the facet joint. Furthermore, we conclude that the increased angle of the facet joint is the result of arthritic remodelling and not the primary cause of degenerative spondylolisthesis. It is more likely to be due to loss of soft-tissue resilience with subsequent failure of the facet joints which are acting as the last restraints to subluxation

Aim:. The purpose of this study was to identify factors (radiographic and MRI) which may be important in determining whether a degenerative spondylolisthesis at L4/5 is mobile. Method:. We identified 60 consecutive patients with a degenerative spondylolisthesis(DS) at L4/5 and reviewed their imaging. Patients were separated into groups on the basis of whether the DS was mobile (group A) or non-mobile (Group B) when comparing the upright plain lumbar radiograph to the supine MRI. We assessed the lumbar lordosis, pelvic incidence, sacral slope, pelvic tilt, grade of the slip, facet angles at L4/5, facet tropism, facet effusion size, facet degenerative score (cartilage and sclerosis values) and disc degenerative score (Pfirrmann) at L4/5. Results:. There were 40 patients in group A and 20 in group B. Mean age for group A was 69.2 years and for group B was 66.2 years. The difference was not significant (p-0.27; 95% CI 2.5–8.7). No significant differences were found between groups for pelvic incidence (p-0.75; 95% CI 4.6–6.3), pelvic tilt (p-0.62; 95% CI 3.2–5.3), sacral slope (p-0.51; 95% CI 3.2–6.5), lumbar lordosis (p-0.46; 95% CI 9.5–4.3), degree of facet tropism (p-0.4) and magnitude of the facet effusions (p-0.1). Facet angle differences between groups approached significance (p-0.058; 95% CI 0.1–6.7). Significant differences between groups were found in cartilage degenerative score (p-0.002), facet sclerosis grade (p-0.00) and disc degenerative score (p-0.00). In group B 10 out of 20 (50%) reduced fully and were not apparent on the MRI only. Conclusions:. Sagittal pelvic parameters do not play a significant role in differentiating between mobile and non-mobile DS at L4/5. Mobile DS tends to be associated with more sagittally orientated facets, lower Pfirmann grade, lower facet cartilage and sclerosis degenerative scores. Standing plain lumbar radiographs are essential in all patients over the age of 40 years in order not to miss up to 17% of DS at L4/5. Conflict Of Interest Statement: No conflict of interest

Background and Purpose. Intervertebral disc (IVD) degeneration is a prominent cause of low back pain. IVD cells expressing angiopoietin-1 receptor Tie2 represent a progenitor cell population which decreases with progression of IVD degeneration. Homing of mesenchymal stem cells (MSCs) is a physiological mechanism aiming to enhance the regenerative capacity of the IVD. The purpose of this study was to assess the effect of MSC homing on the Tie2 positive IVD progenitor cell population, the IVD cell viability, and the proliferative phenotype of the IVD cells. Methods and Results. Human MSCs were isolated from bone marrow aspirates and labelled with fluorescent dye. Whole IVDs with endplates were harvested from bovine tails; MSCs were placed on the endplates. Human traumatic, degenerative and healthy IVD tissues were obtained from patients and organ donors. MSCs were added onto tissue samples. After 5 days, IVD cells were isolated. Percentages of Tie2 positive, DAPI positive (dead) and Ki-67 positive (proliferative) IVD cells were determined. MSC homing or co-culture significantly increased the proportion of Tie2 positive progenitor IVD cells in bovine and 7/10 human IVDs, decreased the fraction of dead IVD cells in bovine and 7/10 human IVDs, and induced a proliferative phenotype in bovine and 5/6 human IVDs. Conclusion. Stimulation of bovine and human IVDs by MSC homing resulted in an enhanced population of Tie2 positive IVD progenitor cells, induced a proliferative response and reduced IVD cell death. Hence, the interaction with recruited MSCs may contribute to an improved survival of IVD cells, helping to reverse or slow down an ongoing degenerative process. Conflicts of interest: The authors declare no conflicts of interest. Sources of funding: AO Foundation and AOSpine International

Aims. There is a paucity of information on the pre-operative coronal imbalance in patients with degenerative lumbar scoliosis (DLS) and its influence on surgical outcomes. Patients and Methods. A total of 284 DLS patients were recruited into this study, among whom 69 patients were treated surgically and the remaining 215 patients conservatively Patients were classified based on the coronal balance distance (CBD): Type A, CBD < 3 cm; Type B, CBD > 3 cm and C7 Plumb Line (C7PL) shifted to the concave side of the curve; Type C, CBD > 3 cm and C7PL shifted to the convex side. Results. A total of 99 of the 284 (34.8%) patient presented with a pre-operative coronal imbalance (mean CBD: 48.5, standard deviation 18.7 mm). More patients with a Type B malalignment were observed than with a Type C malalignment (62 versus 37). A total of 21 pf the 69 (30.4%) surgically treated patients had a post-operative coronal imbalance, which was found to be more prevalent in Type C patients (p < 0.001). At follow-up, less improvement was observed in terms of Short Form-36 Physical Component Score and visual analogue score for back pain (p = 0.034 and 0.025, respectively) in Type C patients. Conclusion. This study shows that patients with Type C coronal malalignment may be at greater risk of post-operative coronal imbalance following posterior osteotomy. Cite this article: Bone Joint J 2016;98-B:1227–33

The prevalence of degenerative spondylolisthesis (DS) increases with age. With an ageing population there will be increasing demands for adult deformity surgery, with associated significant financial and complication costs. The prevalence of lytic spondylolisthesis (LS) is 6–8%. Our clinical observation is that it is extremely rare to see LS in the presence of DS and therefore the objective was to formally describe the prevalence of LS in combination with DS to assess the hypothesis that 6–8% of patients with DS should also have LS. If this is not the case it may further our understanding of the pathogenesis of DS, which could aid in future prevention or treatment. A retrospective review of erect lateral lumbar radiographs demonstrating lumbar spondylolisthesis was performed. Radiographs were identified and analysed on the hospital Synapse Picture Archiving and Communication System (PACS). Search criteria were radiographs requested by primary care and patients aged over 60. 101 patients with spondylolisthesis were identified. 89% were requested for back or leg pain. There were 89 patients with DS (69.7% women) and 12 with LS (83% men). The average age of DS and LS patient was 75 and 70 respectively (not significant). There were no cases found with both DS and LS. This was significantly different to the expected amount of 6% (p=0.03). The level of DS was at L3/4 in 11.2% (n=10), L4/5 in 79.8% (n=71) and L5/S1 in 16.9% (n=15). 2 levels were involved in 7 patients. 94.4% (n=84) demonstrated a Meyerding grade 1 slip and 5.6% (n=5) grade 2 slip. For LS the slipped level was at L5/S1 in all cases. 66.7% (n=8) had a grade 1 slip and 33.3% (n=4) a grade 2 slip. We found no cases of lytic spondylolisthesis in the presence of degenerative spondylolisthesis. We hypothesis that the presence of spondylolysis or lytic spondylolisthesis may be protective against development of degenerative spondylolisthesis. More work is needed to explore this further

Background Context. SPECT-CT is a hybrid imaging modality, which has become very well established in the diagnosis of inflammatory, vascular and malignant processes affecting the spine. However, little evidence exists on its application with degenerative pathologies. Purpose & Study Design. Systematic review on the use of SPECT-CT in the diagnosis of degenerative facet joint arthropathy. Patient Sample. 824 patients across 10 studies conducted over the last 6 years (2012 – 2018), with a mean age of 51.8 years old. All studies excluded patients with malignancy, infection or inflammatory aetiologies or those related to acute trauma. Only degenerative pathologies of the lumbar spine in an adult population were included. Methods. A systematic review of the literature available on the topic was conducted using the PubMed, Cochrane, Medline and Embase online databases of journal articles. Results. Five studies focused on SPECT-CT alone / versus CT. Two focused on SPECT-CT vs MRI, and three focussed on SPECT-CT guided facet joint injections. Of these 10 studies, seven concluded with results supporting SPECT CT's use, two reported discordance between SPECT-CT findings with those diagnosed from clinical examination / MRI scans, and one study's conclusions were equivocal. Conclusion. SPECT-CT shows promise as an imaging adjunct in assisting with the diagnosis and subsequent treatment of degenerative facet joint arthropathies. In patients whose MRI scans reveal multiple potential pain generators, SPECT-CT could help differentiate between clinically significant sources of pain and may even serve a purpose in guiding facet joint injections in patients with inconclusive MRI / CT scans. No conflicts of interest. No funding obtained

Lumbar myelography was a commonly performed procedure but was superseded by MRI and CT which were low risk and provided cross-sectional information. The majority of MRI and CT evaluations are static and supine whereas myelography may be loaded and dynamic. This study evaluates the role of myelography in patients with degenerative scoliosis in a modern surgical practice. Patients with degenerative scoliosis and full imaging (plain radiographs, supine MRI, myelography, including CT myelography) were identified from our database between 2006-2009. Differences between findings of MRI and myelography/CT myelography were noted and whether this subsequently affected treatment. 21 patients fulfilled inclusion criteria. Mean age 68 (45-82), 17 females. 18/21(85.7%) myelograms revealed findings not seen on MRI. 15 patients had a single abnormality, 1 had two and in 2 patients there were 3 new abnormalities. These were facet/ligamentous bulging in 13, a single spondylolisthesis, retrolisthesis and lateral subluxation. On CT a foraminal osteophyte and a pars defect were seen. In 4 cases supine investigation revealed more than MRI. In 7 patients management changed as a result of myelography/CT. There have been no complications of myelography in our unit of the total 270 performed. Myelography is a safe and useful tool in the management of patients with degenerative scoliosis. MRI scan alone understates the true nature of central and lateral recess stenosis. Not only does myelography show more stenosis in the loaded spine, but static myelography and CT myelography are also an invaluable tool in these patients

Degenerative spondylolisthesis is most common at the L4/L5 level and in women. There are several possible reasons for its predilection at this site, but there is no satisfactory explanation for the predominance in women. We considered that pregnancy was a possible influence. We reviewed the records and radiographs of 949 women and 120 men aged 50 years and over who had attended a spinal surgeon for low back pain over a five-year period. We found that women who had borne children had a significantly higher incidence of degenerative spondylolisthesis than nulliparous women (28% v 16.7%; p = 0.043). The men had a 7.5% incidence, significantly less than nulliparous women (p = 0.031). Our results suggest that pregnancy is an important factor in the aetiology of degenerative spondylolisthesis

We have analysed a number of radiological measurements in an attempt to clarify the predisposing factors for degenerative spondylolisthesis of the lumbosacral junction. We identified 57 patients with a slip and a control group of 293 patients without any radiological abnormality apart from age-related changes. The relative thickness of the L5 transverse process, the sacral table angle and the height of the iliac crest were measured and evaluated. The difference in these measurements between men and women was analysed in the control group. We found that the transverse process of L5 was extremely slender, the sacral table more inclined, and the L5 vertebra was less deeply placed in the pelvis in patients with a slip compared with the control group. The differences in these three parameters were statistically significant. We believe that the L5 vertebra is predisposed to slip when these factors act together on a rigidly-stabilised sacrum. This occurs more commonly in women, probably as a result of constitutional differences in the development of the male and female spine

We have measured the dynamic movement of the lumbar spine in 57 patients with degenerative lumbar disc disease. Each completed a questionnaire which recorded pain and subjective signs and symptoms. From plain lateral radiographs, the subjects were graded using the criteria of Kellgren and Lawrence and those of Lane et al, which are both based on the severity of degenerative changes. Measurements of the height of the disc space and the vertebral height were obtained and expressed as a ratio. We found no relationship between the characteristics of spinal movement and the overall grading of degenerative disc disease with either system. Both were influenced (p < 0.01) by age, walking distance, severity of symptoms, drug intake and frequency of pain. The present systems for grading degenerative disc disease from plain lateral radiographs have limited application

Aims. The aim of this study was to explore risk factors for complications associated with dural tear (DT), including the types of DT, and the intra- and postoperative management of DT. Patients and Methods. Between 2012 and 2017, 12 171 patients with degenerative lumbar diseases underwent primary lumbar spine surgery. We investigated five categories of potential predictors: patient factors (sex, age, body mass index, and primary disease), surgical factors (surgical procedures, operative time, and estimated blood loss), types of DT (inaccessible for suturing/clipping and the presence of cauda equina/nerve root herniation), repair techniques (suturing, clipping, fibrin glue, polyethylene glycol (PEG) hydrogel, and polyglycolic acid sheet), and postoperative management (drainage duration). Postoperative complications were evaluated in terms of dural leak, prolonged bed rest, headache, nausea/vomiting, delayed wound healing, postoperative neurological deficit, surgical site infection (SSI), and reoperation for DT. We performed multivariable regression analyses to evaluate the predictors of postoperative complications associated with DT. Results. In total, 429/12 171 patients (3.5%) had a DT. Multivariable analysis revealed that PEG hydrogel significantly reduced the incidence of dural leak and prolonged bed rest, and that patients treated with sealants (fibrin glue and PEG hydrogel) significantly less frequently suffered from headache. A longer drainage duration significantly increased the incidence of headache, nausea/vomiting, and delayed wound healing. Headache and nausea/vomiting were significantly more prevalent in younger female patients. Postoperative neurological deficit and reoperation for DT significantly depended on the presence of cauda equina/nerve root herniation. A longer operative time was the sole independent risk factor for SSI and was also a risk factor for dural leak, prolonged bed rest, and nausea/vomiting. Conclusion. Sealants, particularly PEG hydrogel, may be useful in reducing symptoms related to cerebrospinal fluid leakage, whereas prolonged drainage may be unnecessary. Younger female patients should be carefully treated when DT occurs. Cite this article: Bone Joint J 2019;101-B:1115–1121

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

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