Aims. Developmental cervical spinal stenosis (DcSS) is a well-known predisposing factor for degenerative cervical myelopathy (DCM) but there is a lack of consensus on its definition. This study aims to define DcSS based on MRI, and its multilevel characteristics, to assess the prevalence of DcSS in the general population, and to evaluate the presence of DcSS in the prediction of developing DCM. Methods. This cross-sectional study analyzed MRI spine morphological parameters at C3 to C7 (including anteroposterior (AP) diameter of spinal canal, spinal cord, and vertebral body) from DCM patients (n = 95) and individuals recruited from the general population (n = 2,019). Level-specific median AP spinal canal diameter from DCM patients was used to screen for stenotic levels in the population-based cohort. An individual with multilevel (≥ 3 vertebral levels) AP canal diameter smaller than the DCM median values was considered as having DcSS. The most optimal cut-off canal diameter per level for DcSS was determined by receiver operating characteristic analyses, and multivariable logistic regression was performed for the prediction of developing DCM that required surgery. Results. A total of 2,114 individuals aged 64.6 years (SD 11.9) who underwent surgery from March 2009 to December 2016 were studied. The most optimal cut-off canal diameters for DcSS are: C3 < 12.9 mm, C4 < 11.8 mm, C5 < 11.9 mm, C6 < 12.3 mm, and C7 < 13.3 mm. Overall, 13.0% (262 of 2,019) of the population-based cohort had multilevel DcSS. Multilevel DcSS (odds ratio (OR) 6.12 (95% CI 3.97 to 9.42); p < 0.001) and male sex (OR 4.06 (95% CI 2.55 to 6.45); p < 0.001) were predictors of developing DCM. Conclusion. This is the first MRI-based study for defining DcSS with multilevel canal narrowing. Level-specific cut-off canal diameters for DcSS can be used for early identification of individuals at risk of developing DCM. Individuals with DcSS at ≥ three levels and male sex are recommended for close monitoring or early intervention to avoid traumatic spinal cord injuries from stenosis. Cite this article: Bone Joint J 2024;106-B(11):1333–1341

Purpose of the study. To compare safety and efficacy of cervical disc replacement (CRD) in single and multilevel DDD. Patients were followed up at 1, 3, 6, 12 and 24 months. Methods. 249 patients were enrolled. 171 patients were treated at 1-level, 41 treated at 2 levels and 2 patients were treated at 3 levels. Implant was also used adjacent to a fusion with a cage in 35 patients. The diagnosis was cervical degenerative disc disease between C3 and C7 with symptomatic DH. Population was 106 male 143 female, average age 46 (25-71). Clinical assessment included VAS scores for arm and neck pain and Neck Disability Index (NDI). Range of motion (ROM) from flexion/extension lateral view were measured. Results. Of all NDI scores recorded, 86,50 % demonstrated at least 15 points improvement at two years follow up from pre-op scores. 85,1% of VAS arm Pain scores demonstrated an improvement by = 2 points from pre-op scores and 50,8% for VAS neck Pain scores. The breakdown by levels and adjacent to an interbody cage shown that 80% of reported NDI scores demonstrated at least a 15 point improvement post operatively for two level disc replacement. 82,4% demonstrated a greater than 2 points improvement in VAS arm pain and 53,3% for VAS neck pain. For patients that received both implant and an interbody cage, 72,7% demonstrated a greater than 2 point improvement in VAS arm pain and 41,7% for VAS neck pain. Three (1,8%) cases of subsidence and 4 cases of implant loosening/displacement due to inappropriate sizing were reported. Available radiographic findings show on average a ROM of 8,2 ° at 2 years and an overall change in cervical lordosis of 5° from pre-op. Conclusion. Clinical outcomes demonstrated a significant improvement for both the total population (n=249) and for the single level total disc replacement population (n=171). Given these outstanding results single and multilevel TDR with this implant can be considered to be safe. No significant difference was observed between single and multilevel TDR groups regarding clinical, functional and radiological results. Follow up for this series need however to be extended for up to 5 years at least. The role of this implant in multilevel cases as well as in cases to a fused level still need further evaluation although these preliminary results are encouraging

Introduction. With the use of each pedicle screw for surgical correction of adolescent idiopathic scoliosis (AIS), there is an increase in instrumentation-related costs, operative time, risk of neural injury, and overall health-care expenses. As such, alternate level screw strategy (ALSS) has been reported as a potential alternative to contiguous multilevel screw strategy (CMSS). Moreover, studies have shown the importance in accounting for the flexibility of the curve based on the fulcrum bending radiograph when assessing postoperative curve correction. Therefore, this study addressed a radiographic and cost analysis comparing CMSS with ALSS for the treatment of thoracic AIS with titanium screws and rod application. Methods. 77 patients with AIS underwent surgery (range 6–15 levels). 35 patients received CMSS, which was characterised as bilateral screw fixation at every level. 42 patients underwent ALSS, which entailed bilateral screw fixation at alternate levels. Titanium rods were used in all cases. Preoperative and postoperative posteroanterior and fulcrum bending radiographic Cobb angles were obtained for all patients. The fulcrum flexibility and the fulcrum bending correction index (FBCI) were assessed. Cost analysis was also done. Results. We recorded a statistically significant difference between screw strategy-type to that of preoperative and postoperative Cobb angles, and postoperative curve correction (p<0·05). No statistically significant difference was noted between screw strategy-type and fulcrum flexibility (CMSS mean 66·9%; ALSS mean 62·7%; p>0·05). The mean FBCIs of the CMSS and ALSS were 126·1% and 122·1%, respectively, and did not differ significantly (p=0·734). Compared with CMSS, ALSS was associated with pedicle screw cost reductions of up to 46·2%. Conclusions. This study is the first to show that irrespective of curve rigidity, ALSS with fewer pedicle screws can achieve comparable FBCI as CMSS. We attribute this finding to the relatively flexible titanium rods used in this study. Thus, ALSS is as effective as CMSS in terms of coronal curve correction, and it has the added benefits of reducing operative time and neurological complication risk. Furthermore, it offers the possibility of better kyphosis restoration compared with the lordosing effect of CMSS

Aims. Gram-negative infections are associated with comorbid patients, but outcomes are less well understood. This study reviewed diagnosis, management, and treatment for a cohort treated in a tertiary spinal centre. Methods. A retrospective review was performed of all gram-negative spinal infections (n = 32; median age 71 years; interquartile range 60 to 78), excluding surgical site infections, at a single centre between 2015 to 2020 with two- to six-year follow-up. Information regarding organism identification, antibiotic regime, and treatment outcomes (including clinical, radiological, and biochemical) were collected from clinical notes. Results. All patients had comorbidities and/or non-spinal procedures within the previous year. Most infections affected lumbar segments (20/32), with Escherichia coli the commonest organism (17/32). Causative organisms were identified by blood culture (23/32), biopsy/aspiration (7/32), or intraoperative samples (2/32). There were 56 different antibiotic regimes, with oral (PO) ciprofloxacin being the most prevalent (13/56; 17.6%). Multilevel, contiguous infections were common (8/32; 25%), usually resulting in bone destruction and collapse. Epidural collections were seen in 13/32 (40.6%). In total, five patients required surgery, three for neurological deterioration. Overall, 24 patients improved or recovered with a mean halving of CRP at 8.5 days (SD 6). At the time of review (two to six years post-diagnosis), 16 patients (50%) were deceased. Conclusion. This is the largest published cohort of gram-negative spinal infections. In older patients with comorbidities and/or previous interventions in the last year, a high level of suspicion must be given to gram-negative infection with blood cultures and biopsy essential. Early organism identification permits targeted treatment and good initial clinical outcomes; however, mortality is 50% in this cohort at a mean of 4.2 years (2 to 6) after diagnosis. Cite this article: Bone Jt Open 2024;5(5):435–443

The aim of this study was to compare the treatment ouctomes of severe idiopathic scoliosis (IS) (>90 degrees) using the staged surgery with initial limited internal distraction and typical IS treated using segmental pedicle screw instrumentation. We hypothesized that staged surgical treatment of severe scoliosis would improve more HRQoL and pulmonary function (PF) as compared with posterior spinal fusion (PSF) for typical IS curves. It was a retrospective review of a consecutive series of 60 IS, severe group (SG) vs. moderate group (MG) with min. 2 years of follow up (FU). The mean preoperative major curve (MC) was 120° and thoracic kyphosis (TK) was 80° for the SG and 54° and 17° for the MG, respectively (p<0.001). The MC was corrected to 58° and TK to 32° for the SG; the MC to 26° and TK to 14°, for the MG, respectively (p<0.001). The mean preoperative AVT was 8.9 cm and improved to 2.8 cm at the final FU for the SG and from 6.5 cm to 2.2 cm at the final FU for the MG (p<0.001). At baseline, the FVC% & FEV1% values were significant different between the two groups (41.5% vs. 83%, p <0.001) & (41.6% vs. 77%, p <0.001). Compared the baseline for SG vs. the values at 2-year FU the FVC % values were (41.5% vs. 66.5%, p <0.001), and the baseline for MG vs. the values at 2-year FU, the FEV1 values were (77% vs. 81%, NS). At last FU, no complications were reported. Gradual traction with complicity of multilevel Ponte's osteotomies and neuromonitoring followed by staged pedicle screws instrumentation in severe IS proved to be a safe and effective method improving spinal deformity (52% correction), PF (improved percentage of predicted forced vital capacity by 49%), and health-related quality and allows to achieve progressive curve correction with no neurologic complications associated to more aggressive one-stage surgeries

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The aim of this study was to reassess the rate of neurological, psoas-related, and abdominal complications associated with L4-L5 lateral lumbar interbody fusion (LLIF) undertaken using a standardized preoperative assessment and surgical technique.

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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.

Introduction. Due to co-morbidities in elderly like atherosclerosis and approach-related risks, anterior lumbar surgery is mainly recommended for younger patients. We reviewed approach-related complications in anterior lumbar surgery in senior patients for complex reconstructions. Materials and Methods. Retrospective review of 12 patients (8 female and 4 male), mean age 65.5±4.9 years, treated with anterior fusion mainly for degenerative scoliosis and lumbar kyphosis in between 2007-10. 9(75%) patients had multilevel procedures. Most common co-morbidities were atherosclerosis (CT-proven in 7 patients), coronary heart disease and COPD. Renal impairment was present preoperatively in 3 patients. Results. Mean duration of surgery was 260±120.8 min and mean blood loss 403.3±348.0 ml in the whole group (157±49.1 min and 240.0±162.0 ml in single ALIF; 334.0±100.0 min and 520.0±408.0 ml in multilevel procedures). Retractor related ischaemia occurred in 8 patients (27.3±29.1 min); perfusion of the leg returned immediately after release (confirmed via pulse-oxymetry). 2 patients had a direct vessel suture (2 common iliac veins); hypotension during surgery occurred in 1 patient due to anaesthetic problems. 5 patients needed ICU support after the procedure. Superficial wound infection was reported in one patient. One case of incisional hernia and one case of lymphocele was noticed. Conclusion. In this retrospective review, no specific complications concerning age or co-morbidities occurred in senior patients. In this group, atherosclerosis was the most common co-morbidity. However, no arterial embolism or perfusion deficit occurred. In the future, more and more elderly are to be treated by spinal surgeons. Anterior lumbar surgery is an alternative treatment option even for complex cases in the elderly. This limited group of patients need further investigations and prospective studies regarding anterior lumbar surgery

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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.

We analysed the complications encountered in 102 consecutive patients who had posterolateral lumbosacral fusion performed with transpedicular screw and rod fixation for non-traumatic disorders after a minimum of two years. Of these, 40 had spondylolysis and spondylolisthesis, 42 a degenerative disorder, 14 instability after previous laminectomy and decompression, and six pain after nonunion of previous attempts at spinal fusion without internal fixation. There were 75 multilevel and 27 single-level fusions. There were 76 individual complications in 48 patients, and none in the other 54. The complications seen were screw misplacement, coupling failure of the device, wound infection, nonunion, permanent neural injury, and loosening, bending and breakage of screws. Screw breakage or loosening was more common in patients with multilevel fusions (p < 0.001). Screws of 5 mm diameter should not be used for sacral fixation. Forty-six patients had at least one further operation for one or several complications, including 20 fusion procedures for nonunion. The high incidence of complications is a disadvantage of this technically-demanding method

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The optimal procedure for the treatment of ossification of the posterior longitudinal ligament (OPLL) remains controversial. The aim of this study was to compare the outcome of anterior cervical ossified posterior longitudinal ligament en bloc resection (ACOE) with posterior laminectomy and fusion with bone graft and internal fixation (PTLF) for the surgical management of patients with this condition.

Background and Purpose:. The inability of intervertebral joints to resist perturbation due to laxity is traditionally measured in cadaveric specimens as their neutral zones (NZ). However in patients, quantitative fluoroscopic (QF) examinations substitute the Initial Attainment Rate for this. If these two measures correspond sufficiently, a clinical method for measuring segmental instability is possible. This study explored this by determining the criterion validity of the Initial Attainment Rate against the Dynamic NZ in an unloaded multilevel porcine spine. Methods and Results:. A 5-segment porcine spine was prepared and mounted on a motorised horizontal motion platform fitted with a digital force gage. Left and right bending moments were calculated about each intervertebral joint for 10 repeated side bends using an inverse dynamics method. The Dynamic NZs and Initial Attainment Rates in the first 10° of platform motion at each level were correlated. The Initial Attainment Rates were comparable to those found in vivo in healthy controls. Substantial and highly significant levels of correlation between these and Dynamic NZs were found for left (rho= 0.75, p=0.0002) and combined left-right bending (rho=0.72, p=0.0001) and moderate for right bending alone (rho=0.55, p=0.0012). Conclusion:. This study found good correlation between the Initial Attainment Rate and the Dynamic NZ indicating the feasibility of assessing intervertebral laxity using QF in clinical studies. Confirmatory studies with multiple specimens adding sagittal and axial plane rotations are needed

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To study the associations of lumbar developmental spinal stenosis (DSS) with low back pain (LBP), radicular leg pain, and disability.

Introduction. Spinal conditions commonly cause pain and disability. Various non-operative treatments including acupuncture are practiced for these conditions. Aim. To evaluate the effectiveness of acupuncture in management of common spinal conditions. Methodology. Between Jan 2011 and Feb 2013, 151 patients who received manual acupuncture in a hospital environment were assessed for pain improvement on Numerical-rating- scale (NRS) of 0–10, overall improvement with Core Outcome Measure Index (COMI) and for satisfaction with the care. Results. 110 had low back pain with and or radicular symptoms, 33 had neck pain and or radicular symptoms, 05 had thoracic and 04 multilevel symptoms. Average number of session given were 3.98 (range 2 to 8). Minimum and maximum reported pain improved statistically from 4.17 to 2.94 (Df 1.2, p = 0.00) and 8.00 to 6.03 (Df 1.9, p = 0.00) respectively but were below Minimum Clinically Important Difference (MCID) of 2. COMI improved statistically from 6.39(SD1.6) to 5.37 (SD 1.9) (Df 1.02, p = 0.00) that was below group MCID of COMI of 2.6. Seventy-five required further treatment, 49 were discharged and 11 patient did not complete the treatment. Discussion. Acupuncture is an NICE recommended established adjuvant treatment for treating common spinal conditions. This study demonstrates it to a be a safe technique with high patient satisfaction with statistically significant improvement in outcome measures that are below MCID of improvement raising questions on its cost effectiveness in routine clinical practice

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The aim of this study was to identify the risk factors for adverse events following the surgical correction of cervical spinal deformities in adults.

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The aim of this study was to determine the differences in spinal imaging characteristics between subjects with or without lumbar developmental spinal stenosis (DSS) in a population-based cohort.

Introduction. Recently published results suggest insertion of shorter screws in L5/S1 stand-alone anterior interbody fusion, fearing S1 nerve root violation. However, insertion of shorter screws led to screw fixation failure and new onset of S1 body fractures. Material and Methods. Retrospective review of patients with L5/S1 stand-alone anterior interbody fusion, focussing on screw length, radiological outcomes (especially metal work failure, screw fixation and S1 body fractures) and new onset of S1 nerve root irritation. Results. 38 patients were included (mean age 46.2±13.3 years, 21 females, 17 males). Fusion of the L5/S1 segment was performed in between 2003-2010; postoperative follow-up ranged from 2-24 months. 15 patients had multilevel surgery (7 multiple segmental fusion, 8 hybrid procedures). Screw length ranged from 20-30 mm. No patient had new postoperative S1 nerve root irritation. Interestingly, 2 patients out of the hybrid group had a new onset of L5 radiculopathy, concordant to the level of disc-replacement. Follow-up x-ray review showed no fracture of S1 body fractures in all patients. No evidence of screw loosening, migration or metal work failure was reported. Conclusion. In our opinion, this review showed that insertion of longer screws for stand-alone anterior interbody fusion in L5/S1 is safe. Longer screws offer better stabilization and seem to minimize risks like S1 body fractures. Short and long-term follow-ups were satisfactory regarding screw placement, migration and positioning of implants in all patients

We treated 12 patients with multilevel stenosis of the cervical canal after spondylosis or ossification of the posterior longitudinal ligament by an expansive open-door laminoplasty, stabilised by using an anchor system. The preoperative sagittal diameter of the canal was 9.8 mm(±2.2) which was increased to 16.1 mm (±2.9) after surgery. The mean expansion ratio of the canal was 64% (42 to 100). The anchoring systems did not fail during the follow-up period (mean 29.5 months), and the decompression was maintained. The use of anchor systems to stabilise the posterior elements after laminoplasty is a simple and effective technique for maintaining the increased sagittal diameter of the canal

We studied 27 patients with low back pain and unilateral L5 or S1 spinal nerve root pain. Significant radiological changes were restricted to the symptomatic root level, when compared with controls. Low back and leg pain were graded on a visual analogue scale. Dermatomal quantitative sensory tests revealed significant elevations of warm, cool and touch perception thresholds in the affected dermatome, compared with controls. These elevations correlated with root pain (warm v L5 root pain; r = 0.88, p < 0.0001), but not with back pain. Low back pain correlated with restriction of anteroposterior spinal flexion (p = 0.02), but not with leg pain. A subset of 16 patients underwent decompressive surgery with improvement of pain scores, sensory thresholds and spinal mobility. A further 14 patients with back pain, multilevel nerve root symptoms and radiological changes were also studied. The only correlation found was of low back pain with spinal movement (p < 0.002). We conclude that, in patients with single level disease, dermatomal sensory threshold elevation and restriction of spinal movement are independent correlates of sciatica and low back pain

Postoperative radiculopathy is a complication of posterior cervical decompression associated with tethering of the nerve root. We reviewed retrospectively 287 consecutive patients with cervical compression myelopathy who had been treated by multilevel cervical laminectomy and identified 37 (12.9%) with postoperative radiculopathy. There were 27 men and ten women with a mean age of 56 years at the time of operation. The diagnosis was either cervical spondylosis (25 patients) or ossification of the posterior longitudinal ligament (12 patients). Radiculopathy was observed from four hours to six days after surgery. The most frequent pattern of paralysis was involvement of the C5 and C6 roots of the motor-dominant type. The mean time for recovery was 5.4 months (two weeks to three years). The results at follow-up showed that the rate of motor recovery was negatively related to the duration of complete recovery of postoperative radiculopathy (γ = −0.832, p < 0.01) and that patients with spondylotic myelopathy had a significantly better rate of clinical recovery than those with ossification of the posterior longitudinal ligament (t = 2.960, p < 0.01). Postoperative radiculopathy may be prevented by carrying out an anterior decompression in conjunction with spinal fusion, which will achieve stabilisation and directly remove compression of the cord at multiple levels