Aims. Severe spinal deformity in growing patients often requires surgical management. We describe the incidence of spinal deformity surgery in a National Health Service. Methods. Descriptive study of prospectively collected data. Clinical data of all patients undergoing surgery for spinal deformity between 2005 and 2018 was collected, compared to the demographics of the national population, and analyzed by underlying aetiology. Results. Our cohort comprised 2,205 patients; this represents an incidence of 14 per 100,000 individuals among the national population aged between zero and 18 years. There was an increase in mean annual incidence of spinal deformity surgery across the study period from 9.6 (7.2 to 11.7) per 100,000 individuals in 2005 to 2008, to 17.9 (16.1 to 21.5) per 100,000 individuals in 2015 to 2018 (p = 0.001). The most common cause of spinal deformity was idiopathic scoliosis accounting for 56.7% of patients. There was an increase in mean incidence of surgery for adolescent idiopathic scoliosis (AIS) (from 4.4 (3.1 to 5.9) to 9.8 (9.1 to 10.8) per 100,000 individuals; p < 0.001), juvenile idiopathic scoliosis (JIS) (from 0.2 (0.1 to 0.4) to one (0.5 to 1.3) per 100,000 individuals; p = 0.009), syndromic scoliosis (from 0.7 (0.3 to 0.9) to 1.7 (1.2 to 2.4) per 100,000 individuals; p = 0.044), Scheuermann’s kyphosis (SK) (from 0.2 (0 to 0.7) to 1.2 (1.1 to 1.3) per 100,000 individuals; p = 0.001), and scoliosis with intraspinal abnormalities (from 0.04 (0 to 0.08) to 0.6 (0.5 to 0.8) per 100,000 individuals; p = 0.008) across the study period. There was an increase in mean number of posterior spinal fusions performed each year from mean 84.5 (51 to 108) in 2005 to 2008 to 182.5 (170 to 210) in 2015 to 2018 (p < 0.001) and a reduction in mean number of growing rod procedures from 45.5 (18 to 66) in 2005 to 2008 to 16.8 (11 to 24) in 2015 to 2018 (p = 0.046). Conclusion. The incidence of patients with spinal deformity undergoing surgery increased from 2005 to 2018. This was largely attributable to an increase in surgical patients with adolescent idiopathic scoliosis. Paediatric spinal deformity was increasingly treated by posterior spinal fusion, coinciding with a decrease in the number of growing rod procedures. These results can be used to plan paediatric spinal deformity services but also evaluate preventative strategies and research, including population screening

Aims. This study aimed to evaluate the incidence and prognosis of patients with spinal metastasis as the initial manifestation of malignancy (SM-IMM). Patients and Methods. We retrospectively reviewed the electronic medical records of 338 patients who underwent surgical treatment for metastatic spinal disease. The enrolled patients were divided into two groups. The SM-IMM group included patients with no history of malignancy whose site of primary malignancy was diagnosed after the identification of spinal metastasis. The other group included patients with a history of treatment for primary malignancy who then developed spinal metastasis (SM-DTM). The incidence of SM-IMM by site of primary malignancy was calculated. The difference between prognoses after surgical treatment for SM-IMM and SM-DTM was established. Results. The median follow-up period was 11.5 months (interquartile range (IQR) 3.2 to 13.4) after surgical treatment. During the follow-up period, 264 patients died; 74 patients survived. The SM-IMM group consisted of 94 patients (27.8%). The site of primary malignancy in the SM-IMM group was lung in 35/103 patients (34.0%), liver in 8/45 patients (17.8%), kidney in 10/33 patients (30.3%), colorectum in 3/29 patients (10.3%), breast in 3/22 patients (13.6%), prostate in 3/10 patients (30%), thyroid in 4/8 patients (50%), and ‘other’ in 28/88 patients (31.8%). On Kaplan–Meier survival analysis, the SM-IMM group showed a significantly longer survival than the SM-DTM group (p = 0.013). The mean survival time was 23.0 months (95% confidence interval (CI) 15.5 to 30.5) in the SM-IMM group and 15.5 months (95% CI 11.8 to 19.2) in the SM-DTM group. Conclusion. Of the 338 enrolled patients who underwent surgical treatment for spinal metastasis, 94 patients (27.8%) underwent surgical treatment for SM-IMM. The SM-IMM group had an acceptable prognosis with surgical treatment. Cite this article: Bone Joint J 2019;101-B:1379–1384

Aims. To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation. Methods. A retrospective study was conducted using prospectively collected data and patient-reported outcome measures, including the Oswestry Disability Index (ODI), between 2008 and 2019. Postoperative sRDH was identified from clinical notes and the centre’s MRI database, with all imaging providers in the region checked for missing events. The Kaplan-Meier method was used to calculate five-year sRDH incidence. Cox proportional hazards model was used to identify independent variables predictive of sRDH, with any variable not significant at the p < 0.1 level removed. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs). Results. Complete baseline data capture was available for 733 of 754 (97.2%) consecutive patients. Median follow-up time for censored patients was 2.2 years (interquartile range (IQR) 1.0 to 5.0). sRDH occurred in 63 patients at a median 0.8 years (IQR 0.5 to 1.7) after surgery. The five-year Kaplan-Meier estimate for sRDH was 12.1% (95% CI 9.5 to 15.4), sRDH reoperation was 7.5% (95% CI 5.5 to 10.2), and any-procedure reoperation was 14.1% (95% CI 11.1 to 17.5). Current smoker (HR 2.12 (95% CI 1.26 to 3.56)) and higher preoperative ODI (HR 1.02 (95% CI 1.00 to 1.03)) were independent risk factors associated with sRDH. Current smoker (HR 2.15 (95% CI 1.12 to 4.09)) was an independent risk factor for sRDH reoperation. Conclusion. This is one of the largest series to date which has identified current smoker and higher preoperative disability as independent risk factors for sRDH. Current smoker was an independent risk factor for sRDH reoperation. These findings are important for spinal surgeons and rehabilitation specialists in risk assessment, consenting patients, and perioperative management. Cite this article: Bone Joint J 2023;105-B(3):315–322

Aims. In the United Kingdom, lower incidences of intraspinal abnormalities in patients with early onset idiopathic scoliosis have been observed than in studies in other countries. We aimed to determine the rates of these abnormalities in United Kingdom patients diagnosed with idiopathic scoliosis before the age of 11 years. Patients and Methods. This retrospective study of patients attending an urban scoliosis clinic identified 71 patients satisfying a criteria of: clinical diagnosis of idiopathic scoliosis; age of onset ten years and 11 months or less; MRI screening for intraspinal abnormalities. United Kingdom census data combined with patient referral data was used to calculate incidence. Results. Mean age at diagnosis was six years with 39 right-sided and 32 left-sided curves. Four patients (5.6%) were found to have intraspinal abnormalities on MRI. These consisted of: two combined Arnold-Chiari type 1 malformations with syrinx; one syrinx with a low lying conus; and one isolated syrinx. Overall annual incidence of early onset idiopathic scoliosis was one out of 182 000 (0.0006%). Conclusion. This study reports the lowest rates to date of intraspinal anomalies in patients with early onset idiopathic scoliosis, adding to knowledge regarding current incidences of these abnormalities as well as any geographical variation in the nature of the disease. Cite this article: Bone Joint J 2017;99-B:829–33

Dysphagia is a common complication of anterior surgery of the cervical spine. The incidence of post-operative dysphagia may be as high as 71% within the first two weeks after surgery, but gradually decreases during the following months. However, 12% to 14% of patients may have some persistent dysphagia one year after the procedure. It has been shown that female gender, advanced age, multilevel surgery, longer operating time and severe pre-operative neck pain may be risk factors. Although the aetiology remains unclear and is probably multifactorial, proposed causes include oesophageal retraction, prominence of the cervical plate and prevertebral swelling. Recently, pre-operative tracheal traction exercises and the use of retropharyngeal steroids have been proposed as methods of reducing post-operative dysphagia. We performed a systematic review to assess the incidence, aetiology, risk factors, methods of assessment and management of dysphagia following anterior cervical spinal surgery. Cite this article: Bone Joint J 2013;95-B:868–73

Aim:. To determine if patients with coronal plane deformity in the lumbar spine have a higher grade of lumbar spine subtype compared to controls. Method:. This was a retrospective case/control study based on a review of radiological investigations in 250 patients aged over 40 years who had standing plain film lumbar radiographs with hips present. Measurements of lumbar coronal plane angle, lumbar lordosis, sacral slope, pelvic tilt and pelvic incidence were obtained. “Cases” with degenerative scoliosis (n=125) were defined as patients with a lumbar coronal plane angle of >10°. Lumbar spine subtype was categorised (1–4) using the Roussouly classification. Lumbar spine subtype was dichotomised into low (type 1,2) or high (type 3,4). Prevalence of lumbar spine subtype in cases versus controls was compared using the Chi squared test. Pelvic incidence was compared using an unpaired T-test. Predictors of lumbar coronal plane angle were identified using stepwise multiple regression. Significance was accepted at P<0.05. Results:. The prevalence of type 1–4 lumbar spine subtypes in the case group were 12.8%, 20.8%, 30.4% and 36% respectively and in the control group were 10.4%, 38.3% and 28% and 23.3% respectively. Types 3 and 4 lumbar spine subtypes were more prevalent in the cases group (66.4% vs 51.2% respectively, P=0.0207). Pelvic incidence was not significant different between groups (P=0.0594). No significant predictors of lumbar coronal plane angle were determined. Lumbar spine subtype (P=0.969), pelvic incidence (P=0.740), sacral slope (P=0.203) pelvic tilt (P=0.167) and lumbar lordosis (P=0.088) were not significant. Discussion:. Results show that neither the lumbar spine subtype nor pelvic parameters appear to have a significant influence on determining the coronal plane angle in the degenerative lumbar spine. Conflict Of Interest Statement: No conflict of interest

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

Purpose of study. The aim of this study was to identify the incidence of Gram negative bacterial vertebral osteomyelitis (VO) within our unit during a 3-year study period and evaluate if this corresponds to published evidence that the occurrence is increasing. Methods. Between May 2007 and May 2010, all patients, over the age of 18 years, suffering from Gram-negative VO were identified and their microbiological diagnoses were evaluated. All patients were treated within a large tertiary spinal surgery unit in Leeds. Results. This study identified 79 patients with haematogenous VO. Of these 79 patients, 10 patients (12.66%) had Gram-negative organisms isolated. These organisms included E. Coli (4), Pseudomonal aeruginosa (3), Klebsiella pneumonia (1), Haemophilus influenza (1) and Enterobacter cloacae (1). Four patients had the causative organism isolated on =2 positive blood cultures, three from biopsy and =2 positive blood culture, one from biopsy alone and two were diagnosed from 1 positive blood culture. Conclusion. VO is a common manifestation of osteomyelitis in adults, representing 2-7% of all cases of osteomyelitis. Staphylococcus aureus is the most common causative aetiological agent in haematogenous spinal infections, accounting for between 40 - 60% of cases. Despite the fact that Gram negative bacteria infections represent a minor proportion of all cases of VO, around 15 - 23%, recent evidence suggests that the microbiology of this disease may be changing and the incidence of Gram-negative bacterial infections are increasing. This has been attributed a variety of factors including, an increasing proportion of individuals with predisposing risk factors such as advanced age, diabetes mellitus, malignancy and better diagnostic techniques. Results from our study show an incidence of Gram-negative VO of 12%, which is less than results quoted in the literature and does not confirm recent evidence that these types of spinal infections are increasing in incidence

Incidence of pars defect associated with idiopathic scoliosis has been reported as 6% based on roentgenographic evaluation in previous studies. (Fisk et al, 1978). We aim to present our results in an MRI based study. 224 patients of adolescent idiopathic scoliosis (AIS) who had an MRI scan over a period of three years (2006-2008), performed either as a preoperative investigation or due to other symptoms were reviewed. All MRI scans were reviewed by two experienced musculoskeletal radiology consultants independently. Among 224 patients 13 (5.8%) patients were found to have pars defect. Mean age-group of patients were (19 years, range-11-40). 84.6% (n=11) patients were female and 15.3% patients were male. There was varying severity of curve patterns. We have noted two lumbar/thoraco-lumbar curves (Lenke 5), King Type I-6, King Type II-2 and three King Type III curves. All scoliotic deformities were non-structural. Bilateral pars defect was noted in nine (69%) patients. Previous studies (Fisk et al, 1978; Mau H 1981) have described the incidence of pars defect as approximately 6.2%. Recent studies have emphasized use of MRI to diagnose pars defect based on signal changes in the pedicle (Sairyo et al.). Our study reveals the incidence of pars defect in AIS to be 5.8 % based on MRI diagnosis which does not seem to be different to previous roentgenographic studies

We report the incidence of and risk factors for complications after scoliosis surgery in patients with Duchenne muscular dystrophy (DMD) and compare them with those of other neuromuscular conditions. We identified 110 (64 males, 46 females) consecutive patients with a neuromuscular disorder who underwent correction of the scoliosis at a mean age of 14 years (7 to 19) and had a minimum two-year follow-up. We recorded demographic and peri-operative data, including complications and re-operations. There were 60 patients with cerebral palsy (54.5%) and 26 with DMD (23.6%). The overall complication rate was 22% (24 patients), the most common of which were deep wound infection (9, 8.1%), gastrointestinal complications (5, 4.5%) and hepatotoxicity (4, 3.6%). The complication rate was higher in patients with DMD (10/26, 38.5%) than in those with other neuromuscular conditions (14/84, 16.7% (p = 0.019). All hepatotoxicity occurred in patients with DMD (p = 0.003), who also had an increased rate of deep wound infection (19% vs 5%) (p = 0.033). In the DMD group, no peri-operative factors were significantly associated with the rate of overall complications or deep wound infection. Increased intra-operative blood loss was associated with hepatotoxicity (p = 0.036). In our series, correction of a neuromuscular scoliosis had an acceptable rate of complications: patients with DMD had an increased overall rate compared with those with other neuromuscular conditions. These included deep wound infection and hepatotoxicity. Hepatotoxicity was unique to DMD patients, and we recommend peri-operative vigilance after correction of a scoliosis in this group. Cite this article: Bone Joint J 2014; 96-B:943–9

Background. The incidence of backpain is unknown in children because studies have been cross-sectional or longitudinal with few follow-ups of long intervals. Children cannot be expected to remember past events of backpain correctly. Therefore data-collection must be undertaken with short intervals and using other methods than questionnaires only. Methods and material. The 1208 children from grade 0 to grade 4, who participated in an intervention study (increased physical activity vs. “business-as-usual”) were followed with standardized questions submitted with weekly text-messages (SMS-Track). If they answered “yes” to backpain in the past week, their parents were called up, and the child was seen in person by health personnel. “Backpain” included any type of spinal pain. Results. Our interim analyses show that compliance was 92% for responding to text-messages. Over the total risk time of 35,238 weeks, 576 reported backpain at some time (individual range 0 to 11). The incidence ratio for gender was 0.72 for boys. The 2. nd. to 4. th. school-grades had significantly higher incidence ratios (1.4-2.1) when compared to grades 0 and 1. Conclusion. The results of these analyses show that it is possible to collect weekly incidence data on backpain in children. It was found to be surprisingly high

Aim:. To simplify sagittal plane spinal assessment by describing a single novel angle in the lumbar spine equivalent to the difference between pelvic incidence (PI) and lumbar lordosis (LL) and evaluate its reliability. Methods:. New sagittal modifiers in the classification of adult degenerative spinal deformity have been shown to be valid and reliable with the greatest variability being for pelvic incidence minus lumbar lordosis (PI-LL). This measurement can be simplified to a new angle (alpha) without the need to determine either PI or LL. This angle is between a line intersecting the bicoxofemoral centre and perpendicular to the L1 endplate (alpha line) and a line from the bicoxofemoral centre to the centre of the sacral endplate. Two readers graded 40 non-premarked cases twice each, approximately 1 week apart. Inter- and intra-rater variability and agreement were determined for PI-LL and alpha angle separately. Fleiss' kappa was used for reliability measures. Results:. Inter-rater kappa for PI-LL showed substantial reliability and alpha angle showed almost perfect agreement. Intra-rater kappa showed substantial reliability for PI-LL but almost perfect agreement for alpha angle across both readers. Discussion:. Alpha angle can be used as a surrogate for PI-LL and is easier and more reliable to measure. When PI=LL, alpha angle is 0, so the alpha line bisects the sacral plate. Conflict Of Interest Statement: No conflict of interest

The purpose of this cohort study is to determine the incidence of all congenital vertebral anomalies detected antenatally through ultrasound. We also reported on the early mortality rate for this patient cohort, as well as the frequency and type of associated congenital anomalies. The East Midlands and South Yorkshire Anomalies Register consists of data on all voluntary reports of congenital anomalies, from an annual baseline birth rate of 67000 births. We analysed all registered congenital anomalies reported over a 10 year period. Between January 1997 and January 2007, 108 vertebral anomalies were reported, excluding spinal dysraphism (incidence 0.01%). 61 of these were detected antenatally (56%), 17 were detected postnatally (16%) and in 30 patients, the precise time of diagnosis was unclear (28%). At the time of analysis January 2007, 45 of 108 patients had died, either in utero or soon after delivery (42%). 12 fetuses remained in utero and 51 infants were alive. The mortality rate for antenatally diagnosed patients was 41% and the majority were electively terminated (72%). 2 fetuses electively terminated had vertebral anomalies in isolation. There is a relatively high incidence of elective termination of pregnancy as a result of antenatal anomaly ultrasound screening. We have evidence to suggest that foetuses with potentially minor congenital anomalies are being electively terminated at approximately 18 weeks gestation. A structured and timely spinal counselling should be offered once antenatal vertebral anomalies have been identified

Purpose. To evaluate the complications following percutaneous balloon kyphoplasty and assess the advantage of introducing eggshell technique. Methods and Results. We performed 138 Balloon kyphoplasty procedures in 85 patients during august 2007 to march 2010. Data was collected and analyzed in all these cases. Gender distribution was 60 females and 25 males. Age distribution was 33 to 85 years, with an average age of 67.4 years. Indications of surgery were vertebral fractures due to osteoporosis in 81% of the procedures, trauma in 13% and malignancy in 6%. The most common vertebral levels of the kyphoplasty were at T12 in 32 procedures (23%) and L1 in 28 procedures (20%). Eggshell technique was introduced in 2009 where technical problems were encountered during cementing process. All patients had reduced pain levels, which was assessed by visual analog score. The average length of hospital stay was 2.5 days. Complications were 9 (6.5%) cement leaks (all within one cm from the vertebral body) in procedures performed before the introduction of eggshell technique and no cement leak following the introduction of eggshell technique, 5 (3.6%) fresh fractures, 2 (1.4%) intra-operative fractures and 1 (0.73%) rupture of balloon. There were no complications of cord compression, motor deficit, infection, allergy to cement or pulmonary embolism noted. 30-day mortality rate was zero. Conclusion. Our series had 6.5% incidence of cement leak compared to 11-21% quoted in current literature. Since the introduction of eggshell technique, cement leak rate was reduced to zero%. Hence adopting of eggshell technique during percutaneous balloon kyphoplasty procedure may eliminates the risk of cement leak thereby minimizing complications

We report the results of vertebral column resection (VCR) for paediatric patients with spinal deformity. A total of 49 VCRs in paediatric patients from four university hospitals between 2005 and 2009 with a minimum two-year follow-up were retrospectively identified. After excluding single hemivertebral resections (n = 25) and VCRs performed for patients with myelomeningocele (n = 6), as well as spondylectomies performed for tumour (n = 4), there were 14 patients who had undergone full VCR at a mean age of 12.3 years (6.5 to 17.9). The aetiology was congenital scoliosis in five, neuromuscular scoliosis in three, congenital kyphosis in two, global kyphosis in two, adolescent idiopathic scoliosis in one and secondary scoliosis in one. A total of seven anteroposterior and seven posterolateral approaches were used.

The mean major curve deformity was 86° (67° to 120°) pre-operatively and 37° (17° to 80°) at the two-year follow-up; correction was a mean of 54% (18% to 86%) in the anteroposterior and 60% (41% to 70%) in the posterolateral group at the two-year follow-up (p = 0.53). The mean Scoliosis Research Society-24 total scores were 100 (92 to 108) for the anteroposterior and 102 (95 to 105) for the posterolateral group. There was one paraparesis in the anteroposterior group necessitating urgent re-decompression, with a full recovery.

Patients undergoing VCR are highly satisfied after a successful procedure.

Aims. The aim of this study was to investigate the incidence and characteristics of instrumentation failure (IF) after total en bloc spondylectomy (TES), and to analyze risk factors for IF. Methods. The medical records from 136 patients (65 male, 71 female) with a mean age of 52.7 years (14 to 80) who underwent TES were retrospectively reviewed. The mean follow-up period was 101 months (36 to 232). Analyzed factors included incidence of IF, age, sex, BMI, history of chemotherapy or radiotherapy, tumour histology (primary or metastasis; benign or malignant), surgical approach (posterior or combined), tumour location (thoracic or lumbar; junctional or non-junctional), number of resected vertebrae (single or multilevel), anterior resection line (disc-to-disc or intravertebra), type of bone graft (autograft or frozen autograft), cage subsidence (CS), and local alignment (LA). A survival analysis of the instrumentation was performed, and relationships between IF and other factors were investigated using the Cox regression model. Results. A total of 44 patients (32.4%) developed IF at a median of 31 months (interquartile range 23 to 74) following TES. Most IFs were rod fractures preceded by a mean CS of 6.1 mm (2 to 18) and LA kyphotic enhancement of 10.8° (-1 to 36). IF-free survival rates were 75.8% at five years and 56.9% at ten years. The interval from TES to IF peaked at two to three years postoperatively and continued to occur over a period of time thereafter; the early IF-developing group had greater CS at one month postoperatively (CS1M) and more lumbar TES. CS1M ≥ 3 mm and sole use of frozen autografts were identified as independent risk factors for IF. Conclusion. IF is a common complication following TES. We have demonstrated that robust spinal reconstruction preventing CS, and high-quality bone grafting are necessary for successful reconstruction. Cite this article: Bone Joint J 2023;105-B(2):172–179

Aims. Closed suction subfascial drainage is widely used after instrumented posterior spinal fusion in patients with a spinal deformity. The aim of this study was to determine the effect of this wound drainage on the outcomes in patients with adolescent idiopathic scoliosis (AIS). This was a further analysis of a randomized, multicentre clinical trial reporting on patients after posterior spinal fusion using segmental pedicle screw instrumentation. In this study the incidence of deep surgical site infection (SSI) and chronic postoperative pain at two years’ follow-up are reported. Methods. We conducted a randomized, multicentre clinical trial on adolescents undergoing posterior spinal fusion for AIS using segmental pedicle screw instrumentation. A total of 90 consecutive patients were randomized into a ‘drain’ or ‘no drain’ group at the time of wound closure, using the sealed envelope technique (1:1). The primary outcomes in the initial study were the change in the level of haemoglobin in the blood postoperatively and total blood loss. A secondary outcome was the opioid consumption immediately after surgery. The aim of this further study was to report the rate of deep SSI and persistent postoperative pain, at two years' follow-up. Results. As previously reported, the mean 48-hour opioid consumption was significantly higher in the no drain group (2.0 mg/kg (SD 0.8) vs 1.4 mg/kg (SD 0.7); p = 0.005). There were no delayed deep SSIs. At two years’ follow-up, the mean Scoliosis Research Society 24-item questionnaire (SRS-24) total score did not differ between the groups (4.11 (SD 0.47) vs 4.16 (SD 0.33); p = 0.910). The mean SRS-24 pain score was 4.28 (SD 0.48) in the no drain group compared with 4.33 (SD 0.66) in the drain group (p = 0.245). Seven patients (19%) in the no drain group and six in the drain group (14%) reported moderate to severe pain (numerical rating scale ≥ 4) at two years’ follow-up (p = 0.484). The general self-image domain score was significantly higher in the no drain group compared with the drain group (4.02 (SD 0.74) vs 4.59 (SD 0.54); p < 0.001). Conclusion. The main finding in this study was that more severe pain immediately after surgery did not result in a higher incidence of chronic pain in the no drain group compared with the drain group. Back pain and health-related quality of life at two years’ follow-up did not differ between the groups. The patient-reported self-image domain was significantly better in the no drain group compared with the drain group. Cite this article: Bone Joint J 2024;106-B(10):1176–1181

Aims. The aim of this study was to investigate whether the type of cervical disc herniation influences the severity of symptoms at the time of presentation, and the outcome after surgical treatment. Methods. The type and extent of disc herniation at the time of presentation in 108 patients who underwent anterior discectomy for cervical radiculopathy were analyzed on MRI, using a four-point scale. These were dichotomized into disc bulge and disc herniation groups. Clinical outcomes were evaluated using the Neck Disability Index (NDI), 36-Item Short Form Survey (SF-36), and a visual analogue scale (VAS) for pain in the neck and arm at baseline and two years postoperatively. The perceived recovery was also assessed at this time. Results. At baseline, 46 patients had a disc bulge and 62 had a herniation. There was no significant difference in the mean NDI and SF-36 between the two groups at baseline. Those in the disc bulge group had a mean NDI of 44.6 (SD 15.2) compared with 43.8 (SD 16.0) in the herniation group (p = 0.799), and a mean SF-36 of 59.2 (SD 6.9) compared with 59.4 (SD 7.7) (p = 0.895). Likewise, there was no significant difference in the incidence of disabling arm pain in the disc bulge and herniation groups (84% vs 73%; p = 0.163), and no significant difference in the incidence of disabling neck pain in the two groups (70.5% (n = 31) vs 63% (n = 39); p = 0.491). At two years after surgery, no significant difference was found in any of the clinical parameters between the two groups. Conclusion. In patients with cervical radiculopathy, the type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of the symptoms at presentation, nor to clinical outcomes at two years postoperatively. Cite this article: Bone Joint J 2022;104-B(11):1242–1248

The lordosis distribution index (LDI) describes distribution of lumbar lordosis, measured as the % of lower lumbar lordosis (L4-S1) compared to global lordosis (L1-S1) with normal value 50–50%. Maldistributed LDI is associated with higher revision in short lumbar fusions, 4 vertebrae1. We hypothesise maldistributed LDI is also associated with mechanical failure in longer fusions. Retrospective review of 29 consecutive ASD patients, aged 55+, undergoing long lumbar fusion, 4 levels, with >3-years follow-up. LDI, pelvic incidence (PI) and sagittal vertical axis (SVA) were measured on pre- and post-op whole spine standing X-rays (Fig A and B). Patients were categorized according to their pelvic incidence (PI) and postoperative LDI: Normal (LDI 50 80), Hypolordotic (LDI < 50), or Hyperlordotic (LDI > 80) and assessed for failure rate compared to normal LDI and PI <60. Mean follow-up 4.5 years. 19 patients had mechanical failures including junctional failure and metalware fracture. PI >60o was associated with higher mechanical failure rates (Chi^2 p<0.05). Hypolordotic LDI was associated with 82% mechanical failure (Chi^2 p<0.001), Hyperlordotic 88% mechanical failure (Chi^2 p<0.001) and Normal 8% mechanical failure (Table 1). Maldistributed LDI, whether Hyperlordotic or Hypolordotic, correlated with 10× greater mechanical failure rate compared to Normal LDI in long fusions. LDI is a useful measurement that should be considered, especially in high PI patients

Surgical site infections following spinal surgery profoundly influence continued treatment, significantly impacting psychological and economic dimensions and clinical outcomes. Its reported incidence varies up to 20%, with the highest incidence amongst neuromuscular scoliosis and metastatic cord compression patients. We describe the first reported biphasic osteoconductive scaffold (Cerament G) with a logarithmic elution profile as a cumulative strategic treatment modality for adjacent spinal surgery infections. All patients who developed surgical site infections following instrumented fusion (May 2021-December 2021) had their demographics (age, sex), type and number of procedures, isolated organism, antibiotics given, comorbidities, and WHO performance status analysed. The infected wound was debrided to healthy planes, samples taken, and Cerament g applied. Thirteen patients were treated for deep SSI following spinal instrumentation and fusion procedures with intraoperative Cerament G application. There were four males and nine females with an average age of 40 ranging between 12 and 87. Nine patients underwent initial surgery for spinal deformity, and four were treated for fractures as index procedure. 77% of infections were attributable to MSSA and Cutibacteriousm acnes; others included Klebsiella, Pseudomonas and Streptococcus and targeted with multimodal cumulative therapy. A WHO performance score improved in 11 patients. In addition, there was no wound leak, and infection was eradicated successfully in 12/13 with a single procedure. This series shows the successful eradication of the infection and improved functional outcomes with Cerament G. However, the low numbers of patients in our series are an essential consideration for the broader applicability of this device