In a retrospective cohort study we compared the clinical outcome and complications, including dysphagia, following anterior cervical fusion for the treatment of cervical spondylosis using either a zero-profile (Zero-P; Synthes) implant or an anterior cervical plate and cage. A total of 83 patients underwent fusion using a Zero-P and 107 patients underwent fusion using a plate and cage. The mean follow-up was 18.6 months (. sd. 4.2) in the Zero-P group and 19.3 months (. sd. 4.1) in the plate and cage group. All patients in both groups had significant symptomatic and neurological improvement. There were no significant differences between the groups in the Neck Disability Index (NDI) and visual analogue scores at final follow-up. The cervical alignment improved in both groups. There was a higher incidence of dysphagia in the plate and cage group on the day after surgery and at two months post-operatively. All patients achieved fusion and no graft migration or nonunion was observed. When compared with the traditional anterior cervical plate and cage, the Zero-P implant is a safe and convenient procedure giving good results in patients with symptomatic cervical spondylosis with a reduced incidence of dysphagia post-operatively. Cite this article: Bone Joint J 2013;95-B:543–7

Objective:. The aim of this study was to define a method to identify the location of the great vessel bifurcation (GVB) in relation to the L5/S1 disc and measure the lumbo-sacral angle (LSA) at L5/S1 using routine lumbar spine MRI images on standard PACS software. The information can be used for surgical planning of anterior lumbar interbody fusion (ALIF) at L5/S1 with a plate and cage. Method:. Axial and sagittal T2 sections of 192 lumbar spine MRI scans were viewed simultaneously to classify the position of the GVB and the LSA. A further 75 scans were assessed independently by 2 examiners (E1/E2) utilizing the same classification to record the GVB position (High (H), Middle (M), Low (L)) and size of the LSA using standard radiology software. Twenty five images were randomly selected for repeat measurements one month later. Results:. Inter and Intra-observer agreements were excellent for LSA (0.92, R1=0.92, R2=0.94) and moderate for GVB (0.76, R1=0.85, R2=0.75). Reduced GVB correlation was primarily observed in the high (E1=64% vs E2=50.7%, =57.3%) and Middle (E1=25.3% vs E2=40%, =32.7%) categories. LSA was most prevalent between 121–130° in both assessors (E1= 57.3% vs E20=61.3%, =59.5%). Conclusion:. MRI assessment of GVB height and LSA is feasible and can aid surgical planning of L5/S1 ALIF and permit selection of the implants that best suit the patient's specific anatomy. The results indicate that anterior plate placement, without impingement on the great vessels, would be possible in 90% of cases with a majority having an LSA of between 125° and 130°

The footplate in the current available TDR is flat without any allowance for endplate concavity in the sagittal plane. To assess the morphology of the endplates of the lower lumbosacral in the sagittal plane, and to identify the frequently occurring shape patterns of the end plates at each level. Retrospective Study. 200 consecutive magnetic reasonance imaging (MRI) scans of patients between the age of 30 and 60 years were analysed. In each endplate, the anteroposterior width, the height of concavity of the endplate, and the distance of the summit from the anterior vertebral body margin were noted. The shape of the endplate was noted as oblong (o) if the curve was uniform starting from the anterior margin and finishing at the posterior margin, eccentric (e) if the curve started after a flat portion at the anterior border and then curving backwards, and flat (f) if there is no curve in the sagittal plane. The shape of the end plate is mostly oblong at L3 IEP(59%), equally distributed between oblong and eccentric at L4 SEP (o=43.5%, e=46.5%), eccentric at L4 IEP (e=62.5%), eccentric at L5 SEP (e = 59.0%), eccentric at L5 IEP (e=94.0%), and flat at S1 SEP (f=82.5%). As there is a difference in the shape of the endplate at each level and they are not uniform, there is a need to focus on the sagittal shape of the footplate to avoid subsidence and mismatch of the footplate in cases of endplate concavity

Aim of Study and Background

The vertebral endplate (VEP) is characterised as a bilayer of cartilage and bone, acting as a boundary between the disc and the vertebra. The disc being the largest avascular tissue in the body, relies primarily on the nutritional pathways from the vascular network in the adjacent VEP. Disruption of this nutrient supply has been identified as a major contributor to disc degeneration, yet the 3D topology of the network is poorly understood.

The aim of this work is the characterisation of this vascular network to further understand the physiology of the vascular network and the correlation between disc degeneration and nutrient supply.

Aims. The aim of this study was to investigate whether including the stages of ulnar physeal closure in Sanders stage 7 aids in a more accurate assessment for brace weaning in patients with adolescent idiopathic scoliosis (AIS). Methods. This was a retrospective analysis of patients who were weaned from their brace and reviewed between June 2016 and December 2018. Patients who weaned from their brace at Risser stage ≥ 4, had static standing height and arm span for at least six months, and were ≥ two years post-menarche were included. Skeletal maturity at weaning was assessed using Sanders staging with stage 7 subclassified into 7a, in which all phalangeal physes are fused and only the distal radial physis is open, with narrowing of the medial physeal plate of the distal ulna, and 7b, in which fusion of > 50% of the medial growth plate of distal ulna exists, as well as the distal radius and ulna (DRU) classification, an established skeletal maturity index which assesses skeletal maturation using finer stages of the distal radial and ulnar physes, from open to complete fusion. The grade of maturity at the time of weaning and any progression of the curve were analyzed using Fisher’s exact test, with Cramer’s V, and Goodman and Kruskal’s tau. Results. We studied a total of 179 patients with AIS, of whom 149 (83.2%) were female. Their mean age was 14.8 years (SD 1.1) and the mean Cobb angle was 34.6° (SD 7.7°) at the time of weaning. The mean follow-up was 3.4 years (SD 1.8). At six months after weaning, the rates of progression of the curve for patients weaning at Sanders stage 7a and 7b were 11.4% and 0%, respectively for those with curves of < 40°. Similarly, the rates of progression of the curve for those being weaned at ulnar grade 7 and 8 using the DRU classification were 13.5% and 0%, respectively. The use of Sanders stages 6, 7a, 7b, and 8 for the assessment of maturity at the time of weaning were strongly and significantly associated (Cramer’s V 0.326; p = 0.016) with whether the curve progressed at six months after weaning. Weaning at Sanders stage 7 with subclassification allowed 10.6% reduction of error in predicting the progression of the curve. Conclusion. The use of Sanders stages 7a and 7b allows the accurate assessment of skeletal maturity for guiding brace weaning in patients with AIS. Weaning at Sanders stage 7b, or at ulnar grade 8 with the DRU classification, is more appropriate as the curve did not progress in any patient with a curve of < 40° immediately post-weaning. Thus, reaching full fusion in both distal radial and ulnar physes (as at Sanders stage 8) is not necessary and this allows weaning from a brace to be initiated about nine months earlier. Cite this article: Bone Joint J 2021;103-B(1):141–147

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

Aims

In this investigation, we administered oxidative stress to nucleus pulposus cells (NPCs), recognized DNA-damage-inducible transcript 4 (DDIT4) as a component in intervertebral disc degeneration (IVDD), and devised a hydrogel capable of conveying small interfering RNA (siRNA) to IVDD.

Aims

To determine whether side-bending films in scoliosis are assessed for adequacy in clinical practice; and to introduce a novel method for doing so.

Aims

CRP is an acute-phase protein that is used as a biomarker to follow severity and progression in infectious and inflammatory diseases. Its pathophysiological mechanisms of action are still poorly defined. CRP in its pentameric form exhibits weak anti-inflammatory activity. The monomeric isoform (mCRP) exerts potent proinflammatory properties in chondrocytes, endothelial cells, and leucocytes. No data exist regarding mCRP effects in human intervertebral disc (IVD) cells. This work aimed to verify the pathophysiological relevance of mCRP in the aetiology and/or progression of IVD degeneration.

Aims

Surgical approaches to cervical ossification of the posterior longitudinal ligament (OPLL) remain controversial. The purpose of the present study was to analyze and compare the long-term neurological recovery following anterior decompression with fusion (ADF) and posterior laminectomy and fusion with bone graft and internal fixation (PLF) based on > ten-year follow-up outcomes in a single centre.

Aims

This study was performed to explore the effect of melatonin on pyroptosis in nucleus pulposus cells (NPCs) and the underlying mechanism of that effect.

Background. The rate of subsidence for lumbar fusion surgery is variable from 7- 89%. Subsidance can affect the outcome of surgery by compramising alignment, foraminal height and stability. Modic changes have been shown to affect the stiffness and strength of the vertebral end plate and shown to affect both fusion rates and clinical outcome. Ongoing laboratory investigations into the material properties of the degenerate lumbar spine show modic changes affect the end plate and trabecular bone mechanics. This study aims to bridge this basic science research into clinical practice. Methods. A retrospective analysis of all patients in two tertiary spinal centres who have undergone lumbar interbody fusion with the implantation of a ‘cage’ over the past 6 years were analysed by two independent spinal surgeons. Pre-operative MRI findings were correlated with post-operative interbody cage subsidence after 1 year. Results. A total of 108 Interbody cages were included. Comparison of demographics did not reveal and significant between group variations. Comparison made between those displaying no modic changes and those displaying any of the three modic change types revealed a significantly higher subsidence rate in those displaying modic changes (p=0.003). Subgroup analysis showed that Type 2 modic changes (n=27) had a significantly higher subsidence rate (p=0.002). Those displaying type 3 modic changes (n=7) did not have any incidents of subsidence. Conclusions. Type 2 modic changes are associated with a higher rate of Lumbar interbody cage subsidence in this study. Those displaying type 3 changes seem to be protected from interbody cage subsidence. No Conflict of Interest. Funding: Produced as part of a research grant from the Gwen Fish Trust and Action Arthritis

Aims

To determine the major risk factors for unplanned reoperations (UROs) following corrective surgery for adult spinal deformity (ASD) and their interactions, using machine learning-based prediction algorithms and game theory.

Aims

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.

Aims

The aim of this study was to report the long-term prognosis of patients with multiple Langerhans cell histiocytosis (LCH) involving the spine, and to analyze the risk factors for progression-free survival (PFS).

Aims

The number of patients undergoing surgery for degenerative cervical radiculopathy has increased. In many countries, public hospitals have limited capacity. This has resulted in long waiting times for elective treatment and a need for supplementary private healthcare. It is uncertain whether the management of patients and the outcome of treatment are equivalent in public and private hospitals. The aim of this study was to compare the management and patient-reported outcomes among patients who underwent surgery for degenerative cervical radiculopathy in public and private hospitals in Norway, and to assess whether the effectiveness of the treatment was equivalent.

Aims

The aim of the study was to determine if there was a direct correlation between the pain and disability experienced by patients and size of their disc prolapse, measured by the disc’s cross-sectional area on T2 axial MRI scans.

Introduction. Low back pain is the leading cause of musculoskeletal disease and the biggest cause of morbidity worldwide. Approximately 40% of these are cases are caused by disease of the intervertebral discs (IVDs): the shock absorbing, flexible material located between the bones (vertebrae) along the length of the spine. In severe cases, the spine becomes unstable and it becomes necessary to immobilise or fix the joint in position using a lumbar cage spacer between in the IVD and metal pins with supporting plates in the vertebrae. This is a complex, expensive, major surgery and it is associated with complications, such as spinal fusion failure and inappropriate implant position. These complications have a dramatic impact on the quality of life of the affected patients and the burden to society and the healthcare system is exacerbated. Methods and Results. We present an in vitro study looking at the effect of our Bgel hydrogel on mesenchymal stem cells (MSCs) and their bone forming capacity within lumbar cages: devices used to space the bones apart in the fusion operation, as a mechanism to improve fixation and intra cage bone formation. MSCs were isolated from human hip joint, expanded, seeded within Bgel, cast into well inserts or lumbar cages and cultured for 4 weeks. Using 3D X-ray imaging micro computed tomography (μCT) scans we show that the MSC in the presence Bgel begin to mineralise within the lumbar cages. Histology is currently ongoing and will be presented at the meeting. Conclusion. This study shows the potential to improve current spinal fusion practices with the potential to reduce complications. Conflicts of interest: CS and CLM are named inventors on the patent for NPgel/BGel. Funded by the Medical Research Council and Versus Arthritis UK: SNiPER

Aim. A retrospective review of the management of adjacent level discectomy and fusion using a Zero-P (Synthes) cage and report of ease of technique and outcomes. Method. Surgical approach to adjacent level cervical disc protrusion with previous anterior cervical discectomy and fusion (ACDF) can be difficult. We review 4 patients who had previous ACDF with cage and plate who developed new onset adjacent level cervical disc prolepses causing myelopathy. A retrospective review of demographic data, symptoms, details of surgery, pre and post operative radiology, pre and postoperative ODI and pain score, length of stay, complications and follow-up data were collected in all patients. Results. Previous ACDF with plate was performed in all 4 patients an average of 11.6 years ago. Two patients had bilateral approaches previously and both had previous vascular injuries. The average duration of current symptoms was 9 months with a mean age of 65 years. All patients presented with myelopathy and two also had radiculopathy. Multiple level ACDF were operated in 2 patients previously. Revision surgery and dissection on the disc level was restricted by the previous plate. Screws from the previous plate fusion were removed adjacent to the level of surgery and discectomy was performed using distractor pins through the screw sites. Following discectomy a Zero-P cage was used to fusion with DBX under image intensifier guidance. The advantage was not to remove the previous plate and keep the dissection over the scar tissue to the minimal. All patients improved in their radicular symptoms with improvement of their hand function in the myelopaths. There was no complication and post operative radiographs were satisfactory. Conclusions. Use of the Zero-P cage for adjacent level discectomy and fusion was safe without disturbing the previous cage and plate fusion or stability

Introduction. Type 1 neurofibromatosis is a serious hereditary disease in which mainly skin, nervous, muscular, and bone systems are damaged. In bone systems the most common deformities are thoracic kyphosis and scoliosis. Data for morphological changes in the structural components of spine in neurofibromatosis are scarce. Thus our study aimed to investigate morphological changes in structural components of the spine in NF1 neurofibromatosis. Methods. Growth plates, intervertebral discs, and fragments of vertebral bodies from deformed and adjacent segments of the spine were obtained from 15 patients aged 10–14 years with scoliosis (Cobb angle 90–120°) caused by neurofibromatosis. Preoperative examination included MRI study of the spine and brain to exclude intracanal masses, and radiographic study of the spine. Patients did not present any neurological symptoms. All children underwent anterior release and interbody fusion. Structural spinal components from children aged 12–14 years collected at forensic autopsy were used as controls. Tissues were investigated by conventional histochemical and ultrastructural methods. The levels of aggrecan and NF1 gene expression were studied with the PCR method. Results. The study of growth plate and intervertebral disc specimens removed during surgery for scoliosis in neurofibromatosis showed a clear boundary between their convex and concave sides. Both growth plate and intervertebral disc in convex side retain their architectonic and histochemical characteristics. The concave side of the growth plate is presented by small chondroblasts densely spaced without a definite orientation and surrounded by homogeneous matrix, which is made up of chondroitin sulphates. These embryonic-type chondroblasts are poorly differentiated. Chondroblasts proliferate beyond the growth plate. Proliferating cells invade into vertebral body and are bordered by thin bone lamellae, causing the scalloping of vertebral body as a radiological symptom of the pathology. Changes occurring in the intervertebral disc are of considerable interest. Concave-side disc is characterised by isolated proliferation zones containing poorly differentiated chondroblasts and fibroblasts, and neurinoma-like masses. Bone trabeculae inside a concave-side vertebra are passing the stage of osteogenesis imperfecta. Detected morphological changes in spinal structures are consistent with findings of Stevenson, who registered cartilage and bone deficiencies in animal model (mice with NF1 genemutation). Thus, morphological studies testify to structural disorder in concave side of the growth plate, but unchanged regularities and stages of chondroblast differentiation and adequate osteogenesis in the convex side. NF1 gene regulates the growth, differentiation, and proliferation of chondroblasts at the early stage of embryogenesis. Gene inactivation at a somite stage results in altered development of definitive spinal structures. Continued growth with adequate proliferation, differentiation, osteogenesis, and topochemical characteristics occurs in the convex-side growth plate, and growth disorder in the concave-side part with continued load cause growth asymmetry and development of spinal deformity. Scoliosis associated with neurofibromatosis is notable for deformity progression and pseudoarthrosis development after surgery. Deformity progression (modulation) should be considered in connection with disorder in osteogenic potency of osteoblasts. Conclusions. The causal factor of spinal deformity development in NF1 neurofibromatosis is NF1 gene mutation. Inactivation of NF1 gene results in disorder in chondrogenesis and osteogenesis within structurally altered zones. A continued load causes development of scoliotic spinal deformity