Methods. In this study of patients who underwent internal fixation without fusion for a burst thoracolumbar or lumbar fracture, we compared the serial changes in the injured disc height (DH), and the fractured vertebral body height (VBH) and kyphotic angle between patients in whom the implants were removed and those in whom they were not. Radiological parameters such as injured DH, fractured VBH and kyphotic angle were measured. Functional outcomes were evaluated using the Greenough low back outcome scale and a VAS scale for pain. Results. Between June 1996 and May 2012, 69 patients were analysed retrospectively; 47 were included in the implant removal group and 22 in the implant retention group. After a mean follow-up of 66 months (48 to 107), eight patients (36.3%) in the implant retention group had screw breakage. There was no screw breakage in the implant removal group. All radiological and functional outcomes were similar between these two groups. Although solid union of the fractured vertebrae was achieved, the kyphotic angle and the anterior third of the injured DH changed significantly with time (p < 0.05). . Discussion. The radiological and functional outcomes of both implant removal and retention were similar. Although screw breakage may occur, the implants may not need to be removed. Take home message: Implant removal may not be needed for patients with burst fractures of the thoracolumbar and lumbar spine after fixation without fusion. However, information should be provided beforehand regarding the possibility of screw breakage. Cite this article: Bone Joint J 2016;98-B:109–16

Objective. From our series of 570 Dynesys flexible stabilisation procedures, we studied two prospective series of patients with a minimum one-year follow-up comparing uncoated and hydroxyapatite-coated (HA) screws. Methods. Patients were entered prospectively and followed up at 6 weeks, 3, 6, and 12 months and annually thereafter. Plain radiographs were obtained annually. 58 patients who underwent Dynesys stabilisation with HA coated screws (312 screws) were evaluated. The data was compared with 71 patients who underwent Dynesys stabilisation with non-coated pedicle screws (366 screws). Outcome measures were screw loosening, breakage, implant removal or revision. Follow up was 96 %. Results. In the HA coated group there were five screw breakages in three patients, all affecting S1 screws. There was evidence of loosening in one patient. In the non-HA coated group there were two cases of infection, both had their implants removed. Further 11 patients had screw loosening and required implant removal. There was a significant improvement of anchorage of the HA coated screws. There was no correlation between numbers of level stabilised, or previous surgery and screw loosening. Average time to revision surgery for loosening was 23 months in the non-coated group. Screw fractures occurred at 11 months in the HA coated group. There was no correlation between screw loosening or fracture and gender or age. Conclusions. Change to HA coating was investigated because of high loosening in plain screws. Secure pedicle screw fixation is crucial in dynamic stabilisation as the implant remains under constant load. This study demonstrated the significant improved anchorage of HA coated pedicle screws in dynamic posterior stabilisation of the lumbar spine. HA coating has eliminated the problem of screw loosening irrespective of gender, age, number of level stabilised or whether there was previous lumbar surgery

We have studied two matching cohorts of patients treated by Dynesys flexible stabilisation with and without hydroxyapatite (HA) coating of the pedicle screws. From our series of 570 Dynesys procedures, we studied patients with HA coated screws with a minimum one year follow-up. Patients were entered prospectively and followed up at 6 weeks, 3, 6, and 12 months and annually thereafter. Plain radiographs were obtained annually. 58 patients (26 males, 32 females, mean age 55 years at surgery) underwent Dynesys stabilisation with HA coated screws. The data was compared with 69 patients who underwent Dynesys stabilisation with non-coated pedicle screws between 2004 and 2006 (26 male, 53 female, mean age 54 years). Outcome measures were screw loosening, breakage, implant removal or revision. A total of 320 HA coated pedicle screws were inserted. 12 patients were lost to follow-up. 2 patients underwent subsequent level extension, and 2 had their implants removed. There were four screw breakages in three patients, all affecting S1 screws. There was no evidence of screw loosening in any patient. In the non-HA coated group 354 pedicle screws were inserted. 5 patients required revision or subsequent surgery. 12 patients had screw loosening and required implant removal. There was a significant improvement of anchorage of the HA coated screws. Change to HA coating was investigated because of high loosening in plain screws. The improvement has been highly significant. Flexible stabilisation is a better model than fusion because the implant remains under constant load. Disclosure: The authors did not receive any outside funding in support of preparation of this work

Purpose of Study. To review the medium-term results of the Dynesys stabilisation system used in 113 consecutive patients with discogenic back pain. Methods and Results. 113 consecutive patients with discogenic back pain were treated with Dynesys as the sole intervention. Inclusion criteria included mri proven disc degeneration and an improvement in symptoms following an injection into the disc with local anaesthetic and steroid (spinal disc probing). Patients were followed up for a minimum of 5 years, with outcome measures including SF-36, Oswestry disability index (ODI) and visual pain analogue scores (VPAS). Additional factors reviewed included previous spinal operations, complications, loosening and revision rates with subsequent outcomes. Mean pre-operative ODI was 49.5, SF-36 was 37.6 and VPAS back pain was 60.9. At one year post operatively, these scores were 36.9, 49.4 and 39.8, at five years follow up, the scores were 33.3, 51.8 and 40.1 respectively. We note wide variations in our results. Several significant factors appear to contribute to the outcome of surgery. These include undergoing surgery before the age of 43, no more than 2-level disc degeneration, leg pain less than VPAS 4, and no previous spinal surgery. 19 patients had screw loosening evident on plain film x-rays (4 requiring removal), and 2 patients had screw breakages. 19 patients had implant removal for failure and 2 patients went on to have a fusion procedure. Discussion. Dynesys has a role in the treatment of discogenic back pain. Patient selection is important to outcome and we have identified several pre-operative factors that increase the likelihood of success. The effects are present at 1 year postoperatively and are maintained for at least 5 years. There is a significant screw loosening rate and our series had a 17% revision rate

During the last decade or more, the anchors used for instrumentation in scoliosis surgery are predominantly transpedicular screws, according to Suk. The long term radiographical feature of screw fixation after scoliosis surgery is not previously studied. A consecutive series of 81 cases with AIS operated on with an all screw construct has been studied by means of low dose CT postoperatively and at 2 years postoperatively. There were 67 females and 14 males, with a mean age of 18.3 ± 3 years. In 26 / 81 (32 %) there were signs of loosing of one or more screws, at a maximum 3 screws. We observed loosened screws in the upper thoracic region in 16 cases, in the thoracolumbar 6 and in lumbar area in 4. Mean pre-op Cobb angle was 56 in cases of loosening and 53 of intact screw fixation (n.s.), the correction rate was 69% in loosened vs 70% among intact screws (n.s.). In males there were signs of loosening in 8/14 (57%) and in females 18/67 (27%). Among cases with loosening, 14% had suboptimal screw positioning postoperatively, in intact cases it was observed in 11% (n.s.). In the whole group there were signs of suboptimal screw positioning 12%. Clinically, 1 case had a loosened L4 screw replaced; and at all 21/26 had no complaints and 5/26 reported minor pain or discomfort. 1/26 had a minor proximal junctional kyphosis about 10°, in 3/26 there was a pull-out of some few mms. With plain radiography loosening could be observed in 11/26 cases; 5 were in the lumbar region. In a consecutive series of 81 adolescents with idiopathic scoliosis who had underwent scoliosis surgery according to Suk, one third showed, 2 years after the intervention, some minor screw loosening, assessed by low dose CT. One patient had one lumbar screw replaced and only 5 patients reported minor discomfort. Males were more prone to develop screw loosening

Aims

The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD).

Many operations have been recommended to treat Pars Interarticularis fractures that have separated and are persistently symptomatic, but little other than conservative treatment has been recommended for symptomatic incomplete fractures. 10 consecutive patients aged 15–28 [mean 21.7 years] were treated operatively between 2010–2014. All but one were either professional athletes [3 cricketers, 2 athletics, 1 soccer] or academy cricketers [3 patients]. 8 patients had unilateral fractures, and two had bilateral fractures at the same level. The duration of pre-operative pain and disability with exercise ranged from 4–24 months [mean 15.4 months]. The operation consists of a percutaneous compression screw inserted through a 1.5cm midline skin incision under fluoroscopic guidance: 6 cases were also checked with the O-arm intra-operatively. Post-operation the patients were mobilised with a simple corset and discharged the following day with a customised rehabilitation program. All 12 fractures in 10 patients healed as demonstrated on post-operative CT scans at between 3–6 months. One patient had the screw revised at 24 hours for an asymptomatic breach, and one patient developed a halo around the fracture site without screw loosening, and had a successful revision operation to remove the screw and graft the pars from the screw channel. All patients achieved a full return to asymptomatic activity, within a timescale of 4–12 months post-surgery, depending on the sport. Athletes that have persistent symptoms from incomplete pars interarticularis fractures should consider percutaneous fixation rather than undergoing prolonged or repeated periods of rest

Purpose. Retrospective review of growth sparing spinal instrumentation. Methods and results. Medical records of 30 children with spinal deformity treated were evaluated. There were 14 male and 16 female patients at an average age of 4.9 years (1-14) at the time of presentation. These included 18 idiopathic, 11 congenital and a 14 year old with delayed growth having GH treatment. All patients underwent dual growing rod construct using hook and pedicle screw instrumentation. Extensions were carried out at approximately 6 monthly intervals. Average follow up was 4.2 years (2-8.5) with an average of 7.3(3-15) extension/exchange procedures per patient. Average immediate postoperative Cobb angle was 29(15-55) from a preoperative Cobb of 68(55-100) and this was maintained to a final mean Cobb angle of 30(15-60). Average gain in T1-S1 length was 5.7(3.5-9.8) cm. Five patients had final fusion at an average age of 15.5 years. There were no infections following primary operation. Out of 249 procedures including extensions/exchange, there were 9(4.5%) episodes of deep infection in 7 patients requiring debridement. Four patients (13%) had revisions for rod breakage/screw loosening/hook pullout/junctional kyphosis and three(10%) had prominent implants. Conclusion. Dual growth rods are effective at maintaining correction while attaining height for deformities from a variety of aetiologies in paediatric patients. Families need be informed of associated complications and unplanned/multiple surgeries

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

We do know that the use of stand-alone cage with no plate is prone to subsidence and segmental kyphosis. Cage and plate construct are prone to adjacent level ossification. Zero P (Synthes, UK) cage combines the functionality of spacer and anterior plate. Radiological evaluation of subsidence of cervical spine after anterior cervical interbody fusion using Zero P cage system. Method: Retrospective review of radiographic records of patients undergoing surgery between June 2008- Oct 2009. We evaluated lateral cervical standing radiographs before, after, 6 weeks, 3, 6 months of surgery. We measured subsidence (using Total Intervertebral Height (TIH). All measurements were done using Web 1000 (Impax Agfa). Two level was treated as single segment. Subsidence > 3mm was considered significant. 20 patients (11 male: 9 female) with median age of 51 yrs (40-65) underwent one (n=10) or two level (n= 10) cervical fusion. Immediately post-op there was increase in TIH in one and two level group by 1.74mm (1.61 and 4.25mm (1.48 respectively, which at 6 months reduced to 1.05mm (0.24 (p< 0.003) and 1.32mm (1.29 (p< 0.085) at 6 months respectively. Subsidence was seen in all cases and was rapid in first 3 months and then tailed off. It was significant (> 3mm) only in 2/20 (2%) patients at 6 months. Early results indicate that spine alignment is maintained radiologically with no associated complications as screw loosening, cage extrusion etc

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.

We analysed the complications encountered in 102 consecutive patients who had posterolateral lumbosacral fusion performed with transpedicular screw and rod fixation for non-traumatic disorders after a minimum of two years. Of these, 40 had spondylolysis and spondylolisthesis, 42 a degenerative disorder, 14 instability after previous laminectomy and decompression, and six pain after nonunion of previous attempts at spinal fusion without internal fixation. There were 75 multilevel and 27 single-level fusions. There were 76 individual complications in 48 patients, and none in the other 54. The complications seen were screw misplacement, coupling failure of the device, wound infection, nonunion, permanent neural injury, and loosening, bending and breakage of screws. Screw breakage or loosening was more common in patients with multilevel fusions (p < 0.001). Screws of 5 mm diameter should not be used for sacral fixation. Forty-six patients had at least one further operation for one or several complications, including 20 fusion procedures for nonunion. The high incidence of complications is a disadvantage of this technically-demanding method

Aims

To evaluate the perioperative complications associated with total en bloc spondylectomy (TES) in patients with spinal tumours, based on the extent and level of tumour resection.

Objective. The use of all pedicle screw constructs for the management of spinal deformities has gained widespread popularity. However, the placement of pedicle screws in the deformed spine poses unique challenges for the spinal surgeon. The purpose of this study was to evaluate the complications and radiological outcomes of surgery in 124 consecutive patients with spinal deformity. These patients underwent correction of coronal and sagittal imbalance with segmental pedicle screw fixation only. Background. All pedicle screw constructs have been associated with improved correction in all three planes. In patients with severe deformity, such constructs can obviate the need for anterior surgeries, and the higher implant cost is offset by the avoidance of dual anterior and posterior approaches. Pedicle screw fixation enables enhanced correction of spinal deformities, but the technique is still not widely applied for thoracic deformities for fear of neurological complications. This is a retrospective study that was carried out on 124 patients who underwent segmental screw fixation for coronal and sagittal spinal deformities. The purpose of this study was to evaluate the complications and outcomes of this technique and also assess the evidence of enhanced correction. Material and Methods. A total of 124 consecutive patients subjected to pedicle screw fixation for spinal deformities were analysed after a minimum period of follow-up of two years. Etiologic diagnoses were idiopathic scoliosis in 32, neuromuscular scoliosis 48, Scheuermann's kyphosis in 28 and others 16. They were reviewed using the medical records and preoperative, intraoperative and postoperative radiographs. Computed tomography was performed when screw position was questionable. Deformity correction was determined on preoperative and postoperative radiographs. The positions of the screws were evaluated using intraoperative and postoperative radiographs. There were 51 male and 73 female patients with the mean age of 17.2 years (range, 10-25 years). The average cobb angle for scoliosis and kyphosis were 55°(range 45°-85°) and 72° (range 68°-100°) respectively. Results. A total of 2784 pedicle screws were inserted and 1488 screws were inserted in the thoracic spine (18 screws/patient). Screw-related neurological complications occurred in two patients 0.4%; these comprised a transient paraparesis and dural tear. Other complications comprised six intraoperative pedicle fractures, 12 screw loosening, four postoperative infections and one haemothorax. There were no significant screw-related neurological or visceral complications. The average correction was 78% for scoliosis and 51% for kyphosis. The mean estimated blood loss was 653 ml (range, 510-850), the mean operation time was 148 minutes (range, 120-220). Conclusion. We were able to demonstrate that application of pedicle screw construct is safe and advantageous in the management of spinal deformities. Significant correction has been achieved with a single stage posterior surgery in all groups. Scoliosis and kyphotic deformity corrections were 78% and 51% respectively; this is far superior to correction achieved with one stage surgery with other constructs. This study showed that improved derotation has decreased the need for thoracoplasty, thus eliminating its risk of associated morbidity. Superior control of the deformity obviated the need for an anterior approach in severe curves. Improved correction, lower morbidity and shorter hospitalisation has compensated for higher implant cost. We believe using all pedicle screw fixation is a relatively safe procedure and offers an excellent correction. This correction was maintained throughout the follow up period. Despite our safety record in thoracic pedicle screw placement, we believe this technique can be potentially dangerous in inexperienced hands, and requires a long learning curve. Therefore, a thorough anatomical knowledge of pedicle morphology, a detailed analysis of pre-operative imaging coupled with experience is essential to avoid complications. Ethics approval None. Interest Statement None

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

Whether a combined anteroposterior fusion or a posterior-only fusion is more effective in the management of patients with Scheuermann’s kyphosis remains controversial. The aim of this study was to compare the radiological and clinical outcomes of these surgical approaches, and to evaluate the postoperative complications with the hypothesis that proximal junctional kyphosis would be more common in one-stage posterior-only fusion.

Transarticular screw fixation with autograft is an established procedure for the surgical treatment of atlantoaxial instability. Removal of the posterior arch of C1 may affect the rate of fusion. This study assessed the rate of atlantoaxial fusion using transarticular screws with or without removal of the posterior arch of C1. We reviewed 30 consecutive patients who underwent atlantoaxial fusion with a minimum follow-up of two years. In 25 patients (group A) the posterior arch of C1 was not excised (group A) and in five it was (group B). Fusion was assessed on static and dynamic radiographs. In selected patients CT imaging was also used to assess fusion and the position of the screws. There were 15 men and 15 women with a mean age of 51.2 years (23 to 77) and a mean follow-up of 7.7 years (2 to 11.6). Stable union with a solid fusion or a stable fibrous union was achieved in 29 patients (97%). In Group A, 20 patients (80%) achieved a solid fusion, four (16%) a stable fibrous union and one (4%) a nonunion. In Group B, stable union was achieved in all patients, three having a solid fusion and two a stable fibrous union. There was no statistically significant difference between the status of fusion in the two groups. Complications were noted in 12 patients (40%); these were mainly related to the screws, and included malpositioning and breakage. The presence of an intact or removed posterior arch of C1 did not affect the rate of fusion in patients with atlantoaxial instability undergoing C1/C2 fusion using transarticular screws and autograft.

Cite this article: Bone Joint J 2013;95-B:972–6.

Objectives

To employ a simple and fast method to evaluate those patients with neurological deficits and misplaced screws in relatively safe lumbosacral spine, and to determine if it is necessary to undertake revision surgery.

We describe the results of a prospective case series of patients with spondylolysis, evaluating a technique of direct stabilisation of the pars interarticularis with a construct that consists of a pair of pedicle screws connected by a U-shaped modular link passing beneath the spinous process. Tightening the link to the screws compresses bone graft in the defect in the pars, providing rigid intrasegmental fixation. We have carried out this procedure on 20 patients aged between nine and 21 years with a defect of the pars at L5, confirmed on CT. The mean age of the patients was 13.9 years (9 to 21). They had a grade I or less spondylolisthesis and no evidence of intervertebral degeneration on MRI. The mean follow-up was four years (2.3 to 7.3). The patients were assessed by the Oswestry Disability Index (ODI) and a visual analogue scale (VAS). At the latest follow-up, 18 patients had an excellent clinical outcome, with a significant (p < 0.001) improvement in their ODI and VAS scores. The mean ODI score at final follow-up was 8%. Assessment of the defect by CT showed a rate of union of 80%. There were no complications involving the internal fixation.

The strength of the construct removes the need for post-operative immobilisation.