Aims. To report the outcome of spinal deformity correction through anterior spinal fusion in wheelchair-bound patients with myelomeningocele. Methods. We reviewed 12 consecutive patients (7M:5F; mean age 12.4 years (9.2 to 16.8)) including demographic details, spinopelvic parameters, surgical correction, and perioperative data. We assessed the impact of surgery on patient outcomes using the Spina Bifida Spine Questionnaire and a qualitative questionnaire. Results. The mean follow-up was 5.4 years (2 to 14.9). Nine patients had kyphoscoliosis, two lordoscoliosis, and one kyphosis. All patients had a thoracolumbar deformity. Mean scoliosis corrected from 89.6° (47° to 151°) to 46.5° (17° to 85°; p < 0.001). Mean kyphosis corrected from 79.5° (40° to 135°) to 49° (36° to 65°; p < 0.001). Mean pelvic obliquity corrected from 19.5° (8° to 46°) to 9.8° (0° to 20°; p < 0.001). Coronal and sagittal balance restored to normal. Complication rate was 58.3% (seven patients) with no neurological deficits, implant failure, or revision surgery. The degree of preoperative spinal deformity, especially kyphosis and lordosis, correlated with increased blood loss and prolonged hospital/intensive care unit stay. The patients reported improvement in function, physical appearance, and pain after surgery. The parents reported decrease in need for everyday care. Conclusion. Anterior spinal fusion achieved satisfactory deformity correction with high perioperative complication rates, but no long-term sequelae among children with high level myelomeningocele. This resulted in physical and functional improvement and high reported satisfaction. Cite this article: Bone Joint J 2021;103-B(6):1133–1141

Aims. To report the surgical outcome of patients with severe Scheuermann’s kyphosis treated using a consistent technique and perioperative management. Methods. We reviewed 88 consecutive patients with a severe Scheuermann's kyphosis who had undergone posterior spinal fusion with closing wedge osteotomies and hybrid instrumentation. There were 55 males and 33 females with a mean age of 15.9 years (12.0 to 24.7) at the time of surgery. We recorded their demographics, spinopelvic parameters, surgical correction, and perioperative data, and assessed the impact of surgical complications on outcome using the Scoliosis Research Society (SRS)-22 questionnaire. Results. The mean follow-up was 8.4 years (2 to 14.9). There were 85 patients (96.6%) with a thoracic deformity. Posterior spinal fusion with closing-wedge osteotomies and hybrid instrumentation was used in 86 patients; two patients underwent combined anterior and posterior spinal fusion. The mean kyphosis was corrected from 94.5° to 47.5° (p < 0.001). Coronal and sagittal balance returned to normal. The rate of complications was 12.5%: there were no neurological deficits, implant failure, or revision surgery. SRS-22 scores improved from a mean 3.6 (1.3 to 4.1) to 4.6 (4.2 to 5.0) at two years (p < 0.001) with a high rate of patient satisfaction. Non-smokers and patients with lower preoperative SRS-22 scores showed greater improvement in their quality of life. Sagittal pelvic balance did not change after correction of the kyphosis and correlated with lumbar lordosis but not with thoracic or thoracolumbar kyphosis. Conclusion. Posterior spinal fusion using hybrid instrumentation, closing-wedge osteotomies, and iliac bone grafting achieves satisfactory correction of a severe kyphosis resulting in improvements in physical and mental health and a high degree of patient-reported satisfaction. Cite this article: Bone Joint J 2021;103-B(1):148–156

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The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD).

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Only a few studies have investigated the long-term health-related quality of life (HRQoL) in patients with an idiopathic scoliosis. The aim of this study was to investigate the overall HRQoL and employment status of patients with an idiopathic scoliosis 40 years after diagnosis, to compare it with that of the normal population, and to identify possible predictors for a better long-term HRQoL.

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Postoperative complication rates remain relatively high after adult spinal deformity (ASD) surgery. The extent to which modifiable patient-related factors influence complication rates in patients with ASD has not been effectively evaluated. The aim of this retrospective cohort study was to evaluate the association between modifiable patient-related factors and complications after corrective surgery for ASD.

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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.

Aims. The aims of this study were to evaluate the clinical and radiological outcomes of instrumented posterolateral fusion (PLF) performed in patients with rheumatoid arthritis (RA). . Methods. A total of 40 patients with RA and 134 patients without RA underwent instrumented PLF for spinal stenosis between January 2003 and December 2011. The two groups were matched for age, gender, bone mineral density, the history of smoking and diabetes, and number of fusion segments. . The clinical outcomes measures included the visual analogue scale (VAS) and the Korean Oswestry Disability Index (KODI), scored before surgery, one year and two years after surgery. Radiological outcomes were evaluated for problems of fixation, nonunion, and adjacent segment disease (ASD). The mean follow-up was 36.4 months in the RA group and 39.1 months in the non-RA group. Results. Both groups had significant improvement in symptoms one year after surgery, while the RA group showed some deterioration of outcome scores owing to complications during the second year after surgery. Complications occurred at a higher rate in the group with RA (19 patients, 47.5%) than in those without RA (23 patients, 17.1%) (p < 0.001). A total of 15 patients in the RA group (37.5%) required revision surgery, mainly for implant failure and post-operative infection. . Discussion. Multimodal approaches should be considered when performing instrumented PLF in patients with RA to reduce the rate of complications, such as problems of fixation, post-operative infection and nonunion. Take home message: Specific strategies should be undertaken in order to optimise outcomes in patients with rheumatoid arthritis. Cite this article: Bone Joint J 2016;98-B:102–8

Between January 1990 and December 2000 we carried out 226 SB Charité III disc replacements for lumbar disc degeneration in 160 patients. They were reviewed at a mean follow-up of 79 months (31 to 161) to determine the clinical and radiological outcome. The clinical results were collected by an independent observer, who was not involved in patient selection, treatment or follow-up, using a combination of outcome measures, including the Oswestry Disability Index. Pain was recorded using a visual analogue score, and the most recent radiographs were reviewed. Survival of the device was analysed by the Kaplan-Meier method and showed a cumulative survival of 35% at 156 months when radiological failure was taken as the endpoint. The mean improvement in the Oswestry disability index scores after disc replacement was 14% (6% to 21%) and the mean improvement in the pain score was 1.6 (0.46 to 2.73), both falling below the clinically significant threshold. Removal of the implant was required in 12 patients, four because of implant failure. These poor results indicate that further use of this implant is not justified

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The aim of this study was to compare the clinical and radiological outcomes of patients with early-onset scoliosis (EOS), who had undergone spinal fusion after distraction-based spinal growth modulation using either traditional growing rods (TGRs) or magnetically controlled growing rods (MCGRs).

Aims. The aim of this study is to introduce and investigate the efficacy and feasibility of a new vertebral osteotomy technique, vertebral column decancellation (VCD), for rigid thoracolumbar kyphotic deformity (TLKD) secondary to ankylosing spondylitis (AS). . Patients and Methods. We took 39 patients from between January 2009 and January 2013 (26 male, 13 female, mean age 37.4 years, 28 to 54) with AS and a TLKD who underwent VCD (VCD group) and compared their outcome with 45 patients (31 male, 14 female, mean age 34.8 years, 23 to 47) with AS and TLKD, who underwent pedicle subtraction osteotomy (PSO group), according to the same selection criteria. The technique of VCD was performed at single vertebral level in the thoracolumbar region of AS patients according to classification of AS kyphotic deformity. Pre- and post-operative chin-brow vertical angle (CBVA), sagittal vertical axis (SVA) and sagittal Cobb angle in the thoracolumbar region were reviewed in the VCD and PSO groups. Intra- , post-operative and general complications were analysed in both group. Results. lf patients could lie on their backs and walk with horizontal vision and sagittal profile, radiographic parameters improved significantly post-operatively in both groups. No major acute complications such as death or complete paralysis occurred in either group. In the VCD group, five patients (12.8%) experienced complications such as severe CSF leak (n = 4), deep wound infection (n = 1) and in one patient a transient neurological deficit occurred. In the PSO group, eight patients (17.8%) suffered conditions such as severe CSF leak (n = 5), infections (n = 2) and sagittal translation at osteotomy site (n = 1). Scoliosis Research Society outcomes instrument (SRS-22) improved significantly in both groups. All patients achieved solid fusion at latest follow-up and no implant failures were noted in either group. Take home message: The VCD technique is a new, safe and effective strategy for correction of rigid TLKD in AS patients. The main advantage of the new correction mechanism is that it achieved a satisfactory correction by controlled anterior column opening and posterior column closing, avoiding the occurrence of sagittal translation. Cite this article: Bone Joint J 2016;98-B:672–8

To describe a staged surgical technique to correct significant progressive sagittal malalignment, without the need for 3-column osteotomy, in patients with prior long thoracolumbar instrumentation for scoliosis and to evaluate the radiographic and clinical outcome from this surgical strategy. A small cohort study (n=6) of patients with significant sagittal malalignment following extensive thoracolumbar instrumented fusions for scoliotic deformity. Radiographic parameters analysed included pelvic incidence, pelvic tilt, sacral slope, lumbar lordosis, thoracic kyphosis and sagittal vertical axis. Clinical outcome measures collected included EQ-5D, ODI, SRS 22 and VAS Pain Scores. 3 patients had 2-stage anterior release and instrumented fusion followed by a posterior instrumented fusion 3 patients with a large sagittal plane deformity had a 3-stage surgical technique. All patients achieved an excellent correction of sagittal alignment, with no surgical complications and excellent health related quality of life (HRQOL) outcome measures at follow-up. There was no symptomatic non-unions or implant failures including rod breakages. We present a safe and effective surgical strategy to treat the complex problem of progressive sagittal malalignment in the previously instrumented adult deformity patient, avoiding the need for 3-column osteotomies in the lumbar spine

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The British Spine Registry (BSR) was introduced in May 2012 to be used as a web-based database for spinal surgeries carried out across the UK. Use of this database has been encouraged but not compulsory, which has led to a variable level of engagement in the UK. In 2019 NHS England and NHS Improvement introduced a new Best Practice Tariff (BPT) to encourage input of spinal surgical data on the BSR. The aim of our study was to assess the impact of the spinal BPT on compliance with the recording of surgical data on the BSR.

STUDY DESIGN. Retrospective review of outcome of submuscular rod placement without apical fusion for the treatment of scoliotic deformities in children with severe co morbidities (ASA IV). METHODS. 6 children with progressive scoliosis (2 severe cerebral palsy, 2 congenital cyanotic heart disease, 1 Worster Drought syndrome, 1 Leigh's disease), underwent a serial and limited exposure of the lower and then the upper end of the spine, and insertion of pedicle screws, hooks and clamps. Two submuscularly rods were connected and distracted. Mean age was 13 years old, the mean preoperatively Cobb angle was 87° and the mean postoperatively Cobb angle was 62°. The mean operation time was 120 min and the peri-operative blood loss was 410 ml. Mean follow up is 15 months. RESULTS. There were no adverse peri-operative events. We anticipated late implant failure and revisions but to date only one construct has failed and revised without difficulties (clamps to pedicle screws). 1 patient complicated with increased spasms 1 year postoperatively. The benefits from this procedure were. a) the decreased peri-operative:. blood loss. operation time. respiratory stress. b) the faster patients recovery. c) the significant improvement regarding pain relief and sitting positioning. CONCLUSION. We believe that this procedure can be offered as a safe and viable alternative in selected patients who present with predicted high peri-operative mortality. To the best of our knowledge this technique is not described before

Introduction/Aim. Numerous lumbo-pelvic reconstruction methods based on posterior construct and anterior cages have been proposed for cases involving total sacrectomy and lumbar vertebrectomy. These constructs create long lever arms and generate high cantilever forces across the lumbo-sacral junction resulting in implant failure or breakage. Biomechanical studies have shown that placing implants anterior to lumbo-sacral pivot point provide a more effective moment arm to resist flexion force and improve the ultimate strength of the construct. As a result more emphasis is placed on screws in the pelvis. We report a new and novel technique that allows for the placement of a pelvic ring construct to augment the posterior construct in a lumbo-pelvic reconstruction. Method. In the prone position, two contoured hard rods are passed along the inner table of the pelvis under the iliac muscle from a minor posterior approach. The rods are connected to the posterior lumbo-pelvic construct with T-junction clamps. The patient is turned supine and the anterior ends of the rods are connected to a sub-cutaneously placed hard rod along the anterior abdominal wall with T-junction clamps. This in turn is fixed to the AIIS (anterior inferior iliac spine) with two poly axial screws. The whole construct resembles an oblong ring. Results. At six months she is mobilising independently with a frame and X-rays show no failure of construct or implant. Conclusion. The construct is technically less morbid and bio-mechanically sound to effectively neutralise the flexion to a greater degree than previous constructs described in the literature. It shares and tolerates the flexion moments at the lumbo-pelvic junction by its anterior placement to the sacral pivot point

Clinical and radiological indicators of outcome in the use of X-Stops were sought by evaluating patient-centred outcomes alongside radiographic scrutiny of changes around implants with correlation to outcome. Prospectively collated outcome scores were correlated to outcome, with retrospective analysis of pre-operative MRI scans and 117 post-operative radiographs. Single surgeon series of 44 patients(52 implants). Clinical - ODI, walking distance, Low Back Outcome Score, MZDI and MSP. Radiographic - lucency(anterior and cranio-caudal to implant), coronal rotation, dorsal migration of implant. Failure defined by persistent symptoms requiring removal+/−decompression. Pre-operative features of success: lower ODI(p<0.05), higher LBOS(p<0.01), higher walking distance(p<0.01), lower MZDI(p<0.01). Marked differences were noted in post-operative scores for the two cohorts. An eight-fold improvement in walking distance in success patients compared to an increase to 1.8 times the baseline in failures. ODI improved ten times more in the success group at 20 cf2(failure). MZDI improvement was greater in the revisions at 2.2 cf 0.9 in successes. Ranking Pearson's coefficient of radiograph measurements in success and failure cohorts, revealed failure associated most to anterior lucency(R=0.93), rotation(R=-0.61), cranio-caudal lucency (R=-0.29) and migration (R=-0.25). Success most associated to rotation (R=-0.22). Failure radiographs revealed greater lucency cranio-caudal and ventral to the implant, more coronal rotation, and pronounced dorsal migration. Clinical features of success are older patients with no co-morbidities, unilateral leg pain and multi-level insertion. Males, those with bilateral leg pain, and scoliosis or spondylolistheses are more likely to fail

Aim. To evaluate the level of health resource utilisation by patients after lumbar total disc replacement (TDR) for mechanical low back pain. Method. At our centre, 35 patients underwent TDR and were followed prospectively from surgery. All surgery was performed by the senior author. Patients were followed routinely in clinic at yearly intervals. In addition, the patients and their GPs were contacted via telephone. Information gathered included ODI and VAS, satisfaction with surgery and return to work. We specifically established whether the patients continued to seek healthcare, for persistent back symptoms, from professionals (both NHS and private) including their GP, pain clinic, physiotherapist, acupuncturist, chiropractor or another spinal surgeon, and had any further interventions. Results. We have complete dataset on 30 out of 35 patients and are the subject of this study. There were 13 men, with a mean age of 37.7 years (range 28-45 years), and 17 women with a mean age of 49.8 years (range 27-62 years). Surgery was single level in 26 and two levels in 6 cases. Patients were satisfied with the outcome of surgery in 21 cases (70%), not satisfied in 7. Two cases had implant failures. 25 patients were working pre-operatively and 26 were working postoperatively. Eighteen patients required no further healthcare input. Five had had pain clinic reviews, six had seen their GPs (1-6 visits) and one another spinal surgeon (after late liner extrusion). Seven had facet injections and two had epidurals. One patient underwent posterior fusion for implant migration. Conclusion. In our series TDR is successful in 70% and 60% of the entire cohort needed no further healthcare input. After successful TDR there is almost no ongoing use of health resources

Introduction. Spinopelvic parameters describe the orientation, shape, and morphology of the spine and pelvis. In children without spinal deformity, these parameters change during the first 10 years of life; however, spinopelvic parameters need to be defined in children with significant early-onset scoliosis (EOS). The purpose of this study is to examine the effects of EOS on sagittal spinopelvic alignment. We hypothesise that sagittal spinopelvic parameters for patients with EOS will differ from age-matched children without spinal deformity. These values will act as a baseline for future studies and may predict postoperative complications such as proximal junctional kyphosis and implant failure in children being treated with growing systems. Methods. Standing, lateral radiographs of 82 untreated patients with EOS with Cobb angle greater than 50° were evaluated. Sagittal spine parameters (sagittal balance, thoracic kyphosis [TK], lumbar lordosis [LL]) and sagittal pelvic parameters (pelvic incidence [PI], pelvic tilt [PT], sacral slope [SS], and modified pelvic radius angle [PR]) were measured. These results were compared with those reported by Mac-Thiong and colleagues (Spine, 2004) for a group of similar aged children without spinal deformity. Results. Patients had a mean age of 5·17 years and mean Cobb angle of 73·3° (□}17·3°). Mean sagittal spine parameters were: sagittal balance (+2·4 cm [□}4·03]), TK (38·2° [□}20·8°]), and LL (47·8° [□}17·7°]). These values were similar to those reported for asymptomatic patients (table). Mean sagittal pelvic parameters were: PI (47·1° [□}15·6°]), PT (10·3° [□}10·7°]), SS (35·5° [□}12·2°]), and PR (57·1° [□}21·2°]). Although PI was similar to age-matched controls, PT was significantly higher and there was a trend for lower SS in the study population. Conclusions. Sagittal plane spine parameters in children with EOS were similar to those in children without spinal deformity. Pelvic parameters (PI, SS, PR) were similar between groups; however, children with EOS had signs of pelvic retroversion (increased pelvic tilt)

Background. Wallis implant was developed in 1986 to stiffen unstable operated degenerate lumbar segments while preserving some intervertebral mobility. The long-term results of first-generation Wallis implant from developers were promising. However, documentation pertaining to safety and efficacy of second generation Wallis implant is sparse in literature. Purpose. The objective of this study was to assess the clinical outcome of the second generation Wallis interspinous device for degenerative lumbar disc disease. Study design. Prospective consecutive single surgeon series. Methods. Patients were selected according to recommendations by developers of Wallis implant. Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) were used to assess patient outcomes. Implant failure was determined by disc recurrence, implant removal and revision. Results. 25 patients (13 male, 12 female) with mean age of 51 years (range 47-76) had Wallis implantation (22 one level and 3 two level). Clinical outcome data at average of 60 months (47-76) available for 24 patients (96% FU). Mean ODI scores decreased from 59.1% pre-operatively to 24.7 and 40.5% at 2 years and 5 years follow up, respectively. 34.4 points change from baseline at 2 years and 18.6 points at final follow-up. Mean VAS scores decreased from 7.2 to 3.0 and 4.8 cm for back pain at 2 and 5 years; from 6.8 to 3.8 and 4.2 cm for leg pain at 2 and 5 years follow-up, respectively. Taking a 24 point change in ODI as representing good outcome 96 % (24 patients) of study subjects achieved this at 2 years. Taking a 16 point change in ODI as representing minimum change needed for clinical success 40% (10 patients) failed to achieve this at 5 years. 2 revisions have occurred so far (8% failure rate). Conclusion. The results of our series indicate that the study device is safe and efficacious in the treatment of symptomatic lumbar degenerative discs. However, good clinical outcome obtained at early years is not maintained in medium-term. Interest Statement. There was no commercial support or funding of any sort

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Magnetically controlled growing rods (MCGR) have been gaining popularity in the management of early-onset scoliosis (EOS) over the past decade. We present our experience with the first 44 MCGR consecutive cases treated at our institution.

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To report the mid-term results of a modified self-growing rod (SGR) technique for the treatment of idiopathic and neuromuscular early-onset scoliosis (EOS).