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

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Historically, patients undergoing surgery for adolescent idiopathic scoliosis (AIS) have been nursed postoperatively in a critical care (CC) setting because of the challenges posed by prone positioning, extensive exposures, prolonged operating times, significant blood loss, major intraoperative fluid shifts, cardiopulmonary complications, and difficulty in postoperative pain management. The primary aim of this paper was to determine whether a scoring system, which uses Cobb angle, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and number of levels to be fused, is a valid method of predicting the need for postoperative critical care in AIS patients who are to undergo scoliosis correction with posterior spinal fusion (PSF).

Aims

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

Aims

Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in motor impairment affecting the upper limbs more than the lower, with occasional sensory impairment and urinary retention. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study was to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age.

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To report the outcome of spinal deformity correction through anterior spinal fusion in wheelchair-bound patients with myelomeningocele.

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To evaluate the perioperative complications associated with total en bloc spondylectomy (TES) in patients with spinal tumours, based on the extent and level of tumour resection.

Introduction. Sparing of the spinal growth and scoliotic deformity control in patients with early-onset scoliosis is a challenge in spinal surgery. Loss of the surgical correction, implant breakage, and revision surgeries are the main disadvantages of present treatment methods. The purpose of this study is to investigate whether growing transpedicular instrumentation spares achieved surgical correction during patient's growth. Methods. This is a prospective study of 12 consecutive patients with early-onset scoliosis from one clinical centre. All patients underwent anterior convex growth arrest and posterior transpedicular instrumentation with growing construct. Spinal derotation was used for the correction of the deformity. The diagnoses were infantile idiopathic (n=10) and congenital (n=2) scoliosis (formation failure). Follow-up was 3 years. Mean age at the time of surgery was 9·1 years. Results. Preoperative major Cobb angle was 74·3° (range 52–100°), minor Cobb angle was 32·2° (5–50°), and average preoperative thoracic kyphosis was 27·2° (0–63°). Mean number of the instrumented levels was 12·2. Postoperative major Cobb angle was 22·4° (0–40°), minor Cobb angle was 5·7° (0–23·5°), and postoperative thoracic kyphosis was 26·2° (6–41°). After 3 years of follow-up, primary curve was an average of 22·7° (10–40°), secondary curve was 5·4° (0–25°), and mean thoracic kyphosis was 28° (12–40°). Mean growth of the instrumented spine was 18 mm. We did not observe any gross complications in the patients. Two patients had pleural effusion, and one needed rod exchange 15 months after primary surgery because of insufficient length. Conclusions. The results of this study show that anterior convex growth arrest and polysegmental transpedicular spinal instrumentation with growing construct save spinal growth and anatomical values achieved after surgical correction. Rod derotation for the deformity correction favours spinal growth in skeletally immature patients

Aims

To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach.

Object. Giant thoracic discs (occupying more than 40% of the spinal canal) are a difficult surgical pathology. They are increasingly being recognized as or particular subset of thoracic disc pathology. It has been recommended that an aggressive surgical approach of open 2 level verteberectomy and instruments should be utilized.21 However Retropleural thoracotomy provides the shortest direct route to the anterior thoracic spine and avoids pleural cavity entry making it an ideal if infrequently used approach to access ventral thoracic and thoracolumbar spine abnormalities. We present a detailed description of our experience utilising this approach, for the treatment of Giant Thoracic discs without the need for vertebrectomy or instrumentation. Methods. A prospective cohort of patients with Giant thoracic discs operated on utilizing the mini open retropleural thoracotomy technique was used, intra-operative and post-operative complications and length of post-op stay. Functional outcome and pain scores, were also prospectively recorded using SF-36, Oswestry Disability Index (ODI), and visual analogue pain scores (VAS). Results. 17 patients underwent a retropleural thoracotomy for Giant thoracic disc between 2001 and 2010. There were 8 male and 9 female patients with a median age of 50 years (range 35 – 70). The surgical level was T8/9 (58%) followed by T10/11 (33%) and finally T11/12 (8%). 1 patient had redo surgery following a failed primary discectomy at another institution. The mean post-operative length of stay was 12.8 days Intra-operative complications included 5 pleural tears during the approach. Chest drain was placed post-op in one patient. The tears were primarily repaired and the approach did not have to be abandoned. 2 patients had an intra-operative CSF leak (1 had intradural disc erosion). Post-operative complications included 1 pleural effusion, 1 patient had pneumonia and a PE, 1 patient died from an unrelated respiratory tract infection of the lung (opposite to the side of the approach) 40 days after surgery. Conclusion. Large calcified thoracic disc herniations can be a very challenging pathology. The retropleural transthoracic approach can be employed safely in this setting with acceptable morbidity for the patient

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To report the surgical outcome of patients with severe Scheuermann’s kyphosis treated using a consistent technique and perioperative management.

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This study aimed to evaluate the incidence and prognosis of patients with spinal metastasis as the initial manifestation of malignancy (SM-IMM).

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.

This review of the literature presents the current understanding of Scheuermann’s kyphosis and investigates the controversies concerning conservative and surgical treatment. There is considerable debate regarding the pathogenesis, natural history and treatment of this condition. A benign prognosis with settling of symptoms and stabilisation of the deformity at skeletal maturity is expected in most patients. Observation and programmes of exercise are appropriate for mild, flexible, non-progressive deformities. Bracing is indicated for a moderate deformity which spans several levels and retains flexibility in motivated patients who have significant remaining spinal growth.

The loss of some correction after the completion of bracing with recurrent anterior vertebral wedging has been reported in approximately one-third of patients. Surgical correction with instrumented spinal fusion is indicated for a severe kyphosis which carries a risk of progression beyond the end of growth causing cosmetic deformity, back pain and neurological complications. There is no consensus on the effectiveness of different techniques and types of instrumentation. Techniques include posterior-only and combined anteroposterior spinal fusion with or without posterior osteotomies across the apex of the deformity. Current instrumented techniques include hybrid and all-pedicle screw constructs.

An eight-week-old boy developed severe thoracic spondylodiscitis following pneumonia and septicaemia. A delay in diagnosis resulted in complete destruction of the T4 and T5 vertebral bodies and adjacent discs, with a paraspinal abscess extending into the mediastinum and epidural space. Antibiotic treatment controlled the infection and the abscess was aspirated. At the age of six months, he underwent posterior spinal fusion in situ to stabilise the spine and prevent progressive kyphosis. At the age of 13 months, repeat imaging showed lack of anterior vertebral body re-growth and he underwent anterior spinal fusion from T3 to T6 and augmentation of the posterior fusion. At the age of five years, he had no symptoms and radiographs showed bony fusion across the affected levels.

Spondylodiscitis should be included in the differential diagnosis of infants who present with severe illness and atypical symptoms. Delayed diagnosis can result in major spinal complications with a potentially fatal outcome.

The management of spinal deformity in children with univentricular cardiac pathology poses significant challenges to the surgical and anaesthetic teams. To date, only posterior instrumented fusion techniques have been used in these children and these are associated with a high rate of complications. We reviewed our experience of both growing rod instrumentation and posterior instrumented fusion in children with a univentricular circulation.

Six children underwent spinal corrective surgery, two with cavopulmonary shunts and four following completion of a Fontan procedure. Three underwent growing rod instrumentation, two had a posterior fusion and one had spinal growth arrest. There were no complications following surgery, and the children undergoing growing rod instrumentation were successfully lengthened. We noted a trend for greater blood loss and haemodynamic instability in those whose surgery was undertaken following completion of a Fontan procedure. At a median follow-up of 87.6 months (interquartile range (IQR) 62.9 to 96.5) the median correction of deformity was 24.2% (64.5° (IQR 46° to 80°) vs 50.5° (IQR 36° to 63°)).

We believe that early surgical intervention with growing rod instrumentation systems allows staged correction of the spinal deformity and reduces the haemodynamic insult to these physiologically compromised children. Due to the haemodynamic changes that occur with the completed Fontan circulation, the initial scoliosis surgery should ideally be undertaken when in the cavopulmonary shunt stage.

Cite this article: Bone Joint J 2014;96-B:94–9.

We describe 13 patients with cerebral palsy and lordoscoliosis/hyperlordosis of the lumbar spine who underwent a posterior spinal fusion at a mean age of 14.5 years (10.8 to 17.4) to improve sitting posture and relieve pain. The mean follow-up was 3.3 years (2.2 to 6.2).

The mean pre-operative lumbar lordosis was 108^° (80 to 150^°) and was corrected to 62^° (43^° to 85^°); the mean thoracic kyphosis from 17^° (-23^° to 35^°) to 47^° (25^° to 65^°); the mean scoliosis from 82^° (0^° to 125^°) to 22^° (0^° to 40^°); the mean pelvic obliquity from 21^° (0^° to 38^°) to 3^° (0^° to 15^°); the mean sacral slope from 79^° (54^° to 90^°) to 50^° (31^° to 66^°). The mean pre-operative coronal imbalance was 5 cm (0 cm to 8.9 cm) and was corrected to 0.6 cm (0 to 3.2). The mean sagittal imbalance of -8 cm (-16 cm to 7.8 cm) was corrected to -1.6 cm (-4 cm to 2.5 cm). The mean operating time was 250 minutes (180 to 360 minutes) and intra-operative blood loss 0.8 of estimated blood volume (0.3 to 2 estimated blood volume). The mean intensive care and hospital stay were 3.5 days (2 to 8) and 14.5 days (10 to 27), respectively. Three patients lost a significant amount of blood intra-operatively and subsequently developed chest or urinary infections and superior mesenteric artery syndrome.

An increased pre-operative lumbar lordosis and sacral slope were associated with increased peri-operative morbidity: scoliosis and pelvic obliquity were not. A reduced lumbar lordosis and increased thoracic kyphosis correlated with better global sagittal balance at follow-up. All patients and their parents reported excellent surgical outcomes.

Lordoscoliosis and hyperlordosis are associated with significant morbidity in quadriplegic patients. They are rare deformities and their treatment is challenging. Sagittal imbalance is the major component: it can be corrected by posterior fusion of the spine with excellent functional results.

Cite this article: Bone Joint J 2014;96-B:800–6.

A combined anterior and posterior surgical approach is generally recommended in the treatment of severe congenital kyphosis, despite the fact that the anterior vascular supply of the spine and viscera are at risk during exposure. The aim of this study was to determine whether the surgical treatment of severe congenital thoracolumbar kyphosis through a single posterior approach is feasible, safe and effective.

We reviewed the records of ten patients with a mean age of 11.1 years (5.4 to 14.1) who underwent surgery either by pedicle subtraction osteotomy or by vertebral column resection with instrumented fusion through a single posterior approach.

The mean kyphotic deformity improved from 59.9° (45° to 110°) pre-operatively to 17.5° (3° to 40°) at a mean follow-up of 47.0 months (29 to 85). Spinal cord monitoring was used in all patients and there were no complications during surgery. These promising results indicate the possible advantages of the described technique over the established procedures. We believe that surgery should be performed in case of documented progression and before structural secondary curves develop. Our current strategy after documented progression is to recommend surgery at the age of five years and when 90% of the diameter of the spinal canal has already developed.

Cite this article: Bone Joint J 2013;95-B:1527–32.

There have been very few reports in the literature of gout and pseudogout of the spine. We describe six patients who presented with acute sciatica attributable to spinal stenosis with cyst formation in the facet joints. Cytopathological studies confirmed the diagnosis of crystal arthropathy in each case.

Specific formation of a synovial cyst was identified pre-operatively by MRI in five patients. In the sixth, the diagnosis was made incidentally during decompressive surgery. Surgical decompression alone was undertaken in four patients. In one with an associated degenerative spondylolisthesis, an additional intertransverse fusion was performed. Another patient had previously undergone a spinal fusion adjacent to the involved spinal segment, and spinal stabilisation was undertaken as well as a decompression.

In addition to standard histological examination material was sent for examination under polarised light which revealed deposition of urate or calcium pyrophosphate dihydrate crystals in all cases.

It is not possible to diagnose gout and pseudogout of the spine by standard examination of a fixed specimen. However, examining dry specimens under polarised light suggests that crystal arthropathy is a significant aetiological factor in the development of symptomatic spinal stenosis associated with cyst formation in a facet joint.

We examined the reliability of radiological findings in predicting segmental instability in 112 patients (56 men, 56 women) with a mean age of 66.5 years (27 to 84) who had degenerative disease of the lumbar spine. They underwent intra-operative biomechanical evaluation using a new measurement system. Biomechanical instability was defined as a segment with a neutral zone > 2 mm/N. Risk factor analysis to predict instability was performed on radiographs (range of segmental movement, disc height), MRI (Thompson grade, Modic type), and on the axial CT appearance of the facet (type, opening, vacuum and the presence of osteophytes, subchondral erosion, cysts and sclerosis) using multivariate logistic regression analysis with a forward stepwise procedure. The facet type was classified as sagittally orientated, coronally orientated, anisotropic or wrapped.

Stepwise multivariate regression analysis revealed that facet opening was the strongest predictor for instability (odds ratio 5.022, p = 0.009) followed by spondylolisthesis, MRI grade and subchondral sclerosis. Forward stepwise multivariate logistic regression indicated that spondylolisthesis, MRI grade, facet opening and subchondral sclerosis of the facet were risk factors. Symptoms evaluated by the Short-Form 36 and visual analogue scale showed that patients with an unstable segment were in significantly more pain than those without. Furthermore, the surgical procedures determined using the intra-operative measurement system were effective, suggesting that segmental instability influences the symptoms of lumbar degenerative disease.

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.