Aims. The aim of this study was to evaluate the outcome of spinal instrumentation in haemodialyzed patients with native pyogenic spondylodiscitis. Spinal instrumentation in these patients can be dangerous due to rates of complications and mortality, and biofilm formation on the instrumentation. Patients and Methods. A total of 134 haemodialyzed patients aged more than 50 years who underwent surgical treatment for pyogenic spondylodiscitis were included in the study. Their mean age was 66.4 years (50 to 83); 66 were male (49.3%) and 68 were female (50.7%). They were divided into two groups according to whether spinal instrumentation was used or not. Propensity score matching was used to attenuate the potential selection bias. The outcome of treatment was compared between these two groups. Results. A total of 89 patients (66.4%) underwent non-instrumented surgery and 45 (33.5%) underwent instrumented surgery. There were no significant differences in the rates of postoperative complications, except for an increased rate of wound problems in the instrumented group, which was found in the unmatched cohorts (p = 0.034). There were no significant differences in the rate of recurrent infections (p = 0.328 for the unmatched cohort; p = 0.269 for the matched cohort) and mortality rate, including in-hospital (p = 0.713 for the unmatched cohort; p = 0.738 for the matched cohort) and one-year rates (p = 0.363 for the unmatched cohort; p = 0.787 for the matched cohort), between the groups. However, the interval between the initial diagnosis and the first recurrence was significantly longer in the instrumented group (p = 0.008 for the unmatched cohort; p = 0.032 for the matched cohort). Conclusion. Instrumented surgery for haemodialyzed patients with pyogenic spondylodiscitis showed similar outcomes, including recurrence and mortality, to non-instrumented surgery, despite the instrumented group having more severe neurological deficit, a larger number of involved levels, and increased kyphotic angle

Introduction. Aneurysmal bone cysts are uncommon benign lesions affecting the spinal column. They mostly occur in the lumbar spine and have a propensity to affect adjacent vertebrae. We describe 14 aneurysmal bone cysts affecting the spinal column from the Scottish Bone Tumour Registry with regard to assess the incidence, demography, biological behaviour and recurrence rate. Materials and Methods. We identified 14 patients with aneurysmal bone cysts affecting the spinal column. Case notes and radiographs were retrospectively reviewed from the Scottish Bone Tumour registry. Results. There were 9 female and 5 male patients. The mean age at presentation was 24.5 years (range, 6 to 62 years). The spinal location consisted of cervical (3), thoracic (4), lumbar (6) and sacral (1). The treatment included curettage without bone grafting (3), excision (7) and surgical removal with biopsy in rest. Selective angiographic embolisation was carried out in one patient with a cervical cyst and percutaneous sclerotherapy was carried out on another with a sacral cyst. There were two recurrences, of which one was treated with radiotherapy and other with repeat curettage with successful final outcome. Conclusions. The incidence of aneurysmal bone cysts was 5.5% in our registry of all the spine tumours. The recurrence occurred in 14% (2 of 14). In addition to surgery, one should be aware of the role of angiographic embolisation and radiotherapy in selected primary and recurrent ABCs

Chondrosarcomas are uncommon primary malignant cartilaginous tumours, even less common in spine. Surgical excision is the only mode of successful treatment as these tumours are resistant to conventional chemotherapy and radiation therapy. We share our experience of 22 cases of chondrosarcomas of the spine with special reference to their recurrence and survival. We identified 20 conventional and 2 dedifferentiated chondrosarcomas from the Scottish Bone Tumour Registry database between 1964 and 2009. Radiology and histopathology were documented. The mean follow-up was 5.2 years. There were 14 men and 8 women with a mean age of 50.1 years. There were 7 under the age of 40 years (31.8%). The majority of lesions occurred in the thoracic spine (16), followed by sacrum (3), lumbar (2) and cervical spine (1). The overall local recurrence rate was 45.4% (10/22 cases-once in 5, twice in 2 and thrice in 3 patients). Four patients presented with pulmonary metastases leading to death. The estimated overall 5- and 10-year survival rates were 31.8% and 18.1% respectively. We found that 1/3. rd. of chondrosarcomas of the spine occured below 40 years of age and 3/4. th. in the thoracic spine. Every other case was associated with local recurrence with a 32% 5-year and 18% 10-year survival rates

Objectives

Although vertebroplasty is very effective for relieving acute pain from an osteoporotic vertebral compression fracture, not all patients who undergo vertebroplasty receive the same degree of benefit from the procedure. In order to identify the ideal candidate for vertebroplasty, pre-operative prognostic demographic or clinico-radiological factors need to be identified. The objective of this study was to identify the pre-operative prognostic factors related to the effect of vertebroplasty on acute pain control using a cohort of surgically and non-surgically managed patients.

Aims. 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. Methods. We collected data on 22 patients with DTC (16 follicular and six papillary carcinomas) and one patient with medullary carcinoma who underwent complete surgical resection of SMs at our institution between July 1992 and July 2017, with a minimum postoperative follow-up of five years. The cancer-specific survival (CSS) from the first spinal metastasectomy to death or the last follow-up was determined using Kaplan-Meier analysis. Potential factors associated with survival were evaluated using the log-rank test. We analyzed the clinical parameters and outcome data, including pre- and postoperative disability (Eastern Cooperative Oncology Group PS 3), lung and non-spinal bone metastases, and history of radioiodine and kinase inhibitor therapies. Results. Lung and other bone metastases at the time of surgery were observed in ten and eight patients, respectively. Three patients experienced local tumour recurrences at the operated site. The five- and ten-year CSS rates in the 22 patients with DTC were 77% and 52%, respectively. Pre- and postoperative disability and operative site tumour recurrence were identified as risk factors for short postoperative survival. Conclusion. Metastasectomy for resectable SM from DTC yielded favourable results and has the potential to improve survival. Cite this article: Bone Joint J 2023;105-B(5):575–582

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). Methods. We included 28 patients with multiple LCH involving the spine treated between January 2009 and August 2021. Kaplan-Meier methods were applied to estimate overall survival (OS) and PFS. Univariate Cox regression analysis was used to identify variables associated with PFS. Results. Patients with multiple LCH involving the spine accounted for 15.4% (28/182 cases) of all cases of spinal LCH: their lesions primarily involved the thoracic and lumbar spines. The most common symptom was pain, followed by neurological dysfunction. All patients presented with osteolytic bone destruction, and 23 cases were accompanied by a paravertebral soft-tissue mass. The incidence of vertebra plana was low, whereas the oversleeve-like sign was a more common finding. The alkaline phosphatase was significantly higher in patients with single-system multifocal bone LCH than in patients with multisystem LCH. At final follow-up, one patient had been lost to follow-up, two patients had died, three patients had local recurrence, six patients had distant involvement, and 17 patients were alive with disease. The median PFS and OS were 50.5 months (interquartile range (IQR) 23.5 to 63.1) and 60.5 months (IQR 38.0 to 73.3), respectively. Stage (hazard ratio (HR) 4.324; p < 0.001) and chemotherapy (HR 0.203; p < 0.001) were prognostic factors for PFS. Conclusion. Pain is primarily due to segmental instability of the spine from its destruction by LCH. Chemotherapy can significantly improve PFS, and radiotherapy has achieved good results in local control. The LCH lesions in some patients will continue to progress. It may initially appear as an isolated or single-system LCH, but will gradually involve multiple sites or systems. Therefore, long-term follow-up and timely intervention are important for patients with spinal LCH. Cite this article: Bone Joint J 2023;105-B(6):679–687

Introduction. Treatment of spinal metastatic disease has evolved with the advent of advanced interventional, surgical and radiation techniques. Spinal Oligometastatic disease is a low volume disease state where en bloc resection of the tumour, based on oncological principles, can achieve maximum local control (MLC). Hybrid therapy incorporating Separation surgery (>2mm clearance of the thecal sac) and Stereotactic Ablative Radiotherapy (SABR) offer an alternative approach to achieving MLC. Hybrid therapy is also a viable option in patients eligible for SBRT who have failed conventional radiation therapy. En-bloc surgery may be a suitable option for those patients who are ineligible for or have failed SBRT. A multidisciplinary approach is particularly important in the decision-making process for these patients. Metal free instrumentation is aiding the optimization of these surgeries. The authors present a supra-regional centre's experience in managing spinal oligometastases. Methods. Retrospective review of oligometastatic spinal disease at a supra-regional centre between 2017 and 2021. Demographics, operative course, complications and Instrument type are examined. Results. Demographics: 24 patients with mean age 53.8y (range 12–77), 44% (40y–59y), 40% (60y–69y); 51% Male. Histology: Breast, Renal and Sarcoma accounted for 16.7% each; Thyroid, Prostate and Chordoma accounted for 8.3% each. Primary disease 7%, Synchronous 15%, Metachronous 78%. Instrumentation: Carbon-fibre (85%), TiAl (11%), Non-Instrumented (3%). Separation Surgery (70%), En-bloc resection/Tomita surgery (30%); SABR/Proton Beam Planned: 70%. Average length of hospital stays 19.1 days; twenty patients required intensive care admission for an average 2.7 days. 30 Day Mortality 8.3% (n=2: COVID-19 during admission and ventriculitis post discharge), 1y Mortality – 16.7%, 3y Mortality – 25%; Synchronous Mortality 75% (n=3) at 3 years. 30 Day infection rate 3%; 1y infection rate 7%. 1 Non-instrumented case developed proximal junctional failure post proton beam therapy and required a vascularised fibular strut graft. 2-year Revision for Local Recurrence 5% (Revision at 23 months). Conclusion. There are very few case series of oligometastatic spinal disease due to the relatively new concept of adjuvant SABR and its limited availability. Solid tumours pre-dominated the histology in our series with metachronous disease being the most commonly operated disease state. 92% of cases were eligible for SABR. The majority (85%) of cases were performed with Carbon-fibre instrumentation and has been shown to be safe with no mechanical failures in this series. Infection rates are in keeping with patients requiring radical radiotherapy with 3% early and 7% late. 30-day mortality was 8.3%, 1y=16.7% and 25% at last follow up. Mortality, as expected, is highest within the synchronous disease group and should be operated on sparingly. With the current management strategy, there was no local recurrence at 1 year and excellent local recurrence rate at 2 years (5%). Although radical en bloc surgery carries significant morbidity, it should be considered in selective cases to achieve MLC. All Oligometastatic cases deserve extra consideration and specialist MDT as not all are suitable for SABR. Multimodal Hybrid therapy, incorporating less invasive surgical techniques and SABR, represents a paradigm shift in achieving MLC in oligometastatic spinal disease

Purpose and background of the study. Self-management and behaviour change is at the core of back pain management. Despite the high-rate of recurrence and healthcare utilisation, clinical guidelines do not include guidance for clinicians on return consultations. This project aimed to identify primary care clinicians’ reported practices and experiences of delivering self-management advice for people returning with persistent low back pain (LBP), to inform future delivery of self-management care. Methods and Results. In this qualitative study involving 27 primary care clinicians, four focus groups and two semi-structure interviews were conducted online. GPs (n=5) and physiotherapists working in primary care roles (First contact practitioners n=7, community and interface roles n=7, and mixed roles n=8) in England and Scotland shared their experience of delivering self-management advice to people returning with persistent LBP. Video recordings were transcribed verbatim and analysed with reflexive thematic analysis. Clinicians unanimously shared their frustrations identifying the challenges involved in supporting people who return with LBP. Helpful strategies to support self-management in return consultations were identified by clinicians in addition to service and system-level changes vital to optimise care. Patient-factors affecting delivery of care, lack of defined responsibility and challenges in meeting patients’ expectations illustrated the tensions that exist in return consultations. Conclusion. This novel study provides insight into the experiences and practices of the frontline primary care workforce seeing patients return with persistent or recurrent LBP. It identifies the tensions that exist between services, professional roles and between clinicians and patients regarding self-management. Important practice implications have been identified to improve information-sharing, agenda-setting, and exploring expectations. No conflicts of interest.  . Source of funding. Lisa Osborn-Jenkins is funded by University Hospital Southampton NHS Foundation Trust (UHS) Research & Development PhD Fellowship [GRT0723]

Aims

The aim of this study was to investigate the incidence and characteristics of instrumentation failure (IF) after total en bloc spondylectomy (TES), and to analyze risk factors for IF.

Aims

To systematically evaluate whether bracing can effectively achieve curve regression in patients with adolescent idiopathic scoliosis (AIS), and to identify any predictors of curve regression after bracing.

The main form of treatment of a chordoma of the mobile spine is total en bloc spondylectomy (TES), but the clinical results are not satisfactory. Stand-alone carbon ion radiotherapy (CIRT) for bone and soft-tissue sarcomas has recently been reported to have a high rate of local control with a low rate of local recurrence. . We report two patients who underwent TES after CIRT for treating a chordoma in the lumbar spine with good medium-term outcomes. At operation, there remained histological evidence of viable tumour cells in both cases. After the combination use of TES following CIRT, neither patient showed signs of recurrence at the follow-up examination. These two cases suggest that CIRT should be combined with total spondylectomy in the treatment of chordoma of the mobile spine. Cite this article: Bone Joint J 2013;95-B:1392–5

Aims

Lumbar disc prolapse is a frequent indication for surgery. The few available long-term follow-up studies focus mainly on repeated surgery for recurrent disease. The aim of this study was to analyze all reasons for additional surgery for patients operated on for a primary lumbar disc prolapse.

Chordomas are slowly growing, locally aggressive primary malignant neoplasms derived from primitive notochordal cells. They tend to occur at the extreme of ages and at the two ends of the spinal column. The purpose of this study was to evaluate the presentation, morphology and behaviour of 20 non-clival, non-sacral chordoma cases. Details of 20 cases of histologically confirmed Chordomas of the mobile spine (Cervical-7, Thoracic-7, Lumbar-6) between 1967 and 2006, were extracted from the Scottish Bone Tumour Registry. The casenotes and radiographs were retrospectively reviewed. Non-sacral chordomas comprised 48.7% (20/41 cases) of total chordomas registered. There was a slight feminine predominance (11/20 cases). Mean age was 58.1 years (range, 12 to 82 years). Progressively worsening back pain was the first symptom in all the patients. Seven had intra-lesional (five recurred), six marginal (1 recurred) and 2 wide resections (none recurred). Eleven of the twenty-one patients were treated with adjuvant radiation therapy. In five patients, the chordoma was inoperable and all but one were treated with radiotherapy. There were 2 recurrences in the group of patients treated without adjuvant radiotherapy. Six patients (40%) developed local recurrences and 3 patients (15%) developed metastases. There were 4 survivors including one with local recurrence. Sixteen patients died including 3 with metastases, 7 with persistent primary disease, 1 with local recurrence and 5 with no evidence of disease or died of unrelated causes. Median survival was 19 months (mean-30.2 months), with 5- and 10-year survival rates 10% and 0.0% respectively. We found that non-sacral/non-clival chordomas had a much poorer prognosis than published in the literature. Local recurrences occurred in 40%. Intra-lesional resection should be avoided as it is associated with 71.4% local recurrence in our series

Background. Acute lumbar radiculopathy is a very painful condition sometimes requiring admission for strong analgesia. Purpose. To evaluate the efficacy of distal nerve root blocks as an outpatient procedure for immediate pain relief. Methods. Local anaesthetic was injected in the distal nerve root areas of the leg and foot in the clinic in patients with lumbar radiculopathy who consented to the procedure. Results. There were 29 patients, 18 females and 11 males, aged 25 to 76 years. 13 patients had acute lumbar disc prolapse, 11 had lumbar canal stenosis, 2 had annular tears and one a facet joint cyst. The VAS pain scores ranged from 3 to 11 (patient's description), with an average VAS score of 7.5. The improvement in VAS scores was between 2 and 9 with average improvement of 6. 19 patients had associated back pain which improved in 14. Walking improved in all 29 patients. Pain relief was immediate in all patients. This lasted from 30 min to 11 days with one patient having no recurrence. 27 patients had at least 24 hours pain relief. All patients could be sent home immediately after the procedure. 12 patients had recent onset of foot weakness which improved one MRC grade immediately after the injection. The analgesic effect was most significant in acute disc prolapse. There were no complications. Conclusion. This technique is simple and would be valuable in the acute setting to provide immediate pain relief allowing immediate discharge from accident and emergency. Conflicts of interest: None. Sources of funding: None

Background. Previous work has identified differential kinematics and muscle activity between non-specific chronic low back pain (LBP) subgroups (flexion pattern (FP) and active extension pattern) and healthy controls. However, it is unclear if differences in muscle activity are maintained on resolution of pain and/or if they contribute to pain recurrence. Purpose. To investigate differences in trunk muscle activity between individuals with a history of flexion-related LBP (who are currently pain-free) and no-LBP controls during three functional activities. Methods. Fifteen individuals (10 male, 5 female) with a previous history of FP LBP (but who were currently pain-free) and 15 individuals with no history of low back pain (10 male, 5 female) were recruited. Surface electromyography of bilateral superficial lumbar multifidus, longissimus thoracis, transversus abdominus/internal oblique and external oblique muscle activity was recorded during three functional activities (sit-to-stand, step-up and bending to pick up a pen from the floor). Surface electromyography data was normalised (% maximum voluntary contraction) and compared between groups (Mann-Whitney U test). Results. No significant differences were observed for any muscle in any activity (p>0.05) except for significantly increased right superficial lumbar multifidus during the bending task (p=0.04) in the FP group compared to the control group (36.55 vs. 19.97 respectively). Conclusion. Individuals with resolved FP LBP have similar trunk muscle activation to those with no history of LBP. This suggests that muscle activity behaviours may ‘normalise’ in FP on resolution of pain. Further work should explore muscle activity during recurrent episodes to establish links with pain provocation. No conflicts of interest. No funding obtained

Patients with solitary spinal metastases from Renal Cell Carcinoma (RCC) have better prognosis and survival rates compared to other spinal metastatic disease. Adjuvant therapy has been proven ineffective. Selected patients can be treated with Total En bloc Spondylectomy (TES) for solitary intra-osseous metastasis in the thoracolumbar spine secondary to renal cell carcinoma. Five patients with solitary vertebral metastasis secondary to RCC underwent TES for radical resection of the spinal pathology after pre-operative embolisation. The procedure involves en bloc laminectomy and corpectomy with posterior instrumented fusion and anterior instrumentation with cage reconstruction following the spondylectomy. All patients were fully staged pre-operatively and assessed according to the Tokuhashi scoring system. Recurrence of spinal metastasis and radiological failure of reconstruction. All patients demonstrated full neurological recovery and reported significant pain relief. One patient died at 11 months post-op due to a recurrence of the primary. The other four are well at 24, 45, 52 and 66 months post-op without evidence of recurrence in the spine. There were no major surgical complications. Careful patient selection is required to justify this procedure. The indication is limited to solitary intra-osseous lesions where complete resection of the tumour is possible. The main advantage of this treatment is that it affords significant pain relief and restores spinal stability whilst minimizing local recurrence

Sacro-coccygeal chordomas pose a difficult diagnostic and therapeutic problem due to late presentation, large size, soft-tisue extension, difficulties in obtaining adequate resection margins, higher local recurrence rate and uncertain effectiveness of adjuvant treatment. We present a series of 21 patients of sacral chordomas obtained from Scottish Bone Tumour Registry to analyse predictors of local control and survival. The clinical and morphologic features, type of treatment and follow-up of 21 consecutive patients with sacral chordoma were retrospectively reviewed and analysed. The data were obtained from Scottish Bone Tumour Registry. The average age at time of the biopsy was 59 years (range, 12 to 82 years): twelve patients were male and nine were female. Pain was the presenting symptom in all patients. Two had intralesional (both recurred), 9 marginal (4 recurred) and 3 wide resections (1 recurred). Fifteen of the twenty-one patients were treated with adjuvant radiation therapy. In seven patients, the chordoma was inoperable and all but one were treated with adjuvant radiotherapy. Local recurrence and metastases occurred in 7 (50%) and 5 (23.8%) patients. The 5-year and 10-year survival were 38% and 14.2%, respectively. Excision of the lesion combined with adjuvant radiation therapy provided satisfactory results. Local recurrence presents a major problem in the management of sacral chordomas (50%). Intralesional resection should be avoided as it is associated with 100% local recurrence in our series

Introduction. Spinal osteosarcomas are quite rare and the optimal treatment strategy is unknown. We report a series of 9 cases of osteosarcoma of the spine treated with intralesional resection and adjuvant combination therapy in order to evaluate their clinico-pathological correlation, recurrence rate and survival. Materials and Methods. Between 1980 and 2009, nine histologically confirmed cases of primary conventional osteogenic sarcoma of the spine were identified from Scottish Bone Tumour Registry. This prospectively collected registry database was retrospectively reviewed. Results. There were 9 cases with male predominance (77.7%) at a median age of 39 years (range, 16 – 73 years) and were anatomically distributed as 2-cervical, 6-thoracic, 1-lumbar and 1-sacral. Local and distant staging and histological grading was carried out in all. Seven patients underwent intralesional (including open biopsies) and 2 marginal resections. Seven patients received adjuvant chemotherapy and 8 adjuvant radiotherapy. The overall local recurrence rate was 66.6%. All but one patient died of the disease with a median length of survival of 30 months. The 2-year and 5-year survival rates were 66.6% and 22.2% respectively. Two patients who survived more than 5 years were male patients below the age of 40 years involving thoracic spine (one had a marginal resection without receiving any adjuvant therapy subsequently had a recurrence; other one underwent intralesional resection with adjuvant chemo- and radiotherapy, died with no evidence of disease). Conclusions. Spinal osteosarcoma in Scottish patients showed a higher median age, thoracic spine and male gender predilection with overall poor prognosis. Local recurrence did not affect the survival adversely, however patients older than 40 years and metastases at presentation showed poor survival compared to age under 40 and non-metastatic presentations

Aims

To determine the value of scoliosis surgery, it is necessary to evaluate outcomes in domains that matter to patients. Since randomized trials on adolescent idiopathic scoliosis (AIS) are scarce, prospective cohort studies with comparable outcome measures are important. To enhance comparison, a core set of patient-related outcome measures is available. The aim of this study was to evaluate the outcomes of AIS fusion surgery at two-year follow-up using the core outcomes set.

Vertebral haemangiomas are usually asymptomatic and discovered fortuitously during imaging. A small proportion may develop variable degrees of pain and neurological deficit. We prospectively studied six patients who underwent eight surgical procedures on 11 vertebral bodies. There were 11 balloon kyphoplasties, six lumbar and five thoracic. The mean follow-up was 22.3 months (12 to 36). The indications for operation were pain in four patients, severe back pain with Frankel grade C paraplegia from cord compression caused by soft-tissue extension from a thoracic vertebral haemangioma in one patient, and acute bleeding causing Frankel grade B paraplegia from an asymptomatic vascular haemangioma in one patient. In four patients the exhibited aggressive vascular features, and two showed lipomatous, non-aggressive, characteristics. One patient who underwent a unilateral balloon kyphoplasty developed a recurrence of symptoms from the non-treated side of the vertebral body which was managed by a further similar procedure. Balloon kyphoplasty was carried out successfully and safely in all patients; four became asymptomatic and two showed considerable improvement. Neurological recovery occurred in all cases but bleeding was greater than normal. To avoid recurrence, complete obliteration of the lesion with bone cement is indicated. For acute bleeding balloon kyphoplasty should be combined with emergency decompressive laminectomy. For intraspinal extension with serious neurological deficit, a combination of balloon kyphoplasty with intralesional alcohol injection is effective