Objectives. Understanding lumbar facet joint involvement and biomechanical changes post spinal fusion is limited. This study aimed to establish an in vitro model assessing mechanical effects of fusion on human lumbar facet joints, employing synchronized motion, pressure, and stiffness analysis. Methods and Results. Seven human lumbar spinal units (age 54 to 92, ethics 15/YH/0096) underwent fusion via a partial nucleotomy model mimicking a lateral cage approach with PMMA cement injection. Mechanical testing pre and post-fusion included measuring compressive displacement and load, local motion capture, and pressure mapping at the facet joints. pQCT imaging (82 microns isotropic) was carried out at each stage to assess the integrity of the vertebral endplates and quantify the amount of cement injected. Before fusion, relative facet joint displacement (6.5 ± 4.1 mm) at maximum load (1.1 kN) exceeded crosshead displacement (3.9 ± 1.5 mm), with loads transferred across both facet joints. After fusion, facet displacement (2.0 ± 1.2 mm) reduced compared to pre-fusion, as was the crosshead displacement (2.2 ± 0.6 mm). Post-fusion loads (71.4 ± 73.2 N) transferred were reduced compared to pre-fusion levels (194.5 ± 125.4 N). Analysis of CT images showed no endplate damage post-fusion, whilst the IVD tissue: cement volume ratio did not correlate with the post-fusion behaviour of the specimens. Conclusion. An in vitro model showed significant facet movement reduction with stand-alone interbody cage placement. This technique identifies changes in facet movement post-fusion, potentially contributing to subsequent spinal degeneration, highlighting its utility in biomechanical assessment. Conflicts of interest. None. Sources of funding. This work was funded by EPSRC, under grant EP/W015617/1

We carried out a study to determine the effect of facet tropism on the development of adolescent and adult herniation of the lumbar disc. We assessed 149 levels in 140 adolescents aged between 13 and 18 years and 119 levels in 111 adults aged between 40 and 49 years with herniation. The facet tropism of each patient was measured at the level of the herniated disc by CT. There was no significant difference in facet tropism between the herniated and the normal discs in both the adolescent and adult groups, except at the L4-L5 level in the adults. Facet tropism did not influence the development of herniation of the lumbar disc in either adolescents or adults

Objective. To identify any difference in clinical outcome between Intra-Capsular facet (IF) and Peri-facet (PF) injections in patients with low back pain (LBP). IF and PF joint steroid injections have been used for treatment of LBP with varied reports of pain relief for many years. Methods. Patients randomised into IF and PF groups. Bilateral L4/5 and L5/S1 levels injected. 40mg of Depo-Medrone with Lignocaine (total 1ml) in IF group. 80mg of Depo-Medrone with 1ml of 0.5% Chirocaine (total 3ml) in PF group. Pain visual analogue score (VAS) and analgesic chart – completed till six months. Results. Eighty eight total, 14 withdrew, 69 with feedback available. Sixty-three (91%) had significant pain relief a week following injection, 86% and 94% in IF & PF groups. Mean duration of pain relief was 12.4 weeks (IF-12.2, PF-12.5). Mean change in VAS before & after injection was 4 (IF-4, PF-4). Mean change in analgesic use before & after injection was 2 tablets. (IF-2.9, PF-2.3). Radiation dose area product (DAP) for IF injections- 603 and PF- 45 mGy.cm. 2. 45 (51%) came for repeat injections, 19 & 26 in IF & PF groups. Conclusions. Majority of patients had pain relief with no statistically significant difference between 2 groups in change in pain severity, duration of pain relief or change in analgesic intake. Significant change in VAS after injection in both groups (from 7 to 3). Pain relief for a mean duration of 12.4 weeks. PF - technically easier- 9 patients randomised to IF group had to have PF injections (facet joint osteophytes). Radiation doses much higher for IF injections even in expert hands (P=0.007). It took double the time to perform IF injections compared to PF (30 and 15 minutes)

To determine whether spinal facet osteoblasts at the curve apex display a different phenotype to osteoblasts from outside the curve in patients with adolescent idiopathic scoliosis (AIS). Intrinsic differences in the phenotype of spinal facet bone tissue and in spinal osteoblasts have been implicated in the pathogenesis of AIS. However, no study has compared the phenotype of facet osteoblasts at the curve apex with the facet osteoblasts from outside the curve in patients with AIS. Facet bone tissue was collected from three sites, the concave and convex side at the curve apex and from outside the curve from three female patients with AIS (aged 13–16 years). Micro-CT analysis was used to determine the density and trabecular structure. Osteoblasts were then cultured from the sampled bone. Osteoblast phenotype was investigated by assessing cellular proliferation (MTS assay), cellular metabolism (alkaline phosphatase and Seahorse Analyser), bone nodule mineralisation (Alizarin red assay), and the mRNA expression of Wnt signalling genes (quantitative RT-PCR). Convex bone showed greater bone mineral density and trabecular thickness than did concave bone. The convex side of the curve apex exhibited a significantly higher proliferative and metabolic phenotype and a greater capacity to form mineralised bone nodules than did concave osteoblasts. mRNA expression of SKP2 was significantly greater in both concave and convex osteoblasts than in non-curve osteoblasts. The expression of SFRP1 was significantly downregulated in convex osteoblasts compared with either concave or non-curve. Intrinsic differences that affect osteoblast function are exhibited by spinal facet osteoblasts at the curve apex in patients with AIS

Aims. The purpose of this retrospective study was to investigate the clinical relevance of increased facet joint distraction as a result of anterior cervical decompression and fusion (ACDF) for trauma. Patients and Methods. A total of 155 patients (130 men, 25 women. Mean age 42.7 years; 16 to 87) who had undergone ACDF between 1 January 2001 and 1 January 2016 were included in the study. Outcome measures included the Neck Disability Index (NDI) and visual analogue scale (VAS) for pain. Lateral cervical spine radiographs taken in the immediate postoperative period were reviewed to compare the interfacet distance of the operated segment with those of the facet joints above and below. Results. There was a statistically significant relationship between greater facet distraction and increased NDI and VAS pain scores. This was further confirmed by Spearman correlation, which showed evidence of a moderate correlation between both NDI score and facet joint distraction (Spearman correlation coefficient 0.34; p < 0.001) and VAS score and facet distraction (Spearman correlation coefficient 0.52; p < 0.001). Furthermore, there was a discernible transition point between outcome scores. Significantly worse outcomes, in terms of both NDI scores (17.8 vs 8.2; p < 0.001) and VAS scores (4.5 vs 1.3; p < 0.001), were seen with facet distraction of 3 mm or more. Patients who went on to have a posterior fusion also had increased NDI and VAS scores, independent of facet distraction. Conclusion. After undergoing ACDF for the treatment of cervical spine injury, patients with facet joint distraction of 3 mm or more have worse NDI and VAS pain scores. Cite this article: Bone Joint J 2018;100-B:1201–7

We examined the reliability of radiological findings in predicting segmental instability in 112 patients (56 men, 56 women) with a mean age of 66.5 years (27 to 84) who had degenerative disease of the lumbar spine. They underwent intra-operative biomechanical evaluation using a new measurement system. Biomechanical instability was defined as a segment with a neutral zone > 2 mm/N. Risk factor analysis to predict instability was performed on radiographs (range of segmental movement, disc height), MRI (Thompson grade, Modic type), and on the axial CT appearance of the facet (type, opening, vacuum and the presence of osteophytes, subchondral erosion, cysts and sclerosis) using multivariate logistic regression analysis with a forward stepwise procedure. The facet type was classified as sagittally orientated, coronally orientated, anisotropic or wrapped. Stepwise multivariate regression analysis revealed that facet opening was the strongest predictor for instability (odds ratio 5.022, p = 0.009) followed by spondylolisthesis, MRI grade and subchondral sclerosis. Forward stepwise multivariate logistic regression indicated that spondylolisthesis, MRI grade, facet opening and subchondral sclerosis of the facet were risk factors. Symptoms evaluated by the Short-Form 36 and visual analogue scale showed that patients with an unstable segment were in significantly more pain than those without. Furthermore, the surgical procedures determined using the intra-operative measurement system were effective, suggesting that segmental instability influences the symptoms of lumbar degenerative disease

We previously reported that osteoblasts at the curve apex in adolescent idiopathic scoliosis (AIS) exhibit a differential phenotype, compared to non-curve osteoblasts(1). However, the Hueter-Volkmann principle on vertebral body growth in spinal deformities (2) suggests this could be secondary to altered biomechanics. This study examined whether non-curve osteoblasts subjected to mechanical strain resemble the transcriptomic phenotype of curve apex osteoblasts. Facet spinal tissue was collected perioperatively from three sites, (i) the concave and (ii) convex side at the curve apex and (iii) from outside the curve (non-curve) from six AIS female patients (age 13–18 years; NRES 19/WM/0083). Non-curve osteoblasts were subjected to strain using a 4-point bending device. Osteoblast phenotype was determined by RNA sequencing and bioinformatic pathway analysis. RNAseq revealed that curve apex osteoblasts exhibited a differential transcriptome, with 1014 and 1301 differentially expressed genes (DEGs; p<0.05, fold-change >1.5) between convex/non-curve and concave/non-curve sites respectively. Non-curve osteoblasts subjected to strain showed increased protein expression of the mechanoresponsive biomarkers COX2 and C-Fos. Comparing unstimulated vs strain-induced non-curve osteoblasts, 423 DEGs were identified (p<0.05, fold-change >1.5). Of these DEGs, only 5% and 6% were common to the DEGs found at either side of the curve apex, compared to non-curve cells. Bioinformatic analysis of these strain-induced DEGs revealed a different array of canonical signalling pathways and cellular processes, to those significantly affected in cells at the curve apex. Mechanical strain of AIS osteoblasts in vitro did not induce the differential transcriptomic phenotype of AIS osteoblasts at the curve apex

Aim:. The purpose of this study was to identify factors (radiographic and MRI) which may be important in determining whether a degenerative spondylolisthesis at L4/5 is mobile. Method:. We identified 60 consecutive patients with a degenerative spondylolisthesis(DS) at L4/5 and reviewed their imaging. Patients were separated into groups on the basis of whether the DS was mobile (group A) or non-mobile (Group B) when comparing the upright plain lumbar radiograph to the supine MRI. We assessed the lumbar lordosis, pelvic incidence, sacral slope, pelvic tilt, grade of the slip, facet angles at L4/5, facet tropism, facet effusion size, facet degenerative score (cartilage and sclerosis values) and disc degenerative score (Pfirrmann) at L4/5. Results:. There were 40 patients in group A and 20 in group B. Mean age for group A was 69.2 years and for group B was 66.2 years. The difference was not significant (p-0.27; 95% CI 2.5–8.7). No significant differences were found between groups for pelvic incidence (p-0.75; 95% CI 4.6–6.3), pelvic tilt (p-0.62; 95% CI 3.2–5.3), sacral slope (p-0.51; 95% CI 3.2–6.5), lumbar lordosis (p-0.46; 95% CI 9.5–4.3), degree of facet tropism (p-0.4) and magnitude of the facet effusions (p-0.1). Facet angle differences between groups approached significance (p-0.058; 95% CI 0.1–6.7). Significant differences between groups were found in cartilage degenerative score (p-0.002), facet sclerosis grade (p-0.00) and disc degenerative score (p-0.00). In group B 10 out of 20 (50%) reduced fully and were not apparent on the MRI only. Conclusions:. Sagittal pelvic parameters do not play a significant role in differentiating between mobile and non-mobile DS at L4/5. Mobile DS tends to be associated with more sagittally orientated facets, lower Pfirmann grade, lower facet cartilage and sclerosis degenerative scores. Standing plain lumbar radiographs are essential in all patients over the age of 40 years in order not to miss up to 17% of DS at L4/5. Conflict Of Interest Statement: No conflict of interest

Background. NICE guidance suggests that caudal epidural injections of steroid and local anaesthetic may be considered for acute and severe sciatica, however studies have demonstrated limited long-term benefit and impact on future surgery. This study aimed to investigate the use of caudal epidural injections in a district general hospital setting and the rate of subsequent operation. Methods. All patients undergoing caudal epidural injection between 1. st. January and 30. th. June 2015 were included. Records were reviewed to obtain diagnosis, pre- and post-epidural clinical findings, prior interventions, and subsequent operations. Results. A total of 141 patients underwent a caudal epidural, with a median age of 63 (18 – 90). 37 patients went on to surgical intervention within 3 years, resulting in a conversion rate of 26.1%. Amongst those not requiring surgery, 59 (56.19%) had disc herniation, 42 (40%) stenosis, 4 spondylolisthesis, and 1 a facet cyst. Pre-operatively 63.81% reported back pain and 93.33% sciatica. 39.05% of patients had sensorimotor changes. Post-operatively, 27.62% reported an improvement in their back pain, compared to 62.86% reporting improved leg pain. 36.59% of those with sensorimotor changes reported improvement. 32 later had a further caudal epidural or foraminal block, and 25 had facet and sacroiliac joint injections. Amongst those requiring surgery, 21 (56.76%) had disc herniation, 15 (40.54%) stenosis, and 1 spondylolisthesis (2.7%). Conclusion. In our series, approximately three quarters of patients undergoing caudal epidural injection did not subsequently require surgery. Lumbosacral radicular symptoms improved in two thirds, however the epidural was less effective at treating back pain. No conflicts of interest. No funding obtained

Endoscopic spine surgery is a promising and minimally invasive technique for the treatment of disc herniation and spinal stenosis. However, the literature on the outcome of interlaminar endoscopic decompression (IED) versus conventional microsurgical technique (CMT) in patients with lumbar spinal stenosis is scarce. We analyzed 88 patients (IED: 36/88, 40.9%; CMT: 52/88, 59.1%) presenting with lumbar central spinal stenosis between 2018–2020. Surgery-related (operation time, complications, time to hospital release (THR), ASA score, C-reactive protein (CRP), white blood cell count (WBC), side (unilateral/bilateral), patient-reported (ODI, NRS (leg-, back pain), eQ5D, COMI), and radiological (preoperative dural sack cross-sectional area (DSCA), Shizas score (SC), left (LRH) and right (RRH) lateral recess heights, left (LFA) and right (RFA) facet angle) parameters were extracted. Complication (most often re-stenosis due to hematoma and/or residual sensorimotor deficits) rates were higher in the endoscopic (38.9%) than microsurgical (13.5%) treatment group (p<0.01). Age, THR, SC, CRP, and DSCA revealed significant correlations with 3 weeks and 1 year postoperatively evaluated ODI, COMI, eQ5D, NRS leg, or NRS back values in our cohort. We did not observe significant differences in the endoscopic versus microsurgical group for the patient-reported outcomes. Age, THR, SC, CRP, and DSCA revealed significant correlations with patient-centered outcomes and should be considered in future studies. Endoscopic treatment of lumbar spinal stenosis was similarly successful as the conventional microsurgical approach, although it was associated with higher complication rates in our single-center study experience. This was probably because of the surgeons' lack of experience with this method and the resulting different learning curve compared with the conventional technique

The purpose of our study is to assess the degenerative changes in the motion segments above a L5S1 spondylolytic spondylolisthesis, and to analyse the factors that contribute towards a retro-listhesis in the segment immediately above the slip. Prospective radiographic case series. 38 patients with a symptomatic L5S1 spondylolytic spondylolisthesis, with a mean age of 52.8 yrs (95% CI 47.2 – 58.4). 55.3% (n = 21) were females and 44.7% (n = 17) males. 58% (22) had grade 1 and 42% (16) grade 2 slips. Plain radiographs: Lumbar lordosis, slip angle, sacral slope, grade of the slip, and retro-listhesis at L45. MRI scans: facet angles at L34 and L45, facet degenerative score at L34 and L45 (cartilage and sclerosis), disc degenerative score at L45 and L5S1 (Pfirrmann). The Pfirmann disc score for L45 was 2.75 and L5S1 4.4 (p < 0.0001); the mean facet angle at L34 50.9° and L45 57.9° (p = 0.001) and the facet score at L34 was 8 and at L45 was 10.5 (p = 0.0001). 29% (11) demonstrated a retrolithesis at L45. Analysing the effect of these factors on the causation of retro-listhesis at L45 (table) the slip angle and L45 disc degenerative score were the only factors that predicted a retro-listhesis. There is a cascade of degenerative changes involving both the disc and the facet joints at the levels above a spondylolytic spondylolisthesis. The degenerative changes at the L45 disc and a higher slip angle predict a retro-listhesis at the level above the slip

We have studied fracture-dislocation of the fifth lumbar vertebra in seven patients and reviewed 50 previously reported cases. Based on this information, we have classified the injury into five types: type 1, unilateral lumbosacral facet-dislocation with or without facet fracture; type 2, bilateral lumbosacral facet-dislocation with or without facet fracture; type 3, unilateral lumbosacral facet-dislocation and contralateral lumbosacral facet fracture; type 4, dislocation of the body of L5 with bilateral fracture of the pars interarticularis; and type 5, dislocation of the body of L5 with fracture of the body and/or pedicle, with or without injury of the lamina and/or facet. Conservative treatment of fracture-dislocation of L5 is generally not effective because the lesion is fundamentally unstable. Planning of the operation should be made on the basis of the various types of injury

Aims. The aim of this study was to compare the effect of a percutaneous radiofrequency heat lesion at the medial branch of the primary dorsal ramus with a sham procedure, for the treatment of lumbar facet joint pain. Patients and Methods. A randomised sham-controlled double blind multicentre trial was carried out at the multidisciplinary pain centres of two hospitals. A total of 60 patients aged > 18 years with a history and physical examination suggestive of facet joint pain and a decrease of ≥ 2 on a numerical rating scale (NRS 0 to 10) after a diagnostic facet joint test block were included. In the treatment group, a percutaneous radiofrequency heat lesion (80. o. C during 60 seconds per level) was applied to the medial branch of the primary dorsal ramus. In the sham group, the same procedure was undertaken without for the radiofrequency lesion. Both groups also received a graded activity physiotherapy programme. The primary outcome measure was decrease in pain. A secondary outcome measure was the Global Perceived Effect scale (GPE). Results. There was a statistically significant effect on the level of pain in the factor Period (T0-T1). However, there was no statistically significant difference with the passage of time between the groups (Group × Period) or in the factor Group. In the crossover group, 11 of 19 patients had a decrease in NRS of ≥ 2 at one month crossover (p = 0.65). There was no statistically significant difference in satisfaction with the passage of time between the groups (Group × Period). The independent factors Group and Period also showed no statistically significant difference. There was no statistically significant Group × Period effect for recovery, neither an effect of Group or of Period. Conclusion. The null hypothesis of no difference in the decrease in pain and in GPE between the treatment and sham groups cannot be rejected. Post hoc analysis revealed that the age of the patients and the severity of the initial pain significantly predicted a positive outcome. Cite this article: Bone Joint J 2016;98-B:1526–33

Background. Gore and Nadkarni described a ‘Gore sign’ of reproducing radiating leg pain by palpation of distal nerve root endings in the foot for L5 and S1 nerve roots in lumbar radiculopathy due to disc prolapse. Purpose. This sign was explored and observation of symptoms recorded. Results. There were 31 patients, 20 females and 11 males, aged 25 to 76 years. 13 patients had acute disc prolapse, 14 had lumbar canal stenosis, 3 had annular tears and one had a facet cyst. Radiating leg pain was reproduced in all patients by palpation of distal nerve root endings and was immediately relieved by local anaesthetic injection around distal nerve root endings in all patients (second part of Gore test). New clinical signs were observed which have not been described before:. Back pain was reproduced in 21 patients. L4 nerve root pain was reproduced in 13 patients by palpation of the proximal tibia. Crossed leg pain was reproduced in 5 patients. Reproduction of pain by palpation of more than one distal nerve root ending was observed in 16 patients. Cessation of radiating leg pain by palpation of distal nerve root endings in two patients. These test were positive in patients with varied pathology producing radiculopathy, not just disc prolapse. Conclusion. Provocative nerve root tension signs can be difficult in severe pain. The tests described above can be performed without having to move the patient's lower limb. These observations open up discussion on the mechanism of radiculopathy and new ways of treatment. Conflicts of interest: None. Sources of funding: None

Aims

People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial).

Aims

The aim of this study was to reassess the rate of neurological, psoas-related, and abdominal complications associated with L4-L5 lateral lumbar interbody fusion (LLIF) undertaken using a standardized preoperative assessment and surgical technique.

Purpose of the study. Two patients with very severe thoracolumbar Scheuermann's kyphosis who developed spontaneous bony fusion across the apex of the deformity are presented and their treatment, as well as surgical outcome is discussed. Summary of Background Data. Considerable debate exists regarding the pathogenesis, natural history and treatment of Scheuermann's kyphosis. Surgical correction is indicated in the presence of severe kyphosis which carries the risk of neurological complications, persistent back pain and significant cosmetic deformity. Methods. We reviewed the medical notes and radiographs of 2 adolescent patients with severe thoracolumbar Scheuermann's kyphosis who developed spontaneous posterior and anteroposterior fusion across the apex of the deformity. Results. Patient 1. A male patient aged 17 years and 11 months underwent kyphosis correction when the deformity measured 115o and only corrected to 100o on supine hyperextension radiograph against the bolster; he had a small associated scoliosis. The surgery involved a combined single-stage anterior and posterior spinal arthrodesis T4-L3 with the use of posterior pedicle hook/screw/rod instrumentation and autologous rib graft. The anterior longitudinal ligament was ossified from T10 to L1 with bridging osteophytes extending circumferentially from T11 to T12 at the apex of kyphosis and displacing the major vessels anteriorly. The intervertebral discs from T9 to T12 were very stenotic and immobile. The osteophytes were excised both on the convexity and concavity of the associated thoracolumbar scoliosis. The anterior longitudinal ligament was released and complete discectomies back to the posterior longitudinal ligament were performed from T7 to L1. During the posterior exposure, the spine was found to be spontaneously fused across the apex of the kyphosis from T9 to L1. There were no congenital vertebral anomalies. Extensive posterior apical closing wedge osteotomies were performed from T7 to T12. The fused facets and ossified ligamentum flavum were excised and the spine was mobilised at completion of the anterior and posterior osteotomies. The kyphosis was corrected using a cantilever maneuver from proximal to distal under spinal cord monitoring. Excellent correction to 58o was achieved and maintained at follow-up. Autologous rib graft was used to enhance a solid bony fusion. Patient 2. A female patient aged 18 years and one month underwent kyphosis correction when the deformity measured 115o and only corrected to 86o on supine hyperextension radiograph against the bolster; she had a small thoracolumbar scoliosis. The surgery involved a single-stage posterior spinal arthrodesis T2-L4 with the use of posterior pedicle hook/screw/rod instrumentation and autologous iliac crest bone. The spine was spontaneously fused across the apex of kyphosis from T9 to L1. There were no congenital vertebral anomalies. Extensive posterior apical closing wedge osteotomies were performed from T6 to T12. The fused facets and ossified ligamentum flavum were excised and the spine was mobilised at completion of the osteotomies. The kyphosis was corrected using a cantilever maneuver from proximal to distal under spinal cord monitoring. Excellent correction to 60o was achieved and maintained at follow-up. Autologous iliac crest graft was used to achieve a solid bony fusion. In both patients the preoperative MRI assessed the intraspinal structures but failed to diagnose the solid fusion across the posterior bony elements at the apex of kyphosis. A CT scan with 3D reconstruction would have illustrated the bony anatomy across the kyphosis giving valuable information to assist surgical planning. This is recommended in the presence of rigid thoracolumbar Scheuermann's kyphosis which does not correct in hyperextension, especially if the plain radiograph shows anterior bridging osteophytes. Conclusion. Spontaneous posterior or anteroposterior fusion can occur across the apex of severe thoracolumbar Scheuermann's kyphosis; this should be taken into account when surgical correction is anticipated. The bony ankylosis may represent the natural history of an extreme deformity as an attempt of the spine to auto-stabilise. A combination of factors including a rigid deformity, which limits significantly active movement of the spine, as well as anterior vertebral body wedging with severe adjacent disc stenosis which induces bridging osteophyte formation may result in the development of spontaneous fusion across the apex of the kyphosis either posteriorly or anteroposteriorly. In the presence of an isolated posterior fusion, segmental posterior closing wedge osteotomies with complete excision of the ossified ligamentum flavum and fused facets should mobilise the thoracolumbar spine and allow for kyphosis correction. An additional anterior spinal release including complete discectomies, resection of the anterior longitudinal ligament and osteophytes is required if the bony fusion extends anteroposteriorly. Patients with Scheuermann's kyphosis should be ideally treated at an earlier stage and with a lesser degree of deformity so that this ossification process is prevented

The objective of this study was to assess the reliability and appropriateness of statistical shape modelling for capturing variation in thoracic vertebral anatomy for future use in assessing scoliotic vertebral morphology. Magnetic resonance (MR) images of the thoracic vertebrae were acquired from 20 healthy adults (12 female, 8 male) using a 1.5 T MR scanner (Intera, Philips). A T1 weighted spin-echo sequence (repetition time = 294 ms, echo time = 8 ms, number of signal averages = 3) was used. A set of slices (number = 27, thickness = 1.9 mm, gap = 1.63 mm, pixel size = 0.5 mm) were acquired for each vertebrae, parallel to the mid-transverse plane of the vertebral body. Repeated imaging, including participant repositioning, was performed for T4, T8 and T12 to assess reliability. Landmark points were placed on the images to define anatomical features consisting of the vertebral body and foramen, pedicles, transverse and spinous processes, inferior and superior facets. A statistical shape model was created using software tools developed in MATLAB (R2013a, The MathWorks Inc.). The model was used to determine the mean vertebral shape and ‘modes of variation’ describing patterns in vertebral shape. Analysis of variance was used to test for differences between vertebral levels and subjects and reliability was assessed by determining the within-subject standard deviation from the repeated measurements. The first three modes of variation, shown below (green = mean, red and blue = ±2 standard deviations about the mean), accounted for 70% of the variation in thoracic vertebral shape (Mode 1 = 44%, Mode 2 = 19%, Mode 3 = 4%). Visual inspection indicated that these modes described variation in anatomical features such as the aspect ratio of the vertebral bodies, width and orientation of the pedicles, and position and orientation of the processes and facet points. Variation in shape along the thoracic spine, characterised by these modes of variation, was consistent with that reported in the literature. Significant differences (p< 0.05) between vertebral levels and between some subjects were found. The reliability of the method was good with low relative error (Mode 1 = 5%, Mode 2 = 8%, Mode 3 = 19%). Statistical shape modelling provides a reliable method for characterizing many anatomical features of the thoracic vertebrae in a compact number of variables. This is useful for robustly assessing morphological differences between scoliotic and non-scoliotic vertebrae and in assessing entry points and trajectories for pedicle screws

Aims

Gram-negative infections are associated with comorbid patients, but outcomes are less well understood. This study reviewed diagnosis, management, and treatment for a cohort treated in a tertiary spinal centre.

Aims

Although lumbosacral transitional vertebrae (LSTV) are well-documented, few large-scale studies have investigated thoracolumbar transitional vertebrae (TLTV) and spinal numerical variants. This study sought to establish the prevalence of numerical variants and to evaluate their relationship with clinical problems.