Introduction. Neurological involvement occurs in 10-30% cases of caries spine. Surgical debridement and stabilisation is needed to decompress the cord and prevent progression of deformity. This prospective study was undertaken to determine the efficacy of operative treatment in the management and neurological recovery in patients with caries spine with neural deficit. Material & methods. 20 patients, 14 male, 6 female, were included and followed up for 1 year after surgery. The mean age was 39.45 years. 10 patients had complete paraplegia and 9 patients had paraparesis. 1 patient with cervical involvement had quadriplegia. Anterior decompression and stabilisation was done in all the cases. Objective of surgery was adequate debridement of diseased foci, decompression of cord and stabilisation of spine with correction of deformity. In 19 (95%) patients there with thoraco-lumbar involvement. This was addressed with a titanium mesh cage filled with impacted bone graft and supplemented with 2 Moss Miami screws and a rod construct. In the cervical spine, cervical spine locking plate was used for stabilisation after decompression and bone grafting (tricortical iliac crest graft). Results. Fifteen patients had complete and 5 patients had incomplete neurologic recovery. Neurological recovery started as early as first post-op week (range 3 days to 12 weeks). The ASIA motor score improved from 60.80 (60.80 +/− 20.206) before surgery to 73.55 (73.55 +/− 13.828) at 1 month and 95.30 (95.30+/−11.934) at 6 months after surgery. The ASIA sensory score improved from 173.30 (173.30 +/− 50.689), to 186.85 (186.65 +/− 37.452) at one month and 218.45 (218.45 +/−11.843) at 6 months. All 8 patients with bladder and bowel involvement recovered normal bladder and bowel functions at 6 months. There was no recurrence of infection. Bony fusion was achieved in all patients and there were no implant failures. Conclusion. Anterior debridement, decompression, stabilisation and anti-tubercular chemotherapy resulted in neurological recovery in the majority of the patients

This is a study to investigate the diagnostic and prognostic value of MRI in spinal cord injury.

We performed this prospective study on sixty two patients of acute spinal trauma. We evaluated the epidemiology of spinal trauma & various traumatic findings by MRI. MRI findings were correlated with clinical findings at admission & discharge according to ASIA impairment scale. Four types of MR signal patterns were seen in association with spinal cord injury-cord edema / non haemmorhagic cord contusion (CC), severe cord compression (SCC), cord hemorrhage (CH) and epidural heamatoma (EH). Isolated lesion of cord contusion was found in 40%. All other MR signal patterns were found to be in combination. In cord contusion we further subdivided the group into contusion of size < 3 cm and contusion of size > 3 cm to evaluate any significance of length of cord contusion. In cord heammorhage involving >1cm of the cord, focus was said to be sizable.

On bivariate analysis, there was a definitive correlation of cord contusion (CC) involving <3cm & > 3cm of cord with sensory outcome. In >3cm, chances of improvement was 5.75 times lesser than in patients with CC involving <3cm of cord (odds ratio = 5.75 (95% CI: 0.95, 36), Fisher's exact p = 0.0427 (p<.05). In severe cord compression (SCC) the risk of poor outcome was more (odds ratio 4.3 and p=0.149) however was not statistically significant. It was noted that the patients in which epidural hematoma (EH) was present, no improvement was seen, however, by statistical analysis it was not a risk factor and was not related with the outcome (odds ratio – 0.5 and p = 0.22). Presence of cord oedema / non haemorrhagic contusion was not associated with poor outcome (odds ratio 0.25 and p=0.178). On multiple logistic regression / multivariate analysis for estimating prognosis, sizable focus of haemorrhage was most consistently associated with poor outcome (odds ratio −6.73 and p= 0.32) however it was not statistically significant. The risk of retaining a complete cord injury at the time of follow up for patients who initially had significant haemorrhage in cord was more than 6 fold with patients without initial haemorrhage (odds ratio 6.97 and p= .0047).

Besides being helpful in diagnosis, MRI findings may serve as a prognostic indicator for clinical, neurological and functional outcome in acute spinal trauma patients.

Introduction:

Cervical spondylotic myelopathy (CSM) is a degenerative condition that results in a non-traumatic, progressive and chronic compression of the cervical spinal cord.

Surgery is indicated for patients with moderate to severe myelopathy or progressive myelopathy. Literature shows that decompressive surgery halts progression of the condition. We undertook this study to see if there is a worthwhile improvement in function in patients who had spine decompression for cervical spondylotic myelopathy.

Decision-making regarding operative versus non-operative treatment of patients with thoracolumbar burst fractures in the absence of neurological deficits is controversial, and evidence from trials is sparse. We present a systematic review and meta-analysis of randomised trials comparing operative treatment to non-operative treatment in the management of thoracolumbar burst fractures.

With the assistance of a medical librarian, an electronic search of Medline Embase and Cochrane Central Register of Controlled trials was performed. Trials were included if they: were randomided, had radiologically confirmed thoracolumbar (T10-L3) burst fractures, had no neurological deficit, compared operative and non-operative management (regardless of modality used), and had participants aged 18 and over. We examined the following outcomes: pain, using a visual analogue scale (VAS), where 0=no pain and 100=worst pain; function, using the validated Roland Morris Disability Questionnaire (RMDQ); and Kyphosis (measured in degrees). Two randomised trials including 79 patients (41 operative vs. 38 non-operative) were identified. Both trials had similar quality, patient characteristics, outcome measures, rates of follow up, and times of follow up (mean=47 months). Individual patient data meta-analysis (a powerful method of meta-analysis) was performed, since data was made available by the authors. There were no between-group differences in sex, level of fracture, mechanism of injury, follow up rates or baseline pain, kyphosis and RMDQ scores, but there was a borderline difference in age (mean 44 years in operative group vs. 39 in non-operative group, p=0.046).

At final follow up, there were no between group differences in VAS pain (25 in operative group vs. 22 non-operative, p=0.63), RMDQ scores (6.1 in operative group vs. 5.8 non-operative, p=0.85), or change in RMDQ scores from baseline (4.8 in operative group vs. 5.3 non-operative, p=0.70). But both kyphosis at final follow up (11 degrees vs. 16 degrees, p=0.009) and reduction in kyphosis from baseline (1.8 degrees vs. -3.3 degrees, p=0.003) were better in the operative group.

Operative management of thoracolumbar burst fractures appears to improve kyphosis, but does not improve pain or function.

Sacral fractures are often underdiagnosed, but are frequent in the setting of pelvic ring injuries. They are mostly caused by high velocity injuries or they can be pathological in aetiology. We sought to assess the clinical outcomes of the surgically treated unstable sacral fractures, with or without neurological deficits. unstable sacral fractures were included in the study. Single centre, prospectively collected data, retrospective review of patients who sustained vertically unstable fractures of the sacrum who underwent surgical fixation. out of a total of 432 patients with pelvis and acetabulum injuries. fifty six patients met the inclusion criteria. 18 patients had sustained zone one injuries. 14 patients had zone 2 injuries and 10 patients had zone 3 injurie. Operative fixation was performed percutaneously using cannulated screws in 18 patients.. Open fixation of the sacrum using the anterior approach in 6 patients. Posterior approach was indicates in all 10 of the zone 3 injuries of the sacrum. While in 4 patients, combined approaches were used. 3 patients had decompression and spinopelvic fixation. Neurological deficits were present in 16% of the patients. 2 patients presented with neurgenic bladder. Of the 4 patients who had neurological fall out, 3 resolved with posterior decompression and posterior fixation. All 4 neurological deficits were due to taction or compression of the nerve roots. No hardware failures or non unions observed. The rate of neurological deficit was related more to the degree of pelvic ring instability than to a particular fracture pattern. Low rates of complications and successful surgical treatment of sacral fractures is achiavable. Timeous accurate diagnosis mandatory

Objective. Neurological injuries are most common complication, which has refrained many surgeons from opting elbow arthroscopy for indicated surgeries. The objective of this study was to evaluate the safety of anterolateral (AL) and posterolateral (PL) portals and chances of injury to the radial nerve and posterior interosseous nerve around the elbow joint during elbow arthroscopy. Material & Methods. A cadaveric study was conducted on 16 non dissected cadavers (32 elbow specimens) between the period of January 2021 to June 2022. Four portals were established using 4 mm Steinmann pins which are Proximal AL Portal, Mid-AL Portal, Distal AL Portal and PL Portal. The measurements of each portal were taken for each nerve and compared with each other. Results. In our study, the mean age was 56.5 years. Proximal AL Portal was found to be at an average distance of 12.03 mm from radial nerve, 9.48 mm from the PIN and 9.35 mm from the PACN (Posterior Antebrachial Cutaneous Nerve). Distal AL Portal was at an average distance of 7.95 mm away from the radial nerve which closest to radial nerve amongst all portals. The radial nerve had the most risk of being injured out of all the nerves in the AL and PL portals followed by PIN and PACN in AL portal. Ulnar nerve was found safe in the PL portal. Conclusion. The PL portal was safer than the AL portal for conducting elbow arthroscopy. Care should be taken specially to protect radial nerve while performing elbow arthroscopy

Objective. Guidelines published by the British Association of Spine Surgeons (BASS) and Society of British Neurological Surgeons (SBNS) recommend urgent MRI imaging and intervention in individuals suspected of having CES. The need for an evidence based protocol is driven by a lack of 24/7 MRI services and centralisation of neurosurgery to tertiary centres, compounded by CES's significant medico-legal implications. We conducted an audit to evaluate the pathway for suspected CES in BCUHB West between 2018 and 2021. Methods. A retrospective audit of patients managed for suspected CES between 01/11/2018 and 01/05/2021 was performed, using the SBNS/BASS guidelines as the standard. Results. A total of 252 patients received an emergency MRI for suspected CES between 2018 and 2021. 99% of patients were scanned in compliance with SBNS/BASS standards. Radiological evidence of CES was found in 18% of patients. 33% of emergency scans were performed by out-of-hours services. 4% of patients had repeated scans within the same 6-month period. The majority of referrals originated from Orthopaedics surgeons (78%), or staff in the Emergency Department (8%). 92% of ambulatory patients were not admitted to hospital. During the peak of the COVID-19 pandemic, referrals increased from 2.5 to 3.5 per week. Conclusion. SBNS/BASS standards were largely met, avoiding life changing disability and medico-legal consequences. The department should continue to follow SBNS/BASS guidance on the management of individuals with suspected CES. Challenges regarding the use of repeated scans should be addressed to avoid unnecessary costs. Introduction of new early recognition guidelines and Same Day Emergency Care (SDEC) has likely driven an increase in suspected CES referrals, and subsequent MRI demand. This audit should be utilised as an ongoing tool to ensure best practice continues, and to implement simple measures which may improve compliance with the pathway

Acute spinal cord injury (SCI) is most often secondary to trauma, and frequently presents with associated injuries. A neurological examination is routinely performed during trauma assessment, including through Advanced Trauma Life Support (ATLS). However, there is no standard neurological assessment tool specifically used for trauma patients to detect and characterize SCI during the initial evaluation. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive and popular tool for assessing SCI, but it is not adapted to the acute trauma patients such that it is not routinely used in that setting. Therefore, the objective is to develop a new tool that can be used routinely in the initial evaluation of trauma patients to detect and characterize acute SCI, while preserving basic principles of the ISNCSCI. The completion rate of the ISCNSCI during the initial evaluation after an acute traumatic SCI was first estimated. Using a modified Delphi technique, we designed the Montreal Acute Classification of Spinal Cord Injuries (MAC-SCI), a new tool to detect and characterize the completeness (grade) and level of SCI in the polytrauma patient. The ability of the MAC-SCI to detect and characterize SCI was validated in a cohort of 35 individuals who have sustained an acute traumatic SCI. The completeness and neurological level of injury (NLI) were assessed by two independent assessors using the MAC-SCI, and compared to those obtained with the ISNCSCI. Only 33% of patients admitted after an acute traumatic SCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI includes 53 of the 134 original elements of the ISNCSCI which is 60% less. There was a 100% concordance between the severity grade derived from the MAC-SCI and from the ISNCSCI. Concordance of the NLI within two levels of that obtained from the ISNCSCI was observed in 100% of patients with the MAC-SCI and within one level in 91% of patients. The ability of the MAC-SCI to discriminate between cervical (C0 to C7) vs. thoracic (T1 to T9) vs. thoraco-lumbar (T10 to L2) vs. lumbosacral (L3 to S5) injuries was 100% with respect to the ISNCSCI. The rate of completion of the ISNCSCI is low at initial presentation after an acute traumatic SCI. The MAC-SCI is a streamlined tool proposed to detect and characterize acute SCI in polytrauma patients, that is specifically adapted to the acute trauma setting. It is accurate for determining the completeness of the SCI and localize the NLI (cervical vs. thoracic vs. lumbar). It could be implemented in the initial trauma assessment protocol to guide the acute management of SCI patients

Acute spinal cord injury (SCI) is most often secondary to trauma, and frequently presents with associated injuries. A neurological examination is routinely performed during trauma assessment, including through Advanced Trauma Life Support (ATLS). However, there is no standard neurological assessment tool specifically used for trauma patients to detect and characterize SCI during the initial evaluation. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive and popular tool for assessing SCI, but it is not adapted to the acute trauma patients such that it is not routinely used in that setting. Therefore, the objective is to develop a new tool that can be used routinely in the initial evaluation of trauma patients to detect and characterize acute SCI, while preserving basic principles of the ISNCSCI. The completion rate of the ISCNSCI during the initial evaluation after an acute traumatic SCI was first estimated. Using a modified Delphi technique, we designed the Montreal Acute Classification of Spinal Cord Injuries (MAC-SCI), a new tool to detect and characterize the completeness (grade) and level of SCI in the polytrauma patient. The ability of the MAC-SCI to detect and characterize SCI was validated in a cohort of 35 individuals who have sustained an acute traumatic SCI. The completeness and neurological level of injury (NLI) were assessed by two independent assessors using the MAC-SCI, and compared to those obtained with the ISNCSCI. Only 33% of patients admitted after an acute traumatic SCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI includes 53 of the 134 original elements of the ISNCSCI which is 60% less. There was a 100% concordance between the severity grade derived from the MAC-SCI and from the ISNCSCI. Concordance of the NLI within two levels of that obtained from the ISNCSCI was observed in 100% of patients with the MAC-SCI and within one level in 91% of patients. The ability of the MAC-SCI to discriminate between cervical (C0 to C7) vs. thoracic (T1 to T9) vs. thoraco-lumbar (T10 to L2) vs. lumbosacral (L3 to S5) injuries was 100% with respect to the ISNCSCI. The rate of completion of the ISNCSCI is low at initial presentation after an acute traumatic SCI. The MAC-SCI is a streamlined tool proposed to detect and characterize acute SCI in polytrauma patients, that is specifically adapted to the acute trauma setting. It is accurate for determining the completeness of the SCI and localize the NLI (cervical vs. thoracic vs. lumbar). It could be implemented in the initial trauma assessment protocol to guide the acute management of SCI patients

Acute spinal cord injury (SCI) is most often secondary to trauma, and frequently presents with associated injuries. A neurological examination is routinely performed during trauma assessment, including through Advanced Trauma Life Support (ATLS). However, there is no standard neurological assessment tool specifically used for trauma patients to detect and characterize SCI during the initial evaluation. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive and popular tool for assessing SCI, but it is not adapted to the acute trauma patients such that it is not routinely used in that setting. Therefore, the objective is to develop a new tool that can be used routinely in the initial evaluation of trauma patients to detect and characterize acute SCI, while preserving basic principles of the ISNCSCI. The completion rate of the ISCNSCI during the initial evaluation after an acute traumatic SCI was first estimated. Using a modified Delphi technique, we designed the Montreal Acute Classification of Spinal Cord Injuries (MAC-SCI), a new tool to detect and characterize the completeness (grade) and level of SCI in the polytrauma patient. The ability of the MAC-SCI to detect and characterize SCI was validated in a cohort of 35 individuals who have sustained an acute traumatic SCI. The completeness and neurological level of injury (NLI) were assessed by two independent assessors using the MAC-SCI, and compared to those obtained with the ISNCSCI. Only 33% of patients admitted after an acute traumatic SCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI includes 53 of the 134 original elements of the ISNCSCI which is 60% less. There was a 100% concordance between the severity grade derived from the MAC-SCI and from the ISNCSCI. Concordance of the NLI within two levels of that obtained from the ISNCSCI was observed in 100% of patients with the MAC-SCI and within one level in 91% of patients. The ability of the MAC-SCI to discriminate between cervical (C0 to C7) vs. thoracic (T1 to T9) vs. thoraco-lumbar (T10 to L2) vs. lumbosacral (L3 to S5) injuries was 100% with respect to the ISNCSCI. The rate of completion of the ISNCSCI is low at initial presentation after an acute traumatic SCI. The MAC-SCI is a streamlined tool proposed to detect and characterize acute SCI in polytrauma patients, that is specifically adapted to the acute trauma setting. It is accurate for determining the completeness of the SCI and localize the NLI (cervical vs. thoracic vs. lumbar). It could be implemented in the initial trauma assessment protocol to guide the acute management of SCI patients

Spinal tuberculosis is one of the most common presentations of skeletal tuberculosis. It is one of the major health issues of developing countries as it is associated with significant morbidity and mortality. Pott's paraplegia is a dreaded complication which can result in permanent neurological deficit, unless treated by timely intervention. We evaluated the efficacy of transpedicular decompression and functional recovery in patients of spinal tuberculosis with neurological deficit. A cohort of 23 patients (15 males and 8 female) with diagnosed spinal tuberculosis and having an average age of 37.5±8.4 years, satisfying our inclusion and exclusion criteria's and giving written informed consent were recruited in our study. All patients were managed by transpedicular decompression and fusion with posterior instrumentation. All the patients were followed up clinically, radiologically and hematologically. Patients were followed up at every six weeks for 4 months and thereafter at three monthly intervals to assess the long term outcomes and complications. Neurological evaluation was done by Frankel grading. Functional outcome was assessed by Visual Analog Score (VAS) and Owestry Disability Index score (ODI score). All the patients were followed for a minimum of 27 months. At the final follow-up, there was a statistically significant improvement in VAS score and ODI score. Out of 23 patients, all except three patients showed neurological recovery. We observed that transpedicular decompression is safe and effective approach for management of spinal tuberculosis as it allows adequate decompression of spinal cord while pedicular instrumentation provides stable spinal fixation and helps in early rehabilitation

The evolution of operative technology has allowed correction of complex spinal deformities. Neurological deficits following spinal instrumentation is a devastating complication and the risk is especially high in those with complex sagittal and coronal plane deformities. Prior to intraoperative evoked potential monitoring, spinal cord function was tested using the Stagnara Wake up test, typically performed after instrumentation once the desired correction has been achieved. This test is limited as it does not reflect the timeframe in which the problem occurred and it may be dangerous to some patients. Intraoperative neuromonitoring allows timely feedback of the effect of instrumentation and curve correction on the spinal cord. Pedicle screws that are malpositioned can result in poor fixation or neuronal injury. Evoked EMG monitoring can aid in accurate placement. A positive EMG response can alert the surgeon to a potential pedicle breech and allow them to reassess the placement of their hardware intraoperatively. The stimulation threshold is affected by the amount of surrounding bone acting as an insulator to electrical conduction and is variable in different regions of the spine. In the non-deformed, lumbar spine stimulation thresholds have been established. Such guidelines have not been well-developed for the thoracic spine, or for severely scoliotic spines. Thus our primary objective was to compare the stimulation threshold of the apical pedicle on the concave side to the stimulation threshold of the pedicles at the upper and lower instrumented levels. Intraoperative EMG stimulation thresholds were done at 192 apical pedicles on the concave side of the deformity and then compared to those thresholds found at 169 terminal level pedicles. Only pedicles for which a stimulation threshold was found were reported and excluded those where a breech was suspected. The lowest stimulation required for an EMG response was documented to a maximum stimulation of 20 mA. The mean threshold at the apex was 16.62 milliamps (mA) compared to 18.25mA at the terminal levels. This was compared with the t-test and showed a statistically significant difference (p<0.05). In this study we report only the thresholds for the concave side, the pedicle that is most likely to be reduced in size. The threshold for stimulation is reduced compared to those seen at the highest and lowest instrumented level. Most of the apexes are located in the mid-thoracic spine with the highest instrumented levels being in the high thoracic spine and the lowest levels being in the lumbar spine. This study provides preliminary evidence that the apical, concave pedicle has a lower threshold than the end pedicles and one cannot rely on established thresholds from different areas of the spine. The surgeon should be cognisant of these differences when instrumenting at the apical level. Ongoing work is examining the convex apex threshold as well as the relationship between the effect of age and a diagnosis other than adolescent idiopathic scoliosis

To analyse and compare long-term functional outcome of combined spino-pelvic injuries to an isolated pelvis and spinal fractures, the outcome of matched 30 patients with combined pelvic and spinal fractures was compared with 32 patients with isolated pelvic fractures and 30 patients with isolated spinal fractures. Functional outcome was measured using the self-report questionnaire EuroQol EQ-5D, a generic outcome tool. The functional outcome was compared with the average UK population scores. The mean age, median ISS and demographic profile were similar in all 3 groups. Neurological injuries were seen in 10 patients in the combined injury group, 5 patients in the pelvic injury group and 3 patients in the spinal fracture group. 1 patient had sexual dysfunction in the combined injury group. The EuroQol EQ-5D descriptive scores for the combined group were 0.67±0.11 (0.71±0.12 for spine fracture, 0.61±0.18 for pelvic fracture) and Valuation scores for the combined injury were 69.6±11.4 (65.1±19.4 for spine fracture, 61.5±21.9 for pelvic fracture), which are p=0.004 and p=0.003 for the combined injury compared to the average UK population. Duration of hospital stay was a mean of 13 days in spine injury group compared to 49 days in the combined injury group. 70% of patients with spinal injuries returned to the same level of employment in a mean duration of 5.3 months with only 10% retired due to injury; compared to 56.6% returned to work in the combined injury group after a mean duration of 12.8 months with 23.3% retired due to injury. Long-term functional outcome is significantly better with isolated spinal injuries compared to pelvic injury or combined injury. There is no significant long-term difference between the combined spino-pelvic group and the isolated pelvic injury group. We feel that the spinal injuries in a patient with coexisting pelvic fracture do not contribute towards the overall functional outcome in those patients

Purpose. We report our surgical management of a series of primary and metastatic tumours of the lumbosacral junction, highlighting different methods of fixation, outcome and complications. Method. Seven patients with primary and four with secondary tumours involving the lumbosacral junction underwent surgery. After tumour resection, iliolumbar fixation was performed in all but one case, using Galveston rods (4) or iliac screws (6). All constructs were attached proximally with pedicle screws. Cross links were used in all instrumented cases and autologous and allogenic bone graft applied. Results. There were no perioperative deaths. Mean operating time was 7.3 hours (range 3-18) and there was extensive blood loss (mean transfusion requirement 7.5 units, range 0-20). We estimate a transfusion requirement of approximately one unit per hour operating time. However, we noted no complications attributable to either blood loss or transfusions. Ambulation improved in 5, was unchanged in 5 and deteriorated in one. Neurological status deteriorated in 4 and remained static in the others. However in all but one case the neurological deficit was defined by the nature of proposed surgery. Mean survival from surgery for patients with metastatic disease was 9.5 months (3-18). At mean follow-up of 10 months (1-19 months), all patients with primary tumours were still alive without evidence of tumour recurrence. Extralesional excision, and therefore potentially curative surgery, was achieved in 4 cases where this was the primary goal of surgery (osteosarcoma, osteoblastoma, chordoma, embryonic rhabdomyosarcoma). There were no cases of metalwork failure. One patient has undergone revision surgery for pseudarthrosis. Conclusion. Sacral resection and iliolumbar reconstruction is a feasible treatment option in selected patients, offering potential cure. The fixation methods used by the authors restored lumbosacral stability, sufficient for pain relief and preserving ambulation and usually the predicted level of neurological function

Introduction. Pedicle Subtraction osteotomy (PRO) in correction of severe spinal deformities is well established. Prospective analysis of its efficacy in complex spinal deformities is sparse in literature. Aims and objectives. To assess the role of PRO in correction of uniplanar and multiplanar spinal deformity and to assess the role of revision PRO in failed corrections. Material and methods. 50 patients were operated between 1996-2007 and followed up for 2 years (2-6). 27 had uniplanar kyphosis (60-128 degrees) and kyphoscoliosis was seen in 10. Failed corrections were seen in 11 uniplanar and 2 multiplanar deformities. The average pre-operative kyphosis and sagittal balance was 78.7 degrees and 22 mm (7-30) respectively. Scoliotic deformity ranged from 97-138 (average 108 degrees) and the coronal imbalance from 10-55 (average 24mm). Deformity distribution was upper dorsal 5, mid dorsal 22, dorso-lumbar 18 and lumbar 5. A single posterior approach sufficed in 47 cases while 3 required an anterior approach for reconstruction. 13 patients had pre-operative neurological deficit (bedridden 10, ambulatory 3). The average surgical time required was 300 minutes and blood loss was 800cc. The anterior defect reconstructed averaged 16.5mm (5-28). Results. Pulmonary complications occurred in 8 (21%), (embolism 1, pneumonia 2, hypoxia 5). Wound infection required debridement in 3 (8%). Failed corrections were seen in 10 (3 out of 37 in our series, 8%) due to failure of construct 2, severe disease 2, infection (active 2, quiescent 4). Neurological deterioration occurred in 1(2%), medial pedicle wall perforation. 12 patients regained ambulation (independent 7, support 5). Post-operative kyphosis and sagittal balance was 36.5 (10-108) and 10mm (5-20) respectively. Average correction was: sagittal 46.4%, coronal 37.5% and revisions 58%. The correction of kyphosis and sagittal balance was statistically comparable between primary and revision cases (p >0.05). Conclusions. PRO offers an excellent single stage decompression and controlled correction of kyphosis

Aims

Despite the increase in the surgical repair of proximal hamstring tears, there exists a lack of consensus in the optimal timing for surgery. There is also disagreement on how partial tears managed surgically compare with complete tears repaired surgically. This study aims to compare the mid-term functional outcomes in, and operating time required for, complete and partial proximal hamstring avulsions, that are repaired both acutely and chronically.

Aims

The aim of this study was to examine the association between postoperative glycaemic variability and adverse outcomes following orthopaedic surgery.

The use of robots in orthopaedic surgery is an emerging field that is gaining momentum. It has the potential for significant improvements in surgical planning, accuracy of component implantation and patient safety. Advocates of robot-assisted systems describe better patient outcomes through improved pre-operative planning and enhanced execution of surgery. However, costs, limited availability, a lack of evidence regarding the efficiency and safety of such systems and an absence of long-term high-impact studies have restricted the widespread implementation of these systems. We have reviewed the literature on the efficacy, safety and current understanding of the use of robotics in orthopaedics.

Cite this article: Bone Joint J 2015; 97-B:292–9.

Injury to the sciatic nerve is one of the more serious complications of acetabular fracture and traumatic dislocation of the hip, both in the short and long term. We have reviewed prospectively patients, treated in our unit, for acetabular fractures who had concomitant injury to the sciatic nerve, with the aim of predicting the functional outcome after these injuries.

Of 136 patients who underwent stabilisation of acetabular fractures, there were 27 (19.9%) with neurological injury. At initial presentation, 13 patients had a complete foot-drop, ten had weakness of the foot and four had burning pain and altered sensation over the dorsum of the foot. Serial electromyography (EMG) studies were performed and the degree of functional recovery was monitored using the grading system of the Medical Research Council. In nine patients with a foot-drop, there was evidence of a proximal acetabular (sciatic) and a distal knee (neck of fibula) nerve lesion, the double-crush syndrome.

At the final follow-up, clinical examination and EMG studies showed full recovery in five of the ten patients with initial muscle weakness, and complete resolution in all four patients with sensory symptoms (burning pain and hyperaesthesia). There was improvement of functional capacity (motor and sensory) in two patients who presented initially with complete foot-drop. In the remaining 11 with foot-drop at presentation, including all nine with the double-crush lesion, there was no improvement in function at a mean follow-up of 4.3 years.

Painful neuromas may follow traumatic nerve injury. We carried out a double-blind controlled trial in which patients with a painful neuroma of the lower limb (n = 20) were randomly assigned to treatment by resection of the neuroma and translocation of the proximal nerve stump into either muscle tissue or an adjacent subcutaneous vein. Translocation into a vein led to reduced intensity of pain as assessed by visual analogue scale (5.8 (sd 2.7) vs 3.8 (sd 2.4); p < 0.01), and improved sensory, affective and evaluative dimensions of pain as assessed by the McGill pain score (33 (sd 18) vs 14 (sd 12); p < 0.01). This was associated with an increased level of activity (p < 0.01) and improved function (p < 0.01).

Transposition of the nerve stump into an adjacent vein should be preferred to relocation into muscle.