Study Design. An observational study in patients with congenital spinal deformity. Objective. To review the relationship between hemivertebrae and the posterior spinal elements in congenital spinal deformity. Summary of background data. The vertebral body anomalies of congenital scoliosis have been classified and their natural history is well known. More recently a variety of posterior element anomalies have been classified. The relationship between posterior and anterior structures is important when posterior excision of a hemivertebrae is undertaken. Methods. Patients recorded as having congenital spinal deformity were identified from a database. All available imaging was obtained and reviewed with particular reference to posterior element anatomy as visualised on CT or MRI scans. Results. In total 36 patients with congenital spinal deformity were identified and their imaging was reviewed. 29 hemivertebrae were identified in 24 patients. Clear images were obtained of the posterior elements in 18 cases. 9 isolated hemilaminae (as visualised on coronal CT or MRI) were seen in 8 patients with associated hemivertebrae. In 7 of 9 cases the hemilamina was found to be one level cranial to the hemivertebrae and in the remaining 2 cases it was at the same level. Conclusion. When planning excision of a hemivertebra, whether this is performed by a posterior approach or by combined anterior and posterior surgery, care must be taken to avoid wrong level surgery. Pre-operative assessment with CT and MRI scans is essential. The surgeon must be aware of the high possibility that the posterior element anomaly may be proximal to the vertebral body anomaly both when considering how to excise the hemivertebra and for planning the fixation levels. Statement of interests: The authors declare that they have no competing interests

We made a prospective study of 43 consecutive patients treated for intraforaminal (34) or extraforaminal (9) herniations of a lumbar disc by excision through an interlaminar approach, using an operating microscope. The intraforaminal herniations were contained or extruded in 52% and sequestrated in 47%; for extraforaminal herniation the proportions were 66% and 33%, respectively. There was additional posterolateral protrusion or spinal stenosis at the level of the lateral herniation in seven and four cases, respectively. The patients were reviewed at three months and two years after surgery. Radiographs showed three grades of facetectomy: grade I, removal of 50% or less, grade II, excision of 51% to 75%, and grade III, subtotal or total facetectomy. For intraforaminal herniations the results were excellent or good in 88% of patients when reviewed at three months and in 91% at two years. For extraforaminal herniations, there was an excellent or good outcome in 89% of patients in the short term and in all in the long term. The facetectomy had been grade I in 14 and grade II in 25; it had been grade III in four, but only one had had total facetectomy. No patient had developed vertebral hypermobility as a result of the operation. An intralaminar approach using an operating microscope can provide adequate access to a lateral protrusion. It has the advantage of allowing the treatment of posterolateral protrusion or posterior annular bulge and of spinal stenosis at the same level

We present a study of ten consecutive patients who underwent excision of thoracic or thoracolumbar hemivertebrae for either angular deformity in the coronal plane, or both coronal and sagittal deformity. Vertebral excision was carried out anteriorly alone in two patients. Seven patients had undergone previous posterior spinal fusion. Their mean age at surgery was 13.4 years (6 to 19). The mean follow-up was 78.5 months (20 to 180). The results were evaluated by radiological review of the preoperative, postoperative and most recent follow-up films. The mean preoperative coronal curve was 78.2° (30 to 115) and was corrected to 33.9° (7 to 58) postoperatively, a mean correction of 59%. Preoperative coronal decompensation of 35 mm was improved to 11 mm postoperatively. Seven patients had significant coronal decompensation preoperatively, which was corrected to a physiological range postoperatively. There were no major complications and no neurological damage. We have shown that resection of thoracic and thoracolumbar hemivertebrae can be performed safely, without undue risk of neurological compromise, in experienced hands

Transarticular screw fixation with autograft is an established procedure for the surgical treatment of atlantoaxial instability. Removal of the posterior arch of C1 may affect the rate of fusion. This study assessed the rate of atlantoaxial fusion using transarticular screws with or without removal of the posterior arch of C1. We reviewed 30 consecutive patients who underwent atlantoaxial fusion with a minimum follow-up of two years. In 25 patients (group A) the posterior arch of C1 was not excised (group A) and in five it was (group B). Fusion was assessed on static and dynamic radiographs. In selected patients CT imaging was also used to assess fusion and the position of the screws. There were 15 men and 15 women with a mean age of 51.2 years (23 to 77) and a mean follow-up of 7.7 years (2 to 11.6). Stable union with a solid fusion or a stable fibrous union was achieved in 29 patients (97%). In Group A, 20 patients (80%) achieved a solid fusion, four (16%) a stable fibrous union and one (4%) a nonunion. In Group B, stable union was achieved in all patients, three having a solid fusion and two a stable fibrous union. There was no statistically significant difference between the status of fusion in the two groups. Complications were noted in 12 patients (40%); these were mainly related to the screws, and included malpositioning and breakage. The presence of an intact or removed posterior arch of C1 did not affect the rate of fusion in patients with atlantoaxial instability undergoing C1/C2 fusion using transarticular screws and autograft.

Cite this article: Bone Joint J 2013;95-B:972–6.

Introduction. Tomita En-bloc spondylectomy (TES) of L5 is one of the most challenging spinal surgical techniques. A 42-year-old female was referred with low back pain and L5 radiculopathy with background of right shoulder excision of liposarcoma. CT-PET confirmed a solitary L5 oligometastasis. MRI showed thecal sac indentation and therefore was not suitable for stereotactic ablative radiotherapy (SABR) alone. Planning Methodology. First Stage: Carbon fibre pedicle screws were planned from L2 to S2AI-Pelvis, aligned to her patient-specific rods. Custom 3D-printed navigation guides were used to overcome challenging limitations of carbon instruments. Radiofrequency ablation (RFA) of L5 pedicles prior to osteotomy was performed to prevent sarcoma cell seeding. Microscope-assisted thecal sac-tumour separation and L5 nerve root dissection was performed. Novel surgical navigation of the ultrasonic bone cutter assisted inferior L4 and superior S1 endplate osteotomies. Second stage: We performed a vascular-assisted retroperitoneal approach to L4-S1 with protection of the great vessels. Completion of osteotomies at L4 and S1 to en-bloc L5: (L4 inferior endplate, L4/5 disc, L5 body, L5/S1 disc and S1 superior endplate). Anterior reconstruction used an expandable PEEK cage obviating the need for a third posterior stage. Reinforced with a patient-specific carbon plate L4-S1 promontory. Sacrifice of left L5 nerve root undertaken. Results. Patient rehabilitated well and was discharged after 42 days. Patient underwent SABR two months post-operatively. Despite left foot drop, she was walking independently 9 months post-operatively. Conclusion. These challenging cases require a truly multi-disciplinary team approach. We share this technique for a dual stage TES and metal-free construct with post adjuvant SABR for maximum local control

Introduction. Missile injuries are very serious injuries particularly in the cervical region. They are classified into high and low missile injuries when it involves the cervical spine. In modern guerrilla warfare, one must be aware of ballistic pathology with bullets as well as from explosives. In particular, improvised explosive devices commonly known as IED's play a new and important pathophysiology whether they are suicided vests or roadside bombs. They usually produce severe or lethal injuries and serious neurovascular deficit is frequent. We present the details of 40 patients with local experience on how to handle serious penetrating cervical missile injuries. Methods. All cases were collected from the record of Basrah University Hospital, Iraq. Healthy military gentlemen with ages ranging between 20–35 years were included. Results. 11 patients had bullet injuries and 29patients had fragments of shell injuries. The sites of injuries were 9: C2–C3, 12: C5–C6, 12: C4–C5 and 7: C7-T1. Bullet entrance was anterior in 23 patients, posterior in 7 patients and lateral in 10 patients. The cervical vertebrae were injured in 37 patients at body or lamina level while in 3 patients it was only neural tissue injuries. Missiles were retained in 13 patients. All injuries showed some degree of neurological deficit with quadriplegia in 26 patients. 9 patients presented with very serious injuries. No relation was found between the size of the missile and the extent of damage. Outcome of treatment in all patients was poor. Conclusion. Gunshot wounds only account for approximately one third of penetrating missile injuries in patients who survive and are well enough to receive medical treatment. 62% of patients' cohort were from explosive devices, consistent with data from 2010, where 58% of fatalities were from IED's occurring in foreign soldiers in Afghanistan. We discuss the importance of general supportive measures, generous wound excision, removal of the retained missiles and heavy cover of antibiotics

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

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

Background:. Lumbar intraspinal cysts (LICs) are rare incidental MRI findings in back pain. Their space-occupying nature make them plausible factors in both non-specific and radicular back pain. Methods:. Retrospective cohort study of patients with MRI reports of LICs at our center over 5 years. N=26, 13 male, mean age 66 ± 12 years. Results:. LICs originated at levels from L1-S2 (61.5% at L4/5), reaching 17mm. 2. (rapid one year progression in this case). LICs were described as synovial in all but two cases (hemorrhagic cyst; Tarlov perineural cysts). Background degenerative changes were reported in 88.5% of cases. Patients described up to 30-year histories of non-specific back pain. Clinical features of radiculopathy plus concomitant MRI findings were indications for surgical decompression (n=14) and cyst excision (n=13/14). 2 cases of spontaneous LIC resolution, and 2 cases of post-operative complications were identified (inflammatory/scar tissue stenosis). 0% cyst recurrence rate with sustained resolution of symptoms currently stands. Conclusions:. Frequent co-existence of LICs with degeneration implicates the former as a product of osteoarthritic processes, conceivably contributing to patient accounts of chronic non-specific pain. LICs may equally constitute acute direct causes of radiculopathy, owing to their diverse origins and potential to rapidly expand. A role of LICs in axial and radicular pain, independent of other degenerative changes, is supported by symptom alleviation in cases of spontaneous resolution, versus progression with decompression performed without cyst excision (Tarlov cyst), or following novel cyst formation at the level of previous spinal fusion. Whether image-guided aspiration might reduce surgery-related side-effects is a topic for further work

Objective. To evaluate functional and oncological outcomes following sacral resection. Methods. Retrospective review of 97 sacral tumours referred to spinal or oncology units between 2004 and 2009. Results. 61 males, 37 females (average age of 47 (range 3 – 82). Average duration of symptoms 13 months. 17 metastatic disease, excluded from further discussion. Of the remainder 36/81(44%) underwent surgery – 21 excision, 9 excision and instrumented stabilisation, and 6 curettage. 13(16%) patients were inoperable - 8 advanced disease, 3 unable to establish local control, 2 recurrence. Colostomy was performed in 11/21(52%) patients who underwent excision. Deep wound infections in 6/21(29%). No difference in infection rates between definitive surgery with or without colostomy – 3/11(27%) vs. 3/10(30%). In the instrumented group, no colostomies were performed due to concerns about deep infection and none resulted (0/9). Radiological failure of stabilisation was noted in 7/9(78%). However, functionally, 3/9(33%) were mobilising independently, 3/9(33%) crutches, 2/9(22%) able to transfer and 1/9(11%) undocumented. Mean follow-up 25 months (range 0-70). Local recurrence in 9/36(25%) of operated patients. Metastasis occurred in 4/36(11%) and mortality 8/36(22%) although follow-up period was noted to be short. Conclusions. Results are comparable with current literature. Mechanical stabilisation for extensive sacral lesions is challenging. Despite radiological failure in 7/9 instrumented stabilisations, patients were relatively asymptomatic and only 1/9 required revision stabilisation surgery. By design none had colostomies and there were no deep infections

Aims

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.

Aims

Open discectomy (OD) is the standard operation for lumbar disc herniation (LDH). Percutaneous endoscopic lumbar discectomy (PELD), however, has shown similar outcomes to OD and there is increasing interest in this procedure. However despite improved surgical techniques and instrumentation, reoperation and infection rates continue and are reported to be between 6% and 24% and 0.7% and 16%, respectively. The objective of this study was to compare the rate of reoperation and infection within six months of patients being treated for LDH either by OD or PELD.

Aims

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

Between 1993 and 2008, 41 patients underwent total coccygectomy for coccydynia which had failed to respond to six months of conservative management. Of these, 40 patients were available for clinical review and 39 completed a questionnaire giving their evaluation of the effect of the operation. Excellent or good results were obtained in 33 of the 41 patients, comprising 18 of the 21 patients with coccydynia due to trauma, five of the eight patients with symptoms following childbirth and ten of 12 idiopathic onset. In eight patients the results were moderate or poor, although none described worse pain after the operation. The only post-operative complication was superficial wound infection which occurred in five patients and which settled fully with antibiotic treatment. One patient required re-operation for excision of the distal cornua of the sacrum. Total coccygectomy offered satisfactory relief of pain in the majority of patients regardless of the cause of their symptoms

To report on the management of a patient with grade 1 holocord pilocytic astrocytoma and scoliosis. Case report of a rare spinal cord tumour and a management of the scoliosis. An 11 year boy complained of gradually worsening neck, back pain and pain in all limbs. This was accompanied by unsteadiness, weakness of lower limbs and bed wetting of recent onset. There was a family history of spinal cord tumour. Examination revealed signs of spinal cord compression and a left thoracic scoliosis. Magnetic resonance imaging showed an intra-medullary tumour extending through the spinal cord and syrinx formation. He underwent T1-3 approach for drainage of syrinx, biopsy of tumour and laminoplasty with plates. He was started on chemotherapy for 14 months. During this period a syringo-peritoneal shunt was inserted. There was further growth of the tumour and neurological deterioration. He subsequently underwent T8-L1 laminoplasty, debulking of tumour and insertion of dual diameter growing rods. There has been no significant neurological deterioration. There was good correction of the scoliosis with Cobb angle reducing from 50 to 15 degrees. Lengthening of growing rods has been done 4 times with good length achieved. Excision of tumour and growing rod insertion (not previously reported) is a good way of controlling neurological symptoms and the scoliosis in this rare spinal cord tumour

Chondrosarcomas are uncommon primary malignant cartilaginous tumours, even less common in spine. Surgical excision is the only mode of successful treatment as these tumours are resistant to conventional chemotherapy and radiation therapy. We share our experience of 22 cases of chondrosarcomas of the spine with special reference to their recurrence and survival. We identified 20 conventional and 2 dedifferentiated chondrosarcomas from the Scottish Bone Tumour Registry database between 1964 and 2009. Radiology and histopathology were documented. The mean follow-up was 5.2 years. There were 14 men and 8 women with a mean age of 50.1 years. There were 7 under the age of 40 years (31.8%). The majority of lesions occurred in the thoracic spine (16), followed by sacrum (3), lumbar (2) and cervical spine (1). The overall local recurrence rate was 45.4% (10/22 cases-once in 5, twice in 2 and thrice in 3 patients). Four patients presented with pulmonary metastases leading to death. The estimated overall 5- and 10-year survival rates were 31.8% and 18.1% respectively. We found that 1/3. rd. of chondrosarcomas of the spine occured below 40 years of age and 3/4. th. in the thoracic spine. Every other case was associated with local recurrence with a 32% 5-year and 18% 10-year survival rates

Introduction. Aneurysmal bone cysts are uncommon benign lesions affecting the spinal column. They mostly occur in the lumbar spine and have a propensity to affect adjacent vertebrae. We describe 14 aneurysmal bone cysts affecting the spinal column from the Scottish Bone Tumour Registry with regard to assess the incidence, demography, biological behaviour and recurrence rate. Materials and Methods. We identified 14 patients with aneurysmal bone cysts affecting the spinal column. Case notes and radiographs were retrospectively reviewed from the Scottish Bone Tumour registry. Results. There were 9 female and 5 male patients. The mean age at presentation was 24.5 years (range, 6 to 62 years). The spinal location consisted of cervical (3), thoracic (4), lumbar (6) and sacral (1). The treatment included curettage without bone grafting (3), excision (7) and surgical removal with biopsy in rest. Selective angiographic embolisation was carried out in one patient with a cervical cyst and percutaneous sclerotherapy was carried out on another with a sacral cyst. There were two recurrences, of which one was treated with radiotherapy and other with repeat curettage with successful final outcome. Conclusions. The incidence of aneurysmal bone cysts was 5.5% in our registry of all the spine tumours. The recurrence occurred in 14% (2 of 14). In addition to surgery, one should be aware of the role of angiographic embolisation and radiotherapy in selected primary and recurrent ABCs

Sacro-coccygeal chordomas pose a difficult diagnostic and therapeutic problem due to late presentation, large size, soft-tisue extension, difficulties in obtaining adequate resection margins, higher local recurrence rate and uncertain effectiveness of adjuvant treatment. We present a series of 21 patients of sacral chordomas obtained from Scottish Bone Tumour Registry to analyse predictors of local control and survival. The clinical and morphologic features, type of treatment and follow-up of 21 consecutive patients with sacral chordoma were retrospectively reviewed and analysed. The data were obtained from Scottish Bone Tumour Registry. The average age at time of the biopsy was 59 years (range, 12 to 82 years): twelve patients were male and nine were female. Pain was the presenting symptom in all patients. Two had intralesional (both recurred), 9 marginal (4 recurred) and 3 wide resections (1 recurred). Fifteen of the twenty-one patients were treated with adjuvant radiation therapy. In seven patients, the chordoma was inoperable and all but one were treated with adjuvant radiotherapy. Local recurrence and metastases occurred in 7 (50%) and 5 (23.8%) patients. The 5-year and 10-year survival were 38% and 14.2%, respectively. Excision of the lesion combined with adjuvant radiation therapy provided satisfactory results. Local recurrence presents a major problem in the management of sacral chordomas (50%). Intralesional resection should be avoided as it is associated with 100% local recurrence in our series

Coccygectomy, surgical excision of the coccyx, may be used to treat coccydynia, a chronic and disabling condition of the lowest part of the spine. It is a controversial and infrequently performed operation that many surgeons are reluctant to perform due to the risks of rectal perforation and infection. The criteria for patient selection for coccygectomy remain ill-defined. We present a single surgeon case series of 17 patients who underwent coccygectomy for chronic coccydynia. This was a retrospective observarional case series analysis. Case notes of 17 patients who underwent coccygectomy from 1999 -2009 were obtained and analysed. We then carried out telephone survey for which only 15 patients were contactable. We used the Milton Keynes Orthopaedic Patient Satisfaction survey and the modified Oswestry low back pain disability questionnaire. All patients had a two to three year history of coccydynia; 15 following trauma, one following a caudal injection and one following birth delivery. All patients had received between one and five lignocaine/methylprednisolone injections prior to coccygectomy, with documented initial symptom relief. All 17 patients had documented hypermobile sacro-coccygeal joints. Post-operative symptom relief varied between 60% and 100%, with all patients reporting that they would have their surgery again. Complications included three post-operative wound infections. There were no cases of rectal perforation. Coccygectomy for intractable coccydynia is sometimes the only option available. With good patient selection, including identification of a hypermobile joint with initial symptom relief following local injection, coccygectomy is a successful and safe treatment

Statement of purpose. We review the current state of development of proton therapy and the implications for beam therapy in the management of primary bone tumours. Introduction. The principle of radiotherapy is to deliver a high dose, accurately, to the tumour. Conventional photon and proton therapy irradiates adjacent tissue significantly. This is reduced with intensity modulated proton therapy (IMPT). This has been demonstrably effective in treating tumours refractory to chemotherapy and conventional radiotherapy such as chrondrosarcomas and chordomas. Case Report. We present a patient with an isolated chondrosarcoma involving the anterior and posterior element of the L3 vertebral body with a significant soft tissue component displacing the IVC. The patient underwent a 2 stage en-bloc excision of the tumour: Stabilization was achieved by posterior L2-4 instrumented fusion with PEEK rods, an anterior PEEK cage and bone graft. Post-operatively the patient underwent 12 weeks of bed rest followed by rehabilitation. Due to pedicle involvement (giving a high risk of contamination) and the narrow clear margin found on histology the patient has been accepted for post-operative IMPT. Discussion. The high risk of contamination and the narrow margins presented an ideal case for post-operative IMPT. However, conventionally the stabilization would have been metallic, distorting the treatment mapping and the delivery of the IMPT, reducing any possible benefit. Thus, we used PEEK as it is proven to maintain its properties when subjected to a wide range of conditions while also being tolerant of, and not interfering with, most forms of radiation including proton therapy, maximising the chance of a positive outcome. One concern is that PEEK is less biomechanically stable then metal, hence the prolonged period of bed rest. Conclusion. This report discusses the current evidence for proton therapy while describing a successful technique for stabilization to facilitate delivery of proton treatment post-operatively