To compare the effect of intraoperative red cell salvage on blood transfusion and cost in patients undergoing idiopathic scoliosis surgery. Retrospective. 37 patients (36 females, 1 male) underwent scoliosis surgery from February 2007 to October 2008. Intraoperative red cell salvage (Group 1) was used. They were compared with 28 patients (23 females, 5 males) operated from January 2005 to December 2006 without the use of cell salvage (Group 2). 36 patients in group 1 had posterior surgery and 1 had anterior surgery. In Group 2, 20 patients had posterior surgery, 7 anterior and 1 patient had anterior and posterior surgery. Both groups were comparable for age, number of levels fused, preoperative haemoglobin and haematocrit values. Amount of perioperative blood transfusion, costs. 14 patients (50%) in group 2 had blood transfusion whereas only 6 (16%) were transfused blood in group 1. Average blood loss in group 1 was 1076 mls (range 315-3000) and 1626mls (419-4275) in group 2. An average of 2 units of packed red blood cells per patient was processed by the cell salvage system. Postoperative haemoglobin, haematocrit and hospital stay were comparable in both groups. Cost analysis shows the use of cell salvage is cost beneficial by £116.60 per case. The use of red blood cell salvage reduces the amount of blood transfusion and is cost beneficial

To describe a modification of the existing technique for C2 translaminar screw fixation that can be used for salvage in difficult cases. Bilateral crossing C2 laminar screws have recently become popular as an alternative technique for C2 fixation. This technique is particularly useful in patients with anomalous anatomy, as a salvage technique where other modes of fixation have failed or as a primary procedure. However, reported disadvantages of this technique include breach of the dorsal lamina and spinal canal, early hardware failure and difficulty in bone graft placement due to the position of the polyaxial screw heads. To address some of these issues, a modified technique is described. In this technique, the upper part of the spinous process of C2 is removed and the entry point of the screw is in the base of this removed spinous process. From October 2008 to March 2009, 6 patients underwent insertion of unilateral translaminar screws using our technique. The indications were: basilar invagination(three cases), C1/C2 fracture (two cases), tumour (one case). Age varied from 22 to 81 years (mean 48 years). All patients had post-operative x-ray and CT scan to assess position of the screws. Mean follow-up was 6 months. The screw position was satisfactory in all patients. There were no intraoperative or early postoperative complications. Our modification enables placement of bone graft on the C2 lamina and is also less likely to cause inadvertent cortical breach. Because of these advantages, it is especially suitable for patients with advanced rheumatoid arthritis with destruction of the lateral masses of C2 or as part of a hybrid construct in patients with unilateral high riding vertebral artery. This technique is not suitable for bilateral translaminar screw placement

Aims

Historically, patients undergoing surgery for adolescent idiopathic scoliosis (AIS) have been nursed postoperatively in a critical care (CC) setting because of the challenges posed by prone positioning, extensive exposures, prolonged operating times, significant blood loss, major intraoperative fluid shifts, cardiopulmonary complications, and difficulty in postoperative pain management. The primary aim of this paper was to determine whether a scoring system, which uses Cobb angle, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and number of levels to be fused, is a valid method of predicting the need for postoperative critical care in AIS patients who are to undergo scoliosis correction with posterior spinal fusion (PSF).

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.

We studied the use of autologous pre-donated blood transfusion in surgery for scoliosis in 45 patients who were divided into two groups; 27 who pre-donated autologous blood (group 1) and 18 who were planned recipients of allogenic blood (group 2). Normovolaemic haemodilution and intra-operative blood salvage was used in six patients in group 1 and three patients in group 2. The two groups did not differ significantly with respect to age, American Society of Anaesthesiologists score, mean operative time, number of vertebral segments fused, total blood loss, length of stay in intensive care and length of stay in hospital. The risk of requiring allogenic blood transfusion was found to be significantly less in group 1 (7.4% ν 88.9%, p < 0.001). Only 5.21% of autologous units were wasted. Although intra-operative blood salvage reduced the total blood loss in both groups, it did not affect the need for subsequent allogenic transfusion or reduce the number of pre-donated autologous units which were given (p < 0.67). Autologous blood transfusion required extra time, personnel, resources and cost £28.88 per patient more than allogenic transfusion, however, the projected costs at May 2002 make this programme cost-effective by £51.54 per patient. Pre-donated autologous blood transfusion is acceptable and safe in scoliosis surgery. It significantly reduces the subsequent requirement of allogenic transfusion. Although the cost is currently more than allogenic transfusion, with the increase in the costs of the latter and the decrease in potential donors which is anticipated, pre-donation of autologous blood will become comparatively cost-effective

Aims

To report the surgical outcome of patients with severe Scheuermann’s kyphosis treated using a consistent technique and perioperative management.

The use of interspinous distraction devices should remain the subject of audit and research. They are a relatively new addition to the armamentarium of surgical treatment of lumbar spinal stenosis. The reported results are variable and there are a number of different devices available. It is recognised that there is an early failure rate with interspinous distraction devices. This is a report of the clinical results after conversion to segmental lumbar decompression following a failure of interspinous distraction procedure. 18 patients had removal of device and conversion to a standard lumbar decompression at an average of 13 months after the index procedure. There were 7 females and 11 males. The average age was 68 years (range 49-85). The two youngest patients had a decompression and instrumented fusion, the others had decompression alone. Prior to the Index procedure of stand alone interspinous distraction device the average Oswestry Disability Index (ODI) was 42 and Visual Analogue Score (VAS) leg 7.2. Prior to revision the average ODI was 42 and VAS leg 6.7. Complications: One intra operative myocardial infarction, one incidental durotomy and one post operative infection (pseudomonas isolated). At a mean of 9 months follow up the average ODI was 23 and VAS leg 2.1. The VAS back was 1.9. The walking distance was subjectively reported as 246 yards pre op and 1100 yards post procedure. There was a clinically significant improvement in all patients. A failed interspinous distraction device can be satisfactorily salvaged with a segmental lumbar decompression

Purpose. To evaluate efficacy of blood conservation strategies on transfusion requirements in adult scoliosis surgery and establish a protocol for cross matching. Methods and Results. Retrospective review of 50 consecutive adult scoliosis patients treated using anterior only(14,28%), posterior only(19,38%) or combined(17,34%) approaches. All patients were anaesthetised by the same anaesthetist implementing a standard protocol using cell salvage, controlled hypotension and antifibrinolytics. Mean age was 24.6 years. BMI was 21.9. On an average 9.5(6-15) levels were fused, with an average duration of surgery of 284.6(130-550) minutes. Antifibrinolytics were used in 31(62%) of the patients which included Aprotinin in 21(42%) and Tranexamic acid in 10(20%). Patients on antifibrinolytics had a significantly (p<0.05) lower blood loss (530ml) as compared to other patients (672ml). Mean volume of the cell saved blood re-transfused was 693.8 ml and mean postoperative HB level dropped to 10.7 g/dl(7.7-15) from a mean preoperative of 13.3 g/dl(10-17). 7(42%) with combined approaches and 3(15.8%) with posterior only approach required blood transfusion, 4/50(8%) of which required intra while 6/50(12%) required intra and postoperative transfusion. None of the patients having anterior surgery alone required blood transfusion. Conclusion. Use of antifibrinolytics reduces the need for blood transfusion in scoliosis surgery. For anterior surgery alone, we do not cross match

Surgery of the spine is associated with blood loss and frequently transfusion, with consequent risk of infection and reactions. It also costly, and puts a strain on national blood banks. A new blood salvage device works by ‘washing’ and centrifuging the blood lost during surgery; which can then be re-transfused into the patient. In a retrospective study 46 consecutive spinal surgeries with Cell Saver were compared with 39 matched surgeries without. Blood loss and units transfused was obtained from the transfusion database and the anaesthetic record. Average blood loss in the Cell saver group was 1382ml compared to 1405ml in the pre-Cell Saver group. Average allogenic transfusion was 1.30 units with cell saver compared to 2.78 units without. An average 2.3 units of lost blood were re-infused in the Cell Saver group. 26 (57%) of the Cell Saver group require no allogenic blood at all, whereas only 10 (26%) of patients in the pre-Cell Saver group had no transfusions. One unit of blood costs £130.52, and the Cell saver device costs £100 per patient. The average cost per patient in the Cell saver group was £270 (any transfusion plus cost of Cell Saver), compared to an average of £368.50 in the pre-Cell Saver group: a saving of £92.50. The Cell Saver decreased blood transfusions by 46% per patient and by 40% overall, a saving of £92.50 per patient. The number of patients receiving no allogenic blood increased by 31%

To determine the current practice of scoliosis surgery in the UK. A 10 point questionnaire was constructed to identify the philosophy of surgeons on various aspects of scoliosis surgery such as choice of implant, bone graft, autologous blood transfusion (ABT), cord monitoring and computer assisted surgery. Results are compared with the current best evidence. Consultants and Fellows attending the 2009 British Scoliosis Society meeting. 50 questionnaires were completed: 45 Consultants and 5 Fellows. All pedicle screw construct favored by 25/50, hybrid 24/50 (one undecided). Posterior construct of less than 10 levels, 20/50 would not cross-link, 11/50 used one and 19/20 used two or more. More than ten levels 17/50 considered cross-links unnecessary, 4/50 used one and 29/50 used two or more. 88% preferred titanium alloy implants, while a mixture of stainless steel and cobalt chrome was used by others. For bone graft, substitutes (24), iliac crest (14), allograft (12) and demineralised bone matrix (9) in addition to local bone. 10/50 would use recombinant bone morphogenetic protein (3 for revision cases only). 39/50 routinely used intra-operative cell salvage or ABT drains and 4/50 never used autologous blood. All used cord monitoring, Sensory (19/50), Motor (2/50) and combined (29/50). None used computer-aided surgery. 26 operated alone 12 operated in pairs and 12 varied depending on type of case. This survey has brought to light interesting variations in scoliosis surgery in UK. It may reflect the conflicting evidence in the literature

Aims

The direct posterior approach with subperiosteal dissection of the paraspinal muscles from the vertebrae is considered to be the standard approach for the surgical treatment of adolescent idiopathic scoliosis (AIS). We investigated whether or not a minimally-invasive surgery (MIS) technique could offer improved results.

Aims

It is uncertain whether instrumented spinal fixation in nonambulatory children with neuromuscular scoliosis should finish at L5 or be extended to the pelvis. Pelvic fixation has been shown to be associated with up to 30% complication rates, but is regarded by some as the standard for correction of deformity in these conditions. The incidence of failure when comparing the most caudal level of instrumentation, either L5 or the pelvis, using all-pedicle screw instrumentation has not previously been reported. In this retrospective study, we compared nonambulatory patients undergoing surgery at two centres: one that routinely instrumented to L5 and the other to the pelvis.

Aims

The aim of this study was to determine the efficacy of repeat epidural steroid injections as a form of treatment for patients with insufficiently controlled or recurrent radicular pain due to a lumbar or cervical disc herniation.

Aims

The aim of this study was to report a retrospective, consecutive series of patients with adolescent idiopathic scoliosis (AIS) who were treated with posterior minimally invasive surgery (MIS) with a mean follow-up of two years (sd 1.4; 0.9 to 0 3.7). Our objectives were to measure the correction of the deformity and record the peri-operative morbidity. Special attention was paid to the operating time (ORT), estimated blood loss (EBL), length of stay (LOS) and further complications.

We report the incidence of and risk factors for complications after scoliosis surgery in patients with Duchenne muscular dystrophy (DMD) and compare them with those of other neuromuscular conditions.

We identified 110 (64 males, 46 females) consecutive patients with a neuromuscular disorder who underwent correction of the scoliosis at a mean age of 14 years (7 to 19) and had a minimum two-year follow-up. We recorded demographic and peri-operative data, including complications and re-operations.

There were 60 patients with cerebral palsy (54.5%) and 26 with DMD (23.6%). The overall complication rate was 22% (24 patients), the most common of which were deep wound infection (9, 8.1%), gastrointestinal complications (5, 4.5%) and hepatotoxicity (4, 3.6%). The complication rate was higher in patients with DMD (10/26, 38.5%) than in those with other neuromuscular conditions (14/84, 16.7% (p = 0.019). All hepatotoxicity occurred in patients with DMD (p = 0.003), who also had an increased rate of deep wound infection (19% vs 5%) (p = 0.033). In the DMD group, no peri-operative factors were significantly associated with the rate of overall complications or deep wound infection. Increased intra-operative blood loss was associated with hepatotoxicity (p = 0.036).

In our series, correction of a neuromuscular scoliosis had an acceptable rate of complications: patients with DMD had an increased overall rate compared with those with other neuromuscular conditions. These included deep wound infection and hepatotoxicity. Hepatotoxicity was unique to DMD patients, and we recommend peri-operative vigilance after correction of a scoliosis in this group.

Cite this article: Bone Joint J 2014; 96-B:943–9.

There have been a few reports of patients with a combination of lumbar and thoracic spinal stenosis. We describe six patients who suffered unexpected acute neurological deterioration at a mean of 7.8 days (6 to 10) after lumbar decompressive surgery. Five had progressive weakness and one had recurrent pain in the lower limbs. There was incomplete recovery following subsequent thoracic decompressive surgery.

The neurological presentation can be confusing. Patients with compressive myelopathy due to lower thoracic lesions, especially epiconus lesions (T10 to T12/L1 disc level), present with similar symptoms to those with lumbar radiculopathy or cauda equina lesions. Despite the rarity of this condition we advise that patients who undergo lumbar decompressive surgery for stenosis should have sagittal whole spine MRI studies pre-operatively to exclude proximal neurological compression.

Cite this article: Bone Joint J 2013;95-B:1388–91.

Ventral screw osteosynthesis is a common surgical method for treating fractures of the odontoid peg, but there is still no consensus about the number and diameter of the screws to be used. The purpose of this study was to develop a more accurate measurement technique for the morphometry of the odontoid peg (dens axis) and to provide a recommendation for ventral screw osteosynthesis.

Images of the cervical spine of 44 Caucasian patients, taken with a 64-line CT scanner, were evaluated using the measuring software MIMICS. All measurements were performed by two independent observers. Intraclass correlation coefficients were used to measure inter-rater variability.

The mean length of the odontoid peg was 39.76 mm (sd 2.68). The mean screw entry angle α was 59.45° (sd 3.45). The mean angle between the screw and the ventral border of C2 was 13.18° (sd 2.70), the maximum possible mean converging angle of two screws was 20.35° (sd 3.24). The measurements were obtained at the level of 66% of the total odontoid peg length and showed mean values of 8.36 mm (sd 0.84) for the inner diameter in the sagittal plane and 7.35 mm (sd 0.97) in the coronal plane. The mean outer diameter of the odontoid peg was 12.88 mm (sd 0.91) in the sagittal plane and 11.77 mm (sd 1.09) in the coronal plane. The results measured at the level of 90% of the total odontoid peg length were a mean of 6.12 mm (sd 1.14) for the sagittal inner diameter and 5.50 mm (sd 1.05) for the coronal inner diameter. The mean outer diameter of the odontoid peg was 11.10 mm (sd 1.0) in the sagittal plane and 10.00 mm (sd 1.07) in the coronal plane. In order to calculate the necessary screw length using 3.5 mm cannulated screws, 1.5 mm should be added to the measured odontoid peg length when anatomical reduction seems possible.

The cross-section of the odontoid peg is not circular but slightly elliptical, with a 10% greater diameter in the sagittal plane. In the majority of cases (70.5%) the odontoid peg offers enough room for two 3.5 mm cannulated cortical screws.

Cite this article: Bone Joint J 2013;95-B:536–42.

We studied 70 consecutive patients with adolescent idiopathic scoliosis who underwent corrective surgery. They were divided into two groups. In the study group of 38 patients one or more modern blood-conservation measures was used peri-operatively. The 32 patients in the control group did not have these measures. Both groups were similar in regard to age, body-weight, the number of levels fused and the type of surgery.

Only two patients in the study group were transfused with homologous blood and these transfusions were ‘off-protocol’. Wastage of autologous pre-donated units was minimal (6 of 83 units). By contrast, all patients in the control group were transfused with homologous blood. In the study group there was a significant decrease (p = 0.005) in the estimated blood loss when all the blood-conservation methods were used.

The use of blood-conservation measures, the lowering of the haemoglobin trigger for transfusion and the education of the entire team involved in the care of the patient can prevent the need for homologous blood transfusion in patients undergoing surgery for adolescent idiopathic scoliosis.