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. The aim of this study was to compare the clinical and radiological outcomes of patients with early-onset scoliosis (EOS), who had undergone spinal fusion after distraction-based spinal growth modulation using either traditional growing rods (TGRs) or magnetically controlled growing rods (MCGRs). Methods. We undertook a retrospective review of skeletally mature patients who had undergone fusion for an EOS, which had been previously treated using either TGRs or MCGRs. Measured outcomes included sequential coronal T1 to S1 height and major curve (Cobb) angle on plain radiographs and any complications requiring unplanned surgery before final fusion. Results. We reviewed 43 patients (63% female) with a mean age of 6.4 years (SD 2.6) at the index procedure, and 12.2 years (SD 2.2) at final fusion. Their mean follow-up was 8.1 years (SD 3.4). A total of 16 patients were treated with MCGRs and 27 with TGRs. The mean number of distractions was 7.5 in the MCGR group and ten in the TGR group (p = 0.471). The mean interval between distractions was 3.4 months in the MCGR group and 8.6 months in the TGR group (p < 0.001). The mean Cobb angle had improved by 25.1° in the MCGR group and 23.2° in TGR group (p = 0.664) at final follow-up. The mean coronal T1 to S1 height had increased by 16% in the MCGR group and 32.9% in TGR group (p = 0.001), although the mean T1 to S1 height achieved at final follow-up was similar in both. Unplanned operations were needed in 43.8% of the MCGR group and 51.2% of TGR group (p = 0.422). Conclusion. In this retrospective, single-centre review, there were no significant differences in major curve correction or gain in spinal height at fusion. Although the number of planned procedures were fewer in patients with MCGRs, the rates of implant-related complications needing unplanned revision surgery were similar in the two groups. Cite this article: Bone Joint J 2022;104-B(2):257–264

Introduction. Traditionally correction of idiopathic paediatric scoliosis is done by hybrid fixation. This involves a judicious combination of mono-axial and poly-axial screw constructs. This has inherent perceived advantages with better deformity correction and maintaining alignment without loss of correction over time. Study design. Single centre retrospective review of prospective collected data on the radiological analysis of idiopathic paediatric scoliosis corrections. The study compared hybrid screw constructs (poly-axial & mono-axial) to all poly-axial screw constructs over 28 months. Objective. Compare loss of correction between hybrid screw construct group (HSG) and all poly-axial screw construct group (PSG). Method. Retrospective review of preoperative, post-operative and latest follow-up radiographs on the cohort of 42 consecutive patients over a period of 28 months from a single surgeon series. Results. There were 19 patients (16 females, 3 male) in HSG and 23 (18 females, 5 male) in PSG. Average age at surgery was 14 years for HSG and 15.8 years for PSG. The average baseline Cobbs angle for HSG was 64.57°and 60.79° for PSG. In the HSG, on average 11.6 levels were fused and, in the PSG, it was 11.3 level. Mean screw density for HSG was 1.54 and PSG was 1.6. Mean correction from pre-op to immediate post-op was 46.06° (70.10%) in the HS group and 41.24 degrees (67.78%) in the PS group. At the last follow-up, mean correction was 45.12° (68.0%) for the HSG and 42.43° (70.39%) for PSG. Loss of correction from post-operative radiographs to latest follow up averaged 10.05% in HSG and 3.86% for PSG. Discussion. All poly-axial screw constructs has the advantage of minimal tray inventory, simple logistics, decreased surgical time and overall better efficiency. Rod application and derotation over poly-axial screw constructs is well controlled and we found no difference in the performance of these screws during and after the procedure. Conclusion. There was no statistically significant difference in the degree or loss of correction in HSG or PSG. No difference in radiological outcomes. In poly-axial pedicle screw construct, threading the rod and correction manoeuvres are easier and thereby reducing surgical times. There was no compromise on the derotation manoeuvre and correction of the apical rotation deformity. Our findings show that all poly-axial screw constructs in the management of idiopathic scoliosis corrections is emerging as a tangible alternative for the future

Objectives. This presentation discusses the experience at our Centre with treating traumatic thoracolumbar fractures using percutaneous pedicle screw fixation and also looks at clinical and radiological outcomes as well as complications. Design. This is a retrospective study reviewing all cases performed between Jan 2013 and June 2019. Subjects. In our study there were 257 patients in total, of which there were 123 males and 134 females aged between 17 and 70. Methods. We reviewed the case notes and imaging retrospectively to obtain the relevant data. Results. A total of 257 patients were included, 123 males and 134 females; the mean age was 47.6 years. The majority of injuries were from fall from significant height. In 98 cases the fracture involved a thoracic vertebra and in 159 cases a lumbar vertebra. Percutaneous pedicle screw fixation was performed either one level above and below fracture or Two levels above and below the fracture depending upon the level of injury. Forty two cases were treated with additional short pedicle screws at the level of fracture. More than 15% (39) of patients presented with a neurological deficit on admission and more than 80% (32) of those showed post-operative improvement in their neurology as per Frankel Grading system. The mean Operative time was 117minutes +− 45, and mean length of hospital stay was 7.2 +− 3.8 days, with significant improvement in Visual analogue score. Percutaneous fixation achieved a satisfactory improvement in radiological parameters including sagittal Cobb angle (SCA) post-operatively in all patients. The vast majority of patients achieved a good functional outcome according to modified Macnab criteria. Follow up was for a maximum of two years, with relevant imaging at each stage. Ten (3.8%) patients had wound infection with three patients requiring wound debridement. Four patients had upper level screws pulled out and in Four cases one screw was misplaced. All eight had revision surgery. Conclusions. Percutaneous pedicle screw fixation is a safe surgical option with comparable outcomes to open surgery and a potential reduction in perioperative morbidity. Percutaneous pedicle screw fixation is the primary surgical technique to treat traumatic thoracolumbar fractures at our Centre. There were no major complications in our series, with good functional outcome following surgery

Aims

The aims of this study were first, to determine if adding fusion to a decompression of the lumbar spine for spinal stenosis decreases the rate of radiological restenosis and/or proximal adjacent level stenosis two years after surgery, and second, to evaluate the change in vertebral slip two years after surgery with and without fusion.

Aims

Postoperative complication rates remain relatively high after adult spinal deformity (ASD) surgery. The extent to which modifiable patient-related factors influence complication rates in patients with ASD has not been effectively evaluated. The aim of this retrospective cohort study was to evaluate the association between modifiable patient-related factors and complications after corrective surgery for ASD.

Aims. The surgical treatment of tuberculosis (TB) of the spine consists of debridement and reconstruction of the anterior column. Loss of correction is the most significant challenge. Our aim was to report the outcome of single-stage posterior surgery using bone allografts in the management of this condition. Patients and Methods. The study involved 24 patients with thoracolumbar TB who underwent single-stage posterior spinal surgery with a cortical bone allograft for anterior column reconstruction and posterior instrumentation between 2008 and 2015. A unilateral approach was used for 21 patients with active TB, and a bilateral approach with decompression and closing-opening wedge osteotomy was used for three patients with healed TB. Results. A median of 1.25 vertebrae were removed (interquartile range (IQR) 1 to 1.75) and the median number of levels that were instrumented was five (IQR 3 to 6). The median operating time was 280 minutes (IQR 230 to 315) and the median blood loss was 700 ml (IQR 350 to 900). The median postoperative kyphosis was 8.5° (IQR 0° to 15°) with a mean correction of the kyphosis of 71.6%. Good neurological recovery occurred, with only two patients (8%) requiring assistance to walk at a mean follow-up of 24 months (9 to 50), at which time there was a mean improvement in disability, as assessed by the Oswestry Disability Index, of 83% (90% to 72%). Conclusion. The posterior-only approach using cortical allografts for anterior column reconstruction achieved good clinical and radiological outcomes. Differentiation should be made between flexible (active) and rigid (healed) TB spine. Cite this article: Bone Joint J 2018;100-B:1208–13

Aims. We compared the clinical and radiological outcomes of using a polyetheretherketone cage with (TiPEEK) and without a titanium coating (PEEK) for instrumented transforaminal lumbar interbody fusion (TLIF). Materials and Methods. We conducted a randomised clinical pilot trial of 40 patients who were scheduled to undergo a TLIF procedure at one or two levels between L2 and L5. The Oswestry disability index (ODI), EuroQoL-5D, and back and leg pain were determined pre-operatively, and at three, six, and 12 months post-operatively. Fusion rates were assessed by thin slice CT at three months and by functional radiography at 12 months. Results. At final follow-up, one patient in each group had been lost to follow-up. Two patients in each of the PEEK and TiPEEK groups were revised for pseudarthrosis (p = 1.00). The rate of complete or partial fusion at three months was 91.7% in both groups. Overall, there were no significant differences in ODI or in radiological outcomes between the groups. Conclusion. Favourable results with identical clinical outcomes and a high rate of fusion was seen in both groups. The titanium coating appears to have no negative effects on outcome or safety in the short term. A future study to determine the effect of titanium coating is warranted. Cite this article: Bone Joint J 2017;99-B:1366–72

Patients with neurogenic claudication from lumbar canal stenosis non-responsive to non-surgical treatment are usually managed with spinal decompression with or without fusion. Flexion at stenotic segments relieves symptoms by increasing canal cross-sectional area, intervertebral foraminal height. Interspinous spacers work by causing flexion at the treated segement. We used COFLEX¯ [Paradigm Spine] a titanium interspinous spacer along with interlaminar decompression where indicated. To compare the clinical and radiological results of patients undergoing interlaminar decompression with or without use of COFLEX¯. Pre and post-operative assessment and comparison of clinical outcomes of Oswestry disability index(ODI), Visual analog Scale(VAS), Short Form-36(SF-36) and radiological outcomes of disc heights of operated and adjacent levels, intervertebral foraminal heights, sagittal angles of the operated segment. All consecutive patients undergoing spinal decompression at one or more levels from Jan to Dec 2008 were included. Patients with clinically symptomatic back pain for a duration longer than claudication pain were offered interspinous spacer at L4/5 level or above. In first group(n-20), patients were treated with inter-laminar decompression and COFLEX¯ with a standard posterior approach. In second group(n-25) inter-laminar decompression for the involved segment was performed. All patients are on follow-up. Clinical and radiological outcomes were compared at 6 months and 1 year. Statistically significant(p<0.001) improvements in ODI, VAS(back), VAS(leg) and SF-36 in patients in whom COFLEX¯ was used. Radiological parameters also showed significant improvements(p<0.05). Use of COFLEX¯ spacer is justified in patients with symptomatic disc degeneration with neurogenic claudication when treated operatively

To assess the clinical and radiological outcome of single and multiple level Anterior Cervical Disc Replacement (ACDR) using Peek-on-peek system. We present the largest series of POPCDR at a single centre. Thirty-one patients with radiculopathy and/or myelopathy caused by disc generation who did not respond to conservative treatments were included. Pain and function were evaluated by VAS (Visual Analogue Score) for neck (VAS-NP) and arm pain (VAS-AP). Neck disability index (NDI) and SF-36 questionnaires were completed. Disc height and segmental angular correction (SAC) were measured on radiographs pre- and postoperatively. Seven patients had one-level, fifteen had two-level, seven had three-level and two had four-level ACDR. Sixty-six discs were replaced. Average follow-up was six months. Mean VAS-NP improved from 7.27 to 3.93 and VAS-AP from 7.27 to 3.4. Mean SF-36 improved from 32.21 to 40.22. There was functional improvement for NDI in all patients. There was an improvement in SAC from 5.4. ° . to 8.0. ° . for one-level, 3.1. °. to 7.5. °. for two level, 8.4. °. to 9.4. °. for three-level and 5.8. °. to 26.7. °. for four-level ACDR. Post-operative anterior disc height increased by 152% for lower and 55% for higher levels. Similar improvements were noted for posterior disc heights. Early results show that POPCDR is safe and effective for treatment of symptomatic cervical disc disease. The clinical and radiological outcomes are similar to other types of ACDR reported in literature. POPCDR also allows safe use of MRI during follow-up with fewer artifacts giving it an edge over other systems

The purpose of this study was to evaluate and compare the effect of short segment pedicle screw instrumentation and an intermediate screw (SSPI+IS) on the radiological outcome of type A thoracolumbar fractures, as judged by the load-sharing classification, percentage canal area reduction and remodelling. . We retrospectively evaluated 39 patients who had undergone hyperlordotic SSPI+IS for an AO-Magerl Type-A thoracolumbar fracture. Their mean age was 35.1 (16 to 60) and the mean follow-up was 22.9 months (12 to 36). There were 26 men and 13 women in the study group. In total, 18 patients had a load-sharing classification score of seven and 21 a score of six. All radiographs and CT scans were evaluated for sagittal index, anterior body height compression (%ABC), spinal canal area and encroachment. There were no significant differences between the low and high score groups with respect to age, duration of follow-up, pre-operative sagittal index or pre-operative anterior body height compression (p = 0.217, 0.104, 0.104, and 0.109 respectively). The mean pre-operative sagittal index was 19.6° (12° to 28°) which was corrected to -1.8° (-5° to 3°) post-operatively and 2.4° (0° to 8°) at final follow-up (p = 0.835 for sagittal deformity). No patient needed revision for loss of correction or failure of instrumentation. Hyperlordotic reduction and short segment pedicle screw instrumentation and an intermediate screw is a safe and effective method of treating burst fractures of the thoracolumbar spine. It gives excellent radiological results with a very low rate of failure regardless of whether the fractures have a high or low load-sharing classification score. Cite this article: Bone Joint J 2014;96-B:541–7

Aims

The aim of this retrospective study was to compare the correction achieved using a convex pedicle screw technique and a low implant density achieved using periapical concave-sided screws and a high implant density. We hypothesized that there would be no difference in outcome between the two techniques.

Aims

High-grade dysplastic spondylolisthesis is a disabling disorder for which many different operative techniques have been described. The aim of this study is to evaluate Scoliosis Research Society 22-item (SRS-22r) scores, global balance, and regional spino-pelvic alignment from two to 25 years after surgery for high-grade dysplastic spondylolisthesis using an all-posterior partial reduction, transfixation technique.

To assess implant performance, to evaluate fusion and to assess clinical and radiologic outcome of circumferential fusion using porous tantalum cages for ALIF in a 360-degree fusion. A retrospective cohort study was performed over a 4-year period that included the implantation of 280 tantalum cages in 98 patients by the technique of anterior lumbar interbody fusion (ALIF) and posterolateral spondylodesis. Radiographic follow-up was performed to document any implant related problems. Preoperative and postoperative clinical outcome measures were assessed. No neurological, vascular or visceral injuries were reported. There were no rod breakages and no symptomatic non-unions. One revision procedure was performed for fracture. Mean VAS back pain score in our patient cohort improved from 7.5 preoperatively to 1.9 at latest follow-up, mean VAS leg pain score improved from 6.2 to 1.1 and mean ODI score improved from 51.1 to 18.3. Porous tantalum cages have high strength and flexibility, in addition to having similar biomaterial properties to cancellous bone. Their use in 360-degree spondylodesis to treat degenerative lumbar spine deformity has been demonstrated to be very safe and effective, with excellent clinical and functional outcomes

To assess the clinical and radiologic outcome of MM patients with thoracic spine involvement and concomitant pathologic sternal fractures with a resultant severe sagittal plane deformity. A prospective cohort study (n=391) was performed over a 7-year period at a national tertiary referral centre for the management of multiple myeloma with spinal involvement. Clinical, serological and pathologic variables, radiologic findings, treatment strategies and outcome measures were prospectively collected. Pre-treatment and post-treatment clinical outcome measures utilised included EQ-5D, VAS, ODI and RMD scoring systems. 13 MM patients presented with a severe symptomatic progressive sagittal plane deformity with a history of pathologic thoracic compression fractures and concomitant pathologic sternal fracture. All patients with concomitant sternal fractures displayed the radiographic features and spinopelvic parameters of positive sagittal malalignment and attempted clinical compensation. All patients had poor health related quality of life measures when assessed. Pathologic sternal fracture in a MM patient with thoracic compression fractures is a risk factor for the development of a severe thoracic kyphotic deformity and sagittal malalignment. This has been demonstrated to be associated with a very poor health related quality of life

This is a prospective randomised study comparing the clinical and radiological outcomes of uni- and bipedicular balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures. A total of 44 patients were randomised to undergo either uni- or bipedicular balloon kyphoplasty. Self-reported clinical assessment using the Oswestry Disability Index, the Roland-Morris Disability questionnaire and a visual analogue score for pain was undertaken pre-operatively, and at three and twelve months post-operatively. The vertebral height and kyphotic angle were measured from pre- and post-operative radiographs. Total operating time and the incidence of cement leakage was recorded for each group. Both uni- and bipedicular kyphoplasty groups showed significant within-group improvements in all clinical outcomes at three months and twelve months after surgery. However, there were no significant differences between the groups in all clinical and radiological outcomes. Operating time was longer in the bipedicular group (p < 0.001). The incidence of cement leakage was not significantly different in the two groups (p = 0.09). A unipedicular technique yielded similar clinical and radiological outcomes as bipedicular balloon kyphoplasty, while reducing the length of the operation. We therefore encourage the use of a unipedicular approach as the preferred surgical technique for the treatment of osteoporotic vertebral compression fractures. Cite this article: Bone Joint J 2013;95-B:401–6

In a prospective study between August 2002 and August 2005, we studied the quantitative clinical and radiological outcome 36 months after percutaneous vertebroplasty for intractable type-II osteoporotic vertebral compression fractures which had been unresponsive to conservative treatment for at least eight weeks. We also examined the quality of life (QoL). The clinical follow-up involved the use of a pain intensity numerical rating scale (PI-NRS, 0 to 10), the Short-Form 36 (SF-36) QoL questionnaire and an anamnestic questionnaire before and at seven days (PI-NRS only), and one, three, 12 and 36 months post-operatively. A total of 30 consecutive patients received percutaneous vertebroplasty for 62 vertebral compression fractures with a mean time between fracture and treatment of 7.7 months (2.2 to 39). An immediate, significant and lasting reduction in the average and worst back pain was found, represented by a decrease of 3.1 and 2.7 points after seven days and 3.1 and 2.8 points after 36 months, respectively (p < 0.00). Comparison of the pre- and post-vertebroplasty scores on the various SF-36 domains showed an ultimate significant increase in six of eight domains and both summary scores. Asymptomatic leakage of cement was found in 47 of 58 (81%) of treated vertebrae. Two minor complications occurred, an asymptomatic pulmonary cement embolism and a cement spur along the needle track. Percutaneous vertebroplasty in the treatment of chronic vertebral compression fractures results in an immediate, significant and lasting reduction in back pain, and overall improvement in physical and mental health

Increasing health care costs, limited resources and increased demand makes cost-effective and cost-efficient delivery of Adolescent Idiopathic Scoliosis (AIS) management paramount. Rising implant costs in deformity surgery have prompted justification of high implant density. The objective of this study was to analyse the costs of thoracoscopic scoliosis surgery, comparing initial learning curve costs with those of the established technique and to the costs involved in posterior instrumented fusion from the literature. 189 consecutive cases from April 2000 to July 2011 were assessed with a minimum of 2 years follow-up using a prospective database covering perioperative factors, clinical and radiological outcomes, complications and patient-reported outcomes. The patients were divided into three groups to allow comparison; 1. A learning curve cohort, 2. An intermediate cohort and 3. A third cohort using our established technique. Hospital finance records and implant manufacturer figures were corrected to 2013 costs. A literature review of AIS management costs and implant density in similar curve types was performed. The mean pre-op Cobb angle was 53°(95%CI 0.4) and was corrected postop to mean 22.9°(CI 0.4). The overall complication rate was 20.6%, primarily in the first cohort, with a rate of 5.6% in the third cohort. The average total costs were $46,732, operating room costs of $10,301 (22.0%) and ICU costs of $4620 (9.8%). The mean number of screws placed was 7.1 (CI 0.04) with a single rod used for each case giving average implant costs of $14,004 (29.9%). Comparison of the three groups revealed higher implant costs as the technique evolved to that in use today, from $13,049 in Group 1 to $14577 in Group 3 (P<0.001). Conversely operating room costs reduced from $10,621 in Group 1 to $7573 (P<0.001) in Group 3. ICU stay was reduced from an average of 1.2 to 0 days. In-patient stay was significantly (P=0.006) lower in Groups 2 and 3 (5.4 days) than Group 1 (5.9 days). Our thoracoscopic anterior scoliosis correction has evolved to include an increase in levels fused and reduction in complication rate. Implant costs have risen, however, there has been a concurrent decrease in those costs generated by operating room use, ICU and in-patient stay with increasing experience. Literature review of equivalent curve types treated posteriorly shows similar perioperative factors but higher implant density, 69–83% compared to the 50% in this study. Thoracoscopic Scoliosis surgery presents a low density, reliable, efficient and effective option for selected curves

Introduction. Recently published results suggest insertion of shorter screws in L5/S1 stand-alone anterior interbody fusion, fearing S1 nerve root violation. However, insertion of shorter screws led to screw fixation failure and new onset of S1 body fractures. Material and Methods. Retrospective review of patients with L5/S1 stand-alone anterior interbody fusion, focussing on screw length, radiological outcomes (especially metal work failure, screw fixation and S1 body fractures) and new onset of S1 nerve root irritation. Results. 38 patients were included (mean age 46.2±13.3 years, 21 females, 17 males). Fusion of the L5/S1 segment was performed in between 2003-2010; postoperative follow-up ranged from 2-24 months. 15 patients had multilevel surgery (7 multiple segmental fusion, 8 hybrid procedures). Screw length ranged from 20-30 mm. No patient had new postoperative S1 nerve root irritation. Interestingly, 2 patients out of the hybrid group had a new onset of L5 radiculopathy, concordant to the level of disc-replacement. Follow-up x-ray review showed no fracture of S1 body fractures in all patients. No evidence of screw loosening, migration or metal work failure was reported. Conclusion. In our opinion, this review showed that insertion of longer screws for stand-alone anterior interbody fusion in L5/S1 is safe. Longer screws offer better stabilization and seem to minimize risks like S1 body fractures. Short and long-term follow-ups were satisfactory regarding screw placement, migration and positioning of implants in all patients

8 patients with cervical myelopathy treated by French-door laminoplasty and internal fixation. A novel technique of fixation is employed to provide immediate stability, pain relief and rapid mobilisation. To report the clinical and radiological outcomes of this new fixation device for French–door laminoplasty with minimum follow-up of 30 months. Hardware assisted laminoplasty has the potential advantage of instant stability and prevention of recurring stenosis. The use of titanium mini-plates has been described in open-door laminoplasty and now we describe this technique in French–door laminoplasty. 8 patients with cervical myelopathy secondary to congenital stenosis (2) and multi-level spondylotic myelopathy (6) underwent 2-4 level French–door laminoplasty and mini-plate fixation. The average follow-up was 46.5 months. Autogenous iliac crest bone graft was interposed between the sagittally split spinous processes and 16-18 holed titanium mini-plates were contoured into a trapezoidal shape and secured to the posterior elements with screws. Patients then mobilised without external support. The mean follow-up was 46.5 months. The mean improvement in NDI at final follow-up was 35% and mean improvement in VAS was 4 points. JOA score improved from a mean of 10 to a mean of 14.8 post-operatively. All patients had achieved a significant neurological improvement and pain relief. There were no post-operative hardware related complications, pseudarthrosis or neurological deterioration. French-door laminoplasty is an excellent alternative to laminectomy for treatment of young patients with cervical myelopathy. The use of titanium mini-plates not only provides instant stability and pain relief but also seems to minimize the risk of C5 nerve root palsy. Internal fixation appears to provide instant stability, early mobilisation and therefore reduces hospital stay and associated costs