Injury to the spinal cord and kyphosis are the two most feared complications of tuberculosis of the spine. Since tuberculosis affects principally the vertebral bodies, anterior decompression is usually recommended. Concomitant posterior instrumentation is indicated to neutralise gross instability from panvertebral disease, to protect the anterior bone graft, to prevent graft-related complications after anterior decompression in long-segment disease and to correct a kyphosis. Two-stage surgery is usually performed in these cases. We present 38 consecutive patients with tuberculosis of the spine for whom anterior decompression, posterior instrumentation, with or without correction of the kyphus, and anterior and posterior fusion was performed in a single stage through an anterolateral extrapleural approach. Their mean age was 20.4 years (2.0 to 57.0). The indications for surgery were panvertebral disease, neurological deficit and severe kyphosis. The patients were operated on in the left lateral position using a ‘T’-shaped incision sited at the apex of kyphosis or lesion. Three ribs were removed in 34 patients and two in four and anterior decompression of the spinal cord was carried out. The posterior vertebral column was shortened to correct the kyphus, if necessary, and was stabilised by a Hartshill rectangle and sublaminar wires. Anterior and posterior bone grafting was performed. The mean number of vertebral bodies affected was 3.24 (2.0 to 9.0). The mean pre-operative kyphosis in patients operated on for correction of the kyphus was 49.08° (30° to 72°) and there was a mean correction of 25° (6° to 42°). All except one patient with a neural deficit recovered complete motor and sensory function. The mean intra-operative blood loss was 1175 ml (800 to 2600), and the mean duration of surgery 3.5 hours (2.7 to 5.0). Wound healing was uneventful in 33 of 38 patients. The mean follow-up was 33 months (11 to 74). None of the patients required intensive care. The extrapleural anterolateral approach provides simultaneous exposure of the anterior and posterior aspects of the spine, thereby allowing decompression of the spinal cord, posterior stabilisation and anterior and posterior bone grafting. This approach has much less morbidity than the two-stage approaches which have been previously described

There have been few reports regarding the efficacy of posterior instrumentation alone as surgical treatment for patients with pyogenic spondylitis, thus avoiding the morbidity of anterior surgery. We report the clinical outcomes of six patients with pyogenic spondylitis treated effectively with a single-stage posterior fusion without anterior debridement at a mean follow-up of 2.8 years (2 to 5). Haematological data, including white cell count and level of C-reactive protein, returned to normal in all patients at a mean of 8.2 weeks (7 to 9) after the posterior fusion. Rigid bony fusion between the infected vertebrae was observed in five patients at a mean of 6.3 months (4.5 to 8) post-operatively, with the remaining patient having partial union. Severe back pain was immediately reduced following surgery and the activities of daily living showed a marked improvement. Methicillin-resistant Staphylococcus aureus was detected as the causative organism in four patients. Single-stage posterior fusion may be effective in patients with pyogenic spondylitis who have relatively minor bony destruction

Purpose: This prospective study was conducted to evaluate correction of post-traumatic deformity of the thoracolumbar and lumbar spine at consolidation after posterior instrumentation associated with transpedicular graft. Material and method: The analysis began in 1998 and included 11 patients (mean age 37 years, age range 19–62 years) with lumbar (two L2) or thoracolumbar (four T12 and five L1) fractures. The Magerl classification was A1=2, A2=3, mixed=3. Inclusion criteria were: age < 65 years, regional kyphosis > 10°), intact pedicles, relative gain on local and/or regional kyphosis peroperatively > 70% after correction for reduction-distraction. Posterior instrumentation used the V-V assembly in two cases and 2VV-1VC assembly in nine. Evaluation criteria were, postoperatively and at consolidation: local kyphosis, corrected regional kyphosis, Cobb angle in the frontal plane. Autologous graft tissue harvested from the iliac crest was introduced via the right and left pedicle into the damaged vertebra using an adapted funnel after raising the vertebral plate with a spatula. Results: Mean follow-up was 11 months (range 8–18). Associated procedures were laminectomy in three cases and posterior graft in two. Preoperatively local kyphosis was 19° (12° to 37°) and regional kyphosis was 17° (10° to 35°). Postoperatively, local and regional kyphosis were 4.5° (0–11°) and −2° (−10 to 5°) giving a mean relative gain of 80% (SD = 0.1). Mean relative gain at consolidation was 75% (SD = 0.2 for local kyphosis and 86% for regional kyphosis. The correction was statistically significant. There was no significant difference between the correction postoperatively and at consolidation. Discussion: Transpedicular grafting associated with posterior instrumentation can avoid anterior access in a certain number of cases. Indications are fractures in patients under 65 years of age with a regional kyphosis > 10° and an important anterior defect after reduction (> 40% reduction in height). All patients achieved bone healing without significant loss of correction. The limitations of this technique include the requirement for intact pedicles, a posterior wall displacement of less than 60% and a peroperative relative gain greater than 70% for the local and/or regional kyphosis. An anterior approach must be associated in other cases. Conclusion: Transpedicular grafting is a simple technique allowing true reconstruction of the vertebral body. It can avoid a certain number of supplementary anterior approaches

Purpose of the study: We report the results of a series of seven cases of non-tuberculos infectious lumbar spondylodiscitis treated by posterior instrumentation and secondary anterior curettage of the infectious focus with bone grafting. This particular osteosynthesis method produces a short monosegmentary fixation limited to the space of the infected disc. Material and methods: The series included six men and one woman (mean age 61.7 years, age range 37–82 years). The causal germ was identified in all cases: Staphylococcus aureus in five, and in one each, Staphylococcus epidermidis and Pseudomonas aeruginosa. Levels were L1L2 in one, L2L3 in two, L3L4 in three and L5S1 in one. Predisposing factors were history of prostatic cancer in two patients, coronary heart disease in one and chronic renal failure in one. One patient had received corticosteroid injections and two had no recognized co-morbid conditions. The surgical procedure was undertaken due to persistent pain in three patients (one with quadriceps amyotrophy and weakness), spinal instability with risk of neurological injury in two, and after failure of medical treatment in two patients who had persistent abscesses. Results: Excepting one patient who died from renal failure four months after the surgical procedure, mean follow-up was 31.5 months (range six months to six years). Outcome was excellent in four patients, good in one, and a failure in one patient who was operated on because of instability. Failure of the instrumentation required surgical revision to extend the initial assembly. At last follow-up, all patients had achieved fusion of the instrumented zone and were considered to be cured of their infection. Discussion: Classically, it is advisable to avoid instrumenting close to an infectious area in order to avoid the vicious circle of infection. Configurations described in the literature are usually extensive, blocking healthy levels beyond the infected area and compromising spinal mobility. However, a short instrumentation limited to one segment can be proposed when the end plates at the outer limits of the infectious focus are theoretically healthy. Careful analysis of the imaging data is required to carefully select patients who can benefit from this short configuration. Magnetic resonance imaging is most helpful

Anterior debridement, grafting of the defect and posterior instrumentation as a single-stage procedure is a controversial method of managing pyogenic vertebral osteomyelitis. Between 1994 and 2005, 37 patients underwent this procedure at our hospital, of which two died and three had inadequate follow-up. The remaining 32 were reviewed for a mean of 36 months (12 to 66). Their mean age was 48 years (17 to 68). A significant pre-operative neurological deficit was present in 13 patients (41%). The mean duration of surgery was 285 minutes (240 to 360) and the mean blood loss was 900 ml (300 to 1600). Pyogenic organisms were isolated in 21 patients (66%). All patients began to mobilise on the second post-operative day. The mean hospital stay was 13.6 days (10 to 20). Appropriate antibiotics were administered for 10 to 12 weeks. Early wound infection occurred in four patients (12.5%), and late infection in two (6.3%). At final follow-up, the infection had resolved in all patients, neurological recovery was seen in ten of 13 (76.9%) and interbody fusion had occurred in 30 (94%). The clinical outcome was excellent or good in 30 patients according to Macnab’s criteria. This surgical protocol can be used to good effect in patients with pyogenic vertebral osteomyelitis when combined with appropriate antibiotic therapy

Inßuence of scoliosis surgery on pulmonary changes and even upon thoracic deformity changes are still controversial. The purpose of the study was to determine thoracic volume (TV) changes in patients operated on by means of posterior and anterior surgery because of severe thoracic AIS. 50 patients, operated by þrst author randomly chosen from the period 1993–97 were selected. In 25 patients (21 girls, 4 boys) anterior instrumentation was used (group 1), and posterior instrumentation in other 25 patients (20 girls, 5 boys; group 2). TV calculation was performed basing on preoperative and postoperative plain x-rays, using a well known equation (second and third, independent author). The curves were 73û ± 12.4 pre op, and 19û ± 15 post op (group 1), and 75û ±13 pre op., 37û± 10 post op. (group2). Calculated TV for group 1 increased from 5234 ml to 6043 ml postoperatively (17% ± 16). In group 2, TV increased from 5155 to 5489 to 4,371 (6% ± 7). The correlation between the Cobb angle change and the thoracic volume change was poor (+0.2 for group 1, -0.4 for group 2). To determine the role of frontal, sagital and vertical thoracic diameters in TV increase, further correlation tests were performed. The best correlation was found between the frontal and vertical diameter increase in anterior instrumentation (r=0.62; 0.71), whereas the best correlation was found between TV and sagital parameters in posterior instrumentation (r=0.74). It is concluded that anterior instrumentation can increase TV more than posterior instrumentation

Open anterior surgery, including release and instrumentation, is a widely used technique for correction of dorsal and dorsolumbar curves. In the past we have used various different devices to maintain correction. These include Dwyer cable, Zeilke rods, Webb-Morley rods, vertebral staples and the Kaneda system. Any of these can be combined with posterior correction, stabilization and grafting. Several of these techniques have been successfully adapted for the treatment of our cases in Egypt. We encounter severe deformities due to their late presentation. Over the last five years we have used anterior endoscopic release. All had posterior instrumentation. Results: We did anterior release in 20 scoliosis cases and corpectomy in 10 cases. These were compared with another twenty cases who were treated by open anterior and posterior surgery. The results are very encouraging regarding degree of correction; hospital stay; and costs as compared with our historical series of conventional two-stage surgery. There are a number of constraints on using endoscopic techniques. Surgeons require long training and close co-operation. It is contraindicated in those cases with adhesions and patients unfit for one lung anaesthesia. We found the technique is safe and effective. We recommend it for treatment of rigid curves to gain good results and to reduce hospital costs

Both posterior and anterior surgery have potential for complete scoliosis correction. Significant difference in judging the procedures still persists. Aim. To establish objective advantages and risks of the procedures, basing upon long term results. Method. From 1982–2007, 859 anterior(A) and 388 posterior(P) instrumentations were performed by the same surgeon. Single level thoracotomy used even in double curves. Spinal canal was never opened, rib heads left intact, ribs were fractured at the top of rib hump. Zielke rod was used for correction, and another rod added for aditional correction and stabilisation. Various posterior instrumentations were used. Results. CORRECTION (A)frontal 67-45-16(76%), sagital +6, (P)frontal 66-44-29(56%), sag+3; OP. TIME (A)140(50–300), (P)155(110–350); BLOOD REPL. (A)18%, (P)92%; HOSP STAY (A)10, (P)13; VC (A)-10%, (P)0%; SPORT ACT. (A)3mths, (P)12mths; MAJOR COMPLICATIONS: no deaths, (A)1 aorta rupture, 1 bronchus penetration, 0,7% haematothorax, 0,6% reinstrumentation, 0,7% infections demanding op, (P)2 paraplegia (0,5%), 3.9% infections, 4.9% reinstrumentation. Discussion. (A)required no neuromonitoring, no intensive care unit. Blood replacement was occasionally used only for double curves (11 segm), and in preop. anemia. Most of the complications were preventable. Hospitalisation was longer in (P) group due to wound problems. Pulmonary decrease was found only in curves greater than 100 °. Halo traction improved VC, but both instr. had no influence on further improv. In (A)VC recovered in 6 months. Conclusions. (A) can be performed in less radical and agressive way. Anterior release significantly mobilizes the spine and decreases necessary corrective forces. Infection was more frequent in (P) but consequences were more dramatic in (A). All major complications in (A) were preventable. There is temporary decrease in pulmonary function after (A). We could not find objectives for (A) to have more morbidity than (P). Due to superior results we still prefer (A) in surgery of AIS. Our indications for (P) is VC<40%, age, poor bone quality, surgery in upper thoracic spine

Introduction

Transosseous flexion-distraction injuries of the spine typically require surgical intervention by stabilizing the fractured vertebra during healing with a pedicle-screw-rod constructs. As healing is taking place the load shifts from the implant back to the spine. Monitoring the load-induced deflection of the rods over time would allow quantifiable postoperative assessment of healing progress without the need for radiation exposure or frequent hospital visits. This approach, previously demonstrated to be effective in assessing fracture healing in long bones and monitoring posterolateral spinal fusion in sheep, is now being investigated for its potential in evaluating lumbar vertebra transosseous fracture healing.

Aim. Many aspects of the surgical treatment of patients with tuberculosis (TB) of the spine, including the use of instrumentation and the types of graft, remain controversial. Our aim was to report the outcome of a single-stage posterior procedure, with or without posterior decompression, in this group of patients. Patients and Methods. Between 2001 and 2010, 51 patients with a mean age of 62.5 years (39 to 86) underwent long posterior instrumentation and short posterior or posterolateral fusion for TB of the thoracic and lumbar spines, followed by anti-TB chemotherapy for 12 months. No anterior debridement of the necrotic tissue was undertaken. Posterior decompression with laminectomy was carried out for the 30 patients with a neurological deficit. Results. The mean kyphotic angle improved from 26.1° (- 1.8° to 62°) to 15.2° (-25° to 51°) immediately after the operation. At a mean follow-up of 68.8 months (30 to 144) the mean kyphotic angle was 16.9° (-22° to 54°), with a mean loss of correction of 1.6° (0° to 10°). There was a mean improvement in neurological status of 1.2 Frankel grades in those with a neurological deficit. Bony union was achieved in all patients, without recurrent infection. Conclusions. Long posterior instrumentation with short posterior or posterolateral fusion is effective in the treatment of TB spine. It controls infection, corrects the kyphosis, and maintains correction and neurological improvement over time. . Take home message: With effective anti-TB chemotherapy, a posterior only procedure without debridement of anterior lesion is effective in the treatment of TB spondylitis, and an anterior procedure can be reserved for those patients who have not improved after posterior surgery. Cite this article: Bone Joint J 2016;98-B:834–9

There are few reports of the treatment of lumbar tuberculous spondylitis using the posterior approach. Between January 1999 and February 2004, 16 patients underwent posterior lumbar interbody fusion with autogenous iliac-bone grafting and pedicle screw instrumentation. Their mean age at surgery was 51 years (28 to 66). The mean follow-up period was 33 months (24 to 48). The clinical outcome was assessed using the Frankel neurological classification and the Kirkaldy-Willis criteria.

On the Frankel classification, one patient improved by two grades (C to E), seven by one grade, and eight showed no change. The Kirkaldy-Willis functional outcome was classified as excellent in eight patients, good in five, fair in two and poor in one. Bony union was achieved within one year in 15 patients. The mean pre-operative lordotic angle was 27.8° (9° to 45°) which improved by the final follow-up to 35.8° (28° to 48°). Post-operative complications occurred in four patients, transient root injury in two, a superficial wound infection in one and a deep wound infection in one, in whom the implant was removed.

Our results show that a posterior lumbar interbody fusion with autogenous iliac-bone grafting and pedicle screw instrumentation for tuberculous spondylitis through the posterior approach can give satisfactory results.

Aim: To test the null hypothesis that interbody cage fusion does not improve clinical outcome.

Methods and materials: This is a prospective study of 87 patients. Seventy-one of the 87 patients followed to the conclusion of the study at two years. Inclusion criteria: Patients undergoing interbody cage fusion with the Ray threaded cage, made of Titanium, and posterior stabilisation with Diapason pedicle screw instrumentation, all operated by the same surgeon. Exclusions: Surgery for infection, or tumour. Tools used for assessment: Oswestry low back pain questionnaire; Visual analogue pain score (VAS); SF36 general health questionnaire. Assessment time points were 1) Pre-op, and post-operatively at 2) 3 months, 3) 6 months, 4) 1 year and 5) 2 years. SF 36 was introduced later recruiting 71 of the 87 patients.

Results: There were 31 males and 56 females. Average age was 46 years (range 14–76) Fifty-one of the patients had no previous surgery, while 36 had previous surgery.

There was a significant, gradual improvement in symptoms of an average of 20 points (p< .001) over the first year on the Oswestry score. However, this plateaued between the first and second years. Over two years there was a greater than 20 point increase in all but three concepts of SF36, general health, reported health and mental health improving around 15 points (p< .001). Sixty-five per cent of the patients reported an overall improvement and 12% were worse, with most changes occurring in the first year.

In assessing the symptoms with Oswestry questionnaire there was a significant difference between first time and revision surgical groups. The revision group showed an improvement of 11 points (p< .001) at two years, most occurring in the latter part of the first year followed by some deterioration between the first and second years. In the primary surgery group there is a 28 point (p< .0001) improvement by two years. Most of the improvement in the primary group is achieved by the first six months.

Conclusions: Interbody fusion can significantly improve health and function assessed by Oswestry and SF36 outcome tools. Additional observations – unsatisfactory outcome in 12% of patients; expected progress at fixed times after surgery can assist planned rehabilitation. This paper introduces the concept of time staged assessment of symptoms in spinal fusion.

Twenty-three patients with severe paralytic thoracolumbar scoliosis due to a myelomeningocele were treated by a two-stage procedure. Before operation the mean scoliosis was 98 degrees: after the first-stage procedure, an anterior spinal fusion and correction with Dwyer instrumentation, this was reduced to a mean of 45 degrees. Approximately two weeks later a posterior spinal fusion with Harrington instrumentation was performed, further reducing the scoliosis to a mean of 29 degrees. The pelvic obliquity also was reduced from a mean of 32 degrees to 6 degrees. Although such management carries risks (one patient died of cardiorespiratory failure after the first stage and one patient was made worse), 21 of the 23 patients had improved posture and function.

Aim: In sub-axial cervical vertebrae the lamina appears to project perpendicular to the ipsilateral pedicle axis, and forms a reliable trajectory for avoidance of vertebral artery injury in lateral mass (LM) screw placement: the aim is to confirm these observations.

Material and Methods: 51 digital cervical spine CTs (255 vertebrae; 25 female 26 male; mean age 37.4 range:18–80). Exclusions: Severe degeneration, malformation, tumour, trauma.

Measurement (axial view):

Angle of ipsilateral outer lamina cortex to pedicle axis

Results: Average lamina-pedicle angle (standard deviation):

Females: Right: C3–84.8°(2.6), C4–85.2°(3.1), C5–86.7°(3.3), C6–89.2°(2.5), C7–92.3°(2.4);

Conclusion: The angle formed by the lamina and ipsilateral pedicle ranges from 84° at C3 to 92° at C7. Although the angle is not exactly perpendicular at all levels as hypothesised, the lamina forms a useful reference plane for pedicle screw insertion in the sub-axial cervical spine.

LM screws placed parallel to the lamina find sufficient LM width and are highly unlikely to injure the vertebral artery in bi-cortical placement. This technique appears favourable over conventional 30° LM placement.

Ethics approval: None needed

Interest Statement: None

Introduction: In rigid AIS, the main resistance for thoracic derotation are the anteriorly rotated ribs on the concavity. This study presents clinical and radiographic long term results of the CTP, which is a routine surgical procedure at the authors’ institution.

Material and Methods: Between 1996 and 1997 we have operated on 466 cases of scoliosis. 36 patients with thoracic AIS were evaluated. Technique: The ribs on the concave side are osteotomised close to the costo-transverse joint and elevated over the bended rod.

Results: Mean follow up was 6.4 y. Mean preoperative side bending flexibility was 21%. Mean correction rate was 68%, mean rib hump correction was 3cm. Mean loss of correction 4°. There was no neurological complication, and pulmonary morbidity was not increased.

Conclusion: In rigid thoracic scoliosis, a release of the concave ribs by means of the CTP can both significantly increase the extent of correction and contributes to an excellent cosmetic result.

Background and Purpose: Tuberculosis is a common cause of mortality and morbidity in our country. Late neurological deficits following conservative management can occur though not very common. Deformity correction and decompression at a single sitting in a healed tuberculous spine is a massive undertaking and it requires experience and appropriate technique to achieve a good correction.

Materials and Methods: We operated upon 22 patients with a deformed spine and a progressive neurological deficit following healed tuberculosis. All patients complained of pain and found the cosmetic appearance unacceptable. The average age was 29 years {19 – 35 years}. All patients had completed a course of four drugs anti tuberculous chemotherapy for a minimum period of 12 months. All patients were screened for disease activity before surgery. The average Konstam angle before surgery was 86 degrees {80–105 degrees}. All patients underwent single stage surgical correction by a posterior based pedicle subtraction osteotomy with excision of the internal gibbus and further decompression and posterior stabilization using a screw rod construct. The local bone chips removed during the surgical procedure was used to promote fusion.

Results: We achieved an average kyphosis correction of 60 degrees {52–75 degrees}. At an average follow up of 18 months the average loss of correction was 3 degrees. The mean operating time was 165 minutes {120 – 210 minutes}. The mean blood loss was 800 ml {700–1100 ml}. All patients had significant improvement in their post operative pain scores and disability outcome measures. All patients were greatly satisfied with the cosmetic result obtained. There were no major intra operative or post operative complications.

Conclusion: Transpedicular three-column osteotomy uses a posterior approach and generally leaves no gap anteriorly. The anterior column is not opened as in a Smith-Petersen osteotomy. Posterior approach offers access to all three columns of the spine and avoids the morbidity associated with the anterior approach. The internal gibbus can be addressed and the normal posterior bony elements in tuberculosis can be used for achieving fusion.

Introduction: Some authors (Suk, Barr, Hamill ...) showed that lumbar and thoracic pedicle screws provided adequate reduction of scoliosis. Quality of reduction depends on primary stability of the vertebral anchors. If the anchor has a good primary stability, reduction forces are entirely transferred to the vertebra, which results in reduction of the deformity, whereas, if the anchor has a poor primary stability, it will move when subjected to reduction forces, and this will result in inadequate reduction. Lumbar screws which are advocated by many authors, are extensively used. Thoracic screws are only used by a limited number of surgeons, as most surgeons favour hooks. Polyaxiality facilitates rod positioning; it eliminates the orthogonal stresses that are generated during tightening and which are known to be responsible for screw fracture. The drawback manoeuvre consists in applying forces directly to the vertebra via the anchor; the deformity is reduced by gently translating the vertebra towards the rod. The polyaxial vertebral claw that we are presenting here is a self-stabilising implant that provides the same primary stability as the screw and allows application of multidirectional drawback forces.

Materials and methods: The system consists of self-stabilising vertebral anchors, either screws or claws. Each anchor is polyaxial and features a threaded extension that allows translation of the vertebra towards the rod. Connection of the screw or claw to the rod is provided by connecting clamps. The first operative step consists of inserting the vertebral anchors, favouring the apex of the deformity. The insertion technique is described in detail. The claw is locked independently, prior to securing the rod on to the claw. The second operative step consists of positioning the rods which are bent to the ideal sagittal curve. Polyaxiality and threaded extensions make rod positioning an easy step. Progressive tightening of the nuts results in correction of the deformity as it slowly moves the vertebrae towards the rods. The translation force is distributed over all the anchors, ensuring a gentle reduction manoeuvre with no risk of back out of the implants. Approaching vertebrae at the end of the reduction manoeuvre results in vertebral derotation. It is not necessary to use distraction which is considered hazardous.

Results: 35 such instrumentations have been used in patients with idiopathic scoliosis over the previous 12 months. We have used an average of nine screws and four claws per patient, mainly thoracic pedicle/transverse claws. Main curve correction was 71% (average curve was 59° preoperatively and 17° postoperatively). Average correction of the uninstrumented lumbar curve was 73%. The upper curve improved from 34° to 15°. The slope of the first uninstrumented vertebra was 14° pre-operatively and 6° postoperatively. In the sagittal plane, the average angle of thoracic kyphosis in hollow backs (kyphosis less than 15°) was 9°, increasing up to 27° postoperatively.

Discussion: This instrumentation is characterised by stable implants which provide a quality of reduction similar to that achieved with pedicle screws. Vertebral claws are easy to insert and have a better primary stability than screws.

Poly-axiality is a common feature to all the implants of this system; it greatly facilitates placement of the implants and allows to apply traction simultaneously to all the anchors, which results in progressive, gentle reduction. Simultaneous traction application ensures adequate correction of the thoracic kyphosis (gain of 18°). As a matter of fact, severe kyphosis can be bent into the rods, and translation of the vertebrae towards the rods is very easy. Adequate reduction of the main curve results in correction of the underlying lumbar curve and shifting of the first uninstrumented vertebra into a more horizontal position.

Conclusion: This instrumentation based on stable poly-axial implants, should allow to improve the quality of reduction of scoliosis.

Objective: To evaluate the effect of spinal fusion from T1, T2 to the sacrum with pelvic fixation using unit rod instrumentation on the ambulatory potential of pediatric patients with cerebral palsy.

Study Design: A retrospective study of 24 ambulatory pediatric patients with spastic cerebral palsy and neuro-muscular scoliosis was performed.

Summary of Background Data: Spinal deformities, occurring in patients with cerebral palsy and good ambulatory capacity, are infrequently associated with pelvic obliquity, and so instrumented spinal fusions traditionally do not extend to the pelvis.

Methods: The medical charts and radiographs were reviewed, and the patients’ ambulatory ability was assessed clinically, with video tape or complete gait analysis. A questionnaire assessing patients’ functional improvement was given to the caretakers.

Results: The study group included 17 female and 7 male patients, 19 quadriplegics and 5 diplegics. Follow-up evaluations for ambulatory function occurred at a mean of 2.86 years after surgery. Mean age at surgery was 15.4 years. Twenty patients underwent posterior spinal fusions and 4 patients combined anterior-posterior procedures. The patients were evaluated clinically pre-operatively, postoperatively and at follow-up with no alteration in their ambulatory status, except one patient who developed bilateral hip heterotopic ossification and gradually lost her ability to ambulate. Thirteen patients had both preoperative and postoperative gait analysis, showing no change in their ambulatory function. The surgical outcome survey demonstrated significant improvement in the child’s physical appearance, head and trunk balance, sitting ability, amount of back pain, respiration, and no change in ambulatory capacity.

Conclusions: Spine surgery with fusion extending to the pelvis in ambulatory patients with cerebral palsy provided excellent deformity correction and preserved their ambulatory function.

Purpose: A retrospective study comparing the fusion rate and, the incidence of junctional spinal stenosis between a rigid (Wiltse) and a semirigid (Varifix) posterior spinal fusion system.

Material & Methods: 92 patients, mean age 52.3 year old, underwent posterior fusion with semirigid Varifix system (rod diameter 5.0 mm), and 89 patients, mean age 49.8 year old, with rigid Wiltse system (6.5 mm). The mean follow-up was 4.8 years (range 2–9) for Varifix group and 11.7 years (range 9–17) for Wiltse group. Preoperative diagnosis was spinal stenosis (n=56), disc degenerative disease (n=43), degenerative spondylolisthesis (n=37), post-laminectomy instability (n=34), and isthmic spondylolisthesis (n=11). In all patients autologous iliac crest bone graft was used. Spinal fusion was confirmed by A-P, lateral, and flexion-extension radiographic studies, or by direct surgical exploration and observation. Pain intensity was recorded using the Visual Analogue Scale (VAS).

Results: Successful fusion was achieved in 92.4% in the semirigid group and in 93.2% for the rigid group. There was no statistical difference in fusion rate between these two groups (p=0.82). Eight patients with pseudoarthrosis were treated by anterior fusion and 5 by repaired posterior fusion, with a fusion rate of 100%. Postoperative infection was diagnosed in 5 patients (5.4%) in the semirigid group and in 4 patients (4.5%) in the rigid group. They were treated by debridement, irrigation, and intravenous antibiotics. Hardware removal because of pain was performed in 9 patients (9.8%) in the semirigid group, and 17 patients (19.1%) in rigid group. Removal of hardware resulted in improvement in pain in all patients. Junctional spinal stenosis was diagnosed in 2 patients (2.2%) in semirigid group and in 7 patients (7.9%) in rigid group. There was a trend for higher incidence of adjacent level stenosis in rigid group (p=0.07).

Conclusion: Biomechanical studies have shown that the stiffness of spinal construct depends on rod diameter and a decrease in rod rigidity can increase the risk of implant failure. In our study we didn’t find any difference in the fusion rate and in complication rate between these two systems. The increased percentage of the junctional spinal stenosis in rigid group may be explained by the longer follow-up in this group. According to our data the semirigid system may be better tolerated than the rigid system.